Laser treatment of tattoo and benign pigmented

12/7/2014
WHAT IS NEW IN LASER PIGMENT
REMOVAL
Ashraf Badawi, MD, PhD
Dermatology Department
Laser Institute, Cairo University
Egypt
Laser Consultant,
Oakville, Canada
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CHALLENGES IN TREATING PIGMENTED
LESIONS WITH LASERS
• Resistance
• Recurrence
• Complications
• High/ Unrealistic Patient expectations
• Limited indications of the devices
• Low profitability
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WHEN ARE WE MORE PROFITABLE??
• Able to provide Efficient & Safe treatments
• Know the limits
• Extend the applications of our devices in an
ethical and successful way
• Be able to give our patients realistic expectations
ROLE OF APPROPRIATE PATIENT SELECTION
100
patients
80
20 
30
60 
27 
3
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Benign pigmented lesions
I- Epidermal Lesions
( Courtesy of S. Saracoglu, Turkey)
* Lentigines
* Freckles
* Café au lait macules
* Nevus spilus
* Seborrheic keratoses
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II- Dermal Lesions
* Nevus of Ota
* Nevus of Ito
* Blue Nevus
Before
After
N.I.L.E.S.
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• Best is Qsw 1064nm for deeper penetration.
• Large number of sessions (6-8).
• Delayed response.
III- Dermal - Epidermal Lesions
* Melasma
* Post inflam. hyperpig.
* Becker`s nevus
* Compound nevi
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MECHANISM OF ACTION OF
Q-SW LASERS
a. Absorption
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b. Fragmentation
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...
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c. Phagocytosis
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Worsening
before
improvement
6-8 weeks
interval
between
sessions
After 1 session
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After 2 sessions
Sun protection and
bleaching agents
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CAFE AU LAIT MACULE
before
After 1 session
• Café’ au Lait birthmarks usually respond
to laser treatment, but recurrence within
one year is seen in most of the lesions.
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Before
Immediately After
TATTOO ON UPPER ARM
Before
Immediately After
Aft. 5 sessions
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Tattoo on chest wall
Before
After 1 session
Immediately After
After 5 sessions N.I.L.E.S.
BECKER’S NEVUS
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• Post-inflammatory
hyperpigmentation and melasma respond
unpredictably to laser treatment,
with
the
lesion
darkening,
lightening or not changing at all.
Repigmentation is the role!!
PRETREATMENT PRECAUTIONS
- Any suspicious lesion has not to be treated
except after taking a biopsy.
- Complete surgical removal of atypical nevi is
often recommended specially if they undergo
changes in appearance.
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GIANT PIGMENTED HAIRY NEVUS
N.I.L.E.S.
Cosmetic Eye Brow tattoo
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TRIALS TO IMPROVE THE OUTCOME OF THE Q
SW LASERS
• Different Q SW lasers in the same session
• Q SW laser + Diascopy
• R20
• Q SW + Fractional Er:YAG
• Picosecond lasers
• Fractional Q SW lasers
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Black: NdYAG 1064 nm
Violet and Yellow:
KTP
532 nm
Light Blue:
Yellow 585 nm
5th treatment in 6 months time
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Before
After 10 Tx in nearly 2 years time
GREEN TONING
• For Rejuvenation targeting photodamage
(Dyschromia)
• 2 passes:
1064 nm, 2 J/cm2, 8mm, 8 Hz
532nm, 0.2 J/cm2, 8 mm, 8 Hz
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Indications
* Melasma
* Vascular melasma
* Dermal/epidermal pigmented lesions.
1M After Tx2
Courtesy of A. Bartram Goodall, BodyRecon, Geelong
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Courtesy of A. Bartram Goodall, BodyRecon, Geelong
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After 3 sessions
Diascopy
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• By applying a glass slide in such a way the
dermis is essentially compressed:
i) the capillary plexus blood and some of the
extra-cellular water is squeezed out of the
region
ii) the tattoo pigment is physically nearer to the
skin surface.
• The energy density (fluence) incident on
the pigment is, consequently, higher than
without the skin compression.
• The drop in fluence within the dermis due
to scattering is reduced by shortening the
optical path to the pigments.
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“R20” Method (2012)
Concept:
1 visit,
4 passes,
separated 20 minutes
(clearance of frosting
effect)
Problems:
too long sessions
too painfull
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Combined Fract. Er:YAG + Q-s
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Combined Fract. Er:YAG + Q-s
After the fractional
Er:YAG „priming“ of
tattoo
After the first Q-s
pass
After Er:YAG, tattoo is treated with several
(up to four) Q-s passes
Before
After Tx1
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After Tx5
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Presented at ASLMS 2013 (Boston) and
Cosmetex 2013 (Melbourne)
Study:
11 patients
split tattoos
full tattoo Er:YAG
2 Qs passes vs. 3 Qs passes
Findings:
efficacy better than with
conventional technique
low contribution of 3rd pass
procedure quicker and less
painfull than R20
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2 sessions of combined
Er:YAG & Q SW 1064
3 sessions of Q SW 1064
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Permanent make-up removal
Q-switch Nd:YAG and Er:YAG
1st pass, Fractional Er:YAG,
2nd pass, 532 nm KTP
3rd pass immediately after, 1064 nm Nd:YAG
Before
Courtesy of dr. J. Kozarev
After 2 sessions
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SUB-NANOSECOND PICO
TECHNOLOGY
PicoSure
Alex (755 nm)
700 - 900 ps
Maximal energy of only 200 mJ,
thus limiting its operation with
fluences sufficient for only smaller
spot sizes.
Cutera
Enlighten
Nd:YAG (1064nm)
and KTP (532 nm)
750 ps, 2 ns
New on the market
Currently not yet available in the US
Parameters and stability of the system?
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PICO STORY
• Price?
• Stability?
• Power?
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SUB-NANOSECOND (PICO) AND Q-S PULSE
DURATION ISSUE
Pico theory is trying to prove that there are significant differences between
pico and nano in two mechansims involved in the breaking of pigments:
Photo-thermal and Photo-mechanical effects
There are no noticeable difference
between psec and nsec pulses
in the thermal effect: plasma formation is
indepenedent of pulse duration in
absorptive targets [2]
It was not possible to find a
difference in the shattering effect
even with much shorter pulses
(35 psec)[1]
[1] Ross V, et al. Comparison of Responses of Tattoos to Picisecond and nanosecond Q-Swithced Nd:YAG Lasers, Arch.Derm, Vol.134, Feb1998
[2] Oraevsky AA, Da Silva LB, Rubenchik AM, Feit MD, Glinsky ME, Perry MD, Mammini BM, Small W, Stuart BC, Plasma mediated ablation of
biological tissues with nanosecond-to-femtosecond laser pulses: relative role of linear and nonlinear absorption, IEEE J Select Top Q Electr, Vol 2,
No. 4, 1996; 801-809
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Fractional Q-s
Applications
Two basically different technologies
Focused
fractional
Patterned
ZV, VER 3.2, OCTOBER 2008
Low
Fluence
Low
Fluence
1-5 J/cm2
High
Fluence
Low
Fluence
1-5 J/cm2
10-50 J/cm2
(even up to several hundred J/cm2)
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Combined Q-switch fractional
and Q-s for tattoo removal
1 step:
Q-switch
fractional
Ablation, to drill the „holes“
2 step:
Q-switch
full beam
Removal of the pigment
Benefit:
* Enhances the clearance
* A certain amount of pigment is already removed with the first pass
without a shield effect
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NEW INDICATIONS
• Hair Removal (Shaving)
• Tichostasis Spinulosa
• Non Ablative Rejuvenation
• Carbon peel
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• Use of a topical suspension of carbon particles
followed by treatment with a Q-switched Nd:YAG
laser was the first laser treatment for hair removal the
Food and Drug Administration (FDA) approved.
• This initial method reportedly delayed re-growth by 3
months, but it did not provide permanent hair
reduction.
3 MONTH POST OP
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PARAMETERS
• 1064 nm
• 6 mm
• 2.5 – 3.0 J/cm2
• 5-10 Hz
• End point: Hair bleaching
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ADVANTAGES
• Minimal pain
• Minimal side effects
• Quick
• Any Skin type
• No shaving required
TRICHOSTASIS SPINULOSA
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REJUVENATION
MILD ACNE SCARRING
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CARBON PEEL
• For Generalized Rejuvenation and for
shrinking skin pores
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IN CONCLUSION
• Laser assisted treatment of benign
pigmented lesions is still under evolution.
• More evidence and clinical studies are
required to improve the outcome.
• Patient selection and education remains a
key to success.
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