Lasers In Aesthetic Surgery
Which means light amplification by stimulated emission of radiation. Application of lasers for Treatment of skin conditions has given gratifying results.
The basis for selective skin laser treatment is that light can be manipulated in terms of its wavelength, energy content and pulse duration so that a particular target chromophore absorbs light and is damaged or destroyed, whereas other chromophores are not. The chromophores of importance are melanin, haemoglobin, water and collagen.
The wave length of light influences the extent to which it is absorbed by one or more tissue chromophores. The energy of the light is measured in Joules (J) power which is the rate at which the energy is delivered. Duration is the time in nanoseconds. It was also observed that when the laser beam falls on skin it may undergo –
Based on this effect and due to the curing effect on skin many new machines have evolved. Today we have a bevy of lasers that are being used for rejuvenation and also for skin problems, like treatment for pigmentation, forvascular lesions, for acne, vitiligo, tattoo, psoriasis etc.
The latest technology today is of skin tightening by creating more collagen and matrix. We have a vast number of equipments that enable rejuvenation by non-surgical procedures. Even slimming can be achieved by radio frequency combined with laser or by cool sculpting.
Lasers are named after the constituents of their medium e.g. Gas (ARGON, Co2) LIQUID (Pulsed Dye Laser) SOLID (E.R. Yag; Nd: Yag, Q – switch, ND Yag) SOLID STATE (DIODE LASER)
Lasers are qualified according to their penetration into the tissues. The fluence (energy) and is depicted in Joules/cm. and the time taken for treatment that is the relaxation time (TRT) that is size of the target chromophore and time is noted nanoseconds. Epidermal cooling during the treatment enhances the efficacy of the device by preventing immediate complication. Therefore longer wavelengths – penetrate in deep dermal tissue useful in tattoos, pigmentation, where it targets the melanin. The smaller wavelengths are used (low energy laser) to expedite wound healing. Hence laser depends on energy source, target source, travel time and treatment time.
Melanin absorbs light in the ultraviolet – 1200 m.m. range. Q – Switch Nd : yag (1064 nm.) units light that penetrates
- 2-3 mm into the dermis – hence suitable for the removal of deeper dermal pigmentation, e.g. naevus of ota, tattoo (blue-black tattoos)
- It passed through KTP crystal – wavelength is halved 532 (nm.). This penetrates less deeply and is more useful for removal of epidermal pigmentation e.g. epithelides, freckles etc.
- The Ruby Laser (694) laser penetrates less than 1 mm. It is useful in treating superficial lesions such as freckles, or cafe au luit.
Most of the lightening occurs due to gradual uptake removal of the fragmented particles by activated macrophages that are passed through the lymphatic systems.
TYPES OF LASERS IN PRACTICE
Ablative Laser Resurfacing
1. Co2 Laser (Carbon Dioxide): causes abalation of the epidermis dermis,collagen denaturation + contraction. During the healing process there is re-epithelialisation from the hair follicles and other tissues encouraging collagen remodeling.Co2 laser produce light (10600 nm) which is poorly absorbed by chromophore water and which therefore has a relatively high penetration (30um)
2. Er (erbium yttrium aluminium garnent): Yag laser was then developed – they emit light at (2940nm) which is highly absorbed by water and has a low penetration (3um). This is safer and is associated with more abalation and less thermal damage. Attention is then switched from abalation because of the better result with Er. Yag laser.
Although Ablative lasers like Co2 + Er.yag are highly effective for severe photo- damage and skin laxity yet, their use was severely limited because of the risk of infection, often scarring and hypopigmentation.
These were soon replaced by the fractional lasers. Which create columns of ablated tissue separated by zones of intact tissue resulting in rapid epithelialisation. Healing occurs three dimensionally, from the adjacent untreated bridges of tissue as well as from the hair follicles, adnexal poor tissue can also be treated .
3. Fractional laser: provides a greater margin of safety compared to conventional ablation by avoiding the production of open wounds, besides it also improves the photo damage and scar in one or two treatment sessions. Fractional lasers permitted safe deep dermal treatment of the skin of the Neck. Excellent improvements were observed in photo damage , scars from acne surgery, trauma and striae
INTENSE PULSED LIGHT SYSTEMS (IPL)
Unlike lasers intense pulsed light systems are high – intensity pulsed sources that emit poly chromatic light in a broad wave length spectrum, the xenon flash lamp is a gas – discharged, high – intensity lamp filled with xenon gas that produces the bright light when an electric current passes through the gas. These lamps work in a pulsed mode and convert electrical energy into optical energy. The emiting broadband light is covering the spectrum from ultra- violet (uv) to infrared (IR). The most common systems emit radiations between 400 and 1200nm. With cut on and cut off wave length filters. It can be used for different medications of treatment. It is equipped with a water filter system to prevent damage to the skin.
