The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

Examination of the same patient’s pretreatment views and her results 8 months later
shows general tightening of the skin and notable improvement of deep wrinkling in
the perioral and forehead areas. These photographs, taken with bounce flash, pro-
vide a more accurate rendition of her skin texture and demonstrate the generalized
improvement particularly evident in the glabellar and periorbital areas.
Problems and Complications
Complications from croton oil peels are the same as with any other deep resurfac-
ing technique. The main complications, scarring and hypopigmentation, are largely
preventable by controlling the depth of peel. Delayed healing and thickening is evi-
dence of peeling to the deep reticular dermis. This thickening or mild scarring can
progress to a full scar but can be arrested and reversed by injecting triamcinolone
acetonide 10 mg/ml and 5-fluorouracil (off-label use) in a ratio of 3:2 or 1:1.
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Part III  Nonsurgical Cosmetic Treatments

Both hyperpigmentation and hypopigmentation can occur as blotchy areas or ho-
mogeneous abnormalities. They are less likely to occur in lighter-skinned patients.
Hypopigmentation can occur if the peel penetrates deep enough. Alteration in pig-
mentation is more common in older patients; it seems to be related to decreased
melanocyte synthetic function. For individuals with pronounced rhytids, adequate
improvement may necessitate peeling to a depth that will result in hypopigmenta-
tion. The improvement is well worth it, and the porcelain look of the skin that was
typical of formerly used peels is not seen.
Prevention of hyperpigmentation relies on the pretreatment skin care regimen, which
acts to suppress the melanocytes. Transient hyperpigmentation may be seen during
the recovery period; this responds well to prompt treatment with tretinoin and hy-
droquinone 4% over several weeks. Sun protection must be emphasized to the pa-
tient as an important factor in prevention of hyperpigmentation.
Infection in peeled skin can be bacterial, viral, or fungal. Bacterial infections tend to
develop on postpeel days 2 to 5 and are usually caused by common pathogens such
as Staphylococcus aureus, streptococci, or Pseudomonas aeruginosa. Bacterial in-
fections are heralded by pain, fever, and purulence and are treated with topical wound
care and appropriate antibiotics. Herpes simplex virus (HSV), the most common vi-
ral infection, is often the result of reactivation of a latent infection. It is usually her-
alded by dysesthesia or intense pruritus. Notably, as the epithelium is disrupted, the
presentation of HSV is atypical, with erythematous erosions rather than vesicles be-
ing present. Treatment includes doubling the dose of oral antiviral therapy and adding
a topical antiviral agent, which should be applied with a cotton-tipped applicator to
prevent spreading the infection. A herpes outbreak can be very impressive but typi-
cally does not leave any permanent scars. Fungal infections most commonly occur
with Candida albicans and present as painful ulcerations. Diagnosis is made with a
potassium hydroxide (KOH) smear, and treatment is with oral antifungal agents such
as fluconazole.
Hypertrophic scarring is perhaps the most feared complication with chemical peel-
ing and one of the most difficult to treat. It most commonly occurs in areas of thin-
ner skin such as around the lips or skin overlying bony prominences (for example,
the malar region or chin). As with poor scarring in general, they often occur in ar-
eas where wound healing is delayed beyond 14 days. Treatment is generally nonsur-
gical, involving the application of steroid creams or topical silicone. If this therapy
is ineffective, a course of triamcinolone steroid injections is recommended. However,
given the difficulty in effectively treating postpeel scarring, prevention is undoubt-
edly the best cure through the judicious use of peeling agents, particularly while the
physician is learning the techniques of chemical peeling.
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Chapter 15  Chemical Peels

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Part III  Nonsurgical Cosmetic Treatments
Ectropion can result from excessive peeling of the lower lids. As with blepharoplasty,
caution should be exercised in patients with lid laxity. Sequential lighter peeling and
temporary suspension of the lower lid are helpful in preventing this complication.
Mild tension in the lower lids is not uncommon and responds promptly to massage.
Milia are keratin-retaining cysts, which can be seen early or late in the healing
process. They occur in up to 20% of patients 6 to 8 weeks after a deep peel. They
sometimes respond to an increased intensity of the skin treatment regimen, specifi-
cally increased tretinoin. Failing that, gentle excision with a fine needle or electro-
cautery may be required.
Erythema usually resolves in 10 to 12 weeks after the peel procedure, but prolonged
erythema (longer than 12 weeks) can be troublesome for the patient. Some physi-
cians routinely use a steroid cream for the postpeel skin care regimen as a preventive
measure. If not used already, steroid should be added into the regimen if erythema
seems excessive and extended. Bleaching creams such as hydroquinone can also con-
tribute to erythema and may need to be discontinued or an alternative pigmentation
prevention treatment can be used, such as azelaic acid 20% cream.
Outcomes and Results
An invariable observation of the results obtained with croton oil peels is the overall
qualitative improvement of the skin. The supposition is that there has been a fun-
damental change in the skin anatomy, which not only dramatically improves wrinkles
but also significantly ameliorates the effects of sun damage. The skin reflects light
differently and brightens the dull, ashen look of older, actinically damaged skin. This
is the critical factor that has been missing in surgical facial rejuvenation.
A constant observation of the Baker peel is the long-lasting (if indeed not perma-
nent) results. This has been substantiated by multiple histologic studies that have
shown the deposition of a significant layer of collagen in the dermis after a peel pro-
cedure that is aligned in an orderly manner and is thought to be the mechanism for
the effacement of wrinkles. This layer remains constant for years, even decades.
Since 2000, results with croton oil peels show remarkable improvement in deep wrin-
kles and actinic damage without depigmentation. These improvements are completely
stable, and rather than showing diminishing results, the skin appears to improve with
time.

This 47-year-old woman had brittle, sun-damaged skin and smoker’s lines. Consid-
erable qualitative improvement is seen after a croton oil peel with a stable result
4 years after treatment.
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Chapter 15  Chemical Peels
This 53-year-old woman is shown before a croton oil peel treatment and 4 years af-
ter the peel and a face lift. She also had an endoscopic brow lift and upper and lower
blepharoplasties.

Note the periorbital details in the same patient before treatment, with posttreatment
improvement of texture after 1 year, and evidence of further improvement after
4 years.
Although not yet confirmed histologically, it is reasonable to expect that this stabil-
ity is modulated by a similar deposition of collagen in the dermis, while not dis-
rupting the function of the melanocytes. The fact that repeated peels produce addi-
tive effects suggests that there is more deposition of collagen each time. The skin
looks younger because in essence, younger skin is being created.
Histologic studies have also shown eradication of actinic keratoses in deeply peeled
skin. The anecdotal impression of experienced practitioners has been that individu-
als who have undergone peels do not develop facial basal cell cancer or squamous
cell cancer. In a recent study in the dermatology literature, Hantash et al showed that
laser resurfacing, fluorouracil, and 35% TCA peels were equally effective in keeping
susceptible individuals free of nonmelanoma cancers for the studied 5-year period.
The deeper croton oil peels are expected to have a similar or better effect, further ex-
panding the benefits and utility of this approach.
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Part III  Nonsurgical Cosmetic Treatments
Pretreatment
1 year after peel
4 years after peel

The qualitative degradation of skin with time is obvious, and many patients con-
sider textural changes to be equally or more important than structural changes. It
could be argued that the qualitative and textural improvements achieved with a peel
in this 61-year-old woman had greater impact than surgery could have.
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Chapter 15  Chemical Peels
There are many advanced surgical techniques to deal with gravitational and volume
changes, but surgery can only minimally and indirectly improve textural issues and
has no effect on the perioral area, where it is often needed most. This 59-year-old
woman could certainly have benefited from a face lift, but her pronounced perioral
lines would have been unaltered and a detriment to the results. The overall qualita-
tive improvement, especially around the mouth, seen here 1 year after her peel, have
had a greater impact than surgery would have.
The phrase comprehensive facial rejuvenation is frequently used, but unless these
textural changes are dealt with as well, it is a mere platitude.

The preoperative view of a 75-year-old woman shows advanced structural and tex-
tural changes of aging. Neither surgery nor resurfacing alone could provide a com-
plete result. The second image shows the patient at age 81, 6 years after a face lift
and 1 year after a full-face peel. Croton oil peels provide a powerful and effective
tool to complement surgery and make comprehensive facial rejuvenation a reality.
530
Part III  Nonsurgical Cosmetic Treatments
This 67-year-old woman had undergone two previous face lifts and overresection of
the lower eyelids with rounding of the outer canthi. A corrective face lift and inter-
nal suspension of the orbicularis oculi muscles certainly improved the situation, but
the subsequent peel was critical in completing the look of youth.

This patient had splotchy pigmentation from actinic exposure and upper lip rhytids.
Note the improvement after a 35% TCA peel and upper lip dermabrasion.
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Chapter 15  Chemical Peels
This patient sought treatment for her fine facial wrinkles, particularly in the perior-
bital region. She is shown 5 months after a 35% TCA peel.

