Download Laser treatment

Laser treatment
surgical point of view
prof.
Uroš Ahčan, MD,PhD
Consultant general surgeon
Consultant plastic, reconstructive and esthetic surgeon
University medical Center, Ljubljana, Slovenia
Department of Plastic Surgery and Burns
Why to use laser ?
How to use laser ?
Which laser ?
Laser as a complementary
method?
history
1916
Laser treatment milestones
Albert Einstein in 1916
(theory of spontaneous and stimulated emission of radiation)
witness of huge development
1950
MASER
1960
1963
1983
LASER
Ar, Ru, Nd:YAG
Light
Amplification
Stimulated
Emission
Radiation
dermatology,
ophthalmology,
gynecology,
neurosurgery,
otolaryngology
urology
SPTL
1999
cooling
2003 1950 to 2010
Pontiac
Princip delovanja
Laser vsebuje medij (kristal, tekočino ali plin), ki
ga vzburimo. Fotoni se nato preko zapletenega
sistema ogledal uredijo v svetlobni-laserski
žarek, ki potuje po gibljivih vlaknih do tkiva.
Principi delovanja
Lasnosti laserskega snopa svetlobe so:
Kolimacija (popolna vzporednost žarkov),
Monokromatičnost (žarki imajo eno valovno dolžino, barvo)
Koherentnost (vsi žarki so fazno usklajeni v času in prostoru)
Early laser use
“light was absorbed and the
tissue heated in response”
Continuous wave laser
Inability to control laser parameters precisely
Little was known about tissue reaction to the light energy
Scarring, pigmentation changes, and the need for many treatment
sessions were all serious drawbacks to the early laser use.
Princip delovanja
Z razvojem tehnike je sledilo
poglobljeno znanje o principu
delovanja in
odnosu laserski žarek:tkivo,
tako na površini kože kot na
mikroskopskem nivoju v globjih
plasteh.
Princip delovanja
Laserski žarek se ob stiku s tkivom:
Odbije (nezaželjeni učinek –
nevarnost za bolnika in osebje)
Razprši (neželjeni učinek na sosednje zdravo tkivo)
ugoden učinek v primeru velikih, globje ležečih
struktur, na katere ne moremo učinkovati zgolj s
neposredno absorcijo energije.
Prehaja (neželjeni učinek na globje leče tkivo,
ugodno kadar želimo učinkovati v globini in
ohraniti zgornje plasti PWS)
Absorbira
(absorbirana energije se pretvori v toplotno => koagulacija in ablacija tarčnega tkiva =
klinični učinek odvisen od valovne dolžine in sestave tarče)
Basic mechanism: selectivity
Absorbtion of light energy in target structures:
structures
water, (oxi)hemoglobine, melanin, endogenous
and exogenous pigments, leads to thermal
destructions
of tissues containing these structures.
Selective destruction
of different targets – tissue
“Targets” are chromphores,
with distinct absorbtion
spectrum for light of specific
wavelenght.
ERBIJ
Laser absorption and tissue effect are a function of:
• Energy (proportional to the number of photons – J)
• Energy per square centimeter = fluence (J/cm2)
• Exposure time – pulse duration (ms)
• Rapidity in which pulses are given (pulses/second - Hz)
• Spot size (mm)
• Wavelength
• Number of passes
Ability to control laser parameters precisely
Broad spectrum of indications
Dermatology and Plastic Surgery
•Epidermal nevi
•Telangiectasiae
•Spider veins
•Actinic sheilitis
•Verrucae
•Skin tags
•Anal tags
•Keratoses
•Decubitis ulcers
•Keloids
•Scar revision
•Skin resurfacing
Broad spectrum of indications
ENT Surgery:
•ENT lesions
•Cysts
•Polyps
•Hyperkeratosis
•Oral leukoplakia
Oral/Maxillofacial:
•Oral and glossal lesions
•Gingivectomy
Ophtalmology:
•Soft tissue surrounding the eye and orbit
•Anterior capsulotomy
Broad spectrum of indications
General Surgery:
•Surgical incision/excision
•Vaporization and coagulation of soft tissue
during any general surgery application where
skin incision, tissue dissection, excision of
lesions, complete or partial resection of
internal organs, lesions, tissue ablation and
vessel coagulation in necessary.
