Kamal Alhallak, Adel Abdulhafid, Salem Tomi, Dima Omran - The Ultimate Guide For Laser and IPL in The Aesthetic Field-Springer (2023)

The
Ultimate Guide
for Laser and IPL in
the Aesthetic Field
Kamal Alhallak
Adel Abdulhafid
Salem Tomi
Dima Omran
123
The Ultimate Guide for Laser and IPL
in the Aesthetic Field
Kamal Alhallak • Adel Abdulhafid
Salem Tomi • Dima Omran
The Ultimate Guide

for Laser and IPL
in the Aesthetic Field
Kamal Alhallak Adel Abdulhafid
Albany Cosmetic and Laser Center University of Alberta
Edmonton, AB, Canada Edmonton, AB, Canada
Salem Tomi Dima Omran
Albany Cosmetic and Laser Center Albany Cosmetic and Laser Center
Edmonton, AB, Canada Edmonton, AB, Canada
ISBN 978-3-031-27631-6 ISBN 978-3-031-27632-3 (eBook)

https://doi.org/10.1007/978-3-031-27632-3
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
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This book is dedicated to two of the most
influential people in my life: my mother,
Daad Shiekho, and my wife, Dima Omran,
who is also a co-author. I’d also like to
dedicate this book to my late father, Nizar
Alhallak, may his soul rest in peace. Finally,
this book is dedicated to Nizar Junior and
Mohammad, my children.
Kamal Alhallak
Acknowledgment
I thank all the medical professionals and laser technicians at the Albany Cosmetic
and Laser Center, especially Darian Holtby. Moreover, I wish to extend my grati-
tude to Dr. Shirzad Azarmi’s unwavering assistance throughout my Ph.D. lab work
at the University of Alberta. Special acknowledgment and heartful thanks to my
Ph.D. Supervisor Dr. Raimar Leobenberg and my supervisory committee, Dr.
Wilson Roa, Dr. Warren Finlay, and Dr. Ayman Elkadi.
Finally, I wish to thank Drs. Amir Mardini, George Laham, and Anton Laham for
their unwavering assistance during my time at Damascus University.
Kamal Alhallak
vii
Contents
1 kin, Light, and Their Interactions�� 1

S
Skin Anatomy�� 1
Epidermis (EP)�� 1
Dermis�� 5
Subcutaneous Layer �� 6
Histology of Normal Skin�� 6
Changes due to Intrinsic Aging�� 7
Changes due to Photoaging�� 7
Epidermis (EP)�� 7
Dermis�� 7
Classification of Photoaging�� 9
Light-Based Treatment�� 10
Light-Tissue Interaction�� 10
Skin’s Chromophores�� 11
Light Parameters�� 13
Skin Histology Changes After Laser Interaction �� 25
Skin Lesion Characteristics�� 28
References�� 36
2 aser and Intense Pulsed Light�� 39
L
IPL�� 40
Types of IPLS�� 42
Lasers �� 54
Color Sensitive�� 54
Color-Blind�� 55
Color Sensitive According to Pulse Width�� 58
Color-Blind Lasers�� 78
References�� 96
3 Hair Removal�� 101
Hair Follicles�� 103
Anatomy�� 103
ix
x Contents
Growth �� 104

Assessment�� 106
Wavelength�� 109
Available Technology�� 109
IPL�� 109
Long-Pulsed Alexandrite 755 nm�� 131
Long-Pulsed Diode 810 nm �� 137
Long-Pulsed ND:YAG 1064 nm�� 142
Blended Blend Wavelengths�� 146
Electro-optical Synergy�� 147
How to Choose a System for Hair Removal�� 148
References�� 148
4 Acne Vulguris�� 153
Active Acne Vulgaris�� 153
Acne Assessment �� 155
Subjective Tools and Questioners�� 155
Objective Tools and Skin Analyzers�� 155
Treatment Options�� 156
Comparison of Dual-Filter IPL for Acne �� 165
Choosing a Device for Acne Treatment �� 176
5 Hyperpigmentation�� 181
Epidermal Pigmented Lesions: Actinic Lentigines
and Ephelides �� 182
IPL�� 183
Laser�� 193
Melasma�� 197
Assessment�� 197
Managing Patient Expectation �� 198
Etiology�� 198
Classification�� 199
Treatment �� 199
Conclusion �� 222
6 Scar Revision�� 225
Scar Assessment and Types�� 225
Atrophic Scars�� 226
Summary of Suggested Treatments �� 243
Hypertrophic Scars and Keloids�� 243
Etiology�� 246
Contents xi

Ultrashort Picosecond Lasers�� 250
7 tretch Marks (Striae Distensae)�� 265
S
Etiology�� 265
Light Base Treatment�� 266
IPL�� 266
Pulsed Dye Laser �� 267
1064 nm ND:YAG�� 267
Fractional Non-ablative Lasers�� 268
Fractional Ablative Lasers �� 270
8 Laser Vaginal Rejuvenation�� 273
Laser Vaginal Rejuvenation �� 274
Fractional CO2�� 275
Non-ablative Er:YAG�� 276
Hybrid Fractional Laser �� 277
Treatment Procedures�� 279
Evaluation, Consultation, and Follow-Up�� 280
Consultation/Education�� 280
Medical History �� 280
Informed Consent�� 280
Medication �� 280
Follow-Up�� 281
Possible Side Effects�� 281
Contraindications �� 281
9 uying a New Laser or IPL Devices�� 285
B
Stand-Alone Versus Modular Platforms�� 286
Planning Your Next Device Purchase�� 287
Refurbished Devices�� 298
10 B
uying a Refurbished Laser Device �� 301
Medical Device Regulations in the United States�� 302
Marketing or Selling a New Medical Device�� 302
Marketing or Selling a Refurbished Medical Device�� 304
Appendix �� 309
Laser Hair Removal�� 317

xii Contents
Non-ablative Fractional Laser�� 321
Rosacea and Spider Vein Removal �� 329
Acne Treatments�� 335
Melasma�� 341
Index�� 343
Chapter 1
Skin, Light, and Their Interactions
Skin Anatomy
The epidermis, dermis, and subcutaneous layers are the three major layers of human
skin [1], listed from most superficial to deepest. Figure 1.1 depicts the various layers
of normal skin, each containing a hair follicle.
Each of the three skin layers contains the following sublayers of living and non-
living skin cells.
Epidermis (EP)
The epidermis (EP), the skin’s outermost layer, is responsible for essential cosmetic
qualities such as appearance and texture [2]. The thickness of the facial epidermis is
0.1 mm on average, with four sub-layers: stratum corneum (SC), stratum granulo-
sum (SG), stratum spinosum, and stratum basale (SB) [3].
The epidermis must be renewed for the layers to function properly and for the
skin to look appealing. The epidermis renewal cycle in the healthy skin lasts about
1 month, the time it takes for living keratinocytes from the basale to desquamate and
migrate to the skin’s surface [4].
Stratum Corneum
It comprises approximately 15 layers of nonliving keratinocytes (corneocytes)

coated with a phospholipid film layer and linked by corneodesmosomes, as shown
in the figure below. This layer serves as a physical barrier to pathogens and UV
© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2023
K. Alhallak et al., The Ultimate Guide for Laser and IPL in the Aesthetic Field,
https://doi.org/10.1007/978-3-031-27632-3_1
2 1 Skin, Light, and Their Interactions
Fig. 1.1 Different layers of the human skin, including a hair follicle
light. Furthermore, it regulates water loss through evaporation and keeps the skin
hydrated [5].
The stratum corneum is typically 10–40 μm thick. The remaining epidermis lay-
ers are formed due to keratinocyte differentiation stages caused by migration and
desquamation. This layer contains the least amount of water of any of the skin lay-
ers [6, 7].
Stratum Grаnulоѕum
This is also known as the granular layer, and it is composed primarily of striated
squamous сеllѕ arranged in 1–3 rows of lamellar granules [8]. It is important to note
that beneath the раlmѕ and ѕоlеѕ, the skin lacks a well-defined ѕtrаtum lucidum and
Skin Anatomy 3
Fig. 1.2 Structure of SC and SG layers
stratum granulosum [9]. Figure 1.2 illustrates the structure of the stratum cor-
neum layer.
Stratum Sріnоѕum
Also known as the spinous layer, it consists primarily of a cuboid cell arranged in
multiple layers and synthesizes keratins that function to support structures. The
сеllѕ are held together by specialized сеllѕ known as а dеѕmоѕоmеѕ [10].
Stratum Basale
This іѕ the dеереѕt lауеr of thе eріdеrmіѕ, and it is alѕо known аѕ thе bаѕаl сеllѕ
lауеr. The lауеr consists of tall columnar сеllѕ thаt are constantly undergoing cel-
lular division and help form new kеrаtіnосуtеѕ (kеrаtіnіzаtіоn) thаt will replace thе
lost once from ѕtrаtum соrnеum; the process takes about 1 month [11], as shown in
Fig. 1.3.
Further down thе stratum basale, thе cell lауеr is attached to a basement mem-
brane that serves as demarcation or a boundary between thе epidermis and dermis.
The lауеr also contains the pigment-producing cells, mеlаnосуtеѕ [12].
Melanocytes
The epidermis is also responsible for giving us our skin colour due to its high pig-
ment melanin (MLN) content. Melanocyte produces two types of MLN: pheomela-
nin and eumelanin. Typically, one square mm of skin contains 1000 and 2000
melanocytes and can produce two MLN types, pheomelanin and eumelanin [13].
Fig. 1.3 Differentiation and migration of the basal keratinocyte, starting from SB to the SC layer
The type of MLN in the epidermis determines the skin colour; pheomelanin is
prominent in light skin, while eumelanin is in dark skin. However, there is no differ-
ence in the number of melanocytes between light and dark skin. The production of
MLN starts from the amino acid tyrosine via the enzyme tyrosinase [14].
Once produced, the melanocytes store MLN in small sacks called melanosomes.
In light skin, melanosomes are small and contain only a few tightly packed MLN
granules. In darker skin, melanosomes are larger and contain many loosely distrib-
uted MLN granules [15], as shown in Fig. 1.4.
Each melanocyte establishes connections with an average of 40 keratinocytes via
cellular extensions called dendrites, as shown in Fig. 1.5. MLN is then transferred
to keratinocytes via a keratinocyte-initiated process. This process includes MLN
exocytosis from melanocytes, followed by endocytosis of MLN by the karyocytes.
Any MLN production and distribution irregularities will result in dyschromia
(hyper- or hypopigmentation) [16].
Skin Anatomy 5
Fig. 1.4 Difference between dark and light skin regarding melanocytes’ MLN type and packaging
Dermis
It lies between the epidermis and the subcutaneous lауеr and is about 2 mm thick.
This middle lауеr of skin contains structural protein іn thе form of collagen in bulk
and elastin іn minimal quantities, with a rich intertwining blood supply.
The types of cells located іn thе dermis are fibroblast, mast сеllѕ, and histiocytes.
The dermis’ primary cell type is the fibroblast, responsible for the dermal extracel-
lular matrix (ECM) synthesis. The ECM includes structural proteins (such as col-
lagen and elastin), glycosaminoglycans (such as hyaluronic acid), and adhesive
proteins (such as fibronectin and laminins) [17].
The hydrophilic hyaluronic acid binds to water and increases skin hydration. The
ECM component’s loss is responsible for most skin aging signs regarding sagging
and laxity. The epidermis and dermis’s borders are not straight lines but wavy, form-
ing intertwined fingers. The dermal fingers (extension) are called papilla, and the
epidermal fingers (extensions) are called rete ridges [18].
Hair follicles, nerves, lymphatic vessels, and sweat glands also reside іn thе der-
mal lауеr of the skin and are referred to as appendageal structures or adnexa [19].
Fig. 1.5 Melanocyte connection with a keratinocyte cell
Subcutaneous Layer
This layer is known as the hypodermis, which іѕ the lowermost skin’s lауеr com-
prising mainly fat (adipose). This layer provides protection from injury, produces
heat, and serves аѕ a cushion for the body [10].
Histology of Normal Skin
The normal thickness of the epidermis (top layer) comprises several layers of squa-
mous cells with the delicate basket-weave keratin (stratum corneum) on the surface.
The dermis (bottom part) comprises sparse fibroblasts with abundant extracellular
collagen bundles and embedded capillaries lined by a single layer of endothelial
cells [20]. Figure 1.6a and b show the histology section using hematoxylin-eosin
with two magnifications, 10 and 40, respectively.
Changes due to Photoaging 7
a b
Fig. 1.6 (a) Layers of the epidermis and dermis (hematoxylin-eosin, magnification 10) [21]. (b)
Layers of the epidermis and rete ridges (hematoxylin-eosin, magnification 40) [21]
Changes due to Intrinsic Aging
Like all other organs, the human skin is affected by the normal aging process. The
aging process is mainly induced by oxidative stress [22], resulting in a thinner der-
mal layer and low-quality epidermal layer [23]. This process is invertible; however,
it depends on external aging factors such as photoaging.
Changes due to Photoaging
Epidermis (EP)
The extended exposure to the sun’s UV light affects the keratinocyte maturation
and migration process and the skin’s ability to shed the old corneocytes.
Therefore, the stratum corneum gets thicker, and the texture gets rougher, which
results in poor light reflection (dullness) [21]. Moreover, the epidermis loses
some of its functionality as a barrier allowing a higher evaporating rate (dryness)
and higher irritant and pathogen penetration. Furthermore, the UV light might
disrupt MLN’s production, storing, and transferring, resulting in several hyper-
pigmentation manifestations (melasma, lentigines, freckles) and hypopigmenta-
tion (vertigo) [24].
Dermis
Overall, the human skin loses 1% of its ECM components per year. However,
the UV light accelerates this rate. Since the epidermis would not block the UV
light efficiently, the damaging effect might extend to ECM. The UV light
induces some enzymes responsible for elastin and collagen degradation.
Therefore, photoaging accelerates ECM structural protein loss and denaturation
of hyaluronic acid (dermal atrophy). Moreover, UV light might affect blood ves-
sels in the dermis layer, resulting in visible telangiectasias and erythema.
Melanocyte hyperactivation might result in high MLN concentration at the der-
mal level, such as in melasma [25].
Fig. 1.7 Main differences between the young skin and photoaged skin
Table 1.1 Average thickness of different layers of the skin on different parts of the female
face [26]
Skin thickness chart
Anatomical region Epidermis μm Dermis μm E+D μm Hypodermis μm Total μm
Mental 149 1375 1524 1020 2544
Forhead 202 969 1171 1210 2381
Upper lip 156 1061 1217 931 2148
Lower lip 113 973 1086 829 1915
Tip of nose 111 918 1029 735 1764
Neck 115 138 253 544 797
Cheek 141 909 1050 459 1509
Glabella 144 324 468 223 691
Eyelids 130 215 345 248 593
Figure 1.7 points out the main changes induced by photoaging, such as reduced
elastin and collagen, dermal and hypodermal atrophy, thinner EP, and thicker SC
layer (Table 1.1).
Figure 1.8 shows histology differences between photo-protected and photo-
exposed skin [21].
Changes due to Photoaging 9
Fig. 1.8 The difference in elastic fiber destruction in photo-exposed hypertrophic skin. The photo-
protected skin shows normal architecture, unlike photo-exposed, which shows excess mature elas-
tic fiber deposition, which is truncated and dystrophic. Reproduced from ref. [21] with permission
from the Royal Society of Chemistry
Fig. 1.9 Different stages of photoaging and its corresponding Glogau classification
Classification of Photoaging
Practitioners should have the tool to objectively assess their clients and photoaging
state to provide evidence-based treatments. The Glogau photoaging classification is
a valuable tool if the practice does not make a skin analyzer available. Figure 1.9
shows different stages of photoaging with detailed characteristics of each stage.
Fig. 1.10 Photo-numeric scale for photoaging [21]
Another system to objectively assess photoaging is the photonumeric scales

