Clinical Procedures in Laser Skin Rejuvenation - part 8 pps

Another study compared the 532 nm diode laser with a 1 mm diameter spot at fluences of 2–32 J/cm2 with the 1064 nm Nd:YAG laser at 1–20 ms pulses through a 3 mm diameter spot at 130–160

for wavelengths between 600 and 1064 nm Ideally, a

light source should have a pulse duration that would

allow the light energy to build up in the target vessel so

that its entire diameter is thermocoagulated Optimal

pulse durations have been calculated for blood vessels of

various diameter (Table 14.1)

During the process of delivering a sufficient

amount of energy to thermocoagulate the target

ves-sel, the overlying epidermis and perivascular tissue

should be unharmed This selective preservation of

tissue requires some form of epidermal cooling A

number of different laser and IPL systems have been

developed toward this end, and are discussed in

subse-quent sections

Patients seek treatment for leg veins mostly for metic reasons, and any treatment that is effectiveshould be relatively free of adverse sequelae.2Bernstein,3

cos-for example, evaluated the clinical characteristics of

500 consecutive patients presenting for removal of

532 Nd:YAG

Nd:YAG PDL

Table 14.1 Thermal relaxation times of blood vessels

lower extremity spider veins Patients ranged in age

from 20 to 70 years and had had noticeable spider

veins for an average of 14 years; 28% had leg veins less

than 0.5 mm in diameter and 39% veins less than

1.5 mm in diameter Interestingly, regardless of

exactly how sclerotherapy was performed, more than

half (56%) of patients developed TM Recent advances

in laser and IPL treatments for treating telangiectatic

vessels, if used appropriately, assure minimal (if any)

adverse events

An understanding of the appropriate target vessel

for each laser and/or IPL is important so that

treat-ment is tailored to the appropriate target As detailed

in sclerotherapy textbooks and articles,4most

telang-iectasias arise from reticular veins.Therefore the single

most important concept to keep in mind is that

feed-ing reticular veins must be treated completely before

treating telangiectasia This minimizes adverse

seque-lae and enhances therapeutic results Failure to treat

‘feeding’ reticular veins and short follow-up periods

after the use of lasers may give inflated estimates of the

success of laser treatment.5This chapter reviews and

evaluates the use of these nonspecific and specific laser

and light systems in the treatment of leg venules and

telangiectasias (Table 14.2)

HISTOLOGY OF LEG

TELANGIECTASIA

The choice of proper wavelength(s), degree of energy

fluence, and pulse duration of light exposure are all

related to the type and size of target vessel treated

Deeper vessels necessitate a longer wavelength to

allow penetration Large-diameter vessels necessitate a

longer pulse duration to effectively thermocoagulate

the entire vessel wall, allowing sufficient time for

thermal energy to diffuse evenly throughout the vessel

lumen The correct choice of treatment parameters is

aided by an understanding of the histology of the

target telangiectasia

Venules in the upper and middle dermis typically

maintain a horizontal orientation.The diameter of the

postcapillary venule ranges from 12 to 35 µm.6

Collecting venules range from 40 to 60 µm in the

upper and middle dermis and enlarge to 100–400 µm

in diameter in the deeper tissues Histological

examination of simple telangiectasia demonstratesdilated blood channels in a normal dermal stroma,with a single endothelial cell lining, limited muscu-laris, and adventitial layers.7,8Most leg telangiectasiasmeasure from 26 to 225 µm in diameter Electronmicroscopic examination of ‘sunburst’ varicosities

of the leg has demonstrated that these vessels arewidened cutaneous veins.They are found 175–382 µmbelow the stratum granulosum The thickened vesselwalls are composed of endothelial cells covered withcollagen, elastic, and muscle fibers

Unlike leg telangiectasias, the ectatic vessels of PWSare arranged in a loose fashion throughout the super-ficial and deep dermis They are more superficial(0.46 mm) and much smaller than leg telangiectasias,usually measuring 10–40 µm in diameter This mayexplain the lack of efficacy reported by many physi-cians who treat leg telangiectasias with the same laserand parameters as they do with PWS

KTP AND FREQUENCY-DOUBLED Nd-YAG (532 nm) LASERS

Modulated potassium titanyl phosphate (KTP) lasershave been reported to be effective at removing legtelangiectasia, using pulse durations between 1 and

