Ứng Dụng Laser Trong Da Liễu Và Y Học (Lasers In Dermatology – 2018)

497
References
1. Webster SB.  Professionalism and medical eth-
ics
in
dermatology-­2000.
Arch
Dermatol.
2000;136(1):101–2.
2. Ringel E. The morality of cosmetic surgery for aging.
Arch Dermatol. 1998;134:427–31.
3. Cantor J. Cosmetic dermatology and physicians’ ethi-
cal obligations: more than just hope in a jar. Semin
Cutan Med Surg. 2005;24:155–60.
4. Finklestein D, Wu AW, Holtzman NA, et  al. When
a physician harms a patient by a medical error: ethi-
cal, legal and risk-management considerations. J Clin
Ethics. 1997;8(4):300–35.
5. Guidelines for ethical patient safety practices in today’s
rapidly changing, complex environment.
net/GuidelinesForEthicalPatientSafetyPractices.aspx.
6. Lolis M, Dunbar SW, Goldberg DJ, et  al. Patient
safety in procedural dermatology. Part II safety
related to cosmetic procedures. J Am Acad Dermatol.
2015;73(1):15–24.
7. Standards of perioperative clinical practice in laser
medicine and surgery.
8. Raulin C, Greve B, Raulin S.  Ethical consider-
ations concerning laser medicine. Lasers Surg Med.
2001;28:100–1.
9. Wagner RF, Brown T, McCarthy EM, et  al.
Dermatologist and electrologist perspectives on
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10. Administrative regulations: code of medical ethics for
dermatologists. 2006.
11. Williams HC, Naidi L, Paul C. Conflicts of interest in
dermatology. Acta Derm Venereol. 2006;86(6):485–97.
12. Newburger A. Taking ethics seriously in cosmetic der-
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13. Goldberg D.  Dermatologic surgical research and
the institutional review board. Dermatol Surg.
2005;31(10):1317–22.
14. Perkins AC, Choi JM, Kimball AB.  Reporting of
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15. Sec. 393.200 Laser(s) as medical devices for facelift,
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ora/compliance_ref/cpg/cpgdev/cpg393-200.html.
30  Ethical Issues

499
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Medicolegal Issues
(Documentation/Informed
Consent/Non-physician Operators)
Abel Torres, Tejas Desai, Sailesh Konda,
Alpesh Desai, and William T. Kirby
Abstract
The number of elective laser and light proce-
dures continues to grow eliciting a host of med-
icolegal issues. Informed consent involves a
meeting of the minds as a result of a discussion
between the provider and the patient. The risks,
benefits and alternatives of a procedure should
be disclosed to a patient and is paramount to an
informed consent. Unique patient and physi-
cian concerns regarding the laser procedure
should be documented when possible. The
informed consent process might benefit from
supplementary modes of communication such
as patient questionnaires to improve retention
rates. Most laser procedures require for laser
individualized informed consents.
Keywords
Informed consent · Informed refusal · Medi­
colegal issues · Laser procedures
• The continued growth of elective laser and
light procedures has elicited a host of medico-
legal issues—many of which can be avoided
with proper informed consent.
• Informed consent involves a meeting of the
minds as a result of a discussion between the
provider and the patient.
• The risks, benefits and alternatives of a proce-
dure should be disclosed to a patient and is
paramount to an informed consent.
• Unique patient and provider concerns regard-
ing the laser procedure are best documented as
part of the informed consent.
• The informed consent process might benefit
from supplementary modes of communication
such as patient questionnaires to improve
retention rates.
• Most laser procedures require individualized
informed consents.
• Special considerations for lasers that may be
included in an informed consent can be recalled
by a simple acronym, “L-A-S-E-R-S.”
• It is important that pediatric patients be a part
of the consent discussion if they have the
capacity to do so.
• Informed refusal by the patient can be docu-
mented if the patient is refusing a treatment
the physician is recommending and requesting
another treatment that may be less beneficial.
Additionally,
a
physician
can
decline
­performing a treatment if it can be detrimental
to the patient.
A. Torres (*) · S. Konda
Department of Dermatology, Loma Linda University
School of Medicine, Loma Linda, CA, USA
e-mail: atorres@llu.edu; abelt@aol.com
T. Desai · A. Desai
Heights Dermatology & Aesthetic Center,
Houston, TX, USA
W. T. Kirby
Kirby Dermatology, Beverly Hills, CA, USA
31

500
• Laser procedures should only be performed
by appropriately trained physicians or allied
health providers.
According to the American Society of
Dermatologic Society (ASDS), its members col-
lectively have performed over 100 million laser,
light, and energy-based cosmetic procedures [1].
In 2013 alone, its members performed 2.25 mil-
lion of these procedures, which has increased
34% when compared to 2012 [2]. This number
should continue to expand as life expectancy
increases, causing a seemingly everlasting popu-
lation desiring to achieve a more youthful appear-
ance. Combining these numerous laser procedures
with unrealistic patient expectations may be a
recipe for a legal disaster. Two recent studies
have illustrated the current medicolegal land-
scape with regards to laser procedures.
Jalian and colleagues examined 28  years of
legal cases secondary to cutaneous laser surgery
and demonstrated an increasing trend of litigation
with a peak in 2010. Laser hair removal (63%)
was the most commonly litigated procedure and
lack of proper informed consent (53%) was the
most common legal cause of action. They discov-
ered that 49.2% of cases favored the defendant,
the median indemnity was $380,719, and plastic
surgeons were the most commonly named defen-
dant. Nearly 40% of the cases involved a non-
physician operator, which included both allied
health professionals and non-health professionals,
such as aestheticians and technicians. Even if the
physician supervisor did not perform the proce-
dure, they were still named as a defendant [3].
More recently, Svider and colleagues con-
ducted a focused examination of malpractice liti-
gation regarding laser procedures in the head and
neck. They discovered that 82% of cases involved
female plaintiffs and 56% were resolved with a
defendant verdict. The median indemnity was
$150,000 and dermatologists were the most com-
monly named defendant. Seventy-four percent of
cases involved cutaneous procedures and the most
common allegations included permanent injury
(71%), disfigurement/scarring (68%), inadequate
informed consent (50%), unnecessary/inappropri-
ate procedures (44%), and burns (32%) [4].
The four commonly accepted principles of
healthcare ethics are: respect for autonomy, non-
maleficence, beneficence, and justice. Respect
for autonomy is the basis for the practice of
informed consent in the physician-patient rela-
tionship. Both of the aforementioned studies
underscore the importance of documentation and
informed consent when performing elective laser
procedures in dermatology. Educating the patient
in layman terms, further explaining the risks,
benefits and alternatives are wise actions even
before a test spot and/or treatment is attempted.
Moreover, the nature, course and aim of treat-
ment should be clearly stated to define the objec-
tives for the patient and physician. This allows
the patient to make a rational decision based on
the pertinent information that has been presented
to them.
Informed consent in laser procedures not only
protects the provider, but the patient as well.
Informed consent is not merely a piece of paper
to be signed by the patient. A nonverbal protocol
functioning as an informed consent does not fully
protect a provider and does not serve the best
interest of a patient. Informed consent involves a
meeting of the minds as a result of a discussion
between the provider and the patient. Written
consent is merely a confirmation of what has
been discussed. A patient’s signature on a pre-
printed consent form, which has not been pre-
ceded by a discussion, does not grant free rein,
and in the event of a legal dispute, such forms
may be declared invalid [5]. Unique patient and
provider concerns regarding the laser procedure
are best documented as part of the informed con-
sent. This can help identify and personalize the
treatment plan for each specific patient. Identical
informed consents without additional notes may
sometimes appear like a reflex, rather than a com-
munication between patient and provider.
The authors recommend writing a risk, bene-
fit and alternatives (RBA) note together with a
written informed consent. The note emphasizes
the RBA that is especially pertinent to the
patient. In this way, it is a reminder to the pro-
vider to discuss these issues with the patient, and
supplies additional documentation to the medi-
cal record. Such a note does not have to be
A. Torres et al.

501
lengthy or extensive. It can consist of a sentence.
An example of this would be: “The RBA dis-
cussed with the patient emphasizing the poten-
tial risk of post-treatment, permanent dyschromia
due to the patient’s Fitzpatrick skin type.
Informed consent retention has been shown to
be less than 50% in other fields of medicine [6].
In addition, in patients undergoing dermatologic
surgery, one study showed an overall retention
rate of 26.5% just 20 min after being informed of
ten possible complications [6]. It is apparent
from this study that informed consent might ben-
efit from supplementary modes of communica-
tion to improve retention rates. When treatment is
usually reserved for a future day, the overall
retention rate for patients can be expected to drop
even more. Patient pamphlets for education can
complement written and verbal informed con-
sent. Handouts can be noted in the medical record
indicating an exchange took place on the day of
the consultation. Furthermore, video-based edu-
cation has been shown to be superior to pam-
phlet-based education for patients learning about
a dermatological condition and this could be
expanded to the informed consent process [7]. It
is helpful when numerous modes of communica-
tion are involved in order for the patient to solid-
ify his/her decision on a non-medical procedure.
Some physicians, like Dr. David Duffy, advocate
using a questionnaire that the patient must answer
to demonstrate comprehension of the consent.
It is wise to seek informed consent for each
type of laser that is operated by the physician.
Each laser system functions in a unique fashion.
The same laser created by various competitors
may differ in terms of treatment settings and
potential side effects. For this reason, establishing
a relationship with the laser company for support
is advantageous for the physician. Furthermore,
ensuring that the medical device is FDA approved
for patient therapy could minimize liability.
Special considerations involving informed
consent for laser therapy include type of anesthe-
sia, permission for release of photographs, revo-
cation of consent, observations, no guarantee
clause, and waiver of liability [8]. These key ele-
ments may be forgotten, and provides useful
information to the patient while adding pertinent
documentation to the medical record. If preoper-
ative anesthetic is part of the laser technique, its
risks
and
benefits
should
be
discussed.
Photographs can be taken to measure improve-
ment, but at times, may be a sensitive issue with
certain patients. It is vital that pictures be confi-
dential and without identification when appropri-
ate. This can be explained or added to the medical
record as an informed consent note. A revocation
of consent discussion can let a patient know that
they can discontinue treatment at any time he/she
wishes. It is useful under circumstances when
discontinuation may alter the outcome. A “no
guarantee” clause makes the patient aware that
although the laser procedure is effective in most
cases, no guarantees can be made that a specific
patient will benefit from the laser treatment.
Finally, informed consent may need to include a
waiver of financial liability. A patient should
understand that insurance companies, including
Medicare, only pay for services they determine to
be reasonable and necessary, otherwise, denial of
payment may ensue [8].
The acronym “LASERS,” representing liabil-
ity waiver, type of anesthesia, surveillance and
observations, no expectation/guarantee clause,
revocation of consent, and snapshots/photographs
can remind the physician of the particular ele-
ments to be included into the informed consent
(Table  31.1). Additional documentation may be
Table 31.1  Key elements to be included on an informed
consent
Liability
waiver
A patient needs to be aware that their
insurance company may not cover
services rendered
Anesthesia
type
Disclose the risks, benefits and type
of anesthesia used
Surveillance
Observations, outcomes and side
effects on the postoperative record
documents treatment course in the
best interest of the patient
Expectations
A no guarantee clause indicates that
a patient needs to be aware a positive
clinical outcome cannot be certain
Revocation of
consent
Offer the option of letting the patient
refuse treatment at any time
especially if it alters outcome
Snapshot
Photographs kept confidential
without Identification
31  Medicolegal Issues (Documentation/Informed Consent/Non-physician Operators)

502
specifically geared towards the patient and/or the
type of laser treatment they are receiving. For
example, the informed consent could include the
risks, benefits and alternatives of a postoperative
antiviral if the patient is at risk for herpes
labialis.
The pediatric cosmetic dermatologic patient
poses different considerations to informed con-
sent. The pediatric patient is usually not legally
competent so a physician must obtain consent
from the parents or legal guardians. Otherwise, it
could be considered a battery irrespective of the
result [9]. The patient’s parents become the sur-
rogate decision-makers, and their view of the
child predominates as the primary clinical end-
point. Nevertheless, it is important that pediatric
patients be a part of the consent discussion if they
have the capacity to do so. If general anesthesia is
required for children, consent should encompass
the risks and benefits associated with it.
A competent patient may refuse a recom-
mended laser treatment. Although most laser pro-
cedures are voluntary, the provider should
document the refusal of a specific treatment if
warranted. There is more validity to this state-
ment when a recommended treatment is more
beneficial than another laser procedure. Patients
can be motivated to obtain a laser procedure for
many reasons such as cost. Clinical outcomes
may differ, and the physician is encouraged to
clarify which treatment option offers the best
results. If the patient chooses to undergo another
laser treatment with inferior results, an informed
refusal appended to the medical chart helps
another practitioner understand the issues
involved, and may provide a deterrent to litiga-
tion. Informed consent and informed refusal go
hand in hand, except the latter explains to a
patient about the potential negative implications
of refusing a treatment [10]. Additionally, a phy-
sician can decline performing a treatment if it can
be detrimental to the patient. This ultimately ben-
efits the patient.
Lastly, as noted earlier by Jalian and col-
leagues, there are an increasing number of legal
cases involving non-physician operators [3].
Currently, 33 states define the use of lasers as the
practice of medicine and the remaining states
have varying, and often vague, definitions as to
the scope of practice of non-physician operators.
It is imperative for dermatologists to familiarize
themselves with their respective state’s laws.
Laser procedures should only be performed by
appropriately trained physicians or allied health
providers. If an allied health provider is perform-
ing the procedure, the physician should be avail-
able in accordance with governing state rules and
regulations. A survey of dermatologists in Texas
found that 33% of respondents reported compli-
cations that occurred in the absence of an on-site
supervising physician [11].
A successful laser procedure includes an
informed consent process, allowing the patient
to have peace of mind before he/she receives
treatment and to make an informed decision. In a
cosmetic world, many patients do not view laser
treatments as medical care, but it is the provid-
er’s duty to assert his/her role during the course.
Lasers and light therapies are complex proce-
dures, and a medical problem may occur rather
easily if one is not careful. While complications
of laser and light procedures are uncommon,
there is risk associated with these procedures.
The appropriate level of documentation helps
clarify the care rendered regardless of what
occurs. Periodic audits for quality assurance
may be beneficial in a laser-based practice [12].
An in-house audit could address weaknesses in
the informed consent process and minimize
liability.
Acknowledgement  Funding sources: There are no fund-
ing sources for this work.
Conflict of interest: The authors have no conflict of
interest to declare.
References
1. Goldberg DJ. Legal considerations in cosmetic laser
surgery. J Cosmet Dermatol. 2006;5:103–6.
2. ASDS survey: skin cancer, cosmetic procedures jump
22 percent in 2013. Available at
net/_Media.aspx?id=7744. Accessed 1 Sept 2014.
3. Jalian HR, Jalian CA, Avram MM. Common causes
of injury and legal action in laser surgery. JAMA
Dermatol. 2013;149:188–93.
4. Svider PF, Carron MA, Zuliani GF, Eloy JA, Setzen
M, Folbe AJ. Lasers and losers in the eyes of the law:
A. Torres et al.

