Overview of Laser Therapy for Common Vascular Lesions Naomi Travers

FEATURE ARTICLE 2.5 Contact Hours Overview of Laser Therapy for Common Vascular Lesions Naomi Travers

ABSTRACT: Vascular irregularities, especially on the face, Rosacea can be a source of great cosmetic concern and, as such, Rosacea is a common and challenging condition to treat as constitute a significant portion of complaints presenting it is dynamic and progressive. Different classification sys- to dermatology clinics. Vascular lasers are an important tems have been used to categorize the multifactorial presen- tool in the treatment of these presentations, either as the tation of this complex condition. The discussion of vascular singular modality or as an adjunct to systemic therapies. laser treatment is most relevant to the most predominant Nurses and nurse practitioners play a crucial role in de- subtype, erythematotelangiectatic rosacea. Characterized livering vascular laser treatments, either independently by episodes of facial flushing, it involves primarily the cen- or under physician supervision. It is therefore incumbent tral faceVcheeks, nose, chin, and to a lesser extent, fore- upon them to understand appropriate clinical assess- head. Triggers may include heat, temperature changes, ment of the most common vascular issues and to have a alcohol, stress, strong emotion, and spicy foods (Crawford, firm grasp of the technical concepts that govern optimal Pelle, & James, 2004). Over time, select vessels become per- treatment of each class of lesion. The purpose of this article manently dilated so the individual has a persistent ‘‘ruddy’’ is to provide an overview of the anatomical composition complexion. Patients present with a spectrum of vessel of common vascular conditions, to outline the major tech- sizesVfrom small vessels that coalesce to create a gener- nical concepts of how vascular lasers function, and to alized pinkness to large telangiectasias that are visible to highlight how the laser nurse or nurse practitioner can the naked eye. At its worst, the condition presents as a fla- integrate both clinical assessment and technical theory grant network of visible blood vessels in some or all areas to effectively plan and/or execute a course of vascular of the central face on a background of erythema. Some pa- laser treatment. tients note an unpleasant burning or tingling sensation Key words: Cherry Angiomas, Port Wine Stains, Pulsed during a flare. Dye Laser, Rosacea, Spider Nevi, Vascular Laser It is important to inform patients that laser therapy has no impact on the underlying and still not fully understood ANATOMY OF VASCULAR LESIONS mechanism of flushing. Laser therapy is meant to reduce The vascular concerns that the dermatology nurse or nurse redness and visible vessels. The physical destruction of practitioner are most likely to see range considerably in size vessels not only improves appearance but also can im- and construct. Each class of lesion varies in the diameter, prove symptoms to the extent that it lessens the number configuration, and density of vessels involved. Location and of vessels dilating in response to flushing triggers. This severity also varies from patient to patient, and all of these provides only temporary relief of the condition, however, factors must be included in the treatment assessment. The and over a period of years, patients will likely require following is a summary of lesions commonly considered maintenance treatment. For many patients with the amenable to treatment with a vascular laser, either solely condition, the prospect of any type of treatment that will or in combination with medical treatment, the latter of minimize their facial redness is worth pursuing (Figure 1). which is beyond the scope of this article. Spider Nevi Naomi Travers, MSN, GNP Skin & Cancer Foundation, Westmead, These are focal clusters of dilated vessels that radiate out- NSW, Australia. ward from a central, larger arteriole. They generally appear The author declares no conflicts of interest. on the face, neck, and sometimes, the chest. Their presence Correspondence concerning this article should be addressed to Naomi Travers, MSN, GNP 28 Wandella Avenue, Northmead, may be associated with cirrhosis, especially alcoholic cir- NSW 2152, Australia. rhosis, or excessive estrogen levels but also occurs in approx- E-mail: [email protected] imately 15% of patients, including children, who have no DOI: 10.1097/JDN.0b013e3182a52609 underlying health issues. Although harmless, their red

