Understanding Laser Surgery

Vincent Richer, MD, FRCPC, presented his session “Laser Surgery: What You Need to Know,” at Dermatology Week 2022, weighing in on vascular laser considerations and kicking off with some examples from his past surgical treatments using long-pulse KTP, Nd:YAG, pulsed dye laser, and intense pulsed light (IPL) among others.

In one of his examples, Dr Richer mentioned treatment to biological endpoints with vascular laser. “For nonpurpuric categories, when we want to treat superficial telangiectasia, there will be sustained contraction. When we’re treating background erythema, we see temporary edema. And, when we’re treating deeper blue telangiectasia, we can feel the vessel contracting and, sometimes, there’s a little bit of an audible pop.”

As for the post-procedures for vascular laser, Dr Richer noted, “Foot printing and honeycombing are specific to vascular laser.”

Dr Richer also informed attendees about the treatment outcomes of vascular laser for different diseases.

• Telangiectasias, spider/cherry angiomas, and venous lakes require 1 to 2 treatments and have predictable outcomes.
• Background erythema, poikiloderma, port wine stain, and red scars require multiple treatments and have predictable outcomes.
• Keratosis pilaris rubra faceii, dermatosis papulosa nigra, seborrheic keratosis, and nevi are unpredictable or have unusual applications.

Next, Dr Richer moved on to examples of pigment laser patients and treatments with Q-switched and 4x picosecond lasers. For IPL treatment to biological endpoints, he noted, “Look for that peppering or graying within pigmented lesions.” He also cautioned, “Be careful and treat IPL with respect as it is often handed to the least experienced team member in the office.”

As for the treatment outcomes of pigment laser for different diseases, Dr Richer noted the following:

• Solar lentigines and macular seborrheic keratosis require 1 to 2 treatments and have predictable outcomes.
• Dermal melanocytosis requires multiple treatments and has predictable outcomes.
• Melasma, post-inflammatory hyperpigmentation, Becker’s, nevus, and café-au-lait macule require unusual application or combination of treatments and have unpredictable outcomes.

Dr Richer also indicated the post-procedures for pigment laser and noted, “paradoxical pigment darkening with white and brown tattoo inks are specific to pigment laser.”

Dr Richer then went on to share the safer option of laser devices for skin of color. For higher risk of post-inflammatory pigmentary alteration (PIPA), he noted to use, “IPL, high-density nonablative resurfacing, and ablative lasers.”

Dr Richer concluded his session with some take-home messages:

• Confirm the diagnosis, skin depth of pathology, and expected responsiveness to the laser.
• Treat to biological endpoints when using vascular and pigment lasers.
• Apply strategies to prevent PIPA.
• Can something in your toolbox, other than a laser, do a better job?
• Pick a resurfacing modality that will match the desired improvement per treatment session proportional to recovery time or risks.
• If planning to buy a new device, it should serve the existing dermatology patients.

References:
Richer V. Laser surgery: what you need to know. Presented at: Dermatology Week 2022; May 11-14, 2022; Virtual.