Volume 11 • Issue C10

LASERS IN PLASTIC SURGERY

Justin Perez, MD
John Hoopman, MD
Jeffrey Kenkel, MD

Cosmetic
 www.SRPS.org

Editor-in-Chief Jeffrey M. Kenkel, MD

Editor Emeritus Fritz E. Barton, Jr, MD 30 Topics

Contributing Editors Reconstruction

J. Alford, BS
R. S. Ambay, MD, DDS
R. G. Anderson, MD
S. J. Beran, MD
S. M. Bidic, MD
G. Broughton II, MD, PhD
J. L. Burns, MD
J. S. Chatterjee, MRCS
A. Cheng, MD
J. Cheng, MD
C. P. Clark III, MD
H. J. Desai, MD
M. Dolan, MD
R. W. Ellison, MD
N. Gangopadhyay, MD
R. Ghaiy, MD
D. L. Gonyon, Jr, MD
A. A. Gosman, MD
J. R. Griffin, MD
K. A. Gutowski, MD
R. Y. Ha, MD
F. Hackney, MD, DDS
M. Harirah, BA
B. Harrison, MD
L. H. Hollier, MD
J. Hoopman, MD
R. E. Hoxworth, MD
B. A. Hubbard, MD
J. E. Ireton, MD
K. Itani, MD
J. E. Janis, MD
R. K. Khosla, MD
C. J. Langevin, MD Breast Reconstruction
J. E. Leedy, MD Cleft Lip and Nose
J. A. Lemmon, MD Cleft Palate
A. H. Lipschitz, MD Craniofacial Anomalies
J. H. Liu, MD, MSHS Eyelid Reconstruction
R. A. Meade, MD Facial Fractures
M. Morales, MD Hand: Congenital Anomalies
D. L. Mount, MD Hand: Flexor and Extensor Tendons
P. Nagarkar, MD Hand: Peripheral Nerves
K. Narasimhan, MD Hand: Soft Tissues
A. T. Nguyen, MD Hand: Fractures, Wrist, Rheumatoid Arthritis
J. C. O’Brien, MD Head and Neck Reconstruction
J. Perez, MD Lip, Cheek, Scalp, and Hair Restoration
J. K. Potter, MD, DDS Lower Extremity Reconstruction
S. Ramanadham, MD Microsurgery
R. J. Rohrich, MD Nasal Reconstruction
S. Rozen, MD Plastic Surgery of the Ear
M. Saint-Cyr, MD Trunk Reconstruction
K. Sanniec, MD, MHA Vascular Anomalies
T. Schaub, MD Wounds and Wound Healing
M. Schaverien, MRCS
J. Seaward, MD Cosmetic
J. M. Smartt, Jr, MD Blepharoplasty
M. C. Snyder, MD Body Contouring
M. Swelstad, MD Breast Augmentation
J. F. Thornton, MD Brest Reduction and Mastopexy
M. J. Trovato, MD Brow Lift
A. P. Trussler, MD Facelift
J. G. Unger, MD Neuromodulators and Injectable Fillers
M. Vucovich, MD Lasers
R. I. Zbar, MD Rhinoplasty
Skin Care

Senior Manuscript Editor Dori Kelly

Business Manager Becky Sheldon
Corporate Sponsorship Barbara Williams

Selected Readings in Plastic Surgery (ISSN 0739-5523) is a series of monographs

published by Selected Readings in Plastic Surgery, Inc. For subscription
information, please visit our web site: www.SRPS.org.
This blank page is included for proper presentation in two-page view.

LASERS IN PLASTIC SURGERY
Justin Perez, MD
John Hoopman, MD
Jeffrey Kenkel, MD
Department of Plastic Surgery, University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas
INTRODUCTION
Lasers have been used in plastic surgery for nearly 50 years.
As is true with any relatively new medical technology,
lasers initially experienced a phase of rapid adoption by
plastic surgeons, during which time their applications
might have exceeded their indications. Many practitioners
idealized the use of lasers as a means to offer patients a
scarless or minimally invasive result. However, this notion
is grossly misguided considering that laser therapy induces
a controlled zone of thermal or ablative injury. With better
understanding of selective targeting of skin chromophores,
lasers have become the preferred therapy for numerous
skin conditions, including photorejuvenation, vascular
malformations, and acne scars. We present a review that
aims to refresh the reader on laser history, biophysics,
clinical indications and contraindications, and potential
complications to facilitate meaningful use of laser-based
therapy while ensuring both patient and user safety. For
the sake of a comprehensive overview, non-laser energy
devices, such as intense pulsed light (IPL), radiofrequency,
and ultrasound, are also discussed herein because they
contribute to a plastic surgeon’s armamentarium.
HISTORY
In 1916, Einstein proposed that light could be induced
by stimulated emission of energy in a controlled
fashion, and, if harnessed, could have tremendous
application.1 His work stemmed from fundamental
principles laid down by Plank (theorized light as a form
of electromagnetic radiation), Rutherford (described
SRPS • Volume 11 • Issue C10 • 2018
the atom), and Bohr (theorized that quanta are released
from excited substances). Taken together, their collective
works suggested that light, or photonic energy, could be
emitted spontaneously from various sources; a random
stimulus was all that was required. Their true genius and
foresight can be appreciated by noting that it would be
4 decades before these principles were put into practice.
Two groups of scientists, Arthur Schawlow and Charles
Townes (United States, Columbia University) and Nikolai
Basov and Alexander Prokhovov (Russia, Lebeder Institute
in Moscow), independently developed the Microwave
Amplification by Stimulated Emission of Radiation
(MASER) in 1954.2 For their work, Townes, Basov,
and Prokhovov were awarded the 1964 Nobel Prize in
Physics.3,4 Schawlow later earned the 1981 Nobel prize in
physics for work in nonlinear optics and spectroscopy.5-7
In 1960, Theodore Maiman (Hughes Corporation
Research Laboratories; Malibu, CA) developed the
first Light Amplification by Stimulated Emission of
Radiation (LASER) system.8 The optical laser consisted
of a ruby crystal that was surrounded by a helical flash
tub enclosed in a polished aluminum cylinder cooled
by forced air. Before Maiman’s breakthrough, Gordon
Gould, in 1957, penned the first document in which
the term laser was used. Gould and his assignee, Patlex
Corporation, now hold the basic patents covering optically
pumped and discharged excited laser amplifiers. These
lasers are used in 80% of the industrial, commercial,
and medical applications of lasers. Gould also holds
patents on laser uses and fiber-optic communications.
After these groundbreaking ideas and inventions, laser
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 SRPS • Volume 11 • Issue C10 • 2018
development rapidly progressed. In 1963, Leon Goldman
described the selective destruction of pigmented skin
structures, such as hair follicles, with a 694-nm pulsed
ruby laser, and he subsequently performed experiments
on vascular malformations using the argon laser and
neodymium:yttrium aluminum garnet (Nd:YAG) laser
in treating angiomas. Goldman’s work was subsequently
expanded by Rox Anderson and John Parrish in the
1980s when they developed the theory of selective
photothermolysis, the basis of medical applications of
the laser.9 In 2004, a conceptual shift occurred in laser
resurfacing with the introduction of fractional lasers,
which provided results comparable to those achieved
with CO2 lasers but with reduced morbidity and fewer
complications. Table 1 summarizes key milestones in the
development of laser technology, made possible by the
interplay between industry and academia.10
BIOPHYSICS
Thorough understanding of laser physics requires review
of the characteristics of light. Light travels as an oscillating
wave according to the formula C = f × λ (C = speed of
light, f = frequency, λ = wavelength), where the speed
of light is a constant value at 186,300 miles per second
(~300,000 km/s) in a vacuum. The formula tells us
that light is a product of its frequency and wavelength.
Frequency is the number of wave peaks that pass a given
point in space over a fixed period of time (expressed
in hertz [Hz] or cycles per second). Wavelength is the
distance between two successive peaks of a wave (measured
in nanometers [nm = 10-9 m]). The electromagnetic
spectrum (Fig. 1) represents all light; however, only a small
portion is visible to the human eye.10
MECHANICS OF LASERS
At the atomic level, electrons orbit atoms in discrete
orbital shells. As an atom is exposed to external
stimulation from an energy source, electrons are excited to
a higher energy state (i.e., a higher orbital shell). At that
point, the atom is considered unstable, and the excited
electron seeks a stable ground state by releasing the surplus
energy (photon) as the electrons return to their normal,
lower orbital shell. The energy released as a photon has a
specific electron energy (i.e., voltage). All photons released
2
in this manner will be of similar character (i.e., energy,
wavelength) as long as they are generated from the same
compound or element. In a similar fashion, when an
atom is struck by a photon emitted from another like
atom, it is excited to a higher state before returning to its
normal state. If an already excited atom is then struck by
another photon of equal energy (i.e., incident photon),
two identical photons will be released as the atom returns
to its ground state; this process is referred to as stimulated
emission. These photons have similar wavelength and
frequency. Therefore, laser light, being generated from
stimulated emission, is unique compared with ordinary
light in that it is more organized (Fig. 2).11 Three terms
can be used to characterize the organized quality of laser
light:12
1. Monochromatic—All photons in a laser beam
exhibit the same color (i.e., wavelength) because
they are from the same source with equal energy.
2. Collimated—Photons travel in parallel with one
another, both spatially and temporally, without
marked divergence.
3. Coherent—Photons travel synchronously in the
same direction; that is, they are in phase.
KEY LASER COMPONENTS
With the exception of electronic or diode lasers, all lasers
must have four critical components: an active medium,
an energy source, a rear reflective mirror, and a partially
reflective mirror/output coupler (Fig. 3).10
The active medium can be a solid (e.g., ruby,
Nd:YAG, alexandrite), liquid (e.g., rhodamine 6G dye), or
gas (e.g., CO2, argon). The atoms in a given medium are
excited by an energy source (e.g., flash lamp or electrical
current) in a process known as pumping. Pumping excites
electrons from low- to high-energy states. The excited
electrons then receive energy from incident photons and
release two photons in perfect alignment with the same
energy and wavelength. These two photons released from a
single atom go on to stimulate two other atoms, resulting
in a multiplication effect; those two will produce four,
which produce eight, and so on. This cascade of energy
moves back and forth in controlled fashion between the
mirrors. The reflected photons are released as a laser beam
via the output coupler at the discretion of the operator.
 SRPS • Volume 11 • Issue C10 • 2018

TABLE 1
Key Historical Laser Milestones10

Year Landmark Event

1900 Plank described light as a form of electromagnetic radiation
1911 Rutherford described the atom
1913 Bohr presented the theory of quanta release from excited substances
1916 Einstein published the theory of stimulating radiant energy
1947 Lamb and Rutherford showed stimulated emission
1957 Gould coined the LASER acronym
1958 Townes and Schawlow outlined the working principles of the laser
1960 Maiman developed the ruby laser
1961 Science published first biological application of lasers (retinal photocoagulation)
1963 Goldman published laser application on pigmented lesions and hair follicles
1964 CO2 laser was introduced
1964– Goldman published the use of argon laser and neodymium:yttrium aluminum garnet laser on
1973 vascular lesions
1980s Anderson and Parrish introduced the theory of selective photothermolysis
1996 Erbium (erbium: yttrium aluminum garnet) laser was introduced
2004 Anderson and Manstein introduced fractional thermolysis

400 nm 500 nm 600 nm 700 nm

Visable light

Gamma rays X-rays Ultra- Infrared Radio waves

violet
Radar TV FM AM

0.0001 nm 0.01 nm 10 nm 1000 nm 0.01 cm 1 cm 1m 100 m

Increasing energy

Increasing wavelength

Figure 1. The electromagnetic spectrum. As defined by the above equation, frequency and wavelength are inversely
related. Longer wavelengths (infrared waves, microwaves, radio waves) have smaller frequencies. Shorter wavelengths
(gamma rays, x-rays, UV rays) have higher frequencies. Radiation at shorter wavelengths is considered ionizing because of
its ability to damage DNA. Exposure to ionizing radiation requires special precautions (i.e., lead shielding to protect against
x-rays). Radiation at longer wavelengths is considered nonionizing because it does not damage DNA. Most surgical lasers
are of the nonionizing variety. (Modified from Stewart et al.10)

3
SRPS • Volume 11 • Issue C10 • 2018

Lamplight:
many wavelengths,
noncoherent, diverge

Laser beam: monochromatic,

coherent, colimated

Figure 2. Comparison of ordinary lamp light versus laser light. (Modified from https://lasertechnologies.weebly.com/how-do-
lasers-work.html.11)

Fully reflective mirror Optical cavity Partially reflective mirror

Photons Photons

Laser beam

Power source

Figure 3. Four key components of a laser. The external power source excites a particular medium, which stimulates photon
emission. These photons stimulate the surrounding atoms to release more photons, which are subsequently reflected
between the mirrors at either end of the optical chamber. The opital chamber contains the gain medium (solid, liquid, or gas).
Opening the output coupler allows the passage of a laser beam. (Modified from Stewart et al.10)