This System is Indicated for –
Unwanted hair removal
Photo rejuvenation for acne, cellulite
Treatment of hypertrophic scars and Keloids
Treatment of diffuse redness, telangiectasias epidermal pigmentation, dyschromia
By using cut off filters to filter out shorter wave lengths selective damage of cutaneous vessels is possible. IPL is useful for Haemangioma, port – wine stains and vascular malformation.
Vascular malformations – are lesions that are present at birth and appear to grow at the same rate as the rest of the body.
Haemangioma – are lesions that develop within the first few weeks of life that increases in size asynchronously. Haemangiomas affect 12% of children by one year of age, predominance in females 3:1 ratio. 60% of all haemangiomas are found in the head and neck region. 60% of all haemangiomas appear shortly after birth, undergo rapid growth in the first year. Some begin to involute after one year. By 5 years of age 50% involute spontaneously. Those that do not should be treated with IPL systems in 3 to 4 sessions at weekly intervals.
Port wine stains – These are pink lesions flattened and reddish in colour. Early treatment yields the best response. The pink lesions disappear completely. Nodular port-wine stains respond better to N.D. yag laser.
IPL Treatment For Acne: Acne is an extremely common disorder that predominantly occurs among teenagers and adults. It is capable of causing significant and detrimental psycho social impact & it is associated with depression, suicidal tendencies, social isolation and unemployment.
More acne occurs on the face, back, chest and neck. Hyper functioning sebaceous glands are one of the main contributors to acne. In acne subjects the sebaceous glands and the entire sebaceous follicle are much larger than in non acne subjects. Their miniaturization results in marked decrease in acne lesion counts and severity.
The acne lesion includes open comedones & inflammatory papules and pustules. It is characterised by hornification of the pilo sebaceous duct with increased proliferation and accumulation of sloughed follicular keratniocytes mixed with sebum. There is increased sebum production and proliferation of the propionibacterum (P.acnes) acnes and the development of inflammation.
The main emphasis on management of inflammatory acne is prevention of atrophic and hypertrophic scarring in any acne patient, medical therapies are tried first including treatment with antibiotics – Tretinonin, Benzoyl Peroxide, Azelic Acid. For poor responders IPL – Light treatment has shown to be an efficient modality. The mode of action of light treatment is related to energy and to wave length band of 530 – 750 nm. covering most of the haemoglobin absorption spectrum and it produces the best results in the treatment inflammatory acne along with the medical treatment.
IPL For Treatment Of Unwanted Hair: There are two medical conditions for unwanted hair – Hirsutism and Hypertrichosis. Hirsutism affects only women, resulting in hair growth with a normal male pattern mainly facial hair in the beard and upper lip areas – commonly seen as a secondary effect to come endo crime disorder – (poly cystic ovary syndrome). Hypertrichosis is the presence of excessive amounts of hair in normal and abnormal locations. Generally the cause is genetic or may be endocrime disorders.
The target areas are the stem cells residing in the shaft of the hair follicle particulary in the bulb area. These cells are responsible for hair follicle regeneration. The absorbing chromophore is the melanin in the hair shaft and matrix cells. IPL cut off filters 590 – 645 nm. are suitable for hair removal. Fair or white hair is resistant to the treatment, brown or black hair contain eumelanin which has high absorption of NIR Light.Skin reaction with perifollicular erythema is a sign of correct energy setting predicting an efficient result. In darker skin long wave lengths and cooling devices are necessary for prevention of epidermal damage. Hence IPL devices are always equipped with simultaneous cooling devices. Since melanin absorbs light over a broadband wave length, other lasers are also being tried for hair emoval like ND. Yag Laser, Alexandrite Laser, Diode Laser or combinations but IPL systems have been found better as they are simpler and have larger safety margins.
Treatment Of Scars: IPL is the ideal treatment of scars less than one year old, improvement in the scar erythema & symptoms are visible after the first session. Total resolution may require 2 – 3 sessions.
IPL plus intralesional kenacorts injections have given beneficial results in keloidal scars. Occasionally injections of 5 fluorouracil have also given good results in hypertrophied scars.