50 ms The 532 nm wavelength is one of the globin absorption peaks Although this wavelengthdoes not penetrate deeply into the dermis (about0.75 mm), relatively specific damage (compared withargon laser) can occur in the vascular target by selec-tion of an optimal pulse duration, enlargement ofspot size, and addition of epidermal cooling

hemo-Effective results have been achieved by tracing sels with a 1mm projected spot Typically, the laser ismoved between adjacent 1 mm spots, with vesselstraced at 5–10 mm/s Immediately after laser expo-sure, the epidermis is blanched Lengthening of thepulse duration to match the diameter of the vessel isattempted to optimize treatment

ves-We and others have found the long-pulse 532 nmlaser (frequency-doubled neodymium : yttrium alu-minum garnet (Nd:YAG)) to be effective in treatingleg veins less than 1 mm in diameter that are notdirectly connected to a feeding reticular vein.9Whenused with a 4°C chilled tip, a fluence of 12–15 J/cm2is

Table 14.2 Lasers and light sources for leg veins

Pulse Spot

American OmniLight Fluorescent 480, 515, 535, Up to 90 Up to 500 External

Meditech

contact

V-Star

0.3–300

USA

handpiece

continuously handpiece adjustable

continuously handpiece adjustable

continuously handpiece adjustable

continuously handpiece adjustable

(Continued)

Table 14.2 (Continued)

Pulse Spot

sapphire crystal

sapphire crystal

sapphire crystal

sapphire

StarLux IPL/Nd:YAG 550–670/870– Up to 700 0.5–500

1400/1064

Sapphire Profile BBL IPL 400–1400 Up to 30 Up to 200 30 × 30, 13 × 15

2–25RF

50/up to 100RF

140/up to 100RF

cold air

a IPL, intense pulsed light; Nd:YAG, neodymium:yttrium aluminum garnet laser; CuBr, copper bromide (copper vapor) laser; PDL, pulsed dye laser; diode; diode laser; KTP, potassium titanyl phosphate laser; RF, radiofrequency.

b DCD, dynamic cooling device.

Modified from Goldman MP Cutaneous and Cosmetic Laser Surgery Philadelphia: Elsevier, 2006.

delivered as a train of pulses in a 3–4 mm diameter

spot size to trace the vessel until spasm or thrombosis

occurs Some overlying epidermal scabbing is noted,

and hypopigmentation is not uncommon in

dark-skinned patients.Although individual physicians report

considerable variation in results, usually more than

one treatment is necessary for maximum vessel

improvement, with only rare reports of 100%

resolu-tion of the leg vein

A comparative study of the 532 nm Nd:YAG laser at

20 J/cm2delivered as a 50 ms pulse through a contact

cooling and 5 mm diameter spot was made with a

595 nm pulsed dye laser (PDL) at 25 J/cm2, with a

pulse duration of 40 ms, cryogen spray cooling, and

a 3 mm ×10 mm spot.10After one treatment with the

532 nm Nd:YAG laser, there was 50–75%

ment in 2 of 10 patients and more than 75%

improve-ment in 3 of 10 patients.There was better improveimprove-ment

in the PDL-treated patients, with 6 of 10 having

50–75% improvement

Another study compared the 532 nm diode laser

with a 1 mm diameter spot at fluences of 2–32 J/cm2

with the 1064 nm Nd:YAG laser at 1–20 ms pulses

through a 3 mm diameter spot at 130–160 J/cm2in the

treatment of TM vessels less than 0.3 mm in diameter

that did not respond to sclerotheraopy.11Two to three

passes were needed to close the vessels with each laser

Thirty-nine percent of the 532 nm-treated and 55%

of the 1064 nm-treated vessels had better than 50%

lightening

In short, the 532 nm, long-pulsed, cutaneous, chilled

Nd:YAG laser is effective in treating leg telangiectasia

As summarized previously, efficacy is

technique-dependent, with a potential for achieving excellent

results Patients need to be informed of the possibility

of prolonged pigmentation at an incidence similar to

sclerotherapy, as well as temporary blistering and

hypopigmentation that is predominantly caused by

epidermal damage in pigmented skin (type III or

above, especially when tanned)

