Energy devices 101

The Keys to Better, Faster, Safer Outcomes…

Disclosures
• Nothing to disclose.
• A comprehensive guide to Aesthetic Energy based Devices and
their practice integration.
• Laser, IPL, RF, Microwave, Cosmeceuticals, other devices.
• Patient consultation, diagnosis, treatment, following.
• The best practices, the best concepts, the best device features,
and the best treatment methods from sites around the world.
Patrick J. Clark, PhD, CMLSO

• 36 years of laser medicine

• 1988-90 University of North Carolina Hospitals, Chapel Hill, UNC
• 1990-92 Private practice educator in abdominal Endoscopy and Gyn
• 1992-2004 University of Texas Southwestern Medical Center at Dallas
• 1997 Epicentre MedSpa, Dallas Plastic Surgery
• 1999-2001 Medical Alliance Inc., 38 states, 620 physicians
• 2001-2004 ICN Pharmaceuticals (Valeant)
• 2004- Medical Laser Dynamics, Smarter U.
Our Three Sponsors
and our many thanks…

•Sunshine
•Hormones
•Aging
Kinds of Procedures
• Ablative, A procedure that creates the need for
wound care
• Often Physician managed or performed
• NonAblative, A procedure that is non- or minimally
invasive with no wound care
• Procedures that can be delegated
Non-Ablative Procedures
defined by what they do not do….

• FDA definition of Non-Ablative Procedures

• Based on the signs of the aging face by experts

• Type One What we see

• Things we see, Dyschromia ( reds, browns…)

• Type Two The structure beneath

• The foundations, loss of volume, light return, depletion of components
Type One
what we see….

• We flush out browns from the system.

• That process has an immediate reaction,
• manifested in 24 hours,
• resolution in as much as 14 days

• We contract reds.
• The result can be spontaneous
Type Two
the structure beneath….

• We loose structure and volume with age.

• Collagen. depletion begins in the 30’s,
• Bone is decreasing,
• Action and rest lines appear

• We restore them with time. (90-180 days)

• The healing processes can be stimulated but it takes time
What are our goals?
• To selectively heat something to change
• Understand the impact at 40oC, 50oC, 75oC
• To spare the surrounding tissue
• To avoid complication
• Blistering
• Hyperpigmentation
• Hypopigmentation
• Scaring
Untaught Cardinals Rules
the secret keys…

• 1. Treat Clean Skin only

• 2. Avoid sweaty exercise and tight clothing for 48 hours
• 3. The 1st treatment is both clinical and diagnostic
• 4. We provide Treatment and Not Cure
• 5. Your care falls into three steps: Repair, Maintenance,
Prevention
• 6. Procedures have contraindications and failures
• 7. Be in the moment, watch for reaction
Untaught Cardinals Rules
the secret keys…

• 8. Follow-up for endpoints

• 9. Target color and texture impact success
• 10. Lesions Midline are more resistant
• 11. Those needing most are the worst at skin care
• 12. Their plan includes pre-,peri-, and post-care
• 13. Skin will be dryer for 14 days post
• 14. Keys to understanding:
• What brings you?, how long?, what time frame?,
• expectations?, expense.
A
B

E
 What zone are trying to improve?
• IPL is very shallow
in most applications

• Lasers can be
shallow to full dermal
thickness

• Radio Frequency
and Microwave are
mid-dermal to Sub-Q
Dermal thickness 350µ

in microns (µ) 180µ 700µ

Epidermis is
800µ
100µ on average 1100µ

1300µ
150µ
Where to begin a facial treatment
• Mid thickness
• Preauricular

• Side of the face dependent?

• Sun exposure on left
Do you bake?
Can you open a can of biscuits and put them on a cookie sheet?

• Biscuits

• How hot, for how long, watching for endpoint.

• The core of Selective Photothrmolysis.
 VISIBLE
Ionizing near mid-far Microwave
radiation UV Infrared Infrared
200-400 / 400-750 / 750-1300 / 1300-10,600+

200-400 nanometers – Ultraviolet invisible light

400-750 nanometers – Visible light
(Violet, Indigo, Blue, Green, Yellow, Orange, Red)
750 – 1,300 nanometers – near-Infrared invisible light (NONABLATIVE)
1,300 – 10,600+ nanometers – mid-Infrared invisible light
1,300 – 1,900 heat to coagulation
1,900 - 10,600 heat to boil (ABLATIVE)
Types of Clinical Energy

• Nonablative 400-1,300 (1,900) nanometers

• LASER
• IPL
• Also RF and microwave
• Ablative 1,900 – 10,600 nanometers
• LASER
Two light sources
• Laser
• Collimated
• Coherent
• Monochromatic
• IPL
• Polychromatic
 Types of light source
White

Pulsed Light Devices

Laser
Depth of Penetration
Er C02 KTP PD Ruby Alex Nd:YAG
Penetration of light by wavelength

400-1,064 nm
Differences between IPL and Laser

Lasers like defined targets IPLs like diffuse targets

Lasers prefer vascular IPLs prefer pigment

They both like defined pigmented targets (hair)

 How do they differ?

