LASER TREATMENT FOR VASCULAR, PIGMENTED AND CUTANEOUS DISORDERS: PERFORMANCE AND RECOVERY RATIO RELATED TO SAFETY AND EFFICACY

Transcription

1 A PRELIMINARY REPORT ON THE LINLINE MULTIPLE WAVELENGTH LASER PLATFORM: LASER TREATMENT FOR VASCULAR, PIGMENTED AND CUTANEOUS DISORDERS: PERFORMANCE AND RECOVERY RATIO RELATED TO SAFETY AND EFFICACY Mario A. Trelles, M.D., Ph.D., Instituto Médico Vilafortuny, E Cambrils,Tarragona

2 A PRELIMINARY REPORT ON THE LINLINE MULTIPLE WAVELENGTH LASER PLATFORM: LASER TREATMENT FOR VASCULAR, PIGMENTED AND CUTANEOUS DISORDERS: PERFORMANCE AND RECOVERY RATIO RELATED TO SAFETY AND EFFICACY Mario A. Trelles, M.D., Ph.D., Instituto Médico Vilafortuny, E Cambrils,Tarragona The author declares no commercial interest in the Multiline Linline Laser Platform. This preliminary report was contracted with the Instituto Médico Vilafortuny. The use of this laser is backed by the CE Mark for the Application of Medical Technology. INTRODUCTION The application of laser systems in medicine and surgery is rapidly moving forward, and nowadays is solidly established as a first line therapeutic armamentarium in various specialities (1). Laser treatments are the focus of interest for doctors who are following technological developments and new treatment options with advantages over traditional methods (2). A multi-application laser platform where various wavelength emissions can be selected provides a possibility of a single unit, polyapplication appliance, as an alternative to the typical situation of having a separated laser device for each specific application (3-4). Ideally, a complex technology that accommodates various lasers and includes several programmes too in a single console, offers multiple variables for treatment of different pathologies (5). Appropriate settings based on the experience of well trained and expert doctors when included in the software help achieve successful treatments. Also, simple to carry out treatments should enable amateur physicians to use lasers with correct results based on application programmes built into the device (6). In the specific case of the Linline Multiple Laser Platform (Fig. 1), various wavelengths have been selected to target multiple cutaneous conditions such as pigmented and vascular disorders of congenital or acquired origin, elevated skin lesions, tattoos and hair removal, as well as to treat signs of skin ageing and for scar revision. Applications can extend to incisional surgery and coagulation or ablation using the 1079 nm and 2930 nm wavelength respectively (7-9). Fig. 1 The Linline Multiline laser platform. The console contains the power supply and software, connecting the various laser heads via an umbilical cord.

3 THE VARIOUS APPLICATIONS The KTP, Ruby, Alexandrite and Nd:YAP lasers The visible green light of the potassiumtitanylphosphate (KTP) laser generates effective energy for treatment of superficial pigment and small capillaries as has been described earlier (10). In this application, what makes the Linline laser unique is that pigment and vessels are efficiently targeted and eliminated in a few sessions of treatment, because of the excellent control of collateral thermal damage which is closely related to safety parameters. The KTP nozzle is attached to the Nd:YAP laser head, pumping pulsed energy to obtain the 540 nm wavelength of superficial skin absorption to eliminate pigment and superficial telangiectasias (11). Also, treatment of cutaneous pigmentary disorders can benefit from the Ruby laser, which is one of the options offered by the platform, particularly for the removal of dark deep pigment. The characteristics of these various lasers such as pulse width in nanoseconds (ns), fluence (J/cm2), and changeable pulse repetition rate (Hz), directly influence the effects noticed in the target area of elimination. Patient tolerance to treatment is excellent and this is related to the pulse width, which has been calculated to confine heat effects in the target and avoid thermal propagation. Destructive thermal effects of small vessels and pigment are highly confined in the target itself and in fact, when the Ruby laser is used, energy delivered in a train of pulses is absorbed by the pigment melanin chromophore with drastically obtains an increased photo-acoustic effect, which is followed by a rapid cooling of the target. Actually, and under normal circumstances, when a conventional Q-Switch laser is used, heat often becomes excessive and saturates the chromophore. In this case, the thermal wave is evacuated to adjacent pigment chromophore. In the case of the Linline lasers upon absorption of energy the same therapeutic Switch laser is used, heat often becomes excessive and saturates the chromophore. In this case, the thermal wave is evacuated to adjacent pigment chromophore. In the case of the Linline lasers upon absorption of energy the same therapeutic photo-acoustic process takes place, but a redistribution of thermal effects occurs in order to reach the maximum possible amount of melanin or pigment as is the case of tattoos, targeted for destruction in block achieving a more extensive volume ratio of pigment elimination. In principal, during clinical application of this laser technology, it is