Ilanit Samuels, PA-C

Baumann Cosmetic and Research Institute

Miami, Florida
 Financial Disclosures
 Supervising Physician, Dr Leslie Baumann, CEO- Skin
Type Solutions Franchise Systems LLC, who has close
relationship with 40+ skin care brands and has
preformed research trials for 55+ companies.

 Served as trainer and speaker for companies such as

Allergan, Merz, and Suneva Medical, as well as a Sub-
Investigator on many FDA trails for these, and many
other companies.
 Other Disclosures
Cosmetic Lasers at BCRI:
• Vbeam Perfecta- Candela
• Alex Trivantage- Candela
• Limelight/Nd:YAG- Cutera
• Gentlelase- Candela
 What are Lasers?
• Light Amplification by Stimulated Emission of
Radiation
• Lasers emit one wavelength of light
• Functions by: photothermolysis
 photo = light
 thermo = heat
 lysis = destroy
 4 Basic Laser Parameters
• Wavelength
• Pulse duration
• Spot size
• Fluence
 Lasing Medium
 The lasing Medium inside the laser is the substance that
produces the laser beam (aka: “energy source”)
This could be:
GAS (argon, krypton, CO2)
SOLID (ruby crystals, alexandrite crystals, Nd:Yag)
LIQUID (dye)

•The lasing medium determines the wavelength of the laser.

 Wavelengths
 The distance between 2 peaks
 Measured in nanometers
 Shorter wavelength = more superficial penetration
 Longer wavelength = deeper penetration

 Inverse relationship:
 Shorter wavelength = Higher energy

• Wavelengths must be consistent with target/color

 Targets include redness (hemoglobin) and brown spots (melanin)
Depth of Penetration
 Fluence
• Measured in Joules (J)
• Fluence = energy per area
• As fluence increases, so does the destructive force of
the energy
• Typical fluences vary between 3 and 150 J/cm2.
• The relationship between fluence and spot size is
important.
 Spot Size
• Large spot size = deeper penetration/ decreased scatter
• Small spot size = more energy absorbed in superficial
structures/ increased scatter
 Pulse Duration
• How quickly the energy is delivered to the tissues.
• Longer the pulse, the more gentle heating of target.
• Measured in milliseconds (ms).

*pouring analogy
Repetition Rate
• The number of pulses emitted per second
• Measured in Hz
 Fitzpatrick Scale
• The Fitzpatrick scale (also Fitzpatrick skin typing
test; or Fitzpatrick phototyping scale) is a numerical
classification schema for human skin color
• It was developed in 1975 by Thomas B. Fitzpatrick as
a way to estimate the response of different types of
skin to ultraviolet (UV) light
• Items of consideration include, eye color, hair color,
affinity to tan or burn
Fitzpatrick Scale
 Laser Safety
• Proper eye protection must be worn at all times when
a laser is armed by both staff and patients, or anyone
in the room!
• Each laser utilizes different wavelengths, be sure to
check your wavelength against your eye protection.
• Each set of glasses has a range of wavelengths that is
protected which is printed on the lens.
Laser Safety
Patient Protection
 Laser Location
• The location of the laser is crucial, as they cannot be
in rooms with windows.
• No mirrors in treatment room.
• The door must display a warning sign.
• The door must not permit the transmission of
wavelengths through the door.
• There must be a set of glasses outside of the door.
 Laser Candidates
• Not all lasers are safe for every skin tone (mechanism
of action will determine safety)
• Utilization of the Fitzpatrick schema can be helpful in
determining candidacy
• Patient history and skin aliments must be taken into
consideration as well (Melasma, keloid tendency)
 Vascular Lasers
 To be effective, vascular lasers/light sources must be
wavelength preferentially absorbed by blood vessels
 Absorption of energy is by oxyhemoglobin and
reduced hemoglobin
 Major absorption peaks around 532, 595 and 1064nm

Types:
- Pulse Dye Laser (595nm)
- KTP (532nm)
 Hemoglobin
 The molecule that holds oxygen in red blood cells.
Responsible for the red color of broken or prominent
blood vessels on the skin. Dilated vessels full of
hemoglobin also lead to diffuse redness seen in
rosacea.
 Pulsed Dye Laser- 595nm
Wavelength of 595nm passes through the dermis and epidermis
skin layers and is absorbed by the oxyhemoglobin in the blood
vessels rather than by the surrounding tissue.

