Lasers in Surgery and Medicine 34:189–192 (2004)

Laser Treatment for Neovascular Formation

1 2 Boris Raskin, MD * and Reis R. Fany, MD 1Angiology, Asst. Professor PUCamp, Medicine-Campinas, Brasil 2Raskin Clinic, Angiology-Campinas, Brasil

Background and Objectives: Neovascular formation or quently found after safeness striping, post local venectomy, matting [Davis and Duffy, J Dermatol Surg Oncol 1990; post-phlebitis, and post chemical sclerotherapy. Neovas- 16:327; Folkman and Klagsbrun, Science 1987;235:442; cular formation is difficult to treat because they are very Weiss et al., Lasers Surg Med 1996;8:40–41] is a complex small vessels, less than 0.3 mm and do not respond to problems for doctors to treat. It was done by two different chemical sclerotherapy. When they appear after chemical kinds of lasers, 532 nm [Silver and Livshots, Cosmetic sclerotherapy they can partially vanish after a few months Dermatol 1996;9:61; Adrian, Dermatol Surg 1998; 24:19] or get worse and untreatable with an aesthetically bad and 1,064 nm [Weiss and Weiss, Dermatol Surg 1999; appearance. If treated with chemical agents (polidocanol 12:399–402] Nd:Yag laser. This study was carried out to ethanolamine, hypertonic glucose 75%, sotradecol) most of discover which had better results on the treatment of this the time it could become aesthetically worse. That is one of pathology. the reasons why we prefer to treat large areas of vessels Study Design/Materials and Methods: Thirty-six with lasers of different penetrations and sub-therapeutic patients underwent a monthly treatment, two sessions for [5,10,11] chemical sclerosis. The 1,064 nm laser 3 mm spot neovascular formation by the 532 nm diode laser and the size has better efficacy at 160 J/cm2 on capillaries of larger 1,064 nm [Weiss and Weiss, Dermatol Surg 1999;12:399– diameter less than 0.3 mm or when we find a small capillary 402] Nd:Yag laser. A comparative study was done by digital ‘‘blow up.’’ When we cannot see the capillaries clearly, those photography pre and post laser, 1 month after the second have a cloudy reddish color, I try the 1,064 nm laser at 50 or treatment by the two methods of evaluation, clinical 60 J/cm2. percent clearance and by mathematically counting the number of vessels. MATERIALS AND METHODS Results: There was a significant reduction of the number of Thirty-six consenting adult female volunteers, average capillaries in the affected areas treated by both lasers, age of 32 years, were engaged in this study. Only those with mainly in the 1,064 Nd:Yag group. the Fitzpatrick skin type I–IV were included. Exclusions: Conclusions: The association of 3 and 10 mm spot size of patients recently suntanned (less than 1 month), preg- the 1,064 nm laser group had better results compared with nancy, chronical dermatosis, allergy to lidocaine, those the 532 nm laser for matting treatment. Lasers Surg. Med. under treatment of anti-coagulant drugs, and previous 34:189–192, 2004. ß 2004 Wiley-Liss, Inc. sclerotherapy. Two lasers were used in this study. The first one was treated by a long pulsed laser, Nd:Yag emitting Key words: matting; teleangietatic flare; telangiectasia; 1,064 nm [14] pulses varying from 1 to 20 milliseconds, laser depending on the vessel diameter. Two spot sizes were used. The 3 mm spot size, safe fluences varying from 130 to 160 J/cm2 and the 10 mm spot size, fluences varying from INTRODUCTION 45 to 60 J/cm2, and pulse duration of 15–25 milliseconds. Very few studies have been done on the treatment of Average of 300 pulses in each session. The second laser was neovascular formation or matting [2,4,9] of the lower legs the 532 nm [7] diode laser spot size 1 mm and fluences (sclerotherapy, venectomy of the draining vein, fulgura- varying from 20 to 32 J/cm2, 3 W, 4 Hz. Fluences were tion, and lasers [15,19]). Neovascular formation occurs in chosen after initial test spots with increasing fluences until about 30% of the patients submitted to chemical sclero- the signs of occlusion or vessel spasm were noted (dis- therapy which is still believed to be the gold standard appearance or blurring of the capillaries, capillary velocity treatment of telangiectasia. The purpose of this study was to evaluate the effect of the 532 nm [1,3] diode and the 1,064 nm [6,8,14] Nd:YAG laser for the treatment of this pathology. All were female *Correspondence to: Boris Raskin, MD, 121, Ca˚ndido Gomide patients, Fitzpatrick I–IV and were selected from the St., 13.070-200-Campinas, Sa˜o Paulo, Brasil. vascular ambulatory office. The etiology of neovascular is E-mail: [email protected] unknown and some authors believe that they result from Accepted 4 September 2003 Published online in Wiley InterScience the opening of the micro arterio–venous fistulae occurring (www.interscience.wiley.com). after the occlusion of normal capillaries. They are fre- DOI 10.1002/lsm.10228