4

The laser can be administered in a continuous
energy stream, as a pulse (lasting milliseconds) through
the aid of a mechanical shutter, or quality-switched
(Q-switched) (lasting nanoseconds). The concept of
Q-switching was invented by McClung and Hellwarth.13
Instead of using a partially reflecting mirror, a Q-switched
laser uses a rear reflective mirror that is also 100%
reflective, not the 97% to 99% reflective standard of non-
Q-switched lasers. A flash lamp releases light into the laser
chamber containing photons until high peak powers are
reached. The Q-switch then dumps the entire contents
of the chamber, producing energy in a short, 5- to 10-ns
pulse of very high intensity.
LASER PARAMETERS AND TISSUE EFFECTS
Farkas et al.14 proposed five essential parameters that
should be considered when operating all light-based
devices: wavelength, power, spot size, pulse width,
and cooling. We review the ways in which one can
conceptualize these parameters.
Light can interact with tissue in two ways that are
clinically relevant: it can be absorbed by the tissue or
it can scatter within it. Both absorption and scatter are
functions of light wavelength. Specific wavelengths of light
are preferentially absorbed by organic chromophores (Fig.
4).10 The most common organic chromophores targeted by
light-based modalities include the following:
• Water—homogeneous throughout dermis
and epidermis.
o CO2 and erbium are the most commonly
used resurfacing methods.
o Newer fractionated resurfacing techniques
create micro-islands of damage with
spared collagen and dermal adnexa.
This produces a theoretical advantage
of less total tissue treated and increased
collagenases in affected areas.
• Melanin—most prevalent in the epidermis;
produced by melanocytes that inhabit the
dermal-epidermal junction. Melanocytes are
also dispersed in deep dermis, subcutaneous
tissues, and hair follicle surfaces and are
the targets in depilating procedures. Unlike
SRPS • Volume 11 • Issue C10 • 2018
water and hemoglobin, melanin does not
have any appreciable absorption peak
per se, but rather increasingly absorbs
wavelengths shorter than 1000 nm; thus, a
multitude of lasers can be used to
target melanin.
• Oxyhemoglobin—chosen chromophore
targeted when the true target is translucent
vessel walls located throughout the papillary
and reticular dermis. Hemoglobin has
absorption peaks at 418, 542, and 577 nm.
In general, shorter wavelengths have a higher
absorption coefficient and therefore do not penetrate as
deeply. In an ideal situation, higher absorption and less
scatter results in less overall energy needed to heat target
tissue to the desired temperature and achieve the intended
effect. Shorter wavelength light (e.g., ultraviolet [UV],
200-600 nm) penetrates more superficially compared with
longer wavelengths (e.g., near-infrared spectrum, 650-
1200 nm). However, wavelengths that penetrate the least
are far UV (e.g., excimer) and far infrared (e.g., erbium
and CO2 resurfacing [2940 and 10600 nm, respectively]
for maximal dermal-epidermal removal) because they have
a high affinity for water (Fig. 5).14 Wavelengths in the
visible spectrum are absorbed best by their color opposite.
Wavelengths in the near-infrared spectrum respond to
the darkest shade of gray present, and longer wavelengths
(1200 nm) respond to water as opposed to pigment.
Power (watts; the number of watts delivered over a
given time period equals joules [J; units of work]) and spot
size (measured in cm2, dependent on focal length of laser)
are two parameters that collectively make up power density
(power / spot size = W/cm2) (Fig. 6).14 Power density can
be controlled to increase energy delivery and thermal effect
on target tissue. In a manner similar to a magnifying glass,
a given number of photons can be concentrated over a
smaller area to increase temperature rise and thermal effect
on a given target tissue. For example, if the maximum
available spot size of a device is 12 mm and the maximum
energy output is 50 J/cm2, one might decrease the spot
size to increase the power density for treatment (Fig. 7).14
However, one must take into account that changing spot
size also changes the depth of penetration secondary to
scatter of photons under the tissue surface, resulting in
more superficial tissue effect. When an incident beam hits
5
 SRPS • Volume 11 • Issue C10 • 2018

X-rays Microwaves
cosmic rays Optical window (620–1200 nm) TV/radio waves

UV Visible Infrared

Argon Ruby Nd: YAG Er: YAG CO2

(510) (694) (1064) (2940) (10600)
KTP Alexandrite
(532) (755)
PDL Diode
(595) (810)

Water

Deoxyhemoglobin Melanin

Oxyhemoglobin

300 400 500 600 700 800 900 1000 1500 2000 3000 10000 nm

Figure 4. Skin chromophore absorption spectra. Oxyhemoglobin, melanin, and water absorb light at specific wavelengths.
TV, television; UV, ultraviolet; KTP, potassium titanyl phosphate; PDL, pulsed dye laser; Nd:YAG, neodymium:yttrium aluminum
garnet; Er:YAG, erbium yttrium aluminum garnet; CO2, carbon dioxide. (Modified from Stewart et al.10)

UV IRA IRB
Protein Color opposite Gray scale Water
200–400 400–750 750–1,300 1,300–10,600+

Figure 5. Spectral response. Depiction of variations in spectral response for visible light, near- and far-infrared wavelengths.
(Modified from Farkas et al.14)

6

50 J/cm2
12 mm
200 J/cm2
6 mm
800 J/cm2
3 mm
Figure 6. Power density schematic. Analogous to a
magnifying glass, a given number of photons can be
concentrated in a given area to increase temperature rise
and thermal effect on target tissue. One can increase power
output of a light-based device by controlling density.
(Modified from Farkas et al.14)
the tissue surface, it create an inverse pyramid comprised
of 63% photon concentration, which, if harnessed
appropriately, can limit the energy delivered and limit
the risk of complication. It is important to consider
that the approximately 63% inverse pyramid decreases
proportionally to spot size and that generally speaking,
the scatter of photons at superficial treatment depths is
more rapid. Thus, decreasing spot size can decrease target
heating at a given depth. To compensate for this effect,
the energy output of a device needs to be doubled when
spot size is halved to create the same treatment depth and
account for scatter. For example, a 6-mm spot size and
90 J/cm2 might be needed to close a vessel; however, if
targeting a 3-mm spot, energy would need to be increased
to 180 J/cm2 to have similar effect. Likewise, if targeting
a 1.5-mm spot, 360 J/cm2 might be needed. Although,
ideally, one should use lower energy settings for increased
safety, the lower energy setting might not be the more
practical and efficacious treatment setting.
SRPS • Volume 11 • Issue C10 • 2018
1.5 mm 3 mm 6 mm
Figure 7. Treatment zone as a function of spot size. Area
of treatment response is changed by altering spot size.
(Modified from Farkas et al.14)
Pulse width can be defined as the delivery time of
an energy source to a tissue target. Laser pulses must be
of appropriate duration to deposit enough energy into
the target before the target cools. Key to understanding
pulse width is the concept of thermal relaxation time
(TRT). TRT is the time for target chromophores to release
more than half the temperature rise in the target tissue.
As energy is added to a target tissue, it is transferred as
heat. Furthermore, the heated tissue cools down over a
constant time interval as energy is absorbed by the non-
target surrounding tissues. The goal is to have a delivery
time that is faster than the target’s TRT (Table 2), a
concept previously described by Anderson and Parrish9
as selective photothermolysis. Exceeding the TRT results
in need for excessive amounts of energy and potential
to damage surrounding tissues because of excess heat.
Specifically, unwanted effects of tissue coagulation occur
at approximately 60°C and tissue vaporization occurs
at approximately 100°C. Once the TRT has elapsed,
7
 SRPS • Volume 11 • Issue C10 • 2018
TABLE 2
Thermal Relaxation Times of Common Tissue Chromophores9
Target
200- to 300-μm hair follicle
100-μm port wine stain blood vessel
20-50 μm of epidermis
7-μm erythrocyte
1-μm melanosome
0.1-μm tattoo particle
another pulse can be delivered without damaging thermal
consequences. Generally, the ideal pulse width or energy
exposure time to the target is half the TRT.
Effective laser therapy aims to maximize thermal
effect on targets while minimizing collateral damage that
increases risk of infection, erythema, hyperpigmentation,
and hypopigmentation of the treatment area. Effectively
protecting the superficial skin without compromising
laser efficacy has been a clinical challenge. In an effort
to minimize epidermal injury, selective cooling methods
have been used. Cooling raises the threshold for epidermal
damage so that higher doses of energy can be used.
Cooling also eliminates heat buildup in the superficial
dermis, which in turn minimizes non-target damage.15-21
There are four basic types of skin cooling:
• Pre-cooling—The epidermis and dermis are
cooled before light delivery.
• Parallel cooling—The epidermis and dermis
are cooled during light delivery.
• Post-cooling—The epidermis and dermis
are cooled after light delivery.
• Dynamic cooling—The epidermis and
dermis are cooled before, during, and after
light delivery.
Contact cooling systems, with which a constantly
pre-cooled solid body (approximately 5°C to 30°C) is
8
Thermal Relaxation Time
10-100 ms
5 ms
0.2-1 ms
20 μs
1 μs
10 ns
applied to the skin at the time of laser treatment, have
been used (Fig. 8).14 Two well-studied cooling modalities
are cooled sapphire (at pre-set temperatures) and cryogen
spray. Contact cooling systems work by recirculating
chilled water around transparent medium kept in direct
contact with the target for less than 2 s and then manually
removed. Cryogen spray is comprised of a Freon substitute
sprayed directly over the treatment area in a fixed diameter.
A laser can also exert a mechanical effect on tissue.
For example, selective photothermolysis can target tattoo
pigments, which act as chromophores for the Q-switched
laser light. A photoacoustic shock wave is created,
fragmenting the pigment into smaller particles.
The degree of collateral damage can be altered by
delivering laser light in either a continuous or pulsed
mode. Continuous laser light delivered to a tissue results
in conduction out of the target chromophore and into
non-target surrounding tissue. Although it is very efficient,
continuous laser light is technically demanding and usually
requires a scanner for safe use. Pulsed light intermittently
exposes a targeted chromophore to high energy for a very
short time, heating up the target in less time than it takes
for the heat to dissipate. Collateral tissues are spared from
undesired thermal damage, and it is possible to reach
higher peak temperatures in the targeted chromophore
with lower average power. For these reasons, pulsed lasers
are widely used and cause less collateral damage.
 SRPS • Volume 11 • Issue C10 • 2018

Generally speaking, lasers used in skin resurfacing LASER SAFETY AND NATIONAL STANDARDS
are either ablative or non-ablative. Ablation refers to
The American National Standard for Safe Use of Lasers in
destruction of the epidermis and upper papillary dermis.
Health Care,22 published by the Laser Institute of America,
With subsequent healing, the collagen in the upper
is recognized as the definitive document on laser safety
layers of skin is reorganized and remodeled. Non-ablative
in all health care environments. It provides guidance for
resurfacing spares epidermal destruction and triggers less
safe use of lasers for diagnostic, cosmetic, preventative,
collagen remodeling with healing (Fig. 9).10 Fractional
and therapeutic applications in any location where bodily
photothermolysis is a technology in laser resurfacing that
structure or function is altered or symptoms are relieved.
treats skin in core sections (microthermal zones), leaving
It should be readily available for quick reference in any
untreated areas to promote rapid healing. This is further
medical facility providing laser-based treatment.
discussed in the sections Fractional Ablative and Non-
ablative Lasers and Scar Prophylaxis. Medical lasers are classified based on the ability of
produced radiant energy to injure health care personnel
Lasers are fundamentally different from
(HCP) or the intended patient.22 Class 1 lasers are
electrocautery. Electrocautery uses an electric current to
considered to be incapable of producing damaging levels
create thermal effects on tissue. The electric current can
of laser emission during operation. Therefore, these lasers
travel far and irregularly from the applied site. Electricity
are exempt from hazard warning labels, control measures,
follows the path of least resistance and conducts through
or other means of surveillance. Examples are lasers used for
blood vessels or other fluid channels in the tissue,
diagnostic work in laboratories.
accounting for its hemostatic effects. In contrast, a laser’s
thermal effects are uniform and localized. Laser treatment Class 2 lasers are low-power devices that emit
is more tissue-specific, which translates into better clinical visible light. They can be viewed directly for a period of
efficiency and less collateral damage compared time ≤0.24 s, the typical aversion response time. Normal
with electrocautery. protective reflexes (head turning, blinking) are adequate

Epidermis Epidermis Epidermis

Dermis Dermis Dermis
15°C/~300µm
10°C/~800µm
5°C/~500µm

Figure 8. Cooling effects. A schematic of differential depths of cooling depending on temperature of cooling device applied.
(Modified from Farkas et al.14)

9
 SRPS • Volume 11 • Issue C10 • 2018
Ablative resurfacing
Epidermis
Dermis
Figure 9. Ablative, non-ablative, and fractional resurfacing. (Modified from Stewart et al.10)
protection. Prolonged, constant viewing without eye
protection can cause degenerative eye changes. An example
is a helium-neon laser (e.g., a laser pointer). Class 1M and
class 2M lasers pose the same risk to the unaided eye as
do class 1 and class 2 lasers, but they might pose increased
ocular hazard from intra-beam viewing with certain
optical instruments.
Class 3 lasers require special training for operation.
They can be hazardous for direct exposure or exposure to
specular reflection. They are divided into two subclasses:
3R and 3B. An example is the Nd:YAG laser used
in ophthalmology.
Class 4 lasers are associated with substantial risk for
eye injury, skin burns, and fire hazards. Most surgical lasers
and lasers emitting in excess of 0.5-W average radiant
power are considered class 4 lasers. Examples include CO2,
argon, and pulsed-dye laser. All lasers should be clearly
labeled with the appropriate hazard classification.
The safe use of lasers in medicine requires user
eye protection, patient eye protection, a controlled
treatment area, fire safety, smoke evacuation, and accurate
documentation. Eye safety is defined by maximum
permissible exposure (MPE) and the Nominal Hazard
Zone (NHZ). MPE is the level of laser radiation to which
a person can be exposed without hazardous effects or
adverse biological changes in the eye or skin. The MPE is
10
Non-ablative Ablative
fractional resurfacing fractional resurfacing
determined by a combination of wavelength, exposure
time, and pulse repetition. The NHZ is the space where
the level of direct, reflected, or scattered radiation during
normal laser operation exceeds the MPE.
Ocular injury can occur by various mechanisms.23
For example, CO2 lasers are absorbed by the globe
surface, resulting in scleral and corneal damage. In
contrast, Nd:YAG (1064 nm) lasers emit light that is
transmitted through clear liquids, becoming focused by
the lens and striking the retina. The focusing ability of the
lens increases the power density of the laser, resulting in
severe macular injury. Furthermore, passes through the
cornea are focused by the lens and strike the retina. The
focusing ability of the lens can notably increase the power
density of the laser light and might cause macular injury.
Furthermore, cataracts and retinal damage can also occur
by slow degeneration of the crystalline lens or retinal
tissues secondary to chronic exposure to low-power beams.
Patient Eye Protection
The eye protection method should be determined based
on procedure, wavelength, delivery system, and type of
anesthesia to be administered. Options for eye protection
include goggles, corneal shields, and wet cloth towels
(adequate for CO2; inadequate for argon, potassium
 SRPS • Volume 11 • Issue C10 • 2018

