Laser application in plastic

surgery

BY: DR.AMIT K. CHOUDHARY

RIMS,IMPHAL,MANIPUR,INDIA
 Introduction:
• Light Amplification by the Stimulated Emission of Radiation ( LASER )
• Laser technology used in medicine today has traveled a long way
since the development of the ruby laser in 1960 and the CO2 laser in
1964.Plastic surgeons recognized the potential benefits of treating
vascular lesions with laser in the 1980s.
• With the development of novel laser and plasma technology,
pigmentary changes, scarring, and wrinkles can be conquered
providing smoother, healthier, younger-looking skin.

Taking advantage of the public fascination with

high-technology, laser therapy has been
partially misrepresented as the state-of-the-art
treatment of a variety of conditions.
• LASER Often descried as painless and exaggerated as producing
prefect results, lasers have been misused as a marketing tool to lure
patients away from conventional low-tech techniques that can
often produce equivalent results at significantly lower cost.

• On the other hand there are some conditions such as port-wine

stains that are best treated by laser and the standard of care.

• The modern plastic surgeon is therefore faced with the dilemma of

trying to sort out which lasers are best for which conditions and
which manufacturer's claims are credible.
 Laser Physics:

• Fortunately in the 21st

century most lasers are used
for therapeutic purposes.
• Light energy can be descried
as a series of photons or as a
wave phenomenon.
• The color of light is
determined by the wave
length which is the distance
between the two successive
waves.
• The human can see only a narrow range of the electromagnetic
spectrum (the visible light), and many lasers produce invisible lights
in the infrared range.
• Molecule or atom in it’s resting state is composed of a nucleus and
circulating electrons. If energy is added to the system, the electrons
become excited and circulate at a higher orbit.
• Eventually an excited electron will fall back to it’s resting orbit
releasing a specific packet of energy- a photon, and the photon has a
wave length specific to that molecule.
• As these photons hit other excited electrons more photons are
released and the light energy increases.
STRUCTURE DESIGN
OF LASER MACHINE
• A laser tube has a mirror at each end contains a solid, liquid or gas medium within
it whose electrons are in a resting state. As energy is added to the system the
majority of the electrons become excited and begin to release photons.

• Only those photons that hit the mirror directly are reflected back into the lasing
media creating more and more photons that travel back and forth between the
mirrors parallel to the tube and the intensity of the light increases.

• This phenomenon has been descried as Light Amplification by the Stimulated

Emission of Radiation ( LASER )
Type of LASER
 Laser and light treatments
• Carbon dioxide resurfacing laser
• Erbium:Yttrium-Aluminum-garnet laser
• Combined erbium:yag/co2 dual-mode laser
system
• Fractional photothermolysis
• Plasma resurfacing
• Intense pulsed light therapy
• Vascular lasers (pulsed dye laser, Dornier 940
nm, KTP laser)
 CARBON DIOXIDE LASER
• The mainstay for skin resurfacing over
the past few decades has been the CO2
laser. Developed in the1960s and
implemented in the 1980s, the CO2
laser has largely replaced the more
unpredictable and potentially dangerous
deep phenol peel and mechanical
abrasion.
• The first CO2 lasers developed used a
continuous wave; Now its use as short-
pulsed high energy carbon dioxide lasers
that limit skin heating.

The CO2 laser accurately vaporizes the epidermis and dermis layer by layer
resulting in the reorganization and strengthening of collagen bundles in
addition to epidermal regeneration to rejuvenate the skin.
• CO2 lasers emit light at a wavelength of 10,600 nm that is absorbed
strongly by water chromophore (A chromophore is the part of
a molecule responsible for its color).

• Conversion of radiant energy to heat at the point of absorption

instantly raises the temperature of tissue water to more than 100C,
so that the tissue water vaporizes.

• The threshold for vaporization of human skin is 5 J/cm2 with the

CO2 laser. Thermal diffusion will be confined if the laser pulse-width
is less than the thermal relaxation time of the tissue (1 millisecond).