503
liability for head and neck procedures. JAMA Facial
Plast Surg. 2014;16:277–83.
5. Greve B, Raulin C.  Professional errors caused by
lasers and intense pulsed light technology in derma-
tology and aesthetic medicine: preventive strategies
and case studies. Dermatol Surg. 2002;28:156–61.
6. Fleischman M, Garcia C. Informed consent in derma-
tologic surgery. Dermatol Surg. 2003;29:952–5; dis-
cussion 955.
7. Armstrong AW, Kim RH, Idriss NZ, Larsen LN,
Lio PA. Online video improves clinical outcomes in
adults with atopic dermatitis: a randomized controlled
trial. J Am Acad Dermatol. 2011;64:502–7.
8. Goldberg D.  Laser dermatology. 2nd ed. Berlin:
Springer; 2012.
9. Lahti JG, Shabshin U, Lewis AT, Benedetto
AV. Pediatric cosmetic dermatology. Clin Dermatol.
2003;21:315–20.
10. Wagner RF Jr, Torres A, Proper S. Informed consent
and informed refusal. Dermatol Surg. 1995;21:555–9.
11. Friedman PM, Jih MH, Burns AJ, Geronemus RG,
Kimyai-Asadi A, Goldberg LH. Nonphysician prac-
tice of dermatologic surgery: the Texas perspective.
Dermatol Surg. 2004;30:857–63.
12. Cohen SN, Lanigan SW. Audit cycle of documentation
in laser hair removal. Lasers Med Sci. 2005;20:87–8.
31  Medicolegal Issues (Documentation/Informed Consent/Non-physician Operators)

505
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Photography of Dermatological
Laser Treatment
Shraddha Desai and Ashish C. Bhatia
Abstract
The art and science of photography has
evolved tremendously in the past decade, pro-
viding the practitioner of cutaneous laser pro-
cedures with a versatile and useful set of tools
to enhance this procedure, ultimately improv-
ing patient care. The use of photography in
cutaneous laser therapy is extensive. It encom-
passes the documentation of before-and-after
assessments and long-term reviews of various
skin conditions treated via laser therapy.
Treated lesions and/or any potential complica-
tions that may arise after a procedure can be
monitored closely. This is benefitted by the
ability to upload these photos directly to the
patient’s electronic medical record (EMR).
Here, the photographs are readily accessible
for follow-up patient visit and allows for com-
munication between physicians regarding
identification of lesions and the treatments
performed. Furthermore, outside of the clini-
cal setting photography is an invaluable tool in
the education of trainees, peers, and the gen-
eral public. However, appropriate and stan-
dardized digital photographs are essential for
these benefits to be realized.
Keywords
Photography · Dermatology · Digital camera ·
Digital single lens reflex (DSLR) · Electronic
medical record (EMR) · Tablet · Dermatologic
surgery · Standardized photos · Laser ·
Technique
Introduction
The use of illustrations and imaging has always
had an essential role in the practice of medicine.
In the field of dermatology, where visual identifi-
cation is imperative, the development of small
film cameras not only simplified the description
of lesions made by medical dermatologists, but
also allowed for pre- and post-procedural depic-
tions of interventions for surgical and cosmetic
dermatologists [1–3]. Now, with the advent of
digital cameras and its ongoing evolution, clini-
cians are able to apply this efficient technology to
cataloging outcomes of cutaneous laser therapy.
The applications for digital photography in
laser treatment are numerous. It can be used in
the assessment of the before-and-after appear-
ance of a lesion, thereby determining success
S. Desai
Dermatology Institute of DuPage Medical Group,
Naperville, IL, USA
A. C. Bhatia (*)
Department of Dermatology, Northwestern
University – Feinberg School of Medicine,
Chicago, IL, USA
Oak Dermatology, Schaumburg, IL, USA
e-mail: ashish@derm.md
32

506
rates and long-term reviews of various skin
conditions treated via laser therapy. Photographs
can also be used to monitor treated lesions for
any complications that arise post-procedure [1].
With the implementation of the EMR system,
digital rather than film photos are favored due
to the ease of integration into the medical
record. Photos are routinely used to teach stu-
dents, residents, patients, and staff about the
outcomes; both favorable and unfavorable, of a
laser procedure [3]. In order to gain the benefits
from digital photography, it is necessary to first
know how to operate a digital camera. The sci-
ence of photography, like medicine, is rapidly
evolving as technological innovations continue.
In spite of these advances, the fundamental
principles of photography remain unchanged.
Therefore, a proper understanding and imple-
mentation of photo-taking skills will continue
to aid in the value of photographs used to docu-
ment laser therapy. Disclaimer: Please note that
any mention of specific manufactured products
in this chapter is included only for their value
as examples at this time. There may very well
be faster, less expensive, and easier to use
equipment in the near future that will render
moot any recommendations or brand-specific
comments made here. Additionally, tablet
devices will only be discussed briefly in this
chapter.
Photography Equipment
• Clinical photography relies on the recording
of light, whether it is on film or via an elec-
tronic sensor.
• The required equipment for documenting
laser procedures includes: a digital camera, a
media card, a media card reader, and a
computer.
• Cameras and other photographic equipment
should be selected based upon the needs of the
practice. Portability, image capacity, image
quality, ergonomics, durability, and other sub-
jective factors play into such a decision.
Generally, there are tradeoffs for every deci-
sion point.
Regardless of the subject matter and photo-
graphic equipment used, there is one aspect of
photography that remains universal—the captur-
ing of light. Light has to be reflected off of an
object, passed through a lens, and then recorded
on either light-sensitive film or by a digital sen-
sor. In order for the image to be well-recorded, it
is necessary to accurately resolve the image at the
film plane or CCD (focus), measure and appro-
priately regulate the amount of light entering the
lens, and to account for the color of the light.
Good control of these three functions will result
in a sharp, adequately exposed, and properly col-
ored photograph.
Camera Types
• The main categories of digital cameras are
single-lens-reflex (SLR) type, Compact/
Subcompact (point-and-shoot) type, and
hybrid cameras. Because all offer various
advantages and disadvantages, there is no one
ideal camera type.
• Recently, physicians have begun to incorpo-
rate tablets into the clinical setting. This
allows for documentation of the patient
encounter and photographs of lesions of inter-
est; both of which can be uploaded directly to
the EMR.
• The digital camera selected for clinical pho-
tography should reflect the needs of the clini-
cian and the clinical setting.
In general, clinicians use what is called a
35 mm format camera for photographing patients
in the exam room or surgical suite. This name is
a misnomer, stemming from the days when the
camera film measured 24  ×  36  mm. It is still
unknown how this initially translated to 35 mm;
however the specifications for most digital cam-
eras and lenses reference this standard. Current
35 mm format cameras come in two basic catego-
ries: single lens-reflex (SLR) and compact (point-
and-shoot). The SLR is the most versatile and
some manufacturers refer to it as a digital single-
lens-reflex (DSLR) [4]. The advantage of this
camera is that it has the capacity to vary lenses,
S. Desai and A. C. Bhatia

507
which can be important when recording extreme
close-up images or when using the camera in
conjunction with other optical devices such as
microscopes. The other 35  mm camera type is
much smaller and can fit easily into a pocket
(subcompact) or purse (compact) [4]. Both SLRs
and compacts have the ability to use the same
recording media and produce sharp and well-
exposed
images
when
used
correctly.
Additionally, most are equipped with auto-focus
technology which permits the cameras to make
automatic exposures. Tablet cameras may be eas-
ier to use given the simple “tap” to focus and cap-
ture an image, however, they are unlikely to
provide the same picture quality as the DSLR and
subcompact/compacts.
Single Lens Reflex
In the early and middle part of the twentieth cen-
tury, most cameras consisted of two lenses that
were vertically mounted to the front of the cam-
era body. One lens enabled the operator to view
the scene while the other recorded the image.
Thus, these cameras were “twin lens” as opposed
to “single-lens,” made popular with the advent of
35 mm film. The single lens cameras were also
given the name “reflex” in reference to a penta-
prism and mirrors inside the camera that allow
the photographer to reflexively view the image
through the same lens that permits light passage
to the film. At the instant of exposure, the main
mirror in the camera body flips out of the way so
that light can travel unimpeded onto the film
plane. A disadvantage of SLR cameras is that due
to the necessary movement of the mirrors, the
camera body tends to be large and frequently
heavy. Without an attached lens, these cameras
typically weigh between 18 and 33 oz whereas
subcompact cameras weigh between 4 and 7 oz
and compact cameras weigh between 6 and 19 oz
[6]. However, an advantage of this technology is
that it allows for the use of a variety of lens and
flash options. Several lenses, like the wide-angle
zoom and macro (close-up) are easily attached to
the SLR camera body and are useful for lesion
characterization. Moreover, SLRs have also been
favored in the past by those who require the abil-
ity to set the exposure manually in order to
accommodate unique lighting situations. In
regards to the new digital or DSLR cameras,
many of the older lenses will still function with
the new digital camera body as long as the manu-
facturer is the same. Still, there may be some
minor formatting compromise due to the differ-
ent field of view of the digital media. Some man-
ufacturers, like Nikon™, Canon™, and Fuji™,
have overcome this by introducing reliable and
affordable digital SLR cameras that are compati-
ble with their current non-digital gear. In general,
the cost of good SLR and DSLR cameras ranges
from $150 to $3500 without lenses, although
recent advances in technology have driven the
price to $8000+ for some.
Compact/Subcompact
The other 35 mm format camera is the compact/
subcompact or point-and-shoot. Several years
ago, this camera was referred to as a “Rangefinder”
since this was the focusing mechanism it
employed. Currently, it is the overwhelming
choice of digital camera purchasers in the world.
The main advantages of this camera are its over-
all body size, LCD size, and economy. Because
compacts do not rely on a mirror system, they are
not limited to large body sizes and even when
equipped with a zoom lens, a subcompact and
some compacts will fit easily into a lab coat
pocket—a feat that cannot be managed by an
SLR. At times, the compact size can be problem-
atic for clinicians with larger hands as buttons
and dials on the camera are small. As a result, it
is recommended that clinicians physically test
cameras before purchase. They also have large
LCD (liquid crystal displays) screens so that the
photographer can preview and review a photo-
graph. Often, LCD displays on the SLR cameras
can only be used to review a picture taken, but
they cannot be used for preview. Additionally, the
average cost of subcompact and compact cam-
eras tend to be much lower than that of SLRs. In
general, they range in price from $100 to $450
[5, 6]. Likewise, with recent advances in the art
32  Photography of Dermatological Laser Treatment

508
of lens manufacture, many of the enhanced com-
pact cameras now compare favorably with the
single lens reflex models for most medical situa-
tions. This is especially true if the purpose of the
image is to document relative sizes and locations
of lesions or defects. The majority of these mod-
els come equipped with zoom lenses that can
offer a range of different focal lengths thus emu-
lating, if not equaling, the chief feature of SLRs.
One shortfall of compact cameras is their flash
capability. Most have a very small “pop-up” flash
built into the camera body. Therefore, when
shooting very close to or more than 9 ft from the
subject, the flash can result in overexposure of
the image or be considerably underpowered in
lowlight conditions. However, these situations
can be avoided by using the optical zoom capa-
bilities of the camera while standing at approxi-
mately 4–5 ft from the subject.
Several manufacturers also offer a hybrid
DSLR/compact camera which is thought of as
“SLR-like.” This camera type is larger than most
compacts due to the accommodation of a partic-
ularly un-compact-like lens. This lens, while
larger and of a greater zoom capability than
other compacts, is not interchangeable. Still, the
larger lens may have a better close-up capability
and the camera itself has an option for an auxil-
iary flash. Overall, the camera has the look of a
DSLR without many of the inherent SLR
disadvantages.
Tablet Devices
Although earlier models have been available
since the 1990s, tablets have gained popularity
since the mid-2000s. These devices come stan-
dard with a camera and their main advantage is
the ease of use and ability to upload directly to
EMR systems. Tablets are equipped with a
“Camera” app, which once opened, show an
LCD screen similar to that of the SLRs and com-
pact cameras. Autofocus features and tapping the
screen to capture images make operating this
camera possible at any skill level. The megapix-
els range from 5.0 to 8.0, may come with or with-
out a flash, and cost varies from $329 to $929.
Many EMRs are set up to transfer the photos
directly to the patients’ chart from the tablet once
connected to a PC. Low light performance is
often an issue with the cameras on tablet devices,
so bright and consistent lighting should be used
whenever possible.
Lenses
• SLR cameras have the ability to exchange
lenses for different purposes, while compact
cameras generally have non-interchangeable
lenses with versatile features.
• Due to the nature of dermatology and derma-
tologic surgery, macro or “close up” capabil-
ity is a must when choosing a camera.
• With digital cameras (compact/subcompact
and tablets), avoid using the “digital zoom”
feature since it can degrade image quality.
No matter which type of digital camera is
selected, it is helpful to have a simple familiarity
with lenses. The choice of lens is generally deter-
mined by the purpose of the camera as well as
budgetary and shooting space constraints. If the
intent is to record full body images, it will be nec-
essary to either have a good amount of room in
which to physically back up, or to use a wide-
angle zoom lens. Should the practice be confined
to facial surgery for instance, a normal or short
telephoto lens is adequate. Still, in nearly all
practices the nature of the subject seems to
require at least some macro or close-up
capability.
Wide Angle Zoom
Zoom lenses are often used in smaller examina-
tion rooms to take full-body photographs of
patients. This type of lens is especially useful in
displaying the distribution and pattern of a whole-
body rash [5]. They are designed such that the
internal elements can alter position and produce a
variable field of view, thus capturing the entire
area of focus. The majority of compact cameras
come equipped with zoom lenses as standard
S. Desai and A. C. Bhatia

509
equipment. Most SLRs, however, are sold with a
normal lens and have the option of mounting
other fixed focal length or specialty lenses like
wide-angle zooms. In general, most digital
­cameras contain both optical and digital zoom
capabilities. An optical zoom is like that of an
older film camera. The camera alters its focal
length by changing the position of internal lens
elements. The optical zoom is frequently favored
over the digital zoom, because this camera utilizes
high quality optic lens technology. What has com-
monly been referred to as “digital” zoom does not
involve optics, but rather is an electronic cropping
of the image in the camera’s viewfinder followed
by enlargement. This in turn results in a lower
quality image than a photo taken with an optical
zoom lens. Therefore, it is better not to rely on
digital zoom, but instead, use the digital camera’s
optical zoom feature whenever possible.
Macro or “Close-Up” Lenses
Macro-lenses are used to focus the camera within
millimeters of the lesion in question. This allows
for certain characteristics such as texture and
color to be visualized with great detail [5]. If the
dermatologist’s camera of choice does not have
the mounting capability for different lenses (like
SLRs), the built-in lens should be able to focus
on up-close objects. Unfortunately, many lower-
priced cameras are not manufactured with this
capability. For dermatologic surgery, it is most
appropriate to have a macro-lens that can capture
an image at a 1:1 (subject to film) ratio. At this
setting, a photographed area would be repro-
duced at exactly the same size on the film or
media card as in reality. For 35 mm film, the sub-
ject will cover an area that is 24 × 36 mm; ade-
quate for recording a small lesion. However, not
all close-focusing lenses have a 1:1 capability.
Therefore, it is important to ask about this feature
prior to purchasing a lens.
Note that a lens that has macro capability also
functions as a regular lens that is dependent on its
focal length. This length will determine how far
away the photographer can be while taking both
normally-focused and macro pictures. At our
facilities, we’ve determined that the most appro-
priate macro-lens length for obtaining photo-
graphs of patients and surgeries is 105 mm. This
length allows for close focus of images while the
camera remains at a reasonable distance from the
site of interest. This also makes the situation
more comfortable for both the patient and
surgeon.
Flash
• Using the camera flash (instead of relying on
ambient lighting) allows for image consis-
tency, adequate depth of field, good color, and
proper exposure of photographs.
• A hot shoe is a port on a camera that allows for
an external flash unit to be mounted. This flex-
ibility is desirable if shooting in situations that
require complex external flash setups.
Regardless of office quality or surgical suite
lighting, it is best not to rely on these as primary
light sources. Instead, use the camera flash. It
facilitates image consistency, adequate field
depth, improved color, and appropriate exposure.
An electronic flash produces light that simulates
daylight, so that color balance is not required.
Many newer cameras come with a small flash
unit that is adequate for this in most cases.
However, for images requiring a more profes-
sional look, or for the flash to function farther
than 9 ft for full-body shots, it will be necessary
to supplement the camera with an additional flash
unit. When shopping for a camera or flash, it is
important to note that flashes are rated by their
light output by a “guide number” (GN). A guide
number of 80 or higher (at ISO 100) is adequate
for most dermatology needs.
Flash Options
SLRs have the option to not only exchange
lenses, but flashes as well. This is accomplished
with the aid of a “hot-shoe.” A hot-shoe is a flat,
horizontally mounted, square-shaped socket on
top of the camera that attaches to an external flash
32  Photography of Dermatological Laser Treatment

510
unit. Most of these units have a number of electri-
cal contacts on the socket (metal dots) that mate
with similar contacts on the flash that allow for
communication between the flash and camera. A
ring flash is a unique flash unit that can be
attached via the hot-shoe and has the ability to
eliminate shadows by casting light in all direc-
tions. This can be quite effective if the intent is to
evenly illuminate and record a flat field. It is also
useful for photographing within deep surgical
defects or cavities (like the oral cavity), since no
shadow will be created by the depth. On the other
hand, this even lighting can be a drawback if the
intent is to illustrate a lesion or rash that has a
subtle texture. The major disadvantage of the ring
flash is that the emitted lights are almost univer-
sally underpowered.
As a result, illumination of a full human figure
will often result in underexposure. Still, the ring
flash remains adequate for taking close-focus
photographs. Another flash option is a point flash.
Any flash that can be “pointed” at the field either
by removing it from its mount or by using a mov-
able flash head feature can be called a point flash.
The advantage of this type of flash is that the
angle of light in relation to the photographed
object creates a slight shadow that reveals shape,
contour, and topography. If it is important to dis-
play the depth, height, or texture of a dermato-
logical feature, this type of flash is far superior
to a ring flash. Digital compact cameras do not
have the ability to exchange flash units and
instead contain a built-in flash that may not be
able to produce adequately-exposed photographs.
Additionally, many compact cameras require bat-
teries, so in order to maintain these for a longer
period of time; the flash often has to be reduced
in size and output potential. In order to circum-
vent this, an auxiliary flash can be used.
An auxiliary flash can either be connected
directly to the camera or can be triggered at the
right instance by some other means. Since some
lower-priced compacts and SLRs do not have a
PC socket or hot-shoe for flash connection, one
can use a photo cell as an auxiliary flash. A photo
cell is comparable to a wireless remote, but
instead of controlling a television set, it fires a
flash of light when it senses another flash (the
one built into the camera). Photography studios
have done this for several years, and refer to it as
a “slave” flash unit. Several manufacturers of
slave units can provide the medical photographer
with adequate lighting in virtually all scenarios.
Note that many digital cameras use a series of
rapid low-power “pre-flashes” in order to set the
camera white balance for a shot and to reduce
the “red-eye” effect. These pre-flashes can there-
fore trigger the slave flash at an inappropriate
time. Be certain that the camera has a setting to
disable the pre-flash, or that the slave flash has
the ability to filter out the flashes from its trig-
gering cycle.
White Balance
• Adjusting the white balance on the camera
prior to taking photographs can compensate
for the unnatural color in photographs from
varying ambient light sources.
All light has color, but this often goes unno-
ticed as our brains color-correct light without any
conscious effort on our part. Each light source
produces a particular wavelength which is identi-
fied by degrees Kelvin and commonly referred to
as the light’s “color temperature.” Digital cam-
eras correct for color temperature with “white
balance.” Since daylight, or white light is the
standard by which we measure color, yellow is
usually seen as yellow, green as green, and so on
and so forth. However, when an artificial light
source is introduced, like fluorescent lighting in
the office, the color of light takes on a green
tinge, especially when viewing human skin. The
camera unfortunately records this color very
well. For this reason, we must make adjustments
to the “white balance” setting of a camera if sub-
jects
are
photographed
under
fluorescent
lighting.
The same holds true for tungsten lighting
found in common filament light bulbs and for the
tungsten/halogen hybrid bulbs found in many
surgical rooms. Fortunately, an electronic flash
is designed with a color temperature that approx-
imates daylight so a flash photo is the most
S. Desai and A. C. Bhatia