This patient was displeased with her periorbital rhytids and lower lid pigmentation.
A 35% TCA peel was performed with good results.
Concluding Thoughts
Hetter’s work and subsequent experience have greatly clarified the earlier issues re-
garding deep chemical peels, which are generally classified, possibly inaccurately, as
phenol peels. A weaker concentration of phenol does not penetrate more deeply than
a stronger one, refuting long-held beliefs. This allows greater latitude in the prepa-
ration of solutions. Croton oil has been identified as the critical peeling agent, and
a high concentration of phenol is not necessary to obtain a desired peel. This knowl-
edge also opens the door to investigate other solvents that may act as carriers of the
croton oil and avoid the use of phenol altogether.
The “all-or-none” phenomenon attributed to the Baker peel, which was one of the
main sources of intimidation for surgeons, is simply that the croton oil concentra-
tion was so high that the operator had little control over the application process. By
lowering the concentration of croton oil, application technique and concentration
choice now become the main factors that determine the depth of the peel. In this
manner, the main complication of the traditional peel can be avoided while still pro-
viding the desired clinical result. The principal objections to deep “phenol” peels
were misconceptions based on the experience of older peels that are now obsolete:
hypopigmentation is largely avoidable by controlling the depth and by exercising
rudimentary precautions, cardiac toxicity is simply not clinically seen.
Obagi’s work with TCA in the 1990s was also an important addition to the field.
Concentrations from 20% to 50% were found to be effective at producing superficial
to medium and deeper peels, while largely avoiding the complications of scarring
and hypopigmentation. With multiple concentrations of croton oil and TCA avail-
able as peeling agents, surgeons have significant control and specificity. This fact
makes chemical peeling available to any age group and skin type. The possibility of
doing weaker peels on younger patients with the thought of keeping up with aging
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Part III  Nonsurgical Cosmetic Treatments

is an exciting prospect that has the potential of greatly expanding the patient base.
Weaker concentrations of peeling agent can likewise be used to great advantage on
delicate eyelid skin. Precise deeper peeling can be done on problem rhytids without
adversely affecting other sectors of the face. The potential use of these peels in the
prevention of basal cell and squamous cell carcinomas is a new frontier ripe for
investigation.
The main drawback of modern chemical peels is the difficult recovery, but to date,
there is no way to obtain comparable results without injuring the dermis and deal-
ing with the recovery.
Clinical Caveats
 Modern croton oil peels are a cost-effective means to achieve long-lasting results
in facial resurfacing without hypopigmentation.
 Skin pretreatment and patient education are important aspects of the process to
decrease postpeel erythema and assist the patient in dealing with the postpeel re-
covery period.
 The recognition of croton oil as the critical peeling agent allows the formulation of
solutions with different croton oil concentrations.
 Choice of concentration and control of the application technique allow the sur-
geon to choose the depth of peel desired.
 The depth of peel is determined by the appearance and quality of frosting. This is
a predictable and easily recognized phenomenon.
 The above points give the surgeon great control and specificity. This allows treat-
ment of a large range of ages and skin types.
 The novice can approach the learning curve by peeling lighter with the thought
of repeeling. This is a safe way to gain experience.
 Repeated peels give additive effect. This is especially valuable in the effective treat-
ment of lower eyelid skin.
 Modern chemical peels are an important tool in the plastic surgeon’s armamen-
tarium. Surgery can deal with the gravitational and volume changes associated
with aging, while chemical peels are an excellent adjunct to treat the textural and
pigmentary skin changes that result from age and solar damage. By use a com-
bined approach, the goal of facial rejuvenation can be attained.
533
Chapter 15  Chemical Peels

534
Part III  Nonsurgical Cosmetic Treatments
Annotated Bibliography
Baker TJ. Chemical face peeling and rhytidectomy for facial rejuvenation. Plast Reconstr Surg
29:199-207, 1962.
Classic article that introduced phenol peels to the plastic surgical readership.
De Rossi-Fattaccioli D. Histologic comparison between deep chemical peels (modified Lit-
ton’s formulae) and extreme pulsed laser CO2 resurfacing. Dermatol Peru 15:181-184,
2005.
This article provides histologic evidence showing a qualitative difference between skin
peeled by croton oil and skin resurfaced by CO2 laser.
Hantash BM, Stewart DB, Cooper ZA, et al. Facial resurfacing for non-melanoma skin can-
cer prophylaxis. Arch Dermatol 142:976-982, 2006.
The authors provide clinical evidence supporting the fascinating proposition that skin
resurfacing may be protective against the development of nonmelanoma skin cancer.
Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting the formula. Plast
Reconstr Surg 105:227-239, 2000.
The author analyzes the classic peel formula and identified croton oil as the critical peel-
ing agent. This article describes the basis for the modern croton oil peels.
Hetter GP. An examination of the phenol-croton oil peel: Part II. The lay peelers and their
croton oil formulas. Plast Reconstr Surg 105:240-248, 2000.
This is a fascinating article that describes the colorful history of chemical peels in the
United States and the evolution of various formulas.
Hetter GP. An examination of the phenol-croton oil peel: Part III. The plastic surgeon’s role.
Plast Reconstr Surg 105:752-763, 2000.
The author describes the adoption of lay peelers’ formulas by plastic surgeons and how
the classic Baker formula came to be.
Hetter GP. An examination of the phenol-croton oil peel: Part IV. Face peel results with dif-
ferent concentrations of phenol and croton oil. Plast Reconstr Surg 105:1061-1083, 2000.
The author discusses the basis for altering the classic Baker formula and the clinical ap-
plication of these formulas. This is a key article that introduces the modern croton oil
peel.
Johnson JB, Ichinose H, Obagi ZE, et al. Obagi’s modified trichloroacetic acid (TCA)-
controlled variable-depth peel: a study of clinical signs correlated with histological find-
ings. Ann Plast Surg 36:225-237, 1996.
This article discusses the results of 20 patients who undergo TCA peeling with a modi -
fied 50% solution. Biopsies were taken 5 minutes, 48 hours, and 6 weeks postpeel to as-
sess histologic changes with peeling. Key evidence of neocollagen formation is presented.

Suggested Readings
Baker TJ. Is the phenol-croton oil peel safe? Plast Reconstr Surg 112:353-354, 2003.
Baker TJ, Stuzin JM, Baker TM. Facial Skin Resurfacing. St Louis: Quality Medical Publish-
ing, 1998.
Bensimon RH. Croton oil peels. Aesthet Surg J 28:33-45, 2008.
Demas PN, Bridenstine JB. Diagnosis and treatment of postoperative complications after
skin resurfacing. J Oral Maxillofac Surg 57:837-841, 1999.
Demas PN, Bridenstine JB, Braun TW. Pharmacology of agents used in the management of
patients having skin resurfacing. J Oral Maxillofac Surg 55:1255-1258, 1997.
Dinner MI, Artz JS. The art of trichloroacetic acid chemical peel. Clin Plast Surg 25:53-62,
1998.
Edison RB. Lighter phenol peels allow faster recovery and less discomfort. Aesthet Surg
J 16:239-240, 1996.
Kligman AM, Baker TJ, Gordon HL. Long-term histologic follow-up of the phenol face peels.
Plast Reconstr Surg 75:652-659, 1985.
Landau M. Cardiac complications in deep chemical peels. Dermatol Surg 33:190-193, 2007.
Obagi ZE. Obagi Skin Health Restoration and Rejuvenation. New York: Springer-Verlag,
2000.
Rubin MG. Chemical Peels: Superficial and Medium Depth. Philadelphia: Lippincott Williams
& Williams, 1995.
Stagnone JJ, Stagnone GJ. A second look at chemabrasion. J Dermatol Surg Oncol 8:701-
705, 1982.
Stegman SJ. A comparative histologic study of the effects of three peeling agents and derm -
abrasion on normal and sun-damaged skin. Aesthetic Plast Surg 6:123-125, 1982.
Truppman ES, Ellenby JD. Major electrocardiographic changes during chemical face peel-
ing. Plast Reconstr Surg 63:44-48, 1979.
535
Chapter 15  Chemical Peels

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Lasers and Devices
in Plastic Surgery

JASON N. POZNER, BARRY E. DIBERNARDO,
DAVID J. GOLDBERG
CHAPTER 16

538
Part III  Nonsurgical Cosmetic Treatments
C
osmetic surgeons and other care specialists have expanded their practices to in-
clude many nonsurgical devices and procedures, and the technology associated
with these procedures has become more diverse and complex. For example, liposuc-
tion has become extremely technical, with lasers and other energy devices used to
precondition or tighten skin. Data from the American Society for Aesthetic Plastic
Surgery reveal the changing nature of our practices. Comparisons of procedures per-
formed in the United States in 1997 and 2008 (see below) demonstrate the increas-
ing popularity of nonsurgical procedures. Cosmetic surgeons who do not offer these
procedures may find themselves at a distinct disadvantage, because many patients
who are seen in a practice for nonsurgical procedures tend to look to the same
provider when more invasive surgical procedures are needed.
Ranking of Frequency of Cosmetic Procedures Performed
in the United States*
Rank
1997
2009
1
Chemical peel
Neurotoxin injection
2
Collagen injection
Hyaluronic acid injection
3
Liposuction
Laser hair removal
4
Blepharoplasty
Microdermabrasion
5
Laser resurfacing
Chemical peel
6
Rhinoplasty
Laser resurfacing
7
Breast augmentation
Sclerotherapy
8
Face lift
Pulsed light
9
Hair transplantation
Breast augmentation
10
Forehead lift
Liposuction
*Data from the American Society for Aesthetic Plastic Surgery.
It has become difficult for physicians to differentiate manufacturers’ promotional
claims from reality in determining which lasers and energy sources will be both ben-
eficial for their patients as well as good long-term investments for their practice. The
decision-making process is complex and depends on the scope of the practice, a will-
ingness to accept risk, the number of physicians in the practice, the physical layout of
the office, patient demographics, marketing, and other considerations.

