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Guidelines of care for laser surgery

1999; Elsevier BV; Volume: 41; Issue: 3 Linguagem: Inglês

10.1016/s0190-9622(99)70128-3

1097-6787

Jeffrey S. Dover, Kenneth A. Arndt, Scott M. Dinehart, Richard Fitzpatrick, Ernesto González,

Nail Diseases and Treatments

1.Introduction The American Academy of Dermatology’s Committee on Guidelines of Care is developing guidelines of care for our profession. The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and scope of care provided by dermatologists. For the benefit of members of the American Academy of Dermatology who practice outside the jurisdiction of the United States, the listed devices may include indications that are not currently approved by the US Food and Drug Administration for the particular type of laser. 2.Definition Lasers (light amplification by the stimulated emission of radiation) are sources of high-intensity, monochromatic light that can be advantageously employed in the treatment of a variety of dermatologic diseases depending on the wavelength, the pulse characteristics, and the true irradiance of the laser being used and the nature of the clinical condition being treated. In addition, high-intensity incoherent and multichromatic pulsed light may be used with the same principles of selective targeting by proper choice of wavelength spectrum, pulse characterization, and fluence. 3.Rationale 1.Scope Laser surgery is a rapidly changing field in which new types of lasers, as well as the conditions amenable to treatment, are continually being introduced. The conditions listed below have been treated using the particular laser or group of lasers by different physicians with varying results. 1.Visible light lasers emitting continuous-wave radiation and recognized by the skinLasers in this group include the continuous-wave and quasi-continuous-wave visible light lasers, which are the argon laser (488-514 nm); the continuous-wave dye laser, usually tuned between 585 and 600 nm; the copper vapor laser (511-578 nm); the continuous-wave potassium titanyl phosphate (KTP) lasers (532 nm); and the krypton laser (521, 530 and 568 nm). All these lasers produce continuous or shuttered visible laser light. In general, laser wavelengths from 532 to 595 nm are used predominantly in the treatment of vascular disorders, whereas wavelengths from 488 to as high as 532 are used in the treatment of benign pigmented disorders. With all these continuous and quasicontinuous devices the ability to spatially confine thermal damage is difficult. Thus, unlike treatment with the pulsed dye and pulsed KTP laser, the final outcome is highly dependent on the skill of the laser operator. Computer-driven mechanical scanning devices have been developed to ensure more uniformity of treatment and to help contain the thermal injury spatially, thus reducing the risk of using these continuous and quasicontinuous lasers. 1.Argon laser and continuous-wave argon-pumped dye laser The argon laser produces visible light at 6 wavelengths between 488 and 514 nm. In the continuous-wave argon-pumped tunable dye laser an argon laser is coupled to a dye cavity to produce visible laser light of differing wavelengths depending on the type of dye placed in the laser cavity. The dyes that are used absorb strongly in various portions of the physical spectrum to produce colored light. By choosing the appropriate dye, it is possible to produce a desired wavelength or color of laser light. Dye lasers employed for the treatment of cutaneous vascular disorders use rhodamine dye having a peak emission at or near 577 nm. Fine tuning can be achieved by using a prism to increase or decrease the emitted wavelength by up to 20 nm. 2.Copper vapor lasers Copper vapor lasers produce either yellow light at 578 nm or green light at 511 nm by heating elemental copper or copper salts in the optical cavity. The energy is released as a chain of low-energy, short, 20 to 40 ns pulses at a frequency of 10 to 15 kHz. This chain can be electronically shuttered to produce bursts of pulses of 0.075 to 0.3 seconds in duration. 3.Krypton laser The krypton laser is a gas-medium laser that emits either yellow light at a wavelength of 568 nm to treat vascular lesions or green light at wavelengths of 521 and 530 nm to treat pigmented lesions. 