Laser Treatment For Scars : The wound healing process is divided in three stages – inflammation, proliferation and remodelling. When an injury occurs there is clotting and a cascade of events take place. There is release of chemicals like prostaglandins, and factor like interleukin-1 etc. This stimulates migration of inflammatory cells – which results in debridements of wounds – the release of cykotimes and growth factors TGF – B and POGF that develop the wound matrix that is found by the fibroblast. The keratinocyte start the re-epithelialisation of the wound. During the maturation phase both collagen I and type III increase during wound – healing. Excessive scar tissue may result from excessive matrix deposition. Other factors are the increased hyaluronic acid and collagen from the hypertrophic scar. It usually arises within one month of injury and is consistently confined to the injury site. They appear as red raised and firm scars. Sometimes they may involute also.
Keloids are purple / red nodules that extend beyond the original site of injury and are frequently disfiguring. Keloids persist and do not involute. Keloids can occur from ear piercing, abrasions, tattooing, vaccinations, burns etc. Their common locations are chest, shoulders, upper back etc
Q. Switch Yag Laser
Pigmented lesions and tattoos result from excessive or abnormally deposited melanin or other pigment. As tattoing is becoming more common and accepted in society, the popularity of tattoo removal also continues to grow.
Freckles, lentigines, the naevus of ota, congenital or acquired melamocytic nevi can respond well to laser / light treatment. Other conditions including melasma, cafe au lait patches and Becker’s nevi are less predictive. Light skinned people carry a much lower risk of complications such as P.I.H. This can occur among people with darker skin type.
Laser and light source can be considered as a second – line treatment as well as adjunctive therapy to topical medication.
The follicular melanocytes can be effectively treated in cases of cafe au lait patches and Becker’s nevi with laser and light.
The N.D. Yag laser (1064 nm.) emit light with longer wave lengths and therefore relatively dermal penetration is possible. The N.D. Yag is specially designed to emit a rapid train of higher peak power pulses of energy that are so close together that there is insufficient time for cooling between pulses. The effect on the skin appears as a continuous wave of laser beam.
The Q – switch laser (Quality switching) creates very short pulses with extremely high peak powers. It penetrates (2-3mm.) into the dermis and is therefore suitable for the removal of tattoo and pigmented lesions. The laser targets the melanin or in case of tattoos, the small particles of tattoo ink within the mesophages or they may be scattered throughout the dermis. The cells that contain the melanin are heated and explode making a popping sound. Multiple treatments are normally required and may vary from five to even twenty sessions.
In darker skin patient special care is needed as there may be an adverse side effect due to competitive absorption of laser light within the epidermis. This may result in a temporary hypopigmentation. Besides, since more light is absorbed by the epidermal pigment less light reaches the tattoo ink target. Therefore more treatments than usual may be necessary. Q – Switch, N.D. Yag (1064 nm.) both aregood for treatment of blue and black tattoos. At wavelength of (532 nm.) it can also remove red tattoo ink.
Similarly green tattoo can be removed by Q – Switch. Ruby laser at (694 nm.) wave length. Sometimes tattoo is done for eyebrow enhancement. Q – Switch can remove the unwanted tattoos. If in doubt a test report should be done first, wait for 6 – 8 weeks before doing any further treatment.
B. Non –Abalative Photorejuvenation and skin Remodelling – Skin tightening.
One of the latest technologies of improvement in photo rejuvenation are those where there is no skin breakage but enhances the looks by increased dermal collagenation. Patients who are unable or unwilling to submit to a prolonged downtime of abalative resurfacing as with Co2 laser or are unable to take the risk of surgical treatment such as face-lifts are readily attracted to these simpler technologies.
In the photo damaged skin collagen fibres are thickened and fragmented with higher ratio of collagen III and collagen I compared to the younger skin. The fibres are more loose and the elastic fibres become structurally and functionally abnormal. The ground substance of the dermis which is composed of hyaluronic acid and proteoglycans is unable to maintain efficient dermal hydration and results in wrinkle, dry and fragile skin. This is combined with other features of ageing skin which includes irregular pigmentation, telangiectasis ,coarse texture and increased pore size.
New devices were then produced which helped dermal heating and also in water absorption. There is deep dermal collagen dematuration, new collagen production and subsequent remodeling and tightening achieved by THE IPL and R.F. devices.
ExilisElite uses focused Radio – frequency (R.F.) technology to redefine appearances by reducing wrinkles, treating laxity and reshaping the body from head to toe in just 6-7 comfortable treatment session.