There are many types of lasers/devices available for plastic surgery procedures, in-
cluding skin resurfacing and skin tightening, tattoo placement, treatment of vascu-
lar lesions, hair removal, and treatment of cellulite.
The nature of the practice greatly influences the choice of technology. For instance,
the addition of a device for treating cellulite probably does not make sense in a plas-
tic surgeon’s office in which the focus is primarily hand surgery, but such equipment
may fit nicely in a body-contouring practice. Some of these devices are relatively es-
oteric, such as the excimer laser used to treat vitiligo, whereas others, such as pulsed
light devices, will be used frequently. In this chapter we will review the devices used
in our practices and discuss their applications and potential value. We will also as-
sess newer devices and their potential for long-term use.
Laser Basics
The acronym laser stands for “light amplification for the stimulated emission of ra-
diation”; in medical use this means a device that is composed of an energy source,
a crystal or other laser medium, and a resonating tube. The medium may be a solid,
liquid, or gas, and the laser is often named by this medium, such as carbon dioxide.
The goal of the device is to create a photon that by definition is in the same phase,
direction, wavelength, and frequency as the other photons emitted. The photon or
laser beam created is monochromatic (a single wavelength). This is in contrast to an
intense pulsed light device (discussed later), which is composed of many wavelengths.
The wavelength determines the type of tissue interaction. Ideally, the laser beam is
absorbed by the target tissue or chromophore, although the beam can transmit
through the tissue, be scattered by the tissue, or be reflected by the tissue. The basis
for medical laser use is selective photothermolysis, in which a specific wavelength of
light is absorbed by a specific chromophore. For example, a vascular laser emits a
beam that is absorbed by a blood vessel and heats the vessel until it is coagulated
without damage to adjacent structures.
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Chapter 16  Lasers and Devices in Plastic Surgery

540
Part III  Nonsurgical Cosmetic Treatments
There are a few chromophores that are used for medical purposes: melanin, hemo-
globin, and water. The corresponding wavelength peaks of absorption are shown for
these chromophores.
Devices Used in Plastic Surgery and Dermatology
Pulsed Light
Pulsed light devices are powerful flashbulbs that emit a broad spectrum of light, usu-
ally from 400 to 1300 nm. These devices are different from lasers in that they have
multiple wavelengths of emitted light. These devices either use different handpieces
or cutoff filters that restrict light below a certain wavelength. There is usually a peak
of energy at the wavelength just above the lower cutoff. For example, a 515 filter cuts
off light below 515 nm and has a peak of energy just above this wavelength. These
devices are used for many applications, such as pigment removal, vascular treatment,
hair removal, skin tightening, and activating photodynamic agents. Excellent devices
are available from various manufacturers. Specific differences between devices in-
clude disposable costs (how long the heads last), integrated cooling, programmabil-
ity, and power. These devices are among the most versatile in a plastic surgery office
and often are the first recommended for purchase.
1 m
10 m
100 m
1 mm
10 mm
100 mm
1 m
10 m
100 m
0.1 0.2 0.3 0.4 0.5
1
2
3
4 5
10
Hemoglobin
Melanin
Wavelength
Water
755 Alexandrite
1064 Nd:YAG
1320 Nd:YAG
2010 Tm:YAG
2100 Ho:YAG
2780 Er:YAG
2940 Er:YAG
Er, Erbium; Ho, holmium; Nd, neodymium; Tm, thulium;
YAG, yttrium aluminum garnet

Pigment Removal
Pulsed light treatment for facial pigment removal is often called a fotofacial or photo-
facial. The wavelengths used are in the low 500 to 550 nm range. As such, they are
used on Fitzpatrick skin types 1 through 3 but may be used in Fitzpatrick type 4 skin
types with lower fluences. Multiple treatments are usually recommended as a series
of three or four sessions spaced 3 to 4 weeks apart. The pigmented areas appear darker
immediately after treatment but fade thereafter. This technique is an excellent way
to remove mottled photodamage in a nonablative fashion with minimal downtime.
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Chapter 16  Lasers and Devices in Plastic Surgery
This patient is shown before and 6 months after three pulsed light treatments of the
face for pigment removal.
This woman required pulsed light treatment of the décolleté. She is shown before
and 1 year after five treatments.
Vascular Lesions
Pulsed light treatment for removal of vascular lesions is for small vessel treatment
and rosacea. Filters or handpieces used are near the vascular absorption peak in the
high 585 to 595 nm range. These treatments work best on the face. Multiple hand-
pieces or filters may be used in one treatment session to treat red and brown pig-
mentation. These devices may also be used for photodynamic therapy and will be
discussed in that section.

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Part III  Nonsurgical Cosmetic Treatments
This patient is shown before and 3 months after three vascular treatments at 4-week
intervals.
Vascular Laser Devices
Historically, vascular lesions were one of the first targets for laser therapy. Lasers
such as copper vapor (578 nm), krypton (568 nm), and argon dye (577 nm) were
used and eventually abandoned because they produced unacceptable levels of scarring.
The pulsed dye laser is still considered by most the benchmark for vascular lesion
removal. Newer generations avoid the purpura produced by older devices. For
portwine stains and hemangiomas, the pulsed dye laser is best, but as a device for
a plastic surgery office, it probably will not be the most useful or cost-effective vas-
cular laser. The 1064 nm laser and combination lasers of 532 nm/1064 nm and
585 nm/1064 nm are probably the most useful, because they can be used in all skin
types and for hair removal as well.
Intense pulsed light devices are also very useful for vascular lesion treatment. How-
ever, their use is limited to patients who are not tan and with skin types 1 through
3 because of the melanin absorption. Their use is also limited to smaller vessels,
whereas the 1064 nm devices can be used in vessels up to 2 mm in diameter.
Devices Used to Treat Vascular Lesions
Wavelength
Device
(nm)
Skin Types
Tan
Pulsed dye
585-595
1-3
No
KTP
532
1-3
No
Nd:YAG
1064
1-6
Yes
IPL/BBL
585
1-3
No
BBL, Broadband light; KTP, potassium titanyl phosphate; IPL, intense pulsed light.

Facial vessel treatment is quite easy with any of the devices listed. Leg vein treatment
is another story, and proper treatment usually requires multimodality treatment,
such as venous mapping, evaluation of perforators and flow, sclerotherapy, and laser
treatment for small vessels and for sclerotherapy “cleanup.”
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Chapter 16  Lasers and Devices in Plastic Surgery
Devices Used for Hair Removal
Wavelength
Currently
Device
(nm)
Hair Color
Skin Type
Tan
Used
Ruby
694
Dark
1-3
No
No
Alexandrite
755
Dark
1-3
No
Yes
Diode
810
Dark
1-6
Yes
Yes
Nd:YAG
1064
Dark
1-6
Yes
Yes
IPL/BBL
690
Dark
1-3
No
Yes
This patient is shown before and immediately after vascular laser treatment to the
nose with a 1064 nm laser.
Hair Removal Lasers and Devices
Laser hair removal is an extremely popular procedure: data from the American So-
ciety for Aesthetic Plastic Surgery list it as the second most frequently performed aes-
thetic procedure in 2008. There are many excellent devices by various manufactur-
ers for hair removal.

Hair Basics
Human hair is currently thought to have stages of growth. These are the anagen (growth)
phase, the catagen (regression) phase, and the telogen (resting) phase. In general, the
anagen phase is variable in duration, the catagen phase usually lasts 3 weeks, and
the telogen phase is approximately 3 months long, but there is some site-specific vari-
ation. The hair follicle has three regions—the lower segment, comprising the bulb
and suprabulb; the middle segment (the isthmus); and the upper segment (the in-
fundibulum). The bulb is made up of the hair matrix and dermal papilla. The der-
mal papilla is thought to be responsible for initiating and directing hair growth,
whereas the hair matrix is the actively growing portion that gives rise to the hair
shaft and root sheath.
For long-term hair removal, the laser or device must cause some damage to a growth
section of the hair. The actual target is still somewhat controversial, but most re-
searchers agree that the pluripotential cells of the bulge, dermal papilla, and hair
matrix must be treated in the anagen phase to be effective. Melanin is the target for
most hair removal lasers.
Treatment Considerations
Many variables affect laser or device hair removal: skin color, hair color, hair thick-
ness, the area of the body treated, device type, wavelength, fluence used, spot size,
pulse width, skin temperature and cooling, and treatment timing. Assessment of these
variables is beyond the scope of this chapter; we encourage readers who are inter-
ested to read some of the books listed in the bibliography.
Devices
The many devices currently used for laser hair removal are grouped into lasers (spe-
cific wavelengths) and light devices (IPL/BBL: intense pulsed light/broad-based light—
nonspecific wavelengths). Excellent devices are available from a number of manu-
facturers. The choice of laser/device depends somewhat on patient mix in one’s
practice (such as darker skin types or tan patients). The most popular devices are
alexandrite lasers, diode lasers, Nd:YAG lasers, and IPL/BBL devices. As outlined in
the table on p. 543, alexandrite and pulsed light devices should not be used on darker
skin types or tanned patients. Diode lasers and Nd:YAG lasers may be used for these
patients; Nd:YAG devices are considered safest for these skin types.
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Part III  Nonsurgical Cosmetic Treatments

545
Chapter 16  Lasers and Devices in Plastic Surgery
A patient who underwent treatment of a vascular lesion of the lip with a 1064 nm
laser is shown 8 months after two treatments.
Treatment Protocols
The timing of treatment is a factor of anagen duration, which varies by age, season,
anatomic region, sex, hormonal levels, and genetic predisposition. Some practition-
ers recommend a specific timing interval of 4 to 6 weeks, whereas others recommend
a certain amount of regrowth before treatment.
Recommendations
Laser hair removal is a useful addition to a plastic surgery practice. We recommend
a long pulse width Nd:YAG device for its usefulness in all skin types and a BBL/IPL
device for its overall usability.
This patient is shown before and 3 months after six treatments with 1064 nm laser
for hair removal.