511
color-precise image when taken with a daylight
white balance setting. Most digital cameras
come with menu preset options that change the
color sensitivity of the camera for various light-
ing ­situations. These may be adequate for certain
situations, but for the most effective and accurate
recording of color, it is advisable to use the “cus-
tom white balance” option which is explained in
the camera manual. If the custom white balance
procedure is followed properly, there will be no
need to repeat the process each time the same
room and light source is used. Under no circum-
stances should one rely on a common setting
called “Auto White Balance” or AWB.  This
option is not able to replicate daylight effectively
and because color reproduction is critical to
medical
photography,
AWB
is
not
recommended.
Focal Ratio
The focal ratio, also known as the f-ratio, f-num-
ber, or relative aperture, is the ratio of the lens’
focal length, or the distance from the lens to the
point over which initially collimated rays are
brought into focus, to the diameter of the aper-
ture: N = f/D [7]. F-numbers are usually preceded
by f/. For example, if a lens’s focal length is
10 mm and its diameter is 5 mm, the f-number is
2 and the aperture size would be expressed as f/2.
In general, a lens with a greater f-number proj-
ects darker images. To focus on a subject, while
de-emphasizing the fore- and background, a
small f-number can be used (wide aperture, short
focal length). On the other hand, if multiple sharp
objects are required, a high f-number should be
used [7].
Digital Media
• Images stored by a digital camera are recorded
onto digital media.
• There is an assortment of digital media for-
mats and technological advances ensure
increasing memory capacity and newer
designs.
• Digital cameras can typically only use specific
types of digital media, so it is important to use
the right variety.
When a photograph is taken with a digital
camera, light passes through the lens onto the
image capture device. This is commonly a
charge coupled device (CCD). It is a film-sized
wafer that is embedded with millions of light
sensing units called pixels that filter red, blue,
and green (primary colors) light. With exposure
to light, the pixels transmit light data along
with its position in the array to a micro-proces-
sor which then translates this information into a
coded pattern. This pattern is called a file for-
mat and the information it contains is passed
along to the memory module (media card) for
storage. The media card is the “film” of digital
cameras and its storage size ranges from 64
megabytes (MB) to 128 gigabytes (GB). The
larger the storage size, the more photographs
that can be stored. Presently, there are about
eight memory card types that work in digital
cameras. These include the compact flash (CF),
secure digital (SD), smart media, multimedia
card, memory stick, XQD and xD cards. Most
formats have a large range of capabilities and
are more than adequate for recording photo-
graphic images. Remember that memory card
types are not interchangeable. A single memory
card can only be used in a camera that accepts
that type of storage device. However, each card
can be used repeatedly. And in order to do so, it
will be necessary to empty the card or down-
load the images into a computer once the mem-
ory card becomes full. A useful downloading
accessory for a digital camera is a memory card
reader. These small devices connect to a com-
puter USB port and can accommodate various
memory cards. Once the card is inserted into
the reader, the images can be downloaded into
the computer. The advantage to downloading in
this fashion as opposed to connecting the cam-
era directly to the computer is that because the
camera isn’t required, its battery power is
saved. Most memory card readers are also inex-
pensive and range in price from $10 to $50. The
main disadvantage of using memory cards for
32  Photography of Dermatological Laser Treatment

512
downloading is the risk of damaging the card or
reader contacts with repeated insertion and
removal of the card.
Mega-Pixels
• Mega-pixels reflect the amount of information
or detail contained within an image.
• Larger mega-pixel images contain more detail,
but also require longer transfer times for
recording and greater space for storing the
image.
Mega-pixel refers to how many “picture ele-
ments” (pixels) are on your CCD or comple-
mentary metal oxide semiconductor (CMOS)
chip that are exposed to light reflected off of a
subject. The prefix “mega” means “millions of,”
and each pixel is the smallest unit in the photo-
graph that can be assigned a unique color.
Increasing the number of pixels that makes up
an image increases the detail but only up to a
point. As the number of mega-pixels enlarges,
so does the file size (the amount of space
required to store the image) and the burden of
handling it. Large file sizes can slow down the
recording of the image onto a memory card, the
transfer of the images into a computer, and the
processing of images by editing software.
Moreover, multi-mega-pixel digital cameras
produce just as much detail as 35  mm format
cameras of 10 years ago, and even high mega-
pixel cameras (8  mega-pixels and higher) are
not necessary to attain publisher quality images.
For the purpose of dermatologic surgery and
laser treatment, obtaining a 1.5–2.5 mega-pixel
image will be more than adequate.
Submitting Images for Publications
• Publishers have specific requirements for
accepting and reproducing images.
• It is important to be familiar with the parame-
ters mandated by a publisher prior to submit-
ting images in order to obtain the best quality
reproduction in the publication.
At present, most publishers of medical jour-
nals and texts are producing their material
entirely with digital equipment. In the “instruc-
tions for authors,” most publishers will specify
the parameters for submission of digital images.
In general, the guidelines are as follows.
Resolution: Publishers specify image resolu-
tion in pixels per inch (ppi). Higher ppi equates
better reproduction quality in most cases.
However, it is also true that a resolution that is
greater than that used by the output device is
simply wasted information. For almost all appli-
cations, a resolution of 300  ppi is reasonable.
Some programs, like PowerPoint™, find a reso-
lution of 150 ppi ideal. Images from digital cam-
eras are generally transferred to the computer at
a resolution of 72 ppi. This may seem inadequate
until the actual image dimensions (height and
width) are taken into account. In most cases, the
camera saves images at much larger print dimen-
sions than necessary. Many image enhancement
software programs can be used to change the
image size and adjust the ppi for a faster down-
load. For instance, if an image is saved at 72 ppi
and at 20 × 30 in., one can reset this value to
300 ppi, and the image size will be automatically
reduced to about 5 × 7 in. The file size of the
image will not change, but the download rate
will be faster.
Dimensions: This is the actual print size of the
file in inches (or cm or pixels) measured around
the outside of the image. Usually a 4 × 6 in. or
5 × 7 in. image is adequate for office use. For
publications, check the “instructions for authors”
for specific requirements.
File Format: This describes how the applica-
tion that created the file encodes and stores the
information.
To
use
digital
pictures
in
PowerPoint™, save them as BMP, JPG or TIF
format.
Popular Graphic File Formats
BMP: Windows bitmap. A Microsoft™ creation
that is 32-bit raster, and has the capability of
using limited LZW (lossless) compression. When
used in PowerPoint, however, these images are
S. Desai and A. C. Bhatia

513
frequently too large to load quickly and project
appropriately.
GIF:
CompuServe
GIF™-Graphics
Interchange Format. This is a format that was
invented by CompuServe™ primarily for images
viewed on the Internet. It is limited to only 256
colors (8 bits per pixel), but has several advan-
tages when used in its Internet role. It utilizes
lossless compression, which when combined
with a limited color palette, can result in small
file sizes. It also has the capability of using
“transparent” as one of its colors and in its 89a
revision, it is used to save and display simple ani-
mations. Consequently, it is an adequate format
for line drawings or logos, but not for
photography.
PNG: Portable Network Graphics. Also pro-
nounced “ping”, was created as a replacement for
the GIF format. It is presently the most common
lossless image compression format on the inter-
net. It is best used to transfer images, but not
ideal for professional or medical use.
JPG: Joint Photographic Experts Group. Also
written as JPEG and pronounced “jay´-peg”, this
is another popular Internet format. The main dif-
ference between this and GIF is that JPG files are
in a raster image format of up to 24 bits per pixel.
Thus, a JPG is the preferred format for images
that have more than 256 colors (full color pho-
tos). The JPG compression scheme allows one to
manually determine the amount of compression
to apply to each file. Although this results in a
smaller file size, image quality is degraded as the
file is further compressed [5].
TIF: TIFF (TIF) or Tagged Image File Format
is the industry standard for a cross platform,
multi-use raster image format that can be opened
by almost all graphics applications. These files
employ non-degrading compression. This is the
ideal format for saving images with the best
quality.
Shooting Techniques and Tips
Possibly the most vital element of good surgical
photography is consistency. Just as the use of
standard procedures in a practice result in effi-
ciency and high quality care, standard procedures
for photography should also be implemented to
provide consistent, high quality photographs. See
Table 32.1.
• Prior to any clinical photography, be sure to
obtain written informed consent from the
subject.
• Though a dedicated room for photography
offers the best situation for clinical imaging,
exam room photography can yield consistent
results if good technique and practices are
regularly utilized.
Prior to taking the first photograph of a patient,
it is imperative that the patient signs a photograph
consent form [8, 9]. This can be and often is
incorporated into the consent for treatment.
The form should clearly state that the patient
relinquishes all rights to payments and royalties
that may accrue from any use of the images.
Samples of photo consent forms may be obtained
from the photography department of a local med-
ical school or the local professional photogra-
phers’ guild. Have an attorney review and alter
such a form to suit the requirements of the prac-
tice and keep one in every patient chart. The ideal
office has a location that can be set aside exclu-
sively for photography. There patients can be
photographed, equipment can be stored securely
and a space can be provided for review and stor-
age of these photos [8]. This is often not possible
in busy practices, so compromises must be made,
with an emphasis on retaining consistency and
image quality. The space chosen should ideally
meet the following standards:
Table 32.1  Clinical photography checklist
Obtain informed consent
Remove any unnecessary objects in photo field
Use a neutral background
Take a photo of patient sticker prior to clinical photos
Clean off any make-up
Take photos in standardized manner, ie frontal, lateral,
oblique views
For macro images, use a ruler to demonstrate size
Add patient information to photo log book
Repeat steps for subsequent visits to ensure
reproducibility
32  Photography of Dermatological Laser Treatment

514
• It needs to be large enough to accommodate
the requirements of whatever lens will be used
to shoot the broadest image (Distance to
subject).
• It must have adequate lighting that will help
illuminate the subject without overwhelming
the color balance characteristics of the flash. If
the room has windows, opaque blinds can help
keep the ambient lighting consistent regard-
less of the time of day.
• It must have a reasonably neutral background
with no distractions. The most popular colors
for patient clinical backgrounds is light blue
or black.
• It must have facilities for patient privacy and
comfort. A changing area is ideal, or simply a
chair and some provision for hanging clothes.
• It should have a secure cabinet or closet where
camera gear and adequate media is readily
available so that the clinician needn’t be
searching the office for another lens or back-
up memory card. Clean legible measuring
devices should also be kept here for inclusion
in certain photo fields.
• Near the camera cabinet, there should be an
electrical outlet where the battery charger for
camera and flash batteries is kept plugged-in.
Good lithium-ion rechargeable batteries are
ideal.
• A small desk or table must be present for writ-
ing photo information during the session.
In order to accurately represent the results of
treatment or surgery it is essential that there is
consistency in the photographic procedures.
This can be done by minimizing the variables in
the photography setup. The locations of the
patient and cameraperson can be marked with
tape on the floor. A “photo log” that records
what poses, what camera settings, and what
exposures were made at previous sessions with
the same patient, can be quite helpful. If possi-
ble, before and after type shots should be made
with the previously shot images available for
reference either printed or displayed on a moni-
tor. Establish proper exposure and/or camera
setting information for various shooting dis-
tances through testing. Write this information
on a small piece of paper and tape it to the top of
the flash or the back of the camera. Then, when
any of the office staff needs to take pictures,
they can simply determine the distance to the
subject and refer to the exposure and settings
information written on the guide. This will go a
long way toward establishing a consistent expo-
sure and tonal range in pictures taken on differ-
ent days. It is also important to eliminate any
unnecessary distractions in the photograph.
These can range from background features to
clothing or jewelry worn by the subject, or arti-
cles of clothing. If an object appears in the
viewfinder that has no relevance to the subject at
hand, move it or crop it out later.
Photographic Technique
A professional photographer always keeps in
mind a clear idea of what it is he or she is
about to shoot. This is essential for clinicians
as well. Location and orientation of the condi-
tion can be best shown by first shooting an
image that includes recognizable features such
as face, hands, or feet. When shooting a stand-
ing person, rotate the camera 90° and shoot a
vertical shot to eliminate wasted space in the
photo to the left and right of the patient. This
also allows for greater subject size and thus
more detail in the image. Since this is an
unnatural shooting position for some, care
should be taken to see to it that camera straps
or flash cords do not fall across the lens. Once
the orienting photos are complete, the next
shots should include the total range or extent
of the condition being photographed. Be sure
to include all borders of the area of interest so
that these can be ­compared to the same regions
in subsequent ­post-treatment visits. Once
again, it may be advantageous to shoot verti-
cally. Finally, the last images should be those
that record close-up details that are represen-
tative of the subject matter or that provide a
highly detailed view of a particular area of
concern. At least one of the detail photos
should include a measuring device in the field
to accurately represent the size of the features
shot close-up. Use a small cm scale that is
made of a non-reflective material.
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515
Pre and Postoperative Facial
Photography
Standardizing the poses used in preoperative and
postoperative photography allows the viewer to
objectively compare the images taken at different
points in time [10]. A procedure should be estab-
lished to consistently pose the patient in these
situations. Positioning aids with fixed distances
and chin rests may be used. Alternatively, the staff
can be taught basic posing techniques allowing
for imaging in smaller rooms without the expense
of positioning aids. One technique often used in
cosmetic surgery photography involves position-
ing a patient through five poses at each photo ses-
sion. These views include a frontal view, two
oblique views, and two lateral views (Fig. 32.1).
The camera should be positioned at a fixed dis-
tance from the subject, at a height approximately
level with the subject’s mid-face. The frontal and
lateral views are self-explanatory. However, the
oblique view can be consistently captured using
the technique where the tip of the nose should
align with the most prominent edge of the distal
cheek. Another option is to use alignment soft-
ware such as Photoshop Adobe CS5. Each photo
can be aligned to the previous photo by manually
selecting points on anatomic landmarks, which
will help line up pre and post pictures [11].
Surgical Photography
In surgery, there are concerns with keeping the
field free of contaminating items such as cam-
eras and lenses. Obviously, it would be most
appropriate to have someone who is not
scrubbed-in to handle the camera. This person
should understand both how the camera works
and what it is that needs to be photographed.
Have appropriate stands and stools on hand for
the camera operator to easily get above the field
for the most effective angle. If the camera is
equipped with an auxiliary flash and/or battery,
the cords connecting these devices should be
taped down prior to surgery so they do not fall
into the field if the camera is positioned above it.
Make the first image of each procedure a shot
that will identify the patient, such as the patient
identification sticker or a card with this informa-
tion printed on it. Certain operating room light-
ing conditions are different than will be
encountered in the office setting and may require
some exposure compensation. For this reason, it
is prudent to take some practice photographs
prior to the procedure. If gestures need be made
in photos to point out a small artifact such as a
stitch or tiny vessel, do not use fingers to do so.
Keep the presence of hands to a minimum in
photos and instead indicate the area with a
Fig. 32.1  Standard positioning for full facial photography. (a) Frontal view, (b) Oblique view (note nasal tip lined up
with margin of posterior cheek) and (c) Lateral view
a
b
c
32  Photography of Dermatological Laser Treatment

