for wavelengths between 600 and 1064nm. Ideally, a light source should have a pulse duration that would allow the light energy to build up in the target vessel so that its entire diameter is thermocoagulated. Optimal pulse durations have been calculated for blood vessels of various diameter (Table 14.1). During the process of delivering a sufficient amount of energy to thermocoagulate the target ves- sel, the overlying epidermis and perivascular tissue should be unharmed.This selective preservation of tissue requires some form of epidermal cooling. A number of different laser and IPL systems have been developed toward this end, and are discussed in subse- quent sections. Patients seek treatment for leg veins mostly for cos- metic reasons, and any treatment that is effective should be relatively free of adverse sequelae. 2 Bernstein, 3 for example, evaluated the clinical characteristics of 500 consecutive patients presenting for removal of 158 Clinical procedures in laser skin rejuvenation 532 Nd:YAG Nd:YAG PDL Water Absorption (log scale) 300 500 700 1000 Wavelen g th ( nm ) 2000 Diode Melanin Oxyhemoglobin Fig.14.1 Oxygenated and deoxygenated hemoglobin.Water and melanin absorption curves as a function of wavelength. (Adapted from Boulnois JL.Lasers Med Sci 1986;and reproduced with permission from Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins,4th edn.Goldman MP,Bergan JB,Guex JJ,eds.Elsevier,London,2006.) Table 14.1 Thermal relaxation times of blood vessels Vessel diameter (mm) Relaxation time (s) 0.1 0.01 0.2 0.04 0.4 0.16 0.8 0.6 2.0 4.0 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 158 lower extremity spider veins. Patients ranged in age from 20 to 70 years and had had noticeable spider veins for an average of 14 years; 28% had leg veins less than 0.5mm in diameter and 39% veins less than 1.5mm in diameter. Interestingly, regardless of exactly how sclerotherapy was performed, more than half (56%) of patients developed TM. Recent advances in laser and IPL treatments for treating telangiectatic vessels, if used appropriately, assure minimal (if any) adverse events. An understanding of the appropriate target vessel for each laser and/or IPL is important so that treat- ment is tailored to the appropriate target. As detailed in sclerotherapy textbooks and articles, 4 most telang- iectasias arise from reticular veins.Therefore the single most important concept to keep in mind is that feed- ing reticular veins must be treated completely before treating telangiectasia.This minimizes adverse seque- lae and enhances therapeutic results. Failure to treat ‘feeding’ reticular veins and short follow-up periods after the use of lasers may give inflated estimates of the success of laser treatment. 5 This chapter reviews and evaluates the use of these nonspecific and specific laser and light systems in the treatment of leg venules and telangiectasias (Table 14.2). HISTOLOGY OF LEG TELANGIECTASIA The choice of proper wavelength(s), degree of energy fluence, and pulse duration of light exposure are all related to the type and size of target vessel treated. Deeper vessels necessitate a longer wavelength to allow penetration. Large-diameter vessels necessitate a longer pulse duration to effectively thermocoagulate the entire vessel wall, allowing sufficient time for thermal energy to diffuse evenly throughout the vessel lumen.The correct choice of treatment parameters is aided by an understanding of the histology of the target telangiectasia. Venules in the upper and middle dermis typically maintain a horizontal orientation.The diameter of the postcapillary venule ranges from 12 to 35µm. 6 Collecting venules range from 40 to 60 µm in the upper and middle dermis and enlarge to 100–400 µm in diameter in the deeper tissues. Histological examination of simple telangiectasia demonstrates dilated blood channels in a normal dermal stroma, with a single endothelial cell lining, limited muscu- laris, and adventitial layers. 7,8 Most leg telangiectasias measure from 26 to 225µm in diameter. Electron microscopic examination of ‘sunburst’ varicosities of the leg has demonstrated that these vessels are widened cutaneous veins.They are found 175–382µm below the stratum granulosum.The thickened vessel walls are composed of endothelial cells covered with collagen, elastic, and muscle fibers. Unlike leg telangiectasias, the ectatic vessels of PWS are arranged in a loose fashion throughout the super- ficial and deep dermis. They are more superficial (0.46mm) and much smaller than leg telangiectasias, usually measuring 10–40µm in diameter. This may explain the lack of efficacy reported by many physi- cians who treat leg telangiectasias with the same laser and parameters as they do with PWS. KTP AND FREQUENCY-DOUBLED