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Part III  Nonsurgical Cosmetic Treatments
Laser Skin Resurfacing
There are a wide variety of devices used for laser skin resurfacing. These are broadly
classified into ablative and nonablative devices. Ablative lasers remove skin, whereas
nonablative devices cause some degree of thermal damage to the epidermis or der-
mis without removing skin. These devices are further classified into fractional and
full field devices.
Ablative Full Field Devices
Ablative laser resurfacing with the carbon dioxide laser was introduced in the mid-
1990s and was responsible for creating significant interest in lasers among plastic
surgeons and dermatologists. The CO2 laser has a wavelength of 10,600 nm and a
chromophore of water. There is laser absorption just above the ablation threshold,
which vaporizes the tissue. Continuous mode devices were used initially, but too
much thermal damage was created, which led to scarring. The continuous mode de-
vices fared better as a cutting tool and are still in use today. A modification by one
company (UltraPulse Laser; Lumenis Ltd., Yokneam, Israel) broke the continuous
beam into short pulses, which caused tissue ablation with much less thermal dam-
age. Originally the device was used with a nonscanning small spot handpiece, but
the inaccuracy of the handheld probe led to overlapped pulses with excessive heat
deposition through pulse stacking and/or else inadvertent deep resurfacing, both of
which had the potential for delayed healing and scarring. The development of a com-
puter pattern generator solved this problem by scanning the pulses sequentially onto
the skin with a defined geometric pattern and spacing. A different approach was used
by another manufacturer (SilkTouch and FeatherTouch lasers (Shurplan Lasers, Lon-
Full Field and Fractional Resurfacing Devices
Wavelength
Name
(nm)
Ablative
Nonablative
Full Field
Fractional
CO2
10,600
Yes
No
Yes
Yes
Erbium
2940
Yes
No
Yes
Yes
YSGG
2790
Yes
No
Yes
Yes
Thulium
1927
No
Yes
No
Yes
Er:Glass
1540
No
Yes
No
Yes
Nd:YAG
1440
No
Yes
No
Yes
Nd:YAG
1319
No
Yes
Yes
Yes
Nd:YAG
1064
No
Yes
Yes
No
YSGG, Yttrium-scandium-gallium-garnet.

don, UK); they used an optomechanical flashscanner to scan a continuous laser beam
in a spiral pattern. This allowed another method of creating a short exposure time
by rapidly moving a continuous laser beam in a spiral, keeping the exposure or dwell
time at any particular point below 1 millisecond. These devices led to excellent re-
sults in eradicating wrinkles and tightening lax tissue. The problem with this series
of carbon dioxide lasers was the considerable downtime created for the patient and
the permanent pigmentary problems that occasionally arose.
Erbium:YAG lasers (2940 nm) were introduced as a safer alternative for superficial
resurfacing. Initially machines were low powered and lacked pattern generators. The
second generation of systems had more power and were used instead of carbon diox-
ide lasers for deeper resurfacing. Complications were fewer, yet downtime appeared
to be similar to that of carbon dioxide systems. Combination systems of carbon diox-
ide and erbium lasers were popular for a short time (Derma-K, Lumenis), with the
beams being delivered either sequentially or simultaneously. Variable or long pulse
erbium lasers (Sciton Inc., Palo Alto, CA) are popular today. These devices allow vari-
ation of pulse width in addition to energy per pulse, which allows control over the
amount of residual thermal injury produced for a given amount of tissue removal.
These variable pulse Er:YAG systems seem to produce skin tightening and wrinkle
reduction similar to carbon dioxide lasers, with a much shorter period of erythema
and much lower risk of hypopigmentation.
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Chapter 16  Lasers and Devices in Plastic Surgery
This woman is shown before and 1 year after full field erbium resurfacing.

This patient underwent full field erbium resurfacing and is shown 3 years later.
Yttrium-scandium-gallium-garnet crystal (YSGG) lasers (2790 nm) were introduced
by Cutera (Brisbane, CA) to offer a device with a middle alternative to the CO2 and
erbium wavelengths. Erbium has the highest affinity for water in the absorption spec-
trum at 2940 nm. The laser was designed to create a wavelength with half the ab-
sorption that occurs at 2790 nm, the purpose of which is to create more heat driven
down into the dermis for stimulation and remodeling. The mechanism of action is
in three parts:
1. Ablation: Safe removal of a portion of the epidermis is achieved with a con-
trolled amount of vaporization; 10 to 30 microns of epidermis are vaporized
in this process.
2. Coagulation: Simultaneously, sufficient heat to produce coagulation is gen-
erated in the remaining epidermis. Depending on the energy selected, the co-
agulation region can vary from partial to full epidermal damage. This coag-
ulation region creates a natural protective dressing on the skin that remains
intact during the restorative process.
3. Collagen remodeling: Finally, residual heat in the dermis generates new col-
lagen growth.
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Chapter 16  Lasers and Devices in Plastic Surgery
This 74-year-old woman was treated for all of these conditions with a YSGG laser.
Downtime is typically 3 to 5 days, and application of a thin ointment is the only re-
quired postprocedure care. She is shown before and 10 days after one treatment.
Plasma skin resurfacing used nitrogen plasma energy to coagulate a very controlled
depth of skin. Healing times and results appeared to be similar to those with erbium
devices. However, the company (Rhytec) that was manufacturing the plasma device
is no longer in business.
Full field ablative resurfacing enjoyed an initial heyday from 1994 to 2001, but the
associated prolonged healing times and hypopigmentation led to wariness of the
technology. Consumers and physicians reversed direction, opting for procedures with
minimal morbidity and downtime. This brought about the development of nonab-
lative resurfacing devices.
Nonablative Devices
These devices were developed from the theory that full field ablative devices had two
skin effects: removal of outer damaged layers and heating of the collagen/dermis
to provoke a wound-healing response. The initial devices used were q-switched
1064 nm lasers. These extremely short pulsed lasers caused superficial dermal water
heating and led to eradication of some fine lines and rhytids. However, there was
some pinpoint bleeding, petechiae, and occasional purpura. Further development of
The YSGG laser can be operated as a horizontal ablative resurfacing unit or as a frac-
tional device. Combination treatment called fusion can combine clinical situations
of pigmentation, fine lines, and stimulation with the fractional effects of deeper der-
mal imperfection such as acne scarring, deep lines, and skin laxity.

