Pulsed Lasers And Light Sources

Potassium-Titanyl-Phosphate Laser

For small telangiectatic leg veins in fair-skinned patients, the pulsed KTP laser has become the treatment of choice. The Versapulse KTP laser (Lumenis, Santa Clara, California, U.S.) uses the following parameters: a spot size of 3

5 mm, pulse duration of10-15 ms, and fluences of 14-20 J/cm2, which have proven to be effective. A 4°C chilled tip provides epidermal protection. Side effects include transient erythema, crusting superficially, and purpura. When administering the pulsed KTP laser, lower fluences must be employed in the

Physical Examination

Physical Examination

Non-invasive Testing Doppler / Duplex / Plethysmography

Reflux

Incompetent Perforators or

Saphenofemoral Junction

No Reflux

Surgical Ligation or

Compression Sclerotherapy

Treat Varicosities and Reticular Veins with Compression Sclerotherapy or Ambulatory Phlebectomy

Superficial Sclerotherapy or Laser or Light Therapy of Superficial Telangiectasia, Residual Vessels and of Sclerotherapy Induced Matting

FIGURE 16.3 Systematic approach to the treatment of leg veins.

Laser Depth Penetration Graph
FIGURE 16.4 Wavelength and depth of penetration.

darker skinned or tanned patient because of their increased melanin and its absorption of green light. This increased absorption is more likely to increase the risk of epidermal damage. Treatment failure, consequently, is higher in this subset of patients because the lower fluences are not very effective in coagulating the target vessel. Patient acceptance of this laser treatment system is high with minimal treatment discomfort of the longer penetrating wavelengths and a relatively uncomplicated postoperative course.11 Other technologies including the Aura (Laserscope, San Jose, California, U.S.) have produced comparable results.

Flashlamp-Pumped Pulsed Dye Laser

The pump pulsed dye laser was the first laser to achieve notable results in the treatment of leg veins in the 1980s. This treatment system utilizes short wavelength technology, at a wavelength of 577 nm. This has become acceptable for treatment of leg vessels <1.0 mm, but cannot be recommended for treatment of blue vessels or red vessels >1.0 mm given its short wavelength, relatively short pulse duration, and moderate energy fluence.12 This system, in contrast to long wavelength technologies, is less effective, and is associated with a number of side effects including bruising and post-therapy hyperpigmentation.

Longer Wavelength Pulsed Lasers

With the advent of longer wavelength technologies, including the long-pulsed alexandrite laser and 1064 nm Nd: YAG, longer pulse duration lasers and light sources, there has been a great increase in treatment outcomes. Presently, there are several long-pulse dye lasers available with variable pulse durations capable of deeper penetration into the skin and treatment of larger caliber spider and feeding reticular veins of the lower extremity.

Long-Pulsed Alexandrite Lasers

This system recently has been applied to the treatment of leg telangiectasia and reticular veins, less than 3 mm in diameter, with good results. The longer wavelength (755 nm) provides deeper tissue penetration and an ability to treat larger diameter and more deeply situated vessels. Although hemoglobin absorption of this wavelength is lower than that of 532 and 595 nm wavelengths, it is sufficient to achieve photocoagulation of a wide range of vessel sizes with the use of higher fluences. Optimal treatment parameters for the long pulsed alexandrite laser include 20 J/cm2, double pulsed at a repetition of 1 Hz. To penetrate tissue more deeply and to allow greater thermal diffusion time to treat larger vessels, the alexandrite laser has been modified to provide pulse duration of up to 20 milliseconds. Side effects include purpura, matting, and long-term pigmentary alterations due to melanin absorption.

In a recent study, the alexandrite laser system evoked a significant inflammatory response with concomitant purpura and matting when used at a fluence of 60-70 J/cm2 and a wavelength of 755 nm, in comparison to other available laser treatment systems. A study conducted by Eremia et al. concluded that the 755 nm wavelength utilized by the alexandrite system is limited to use in nontanned patients with I-III skin types.13