titanyl phosphate [KTP], Nd:YAG) over the ocular

area. The eye protection should have the appropriate
filtering capabilities with a satisfactory optical density
(OD). The OD is a mathematical representation of the
ability of a lens material to absorb a specific wavelength.
Higher OD does not necessarily result in more eye
protection. Awake patients can wear goggles or glasses;
patients under anesthesia can be fitted with eye pads or
corneal shields containing lead. All eyewear should be
labeled with the OD and wavelength for which protection
is afforded and be routinely inspected for pitting, cracking,
and discoloration. The importance of appropriate and
effective eye protection cannot be overstated. Eye injuries
can occur in patients, treating physicians, and ancillary
personnel.14 Figure 10. Laser treatment area warning sign. (Reprinted
from the Laser Institute of America.22)
Laser treatment controlled areas (LTCA) are required
for class 3B and class 4 lasers. LTCA need to be clearly
delineated and must contain the following elements: all potential flammable agents (e.g., methane gas from
bowels, foam positioning devices, plastic endotracheal
• Appropriate area warning signs
tubes). Surgically relevant examples of fire safety when
o Class 2 and class 2M lasers using lasers include the following:
require “caution” warning signs.
• Anesthetic gases containing high
o Class 3R, class 3B, and class 4 lasers concentrations of oxygen—such as those
require “danger” warning signs (Fig. 10). within an endotracheal tube or a tube
• Supervising HCP fully trained in laser covered by sterile drapes—can ignite and
safety cause fires. Endotracheal tubes should be
protected with a moistened barrier.
• Door, blocking barrier, screen, or curtain at
the entryway that attenuates laser radiation • Sponges, gauze pads, and swabs should be
eliminated from the operating filed; if used,
o Typical window glass (3 mm+ thickness)
they should be kept wet.
has OD of 5.0 for lasers operating in
spectral range 180 to 300 nm and • To protect wires from fracturing,
2800 nm+. avoid excessive bending, clamping, or other
stress to the wires. If performing a perianal
o If not using a laser within this spectral
laser procedure, consider perioperative anti-
range, appropriate curtains must be used.
flatulent and/or insertion of moist cotton
• Means for rapid egress and admittance into into anal area.
LTCA
The plume produced during laser procedures can
Fire hazards associated with medical lasers should contain gaseous toxic compounds, dead or live cellular
be taken seriously. All HCP should be aware of potential material, and viruses. At certain concentrations, the
hazards and prepared to act swiftly to control a fire. plume can cause ocular and upper respiratory tract
First steps to be taken include unplugging all electrical irritation and unpleasant odors and has been shown to
equipment and having expeditious access to fire have carcinogenic potential. Airborne contamination is
extinguishers. Sterile water or saline should be readily controlled through local exhaust ventilation systems. The
available to control small fires. HCP should be aware of local exhaust ventilation should be as close to the point

11
 SRPS • Volume 11 • Issue C10 • 2018
of plume generation without compromising the surgical
effectiveness of the laser used. General room ventilation
should also be provided; however, in and of itself, general
room ventilation is inadequate.
The Joint Commission (TJC), formerly known as
the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), mandates meticulous
documentation of laser safety measures implemented in all
cases. Accurate and complete records help preserve patient
and staff safety, provide a legal record in the event of an
inquiry or litigation, and serve as an operational log for
any future problem-solving or technical support.22
In 1985, the American Society for Laser Medicine
and Surgery created guidelines for safe laser use, which
was most recently revised in 2011.22 A Laser Safety
Officer (laser user, operator, or other trained person)
should be appointed to oversee strict adherence to the
guidelines and implement a set of policies/procedures for
the given facility.
The issue of physician supervision of laser
procedures continues to be hotly debated, and professional
qualifications for laser use are currently being considered
by legislators. Regardless of whether and when laws are
enacted, all laser users should be intimately familiar
with the machine and able to recognize abnormal tissue
responses to lessen complications of laser treatment.24-30
Types of Medical Lasers
Excimer Laser
The 308-nm excimer laser is composed of a xenon and
chloride gas mixture, which together form unstable
“excited dimers” that subsequently dissociate and give
off 308 nm of light within the ultraviolet B spectrum
(Table 3).30-33 Considering its short wavelength, its tissue
penetration is limited. Its common uses include corrective
eye surgery and cardiac angioplasty. Regarding cutaneous
uses, the excimer laser has been approved by the U. S.
Food and Drug Administration (FDA) for treatment
of focal inflammatory and hypopigmentary conditions,
such as vitiligo and psoriasis. In inflammatory conditions,
ultraviolet B light causes apoptosis and cell cycle arrest
of T-lymphocytes through deoxyribonucleic acid (DNA)
breakage and regulation of tumor suppressor gene p53. In
hypopigmentation diseases, re-pigmentation is thought
12
to be secondary to increased melanocyte proliferation and
migration; histological studies show increased numbers
and larger melanocytes in excimer-treated vitiligo
lesions.31-36
Argon Laser
The argon gas laser system was invented by William
Bridges at Hughes Aircraft.37 It uses a noble gas as its active
medium. The two dominant wavelengths emitted are 488
nm (blue) and 514 nm (green), which comprise 67% of its
total beam output power. Prism systems are used to filter
out unwanted wavelengths. Argon lasers are considered
class 4; they are a serious hazard to view, and any diffuse
or direct exposure beyond MPE can seriously damage
the retina. Accordingly, its medical uses are generally
limited to ophthalmic surgery (retinal photocoagulation,
trabeculectomy, iridoplasty).38,39
Copper Vapor Laser
This non-ablative continuous wave laser generates 510
nm (green) or 578 nm (yellow) wavelengths. It was
originally used to treat pigmented lesions. However,
pulse durations typically exceeded TRT of melanosomes,
increasing risk for unsightly scarring and textural
changes. Its contemporary use is limited to forensics for
denture marking, allowing rapid personal postmortem
identification.40,41
KTP Laser
KTP lasers have a wavelength of 532 nm, generated by
passing a 1064-nm wavelength beam through a KTP
crystal that halves the wavelength (1064 nm / 2 = 532
nm). KTP lasers target melanin and hemoglobin. It is a
popular laser for the treatment of fine facial capillaries
because its wavelength closely matches the absorption peak
of hemoglobin. Other uses include small leg veins, tattoos,
capillary malformations/port wine stains (i.e., Sturge
Weber Syndrome), rosacea, and solar lentigenes.42 When
used to treat children for capillary dense lesions (such
as capillary malformations), it is important to counsel
patients and/or parents that serial treatments (~six to
12 treatments) might be required, likely under
general anesthesia.
 SRPS • Volume 11 • Issue C10 • 2018

TABLE 3
Characteristics of Common Lasers Used in Plastic Surgery30-33

Laser Wavelength Target Chromophore Common Uses

(nm)
Excimer 308 Very superficial Laser eye surgery, cardiac
penetration angioplasty, psoriasis
Argon* (continuous wave/scanner) 488, 514 Melanin, hemoglobin Port wine stain,
telangiectasias
Pulsed dye (green) 510 Melanin, Benign epidermal
red tattoo ink pigmented lesions,
red tattoos
Copper vapor* 510, 578 Melanin, hemoglobin Port wine stain,
telangiectasias, lentigines
Q-switched Nd:YAG-KTP 532 Melanin, Benign pigmented
tattoo ink (red) lesions, red tattoos
KTP 532 Melanin, hemoglobin Telangiectasias
Pulsed dye (yellow) 585 Hemoglobin Port wine stain,
hemangiomas,
telangiectasias
Q-switched ruby* 694 Melanin, Benign pigmented
tattoo pigment lesions, dark tattoos
(purple and violet)
Q-switched alexandrite 755 Melanin, Benign pigmented
tattoo pigment lesions, dark tattoos
(green, blue, black)
Diode 800-900 Melanin Hair removal
Q-switched Nd:YAG 1064 Melanin, Benign pigmented
tattoo pigment lesions, dark tattoos
(blue, black)
Er:YAG 2940 Water Rhytides
CO2 10600 Water Rhytides, atrophic scars
IPL 500-1200 Melanin, hemoglobin, Pigmented lesions
tattoo pigment, water (560-nm filter for
superficial reds and
browns), birthmarks,
facial spider veins, leg
veins,
hair removal

Q-switched, quality-switched; Nd:YAG, neodymium:yttrium aluminum garnet; KTP, potassium titanyl phosphate; Er:YAG,
erbium yttrium aluminum garnet; CO2, carbon dioxide; IPL, intense pulsed light.

*These lasers were included for completeness although they are rarely used.

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 SRPS • Volume 11 • Issue C10 • 2018
Ruby Laser
The first commercially available medical laser in the
United States was a ruby laser used for photocoagulation.
It resulted in subretinal hemorrhage and was abandoned in
ophthalmology thereafter. It has largely been abandoned
in cutaneous applications because of its harsh effects on
tissues, resulting in alopecia, hyperpigmentation, and/
or scarring. Its use in tattoo removal is being replaced by
more predictable alexandrite and Nd:YAG lasers.43-50
Alexandrite Laser
Alexandrite lasers use Q-switching technology and emit
light at 755 nm in near-infrared bands. It has a pulse
duration of 100 ns, a spot size of 3 mm, and a repetition
rate of 1 Hz. Its advantages over earlier ruby lasers
include reliability, speed, and repetition rates. Target
chromophores include melanin and tattoo pigment (e.g.,
green, blue, and black). It is considered the treatment of
choice for removing green-colored tattoos but has also
been shown to be efficacious for blue and black pigment
by Fitzpatrick and Goldman51 It can also be used for
removal of hair and benign pigmented lesions.51-56
Diode Laser
Diodes are one-way valves for electricity that rely on
electrical stimulation of solid-state semiconductors for
photon emission. Commonly used commercial laser
pointers are diode lasers. Clinical diode lasers emit light
in the near-infrared range (800–900 nm). Currently,
their principle use is in pulsed mode for hair removal.
Histological analysis showed skin treated with diode laser
to achieve statistically significant (P = 0.008) reductions
in both hair density and thickness.57 In general, lasers
with longer wavelengths, such as the diode laser, are
preferred when treating darker skin types because of a
more favorable side effect profile of less pain and post-
inflammatory hyperpigmentation (PIH) compared
with lasers with shorter wavelengths (recall, melanin’s
inversely sloped absorption coefficient curve) (Fig. 11).14
Furthermore, diode lasers have been explored in plastic
surgery to complement laser-assisted liposuction, removal
of filler-related nodules and/or granulomas, and neck
rejuvenation, although its use in these regards is limited to
select studies.57-68
14
Nd:YAG Laser
The Nd:YAG laser functions in the near-infrared range at a
wavelength of 1064 nm. The active medium is a crystal of
yttrium, aluminum, and garnet. It is doped with a rare-
earth element called neodymium, which produces the laser
light when exposed to flash lamps. The beam is invisible
and requires an aiming beam, which is often a 1-mW
helium-neon pilot laser light.
The longer wavelength corresponds to an optical
window that allows deeper dermal penetration, allowing
it to target larger vessels up to 3 mm in diameter, such
as course capillaries, facial venules, and bluish vascular
venous lakes. It also produces more uniform coagulation
and can cause bulk heating; thus, one must be vigilant
regarding the potential for burns and scarring.69-71
The Q-switched Nd:YAG laser allows targeting
of deeper dermal pigment, such as that in melanocytic
nevi and blue or black tattoos. It is versatile and has
multiple clinical applications, including non-ablative
facial resurfacing, photodamaged skin, hair removal, and
treatment of hypertrophic scars, acne scars, leg veins,
pigmented lesions, and vascular anomalies.72-85
Erbium:YAG Laser
The erbium yttrium aluminum garnet (Er:YAG) laser was
introduced in 1996. This laser operates at 2940 nm and
is absorbed by water 10- to 16-fold more than with CO2
lasers. The resultant effect is more superficial ablation with
less thermal damage to surrounding tissues compared with
CO2. For example, the zone of thermal necrosis of the
erbium laser is usually <50 mcm in depth, compared with
75 to 150 mcm for CO2 lasers. However, by lengthening
the pulse width, the penetration depth can be extended to
~100 mcm to simulate CO2 laser effects. Alleged benefits
to Er:YAG over CO2 are decreased healing time, increased
patient tolerance, and less hypopigmentation. Alleged
downsides of Er:YAG include reduced hemostasis and
loss of collateral heating of underlying dermis, resulting
in less collagen remodeling than achieved with CO2
laser. Variable-pulse-width erbium lasers can ablate with
good control, making them popular for ablative skin
resurfacing.86-94

