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

395
experience. This observer dependency is not dis-
similar
to
histopathological
interpretation.
Nowadays the development of teledermatology
has partially solved this problem because of we
have the chance to contact with RCM experts in
real-time and send them the images.
Problems related to imaging include a depth
of penetration limited to the superficial dermis, or
even less, when a lesion is particularly hyperker-
atotic or hyperpigmented. Considering that thick-
ness of melanoma is an important prognostic
factor, improvements in the technique will be
necessary in order to increase RCM potency and
imaging depth. This might be improved by exper-
imenting with different immersion media and
illumination sources. The use of additional signal
filtering techniques such as coherence gating
[103] to better isolate backscattered light from
our focal plane and chemical agents such as glu-
cose and glycerol [104] to improve index match-
ing at the surface could improve penetration
depth. Decrease in contrast may be solved
through development of exogenous contrast
agents [105]. The current contact device is also
cumbersome and difficult to use on a non-flat sur-
face such as ears or noses.
Concerning the visual quality of RCM images,
there are three problem areas. The first is that
there is an uneven brightness within an image,
mostly caused by reflection from the skin surface
or from poorly reflecting structure of the superfi-
cial dermis. Other problem is a lack of contrast,
where details of certain structures are displayed
with a limited subset of grey levels. The third
problem is a considerable degree of noise. This
last feature is immanent to the scanning process
and the in  vivo situation in which images are
taken. Digital image enhancement corrects at
least in part one or more of these problems [106].
Work is ongoing to facilitate the creation of
vertical sections and three-dimensional sections
[107], which would vastly increase the potential
of RCM. There is also the possibility of a porta-
ble prototype using fibre optics. This would make
it much more practical and this might facilitate
the diffusion of this new technology for the
in vivo diagnosis in dermatology.
Conclusions
RCM potentially represents a new era for skin
oncology. In research, it offers benefits both
ex vivo and in vivo. Ex vivo, it enables repeti-
tive tissue sampling and noninvasively evalua-
tion to determine whether further testing is
necessary. In vivo, RCM can be used to study
normal processes or pathophysiologic pro-
cesses noninvasively over time. It can also be
used to establish the presence or absence of a
reactive immunologic event and guide tissue
sampling such as fine needle aspiration for
cells or molecular analysis (DNA, RNA or
proteins) of a specific immunological response
against neoplastic cells. RCM can also be
used to establish timing and dosing responses
to non-invasive therapies such as criotherapy,
imiquimod, and photodynamic therapy.
Clinically, RCM has value both ex vivo and
in vivo. Ex vivo tissue can first be evaluated
with RCM, and when necessary, a specific
finding can be confirmed on the same exact
tissue using appropriate markers or stains. In
vivo, the potential is tremendous. RCM may
be useful for the in vivo diagnosis, lesion mar-
gins assessment, and monitoring response to
non-invasive therapies. Although RCM is a
promising technique, we think that it is only in
its infancy and further investigations are nec-
essary for determine the real role in the future
management of skin cancer.
Acknowledgements  This work has been partially sup-
ported by a grant from Ministerio de Economía y
Competitividad of Spain (Instituto de Salud Carlos III,
PI15/00974 financed jointly by the European Regional
Development Funds, FEDER). S.G. also plays a role of
Consultant for Caliber I.D., the manufacturer of the com-
ercial reflectance confocal system.
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© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Laser Clinical and Practice Pearls
Hana Jeon, Lori A. Brightman,
and Roy G. Geronemus
Abstract
All laser operators should be up-to-date on
associated laser risks and standard safety mea-
sures for each laser that they use. Different
wavelengths of light are responsible for differ-
ent ocular damage; thus, appropriate eyewear
should be used with each laser treatment.
Keywords
Laser · Practice pearls · Eyeshield · Safety ·
Tattoo removal · Scars · Acne scar · PFD ·
Perfluorodecalin
Safety Measures
*All laser operators should be up-to-date on
associated laser risks and standard safety mea-
sures for each laser that they use.
*Different wavelengths of light are responsi-
ble for different ocular damage; thus, appropriate
eyewear should be used with each laser
treatment.
*Corneal eye shield placement is a safe and
effective method of eye protection.
*Surgical lubricant can be applied to protect
hair, eyelashes, and eyebrows from laser
treatments.
*Diligence must be taken to eliminate
any  combustible product in the laser treatment
field.
Here we discuss additional safety measures.
See Chaps. 1 and 2 for complete laser safety
discussions.
Eye Safety
Unprotected eyes are at great risk for injury dur-
ing laser treatments from either direct or indirect
laser beams. Different wavelengths of laser light
are responsible for various ocular damages,
which can be permanent. As the injury may be
H. Jeon (*) · L. A. Brightman
Laser & Skin Surgery Center of New York,
New York, NY, USA
e-mail: hjeon@laserskinsurgery.com
R. G. Geronemus
Laser & Skin Surgery Center of New York,
New York, NY, USA
Department of Dermatology, New York University
Medical Center, New York, NY, USA
e-mail: rgeronemus@laserskinsurgery.com; mail@
laserskinsurgery.com
23

402
painless and the laser beam invisible to the eye,
damage can occur inconspicuously. Hence,
appropriate eye protection should be used at all
times during any laser treatment.
There are different types of eyewear avail-
able for protection. For the practitioner, there
are ­optically coated goggles, spectacles, and
wraps.  Any  eyewear that  is used must fit
tightly on the  face and cover the  entire
eyes.  The chosen eyewear should also be of
appropriate wavelength and optical density for
the laser being employed. The parameters are
most often written on the frame of the eye-
wear. For the patient, when treating non-facial
areas, one can use plastic or metal eye shield
goggles that completely cover the orbit as well
as partial periorbital area. When treating in the
facial area, one should use metal corneal eye
shields [1, 2].
Corneal eye shield placement begins with a
thorough tray  setup (Fig.  23.1). Choose the
appropriate size shield for the patient; sizes
range from infant to adult (Fig. 23.2). A topical
ophthalmic anesthetic (e.g. tetracaine hydro-
chloride 0.5% ophthalmic solution) is used for
corneal anesthesia followed by lower lid retrac-
tion, placing the  shield with slight pressure
inferiorly. This will allow the upper lid to be
placed over the  shield simultaneously with
ease. The reverse approach can also be used
beginning with upper lid retraction (Figs. 23.3
and 23.4).
Hair Protection
During periorbital laser treatment, one must
be certain to protect the eyelashes and eye-
brows, as the laser beam can inadvertently
singe these hairs. Surgical lubricant acts as a
semi-hydrated coating medium that prevents
laser penetration.
After eye shield placement, use a cotton tip
applicator or tongue depressor to apply surgical
lubricant to the eyebrows and eyelashes prior to
commencement of laser treatment (Figs. 23.5 and
23.6). One can also use a tongue depressor to
cover the eyebrows in lieu of surgical lubricant
for hair protection (Fig. 23.7).
Anesthesia Safety
When the laser beam of the pulsed dye laser
strikes a combustible object such as oxygen or
nitrous oxide in an endotracheal tube, there is a
risk of spontaneous fire eruption. This risk is
not only applicable to laser use but also has
been reported during electrosurgical coagula-
tion. Regulatory groups as well as laser manu-
facturers have well documented the items that
are at risk for  ignition and advise that these
items be kept out of the laser field; these items
include oxygen, nitrous oxide, hair, gauze,
paper drapes, clothing, masks, cannulas, air-
way materials, and even flame-retardant paper
Fig. 23.1  Tray setup for corneal eye shield placement
Fig. 23.2  Various sizes of corneal eye shields
H. Jeon et al.

403
drapes. Therefore, all of these potential ignit-
able materials must be ­diligently kept away
from the laser field. Those that must remain in
the field must be kept wet with saline or water-
based lubricant.
Most cases of pulse dye laser-treated port wine
stains are in-office procedures without sedation
and its accompanying oxygen supplementation and
monitoring equipment. When the oxygen supple-
mentation and monitoring equipment are needed in
a
c
b
Fig. 23.3  Placement of child corneal eye shield. (a) With
upper lid retraction, place ophthalmic drops for mucosal
anesthesia; (b) retract upper lid, place shield with slight
pressure superiorly; (c) retract lower lid slightly, allowing
the lower lid to then slide over the eye shield. Eye shield
is now in place
23  Laser Clinical and Practice Pearls

404
cases of sedation, it is important to choose an air-
way with a lower risk of ignition. Nasal cannulas
are an open system and can ignite quite easily. Face
masks are not considered a tight seal and therefore
can also leak oxygen. Endotracheal tubes used in
the pediatric population can lead to a greater risk of
oxygen leak if the cuff is not tight and during posi-
tive pressure ventilation. Colored airways – espe-
cially green – or masks should not be used, as they
are likely to ignite.
a
c
d
b
Fig. 23.4  Placement of adult corneal eye shield. (a)
Ophthalmic anesthesia is placed; (b) Retract upper lid.
With slight pressure  superiorly, place adult-sized eye
shield; (c) Retract the upper lid (i), allowing eye shield to
glide into the  superior sclera space (ii); (d) Adult eye
shield in place
H. Jeon et al.

405
Laryngeal mask airway (LMA) is a device
that can be inserted into the patient’s pharynx.
With spontaneous ventilation, the LMA prevents
oxygen and nitrous oxide leakage by approxi-
mately 95%. Leakage is more likely to occur with
positive pressure ventilation. In all types of venti-
lation, one can employ an oxygen analyzer or
capnograph to detect oxygen level at airway.
Regardless of the type of airway used, one should
drape wet gauze around the airway, use a non-­
flammable petrolatum over hair bearing areas and
use ocular shields. When not using the laser it
should be placed in standby mode.
Even with all precautions taken, there is still a
risk that exists and it is prudent for all staff
involved in the patient’s care to be up-to-date on
the American National Standard for the Safe Use
of Lasers. During all operative room laser proce-
dures, there should always be a basin of water
and a fire extinguisher readily available [3].
Tattoos
*Cosmetic tattoos have a higher likelihood of
containing ferric oxide or titanium dioxide pig-
ments which darken with Q-switched laser
treatment.
*Ablative or fractional ablative laser treat-
ment allow for cosmetic tattoo removal without
risk of tattoo pigment darkening.
*Fractional CO2 lasers can be employed when
treating dark skin patients with known contact
allergen to tattoo pigment to minimize risk of
anaphylaxis.
*Hypopigmentation secondary to laser treat-
ment for tattoo removal can be treated with frac-
tional CO2 lasers.
Tattoos
Tattoos come in many forms including amateur,
professional, cosmetic, medicinal and traumatic.
Laser treatment is a method of tattoo removal
with minimal risk of scarring particularly when
compared with alternative tattoo removal meth-
ods such as dermabrasion or surgical excision.
Amateur tattoos are generally easier to treat than
professional tattoos as the ink is usually more
superficial and of less dense particles. Multicolor
Fig. 23.5  Application of surgical lubricant on eyelashes
Fig. 23.6  Application of surgical lubricant on eyebrows
Fig. 23.7  Tongue depressor to protect eyebrows
23  Laser Clinical and Practice Pearls

406
tattoos will require different lasers in order to treat
the various colors. Double treated, densely pig-
mented and multi-colored tattoos are more likely
to be recalcitrant to laser therapy. See Chap. 7 for
complete discussion of laser tattoo removal.
Cosmetic Tattoo Removal
Cosmetic tattoos are generally composed of pig-
ments in the beige, white, and red families of which
most contain ferric oxide or titanium dioxide pig-
ment. When exposed to Q-switched lasers, oxida-
tion of the pigment to ferrous oxide occurs,
resulting in an immediate pigment darkening [4, 5].
As there is no standardization of tattoo ink, all
tattoo pigments should be viewed on an individ-
ual basis. It can be very difficult to predetermine
which cosmetic tattoos will be able to undergo
laser tattoo removal without darkening. One may
preemptively treat cosmetic tattoos with ablation
or fractional ablation to avoid this oxidation risk.
The superficial fractional ablation will allow pig-
ment removal in the sloughing of skin. There is
minimal risk of scarring or pigmentary changes
as the zones of untreated skin in between ablative
zones act as a resource for epithelial repair
(Figs.  23.8, 23.9, 23.10, and 23.11). In this
patient, a fractional CO2 laser was used for eye-
brow tattoo removal. One can appreciate immedi-
ate lessening of tattoo pigment after two passes
of fractional ablative laser treatment (Figs. 23.11
and 23.12).
Use of PFD in Tattoo Removal
Perfluorodecalin (PFD)-infused patches have
been found to be effective in tattoo treatments by
resolving immediate whitening reactions that fol-
low the usual tattoo treatment and allowing
immediate re-treatment of tattoos. This technique
significantly shortens the time required to treat as
the conventional treatment involves waiting
20 min for the whitening reactions to dissipate
before proceeding with the next pass [6].
Fig. 23.8  Fractional CO2 treatment of cosmetic eyebrow
tattoo
Fig. 23.9  Fractional CO2 treatment of cosmetic eyebrow
tattoo
Fig. 23.10  Remove sloughed skin in between laser
passes with wet gauze
H. Jeon et al.

