Clinical Procedures in Laser Skin Rejuvenation - part 1 ppsx

Clinical Proceduresin Laser Skin Rejuvenation Edited by Paul J Carniol MD FACS Cosmetic Laser and Plastic Surgery Summit, N J USA Neil S Sadick MD FAAD FAACS FACP FACPh Sadick Aesthetic

Clinical Procedures

in Laser Skin

Rejuvenation

SERIES IN COSMETIC AND LASER THERAPYPublished in association with the Journal of Cosmetic and Laser Therapy

Already available

1 David Goldberg

Fillers in Cosmetic Dermatology.ISBN: 1841845094

2 Philippe Deprez

Textbook of Chemical Peels.ISBN: 1841844950

3 C William Hanke, Gerhard Sattler, Boris Sommer

Textbook of Liposuction ISBN 1841845329

Of related interest

1 Robert Baran, Howard I Maibach

Textbook of Cosmetic Dermatology, 3rd edition.ISBN: 1841843113

2 Anthony Benedetto

Botulinum Toxin in Clinical Dermatology.ISBN: 1842142445

3 Jean Carruthers, Alistair Carruthers

Using Botulinum Toxins Cosmetically.ISBN: 1841842176

Aesthetic Mesotherapy and Injection Lipolysis in Clinical Practice.ISBN: 1841845531

8 Avi Shai, Howard I Maibach, Robert Baran

Handbook of Cosmetic Skin Care.ISBN: 1841841793

Clinical Procedures

in Laser Skin

Rejuvenation

Edited by

Paul J Carniol MD FACS

Cosmetic Laser and Plastic Surgery

Summit, N J

USA

Neil S Sadick MD FAAD FAACS FACP FACPh

Sadick Aesthetic Surgery and Dermatology

New York, NY

USA

© 2007 Informa UK Ltd

First published in the United Kingdom in 2007 by Informa Healthcare,Telephone House, 69–77 Paul Street, London EC2A 4LQ Informa Healthcare is a trading division of Informa UK Ltd Registered Office: 37/41 Mortimer Street, London W1T 3JH Registered in England and Wales number 1072954.

Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would

be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention.

A CIP record for this book is available from the British Library.

Library of Congress Cataloging-in-Publication Data

Data available on application

ISBN-10: 0 415 41413 X

ISBN-13: 978 0 415 41413 5

Distributed in North and South America by

Taylor & Francis

6000 Broken Sound Parkway, NW, (Suite 300)

Boca Raton, FL 33487, USA

Within Continental USA

Tel: 1 (800) 272 7737; Fax: 1 (800) 374 3401

Outside Continental USA

Tel: (561) 994 0555; Fax: (561) 361 6018

Email: orders@crcpress.com

Distributed in the rest of the world by

Thomson Publishing Services

Composition by C&M Digitals (P) Ltd, Chennai, India

Printed and bound in India by Replika Press Pvt Ltd

List of contributors vii

3 Carbon dioxide laser resurfacing,

Fractional resurfacing and YSGG resurfacing 17 Dee Anna Glaser, Natalie L Semchyshyn and Paul J Carniol

4 Erbium laser aesthetic skin rejuvenation 31

Richard D Gentile

5 Complications secondary to lasers

Robert M Adrian

6 Nonablative technology for treatment

Amy Forman Taub

7 Lasers, light, and acne 69

Kavita Mariwalla and Thomas E Rohrer

8 Treatment of acne scarring 89

Murad Alam and Greg Goodman

9 Nonsurgical tightening 103

Edgar F Fincher

10 Laser treatment of pigmentation

associated with photoaging 111 David H Ciocon and Cameron K Rokhsar

11 Management of vascular lesions 125 Marcelo Hochman and Paul J Carniol

12 Laser treatment for unwanted hair 135 Marc R Avram

13 Non-invasive body rejuvenation

Monica Halem, Rita Patel, and Keyvan Nouri

14 Treatment of leg telangiectasia with laser and pulsed light 157 Mitchel P Goldman

Papri Sarkar and Ranella J Hirsch

16 Adjunctive techniques I: the bioscience of the use of botulinum toxins and fillers for non-surgical facial rejuvenation 181 Kristin Egan and Corey S Maas

17 Adjunctive techniques II: clinical aspects

of the combined use of botulinum toxins and fillers for non-surgical facial rejuvenation 191 Stephen Bosniak, Marian Cantisano-Zilkha,

Baljeet K Purewal and Ioannis P Glavas

18 Adjunctive techniques III:

complementary fat grafting 205 Robert A Glasgold, Mark J Glasgold

and Samuel M Lam

Contents

Robert M Adrian MD FACP

Center for Laser Surgery

New York Presbyterian Hospital-Weill Medical

College at Cornell Medical Center

New York, NY

USA

William Beeson MD AAFPRS AACS

Beeson Aesthetic Surgery Institute

San Francisco, CAUSA

Facical Plastic and Aesthetic Laser CenterYoungston, OH

USADee Anna Glaser MD

Dermatology Department

St Louis University

St Louis, MOUSA

Mark J Glasgold MD

Department of SurgeryRobert Wood Johnson Medical SchoolUniversity of Medicine and Dentistry of New JerseyPiscataway, NJ