516
straight clamp, pick-ups, or other such blunt but
slim devices. It is a sign of professionalism and
pride if the field and any instruments or gloves
that must be shown in a surgical photo are wiped
clean of blood prior to taking a photograph.
Also, if the periphery of the operating area is
draped with blue towels, be sure that fresh clean
ones are available to cover those that have been
stained with fluids. Maintain suction in deep
wounds right up until the image is made. Pools
of blood are very distracting in photographs and
can in fact obscure areas of interest. Similarly, if
the wound is wet from irrigation or from wiping
with wet sponges, quickly pat it dry just before
the shot is taken in order to reduce the incidence
of specular highlights. When shooting excised or
extracted gross specimens, use a clean blue
towel as a background. Images of specimens
should be photographed in their correct anatomi-
cal orientation and with at least one of the images
including a size scale placed just far enough
away from the tissue that it may be easily
cropped out later if necessary [6]. In the case of
Mohs surgery where multiple stages may be nec-
essary, it’s possible that more than one patient
may be treated at a time. In this instance, it’s
imperative to take a photo of the patient sticker/
chart prior to capturing the clinical photo to
ensure proper documentation of the correct
patient.
Final Thoughts
• Current digital camera technology has come
to the threshold where it is now virtually indis-
tinguishable from 35  mm image quality for
most dermatologic purposes.
• If you purchase a good digital 8 mega pixel
SLR camera system, you will soon recover
your investment in film and processing costs
as well as save on office expenses and per-
sonnel time.
• In dermatology perhaps more than any other
medical discipline, well-crafted imaging skills
can enhance your career even as it helps you
to be of greater value to your profession and
your colleagues and of a greater service to
your patients.
References
1. Acetta P, Acetta J, Kostecki J.  The use of digital
cameras by US dermatologists. JAAD. 2013;69(5):
837–8.
2. Sasson M, Schiff T, et al. Photography without film:
low-cost digital cameras come of age in dermatology.
Int J Dermatol. 1994;33(2):113–5.
3. Stone JL, Peterson RL, et al. Digital imaging tech-
niques in dermatology. J Am Acad Dermatol.
1990;23(5 Pt 1):913–7.
4. Bhatia AC, Desai S, Brodell RT, Horvath MM. Digital
photography. eMedicine website. Available at http://
emedicine.medscape.com/article/1131303-overview.
Accessed 1 July 2010.
5. Chilukuri S, Bhatia AC. Practical digital photography
in the dermatology office. Semin Cutan Med Surg.
2008;27(1):83–5.
6. Lin BB, Taylor RS, et al. Digital photography for map-
ping Mohs micrographic surgery sections. Dermatol
Surg. 2001;27(4):411–4.
7. Taheri A, Yentzer BA, Feldman SR.  Focusing and
depth of field in photography: application in derma-
tology practice. Skin Res Technol. 2013;19:394–7.
8. Kunde L, McMeniman E, Parker M.  Clinical pho-
tography in dermatology: ethical and medico-legal
considerations in the age of digital and smartphone
technology. Australas J Dermatol. 2013;54:192–7.
9. Lakdawala N, Fontanella D, Grant-Kels JM. Ethical
considerations in dermatologic photography. Clin
Dermatol. 2012;30:486–91.
10. Bhatia AC, et al. The clinical image archiving clini-
cal processes and an entire specialty. Arch Dermatol.
2006;142(1):96–8.
11. Balakrishnan N, Sathish BP, Handattu S.  A simple
instrument designed to provide consistent digital
facial images in dermatology. Indian J Dermatol.
2013;58(3):194–6.
S. Desai and A. C. Bhatia

517
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Online Resources of Dermatologic
Laser Therapies
Shraddha Desai, Elizabeth Uhlenhake,
and Ashish C. Bhatia
Abstract
The internet is an abundant and easily acces-
sible source of current health-related informa-
tion for both patients and physicians.
Physicians can harness the power of the inter-
net to keep up-to-date on developments in
their field and review the literature on a regu-
lar basis. They can also help direct patients to
accurate and reliable resources which are
geared towards the general public. Proper
guidance of patients and their families can
help make the internet a valuable tool for
education.
Keywords
Internet · Resources · Dermatology · Laser
AAD · ASLMS · ASDS · Online search
Patient education
Introduction
The internet has revolutionized the way in which
both lay-people and health care professionals
seek out and research information regarding
health care topics and specific disease conditions
[1, 2]. An updated report states that approximately
80% of adult Internet users have conducted
searches online for health or medical information
[1–3]. With increasing access to the internet and
rising familiarity with search engines, this per-
centage continues to grow. Aside from accessibil-
ity and convenience, the Internet is superior to
most paper-based medical resources due to the
ease of updating information to reflect the most
timely and current data. The wealth of knowledge
that can be obtained from the Internet however,
has its drawbacks. Unfortunately, there is no con-
trol over what information can be accessed and
anyone, from a physician to common layperson,
can contribute information regardless of accuracy.
This can lead to misinformation that ultimately
results in mistakes and malpractice [4]. In order to
prevent this from occurring, websites should be
critically analyzed to determine their validity, reli-
ability, and credibility. This holds true for anyone
using such information from a website, but espe-
cially for physicians. It is imperative for physi-
cians to provide their patients with a means of
evaluating different websites and using only the
most reliable and precise sources to prevent medi-
cal ­misunderstandings. In doing so, patients will
S. Desai
Department of Dermatology, The Dermatology
Institute of DuPage Medical Group, Naperville, USA
E. Uhlenhake
The Dermatology Group, Mason, OH, USA
A. C. Bhatia (*)
Department of Dermatology, Northwestern
University – Feinberg School of Medicine, Chicago,
IL, USA
Oak Dermatology, Schaumburg, IL, USA
e-mail: ashish@derm.md
33

518
get a sense of empowerment over their condition,
knowing that only the most relevant information
is being provided to them. Therefore, physicians
should improve their patients’ knowledge by sup-
plying them with a list of highly reputable web-
sites; an action commonly desired by patients
according to recent studies [5, 6]. The guidelines
for evaluating websites that provide information
on cutaneous laser therapies are reviewed here.
Internet Website Quality Evaluation
In evaluating the quality of a website, there are
several indicators which can be used to measure
the usefulness of the information presented.
These include, but are not limited to: easy identi-
fication of the background and significance of the
authors, the recent nature of information and its
stability, the time since the last update of infor-
mation, the completeness of the information and
its ability to match the searcher’s needs, the
domain of the website, comparability with other
resources, and the ease of use [7, 8]. Table 33.1
highlights the important details which should be
considered in each of these categories.
Websites for Physicians
Professional society websites offer valuable and
reliable information for physicians in addition to
links to other highly regarded sites. Access to
abstracts of peer-reviewed articles in medicine is
readily available, providing a convenient way to
keep abreast of the current literature. It is the phy-
sician’s responsibility to his patients to be critical
of any and all information that is retrieved from
the internet. Consequently, suitable sites pertain-
ing to laser therapies include those of well-known
societies that deal specifically with these proce-
dures. Such groups include the American
Academy of Dermatology (AAD), Skin Care
Physicians (from the AAD), the American Society
of Dermatologic Surgeons (ASDS), and the
American Society for Laser Medicine and Surgery
Table 33.1  Consideration in the evaluation of laser related websites
Easy identification of the background and authority of the authors
  •  Check the authors’ credentials
  •  Author’s level of education
  •  Experience author has in the subject matter
  •  Previous list of publications
Current information/update
  •  When was the information published and/or uploaded onto the Internet
  •  When was the information last updated
Stability of the information
  •  Will the information remain on the site
Information contained matches the searcher’s needs
  •  Focus on what you are looking for: laser therapy information, statistics, latest treatments, risks and benefits
involved, procedural techniques, complications arising during laser procedures, costs involved
Domain of the website
  •  Check the URL to see if it is someone’s personal page. If so, be sure to investigate the author thoroughly
  •  Is the website educational (.edu), nonprofit organizations (.org), commercial, or government (.gov, .mil, .us)
Comparability with other resources
  •  Look for a site with related links, explore other sites and publications by the author
  •  Check to see that the links to the other sources are on the same topic, well organized, and use the above
criterion to evaluate them
Ease of use
  •  Easy navigation of site
  •  Check to see if the information is targeted toward the physician or the patient
  •  Check if the speed and connection of your Internet is compatible with that of patients visiting this website
S. Desai et al.

519
Table 33.2  Web addresses of useful websites for physicians and patients
Website
Information for the
physician
Information for the
patient
MedicineNet
  
✓
Mayo Clinic
  
✓
The Hair Removal Journal
  
✓
Derm Net
  
✓
✓
American Academy of Dermatology
  
✓
✓
American Society for Laser Medicine & Surgery
  
✓
✓
American Society for Dermatologic Surgery
  
✓
✓
EMedicine
  
✓
✓
Skin Care Physicians (AAD)
  
✓
✓
Skin Care Guide
  
✓
✓
Journal of Investigative Dermatology Symposium Proceedings
  
full/5640219a.html
✓
Cochrane Library
  
✓
PubMed
  
✓
Medscape Dermatology
  
✓
Skin Therapy Letter
  
✓
(ASLMS).
The
Journal
of 
Investigative
Dermatology Symposium Proceedings and Derm
Net websites are also available options for infor-
mation on laser interventions. Additionally, jour-
nal abstracts provided by PubMed, eMedicine,
and the Cochrane Library are excellent sources
for up-to-date information. The web addresses for
these sites and others are provided in Table 33.2.
The AAD website is a practical site in which to
begin researching laser treatments due to its
extensive knowledge base and broad list of
resources and links. Dermatologists also have the
ability to learn about current issues like new treat-
ment options and management plans with
Dermatology World Online. Additionally, the
website contains links for the Journal of the
American Academy of Dermatology (JAAD),
Dermatology World publication, the Dermatology
Insights Journal (a patient-oriented journal), and
the medical web guide. As a result, dermatolo-
gists can safely recommend the AAD website to
their patients as a source of information on laser
procedures, with close attention paid to the
Dermatology Insights page and medical web
guide that offer links for patient education mate-
rial and support groups. Another website created
by the AAD is Skin Care Physicians which is
geared specifically for patients and dermatolo-
gists to use as a resource for the latest information
on the management of skin conditions including
33  Online Resources of Dermatologic Laser Therapies

520
hair removal, photorejuvenation, resurfacing, and
vascular procedures. It is an excellent tool that
provides patients with easy-to-understand expla-
nations and basic information regarding laser pro-
cedures. Another well-­known group is the
American Society for Dermatologic Surgery
(ASDS) and their website is appealing to derma-
tologists for several reasons. First, it contains a
physician discussion forum designed specifically
to begin a dialogue about laser procedures, includ-
ing advances in the latest technology and research
in the field. Dermatologists can also access recent
­information regarding dermatologic surgery pro-
cedures, guidelines, and upcoming educational
events and meetings. The site also contains links
to other websites providing additional informa-
tion on dermatology and laser procedures, local
research, and legislative advocacy groups.
Members of the group are given access to the
Journal of Dermatologic Surgery as well. Patients
also gain benefit from this website. Here they can
read reports about most dermatologic surgery pro-
cedures like laser or light therapy, laser hair
removal, nonablative skin rejuvenation, resurfac-
ing, and vascular treatment. The site also provides
fact sheets for each procedure with before and
after pictures and frequently asked questions.
Finally, patients can use the site to search for a
dermatologic surgeon by geographic region. This
is also true for the AAD website. The American
Society for Laser Medicine & Surgery (ASLMS)
website is another physician and patient-friendly
resource. It offers physicians guidelines for office-
based laser procedures, patient and procedure
selection, patient safety, and quality assurance. It
also addresses patient issues with a brief introduc-
tion to laser procedures, a physician locator fea-
ture, and safety tips for patients considering
dermatologic laser and light-based device proce-
dures. Additionally, it includes a checklist of ser-
vices each facility that performs such interventions
should maintain. Similar to other dermatology
organizations, ASLMS also provides access to the
Lasers in Surgery and Medicine journal, another
valuable resource for dermatologists. Another
site, the Journal of Investigative Dermatology
Symposium Proceedings, has laser hair removal-
specific information and provides the physician
with an overview on the physiology of the hair
follicle in order to discuss the latest strategies for
photo-­epilation. The website also contains a list of
clinical guidelines that is useful to dermatologists.
It is more physician-specific and therefore less
helpful for patients. On the other hand, the
DermNet website is good source of valuable
information on laser procedures and includes
material for both physicians and patients. A
patient information link leads the patient to data,
including history, effectiveness, indications, com-
plications, and adverse effects of various lasers.
Under the doctors tab, the site features numerous
quizzes and topics for laser discussions and offers
an extensive list of resources available for more
information. Another respectable website for
patients and dermatologists for continuing educa-
tion is eMedicine. This particular site notes the
history of laser procedures in addition to describ-
ing the various types of lasers that are currently
and were historically used for laser hair removal,
treatment of acquired and congenital vascular
lesions, and non-ablative resurfacing. General
principles and physics of laser therapy, indica-
tions, contraindications, clinical workup, follow-
up protocols, outcomes, and alternative therapies
are also discussed. Finally, PubMed, a National
Institute of Health (NIH) affiliate, offers an enor-
mous amount of information that encompasses
virtually all aspects of medicine. The information
obtained on this site is in the form of medical arti-
cles obtained from peer-reviewed medical jour-
nals. Thus, the information is limited to physicians
and not appropriate for patient use. Although
searches can be made for any medical specialty
and subject, dermatologists can specifically
search for articles relating to laser therapy.
Furthermore, many academic institutions offer
specialized access to PubMed that allows users to
view full text articles rather than abstracts for any
subscribed journal.
Websites for Patients
Many valuable online resources for physicians
have sections geared towards patient education as
well. Guiding patients to appropriate resources
S. Desai et al.

521
can be an asset in laser procedure education. This
also supplements any information given during
routine office visits. Patient-oriented websites are
discussed below. Many of the aforementioned
websites also provide useful knowledge for the
patient population. The American Academy of
Dermatology (AAD), Skin Care Physicians
(AAD), eMedicine, the American Society of
Dermatologic Surgeons (ASDS), and the
American Society for Laser Medicine & Surgery
(ASLMS) websites are of use to both physicians
and patients. Patients, in particular, can access
basic information about current laser treatments
and follow helpful links to a number of other
knowledgeable websites. This not only helps
them understand how the lasers operate, but what
to expect prior to, during, and after the treatment.
The Mayo Clinic also maintains a website for
patient inquiries on health-related topics. Similar
to other patient-geared websites, questions
regarding what the procedure entails, including
pictures, prep work for the patient, risks and long
term effects, eligibility for such treatments, and
typical results from laser resurfacing and hair
removal procedures, are all answered. The Hair
Removal Journal is also a great resource for
patients considering hair removal with lasers. A
frequently asked questions page contains infor-
mation on almost every aspect of the process,
including cost, where it can be performed, and
the effect of color-treated hair and tanned skin on
the process. This website is highly patient-­
oriented and provides a great deal of information
in a simple and concise way. And like the other
websites, it has links to related sites for more
information.
Final Thoughts
The internet is an expansive source of informa-
tion on numerous topics including laser treat-
ment modalities. Because of its availability
and low maintenance costs, it has become an
attractive alternative to the more costly and
time-­consuming process of paper publishing.
However, the ease of adding information in
spite of its credibility also makes it a tool that
must be used cautiously. Therefore, it is of
utmost importance for physicians to critically
assess the information obtained from websites
not only for themselves but also for their
patients. Implementation of the above men-
tioned methods of analysis can make the inter-
net an excellent resource for all that wish to
learn more about laser therapies and other der-
matologic procedures.
References
1. Fox S. Online health search 2006. Washington: Pew
Internet and American Life Project; 2006.
2. Fox S, Fallows D.  Internet health resources: health
searches and email have become more commonplace,
but there is room for improvement in searches and
overall Internet access. Washington: Pew Internet and
American Life Project; 2003. p. 1–42.
3. Diaz JA, Griffith RA, et  al. Patients’ use of the
Internet for medical information. J Gen Intern Med.
2002;17(3):180–5.
4. Murray E, Lo B, Pollack L, et al. The impact of health
information of the Internet on health care and the
physician-patient relationship: a national U.S. survey
among 1,050 U.S. physicians. J Med Internet Res.
2003;5(3):e17.
5. Diaz JA, Sciamanna CN, Evangelou E, et  al. Brief
report: what types of Internet guidance do patients
want from their physicians? J Gen Intern Med.
2005;20(8):683–5.
6. Murray E, Lo B, et al. The impact of health informa-
tion on the Internet on health care and the physician-­
patient relationship: patient perceptions. Arch Intern
Med. 2003;163(14):1727–34.
7. Tillman HN. Evaluating quality on the net. Babson
Park: Babson College; 2006.
com/findqual.html
8. University of California Berkeley Library. Evaluating
web pages: techniques to apply and questions to ask.
Berkley: University of California Berkeley Library;
2006. ­
internet/evaluate.html
33  Online Resources of Dermatologic Laser Therapies

523
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Starting a Laser Practice
Vic A. Narurkar
Abstract
The field of energy based devices has wit-
nessed an unparalleled growth in the last 10
years. The practicing physician is often over-
whelmed and confused with the decision of
how to integrate these devices into a practice.
The marketing materials associated with these
devices often override their actual clinical
merits. Moreover, elaborate terms of financing
these devices with unrealistic returns on
investment (ROI) can further confuse the
practicing physician. This chapter will review
some fundamental aspects on how to integrate
energy based devices in practical practice.
Keywords
Energy based devices · Lasers · Light sources
Radiofrequency · Ultrasound · Laser practice
Introduction
The field of energy based devices has witnessed
an unparalleled growth in the last 10 years. The
practicing physician is often overwhelmed and
confused with the decision of how to integrate
these devices into a practice. The marketing
materials associated with these devices often
override their actual clinical merits. Moreover,
elaborate terms of financing these devices with
unrealistic returns on investment (ROI) can fur-
ther confuse the practicing physician. This chap-
ter will review some fundamental aspects on how
to integrate energy based devices in practical
practice.
Integrating Energy Based Devices:
A Systematic Approach
The question that one often asks when starting a
practice is “what laser/light/energy” source
should I choose that will benefit most clinical
indications? Often, devices are touted as “one
• Different types of lasers or light sources
have specific functions for indicated
treatments
• Treatment options are based on cost-
effective methods
• Popularity of devices depends on histo-
logical data regarding pros and cons of
treatment outcomes
• Laser or light options chosen by physi-
cian depend on practicality of device
V. A. Narurkar
Department of Dermatology, California Pacific
Medical Center, San Francisco, CA, USA
e-mail: info@bayarealaserdr.com
34