observed that deep localised pigment can be also reached with an effective outcome, due to the repeated sequence of Ruby or Alexandrite laser train of pulses, that operate in a rebound form targeting pigment to pigment, in a nonlinear process of light-energy absorption. This principal, used for pigment elimination, which the manufactures calls pinpoint effect, is also used for vessel coagulation. In vascular treatments, the software included in the platform console shows on the screen the recommended convenient settings. Laser emission adapts for a reliable outcome, depending on diameter and colour of vessel, details which are of maximum importance (12). The various lasers are built-in to hand pieces. In the laser hand piece window, the spacer is adapted and changeable in order to adjust the spot diameters to the selected target vessel. The technology is then able to automatically adapt energy density demanded, so that treatment can be performed with efficacy. For vessel coagulation the Nd:YAP Q- Switch/KPT laser hand piece is selected. Interestingly, the series of short, high energy pulses during treatment can effectively treat dilated vascular malformations of rapid growth. Also, in tuberous haemangiomas, the combination of 540 nm wavelength and the 1079 nm of the Nd:YAP laser operating sequentially, increase the effectiveness of vessel coagulation. The simultaneous deposit of laser energy obtained by rapidly repeated pulses, quickly picks up thermal gradient in the absorbing haemoglobin chromophore. The KPT energy when absorbed, forms small areas of coagulated blood but, thanks to the block of short width energetic pulses, heat is confined within the vessel avoiding thermal propagation and damage to adjacent tissue. Coagulated blood by 540 nm energy wavelength gives the Nd:YAP energy pulses a chance to play a stronger role to produce vessel damage. A consistent thermal increased gradient is obtained by the latter laser, which is distributed

4 to the adjacent blood portions from the already formed coagulated ones achieved by the KTP absorbed energy. Then, heat effect reaches the vessel wall, producing its damage. This principle of heating the selected vessels for closure by thermally signalling laser pulses has been previously reported as being very efficient for vein coagulation (13). According to our observations, the result is then a progressive highly selective thermal effect without relevant collateral damage. The efficient absorption of laser energy is produced in a sort of feedback mechanism, making vessel damage more and more effective. Therefore, the practice of a successful outcome is expected with a rapid tissue recovery which will be enhanced by the practice of a few extra treatments. The Nd:YAP/KTP Q-Switch is also indicated in scar revision and for the treatment of keloids. Treatment addresses the vascular feeder. In the case of fibrotic scarring residual tissue, effects are particularly interesting in lesions presenting a phase of active growth (Fig. 2). Fig. 2 A) Keloid presenting an inflammatory phase. B) After KTP laser treatment, vessel feeders are closed. The lesion looks whitish with better aspect and less elevated. Red and green tattoo pigment can be targeted as well as pale decorative pigment, which are usually difficult to treat (Fig.3). Fig. 3 A multilayer, multicolour tattoo A) Before treatment. B)Aspect before starting treatment with the Ruby/Alexandrite lasers. At this stage the tattoo had been treated before with regular Q-witch Nd:YAG laser C) D) and E) present decrease in colour after the corresponding 3 sessions of treatment. Notice the good skin quality characteristics, also achieving nice recovery of the few residual depressed scars present after regular Q-switch laser treatment. Elimination of lentigines and lentigo becomes a friendly rapid treatment, and the high short width energetic combined pulses proved very efficient in these cases (Fig. 4). Fig. 4 Lentigo. Histological examination was carried out to certify the diagnosis. A) Area presented pigment and tissue atrophy due to two previous CO2 laser treatments. B) Results of three combined treatments with the KTP laser, which obtained pigment elimination. The RecoSMA sessions, done alternatively, achieved improvement of skin condition and repaired tissue atrophy. Deep localised pigment elimination can also be achieved by the Ruby and Alexandrite lasers at 694 and 755 nm respectively. Both wavelengths, used separately or combined, increase chances for a selective and effective pigment elimination (14,15). As is the case in this indication, when the Alexandrite laser is used for laser epilation, all parameters of treatment are registered in the software of the platform: Pulse sequence, energy, pulse width and delay time change according to variables that hair presents. The power supply included in the console of the platform, has been implemented via the software to provide the necessary electric power to multiple laser wavelengths, according to operation needs. Selection of laser epilation programme is established accordingly and automatically in direct relation to hair characteristics, so that application is also possible on fine, low melanin hair content and in dark skin phototypes (16).

