Vol. 27. No. 4


This Update on Lasers is a practical clinical review of the newest technologies and techniques. Although the contributing authors have been involved in laser research, they also are engrossed in the day-to-day practice of laser surgery. Whether one has just begun to work with lasers or is a fellowship- trained laser surgeon, each article offers something for the practitioner. In the following pages, an overview of some of these technologies is discussed within the context of how we currently integrate them in our practice. Combination Treatments and Optimization of Potential An important concept in laser and cosmetic surgery is the optimization of potential. This concept relates to the creative integration of devices and other interventions for an individual patient. For instance, the long pulsed 755-nm alexandrite has great potential. By understanding the respective absorption coefficients for melanin and bloods as well as clinical end points, the 755-nm laser can be optimized to treat a wide range of conditions. It is quick and effective for laser hair reduction, pigmented lesions, and selected vascular lesions— namely port wine stains, telangiectasia, and vascular malformations (Fig. 1). Although “cookbook” settings are reassuring for the novice practitioner, simply using a given manufacturer’s laser setting often is inappropriate. What is more important in optimizing a device’s potential is recognition of clinical end points such as Purpura in a port wine stain (PWS) or graying and subsequent darkening of a Lentigo. A test site is advisable, such that the physician can adjust the cooling and fluence until a patient-specific desired end point is achieved. The optimization of potential concept should be considered when choosing among lasers and light devices. There are 3 main targets that the laser surgeon can affect: dyschromias, making up the first 2 (brown pigmentation and red telangiectasia) and rhytides. These “three uglies” can be approached with various wavelengths. Optimizing the potential efficacy and safety for each individual patient requires the use of a multiprocedural approach. Fractionated Midinfrared Nonablative Lasers As midinfrared (mid-IR) fractionated devices have become more popular, their capabilities and limitations have become more clearly defined. Dr Bogle does an excellent job of reviewing the literature and discussing the role of these lasers in clinical practice in the article titled “Fractionated Mid-Infrared Resurfacing” on page 252. As with many newly introduced technologies, the fractionated devices, pioneered by Reliant’s Fraxel (Reliant Technologies, Mountain View, CA), have received enthusiastic support from the industry as well as the dermatologic laser literature. In comparison with some previous laser fashions of the day, many initial claims have stood the test of time. These devices work most consistently in reducing dark lentigines and fine facial lines. More importantly, mid-IR fractional lasers offer a degree of operator independence with respect to outcomes, as well as allowing for user-titratable downtimes. Ablative options before 2004 presented a greater permanent scarring risk, and greater operator skill and familiarity with laser mechanics and laser–tissue interactions (LTIs) were required to avoid complications. With the advent of fractionated devices, the safety and effectiveness profiles have improved enough such that providers with less LTI knowledge and experience can treat fine facial textural irregularities with minimal risk. As Dr Bogle points out, there are many ways to “tweak” the mid-IR devices to obtain even greater results and to treat other conditions that are more operator dependent, including melasma, striae distensae, periocular rhytides, and acne scars. Although we offer fractionated laser treatment as a monotherapy, we often combine fractionated treatment with a 532-nm potassium-ttitrium-phosphate (KTP) or 595-nm pulsed dye laser (PDL), facial fillers, or q-switched lasers. Patients disappointed with previous fractional laser therapy often have been poorly educated on expected outcomes. Most frequently they complain of residual lentigines. In these patients, we often “finish” the treatment by simply using either long pulsed or q-switched visible light or localized ablative techniques (Fig. 2). However, these goals and potential outcomes and risks should be thoroughly discussed with the patient so that he or she understands the relationship among downtime, number of treatments, and efficacy. The same is true for residual rhytides. Patients often state that a previous provider promised resolution of periocular and perioral lines after a set of 4-5 fractional nonablative treatments. Laser surgeons who have used these devices on a consistent basis know that periocular and perioral rhytides are resistant and require more aggressive interventions. Furthermore, patients must understand the differences between dynamic and static lines and the range of options for improvement. Adjunctive procedures such as fillers or botulinum toxin will enhance the results of laser. Finally, although devices can improve rhytides consistently, none will consistently eliminate them. Overall, the mid-IR fractionated devices offer consistent results with less operator dependence and an acceptable downtime. Although the development of the fractionated CO2 laser is promising, the mid-IR fractionated devices retain the advantage of less downtime. Fractionated Ablative Lasers The new generation of fractionated ablative lasers allows treatment of more refractory facial irregularities such as acne scars and perioral and periocular rhytides. In our limited experience, we have determined that patients who are treated an Axis I or Axis II diagnosis but more commonly will have traits of personality disorders or “routine” anxiety or depression. Those who provide cosmetic surgical care know that these patients can be difficult when an unexpected outcome occurs. For example, use of the same education and bedside manner with a patient with borderline traits as in a patient with obsessive-compulsive traits can result in frustration for both physician and patient. Although the expected outcome for the physician may have occurred (ie, dramatic reduction in facial telangiectasia) the outcome might be interpreted as a failure (ie, obsession with the remaining facial telangiectasia or discontent with the downtime). Furthermore, any patient with a previously diagnosed personality disorder should be carefully evaluated, and the surgeon should consider using a multispecialty approach that includes a mental health provider. Medical assistants and nurses can be instrumental in creating a positive experience. Patients and staff assignments should be choreographed so that there is optimal pairing of educator and patient. The physician should consider carefully the staff impressions of the patient’s “attitude.” Those impressions can direct the patient toward the most appropriate procedures. Conclusions We are in an exciting era of laser and light therapy in dermatologic surgery. Technologic advances continue to refine the delivery of various wavelengths more effectively, safely, and predictably. However, optimizing the potential of both the settings of each individual laser, as well as combining lasers and other treatment modalities, remains the laser surgeon’s objective. Addressing the individual patient’s needs, goals, and personality connects the science of treatment with the care of our patients. Acknowledgment Dr. Uebelhoer would like to thank Dr. George Martin and his MauiDerm 2008–Advances in Cosmetic and Medical Dermatology meeting. The seminar was instrumental in providing key details for the content and structure of this edition