524
size fits all,” where one laser or light source may
have a myriad of clinical indications. While this
is an ambitious goal, it is far from realistic. The
majority of devices do one or two things well,
and other indications are suboptimal at best.
Therefore, the first question one must ask is
“What procedure do I foresee being the most in
demand in my practice?” For example, in a der-
matology practice, a significant number of
patients seek care for vascular and pigmented
lesions. In a plastic surgery practice, the empha-
sis is placed more on rhytids and laxity. Thus, the
initial device that may be most optimal may
reflect the specialty of the physician, as well as
the clinical demographics of the practice.
Vascular and pigmented lesion treatments are
also often highly gratifying, as clinical improve-
ment of these entities is quite remarkable with
excellent photographic documentation showing
efficacy. Examples of “workhorse” devices for
vascular lesions include pulsed dye lasers, pulsed
KTP lasers and pulsed light sources. Examples of
“workhorse” devices for pigmented lesions
include Q-switched lasers (532, 694, 755  nm)
and pulsed light sources. Newer generation
pulsed light sources and newer generation pulsed
dye lasers are effective for the treatment of both
vascular and pigmented lesions, and, therefore,
may be a more cost-effective method for integrat-
ing a single device, as opposed to investing in
multiple devices. Resurfacing devices include
nonablative fractional lasers, ablative fractional
lasers and traditional ablative lasers. For plastic
surgery practices, resurfacing lasers are most
likely the first device of choice. While traditional
ablative resurfacing is highly effective, the down-
sides such as prolonged erythema, risks of
hypopigmentation and limitation to facial areas,
make these devices less popular in the twenty-
first century. The advent of fractional laser resur-
facing has reduced some of these risks. Thus, a
fractional laser resurfacing device is often the
ideal first device for a plastic surgery practice.
After investing in the initial device, expansion to
other devices in a systematic fashion is optimal.
For dermatologists, a resurfacing device, should
be the second device to integrate into a practice
and for plastic surgeons, a vascular/pigmented
lesion device fits this role. Afterwards, other
devices can be integrated in a step wise fashion
based on economic returns on the first two. These
include skin tightening devices, acne devices and
body contouring devices. The question of hair
reduction devices remains dubious. While this
procedure is highly effective, it has now become
much more commoditized and thus, should be
considered as an adjunctive procedure in both
dermatology and plastic surgery practices.
Moreover, the advent of home held hair removal
devices is further clouding the issue.
Costs of Devices: Direct and Indirect
When considering the purchase of an energy based
device, one must account for all costs—direct and
indirect. These include the cost of the capital
equipment (usually defined as a direct cost) and
the cost of consumables and service (usually
defined as indirect costs). Often, the latter two are
a significant portion of the overall cost of the
device. Indirect costs are associated with all
devices, regardless of the cost of “obvious” con-
sumables. “Obvious” consumables include tips.
Less obvious consumables include handpieces on
light sources which expire, flashlamps, cryogen
and parts of devices which expire. Finally, service
costs are a component of any device. Therefore,
inclusion of a service contract of reasonable terms
is advisable in the initial purchase of a device. It is
imperative to review the terms of the service con-
tract to see what is included similar to an automo-
bile “bumper to bumper” warranty. The longevity
of the device and the manufacturer should always
be considered when making a purchase. Recently,
several aesthetic companies have closed, leaving
buyers with unserviceable devices or unattainable
consumables.
Evidence Based Reviews and Peer
Reviews
The purchase of a device should integrate evidence
based review and a review by your peers. The first
is often underwhelming for devices, as many
V. A. Narurkar

525
devices may be a few years old. This should not
preclude some evidence based review, as the mar-
kets are now mature and many devices have numer-
ous peer reviewed publications to support their
claims. “White papers” should not substitute for
evidence based review, as these are usually spon-
sored marketing materials which should only be
used to supplement evidence based publications.
The next step after evidence based review, is to lis-
ten to your peers. Often, a manufacturer will pro-
vide names and testimonials from “experts” in the
field. It is imperative to ask these references of their
involvement with the company (e.g., was the device
gifted and what the terms were, was it a study, etc.).
With mature device markets, it is now easier to get
a true review by peers. This is more challenging
when one is considering the purchase of a newer
device with limited penetration in the field.
Rent Versus Lease Versus Purchase
Most manufacturers now provide in office dem-
onstrations of their devices in the practice and
many will leave the device in the office for a short
period of time for physician evaluation. This is
the optimal way of determining whether the
device will be a “fit” into the practice. When this
is not possible, renting devices is an excellent
opportunity to see if these devices are indeed
appropriate for the practice. Long term renting
does not make sense, as scheduling becomes dif-
ficult and the long term costs of renting are much
higher than leasing/purchasing the machine.
Some devices are amenable to renting, such as
tattoo removal devices or ablative devices, where
it may be feasible to schedule patients on a
restrictive basis. Whether to lease or purchase a
piece of equipment is based on the financial
health of the practice, the capital outlay and long
term plans for the device. Used devices have very
little value, and, like automobiles, once pur-
chased the value declines significantly. A lease
may be an easier way of integrating an expensive
device without the initial capital outlay; but, as
with all leases, one needs to review all of the
terms very carefully to determine “the final costs”
of the equipment. When purchasing/leasing the
equipment, negotiation of a service contract
within the initial cost of the equipment is highly
advisable.
Marketing
The central dogma of marketing is internal mar-
keting and is the most effective method for mar-
keting your business. Therefore, for mature
practices, when integrating a device into the prac-
tice, dissemination of the information of the
device to the existing data base in the form of
educational seminars, newsletters and web based
information is a very cost effective method for
marketing. New practices may benefit from
investing in external marketing. Many device
companies offer marketing incentives. Moreover,
most device companies have sophisticated web
based strategies such as “Find a doctor” which
can assist physicians to grow their practices. It is
imperative to link the physician website to the
manufacturer website for streamlining patient
referrals. Excessive external marketing is a waste
of time and money. If external marketing is the
main goal, target based external marketing is the
best approach. Finally, if the staff of the physi-
cian can benefit from any of the device based pro-
cedures, they should be offered treatment so they
can discuss the outcomes and benefit in a positive
way to grow the practice. As the practice matures,
marketing should be used primarily for branding,
as new devices are integrated into the practice,
the branding of the practice will enable existing
and new patients to consider these procedures.
How to Avoid Common Mistakes
The single most common mistake is to obtain
every single device on the market, buy every single
handpiece on a platform model and to get the latest
and the greatest. While it is tempting to be the first
kid on the block to offer the latest laser procedure,
this can be one of the greatest mistakes. Patients
are looking for results and good outcomes.
Disappointing outcomes and bad results can
destroy the reputation of the physician and the
34  Starting a Laser Practice

526
practice. The second most common mistake is not
accounting for all costs (direct and indirect) when
considering devices. The true overhead costs of
the device should include fixed and variable over-
head. For example, if it takes 60 min to perform
procedure X with device X and 30 min to perform
procedure X with device Y, the fixed costs should
be considered in the purchase price. A business
plan with a “real” return on investment (ROI)
should be included in all device based purchases.
One should not rely on the manufacturer’s
ROI.  Instead, the ROI should be based on the
maturity of the practice, the demographics of the
practice and the competition in the marketplace.
To Delegate or Not to Delegate
Energy based devices have rapidly become “dele-
gated” procedures. In our practice, we do not del-
egate any energy based device treatments. This is
not the norm in most practices. However, one
needs to assess several parameters before deciding
whether to delegate an energy based device proce-
dure. First and foremost, is it safe for this device to
be utilized by a non-physician? This is particularly
true of ablative devices. They really should only be
utilized by experienced physicians with a thor-
ough understanding of the skin. Second, what are
the state regulations of delegatable procedures?
Third, what is the financial value of delegation?
With the changing economy, many practices
which relied highly on “delegating” procedures to
non-physicians are seeing a sharp decline, as
patients get more conscious of spending dispos-
able income on procedures. Fourth, what is the
possibility of the non-physician going elsewhere
and having those patients follow them to a com-
petitor? While it may be impossible (as in our
practice) to perform all of the procedures yourself,
there are reasonable approaches. Before delegat-
ing any procedure to a non-physician, the physi-
cian should master the energy based device and be
aware of all of the complications and how to fix
them. When delegating the procedure to a non-
physician, direct supervision is optimal. Many
states are now mandating direct supervision
because of the plethora of complications from
inexperienced users. Finally, when delegating pro-
cedures, one should never lose the relationship
with the patient, as it is this critical bond that builds
and sustains a practice.
Conclusions
The field of energy based devices (lasers, light
sources, radiofrequency, and ultrasound) is
undergoing a true revolution. The physician is
bombarded with information touting the latest
and the greatest device. It is imperative for the
physician considering energy based devices to
approach it in a stepwise fashion. This includes
evidence based review, discussion with peers
and assessment of the equipment in a real time
fashion for choosing the optimal device for
the practice. It should also include sound busi-
ness decisions including direct and indirect
costs of the equipment, marketing and sustain-
ability of the device in the marketplace.
• The indirect/direct costs of the capital
equipment and the cost of consumables
and service should be considered at the
time of purchase
• Journal and peer reviews are preferred
over manufacturer’s review since they
resemble experience, not commercial-
ism. Validity of new laser/light products
can be evaluated by physician through
sample trials. Renting, leasing or pur-
chasing is dependent on physician’s
capital and demand for product
• Physician can attract patients to preferred
treatment options by using targeted based
marketing between manufacturer and
physician website, providing cost-effi-
ciency and effectiveness
• Results and good outcomes are pre-
ferred over new untested products. Poor
reliability of device may ruin physi-
cian’s reputation and practice
• Most efficiency of laser/light treatment
is obtained by an experienced physician
using a product that has been previously
tested for efficacy
V. A. Narurkar

527
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Research and Future Directions
Yakir S. Levin, Fernanda Hidemi Sakamoto,
and R. Rox Anderson
Abstract
In this chapter, an overview of new research
and emerging technologies is provided. The
subject is inherently speculative and the
clinical adoption of these technologies is far
from certain. Notwithstanding this limita-
tion, discussion of the following subjects is
undertaken: fractionated technologies, selec-
tive cryolysis, selective and deeper targeting
in photodynamic therapy, laser treatment of
basal cell carcinoma, development of new
materials in dermatology, and nondestruc-
tive microscopy.
Keywords
Laser surgery · Laser tissue ablation · Skin
resurfacing · Fractional technology · Cryolysis
Photodynamic therapy · Photosensitizers · Basal
cell carcinoma · Nondestructive microscopy
“It is difficult to make predictions, especially
about the future.” (Attributed to Karl Steincke,
Niels Bohr, and/or Yogi Berra)
• What is new and what is next in fractional
technology?
• Selective cryolysis: beyond bodysculpting.
• Selective targeting and deeper targeting
using photodynamic therapy: development of
new photosensitizers and new activation
techniques.
• Laser treatment of basal cell carcinoma
• New materials in dermatology
• Nondestructive microscopy for in  vivo and
ex vivo use
Y. S. Levin (*) · F. H. Sakamoto · R. R. Anderson
Department of Dermatology, Massachusetts General
Hospital, Harvard Medical School, Boston,
MA, USA
Wellman Center for Photomedicine,
Massachusetts General Hospital, Harvard Medical
School, Boston, MA, USA
e-mail: ylevin2@partners.org;
fsakamoto@mgh.harvard.edu;
fsakamoto@partners.org;
rranderson@mgh.harvard.edu
35

528
Introduction
Advances in medical diagnosis and treatment
sometimes proceed incrementally through con-
tinued refinement of existing technologies. At
other times progress comes in greater leaps,
enabled by development of a new technology or
application of an existing one to a previously
unrecognized problem. It is not unusual for a new
development to seem, in retrospect, obvious, as if
it could have been implemented years or even
decades earlier. Such was the case for fractional
laser treatments, which were introduced long
after the technology to make microscopic laser
beams existed. Similarly, selective cryolysis was
developed long after the invention of refrigera-
tors (and more sophisticated cooling devices) and
long after the effects of cooling on cells and tis-
sues had been observed. Conversely, the intro-
duction of a new technology or technique often
opens new vistas not foreseen by the inventors.
For example, fractional photothermolysis was
introduced as a technique for resurfacing and
photorejuvenation. But new uses such as drug
delivery and scar treatments, as well as new
insights about tissue regeneration and scarring
may prove to be more relevant.
With this in mind, we present perspectives on
a number of advances in dermatology that involve
energy based devices or that have been developed
as outgrowths of work in such devices. We focus
on recent developments and speculate about what
the future may bring in a number of areas: frac-
tionated technologies, selective cryolysis, selec-
tive and deeper targeting in photodynamic
therapy, laser treatment of basal cell carcinoma,
development of new materials in dermatology,
and nondestructive microscopy. However, we do
not know what the future will bring.
Fractional Technology: What Is New
and What Is Next?
The creation of microscopic patterns of injury and
sparing described by Manstein et al. [1], resulted
in a new approach to skin resurfacing and photore-
juvenation. Fractionated laser methods were rap-
idly incorporated into clinical practice, with
options of ablative and nonablative devices as well
as stamping and scanning modes. The technology
overcame some of the limitations of fully ablative
resurfacing by stimulating skin remodeling with
rapid post-treatment healing, thus reducing down-
time and decreasing the risk of dyspigmentation,
infection and scarring. However, since its incep-
tion, the use of fractional lasers, and more broadly
the concept of fractional injury, has been extended
far beyond its initial applications of photorejuve-
nation and resurfacing. What follows is a discus-
sion of several areas of advancement in fractional
therapies, both direct applications of fractional
lasers as well as new technologies that borrow
from the concepts initially developed or high-
lighted by fractional laser treatments.
Scars and Contractures
Fractional lasers have been shown to improve the
appearance and function of atrophic and hyper-
trophic scars of many types including those origi-
nating in trauma, acne, and burns [2–6]. Fractional
lasers can also increase the mobility of joints that
are affected by severe contracture [7, 8]. Used
alone or in conjunction with z-plasty, fractional
lasers can be life-changing for patients with
severe hypertrophic scars. Additionally, although
biologically distinct from the above scarring pro-
cesses, radiation scars may prove to be another
type of chronic injury that benefits from frac-
tional laser treatments.
Fractional Laser Assisted Drug
Delivery
Fractional laser assisted drug delivery is chang-
ing the way that many skin directed therapies are
administered. Fractional lasers enable more effi-
cient and more uniform drug delivery than other
methods, including simple topical application,
injection, microdermabrasion and microneedling
[9]. This is thought to be due to the high density
Y. S. Levin et al.