• Thus, with CO2 resurfacing lasers, if the pulse width is less than 1
millisecond, minimal thermal necrosis will result. This zone of
thermal necrosis is sufficient to seal small dermal blood vessels and
lymphatics, yet narrow enough to reduce the incidence of scarring.
• Laser remove the outermost layer of the epidermis and some
portion of the superficial dermis and then reestablishing this layer
through normal wound healing. Healthy epidermis migrates from
adjacent tissue and adnexal structures, and new collagen and
elastic tissue are deposited by activated fibroblasts.

• Theory of selective photothermolysis, to confine ablation to a

- thin layer (20 to 50 mm) and
-deliver enough energy to vaporize tissue (5 J/cm2)
- in a time shorter than the thermal relaxation time of the skin (1
millisecond).

Wound remodeling then continues for 6 to 18 months.

 Two different types of CO2 lasers are :
• Highpower, pulsed CO2 laser that can deliver a treatment fluence of 5 to 7
J/cm2 with each submillisecond pulse by computerized pattern generator
that rapidly and precisely places small, individual laser pulses in several
different arrangements.
• The second uses an optomechanical flash scanner connected to a
conventional continuous wave CO2 laser. This scanner efficiently
distributes continuous-wave laser energy so that time is shorter than skin
thermal relaxation time.
• Later, CO2 resurfacing lasers with very short pulse durations (60
microseconds) emerged; they ablate less tissue per pass and leave behind
a narrower zone of thermal necrosis than the original CO2 resurfacing
lasers.
• Newer laser systems allow epidermal vaporization with minimal thermal
damage to the papillary dermis. The newer superpulsed lasers have pulse
energies 5 to 7 times higher than conventional superpulsed lasers to
maximize tissue vaporization, as well as a pulse duration of less than 1
millisecond, following the principles of selective photothermolysis. This
results in pure steam vaporization with minimal thermal injury diffusing
into adjacent tissue.
 ERBIUM:YTTRIUM-ALUMINUM-GARNET
LASER
• In the 1990s, the first Er:YAG lasers were
introduced for the resurfacing of photo
damaged skin. Currently, there are more
than 30 different brands of Er:YAG lasers
available.
• These lasers vary greatly in spot size,
power, speed, and availability of scanners.
• The wavelength of the Er:YAG laser is
2940 nm, and its chromophore is water.
• The major innovation of the Er:YAG laser
over the CO2 laser is its shorter
wavelength, which increases its
absorption coefficient through water 10-
to 16-fold.
 • A single pulse of the Er:YAG laser at 5 J/cm2 will ablate 20 to 25 mm
of tissue.There will also be a 5- to 10-mm zone of thermal necrosis
at the treatment site.

Uses-
syringomas, sebaceous
actinic keratoses
hyperplasia,
solar lentigines
rhinophyma,
superficial rhytides
atrophic facial acne scars,
mild dyschromia
atrophic discoid lupus scars,
Favre-Racouchot disease.
trichoepitheliomas,
colloid milium,
actinic cheilitis,
Angiofibromas
Bowen’s disease,
Nevi
erythroplasia of Queyrat, and
seborrheic keratosis
laser assisted hair grafting in
Xanthelasma
androgenic alopecia.

Additionally, it has been used in combination

with topical 5-fluorouracil to treat
keratoacanthomas and superficial basal cell
carcinomas.
 side effects from the Er:YAG laser

• pigmentary change - most common

• Pain
• Swelling
• Pruritus
• Oozing
• Crusting
Milia
• erythema.
• permanent hyper- or
hypopigmentation
• Eczema
• impaired healing
• Scars
• Infections
• persistent erythema, milia, and
acneiform eruptions.
 COMBINED ERBIUM:YAG/CO2 DUAL-MODE
LASER SYSTEM

