IN THE NAME OF GOD

QSWITCH PICOSECOND LASER

.MAHLA ALIZADEH,M.D
ABAN 01
PICOSURE:
• TATTOO REMOVAL
• PIGMENTED LEISIONS REMOVAL
• CARBON PEELING
:TATTOOS

• AMATEUR DECORATIVE
• PROFESSIONAL DECORATIVE
• COSMETIC
• TRAUMATIC
• MEDICAL
LASER PRINCIPLES
• SELECTIVE PHOTOTHERMOLYSIS
• PHOTOACOUSTIC VIBRATION

• FRAGMENTATION OF LARGE PARTICLES

• RUPTURE OF FIBROUS CAPSULES

• EPIDERMAL EXTRUSION,
• LYMPHATIC DRAINAGE,
• AND MACROPHAGE PHAGOCYTOSIS
LASER PARAMETERS:

• WAVELENGTH aggressive
• FLUENCE • short wavelengths
• high fluences
• PULSE WIDTH • small spot sizes

• SPOT SIZE conservative

• long wavelengths
• REPETITION RATE • low fluences
• large spot sizes
FACTORS AFFECTING THE NUMBER OF TREATMENTS NEEDED FOR TATTOO REMOVAL
DEVICES CURRENTLY AVAILABLE FOR TATTOO REMOVAL
CONTRAINDICATIONS
•
ACTIVE INFECTION
•DERMATOSES
•MELANOMA, OR LESIONS SUSPECTED FOR MELANOMA
• DEEP CHEMICAL PEEL, DERMABRASION OR RADIATION THERAPY PRECEDING 6 MONTHS
• KELOIDAL SCARRING
• BLEEDING ABNORMALITY
• IMPAIRED HEALING
• PERIPHERAL VASCULAR DISEASE
• SEIZURE DISORDER
• UNCONTROLLED SYSTEMIC CONDITION
• CARDIAC PACEMAKER
•SKIN ATROPHY
• LIVEDO RETICULARIS
• ERYTHEMA AB IGNE

• EXPOSURE WITH LASERS

• DIRECT SUN EXPOSURE WITHIN THE PRECEDING 2 WEEKS
• SELF-TANNING PRODUCT WITHIN THE PRECEDING 2 WEEKS
• TOPICAL PRESCRIPTION RETINOID WITHIN THE PRECEDING WEEK
• ISOTRETINOIN (ACCUTANETM) WITHIN THE PRECEDING 6 MONTHS
• GOLD THERAPY (E.G., USED FOR TREATMENT OF ARTHRITIS)
• PHOTOSENSITIZING MEDICATIONS
• PHOTOSENSITIVE DISORDER
• PREGNANT OR NURSING
• UNREALISTIC PATIENT EXPECTATIONS
• BODY DYSMORPHIC DISORDER
• TREATMENT INSIDE THE EYE ORBIT
CONTRAINDICATIONS SPECIFIC TO TATTOO REMOVAL

• TATTOO INK ALLERGY

• AN ALLERGIC REACTION TO TATTOO INK AT THE TIME OF PLACEMENT IS A CONTRAINDICATION
TO LASER TATTOO REMOVAL

• SIGNS OF AN ALLERGIC DERMATITIS (ERYTHEMA, EDEMA, PRURITUS, AND INDURATION), AND

RARELY INFLAMMATORY NODULES AND GRANULOMAS.

• ALLERGIC REACTIONS ARE MOST COMMONLY SEEN WITH BRIGHT-COLORED INKS SUCH AS RED
AND LESS COMMONLY WITH YELLOW, GREEN, AND BLUE INKS.
PREPROCEDURE CHECKLIST
• AESTHETIC CONSULTATION
• TATTOO HISTORY

• TATTOOS EXAMINATION
• FITZPATRICK SKIN TYPE
• INFORMED CONSENT
• PRETREATMENT PHOTOGRAPHS
• AVOIDANCE OF DIRECT SUN EXPOSURE AND DAILY USE OF A BROAD-SPECTRUM SUNSCREEN
• LIGHTENING BACKGROUND SKIN
• TEST SPOT
• ANTIVIRAL MEDICATION
• HAIR IN THE TREATMENT
• SNACKS
• WRITTEN PREPROCEDURE INSTRUCTIONS
PREPROCEDURE CHECKLIST
• AESTHETIC CONSULTATION
• TATTOO HISTORY