Nd-YAG (532 nm) LASERS Modulated potassium titanyl phosphate (KTP) lasers have been reported to be effective at removing leg telangiectasia, using pulse durations between 1 and 50ms.The 532nm wavelength is one of the hemo- globin absorption peaks. Although this wavelength does not penetrate deeply into the dermis (about 0.75mm), relatively specific damage (compared with argon laser) can occur in the vascular target by selec- tion of an optimal pulse duration, enlargement of spot size, and addition of epidermal cooling. Effective results have been achieved by tracing ves- sels with a 1mm projected spot.Typically, the laser is moved between adjacent 1mm spots, with vessels traced at 5–10mm/s. Immediately after laser expo- sure, the epidermis is blanched. Lengthening of the pulse duration to match the diameter of the vessel is attempted to optimize treatment. We and others have found the long-pulse 532nm laser (frequency-doubled neodymium:yttrium alu- minum garnet (Nd:YAG)) to be effective in treating leg veins less than 1mm in diameter that are not directly connected to a feeding reticular vein. 9 When used with a 4°C chilled tip, a fluence of 12–15J/cm 2 is Treatment of leg telangiectasia with laser and pulsed light 159 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 159 160 Clinical procedures in laser skin rejuvenation Table 14.2 Lasers and light sources for leg veins Pulse Spot Product Device Wavelength Energy duration diameter Supplier name type a (nm) (J) (ms) (mm) Cooling b American OmniLight Fluorescent 480, 515, 535, Up to 90 Up to 500 External BioCare FPL IPL 550, 580–1200 continuous Adept Medical Ultrawave Nd:YAG 1064 5–500 5–00 2, 4, 6, 8, 10, 12 None Alderm Prolite IPL 550–900 10–50 10×20, 20×25 Asclepion- Pro Yellow CuBr 578 55 300 1.5 None Meditech Candela Vbeam PDL 595 25 0.45–40 5, 7, 10, 12 DCD Cbeam PDL 585 8–16 0.45 5, 7, 10 DCD Gentle YAG Nd:YAG 1064 Up to 600 0.25–300 DCD CoolTouch Varia Nd:YAG 1064 Up to 500 300–500 3–10 DCD Cutera Vantage Nd:YAG 1064 Up to 300 0.1–300 3, 5, 7, 10 Copper contact XEO IPL 600–850 5–20 ?Automatic None Cynosure PhotoGenicaV PDL 585 20 0.45 3, 5, 7, 10 Cold air PhotoGenica PDL 585–595 40 0.5–40 5, 7, 10, 12 Cold air V-Star SmartEpill II Nd:YAG 1064 1–200 Up to 100 2, 5, 7, 10 Cold air Acclaim 7000 Nd:YAG 1064 300 0.4–300 3, 5, 7, 10, 12 Cold air PhotoLight IPL 400–1200 3–30 5–50 46 ×18, 46 ×10 None Cynergie IPL/Nd:YAG 595/1064 20/160 0.5–40/ 7 Cold air 0.3–300 DDD Elipse IPL 400–950 Up to 21 0.2–50 10 ×48 DermaMed Quadra Q4 IPL 510–1200 10–20 60–200 33×15 None USA Fotana Dualis Nd:YAG 1064 Up to 600 5–200 2–10 None Iridex Apex-800 Diode 800 5–60 5–100 7, 9, 11 Cooling handpiece Laserscope Lyra Nd:YAG 1064 5–900 20–100 1–5 Cooling continuously handpiece adjustable Aura KTP 532 1–240 1 – 50 1–5 Cooling continuously handpiece adjustable Gemini KTP 532 Up to 100 1–100 1–5 Cooling continuously handpiece adjustable Nd:YAG 1064 Up to 990 10–100 1–5 Cooling continuously handpiece adjustable (Continued) 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 160 Treatment of leg telangiectasia with laser and pulsed light 161 Table 14.2 (Continued) Pulse Spot Product Device Wavelength Energy duration diameter Supplier name type a (nm) (J) (ms) (mm) Cooling b Lumenis Quantum IPL 515–1200 Cooled sapphire crystal Vasculite Elite IPL 515–1200 3–90 1–75 35 ×8 Nd:YAG 1064 70–150 2–48 6 Cooled sapphire crystal Lumenis One IPL 515–1200 10–40 3–100 15 ×35, 8 ×15 Cooled sapphire crystal Nd:YAG 1064 10–225 2–20 2×4, 6, 9 Cooled sapphire Med-Surge Quantel Viridis Diode 532 Up to 110 15–150 ProliteII IPL 550–900 10–50 10×20, 20 × 25 None OpusMed F1 Diode 800 10–40 15–40 5, 7 None Orion Lasers Harmony Fluorescent IPL 540–950 5–20 10, 12, 15 40×16 None Nd:YAG 1064 35–145 40–60 6 None Nd:YAG 1064 35–450 10 2 None Palomar MediLux IPL 470–1400 Up to 45 10–100 12×12 None EsteLux IPL 470 – 1400 Up to 45 10–100 16×46 None StarLux IPL/Nd:YAG 550–670/870– Up to 700 0.5–500 1400/1064 Quantel Athos Nd:YAG 1064 Up to 80 3.5 4 None Sciton Profile Nd:YAG 1064 4–400 0.1–200 Contact Sapphire Profile BBL IPL 400–1400 Up to 30 Up to 200 30×30, 13×15 Syneron Aurora SR IPL/RF 580–980 10–30/ Up to 200 12 × 25 2–25RF Polaris Diode/RF 900 Up to 50/up to 100RF Galaxy Diode 580–980 Up to Up to 200 140/up to 100RF WaveLight Mydon Nd:YAG 1064 10–450 5–90 Contact or cold air a IPL, intense pulsed light; Nd:YAG, neodymium:yttrium aluminum garnet laser; CuBr, copper bromide (copper vapor) laser; PDL, pulsed dye laser; diode; diode laser; KTP, potassium titanyl phosphate laser; RF,radiofrequency. b DCD,dynamic cooling device. Modified from Goldman MP. Cutaneous and Cosmetic Laser Surgery. Philadelphia: Elsevier,2006. 