Annual Masters of Aesthetics Symposium 2018

SAN DIEGO – Volatile organic compounds were detected in laser plume during laser tattoo removal, but not at levels deemed unsafe, results from a novel study demonstrated.

“The laser plume is known to contain possible hazards,” Yakir Levin, MD, PhD, said at the annual Masters of Aesthetics Symposium. “Intact human papillomavirus DNA has been demonstrated in the CO₂ laser plume of common wart treatments,” he noted, and transmission of bovine papillomavirus has been shown in a bovine model of CO² laser treatment (Arch Dermatol 2002;138[10]:1303-7). “In addition, aerosolized human cells have been demonstrated in laser tattoo removal.”

In a more recent study, Gary S. Chuang, MD, and his colleagues demonstrated hazards in the laser hair removal plume (JAMA Dermatol 2016;152[12]:1320-6). “These include ultrafine particles that become lodged in pulmonary alveoli and cause long-term respiratory problems, as well as volatile organic compounds, which can be carcinogens and environmental toxins,” said Dr. Levin of the Massachusetts General Hospital department of dermatology and the Wellman Center for Photomedicine, both in Boston. “They showed that this can be improved but not cured by proper use of a smoke evacuator; they also emphasized the importance of wearing a mask.”

Dr. Levin and his colleagues chose to study laser tattoo removal plume because more than 40 million Americans have tattoos, especially younger adults. In addition, 17% regret having their tattoo and 11% are undergoing or have undergone tattoo removal procedures. In what is believed to be the first study of its kind, the researchers performed a study in ex vivo pig skin and in humans undergoing routine laser tattoo removal. They measured the concentration of nanoparticles as well as the presence of heavy metals, volatile organic compounds, and airborne bacteria.

For the swine study, the excised pig skin was tattooed with several differently colored inks. Dr. Levin and his colleagues found that the concentration of airborne nanoparticles measured during laser tattoo removal was elevated and varied with different inks and different lasers used. Fine metals were measured in mcg/m³ air and were below safe occupational exposure limits. The same effect was seen for volatile organic compounds.

Next, the researchers analyzed the laser plume in humans undergoing removal of blue, black, and multicolored tattoos. “Here, the results were a little bit different,” Dr. Levin said. “Airborne particle concentrations were higher in the dermatologist’s breathing zone and near the tattoo removal site than in the remainder of the room or outside of the room. However, concentrations were 30 times lower for human skin than for pig skin. That’s because the pig study was somewhat artificial in that the tattoos were done when the pig was dead.”

Metals were detected in the plume in the human study, but they were all below occupational exposure limits. The same effect was seen for volatile organic compounds.

Dr. Levin said that airborne nanoparticle concentrations for laser tattoo removal of ex vivo tattooed swine skin were comparable to those reported for hair removal, while airborne nanoparticle concentrations for laser removal of in vivo human skin were much lower than those reported for laser hair removal. “So it’s probably true that the potential health hazards from laser tattoo removal are lower than for laser hair removal, but we did not study viral particles or the presence of viable human cells in the plume,” he said.

Current methods to limit laser plume exposure include suction of the plume with a smoke evacuator, use of a barrier device placed over the skin, and wearing a face mask constructed to filter nanoparticles, such as an N95 mask.
 

Other safety issues to consider

Dr. Levin discussed additional safety considerations in performing laser treatments.

“We want to protect the epidermis from injury during the laser exposure, which is currently done with spray cooling, air cooling, and/or contact cooling,” he said. “We want to limit the pain experienced by patients throughout the laser treatment before and after the brief laser exposure. This is often accomplished with the use of ice packs or air cooling. We also want to avoid double pulsing and skip areas. This can sometimes but not always be achieved by paying close attention to clinical endpoints.”

He and his associates are currently developing a device to accomplish all of those safety goals with a multilayer approach. “One of the layers would be a hydrogel, which serves to protect the epidermis and to provide pain relief throughout the laser treatment,” he said. “Above that layer is an indicator layer that is not aqueous, and on top of that is a fine layer of particles. The idea is, if you’re looking at this from above, when you fire the laser, you would see a change of color or some other indicator to show you exactly where you fired the laser. Finally, the multilayer patch also serves to obstruct the laser plume.”

Dr. Levin acknowledged research support from the American Society for Dermatologic Surgery’s Fredric S. Brandt, MD, Innovations in Aesthetics Fellowship Fund and assistance from the Health Hazard Evaluation Program of National Institute for Occupational Safety and Health.

dbrunk@mdedge.com

SAN DIEGO – Volatile organic compounds were detected in laser plume during laser tattoo removal, but not at levels deemed unsafe, results from a novel study demonstrated.

“The laser plume is known to contain possible hazards,” Yakir Levin, MD, PhD, said at the annual Masters of Aesthetics Symposium. “Intact human papillomavirus DNA has been demonstrated in the CO₂ laser plume of common wart treatments,” he noted, and transmission of bovine papillomavirus has been shown in a bovine model of CO² laser treatment (Arch Dermatol 2002;138[10]:1303-7). “In addition, aerosolized human cells have been demonstrated in laser tattoo removal.”

In a more recent study, Gary S. Chuang, MD, and his colleagues demonstrated hazards in the laser hair removal plume (JAMA Dermatol 2016;152[12]:1320-6). “These include ultrafine particles that become lodged in pulmonary alveoli and cause long-term respiratory problems, as well as volatile organic compounds, which can be carcinogens and environmental toxins,” said Dr. Levin of the Massachusetts General Hospital department of dermatology and the Wellman Center for Photomedicine, both in Boston. “They showed that this can be improved but not cured by proper use of a smoke evacuator; they also emphasized the importance of wearing a mask.”

Dr. Levin and his colleagues chose to study laser tattoo removal plume because more than 40 million Americans have tattoos, especially younger adults. In addition, 17% regret having their tattoo and 11% are undergoing or have undergone tattoo removal procedures. In what is believed to be the first study of its kind, the researchers performed a study in ex vivo pig skin and in humans undergoing routine laser tattoo removal. They measured the concentration of nanoparticles as well as the presence of heavy metals, volatile organic compounds, and airborne bacteria.

For the swine study, the excised pig skin was tattooed with several differently colored inks. Dr. Levin and his colleagues found that the concentration of airborne nanoparticles measured during laser tattoo removal was elevated and varied with different inks and different lasers used. Fine metals were measured in mcg/m³ air and were below safe occupational exposure limits. The same effect was seen for volatile organic compounds.

Next, the researchers analyzed the laser plume in humans undergoing removal of blue, black, and multicolored tattoos. “Here, the results were a little bit different,” Dr. Levin said. “Airborne particle concentrations were higher in the dermatologist’s breathing zone and near the tattoo removal site than in the remainder of the room or outside of the room. However, concentrations were 30 times lower for human skin than for pig skin. That’s because the pig study was somewhat artificial in that the tattoos were done when the pig was dead.”

Metals were detected in the plume in the human study, but they were all below occupational exposure limits. The same effect was seen for volatile organic compounds.

Dr. Levin said that airborne nanoparticle concentrations for laser tattoo removal of ex vivo tattooed swine skin were comparable to those reported for hair removal, while airborne nanoparticle concentrations for laser removal of in vivo human skin were much lower than those reported for laser hair removal. “So it’s probably true that the potential health hazards from laser tattoo removal are lower than for laser hair removal, but we did not study viral particles or the presence of viable human cells in the plume,” he said.

Current methods to limit laser plume exposure include suction of the plume with a smoke evacuator, use of a barrier device placed over the skin, and wearing a face mask constructed to filter nanoparticles, such as an N95 mask.
 

Other safety issues to consider

Dr. Levin discussed additional safety considerations in performing laser treatments.

“We want to protect the epidermis from injury during the laser exposure, which is currently done with spray cooling, air cooling, and/or contact cooling,” he said. “We want to limit the pain experienced by patients throughout the laser treatment before and after the brief laser exposure. This is often accomplished with the use of ice packs or air cooling. We also want to avoid double pulsing and skip areas. This can sometimes but not always be achieved by paying close attention to clinical endpoints.”

He and his associates are currently developing a device to accomplish all of those safety goals with a multilayer approach. “One of the layers would be a hydrogel, which serves to protect the epidermis and to provide pain relief throughout the laser treatment,” he said. “Above that layer is an indicator layer that is not aqueous, and on top of that is a fine layer of particles. The idea is, if you’re looking at this from above, when you fire the laser, you would see a change of color or some other indicator to show you exactly where you fired the laser. Finally, the multilayer patch also serves to obstruct the laser plume.”

Dr. Levin acknowledged research support from the American Society for Dermatologic Surgery’s Fredric S. Brandt, MD, Innovations in Aesthetics Fellowship Fund and assistance from the Health Hazard Evaluation Program of National Institute for Occupational Safety and Health.

dbrunk@mdedge.com

SAN DIEGO – Volatile organic compounds were detected in laser plume during laser tattoo removal, but not at levels deemed unsafe, results from a novel study demonstrated.

“The laser plume is known to contain possible hazards,” Yakir Levin, MD, PhD, said at the annual Masters of Aesthetics Symposium. “Intact human papillomavirus DNA has been demonstrated in the CO₂ laser plume of common wart treatments,” he noted, and transmission of bovine papillomavirus has been shown in a bovine model of CO² laser treatment (Arch Dermatol 2002;138[10]:1303-7). “In addition, aerosolized human cells have been demonstrated in laser tattoo removal.”

In a more recent study, Gary S. Chuang, MD, and his colleagues demonstrated hazards in the laser hair removal plume (JAMA Dermatol 2016;152[12]:1320-6). “These include ultrafine particles that become lodged in pulmonary alveoli and cause long-term respiratory problems, as well as volatile organic compounds, which can be carcinogens and environmental toxins,” said Dr. Levin of the Massachusetts General Hospital department of dermatology and the Wellman Center for Photomedicine, both in Boston. “They showed that this can be improved but not cured by proper use of a smoke evacuator; they also emphasized the importance of wearing a mask.”

Dr. Levin and his colleagues chose to study laser tattoo removal plume because more than 40 million Americans have tattoos, especially younger adults. In addition, 17% regret having their tattoo and 11% are undergoing or have undergone tattoo removal procedures. In what is believed to be the first study of its kind, the researchers performed a study in ex vivo pig skin and in humans undergoing routine laser tattoo removal. They measured the concentration of nanoparticles as well as the presence of heavy metals, volatile organic compounds, and airborne bacteria.

For the swine study, the excised pig skin was tattooed with several differently colored inks. Dr. Levin and his colleagues found that the concentration of airborne nanoparticles measured during laser tattoo removal was elevated and varied with different inks and different lasers used. Fine metals were measured in mcg/m³ air and were below safe occupational exposure limits. The same effect was seen for volatile organic compounds.

Next, the researchers analyzed the laser plume in humans undergoing removal of blue, black, and multicolored tattoos. “Here, the results were a little bit different,” Dr. Levin said. “Airborne particle concentrations were higher in the dermatologist’s breathing zone and near the tattoo removal site than in the remainder of the room or outside of the room. However, concentrations were 30 times lower for human skin than for pig skin. That’s because the pig study was somewhat artificial in that the tattoos were done when the pig was dead.”

Metals were detected in the plume in the human study, but they were all below occupational exposure limits. The same effect was seen for volatile organic compounds.

Dr. Levin said that airborne nanoparticle concentrations for laser tattoo removal of ex vivo tattooed swine skin were comparable to those reported for hair removal, while airborne nanoparticle concentrations for laser removal of in vivo human skin were much lower than those reported for laser hair removal. “So it’s probably true that the potential health hazards from laser tattoo removal are lower than for laser hair removal, but we did not study viral particles or the presence of viable human cells in the plume,” he said.

Current methods to limit laser plume exposure include suction of the plume with a smoke evacuator, use of a barrier device placed over the skin, and wearing a face mask constructed to filter nanoparticles, such as an N95 mask.
 

Other safety issues to consider

Dr. Levin discussed additional safety considerations in performing laser treatments.

“We want to protect the epidermis from injury during the laser exposure, which is currently done with spray cooling, air cooling, and/or contact cooling,” he said. “We want to limit the pain experienced by patients throughout the laser treatment before and after the brief laser exposure. This is often accomplished with the use of ice packs or air cooling. We also want to avoid double pulsing and skip areas. This can sometimes but not always be achieved by paying close attention to clinical endpoints.”

He and his associates are currently developing a device to accomplish all of those safety goals with a multilayer approach. “One of the layers would be a hydrogel, which serves to protect the epidermis and to provide pain relief throughout the laser treatment,” he said. “Above that layer is an indicator layer that is not aqueous, and on top of that is a fine layer of particles. The idea is, if you’re looking at this from above, when you fire the laser, you would see a change of color or some other indicator to show you exactly where you fired the laser. Finally, the multilayer patch also serves to obstruct the laser plume.”

Dr. Levin acknowledged research support from the American Society for Dermatologic Surgery’s Fredric S. Brandt, MD, Innovations in Aesthetics Fellowship Fund and assistance from the Health Hazard Evaluation Program of National Institute for Occupational Safety and Health.

dbrunk@mdedge.com

SAN DIEGO – Hair removal has been ranked as the most commonly litigated procedure in laser surgery, although fewer procedures for hair removal are performed annually than for other applications, Kristen M. Kelly, MD, said at the annual Masters of Aesthetics Symposium.

Clinicians perform an estimated 445,000 laser hair removal procedures each year, trailing those performed for wrinkles (561,000), facial redness (598,000), and sun damage (610,000), according to the 2017 American Society for Dermatologic Surgery Procedures Survey. However, hair removal has been found to be the most common procedure resulting in litigation (JAMA Dermatol. 2013;149[2]:188-93), “which is what we want to avoid,” Dr. Kelly said. “We want to learn how to do it in the best way possible.”

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, pointed out that clinicians are targeting melanin during laser hair removal. “This is important because it means that gray, white, blonde, and in some cases, red hair are not going to respond very well. In order to reach stem cells in the hair follicle, you can’t use superficial wavelengths, so we end up using the 755-nm alexandrite laser, 810-nm diode laser, or the 1064-nm long-pulsed Nd:YAG laser for the most part in order to get our result. You can also use intense pulsed light at 590-1200 nm.”

The pulse duration should be on the order of the thermal relaxation time (TRT) of the target. She defined thermal relaxation time as the duration required for the heat generated by absorbed light energy within the chromophore to dissipate to 50% of its value immediately after laser exposure.

“We want that heat to be absorbed by the melanin in the hair,” Dr. Kelly said. “Then we want that heat to radiate out to the hair follicle and the stem cells, which is going to prevent the hair from coming back in the future.” Epidermal cooling via cryogen spray cooling, contact cooling, or air-cooling allows clinicians to use higher fluences, allows for the use of safe treatment of darker skin types, and decreases treatment discomfort.

Prior to performing laser hair removal on the perioral area, Dr. Kelly provides a prophylactic antiviral medication for patients with a history of herpetic infection to suppress recurrence. She also advises patients to remove sunless tanner or other products from the skin surface, and she shaves or clips hair close to the surface gently, avoiding abrasion or surface damage. Most of the time she does not use a topical anesthetic. “You always want to make sure the laser is functioning properly by checking the laser’s cooling components, etc.,” she said. “I always tell patients, ‘8-10 treatments is not uncommon. You’re going to have fewer hairs and thinner hairs, but it doesn’t mean that you’re going to have zero hairs in this area for the rest of your life.’ Set the expectation correctly.”

Patients should wear protective goggles if being treated in areas other than the face. “If being treated on the face, make sure they’re wearing appropriate protective eyewear such as laser safe eye shields. Those performing the treatment should wear surgical masks and use a smoke evacuator, as there are multiple known carcinogens and environmental toxins in the plume generated by laser hair removal,” she said (JAMA Dermatol. 2016;152[12]:1320-6).

Factors to consider in choosing treatment settings include hair color, the patient’s skin color, hair thickness, hair density, and body location. For example, the genital area may be more pigmented in some patients, and also may be more sensitive. “If you have thicker and darker hair it’s going to absorb more energy, so you have to adjust your settings,” Dr. Kelly said. She also avoids treating acutely tanned patients. “What you don’t want is for a tanned patient have a complication. I’d rather have them wait 2 or 3 weeks and come back. Sometimes it frustrates them a little, but it is safer.”