these devices led to use of other wavelengths with no epidermal injury through more
water absorption and more dermal heating. The most popular of these devices were
in the 1319 to 1320 nm range, although longer pulse width 1064 nm lasers and
1450 nm lasers were also used. These devices all caused some degree of dermal in-
jury that led to a dermal wound-healing response. This then led to skin improvement
with removal of some fine lines and wrinkles. The disadvantages of these devices are
that results are inconsistent, and it takes months for results to occur.
Fractional Lasers
Fractional lasers have revolutionized laser resurfacing. Fractional photothermolysis
refers to classes of devices that cause zones of epidermal and dermal thermal dam-
age (nonablative fractional lasers) or that cause epidermal or dermal mini-holes or ab-
lation channels (ablative fractional lasers). The adjacent areas are left free of dam-
age, and healing occurs from areas deep and lateral to the damage.
The first fractional laser to be developed was the Fraxel laser (Solta, CA), a nonab-
lative fractional device that used an erbium-doped fiber laser with a wavelength of
1550 nm. This device created microthermal zones (MTZ) between 125 and 250 per
square centimeter. Multiple passes were performed, with a final density of 1000 to
3000 zones per square centimeter, a small fraction of the skin. Multiple sessions were
used (usually three to five) spaced 2 to 4 weeks apart. Other manufacturers de veloped
nonablative fractional lasers with different wavelengths (1319, 1440, and 1540 nm),
energies, and spot sizes. The most recent ablative wavelength to be introduced is the
thulium laser (1927 nm). This device may have some advantages, especially in treat-
ing actinic keratosis. Since different devices have different spot sizes, scanners, and
depths of injury, it is difficult to compare devices. The easiest way to understand the
degree of tissue injury is to understand depth of injury, width of thermal injury, and
fraction of area treated.
These devices are in use today and are used to treat fine lines, deeper rhytids, pho-
todamage, acne scarring, and melasma. Both facial and nonfacial areas can be treated.
Downtime is related to the depth and density of the treated areas, but in general,
downtime is minimal, with a mild bronzing of the skin for a day or so after treat-
ment. These devices have enjoyed worldwide acceptance for all skin types; they pro-
duce minimal complications. The problem with treatment with nonablative frac-
tional lasers is the relative lack of efficacy compared with full laser resurfacing.
Currently these devices are used for mild photodamage and acne scarring, especially
in darker-skinned individuals and areas off the face.
The development of fractional ablative lasers has increased the efficacy over nonab-
lative fractional lasers. Three wavelengths are currently used for fractional ablative
resurfacing: carbon dioxide, 10,600 nm; erbium, 2940 nm; and YSGG, 2790 nm (see
the table on p. 546). The differences among these wavelengths are related to the dif-
ferences in water absorption and in the resultant amount of thermal damage created.
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Chapter 16  Lasers and Devices in Plastic Surgery
A comparison of fractional technologies is shown, although not the variation in lat-
eral thermal damage. YSGG (not illustrated) is similar to erbium long pulse. Also
shown are the types of channels created. A newer development is the variable pulse
width erbium fractional laser (Sciton). This device provides a short pulse followed
by a longer pulse or a series of pulses to increase the amount of thermal damage.
Studies of this device with maximum pulse duration or coagulation setting show his-
tologic results similar to that with the carbon dioxide laser. Another new develop-
ment is the introduction of grooves of ablated areas rather than the spots of frac-
tional lasers.
As with fractional nonablative resurfacing, these devices are used to treat fine and
deeper lines and rhytids, acne scars, dyschromias, and photodamage. These devices
can create more skin tightening than nonablative fractional lasers. Comparison of
devices and treatments is sometimes difficult because of treatment parameters, in-
cluding spot size, depth of treatment, density of treatment, and thermal damage per
spot. Treatments are usually performed with topical or regional anesthesia. Down-
time depends on wavelength, depth, and density but in general is much less than for
full field resurfacing.
Erbium fractional
Nonablative fractional
Long pulse erbium fractional
Carbon dioxide fractional

This patient underwent one erbium fractional treatment of the forehead and is shown
3 months after the procedure.
Complications of ablative and nonablative fractional resurfacing are the same as one
might get from full field resurfacing except for a much lower frequency. These in-
clude scarring, infections, prolonged erythema, and pigmentary changes, including
hypopigmentation and hyperpigmentation. Scarring incidence is extremely low but
is more common in nonfacial areas, especially when high energies (deep depth of
treatment) and high densities are used. High densities with large amounts of ther-
mal damage may approach full field resurfacing with a corresponding increase in
complications. Infection rates appear to be low, most likely because of the wide-
spread use of antiviral medications with treatment. Erythema is a product of in-
flammatory response, and duration of erythema increases with depth, density, and
the degree of thermal damage.
The latest developments in laser resurfacing are combination treatments used to in-
crease efficacy. One combination involves ablative and nonablative resurfacing. Early
results of this combination show results that are superior to either modality used in-
dividually. Another combination is a light full field ablative treatment followed by a
fractional ablative or nonablative treatment. The advantage of this approach is the
full epidermal texture improvement seen. Downtime and efficacy depend on the depth
of full field treatment and the depth and density of fractional treatment. Intense
pulsed light treatment may also be added to these combination treatments to fur-
ther correct pigmentation or vascularity.
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Chapter 16  Lasers and Devices in Plastic Surgery
The progression of healing is shown following a combination superficial erbium and
erbium fractional treatment.
Before treatment
Immediately after treatment
1 day later
2 days later
3 days later
1 week later

This patient is shown before and after a fractional carbon dioxide treatment.
Skin Tightening
The concept of nonsurgical skin tightening is the holy grail of plastic surgery and
dermatology. Many devices have been used for both facial and nonfacial skin tight-
ening. The tightening is thought to result from dermal thermal damage, which causes
release of heat shock proteins. The initial nonablative devices discussed previously
did not cause enough injury to cause tightening. The next-generation devices cur-
rently in use are best described as being in one of three groups: radiofrequency, light-
based, and ultrasound.
Radiofrequency devices used for skin tightening are based on radio waves. Various
devices use different frequency waves and are measured in megahertz. The devices
are either (1) bipolar, in which both electrodes are at the treatment site and charged
particles are rotated between electrodes causing heat, or (2) unipolar or monopolar,
in which the return electrode is distant. The depth of penetration with monopolar
or unipolar devices is greater. Devices also differ in their power; some have far greater
energy than others. These devices have been extensively studied. Initial protocols of
one of the first to market devices, Thermage (Solta), caused deep tissue heating and
undue complications, including burns and fat atrophy. Modifications and refinements
to these systems have improved efficacy and decreased complications. The skin tight-
ening in some cases is profound; in others it is virtually nonexistent. Current research
is attempting to determine who are the best responders and why.
Primaeva, recently purchased by Syneron (Yokneam, Israel), has developed a skin-
tightening technique that uses bipolar radiofrequency needles that actually pierce
into the skin. Energy is delivered directly within the reticular dermis. With this tech-
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Courtesy C. William Hanke, MD

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Chapter 16  Lasers and Devices in Plastic Surgery
nique, there is real-time feedback of tissue temperature and impedance. Energy is de-
livered in a fractional pattern, so healing is optimized. A local anesthetic is required.
A similar situation exists for light-based devices. These devices are long pulse width
IPL devices. Different manufacturers have devices with different wavelengths. Light-
based nonablative treatment has existed for years. The Titan (Cutera) uses a very
long pulse, 6 seconds, to cause deep heating in the deep dermis. A tricyclic pulse of
cooling, heating, and cooling safely deposits the energy at a wavelength range of
1100 to 1800 nm. Initially used for facial tightening, other applications include body
areas such as the neck, arms, abdomen, and some newer gynecologic applications.
SkinTyte (Sciton) has a wavelength from 800 to approximately 1400 nm. These de-
vices have integrated cooling and long pulse widths in the seconds range. Their chro-
mophore is water, and they heat up the dermis to induce collagen changes. As with
the radiofrequency devices, responders are inconsistent, with excellent tightening be-
ing achieved in some and minimal tightening in others.
This patient is seen before and 1 year after three treatments with a light-based skin-
tightening device.
These devices are used in patients with lax facial and body skin who have residual
laxity after surgery or who will not or cannot undergo surgery. It is thought by some
that the best responders are younger individuals, with less-photodamaged collagen.
The newest devices on the market are ultrasonic. The first to achieve FDA approval
is by Ulthera (Mesa, AZ); this novel device has a diagnostic ultrasound unit to dis-
cern target depth, and treatment heads that deliver small ultrasonic thermal bursts
to the previously measured area. The initial FDA approval is for brow elevation, but
European experience suggests that tightening of the SMAS and platysma bands may
produce face lift–like results.

This patient is seen before and 90 days after a single Ulthera treatment.
Concluding Thoughts
The modern practice of plastic surgery includes many nonsurgical aspects, includ-
ing lasers and laserlike devices. Some of these may take the place of surgery, while
others are complementary to surgical options. As progress continues, a day may come
when a face lift is uncommon and facial tightening devices provide face lift–like re-
sults. The beauty of plastic surgery is that we can mold and adjust ourselves to ac-
commodate technologic advances.
Clinical Caveats
 Pulsed light devices may be used for treating pigmentary irregularities, vascular
lesions, and hair removal in lighter skinned, nontanned patients.
 Leg vein treatment requires multimodality therapy.
 Many types of hair removal lasers and devices are available. Selection depends on
the patient’s skin type and tanning, and on surgeon preference.
 Laser resurfacing can be performed in full field or fractional treatments.
 Laser resurfacing can be performed with carbon dioxide, erbium, or YSGG devices.
 Combination therapy is often used with laser devices.
 Fractional devices may use laser, radiofrequency, or ultrasound technology.
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Chapter 16  Lasers and Devices in Plastic Surgery
Annotated Bibliography
Bass L. Rejuvenation of aging face using Fraxel laser treatment. Aesthet Surg J 25:307-309,
2005.
According to the author, Fraxel laser treatment produces the resurfacing effects of tis-
sue removal, treats pigmentary changes, improves rhytids, and stimulates tissue re-
modeling. Compared with other classical approaches, it has the advantages of no re-
covery time, no open wound, few nonresponders, few complications, and the ability to
be used in all skin types. Data confirm that improvement with this treatment is sub-
stantial but is not yet well defined quantitatively in comparison with laser resurfacing.
DiBernardo BE, Pozner JN. Techniques in Aesthetic Plastic Surgery Series: Lasers and Non-
surgical Rejuvenation. Philadelphia: Elsevier, 2009.
Comprehensive up-to-date review by the authors of this chapter on ablative and non-
ablative laser surgery, including the newest techniques and how to use them.
Goldberg DJ. Laser Hair Removal, 2nd ed. Cosmetic and Laser Therapy Series. London: In-
forma Healthcare, 2008.
Excellent comprehensive review of laser hair removal.
Ross EV. Laser versus intense pulsed light: competing technologies in dermatology. Lasers
Surg Med 38:261-272, 2006.
Review of pulsed light and lasers, including the pros and cons of lasers and IPLs: de-
sign, cost, and other practical concerns for a typical office-based practice.
Weinstein CW, Ramirez OM, Pozner JN. Carbon dioxide laser resurfacing complications
and their prevention. Aesthet Surg J 17:216-225, 1997.
A good overall review of laser resurfacing complications. In a series of 1925 patients,
undesirable outcomes occurred mainly in the authors’ early experience. These could be
attributed to poor preoperative evaluation, faulty technique, and suboptimal postoper-
ative care: 537 cases were perceived as an adverse outcome; 461 had either normal se-
quelae or complications that were readily preventable with proper preoperative evalu-
ation and improved postoperative care; only 10 were the result of poor technique.
Energies need to be directed toward perioperative factors to achieve a better under-
standing of skin healing and prevention of possible complications.
Weiss RA, Weiss MA. Devices for nonablative photorejuvenation. In Goldman MP, ed. Cu-
taneous and Cosmetic Laser Surgery. Philadelphia: Elsevier, 2006.
This chapter provides a good overview of the subject by two experts in the field.
Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin: 5 years results with intense
pulsed light of the face, neck, and chest. Dermatol Surg 28:1115-1119, 2002.
The authors investigated the long-term clinical results on the face, neck, and chest us-
ing filtered flashlamp IPL for treatment of photoaging changes of telangiectasias, dys-
pigmentation, and rough skin texture through a chart review of patients with skin types
I through IV who were treated by IPL. They concluded that signs of photoaging can
be improved by IPL with a long-lasting result. Minimal or no downtime with minimal
adverse effects can be achieved, and lasting skin textural smoothing, although not eas-
ily quantified, is an additional benefit.