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 161 delivered as a train of pulses in a 3–4 mm diameter spot size to trace the vessel until spasm or thrombosis occurs. Some overlying epidermal scabbing is noted, and hypopigmentation is not uncommon in dark- skinned patients.Although individual physicians report considerable variation in results, usually more than one treatment is necessary for maximum vessel improvement, with only rare reports of 100% resolu- tion of the leg vein. A comparative study of the 532nm Nd:YAG laser at 20J/cm 2 delivered as a 50 ms pulse through a contact cooling and 5mm diameter spot was made with a 595nm pulsed dye laser (PDL) at 25 J/cm 2 , with a pulse duration of 40ms, cryogen spray cooling, and a 3mm × 10 mm spot. 10 After one treatment with the 532nm Nd:YAG laser, there was 50–75% improve- ment in 2 of 10 patients and more than 75% improve- ment in 3 of 10 patients.There was better improvement in the PDL-treated patients, with 6 of 10 having 50–75% improvement. Another study compared the 532 nm diode laser with a 1mm diameter spot at fluences of 2–32 J/cm 2 with the 1064nm Nd:YAG laser at 1–20ms pulses through a 3mm diameter spot at 130–160J/cm 2 in the treatment of TM vessels less than 0.3 mm in diameter that did not respond to sclerotheraopy. 11 Two to three passes were needed to close the vessels with each laser. Thirty-nine percent of the 532 nm-treated and 55% of the 1064nm-treated vessels had better than 50% lightening. In short, the 532nm, long-pulsed, cutaneous, chilled Nd:YAG laser is effective in treating leg telangiectasia. As summarized previously, efficacy is technique- dependent, with a potential for achieving excellent results. Patients need to be informed of the possibility of prolonged pigmentation at an incidence similar to sclerotherapy, as well as temporary blistering and hypopigmentation that is predominantly caused by epidermal damage in pigmented skin (type III or above, especially when tanned). PULSED DYE LASER, 585 OR 595nm The PDL has been demonstrated to be highly effective in treating cutaneous vascular lesions consisting of very small vessels, including PWS, hemangiomas, and facial telangiectasia.The depth of vascular damage is estimated to be 1.5mm at 585nm, and 15–20µm deeper at 595nm. Consequently, penetration to the typical depth of superficial leg telangiectasia may be achieved. 12 However, telangiectasia over the lower extremities has not responded as well, with less light- ening and more post-treatment hyperpigmentation. This may be due to the larger diameter of leg telang- iectasia as compared with dermal vessels in PWS and larger diameter feeding reticular veins, as described previously. Vessels that should respond optimally to PDL treat- ment are predicted to be red telangiectasias less than 0.2mm in diameter, particularly those vessels arising as a function of TM after sclerotherapy.This is based on the time of thermocoagulation produced by this relatively short-pulse laser system (Table 14.1). In an effort to thermocoagulate larger-diameter blood vessels, the pulse duration of the PDL has been lengthened to 1.5–40ms and the wavelength increased to 595nm.This theoretically permits more thorough heating of larger vessels.These longer pulse durations are created by using two separate lasers, each emitting a 2.4ms pulse. Such LPDLs operate at 595nm, with an adjustable pulse duration from 0.5 to 40 ms deliv- ered through a 5, 7, or 10mm diameter spot size or a 3mm ×10mm or 5 mm ×8mm elliptical spot. Dynamic cooling with a cryogen spray is also available, with the cooling spray adjustable from 0 to 100ms, given 10–40ms after the laser pulse or as continuous 4°C air cooling at variable speed.A fluence of 10–25 J/cm 2 can be delivered through a 3 mm × 10mm or 5mm × 8mm spot. Polla 13 evaluated the Candela LPDL on 40 patients with leg veins 0.05–1.5mm in diameter. He used a 6 or 20ms pulse with 7 or 10 mm diameter spot at 10–13J/cm 2 and 6–7J/cm 2 , respectively, with a dynamic cooling device (DCD) setting of 30 ms and 10ms delay. One to seven treatments were performed at 3-week intervals. Optimal results were obtained after two sessions, with 8% having total clearance and 67% having clearance above 40%.All patients had pur- pura for 7–10 days, 33% had pigmentation for less than 2 months, and 15% for over 2 months. Weiss and Weiss 14 had similar results using the Cynosure LPDL on 20 patients with sclerotherapy- resistant TM.They performed a single treatment with 162 Clinical procedures in laser skin rejuvenation 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 162 a 20ms pulse and a 7 mm diameter spot at 7J/cm 2 for a total of three stacked pulses with simultaneous cold air cooling. Of 20 patients, 18 had at least 50% improvement at 3 months post treatment. Purpura only occurred in 25% of patients and lasted 10 days. A longer pulse duration of 40ms was used on 10 patients with leg telangiectasia up to 1 mm in diameter at 595nm with DCD cooling at 25J/cm 2 . 