Aesthetic Lasers, IPL, and LED Just the Facts Ma am Patrick Clark, PhD, CMLSO Founder Medical Laser Dynamics, Inc. Director of Clinical Education Program Founder University of Texas Southwestern Medical Center Laser Program
My Grandfather: With one eye closed would smile and wryly say I don t think you understand everything you know. Common sense is based on common experiences
Converted by Federal Law in 1971 Standardized in 1954
Cardinal Rules 1.Treat only clean skin 2.Avoid sweaty exercise for 24 hours 3.The first treatment is clinical and diagnostic We are learning your reaction 4.We provide treatments and not cures 5.Your care falls into one of three categories Repair Maintenance Prevention
Cardinal Rules 6.Most procedures have nonresponders or contraindicators 7.If skin turns grey or white STOP treating. +10 mseconds for safety 8.Follow-up in 24 hours for efficacy 9.The closer the target is in color and texture to the surrounding tissue the harder it will be to treat. 10.Lesions midline to the body are more resistant. More treatments.
Cardinal Rules 11. Those who need the most repair often have the poorest habits and care. 12. It takes a care plan not a treatment series. Education, Cosmeceuticals, Light 13. Skin is often dryer for 10-14 days post procedure. 14. What new meds or topical applications since last visit?
Light based treatments heat selected targets to select temperatures for reaction. What is skin s natural reaction to heat and how can it be controlled? Many of the reactions we elicit occur at or near 50 or 75 0 C. What happens at those temperatures? What happens above? Destruction or Stimulation Nonablative, Ablative, Subablative
Complications and the location in skin. Complications, in order of occurrence and in reverse order of severity: Blistering Hyperpigmentation Hypopigmentation Scarring Blistering and Hyperpigmentation are commonly transient. Hypopigmentation and scarring are commonly permanent. Nikolsky s Sign, Blistering, and Hyperpigmentation occur at the junction of the epidermis and the dermis.
Layers of the Skin A cross section of the skin reveals three layers skin is 0.5-4.0+ mm thick by area. Epidermis - thin, avascular layer composed of cells containing keratin in different stages of growth and degeneration Dermis - thick, highly vascular layer composed of connective tissue Hypodermis / subcutaneous - tissue and fat that connects skin to muscle and bone (viscera)
Average Skin Thickness Epidermis Dermis E/D (µ) Hypodermis (µ) Total (µ) (µ) Mental 149 1375 1524 1020 2554 Forehead 202 969 1171 1210 2381 Upper lip 156 1061 1217 931 2381 Lower lip 113 973 1086 829 1915 Tip of nose 111 918 1029 735 1764 Neck 115 138 253 544 697 Cheek 141 909 1050 459 1509 Glabella 144 324 468 223 691 Eyelids 130 215 345 248 593 Medical Laser 2012 Dynamics, Medical Inc Laser 2011 Dynamics, Inc.
Points to remember: Blistering, hyperpigmentation, and hypopigmentation commonly occur between the epidermis and the dermis at or near the D/E junction. The two best tools for control of these complications is a pulse time of beyond 10 milliseconds, the time below which full skin injury will occur, and superficial cooling which will protect the D/E junction while heating the selected target. Cooling in not just anesthesia, but also a nonheating control of the nontarget. While focusing parameters on the target be sure to use cooling to protect the non target from the targeted heating.
Light Ranges UV VISIBLE near mid Infrared Infrared 200-400 / 400-750 / 750-1300 / 1300-10,600+ 200-400 nanometers Ultraviolet invisible light 400-750 nanometers Visible light (Violet, Indigo, Blue, Green, Yellow, Orange, Red) 750 1,300 nanometers near-infrared invisible light 1,300 10,600+ nanometers mid-infrared invisible light
Types of Clinical Light There are two distinct ways of making the two central ranges of clinical light: UV, Visible, Near IR and Mid IR. Lasers Pulsed Light Devices
Father of Light Theory on Tissue
TREAT at 100 J/cm 2 15 to 20 ms or until golden brown.
Selective Photothermolysis Wavelength, Power, Spot Size, Time Thermal Relaxation Time Anderson/Parrish Law Leads us to Photostimulation
Types of light source White Pulsed Light Devices Filter Laser
How do they differ? 400nm 515 640 750 1300 UV IRA IRB Laser IPL
Differences between IPL and Laser Lasers favor defined targets Lasers favor vascular IPLs favor diffuse targets IPLs favor pigment They both like defined pigmented targets (hair)
J/cm 2 The amount of energy required (fluence in Joules/ centimeter squared) is determined by the color content of the target. Dark targets heat to a specific thermal endpoint with less energy than a lighter target. Think of a black versus tan car parked in the sun.