407
Metabolically inert, perfluorodecalin absorbs gas
and helps to achieve optical clearing [7]. PFD-­
infused silicone patches also serve as a heat sink
and physical barrier that prevents splattering of
the debris being ejected from the skin during
treatment (Fig. 23.13).
Tattoo Removal in Dark Skin Types
The principal of tattoo removal is destruction of
unwanted pigment with minimal collateral dam-
age. This concept is particularly challenging
when treating darker skin types as the melano-
somes act as competing targets with the potential
to cause epidermal damage. The 1,064-nm wave-
length has the least absorption by melanocytes
and is therefore the best choice for laser tattoo
removal in darker skin types. There is less risk for
hypopigmentation, scarring, or textural change.
However, the 1,064-nm wavelength will not treat
all tattoo colors. Therefore, one must employ
alternate methods for multicolored or densely
colored tattoos in dark skin types [3, 4].
Fractional ablation of tattoos in dark skin
types will allow extraction of tattoo pigment par-
ticles with minimal risk of scarring or pigmen-
tary change. This concept is particularly useful in
dark skin types within a patient that has demon-
strated allergic reaction to the tattoo pigment. For
instance, red pigment is the most common known
tattoo allergen and can result in a granulomatous
reaction. If targeted with a 532-nm wavelength
for removal, the pigment can shatter into many
smaller particles followed by uptake systemically
with the potential for anaphylaxis. To avoid this
Fig. 23.11  Right eyebrow after second laser pass
a
b
Fig. 23.12  (a) Before treatment. (b) After treatment
Fig. 23.13  Removal of cosmetic lip tattoo
23  Laser Clinical and Practice Pearls

408
issue, fractional CO2 laser can be used for slough-
ing of the pigment through epidermal loss with
limited systemic elimination. Non-fractional CO2
laser has limited use in this circumstance as it has
significant potential to permanently depigment or
scar the skin (Figs. 23.14 and 23.15) [5, 8–10].
Complications in Laser Tattoo
Removal
Even in the most experienced hands, lasers can
induce scarring, textural changes, or hypopig-
mentation. When hypopigmentation does occur, it
is transient majority of the time and will resolve
over the course of months with appropriate care.
There is a small percentage of cases in which the
hypopigmentation is permanent. This is cosmeti-
cally unappealing and in the view of the patient,
sometimes worse than the original tattoo. Again,
fractional lasers can be employed to stimulate
repigmentation. This is accomplished via melano-
cyte stimulation in the zones of untreated skin
adjacent to ablated zones, acting as a pigment
resource [5, 8–11] (Figs. 23.16, 23.17, and 23.18).
Scars
*Hypertrophic and atrophic scars, whether trau-
matic, surgical, or acne in etiology, can be signifi-
cantly improved with fractional erbium doped
1,550  nm, 1,927  nm, and fractional CO2 laser
treatments.
*Hypopigmented scars can be repigmented
with fractional erbium doped 1,550  nm,
1,927 nm, and fractional CO2 laser treatments.
Fig. 23.14  Note depigmentation after CO2 laser treat-
ment for tattoo removal
Fig. 23.15  Note repigmentation of prior treated area,
accomplished with fractional CO2 laser treatment
H. Jeon et al.

409
Scars
Any injury to the skin that goes beyond the
epidermis will result in scarring. Scars come
in many varieties. They can be categorized
according to etiology, such as traumatic scar,
surgical scar, or acne scar. They can also be
grouped by wound healing response, such as
hypertrophic or keloid scars resulting from
excessive wound healing. Regardless of etiol-
ogy, there are limited resources for significant
cosmetic improvement with limited downtime
or risk. See Chap. 4 for complete discussion of
scar treated with lasers.
Fig. 23.16  Hypopigmentation in skin type II after ruby
laser treatment for black tattoo removal
Fig. 23.17  Note repigmentation of previously  treated
area, accomplished with non-ablative fractional 1,550 nm
laser
a
b
Fig. 23.18  (a) After multiple ruby laser treatments for
tattoo removal, slight tattoo pigment remains as well as
mild hyperpigmentation of normal surrounding skin;
(b) After four treatments of non-ablative fractional erbium
treatments, no appreciable tattoo pigment remains
23  Laser Clinical and Practice Pearls

410
Hypertrophic and Atrophic Scars
Past studies have demonstrated mild to moderate
reduction in scar erythema, thickness, and pruritus
with PDL treatment. This is theorized to be sec-
ondary to reduction in vasculature of the scar.
Ablative lasers (erbium or CO2) can be used to
reduce the excess tissue. However, there is a great
risk of further scarring or dyspigmentation from
the laser treatment itself. More recent technology
such as fractional photothermolysis can result in
significant cosmetic improvement of scars via col-
lagen remodeling with limited risk of side effects.
Ablative fractional photothermolysis allows for
reduction of excess tissue in a controlled capacity
within the thermal microzones. This leaves the
normal adjacent tissue to act as the resource for
repair, minimizing risk of dyspigmentation and
scarring. The deep coagulation allows for scar
contraction and smoothing of texture that result in
a remodeling of scar tissue. Non-ablative frac-
tional photothermolysis is also effective in treating
scars. The collagen remodeling allows for
improvement in overall texture as well as repig-
mentation of hypopigmented scars. The scars con-
tinue to improve in pliability, texture, and
pigmentation with each successive treatment. Both
non-ablative and ablative fractional resurfacing
allow for scar improvement in all skin types in
contrast to standard ablative lasers (Figs.  23.18,
23.19, 23.20, 23.21, 23.22, 23.23) [10–15].
Acne Scars
Facial acne scarring affects many patients of
all skin types. There are multiple options for
treatment, but not all have significant improve-
a
b
Fig. 23.19  (a)
Post-surgical scar on the
nasal sidewall. (b)
Improvement after
ablative fractional CO2
laser treatment
H. Jeon et al.

411
ment and not all can be used in darker skin
types. Non-­ablative lasers such as Nd:Yag have
been used for dermal collagen stimulation with
a low risk profile and convenient treatment
course but limited results. Fractional photother-
molysis has demonstrated consistent efficacy in
scar improvement with limited risk of side
effects. Importantly, it can be used in all skin
types with appropriate parameter selection
(Fig. 23.24) [13–18].
a
b
Fig. 23.20  (a) Atrophic
scars with
hypopigmentation and
textural changes in skin
type III; (b) Significant
improvement after five
fractional non-ablative
1,550 nm erbium-doped
laser treatments
a
b
c
Fig. 23.21  (a) Infantile hemangioma; (b) Involution of hemangioma with resulting textural and pigmentary changes;
(c) Significant improvement after three erbium-doped 1,550 nm laser treatment
23  Laser Clinical and Practice Pearls

412
a
b
Fig. 23.22  (a) Linear atrophic scar caused by traumatic injury 18 years prior; (b) Near complete resolution of atrophic
scar status post fractional CO2 laser treatment (1 month post treatment #1)
a
b
Fig. 23.23  (a) Skin type II patient with moderate acne scarring; (b) After a series of five treatments with fractional
1,550 nm erbium-doped fiber laser, there is a significant reduction of scar appearance
H. Jeon et al.

413
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thermolysis: a new concept for cutaneous remodeling
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rent and future applications. Lasers Surg Med.
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10. Hantash B, Mahmood M. Fractional photothermoly-
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responses to fractional photothermolysis. Lasers Surg
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12. Rahman Z, Alam M, Dover J. Fractional laser treat-
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a
b
Fig. 23.24  (a) Baseline with moderate acne scarring and melasma; (b) After five fractional 1,550 nm laser treatments
and one fractional CO2 laser treatment with notable resolution of acne scars as well as melasma
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415
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
The Selection and Education
of Laser Patients
Murad Alam and Meghan Dubina
Abstract
Several measures can affect the likelihood of
optimal treatment results and patient satisfac-
tion. First, a suitable candidate must be
selected. As with many cosmetic procedures,
unreasonable expectations, body dysmorphic
disorder, relevant psychiatric illness, and
chronic dissatisfaction with prior physicians
are concerning factors. Additionally, patient
dissatisfaction is frequent following treatment
of minor complaints or those for which reli-
able, efficacious treatments are not available.
Tanned patients or patients of color are at risk
for dyschromia, and treatment may need to be
delayed or modified accordingly.
Keywords
Adverse events · Body dysmorphic disorder
Contraindications · Counseling · Dissatis­
faction · Education · Hyperpigmentation
Patient selection · Psychiatric illness
Outline
• Basic Considerations in Patient Selection
• Procedure
Delegation
to
Non-Physician
Caregivers
• Initial Consultation and Patient Education
• Exclusion Criteria for Laser Treatments
• Patient
Education
Regarding
Undesired
Effects
Introduction
Several measures can affect the likelihood of
optimal treatment results and patient satisfac-
tion. First, a suitable candidate must be selected.
As with many cosmetic procedures, unreason-
able expectations, body dysmorphic disorder,
relevant psychiatric illness, and chronic dissatis-
faction with prior physicians are concerning fac-
tors. Additionally, patient dissatisfaction is
frequent following treatment of minor com-
plaints or those for which reliable, efficacious
treatments are not available. Tanned patients or
patients of color are at risk for dyschromia, and
treatment may need to be delayed or modified
accordingly.
Following patient selection, there is a detailed
pretreatment consultation during which patient
education occurs. When counseling patients,
physicians may first listen to patient concerns,
then ask salient questions for clarification, and
M. Alam (*)
Department of Dermatology, Otolaryngology, and
Surgery, Northwestern University, Chicago, IL, USA
Department of Dermatology, Northwestern
University, Chicago, IL, USA
e-mail: m-alam@northwestern.edu
M. Dubina
Department of Dermatology, Northwestern
University, Chicago, IL, USA
24

416
finally suggest a range of appropriate options. To
further ensure redundancy and clarity, physi-
cians may involve multiple caregivers in the edu-
cation process and utilize photographs and
brochures. Some physicians are now routinely
using prerecorded videos that patients can watch
in a clinic room to describe the risks and bene-
fits, likely course, and patient experience associ-
ated with particular procedures; such videos are
often just a few minutes long, and are able to
provide an engaging narrative akin to a short
documentary [1, 2].
Patients should be informed of the approxi-
mate number of laser treatments that may be
necessary, expected downtime after treatment,
and potential alternatives or combination ther-
apies. Physicians may also preemptively dis-
close that some patients do not respond with
the same success as others to certain
procedures.
Lastly, patients should be told of common
undesired effects before treatment, and be given
contact information to encourage prompt report-
ing of unexpected adverse events after treat-
ment. In the event of procedure-related adverse
events, calm and honest discussion is the guid-
ing principle. Physicians should explain correc-
tive options and assure their commitment to the
patient. Careful patient selection and education
will prove beneficial for both patient and
physician.
Selecting the Laser Patient
Finding the Reasonable Patient
In discourses on patient selection in cosmetic and
laser surgery, there is an emphasis on ensuring
that the patient has so-called “reasonable expec-
tations.” The difficulty lies in defining this phrase
and in ascertaining whether a particular patient
meets the test. Among the useful cues are facial
expressions and the patient’s responses to the
physician’s discourse [3]. A patient who nods in
response and asks appropriate questions in a
modulated voice of moderate volume is reassur-
ing for the physician. The implication is that the
patient is a partner in the discussion and is both
understanding what the physician is saying and
agreeing with the physician’s plan. An exces-
sively emotional, or alternatively stone-face and
hostile, patient is cause for concern.
Body Dysmorphic Disorder
Much has also been written about the unsuitabil-
ity for cosmetic procedures of patients with body
dysmorphic disorder. The full-blown disorder is
probably uncommon among patients seeking
laser treatment. But less extreme variants are
seen often. In brief, the problem is that some
patients perceive their own bodies in an unrealis-
tic manner [4]. Minor flaws are seen as major dis-
figurement, and some normal features are viewed
as problems needing correction. Such patients are
chronically dissatisfied with their appearance,
and there may be no limit to the number of com-
plaints they have. Correcting a given complaint
with a perfectly executed laser procedure will be
of no value: either the patient will immediately
generate another complaint, or they will deny
that the first was adequately treated despite objec-
tive evidence to the contrary [5].
Identifying the patient with body dysmorphic
disorder or a lesser subtype is not always simple.
Patients may be expert at concealing their pathol-
ogy. They may appear eminently reasonable.
Evidence in support of a diagnosis of body dys-
morphic disorder is a large number of prior
­surgeries or procedures to address the same
problem [6]. These may be invasive surgeries
Potential Contraindications in Patient
Selection
1. Unreasonable expectations
2. Body dysmorphic disorder
3. Unmanaged psychiatric illness
4. Complaints regarding prior physicians
and treatments
5. Hard to see, hard to treat problems
6. Selection of procedures with highly
variable efficacy
M. Alam and M. Dubina

