Atlas Phẫu Thuật Thẩm Mỹ (Tập 2) – Atlas of Cosmetic Surgery

History and Science
Background and history
In 1963, Goldman and colleagues first demonstrated that ruby
laser radiation with a 0.5 ms pulse duration was selectively
absorbed by pigmented skin.1 Goldman and colleagues also
demonstrated that the threshold radiant exposure for epider­
mal damage was 10 to 100 times lower for a Q-switched ruby
laser (QSRL) with pulse width of 50 ns.2 Despite these initial
reports, the ability of the QSRL to selectively target pigment
was not appreciated, and for many years pigmented lesions
were treated with nonselective continuous wave sources such
as the argon3 and carbon dioxide lasers.4 Over the last two
decades, on the basis of a large amount of basic and clinical
investigation performed with pulsed lasers, Q-switched lasers
have become the treatment of choice for both epidermal and
dermal pigmented lesions, including tattoos.
Basic science
Laser–tissue interactions in pigmented skin
In 1983, Anderson and Parrish described the principle of
selective photothermolysis,5 which predicted that selective
thermal damage to an absorbing target could be achieved
­using suitable laser parameters. This concept requires the use
of a wavelength well absorbed by the target, a pulse dura­
tion shorter than the thermal relaxation time of the target
(defined as the time required for a heated target to cool by
50%), and sufficiently high energy density to achieve the de­
sired tissue effect. This principle was first applied to the treat­
ment of port-wine stains with oxyhemoglobin as the target
Lasers in the Treatment
of Pigmented Lesions
Thomas E. Rohrer,
Richard J. Ort,
Kenneth A. Arndt, and
Jeffrey S. Dover
C H A P T E R
12
p a r t 2
n Melanin absorption decreases steadily over the
­visible light spectrum with optimal absorption
­between 500 and 1100 nm.
n Tattoo absorption varies depending on the color
and substance used in the tattoo.
n Melanosomes and tattoo granules are very small
structures and therefore have very short thermal
relaxation times.
n Lasers with very short pulse durations such as
the Q-switched lasers are optimally set up for
­melanosome and tattoo particle destruction.
n Some destruction occurs from a photomechanical
effect produced by the rapid rise in temperature
­following Q-switched laser tissue interaction.
Key Points
chromophore. Soon thereafter it was applied to the treatment
of pigmented lesions where either endogenous melanin or an
exogenous chromophore such as carbon particles served as
the target.
Melanin has a broad absorption spectrum within the
ultraviolet, visible, and near-infrared range, but absorption
decreases steadily with longer wavelengths (Fig. 12-1).6 It is
the primary absorber between 600 and 1100 nm, the ‘opti­
cal window’ where light penetrates deeply into the dermis.6
Microscopically, melanin consists of melanosome granules
that evolve through four stages of increasing melanization before
being transferred from melanocytes to keratinocytes. With a

156
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
diameter of 1 μm, melanosomes are predicted to have a ther­
mal relaxation time between 50 and 500 ns.5,7 Depending on
coloration, individual tattoo pigments can be characterized by
their own absorption spectra (Fig. 12-2).8 For example, black
pigment absorbs broadly from 600 nm to near infrared while
red pigment has maximum absorption from 505–560 nm.8
With a diameter of approximately 40 nm, the most com­
mon type of tattoo pigment particle has a predicted thermal
relaxation time of less than 10 ns.9,10 Given the short thermal
relaxation time of melanosomes and tattoo pigment parti­
cles, they are optimally treated with lasers utilizing extremely
short pulse durations. Q-switched ruby, alexandrite, and Nd:
YAG lasers have pulse durations in the nanosecond range
and encouraging work is presently being done on lasers
with pulse durations in the pico- (10−12) and femtosecond
(10−15)­ domain.
The principle of selective photothermolysis predicts that
thermal confinement to the melanosome or tattoo particle will
occur over a range of wavelengths if the laser pulse width is
less than 1 μs. The delivery of an extremely high-energy laser
pulse within this time span results in rapid heating of the
target particle (estimated at 10 million degrees per second),
causing it to explode.11 Selective damage to melanosomes in
human skin was first demonstrated with a 351 nm XeF exci­
mer laser delivering 20 ns pulses.12 Although light at 351 nm
is well absorbed by melanin, it penetrates less than 100 μm
into the skin because of pronounced dermal scattering at
shorter wavelengths.6 Longer wavelengths penetrate progres­
sively deeper into the skin, such that wavelengths of 694 nm
or greater penetrate at least 1 mm.6 It was subsequently
demonstrated that selective damage to melanosomes could
be produced by the pulsed tunable dye laser13,14 (wavelength
435–750 nm, pulse width 300–750 ns), Q-switched ruby laser7
(wavelength 694 nm, pulse width 40 ns) and the Q-switched
neodymium:YAG laser15 (wavelength 355, 532, and 1064 nm,
pulse width 10–12 ns). Electron microscopy confirmed highly
selective, dose-dependent disruption of melanosomes within
melanocytes and melanized keratinocytes.
It is believed that destruction of pigment-containing cells
is largely due to mechanical damage from acoustic waves that
emanate from the absorbing melanosome or tattoo particle.9,16
Damage to these cells results in vacuolization, condensation
of pigment and nuclear material at the cellular periphery, and
subepidermal vesiculation at the level of the lamina lucida. In
both guinea pig17 and human skin18 treated with the QSRL,
necrotic pigmented cells slough in a fine scale or crust over
several weeks, followed by transient hypopigmentation and
gradual repigmentation without textural change. Repigmen­
tation results from migration of residual melanocytes within
adnexal structures or within unirradiated adjacent skin.
Q-switched lasers produce an immediate ash-white color
at the site of impact. Although the exact cause of this tissue
response is unknown, it is most likely due to scattering of visible
light by steam cavities formed within melanosomes.17 Under
confocal microscopy, electron microscopy, and optical coher­
ence tomography, well-demarcated, circular, highly reflective
structures of 1–30 μm were identified. These structures, pre­
sumed to be gas bubbles, gradually shrank over ­approximately
20 minutes and correlated with the disappearance of the
whitening of the skin.18 The exact composition of the steam
cavities is unknown but may be water vapor, nitrogen, or other
gases. The threshold exposure dose for melanosome damage
correlates well with the clinical threshold for immediate skin
whitening. Darker skin has a lower threshold whitening dose
due to higher epidermal melanin content.18 The required
threshold dose increases progressively with longer wavelength,
grossly consistent with the melanin absorption spectrum.14,15
Longer wavelengths up to 1064 nm penetrate more deeply
into the dermis, causing melanosome alterations within fol­
licles at a depth of over 1 mm.15 Subthreshold fluences appear
to actually stimulate melanogenesis because of activation of
epidermal melanocytes after nonlethal injury.19
Q-switched and pulsed lasers and light
sources
A variety of lasers can be used to treat pigmented lesions of
the skin (Table 12-1). These can be categorized into lasers that
are pigment nonselective, those that are somewhat pigment
Wavelength (nm)
Absorption
1.4
1.2
1
0.8
0.4
0.2
0
300
400
500
600
700
800
900
1000
1100
1200
Melanin
Hemoglobin
Water
Fig. 12-1  Absorption spectrum of melanin, oxyhemoglobin, and
water.
• Pigment nonselective lasers, such as CO2,
Er:YAG, and fractional infrared, as well as
plasma devices, improve pigment by ablating
the ­epidermis where the pigment resides.
• Pigment selective devices include Q-switched
and normal mode ruby, Q-switched and normal
mode alexandrite, Q-switched and normal mode
Nd:YAG, as well as KTP and pulsed dye lasers.
• Intense pulsed light sources may also be used
to improve epidermal pigment.
Pearls

157
Lasers in the treatment of pigmented lesions  •  Chapter 12
selective, and those that are highly selective for pigment re­
moval. Pigment nonselective lasers such as the carbon diox­
ide4,20 (10 600 nm) and erbium:YAG (2940 nm) lasers can be
used to eliminate epidermal pigment because of their ability
to target water and remove the entire epidermis, including
melanocytes and melanized keratinocytes, in a selective fash­
ion. Pigment is removed as a secondary event. ­Nonselective
targeting of ­epidermal pigmented lesions can also be accom­
plished with newer technologies, such as fractional laser re­
surfacing (1500 nm) or plasma resurfacing. Continuous wave
(CW) and quasi-CW visible light lasers, such as argon laser
(488, 514 nm), copper vapor laser (511 nm), and krypton la­
ser (521, 530 nm), can be used to selectively remove epider­
mal pigmented lesions, although reproducible spatial thermal
injury confinement is not possible. The risk/benefit ratio is
higher with these devices than with pulsed lasers. To date,
only pulsed lasers have been shown to treat both epidermal
and dermal pigmented lesions effectively in a safe, reproduc­
ible manner (Table 12-2).
There are four principal short-pulsed, pigment-selective
lasers that are widely used today: the Q-switched ruby laser
(QSRL), the Q-switched alexandrite laser, the Q-switched
neodymium:YAG (Nd:YAG and KTP) laser, and the pig­
mented lesion pulsed dye laser. These lasers specifically
target melanosomes or tattoo particles by delivering high-
intensity, short-pulsed radiation at appropriate wavelengths.
The term Q-switched is short for ‘quality-switched,’ which
refers to the ability to store large amounts of energy in the
laser cavity through the use of an optical shutter. When the
laser fires, the shutter releases an extremely high-powered
pulse (109 W) with an ultrashort pulse duration (nanosecond
range).
The QSRL emits red light at a wavelength of 694 nm
and pulse duration of 28–40 ns. Light is delivered through a
­mirrored articulated arm at a spot size of 5 or 6.5 mm and
repetition rate of 2 Hz. The Q-switched Nd:YAG laser emits
infrared light at 1064 nm. By placing a frequency-doubling
KTP (potassium-titanyl-phosphate) crystal in the laser beam’s
Diffuse reflectance
1.00
.80
.60
.40
.20
400 500 600 700 800
Wavelength (nm)
Reflectance spectra of melanin
and black tattoo pigment
755 nm
Melanin
Black tatto pigment
1064 nm
694nm 755 nm
Diffuse reflectance
.80
.60
.40
.20
550 650 750 850 950 1050 1150
Reflectance spectra of professional
tattoo pigments
Red
Texas blue
Mist green
Mint green
Black
A
C
B
D
Diffuse reflectance
1.00
.80
.60
.40
.20
Wavelength (nm)
Reflectance spectra of professional
tattoo pigments
510 nm 532 nm
694 nm 755 nm
Red
Yellow
Orange
Violet
450 550 650 750
Reflectance spectra of professional
tattoo pigments
510 nm 532 nm
694 nm 755 nm
1.00
.80
.60
.40
.20
450 550 650 750
Wavelength (nm)
Diffuse reflectance
Flesh
Tan
Fig. 12-2  Absorption spectrum of various tattoo pigments

158
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
path, the wavelength may be halved to 532 nm (green light).
Recently introduced dye-impregnated handpieces can convert
the 532 nm wavelength to either 585 nm (yellow) or 650 nm
(red) light. Pulses of 5–10 ns duration are delivered through
an articulated arm at a spot size of 1.5–8 mm and repetition
rate of up to 10 Hz. The Q-switched alexandrite laser has a
­wavelength of 755 nm (infrared), pulse duration of 50–100 ns,
spot size of 2–4 mm, and repetition rate of up to 10 Hz.
Light is delivered through an articulated arm or through a
semi-­flexible fiberoptic cable. A pigmented lesion pulsed dye
­laser (­non-Q-switched) utilized a xenon flashlamp to pump a
coumarin-­containing dye that emitted pulses of laser energy
at 510 nm (green light). ­ Although this system worked well
for ­epidermal lesions, its limited depth of penetration made
it much less ­effective on ­dermal lesions and it is no longer
manufactured.
Long-pulsed (millisecond domain) 532 nm (KTP) Nd:YAG
lasers and 595 nm pulsed dye lasers, which are commonly
used to treat vascular lesions, can be also be used to treat
­superficial pigmented lesions. However, the long pulse width
of these ­lasers approximates the thermal relaxation time of
the ­entire epidermis (about 10 ms)21 and does not allow for
selective damage to subcellular organelles such as melano­
somes. The use of millisecond domain lasers may have some
advantages in the treatment of epidermal pigmented lesions
in patients with darker skin types, where a more ‘gentle’
heating of the target may be desirable to reduce the risk
of postinflammatory hyperpigmentation. Because of their
longer pulse width, ­ millisecond domain lasers produce a
purely photothermal ­effect on their target, unlike the photo­
mechanical effect of Q-switched lasers. Because of the limited
penetration depth of the 532 nm and 595 nm wavelengths,
these lasers are not effective for treatment of dermal pigmented
lesions.22
Long-pulsed ruby, alexandrite, and Nd:YAG lasers, widely
used for laser hair removal, share the same wavelengths as
Table 12-1  Lasers in the treatment of pigmented lesions
Device
Manufacturer Laser type
Wave length
(nm)
Pulse
­duration
Spot size
(mm)
Maximum
­repetition
rate (Hz)
Comments
Spectrum
RD-1200
Spectrum
(Palomar)
QS Ruby
694
28 ns
5, 6.5
0.8
Large spot size
­promotes deeper
­penetration
EpiTouch
Lumenis
QS Ruby
694
25 ns
5
0.8
Long pulse mode
­available for hair
­removal
RubyStar
Aesculap
Meditec
QS Ruby
694
40 ns
1.5, 3, 4
0.8
Long pulse mode
available for hair
removal
Sinon
Wavelight
QS Ruby
694
Variable
15–40 ns
3–9 mm
20 Hz
Long pulse mode
available for hair
removal
AlexLAZR
Candela
QS alexandrite
755
50 ns
2, 3, 4
5
Fiberoptic
­delivery system
HT 10
Cynosure
QS alexandrite
755
45–75 ns
2.4
10
Fiberoptic
­delivery system
VersaPulse
VPC
Lumenis
FD Nd:YAG
QS FD Nd:YAG
QS Nd:YAG
QS alexandrite
532
532
1064
755
2–50 ms
4 ns
5 ns
45 ns
2–10
2–6
2–6
2–6
6
10
10
10
Four laser within
one box
Medlite IV
Continuum
Biomedical
QS FD Nd:YAG
QS Nd:YAG
532
1064
5–7 ns
5–7 ns
2, 3, 4, 6
3, 4, 6, 8
10
10
Handpiece
converts λ to 585
and 650 nm
TatuLAZR
Candela
Pulsed dye
510
400 ns
3–5
1
Fiberoptic
­delivery system
No longer
­manufactured

159
Lasers in the treatment of pigmented lesions  •  Chapter 12
their Q-switched counterparts but operate in a normal (non-
Q-switched) mode and deliver high-energy pulses in the
­millisecond rather than nanosecond domain. Because of their
higher fluences and longer pulse duration, these lasers can
­target large pigmented structures such as hair follicles or nests
of cells rather than individual melanosomes or pigmented
cells.23 Although not optimal, with higher energies, the long-
pulsed ruby, alexandrite, and diode lasers, with or without skin
cooling, have been shown to be effective in the removal of epi­
dermal pigmented lesions. These non-spatially selective lasers
should not be used to treat tattoos.
Pigment removal can also be accomplished with a non­
coherent light source (intense pulsed light or IPL) that emits
polychromatic light ranging from 515 to 1200 nm (visible to
infrared). Filters are used to cut off the light above or below
predetermined wavelengths. Because melanin exhibits a broad
absorption spectrum, monochromatic devices are not neces­
sary to target superficial melanin. The shorter wavelengths
emitted by IPL devices are highly absorbed by melanin. IPL
devices emit light as a sequence of single, double, or triple
pulses (millisecond domain), which are separated by variable
time intervals. Similar to millisecond domain lasers, the milli­
second domain pulse width of IPL devices ­ approximates
the thermal relaxation time of the epidermis (10 ms) and
­produces a photothermal, not photomechanical effect, on its
­target. Although it may seem somewhat counterintuitive when
targeting epidermal pigment, most IPL devices are utilized
with active skin cooling during treatment to protect the epi­
dermis from excessive thermal injury. These broadband light
sources are also used for treatment of vascular lesions and for
­photorejuvenation. They should not be used for treatment of
dermal pigmented lesions or tattoos.
Clinical studies and discussion
Epidermal pigmented lesions
Numerous clinical studies have confirmed the efficacy and
safety of Q-switched lasers24–26 and the 510 nm pulsed dye la­
ser27 in the treatment of various epidermal pigmented lesions,
including ephelides, lentigines, café au lait ­macules, seborrheic
keratoses, nevi spilus, and Becker’s nevi. Q-switched lasers
have been shown to be superior to both 35% trichloroacetic
acid peels and cryotherapy in the treatment of ­lentigines.28,29
Pigment in epidermal lesions is located superficially, so shorter-
wavelength devices can be used effectively despite their limited
penetration depth. For example, the 510 nm wavelength of the
pulsed dye laser penetrates only about 250 μm into the skin
but is highly absorbed by melanin.6 The Q-switched ruby and
alexandrite lasers effectively treat both epidermal and dermal
lesions, since their wavelengths are well absorbed by melanin
and penetrate deeply into the dermis. The 1064 nm wavelength
Table 12-2  Treatment of pigment lesions and tattoos
Laser
Epidermal
lesions
Dermal
lesions
Mixed
lesions
Amateur tattoos
(blue or black)
Professional
tattoos (primary
colors)
Q-switched ruby
(694 nm)
++++
++++
+
++++
++++ (black,
blue, green)
Q-switched Nd:YAG
(1064 nm)
++
++++
+
++++
++++ (black,
blue)
Q-switched Nd:YAG
(532 nm)
++++
+ to ++
+
++
+++ (red and
other bright colors)
Q-switched Nd:YAG
(585 nm)
+++
+ to ++
+
++
+++ (light blue)
Q-switched Nd:YAG
(650 nm)
+++
+ to ++
+
++
+++ (green)
Q-switched alexandrite
(755 nm)
+++
++++
+
++++
++++ (black,
blue, green)
Pulsed dye (510  nm)
++++
++
+
+
++++ (red,
yellow)
+, Poor; ++, fair; +++, good; ++++, excellent
• Many different devices have been shown to
safely and effectively improve or clear epidermal
pigmented lesions.
• Any device that is selectively absorbed in
­pigment or the epidermis, and is of sufficient
energy to destroy the melanosome or epidermis
may be used.
• Q-switched lasers have been shown to be
more ­effective and safer than chemical peels
and ­cryotherapy in the removal of lentigines.
Pearls

160
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
of the Nd:YAG laser penetrates deeply but is poorly absorbed
by melanin, making the 532 nm wavelength a better choice
when treating epidermal lesions. At the 510 nm and 532 nm
(green) wavelengths, hemoglobin competes with melanin for
absorption of light. Ultrashort (nanosecond range) pulses at
these wavelengths cause rupture of superficial blood vessels,
which is evident clinically as purpura.14
Lentigines
Lentigines are extremely common hyperpigmented macules
that most often result from chronic sun exposure. Histologi­
cally, melanocytes in the basal layer are increased in number
without nesting, and rete ridges are elongated. Lentigines
can be classified into several categories, including those due
to chronic sun exposure (solar lentigines), those associated
with a syndrome (e.g. Peutz-Jeghers [Fig. 12-3]), and the ­labial
melanotic macule. All three Q-switched lasers are highly
­effective in the treatment of lentigines. After one treatment,
at least 50% clearing is expected, although additional treat­
ments may be required to remove residual pigment (Fig. 12-4,
Fig. 12-5). Labial melanotic macules respond equally well to
laser treatment.30,31 One study determined that treatment of
facial lentigines with the 532 nm Q-switched Nd:YAG laser
was more effective than application of 35% trichloroacetic
acid.32 In another study, blinded observers found that the
532 nm Q-switched Nd:YAG laser was superior to cryother­
apy with liquid nitrogen in efficacy, healing time, and patient
­preference.33 Although less selective, non-Q-switched (msec)
KTP, 595 nm pulsed-dye, ruby, alexandrite, and diode lasers
may also be used to treat lentigines. In a study of Asian pa­
tients with facial lentigines, a long-pulsed KTP (532 nm) laser
­(without skin cooling) was found to be as effective as 532 nm
Q-switched Nd:YAG laser, but with a lower risk of postinflam­
matory hyperpigmentation. A recent study using the 595 nm
pulsed dye laser on lentigines in Asian patients showed good
to excellent results in 38 of 40 patients with an average of
82% improvement in pigment by reflectance spectrometer.22
In addition, multiple studies have demonstrated the effective­
ness of broadband light sources in clearing lentigines. Recent
studies have also shown photopneumatic devices to be effec­
tive in the improvement of epidermal pigment.34 Adjunctive
use of 5-aminolevulinic acid (5-ALA) with intense pulsed light
has been shown to provide greater improvement of epidermal
pigmentation than treatment with IPL alone.
Café au lait macules
Café au lait macules (CALMs) are well-circumscribed,
light-brown macules that may occur as isolated lesions in
the general population or as multiple lesions in association
with a syndrome (e.g. neurofibromatosis and Albright’s syn­
drome). Histologically, one sees an increase in the number of ­
melanocytes, hypermelanosis of melanocytes and keratino­
cytes, and giant melanin granules. The efficacy of lasers in the
removal of CALMs is variable, and results are often unpredict­
able.35 Short-term lightening or clearing is frequently achieved
after multiple treatments (Fig. 12-6). However, recurrences are
common, seen in up to 50% of treated lesions, even when
complete clearing has occurred initially. Transient postinflam­
matory hyperpigmentation is frequent following laser treat­
ment of CALMs, especially in patients with skin phototypes
III and higher. Alster reported complete elimination of most
CALMs after an average of 8.4 treatment sessions with the
510 nm pulsed dye laser, indicating that multiple treatments
may be necessary to achieve optimal results.36,37 Er:YAG re­
surfacing lasers have also been shown to clear CALM.37
Other epidermal lesions
Ephelides (freckles) are small hyperpigmented macules ­located
on sun-exposed skin. Histologically, there is hyperpigmenta­
tion of the basal layer but no increase in the concentration
of melanocytes. These lesions uniformly respond well to
Q-switched laser treatment (Fig. 12-7). Flat seborrheic ­keratoses
A
B
Fig. 12-3  (A) A patient with Peutz-Jeghers
syndrome with extensive macular pigmented
lesions over the lip prior to treatment.
(B) After two treatments with the Q-switched
ruby laser, the lesions are completely cleared
(Courtesy Tadashi Tezuka, MD).

161
Lasers in the treatment of pigmented lesions  •  Chapter 12
also respond well to laser treatment,27 but thicker lesions are
resistant and are better treated with cryosurgery. Nevi spilus
and Becker’s nevi, which may have combined epidermal and
dermal components, respond variably to laser treatment. Re­
sults are unpredictable, and incomplete clearing or recurrences
are not uncommon. Successful clearing of the darker nevocel­
lular component of nevus spilus has been reported with the
QSRL, but the background café au lait ­component tends to
recur.24 Becker’s nevus is a large, hyperpigmented, slightly
verrucous plaque that occurs most commonly on the shoul­
der area of males. These lesions are reported to be ­similar to
café au lait macules in their response to laser treatment, with
a high incidence of post-treatment hyperpigmentation and
recurrence within 6–12 months.38
Dermal pigmented lesions and tattoos
A
B
Fig. 12-5  (A) A women in her 60s with significant photoaging of her hands including numerous lentigines prior to treatment. (B) Hands
6 weeks following a single treatment with a Q-switched alexandrite laser.
A
B
Fig. 12-4  (A) A woman
in her early 40s with
significant photoaging
and numerous lentigines
prior to treatment.
(B) Six weeks after one
single treatment with a
Q-switched ruby laser.
There is about 70%
improvement of the
lesion. No further treat­
ments were requested
by the patient.
• Q-switched ruby, alexandrite, and Nd:YAG lasers
are most commonly used in the treatment of
dermal pigmented lesions such as nevus of Ota,
minocycline pigmentation, and tattoos.
• Longer wavelengths penetrate to a greater depth
than shorter wavelengths.
• Melasma should be treated with great caution, if
at all.
• Tattoos with shades of white, tan, brown, or
other flesh tones should be avoided since these
may become even darker following treatment
with a Q-switched laser.
Pearls

162
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
Q-switched lasers have revolutionized the treatment of
dermal pigmented lesions, including melanocytoses, some
melanocytic nevi, and tattoos. Prior to the use of Q-switched
lasers, treatment of these lesions was limited to non-­specific
destructive methods such as excision,39,40 dermabrasion,41
­salabrasion,42 liquid nitrogen,43 solid carbon dioxide ice,44 or
continuous wave laser ablation.45 Treatment was ­relatively in­
effective and almost always resulted in scarring or ­pigmentary
changes. By selectively targeting dermal pigment, Q-switched
lasers ­provide highly effective treatment of these lesions while
dramatically reducing the risk of textural or permanent
pigmentary change. The Q-switched ruby, alexandrite, and
1064 nm Nd:YAG lasers are most commonly used. The wave­
length range of these lasers falls within the optical window that
transmits light deeply into the dermis. Shorter wavelengths
such as 510 or 532 nm are highly scattered by dermal col­
lagen and penetrate poorly into the dermis (about 300 μm),6
­making them inappropriate sources for the treatment of der­
mal pigment. Because they are so well absorbed by the color
red, however, they are effective for treating red tattoo pigment.
The lack of wavelength specificity and the longer (msec range)
pulse durations of broadband light sources make these devices
inappropriate for the treatment of dermal pigmented lesions.
Nevus of Ota
Nevus of Ota is a mottled, bluish or gray-brown patch that is
usually located unilaterally within the distribution of the first
and second branches of the trigeminal nerve. It is ­classified
A
B
C
D
Fig. 12-6  (A) Café au lait macule of the thigh (Courtesy Karen Wiss, MD). (B) Café au lait macule after four treatments with a Q-switched ruby
laser, showing near complete clearing of the lesion. There is one small focal scar that is the result of a skin biopsy (Courtesy Karen Wiss, MD).
(C) A young woman with a café au lait macule of the right temple prior to treatment (Courtesy Tadashi Tezuka, MD). (D) After four treatments
with the Q-switched ruby laser, there is dramatic lightening of the lesion.

