Laser surgery of leg veins

The role of lasers and intense pulsed light technology in dermatology

The role of light-based technologies in dermatology has expanded dramatically in recent years. Lasers and intense pulsed light have been used to safely and effectively treat a diverse array of cutaneous conditions, including vascular and pigmented lesions, tattoos, scars, and undesired hair, while also providing extensive therapeutic options for cosmetic rejuvenation and other dermatologic conditions. Dermatologic laser procedures are becoming increasingly popular worldwide, and demand for them has fueled new innovations and clinical applications. These systems continue to evolve and provide enhanced therapeutic outcomes with improved safety profiles. This review highlights the important roles and varied clinical applications that lasers and intense pulsed light play in the dermatologic practice.

Laser treatment of dark skin: an updated review

The growing diversification of the patient population coupled with the increasing demand for cosmetic laser rejuvenation has highlighted the need to develop cutaneous laser systems and establish treatment protocols for patients with a wide range of skin conditions and phototypes. Recent technologic advancements have provided viable treatment options to achieve clinical outcomes that were previously only attainable in patients with lighter skin tones. This review provides an updated discussion of the range of laser treatments available for pigmented skin and sets the stage for further advancements. Pigment-specific laser technology with green, red, or near-infrared light targets a variety of pigmented lesions such as lentigines, ephelides, café-au-lait macules, and melanocytic nevi as well as tattoos and unwanted hair. Short-pulsed alexandrite, ruby, and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are used for pigmented lesions and tattoos, whereas their longer pulse-width laser counterparts are used for laser-assisted hair removal. Vascular lesions and hypertrophic scars can be treated with a variety of vascular-specific lasers, but it is the pulsed dye laser (PDL) that has long been the gold standard treatment for these lesions due to its high specificity for hemoglobin and its ability to improve skin surface texture in children and adults. Laser skin resurfacing techniques for photodamaged skin and atrophic scars have been optimized with fractional technology to produce excellent clinical outcomes and minimal complication risks. Radiofrequency and nonablative lasers are also used to provide skin tightening and collagen remodeling with virtually no postoperative recovery.

Shedding light: laser physics and mechanism of action

Lasers have affected health care in many ways. Clinical applications have been found in a number of medical and surgical specialities. In particular, applications of laser technology in phlebology has made it essential for vein physicians to obtain a fundamental knowledge of laser physics, laser operation and also to be well versed in laser safety procedures.

This article reviews recommended text books and current literature to detail the basics of laser physics and its application to venous disease. Laser safety and laser side effects are also discussed.

Response of spider leg veins to pulsed diode laser (810 nm): a clinical, histological and remission spectroscopy study

BACKGROUND

Spider leg veins are common. Their treatment with laser or intensed light therapy shows generally variable success rates and often adverse side effects such as hyper- or hypopigmentation. This study was performed to investigate whether pulsed diode laser (810 nm) treatment is effective and safe.

METHODS

Thirty-five female patients with spider leg veins were included in this prospective trial. They were treated twice with a pulsed diode laser (810 nm; spot size 12 mm, frequency 2-4 Hz, pulse width 60 msec, fluence 80-100 Jcm(-2)). Laser therapy was performed on day 0 and day 14. Clinical assessments were carried out before and immediately after the first laser therapy, after 2 weeks, 8 weeks, and one year. Skin biopsies were taken before and immediately after the first laser treatment, and after 10 weeks. Contact-free remittance spectroscopy was performed before laser treatment, immediately after the first treatment, after 2 weeks and 8 weeks.

RESULTS

After the first treatment 15 patients showed a complete disappearance (CR) of spider leg veins; in the remaining 20 patients a remarkable improvement (RI) was noted (n=35). After six months of follow-up CR was seen in 6 patients, RI in 6, a stable situation in 9, and scar formation in 1 patient (n=21). The effect was almost completely stable during one year of follow-up. The examination of histological specimens before and after laser treatment showed no cellular inflammatory reaction. The mean vascular area was significantly reduced after the first (p<0.05) and after the second (p<0.05) laser treatment. Spectral analysis showed a marked decrease of peaks for oxygenized haemoglobin immediately after laser treatment and during the follow-up. Safety profile was excellent without purpuric reaction or pigmentary changes. Mild scarring was observed in two patients at the end of follow-up.

CONCLUSIONS

Pulsed diode laser therapy (810 nm) is an effective and safe treatment option for spider leg veins. The effects can be seen immediately. Objective monitoring by non-invasive remission spectroscopy and histology of biopsy specimens demonstrates selectivity of the laser action.

