Targeting Vascular Lesions

Stuart Nelson, MD, PhD

There are a variety of different “optical technologies” that can be used to treat vascular skin lesions. These technologies include: pulsed green or yellow light, intense pulsed light, alexandrite, diode, Nd:YAG and dual devices such as combined pulsed dye + Nd:YAG. Dermatologists should remember that a variety of vascular skin lesions are amenable to laser therapy such as angiomas, adenoma sebaceum, angiokeratomas, blue rubber bleb nevus, ecchymosis, poikiloderma, rosacea, scars, telangiectasias, vascular malformations and warts.  Therapies are based on the concept of selective photothermolysis (Anderson and Parrish, 1983). Wavelengths of light highly absorbed by targeted hemoglobin with thermal injury confined to the vessel and immediate perivascular area.

Clinical Pearls
  • Epidermal melanin is a competing chromophore for many of the wavelengths used to treat vascular lesions. Epidermal cooling is essential, particularly for the treatment of lesions in patients with darker skin phototypes.
  • Short pulse durations (< 6 ms) can cause purpura and should be used cautiously for the treatment of facial vascular lesions, particularly in men.
  • Facial telangiectasia are easy to treat by pulsed green or yellow light or intense pulsed light and the operator should see an immediate response (vessel disappearance or collapse). Pick one, understand treatment endpoints and then perfect your technique.
  • Paradoxically, scars respond much better to lowerenergy densities.
  • Nd:YAG lasers can be used to treat linear arborizing telangiectasia of the lower extremities with pulse durations of 10-100 ms (depending on vessel diameter), energy densities of 50- 200 J/cm2 delivered on small spots (2-3 mm). Also consider “endovenous” approaches.


Treatment of port wine stains by pulsed dye laser remains the standard of care. Caveats for treatment include: 1) begin treatment as early as possible and treat aggressively; 2) due to blood vessel size heterogeneity, multiple wavelengths and pulse durations should be used; and 3) maintenance treatments helpful to maintain result. Many lesions that respond well initially to treatment may reach a response plateau. Such lesions may also be treated with a deeper penetrating 755 nm alexandrite laser.  The pulsed dye laser is effective for treating superficial hemangiomas. The risk/benefit ratio is favorable and, at least for symptomatic lesions (e.g., bleeding/ulcerating) and those that cause functional impairment (e.g., periorbital), laser therapy is appropriate. Caveats for therapy include: 1) lesions <3 mm thick; 2) low energy densities (<5 J/cm2) with large spot sizes; 3) epidermal cooling essential; and 4) repeat treatments every 2-4 weeks.


Lasers: Safety and Complications

Key Safety Pearls

Omar Ibrahimi, MD, PhD
  • Lasers are extremely powerful methods for delivery of light. A basic understanding of laser safety is mandatory for anyone operating a laser
  • The major risks associated with laser use in dermatology include: eye injury, infectious hazards, medication overdoses, fire, and electrical shock
  • Lasers in the visible light and near infrared range are absorbed by melanin and can damage the retina (can cause blindness)
  • Lasers in the mid-far infrared range are absorbed by water and can damage the cornea
  • Use of appropriate eye goggles can minimize the risk of eye damage (remember that eyewear is wavelength-specific)
  • There are risks with topical anesthesia

Complications with Lasers

Matt Avram, MD, JD

As dermatologists, here are some clinical pearls to keep in mind with regards to lasers:

  • Practice good common sense
  • Know your limits
  • Examine the patient in the same day, if possible. If you are uncertain as to what is happening, consult a colleague
  • Do not abandon or avoid a patient with a poor outcome or side effect
What are some of the common reasons for litigations with laser treatment?

Dr Avram and colleagues revied 1,601 cases. They found that 75% of physicians in low-risk specialties will face a malpractice claim by age 65. Of the cases that were reviewed, they found 182 unique legal claims involving injury from a cutaneous laser treatment. These cases were mainly in California, New York, and Texas.