At the start of each procedure, Dr. Kelly delivers a couple of pulses then asks patients how uncomfortable they are on a scale from 1 to 10. “It often will vary,” she said. “Even if I’ve seen a patient for 10 treatments, some days it will hurt a little more than others. If the patient says it hurts a lot more than it normally does, you need to stop and think. That tells you that something is not right. They might be too tanned, or perhaps the [device] settings are wrong or the laser’s not functioning properly. Monitor the skin response. It takes time to see the final skin response, so wait before adjusting the energy. You want to see mild redness or mild follicular response. People report a little bit of a burning sensation.”

Postprocedure, she routinely applies a topical steroid such as betamethasone or clobetasol immediately after treatment. “That calms down the inflammatory response. If I see an area that I think is going to blister, I will apply the steroid multiple times until I see that response go away.” She asks patients about their pain level and typically applies ice to the treated area for 10 minutes before they leave the office, and they head home with after-care instructions, including a phone number where Dr. Kelly can be reached if patients have concerns. “I call my patients in the evening to ask how they’re doing, and if they have any questions.”

Dr. Kelly does not do laser hair removal inside the eye orbit or between the eyebrows, “because even with eye shields, you can have a problem,” she said. A potential outcome to be aware of is paradoxical hypertrichosis, or increased hair growth after laser hair removal estimated to occur in 0.6%-10% of patients. She discusses this with patients when consenting them. “Some people say this occurs in darker skin types, while others say it happens in people with thicker hair or thinner hair. Some of it occurs on the edges of the treatment area.” The treatment for paradoxical hypertrichosis is to continue laser hair removal and “try to push the energy just a little bit, but be cautious. It can be a difficult problem to resolve.”

Dr. Kelly has noticed a recent uptick at her practice in gender transition patients seeking hair removal procedures. “Removing facial and chest hair may be desirable, and may be covered by the patient’s health insurance,” she said. “Multiple treatments are required. A thick beard area needs to be approached cautiously.”

She referred to future advances in laser hair removal that may involve the use of topical agents to improve outcomes. For example, Sienna Biopharmaceuticals has developed Topical Photoparticle Therapy which, according to its website, uses “silver particles to absorb laser light and convert the light energy into heat to facilitate local tissue injury ... in the case of unwanted light or mixed pigment hair, which can’t be removed with lasers alone, [this process] targets the hair follicle.”

Dr. Kelly disclosed that she is an advisory consultant to Syneron Candela and Allergan. In addition, Allergan has provided drug products to Dr. Kelly for research purposes, while Solta Medical and ThermiRF have provided her with donated light sources for research or clinical use. Dr. Kelly has also received funding from the Sturge-Weber Foundation, the American Society for Laser Medicine and Surgery, and the National Institutes of Health.

dbrunk@mdedge.com



 

SAN DIEGO – Hair removal has been ranked as the most commonly litigated procedure in laser surgery, although fewer procedures for hair removal are performed annually than for other applications, Kristen M. Kelly, MD, said at the annual Masters of Aesthetics Symposium.

Clinicians perform an estimated 445,000 laser hair removal procedures each year, trailing those performed for wrinkles (561,000), facial redness (598,000), and sun damage (610,000), according to the 2017 American Society for Dermatologic Surgery Procedures Survey. However, hair removal has been found to be the most common procedure resulting in litigation (JAMA Dermatol. 2013;149[2]:188-93), “which is what we want to avoid,” Dr. Kelly said. “We want to learn how to do it in the best way possible.”

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, pointed out that clinicians are targeting melanin during laser hair removal. “This is important because it means that gray, white, blonde, and in some cases, red hair are not going to respond very well. In order to reach stem cells in the hair follicle, you can’t use superficial wavelengths, so we end up using the 755-nm alexandrite laser, 810-nm diode laser, or the 1064-nm long-pulsed Nd:YAG laser for the most part in order to get our result. You can also use intense pulsed light at 590-1200 nm.”

The pulse duration should be on the order of the thermal relaxation time (TRT) of the target. She defined thermal relaxation time as the duration required for the heat generated by absorbed light energy within the chromophore to dissipate to 50% of its value immediately after laser exposure.

“We want that heat to be absorbed by the melanin in the hair,” Dr. Kelly said. “Then we want that heat to radiate out to the hair follicle and the stem cells, which is going to prevent the hair from coming back in the future.” Epidermal cooling via cryogen spray cooling, contact cooling, or air-cooling allows clinicians to use higher fluences, allows for the use of safe treatment of darker skin types, and decreases treatment discomfort.

Prior to performing laser hair removal on the perioral area, Dr. Kelly provides a prophylactic antiviral medication for patients with a history of herpetic infection to suppress recurrence. She also advises patients to remove sunless tanner or other products from the skin surface, and she shaves or clips hair close to the surface gently, avoiding abrasion or surface damage. Most of the time she does not use a topical anesthetic. “You always want to make sure the laser is functioning properly by checking the laser’s cooling components, etc.,” she said. “I always tell patients, ‘8-10 treatments is not uncommon. You’re going to have fewer hairs and thinner hairs, but it doesn’t mean that you’re going to have zero hairs in this area for the rest of your life.’ Set the expectation correctly.”

Patients should wear protective goggles if being treated in areas other than the face. “If being treated on the face, make sure they’re wearing appropriate protective eyewear such as laser safe eye shields. Those performing the treatment should wear surgical masks and use a smoke evacuator, as there are multiple known carcinogens and environmental toxins in the plume generated by laser hair removal,” she said (JAMA Dermatol. 2016;152[12]:1320-6).

Factors to consider in choosing treatment settings include hair color, the patient’s skin color, hair thickness, hair density, and body location. For example, the genital area may be more pigmented in some patients, and also may be more sensitive. “If you have thicker and darker hair it’s going to absorb more energy, so you have to adjust your settings,” Dr. Kelly said. She also avoids treating acutely tanned patients. “What you don’t want is for a tanned patient have a complication. I’d rather have them wait 2 or 3 weeks and come back. Sometimes it frustrates them a little, but it is safer.”

At the start of each procedure, Dr. Kelly delivers a couple of pulses then asks patients how uncomfortable they are on a scale from 1 to 10. “It often will vary,” she said. “Even if I’ve seen a patient for 10 treatments, some days it will hurt a little more than others. If the patient says it hurts a lot more than it normally does, you need to stop and think. That tells you that something is not right. They might be too tanned, or perhaps the [device] settings are wrong or the laser’s not functioning properly. Monitor the skin response. It takes time to see the final skin response, so wait before adjusting the energy. You want to see mild redness or mild follicular response. People report a little bit of a burning sensation.”

Postprocedure, she routinely applies a topical steroid such as betamethasone or clobetasol immediately after treatment. “That calms down the inflammatory response. If I see an area that I think is going to blister, I will apply the steroid multiple times until I see that response go away.” She asks patients about their pain level and typically applies ice to the treated area for 10 minutes before they leave the office, and they head home with after-care instructions, including a phone number where Dr. Kelly can be reached if patients have concerns. “I call my patients in the evening to ask how they’re doing, and if they have any questions.”

Dr. Kelly does not do laser hair removal inside the eye orbit or between the eyebrows, “because even with eye shields, you can have a problem,” she said. A potential outcome to be aware of is paradoxical hypertrichosis, or increased hair growth after laser hair removal estimated to occur in 0.6%-10% of patients. She discusses this with patients when consenting them. “Some people say this occurs in darker skin types, while others say it happens in people with thicker hair or thinner hair. Some of it occurs on the edges of the treatment area.” The treatment for paradoxical hypertrichosis is to continue laser hair removal and “try to push the energy just a little bit, but be cautious. It can be a difficult problem to resolve.”

Dr. Kelly has noticed a recent uptick at her practice in gender transition patients seeking hair removal procedures. “Removing facial and chest hair may be desirable, and may be covered by the patient’s health insurance,” she said. “Multiple treatments are required. A thick beard area needs to be approached cautiously.”

She referred to future advances in laser hair removal that may involve the use of topical agents to improve outcomes. For example, Sienna Biopharmaceuticals has developed Topical Photoparticle Therapy which, according to its website, uses “silver particles to absorb laser light and convert the light energy into heat to facilitate local tissue injury ... in the case of unwanted light or mixed pigment hair, which can’t be removed with lasers alone, [this process] targets the hair follicle.”

Dr. Kelly disclosed that she is an advisory consultant to Syneron Candela and Allergan. In addition, Allergan has provided drug products to Dr. Kelly for research purposes, while Solta Medical and ThermiRF have provided her with donated light sources for research or clinical use. Dr. Kelly has also received funding from the Sturge-Weber Foundation, the American Society for Laser Medicine and Surgery, and the National Institutes of Health.

dbrunk@mdedge.com



 

SAN DIEGO – Hair removal has been ranked as the most commonly litigated procedure in laser surgery, although fewer procedures for hair removal are performed annually than for other applications, Kristen M. Kelly, MD, said at the annual Masters of Aesthetics Symposium.

Clinicians perform an estimated 445,000 laser hair removal procedures each year, trailing those performed for wrinkles (561,000), facial redness (598,000), and sun damage (610,000), according to the 2017 American Society for Dermatologic Surgery Procedures Survey. However, hair removal has been found to be the most common procedure resulting in litigation (JAMA Dermatol. 2013;149[2]:188-93), “which is what we want to avoid,” Dr. Kelly said. “We want to learn how to do it in the best way possible.”

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, pointed out that clinicians are targeting melanin during laser hair removal. “This is important because it means that gray, white, blonde, and in some cases, red hair are not going to respond very well. In order to reach stem cells in the hair follicle, you can’t use superficial wavelengths, so we end up using the 755-nm alexandrite laser, 810-nm diode laser, or the 1064-nm long-pulsed Nd:YAG laser for the most part in order to get our result. You can also use intense pulsed light at 590-1200 nm.”

The pulse duration should be on the order of the thermal relaxation time (TRT) of the target. She defined thermal relaxation time as the duration required for the heat generated by absorbed light energy within the chromophore to dissipate to 50% of its value immediately after laser exposure.

“We want that heat to be absorbed by the melanin in the hair,” Dr. Kelly said. “Then we want that heat to radiate out to the hair follicle and the stem cells, which is going to prevent the hair from coming back in the future.” Epidermal cooling via cryogen spray cooling, contact cooling, or air-cooling allows clinicians to use higher fluences, allows for the use of safe treatment of darker skin types, and decreases treatment discomfort.

Prior to performing laser hair removal on the perioral area, Dr. Kelly provides a prophylactic antiviral medication for patients with a history of herpetic infection to suppress recurrence. She also advises patients to remove sunless tanner or other products from the skin surface, and she shaves or clips hair close to the surface gently, avoiding abrasion or surface damage. Most of the time she does not use a topical anesthetic. “You always want to make sure the laser is functioning properly by checking the laser’s cooling components, etc.,” she said. “I always tell patients, ‘8-10 treatments is not uncommon. You’re going to have fewer hairs and thinner hairs, but it doesn’t mean that you’re going to have zero hairs in this area for the rest of your life.’ Set the expectation correctly.”

Patients should wear protective goggles if being treated in areas other than the face. “If being treated on the face, make sure they’re wearing appropriate protective eyewear such as laser safe eye shields. Those performing the treatment should wear surgical masks and use a smoke evacuator, as there are multiple known carcinogens and environmental toxins in the plume generated by laser hair removal,” she said (JAMA Dermatol. 2016;152[12]:1320-6).

Factors to consider in choosing treatment settings include hair color, the patient’s skin color, hair thickness, hair density, and body location. For example, the genital area may be more pigmented in some patients, and also may be more sensitive. “If you have thicker and darker hair it’s going to absorb more energy, so you have to adjust your settings,” Dr. Kelly said. She also avoids treating acutely tanned patients. “What you don’t want is for a tanned patient have a complication. I’d rather have them wait 2 or 3 weeks and come back. Sometimes it frustrates them a little, but it is safer.”

At the start of each procedure, Dr. Kelly delivers a couple of pulses then asks patients how uncomfortable they are on a scale from 1 to 10. “It often will vary,” she said. “Even if I’ve seen a patient for 10 treatments, some days it will hurt a little more than others. If the patient says it hurts a lot more than it normally does, you need to stop and think. That tells you that something is not right. They might be too tanned, or perhaps the [device] settings are wrong or the laser’s not functioning properly. Monitor the skin response. It takes time to see the final skin response, so wait before adjusting the energy. You want to see mild redness or mild follicular response. People report a little bit of a burning sensation.”

Postprocedure, she routinely applies a topical steroid such as betamethasone or clobetasol immediately after treatment. “That calms down the inflammatory response. If I see an area that I think is going to blister, I will apply the steroid multiple times until I see that response go away.” She asks patients about their pain level and typically applies ice to the treated area for 10 minutes before they leave the office, and they head home with after-care instructions, including a phone number where Dr. Kelly can be reached if patients have concerns. “I call my patients in the evening to ask how they’re doing, and if they have any questions.”

Dr. Kelly does not do laser hair removal inside the eye orbit or between the eyebrows, “because even with eye shields, you can have a problem,” she said. A potential outcome to be aware of is paradoxical hypertrichosis, or increased hair growth after laser hair removal estimated to occur in 0.6%-10% of patients. She discusses this with patients when consenting them. “Some people say this occurs in darker skin types, while others say it happens in people with thicker hair or thinner hair. Some of it occurs on the edges of the treatment area.” The treatment for paradoxical hypertrichosis is to continue laser hair removal and “try to push the energy just a little bit, but be cautious. It can be a difficult problem to resolve.”

Dr. Kelly has noticed a recent uptick at her practice in gender transition patients seeking hair removal procedures. “Removing facial and chest hair may be desirable, and may be covered by the patient’s health insurance,” she said. “Multiple treatments are required. A thick beard area needs to be approached cautiously.”

She referred to future advances in laser hair removal that may involve the use of topical agents to improve outcomes. For example, Sienna Biopharmaceuticals has developed Topical Photoparticle Therapy which, according to its website, uses “silver particles to absorb laser light and convert the light energy into heat to facilitate local tissue injury ... in the case of unwanted light or mixed pigment hair, which can’t be removed with lasers alone, [this process] targets the hair follicle.”

Dr. Kelly disclosed that she is an advisory consultant to Syneron Candela and Allergan. In addition, Allergan has provided drug products to Dr. Kelly for research purposes, while Solta Medical and ThermiRF have provided her with donated light sources for research or clinical use. Dr. Kelly has also received funding from the Sturge-Weber Foundation, the American Society for Laser Medicine and Surgery, and the National Institutes of Health.

dbrunk@mdedge.com



 

SAN DIEGO – The United States is more ethnically diverse than ever before, creating an added challenge for dermatologists to identify skin types in patients considering aesthetic procedures.

“Unfortunately, one’s ethnic background is not always clear,” Ashish C. Bhatia, MD, said at the annual Masters of Aesthetics Symposium. “There’s a lot more blending, a lot more difficulty figuring out what people’s ethnicity is and how their skin is going to respond to different treatments.”

When consulting with patients, Dr. Bhatia, director of dermatologic and cosmetic surgery at Oak Dermatology, outside of Chicago, determines their Fitzpatrick skin type and asks about their heritage. “Some people who are adopted don’t know their heritage,” he said. “We also ask about their history of keloids, hypertrophic scars, postinflammatory hyperpigmentation or postinflammatory erythema.”

He also makes it a point to ask patients about blemishes. “If they get pimples, how long do the marks last, and what do they look like?” is one question he asks patients. “That dialogue gives you a lot of useful information. If they get hyperpigmentation, that’s one thing. But many times, people just get postinflammatory erythema, which is often a lot easier to treat.”

In his clinical experience, challenges and risks of performing aesthetic procedures on ethnic skin include postinflammatory hyperpigmentation and hypopigmentation, depigmentation, keloids, and hypertrophic scars. He explained that patients with darker skin types have bigger melanin granules and melanosomes, and more of them are deposited into keratinocytes.

“There’s a complex interaction that occurs between the melanocytes and the keratinocytes, where they phagocytize the ends and take up the melanosomes,” said Dr. Bhatia, also of the department of dermatology at Northwestern University, Chicago. “There’s an opportunity to block tyrosinase to prevent the production of melanin, but once the melanin is produced, what we really worry about is where that melanin ends up. It may end up in the epidermis in the form of light brown pigment. You can see this enhanced if you look at it with a Wood’s light. But if it ends up in the dermis, you don’t get enhancement and clinically it’s more of a bluish-gray pigment. The deeper melanin is much more difficult to treat. Often the postinflammatory hyperpigmentation people get is a combination of these two.”