529
of uniformly distributed microchannels in the
skin, resulting in decreased barrier to drug pene-
tration. Triamcinolone has been delivered to
hypertrophic scars, and numerous therapies
directed at field cancerization and superficial skin
cancers have been shown to be effective. These
include 5-fluorouracil [10], ingenol mebutate
[11], aminolevulinic acid (ALA) [12, 13], and
imiquimod [14]. Methotrexate, used as chemo-
therapy and for inflammatory conditions [15] and
diclofenac [16], a nonsteroidal anti-inflammatory
agent, have also been tested.
One point of caution in the burgeoning field of
fractional laser assisted drug delivery involves the
choice of appropriate drug. Although a medication
may be approved for topical administration, intro-
duction directly into the dermis may be harmful. At
this time, we recommend routine use of fractional
assisted drug delivery only for medications that are
already approved for dermal administration. In a
research setting and with appropriate oversight,
other medications can be considered with careful
attention to dosimetry and potential complications.
Immunogenicity
The creation of microchannels does more than
simply promote growth of new tissue (in the case
of rejuvenation) and overcome resistance to pen-
etration (in the case of drug delivery). The injury
itself seems to result in an immune response that
is additive to or perhaps synergistic with the
pharmaceutical being delivered. Wang et  al.,
demonstrated improved uptake and transporta-
tion of antigens as well as broader overall immu-
nity when a nonablative fractional laser was used
in conjunction with microneedle delivery of
influenza vaccine than when using a microneedle
array alone [17]. More recently, Kawakubo et al
[18], demonstrated in a mouse model of colon
carcinoma that ablative fractional laser treatment
of tumors resulted in significantly slower tumor
growth as well as a significant increase in anti-
tumor immunity. As the immune response is
increasingly recognized as a powerful compo-
nent the body’s defense against not only infec-
tious disease but also cancer, fractional lasers
may have a significant role to play.
Tissue Copying and Regeneration
Fractional lasers highlighted the regenerative
capacity of skin. When the injury is sufficiently
small, skin regrows without scarring; approxi-
mately 40% of skin can be “taken” from a given
site without any permanent evidence of the theft.
This observation spurred the development of
technologies to graft skin from a donor site with-
out donor site morbidity, and to regenerate skin at
a recipient defect with minimal scarring.
A device to perform fractional epidermal har-
vesting was developed at the Wellman Center for
Photomedicine and recently received FDA clear-
ance [19]. It was initially used for the treatment
of vitiligo by enabling rapid production of micro-
blister grafts without donor site morbidity. A
commercial version is being used mainly for
chronic wounds.
The concept has been extended beyond epi-
dermal harvesting to harvesting of full thickness
skin columns. Tam et al., have demonstrated [20]
the ability to harvest sufficiently small columns
from the skin without donor site morbidity, and
to reconstitute full-thickness skin (including skin
appendages) at a recipient site [21]. A device
based on this technology was recently cleared by
the FDA and will be used in the treatment of both
acute and chronic wounds.
Study of tissue regeneration through microin-
jury or micrografting has to date been primarily
confined to the skin. Could fractionated treat-
ments be used to treat or expand other solid
organs? Could they be used to regenerate ­neurons,
muscle, liver or any other vital cells? It is not
impossible that fractionated treatments could
promote solid organ “rejuvenation”.
Skin Tightening
Skin changes are among the most visible signs of
aging. Increasing age is evidenced in part by skin
35  Research and Future Directions

530
laxity and rhytides. As a result, skin tightening
procedures are increasingly popular. The most
effective improvements in skin laxity can be
accomplished with surgery, but many patients
prefer less invasive and less expensive proce-
dures with decreased downtime.
Fractional lasers have been shown to induce
some amount of skin tightening [22]. Other frac-
tional skin tightening treatments, including frac-
tionated microfocused ultrasound [23, 24] and
radiofrequency devices [25], are among many
device-based strategies for decreasing skin laxity.
The precise mechanisms of the tightening
achieved by these devices is uncertain; it may be
a combination of tissue reduction and restoration
of skin elasticity through formation of new col-
lagen and elastin, or simple microcontraction
caused by tissue damage. None of these devices,
however, produces results that approach a surgi-
cal facelift.
An alternate approach that utilizes tissue
removal along with directional closure is cur-
rently under investigation. In a swine model,
Russe et al. [26], created full thickness wounds in
skin using 19 G coring needles. When combined
with a compressive dressing, tissue shrinkage
was achieved along the direction of application
of the dressing. This approach may enable results
closer to those of a standard surgical approach
while minimizing scarring and downtime.
Robotic Microsurgery
The concept of selective photothermolysis
enabled performance of microsurgery using elec-
tromagnetic radiation [27]. Knowledge of the
pigmented target-selective properties as well as
size and geometry of a given target allowed
choice of treatment/illumination wavelength and
pulse duration to achieve target destruction.
Fractional photothermolysis [1] also performs
“micro” treatment, but it does so in a nonselec-
tive way; water is its chromophore. The method
achieves rejuvenation by using a narrow beam
laser to create very many, very small wounds.
Many potential targets, however, are too small
or too numerous for manual destruction and lack
suitable chromophores for traditional selective
photothermolysis. Examples in the skin include
nonpigmented hair follicles, sweat glands and
sebaceous glands. At the several-micrometer
scale, individual cells, such as melanocytes, lym-
phocytes, mast cells, and keratinocytes, are large
enough to be addressed by a sufficiently narrow
laser beam. An autonomous robot that can accu-
rately identify individual targets—whether using
a standard CCD camera or any of several forms
of in vivo microscopy—and then deliver a narrow
beam of electromagnetic radiation to the precise
location of that target, represents the next step in
therapeutic laser treatments.
Selective Cryolysis: Beyond
Bodysculpting
The introduction of cryolipolysis in 2008 [28]
spawned the popular industry of noninvasive
body contouring. The differential susceptibility
of adipocytes to cold temperatures enabled the
destruction of subcutaneous fat while sparing
overlying skin and subcutaneous structures. The
concept of selective cryolysis can be extended to
other lipid-rich tissues.
Jalian et al. [29], used this method to selec-
tively decrease sebaceous gland density in mice
and swine, and to damage sebaceous glands and
reduce sebum output in humans. Acne is a condi-
tion experienced by almost all of humanity at
some point during life, and controlled cooling
may offer a new and effective treatment strategy
by addressing the sebaceous gland, a major con-
tributor to its pathogenesis.
Garibyan et al. [30], demonstrated a marked
decrease in mechanical and thermal pain sensitiv-
ity in human subjects starting 2–7  days after
­cryolysis and lasting at least 35 days. The treat-
ment caused decreased epidermal nerve fiber
density and myelinated nerve fiber density.
Chronic pain and itch represent two major
sources of morbidity, and the prospect of achiev-
ing long-lasting relief by physical means is a
source of great anticipation.
In the future, the concept of cryoselectivity
may also prove useful in the treatment of disor-
Y. S. Levin et al.

531
ders of pigmentation, as the melanocyte is known
to have greater cold sensitivity than its neighbor-
ing keratinocytes.
Laser Treatment of Basal Cell
Carcinoma
Long-pulsed lasers have been investigated for
their ability to clear skin cancer. Initial studies
were performed with the pulsed dye laser (PDL)
operating at 585 or 595 nm. A preliminary study
with PDL showed clearance in only one of seven
treated tumors [31]. Ballard et  al., used pulsed
dye laser to treat seven volunteers with nine well-
defined biopsy proven basal cell carcinomas
(BCC). Four weeks after laser treatment, shave
biopsies were performed to assess for residual
cancer. Five of nine (55.6%) demonstrated no
evidence of BCC, but the remainder of lesions
persisted [32]. Shah et al., treated twenty biopsy-
proven BCCs with four PDL treatments at 2 week
intervals. In tumors <1.5 cm in diameter, there
was a 92% regression rate. For tumors ≥1.5 cm in
diameter, complete response was only 25% [33].
In a follow-up study of BCCs measuring 0.8–
3.5 cm, 19 of 20 BCCs demonstrated complete
clinical response to PDL treatment. When biopsy
was performed as 12–21 month follow-up, com-
plete clearance was demonstrated in 18 of the 19
tumors that had initially demonstrated complete
clinical response [34].
More recently, the utility of the 1064  nm
Nd:YAG laser has been investigated in the treat-
ment of BCC. It is thought that this laser may be
more effective due to its increased depth of pene-
tration and greater selectivity for arterial blood
(oxyhemoglobin over deoxyhemoglobin). Ten
subjects with a total of 13 biopsy-proven BCCs
less than 1.5 cm in diameter received a single laser
treatment. Standard excision was performed one
month later. Complete clearance was 92% [35].
The potential for a rapid, minimally invasive,
and minimally destructive treatment to clear
BCC is exciting as it may mitigate the high cost
of treatment of this common condition. If the
lesion were to recur following laser treatment,
standard excision would remain an option.
New Materials in Dermatology
The field of materials science has recently yielded
several new technologies with cutaneous applica-
tion, both therapeutic (as in the cases of photo-
chemical tissue bonding and a wearable “second
skin”) and diagnostic (as in the case of a bandage
that senses tissue oxygenation).
Photochemical Tissue Bonding
Photochemical tissue bonding (PTB) was devel-
oped by Kochevar and colleagues using rose ben-
gal as a photosensitizer and green light for
photochemical activation. The photosensitizer is
totally reabsorbed into the body, causes little irri-
tation and has no other known side effects. PTB
causes collagen at tissue surfaces to cross-link
during about 5 min of light irradiation, yielding a
bond with less inflammation or scarring than
would occur with conventional sutures. Studies
for blood vessel [36, 37], nerve repair [38–42],
cornea [43–46], and skin [47–49] have been pre-
sented. Interestingly, nerve repair with PTB in
combination with human amniotic membrane
was shown to be more efficacious than common
suture for functional recovery. In comparison to
standard sutures, the photochemically sealed
amnion wrap also improved histological recovery
[39]. This novel light-activated method of tissue
repair may potentially produce better appearance
and functional recovery.
Second Skin
An elastic, wearable crosslinked polymer layer
(XPL) that mimics the properties of normal skin
has been developed [50]. The XPL is a skin-
adherent, three-dimensional polymer network
that is chemically crosslinked in situ on skin, fol-
lowing a two-step topical application process.
The technology has potential medical and cos-
metic applications, as it is breathable, long-last-
ing (~24 h) and permeable to sweat. With those
qualities, XPL is a new therapeutic platform and
can be used as an invisible layer or a new method
35  Research and Future Directions

532
for drug-delivery. A second skin may preserve or
restore skin barrier function in diseases such as
atopic dermatitis. It may also serve to improve
appearance of aging skin by decreasing the
appearance of fat herniation, increasing skin elas-
ticity, and by flattening rhytides.
Oxygen Sensing Bandage
A breathable, transparent, simple-to-apply-and-
read and easily removable bandage has been
developed to measure oxygenation in human
skin. In this method, an oxygen sensing phosphor
and a reference dye are embedded in a transpar-
ent liquid polymeric bandage material. The oxy-
gen-sensing phosphor is excited by 415 nm light
and demonstrates peak emission at 690 nm (red
light). The intensity of its phosphorescence
depends on pO2  in the local environment. The
reference dye is excited by 392  nm light and
demonstrates peak emission at 495  nm (green
light). In contrast to the oxygen sensing phos-
phor, the phosphorescence intensity of the refer-
ence dye is not dependent on local oxygenation.
Red and green filters are used to detect both col-
ors emitted by the bandage. A reference curve is
created so that the ratio of intensity in the red
“channel” and the green “channel” corresponds
to a specific pO2. The technology is unique in its
ability to provide an oxygenation map of live tis-
sue rapidly and at low cost. It is under investiga-
tion for mapping oxygen in burns and grafts, two
areas in which adequate oxygenation is necessary
for appropriate healing [51–55].
Photodynamic Therapy
Photodynamic therapy involves delivery of a
light-activated drug or precursor. Following light
irradiation, the drug reacts with oxygen, produc-
ing free radicals, singlet oxygen and other reac-
tive oxygen species (ROS). The ROS damage
certain “targets” in tissue, by inducing apoptosis,
necrosis, or by activating local inflammatory/
immune responses.
Photodynamic therapy achieves selectivity by
localized application or uptake of the drug (or its
precursor) and/or by localized illumination. The
first photosensitizers (PS) were systemically
administered and included hematoporphyrin
derivatives (HpD) such as porfimer sodium
(brand name Photofrin). These were limited by
side effects, however, primarily due to their pro-
longed phototoxicity. Second generation photo-
sensitizers, also systemically administered,
overcame some of the prolonged phototoxicity.
These include BPD-MA (verteporfin, brand
name Visudyne) and mTHPC (temoporfin, brand
name Foscan).
In dermatology, photosensitizers in the pso-
ralens family are primarily administered orally or
by soaking in a tub, followed later by UV illumi-
nation. This technique, called PUVA (Psoralen
and UltraViolet A), is often categorized sepa-
rately from photodynamic therapy, but is based
on the same principles. It has been used to treat
psoriasis, atopic dermatitis, chronic cutaneous
graft-versus-host disease, lichen planus, mycosis
fungoides, polymorphous light eruption, and
many other dermatoses. PUVA has largely been
supplanted by other treatment options for these
conditions, including UV light without a PS as
well as topical and systemic drugs. However, it
remains a potent and viable treatment option.
The most commonly used photosensitizers in
dermatology today are topically applied. These
include ALA and its methyl derivative, methyl
aminolevulinate [56]. Other topically applied
photosensitizers include older compounds such
as methylene blue. These are currently used pri-
marily in the treatment of superficial nonmela-
noma skin cancers and actinic keratosis. However,
PDT applications in skin are expanding and have
been successfully demonstrated in the treatment
of infections (including biofilms), acne vulgaris,
other inflammatory dermatoses, and vascular
malformations. Challenges in PDT include selec-
tivity of the drug and achieving sufficient illumi-
nation of the target to enable formation of
ROS.  These challenges are subjects of active
research.
Different approaches have been described to
improve PS delivery and accumulation into tar-
Y. S. Levin et al.

533
geted structures [57]. One simple approach, frac-
tional laser assisted drug delivery, was described
previously in this chapter. In addition, PS have
been developed that can penetrate more easily
into the plasma cell membrane. This is accom-
plished by changing molecular physico–chemi-
cal properties, with consequent increased and
faster local drug accumulation. An example is the
use of alkyl-esters of ALA with greater lipophi-
licity such as the methyl, propyl and hexyl-esters
of ALA [58]. Alternatively, the use of liposome-
encapsulated molecules, oil-dispersions, poly-
mers, or other nanoparticle carriers have been
described [59].
Another strategy for selective PDT is by
changing or modulating the target environment.
For example, it is possible to inhibit the accumu-
lation of PS in normal surrounding areas while
increasing the amount of PS or its photodynamic
effect within the targeted structures. When using
ALA and ALA-derivatives to produce PDT, the
drug must be metabolized into porphyrins, espe-
cially protoporphyrin IX (PpIX). PpIX is the
active PS.  PpIX accumulation is dependent on
the enzymes of the heme synthesis pathway, iron
stores, and other variables. By manipulating
these factors, greater selectivity can be achieved.
One example is the use of temperature to control
tissue targeting. Willey et  al., demonstrated
increased PDT efficacy if an affected limb is
heated during incubation [60], and other types of
temperature manipulation have been shown to
affect PDT efficacy [58]. Perhaps a simple tem-
perature gradient in skin may localize photosen-
sitizer in target tissue and spare normal
surrounding areas.
Selective PDT can also be accomplished
using a PS that actively binds to specific mark-
ers. These markers can be located on target cells
(e.g. cancer), in cells involved in development
of the disease, or in the cells effecting immune
response. PS antibody conjugates (commonly
referred to as photoimmunoconjugates) have
been successfully employed for selective deliv-
ery of PS to cancers [61, 62]. PS can also be
conjugated to specific peptides that bind known
integrins or to specific ligands that bind known
cell surface receptors [63].
Due to the limited tissue penetration of ultra-
violet and visible light, PDT has historically been
limited to tissues that are less than a millimeter
from an epithelial surface and therefore easily
accessible to external light sources or to optical
fibers. These include superficial lesions of the
skin, esophagus, respiratory tract (including head
and neck cancers and some non small cell lung
cancers), and bladder. However, additional strate-
gies have been utilized to increase accessibility to
PDT. There are several examples of optical fibers
being placed directly into vascular anomalies
within limbs or deep seated abdominal tumors in
order to achieve sufficient illumination of the tar-
get. Careful adjustment of PS dose and location
can increase the achieved depth by avoiding PS
self-shielding, a phenomenon in which high con-
centration of PS in superficial tissue prevents the
passage of light into deeper tissues. Fractionated
PDT has also been shown to increase the depth of
tissue necrosis [64]. Considerable effort has been
made to increase the tissue depth of penetration
through development of PDT agents that are acti-
vated by near infrared light, which can penetrate
more deeply than ultraviolet or visible light; such
PS include Lumin, Motexafin lutetium, and
TOOKAD. Near infrared light is still limited to
millimeters of penetration, however. An alterna-
tive approach utilizes x-rays or γ-rays to activate
the PS. These are of considerably higher energy
and penetrate more deeply into tissue. If a PS
cannot be directly excited by penetrating radia-
tion, a nanoparticle transducer can be used to
locally absorb the incoming radiation and trans-
fer part of its energy to activate the PS [64, 65].
Nondestructive Microscopy
for In Vivo and Ex Vivo Use
Dermatology has mainly benefited, but in some
ways suffered, from the ready accessibility of
skin. The many advances in noninvasive imaging
that have permeated other medical specialties
have not yet been widely adopted in the clinical
practice of dermatology. In general, when a diag-
nosis based on clinical examination is lacking, or
cancer is a suspected diagnosis, a biopsy is per-
35  Research and Future Directions

534
formed. When assessment of tumor margins is
done during a Mohs procedure or after a standard
excision, standard histologic methods are
employed.
Since about 1990, biomedical research has
been transformed by laser-based microscopic
imaging methods including confocal microscopy
and
multi-photon
fluorescence
microscopy
among others. These lend themselves for use in
dermatology research, but have not had much
clinical impact yet because of cost, lack of stan-
dardization, and (until recently) lack of verified
diagnostic value and lack of reimbursement for
their use. The technology continues to progress
rapidly for small reliable lasers, fast beam scan-
ning, optical components and high-speed com-
puting—all of which underlie in vivo microscopy.
When in vivo microscopy achieves greater adop-
tion in dermatology, it will change the way in
which many skin diseases are diagnosed and
treated.
Confocal laser scanning microscopy (CM) of
skin was first described by Rajadhyaksha et al.
[66, 67], and commercialized devices are avail-
able and cleared for human use. CM can operate
in either reflectance (RCM) or fluorescence
(FCM) modes. Light returning from a tightly-
focused laser beam is passed through a pinhole
that eliminates out-of-focal-plane light, creating
a virtual tissue section when the beam is scanned
in a conjugate focal plane through live tissue.
RCM has been confirmed to offer valuable sensi-
tivity and specificity for detection of melanoma
and other pigmented lesions as well as nonmela-
noma skin cancer [68–78]. In surgical planning,
in vivo RCM has been used to assess preopera-
tive surgical margins, with some benefit over
standard dermoscopy in delineation of tumors
[79]. RCM is capable of reaching a depth of
about 0.3 mm in vivo, which includes epidermis,
papillary dermis and upper reticular dermis.
While no stains are used, the technique allows
imaging of function than cannot be seen by con-
ventional histopathology such as blood flow and
cell movement. Perhaps most importantly, the
technique enables longitudinal imaging because
it is not destructive. RCM has recently been
granted a CPT code for cellular and sub-cellular
imaging of skin, allowing physicians to receive
reimbursement for its use in the clinic [80]. Ex
vivo, both RCM and FCM have been used to
evaluate margins of Mohs specimens between
surgical stages; this could perhaps eliminate the
need for slide preparation [73, 81–83]. FCM is
more effective than RCM in evaluation of mar-
gins in ex vivo tissue because it uses fluorescence
dyes such as acridine orange to stain nuclear
DNA in epidermal keratinocytes. By contrast, in
RCM studies using acetic acid or citric acid as
contrast agents, nuclear contrast was not as
robust.
Multiphoton microscopy (MPM) is based on
the nonlinear process of 2-photon excitation of
endogenous fluorophores, which can be used to
acquire horizontal optical sectioning of intact
biological tissue samples. Two-photon excitation
achieves relatively deep penetration (compared
to conventional ultraviolet excitation) with low
phototoxicity. When studying human skin, MPM
provides high-resolution fluorescence imaging,
allowing visualization of cellular and subcellular
structures of the epidermis and upper dermis
[84]. Like RCM, the technique does not use
stains; near-infrared light is used to excite the
same natural tissue fluorescence that is seen with
a Wood’s lamp or other ultraviolet sources. MPM
has not been developed for clinical dermatology,
but preliminary studies suggest promise [85–87].
The fluorescence of mitochondria provide imag-
ing of cell cytoplasm; elastin fibers can be spe-
cifically seen; collagen is easily imaged by the
same instrument through process called second
harmonic generation; and the same information
of RCM can be obtained. Depth of penetration
with MPM is similar to CM, with the above
advantages and resolution exceeding that of con-
ventional histopathology.
Optical coherence tomography (OCT), like
CM, was invented and developed many years
ago, initially for imaging of the retina. However,
the technology has been extended beyond the
eye. A tethered capsule has been proposed for
in vivo endomicroscopy of the human esophagus
in order to better identify cancerous lesions [88,
89], and is currently in advanced stages of devel-
opment. Coronary OCT has also been developed
Y. S. Levin et al.