Most common litigated procedures
  • Hair removal
  • Rejuvenation
  • Leg veins
Most common injuries
  • Burn
  • Scar
  • Pigmentation
Most common reasons for litigation
  • Negligence
  • Informed consent
  • Fraud

In 50% of the cases, the courts ruled in favor of the plaintiffs.

Common Complications with Laser Treatment
  • Hypopigmentation
  • Pigmented lesions
  • Scarring

Remember that lasers can be an effective treatment for

  • Lentigines
  • Ephelides
  • Nevus of Ota/Ito

They should NOT be utilized for

  • Atypical nevi
  • Lentigo maligna
  • Melanoma

*When in doubt-perform a biopsy

 In Summary
  • Use common sense
  • If you can’t recognize or treat the condition- don’t use a laser
  • If you’re uncertain, call an experienced colleague



Introduction to Lasers and Light

Victor Ross, MD

“To understand laser tissue interactions and heat transfer is to understand laser medicine.” It’s important that Dermatologists understand how lasers work and how they interact with the skin. Electromagnetic radiation is energy. To best understand lasers, one should be familiar with the definitions that are associated with their use, i.e., fluence, pulse width, spot size and incident light. LASER is defined as Light Amplification by the Stimulated Emission of Radiation. It is a means to direct light in a focal, monochromatic way.  Why do we need to know how and why lasers work? This way, if something goes wrong, you have a basic troubleshooting guide. Non-familiarity with the device is probably the number one reason that complications occur.

Clinical Pearls
  • Check beam profile
  • Don’t forget that parts on the laser can break (mirrors, lamps, etc)
  • Lots of different technologies exist
  • Lots of different scanners available to enhance lasers
  • Understand aesthetic laser wavelengths
  • Understand pulse width
  • The majority of laser interactions are thermal
  • Cool the epidermis before the laser pulse comes down
  • Pulse duration is very important You can’t use long pulses with tattoos
  • We have a lot of cooling devices now available
  • Use short pulses to resurface
There are three basic targets for skin and lasers:
  • Water
  • Blood
  • Melanin
Three important considerations
  • Photon migration in tissue
  • Temperature increase as a response of chromophore absorption
  • Response of chromophore to temperature-time combination (generally speaking, the higher the temperature, the less time to heat the target)
What is selective photothermolysis?

Site-specific, thermally mediated injury to pigmented targets; Only gets hot with the right wavelength and the right pulsewidth.

Physical Characteristics We can Exploit (e.g. scar)
  • Hyperemia
  • Hyper-pigmentation
  • Exophytic nature
  • Hyper-metabolism
  • Inflammation

Photomodulation- Can we rejuvenate without heat?

Maybe some day we will see this, it’s not quite ready at this point.

Combining Technology for Facial Rejuvenation

Suzanne L. Kilmer, MD

 Clinical Pearls: When Combining Devices with Injectables and Other Devices

In this presentation, Dr Kilmer reviews the techniques for combining the various technologies that are currently available for facial rejuvenation in order to obtain optimal cosmetic improvement for patients.

Dr Kilmer stresses the importance of remembering the 4 Rs:

  • Relax
  • Refill
  • Resurface
  • Redrape

During her initial consult with patients Dr Kilmer discusses the 4 Rs and how the various techniques that she uses in combination for facial rejuvenation can aide in maximizing the outcomes. It is also important, as dermatologists that full disclosure regarding outcomes is presented. Dr Kilmer informs her patients that she does not “have a magic wand or a crystal ball”; therefore, she can’t predict the outcomes of any given patient.


It is important to relax the skin with a botulinum toxin to keep both the muscles and the skin from moving as much as it otherwise would. If she is going to laser the skin, the results are improved when the skin/muscles are not moving. Dr Kilmer also uses fillers, in conjunction with the toxins and lasers to fill in lines, tighten up the skin and remove brown/red spots.

Clinical Pearl: Never use toxins, lasers, or any other device that can cause significant swelling on the same day. This can result in the toxin migrating to other places where you do not want it.