417
like rhinoplasty or rytidectomy that are seldom
repeated multiple times, and they may have been
performed by a number of different physicians.
A surgeon who is convinced that a patient has
body dysmorphic disorder should refer the patient
for appropriate counseling with a mental health
professional. If there is some doubt about the
diagnosis, it may be appropriate to consult with or
refer the patient to another cosmetic surgeon for a
second opinion. If the diagnosis is far from certain
and the physician thinks the patient is anxious but
not mentally ill, it may still be preferable to avoid
any major procedures until the patient has under-
gone some minor nonablative procedures and
evinced a satisfactory post-treatment course.
Patients with Psychiatric Illness
and Factitial Dermatoses
Patients with depression and anxiety disorders,
schizophrenia, and other psychiatric disorders
may present for laser surgery. Importantly, these
conditions are not absolute contraindications for
treatment. Patients who understand their illness,
are appropriately medicated, and are under the
care of a physician who is both managing their
mental illness and supportive of their desire for
laser surgery may in fact be appropriate laser
patients. Needless to say, patients with mental ill-
ness who lack insight and whose underlying dis-
ease is not managed are not suitable candidates
for laser procedures.
One problem in the post-operative period is
picking and self-mutilation [7]. Picking behaviors
are often exacerbated by the appearance of what is
perceived as “damaged” skin, such as the re-epithe-
lializing skin after ablative resurfacing. Since pick-
ing can lead to prolonged healing and scarring,
picking should be treated before ablative or par-
tially ablative laser treatments are commenced.
Patients Who Have Been Dissatisfied
with Prior Physicians
Not uncommonly, laser physicians see patients
who are unhappy with doctors who have treated
them previously. On initial presentation, such
patients may convey delight at having finally
found the perfect, best qualified physician for their
needs. They may relate the horrors of prior experi-
ences with different physicians, who were in their
estimation incompetent and dangerous quacks.
These patients may be effusive and smiling, and
convey their relief at finally being under the care of
a master and magician, the physician in question.
While this level of approbation can be intoxi-
cating for the physician toward whom it is
directed, caution should be exercised in treating
patients who present thus. Often, dissatisfaction
with prior physicians is founded not on the incom-
petence of these professionals but rather on unre-
alistic patient expectations that could not have
been, and hence were not, met [8]. Patients who
hated their other doctors, may soon come to hate
their current doctor. In such patients, there is a
pervasive tendency to view physicians as either all
good, or all bad. Oversimplification of this type is
incompatible with the more shades-of-grey medi-
cal model, in which good care often results in par-
tial resolution of ill-defined problems.
In working with a patient of this type, it may
be wise for the physician to communicate force-
fully early in the consultation that he or she is
quite certainly unable to help the patient in the
manner they seek. Additional referrals may be
provided to other physicians who may or may not
be able to assist the patient. Disappointing the
patient early in the process may, for the physi-
cian, be preferable to managing an unhappy
patient after treatment.
Identifying Problems That Are
Difficult to Treat
Some patients have very high standards. They
may ask to have removed minute lentigines that
are difficult to see. Or they may request a further
scar revision for an accident-induced scar that
was previously expertly revised and is now a faint
flat line.
In considering the needs of such patients, it is
important to maintain a realistic appraisal of what
is possible. One approach is for the physician to
24  The Selection and Education of Laser Patients

418
communicate that he or she definitely under-
stands the patient’s concern, but is unsure that he
or she has the means to resolve it. The physician
may wish to share that given the subtlety of the
defect, it is difficult to say whether it would be
improved, unchanged, or even exacerbated after a
laser procedure. Since no physician is omni-
scient, it is reasonable to concede that some other
laser surgeon may offer a superior treatment
strategy associated with a greater likelihood of
success; it may thus be appropriate for the physi-
cian to suggest a second opinion be obtained
from another laser expert in the area. If the initial
physician chooses to treat the minor defect per-
ceived by the patient as a major one, the physi-
cian should be prepared for a dissatisfied patient
after treatment. To avoid this, the physician
should be clear about the weak prospects for
improvement, and the likely need for many treat-
ments; a comprehensive oral and written consent
may be obtained.
Performing Procedures to Which
Some Patients Do Not Respond
Some energy procedures, such as nonablative
skin tightening, do not provide all patients with
similar benefits. Perhaps a fourth of patients
obtain excellent results, another half have modest
improvement, and a quarter may have no discern-
ible change from baseline. If there is a reasonable
likelihood that a laser procedure will be unsuc-
cessful for a particular patient, it is important to
communicate this before the procedure is per-
formed. It is more credible for the physician to
predict lack of response than to justify it after it
has happened. Prediction implies superior knowl-
edge and honesty; justification after the fact sug-
gests lack of competence and the possibility that
a mistake is being rationalized. Of course, any
laser procedure, and any medical procedure in
general, can be ineffective in a specific case with-
out any physician fault. But when such an out-
come is probable, it behooves the physician to
clearly communicate this in a pre-emptive man-
ner. In general, it is better to lose a patient than to
regret having performed a procedure on a now
unhappy patient, who feels mislead and whose
needs have not been met.
Retreating or Managing
the Reasonable Patient Who Is
Dissatisfied
Even when surgery is performed on reasonable,
emotionally stable patients who have appropriate
expectations and are not unduly critical, prob-
lems can occur. In these cases, it is appropriate to
promptly address the issues and find a solution
that best meets the patient’s needs. If a prior pro-
cedure has not been as effective as anticipated, an
additional procedure of the same type, or a differ-
ent procedure with the same desired outcome,
may be undertaken. If a prior procedure resulted
in troublesome adverse events, these should be
addressed first, and all efforts undertaken to mini-
mize the signs and symptoms as quickly as pos-
sible, and usually before initiating further
treatment. When problems have occurred that are
unfortunate and unforeseen, it may still be help-
ful for the physician to sympathize and even
apologize for the inconvenience. Reasonable
patients understand that outcomes are not always
as desired, but a failure to empathize with the
patient, acknowledge the problem, and convey a
commitment to taking corrective steps can be
perceived as evidence of arrogance or lack of car-
ing on the part of the laser surgeon. When the
patient is very unhappy despite the physician’s
best efforts to address problems sensitively, it is
not unreasonable for the physician to help the
patient find another doctor. Not all patients may
leave happy, but efforts should be taken to miti-
gate their unhappiness and redeem their opinion
of the referring practice to the extent possible.
Delegating Procedures to Non-
Physician Caregivers
Smaller laser procedures are frequently delegated
to nurses, physician assistants, and other non-
physician providers. After a consultation with the
physician, who may recommend a series of laser
M. Alam and M. Dubina

419
treatments, the patient may follow up on a
monthly basis with a trained non-physician pro-
vider who performs these treatments under phy-
sician supervision. Medical practices vary with
regard to the degree of delegation: on-site versus
off-site delegation; the types of laser procedures
that are delegated; and the level of training and
education of the providers performing the dele-
gated functions. Potential problems with delega-
tion, especially if the non-physician providers are
not comprehensively trained, include the risk of
compromising patient safety though the increased
frequency of preventable adverse events and fail-
ure to efficiently and effectively treat these unde-
sired outcomes. Other potential pitfalls include
inappropriate or unnecessary use of lasers and
risk of overtreatment [9].
Another variable is patient acceptance of del-
egation. Some patients insist upon treatment by
the attending physician. Others may be more
flexible, but may want the attending physician to
be in-house or to perform at least part of the pro-
cedure. Still others may be indifferent as to who
provides the service as long as the physician is in
charge and responsible for the outcome. Before
delegating a procedure, the physician must make
sure that the patient is accepting of this. If the
patient insists on the physician performing the
procedure, it is appropriate to charge a higher fee,
which accounts for the additional physician time
required. When procedures are delegated, if the
patient is dissatisfied with the non-physician pro-
vider, this should be conveyed forthwith to the
physician by the provider; the physician can then
see the patient, address the concerns, and repair
the patient-physician relationship.
Educating Laser Patients Presenting
for Consultation
Presenting Complaints in Laser
and Cosmetic Patients
Patients who present for laser procedures either
have a specific complaint they wish addressed, or
have a general interest in laser therapy. In the lat-
ter case, they are typically unsure what laser
might be able to do for them, but are attracted to
laser therapy, which they consider precise and
definitive.
Counseling Patients Who Know What
They Want Treated
Listen to Patient Concerns
If patients present with a specific concern, say
excess hair on the upper lip or telangiectasia on
the nose, the first step is for the physician to
assess the problem. It is best to let the patient
speak for several minutes, as this will help the
physician understand the exact concerns as well
as the degree of emotional overlay. For instance,
if the patient has telangiectasia over much of her
face but is only bothered by a large spider angi-
oma on her nasal tip, this is useful information.
Similarly, it is useful to understand whether the
patient is only mildly disturbed by a concern or
whether this subjectively a life-altering problem
for which she is willing to consider most any
treatment option. As the patient is describing her
presenting complaint, it is helpful to offer her a
handheld mirror, so that she can point to the rel-
evant areas, and the physician can see these
clearly.
Ask Questions to Clarify the Extent
of the Concern, and Prior Treatment
History
Once the patient has had an opportunity to
describe the problem, the physician should ask
salient questions. If the physician believes that
the patient may have omitted some concerns or
not have provided adequate history, questions
may be asked to elicit this information. For
example, the physician may ask, “I know the red
spot on your nose bothers you, but what about
the blood vessels on your cheek, and the redness
elsewhere on your head and neck?” The purpose
here is not to induce insecurity in the patient,
but rather to obtain complete information. If the
patient comments that other areas of redness are
not too noticeable and looks to the physician for
confirmation, it behooves the physician to say
something reassuring, like “I see what you
24  The Selection and Education of Laser Patients

420
mean, it’s really only the nose that is a problem
at this time.” With regard to history, it is impor-
tant to know the genesis of a problem and what
prior treatments may have been undertaken. A
red, indented scar caused by a motor vehicle
accident 2 days ago may be treated with conser-
vative wound therapy, a waiting period, and then
laser for redness and scar; conversely, a long-
standing red scar may be treated immediately
with laser. In the same vein, an angioma previ-
ously treated unsuccessfully three times with
pulsed-dye laser may require either higher flu-
ence therapy with bruising or possibly a more
aggressive vascular laser, such as an Nd:YAG; a
so-called “virgin” angioma may only require
gentle pulsing from a KTP or pulsed-dye laser.
While laser procedures are often elective, and
not reimbursed by insurance, it is imperative
that the physician retain the vigilance usually
required when confronted with serious medical
problems. For instance, if there is a scar adja-
cent to the presenting complaint that the patient
has not explained, the doctor should ask about
it. If the patient has complicating medical ill-
nesses, like lupus or scleroderma, that may
inhibit healing, the physician should glean this
information from the chart or ask the patient
directly.
Communicate to the Patient That
You Are Carefully Considering Options
Having had the patient describe the problem and
having asked additional questions for clarifica-
tion, the physician should take a moment to think.
It is best to be sitting down for this, as studies
have shown that patients prefer this, and view a
physician who sits as one who spends more time
with them [10]. Patients are used to being inter-
rupted hurried by their physicians, so some quiet
thinking time may give them the correct impres-
sion that their concerns are being evaluated. A
furrowed brow, leaning back in a chair, or even
saying aloud, “let me consider what you have
said,” will communicate that the physician is
hard at work solving the problem. Of course, this
phase should not last too long to avoid creating
the impression that the physician is confused or
unsure.
Suggest a Range of Appropriate
Treatment Options
Based on the information provided, the physician
should provide treatment options to the patient.
In some cases a specific treatment may be sug-
gested. In other cases, a range of options, from
the less costly and minimally invasive to the more
expensive and more downtime-intensive, can be
presented. Whether one or several options are
presented will depend on: (1) the medical issue
being addressed, and whether multiple therapies
exist for its management; (2) patient preference,
with some patients wanting the doctor to decide
and others wanting to select from a series of well-
described options themselves. Patients vary in
the degree of risk they wish to assume. Should
the physician have a sense of their set point for
risk, this can be taken into account. To wit, a
patient who wants something very gentle, like a
topical cream, for facial rejuvenation, may be
amenable to microdermabrasion, superficial
chemical peels, and nonablative laser; another
equally photodamaged person who has previ-
ously had a two face-lifts and a blepharoplasty
may not be satisfied with anything less than max-
imal therapy with full face laser resurfacing or
fractional carbon dioxide laser treatment.
Involve Other Caregivers, Photographs,
and Written Materials to Ensure
Redundancy and Enhance Clarity
In providing information about therapeutic
options, it is useful to include other educators and
visual aids. Due to the inordinate time commit-
ment associated with initial patient consultations,
mid-level professionals may be asked to partici-
pate. Nurses, clinical nurse practitioners, physi-
cian assistants, and residents or fellows in training
may join the attending physician in the patient
room, and they may stay after the physician exits
to answer additional questions. Alternatively, a
similar professional may be the first to see the
patient, elicit a history, and prepare a possible list
of therapeutic options before the attending enters
the room. From the patient perspective, meeting
with several caregivers sequentially may allow
patients to refine their thoughts and to have all
their questions answered. From the perspective
M. Alam and M. Dubina