Pediatric Surgery :
•Warts
•Plantar verrucae
•Large mosaic verrucae
•Matrixectomy
Broad spectrum of indications
Aesthetics
•Permanent reduction of unwanted hair
•Skin rejuvenation
•Non-ablative wrinkle reduction
•Photocoagulation of pigmented lesions to
reduce lesion size
•Leg veins
•Telangiectasias
•FacialNasalTruncal
•Reticular veins
•HaemangiomaCherry (senile) angioma
•RosaceaTelangiectatic matting
•Verrucae and warts
•Venous lake
•Pyogenic granuloma
•Laser resurfacing for dermal photoaging
Broad spectrum of indications
Vascular Surgery
•EVLA Varicose veins (with or without
sapheno-femoral or sapheno-popliteal
junction insufficience)
•Truncal varicose veins
•Large branch veins
•Large tributaries
•All veins that are not extremely tortuous
•Perforator vein insufficiency
•Laser Lipolysis
•Laser Axillar Hyperhidrosis Reduction
Other Indications
• Nail fungal infection (Onychomycosis)
Vascular
lasers
Ablative
lasers
532 nm KTP
Er,
1064 nm Nd Yag
CO2
585 PDL
Vascular laser
Energy of light is transformed into
heat (fototermolysis)
Destruction of blood cells and vessel
walls (denaturation of colagen) 70°C
Ablative laser
Ablation:Thermal damage for Er:YAG laser is
limited to upper 5-20 µm of tissue.
Good plastic surgery unit
basic knowledge
• Knowledge about skin biology and pathology
(B and M skin lesions, vascular disorders, photo-aging)
• Knowledge about wound healing, burns, dressing
• Good surgical technique, alternative methods
(dermabrasion, chemical peeling, botulinum toxin, fillers),
• Experience with surgical cosmetic procedure
• Different laser systems
Why laser ?
•
•
•
•
•
Indications only for laser (vascular malformation..)
Advantages of modern laser therapy
Patient wishes (media, internet) 2/10
Different age groups
Laser treatment as a complement. method
Vascular skin lesions
• The goal of laser therapy of vascular skin
lesions is selective destruction of vessels
with minimal damage to the surounding
tissues
• Normal skin colour and texture
Laser beam penetrates the
upper skin layers and reacts
with Hb in RBC
Energy of light is
transformed into
heat
(fototermolysis)
Destruction of blood cells and vessel
walls (denaturation of colagen) 70°C
angiofibroma
5 visits, 4 specialists
young
(spider naevus, naevus araneus, angioma stellatum)
elderly
Hemangioma senilis (cherry hemangioma,haemangioma senilis)
80% of females
Dilatated leg vessels
telangiectasias
Acquired benign vascular lesions of skin and subcutis present a problem from
aesthetical and psycho-social point of view.
telangiectasias
Acquired benign vascular lesions of skin and subcutis present a problem from
aesthetical and psycho-social point of view.
• The most common vascular malformantion with
incidence 3-5/ 1000 births
PORT WINE STAIN
• Equal sex distribution
NAEVUS FLAMMEUS
• 80 % on face and neck
• HI: Ectatic, dilatated capilaries with diameter of 30170 µm in upper dermal layers (0,3-1,5 mm)
• CP: Flat lesions with a red to pink hue which tend to
darken throughout life turning a deeper shade of red
or blue and may even become thicker and more
nodular.
• No spontaneous regression
• Psycho-social stress
If treatment is not started in time the lesion darkens becomes nodular and resistant to
laser therapy.
Functional and esthetical problems
Testno področje
Takoj po zdravljenju
Po mesecu dni
Port wine stain, Naevus flammeus
100% improvement rare
Zdravljenje v tujini
Venous lake
Port wine stain – tuberous type
All age groups
Lasers and benign skin lesions
Er:YAG laser
Patients with extensive solar-induced epidermal
pigment changes and benign skin lesions
Ablate skin (from 0µm to 50 µm) with little or no
residual thermal damage-effect.
Why Erbium:YAG Laser ?
1. Er:YAG has the highest
absorption and therefore
the most efficient ablation
2. Er:YAG has the smallest
penetration depth and
therefore enables
treatments with basically
no thermal effects
3. Er:YAG pulse duration can
be varied to obtain deeper
thermal effects when
desired
Er:YAG is the ideal laser for skin resurfacing
Laser and autol. fibroblasts and laser
Seboroic keratosis
Seboroic
keratosis
pigmented dermatofibromas
After treatment
3 weeks later
warts
Verrucae vulgares
Acne scars
Xantelasm
rinophima
Why laser ?
