Lasers and Energy-Based Treatments for Cosmetic Improvement and Skin Rejuvenation

Indications and contraindications

Indications

• Rhytides
• Acne and burn or contracted scars: best with fractional ablative lasers
• Photo-damaged skin
• Laser-assisted drug delivery: fractional
• Useful adjunct to blepharoplasty, particularly in the lower eyelid

Contraindications

• Patients who used isotretinoin (Accutane) within the past 12 months: controversial
• Collagen vascular disease (scleroderma, active systemic lupus erythematosus)
• Previous lower lid transcutaneous blepharoplasty: could develop cicatricial ectropion (relative contraindication)
• Uncorrected lower eyelid laxity: relative contraindication

Preprocedure evaluation

• Fitzpatrick skin typing
• Glogau scale for photodamage
• Assess whether rhytides are resultant from chronological aging or photoaging
• Topical retinoid use: may have thinner epidermal thickness
• Consider areas of zonal variation from patient to patient
• History of previous peels, hypertropic scars, keloid formation, cold sores
• For full face or perioral treatment, or if known history of perioral HSV, antiviral prophylaxis (Valtrex 1000 mg PO QD) should be started 1 day before the procedure and continued until post-operative day 10. Double the dose if breakthrough HSV dermatitis occurs.

Procedure alternatives

• Conventional dermabrasion
• Chemical peels
• Alpha hydroxy acids: glycolic, lactic
• Beta hydroxy acids: noninflammatory salicylic, lipo hydroxy
• Jessner’s solution: 14% lactic acid, 14% resorcinol, 14% salicylic acid
• Trichloroacetic acid (TCA)
• Tissue augmentation by autologous fat, and fillers such as bovine collagen, and hyaluronic acid
• Botulinum toxin
• Skin care regimen
• Nonablative lasers
• Micro-needling devices either with or without radiofrequency

Instrumentation, anesthesia, and technique

Instrumentation

• Traditional versus fractional — both available in CO2 and Erbium:YAG
• Traditional ablative laser will remove 100% of the epithelium by fluence = 7–10 J/cm²
• Requires more time to epithelialize: approximately 10 days
• Prolonged erythema lasts typically for 4–6 months
• The reservoir for new epithelium needs to arise from appendages (hair pores and hair follicles).
• Preferred for patients with diffuse superficial pigment
• Fractional ablative laser will remove only about 9% to 60% of the total surface area of the skin.
• Micro ablated columns (MACs) are created that extend 200 to 2000 microns into the skin created by fluence up to 700 J/cm2
• Intervening islands of untouched epithelium will help to re-epithelialize the skin faster
• Preferred for darker pigmented skin to avoid postinflammatory hyperpigmentation
• CO2 and Erbium lasers are produced by over a dozen companies. The chromophore for both is water.
• CO2
• Less bleeding because it is absorbed by water as well as other proteins and fat that increase heat and thus coagulation
• Can also be used for incisional blepharoplasty and other surgery
• Erbium YAG: nearly 20 times more specific for water and less absorption by adjacent proteins = increased bleeding

Anesthesia

• Topical anesthesia
• EMLA and Pliaglis are FDA approved.
• Others can be formulated depending on state laws.
• Regional nerve blocks to supraorbital, supratrochlear, infraorbital, nasal, and local with IV sedation may be required for deeper treatments.
• General
• May be helpful for full face treatments using ablative CO2 laser
• When ablative resurfacing is performed in conjunction with surgery
• Requires laser-safe endotracheal tube

