The laser treatment of various vascular lesions utilizes the principle of selective thermolysis. The energy of the lasers is targeted at the vessels or at times more specifically at the contents of the vessels that comprise the lesion. Thus, in a non-invasive manner, selective destruction of the lesions is accomplished, while minimizing collateral damage to the surrounding skin. Vascular lesions vary in the size, the composition, the color, and the location of the vessels. These qualities serve to impart unique characteristics, which allow the laser surgeon to select the best-suited laser or lasers to treat the particular lesion.
There Are Two Main Types Of Lesions That We Shall Focus On:
1) Telangiectasias:
These are small diameter, linear blood vessels that occur on the surface of the skin. Some people may refer to them as “broken blood vessels”. Common areas where these lesions occur are the face and cheeks, particularly on the sides of the nasal ala and around the nostrils.
Telangiectasias are common in people with sun-damaged skin and also in people with rosacea. Nasal vessels tend to be more resistant to treatment and may require multiple treatments. Pulsed-dye lasers and pulsed green lasers have been used effectively for the treatment of telangiectasias.
2) Flushing and facial redness:
These are components of rosacea that can be treated with a pulsed-dye laser. Multiple treatments are usually required. The newer vascular lasers can be modified so that the pulse of light is on for longer which results in reduced bruising after the treatment. Experience shows particularly with the pulsed dye laser that those who are treated more aggressively and bruise may indeed respond better.
Frequently Asked Questions:
1. “Is anesthesia needed?”
Laser treatment of vascular lesions can be mild to moderately uncomfortable. Most experience only a brief stinging sensation with each laser treatment and are able to tolerate the procedure without medication. The need for anesthesia when treating vascular lesions is dependent on the pain threshold of the patient and the size of the lesion.
2. “How many treatments are necessary?”
Multiple treatments are generally necessary to obtain satisfactory results in the treatment of vascular lesions, the exact number is difficult to predict Telangiectasias may clear after one treatment, particularly the smaller vessels, the larger vessels may require a second treatment. Nasal telangiectasias may require several treatments, the interval between treatments is 4 to 6 weeks.
3. “What are the complications?”
Fortunately, the complications in treating vascular lesions are rare in the hands of experienced and skilled physicians.
- Bruising is the most common reaction, this is particularly true of the pulsed dye lasers, the bruising resolves in 7-10 days.
- Mild crusting develops in about 20%, this resolves in 5-7 days.
- A certain degree of pain, swelling, and redness, these symptoms resolve in 24 to 48 hours after treatment.
- Pigment alteration – postinflammatory hyperpigmentation, or darkening of the skin in the treated area may occur, this effect is usually temporary.
- Strict sun avoidance is recommended, hyperpigmentation or lightening of the treated is rare and usually transient.
- Infection – Bacterial infections are rare and occur when the superficial skin is injured, cooling the skin either through cryogen spray, contact cooling, or various cooling gels, lessens the incidence of skin injury.
- Antibiotic treatment may be prescribed if infection develops, but generally good wound care is sufficient to prevent infection.
- Scarring is rare with the pulsed dye lasers.
- Pulse dye laser pulses are flammable, CAUTION should be observed when using this laser around flammable sources such as oxygen, alcohol, nitrous oxide, etc.
4. “Who is a candidate for laser treatment of vascular lesions?”
Almost any patient with one of the vascular lesions described above is a candidate for laser treatment. Many physicians will not treat patients with a recent history of isotretinoin (Accutane) use due to the risk atypical scarring.
In patients undergoing their first laser treatment for vascular lesions, a test area can be treated to assure the appropriate dosage and tissue response.
5. “Where are lasers used?”
Laser treatments can be performed on virtually any skin surface. Care must be taken to protect the patient’s eyes from the laser light. Goggles or metal eye shields may be used.
Objectives Of Therapy:
- Safe and effective improvement in the appearance of the skin involved with the vascular lesion.
- Total removal of the vascular lesion, while desirable, is not always possible.
- Fading or lightening of a vascular lesion is reasonable expectation, complete resolution of some lesions is possible.
- Multiple treatments may be necessary to achieve the desired response.
Preoperative Care:
- Patients should avoid excessive tanning.
- Anesthetic cream application 30-60 minutes prior to treatment (if necessary).
- Immediately prior to treatment, all creams and cosmetics need to be removed from the skin.
Postoperative Changes:
Pulsed dye laser (PDL)
- Immediately to several minutes after treatment with the PDL, the area may turn ashen gray, this changes to a bruised appearance within several hours and fades over the next 7 to 14 days.
- Crusting occurs in 20% of patients (PDL).
- Blisters are rare but may occur when higher fluences are used, particularly in the treatment of large warts (PDL).
- Temporary pigment changes may occur in 10% of patients treated with the PDL.
Pulsed green laser and intense pulse light source
- Erythema develops immediately following treatment and subsides in 24 hours.
- Crusting is a rare occurrence but seen when larger vessels are treated.
Postoperative Care:
- Immediately following treatment, cold compresses can be applied to skin surface.
- Blisters and crusting are treated with antibiotic ointment and daily soaks.
- Strict sun avoidance to prevent pigmentary changes.
- Makeup should be avoided in crusted areas.
- Treated areas should be washed gently with soap and water then an emollient can be applied.
Types Of Lasers Used For Vascular Lesions:
Pulsed dye laser (595 nm, yellow)
- Safe and effective for the treatment of port-wine stains for patients of all ages, including infants and children.
- Highest degree of success on the head and neck.
- Less success on extremities and torso.
- Minimal risk of scarring or pigment alteration.
- Some models utilize a dynamic cooling system to decrease pain and epidermal injury.
- Lighter skinned patients respond quicker, due to deeper penetration of the laser energy
- Newer models may produce less bruising.
- Treatment of choice for port-wine stains and facial erythema in rosacea.
- Other indications include hemangiomas, spider angiomas, telangiectasias, venous lakes, scars, and warts.
Pulsed Nd:YAG (KTP) green laser (532 nm, green)
- Suited to treat superficial vessels
- Little or no bruising seen
- Most effective for lighter skinned patients, tanned skin may lead to increased incidence of skin injury
- Skin cooled through contact cooling and/or cooling gels
- Indications include telangiectasias, adult port-wine stains, cherry angiomas, spider angiomas, and venous lakes
Intense pulsed light source (515-1200 nm)
- Multiple wavelengths delivered simultaneously
- Bruising occurs with treatment and correlates with response to treatment
- Useful for port-wine stains, telangiectasias, hemangiomas