10 Six patients had 50–75% improvement and 2 of 10 had hyperpigmentation that lasted over 3 months. Our experience is similar to that reported above. We utilize the LPDL at pulse durations matching the thermal relaxation time of the leg veins.The energy fluence used is just enough to produce vessel purpura and/or spasm. Like Weiss and Weiss, 14 we use stacked pulses to achieve this clinical endpoint.We have used both LPDL systems and have found them to be compa- rable. Because of the necessity for multiple treatments and the significant occurrence of long-lasting hyper- pigmentation, we reserve the use of the LPDL for sclerotherapy-resistant, red, telangiectasia less than 0.2mm in diameter. DIODE LASERS Many diode-pumped lasers are now available, includ- ing a 532, 810, 915, and 940nm devices (Table 14.2). Diode lasers generate coherent monochromatic light through excitation of small diodes. As a result, these devices are lightweight and portable, with a relatively small desktop footprint. Thirty-five patients with spider leg veins were treated with an 810nm diode laser with a 12mm diameter spot, 60ms pulse duration, and 80–100J/cm 2 , with a cooled hand-piece. 15 Of these 35 patients,15 showed complete disappearance of the spider veins. Six months after the second laser treatment, 12 patients with partial or no response had dropped out of the study and 7 patients had a relapse in their leg veins, with an additional patient having a relapse at 1 year follow-up. Of the 35 patients, 2 had scarring. One hour of topical EMLA cream had to be applied to limit pain during treatment. A 940nm diode laser has also been used in the treat- ment of blue leg telangiectasia less than 1 mm in diame- ter without Doppler evidence of refluxing feeding veins. 16 Twenty-six patients were treated with 300–350J/cm 2 with a 40–70ms pulse and 1 mm diam- eter spot, and this gave a clearance of greater than 50% in 20 patients and greater than 75% in 12 patients. Slight textural changes were seen in 5 patients and pig- mentation took several months to resolve in 4 patients. No cooling was provided except for ice packs after treatment. In a follow-up of these patients 1 year later, 75% of patients had greater than 75% clearance. 17 These outstanding long-term results were not seen in a separate study using the same laser but with a variety of pulse durations (10–100ms) and fluences (200–1000J/cm 2 ) through a 0.5mm diameter spot for vessels less than 0.4 mm in diameter, a 1mm diameter spot for vessels 0.4–0.8mm in diameter, and a 1.5mm diameter spot for vessels 0.8–1.4mm in diameter. 18 Fluences were adapted to have complete vessel clear- ance without epidermal blanching . No cooling device was used and patients were evaluated at 1 year. The largest-diameter vessels had the highest clearance rates, with 13% of vessels less than 0.4mm in diameter clearing by more than 75%, versus 88% of vessels 0.8–1.4mm in diameter clearing by more than 75%. Laser therapy was more painful than sclerotherapy in 31 of 46 patients, with equal efficacy being noted by the patients who had had both forms of treatment. Finally, a combination diode laser at 915nm with radiofrequency (RF) at levels up to 100J/cm 2 has been used to treat leg telangiectasia. Chess 19 treated 25 patients with 35 leg veins 0.3–5 mm in diameter with 60–80J/cm 2 fluence and 100J/cm 2 RF energy through a 5mm × 8mm spot size with 5°C contact cooling in up to three sessions every 4–10 weeks. He found that 77% of treated sites exhibited greater than 75% improvement at 6 months.The average discomfort rating was 7 out of 10. Three sites on three different patients developed eschar formation without permanent scarring. Another study treated leg telangiectasia 1–4 mm in diameter with 60–80J/cm 2 fluence and 100J/cm 2 RF energy through a 5mm × 8mm spot size with 5°C contact cooling in three separate sessions at 2- to 4-week intervals. 