Laser In Plastic Surgery

Dr.Aabdelhamid Abdelsalam

Introduction:

• Plastic surgeons recognized the potential benefits of treating vascular lesions with laser in the 1980s.

• It was not until the widespread popularity of laser skin resurfacing in the following decade that most plastic surgeons jumped in laser use.

• Taking advantage of the public fascination with high-technology, laser therapy has been partially misrepresented as the state-of-the-art treatment of a variety of conditions.

• Often descried as painless and exaggerated as producing prefect results, lasers have been misused as a marketing tool to lure patients away from conventional low-tech techniques that can often produce equivalent results at significantly lower cost.

• On the other hand there are some conditions such as port-wine stains that are best treated by laser and the standard of care demands familiarity with this treatment modality.

• The modern plastic surgeon is therefore faced with the dilemma of trying to sort out which lasers are best for which conditions and which manufacturer's claims are credible.

Laser Physics:

• Fortunately in the 21st century most lasers are used for therapeutic purposes.

• Although the vast array of available lasers can be confusing , laser physics are straightforward.

• Light energy can be descried as s series of photons or as a wave phenomenon.

• The color of light is determined by the wave length which is the distance between the two successive waves

• The human can see only a narrow range of the electromagnetic spectrum (the visible light), and many lasers produce invisible lights in the infrared range.

• Molecule or atom in it’s resting state is composed of a nucleus and circulating electrons. If energy is added to the system, the electrons become excited and circulate at a higher orbit.

• Eventually an excited electron will fall back to it’s resting orbit releasing a specific packet of energy- a photon, and the photon has a wave length specific to that molecule.

• As these photons hit other excited electrons more photons are released and the light energy increases.

• A laser tube has a mirror at each end contains a solid, liquid or gas medium within it whose electrons are in a resting state. As energy is added to the system the majority of the electrons become excited and begin to release photons.

• Only those photons that hit the mirror directly are reflected back into the lasing media creating more and more photons that travel back and forth between the mirrors parallel to the tube and the intensity of the light increases.

• This phenomenon has been descried as Light Amplification by the Stimulated Emission of Radiation ( LASER )

Types of laser:

Laser Tissue interaction:

• When the laser strikes on object, a variety of desirable and undesirable effect may result as the light is reflected, scattered, transmitted and absorbed.

• Glass and clear liquids will transmit some types of laser light, allowing photocoagulation through glass slides, the vitreous of the eye, and water.

• Some lasers will also pass through the epidermis allowing energy to reach dermal vessels and pigments without disrupting the epidermal layer.

• The depth of penetration depends upon the laser type.

• It is the absorbed light that causes the desirable and undesirable biologic effect.

• Except for Excimer lasers that break chemical bonds, most laser energy is converted into thermal energy.

• Depending upon the rate of tissue heating, surgical effects include welding, coagulation, protein denaturation, desiccation and vaporization.

• Some lasers will indiscriminately target living tissue, while other lasers will semi-selectively target a specific chromophore such as oxyhemoglobin, melanin, and tattoo pigmentation

• Selective photothermolysis describes the ability of laser to target blood vessels or pigment without harming the surrounding dermis or epidermis.

• It is generally safer to deliver cutaneous laser light in pulses rather than as a continuous beam, as the interval between pulses allows the tissue to cool before the heat is transferred to the surrounding dermis.

• Pulsed lasers respect the thermal relaxation time of dermal vessels (the time to dissipate the heat absorbed during a laser pulse)

Ablative laser:

• Lasers that nonspecifically destroy the tissue can be used to remove skin lesions or remove layers of the skin, usually with minimal blood loss because the dermal vessels are coagulated as the tissue vaporized.

• CO2 laser light is absorbed by intracellular water which vaporizes the tissue as the water turns to steam.

Vascular lesion laser:

• The fact that oxyhemoglobin absorbs green and yellow light has spawned a variety of lasers appropriate for treating dermal vessels.

• Yellow light has become the preferred color with the yellow dye argon laser because the oxyhemoglobin absorption peak at 577 nm.

• The high energy/shot duration pulse causes vascular disruption as the blood rapidly heats up and expands.