Used to target:
• Redness (diffuse facial/Rosacea)
• Scars (before turning white)
• Telangiectasias
• Bruises
• Cherry angiomas
• Improve skin texture
• Psoriasis
• Benign pigmented lesions
• Safe for Fitzpatricks 1-3 (595)
Other Clinical Applications:
 Capillary malformations
 Hemangiomas
 Venous malformations
 Facial erythema
 Venous lakes
 Poikiloderma of Civatte
 Others: adenoma sebacea, hypertrophic and
erythematous scars, striae distensae, warts
 PDL
 Selective Photothermolysis - The process of targeting a
specific chromophore. PDL targets oxyhemoglobin.
Ideally, the wavelength selected for eradiation of
vascular lesions is highly absorbed by the lesion and
only minimally absorbed by other competing
chromophores in the skin.
 Pulse Duration - By varying the pulse duration,
treatments can be performed purpurically (with
bruising) by rupturing the blood vessel, or sub-
purpurically by slowly heating the vessel causing
coagulation of the blood vessel.
 Selective Photothermolysis
 Wavelength can destroy a target containing the
adequate chromophore without damaging the
surrounding tissue. This is possible if the thermal
relaxation time of the target is longer than the
duration of the laser pulse.
 PDL
 The shorter the pulse duration the more destructive the
energy becomes, while with the longer pulse durations, the
energy is more gentle thus causing coagulation of the
target without harming structures around the treated area.
 For coagulation and treatments without purpura, the laser
pulse duration should be shorter than the thermal
relaxation time of the target absorbing the laser radiation
in order to confine the thermal damage and spare
surrounding tissue. The relaxation time of a target is
determined by the target's size (milliseconds or greater for
vascular lesions).
 KTP
 KTP Lasers (532nm) is a solid-state laser that uses a
potassium titanyl phosphate (KTP) crystal as its
frequencing doubling device. The KTP crystal is
engaged by a beam generated by a neodynium:yitrium
aluminium garnet (Nd: YAG) laser.

 Typical KTP Laser

 100u-2 mm spot size
 No cooling
 Low Energy Delivery Systems
 Rosacea
• Laser is not a cure for rosacea
• Requires multiple treatments, spaced one month apart
• Maintenance therapy may also be needed depending
on rosacea severity
• Can use a laser to improve cosmetic appearance
 Blood Vessels and Angiomas
 Vessels respond best when on the face, neck, and chest
 Cherry angiomas are often treatable in 1-2 sessions
 Bruises
 PDL does not completely eradicate bruising
 Helps bruises clear more quickly (24-72 hours post-
procedure)
 Bruise should still be purple/red for best results
 Scars
• For healed, scars pink in appearance
• White scars are not eligible
• May take multiple treatments
• Advise patient that treatment area will become dark
directly after treatment
 Warts
 Both a general and cosmetic dermatology issue
 Effective therapy in conjunction with at-home
treatments
 Works by heating up blood vessels of the wart
 Tattoo Removal Lasers
• Used for pigmented lesions and tattoo removal
• Painful
• Compounded numbing cream to be applied for at least 20
minutes pre-procedure
• Targets: black/blue/green/red/brown (tattoo or pigmented
lesions). Also used for removal of traumatic tattoos such as
graphite or lead, and solar lentigines.
• Alexandrite medium; 532nm (reds), 755nm & 1064nm (blacks)
• Q-switch technology – ultra-short energy bursts lead to
mechanical damage (as opposed to heat) to target – epidermal
damage and dye destruction
• Multiple wavelengths up to 1064 and multiple spot sizes make it
safer for skin of color
 “Q-Switched”
 • Quality switched (Q-switched) lasers allow for the
generation of nanosecond-range laser pulses
 • Pulses result in rapid thermal expansion and
fragmentation of the target
 Three standard nanosecond lasers regularly used in
removal include: :
 • ruby (694nm); 20-40 nanosecond pulse duration
• Nd:YAG (532,1064nm); 5-40ns
• alexandrite (755nm); 50-100ns
 Success with these pulse durations can take an average
of six to ten tattoo txs, but possibly as many as twenty
treatments or more to achieve optimal clearance, often
with prolonged downtime.
 PicoSecond
 Newer technology
 Picosecond Pulse Duration
 Generates higher mechanical stress in target without
increased heating
 Rapid delivery results in a shock wave reverberating
inward
 Improved recovery time with better treatment
outcomes likely due to less collateral injury of
surrounding tissue.
 Tattoo Removal Lasers Cont.
• Use ice throughout procedure and for 10 minutes
post- procedure (prior to applying occlusive dressing
and aquaphor)
• Melanosome rupture can lead to hypopigmentation
(side effect)
• Aftercare: Aquaphor/Vaseline/Neosporin 2xs per day
with occlusive dressing on area. Changed regularly
until healed, sun protection daily
• Treatments every 6 weeks
• Requires multiple treatments
 Intense Pulse Light
 Lasers and IPLs have been used for permanent hair
reduction and skin rejuvenation treatments for many
years. Although both IPL and Laser are light-based
technologies, there are distinct differences between
the two. Lasers use a single wavelength of coherent
light while IPLs utilize various wavelengths of
incoherent light.
 IPL VS Laser
 Incoherent Light: (IPL) is emitted by normal means such as
a flashlight or a bulb. The photons of the many wave
frequencies of light are oscillating in different directions,
therefore photons will dissipate before reaching the follicle.
 Coherent Light: (true laser) is a beam of photons (almost
like particles of light waves) that have the same frequency
and are all at the same frequency. Only a beam of laser light
will not spread and diffuse. In genuine lasers, waves are
identical and in phase, which produces a beam of coherent
light. To achieve best results for laser hair removal,
coherent light is best in order to accurately target the
follicle.
 IPL
• IPL= Intense pulsed light
• Utilizes a light source (not Genuine laser)
• Treats brown spots/uneven pigmentation and reds/
vascular lesions. Can aslo be used for LHR.
• Wavelength 520-1100nm
• For skin types I, II, III – not safe for skin of color
• Sun protection 2 weeks before and after treatment are
crucial
• Crusting/”coffee ground” dark spots are NORMAL after
treatment and should not be picked off – will come off
within 2 weeks
 IPL Mechanism of Action
 Targets hemoglobin and melanin simultaneously, best
for people with uneven skin tone from sun damage and
redness. Also destroys hair follicle (caution!!)
 Laser Hair Removal
 Wavelength: Longer (scatter less) Deeper
penetration (Less Epidermal damage)
 Long Pulsed:
 Ruby Laser —- (694 nm)
 Alexandrite Laser —- (755 nm)
 Pulsed diode Laser —- (800 nm)
 Long Pulsed Nd: YAG —- (1064 nm)
 Flashlamp system —- (515 – 1200 nm)
 Nd:YAG
• LHR, safe and effective for all skin types (used on
darker skin types more often at BCRI)
• Application of numbing cream for at least 20 minutes
• Application of ultrasound cooling gel pre procedure
• Tip of hand piece is cold to help promote comfort
during procedure
 Nd:YAG Cont.
• LHR for all skin types (safe on dark skin)
• Will take multiple treatments (6+), spaced 4-6 weeks apart
• Good option for those with tendency towards ingrown
hairs
• Shaving or trimming in between treatments is okay – no
tweezing, threading, or waxing
• Patients should shave 1-2 days before treatment
• The YAG penetrates the deepest of all the lasers (up to
7mm)
• Does not focus on melanin
• Destroys the hair follicle with heat
 Alex-755nm
• Safe for Fitzpatrick I-III
• Detachable spot size/ lens
• Utilizes cryogen to deliver cool air miliseconds before
administering the laser source
• Used for LHR and Brown spots (shut off cryo)
• Laser is attracted to the melanin in hair, travels down
hair shaft and is destroyed by heat at the root
 Phases of Growth
• The best time to kill the hair is when it is still attached
to the papilla (vascular part of the hair follicle) For
both lasers.