163
Lasers in the treatment of pigmented lesions  •  Chapter 12
into four types, depending on extent and distribution of
­pigmentation (I-small, II-moderate, III-extensive, IV-bilateral).
Nevus of Ota may affect mucosal surfaces such as cornea,
sclera, nasal and buccal mucosa, and tympanic membrane.
Lesions are present at birth in about 50% of cases, and the
remainder usually appear by the second decade of life. Asians
are most commonly affected, with an incidence of 1 in 500 re­
ported in Japan.46 The incidence in Caucasians is significantly
lower. Women are five times more likely to be affected than
men. The occurrence of melanoma within nevus of Ota has
been reported47 but is rare. Histologically, dendritic melano­
cytes are scattered within the papillary and reticular dermis.
Q-switched lasers provide an extremely effective means
of treating this condition. The degree of lightening is usually
directly proportional to the number of treatments performed.
Lightening of 70% or more has been reported in the vast major­
ity of patients treated four or five times with the QSRL48 (Fig.
12-8). Although pigmentary change such as hyperpigmenta­
tion or hypopigmentation occurs occasionally, textural change
has not been reported. Post-treatment biopsies have revealed
degeneration of melanocytes up to a depth of 1.5 mm from
the skin surface.58 Although the QSRL has been most widely
used,48–52 the Q-switched alexandrite53 and Nd:YAG25 lasers
appear as effective. Large-scale comparative trials between
these lasers have not been performed. Manuskiatti et al. dem­
onstrated greater clearing of bilateral nevus of Ota-like mac­
ules with a combination carbon dioxide (CO2) and Q-switched
ruby laser (QSRL) treatment than with QSRL alone.54
Melanocytic nevi
Laser treatment of nevomelanocytic lesions is somewhat con­
troversial as it is unclear whether nonlethal laser irradiation has
any potential to induce malignant change in ­nevomelanocytic
cells. In vitro studies of melanoma cells treated with
Q-switched lasers have found changes in cell surface integrin
expression, with subsequent alteration of such cellular be­
havior as migration.55 Chan et al. demonstrated a significant
increase in p16INK4a in p16-positive cell lines following
­irradiation with Q-switched laser light and suggested that sub­
lethal laser damage may increase DNA damage leading to an
increase in p16 expression.56 In addition, benign lesions that
recur following treatment may show clinical and histologic
atypia, a condition termed pseudomelanoma.57 However, true
malignant transformation of a benign pigmented lesion fol­
lowing laser treatment has never been reported.58 Theoreti­
cally, laser treatment of melanocytic lesions might decrease
the risk of malignant transformation by reducing the popula­
tion of available premalignant cells.59 Goldberg et al. recently
reported no significant markers (proliferating cell nuclear
antigen, pyrimidine dimers, 8-OhdG, and p53) were detect­
able following treatment of nevi with Q-switched lasers.60
­Additional study is required to assess the effects of Q-switched
laser irradiation on nevomelanocytic cells. For the time
being, it is recommended that Q-switched laser treatment be
reserved for benign nevomelanocytic lesions exhibiting little
to no atypia. If any doubt exists about the clinical diagnosis,
a biopsy should be performed prior to laser treatment. Laser
treatment should not be performed in patients with a personal
or family history of malignant melanoma.
Studies indicate that the Q-switched ruby, alexandrite, and
1064 nm Nd:YAG lasers all have some degree of ­effectiveness
in the removal of flat or slightly raised, junctional or com­
pound, acquired nevi.61–63 Lighter nevi often respond best to
shorter wavelengths that maximize melanin absorption, while
darker nevi typically respond to any wavelength. ­ Multiple
treatments are usually necessary for maximal lightening. It
B
A
Fig. 12-7  (A) Japanese male with exten­
sive numbers of freckles prior to treatment.
(B) After treatment with a Q-switched ruby
laser, the freckles are entirely clear (Courtesy
T.K. Lee, MD).

164
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
is often not possible to achieve complete clearing of nevi,63
and recurrence after laser treatment is not uncommon.
There may be persistence of nevomelanocytes containing
­little or no pigment or located within deeper layers that are
shielded from laser radiation by pigmented superficial cells.61
Q-switched laser radiation does not penetrate sufficiently to
effectively treat thicker lesions such as papillated or ­dome-
shaped dermal nevi. The QSRL has been reported to suc­
cessfully eliminate flat blue nevi.64 The short-pulsed erbium:
YAG laser has been reported to be quite effective in remov­
ing flat or slightly palpable melanocytic nevi. Single pulses of
5.2–14 J/cm2 clinically and histologically were found to clear
27 of 28 nevi.65
Although Q-switched lasers may effectively lighten congen­
ital nevi, there is a high rate of repigmentation due to persist­
ence of nevomelanocytes within the deeper reticular ­dermis
and within adnexae.58,59 In theory, millisecond-domain pulses
are more appropriate than Q-switched pulses for treating
thick lesions such as congenital nevi because they produce
less selective thermal damage, destroying entire nests of cells
rather than individual pigmented cells. Japanese investigators
have reported impressive long-term clearing of congenital
nevi treated with the millisecond-domain normal-mode ruby
laser66,67 (Fig. 12-9). In a split nevus study on 15 patients, Kono
et al. showed greater clearing with combined Q-switched and
normal-mode ruby laser (NMRL) than in NMRL alone.22
They also showed a marked decrease in nevomelanocytic
nests in the junctional, papillary, and reticular dermis. Clini­
cal lightening is also associated with the development of a sub­
tle microscopic scar up to 1 mm thick that obscures residual
nevus cells. Long-pulse ruby lasers also offer the potential to
reduce the amount of hair within congenital nevi. Because
congenital nevi have the potential to transform into malignant
melanoma, and residual nevus cells persist in the dermis after
laser treatment, cautious long-term follow-up of nevi treated
with lasers is required. In Japanese studies, no histological or
clinical evidence of malignancy has been demonstrated up to
8 years after normal-mode ruby laser treatment.66,67
Both continuous wave lasers68,69 and the QSRL70 have
been used to treat lentigo maligna. However, there are several
reports of lentigo maligna recurring following laser treatment,
most likely due to persistence of melanocytes within deeper
adnexal structures.71,72 Laser treatment of lentigo maligna
should be considered only in extreme situations where surgi­
cal excision is not feasible due to large lesion size, advanced
patient age, or underlying medical condition. Close follow-up
to detect any early recurrence is essential.
Other dermal pigmented lesions
Melasma is a common acquired facial hypermelanosis, occur­
ring most commonly on the cheeks, forehead, upper lip, nose,
and chin and varying in color from brown to blue-gray. It is
particularly common in women of childbearing age and in
individuals with skin phototypes III or higher. It is associated
with sun exposure, pregnancy, and use of oral contraceptives,
although its presence often cannot be ascribed to any known
cause. Postinflammatory hyperpigmentation is another type
of acquired hypermelanosis that may develop following nearly
any cutaneous injury or inflammatory process. Histologically,
three types of pigmentation occur in these two conditions:
(1) the epidermal type in which there is increased melanin in
the epidermis; (2) the dermal type in which melanophages are
found in the superficial and mid-dermis; and (3) a combina­
tion of epidermal and dermal types.
A
B
Fig. 12-8  (A) A young girl with a nevus
of Ota extending over a significant portion
of the face prior to treatment. (B) After a
series of treatments with the Q-switched ruby
laser, there is impressive lightening of the
lesion with no textural change (Courtesy
S. Ueda, MD).

165
Lasers in the treatment of pigmented lesions  •  Chapter 12
Traditional treatment of these disorders includes cessa­
tion of offending medication such as oral contraceptives, sun
­protection, and the use of topical steroids, hydroquinone, retin­
oids, azelaic acid, and superficial chemical peels. While the
epidermal component often responds to this regimen, dermal
pigmentation is generally resistant. Studies have shown that
Q-switched lasers are for the most part ineffective in the
treatment of melasma and postinflammatory hyperpigmen­
tation.27,73 Q-switched laser treatment may actually cause an
increase in dermal melanophages and worsening of hyperpig­
mentation. Carbon dioxide74 or erbium:YAG75 laser resurfac­
ing provides an alternative treatment modality for melasma,
but postinflammatory hyperpigmentation is an almost univer­
sal occurrence in the postoperative period. Aggressive topical
therapy should be initiated promptly following laser ­resurfacing.
Recent studies suggest that fractional resurfacing may offer a
reasonable treatment option for patients with melasma.76
Infraorbital hyperpigmentation (dark circles) may result
from a variety of causes, including dermal melanin deposition,
postinflammatory hyperpigmentation from atopic or allergic
contact dermatitis, prominent superficial blood vessels, and
shadowing from skin laxity and infraorbital swelling.67 The
QSRL has been reported to effectively treat infraorbital hyper­
pigmentation when due to deposition of dermal ­melanin.77
Improvement of this condition has also been reported follow­
ing carbon dioxide laser resurfacing78 and the combination
of carbon dioxide laser followed by Q-switched alexandrite
laser. In one study, a striking 75–100% clearing of periorbital
hyperpigmentation was noted using a combined CO2 resur­
facing followed immediately by Q-switched alexandrite laser
treatment.79 Blepharoplasty may be indicated when infra­
orbital darkening is due to excessive skin laxity.
Minocycline therapy may cause localized or diffuse muco­
cutaneous pigmentation. Minocycline-induced pigmenta­
tion occurs in approximately 5% of acne vulgaris patients
treated with the drug after prolonged use.80 Two pat­
terns of pigmentation have been reported. In type I, focal
blue-gray pigmentation occurs in inflamed or scarred skin, or
in previously normal skin. Histologic studies show pigment
within dermal macrophages that stains positively for mela­
nin and iron.81 Type II consists of generalized blue to brown
discoloration that is more prominent on sun-exposed areas.
Histologically,­ epidermal and superficial dermal pigment is
present that stains only for melanin.81 Although pigmentation
typically fades after discontinuation of the drug, it may per­
sist for years following cessation of therapy. The Q-switched
ruby laser is highly effective in treating minocycline-induced
pigmentation, with clearing occurring after one to four treat­
ment sessions without untoward sequelae.82–84 Successful
treatment has also been reported with the Q-switched 532 nm
and 1064 nm Nd:YAG laser,85,86although the latter wave­
length has not proved effective in several reports.84,85 Similar
results have been ­reported with amiodarone and imipramine-
induced hyperpigmentation treated with the Q-switched
ruby laser.87,88 In order to prevent recurrences, laser treat­
ment of these conditions should be deferred until the offend­
ing medication has been discontinued and sufficient time has
elapsed to allow most of the pigmentation to resolve sponta­
neously.
Q-switched laser treatment may cause paradoxical hyper­
pigmentation in patients receiving certain medications. In one
report, localized chrysiasis developed in a patient on parenteral
gold therapy who underwent treatment with a Q-switched
ruby laser for postinflammatory hyperpigmentation.89 This
phenomenon is due to a laser-induced alteration in the physio­
chemical properties of dermal gold deposits and resembles the
pigment darkening that may occur following Q-switched laser
treatment of tattoos containing iron oxide or titanium dioxide
(see the next section). The patient with the laser-­induced chry­
siasis was studied further and it was found that the ­induction
of this change in pigmentation is irradiance-­dependent, i.e.
related to the power delivered per unit area (W/cm2) rather
than fluence-dependent. It was concluded that any millisec­
ond laser emitting between 550 and 850 nm should clear
A
B
Fig. 12-9  (A) A congenital nevus of the upper and lower eyelid prior to treatment. (B) After a series of treatments with a long-pulsed ruby laser,
there is significant lightening but incomplete clearing of the nevus (Courtesy S. Ueda, MD).

166
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
this pigment, and subsequent treatment with a normal mode
(3 ms) ruby laser resulted in substantial ­clearing.90
Tattoos
Tattoos are produced when an exogenous pigment is ­implanted
traumatically or intentionally into the dermis. In most amateur
tattoos, a crude instrument is used to drive a carbon-based pig­
ment such as India ink into the skin. ­Pigment is usually lightly
concentrated within various levels of the dermis. In contrast,
professional tattoos are made with an electric tattoo machine
that uses rapidly vibrating needles to repeatedly puncture the
skin. Pigment is densely concentrated ­primarily at the junction
of the papillary and reticular dermis.9 Professional tattoo pig­
ments are composed of mixtures of metallic salts and organic
dyes. Common pigments include mercuric oxide (red) cadmium
sulfide (yellow), chromium salts (green), cobalt salts (dark blue),
titanium dioxide (white), and iron oxide (red-brown). Although
tattooing is widely practiced, there is virtually no federal and
inconsistent state regulation of the industry. The FDA does not
regulate the manufacture or use of tattoo pigment, despite the
potential for infection, ­allergic reaction, and metal toxicity.91
After a tattoo is placed, an initial inflammatory heal­
ing phase occurs in which ink is internalized by a variety of
cells, including keratinocytes, fibroblasts, and macrophages.92
Clinically, slight erythema, induration, crusting, and tender­
ness occur at the tattoo site, lasting about 10 days.93 Although
tattoo needles deposit pigment within both epidermis and
dermis, only dermal pigment remains permanently, as the
epidermis typically sloughs within 1 week after tattoo place­
ment. During this time, inflammatory cells carry some dermal
pigment to the skin surface through the disrupted epidermis.
The epidermis and basement membrane regenerate within
1 month, preventing further loss of pigment via this route. The
majority of the tattoo pigment eventually becomes encapsu­
lated within dermal fibroblasts and macrophages. Thereafter,
tattoos evolve in a slowly progressive manner over the course
of the bearer’s lifetime. Some pigment is gradually carried out
of the skin into the lymphatic system by macrophages. Older
tattoos contain only a fraction of the original pigment, which
is contained primarily within dermal fibroblasts surrounded
by a prominent connective tissue network.92
Q-switched lasers can lighten almost all tattoos, but the
degree of clearing depends on pigment density, color, and com­
position. Black amateur tattoos generally respond well, ­typically
clearing within three to six treatment sessions (Fig. 12-10).
The response of densely pigmented, multicolored ­professional
tattoos is far more variable (Fig. 12-11). These tattoos typically
require six to twelve treatment sessions for clearing but may
require up to twenty sessions.94 Although most tattoos can be
lightened significantly, it is often not possible to achieve true
100% clearing, as small pockets of ink may persist in the skin
despite repeated treatments (Fig. 12-12).94 Tattoos located
on the distal extremities may be more resistant to treatment,
possibly because of decreased lymphatic drainage from these
areas.94 Because they contain less pigment, older tattoos may
require fewer treatment sessions than fresh tattoos containing
dense deposits of ink. Due to the ­competing absorption in epi­
dermal melanin, patients with skin types V and VI are at high
risk for pigmentary alteration and should not be treated.
No single laser can remove all tattoo colors. Black pigment
has minimal reflectance and is absorbed by all wavelengths,
blue and green is optimally absorbed between 600 and 800 nm,
red is best absorbed under 575 nm, and tan below 560 nm.
Clinically, the Q-switched ruby95–97 and alexandrite98–100 lasers
are most useful for the treatment of black, blue, and green
colors, while the Q-switched 1064 nm Nd:YAG laser101 effec­
tively treats black and blue pigment (not green). The 510 nm
pulsed dye102 and Q-switched 532 nm Nd:YAG 94 lasers are
most effective for treatment of red and yellow colors. In vitro
agarose gel assays have revealed that the newer 585 nm and
650 nm wavelengths of the Nd:YAG laser are absorbed well
by sky blue and green pigment, respectively.103
Fitzpatrick and Goldman, using the Q-switched alexan­
drite laser, showed a 25% clearing of tattoos was achieved
after an average of 1.7 treatments, 50% clearing after an aver­
age of 2.8 treatments, 75% after 5 treatments, and 90% after
6.4 treatments. Professionally applied tattoos are much more
resistant to treatment than amateur ones.98 One study showed
the QSRL had an excellent result in 78% of amateur tattoos
but in only 23% of professional tattoos. Ferguson and August,
using the Q-switched Nd:YAG laser (1064 and 532 nm),
found that 79% of amateur black tattoos were 75% or greater
cleared after 1–5 treatments (mean 2) using 1064 nm, 74% of
black professional tattoos were 75% or greater cleared after
1–11 treatments (mean 6.3), and 75% or greater of red ­tattoos
responded to 1–5 treatments with 532 nm. Red, orange, blue,
and green tattoos were resistant to treatment.104 Prinz et al.,
treating 74 consecutive patients with either Q-switch Nd:
YAG, alexandrite, or variable-pulse Nd:YAG (532 nm) lasers,
found that 19% achieved a complete response, 31% 76–95%
lightening, 28% 51–75% lightening, and 22% only a slight
response. Multicoloured professional tattoos needed a mean
of 5.7 treatments, single-colored tattoos 3.5 treatments, and
amateur tattoos 2.8 treatments.105
A recent report describes the use of tattoo pigments specifi­
cally designed to be more easily removed with laser treatment.
Bioresorbable dye is encapsulated in a nondegradable protec­
tive microsphere capsule and used as the tattoo ­pigment. When
radiated with laser energy, the capsule ruptures and releases
the bioresorbable dyes. The pilot study showed a removal effi­
cacy more than twice that of traditional India ink tattoos.106
Prior to the standard use of selective Q-switched lasers,
continuous-wave CO2 and argon lasers were used with some
success in recently applied tattoos. Their greater success in
more recent tattoos is likely due to the greater concentration
tattoo pigment that is still free in the papillary dermis (before
it encapsulated into dermal fibroblasts).
There are few well-controlled studies comparing ­different
Q-switched lasers. Zelickson et al. compared the efficacy of
various Q-switched lasers on a spectrum of tattoo colors in

167
Lasers in the treatment of pigmented lesions  •  Chapter 12
­hairless guinea pigs.107 They found that black pigment respond­
ed best to the alexandrite and Nd:YAG lasers (1064 and 532 nm),
while purple pigment responded best to the QSRL. In addi­
tion, they found that the alexandrite laser was most effective for
removing blue and green pigment, the 1064 nm Nd:YAG laser
was best for removing red-brown, dark brown, and orange pig­
ment, and the Q-switched 532 nm Nd:YAG laser was best for
treating red. In contrast, several studies in humans found that
the QSRL was more effective than other lasers in the treat­
ment of black ink.108–110 The enhanced efficacy of the QSRL
in these reports may have been the result of its larger spot size
(6.5 mm) rather than its precise wavelength. Indeed, DeCoste
and Anderson found that, when the QSRL and Nd:YAG lasers
were used at the same fluence and spot size, there was no dif­
ference in the lightening of blue-black tattoos.111
A few studies have shown the Q-switched 1064 nm Nd:
YAG laser to have a lower incidence of hypopigmentation and
therefore may be a better option in treating darker skin types.
Tattoos showing signs of allergic reaction such as erythema,
induration, or pruritus should not be treated with Q-switched
lasers to avoid triggering a generalized allergic reaction.112
Q-switched laser treatment releases pigment into the extracel­
lular space, where it may be recognized by the immune system as
a foreign body. Tattoos with localized reactions are usually best
treated nonselectively with a continuous-wave carbon dioxide
laser to remove the epidermis and promote transepidermal
elim­ination of the ink. Unfortunately, textural change often
results.113 One study did show significant clearing and flatten­
ing of red ink tattoo reactions in seven patients treated with
a strong topical steroid and Q-switched 532 nm KTP laser
A
B
C
D
E
F
G
Fig. 12-10  (A) An amateur tattoo of the back of a young man prior to treatment. (B) Immediately after Q-switched Nd:YAG laser treatment, there
is some epidermal disruption and hemorrhage. (C) Six weeks after the first treatment, there is dramatic lightening of the tattoo. (D) ­Immediately
after the second treatment, there is an epidermal disruption and hemorrhage. (E) Six weeks after the second treatment, there is improved
­lightening of the tattoo. (F) Immediately after the third treatment with the Q-switched Nd:YAG laser, there is some epidermal disruption but less
hemorrhage. This is accounted for by the decreasing amount of pigment after two treatments. (G) The tattoo 6 weeks after the third treatment.

168
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
treatments. All patients had negative patch tests to mercury a
48 and 96 hours.114
Extreme caution is advised when treating cosmetic tat­
toos that commonly exhibit shades of white, red, orange, yel­
low, turquoise, lavender, pink, tan, or even brown.115 These
tattoos are at risk for immediate pigment darkening after
laser exposure because of reduction of pigment containing
iron oxide or titanium dioxide. When ferric oxide is heated
above 1400°C it may ignite and turn black (Fig 12-13).116
Should this paradoxical darkening occur, there are limited
therapeutic options available. The darkened pigment may
respond to further treatment with Q-switched lasers117 or to
resurfacing lasers. Alternatively, it can be excised. To minimize
the risk of pigment darkening, test spots should be performed
prior to treating any cosmetic tattoo. The test site should be
evaluated about 10 minutes after exposure, since immediate
skin whitening may temporarily obscure the color change.
Traumatic tattoos generally respond well to treatment
with Q-switched lasers. This is likely due to predominance of
­carbon-based pigment and the generally superficial implanta­
tion. Responses are usually greater and more rapid with short­
er ­delays between the trauma and the initiation of treatment.
Procedures and Techniques
Preoperative clinical considerations
Safety procedures
A
B
Fig. 12-11  (A) A multicolored tattoo on the posterior shoulder before treatment. (B) The tattoo after four treatments with a Q-switched
­alexandrite laser.
A
B
C
Fig. 12-12  (A) Multicolored tattoo of the arm prior to treatment. (B) The tattoo after three treatments with both the Q-switched ruby and
Q-switched Nd:YAG laser. (C) Tattoo after six treatments shows dramatic lightening of all colors of the tattoo but some residual tattoo ink.
Incomplete clearing of tattoos is not uncommon with Q-switched laser treatment.
• Retinal injury is the primary hazard of pigmented
lesion lasers and appropriate protective eyewear
must be worn.
• Nonflammable, water-based lubricants may be
used to protect eyebrows and other hair-bearing
areas from singeing.
• All makeup must be removed prior to treatment
with a pigmented lesion laser.
• Universal precautions must be used with
Q-switched lasers since significant tissue
­splatter may occur.
• Clear hydrogel dressings may be applied over
the lesion during treatment to act as a barrier
and a heat sink.
Pearls