• The diode laser can also be used(800nm), as the light is absorbed by oxyhemoglobin and melanin.

Pigmented lesion laser:

• Pigmented lesion lasers target melanin.

• Benign pigmented lesions such as lentigines,

Or café au lait spots

Or melasma

and nevus of ota

All these lesions may improve with laser treatment.

• Congenital nevai will also lighten with laser but this is controversial.

• Laser is unlikely to increase the risk of malignant transformation, but may delay the diagnosis of a changing nevus by masking the colour change associated with melanoma.

Photodynamic therapy:

• The use of light-activated drugs to treat acne and other skin conditions currently is best represented by topical 5-aminolevulinic acid, (Levulan).

• .

• The compound is metabolized by sebaceous gland in to porphyrins.

• The acne bacteria itself also produces porphyrin, and the use of blue, green or red light stimulates the production of oxygen free radicals that destroy the bacteria and suppress the sebaceous gland activity

• Photodynamic therapy has also been used for actinic keratosis

• And for photorejuvenation

Special laser treatment

Vascular lesions:

•Hemangiomas:• Hemangiomas are the most common benign tumors of infancy.

• 60% occur at head and neck region

• 70% of hemangiomas regress satisfactorily but 30% of patients will have cosmetically significant deformity.

• Laser is a potentially useful option in several settings.

• The pulsed yellow dye laser may be very useful for very early hemangiomas, ulcerated hemangiomas, and regressed hemangiomasthat still contain vascular pigmentation or visible ectatic vessels

Hemangioma

• Ulcerated hemangioma.

• The laser only penetrates about one millimeter into the skin and therefore, it is most effective for small flat hemangiomas.

• Parents should be advised that multiple laser treatment may be necessary every two to four weeks during the proliferative phase as hemangiomas will often exhibit temporary regression followed by rebound growth.

• Laser therapy can be discontinued when the hemangioma finally enters a permanent state of regression.

• Topical anesthetic cream is desirable to reduce both the patient and parents discomfort.

• Laser treatments are not effective for already bulky or subcutaneous hemangiomas as the light will not penetrate deeply enough to produce noticeable improvement.

• Hemangiomas can be excruciatingly painfull specially when located in the perineal region, there has been some success with pulsed yellow dye laser treatment of these hemangiomas, with some babies showing significant pain relief within 24 to 48 hours probably due to coagulation of sensitive nerve endings within the wound.

Ulcerated perineal hemangioma

• Faster healing has also been reported with laser although the mechanism for this observation is unclear.

• Hemangiomas that have regressed well enough to avoid the need for surgical excision may have residual ectatic vessels that will improve with pulsed dye laser.

• Larger telangiectasias may also respond to simultaneous sclerotherapy and laser treatment.

Capillary vascular malformation:

• Port wine stains tend to darken with age as the dilated dermal capillaries and venules enlarge with time.

• The involved areas may also show textural changes and soft tissue hypertrophy and hyperplastic vascular nodule, pyogenic granulomas may develop with problematic bleeding, again the pulsed dye laser (595 nm) is the treatment of choice.

• Children respond better than teenagers because the immature vessels are more photosensitive and treatment can be offered beginning in infancy.

• Parents should be advised that multiple (at least six to eight) treatments are needed as recommended for cumulative benefit, and that it is extremely rare for any capillary vascular malformation to completely disappear.

• Associated bruising from the laser lasts for about two weeks, the gradual lightening of the vascular pigmentation may last for at least two months.

• Topical anesthetic cream is helpful on the trunk and extremity but children with large facial port-wine stain will be better treated under a general anesthesia.

• Metal eye shields for periorbital laser therapy.

Venous malformations:

• Venous malformations consist of dilated clusters of varicose veins and treatment options include laser photocoagulation, sclerotherapy and surgical debulking.

• Small superficial veins may improve with pulsed dye laser therapy but usually the energy pulse is too brief and the vessels are too large to show significant benefit.

• Longer energy delivery with a continuous wave laser such as KTP or neodymium:YAG laser can result in significant heat absorption and vascular destruction with a significant shrinkage in the size of malformation

• Large venous malformation can be debulked by surgery or by using the fiber of a KTP or neodymium-YAG laser as a contact tip laser scalpel.