developed by Ellis et al., as shown in Fig. 1.10 [27]. The photo-numeric scale
assesses assign hypertrophic facial photoaging between 0 and 8, where 0 = no pho-
toaging, 2 = mild, 4 = moderate, 6 = severe, and 8 = very severe. Interdigitate values,
i.e., 1, 3, 5, and 7, could also be assigned if appropriate [27].
Light-Based Treatment
This term is widely used to describe all light-based (lasers and intense pulsed light)
procedures for correct cosmetic and medical procedures. Practitioners in the aes-
thetic field use “photorejuvenation” to describe methods to improve skin conditions
or correct a particular skin concern [28].
Therefore, choosing the correct technology requires a comprehensive under-
standing of the skin anatomy, the treated cosmetic issue, and the principle of laser
and IPL. All photo-based treatments have one of three mechanisms of action: selec-
tive photothermolysis [29], chemical photosensitization [30], or photoacoustic
effect [31].
Light-Tissue Interaction
Theoretically, a laser beam can travel in a vacuum till infinity if there is no interac-
tion. However, once a laser beam collides with an object (skin tissue), it combines
four physical processes: absorption, reflection, transmission, and scattering. The
object’s physical characteristics and the laser beam parameters define the most
prominent type of interaction. Figure 1.11 illustrates the four different possible out-
comes of the light-skin interaction.
Light-Tissue Interaction 11
Fig. 1.11 Four different possible outcomes of the light-skin interaction
Our goal is to maximize the light absorption by a specific skin component at a

particular depth in light-based therapy in the aesthetic field. We use “chromophore”
to refer to the skin component with the highest laser absorption properties [32].
Skin’s Chromophores
All photo rejuvenation processes target the chromophores of specific skin compo-
nents in the dermis and epidermis layers. These chromophores selectively absorb
photons’ energy and turn it into thermal energy (heat) [33]. The main three chromo-
phores in the human skin are:
• MLN for pigmented lesion and laser hair removal (absorbs light of wavelengths
between 400 and 1100 nm, with no peaks).
• Water for wrinkle and dermal ECM induction (show a significant absorption
peak at 3000 nm).
• Hemoglobin (Hgb) and its derivatives (oxy-Hgb and deoxy-Hgb) for vascular
lesion (shows strong absorption at 400–600 nm with peaks at 418, 542, and 577).
MLN and Oxy-Hgp share a vast portion of the absorption spectrum. Therefore,
lasers designed to target MLN (755 nm Alexandrite) have wavelengths with good
MLN selectivity and low Oxy-Hgb affinity [34].
Photorejuvenation targets a specific chromophore to enhance (or prohibit) a spe-
cific process [35] or remove unwanted lesions [36]. In case of removing unwanted
lesions, the thermal energy that builds up in the skin lesion that contains the chro-
mophore ends up burning the chromophore without damaging any other skin cell,
theoretically. This concept is “selective photothermolysis.”
Selective Photothermolysis
Photo energy (light) needs a medium to turn itself into thermal energy (heat); this
medium is called a chromophore (we will discuss the three skin chromophores in
detail). A chromophore is a molecule (or part of a molecule) that absorbs light in a
certain spectrum range. The colour of a chromophore is the light minus that specific
absorbed spectrum.
To absorb photon energy, a chromophore should be able to turn it into a different
form, such as thermal energy (heat). Therefore, a chromophore temperature would
increase due to heat buildup, and depending on the heating rate, there are three pos-
sible scenarios:
1. The light energy has a low intensity, and the chromophore temperature heat does
not rise significantly. Thus, the chromophore confines the heat, then dissipates
the extra heat to the surroundings, and eventually cools down to normal tempera-
ture without disrupting the surroundings.
2. The light energy has a medium intensity, and the chromophore temperature heat
rises significantly. However, the chromophore will try to cool down and return to
a normal temperature as fast as possible. Thus, the chromophore will dissipate
the extra heat to the surroundings at a higher rate, raising their temperature. The
chromophore and its surrounding will eventually cool down with or without
physiochemical changes. This phenomenon is referred to as a bystander effect,
as shown in Fig. 1.12. The effect is one of the main theories that explain the laser
hair removal mechanism of action.
3. The light energy is highly intense, and the chromophore temperature heat rises
dramatically. The chromophore will try to cool down and return to a normal
temperature as fast as possible. However, this cooling rate would not be suffi-
cient, and the temperature will reach a point that induces physicochemical
changes. The chromophore will cease to exist in the same physiochemical prop-
erties, and the surroundings might (might not) experience thermal-induced
changes. This is referred to as the selective photothermolysis principle.
Most of the aesthetic field’s photo-based treatments use the selective photother-
molysis principle and its bystander effect to induce skin tissue changes. For this to
happen, there are three key conditions:
1. The targeted tissue should have a higher concentration of a specific chromophore
than its surroundings.
Fig. 1.12 Heat diffusion

after laser exposure
commonly called the
bystander effect of the
laser
2. We should use a specific wavelength to target that chromophore selectively.

3. We could control the temperature rise rate to induce the required photothermoly-
sis and bystander effect, not more or less.
Chemical Photosensitization
Acne vulgaris light-based treatments rely, in part, on the photosensitization of por-

phyrins into oxygen-free radicals with antibacterial properties [37].
Photoacoustic Effect
This is one physical property that is specific to the laser in short and ultrashort pulse
width. In a brief explanation, a laser could induce intense vibration on a microscopic
level that is mainly used for pigmentation and tattoo removal [38].
Light Parameters
Wаvеlеngthѕ (nm)
Thе wаvеlеngth is related to the light colour. Laser light is еxtrеmеlу mоnосhrоmаtіс
(one colour) when compared to other sources of light. All of the photons that make
up the laser beam have a fixed phase relationship (coherence) with respect to one
another [39].
The selection of the wavelength emerges from the selective photothermolysis
principle. Therefore, the wavelength should present the highest affinity between the
laser and the lesion, hence the highest absorption. However, we should consider the
effect of wavelength on skin-laser physical interactions [40].
Lower wavelength is associated with lower penetration due to high scattering.
This makes lower wavelength laser not suitable for dermal level lesions. Moreover,
it is associated with a higher risk of epidermal damage. We will discuss different
available wavelengths and their indication in a later section. Figure 1.13 shows the
relative penetration of the most commonly used wavelength [41].
Scientifically, we express a chromophore’s ability to absorb light in a specific
wavelength by the absorption coefficient (cm−1). A higher absorption coefficient
means a higher affinity between the wavelength and the chromophore [42].
Figure 1.14a and b show the three targeted chromophores in the skin and the
absorption and coefficient of each wavelength [43]. We will discuss the meaning of
chromophores and their relevance in aesthetic treatment in detail. As shown in
Fig. 1.14b, MLN and Hgb do not show photo absorption after 1064 nm, as water
becomes the main targeted chromophore.
Table 1.2 shows the absorption coefficient and ratio of the three wavelengths
commonly used in a picosecond range. A higher ratio indicates more specificity
toward one chromophore [44].
On the contrary, intense pulsed light (IPL) is not a laser, as it is polychromatic
(spectrum of wavelengths) and non-coherent. However, a practitioner can use a spe-
cific bandwidth by applying a specific filter with an upper or lower cutoff wave-
length or replacing the handpiece [45]. As discussed in lasers, each wavelength
band has a different penetration depth, tissue interaction, and selective chromo-
phores [46].
Figure 1.15 shows the penetration depth of different IPL spectrums produced by
different filters. Blue light is the unfiltered IPL, which includes the full spectrum
between 420 and 1200 nm. As shown in Fig. 1.15, the full spectrum has the least pen-
etration; a higher filter number correlates with a high cutoff wavelength and deeper
Absorption Length
532 585 755 810 1064 1550 1927 2.94 10.6
Fig. 1.13 Relative penetration of the most commonly used wavelength

Fig. 1.14 (a) Absorption peak of Hgb, MLN, and water for lasers between 532 and 1064 nm. (b)
Absorption peak of water for lasers between 1064 and 10,600 nm
Table 1.2 Absorption coefficient and ratio of 532 nm, 1064 nm and 755 nm
Wavelength, nm 532 1,064 755
Melanin abs, cm−1 555 50 163
Blood abs, cm−1 235 3.2 3.0
Absorption ratio 2.4:1 16:1 54:1
Fig. 1.15 Penetration depth for different IPL spectrums produced by different filters
penetration. For example, the 690 red filter cut all light with a wavelength less than
690 nm, thus producing light between 690 nm and 1200 nm for deeper penetration.
Fluence (J/cm2)
If the laser beam is a string, the fluence would be the string’s density/thickness. As
inferred by the unit (J/cm2), it is a measure of energy (in joules) delivered to the
treated area of one cm2. Low fluence may result in less than satisfactory results,
while high fluence may result in burns and adverse events [47].
Therefore, practitioners should be conservative when choosing the fluence to
ensure efficacy while preserving safety. A higher affinity between the laser and skin
lesion allows the practitioner to increase the fluence without risking the cells and
tissues around the targeted lesion. Notice that the fluency unit does not have the
“time” factor in it.
Pulse Widths (Fraction of a Second)
The concept of pulse width adds the “time” dimension missing from the fluence. It
is essential to understand that a laser beam does not deliver energy continuously.
However, it provides the energy in waves (pulses of photo-energy) with an interval
between each pulse (inter-pulse delay times) [48].
To simplify this concept, let us say that we have two different laser beams, A and
B (Fig. 1.16), with the following parameters
• A: energy flow of 200 J/s and pulse width of 30 ms (top)
• B: energy flow 200 J/s and pulse width of 10 ms (bottom)
Fig. 1.16 A simple

illustration of two different
lasers (a and b) with the
same fluence and different
pulse widths. The blue
color is the laser pulse, and
the red is the inter-pulse
delay
Figure A tissue was exposed to both lasers for 100 ms; the skin would receive the
same 20 J of photo energy in two pulses from both lasers; each is 10 J.
However, laser B will provide energy to the skin lesions in a more intense (higher
peak) but shorter pulse width than A. In another word, the continuous delivery time
of the energy is different. Laser A delivers the energy in 60 ms out of 100 ms, but
laser B takes only 20 ms out of the total exposure time to deliver the energy (100 ms).
A laser’s short pulse duration produces a more efficient photothermolysis pro-
cess to reach the clinically required temperature faster without thermal diffusion to
unwanted tissues [49]. Practitioners should choose pulse width according to the
target’s thermal relaxation, which is the time (in a fraction of a second) required by
an object to dissipate 63% of the excess thermal energy (heat) [50]. We will discuss
this concept in detail later on, but an object with a longer thermal relaxation time
can confine the heat for longer times and spare unwanted heat diffusion. Therefore,
targeting a lesion with a shorter relaxation time, such as melanosomes, is more chal-
lenging. Such targets dissipate (relax) heat to the surrounding tissue, making it hard
to reach the required temperature inside the lesion itself.
Moreover, unwanted heat diffusion might result in side effects in healthy tissues,
such as burns and post-inflammatory hyperpigmentation (PIH). Therefore, practi-
tioners should use a shorter pulse when targeting certain types of pigmentation to
induce photothermolysis without giving the lesion time to cool down (by dissipating
the heat to unwanted tissues) [38]. The fast heat buildup raises the lesion tempera-
ture to the required level to induce photothermolysis, minimizing heat dissipation
and unwanted side effects [51]. The following figure shows a simple schematic
illustration for laser A (top) and laser B (bottom). The areas colored in red refer to
intra-pulse delay, which is the time between two consequent pulses.
We wish to emphasize that this example is oversimplified, and relaxation time dif-
fers from the intra-pulse delay time but is an intrinsic characteristic of the target.
Figure 1.17 shows one laser pulse with the same fluence but different pulse widths, long
and short, A and B, respectively. As shown in Fig. 1.16a, the long pulse works well for
larger targets and long relaxation times but is less effective in smaller targets. It would
not be practical to induce clinical temperature in small targets using a long pulse laser.
On the contrary, the short pulse is more effective in irradiating smaller targets
with a short relaxation time. The heat accumulation induced by the short-pulsed
a b
Fig. 1.17 One pulse of two different lasers (a and b) with the same fluence and pulse width and
how they affect large and small targets differently. The top (a) is a long pulse, and the bottom (b)
is a long pulse
Fig. 1.18 Effect of the pulse width on heat diffusion after irradiation with Er:Yag laser
laser effectively exceeds the heat diffusion rate to reach clinical temperature in the
targeted lesion [52].
We could use the Er:Yag laser’s pulse width to illustrate the relation between the
pulse width and dynamic heat change (thermal diffusion). This laser is ablative and
drills a hole in the exposed tissues. The following figure shows that the hole’s depth
is almost the same regardless of the pulse width. However, long pulse width gener-
ates more heat in the surrounding tissue, as shown in Fig. 1.18.
The difference is more profound if we compare a long and short pulse width
laser. The following graph shows the difference in energy intensity (peak) of
flashlamp-pumped pulsed dye laser and Q-switched Nd:YAG laser.
Fig. 1.19 Difference between pulse width and shape between flashlamp dye laser (in green) and
nanosecond laser (red), recreated from [53]
The short-pulsed laser provides a concentrated, high-intensity laser pulse usually

illustrated as a needle shape, as shown in Fig. 1.19 [53]. It is essential to realize that
all pulse widths (from ultrashort to ultralong) are equally important but have differ-
ent applications in aesthetic fields. Moreover, the same laser wavelength has differ-
ent applications and indications according to the pulse width. Other synonyms of
pulse width are pulse duration and dwell time.
For example, Nd:Yag laser comes in ultralong pulsed (second) for lipolysis [54],
long-pulsed (ms) for laser hair removal [54], quasi-long microsecond (μs) for pig-
mentation [55], short nanosecond (ns) for tattoo removal [56], and ultrashort pico-
second (ps) pulse width for skin rejuvenation [57].
Train of Sequential Sub-pulses
Some systems can deliver the required total pulse energy in a train of consequent
shots (sub-pulses) with a short intra-pulse delay [58]. The total pulse width equals
the sum of the sub-pulse’s duration and the intra-pulse duration.
Figure 1.20 is an illustration of the M22 IPL interface [59]. The interface shows
a total pulse width of 15 ms divided into three sub-pulses with 3.8, 3.2, and 3 sub-
pulse widths; we refer to the sum as active light emission time. The intra-pulse delay
is 2.6 (between the first and second sub-pulse) and 2.4 ms (between the second and
third sub-pulse). The total pulse width here is the sum of all sub-pulse widths and
intra-pulse delay (3.8 + 2.6 + 3.2 + 2.4 + 3.0 = 15 ms).
Photo energy may be delivered in two different patterns: A shows the traditional
pattern of light-based therapy, in which the photo energy is delivered in a continu-
ous-solid pulse, and B shows the same every delivered in three equal sequential
sub-pulses. It is important to emphasize that Fig. 1.21b shows only two pulses, with
three sub-pulses each, not six.
Pulse (ms)
Number of pulses
per trigger
Duration of 3.8 3.2 3.0

pulses in ms
Duration of pulse
2.6 2.4
delay in ms
Increase/Decrease
Buttons
‘Same’ Button
Pulse Characteristics
Fig. 1.20 M22 IPL interface from Lumenis
Fig. 1.21 (a) (Top) Two a

solid pulses and (b)
(bottom) two pulses
delivered in three equal
sub-pulses
This technology is mainly utilized in IPL platforms to provide a higher safety