Technique

• Turn off supplemental oxygen, wear approved protective eyewear (patient and all staff), place sign on door, use smoke evacuator, surround treatment area with wet towels.
• The angle of the jaw and areas of heavy rhytides should be marked in the upright position prior to anesthetizing the area.
• Sterile skin prep
• Test the laser on a wet tongue depressor.
• Single pulse or repeat pulse may be utilized.
• Power setting depends on the area treated; in the periorbital area, lower power is recommended.
• Shallow rhytides usually require a single pass; moderate to deep rhytides may require a double or triple pass.
• Dynamic rhytids such as crow’s feet due to muscles will not improve; these require neuromodulators.
• After each pass, exfoliation is performed for traditional laser resurfacing, prior to the next pass of laser.
• The angle of the jaw and neck are prone to scarring because there are less appendages (hair follicles and pores) to serve as reservoir for new epithelial cells.
• The laser should be delivered in a “feathered” fashion at the treatment borders to avoid demarcation lines where each pass is smaller than the previous pass.
• The perioral area and festoons can be resurfaced with 2–3 passes.
• Generally avoid more than 1 pass on the inferior tarsal plate to avoid ectropion.
• Review the differing depths of the epithelium and dermis for each facial region to avoid complications.

Preventing and managing treatment complications

Intraoperative

• Bleeding: more common with erbium laser because there is less coagulation of blood vessels
• Thermal burns
• Laser-associated risks: eye injury, fire

Postoperative

• Infection
• Prolonged erythema
• Scar formation: often along angle of jaw and neck
• Lid retraction (if lower lid resurfacing was performed)
• Hyperpigmentation: common, usually resolves with time, topical bleaching agents, or intense pulsed light
• Hypopigmentation: uncommon but often permanent
• Milia/acne

Prevention of complications

• Stop aspirin and blood thinners before surgery for erbium.
• Select the adequate patient and individualize treatment.
• Avoid or use with extreme caution in Fitzpatrick skin types IV-VI.
• In darker skins, to reduce the risk of hyperpigmentation, pretreat for 7–14 days with Retin-A or pigment gel with kojic acid or hydroquinone
• Oral Valtrex 100 mg PO Q day for 10 days
• Turn off the oxygen while resurfacing.
• Do not extend resurfacing down to the reticular dermis; treating physician must know the differing depths of the epithelium, papillary dermis, and reticular dermis for each facial region.

Management of complications

• Hydroquinone cream or pigment gel in cases of post-procedure hyperpigmentation
• Be aware of possible skin infections and select appropriate treatment.
• Early identification of (often subtle) bacteria, fungal and viral infection and rapid initiation of appropriate antimicrobial treatment.

Patient postoperative instructions

• Days 1–6
• Acidity inhibits bacterial growth and removing emollients minimizes chance of infection by decreasing chance of colonization.
• Mix 1 teaspoon distilled white vinegar in 1 cup water.
• Soak for 2 minutes every 2 hours, then replace topical emollients.
• Frequent lubrication with Aquaphor or Vaseline
• Avoid all sun exposure
• Days 7–10
• Decrease soaks to 4 times daily.
• Begin sunblock.
• Day 10: Makeup can be used.
• Long-term
• Avoid excessive sun exposure for up to 6 months.
• Wear sunglasses, zinc-based sunscreen, and hat.

Physician care

• Topical antioxidants and growth factor products have safely been started immediately after surgery.
• If full-face resurfacing is performed, consider use of antiviral medication for 7–10 days.
• Assessment for early infection, which can often be subtle in deepithelialized skin, should be performed at all post laser appointments.
• Post-procedure appointments
• Day 1 or 2 to check for proper amount of topical emollients
• Day 4 or 5 to check for contact dermatitis
• Day 6 or 7 to check for proper epithelialization and switch to sunblock
• Day 10 to check for complete epithelialization and approve use of makeup

Controversies

• Oral antibiotics: Some studies show these disturb normal flora and actually increase infection.
• Topical antibiotics can cause scarring from contact dermatitis when skin is vulnerable and healing.
• Laser-assisted drug delivery with fractional lasers — drugs include
• L-ascorbic acid (vitamin C)
• Botulinum toxins
• Hyaluronic acids
• Poly-L-Lactic Acid
• Melanocytes for vitiligo
• Accutane is generally recommended to stop for 6 months to 1 year prior, but many dermatologists perform various lasers earlier.