• Laser scalpel Laser scalpel

• Endovenous laser photocoagulation with the assistance of ultrasonic guidance is now a therapeutic option for cosmetic varicose veins as well as congenital venous malformations.

• Large venous malformation in the

mouth.

• Congenital venous malformation

Lymphatic malformations:

• Cutaneous vesicles resembling tiny water blisters represents the dermal component of a lymphatic malformation.

• Usually associated with a more extensive subcutaneous component.

• Problematic lymphatic oozing from ulcerated vesicles can be palliatively treated with the CO2 laser which is absorbed by water.

• The heat of the absorbed laser energy may cause a desirable fibrosis at the site of leaking lymphatics.

• This treatment is palliative but can be repeated for unresectablelesions.

Venolymphatic malformations

• Similar to lymphatic malformation but associated with additional venous component.

• The cutaneous component may appear as tiny purple vesicle or crusting scabs (angiokeratoma).

• Commonly associated with Klippel-Trenaunay syndrome.

• Vesicles are more responsive to coagulation by continuous laser than the yellow dye pulsed laser, therefore the KTP is more effective.

• Crusting lesions can be tangentially shaved, then compressed with a glass slide to control bleeding before being lased.

• Venolympahtic malformation of the tongue

treated by laser

Angiokeratoma

Telangiectasia/Rosacea

• Represents undulating dilated dermal vessels that course through the dermal layer.

• They appear discontinuous because they are visible near the surface and then disappear as they dive into the deeper dermis.

• Associated with U/V damage or rosacea, they respond to a variety of vascular lesion lasers.

• They respond to IPL therapy after multiple sessions.

• Telangiectasia before and after laser treatment.

• Rosacea treated by laser

Pyogenic granuloma:

• Shiny nodule of proliferative vascular tissue covered by a fragile epidermal layer.

• they have an annoying propensity to bleed when ulcerated.

• Can occur at any age but more common in children and pregnant women.

• May result from minor trauma.

• Treated by tangential shave excision followed by laser. photocoagulation of the dermal base.

• A glass slide is used to compress the bleeding base and a continuous laser such as KTP will pass through the glass to coagulate the proliferative lesion

• Pyogenic granuloma

•

• Pyogenic granuloma

• before and after removal

Spider angiomas:

• Superficial vascular lesions characterized by central feeding arteriole and radiating braches.

• Compression will blanch the lesion which will then readily reappear at the center and expands outwards after the pressure is released.

• Pulsed yellow dye laser is excellent way to coagulate the entire lesion

• Spider angioma

Cherry angiomas:

• Macular or papular cherry-colored nodules commonly seen in adult skin.

• Range in size from punctate lesions to several millimeters.

• Laser is effective in treatment.

Spider veins/Varicose veins:

• Dilated leg spider veins may respond to a variety of lasers but it is usually most efficient to remove the larger veins first.

• Endovenous laser therapy using a 810 nm diode laser has become a good treatment alternative.

• Pulsed dye or diode laser will penetrate in to the deep dermis to treat residual spider veins as well as the peripheral blush that is often seen after sclerotherapy of large vessels.

• Endovenous laser for V.V

• Diode laser for

residual spider veins

Adenoma sebaceum/tuberous sclerosis:

• Patients with tuberous sclerosis will develop firm pink nodules in a butterfly pattern across their cheek and nose with additional involvement of chin and forehead.

• Neither adenomatous nor sebaceous, these lesions are more accurately are angiofibromas.

• Vaporization with a defocused CO2 laser appears to be much more efficient in improving the skin surface contour.

• The heat from laser coagulates the exposed dermis making the procedure virtually bloodless.

• Tuberous sclerosis

• Tuberous sclerosis

before and after

laser treatment

Pigment lesions:

• Melanin absorbs light in the ultraviolet to near infrared range, therefore a wide variety of lasers have been used to target benign melanocytic lesions.

• Pulse lasers are safer and less likely to cause scarring than continuous lights.

• Shorter wavelengths will treat epidermal pigmentations, while long waves are more effective for dermal pigmentation.

