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Pushing the Spectrum Optimizing Treatment of Vascular and Pigmented Lesions

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Pushing the Spectrum Optimizing Treatment of Vascular and Pigmented Lesions Pushing the sPectrum Optimizing treatment Of Vascular and pigmented lesiOns Funding and content assistance provided by Pushing the sPectrum Optimizing treatment Of Vascular and pigmented lesiOns s the aesthetic challenge presented by vascular and Dr. arnDt: For a long time, we have known how to induce some selective pigmented lesions adequately addressed by current laser damage to vascular targets, and for and light-based technologies? Might clinicians benefit from some time, we have settled on 585, 595 Ia review of innovations in their clearance—using optimized nanometers as being selective. As intense IPL technology in particular? Are there condition-specific tools pulse light has evolved over time, it has become clear that it is close to the equal and techniques that can leverage treatment—even foster skin of—or perhaps better than—the sort of rejuvenation? Recently, an expert panel convened to explore classical therapy, which has been the pulsed these multifactorial dermatological conditions, to assess the dye laser. The MaxG™ (Palomar Medical science that may optimize outcomes, and to share how they’ve Technologies, Inc., Burlington, MA) is very exciting because it takes us to another level approached some of their most challenging patient cases. in which we are able to either damage vessels so they slowly go away or destroy mechanism of Action of iPLs on them entirely immediately. Pigmented and Vascular Lesions Dr. ross: I think there are two mechanisms that are Drilling Down on Selective Damage active here. One is the coagulation of the vessel and the Dr. ross: What is the best mechanism of action (MOA) associated thrombus, and the second is the actual collagen for clearance of vascular lesions particularly on the face— shrinkage of the vessel as the wall is heated from the heat and maybe the legs as well—and how does that relate to the conduction from the blood. I think both are operative IPL technologies? (Figure 1). FACULtY Jeffrey s. Dover, mD, emil A. tanghetti, mD FRCPc founder, center for e. Victor ross, mD associate clinical professor dermatology and laser panel mOderatOr of dermatology, section of surgery, sacramento, ca director of the scripps dermatologic surgery and clinic laser and cosmetic Oncology, department of dermatology center in san dermatology, Yale university diego, ca, and assistant school of medicine; adjunct David B. Vasily, mD, Volunteer professor, professor of medicine FAAD ucsd division (dermatology), dartmouth founder and president, lehigh of dermatology medical school; and director, Valley dermatology associates, skincare physicians, chestnut ltd., and aesthetica & Kenneth A. Arndt, mD Hill, ma lengo cosmetic laser surgery center, a adjunct professor of surgery Bethlehem, PA (dermatology), dartmouth Vic A. narurkar, mD, medical school; clinical FAAD robert A. Weiss, mD hotodisc / p professor of dermatology chair, dermatology, california associate professor of emeritus, Harvard medical pacific medical center, and dermatology, Johns Hopkins mages / school; and partner, skincare founder, Bay area laser university school of medicine, i physicians, chestnut Hill, ma and founder, maryland laser, institute, san francisco, ca etty skin and Vein institute, Hunt g Valley, md llustration: i hoto p over: ©2010 palomar medical technologies, inc. c 2 PushingContact the Palomar sPectrum to • learnOptimizing more treatment about of the Vascular MaxG and p handpiece.igmented lesions Contact Palomar to learn more about the MaxG handpiece. figure 1. iPL MOA on Pigmented and Vascular Lesions 1a 1B the maxg’s optimized range of light waves is targeted at melanin pigment (1a) or hemoglobin in the blood vessels (1B). the light is absorbed by either melanin or hemoglobin, resulting in fragmentation of melanin pigment or damage to the vessel wall. the melanin pigment and these tiny vessels are then absorbed by the body, making them less visible. Dr. Dover: I think you described it well. It looks studies looking at hamster blood vessels and showing that like there are three end events that occur after we deliver there was definitely both coagulation and thrombosis, but, light that converts to heat in the vessel wall and within like you said, some of the vessels would reappear within the lumen. Either you can get spasm of the vessel, which minutes even after you saw the clot through a microscope. is often very temporary, and those vessels reopen literally Some “micro-thrombi” would sit there in the vessel and while the patient is still in the room—usually within a then it would move along and then the blood vessel would minute to 10 minutes. Or the red