lasersinplasticsurgery-180614061135.pptx

lasers

1. LASERS IN PLASTIC SURGERY Dr. S V NARAYANA

2. HISTORY 1960 - MAIMAN –Ruby rod(694 nm) 1961-Nd:YAG 1962-Argon 1964-CO2 Dr Leon Goldman -pioneered use of Ruby LASER on cadaver and later on patients. 1983-theory of selective photothermolysis by Anderson and Parrish.

3. LASER L ight A mplification by S timulate E mission of R adiation Characteristics: 1) M onochromaticity -same wave length 2)Coherence-waves are in phase in time and space 3)Collimation-waves remain parallel

4. COMPONENTS OF LASER DEVICE: 1)Energy source 2)Lasing medium 3)Amplifier

5. TYPES OF LASER LASING MEDIUM SOLID: 1) Ruby- 694nm Melanin , Tatoo pigment 2) Nd:YAG - 1064nm Pigment 3)KTP- 532 OxyHB,Melanin 4) Er:YAG 2940 Water 5)Diode 800 OxyHB,Melanin 6)Alexandrite 755 Melanin , Tatoo pigment 7)Copper vapor 578 OxyHB LIQUID:1)Yellow dye 585,595 OxyHB 2)Green dye 510 Melanin

6. GAS: 1)Argon 488,514 OxyHB,Melanin 2) Helium:Neon 633 3)CO2 10600 water 4) Excimer UV breaks chemical bonds LASER OUTPUT CONTINUOUS MODE- co2 LASER PULSD MODE- pulse duration in micro second QUALITY SWITCHING- pulse duration in nanoseconds with extremely high peak power

7. TISSUE OPTICS: FATE OF LASER LIGHT 1)Reflection -4to6% 2)Absorption -initial intensity - chromophores a)Endogenous- HB,melanin,water,collagen b)Exogenous-tattoo ink,photosensitizer 3)Scattering- mainly due to collagen more with shorter wave length 4)Transmission -residual light is transmitted -more with large wave length as there is less scattering

8. LASER OUTPUT Depends on lasing medium and electric supply Energy: Joule( J ) Power is the rate at which energy is delivered W=J / sec Power density is the rate at which energy is delivered per unit area ( W / cm2 ) FLUENCE :amount of energy delivered per cm2 J/cm2 THERMAL RELAXATION TIME :

9. LIGHT TISSUE INTERACTION: 1) Photostimulation : wound healing 2)Photodynamic reactions : topical or systemic administration of photo sensitizer dye and later irradiation leads to oxidative reactions(cancer ,acne) 3) Photothermolytic and photomechanical reaction : 37-60 C –tissue retraction 60-90 C-protein denaturation and coagulation 90-1oo C- carbonization & burning >100 C- tissue is vaporized and ablated

10. TISSUE COOLING AIM: 1)Preservation of epidermis. 2) Delivery of higher energy to target area. 3) Analgesia 1)Cold air convection -chilled air -30 c is directed onto the area to be treated 2)Contact cooling -application of ice packs or chilled water is passed in between transparent plates of sapphire 3)Cryogen spray (dynamic cooling)-frozen gas is sprayed onto the skin immediately before the laser pulse

11. ADVANTAGES Increased precision while cutting No contact Specificity Sterilization of operating site Less pain ,bleeding and quicker healing Lesser coagulation causes little surrounding damage Reduced hospitalization time

12. LASER HAZARDS EYE HAZARD- corneal and retinal burns, corneal and lenticular opacities cataract visual loss SKIN HAZARDS- burns,purpura,vesicles FIRE HAZARDS

13. CO2 LASER - 10,600nm Infrared invisible LASER Target chromophore : water Penetration <1 mm CW / Superpulsed CO2 USES:Focused Mode-skin tags, warts moles , as a knife Defocused Mode-skin resurfacing,acne scars, chickenpox scars, rhinophyma