To reduce the risks of hyperpigmentation and hypopigmentation from procedures, he generally advises against the use of intense pulsed light (IPL), fractional ablative lasers, shorter-wavelength lasers, and cryotherapy. “It’s not to say you can’t use them, but you have to be very careful,” he said. For clinicians with less experience treating skin of color, he recommends using procedures that spare the epidermis and the dermal/epidermal junction altogether. “This includes lasers with longer wavelengths such as the 1,064-nm Nd:YAG, always using generous cooling to avoid injury or trauma to the dermal/epidermal junction and using longer pulse durations.”

Nonlaser procedures to consider using for darker-skinned patients include superficial chemical peels, radiofrequency (RF) microneedling with semi-insulated needles, microfocused ultrasound, and noninvasive RF procedures that spare or cool the epidermis. “You should never be afraid to do a test spot,” he said. Adjunctive therapies to consider using include hydroquinone and other tyrosinase-receptor blockers, and preprocedural preparatory formulas. “Always advise sun protection and avoidance and administer HSV [herpes simplex virus] prophylaxis as indicated,” he added. “Ample evidence exists to show that currently available fillers and neuromodulators are safe to use in darker skin types. The issue here is more with postinflammatory hyperpigmentation, which can occur from needle punctures, so small-gauge needles and linear threading versus serial puncture is preferred.”

Adjunctive postprocedure preventative therapies include hydroquinone and other tyrosinase-receptor blockers; high-potency topical steroids such as clobetasol twice a day for 3 days and tapering to once a day for 3 days before halting; and postprocedural recovery/healing formulas.

Dr. Bhatia said that hypopigmentation can be treated with UV therapy, with bimatoprost topically combined with needling or low-density fractional lasers, as well as with epidermal microsuction grafting such as the CelluTome Epidermal Harvesting System. Hyperpigmentation can be treated with tyrosinase inhibitors, retinoids, chemical peels, and with microdermal/dermal infusion.

As for cosmeceuticals, sunscreens are necessary for keeping skin tone even. Retinoids are also helpful for maintenance, “but irritation can lead to postinflammatory hyperpigmentation, so go slow,” he said. Hyperpigmentation can be treated with hydroquinone, azelaic acid (Finacea), as well as many other preparations.

“Don’t be afraid to treat these patients,” Dr. Bhatia concluded. “As you get more used to performing procedures on people with darker skin types, you discover the limits of what you can and can’t do. But in general, we can do a lot to make these patients happy.”

Dr. Bhatia reported having research and financial ties to numerous pharmaceutical and device companies.

dbrunk@mdedge.com

SAN DIEGO – The United States is more ethnically diverse than ever before, creating an added challenge for dermatologists to identify skin types in patients considering aesthetic procedures.

“Unfortunately, one’s ethnic background is not always clear,” Ashish C. Bhatia, MD, said at the annual Masters of Aesthetics Symposium. “There’s a lot more blending, a lot more difficulty figuring out what people’s ethnicity is and how their skin is going to respond to different treatments.”

When consulting with patients, Dr. Bhatia, director of dermatologic and cosmetic surgery at Oak Dermatology, outside of Chicago, determines their Fitzpatrick skin type and asks about their heritage. “Some people who are adopted don’t know their heritage,” he said. “We also ask about their history of keloids, hypertrophic scars, postinflammatory hyperpigmentation or postinflammatory erythema.”

He also makes it a point to ask patients about blemishes. “If they get pimples, how long do the marks last, and what do they look like?” is one question he asks patients. “That dialogue gives you a lot of useful information. If they get hyperpigmentation, that’s one thing. But many times, people just get postinflammatory erythema, which is often a lot easier to treat.”

In his clinical experience, challenges and risks of performing aesthetic procedures on ethnic skin include postinflammatory hyperpigmentation and hypopigmentation, depigmentation, keloids, and hypertrophic scars. He explained that patients with darker skin types have bigger melanin granules and melanosomes, and more of them are deposited into keratinocytes.

“There’s a complex interaction that occurs between the melanocytes and the keratinocytes, where they phagocytize the ends and take up the melanosomes,” said Dr. Bhatia, also of the department of dermatology at Northwestern University, Chicago. “There’s an opportunity to block tyrosinase to prevent the production of melanin, but once the melanin is produced, what we really worry about is where that melanin ends up. It may end up in the epidermis in the form of light brown pigment. You can see this enhanced if you look at it with a Wood’s light. But if it ends up in the dermis, you don’t get enhancement and clinically it’s more of a bluish-gray pigment. The deeper melanin is much more difficult to treat. Often the postinflammatory hyperpigmentation people get is a combination of these two.”

To reduce the risks of hyperpigmentation and hypopigmentation from procedures, he generally advises against the use of intense pulsed light (IPL), fractional ablative lasers, shorter-wavelength lasers, and cryotherapy. “It’s not to say you can’t use them, but you have to be very careful,” he said. For clinicians with less experience treating skin of color, he recommends using procedures that spare the epidermis and the dermal/epidermal junction altogether. “This includes lasers with longer wavelengths such as the 1,064-nm Nd:YAG, always using generous cooling to avoid injury or trauma to the dermal/epidermal junction and using longer pulse durations.”

Nonlaser procedures to consider using for darker-skinned patients include superficial chemical peels, radiofrequency (RF) microneedling with semi-insulated needles, microfocused ultrasound, and noninvasive RF procedures that spare or cool the epidermis. “You should never be afraid to do a test spot,” he said. Adjunctive therapies to consider using include hydroquinone and other tyrosinase-receptor blockers, and preprocedural preparatory formulas. “Always advise sun protection and avoidance and administer HSV [herpes simplex virus] prophylaxis as indicated,” he added. “Ample evidence exists to show that currently available fillers and neuromodulators are safe to use in darker skin types. The issue here is more with postinflammatory hyperpigmentation, which can occur from needle punctures, so small-gauge needles and linear threading versus serial puncture is preferred.”

Adjunctive postprocedure preventative therapies include hydroquinone and other tyrosinase-receptor blockers; high-potency topical steroids such as clobetasol twice a day for 3 days and tapering to once a day for 3 days before halting; and postprocedural recovery/healing formulas.

Dr. Bhatia said that hypopigmentation can be treated with UV therapy, with bimatoprost topically combined with needling or low-density fractional lasers, as well as with epidermal microsuction grafting such as the CelluTome Epidermal Harvesting System. Hyperpigmentation can be treated with tyrosinase inhibitors, retinoids, chemical peels, and with microdermal/dermal infusion.

As for cosmeceuticals, sunscreens are necessary for keeping skin tone even. Retinoids are also helpful for maintenance, “but irritation can lead to postinflammatory hyperpigmentation, so go slow,” he said. Hyperpigmentation can be treated with hydroquinone, azelaic acid (Finacea), as well as many other preparations.

“Don’t be afraid to treat these patients,” Dr. Bhatia concluded. “As you get more used to performing procedures on people with darker skin types, you discover the limits of what you can and can’t do. But in general, we can do a lot to make these patients happy.”

Dr. Bhatia reported having research and financial ties to numerous pharmaceutical and device companies.

dbrunk@mdedge.com

SAN DIEGO – The United States is more ethnically diverse than ever before, creating an added challenge for dermatologists to identify skin types in patients considering aesthetic procedures.

“Unfortunately, one’s ethnic background is not always clear,” Ashish C. Bhatia, MD, said at the annual Masters of Aesthetics Symposium. “There’s a lot more blending, a lot more difficulty figuring out what people’s ethnicity is and how their skin is going to respond to different treatments.”

When consulting with patients, Dr. Bhatia, director of dermatologic and cosmetic surgery at Oak Dermatology, outside of Chicago, determines their Fitzpatrick skin type and asks about their heritage. “Some people who are adopted don’t know their heritage,” he said. “We also ask about their history of keloids, hypertrophic scars, postinflammatory hyperpigmentation or postinflammatory erythema.”

He also makes it a point to ask patients about blemishes. “If they get pimples, how long do the marks last, and what do they look like?” is one question he asks patients. “That dialogue gives you a lot of useful information. If they get hyperpigmentation, that’s one thing. But many times, people just get postinflammatory erythema, which is often a lot easier to treat.”

In his clinical experience, challenges and risks of performing aesthetic procedures on ethnic skin include postinflammatory hyperpigmentation and hypopigmentation, depigmentation, keloids, and hypertrophic scars. He explained that patients with darker skin types have bigger melanin granules and melanosomes, and more of them are deposited into keratinocytes.

“There’s a complex interaction that occurs between the melanocytes and the keratinocytes, where they phagocytize the ends and take up the melanosomes,” said Dr. Bhatia, also of the department of dermatology at Northwestern University, Chicago. “There’s an opportunity to block tyrosinase to prevent the production of melanin, but once the melanin is produced, what we really worry about is where that melanin ends up. It may end up in the epidermis in the form of light brown pigment. You can see this enhanced if you look at it with a Wood’s light. But if it ends up in the dermis, you don’t get enhancement and clinically it’s more of a bluish-gray pigment. The deeper melanin is much more difficult to treat. Often the postinflammatory hyperpigmentation people get is a combination of these two.”

To reduce the risks of hyperpigmentation and hypopigmentation from procedures, he generally advises against the use of intense pulsed light (IPL), fractional ablative lasers, shorter-wavelength lasers, and cryotherapy. “It’s not to say you can’t use them, but you have to be very careful,” he said. For clinicians with less experience treating skin of color, he recommends using procedures that spare the epidermis and the dermal/epidermal junction altogether. “This includes lasers with longer wavelengths such as the 1,064-nm Nd:YAG, always using generous cooling to avoid injury or trauma to the dermal/epidermal junction and using longer pulse durations.”

Nonlaser procedures to consider using for darker-skinned patients include superficial chemical peels, radiofrequency (RF) microneedling with semi-insulated needles, microfocused ultrasound, and noninvasive RF procedures that spare or cool the epidermis. “You should never be afraid to do a test spot,” he said. Adjunctive therapies to consider using include hydroquinone and other tyrosinase-receptor blockers, and preprocedural preparatory formulas. “Always advise sun protection and avoidance and administer HSV [herpes simplex virus] prophylaxis as indicated,” he added. “Ample evidence exists to show that currently available fillers and neuromodulators are safe to use in darker skin types. The issue here is more with postinflammatory hyperpigmentation, which can occur from needle punctures, so small-gauge needles and linear threading versus serial puncture is preferred.”

Adjunctive postprocedure preventative therapies include hydroquinone and other tyrosinase-receptor blockers; high-potency topical steroids such as clobetasol twice a day for 3 days and tapering to once a day for 3 days before halting; and postprocedural recovery/healing formulas.

Dr. Bhatia said that hypopigmentation can be treated with UV therapy, with bimatoprost topically combined with needling or low-density fractional lasers, as well as with epidermal microsuction grafting such as the CelluTome Epidermal Harvesting System. Hyperpigmentation can be treated with tyrosinase inhibitors, retinoids, chemical peels, and with microdermal/dermal infusion.

As for cosmeceuticals, sunscreens are necessary for keeping skin tone even. Retinoids are also helpful for maintenance, “but irritation can lead to postinflammatory hyperpigmentation, so go slow,” he said. Hyperpigmentation can be treated with hydroquinone, azelaic acid (Finacea), as well as many other preparations.

“Don’t be afraid to treat these patients,” Dr. Bhatia concluded. “As you get more used to performing procedures on people with darker skin types, you discover the limits of what you can and can’t do. But in general, we can do a lot to make these patients happy.”

Dr. Bhatia reported having research and financial ties to numerous pharmaceutical and device companies.

dbrunk@mdedge.com

SAN DIEGO – The development of ablative fractional lasers has revolutionized how dermatologists treat scars, according to Jill S. Waibel, MD.

“I tell patients it’s like boiling water in a tea kettle and watching the vapor form,” Dr. Waibel, a dermatologist with the Miami Dermatology and Laser Institute, said at the annual Masters of Aesthetics Symposium. “You literally ‘steam off’ their bad scar and the human body will heal that wound to almost normal skin. It’s the closest thing we have to a magic wand.”

In the not-too-distant past, dermatologists “were treating scars just to make them look better,” she said. However, thanks to groundbreaking work by clinicians at Naval Medical Center San Diego, the use of ablative fractional lasers to treat scars was found to improve range of motion in patients, as well as their pain and pruritus. “It represents a major innovation that heals in ways not previously possible,” said Dr. Waibel, who is also chief of dermatology at Baptist Hospital in Miami. “We’re not just healing the scar; we’re healing the skin back to its physiological normal place. A lot of these patients suffer quite a bit.”

Dr. Waibel likened her scar treatment approach to a three-course meal. Lesion color drives her choice of what device to use as an “appetizer” treatment. Most scars are either red (erythematous), brown (hyperpigmented), or white (hypopigmented). Though every scar is unique and individually evaluated for treatment, typically she uses pulsed dye laser, intense pulsed light, or broadband light therapy to treat erythematous/early scars; nonablative fractional lasers to treat atrophic scars, and the thulium or 1,470-nm laser to treat hyperpigmented scars. The “main course” device in her practice is an ablative fractional erbium or CO₂ laser.

“Once I treat the scar three to five times, I might switch to a nonablative laser, but I’m really an ablative fractional user,” Dr. Waibel said. “Dessert” can be whatever adjunctive therapies you need, she continued. This may include triamcinolone acetonide, 5-fluorouracil, poly-l-lactic acid, hyaluronidase, Z-plasty, punch biopsies, shave biopsies, compression, chemical reconstruction of skin scars (CROSS), and subcision.

For erythematous surgical and trauma scars, she uses a combination of pulsed dye laser and ablative fractional laser. “Same day, same treatment; one after each other,” she said. She favors using intense pulsed light for donor sites because it has filters that address both melanin and hemosiderin, superiority for scar erythema, and deeper penetration with greater speed to treat large surface areas.

One recent advance in the vascular arena is the new 595-nm pulsed dye laser by Candela, known as the VBeam Prima. It features increased energy, a 15-nm spot size, a zoom hand piece, once-a-day calibration, and contact cooling, which may be better for pigmented and possibly microvascular structures. The device is cleared for treating conditions like rosacea, acne, spider veins, port-wine stains, wrinkles, warts and stretch marks, as well as photoaging and benign pigmented lesions.

Dr. Waibel’s go-to device for treating a hypertrophic, hyperpigmented surgical scar is a 1927-nm or 1470-nm nonablative fractional laser, followed by a fractional ablative laser and injection of 1-2 ccs of 5-fluorouracil only to elevated areas. Hypopigmented scars are “by far the toughest to treat,” she said. However, she has a formula for these, too, and recently conducted a trial comparing the efficacy of nonablative fractional laser, ablative fractional laser, and ablative fractional laser followed by laser-assisted delivery of bimatoprost (Latisse) to treat hypopigmentation.

Surgical scars get better on their own in many cases, but sometimes early intervention is warranted. “Most surgeons will tell patients, ‘Wait a year. What you have [in terms of scar formation] is what you have,’” Dr. Waibel said. “If a surgical scar becomes hypertrophic, it does so within a month of surgery. I don’t prophylactically treat surgical scars unless the patient has had multiple surgeries in the same location with trouble healing. But if it’s been 6 months to a year, or if the patient is developing hypertrophic scars, then I will treat.”

Acne scars are challenging, because patients want to look good right away. “With deep scars, it takes several treatments to see good improvements,” she said. “I tell all my acne scar patients it takes a year [to get good results].”

Most burn patients require three to six treatment sessions, “but sometimes you get remarkable improvement sooner,” she said. “That’s due to the patient’s healing.” She and her associates recently completed an unpublished study that examined early intervention of fractional ablative laser versus control in 20 subjects with acute burn injuries who ranged in age from 18 to 80 years. The subjects underwent treatment with an ablative fractional CO₂ laser within 3 months of sustaining the burn injury, leaving an untreated control area for comparison. According to Dr. Waibel, 100% of the blinded physician evaluators graded the laser-treated area correctly, compared with the control area. In addition, a significant improvement in all points of the Manchester Scar Scale was observed in the laser-treated area. “The earlier you treat burn and trauma patients, the easier it is to get them back to normal,” she said.

Dr. Waibel disclosed that she has conducted clinical research for Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.

dbrunk@mdedge.com

SAN DIEGO – The development of ablative fractional lasers has revolutionized how dermatologists treat scars, according to Jill S. Waibel, MD.

“I tell patients it’s like boiling water in a tea kettle and watching the vapor form,” Dr. Waibel, a dermatologist with the Miami Dermatology and Laser Institute, said at the annual Masters of Aesthetics Symposium. “You literally ‘steam off’ their bad scar and the human body will heal that wound to almost normal skin. It’s the closest thing we have to a magic wand.”