4.Conditions amenable to continuous and quasi-continuous-wave laser treatment 1.Vascular lesions 1.Angiokeratomas 2.Angiolymphoid hyperplasia 3.Superficial (capillary) hemangiomas 4.Cherry angiomas 5.Blue rubber bleb nevi (perform adequate biopsy before laser treatment) 6.Essential telangiectasia 7.Red nose caused by telangiectasia seen in the posttraumatic red nose syndrome 8.Facial and truncal telangiectases of a variety of causes including rosacea, solar-induced chronic dermatitis, radiation dermatitis, CREST syndrome, and Osler-Weber-Rendu syndrome 9.Spider angiomas 10.Lymphangiomas 11.Kaposi’s sarcoma (perform adequate biopsy before laser treatment) 12.Port-wine stains (particularly those which are deeply colored, cobblestoned and nodular in surface texture when the nonspecific thermal effects are desired) 13.Pyogenic granulomas 14.Venous lakes 15.Other 16.Benign pigmented disorders 1.Café-au-lait macules 2.Lentigines 3.Early, relatively flat, seborrheic keratoses 4.Other 5.Miscellaneous conditions 1.Adenoma sebaceum 2.Fibrous papule of the nose (perform adequate biopsy before laser treatment) 3.Glomus tumors (perform adequate biopsy before laser treatment) 4.Granuloma faciale 5.Other 6.Visible light pulsed vascular lasers 1.Flashlamp-pumped pulsed dye laser The flashlamp-pumped pulsed dye laser produces short (450-1500 μs) pulses of yellow light at a wavelength of 585, 590, 595, or 600 nm. The characteristics of these laser systems induce selective thermal damage confined to cutaneous vessels, making them most effective in the treatment of port-wine stains and benign cutaneous ectasias. The shorter pulse duration and the shorter wavelength pulse dye laser may be more effective for smaller, more superficial vessels, whereas the newer, longer pulse duration (1.5 ms), longer wavelength (595 nm) pulsed dye laser may be more effective for deeper, larger vessels, and for leg veins. 2.Pulsed KTP lasers A group of pulsed KTP (532 nm) and Nd:YAG (1064 nm) lasers has been developed with pulse durations in the 1 to 100 ms range, which induce spatially confined thermal injury to cutaneous vessels. They are effective in the treatment of benign vascular ectasias and some port-wine stains. 3.Visible light, pulsed nonlaser sources By using wavelength filters, a broad band of light from either 515, 550, 570, or 590 nm to approximately 1000 nm is produced with a high-intensity flashlamp. Depending on the filter chosen, treatment spectra are 515 to 1000 nm, 550 to 1000 nm, etc. The pulse width may be adjusted from 1 to 10 ms and the interval between pulses, as well as the fluence, may be selected. Because of the mix of wavelengths used, a more nonspecific response may be seen with competing tissue chromophores. However, the longer pulse widths and longer wavelengths may be useful in treating larger vessels. 4.Conditions amenable to pulsed lasers and pulsed light sources 1.Vascular lesions 1.Angiokeratomas 2.Angiolymphoid hyperplasia 3.Blue rubber bleb nevi (perform adequate biopsy before laser treatment) 4.Superficial (capillary) hemangiomas 5.Telangiectatic superficial leg veins 6.Cherry angiomas 7.Essential telangiectases 8.Posttraumatic red nose syndrome 9.Port-wine stains (large nodular mature port-wine stains usually require repeated treatments) 10.Spider angiomas 11.Facial and truncal telangiectases of a variety of causes including rosacea, solar-induced chronic dermatitis, radiation dermatitis, CREST syndrome, and Osler-Weber-Rendu syndrome 12.Venous lakes 13.Other 14.Miscellaneous conditions 1.Warts 2.Hypertrophic scars 3.Striae distensae 4.Other 5.Short-pulsed pigment lasers A group of short-pulsed lasers is effective for treatment of a variety of benign pigmented disorders. All have pulse durations less than 1 μs, the thermal relaxation time of 1-μm diameter melanosomes. Their effect is through combined photoacoustic and photothermal effects. 1.Q-switched ruby laser The Q-switched ruby laser produces very short pulses (25 ns) of high-intensity red light at a wavelength of 694 nm. Because red light penetrates through the dermis, the Q-switched ruby laser is effective for the treatment of both epidermal and dermal benign pigmented disorders, as well as blue, black, and green tattoos. 2.Q-switched and millisecond pulsed neodymium:yttrium aluminum garnet (Nd:YAG) laserThe Q-switched Nd:YAG laser produces 5 to 10 ns high-intensity pulses at 1064 nm in the near infrared spectrum. The laser can be frequency doubled by means of a KTP doubling crystal to produce green light at 532 nm. Light at 1064 nm penetrates several millimeters into the depths of the dermis; therefore, even deep dermal pigmented disorders, including black and blue tattoos, can be treated. The 532 nm light penetrates only into the upper dermis and is not effective for deep melanocytic processes, but is well suited for treatment of superficial pigmented lesions, such as lentigines and red, orange, and purple tattoos. In combination with a carbon-based topically applied solution, Q-switched Nd:YAG lasers may be used to temporarily remove hair and to remove superficial layers of skin for skin rejuvenation. 