ß 2004 Wiley-Liss, Inc. 190 RASKIN AND FANY slowing down or intra-venous coagulation). The average TABLE 1. Evaluation Based on Clinical Grounds number of pulses were 2,000. Both the lasers needed two to Grade Improvement Percent clearance three passes in most number of the cases to close the vessels. Pre and post cooling [12,13] of the skin was done. A No improvement 75–100 Treatment was done on the internal or external part of B Improvement of 50–75 the thigh and ankle. Two areas were treated on each C Improvement of 25–50 patient, one with the 532 nm laser and the other with the D Improvement of 0–25 1,064 nm laser (Fig. 1). Digital photographs were taken of

Fig. 1. Before and after second treatment with laser 532 and 1,064 nm. NEOVASCULAR FORMATION 191

TABLE 2. Percent Clearance Pre and Post Digital TABLE 3. Mathematically Counting Evaluated Pre Photography and Post Laser by Digital Photography

532 nm 1,064 nm 532 nm 1,064 nm

Grade No. of patients (%) No. of patients (%) Grade No. of patients (%) No. of patients (%) A 4 (22) 4 (22) A 3 (17) 4 (22) B 3 (17) 6 (33) B 3 (17) 5 (28) C 4 (22) 3 (17) C 3 (17) 3 (17) D 7 (39) 5 (28) D 9 (49) 6 (33) Total 18 (100) 18 (100) Total 18 (100) 18 (100)