In the not-too-distant past, dermatologists “were treating scars just to make them look better,” she said. However, thanks to groundbreaking work by clinicians at Naval Medical Center San Diego, the use of ablative fractional lasers to treat scars was found to improve range of motion in patients, as well as their pain and pruritus. “It represents a major innovation that heals in ways not previously possible,” said Dr. Waibel, who is also chief of dermatology at Baptist Hospital in Miami. “We’re not just healing the scar; we’re healing the skin back to its physiological normal place. A lot of these patients suffer quite a bit.”

Dr. Waibel likened her scar treatment approach to a three-course meal. Lesion color drives her choice of what device to use as an “appetizer” treatment. Most scars are either red (erythematous), brown (hyperpigmented), or white (hypopigmented). Though every scar is unique and individually evaluated for treatment, typically she uses pulsed dye laser, intense pulsed light, or broadband light therapy to treat erythematous/early scars; nonablative fractional lasers to treat atrophic scars, and the thulium or 1,470-nm laser to treat hyperpigmented scars. The “main course” device in her practice is an ablative fractional erbium or CO₂ laser.

“Once I treat the scar three to five times, I might switch to a nonablative laser, but I’m really an ablative fractional user,” Dr. Waibel said. “Dessert” can be whatever adjunctive therapies you need, she continued. This may include triamcinolone acetonide, 5-fluorouracil, poly-l-lactic acid, hyaluronidase, Z-plasty, punch biopsies, shave biopsies, compression, chemical reconstruction of skin scars (CROSS), and subcision.

For erythematous surgical and trauma scars, she uses a combination of pulsed dye laser and ablative fractional laser. “Same day, same treatment; one after each other,” she said. She favors using intense pulsed light for donor sites because it has filters that address both melanin and hemosiderin, superiority for scar erythema, and deeper penetration with greater speed to treat large surface areas.

One recent advance in the vascular arena is the new 595-nm pulsed dye laser by Candela, known as the VBeam Prima. It features increased energy, a 15-nm spot size, a zoom hand piece, once-a-day calibration, and contact cooling, which may be better for pigmented and possibly microvascular structures. The device is cleared for treating conditions like rosacea, acne, spider veins, port-wine stains, wrinkles, warts and stretch marks, as well as photoaging and benign pigmented lesions.

Dr. Waibel’s go-to device for treating a hypertrophic, hyperpigmented surgical scar is a 1927-nm or 1470-nm nonablative fractional laser, followed by a fractional ablative laser and injection of 1-2 ccs of 5-fluorouracil only to elevated areas. Hypopigmented scars are “by far the toughest to treat,” she said. However, she has a formula for these, too, and recently conducted a trial comparing the efficacy of nonablative fractional laser, ablative fractional laser, and ablative fractional laser followed by laser-assisted delivery of bimatoprost (Latisse) to treat hypopigmentation.

Surgical scars get better on their own in many cases, but sometimes early intervention is warranted. “Most surgeons will tell patients, ‘Wait a year. What you have [in terms of scar formation] is what you have,’” Dr. Waibel said. “If a surgical scar becomes hypertrophic, it does so within a month of surgery. I don’t prophylactically treat surgical scars unless the patient has had multiple surgeries in the same location with trouble healing. But if it’s been 6 months to a year, or if the patient is developing hypertrophic scars, then I will treat.”

Acne scars are challenging, because patients want to look good right away. “With deep scars, it takes several treatments to see good improvements,” she said. “I tell all my acne scar patients it takes a year [to get good results].”

Most burn patients require three to six treatment sessions, “but sometimes you get remarkable improvement sooner,” she said. “That’s due to the patient’s healing.” She and her associates recently completed an unpublished study that examined early intervention of fractional ablative laser versus control in 20 subjects with acute burn injuries who ranged in age from 18 to 80 years. The subjects underwent treatment with an ablative fractional CO₂ laser within 3 months of sustaining the burn injury, leaving an untreated control area for comparison. According to Dr. Waibel, 100% of the blinded physician evaluators graded the laser-treated area correctly, compared with the control area. In addition, a significant improvement in all points of the Manchester Scar Scale was observed in the laser-treated area. “The earlier you treat burn and trauma patients, the easier it is to get them back to normal,” she said.

Dr. Waibel disclosed that she has conducted clinical research for Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.

dbrunk@mdedge.com

SAN DIEGO – The development of ablative fractional lasers has revolutionized how dermatologists treat scars, according to Jill S. Waibel, MD.

“I tell patients it’s like boiling water in a tea kettle and watching the vapor form,” Dr. Waibel, a dermatologist with the Miami Dermatology and Laser Institute, said at the annual Masters of Aesthetics Symposium. “You literally ‘steam off’ their bad scar and the human body will heal that wound to almost normal skin. It’s the closest thing we have to a magic wand.”

In the not-too-distant past, dermatologists “were treating scars just to make them look better,” she said. However, thanks to groundbreaking work by clinicians at Naval Medical Center San Diego, the use of ablative fractional lasers to treat scars was found to improve range of motion in patients, as well as their pain and pruritus. “It represents a major innovation that heals in ways not previously possible,” said Dr. Waibel, who is also chief of dermatology at Baptist Hospital in Miami. “We’re not just healing the scar; we’re healing the skin back to its physiological normal place. A lot of these patients suffer quite a bit.”

Dr. Waibel likened her scar treatment approach to a three-course meal. Lesion color drives her choice of what device to use as an “appetizer” treatment. Most scars are either red (erythematous), brown (hyperpigmented), or white (hypopigmented). Though every scar is unique and individually evaluated for treatment, typically she uses pulsed dye laser, intense pulsed light, or broadband light therapy to treat erythematous/early scars; nonablative fractional lasers to treat atrophic scars, and the thulium or 1,470-nm laser to treat hyperpigmented scars. The “main course” device in her practice is an ablative fractional erbium or CO₂ laser.

“Once I treat the scar three to five times, I might switch to a nonablative laser, but I’m really an ablative fractional user,” Dr. Waibel said. “Dessert” can be whatever adjunctive therapies you need, she continued. This may include triamcinolone acetonide, 5-fluorouracil, poly-l-lactic acid, hyaluronidase, Z-plasty, punch biopsies, shave biopsies, compression, chemical reconstruction of skin scars (CROSS), and subcision.

For erythematous surgical and trauma scars, she uses a combination of pulsed dye laser and ablative fractional laser. “Same day, same treatment; one after each other,” she said. She favors using intense pulsed light for donor sites because it has filters that address both melanin and hemosiderin, superiority for scar erythema, and deeper penetration with greater speed to treat large surface areas.

One recent advance in the vascular arena is the new 595-nm pulsed dye laser by Candela, known as the VBeam Prima. It features increased energy, a 15-nm spot size, a zoom hand piece, once-a-day calibration, and contact cooling, which may be better for pigmented and possibly microvascular structures. The device is cleared for treating conditions like rosacea, acne, spider veins, port-wine stains, wrinkles, warts and stretch marks, as well as photoaging and benign pigmented lesions.

Dr. Waibel’s go-to device for treating a hypertrophic, hyperpigmented surgical scar is a 1927-nm or 1470-nm nonablative fractional laser, followed by a fractional ablative laser and injection of 1-2 ccs of 5-fluorouracil only to elevated areas. Hypopigmented scars are “by far the toughest to treat,” she said. However, she has a formula for these, too, and recently conducted a trial comparing the efficacy of nonablative fractional laser, ablative fractional laser, and ablative fractional laser followed by laser-assisted delivery of bimatoprost (Latisse) to treat hypopigmentation.

Surgical scars get better on their own in many cases, but sometimes early intervention is warranted. “Most surgeons will tell patients, ‘Wait a year. What you have [in terms of scar formation] is what you have,’” Dr. Waibel said. “If a surgical scar becomes hypertrophic, it does so within a month of surgery. I don’t prophylactically treat surgical scars unless the patient has had multiple surgeries in the same location with trouble healing. But if it’s been 6 months to a year, or if the patient is developing hypertrophic scars, then I will treat.”

Acne scars are challenging, because patients want to look good right away. “With deep scars, it takes several treatments to see good improvements,” she said. “I tell all my acne scar patients it takes a year [to get good results].”

Most burn patients require three to six treatment sessions, “but sometimes you get remarkable improvement sooner,” she said. “That’s due to the patient’s healing.” She and her associates recently completed an unpublished study that examined early intervention of fractional ablative laser versus control in 20 subjects with acute burn injuries who ranged in age from 18 to 80 years. The subjects underwent treatment with an ablative fractional CO₂ laser within 3 months of sustaining the burn injury, leaving an untreated control area for comparison. According to Dr. Waibel, 100% of the blinded physician evaluators graded the laser-treated area correctly, compared with the control area. In addition, a significant improvement in all points of the Manchester Scar Scale was observed in the laser-treated area. “The earlier you treat burn and trauma patients, the easier it is to get them back to normal,” she said.

Dr. Waibel disclosed that she has conducted clinical research for Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.

dbrunk@mdedge.com

SAN DIEGO – When it comes to treating pigmented lesions with laser and light, not all devices are created equal.

Victor Ross, MD, turns to the Q-switched alexandrite laser as his device of choice for most pigmented lesions. “I also use the Q-switched 1,064 nm Nd:YAG and sometimes use the Q-switched 532 nm Nd:YAG, particularly for lighter-skinned patients with lighter lesions,” he said at the annual Masters of Aesthetics Symposium.

Compared with long-pulsed devices, the Q-switched 532 nm neodymium:YAG laser is better for one-time pigment reduction and better for treating lighter pigmented spots, yet it’s associated with a higher risk of postinflammatory hyperpigmentation and short-term crusting. “The Q-switched 532 nm Nd:YAG laser will even treat very tight lentigines, but vascular effects tend to cause an immediate bright red color and more postinflammatory hyperpigmentation,” said Dr. Ross, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego. He cautioned that the Q-switched 532 nm Nd:YAG laser may cause prolonged redness on the legs and arms of some patients. “This laser is best reserved for lighter skinned patients with very light lentigines – the brisk purpura can prove distasteful short term for cosmetic patients,” he said. “For darker lentigines, I prefer the IPL [intense pulse light], KTP [potassium titanyl phosphate] laser, or Q-switched alexandrite lasers.”

Meanwhile, treating pigmented lesions treated with long-pulse IPL, KTP, and pulsed dye lasers show less risk of postinflammatory hyperpigmentation and better coverage rates. However, they are sensitive to background color and are less likely to achieve complete one-time removal. The first treatment works the best because the “low hanging fruit” (darker lesions) will do well, he said.

For clinicians looking to improve their skills in treating pigmented lesions with lasers, Dr. Ross recommended using a skin meter such as Cynosure’s Skintel Melanin Reader, which measures the real-time pigment of skin. “You measure the pigment, and it gives you a reading,” he said. “It gives you a recommended setting based on the hand piece and the pulse duration.”

Melasma remains a difficult condition to treat with laser and light. In fact, Dr. Ross joked that he wouldn’t mind if the words “He cured melasma” graced his tombstone one day. “I have been treating melasma patients for 29 years now, and I’m not closer to a cure than when I started out,” he said. “I’ve tried lots of things. In my defense, I’ve made more people better than worse.”

His approach to treating melasma is to begin with a KTP laser or a gentle IPL if discrete lesions or telangiectasia are present. Next, he applies hydroquinone followed by a series of treatment sessions with the Q-switched Nd:YAG laser or a conservative fractional laser. “This tends to induce remission, but is associated with a high rate of relapse,” he said.

Dr. Ross disclosed having research and financial ties to numerous pharmaceutical and device companies.

dbrunk@mdedge.com

SAN DIEGO – When it comes to treating pigmented lesions with laser and light, not all devices are created equal.

Victor Ross, MD, turns to the Q-switched alexandrite laser as his device of choice for most pigmented lesions. “I also use the Q-switched 1,064 nm Nd:YAG and sometimes use the Q-switched 532 nm Nd:YAG, particularly for lighter-skinned patients with lighter lesions,” he said at the annual Masters of Aesthetics Symposium.

Compared with long-pulsed devices, the Q-switched 532 nm neodymium:YAG laser is better for one-time pigment reduction and better for treating lighter pigmented spots, yet it’s associated with a higher risk of postinflammatory hyperpigmentation and short-term crusting. “The Q-switched 532 nm Nd:YAG laser will even treat very tight lentigines, but vascular effects tend to cause an immediate bright red color and more postinflammatory hyperpigmentation,” said Dr. Ross, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego. He cautioned that the Q-switched 532 nm Nd:YAG laser may cause prolonged redness on the legs and arms of some patients. “This laser is best reserved for lighter skinned patients with very light lentigines – the brisk purpura can prove distasteful short term for cosmetic patients,” he said. “For darker lentigines, I prefer the IPL [intense pulse light], KTP [potassium titanyl phosphate] laser, or Q-switched alexandrite lasers.”

Meanwhile, treating pigmented lesions treated with long-pulse IPL, KTP, and pulsed dye lasers show less risk of postinflammatory hyperpigmentation and better coverage rates. However, they are sensitive to background color and are less likely to achieve complete one-time removal. The first treatment works the best because the “low hanging fruit” (darker lesions) will do well, he said.

For clinicians looking to improve their skills in treating pigmented lesions with lasers, Dr. Ross recommended using a skin meter such as Cynosure’s Skintel Melanin Reader, which measures the real-time pigment of skin. “You measure the pigment, and it gives you a reading,” he said. “It gives you a recommended setting based on the hand piece and the pulse duration.”

Melasma remains a difficult condition to treat with laser and light. In fact, Dr. Ross joked that he wouldn’t mind if the words “He cured melasma” graced his tombstone one day. “I have been treating melasma patients for 29 years now, and I’m not closer to a cure than when I started out,” he said. “I’ve tried lots of things. In my defense, I’ve made more people better than worse.”

His approach to treating melasma is to begin with a KTP laser or a gentle IPL if discrete lesions or telangiectasia are present. Next, he applies hydroquinone followed by a series of treatment sessions with the Q-switched Nd:YAG laser or a conservative fractional laser. “This tends to induce remission, but is associated with a high rate of relapse,” he said.

Dr. Ross disclosed having research and financial ties to numerous pharmaceutical and device companies.

dbrunk@mdedge.com

SAN DIEGO – When it comes to treating pigmented lesions with laser and light, not all devices are created equal.

Victor Ross, MD, turns to the Q-switched alexandrite laser as his device of choice for most pigmented lesions. “I also use the Q-switched 1,064 nm Nd:YAG and sometimes use the Q-switched 532 nm Nd:YAG, particularly for lighter-skinned patients with lighter lesions,” he said at the annual Masters of Aesthetics Symposium.

Compared with long-pulsed devices, the Q-switched 532 nm neodymium:YAG laser is better for one-time pigment reduction and better for treating lighter pigmented spots, yet it’s associated with a higher risk of postinflammatory hyperpigmentation and short-term crusting. “The Q-switched 532 nm Nd:YAG laser will even treat very tight lentigines, but vascular effects tend to cause an immediate bright red color and more postinflammatory hyperpigmentation,” said Dr. Ross, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego. He cautioned that the Q-switched 532 nm Nd:YAG laser may cause prolonged redness on the legs and arms of some patients. “This laser is best reserved for lighter skinned patients with very light lentigines – the brisk purpura can prove distasteful short term for cosmetic patients,” he said. “For darker lentigines, I prefer the IPL [intense pulse light], KTP [potassium titanyl phosphate] laser, or Q-switched alexandrite lasers.”

Meanwhile, treating pigmented lesions treated with long-pulse IPL, KTP, and pulsed dye lasers show less risk of postinflammatory hyperpigmentation and better coverage rates. However, they are sensitive to background color and are less likely to achieve complete one-time removal. The first treatment works the best because the “low hanging fruit” (darker lesions) will do well, he said.

For clinicians looking to improve their skills in treating pigmented lesions with lasers, Dr. Ross recommended using a skin meter such as Cynosure’s Skintel Melanin Reader, which measures the real-time pigment of skin. “You measure the pigment, and it gives you a reading,” he said. “It gives you a recommended setting based on the hand piece and the pulse duration.”

Melasma remains a difficult condition to treat with laser and light. In fact, Dr. Ross joked that he wouldn’t mind if the words “He cured melasma” graced his tombstone one day. “I have been treating melasma patients for 29 years now, and I’m not closer to a cure than when I started out,” he said. “I’ve tried lots of things. In my defense, I’ve made more people better than worse.”

His approach to treating melasma is to begin with a KTP laser or a gentle IPL if discrete lesions or telangiectasia are present. Next, he applies hydroquinone followed by a series of treatment sessions with the Q-switched Nd:YAG laser or a conservative fractional laser. “This tends to induce remission, but is associated with a high rate of relapse,” he said.