profile, especially in patients with darker skin.
An older example of this technology is the Surepulse configuration in the new
Icon IPL from Cynosure for hair removal. It provides the energy in two micro-
pulses: the first is 20 ms, then 100 ms intra-pulse delay, and finally, a 10-ms pulse
(total of 130 ms). The advantage is to provide a higher peak power with the same
total energy of a longer pulse, as shown in Table 1.3 [60]. More advanced IPL plat-
forms, such as Luminus M22 with Multiple Sequential Pulsing Technology
(MSP™), allow up to four sequential pulses to enhance safety and tolerability.
Pulse Shape
Modifying pulse width is a new advancement in laser and IPL that new practitioners
usually overlook. A normal pulse’s energy distribution is bell-shaped, with a sum-
mit and two tails; a pulse with wide tails indicates energy waste [58]. The new
Table 1.3 Advantages of using the Surepulse in Cynosure Icon IPL MaxR handpiece
Pulse 1 Pulse 2 Pulse 3
Benefit of
Off Off greater total
energy
MaxRs Fluence and Power Comparison
Pulse Benefit of
Injury threshold Peak
Fluence high peak
Pulse width Intensity
j/cm2 power
Temperature
msec watts/cm2
Sure Pulse 130ms 62 2,500
Short Pulse 20ms 40 2,000
Long Pulse 80ms 62 775
Epidermis Lesion
technology converts the pulse from a bell shape to a square; some examples are
Advanced Fluorescence Technology (AFT) in Alma IPL systems and the squared-
adaptive structured pulse in Fotona laser.
Modifying the pulse shape aims to improve equal energy distribution and enhance
some properties, such as ablation, coagulation, or photoacoustic phenomena. As
discussed with the 10,600 nm CO2 laser, the ablation/coagulation ratio differs
according to the pulse shape (CW, Ultrapulse, Superpulse) [61]. The chopped con-
tinuous delivery method provides high coagulation properties compared to the
pulsed and superpulsed [62], as shown in Fig. 1.22a.
The Superpulse mode has high peak power and relatively long pulse width,
which balances ablation and coagulation, as shown in Fig. 1.22b.
Ultrapulse delivers an ultrashort burst of energy and shifts the effect toward abla-
tion with minimal coagulation effect, as shown in Fig. 1.22c.
Spot Size (mm)
Spot size correlates to the lens aperture that defines the diameter of the laser beam.
All laser devices have adjustable spot sizes. Moreover, any adjustment in spot size
would affect the maximum laser beam fluence. It is possible to get a much high laser
fluence with a smaller spot size (2 mm) than with a bigger spot size (20 mm). More
importantly. The spot size also affects the physical interaction between the laser and
the skin and penetration depth. Smaller spot size is associated with high scattering
and less penetration than laser spot size [63], as shown in Fig. 1.23.
Therefore, a larger spot size had a higher safety profile due to less epidermal
interaction. This effect is significant when moving from 1 to 20 mm in size. However,
the spot size has an insignificant effect on the penetration depth after 20 mm. This
concept is only correct within the mm range and does not apply to the fractional
laser, as we will discuss later (Fig. 1.24).
Fig. 1.22 (a) Pulse shape and effect of the CO2 laser delivered in the CW mode. (b) Pulse shape
and effect of the CO2 laser delivered in Superpulse mode. (c) Pulse shape and effect of the CO2
laser delivered in Ultrapulse mode
Fig. 1.23 Schematic representation of the spot-size-dependent depth of penetration, recreated

from [63] with permission
Fig. 1.24 Calculated penetration profiles for uniform 1, 5, 10, 20, and 40 mm width beam of equal
incident fluence obtained by Monte Carlo simulation using typical skin parameters for wave-
lengths of 525–1100 nm, recreated from [63] with permission
Depth of Penetration
The depth of laser penetration results from combining all laser parameters such as
wavelength, fluence, pulse width, and spot size. Figure 1.25 is a summary of how
these factors would affect the depth of penetration. The practitioner should consider
the thickness of the skin on the treated area and the depth of the treated lesion
(Table 1.4).
Fig. 1.25 Effect of

different laser parameters
on the depth of penetration
Table 1.4 Absorption of different laser wavelengths by different layers and components of the
human skin [64]
Human skin optical properties used in the present study
Wavelength Optical Basal Basal Basal
(nm) properties Epidermis layer (L)a layer (M)a layer (H)a Dermis Blood
810 μa (cm-1) 0.2482 20.65 68.24 129.44 0.2576 4.935
μs (cm-1) 148.02 148.02 148.02 148.02 148.02 590.62
g 0.91 0.91 0.91 0.91 0.91 0.99
940 μa (cm-1) 0.2446 12.66 41.62 78.85 0.2577 6.791
μs (cm-1) 105.57 105.27 105.57 105.57 105.57 458.58
g 0.91 0.91 0.91 0.91 0.91 0.99
1064 μa (cm-1) 0.2441 8.45 27.59 52.20 0.2501 3.23
μs (cm-1) 81.37 81.37 81.37 81.37 81.37 371.48
g 0.91 0.91 0.91 0.91 0.91 0.99
595 μa (cm-1) 0.3531 57.38 190.45 361.53 0.4492 48.4
μs (cm-1) 148.69 148.69 148.69 148.69 148.69 523.12
g 0.8 0.8 0.8 0.8 0.8 0.995
585 μa (cm-1) 0.3709 60.71 201.50 382.52 0.8 214.9
μs (cm-1) 156.06 156.06 156.06 155.06 156.06 525.38
g 0.8 0.8 0.8 0.8 0.8 0.995
a
L: light pigmentation; M: moderate pigmentation; H: heavy pigmentation
Repetition Rate (Hz) for the Device
It is essential to understand that the pulse rate we discuss here is for the machine,
not the laser itself. The repetition rate for the laser device is related to the laser-firing
rate. All laser machines have manual and automatic settings; the manual settings
mean the laser fires only when the operating practitioner pushes the button.
Most practitioners start slow, so they fire the laser every 20 s. However, with
experience, they increase the laser firing rate (repetition rate), which might be tiring
for the thump. Once a practitioner gets comfortable with a repetition rate, they can
use the auto setting to program the device to fire the laser in fixed intervals (e.g., on
1 Hz), which means the machine will fire the laser once every second.
Therefore, the practitioner should have enough experience to move the hand-
piece swiftly before the laser fires again. Otherwise, the laser might result in adverse
effects such as skin burns or fat atrophy. Remember that the repetition rate is affected
by the spot size, as a larger spot size would limit the laser source’s ability to fire
more frequently. For example, some platforms could profile a 3 Hz rate with a 5 mm
spot size but only 1 Hz repetition in 20 mm.
Skin Histology Changes After Laser Interaction
The type of skin cells predominately affected by lasers depends on the wavelength
of light used. The specific changes in the epidermis and dermis after laser treatment
depend on several factors, including the wavelength of light used, the fluence deliv-
ered to the tissue, and the type of epidermal cell that is predominantly affected.
Laser Hair Removal
There was a reduction in large terminal hairs with a proportionate increase in tiny
vellus-like hairs in the laser-treated areas. After laser therapy, the average hair shaft
diameter assessed from histological sections reduced, as seen in Fig. 1.26.
Skin Rejuvenation with Color-Sensitive Laser
Skin treated with a high fluence of Nd:YAG 1064 nm laser had ablative alterations
to the epidermis, including separation of the keratinized and non-keratinized layers,
enhanced vacuolization of deeper epidermal cells, and rupture of the epidermal-
dermal junction. There is also an increase in epidermal thickness, which remained
visible 8 weeks after laser treatment, as seen in Fig. 1.27.
Fig. 1.26 Routine
hematoxylin-eosin–stained
section (magnification
×40) of untreated (top) and
normal-mode Nd:YAG
laser-treated (bottom)
areas [65]
Fig. 1.27
Photomicrograph of
biopsies acquired
immediately after a 50 J/
cm2 treatment (right: B1,
50 J treatment, H&E stain,
20X.jpg). (Hematoxylin-
eosin-phloxine stain, 20×
magnification originally)
Following treatment, the
epidermis is thicker, and its
deeper layer cells are
vacuolized [65]
Non-ablative Color-Blind Laser
A column-like denaturation of the epidermis and dermis, a distortion of the dermo-

epidermal junction, subepidermal coagulation within the MTZ, and an intact stra-
tum corneum can be seen in the non-ablative version, as shown in Fig. 1.28. The
a b
Fig. 1.28 Fractional non-ablative laser. (a) Focal coagulation of the epidermis and dermis with
preservation of the stratum corneum after fractional 1540 nm laser (H&E ×100). (b) Focal coagu-
lation of the epidermis and papillary dermis with preservation of the stratum corneum after frac-
tional 1927 nm laser (H&E ×100) [67]
surrounding tissue is not damaged. Within 24 h, keratinocytes migrate from the
surrounding healthy tissue to replace the thermally injured tissue [66].
Picosecond
Picosecond lasers were first utilized to treat tattoos and pigmentary problems. When
a microlens or diffractive lens array is attached to a picosecond laser, it produces a
fractional array of focused, high-fluence micro spots surrounded by low fluence
background. This energy distribution focuses on extremely high peak fluences over
a limited surface area, resulting in distinct nonthermal, photomechanical histologic
alterations in the epidermis and dermis in the form of cavitation, as shown in
Fig. 1.29. The sizes of each of these micro spots vary depending on the device but
are in the μm range [68].
Pico lasers can cause intraepidermal and dermal vacuoles at high fluences via a
process known as a laser-induced optical breakdown. Laser-induced optical break-
down occurs when a chromophore, most often melanin, absorbs enough energy to
exceed its irradiance threshold. When the irradiance threshold is exceeded, the chro-
mophore releases a free electron, which starts the creation of more free electrons
and the development of localized ionized plasma. The extremely intense ionized
plasma can induce a fast rise in the water temperature within the tissue, resulting in
the formation of steam bubbles. Cavitation occurs when tissue expands and con-
tracts, causing pressure fluctuations in the epidermis and dermis [44].
CO2 Fractional
CO2 laser creates microarrays of ablative and thermal damage; the ablation depth is
related to the laser energy. Tissue ablation zones were bordered by tissue coagula-
tion zones that spanned the epidermis and a portion of the dermis. A thin condensed
lining was found on the inside wall of the lesion cavity, as seen in Fig. 1.30.
a b
c d
Fig. 1.29 Tissue reactions after 1064 nm fractional picosecond laser treatment. Single-pulse,
1064 nm picosecond laser treatment at a 7 mm spot size and a fluence of 1.9 J/cm2 generated the
fractionated appearance of cystic cavitation lesions (asterisks) throughout the lower epidermis and
upper papillary dermis at regular intervals. Microscopic perinuclear vacuolar changes (arrows)
were found around the areas of cystic cavitation. (a, b) Single-pulse mode and (c, d) dual-pulse
mode treatment. H&E stain at original magnification (a, c) ×100 and (b, d) ×400 [69]
Er:YAG Fully Ablative
Fully ablative lasers result in a full-thickness epidermal injury with partial denuda-
tion of the epidermis. The depth of the epidermal injury depends on the laser energy.
At high laser fluence, full vaporization of the epidermis and superficial dermis could
be achieved, as seen in Fig. 1.31 [71].
Skin Lesion Characteristics
As we mentioned, laser-skin interaction depends on the laser parameters and objec-

tion characteristics.
a b
c d
Fig. 1.30 Depth of ablation of hematoxylin-eosin–stained sections of ex vivo human abdominal

tissue treated with the 30 W, 10.6 mm, CO2 laser at 9.2 mJ (a), 13.8 mJ (b), 18.0 mJ (c), and
23.3 mJ (d). The arrows outline the extent of coagulation collagen zones [70]
a b
Fig. 1.31 Fully ablative Er:YAG laser. (a) Full vaporization of the epidermis and superficial der-
mis (H&E 3100). (b) Magnified (H&E 3200) [67]
Absorption and Contrast
Different skin lesions should be targeted relatively to the most abundant chromo-
phore. The same chromophore might exist in the lesion’s cells and surrounding
cells, such as MLN, in both normal hyperpigmented skin. Moreover, in telangiecta-
sia, two competitive chromophores may co-reside in some skin lesions, such as
MLN and Oxy-Hgb [33].
Therefore, we should consider each chromophore’s concentration level and
absorption before choosing a laser. The term “contrast” refers to the relative concen-
tration of the chromophores and the absorption ratio. The most practical example is
the laser of choice in hair removal; the 755 nm Alexandrite laser is more effective in
laser hair removal (LHR) due to the MLN’s high absorption in the hair follicle.
Therefore, the 755 nm Alexandrite laser is considered the LHR laser in skin
types I–II and III as the keratinocytes do not have a high MLN concentration, thus,
high contrast between the lesion and the surrounding skin.
MLN does exist in darker skin types in the hair follicle and epidermis cells in
relatively similar quantities. However, there is low contrast between the lesion and
the surrounding skin. MLN’s high absorption of the Alexandrite makes it a less
favorable choice in darker skin types III–VI and out of the choice list in skin type V
due to the lack of contrast.
It is worth mentioning that while it is not recommended, the 755 nm Alexandrite
laser can be used in darker skin types but requires fine-tuning of the laser parame-
ters [72].
Therefore, in such cases, we prefer to use a laser wavelength with less absorption
by the chromophore, such as the 1064 nm ND:Yag. If the lesion is to pronounce
(intense ecthyma in rosacea), practitioners should adjust the parameters to decrease
the treatment intensity by applying one or more of the following: decreasing the
fluence, increasing the pulse width, using a longer wavelength, decreasing the over-
lap, or using a train of sub-pulses.
Skin Phototypes
The skin phototype assessment is one of the most critical steps a practitioner should
perform before a laser or light-based treatment.
Fitzpatrick Assessment
The Fitzpatrick assessment is the most used method to determine the skin phototype due
to the ease of implementation. The original assessment was developed in 1972 to assess
skin sensitivity to sun exposure via skin color and the tendency to burn due to sunlight.
Lower Fitzpatrick skin numbers indicate that skin is more prone to burn than to tan.
However, practitioners have improved the original assessment in the dermatol-
ogy field to include several items such as ethnicity and eye color. The improved
Fitzpatrick assessment is still the most used tool to determine skin phototype. Most
newly adapted skin type assessment forms have four fields: genetic background and
deposition, genetic deposition, reaction to sun exposure, and tanning habits with
10–12 multiple-choice questions, as shown in Tables 1.5 and 1.6.
The practitioner should help the client choose one of the four suggested answers
and grade each question accordingly. The client’s skin phototype is directly related
to the total score of the questionnaire. A higher score is related to higher skin type
and risks with photo treatments such as epidermis burns and post-inflammatory
pigmentation.
Table 1.6 is a modern skin type assessment that includes three factors: genetic
disposal, tanning habits, sun exposure, and heritage score. Several other assess-
ments have been published, such as Lancer, Goldman, FANOUS, and Tayler scales
[73]. Some studies argued that all these assessments are subjective and do not pro-
vide a reliable measure of laser-skin interaction [74].
Despite the improvements, several studies have criticized the objectivity and
validation of the self-reported assessment. Therefore, other methods, such as
Wood’s lamp and skin colorimeter, have been developed to evaluate skin photo-
types better.
Skin Reflectance Colorimeter
The new handheld colorimeters emit light of a specific spectrum and measure the
light’s wavelength and intensity reflected by the skin [75]. This data is converted
into a colorimetric value and suggests skin color. One deficiency of these devices is
that they measure only a small skin area. Therefore, the practitioner should perform
multiple tests and ensure to include the darker spots if they exist.
Table 1.5 Skin type assessment with 12 multiple-choice questions that take genetic and heritage
disposition into account
Genetic Disposition
Score 0 1 2 3 4
Your eye color? Light blue, Gray, Blue, Gray, or Blue Dark Brown Brownish Black
Green Green
Natural color of your Sandy Red Blond Chestnut/ Dark Brown Black
hair? Dark Blond
Color of your non- Reddish Very Pale Pale with beige tint Light Brown Dark Brown
exposed skin?
Do you have freckles on Many Several Few Incidental None

unexposed areas?
Total score for genetic disposition: 12
Reaction to Sun Exposure

Score 0 1 2 3 4
What happens when Painful redness, Blistering followed Burn sometimes Rarely burn Never burn
you stay too long in the blistering, peeling by peeling followed by
sun? peeling
To what degree do you Hardly or not at all Light color tan Reasonable tan Tan very easily Turn dark brown
turn brown? quickly
Do you turn brown Never Seldom Sometimes Often Always

within several hours of
sun exposure?
How does your face Very sensitive Sensitive Normal Very resistant Never had a
react to the sun? problem
Total Score for reaction to sun exposure: 10
Tanning Habits
Score 0 1 2 3 4
Last exposure to the More than 3 2-3 months ago 1-2 months ago Less than 1 month Less than 2 weeks
sun or tanning booth / months ago ago ago
cream?
Did you expose the area Never Hardly ever Sometimes Often Always
to be treated to the
sun?
Total Score for tanning habits: 0
Heritage Score
For each parent of african american or east indian descent add 10 points 0 10 20
My Skin Type Score: 32