Fig. 2. Mathematical method for vessel counting. We compare the difference of vessels by counting equidistant square. For instance count F 3 pre laser five vessels and counting F 3 post laser two vessels. 192 RASKIN AND FANY all of the patients before using the lasers. The second REFERENCES treatment was repeated 30 days after and the fluences were 1. Silver BE, Livshots YL. Preliminary experience with the necessarily adapted, using the same laser. The last digital KTP/532 nm in the treatment of facial telangiectasia. picture was taken 30 days after the second treatment. Two Cosmetic Dermatol 1996;9:61. 2. Davis LT, Duffy DM. Determination of incidence and risk methods of evaluations were done by comparative digital factors for post sclerotherapy telangietatic matting of the photographs (Nikon 5.2 mega pixels) of high resolution, lower extremity: A retrospective analysis. J Dermatol Surg macro lenses, white balance preset, blue light illumination Oncol 1990;16:327. 3. Adrian RM. Treatment of leg telangietasias using a long- at the same distance pre and post laser. pulse frequency-doubled neodymium: YAG laser at 532 nm. The first one was carried out by clinical evaluation of two Dermatol Surg 1998;24:19. members of the staff based on criteria of percent clearance 4. Folkman J, Klagsbrun M. Angiogenic factors. Science 1987; 235:442. of the vessels. They evaluated the results from pre and post 5. Goldman MP, Fitzpatrick RE. Pulsed dye laser treatment laser based on clinical improvement according to Table 1. of teleangiectasia with and without sub-therapeutic scler- The second method of evaluation was done by a mathema- otherapy: Clinical and histologic examination in the rabbit tically counting of the vessels. Pre and post laser digital ear vein model. J Am Acad Dermatol 1990;23:23. 6. Goldman MP, Benett RG. Treament of teleagiectasias: photographs were put side by side, equidistantly, always A review. J Am Acad Dermatol 1987;17:167–182. seeking for a peculiar mark on the skin or typical anatomy 7. Kienle A, Hibst R. Optimal parameters for laser treat- of vessels to compare the same area and the same spot of ment of leg teleangiectasia. Lasers Surg Med 1997;20:346– 353. the treated area. The Corel Draw 10 computer program 8. McDaniel DH, Apfelberg DB. Options for laser selection in was used. Then the icon grade from the program was laid the treatment of cutaneous vascular and pigmented disorders uniformly over both pictures. This was to fill out all the J Dermatol Surg Oncol 1993;19:312–319. pictures uniformly with equal 0.4-inch squares. Through 9. Weiss RA, Weiss MA, Goldman MP. Photodermal sclerosis of resistant teleangiectatic leg and facial vein using Photoderm this new method we can obtain comparative areas of capil- VL. Lasers Surg Med 1996;8:40–41. laries that can be counted mathematically within each 10. Goldman MP, Martin DE, Fitzpatrick RE. Pulsed dye square and an entire column counting vessel by vessel pre laser treatment of teleangiectasias with and without sub- therapeutic scleroterapy. J Am Acad Dermatol 1990;23:30. and post laser in equidistant areas. 11. Varma S, Lanigan SW. Laser therapy of teleangiectatic leg veins: Clinical evaluation of the 810 nm diode laser. Clin Exp Dermatol 2000;25:419–421. RESULTS 12. Goldman MP. Sclerosing agents in the treatment of tele- The classification of improvement (percent) of the treat- angectasia: Comparison of the clinical and histologic effects of intravascular polidocanol, sodium tetradecyl suffate, ment results were: analyzing Table 2 we can assume that hipertonia saline in the dorsal rabbit ear vein model. ARCH group A, B, and C from the 1,064 nm group had better Dematol 123:1196–1197. results (72%) than that of the 532 nm group (61%). 13. Hohenleutner U, Walther T. Leg teleangiectsia treatment with a 1.5 ms pulsed dye laser, ice cub cooling of the skin, a nd Analyzing Table 3 by mathematically counting the vessels 595 versus 600 nm: Preliminary results. Lasers Surg Med picture 3 we had 51% improvement on the 532 nm laser 1998;23:72–78. group and 67% improvement on the 1,064 nm laser group 14. Weiss RA, Weiss MA. Early clinical results with a multiple (Fig. 2). Both methods show that there is a significant syncronized pulsed 1,064 nm laser. Dermatol Surg 1999;12: 399–402. improvement of the treatment of matting with these two 15. Bernstein EF, Kornbluth S. Treament of spider veins using lasers. 10 ms neodimiumYag laser. Dermatol Surgeryn 1999; 25: 316–320. 16. Adrian RM. Treatment of leg teleangiectasia using a long DISCUSSION pulse frequency doubled Nd:Yag laser at 532 nm. Dermatol Surgery 1998;24:19–23. The 1,064 nm laser group had slightly better results 17. Goldman MP, Fitzpatrick RE. Pulsed dye laser treatment of (13 out of 18 patients) in comparison with the 532 nm group teleangiectasia; with and without simultaneous sclerother- apy. Dermatol Surg Onco 1990;16:338. (11 out of 18 patients). We may assume that the better 18. West TB, Kovak SJ. Laser treatment of facial and results were because of the superficial and deeper penetra- leg teleangiectasia. In: Alster TS, Apfelberg DB, editors. tion of the 10 mm spot size, which have their phototermo- Wiley-Liss, Inc; 1999. pp 255–277. lisis effect acting diffusely on capillaries of the skin thus 19. Goldman MP, Sadick NS, Weiss RA. Cutaneous necrosis, teleangiectatic matting, hyperpigmentation following scler- rendering better results. We did not find one single case of otherapy.Ethiology,prevention and treatment. Dermatol Surg matting formation in our study. 1995;21:19–29.