5 Moreover, patients can resume sun exposure after treatment without typical precautions recommended for other lasers (Fig. 5). after treatment inducing a rapid non-traumatic repair mechanism (Fig.6). Fig. 5 A) Axilla before epilation. B) Hair follicle appears normal. C) Immediately after Alexandrite laser treatment hair follicle presents signs of haemorrhage and changes in architecture compromising its viability. RecoSMA The Er:YAG hand piece which is also offered by the platform, has all the well-known advantages of the nm wavelength ablation effects, thanks to its excellent absorption by water. This laser is indicated for conventional layer by layer elimination of skin, resurfacing, tissue debulking and/or reshaping of elevated lesions (17). In fractional mode it offers the advantage of eliminating fine shallow layers of epidermis to obtain rapid reepithelization refreshing the skin aspect (18). In this indication, to the typical well established advantages of the Er:YAG in dermatology, aethetics and dentistry, the SMA (Space Modulated Ablation) contributes by acting as an original tool for ablative skin rejuvenation. This nozzle technology added to the Er:YAG laser, makes it possible to carry out skin treatments rapidly, without anaesthesia and with short recovery time. The SMA nozzle when adapted to the Er:YAG hand piece has a sophisticated system of lenses that drill 50μm holes in the skin. These tiny micro spots of less than a cell in size, form a grid of over laser impacts on the skin, that are collectively absorbed with absence of lesion to adjacent tissue. The well controlled thermal effect obtained with this technology opens possibilities for rejuvenation treatment of hands, neck and décolleté. Treatment with RecoSMA, leads to collagen neo-formation with practically no thermal effects. According to histologies, fibres in the dermis become separated immediately Fig. 6 Skin x125 Hematoxylin/Eosin staining. A) Before. Skin is normal with images of elastosis and tissue ageing. B) After RecoSMA epidermis appears hyalinized and there is a cone-like image in dermis with fibres in a different lighter colour. No signs of thermal effects. C) x 400 corresponds to a magnified image of B). Epidermis appearance is gel-like, with a separation of fibres in the dermis and scarce inflammatory cell infiltration. The considerable number of micro-beams hyalinizes the epidermis when going through, and fibres adopt a visible increase of the interfibrillary spaces due to mechanical energy waves that pushes tissue apart. Multiple frequency of pulses per second, according to programme, produce immediate reactive edema, but without the typical thermal signs or inflammatory cell reaction which are minimal. In this case, inflammatory polimorfonuclear cell infiltration is almost inexistent and different from conventional laser fractional ablation resurfacing. The manufacturer recommends the laser not be passed more than once over the skin, because extra energy could lead to damaging tissue effects. In fact, extra passes with the SMA lead to loss of anatomical tissue pattern, with elimination of epidermis and clinically visible with the well know charring aspect (Fig. 7).