My Skin Type: V
Skin Type Score Fitzpatrick Skin Type

0-7 I
8-16 II
17-25 III
25-30 IV
31-34 V
Over 35 VI
Table 1.6 Simple skin-type assessment with ten multiple-choice questions
SAMPLE SKIN TYPING
Client Name: Date:
Score: 0 1 2 3 4
Hazel
Light blue Blue or Dark Brownish
What is your eye color? Light
or gray green brown black
brown
Dark
Red, blonde Dark
What is the natural color of your hair? Blonde Black
Sandy red chestnut brown
Brown
What is the color of your skin Pale with Light Dark

Reddish Very pale
(unexposed areas)? beige tint brown brown
Do you have freckles on sun-exposed Many Several Few Incidental None

areas?
Painful Burns,
Blistering
What happens when you stay in the sun redness, sometimes Rarely Never had
followed
too long? blistering followed by burns burns
by peeling
peeling peeling
Hardly Turn dark

Reasonable Tan very
To what degree do you turn brown? any or not Light tan brown
tan easily
at all quickly
Do you turn brown several hours after Never Seldom Sometimes Often Always
sun exposure?
Very Very Never had

How does your face respond to the sun? Sensitive Normal
sensitive resistant a problem
When did you last expose yourself to the More than 2-3 Less than Less than
1-2 months
sun, tanning bed or self-tanning creams? 3 months months 1 month 2 weeks
ago
ago ago ago ago
How often is the area you want to have Hardly

Never Sometimes Often Always
treated exposed to the sun? ever
Add
above
for Match your total score with the Fitzpatrick
Total corresponding Skin Type. Skin Type:
score:
0-7 I
8-16 II
17-25 III
26-30 IV
Over 30 V-VI
Older devices, such as Mexameter MX 18 (Courage+Khazakauses, Germany),

use only a narrow-band reflectance spectrophotometer. Other devices, such as
Antera 3D (Miravex Limited, Ireland), use seven different wavelengths. However,
these devices’ data is not absolute and may change according to external variables
such as previous tanning and room temperature.
Other than the Mexameter and Antera 3D, we are aware of three handheld
devices to assess skin color: Chroma Meter (Minolta, Japan), DSM III (Cortex tech-
nology, Denmark), and Skintel (Cynosure).
Some new LHR platforms’ handpiece is integrated with an internal skin colorim-
eter to help practitioners choose the best treatment settings. For example, the Skintel
melanin reader is integrated with the Cynosure Icon IPL and Vectus diode laser.
After taking three readings for the treatment area, the software converts the reading
into melanin index (MI) and communicates with the treatment platform to suggest
a test spot parameter [76], as shown in Figs. 1.26 and 1.32.
It is important to understand that these skin types do not correlate with an abso-
lute MI value but with a range [28], as shown in Fig. 1.28; for example, the melanin
index of 20 is shared between skin types III and IV. Therefore, practitioners should
always seek and observe clinical endpoints (Fig. 1.33).
Fig. 1.32 Skintel device, a handheld melanin reader by Cynosure [76]
VI
Fitzpatrick
Skin Type
V
IV
III
I-II
0 10 20 30 40 50 60 70 80 90 100
Melanin Index
Fig. 1.33 MI range for each skin type [76]

Thermal Relaxation Time (TRT) and Size
As explained before, as the lesion’s chromophores receive laser pulses, the heat
builds up. However, the lesion’s cells that contain the chromophore are not ther-
mally isolated from surrounding cells. Therefore, it starts dissipating the thermal
heat to adjacent cells.
Thermal relaxation is an object’s ability to cool down by dissipating thermal
energy to the surroundings [50]. The TRT is a measure of the time (in a fraction of
a second) required by an object to dissipate 63% of the excess thermal energy (heat).
TRT is directly related to the density and size of the chromophore in the lesion.
A lesion with high laser absorption and short relaxation time would damage the
surrounding cells. Therefore, a short-pulsed laser with high energy is the laser of
choice as it removes the lesion before it can dissipate the heat and damage surround-
ing cells. Q-switch ns and the newer picosecond lasers are examples of high-energy
short-pulsed lasers.
The thermal relaxation’s secondary (by standard) effect should be controlled to
exert the desired clinical outcomes without side effects. For example, laser hair
removal relies on the hair strand’s ability to relax the heat by dissipating it to the
follicle’s germinative cells. However, if the heat exceeded the clinical limit, it would
result in burns and other side effects.
Small targets like melanosomes cool down extremely fast, and they do not retain
the photo-thermal energy (heat) to a specific clinical level. Therefore, such targets
should be exposed to a high-energy short-pulsed laser. The TRT and the pulse width
are strongly tied together but from different perspectives, as discussed later.
Depth of the Lesion
All laser targets for photo rejuvenation purposes exist in the epidermal and dermal
levels, a total of 2.1 mm. Therefore, we can adjust the laser settings to provide the
required penetration to reach the lesion and protect the other tissues—less than
optimal laser penetration (too shallow or too deep) results in unwanted adverse
reactions [77].
Most new laser systems are equipped with a computing unit to suggest adequate
parameters relevant to the lesion depth, intensity, and skin phototype [78]. Moreover,
the parameter of fractional lasers such as CO2 and Er:Yag is chosen in relevance to
the required depth of ablation or coagulation. If a lesion exists in variable depth
(rosacea and melasma), practitioners should target the deeper section and adjust
parameters to correct the superficial parts [79].
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Chapter 2
Laser and Intense Pulsed Light
The acronym LASER, which is frequently used as a stand-alone word, stands for
the more technical scientific term “light amplification by stimulated emission of
radiation.”
Some materials respond to stimulation by emitting light. This light is categorized
as a laser if it possesses specific physician characteristics, such as a single wave-
length (monochromatic), collimated (parallel rays), and a highly focused beam [1].
Figure 2.1 demonstrates that intense pulsed light (IPL) is not a laser because it is
polychromatic (spectrum of wavelengths) and non-coherent high-energy light [2];
despite these distinctions, the majority of practitioners use the term laser to refer to
laser and IPL machines. Figure 2.1b is a simple illustration that categorizes lasers
according to its aesthetic indication.

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27632-3_2
40 2 Laser and Intense Pulsed Light
a
IPL system Lasers
Polychromatic (a band of wavelengths) Monochromatic (only one wavelength)

Non-coherent (waves are not in phase) Coherent (waves are always in phase)
Defocused light Parallel light (directional)
b
Ablative lasers Nonablative lasers
Red Mild Hair Tatto

Moderate to
vascular Pigmentation skin removal removal
severe rhytids’
ectasis resurfacing
dyschromia
2790 (YSGG) 585 532 755 1540 1320 755 Q-switched

2940 (Er:YAG) 595 IPL 1064 1550 1410 810 532
10600(CO2) 1565 1440 1064 585
IPL 650
755
1064
Fig. 2.1 (a) Summary of differences in the emitted light between laser and IPL. (b) Common use
of photo-based treatment for common aesthetic conditions
IPL
Intense pulsed light (IPL) devices emit a broad band of high-energy light, typically
between 400 and 1200 nm in wavelength [3]. At the end of the handpiece (applica-
tor), which is in direct contact with the skin, there is a sapphire or quartz crystal;
IPL 41
this crystal serves two purposes: (1) contact cooling to protect the epidermis layer
and (2) as a photon energy delivery medium. All IPL systems are available in a
variety of crystal sizes (from small to large) to accommodate various treatments and
areas. In addition to the standard 400–1200 nm range, some IPL systems, such as
Cutera’s Solera Titan, emit infrared pulsed light sources between 1100 and
1800 nm [4].
Most IPL systems include a contact cooling system to make treatment more
comfortable and protect the epidermis [5]. However, practitioners may require
separate cooling systems, such as forced refrigerated air (chiller) or cryogen
spray, to cool down sensitive lesions (such as melasma) prior to and after treat-
ment [6, 7].
IPL systems enable practitioners to control light characteristics such as light
band wavelength in nanometers (400–1200 nm), fluence in joules per square centi-
meter (1–30 J/cm2), and pulse width (duration) in milliseconds (0.5–100 ms).
Here are some “rules of thumb” when using IPL for skin lesions other than hair
removal:
• For superficial lesions on lighter skin (up to skin type IV), use the 560 nm filter.
• For medium-depth and superficial lesions in darker skin, use the 590 nm filter
(skin type IV and light V).
• When the desired effect is deeper in the dermis or the skin is dark (skin type V),
use the 640 nm filter.
• Reduce the fluence by 1 to 2 joules when treating the neck, hands, arms, and
chest. Reduce the fluence even more when treating the chest.
• Use the same fluence when treating body areas other than the neck, hands, arms,
and chest.
• If lesions begin to clear and show less contrast, practitioners should increase the
intensity in subsequent sessions. Increase the fluence by 1 to 2 J/cm2 per session
as the lesions lighten during the treatment sessions.
• If available, use the 515 nm filter on stubborn lesions and skin types I and II. If
the system supports such a delivery model, potential side effects may be reduced
if the energy is delivered in the form of a 2–3 sequential pulse train.
• Larger treatment tips deliver deeper penetration.
• Avoid treating areas with tattoos or permanent ink.
• Reduce fluence in areas close to the bone because of light reflection and fatty
areas because of heat retention.
• If a practitioner does not see a good clinical response, they can increase the
intensity of the treatment by doing one of the following: increasing the fluence
by 1 J/cm2, decreasing the pulse duration by 1 ms, or using a different filter (or
handpiece) with a lower cutoff wavelength.
• Some clinical responses or adverse effects may take up to 24 hours to mani-
fest fully.
Types of IPLS
IPL with Interchangeable Filters
These systems typically include a single handpiece and multiple replaceable fil-
ters. The filters slide and lock into a slot in the handpiece (plug and play). The
inserted filter contains one or more cutoff filters to eliminate the unwanted
light band.
For example, the traditional 615 filter, mostly used in hair removal, eliminates
light with a wavelength lower than 615 nm to target melanin. More advanced sys-
tems include filters that provide a narrower light band, such as the Lumenis M22
acne filter, which offers dual bands of 400–600 and 800–1200 nm for more effective
acne treatment [8].
The depth of light penetration is multifactorial, but one of the important factors
determining it is wavelength. The higher the filter in the IPL light emission range,
the deeper the penetration and the less epidermis effect (higher safety). Figure 2.2
shows how each filter produces a different light spectrum and thus a different pen-
etration depth. It shows that the higher the filter number, the narrower the light band
and the deeper the penetration [9].
IPL filter technology has progressed over the last two decades to provide
consistent energy distribution through the pulse without reducing the energy
output [10]. Besides, the new generations of IPL systems could emit the photo
energy in a train of sequential pulses (double or triple) to enhance treatment
safety [11].
Fig. 2.2 Penetration depth

440mm
650mm
540mm
580mm
with four different IPL Hair
filters, 440 nm, 540 nm, mm
580 nm, and 650 nm 0
Sebaceous
gland 1
2
Sweat gland
Blood vessels
4
IPL 43
There are numerous IPL systems available with replaceable filters. Therefore,
this book will not be able to cover all of them. We chose to focus on systems with
which we have firsthand experiences, such as Vydence IPL-Sq and the Lumenis
M22 and Sciton BBL Joule.
The comparison includes the filter technology, pulse width, irradiance mode,
train of pulses, and cooling system. We will also attempt to capture any features that
we believe are noteworthy. Any light-based therapy can be delivered in either
dynamic or static mode; both should heat the target tissues to clinical temperatures.
The platform’s dynamic (in-motion) mode is commonly referred to as painless, as
the heat builds up gradually in the tissues via a continuous movement of the applica-
tor [12]. The static (stamping) mode involves zapping the lesion with a strong pulse
before moving on to the next area [13]. Dynamic mode is mainly used for hair
removal in IPL and diode laser machines [14]. It is important to note that we will not
recommend one system or manufacturer over another; instead, we aim to provide
this information to the reader to make an educated decision.
Comparison
Table 2.1 compares three IPL systems with interchangeable filters in terms of filter
technology, pulse width, irradiance mode, pulse sequence, cooling mechanism, and
other characteristics.
Table 2.1 Comparison of different IPL systems with interchangeable filters

Pulse Train of
System Filter width Irradiance sequential
name technology (ms) mode pulses Cooling Features
IPL-Sq Square Pulse 5–100 Static No Continuous A second-
Vydence Technologya contact generation IPL that
cooling (not can be added to the
adjustable) Ethera platform
M22 Optimal Pulse 4–20 Static Yes (1, 2, Continuous The M22 is a
Lumenis Technology and 3 contact comprehensive
OPT™) and pulses) cooling (not workstation that
Multiple Pulse delay adjustable) could be custom
Sequential 5–150 ms built with Q-switch
Pulsing YAG and 1565 nm
(MSP™)b fractional laser
OPT thin filters,
dual brand filters
for acne and
vascular lesion
(continued)
Table 2.1 (continued)
Pulse Train of
BBL Smart Filter 5–200 Static and No Continuous The only IPL with
Joule with Finesse dynamic contact dynamic mode that
Sciton Spot cooling offers a no-pain
Adapters™c adjustable, option. SkinTyte
0–30 °C (S.T.) special filters,
part of the Joule
comprehensive
platform
a
According to Vydence, the IPL-Sq® technology promotes controlled and microprocessor delivery
of energy, released evenly throughout the pulse, in contrast to traditional IPL equipment in which
the energy discharge is uncontrolled, and thus the energy delivered at the beginning of the pulse
duration is greater than that delivered at the end. This discharge configuration (1) prevents the
formation of critical risk areas that, in practice, can result in undesirable effects; (2) ensures the
emission of energy with a constant and uniform spectrum along the pulse, resulting in a more
effective therapeutic outcome; and (3) increases the procedure’s safety and efficacy. This technol-
ogy is not exclusive to Vydence, as all second-generation IPL systems are equipped with the
square pulse feature. Table 2.2 lists the technical specifications for IPL-Sq
b
Lumenis claims that OPT provides gentler, more comfortable, and patient-friendly procedures
with lower effective fluences • High peak power, shorter pulses—ideal for IPL skin treatments
using photorejuvenation and treatment of benign pigmented lesions • Advanced OPT will also
allow determining the specific fluence per sub-pulse when using multiple-sequential pulsing
(MSP), for fine-tuned treatment settings [15]. Lumenis launched the Stellar M22 with three
SapphireCool™ lightguides to provide better continuous contact cooling for patient comfort. At
the time of writing, a new version of the M22 with advanced OPT (AOPT) had just been released
in China. The benefits of AOPT over OPT are not yet clear. Table 2.3 lists the M22 system speci-
fications
c
According to Sciton, Smart Filter with Finesse Spot Adapters™ provides an easy and quick way
to change filters and reach difficult spots [16]. Table 2.4 lists different handpieces for the Joule
system and their indications. Table 2.3 lists indications of different handpieces from Joule systems
Table 2.2 IPL-Sq® technical IPL spectrum 400–1200 nm

specifications
Filters 400, 540, 580, 640 and 695 nm
Spot size 40 × 12 nm
Vascutip TM 8 mm and 12 × 12 mm
Fluence Up to 33 J/cm2
Pulse width 5 to 100 ms
Cooling system Built-in sapphire contact cooling
Repetition rate Up to 2 Hz
IPL 45
Table 2.3 M22® technical specifications