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BASIC LASER CONCEPTS Familiarity with the above lesions is essential for the nurse practitioner ordering treatment and for the nurse follow- FIGURE 1. (Left) Patient with rosacea before treatment with ing prescribed parameters. This becomes evident after a re- intense pulsed light (IPL) and after two treatments with IPL. view of the basic technical components of laser mechanics. Each treatment had two parameter sets: visible telangiectasias were treated with a 560-nm filter at a pulse width of The cornerstone concept of vascular laser technology is 20 ms and fluence of 25 J/cm2; generalized erythema was that of ‘‘selective photothermolysis,’’ which Kim, Roher, treated with the 560-nm filter, a pulse width of 10 ms, and and Geronemus (2005) succinctly define as ‘‘the ability to 2 fluence of 16 J/cm . Copyright Dr. Shawn Richards, Sydney, target a specific chromophore in the skin without damag- Australia. All permission requests for this image should be ing surrounding structures through the selection of proper made to the copyright holder. wavelength, pulse duration and fluence’’ (p. 11). Oxyhemoglobin is the operative chromophore in all color and solitary presence on the face make them a con- vascular lesions (Kim et al., 2005). Science has shown that spicuous cosmetic annoyance to many patients (Goldsmith, hemoglobin preferentially absorbs light energy to a max- Katz, Gilchrest, Leffell, & Wolff, 2012). imum degree at the wavelengths, in nanometers (nm), of 418, 542, and 577 nm and has a smaller peak between 700 Venous Lakes and 1100 nm. Lasers relevant to vascular treatments are de- These small, elevated lesions with a dark-purple, almost signed to emit wavelengths within the range of these peaks. blue color are found predominantly on the lips and, some- When hemoglobin absorbs light energy, the resulting heat times, the ears or face of older adults (see Figure 2). They is transmitted to the encasing vessel, causing intravascular are composed of dilated veins, either singularly or in a cluster coagulation and contraction of collagen (Wall, 2007). of such vessels, that appear as one papule on gross exam- ination (Kelly & Baker, 2012).

Port Wine Stains (PWS) Also known as nevus flammeus, PWS are congenital cap- illary malformations that occur in approximately 0.3% of all newborn infants (Jasim & Handley, 2007). They come in virtually all shapes, sizes, and densities. They can occur anywhere on the body but are most common on the head and neck, where they are of particular cosmetic concern to parents and the socially aware patient. These pink to dark-red macules consist of a dense network of dilated capillaries in the superficial papillary and upper reticular dermis (Figure 3). If not treated, the involved skin can become thickened and even form nodules (Wall, 2007).

Cherry Angiomas Cherry angiomas are round papules that may grow to several millimeters in size and are predominantly found on the trunk and extremities with increasing age. They are benign and generally asymptomatic, although larger ones may bleed with trauma (North & Kincannon, 2012).

Other Lesions With Vascular Involvement Lasers may play an adjunct role in many other conditions FIGURE 2. Venous lake before and after treatment with that have a vascular component such as keratosis pilaris 595-nm PDL. First treatment was with a 7-mm spot at a pulse 2 rubra, poikiloderma of Civatte, acne scars, striae, and sur- width of 20 ms and fluence of 15 J/cm . A second treatment with a 7-mm spot, 10-ms pulse width, and 12-J/cm2 fluence gical scars. These presentations all have unique textural was required to clear some remaining lesion. Copyright Dr. issues that may be addressed by methods beyond the scope Shawn Richards, Sydney, Australia. All permission requests for of this article. However, to the extent that laser treatment this image should be made to the copyright holder.