20 Seventy-five percent of vessels had greater than 50% improvement and 30% had greater than 75% improve- ment at 2-month follow-up.Almost no complications were noted to occur. In summary, diode lasers are limited by treatment pain and adverse effects.Of note, unless feeding reticular veins Treatment of leg telangiectasia with laser and pulsed light 163 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 163 are treated, the distal treated telangiectasias recur at 6–12 months post treatment. Some authors appear to be able to achieve better results than others using similar para- meters.The addition of RF to the diode laser appears to offer little advantage over the laser alone. INTENSE PULSED LIGHT IPL was developed as an alternative to lasers to maxi- mize efficacy in treating leg veins (PhotoDerm VL, ESC/Sharplan, now Lumenis Santa Clara, CA).This device permits sequential rapid pulsing, longer-duration pulses, and longer penetrating wavelengths than laser systems. Theoretically, a phototherapy device that produces noncoherent light as a continuous spectrum with wave- lengths longer than 550nm should have multiple advan- tages over a single-wavelength laser system. First, both oxygenated and deoxygenated hemoglobin absorb light at these wavelengths. Second, blood vessels located deeper in the dermis are affected.Third, thermal absorption by the exposed blood vessels should occur with less overly- ing epidermal absorption, since the longer wavelengths penetrate deeper and are absorbed less by the epidermis, including melanin (Fig. 14.2). 164 Clinical procedures in laser skin rejuvenation 800 Average temperature increase across a 0.2-mm deep, 0.05-mm diameter vessel vs wavelength Average temperature increase across a 2-mm deep, 1-mm diameter vessel vs wavelength 700 600 500 400 300 200 100 400 ∆ T (°C) ∆ T (°C) 440 480 520 560 600 640 Wavelength (nm) Wavelength (nm) 680 720 760 800 840 880 920 960 1000 400 440 480 520 560 600 640 680 720 760 800 840 880 920 960 1000 0 0 2 4 6 8 10 12 DeOxy Oxy DeOxy Oxy Fig.14.2 Average temperature increase across a cutaneous vessel as a function of wavelength for two cases:a shallow capillary vessel (similar to those found in a port wine vascular malformation) and a deeper (2 mm) and larger (1 mm) vessel typical of a leg venule.The calculated curves are generated assuming that the main light-absorbing chromophore in the blood is either oxygenated or deoxygenated hemoglobin.The calculation is carried out for a 10J/cm 2 fluence and does not take into account cooling by heat conductivity.Note the dramatic shift in the optimal wavelength as a function of vessel depth and diameter.Also note the difference between oxygenated and deoxygenated hemoglobin.(Reproduced with permission from SclerotherapyTreatment of Varicose and Telangiectatic Leg Veins,4th edn.Goldman MP,Bergan JB,Guex JJ,eds.Elsevier,London,2006.) 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 164 With the theoretical considerations just mentioned, an IPL in the 515–1000nm range was used at varying energy fluences (5–90J/cm 2 ) and various pulse dura- tions (2–25ms) to treat venectasia 0.4–2.0mm in diameter.This IPL allows treatment through a quartz crystal of 8 mm × 35 mm or 8mm × 15mm (up to 2.8cm 2 ) that can be decreased in size to match the clinical area of treatment. Clinical trials using various parameters with the IPL, including multiple pulses of variable duration, demonstrated efficacy ranging from over 90% to total clearance in vessels less than 0.2 mm in diameter, 80% in vessels 0.2–0.5 mm in diameter, and 80% in vessels 0.5–1 mm in diameter. 21 The inci- dence of adverse sequelae was minimal, with hypopig- mentation occurring in 1–3% of patients, resolving within 4–6 months. Tanned or darkly pigmented Fitzpatrick type III patients were more likely to develop hypopigmentation and hyperpigmentation in addition to blistering and superficial erosions.These all cleared over a few months.Treatment parameters found to be most successful ranged from a single pulse of 22J/cm 2 in 3ms for vessels less than 0.2mm or a double pulse of 35–40J/cm 2 given in 2.4 and 4.0ms with a 10 ms delay. Vessels between 0.2 and 0.5 mm were treated with the same double-pulse parameters or with a 3.0–6.0 ms pulse at 35–45J/cm 2 with a 20ms delay time.Vessels above 0.5mm were treated with triple pulses of 3.5, 3.1, and 2.6ms with pulse delays of 20ms at a fluence of 50J/cm 2 or with triple pulses of 3, 4, and 6 ms with a pulse delay of 30 ms at a fluence of 55–60 J/cm 2 .The choice of a cutoff filter was based on skin color, with light-skinned patients using a 550nm filter and darker- skinned patients a 570 or 590nm filter. Treatment of essential telangiectasia, especially on the legs, is efficiently accomplished with the IPL (Fig. 14.3). A variety of parameters have been shown to be effective.We recommend testing a few different para- meters during the first treatment session and using the most efficient and least painful parameter on subsequent treatments. The use of IPL to treat leg veins is encouraging but far from being easily reproduced. This technology requires significant experience and surgical ability to produce good results. Various parameters must be matched to the patient’s skin type as well as to the diameter, color, and depth of the leg vein.With older Treatment of leg telangiectasia with laser and pulsed light 165 Fig.14.3 Before and after treatment of essential leg telangiectasia with intense pulsed light.