USARobert A Glasgold MD

Department of SurgeryRobert Wood Johnson Medical School University of Medicine and Dentistry of New JerseyPiscataway, NJ

USA

Contributors

Willow Bend Wellness Center

Lam Facial Plastic Surgery Center and

Hair Restoration Institute

Philip J Miller MD FACS

Department of OtolaryngologyNew York University School of Medicine andThe NatraLook ProcessTMand East Side CareNew York, NY

USAKeyvan Nouri MD

Department of DermatologyMiller School of MedicineUniversity of MiamiMiami, FL

USARita Patel MD

Department of DermatologyMiller School of MedicineUniversity of MiamiMiami, FL

USABaljeet K Purewal MD

Department of OpthalmologyLutheran Medical CenterBrooklyn, NY

USAThomas E Rohrer MD

Department of DermatologyBoston University School of Medicineand

Skin Care Physicians of Chestnut HillChestnut Hill, MA

USACameron K Rokhsar MD FAAD FAACS

Department of DermatologyAlbert Einstein College of MedicineNew York, NY

USAviii List of contributors

Amy Forman Taub MD

Advanced DermatologyNorthwesten University Department of DermatologyLincolnshire, IL

USA

List of contributors ix

Although every effort has been made to ensure that

information about techniques and equipment is

pre-sented accurately in this publication, the ultimate

responsibility rests with the practitioner physician

Use of these techniques or items of equipment does

not guarantee outcomes or that they are the optimal

procedures available Procedure results and potential

complications frequently vary between patients:

physicians must evaluate their patients individually

and make appropriate decisions about treatment

based on each analysis Although it is not always

nec-essary, when a physician initiates any new therapy on a

patient the use of ‘test spots’ or other tests of limited

areas should be considered for patient response beforeinitiating the full treatment itself

Neither the publishers, nor the editors, nor theauthors can be held responsible for errors or for anyconsequences arising from the use of information con-tained herein For detailed instructions on the use ofany product or procedure discussed herein, pleaseconsult the instructional material issued by the manu-facturer Some of the use of technology and proce-dures described in this text may be ‘off label’ asregards the FDA in the USA and may also not have ECapproval in Europe, and are described as such, to beused at the discretion of the physician

Note on outcomes

using the alignment beam and be aware that ocular

damage can occur with misuse Class III-B lasers

comprise those in the 5–500 mW output range Even

momentary viewing of class III-B lasers is potentially

hazardous Class IV lasers are those emitting > 500 mW

(0.5 W) radiant power Most surgical lasers fall within

this class, and pose a potential hazard for skin injury,

ocular injury, and fire hazards

REGULATIONS

In addition to FDA enforcement, other rules and

regu-lations apply to the use of lasers in the medical setting

In recent years, the Occupational Safety and Health

Administration (OSHA) has stressed the need for

employers to inform and educate workers on

work-place risks This has been of particular importance

with regard to the use of lasers in the workplace The

Department of Labor has developed guidelines for

Laser Safety Hazard Assessment, which pertain to the

use of medical lasers.2

Compliance with OSHA rules is an important

com-ponent of a laser safety program

HAZARD CLASSIFICATION

There are no specific OSHA guidelines for assessing

the level of compliance of a facility providing laser

facelifts and laser blepharoplasty However, the

American National Standards Institute (ANSI)

stan-dard ‘Safe Use of Lasers in Health Care Facilities’

(Z-136.3) is used as a benchmark All assessments by the

OSHA are made under the ‘general duty clause’,

which states that there is a shared duty between the

employer and employee for establishing and

maintain-ing a safe workmaintain-ing environment The employer has a

duty to provide the proper safety equipment,

appro-priate education and training, and a work environment

free of known potential risks and hazards The

employee has a duty to attend the training, use of

personal protective equipment, and follow safe work

practices at all times OSHA compliance officers

respond to requests, complaints, and accidents

reported Facilities must demonstrate that they have

established policies and procedures, identified proper

personal protective equipment, implemented a

program for education of all employees who might be

at risk for exposure to laser hazards, performed anddocumented periodic safety audits, and assured ongo-ing administrative control in program surveillance.3

In addition to governmental agencies such as theFDA, OSHA, and state departments of health,nongovernmental accrediting and review organiza-tions also have guidelines and recommendations forthe laser safety in healthcare facilities The ANSI is anonregulatory body that promulgates thousands ofsafety standards in the USA.Working committees haverepresentation from industry, the military, regulatorybodies, user groups, research and educational facili-ties, and professional organizations The ANSI alsoparticipates in international standard work throughgroups such as the International Organization forStandardization (ISO).The main objective of the ANSI

is to establish and maintain benchmarks for nationalsafety through consensus documents