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Copyright © 2013 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. peaks mentioned (Kim et al., 2005). Although the 1064 nm is less absorptive than those emitted by the PDL, the en- hanced depth of penetration can play a role in treating deeper, recalcitrant vessels that may comprise a component of many common presentations such as PWS, telangiectasias, and hemangiomas. Similarly, the alexandrite laser, which emits light at 755 nm, is not the first choice for most vascular lesions because hemoglobin suboptimally absorbs light at this wavelength. However, it may play a role for deeper vessels that are better reached by this relatively long wavelength (Srinivas & Kumaresan, 2011; Wall, 2007). Finally, intense pulsed light (IPL), which is technically not a laser, can be an important tool in treating vascular lesions. IPL functions per the principles of selective photo- FIGURE 3. PWS before treatment and after three treatments thermolysis, but in a less precise way. Rather than emitting of PDL. Copyright Dr. Shawn Richards. All permission requests for this image should be made to the copyright holder. a solitary wavelength, IPL systems produce a spectrum of wavelengths from 500 to 1200 nm and come with a series of filters to manipulate exposure of wavelengths based on Macrophages gradually dispose of the nonviable tissue so skin type and lesion characteristics (Srinivas & Kumaresan, the vessels no longer fill with blood. 2011). Unlike laser systems, the IPL delivery device is placed As light waves pass through the skin, some are scat- directly onto the skin. The author’s experience is primarily tered in various directions as they encounter different skin with the 595-nm PDL and the IPL system, and these will molecules, thus lessening the energy delivered to the target. therefore be the focus of this article. Longer wavelengths scatter less and therefore penetrate deeper into the skin compared with shorter wavelengths Laser Variables (Barlow & Hruza, 2005). Given a fixed wavelength (or spectrum of wavelengths in If hemoglobin were the only chromophore in the skin, the case of IPL), there is a set of three parameters that the vascular treatments would certainly be more straightfor- laser technician can manipulate to tailor treatment to a ward. However, water and melanin molecules also act as particular lesion. Fluence is the level of energy unleashed light absorbers. Ross and Paithankar aptly describe the onto the skin and is measured in joules per square centi- melanin-dense epidermis as the ‘‘innocent bystander’’ of 2 meters (J/cm˙); the pulse width is the time in which a laser treatments intended for deeper vascular lesions (p. 128). given fluence is delivered and is measured in milliseconds As the laser light passes through the skin, absorption by mel- (ms). Finally, the spot size refers to the diameter of the anin can cause the unwanted side effect of hyperpigmentation circular delivery aperture and is measured in millimeters and surface injury, especially with shorter wavelengths. Cur- (mm). Smaller spot sizes tend to cause more scatter of rent lasers contain integrated cooling systems that coordinate light and therefore deliver less energy compared with with the laser pulse to minimize epidermal damage without larger spot sizes (Srinivas & Kumaresan, 2011). impeding the laser itself (Ross & Paithankar, 2005). Still, Once heated to a maximum level, a vessel will cool as patients with dark skin types and especially those with ten- heat dissipates to the surrounding tissues. The time it takes dency toward hyperpigmentation should be treated conser- to lose approximately 50% of that peak temperature is vatively and cautiously. called the thermal relaxation time (TRT; Bencini, Tourlaki, De Giorgi, & Galimberti, 2012). TRT is a function of ves- Types of Lasers sel diameter, such that the larger the vessel, the longer the There are several types of lasers that play a role in treating TRT. Theoretically, optimal vessel damage occurs when the vascular lesions, and the laser technician would benefit pulse width is about equal to the TRT: Any longer and from being familiar with the basic properties of each. Per- excess heat will incur damage to nearby structures; any less haps, the most pertinent is the flashlamp-pumped pulsed and the vessel itself will not receive enough heat to induce dye laser (PDL), which emits wavelengths of 585 or 595 nm the desired end point of coagulation (Kim et al., 2005). depending on the manufacturer (Kim et al., 2005). These Comparable to boiling a cup of water versus a full bathtub, have been purposely developed based on the principle of at a fixed output of heat (analogous to fluence), the former selective photothermolysis to optimize treatment of vascular will take much less time before it releases heat energy into lesions. the surrounds in the form of steam; the larger volume will Another technology is the neodymium:yttrium-aluminum- require much more. garnet laser, which emits a wavelength of 1064 nm and Thus, when determining what treatment parameters to can be manipulated to halve the wavelength to 532 nm. use, the first step is to consider the anatomy of the lesion Both wavelengths correspond to hemoglobin absorption and the average size of the vessel structures involved. This