3.Q-switched alexandrite laser The Q-switched alexandrite laser produces either 50 or 100 ns high-intensity pulses at 755 nm in the red portion of the spectrum. Like the Q-switched ruby laser, alexandrite laser light is effective for treatment of epidermal and dermal pigmented processes and black, blue, and green tattoos. 4.Pulsed dye laser (510 nm) This pulsed dye laser produces short pulses (300 ns) of green (510 nm) light and is used for the treatment of epidermal pigmented disorders and red, orange, and purple tattoos. The wavelength is not long enough to penetrate sufficiently to affect deeper dermally pigmented disorders, such as nevus of Ota. 5.Conditions amenable to treatment with the short pulsed lasers 1.Benign pigmented lesions (epidermal) 1.Lentigines 2.Café-au-lait macules 3.Ephelides 4.Epidermal melasma 5.Nevus spilus (perform adequate biopsy before laser treatment) 6.Becker’s nevus 7.Lower labial macule 8.Peutz-Jeghers spots 9.Other 10.Benign pigmented lesions (dermal) 1.Dermal melasma may lighten with treatment, but almost invariably recurs with sun exposure. 2.Nevus of Ota 3.Nevus of Ito 4.Blue nevi (flat) (perform adequate biopsy before laser treatment) 5.Mongolian spot 6.Postinflammatory hyperpigmentation 7.Hyperpigmented scars 8.Other 9.Tattoos 1.Amateur 2.Professional 3.Traumatic 4.Miscellaneous conditions 5.Long pulsed long wavelength lasers A group of longer pulsed, non-Q-switched, relatively long wavelength lasers has recently been developed in an effort to damage larger cutaneous targets selectively. 1.Long pulsed ruby laser Long pulsed ruby lasers produce up to 60 J/cm2 in 0.3 to 3.0 ms pulses at 694 nm. 2.Long pulsed alexandrite laser Long pulsed alexandrite lasers produce more than 20 J/cm2 and pulse durations of 3-20 ms at 755 nm. 3.Flashlamp pumped pulsed light sources This device emits up to 60 J/cm2 over a broad band in 2 to 20 ms pulses at wavelengths above 590, 615, 645, or 690 nm to an upper limit of approximately 1000 nm. 4.Pulsed diode lasers Pulsed diode lasers produce up to 40 J/cm 2 in 5-30 ms pulses at 810 nm. 5.Pulsed Nd:YAG lasers Long pulsed Nd:YAG lasers produce up to 150 J/cm2 in 50 ms pulses at 1064 nm. 6.Conditions amenable to treatment with long pulsed long wavelength lasers 1.Excessive facial or body hair 2.Veins (0.4-1.5 mm diameter) 3.Other 4.Ablative and cutting lasers 1.Continuous-wave carbon dioxide (CO2) laser 1.Characteristics The CO2 laser produces invisible, mid-infrared light at a wavelength of 10,600 nm. It can be used in the continuous mode of operation (focused or incisional) for making relatively bloodless incisions, or defocused (vaporization) for ablating a variety of superficial cutaneous disorders. Incisional surgery with the CO2 laser may be valuable in patients requiring anticoagulation therapy or cardiac monitoring, and patients with cardiac pacemakers. It may also be valuable in patients undergoing scalp surgery, and in reducing bruising and postoperative swelling. 2.Conditions amenable to continuous-wave CO2 laser treatments in the vaporization or defocused mode 1.Actinic cheilitis and actinic keratoses 2.Adenoma sebaceum 3.Angiokeratomas 4.Angiolymphoid hyperplasia 5.Balanitis xerotica obliterans 6.Basal cell carcinomas (superficial type) 7.Bowenoid papulosis 8.Bowen’s disease 9.Cherry angiomas 10.Condyloma acuminatum 11.Cutaneous squamous cell carcinoma in situ 12.Cylindromas 13.Digital mucous cysts 14.Epidermal nevi (nonmelanocytic) 15.Eruptive vellus hair cysts 16.Granuloma faciale 17.Hailey-Hailey disease 18.Ingrown nails and other nail disorders requiring ablation or removal of a portion of the nail or the entire nail 19.Lichen myxedematosus 20.Lichen sclerosus et atrophicus 21.Lymphangioma circumscriptum 22.Neurofibromas 23.Nodular amyloidosis 24.Pearly penile papules 25.Port-wine stains (adult, nodular type) 26.Pyogenic granulomas •aa) Rhinophyma •bb) Sebaceous hyperplasia •cc) Steatocystoma multiplex •dd) Syringomas •ee) Trichoepitheliomas (perform adequate biopsy before laser treatment) •ff) Trichilemmomas •gg) Tumors of the appendages (perform adequate biopsy before laser treatment) •hh) Warts (refractory, periungual, plantar types) •ii) Xanthelasma •jj) Other •Pulsed and scanned CO2 laser 1.Characteristics Most conventional continuous-wave CO2 lasers can be superpulsed, a pulsing technique in which the laser produces a train of relatively high-power, short-duration pulses. Although superpulsed CO2 laser light can theoretically vaporize or cut tissue leaving a smaller residual zone of thermal damage than with continuous-wave CO 2 lasers, in practice this is only achieved using a spot size of 0.8 mm or smaller. Recently developed pulsed CO2 lasers produce short pulses (< 1 ms) at high power (> 5 J/cm2) that can remove thin layers of skin (30-50 μm) in a single pass with little subadjacent thermal damage (50-100 μm). Short-pulsed CO2 lasers and some scanned CO2 lasers are effective for resurfacing photoaged and scarred skin. The precision of these laser systems is due to the selective absorption of this wavelength of light by intracellular and extracellular water combined with the appropriate fluence to vaporize tissue and/or the appropriate pulse width to confine residual thermal damage. 