IPL spectrum 400–1200 nm
Filters Acne (400–600 and 800–1200); 515 nm
Vascular (530–650 and 900–1200); 560 nm; 590 nm; 615 nm; 640
nm; 695 nm; 755 nm
Fluence 8 × 15 mm—up to 35 J/cm2
15 × 35 mm—up to 35 J/cm2 6 mm round—up to 56 J/cm2
Pulse duration 4–20 ms
Pulse delay 5–150 ms
Pulse characteristic Multiple Sequential Pulsing
Spot size 35 × 15 mm2; 15 × 8 mm2, 6 mm
Cooling Continuous contact cooling
ResurFX™
Wavelength 1565 nm
Pulse energy 10–70 mJ per micro-beam
Pulse characteristic CoolScan™ Scanner
Pattern shapes Line, square, rectangle, circle, doughnut, hexagon
Beam density Up to 500 micro-beams/cm2
Repetition rate 0.5–2 Hz
Tip Sapphire; Precision
Spot size Up to 18 mm
Multi-Spot™ Nd:YAG
Wavelength 1064 nm
Fluence 10–225 J/cm2
Pulse characteristic Multiple Sequential Pulsing
Spot size 6 mm; 2 × 4 mm2; 9 mm
Q-Switched Nd:YAG
Wavelength 1064 nm
Fluence 0.9–14 J/cm2
Pulse duration 6–8 ns
Pulse characteristic Top-Hat
Repetition rate 0.5–5.0 Hz
Spot size 2; 2.5; 3.5; 4; 5; 6 and 8 mm
Table 2.4 BBL® technical specifications
Table 1.3 BBL® TECHNICAL SPECIFICATIONS

IPL spectrum 20 – 1400 nm
Filter 420 nm, 515 nm, 560 nm, 590 nm, 640 nm, 695
nm, 800 nm
Pulse Width Up to 200 msec
Repetition Rate Up to 1 pulse-per-second
Cooling Method Skin Cooling Continuous thermoelectric sapphire plates
Adjustable from 0 - 30 ˚C
Spot Size 15 x 45 mm
Finesse Adapters 15 x 15 mm square, 11 mm & 7 mm round
Handpiece FIBER BBL
Forever Bare BBL™

ProFractional-XC™
ClearScan YAG™
ClearScan ALX™
ThermaScan™
CelluSmooth™
ProLipo PLUS ™
Contour TRL™
ClearSense™
JOULE Module
SkinTyte™
Pro-V™
Halo™
diVa®
BBL™
1064 Nd:YAG
1319 Nd:YAG
1064 Nd:YAG
1319 Nd:YAG
1319 Nd:YAG
2940 Er:YAG
2940 Er:YAG
2940 Er:YAG
2940 Er:YAG
1470 Diode &
1470 Diode &
Smart Filters
Smart Filters
Smart Filters
1064 / 1319
420 to 1400
590 to 1400
590 to 695
755 Alex.
Nd:YAG
Wavelength (nm)
Acne • •
Acne Scars •
Pigmented Lesions • • •
Scar Revision • • •
SKIN
Skin Resurfacing • • •
Skin Texture Improvement • • • • •
FY BBL Concept •
Wrinkles • •
Vascular Lesions • • •
VASCULAR
Telangiectasia • •
Reticular/Spider Veins • •
Endovenous Ablation •
Laser Lipolysis •
HD Lipo Sculpting •
BODY
Lumpy, Dimpled Skin •
Appearance of Firmer Skin •

HAIR & SPECIALTIES
Permanent Hair Reduction • • • •
Onychomycosis • •
Warts • • •
Vaginal Therapy •
IPL 47
Fig. 2.3 IPL handpiece

with a replaceable filter;
the filter is marked as
515 nm
IPL with Interchangeable Handpieces (Applicators)
Handpieces in these systems are outfitted with stationary filters. As a result, practi-
tioners should switch handpieces to obtain a different light band wavelength. There
are numerous options for this type of IPL system on the market. This book will
cover three systems: Cynosure’s Icon (formerly Palomar Icon), Syneron-Nordlys
Candela’s IPL (formerly Ellipse IPL), and Alma’s Harmony XL. Figure 2.3 depicts
some of these IPL machines’ key characteristics and applicators.
Comparison
Table 2.5 compares three IPL systems with replaceable handpieces: Nordlys
Ellipse from Candela, Icon Palomar from Cynosure, and Harmony from Alma in
filter technology, pulse width, irradiance mode, sequence of pulses, cooling mech-
anism, and different features.
Table 2.5 Comparison of different IPL systems with interchangeable handpieces
48
System Pulse width Fluence Train of sequential

name Filter technology (ms) (J/cm2) pulses Cooling Features
®
Nordlys SWT (Selective Waveband 0.5–99.5 2–26 Yes (1, 2, 3, and 4 Continuous The workstation can be equipped with long-
Ellipse Technology)a, which means pulses) duration of contact cooling pulsed Nd:YAG1064 nm, 1550 nm, and 1940 nm
Candela that all filters are dual cutoff pulse train 0.5–700 (not adjustable) lasers and five IPL handpieces for a wide range of
to eliminate light over 950 ms applications
nm, as shown in Fig. 2.4a
Icon MaxG is the only filter with a 1–100 Up to 81 Surepulse for hair Adjustable It comes with SkinIntel for skin phototype. It has
Palomar dual cutoff, as shown in removal (20 ms continuous three optional laser handpieces: 2940 fractional
cynosure Fig. 2.4b SmoothPulse™ b laser on, 100 ms contact cooling ablative laser, 1540 fractional non-ablative, 1064+
delay, 10 ms laser laser handpiece
on) with a Advanced contact cooling that maintains constant
high-power peak 5° temperature during treatments
Harmony All handpieces are equipped Each Static NA Continuous Advanced Fluorescence Technology (AFT),
Alma with a dual cutoff to eliminate handpiece and contact cooling pulsed UVB for hypopigmentation. The platform
light over 950 nm, as shown has three dynamic (not adjustable) can be equipped with a long-pulsed Nd:YAG
in Fig. 2.4dc pulse 1064 nm, fractional q-switched 1064 nm, and
widths to fractional 1540 and 2940 nm laser under different
choose trademark names such as ClearSkin, ClearLift,
from. See etc.
Table XX
a
According to Candela, the SWT is a narrowband technology defined by dual filters and sub-millisecond pulses. Table 2.6 lists the Nordlys system specifica-
tion. The system has eight Ellipse IPL handpieces and Frax 1550, Frax 1940, and Nd:YAG 1064 nm with different indications, as shown in Table 2.7
b
According to Cynosure, the SmoothPulse™ technology avoids energy spikes often used by competing systems to deliver treatment—patient skin stays cooler
and more comfortable without sacrificing efficacy. Full technical specification for Cynosure Icon is listed in Fig. 2.4a, and the light spectrum of the Max G
handpiece in Fig. 2.4b
c
The new platform has several IPL handpieces such as Dye VL PRO 450–600 nm Cooled Applicator, Dye VL 500-600 nm Cooled Applicator in a stationary
and in-motion mode, Cooled VL-PL 540 nm Applicator, and Cooled and non-cooled SR 570 nm Applicator [17]. According to Alma, Advanced Fluorescence
Technology (AFT) is the new generation of IPL that enables continuous square-shaped pulsing with moderate peak power throughout the entire pulse.
However, a 2007 study did not show a significant difference in results between Lumenis and Harmony IPL [18]. The full technical specification for Alma
Harmony XL Pro is listed in Table 2.8
2 Laser and Intense Pulsed Light
IPL 49
MaxG MaxR MaxRs

Wavelength: 500- Wavelength: 650-1200 nm Wavelength: 650-1200 nm
670 nm and 870- Pulse width: 1-100 msec Pulse width: 1-100 msec
1200 nm Spot size: 16 x 46 mm Spot size: 12 x 28 mm
Pulse width: 1-100 Energy: Up to 46 J/cm2 Energy: Up to 70 J/cm2
msec
Spot size: 10 x 15
mm
Energy: Up to 80
J/cm2
Fig. 2.4 (a) Characteristic of different Icon Palomar in terms of size, light spectrum, fluence
range, and application. (b) Light spectrum of the Max G handpiece that balances the affinity
between melanin and hemoglobin to induce photothermolysis equally in both chromophores
MaxYs 2940 fractional ablative laser

Wavelength: 525-1200 nm Wavelength: 2940 nm
Pulse width: 1-100 msec Treatment zone-fractional:
Spot size: 18 x 28 mm 10 x 10, 6 x 6 mm
Energy: Up to 81 J/cm2 Flatbeam: 6 x 6 mm
Microbeam density: Up to 1000 cm2
Pulse width: 0.25-5 msec
Max. repetition rate: Up to 6 Hz
80
100
Spectral fluence J/(cm2/µm)
Absorbtion coefficient, cm–1

60
Filtered Out
Light
40 10
20 1
0 0.1
500 700 800 1000
Wavelength, nm
Fig. 2.4 (continued)
IPL 51
Table 2.6 Nordlys applicator specifications
Table 2.1: NORDLYS APPLICATOR SPECIFICATIONS

ELLIPSE IPL
Type/Wavelength HRD 645 (645-950 nm) PR/PRS 530 (530-750 nm)
Band HR/HRL 600 (600-950 nm) PL 400 (400-720 nm)
VL/VLS 555 (555-950 nm)
Fluence Range 2-26 J/cm2
Pulse Time 0.5-99.5 msec (depending on applicator)
Pulse Delay 1.5-99.55 msec
Number of Pulses 1-4
Duration of 0.5-700 msec

Pulse Train
Spot Size HR 600, HRD HRL 600 VLS 555, PRS 530
645, VL 555, PR 18 mm x 48 mm Hexagonal: 90 mm2
530, PL 400
10 mm x 48 mm
FRAX 1550 ND:YAG 1064

Laser 1550 nm 1064 nm
Wavelength
Fluence Range/ 5-100 mJ 20-500 J/cm2

Energy 6-40 J/cm2 (onychomycosis)
Pulse Duration 1-20 msec 2.5-90 msec

0.3-0.9 msec (onychomycosis)
Scan Width/ 4-12 mm 1.5-5.0 mm

Spot Sizes
Skin Cooling SoftCoolTM Integrated Air Cooling

Table 2.7 List of indications for Nordlys different handpieces

HR
(600–950)
Nd:YAG PR (530–950) HDR
Frax 1550 Frax 1940 1064 nm PL 400 VL (555–950) (645–950)
Skin Skin resurfacing Leg vessels Benign Telangiectasias Permanent
resurfacing Coagulation of soft (0.1–3 mm epidermal Port-wine stains hair
Coagulation tissue in pigmented Benign reduction
of soft tissue Benign pigmented diameter) lesions (e.g., pigmented
lesions, including but Benign solar lesions
not limited to vascular lentigines) Benign vascular
lentigines (age lesions lesions (e.g.,
spots), solar Port-wine diffuse redness)
lentigines (sunspots), stains Rosacea
and ephelides Venous Poikiloderma of
(freckles) for lakes Civatte
Fitzpatrick skin types Epidermal Inflammatory
I–IV pigmented acne vulgaris
lesions (PR 530)
Table 2.8 Harmony XL pro system specifications

Spot Pulse Pulse Energy
Light size Wavelength widths/ repetition density (J/
Module source (cm2) (nm) Mode timers rate (Hz) cm2)
Cooled IPL Module 5 cm2 spot size
SHR Pro Flash 5 650–950 HR 30, 40, 50 1/2 5–20
(5) cooled lamp ms
SHR Timer: 1, 3 3–7
3, 30 s
SVL Flash 3 515–950 10, 12, 15 2/3 5-30
cooled lamp ms
VL/PL Flash 3 440–950 10, 12, 15 2/3 5–30
cooled lamp ms
SR cooled Flash 3 570–950 10, 12, 15 2/3 5–30
lamp ms
Dye-SR Flash 3 550–650 Dye-SR 10, 12, 15 1/2 Up to 14
Pro lamp ms
Dye- Timer: 1,3, 3 1–4
SSR 30 s
Dye Flash 3 450–600 Dye-VL 10, 12, 15 1/2 Up to 15
VL-Pro lamp ms
Dye- Timer: 1,3, 3 1–4
SVL 30 s
SHR Pro Flash 3 650–950 HR 30, 40, 50 1/2 5–25
(3) cooled lamp ms
SHR Timer: 3 3–7
1,3,30 s
(continued)
IPL 53
Spot Pulse Pulse Energy
Light size Wavelength widths/ repetition density (J/
SSR Flash 3 540–950 Timer: 2 1–15
cooled lamp 1,3,30 s
SST Flash 3 780–950 Timer: 5 0.5–3.5
cooled lamp 1,3,30 s
Non-cooled IPL Module 6.4 cm2 spot size
SVL Flash 6.4 515–950 10, 12, 15 2/3 5–25
lamp ms
VL/PL Flash 6.4 440–950 10, 12, 15 2/3 5–25
lamp ms
SR Flash 6.4 570–950 10, 12, 15 2/3 5–25
lamp ms
HR Flash 6.4 650–950 30, 40, 50 1/2 5–25
lamp ms
ST Flash 6.4 780–950 Timer: 2 1–7
lamp 10,30,90 s
Acne Flash 6.4 420–950 Acne 30, 40, 50 1/2 5–25
lamp ms
S-Acne 2 ms 10 0.3–1.2
Energy
Pulse density/
Wavelength Spot size Pulse frequency fluence/
Module Technology (nm) (mm) width (Hz) depth
Laser Nd:YAG cooled module
Cooled long Nd:YAG 1064 2 10 ms 1 30–450 J/
pulse 1064 nm cm2
Nd:YAG 6 15, 45, 1 30–150 J/
60 ms cm2
10 15 ms 1 20–50 J/
cm2
5 × 5 Pixel 10 ms 1 3–25 J/cm2
Cooled long Nd:YAG 1320 6 30, 40, 1 5–40 J/cm2
pulse 1320 nm 50 ms
Nd:YAG 5 × 5 Pixel 30, 40, 1 1–11 J/cm2
50 ms
Laser Nd:YAG non-cooled module
Q-Switched Q-Switched 1064 1,2,3,4,5,6 20 ns 1, 2, 4 600–1200
1064 nm Nd:YAG 1064 5 × 5 Pixel 20 ns 1, 2, 4 mJ/p
Nd:YAG 532 2, 3, 4 20 ns 1, 2, 4
KTP
High Power Q-Switched 1064 1,2,3,4,5,6 20 ns 1, 2, 4 600–1200
Q-Switched Nd:YAG 1064 5 × 5 Pixel 20 ns 1, 2, 4 mJ/p
1064 nm 532 2,3,4 mm 20 ns 1, 2, 4
Nd:YAG KTP
1064 5 × 5 roller 20 ns N/A
1064 7 × 1 roller
Cleanse Purify Replenish
A special treatment tip Broadband light is applied With profusion technology. The vacuum is released,
usesvacuum to gently helping to destroy acne vacuum gently stretches having helped enhance
lift acne impurities helping causing bacteria and to the skin cells, allowing the topical product application
extract dirt, blackheads, reduce sebum production. application at topical for improved overall
dead cells and excess oil products into the intercellular treatment outcomes.
from the pores. spaces in the skin.
Fig. 2.5 Mechanism of action of Isolaz IPL from Solta
Special IPL
Some IPL systems provide some extra features. For example, Isolaz from Solta has
negative pneumonic pressure (vacuum) for acne [19] as shown in Fig. 2.5, or
Lumecca from Inmode has higher energy on a specific light band (higher in the
500–600 nm range) to target vascular and pigmented lesions specifically [20].
Lasers
Laser systems, as previously stated, produce a single wavelength of light in parallel