UV IRA IRB
400nm 515 640 750 1300

Laser IPL
 How do they differ?
• Lasers
• Monochromatic, looking for exact target
• IPL
• Polychromatic, looking within a layer of dermis
• Radio Frequency
• Bipolar, a specific level or dermis or subQ
• Monopolar, from a dermal level and deeper
• Microwave
WHAT IS TISSUE’S REACTION?

Chemical
Photodynamic
Therapy
Thermal
Stimulate,
necrose,
coagulate
Acoustic
Lithotripsy
 Laws of Photochemistry:
1. Nothing happens without absorption
2. We titrate change with photons or electrons
3. Selective Photothermolysis
Wavelength, Power, Spot Size, Time
How hot. How Long

Thermal Relaxation Time (reaction time)

Anderson/Parrish Law
 How Hot?
• (Rule of Thirds)
• Selection of a range of energies, 10-35 J/cm2
• Determined by the target (intensity) color.
Look to the cars…
The result…

• Similar things of different shades require

different energies.
• The target reaction is always set temperature
• Less energy required when target is darker.
More as it lightens.
 How Long?
• Pulse time, pulse duration, pulse width are all how long
energy is exposed to the target.
• The time is commonly in milliseconds.
• Time for the target is determined by it’s size. Smaller targets
have smaller (shorter) reaction times and vice versa.
Look to the pots…
What is the true target?
Reduced & Oxy-hemoglobin
vascular lesions
Melanin
pigmented lesions, hair
Water
tissue stimulation, incision/excision, ablation
Exogenous
tattoo ink, PDT
 Visible Spectrum and
Complementary Color Reaction

570-600nm

540-560nm

510-530nm
Spectral Response

UV IRA IRB

Visible spectrum devices respond best to their color

opposite.
In the IRA, the 1,064 nm Nd:YAG laser, some diodes, and
much of the output from an IPL respond to shades of grey
seeking the darkest target in the light field.
 Co Fo Reaction

205 400 vaporization

Thermal 100 212 cell extravasation

Thresholds... 90 desiccation and contraction

194

65 149 protein destruction

50-55 131 tissue contraction

44 111 cell stasis

42 108 top of peak stimulation window

40 104 collagen stimulation

37 98.6 normal body temperature

 Ideal Spot Size
Applies only to visible targets,
either indigenous or exogenous
Should equal or exceed the depth of penetration
Larger is better, but there is an energy limit

532nm = 3mm spot

1,064nm = 6mm spot

IPL
Laser
Time of the Pulse(s)

Joules do not equal Joules

Heating is a transitory and dynamic process, rate
dependent
Ideal Pulse Time is based in two things:
Volume of tissue to be treated with transmitted
heat
Time to resolve conducted heat
 Ideal Exposure Time

Thermal Relaxation Time – time to drain full funnel

Perfect Pulse time is ½ TRT
 Longer Times Equal More Waste

Fast
Slow

Drain rate is constant so longer pulse time means more energy

drain to collateral tissues
Light vs. RF and Microwave
• Light ‘from the outside in’
• Always transfer through DE Junction
• Best for Upper to Mid-dermal targets
• RF and Microwave ‘from the inside out’
• Most transfer through DE Junction
• RF Microneedling can bypass DE Junction
• Better for deep dermal and SubQ targets
Light vs. RF and Microwave
• Light ‘from the outside in’
• Better for Type I nonablative, dyschromia
• Flushing out reds and browns
• RF and Microwave ‘from the inside out’
• Better for Type II nonablative
• Contracting dermal and subdermal tissue
• Increasing dermal volume
Understanding ‘COOLING’
• The goal of ‘cooling‘ is to protect the DE Junction
• The function there is to not allow the DE junction to heat
• It is not about cooling but thermal stabilization
• High cooling impacts change in shallow targets
• High cooling exposes patient to unnecessary risk by
elevated energy
• Know the conversion: 22oC equals 72oF
• Post cooling is the most important
 Safety With Light
Why laser rules are so tight and IPL rules are not…
Safety with Light
photons and PPEs

