Since the invention of the laser, we’ve seen many advances in understanding the nature of laser-tissue interactions and improvements in the devices themselves. Not only have lasers’ optics improved, but also as practitioners we’ve learned how to vary wavelength, energy and pulse duration to enhance the efficacy of procedures and decrease adverse events.
These advances have made treatments faster, easier to perform and less expensive. In this article, we’ll discuss new advances for treating vascular lesions and removing hair and tattoos. Using lasers to treat all of these problems continues to be less invasive, more effective and more comfortable for patients. We’ll also talk about laser resurfacing vs. photorejuvenation and the intense pulsed light (IPL) devices. Here’s a look at some of the newest devices and how to optimally use them.

Vascular Lasers
We have multiple types of lasers to choose for treating vascular lesions, each with varying strong points. Treatment success depends on wavelength, fluence and pulse duration. Each device has its own method of optimizing thermocoagulation of vascular lesions while minimizing patient discomfort and epidermal damage. The lower wavelengths offer maximum absorption but have decreased depth of penetration and increased epidermal absorption, which can lead to more surface burns. The longer wavelengths have less epidermal absorption and an increase in depth penetration but require an increase in fluence.
Each of the devices has unique properties for increased efficacy and fewer adverse effects. Future studies will show which have the best benefits. Here’s a look at some of the newer lasers.
Vbeam. A pulsed dye laser manufactured by Candela, the VBeam has a wavelength of 595 nm. Compact and easy to use, it has been studied for treating conditions such as facial telangiectasias, rosacea, poikiloderma of Civatte, leg veins and port wine stains.1,2
Equipped with the dynamic cooling device, this feature provides epidermal cooling with a cryogen spray spurt prior to laser impact. This allows you to increase penetration while decreasing patients’ pain. In addition, you can use higher fluences to increase efficacy.
With a pulse duration of 1.5 to 40 msec, the device delivers laser energy over a longer time, uniformly heating vascular lesions and decreasing purpura. The cooling device has the dual purpose of increasing efficacy and decreasing purpura, which had been common in the past.
CoolGlide excel Nd:YAG. Manufactured by Altus, the CoolGlide Excel is a long-pulse Nd:YAG laser with a wavelength of 1064 nm. This device is also equipped with a contact-cooling device located in the handpiece. The handpiece has an adjustable spot size feature for 3, 5, 7, or 10 mm.
The longer wavelength of the CoolGlide Excel allows for greater photon penetration, allowing you to treat deeply located vascular lesions; however, you need an increase in fluence to thermocoagulate vessels. The longer wavelength offers the benefit of reducing epidermal damage because the delay in pulses is greater than the thermal relaxation time for the epidermis. Also the epidermis is directly cooled so that the photons can pass through without generating damaging heat. This allows you to treat vessels 3 mm to 4 mm in diameter and skin types I to VI since melanin absorption is decreased at this wavelength.3 The device is beneficial for treating telangiectasia, spider veins, leg veins and removing hair as well.
SLP 1000. A super long-pulse diode laser made by Palomar, the SLP 1000 has a pulse (up to 1000 ms) with a wavelength of 810 nm. This enables you to deliver energy over a longer time, resulting in less epidermal damage, less patient discomfort, and more success treating darker skin types.
The larger diameter and deeper vessels have a long thermal relaxation time, requiring high fluences and longer pulses. The longer pulse duration of the SLP 1000 allows you to treat these vessels while protecting epidermal damage with the handpiece cooling device. The SLP 1000 also utilizes photon recycling — capturing light that has been reflected away from the skin and reflecting it back toward the skin surface. The device is also equipped with spot sizes of 4 mm, 8 mm, and 12 mm, allowing treatment of various vessel sizes.
You can employ this laser to treat spider veins, leg veins, telangiectasia and to remove hair.4 The system is also compact, which is ideal for easy transport — plus, it takes less space in treatment suites.

Hair Removal
We’ve only used lasers to remove hair since 1995, and since then we’ve made great strides forward. Originally, it was difficult to treat patients with darker skin types, but technology has found ways around this. Solutions include:
u longer wavelengths with higher fluences
u cooling the epidermis for protection
u longer pulse duration, which slows the delivery of light and protects the epidermis.
These innovations have also led to using longer wavelength lasers for hair removal, as well. At the very least, these treatments enable us to reduce the density of unwanted hair, and sometimes, permanently remove hair after several treatments. The hair that remains is usually lighter in color, less dense and grows much slower.5
Highlighted below are examples of some of the newer lasers that work well for hair removal.
The Palomar Estelux. A xenon flash lamp device with a wavelength of 500 nm to 1200 nm, this laser has a dual-function sapphire tip waveguide:
1. Photon recycling. Light is captured and redirected back toward the follicle for increased efficacy. Because light skin types reflect more light, photon recycling increases efficacy. Conversely, in darker skin less light is reflected, allowing for a milder regimen.6
2. The waveguide’s high thermal conductivity aids in protecting the epidermis by extracting heat.
Other features of this system include a larger spot size of 16 mm x 46 mm, allowing for an increase in fluence and photon recycling. The system also has a broad spectrum that allows for more thorough treatment of hair follicles. In addition, it’s quite compact so it’s easier to store and transport.
Candela GentleLase Plus. This device has a flash lamp excited long-pulse alexandrite laser with a wavelength of 755 nm. The laser is equipped with dynamic cooling device that allows for treatments at higher fluences and provides epidermal protection, minimizing skin injury. The ability to treat at higher fluences allows for long-term hair removal.7
This device also has spot sizes of 8 mm, 12 mm, 15 mm, 18 mm and a 3-mm x 10-mm elliptical. The larger spot size decreases treatment time and increases depth of treatment. It also causes less purpura because of its cooling device and the ability to treat areas with lower fluences. This system is also approved to treat leg veins 0.5 mm to 2.0 mm in diameter.
The Epilight. Manufactured by Lumenis, this device produces an intense pulsed light source emitting a continuous light spectrum with most of its energy fluence between 515 nm and 1000 nm. The light source produces incoherent light with a spectrum that can be cut off with colored filters.
A cooling gel is used on the surface of the skin for epidermal protection. In addition, the laser delivers longer wavelength pulse duration and has a large spot size that increases efficacy. This device was shown to have 60% hair clearance after one treatment and 76% hair clearance after two to three treatments in light and dark skin types with minimal side effects.8,9 Software enables the operator to store patient data and settings to ease future treatment. The system can also be upgraded to the Vasculight.
With the growth in technology in just the past 5 years, expect to see continuing innovations that will improve results and lessen side effects.