rays [21]. The light source determines the wavelength of a laser; one light source
can produce more than one laser wavelength using different frequency conversion
technologies [22]. For example, a neodymium-doped yttrium aluminum garnet
crystal (Nd:YAG) can be used for 1064 nm and 532 nm lasers by doubling the fre-
quency using a potassium titanyl phosphate (KTP) crystal [23]. As discussed in
Chap. 1, all lasers are available in different pulse widths:
• Long pulses ranging from 0.45 to 400 ms.
• Quasi-long pulses typically last around 300 s (0.3 ms).
• A short pulse, typically lasting 5 ms (0.005 s) and referred to as Q-switch.
• An ultrashort pulse with a duration of 300 to 500 ps (0.5 ns). Many authors have
discussed the shortcomings of picosecond lasers, describing them as not true pico-
second lasers, claiming “further development of this technology is warranted” [24].
Color Sensitive
These lasers have high absorption coefficients for colored chromophores, including
hemoglobin (and its derivative) and melanin. The higher a laser’s absorption coef-
ficient toward a chromophore, the greater the absorption and photothermolysis
effect, which has pros and cons. When compared to color-blind lasers, these have
Lasers 55
relatively shorter wavelengths. Here is a list of the most frequently employed wave-
lengths in the aesthetic and dermatology fields, from short to long:
• 532 nm is available in long, short, and ultrashort pulse widths. This laser, also
known as the green laser, is made by doubling the 1064 nm Nd:YAG laser using
a KTP medium [25]. Therefore, practitioners might notice that 532 nm and
1064 nm lasers are standard on all Q-switched laser devices. Because of its high
hemoglobin absorption and shallow skin penetration, the KTP 532 nm laser is
primarily used to treat vascular lesions such as erythema, telangiectasia, and
some superficial pigmentation lesion [26, 27].
• 585 and 595 nm pulsed dye lasers have wavelengths of 585–595 nm and a high
absorption coefficient for oxyhemoglobin and deoxyhemoglobin [28]. Therefore,
these are mainly used for vascular, pigmentation, and keloid scars [29, 30].
Pulsed dye lasers are available in long and short pulse ranges [31, 32].
• 694 nm ruby laser is not frequently used in the aesthetic field.
• 755 nm alexandrite is a versatile laser that is also known as the Alex laser. Several
indications vary depending on the pulse width in long, quasi-long, short, and
ultrashort. The long-pulsed Alex laser is mostly known for its indication in laser
hair removal (LHR) in skin types I, II, and III.
• Diode laser (805 nm, 808 nm, 810 nm) is available as high and low fluences in
long pulse and is mainly indicated for LHR [33, 34]. It is worth noting that some
devices generate diode wavelengths from the Nd:YAG medium, and some laser
devices emit three different lasers (755 nm, 810 nm, and 1064 nm) simultane-
ously within the same pulse [35, 36].
• 1064 nm Nd:YAG laser is the most versatile laser available in long, quasi-long,
short, and ultrashort pulses. This is due to the 1064 nm laser’s moderate and
equal absorption coefficient for melanin and hemoglobin [37]. The YAG laser is
the gold standard for LHR and vascular lesions in long pulses, especially in
darker skin types (IV and V) [38]. This laser is frequently used for pigmentation
and skin rejuvenation in short and ultrashort pulses [39, 40] (Fig. 2.6).
–– This video discusses optimizing the YAG laser parameters for hair removal
application. https://drive.google.com/file/d/1IW-FQO8mNYyHlTTUlf2v7S0
OE_BZgFhf/view?usp=share_link
–– This video discusses optimizing the Yag parameters for Laser vein removal.
https://drive.google.com/file/d/14wYF8em9BKTj3zQrK_oOrUO3FEyB-
Mmf/view?usp=share_link
–– This video discusses optimizing the Yag Laser parameters to target superficial
vascular lesions. https://drive.google.com/file/d/1JzNlu2NUwbUB8NOfk15
Qs7JIRxR5afEm/view?usp=share_link
Color-Blind
These lasers, such as water molecules, are absorbed by transparent chromophores in

the skin and have little affinity for colored chromophores. As a result, skin type has
less of an impact on choosing laser settings, and darker skin types are considered
532 755 1064

1000
Melanin
Hb02
Absorption coefficient, cm–1
Hb
100
10
1
500 600 700 800 900 1000 1100
Wavelength, nm
Fig. 2.6 Absorption coefficients of melanin and hemoglobin at 532 nm, 755 nm, and 1064 nm lasers
safer to be treated with these lasers. Color-blind lasers work by ablation (ablative
lasers) and coagulation (non-ablative) or a combination of both [41, 42].
Ablative lasers have a longer wavelength and, thus, a higher water absorption
coefficient. As a result, ablation refers to the process by which skin tissues vaporize
due to an aggressive photothermolysis process. Furthermore, ablative lasers have
relatively shallow penetration (max of 400 μm).
Coagulation, on the other hand, refers to producing an effect by heating the treat-
ment area to a clinical point to induce protein coagulation, followed by skin rejuvena-
tion, with little to no ablation effect. Non-ablative fractional lasers work by performing
thermal micro-coagulation columns in the dermis. The collagen is denatured, which
promotes regeneration and results in skin smoothing and rejuvenation [43].
As the wavelength of a laser increases, so does its affinity for water; as a result,
lasers perform more ablation and less coagulation. These lasers are mainly delivered
in fractional mode, as the laser beam is delivered in small beams called microther-
mal treatment zones (MTZs). As illustrated in Fig. 2.7, fractional lasers can leave
untreated areas intact, which act as reservoirs [44]. As a result, fractional lasers are
safer and have a shorter downtime and recovery time than non-fractional ones. This
concept will be covered in greater depth in a later chapter.
• 1320 nm Nd:YAG in long pulse
• 1450 nm diode lasers in long pulse
• 1540 nm, 1550 nm, and 1560 nm Er:Glass lasers are non-ablative, mostly frac-
tional, and commonly referred to as fractional non-ablative lasers (FNAL). These
lasers have a nearly pure coagulation effect and can penetrate to 1.4 mm depth.
• The 1927 nm thulium laser has an excellent balance of ablative and coagulative
effects. This laser has a penetration depth of 400 microns.
• The 2940 nm Er:YAG laser used to be available only in long pulses (1–2 ms), and
because of its purely ablative nature, Er:YAG is commonly referred to as the cold
Lasers 57
Nonfractional Fractional
Fig. 2.7 Difference between the non-fraction laser (left) and fractional (right). The untreated areas
between the MTZ work as a source for stem cells to shorten the recovery time
laser. However, a newer system provides variable square pulse (VSP) between
175 and 800 s, greatly increasing its indications.
• The 10,600 nm CO2 laser is the most studied ablative laser [45]. Most CO2
lasers can generate a high peak pulse (super pulse) in the 200–800 μs range, with
lesion depths ranging from 200 to 650 μm according to the energy used (5 to 30
mJ) [45, 46].
All ablative lasers have an intrinsic ablation and coagulation ratio. The fluence
controls the ablation depth, but the coagulation/ablation ratio for the same wave-
length and fluence can be controlled by changing the pulse width. Figure 2.8 shows
how increasing the pulse width increases coagulation. Some lasers, such as Er-YAG,
can provide a pure ablation effect with minimal coagulation when used in short
pulse width. This is known as cold ablation.
All ablative lasers generally show intrinsic ablation and coagulation ratio [47].
The fluence controls the ablation depth, but the coagulation/ablation ratio for the
same wavelength and fluence can be controlled by changing the pulse width; the
coagulation increases by increasing the pulse width [48], as shown in Fig. 2.8. When
used in short pulse width, some lasers, such as Er-YAG, can provide a pure ablation
effect with minimal coagulation, known as cold ablation [49]. A longer pulse width
would result in a more noticeable coagulation effect, making the treatment warmer [9].
This section discusses the available laser platforms and devices according to
wavelength, pulse width, and special features. We will discuss each one of these
indications explicitly in a separate chapter. The same laser wavelength might be
used for different indications by adjusting other settings such as fluence and spot size.
Most standard laser devices emit laser light in three modes: long, short, or ultra-
short. Nonetheless, practitioners can customize two or more modules with different
emission modes with the new modular. SharpLight’s OmniMax S4, for example,
offers a 1064 nm Nd:YAG laser in both long (ms) and short (Q-switch ns) pulse
Long laser pulse Medium Laser pulse Short laser pulse
Time Time Time
Hot Warm Cold

Ablation Ablation Ablation
Fig. 2.8 Effect of pulse width on the coagulation/ablation effect for an ablative laser
modes. Some devices, such as the Lutronic PicoPlus, provide Nd:YAG laser in both
shot and ultrashort modes.
Color Sensitive According to Pulse Width
Long Millisecond (ms) and Quasi-long Microsecond (μs) Laser
Because of the long pulse width, these lasers are effective on relatively large targets
such as hair follicles and blood vessels (between 30 and 100 μm). These targets’
long thermal relaxation time (few ms) allows for efficient heat buildup and a clinical
temperature target [50]. Because of the short relaxation time, these lasers cannot be
used to target small targets like melanosomes, and miniature vessels will cool down
quickly as they pass heat to surrounding tissues.
532 nm KTP
Melanin and hemoglobin absorption coefficients are 555 and 235 cm−1, respectively
[51]. The low ratio of 2.4:1 indicates that the two chromophores compete with each
other and have low selectivity. As a result, this laser should be used with caution in
skin type III and avoided in skin types IV and above. As a result, the 532 nm laser
is always used in conjunction with the 1064 nm laser on the same platform because
they share the same light source; the 532 nm laser is created by passing a 1064 nm
laser through a KTP crystal to double the frequency [52].
Because of the high melanin absorption in higher skin types, the use of 532 nm
in long pulse mode is limited to skin types I–II. Long-pulsed 532 nm laser is used
to treat superficial, small, and pink and purple veins, facial telangiectasia, and dif-
fused redness [53]. It also treats new scar redness (erythema), port-wine stain
Lasers 59
(PWS), hyperpigmentation, and small warts in skin types I and II [54]. In our opin-
ion, the use of this laser in the aesthetic field is limited, but it is more widely used in
dermatology settings. To our knowledge, two platforms offer the 532 nm laser in ms
pulse width range, the excel V+ from Cutera, and Light C from Quanta. This is the
last laser a practitioner would add to their aesthetic practice.
Comparison
Table 2.9 compares two long-pulsed 532 nm laser systems.
excel V Interface
Figure 2.9 shows the interface of excel V and the function reported by the user
manual [55].
1. The fluence is the amount of energy measured in J/cm2. To make changes, use
the Up/Down arrows.
2. The duration of each pulse is measured in milliseconds (ms). To make changes,
use the Up/Down arrows. When using the Genesis V handpiece, the pulse dura-
tion is fixed at 0.3 ms and cannot be changed.
3. The repetition rate is the number of pulses per second measured in Hz with the
foot pedal depressed. To make changes, use the Up/Down arrows.
4. By selecting the Temperature icon, you can set the temperature to 5°C, 10°C,
15°C, or 20°C. The current temperature is also shown. When using the Genesis
V handpiece, the temperature cannot be adjusted.
5. For common indications, the Memory button saves three different settings per
wavelength.
6. The number of pulses is shown. To reset, press the reset button.
7. The spot size can be adjusted from 2 to 12 mm. To make changes, use −/+. The
spot size cannot be changed when using the Genesis V handpiece.
8. Toggle between Standby and Ready mode by pressing the Standby/Ready but-
ton. When in Standby mode, the Standby/Ready button is yellow, and the hand-
piece cannot be fired. When in Ready mode, the Standby/Ready button turns
green. Unless the handpiece is removed from the holster, the system will not
Table 2.9 Comparison of two long-pulsed 532 nm laser systems

System Spot Pulse Max
name size width fluence Handpiece Features
Excel V+ 2 to Up to 25 J/cm2 Cool view with The platform is integrated
from 12 mm 25 ms contact adjustable with short- and long-pulsed
Cutera cooling 1064 nm (Genesis VTM)a
Light C up to Up to 12.5 J/ Contact and air The platform is integrated
from 6 mm 25 ms cm2 cooling integrated with long- and short-pulsed
Quanta with the handpiece 1064
a
The Genesis VTM handpiece delivers 532 or 1064 nm Nd:YAG laser light in micro-pulses that
gently and safely target microvasculature to accelerate the process of collagen production, there-
fore improving the look of wrinkles and other visible indications of aging
Fig. 2.9 excel V interface. The functions are numbered as follows: (1) The user can adjust fluence
control depending on the condition being treated. (2) Pulse duration control: the operator should
choose a shorter pulse duration with smaller targets. (3) Repetition rate: the operator should choose
the repetition rate of laser shots based on their experience and comfort with moving the handpiece.
(4) The contact cooling device’s temperature. (5) Memory: the user’s preferred settings can be
saved. (6) The number of shots required in the current treatment. (7) Spot size in millimeters: the
size of the spot is related to the lens aperture, which can be adjusted depending on the depth of the
target. (8) Ready/standby switch. (9) Setting the wavelength
enter Ready mode. After the “flute” sound indicates that the system is ready,
press the foot pedal to begin the pulse.
9. Wavelength—the wavelength selected will be displayed. To choose a wave-
length for treatment, choose either 532 nm or 1064 nm. When using the Genesis
V handpiece, the wavelength cannot be adjusted.
10. Screen of information—the Information & Adjustment screen can be accessed
to check the system software version or to change the screen brightness, volume
level, or beam intensity.
585 and 595 nm Pulsed Dye Lasers (PDL)
The longer wavelength pulsed dye lasers make it safer than 532 nm because they
penetrate deeper and have less affinity for melanin in the epidermis. PDL lasers’
indications include all 532 nm, exceeding them to include inflammatory acne, pho-
torejuvenation, and rosacea [29, 56]. Furthermore, it can be used with other lasers
to treat keloid scars, melasma, and other dyschromia lesions [29, 57].
595 nm wavelength replaced 585 nm in the aesthetic field to increase the penetra-
tion depth in large-sized blood vessels or vessels at the dermis. Some studies showed
that the 585 nm wavelength is superior in treating vascular lesions, such as port-
wine stains [58]. According to the parameters and mechanism of action, PDL treat-
ment can be classified as purpuric or non-purpuric [59]; the traditional high fluence
and short pulse width cause blood vessel rupture and possibly bruising. The new
systems can slowly heat the targeted blood vessels and include blood coagulation
instead of rupturing the blood vessels [60], as shown in Fig. 2.10.
Lasers 61
Fig. 2.10 Difference
between the pulse width of
purpuric (0.45 ms) and
non-purpuric (40 ms)
pulsed dye laser
Comparison
Table 2.10 compares two long-pulsed 532 nm laser systems.
Vbeam from Candela is the main commercial PDL in the ms range in North
America. The system has been recently updated from Perfecta to Prima. The new
Prima has a larger collimated handpiece (up to 15 mm) and an additional cooling
method. Both models have a special compression handpiece for pigmentation; this
pigmentation handpiece is fitted with a special lens to reduce the blood flow in the
treatment area (less oxyhemoglobin competition). The handpiece is available in 7
and 10 mm.
Table 2.11 compares the Vbeam Perfecta and Prima in terms of spot size, pulse
width, maximum energy, and other features.
The long-pulsed dye laser is an excellent addition for an advanced aesthetic prac-
titioner. It can, however, be easily replaced with a versatile Nd:YAG system, which
is a cornerstone of any aesthetic practice.
Vbeam Interface
Figure 2.11a shows the interface of the Vbeam as provided by its user manual [61].
There are five main applications: telangiectasia, photorejuvenation, angiomas, port-
wine stains, and warts. Each main application has a submenu with several applica-
tions with suggested settings. However, the operator can override these settings, as
shown in Fig. 2.11b, which represents the interface of the Vbeam. The operator can
see the similarity between Figs. 2.9 and 2.11b as the operator has to deal with the
same concepts when operating any laser machine.
Table 2.10 Comparison of two long-pulsed 532 nm laser systems

Max
fluence
Pulse at
System name Spot size width 12 mm Handpiece Features
Vbeam from Up to 15 mm 0.45 8 J/cm2 Cryogen spray It has an additional 1064 nm
Candela to 40 with Nd:YAG laser
ms additional
contact
cooling
method
CYNERGY Up to 12 mm 0.5 to 7 J/cm2 Stand-alone It has an additional 1064 nm
from with an 40 ms forced-chilled Nd:YAG laser. Both
Cynosure additional air wavelengths are emitted
15 mm sequentially—pulsed dye first
handpiece and then Nd:YAG—with a
configurable delay for
improved energy absorption
Table 2.11 Vbeam Perfecta and Prima comparison