Light-Emitting Diodes (LEDs) in Dermatology

Daniel Barolet, MD

Light-emitting diode photobiomodulation is the newest category of nonthermal light therapies
to find its way to the dermatologic armamentarium. In this article, we briefly review
the literature on the development of this technology, its evolution within esthetic and
medical dermatology, and provide practical and technical considerations for use in various
conditions. This article also focuses on the specific cell-signaling pathways involved and
how the mechanisms at play can be put to use to treat a variety of cutaneous problems as
a stand-alone application and/or complementary treatment modality or as one of the best
photodynamic therapy light source.
Semin Cutan Med Surg 27:227-238 © 2008 Elsevier Inc. All rights reserved.


Fractional Carbon Dioxide Laser and Plasmakinetic Skin Resurfacing

Nathan S Uebelhoer, DO | Richard E. Fitzpatrick, MD, FAAD | William F. Groff, DO, FAAD

Photodamage is one of the most common reasons that patients visit a dermatologist’s
office. Carbon dioxide (CO2) laser resurfacing has always been the gold standard for
reversing photodamage. Because of the relatively high incidence of side effects and the
prolonged downtime associated with CO2 resurfacing, new technologies have emerged to
address photodamage. Portrait skin regeneration (PSR) is a novel device that has been
developed to treat photodamage, and this device yields fewer side effects and downtime
than traditional CO2 laser resurfacing. At our center, we have performed more than 500
high-energy PSR treatments and have developed a unique and highly effective treatment
protocol. In addition, fractional CO2 laser resurfacing has emerged as the latest technology
developed to combat photoaging. This technology yields impressive results and is much
safer and causes less downtime than traditional CO2 laser resurfacing. In this article, we
will review our treatment techniques and protocols as well as address patient selection,
preoperative and postoperative care, and anesthesia.
Semin Cutan Med Surg 27:239-251 © 2008 Elsevier Inc. All rights reserved.


Fractionated Mid-Infrared Resurfacing

Melissa A. Bogle, MD

Fractional resurfacing devices thermally alter microscopic treatment columns in the skin,
leaving intervening areas between the columns untouched. Because only a fraction of the
skin is being modified, untreated areas are able to rapidly repopulate the treatment columns
to greatly reduce recovery time and adverse events. Mid-infrared fractional systems have
shown improvement in treating photoaging, scars, rhytides, dyschromia, and textural
disorders. An additional advantage is that they are safe and effective for the treatment of
nonfacial areas such as the neck, chest, and extremities.
Semin Cutan Med Surg 27:252-258 © 2008 Elsevier Inc. All rights reserved.


Laser-Assisted Liposuction: Here’s the Skinny

Eric C. Parlette, MD | Michael E. Kaminer, MD

Liposuction is one of the most popular cosmetic procedures. The advent of laserassisted
liposuction is the next evolutionary step in the market of body contouring. The
goal of laser-assisted liposuction is to facilitate liposuctioning, enhance tissue tightening,
and reduce downtime and morbidity. Several different protocols using different
devices and wavelengths generate variable results. Current laser-assisted lipolysis
technology and techniques are reviewed with respective expectations. As laser lipolysis
technology and coinciding experience grow, so will the ability to achieve the aims of
more efficient, safer, and cosmetically pleasing body sculpting.
Semin Cutan Med Surg 27:259-263 © 2008 Elsevier Inc. All rights reserved.


Endovenous Laser Ablation and Sclerotherapy for Treatment of Varicose Veins

David Lopresti, MD | Hugh McSwain, MD | Natasha Brasic, MD

Superficial venous insufficiency is a common problem associated with varicose veins.
Venous insufficiency and varicose veins can be symptomatic, but more commonly they are
a cosmetic concern. In this article, we discuss the relevant anatomy and pathophysiology
of superficial venous insufficiency, review the current literature for varicose vein treatment,
and cover the technical aspects of diagnosing and treating superficial venous insufficiency.
Saphenofemoral junction incompetence with resultant greater saphenous vein reflux is the
most common cause of varicose veins; because this condition constitutes the majority of
patients encountered in practice, we will concentrate on this area. Endovenous laser
ablation and sclerotherapy are covered, including patient workup and selection, procedure
set-up, and anesthesia.
Semin Cutan Med Surg 27:264-275 Published by Elsevier Inc.