2.Conditions that may be amenable to treatment with pulsed and some scanned CO2 lasers 1.Photoaged skin with dyspigmentation and fine, or occasionally coarse, rhytides 2.Acne scars 3.Slightly raised hypertrophic scars 4.Actinic keratoses 5.Actinic cheilitis 6.Rhinophyma 7.Small tumors of the appendages, such as syringomas (perform adequate biopsy before laser treatment) 8.Epidermal nevi (nonmelanocytic) 9.Cosmetic surgical procedures (eg, blepharoplasty, rhytidectomy, and hair transplantation) 10.Other 11.Erbium:yttrium aluminum garnet (Er:YAG) lasers 1.Characteristics Er:YAG lasers produce short pulses (< 1 ms), at high powers (> 2.5 J/cm2), at a wavelength of 2.94 μm which, like pulsed CO2 lasers, can remove very thin layers of skin (25 μm) in a single pass with even less thermal damage (5 μm) because of highly selective absorption by intracellular and extracellular water. 2.Conditions that may be amenable to treatment with the Er:YAG laser 1.Photoaged skin with fine rhytides 2.Acne scars 3.Actinic cheilitis and actinic keratoses 4.Small tumors of the appendages (perform adequate biopsy before laser treatment) 5.Other 6.Issue Physician qualifications 1.General The physician should have 1.Completed residency training in an appropriate specialty such as dermatology, which provides training in cutaneous surgery; and 2.General knowledge of basic laser physics, laser-tissue interaction, and laser safety; and 3.Knowledge of the special safety requirements and elements of the laser, and the prevention and management of potential complications for the specific type of laser to be used; and 4.Knowledge of cutaneous anatomy and basic factors regarding cutaneous wound healing 5.Specific 1.The physician should have laser surgery training in residency, or 2.Attendance at an appropriate laser course that includes instruction in basic laser physics, laser safety, didactic lectures on clinical applications of lasers, hands-on experience, or equivalent hands-on experience conducted under the supervision of an appropriately trained and experienced laser surgeon 3.Diagnostic criteria 1.Clinical 1.Medical history 1.Duration 2.Location 3.Changes that have occurred over time 4.Cosmetic concerns 5.Family history 6.Concurrent medical problems 7.Current medications 8.History of isotretinoin usage 9.Previous dermabrasion 10.Previous cutaneous radiation 11.Allergies 12.History of abnormal scarring, especially keloids 13.History of herpes simplex infection in area to be treated 14.Skin type (facultative and acquired pigmentation) 15.Physical examination 1.Description of the lesion 2.Extent 3.Location 4.Diagnostic tests 1.If the clinical appearance of the condition or lesion is insufficient to ensure an accurate diagnosis, then a biopsy should be performed, especially with pigmented lesions. 2.In some conditions, the performance of a small representative test area may be necessary to accurately determine the proper laser parameters to use and tissue response in the treatment of larger areas. 3.Recommendations 1.Treatments 1.Medical Positive findings in the medical history should be addressed in planning the care and management of the patient. 2.Surgical 1.Preoperative 1.Patient selection is very important and care must be taken to explain the procedure and to ensure that the patient has a complete understanding of the nature of the problem, the treatment options that are available, the risks and benefits of the various forms of treatment, the associated complications, and the potential for scarring and/or pigment changes. 2.In many cases, especially tattoos, port-wine stains, some pigmented lesions such as café-au-lait macules, several treatments may be required to achieve the best results and the greatest degree of improvement. 3.Pretreatment and posttreatment photographs may be useful in ensuring reasonable expectations. 