421
of the attending physician, this serial approach
reduces the amount of attending time to be spent
with each patient while ensuring that nothing
salient is missed by the treating team and that
routine elements of the consultation, such as
description of adverse events, prices, and preop-
erative instructions, are conveyed clearly. While
some practitioners do not like to provide repre-
sentative before and after photographs, these can
be very helpful. A nurse or other caregiver may
review a book of such photographs with a pro-
spective patient, thus creating reasonable expec-
tations, affording the patient a further opportunity
to ask questions, and providing the patient with
information that she may need before deciding to
proceed with the laser therapy. Brochures about
procedures and a carefully customized menu of
recommended services with prices are also ben-
eficial for patient information [11]. Patients often
forget what they have heard. Written materials
can be used to refresh memories, and perused at
home with a spouse or significant other. For
major procedures requiring some downtime ad
risk, phone numbers of willing patients who have
previously been satisfied with similar procedures
may allay patient worries. A designated cosmetic
coordinator or cosmetic consultant from the phy-
sician practice may contact the patient at home or
provide a contact number in case the patient has
further queries. Some practices will permit a free
or low-cost reconsultation with the physician to
address lingering issues before a procedure.
Counseling Patients Who Offer No
Specific Complaints But Want to Look
Better
The patient who is unsure about precisely what
she wants but desires to look better overall is
slightly more challenging in initial consultation.
Usually, even such relatively unsophisticated or
indecisive patients do have some internal view of
their flaws. Gentle questioning can often lead
them to reveal these self-assessments. If adequate
information is thus obtained, management of
these concerns can proceed as if the patient ini-
tially presented with them. If, on the other hand,
the patient is not providing much guidance even
after some pointed queries, the physician may
prompt pursue a systematic approach: Starting on
the face, the physician can assess color and tex-
tural irregularities. The physician can verbally
list the apparent problems and visible signs of
aging, and then suggest the modalities that may
be suitable for improving each. The physician
may also allude to the approximate degree of
invasiveness, downtime, and cost associated with
various treatment options. Finally, the physician
may suggest a step-by-step program for proceed-
ing. High on the list should be procedures that are
simple, inexpensive, and highly likely to produce
an appreciable improvement; the successful out-
come of these may help diminish patient anxiety
and increase patient willingness to undergo more
invasive or complex procedures in the future.
Explaining the Laser Treatment
in the Context of a Larger Treatment
Plan
One laser treatment will seldom completely cor-
rect a patient complaint. The exception may be
full-face laser resurfacing or aggressive fractional
resurfacing with carbon dioxide laser. In most
cases, 3–6 or more laser treatments may be needed
to mostly treat a problem; for instance, a series of
nonablative treatments with various lasers will
improve telangiectasia, diffuse facial erythema,
lentigines, acne scars, and excess hair. Tattoo
removal may require ten, or more, treatments.
Further, laser is not the only treatment type
that may be appropriate. Other methods, like
Treatments That Can Be Combined with
Lasers
• Injectable fillers
• Surgical excision
• Neurotoxins
• Other energy devices (radiofrequency,
ultrasound)
24  The Selection and Education of Laser Patients

422
injectable fillers, surgical excision, neurotoxins,
and other energy devices, may be used in combi-
nation. Such multimodality treatments can maxi-
mize the efficacy and persistence of results while
maintaining an excellent safety profile. If appro-
priate, patients should be counseled during the
consultation phase about the utility of other treat-
ments to enhance the effect of laser. Considerations
of cost and time may intrude, but patients should
be offered the choice. Also, in raising this issue,
the physician will clarify that complete resolu-
tion of the target complaint is not possible by
laser alone.
When Laser Treatments Should
Be Deferred or Modified
In certain cases, laser treatment may be inappro-
priate or at least need to be postponed. Different
lasers may have specific exclusion criteria. For
example, if a Caucasian patient has plucked their
chin hair recently, they would not be a candidate
for laser hair removal until several weeks later
since the presence of hair roots at the target site is
essential for the efficacy of this procedure. Some
cautions are more general, applying to all cutane-
ous laser devices.
Tanned Patients
Caucasian patients who are intensely tan due to
tanning beds, prolonged outdoor exposure, or a
recent sunny vacation should not receive laser
treatment as they are at risk for brownish discol-
oration. While dyschromia of this type will even-
tually resolve, it can be disfiguring and take
months to remit. Patients about to embark on a
vacation where they will be sun-exposed should
also defer laser treatment. Athletes pending a
major outdoor sporting event, such as a triathlon,
or tennis or golf tournament, may wish to be
treated a few weeks after this is over. In general,
laser treatments should be avoided a few weeks
before and a few weeks after significant sun
exposure. Tanning booths are considered sun
exposure, but artificial tanning solutions are not;
even so, artificial tanners should be discontinued
4–5 days prior to laser procedures.
Patients of Color
Darker skinned patients, especially those of
Fitzpatrick skin types IV–VI, are at greater risk of
post-inflammatory hyperpigmentation after laser
procedures. Ablative and partially ablative lasers
are much more likely to induce pigmentary
change in susceptible patients, but all lasers are a
potential risk. Bruising after pulsed-dye laser pro-
cedures can also culminate in brownish discolor-
ation. In darker skinned patients, including those
of Indian, Middle Eastern, Far Eastern, and Latino
origin,
post-inflammatory
hyperpigmentation
may be slow to resolve, and may last many months
or even years. Higher energy treatments are com-
monly avoided in patients with ethnic skin. More
numerous lower-energy treatments may be substi-
tuted in lieu of fewer more aggressive treatments.
Educating Patient About Common
Undesired Effects
Redness and Swelling
Patients should be told that a certain degree of
redness and swelling are inevitable after most
Common Undesired Effects
Before treatment
• Redness
• Swelling
• Bruising
• Erosions
• Downtime
After treatment
• Hives
• Blisters
M. Alam and M. Dubina

423
laser procedures. Such sequelae can be covered
with makeup and will remit in hours, or at most
1–2 days. In describing these results, it is prefer-
able to avoid using the technical terms “ery-
thema” and “edema,” as these are not understood
by most patients. It may be helpful to also explain
that there is individual variation, and some
patients may become redder or swell more than
most. When the upper cheeks and lower forehead
area are treated, periorbital swelling is extremely
common. In such cases, patients should be
apprised that their eyes may almost swell shut for
a day or two, and that this can occur a day or two
after treatment. Eyelid swelling is a common
stimulus for a worried phone call from patients;
proper pretreatment counseling can avert this
needless anxiety, and inconvenience to both
patient and physician.
Bruising
Bruising (ecchymoses) can occur after some
laser treatments, including pulsed-dye laser and
some ablative resurfacing lasers. Bruising can
persist for a week or longer, with more protracted
course periorbitally. In the initial consultation, it
is important to ascertain the degree to which
patients can tolerate bruising. Some patients in
the public eye may not want even the smallest,
faintest bruise; for them, laser treatment parame-
ters should be adjusted to ensure that bruising is
entirely avoided. Pretreatment or posttreatment
with oral arnica montana supplementation can
also reduce the degree and duration of bruising.
Many patients have great faith in vitamins, herb-
als, and dietary supplements, and the recommen-
dation to acquire a supply of arnica may be
well-received. Patients should also be advised to
avoid elective medications and supplements that
exacerbate bleeding in the days to weeks prior to
laser treatment.
Erosions
Even nonablative laser treatments may result in a
few pinpoint or small erosions. These reddish,
crusted areas are best treated with bland emol-
lients. Hard crust should not be allowed to form.
Since patients are often reluctant to disturb crust
or scabs, they should be told something like,
“greasy wounds without crust heal better.” For
many patients, this is a revelation, and they can
be useful allies in facilitating wound healing once
they know what to do. Avoidance of antibiotic
ointments when infection is not suspected can
also decrease the chance of developing contact
dermatitis at the treatment site.
Hives and Blisters
Urticaria and blisters occur infrequently after
laser treatment, but can be very striking and wor-
risome when they manifest. It is probably not
necessary to educate patients preemptively about
these unusual outcomes. However, if urticaria
and transient micro-blisters occur, antihistamines
and topical steroids can be commenced immedi-
ately. Concurrently, the patient should be reas-
sured that these problems look very bad but are
not serious and easily treated. In addition, pre-
treatment with antibiotics or antivirals, when
indicated,
can
prevent
treatment-induced
infections.
Downtime
After every laser procedure, there is a recovery
period. For nonablative lasers like Q-switched
lasers, pulsed-dye lasers, hair removal lasers, and
nonablative tightening devices, this may be brief.
No time off from work or social engagements is
usually necessary after these “lunchtime” proce-
dures. However, some partially ablative and fully
ablative modalities may be followed by more
substantial downtime. Fractionated laser treat-
ments may have 3–4  days of post-procedure
downtime, and higher energy treatments with
fractionated carbon dioxide devices may be asso-
ciated with downtime of 7–10  days. Notably,
even though traditional full-face laser resurfacing
with carbon dioxide laser has approximately
equivalent downtime in days, the character of
24  The Selection and Education of Laser Patients

424
downtime after fractionated carbon dioxide is
better. Patients in the latter case do not have
extreme crusting and scabbing for the duration,
and they are not as uncomfortable; they still look
unpresentable for many days, but the degree of
disfigurement is less and the associated discom-
fort largely lacking. When counseling patients, it
is important to understand their limits for down-
time. Some patients are relatively more relaxed,
and older patients who are no longer working
may be able to remain at home for a longer
period. Other patients may know exactly how
many days of work they can miss, and the inten-
sity of partially ablative procedures may need to
be titrated to fit these bounds. That being said,
there is a balance between providing adequate
information about downtime, and needlessly
scaring patients to the point where they decline
an otherwise effective, indicated procedure.
Encouraging Patients to Promptly
Report Unexpected Adverse Events
Apart from common adverse events, unusual or
rare undesired events can occur after laser treat-
ments. Providing patients with contact informa-
tion to report such outcomes increases the
likelihood that problems can be corrected with-
out permanent sequelae. Sometimes, patients will
forget instructions, and be unable to manage even
an expected adverse event. If they feel their phy-
sician is approachable, they will be motivated to
contact the office for help. In this manner, patients
will not only protect their health but also allow
the physician to avoid the risk that an untreated
minor problem devolves into a serious treatment-
associated complication.
Discussing Procedure-Related
Problems with Patients
Not every laser procedure is entirely successful.
Problems can occur preoperatively, intraoperatively,
or postoperatively. Preoperative problems may per-
tain to anesthesia adverse events, device malfunc-
tions, and patient anxiety. Intraoperative problems
may be excessive pain, inappropriate laser parame-
ters, cooling failures, incorrect use of protective
eyewear, and the like. Post-operative adverse events
are discussed elsewhere in this book, but may com-
monly include dyspigmentation, bruising, infection
or inflammation, delayed healing, and scar.
In discussing procedure-associated issues
with patients, the guiding principles are clarity,
calmness, honesty, and reassurance. Full infor-
mation should be provided in a timely manner.
The physician should be empathetic, clearly
showing his or her commitment ensuring the best
possible outcome for the patient. Explanations
should be accurate and concise, not colored by
excessive emotion or rationalization. The physi-
cian should explain what needs to be done now, if
anything, to correct residual problems. Corrective
action should be compatible with the patient’s
schedule; efforts should be made to respect the
patient’s time and finances. Finally, the physician
should state clearly that he or she will do every-
thing in his or her power to resolve the situation,
and will continue to work closely with the patient
for the duration.
One excellent strategy is to bring the patient
back weekly to assess the problem, and the extent
to which it is responding to treatment. Not only
does this communicate to the patient that the doc-
tor cares, it also allows the physician to provide
timely interventions when necessary and to detect
any new problems as they arise. Regular follow-
up also protects the physician from any subse-
quent charges of abandoning a patient in need.
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2. Migden M, Chavez-Frazier A, Nguyen T.  The use
of high definition video modules for delivery of
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4. Phillips KA.  Body dysmorphic disorder: the dis-
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24  The Selection and Education of Laser Patients

427
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Anesthesia for Laser Surgery
Marina Perper, Ali Rajabi-Estarabadi, Ariel E. Eber,
Voraphol Vejjabhinanta, Ran Huo, Keyvan Nouri,
and John Tsatalis
Abstract
• Some of laser procedures such as laser resur-
facing or tattoo removal are associated with
some discomfort.
• Anesthesia provides a reversible loss of sensa-
tion and alleviates most of the discomforts.
• The techniques most commonly used are topi-
cal anesthesia and regional anesthesia with or
without
systemic
analgesics
and/or
anxiolytics.
• Concomitant cooling, vibration or pinching of
the area may be utilized to minimize the pain
perception.
Keywords
Topical anesthesia · Regional anesthesia
Laser surgery
Introduction
Local anesthesia has been one of the most signifi-
cant advancements in surgery for the past cen-
tury. Before the advent of local anesthetics,
patients had few options for dealing with pain.
Inebriation was a common, albeit ineffective,
practice.
In the early nineteenth century, it was reported
that the Peruvian Indians experienced numbness
of the lips after chewing leaves of the coca plant,
Erythroxylon coca. In 1859, Albert Niemann, a
German chemist, first extracted and isolated
cocaine from the coca plant in a purified form.
Local anesthetics were first introduced into
medical practice in 1884 when ophthalmologist
Carl Kollar used purified cocaine as a topical
agent by applying it to the cornea of animal mod-
els. In its first clinical application, cocaine was
used in operation for glaucoma. In the same year,
Halsted and Hall infused cocaine into the bra-
chial vein of a patient to achieve regional
anesthesia.
Previously, dentists had a practice of dissolv-
ing cocaine hydrochloride pills in water and per-
forming nerve infiltrations and blocks after
M. Perper · A. Rajabi-Estarabadi · A. E. Eber · K. Nouri
J. Tsatalis
Department of Dermatology and Cutaneous Surgery,
University of Miami Miller school of Medicine,
Miami, FL, USA
e-mail: m.perper@umiami.edu;
arajabi@med.miami.edu; a.eber@med.miami.edu;
knouri@med.miami.edu
V. Vejjabhinanta (*)
Dermatologic Surgery and Lasers Unit, Department
of Medical Services, Ministry of Public Health,
Institute of Dermatology, Bangkok, Thailand
R. Huo
Broward Dermatology Clinic, Pembroke Pines, FL,
USA
25

