Ilanit Samuels, PA-C Baumann Cosmetic and Research Institute Miami, Florida Financial Disclosures Supervising Physician, Dr Leslie Baumann, CEO- Skin Type Solutions Franchise Systems LLC, who has close relationship with 40+ skin care brands and has preformed research trials for 55+ companies.
Served as trainer and speaker for companies such as Allergan, Merz, and Suneva Medical, as well as a Sub- Investigator on many FDA trails for these, and many other companies. Other Disclosures Cosmetic Lasers at BCRI: • Vbeam Perfecta- Candela • Alex Trivantage- Candela • Limelight/Nd:YAG- Cutera • Gentlelase- Candela What are Lasers? • Light Amplification by Stimulated Emission of Radiation • Lasers emit one wavelength of light • Functions by: photothermolysis photo = light thermo = heat lysis = destroy 4 Basic Laser Parameters • Wavelength • Pulse duration • Spot size • Fluence Lasing Medium
The lasing Medium inside the laser is the substance that produces the laser beam (aka: “energy source”) This could be:
GAS (argon, krypton, CO2) SOLID (ruby crystals, alexandrite crystals, Nd:Yag) LIQUID (dye)
•The lasing medium determines the wavelength of the laser. Wavelengths The distance between 2 peaks Measured in nanometers Shorter wavelength = more superficial penetration Longer wavelength = deeper penetration
Inverse relationship: Shorter wavelength = Higher energy
• Wavelengths must be consistent with target/color Targets include redness (hemoglobin) and brown spots (melanin)
Depth of Penetration Fluence • Measured in Joules (J) • Fluence = energy per area • As fluence increases, so does the destructive force of the energy • Typical fluences vary between 3 and 150 J/cm2. • The relationship between fluence and spot size is important. Spot Size • Large spot size = deeper penetration/ decreased scatter • Small spot size = more energy absorbed in superficial structures/ increased scatter Pulse Duration • How quickly the energy is delivered to the tissues. • Longer the pulse, the more gentle heating of target. • Measured in milliseconds (ms).
*pouring analogy Repetition Rate • The number of pulses emitted per second • Measured in Hz Fitzpatrick Scale • The Fitzpatrick scale (also Fitzpatrick skin typing test; or Fitzpatrick phototyping scale) is a numerical classification schema for human skin color • It was developed in 1975 by Thomas B. Fitzpatrick as a way to estimate the response of different types of skin to ultraviolet (UV) light • Items of consideration include, eye color, hair color, affinity to tan or burn Fitzpatrick Scale
Laser Safety • Proper eye protection must be worn at all times when a laser is armed by both staff and patients, or anyone in the room! • Each laser utilizes different wavelengths, be sure to check your wavelength against your eye protection. • Each set of glasses has a range of wavelengths that is protected which is printed on the lens. Laser Safety Patient Protection Laser Location • The location of the laser is crucial, as they cannot be in rooms with windows. • No mirrors in treatment room. • The door must display a warning sign. • The door must not permit the transmission of wavelengths through the door. • There must be a set of glasses outside of the door. Laser Candidates
• Not all lasers are safe for every skin tone (mechanism of action will determine safety) • Utilization of the Fitzpatrick schema can be helpful in determining candidacy • Patient history and skin aliments must be taken into consideration as well (Melasma, keloid tendency) Vascular Lasers To be effective, vascular lasers/light sources must be wavelength preferentially absorbed by blood vessels Absorption of energy is by oxyhemoglobin and reduced hemoglobin Major absorption peaks around 532, 595 and 1064nm
Types: - Pulse Dye Laser (595nm) - KTP (532nm) Hemoglobin The molecule that holds oxygen in red blood cells. Responsible for the red color of broken or prominent blood vessels on the skin. Dilated vessels full of hemoglobin also lead to diffuse redness seen in rosacea.
Pulsed Dye Laser- 595nm Wavelength of 595nm passes through the dermis and epidermis skin layers and is absorbed by the oxyhemoglobin in the blood vessels rather than by the surrounding tissue.