Diode Lasers

The diode lasers utilize a wavelength of 800 nm at 5 to 250 millisecond duration, and have been indicated in the treatment of superficial leg telangiectasis and reticular veins. This technology system with near infrared wavelengths allows deeper tissue penetration with decreased absorption of melanin. The efficaciousness of the diode was demonstrated in a study conducted by Garden et al. The patients, having a vessel size between 0.2 to 0.5 mm, were treated with an 810-nm quasi-continuous diode laser 20 millisecond pulse duration. The results of the study showed a 60% mean vessel clearance after a mean of 2.2 treatment sessions.14 With the recent introduction of higher fluence capability, the diode laser's efficacy continues to increase.415

Long-Pulsed Nd:YAG Laser (1064)

The treatment of choice for spider and feeding reticular veins has become the long-pulsed Nd:YAG laser (1064). As discussed earlier in the chapter, spot sizes, energy, and pulse duration can be adjusted to target both small telangi-ectasias and larger reticular veins with a single device. In addition, this system via its utility of a longer, deeper penetrating wavelength and subsequent epidermal bypass increases the efficacy of this system in treatment of darker skin phenotypes. This system also addresses issues stemming from the hydrostatic pressure of feeder and reticular veins because veins up to 3 mm can be treated, although the patient's tolerance to pain may become an issue as pain increases with treatment of larger vessels. The newer pulsed 1064 nm lasers have pulsed durations between 1 and 200 milliseconds [Vasculight Lumenis (Palo Alto, California, USA), Cool touch Vantage (San Jose, California, USA), Cool Glide Excel (Burlingame, California, USA), Lyra (Laserscope, San Jose, California, USA), Gemini (Laser-scope, San Jose, California, USA), and Sciton Profile, Sciton (Palo Alto, California, USA)]. For superficial vessels less than 1 mm in diameter, the optimal parameters include small spot sizes of <2 mm, short pulse durations of 15-30 ms, and high fluences of 350-600 J/cm2. For reticular veins, 1 to 4 mm in diameter, larger spot sizes (2-8 mm), longer pulse durations (30-60 ms), and moderate fluences (100-370 J/ cm2) should yield successful results. As a result, the Nd: YAG laser has been embraced by many clinicians worldwide as the state of the art for laser treatment of lower extremity vessels.

The Lyra and Gemini systems use contact cooling and encompass a 1064 nm Nd:YAG technology. Seventy-five percent improvement of veins of all colors and sizes has been reported with this technology. The Sciton Image has been used predominantly for treatment of the lower extremity telangiectasias and reticular veins up to 3 mm in diameter. Its high energy fluence and large spot size have increased its efficacy in treating both large diameter vessels (i.e., reticular veins and small capillary mats less than 1 mm in diameter). A static cooling device also is employed in this treatment system. The Vasculight also has been utilized for treatment of both smaller vessels and larger reticular veins up to 4 mm in diameter. The operator applies a coupling cooling gel in addition to an internal DCD (1-4°C) and applies the laser tip directly to the treatment vessel under consideration. Superficial red telangiectasias less than 1 mm in diameter may be treated with the hand piece coagulated and defocused off the skin and a lower energy fluence of 90-100 J/cm2 with a pulse duration of 10 to 12 milliseconds delivered as a single pulse.

Weiss et al. achieved 75% improvement at the three-month follow-up of 0.3 to 3.0 mm vessels documented by Duplex closure. Settings in this study including fluence of 80 to 120 J/cm and single-pulse durations of 10 to 30 milliseconds were utilized.16 Sadick et al. treated 20 patients with Fitzpatrick skin type II to IV with a similar technology. A mean of 2.5 treatments produced 100% clearance in 88% of patients. Mild purpura was noted in 20% of patients, and post laser hyperpigmentation was noted in 10% of patients.17

COMBINED LASER/RADIOFREQUENCY TECHNOLOGIES

The most recent development in laser technology in the treatment of leg veins is the combination of bipolar radio-frequency and optical energy, using either the diode laser or an intense pulsed light source. The basis of this technology is rooted in the idea that the two forms of energy act syner-gistically to enhance clearance of the target vessel; with utilization of this system a high energy penetration depth (>2 mm) and a high energy density on the treated vein (>100 J/cm2) can be achieved. The laser component selectively heats the vessel, allowing the preferential absorption of radiofrequency energy because of the increased temperature and the high electrical conductivity of blood. Moreover, this system has demonstrated 80% clearing of vessels <3 mm in diameter after an average of 2.5 treatment sessions by the author.

How To Deal With Rosacea and Eczema

How To Deal With Rosacea and Eczema

Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.

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