532 585 755 810 1064 1320 1450 2.94 10.6
Figure 11. Wavelength determines depth of penetration.
Illustration shows absorption length, or penetration depth,
for common wavelengths of devices in near-infrared
spectrum. (Modified from Farkas et al.14)
CO2 Laser
Before the advent of the Er:YAG laser, the CO2 laser was
the front runner in ablative skin resurfacing. Developed
in the 1990s, when pulse widths were shortened to
minimize residual thermal injury, the CO2 laser became
widely popular. In the right hands, exceptional results
are possible. The active laser medium is a combination of
CO2, nitrogen, and helium gases. This mixture of gases
is excited by an electrical current to generate a laser beam
with a wavelength of 10,600 nm, which is in the middle
infrared spectrum and therefore invisible. A helium ion
light is coaxially transmitted to serve as the aiming beam.
The primary chromophore is water, which comprises
75% to 90% of all biological tissues. At low energies,
coagulation of vessels or protein denaturation occurs. At
high energies (when tissues reach the boiling point and
above), cell membranes explode and a smoke plume
is generated.
SRPS • Volume 11 • Issue C10 • 2018
The depth of penetration can be controlled by
altering the power, density, and duration of exposure.
At high powers with small beams and short exposures,
tissue cutting can be achieved. By enlarging the spot size,
the laser beam is effectively defocused and the energy is
spread over a larger area, which causes tissue ablation or
coagulation. There are two main types of CO2 lasers: the
free-flowing laser and the sealed tube laser. The free-
flowing CO2 laser uses a gas cylinder containing CO2,
nitrogen, and helium. When the gas is consumed and
emptied after laser use, the tank must be replenished
before the laser can function again. In contrast, a sealed
tube CO2 laser relies on regeneration of the appropriate
mixture of gases. Very little of the CO2 breaks down,
and what is consumed is split into products that catalyze
gas regeneration. The CO2 laser is a time-tested device
and the mainstay of laser incisional surgery and ablative
tissue resurfacing.95-105 Potential downsides include glossy
appearance, demarcation, and painful and
lengthy recovery.
Er:YSGG Laser
The erbium-doped yttrium scandium gallium garnet
(Er:YSGG) laser was designed to specifically inhabit
the middle ground between Er:YAG and CO2 lasers.
It operates at a wavelength of 2790 nm (Cutera Lasers;
Cutera, Brisbane CA; Palomar Lasers; Cynosure Inc.,
Westford, MA).
NON-LASER, LIGHT-BASED MODALITIES
IPL Device
The IPL device is a filtered flash lamp device that emits
noncoherent, non-collimated, polychromatic radiation
at a range of 420 to 1300 nm. Thus, by definition, it
is not a laser (Fig. 12).10 Whereas a laser beam delivers
only one wavelength of light, IPL devices deliver many
different wavelengths at a time. However, much like
a laser, IPL devices can be fitted with special filters to
eliminate unwanted wavelengths and tailor for specific
chromophores with each pulse. For example, a 550-nm
cutoff filter can be used to block light from 500 to 550
nm and allow only wavelengths 551 to 1200 nm to be
delivered to the tissues. Similar to the penetration of light
produced by lasers, longer IPL wavelengths penetrate
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 SRPS • Volume 11 • Issue C10 • 2018
Light Device
Laser
Intense pulsed light Filter
Figure 12. Schematic of laser light versus IPL illustrates the noncoherent, non-collimated, polychromatic nature of IPL
compared with laser light. (Modified from Stewart et al.10)
deeper into tissues (to treat deeper targets) and shorter
wavelengths are used to treat more superficial targets.
Pulsed light can also be delivered in bursts of one to five
pulses at a time. One can adjust the duration of each
pulse and the delay time between pulses. Long bursts
are better suited for treating large targets; short, rapid
pulses are better for small areas. As with lasers, great
care should be taken when treating patients with darker
skin types (Fitzpatrick IV–VI) and those with recent
significant sun exposure. In those cases, epidermal cooling
is recommended in addition to less aggressive treatment
parameters.81 The impressive functional diversity of IPL
can be attributed to the use of various selective filters that
preferentially address removal of unwanted hair,106,107
telangiectasia,108,109 dyschromia,110,111 hypertrophic scars
and striae,112 and non-ablative resurfacing.113,114
16
Waveform Spectrum
Coherent Monochromatic
and collimeted
Noncoherent Polychromatic
and non-collimated
NON-LASER, ENERGY-BASED MODALITIES
Radiofrequency
Radiofrequency is commonly used for medical
applications ranging from tumor ablation to noninvasive
facial rejuvenation. By definition, radiofrequency
includes electromagnetic frequencies from 3 kHz to
300 GHz (Table 4). When radiofrequency is applied
by an alternating current, an electric field is generated
throughout the skin and subcutaneous tissue. Rapid
electric field shifts result in alternating particle orientation,
resulting in generation of thermal energy, and subsequent
heating of target tissue. Immediate physiological effects
of radiofrequency heating include disruption of hydrogen
bonds between collagen triple helices resulting in random
coils. As a result of thermal injury, inflammatory response
results in neocollagenesis, elastic, and ground substance

TABLE 4
Radiofrequencies and Associated Practical Effects
Frequency Designation
3-30 Hz Extremely low frequency
3-30 kHz Very low frequency
30-300 kHz Low frequency
30-300 GHz Extremely high frequency
0.3-3 THz Terahertz radiation
production. It is purported that collagen remodeling
results in contour changes within the treatment area.
Radiofrequency does not affect epidermal melanin and can
therefore be used in all skin types. Of note, the maximal
dose of radiofrequency has not been standardized.
A wide range of radiofrequency products are
available. A standard radiofrequency device is composed
of three components: a radiofrequency generator, a
handheld tip, and a cooling device. An example of typical
treatment parameters is fluences of 70 to 150 J/cm2 over
fixed pulses (~2.3 s), with associated epidermal cooling
to 35°C to 45°C, and heating at a depth of 3 to 6 mm
to 65°C to 75°C. Sensors in the handheld tip monitor
surface temperature for more uniform energy dispersal.
Radiofrequency devices have been FDA approved for
brow elevation, periorbital rhytides, nasolabial folds, and
middle/lower facial laxity. Radiofrequency technology
is not a substitute for surgical intervention. An ideal
candidate has only early signs of aging or seeks “touch
up” improvement after previous surgical rejuvenation
(e.g., rhytidectomy). Relative contraindications include
elderly patients with thin skin, smokers, history of collagen
vascular disease, and presence of pacemaker or other
implantable device.115,116
ULTRASONIC TECHNOLOGY
Two forms of ultrasound are used in medicine: high-
intensity focused ultrasound (HIFU) and micro-focused
SRPS • Volume 11 • Issue C10 • 2018
Effects
Causes tingling sensation, often imperceptible
Low-level communications
Long-distance communications
Alters cell growth and proliferation, stimulates repair
Medical imaging, spectroscopy
ultrasound (MFU). HIFU uses high energy for an ablative
procedure (e.g., tumor ablation). HIFU has also been
used to ablate adipose tissue using 47 to 59 J/cm2 of
energy at a frequency of 2 MHz, penetrating to depths
of 1.1 to 1.8 cm with the goal of ablating subcutaneous
fat for noninvasive body contouring. HIFU results in
thermal heating and cavitation to cause cell membrane
disruption and cell death. Ultrasound energy causes
molecular vibration to generate heat in the target tissue.
Furthermore, repeated compression and rarefaction of
tissues causes microscopic shear motion to cause further
frictional heating.
In contrast, MFU uses lower ultrasonic energy to
treat superficial skin layers at 0.4 to 1.2 J/mm2 of energy
with a frequency of 4 to 10 MHz at a depth of 1.5 to
4.5 mm. MFU is capable of tissue heating up to 60°C to
produce small thermal coagulation points at depths of
5 mm in the deep reticular dermis and subdermis while
more superficial layers are spared. The goal of MFU is
to heat deep dermis to at least 65°C, the temperature at
which collagen contraction occurs. Commercially available
MFU devices include Ultherapy (Ulthera Inc., Mesa,
AZ). Various transducer hand pieces are available that
emit frequencies of 10.0 MHz, 7.0 MHz, and 4.0 MHz
for treatment focal depths of 1.5, 3, and 4.5 mm to treat
dermis, deep dermis, and subdermal tissues, respectively.
Hand pieces also contain a high-resolution ultrasound
component to allow imaging of facial anatomy during
treatment and to allow the user to have proper coupling
17
 SRPS • Volume 11 • Issue C10 • 2018
between the transducer and skin before energy is applied.
The most commonly reported adverse event is pain
during treatment. This can be mitigated with infiltration
of local anesthetic before the procedure. For example,
one can infiltrate with a 23-G spinal needle along the
neck and mandibular border before treating the jowl and
neck. Potential adjuncts include EMLA cream (Astra
Pharmaceuticals, Wayne, PA) or oral benzodiazepines
administered 60 and 30 minutes pre-procedure,
respectively. Common immediate effects include
erythema, edema, and occasional bruising. Uncommon
events include PIH, muscle weakness, transient numbness,
and wheals. A few absolute contraindications include
open skin lesions, severe cystic acne, and presence of
metallic implants or pacemakers within the treatment
area. Importantly, not all patients experience an aesthetic
benefit. An ideal patient is younger, with normal wound
healing, good skin quality, and mild skin laxity or jowl
formation. Limited data are available to indicate that
patients with BMI ≤30 kg/m2 experience better aesthetic
outcomes. In our experience, a 10% to 15% patient
conversion rate to surgical rejuvenation is typical.117,118
PRE-PROCEDURAL PATIENT EVALUATION
Medical History
It is important to understand how to conduct an initial
patient evaluation in the office before proceeding with
laser-based therapies. The surgeon must be able to
determine whether a patient has realistic expectations
regarding the outcome of laser treatment. Patients should
be able to prioritize and communicate their areas of
concern. A detailed medical history should be obtained
to elucidate any existing medical comorbidities that could
interfere with therapy, such as light-induced seizures.
One should inquire about previous laser treatments for
lesion or hair removal and tattoos to the affected area
(e.g., tattooed makeup or eyebrows), which can become
severely miscolored after treatment. Additional gathered
information should include age, degree of laxity, history
of smoking, ethnicity, and pain threshold. A skin care
regimen should be discussed and encouraged. As a general
rule, we recommend that patients pursue 30 days of
diligent skin care to optimize skin health before laser
treatment. If a patient seeks hair removal, one should
inquire whether the patient tweezes, waxes, or shaves the
18
affected area to ensure that potential treatment areas are
not missed. Considering that a large proportion of patients
seeking laser therapy are of child-bearing age, one should
inquire about the possibility of pregnancy. Although
pregnancy is not a strict contra-indication, it might be
prudent from a medicolegal perspective to delay treatment
until after pregnancy. History of both systemic and topical
medications should be reviewed, particularly in cases
of dermatological inflammatory conditions and topical
immunomodulatory therapy.
Physical Examination
One should note the overall appearance of the patient’s
skin, including thickness, quality, Fitzpatrick skin type
(Table 5), and hair growth thickness and pattern. A
templated face or body diagram can be useful. Of note,
if a patient is of a higher-risk Fitzpatrick skin type,
consideration should be given to pre-procedural treatment
with hydroquinone. Pre-procedural photos should always
be taken before proceeding with any laser or light-based
therapy.
Glogau Classification of Photoaging
Typically, ablative resurfacing has the potential to change
a patient’s photoaging score by one tier but not more
(Table 6).119
Pre-procedural Counseling and Informed Consent
The clinician should have a frank discussion with the
patient regarding potential discomfort during laser therapy
to manage expectations before proceeding with treatment.
Treatment end points include light erythema, perifollicular
edema, and slight “hot needle” sensation. End points in
excess of these place the patient at substantial risk for
thermal injury. The potential for unwanted blistering,
hyperpigmentation, or hypopigmentation should be
explicitly discussed with the patient pre-procedurally
and well documented with informed consent. Patients
should be counseled that their skin might have a slight
“sunburned” appearance for up to 6 hours after the
procedure. Before treatment of vascular lesions, patients
should be warned to avoid vasodilatory activities (e.g.,
drinking alcohol, eating spicy foot, and vigorously
 SRPS • Volume 11 • Issue C10 • 2018

TABLE 5
Fitzpatrick Skin Type and Commonly Associated Nationalities

Skin Fitzpatrick Skin Type Common Nationalities

Type

1 Very fair: always burns in the sun and never tans Celtic

2 Fair: burns in the sun and tans with great difficulty Scandinavian

3 Fair: burns in the sun but tans gradually Caucasian

4 Medium: hardly ever burns in the sun and tans with ease Mediterranean, Hispanic,
and some Asian

5 Light brown: rarely burns in the sun and tans profusely Pakistani and Indian

6 Dark brown: never burns in the sun and is deeply pigmented African

TABLE 6
Glogau Classification of Photoaging119

Type Description Skin Characteristics

I No wrinkles Early photoaging with mild pigmentary changes

II Wrinkles in motion Early to moderate photoaging with lentigines and smile lines

III Wrinkles at rest Advanced photoaging with dyschromias and wrinkles

IV Only wrinkles Severe photoaging with wrinkles throughout, no normal skin

exercising) for at least 5 days. Vasodilatory activities
can cause the treated vessels to reopen. The clinician
should discuss options for pre-procedural analgesia (e.g.,
nerve blocks, local infiltration, or topical anesthetics).
Limited data indicate that transdermal delivery of topical
anesthetics might be enhanced with low-energy laser
pretreatment.120
POST-PROCEDURAL CARE
Meticulous post-procedural care is necessary to
obtain optimal results after laser resurfacing. Debate
exists regarding whether open or closed dressings are
optimal after laser resurfacing. Open dressings can be
associated with a slight increase in patient discomfort
and inconvenience of persistent skin weeping. Potential
advantages to open dressings include fewer wound
infections, decreased wound maceration, and ongoing
surveillance of resurfaced skin. Most open wound care
regimens consist of frequent normal saline, 0.25% acetic
acid or cool water soaks for 20 minutes every 2 to 4
hours, and then gentle skin wiping. Adjuncts include cold
compresses and emollients. On the other hand, numerous
studies suggest that closed wound care with occlusive
dressings might speed reepithelialization, decrease crusting,