• TATTOOS EXAMINATION
• FITZPATRICK SKIN TYPE
• INFORMED CONSENT
• PRETREATMENT PHOTOGRAPHS
• AVOIDANCE OF DIRECT SUN EXPOSURE AND DAILY USE OF A BROAD-SPECTRUM SUNSCREEN
• LIGHTENING BACKGROUND SKIN
• TEST SPOT
• ANTIVIRAL MEDICATION
• HAIR IN THE TREATMENT
• SNACKS
• WRITTEN PREPROCEDURE INSTRUCTIONS
PREPROCEDURE CHECKLIST
• AESTHETIC CONSULTATION
• TATTOO HISTORY

• TATTOOS EXAMINATION
• FITZPATRICK SKIN TYPE
• INFORMED CONSENT
• PRETREATMENT PHOTOGRAPHS
• AVOIDANCE OF DIRECT SUN EXPOSURE AND DAILY USE OF A BROAD-SPECTRUM SUNSCREEN
• LIGHTENING BACKGROUND SKIN
• TEST SPOT
• ANTIVIRAL MEDICATION
• HAIR IN THE TREATMENT
• SNACKS
• WRITTEN PREPROCEDURE INSTRUCTIONS
PREPROCEDURE CHECKLIST
• AESTHETIC CONSULTATION
• TATTOO HISTORY

• TATTOOS EXAMINATION
• FITZPATRICK SKIN TYPE
• INFORMED CONSENT
• PRETREATMENT PHOTOGRAPHS
• AVOIDANCE OF DIRECT SUN EXPOSURE AND DAILY USE OF A BROAD-SPECTRUM SUNSCREEN
• LIGHTENING BACKGROUND SKIN
• TEST SPOT
• ANTIVIRAL MEDICATION
• HAIR IN THE TREATMENT
• SNACKS
• WRITTEN PREPROCEDURE INSTRUCTIONS
ANESTHESIA
• A TOPICAL ANESTHETIC CREAM :
BENZOCAINE:LIDOCAINE:TETRACAINE (BLT)
LIDOCAINE (L-M- XTM),
LIDOCAINE/PRILOCAINE (EMLATM)

• MAY BE APPLIED TO THE TATTOO AND OCCLUDED WITH PLASTIC WRAP TO ENHANCE PENETRATION FOR 30–45 MINUTES
PRIOR TO THE LASER TREATMENT

• SMALL VOLUMES OF 1% LIDOCAINE WITH EPINEPHRINE INJECTED SUBDERMALLY

• ORAL ANALGESICS SUCH AS TRAMADOL (ULTRAMTM) 50 MG 1–2 TABLETS TAKEN 1 HOUR PRIOR TO PROCEDURE OR
STRONGER OPIOIDS SUCH AS HYDROCODONE/ACETAMINOPHEN (VICODINTM) AND OXYCODONE/ACETAMINOPHEN
(PERCOCETTM) ARE OTHER OPTIONS.
TECHNIQUE
• PERPENDICULAR TO THE SKIN AT ALL TIMES

• IN CONTACT WITH THE SKIN WHEN PULSING THE LASER TO MAINTAIN A UNIFORM DISTANCE
FROM THE SKIN.

• COVER THE TATTOO CONFLUENTLY BY PLACING TATTOO PULSES ADJACENT TO ONE ANOTHER
WITH MINIMAL OVERLAP (APPROXIMATELY ≤10%).

• AVOID TOURNIQUETING EFFECT FROM CIRCUMFERENTIAL LIMB EDEMA.

DESIRABLE CLINICAL ENDPOINTS

• WHITENING
• SNAPPING
• ERYTHEMA
• EDEMA (SWELLING)
• PETECHIAE AND PURPURA
UNDESIRABLE CLINICAL ENDPOINTS

• IMMEDIATE BLISTERING

• FRANK BLEEDING
AFTERCARE
• ICE PACK FOR 15 MINUTES EVERY 1–2 HOURS ON THE DAY OF TREATMENT
• BROAD-SPECTRUM SUNSCREEN CONTAINING ZINC OXIDE OR TITANIUM DIOXIDE WITH AN SPF OF 30 OR GREATER IS
APPLIED DAILY WITHOUT A DRESSING.

• IF THE SKIN IS NOT INTACT :

• AQUAPHOR OR BACITRACIN
• LOOSELY COVERED WITH A GAUZE AND TAPE DRESSING THAT IS CHANGED DAILY

• TOPICAL SILICONE
• STRENUOUS EXERCISE AND EXPOSURE TO WATER ARE AVOIDED UNTIL THE SKIN IS INTACT.
TREATMENT INTERVALS

• 4–8 WEEKS APART

SUBSEQUENT TREATMENTS FOR BLACK TATTOOS

• • INTENSIFY LASER TREATMENT PARAMETERS. AT SUBSEQUENT VISITS TATTOO INK WILL BE LIGHTER AND
THE LASER FLUENCE WILL NEED TO BE INCREASED AND SPOT SIZE REDUCED TO ACHIEVE DESIRED CLINICAL
ENDPOINTS.