(Reproduced with permission from Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins, 4th edn.Goldman MP, Bergan JB, Guex JJ,eds.Elsevier, London,2006.) 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 165 machines that do not have integrated cooling through sapphire crystals, a cold gel must be placed between the IPL crystal and the skin surface to provide optimal elimination of epidermal heat. Many have compared using the IPL to playing a violin. A 2- to 3-year-old playing a violin will make a squeaky noise, but, with practice, by the time the child is 7 or 8, he or she will make beautiful music. Regarding the IPL, it is the art of medicine that assumes an equal importance to its science. Fortunately, for those who do not play musical instruments, there are now dozens of IPLs available from many different manufacturers (Table 14.2). Nd:YAG LASER, 1064nm The Nd:YAG laser, 1064 nm, is probably the most effective laser available to treat leg telangiectasia. In an effort to deliver laser energy to the depths of leg veins (often 1–2mm beneath the epidermis) with thermo- coagulation of vessels 1–3 mm in diameter, 1064nm lasers with pulse durations between 1 and 250ms have been developed. However, because of the poor absorp- tion of hemoglobin and oxyhemoglobin at 1064 nm wavelength, higher fluences must be used. Depending on the amount of energy delivered, the epidermis must be protected to minimize damage to pigment cells and keratinocytes.Three mechanisms are avail- able to minimize epidermal damage through heat absorption. First, the longer the wavelength, the less energy will be absorbed by melanocytes or melanosomes.This will allow darker skin types to be treated with minimum risks to the epidermis due to a decrease in melanin interaction. Second, delivering the energy with a delay in pulses greater than the ther- mal relaxation time for the epidermis (1–2 ms) allows the epidermis to cool conductively between pulses. This cooling effect is enhanced by the application to the skin surface of cold gel that conducts away epider- mal heat more efficiently than air. Finally, the epider- mis can be cooled directly to allow the photons to pass through without generating sufficient heat to cause damaging effects. Epidermal cooling can be given in many different ways. The simplest method is continuous contact cooling with chilled water, which can be circulated in glass, sapphire, or plastic housings.The laser impulse is given through the transparent housing, which should be constructed to ensure that the laser’s effective fluence is not diminished.This method is referred to continuous contact cooling.The benefit is its simplicity.The disad- vantage is that the cooling effect continues throughout the time that the device–crystal is in contact on the skin. This results in a variable degree and depth of cooling, determined by the length of time the cold housing is in contact with the skin.This nonselective and variable depth and temperature of cooling may necessitate additional treatment energy so that the cooled vessel will heat up sufficiently to thermocoagulate. Another method of cooling is contact precooling. In this approach, the cooling device contacts the epidermis adjacent to the laser aperture.The epidermis is pre- cooled and then treated as the handpiece glides along the treatment area. Because the cooling surface is not in the beam path, no optical window is required, and bet- ter thermal contact can be made between the cooling device and the epidermis.The drawback is the nonre- producibility of cooling levels and degrees, which are based on the speed and pressure at which the surgeon uses the contact cooling device. Yet another method for cooling the skin is to deliver to the skin a cold spray of refrigerant that is timed to precool the skin before laser penetration and also to postcool the skin to minimize thermal backscattering from the laser- generated heat in the target vessel.We have termed this latter effect ‘thermal quenching’.This method repro- ducibly protects the epidermis and superficial nerve end- ings. In addition, it acts to decrease the perception of thermal laser epidermal pain by providing another sensa- tion (cold) to the sensory nerves. Finally, it allows an effi- cient use of laser energy because of the relative selectivity of the cooling spray, which can be limited to the epider- mis. The millisecond control of the cryogen spray prevents cooling of the deeper vascular targets and is given in varying amounts so that epidermal absorption of heat is counteracted by exposure to cryogen. Since the target vessel absorbs the 1064nm wave- length poorly, a much higher fluence is necessary to cause thermocoagulation. Whereas a