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Copyright © 2013 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. will help determine the appropriate pulse width to use. erally achieved with pulse widths in the middle range, Likewise, optimal fluence levels correlate to the size of the depending on the fluence. vessel to be treated. The parameters typically used to treat For telangiectasias, coagulation of the vessels is marked venous lakes (Figure 2) and PWS (Figure 3) exemplify by an instantaneous change from red to a gray/black out- this concept. The PWS, composed of many fine vessels line. Smaller vessels may be seen as a gray/purple outline with small diameters, would best be treated with a 595-nm before disappearing into a background of erythema. Larger PDL system at relatively short pulse widths of 1.5 or even vessels will turn dark purple upon coagulation and remain 0.45 ms (other levels are 3, 6, 10, 20, and 40 ms). The so for varying lengths of time measured in seconds. If they pictured lesion is relatively light and required three treat- are seen to revascularize quickly, the fluence is probably too ments. A darker, denser lesion would require several more, low. Ideally, the vessel will remain purple for 10 seconds or depending on the patient’s goals. more. The longer the intravascular coagulation time, the At the other end of the spectrum is the venous lake, better chance of permanent removal. Similarly, venous lakes which was treated with a comparatively long pulse and cherry angiomas should remain purple if treated effec- width of 20 ms, a spot size of 10 mm, and a fluence of tively (Figure 4). If telangiectasias do not appear to coag- 15 J/cm2. This significantly reduced the lesion, but a se- ulate with a given fluence, the operator may either increase cond treatment at 10 ms, 10-mm spot, and 15 J/cm2 was the fluence or employ the technique of ‘‘pulse stacking.’’ required to achieve complete clearance. By delivering two pulses in rapid succession, the vessels The same general principle applies to the IPL system, are first damaged and then coagulated by the additive heat although the figures are on a different scale. Illustrating from the second pulse. this is the patient with rosacea in Figure 1. In this case, The novice laser operator will want to review the manu- the visible telangiectasias were treated with a 560-nm fil- facturer’s treatment guidelines and titrate up from conser- ter, a relatively long pulse width of 20 ms, and a fluence of vative doses until experience allows for more fluent decision 25 J/cm2. In contrast, the fine vessels comprising the un- making. Taking the time to do test spots using a series of derlying erythema were treated with the same filter at a pulse widths and fluences is an invaluable investment for the shorter pulse width of 10 ms and lesser fluence of 16 J/cm2. new operator and certainly for the trusting patient. (Candela Corporation, 2005). CLINICAL APPLICATION Familiarity with the anatomy of vascular lesions and tech- Patient Preparation nical understanding of laser/tissue interaction are basic Proper assessment of the lesion and a firm grasp of appro- requirements to treat the vascular patient. They are the priate treatment parameters are not only essential from a building blocks on which the laser nurse adds assessment clinical perspective but also for reassuring the patient before of intratreatment response to finesse treatment parameters embarking on what is often an emotional and anxiety- according to the goals that have been established between provoking process. The practitioner’s authoritative ex- the patient and the practitioner. planation of the procedure, in terms appropriate to the Fortunately, response to treatment is easily assessed as patient’s level of understanding, is foremost in instilling it is immediate and visually apparent. Depending on the confidence. parameters used, skin response with the PDL laser will fall Many patients are justifiably curious as to how the tech- somewhere along a spectrum: from no response or slight nology works. A simple analogy of a bucket filled with rocks pinkness at one end, increasingly intense erythema in the and sponges and covered with fine netting may be used to middle and dark purpura at the extreme. Shorter pulse help patients relate to the process. Water poured into the widths tend to cause purpura, and indeed, this is the op- bucket will pass easily through the net without tearing. timal end point for effective treatment of PWS with PDL. Similarly, laser light passes through the stratum corneum, This will be seen as a deep purple mark immediately after apulse. For other conditions with fine erythema, such as the erythema of rosacea or keratosis pilaris rubra, treatment at a purpuric level is also ideal. However, it may take 10 days to 2 weeks for purpuric discoloration to clear, and most patients cannot afford the downtime socially and/or profes- sionally. In these cases, improvement can still be achieved at subpurpuric levels but with more treatments. Clinically, the subpurpuric threshold can be appreciated immediately FIGURE 4. Cherry angioma before and after one treatment after delivering a pulse as an almost-imperceptible dusky with 595-nm PDL with a 7-mm spot, 10-ms pulse width, and 12-J/cm2 fluence. Note that the dark purple/black color gray color in the shape of the circular spot aperture. The indicates thorough coagulation. Copyright Dr. Shawn grayish color can be fleeting or last a few seconds before the Richards, Sydney, Australia. All permission requests for this image skin flushes with erythema. This subpurpuric level is gen- should be made to the copyright holder.