• CO2 laser has a wavelength of 10,600 nm, and

the Er:YAG laser has a wavelength of 2940 nm.
Although they have vastly different wavelengths,
both are resurfacing lasers and both target the
same chromophore: water.
• The Er:YAG laser’s affinity for water is 10- to 16-
fold greater than the CO2 laser’s affinity, and
therefore, the Er:YAG laser causes less heat injury,
has more depth control, and has less risk of
causing permanent scarring and pigmentary
changes.
• By using the two lasers together, one can ‘‘fine tune’’
the resurfacing procedure by utilizing different
wavelengths, different depths of penetration, and
different surface necrosis that are required to give a
uniform treatment to different areas on the head and
neck, which have variable thickness, color, and
regenerative capabilities and require different
resurfacing wavelengths for optimum results.
• Two laser systems that combine erbium/CO2
capabilities are the Sciton Contour (Palo Alto, CA) and
the Derma K (Lumenis. Santa Clara, CA)
 FRACTIONAL PHOTOTHERMOLYSIS
• Fractional photothermolysis was developed and released by Reliant Technologies
(Mountain View, CA) in 2004, and given the brand name FraxelTM.
• It is one of the newest technologies used for skin resurfacing.
• The wavelength of the laser is estimated to be 1550 nm, and its chromophore is water.
• The major innovation of the Fraxel laser is its unique delivery of energy into the
aqueous tissue. Prior to laser use, a blue dye is applied to the patient’s skin.
• This dye does not react to the laser but gives the contrast necessary
to allow the revolutionary computer guidance system to track the
movement of the hand piece and evenly deliver and distribute from
150 to 250 microthermal wounds/cm2. The diameter of these
microthermal zones ranges from 30 to 70 mm, and the depth of
penetration into the epidermis and dermis is 400 to 700 mm.

• Fraxel laser is believed to cause an optimum balance between

selective skin photothermolysis and wound regenerative capacity.
• Fraxel therapy revealed complete re-epithelialization within 1 day
and enhanced undulating rete ridges and increased mucin deposition
within the superficial dermis after 3 months.
• Patients are usually scheduled for Fraxel therapy every 2 to 4 weeks
for a total of three to five sessions.
 USES
Treatment of pigmented skin lesions,
Periorbital rhytides,
Skin resurfacing,
Melasma,
Soft tissue coagulation.
Fraxel therapy has also been reported to help with
‘‘ice-pick,’’ ‘‘boxcar,’’ and ‘‘rolling’’ acne scars in a
limited number of patients, as well as solar
lentigines.
 The common short-term side effects of the
Fraxel laser include

• postoperative erythema,
• minimal facial swelling,
• xerosis,
• scaling,
• pruritus,
• mild superficial scratches secondary to the
hand piece, and bronzing.
 PLASMA RESURFACING
• The Plasma Skin Regeneration (PSR)
system launched in February 2005 by
Rhytec Ltd .
• Energy is delivered to the skin surface
via nitrogen plasma.
• Plasma is the fourth state of matter in
which electrons are stripped from
atoms to form an ionized gas.
• Pulses of ultrahigh-frequency (UHF) RF
energy are used to ionize a flow of
nitrogen gas, producing millisecond
pulses of plasma, with no UHF energy
delivered to the skin.

The plasma is characterized by a lilac glow transitioning to a yellowish light

known as a Lewis-Rayleigh afterglow.

This glow is directed, in pulses, through a quartz nozzle held 5 mm from the
skin’s surface, delivering energy through a 6-mm spot size.
Upon impact, the ionized energy is released, causing a localized heating in a
controlled, uniform manner without relying on a chromophore mediator.
The result is a uniform and efficient distribution of energy into the dermis.
• One unique feature of
plasma resurfacing is its
nonablative nature.
Immediately post
procedure, the stratum
corneum and epidermis are
retained.
• Plasma resurfacing is
approved by the FDA for the
treatment of facial rhytides,
actinic keratosis, and benign
skin lesions.
• It has also been used to
improve skin tone, texture,
and pigmentation.
• The expected side effects from plasma
resurfacing thus far are minimal.
• The most common side effect is postoperative
erythema, which usually subsides by day 3.
• By postoperative day 4, a new epidermis has
formed, and by day 10, fibroblasts are
increased and the tissue remodeling cascade
has started.
Laser Tissue interaction
 • When the laser strikes on object, a variety of desirable
and undesirable effect may result as the light is reflected,
scattered, transmitted and absorbed.

Glass and clear liquids will transmit some types

of laser light, allowing photocoagulation
through glass slides, the vitreous of the eye,
and water.