• Epidermal lesions such as freckles, solar letigines, and labial melanocytic macules respond to green pulse dye, while deeper dermal pigmented lesions such as café au lait spots, nevus of ota may respond to longer wavelength such as ruby, alexandrite and diode.

• Freckles

• Solar lentigines

• Labial melanocytic macules

Neurofibromatosis:

• Large plexiform neurofibromas should be excised by standard surgical techniques.

• Patients who request removal of hundreds of small neurofibromas may be well served by CO2 laser destruction.

• The laser in slightly defocused mode can vaporize and coagulate small neurofibromas.

• Treatment is palliative

• Neurofibromatosis

• Neurofibromatosis

before and after

treatment

Syringioms:

• Benign tumors of eccrine origin most commonly found in periorbital area.

• CO2 laser results in rapid obliteration of these lesions usually without recurrence.

• After laser treatment

Cylindroma

• Nodular benign dermal tumor thought to be of primitive sweat gland origin.

• Large disfiguring nodules involving the face and scalp (so-called turban tumor) can be excised or vaporized using CO2 laser to reduce associated blood loss.

• The procedure is only palliative.

• Cylindroma

• After excision.

Actinic keratosis

• Patients with extensive actinic changes of their facial skin and lower lip are candidates for laser skin resurfacing.

• It may be better tolerated than topical 5-fluorouracil therapy or a surgical lower lip vermilion shave.

• CO2 laser can readily vaporize the epidermis and papillary dermis allowing the regeneration of healthier skin.

• The laser will also readily vaporize the vermilion of the lower lip, which heals remarkably well in 2 to 3 weeks.

• Although painful until the vermilion mucosa regenerates, it avoids the need for a mucosal advancement flap

• Actinic keratosis of lower lip

Verruca Vulgaris:

• CO2 laser has been most commonly used to vaporize the involved areas particularly when there are multiple lesions that may make surgical excision difficult.

• To reduce the risk of viral transmission to medical personal, it is advisable to sharply excise the bulk of the lesion and then vaporize the base.

Rhinophyma

• Characterized by hypertrophic sebaceous glands and marked thickening and distortion of the dermis layer of the nose.

• Can be effectively vaporized with the CO2 laser with minimal bleeding.

• The end result is superior to shave excision and skin grafting.

Epidermal nevi:

• While possessing no significant malignant risk, can cause severe disfigurement, as the nevi thicken and create a verrucous surface texture.

• Epidermal

nevi

• Verrucous appearance of the epidermal nevi

• Palliative options include tangential shave excision, dermabresion, and full thickness excision.

• CO2 laser provides a fast and clean way to improve the surface texture with minimal bleeding.

• For relatively thin but raised epidermal nevi the laser appear to vaporize the nevus along a clean and consistent dermal plain.

• Thicker nevi may require multiple laser passes.

• Wounds are covered with topical antibiotic ointment and are left to re-epithelialize

• Epidermal nevi before

and after CO2 laser

treatment

Hair removal:

• The basic principal of laser hair removal is to use light energy to destroy the hair root for permanent hair reduction.

• This requires a deeply penetrating wave length that must reach the dermal papilla without adversely destroying the surrounding dermis.

• Most hair removal lasers target melanin and deeply penetrating lasers such as diode, alexndrite and YAG lasers are most effective on patients with dark and fair skin.

• Hair

• Patients with light or grey hair are poor candidates for these lasers even with efforts to darken the hairs with carbon particles.

• Patients should be advised that multiple treatment sessions are the routine and that hair removal is not necessary permanent.

Tattoo removal:

• Tattoos are created by pigments or foreign matter that is embedded in dermis layer of the skin for decorative purposes or therapeutic as in case of nipple/areola reconstruction.

• Historically the tattoos have been removed by abrasion of the skin until the deepest pigment has been removed, this routinely shineyatrophic scars at best and hypertrophic and keloid scars in unfavorable areas.

Decorative Tattoo for nipple

tattoo reconstruction

• CO2 laser is simply a high-tech method of dermabrasion and offers little advantage over mechanical dermabrasion.

• The advent of Q-switched ruby, YAG and Alexandrite lasers offers the possibility of tattoo removal without clinically apparent scarring.

• Pigment granules are fragmented into smaller particles that are then phagocytized by macrophages.

Thank you