19
 SRPS • Volume 11 • Issue C10 • 2018
and cause discomfort, erythema, and edema.121-124
Options for closed dressings include Biobrane (Smith &
Nephew, Memphis, TN), Flexzan (UDL Laboratories, Inc.
Rockford, IL), or Vigilon (C. R. Bard, Inc., Covington,
GA) for 3 to 5 days. Some clinicians opt for closed
dressings for 1 or 2 days, after which time wounds are then
left open to air.
Routine use of antioxidants is generally not
recommended. In the event that PIH occurs, the clinician
should be prepared to prescribe a comprehensive skin
care regimen, which can include hydroquinone and
antioxidants such as vitamin C or vitamin A. Further
adjuncts for the management of post-procedural PIH
include a light chemical peel every 4 weeks and then
a round of IPL down the line if necessary. Further
management protocols for specific laser treatment-
related complications are discussed in the Side Effects,
Complications, and Corresponding Management
Options section.
SKIN RESURFACING
Skin Physiology and Characteristics of Aging Skin
Normal skin has an organized arrangement of elastic fibers
on a dense background of well-aligned collagen fibers. The
dermis comprises cellular and extracellular components.
It derives its structural support from an extracellular
matrix made up of collagen. Collagen fibers are triple
helical amino acid compounds that are strengthened by
crosslinking of proline and hydroxyproline. There are
up to six different types of collagen. In adult skin, the
most common is type I collagen, produced by fibroblasts
and comprising 80% of the dermal collagen.91 Elastic
fibers make up a relatively small portion of skin (1%–
2%) and are responsible for the properties of stretch
and recoil. They are composed of amorphous elastin
proteins and more structured proteins called fibrillin.
Glycosaminoglycans, which are polysaccharides linked to
proteins in their terminal ends, bind a large amount of
water in the dermis and regulate skin hydration. These
compounds are important in the regulation of cellular
movement, cellular interactions, basement membrane
integrity, and collagen and elastic fiber formation. Other
cellular components of the dermis are fibroblasts, mast
cells, and macrophages. Fibroblasts are responsible
20
for production of the extracellular matrix (collagen).
Mast cells release vasoactive substances that mediate
inflammatory responses and promote wound healing.
Macrophages are phagocytic cells that remove
injured tissue.
Our skin is the most visible indicator of age. Skin
aging is a process in which intrinsic and extrinsic factors
lead to progressive loss of skin integrity and physiological
function. Extrinsic aging factors are, in part, controllable.
Examples include environmental or lifestyle contributors,
such as UV solar radiation, prolonged exposure to cigarette
smoke, and repetitive mimetic muscle movements (e.g.,
squinting and frowning). Studies have shown that both
UVA exposure and repeated contact with tobacco smoke
each independently leads to accelerated skin aging. The
effects of UV radiation on skin are commonly referred to
as photoaging. Factors that influence photoaging include
frequency, duration, and intensity of sun exposure
and natural protection afforded by skin pigmentation.
Photoaging more prominently affects fair-skinned patients
(Fitzpatrick skin types I and II) and can be less noticeable
in those with Fitzpatrick skin types III+. Photoaging
accounts for the vast majority (80%-90%) of skin aging,
and its effects can be seen as early late teenage years. In
contrast, intrinsic aging occurs inevitably as a result of
genetic predisposition, also known as chronological aging.
Chronological aging manifests as decreased number of
fibroblasts, mast cells, and blood vessels, with global
thinning of the dermis. These microscopic changes usually
manifest in persons later in life, typically in their 60s to
70s.125 Decreased elasticity occurs with aging, as evidenced
by fewer or disorganized elastic fibers. The effects of
chronic sun exposure can be profound. In a process
called solar elastosis, normal elastic fibers accumulate in
an abnormal arrangement while collagen fibers decrease
in number. Sun-damaged skin shows poor organization
of collagen fibers with clumps of elastic material
interspersed. In a layer superficial to this solar elastosis
(but still deep to the epidermis) is a thin zone of dermis
called grenz or border zone. The production of this layer
is thought to be a reparative process, providing a normal
layer of dermis over the damaged dermis, and to supply
appropriate nutrients to the epidermis (Table 7).119,126-131
In general, skin resurfacing removes the photodamaged,
aged, or scarred skin to allow dermal regeneration and
reepithelialization.132,133
 SRPS • Volume 11 • Issue C10 • 2018

TABLE 7
Changes in Skin Characteristics Caused by Photoaging versus Intrinsic Aging

Characteristic Photoaging Intrinsic Aging Reference

Clinical appearance
Skin color
Onset
Severity
Epidermal thickness
Epidermal proliferative rate
Keratinocytes
Dermal-epidermal junction
Vitamin A content
Dermal elastin
Elastin matrix
Collagen production
Grenz zone
Microcirculation
Inflammatory response
Nodular, leathery, course Smooth, unblemished, loss Glogau119
wrinkles, furrows of elasticity, fine wrinkles,
pigment diminishes
to pallor
Irregular pigmentation Pigment diminishes Rees126
(dyschromias, lentigines) to pallor
As early as late 2nd decade Typically 60s+ (women Klingman and
earlier than men) Lavker127
Strongly associated with degree Only slightly associated Rees126
of pigmentation with degree of
pigmentation
Acanthropic (increased) in early Thins with ageing Takema et al.128
stages, atrophy in end stages
Higher than normal Lower than normal Lavker129
Loss of orderly maturation, Modest cellular irregularity Kligman and
increased atypia among Lavker127
individual keratinocytes
Extensive reduplication of Modest reduplication of Gilchrest130
lamina dense lamina dense
Destroyed by sun exposure Retinol content of Seité et al.131
plasma increases
Degeneration of collagen and Elastolysis (“moth-eaten Kligman and
deposition of abnormal elastotic fibers”) Lavker127
material (thickened, tangled
elastic fibers)
Massive increase in elastic fibers, Gradual decline in Klingman and
replacing the collagenated production of dermal Lavker127
dermal matrix matrix, only modest
increase in number and
thickness of elastic fibers in
the reticular dermis
Decreased amounts of Mature collagen more Lavker129
mature collagen stable in degradation
Prominent Absent Lavker129
Vessels dilated (2/2 loss of Microvessels decrease, Gilchrest130
extracellular matrix support) à remaining vessels
telangiectasias unchanged
Pronounced chronic No inflammatory Gilchrest130
inflammation, perivenular, response observed
histocytic-lymphocytic infiltrate

21
 SRPS • Volume 11 • Issue C10 • 2018
Ablative Rejuvenation
Ablative lasers are used to resurface and rejuvenate the
skin, treating rhytids, dyspigmentation, and scars. The
most common lasers used for skin resurfacing are the CO2
and the erbium:YAG systems.
Initial CO2 continuous-wave lasers, introduced in
1964, have given way to newer short-pulsed (UltraPulse
laser; Lumenis, Yokneam, Israel) and scanned systems
(SilkTouch and FeatherTouch lasers; Lumenis) with less
collateral thermal damage.134 CO2 and erbium lasers
are considered ablative lasers because they produce
epidermal vaporization. After laser energy is absorbed,
a zone of tissue vaporization forms, surrounded by a
zone of thermal injury. The thermally damaged zone is
subdivided into areas of irreversible damage (necrosis)
and areas of reversible damage. Both zones stimulate an
inflammatory reaction leading to subsequent wound
healing. The treatment goal is to ablate (vaporize) more
superficial tissues and to coagulate deeper tissues. Then
collagen remodeling can occur within the controlled
region of thermal injury.134,135 It is generally accepted that
treatment should be limited to areas with an abundance
of pilosebaceous units (e.g., the face). CO2 lasers have a
higher ablation threshold than erbium lasers, which results
in deeper thermal heating and ablation for the CO2 laser.
The average depth of ablation for CO2 lasers is 20 to 60
mcm/pass (with 20–150 mcm of additional collateral
thermal injury). This is true for the first pass, but with
each subsequent pass less ablation and more thermal injury
occurs. The average time for skin to reepithelialize after
CO2 laser treatment is 8.5 days.
Introduced in 1996, erbium lasers have a higher
water absorption coefficient than CO2 lasers (~10×
more efficient), and they ablate tissue with less thermal
damage. Erbium lasers can ablate tissue to a depth of
3 to 5 mcm/pass, with collateral thermal damage of 20
to 50 mcm.136 The pulse width of variable-pulse-width
erbium lasers (such as those manufactured by Sciton Inc,
Palo Alto, CA) can be expanded to 100 mcm to increase
dwell time on tissue. Thus, an erbium laser can mimic
the effect of the CO2 laser by creating more thermal
effect and less ablation per pass. The increased control
afforded by these systems has been reported to contribute
to shorter periods of post-procedural erythema and
lower risk of hypopigmentation.137 The average time for
22
reepithelialization after treatment with erbium laser is
shorter (~5.5 days). However, comparative studies showed
that recovery time and results were determined more by
the depth of injury rather than by the type of laser used.138
Clinically, the extent of post-treatment skin erythema
correlates with the depth of injury and with the degree of
thermal injury. Erythema is more intense and persistent
after CO2 laser treatment—usually lasting for 3 to 4
months but occasionally present for 6 months or more—
than with erbium laser treatment—several weeks.139
CO2 lasers cause skin contraction. Studies have
demonstrated 20% to 60% long-term reduction in dermal
surface area.139-141 Although the exact mechanism of skin
shrinkage is unclear, histological examination shows that
shortened collagen fibers are seen deep to the zone of
thermal damage after laser application. These collagen
fibers are thought to be responsible for the apparent skin
tightening observed clinically. Other studies suggest that
skin contraction is a function of collagen remodeling
rather than contraction.142 The histological effects during
a pass of an ultrashort-pulsed or scanned CO2 laser are
fairly consistent. The initial pass ablates epidermis and
creates epidermis-dermis separation. Any additional passes
deliver energy to the dermis, causing an increasing zone of
residual thermal damage but with minimal additional true
ablation. The region of solar elastosis is thinned after laser
application, and the subepidermal grenz zone is thickened
in the healing process. The grenz layer contains collagen at
a higher density than in normal papillary dermis but less
than in scar tissue. On the other hand, the cellular content
of this layer is higher than that of scar tissue.143 The elastic
fiber content is reduced during the healing phase. Overall,
wound healing is mediated by controlled inflammation,
thickening the grenz zone over a thinned layer of solar
elastosis. This period of inflammation tends to last longer
than the typical acute phase of wound healing and
manifests clinically as prolonged erythema. The theory
that reduced residual or collateral thermal damage allows
for faster healing and a shorter inflammatory phase (less
erythema) was the impetus for the development of the
Er:YAG laser. However, some studies comparing CO2 and
erbium:YAG lasers have shown equivalent healing times
when controlling for the depth of ablation and thermal
damage.144,145 The skin contraction and hemostasis seen
with CO2 lasers is not as readily apparent initially for
the Er:YAG lasers but is almost the same by 90 days.