Safety with light devices used for ablative and nonablative

procedures has several aspects:
Logically they include risk to the patient/client and others in
the room during a procedure including the person delivering
the light therapy.
ANSI Z136.1, -.3
• The American National Standards Institute is a group of nonaligned
professionals who establish safety and process guidelines for many
things around the country. They were enlisted by the FDA ,OSHA,
and others to generate the guidelines for laser and light safety.
• The ANSI Z136.3 is the accepted standard for all professional and
regulatory groups in the US including the ASLMS, AAD, ASAPS, and
many others. It is the core of most State ruling and control.
• It details safety from three viewpoints: performance, administration,
and devices (PPE, signs, etc.)
• But the core is the Laser Safety Officer and the recognition of the
need for control .
 • The Laser
• Physics and biological effects
• Components of the laser system, delivery
devices,

Minimum goals for •

•
and instrumentation
Overview of clinical applications

accepted
• Administrative Controls
• Laser Committee
• Role of the LSO

education and skill •

•
Development of policies/procedures
Documentation methods

demonstration
• Regulations, standards and recommended
professional practices
• Certification criteria and skills validation
• Medical Surveillance
• Perioperative Safety

Confidence and
• Controlled access
• Eye Protection

Competence
• Refection hazards
• Flammability hazards and draping
• Electrical Safety
• Management of plume
• Management of anesthesia in airway surgery
• Equipment testing, aligning, and troubleshooting
Classes of Laser Risk
that very first day in a hospital….x-rays
• Class I-II present no calculable risk unless viewed constantly for
a full work day
• Class III
• Require safety eyewear
• Must not be directly viewed
• Class IV
• All medical/aesthetic lasers
• Require safety eyewear
• Must not be viewed at all, any reflection even if diffuse
• “If the laser product Is applied in contact-mode to the skin of humans
or animals with levels of radiation which are associated with Class 3R,
Class 3B or Class 4, and has safeguarding devices that are specified in
clause 6.12., then the product can be assigned to Class 1C.”
IPL risk
• Intense Pulsed Light does not carry the same viewing risks as do
lasers
• There is no collimated beam
• The footprint is dimensionally much larger
• The energies are less
• BUT eyewear should be worn as protection from intense light
Eye Risk
Internal

External
Laser Eyewear Guidelines
• IPL glasses have no guidelines, they are just dark glasses
• Laser Eyewear have two defined safety factors that must be on the
lenses or frame
• Wavelengths protected against (in a band of wavelengths)
• Optical Density (OD) at those wavelengths (3.0-9.0)
• Higher OD often present lower VLT

• Clean both types with soap and water

Electrical Safety
• Make sure the proper 110 or 220-volt outlets and plugs are
provided
• Make sure the laser or IPL is not used in standing water
• Never remove the covers from the device
Know the cooling requirements for the
Room

• Lasers are very inefficient

• Many create up to 14,000 BTU of heat in room
• A ‘ton’ of air conditioning is 12,500 BTU
• Add all the other devices running simultaneously
 Plume!
• If you can smell it it is not being captured
• OSHA and NIOSH have done lots of studies without conclusion
• Use a vacuum device, correctly
• Wear masks correctly
• Negated if cold air being used to comfort patient
Which National and International Standards Affect
Medical Laser Practices?
 LTCA Shall Be Clearly Delineated,
and Shall:

• Approved Signs Posted

• Supervised By Trained HCP
• Only Authorized Persons in Room
• Windows Restricted
• Doors Closed (not locked)
• Easy Entry / Exit in Emergency
Section 4.6.2 Laser Protective Eyewear (LPE)
LPE Specifically Designed…for
Protection Against Radiation
From Class 3b / 4 HCLS, Shall
be Administratively
Required…Use Shall be
Enforced Within the NHZ.
Section 4.6.2.1 Laser Protective Eyewear (LPE)
• LPE can include:
spectacles, goggles,
periorbital goggles,
corneal shields or wet
cloth towels over the
ocular area.

• Must reduce the potential

ocular exposure below
the applicable MPE level.
Section 4.6.2.3 Identification of
Eyewear
All LPE shall be clearly labeled
with the O.D. and wavelength
for which protection is afforded

Adequate O.D. at the laser

wavelength of interest shall be
balanced with the need for
adequate visible light
transmission (VLT)
 Hazards with IPL Systems

Ocular Complication of Intense Pulsed Light Therapy: Iris Photoablation

GOLNAZ JAVEY, MD, STEPHEN G. SCHWARTZ, MD, MBA,y AND THOMAS A. ALBINI,
MD

2010 by the American Society for Dermatologic Surgery, Inc. Published by Wiley
Periodicals,
ISSN: 1076-0512 Dermatol Surg 2010;36:1466–1468
 4.7.1 Display Of Area Warning Signs
Area warning signs should be conspicuously displayed on
all doors entering the LCTA so to warn those entering the
area of laser use. Signs should be displayed in accordance
to ANSI Z136.1 2007 Section 4.7
Area warning signs shall be covered or removed
when laser is not in use.