References and additional resources

1. AAO, Basic and Clinical Science Course. Section 7: Orbit, Eyelids and Lacrimal System, 2014-15.
2. net Photographic Standards in Dermatologic Surgery
3. Fitzpatrick RE, Goldman MP, Ruiz-Esparza J. Clinical advantage of the CO2 superpulsed mode. J Dermatol Surg Oncol 114; 20:449-456.
4. Goldbaum AM, Woog JJ. The CO2 laser in oculoplastic surgery. Surv Ophthalmol 1997;42:255-267.
5. Ortiz AE, Goldman MP, Fitzpatrick RE. Dermatol Surg. Ablative CO2 lasers for skin tightening traditional versus fractional 2014 Dec; 40 Suppl 12;S147-51.
6. Sullivan SA, Dailey RA. Complications of laser resurfacing and their management. Ophthal Plast Reconstr Surg 2000;16:417-426.
7. Sklar, LR, Burnett CT, Waibel JS, Moy, RI. Laser Assisted Drug Delivery: A Review of An Evolving Technology. Lasers in Surgery and Medicine, April 2014
8. Walia S1, Alster TS. Cutaneous CO2 laser resurfacing infection rate with and without prophylactic antibiotics. Dermatol Surg. 1999 Nov;25(11):857-61.
9. Woodward JA, Fabi SG, Alster T, Colón-Acevedo B. Safety and efficacy of combining microfocused ultrasound with fractional CO2 laser resurfacing for lifting and tightening of the face and neck. Derm Surg. 2014 Dec; 40 suppl 12:S90-3.
10. Woodward JA. Techniques, Pearls and Management of Complications of Fractional Laser Resurfacing and Blepharoplasty by May 29, 2013. http://www.usa.lutronic.com/webinars

Goals, indications, contraindications

Goal

• To resurface the skin with minimal downtime.
• Disadvantages
• Multiple treatments required
• Results still remain minimal compared to ablative lasers.
• Nonfractional
• 1319 nm Sciton Thermascan
• 1320 nm Nd:YAG: Cool Touch or Alma Harmony
• 1450 nm Candela Smoothbeam
• Fractional: with thousands of microthermal zones (MTZs) that are columns of coagulated (not ablated) tissue to provide mild improvement of fine rhytids, pigment, scars, and erythema/telangiectasia
• 1410 nm: Solta/Valeant, Fraxel Re:Fine
• 1440 nm Infrared diode/1927 nm thulium (Clear and Brilliant Solta/Valeant)
• 1565 nm: ResurFX Lumenis
• 1540 nm: Palomar StarLux and Icon
• 1550 Erbium glass or with1927 nm: Fraxel, Solta/Valeant re:store and re:store DUAL
• Technical details
• The fractional devices can place up to 1 million MTZs of 500 to 1500 microns during a full-face treatment.
• Turnover and tissue remodeling of the epidermis and dermis are stimulated.
• Healing is rapid because zones of unheated tissue between the MTZs initiate rapid repair.
• Advantage is minimal downtime in comparison to ablative devices.
• Disadvantage is that it is less efficacious, or requires more treatments for adequate effect.

Indications

• Fine rhytids
• Superficial pigment
• Scars
• Erythema matting
• Telangiectasia
• Melasma in combination with other treatments

Contraindications

• Relative
• Darker Fitzpatrick skin types 4–6
• Larger telangiectasia
• Deep dermal pigmented lesions
• History of HSV
• Use of Accutane in past 6 months to 1 year
• Unrealistic expectations
• Absolute
• Active infection
• Scleroderma

Preprocedure evaluation

• Goal: rhytid improvement versus acne scars versus pigmentation
• Patient history
• Prior HSV
• Prior Accutane use
• Clinical examination
• Fitzpatrick skin type
• Lentigos
• Superficial pigment versus melasma
• Preoperative assessment: standardized photographs

Procedure alternatives

• Rhytids: ablative lasers, chemical peels
• Scars: subcision, facial fillers
• Pigmentation
• Superficial pigment: pigment lasers IPL or green lasers
• Melasma: possibly q-switched or picosecond
• Topical creams such as
• Retinoids
• Antioxidants
• Skin lighteners (tyrosinase inhibitors)
• Topical bleaches (lignin peroxidase)

Technique

• Often can be performed by physician extenders under topical anesthetic such as Pliaglis or EMLA or regional nerve blocks

Controversies

Efficacy

• Patient counseling needed for multiple treatments with slower results
• Enhancement of topical drug delivery such as steroids or antioxidants with fractional devices

Patient management: treatment and follow-up

Postoperative instructions

• Ice compresses for discomfort and erythema
• Usually recovery is rapid in only 1–2 days.