Spot Pulse Max Additional
Name/maker size width energy wavelength Features
Vbeam Perfecta Up 0.45–40 8 J NA Cryogen spray cooling
from Candela to 12 ms system only
Vbeam Prima Up 0.45–40 12 J 1064 nm Additional contact
to 15 ms cooling method
a
Submenu
Treatment applications Applications menu bar
Needs calibration
Applications
Telangiectasia Pulse Duration
Photorejuvenation Diffuse redness 7 10 12
Angiomas Wrinkles 7 10
Port wine stains Pigmented lesions 7PL 10PL
Warts Dyschromia 7PL 10PL
Miscellaneous
3x10 3 5 7 10 12 7PL 10PL
Fig. 2.11 (a) Main treatment applications of Vbeam with its submenu. (b) Operator interface of
the Vbeam laser machine, in which they can adjust treatment settings to customize the treatment
according to the client’s condition
Lasers 63
b
System status bar
Ready/standby button and system status symbol
Calibration button
System status
Screen lock button

System settings menu button
Applications menu bar
Needs calibration
Applications
Fluence Pulse Duration
10ms
8.25 J/cm2
Cooling Pulse count
3x10 3 5 7 10 12 7PL 10PL
Active spot size

identification bar
Fluence select buttons
Pulse Duration select buttons
Cooling Button
Cooling menu button
Treatment pulse counter and reset button
Treatment summary button
755 nm Alexandrite (Alex) Laser
The Alex laser’s absorption coefficient is 163 and 3 cm−1 for melanin and oxyhemo-
globin, respectively [37]. The ratio is 54:1, making Alex the most selective melanin
laser. As a result of melanin’s high absorbance and selectivity, the long-pulsed Alex
laser is the treatment of choice for laser hair removal (LHR) and benign superficial
Fig. 2.12 New concept of

using a blend of two
different wavelengths, 755
and 1064 nm lasers, to
target hair follicles at two
different depths
pigmentation in skin types I–III [62]. However, the high melanin absorption makes
it less suitable for skin type IV [63]. Nonetheless, practitioners can still use the Alex
on skin type IV, with more conservative settings (large spot size, low fluence, and
long pulse width). Most platforms provide 755 nm and also a 1064 nm laser, known
as a dual-wavelength LHR workstation. The 755/1064 nm laser devices are the
foundation for practitioners who want to begin with simple aesthetic indications like
LHR in skin types I to IV. These platforms, however, are bulky and heavy (200–300
LB) and may require an external cooling device.
New hybrid systems, such as SPLENDOR X from Lumenis and Duetto MT
EVO from Quanta, can be synchronized to be fired at both 755 and 1064 nm wave-
lengths individually or simultaneously, as shown in Fig. 2.12 [64]. It is important to
note that unlike the Alma Soprano series, these two systems have two separate laser
sources. On the other hand, the Soprano series uses a modified Diode laser source
for the 755, 810, and 1064 nm lasers.
Comparison
Table 2.12 compares five 755 nm laser systems in terms of available wavelength,
cooling mechanism, operation interface, maximum energy, pulse width, and
spot size.
Table 2.12 Comparison between different laser systems that have Alex lasers
Pulse
Lasers
Name/maker Emission Cooling Interface Energy with Spot size Features

a
Elite+ Combo Forced air as a Mono-color, 45 J Alex, 0.5–100 Up to No consumables
Cynosure separate unit non-intuitive 63 J Nd:YAG ms 24 mm
Elite iQ Combo Forced air as a Digital LCD, 45 J Alex, 0.5–300 Up to No consumables, equipped with Skintel Melanin Reader
Cynosure separate unit intuitive, and 63 J Nd:YAG ms 24 mm
user-friendly
Arion Alma 755 nm Forced air Mono-color, 70 J Alex 2-100 ms Up to Scanner for large areas (add-on), special burst mode (each laser
non-intuitive 16 mm pulse is split up into several short, quick sub-pulsesb. The skin
surface can cool down between the sub-pulses
The risk of side effects is minimized), and does not require gel
GentleMax Pro Combo Cryogen spray Digital LCD, 53 J Alex, 0.35–300 Up to Cryogen spray needs to replace the cryogen canister
Candela intuitive, and 79.2 J ms 18 mm
user-friendly Nd:YAG
AvalancheLase Combo DMC™ (Dry Digital LCD, 53 J Alex, 0.6 ms to Up to Scanner for large areas (add-on), avalanche effectb, DMC™
Fotona Molecular intuitive, and 79.2 J 1s 30 mm (Dry Spray Molecular Cooling) c
spray Cooling) user-friendly Nd:YAG
Light A 755 Contact or LCD 100 J Alex 2–100 ms Up to The practitioner can configure the platform to add IPL, 1064
Quanta forced air 16 mm nm, 2940 nm, and 1320 nm
SPLENDOR X Combo, Cryogen spray Digital LCD, 55 J Alex, 3-100 20 × 20 mm, Simultaneous Alex-Nd:YAG hybrid laser shots, integrated
Lumenis hybrid and forced air intuitive, and 80 J Nd:YAG 24 × 24 mm smoke evacuate technology, square and round treatment area for
user-friendly square easy treatment
a
This video shows the Elite+ from Cynosure and discusses different treatment parameters. https://drive.google.com/
file/d/1knB1X9HEtWmqW5m0FO2jvFCv3VNJ8HHw/view?usp=share_link
b
It has recently been claimed that delivering laser in successive pulses allows hair follicles to absorb it more efficiently. Following each laser pulse, there was
increased laser absorption at the hair follicles level, known as the avalanche effect or stacking. The new hair removal technology involves sending a series of
laser pulses to the same skin area while optimizing the laser pulse parameters for maximum avalanche impact. This method differs from a standard “stamping”
technique in which the laser handpiece is moved from spot to spot across the treated skin with no overlap, and single high-fluence pulses are delivered to each
location [65, 66]
c
A non-contact cooling method that uses dry water mist rather than cryogen to avoid epidermal injury caused by excessive freezing
65
GentleMax
Figure 2.13a shows the GentleMax interface as shown in their clinical manual [67].
The GentleMax and GentleMax Pro interfaces are more user-friendly and interac-
tive compared to the Cynosure Elite+ (Cynosure Elite iQ was released by Cynosure
at the time of writing the book). As discussed, the laser machine could suggest set-
tings according to skin type, tanning condition, hair color, and thickness. Once the
operator inputs the information, the system will take you to the operator interface
shown in Fig. 2.13b. At this stage, the operator can adjust the treatment setting and
individualize it accordingly.
The GentleMax series is equipped with a dynamic cooling device (DCD) that uses
a cryogen spurt to cool the epidermis during the procedure. The integrated cooling
device has three important timing inputs. Pre is the spurt duration before the laser shot
in ms. After the Pre-spurt, there is a delay time associated with the laser shot; then the
Post-spurt after the laser shot [68]. Some reports about hyperpigmentation are associ-
ated with laser hair removal due to CDC malfunction, as shown in Fig. 2.13c [69].
a
Standby
Alex Appications 755nm
Hair Removal: Select Parameters
Skin Hair
Fitzpatrick Type TAN Color Thickness
I IV No Tan Light Fine
II IV Active Medium Medium
III VI Established Dark Coarse
1.5 3 6 8 10 12 15 18
Fig. 2.13 (a) Main interface window of GentleMax in hair removal treatment. The settings depend
on four factors; two factors are related to the skin, and the others are related to the hair. (b) Operator
interface window. In this window, the operator can change the pulse width (duration), the firing
rate, the fluence, and the cryogen cooling. (c) Several ring-shaped brown hyperpigmentations on
the cheek 2 weeks following 1450 nm diode laser treatment with a DCD [69]
Lasers 67
b Ready/Standby Button
System status messages
Cooling spray settings
System laser/Guided mode select

Applications menu bar
Standby
Alex Appications 755nm
Fluence
Fluence Cooling
controls/ Pre
indicator
Delay
0
Post
Alex
Press to select
Duration Rate Pulse count
0.25 ms Single
0
0.25 300 S 1 10
1.5 3 6 8 10 12 15 18
Pulse duration Calibrate Cryogen

control Spot size button purge
Identifier Bar Reports
Cryogen canister
button System
status
settings
Repetition rate select menu
Pulse count & reset
c
Diode Laser
The intermediate absorption of the diode laser by melanin and low absorption by
oxyhemoglobin positioned it as the gold standard in LHR. Consequently, the diode
laser is mainly used in LHR but still has other indications, such as benign superficial
pigmentation and photorejuvenation [70]. Systems offer this wavelength alone or in
combination with other wavelengths, such as 755 and 1064 [36].
Similar to what we discussed in the IPL section, there are two treatment modes
of LHR with diode static and dynamic.
High-Fluence Static Mode

The platforms rely on the same traditional “selective photothermolysis” and its
bystander concept as it delivers a high fluence pulse to “zap” the hair strand.
Practitioners should select the appropriate parameters according to skin phototype
and hair texture. The LightSheer Duet from Lumenis has an extra negative pneu-
matic handpiece HS that creates a vacuum, as shown in Fig. 2.14. When the hand-
piece is placed on the treatment area, it creates suction that draws the skin closer to
the treatment handpiece, reducing stray light while increasing the therapeutic
Fig. 2.14 Operator interface window for the LightSheer pneumatic handpiece HS. In this window,
the operator can change the vacuum settings
Lasers 69
effectiveness. Therefore, the treatment parameters are significantly lower than the
standard handpiece ET, shown in Fig. 2.15 [71]. Another example of the static diode
laser is Vectus from Cynosure.
LightSheer
HS Vacuum Handpiece
The “No. pulses” indicates the number of consequent pulses the handpiece provides
each time it is triggered. The number shown under the number of pulses (500) in
Fig. 2.15 indicates the actual pulse interval between pulses and ranges from 333 to
2000 ms. Within this time, the area is under vacuum and irradiated with laser in 1,
2, or 3 pulses.
ET Standard Handpiece
Similar to other platforms, The LightSheer Duet from Lumenis has recommended
setting according to the skin type, hair color, and texture, as seen in Fig. 2.15a and b.
Figure 2.15b shows the treatment screen, where the operator can manually adjust
the treatment parameter. When the OptiPulse is sent on auto, the system will choose
the suitable pulse width for a given fluence.
a
Clinical indications screen for ET handpiece
Clinical Indications
Select the skin type Skin Type: I II III IV V VI
Select the hair color Hair color: Blond/Red Light Brown Dark Brown Black
Select the hair texture Hair Texture: Fine Coarse Dense
Treatment parameters
Load Physician OptiPulse Auto Fluence 40 j/cm2
L Rate (Hz) Fast ChillTip On
recommended presets
OK Cancel
Load use presets
Presets for currently selected

clinical indications
Fig. 2.15 (a) Clinical indications interface. The operator can use the suggested treatment param-
eters by feeding his input in the clinical indications interface window. (b) Operator interface win-
dow. The operator can override the suggested treatment parameters by manually changing the rate,
OptiPulse (pulse width), and fluence
b
ET Handpiece Treatment Screen
After you have selected the ET handpiece on the startup screen and calibration
is completed, the ET handpiece treatment screen is displayed.
Load user presets Save user presets
Load physician Current clinical

Recommended presets settings
Cllinical indications
Clinical indications
screen selector L Skin Type: 1
Hair color: Blond Red M
Hari texture: Fine
Rate (Hc) Opti pulse (ms) Fluence (j/cm2)

00 Fluence field
Fast Auto
Pulse rate field
Fluence bar
Med 30
40 Fluence j/cm2
Slow 100
3.00 Hz 400 - + Increase fluence

OptiPulseTM mode
10 Decrease fluence
1000 0000
Check 0 000000 Standby Ready
TIP
Toggle chill tip on/off
ET handpiece treatment screen
Vectus Cynosure
Vectus is another static diode LHR platform from Cynosure with new photon-
recycling technology [72]. Figure 2.16 shows the clinical indication interface win-
dow for Cynosure Vectus. The settings suggested by the platform depend on four
factors; one is related to the skin (skin type), and the other three are related to the
hair (diameter, density, and color). We will learn more about identifying these fac-
tors in Chap. 3.
Low-Fluence Dynamic Super Hair Removal (SHR)

These platforms are new and use multiple passes of low-level fluence laser. Instead of
zapping the targeted hair follicle with one pulse of laser to induce thermolysis, this
diode laser induces incipient necrosis and perifollicular edema via a high repetition rate
of short pulses to build up the heat gradually, as shown in Fig. 2.17 [73]. The gradual
heat buildup in the dermis damages the hair follicles and prevents regrowth while shun-
ning injury to the surrounding tissue. This approach significantly decreases the treat-
ment discomfort by delivering average high energy over a large area (10 × 10 cm2) by
continuously moving the handpiece over the treatment area (multiple passes or in-
motion). Areas of 100 cm2 should be treated with multiple in-motion passes to reach a
cumulative energy dose between 6 and 10 kJ [73]. However, some studies showed that
this technology is more successful with coarse hair and darker skin type [74].
Lasers 71
Fig. 2.16 Clinical
indications interface. The
operator can use the
suggested treatment
parameters by feeding his
input in the clinical
indications interface
window
Fig. 2.17 Concept of

gradual heating that
induces incipient necrosis
and perifollicular edema in
dynamic SHR
Another observation is that hair grows back into finer and lighter follicles that are
more challenging to remove by laser [62]. Therefore, Alma laser introduced the
Soprano ICE platform with an additional alexandrite handpiece to deal with fine
hair. Later, Alma Laser introduced the Soprano ICE Platinum, which offers three
wavelengths 755, 810, and 1064. According to the attached tip, the applicator ema-
nates one wavelength during the treatment. The newer Soprano Titanium emits the
three wavelength simultaneously [36].
Comparison
Table 2.13 compares five different diode laser systems in SHR mode in terms of
available wavelength, pulse width, maximum energy, treatment modes, and other
features.
Table 2.13 Comparison of five different diode laser systems in SHR mode
System Pulse Treatment
name Wavelength width Handpiece Max fluence mode Features
LightSheer 808 nm 5–400 Vacuum Up to 12.5 J Static, Standard and
Duet ms handpiece and in the with or vacuum
9 × 9 mm vacuum without handpieces
standard handpiece vacuum
handpieces with and 100 J/
continuous cm2 in the
contact cooling 9 × 9 contact
handpiece
LightSheer 805 nm 5–400 Vacuum Up to 12.5 J Static, Standard and
Desire ms handpiece, in the with or vacuum
12 × 12 and vacuum without handpieces
9 × 9 mm handpiece vacuum
standard and 100 J/
handpieces with cm2 in the
continuous 9 × 9 and
contact cooling 40 J/cm2 in
the 12 × 12
contact
handpieces
LightSheer 805 and 5–400 Vacuum Up to 12.5 J Static, The dual-
Quadro 1060 nm ms handpiece, in the with or wavelength,
12 × 12 and vacuum without standard, and
9 × 9 mm handpiece vacuum vacuum
standard and 100 J/ handpieces
the 12 × 12
contact
handpieces
Soprano 755, 810, Three different Dynamic Three diode
ICE from 1064 nm handpieces, one wavelengths,
Alma for each special
wavelength handpiece for
ear and nostril
hair removal
Soprano 755, 810, It has three Dynamic Three diode
ICE 1064 nm different wavelengths,
platinum separate and handpieces, one special 3D
and in trio for each handpiece,
titanium technology wavelength, and handpiece for
from Alma (3D) a 3D handpiece ear and nostril
that emits the hair removal
three
wavelengths
simultaneously
Lasers 73
1064 nm ND:YAG Laser
This is aesthetic practice’s most versatile laser cornerstone [75]. The lower melanin
absorption and low melanin/oxyhemoglobin ratio allow us to use this wavelength:
LHR, benign pigmentation removal, vascular lesion, and photorejuvenation in darker
skin types (III–VI). By changing pulse width, fluence, spot size, and repetition rate,
practitioners can target the correct depth to target a specific lesion. However, this laser’s
deep penetration may increase the risk of deep tissue damage, such as fat atrophy.
Comparison
As we discussed earlier, on the section with “Alex laser,” most available platforms
provide 755 and 1064 nm wavelengths. Almost all new platforms, as observed
before, contain an Nd:YAG laser and other light sources such as IPL and fractional
ablative and non-ablative lasers.
Some YAG platforms offer an extralong pulse of 1064 nm, up to 5 s; at this pulse
width, the gentle bulk heating occurs at the deep dermis layer to help photorejuve-
nation, skin tightening, and body shaping like the Piano Mode in Fotona Dynamis,
as shown in Fig. 2.18 [76].
GentleMax
The reader can refer to the section on GentleMax in “755 nm Alexandrite
(Alex) Laser.”
Short Q-Switched Nanosecond (ns) Laser
The pulse width gets 1,000,000 shorter as we move from the ms to the ns range (5–7
nm). As a result, the ns range pulses have a much higher energy peak, as shown in
Fig. 2.18 [77]. The ns laser is suitable to heat small targets with a short thermal
relaxation time. The heat buildup is rapid enough to overcome the TRT and reach a
clinically significant temperature. The indications of the Q-switch lasers are simple
Fig. 2.18 Relations POWER

between the pulse width Q-SWITCH
and energy of the Nd:YAG
laser. All traditional
Nd:YAG laser platforms Megawatts
NEW MODE
provided only the ms range

FRAC3
Kilowatts LP
PIANO
Watts
TIME
Nanoseconds Microseconds Miliseconds Seconds
and advanced pigmentation correction, photorejuvenation, and tattoo removal.