ANSI Z136.3-2011 compliant NEW: ANSI Z136.1-2014 compliant example

In summary
• Lasers have highest risk and highest level of control and regulation.
• IPLs are next on optical risk, higher on patient risk, included in many
regulations.
• ‘Energy based’ devices are now beginning to include Radio Frequency
and Microwave driven devices.

• For both patient/client, employee/practitioner, and regulatory

medical/legal safety regulations are increasing.
 Dealing with Pigment

Laying down patient evaluation guidelines and how to

address unwanted pigment
 Pigment
• The most common target for light-based therapy.
• The elusive chase for hair, age spots, freckles, melasma, café-
au-lait, poikiloderma and many more unwanted targets
What is
Hydroquinone?

How else can

we inhibit
tyrosinase?
The signs of aging skin
• The experts tell us that the two primary signs of aging skin
are:
• Dyschromia, irregular pigmentation or vasculation
• (Type One)
• Loss of Collagen reducing the volume of the face and body
parts
• (Type Two)
Melanin
• Formed as an end product during metabolism of the
amino acid tyrosine.
• The body generates melanin as a protective umbrella to
prevent Ultraviolet light damage to the cells.
• Each melanocyte watches over about 36 keratinocytes
• Our concern is NOT TAN
• Our concern is recent sun exposure which indicates and
active melanocyte
 Active melanocytes create complication and
PIH, active tanning
• When were you last in the sun for:
• 30 minutes without protection
• before and after treatment
• Laser: 3-7 days before and after treatment
• IPL: 14-28 days before and after
Triggers and concerns
• What causes the increased production of melanin is not
always known but some triggers include:
• * Heredity factors and hormone fluctuation/production:
• *Rash is most common in pregnant females
• * Prolonged sun exposure
• * Use of birth control pills
• * Certain medications like tetracycline and anti-malarial
drugs (derived from quinine)
Melanotan and Melanotan II
• Barbie or James Bond drug
• Designed by the University of Arizona to provide protection
• M II has other impact
• Definitely alters Fitzpatrick Type and Sun Exposure rules
• Most active in the first three days
• Studies still unclear as to when the peptide clears the system

• Some consider it a hard contraindication

Gauging Skin Tone
• Early in the application of lasers to skin (circa
1960), and even more so in the application of
Intense Pulsed Light (circa 1995), we discovered
that risk of complication was directly tied to
patient’s ethnic color and sun habits.
• A predictive tool was necessary to evaluate
potential risk of skin injury.
 Von Luschan’s Chromatic Scale
• Von Luschan's chromatic scale is a method of classifying skin color. It
is also called the von Luschan scale or von Luschan's scale. It is named
after its inventor, Felix von Luschan. The method consists of 36
opaque glass tiles which were compared to the subject's skin, ideally
in a place which would not be exposed to the sun (such as under the
arm).
• A tiered scale of skin types is currently in use for the
purpose of classifying sun tanning risk. These types
correspond to:

• type I: von Luschan 1-5 (very light).

• type II: von Luschan 6-10 (light).
• type III: von Luschan 11-15 (intermediate).
• type IV: von Luschan 16-20 ("Mediterranean").
• type V: von Luschan 21-28 (dark or "brown").
• type VI: von Luschan 29-36 (very dark or "black").
The Fitzpatrick Chart

The validity and practicality of sun-reactive skin types I through VI.

Arch Dermatol. 1988 Jun
Eyes do not Lie
• Three Patient Types
• Non-Brown Eyes: Blue, green, hazel
• Fitzpatrick I-II
• Medium Brown Eyes
• Fitzpatrick III-IV
• Dark Brown Eyes
• Fitzpatrick V-VI

• Do Your Parents or Grandparents have different eye, skin, or hair

color than you?
What does a Photofacial Do?

Evaluate all aspects of the treatment and response

Consider a
real time
evaluation
tool
We will not remove your brown spots!

• We will remove the excess brown from you pigmenting

spots
• Removing would result in hypopigmentation
• We will sweep out the extra pigment produced and
reset the site
Take Good Photos
• Good Photographs are vital both and predictive.
• Good photos of each patient visit showing development and improvement.
• But also, as a ‘before and after’ for other potential clients who need to know they
will look worse before they improve. In this case it is not before and after as
much as ‘during’ that is important.
• So many do not understand the temporary darkening. Photos tell the story.
Type IV Skin Treatment
Make a ‘During’ Book
• Before and After is great
• Have a clinical book to show progression after any procedure
from which they will look worse immediately after.
• This includes:
• Peels, Photofacial, Fractional, Microneedling, etc.
Transient Depigmentation
Treat Globally, not Spot Treatment
Melasma is induced by Female 20-45 with Fitz III_IV
thermal or hormonal
extreme

It commonly has
pixelated edges

It initiates over convex

areas and spills
ABNOM
Ideal treatment methods
• For most native pigment disorders a Q-Switch nano/picosecond laser
is best
• It modifies the melanocyte
• Visible laser and IPL is contraindicated for melasma and ABNOM
• Biggest reason is incorrect energy and time selection

• The greatest fear is not failure to clear but rebound Melasma or

ABNOM which is usually much worse
 Hair
Reduction
Where on your body do you
not have hair?