Dr. Ross disclosed having research and financial ties to numerous pharmaceutical and device companies.

dbrunk@mdedge.com

SAN DIEGO – Noninvasive fat removal, such as laser treatment and cryolipolysis, is here to stay.

That’s what Mathew M. Avram, MD, JD, told attendees at the annual Masters of Aesthetics Symposium.

“It does not compare to liposuction, but many patients prefer these devices because there’s less downtime,” he said. “They don’t want pain. They don’t want time away from work.”

In the decade or so since the inception of the noninvasive body contouring field, noninvasive and minimally invasive devices have become far more popular than traditional liposuction, said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital in Boston. “It’s not even close. Among American Society for Dermatologic Surgery [ASDS] members, for every 1 liposuction, there are over 10 noninvasive body sculpting treatments.”

There were 408,000 body-sculpting procedures performed in 2017. More than half of those (208,000) were cryolipolysis, followed by use of radiofrequency (89,000), deoxycholic acid (46,000), laser lipolysis (25,000), “other” procedures (25,000), and tumescent liposuction (15,000), according to data from the ASDS.

“Each treatment has improved in efficacy with time,” Dr. Avram said.

Devices currently cleared by the Food and Drug Administration for the noninvasive removal of fat include ultrasound, lasers, low-level laser therapy, cryolipolysis, and radiofrequency. One of the most common is low-level laser therapy.

“There are several different devices on the market, but there’s no good histology to confirm mechanism of action, so you question what the efficacy is,” said Dr. Avram, who is also the immediate past president of the American Society for Laser Medicine and Surgery.

SculpSure

In the traditional laser domain, the one most commonly used for fat removal is SculpSure, an FDA-cleared hyperthermic 1,060-nm diode laser. It features four flat, nonsuction applicators, a contact cooling system, and it enables the user to treat more than one area in a 25-minute session. There is minimal absorption by melanin.

“You shouldn’t treat over tattoos, however, because if there’s black ink, the tattoo will absorb the wavelength,” Dr. Avram said. “It’s safe in all skin types and there are a variety of different configurations you can use to treat the desired area.”

Initially there is a 4-minute warm-up cycle to achieve the target temperature. Over the next 21 minutes, 1,060-nm energy is delivered via proprietary modulation, alternating between heat and cooling.

“There is definitely some pain with this device,” he said. “Whether or not it’s a relevant endpoint is not known at this point. But typically, if you’re destroying fat with heat there should be some pain. It’s relieved by a period of cooling. A submental fat treatment is now available. I have not personally used it, but it’s the same technology.”

CoolSculpting

Another popular technology is cryolipolysis (CoolSculpting), which was developed at Massachusetts General Hospital by R. Rox Anderson, MD, and Dieter Manstein, MD, PhD.

It’s FDA cleared for noninvasive fat removal and there have been more than 6 million cryolipolysis treatments performed around the world. The purported mechanism of action is selective crystallization of lipids and fat cells at temperatures below freezing. An inflammatory process results in fat reduction over 2-4 months.

“When it first started, cryolipolysis was designed to treat local areas like love handles in males,” Dr. Avram said. “Over time, applicators have been designed to treat different areas, most recently, one for the posterior upper arms and above the knees. There is now a larger, faster CoolSculpting applicator which results in a 35-minute treatment. It’s a little larger, there’s a little less pain, a lower temperature, and it’s a little bit more effective. This has been helpful in our practice in terms of getting more treatment cycles in a visit.”

Postprocedurally, massage may improve clinical results by mobilizing lipid crystals created from treatment.

Extracorporeal shock wave therapy

Another modality to consider is extracorporeal shock wave therapy, which is the application of mechanically generated external sound waves. “It’s not the same as ultrasound or focused ultrasound, and it’s FDA cleared for the treatment of cellulite,” Dr. Avram said.

EmSculpt

A newer innovation, known as High Intensity Focused Electromagnetic (HIFEM) technology (EmSculpt), induces 20,000 forced muscle contractions per session, which leads to supramaximal contractions that can’t be achieved through normal voluntary muscle action.

“The idea is that you’re getting hypertrophy of the muscle to get volumetric growth,” he said. “There’s believed to be a cascaded apoptotic effect, inducing apoptosis and fat disruption.”

Dr. Avram added that HIFEM is nonionizing, nonradiating, nonthermal, and it does not affect sensory nerves. “It’s designed to only stimulate motor neurons. Time will tell in terms of what the ultimate results are with that device.”

truSculpt

Some clinicians are using monopolar radiofrequency with truSculpt, the proprietary delivery of deep radiofrequency energy. This device increases fat temperature between 6 and 10 degrees Celsius with dual frequency at 1 and 2 MHz.

Published data show that 45 degrees Celsius sustained for 3 minutes resulted in a 60% loss of adipose tissue viability (Lasers Surg Med. 2009;41:745-50; Lasers Surg Med. 2010;42:361-70).

“The heat delivery induces cell apoptosis, leading to the removal of those cells by natural healing processes,” said Dr. Avram, who added that he has not used the device. “We need more clinical data to assess this as well.”

Selective photothermolysis

Another technology being evaluated for fat removal is selective photothermolysis, a concept developed at Massachusetts General Hospital in 1983. It extends the theory of selective photothermolysis to target the lipids that make up subcutaneous fat.

“The theory is that you must select a wavelength well absorbed by the target chromophore with a pulse duration shorter than the target’s thermal relaxation time,” Dr. Avram explained. “This produces selective, localized heating with focal destruction of the target with minimal damage to the surrounding tissue. It requires a deeply penetrating wavelength.”

Lipids are a tempting target “because they heat quickly and easily and they do not lose their heat easily to surrounding structures. You want to target fat selectively and confine thermal damage effectively,” he said.

Nearly 10 years ago, Dr. Avram and his associates evaluated the effects of noninvasive 1,210-nm laser exposure on the adipose tissue of 24 patients with skin types 1-5 (Laser Surg Med. 2009;41:401-7).

“The laser pulses were painful, which limited the efficacy,” he said.

The contact cooling device failed in some subjects, and two patients had bulla, but no scarring. Histologic evidence of laser-induced fat damage was observed in 89% of test sites at 4-7 weeks, but dermal damage was also seen.

“This was the first study to show histologic evidence of laser-induced damage to subcutaneous fat,” Dr. Avram said.

Development of selective photothermolysis technology fell off the wayside after the Great Recession of 2008, but it is still being evaluated at Massachusetts General Hospital and other centers.

To optimize the technology, Dr. Avram said that longer pulse durations may target larger volumes of fat. “Cooling is essential to protect the epidermis, as well as to control pain.”

Injectables

Injectables provide a new, minimally invasive means to achieve noninvasive fat removal, Dr. Avram noted.

“Many injectables of questionable efficacy and safety had been available internationally for years,” he said, but none had FDA clearance until 2015, when the agency gave ATX-101 (Kybella) the nod.

ATX-101 is a nonanimal-derived formulation of deoxycholic acid that causes preferential adipocytolysis. Data from a phase 3 trial presented at the 2014 American Society of Plastic Surgery and the American Society of Aesthetic Plastic Surgery meetings showed a statistically significant reduction in submental fat among subjects who received ATX-101, compared with placebo. It requires an average of 2-4 treatments.

“In my experience, it tends not to require that many, but based on MRI, as well as clinician and patient-reported outcomes, there are significant improvements in the visual impact of chin fat,” Dr. Avram said.

Most adverse events are mild to moderate in severity, primarily bruising, pain, and a sensation of numbness to the anesthesia. “They decrease in incidence and severity over successive treatments, and they infrequently lead to discontinuation of treatment,” he said.

For submental fat, clinicians can combine cryolipolysis and deoxycholic acid. “Here, the idea is to assess the amount of fat targeted for treatment,” Dr. Avram said. “If the fat fills the cryolipolysis cup, use cryolipolysis alone. If the fat does not fill the cup, inject deoxycholic acid for a more targeted treatment. If there is residual fat after cryolipolysis, consider treating more focally with deoxycholic acid.”

Both treatments can produce temporary marginal mandibular nerve injury. “It’s not common, but that’s something to include in your consent forms,” he said.

Dr. Avram reported that he has received consulting fees from Allergan, Merz Pharma, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis Biosystems, Invasix, and Zalea.

dbrunk@mdedge.com


 

SAN DIEGO – Noninvasive fat removal, such as laser treatment and cryolipolysis, is here to stay.

That’s what Mathew M. Avram, MD, JD, told attendees at the annual Masters of Aesthetics Symposium.

“It does not compare to liposuction, but many patients prefer these devices because there’s less downtime,” he said. “They don’t want pain. They don’t want time away from work.”

In the decade or so since the inception of the noninvasive body contouring field, noninvasive and minimally invasive devices have become far more popular than traditional liposuction, said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital in Boston. “It’s not even close. Among American Society for Dermatologic Surgery [ASDS] members, for every 1 liposuction, there are over 10 noninvasive body sculpting treatments.”

There were 408,000 body-sculpting procedures performed in 2017. More than half of those (208,000) were cryolipolysis, followed by use of radiofrequency (89,000), deoxycholic acid (46,000), laser lipolysis (25,000), “other” procedures (25,000), and tumescent liposuction (15,000), according to data from the ASDS.

“Each treatment has improved in efficacy with time,” Dr. Avram said.

Devices currently cleared by the Food and Drug Administration for the noninvasive removal of fat include ultrasound, lasers, low-level laser therapy, cryolipolysis, and radiofrequency. One of the most common is low-level laser therapy.

“There are several different devices on the market, but there’s no good histology to confirm mechanism of action, so you question what the efficacy is,” said Dr. Avram, who is also the immediate past president of the American Society for Laser Medicine and Surgery.

SculpSure

In the traditional laser domain, the one most commonly used for fat removal is SculpSure, an FDA-cleared hyperthermic 1,060-nm diode laser. It features four flat, nonsuction applicators, a contact cooling system, and it enables the user to treat more than one area in a 25-minute session. There is minimal absorption by melanin.

“You shouldn’t treat over tattoos, however, because if there’s black ink, the tattoo will absorb the wavelength,” Dr. Avram said. “It’s safe in all skin types and there are a variety of different configurations you can use to treat the desired area.”

Initially there is a 4-minute warm-up cycle to achieve the target temperature. Over the next 21 minutes, 1,060-nm energy is delivered via proprietary modulation, alternating between heat and cooling.

“There is definitely some pain with this device,” he said. “Whether or not it’s a relevant endpoint is not known at this point. But typically, if you’re destroying fat with heat there should be some pain. It’s relieved by a period of cooling. A submental fat treatment is now available. I have not personally used it, but it’s the same technology.”

CoolSculpting

Another popular technology is cryolipolysis (CoolSculpting), which was developed at Massachusetts General Hospital by R. Rox Anderson, MD, and Dieter Manstein, MD, PhD.

It’s FDA cleared for noninvasive fat removal and there have been more than 6 million cryolipolysis treatments performed around the world. The purported mechanism of action is selective crystallization of lipids and fat cells at temperatures below freezing. An inflammatory process results in fat reduction over 2-4 months.

“When it first started, cryolipolysis was designed to treat local areas like love handles in males,” Dr. Avram said. “Over time, applicators have been designed to treat different areas, most recently, one for the posterior upper arms and above the knees. There is now a larger, faster CoolSculpting applicator which results in a 35-minute treatment. It’s a little larger, there’s a little less pain, a lower temperature, and it’s a little bit more effective. This has been helpful in our practice in terms of getting more treatment cycles in a visit.”

Postprocedurally, massage may improve clinical results by mobilizing lipid crystals created from treatment.

Extracorporeal shock wave therapy

Another modality to consider is extracorporeal shock wave therapy, which is the application of mechanically generated external sound waves. “It’s not the same as ultrasound or focused ultrasound, and it’s FDA cleared for the treatment of cellulite,” Dr. Avram said.

EmSculpt

A newer innovation, known as High Intensity Focused Electromagnetic (HIFEM) technology (EmSculpt), induces 20,000 forced muscle contractions per session, which leads to supramaximal contractions that can’t be achieved through normal voluntary muscle action.

“The idea is that you’re getting hypertrophy of the muscle to get volumetric growth,” he said. “There’s believed to be a cascaded apoptotic effect, inducing apoptosis and fat disruption.”

Dr. Avram added that HIFEM is nonionizing, nonradiating, nonthermal, and it does not affect sensory nerves. “It’s designed to only stimulate motor neurons. Time will tell in terms of what the ultimate results are with that device.”

truSculpt

Some clinicians are using monopolar radiofrequency with truSculpt, the proprietary delivery of deep radiofrequency energy. This device increases fat temperature between 6 and 10 degrees Celsius with dual frequency at 1 and 2 MHz.

Published data show that 45 degrees Celsius sustained for 3 minutes resulted in a 60% loss of adipose tissue viability (Lasers Surg Med. 2009;41:745-50; Lasers Surg Med. 2010;42:361-70).

“The heat delivery induces cell apoptosis, leading to the removal of those cells by natural healing processes,” said Dr. Avram, who added that he has not used the device. “We need more clinical data to assess this as well.”

Selective photothermolysis

Another technology being evaluated for fat removal is selective photothermolysis, a concept developed at Massachusetts General Hospital in 1983. It extends the theory of selective photothermolysis to target the lipids that make up subcutaneous fat.

“The theory is that you must select a wavelength well absorbed by the target chromophore with a pulse duration shorter than the target’s thermal relaxation time,” Dr. Avram explained. “This produces selective, localized heating with focal destruction of the target with minimal damage to the surrounding tissue. It requires a deeply penetrating wavelength.”

Lipids are a tempting target “because they heat quickly and easily and they do not lose their heat easily to surrounding structures. You want to target fat selectively and confine thermal damage effectively,” he said.

Nearly 10 years ago, Dr. Avram and his associates evaluated the effects of noninvasive 1,210-nm laser exposure on the adipose tissue of 24 patients with skin types 1-5 (Laser Surg Med. 2009;41:401-7).

“The laser pulses were painful, which limited the efficacy,” he said.

The contact cooling device failed in some subjects, and two patients had bulla, but no scarring. Histologic evidence of laser-induced fat damage was observed in 89% of test sites at 4-7 weeks, but dermal damage was also seen.

“This was the first study to show histologic evidence of laser-induced damage to subcutaneous fat,” Dr. Avram said.

Development of selective photothermolysis technology fell off the wayside after the Great Recession of 2008, but it is still being evaluated at Massachusetts General Hospital and other centers.

To optimize the technology, Dr. Avram said that longer pulse durations may target larger volumes of fat. “Cooling is essential to protect the epidermis, as well as to control pain.”

Injectables

Injectables provide a new, minimally invasive means to achieve noninvasive fat removal, Dr. Avram noted.

“Many injectables of questionable efficacy and safety had been available internationally for years,” he said, but none had FDA clearance until 2015, when the agency gave ATX-101 (Kybella) the nod.

ATX-101 is a nonanimal-derived formulation of deoxycholic acid that causes preferential adipocytolysis. Data from a phase 3 trial presented at the 2014 American Society of Plastic Surgery and the American Society of Aesthetic Plastic Surgery meetings showed a statistically significant reduction in submental fat among subjects who received ATX-101, compared with placebo. It requires an average of 2-4 treatments.

“In my experience, it tends not to require that many, but based on MRI, as well as clinician and patient-reported outcomes, there are significant improvements in the visual impact of chin fat,” Dr. Avram said.

Most adverse events are mild to moderate in severity, primarily bruising, pain, and a sensation of numbness to the anesthesia. “They decrease in incidence and severity over successive treatments, and they infrequently lead to discontinuation of treatment,” he said.

For submental fat, clinicians can combine cryolipolysis and deoxycholic acid. “Here, the idea is to assess the amount of fat targeted for treatment,” Dr. Avram said. “If the fat fills the cryolipolysis cup, use cryolipolysis alone. If the fat does not fill the cup, inject deoxycholic acid for a more targeted treatment. If there is residual fat after cryolipolysis, consider treating more focally with deoxycholic acid.”

Both treatments can produce temporary marginal mandibular nerve injury. “It’s not common, but that’s something to include in your consent forms,” he said.

Dr. Avram reported that he has received consulting fees from Allergan, Merz Pharma, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis Biosystems, Invasix, and Zalea.

dbrunk@mdedge.com


 

SAN DIEGO – Noninvasive fat removal, such as laser treatment and cryolipolysis, is here to stay.

That’s what Mathew M. Avram, MD, JD, told attendees at the annual Masters of Aesthetics Symposium.