428
drawing the mixture into a syringe. Although it
provided profound local anesthesia that revolu-
tionized dentistry and medical practice, the
extreme vasoconstrictive action of cocaine often
leads to tissue necrosis.
By the 1900s, cocaine’s narcotic effects had
become well recognized, including its mood-
altering effects and cardiac and central nervous
system stimulation. In addition, due to
cocaine’s severe physical and psychological
dependence, its use for local anesthesia was
discontinued.
In 1904, Alfred Einhoin synthesized procaine
(Novocaine), an ester anesthetic, as a safer and
less toxic alternative. Novocaine was the main-
stay of care for topical anesthetics for the follow-
ing 40  years, until Nils Lofgren synthesized
lidocaine. Lidocaine was the first of the amide
group of local anesthetics, which exhibited
greater potency, fewer allergic reactions, and
more rapid onset of action.
Proper local anesthesia is essential in laser
surgery, as most laser procedures are associated
with some discomfort, ranging from mild warmth
to severe burning pain. An understanding of vari-
ous local anesthesia indications, techniques, and
side effects will provide a basis for the selection
of the most appropriate anesthetic agent for the
given procedure.
Classification and Mechanism
of Action
• Local anesthetics share a similar chemical
structure: a hydrophilic amine portion, an
intermediate chain, and a lipophilic aromatic
ring.
• They are divided into amide or ester groups
and are classified based on their intermediate
chain.
• Anesthetics act by disrupting sodium channel
activity and blocking electrical impulse trans-
mission at nerve endings.
• Most local anesthetics except cocaine have
vasodilatory effects.
• Epinephrine is often added as a vasoconstric-
tive agent and has the added benefit of mini-
mizing systemic effects and increasing the
length of anesthetic effect.
Topical Anesthesia
• Topical anesthetics are used for superficial
laser surgery and minor dermatological
procedures.
• Cooling agents are indicated for quick proce-
dures that require only a few seconds of
anesthesia.
• Lidocaine is the most widely used topical
anesthetic.
• Occlusion with a plastic wrap enhances anes-
thetic penetration and delivery to the dermis.
• Methemoglobinemia is a major concern
regarding the use of EMLA, particularly in
neonates.
Local anesthetic agents are functionally
divided into the amino amide and amino ester
groups (Fig. 25.1). Both groups share a similar
chemical structure that contains three compo-
nents: a hydrophilic amine portion, an intermedi-
ate chain, and a lipophilic aromatic ring. The
intermediate chain contains either an ester or
amide linkage, which categorizes the agent.
Pain sensation is carried via C fiber (unmy-
elinated nerve, 0.5–1  μm) and A-delta fiber
(2–5 μm). These fibers are more sensitive to the
actions of local anesthetics as compared with
large nerve fibers. Consequently, patients may be
able to feel sensations such as pressure and vibra-
tion while being insensitive to pain.
The effectiveness of a local anesthetic depends
on its ability to diffuse across the nerve cell’s
membrane (lipophilic properties) and then convert
to a cationic form which results in better protein
binding (hydrophilic properties). The higher the
lipid solubility of an agent, the more it can diffuse
across a cell’s membrane, leading to higher
potency and a lower concentration needed to pro-
duce the desired result. However, greater protein-
binding ability leads to a longer duration of action
due to a higher affinity for intracellular receptors.
Most local anesthetics, except cocaine, have
vasodilatory effects, which increase the chances
M. Perper et al.

429
of excessive bleeding during the course of a pro-
cedure. To counteract this, epinephrine is often
added as a vasoconstrictive agent, which has the
added benefits of increasing the local sequestra-
tion of the anesthetic, minimizing systemic
effects and increasing the length of anesthetic
effect.
Topically applied anesthetic agents are suit-
able for use in superficial laser surgery and minor
dermatological procedures. Topical anesthetics
act by disrupting sodium channel activity and
blocking electrical impulse transmission at nerve
endings. They can also be used to permit painless
needle insertion when infiltrative anesthesia is
required. These agents are usually encountered in
an oil-in-water base or similar cream compound.
For quick procedures, cooling sprays such as
dichlorotetrafluoroethane or ethylchloride may
be used.
The skin’s stratum corneum serves as a
mechanical barrier, slowing down topical anes-
thesia penetration. Thus, the vehicle is very
important in helping the anesthetic traverse the
epidermis. The thickness of the stratum corneum
varies with anatomical locations, altering the
time needed to achieve adequate anesthesia.
Occlusion with a plastic wrap is one way of
enhancing product penetration and delivery to the
dermis. This method also hydrates the skin,
which may help explain the lower incidence of
side effects seen after its use in carbon dioxide
resurfacing laser procedures.
The most widely used topical anesthetic is
EMLA cream, a 5% eutectic mixture of lidocaine
2.5% and prilocaine 2.5% in an oil-in-water
emulsion. It must be applied under an occlusive
dermal dressing for 60 min for adequate dermal
anesthesia. EMLA has been shown to provide
adequate anesthesia for pulsed dye laser treat-
ments of Port Wine Stains (PWSs) without affect-
ing the laser treatment’s efficacy. It is also used in
ablative laser resurfacing. The major concern
regarding the use of EMLA relates to the poten-
tial risk of methemoglobinemia, also a known
side effect of prilocaine. It is more likely in neo-
nates, especially in pre-term infants.
LMX-4 (formerly called ELA-Max) is 4%
lidocaine cream in a liposomal vehicle. It only
requires 15–45 min of application time without
the need of an occlusive dressing following its
application. LMX-5 is the 5% concentration and
although it is marketed for anorectal use, it can
also be applied as a topical anesthetic agent.
Betacaine-LA ointment contains lidocaine,
prilocaine and a vasoconstrictor in a liquid paraf-
fin ointment. It has a recommended application
Ester
O
O
O
C
C
Intermediate
bond
(Ester or Amide)
Tertiary
amine
Aromatic
group
(Lipophilic)
(Hydrophilic)
R
NH
Amide
R
N
N
R1
R1
R2
R2
Fig. 25.1  Chemical
structure of local
anesthetic agents
25  Anesthesia for Laser Surgery

430
time of 30–45 min without the requirement of an
occlusive dressing.
Tetracaine gel is a long-acting ester anesthetic
composed of 4% tetracaine in a lecithin gel. Its
application time is 30  min under an occlusive
dressing.
The 7% lidocaine and 7% tetracaine (LT) peel
is a self-occlusive topical anesthetic, presenting
as a 1:1 eutectic mixture that is applied as a
cream. It air-dries to form a flexible membrane
that can be peeled from the skin. The recom-
mended application time is 30 min. LT peel has
been successfully used in a variety of dermato-
logical procedures such as PDL therapy, laser-
assisted hair removal, non-ablative facial laser
resurfacing, laser therapy for leg veins, cutaneous
laser resurfacing and laser-assisted tattoo
removal. It has shown to have a superior anes-
thetic efficacy to ELMA cream in adult patients
undergoing a variety of cutaneous procedures.
Quick procedures that require only a few sec-
onds of anesthesia can utilize cooling refrigerant
sprays, such as dichlorotetrafluoroethane or ethyl
chloride. Ice cubes can also be used, especially to
increase numbness in injections given to children.
Infiltrative Anesthesia
• Local infiltration can be performed for proce-
dures associated with increased pain, such as
ablative laser resurfacing.
• The ester-linked anesthetics have a much
greater allergenic potential than the amide-
linked anesthetics.
• Cross reactivity exists among ester-linked
anesthetics, PABA, paraphenylenediamine,
and sulfonamides.
Infiltrative anesthesia is the most commonly
performed form of skin anesthesia. The concen-
tration and selection of infiltrative anesthetics
depend on the procedure to be performed, the
speed of onset desired, and duration of action
required. For quick and simple procedures, a
short-acting anesthetic with rapid onset can be
chosen. As for larger procedures, longer-acting
agents will be needed.
When an extensive area of the skin is to be
anesthetized, the anesthetic should be diluted to
limit the total amount applied to the tissue and to
reduce possible systemic adverse reactions.
Conversely, higher concentrations can be used in
smaller quantities for specific nerve blocks.
The ester-linked anesthetics (i.e. procaine,
cocaine, tetracaine) have decreased in popularity
due to allergic and cross-reactions with benzo-
caine, para-aminobenzoic acid (PABA), para-
phenylenediamine, and sulfonamides.
Most procedures are performed using 1% or
2% lidocaine which provides quick onset, long
duration (45 min to 3 h without epinephrine), and
has a low allergic reaction potential. When com-
bined with epinephrine, an even longer anesthetic
response can be achieved.
Bupivacaine and etidocaine are first-line
agents used to achieve longer anesthetic periods,
such as in the cases of nerve blocks. Etidocaine
has a short onset of action, a long duration, and
high potency without excessive increase in toxic-
ity, and is ideal when a long procedure is planned
and epinephrine is contraindicated. A summary of
the most commonly used anesthetics, their onset,
and duration of action are displayed on Table 25.1.
Injections may be placed subcutaneously or
intradermally. Intradermal injection has a faster
onset and longer duration of action, although it
is much more painful than a subcutaneous injec-
tion. Distortion of the skin by injection can be
compensated for in procedures by marking the
skin
before
injection
and
massaging
it
afterwards.
If amide and ester anesthetics cannot be used
for a patient, a 1% solution of diphenhydramine
(an antihistamine) can be used, with an anesthetic
effect equivalent to that of 1% lidocaine. However,
the duration of action is shorter and the pain upon
injection is greater than that of lidocaine.
Procedures and Anesthesia of Choice
The specific laser procedure to be performed
impacts the choice of anesthesia. The dermatolo-
gist has to consider factors such as onset of
action, potency, potential vasoactivity, depth,
M. Perper et al.

431
length of anesthesia required, potential adverse
events, and host sensitivity.
Laser Treatment for Tattoos, Pigmented
Lesions, and Hair Removal
LMX 4–5% is the most practical choice in laser
treatment of tattoos, pigmented lesions, and hair
removal. It can be prescribed ahead of a clinic
visit, so that the patient can apply it prior to his or
her visit. Since the laser targets in these proce-
dures are pigment chromophores, the vasoactiv-
ity of the anesthetic agent does not influence the
outcome of the procedure.
Non-ablative Rejuvenation
Vasoactive agents, such as anesthetics, will dimin-
ish the target chromophore hemoglobin in non-
ablative rejuvenation, thus interfering with the
clinical outcome. For this reason, the use of a non-
vasoactive or vasodilating agent is recommended.
Some non-ablative treatments do not require
anesthesia. In order to assess a patient’s discom-
fort level, the practitioner can perform a spot test
prior to the application of the anesthetic; the
patient may be able to tolerate the treatment with-
out anesthetics. If anesthesia is needed, the use of
LMX 4–5% cream may be applied.
Tumescent Anesthesia
Jefferey Klein introduced low-concentration lido-
caine anesthesia (tumescent technique) for cutane-
ous surgery in the late 1980s. It is defined as direct
infiltration of dilute lidocaine (<1 mg/L), epineph-
rine (<1 mg/L), and sodium bicarbonate (10 mEq/L),
and provides excellent pain control with minimal
adverse effects. Initially used for liposuction, this
method has been successfully applied to many other
dermatologic procedures such as hair transplanta-
tion, removal of skin tumors, localized phlebec-
tomy, laser surgery, and dermabrasion. This
approach has the advantage of achieving anesthesia
in a very large area of skin. The safest maximum
dose for the tumescent technique with lidocaine
with epinephrine (1:100,000) in concentrations of
0.05% and 0.1% is between 45 and 50 mg/kg. The
solution preparation and concentration of the solu-
tions are displayed in Table 25.2.
The use of the tumescent anesthesia technique
reduces blood loss, bruising, and postoperative
soreness. It has been reported that this type of
local anesthesia has contributed to pain relief for
up to 18 h after the procedure, therefore minimiz-
ing the need for post-operative narcotics.
Nerve Blocks
A detailed knowledge of the head and face neuro-
anatomy allows the cosmetic surgeon to perform
Table 25.1  Common anesthetic agents
Anesthetic
agents
Onset plain
(min)
Duration plain
(min)
Duration with
epinephrine (min)
Max dose plain
(mg/kg)
Max dose with
epinephrine (mg/kg)
Amides
Lidocaine
<2
30–120
60–400
4.5
7
Prilocaine
<2
30–120
60–400
5.5
8.5
Bupivacaine
3–5
120–240
240–480
2.5
3
Esters
Procaine
<2
15–30
30–90
7
8.5
Tetracaine
<15
120–40
240–480
1.4
–
Table 25.2  Tumescent local anesthesia mixture
0.1% solution (0.1% lidocaine, epinephrine
1:1,000,000, pH 7.4)
0.9% normal saline
1 L
2% lidocaine
50 ml
Epinephrine 1:10,000
1 ml
8.45% sodium bicarbonate
12.5 ml
0.05% solution (0.05% lidocaine, epinephrine
1:1,000,000, pH 7.4)
0.9% normal saline
1 L
2% lidocaine
50 ml
Epinephrine 1:10,000
1 ml
8.45% sodium bicarbonate
12.5 ml
25  Anesthesia for Laser Surgery