Only Machine that successfully removes stare and wrinkles in just 6 to 7 session.
Laser Skin Tightening
Laser skin tightening is a minimally invasive non – surgical process that uses an infrared light source ( a laser ) to tighten skin by heating the collagen under the skin surface. Sufficient dermal heating results in collagen dematuration. The collagen fibril assumes a random coil configuration that results in shortening and thickening of the collagen fibers. This stimulates the subsequent wound healing and leads to activation and proliferation of the fibroblasts and new collagen deposition. This dermal remodeling helps in improvement of wrinkles, skin tone, and other attributes of ageing and photo damaged skin. Facial skin tightening is noticeable immediately after the treatment and there is no downtime. Additional skin tightening occurs over the next few months. For optimal results usually two or three treatments are required about a month apart.
Skin tightening not only encourages growth of new collagen in the treated areas but also promotes absorption of collagen from surrounding untreated areas. With the regeneration of natural collagen, laser skin tightening patients immediately begin to notice smoother, softer skin and a more youthful appearance. After laser skin tightening, patients are able to return to work immediately. Side affects are minimal. It may include a warm sensation to the skin, redness or minor swelling. The side affects usually resolve in a few hours.
Q. Is Skin Tightening Painful ?
It is not painful. No anaesthesia is required. There is a warm heating sensation, which is cooled simultaneously by the regular cooling blasts from hand piece.
Q. Ideal Skin Tightening Candidates ?
Men and women between the ages of 30 to 60 years. Laser skin tightening is appropriate for men and women of all skin types and skin tones who wish to achieve dramatic results without painful surgery and lengthy recovery time. The candidates experience permanent results as the collagen under the skin regenerated produce a more youthful complexion. It is a safe effective way to lessen the effects of time. Using advanced laser technology the collagen beneath the surface of the skin is heated causing it to constrict. Thus tightening loose facial skin and loose skin of neck, arms and body and giving the appearance of firm youthful skin with less lines and wrinkles.
Q. What areas of the face and body can laser skin tightening treat ?
Laser skin tightening has been proven effective for tightening of the skin of all areas of the body. Patients get a rejuvenated look when this treatment is applied to the face, neck, abdomen, arms, legs, buttocks. Most patients feel changes in the tone and condition of their skin immediately following skin tightening treatment, Since the collagen growth is stimulated by this procedure. The optimum results are available after a few months as the natural growth continues for 3 to 4 months approx. 90 to 180 days after initial treatment by which patient enjoys a rejuvenated appearance.
Q. Is laser tightening safe. What are the side effects?
This is a safe and painless way to rejuvenate appearance of skin in any area of the body. Laser skin tightening does not burn or break the skin. There are no side effects. There may be some redness or swelling temporarily. It is FDA approved in the U.S.A.
Q. Candidates for Exilis ?
Ages between 20 – 70 years age. Any patient who desires cosmetic improvement on the face and body, particularly in those areas that show signs of ageing and have not responded to exercise or weight loss. Exilis is ideal for treating wrinkles, skin laxity and shaping. The face and body. Common areas of treatment includes – i. eye area ii. Around the mouth iii. Chin area iv. Arms v. legs vi. Jaw lines vii. Décolleté vii. Abdomen viii. Back ix. Knees and x. ankles.
Q. What to expect after laser skin tightening?
After laser skin tightening result will be immediately visible. The rejuvenating effects of increased collagen production will become markebly more noticeable in the months following treatment. Typical skin tightening results are visible upto two years, it can be extended further with a few touch up sessions. One session will necessitate at least 6-7 therapies every fortnight. After roughly two years another series of treatments may be necessary to promote the growth of new collagen. If treating the face patient must be encouraged to use sunscreen to protect the area.
Non surgical face lift with High Intense Focused Ultra Sound. HIFU Technology.
This is a unique facial rejuvenation option that produces dramatic results. Laser skin tightening effectively reduces the appearance of wrinkles and loose skin for a smoother and more youthful appearance. It is a minimally invasive non- surgical process that uses a laser to heat the collagen under the skin surface causing the skin to contract (tighten)
Facial skin tightening is noticeable immediately after the treatment. There is no downtime hence today HIFU has become an increasingly popular procedure. Further skin tightening occurs over the next few months. Optimal results usually require two or three treatments about a month apart. Recently a new versatile instrument has been created which is the 2nd generation of HIFU system known as the Dublo uses High Intensity Focused Ultra Sound Technology. This is the improved version. It is gentler than the 1st generation.