Used to target: • Redness (diffuse facial/Rosacea) • Scars (before turning white) • Telangiectasias • Bruises • Cherry angiomas • Improve skin texture • Psoriasis • Benign pigmented lesions • Safe for Fitzpatricks 1-3 (595) Other Clinical Applications: Capillary malformations Hemangiomas Venous malformations Facial erythema Venous lakes Poikiloderma of Civatte Others: adenoma sebacea, hypertrophic and erythematous scars, striae distensae, warts PDL Selective Photothermolysis - The process of targeting a specific chromophore. PDL targets oxyhemoglobin. Ideally, the wavelength selected for eradiation of vascular lesions is highly absorbed by the lesion and only minimally absorbed by other competing chromophores in the skin. Pulse Duration - By varying the pulse duration, treatments can be performed purpurically (with bruising) by rupturing the blood vessel, or sub- purpurically by slowly heating the vessel causing coagulation of the blood vessel. Selective Photothermolysis Wavelength can destroy a target containing the adequate chromophore without damaging the surrounding tissue. This is possible if the thermal relaxation time of the target is longer than the duration of the laser pulse. PDL The shorter the pulse duration the more destructive the energy becomes, while with the longer pulse durations, the energy is more gentle thus causing coagulation of the target without harming structures around the treated area. For coagulation and treatments without purpura, the laser pulse duration should be shorter than the thermal relaxation time of the target absorbing the laser radiation in order to confine the thermal damage and spare surrounding tissue. The relaxation time of a target is determined by the target's size (milliseconds or greater for vascular lesions). KTP KTP Lasers (532nm) is a solid-state laser that uses a potassium titanyl phosphate (KTP) crystal as its frequencing doubling device. The KTP crystal is engaged by a beam generated by a neodynium:yitrium aluminium garnet (Nd: YAG) laser.
Typical KTP Laser 100u-2 mm spot size No cooling Low Energy Delivery Systems Rosacea • Laser is not a cure for rosacea • Requires multiple treatments, spaced one month apart • Maintenance therapy may also be needed depending on rosacea severity • Can use a laser to improve cosmetic appearance
Blood Vessels and Angiomas Vessels respond best when on the face, neck, and chest Cherry angiomas are often treatable in 1-2 sessions
Bruises PDL does not completely eradicate bruising Helps bruises clear more quickly (24-72 hours post- procedure) Bruise should still be purple/red for best results
Scars • For healed, scars pink in appearance • White scars are not eligible • May take multiple treatments • Advise patient that treatment area will become dark directly after treatment
Warts Both a general and cosmetic dermatology issue Effective therapy in conjunction with at-home treatments Works by heating up blood vessels of the wart Tattoo Removal Lasers • Used for pigmented lesions and tattoo removal • Painful • Compounded numbing cream to be applied for at least 20 minutes pre-procedure • Targets: black/blue/green/red/brown (tattoo or pigmented lesions). Also used for removal of traumatic tattoos such as graphite or lead, and solar lentigines. • Alexandrite medium; 532nm (reds), 755nm & 1064nm (blacks) • Q-switch technology – ultra-short energy bursts lead to mechanical damage (as opposed to heat) to target – epidermal damage and dye destruction • Multiple wavelengths up to 1064 and multiple spot sizes make it safer for skin of color “Q-Switched” • Quality switched (Q-switched) lasers allow for the generation of nanosecond-range laser pulses • Pulses result in rapid thermal expansion and fragmentation of the target Three standard nanosecond lasers regularly used in removal include: : • ruby (694nm); 20-40 nanosecond pulse duration • Nd:YAG (532,1064nm); 5-40ns • alexandrite (755nm); 50-100ns Success with these pulse durations can take an average of six to ten tattoo txs, but possibly as many as twenty treatments or more to achieve optimal clearance, often with prolonged downtime. PicoSecond Newer technology Picosecond Pulse Duration Generates higher mechanical stress in target without increased heating Rapid delivery results in a shock wave reverberating inward Improved recovery time with better treatment outcomes likely due to less collateral injury of surrounding tissue. Tattoo Removal Lasers Cont. • Use ice throughout procedure and for 10 minutes post- procedure (prior to applying occlusive dressing and aquaphor) • Melanosome rupture can lead to hypopigmentation (side effect) • Aftercare: Aquaphor/Vaseline/Neosporin 2xs per day with occlusive dressing on area. Changed regularly until healed, sun protection daily • Treatments every 6 weeks • Requires multiple treatments
Intense Pulse Light Lasers and IPLs have been used for permanent hair reduction and skin rejuvenation treatments for many years. Although both IPL and Laser are light-based technologies, there are distinct differences between the two. Lasers use a single wavelength of coherent light while IPLs utilize various wavelengths of incoherent light. IPL VS Laser Incoherent Light: (IPL) is emitted by normal means such as a flashlight or a bulb. The photons of the many wave frequencies of light are oscillating in different directions, therefore photons will dissipate before reaching the follicle. Coherent Light: (true laser) is a beam of photons (almost like particles of light waves) that have the same frequency and are all at the same frequency. Only a beam of laser light will not spread and diffuse. In genuine lasers, waves are identical and in phase, which produces a beam of coherent light. To achieve best results for laser hair removal, coherent light is best in order to accurately target the follicle. IPL • IPL= Intense pulsed light • Utilizes a light source (not Genuine laser) • Treats brown spots/uneven pigmentation and reds/ vascular lesions. Can aslo be used for LHR. • Wavelength 520-1100nm • For skin types I, II, III – not safe for skin of color • Sun protection 2 weeks before and after treatment are crucial • Crusting/”coffee ground” dark spots are NORMAL after treatment and should not be picked off – will come off within 2 weeks
IPL Mechanism of Action Targets hemoglobin and melanin simultaneously, best for people with uneven skin tone from sun damage and redness. Also destroys hair follicle (caution!!)