14. Pre op 3 months

15. Nd:YAG LASER -1064nm Infrared invisible LASER in which Nd is doped in a crystal of YAG. Target chromophore : pigments Penetration -10-20mm vessel- 3 mm USES: tattoo marks pigmented skin lesions vascular lesions useful in hemorrhagic disorders

16. pre op at 3 months

17. Er:YAG - 2940nm Infrared invisible laser Target chromophore : water Tissue penetration less than co2 laser USES: skin resurfacing The 1540 erbium glass laser

18. pre op 1 month

19. PULSED DYE LASER(PDL) 585nm -595nm Target chromophore-oxyhemoglobin VASCULAR LASER Uses: vascular lesions hypertrophied , keloid scar pigmented nevus

20. DIODE LASER 800nm Semiconductor laser. Target chromophore : melanin,oxyhemoglobin Uses: hair removal benign skin lesions pigmented skin lesions

21. ALEXANDRITE LASER - 755nm Target chromophore -melanin , tatoo pigments Uses: tattoo removal pigmented skin lesions hair removal

22. Solar lentigines (2 months)

23. ARGON LASER 488nm,514nm Bluish green coloured laser light Target chromophore:oxyhemoglobin,melanin Uses: vascular lesions hair removal

24. RUBY LASER - 694nm Target chromophore : melanin , tattoo pigments Uses: tattoo marks benign skin pigmented lesions- freckels ,nevi lentigenes hair removal

25. Long pulse ruby laser

26. EXCIMER LASER They are Ultraviolet LASERS( 193 ,248 ,308 ,355nm ) The lasing medium uses a gas mixture of 0.1% Ar Fl or Kr Fl / Xe Cl / Xe Fl Used in LASIK

27. COPPER VAPOR LASER CVL use elemental copper to emit either green light at 511 nm or yellow light at 578 nm . Target chromophore-oxyhemoglobin,melanin Uses: vascular lesions More scarring and pigmentary changes

28. Portwine stain-3months,2 session

29. KTP LASER 532 nm frequency- doubled YAG laser Target chromophore : melanin,oxyhemoglobin Uses: vascular lesions varicose veins

30. Helium:Neon 633 Laser with red colored aiming beam for accurate placement of target spot, incorporated with laser probes

31. IPL- 515-1200nm Emits polychromatic ,non coherent light beam by flash lamp Follows principle of selective thermolysis Used along with filters USES: facial telangiectsia port wine stain superficial hemangiomas

32. NEWER ONE Ti-SAPPHIRE LASER: CUTTING PURPOSE

33. ANESTHESIA Topical anesthetics - EMLA LIDOCAINE- 5 % TOPICAINE TETRACAINE Local injections and facial nerve blocks Other drugs- anxiolytics and NSAIDs According to need –regional block, G/A, conscious sedation

34. SCARS Currently-Pulsed dye laser(PDL-585nm) selective photothermolysis theories- PATIENT SELECTION-light skinned individual(I-III) relatively new(<1 yr) red ,raised scar Expected benefits: decrease in redness , height,pruritus improves pliability

35. Treatment protocol-hypertrophic scar RED -PDL alone or combined with steroids or 5-FU every 4 weeks until desired results achieved NOT RED- occlusion, steroids or 5-FU every 4 weeks until desired results achieved (5-FU: 50mg/ml) Steroids to be injected after laser multiple visits-4-6 wk interval SIDE EFFECTS-burning, pain , purpura hyper pigmentations

36. Fitzpatrick skin type Type I White, never tans, always burns Type II White, sometimes tans, usually burns Type III White, tans at average rate, sometimes burns Type IV Moderate brown, tans with ease, rarely burns Type V Dark brown, tans very easily, very rarely burns Type VI Black, tans very easily, does not burn