6 laser pass was applied. Treatment took only 4 minutes (Fig.8). Fig. 7 Brownish colour of the upper lip during RecoSMA treatment of wrinkles. Repeated pulses on the same spot lead to this image of parched-like and charred tissue. However, and according to our experience, tissue continues to recover rapidly and safety ratio is not violated, because we have not seen complications on over 40 patients treated for skin resurfacing. Nevertheless, if the doctor is seeking more evident results of the laser treatment, it is better to carry out several sessions, spaced 2 to 3 weeks between them, because skin obviously takes fewer days to recover with only one pass of the laser. The Nd:YAP hand piece can also be plugged into an optic fibre so that the 1079 nm wavelength can be used as a surgical knife. The frequency rate pulses in which this laser can emit when prepared for scalpel performance, coagulates and carbonizes tissue transforming this laser into an interesting cutting-coagulating surgical tool, especially in interventions of dilated vascular pathologies. Excision and coagulation of haemorrhoids, vaporisation of condylomas or excision of bulky skin tumours, in which cutting and coagulation effects are necessary, are indicated for this laser. ILLUSTRATIVE EXAMPLES Skin Rejuvenation Case 1: Female, 52 years of age, phototype III presenting periocular lines and wrinkles degree 2. The RecoSMA was used under no type of anaesthesia. Settings were 2 Hz, single pass, with 10% overlapping 2,21 J/cm2. After safety measures and eye protection, a single Fig. 8 Wrinkles and skin laxity of the lower lids. A) Before treatment. B) Treatment has been carried out without anaesthesia. Immediately after, skin appears slightly swollen but without charring. Case 2: Female, 79 years of age, phototype IIIIV, presenting degree 3-4 wrinkles on the whole face. Extensive signs of solar damage, keratosis and changes in skin colour typical of elastosis are observed. Two treatments of the whole face were carried out without anaesthesia. The RecoSMA laser system was used(3.2 J/cm2, 4 Hz). Extra passes were applied on the perioral area in both of the treatment sessions. (Fig. 9). Fig. 9 A) Patient phototype III prior to full face fractional resurfacing with RecoSMA. Wrinkles are degree III and IV. B) 48 hours after the second treatment, reactive erythema and brownish coloured scab was evident on lips and other areas to which more laser passes were given. C) Results presented are one month after the 2nd treatment which have produced an evident improvement. Recommendations: a) Patient should thoroughly wash and perfectly dry the area of treatment before resurfacing with RecoSMA. Not doing so will prevent Er:YAG

7 energy absorption, buy the skin tissue missing the aimed ablation during energy interaction. b) When pulse rate increases over 2 Hz it produces discomfort. This may be due to rapid pulse frequency which adds extra stress to the patient, especially when large areas are resurfaced. Skin may feel like a rubber band stretching with the treatment. c) When doing full face fractional resurfacing, without anaesthesia, leave more sensitive areas such as the upper lip and lids for the end of treatment. d) Hold patient control by constant communication to gain confidence and relaxation. Establish a conversation and always explain what you are doing during treatment. This helps patient to better accept the skin ablation procedure e) Keep in mind that once treatment is completed the skin is open and exposed to environmental conditions. Moreover, superficial nerve endings are being heated, responding actively to external aggression with a burning sensation and tissue dryness. Use a non-fluorate Prednicarbate ointment (Peitel, Laboratorios Novag S.A., Spain) mixed with Lambdalina (Laboratorios ISDIN S.A., Barcelona, Spain). Then, refresh with a spray of thermal antiseptic, anti-inflammatory water (Thermal tonic calendula and Apple Extract, Laboratorios Profarplan, Barcelona.Spain). The ingredients contained such as apple extract act against bacteria colonisation, refresh tissue rapidly calming the itching sensation. f) Patient should avoid washing the treated area for 3 days. After this time, cleaning with a mild soap is permitted. Recommend then the frequent use of a moisturiser adapted for tissue recovery (TT1, Nutritive Moisturizing Calendula Cream, Laboratorios Profarplan, Barcelona, Spain) g) A brownish dry layer of parchment-like skin is to be expected 24 to 48 hours after treatment (Fig. 10A), which normally starts to peel off from the fourth day onwards (Fig.10D). Fig. 10 A) 80 year old female, phototype III, immediately after treatment with RecoSMA. Upper lip presents brownish colour due to more laser passes. B) Following treatment, white dry skin without charring is observed in other areas of the face. C) 48 hours after treatment periocular skin appears dry and parchment-like. D) The dry epidermis detaches on the 4th day letting new skin resurface. E) Detail of the forehead 5 days after treatment. Epidermis is changing and new skin is