 Refill-Restore Volume Loss

When using dermal fillers, the objective is to restore volume based on a patient’s specific needs. Fillers can be placed in various areas locally such as the nasolabial folds, marionette lines, deep glabellar rhytids, tear troughs, and the nasal bridge. Fillers can also be used globally in the cheeks and temples.  It is important to remember that there may be a lag time resulting in delayed gratification.

It is very important to keep in mind that one can’t massage post poly-L-lactic acid (Sculptra) in areas where Botulinum toxin was placed.

If all of these procedures are being done in one patient, Dr Kilmer typically tries to slow down the movement and relax the muscles. Discussions with patients regarding the overall procedures that could be performed are very important. Considerations for patients include money, down time, and fear factor, i.e., what are they willing to go through? In these consultations, Dr Kilmer and her patients decide on the best approach based upon their issues and the issues that she sees.

 Combination Treatments

  • Best order
    • Start with toxins to stop movement and relax muscles.
      • Relax frown, smile and lip lines when doing facial rejuvenation
      • Relax DAOs and neck bands when doing fillers, tightening or resurfacing
        • May need less filler and patients are happy sooner with tightening devices
        • Then filler or laser depending on a patient’s specific needs (and ability for downtime)
          • Never do toxins and lasers that cause swelling at the same time because toxins can migrate.
          • Typically end with filler if still needed after toxins and laser
            • Sometimes the combination will diminish the need for filler
            • If able to tell that will need volume, can do before or at same time as laser

Caveats of Combining Treatments

  • Toxin with Filler
    • Can’t massage post poly-L-lactic acid (Sculptra) in areas where Botulinum toxin was placed
    • Toxin with Laser
      • Can’t do toxin same day as Fractional lasers – swelling can lead to migration
      • Can do botulinum toxin with PDL, IPL, CoolTouch, SmoothBeam, Thermage, Titan
      • Filler with Laser
        • Can do filler same day but do first if doing fractional as swelling can mask need for filler.
        • Fractional with nonablative RF tightening
          • Same day – do Thermage 1st because need intact skin but when you do the fractional laser the skin may still be sensitive. (wait an hour or two because the sensation will decrease with time)

Combining Fractional with other Devices

  • Fractional laser with other lasers/txs
    • Lentigines – pre-tx QS lasers, KTPs, etc
    • AKs – LN2
    • Sebaceous hyperplasia, nevi – 1450 nm
    • Vascular lesions – PDL, KTP, Alex
    • Downtime from other treatment is simultaneous and shortened
    • Fractional resurfacing with ablative resurfacing
      • Almost always do fully ablative to upper eyelids
        • More tightening/more predictable – do inner canthi
  • Can ablate/sculpt edges of scars, upper lip lines and elevated lesions
  • Ablative fractional and nonablative fractional resurfacing
    • Nonablative fractional to face, ablative to neck for more tightening /crepiness – useful for those with hx ablative resurfacing/chemical peels/dermabrasion

Other Combination Therapy

Other combination therapy includes fat loss and tissue tightening (CoolSculpting + RF tissue tightening, lipo/laser lipo + tissue tightening); Fractionated RF ((ePRime) + QS/KTP/PDL); and Fractionated US ((Ulthera) + QS/KTP/PDL).

Now that the 4Rs have been implemented, dermatologists need to be particularly aware of reassessing. Combination treatments may minimize the need for other treatments; therefore, increasing the interval for maintenance. For example, one can decrease the need for the amount and frequency of dermal fillers and one can conduct fewer fractional treatments when lentigines are specifically targeted. There may also be the possibility of foregoing vascular laser treatment if the fractional laser used to treat facial vessels was sufficient. Patient concerns should be addressed, i.e., were his/her expectations met? Is there anything new on the patient that has become noticeable since the initial treatment needs have been performed and met? Normally, with time, additional needs will become apparent.


In summary, botulinum toxins, fillers and lasers can be used synergistically to minimize the signs and sun damage and aging. To produce the optimal results, expertise in the techniques are required, one should use the best possible modalities and watching and treating for any possible complications is imperative. Combining these modalities may obviate the need for more invasive procedures.