PULSED DYE LASER, 585 OR 595nm

The PDL has been demonstrated to be highly effective

in treating cutaneous vascular lesions consisting of

very small vessels, including PWS, hemangiomas, and

facial telangiectasia The depth of vascular damage isestimated to be 1.5 mm at 585 nm, and 15–20 µmdeeper at 595 nm Consequently, penetration to thetypical depth of superficial leg telangiectasia may beachieved.12 However, telangiectasia over the lowerextremities has not responded as well, with less light-ening and more post-treatment hyperpigmentation.This may be due to the larger diameter of leg telang-iectasia as compared with dermal vessels in PWS andlarger diameter feeding reticular veins, as describedpreviously

Vessels that should respond optimally to PDL ment are predicted to be red telangiectasias less than0.2 mm in diameter, particularly those vessels arising

treat-as a function of TM after sclerotherapy This is btreat-ased

on the time of thermocoagulation produced by thisrelatively short-pulse laser system (Table 14.1)

In an effort to thermocoagulate larger-diameterblood vessels, the pulse duration of the PDL has beenlengthened to 1.5–40 ms and the wavelength increased

to 595 nm This theoretically permits more thoroughheating of larger vessels These longer pulse durationsare created by using two separate lasers, each emitting

a 2.4 ms pulse Such LPDLs operate at 595 nm, with

an adjustable pulse duration from 0.5 to 40 ms ered through a 5, 7, or 10 mm diameter spot size or a

deliv-3 mm ×10 mm or 5 mm ×8 mm elliptical spot Dynamiccooling with a cryogen spray is also available, withthe cooling spray adjustable from 0 to 100 ms, given10–40 ms after the laser pulse or as continuous 4°C aircooling at variable speed.A fluence of 10–25 J/cm2can

10 ms delay One to seven treatments were performed

at 3-week intervals Optimal results were obtainedafter two sessions, with 8% having total clearance and67% having clearance above 40%.All patients had pur-pura for 7–10 days, 33% had pigmentation for lessthan 2 months, and 15% for over 2 months

Weiss and Weiss14 had similar results using theCynosure LPDL on 20 patients with sclerotherapy-resistant TM They performed a single treatment with

a 20 ms pulse and a 7 mm diameter spot at 7 J/cm2for

a total of three stacked pulses with simultaneous cold

air cooling Of 20 patients, 18 had at least 50%

improvement at 3 months post treatment Purpura

only occurred in 25% of patients and lasted 10 days

A longer pulse duration of 40 ms was used on 10

patients with leg telangiectasia up to 1 mm in diameter

at 595 nm with DCD cooling at 25 J/cm2.10 Six

patients had 50–75% improvement and 2 of 10 had

hyperpigmentation that lasted over 3 months

Our experience is similar to that reported above

We utilize the LPDL at pulse durations matching the

thermal relaxation time of the leg veins The energy

fluence used is just enough to produce vessel purpura

and/or spasm Like Weiss and Weiss,14we use stacked

pulses to achieve this clinical endpoint We have used

both LPDL systems and have found them to be

compa-rable Because of the necessity for multiple treatments

and the significant occurrence of long-lasting

hyper-pigmentation, we reserve the use of the LPDL for

sclerotherapy-resistant, red, telangiectasia less than

0.2 mm in diameter

DIODE LASERS

Many diode-pumped lasers are now available,

includ-ing a 532, 810, 915, and 940 nm devices (Table 14.2)

Diode lasers generate coherent monochromatic light

through excitation of small diodes As a result, these

devices are lightweight and portable, with a relatively

small desktop footprint

Thirty-five patients with spider leg veins were

treated with an 810 nm diode laser with a 12 mm

diameter spot, 60 ms pulse duration, and 80–100 J/cm2,

with a cooled hand-piece.15Of these 35 patients,15

showed complete disappearance of the spider veins

Six months after the second laser treatment, 12

patients with partial or no response had dropped out

of the study and 7 patients had a relapse in their leg

veins, with an additional patient having a relapse at 1

year follow-up Of the 35 patients, 2 had scarring One

hour of topical EMLA cream had to be applied to limit

pain during treatment

A 940 nm diode laser has also been used in the

treat-ment of blue leg telangiectasia less than 1 mm in

diame-ter without Doppler evidence of refluxing feeding

veins.16 Twenty-six patients were treated with300–350 J/cm2with a 40–70 ms pulse and 1 mm diam-eter spot, and this gave a clearance of greater than 50%

in 20 patients and greater than 75% in 12 patients.Slight textural changes were seen in 5 patients and pig-mentation took several months to resolve in 4 patients