observed clean, fine and rejuvenated with no signs of erythema. The rational behind the RecoSMA treatment: Why is this technology different for skin rejuvenation? The fact that the various thousands of 50μm micro beams per spot stack on the skin has several consequences: i) thermal effect is noticed in tissue as thousands of dots of very confined high energy. The epidermis is kept in place with a changed whitish aspect at the point of impact (Fig. 10B) Macroscopically, skin surface appears dry and whitish and turns rapidly into a darker colour. Histologically epidermal layers appear dissolved but in place having a hyalinization aspect, but not detached or eliminated. There is a clear difference of cell layer structure when compared to neighbouring epidermis. At the point laser stacks on the skin, the normal anatomical pattern is lost but epidermis stays glued to the dermis, respecting epidermal dermal junction. This may be responsible for the dry parchment-like skin of brownish colour, which starts to show a few hours after treatment. Actually patients report the sense of dry skin and a tugging sensation, but no pain is experienced except for a burning feeling and

8 itching that when refreshed is rapidly alleviated (Fig. 10C). The high energy produced by a train of multiple short width pulses, of the Er:YAG laser, passing through the SMA lenses, stimulates fibroblast and formation of new fibres. Actually, effects noticed in the dermis show distortion of normal fibre disposition and this action will act as an active mechanism for collagen formation and tissue remodelling, helping fibres to adopt a parallel display, running close to the epidermaldermal junction, characteristics of a young skin, as it is histologically noticed. In spite of using typical energies of around 3,2 J/cm2 for skin rejuvenation, if pulses are repeated on the same spot, progressive elimination of the epidermis and even the dermis will occur. (Fig. 11). Fig. 11 Skin x125 Hematoxylin/Eosin. A), B) and C) correspond to RecoSMA laser with the same energy of 3,09 J/cm2 but using 2, 3 and 4 passes. Notice epidermis refinement in A) with extensive vacuolization. B) Epidermis elimination with separation and dismantling of dermal fibres C) Full epidermis and papillar dermis ablation. In all three samples no signs of residual thermal damage are observed. Although Er:YAG laser is known to be superficially absorbed. Clinically, typical energies used for treatment (around 2,6 to 3,2 J/cm2) produce effects on papillar reticular epidermis. This will be the cause for a brownish coloured dehydrated skin surface which remains attached to the dermis. Then, it is advisable not to wash the areas treated for to 4 days as this fine skin surface necrotic layer serves as a natural dressing. At 3 to 5 days, depending on energies used for treatment, and once skin is washed, the fine scab peels of offering a fresh new aspect of the skin. Clinically, these quasi non-thermal effects, permit rapid skin recovery, and after about two weeks, treated area does not present residual erythema. total renewal, for the former low fluences are recommended; but if a total epidermis ablation is required, high fluence should be programmed or more than one laser pass has to be carried out. More than one laser pass with RecoSMA will produce more evident fibre separation but practically without tissue thermal reaction in dermis and evident total removal of epidermis. In fact, when an evident rejuvenation outcome is the aim of the treatment, according to our observations, it will be necessary to carry out a session with fluences of 3,2 J/cm2 or over, and more than one laser pass, but this implies an extra skin recovery time of 3 to 4 days. If this treatment technique is not possible to practice, because patient for example requires a rapid tissue recovery, in this case 2 to 3 sessions prove enough to achieve a solid result of skin rejuvenation, with changes in the epidermis aspect and luminosity and with tightening of the dermis. TATTOO ELIMINATION The Q-Switch laser of this device mounts an advanced technology to use as a method of pigment treatment, accelerating decorative injected colour elimination. In traditional Q- Switch lasers, in which single pulses are in the order of 10 to 12 nanoseconds (ns) width, energy used is absorbed in one go by the matching colour located more externally in the skin, remaining deeper located pigment unaffected. Therefore multiple sessions are needed to eliminate a tattoo, especially those of dark, dense colour in which a considerable amount of ink was used during its elaboration. Contrary to this, the pulses of the Linline are of less ns, packed in a block in a carrier pulse, which is delivered on the skin as a solo pulse producing a different interaction mechanism with the tattoo (Fig.12 ). Inconveniences: In spite that energy can be selected according to skin requirements, such as for simple elimination of a few epidermal cell layers or