37. Pre op at 6 wks

38. Pre op 3 months

39. VASCULAR LESIONS SELECTIVE THERMOLYSIS: It is the ability to target a specific chromophore in the skin without damaging surrounding structures through the selection of the proper wavelength, pulse duration and fluence . TARGET CHROMOPHORE: Oxyhemoglobin PEAKS: 18nm, 542nm, 577nm Pulse duration< thermal relaxation time of intended target Initial LASER:488nm &514 nm continuous argon LASER

40. HEMANGIOMA Indications:1)compromised airway 2)visual axis impairment 3)obstruction 4)auditory involvement 5) bleeding,ulceration,infection,facial involvement Superficial hemangioma -better outcome Deep-poor Multiple treatments

41. SUPERFICIAL HEMANGIOMAS: 1) Pulsed dye LASER -585-595nm depth of penetration – 1.2 mm 2)Intense pulse light(IPL) 515-1200nm 3)KTP 532nm DEEP HEMANGIOMAS 1) Nd:YAG 1064 nm depth of penetration-4 to 6 mm 2)Intense pulse light(IPL) 515-1200nm -effective for sup. and deep vasculature -high fluence and large spots -more uniform heating and coagulation

42. PORT WINE STAIN –dilated dermal cappilaries and venules -(50-100 micro met) 1) Pulsed dye LASER -585-595nm better results in infants,light skin,small area 2) Nd:YAG 1064nm for nodular and hypertrophic port winestain

43. VENOUS MALFORMATIONS Consist of dilated cluster of varicose vein for superficial small lesion-PDL bulky lesion-KTP / Nd:YAG LASER Photocoagulation can be done using a laser fiber passed percutaneously through a hypodermic needle

44. LYMPHATIC MALFORMATIONS: cutaneous vesicle resembling tint blisters represent the dermal component of a lymphatic malformation which is associated with a more extensive subcutaneous component Problematic lymphatic oozing occurs from ulcerated vesicle can be palliatively treated with CO2 laser TELENGIECTASIA: They are small dilated dermal vessel commonly located on midface region and appear as linear red or blue vessel-PDL, KTP, IPL, Nd:YAG

45. SPIDER ANGIOMAS-consist of central feeding arteriole and radiating branches-PDL has excellent result CHERRY ANGIOMAS- superficial macular or papular cherry colored nodule-PDL PYOGENIC GRANULOMA-they are shiny nodules of proliferative vascular tissue covered by a fragile epidermal layer,found in children and pregnant women and has property to bleed when ulcerated PDL or KTP laser are good alternatives ,can be used with glass slide to compress the bleeding base.

46. NON MELANOMA SKIN CANCER Ideal candidate: sup BCC <2mm thick,SCC in situ elderly or frail patient multiple co morbidities multiple lesions lesion covering a cosmetic unit LASER:superpulsed co2 Er:YAG PDT:MOA-generation of phototoxic protoporphyrin IX ALA /Methyl ALA (14-18 hours) –BLU-U light exposure (16 min)

47. Pre op 1 week 3months

48. SIDE EFFECTS: pain , wound infection,s carring , hypo /hyper pigmentation prolonged healing chances of recurrence Warts epidermal nevus and actinic keratosisCO2 laser

49. SKIN RESURFACING

50. Er:YAG 8 months

51. TATTOOS Decorative tattoos -pigments or foreign matter is imbedded in the dermis of the skin intentionally. Therapeutic -radiation marking/nipple areola reconstruction Traumatic -road rash/gun shot injury/explosions Pre op counselling :multiple sessions( 5 -20) possible complications

52. Target chromophore : tattoo ink particles present in macrophages or scattered throughout the dermis. LASER acts by shattering ink particles into small fragments facilitating more rapid removal by macrophages Patient selection :amateur variety fair skin , untanned skin dark blue or black tattoo>1 yr

53. Dark blue and black tattoos Light skin- 755 nm Q-s alexadrite Dark skin- 1064 nm Q-s Nd:YAG Green tattoos 694 nm Q-s ruby Red tattoos 532 nm Q-s Nd:YAG Test spots should be performed ,evaluate after 4-8 wks, Entire area should be treated