Medications

• Often over-the-counter medications only
• Consider topical emollient for first day.

Complications

• Postinflammatory hyperpigmentation (PIH)
• Urticaria
• Accutane
• But many argue that lasers can be used on patients who have been on Accutane; might be more of an issue in ablative laser, where depth of injury is beyond the epidermis.

References and additional resources

1. ncbi.nlm.nih.gov
2. Ramsdell WM. Fractional Carbon Dioxide Laser Resurfacing. Seminars in Plast Surg. 2012; 26:125-30.
3. Ramsdell WM. Complications of Fractional Carbion Dioxide Laser Resurfacing. Seminars in Plast Surg. 2012; 26:137-40.

Goals, indications, contraindications

Goal

• To create a subepidermal wound to tighten the deep layers of the dermis and beneath the dermis by creating heat stimulating new collagen and elastin and thus tissue tightening
• Immediate partial collagen denaturation followed by long-term wound healing; collagen bonds break at 60 degrees C.
• Might not completely rejuvenate skin; might be best used in conjunction with machine that treats superficial dermis
• Can be in a device combined with infrared (IR) or intense pulsed light (IPL)
• Can be used in any Fitzpatrick skin type because risk of PIH is low
• Younger patients with minimal skin laxity are better candidates.
• Results are subtle, even after multiple treatments; proper patient counseling to manage expectations is necessary; not a replacement for patients who need surgery.

Indications

• Brow ptosis
• Lax jowls
• Submental ptosis
• Lax nonfacial skin
• Acne scars

Contraindications — all relative

• Accutane use less than 6 months
• History of HSV
• Gold therapy
• Connective tissue disease
• Extremely lax platysma from advanced age
• Monopolar devices in patients with cardiac arrhythmias or pacemakers
• Cystic acne
• Open wounds

Devices

Radiofrequency (RF)

• Takes 2–3 treatments
• Bipolar RF from Lumenis Aluma and Syneron/Candela
• Monopolar: low intensity, high volume heating
• Thermage
• Has undergone 3 versions
• Has disposables tips and active cooling T: Solta/Valeant
• Brow lift can be 2–4 mm.
• FDA approved for periorbital reduction
• Comfort pulse technology (CPT) minimizes pain and risk of damage to SQ fat.
• Pelleve/Ellman: monopolar with disposable wand
• Exilis: face and body handpieces
• Titan/Cutera: stamping wand
• Accent
• Viora
• Fractora Firm
• Moveable lightweight wand
• Epidermal temperature control for about 43 degrees C
• Matrix RF
• Micro-needles with bipolar RF: low-volume high-intensity heating
• Lutronic Infini, South Korea, disposable tips with multidepth range with 49 insulated 34-gauge needles coagulation 60–85 degrees C.
• ThermiRF: the first micro-needle RF target temperature 65–70 degrees F
• Thermitight
• Fat in the neck
• Tissue tightening up to 23%
• Thermi-dry: for axillary hyperhidrosis
• E-prime: 10 needles, 4 seconds
• Fractora
• Noninsulated micro-needles: EndyMed PRO, Intensif applicator, EndyMed Medical, Cesarea, Israel: disposable tips multidepth range 1–3.5 mm
• Multiphase RF fractional Eclipse
• CO₂ laser with RF: Eclipse

Microfocused ultrasound

• Ulthera/Merz Aesthetics
• Disposable transducers 4.5 mm 7.5 MHz, 3.0 mm 7.5 MHz, and 1.5 mm 10 MHz depth
• Creates temperatures of up to 60 degrees C that create zones of thermal injury measuring 1–1.5 mm³.
• No eye shield can protect the eyes from ultrasound energy.
• FDA approved for brow lift
• High-cost disposables
• 60%–65% patient satisfaction

Skintyte Sciton

• Uses infrared light technology with sapphire contact cooling to protect the skin surface
• No consumable tip costs

Preprocedure evaluation

Patient history

• Previous treatments/facelift
• Facial asymmetries
• Patients in their 30s–50s are best candidates, unless there is significant laxity that requires platysmaplasty and neck lifting.