Suggested Readings
Achauer BM, Vander Kam VM, Padilla JF III. Clinical experience with the tunable pulsed-
dye laser (585 nm) in the treatment of capillary vascular malformations. Plast Reconstr
Surg 92:1233-1241, 1993.
Anderson RR. Laser-tissue interactions. In Baxter SH, ed. Cutaneous Laser Surgery. The Art
and Science of Selective Photothermolysis. St Louis: CV Mosby, 1994.
Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective ab-
sorption of pulsed radiation. Science 220:24-27, 1983.
Bass LS. Erbium:YAG laser skin resurfacing: preliminary clinical evaluation. Ann Plast Surg
40:328-334, 1998.
Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense
pulsed light treatments. Dermatol Surg 26:835-842, 2000.
Chan HH, Lam LK, Wong DS, et al. Use of 1,320 nm Nd:YAG laser for wrinkle reduction
and the treatment of atrophic acne scarring in Asians. Lasers Surg Med 34:98-103, 2004.
Clementoni MT, Gilardino P, Muti GF, et al. Nonsequential fractional ultrapulsed CO2 resur-
facing of photoaged facial skin: Preliminary clinical report. J Cosmet Laser Ther 9:218-
225, 2007.
Fitzpatrick RE, Rostan EF, Marchell N. Collagen tightening induced by carbon dioxide laser
versus erbium:YAG laser. Lasers Surg Med 27:395-403, 2000.
Garden JM, Bakus AD. Clinical efficacy of the pulsed dye laser in the treatment of vascular
lesions. J Dermatol Surg Oncol 19:321-326, 1993.
Goldberg DJ. Unwanted hair: evaluation and treatment with lasers and light source tech-
nology. Adv Derm 14:115-139, 1999.
Hatash BM, Vikraditya PB, Kapadia B, et al. In vivo histological evaluation of a novel abla-
tive fractional resurfacing device. Lasers Surg Med 39:96-107, 2007.
Huang YL, Liao YL, Lee SH, et al. Intense pulsed light for the treatment of facial freckles in
Asian skin. Dermatol Surg 28:1007-1012, 2002.
Kligman DE, Zhen Y. Intense pulsed light treatment of photoaged facial skin. Dermatol Surg
30:1085-1090, 2004.
Laws RA, Finley EM, McCollough ML, et al. Alabaster skin after carbon dioxide laser resur-
facing with histologic correlation. Dermatol Surg 24:633-636, 1998.
Pozner JN, Goldberg DJ. Histologic effect of a variable pulsed Er:YAG laser. Dermatol Surg
26:733-736, 2000.
Pozner JN, Goldberg DJ. Nonablative laser resurfacing: state of the art 2002. Aesthet Surg
J 22:427-434, 2002.
Pozner JN, Goldberg DJ. Superficial erbium:YAG laser resurfacing of photodamaged skin.
J Cosmet Laser Ther 8:89-91, 2006.
Pozner JN, Roberts TL. Variable-pulse width Er:YAG laser resurfacing. Clin Plast Surg
27:263-271, 2000.
Rahman Z, Tanner H, Tournas J, et al. Ablative fractional resurfacing for the treatment of
photodamage and laxity. Lasers Surg Med 39(Suppl 19):S15, 2007.
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Ross EV, Miller C, Meehan K, et al. One-pass CO2 versus multiple-pass Er:YAG laser resur-
facing in the treatment of rhytides: a comparison side-by-side study of pulsed CO2 and
Er:YAG lasers. Dermatol Surg 27:709-718, 2001.
Ross EV, Naseef GS, McKinlay JR, et al. Comparison of carbon dioxide laser, erbium:YAG
laser, dermabrasion, and dermatome. J Am Acad Dermatol 42:92-105, 2000.
Sadick NS, Weiss R, Kilmer S, et al. Photorejuvenation with intense pulsed light: results of a
multi-center study. J Drugs Dermatol 3:41-49, 2004.
Tanzi EL, Alster TS. Comparison of a 1450-nm diode laser and a 1320-nm Nd:YAG laser in
the treatment of atrophic facial scars: a prospective clinical and histologic study. Der-
matol Surg 30(2 Pt 1):152-157, 2004.
Tanzi EL, Alster TS. Long-pulsed 1064-nm Nd:YAG laser-assisted hair removal in all skin
types. Dermatol Surg 30:13-17, 2004.
Weiss RA, Weiss MA, Marwaha S, et al. Hair removal with a noncoherent filtered flashlamp
intense pulsed light source. Lasers Med Surg 24:128-132, 1999.
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Sclerotherapy and
Laser Vein Treatment

GIRISH S. MUNAVALLI, SIRUNYA SILAPUNT,
ROBERT A. WEISS
CHAPTER 17

V
enous disease encompasses a wide spectrum of clinical manifestations, includ-
ing asymptomatic spider veins on the legs; intermittently bulging branches of
the greater saphenous vein that extend across the knee; and dull, achy pain in the
posterior calf after prolonged standing. The science of treatment of venous disease,
phlebology, has roots dating to 400 BC: the ancient Greeks recognized venous dis-
ease as an undesirable and unsightly condition. Procedures involving the use of in-
strumentation to traumatize veins were described by Hippocrates in the fourth cen-
tury BC, and procedures such as vein stripping were routinely practiced in the years
that followed.
Today venous disease still presents a formidable challenge to diagnose and treat; it
affects 40% to 55% of the population, with common symptoms of leg pain, swelling,
and skin changes. Venous insufficiency, which is caused by valvular incompetence in
the deep or superficial venous system, is the most common form of venous disease.
Deep venous insufficiency occurs when valves are damaged by thrombosis and is be-
yond the scope of this chapter. Superficial venous insufficiency occurs when high-
pressure leakage develops between the deep and superficial systems or within the su-
perficial system itself. This elevated venous pressure results in sequential failure of
the venous valves in superficial veins. Venous insufficiency in this system allows ve-
nous blood to escape from its normal flow path and to flow in a retrograde direc-
tion down into an already congested leg. Over time, incompetent superficial veins
acquire the typical dilated and tortuous appearance of varicosities. Furthermore, in-
sufficiency can lead to chronic morbidity in the form of stasis dermatitis, lipoder-
matosclerosis, atrophie blanche, and ulcerative, edematous skin changes in the lower
extremities.
Farther downstream, changes involving the smaller branching vessels, such as un-
sightly or symptomatic venulectasis and/or telangiectasias, are a major consequence
of superficial venous valvular insufficiency. These entities occur in 29% to 41% of
women and 6% to 15% of men in the United States. Although up to 53% of patients
with leg telangiectasias have associated symptoms, the most common reason patients
seek consultation is cosmetic.
In the upper extremity, the forearm and dorsal hand veins represent the equivalent
of varicose veins of the lower extremities. Sun, gravity, and other environmental ex-
posures subject the hands to unique combinations of physiologic and environmen-
tal stress. With the passage of time, the hands lose volume as a result of muscle at-
rophy, bone demineralization, and loss of adipose tissue. Elasticity is lost and skin
texture dramatically changes. This process is accelerated by solar-induced damage,
which results in wrinkled, dyschromic skin and prominent and tortuous varicosities
of the superficial veins of the hand and forearms, such as the cephalic vein and the
basilic vein.
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Chapter 17  Sclerotherapy and Laser Vein Treatment
Pretreatment Assessment
Lower Extremity
Careful patient assessment is essential for patients seeking amelioration of the symp-
toms of venous disease. Evaluation and treatment in the lower extremity should be di-
rected in a systematic fashion toward the size and type of vessel, starting with the
proximal, larger vessels and working down to the distal, smaller vessels. Vessel types
classified in the superficial venous system (from largest size to smallest) include:
 The greater and lesser saphenous veins with their respective direct tributaries
 Nonsaphenous vein varicosities (often visibly bulging veins)
 Reticular or feeder veins (often bluish colored)
 Spider veins or telangiectasia (located just below the epidermis)
The majority of symptomatic lower extremity venous insufficiency is attributable to
the superficial venous system and specifically includes reflux of the great saphenous
vein. Reflux of the lesser saphenous vein accounts for approximately 5% of super-
ficial venous disease, whereas reflux of the remaining division of the superficial sys-
tem is called the lateral subdermic venous system. Younger patients, in their twenties
and thirties, usually present with telangiectatic webs on the lateral thigh originating
from reverse flow or reflux in the lateral venous system. When there is a family his-
tory of large varicose veins, reflux originating from the greater saphenous vein or
lesser saphenous vein must be suspected. A duplex ultrasound study in patients who
presented for “cosmetic” treatment of leg veins demonstrated a relatively high inci-
dence of early associated axial or truncal reflux in the greater saphenous vein.
During an initial consultation, reflux in the greater saphenous vein is first suspected
based on active symptoms elicited during a thorough history and physical examina-
tion. Often these patients have a strong family history of venous disease, especially
the presence of varicose veins in immediate family members. Symptoms of venous
disease are most often localized to the medial surface of the leg and exacerbated by
prolonged standing, or during the premenstrual period in women, and are typically
relieved by cold, ambulation, or rest with leg elevation or by wearing compression
stockings. Characteristics of venous pain can include a dull ache, burning, heavy legs,
throbbing, leg cramping, or pruritus that worsens at the end of the day. Generally
speaking, abnormalities on physical examination of the lower extremities such as
pain, bulging veins, or skin findings such as discoloration or ulceration located on
the medial thigh and ankle correspond with the greater saphenous vein distribution,
whereas those located on the posterior calf and lateral ankle correspond to the lesser
saphenous vein distribution.