No cooling was provided except for ice packs aftertreatment In a follow-up of these patients 1 year later,75% of patients had greater than 75% clearance.17

These outstanding long-term results were not seen

in a separate study using the same laser but with avariety of pulse durations (10–100 ms) and fluences(200–1000 J/cm2) through a 0.5 mm diameter spot forvessels less than 0.4 mm in diameter, a 1 mm diameterspot for vessels 0.4–0.8 mm in diameter, and a 1.5 mmdiameter spot for vessels 0.8–1.4 mm in diameter.18

Fluences were adapted to have complete vessel ance without epidermal blanching No cooling devicewas used and patients were evaluated at 1 year Thelargest-diameter vessels had the highest clearance rates,with 13% of vessels less than 0.4 mm in diameterclearing by more than 75%, versus 88% of vessels0.8–1.4 mm in diameter clearing by more than 75%.Laser therapy was more painful than sclerotherapy in 31

clear-of 46 patients, with equal efficacy being noted by thepatients who had had both forms of treatment

Finally, a combination diode laser at 915 nm withradiofrequency (RF) at levels up to 100 J/cm2has beenused to treat leg telangiectasia Chess19 treated 25patients with 35 leg veins 0.3–5 mm in diameter with60–80 J/cm2fluence and 100 J/cm2RF energy through

a 5 mm ×8 mm spot size with 5°C contact cooling in up

to three sessions every 4–10 weeks He found that 77%

of treated sites exhibited greater than 75% improvement

at 6 months.The average discomfort rating was 7 out of

10 Three sites on three different patients developedeschar formation without permanent scarring Anotherstudy treated leg telangiectasia 1–4 mm in diameter with60–80 J/cm2fluence and 100 J/cm2RF energy through

a 5 mm ×8 mm spot size with 5°C contact cooling inthree separate sessions at 2- to 4-week intervals.20

Seventy-five percent of vessels had greater than 50%improvement and 30% had greater than 75% improve-ment at 2-month follow-up Almost no complicationswere noted to occur

In summary, diode lasers are limited by treatment painand adverse effects Of note, unless feeding reticular veins

are treated, the distal treated telangiectasias recur at 6–12

months post treatment Some authors appear to be able

to achieve better results than others using similar

para-meters.The addition of RF to the diode laser appears to

offer little advantage over the laser alone

INTENSE PULSED LIGHT

IPL was developed as an alternative to lasers to

maxi-mize efficacy in treating leg veins (PhotoDerm VL,

ESC/Sharplan, now Lumenis Santa Clara, CA) This

device permits sequential rapid pulsing, longer-duration

pulses, and longer penetrating wavelengths than lasersystems

Theoretically, a phototherapy device that producesnoncoherent light as a continuous spectrum with wave-lengths longer than 550 nm should have multiple advan-tages over a single-wavelength laser system First, bothoxygenated and deoxygenated hemoglobin absorb light atthese wavelengths Second, blood vessels located deeper

in the dermis are affected.Third, thermal absorption bythe exposed blood vessels should occur with less overly-ing epidermal absorption, since the longer wavelengthspenetrate deeper and are absorbed less by the epidermis,including melanin (Fig 14.2)

800

Average temperature increase across a 0.2-mm deep, 0.05-mm

diameter vessel vs wavelength

Average temperature increase across a 2-mm deep, 1-mm

diameter vessel vs wavelength

700 600 500 400 300 200 100

DeOxy Oxy

DeOxy Oxy

Fig.14.2 Average temperature increase across a cutaneous vessel as a function of wavelength for two cases:a shallow capillaryvessel (similar to those found in a port wine vascular malformation) and a deeper (2 mm) and larger (1 mm) vessel typical of a legvenule.The calculated curves are generated assuming that the main light-absorbing chromophore in the blood is either oxygenated ordeoxygenated hemoglobin.The calculation is carried out for a 10 J/cm2

fluence and does not take into account cooling by heatconductivity.Note the dramatic shift in the optimal wavelength as a function of vessel depth and diameter.Also note the differencebetween oxygenated and deoxygenated hemoglobin.(Reproduced with permission from Sclerotherapy Treatment of Varicose andTelangiectatic Leg Veins,4th edn.Goldman MP,Bergan JB,Guex JJ,eds.Elsevier,London,2006.)