Both CO2 and Er:YAG lasers have water as their tissue
target chromophore. Peak absorption for water occurs at
approximately 2.9 mcm, which corresponds to the Er:YAG
laser. At 10,600 nm, water absorption is still notable but
is less than at 2940 nm. The increased affinity for water
by Er:YAG lasers results in more absorption of energy
and more ablation compared with CO2 lasers, especially
when treating the dermis. The ablation threshold is 1 J/
cm2 for erbium lasers versus 5 J/cm2 for CO2. Ablation
with Er:YAG is 3 to 5 mcm/J. Initially, Er:YAG lasers
were thought to have only superficial effects, but a deeper
ablation level can be achieved with increasing energy. For
example, an energy level of 10 to 20 J will ablate 40 to 80
mcm of tissue with each pass. Similar increases in energy
with CO2 lasers extend residual thermal damage, which
primarily causes coagulation with minimal
additional ablation.
Variable-pulse-width Er:YAG lasers are capable of
delivering energy with long pulses relative to the tissues’
TRT. Increased pulse duration increases residual thermal
damage, such that the erbium laser behaves more like
the CO2 laser. These variable-pulse-width lasers were
developed to have a controllable mix between primary
ablation (Er:YAG effect) and primary coagulation (CO2
effect).146 The ablation threshold is the energy required
for tissue vaporization. The energy must be delivered
within a short enough time to limit surrounding thermal
diffusion. The epidermal ablation threshold for CO2 lasers
is approximately 5 J/cm2. CO2 lasers operate within this
ablation threshold to limit the surrounding damage on
the first pass while within the epidermis. On secondary
passes, non-ablative thermal effects predominate because
the ablation threshold for dermis is much higher. With
variable-pulse-width erbium lasers, a deeper penetration
in a controlled fashion can be realized by adjusting pulse
widths and simply making additional passes. For CO2
lasers, additional passes in the dermis lead primarily to
thermal coagulation, not ablation. Treatment techniques
and parameter settings with both the CO2 and Er:YAG
lasers vary widely, although the same basic principles apply.
Initial application removes the epithelial layer and causes
some dermal heating and collagen shrinkage. Additional
passes cause a mix of some degree of ablation with thermal
damage and variable degrees of shrinkage. Ablation
predominates with erbium, whereas CO2 displays more
thermal heating and coagulation. The clinical end point
SRPS • Volume 11 • Issue C10 • 2018
for CO2 laser treatment is a pale yellow color of the skin
surface, representing treatment depth to the mid-reticular
dermis.147-149 The erbium laser’s end points are similar to
those of conventional dermabrasion when ablation is the
primary mode.150 When variable-pulse-width Er:YAG
lasers are used, the end point becomes less well defined
and experience is required to optimize outcome and safety.
Common complications of ablative laser
resurfacing include but are not limited to scarring,
infection, pigmentary changes (hyperpigmentation or
hypopigmentation),150,151 and prolonged wound healing.
To prevent wound healing complications, great care
should be taken to respect clinical end points and stop
treatment before violating the deeper reticular dermis.
Deepithelialization in perioral regions subjects patients
to problematic herpetic lesions, and prophylaxis is
recommended regardless of history of previous herpetic
infection.152 Treatment should be avoided with suspected
active infection. The question of prophylaxis for bacterial
or fungal infection is debated in the literature. Any
apparent post-treatment infection should be cultured
and treated with culture-guided appropriate therapy.
Pigmentary changes range from transient PIH, which
commonly is associated with post-treatment sun exposure
and more permanent hypopigmentation. Judicious use of
sun-blocking agents and sun avoidance is recommended
after treatment extending throughout the period of
post-treatment erythema—usually 4 to 6 months.
Comparisons of the CO2 and Er:YAG lasers in terms of
efficacy and postoperative healing have yielded ambiguous
results.70,138,153-157 It is generally accepted that CO2 lasers
result in longer periods of erythema than do Er:YAG
devices.158 Many regard erythema as a sign of collagen
deposition,96 whereas others consider prolonged erythema
a treatment complication.105,159 Combination treatment
using both the CO2 and erbium lasers has been reported
in a large series.105 Pretreatment with botulinum toxin can
lead to an increased ability to improve problematic facial
rhytides.160,161
Non-ablative Rejuvenation
Because of the increasing desire of patients for minimal
downtime and decreased morbidity from elective cosmetic
procedures, non-ablative laser resurfacing has gained
widespread popularity. Although the results are highly
23
 SRPS • Volume 11 • Issue C10 • 2018
variable and cannot compare with those obtained from
ablative lasers, non-ablative techniques are still deservedly
popular.162-165 Non-ablative lasers and light sources for
skin resurfacing come from both the infrared and visible
portions of the electromagnetic spectrum and from
broadband light sources.
Infrared lasers used for non-ablative resurfacing
include the 1320-nm YAG,72,166 1450-nm diode, and
1540-nm Er:Glass.167,168 Again, although infrared lasers
cannot match the results obtained with CO2 or Er:YAG
devices, they have the advantage of speedy recovery.
Candidates for infrared laser treatment must be willing
to trade small gains and variability of outcome for the
convenience of minimal downtime. A great debate exists
regarding which system is more efficacious.169 Visible
light lasers, such as the pulsed-dye170-173 and pulsed
532-nm systems, and the Q-switched Nd:YAG174 and
Q-switched alexandrite lasers conservatively remodel
with minimal healing times. Regarding the pulsed-
dye laser (585 nm),175 it is theorized that the typical
urticaria after treatment represents vasoactively mediated
remodeling of the dermal extracellular matrix. Broadband
light sources—IPL systems—have shown impressive
versatility and have made an impact on non-ablative
remodeling and photorejuvenation. The benefit of IPL
treatments in photoaged skin seems to be primarily an
improvement in irregular skin pigmentation, although
skin textural improvement is also noted.113,176-178 Collagen
deposition in the papillary dermis has been documented
in immunohistological studies.74 Several treatments are
recommended to produce maximal effect. In addition,
patients with higher Fitzpatrick skin types (IV, V, or
VI) should be treated cautiously and with less aggressive
protocols.176 Levulinic acid (ALA) (Levulan; DUSA
Pharmaceuticals, Inc., Wilmington, MA) or methyl
aminolevulinate (MAL) (Metvix; Galderma, Lausanne,
Switzerland) can be applied to the skin and activated by a
laser or broadband light source using a treatment known
as photodynamic therapy (PDT).179,180 Photorejuvenation
using broadband light sources typically requires a series
of treatments, and the number of these treatments can
often be reduced with PDT. These treatments result in
more post-treatment erythema and a period of extreme
photosensitivity but are offset by greater efficacy of
treatment, in the general opinion. The only FDA-approved
indication for ALA and MAL PDT is the treatment of
24
actinic keratosis. Off-label uses include treatment of acne
vulgaris and Bowen disease.181-183
Fractional Ablative and Non-ablative Lasers
Fractional photothermolysis is a relatively new concept
in laser resurfacing whereby skin is treated in core
sections (microthermal zones), leaving untreated areas
to promote rapid healing.184-188 Because this technology
takes advantage of non-uniform injury to the skin, it
can be used both on and off the face. Initially, fractional
photothermolysis was developed as a non-ablative
modality using an erbium glass laser (1550 nm). Treated
tissue is not vaporized, so the stratum corneum is
intact. The epidermal coagulated tissue is expelled and
replaced by keratinocyte migration. Dermal byproducts
are also expelled as microscopic epidermal and dermal
necrotic debris (MEND). In this way, epidermal and
dermal pigmentation is treated using water and not
melanin as the primary chromophore. Zones of collagen
denaturation in the dermis cause upregulation of the
inflammatory cascade, which leads to collagen production
and remodeling. Fractional photothermolysis is used to
treat epidermal pigmentation, melasma,188,189 rhytides,
and textural abnormalities such as acne190 and surgical
scars.124,191,192 Recently, the technology has been applied
with the CO2 wavelength as an ablative alternative to
traditional resurfacing. This application has the theoretical
advantage of fewer complications than traditional
uniformly ablative lasers—e.g., less risk of PIH or
prolonged wound healing. Because it is ablative, CO2
fractional photothermolysis works better on rhytides than
the non-ablative erbium glass counterpart, albeit with
longer downtimes for wound healing. It also can be used
safely off the face provided the parameters are adjusted
accordingly. Although this technology is still relatively
new, its clinical uses are notable in terms of efficacy,
decreased downtime, decreased complication rates, and
office applications.
Hybrid Fractionated Lasers
Historically, patients who did not want deep, full-field
erbium resurfacing were presented with two alternatives:
either fractional ablative treatment (fewer sessions with
more downtime in between) or non-ablative fractional

treatments (more sessions with less downtime). Dual
wavelength hybrid fractional lasers (HFL) have since been
developed that use both 2840-nm Er:YAG laser (delivering
epidermal ablation, 0-100 mm) sequentially followed
by 1470-nm diode laser (for 100-700 mm of dermal
coagulation) for simultaneous treatment of epidermis
and dermis (Fig. 13)193 within the same treatment zone
(Sciton). The fractional component of the treatment allows
the epidermis to more quickly heal over an intact dermis,
considering that keratinocytes can rapidly migrate across
fractionate holes. For example, with <100 mm ablation,
the epidermis is able to regenerate from the basal cell layer
within 24 hours. Coagulated dermis heals more slowly
during a period of approximately 1 week. The rationale
for combining ablative and non-ablative modalities in a
fractionated way is that one can obtain more dramatic
ablative-type results with a shorter, more non-ablative-
type healing process. Early studies of clinical results
report improved skin texture, pigment, and pore size and
number. Further studies to corroborate these results are
ongoing.137
VASCULAR LESIONS
Table 8 presents information on lasers commonly used in
the treatment of vascular anomalies.
TATTOO REMOVAL
Tattoo art has existed for thousands of years. A recent
American poll indicates that tattoos are on the rise, with
just under 30% of all American adults and approximately
50% of millennials having at least one tattoo.194 However,
approximately 25% of adults regret getting a tattoo.
Accordingly, tattoo removal is also on the rise. Laser
therapy remains the gold standard for tattoo removal.
Understanding tattoo classification is critical for
thorough pre-procedural counseling and setting realistic
expectations regarding successful clinical outcome.
Professional tattoos are typically harder to treat as a result
of elaborate organometallic dye mixtures and deeper,
more uniform pigment placement with a handheld tattoo
gun. They require the greatest number of laser sessions
for effective removal. In contrast, amateur tattoos are
generally easier to treat because of smaller size, more
superficial pigment placement with handheld needles,
SRPS • Volume 11 • Issue C10 • 2018
relative paucity of ink, and a more basic color palate
(i.e., India ink or carbon pigment). Cosmetic tattoos are
applied as permanent makeup, such as eyeliner, lip liner,
or eyebrow pencil. The skin tone and pink shades of ink
that are used typically contain titanium dioxide and iron
oxide pigments. Thus, removal is difficult because of
oxidative reactions that cause ink to turn black during
laser treatment.195 This paradoxical reaction is caused by
the chemical reduction of rust-colored ferric oxide to black
ferrous oxide or white titanium 4+ oxide to blue titanium
3+ oxide.196 If such a tattoo is to be removed, a test spot
or ablative laser treatment (CO2 or erbium) should be
considered.197 Medicinal tattoos are small blue-black
markings placed for the purposes of radiotherapy fields or
port placement sites. These are akin to amateur tattoos in
that they contain sparse black ink. Traumatic tattoos form
as a result of foreign debris like glass, dirt, metal, or carbon
particles that become deeply embedded by blast or abrasive
mechanical forces. Their removal is difficult as a result
of deep pigment location and the potentially incendiary
nature of the embedded material.196 Laser treatment
of incendiary material can cause micro-explosions and
cavitation that ultimately result in atrophic scarring.198
Histological examination of tattooed skin shows
cells containing ink located at the dermal-epidermal
junction. Scattered pigments are found throughout the
upper dermis and within the cell membranes of fibroblasts.
The cells have a surrounding matrix of collagen and
elastic fibers. Pigment can also be found outside fibroblast
membranes, either free within the cellular stroma or
within perivascular macrophages and/or mast cells. With
time, tattoo edges become blurred and pigments fade as a
result of ink migration into deeper dermis and drainage via
lymphatics. As a result, older tattoos might require fewer
treatment sessions.196
Pigments used by tattoo artists are varied and
can elicit intense inflammatory reactions in the skin.
Systemic allergic or hypersensitivity reactions are
uncommon. Patients who experienced allergic reactions
(local or systemic) can potentially incur relapse with laser
treatment; therefore, premedication with antihistamine
or precautions regarding anaphylaxis should be taken.199
Mercury-based (red) pigments can cause allergic
eczematous dermatitis, and all pigments can produce
foreign body giant cell reactions, granulomas, and sarcoid-
like reactions.200
25
 SRPS • Volume 11 • Issue C10 • 2018

Ablative

Ablative
Coagulation
Coagulation

Figure 13. Schematic of hybrid fractional laser system compared with single non-ablative laser. (Modified from Pozner and
Robb.193)

TABLE 8
Lasers Commonly Used in the Treatment of Vascular Anomalies

Laser Wavelength Pulse Duration Commonly Treated

(nm) (ms) Vascular Lesions

Pulsed dye 585, 595, 600 1.5-40 Port wine stains,

superficial hemangiomas

IPL 515-1200 1-10 Telangiectasias,

poikiloderma of Civatte

Pulsed 532 nm 532 1-50 Port wine stains

Pulsed alexandrite 755 3, 5, 10, 20 Port wine stains, spider veins

Diode 800 5-100 Port wine stains, spider veins

Pulsed 1064 nm 1064 50 Port wine stains, spider veins,

superficial hemangiomas

26

TABLE 9
Optimal Treatment Wavelengths for Tattoo Removal
Tattoo Ink Color
Black
Green
Blue
Red
Orange
Yellow
Purple
Tan/Nude/White
Tattoo removal is based on the concept of selective
photothermolysis, as previously described, whereby
a chromophore is heated for shorter than its TRT.
Exogenous pigments are small and have short TRT
(Table 2). Therefore, rapid heating is required to cause
destruction.201,202 Optimal treatment wavelengths are
determined by the absorption peaks of the particular ink
(Table 9).
The Kirby-Desai scale (Table 10) was proposed
to assist in estimating the number of anticipated laser
treatments for removal of a given tattoo.203 Scales are
assigned to six different factors: Fitzpatrick skin type,
tattoo location, color, amount of tattoo ink, inherent
scarring, and ink layering. The authors proposed that
cumulative score correlates with number of anticipated
treatments. The main limitation of this scale is that it does
not take into account the type of laser used.204 No other
prediction scales have been recently assessed or validated.
The use of the argon and CO2 lasers for tattoo
SRPS • Volume 11 • Issue C10 • 2018
Optimal Treatment
Wavelength (nm)
694, 775, 1064
694, 755
694, 755, 1064
532
532
532
694, 755
10, 6000
removal is mostly of historical interest. The argon laser
was the first laser used in tattoo removal by Apfelberg et
al. in 1979.205 Early series showed that more than 50%
of patients had residual tattoo pigment and 20% had
hypertrophic scars. Argon’s laser wavelengths of 488 nm
and 514 nm were appropriate for tattoo pigment, but
non-target absorption of hemoglobin and melanin caused
excessive collateral injury. Poor argon specificity resulted in
diffuse tissue necrosis and fibrosis. The mechanism of CO2
lasers is similar to the thermal coagulation argon lasers,
resulting in nonspecific tissue destruction.206,207 Thus, the
use of CO2 and argon lasers for tattoo removal is no
longer advocated.
Q-switched lasers revolutionized tattoo treatment
and have been the mainstay of treatment for the last
2 decades.208 They produce nanosecond range (10-9 s)
pulse durations with peak energies up to 10 J/cm2. The
Q-switched ruby209 provides permanent dissolution of
tattoo pigment with little collateral damage to normal
tissue.210,211
27
 SRPS • Volume 11 • Issue C10 • 2018

TABLE 10
Kirby Desai Scale for Estimating Number of Treatment Sessions Needed for Tattoo Removal*203

Phototype Location Color Ink Amount Scarring Layering

I: 1 point Head and Black only, Amateur, No scar, No layering,

neck, 1 point 1 point 1 point 0 points 0 points

II: 2 points Upper trunk, Mostly black Minimal Minimal Layering,

2 points with some amount of scarring, 2 points
red, 2 points ink, 2 points 1 point

III: 3 points Lower trunk, Mostly black Moderate Moderate

3 points and red with amount of scarring,
some other ink, 3 points 3 points
colors, 3
points

IV: 4 points Proximal Multiple col- Significant Significant

extremity, ors, 4 points amount of scarring,
4 points ink, 4 points 5 points

V: 5 points Distal ex-

tremity,
5 points

VI: 6 points

* The points for each column can be added up for individual tattoos to arrive at the estimated number of treatment
sessions needed for laser removal, plus or minus 2.5.

A 1990 study conducted by Taylor et al.211
elucidated the mechanism of pigment removal.
The extremely high energy delivered at short pulses
(nanoseconds) causes rapid thermal expansion of pigment
granules. Photoacoustic fragmentation of the pigment into
microscopic particles then occurs, and these particles are
removed by redistribution, trans-epidermal elimination,
and phagocytosis. Because of short pulse widths, thermal
buildup and collateral damage are minimal and subsequent
scarring is rare.160
The Q-switched alexandrite laser emits light at a
wavelength of 755 nm, which is longer than the ruby laser
at 694 nm but shorter than the Nd:YAG laser at 1064 nm.
Typical pulse widths are 90 to 100 ns. In 1994, Fitzpatrick
and Goldman212 analyzed the clinical and histological
effects of this laser. He found good results in the treatment
of blue-black and green pigments but a poor response with
other colors.
The Q-switched Nd:YAG laser with a wavelength of
1064 nm was developed to avoid melanin absorption and
the resultant hypopigmentation common with Q-switched
ruby lasers (694 nm).213-215 The longer wavelength
increases the depth of penetration at pulse widths of 6 to
10 ns.
The Q-switched Nd:YAG laser has been shown
in some studies to be as effective at tattoo removal as
the Q-switched ruby laser.214 The response of black ink
is excellent. Other studies comparing Q-switched Nd-
:YAG to Q-switched ruby laser have shown ruby laser
to be superior in ink clearance but more fraught with
long-lasting pigmentary changes.52,216 As a result, use of
the ruby laser is starting to fall out of vogue. Decreased
melanin absorption at 1064 nm potentially leads to
fewer postoperative problems and is safer in dark-skinned
patients.217,218 Thus, the Q-switched Nd:YAG laser has
become a workhorse laser for tattoo removal.