9 Fig. 12 Monochromatic black professional tattoo. A) to H) present results 15 days after various sessions of treatment with Alexandrite Ruby Q-swtich laser. Progressive pigment elimination is observed maintaining skin texture and its normal colour. The train of pulses, in this case, which are programmed for operation in a frequency from 1 to 4 Hz, obtain sequential effects, reaching the deeper located pigment. During interaction, the small width high energy train of pulses delivered in Block in a few milliseconds of time, are absorbed first by the pigment chromophore located more superficially. By elimination of this pigment a path is opened for the following mini pulses, contained in the carrier block to operate their action in the deeper pigment. Selectivity of laser Q-switch energy interaction progressively increases in efficacy during treatment, because the train of pulses acts layer after layer fragmenting pigment. The continuous exposure of pulse after pulse, containing high energy interacts producing minimal acoustic waves practically not perceived during treatment. Visually, progressive changes are noticed in the colour of the epidermis which indicates that pulses have to be stopped. Pulses on a tattoo act as a sort of drill-like pigment destruction but preserving the epidermis. Under these circumstances minimal damage occurs to neighbouring structures, therefore the speed of skin recovery is not compromised. Clinically, the white colour of a detached skin, which typically appears with standard Q-switch lasers is not seen with the Linline device. Sometimes, if energy absorption is high, a greyish blister-like formation is seen instead. So epidermis does not appear whitish and opened after treatment, giving the skin all chances for a rapid recovery. Also, less traumatic post treatment is noticed and less treatment sessions are needed for tattoo removal. Inconveniences Removal of pigment is different from conventional Q-Switch lasers. Training for the use of the technique is necessary, particularly to recognise when to stop pulses on the same spot and how to programme pulse repetition rate. The train of pulses destroys and penetrates pigment layers with photo-acoustic waves rebounding inside the tissue. This should be recognised, in order to stop beam on the skin when external changes in the epidermis appear, and to avoid extending tissue collateral damage. The manufacturer should consider producing a larger, changeable beam diameter, together with a longer focal distance. In this case, solution to this particular will imply maintaining an effective high fluence in a larger beam area (4). THE TREATMENT OF FACIAL VASCULAR LESIONS Two laser wavelengths acting simultaneously are used in the process of vessel coagulation. The KTP, pulsing at 540 nm, is absorbed by haemoglobin of tiny superficial vessels, producing blood coagulation. The small multiple dots of coagulated blood inside the targeted vessel serve as a pole of attraction to the 1079 nm Nd:YAP laser which is pulsed in combination with pulses of the KTP laser. The Nd:YAP laser energy looks for the hot eye concentrating laser/haemoglobin interaction therein for a more efficient vessel closure. The thermal effect increases by the dual action of both lasers achieving effective vessel coagulation, using lower fluences than those of conventional laser facial vascular treatment (Fig. 13). Fig. 13 Chin telangiectasias. A) Before. B) One week after the first treatment with the KTP laser C) 2 weeks after the second treatment. D) During treatment with the KTP head of the Multiline Linline Platform. Results are very satisfactory preserving skin condition. Following, the train of pulses, collateral thermal effects are avoided and, because secondary heat effects responsible for residual heat damage are not present, treatment can be conducted almost pain free, also in vessels located in the legs (Fig. 14).

10 Fig. 14 Leg variculas. A) Before B) four weeks after a single treatment with the KTP/Nd:YAP laser. Clear improvement without residual skin damage. In the lower limbs, vein closure results quite effective in externally located vessels and are free of side effects. However, we have had no time to conduct formal trials on large number of varicules and to have a prolonged follow-up to validate clinical evidence of results. On the contrary, facial capillaries treatment is rapid and conducted almost without discomfort, even on critical areas like the nostrils. Inconveniences: The help of an aiming beam is missing. Treatment needs adapting Doctor's visual control of laser beam with the point of stacking it on skin, to accurately target small facial capillars. Ergonomy of the handpiece should be improved, and a larger beam diameter would be necessary, in order to treat thicker vessels (19). Also, a larger distance between the laser handpiece and the point of beam touching the skin would be better. Fig. 15 Keloid as a result of a vaccine and surgical removal of scar tissue on a patient phototype IV-V. A) Before. B) to F) progressive improvement after 4 sessions of scar revision with the RecoSMA laser. In case scar tissue is flat or slightly elevated but presenting fibrotic