With the theoretical considerations just mentioned,

an IPL in the 515–1000 nm range was used at varying

energy fluences (5–90 J/cm2) and various pulse

dura-tions (2–25 ms) to treat venectasia 0.4–2.0 mm in

diameter This IPL allows treatment through a quartz

crystal of 8 mm × 35 mm or 8 mm × 15 mm (up to

2.8 cm2) that can be decreased in size to match the

clinical area of treatment Clinical trials using various

parameters with the IPL, including multiple pulses of

variable duration, demonstrated efficacy ranging from

over 90% to total clearance in vessels less than 0.2 mm

in diameter, 80% in vessels 0.2–0.5 mm in diameter,

and 80% in vessels 0.5–1 mm in diameter.21The

inci-dence of adverse sequelae was minimal, with

hypopig-mentation occurring in 1–3% of patients, resolving

within 4–6 months Tanned or darkly pigmented

Fitzpatrick type III patients were more likely to develop

hypopigmentation and hyperpigmentation in addition

to blistering and superficial erosions These all cleared

over a few months Treatment parameters found to be

most successful ranged from a single pulse of 22 J/cm2

in 3 ms for vessels less than 0.2 mm or a double pulse of

35–40 J/cm2given in 2.4 and 4.0 ms with a 10 ms delay

Vessels between 0.2 and 0.5 mm were treated with thesame double-pulse parameters or with a 3.0–6.0 mspulse at 35–45 J/cm2with a 20 ms delay time Vesselsabove 0.5 mm were treated with triple pulses of 3.5,3.1, and 2.6 ms with pulse delays of 20 ms at a fluence

of 50 J/cm2or with triple pulses of 3, 4, and 6 ms with apulse delay of 30 ms at a fluence of 55–60 J/cm2 Thechoice of a cutoff filter was based on skin color, withlight-skinned patients using a 550 nm filter and darker-skinned patients a 570 or 590 nm filter

Treatment of essential telangiectasia, especially onthe legs, is efficiently accomplished with the IPL (Fig.14.3) A variety of parameters have been shown to beeffective.We recommend testing a few different para-meters during the first treatment session and usingthe most efficient and least painful parameter on subsequent treatments

The use of IPL to treat leg veins is encouraging butfar from being easily reproduced This technologyrequires significant experience and surgical ability toproduce good results Various parameters must bematched to the patient’s skin type as well as to thediameter, color, and depth of the leg vein With older

Fig 14.3 Before and after treatment of essential leg telangiectasia with intense pulsed light (Reproduced with permissionfrom Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins, 4th edn Goldman MP, Bergan JB, Guex JJ, eds Elsevier,London, 2006.)

machines that do not have integrated cooling through

sapphire crystals, a cold gel must be placed between

the IPL crystal and the skin surface to provide optimal

elimination of epidermal heat Many have compared

using the IPL to playing a violin A 2- to 3-year-old

playing a violin will make a squeaky noise, but, with

practice, by the time the child is 7 or 8, he or she will

make beautiful music Regarding the IPL, it is the art

of medicine that assumes an equal importance to its

science

Fortunately, for those who do not play musical

instruments, there are now dozens of IPLs available

from many different manufacturers (Table 14.2)

