PROCEDURES IN COSMETIC DERMATOLOGY Series editor Jeffrey S Dover Associate editor Murad Alam PROCEDURES IN COSMETIC DERMATOLOGY L ers and Lights Edited by George J. Hruza MD, MBA Clinical Professor, Dermatology, Saint Louis University, Saint Louis; Medical Director, Laser & Dermatologic Surgery Center, Chesterfield, MO, USA Mathew M. Avram MD, JD Assistant Professor of Dermatology, Harvard Medical School; Affiliate Faculty, Wellman Centerfor Photomedicine; Director, Massachusetts General Hospital Dermatology Laser & Cosmetic Center, Boston, MA, USA Series Editor Jeffrey S. Dover MD, FRCPC, FRCP Associate Professor of Clinical Dermatology, Yale University School of Medicine, New Haven, CT; Adjunct Professor of Medicine (Dermatology), Dartmouth Medical School, Hanover, NH; Adjunct Associate Professor of Dermatology, Brown Medical School, Providence, Rl; Director, SkinCare Physicians, Chestnut Hill, MA, USA Associate Editor Murad Alam MD Professor of Dermatology, Otolaryngology, and Surgery; Chief, Section of Cutaneous and Aesthetic Surgery, Northwestern University, Chicago, IL, USA l-or addit:onal online content visit expertccnsult.com London New York Oxford St Louis Sydney Toronto 2013 CONTENTS Series Preface to the Third edition vii 6 Non-ablative Fractional laser Series Preface (First edition) ix Rejuvenation 59 Preface to the Third edition xi (E Chung-Yin Stanley Chan, Andrei Metelitsa, Jeffrey S. Dover Contri butors xiii Dedication XV 7 laser Resurfacing 72 1 Understanding lasers, lights, and lE Jason N. Pozner, Barry E. DiBernardo, Tissue Interactions Lawrence S. Bass Fernanda H. Sakamoto, H. Ray Jalian, 8 Non-Surgical Body Contouring 86 R. Rox Anderson lE Andrew A. Nelson, Mathew M. Avram 2 laser Treatment of Vascular lesions 10 9 Non-surgical Skin Tightening 97 lE Iris Kedar Rubin, Kristen M. Kelly lE Melissa A. Bogle, Michael S. Kaminer 3 laser Treatment of Pigmented lesions and Tattoos 20 10 laser Treatment of Ethnic Skin 114 ~ Kavita Mariwalla, George J. Hruza (E Stephanie G. Y. Ho, Henry H.L. Chan 4 laser Hair Removal 33 11 Complications and legal Considerations of laser and light Treatments 130 Omar A. lbrahimi, Suzanne L. Kilmer lE David J. Goldberg, Jeremy Man 5 Non-ablative laser and light Skin Rejuvenation 47 Index 137 lE Travis W. Blalock, E. Victor Ross Laser treatment of pigmented 3 lesions and tattoos Kavita Mariwalla, George J. Hruza Summary and Key Features • Topical anesthesia is helpful when treating dermal pigmented lesions and tattoos • Just as placement of tattoos has gained popularity, • Factors to consider prior to estimating the number so has the number of people interested in their of treatment sessions a patient will need for tattoo removal removal include: Fitzpatrick skin phototype, location, • Black and blue tattoos are the easiest to fade with color, amount of ink used in the tattoo, scarring or the most predictable results, whereas multicolored tissue change, and ink layering tattoos are the most difficult • As with any procedure, patient selection and • Of the various benign pigmented lesions that can preparation are important to success and be treated with laser, the easiest to treat are photographs of the lesions should be taken prior to lentigines while the most difficult are the nevi of each treatment session Ota, Ito, and Hori • Side effects of laser treatment for pigmented lesions • Pigment-specific lasers such as the quality- include textural change, scarring, pruritus, hypo- or switched (QS) ruby (694 nm), QS alexandrite hyperpigmentation, and immediate pigment change (755 nm), and QS Nd : YAG (532 nm and 1064 nm) • Tattoos with white or red ink carry an increased risk continue to be the workhorse systems for both of paradoxical darkening after laser treatment, which tattoo and pigmented lesion removal is why test spots should be carried out prior to the • QS lasers remove tattoo pigment through first treatment session photoacoustic injury, breaking up the ink particles • Caution should be exercised prior to treatment of a and making them more available for macrophage tattoo with an allergic reaction as the dispersed ink phagocytosis and removal particles can elicit a systemic response • Fractional photothermolysis has provided • For pigmented lesions such as melasma and expanded options for pigmented lesion removal in postinflammatory hyperpigmentation, pre- and the last decade, though generally more treatment postoperative treatment should include hydroquinone sessions are required and the cost is higher and topical retinoids • In general, patients with Fitzpatrick skin phototypes • Postoperative care includes gentle cleansing and a I–III have a better response than those with skin bland emollient while the skin heals phototypes IV–VI as the lasers used for pigment