Laser surgery in dark skin

Although challenging, effective laser surgery in patients with darker skin tones can be achieved despite a higher inherent risk of side effects. Although the incidence of undesirable postoperative sequelae has decreased with the development of advanced laser technology and individualized treatment parameters, these risks may never be eliminated completely. Consequently, thorough patient preoperative preparation and education regarding the risks of cutaneous laser therapy will remain an essential component of treatment in darkly pigmented patients. In the future, as more refined laser techniques evolve, the ability to safely and effectively treat these patients will improve.

Vascular lasers and IPLS: guidelines for care from the European Society for Laser Dermatology (ESLD)

Dermatology and dermatologic surgery have rapidly evolved during the last two decades thanks to the numerous technological and scientific acquisitions focused on improved precision in the diagnosis and treatment of skin alterations. Given the proliferation of new devices for the treatment of vascular lesions, we have considerably changed our treatment approach. Lasers and non-coherent intense pulse light sources (IPLS) are based on the principle of selective photothermolysis and can be used for the treatment of many vascular skin lesions. A variety of lasers has recently been developed for the treatment of congenital and acquired vascular lesions which incorporate these concepts into their design. The list is a long one and includes pulsed dye (FPDL, APDL) lasers (577 nm, 585 nm and 595 nm), KTP lasers (532 nm), long pulsed alexandrite lasers (755 nm), pulsed diode lasers (in the range of 800 to 900 nm), long pulsed 1064 Nd:YAG lasers and intense pulsed light sources (IPLS, also called flash-lights or pulsed light sources). Several vascular lasers (such as argon, tunable dye, copper vapour, krypton lasers) which were used in the past are no longer useful as they pose a higher risk of complications such as dyschromia (hypopigmentation or hyperpigmentation) and scarring. By properly selecting the wavelength which is maximally absorbed by the target--also called the chromophore (haemoglobin in the red blood cells within the vessels)--and a corresponding pulse duration which is shorter than the thermal relaxation time of that target, the target can be preferentially injured without transferring significant amounts of energy to surrounding tissues (epidermis and surrounding dermal tissue). Larger structures require more time for sufficient heat absorption. Therefore, a longer laser-pulse duration has to be used. In addition, more deeply situated vessels require the use of longer laser wavelengths (in the infrared range) which can penetrate deeper into the skin. Although laser and light sources are very popular due to their non-invading nature, caution should be considered by practitioners and patients to avoid permanent side effects. These guidelines focus on patient selection and treatment protocol in order to provide safe and effective treatment. Physicians should always make the indication for the treatment and are responsible for setting the machine for each individual patient and each individual treatment. The type of laser or IPLS and their specific parameters must be adapted to the indication (such as the vessel's characteristics, e.g. diameter, colour and depth, the Fitzpatrick skin type). Treatments should start on a test patch and a treatment grid can improve accuracy. Cooling as well as a reduction of the fluence will prevent adverse effects such as pigment alteration and scar formation. A different number of repeated treatments should be done to achieve complete results of different vascular conditions. Sunscreen use before and after treatment will produce and maintain untanned skin. Individuals with dark skin, and especially tanned patients, are at higher risk for pigmentary changes and scars after the laser or IPLS treatment.

Laser treatment of leg veins: Physical mechanisms and theoretical considerations

BACKGROUND AND OBJECTIVES

A discussion of laser treatment of leg veins is based on a review of the literature, theoretical analysis, and the clinical experiences of the authors. Theoretical computations are discussed within the context of clinical observations.

STUDY DESIGN/MATERIALS AND METHODS

A Monte Carlo model is used to examine volumetric heat production, fluence rate, and temperature profiles in blood vessels at 1,064 and 532 nm wavelengths with various beam diameters, vessel diameters, and pulse durations.

RESULTS

Clinical observations, Monte Carlo results, and a review of the literature suggest that longer wavelengths and longer pulses durations favor vessel contraction over intraluminal thrombosis. Monte Carlo simulations show that longer wavelengths are more likely to uniformly heat the vessel compared to highly absorbing wavelengths. Methemoglobin production causes deeply penetrating wavelengths to generate more volumetric heat for the same input radiant exposure.

CONCLUSIONS

Clinical observations and models support the role of long wavelengths and long pulses in optimal clearance of most leg telangiectasias.

A clinical, histological, and computer-based assessment of the Polaris LV, combination diode, and radiofrequency system, for leg vein treatment

BACKGROUND AND OBJECTIVES

Electro-optical synergy (ELOS) is a novel technology that combines radiofrequency (RF) with optical energy. This study investigated the safety and effectiveness of the Polaris LV system, which is based on combined RF and diode laser (915 nm), for the treatment of leg veins.