Nd:YAG LASER, 1064 nm

The Nd:YAG laser, 1064 nm, is probably the most

effective laser available to treat leg telangiectasia In an

effort to deliver laser energy to the depths of leg veins

(often 1–2 mm beneath the epidermis) with

thermo-coagulation of vessels 1–3 mm in diameter, 1064 nm

lasers with pulse durations between 1 and 250 ms have

been developed However, because of the poor

absorp-tion of hemoglobin and oxyhemoglobin at 1064 nm

wavelength, higher fluences must be used Depending

on the amount of energy delivered, the epidermis

must be protected to minimize damage to pigment

cells and keratinocytes Three mechanisms are

avail-able to minimize epidermal damage through heat

absorption First, the longer the wavelength, the

less energy will be absorbed by melanocytes or

melanosomes This will allow darker skin types to be

treated with minimum risks to the epidermis due to a

decrease in melanin interaction Second, delivering

the energy with a delay in pulses greater than the

ther-mal relaxation time for the epidermis (1–2 ms) allows

the epidermis to cool conductively between pulses

This cooling effect is enhanced by the application to

the skin surface of cold gel that conducts away

mal heat more efficiently than air Finally, the

epider-mis can be cooled directly to allow the photons to pass

through without generating sufficient heat to cause

damaging effects

Epidermal cooling can be given in many different

ways The simplest method is continuous contact

cooling with chilled water, which can be circulated inglass, sapphire, or plastic housings.The laser impulse isgiven through the transparent housing, which should beconstructed to ensure that the laser’s effective fluence isnot diminished This method is referred to continuouscontact cooling The benefit is its simplicity The disad-vantage is that the cooling effect continues throughoutthe time that the device–crystal is in contact on the skin.This results in a variable degree and depth of cooling,determined by the length of time the cold housing is incontact with the skin This nonselective and variabledepth and temperature of cooling may necessitateadditional treatment energy so that the cooled vesselwill heat up sufficiently to thermocoagulate

Another method of cooling is contact precooling Inthis approach, the cooling device contacts the epidermisadjacent to the laser aperture The epidermis is pre-cooled and then treated as the handpiece glides alongthe treatment area Because the cooling surface is not inthe beam path, no optical window is required, and bet-ter thermal contact can be made between the coolingdevice and the epidermis The drawback is the nonre-producibility of cooling levels and degrees, which arebased on the speed and pressure at which the surgeonuses the contact cooling device

Yet another method for cooling the skin is to deliver tothe skin a cold spray of refrigerant that is timed to precoolthe skin before laser penetration and also to postcool theskin to minimize thermal backscattering from the laser-generated heat in the target vessel.We have termed thislatter effect ‘thermal quenching’ This method repro-ducibly protects the epidermis and superficial nerve end-ings In addition, it acts to decrease the perception ofthermal laser epidermal pain by providing another sensa-tion (cold) to the sensory nerves Finally, it allows an effi-cient use of laser energy because of the relative selectivity

of the cooling spray, which can be limited to the mis The millisecond control of the cryogen sprayprevents cooling of the deeper vascular targets and isgiven in varying amounts so that epidermal absorption ofheat is counteracted by exposure to cryogen

epider-Since the target vessel absorbs the 1064 nm length poorly, a much higher fluence is necessary

wave-to cause thermocoagulation Whereas a fluence of10–20 J/cm2is sufficient to thermocoagulate bloodvessels when delivered at 532 or 585 nm, a fluence of

70–150 J/cm2is required to generate sufficient heat

absorption at 1064 nm.Various 1064 nm lasers are

cur-rently available that meet the criteria for selectively

thermocoagulating blood vessels, including, among

others, the Lumenis One and Vasculite (Lumenis, Santa

Clara, CA), Varia (CoolTouch Corp., Roseville, CA),

Lyra (Laserscope, San Jose, CA), GentleYAG (Candela,

Wayland, MA), SmartEpil II (Cynosure, Chelmsford,

MA), Harmony (Orion Lasers, FL), Profile (Sciton,

Palo Alto, CA), Mydon (WaveLight, Erlsngen,

Germany), and CoolGlide (Cutera, Burlingame, CA)

(Table 14.2) The long-pulse 1064 nm Nd:YAG lasers

are not all the same.There are variabilities in spot size,

laser output both in fluence and in how the extended

time of the laser pulse is generated), pulse duration,

and epidermal cooling In addition, although many

claims are made by the laser manufacturers, few

well-controlled peer-reviewed medical studies are available

Because of the vaariability between the 1064 nm

Nd:YAG lasers, a review of the clinical studies with

each system will be presented separately

Vasculite

The Vasculite was the first long-pulsed 1064 nm laser

to be approved by the US Food and Drug Administration

(FDA) for vascular treatment The Nd:YAG 1064 nm

laser is pulsed with IPL technology Individual pulses

up to 16 ms in length can be delivered as single,

double, or triple synchronized pulses with a total

maximum fluence of 150 J/cm2 The laser beam is

generated in the handpiece and delivered through a

sapphire crystal 6 mm, 9 mm, or 3 mm ×6 mm in size

Weiss and Weiss,22 Sadick,23 and Goldman24 have

reported excellent results in treating leg telangiectasia

from 0.1 to 3 mm in diameter Application of a cool

gel to the skin (without cooling of the crystal – which

is not necessary with the most advanced version,

Lumenis 1, which is thermokinetically cooled to 4°C)