• TYPICALLY, ONLY ONE PARAMETER IS INTENSIFIED IN A GIVEN VISIT.

• THE FLUENCE IS INCREASED FIRST, WHILE KEEPING THE SPOT SIZE CONSTANT.
• AFTER MAXIMIZING THE FLUENCE OVER SEVERAL VISITS, THE SPOT SIZE IS THEN DECREASED WITH AN
ASSOCIATED REDUCTION IN FLUENCE.

• ONCE THE INK COLOR IS LIGHTENED, AND IF THERE IS MINIMAL TO NO CHANGE WITH THE Q-SWITCHED
• 1064 NM WAVELENGTH, SHORTER WAVELENGTHS SUCH AS QS 532 NM CAN BE USED INSTEAD OF THE QS
1064 NM TO INTENSIFY TREATMENTS.
SUBSEQUENT TREATMENTS FOR MULTICOLORED
TATTOOS

• FOLLOW RECOMMENDATIONS ABOVE FOR BLACK TATTOOS

• ONCE THERE IS MINIMAL TO NO CHANGE IN A PARTICULAR COLOR AFTER TREATMENT WITH THE
Q- SWITCHED 1064 NM, DISCONTINUE USE OF 1064 NM AND SELECT THE WAVELENGTH SPECIFIC
TO THE TATTOO INK COLOR BEING TARGETED

• TOWARD THE END OF A TREATMENT SERIES, MULTICOLORED TATTOOS OFTEN LOOK “MUDDY”
WITH INDISTINCT COLORS. SHORTER WAVELENGTHS SUCH AS Q-SWITCHED 532 NM CAN BE USED
FOR THE FINAL STAGES OF REMOVAL.
RESULTS
COMPLICATIONS
• Pain
• Hyperpigmentation
• Hypopigmentation
• Blisters and bullae
• Bleeding
• Prolonged healing
• Textural change
• Scarring
• Incomplete ink removal
• Infection
• Dermatosis exacerbation (e.g., psoriasis, atopic dermatitis)
• Allergic reactions
• Paradoxical tattoo darkening (common with cosmetic tattoos)
• Ignition of flammable debris (possible with traumatic tattoos)
• Vasovagal episode/syncope or hypoglycemia
• Compartment syndrome
PIGMENTED LEISIONS BY QSWITCH LASER
TYPES OF BENIGN PIGMENTED LESIONS
• SHORT WAVELENGTH LASERS THAT TARGET MELANIN (E.G., 532 NM) ARE MOST EFFECTIVE FOR
EPIDERMAL LESIONS AS THEY HAVE HIGH MELANIN ABSORPTION AND SUPERFICIAL
PENETRATION. LONGER WAVELENGTH LASERS (E.G., 1064 NM) ARE MOST EFFECTIVE FOR
DERMAL PIGMENTATION AND ARE SAFER FOR TREATMENT OF PATIENTS WITH DARK SKIN TYPES
(IV–VI).
• MELANOSOMES ARE VERY SMALL IN SIZE (APPROXIMATELY 1 ΜM)
AND RESPOND WELL TO THESE EXTREMELY SHORT PULSE WIDTHS.
• IN ADDITION, THE SHORTER WAVELENGTH LASERS (QS 532 NM,AND
QS 755 NM) HAVE STRONG ABSORPTION BY MELANIN AND ARE VERY
EFFECTIVE FOR TREATING EPIDERMAL PIGMENTED LESIONS SUCH AS
FRECKLES AND LENTIGINES IN LIGHT SKIN TYPES.
CLINICAL ENDPOINTS :

• CRISP
• WHITE SPOTS
• AND OFTEN INDUCE PETECHIAE.

• WHEN TREATING DISCRETE LESIONS WITH THESE WAVELENGTHS, SPOT SIZE IS CHOSEN TO
MATCH THE SIZE OF THE LESION TO AVOID PIGMENTARY CHANGES TO THE SURROUNDING SKIN.
• IN ADDITION TO TREATING DISCRETE EPIDERMAL LESIONS, QS 532 NM AND QS 755
NM LASERS CAN BE USED TO TREAT LARGE PHOTODAMAGED AREAS CONFLUENTLY
IN LIGHT SKIN TYPES.

• DUE TO A GREATER DEPTH OF PENETRATION AND LOWER MELANIN ABSORPTION,

THE QS 1064 NM LASER IS USED TO TREAT DERMAL CONDITIONS SUCH AS MELASMA,
POIKILODERMA OF CIVATTE, AND PIH, AND IS SAFE IN ALL SKIN TYPES (I–VI).
CARBON PEEL: