LASERS IN PLASTIC SURGERY

Souvik Adhikari

A long time ago……

GOD said“Let there be light , and there was light, and GOD saw that it

was good, and GOD divided the light from the darkness”

DEFINITION

• Light Amplification by the Stimulated Emission of Radiation (acronym coined by Gordon Gould).

CONCEPTUALIZATION

HISTORY OF LASERS

• 1917: Albert Einstein developed the theoretical concept of photons & stimulated emission.

• 1954: Charles Townes & Arthur Schawlow built the first MASER using ammonia and microwave energy.

• 1960: Thomas Maiman produced the first laser using a synthetic ruby rod.

• 1960: Dr. Ali Javan-first continuous laser (He-Ne 632.6 nm red gas ion laser.

PIONEERS

HISTORY OF LASER

• 1960s: Dr. Leon Goldman: Father of Laser Medicine & Surgery-usage of laser in medical practice.

• 1962: Bennett et al: blue-green argon laser (retinal surgery).

• 1964: Kumar Patel: CO2 laser.• 1964: Nd:YAG laser.• 1969: dye laser.• 1975: excimer laser (noble gas-halide).

PIONEERS

BASIC PROPERTIES OF LASER

• Photons are emitted parallel & in phase with each other (coherence: intensity does not decrease with distance).

• Light from laser is monochromatic but wavelength is modifiable.

• High photon emission (even more than sun!!).

• Only those atoms & molecules possessing a metastable stage can undergo lasing.

• 4 types of lasing materials: solid, liquid, gas, semiconductor.

PROPERTIES

• Frequency doubling: passing a laser beam through a KTP crystal.

• Continuous wave & pulsed lasers.• Q switching.• Laser delivery: articulated arms (CO2,

Er:YAG lasers), optical fibers, micromanipulators.

• Laser-tissue interactions: reflection, scattering, transmission, absorption.

PORT WINE STAIN (PWS)

• Never regress.• Blood is the major chromophore.• OxyHb: absorption peaks at 418, 542, 577

nm.• Argon laser: high incidence of scarring,

arophy & hypopigmentation.• Flashlamp pumped pulsed dye laser:

selective photothermolysis, thrombosis formation without epidermal/dermal damage.

PWS: OTHER LASERS

• IPL systems: high intensity flashlamps, used for purple, hypertrophic & resistant lesions.

• Pulsed KTP lasers: higher incidence of adverse effects like scarring, altered pigmentation.

• Alexandrite, diode, Nd:YAG lasers are currently being explored.

COMPLICATIONS

• Reticulation.• Immediate skin graying/whitening.• Hyper & hypopigmentation

(transient).• Atrophic & hypertrophic scars.• Dermatitis.

PWS: EFFECTS OF LASERS

CANDELA’S DYNAMIC COOLING DEVICE

PWS WITH DCD

LASER TREATMENT OF HEMANGIOMAS

• Proliferating hemangiomas: to resolve/prevent further proliferation & to treat ulceration: pulsed dye laser.

• Ulcerated hemangiomas: treatment.• Compound/deep lesions: ILT using

Nd:YAG or diode laser.• Involuting hemangiomas: treatment of

residual telangiectasia: Pulsed dye, KTP, copper bromide lasers.

• Atrophic scarring: CO2, Er:YAG laser.

PROLIFERATING HEMANGIOMAS

PROLIFERATING HEMANGIOMAS

ULCERATED HEMANGIOMAS

RESIDUAL TELANGIECTASIA

ACQUIRED VASCULAR LESIONS

• Facial telangiectasias: CW & quasi CW lasers: APTDL, copper vapor lasers.

• Spider angiomata, cherry angiomata, poikilodermata, venous lakes, pyogenic granulomas: PDL.

FACIAL TELANGIECTASIAS

SPIDER ANGIOMATA

POIKILODERMATOSIS

PIGMENTED LESIONS

• Epidermal: ephelids, lentigines, café-au-lait macules, seborrheic keratoses, nevi spilus, Becker’s nevi – Q switched lasers, PDL.

• Dermal: Nevus of Ota, melanocytic nevi, melasma, postinflammatory hyperpigmentation – QS lasers, alexandrite lasers, resurfacing with CO2 lasers.

• Side effects: hyperpigmentation, transient hypopigmentation.