169
Lasers in the treatment of pigmented lesions  •  Chapter 12
The primary hazard of Q-switched laser treatment is retinal
injury, which can occur from direct exposure or reflection
from a shiny surface such as the face of a watch. Infrared
wavelengths such as 1064 nm are particularly insidious
­because they are invisible. The retina does not sense pain and
the first symptom of ocular injury may be blindness. Protec­
tive goggles covering the appropriate wavelength must be
worn by all personnel in the treatment room. In the treat­
ment of a ­multicolored tattoo, the use of two or more lasers
may be necessary, each requiring the use of different goggles.
If treatment is in the immediate periocular area, protective
metal eye shields should be inserted over the conjunctiva
after the application of a topical ophthalmic anesthetic agent.
A nonflammable, water-based lubricant such as Surgilube or
K-Y Jelly should be applied to the eyebrows to avoid singeing
the hair. The room should be designed in such a way that all
reflective surfaces and windows are covered, the door is locked
from the inside, appropriate signs are posted, and no flamma­
ble materials or anesthetics are present.
Q-switched laser pulses may produce a significant amount
of blood and tissue splatter, especially the 1064 nm Nd:YAG
laser. Use of universal precautions is mandatory, including
use of gloves, goggles, and laser masks. The protective plas­
tic cone provided with most Q-switched lasers should always
be attached to the handpiece before use to minimize tissue
splatter and keep tissue debris off the handpiece lens. The
plastic cone must be placed in direct contact with the skin to
efficiently trap tissue debris. To minimize tissue splatter, pulses
may be delivered through a clear hydrogel dressing (e.g. Tega­
derm, Second Skin) placed on the skin, although this reduces
transmission of light into the skin and raises the risk of ocular
injury from reflection of light off the dressing surface. Vac­
uum suction is useless at capturing tissue splatter because it
leaves the surface of the skin far too rapidly.
All makeup and sunscreen should be removed from the
area to be treated, as these products will prevent transmission
of light to the skin surface. Furthermore, many of these prod­
ucts contain metal-based salts and oxides (such as titanium
dioxide) that may ignite following exposure to Q-switched
laser pulses.
Anesthesia
The need for anesthesia when treating pigmented lesions
and tattoos depends on the location and size of the lesion as
well as the pain threshold of the patient. The sensation of a
­laser pulse at low fluences has been likened to a rubber band
snapping against the skin surface. The higher fluences used in
the treatment of dermal pigmented lesions such as nevus of
Ota or tattoos produce more discomfort and are more likely
to require some type of anesthesia. When limited areas are
treated, such as small tattoos or scattered lentigines, many pa­
tients require no anesthesia at all. For the treatment of larger
tattoos or pigmented lesions, one or more of the following
­anesthetic techniques may be required: topical anesthesia (e.g.
LMX-5 cream), local infiltration of lidocaine with or without
epinephrine, regional nerve block, or oral or intramuscular
sedation. In many children and rarely in adults, intravenous
sedation or general anesthesia may be necessary. Following
treatment, the use of ice packs is helpful to reduce postopera­
tive discomfort and swelling.
Patient evaluation
A general medical history should be obtained prior to treat­
ment, including information on wound healing, any bleeding
diatheses, or history of infectious diseases, particularly hepatitis
and HIV infection. Although there have been no cases of trans­
mission, the presence of HIV proviral DNA has been demon­
strated in the laser plume generated by carbon dioxide laser
irradiation of HIV-infected tissue culture.118 Patients with a his­
tory of isotretinoin use within the previous 6 months or history
of hypertrophic scarring should be treated with caution because
they may have a higher risk of scarring after laser treatment.
Fig. 12-13  Test spot showing darkening (black) of red and flesh
colored tattoo that contained ferric oxide and was converted to
­ferrous oxide following treatment with a Q-switched laser.
• Some treatment areas may require topical or
local anesthesia to increase patient comfort.
• Intravenous and general anesthesia is rarely
needed for adult patients.
Pearls
• A good general medical history is important to
attain before any procedure.
• Correct diagnosis of any pigmented lesion prior
to treatment is mandatory.
• Appropriate patient expectations are very
­important to instill before treatment begins.
Pearls

170
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
Before treating any pigmented lesion, it is imperative to cor­
rectly diagnose the lesion in question. A pretreatment biopsy
should be performed if there is any question of atypia in a pig­
mented lesion or if the diagnosis is at all unsure. Once the cor­
rect diagnosis has been established, the appropriate ­laser can be
selected based on the probable depth of pigment in the skin (i.e.
epidermal versus dermal), its type, and the way it is packaged.
Many patients are ill-informed and harbor unrealistic expec­
tations about the benefits of laser surgery. Patients should be
fully informed of what to expect from each treatment and the
potential side and adverse effects. Patients undergoing laser
tattoo removal should understand that it will take multiple
treatments and that the lesion may not clear entirely.
Procedural techniques
Epidermal pigmented lesions
Technique
Anesthesia is generally not required for treatment of ­epidermal
lesions. When needed, a topical anesthetic may be sufficient
(e.g. LMX-5 applied at least 1 hour beforehand). Infiltration
of lidocaine into the skin, although effective in providing
anesthesia, often causes as much discomfort as the treatment
itself.
The Q-switched laser should always be calibrated prior to
treatment. The laser handpiece should be held perpendicular
to the skin with the attached plastic cone or guide resting on
the skin to ensure that the laser beam is focused on the area to
be treated. Exact parameters vary depending on the particular
laser, the patient’s Fitzpatrick skin type, and the type of lesion
(Table 12-3). In general, lower fluence is used for dark lesions
that contain larger amounts of absorbing chromophore. One
or two laser pulses should be fired at the lesion to ensure that
a threshold response occurs, which is defined as immediate
whitening of the lesion (Fig. 12-14). The optimal tissue end
point is uniform but faint immediate whitening without epi­
dermal disruption. The lowest fluence required to invoke this
response should be used.
If the fluence is too low, the whitening will be barely per­
ceptible. If the fluence is too high, whitening is bright white
and solid, and epidermal damage with bleeding may occur.
When fluences less than threshold are used, hyperpigmenta­
tion due to stimulation of melanogenesis can result. Use of
excessive fluences may cause tissue sloughing, prolonged heal­
ing, and a greater likelihood of postinflammatory hyperpig­
mentation or hypopigmentation or textural changes. After the
optimal fluence is determined, pulses can be delivered rapidly
(up to 10 Hz, depending on the laser), with overlapping of
about 10% to ensure confluent whitening.
Patients with darker skin (phototypes IV and V) should
be treated with caution at lower fluences, since their thresh­
old response will likely occur at lower fluences than patients
with lighter skin. Patients with ‘suntans’ should not be treated
because they are at risk of spotty hypopigmentation, which
can last for weeks to months after treatment.
In most cases, additional treatment sessions may be safely
performed 6 weeks after the original treatment. While some
pigmented lesions (e.g. lentigines) may require only one to two
treatments, other lesions (e.g. café au lait macules) may need
multiple treatments.
Epidermal pigmented lesions can also be treated with
­millisecond-domain lasers and intense pulsed light devices.
The clinical end point of treatment with these devices
is ­ significantly different from that seen after Q-switched
laser treatment. One should expect to see a slight immedi­
ate ­darkening of ­lentigines, although lighter lentigines may
remain unchanged. A faint erythema may also be observed
at the edge of darker lentigines. After treatment, pigmented
lesions are expected to develop a slight microcrust which peels
away over the course of a few days. Active skin cooling is
used during treatment with most IPL devices to protect the
­epidermis from excessive thermal injury. Multiple treatment
sessions with IPL are ­typically required for optimal clearing
of epidermal pigmented lesions. Lighter lentigines which con­
tain less of the melanin chromophore may be more resistant
to IPL treatment and may respond better to Q-switched laser
treatment.
The large rectangular spot size of IPL devices lends itself
best to treatment of larger areas (e.g. for pan-facial photore­
juvenation). Treatment of individual lesions such as lentigines
is more problematic, as the large spot size results in ­significant
overlap of normal skin. The spot size can be effectively shrunk­
en by utilizing a flat template device which contains holes of
various sizes that can be matched to the size of the lesion
and will physically block the remainder of the light. This is a
suboptimal approach, as the template is ­cumbersome to use
and negates the efficacy of contact cooling. For this reason,
Q-switched lasers have a distinct advantage over IPL ­devices
for treating individual lesions.
• Anesthesia is generally not required for
­treatment of epidermal pigmented lesions.
• The skin should be cleaned of all makeup prior
to treatment.
• An appropriate laser or light device is chosen
and calibrated.
• Optimal tissue end point when using a
Q-switched laser is uniform but faint immediate
whitening without epidermal disruption.
• The lowest fluence required to invoke this
­response should be used.
• Optimal tissue end point when using a
­millisecond mode laser or intense pulsed light
device is slight lesional darkening
• Do not treat patients with a tan.
Pearls

171
Lasers in the treatment of pigmented lesions  •  Chapter 12
Postoperative changes
The white tissue response that develops immediately after
Q-switched laser treatment fades within 20 minutes. An
­urticarial reaction, causing erythema, edema, itching, and
stinging, may develop in and around the treated area.
This may last for several hours and can be treated, but not
­prevented, by taking an antihistamine preoperatively. The
treated area generally appears darker for several days before
developing a crust that falls off in 7–10 days, depending on the
site and aggressiveness of treatment. Following treatment with
Table 12-3  Standard treatment parameters for pigmented lesions and tattoos
Lesion
Laser
Spot size
(mm)
Fluence
(J/cm2)
Retreatment interval
Lentigines
QS ruby
QS Nd:YAG (532 nm)
QS alexandrite
Pulsed dye (510 nm)
6.5
3
4
3
2.0–4.0
0.7–1.0
3.5–5.5
2.5
4–8 weeks
Café au lait macules
QS ruby
QS Nd:YAG (532 nm)
QS alexandrite
Pulsed dye (510 nm)
6.5
3
4
5
3.0– 4.5
1.0–1.5
2.5–4.5
2.0–3.5
4–8 weeks
Becker’s nevus
QS ruby
QS Nd:YAG (532 nm)
QS Nd:YAG (1064 nm)
QS alexandrite
6.5
3
3
4
3.0–4.5
1.5–1.8
4.0–5.0
3.5–5.0
4–8 weeks
Nevus spilus
QS ruby
QS Nd:YAG (532 nm)
QS Nd:YAG (1064 nm)
QS alexandrite
6.5
3
3
3
3.0–4.5
1.5–2.0
4.0–4.4
5.0–6.0
4–8 weeks
Nevus of Ota
QS ruby
QS Nd:YAG (1064 nm)
QS alexandrite
6.5
3
3
5.0–6.0
4.0–7.0
5.5–6.5
6–12 weeks
Tattoos
QS ruby
QS Nd:YAG (532 nm)
QS Nd:YAG (1064 nm)
QS alexandrite
Pulsed dye (510 nm)
5
6.5
6
3
4
3
3–5
7.0–10.0
3.0–6.0
3.0–4.0
4.0–7.0
3.0–5.5
6.0–6.5
2.5–3.5
6–12 weeks
A
B
Fig. 12-14  Appearance of lentigo (A) before and (B) immediately following treatment with a Q-switched Nd:YAG laser. Note whitening of pigment.

172
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
the Q-switched 532 nm Nd:YAG or 510 nm pulsed dye lasers,
purpura usually develops after skin whitening has faded. This
occurs because, in addition to being absorbed by melanin,
these wavelengths are well absorbed by hemoglobin, caus­
ing rupture of blood vessels. Purpura persists for 5–10 days,
and its occurrence is a distinct disadvantage of treatment
with the above devices. The occurrence of purpura can be
minimized by treating through a microscope slide held in firm
contact with the skin to compress blood vessels and remove
­hemoglobin from the skin.
Postoperative care
Postoperative discomfort may be treated with application of
cold water-soaked gauze, ice packs, or a hydro-occlusive dress­
ing such as Second Skin or Vigilon. Analgesics are usually not
needed. Antihistamines may be given if the patient has an
urticarial reaction. Patients should be instructed to gently
wash the treated area with mild soap and apply an occlusive
ointment (e.g. Aquaphor Healing Ointment) twice a day. Any
crusting should be allowed to slough spontaneously. In order
to minimize the risk of hyperpigmentation, patients should
avoid excessive sun exposure and use a broad-spectrum sun­
screen of SPF 30 or higher for at least several months after
treatment.
Dermal pigmented lesion
Technique
Anesthesia is rarely required for small lesions. For larger le­
sions, use of topical anesthetics, local infiltration of lidocaine,
or regional nerve blocks may be required. In the treatment of
nevus of Ota, nerve blocks plus supplemental infiltration of
lidocaine usually provides excellent anesthesia. Nerve blocks
are performed with 1% or 2% lidocaine with 1:100 000 or
1:200 000 epinephrine. The forehead may be anesthetized by
blocking the supraorbital and supratrochlear nerves, ­branches
of the ophthalmic division of the trigeminal nerve. The supra­
orbital nerve exits from the supraorbital notch, located in
the midpupillary line in the supraorbital ridge, while the supra­
trochlear nerve exits from the supratrochlear notch at the
medial edge of the eyebrow. The lower eyelid, medial cheek,
upper lip, and part of the medial nose may be anesthetized
by blocking the infraorbital nerve, which exits in the midpu­
pillary line just below the infraorbital ridge. Although infraor­
bital blocks can be performed transcutaneously, it is preferable
to inject through the mouth after numbing the buccal mucosa
with topical benzocaine or tetracaine. For local tissue infil­
tration, especially around the eyes, a mixture of equal parts
of 2% lidocaine with 1:100 000 epinephrine and 0.5% bupi­
vacaine, plus 75 U of hyaluronidase (Wydase), provides effec­
tive and long-lasting anesthesia. The hyaluronidase facilitates
tissue diffusion of anesthetic.
The laser should always be calibrated prior to treatment.
Actual treatment technique is similar to that used for treatment
of epidermal lesions, with the handpiece held perpendicular
to the skin, the protective cone held flush with the skin sur­
face, and pulses delivered with approximately 10% overlap.
Exact parameters vary depending on type of lesion, choice of
laser, and patient skin phototype (see Table 12-3). In general,
dermal lesions require higher fluences than epidermal lesions.
Given the increased depth of penetration, larger spot sizes are
preferred to smaller ones. To achieve the same effect in the
dermis, a larger spot size will require lower energy and there­
fore be more gentle on the epidermis and dermal–epidermal
junction. Treatment should start with just one or two laser
pulses fired onto the lesion to ensure that the threshold ­whitening
response occurs. An end point of uniform whitening of the irra­
diated site is desirable. The lowest fluence required to invoke
this response should be used. Use of subthreshold fluences may
result in poor efficacy and postinflammatory hyperpigmenta­
tion. Suprathreshold fluences may produce excessive ­epidermal
injury and bleeding, resulting in increased patient discomfort
and prolonged wound healing, as well as an increased risk of
postoperative pigmentary and textural change.
Lower fluences should be used in the treatment of patients
with darker skin types, since the threshold response will
likely occur at a lower fluence. Patients with darker skin are at
greater risk for postoperative hyperpigmentation or hypopig­
mentation. It may be preferable to utilize a longer wavelength
device, such as the 1064 nm Nd:YAG laser, since longer wave­
lengths penetrate more deeply than shorter wavelengths and
produce relatively less epidermal damage for the same dermal
effect.
• Anesthesia is rarely required for treatment of
smaller dermal pigmented lesions but may be
required for larger ones.
• The skin should be cleaned of all makeup prior
to treatment.
• An appropriate laser or light device is chosen
and calibrated.
• Optimal tissue end point when using a
Q-switched laser is uniform but faint ­immediate
whitening without epidermal disruption or
­significant pin-point bleeding.
• The lowest fluence required to invoke this
­response should be used.
• Larger spot sizes and lower fluences are
preferred over smaller spot sizes and higher
­fluences.
• The handpiece should be held perpendicular
to the skin and the pulses should have minimal
overlap.
• Clear hydrogel dressings may be applied over
tattoos to act as a heat sink and to protect
against splatter.
• Millisecond-mode lasers or intense pulsed light
devices are not optimally set up for treatment
of tattoos.
• Do not treat patients with a tan.
Pearls

173
Lasers in the treatment of pigmented lesions  •  Chapter 12
In general, dermal pigmented lesions require multiple
treatment sessions for maximal clearing. Treatment is usually
performed at 6–8 week intervals or longer to give the tissue
adequate time to fully recover. Lesions such as nevus of Ota
will continue to gradually lighten for several months after each
treatment session.
Postoperative changes
Because dermal lesions typically require the use of higher flu­
ences, postoperative changes are more apparent. The whit­
ening response that occurs immediately after treatment fades
within 20 minutes. Erythema and swelling are usually seen
in the immediate postoperative period, especially in the peri­
orbital area of the face. The amount of crusting that occurs
depends on the aggressiveness of treatment. Treated areas will
generally appear darker for up to 10 days until the superficial
scale/crust sloughs. Overly aggressive treatment may result in
vesiculation or frank blistering. The risk of blistering is highest
when shorter wavelength devices (e.g. QSRL) are used to treat
patients with dark skin phototypes.
Postoperative care
Ice packs, cold water-soaked gauze, or hydro-occlusive dress­
ings (e.g. Second Skin, Vigilon) help reduce immediate post­
operative discomfort and swelling. Patients should wash the
treated area gently and apply an occlusive ointment (e.g.
­Aquaphor Healing Ointment) at least twice a day. Analgesics
more potent than acetaminophen are rarely required. To
­reduce the risk of hyperpigmentation, patients should avoid
excessive sun exposure and wear a broad-spectrum sunscreen
for at least several months after treatment.
Tattoos
Technique patients must be counseled appropriately based on
tattoo type (amateur or professional), color, ink density, age,
body location, and patient skin phototype. In appropriately
selected tattoos (e.g. blue or black amateur tattoos), dramatic
lightening can generally be achieved. On the other hand,
patients with multicolored, intensely pigmented, professional
tattoos should be informed that 100% clearing of pigment
is unlikely. Tattoo treatment typically requires multiple treat­
ment sessions for maximal lightening. Traditional treatment
modalities such as excision or CW carbon dioxide laser may
be less costly in time and expense because fewer treatment
sessions are required,119 but only Q-switched lasers offer the
potential for tattoo clearing without scarring. Preoperative
photographs should be taken to provide objective evidence
of treatment response. Patients with cosmetic tattoos should
be informed of the risk of immediate pigment darkening and
only treated with Q-switched lasers with extreme caution.
These cosmetic tattoos may be approached with nonselective
resurfacing lasers such as the Er:YAG or CO2.
Anesthesia is often not required for small tattoos, but larger
tattoos usually require the use of topical anesthetics or local
infiltration of lidocaine. For infiltrating lidocaine, a 30-gauge
needle should be used to minimize patient discomfort. Use of
a 1-inch needle permits infiltration of anesthetic into large
areas via a fanning motion, minimizing the number of needle
insertions into the skin. Nerve blocks can be used when the
tattoo is located in an appropriate location.
Treatment technique is similar to that outlined for treat­
ment of dermal lesions. The laser handpiece should be held
perpendicular to the skin and pulses delivered in a slightly
overlapping manner to avoid leaving untreated fragments of
tattoo. Exact parameters vary based on tattoo color, ink den­
sity, laser chosen, and patient skin phototype (see Table 12-3).
Generally, high-energy fluences and larger spot sizes are
required for the optimal removal of tattoos. The desired clini­
cal end point is immediate, bright tissue whitening. At the start
of treatment, one or two laser pulses should be fired at the
tattoo to determine the tissue response, with fluence adjusted
accordingly. The presence of significant epidermal disruption
or bleeding indicates use of excessive fluence, although pin­
point bleeding is acceptable with the 1064 nm Nd:YAG laser.
In general, lower fluence is used for dark tattoos that contain
large amounts of absorbing chromophore. In subsequent
treatment sessions, the fluence may need to be increased as
the amount of pigmentation decreases. Hydrocolloid dress­
ings such as Vigilon or Second Skin may be placed over tattoos
to decrease back-splatter of tissue and to act as heat sink and
provide some epidermal protection (Fig. 12-15). The hydro­
colloid dressings do reflect some laser light and an increase
of approximately 0.5 J/cm2 will be required to achieve the
same effect on the tattoo. Fluences should be decreased when
treating patients with darker skin phototypes, since the thresh­
old for skin whitening is lower. The 1064 nm Nd:YAG laser
is the treatment of choice for blue or black tattoos in darkly
pigmented patients, since its longer wavelength largely spares
epidermal melanocytes.120
Multicolored tattoos require the use of multiple-wavelength
devices. When switching between lasers, extreme caution is
required to ensure that correct goggles are worn. If adequate
energy is available from the laser, it is best to use the largest
spot size because it promotes deeper penetration of light and
shortens the treatment time. Treatment sessions should be per­
formed at intervals of 6–8 weeks or longer to allow the sur­
rounding skin to fully recover. Some patients will notice that
the tattoo ink continues to lighten for several months following
treatment.
Postoperative changes
Skin whitening fades within 20 minutes of treatment. Some
erythema and swelling usually develop around the tattoo, al­
though edema is generally insignificant unless the periorbital
area or an extended area is treated. Patients can expect a sur­
face crust that falls off within 10–14 days. True vesiculation is
not uncommon for the first day or two after treatment, partic­
ularly when shorter-wavelength devices are used (e.g. QSRL).
In the vast majority of cases, tattoos heal without permanent
alteration in skin texture.

174
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
Postoperative care
Postoperative stinging, which usually lasts less than 6 hours,
may be treated with ice packs, cold water-soaked gauze, or hy­
dro-occlusive dressings (e.g. Second Skin, Vigilon). If swelling
develops, keep the area elevated. Wash the treated site gen­
tly with mild soap and cover with an occlusive ointment (e.g.
Aquaphor Healing Ointment or bacitracin) at least twice a
day. Any crusting should be allowed to slough spontaneously.
Alternatively, oxygen-permeable dressings (e.g. Opsite, Tega­
derm) can be used for several days to promote moist wound
healing. Acetaminophen is generally sufficient to control post­
operative discomfort. Patients should avoid sun exposure in
the postoperative period because resultant hyperpigmentation
will interfere with subsequent treatment sessions and raise the
risk of hypopigmentation.
Complications
Although Q-switched lasers are far safer than traditional
treatment modalities, treatment is not without risk. In gen­
eral, because treatment of dermal lesions and tattoos is more
­aggressive, it is associated with a higher risk of side effects than
treatment of epidermal lesions. The most common side effect
is the occurrence of pigmentary change. ­Hyperpigmentation
is commonly seen in patients with darker skin phototypes but
almost always resolves with time. Use of topical hydroquinone
creams may help speed resolution. Patients at risk for hyper­
pigmentation should avoid sun exposure and use a UVA/UVB
sunblock of SPF 30 or higher for at least several months after
treatment. Transient hypopigmentation is also common, but
true depigmentation is extremely rare. The risk of hypopig­
mentation is wavelength dependent, with shorter-wavelength
devices such as the QSRL posing higher risk due to greater
injury to epidermal melanocytes.
The risk of scarring with pigment-specific lasers is ­extremely
low. When appropriate parameters are used, the risk of scar­
ring from treatment of epidermal lesions is negligible. In the
treatment of tattoos, the risk is reported to be less than 5%.94
Scarring is associated with the use of excessive fluences or very
small spot sizes that cause a greater degree of tissue damage.
Tattoos located on the chest, deltoid, or ankle, as well as those
with dense deposits of ink (e.g. ‘double tattoos’), have a higher
risk of scarring.121 The act of tattooing may itself produce
subtle textural change that remains unnoticed by the patient
until after the pigment has cleared. Preoperative photographs
provide essential documentation.
REFERENCES
  1. Goldman L, Blaney DJ, Kindel DJ, et al. Effect of the laser beam on
the skin: preliminary report. J Invest Dermatol 1963; 40:121–122.
  2. Goldman L, Wilson RG, Hornby P, et al. Radiation from a
Q-switched ruby laser: effect of repeated impacts of power output of
10 megawatts on a tattoo of man. J Invest Dermatol 1965; 44:69–71.
  3. Ohshiro T, Maruyama Y. The ruby and argon lasers in the treatment
of naevi. Ann Acad Med 1983; 12:388–395.
  4. Dover JS, Smoller BR, Stein RS, et al. Low-fluence carbon dioxide
laser irradiation of lentigines. Arch Dermatol 1988; 124:1219–1224.
  5. Anderson RR, Parrish JA. Selective photothermolysis: precise
microsurgery by selective absorption of pulsed radiation. Science
1983; 220:524–527.
  6. Anderson RR, Parrish JA. The optics of human skin. J Invest
Dermatol 1981; 77:13–19.
  7. Polla LL, Margolis RJ, Dover JS, et al. Melanosomes are a primary
target of Q-switched ruby laser irradiation in guinea pig skin. J Invest
Dermatol 1987; 89:281–286.
  8. Hodersdal M, Bech-Thomsen N, Wulf HC. Skin reflectance-guided
laser selections for treatment of decorative tattoos. Arch Dermatol
1996; 132:403–407.
  9. Taylor CR, Anderson RR, Gange RW, et al. Light and electron
microscopic analysis of tattoos treated by Q-switched ruby laser.
J Invest Dermatol 1991; 97:131–136.
10. Ross EV, Naseef G, Lin C, et al. Comparison of responses of tattoos
to picosecond and nanosecond Q-switched neodymium:YAG lasers.
Arch Dermatol 1998; 134:167–171.
11. Levins PC, Anderson RR. Q-switched ruby laser for the treatment of
pigmented lesions and tattoos. Clin Dermatol 1995; 13:75–79.
12. Murphy GF, Shepard RS, Paul BS, et al. Organelle-specific injury to
melanin-containing cells in human skin by pulsed laser irradiation. Lab
Invest 1983; 49:680–685.
13. Sherwood KA, Murray S, Kurban AK, et al. Effect of wavelength on
cutaneous pigment using pulsed irradiation. J Invest Dermatol 1989;
92:717–720.
Fig. 12-15  The use of a hydrocolloid dressing over a tattoo to
decrease splatter and act as a modest cooling agent by minimizing
differences in index of refraction. The hydrocolloid dressing may be
taped in place following the treatment as a dressing.
• Pigmentary change is the most common side
effect of treatment.
• Patients with darker skin types are at a higher
risk for hyperpigmentation and may benefit from
pre- and postoperative use of hydroquinones
and sun avoidance.
• Pigmented lesions should be treated with the
lowest fluence that will effect the desired tissue
change (whitening).
• Using a larger spot size allows a lower fluence
to be used to achieve the same tissue effect.
• The chest, deltoid area, and ankle have the
­highest risk of complications.
Pearls