and synchronization of the pulses allow epidermal

cooling and protection In addition, synchronized

tim-ing between pulses can be tailored to the thermal

relaxation times of blood vessels

Weiss and Weiss22treated 30 patients who had been

dissatisfied with previous leg vein treatments with

either sclerotherapy or other laser light or IPL.A single

14–16 ms pulse at 110–130 J/cm2was given to treatvessels 1–3 mm in diameter A double pulse of 7 msseparated by 20–30 ms at a fluence of 90–120 J/cm2

was used to treat vessels 0.6–1 mm in diameter, and atriple synchronized pulse of 3–4 ms at a fluence of80–110 J/cm2was used to treat vessels 0.3–0.6 mm indiameter Immediate contraction of the vessel wasused as an endpoint of treatment, followed by urtica-tion Immediate bruising from vessel rupture occurred

in 50% of vessels At 3 months after treatment, themajority of sites improved by over 75% (Fig 14.4).Hyperpigmentation was noted in 28% of patients atthe 3-month follow-up In short, this report demon-strated successful treatment of otherwise-difficult ves-sels, and mirrors our experience Weiss and Weiss25

reported on 3-year results in the treatment of legtelangiectasia 0.3–3 mm in diameter at slightly higherfluences of 110–150 J/cm2 They found an average75% improvement in 2.38 treatments Sixteen percent

of patients developed pigmentation which resolved at

6 months, and 4% developed TM

Sadick26 reported on 12-month follow-up in 25patients with leg veins with a fluence of 120 J/cm2

given through a 6 mm diameter spot in a 7 ms doublepulse to vessels 0.2–2 mm in diameter and as a singlepulse of 14 ms and a fluence of 130 J/cm2to vessels2–4 mm in diameter Using these parameters, 64% ofpatients could achieve 75% or greater clearance inthree treatments Two of the 25 treated patients whohad less than 25% vessel clearance developed a recur-rence of the veins within 6–12 months Sixteen per-cent of patients developed pigmentation, which lasted

4 months, and 8% developed TM

CoolTouch Varia

The CoolTouch Varia combines a multiple train ofpulses to generate a pulse width from 10 to 300 msbursts Fluences of up to 150 J/cm2can be generated

A 3–10 mm diameter beam is delivered through afiberoptic cable Dynamic cooling is given with a cryo-gen spray that can be delivered before, during, and/orafter the laser pulse The cooling spray can be variedfrom 5 to 200 ms and can be given in 5–30 ms bursts in

5 ms intervals before and/or after the laser pulse Inthis manner, in the treatment of larger or deeper

vessels, the postcooling quenching cryogen spray can

be given 20–30 ms after the laser pulse to coincide

with conduction of heat absorbed by the vessel

propa-gating back to the epidermis More superficial and

smaller vessels require a shorter delay in the postlaser

cooling spray of 5 ms We have found this laser to be

therapeutically beneficial in treating leg telangiectasia

0.1–2 mm in diameter (Fig 14.5) A comparative

study of two long-pulsed 1064 nm Nd:YAG lasers was

performed on 11 patients with leg telangiectasia

with-out feeding (or with previously treated) feeding

retic-ular veins.The CoolTouch Varia was used with a 6 mm

diameter spot size at a fluence of 135 J/cm2 with a

25 ms pulse and precooling of 5 ms and postcooling of

15 ms The CoolGlide laser was used with a 5 mm

diameter spot, 25 ms pulse at 200 J/cm2and contact

cooling Both lasers produced comparable clearing of

75% in all treated vessels However, the CoolGlide

laser was significantly more painful.27

Two papers were published on the same 23 of 30 leg

vein patients (completing the study) treated with the

CoolTouch Varia.28,29Greater than 75% improvement

was noted at 85% of treated sites.Transient

pigmenta-tion was noted in 6 of 23 patients, with TM in 1 of 23

patients Fluences of 150 J/cm2 were used for

all-diameter veins, with a 25 ms pulse duration on veins

less than 1.5 mm in diameter and 50–100 ms on veins

1.5–3 mm in diameter Patients received up to two

treatments 4–6 weeks apart One to three passes were

required to blanch the targeted vessels Laser spotdiameters and the time of pre and/or pulse coolingwas not noted in either of the two papers Patientswho had previously had treatment with nonhypertonicsaline sclerotherapy preferred sclerotherapy over laserbecause of the increased pain with the laser