432
facial surgical procedures with minimal pain in
the patient. Skillful administration of the chosen
anesthesia can also minimize the potential risks
involved, including nerve laceration, hematoma,
and paralysis.
A specific nerve block provides pain relief
without the local distortion sometimes seen with
local infiltration. The central face allows the use
of field block anesthesia due to multiple foramina
and their respective nerve roots accessibility.
With the knowledge of anatomical nerve land-
marks, the surgeon can perform nerve blocks
according to the area that needs to be anesthetized
by injecting anesthetic solution in adequate con-
centrations throughout the nerve foramen either
by a percutaneous or intraoral approach. Due to
the complexity of nerve ramifications, infiltrative
anesthesia may be added to the nerve block.
Peripheral nerve blocks commonly used in
dermatologic practice include digital blocks,
supraorbital and supratrochlear/infratrochlear
blocks (forehead and vertex of the scalp), infraor-
bital blocks (nose except the tip, medial cheek,
lower eyelids and upper lip), anterior ethmoidal
nerve block (tip of the nose), mental blocks (chin,
lower cheek and lips), and inferior alveolar
blocks (tongue and lower lip).
Many of the facial nerves can be easily
approached either percutaneously or intraorally.
The supraorbital nerve exits the orbit through
the supraorbital foramen which is palpable in
most patients. The supratrochlear nerve exits the
orbit through a foramen approximately 17 mm
from the glabellar midline. The infratrochlear
nerve exits the orbit through a foramen below
the trochlea. The infraorbital nerve exits the
orbit through the infraorbital foramen 4–7 mm
below the orbital rim. The mental nerve exits the
mental foramen on the hemimandible at the base
of the root of the second pre-molar (Fig. 25.2).
Injection of 2–4 cc’s of local anesthetic solution,
about 10 mm inferior to the gum line or 15 mm
inferior to the top of the crown of the second
premolar tooth, usually leads to a successful
nerve block. Alternatively, the mental nerve may
be blocked with a facial approach aiming for the
same target. After the procedure, the numbed
area will extend from the unilateral lip down to
the mentolabial fold. The anesthesia may also
reach other areas like the anterior chin and
cheek, depending on the patient’s anatomy and
nerve ramification.
Nerve damage is a possible complication of
nerve blocks, and care should be employed to
avoid direct injection of anesthesia into a nerve or
foramen.
Digital nerve blocks of fingers can effec-
tively provide anesthesia by injecting the anes-
thetic solution (usually 2  ml of 2% plain
lidocaine) on the side of the finger just distal to
the metacarpophalangeal joint. By directing the
needle inferiorly and then superiorly, both
inferior and superior digital nerves can be
anesthetized (Fig. 25.3).
Adverse Effects of Local Anesthetics
Local anesthetics (LA) are widely used drugs.
Adverse reactions are rare but may be caused by
the needle insertion, delayed-type hypersensitiv-
ity reactions and probably also immediate-type
reactions.
Possible consequences of needle insertion
include fainting, pain, itching, erythema, ecchy-
mosis, edema, infection, hematoma, hyperalge-
sia, nerve damage, and muscle trismus.
Psychogenic reactions may occur due to pain of
the injection or to the patient’s fear of pain or
needles, and a vasovagal response involving skin
pallor, diaphoresis, bradycardia, and hypotension
may result. For this reason, the patient should
always be lying down during injections.
Commonly used needles are between 25 and 30
gauge, with smaller needles preferred to mini-
mize injection pain.
Adverse events of anesthetic solutions include
local and systemic toxicity, allergy and anaphylaxis,
and idiosyncratic responses. Local reactions may
occur secondary to improper injection of the conse-
quences may be lethal if the targeted area is a large
vessel and needle insertion can cause pain, faint-
ness, bruising, infection, hematoma, hyperalgesia,
and muscle trismus.
Vasovagal/Neurogenic/Psychogenic reactions
may result from patient perception of fear or pain
due to needles or impending procedure which
may result in a vasovagal episode that mimics a
more serious adverse effect, such as an allergic
reaction.
M. Perper et al.

433
Two types of allergic reactions to LAs are rec-
ognized: IgE-mediated type 1 reactions and T-cell-
mediated type 4 reactions. As prevalent subtypes of
ester and amide LAs are available both as topical
preparations and injectable agents, both reaction
types may be caused by members of both groups.
Immediate type 1 reactions are characterized
by release of histamine and other mediators from
mast cells and basophils, following IgE antibody
bridging by the allergen. A rapid increase in vas-
cular permeability as well as contraction of
smooth muscles lead to symptoms such as urti-
caria, angiooedema, bronchospasm, cardiovascu-
lar depression and in severe cases shock. It
response occurs more often with ester group
anesthetics. Esters are metabolized to PABA,
which is responsible for their strong allergenic
potential. Preservative-free lidocaine should be
used for allergic patients; these formulations do
not contain preservatives that may cause type I
reactions. Monitored skin prick testing, intrader-
mal testing, and subcutaneous challenge may be
defensible in high-risk cases.
Delayed-type 4 hypersensitivity reactions are
most often induced by skin contact with topical
preparations but localized edema may also
develop following injection reactions include
allergic contact dermatitis. If a patient is reactive
to one group of anesthetics (amide or ester), the
other group can be used since the groups do not
cross-react.
Systemic reactions to anesthetics occur most
often when the agent is used over the maximum
recommended dose or when the agent is acci-
dentally injected intravenously. Aspirating
before injection can help reduce instances of
intravenous injection. Central nervous system
toxicity of local anesthetics can lead to tinnitus,
Midpupillary
line
Supraorbital
foramen
Infraorbital
foramen
Mental
foramen
Supraorbital
Notch
1cm
1 cm from
Inferior orbital rim
Mid - mandible
below 2nd premolar
Created and designed by: Juan Sebastian Gomez Gutierrez
Fig. 25.2  Landmarks for facial nerve blocks
25  Anesthesia for Laser Surgery

434
blurred vision, light-headedness, nausea, hallu-
cinations, slurred speech, tonic-clonic seizures
and respiratory arrest. Cardiovascular effects
can lead to mild tachycardia, tremors, palpita-
tions, and at higher doses, hypotension and
arrhythmias. Amide group anesthetics are more
dependent on the liver for metabolism; for
patients with liver problems, ester-linked anes-
thetics are recommended.
Pseudo-allergic Reaction is a category of
immediate-type adverse reactions to local anes-
thetics has been hypothesized to be due to direct
neuronal stimulation causing a reflex cascade
that results in a reaction similar to those seen
with radiocontrast media and nonsteroidal anti-
inflammatory medications.
Patients with have coagulation disorders or
those using anticoagulants are more prone to
develop ecchymosis and hematomas. Patients
taking beta blockers should not be given epi-
nephrine, due to paradoxical hypertension fol-
lowed by reflex bradycardia that can lead to
cardiac arrest or hypertensive stroke. A detailed
medical history is essential to prevent and man-
age these aforementioned complications. Direct
injection of anesthesia into a nerve or foramen
should be avoided, as it can lead to nerve
damage.
Local Anesthesia in Special Patients
Anesthesia
and Pregnancy—Lactation
Due to concerns about potential harm to the
mother or fetus, dermatologic surgeons are fre-
quently hesitant to perform cutaneous surgery on
pregnant patients.
In general, the effects of pregnancy hormones
may increase local anesthetic sensitivity, while
increasing cardiac output in pregnancy can
increase local anesthetic concentration. Avoidance
of intravascular injection is key in order to avoid
maternal and fetal toxicity. Ropivacaine and bupi-
vacaine in this population have an increased risk
of cardiotoxic effects due to progesterone levels.
Lidocaine is pregnancy category B and epineph-
rine is pregnancy category C. Their safety in preg-
nancy is level of evidence III while safety in
lactation is level of evidence IV.
Low doses of most local anesthetics with epi-
nephrine as well as nitrous oxide less than 50%
are safe to use during pregnancy. However, use of
epinephrine should be avoided during labor.
Sedatives and opioids are potential teratogens
and should be avoided.
Anesthesia in Pediatric Patients
Local anesthetic toxicity is rarely seen in infants
and young children. Lidocaine has been widely
used in infants and children for topical, regional,
plexus, epidural, and spinal anesthesia. Prilocaine
has been linked to methemoglobinemia, and thus
may not be suitable for use in infants and
children.
Created and designed by:
Juan Sebastian Gomez Gutierrez
Fig. 25.3  Digital nerve block
M. Perper et al.

435
In the neonatal population, the skin is attenu-
ated and result in greater and quicker absorption
of anesthetics especially in premature infants.
Due to decreased plasma protein binding, free
local anesthetic drug concentrations will be
higher in the blood.
Systemic Sedation for Outpatient
Clinic
Conscious sedation is typically used in conjunc-
tion with local anesthesia and may be preferable
over general anesthesia in dermatologic surgery
in many cases. Conscious sedation utilizes a
combination of sedatives, analgesics, and tran-
quilizers to induce a state of amnesia, anxiolysis,
and analgesia.
Some of the advantages of conscious sedation
as compared to general anesthesia include
• Reduced risk of drug-related side effects since
fewer drugs and smaller doses are used
• Faster recovery and less postoperative nausea
and vomiting
• Absence of complications from airway manip-
ulation since there is no need for intubation
• Less expensive because general anesthesia
equipment is not needed
However, some disadvantages of conscious
sedation include
1. Measures to control the airway must be pre-
pared in case of over sedation
2. Patients who suffer from extreme anxiety may
benefit more from general anesthesia
Conclusion
The advent of local anesthesia has dramati-
cally improved patient experience in dermato-
logic surgery. Physician experience and
attention to patient history are two of the most
important factors in choosing the right anes-
thetic. Appropriate selection and application
of local anesthetics and knowledge of the
means to prevent potential adverse effects.
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Bhole MV, Manson AL, Seneviratne SL, Misbah SA. IgE-
mediated allergy to local anaesthetics: separating fact
from perception: a UK perspective. Br J Anaesth.
2012;108:903–11.
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tologic medications in pregnancy and lactation:
Part II. Lactation. J Am Acad Dermatol. 2014;70:417.
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thesia for pediatric dermatologic procedures: risks and
complications. Arch Dermatol. 2005;141(5):573–6.
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Dermatol Surg. 2001;27(12):1006–9. J Am Acad
Dermatol. 2000;43(2 Pt 1):286–98
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Kilmer SL, Chotzen V, Zelickson BD, et al. Full-face laser
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alterations
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Niamtu J III.  Local anesthetic blocks of the head and
neck for cosmetic facial surgery. I: A review of
basic sensory neuroanatomy. Cosmet Dermatol.
2004a;17(8):515–22.
Niamtu J III.  Local anesthetic blocks of the head and
neck for cosmetic facial surgery. II: Techniques
for the upper and mid face. Cosmet Dermatol.
2004b;17(9):583–7.
Niamtu J III. Local anesthetic blocks of the head and neck
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25  Anesthesia for Laser Surgery

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Niamtu J III. Local anesthetic blocks of the head and neck
for cosmetic facial surgery. III: Techniques for the
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Rosenberg PH, Veering BT, Urmey WF. Maximum rec-
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M. Perper et al.