Bottoms of the feet and the

palms of the hands only.
(Glabrous Skin)
 Where on your body is hair
density the highest?

Across the malar ridge of the cheek there are 880

hairs per squared centimeter.
How often do you hear a complaint?
 Pulse Time for Terminal Hair

•Treat hair shaft •Treat hair follicle

•60-100 microns •150-200 microns
•3-5 mseconds •15-30 mseconds
Hair Phases
How
• Light selectively
targets dark
terminal hair
does follicles and heats
them with energy.

light
• The heat alters the
bulge, the hair will
not grow back the
work? same
• (if at all).
Consultation
Patient history

Any previous hair methods

Expectations

Treatment explanation

Photographs

Consent

Periprocedure instructions
WHEN DO YOU TREAT?

During Anagen cycle

not catagen, not telogen

Cycle time (natural) determined by

• Richards-Merhag chart

What about after series?

Can we synchronize the phases?

Richards-Merhag

These are natural times, light interrupts these rates

Contraindications
Pregnancy

Recent sun exposure

Suspicious lesions

Drug Therapy

Others?
 Caution
Tattooed areas should not be treated.
Tattoo ink may absorb laser energy
resulting in a color change in tattoo
ink or a risk of epidermal damage.
Red is commonly Iron
White is often titanium
 Caution
Darkened moles should not be
treated. Moles may absorb laser
energy resulting in a color change
creating a risk of epidermal damage
and the inability to monitor the lesion
under ABCD(E) guidelines.
Who can be All patients, all All skin colors
(Fitzpatrick Type
(skin color as mesh
screen, dark skin =
treated? areas I-VI)
tight mesh, longer
time)

Unwanted
The results hair will
disappear
 Caution
•Do not treat with hair present on skin
surface. Any length beyond visible
stubble allows heat collection at the
epidermis and possible complication
including blistering.
Caution
•Tattooed areas should not be treated.
Tattoo ink may absorb laser energy
resulting in a color change in tattoo ink or a
risk of epidermal damage.
 Caution
•Overlapping pulses may lead to excessive
subsurface temperature resulting in blisters or
denatured collagen. Proper pulse spacing will
avoid this.
Caution
•Do not stack pulses or overlap consecutive
scans. Repeated pulses in the same location
may lead to a build up of subsurface heat and
a subsequent blister or burn.
In summary
Most pigmented lesions and pigmented hair
respond better to IPL treatment than to laser
treatment.

Most will require three or more treatments

scheduled at least two weeks apart for
pigmented lesions and timed according to
body site for hair.

Some lesions like freckles, melasma, and Café-

au-lait will not respond well and often return.
In those cases clients should be prepared for
on-going treatment and possible failure.
 Tattoos
The gift that keeps on giving…
 Mechanism
Laser light of the correct wavelength is absorbed by the particles of tattoo
pigment that lie between 0.5mm and 3mm into the skin.

This laser light causes the particles to heat rapidly leading to an explosive
fragmentation of the collagen capsule and the pigment contained within.

The fragmented particles are gradually removed by the body's own defence
mechanisms.

The skin heals and the process can be repeated to remove deeper lying
tattoo pigment with each treatment.

The tattoo fades away.

 What exactly happens?
• • Laser light of the correct wavelength is absorbed by pigment contained within
the dermis.
• • The pigment heats up rapidly and explodes into small fragments.
• • The interaction is too rapid for any heat to be conducted away to normal skin
tissue.
• • The exploding particle causes localized damage to the dermis in the form of
vacuoles (microscopic holes), erythema (inflammation) and possibly ruptured
capillary vessels (bleeding).
• • The small fragments of the target particle are removed by normal
macrophage activity and other dermal repair mechanisms.
• • The skin heals well because no damage is caused to the underlying
architecture of the dermis and therefore minimal scar tissue is formed.
 • Most dermatologists caution that complete tattoo removal is not possible.
Tattoos are meant to be permanent, so removing them is difficult. The degree
of remaining color variations or blemishes depends upon several factors,
including size, location, the individual's ability to heal, how the tattoo was
applied and how long it has been in place. For example, a tattoo applied by a
more experienced artist may be easier to remove since the pigment was evenly
injected in the same level of the skin. New tattoos may also be more difficult to
remove than old ones.
• Doctors say they can't predict the exact degree of removal because they
generally don't know which of the 100 tattoo inks available today were used.
(The U.S. Food and Drug Administration currently lists tattoo pigments as "color
additives," which are intended only for application to the top layer of the skin.)
Kirby-Desai
• A predictive scale, the "Kirby-Desai Scale", was developed to assess
the potential success and number of treatments necessary for laser
tattoo removal, provided the medical practitioner is using a quality-
switched Nd:YAG (neodymium-doped yttrium aluminum garnet) laser
incorporating selective photothermolysis with eight weeks between
treatments.
• The Kirby-Desai Scale assigns numerical values to six parameters: skin
type, location, color, amount of ink, scarring or tissue change, and
layering. Parameter scores are then added to yield a combined score
that will show the estimated number of treatments needed for
successful tattoo removal.
Instinctive versus Acquired targets