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Part III  Nonsurgical Cosmetic Treatments
EVALUATION OF LOWER EXTREMITY VENOUS DISEASE
Clinical history
and examination of
lower extremities
History of pain in medial
thighs or bulging veins in
medial or anterior thigh
If positive or equivocal,
confirm with duplex
evaluation of entire
greater saphenous vein
If positive or equivocal,
confirm with duplex
evaluation of lesser
saphenous vein
History of persistent
pain/swelling with stand-
ing, or presence of stasis
dermatitis, corona phle b -
ec tatica, edema, active/
healed ulcer, atrophie
blanche, or lipodermato -
sclerosis of the medial
lower leg
History of persistent pain/
swelling in posterior calf
Presence of bulging veins
or constellation of telan gi -
ectasia on the posterior
calf/popliteal fossa/lateral
ankle
Select Conditions Precipitating Telangiectasia Formation
Hormonal Factors
 Pregnancy
 Estrogen therapy
 Topical corticosteroid preparations
Physical Factors
 Trauma (contusion, surgical incision, lacerations)
 Infection
 Radiation dermatitis
 Erythema ab igne (chronic thermal injury)
 Actinic neovascularization
Component of a Primary Cutaneous Disease
 Varicose veins
 Necrobiosis lipoidica diabeticorum
 Capillaritis (progressive pigmentary purpura)

Postero-
medial
tributary
vein
Sapheno-
femoral
junction
Greater
saphenous
vein
Superficial
inferior
epigastric vein
Superficial iliac
circumflex vein
Antero-
lateral
tributary
vein
Unlike the symptomatology associated with reflux in the larger vessels, telangiectatic
lesions more often present as a cosmetic concern. The term telangiectasia was first
used in the early 1800s to describe a superficial vessel of the skin visible to the hu-
man eye. These typically measure 0.1 to 1 mm in diameter and can be either a dis-
tended arteriole or venule. A host of conditions can precipitate telangiectasia for-
mation. Varicose veins most likely lead to the formation of telangiectasias through
either associated venous hypertension with resulting angiogenesis or vascular dila-
tion. These varicose veins may or may not be clinically evident at the time of telan -
giectasia presentation but should trigger the systematic proximal-to-distal vein eval-
uation of the affected extremity in efforts to unmask subclinical venous disease.
Pertinent Anatomy
Normal Venous Anatomy of the Lower Extremity
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Chapter 17  Sclerotherapy and Laser Vein Treatment
Knowledge of superficial venous anatomy and the lo-
cation of important perforating vessels is fundamen-
tal to recognition of normal patterns of varicose veins.
The greater saphenous vein is of primary concern when
treating venous problems in the lower extremity. The
saphenous vein originates on the dorsum of the foot
in the dorsal venous arch, passes anterior to the me-
dial malleolus, progresses through the medial calf
across the posteromedial aspect of the popliteal space,
ascends in the medial thigh, and terminates in the
femoral vein at the saphenofemoral junction. It dom-
inates the anteromedial superficial drainage system.
As the saphenous vein reaches its termination, it re-
ceives important tributaries medially and laterally. Du-
plex ultrasound examination may identify reflux in
one or both of these vessels.
The anatomy of the greater saphenous vein is rela-
tively constant. It is understood that this vein lies on
the deep fascia of the leg and thigh, but it is less well
recognized that it lies below or deep to the superficial
fascia. Current descriptions of the anatomy of the
lower extremity vasculature do not always make this
distinction, yet this fact is crucial to understanding
the development of varicosities.

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Part III  Nonsurgical Cosmetic Treatments
In varicose venous anatomy, the important tributaries to the greater saphenous vein
extending upward from below are the posterior arch vein (vein of Michelangelo),
which receives the three Cockett’s perforating veins (posterior tibial perforators); the
anterior tributary vein to the saphenous system, which lies below the patella and col-
lects blood from the anterior and lateral surface of the leg; and the posterior tributary
vein, which also empties into the greater saphenous vein in the upper anteromedial
calf. Other tributaries that may terminate high in the saphenous system near the groin
are the posterior medial thigh vein and the anterior lateral thigh vein. Either or both
of these veins may become the site of varicose clusters.
Less common in primary varicosities, and more important in recurrent varicose veins
after treatment, are other tributaries in the greater saphenous vein as it terminates
in the fossa ovalis. These include the superior external pudendal vein, the superior
epigastric vein, and the superficial circumflex iliac vein.
Leg varicose veins could be the result of retrograde flow from pelvic vein varicosi-
ties from the connection of pelvic veins, the external pudendal vein, and the saphe-
nofemoral junction. The findings of varicose veins of the medial groin, medial but-
tocks, and pubic area in patients with chronic pelvic pain should lead one to suspect
pelvic congestion syndrome.
This 34-year-old woman presented with recurrent varicose veins of the left groin and
thigh 2 years after she underwent endovenous laser ablation for left greater saphe-
nous vein reflux. She reported feeling heaviness and intermittent pain of the left pelvic
area and groin for several years; her symptoms worsened with prolonged standing
and during menstruation. Physical examination revealed reticular veins and bulging
varicose veins of the left medial groin in addition to a varicose vein of the left thigh.
Duplex ultrasound showed several dilated veins in the left groin that continued prox-
imally to the pelvic area. Her MRI/MRV showed an enlarged left gonadal and pelvic
vein. She was diagnosed with pelvic congestion syndrome and was treated, with no
subsequent recurrence of varicose veins.

Posteriorly, the most important of the axial veins is the
lesser saphenous vein. This vein originates on the lateral
aspect of the foot in the dorsal venous arch and ascends
virtually in the midline of the calf, between the bellies of
the gastrocnemius muscle. Unlike the greater saphenous
vein, the lesser saphenous vein may penetrate the deep
fascia at any point from the middle third of the calf up-
ward. This fact explains the segmental rather than total
nature of reflux that is found in the lesser saphenous vein.
Important tributaries to the saphenous vein are variable
in location or existence but may include the posterolat-
eral tributary vein. Superiorly, this tributary may be as-
sociated with a lateral thigh vein called the anterolateral
superficial thigh vein. Another important and frequently
encountered vein is the vein of Giacomini, which con-
nects the lesser and greater saphenous veins. It may orig-
inate from the lesser saphenous vein or from its thigh ex-
tension and ends in the greater saphenous vein or its
posterior accessory.
The value of knowing the gross anatomy of the superfi-
cial veins of the lower extremity is that any one of the
systems may be the site of the growth of clusters of vari-
cosities.
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Chapter 17  Sclerotherapy and Laser Vein Treatment
Postero-
lateral
tributary
vein
Vein of
Giacomini
Greater
saphenous
vein
Lateral
subdermic
venous
system
Antero-
lateral
superficial
thigh vein
Dorsal
venous
arch
Lesser
saphenous
vein
Postero-
medial
superficial
thigh vein
Significant Perforating Veins
The perforating veins connect the superficial venous system to the deep venous sys-
tem and penetrate the fascia. Any one of these veins, alone or in combination, may be
the source of hydrodynamic forces of venous hypertension that produce superficial
varicosities. It is the abnormally high pulses of hydrodynamic pressure transmitted
through incompetent valves that affect relatively unsupported superficial veins. Such
pulses of increased fluid force originate to some extent from increased abdominal
pressure and to a greater extent from increased compartmental pressure during mus-
cular contraction.
The best recognized connections between the superficial venous system and the deep
venous system are the saphenofemoral and saphenopopliteal junctions. Incompe-
tence of the check valves at their termination has been suggested as the cause of dis-
tal varicosities from gravitational reflux. This reverse flow is said to dilate veins in a
progressive fashion, from proximal to distal.