Clinical examination

• All Fitzpatrick skin types can be treated for all devices that treat deeply.
• PIH is a consideration if treatment is superficial.

Preoperative assessment

• Moderate jowls and submental ptosis is ideal.
• Severe laxity in older patients will not see much improvement.
• Can be used after facelift to treat small areas of residual laxity

Technique

• Performed as an office procedure by physician or physician extenders with topical or regional anesthesia
• Fillers can be performed after these procedures.

Controversies

• Efficacy, unpredictable results
• Physicians should carefully evaluate photographs from industry.
• More comparison studies are needed.
• Accutane: Many argue that lasers can be done on patients who have been on Accutane.

Patient management: treatment and follow-up

• Minimal downtime, or just 1 day after a micro-needling procedure
• Ecchymosis possible if injected anesthetic was used
• Rare postoperative pain medicines
• Series of treatments are often necessary and can be performed several weeks apart.

Complications

• Nerve paresis, particularly the marginal mandibular
• Dysesthesias
• Depressed scars
• Undesirable loss of subcutaneous fat
• Skin necrosis

References and additional resources

1. Gold MH et al. Noninvasive Skin Tightening Treatment. J Clin Aesthet Dermatol. 2015 Jun;8(6):14-8.
2. Northington M et al. Patient selection for skin-tightening procedures. J Cosmet Dermatol. 2014 Sep;13(3):208-11. doi: 10.1111/jocd.12106.
3. Pritzker RN, Hamilton HK, Dover JS. Comparison of different technologies for noninvasive skin tightening. J Cosmet Dermatol. 2014 Dec;13(4):315-23. doi: 10.1111/jocd.12114.

Goals

• To shut down small blood vessels in the skin without disturbing the surrounding skin architecture
• Critical issue is that the peak absorption of the chromophore oxyhemoglobin is 577 nm.

Wavelengths

• The longer wavelengths are less well absorbed by hemoglobin but penetrate deeper into the skin.
• 532 nm KTP: variable pulse widths (PW) 1–100 ms: red facial telangectasias, rosacea: does not leave purpura
• 585–595 nm pulsed dye: 0.5–40 ms: port wine stains, rosacea, venous lakes: purpura will last 5–10 days
• 755 nm long pulsed alexandrite: 3–100 ms: leg telangiectasia, venous malformations
• 800 nm diode: 5–400 mn: leg venulectasias, blue reticular veins
• 1064 nm long pulsed neodymium YAG: 0.25–500 ms: deep reticular veins
• Intense pulsed or broadband light (IPL or BBL): 400–1200 nm
• Sciton BBL filter for vascular lesions is 560 nm

Common treatable face and neck lesions

Indications

• Telangectasias
• Commonly associated with rosacea or photodamage
• Multiple sessions often required
• Best treated KTP 15–20 ms, IPL and PDL 10–16 ms
• Vigorous cooling needed for surrounding skin structures, especially with the PDL
• Cherry hemangiomas
• Best treated with the above devices
• Generally easily eradicated
• Port-wine stains
• Capillary malformation of mid to upper dermis
• 5%–10% have Sturge Weber
• Most often treated by specialized dermatologists with PDL
• Poikiloderma of Civatte
• Red flushing along angle of jaw, upper neck and chest with epidermal atrophy and actinic dyspigmentation
• IPL, PDL, and KTP
• Venulectasias
• Commonly noted on leg and inferolateral orbital rim
• Often treated with long pulsed 1064 nm
• Cooling is needed to avoid burns to skin.
• On legs surrounding hypopigmentation can occur.
• Infantile capillary hemangiomas
• 50% regress by age 5.
• Laser treatment remains controversial.
• Dry eye
• IPL and BBL have been touted to decrease problematic dry eyes associated with rosacea; this might be due to decreasing inflammatory cytokines extruding from dilated facial vessels.
• There is minimal peer-reviewed research in this area.