“It does not compare to liposuction, but many patients prefer these devices because there’s less downtime,” he said. “They don’t want pain. They don’t want time away from work.”

In the decade or so since the inception of the noninvasive body contouring field, noninvasive and minimally invasive devices have become far more popular than traditional liposuction, said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital in Boston. “It’s not even close. Among American Society for Dermatologic Surgery [ASDS] members, for every 1 liposuction, there are over 10 noninvasive body sculpting treatments.”

There were 408,000 body-sculpting procedures performed in 2017. More than half of those (208,000) were cryolipolysis, followed by use of radiofrequency (89,000), deoxycholic acid (46,000), laser lipolysis (25,000), “other” procedures (25,000), and tumescent liposuction (15,000), according to data from the ASDS.

“Each treatment has improved in efficacy with time,” Dr. Avram said.

Devices currently cleared by the Food and Drug Administration for the noninvasive removal of fat include ultrasound, lasers, low-level laser therapy, cryolipolysis, and radiofrequency. One of the most common is low-level laser therapy.

“There are several different devices on the market, but there’s no good histology to confirm mechanism of action, so you question what the efficacy is,” said Dr. Avram, who is also the immediate past president of the American Society for Laser Medicine and Surgery.

SculpSure

In the traditional laser domain, the one most commonly used for fat removal is SculpSure, an FDA-cleared hyperthermic 1,060-nm diode laser. It features four flat, nonsuction applicators, a contact cooling system, and it enables the user to treat more than one area in a 25-minute session. There is minimal absorption by melanin.

“You shouldn’t treat over tattoos, however, because if there’s black ink, the tattoo will absorb the wavelength,” Dr. Avram said. “It’s safe in all skin types and there are a variety of different configurations you can use to treat the desired area.”

Initially there is a 4-minute warm-up cycle to achieve the target temperature. Over the next 21 minutes, 1,060-nm energy is delivered via proprietary modulation, alternating between heat and cooling.

“There is definitely some pain with this device,” he said. “Whether or not it’s a relevant endpoint is not known at this point. But typically, if you’re destroying fat with heat there should be some pain. It’s relieved by a period of cooling. A submental fat treatment is now available. I have not personally used it, but it’s the same technology.”

CoolSculpting

Another popular technology is cryolipolysis (CoolSculpting), which was developed at Massachusetts General Hospital by R. Rox Anderson, MD, and Dieter Manstein, MD, PhD.

It’s FDA cleared for noninvasive fat removal and there have been more than 6 million cryolipolysis treatments performed around the world. The purported mechanism of action is selective crystallization of lipids and fat cells at temperatures below freezing. An inflammatory process results in fat reduction over 2-4 months.

“When it first started, cryolipolysis was designed to treat local areas like love handles in males,” Dr. Avram said. “Over time, applicators have been designed to treat different areas, most recently, one for the posterior upper arms and above the knees. There is now a larger, faster CoolSculpting applicator which results in a 35-minute treatment. It’s a little larger, there’s a little less pain, a lower temperature, and it’s a little bit more effective. This has been helpful in our practice in terms of getting more treatment cycles in a visit.”

Postprocedurally, massage may improve clinical results by mobilizing lipid crystals created from treatment.

Extracorporeal shock wave therapy

Another modality to consider is extracorporeal shock wave therapy, which is the application of mechanically generated external sound waves. “It’s not the same as ultrasound or focused ultrasound, and it’s FDA cleared for the treatment of cellulite,” Dr. Avram said.

EmSculpt

A newer innovation, known as High Intensity Focused Electromagnetic (HIFEM) technology (EmSculpt), induces 20,000 forced muscle contractions per session, which leads to supramaximal contractions that can’t be achieved through normal voluntary muscle action.

“The idea is that you’re getting hypertrophy of the muscle to get volumetric growth,” he said. “There’s believed to be a cascaded apoptotic effect, inducing apoptosis and fat disruption.”

Dr. Avram added that HIFEM is nonionizing, nonradiating, nonthermal, and it does not affect sensory nerves. “It’s designed to only stimulate motor neurons. Time will tell in terms of what the ultimate results are with that device.”

truSculpt

Some clinicians are using monopolar radiofrequency with truSculpt, the proprietary delivery of deep radiofrequency energy. This device increases fat temperature between 6 and 10 degrees Celsius with dual frequency at 1 and 2 MHz.

Published data show that 45 degrees Celsius sustained for 3 minutes resulted in a 60% loss of adipose tissue viability (Lasers Surg Med. 2009;41:745-50; Lasers Surg Med. 2010;42:361-70).

“The heat delivery induces cell apoptosis, leading to the removal of those cells by natural healing processes,” said Dr. Avram, who added that he has not used the device. “We need more clinical data to assess this as well.”

Selective photothermolysis

Another technology being evaluated for fat removal is selective photothermolysis, a concept developed at Massachusetts General Hospital in 1983. It extends the theory of selective photothermolysis to target the lipids that make up subcutaneous fat.

“The theory is that you must select a wavelength well absorbed by the target chromophore with a pulse duration shorter than the target’s thermal relaxation time,” Dr. Avram explained. “This produces selective, localized heating with focal destruction of the target with minimal damage to the surrounding tissue. It requires a deeply penetrating wavelength.”

Lipids are a tempting target “because they heat quickly and easily and they do not lose their heat easily to surrounding structures. You want to target fat selectively and confine thermal damage effectively,” he said.

Nearly 10 years ago, Dr. Avram and his associates evaluated the effects of noninvasive 1,210-nm laser exposure on the adipose tissue of 24 patients with skin types 1-5 (Laser Surg Med. 2009;41:401-7).

“The laser pulses were painful, which limited the efficacy,” he said.

The contact cooling device failed in some subjects, and two patients had bulla, but no scarring. Histologic evidence of laser-induced fat damage was observed in 89% of test sites at 4-7 weeks, but dermal damage was also seen.

“This was the first study to show histologic evidence of laser-induced damage to subcutaneous fat,” Dr. Avram said.

Development of selective photothermolysis technology fell off the wayside after the Great Recession of 2008, but it is still being evaluated at Massachusetts General Hospital and other centers.

To optimize the technology, Dr. Avram said that longer pulse durations may target larger volumes of fat. “Cooling is essential to protect the epidermis, as well as to control pain.”

Injectables

Injectables provide a new, minimally invasive means to achieve noninvasive fat removal, Dr. Avram noted.

“Many injectables of questionable efficacy and safety had been available internationally for years,” he said, but none had FDA clearance until 2015, when the agency gave ATX-101 (Kybella) the nod.

ATX-101 is a nonanimal-derived formulation of deoxycholic acid that causes preferential adipocytolysis. Data from a phase 3 trial presented at the 2014 American Society of Plastic Surgery and the American Society of Aesthetic Plastic Surgery meetings showed a statistically significant reduction in submental fat among subjects who received ATX-101, compared with placebo. It requires an average of 2-4 treatments.

“In my experience, it tends not to require that many, but based on MRI, as well as clinician and patient-reported outcomes, there are significant improvements in the visual impact of chin fat,” Dr. Avram said.

Most adverse events are mild to moderate in severity, primarily bruising, pain, and a sensation of numbness to the anesthesia. “They decrease in incidence and severity over successive treatments, and they infrequently lead to discontinuation of treatment,” he said.

For submental fat, clinicians can combine cryolipolysis and deoxycholic acid. “Here, the idea is to assess the amount of fat targeted for treatment,” Dr. Avram said. “If the fat fills the cryolipolysis cup, use cryolipolysis alone. If the fat does not fill the cup, inject deoxycholic acid for a more targeted treatment. If there is residual fat after cryolipolysis, consider treating more focally with deoxycholic acid.”

Both treatments can produce temporary marginal mandibular nerve injury. “It’s not common, but that’s something to include in your consent forms,” he said.

Dr. Avram reported that he has received consulting fees from Allergan, Merz Pharma, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis Biosystems, Invasix, and Zalea.

dbrunk@mdedge.com


 

SAN DIEGO – According to J. Stuart Nelson, MD, PhD, three general principles guide the laser treatment of vascular skin lesions. The first is to target blood vessels beneath the surface of the skin.

“You’re going to be using wavelengths of light generally in the green and yellow portion of the spectrum,” Dr. Nelson, professor of surgery and biomedical engineering at the Beckman Laser Institute and Medical Clinic at the University of California, Irvine, said at the annual Masters of Aesthetics Symposium. “Blue light is highly absorbed by hemoglobin but unfortunately, blue light is highly scattered by human skin, so it won’t penetrate deep enough into the dermis. So primarily, we’re targeting hemoglobin using green and yellow light sources.”

The second principle is to match the pulse width with the vessel size, while the third is to give sufficient energy to irreversibly injure vessels based on selective photothermolysis.

Next, he advised clinicians to ask themselves three questions: What is the vessel size? “The larger the vessel, the longer the thermal relaxation time,” he said. What is the vessel depth? Deeper vessels require longer wavelengths of light and larger spot sizes. What is the patient’s skin phototype? Darker skin contains more epidermal melanin and requires extra caution during treatment.

Dr. Nelson listed seven optimal devices for the treatment of vascular skin lesions: intense pulsed light (IPL) with wavelengths of 515-1,200 nm and pulse durations of 1-10 ms, pulsed green light with a wavelength of 532 nm and pulse durations of 1-50 ms, pulsed dye yellow light with wavelengths of 585-600 nm and pulse durations of 0.5-40 ms, pulsed dye plus Nd:YAG with wavelengths of 595 and 1,064 nm and pulse durations of 0.5-40 ms, alexandrite laser with a wavelength of 755 nm and pulse durations of 0.25-100 ms, diode laser with a wavelength of 940 nm and pulse durations of 5-100 ms, and the pulsed Nd:YAG laser with a wavelength of 1,064 nm and pulse durations of 0.25-100 ms.

“You can get good results with every one of these devices,” Dr. Nelson said. “What you need to do is pick one and become what R. Rox Anderson, MD, calls an ‘endpointologist,’ so you can understand the clinical endpoints. Do not use a cookbook approach by trying to memorize treatment settings.”

Pulsed dye lasers with a wavelength of 585-600 nm have been the standard of care for years, he said, and is the treatment of choice for port wine stains in infants and young children. Upsides include the ability to treat large areas quickly and the ability to use two to three separate passes. It also induces diminution in diffuse redness and telangiectasia. Drawbacks include its potential to cause purpura when short pulse durations are used, it requires several treatments, it can be painful, and it causes considerable edema and erythema.

Millisecond green lasers at a wavelength of 532 nm are also effective for treating vascular skin lesions. “The nice thing about these devices is that you can focus them down to very small spots, so you can literally trace out individual blood vessels,” Dr. Nelson said. Other upsides include the fact that it can be performed without producing purpura, only transient erythema if few areas are treated. Drawbacks are that it’s moderately painful and may cause considerable edema. It also causes significant melanin absorption so is not advised for use in tanned and darker-skinned individuals. For all patients, contact cooling must be assured.

IPL, meanwhile, “can be very useful for treating not only vascular lesions, but also concurrently pigmented lesions such as poikiloderma of Civatte,” Dr. Nelson said. Potential drawbacks to IPL therapy are that the spectrum of light emitted and the pulse duration characteristics vary between devices and multiple treatments are required.

Finally, in the millisecond domain, the pulsed alexandrite 755-nm and Nd:YAG 1,064-nm lasers “are very good when trying to target something very deep in the skin like a vein,” he said. “But when you’re using those devices, you’re coagulating a large volume of tissue, so you need to be very careful about the amount of heat that you’re generating deep in the skin.”

When consulting with patients who have rosacea or telangiectasia, Dr. Nelson tells them multiple treatments will be required. “These are chronic conditions, and they may need ongoing maintenance treatments. The nice thing about all these procedures you’re doing for rosacea and telangiectasia is that they can be combined with all of your FDA [Food and Drug Administration]-approved topical and oral treatment protocols. All of these drugs you have at your disposal to medically treat rosacea can be all used concurrently with your laser treatment. When you see a patient you need to emphasize to them: ‘I’m not treating your rosacea with the laser. I’m treating a symptom of your rosacea with the laser.’ ”

Dr. Nelson closed his presentation by offering basic principles for success, the first being do no harm. “That’s the single most important thing you want to remember. No one will get mad if the blood vessel’s still there, but they’ll get very mad if something bad happens. You also want to underpromise and overdeliver. I always tell patients it’s going to require two to four treatments. When in doubt, don’t treat or undertreat. You can always treat again.”

If you’re concerned, perform a test spot. “There’s nothing wrong with that, particularly in a patient where you’re not sure what the outcome will be,” he said. “Check for any unusual skin reaction and for potential success of the procedure. Finally, don’t treat patients who are tanned.”

Dr. Nelson reported having intellectual property rights with Syneron Candela.

dbrunk@mdedge.com

SAN DIEGO – According to J. Stuart Nelson, MD, PhD, three general principles guide the laser treatment of vascular skin lesions. The first is to target blood vessels beneath the surface of the skin.

“You’re going to be using wavelengths of light generally in the green and yellow portion of the spectrum,” Dr. Nelson, professor of surgery and biomedical engineering at the Beckman Laser Institute and Medical Clinic at the University of California, Irvine, said at the annual Masters of Aesthetics Symposium. “Blue light is highly absorbed by hemoglobin but unfortunately, blue light is highly scattered by human skin, so it won’t penetrate deep enough into the dermis. So primarily, we’re targeting hemoglobin using green and yellow light sources.”

The second principle is to match the pulse width with the vessel size, while the third is to give sufficient energy to irreversibly injure vessels based on selective photothermolysis.

Next, he advised clinicians to ask themselves three questions: What is the vessel size? “The larger the vessel, the longer the thermal relaxation time,” he said. What is the vessel depth? Deeper vessels require longer wavelengths of light and larger spot sizes. What is the patient’s skin phototype? Darker skin contains more epidermal melanin and requires extra caution during treatment.

Dr. Nelson listed seven optimal devices for the treatment of vascular skin lesions: intense pulsed light (IPL) with wavelengths of 515-1,200 nm and pulse durations of 1-10 ms, pulsed green light with a wavelength of 532 nm and pulse durations of 1-50 ms, pulsed dye yellow light with wavelengths of 585-600 nm and pulse durations of 0.5-40 ms, pulsed dye plus Nd:YAG with wavelengths of 595 and 1,064 nm and pulse durations of 0.5-40 ms, alexandrite laser with a wavelength of 755 nm and pulse durations of 0.25-100 ms, diode laser with a wavelength of 940 nm and pulse durations of 5-100 ms, and the pulsed Nd:YAG laser with a wavelength of 1,064 nm and pulse durations of 0.25-100 ms.

“You can get good results with every one of these devices,” Dr. Nelson said. “What you need to do is pick one and become what R. Rox Anderson, MD, calls an ‘endpointologist,’ so you can understand the clinical endpoints. Do not use a cookbook approach by trying to memorize treatment settings.”

Pulsed dye lasers with a wavelength of 585-600 nm have been the standard of care for years, he said, and is the treatment of choice for port wine stains in infants and young children. Upsides include the ability to treat large areas quickly and the ability to use two to three separate passes. It also induces diminution in diffuse redness and telangiectasia. Drawbacks include its potential to cause purpura when short pulse durations are used, it requires several treatments, it can be painful, and it causes considerable edema and erythema.

Millisecond green lasers at a wavelength of 532 nm are also effective for treating vascular skin lesions. “The nice thing about these devices is that you can focus them down to very small spots, so you can literally trace out individual blood vessels,” Dr. Nelson said. Other upsides include the fact that it can be performed without producing purpura, only transient erythema if few areas are treated. Drawbacks are that it’s moderately painful and may cause considerable edema. It also causes significant melanin absorption so is not advised for use in tanned and darker-skinned individuals. For all patients, contact cooling must be assured.

IPL, meanwhile, “can be very useful for treating not only vascular lesions, but also concurrently pigmented lesions such as poikiloderma of Civatte,” Dr. Nelson said. Potential drawbacks to IPL therapy are that the spectrum of light emitted and the pulse duration characteristics vary between devices and multiple treatments are required.

Finally, in the millisecond domain, the pulsed alexandrite 755-nm and Nd:YAG 1,064-nm lasers “are very good when trying to target something very deep in the skin like a vein,” he said. “But when you’re using those devices, you’re coagulating a large volume of tissue, so you need to be very careful about the amount of heat that you’re generating deep in the skin.”