437
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Lasers in Skin of Color
Heather Woolery-Lloyd and Nkanyezi Ferguson
Abstract
The popularity of cutaneous laser surgery has
soared, however, the use of lasers in patients
with darker skin types has been quite chal-
lenging. The main obstacle with cutaneous
laser surgery in darker skinned patients is epi-
dermal melanin absorption of laser energy.
The absorption spectrum of melanin ranges
from 320 to 1200 nm with the greatest absorp-
tion observed in the lower end of this spec-
trum. The main objective in treating patients
with skin of color is to avoid epidermal mela-
nin absorption of laser energy and resultant
thermal injury. Laser surgery in darker skinned
patients must be approached carefully to avoid
this unwanted side effect of post inflammatory
pigment alteration. In this chapter, we will
review the advances in lasers for ethnic skin
with special emphasis on the treatment of acne
scars, photorejuvenation, skin tightening, hair
removal, tattoos, and body contouring.
Keywords
Cutaneous laser surgery · Skin of color ·
Epidermal melanin absorption · Acne scars ·
Photorejuvenation · Skin tightening · Hair
removal · Body contouring · Tattoos
Lasers in skin of color can be challenging due to
the unique characteristics of patients with darker
skin types. Increased risk of hyperpigmentation,
hypopigmentation, and keloid scarring contribute
to the challenges of achieving a desired cosmetic
end result with minimal side effects. Lasers and
light devices have been safely used to treat many
skin conditions in skin of color including acne
scars, unwanted hair, skin laxity, tattoos, and
some pigmentary disorders. This list continues to
grow as newer “color blind” technologies are
introduced each year. There have been significant
advances in lasers that can safely treat people
with darker skin types. In this chapter, we will
review the data on safety and efficacy of the most
commonly used lasers and light-based devices in
ethnic skin.
Key Considerations
Skin of color is defined as Fitzpatrick skin pho-
totypes (SPT) IV–VI. Successful use of lasers in
these darker skin types involves minimizing the
H. Woolery-Lloyd, M.D. (*)
Department of Dermatology and Cutaneous Surgery,
University of Miami, Miller School of Medicine,
Miami, FL, USA
N. Ferguson, M.D.
Department of Dermatology, University of Iowa
Hospital and Clinics, Iowa City, IA, USA
e-mail: nkanyezi-ferguson@uiowa.edu
26

438
epidermal thermal injury and an inflammatory
response which can both increase the risk of
post inflammatory hyperpigmentation (PIH) and
hypopigmentation.
In addition to pigmentary concerns, there is an
increased risk of development of keloid scars in
darker racial ethnic groups. This appears to be
due a genetic predisposition toward fibroblast
reactivity in this patient population. Increased
risk of keloid scars limits the use of laser and
light devices that cause significant disruption of
the dermis. For this reason, ablative lasers are
often avoided in this patient population.
Acne Scars
A recent study examining the prevalence of acne
in the general population demonstrated higher
rates of acne in African American and Hispanic
subjects. Interestingly, this same study also dem-
onstrated higher rates of atrophic scarring in the
skin of color population when compared to
Caucasian subjects [1]. Laser treatment of acne
scars includes ablative lasers, ablative fractional
lasers, nonablative fractional lasers, nonablative
lasers and radiofrequency technology. Each
approach will be discussed separately below:
Ablative
Carbon dioxide (CO2) laser resurfacing has been
used for the treatment of acne scars. The laser’s
usefulness has been limited in skin of color due
to increased risk of hyperpigmentation, hypopig-
mentation, and scarring. For this reason, other
modalities have been investigated for optimal
acne scar treatment in ethnic skin.
Ablative Fractional Lasers
Most of the published studies of ablative frac-
tional lasers in skin of color include primarily
Asian subjects. One study evaluated 20 Korean
subjects with atrophic acne scars treated with a
single session of the CO2 fractional Ultrapulse
Encore laser (Lumenis Inc., Santa Clara, CA).
Acne scars were treated in the Deep FX mode
and the entire face was treated using the Active
FX mode. One subject had 76–100% clinical
improvement. Nine subjects had 51–75%
improvement. Seven subjects had 26–50%
improvement, and three subjects had minimal to
no improvement. Post therapy crusting or scaling
lasted 6.3 ± 3.0 days and post therapy erythema
lasted 2.8 ± 4.6 days [2].
Another study evaluated the efficacy of CO2
ablative fractional resurfacing in 13 Thai subjects
with SPT IV. Subjects received three sessions on
an average of 7 week intervals. At the 6-month
follow-up, 85% of the subjects were rated as hav-
ing at least 25–50% improvement of atrophic
acne scars. Sixty-two percent of subjects rated
themselves as having at least 50% improvement
in their scars. Mild PIH was the most common
adverse effect observed in 92% of the subjects or
51% of treatment sessions, and was completely
resolved in an average of 5 weeks [3].
One retrospective study included 82 Saudi
Arabian subjects (SPT III–V). The study com-
pared 45 patients treated with the 1550  nm
nonablative fractional laser (NAF) and 37 patients
treated with the ablative fractional (AF) CO2
laser. Thirty-five percent and 37% of patients
attained more than 50% improvement with NAF
1550 nm and AF CO2 lasers, respectively. Patients
treated with NAF 1550 nm laser had less down
time. Transient PIH was noted in 17% of patients
treated with NAF 1550  nm laser compared to
14% with AF CO2. PIH decreased with prophy-
lactic use of bleaching cream [4].
There are no published studies of ablative
fractional laser treatments including SPT VI.
Ablative fractional lasers should be avoided or
used with caution in this patient population. In
darker skin types, pretreatment with bleaching
agents may minimize the risk of PIH, however
patients should understand that transient hyper-
pigmentation is a common side effect with these
lasers.
Nonablative Fractional Lasers
Non-ablative fractional resurfacing has been
studied in all skin phototypes including SPT IV–
H. Woolery-Lloyd and N. Ferguson

439
VI. In a retrospective review of 961 treatments
with a 1550-nm erbium-doped laser (Fraxel,
Reliant Technologies Inc.) in all skin types, the
overall rate of hyperpigmentation reported was
0.73%. The incidence of hyperpigmentation
however when compared to SPT II (0.26%) and
SPT III (2.6%) was found to be overrepresented
in darker skin types with 11.6% in skin type IV
(n = 8) and 33% in skin type V (n = 3) [5].
Studies looking at the skin of color population
suggest that lower treatment densities are associ-
ated with lower rates of PIH. Specifically, in a
retrospective study of 37 Chinese patients, six
high-energy, low-density treatments had a lower
rate of PIH than subjects who received three low-
energy, high-density treatments (6% vs 18.2%)
[6].
A prospective single blind trial evaluated 15
American subjects with Fitzpatrick skin types
IV–VI treated with the 1550-nm erbium fraction-
ated laser. Significant improvement was achieved
in the acne scarring and overall appearance
(p < 0.001). There was no significant difference
in efficacy between subjects treated with 10 mJ
versus 40 mJ and subjects were highly satisfied
with the results. However, significant transient
post-inflammatory pigment was observed in 6 of
the 15 subjects and pain was significantly higher
in the darker skin types [7, 8].
These studies suggest that non-ablative frac-
tional resurfacing is effective for the treatment of
acne scars in darker skin types, but practitioners
should utilize a series of treatments at lower
treatment densities to reduce the risk of PIH. In
addition, clinicians should be aware of the higher
incidence of pain and post-inflammatory hyper-
pigmentation in individuals with darker skin
types.
Radiofrequency
Matrix-tunable radiofrequency (RF) technology,
has been used for the management of acne scars.
In one study, 30 subjects (SPT IV-VI) with acne
scars were treated RF device (Syneron Corp.
Israel) monthly for a maximum of four sessions.
The Visual Analogue Scale (VAS) improvement
in scars ranged from 10% to 50% at the end of
2 months and ranged from 20% to 70% at the end
of 6 months. Out of the 30 patients, the cosmetic
result was excellent (>60% improvement) in
four, good (35–60% improvement) in 18 and
moderate to poor (<35% improvement) in eight.
Reported side effects included a burning sensa-
tion, a mild sunburn-like sensation for about 1 h
after treatment, and mild erythema for 2–3 days.
No PIH was observed [9].
A split-face double-blinded randomized con-
trol trial compared high versus moderate energy
bipolar fractional RF for the treatment of atro-
phic acne scars in SPT III–IV. Subjects received
four monthly treatment sessions. Left and right
sides of the face were randomized to receive high
energy (100  mJ/pin) versus moderate energy
(60  mJ/pin). At 1 month, the high energy side
showed significant improvement of global acne
scarring scale (GASS) when compared to the
moderate energy side. However at 3- and
6-months the efficacy between the two energy
levels was comparable. Of note, PIH developed
in 17.5% of treatment sessions in the high energy
side compared to 13.3% of sessions in the moder-
ate energy side. PIH was noted to be mild to mod-
erate and resolved within 4 weeks [10].
Sublative rejuvenation provides a coagulative
(nonablative) effect in the mid-dermis in addition
to an ablative injury to less than 5% of the epider-
mis. A combination of sublative fractional bipolar
radiofrequency and bipolar radio frequency com-
bined with diode laser has been studied in a pro-
spective study of 20 subjects (SPT II–V). Subjects
received up to five treatments every 4  weeks.
Acne scars improved 1 month after three treat-
ments and this improvement persisted for at least
12 weeks after the fifth treatment. Improvement
was not affected by skin type. Adverse effects
were limited to transient erythema and edema.
This technology may offer another option to treat
acne scars in skin of color, however, as in most
laser studies, the number of skin of color subjects
in this study was limited [11].
Overall, RF devices offer a safe treatment
option in treating skin of color. One of the bene-
fits of devices utilizing RF in skin of color is that
RF energy is not absorbed by melanin, which
may make this modality safer in subjects with
darker skin types.
26  Lasers in Skin of Color

440
Nonablative Lasers
Nonablative lasers offer one of the safest side
effect profiles among lasers when treating
acne scars in skin of color. Nonablative lasers
typically deliver heat to the dermis to induce
new collagen formation. A small case series of
nine patients (SPT I-V) examined the efficacy
of the nonablative 1064  nm neodymium-
yttrium-aluminum-­garnet
(Nd:YAG)
laser
(Laser Genesis, Cutera Inc.) in treating atro-
phic acne scars. Settings were 14  J/cm2,
0.3 ms, 5-mm spot size, 7-Hz with 2000 pulses
per side of face. Subjects were treated every 2
weeks for eight treatments. Three blinded phy-
sician observers used photographs to rate scar
severity. Using a grid overlying the pictures,
observers counted scars at baseline and after
the final treatment. A 29% improvement in
scar severity score was achieved at the end of
a series of eight treatments. Eight of the nine
patients reported improvement in their acne
scars ranging from 10% to 50% improvement
and no treatment related adverse events were
observed [12].
In a larger retrospective analysis of 22
Egyptian and Sudanese patients with SPT III–VI
who received a series of six treatments with the
same non-ablative Nd:YAG laser, reviewers were
asked to rank the degree of improvement in scar-
ring, texture, and PIH using a four-point scale (0:
<25%, 1: 25–50%, 2: 51–75%, 3: 76–100%). The
results of the blinded photo assessments indi-
cated clinically and statistically median improve-
ment of 2 in scarring, 2.3 in texture, and 2 in PIH
(P < 0.001). It is important to note that, in this
series, patients had concomitant acne which
made isolating the improvement of acne scarring
challenging. Interestingly, although adjunctive
bleaching agents were not used, an improvement
in acne-induced PIH was also observed [13].
These studies suggest that non-ablative lasers
are well tolerated and safe in skin of color, how-
ever, results with non-ablative lasers may be
variable. These lasers offer a safe treatment
option for atrophic scars in darker skinned
patients.
Photorejuvenation
Photoaging in skin of color patients typically
manifests as textural changes, large pores, pig-
mentary alteration, lentigines, and seborrheic
keratoses. Fine lines and deep rhytides are less
prominent and occur in later decades. It is impor-
tant to note, most studies focusing on lasers for
photorejuvenation in skin of color are in Asian
skin. The use of fractional resurfacing has been
well documented in this particular skin of color
population.
Fractionated Diode
A series of low-energy, low-density nonablative
fractional laser treatments using a 1440 nm frac-
tionated diode device (Clear  +  Brilliant, Solta
Medical), has been reported to be effective in
addressing photoaging in skin of color. Ten
Chinese subjects (SPT III–V) with visible signs of
photodamage completed a series of four biweekly
treatment sessions. The physician assessment
demonstrated an overall mean reduction in skin
roughness,
wrinkles
and
dyspigmentation.
Changes in pore size and tissue laxity failed to
reach statistical significance. Side effects included
pain and heat sensation during treatments, which
decreased with subsequent treatments. Transient
PIH was noted in one patient that lasted less than 1
month [14].
In another study of the fractionated diode
laser, investigators specifically evaluated pore
size and texture. Twenty subjects (SPT I–VI)
completed a series of six biweekly treatments. At
the end of the study, there was a 17% average
reduction in pore score as measured by VISIA-CR
(Canfield Scientific Inc., Fairfield, NJ). Physician
and subject assessment also reported improve-
ment in pore appearance and overall appearance
of the skin. There were no serious or long-term
side effects [15].
These studies suggest that the fractionated
diode, a very low-density and low-energy frac-
tionated device, improves the early signs of
photoaging in skin of color with minimal
H. Woolery-Lloyd and N. Ferguson