Some lasers will also pass through the

epidermis allowing energy to reach dermal
vessels and pigments without disrupting the
epidermal layer.
The depth of penetration depends upon the laser type.
• It is the absorbed light that causes the desirable and
undesirable biologic effect. Except for Excimer lasers
that break chemical bonds, most laser energy is
converted into thermal energy.
• Depending upon the rate of tissue heating, surgical
effects include welding, coagulation, protein
denaturation, desiccation and vaporization.
• Some lasers will indiscriminately target living tissue,
while other lasers will semi-selectively target a specific
chromophore such as oxyhemoglobin, melanin, and
tattoo pigmentation.
• Selective photothermolysis describes the ability of
laser to target blood vessels or pigment without
harming the surrounding dermis or epidermis.
• It is generally safer to deliver cutaneous laser light in
pulses rather than as a continuous beam, as the
interval between pulses allows the tissue to cool
before the heat is transferred to the surrounding
dermis.
• Pulsed lasers respect the thermal relaxation time of
dermal vessels (the time to dissipate the heat absorbed
during a laser pulse).
USE OF LASER IN PLASTIC
SURGERY
 Ablation
• Lasers that nonspecifically destroy the tissue can be used to remove
skin lesions or remove layers of the skin, usually with minimal blood
loss because the dermal vessels are coagulated as the tissue
vaporized.

• CO2 laser light is absorbed by intracellular water which vaporizes

the tissue as the water turns to steam.
 Vascular lesion
• The fact that oxyhemoglobin absorbs green and yellow light has
spawned a variety of lasers appropriate for treating dermal vessels.
• Yellow light has become the preferred color with the yellow dye
argon laser because the oxyhemoglobin absorption peak at 577 nm.
• The high energy/shot duration pulse causes vascular disruption as
the blood rapidly heats up and expands.
• The diode laser can also be used(800nm), as the light is absorbed
by oxyhemoglobin and melanin.
 Pigmented lesion

• Pigmented lesion lasers target melanin.

• Benign pigmented lesions such as
lentigines
 nevus of ota
café au lait spots

Nevus of Ota (also known as

Melasma (muh-LAZ-muh) is a "congenital melanosis bulbi",
common skin problem. It causes "nevus fuscoceruleus
brown to gray-brown patches, ophthalmomaxillaris",
usually on the face. Most people get "oculodermal melanocytosis",
it on their cheeks, bridge of their and "oculomucodermal
nose, forehead, chin, and above melanocytosis") is a blue
their upper lip. It also can appear on hyperpigmentation that occurs on
other parts of the body that get lots the face.
of sun, such as the forearms and
neck.