Milliseconds Time is determined by target size. Think of the comparative boiling times for a small vs. large volume of water Large volumes take longer to heat Small targets react to short pulse times Large targets react to long pulse times The cooling times also correlate
Targets as funnels The goal is not just to pass heat through tissue targets, but to retain heat as the target passes the heat The goal is to fill the target with heat faster than it can be dissipated 75% retention is the common goal
Thermal Relaxation Time How long does it take to dissipate 51% of the heat from the surrounding tissues. Longest time able to keep heat within the target. Anything less is good. One half is ideal.
Ideal Pulse Time If Thermal Relaxation Time (TRT) is the calculated time for a target to release at least half of the heat transmitted from a laser/pulsed light device to the target. Then a light exposure time of less than TRT will allow for heating of a specific target without influencing surrounding similar and dissimilar targets through conduction from the original target.
Cooling the nontarget Cryogen Cold Roller Before Before and After Cold Air Cold Fluid/Plate Before, During, and After Before, During, and After
Less cooling if the target near the surface. More allowed if deep.
Value of Cooling Control the temperature of the D/E junction. A thermally stable D/E junction reduces complication and discomfort significantly. Use cooling to control for Fitz Type before time or fluence. Avoids unwanted heating and complication
Nonablative Thoughts Target isolated and controlled by Wavelength(s), Power, Spot size, and Time (<TRT) NonTarget is isolated by Time (>TRT) and Cooling Lasers seek specific defined targets, IPLs look for diffuse targets. Time, energy, and cooling will change as target changes throughout the nonablative series
Ablative Thoughts Action on tissue more dependent on time than on wavelength. Carbon Dioxide, Er:YAG, Er:YSGG all ablative 700 microseconds is the barrier between Coag and no Coag No longer a blanket Gold Standard
LLLT, Diodes and LED Photostimulation is very real. But also very subtle. Not 1-5 days but 90-180 days for reaction and result. Remember Arndt-Schultz Principle Know what each wavelength does what.
LED clinical History Russian researcher reported creation of the first LED in 1927. The first practical visible-spectrum (red) LED was developed in 1962 at General Electric. Nick Holonyak is seen as the "father of the lightemitting diode They cost over $200 each.
studies By the early 1980s the cost of diodes was dropping and the introduction of most colors (blue was last in 2003) offered all aspects of light stimulation. 1989 GM acted on studies from NASA (1970s) and funded a project to treat carpel tunnel syndrome with transdermal red LED. Clinical success was found. GM used on factory line workers. Did not eliminate surgery but offered relief both before and after surgery. Shown to be good supplement to other treatments.
Studies Asian studies from the same period began showing application similar to acupuncture. Clinical studies now moving into peerreviewed medicine with measured results. This is Photostimulation, so effects are commonly subtle and take 60-120 (180) days for full result. Energies are often at 200-500milliwatts.
Blue Blue light therapy reported to help improve acne on the face, neck, back and/or body. The acne fighting wavelength frequencies are favored for antibacterial properties and the ability to superficially drive prophyryn. Wavelength frequencies range 410-420nm( +/-10 nm)
Green Green is designed to improve the appearance of suninduced, photo-damaged pigmentation/freckling on the face, neck, décolleté, arms, hands, and shoulders. The specific wavelengths act directly on melanocytes and hyperpigmentation, decreasing melanin production, helping to stimulate melanin deposit breakdown in epidermal layers of the skin. Wavelength frequencies range 515nm-525nm
Yellow Yellow LED is often recommended for skin types that want to minimize the appearance of facial redness, rosacea, irritation, inflammation, facial vessels that occur with UV damaged and aging skin. Yellow (technically orange) offers LLLT which is based on clinical (wavelengths from 575nm-595nm) that has shown, in vitro, to stimulate fibroblasts to increase procollagen and to down-regulate metalloprotease-1(mmp-1 or collagenase). After a series of treatments, fibroblasts can continue to produce new collagen for up to six months. Wavelength frequencies range 570nm-600nm
Red Red/Infrared LED is recommended for skin types that are experiencing predominately signs of agingwrinkles/lines, and loss of skin firmness/tone. Red/Infrared is recommended to minimize inflammatory acne conditions, soften fine to moderate facial/expression wrinkles, and improve facial skin firmness due to aging of the skin at the cellular level. Fights inflammation. Wavelength frequencies range 630nm-880nm
Infrared 9.8 and 10.6 micron wavelengths have deep heating ability. Canadian and US patents and FDA clearance for deep tissue heating, muscle soreness, and repair. First used in therapeutic horse blankets in Canada.
Future DPSS (Diode Pumped Solid State) lasers and LED alone devices will continue to grow in number and application.
To Close: ablative and nonablative laser and IPL Selective Photothermolysis applied to both ablative and nonablative procedures. What is the target, how hot should it be, and for how long. cooling protects the D/E junction and the surrounding nontargets How hot and how long change as target changes.
To Close: Selective Photostimulation Occurs in every light-based therapy on some level. Low level, long duration light often has deeper penetration by slow cooking LEDs and Diodes are the future for enhancement and new development.
Thank You