2/2/18 AVOIDING LASER COMPLICATIONS AND MAXIMIZING RESULTS. Relative Absorption GOLD THERAPY GENERAL CONSIDERATIONS GENERAL CONSIDERATIONS

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1 AVOIDING LASER COMPLICATIONS AND MAXIMIZING RESULTS DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY Eric F. Bernstein, MD Research Grant Syneron Advisory Board Syneron, Solta, Zeltiq Consulting fee-syneron, Solta Equity-Novoxel, Syneron ERIC F. BERNSTEIN, M.D., M.S.E. MAIN LINE CENTER FOR LASER SURGERY ARDMORE, PA Relative Absorption GENERAL CONSIDERATIONS Do NOT take treatment advice from sales reps There is NO ONE DEVICE that does EVERYTHING well Understand the physics and biology of what you are doing Pick the right wavelength for the job Small spots generally penetrate very little while big one go deeply (visible and near visible wavelengths) GENERAL CONSIDERATIONS GOLD THERAPY History Accutane use (wait 1? month) HSV Gold therapy EVER Connective Tissue Disease Pregnancy? Tattoo removal Others? Sun exposure/tanning booth: Honesty? 1

2 GENERAL CONSIDERATIONS: PIGMENT GENERAL CONSIDERATIONS Be very cautious treating dark-skinned patients If hyperpigmentation occurs, do not re-treat until it is gone Use bleaching agents/topical steroids when necessary Perform test spots on dark skin Assistant holds glasses in place during treatment Try not to have more than one wavelength per room-multi-wavelength glasses No long wavelength big spots around eye NO LASER on same day (week) as TOXINS Anyone can hand you the wrong glasses, only you can put them on! GENERAL CONSIDERATIONS: EYE Long-pulsed 1064 nm Nd:YAG laser/also seen w IPL used to treat unibrow. Corneoscleral shields reportedly in place. Patient developed a keyhole pupil Do not use lasers/ipls to perform hair removal on the eyelids or eyebrows. Courtesy of Suzanne Kilmer, M.D. 2

3 Hb0 2 2/2/18 GENERAL CONSIDERATIONS: PEOPLE You don t have to treat every patient, if something seems amiss it probably is Don t get talked into anything ROSACEA/FACIAL VEINS The 595 nm and 532 nm wavelengths are highly absorbed by hemoglobin KTP Dye Tunable Dye Nd:YAG Melanin 1e+03 Hb Absorption 1e+02 1e+01 Tunable Dye 1e Wavelength (nm) Safest laser I have-longest safety record Scarring EXTREMELY rare Purpura and Edema are common side-effects 3

4 IPL Heat production, a.u Wavelength, nm OPL Output Spectrum, a.u. 100 ms PIH FROM IPL (7 YEARS POST RX) HYPOPIGMENATION FROM IPL ROSACEA/FACIAL VEINS: ALEX AND ND:YAG BEWARE! Depression after 1064 nmyag laser treatment of vessel 4

5 755 NM LONG PULSE-DURATION ALEXANDRITE RX SPIDER VEINS IPL AND LP YAG FOR REJUVENATION Watch out for men with dark facial hair PITFALLS SPIDER VEINS 1,064 nm Nd:YAG has poor hemoglobin absorption compared to 532/595, need high fluences BEWARE IPL-melanin absorbs quite broadly, hemoglobin does NOT BEWARE Purpura goes away, but people can be pretty mad in the interim Leg veins are less forgiving than facial veins KTP LEG VEIN TREATMENT Leg veins are the hardest to treat Use adequate spot size Respect melanin pigment-patients with PIH have a tattoo -do not treat with a ms domain device-use bleaching agents and WAIT as necessary Lasers Surg Med. 46:81-88,

6 CONTACT COOLING-REP RATE 1,064/755 ND:YAG/ALEX Scars Port-wine stains HAIR GENERAL CONSIDERATIONS Place gauze/telfa to protect teeth Draw line (white eye liner) from inferior infra-orbital rim and do not treat above Lighten dark spots with topicals, Nd:YAG for skin types V-VI, test spots Hormonal w/u with suspected PCOS/other 6

7 Choose the appropriate tool for the task at hand. Hormonal work-up Bleaching agents PARADOXICAL HAIR GROWTH URTICARIA POST LASER HAIR REMOVAL Paradoxical hair growth on jawline of women of Mediterranean descent More common in people with hormone disorder-pcos (hormonal w/u) Use ice pack while treating at periphery and use adequate fluences Dermatol Surg. 36: , 2010 FRECKLES AND LENTIGOS IPL with poor cooling on patient's right chest Hypopigmentation from IPL 7

8 Wrong device for the application MELASMA=TOPICALS + LIGHT FRACTIONATED OR PICO? TATTOOS TYPES OF LASERS FOR TREATING TATTOOS Nd:YAG-black/red, use 1,064 nm in dark skin to treat black ink (pico/nano), 532 nm for red Alexandrite-use for blue/green ink (pico/nano) Ruby-can use for black and blue/green, not to start in darker skin types (nano) Pico-532 for yellow ink Bernstein EF, Civiiok. Lasers Surg Med 45: ,2013. Bernstein EF, Schomacker KT, et al. Lasers Surg Med 47: , 2015 The most common reason for complications following tattoo treatment are: Using the wrong device (ms domain, IPL) Using a single device and turning it up (increasing fluence with same laser by shrinking spot size) Poor after care by patient Not respecting melanin pigment Use the right tool for the job! Q-switched/nano lasers ONLY for tattoos 8

9 Respect Melanin Pigment Be very cautious treating dark-skinned patients If hyperpigmentation occurs, do not re-treat until it is gone Use bleaching agents/topical steroids when necessary Perform test spots on dark skin If more than one laser pick longer wavelength to start with black ink TREAT THROUGH HYDROCOLLOID DRESSING Treat through Vigilon (order large size Vigilon it s worth the cost) Remember to remove plastic covering on BOTH sides of dressing (it s clear) Dramatically reduces splatter-blood borne pathogens HYDROCOLLOID DRESSING CAN REFLECT DO NOT TREAT TATTOOS EVIDENCING AN ALLERGIC REACTION BEWARE OF WHITE PIGMENT Look for Clues white may be present (Learn from Little Cindy Loo Hoo, she s no more than 2) Beware of systemic/widespread allergic rxn Even C02 laser has resulted in a systemic allergic reaction Certain colors like light blue, green, purple, or pink ALWAYS contain white Lasers Surg Med. 47: ,

10 THE ONLY WAY TO AVOID COMPLICATIONS IS TO NOT PERFORM LASER SURGERY.. Be humble Use the right tool for the job Respect melanin pigment Know some science Smaller beam diameters don t penetrate deeply Beware turning up the fluence by shrinking the spot size FOUR DOUBLES SCORE MORE RUNS THAN A HOMER LASERS ARE FUN! 10

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