54. Multicolored professional tattoo alexandrite laser,3sessions,2 months

55. Side effects and complications -alteration in pigmentation -darkening of tattoo pigment -thermal injury and scarring TATTOO GRANULOMA :CO2 LASER

56. PIGMENTED SKIN LESIONS FRECKLES PDL ( Green 510nm) SOLAR LENTIGEENES KTP CAFE-AU-LAIT SPOTS Nd:YAG (532nm) NEVI OF OTA RUBY NEVI OF ITO ALEXANDRITE DIODE

57. Pre op 3 months,4 sessions,alexandrite

58. LASER HAIR REMOVAL Light energy is used to destroy the hair root for permanent hair reduction Delayed hair regrowth are common. Multiple sessions are required. EXTENDED THEORY OF SELECTIVE PHOTOTHERMOLYSIS Target chromophore is MELANIN of hair shaft and matrix cell in which heat is generated and transmitted to stem cell of isthmus and blood vessel in papilla Diode,alexandrite,Nd:YAG - dark hair and fair skin, IPL for light or grey hair

59. ruby laser ,2 months, 2 sessions

60. LASER LIPOSUCTION SMART LIPO/ LASER LIPO/ LUNCH TIME LIPO Through 2 to 3 mm incision a small caliber tube is introduced containing low energy LASER fiber , which selectively destroys fat cells. Upto 3.5 kg wt loss achieved. Adv: rapid recovery ,minimal pain ,can be done under L/A, no scar Disadv : swelling ,bruising , infection

61. RHYTIDES removal of epidermis and papillary dermis,stimulates formation of new collagen and rejuvenate superficial skin layer. Skin actually tightens as the dermal collagen is contracted because heat generated by the laser. Pretreatment with 1 month of retinoic acid and hydroquinone bleaching cream is common. Er:YAG ,CO2 laser are of choice. Post therapy erythema lasts for many months.

62. LASER BLEPHAROPLASTY CO2 LASER: focused & defocused mode Adv: making incision hemostasis less operative time fast recovery S/E: ocular laser burns intra operative fire post op edema delayed wound healing wound dehiscence

63. pre op at 4 months

64. OTHER USES LASER FACELIFT/NECK LIFT FLAP MONITORING VARICOSE VEINS ACTIVE ACNE LESIONS PSORIASIS

65. GENERAL COMPLICATIONS CRUSTING CO2 , Argon TEXTURAL CHANGES CO2 , Argon HYPERTROPHY SCARRING CO2 PURPURA PDL HYPERPIGMENTATIONS PDL HYPOPIGMENTATIONS Argon

66. LASER SAFETY Wavelength specific safety goggles Limited entry Warning sign Eye shields Wet drapes or crumpled aluminum foil LASER safe ET tube Lowest FiO2 Plume evacuator and viral mask

67. CLINICALLY USEFUL LASERS Vascular lesions yellow dye KTP Nd:YAG Copper vapor Skin Resurfacing CO2 Erbium:YAG Benign lesions, pig. Diode Ruby Benign lesions,cutan. Carbon dioxide Hair Removal Alexandrite Diode Neodynium:YAG Ruby Intensed pulsed light Tattoo Removal Ruby Alexandrite Neodynium:YAG

68. Telangiectasias: in order of preference/effectiveness Diode laser (variable-pulsed-width 532nm)-as effective as pulsed-dye without puerperal pulsed-dye laser (puerperal results) IPL Hemangiomas pulsed-dye laser (585nm wavelength) 2-10 treatments spaced 6-8 weeks apart Port-wine stains Pulsed-dye laser (585nm) 2-12 treatments spaced 6-8 weeks apart superficial lesions, red lesions, younger than 10, head and neck lesions respond better Laser -- vascular lesions

69. THANK YOU