During the treatment Dublo emits and transfers high intensity focused ultra sound energy to the deep structures of the skin without cutting or damaging the surface of the skin. It triggers 5 important processes in the skin so that after the first time one can see clear and spectacular results.
Five effects of Dublo on the skin
Stimulates the reconstruction of collagen.
Triggers the production of elastic fibres.
It strengthens the subcutaneous layers of the epidermis, that increases the skin-lifting.
- Reaches the connective tissue layer of muscle contraction, so lifts the skin.
Removes the unnecessary fat tissue , improves facial contour and reduces the double Chin.
It has been observed that pigmentation on the skin can also be reduced.
Q . What areas can be treated ?
Dublo gives spectacular results and lasting results in the checks, forehead,
Eye, eyebrow, neck, decolletape area and areas above the knee.
Q. How much time is required ?
One full face treatment with HIFU Dublo takes approximately 2 to 3 hours after applying local anaesthetis cream.
After completion there may be mild redness and swelling which disappears within a few hours. The skin is then cooled with ice to reduce the redness swelling.
Q. How many treatments are required ?
Over 50 years age – 1, 2 or even 3 treatments .
For 30 years age – one treatment to delay the signs of ageing.
For 40 years age – there may be slight sagging, it can correct the slight sagging highlight the facial contours , prevent aggravation of crows feet around the eyes.
For 50 years age – highly recommended for lifting the jaws , double chin and facial contours and neck lift. On the forehead –eyebrow lifting gives a more youthful appearance.
For 60 years and above – There is more sagging of the slack muscles and there is reduction of the collagen fibres, hence is it advisable to do extra sessions with higher energy to increase the collagen.
Q. How long does it take to show results ?
In the younger age group the results are visible immediately but is continues to improve in the next 2-3 months. Final restructuring however can be seen after 6 months.
Another very effective result is that there is also improvement in the skin colour, patient appears fairer.
Patient satisfaction rate after the focused ultrasound therapy is 80 higher than other therapies.
Patients in the Eastern world are known to take 3-4 treatments at 6 monthly intervals, with improvement every time. This is a very safe and effective procedure.
Laser Treatment for Vitiligo and Psoriasis.
Vitiligo is an acquired disease in which melanocytes in localised areas of the body stop producing melanin. Sometimes hairs may also become depigmented. This is called leucotrichia. The disease may be single patch or may involve several segments. Sometimes it may be located in wearing apparel areas like shoes, gloves, chappals etc. It may also occur in areas subjected to tight prolonged pressure . Vitiligo is considered as an auto immune disease.
Treatment is based on Topical corticosteroids, tacrolimus, psorolens and exposure to sunlight and lasers. In cases where repigmentation fails by medical therapy they are subjected to surgical procedures of melanocyte grafting like skingrafting.
The 308 mm excimer laser along with other medical therapies have shown some good results . Laser is given as sessions of twice or thrice a week. Sometimes combination therapy of steroids tracolimus and laser have shown partial or total repigmentation in two years.
Psoriasis is an auto immune disorder of the skin that results in hyperproliferation of the skin. It is a chronic skin disease characterised by itching, inflamed dry skin, and raised rough, red areas on the skin covered with silvery scales, Psoriasis in non infections and is often seen in people between 15 to 40 years of age.
Causes of Psoriasis
The exact cause is not known but it is believed that a combination of several factors contributes to the development of this disease. It is usually found on the knees or elbows.
Thick red patches known as plaques and dry silvery scales appear on the scalp , face, elbow, knees and sole of feet. Sometimes there is dry cracked skin that may bleed. There may be joint swelling, tenderness and pain.
The goal of treatment is to control the symptoms and prevent infection.
Local application of ointments and creams are given to keep the skin smooth, and to remove the scaling, cortisone creams help in severe cases of itching. Shampoos help in removing dandruff. These medical therapies are now being combined with photo therapy system by Levia 308- Excimer LASER.
Levia is a UVB Select Targeted Phototherapy system . The UVB targets the nuclear DNA this (1) Leads to suppression of the accelerated DNA Synthesis, and also promotes (2) repigmentation.
The melanocytes and melanosomes in the epidermis are stimulated by the UUB light. The Tyrosinase in the melanasome when activated transfers the melasomes to the surrounding keratinocytes of the skin and increases the production of melanin. However this process takes several days to process.
Levia has other uses in the treatment of