When consulting with patients who have rosacea or telangiectasia, Dr. Nelson tells them multiple treatments will be required. “These are chronic conditions, and they may need ongoing maintenance treatments. The nice thing about all these procedures you’re doing for rosacea and telangiectasia is that they can be combined with all of your FDA [Food and Drug Administration]-approved topical and oral treatment protocols. All of these drugs you have at your disposal to medically treat rosacea can be all used concurrently with your laser treatment. When you see a patient you need to emphasize to them: ‘I’m not treating your rosacea with the laser. I’m treating a symptom of your rosacea with the laser.’ ”

Dr. Nelson closed his presentation by offering basic principles for success, the first being do no harm. “That’s the single most important thing you want to remember. No one will get mad if the blood vessel’s still there, but they’ll get very mad if something bad happens. You also want to underpromise and overdeliver. I always tell patients it’s going to require two to four treatments. When in doubt, don’t treat or undertreat. You can always treat again.”

If you’re concerned, perform a test spot. “There’s nothing wrong with that, particularly in a patient where you’re not sure what the outcome will be,” he said. “Check for any unusual skin reaction and for potential success of the procedure. Finally, don’t treat patients who are tanned.”

Dr. Nelson reported having intellectual property rights with Syneron Candela.

dbrunk@mdedge.com

SAN DIEGO – According to J. Stuart Nelson, MD, PhD, three general principles guide the laser treatment of vascular skin lesions. The first is to target blood vessels beneath the surface of the skin.

“You’re going to be using wavelengths of light generally in the green and yellow portion of the spectrum,” Dr. Nelson, professor of surgery and biomedical engineering at the Beckman Laser Institute and Medical Clinic at the University of California, Irvine, said at the annual Masters of Aesthetics Symposium. “Blue light is highly absorbed by hemoglobin but unfortunately, blue light is highly scattered by human skin, so it won’t penetrate deep enough into the dermis. So primarily, we’re targeting hemoglobin using green and yellow light sources.”

The second principle is to match the pulse width with the vessel size, while the third is to give sufficient energy to irreversibly injure vessels based on selective photothermolysis.

Next, he advised clinicians to ask themselves three questions: What is the vessel size? “The larger the vessel, the longer the thermal relaxation time,” he said. What is the vessel depth? Deeper vessels require longer wavelengths of light and larger spot sizes. What is the patient’s skin phototype? Darker skin contains more epidermal melanin and requires extra caution during treatment.

Dr. Nelson listed seven optimal devices for the treatment of vascular skin lesions: intense pulsed light (IPL) with wavelengths of 515-1,200 nm and pulse durations of 1-10 ms, pulsed green light with a wavelength of 532 nm and pulse durations of 1-50 ms, pulsed dye yellow light with wavelengths of 585-600 nm and pulse durations of 0.5-40 ms, pulsed dye plus Nd:YAG with wavelengths of 595 and 1,064 nm and pulse durations of 0.5-40 ms, alexandrite laser with a wavelength of 755 nm and pulse durations of 0.25-100 ms, diode laser with a wavelength of 940 nm and pulse durations of 5-100 ms, and the pulsed Nd:YAG laser with a wavelength of 1,064 nm and pulse durations of 0.25-100 ms.

“You can get good results with every one of these devices,” Dr. Nelson said. “What you need to do is pick one and become what R. Rox Anderson, MD, calls an ‘endpointologist,’ so you can understand the clinical endpoints. Do not use a cookbook approach by trying to memorize treatment settings.”

Pulsed dye lasers with a wavelength of 585-600 nm have been the standard of care for years, he said, and is the treatment of choice for port wine stains in infants and young children. Upsides include the ability to treat large areas quickly and the ability to use two to three separate passes. It also induces diminution in diffuse redness and telangiectasia. Drawbacks include its potential to cause purpura when short pulse durations are used, it requires several treatments, it can be painful, and it causes considerable edema and erythema.

Millisecond green lasers at a wavelength of 532 nm are also effective for treating vascular skin lesions. “The nice thing about these devices is that you can focus them down to very small spots, so you can literally trace out individual blood vessels,” Dr. Nelson said. Other upsides include the fact that it can be performed without producing purpura, only transient erythema if few areas are treated. Drawbacks are that it’s moderately painful and may cause considerable edema. It also causes significant melanin absorption so is not advised for use in tanned and darker-skinned individuals. For all patients, contact cooling must be assured.

IPL, meanwhile, “can be very useful for treating not only vascular lesions, but also concurrently pigmented lesions such as poikiloderma of Civatte,” Dr. Nelson said. Potential drawbacks to IPL therapy are that the spectrum of light emitted and the pulse duration characteristics vary between devices and multiple treatments are required.

Finally, in the millisecond domain, the pulsed alexandrite 755-nm and Nd:YAG 1,064-nm lasers “are very good when trying to target something very deep in the skin like a vein,” he said. “But when you’re using those devices, you’re coagulating a large volume of tissue, so you need to be very careful about the amount of heat that you’re generating deep in the skin.”

When consulting with patients who have rosacea or telangiectasia, Dr. Nelson tells them multiple treatments will be required. “These are chronic conditions, and they may need ongoing maintenance treatments. The nice thing about all these procedures you’re doing for rosacea and telangiectasia is that they can be combined with all of your FDA [Food and Drug Administration]-approved topical and oral treatment protocols. All of these drugs you have at your disposal to medically treat rosacea can be all used concurrently with your laser treatment. When you see a patient you need to emphasize to them: ‘I’m not treating your rosacea with the laser. I’m treating a symptom of your rosacea with the laser.’ ”

Dr. Nelson closed his presentation by offering basic principles for success, the first being do no harm. “That’s the single most important thing you want to remember. No one will get mad if the blood vessel’s still there, but they’ll get very mad if something bad happens. You also want to underpromise and overdeliver. I always tell patients it’s going to require two to four treatments. When in doubt, don’t treat or undertreat. You can always treat again.”

If you’re concerned, perform a test spot. “There’s nothing wrong with that, particularly in a patient where you’re not sure what the outcome will be,” he said. “Check for any unusual skin reaction and for potential success of the procedure. Finally, don’t treat patients who are tanned.”

Dr. Nelson reported having intellectual property rights with Syneron Candela.

dbrunk@mdedge.com

SAN DIEGO – Of all the data points featured in a 2017 survey on cosmetic dermatologic procedures, one stands out to Jean Carruthers, MD: Among the 7,322 consumers surveyed, about 70% cited the lower face and submental contour as a significant cosmetic and social concern.

“That is quite a key statistic,” she said at the annual Masters of Aesthetics Symposium. The Consumer Survey on Cosmetic Dermatologic Procedures was conducted by the American Society for Dermatologic Surgery.

Dr. Carruthers, who, with her husband, Alastair Carruthers, MD, pioneered the cosmetic use of onabotulinumtoxinA (Botox), said that the world’s great sculptors “think that there is a difference between the classical faces of males and females, and we all know instinctually what those changes are, with a square face and larger jawline in males and a smooth oval, heart-shaped face in women,” she said.

“But what about the neck?” She cited an article by Greg J. Goodman, MD, and colleagues, which defined an ideal neck as the distinct inferior mandibular border from mentum to angle with no jowl overhang (Dermatol Surg 2016;42:S260-2). It includes subhyoid depression, which visually enhances the impression that the neck is thin and long; visible thyroid cartilage bulge; a visible anterior border of the sternocleidomastoid muscle, distinct in its entire course from the mastoid to the sternum; and a cervicomental angle between 105 and 120 degrees. An angle greater than 120 degrees appears as a double chin or heavy neck, according to the authors.

In the past, clinicians used to think of the lower face and neck as two separate cosmetic units, but now they are considered one cosmetic unit, said Dr. Carruthers, of the University of British Columbia, Vancouver. “Don’t forget the platysma muscle,” she added. “The platysma is a lower facial muscle of expression and it affects all the other muscles. It interdigitates with the depressor anguli oris, with orbicularis oris, and depressor labii inferioris muscles, and it goes backwards into the masseter muscle.”

She and two Brazilian investigators published a retrospective analysis of 161 patients treated by a Botox injection pattern encompassing the facial platysma components, aiming to block the lower face as a whole complex (Dermatol Surg. 2017;43[8]:1042-9). According to the article, results included “frontal and lateral enhancement of lower facial contour, relaxation of high horizontal lines located just below the lateral mandibular border, and lower deep vertical smile lines present lateral to the oral commissures and melomental folds.”

Fillers and tightening the face and neck envelope without surgery takes maintenance, Dr. Carruthers said. She also noted that deoxycholic acid works on jowls as well as submental fat. Noninvasive combinations for lower face and neck include neuromodulators and deep and superficial fillers, cryolipolysis and deoxycholic acid, energy-based devices, and microneedling. “I think that these are fantastic combinations, and they don’t have to all be done at the same time on the same day,” Dr. Carruthers said. “I’m very impressed with cryolipolysis as the unheralded skin tightener. I looked at our first 464 patients and saw tremendous skin tightening.”

Of all the injectable products on the market, she said that neuromodulators “have set a new gold standard for all aesthetic treatments. It’s the most powerful primary aesthetic modulator and enhances the result of everything else that you do.”

Dr. Carruthers disclosed that she is a consultant to and has received research support from Allergan, Alphaeon, Bonti, Merz, Revance, and Zeltiq.

dbrunk@mdedge.com

SAN DIEGO – Of all the data points featured in a 2017 survey on cosmetic dermatologic procedures, one stands out to Jean Carruthers, MD: Among the 7,322 consumers surveyed, about 70% cited the lower face and submental contour as a significant cosmetic and social concern.

“That is quite a key statistic,” she said at the annual Masters of Aesthetics Symposium. The Consumer Survey on Cosmetic Dermatologic Procedures was conducted by the American Society for Dermatologic Surgery.

Dr. Carruthers, who, with her husband, Alastair Carruthers, MD, pioneered the cosmetic use of onabotulinumtoxinA (Botox), said that the world’s great sculptors “think that there is a difference between the classical faces of males and females, and we all know instinctually what those changes are, with a square face and larger jawline in males and a smooth oval, heart-shaped face in women,” she said.

“But what about the neck?” She cited an article by Greg J. Goodman, MD, and colleagues, which defined an ideal neck as the distinct inferior mandibular border from mentum to angle with no jowl overhang (Dermatol Surg 2016;42:S260-2). It includes subhyoid depression, which visually enhances the impression that the neck is thin and long; visible thyroid cartilage bulge; a visible anterior border of the sternocleidomastoid muscle, distinct in its entire course from the mastoid to the sternum; and a cervicomental angle between 105 and 120 degrees. An angle greater than 120 degrees appears as a double chin or heavy neck, according to the authors.

In the past, clinicians used to think of the lower face and neck as two separate cosmetic units, but now they are considered one cosmetic unit, said Dr. Carruthers, of the University of British Columbia, Vancouver. “Don’t forget the platysma muscle,” she added. “The platysma is a lower facial muscle of expression and it affects all the other muscles. It interdigitates with the depressor anguli oris, with orbicularis oris, and depressor labii inferioris muscles, and it goes backwards into the masseter muscle.”

She and two Brazilian investigators published a retrospective analysis of 161 patients treated by a Botox injection pattern encompassing the facial platysma components, aiming to block the lower face as a whole complex (Dermatol Surg. 2017;43[8]:1042-9). According to the article, results included “frontal and lateral enhancement of lower facial contour, relaxation of high horizontal lines located just below the lateral mandibular border, and lower deep vertical smile lines present lateral to the oral commissures and melomental folds.”

Fillers and tightening the face and neck envelope without surgery takes maintenance, Dr. Carruthers said. She also noted that deoxycholic acid works on jowls as well as submental fat. Noninvasive combinations for lower face and neck include neuromodulators and deep and superficial fillers, cryolipolysis and deoxycholic acid, energy-based devices, and microneedling. “I think that these are fantastic combinations, and they don’t have to all be done at the same time on the same day,” Dr. Carruthers said. “I’m very impressed with cryolipolysis as the unheralded skin tightener. I looked at our first 464 patients and saw tremendous skin tightening.”

Of all the injectable products on the market, she said that neuromodulators “have set a new gold standard for all aesthetic treatments. It’s the most powerful primary aesthetic modulator and enhances the result of everything else that you do.”

Dr. Carruthers disclosed that she is a consultant to and has received research support from Allergan, Alphaeon, Bonti, Merz, Revance, and Zeltiq.

dbrunk@mdedge.com

SAN DIEGO – Of all the data points featured in a 2017 survey on cosmetic dermatologic procedures, one stands out to Jean Carruthers, MD: Among the 7,322 consumers surveyed, about 70% cited the lower face and submental contour as a significant cosmetic and social concern.

“That is quite a key statistic,” she said at the annual Masters of Aesthetics Symposium. The Consumer Survey on Cosmetic Dermatologic Procedures was conducted by the American Society for Dermatologic Surgery.

Dr. Carruthers, who, with her husband, Alastair Carruthers, MD, pioneered the cosmetic use of onabotulinumtoxinA (Botox), said that the world’s great sculptors “think that there is a difference between the classical faces of males and females, and we all know instinctually what those changes are, with a square face and larger jawline in males and a smooth oval, heart-shaped face in women,” she said.

“But what about the neck?” She cited an article by Greg J. Goodman, MD, and colleagues, which defined an ideal neck as the distinct inferior mandibular border from mentum to angle with no jowl overhang (Dermatol Surg 2016;42:S260-2). It includes subhyoid depression, which visually enhances the impression that the neck is thin and long; visible thyroid cartilage bulge; a visible anterior border of the sternocleidomastoid muscle, distinct in its entire course from the mastoid to the sternum; and a cervicomental angle between 105 and 120 degrees. An angle greater than 120 degrees appears as a double chin or heavy neck, according to the authors.

In the past, clinicians used to think of the lower face and neck as two separate cosmetic units, but now they are considered one cosmetic unit, said Dr. Carruthers, of the University of British Columbia, Vancouver. “Don’t forget the platysma muscle,” she added. “The platysma is a lower facial muscle of expression and it affects all the other muscles. It interdigitates with the depressor anguli oris, with orbicularis oris, and depressor labii inferioris muscles, and it goes backwards into the masseter muscle.”

She and two Brazilian investigators published a retrospective analysis of 161 patients treated by a Botox injection pattern encompassing the facial platysma components, aiming to block the lower face as a whole complex (Dermatol Surg. 2017;43[8]:1042-9). According to the article, results included “frontal and lateral enhancement of lower facial contour, relaxation of high horizontal lines located just below the lateral mandibular border, and lower deep vertical smile lines present lateral to the oral commissures and melomental folds.”

Fillers and tightening the face and neck envelope without surgery takes maintenance, Dr. Carruthers said. She also noted that deoxycholic acid works on jowls as well as submental fat. Noninvasive combinations for lower face and neck include neuromodulators and deep and superficial fillers, cryolipolysis and deoxycholic acid, energy-based devices, and microneedling. “I think that these are fantastic combinations, and they don’t have to all be done at the same time on the same day,” Dr. Carruthers said. “I’m very impressed with cryolipolysis as the unheralded skin tightener. I looked at our first 464 patients and saw tremendous skin tightening.”

Of all the injectable products on the market, she said that neuromodulators “have set a new gold standard for all aesthetic treatments. It’s the most powerful primary aesthetic modulator and enhances the result of everything else that you do.”

Dr. Carruthers disclosed that she is a consultant to and has received research support from Allergan, Alphaeon, Bonti, Merz, Revance, and Zeltiq.

dbrunk@mdedge.com

SAN DIEGO – The way Doris Day, MD, sees it, before establishing a professional presence on Facebook, Twitter, YouTube, or any other social media channel, the first question to ask yourself is why.

“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”

Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”

She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”

According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.

dbrunk@mdedge.com

SAN DIEGO – The way Doris Day, MD, sees it, before establishing a professional presence on Facebook, Twitter, YouTube, or any other social media channel, the first question to ask yourself is why.

“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”

Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”

She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”

According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.

dbrunk@mdedge.com

SAN DIEGO – The way Doris Day, MD, sees it, before establishing a professional presence on Facebook, Twitter, YouTube, or any other social media channel, the first question to ask yourself is why.

“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”

Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”

She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”

According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.

dbrunk@mdedge.com

SAN DIEGO – Picosecond lasers have surpassed Q-switched lasers as the treatment of choice for tattoo removal, delivering high energies in trillionths of a second.

Dr. Amanda Champlain

“A picosecond is to a second as 1 second is to 37,000 years,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “That’s equivalent to the total energy of the city of San Diego for 300-750 trillionths of a second.”

According to Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, picosecond lasers produce extreme cavitation and cell rupture, with a desired clinical endpoint of immediate dermal whitening of tattooed skin. The process causes transdermal elimination of the tattoo ink. Some of the ink flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.