Contraindications

• Darker Fitzpatrick skin types can experience loss of pigment especially on the legs.
• Treatment too close to the eyes can cause ocular damage; extreme caution must be used in the periocular area.
• Active infections
• Redness from same-day neuromodulator or filler injections

Preprocedure evaluation

• Patient history: Document above conditions and Fitzpatrick skin types 1–6.
• Clinical examination: Document red or blue color of lesions and their location.

Alternatives

• Electrocautery or radiofrequency to fine vessels
• For rosacea: topical Metrogel or Mirvaso

Techniques

• There is a broad range of machines and companies that supply these devices. Staff and physician must be must be properly trained by the company.
• Protective lenses must be worn by the patient and all staff in the room
• Cooling devices for the skin are required
• Pain control
• Usually the treatment feels like a “hot rubber band snap.”
• Topical anesthetic creams are an option but often not needed.
• Skin cooling with forced cold air, a chill tip associated with the laser or ice are effective.
• Regional nerve blocks without epinephrine are an option for port-wine stains.

Controversies

• Dry eye treatment with IPL and BBL
• Treatment of deep periocular reticular veins with long pulsed 1064 nm

Patient management: treatment and follow-up

Postoperative instructions

• 532 nm often just ice for day of treatment. If a blister develops see below. Makeup can be worn same evening
• Longer pulsed lasers: patience for purpura to resolve

Complications

Blisters

• Usually occur along corners of the nose
• Treat with vinegar soaks QID and Aquaphor or Vaseline.
• If severe could cause scaring

Surrounding hypopigmentation

• Might be permanent.
• Topical prostaglandins might help repigment.

Disease-related complications

• Rosacea and venous insufficiency tend to promote reoccurrence of vascular lesions over time.
• Patients must be made aware of need for future treatments.

Historical perspective

Earlier lasers included 488–638 nm argon, 511- and 578-nm copper bromide, and 568 nm krypton, but these often caused scarring due to improper pulse durations.

References and additional resources

1. Becher GL, Cameron H, Moseley. Treatment of superficial vascular lesion with the KTP 532 nm laser experience of 647 patients. Lasers Med Sci. 2014 Jan;29(1):267-71.
2. Bencini PL, Tourlaki A, De Giorgi V, Galimberti M. Laser use for cutaneous vascular alterations of cosmetic interest. Dermatol Ther 2012 Jul-Aug;25(4):340-51.
3. Zachary CB, Rofagha R. Laser Therapy. Physical treatment modalities section 20. 2261-2281.

Goals, indications, contraindications

Goal

• To minimize melanin containing lesions
• Treatment can involve either removal of only the pigment or ablation of the entire lesion via ablative lasers.
• Melanin has a broad absorption spectrum; many lasers can be used to treat these lesions with appropriate laser selection considering the depth of the lesion.

Indications

• Ephelides and lentigines
• Superficial papillary dermis
• Best treated with IPL, BBL, 532 nm or QS 532 nm
• Ablative CO₂ and erbium nicely remove, yet risk of recurrence
• Benign melanocytic nevi
• Controversial without pathology
• Post‑treatment fibroplasia overlying lesion can mask early signs of malignant change.
• Café au lait macules (CALM)
• Hypermelanosis of basal melanocytes and keratinocytes
• Prone to resistance and recurrence.
• Melasma
• Common yet complex and challenging condition with pigment in epidermal melanocytes and/or dermal melanophages caused by genetics, hormones, and UV light
• Commonly seen on the face in women after pregnancy or oral contraceptive use
• Recurrence is likely.
• PIH after treatment can exacerbate the problem.
• Treatment must be done in conjunction with topical retinoids, steroids, skin lightening creams, and sun block.
• Categorized by pigment depth and location
• Epidermal versus dermal pigment
• Woods lamp detects epidermal pigment.
• Dermal pigment does not respond to topical treatments.
• All the aforementioned lasers have been used; additionally, nonablative fractionated devices may of benefit, possibly by increasing drug delivery of hydroquinone through microthermal zones.
• Nevus of Ota
• Spindled melanocytes in papillary dermis; Nevus of Ota and blue nevi have similar histology.
• High fluences and multiple treatments spaced 6 weeks or more apart required
• Q‑switched lasers required; risk of hypopigmentation is lower with alexandrite.
• Postinflammatory hyperpigmentation (PIH)
• Can be due to melanin, extravasated hemosiderin after sclerotherapy, or drug metabolites.
• Topical treatment as described above.
• Q‑switched lasers expedite resolution.