4.Anesthesia (See “Guidelines of Care for Local and Regional Anesthesia in Cutaneous Surgery” [J Am Acad Dermatol 1995;33:504-9] and “Guidelines of Care for Office Surgical Facilities, Parts I and II” [Ibid: 1992;26:763-5 and 1995;33:265-70, respectively.) The choice of no anesthesia, topical anesthesia, local anesthesia, local anesthesia in combination with sedation, cryanesthesia, regional nerve blocks, intravenous sedation, or general anesthesia is determined by the physician. 5.Treatment techniques The lowest power density or energy fluence that is consistent with a good clinical result is strongly encouraged except when using the CO2 laser for cutting or ablation. By choosing the most appropriate wavelength and pulse characteristics that limit unwanted thermal damage, therapeutic outcome can be optimized. 6.Postoperative findings The frequency of complications is related to the type of laser that is used and the condition that is treated. 1.Occasional 1.Irregular pigmentation 2.Pain 3.Persistent erythema 4.Recurrence 5.Rare 1.Bleeding 2.Failure to show satisfactory improvement 3.Infection 4.Scarring or textural changes 5.Other Follow-up examinations are highly encouraged and are strongly recommended. 6.Surgical setting Laser surgical treatments may be performed in a physician’s office, in an ambulatory surgical center, or in a hospital. The American Academy of Dermatology has recommended guidelines for office surgical facilities to help assure the provision of quality office surgical care. (See “Guidelines of Care for Office Surgical Facilities, Parts I and II” [J Am Acad Dermatol 1992;26:763-5 and 1995;33:265-70, respectively].) In addition to the recommendations set forth in those guidelines, the Academy recommends the following for laser surgery facilities. These guidelines do not supersede any existing local, state, or federal regulations. 1.Facility 1.The entranceway to the laser facility has a laser device safety sign posted in plain view on the door when the laser is in use. 2.Protective measures are taken to prevent stray laser irradiation from leaving the room or from reflecting. 3.The room is adequately ventilated with a smoke evacuator. 4.Smoking is not allowed in the surgical suite. 5.Equipment 1.Laser Laser equipment is appropriately sign-posted. 2.Laser maintenance 1.Each laser system is maintained by trained personnel who are skilled in assuring proper laser output, beam alignment, and lenses employed in each procedure. 2.Up-to-date preventive maintenance logs are kept. 3.Safety maintenance includes 1.Intact electrical cables 2.Functioning shutters and safety interlocks 3.Warning light indicators 4.Eye protection 1.Appropriate safety goggles of sufficient optical density specified for the wavelength of each laser in the facility are available. 2.Patients and personnel are protected by appropriate eye protection. 3.Goggles are labeled with the wavelength protection provided. 4.Masks The use of masks that filter particles as small as 0.1 μm in diameter are available. 5.Vacuum devices 1.Vacuum devices with sufficient power and with the ability to filter to 0.1 μm are used for all procedures in which a plume is produced. 2.Silastic tubing is changed after each individual patient treatment. 3.Filters are replaced according to the manufacturer’s recommendation. 4.Dyes 1.Dye and filter changes are performed when the room is empty. 2.Gloves and an adequate ventilating mask are worn by all personnel handling the dyes because of their potential toxicity. 3.Dye spills are reported to the environmental service representative in the building and to the laser company. 4.Other 1.Nonreflective or ebonized instruments are used. 2.Nonflammable surgical drapes are used. 3.Oxygen sources, such as nasal prongs and tubes, should be removed from the patient before surgery. 4.Documentation Laser parameters such as fluence, spot size, pulse duration, and wavelength are recorded. Document scanner setting when using systems with scanners. 5.Staff Appropriate nursing and technical staff have documentation of laser training and safety training. 6.Procedure manuals A periodic review program is in effect and includes review of 1.Adequacy of safety protocols for the laser, vacuum, and power meters 2.Procedure manuals for laser use and safety that are available in the facility 3.Supporting evidence See Bibliography (Appendix) 4.Disclaimer Adherence to these guidelines will not ensure successful treatment in every situation. Furthermore, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. For the benefit of members of the American Academy of Dermatology who practice outside the jurisdiction of the United States, the listed devices may include indications that are not currently approved by the US Food and Drug Administration for the particular type of laser.