Controversies in laser medicine: Experience remains clinician's most important asset

October 1, 2009

According to one expert, experience plays a major role in the mastery of laser surgery, especially for physicians who are just learning to use these devices.

Key Points

However, if this power is neither respected nor wielded properly, unwanted side effects might ultimately result.

'Deciding factor'

"The difference between procedure success or failure in a given dermatologic laser intervention can sometimes be a very fine line to walk, and often, the experience of the physician can prove to be the deciding factor in treatment success," says J. Stuart Nelson, M.D., Ph.D., professor of surgery and biomedical engineering, Beckman Laser Institute and Medical Clinic, University of California, Irvine.

Face, neck

Fractional skin resurfacing is commonly used on the face and neck in skin rejuvenation procedures.

Dr. Nelson says that the neck area needs to be respected, because the skin is much thinner and there are fewer pilosebaceous units on the neck. Possibly due to these factors, severe scarring after fractional skin resurfacing procedures on the neck has recently been seen.

Dr. Nelson suggests that when performing fractional resurfacing procedures on the neck, clinicians may want to exercise caution by initially using much lower energies and not making as many passes.

Risks

"There seems to be some indications that perhaps patients who have had previous face-and/or neck-lifting cosmetic surgical procedures may be at a higher risk for developing scarring after fractional skin resurfacing on the neck," Dr. Nelson says.

Though it has a proven efficacy, Dr. Nelson says the long-pulsed Nd:YAG laser is possibly one of the most treacherous devices available on the market in that it can be very unforgiving, especially in inexperienced hands. The infrared light from the device penetrates several millimeters into the skin.

As a result, the depth of the coagulation or induced injury is not immediately visible to the eye.

This can often result in overheating or a deep dermal burn, which may not at first be appreciated during the procedure if the clinician does not exercise extreme caution.

Complications

"Laser devices in the hands of physicians who have not had significant or appropriate training can likely cause complications, such as scarring, skin dyspigmentation and even sloughing of the skin due to infarction of the local blood supply from the laser radiation," Dr. Nelson says.

The Q-switched Nd:YAG laser is routinely used for a variety of different indications, such as for the treatment of tattoos and other benign pigmented lesions, and it can be very safe when using short pulses (a billionth of a second).

According to Dr. Nelson, clinicians have used the long-pulsed Nd:YAG laser for the treatment of vascular lesions, leg veins, port wine stains and hemangiomas, but they have often encountered adverse events. This is probably because of their failure to understand that the depth of coagulation in the long-pulsed mode is significantly deeper than what they were used to seeing with other similar devices.

Boundaries

Dr. Nelson says clinicians should be wary of overzealous treatments, and they should avoid overstepping their boundaries in terms of knowledge and experience.

"Those clinicians with less experience should take their time and may want to start with lower light doses. If lesions recur, the clinician could gradually increase the light dosage and simply retreat the area at slightly higher energies.

"Also, they may want to fire one or two test pulses first and re-evaluate and assess the subsequent effect at the target lesion, and then proceed with caution," Dr. Nelson says.