ANSI Z-136.3 has become the expected laser safetystandard in healthcare Although it is not regulatory, ithas taken on the impact of regulations through its wideacceptance It is used by the OSHA and many accredit-ing organizations such as the Joint Commission(previously the Joint Commission on Accreditation ofHealthcare Organizations, JCAHO) and the Accredita-tion Association of Ambulatory Healthcare (AAAHC),and it is exhibited as reference during litigations Thestandard provides a comprehensive guide for thedevelopment of administrative and procedural controlmeasures that are necessary for maintaining a safe laserenvironment and should be used as the cornerstonefor all clinical laser programs

It is important to develop a risk managementprocess regarding the safe use of lasers, consisting ofwritten policies and procedures, as well as ongoingevaluations of compliance, and demonstrating timelyand appropriate responses to incidents or accidentsthat could occur Typically, the person responsible forthe management of the laser safety–risk managementprogram will be the laser safety officer The ANSI Z-136.3 standard defines the laser safety officer as ‘anindividual with the training, self-study, and experience

to administer a laser safety program This individual(who is appointed by the administration) is authorizedand is responsible for monitoring and overseeing thecontrol of laser hazards The laser safety officer shalleffect the knowledgeable evaluation and control of

2 Clinical procedures in laser skin rejuvenation

laser hazards by utilizing, when necessary, the

appro-priate clinical and technical support staff and other

resources.’4

The laser safety officer should be responsible for

verifying the classifications of the laser systems, hazard

analysis, ensuring appropriate control measures are in

effect, approving all policies and procedures, ensuring

that protective equipment is available, overseeing

instillation of equipment, ensuring that all staff are

properly trained, and maintaining medical surveillance

records In private practice in small clinical settings,

the physician who owns and runs the practice or clinic

is very likely to serve as the laser safety officer

All laser users must adhere to the following principles:

• Laser safety requirements are no less stringent in

private practice than in a hospital setting

• The individual laser user must know all

profes-sional standards and regulations and be thoroughlytrained in laser safety

• The user must ensure that the entire staff are

properly trained in the safe use of lasers

• There must be an appointed laser safety officer

• The user must establish and follow standard-based

policies and procedures

It is important that safety audits be utilized in a routine

manner to be sure that laser safety programs are being

adhered to ANSI standards require an audit at least

annually A laser safety audit is an assessment of all

equipment, supplies, and documents involved in

per-forming laser treatments in a facility It is supervised

by the laser safety officer and consists of four basic

components:

1 Inventory all equipment and develop a checklist

2 Inspect every item on the checklist

3 Document results

4 Identify action items based on audit results

In addition to the ANSI, voluntary healthcare

accredit-ing organizations such as the Joint Commission and the

AAAHC all have standards that apply to the use of

lasers in the medical environment, including the office

surgical setting

Laser regulation at state and local government levels

has increased significantly in recent years Regulations

vary from state to state The current trend is for state

regulatory bodies, such as medical licensing boardsand departments of health, to address laser safety issues

by setting standards for credentialing and training.Regulations will usually dictate the type of individual orindividuals who are qualified to perform laser treat-ments and prescribe levels of training to document cur-rent competency with each type of laser being used.Almost all require personnel using lasers in healthcarearenas to be cognizant of basic laser safety issues.Some states allow only physicians to perform lasersurgery, while others allow physician assistants andadvanced practice nurses to perform laser treatments.Some will allow nurses and other allied health person-nel to perform laser treatments, but only with the directsupervision of a trained physician Still other statespermit the use of lasers by paramedical personneland ‘others’ in less supervised situations However, thecurrent trend is for increased supervision and training.While some states may not directly address lasersurgery, they do so indirectly by requiring accredita-tion of ambulatory surgical or office surgical units Inthese cases, the medical licensing board has subrogatedauthority to a national accrediting organization such asthe Joint Commission, the AAAHC, or the AmericanAssociation for Accreditation of Ambulatory SurgeryFacilities (AAAASF) Each of these organizations hasdeveloped specific standards that can be applied tolaser use in the medical setting

In 2005, the Joint Commission, currently in its tinel event program, adopted measures for its accreditedorganizations to utilize in an attempt to reduce the likeli-hood of patient injury from fire resulting from the use oflasers in the operating room Since the Joint Commissionaccredits the vast majority of hospitals in the USA andsince all Joint Commission-accredited organizationsusing medical lasers must adhere to these recommendedstandards, one could argue from a legal standpoint thatthese are de facto ‘community standards’ The legalimplications of not meeting the accepted ‘communitystandards’ if a patient has an injury when being treatedwith a medical laser are significant

sen-It is imperative that any person in a medical practicewho treats with a laser adhere to strict regulationsregarding scope of practice, licensing requirements, andstandardized procedures It is also extremely importantfor the physician’s malpractice insurance carrier todetermine who is covered under the physician’s policy It

is essential to know if the person doing the laser

Laser safety 3