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Copyright © 2013 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. treating the target vessels without rupturing the skin. Most the specific wavelengths emitted by the machine being patients intuitively understand that, because of their nat- used (Candela Corporation, 2005). ural properties, the sponge will absorb the water, whereas the rocks will not. Such is the behavior of light, which is Pain absorbed by the blood in the vessels while the surrounding The issue of intraprocedural pain is of enough concern skin remains unaffected. Patients are often put at ease by to warrant extra discussion. ‘‘Does it hurt?’’ is perhaps the fact that they will not have open sores; female patients the most common question patients ask during the consul- are also happy to know that they can therefore apply tation process. Laser therapy involves intense heat energy makeup soon after the treatment to conceal the aftereffects. delivered in a concentrated time frameVdiscomfort is to Informed consent, including possible risks, side effects, be expected. Each patient’s perception, emotional state, expected outcomes, the expected course of healing, and proj- and pain threshold will vary considerably. The laser pulse ected course of treatment should all be reviewed. Small, is often described as a ‘‘rubber band snapping,’’ but many superficial lesions like the spider nevus (Figure 5) or cherry patients might argue this is a gross understatement, espe- angiomas may clear with one treatment, but most con- cially given that a treatment session can require up to ditions involving diffuse erythema will realistically require several hundred pulses. The sensation of a laser pulse is two to three sessions for adequate suppression. PWS can unique unto itself; patients are not likely to have had any take eight or more sessions to lighten, and full clearance similar experience to which they can refer as mental prep- is often not possible. Treatments are typically repeated aration. The combined prospect of exposing oneself to an 4Y6 weeks apart. unfamiliar and painful sensation while vulnerably blindfolded with eye shields can create a great deal of anticipatory Side Effects anxiety. In the case of vascular laser treatment, many side effects The effective laser nurse will prepare the patient for such as swelling, erythema, and various degrees of pur- the prospect of discomfort with empathy and reassur- pura are in fact inherent to the goal of inducing tissue ance (see Table 1) as well as a repertoire of options for damage. The patient should be made fully aware of these pain control. On this subject, the literature seems notably anticipated outcomes as well as the rare but possible unwanted sparse. Research to date has primarily focused on laser side effects of infection, scarring, hyperpigmentation, or mechanics and little on the patient experience. The ideal hypopigmentation. These complications are very rare with analgesia should be effective, be easy to administer, and the advent of PDL lasers, whose target selectivity and sur- have no or very mild potential side effects. Cold air is one face cooling system allow for much more refined vascular such modality and should be considered a basic compo- treatment than in the past (Tanzi, Lupton, & Alster, 2003). nent of any laser program. Patients can hold the nozzle and direct it where needed during the procedure. The cool Safety air counteracts some of the painful heat sensation while giving the patient a distraction and sense of control. Obviously, the safety of the patient and operator is of utmost Pharmacological options include topical agents, anxi- importance. Anyone operating a laser should complete a olytics, and oral analgesics (Kilmer, 2005). Topical lido- certified laser safety course. For the purposes of this article, caine, prilocaine, and tetracaine in different concentrations the fundamental precaution deserving mention is that of eye and bases are available for use before treatment. Presum- safety. Laser light can be potentially damaging to eye ably, oral analgesics would play a role in prophylactic anal- structures. It is essential that patients’ eyes are covered gesia, but there are no controlled studies comparing different and that the operator have eyewear that protects against agents or the effectiveness of individual agents at various fluence thresholds. As lasers become more widely available and their use becomes more common, this should be an area of more study in an effort to improve the patient experience. Anecdotally, the clinic of this author has had some suc- cess using the inhaled analgesic methoxyflurane (Penthrox) forpatientswhoareeitherhighly anxious and/or find vascular laser treatments prohibitively painful. It is indicated for pain relief in conscious, hemodynamically stable patients, and although it can cause drowsiness, patients are able to self-administer the vapor via a handheld device while undergoing the laser treatment. The device comes FIGURE 5. Spider nevus before and after one treatment with3mLofdrug,whichprovidesenoughanalgesiafor with PDL with 7-mm spot, 10-ms pulse width, and 12-J/cm2 fluence. Copyright Dr. Shawn Richards, Sydney, Australia. the average treatment session. It has a quick onset of All permission requests for this image should be made to the about 10 inhalations, and the effects begin to wear off copyright holder. within minutes of ceasing to inhale the drug. The major