cells “sludge” and become be reperfused. I think that is part of what we are seeing thermally damaged and you stop blood flow—but very with these nasal vessels that are so persistent. Probably the temporarily—and then it restarts over a period of hours to other action, too, is you get the spasm, but then the spasm weeks to even a month or so. relaxes and you come back five minutes later and the vessel Finally, every once in a while, you get what I described is back. So, those are tough vessels. before, thermal damage to the red cells and collapse of the Dr. Dover: The other vessels this happens to are the vessel wall; the vessel wall lining sticks to itself and it stays tiny ones. You see them disappear and they either go into shut and then you get some resorption of that vessel and it spasm or, if you are wearing loupes, you can actually see never recurs. That is the ideal situation, but I don’t know the blood boiling. You see it change color. You can actually what percentage of the vessels do this versus those that see the clot and then, before you know it, the vessel is back, respond with the other two mechanisms. open with blood flowing again. The real question is how do you make those vessel walls Dr. tanghetti: That is why the pulse duration is stick—one to another—to stay closed forever, and I’m not extremely important in how the energy is delivered. If it is sure we know the answer. You wonder if repeat treatments, delivered in little spikes, as you see with a pulsed dye laser a week later, as opposed to four to six weeks later before the (Figure 2), you often have a tendency not to see the whole vessel reopens, might seal the deal. vessel wall [become] coagulated and the adjacent areas Dr. ross: Jennifer Barton has done some beautiful thermally damaged. Pushing the sPectrum • Optimizing treatment of Vascular and pigmented lesions 3 Contact Palomar to learn more about the MaxG handpiece. figure 2. Pulsewidth Structure of a PDL compared to the Maxg 25 ) 6ms 2 20 PDL 15 7.5 J/cm2 10 MaxG 36 J/cm2 5 10ms PeakIntensity (kW/cm 0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 Time (msec) peak powers should be limited to the minimum necessary to avoid temperatures in excess of coagulation temperatures. Otherwise, vaporization or ablation can occur, which are not ideal mechanisms of injury to vascular components. for these reasons, the maxg output power is highly controlled and uniform, free from high peak power spikes. note the PDL pulse actually consists of four 100-microsecond pulses during the 6 ms, each with peak intensity of 18.75 kW/cm2. in contrast, the maxg peak intensity is 3.6 kW/cm2. See Character Styles for number adjustments The longer 532 devices generally have the entire pulse on cannot deliver with a laser device. With lasers, you are for the 10 or 40 milliseconds or whatever you use. You are stuck in a 532, 585, 595, 940 wavelength. But with the IPL not having these little spikes, so it heats differently and you device, you have a broad spectrum of light that can absorb can see this in the vessels—especially with the MaxG at 100 in the whole hemoglobin range—even the red range—which milliseconds on the large nasal vessels. You can actually see a lot of us think is useful for treating blood vessels. a zone of thermal injury around the vessel. Dr. Dover: Actually, Emil, I think that the point you just Dr. ross: Yes, in that case, clearly you are beyond a made is an important one which has been lost on the majority thermal relaxation time with the vessel—or certainly near of treating physicians—including me. We were so set on it. You are getting full trans-vessel coagulation and actually looking for the ideal wavelength say, 577 or 585 or 595, when, damaging the wall directly during the pulse and relying on in fact, the IPL was in front of us for well over a decade. We the heat conduction. That may be optimal for larger vessels, sort of almost ignored it, thinking, “Well, white light is not as [but] smaller vessels, unfortunately, are cooling off during good.” But, in fact, the way you describe it, frankly, it gives us that 100-millisecond pulse, particularly the really tiny more potential hits on that vessel; more absorption peaks and .1-millimeter vessels. One needs a shorter pulse or higher the theoretical possibility of getting an even better result than fluence to damage those vessels. you would with a targeted wavelength at one nanometer. Dr. tanghetti: Right. Even with the shorter pulse, they Dr. ross: Right. One of the myths is that hemoglobin still see the pulse on for the whole 10 milliseconds. It is not has these very sharp peaks. But the peaks are somewhat spiking; you are not having any of these little mini-pulses broad, so having the output spectrum of the IPL mirror the in there, so there is a difference in heating those two ways.
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