Instinctively lasers seem to excel above IPL when there is a

the defined vascular target.

Telangiectasia, Venulectasia, and Varicosities are often more

successfully treated with a laser wavelength over IPL.

However, Port Wine Stains, Rosacea, and some other the

diffuse vascular lesions are well targeted and cleared by IPL.
 Rosacea

"Skin Rejuvenation for Sun Damage,

Aging, and Rosacea using IPL"
by Dr. Patrick Bitter Sr., M.D., and Dr. Geoffrey Nase, Ph.D.
 • Following more than 30 years of treatment of vascular
lesions using lasers, a new laser-like intense pulsed light
(IPL) device was developed that treats these conditions
with success and answers the essential lifestyle criteria
when used in a carefully administered program.
• This new IPL skin rejuvenation technique called
PhotoFacial now has a clinical history of more than
30,000,000+ treatments with excellent patient acceptance.
 • The PhotoFacial technique is a proprietary treatment
protocol developed by Dr. Patrick Bitter, Sr. It consists of a
series of IPL treatments, usually five treatments over a
period of 4 months.
• After a thorough consultation and discussion of risks and
benefits, a full patient history and three high-quality facial
photographs are taken.
• The IPL is performed on the full face after administration of
topical analgesia.
• As reported by the Rosacea Society, rosacea sufferers
number more than 13 million in the U.S. alone. This
is a chronic skin disorder affecting the face,
characterized by redness and telangiectasias, and is
punctuated by episodes of inflammation with
papules, pustules, and swelling.
• There are four basic stages through which rosacea
sufferers may progress: pre-rosacea, mild, moderate,
and severe forms.
• Pre-rosacea refers to the stage where a person
flushes or blushes to a stimulus, but returns
immediately to normal when the stimulus is
removed.
• The progression of pre-rosacea to bouts of
flushing and blushing that do not dissipate for
hours or days is now considered to be directly
related to micro vascular dysfunction or
damage.
• Therefore, therapy should be centered around
the removal of damaged and dysfunctional
micro vessels such that new thicker walled
micro vessels with normal plump endothelial
cells laid down.
• Physicians have used tetracycline, dapsone,
erythromycin, chloramphenicol,
metridonazole, clonidine with limited success.
Topical treatments with antibiotics, sulfa
preparations, and topical steroids have also
been used.
 • The most difficult patients to treat are those with
Fitzpatrick skin type I who have a long history of sun
exposure.
• In these patients, connective tissue is so fragile that
IPL parameters selected for optimal relief of redness
may damage the skin, with higher incidence of
purpura, swelling, and blistering.
• The standard five treatment program is usually
extended in this patient group.
 Port Wine Stains
(Port Wine Stains) PWS occurs in about 0.3% of the
population with equal incidence in males and females.
They are present at birth and develop over time. In the
past these lesions were called "capillary hemangiomas."
The exact cause of PWS is not known although some
physicians believe that the progression of a PWS is
related to a problem in the nerve control over dilation
and relaxation of the blood vessels. PWS treatment
historically involves treatment with Pulse Dye lasers.
Waner, M., Suen, J., Hemangiomas and Vascular Malformations of the
Head and Neck, 1999 Wiley-Liss New York .
The results vary and may be temporary. As the
PWS progresses maintenance may be necessary
through life. It is believed that early laser in
childhood may prevent a darkening of the PWS
or a "cobbling" and thickening of the skin which
occurs in adult years. Patients diagnosed with
PWS should be evaluated by a dermatologist in
early childhood and followed through life.
 A PWS is said to be a result of a deficiency or absence of
the nerve supply to the affected area’s blood supply. The
nerves control the size and diameter of the blood vessels.
An abnormality results in a dilation of the blood vessels.
The number of blood vessels is usually normal in the
affected area. Since only the size is affected, more blood
can flow through the dilated vessel. Since these vessels are
close to the surface of the skin the skin appears pink or
purple. The faster the flow of blood the darker the stain.
 PWS follow a progression. From birth they are flat, and
most often light pink. As the vessels continue to enlarge
and thicken the lesion will darken. In the teens it can be
red and by age 30 many are purple. The skin can become
lumpy. The growth of these lesions is varied from person
to person. Some do not darken until 50-60 years of age.
However it is important to note that all PWS will
eventually darken, thicken and form irregularities to the
skin texture.
Since Port Wine Stains are considered superficial (not deep
in the skin) lesions the best treatment course is light
therapy. Rarely should surgical removal be considered and
only in older patients. Port wine stains need multiple
treatments.