consistence and/or atrophic depressed areas, the RecoSMA is the technology we found most interesting. The fibre modulating and reshaping capabilities of this laser technology (we understand), reinitiates the process of wound healing monitoring tissue repair, leading to a refined appearance of the skin, which turns softer to touch and patients manifest disappearance of pain on touching. For the same reason, healing chronic ulcers can be activated. Ulcers of various aetiologies, including cutaneous-vascular conditions and the diabetic foot, are elective indications for this laser (Fig. 16). SCAR REVISION To treat this condition a combined technique is chosen. If scars are elevated, first, debulking and reshaping of fibrotic elevated tissue is to be done using the Er:YAG. Then, the KTP laser pulses are used to get rid of the nutrient capillaries, once area treated reepithelize. The KTP laser is recommended once wound is closed, particularly when lesion presents a reddish colour (Fig. 15). Fig. 16 Chronic ulcer of the heel after accidental burn. A) Before. B) to G) show stages immediately after the various treatments with the Er:YAG/MA laser. H) The ulcer is closed and skin presents a revitalised condition. Actually, using the combined RecoSMA on the ulcer is practically pain free. The laser effect

11 might operate reactivation of microvasculature formation according to what we have noticed. For treatment, laser is pulsed externally and on the ulcer itself. Patient follows the same recommendations as when skin resurfacing treatment is practiced. The sessions we carried out were every two weeks. (Fig. 17). Fig. 17 Treatment of haemosiderin staining skin fragility and ulceration as a consequence of deteriorated skin condition due to venous insufficiency. A) Before. and B) Immediately after treatment, skin appears with a typical whitish colour produced by the RecoSMA laser. C) Ulcers are closed and skin is of better condition one month after 3 treatments HAIR REMOVAL This treatment is painless and permits the practice on borderline epilation cases such as dark phototypes, tanned skins and in cases of scarce hair pigment. Software built in treatment parameters permit energy to focus on the hair melanin respecting the skin melanin. During pulse operation the hair thermal relaxation time is maintained, so that adjacent structures are thermally respected. The delay time between pulses has been calculated to allow heat evacuation from the target, avoiding thermal transference to upper skin layers, which are responsible for skin damage and burns. During treatment no skin cooling is used. constant laser energy absorption becoming more prone to damage. Histologies show architectural changes in hair follicle after treatment, which should imply interruption of hair viability. However, further and more precise studies are advisable, as well as prolonged controls of evolution of epilated areas as happens in other dark skin phototypes case when depilation is carried out with the Nd:YAP laser (20). Inconveniences: The laser beam diameter is small, therefore epilation of large areas is long and tedious. A larger beam will make this technical laser approach of hair removal very helpful in treating dark, tanned skins or hair with low melanin content. Treatment is slightly painful, therefore cold air directed to areas treated will make this laser epilation more acceptable, especially of large areas. THE ND:YAP AND ND:YAG LASERS IN SURGICAL APPLICATIONS The various laser emissions of the Linline platform can be used to tailor the lesion in question such as for cutting effects, ablation or coagulation. In dermatology and for skin aesthetics, the 1079 nm Nd:YAP programmed for emission in high repetition pulses achieves cutting and extended coagulation necessary for treatment of vascular pathologies (Fig. 18). THE RATIONAL BEHIND HAIR REMOVAL TREATMENT The mechanism of action in hair removal is based on the energy produced by a train of nanosecond pulses, packed together and acting during microsecond periods of time, Energy of the Nd:YAP laser focuses on the hair melanin and, due to slow step by step increase of laser light absorption in the targeted hair, a constant modification of the absorption coefficient of the melanin is produced. Pilous structures are in Fig. 18 A) Cavernous giant haemangioma and congenital long development venous malformation. B) and C) present detail of the fibre and during laser application. D) Observe coagulation produced by the Nd:YAP laser to test possibilities of treatment and skin recovery condition. Notice immediate results of effective laser coagulation and carbonisation without bleeding.