melasma
 Photodynamic therapy:
• The use of light-activated
drugs to treat acne and other
skin conditions currently is
best represented by topical 5-
aminolevulinic acid, (Levulan).
The compound is metabolized
by sebaceous gland in to
porphyrins.
• The acne bacteria itself also
produces porphyrin, and the
use of blue, green or red light
stimulates the production of
oxygen free radicals that
destroy the bacteria and
suppress the sebaceous gland
activity
 photorejuvenation
Photorejuvenation is a skin treatment that uses lasers, intense pulsed light,
or photodynamic therapy to treat skin conditions and remove effects of
photo aging such as wrinkles, spots, and textures. The process induces
controlled wounds on the skin, prompting it to heal itself by creating new
cells.
Special laser treatment
 Vascular lesions:
Hemangiomas:
• Hemangiomas are the most common benign tumors of
infancy.
• 60% occur at head and neck region
• 70% of hemangiomas regress satisfactorily but 30% of
patients will have cosmetically significant deformity.
• Laser is a potentially useful option in several settings.
• The pulsed yellow dye laser may be very useful for very early
hemangiomas, ulcerated hemangiomas, and regressed
hemangiomas that still contain vascular pigmentation or visible
ectatic vessels.
• The laser only penetrates about one millimeter into the skin and
therefore, it is most effective for small flat hemangiomas.
• Multiple laser treatment may be necessary every two to four weeks
during the proliferative phase as hemangiomas will often exhibit
temporary regression followed by rebound growth.
• Laser treatments are not effective for already bulky or
subcutaneous hemangiomas as the light will not penetrate deeply
enough to produce noticeable improvement.
• Hemangiomas can be excruciatingly painfull specially when located
in the perineal region, there has been some success with pulsed
yellow dye laser treatment of these hemangiomas.
• Faster healing has also been
reported with laser
although the mechanism for
this observation is unclear.
• Hemangiomas that have
regressed well enough to
avoid the need for surgical
excision may have residual
ectatic vessels that will
improve with pulsed dye
laser.
 Capillary vascular malformation:
• Port wine stains tend to darken with age as the dilated dermal capillaries
and venules enlarge with time.
• The involved areas may also show textural changes and soft tissue
hypertrophy and hyperplastic vascular nodule, pyogenic granulomas may
develop with problematic bleeding, again the pulsed dye laser (595 nm) is
the treatment of choice.
• Children respond better than teenagers because the immature vessels are
more photosensitive and treatment can be offered beginning in infancy.
• Multiple (at least six to eight)
treatments are needed as
recommended for cumulative
benefit, and that it is
extremely rare for any
capillary vascular
malformation to completely
disappear.
• Topical anesthetic cream is
helpful on the trunk and
extremity but children with
large facial port-wine stain
will be better treated under a
general anesthesia.
Metal eye shields for periorbital laser therapy
 Venous malformations
• Venous malformations consist of dilated clusters of
varicose veins and treatment options include laser
photocoagulation, sclerotherapy and surgical
debulking.
• Small superficial veins may improve with pulsed dye
laser therapy but usually the energy pulse is too brief
and the vessels are too large to show significant
benefit.
• Longer energy delivery with a continuous wave laser
such as KTP( potassium titanyl phosphate crystal) or
neodymium:YAG laser can result in significant heat
absorption and vascular destruction with a significant
shrinkage in the size of malformation.
• Large venous malformation can be debulked by
surgery or by using the fiber of a KTP or neodymium-
YAG laser as a contact tip laser scalpel.
• Endovenous laser photocoagulation with the
assistance of ultrasonic guidance is now a
therapeutic option for cosmetic varicose veins as
well as congenital venous malformations.
• Congenital venous malformation
 Lymphatic malformations:
• Cutaneous vesicles resembling tiny water blisters represents the
dermal component of a lymphatic malformation.
• Usually associated with a more extensive subcutaneous
component.
• Lymphatic oozing from ulcerated vesicles can
be palliatively treated with the CO2 laser
which is absorbed by water.
• The heat of the absorbed laser energy may
cause a desirable fibrosis at the site of leaking
lymphatics.
• This treatment is palliative but can be
repeated for unresectable lesions.
 Venolymphatic malformations
• Similar to lymphatic malformation but associated with additional venous
component.
• The cutaneous component may appear as tiny purple vesicle or crusting
scabs (angiokeratoma).
• Commonly associated with Klippel-Trenaunay syndrome.
• Vesicles are more responsive to coagulation by continuous laser than the
yellow dye pulsed laser, therefore the KTP is more effective.
• Crusting lesions can be tangentially shaved, then compressed with a glass
slide to control bleeding before being lased.

Angiokeratoma
 Telangiectasia/Rosacea
• Represents undulating dilated dermal vessels that course through
the dermal layer.
• They appear discontinuous because they are visible near the
surface and then disappear as they are into the deeper dermis.
• Associated with U/V damage or rosacea, they respond to a variety
of vascular lesion lasers.
• They respond to Intense pulsed light therapy after multiple
sessions.
Rosacea treated by laser
 Pyogenic granuloma:
• Shiny nodule of proliferative vascular tissue covered by a fragile epidermal layer.
• They have an annoying propensity to bleed when ulcerated.
• Can occur at any age but more common in children and pregnant women.
• May result from minor trauma.
• Treated by tangential shave excision followed by laser photocoagulation of the
dermal base.
• A glass slide is used to compress the bleeding base and a continuous laser such as
KTP will pass through the glass to coagulate the proliferative lesion.
 Spider angiomas:
• Superficial vascular lesions characterized by central feeding
arteriole and radiating braches.
• Compression will blanch the lesion which will then readily reappear
at the center and expands outwards after the pressure is released.
• Pulsed yellow dye laser is excellent way to coagulate the entire
lesion
 Cherry angiomas
• Macular or papular
cherry-colored
nodules commonly
seen in adult skin.
• Range in size from
punctate lesions to
several millimeters.
• Laser is effective in
treatment
 Spider veins/Varicose veins:

• Dilated leg spider veins may respond

to a variety of lasers but it is usually
most efficient to remove the larger
veins first.
• Endovenous laser therapy using a
810 nm diode laser has become a
good treatment alternative.
• Pulsed dye or diode laser will
penetrate in to the deep dermis to
treat residual spider veins as well as
the peripheral blush that is often
seen after sclerotherapy of large
vessels.