Laser Hair Removal Wavelength: Longer (scatter less) Deeper penetration (Less Epidermal damage) Long Pulsed: Ruby Laser —- (694 nm) Alexandrite Laser —- (755 nm) Pulsed diode Laser —- (800 nm) Long Pulsed Nd: YAG —- (1064 nm) Flashlamp system —- (515 – 1200 nm) Nd:YAG • LHR, safe and effective for all skin types (used on darker skin types more often at BCRI) • Application of numbing cream for at least 20 minutes • Application of ultrasound cooling gel pre procedure • Tip of hand piece is cold to help promote comfort during procedure Nd:YAG Cont. • LHR for all skin types (safe on dark skin) • Will take multiple treatments (6+), spaced 4-6 weeks apart • Good option for those with tendency towards ingrown hairs • Shaving or trimming in between treatments is okay – no tweezing, threading, or waxing • Patients should shave 1-2 days before treatment • The YAG penetrates the deepest of all the lasers (up to 7mm) • Does not focus on melanin • Destroys the hair follicle with heat
Alex-755nm • Safe for Fitzpatrick I-III • Detachable spot size/ lens • Utilizes cryogen to deliver cool air miliseconds before administering the laser source • Used for LHR and Brown spots (shut off cryo) • Laser is attracted to the melanin in hair, travels down hair shaft and is destroyed by heat at the root
Phases of Growth • The best time to kill the hair is when it is still attached to the papilla (vascular part of the hair follicle) For both lasers.
• Anagen- phase is most ideal for LHR • Catagen- may still work for LHR • Talogen- LHR will not work 755nm for Pigmented Lesions • Delivers heat energy to lesion • Absorbed by melanin • Melanin breaks into smaller particles • The body recognizes thee articles as waste to be removed • Excess particles flake off • Pigmentation appears more even when excess melanin has cleared.
Resurfacing Lasers Can be divided into: Ablative Fractional Ablative Non-Ablative Ablative Resurfacing Lasers May provide best results in terms of targeting texture and color (Scars/Pigment). Utilize electromagnetic waves to erode the entire epidermis and upper layer of dermis. CO2 was the original, and for a long time, the primary modality of resurfacing, but rarely used today due to risks and downtime. 2 week + downtime, “Pizza face” CO2 Laser Side Effects Redness Swelling Skin dyschromia Scarring Skin infection Eczematous reactions Fractional Ablative Lasers Delivers hundreds of laser “beamlets” = controlled dermal damage in microthermal treatment areas that then stimulates fibroblast formation to induce neocollagenesis and collagen remodeling. Principle is dermal injury with adjacent areas spared. Addresses Epidermis and Dermis Trade Off Effective yet safer Quicker recovery, minimal downtime Slower results Non Ablative Lasers Good for dyschromia, but minimal scar improvement Series of treatment needed
Types -Mid Infrared -Pulse Dye Lasers -Broadband Lights Systems Laser Side Effects and Complications • Erythema (redness) – should resolve within 1-2 days • Edema (swelling) – should resolve within 1-2 days • Purpura (bruising) – more common with PDL, should clear within a week • Hypo or hyperpigmentation – may be visible after a few days; should resolve after a few months; topical bleaching agents may help with hyper. • Superficial burns or blisters – uncommon, but may occur and can lead to scarring. Early intervention and treatment crucial. Prevention PRE and POST cooling essential!!!!! Plume Issues Thermal destruction of tissue creates smoke byproduct. • Plume can contain toxic gases and vapors such as benzene, hydrogen cyanide and formaldehyde, bioaerosols, dead and live cellular materials including blood fragments and viruses. • A laser protective mask (0.1µ) should be used to decrease inhalation of particulate matter. Plume Issues • General room ventilation is not sufficient to capture contaminants. • Smoke evacuators should have high efficiency in airborne particle reduction. • HEPA filter or equivalent is recommended for trapping particulates. • Generally, the use of smoke evacuators is more effective than room suction systems. Thank You!!!!