441
adverse effects and short recovery. Results are
mild and a series of treatments are required for
best results.
Ablative and Nonablative Fractional
Lasers
Both ablative and nonablative fractional lasers
have all been reported to be effective in treating
photoaging in certain skin of color patients.
Ablative lasers target water as a chromophore
resulting in instant vaporization of columns of
tissue including epidermal ablation. Nonablative
lasers also target water containing tissues but cre-
ate columns of coagulative damage within the
dermis that are below the ablative threshold [16].
One study compared the ablative fractional
Er:YAG laser and nonablative fractional 1550-­nm
Er:glass laser to treat photoaging in Asian subjects.
Three monthly sessions were performed. Nineteen
patients received ablative fractional Er:YAG laser,
and 15 patients received nonablative fractional
1550-nm Er:glass laser. Reductions in pigmenta-
tion and uneven tone/erythema scores were signifi-
cantly greater after ablative fractional Er:YAG,
while wrinkle score reduction was significantly
greater after nonabalative fractional Er:glass laser.
Physician and patient assessments for the overall
features showed greater improvement in the nonab-
lative fractional Er:glass laser. Treatment-related
pain or adverse events were less in the ablative
fractional Er:YAG.  The authors concluded that
both fractional lasers are effective and safe to treat
photoaging in Asian skin [17]. The findings are
consistent with other studies that support the use of
the nonablative fractional 1550-nm Er:glass laser
as an effective treatment for photoaging in Asian
subjects [18].
The fractionated 1927-nm thulium fiber (Fraxel
Dual, Solta Medical) has also been reported to
treat photoaging and melasma in Asian subjects
(SPT III (n = 23) and IV (n = 2)) and may be useful
when patients present with diffuse, mottled super-
ficial pigmentation. Three participants in this study
were noted to develop PIH after treatment that
spontaneously resolved within 3 weeks [19].
Intense Pulsed Light
The use of intense pulsed light (IPL) to address
the signs of photoaging is well documented in
Asian skin. One of the earliest papers reported the
use of IPL in 97 Japanese subjects (SPT IV–V).
After a series of 3–6 treatments, a combined rat-
ing of “good” or “excellent” was given to more
than 90% of the patients for pigmentation, more
than 83% for telangiectasia, and more than 65%
for skin texture. Three subjects had minor blisters
that resolved without sequalae [20].
Numerous other papers support the use of IPL
for photoaging in Asian patients [21, 22].
Although most studies are in Asian subjects, one
case series in Latin subjects (SPT II–IV) also
found IPL to be effective for various superficial
melanocytic lesions (e.g. ephelides, Café au lait
macules, melasma, nevus spilus, nevus of Becker
and epidermal nevus) [23].
When treating photoaging with IPL in skin of
color, it is important to note that IPL-induced
melasma-like hyperpigmentation can be an
unwanted side effect despite the appearance of
normal skin at baseline. It has been proposed that
these patients seem to have very subtle epidermal
melasma not visible to the naked eye at baseline.
One study examined the use of UV photography
to identify these patients and prevent complica-
tions. Two hundred and twenty-three Japanese
women, 30–69  years old, were included in the
study. Very subtle melasma invisible to the naked
eye under normal light was diagnosed by UV
photography by two physicians in 63 subjects
(28.3%). These subjects were treated with mild IPL
parameters and did not suffer induced ­secondary
hyperpigmentation. The authors suggested that IPL
users should be aware of the age (i.e. women in
their 40s and 50s) and sunscreen-­related (i.e. lack
of regular sunscreen use) incidence of this phe-
nomenon in Asian patients to help avoid compli-
cations after treatment [24].
The use of fractionated lasers and IPL to treat
photoaging in Asian subjects has been well estab-
lished. It is important to note, however, that since
the vast majority of these studies were performed
in Asian subjects, one should use caution when
26  Lasers in Skin of Color

442
extrapolating to other ethnicities with skin of
color. Due to the paucity of studies and increased
risk of side effects, the use of IPL in type V and
VI skin should be avoided.
Melasma
IPL has been used for the treatment of melasma
in patients with skin type IV. IPL treatment com-
plications may result in IPL-induced melasma-­
like hyperpigmentation. Due to the risk of post
inflammatory hyperpigmentation documented in
skin type IV, IPL should be used with caution in
these patients and completely avoided in skin
types V and VI.
The fractional 1550  nm laser is an FDA-­
approved laser modality for melasma [25].
Although it can be effective, it also carries a risk
of postinflammatory hyperpigmentation, espe-
cially in individuals that may have hyperactive
melanocytes. Due to the risk of hyperpigmenta-
tion with melasma, this laser should be consid-
ered in cases that have failed conventional
therapies [26].
The response of melasma to irradiation with
any laser is variable. A lack of response, wors-
ening of the hyperpigmentation, and recurrence
are frequent outcomes. For these reasons, treat-
ment of melasma with lasers is extremely chal-
lenging and should be reserved for resistant
cases where conventional topical therapies have
failed.
Laser Assisted Hair Reduction
Laser hair removal is by far the most common
cosmetic procedure performed in all skin types
and unwanted facial hair is a common complaint
in skin of color. Due to the prevalence of associ-
ated psuedofolliculitis barbae and PIH, unwanted
facial hair is particularly disfiguring in African
American patients. Fortunately, laser hair
removal is one of the safest laser procedures in
skin of color. When the appropriate device is
used, cosmetic outcomes are excellent and life
changing for many patients.
Alexandrite
The Alexandrite laser has been studied in skin
types IV–VI. One study examined a long pulsed
755 nm laser with a 40 ms pulse width in 150
patients with skin types IV–VI. A test site with a
fluence of 16  J/cm2 was first performed and
energy fluence was selected according to
response. A small complication rate (2.7%) was
reported, however, only two patients with skin
type VI were included in the study and both
developed blistering [27]. A smaller study of the
Alexandrite (755 nm, 3 ms pulse width) included
four women with Fitzpatrick skin type VI. In this
study, lower fluences were used (8–14 J/cm2) and
no side effects were noted [28]. Although treat-
ment of skin types IV–VI is possible with the
Alexandrite, the availability of safer options
make this laser a poor choice in skin of color and
specifically SPT V and VI.
Diode
The Diode laser has been studied with greater
success in the treatment of darker skinned
patients. The 800  nm diode laser was studied
with pulse widths of 30 ms and 100 ms. When
comparing the two pulse widths, investigators in
one study reported that longer pulse widths
(100 ms) allowed higher fluences to be utilized
with fewer complications [29]. Another study uti-
lized the 810 nm Diode laser to treat eight patients
with skin types V and VI. These patients were
treated with a lower fluence of 10 mJ/cm2 and a
pulse width of 30 ms. Despite the lower fluence,
transient blistering and pigment alterations were
noted in some patients [30]. Overall, while the
diode laser offers increased safety over the
Alexandrite laser in African-American patients,
complications may remain an issue SPT VI.
Nd:YAG
The long pulsed Nd:YAG is the safest laser for
hair removal in darker skin types. This wave-
length is at the end of the absorption spectrum of
H. Woolery-Lloyd and N. Ferguson

443
melanin, and is sufficient to achieve significant
thermal injury in dark coarse hairs while sparing
epidermal pigment. In addition, the adjustable
pulse width of long pulsed Nd:YAG lasers allow
the laser energy to be delivered over an longer
period of time allowing for the heat to dissipate
with sufficient epidermal cooling.
The long pulsed Nd:YAG is the treatment of
choice for hirsutism and pseudofolliculitis barbae
in skin of color individuals with SPT V–VI. The
Nd:YAG is particularly effective when treating
dark coarse hair. In SPT V–VI, it is both safe and
highly effective at achieving permanent hair
reduction after a series of treatments [31, 32].
Challenges with the long pulsed Nd:YAG in
darker skin types arise in patients with dark skin
but fine hair, as is typically seen in patients of
Southeast Asian descent. In these patients, per-
manent hair reduction is more challenging
because the fluence and pulse width that are
required to achieve permanent reduction of fine
hair are risky in darker skin types. In these
cases, it is important to educate the patient on
the limitations of laser hair removal. Patients
must have realistic expectations and understand
that lasers can offer an excellent hair manage-
ment program but may not offer permanent
long-term removal of fine hairs. Many patients
who fall into this category still prefer laser hair
removal due to the elimination of irritation and
dyschromia frequently seen with shaving, wax-
ing or threading.
Laser Tattoo Removal
Tattoo removal in skin of color can present a
challenge given the concern for laser-induced
dyschromia. This is especially true in patients
with SPT V–VI. The goal of treatment is to uti-
lize the lowest fluence in order to obtain the
desired endpoint without causing thermal
injury. Tattoo color and skin type are important
factors when selecting appropriate lasers.
Q-switched lasers (including the alexandrite,
ruby and Nd:YAG) and picosecond lasers be
used efficaciously and safely to treat tattoos in
skin of color [7].
Q-switched alexandrite laser has been demon-
strated to be safe in treating amateur tattoos in 20
Arabic females with SPT III-IV. Patients received
3–6 treatment sessions at 6–12  week intervals
after spot tests were performed to determine safe
and efficacious treatment fluences. Half of the
patients experienced 76–95% tattoo clearance
while an additional quarter had >95% clearance.
Except for pin point bleeding, no pigmentary
changes or scarring was noted. Q-switched alex-
andrite lasers are however not appropriate to use
in darker skin types given the risk of pigmentary
changes and in these cases alternative lasers
should be considered [33].
One study described the use of the Q-switched
Nd:YAG laser on eight SPT VI patients. A total
of 15 amateur tattoos were treated at 8-week
intervals for an average of 3–4 treatments. Eight
of the 15 tattoos demonstrated 75–90% clear-
ance, while five showed 50% clearance and the
remaining two showed 25% clearance. Two of
the treated tattoos were noted to have slight skin
lightening [34].
Another study treated blue/black carbon
based tattoos in 404 Ethiopian Jews in Israel
(SPT V–VI) with either Q-switched Nd:YAG
(380 patients) or Q-switched ruby (24 patients).
Eight-­week treatment intervals were used with a
total of 3–6 laser treatment sessions. Clearance
of 75–100% was noted in 92% of treated tat-
toos. Although transient hyperpigmentation
lasting 2–4 months was noted in 44% of patients
and mild textural changes in two patients, there
was no long-term scarring or pigmentary
changes [35].
Picosecond laser technology continues to
expand with introduction of new wavelengths to
allow for more targeted tattoo removal. More
research is needed to determine safety of use for
tattoo removal in skin of color [36–38].
Skin Tightening
In contrast to the later presentation of photoaging
in skin of color, increasing skin laxity with
advanced age is equally common among all skin
types. Older patients commonly seek treatment
26  Lasers in Skin of Color

444
for prominent jowls and nasolabial folds. Younger
patients on the other hand, may seek treatment
for abdominal laxity post pregnancy. Due to the
significant risk of scarring and pigmentary
changes among patients with skin of color, many
seek non-surgical interventions to improve skin
laxity.
Non-invasive skin tightening devices induce
thermal injury to the dermis and underlying tis-
sue while sparing the epidermis through effective
epidermal cooling. Deep dermal heating is
thought to promote neocollagenesis and creation
of new elastic fibers over time. Immediate skin
tightening noted after treatment is thought to be
due to contraction of existing collagen fibers.
There are different methods and a number of
devices created for the purpose of heating the
dermis to produce skin tightening. There is ongo-
ing advancement in technology and frequent
addition or new devices to the market. Appropriate
patient selection is paramount to achieving suc-
cess with these devices. Managing patient expec-
tations and selecting patients who will be satisfied
with modest improvement is an important step.
The ideal patient is one with mild to moderate
skin laxity and absence of underlying redundant
fatty tissue [39–41].
Radiofrequency (RF)
Radiofrequency (RF) is electromagnetic radia-
tion in the frequency range of 300 MHz to 3 kHz.
These devices induce dermal heating, collagen
denaturation and subsequent collagen remodel-
ing. Wound healing mechanisms promote wound
contraction, to improve skin laxity. Because RF
energy is not dependent on a specific chromo-
phore interaction, epidermal melanin is not tar-
geted and treatment of all skin types is possible.
One device (Thermacool, Thermage Inc.,
Hayward, CA, USA) has reported efficacy in the
treatment of laxity involving the lower face and
neck [42].
Kushikata et al. reported the use of RF in a
series of 85 Japanese patients (SPT III–IV) for
the treatment of nasolabial folds, marionette lines
and jowls. The treatment was well tolerated over-
all with noted side effects in seven patients
including edema (n = 3), burn (n = 1), blister for-
mation (n = 1) and hyperpigmentation (n = 2). In
all of these cases the complications were tran-
sient and healed without permanent sequelae.
Objective physician assessment determined good
improvement at 3  months after treatment, and
even better improvement at 6-months post treat-
ment. RF treatment was concluded to be effective
for skin tightening in Asian facial skin, offering
safe and effective treatment of skin laxity [43].
Infrared Tightening
Delivery of heat to the deep dermis can be facili-
tated by the direct application of infrared heat.
This results in thermal induction of collagen con-
traction and subsequent collagen remodeling and
neocollagenesis. Titan (Cutera, Inc., Brisbane,
CA) is a device that uses infrared light to volu-
metrically heat the dermis. Utilizing a long pulse
of infrared light with a spectrum from 1100 to
1800 nm, it specifically targets water as its chro-
mophore. The settings range from 32–40 J and
are determined by patient tolerance. Even lower
fluences can be used when treating Asian facial
skin in order to prevent complications such as
superficial blisters. The penetration depth is
1–2 mm, which is best for targeting the reticular
dermis [44]. Light is emitted in multisecond
cycles in order to sufficiently heat the dermis
while providing appropriate cooling of the
­epidermis through integrated contact cooling.
The procedure is safe to use in skin of color and
is associated with minimal downtime. Although,
an immediate tightening effect is seen after treat-
ment; the full effect is not observed until 6
months after treatment [45]. Multiple sessions
(three to five) are needed for the best results in all
skin types [46]. Response rates are variable and
can be influenced by patient selection [47].
In a prospective open label trial in 21 Asian
patients, skin tightening as defined by lifting of
sagging skin folds was observed in 86% of patients
as measured by three independent physician
observers. This improvement ranged from mild to
excellent (mild 29%, moderate 38%, excellent
H. Woolery-Lloyd and N. Ferguson