Removing Tattoos
Dermatologists have used many different methods used for removing tattoos, including excision, dermabrasion, caustic chemicals and liquid nitrogen. These methods have fallen short because they can’t completely remove the tattoo or eliminate scarring.
Many earlier lasers were unable to treat all of the colors present in the tattoo because of the limited wavelengths offered by each device.5 This also limited the skin types we could treat. Since these first offerings, many innovations have paved the way for an all-in-one device to treat all skin types and tattoo pigments. Technology hasn’t achieved this yet, but many systems show promise.10 Here’s a look at one such device.
Palomar Q-YAG 5 system. An Nd:YAG with KTP frequency doubling, this laser has wavelengths of 1064 nm/532 nm and 1064 nm single wavelength. This device also features a shorter pulse width, a higher peak power at a given fluence and a larger spot size, which all influence treatment to the pigment granules.
The Q-YAG 5 also allows users to switch between a 1064 single wavelength beam and a 1064 nm/532 nm mixed wavelength beam. With the mixed beam, you can treat brighter colors; the 1064 nm wavelength beam treats darker pigments. No studies have yet been reported on this device’s efficacy.
The entire laser is built into the handpiece, which protects the optics from misaligning. This design also gives more operator freedom, without restrictions from the earlier reticulated arm. In addition, the system is compact and weighs 42 pounds.

Laser Resurfacing
We’ve predominantly used the pulsed carbon dioxide and erbium: ytrium-aluminum-garnet (Er:YAG) lasers to resurface photodamaged skin. Each has its upsides and downsides.
The super pulsed carbon dioxide laser has the advantages of controlling tissue vaporization and hemostasis and minimizing residual thermal damage. The carbon dioxide laser, although quite effective, can cause adverse effects, especially if overlap occurs.11 The Er:YAG laser has the advantage of decreased erythema, healing time and scarring, but it lacks hemostasis. This device has been indicated more in the treatment of early photodamage and requires one to three passes.12
However, both are ablative techniques and have many adverse effects such as the need for significant anesthesia, prolonged healing time, scarring, hyperpigmentation, hypopigmentation, infection (herpetic or bacterial) and difficult wound care. The two devices have been used in concert to decrease some of the side effects as well. Efforts to achieve the same results with fewer adverse effects have been somewhat successful with recently developed photorejuvenative techniques.

Photorejuvenation
Intense pulsed light shows promise in photorejuvenation. Photorejuvenation has many advantages when compared with laser resurfacing using ablative methods. Patients have no downtime, they have fewer pigmentary changes, they need little to no anesthesia and less wound care. However, they need multiple treatments and results may not equal ablative therapy.
As discussed, the devices produce an intense pulsed light source, emitting a continuous light spectrum with most of the fluence between 515 nm and 1000 nm. The light source produces incoherent light with a spectrum that can be cut off with colored filters. A cooling gel used on the skin’s surface protects the epidermis. These devices deliver longer wavelength, pulse duration and have a large spot size that increases efficacy. Here’s a closer look at some of them.
The Vasculight. This device contains an IPL and Nd:YAG. The wavelengths are 512 nm to 1200 nm (IPL) and 1064 nm (Nd:YAG). The IPL rejuvenates skin by treating vascular lesions, pigment changes, pigmented lesions, rosacea and poikiloderma of Civatte.13 The Nd:YAG can treat deeper and larger vessels.14
IPL Quantum SR. From Lumenis, this product is used in photorejuvenation and has a spectrum of 560 nm to 1200 nm. This system is equipped with a cooling device, and you can upgrade it for hair removal. The device is indicated for treating vascular changes, telangiectasias, pigmentary changes and sun damage, with reports of decreased wrinkles.15
The Cool Touch II. A 1320-nm device manufactured by Cool Touch Corp., this laser is FDA approved for treating periorbital wrinkles. It’s also non-ablative and has pulsed cooling for better comfort and efficacy.16 Studies have also shown promise with the pulsed dye lasers for photorejuvenation.17
Non-ablative photorejuvenation lends itself to becoming a force in treating photodamaged skin and may lead to less-desirable ablative means in the future.

Looking Ahead
Laser and IPL treatments for vascular lesions, hair removal, tattoo removal and photodamaged skin continue to be exciting and quickly expanding arenas.
The future holds many exciting possibilities as our understanding of selective photothermolysis, laser-tissue interactions and optics continues to expand. In the future, all of these factors will continue to advance, extending therapeutic indications. n

Drs. Mallette and Moy are in Manhattan Beach, CA.