fluence of 10–20J/cm 2 is sufficient to thermocoagulate blood vessels when delivered at 532 or 585nm, a fluence of 166 Clinical procedures in laser skin rejuvenation 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 166 70–150J/cm 2 is required to generate sufficient heat absorption at 1064nm.Various 1064 nm lasers are cur- rently available that meet the criteria for selectively thermocoagulating blood vessels, including, among others, the Lumenis One and Vasculite (Lumenis, Santa Clara, CA),Varia (CoolTouch Corp., Roseville, CA), Lyra (Laserscope, San Jose, CA), GentleYAG (Candela, Wayland, MA), SmartEpil II (Cynosure, Chelmsford, MA), Harmony (Orion Lasers, FL), Profile (Sciton, Palo Alto, CA), Mydon (WaveLight, Erlsngen, Germany), and CoolGlide (Cutera, Burlingame, CA) (Table 14.2).The long-pulse 1064nm Nd:YAG lasers are not all the same.There are variabilities in spot size, laser output both in fluence and in how the extended time of the laser pulse is generated), pulse duration, and epidermal cooling. In addition, although many claims are made by the laser manufacturers, few well- controlled peer-reviewed medical studies are available. Because of the vaariability between the 1064 nm Nd:YAG lasers, a review of the clinical studies with each system will be presented separately. Vasculite The Vasculite was the first long-pulsed 1064 nm laser to be approved by the US Food and Drug Administration (FDA) for vascular treatment.The Nd:YAG 1064nm laser is pulsed with IPL technology. Individual pulses up to 16ms in length can be delivered as single, double, or triple synchronized pulses with a total maximum fluence of 150J/cm 2 . The laser beam is generated in the handpiece and delivered through a sapphire crystal 6 mm, 9mm, or 3 mm × 6mm in size. Weiss and Weiss, 22 Sadick, 23 and Goldman 24 have reported excellent results in treating leg telangiectasia from 0.1 to 3mm in diameter. Application of a cool gel to the skin (without cooling of the crystal – which is not necessary with the most advanced version, Lumenis 1, which is thermokinetically cooled to 4°C) and synchronization of the pulses allow epidermal cooling and protection. In addition, synchronized tim- ing between pulses can be tailored to the thermal relaxation times of blood vessels. Weiss and Weiss 22 treated 30 patients who had been dissatisfied with previous leg vein treatments with either sclerotherapy or other laser light or IPL.A single 14–16ms pulse at 110–130 J/cm 2 was given to treat vessels 1–3 mm in diameter. A double pulse of 7 ms separated by 20–30 ms at a fluence of 90–120 J/cm 2 was used to treat vessels 0.6–1mm in diameter, and a triple synchronized pulse of 3–4ms at a fluence of 80–110J/cm 2 was used to treat vessels 0.3–0.6mm in diameter. Immediate contraction of the vessel was used as an endpoint of treatment, followed by urtica- tion. Immediate bruising from vessel rupture occurred in 50% of vessels. At 3 months after treatment, the majority of sites improved by over 75% (Fig. 14.4). Hyperpigmentation was noted in 28% of patients at the 3-month follow-up. In short, this report demon- strated successful treatment of otherwise-difficult ves- sels, and mirrors our experience.Weiss and Weiss 25 reported on 3-year results in the treatment of leg telangiectasia 0.3–3mm in diameter at slightly higher fluences of 110–150 J/cm 2 . They found an average 75% improvement in 2.38 treatments. Sixteen percent of patients developed pigmentation which resolved at 6 months, and 4% developed TM. Sadick 26 reported on 12-month follow-up in 25 patients with leg veins with a fluence of 120 J/cm 2 given through a 6mm diameter spot in a 7 ms double pulse to vessels 0.2–2mm in diameter and as a single pulse of 14ms and a fluence of 130 J/cm 2 to vessels 2–4mm in diameter. Using these parameters, 64% of patients could achieve 75% or greater clearance in three treatments.Two of the 25 treated patients who had less than 25% vessel clearance developed a recur- rence of the veins within 6–12 months. Sixteen per- cent of patients developed pigmentation, which lasted 4 months, and 8% developed TM. CoolTouch Varia The CoolTouch Varia combines a multiple train of pulses to generate a pulse width from 10 to 300 ms bursts. Fluences of up to 150 J/cm 2 can be generated. A 3–10mm diameter beam is delivered through a fiberoptic cable. Dynamic cooling is given with a cryo- gen spray that can be delivered before, during, and/or after the laser pulse.The cooling spray can be varied from 5 to 200ms and can be given in 5–30ms bursts in 5ms intervals before and/or after the laser pulse. In this manner, in the treatment of larger or deeper Treatment of leg telangiectasia with laser and pulsed light 167 14 Carniol-8028.qxd 8/23/2007 10:33 AM Page 167 [...]