12 Also, the cleaning potential of heat can be easily implemented for extended thermal effects when treating viral lesions as is the case of, for example condylomas, where it is necessary to determine location of warts, particularly those which have not yet erupted and are not visible on the skin (21). Thermal effects of the laser are useful and surgery is conducted using a fibre adapted to the laser head nozzle. The point of the fibre almost touches the area of treatment in order to obtain surgical cutting effects and/or coagulation and to produce tissue shrinkage (Fig. 19) Fig. 19 Perianal condylomata. A) Before. B) One week after, area treated is in stage of granulation. C) Two weeks after mucosa and skin repair continues. D) Lesion is healed at three weeks. SUMMARY The Multiline laser platform which we have examined in close to 150 cases of various pathologies, is a new interesting approach in treatment. It is convenient as a part of or as a whole, because it has various laser wavelengths that doctors might be in need of in the arena of clinical applications. In our opinion, nowadays patients usually request a warranty of results and a risk free laser intervention, this platform has a place to occupy (23). Treatments can be carried out with little or very short postoperative down time. REFERENCES [1] Vélez M, Serra M, Trelles MA, Pérez-Peña P. Estado Actual Del Láser Quirúrgico En España. S.E.L.M.Q. Boletin Informativo, 2001;1: 9-15 [2] Trelles MA. Cosmetic laser surgery: current procedures and developments to come. Private Hospital Healthcare Europe, Ed.: S. Taylor Campden Publishing Ltd., London, 2003: T15- T16 [3] Trelles MA, Vélez M, Rigau J. Interacción de la Luz con los Tejidos. Láser y Fuentes de Luz P u l s a d a I n t e n s a e n D e r m a t o l o g í a y Dermocosmética, Editorial Aula Medica, Libros Princeps Biblioteca, Madrid, 2000; Capitulo 2.2:41-55 [4] Vélez M, Trelles MA, Rigau J. Características Técnicas y Parámetros Disimétricos de los Sistemas Láser y otros Sistemas Lumínicos. Láser y Fuentes de Luz Pulsada Intensa En Dermatología Y Dermocosmética. Editorial Aula Medica, Libros Princeps Biblioteca, Madrid, 2000; Capitulo 2.3: [5] Multiline laser complex. Published by LINLINE, [6] Trelles MA. Skin rejuvenation: Where are We? J Cosm Laser Ther, 2002; 4(3-4): [7] Green HA, Burd E, Nishioka Ns et al. Middermal wound Healing: a comparison between dermatomal excision and pulsed carbon dioxide laser ablation. Arch Dermatol, 1992;128:639 [8] Apfelberg DB, Maser MR, Lash H. Argon laser treatment of cutaneous vascular abnormalities: progress report. Ann Plast Surg, 1981;1:14 [9] Gillis TM, Strong ;MS: Surgical lasers and soft tissue interactions. Otorlaryngol Clin North Am, 1983;16:775 [10] Levine Hl. Endoscopy and the KTP/532 laser for nasal sinus disease. Ann Otol Rhinol Laryngol, 1989:93:211. [11] Apfelberg Db, Bailin P, Rosenberg H. Preliminary Investigation of KTP/532 laser light in the treatment of haemangiomas and tattoos. Lasers Surg Med, 1986;6:38-42 [12] Tan Ot, Morrison P, Kurban AK. 585 nm for the treatment of port-wine stains. Plast Reconstr Surg, 1990; 86:112 [13] Mordon S, Brisot D, Fournier N. Using a non uniform pulse sequence can improve selective coagulation with a Nd:YAG laser (1.06 micron) thanks to Met-hemoglobin absorption: A clinical study on blue leg veins. Lasers Surg Med 2003; 32(2): [14] Taylor Cr, Grange RW, Dover JS et al. Treatment of tattoos by Q-switch ruby laser pulses. Arch Dermatol, 1990;126:893 [15] Fitzpatrick re, Ruiz-Esparza J, Goldman MP. The alexandrite laser for tattoos. A preliminary report. Lasers Surg Med Suppl, 1992;4:72 [16] Bencini PL, Luci A, Galimberti AO et al. Ryby laser-assisted hair removal reduces the coarseness of regrowing hairs: fallacy or fact. Br J Plast Surg, 1999;52: [17] Trelles MA, Vélez M, Mordon S. Correlation of histological findings of single session Er:YAG skin fractional resurfacing with various passes and energies and the possible clinical implications. Laser Surg Med, 2008; 40 (3): [18] Trelles MA, Mordon S, Vélez M, Urdiales F, Levy JL. Results of fractional ablative facial skin resurfacing with the Erbium:Yttrium- Aluminium-Garnet laser

13 Author Profile MARIO A. TRELLES, M.D., Ph.D. Instituto Médico Vilafortuny/ANTONI DE GIMBERNAT FOUNDATION, E Cambrils, Spain Mario A. Trelles is internationally renowned for his expertise and contributions to laser advancements in medicine and surgery. He received his medical degree and specialised general, plastic, aesthetic and reconstructive surgical training at the University of Barcelona, Spain, his Ph.D. in medicine and surgery at the University of Seville and his Board Certification in Lasers in Aesthetic Plastic Surgery in the USA. Dr. Trelles has since shared his experience with others, both as a professor at various European Universities, where he is currently a visiting Professor, and writing and editing books and over 350 scientific manuscripts on advances in lasers. He has held executive positions at numerous professional medical organisations, including present terms as President of the European Laser Association (ELA), the Spanish Society for Laser in Medicine and Surgery (SELMQ), and Honorary President of the European Society for Laser Aesthetic Surgery (ESLAS). Dr. Trelles was awarded for Excellence in Cosmetic Surgery by the American Academy of Cosmetic Surgery in January 1999 and honored with the Medallaille de la Cité de Marselle (France) for his contribution to medicine in May 2001.