• Anagen- phase is most ideal for LHR

• Catagen- may still work for LHR
• Talogen- LHR will not work
755nm for Pigmented Lesions
• Delivers heat energy to lesion
• Absorbed by melanin
• Melanin breaks into smaller particles
• The body recognizes thee articles as waste to be
removed
• Excess particles flake off
• Pigmentation appears more even when excess
melanin has cleared.
Resurfacing Lasers
Can be divided into:
Ablative
Fractional Ablative
Non-Ablative
 Ablative Resurfacing Lasers
 May provide best results in terms of targeting texture
and color (Scars/Pigment).
 Utilize electromagnetic waves to erode the entire
epidermis and upper layer of dermis.
 CO2 was the original, and for a long time, the primary
modality of resurfacing, but rarely used today due to
risks and downtime.
 2 week + downtime, “Pizza face”
 CO2 Laser Side Effects
 Redness
 Swelling
 Skin dyschromia
 Scarring
 Skin infection
 Eczematous reactions
 Fractional Ablative Lasers
 Delivers hundreds of laser “beamlets”
 = controlled dermal damage in microthermal
treatment areas that then stimulates fibroblast
formation to induce neocollagenesis and collagen
remodeling.
 Principle is dermal injury with adjacent areas spared.
 Addresses Epidermis and Dermis
 Trade Off
 Effective yet safer
 Quicker recovery, minimal downtime
 Slower results
 Non Ablative Lasers
 Good for dyschromia, but minimal scar improvement
 Series of treatment needed

Types
-Mid Infrared
-Pulse Dye Lasers
-Broadband Lights Systems
 Laser Side Effects and
Complications
• Erythema (redness) – should resolve within 1-2 days
• Edema (swelling) – should resolve within 1-2 days
• Purpura (bruising) – more common with PDL, should
clear within a week
• Hypo or hyperpigmentation – may be visible after a
few days; should resolve after a few months; topical
bleaching agents may help with hyper.
• Superficial burns or blisters – uncommon, but may
occur and can lead to scarring. Early intervention and
treatment crucial.
Prevention
 PRE and POST cooling essential!!!!!
 Plume Issues
Thermal destruction of tissue creates smoke
byproduct.
• Plume can contain toxic gases and vapors such as
benzene, hydrogen cyanide and formaldehyde,
bioaerosols, dead and live cellular materials
including blood fragments and viruses.
• A laser protective mask (0.1µ) should be used to
decrease inhalation of particulate matter.
 Plume Issues
• General room ventilation is not sufficient to
capture contaminants.
• Smoke evacuators should have high efficiency in
airborne particle reduction.
• HEPA filter or equivalent is recommended for
trapping particulates.
• Generally, the use of smoke evacuators is more
effective than room suction systems.
Thank You!!!!