535
to characterize coronary plaques and thus distin-
guish between different causes of acute coronary
syndrome, and to assess stent placement and neo-
intimal hyperplasia within stents [90]. In live
human skin, OCT creates vertical-section images
of reflected light with lower resolution than CM
or MPM, but much greater depth. OCT is based
on interferometry; spatial and temporal coher-
ence of optical waves backscattered from tissue
is used to create images. It is conceptually similar
to detecting the ‘echo’ of ultrasound waves for
medical imaging. For many years, OCT images
of skin were not felt to be useful because of the
technology’s inability to resolve cells, because
most structures were indistinct (low contrast),
and because images were grainy due to speckle, a
phenomenon that reduces image contrast and
results from multiple backscattering and forward
scattering of the source laser beam within the
imaging volume. These problems have been
nearly eliminated. The speed and signal-to-noise
characteristics of OCT have increased dramati-
cally through the introduction of Fourier domain
imaging [91, 92]. Speckle noise has been signifi-
cantly improved through a variety of methods,
including some developed very recently [93]. In
addition to microstructural imaging, versions of
OCT that highlight microvasculature (angio-
graphic OCT), extracellular matrix structure
(polarization-sensitive OCT), and other contrast
mechanisms have also been developed [94]. OCT
lacks the spatial resolution to enable histologic
diagnosis at the cellular level, thus making diag-
nostic distinction among different types of cuta-
neous
neoplasms
difficult.
However,
the
technology has been used successfully in surgical
mapping of nonmelanoma skin cancer [95, 96].
The additional contrast mechanisms mentioned
above are likely to further improve the ability of
OCT to serve as a tool for noninvasive diagnosis
of skin lesions and for surgical planning.
Additional strategies for tumor margin detec-
tion have also been demonstrated. One such
method, polarization imaging, has been shown to
provide real-time, intraoperative delineation of
nonmelanoma skin tumor margins in ex  vivo
samples. It was recently used in vivo in combina-
tion with methylene blue fluorescence (following
intralesional injection of dye) to rapidly delineate
tumor margins during Mohs surgery [97–99].
In the forms of optical microscopy discussed
above, the detection occurs at or (in the case of
fluorescence) near the frequency(ies) of illumina-
tion. By contrast, signals in Raman spectroscopy
and related imaging technology result from
inelastic scattering of light within tissue; they
correlate with the molecular vibrations of various
tissue biomolecules. These vibrational frequen-
cies are generally very different from illumina-
tion
frequencies.
Conventional
Raman
spectroscopy involves illumination of a sample
with a laser at a single frequency, and collection
of emitted signals. From this time-domain signal,
a spectrum can be constructed [100]. Using con-
ventional Raman spectroscopy, both ex vivo and
in vivo spectra have been collected from many
different skin lesions and from normal skin, and
various algorithms have been implemented to
distinguish benign lesions, malignant lesions,
and normal skin with overall good sensitivity and
specificity [101–113]. In order to significantly
enhance the intensity of Raman signals and to
enable collection of images within a reasonable
timeframe, strategies under the general category
of coherent Raman scattering have been imple-
mented. Examples include Stimulated Raman
Spectroscopy and Coherent Anti-stokes Raman
Spectroscopy (CARS). In these methods, two dif-
ferent frequencies of light are used to illuminate
a sample. The difference between the frequencies
is tuned to match molecular vibrations of interest,
such as the known vibrational frequencies of lip-
ids, proteins, DNA, amino acids, etc. The signal
that is produced is several orders of magnitude
larger than that of conventional Raman spectros-
copy. By scanning over a surface, an image cor-
responding to the quantity of a particular bond is
created [100]. For example, Jung et  al., used
CARS microscopy to study sebaceous glands in
mouse ears and their response to cryotherapy by
probing the vibrational frequency of CH2 bonds
in lipids [114]. CARS techniques have been used
to detect pheomelanin [115] and to aid in detec-
tion of skin cancer [116, 117].
Like the methods described above, photoacous-
tic imaging (also known as optoacoustic imaging)
35  Research and Future Directions

536
uses a light source to illuminate the tissue of inter-
est. However, instead of detecting scattered or
emitted photons, this imaging technology uses
ultrasonic technology to detect acoustic waves. A
pulsed nanosecond-long laser beam is used to illu-
minate the tissue of interest causing photons to
propagate diffusely inside. The absorption of these
photons leads to a slight localized heating of the
tissue causing thermoelastic expansion. This tran-
sient thermoelastic tissue expansion generates
pressure waves (ultrasound), which can then be
detected by broadband ultrasonic transducers, and
converted into images [118]. There are a few
examples of use of this technology in skin.
Photoacoustic microscopy has been explored for
melanoma detection and staging, with penetration
depths up to 3  mm [119]. Favazza et  al. [120],
investigated the technique in volunteers by assess-
ing skin microvasculature as well as a nevus. The
technique has also been used to assess cutaneous
wounds [121–124].
As noted in the introduction to this section, the
slow uptake of noninvasive and nondestructive
imaging techniques in dermatology has been due
to multiple factors. As these technologies have
been refined and improved, their potential clini-
cal utility is becoming increasingly clear. Clinical
adoption will depend on additional factors such
as standardization, reimbursement for clinical
use, cost, and physician education and training.
RCM is the first such modality to be reimbursed
for clinical use, and the other barriers to adoption
(particularly physician education and comfort
with the technology) are slowly being addressed.
Hopefully this process will be repeated with
other modalities. In the long term, a multimodal
imaging approach will, in all likelihood, be most
effective, and we may be left wondering how we
could ever have practiced without it.
Final Words
We have seen an explosion of new medical treat-
ments in recent decades since the introduction of
lasers as medical tools. As we increase our under-
standing, the number of applications continues to
expand. At the same time, new technologies per-
meate our lives, including everything from smart-
phones to self-driving cars. We are not far away
from medical apps for complex diagnosis or
robotic treatment methods. Let the future tell us
what is next!
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Y. S. Levin et al.

541
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
A
Ablative approaches, 23
Ablative fractional photothermolysis (AFP), 484–485
characteristics, 166, 168–169
clinical course, 187, 189
drug and cell delivery into skin, 192
operator technique, 191
optical radiation, 192
photoaging, 188, 190
procedure, 186
skin histology, 187
treatments, 188
wound healing, 187, 188
Ablative fractional resurfacing (AFR), 157, 158
Ablative laser skin resurfacing, 68, 69, 198–200, 314
AFR (see Ablative fractional resurfacing (AFR))
complications, 147
contraindications, 139
cutaneous lesions, 139
ectropion formation, 147
Er:YAG laser, 143–145
hyperpigmentation, 147, 148
hypertrophic scar, 147
indications, 139
non-ablative/fractional laser procedure, 139
patient selection, 139, 140
photodamaged facial skin, 159
postinflammatory hyperpigmentation, 147
postoperative hypopigmentation, 147
postoperative management, 145
postoperative morbidity, 159
preoperative management, 140, 141
preoperative patient evaluation and education, 139
pulsed CO2 laser systems, 141, 142
short-pulsed Er:YAG laser, 139
side effects and complications, 146, 147
wound care, 145
wound infections, 146
Absorption spectra of skin chromophores, 5
Acne scars, 410–413
ablative fractional lasers, 438
CO2 laser resurfacing, 438
energy bipolar fractional RF, 439
GASS, 439
IPL, 280, 281
matrix-tunable radiofrequency technology, 439
non-ablative fractional lasers, 438–440
sublative rejuvenation, 439
VAS, 439
Acne vulgaris, 228–234, 310–313
definition, 228
genetic, neuroendocrine, and dietary factors, 228
laser based therapies
erbium glass laser, 231
585-nm and 595-nm pulsed-dye lasers, 228
fractionated Er:glass, 231
Nd:YAG, 230
1450-nm diode laser, 229
light based therapies
blue light, 231–232
blue–red light, 232
intense pulsed light, 233–234
longer wavelengths, 232
shorter wavelength, 232
prevalence, 228
treatment, 228
Acquired nevus of Ota-like macules, 96
Actinic keratoses (AK), 262, 267–269, 309, 310, 380, 381
RCM
imiquimod therapy, 393
photodynamic therapy, 393
shave biopsy, 394
Acute wound healing
dye-enhanced tissue soldering, 344
growth factors, 344
lasers-assisted wound bonding, 345, 346
lasers vs. conventional methods, 344, 345
optimal wound bonding, 346
tissue soldering, 343, 344
tissue welding, 343
Adipose tissue, 251–253
invasive fat removal (see Liposuction)
non invasive fat removal
cryolipolysis, 248
HIFU, 249
low frequency focused ultrasound, 249–250
low level laser therapy, 250
mechanism, 248
radiofrequency, 250
1210 nm laser, 251
Index

542
Air cooling, 4
Aktilite device, 264
Alabaster skin, 166
Alexandrite laser, 4, 51, 442
Allergenicity, tattoo, 112
Allergic contact dermatitis, 488–489
Alma Accent RF System, 255
Alopecia areata, 359
Alopecic skin, 354, 357
Alpha bisabolol, 469
Amateur tattoos, 405
American Academy of Dermatology (AAD),
518, 521
American National Standard for the Safe Use of Lasers,
405
American Society for Dermatologic Surgery (ASDS),
518, 520, 521
American Society for Laser Medicine and Surgery
(ASLMS), 37, 518–521
Aminolevulinic acid (ALA), 261, 305
acne, 265
actinic keratoses, 262, 267–269
basal cell carcinomas, 262
contraindications, 266–267
hypertrophic AKs, 262
micro-invasive squamous cell carcinomas, 262
nonhypertrophic actinic keratoses, 262
non oncologic skin conditions, 265
onychomycosis, 266
photoaging, 266
plaque-type (stage I) mycosis fungoides, 264
rosacea, 265
Amplification of light, 3
Androgenetic alopecia (AGA), 359, 361,
368, 369, 372
Anesthesia
action mechanism, 428
classification, 428
conscious sedation, 435
hair removal, 431
historical development, 427, 428
infiltrative anesthesia, 430 (see also Local
anaesthesia)
nerve blocks, 431–433
non-ablative rejuvenation, 431
pigmented lesions, 431
safety, 402–405
tattoos, 431
topical anesthesia, 428
treatment, 370–371
tumescent anesthesia, 431
Angioma, 384, 385
Argon dye lasers, 340, 346
Arnd-Schultz law, 300
Atrophic scarring, 410–412
laser resurfacing, 68
ablative, 68, 69
fractional resurfacing, 69, 70
nonablative, 69
Authorized Personnel-Laser Users, 41
Autonomy, 500
Auxiliary flash, 510
B
Basal cell carcinomas (BCC), 378–380
laser treatment, 531
RCM
cryotherapy, 394
imiquimod therapy, 393
non-melanocytic skin lesions, 378–380
photodynamic therapy, 393
pigmented lesions, 385
Basic fibroblast growth factor (bFGF), 363
Beam directionality, 3
Beam profiles, laser, 7
Beam propagation, 11–13
Beam, temporal profile, 302, 303
Betacaine-LA ointment, 429
Biostimulation, 20, 319
Biphasic dose response curve, 357
Bipolar radiofrequency, 27, 254, 255
Blisters, 423
Blu-U device, 263
Body dysmorphic disorder, 416, 417
Body self-awareness, 451
Bovine mucopolysaccharide-cartilage complex (MCC), 470
Bowen disease (BD), 381
Bronzing effect, 181, 182
Bruising (ecchymoses), 423
Brushing technique, see Rolling technique
Bulk tissue heating, 173
Bupivacaine, 430
C
Café au lait macules (CALMs), 94, 101
Er:YAG resurfacing, 94
prevalence, 93
treatment, 93
Capillary malformations, 53–55
Capillus® 272 device, 369
Carbon di oxide laser skin resurfacing, 141, 142, 438
Carbon dioxide fractional laser therapy, 355
Carbon dioxide lasers, 6, 340, 346, 459
tatto removal, 408
CARS techniques, 535
Catastrophic pancutaneous thermal damage, 14
Cellulite treatments, 253–256
laser and light based treatments, 253
sources
intense pulsed light, 253
laser, 254
light emitting diode, 254
massage, 254
Nd:YAG Laser, 255–256
radiofrequency, 254
radiofrequency devices, 253
Index

543
Cerebriform nests, 391
Charge coupled device (CCD), 511
Children, laser surgery, 449–452, 455–457
ablative/resurfacing lasers, 458, 459
adverse effects, 459
congenital melanocytic nevi, 458, 459
dermal lesions
Nevus of Ito and Nevus of Ota, 457
traumatic tattoos, 457
epidermal lesions
café-au-lait macules, 456, 457
lentigenes, 456
nevus spilus, 457
epidermal nevi, 459
hypertrophic scars, 455
infantile hemangiomas, 452–454
intra operative management, 461
molluscum contagiosum, 454
palmar plantar warts, 454
pigmented lesions, laser types, 455
port-wine stains
blood vessel destruction, 451
flashlamp-pumped PDL, 450
follow-up, 452
IPL, 452
natural history, 450
PDL, cryogen cooling spray device, 451
photodynamic therapy, 452
post-treatment purpura, 450
treatment, 451
preoperative management, 460, 461
spider telangiectasias, 454
vascular lesions, 450
KTP laser, 455
PDL, 449, 450
quasi continuous lasers, 455
verrucae vulgaris, 454
Chromophores, 13
absorption coefficients, 9, 12
carbon, 13
dry collagen, 13
fat, 13
hemoglobin, 13
melanin, 13
water absorption, 13
Chronic wounds
healing, 346, 347
incidence, 340
molecular and cellular effects, 348
Coagulation-denaturation, 18
Cocaine, 427, 428
Coherence gating, 395
Coherent Raman scattering, 535
Cold laser therapy, 357
Collagen shrinkage and dermal remodeling, 142
Collimation, 3
Combination KTP/Nd:YAG, 52
Combination PDL/Nd:YAG therapy, 52
Compact/Subcompact (point-and-shoot) type, 506
Complaints, laser and cosmetic patients, 419
Complementary metal oxide semiconductor (CMOS)
chip, 512
Complete hair loss, 122
Compression therapy, 75
CompuServe GIF™-Graphics Interchange
Format, 513
Confocal laser scanning microscopy (CM), 534
Conscious sedation, 435
Contact dermatitis, 487
Continuous wave lasers (CW mode), 4
Convective air cooling, 21
Conventional Raman spectroscopy, 535
Cooling devices, 481
CoolSculpting®, 446
CoolTouch®, 204
Corneal eye shield
in adults, 402, 404
in child, 402, 403
sizes, 402
tray set up, 402
Corticoids, 469
Corticosteroids, 472
Cosmetic dermatology, 46, 122, 123, 134
Cosmetic lip tattoo, 407
Cosmetic rejuvenation, 16
Cosmetic tattoo, 406, 407
Counseling patients, 415, 417
caregivers, 420
communication with physician, 420
patient concerns, 419
photographs, 421
physician question, 419
treatment history, 420
treatment options, 420
written materials, 421
Crusting
prevention and treatment, 482–483
risk factors, 482
Cryolipolysis, 248–249, 446
Cryoselectivity, 530
Cryotherapy, BCC, 394
Cutaneous laser medicine, 13
D
Deep vein thrombosis (DVT), 73
Delegation, to non-physician caregivers, 418, 419
Dermabrasion, tattoo removal, 114
Dermal heating, 27–29
Dermal pigmented lesions
broad band light sources, 95
drug-induced pigmentation, 98, 99
melanocytic nevi, 95, 96
melasma, 96–98
nevus fuscoceruleus ophthalmomaxillaris, 96
Nevus of Ota, 96
oculodermal melanoma, 96
Q-switched lasers, 95
Index