Statistics show that 15-20% will respond and completely

resolve after completion of therapy. The deeper the lesion
the less likely for a good response since the laser wont
penetrate the deep components of the PWS. (Nd:YAG)
Even with treatment many PWS reoccur after 5-
10 years. This occurs because the remaining
vessels continue to dilate since the nerve
supply is still deficient.
The laser or light source does not treat the
nerve supply.
Touch up treatments can be performed through
out life.
 Hemangioma

In order to understand how hemangioma is treated

you first must consider the unique natural history a
hemangioma presents. Untreated all hemangioma
will involute, however some will cause functional
impairment and psycho-social concerns.
After involution is complete many will leave residual
scarring in the form of fibro fatty tissue,
telangiectases and other skin irregularities.
How hemangiomas are treated is therefore
individualized. The location, potential for
complications, size, age of the patient and
rate of growth must be considered and
weighed against the risks and benefits of
treatment.
Clinicians will evaluate the hemangioma for ulceration,
bleeding, infection and pain. They will consider the risk of
scarring or permanent disfigurement after involution is
complete and examine the psychosocial distress on the
patient and the family unit. Up until recently
uncomplicated hemangiomas were “observed” and never
treated. This practice was based on research information
from as far back as 1928, and was in large part due to the
fact that there was no dictable treatment options
available.
It was hoped that most lesions would become smaller
on their own. Clinicians agree that there are some
general indications for treatment of hemangioma. Life-
threatening hemangioma and those that are causing
impairment of vision, hearing, airway or are at risk for
liver involvement, heart failure or respiratory
compromise. There are certain anatomic locations that
are known to leave permanent deformity, and
therefore should be treated.
Hemangiomas located on the nose, lip and
ear or large facial hemangiomas with
ulceration are known to leave permanent
scarring or disfigurement.
Patients with lesions meeting these criteria
should be evaluated for the best course of
treatment.
That course has historically been a long wavelength laser like the
Nd:YAG. However recent literature indicates that an IPL with the
appropriate settings and cooling are very effective also.

The client should be advised of the complications (blistering,

bruising, ulceration).

This is a multitreatment process with retreatment occurring

every 4-8 weeks until satisfaction or stabilization without change
is observed.
Differing in both size and content from a PWS, the
hemangioma will require a pulse time beyond 20
milliseconds entering into the 40-60+ millisecond domain.

Fluence will be adjusted up to the appearance and

avoidance of skin blanching grey or white at the treatment
site.

Often no immediate endpoint is visible. Improvement

from a treatment is often seen in 14-21 days.
 Mary Wu Chang, MDPosted: 08/28/2008; Journal Watch. 2008;7(6) © 2008 Massachusetts Medical Society
A serendipitous discovery suggests that propranolol holds great promise for
treating endangering hemangiomas.

• These investigators serendipitously discovered that propranolol effectively treated hemangiomas in two infants
who received the drug for cardiac complications while on corticosteroid therapy. One index patient was a 1-
month-old infant with a rapidly growing segmental facial hemangioma who had ocular complications and
tracheal–esophageal deviation despite oral corticosteroid treatment. Increased cardiac output developed, and
propranolol was started. Seven days later, the hemangioma was significantly smaller. Prednisolone was
discontinued at 4 months of age, and no rebound occurred.
• Subsequently, an additional nine infant… were treated with propranolol. Two had prior oral corticosteroid
therapy; seven did not. Propranolol (2 mg/kg/day) was initiated at 2 to 6 months of age and discontinued at 8 to
All patients responded within 24 hours after
14 months of age.
propranolol initiation, and the color and thickness of the
hemangioma continued to improve. There was no significant
rebound growth after propranolol was discontinued. The authors
hypothesize that propranolol (a nonselective beta-blocker) effectively treats infantile hemangioma by causing
vasoconstriction; decreasing expression of the genes for vascular endothelial growth factor (VEGF) and basic
fibroblast growth factor (bFGF), which contribute to angiogenesis; and triggering apoptosis of capillary
endothelial cells.
 Veins
Anatomic Terms:
The terms used in describing the venous system are
often unfamiliar and confusing. Hopefully the
descriptions below will help you understand the
subject matter more clearly.