Commercially available picosecond lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 picoseconds. Nd:YAG lasers work best for red and black ink, while alexandrite lasers work best for green and blue ink. In Dr. Avram’s experience, picosecond lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There is some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos, but the devices are more expensive,” he said.

Dr. Avram, who is also the faculty director for laser and cosmetic dermatology training at Harvard Medical School, also in Boston, advises against promising a certain number of laser treatments during initial patient consultations. “You will regret it,” he said. “Tattoos are notoriously unpredictable in how they respond. I often hear people say they get rid of these in three to five treatments. That isn’t my experience with these lasers. Often, all you’re going to be able to do is get significant clearing rather than tattoo removal. Professional tattoos are the most difficult to treat because they are the deepest and they have the most amount of ink.”

On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos require far fewer treatments. “The color is important,” he said. “Multicolored tattoos, regardless of the colors, are always going to be more difficult to clear than a single-color tattoo.” Black and dark-blue tattoos respond best to laser light; light-blue and green also respond well. Red responds well, while purple can be challenging. Yellow and orange do not respond very well, but they do respond partially.

According to a trial that analyzed variables influencing the outcome of tattoos treated by Q-switched lasers, 47% were cleared after 10 sessions, while 75% were cleared after 15 sessions (Arch Dermatol 2012;148[12]:1364-9). “It’s very important to message to your patients how many treatments this might take, because there is going to be an annuity of patients who are unhappy because they have to keep coming back,” said Dr. Avram, who is the immediate past president of the American Society for Laser Medicine and Surgery. Skin type and pigmentation also affect treatment outcomes. “For darker skin types or tanned individuals, hyper- or hypopigmentation is a greater concern than in patients with lighter skin types,” he said. “A test spot may be beneficial. The 1,064-nm Q-switched Nd:YAG laser is least likely to affect skin pigment; it’s safest for skin types IV-VI . This is great if it’s a black tattoo. But if it’s a green, blue, or red tattoo, you have a problem because you’re not going to target it very effectively.”

Some degree of posttreatment hypopigmentation is likely to occur, regardless of skin type. “Let patients know this is going to happen, but over time, this usually resolves, because you’re not destroying the melanocytes, unless you’re going too strong,” Dr. Avram said. “It may take a few months. It may take a year or 2, but the pigment should recur.”

He emphasized that the key variable during laser treatment of tattoos is the clinical endpoint, not the energy setting of the device. “What you want to see is immediate whitening of the treated area,” he said. “With the 1,064-nm Nd:YAG, you may get a little pinpoint bleeding in addition to whitening. Do not memorize treatment settings. Many Q-switched lasers are not externally calibrated. Thus, energy levels may change day to day or before and after servicing [of the device]. Trust your eyes; trust your clinical skills.” If you see epidermal disruption and bleeding during treatment, you’re probably being too aggressive. If that happens, “decrease your fluence,” he recommended. “You also want to decrease fluences when treating tattoos that are placed over other tattoos.”

Another rule of thumb is to use larger spot sizes during treatment sessions. “The larger the spot size, the more efficient the energy is going to get more deeply, and less is going to be at the dermal-epidermal junction,” Dr. Avram said. “So you’re going to get less hypopigmentation and less hyperpigmentation. Follow your endpoints and you are less likely to get pigmentation changes.”

Posttreatment care typically includes the application of topical petroleum jelly and a Telfa dressing. “Wait about a week to heal, counsel patients to keep out of the sun, and avoid friction to the treated area during healing,” he said. Patients can be rescheduled for retreatment 6-8 weeks later.

Common adverse events during laser treatment of tattoos include erythema, blistering, hyperpigmentation, hypopigmentation, and scarring, which occurs in about 5% of cases. Less common adverse events include allergic reaction, darkening of cosmetic tattoos, immune reaction, and chrysiasis, which is a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold salt ingestion. “Any history of gold salt ingestion will produce this characteristic finding, even if they took it when they were 5 years old and they come to you when they’re 85,” Dr. Avram said. “All of our intake forms include a question about this, and before I treat patients I always ask if they have a history of gold ingestion, because it’s very difficult to treat.”

Surgical excision may be an alternative for smaller tattoos. “Another option is ablative fractional resurfacing as a solo treatment or in combination with the Q-switched or picosecond laser, which has better efficacy,” he said. “The ablative fractional laser also may help with fibrosis after multiple treatments in a recalcitrant tattoo.” He noted that cosmetic tattoos such as lip liner and blush tattoos might darken because of oxidation of ferric oxide or titanium oxide pigment. The best approach to such cases is to perform an inconspicuous test spot prior to treatment.

Clinicians continue to explore the optimal interval between treatments. For example, the “R20” method consists of four consecutive treatment passes separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol 2012;66[2]:271-7). A follow-up study by Dr. Avram and his colleagues contradicted these findings, while another follow-up study was supportive.

Another technology playing a role in such repeat treatments is a perfluorodecalin-infused silicone patch, which is placed over the treatment area. According to Dr. Avram, the FDA-cleared patch helps reduce scatter during treatment and likely improves efficacy. It also allows for performing consecutive repeat laser treatments at the same visit. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side treated without the patch (Laser Surg Med 2015;47[8]:613-8).

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.

dbrunk@mdedge.com





 

SAN DIEGO – Picosecond lasers have surpassed Q-switched lasers as the treatment of choice for tattoo removal, delivering high energies in trillionths of a second.

Dr. Amanda Champlain

“A picosecond is to a second as 1 second is to 37,000 years,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “That’s equivalent to the total energy of the city of San Diego for 300-750 trillionths of a second.”

According to Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, picosecond lasers produce extreme cavitation and cell rupture, with a desired clinical endpoint of immediate dermal whitening of tattooed skin. The process causes transdermal elimination of the tattoo ink. Some of the ink flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.

Commercially available picosecond lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 picoseconds. Nd:YAG lasers work best for red and black ink, while alexandrite lasers work best for green and blue ink. In Dr. Avram’s experience, picosecond lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There is some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos, but the devices are more expensive,” he said.

Dr. Avram, who is also the faculty director for laser and cosmetic dermatology training at Harvard Medical School, also in Boston, advises against promising a certain number of laser treatments during initial patient consultations. “You will regret it,” he said. “Tattoos are notoriously unpredictable in how they respond. I often hear people say they get rid of these in three to five treatments. That isn’t my experience with these lasers. Often, all you’re going to be able to do is get significant clearing rather than tattoo removal. Professional tattoos are the most difficult to treat because they are the deepest and they have the most amount of ink.”

On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos require far fewer treatments. “The color is important,” he said. “Multicolored tattoos, regardless of the colors, are always going to be more difficult to clear than a single-color tattoo.” Black and dark-blue tattoos respond best to laser light; light-blue and green also respond well. Red responds well, while purple can be challenging. Yellow and orange do not respond very well, but they do respond partially.

According to a trial that analyzed variables influencing the outcome of tattoos treated by Q-switched lasers, 47% were cleared after 10 sessions, while 75% were cleared after 15 sessions (Arch Dermatol 2012;148[12]:1364-9). “It’s very important to message to your patients how many treatments this might take, because there is going to be an annuity of patients who are unhappy because they have to keep coming back,” said Dr. Avram, who is the immediate past president of the American Society for Laser Medicine and Surgery. Skin type and pigmentation also affect treatment outcomes. “For darker skin types or tanned individuals, hyper- or hypopigmentation is a greater concern than in patients with lighter skin types,” he said. “A test spot may be beneficial. The 1,064-nm Q-switched Nd:YAG laser is least likely to affect skin pigment; it’s safest for skin types IV-VI . This is great if it’s a black tattoo. But if it’s a green, blue, or red tattoo, you have a problem because you’re not going to target it very effectively.”

Some degree of posttreatment hypopigmentation is likely to occur, regardless of skin type. “Let patients know this is going to happen, but over time, this usually resolves, because you’re not destroying the melanocytes, unless you’re going too strong,” Dr. Avram said. “It may take a few months. It may take a year or 2, but the pigment should recur.”

He emphasized that the key variable during laser treatment of tattoos is the clinical endpoint, not the energy setting of the device. “What you want to see is immediate whitening of the treated area,” he said. “With the 1,064-nm Nd:YAG, you may get a little pinpoint bleeding in addition to whitening. Do not memorize treatment settings. Many Q-switched lasers are not externally calibrated. Thus, energy levels may change day to day or before and after servicing [of the device]. Trust your eyes; trust your clinical skills.” If you see epidermal disruption and bleeding during treatment, you’re probably being too aggressive. If that happens, “decrease your fluence,” he recommended. “You also want to decrease fluences when treating tattoos that are placed over other tattoos.”

Another rule of thumb is to use larger spot sizes during treatment sessions. “The larger the spot size, the more efficient the energy is going to get more deeply, and less is going to be at the dermal-epidermal junction,” Dr. Avram said. “So you’re going to get less hypopigmentation and less hyperpigmentation. Follow your endpoints and you are less likely to get pigmentation changes.”

Posttreatment care typically includes the application of topical petroleum jelly and a Telfa dressing. “Wait about a week to heal, counsel patients to keep out of the sun, and avoid friction to the treated area during healing,” he said. Patients can be rescheduled for retreatment 6-8 weeks later.

Common adverse events during laser treatment of tattoos include erythema, blistering, hyperpigmentation, hypopigmentation, and scarring, which occurs in about 5% of cases. Less common adverse events include allergic reaction, darkening of cosmetic tattoos, immune reaction, and chrysiasis, which is a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold salt ingestion. “Any history of gold salt ingestion will produce this characteristic finding, even if they took it when they were 5 years old and they come to you when they’re 85,” Dr. Avram said. “All of our intake forms include a question about this, and before I treat patients I always ask if they have a history of gold ingestion, because it’s very difficult to treat.”

Surgical excision may be an alternative for smaller tattoos. “Another option is ablative fractional resurfacing as a solo treatment or in combination with the Q-switched or picosecond laser, which has better efficacy,” he said. “The ablative fractional laser also may help with fibrosis after multiple treatments in a recalcitrant tattoo.” He noted that cosmetic tattoos such as lip liner and blush tattoos might darken because of oxidation of ferric oxide or titanium oxide pigment. The best approach to such cases is to perform an inconspicuous test spot prior to treatment.

Clinicians continue to explore the optimal interval between treatments. For example, the “R20” method consists of four consecutive treatment passes separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol 2012;66[2]:271-7). A follow-up study by Dr. Avram and his colleagues contradicted these findings, while another follow-up study was supportive.

Another technology playing a role in such repeat treatments is a perfluorodecalin-infused silicone patch, which is placed over the treatment area. According to Dr. Avram, the FDA-cleared patch helps reduce scatter during treatment and likely improves efficacy. It also allows for performing consecutive repeat laser treatments at the same visit. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side treated without the patch (Laser Surg Med 2015;47[8]:613-8).

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.

dbrunk@mdedge.com





 

SAN DIEGO – Picosecond lasers have surpassed Q-switched lasers as the treatment of choice for tattoo removal, delivering high energies in trillionths of a second.

Dr. Amanda Champlain

“A picosecond is to a second as 1 second is to 37,000 years,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “That’s equivalent to the total energy of the city of San Diego for 300-750 trillionths of a second.”

According to Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, picosecond lasers produce extreme cavitation and cell rupture, with a desired clinical endpoint of immediate dermal whitening of tattooed skin. The process causes transdermal elimination of the tattoo ink. Some of the ink flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.

Commercially available picosecond lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 picoseconds. Nd:YAG lasers work best for red and black ink, while alexandrite lasers work best for green and blue ink. In Dr. Avram’s experience, picosecond lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There is some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos, but the devices are more expensive,” he said.

Dr. Avram, who is also the faculty director for laser and cosmetic dermatology training at Harvard Medical School, also in Boston, advises against promising a certain number of laser treatments during initial patient consultations. “You will regret it,” he said. “Tattoos are notoriously unpredictable in how they respond. I often hear people say they get rid of these in three to five treatments. That isn’t my experience with these lasers. Often, all you’re going to be able to do is get significant clearing rather than tattoo removal. Professional tattoos are the most difficult to treat because they are the deepest and they have the most amount of ink.”

On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos require far fewer treatments. “The color is important,” he said. “Multicolored tattoos, regardless of the colors, are always going to be more difficult to clear than a single-color tattoo.” Black and dark-blue tattoos respond best to laser light; light-blue and green also respond well. Red responds well, while purple can be challenging. Yellow and orange do not respond very well, but they do respond partially.

According to a trial that analyzed variables influencing the outcome of tattoos treated by Q-switched lasers, 47% were cleared after 10 sessions, while 75% were cleared after 15 sessions (Arch Dermatol 2012;148[12]:1364-9). “It’s very important to message to your patients how many treatments this might take, because there is going to be an annuity of patients who are unhappy because they have to keep coming back,” said Dr. Avram, who is the immediate past president of the American Society for Laser Medicine and Surgery. Skin type and pigmentation also affect treatment outcomes. “For darker skin types or tanned individuals, hyper- or hypopigmentation is a greater concern than in patients with lighter skin types,” he said. “A test spot may be beneficial. The 1,064-nm Q-switched Nd:YAG laser is least likely to affect skin pigment; it’s safest for skin types IV-VI . This is great if it’s a black tattoo. But if it’s a green, blue, or red tattoo, you have a problem because you’re not going to target it very effectively.”

Some degree of posttreatment hypopigmentation is likely to occur, regardless of skin type. “Let patients know this is going to happen, but over time, this usually resolves, because you’re not destroying the melanocytes, unless you’re going too strong,” Dr. Avram said. “It may take a few months. It may take a year or 2, but the pigment should recur.”

He emphasized that the key variable during laser treatment of tattoos is the clinical endpoint, not the energy setting of the device. “What you want to see is immediate whitening of the treated area,” he said. “With the 1,064-nm Nd:YAG, you may get a little pinpoint bleeding in addition to whitening. Do not memorize treatment settings. Many Q-switched lasers are not externally calibrated. Thus, energy levels may change day to day or before and after servicing [of the device]. Trust your eyes; trust your clinical skills.” If you see epidermal disruption and bleeding during treatment, you’re probably being too aggressive. If that happens, “decrease your fluence,” he recommended. “You also want to decrease fluences when treating tattoos that are placed over other tattoos.”

Another rule of thumb is to use larger spot sizes during treatment sessions. “The larger the spot size, the more efficient the energy is going to get more deeply, and less is going to be at the dermal-epidermal junction,” Dr. Avram said. “So you’re going to get less hypopigmentation and less hyperpigmentation. Follow your endpoints and you are less likely to get pigmentation changes.”

Posttreatment care typically includes the application of topical petroleum jelly and a Telfa dressing. “Wait about a week to heal, counsel patients to keep out of the sun, and avoid friction to the treated area during healing,” he said. Patients can be rescheduled for retreatment 6-8 weeks later.

Common adverse events during laser treatment of tattoos include erythema, blistering, hyperpigmentation, hypopigmentation, and scarring, which occurs in about 5% of cases. Less common adverse events include allergic reaction, darkening of cosmetic tattoos, immune reaction, and chrysiasis, which is a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold salt ingestion. “Any history of gold salt ingestion will produce this characteristic finding, even if they took it when they were 5 years old and they come to you when they’re 85,” Dr. Avram said. “All of our intake forms include a question about this, and before I treat patients I always ask if they have a history of gold ingestion, because it’s very difficult to treat.”

Surgical excision may be an alternative for smaller tattoos. “Another option is ablative fractional resurfacing as a solo treatment or in combination with the Q-switched or picosecond laser, which has better efficacy,” he said. “The ablative fractional laser also may help with fibrosis after multiple treatments in a recalcitrant tattoo.” He noted that cosmetic tattoos such as lip liner and blush tattoos might darken because of oxidation of ferric oxide or titanium oxide pigment. The best approach to such cases is to perform an inconspicuous test spot prior to treatment.

Clinicians continue to explore the optimal interval between treatments. For example, the “R20” method consists of four consecutive treatment passes separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol 2012;66[2]:271-7). A follow-up study by Dr. Avram and his colleagues contradicted these findings, while another follow-up study was supportive.

Another technology playing a role in such repeat treatments is a perfluorodecalin-infused silicone patch, which is placed over the treatment area. According to Dr. Avram, the FDA-cleared patch helps reduce scatter during treatment and likely improves efficacy. It also allows for performing consecutive repeat laser treatments at the same visit. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side treated without the patch (Laser Surg Med 2015;47[8]:613-8).

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.

dbrunk@mdedge.com