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Part III  Nonsurgical Cosmetic Treatments
Because it is frequently the site of the first varicose veins
or the first reticular veins that become varicose, the Boyd
perforating vein in the anteromedial calf now receives
great attention by physicians who treat venous problems.
Experience with the duplex scanner reveals that venous
incompetence at this level may be isolated and may be
the first reflux to appear. Such incompetence may be
asymptomatic; however, when the incompetence is symp-
tomatic, it produces aching pain, fatigue, and even a
throbbing discomfort as mentioned previously. These
symptoms can be relieved by firm local pressure. Pro-
gressing proximally from the Boyd communicating vein
are the perforating veins in the distal third of the thigh.
These veins are named for English surgeon Harold Dodd
and may be found in any location along the saphenous
pathway in the distal third of the thigh. The third im-
portant series of communicating veins, the Hunterian
(midthigh) perforators, are named for Scottish surgeon
and anatomist John Hunter.
Hunterian
(midthigh)
perforating
vein
Boyd’s
paratibial
perforating
vein
Dodd’s
perforating
vein of
femoral
canal
Cockett’s
posterior tibial
perforating
vein (I, II, III)
Inframalleolar
perforating
vein
Recognizing the normal anatomy and the most common perforating vein sources of
varicosities makes identification of patterns of varicosities relatively easy.
Telangiectatic Leg Veins
Telangiectatic leg veins may be described as venous spiders, spider veins, sunburst
veins, starburst veins, venous plexuses, dilated venules, venous blemishes, dilated
venules and venulectasias, superficial or minor varicosities, essential cutaneous telan -
giectasias, vanity veins, and cosmetic veins. All of these terms describe the type of
telangiectatic networks that may cause physical symptoms of pain and discomfort.
More than 50% of patients presenting for treatment of these “spider veins” express

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Chapter 17  Sclerotherapy and Laser Vein Treatment
Greater
saphenous
vein
Lateral
subdermic
venous
system
Antero-
lateral
superficial
thigh vein
aching associated with them. These symptomatic veins are best categorized as ar-
borizing networks (according to the Redisch and Pelzer classification). They are ac-
tually combinations or networks of telangiectasias (0.1 to 1 mm) and venulectases
(1 to 2 mm). Painful telangiectasias on the leg are usually grouped; they are rarely
present as isolated telangiectatic vessels or spider angiomas with a central arteriole.
More important, symptomatic telangiectasias and venulectases commonly are asso-
ciated with slightly larger blue veins, which have been called “feeder” veins, reticular
veins, or minor varicose veins. These small subdermal blue veins may be tributaries
of the saphenous system. Reticular veins are most commonly part of a superficial ve-
nous system that is separate from either of the saphenous systems, originally de-
scribed as the “lateral subdermic venous system” by Albanese et al.
To diagnose and treat painful telangiectasias in a log-
ical way, a precise classification is helpful. This includes
telangiectasias (type I), venulectases (type II), associ-
ated blue reticular veins (type III), and reflux from pri-
mary varicose veins (types IV and V).
A disturbance of normal venous physiology with back
pressure and reverse flow or reflux through incompe-
tent valves results in transmission of pressure through
reticular veins into venules, causing their expansion
into telangiectasias and venulectases.
Telangiectasias located on the anterior aspect of the
thigh could occur as a consequence of reflux in the fol-
lowing vessels: anterolateral tributary of the greater
saphenous vein, inguinal fold reticular veins, incompe-
tent saphenofemoral junction, superficial axial branches
of the greater saphenous vein, or anterior branches of
the lateral subdermic venous system. Although painful
telangiectasias and venulectases may appear anywhere
on the leg, they are most likely to occur near the knee.

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Part III  Nonsurgical Cosmetic Treatments
Lateral
Medial
Revised Vessel Classification
This simplified classification eliminates the mixed telangiectasia/varicose category. Be-
cause most patients have a combination of multiple varicose vein types, a description of
type I in association with type II or type III varicosities is simpler. Classifying varicose
veins in this way facilitates a more straightforward treatment plan.
Type I
Telangiectasia, spider veins
0.1-1 mm diameter
Usually red (rarely, may be cyanotic)
 Type IA
– Telangiectatic matting
– 0.2 mm diameter network, bright red
Type II
Venulectasia (usually protrudes above skin surface; distinguished from telan -
giectasia by deeper color and larger diameter)
1-2 mm diameter
Violaceous, cyanotic
Type III
Reticular veins (“minor” varicose veins, “feeder” veins)
2-4 mm diameter
Cyanotic to blue
Type IV
Nonsaphenous varicose veins (primary varicosity of saphenous tributary
usually related to incompetent perforator)
3-8 mm diameter
Blue to green
Type V
Saphenous varicose veins (varicosities associated with reflux at saphenofemo -
ral or saphenopopliteal junction or major perforators of saphenous system
causing enlargement of long or short saphenous vein)
Usually 8 mm diameter
Blue to bluish-green
Lateral
Regions in which painful groups of telangiectasias and venulectases are most likely
to occur are shown by the shaded areas above. Patients most often complain of fo-
cal burning, throbbing, and aching in these areas.

Upper Extremity
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Chapter 17  Sclerotherapy and Laser Vein Treatment
The veins of the upper extremities, primarily the cephalic and basilic veins, are anal-
ogous to the greater and lesser saphenous veins of the superficial venous system in
the lower extremities. Because of the proximity of these veins to the radial and ul-
nar veins, they are commonly used as bypass routes for procedures such as arteri-
ovenous shunts in patients with renal disease. Sclerotherapy of upper extremity veins
is not commonly performed for several reasons. Because these veins are not subject
to the same hydrostatic pressures as the lower extremity veins, valves in cephalic and
basilic veins do not commonly exhibit reflux and associated symptomatology. These
veins usually do not appear overly distended or tortuous, and varicosities/telangiec-
tasias do not generally develop in the upper extremities. A noted exception occurs
with upper extremity exercisers, such as weight lifters, who perform frequent Val-
salva maneuvers during exercise. Prolonged increase in intrathoracic pressure will in-
crease flow through upper extremity veins and can result in clinically noticeable vein
distention. This is a normal physiologic response and not considered pathologic. In
our experience, branches of the cephalic vein in the forearm and dorsal hand are the
most common areas treated with sclerotherapy. Detailed upper extremity venous
anatomy is beyond the scope of this chapter.
Cephalic
vein of the
forearm
Median
vein of the
forearm
Median
cubital vein
Accessory
cephalic vein
Dorsal
venous
network
Dorsal
digital
veins
Cephalic
vein

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Part III  Nonsurgical Cosmetic Treatments
Treatment Options
Ideally, treatment for unwanted leg veins would be performed in one session, cause
no pain, and be 100% effective in clearing vessels, with no associated side effects.
Unfortunately, the variation in vessel size, flow, depth, and type preclude the possi-
bility of a single effective treatment modality. However, there are a number of effec-
tive treatments that can produce excellent results, including conventional and
duplex-guided sclerotherapy for the treatment of larger vessels and telangiectasias
and laser treatment of reticular and spider veins.
Conventional (Visual) and Duplex-Guided Sclerotherapy
Conventional sclerotherapy is indicated for the elimination of unwanted reticular
veins and telangiectasias. When leg veins are managed in a systematic approach,
feeder vessels or larger varicose veins are first eliminated surgically, with radiofre-
quency or laser ablation, and sclerotherapy proceeds from largest to smallest vessels,
with 80% to 90% of vessels responding to one or two treatments. As with endove-
nous ablation, sclerotherapy is performed in patients of all age groups, ranging from
patients in their late twenties to early seventies. If treatment is initiated early in the
course of the disease and with proper proximal-to-distal treatment techniques, pa-
tients can expect to achieve excellent results. Although hypertonic saline solution is
the sclerosant most widely available and used in the United States, there are many
others from which to choose that are less painful to inject and less ulcerogenic if ex-
travasated. Vessel size and, to some extent, location are two of the most important
factors to consider when choosing a sclerosant.
In expert hands, nearly any vessel can be treated with traditional sclerotherapy tech-
niques. It is more difficult to treat larger vessels, vessels with a high-grade source of
reflux, vessels with a complex pattern of reflux, and vessels that lie deeper beneath
the surface of the skin. Failures can be caused by incorrect assumptions about the
patterns of flow, incomplete understanding of the anatomy, or incorrect placement
of the delivery catheter or needle.
Direct duplex ultrasound visualization offers an alternative to “blind” sclerotherapy
that has one very important advantage—after a treatment under direct visualization,
there can be no doubt that sclerosant has been delivered where it was intended and
that all areas of reflux have been exposed to the sclerosing solution. An important
secondary benefit is that observable spasm is a predictor of vessel closure.