Veins- general name given to the anatomic vascular

structures that return blood to the heart. These
structures contain one-way valves which begin to
appear when the size of the vein gets to be > 40
micrometers in size.
Venous Disease
• Millions of Americans have this problem? What is venous disease? Is it
dangerous? How can one recognize it?
• Can it explain many of the symptoms you have in your legs? Can it be
treated successfully without hospitalization and open surgery? Can it
be prevented? These questions are of concern for patients, doctors,
and the general public.
• The prevalence of venous disease in Western populations is
estimated at 40+%; with 25-33% of the females and 10-20%
of the males in the US afflicted.
• Deep venous system-this refers to the system of veins that lies deep to the
connective tissue layer that surrounds the muscles. Most of the blood that returns
to the heart travels through this system.

• Superficial venous system-this is the system of veins that lies superficial to the
connective tissue layer that surrounds the muscles. Problems with this system are
the cause of most of the treatable venous problems.

• Perforating veins-these are veins that connect the deep system to the superficial
system. blood is directed normally to the deep system by these veins. When blood
goes backwards (reflux), then problems can develop.
Telangiectasias can be successfully treated
over a 3-4 treatment regimen with some
IPLs and most Nd:YAG lasers.

Venulectasias and varicosities cannot be

successfully treated with light and should
be sent to sclerotherapy, ligation,
stripping, and EVLT.
• Sclerosants include:

• * Hypertonic saline
• (20% NaCl i.e. strong salt solution)
• * Sodium tetradecyl sulphate
• * Polidocanol

• By Class: Detergent, Caustic, Clotting agent

 Generally, when we talk about leg vein therapy, we divide leg veins into the following four
groups:

• telangiectasia — these are 100 microns to 1 mm in size

• venulectasia — these are 1 mm to 2 mm

• reticular veins — these range from 2 mm to 4 mm

• varicose veins — which are larger than 4 mm.

For most leg vessels, we’re typically treating veins that are 0.4 mm to 2.0 mm in diameter and
the laser is preferred.
 For effective treatment, we really need pulse
durations in the 10 ms to 100 ms range. At 10 ms to
55 ms, we advantageously produce thermal
confinement for vessels that are less than 1 mm.

Longer pulse times (trains) are effective for larger vessels

.

In addition, we’re also sparing the smaller diameter

vessels that are less than 0.1 mm in diameter.
With the longer pulse durations, we can avoid
hemorrhage and purpura and also spare the
epidermis .
 Quasi-Continuous Wave (CW) Pulsing
A 20 ms treatment pulse Nano-pulses:
consists of 240 nano-pulses

A click on the scanner trigger gives one treatment pulse of a duration of 20 ms or more
The duration of the treatment pulse is automatically adjusted to obtain the pulse energy (J/cm2) chosen by the user
The treatment pulse is composed of 240 or more nano-pulses
The therapeutical effect is similar to that of a continuous wave, hence the term quasi-cw
 Thermokinetic Selectivity

5 ms 15 ms 30ms

Surface area =4 πr2

Volume = 4/3 πr3
 Advantages of
Continuous Dynamic Cooling
•Without cooling tissue is only 3-5o
below vessel temp
•With cooling tissue temp. drops 33-
37o to 50
•When tissue and vessel
temperature increased by ~40o
tissue remains below level of
protein destruction.
 Adequate energy to heat the target...

•Correct energy will :

•1. heat the blood to above 70 o C
•2. break down vessel wall
•3. pass outside vessel to Type
I&III collagen
•4. shrink vessel…
Strict post-treatment compliance...

compression stockings for 5 days,

no hot tubs or impact exercise for 5 days,

avoid sun/tanning bed for 1-2 weeks

after five days, lots of walking, swimming, biking.

 Ideal Spot Size
Applies only to visible targets,
either indigenous or exogenous
Should equal or exceed the depth of penetration
Larger is better, but there is a limit

3mm 6mm

200 J/cm2 90 J/cm2

30% 70%
 Work at a single pulse per pedal
depression.
Watch for collagen collapse.
Watch for ashen grey to white appearance.
Midface lesion will return after first (even
2nd) treatment.

Use caution with facial lesions.

Cherry Angioma / Venous Lake

• Titrate pulse time to anticipated thickness of lesion (20-45 msec)

• Use 3 - 6 millimeter spot depending on wavelength
• Set chiller at 5o C
• Utilize only one or two pulses per second
• Do not stack pulses
• Target should darken to brown to maroon
• 3 to 8 weeks to respond
 Fractional Application

Peels are Type One procedures

Fractional are Type Two

Nonablative
Mends
Ablative
Hole diameter and depth
RF Microneedling
• Insulated vs Noninsulated

• Bipolar vs Monopolaser

• The zone in which you treat…originally dermal enhancement

• E/D junction, Dermal, SubQ