Contraindications

• Relative: Fitzpatrick skin types 3–6 more prone to PIH and recurrence or unwanted hypopigmentation; a test spot can be used to determine patient individual response to treatment.
• Absolute: Pigmented intradermal melanocytic nevi require biopsy.

Technology

Long-pulsed devices with pigment chromophore

• Used at their shorter pulse widths (PW) available
• IPL or BBL: 500–1200 nm, 5–10 ms, ≤ 30 J/cm², for lentigines and ephlids, nevi
• 532 nm KTP: 8–10 ms for superficial lentigines and ephlids
• 595 nm pulsed dye: 0.45–1.5 ms, 3–5 J/cm², often used for treatment of vascular lesions, use of compression blanches the vascular component and allows melanin to be targeted
• 694 nm ruby: 1–4 ms, 5–30 J/cm², acquired junctional melanocytic nevi, recurrence is common with congenital nevi due to remaining deeper nevus cells
• 755 nm alexandrite: 0.5–300 nm, acquired junctional melanocytic nevi, recurrence is common with congenital nevi due to remaining deeper nevus cells
• 800 nm diode: 5–100 ms, 5–50 J/cm²
• 1064 nm Neodymium:YAG: 1–100 ms, ≤ 300 J/cm², nevi

Q‑switched lasers PW available in nanoseconds

• 532 nm frequency doubled Nd:YAG: 5–10 ms, 0.4–6 J/cm², for superficial lentigines and ephlids
• 694 nm ruby: 20–40 ms, 3–12 J/cm², good for deep pigment, nevus of Ota
• 755 nm alexandrite: 50–100 ms, 1–12 J/cm², deep pigment, nevus of Ota
• 1064 nm Nd:YAG: 5–10 ms, 3–12 J/cm², deeper penetration, useful for dermal pigmented lesions, safer than shorter wavelength lasers in darker skin

Ablative lasers

• Chromophore is water and not melanin
• 10,600 nm carbon dioxide: ablates lesion and surrounding epithelium with moderate coagulation, could risk PIH post‑o
• 2940 nm erbium YAG: ablates with minimal coagulation, slightly less risk of PIH

Preprocedure evaluation

Patient history

• History of skin cancer, autoimmune disease, resistant melasma
• Location of lesions
• Association with pregnancy or oral contraceptives
• Sun exposure/protection habits

Clinical examination

• Best treated lesions are superficial ephelides and lentigines (lentigos).
• The physician needs to be confident in diagnosing
• Pigmented intradermal melanocytic nevi that contain a chaotic pigment pattern at risk for melanoma
• Hyperpigmented actinic keratosis
• Pigmented seborrheic keratosis
• Other potentially malignant lesions
• Patients must return for assessment if the laser treated lesion changes in the future.

Preoperative assessment

• Medical aestheticians should not treat lesions unsupervised by the physician directly.
• Ability of an aesthetician to use IPL and BBL is determined by individual states laws.