MELANIN ABSORPTION SPECTRUM

LENTIGINES

CALM OF THIGH

FRECKLES

NEVUS OF OTA

CONGENITAL NEVUS

TATTOOS

• First lasers used were CO2 & argon lasers: hypertrophic scar formation.

• PDL, QS lasers are most commonly used now.

• Side effects: pigment & textural changes, allergic reactions, ink darkening, tissue aerosolization with possible infectious particles.

TATTOOS

INCOMPLETE CLEARING

INK DARKENING

CO2 LASERS & SKIN LESIONS

• Chromophore is water.• Used in actinic keratosis, condyloma

acuminatum, epidermal nevus, lichen sclerosis, porokeratosis, verruca plantaris, verruca vulgaris, adenoma sebaceum, cylindromas, leiomyomas, neurofibromas, syringomas, etc.

• Effective hemostasis with sterile wound bed.• No tissue specimen is available for

pathologist!

RHINOPHYMA TREATED WITH CO2 LASER

SKIN RESURFACING & CO2 LASERS

• Advantages: efficient single pass removal of epidermis, heat induced collagen shrinkage, limited ablation depth with single pass vaporization, hemostasis.

• Complications: postoperative swelling, erythema, itching, infection, acne & milia, hyperpigmentation, hypopigmentation, petechiae, scarring, ectropion.

FACIAL RESURFACING

SKIN RESURFACING: Er:YAG LASERS

• 16 times better absorbed by water than CO2.• Depth of penetration 1/20 of CO2 laser.• Much lesser zone of thermal injury created:

lower incidence of scarring.• Bleeding is a major problem, less collagen

contraction than CO2 laser.• Resurface nonfacial skin: neck, hands,

forearms.• Mild-moderate rhytides/acne scar treatment.

TREATMENT OF RHYTIDES

PERIORBITAL RHYTIDES

COMBINED LASER RESURFACING

• Resurfacing with UPCO2 followed by Er:YAG.

• Derma-K laser: near simultaneous beam.• Sandwich technique: Er:YAG followed by

CO2 followed by Er:YAG.• CO3 laser: single head Er:YAG laser with

extended pulse duration.• Sciton Contour Laser Resurfacing: 2

Er:YAG heads of different pulse durations.

UPCO2 & Er:YAG

DERMA-K

SCARS & STRIAE

• PDL: hypertrophic scars & striae, keloids require additional treatment.

• Atrophic facial scars: CO2 and Er:YAG lasers.

• Nonablative laser scar remodeling: Nd:YAG & 1450 diode lasers.

STRIAE DISTENSAE

ATROPHIC FACIAL SCARS

NONABLATIVE SKIN REJUVENATION

• Thermal injury to papillary & superficial reticular dermis sparing the epidermis.

• PDL, KTP, IPL, Q switched Nd:YAG, diode, long pulsed Nd:YAG, Er:Glass laser, PDT all used.

• Can also be used for acne.

DERMAL REMODELING

ACNE TREATMENT

LEG VEINS

• Telangiectasia, venulectasia & reticular veins excellent targets: PDL, KTP lasers, IPL.

• Effective skin cooling methods required with long pulsed dye lasers.

• EVLT: for varicose veins using PDL.• Complications: purpura, vesiculation

& crusting, pigmentary changes, scarring, thrombus formation.

ALEXANDRITE & Nd:YAG LASERS FOR LEG VEINS

LASER HAIR REMOVAL

• Indications: hypertrichosis, hirsutism, aesthetic & medical reasons.

• Photothermal destruction: ruby, alexandrite, pulsed diode, long pulsed Nd:YAG lasers, IPL.

• Photomechanical destruction: carbon suspension Q switched Nd:YAG.

• Photochemical destruction: PDT.• Side effects: pain, perifollicular erythema &

edema, epidermal damage, herpes simplex outbreaks, bacterial infections, pigmentary changes, scarring, etc.

LASER ASSISTED HAIR TRANSPLANTATION

• Pulsed & scanned CO2 lasers can control bleeding in hundreds of recipient sites.

• CO2 laser can also be used to harvest donor sites but it is much slower than a scalpel and is therefore not used.

• Disadvantages: less yield, longer postoperative crusting & erythema, telogen precipitation.

• Er:YAG laser now used.

RECIPIENT SITE CREATION