28

A KTP crystal, which doubles the frequency and
halves the wavelength to 532 nm, is highly effective at
treating red, orange, and yellow inks.217,218 Bear in mind
that a 532-nm wavelength also targets hemoglobin, so
purpura might occur.
In 2012, The FDA approved the use of a 755-ps
alexandrite laser (CynoSure aesthetic laser; Cynosure,
Inc., Westford, MA) for tattoo removal. This technology
delivers energy over a shorter period of time, with lower
fluences and lower thermal diffusion to surrounding
tissues and more specific targeting of pigmented particles
compared with nanosecond lasers, which in theory
lead to fewer adverse affects because tattoo pigment has
TRT of 10 ns or less.219,220 Newer case series propose
improved clinical results and fewer required treatments
with picosecond lasers. Brauer et al.219 examined 12
patients with blue and/or green tattoos and showed 75%
ink clearance after single-treatment 755-nm picosecond
alexandrite laser. In a similar case series, Saedi et al.221
presented 12 patients with black and/or blue tattoos and
showed an average of 4.25 necessary treatments with
755-nm picosecond alexandrite laser for 75% clearance,
compared with eight or nine treatments using Q-switched
755-nm alexandrite and 1064-nm Nd:YAG in separate
studies.84,212,222-224 Additional case series have shown
efficacy (but not superiority) of picosecond Nd:YAG lasers
for treatment of multicolored and yellow tattoos.225,226
Further studies, such as randomized controlled trials, are
needed to substantiate these findings.
HAIR REMOVAL
Unwanted hair growth is an exceedingly common aesthetic
problem. Methods such as plucking, shaving, waxing,
and chemical depilation are temporary measures.227
Traditionally, electrolysis was used for longer-term results;
however, this is a slow process with which a needle is
inserted into a hair follicle and electric pulse is transmitted
through it. With this method, it is feasible to treat only
small areas, numerous sessions over an extended period
are required, and treatment can leave minute scars that are
visible as small follicular bumps.228,229 During the last 20
years, laser treatment has become the leading treatment
for long-term hair removal. Although Goldman et al.139
noted hair follicle injury with ruby laser in 1963, the first
controlled study of laser hair removal with the ruby laser
SRPS • Volume 11 • Issue C10 • 2018
was conducted in 1996. Its introduction was followed by
use of the Nd:YAG laser with carbon topical suspension,
which was the first method approved by the FDA.230,231
Laser heating of carbon damaged hair follicles, but hair
regrowth occurred at 3 months.232 Future methods were
able to target the germinative cells within the follicle bulge
for more sustainable results.
Hair undergoes characteristic cycles of rest (telogen),
transition (catagen), and growth (anagen), and melanin is
most active during the anagen phase. Wavelengths 600 to
1100 nm (e.g., ruby, alexandrite, diode, Nd:YAG, 590-
1200 IPL) are well-absorbed by follicular melanin. Hair
follicles are unique structures in that the chromophore
proper (e.g., melanin) differs from the biological target,
namely pluripotent stem cells in the follicle bulge 1 to
1.5 mm deep to the skin surface. As the melanin absorbs
laser light, it is actually the collateral damage that destroys
bulge cells to affect a long-lasting change.233 Long-pulse
lasers perform within the millisecond range, which is most
appropriate for the 10- to 100-ms TRT of a hair follicle
(Table 2).
Not all hair follicles are in the anagen phase at a
particular location. Therefore, repeated laser treatments are
needed for optimal results. Ideally, treatments are timed to
capture the maximum number of hairs in anagen phase,
but in real life, this is impractical. Anagen and telogen
phases vary widely with body location. Laser hair removal
on the head (telogen, 6–12 weeks) can be at 1-month
intervals; on the trunk and extremities (telogen, 12–24
weeks), 2-month intervals are appropriate. Typically,
two to six sessions are required to achieve optimal hair
removal.169 Most clinical laser centers schedule treatment
intervals at 4 to 6 weeks.
It is important to consider that epidermal melanin is
a competitive target. It follows that darker skinned patients
are at greater risk for thermal blisters and pigmentary
changes, particularly with alexandrite and ruby systems.234
They should be treated at longer wavelengths and lower
initial fluences with aggressive epidermal cooling to
minimize complications. Ideal candidates for laser hair
removal are fair skinned with dark hair.
Long-term results after use of long-pulsed
alexandrite laser range from 65% to 80%.235,236 Bouzari et
al.237 found no significant difference in efficacy between
alexandrite and diode laser when treating Fitzpatrick
29
 SRPS • Volume 11 • Issue C10 • 2018
skin types I through V for hair removal. Handrick and
Alster238 found similar results, comparing long-pulse
alexandrite with long-pulse diode laser in Fitzpatrick
skin types I through IV. However, diode laser-treated
patients experienced more side effects. Further studies
regarding sequential therapy with diode laser followed by
alexandrite laser did not improve efficacy and worsened
side effects, including folliculitis and blistering.239 When
trialed head-to-head, long-pulse alexandrite and long-pulse
diode laser have similar efficacy in skin types I through
IV.240 Similarly, alexandrite lasers show no difference in
efficacy compared with IPL in skin types II through IV.54
Considering that the alexandrite laser can produce shorter
pulse durations, it is well-suited for fine vellus
hair removal.
The 810-nm diode laser relies on light emission
from semiconductor diodes. A sapphire lens is actively
cooled to protect the epidermis while transmitting high
energy to hair follicles. The efficacy of this laser for hair
removal is well documented.45,241,242 It produces efficacy
of 22% to 59% hair removal, which was confirmed by
histological studies assessing reduction in hair thickness
and density.58,59,62,243-245 Because of its longer wavelength,
the diode laser is preferred in treating darker skin types
to produce a more favorable side effect profile. Studies
comparing diode laser head-to-head against Nd:YAG laser
have yielded mixed results. Li et al.246 found higher efficacy
in hair removal with diode laser (78%) compared with
long-pulsed Nd:YAG laser (64%). However, Chan et al.247
found no difference. Barolet248 proposed that the diode
laser produces less pain compared with Nd:YAG in the
treatment of Asian skin. Traditionally, increased fluence
was associated with reduced hair counts, but recent studies
propose a low-fluence approach (5-15 J/cm2) for hair
reduction.248-254 Barolet248 reported decreased discomfort
and fewer side effects, even with high Fitzpatrick skin
types. Reported side effects include transient erythema and
pigment changes. No long-term adverse effects have been
reported. Proposed mechanisms for hair reduction include
“miniaturization” of course hair or photomodulation of
germinative cells to alter hair growth rather than photo-
destroy stem cells in the hair follicle bulge.255
Similar to diode laser, the longer wavelength of
an Nd:YAG laser offers the benefits of less epidermal
melanin absorption during hair removal treatment. A
recent study comparing Nd:YAG against IPL in a within-
30
patient, right-left, assessor-blinded study showed a greater
reduction in hair counts on the Nd:YAG-treated side
(79%) compared with the IPL side (54%) at 6 months.256
The Nd:YAG-treated side was associated with more pain
and inflammation, greater hair reduction, and increased
patient satisfaction. Some authors propose that it can
be considered for patients with Fitzpatrick skin types IV
through VI who desire hair removal as long as the risk
profile is cautiously and thoroughly discussed and the
appropriate aforementioned precautions are taken.257-260
IPL technology is also commonly used for hair
removal. The advantages afforded by IPL include larger
spot size, which allows easier and faster treatment of large
surface areas such as the back or chest. The downsides of
IPL include bulky hand pieces that contain the lamp and
cooling device, which can be challenging to maneuver.
During treatments, the treatment area is coated with gel
and direct skin contact is required, which arguably hinders
direct visualization of the treatment area for local tissue
reaction. Care should be taken to avoid inadvertently
leaving untreated patches of skin. Amin and Goldberg.261
compared IPL with red filter, IPL with yellow filter, diode
laser, and alexandrite laser among patients with skin types
I through III. No statistically significant difference was
observed in efficacy at 6-month follow-up. A split-face
study compared diode with IPL in hirsute women and
showed 40% efficacy in the IPL group versus 34% in
the diode group.262 No difference was noted in patient
assessment of hairiness or patient satisfaction. These
limited data support that IPL has efficacy similar to that of
alexandrite and diode lasers and should be considered for I
through III skin types.
Pretreatment application of sun block, tretinoin,
and/or hydroquinone can reduce the impact of melanocyte
activation. Patients are instructed not to undergo any
chemical or mechanical depilation for several weeks before
treatment. Hair is then shaved, topical anesthetic (e.g.,
EMLA cream) applied, and laser treatment performed
with or without appropriate epidermal cooling.
Immediately after laser treatment, parafollicular
edema and generalized tissue hyperemia or erythema
occur and last 3 to 5 minutes. The intensity of the
reaction diminishes with light colored and sparse hairs.
Most patients describe a transient sensation similar to
sunburn. The erythema can persist for up to 3 days in

the face and up to 1 week on the trunk. Paradoxical
hyptrichosis has been reported to occur after IPL, diode,
and alexandrite lasers in 0.6% to 10% of cases.263-271
The precise mechanisms remain unknown; however,
hypotheses include light stimulating new hair growth
by synchronizing dormant hair follicles into anagen hair
growth and suboptimal fluence inducing vellus hairs to
form terminal hairs. Populations at risk include darker
skin types (III-VI), Mediterranean, Middle Eastern, and
South Asian descent. The treatment includes continued
laser therapy, which ultimately decreases growth.
REMOVAL OF PIGMENTED LESIONS
When considering pigmented lesions amenable to laser
treatment, it is helpful to conceptualize epidermal versus
dermal pigmented lesions. Epidermal lesions include
ephelides (freckles) and solar lentigines. These lesions
are composed of epidermal pigment that originated
from melanocytes in the basal layer. Lasers that target
melanin can be considered to treat these lesions, such
as Q-switched alexandrite, QD ruby, and Q-switched
frequency-doubled Nd:YAG (532 nm).272 IPL with a
500- to 600-nm filter can also be considered for the
aforementioned indications, particularly on the hands,
face, or neck.272-275 Resurfacing is also an option and can
simultaneously address mild textural changes; however,
recovery time is longer at approximately 1 week.
The treatment of congenital melanocytic nevi and
dermal pigmented lesions has been tried with varying
success and remains controversial.276 The largest patient
series consisted of 52 patients, with a total of 314 lesions
treated with ultrapulsed CO2 laser and QD Nd:YAG (532
nm).277 At 8-year follow-up, 95% of patients experienced
pigment reduction, treatment failed in five patients,
and one patient ultimately developed melanoma. This
emphasizes that lesions with malignant potential and those
suspected of being malignant should not be treated with
laser therapy. After laser therapy, nevus cells might remain
viable but non-pigmented, causing serious problems with
lesions surveillance. Pre-procedurally, it can be difficult
to identify premalignant lesions and lesions harboring
malignant cells; if in doubt, a biopsy should be performed
before proceeding with treatment. Citron will not treat
any nodular, asymmetric, ulcerated, variegated, irregular,
large (>10 mm), enlarging, or changing skin lesion or any
SRPS • Volume 11 • Issue C10 • 2018
suspicious or questionable pigmented lesion.278 Therefore,
surgical excision of congenital melanocytic nevi remains
the gold standard.
Café-au-lait macules, either in isolation or in
neurocutaneous syndromes, can be treated with QD
frequency-doubled Nd:YAG, Q-switched alexandrite,
and QD ruby, according to some authors.279,280 However,
recurrence can occur and lesions might require numerous
treatments.281 At best, patients might experience reduced
macule coloration, particularly if sun is avoided.
Examples of histopathologically similar dermal nevi
include Nevus of Ito, Nevus of Ota, and Nevus of Hori.
With these lesions, the melanocytosis is dermally situated;
thus, pigment-specific longer wavelength QD lasers
(e.g., 694-, 755-, and 1064-nm lasers) are preferred.272
Several case series report success in treating these lesions
with Q-switched ruby, QD alexandrite, and Q-switched
Nd:YAG.282-286 A large study of 602 Chinese patients
reported a 92% success rate with QD alexandrite laser over
nine treatments.283
Melasma presents clinically as hyperpigmented
patches across the mid-face, resulting from dermal or
epidermal hypermelanosis. The mainstay of melasma
treatment is topical therapy. Topical regimens include
superficial chemical peels, hydroquinone, tranexamic acid,
and triple topical therapy (mix of hydroquinone, retinoid,
and steroid). The benefits of topical agents include reduced
risk of post-inflammatory pigmentation and rebound
hyperpigmentation. Laser therapies have been cautiously
used as second- or third-line options in cases of recalcitrant
melasma.287 Randomized controlled trials of the treatment
of melasma with triple therapy combined with fractional
Er:glass non-ablative laser versus triple therapy alone
showed worse outcomes with laser treatment because
of PIH.288 Few trials have shown synergistic effects of
combining topical modalities with fractional CO2, pulsed
dye laser (PDL) (to treat accompanying telangiectasias),
or low-fluence Q-switched Nd:YAG.289-291 Proposed
mechanisms for synergy include laser-enhanced
drug delivery.
Treatment of PIH with lasers has largely produced
disappointing results. The response is often variable,
consisting of either incomplete clearance or worsening of
PIH.272,292 Therefore, laser therapy for treatment of PIH is
not recommended.
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 SRPS • Volume 11 • Issue C10 • 2018
Lasers have long been used for facial rejuvenation to
treat rhytides. The mainstay of therapy remains CO2 laser
or Er:YAG, although some authors argue that popularity
is limited by prolonged healing time and CO2-associated
hypopigmentation. Novel fractionated lasers continue to
enhance a plastic surgeon’s armentarium in this arena.293
Several randomized controlled trials comparing CO2
to Er:YAG treatment for facial rejuvenation reported
similar clinical outcomes.144,157,294 Some proposed that
Er:YAG is better for fine-medium rhytides whereas CO2
is better suited for deep lines and skin that is in need of
more extensive tissue tightening.272 Several studies have
shown improved aesthetic outcomes with concomitant
onabotulinumtoxinA administration in patients who have
undergone laser resurfacing.160,161
Other textural conditions, such as the
rhinophymatous nose, can be difficult to treat. Ablative
therapies have been documented to assist with re-
contouring.295-297 CO2 is recommended over erbium laser
because of enhanced blood vessel coagulation and a more
bloodless field. Other methods of addressing rhinophyma
include mechanical debulking with dermabrasion
techniques or sculpting with radiofrequency electrosurgery
wire loop.
TREATMENT OF INFLAMMATORY DERMATOSES
Acne vulgaris is a common inflammatory dermatosis
consisting of comedome and pustule formation, with
severe cases resulting in deep cyst and pustules. Its
psychosocial effects on patients of all ages, including
anxiety, depression, and dysphoria, are pervasive and well
documented. Lasers have been used for non-first-line
therapy and are a subject of ongoing research. Light-
based acne therapy often uses photosensitizers. These
photosensitizers can be endogenously or exogenously
produced. For example, Propionibacterium acnes produces
endogenous porphyrins—heterocyclic tetrapyrole
biochromes that strongly absorb light that then forms
reactive oxygen species within illuminated areas.298
Exogenous photosensitizers are used in PDT, wherein
exogenous light-activated agents, such as ALA and
MAL, and porphyrin precursors are topically applied
and absorbed into the skin. The reactive oxygen species
formed from such compounds are proposed to propagate
oxidative stress that damages bacteria, obliterates sebaceous
32
glands, and reduces follicular obstruction. Evidence
suggests that 10% to 15% ALA is safe and minimizes
side effects, such as blistering, which can occur with 20%
formulations. PDL has been shown to decrease acne
severity, with improvements observed within 4 weeks of
starting treatment.299 IPL has been shown to be as effective
as PDL and diode phototherapy in acne treatment300,301
The effects of PDL have been shown to be enhanced
by photosensitizers like MAL; however, no additional
benefit is conferred with topical clindamycin-benzoyl
peroxide.302,303 Studies regarding KTP, diode (1450 nm),
and Nd:YAG are less conclusive.304-307 Considering the
well-established effectiveness of medical management,
light-based therapies should be reserved for refractory
cases and for patients with contraindications to
acne medications.
TREATMENT OF PREMALIGNANT CONDITIONS
Actinic keratosis have historically been treated with full
CO2 and erbium resurfacing, with results comparable
to those achieved with field 5-fluorouracil and 30%
trichloroacetic acid peels.308,309 Prospective controlled
trials310,311 have shown that premalignant lesions caused
by photoaging can be addressed with PDT. Specifically,
combination therapy with PDT plus fractional CO2 laser
treatment resulted in lower AK recurrence compared
with PDT monotherapy.310,311 Additionally, PDT with
photosensitizers such as ALA with PDL (575-595 nm)
or IPL can significantly clear actinic keratosis.310,312
Pretreatment with ALA 1 hour before vascular laser
therapy not only greatly decreases dysplasic lesions but also
can address pigmentary or vascular changes associated
with photoaging.
NAIL DISEASE
Onychomycosis and nail psoriasis are two nail-
based pathological conditions that deserve special
attention regarding laser therapy. Medical treatment of
onychomycosis can be difficult to implement because of
poor penetration of topical treatments to the nail bed
and the need for prolonged oral medication (e.g., azoles,
polyenes, and allylamines) a with serious side effect profile
(particularly regarding liver toxicity).313 Furthermore, 80%
of patients with psoriasis experience nail involvement,
 SRPS • Volume 11 • Issue C10 • 2018