Procedure alternatives

• Retinoids
• Both increase penetration of skin-lightening agents and lighten the skin themselves
• Decrease c‑Jun gene
• Increase TGF beta and matrix metalloproteinase
• OTC: Retinol, retinaldehyde
• Rx: tretinoin, tazarotene, adapalene
• Skin lighteners — block production of tyrosinase or block melanin transfer to keratinocyte
• Hydroquinone
• Decapaptide 12 (Lumixyl)
• Kojic acid
• Elagic acid
• Hydroxyphenoxypropionic acid
• Bleach: lignin peroxidase (Elure)
• Fibroblast stabilization: yeast extract
• SPF: zinc, titanium
• Oral polypodium leucotomos extract (Heliocare)
• Multiple chemical peels
• Viable option possibly with less risk of PIH
• See chemical peel article: Salicylic acid (noninflammatory), TCA, glycolic

Techniques

• Protective lenses worn by staff and patient because these devices can cause ocular damage
• Laser measures
• Sign on door
• Consider smoke evacuator.
• Skin might require open-wound healing, necessitating cleansing with vinegar soaks and emollients especially for ablative lasers. See above.

Patient management: treatment and follow‑up

Postoperative instructions

If there is epithelial breakdown, consider vinegar soaks (1 cup water to 1 teaspoon distilled white vinegar) followed by emollient.

Medications

See topical medications in previous section.

Other management considerations

Patients should be aware that pigmented lesions could remain the same, improve, or less likely become more hyperpigmented, therefore diligent postoperative treatments described in the previous section should be followed for up to 6 months.

Controversies

Should aestheticians be unsupervised in treating pigmented lesions when cancer is a risk?

Complications

• Failure to improve
• PIH (nonresolution or possibly increased pigment)
• Inadvertent hypopigmentation
• Scar

Historical perspective

The device treatments have not changed much over the past 20 years to treat pigmented lesions other than the development of the nonablative fractional devices. There has been much research and advancement in the area of topical skin lighteners that can be used in conjunction with device treatments.

Goals, indications, contraindications

Goal

• To shatter tattoo ink via a photoacoustic effect rather than a heating effect

Indication

• Tattoo ink: Black and red are removed more easily than green and purple.

Contraindications

• Relative: Patient expectations are important to manage because the treatment can take up to 1 year and can be expensive over time.
• Absolute: active infection

General concepts

• 532 nm: red, yellow, orange ink
• 755 nm: blue, green
• 1064 nm: black ink
• Destruction of tattoo ink requires very short laser wavelengths:
• Q‑switched (QS) (nanoseconds) or picosecond (PS) lasers
• Femtosecond lasers (under development)

Preprocedure evaluation

• Patient history
• Who placed tattoo? Professional tattoos tend to have more ink than home or prison tattoos and therefore be more difficult to remove.
• Clinical examination
• Fitzpatrick skin type
• Description of the various tattoo colors
• Preoperative assessment
• Preoperative photos
• Pain can be significant so topical EMLA or Pliaglis or local infiltration
• Treatment results can potentially be enhanced with a perfluorodecalin (PFD)‑infused transparent patch or a fractional lens array.

Procedure alternatives

• Dermabrasion
• Surgical excision
• Micro-needle pen

Lasers

Q‑Switched

• Technology more than 15 years old, thus multiple versions
• QS 532 nm frequency doubled Nd:YAG
• QS 755 nm Alexandrite
• QS 1064 nm Nd:YAG

Picosecond

• Create intra‑epidermal laser-induced optical breakdown (LIOB)
• Only 3 on the market thus far
• Cynosure: 755 nm/532 nm; 550–750 ps
• Cutera: 1064 nm/532 nm; 750 ps–2 ms
• Candela/Syneron: 1064 nm/532 nm; 450 ps/375 ps

Controversies

• Pico second lasers are very expensive and were initially thought to be better to shatter the tattoo ink. Although some studies show that this is sometimes the case, but often the Q‑Switched lasers work better.
• These short pulsed lasers are also helpful for Nevus of Ota

Patient management: treatment and follow‑up

• Postoperative instructions: ointment if pinpoint bleeding
• Describe the common patterns of response to treatment and discuss strategies of follow‑up and secondary treatment

Complications

• Hypopigmentation
• Fibrotic scar
• Paroxysmal darkening of lighter colored tattoos
• Urticaria
• Allergy to the new pigment forms created

References and additional resources

• Controversies in Dermatology Meeting Napa Valley, Aug 13–15, 2015