removal can also damage epidermal pigment looking to rid themselves of tattoo ink but also seeking Introduction removal of benign pigmented lesions. Tattooing has become increasingly popular in recent times, In this chapter, we will discuss the use of laser for with an estimated 7–20 million people in the USA with removing tattoos and ameliorating the appearance of at least one. In a 2008 online survey conducted by Harris benign pigmented lesions. Although the target for both is Interactive, an estimated 14% of all adults in the USA pigment, the management of lightening and removal for have a tattoo, which corroborates with phone survey each condition is distinct. results from 2004 in which Laumann & Derick found tattoo prevalence in 26% of males and 22% of females. Pigment removal principles Interestingly, 17% of those with tattoos considered removal. With advances in laser- and light-based technol- Quality-switched (‘QS’) lasers have traditionally been the ogy, as well as their availability, many patients are not only workhorse laser systems for the removal of pigmentation Laser treatment of pigmented lesions and tattoos 3 and tattoos. The laser treatment of pigmented lesions is based on the concept of selective photothermolysis; in essence the chosen laser must emit a wavelength that is specific and well absorbed by the intended target. In the case of tattoos, the chromophore is exogenously placed ink found either within macrophages or extracellularly throughout the dermis. In the case of benign pigmented lesions, the intended chromophore is melanin found within melanocytes, keratinocytes or dermal macrophages. Destruction of this pigment is thought to occur mainly through photoacoustic injury. Because the target particles are small, it is important to use pulses of energy that are extremely short to minimize collateral thermal injury to the normal surrounding tissue. For this reason, QS lasers, with energy pulses in the nanosecond range, enable energy to be deposited very quickly. The intense heat transients cause some particles to shatter and kill the cells in which Figure 3.1 Amateur tattoo placed on the hand in a person with the pigment resides. The rupture of pigment-containing Fitzpatrick skin phototype IV. cells eventually triggers phagocytosis and the packaging of pigment fragments for lymphatic drainage and scavenging by dermal macrophages. For epidermal pigment, the pigment-containing cells are killed with the laser pulses significant increase in carcinogenic markers after laser resulting in epidermal necrosis and subsequent sloughing stimulation of melanocytes. and replacement with normal epidermis. QS lasers used for pigmented lesions include the QS ruby (694 nm), the QS alexandrite (755 nm) and the QS Patient selection in general Nd : YAG (532 and 1064 nm) though it is also possible to At initial consultation for removal of a pigmented lesion, use the long-pulsed ruby, alexandrite and diode lasers, or it is important to take a thorough medical history includ- intense pulsed light (see Ch. 5). Within the last decade, ing a history of allergy to anesthetics (both topical and fractional photothermolysis (‘FP’) has gained popularity injectable), current medical conditions, and medications. for its ability to treat pigmented conditions such as If a patient is currently taking isotretinoin, laser treatment melasma, solar lentigines, nevus of Ota, and postinflam- should be delayed until medication completion as, theo- matory hyperpigmentation (see Ch. 6). retically, there is a potential for increased scarring and delayed healing. In addition, it is important to note if the patient was ever treated with systemic gold therapy (e.g. Lesion selection rheumatoid arthritis therapy) as this is an absolute contra- Just as important as patient selection is evaluation of the indication to QS laser treatment since darkening of gold- lesion itself. Tattoos can be divided into amateur, profes- containing skin is immediate and irreversible. Prophylaxis sional, cosmetic, medical, and traumatic categories. In is appropriate in patients with a history of herpes simplex amateur tattoos, a steel needle is used to deposit ink, virus if treating near the trigger point. A history of keloidal which may be at various depths of the skin, whereas in scarring and a tendency toward postinflammatory hypo- or professional tattoos, a hollow needle is used to inject ink hyperpigmentation should also be documented. into the dermal layer of skin. Amateur tattoos typically contain pigment of unknown sources such as ash, coal, or India ink (Fig. 3.1). On the other hand, professional tattoo Patient selection for tattoo removal artists often combine ink pigments to achieve novel colors Though tattoos are increasingly popular, they often and