STUDY DESIGN/MATERIALS AND METHODS

Fifty women (Fitzpatrick II-IV) with red or blue leg veins (1-4 mm in diameter) were treated with the Polaris LV, using a fluence of 60-80 J/cm(2) and conducted RF energy of 100 J/cm(3). Patients received up to three treatment sessions at 2- to 4-week intervals. Both patients and an independent physician graded the level of vessel clearance at 2 months following the last treatment, using pre- and post-treatment photographs. Also, a computer-generated assessment of vessel clearance was done in 40 patients. Twenty patients provided biopsy specimens for histologic assessment.

RESULTS

Approximately three-quarters of patients demonstrated >/= 50% vessel clearance, and about 30% had 75%-100% vessel clearance. Computer-generated scores correlated closely with physician scores. Histologic assessment showed signs of coagulation and prominent endothelial degeneration in all treated vessels, but the epidermis remained normal. There were minimal complications.

CONCLUSIONS

The Polaris LV is effective and safe in treating red and blue leg veins up to 4 mm in diameter.

Laser and intense pulsed light therapy for the esthetic treatment of lower extremity veins

The role of lasers and intense pulsed light sources has gained increasing popularity over the last decade. Major advances associated with improved results are the main reasons associated with this increasing popularity. These advances include epidermal cooling technologies, variable spot sizes and pulse durations as well as the ability to deliver high-energy fluences. These advances have allowed the delivery of sufficient energy to cause uniform pan-endothelial necrosis without affecting epidermal structures causing adverse sequelae such as post-inflammatory hyperpigmentation and epidermal surface irregularities. The advent of extended-pulse longer-wavelength technologies such as the 1064 Neodymium : Yttrium Aluminum Garnet (Nd : YAG) laser have allowed the treatment of individuals with darker phenotypic skin types as well as deep blue reticular veins up to 3mm in diameter in a monomodal fashion. Combined approaches of sclerotherapy plus laser treatments performed at the same treatment session may produce synergistic results in selected individuals.

Laser treatment with a 1064-nm laser for lower extremity class I-III veins employing variable spots and pulse width parameters

BACKGROUND

The long-pulsed 1064-nm Nd:YAG laser (employing varying spot sizes, pulse widths, and fluences) has gained popularity for treating lower extremity blue and red vessels that are less than 4 mm in diameter.

OBJECTIVE

To evaluate the efficacy of high-power 50-ms 1064 Nd:YAG laser in the treatment of class I-III lower extremity vessels.

METHODS

Ten female patients (mean age of 39 years) had a 5-cm2 area of veins measuring 0.2 to 3 mm in diameter treated with up to three treatment sessions using a new 1064 Nd:YAG laser, with the end point being 100% vessel clearing after three treatments. Red vessels were treated with a spot size of 1.5 mm, a fluence of 400 to 600 J/cm2, a pulse width of 30 to 50 ms; blue vessels of 1 to 3 mm were treated with a spot size of 3 mm, a fluence of 250 to 370 J/cm2, and a pulse width of 50 to 60 ms. Macrophotographic imaging evaluations by blinded observers using a quartile scale and a patient satisfaction scale were employed to evaluate results.

RESULTS

At month 3 after the final treatment session, 20% of all vessel types had 50% to 75% improvement. Equal clearing was noted for blue and red vessels. At month 6, 80% of patients had a greater than 75% clearing. Ninety percent of patients were highly satisfied with the treatment results at 6 months.

CONCLUSION

By varying spot size, fluence, and pulse duration, a long-wavelength 1064-nm Nd:YAG laser can achieve excellent results for treating both blue and red lower extremity vessels that are less than 3 mm in diameter.

Lasers in dermatology: four decades of progress

Advances in laser technology have progressed so rapidly during the past decade that successful treatment of many cutaneous concerns and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair-can be achieved. The demand for laser surgery has increased substantially by patients and dermatologists alike as a result of the relative ease with which many of these lesions can be removed, combined with a low incidence of adverse postoperative sequelae. Refinements in laser technology and technique have provided patients and practitioners with more therapeutic choices and improved clinical results. In this review, the currently available laser systems with cutaneous applications are outlined, with primary focus placed on recent advancements and modifications in laser technology that have greatly expanded the cutaneous laser surgeon's armamentarium and improved overall treatment efficacy and safety.

Laser surgery in dark skin

Although challenging, effective laser surgery in patients with darker skin tones can be achieved despite a higher inherent risk of untoward side effects. While the incidence of undesirable postoperative sequelae has decreased with the development of advanced laser technology and individualized treatment parameters, these risks may never be eliminated completely. Consequently, thorough patient preoperative preparation and education regarding the risks of cutaneous laser therapy will remain an essential component of treatment in darkly pigmented patients. In the future, as more refined laser techniques evolve, the ability to safely and effectively treat these patients will improve.