175
Lasers in the treatment of pigmented lesions  •  Chapter 12
14. Margolis RJ, Dover JS, Polla LL, et al. Visible action spectrum for
melanin-specific selective photothermolysis. Lasers Surg Med 1989;
9:389–397.
15. Anderson RR, Margolis RJ, Watenabe S, et al. Selective
photothermolysis of cutaneous pigmentation by Q-switched Nd:YAG
laser pulses at 1064, 532, and 355 nm. J Invest Dermatol 1989;
93: 28–32.
16. Ara G, Anderson RR, Mandel KG, et al. Irradiation of pigmented
melanoma cells with high-intensity pulsed radiation generates acoustic
waves and kills cells. Lasers Surg Med 1990; 10:52–59.
17. Dover JS, Margolis RJ, Polla LL, et al. Pigmented guinea pig skin
irradiated with Q-switched ruby laser pulses. Arch Dermatol 1989;
125:43–49.
18. Kossida T, Farinelli W, Flotte T, et al. Mechanism of immediate
whitening during tattoo removal. Lasers Surg Med 2006; 18:70.
19. Hruza GJ, Dover JS, Flotte TJ, et al. Q-switched ruby laser irradiation
of normal human skin. Arch Dermatol 1991; 127:1799–1805.
20. Nakamura Y, Hossain M, Hirayama K, et al. A clinical study on the
removal of gingival melanin pigmentation with the CO2 laser. Lasers
Surg Med 1999; 25:140–147.
21. Ross EV, Ladin Z, Kreindel M, et al. Theoretical considerations in
laser hair removal. Dermatol Clin 1999; 17:333–355.
22. Kono T, Manstein D, Chan HH. Q-switched ruby versus long-pulsed
dye laser delivered with compression for treatment of facial lentigines
in Asians. Lasers Surg Med 2006; 38(2):94–97.
23. Ueda S, Imayama S. Normal-mode ruby laser for treating congenital
nevi. Arch Dermatol 1997; 133:355–359.
24. Taylor CR, Anderson RR. Treatment of benign pigmented epidermal
lesions by Q-switched ruby laser. Int J Dermatol 1993; 32:908–912.
25. Tse Y, Levine VJ, McClain SA, et al. The removal of cutaneous
pigmented lesions with the Q-switched ruby laser and the Q-switched
neodymium:yttrium-aluminum-garnet laser. J Dermatol Surg Oncol
1994; 20:795–800.
26. Kilmer SL, Wheeland RG, Goldberg DJ, et al. Treatment of
epidermal pigmented lesions with the frequency-doubled Q-switched
Nd:YAG laser. Arch Dermatol 1994; 130:1515–1519.
27. Fitzpatrick RE, Goldman MP, Ruiz-Esparza J. Laser treatment of
benign pigmented epidermal lesions using a 300 nsecond pulse and
510 nm wavelength. J Dermatol Surg Oncol 1993; 18:341–347.
28. Watanabe S, Ttakahashi H. Treatment of nevus of Ota with the
Q-switched ruby laser. N Engl J Med 1994; 331:1745–1750.
29. Alster TS, Williams CM. Treatment of nevus of Ota by the
Q-switched alexandrite laser. Dermatol Surg 1995; 21:592–596.
30. Ashinoff R, Geronemus RG. Q-switched ruby laser treatment of labial
lentigos. J Am Acad Dermatol 1992; 27:809–811.
31. Gupta G, MacKay IR, MacKie RM. Q-switched ruby laser in the
treatment of labial melanotic macules. Lasers Surg Med 1999; 25:219–222.
32. Yung-Tsai L, Kao-Chia Y. Comparison of the frequency-doubled
Q-switched Nd:YAG laser and 35% trichloroacetic acid for the
treatment of face lentigines. Dermatol Surg 1999; 25:202–204.
33. Todd M, Rallis T, Hata T. A comparison of three lasers and liquid
nitrogen in the treatment of solar lentigines: a randomized, controlled,
comparative trial. Arch Dermatol 2000; 50:536–540.
34. Miranda C, Narurkar VA. Photoneumatic therapy for pigmented
lesions and photorejuvenation of neck, chest and extremities. Lasers
Surg Med 2006; 18:17.
35. Grossman MC, Anderson RR, Farinelli W, et al. Treatment of cafe au
lait macules with lasers: a clinicopathologic correlation. Arch Dermatol
1995; 131:1416–1420.
36. Alster TS. Complete elimination of large cafe-au-lait birthmarks by
the 510-nm pulsed dye laser. Plast Reconstr Surg 1995; 96:1660.
37. Alora MB, Arndt KA. Treatment of a cafe-au-lait macule with the
erbium:YAG laser. J Am Acad Dermatol 2001; 45:566–568.
38. Goldberg DJ. Benign pigmented lesions of the skin. J Dermatol Surg
Oncol 1993; 19:376–379.
39. Rosio TJ. Techniques for tattoo removal. In: Wheeland RG, ed.
Cutaneous surgery. Philadelphia: WB Saunders; 1994:982–997.
40. Kobayashi T. Microsurgical treatment of nevus of Ota. J Dermatol
Surg Oncol 1991; 17:936–941.
41. Clabaugh WA. Tattoo removal by superficial dermabrasion: five-year
experience. Plast Reconstr Surg 1975; 55:401–405.
42. Koerber WA, Price NM. Salabrasion of tattoos: a correlation of the
clinical and histological results. Arch Dermatol 1978; 114:884–888.
43. Dvir E, Hirshowitz B. Tattoo removal by cryosurgery. Plast Reconstr
Surg 1980; 66:373–378.
44. Cosman B, Apfelberg DB, Drucker D. An effective cosmetic treatment
for Ota’s nevus. Ann Plast Surg 1989; 22:36–42.
45. Reid R, Muller S. Tattoo removal by CO2 laser dermabrasion. Plast
Reconstr Surg 1980; 65:717–728.
46. Hidano A, Kajama H, Ikeda S, et al. Natural history of nevus of Ota.
Arch Dermatol 1967; 95:187–195.
47. Jay B. Malignant melanoma of the orbit in a case of oculodermal
melanocytosis (nevus of Ota). Br J Ophthalmol 1965; 49:359.
48. Watanabe S, Takahashi H. Treatment of nevus of Ota with the
Q-switched ruby laser. N Engl J Med 1994; 331:1745–1750.
49. Geronemus RG. Q-switched ruby laser therapy of nevus of Ota. Arch
Dermatol 1992; 128:1618–1622.
50. Lowe NJ, Wieder JM, Sawcer D, et al. Nevus of Ota: treatment
with high-energy fluences of the Q-switched ruby laser. J Am Acad
Dermatol 1993; 29:997–1001.
51. Taylor CR, Flotte TJ, Gange W, et al. Treatment of nevus of Ota by
Q-switched ruby laser. J Am Acad Dermatol 1994; 30:743–751.
52. Chang CJ, Nelson JS, Achauer BM. Q-switched ruby laser treatment
of oculodermal melanosis (nevus of Ota). Plast Reconstr Surg 1996;
98:784–790.
53. Alster TS, Williams CM. Treatment of nevus of Ota by the
Q-switched alexandrite laser. Dermatol Surg 1995; 21:592–596.
54. Manuskiatte W, Sivayathorn A, Leelaudomlipi P, et al. Treatment of
acquired bilateral nevua of Ota-like macules (Hori’s nevus) using a
combination of scanned carbon dioxide laser followed by Q-switched
ruby laser. J Am Acad Dermatol 2003; 48(4):584–591.
55. van Leeuwen RL, Dekker SW, Byers HR, et al. Modulation of α4β1
and α5β1 integrin expression: heterogenous effects of Q-switched ruby,
Nd:YAG, and alexandrite lasers on melanoma cells in vitro. Lasers
Surg Med 1996; 18:63–71.
56. Chan HH, K Xiang L, Leung et al. In vitro study examining the effect
of sub-lethal QS 755 nm lasers on the expression of p161nk4a on
melanoma cell lines. Lasers Surg Med 2003; 32(2):88–93.
57. Dummer R, Kempf W, Burg G. Pseudo-melanoma after laser therapy.
Dermatology 1998; 197:71–73.
58. Grevelink JM, van Leeuwen RL, Anderson RR, et al. Clinical and
histological responses of congenital melanocytic nevi after single
treatment with Q-switched lasers. Arch Dermatol 1997; 133:349–353.
59. Waldorf HA, Kauvar ANB, Geronemus RG. Treatment of small
and medium congenital nevi with the Q-switched ruby laser. Arch
Dermatol 1996; 132:301–304.
60. Goldberg DJ, Zeichner JA, Hodulik SG, et al. Q-switched laser
irradiation of pigmented nevi: analysis of markers for malignant
transformation. Lasers Surg Med 2006; 18:18.
61. Vibhagool C, Byers R, Grevelink JM. Treatment of small
nevomelanocytic nevi with a Q-switched ruby laser. J Am Acad
Dermatol 1997; 36:738–741.
62. Rosenbach A, Williams CM, Alster TS. Comparison of the
Q-switched alexandrite (755 nm) and Q-switched Nd:YAG (1064 nm)
lasers in the treatment of benign melanocytic nevi. Dermatol Surg
1997; 23:239–245.
63. Duke D, Byers R, Sober AJ, et al. Treatment of benign and atypical
nevi with the normal-mode ruby laser and the Q-switched ruby
laser: clinical improvement but failure to completely eliminate
nevomelanocytes. Arch Dermatol 1999; 135:290–296.
64. Milgraum SS, Cohen ME, Auletta MJ. Treatment of blue nevi with
the Q-switched ruby laser. J Am Acad Dermatol 1995; 32:307–310.
65. Baba M, Bal N. Efficacy and safety of the short-pulse erbium:YAG
laser in the treatment of acquired melanocytic nevi. Dermatol Surg
2006; 32:256–260.
66. Imayama S, Ueda S. Long- and short-term histological observations
of congenital nevi treated with the normal-mode ruby laser. Arch
Dermatol 1999; 135:1211–1218.

176
Chapter 12
C�����������������������������������������
Cosmetic surgery procedures and techniques
67. Tse Y, Levine VJ, McClain SA, et al. The removal of cutaneous
pigmented lesions with the Q-switched ruby laser and the Q-switiched
neodyminum:yttrium-aluminum-garnet laser. J Dermatol Sug Oncol
1994; 20:795–800.
68. Arndt KA. Argon laser treatment of lentigo maligna. J Am Acad
Dermatol 1984; 10:953–957.
69. Kopera D. Treatment of lentigo maligna with the carbon dioxide laser.
Arch Dermatol 1995; 131:735–736.
70. Thissen M, Westerhof W. Lentigo maligna treated with ruby laser.
Acta Derm Venereol 1997; 77:163.
71. Arndt KA. New pigmented macule appearing 4 years after argon laser
treatment of lentigo maligna. J Am Acad Dermatol 1986; 14:1092.
72. Lee PK, Rosenberg CN, Tsao H, et al. Failure of Q-switched ruby
laser to eradicate atypical-appearing solar lentigo: report of two cases.
J Am Acad Dermatol 1998; 38:314–317.
73. Taylor CR, Anderson RR. Ineffective treatment of refractory melasma
and postinflammatory hyperpigmentation by Q-switched ruby laser.
J Dermatol Surg Oncol 1994; 20:592–597.
74. Nouri K, Bowes L, Chartier T, et al. Combination treatment of
melasma with pulsed CO2 laser followed by Q-switched alexandrite
laser: a pilot study. Dermatol Surg 1999; 25:494–497.
75. Manaloto RMP, Alster T. Erbium:YAG laser resurfacing for refractory
melasma. Dermatol Surg 1999; 25:121–123.
76. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with
fractional photothermolysis: a pilot study. Dermatol Surg 2005;
32:1645–1650.
77. Lowe NJ, Wieder JM, Shorr N, et al. Infraorbital pigmented skin: prelimi­
nary observations of laser therapy. Dermatol Surg 1995; 21:767–770.
78. West TB, Alster TS. Improvement of infraorbital hyperpigmentation
following carbon dioxide laser resurfacing. Dermatol Surg 1998;
24:615–616.
79. Manuskiatti W, Fitzpatrick RE, Goldman MP. Red ink tattoo
reactions: successful treatment with the Q-switched 532  nm Nd:YAG
laser. Dermatol Surg 2000; 26(2):113–120.
80. Dwyer CM, Cuddihy AM, Kerr REI, et al. Skin pigmentation due
to minocycline treatment of facial dermatoses. Br J Dermatol 1993;
129:158–162.
81. Argenyi ZB, Finelli L, Bergfeld WF, et al. Minocycline-related
cutaneous hyperpigmentation as demonstrated by light microscopy,
electron microscopy and X-ray energy spectroscopy. J Cutan Pathol
1987; 14:176–180.
82. Collins P, Cotterill JA. Minocycline-induced pigmentation resolves
after treatment with the Q-switched ruby laser. Br J Dermatol 1996;
135:317–319.
83. Knoell KA, Milgraum SS, Kutenplon M. Q-switched ruby laser
treatment of minocycline-induced cutaneous hyperpigmentation. Arch
Dermatol 1996; 132:1251–1253.
84. Tsao H, Dover JS. Treatment of minocycline-induced
hyperpigmentation with the Q-switched ruby laser. Arch Dermatol
1996; 132:1250–1251.
85. Wilde JL, English JC, Finley EM. Minocycline-induced
hyperpigmentation: treatment with the neodymium:YAG laser. Arch
Dermatol 1997; 133:1344–1346.
86. Greve B, Schonermark MP, Raulin C. Minocycline-induced
hyperpigmentation: treatment with the Q-switched Nd:YAG laser.
Lasers Surg Med 1998; 22:223–227.
87. Karrer S, Hohenleutner U, Szeimies RM, et al. Amiodarone-induced
pigmentation resolves after treatment with the Q-switched ruby laser.
Arch Dermatol 1999; 135:251–253.
88. Atkins DH, Fitzpatrick RE. Laser treatment of imipramine-induced
hyperpigmentation. J AM Acad Dermatol 2000; 43(1):77–80.
89. Trotter MJ, Tron VA, Hollingdale J, et al. Localized chrysiasis induced
by laser therapy. Arch Dermatol 1995; 131:1411–1414.
90. Yun PK, Arndt KA, Anderson RR. Q-switched laser-induced
chrysiasis treated with long-pulsed laser Arch Dermatol 2002:
138:1012–1014.
91. Tope WD. State and territorial regulation of tattooing in the United
States. J Am Acad Dermatol 1995; 32:791–799.
92. Lea PJ, Pawlowski A. Human tattoo: electron microscopic assessment
of epidermis, epidermal–dermal junction, and dermis. Int J Dermatol
1987; 26:453–458.
93. Sperry K. Tattoos and tattooing, part II: gross pathology,
histopathology, medical complications, and applications. Am J Foren
Med Pathol 1992; 13:7–17.
94. Kilmer SL, Anderson RR. Clinical use of the Q-switched ruby and
the Q-switched Nd:YAG (1064 nm and 532 nm) lasers for treatment of
tattoos. J Dermatol Surg Oncol 1993; 19:330–338.
95. Reid WH, Miller ID, Murphy MJ, et al. Q-switched ruby laser
treatment of tattoos: a 9-year experience. Br J Plast Surg 1990;
43:663–669.
96. Scheibner A, Kenny G, White W, et al. A superior method of tattoo
removal using the Q-switched ruby laser. J Dermatol Surg Oncol 1990;
16:1091–1098.
97. Taylor CR, Gange RW, Dover JS, et al. Treatment of tattoos by
Q-switched ruby laser: a dose–response study. Arch Dermatol 1990;
126:893–899.
98. Fitzpatrick RE, Goldman MP. Tattoo removal using the alexandrite
laser. Arch Dermatol 1994; 130:1508–1514.
99. Stafford TJ, Lizek R, Tan OT. Role of the alexandrite laser for
removal of tattoos. Lasers Surg Med 1995; 17:32–38.
100. Alster TS. Q-switched alexandrite laser treatment (755  nm) of
professional and amateur tattoos. J Am Acad Dermatol 1995;
33:69–73.
101. Kilmer SL, Lee MS, Grevelink JM, et al. The Q-switched Nd:YAG
laser effectively treats tattoos: a controlled, dose–response study. Arch
Dermatol 1993; 129:971–978.
102. Grekin RC, Shelton RM, Geisse JK, et al. 510-nm pigmented lesion
dye laser: its characteristics and clinical uses. J Dermatol Surg Oncol
1993; 19:380–387.
103. Kauvar ANB, Bigelman J, Geronemus RG. In-vitro analysis of tattoo
pigment response to Q-switched and long-pulsed lasers. Lasers Surg
Med 1999; 11(suppl):31.
104. Ferguson JE, August PJ. Evaluation of the Nd:YAG laser for treatment
of amateur and professional tattoos. Br J Dermatol 1996; 135:
586–591.
105. Prinz BM, Vavricka SR, Graf P, et al. Efficacy of laser treatment
of tattoos using lasers emitting wavelengths of 532 nm, 755 nm and
1064 nm. Br J Dermatol 2004; 150:245–251.
106. Shawgo RS, Kundakovic L, Farinelli W, et al. In vivo evaluation of
pigments engineered for removal. Lasers Surg Med 2006; 18:18.
107. Zelickson BD, Mehregan DA, Zarrin AA, et al. Clinical, histologic,
and ultrastructural evaluation of tattoos treated with three laser
systems. Lasers Surg Med 1994; 15:364–372.
108. Levine VJ, Geronemus RG. Tattoo removal with the Q-switched ruby
laser and the Q-switched Nd:YAG laser: a comparative study. Cutis
1995; 55:291–296.
109. Goyal S, Arndt KA, Stern RS, et al. Laser treatment of tattoos: a
prospective, paired, comparison study of the Q-switched Nd:YAG
(1064 nm), frequency-doubled Q-switched Nd:YAG (532 nm), and
Q-switched ruby lasers. J Am Acad Dermatol 1997; 36:122–125.
110. Leuenberger ML, Mulas MW, Hata TR, et al. Comparison of the
Q-switched alexandrite, Nd:YAG, and ruby lasers in treating
blue-black tattoos. Dermatol Surg 1999; 25:10–14.
111. DeCoste SD, Anderson RR. Comparison of Q-switched ruby and
Q-switched Nd:YAG laser treatment of tattoos. Lasers Surg Med 1991;
3(suppl):64.
112. Ashinoff R, Levine VJ, Soter NA. Allergic reactions to tattoo pigment
after laser treatment. Dermatol Surg 1995; 21:291–294.
113. Kyanko ME, Pontasch MJ, Brodell RT. Red tattoo reactions: treat­
ment with the carbon dioxide laser. J Dermatol Surg Oncol 1989;
15:652–656.
114. Antony FC, Harland CC. Red ink tattoo reactions: successful
treatment with the Q-switched 532 nm Nd:YAG laser. Br J Dermatol
2003; 149(1):94–98.
115. Anderson RR, Geronemus R, Kilmer SL, et al. Cosmetic tattoo ink
darkening: a complication of Q-switched and pulsed-laser treatment.
Arch Dermatol 1993; 129:1010–1014.

177
Lasers in the treatment of pigmented lesions  •  Chapter 12
116. Kilmer S. Laser and lights. In: Goldberg DJ, ed. Procedures in
Cosmetic Surgery. 513–514.
117. Fitzpatrick RE, Lupton JR. Successful treatment of treatment-resistant
laser-induced pigment darkening of a cosmetic tattoo. Lasers Surg
Med 2000; 27(4):358–361.
118. Baggish MS, Poiesz BJ, Joret D, et al. Presence of human
immunodeficiency virus DNA in laser smoke. Lasers Surg Med 1991;
11:197–203.
119. Ort RJ, Arndt KA. Tattoos and their treatment: traditional treatments.
Med Surg Dermatol 1999; 6:1–5.
120. Grevelink JM, Duke D, van Leeuwen RL, et al. Laser treatment of
tattoos in darkly pigmented patients: efficacy and side effects. J Am
Acad Dermatol 1996; 34:653–656.
121. Alora MBT, Arndt KA, Taylor CR, Arch Dermatol. Scarring
following Q-switched laser treatment of ‘double tattoos.’ 2000;
136:269–270.

History and Science
Background and history
Modern culture has created unwritten standards for accept­
able levels of facial and body hair. In order to conform to
­society’s expectations, millions of individuals either hide ar­
eas of excessive hair or attempt to reduce the amount of vis­
ible hair. Traditional methods of hair removal have included
shaving, bleaching, plucking, waxing, use of chemical depila­
tories, and electrolysis. These techniques have been limited
by their pain, inconvenience, and poor long-term efficacy.
Only ­ electrolysis has offered the potential for permanent
hair removal, but the technique is tedious, highly operator
­dependent, and ­impractical for the treatment of large num­
bers of hairs. Recently, a number of lasers and other light
sources have been developed specifically to target hair follicles.
These devices offer the potential for rapid treatment of large
areas and long-lasting hair removal. Physicians and patients
alike have embraced this technology, although published stud­
ies assessing the permanency of hair removal have emerged
only recently. With the proliferation of devices targeting hair
and unsubstantiated claims by manufacturers, significant con­
fusion exists in this field. This chapter will attempt to clarify
laser and light hair removal by exploring hair follicle biology
as well as the scientific underpinnings of hair removal by
light before examining the attributes of specific laser systems.
A detailed discussion of treatment guidelines as well as pre­
operative and postoperative considerations follows.
Basic science
Anatomy and growth cycle of the hair follicle
The hair follicle consists of three regions in vertical ­sections:
the infundibulum, isthmus, and inferior segment (Fig. 13-1).
The infundibulum is the uppermost portion of the ­follicle, ex­
tending from the skin surface to the sebaceous duct entrance.
The isthmus is a short section that extends from the entrance of
the sebaceous duct to the insertion of the arrector pili muscle.
The inferior segment of the follicle lies below the arrector pili
muscle insertion and includes the hair bulb and dermal papilla.
The hair bulb represents an expansion of the lowermost por­
tion of the follicle during its growing, or anagen, phase. It is
made up of germinative matrix cells along with interspersed
melanocytes. The hair bulb surrounds a core of richly vascu­
larized connective tissue known as the dermal papilla.
Hair follicles show a cyclical pattern of growth, progress­
ing from the growing (anagen) phase to the resting (telogen)
Laser Hair Removal
Christine M. Choi,
Christine Dierickx, and
Jeffrey S. Dover
C H A P T E R
13
P a r t 2
Key Points
n Lasers and light sources offer safe and effective
long-term treatment of unwanted hair for individuals
with a variety of skin phototypes.
n Cooling methods are essential to protecting the
epidermis during laser hair removal.
n Longer wavelength lasers allow for safe treatment
of patients with darker skin types.
n An effective method of removing blonde, white, or
gray hairs remains a challenge and is an area of
active research.
n Proper patient selection and management of expec­
tations are keys to successful treatment encounters.

180
Chapter 13
Cosmetic surgery procedures and techniques
phase via the intermediary (catagen) phase (Fig. 13-2). During
anagen, matrix cells proliferate and move upward, giving rise
to the hair shaft and inner root sheath. Anagen follicles of
terminal hair extend deeply into the subcutaneous fat, lying
2–7 mm below the skin surface, depending on body site.1 Dur­
ing catagen, cell division and melanin production in the bulb
cease and the entire lower portion of the hair follicle under­
goes apoptosis.2 Only a thin cord of epithelial cells remains; it
shrinks and retracts upward to become the secondary germ.
The ensuing telogen phase represents a stage of follicular qui­
escence. When a new anagen phase begins, a burst of epithe­
lial cell division occurs near the insertion of the arrector pili
muscle and hair growth resumes as the secondary hair germ
grows downward to form a new bulb.
Initially, it was thought that follicular stem cells resided
within or near the matrix of the hair bulb.3,4 In mouse folli­
cles, however, a population of slow-cycling stem cells has been
found in a bulge coming off the outer root sheath.5 The bulge
is located at the site of attachment of the arrector pili muscle,
approximately 1 mm below the skin surface. This represents
the lower end of the ‘permanent’ portion of the hair follicle.5
Recently, follicular stem cells expressing cytokeratin 15 and β1
integrin have been identified. It is now believed that, during
late telogen or early anagen, the bulge stem cells are ­activated
by dermal papilla cells and proliferate briefly to form the
­epithelial downgrowth before returning to their ­ normally
dormant state.
The duration of anagen and telogen phases, as well as the
ratio of anagen to telogen hairs, depends on body location.
At any given time, about 84% of scalp hairs are in anagen
phase, 2% in catagen phase, and 14% in telogen phase.6 In
contrast, over 50% of leg or arm hair is in telogen at any
given time.7 Since duration of anagen is the primary deter­
minant of hair length, body sites with long hair have a pro­
longed anagen phase, whereas sites with shorter hair have a
shorter anagen phase and a somewhat longer telogen phase.
The anagen phase of scalp hair lasts up to 6 years, and the
telogen phase lasts about 3 months.1 In contrast, hairs on
other body sites such as the extremities or trunk have anagen
phases lasting from 1 to 6 months and telogen phases lasting
up to 9 months.1,7 This implies that long-lasting hair loss can
be achieved by any method of hair removal that can induce
telogen. To assess permanency of hair removal, it is necessary
to follow patients for at least the duration of one complete
hair cycle.
Hair color is dependent upon the type and amount of mel­
anin within the hair shaft. Melanin is produced by melano­
cytes within the bulb, which transfer melanin granules to
matrix cells. Melanin production occurs only during anagen,
as melanocytes within the bulb degenerate during catagen.
Follicular melanocytes produce two distinct types of melanin,
eumelanin and pheomelanin. Dark hair contains abundant,
heavily melanized eumelanin granules while red hair contains
primarily pheomelanin granules. In gray hair, melanocytes
show degenerative changes such as vacuolization and poorly
melanized melanosomes, while in white hair melanocytes are
greatly reduced in number or absent.8
The diameter and length of hair is variable, ranging from
fine, nonpigmented vellus hairs to coarse terminal hairs. Hair
shaft diameter is determined by the size of the dermal papilla
and hair bulb.9 In cross-section, the diameter of the bulb from
terminal hairs varies from 200 to 300 μm,1 while the diameter
of terminal hair shafts ranges from 40 to 120 μm.10 Vellus hair
is arbitrarily defined as having a cross-sectional diameter of
30 μm or less.11 The type of hair produced by a given follicle
can change, as evidenced by the follicular miniaturization that
occurs in androgenetic alopecia. In individuals with ­excessive
hair, it is generally the terminal hairs that are of cosmetic
­concern.
Causes of excessive hair
Unwanted hair falls into four main categories. Each one of
them can be a reason for seeking a method for hair removal.
Hypertrichosis is defined as an increase in hair growth
that is not androgen dependent. It may result from intake of
Infundibulum of the
sebaceous gland
Arrector pili muscle
The bulge
Hair shaft
Hair bulb
Matrix cells
Follicular
papilla
Fibrous tract
Inner root
sheath layer
Outer root
sheath layer
Fig. 13-1  Hair follicle anatomy. (From McDaniel DH, Lord J, Ash K,
et al. Laser hair removal: a review and report on the use of the long-
pulsed alexandrite laser for hair reduction of the upper lip, leg, back,
and bikini region. Dermatol Surg 1999; 25:426–430.)
Early aragen
Aragen
Catagen
Telogen
Papilla
Papilla
Papilla
Papilla
Fig. 13-2  The hair growth cycle. (From McDaniel DH, Lord J,
Ash K, et al. Laser hair removal: a review and report on the use of
the long-pulsed alexandrite laser for hair reduction of the upper lip,
leg, back, and bikini region. Dermatol Surg 1999; 25:426–430.)