A direct comparison of the CoolTouch Varia with rotherapy utilizing sodium tetradecyl sulfate (STS) wasperformed on 20 patients with size-matched superficialleg telangiectasia 0.5–1.5 mm in diameter.30Laser treat-ments were given through a 5.5 mm diameter spot at125–150 J/cm2with a 25 ms pulse duration Precoolingranged from 0 to 5 ms and postcooling from 20 to 50 mswith a delay of 5–20 ms.The endpoint of laser treatmentwas vessel contraction Sclerotherapy with STS 0.25%was followed by 48 hours of 20–30 mmHg graduatedcompression stockings Sclerotherapy-treated patientshad a significantly better response in fewer treatments,with comparable adverse effects

scle-CoolGlide

The CoolGlide can deliver fluences up to 100 J/cm2

through a 10 mm diameter spot The pulse durationcan be varied continuously from 10 to 100 ms Unlikethe other two systems, which can deliver each burst at

a 1 Hz speed, the CoolGlide can deliver pulses at 2 Hz.Cooling is provided by a contact system that glides in

Fig 14.4 Treatment of leg telangiectasia with the Vasculight at the parameters specified in the text (a) Before treatment.(b) 60 days after treatment (Courtesy of Robert Weiss MDand reproduced with permission from Sclerotherapy Treatment ofVaricose and Telangiectatic Leg Veins, 4th edn Goldman MP, Bergan JB, Guex JJ, eds Elsevier, London, 2006.)

front of the laser beam so that 2 cm of skin is

pre-cooled before the laser aperture glides over the

treat-ment site We have also found this system to be

effective in treating leg telangiectasia 0.1–3 mm in

diameter.27 However, the lack of effective,

repro-ducible cooling can lead to the production of

epider-mal scars more often than the other 1064 nm laser

systems, as well as an increase in procedural pain

Fifteen women with 21 sites of leg telangiectasia

0.25–4 mm in diameter were treated twice at 6–8

weeks with the CoolGlide using a 7 mm spot, fluences

of 90–160 J/cm2and pulse durations of 10–50 ms.31

Significant improvement was seen in 71% of sites, but

hyperpigmentation was present in 61% of sites at

3-month follow-up A second study on 20 patients with

reticular veins 1–3 mm in diameter was performed

using 100 J/cm2and 50 ms pulse, without mention of

the laser spot diameter.32Although 66% of the vessels

cleared more than 75% with one treatment at 3

months, pain was significant, especially without the

use of EMLA cream applied for 1 hour Unfortunately,

longer follow-up was not reported

Lyra

The Lyra long-pulse 1064 nm Nd:YAG laser was

used to treat 20 patients with leg telangiectasia

0.5–5 mm in diameter with 100–200 J/cm2 at50–100 ms with a 3–5 mm diameter spot and one tofour treatments.33Comparable telangiectasias on thesame patient were treated with one treatment ofSTS 0.6% No compression was used Even at theseparameters with excessive concentration of STSwithout compression, and four laser treatments ver-sus one sclerotherapy treatment, adverse effects andtreatment efficacy were not statistically differentbetween the two treatment modalities Patientsurveys found that 35% preferred laser and 45%preferred sclerotherapy

Sadick34 also evaluated the Lyra with a 30–50 mspulse duration, 1.5 mm diameter, 400–600 J/cm2forred vessels and a 50–60 ms pulse, 1–3 mm diameterspot, and 250–370 J/cm2for blue vessels through a4°C cold window for three treatments At 6 months,80% of vessels had greater than 75% clearance Thiswas a limited study on 10 patients Two of the 10patients had pigmentation lasting up to 6 months, and

TM occurred in 1 of the 10 Moderate discomfort wasexperienced by all patients

Quantel Medical Multipulse mode

The most recent development in long-pulse 1064 nmNd:YAG technology has been the production of a

Fig 14.5 (a) After sclerotherapy – an ulceration occurred that is covered with an occlusive dressing (b) After treatment of afoot telangiectasia with the CoolTouch Varia at 150 J/cm2with a 50 ms pulse and 5 ms of precooling 10 ms before the laser pulse,followed by a 10 ms cooling burst 10 ms after the laser pulse Note the complete clearing 60 days after treatment (Reproducedwith permission from Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins, 4th edn Goldman MP, Bergan JB, Guex JJ,eds Elsevier, London, 2006.)