The Evolving Field of Laser Surgery

September 2014
The Evolving Field of Laser Surgery
Andrei Metelitsa, MD, FRCPC
Although the field of laser surgery was developed years ago, innovative applications and
devices continue to evolve in the treatment of skin disorders. The scope of available treatment
applications is expanding as more treatment targets are discovered and new laser
wavelengths are established. While a variety of laser treatments are utilized strictly for
cosmetic indications, there are many examples of novel laser procedures that can be
incorporated into a medical dermatology practice.
I.
Cosmetic indications
Scarring and resurfacing
The concept of ablative laser skin resurfacing techniques with high-energy, pulsed carbon
dioxide (CO2) and erbium-doped yttrium aluminum garnet (Er:YAG) devices in the mid-1990s
provided superb clinical outcomes in the treatment of atrophic scars and photodamaged
facial skin, including rhytides, lentigines, and dermal elastosis. Fractional photothermolysis
represents a new milestone of laser skin resurfacing that was developed to provide a
successful clinical response while minimizing postoperative recovery and limiting treatment
complications, more likely associated with fully ablative procedures. In addition to fractional
ablative devices, fractional non-ablative lasers, developed to treat scars, rhytides, dyschromia
and striae, continue to evolve, including already established 1540, 1550 and 1927 nm
wavelengths. Often done over a series of sessions, these treatments offer effective clinical
results with minimal downtime. More recently developed fractional devices utilizing 1565 nm
and 1940 nm wavelengths continue to expand the fractional array of devices.
Tattoos
While q-switched nanosecond lasers have become the mainstay devices in the treatment of
tattoos, multiple appointments are often needed. Newly introduced lasers in picosecond
domain enhance photoacoustic breakup of the tattoo target, thus decreasing the risk of
adverse reactions, and allowing the use of lower treatment fluences. Pilot studies utilizing a
commercially-available 755 nm alexandrite picosecond laser have generated greater clearance
of tattoos with significantly fewer treatments compared to previously developed devices.
Additional picosecond lasers that incorporate dual 532/1064 nm wavelengths will soon
become available in Canada, further enhancing treatment of tattoos, including those that
contain red color.
II.
Medical indications
Acne
When managing acne, a number of device-based treatments attempt to specifically target
sebaceous oil glands. Photodynamic therapy (PDT), activated by a variety of light sources
including 595 nm pulsed dye laser (PDL) and intense pulsed light (IPL), can induce significant
reductions in inflammatory lesions associated with acne vulgaris partially contributing to the
apoptosis of sebocytes. New developments into 1720 nm wavelength might lead to preciselycalculated selective photothermolysis of sebaceous gland, adding this structure to our list of
commonly-recognized chromophores.
Vascular conditions
In the treatment of common cutaneous facial vascular conditions, including telangiectatic
rosacea, port-wine stains, angiomas and poikiloderma, PDL-based and IPL-based devices
continue to offer effective treatments. More recently, effective treatment of procedureinduced and traumatic ecchymoses have also been described with these devices. Novel
potassium titanyl phosphate (KTP) and long-pulsed Nd:YAG lasers have taken a lead in the
treatment of vascular conditions. Enhanced cooling and fluence parameters allow us to
overcome previously identified obstacles associated with the 532nm wavelength, thus
providing treatments that have minimal bruising and excellent efficacy.
Enhanced drug delivery
Ablative fractionated lasers are capable of enhancing the epidermal permeability barrier, thus
raising the possibility of facilitated transdermal delivery of drugs in the field of wound healing
and aesthetics. In fact, preliminary reports describe utilization of fractional lasers in enhanced
delivery of triamcinolone and 5-fluorouracil into hypertrophic scars.
Laser therapy does not provide answers to every clinically-relevant condition in dermatology.
Questions remain on the relevance of laser use in conditions such as melasma and
onychomycosis, understanding the scope of available procedures is absolutely essential in
providing a comprehensive treatment to patients.
Editorial Board /
Conseil de rédaction
National editor/
Rédacteur en chef
Charles W. Lynde, MD
Markham, ON
Chief Executive Officer /
Chef de la direction
Chantal Courchesne
Ottawa, ON
Regional editors /
Rédacteurs régionaux
Robert Jackson, MD
Ottawa, ON
Paul Kuzel, MD
Edmonton, AB
Benjamin Barankin, MD
Toronto, ON
Ian Landells, MD
St. John’s, NL
G. Daniel Schachter, MD
Toronto, MD
Marc Bourcier, MD
Moncton, NB
Catherine McCuaig, MD
Montréal, QC
Victoria Taraska, MD
Winnipeg, MB
Peter R. Hull, MD
Saskatoon, SK
Kathleen Moses, MD
Ottawa, ON
Catherine Zip, MD
Calgary, AB
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CHIEF EXECUTIVE OFFICER / CHEF de la DIRECTION
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