... treatment of acne vulgaris J Invest Dermatol 2000;115: 183 –92 14 Pottier RH, Chow YFA, LaPlante JP et al Non-invasive technique for obtaining fluorescence excitation and emission spectra in vivo Photochem Photobiol 1 986 ;44: 679 87 15 Carniol -8 0 28. qxd 180 8/ 23/2007 10:34 AM Page 180 Clinical procedures in laser skin rejuvenation 15 Morton CA Photodynamic therapy in skin cancer In: Rigel DS, Friedman RJ,... in a double-pulse mode of 4.0 ms with a 20 ms interpulse delay Thirtythree of 38 AK disappeared with two treatments of ALA–PDT.Treatments were well tolerated Erythema and crusting took 1 week to resolve Although no 15 Carniol -8 0 28. qxd 176 8/ 23/2007 10:34 AM Page 176 Clinical procedures in laser skin rejuvenation a b Fig 15.4 Photorejuvenation using δ-aminolevulinic acid (ALA) followed by intense pulsed... of δ-aminolevulinic acid (ALA) is the rate-limiting step in this pathway Exogenous ALA or methyl δ-aminolevulinate (MAL) bypasses this step and drives heme synthesis, producing the endogenous photosensitizer protoporphyrin IX (PpIX) compromise Direct cell killing and immunological effects, including the production of interleukin-1β (IL-1β), IL-2, tumor necrosis factor (TNF), and granulocyte colony-stimulating... development in long-pulse 1064 nm Nd:YAG technology has been the production of a 14 Carniol -8 0 28. qxd 170 8/ 23/2007 10:33 AM Page 170 Clinical procedures in laser skin rejuvenation nonuniform pulse sequence mode device with contact cooling to 5°C.35 This device has a fluence of 300–360 J/cm2 through a 2 mm diameter spot The rationale for multiple pulsing is to convert oxyhemoglobin to met-hemoglobin, which... cellular components, causing tissue injury and necrosis.12 PDT also affects the microvasculature and immune system.Vascular effects include vasoconstriction of the arterioles within a tumor, reduction of erythrocyte flow in nearby venules, and thrombosis of tumor vessels leading to ischemia and vascular 15 Carniol -8 0 28. qxd 174 8/ 23/2007 10:34 AM Page 174 Clinical procedures in laser skin rejuvenation NEGATIVE... 2000;13:27–30 14 Carniol -8 0 28. qxd 172 8/ 23/2007 10:33 AM Page 172 Clinical procedures in laser skin rejuvenation 25 Weiss MA, Weiss RA Three year results with the long pulsed Nd:YAG 1064 laser for leg telangiectasia Presented at the American Society for Dermatologic Surgery Annual Meeting, Dallas,TX, October, 2001 26 Sadick NS Long-term results with a multiple synchronized-pulse 1064 nm Nd:YAG laser for the... Photodynamic photorejuvenation Dermatol Surg 2002; 28: 742–4 19 Alster TS, Tanzi EL, Welsh EC Photorejuvenation of facial skin with topical 20% 5-aminolevulinic acid and intense pulsed light treatment: a split-face comparison study J Drugs Dermatol 2005;4:35 8 20 Dover JS, Bhatia AC, Stewart B, Arndt KA Topical 5aminolevulinic acid combined with intense pulsed light in the treatment of photoaging Arch Dermatol... product BOTULINUM NEUROMODULATORS In the 1 980 s, Allen Scott in San Francisco used botulinum neuromodulator in laboratory chick models for selective weakening of treated muscles, and soon thereafter it was used for the management of strabismus.1 Botulinum neuromodulator is found in nature in seven serotypes (A–G) defined by their specific biological action in cleaving particular proteins involved in the active... eds Cancer of the Skin Philadelphia: Elsevier Saunders, 2005:515–26 16 Szeimies RM,Abels C, Fritsch C.Wavelength dependency of photodynamic effects after sensitization with 5aminolevulinic acid in vitro and in vivo J Invest Dermatol 1995;105:672–7 17 Gold MH 5-aminolevulinic acid in photodynamic therapy An exciting future VS Dermatology Review 2006;7 :81 –7 18 Ruiz-Rodriguez R, Sanz-Sanchez T, Cordoba... variety of cooling and pulsing scenarios One can cool the skin directly with a contact probe before and after the laser pulse or through a sapphire window before, during, and after the laser pulse Cooling can also be given dynamically 14 Carniol -8 0 28. qxd 8/ 23/2007 10:33 AM Page 171 Treatment of leg telangiectasia with laser and pulsed light with a cryogen spray before, during, or after the laser pulse . results using the Cynosure LPDL on 20 patients with sclerotherapy- resistant TM.They performed a single treatment with 162 Clinical procedures in laser skin rejuvenation 14 Carniol -8 0 28. qxd 8/ 23/2007. overly- ing epidermal absorption, since the longer wavelengths penetrate deeper and are absorbed less by the epidermis, including melanin (Fig. 14.2). 164 Clinical procedures in laser skin rejuvenation 80 0 Average. be given dynamically 170 Clinical procedures in laser skin rejuvenation 14 Carniol -8 0 28. qxd 8/ 23/2007 10:33 AM Page 170 with a cryogen spray before, during, or after the laser pulse. Most patients