181
Laser hair removal  •  Chapter 13
­certain medications such as phenytoin, ciclosporin, cortisone,
or penicillamine. It has also been seen in a variety of diseases
such as porphyria cutanea tarda, thyroid disorders, metastatic
carcinoma, and malnutrition/anorexia nervosa.
Hirsutism is characterized by the growth of terminal hair in
women on androgen-dependent areas of the body such as the
upper lip, chin, or chest. Often the result of androgen excess,
hirsutism may be accompanied by acne, androgenetic alo­
pecia, and acanthosis nigricans. The most common hormonal
cause of hirsutism is polycystic ovary disease, estimated to
­occur in 1–4% of the female population of reproductive age.
Rapid onset of hirsutism or other signs of androgen excess
should prompt a hormonal evaluation, including levels of free
testosterone and dehydroepiandrosterone-sulfate (DHEA-S),
to rule out the presence of an androgen-secreting neoplasm.
Hair-bearing flaps, used for reconstruction of any kind, may
contain unwanted hair that interferes with proper function. Epi­
lation of hair-bearing flaps before surgery is therefore indicated.
For example, myocutaneous flaps used in urethral reconstruc­
tion may cause urinary obstruction, calcification, or infection.
Most individuals seek consultation for unwanted hair pri­
marily because of cosmetic concerns. Facial or body hair in
excess of the cultural norm can be very distressing to some
patients. The most common areas treated include the axil­
lae, bikini line, legs, and face in women, and the chest, back,
shoulder, neck, and ears in men.
Traditional treatment methods
Many different methods have been used to treat unwanted
hair, including shaving, plucking, waxing, bleaching, and the
use of chemical depilatories.12 Although shaving is effective,
simple, and inexpensive, it is a frequent chore that is unaccept­
able to many women with facial hair. Hair removal by pluck­
ing and waxing can last up to several months but ­treatment
is painful and may be complicated by hyperpigmentation,
ingrown hairs, folliculitis, or scarring. Chemical depilatories
most commonly contain thioglycolates mixed with either
NaOH or CaOH and dissolve hair structure by hydrolyzing
disulfide bonds. Although they can provide results that last up
to 2 weeks by dissolving part of the hair shaft below the skin
surface, they are messy and commonly cause irritant dermati­
tis.13 Antiandrogenic medications such as oral contraceptives,
spironolactone, cyproterone acetate, and flutamide may pro­
vide modest improvement of hirsutism. However, results are
temporary as treatment is suppressive rather than curative,14
and undesirable side effects are not uncommon.
Until recently, electrolysis was the only method capable of
producing permanent hair removal. There are several types of
electrolysis, although all utilize a needle to carry current deep
into the follicle. In galvanic electrolysis, direct electric cur­
rent acts on tissue saline to produce sodium hydroxide, which
chemically destroys the follicle. In contrast, thermolysis passes
a high-frequency alternating current down the needle to ther­
mally destroy the follicle.15 Although it is generally accepted
that electrolysis can provide permanent hair removal, there is
little scientific data on which to base efficacy.13 Potential side
effects include pain, hyperpigmentation, hypopigmentation,
and scarring. Both efficacy and side effects are highly operator
dependent. The technique is most useful for epilation of a few
stubborn hairs but is impractical for the treatment of large
areas or large amounts of excessive hair.
Basic mechanisms of laser hair removal
Historically, it was assumed that the hair shaft was produced
by rapidly dividing matrix stem cells located in the deepest
portion of the hair follicle, 2–7 mm below the skin surface.
However, recent evidence suggests that follicular stem cells are
located in the outer root sheath, in an area called the bulge,
near the attachment of the arrector pili muscle, approximately
1.5 mm below the epidermis.5 Thus, both bulge and bulb are
important targets for permanent hair follicle destruction.
There are three ways light can potentially destroy hair ­follicles:
thermal (due to local heating), mechanical (due to shockwaves
or violent cavitation), and photochemical (due to generation of
toxic mediators like singlet oxygen or free radicals). All of these
methods have been studied for hair ­removal (Box 1).
Photothermal destruction
Photothermal destruction is based on the principle of selective
photothermolysis. This principle predicts that selective ther­
mal damage of a pigmented target structure will result when
sufficient fluence at a wavelength, preferentially absorbed by
the target, is delivered during a time equal to or less than the
thermal relaxation time of the target.
The normal-mode 694 nm ruby, normal-mode 755 nm
­alexandrite, 800 nm pulsed diode lasers, long-pulsed 1064 nm
Nd:YAG lasers, and filtered flashlamp technology, alone or in
combination with electrical energy from radiofrequency, all
employ this mechanism.
In the visible to near-infrared region, melanin is the natural
chromophore for targeting hair follicles. Lasers or light sources
that operate in the red or near-infrared wavelength ­region lie
Box 13.1  Methods for hair removal
I Photothermal destruction
• Normal mode ruby lasers (694 nm)
• Normal mode alexandrite lasers (755 nm)
• Pulsed diode laser (800 nm)
• Long pulsed Nd: YAG lasers (1064 nm)
• Intense pulsed light source (590–1200 nm)
II Photomechanical destruction
• Carbon suspension – Q-switched Nd:YAG laser
• Q-switched Nd:YAG lasers
III Photochemical destruction
• Photodynamic therapy
From Dierickx CC, Grossman MC. Laser hair removal. In: Dover JS,
Goldberg DJ, eds. Laser and lights, Volume 2. ­Philadelphia: Elsevier
Saunders, 2005:63.

182
Chapter 13
Cosmetic surgery procedures and techniques
in an optical window of the spectrum where ­selective absorp­
tion by melanin is combined with deep penetration into the
dermis. Deep, selective heating of the hair shaft, hair follicle
epithelium, and the heavily pigmented matrix is therefore pos­
sible in the 600–1100 nm region. However, melanin in the epi­
dermis presents a competing site for absorption. ­Selective cool­
ing of the epidermis has been shown to minimize ­epidermal
injury. Cooling can be achieved by various means, including
a cooled gel layer, a cooled glass chamber or cooled sapphire
window, and a pulsed cryogen spray.
Laser pulse width also appears to play an important role, as
suggested by thermal transfer theory. Thermal conduction dur­
ing the laser pulse heats a region around each ­microscopic site
of optical energy absorption. To obtain spatial ­confinement
of thermal damage, the pulse duration should be shorter or
equal to the thermal relaxation time of the hair follicle. Ther­
mal relaxation of human terminal hair follicles has never been
measured, but is estimated to be about 10–50 ms, depending
on size. Devices for hair removal therefore have pulse dura­
tions in the millisecond domain region.
Sometimes, the actual target is not pigmented and is at
some distance from a pigmented structure: for example, the
follicular stem cells, which line the outer root sheath. These
cells are not pigmented and reside at some distance from the
pigmented hair shaft and appear to be an important target for
permanent hair destruction. The concept of thermal damage
time (TDT) has therefore been proposed in the case of the
hair follicle. Pulses longer than the thermal relaxation time of
the hair shaft allow propagation of the thermal damage front
through the entire volume and better damage of the follicu­
lar stem cells. Super-long pulse heating (>100 ms) appears to
­allow for long-term hair removal.
Photomechanical destruction
Photomechanical destruction due to small local ‘explosions’
results from Q-switched laser pulses. The spatial scale of ther­
mal confinement and resulting thermal or thermomechanical
damage is strongly related to laser pulse width. Q-switched
­(nanosecond domain) laser pulses effectively damage indi­
vidual pigmented cells within hair follicles by confinement of
heat at the spatial level of melanosomes leading in animals to
leukotrichia but not to hair loss after Q-switched ruby laser
­pulses. Consistent with this behavior, temporary hair loss with
an absence of permanent hair loss has been reported in hu­
mans after Q-switched laser treatments, despite a decade of
using Q-switched ruby and Nd:YAG lasers widely for tattoo
removal.
Photomechanical destruction of hair has been attempted
by the so called ‘Softlight’ technique. The method uses a pro­
prietary suspension of carbon particles applied to the skin,
with relatively low energies (2–3 J/cm2) of Q-switched Nd:
YAG laser light (1064 nm, 10 Hz, 10  ns pulse duration, 7 mm
spot size). Higher-powered, 1064 nm Q-switched Nd:YAG
­lasers have also been studied for laser hair removal. However,
when these very short pulses are used to target hair follicles,
there is an extremely rapid heating of the chromophore
­(melanin). This generates photoacoustic shock waves that
cause focal photomechanical disruption of the melanocytes in
the bulb but incomplete follicular disruption.
Photochemical destruction
Photodynamic therapy is the use of light and a photosen­
sitizer to produce a targeted photochemical reaction and
­therapeutic effect. Aminolevulinic acid (ALA) is a precursor
in the ­porphyrin synthesis and is rapidly and selectively con­
verted to protoporphyrin IX (PPIX) by cells derived from the
epidermis and follicular epithelium. Upon absorption of a
photon, PPIX efficiently crosses into an excited triplet state,
which in turn generates singlet oxygen by collision with ground
state oxygen. Singlet oxygen is a potent oxidizer that damages
cell ­membranes and protein. This is a so-called ­photodynamic
­reaction. A host of other porphyrins, chlorins, ­phthalocyanines,
purpurins, and phenothiazine dyes can act as photodynamic
agents and are under development as drugs for photodynamic
therapy. It is likely that ALA or one of these other drugs will
prove useful for hair removal. This approach will potentially
provide an effective means of treating nonpigmented hair.
Animal studies have shown that the hair growth cycle ­affects
the hair follicle destruction by ruby laser pulses: actively grow­
ing and pigmented anagen-stage hair follicles were sensitive to
hair removal by normal-mode ruby laser exposure, whereas
catagen- and telogen-stage hair follicles were resistant to laser
irradiation.16 However, in humans, the efficacy of laser hair
removal does not appear to always be influenced by the hair
growth cycle. Unlike the animal model, there is enough mela­
nin present in each growth cycle of the human hair follicle to
obtain selective damage to the hair.17
A recent study showed no acute changes in the immunohis­
tochemical staining properties of hair follicles treated with an
800 nm diode laser or a 1064  nm Nd:YAG laser. These find­
ings challenge the widely accepted belief that the mechanisms
of laser hair removal are mediated by frank destruction of fol­
licular stem cells. Instead, functional alterations of these cells
may lead to the desired clinical outcomes.18
Cooling
Melanin within the overlying epidermis functions as a com­
peting absorber for laser light. The risk of epidermal injury
increases with increasing skin pigmentation, whether consti­
tutive or the result of a ‘tan.’ Various methods can be used
to protect the epidermis from thermal damage, including
longer pulse duration and longer wavelength. An alternative
is to externally cool the skin surface either before, during, or
after the laser pulse. The simplest, least expensive, and least
effective method of skin cooling is to apply ice or refriger­
ated aqueous gel to the skin. A more sophisticated method is
to utilize conductive contact cooling by circulating cold water
(2–6°C) through a glass housing or sapphire window placed
on the skin surface. Sapphire has a higher thermal conductiv­
ity than glass, providing more rapid extraction of heat from

183
Laser hair removal  •  Chapter 13
the skin. When a 0°C sapphire window is applied for 0.5 s to
the skin, the temperature of the basal layer drops 20°C.1 Sap­
phire also provides index matching with the stratum corneum,
optimizing coupling of laser light into the skin and decreasing
backscattered light into the epidermis. In addition, when the
glass or sapphire window is pressed into the skin with moder­
ate pressure, the dermis is compacted, decreasing the relative
depth of the bulb and bulge by up to 30% relative to the skin
surface.1 The Cryo 6 (Zimmer Elektromedizin, Germany) is
a device that uses a forced flow of chilled air as the cooling
medium and is licensed to several laser light companies. The
efficacy of this device relative to glass or ­ sapphire window
cooling has not been evaluated. Theoretically, air cooling is
less optimal because air is a good insulator with a thermal
conductivity of only 1/50 that of sapphire.1
An alternative technique utilizes evaporative cooling
by ­ delivering a cryogen spray just prior to the laser pulse.
­Because evaporative cooling is more efficient than conductive
cooling, larger temperature gradients can be created between
epidermis and dermis, with less risk of inadvertent dermal
cooling.1 The commercially available device (dynamic cooling
device or DCD, Candela Corporation, Wayland, MA) utilizes
tetrafluoroethane as the cryogen. The duration of the cryogen
spray and the time interval between the spray and the laser
pulse can be programmed by the operator. A longer spray
­duration provides a greater degree of cooling. The time delay
between cryogen spray and laser pulse must be long enough to
allow complete evaporation of cryogen, because any cryogen
remaining on the skin surface will tend to disperse incident
laser light. Cryogen is a consumable that must be purchased
and replaced periodically.
Clinical comparisons of cooling methods have not yet
been reported. However, it is clear that all of them provide
some protection against epidermal injury in pigmented skin
and that actively cooled sapphire and cryogen spray cooling is
more protective than passive methods.
A different approach that does not actively chill the skin
is pneumatic skin flattening (PSF) technology. PSF technol­
ogy uses a vacuum to generate negative pressure on the skin’s
­surface in order to flatten it against a transparent sapphire win­
dow. By applying pressure on nerves and expelling blood from
the treatment area, PSF is purported to decrease acute pain
and post- treatment erythema and edema. It does not appear
to decrease, and may even enhance, hair removal ­efficacy.19
Specific laser systems
The FDA initially used electrolysis as a benchmark to evalu­
ate laser treatment efficacy, despite the lack of scientific data
on electrolysis. To receive FDA clearance, lasers must demon­
strate a 30% decrease in hair growth 3 months after a single
treatment.20 This criterion clearly does not equate with per­
manent hair loss, because the duration of telogen can easily
exceed 3 months. A more functional definition of permanent
hair removal has been proposed, based on the cyclic growth
phases for hair follicles. Permanent hair loss can be defined as
a significant reduction in the number of terminal hairs, which
is stable for a period longer than the complete growth cycle of
hair follicles at a given body site.21
A summary of laser and light source hair removal devices
is presented in Table 13-1. This table is not meant to be all-
inclusive; rather, it should be used as a broad survey of various
hair removal devices that may or may not be commercially
available at the time of publication. We advise contacting the
device companies directly to obtain the most updated product
information possible.
Endogenous Chromophore
694 nm ruby lasers
Because of high melanin absorption at 694 nm, the ruby
­lasers are best indicated in light-skinned (Fitzpatrick skin type
I–III) individuals with dark hairs. Because of this limitation,
their high power consumption, and relatively slow repetition
rate, ruby lasers have become less popular for laser hair
­removal over the years.
Of the original normal-mode 694 nm ruby lasers, only two
are still commercially available for hair removal: the RubyStar
and the Sinon. The RubyStar (Asclepion, Jena, Germany)
and the Sinon ruby laser (Wavelight; Erlangen, Germany) are
dual-mode ruby lasers. They can operate in the conventional
Q-switched mode for the treatment of tattoos and pigmented
lesions and in the normal mode for hair removal. An inte­
grated cooling device consisting of a cooled contact handpiece
for the RubyStar or cold-air cooling for the Sinon precools the
skin prior to laser pulse delivery.
755 nm alexandrite lasers
Long-pulsed alexandrite lasers (755 nm) are effective devices
for hair removal. At this longer wavelength, the ratio of energy
deposited in the dermis to the epidermis is greater because of
greater depth of penetration. The risk for epidermal damage
in darker skin types is therefore reduced. Various different al­
exandrite lasers are available. These include Elite (Cynosure,
Chelmsford, MA, USA), GentleLASE (Candela, Wayland,
MA, USA), Ultrawave II-III (Adept Medical, Rancho ­Santa
Margarita, CA, USA), and Epicare (LightAge, Somerset,
NJ, USA).
The Elite laser combines 755 nm and 1064 nm wave­
lengths. A cooling handpiece (SmartCool) allows a continuous
flow of chilled air to the treatment area. GentleLASE ­employs
a ­ dynamic cooling device (DCD) to protect the epidermis.
This DCD cooling method uses short (5–100 ms) cryogen
spurts, delivered on the skin surface through an electronically
controlled solenoid valve; the quantity of cryogen delivered
is proportional to the spurt duration. The liquid cryogen
droplets strike the hot skin surface and undergo evaporation.
Skin temperature is reduced as a result of supplying heat for
vaporization. This cooling method allows for fast and ­selective

184
Chapter 13
Cosmetic surgery procedures and techniques
Table 13-1  Laser and light source technology*
Light source
Wavelength
(nm)
System
name
Pulse
duration
Fluence
(J/cm2)
Spot size
(mm)
Repetition
rate
Other
features
Long-pulse
ruby
694
Ruby Star
(Asclepion)
4 ms
Up to 35
Up to 14
1 Hz
Dual mode
May also be
Q-switched
Sinon
(Wavelight)
4 ms
Up to 30
5,7,9
0.5–2 Hz
Cold air unit
May also be
Q-switched
Long-pulse
alexandrite
755
Elite 755/1064
(Cynosure)
Up to
300 ms
Up to 600
1.5–15
3/5 Hz
Cold air or
integrated
cooling
GentleLASE
(Candela)
3 ms
10–100
6,8,10,12,15,18
Up to 1.5 Hz
Dynamic
cooling
device
Ultrawave
II/III(Adept
Medical)
5–50  ms
5–55
8,10,12
1–2  Hz
Available with
532 nm and/
or 1064 nm
Nd:YAG
Epicare LP/
LPX (LightAge)
3–300 ms
25–40/Up to
100
7,9,12,15
1–3 Hz
Arion
(WaveLight)
1–50 ms
5–70
6,8,10,12,14
Up to 5 Hz
Cold air unit.
60×65 mm
scanner
Diode laser
800
LightSheer
(Lumenis)
5–400  ms
10–100
9×9, 12×12
Up to 2 Hz
Cooling
handpiece
VariLite
532/940 nm
(Iridex)
5–100 ms
<950/<900
0.7–2.8
Up to 4  Hz
Cooling
handpiece
HR- Force
(Alderm)
<1000 ms
<200
8, 8×24, 24×24
0.3– 100 Hz
Scanner
Soprano
(Alma)
<1350 ms
<120
10×12
Up to 3 Hz
Cold air
MeDioStar
808/940 nm
(Asclepion)
<500 ms
Up to 90 (170
with upgrade)
10,12, (4–14)
Up to 4 Hz
Contact
cooling
F1 Diode Laser
(Opusmed)
15–40 ms
10–40
5,7
4 Hz
MD30/60
Compact
808 nm
5–250 ms
300/600
1.8,4/ 1.8,6
Up to 3 Hz
Cold air
eLaser
810 mn/ RF
(Syneron)
<100 ms
<50/<50 RF
12×15
Up to 2 Hz
Contact
cooling
Q-switched
Nd:YAG
1064
Softlight
(Telsar)
12–18 ns
2.5–3
7
Up to 10 Hz
532/1064
Q-YAG 5
­(Palomar)
3±1 ns
Up to 12.5
Up to 10 Hz
532/1064
MedLite C6
(Hoya/ConBio)
<20 ns
Up to 12
3,4,6,8
Up to 10 Hz

185
Laser hair removal  •  Chapter 13
Light source
Wavelength
(nm)
System
name
Pulse
duration
Fluence
(J/cm2)
Spot size
(mm)
Repetition
rate
Other
features
Long-pulsed
Nd:YAG
1064
CoolGlide
(Cutera)
0.1–300  ms
Up to 300
3,5,7,10
Up to 2 Hz
Contact
(copper)
precooling
Lyra i
(Iridex)
20–100  ms
5–900
1–5, 10
Up to 10 Hz
Contact
cooling Pho­
ton recycling
Available
with 532  nm
(Gemini)
Ultrawave
I/II/III (Adept
Medical)
5–100 ms
5–500
2,4,6,8,10,12
1–2 Hz
Available with
532 nm Nd:
YAG and/or
755 nm
alexandrite
GentleYAG
(Candela)
0.25–300 ms
Up to 600
1.5,3,6,8,10,
12,15,18
Up to 10 Hz
Cryogen
spray
optional
Varia
(CoolTouch)
0.3–500 ms
Up to 500
3–10
Pulsed cryo­
gen cooling
with Thermal
Quenching
Cynergy
595/1064 nm
(Cynosure)
<40/<600
<40/<300
3,5,7,10,12,15
Up to 2/5 Hz
Cold air or
integrated
cooling
Smartepil II
(Cynosure)
Up to 100 ms
16–200
2.5,4,5,7,10
6 Hz
Smart cool
scanner
Dualis (Fotona) 5–200 ms
Up to 600
2–10
Air cooling
Available
with 2940 nm
Profile (Sciton)
0.1–200 ms
Up to 400
Varies
Varies
­Combined
with
2940  nm/
1064 nm/
1319 nm/
410–
1400 nm
ClearScan S
(Sciton)
<200 ms
Up to 480
3,6,8
Up to 15 Hz
Contact cool­
ing, scanner
30×30
LightPod Neo
(Aerolase)
0.65– 1–5 ms
Up to 1274
6,8
Up to 1 Hz
Mydon C
(WaveLight)
5–90 ms
10–450
1.5,3,5,7,10
1–10 Hz
Contact or air
cooling
NaturaLase
LP (Focus
Medical)
0.5–100 ms
<400
4–12
Up to 4 Hz
Cold air
Table 13-1  Laser and light source technology*—cont’d
continued

186
Chapter 13
Cosmetic surgery procedures and techniques
Light source
Wavelength
(nm)
System
name
Pulse
duration
Fluence
(J/cm2)
Spot size
(mm)
Repetition
rate
Other
features
Intense pulsed
broadband
light source
560–1200
IPL Quantum
(Lumenis)
6-26 ms
15–45
8×34
0.5 Hz
Contact
cooling
570–1200
Elora
(­Lumenis)
<22
20×30
0.33 Hz
400–1200
PPx (Aesthera) 2 ms
<10
6×12, 10×20,
15×30
0.25 Hz
Pneumatic
system
410–1400
Nanno Light
(Sybaritic)
<30 ms
<40
8×40
0.33 Hz
Contact cool­
ing. Spectra
Quattro
­available
400–1200
SilkLight/ Ultra­
Silk (Adept)
5–40 ms
<49
13×25
0.5 Hz
Cool gel or
ice pack
600– 950
Ellipse (DDD)
0.2–50 ms
12–22
10×50
0.25 Hz
Dual mode
filtering
technique
450–1200
NaturaLight
(Focus)
<200 ms
Up to 35
10×40
NA
NA
500–1200
Estelux and
Starlux
(­Palomar)
10–100 ms
4–40
16×46
Up to 1 Hz
Fast cover­
age rate
Cool roller/
contact
­cooling
515–1000/
535–1200
OmniLight
FPL/ Nova­
Light FPL
(American
Medical
­Biocare)
2–500 ms
<90/<50
Varies
Up to 1 Hz
Contact
cooling
400–1200
Duet/ SkinSta­
tion (Radiancy)
10,35 ms
Up to 65
22×55
0.25 Hz
Light Heart
Energy
(LHE).
SpaTouch
Pro available
500–1200
Quadra Q4
Platinum
(Derma Med
USA)
Up to 110
Up to 20
27×34
0.5 Hz
Quad Pulsed
Light System
560–950
Cynergy PL
(Cynosure)
5–50
<30
10×21, 10×46,
18×46
1 Hz
Contact
cooling
630–1200
Clareon HR
(Novalis)
30,50,70
<45
14.5×33.5
1 Hz
630–1200
Solarus HR
20,40,60
<35
14.5×33.5
0.5 Hz
770–1100
Solera Opus
(Cutera)
NA
5–35
10×30
2 Hz
IPL+Nd:YAG
525–
1200/1064
StarLux
(­Palomar)
1–500/<100
Up to 70/<700 16×46/1.5,3,6,9
<2/<1 Hz
Contact
cooling
Table 13-1  Laser and light source technology*—cont’d

