ilanit samuels, pa-c baumann cosmetic and research...

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 DisclosuresCosmetic 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- 595nmWavelength 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:yitriumaluminium 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 LasersCan 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 microthermaltreatment 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

• 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.

Laser Side Effects and Complications

Prevention PRE and POST cooling essential!!!!!

Plume IssuesThermal 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!!!!