Time: 1‘ 35''
Time: 8‘ 47''
Advantages of laser therapy:
• Safe and effective procedure on
out-patient basis for benign skin
lesions
• Less invasive procedure,
• Less risk for infection,
• Relatively ˝bloodless˝ sugery,
• damage to the surounging skin
is minimized,
• Less scars,
• Mostly less painful procedure
Hiperthrophic scars after
excisions
NOTICE!
Careful examination of
the skin is mandatory
before laser therapy!
skin melanoma
Granuloma pyogenes
cutaneous melanoma
Skin of the palm:
cutaneous melanoma, Clark IV, Breslow 4.3 mm.
Inapropriate Treatment=>Surgery +
Histology
A mistake at the beggining...
Why laser ?
In aesthetic surgery
The use of lasers in aesthetic
surgery is a recent but rapidly
expanding practice!
Lasers in plastic surgery
dictate
Tehnological advances: safe and efficient lasers
Media, internet: more aware patients
(want most up to date treatment)
Rapidly increasing number of aesthetical procedures
(younger people, uninvasive, out-patient, safe
procedures, short recovery).
CASE 1
LASER RESURFACING
local anesthesia
laser resurfacing - mechanism
• With a controlled amount of heat deposited
could induce a biologic response leading to
improved new collagen deposition.
• Epidermal ablation
• Dermal damage with collagen remodeling
• Thermal contraction
• Relatively young people who lack deep wrinkles
or extensive photodamage
TEXTURAL CHANGES IN THE SKIN
should be classified
Treatment plan – esthetic units
Treatment plan
epidermal ablation
photocoagulation
CASE 3
SURGERY & LASER
forehead
glabela
periorbital
cheek
nasolabial
perioral
neck
Plan of treatment
The
one re is m
• Rhytides (mild, moderate, severe)rhy way t ore th
tide o im an
pro
• Photoaging (mild, moderate, severe) s.
ve
• patient age and wishes
• laser resurfacing (ablative, non-ablative, combination)
• face-lifting
• botulinum toxin application
combination
forehead
periorbital
cheek
perioral
neck
Combination of different
aproaches:
•
•
•
•
•
LASER and
Fillers
Botox
Surgery
Ointments…
Synergistic effect 1 + 1 = 3
Tatoo
The skin serves as a useful canvas on which to portray statements
of individuality, sexuality, belonging, machismo, frustration, anger..
9 - 11% men in the USA have tatoo
The quest for identity by teenagers often becomes irrelevant or embarrasing by
age 40 years and 50% or more individuals later regret their tatoos.
The Highest Performance, Best Made
Q-switched Laser in The World
Fotona QX Max
Nanosecond Nd:YAG +KTP:YAG
Largest single pulse fluence at
large spot sizes
Unprecendented beam profile
Two additional colors: 585, 650
Optoflex arm
Additonal Accelera mode for
FRAC3 treatments
Wireless footswitch
Laser treatment
Relative indications
Hypertrophic scars and keloids
Treatment with Erbium and KTP+ Laser
Non-Ablative Fractional Applications
Post pregnancy stretch marks and skin flaccidity
Before
1 Year after two treatments
Combined Fractional Applications
(Non-Ablative Fractional Smooth Mode + Ablative Fractional Light Peel)
Reduction of Strech Marks
Before
(Courtesy of dr. C.Pidal )
1 week after 1 treatment
Hair Removal (HR) Examples: Back
before
after
Courtesy of Robin Sult
SP Dynamis Nd:YAG Selected
Surgical Applications
● EVLA
(varicose veins treatment)
● Laser Lipolysis
(body shaping – fat reduction and skin tightening)
● Laser Axillar Hyperhidrosis
(permanent sweat reduction)
●
….. (many other FDA approved applications in Aesthetics,
Dermatology, Surgery, Dentistry,…)
Quo vadis plastikos?
Past. Present. Future.
“We repair and fix body parts that were
given by nature but taken away by fate”
Gaspare Tagliacozzi (1545-1599) founder of modern plastic surgery.
However, they regarded his nasal operations as
ilegal and crime against nature.
He was eventually buried in unconsecrated
ground.
Modern approach
• reconstructing composite tissue defect
• different techniques, materials, instruments...
• for high success rate (function, esthethic)
Surgery
Laser and surgery
Laser
Modern aproach in leading institutions.
Do not forget
final goal
Happy Patient