187
Laser hair removal  •  Chapter 13
­cooling of the epidermis. The Epicare laser has a cold air cool­
ing option and a Smartscreen software package that assists in
record keeping, protocols, and even practice management.
The UltraWave II and III offers the convenient combination
of 755 nm and 1064  nm wavelength in a single device and is
well suited for removing unwanted hair in all skin types.
800 nm diode lasers
An extremely high-powered (2900 W) diode laser (LightSheer,
Lumenis, Santa Clara, CA, USA) is a popular laser hair
­removal device. Long-term results suggest that the pulsed,
800 nm diode laser is very effective for removal of dark,
­terminal hair: permanent hair reduction can be obtained
in a significant ­ percentage of patients. This laser operates
at 800 nm, has pulse widths between 5 and 400 ms, a 12 ×
12 mm spot, a 2  Hz repetition rate, fluences between 10 and
100 J/cm2, and a patented contact cooling device (ChillTip).
Because of the longer wavelength, the active cooling, and the
longer pulse widths, darker skin types can be treated more
safely than with ruby and alexandrite lasers.
Various other diode lasers are available (see Table 13-1).
Q-switched 1064 nm Nd:YAG laser
A high-powered, 1064 nm Q-switched Nd:YAG laser (MedL­
ite 6, Hoya/ConBio, Fremont, CA, USA) is now available for
hair removal. This laser has a very short pulse duration in the
­nanosecond range, a 3–8 mm spot, a repetition rate of 10 Hz,
and fluences up to 12 J/cm2. The high repetition rate (10 Hz)
­delivers the laser pulses very rapidly and therefore larger ­
areas can easily be covered and operative time is significantly
shortened. The longer wavelength (1064 nm) makes it useful
for darker skin types. Although capable for inducing a growth
delay, it appears to be ineffective for long-term hair removal.
Long-pulsed 1064 nm Nd:YAG lasers
Several long-pulsed Nd:YAG lasers (1064 nm wavelength) that
deliver pulses in the millisecond domain are now available for
hair removal laser treatment on all skin types (see Table 13-1).
These lasers include Lyra i/ Gemini (Iridex Corporation,
Mountain View, CA, USA), CoolGlide (Cutera; ­Brisbane, CA,
USA), Ultrawave II-III (Adept Medical, Rancho Santa Marga­
rita, CA, USA), Profile (Sciton, Palo Alto, CA, USA), Cynergy
and SmartEpil II (Cynosure, Chelmsford, MA, USA), Dualis
(Fotona, Ljubljana, Slowenie), Varia ­ (CoolTouch, ­ Roseville,
CA, USA), Mydon (Wavelight, Erlangen, Germany), and
GentleYAG (Candela, Wayland, MA, USA).
The long-pulsed Nd:YAG lasers emit deeply penetrating
1064 nm wavelengths. The reduced melanin absorption at this
wavelength necessitates the need for high fluences in ­order to
adequately damage hair. However, the poor melanin absorp­
tion at this wavelength coupled with epidermal cooling device
makes the long-pulsed Nd:YAG laser a safer laser treatment
for darker skin types up to phototype VI. The Nd:YAG laser
is also often used for treatment of pseudofolliculitis barbae, a
skin condition commonly seen in darker skin types.
Pulsed, noncoherent broadband light sources
Many different intense-pulsed, non-laser light sources, emit­
ting noncoherent, multiwavelength light have also been used
for hair reduction (e.g. Lumenis One, Lumenis, Santa Clara,
Light source
Wavelength
(nm)
System
name
Pulse
duration
Fluence
(J/cm2)
Spot size
(mm)
Repetition
rate
Other
features
420–950/
Harmony
(Alma)
<50
5–20
16×40
0.3 Hz
Cool air
295–380/
<50/
100 800 mJ/
16×40
0.1 Hz
1064 LP, QS/
<60,30 ns
35–140,
0.4–1.0
3,6
0.3,10 Hz
1320
<50
15–30
1,6
0.3 Hz
515–1200/
Lumenis One
(Lumenis)
3–100 ms/
10–40/
8×15, 15×35/
1/2/1  Hz
Contact
cooling
800 nm/
5–400 ms/
10–100/
9×9/
1064 nm
2–20 ms
10–225
2×4,6,9
ELOS
technology
Optical energy
(680–980 nm)
combined
with electrical
energy radio­
frequency
eLight DS,
eMax (Syner­
on)
<25/<200 RF
Light energy
<45
RF energy
<25 J/cm2
12×25
0.7 Hz
Cooling
(5–20°C on
skin surface)
combined
with skin
impedance
control
*Modified from Table 4.2 in Dierickx CC, Grossman MC. Laser hair removal. In: Dover JS, Alam M, series eds; Goldberg DJ, ed. Laser and lights, vol. 2. Philadelphia:
Elsevier Saunders; 2005.
Table 13-1  Laser and light source technology*—cont’d

188
Chapter 13
Cosmetic surgery procedures and techniques
CA, USA; Ellipse, Danish Dermatologic Development,
­Hørsholm, Denmark). By placing appropriate filters on the
light source, wavelengths ranging from 590 to 1200  nm can
be generated. Cut-off filters are used to eliminate short wave­
lengths so that only the longer, more deeply penetrating wave­
lengths are emitted. Pulse durations vary in the millisecond
domain. A single or multiple pulse mode (2–5), with various
pulse delay intervals, can be chosen. The wide choice of wave­
lengths, pulse durations, and delay intervals makes this device
potentially effective for a wide range of skin types. The devices
come with software which guides the operator in determining
treatment parameters depending on the patient’s skin type,
hair color, and coarseness.
The newest emerging hair removal technologies are the
lower priced, small, pulsed light hair removal systems. These
include the SpaTouch photoepilation system (Radiancy,
Orangeburg, NY, USA), Cynergy PL (Cynosure, Chelmsford,
MA, USA), Quadra Q4 (DermaMed USA,Lenni, PA, USA),
and the Estelux (Palomar, Burlington, MA, USA). These sys­
tems have been optimized for hair removal with wavelengths
preferentially ­ absorbed by melanin, long pulse widths, and
large spot sizes.
Recently, IPL systems have been developed that are com­
bined with 1064 nm laser light (Lumenis One, Lumenis, Santa
Clara, CA, USA; Starlux, Palomar, Burlington, MA, USA;
Harmony, Alma, Fort Lauderdale, FL, USA). These devices
should allow for treatment of a wide spectrum of hair and
skin colors.
Electro-optical synergy (ELOS) technology
ELOS technology utilizes a synergy between electrical (con­
ducted radiofrequency [RF]) and optical (laser or light) ener­
gies. The electrical energy causes heat that is focused on the
hair follicle and the bulge area, while the optical energy heats
mainly the hair shaft. When combined, a uniform tempera­
ture distribution across the hair shaft and the follicle should be
obtained to achieve effective hair removal.
Based on this ELOS technology, Syneron (Yokneam Illit,
Israel) has developed the eMax, eLaser, and eLight systems.
All devices are equipped with cooling. The use of the RF
­energy should also allow for treatment of all skin types, since
this form of energy is not absorbed by epidermal melanin.
Exogenous chromophore
In persons with blonde, gray, or white hair, an effective per­
manent laser hair removal treatment is still lacking (Fig. 13-3).
Potentially, the exogenous chromophore approach could solve
this problem. Rather than targeting endogenous melanin, an
exogenous chromophore (such as dyes, photosensitizers, or
carbon particles) can be introduced into the hair follicle and
then irradiated with light of a wavelength that matches its ab­
sorption peak. The main problem is reliable penetration of
the chromophore into all depths of the hair follicle. Therefore,
the technique in its present form is apparently inadequate for
inducing permanent hair loss.
Carbon suspension-Q-switched Nd:YAG laser
In this method, an exogenous chromophore (carbon suspen­
sion) with a peak absorption in the near-infrared portion of
the spectrum is used in combination with a Q-switched Nd:
YAG laser. The Softlight system (Telsar, Wood River, IL, USA)
uses a proprietary suspension of 10 mm diameter carbon par­
ticles applied to wax-epilated skin. The skin, after being wiped
clean of the topical carbon material, is irradiated with rela­
tively low energies (2–3 J/cm2) of Q-switched Nd:YAG laser
light (1064 nm, 10 Hz, 10 ns pulse duration, 7  mm spot size).
However, the short pulse duration of the laser used in this
technique limits the extent of follicular damage. This tech­
nique successfully induces a delay in hair growth, but fails to
produce long-lasting hair removal.
Meladine
Alternatively, a dye other than carbon could be used, which
stains the viable follicular epithelium and absorbs red or near-
infrared wavelengths. The solution would be a chromophore
that is absorbed selectively by the hair follicle and provides a
temporary target for laser treatments. Meladine is a topical
melanin encased, phosphatidylcholine-based liposome solu­
tion which, when sprayed on the desired area, selectively de­
posits melanin directly into the hair follicle without staining
A
B
Fig. 13-3  Effective laser hair removal can be obtained for dark, pigmented hair, but not for white hair. (A) Before. (B) After.

189
Laser hair removal  •  Chapter 13
surrounding skin. The proprietary liposome molecules are
small enough to potentially penetrate the infundibulum. The
result should be temporarily melanin-rich follicles, which al­
lows patients with lighter hair colors to benefit from laser hair
removal.
Meladine received FDA clearance as an accessory to hair
removal lasers to treat nonpigmented hair in 2003. Although
European clinical studies showed that patients pretreated with
Meladine experienced permanent hair reduction, a study by
Tanzi and Alster22 using Meladine found growth delay, but
not permanent hair loss, in subjects treated.
Photodynamic therapy
Photodynamic therapy (PDT), which has been used prima­
rily for treatment of malignant skin tumors, involves the use
of a photosensitizer and light to produce therapeutic effects.
The mechanism of action is presumed to involve the genera­
tion of toxic reactive oxygen species, subsequent to the photo­
chemical activation of the photosensitizer by light. The recent
introduction of 5-aminolevulinic acid (5-ALA) as a topical
­photosensitizer has opened up a variety of potential thera­
peutic options.
In a small pilot study of 12 subjects, 5-ALA was applied
topically to hair-bearing skin after wax epilation. Test sites
were irradiated 3 hours later with 630 nm light from an ­argon
pumped tunable dye laser. At 6 months following a single
treatment, a dose-dependent decrease in hair regrowth was
observed, with the greatest loss (40%) occurring in areas that
received the highest doses of light (200 J/cm2). Temporary
­hyperpigmentation was the only adverse effect noted.23
Photodynamic therapy may be a useful approach for hair
removal. Since photosensitizers tend to localize in the follicu­
lar epithelium, photochemical destruction of all hair follicles,
no matter what hair color, could potentially be obtained. The
technique does not require a laser light source, making it
­potentially less costly than laser treatment. Long-term data
and large-scale studies are needed to determine the safety
and long-term efficacy of this modality.
Clinical studies
An evidence-based review of laser and light sources for hair
removal demonstrated partial short-term hair removal
­efficacy up to 6 months after treatment with the ruby, al­
exandrite, diode, and Nd:YAG lasers and IPL.24 Substantial
evidence for long-term hair removal beyond 6 months post-
treatment was found with the alexandrite and diode lasers,
while similar but less unequivocal data were found with the
ruby and Nd:YAG lasers. This systematic review also dem­
onstrated improved efficacy with repetitive treatments and a
low occurrence of side effects for all included laser and light
source systems.
Rao and Goldman25 compared the use of three differ­
ent laser systems (long-pulse 1064 nm Nd:YAG, long-pulse
755 nm alexandrite, long-pulse 810 nm diode) individually
and in rotation for axillary hair removal. Three treatments
were performed at 6–8-week intervals. At 3 month follow-up,
the alexandrite and diode laser showed similar results for ef­
ficacy, tolerability, and subject satisfaction. Rotational therapy
was not as effective as either of these alone, but was more
effective than the Nd:YAG system alone. In addition, the Nd:
YAG laser was the least tolerable during treatment. Overall,
only local transient side effects were seen.
Amin and Goldberg26 compared the efficacy of four differ­
ent hair removal lasers and light sources in the same individ­
ual. Ten subjects were treated twice in adjacent regions with
an IPL with a red filter, an IPL with a yellow filter, an 810 nm
diode laser, and a 755  nm alexandrite laser. At 6 months, there
was a significant 50% decrease in hair counts, with no statis­
tical difference in efficacy among the four different systems.
However, the cryogen spray-based alexandrite laser showed
the highest pain scores.
Discussion
The presence of unwanted hair continues to plague many
individuals for whom traditional methods of hair removal
remain unsatisfactory. Laser and flashlamp technology now
offers the potential for rapid, safe, and effective treatment of
unwanted hair for individuals with a variety of skin photo­
types. A growing number of published studies have confirmed
the long-term efficacy of laser and flashlamp treatment.
Long-term studies with follow-up durations beyond 2 years
post-treatment should be designed.
What lies beyond the horizon for laser/light hair removal?
The remaining challenge is to develop the means to effectively
eliminate light-colored hair. Furthermore, the increasing
­demand for at-home hair removal devices is certain to impact
the practice of laser hair removal by trained professionals as
well as drive regulatory change. Consumer safety is of utmost
importance. Finally, multifunctional devices that combine
both laser and light/radiofreqency energy for hair removal
and other diverse applications are likely to gain increasing
popularity. The rapid pace of technological advancement as
well as continued studies of hair follicle biology promise to
improve this field over the years to come.
Procedures and Techniques
Preoperative clinical considerations
Treatment approach
The numerous lasers and non-laser light sources available to­
day provide clinicians with multiple options. Several variables
need to be considered when determining whether or not laser
or light-assisted hair removal is appropriate for a particular
patient and which technique to use. These include a patient’s

190
Chapter 13
Cosmetic surgery procedures and techniques
hair color, hair type, hair density, skin color, hormonal factors,
and anatomic location. In order to determine the various criti­
cal factors for this procedure, the following general approach
is used:

• A history is taken for appropriate patient selection.

• A physical examination is performed to evaluate skin color
and skin condition, hair color, hair diameter, and hair density.

• Expected benefits and risks are discussed and informed
consent is obtained.

• Instructions are given to the patient concerning pretreat­
ment hair management and skin care.

• Treatment guidelines are determined by skin and hair
properties.

• Appropriate post-treatment care is provided.
Patient selection
Any individual wishing to have hair removed permanently
may be considered a candidate for laser hair removal. Hair can
be removed from children and adults alike from most areas
of the body. The individual’s skin type, hair color, and hair
coarseness will determine which device is the most appropri­
ate as well as predict response to treatment. The ideal candi­
date for laser hair removal is a patient who presents with dark,
coarse hair. Current techniques are not generally successful
in permanently removing white hairs or fine vellus hairs. Ad­
ditionally, due to increased risk for eye injury, patients should
not be treated within the orbital rim. The ideal patient has
­realistic expectations, normal endocrine status, with thick
dark hair and light skin tones.
While treatment can be safely performed with a shorter-
wavelength device (e.g. ruby laser) in fair-skinned patients, it is
preferable to use longer-wavelength devices in darker-skinned
­patients. Further epidermal protection is also afforded by uti­
lizing longer pulse durations and active cooling. Suntanned
­patients are advised to avoid treatment until skin tan has ­faded.
When obtaining a patient history, information that will
­enable the best result should be obtained (Box 2).
It is vital to discuss patient expectations, medications, his­
tory of scarring, local infections, previous hair removal strate­
gies, endocrine status, recent sun exposure, and the patient’s
habits (i.e. sports, hot tub use, etc.).
Patients with active cutaneous infections are not treated.
Perianal and perivaginal areas may be at increased risk for
infection and should be treated with caution. Patients with a
history of recurrent staphylococcal and herpes simplex infec­
tions are started on appropriate prophylaxis to diminish the
likelihood of an outbreak.
Although a history of keloids or hypertrophic scarring is
not an absolute contraindication to treatment, individuals
with these conditions are treated less aggressively. Although it
has been reported that laser treatment of individuals who are
taking isotretinoin is safe, the issue remains controversial.
Certain medications and hormonal imbalances may inhibit
permanent hair removal due to hair stimulation. Patients on
minoxidil, or with spouses who use this medication, should be
advised that hair removal attempts may be hindered by the
stimulating effects of this drug. Patients on hormonal therapy
or with underlying endocrine abnormalities are alerted to the
potential limitations of hair removal treatment.
There is a report of a patient whose arthritis was treated with
elemental gold, and who was found to have green skin ­ after
treatment with Q-switched Nd:YAG laser.27 It should also be
noted that subsequent laser treatments eventually ­improved her
cosmetic appearance. Thus, caution should be exercised when
treating patients who have known exposure to gold therapy.
Patients with skin diseases such as vitiligo and psoriasis
should be warned of the risk of koebnerization following laser
surgery. Clinically, this problem is rarely seen. In fact, there is
anecdotal evidence that use of long-pulsed lasers to remove
remaining pigmented skin in a patient with vitiligo was unsuc­
cessful after multiple attempts.
The Q-switched lasers should be avoided in the hair-
bearing areas that overlie tattoos.
A listing of previous hair removal treatment modalities
as well as response to these treatment modalities should be
­recorded at the time of the initial consultation. Finally, ­patients
should be carefully questioned on their onset of hair growth
and evaluated for unknown medical problems.
Box 13.2  Pertinent history for laser/pulsed light hair
removal
• Presence of conditions that may cause hypertrichosis:

Hormonal

Familial

Drug (i.e. corticosteroids, hormones, immunosuppressives
self or spousal use of minoxidil)

Tumor
• History of local or recurrent skin infection
• History of herpes simplex, especially perioral
• History of herpes genitalis, important when treating the
pubic or bikini area
• History or keloids/hypertrophic scarring
• History of koebnerizing skin disorders such as vitiligo
and psoriasis
• Previous treatment modalities—method, frequency,
and date of last treatment, as well as response
• Recent suntan or exposure to tanning or light cabinet
• Onset of hair regrowth (recent)
• Tattoos or nevi present
• Patient’s expectations
• Patient’s hobbies or habits which might interfere with
­treatment
• Present medications:

Photosensitizing medications

Accutane intake within the past year

Gold therapy
From Dierickx CC, Grossman MC. Laser hair removal. In: Dover JS,
Goldberg DJ, eds. Laser and lights, Volume 2. ­Philadelphia: Elsevier
Saunders, 2005:63.

191
Laser hair removal  •  Chapter 13
Major determinants
When seeing a patient for the first time, the individual’s skin
type, hair color, and hair coarseness are noted, because this
will determine which device is most suited as well as predict
response to treatment (Table 13-2). Location and density of
excess hair should also be taken into consideration.
Expected benefits and risks
Generally, the average number of hair removal treatments to
achieve a significant reduction of excess hair is between five
and seven treatments performed at 1–3 month intervals. Clin­
ical improvement includes absolute hair number reduction,
finer, lighter regrowing hair, and slower regrowth.
The concept of hair removal has recently been defined in
the following way. ‘Temporary hair loss’ is defined as a delay
in hair growth, which usually lasts for 1–3 months, consistent
with the induction of telogen. ‘Permanent hair reduction’ re­
fers to a significant reduction in the number of terminal hairs
after a given treatment, which is stable for a period of time
longer than the complete growth cycle of hair follicles at the
given body site. Recently, it has been suggested to add another
6 months to this post-treatment observation time, i.e. the time
it takes for damaged follicles to recover from the laser injury
and reenter a normal growth cycle.
A distinction needs also to be made between permanent
and complete hair loss. Complete hair loss refers to a lack of
regrowing hairs (i.e. a significant reduction in the number of
regrowing hairs to zero). Complete hair loss may be either
temporary or permanent. Laser treatment usually produces
complete but temporary hair loss for 1–3 months, followed by
partial but permanent hair loss.
The range of outcome can be summarized as:

• fewer hairs

• thinner hairs

• slower regrowing hairs

• lighter hairs.
Patients have different expectations of treatment (e.g.
temporary versus permanent, partial versus complete hair
removal). All responses are clinically significant and may be
separately desirable for different patients. Growth delay that
provides a few months of hairless skin is far more reliably
achieved than permanent hair loss. All laser systems have been
shown to temporarily reduce hair growth for all hair colors
(except white) and at all fluences. Blonde, red, or gray-haired
patients are unlikely to experience a permanent reduction, but
hair loss in these patients can be maintained by treatment at
approximately 1–3-month intervals.
Laser hair removal was cleared by the FDA in l996 and has
an excellent safety and efficacy profile. Complications are rare
if treatments are done carefully and with the patients’ skin
type in mind. The most common side effects are temporary
pigmentation changes.
Effectiveness for permanent hair reduction is strongly
­correlated with hair color and fluence. Long-term, controlled
hair counts indicate an average of 20–30% hair loss with each
treatment, indicating the need for multiple treatments to ob­
tain near-complete hair removal. Research also shows that in
the ideal patient with fair skin and dark hair, the probability
for long-term hair removal is about 80–89%, depending on
the device used (Fig. 13-4).
The maximum fluence tolerated is determined by the
­epidermal pigmentation. Fair-skinned, dark-haired patients
are most easily treated. Dark-skinned patients pose a greater
challenge. Any of the hair removal devices are safe and
­effective in light-skinned patients, while longer wavelengths
(near-infrared) and longer pulse durations have been shown
to treat darker skin types more safely when combined with
cooling devices. A Q-switched Nd:YAG laser, with or without
Table 13-2  Indications and expected efficacy for different hair removal devices*
Laser or light source
expected efficacy
Skin type
Hair color
Hair diameter
Normal-mode ruby. Long-term
hair removal
I–III
Dark to light brown
Fine and coarse
Normal-mode alexandrite.
Long-term hair removal
I–IV
Dark to light brown
Fine and coarse
Pulsed diode. Long-term hair
removal
I–IV
Dark to light brown
Coarse
Normal-mode Nd:YAG.
Long-term hair removal
I–VI
Dark to light brown
Coarse
Q-switched Nd:YAG. Temporary
hair removal
I–VI
Dark to light brown
Fine
Intense pulsed light. Long term
hair removal
I–VI
Dark to light brown
Coarse
*Modified from Table 4.1 in Dierickx CC, Grossman MC. Laser hair removal. In: Dover JS, Alam M, series eds; Goldberg DJ, ed. Laser and lights, vol. 2. Philadelphia:
Elsevier Saunders; 2005.

192
Chapter 13
Cosmetic surgery procedures and techniques
an external chromophore, has been shown to be very useful
for treatment of dark skin types but appears to be ineffec­
tive for permanent hair removal. For patients presenting with
­recent sun exposure, pretreatment with a bleaching agent,
sunscreen, and/or sun avoidance is recommended prior to
laser ­treatment.
The number of treatments needed to obtain the best results
for different anatomic sites is unknown. A rare patient can ob­
tain long-term complete hair removal after a single treatment,
while others may respond poorly, for yet unknown reasons.
However, most patients (80–89%) respond favorably.
Often, regrowing hairs are thinner and lighter in color,
as indicated by measurements of diameter and color of
­regrowing hairs. This also contributes to the overall cosmetic
outcome since the clinical impression of hairiness is not only
defined by the absolute number of hairs, but also by the color,
the length, and the diameter of the hairs.
Recent reports indicate the rare induction of hair growth
after laser hair removal. This usually occurs in young female
patients with skin types III–VI, who present with fine dark
hairs on the lateral face. Laser-induced hypertrichosis is ob­
served in the treated areas as well as in the adjacent nontreated
zones. Although the exact mechanism for this observation is
not known, patients should be advised of this possibility prior
to treatment.
Pretreatment instructions
Six weeks before laser treatment
Laser treatment is much more effective when the pigmented
hair shaft is present within the follicle. Therefore, patients are
advised to refrain from plucking or waxing for a period of
time prior to treatment. Shaving, bleaching, or use of chemi­
cal depilatories are acceptable alternatives for patients await­
ing laser treatment.
Use of a broad-spectrum sunscreen is recommended. Sun
avoidance must be practiced if hair removal is planned on
sun-exposed sites. A bleaching cream such as 3% hydroqui­
none, retinoic acid 0.025%, and hydrocortisone 2% can be
prescribed to patients with darker skin types or who have
­received recent sun exposure.
Day before laser treatment
The skin should always be shaved immediately prior to
­treatment to remove all visible external hair. This minimizes
the production of noxious plume during treatment, which
results from the vaporization of external hair. Shaving also
reduces the risk of skin damage due to heat transfer from
­coagulated surface hair that has adhered to the skin. Since
close shaving may obscure the border of the treatment area,
a red marking pen can be used to mark the border prior
to shaving. If the patient is uncomfortable with the idea of
shaving the area, a depilatory cream can be used instead.
­Alternately, shaving may be done on the day of treatment after
physician assessment is performed. Use of prophylactic antivi­
ral agents such as valacyclovir, famciclovir, or ­acyclovir may be
started, when indicated, on the day prior to the procedure.
Procedural techniques
The procedure for hair removal is similar using any of the
devices previously described. Anesthetic cream, makeup,
and skin cream must be removed from the treatment site
before commencing treatment. Although less sensitive areas
(back, legs, arms) can frequently be treated without anesthe­
sia, topical anesthesia is generally used on more sensitive
areas. If needed, 1–2 hours before the scheduled laser treat­
ment, a thick layer of a topical anesthetic cream (e.g. EMLA
(Astra-zeneca, Wilmington, DE, USA), ELA-Max (Fern­
dale Laboratories, Ferndale, MI, USA), or Topicaine (ESBA
Laboratories, Mountain View, CA, USA)) may be applied
with a cover of plastic wrap. If shaving is done on the day
of treatment, it should precede application of topical anes­
thetic. Care should be taken to limit the percentage of body
surface area exposed to topical anesthetics to avoid potential
complications of anesthetic toxicity. Local infiltration of
lidocaine or regional nerve blocks may be utilized, but these
B
A
Fig. 13-4  Chest before (A) and 8 months after fourth IPL hair removal treatment (B).