Diode laser for

residual spider veins
 Adenoma sebaceum/tuberous sclerosis:
• Patients with tuberous sclerosis
will develop firm pink nodules in a
butterfly pattern across their
cheek and nose with additional
involvement of chin and forehead.
• Neither adenomatous nor
sebaceous, these lesions are more
accurately are angiofibromas.
• Vaporization with a defocused
CO2 laser appears to be much
more efficient in improving the
skin surface contour.
 Pigment lesions
• Melanin absorbs light in the ultraviolet to near infrared range, therefore a
wide variety of lasers have been used to target benign melanocytic
lesions.
• Pulse lasers are safer and less likely to cause scarring than continuous
lights.
• Shorter wavelengths will treat epidermal pigmentations, while long waves
are more effective for dermal pigmentation.
• Epidermal lesions such as freckles, solar letigines, and labial melanocytic
macules respond to green pulse dye, while deeper dermal pigmented
lesions such as café au lait spots, nevus of ota may respond to longer
wavelength such as ruby, alexandrite and diode.

Freckles Solar lentigines

Labial melanocytic macules
 Neurofibromatosis
• Large plexiform neurofibromas should be excised
by standard surgical techniques.
• Patients who request removal of hundreds of
small neurofibromas may be well served by CO2
laser destruction.
• The laser in slightly defocused mode can vaporize
and coagulate small neurofibromas.
 Syringioms
• Benign tumors of eccrine origin most
commonly found in periorbital area.
• CO2 laser results in rapid obliteration
of these lesions usually without
recurrence.
 Cylindroma
• Nodular benign dermal tumor
thought to be of primitive sweat
gland origin.
• Large disfiguring nodules involving
the face and scalp (so-called turban
tumor) can be excised or vaporized
using CO2 laser to reduce associated
blood loss.
 Actinic keratosis
• Patients with extensive
actinic changes of their facial
skin and lower lip are
candidates for laser skin
resurfacing.
• It may be better tolerated
than topical 5-fluorouracil
therapy or a surgical lower lip
vermilion shave.
• CO2 laser can readily
vaporize the epidermis and
papillary dermis allowing the
regeneration of healthier
skin.
 Verruca Vulgaris

• CO2 laser has been most commonly used to vaporize the

involved areas particularly when there are multiple lesions that
may make surgical excision difficult.
• To reduce the risk of viral transmission to medical personal, it is
advisable to sharply excise the bulk of the lesion and then
vaporize the base.
 Rhinophyma
• Characterized by hypertrophic sebaceous glands and marked
thickening and distortion of the dermis layer of the nose.
• Can be effectively vaporized with the CO2 laser with minimal
bleeding.
• The end result is superior to shave excision and skin grafting.
 Epidermal nevi:

• While possessing no
significant malignant risk,
can cause severe
disfigurement, as the nevi
thicken and create a
verrucous surface texture.

Verrucous appearance of the epidermal nevi

 Hair removal:
• The basic principal of laser hair removal is to use light energy to destroy
the hair root for permanent hair reduction.
• This requires a deeply penetrating wave length that must reach the
dermal papilla without adversely destroying the surrounding dermis.
• Most hair removal lasers target melanin and deeply penetrating lasers
such as diode, alexndrite and YAG lasers are most effective on patients
with dark and fair skin.
 Tattoo removal:

• Tattoos are created by pigments or foreign matter that is embedded

in dermis layer of the skin for decorative purposes or therapeutic as
in case of nipple/areola reconstruction.
• Historically the tattoos have been removed by abrasion of the skin
until the deepest pigment has been removed, this routinely shiney
atrophic scars at best and hypertrophic and keloid scars in
unfavorable areas.

The advent of Q-switched ruby, YAG and

Alexandrite lasers offers the possibility of
tattoo removal without clinically apparent
scarring.
Pigment granules are fragmented into smaller
particles that are then phagocytized by
macrophages.
THANK YOU