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Copyright © 2013 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. ical assessment before, during, and after therapy. Whether TABLE 1. Pearls prescribing treatment parameters or applying the parame- & Always use loupes to accurately assess the vessel sizes ters set by a supervisor, the laser nurse has a responsibility contained within lesions. to his or her patients to understand the rationale behind & When treating PWS, mark the treatment area with a dosing levels. This understanding increases the operator’s medical marker. Once the treatment has started, confidence, enhances communication between supervisors purpura may obscure the lesion boundaries. and operators, and allows the laser professional to accu- & Once their eyes are covered, describe all of your rately answer the inevitable patient questions about how movements and mechanical sounds to the patients to laser technology can treat vascular lesions. As knowledge put them at ease. and experience deepen, the laser nurse can look forward to & Advise patients that, even with eyes shields, they will a great sense of satisfaction from helping patients resolve still be able to appreciate the bright flash emitted with their cosmetic concerns. h each laser pulse. Reassure them that their eyes are protected from direct exposure to the laser beam. REFERENCES & Touch the patients in the area where you will administer Barlow, R. J., & Hruza, G. J. (2005). Lasers and light tissue interactions. In the first pulse so they can localize it mentally. D. Goldberg (Ed.), Lasers and lights: Volume 1, vascular, pigmentation, scars and medical applications.(pp.11Y27). Philadelphia, PA: Elsevier & Deliver one or two pulses and then stop, giving the Saunders. patients a moment to acclimate to this new sensation. Bencini, P. L., Tourlaki, A., De Giorgi, V., & Galimberti, M. (2012). Laser use for cutaneous vascular alterations of cosmetic interest. Dermatologic & To accurately assess the subpurpuric threshold, do a Therapy, 25,340Y351. few test pulses and wait at least a minute to fully Candela Corporation, (2005). Clinical in-service manual: Candela pulsed- appreciate response. Sometimes, patients have dye lasers. No. 8501-00-16995. Irvine, CA. Crawford, G. H., Pelle, M. T., & James, W. D. (2004). Rosacea: Etiology, delayed purpura, and waiting will avoid overtreating pathogenesis, and subtype classification. Journal of the American Academy before it is too late. of Dermatology, 51(3), 327Y341. & Patients on blood-thinning agents such as aspirin, fish Goldsmith,L.A.,Katz,S.I.,Gilchrest,B.A.,Leffell,D.J.,&Wolff,K.(Eds.). (2012). Fitzpatrick’s dermatology in general medicine (8th ed.). New York, oil, or gingko biloba may be more prone to purpura at NY: McGraw-Hill Medical. standard laser doses. Jasim, Z. F., & Handley, J. M. (2007). Treatment of pulsed dye laser-resistant port & wine stain birthmarks. Journal of the American Academy of Dermatology, If patients seems anxious, it may help to break the 57(4), 677Y682. treatment into a certain number of pulses, i.e., 10. Kelly, R., & Baker, C. (2012). Other Vascular Disorders. In J. L. Bolognia, J. L. Then, count down with each section. Jorizzo, & J. V. Schaffer (Eds.), Dermatology (3rd ed., pp. 1747Y1757). Philadelphia, PA: Elsevier Saunders. & When using an IPL, avoid pressing too firmly on the Kilmer, S. (2005) Anesthesia. In D. Goldberg (Ed.), Lasers and lights: Volume 1, delivery sapphire as the pressure can compress the vascular, pigmentation, scars and medical applications (pp. 137Y141). target vessel and lessen effectiveness. Philadelphia, PA: Elsevier Saunders. & Kim, K. H., Rohrer, T. E., & Geronemus, R. G. (2005). Vasular lesions. In Remind patients that swelling will likely be most intense D. Goldberg (Ed.), Lasers and lights: Volume 1, vascular, pigmentation, scars the morning after the treatment. This is normal after and medical applications (pp. 11Y27). Philadelphia, PA: Elsevier Saunders. sleeping in supine position. Elevating the head with extra Medical Developments International. (2012). Product catalogue. Retrieved pillows may help. Otherwise, very puffy cheeks and eyes from http://www.medicaldev.com/wp/wp-content/uploads/2012/09/MDI- Product-Catalog-Sep-2012.pdf are to be expected. North, P. E., & Kincannon, J. (2012). Vascular neoplasms and neoplastic-like proliferations. In J. L. Bolognia, J. L. Jorizzo, & J. V. Schaffer (Eds.), Dermatology (3rd ed., pp. 1915Y1941). Philadelphia, PA: Elsevier Saunders contraindications relevant to the outpatient population Ross, E. V., Jr., & Paithankar, D. (2005). Cooling. In D. Goldberg (Ed.), Lasers and lights: Volume 1, vascular, pigmentation, scars, medical applications are renal or liver impairment/failure, hypersensitivity to (pp. 127Y135). Philadelphia, PA: Elsevier Saunders. the drug, and malignant hyperthermia (Medical Develop- Srinivas, C. R., & Kumaresan, M. (2011). Lasers for vascular lesions: Standard guidelines of care. Indian Journal of Dermatology, Venereology ments International, 2012). and Leprology, 77,349Y368. Tanzi, E. L., Lupton, J. R., & Alster, T. S. (2003). Lasers in dermatology: Four Conclusions decades of progress. Journal of the American Academy of Dermatology, 49(1), 1Y19. Successful treatment of vascular lesions requires a firm Wall, T. L. (2007). Current concepts: Laser treatment of adult vascular lesions. grasp of the technical concepts coupled with attentive clin- Seminars in Plastic Surgery, 21(3), 147Y158.

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