193
Laser hair removal  •  Chapter 13
techniques are rarely necessary. An alternative to topical an­
esthetics is piroxicam gel, which has been shown to provide
adequate pain relief and to decrease the inflammatory side
effects of laser hair removal when compared to placebo.28
The laser should always be calibrated before treatment
and after changing fluence, spot size, or any other parameter.
The laser handpiece should be held perpendicularly to the
skin and the skin should be stretched taut. Pulses should be
delivered in a slightly overlapping pattern to ensure confluent
skin coverage. A grid may be utilized to facilitate placement
of laser pulses and minimize skip areas or doubly pulsed ­areas.
Routine use of a grid is usually not required provided that the
operator is attentive during treatment. Visibility can also be in­
creased by the Syris Vizualisation system, a polarized headlamp
with magnifying loupe (Syris Scientific, Gray, MA, USA).
The ideal treatment parameters must be individualized for
each patient. It is recommended that the largest spot size and
the highest tolerable fluence, based on pain and evidence of
epidermal injury, are used to obtain the best results. The ideal
immediate response is vaporization of the hair shaft with no
other apparent effect. The desired clinical end point is peri­
follicular erythema and edema, which usually develops within
several minutes of treatment (Fig. 13-5). The intensity and
duration depends on the hair color and hair density. Marked
or confluent erythema, whitening, blistering, or purpura indi­
cates acute epidermal injury from overly aggressive treatment.
If there is a sign of epidermal damage, the fluence should be
reduced by 20–30%.
A large spot size should be used to promote deeper pen­
etration of light and provide more rapid treatment. For ruby
and alexandrite lasers, best results are achieved with a spot
size of at least 7 mm and a fluence of at least 30 J/cm2. It may
be necessary to reduce the fluence as spot size is increased to
10 mm or more, since an equivalent tissue response will occur
at lower fluences due to greater penetration of light into the
dermis. Devices emitting at longer wavelengths (e.g. 1064 nm)
require the use of higher fluences to compensate for reduced
melanin absorption.
Before performing a full treatment, it may be helpful to
perform test spots in inconspicuous areas using varying flu­
ences, especially in patients with darker skin phototypes. The
treatment fluence is carefully increased while the skin is ob­
served for signs of acute epidermal injury, such as whitening,
blistering, ablation, or Nikolsky’s sign. For these patients, it
may be prudent to use a more conservative fluence for the
initial treatment session and to increase the fluence in subse­
quent sessions if treatment has been well tolerated.
Cooling approaches are discussed elsewhere in this chapter.
If the device is not equipped with a cooling device, a thick
­layer of cooled gel is applied before delivery of the laser ­pulses.
Contact cooling systems such as sapphire window handpieces
must maintain good contact with the skin in order to be effec­
tive. Prior to pulse delivery, the handpiece is pressed firmly
against the skin. After delivery, the handpiece is picked up and
placed firmly on an adjacent site, until the entire area is cov­
ered. The sapphire contact cooling tip should be wiped clean
every 5–10 pulses to remove debris. Between patients, disin­
fection of the handpiece is mandatory.
Safety with hair removal devices
The devices used for hair removal all target melanin deep
within the skin. The highest concentration of melanin in the
body is in the retina and choroid, which extend all the way to
the front of the eye. Consequently, it is imperative that both
patient and physician wear protective eyewear with sideguards
that covers the emission wavelength of the device being used.
Extreme caution must be used when treating around the
eye, as ocular injury may occur even when light is delivered
through the intact eyelid and sclera combined. Even the inser­
tion of laser-protective eye shields over the cornea does not
provide complete safety because they cover only the anterior
surface of the globe. The flashlamp device presents less risk of
ocular injury at a great distance than laser devices because it
delivers incoherent light. However, at close (treatment) range,
it is at least as hazardous as true lasers.
When hair-bearing skin is treated with lasers or flash­
lamps, hair vaporization produces a noxious plume with an
unpleasant, sulfurous odor. It is not known whether the plume
poses any health risks. Hair should be closely shaved prior to
­treatment to minimize the vaporization of external hairs. The
use of smoke evacuators and adequate ventilation is ­essential.
Postoperative clinical considerations
Most patients develop mild edema and erythema after treat­
ment, which generally lasts no more than 1–2 days. Postop­
erative pain is mild and transient, rarely requiring the use
of oral analgesics. The use of ice packs and a short course
(1–2 days) of high-potency topical steroids may lessen post-
­treatment erythema and discomfort. Patients should apply
bland emollients to the treated area twice a day, particularly
if any crusting or blistering has occurred. Any trauma (e.g.
picking or scratching) to the treated area should be avoided.
Fig. 13-5  Formation of selective perifollicular erythema and edema
immediately after laser treatment.

194
Chapter 13
Cosmetic surgery procedures and techniques
During the first week of healing, direct sun exposure should
be avoided or sunblocks used. Makeup may be applied on the
day following treatment unless blistering or crusts develop.
Treated hairs may be shed over the course of several weeks
and should not be confused with actual hair regrowth.
Although the optimal schedule for repeat treatments is
unknown, most practitioners recommend repeat treatments
every 4–8 weeks, or when the first signs of regrowing hair are
present. Regrowing hairs are often more lightly pigmented
and of decreased caliber, which contributes to patient satisfac­
tion with treatment.
One study demonstrated that applying eflornithine cream
(Vaniqa, SkinMedica, Carlsbad, CA, USA) in ­ conjunction
with laser hair removal treatments (755 nm alexandrite ­laser
and 1064 nm Nd:YAG laser) promoted more rapid hair
­removal than with laser treatments alone. However, long-
term differences in hair growth reduction were not seen.
­Patients may prefer a more rapid rate of response to laser hair
­removal even if the overall long-term reduction of hairs is not
impacted.29 A more recent study compared treatment of the
upper lip with a 755 nm alexandrite laser using either twice-
daily application of eflornithine cream or placebo cream.30
At 6-month follow-up the investigator assessment, patient
­assessment, and objective hair count analysis results were in
favor of eflornithine plus laser versus laser alone.
Side effects
Laser hair removal is not a painless procedure. Most patients
experience some discomfort during and immediately after
treatment. A topical or local anesthetic can be used before
treatment to reduce this effect. Perifollicular erythema and
edema are expected in many patients treated with significant
laser fluences. The intensity and duration depend on hair
color and hair density. This usually lasts a few hours.
Side effects after laser treatment are directly correlated
with skin type, with darker-skinned and tanned patients expe­
riencing a much higher rate of complications. Complication
rates also vary according to the anatomic location treated.
Sun-­exposed areas such as the extensor extremities have a
higher rate of side effects than sites protected from the sun,
such as axillary and inguinal areas.31 All lasers and light
sources that target melanin have the potential to produce
epidermal damage through competitive absorption by epi­
dermal melanin. However, the risk of side effects is probably
higher with shorter-wavelength devices (e.g. ruby laser). The
use of lower fluences, active cooling, longer pulse durations,
and minimal overlap of pulses can help to spare the epider­
mis from injury.
The most common side effects are transient postinflamma­
tory hyperpigmentation32 and hypopigmentation (Fig. 13-6).
The overall incidence of these pigmentary changes is ap­
proximately 10–20%.32 They can be prevented if the ideal
patient and treatment fluences are chosen. This problem is
mostly seen in patients with darker skin types or when pa­
tients have had a recent tan. Hyperpigmentation typically
lasts for approximately 2 months, whereas hypopigmenta­
tion lasts an average of 3.5 months.32 To reduce the risk of
hyperpigmentation, patients should be instructed to avoid
sun exposure and wear a UVA/UVB sunscreen with SPF
30 or higher for at least 2 months after treatment. Perma­
nent pigmentary changes are unlikely except in dark-skinned
­individuals.
Epidermal damage occurs if excessive fluences are used
(Fig. 13-7). It is also more common in patients with a tan. Her­
pes simplex outbreaks are uncommon but may occur. There is
a higher risk among patients with a previous history of herpes
simplex and when the perioral, pubic, or bikini area is treated.
The risk of bacterial infection is extremely low. However, it
may occur following epidermal damage.
Folliculitis may occur in areas treated after excessive sweat­
ing or vigorous exercise. An additional risk is posed by swim­
ming, or using a hot tub around treatment sessions.
Fig. 13-6  Treatment of recently tanned skin resulted in develop­
ment of hypopigmentation.
Fig. 13-7  Epidermal damage with focal crusting can occur when
excessive fluences are used.

195
Laser hair removal  •  Chapter 13
Scarring is unlikely except in cases of overaggressive treat­
ment or postoperative infection.
Loss of freckles or lightening of tattoos or pigmented
lesions is not uncommon. Patients should be aware of this
possibility.
Temporary or permanent leukotrichia has been said to
develop following laser or IPL hair removal. However, this
­potential side effect is not well documented and may reflect
the removal of all dark hairs leaving only the white hairs, in
an area of mixed hair color.
A
B
Fig. 13-8  Conversion of fine, vellus-like hairs (A) to terminal dark hairs (B) after a single laser hair removal treatment.
• Take the time to review the patient’s ­expectations
and emphasize that multiple treatment sessions
will be necessary.
• Shave or clip hairs prior to treatment in order to
minimize plume and decrease the risk of skin
damage from transferred heat.
• Premedicate with antiviral medications if treating
perioral or genital skin in a patient with a history
of herpes simplex infection.
• Use a red marking pen to help define the
borders of the treatment area and to reduce
overlapping spots as well as skipping areas.
• Use a combination of cooling methods to protect
the epidermis, especially in darker skin types.
• Check that cooling systems are working
­appropriately before and during each treatment
session. Remember to constantly look, listen,
and feel for signs of cooling failure.
• Rule out underlying endocrine disorders in
­patients who present with hirsutism in the
­context of other signs and symptoms of
­hormonal imbalance. Refer to a specialist
as necessary.
• Offer prescription bleaching agents and
­reassurance to patients with post-treatment
hyperpigmentation.
• Eflornithine cream in combination with laser or
light source hair removal may accelerate results.
Pearls
• Patients should not pluck, wax, or otherwise
mechanically remove hairs by the root prior to
treatment sessions.
• Avoid treating patients with recent sun exposure.
Wait 2–3 weeks until the tan fades before
treating.
• Limit the use of topical anesthetics to avoid
systemic absorption and toxicity. Train
ancillary staff to recognize and respond to signs
of anesthetic toxicity.
• Postpone treatment if a patient presents with
active signs of bacterial or viral infection.
• Treatment with longer-wavelength lasers
(1064  nm Nd:YAG) may require more treatments
before significant results are seen but are still
considered the safest for darker skin types.
• Extreme caution must be used when treating
near the eye.
Pitfalls

196
Chapter 13
Cosmetic surgery procedures and techniques
Logic would suggest that all patients with a history of skin
diseases known to show a Koebner phenomenon, such as pso­
riasis vulgaris, vitiligo, lichen planus, or Darier disease, should
be informed about this possible adverse effect of treatment;
clinically, this is rarely seen.
Livedo reticularis,33 intense pruritus and urticaria, and
urticarial vasculitis34 have been reported, including a case of
intense swelling and erythema. The pathophysiology of these
phenomena is not known. Management included topical cor­
ticosteroids, antihistamines, and discontinuing treatment.
Several cases of induction of hair growth following laser
hair removal in young female patients with darker skin types
have been reported.35,36 Two different phenomena have been
observed: either conversion of fine vellus hair to dark, coarse
terminal hair at the site of treatment (Fig. 13-8) or induction
of growth of long fine hairs in the immediate vicinity of the
treatment area. Further study is ongoing to assess the mecha­
nisms for this response. Treatment of this side effect has
­included continued treatment in some cases.
REFERENCES
  1. Ross EV, Ladin Z, Kreindel M, et al. Theoretical considerations in laser
hair removal. Dermatol Clin 1999; 17:333–355.
  2. Seiberg M, Marthinuss J, Stenn KS. Changes in expression of apoptosis-
associated genes in skin mark early catagen. J Invest Dermatol 1995;
104:78–82.
  3. Van Scott EJ, Ekel TM, Auerbach R, et al. Determinants of rate and
kinetics of cell division in scalp hair. J Invest Dermatol 1963;
41:269–273.
  4. Kligman AM. The human hair cycle. J Invest Dermatol 1959;
33:307–316.
  5. Cotsarelis G, Sun TT, Lavker RM. Label-retaining cells reside in the
bulge area of pilosebaceous unit: implications for follicular stem cells,
hair cycle, and skin carcinogenesis. Cell 1990; 61:1329–1337.
  6. Murphy GF. Histology of the skin. In: Elder D, Elenitsas R, Jaworsky
C, Johnson B, eds. Lever’s histopathology of the skin. Philadelphia:
Lippincott-Raven; 1997:5–50.
  7. Seago SV, Ebling FJG. The hair cycle on the human thigh and upper
arm. Br J Dermatol 1985; 113:9–16.
  8. Hertzberg J, Gusck W. Das Ergrauen des Kapfhaares. Eine histound
fermentschemische sowie elektronen-mikroskopische Studie. Arch Klin
Exp Dermatol 1970; 236:368–375.
  9. Van Scott E, Ekel T. Geometric relationships between the matrix of the
hair bulb and its dermal papilla in normal and alopecic scalp. J Invest
Dermatol 1958; 29:281–287.
10. Hayashi A. Trichogram. J Invest Dermatol 1975; 60:70.
11. Headington JT. Transverse microscopic anatomy of the human scalp:
a basis for a morphometric approach to disorders of the hair follicle.
Arch Dermatol 1984; 120:449–456.
12. Richards RN, Uy M, Meharg G. Temporary hair removal in patients
with hirsutism: a clinical study. Cutis 1990; 45:199–202.
13. Olsen EA. Methods of hair removal. J Am Acad Dermatol 1999;
40:143–155.
14. Liew SH. Unwanted body hair and its removal: a review. Dermatol Surg
1999; 25:431–439.
15. Richards RN, Meharg GE. Electrolysis: observations from 13 years and
140,000 hours of experience. J Am Acad Dermatol 1995; 33:662–666.
16. Lin TYD, Manuskiatti W, Dierickx C, et al. Hair growth cycle affects
hair follicle destruction by ruby laser pulses. J Invest Dermatol 1998;
111:107–113.
17. Liew SH, Grobbelaar AO, Gault D, et al. A preliminary report of the
correlation between efficacy of treatment and melanin content of hair
and the growth phases of hair at a specific site. Ann Plast Surg 1999;
42:255–258.
18. Orringer JS, Hammerberg C, Lowe L, et al. The effects of laser-
mediated hair removal on immunohistochemical staining properties of
hair follicles. J Am Acad Dermatol 2006; 55:402–407.
19. Lask G, Friedman D, Elman M, et al. Pneumatic skin flattening (PSF):
a novel technology for marked pain reduction in hair removal with high
energy density lasers and IPLs. J Cosmet Laser Ther 2006; 8:
77–81.
20. Tope WD, Hordinsky MK. A hair’s breadth closer? Arch Dermatol
1998; 134:867–869.
21. Dierickx CC, Grossman MC, Farinelli WA, et al. Permanent hair
removal by normal-mode ruby laser. Arch Dermatol 1998;
134:837–842.
22. Tanzi EL, Alster TS. Treatment of blonde and non-pigmented facial
hair: use of a melanin-containing solution prior to laser-assisted hair
removal. Proceedings of the 29th Annual Meeting of the American
Society for Dermatologic Surgery. Chicago, Illinois, November 3, 2002.
23. Grossman MC, Dwyer P, Wimberley J, et al. PDT for hirsutism
[abstract]. Lasers Surg Med 1995; 7:44.
24. Haedersdal M, Wulf HC. Evidence-based review of hair removal using
lasers and light sources. J Eur Acad Dermatol Venereol 2006; 20:9–20.
25. Rao J, Goldman MP. Prospective, comparative evaluation of three laser
systems used individually and in combination for axillary hair removal.
Dermatol Surg 2005; 31:1671–1676.
26. Amin SP, Goldberg DJ. Clinical comparison of four hair removal lasers
and light sources. J Cosmet Laser Ther 2006; 8:65–68.
27. Dierickx CC, Grossman MC. Laser hair removal. In: Dover JS,
Goldberg DJ, eds. Laser and lights, vol. 2. Philadelphia: Elsevier
Saunders; 2005:61–76.
28. Akinturk S, Eroglu A. Effect of piroxicam gel for pain control and
inflammation in Nd:YAG 1064-nm laser hair removal. J Eur Acad
Dermatol Venereol 2007; 21:380–383.
29. Smith SR, Piacquadio DJ, Beger B, et al. Eflornithine cream combined
with laser therapy in the management of unwanted facial hair growth in
women: a randomized trial. Dermatol Surg 2006; 32:1237–1243.
30. Hamzavi I, Tan E, Shapiro J, et al. A randomized bilateral vehicle-
controlled study of eflornithine cream combined with laser treatment
versus laser treatment alone for facial hirsutism in women. J Am Acad
Dermatol 2007; [Epub ahead of print].
31. Hasan AT, Eaglstein W, Pardo RJ. Solar-induced postinflammatory
hyperpigmentation after laser hair removal. Dermatol Surg 1999;
25:113–115.
32. Nanni CA, Alster TS. Laser-assisted hair removal: side effects of
Q-switched Nd:YAG, long-pulsed ruby, and alexandrite lasers.
J Am Acad Dermatol 1999; 41:165–171.
33. Lapidoth M, Shafirstein G, Ben Amitai D, et al. Reticulate erythema
following diode laser-assisted hair removal: a new side effect of a
common procedure. J Am Acad Dermatol 1994; 51:774–777.
34. Moreno-Arias GA, Tiffon T, Marti T, et al. Urticarial vasculitis induced
by diode laser photo-epilation. Dermatol Surg 2000; 26:1082–1083.
35. Alajlan A, Shapiro J, Rivens J, et al. Paradoxical hypertrichosis after
laser epilation. J Am Acad Dermatol 2005; 53:85–88.
36. Moreno-Arias GA, Castelo-Branco C, Ferrando J. Paradoxical effect
after IPL photoepilation. Dermatol Surg 2002; 28:1013–1016.

History and Science
Background and history
When patients seek skin rejuvenation, they most common­
ly request improvement in their fine wrinkles, uneven skin
texture, or skin discoloration including red or brown color.
Moreover, since the earliest reports of surgical facial rejuve­
nation at the beginning of the twentieth century,1 physicians
have sought means of facial rejuvenation that are both dura­
ble and minimally traumatic, and patients prefer such treat­
ments, too. In the context of laser-assisted skin rejuvenation,
nonablative light treatments, which do not disrupt the epider­
mis, offer the promise of results similar to those of traditional
ablative carbon dioxide or erbium:YAG laser resurfacing but
without protracted healing time and heightened risk of side
effects.
Nonablative laser therapy was first conceptualized in 1999
by Zelickson, Kilmer, and colleagues.2 Treating patients with
single treatments of 585 nm pulsed dye laser, they found both
a clinical improvement in wrinkles as well as microscopic evi­
dence of collagen remodeling that coincided with the visible
changes. Since then, it has been demonstrated in successive
studies that many if not all cutaneous laser and light devices
can induce similar dermal collagen remodeling, the extent
and character of which varies with the device and treatment
settings. Based on these findings, new devices and techniques
have been perfected to provide progressively longer-lasting
results of increasing magnitude with ever less post-treatment
recovery time.
Nonablative Rejuvenation
Lucile White,
Jeffrey S. Dover,
Kenneth A. Arndt, and
Murad Alam
14
n Traditional nonablative rejuvenation addresses
periorificial fine lines, skin texture abnormalities,
and dyspigmentation, including brown and red
discoloration.
n Nonablative rejuvenation is increasingly preferred
by patients over ablative rejuvenation due to
diminished recovery time and discomfort.
n Nonablative rejuvenation is rapidly evolving and
becoming more effective as we understand the
underlying mechanisms, including collagen
remodeling.
n Multiple treatments are required to achieve clinical
efficacy.
n Improvements in fine skin texture and
­dyspigmentation are commonly achieved, and
reduction of coarser lines and wrinkles may be
­possible.
n Patient expectations must be managed carefully
to ensure patient satisfaction.
n Nonablative rejuvenation may provide the best
overall effects when used in combination with
other minimally invasive energy devices, includ­
ing partially ablative and tightening devices, and
injectables.
Key Points
C H A P T E R
P a r t 2

198
Chapter 14
Cosmetic surgery procedures and techniques
As a consequence, nonablative rejuvenation is an increas­
ingly popular choice of patients, and has largely replaced
ablative resurfacing in clinical practice. A typical treatment
course with nonablative laser or light devices comprises 3–6
treatments delivered to the entire facial skin, approximately
1 month apart. Apart from mild intraprocedure discomfort,
treatment-related undesired events are typically mild ery­
thema and edema that resolve spontaneously. Thus, minimal
healing time is required after nonablative resurfacing, in con­
trast to the weeks of reepithelialization that follows ablative
laser resurfacing.
There remains controversy about the degree of efficacy of
nonablative therapy compared to ablative resurfacing. Some
patients and physicians believe that the absolute efficacy of
nonablative lasers and lights in reducing the visible signs of
photoaging is too minimal to warrant treatment in most cases.
The extreme version of this view holds that standardized pho­
tographs taken before and after a treatment course are virtu­
ally indistinguishable, with this reflecting the minimal degree
of change. However, probably a majority of physicians are
convinced of the efficacy of nonablative treatment, which
they consider somewhat less effective but much more toler­
able than ablative resurfacing. The predominant view appears
to be that color and fine texture improvements are apparent
after a treatment course, while the degree and character of
these changes may vary based on patient characteristics and
the specific device used. Interestingly, ablative resurfacing,
­especially carbon dioxide laser resurfacing, is likely to result in
persistent, confluent erythema that resolves over 2–3 months;
nonablative devices, especially those with vascular selective
features, like the pulsed dye and potassium-titanyl-phosphate
(KTP) lasers, not only do not worsen redness but actually
­improve it.
Basic science
Altering the fluence, pulse duration, cooling parameters, and
number of passes affects the energy delivered to the dermis
and the efficacy of the treatment. Regardless of the dearth of
split-face or head-to-head trials with these devices, the goal of
nonablative rejuvenation is similar across devices: to heat the
dermis to a temperature of 70°C and cause collagen dena­
turation3 without damaging the epidermis.
The so-called mid-infrared (1320 nm, 1450 nm, 1540 nm)
lasers cause a controlled injury to the dermis that spares
the epidermis (Table 14-1). These wavelengths of energy
­target water in the dermis, creating thermal energy. The
thermal energy theoretically triggers events that cause collagen ­
remodeling. The skin becomes smoother as the dermal colla­
gen remodels. The exact mechanism of this remodeling is
not known but suspected to follow the typical wound healing
model of inflammation, proliferation, and remodeling.
The depth of thermal damage can be controlled by chang­
ing the number of pulses delivered to the tissue. Pulse-stacking
is more effective than single pulses, but the optimal interval
between the multiple pulses may be three to five times the
thermal relaxation time.4,5
The flashlamp pulsed dye laser uses a rhodamine dye as its
source. A flashlamp excites the electrons in the dye to release
photons at wavelengths that target hemoglobin. Traditionally,
the pulsed dye laser has been used to treat superficial vascular
lesions, and the mechanism of collagen generation due to the
photonic absorption of hemoglobin is unclear. Recent studies
have found that the pulsed dye laser up-regulates TGF-β, in turn,
stimulating neocollagenesis.6 The mechanism of rejuvenation
with KTP lasers is likely similar to that with the pulsed dye laser;
however, at this time the exact mechanism is not described.
Unlike lasers, conventional intense pulsed light (IPL) sources
emit polychromatic light in wavelengths between 500 and
1200 nm. Filters are applied to the polychromatic emitted
light to narrow the spectrum and target specific structures in
the skin. Because emission spectra of these devices subsume a
range of wavelengths that coincide with the absorption spec­
tra of numerous chromophores, these devices can induce res­
olution of vascular and pigmented lesions, as well as promote
collagen remodeling. For collagen remodeling, the intention
is to cause a light–tissue interaction that spares the epider­
mis and causes thermal damage to the underlying dermis in a
manner similar to but less intense than that effected by abla­
tive resurfacing devices.
The results of histologic studies involving IPL devices have
not been consistent. A few studies have revealed increased
Table 14-1  Mid-infrared devices
Source
Wavelength (nm)
Tradename
Fluence (J/cm2)
Pulse width
(milliseconds)
Spot size(mm)
Nd:YAG
1064
Lyra (Laserscope)
5–900
20–100
1.5
Coolglide (Cutera)
Up to 300
0.1–300
Nd:YAG
1320
Cooltouch (Cooltouch)
10
Diode
1450
Smoothbeam
­(Candela)
8–25
250
4–6
Er:glass
1540
Aramis
(Quantel Medical)