characterized by pitting, ridging, splinter hemorrhages, of photosensitizing agent by removing overlying

and/or pain caused by involvement of the nailbed and
hyponychium.314-317 Outcomes after topical treatment of
nail psoriasis are largely disappointing and notoriously
refractory, considering that only 20% of patients
experience substantial improvement with topical therapy
and more than 70% of patients desire further therapy
to ameliorate their abnormal nail appearance despite
treatment with corticosteroids, tazorotene, cyclosprin,
or 5-fluorouracil.318 However, combination therapies,
such as PDL in combination with tazarotene, have
been shown to substantially improve psoriatic nails
compared with tazarotene alone.319 Numerous studies
propose that onychomycosis can be effectively treated
with photosensitizers and red light (630 nm) every 1
to 2 weeks, with mycobiological cure noted within 3
to 6 months and lasting up to 2 years in 90% to 100%
of patients.320-322 Typical photosensitizers used include
ALA and MAL. Pretreatment might also include
urea or mechanical abrasion to increase permeability
hyperkeratosis.322-324 A summary of several studies
regarding PDT for use in nail diseases is provided in
Table 11.315,316,320-324
SCAR TREATMENT
Acne Scars
Although acne scars are prevalent in most patient
populations, their treatment poses a difficult challenge.
Long-term results have been marginal at best. During
the last decade, lasers have been used in combination
with surgery (punch excision or grafting), dermal fillers,
chemical peels, and dermabrasion.325,326 Acne scars are
described by their appearance: ice pick, rolling, and
boxcar scars. Ice pick scars are deep seated and narrow.
Rolling scars are undulating, wavy, diffuse, and of
variable depth. Boxcar scars can be superficial or deep,
round or oval, and have sharply demarcated vertical
edges. Boxcar scars resemble chickenpox scars and

TABLE 11
Photodynamic Therapy to Treat Nail Diseases

Study Patients Photosensitizer Incubation Light Source Treatment

Time (h)
Session and
Duration
Fernández- 14 (NP) 16% MAL 3 Pulse dye laser 6 sessions at
Guarino et al.315 4-week intervals
Aspiroz et al.316 1 (O) 16% MAL 3 Red light (635 nm) 3 sessions at
at 37 J/cm2 2-week intervals
Watanabe et 2 (O) 20% ALA 5 Pulsed laser light (630 6–7 sessions at
al.320 nm) at 100 J/cm2 1-week intervals
Piraccini et al.321 1 (O) 16% MAL 3 Red light (630 nm) 3 sessions at
at 37 J/cm2 2-week intervals
Sotiriou et al.322 30 (O) 20% ALA 3 Red light (570–670 3 sessions at
nm) at 40 J/cm2 2-week intervals
Robres et al.323 Literature 16% MAL 3 Red light (630 nm) 3 sessions at 1- to
review (O) at 37 J/cm2 2-week intervals
Souza et al.324 22 (O) 2% Methylene None Red light (630 nm) 12 sessions at
blue at 35 J/cm2 2-week intervals

NP, nail psoriasis; O, onychomycosis; MAL, methyl aminolevulinate; ALA, levulinic acid.

33
 SRPS • Volume 11 • Issue C10 • 2018
respond best to ablative lasers that minimize the steep
scar wall. Ice pick and deep boxcar scars are deeper than
most lasers can penetrate; laser therapy is therefore not as
effective for these scars, which require a surgical approach,
such as punch excision or fat grafting. Shallow boxcar
or superficial rolling scars can be effectively treated with
ablative lasers, such as CO2 or Er:YAG.94,327-330
In 2014, the 755-nm picosecond laser with the
addition of a diffractive lens array (DLA) was cleared for
use in the treatment of acne scars in skin types I through
IV. As previously noted, picosecond lasers deliver short
pulse bursts within the picosecond range, confining
energy to the target and using lower fluences to decrease
epidermal injury and risk of dyspigmentation. The
DLA attachment is comprised of 120 packed diffractive
lenses spaced 500 mm from each other for more highly
concentrated, focused energy that minimizes collateral
damage. The DLA was implemented in part to allow
clinicians to more safely deliver laser treatment to patients
with darker skin types. Studies are limited, but preliminary
retrospective data suggest that picosecond lasers might
be safe and effective for atrophic, hypertrophic, and acne
scars when combined with intralesional adjuncts. More
supporting data are needed; thus, picosecond laser scar
treatment remains an area of ongoing research.331
Scar Prophylaxis
No consensus has been reached regarding the standard of
care for scar prophylaxis or treatment of pathological scars
with laser therapy. However, a few updates regarding laser-
based scar care are worth noting.
Previous work has shown that PDL improves the
cosmetic appearance of erythematous, raised postsurgical
scars. However, recent data suggest that fractional
laser resurfacing outperforms PDL, particularly in re-
pigmenting hypopigmented scars.332 These results are not
altogether surprising considering that fractional lasers have
greater penetration depth and induce focal microthermal
zones of injury in papillary and reticular dermis to
stimulate collagen remodeling.333-335 Furthermore, it is
hypothesized that NAFL can re-pigment hypopigmented
scars by stimulating the migration of normal melanocytes
into resurfaced tissues.336
Few studies have specifically addressed the role of
34
prophylactic laser postoperatively in those Fitzpatrick skin
types that are at high risk for pathological or unattractive
scarring. Several clinical trials have shown prophylactic
1550-nm fractional erbium and 532-nm KTP lasers to be
cosmetically beneficial in Korean patients with postsurgical
head and neck scars with an acceptable safety profile.337,338
However, more data are needed to assess whether
acceptable aesthetic results with low risk of PIH can be
recapitulated in other ethnic cohorts (e.g., Hispanics and
African Americans). Until then, prophylactic laser should
be used with great caution in high-risk Fitzpatrick
skin types.
Hypertrophic and Keloid Scars
Existing evidence supports that fractional ablative CO2
and PDL improve not only the aesthetic appearance of
hypertrophic burn scars (e.g., thickness, erythema, and
pliability) but also symptoms (e.g., pain, pruritus, and
paresthesias) up to 1 year after treatment.339,340 Other
studies emphasize the importance of laser therapy as an
adjunct to traditional pressure garments and a means
to enhance corticosteroid drug delivery to improve
hypertrophic burn scars.341,342 There is no evidence that
laser-treatment of large keloids produces cosmetically
acceptable results.
SIDE EFFECTS, COMPLICATIONS, AND
CORRESPONDING MANAGEMENT OPTIONS
Table 12 lists common side effects and complications of
laser therapy and preventative and treatment measures.
CONCLUSION
From their roots in theoretical physics and works by
Albert Einstein, lasers have transformed modern science.
The development of medical lasers has revolutionized
the practice of cutaneous surgery and is a true testament
to the interplay between industry and academia. Still,
lasers remain a strong component of a plastic surgeon’s
armamentarium. It is critical that all clinicians using
these devices understand not only the physics but also the
dangers, applications, and limitations of laser therapy so
we can deliver high-quality, comprehensive care to our
patients by both surgical and nonsurgical means.
 SRPS • Volume 11 • Issue C10 • 2018

TABLE 12
Laser Therapy: Common Side Effects, Complications, Preventative Measures, and Treatment Options
Side Effect or Complication Prevention Treatment Options

Pain Topical and local anesthetics, cooling measures Ice application immediately
post-procedurally, NSAIDs or narcotics

Erythema and perifollicular Transient, no prevention, expected endpoint of treatment Ice pack application, topical vitamin C
edema after reepithelization

Pruritus Use of bland, non-fragrance-containing emollients to avoid Discontinuation of any self-prescribed

contact dermatitis topical agents/lotions/perfumes,
Steroids and antihistamines to prevent
unintentional scratching of
treated area
Frequent cool compresses

Dyspigmentation Sun avoidance and sun protection (minimum SPF 15) 1 Hyperpigmentation: sun avoidance/
month before and after treatment protection, topical steroids (early),
bleaching agents (hydroquinone, kojic
Use of longer wavelengths
acid), retinoic, azelaic, ascorbic, and
Conservative fluences glycolic acids
Cooling devices Light glycolic acid peels (30-40%)
Appropriate laser selection q2-4 weeks

Judicious laser treatment in darker skin types Hypopigmentation: sun avoidance,

chemical peels to blend lines of
demarcation; 1550 nm nonablative
fractionated laser

Hypertrophic scarring Avoidance of treatment in patients with known history of Steroid (topical versus injection), silicone
pathological scarring gel sheeting, 585 nm pulsed dye
Avoidance of high-energy densities and overlapping of pulses laser, excision

Thermal burns Pre-procedural hair trimming Supportive care with emollients (i.e.,
(blistering, ulceration) Aquaphor or plain petrolatum), analgesics
Selecting appropriate laser device
Avoidance of pigmented lesions or tattoos

Ocular damage (cataracts, iritis, Use of wavelength-specific goggles by patient and all health Urgent ophthalmology referral
pupillary distortion, uveitis, care personnel
photophobia, visual
field defects)

Reactivation of herpes simplex Valacyclovir 1g by mouth b.i.d. for 7 days

virus
Anti-viral premedication 1-2 days before procedure If outbreak on adequate prophylaxis:
Potentiation of vellus hairs in • Acyclovir 400 mg t.i.d • Change antiviral
treatment area
• Famciclovir 250-500 mg b.i.d. • Double dose five times daily
• Valacyclovir 250-500 mg b.i.d. (acyclovir) or 300 mg t.i.d.
(famciclovir and valacyclovir)
If herpetic dissemination, hospitalization
for intravenous acyclovir

Acne induction or Avoidance of occlusive dressings during acute recovery phase Discontinue occlusive dressings
aggravation, milia More common in younger patients Mild: no treatment necessary
Moderate to severe: tetracycline or
minocycline, topical erythromycin or
clindamycin once reepithelialized
Milia: self-resolving versus
manual extraction

Persistent urticaria Avoidance in patients with history of heat- or Topical steroids for 1 week, antihistamines
cold-induced urticarial

Hyperhidrosis Unknown Aluminum chloride, botox injection

NSAIDs, nonsteroidal anti-inflammatory drugs; t.i.d., three times per day; b.i.d., twice a day.

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 SRPS • Volume 11 • Issue C10 • 2018
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SRPS • Volume 11 • Issue R14 • 2018

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