544
Dermatofibroma (DF), 383, 384
Dermatological laser treatment, 476, 480, 513
compact/subcompact, 506–508
digital media, 511–512
flash
advantage, 510
auxiliary flash, 510
camera, 509
electronic, 509
hot-shoe, 509
rapid low-power pre-flashes, 510
ring, 510
focal ratio, 511
lenses
macro/close-up lenses, 509
wide angle zoom, 508–509
mega-pixel, 512
photographic technique
equipment, 506
location and orientation, 514
pre and postoperative facial photography, 515
surgery, 515–516
publications, submitting images
CompuServe GIF™-Graphics Interchange
Format, 513
dimensions, 512
File Format, 512
Joint Photographic Experts Group, 513
Portable Network Graphics, 513
resolution, 512
Tagged Image File Format, 513
Windows bitmap, 512
shooting techniques, 513–514
single lens reflex, 506, 507
tablet devices, 508
white balance, 510–511
Dermatologic laser therapies, websites
internet website quality evaluation, 518
patients, 520
physicians, 518
Dermatology
medical and cosmetic applications, 531
noninvasive and nondestructive imaging techniques,
536
oxygen sensing bandage, 532
photochemical tissue bonding, 531
second skin, 532
XPL, 531
Dermatology Insights Journal, 519
Dermatology World publication, 519
DermNet website, 520
Dermoscopy-RCM correlation, 391, 392
Digital Media, 511–512
Digital nerve block, 432, 434
Digital photography, 505, 506
Digital single-lens-reflex (DSLR), 506
Diode laser (DL) system, 3, 78, 79, 198, 207, 442
acne vulgaris, 229–230
Dissatisfaction, of patients, 415, 417
Dosimetry, 302
Dressing/wound care
anti-inflammatory agents, 469–470
early post-operative treatment, 470
hyaluronic acid, 470
immediate post-operative treatment, 469
intermediate post-operative treatment, 471
late post-operative treatment, 471
MCC, 470
olive oil, 470
post-operative care, 468
post-recovery pigment correction, 471
scarring, 472
silicone ointment, 471
Dual wavelength combination lasers, 52
Dye-enhanced tissue welding, 343, 344
Dye lasers, 3
Dyschromias, 219
Dyspigmentation
prevention and treatment, 484–485
risk factors, 483–484
Dysplastic nevi, 387–388
E
Ectropion, 488
Edema
prevention and treatment, 482
risk factors, 482
Educating laser patients
adverse events, 424
bruising, 423
complaints, 419 (see also Counseling patient)
downtime, 423, 424
erosions, 423
hives and blisters, 423
procedure-associated issues, 424
redness and swelling, 422, 423
ELA-Max, 429
Elective laser procedures, 500
Electric tattoo device, 111
Electronic flash, 509
eMedicine, 520, 521
Emitted laser radiation, 4
Endogenous chromophores, 476
Endogenous photodynamic therapy, 306
Endovenous laser ablation, 75
Enoxolone, 469
Epidermal cooling devices, 203
Epidermal pigmented lesions
CALMs, 93
clinical studies, 92
ephelides (freckles), 94
intense pulsed light devices, 101
lentigines, 92, 93
melanocyte, 87
millisecond domain lasers, 101
seborrheic keratoses, 94
treatment, 213
Erbium:YAG laser resurfacing, 143–145,
148, 441, 459
Index

545
Erbium glass laser, 198, 207, 208, 355
acne vulgaris, 231
devices, 204
Erosions, 423
Erythema
prevention and treatment, 482
risk factors, 482
Ethical issues
advertisements, 496
contraindications, 496
economics, 494
heart to heart discussion, physician and patient, 495
interest, 495, 496
training, 494–495
Etidocaine, 430
Eutectic mixture of local anesthetics (EMLA), 460
Excimer lasers (XeCl), 4, 19
ablative decomposition, 238
cold ablation, 238
hypopigmentation, 239–240
psoriasis, 237–239
Vitiligo, 238–239
Exogenous photodynamic therapy, 304–306
Eye and skin protection, 43, 44
Eyewear, 402
F
Facial acne scarring, 67, 410
Facial and nasal telangiectasias, 58
Facial nerve blocks, 433
Facial telangiectasias, 57, 278
Factitial dermatoses, 417
Far infrared systems, 11
Fashlamp-pumped pulsed dye lasers, see Pulsed dye
lasers
FDA Center for Devices and Radiological Health
(CDRH), 38
Federal Laser Product Performance Standard, 42
Feedback mechanism, 3
Femtosecond (10−15) domain lasers, 103
Fiber optics, 4
Field radiofrequency, 250
Finsen’s electric arc lamp-based system, 286
Fitzpatrick skin types IV–VI, 181, 422
Flash lamp-pumped pulsed dye laser (PDL), 51
vascular lesions, 450
Flash lamp-pumped ruby-based laser, 286
Fluence, 477
Fluorescence confocal microscopy (FCM), 534
F-number, see Focal ratio
Focal ratio, 511
Focused intense ultrasound (IUS), 445
Follicular unit extraction, 353
Folliscope, 371, 372
Food Drug and Cosmetic Act, 494
Forward looking infrared camera (FLIR), 30
Fractional CO2 laser, 70
Fractional CO2 laser-assisted transdermal delivery of
topical timolol, 56
Fractional delivery systems, 11
Fractional epidermal harvesting, 529
Fractional Erbium YAG laser, 70
Fractional laser assisted drug delivery, 533
Fractional laser skin resurfacing
ablative system, 156
contraindications, 156
indications, 156
non-ablative lasers, 156
optimal treatment parameters, 159
photothermolysis, 156, 157
post-inflammatory hyperpigmentation, 159
postoperative management, 159
postoperative recovery period, 156
preoperative patient evaluation and education, 158
side effects, 159
and skin phototypes, 159
skin rejuvenation, 156
topical anesthetic cream, 158
treatment techniques and parameters, 158, 159
Fractional photothermolysis (FP), 22, 171–173,
194, 530
aFP (see Ablative fractional photothermolysis (aFP))
annual citations, 166, 167
biological organs, 193
complexity, 175
complications, 191
concept, 166
home-use product, 193
MTZs
bulk tissue heating, 173
depth of, 171
pulse duration, 172
rolling technique, 172
skin cooling, 173
stamping technique, 172
thermal injury, 173
wavelength, 171
multiple treatment, 174
nFP (see Non-ablative fractional photothermolysis
(nFP))
post-operative considerations, 192
pre-operative considerations, 191, 192
rules of, 175
side effects, 174
Fractional radiofrequency microneedle system, 70
Fractional resurfacing, 69, 70
Fractional technology, 314
fractional laser assisted drug delivery, 528
full thickness skin columns, 529
immunogenicity, 529
robotic microsurgery, 530
scars and contractures, 528
skin regeneration, 529
skin tightening, 529–530
tissue regeneration, 529
Fractionated erbium glass laser, tissue coagulation, 91,
231
F-ratio, see Focal ratio
Full thickness skin columns, 529
Index

546
G
Gallium arsenate (AsGa) laser, 358
Gallium-aluminum-arsenide (GaAlAs) lasers, 340, 346
Gallium-arsenide (GaAs) lasers, 340, 343, 346, 347
Gas lasers, 3
Gaussian profile, 7
Global acne scarring scale (GASS), 439
Gorlin syndrome (GS), 269, 393
Green light laser, 5
Grotthuss-Draper Law, 295
Guide number (GN), 509
H
Hair growth, 356
LLLT (see Low level light therapy (LLLT))
paradoxical hypertrichosis, 356
Hair removal, 46
device, 2, 21
Hair Removal Journal, 521
Hair removal, laser
active cooling, 123
advantages, 122
alexandrite laser, 125
chromophore’s thermal relaxation time, 122
contraindications, 125
diode laser, 125, 127, 128
endogenous chromophore melanin, 123
home-use devices, 130, 131
indications, 125
IPL systems, 129, 130
long-pulsed alexandrite laser, 123, 126, 127
long-pulsed Nd:YAG laser, 123
long-pulsed ruby laser, 123
long-pulsed semiconductor diode laser, 123
Nd:YAG, 128
nonsurgical procedures, 122
patients with hypertrichosis/hirsutism, 122
perioral area pretreatment, 129
pre-operative management
patient history, 125
physical examination, 125
prophylactic antiviral agents, 126
right axillary area pretreatment, 129
ruby laser, 125, 126
theory of selective photothermolysis, 122
vascular reduction, 123
Hair transplantation
advantages, 356, 357
after 900 grafts, 352
after 1000 grafts, 352
before surgery, 352, 353
CO2 fractional laser therapy, 355
CO2 laser assisted recipient sites, 354, 355
CO2 laser, risk, 356
disadvantages, 356, 357
erbium laser, 355
follicular unit extraction, 353
holmium laser, 355
incidence, 352
instruments for recipient sites, 356, 357
laser-recipient sites vs. steel created sites, 354
physicians challenges, 353
Hairmax Lasercomb™, ®, 360–362, 369
Hand-based tattooing technique, 111
Healthcare ethics, 500
Health provider, 502
Heat conduction, 20, 21
Heat diffusion, 11
Heat generation
LTIs, 16
SPT, 13–16
Heat shock protein (HSP), 347
expression, 18
Heat transfer to epidermis, 51
Helium-neon lasers, 340, 346, 358
Hemangiomas, 278
Heme biosynthetic pathway, 261
Herpes simplex virus (HSV), resurfacing, 488
Hidradenitis suppurativa, 281
High efficiency particulate air (HEPA) filter, 44
High energy short pulses (Q-switched ns pulses), 5
High intensity, beam, 3
High intensity focused ultrasound (HIFU), 248–249
Home-use dermatology devices, 193
Home-use diode laser, 130
hair removal devices, 125
side effects, 131
Hybrid cameras, 506
Hydroquinone, 471
Hyperpigmentation, 422, 483
Hypertrichosis, 486
Hypertrophic PWSs, 54
Hypertrophic scars, 65, 280, 410, 455, 472
ablative CO2 and Erbium:YAG lasers, 65
in burn wounds, 66
collagen fibers, 64
combination therapy, intralesional corticosteroids and
5-FU, 70
fibroblasts, 64
and keloids, 64–65
PDL treatment, 67
treatment, 66
wound healing process, 64
Hypopigmentation, 239–240, 483, 484
I
Idiosyncratic complications, 486–489
photoepilation
hypertrichosis, 486
leukotrichia, 486
reticulate erythema, 487
urticarial-like plaques, 487
pigmented lesions
leukotrichia, 487
tissue splatter and pinpoint bleeding, 487
resurfacing
acne flares, 487
bacterial infection, 488
Index

547
contact dermatitis, 487
ectropion, 488
fungal infection, 488
herpes simplex virus, 488
milia formation, 487
tissue splatter, 488
tattoos
allergic contact dermatitis, 488–489
combustion, 489
paradoxical darkening, 489
photoallergic contact dermatitis, 489
pinpoint bleeding, 489
tissue splatter, 489
iGrow®, 369, 371
Imiquimod cream, 472
Immunogenicity, 529
Inebriation, 427
Infantile hemangiomas (IH), 55, 56, 411, 452–454
Infiltrative anesthesia, 430
Informed consent, 500–502
Infrared tightening, 444, 445
Institutional board review (IRB), 495
Insulin-like growth factor-1 (IGF-1), 363
Integrated cooling device, 123
Intense pulsed light (IPL), 78, 125, 198, 223, 278–282, 290
acne vilgaris, 233
cellulite treatment, 253
clinical treatment
acne, 280, 281
facial telangiectasias, 278
hair removal, 280
hemangiomas, 278
hidradenitis suppurativa, 281
nail psoriasis, 281–282
PDT, 280
photorejuvenation, 279
pigmented lesions, 279
Poikiloderma of Civatte, 278
reticular leg veins, 278
sarcoidosis, 281
scars, 280
seborrheic keratosis, 281
dermatologic treatment, 276
devices, 5, 52, 53
energy, 277
flashlamp, 3
for hair removal, 124, 129, 130
history, 276
melasma, 442
photorejuvenation, 441
port-wine stains, 452
pulse duration, 277
sources, 200, 201, 208–210
spot size, 277
system, hair reduction, 123
water-filled gel, 276
wavelengths, 277
xenon flash lamp, 276
Intensity, 332–333
International Society of Hair Restoration Surgery, 352
Investigational Device Exemption (IDE) regulation, 496
Irradiance, 298–302
J
Joint Photographic Experts Group (JPG), 513
Journal of Investigative Dermatology Symposium
Proceedings, 520
Journal of the American Academy of Dermatology
(JAAD), 519
Junctional nevi, 385
K
Keloid scars, 438
Keratinocytes, 342
Krypton lasers, 340, 346
KTP lasers, 198, 201
L
Laryngeal mask airway (LMA), 405
Laser-assisted wound closure, 345, 346
Laser complications, 481–489
adverse events, 480
cooling, 477
idiosyncratic (see Idiosyncratic complications)
indications, 480, 481
laser devices malfunction, 478
laser mechanics, 476–477
medications, 480
patient factors, 479, 480
prevention and treatment
crusting, 482–483
dyspigmentation, 484–485
edema, 482
erythma, 482
pain, 481–482
purpura, 483
scarring, 485–486
vesiculation, 482–483
professional errors, 479
risk factors
crusting, 482
dyspigmentation, 483–484
edema, 482
erythema, 482
pain, 481
purpura, 483
scarring, 485
vesiculation, 482
safety, 478
vascular lesions, 489
Laser devices malfunction, 478
Laser exposure spot size, 6
Laser hair reduction, 8
Laser hair removal
Alexandrite laser, 442
diode laser, 442
Nd:YAG laser, 442, 443
Index

548
Laser lipolysis, 251
Laser mechanics, 476–477
Laser physics, 477
Laser practice
delegating procedures, 526
direct and indirect costs, 524, 526
evidence based review, 525
integrating energy based devices, 523–524
marketing, 525
peers review, 525
rent vs. lease vs. purchase, 525
results and good outcomes, 525
return on investment, 526
Laser Protective Barriers and Curtains, 43
Laser Protective Eyewear, 43
Laser safety, 37
administrative controls, 41
delegation of medical procedures, 45
in dermatology, 40
healthcare, 40
for perioperative nursing, 39
program, 42
for support personnel, 39
training and credentialing, 39
warning signs and labels, 42, 43
Laser skin resurfacing, 18
Laser systems, 198, 204, 206
Laser therapy, 501
Laser toning, see Sub-surfacing lasers
Laser welding, 342–344
LaserCap®, 369
Lasers and light therapies, 502
Laser-tissue interactions (LTIs)
carbonization, 25
chromophore concentrations, 22, 24
dermal transmission, 23
epidermal damage ratio, 22
hyperosmolar solutions, 25
immediate and delayed pigmented darkening, 24
logical sequence, 32
macroscopic responses, 25
medical treatment, 2
molecular basis, 16
non-radiative relaxation of optical energy, 25
optical damping, 23
Perfluorodecalin, 25
and photobiologic effects, 16
photon recycling, 25
photothermal response, 26
physical aspects, 32
pixilated injury, 22
pulse duration, 21
skin transparency, 25
threshold-based, 24
two-photon absorption, 21
vascular applications, 24
vascular heating, 24
wound healing, 22
Lasing media, 3, 4
LED low level light therapy
(LED-LLLT), 317
Leg veins, 75, 76, 79–81
anatomy, 73, 74
clinical evaluation, 74
dilated vessels, 74
diode laser, 78, 79
duplex imaging, 74
IPL, 78
KTP laser, 77
laser therapy
fluence, 76
hydrostatic pressure, 75
oxyhemoglobin, 75
procedure end point, 80
pulse duration, 76
side effects, 81
vessel heating, 76
LPA laser, 78
Nd:YAG laser, 79, 80
patient populations, 73
PDL, 77
prevalence, 73
surgical stripping, 73
treatment approaches, 75
with venous outflow obstruction, 75
venous structure and function, 74
Lenses
macro/close-up lenses, 508–509
wide angle zoom, 508–509
Lentigines, 2, 9, 15
Lentigo maligna melanoma (LMM), 394
Leucoderma, 239, 240
Leukocyte trafficking, 379
Leukotrichia, 486, 487
Lichen planopilaris, 359
Lidocaine, 428–431, 433, 434
Light
absorption/scattering, 3, 11
applications, 3
device terminology, 5–7
electromagnetic spectrum, 2
Far IR, 2
MIR, 2
molecular/microscopic level, 3
NIR I, 2
NIR II, 2
peak power, 3
photons, 3
scattering, 3
therapeutic applications, 3
UV, 2
VIS, 2
wavelength, 3
waves, 2
Light devices, skin
deep stratum, 219–222
mid stratum, 223
superficial stratum, 223–224
Light-emitting diodes (LEDs), 4, 293–302, 304–306,
309, 310, 312, 313, 324–327, 368, 369
advantages, 290, 292
applications, 330, 331
Index