199
Nonablative rejuvenation  •  Chapter 14
dermal collagen after treatment.7,8 However, other studies
have found minimal to no difference in the collagen, elastin,
or reticulin content after treatment.9
Light emitting diodes (LEDs) release narrow bands of poly­
chromatic, low-intensity light. Theoretically, LEDs attain their
molecular and clinical effects through a process known as
­photomodulation. In photomodulation, visible light is abs­
orbed by components of the mitochondrial respiratory chain
(i.e. flavine dehydrogenases, cytochromes, and cytochrome
oxidase), affecting membrane permeability and transport,
increasing the sodium-potassium-ATPase activity, and caus­
ing calcium ion flux in cells (Fig. 14-1). The calcium ion flux
affects cyclic nucleotides that regulate DNA synthesis, RNA
synthesis, and cell proliferation.10,11 This process is poorly
understood in humans and likely varies depending with wave­
length, irradiance, and cell type.
To the extent that thickened horizontal bands of collagen in
the dermis are induced by nonablative laser, it has been specu­
lated that these collagen growth phenomena resemble scar for­
mation.12 Some have even argued13 that repeated treatments
of nonablative laser may be harmful, possibly worsening pho­
todamage much like repeated, prolonged exposure to ultra­
violet light. However, in defense of nonablative rejuvenation,
there is no indication that these treatments result in any visible
or palpable features indicative of a sclerotic, atrophic, or thick­
ened scar. Similarly, none of the nonablative light and laser
devices emit in the ultraviolet spectrum, so there appears to be
no even theoretic risk of photodamage via this ­mechanism.
Discussion
A number of lasers and light sources are used to initiate
light–tissue interactions that induce collagen remodeling and
other molecular events which culminate in improvement of
rough texture, red and brown discoloration, and fine lines.
Research on the precise molecular genetic underpinnings
of such improvements remains primitive, and better devices
may become available as the underlying mechanisms are
better understood. Given the multiple devices available for
­non­ablative rejuvenation, we will discuss each class of devices
separately to highlight specific properties.
Procedures and Techniques
Preoperative clinical considerations
The ideal patient for nonablative rejuvenation has mild to
moderate photoaging. Severe laxity, including deep wrin­
kles on the cheeks, sagging jowls, copious crepe-like skin, is
not usually much improved after treatment with nonablative
modalities. Patients with severe laxity may still choose a non­
ablative treatment option if they are not candidates for abla­
tive treatments or surgical options; however, in these cases, the
physician must manage the patients’ expectations carefully.
Because light energy can be absorbed by melanin, skin pig­
mentation must also be considered when choosing nonablative
devices (Fig. 14-2). Lasers that target vasculature emit photons
at wavelengths that are close to the absorption spectrum for
melanin; thus, these devices may be inappropriate for patients
with darker pigmentation. Infrared devices target water and
generate heat, thus causing a thermal injury. However, the
thermal energy may also result in blisters, ­postinflammatory
­hyperpigmentation, or longer-lasting scarring in patients
with darker skin types. The cryogen cooling imbedded in
TGF-B
FGF
Cytochrome
oxidase
activity in
mitochondria
Fig. 14-1  LEDs for facial rejuvenation are purported to modulate
mitochondrial processes.
Epidermis
Dermis
250–
320
UV-B
320–
400
UV-A
Violet
400–
470
Blue
470–
550
Green
550–
600
Yellow
Orange
600–
650
Red
650–
1000
Deep
red
1000 &
more
infrared
Fig. 14-2  Light absorption in tissue.

200
Chapter 14
Cosmetic surgery procedures and techniques
some lasers can also cause hyperpigmentation in darker skin
types, and both inadequate and excessive cryogen cooling
can scorch the epidermis, with subsequent skin darkening.
Despite the increased risk for side effects, judicious selection
of devices and treatment parameters has allowed nonablative
­rejuvenation treatments to remain popular among patients
with darker skin types.14
Managing patient expectations is crucial to successful
nonablative rejuvenation. This process is initiated by asking
patients to articulate their treatment goals (Figs 14-3, 14-4;
Table 14-2). If patients cannot say what causes them dissatis­
faction with their current appearance or deflect this decision
to the physician, the risk of not satisfying the patient’s needs
is high. Additionally, patients must be informed that most
nonablative modalities require several treatment sessions,
and improvement may take up to a year to appreciate. Most
importantly, because the patients are opting for a treatment
with little morbidity, the effects may be subtle. Taking before-
and-after photographs can help extinguish complaints that the
treatment was ineffective. Also, sharing with patients that a
minority of patients obtain no to very minimal improvements
after treatment can help set their expectations. If, after this
information is conveyed, patients voice great concern about
the potential for minimal treatment effect, they may not be
ideal ­candidates.
Prior to treatment, patients must cleanse their face to
remove any makeup or sunscreen. If a patient has been on
isotretinoin, laser treatment should be delayed for at least 6
months. Similarly, it may be prudent to discontinue ­topical
tretinoin and other at-home facial treatments, such as
­superficial peel products, a week before treatment to minimize
­irritation and redness after treatment. Since recent significant
sun exposure increases the risk of postinflammatory hyperpig­
mentation with all lasers and light devices, it is imperative that
all patients, even those who are lighter skinned, not be tanned
or planning a sunny vacation at the time of treatment.
Procedural techniques
Mid-infrared
Mid-infrared lasers that are marketed and used for facial reju­
venation include the 1064 nm neodymium:yttrium-aluminum-
garnet (Nd:YAG) (CoolGlide Vantage; Cutera, Brisbane, CA),
Fig. 14-3  Age-related skin complaints most improved with
­nonablative laser and intense pulsed light .
Fig. 14-4  Fine lines improved modestly with mid-infrared lasers
and some hybrid radiofrequency and intense light devices.
Table 14-2  Clinical complaint and choice of device
Complaint
Device
Telangiectasias
PDL, KTP, IPL
Lentigines, mottled
­pigmentation
KTP, IPL, Q-switched Nd:YAG
Mild rhytides
1320, 1450, 1540
Moderate rhytides
Er:YAG or carbon dioxide
ablative resurfacing
Jowls and sagging
Thermage or surgical
­treatment
PDL, pulsed dye laser; KTP, potassium titanyl phosphate; ITP, intense pulsed
light.

201
Nonablative rejuvenation  •  Chapter 14
the 1320 nm Nd:YAG (Cooltouch; Cooltouch Corporation,
Roseville, CA), the 1450 nm diode laser (Smoothbeam; Candela
Corporation, Wayland, MA), and the 1540 nm erbium:glass
laser (Aramis; Quantel Medical, Clermond-Ferrand, France).
Nd:YAG, 1064 nm
The 1064 nm Nd:YAG laser was originally developed to target
pigment, but a few reports of its use in nonablative rejuvena
tion have emerged. The 1064 nm laser is available as devices
that provide pulses in nanoseconds (Q-switched), or micro­
seconds and milliseconds (long-pulsed). Both Q-switched and
long-pulsed devices have been reported to have efficacy for
nonablative skin rejuvenation.15,16
One report16 regarding the efficacy of a 300 microsecond
1064 nm laser in facial rejuvenation noted clinical and electron
micrographic (EM) evidence of improvement in seven of nine
patients, but the oldest patient in the study did not have changes
on EM. The laser was set to parameters of 13 J/cm2, spot size of
5 mm, pulsing without overlap, and no epidermal cooling, and
only transient erythema was seen immediately after treatment.
Nd:YAG, 1320 nm
The 1320 nm Nd:YAG laser has also been shown to promote
nonablative tissue remodeling. This device penetrates 200–
300 μm into the dermis due to a large scattering coefficient,
and provides several sequential pulses with each firing of the
handpiece by the operator. Cryogen cooling is also delivered
over the multiple pulses to protect the epidermis. There are
several commercially available iterations of this laser, the
CoolTouch 1 through the CoolTouch 3, with the presumed
implication that the subtle modifications in later generation
devices are more adapted to maximize patient convenience
and clinical efficacy.
After treatment with the CoolTouch 1, acute biochemical tis­
sue changes have been demonstrated, and these may underpin
associated patient satisfaction and rhytide improvement.17 Three
passes with cryogen cooling to achieve a dermal temperature
target of between 45°C and 48°C have yielded good results.
The CoolTouch 3 laser is typically used at fluences of
18–20 J/cm2. Of the 35 patients in a recent study, 55.6% were
satisfied and 16.7% were somewhat satisfied after six treat­
ments that were performed at 4-week intervals. Approximately
three to four treatments were required before patients noted
improvement.18
Diode, 1450 nm
The 1450 nm diode laser has been used for facial rejuvena­
tion and to diminish acne scarring. It has also been reported
to reduce active acne. This device includes integrated ­cooling.
The surface cooling is through a dynamic cooling device (DCD)
that applies tetrafluoroethane at −26°C to the epidermis via a
sequence consisting of 10 ms of precooling, 30 ms of intracool­
ing, and 20  ms of postcooling for a total of 60 ms of cooling.
In studies, pulse widths of 160–260 ms have been used with
a repetition rate of 0.5–1.0 Hz and a 4 mm spot size.19 It is
suspected that the 1450 nm diode laser causes neocollagenesis
by a similar mechanism as the 1320 nm laser; however, at this
time, the precise mechanism is not known.
Of twenty patients with Glogau class I and II rhytides
studied by Goldberg et al.19 twelve had periorbital rhytides
and eight had perioral rhytides. The patients underwent two
to four treatments 1 month apart. While treatment param­
eters were not noted in the study, seven of the twenty patients
showed no improvement, ten had mild improvement, and
three had moderate improvement. The perioral sites were the
least improved.
In a study of 25 patients, all patients noted improvement in
their periorbital and perioral rhytides.20 These patients had been
treated with four treatments at 3–4 week intervals with settings
of 15–20 J/cm2 and a pulse duration of 210 ms. The maximum
improvement was seen 6 months after treatment. Among the five
patients who provided tissue for histology, all five had evidence
of increased collagen, although exact staining and histopatho­
logic measures were not provided in the published report. It has
been suggested that this laser may be as or more effective than
the 1320 nm laser for treating atrophic acne scars.21
Side effects with 1450 nm laser include transient post­
inflammatory hyperpigmentation in 10% of subjects when
this device is used for treating acne. Acne patients were treated
with an average fluence of 18 J/cm2, similar to the fluence
parameters used in nonablative rejuvenation.22
Erbium:glass, 1540 nm
The 1540 nm Er:glass laser, which generates its mid-­infrared
emission from co-doped Yb:Er:phosphate glass, is also spe­
cifically designed for nonablative facial rejuvenation. The
1540 nm laser emits a wavelength that corresponds to a trough
in the melanin absorption spectrum, and thus is less likely than
other infrared lasers to cause pigmentary side effects. Contin­
uous contact cooling is provided with tetrafluoroethane to the
epidermis through a sapphire lens. After treatment, changes
in collagen can be seen at a depth of 200–1300 μm below the
skin surface. Increased fibroblasts and dermal fibroplasia have
been observed in the zones of thermal damage.23,24
The Aramis laser (Quantel Medical, Clermond-Ferrand,
France) can deliver up to 5 J in 3 ms. The device can operate
in a single pulse mode or in a serial pulse mode with a rate of
3 Hz.21 A different 1540 nm laser (Candela Corp, Wayland,
MA) can be used at pulse energies up to 1.2 J, pulse width of
1 ms, in a pulse-train mode up to 8 Hz.23
Fournier et al. reviewed the efficacy of this device.25 Clinical
efficacy has been demonstrated by photography, ultrasound
imaging, and volumetric changes of anisotropy demonstrated
through silicon skin models.25–28
The early studies of this device revealed non-neglible side
effects. Blisters and scarring were seen in an early study of
eight men and one woman23 in which contact cooling was
applied for 2 seconds at −10°C, laser pulses were delivered
at 8 Hz, fluences ranged 400–1200 mJ, and a second pass was
applied 3–5 seconds after the first pass.

202
Chapter 14
Cosmetic surgery procedures and techniques
Larger studies have used treatment settings of 8 J/cm2/
pulse with a 4 mm spot handpiece.27 Perioral areas have
been treated with five pulses for a total of 40 J/cm2 and peri­
orbital areas with three pulses for a total of 24 J/cm2. After
four treatments at 6-week intervals in a cohort of 60 patients,
maximum clinical improvement was seen at 3–6 months
and periorbital rhytides were found to improve more than
perioral rhytides. Ultrasound changes indicative of increased
dermal thickness persisted through the 14-month follow-up
period.
Lupton et al.29 used settings of 10 J/cm2 per pulse for three
to four pulses, for a total of 30–40 J/cm2 with a 4 mm spot
size. The 24 women in this study received three treatments
at 4-week intervals. Patients and physicians noted clinical
improvement based on a four-point scale, and histologically,
a mild increase in dermal fibroplasia was observed 6 months
after treatment.
More recently, Fournier et al. performed a follow-up study26
on their original patients27 in which 11 of these patients were
retreated. Further improvement of 25–30% in rhytides was
noted at 35 months. The retreated patients were more satis­
fied, but the volumetric skin assessments of anisotropy were
not different between the retreated group and the control
group that did not receive retreatment.
This device has also been demonstrated to be effective for
neck lines and forehead rhytides.28 Patients were treated with
three pulses at 10 J/cm2/pulse for a total fluence of 30 J/cm2,
and again, ultrasound imaging was used to assess efficacy by
assessing the change in skin thickness.
Treatment-associated adverse effects of transient ­erythema,
edema, and one case of orolabial HSV reactivation were ­noted
by Lupton et al.29 but significant, nontransient side ­ effects
were not observed in later studies employing lower ­fluences
and increased delay between pulses.25
Visible light
Pulsed dye and KTP lasers were originally developed to treat
vascular lesions but have been reported effective for skin
­rejuvenation (Table 14-3).
Pulsed dye
Currently installed pulsed dye lasers include the N Lite (USA
Photonics, Nanuel, NY) with a 585 nm wavelength, the
VBeam (Candela Corporation, Wayland, MA) with 595 nm
wavelength, and the V Star (Cynosure Inc., Chelmsford, MA)
with 585 nm and 595 nm wavelengths.
Table 14-3  Visible light devices
Source
Wavelength (nm)
Tradename
Fluence (J/cm2)
Pulse width
(milliseconds)
Spot size (mm)
KTP
532
Aura (Laserscope)
1–240
1–50
1–5
DioLite (Iridex)
1–950
5–100
0.5, 0.7, 1
KTP and Nd:YAG
532 and 1064
Gemini (Laser­
scope)
Up to 100
Up to 990
10–100
1–100
1–5
Pulsed-dye
585
N Lite (USA
Photonics)
Depends on spot
size
0.450
5 or 7
C Beam (Candela)
Depends on spot
size
0.450
5, 7, or 10
Pulsed-dye
595
V Beam (Candela)
Depends on spot
size
0.45–40
5, 7, or 10
V Star (Cynosure)
Depends on spot
size
0.45–40
5, 7, 10, or 12
Pulsed-dye and Nd:
YAG
585 and 1064
Cynergy (Cynosure)
Depends on spot
size
0.5–40
0.3–300
5, 7, 10, or 12
•  With regard to mid-infrared lasers, the fluence
and cooling parameters must be carefully
selected to reduce the risk of side effects and
optimize response.
• Multiple treatments are necessary to achieve
clinical efficacy.
• Improvements in rhytides are modest, and
they are not completely removed but can be
softened.
• Degree and duration of efficacy vary across
patients.
Pearls
• Mid-infrared lasers cause pain, edema, and
erythema that resolve within 48 hours.
• Side effects include less common postinflam­
matory hyperpigmentation, which also resolves.
• Eye injury is possible to the cornea30,31 and
­appropriate precautions should be taken.
Pitfalls

203
Nonablative rejuvenation  •  Chapter 14
The 585 nm wavelength lasers are used for facial reju­
venation at setting of 0.45–40 ms. The 595 nm wavelength
lasers are used at settings of 0.5–40 ms, and fluences of up
to 20 J/cm2, with a variety of medium and large spot sizes.
Immediate treatment end points include erythema or, less
commonly, purpura, which can occur at short pulse durations
or with 585 nm lasers. In general, 595 nm pulsed dye lasers are
used without purpura for rejuvenation, redness reduction,
and texture improvement, with a common treatment course
including 3–6 treatments. Newer devices (VBeam Perfecta)
are able to blanch the skin during treatment to further reduce
the likelihood of bruising and enhance potential reduction in
brown dyspigmentation.
These lasers have been reported to improve ­hypertrophic
scarring32 and rhytides. The smoothing effect seen with
the 595 nm lasers may be the result of histologic improve­
ments such as increased collagen, type I procollagen, fibro-
blasts and elastic fibers.33,34 The 585 nm laser has also been
found to ­ induce both clinical and histologic improvement
in rhytides. A study using a 350 microseconds pulse dura­
tion with such a device found new collagen formation on
electron microscopy, while blinded, nontreating physician
assessment revealed clinical rhytide improvement in 50%
of treated subjects.35 While most data are strongly support­
ive of the smoothening efficacy of pulsed dye laser, a single
randomized, split-face study has shown the 595 nm pulsed
dye laser to be relatively ineffective for resolving periorbital
rhytides.36
KTP
The potassium titanyl phosphate (KTP) laser was originally
developed to treat focal facial telangiectasias. Currently mar­
keted KTP lasers include the Aura (Laserscope, San Jose, CA)
and Diolite (Iridex).
Recent studies have revealed improvement in the textural
appearance of skin after combination KTP and Nd:YAG
­treatment. A combination of KTP and Nd:YAG 1064 nm was
used successfully in nine patients to improve the appearance
of dryness, roughness, and pigmentation.37 A larger study of
150 patients38 also demonstrated that treatment with a 532 nm
laser followed by treatment with a long-pulsed 1064 nm laser
can result in improvement of redness and pigmentation, skin
tone, skin texture, and rhytides, thus heightening patient
­satisfaction. The combined laser treatment was found to be
superior to KTP treatment or long-pulsed Nd:YAG treatment
alone, although, when evaluating the individual laser modali­
ties, the KTP alone provided superior results compared to the
Nd:YAG alone.
The treatment parameters in the larger study were com­
plicated. Initially, KTP laser parameters were set at pulse
widths of 10–20 ms and fluences of 10–15 J/cm2 for the tel­
angiectasias and 7–10 ms and 7–10 J/cm2 for the lentigines.
After the focal telangiectasias and lentigines were treated,
the entire face was treated in a ‘sweeping’ manner at ­fluences
of 6–15 J/cm2 and pulse durations of 30–50 ms. For the
combination treatment that yielded the best results, the KTP
treatment was followed by Nd:YAG treatment at settings of
30–65 ms at 24–30 J/cm2. A 10 mm spot size handpiece
with sapphire contact cooling was used in a ‘brushstroke’
manner over the entire face after the KTP treatment was
­performed.
Noncoherent light sources
Intense pulsed light
Many manufacturers make intense pulsed light (IPL) devices.
Some of the most popular devices include the Quantum SR
and Lumenis One (Lumenis Inc, Santa Clara, CA), and the
MediLux, StarLux, or EsteLux (Palomar, Burlington, MA).
There has been a proliferation of IPL devices to address
specific chromophores and complaints associated with aging.
‘Photon recycling,’ a technique for increasing the actual fluence
at the target site beyond the rated fluence, is of most benefit
with the newer, larger IPL spot sizes, for which it can ­markedly
improve clinical efficacy. Using these and other advanced
technologies, a plethora of handpieces have been developed to
channel and direct the light energy generated by the increas­
ingly powerful lamps and platforms offered by the major
manufacturers. For instance, Palomar offers the MediLux and
EsteLux platform-compatible 470–1400 nm LuxB handpiece
for treatment of lighter pigmented lesions on fair skin, and the
500–670 nm and 870–1400 nm LuxG (available with StarLux,
MediLux, and EsteLux) for rejuvenation via simultaneous tar­
geting of pigmented and vascular lesions. Additionally, there
is a bewildering array of so-called ‘fractional’ IPL handpieces,
including the LuxIR Fractional Infrared (800–1350 nm) and
the LuxDeepIR Fractional Infrared, which appear to work in
a nonablative manner that, unlike laser fractional resurfacing
• Treatment end points for visible light lasers
are transient blanching, erythema, or (rarely)
purpura.
• Classify the skin type according to Fitzpatrick
scale,39 and use lower fluences in darker-
skinned patients, to ensure that treatment
parameters are unlikely to cause transient hyper­
pigmentation.
Pearls
• Current pitfalls with the vascular lasers include
potential purpura at short pulse durations or
wavelengths. Other side effects, such as blister­
ing, pigmentation changes, and scarring, are
exceedingly rare.
• If a patient has been treated with oral isotretin­
oin, laser treatment should be delayed for at
least 6 months. Keloid formation after treatment
with a 585  nm laser has been reported.
pitfalls

204
Chapter 14
Cosmetic surgery procedures and techniques
(Reliant), avoids downtime or pain. Off the face, early work
with continuous-wave infrared IPL has shown some efficacy
for body rejuvenation, including reduction of cellulite.
No significant difference in rhytides was found in one split-
face trial with IPL.40 In this study, both patients and blinded
observers noted improvement in telangiectasias and pigmen­
tation. The maximum benefit of treatment with IPL was seen
1 month after treatment.
Erythema and edema are immediate responses to IPL
treatment, while purpura and scarring are rare. To the extent
that IPL devices rarely induce bruising, they may be consid­
ered superior in this regard to traditional pulsed dye devices
for routine use in facial rejuvenation. That being said, the
inherent complexity of intense pulsed light devices means
that parameters have to be selected carefully, and novices can
induce undesired effects such as configurate hypopigmenta­
tion and even scar (Fig. 14-5). Modest intraoperative pain is a
frequent complaint of patients undergoing IPL treatment, but
topical anesthesia is rarely needed.
Theoretically, the broad spectrum of light emitted by IPL
devices enables the simultaneous treatment of multiple chromo­
phores, and hence clinical complaints. In practice, traditional
devices modify 500–1200 nm light with filters so as to effective­
ly treat red and brown superficial lesions. Fine lines and coars­
er wrinkles are much less susceptible to treatment with IPL.
­Newer generation IPL devices may also be superior to some
lasers for amelioration of melasma, and confluent hyperpig­
mentation of the forehead, cheeks, and infraorbital area, as the
­hypopigmentation induced by IPL may be desirable at selected
sites. However, some commentators remain skeptical that any
treatment other than conservative therapy, including sun avoid­
ance and bleaching creams, is useful against melasma.
As with lasers, retreatment is usually performed at 4–6-week
intervals, and three to six treatments are often required.
Radiofrequency and light/laser combination
for nonablative rejuvenation
In an attempt to increase the efficacy of nonablative col­
lage remodeling, several devices that utilize light and radio­
frequency (RF) energy have been developed for nonablative
rejuvenation. These devices have a skin rejuvenation as well
as tightening function, and are discussed here, unlike radio­
frequency alone devices, which are predominantly selected
for their tightening function, and discussed in a later chapter
focusing on skin tightening.
Devices incorporating radiofrequency energy as well as
visible light include the Aurora and Polaris systems (Syneron,
Yokneam, Israel). The Aurora is comprised of a bipolar radio­
frequency generator coupled with a flashlamp pulsed light
that emits at 400–980 nm, 580–980 nm, or 680–980 nm.
­Radiofrequency energy type is delivered by electrodes
­imbedded in the handpiece and in contact with the skin, and
light through a contact sapphire light window. The Polaris
­employs a high-power diode laser (900 nm) in lieu of broad­
band light but is otherwise similar. In both Polaris and Aurora,
the ­underlying technology is designed to work synergistically,
with lower peak light and radiofrequency energies collectively
able to successfully heat target chromophores (Fig. 14-6).
Among the studies supporting the utility of ­radiofrequency
cum IPL device in skin rejuvenation is one by Bitter and
­Mulholland41,42 showing that 108 patients of skin types II to IV
Fig. 14-5  Risks of configurate hypopigmentation with traditional
intense pulsed light devices.
RF
IPL
Fig. 14-6  Devices delivering multiple modalities, such as radiofre­
quency energy and intense light, may simultaneously but differen­
tially heat, treat, and shrink different levels of epidermis and dermis.