More importantly, as discussed before, the laser shows significant photoacoustic
properties at this short pulse width. Some systems have the quick pulse-to-pulse
mode (Q-PTP), enabling greater energy delivery by shooting two pulses 80 μs apart
to enhance the laser’s safety and tolerability [78].
532 nm KTP
Just like what we discussed about the long-pulsed 532 nm laser, the use of this
wavelength is restricted to skin types I and II. With low fluences and larger spot size,
this laser in the ns range provides a medium-depth laser peel with less downtime
and high patient satisfaction. However, one thing about it is that it should be used
only after a test patch (test spot), with proper sun protection after treatment. Besides,
it can be used for superficial vascular lesions and effective treatment for lip lighten-
ing [79]. Usually, the 1064 nm is the main wavelength in all Q-switch systems, and
the 532 nm is, by default, complimentary. Thus, we will postpone the comparison
section and include it under the Q-switch 1064 nm ns laser [80].
585 and 595 nm Pulsed Dye Lasers (PDL)
The Q-switched ns PDL 2 mm spot-size handpiece is an add-on to most Q-switched

laser systems for colored tattoo removal [81]. However, using this laser with larger
spot size (5 mm) and low fluence is an efficient tool to correct inflammatory and post-
inflammatory erythema in acne, hypertrophic scars, and stretch marks combined with
other lasers [82]. Practitioners should be aware that the 2 mm handpiece doesn’t deliver
enough depth for the previously mentioned indications, other than tattoo removal.
1064 nm ND:YAG Laser
This is the most studied and used Q-switched laser with a similar indication to the
532 nm but a much better safety profile. Melasma is commonly treated with a low-
fluence Q-switched Nd:YAG laser, which is considered safe and relatively effective,
but not as monotherapy [80, 83, 84]. The melanocytic and pigmentation lesions will
be discussed in detail in different chapters.
Comparison
Table 2.14 compares four different 1064 nm Q-switch laser systems in terms of
available wavelength, cooling mechanism, operation interface, maximum energy,
and pulse width.
https://drive.google.com/file/d/1z7CukKd5PZYtLOpEYqmYHjZMapYTjuZT/
view?usp=share_link
Lasers 75
Table 2.14 Comparison of four different 1064 nm Q-switch laser systems

System Fluence
name Wavelength Pulse width range Handpieces Features
Alma Q 532, 585, Q-switched, Max single Zoom (1–7 mm), Long-pulsed
640, and long, and pulse energy collimated (8 and Quasi-long-
1064 nm quasi-long is 0.45 J and mm), square pulsed,
1.2 J for 532 (5 × 5 mm), and fractional
and 1064 fractional (7 × 7 handpiece
mm) (add-on),
Q-PTP
Lutronic 532, 585, Q-switched Max single Collimated (2–8 Q-PTP
Spectra a 640, and and pulse energy mm), gold toning
1064 nm quasi-long is 0.45 J and 5 mm handpiece
1.2 J for 532
and 1064
Fotona 532, 585, Q-switched, Max single Collimated (2–8 ASPb
StarWalker 640, and long, and pulse energy mm), fractional
1064 nm quasi-long is 10 J for
532 and
1064
Cynosure 532, 585, 300 ps Max single Collimated (3–8 Q-PTP
RevLite 640, and pulse energy mm)
1064 nm is 0.45 J and
1.2 J for 532
and 1064
a
This video shows the Lutronic Spectra laser device and discusses different treatment parameters
b
Adaptive Structured Pulse (ASP) permits the laser pulses to be shaped in ways that may be more
favorable, such as switching from a square pulse form to something more complicated, which
might have more indication in the dental application [85]
Lutronic Spectra Interface

An illustration of the Lutronic Spectra is shown in Fig. 2.19 [86].
Ultrashort Picosecond (ps) Laser
In the last decade, a great deal of research focused on improving the peak and reduc-
ing the total energy of the laser pulse by reducing the pulse width from ns to the ps
range [87]. The first generation of picosecond laser (PicoSure) was disappointing in
performance and suffered some maintenance issues. The second-generation pico-
second laser emerged with more robust performance and multi-wavelength configu-
ration [24]. In ultrashort time, the intense energy delivery mode correlates with a
high-power peak in the gigawatt (GW) range and enhanced photoacoustic vibration.
Hence, just like Q-switched, ps lasers are indicated for benign pigmentation, acne
scarring, stretch marks, photorejuvenation, and tattoo removal. Below is a sample of
PicoWay (a second-generation picosecond laser) indication according to wave-
lengths, skin types, and parameters [24] (Table 2.15).
Fig. 2.19 Operation interface window for the Spectra laser. The touch screen has the following
indicators: (1) Reset button. (2) Pulse rate. (3) Spot size is an indicator that shows the spot size
chosen on the handpiece. (4) Aiming beam adjustor. (5) Fluence. (6) Wavelengths: the 1064 and
532 are in the ns range; Spectra 1064 nm in the μs range (quasi-long). (7) Memory. (8) Toning:
special function for melasma treatment. It operates on low fluence, large spot size, and low repeti-
tion rate. (9) Setup
Table 2.15 Cleared indication for the PicoWay laser platform from Candela as reported by a panel
of experts [88]
Lasers 77
Comparison
Table 2.16 compares five different picosecond laser systems in terms of available
wavelength, pulse width, fluence, and other features.
Color-Blind Lasers
Resurfacing Lasers
In this book, these lasers use skin water molecules as chromophores called color-
blind lasers. These lasers have longer wavelengths than the color-sensitive ones and
are in the more extended range to match the water absorption spectrum [56]. The
photothermolysis of resurfacing lasers is not specific to the pigmented lesion but
relies on peeling the skin layer that contains the unwanted pigment. Older systems
used to be non-fractional; however, all current systems adapted the “fractional”
function due to higher safety, shorter downtime, and better results [89]. A fractional
Table 2.16 Comparison of five different picosecond laser systems

System Laser Fluence
name wavelength Pulse width range Handpieces Features
Discovery 532, 694, 450 ps for the 600 mJ (1.8 Round Zoom A second
by Quanta 1064 nm 1064 nm GW) for the (2–10 mm), generation with
1064 nm fractional (7 × 7 complete Nd:YAG
mm), and square pulse mode profiles
(5 × 5 mm) (long, short, and
ultrashort)
PicoWay 532, 785, 450 ps for the Round zoom The second
by Candela 1064 nm 1064 nm (2–10 mm), generation,
fractional (6 × 6 fractional
mm) handpiece
PicoSure 532, 755, 750 ps for the 200 mJ Round A first-generation
by and 755 nm, the (0.36 GW) collimated (2–6 pico laser with a
Cynosure 1064 nm actual pulse for the mm), round focus lens to
width for 755 nm fixed (6,8, and distribute energy
1064 nm is 10 mm) into microbeams
not revealed
Pico Clear 532, 585, 300 ps for the 450 mJ (1.3 Round (2–10 A second
by Alma 640, and 1064 nm GW) for the mm), fractional generation, PTP,
1064 nm 1064 nm (7 × 7 mm), and four wavelengths
square (5 × 5
mm)
PicoPlus 532, 585, 450 ps for the 800 mJ (2.2 Round zoom A second
by 660, and 1064 nm GW) for the (2–10 mm), generation, focus
Lutronic 1064 nm 1064 nm round collimated lens, distributes
(2–6 mm) energy into
microbeams
Lasers 79
laser handpiece divides the laser beam into microscopic columns called microther-
mal zones (MTZ). So, the laser beam does not hit skin as one thick beam but in a
non-continuous fractionated pattern. The result is a pattern of alternative treated and
non-treated microscopic dots on the skin [46].
The untreated areas facilitate healing, resulting in higher safety and shorter
downtime than the non-fractional ones [90]. It is important to clarify that the inverse
relationship between the spot size and the penetration is not valid at the fractional
microscopic level. The laser’s MTZ is delivered by either a stamping handpiece, a
roller tip, or a scanner handpiece (a scanner is usually an add-on for an extra
charge).
A scanner is a very beneficial add-on to fractional lasers as it allows practitioners
to change the shape and the percentage of treated/untreated spots. Some platforms
(such as Fraxel Dual) would allow the practitioner to choose the relative percentage
between the treated and non-treated areas without needing a scanner. The interac-
tion between these lasers and skin water is either coagulation, ablation, or both,
depending on the wavelengths and the fluence. The following pictures show skin
irradiation histology by one of the most commonly used resurfacing lasers, 1550,
1927, 2940, and 10,600 nm [91].
Fractional Non-ablative Lasers (FNAL)
These lasers have shorter wavelengths than ablative lasers and thus have less affinity
for water. Diode 1410 nm, Nd:YAG 1440 nm, Er:Glass laser 1550 nm, and Thulium
1927 nm are the most well-known FNAL. Because Er:Glass has a lower affinity for
water, it can penetrate deeper and produce a stronger coagulation effect. The pene-
tration depth increases in direct proportion to the energy output. When the energy of
a 1550 nm laser increases from 6 mJ to 70 mJ, the penetration depth increases from
0.4 mm to 1.4 mm. The result of FNAL interaction with the skin is mainly coagula-
tion. Coagulation is a process through which a liquid material turns solid or semi-
solid. The heated water molecule causes collagen’s denaturation (coagulation
zones), which mimics the wound environment. The coagulation zones’ existence
induces the skin to go through the wound healing process and produce more colla-
gen, as shown in Fig. 2.20 [92, 93].
FNAL wavelengths do not damage the stratum corneum and leave it intact
because of low water content. Therefore, FNAL lasers do not cause pinpoint bleed-
ing but result in noticeable redness and erythema. The Er:Glass lasers are the most
studied laser among all FNAL, with benign hyperpigmentation, scar correction,
stretch marks, and general skin rejuvenation [94]. Moreover, their effectivity and
high safety profile make them a popular addition to most platforms. For example,
Lumenis M22 contains universal IPL, long-pulsed/Q-switched Nd:YAG and 1556
FNAL. Fraxel Dual from Solta includes two wavelengths, 1550 and 1927 nm, to
improve the coagulation/resurfacing ratio. The depth of penetrations depends
mainly on laser energy, as shown in Fig. 2.21.
Microscopic Epidermal Necrotic Debris (MEND)
Controlled Zones of 100um

Denatured Collagen in the Dermis
Fig. 2.20 Zones of denatured collagen in the dermis after fractionated laser beam and the micro-
scopic epidermal necrotic debris being expelled on day 16. Healing occurs from surrounding via-
ble tissue, and there is complete re-epithelization in 24 h
Fig. 2.21 Human skin and

penetration depth of
1550 nm Er:Glass (Fraxel
laser) with corresponding
energy settings [93]
Lasers 81
As mentioned previously, two laser delivery patterns are continuous roller move-
ment (Fraxel dual) and a stamp with a scanner (Alma Hybrid). Laser devices with
rollers are associated with significant consumable costs (Table 2.17).
The level of treatment and the coverage percentage with Fraxel laser correlate to
redness and swelling of Fraxel treatment, as shown in Fig. 2.22 [93].
Table 2.17 Recommended treatment settings for approved indications of the 1550 nm erbium-
doped and 1927 nm thulium laser system and treatment settings for combination treatment [95]
Treatment Levels and Percent Coverag
1 2 3 4 5 6 7 8 9 10 11 12 R1 R2 R3
5% 7% 9% 11% 14% 17% 20% 23% 26% 29% 32% 35% 38% 43% 46%
Edema
Lowest Erythema Highest
Fig. 2.22 Percentage of skin treated per session and the amount of redness a patient would experi-
ence. If the patient is prone to prolonged redness and swelling, the settings can be adjusted to
achieve a better result. For near-total coverage in five treatments, we recommend treating at level
9 [93]. This video shows optimizing FNAL parameters using the Fraxel Dual laser device: https://
drive.google.com/file/d/1G0bW-80xHvipwN-o4BfxY4gmmMkmG-gh/view?usp=share_link
Comparison
Table 2.18 compares five different non-ablative laser systems in terms of available
wavelength, maximum depth, beam diameter, treatment mode, available handpiece,
and other features.
Table 2.18 Comparison of five different non-ablative lasers

Max
System coagulation Beam Delivery
name Wavelength depth diameter pattern handpieces
Features
Fraxel 1550/1927 nm 1.5 mm 63 μm Roller One A stand-alone
Dual from handpiecesystem, two
Solta with two FNAL
different tip
wavelengths
sizes Has substantial
consumable use
Microlens 1540 nm 1 mm 230 μm Stamping Deep (XD) Part of the Icon
1550 nm (stamp) and Fast platform
from (XF) alongside IPL,
Cynosure handpieces long-pulsed
Nd:YAG, and
fractional
2930 nm ablative
laser
ResurFX 1540 0.15 mm 400 μm Stamping Coolscan A stand-alone or
from (scanner) scanner part of the M22
Lumenis platform, a
scanner with
contact cooling
Halo laser 1470 Not 0.25, Roller One Halo Pro was the
from revealed 3.7, and handpiece first Hybrid
Sciton 5 ms with two 1470/2940
fractional fractional
zones of non-ablative/
10 × 10 and ablative
6 × 6 mm handpiece
Alma 1570/10600 1 mm 400 μm Static Scanner Contact cooling,
Hybrid (scanner) with contact Hybrid
cooling 1570/10600
fractional
non-ablative/
ablative
handpiece with
radiofrequency
ClearSkin 1540 nm NA 600–100 Static 2 mm Integrated
in Er:Glass mJ/P cooling vacuum
Harmony The vacuum can
Alma be turned on/off
Pixel® 1320 nm 2–4 mm Not Static 7 × 7 mm Variable pulse
1320 nm revealed handpiece widths 30–40–50
Nd:YAG with two ms for darker
from Alma Pixel counts skin types
(49 and 81)
Lasers 83
Halo Laser
One example of the non-ablative/ablative combination is Halo. The hybrid Halo is
a fractional laser that irritates the skin with a combo of 1470 and 2940 nm simulta-
neously, as shown in Fig. 2.23.
Coverage (or density) becomes important when dealing with fractional lasers. A
larger coverage indicates that a higher portion of the skin is irritated with laser. The
coverage percentage ranges between 5 and 25% on most platforms, and a higher
density correlates with more aggressive treatment and longer downtime.
Figure 2.23 shows the treatment area divided into five face zones when using
Halo. By pressing this soft key, users are sent to the data entry page, where they may
enter the length and breadth of these zones in cm2. The dimensions can be input by
simply running the Halo handpiece down the length (and breadth) while holding
down the footswitch or by physically measuring the dimensions and entering them
using the “+” or “−” soft keys.
Fig. 2.23 Operation
interface window for the
Halo laser from Sciton
1. Keys to selecting the treated area.

2. Reset softkey.
3. This bar provides a graphical representation of the fraction of the selected per-
cent coverage.
4. Target % of coverage selected for the treatment.
5. This number represents the current percentage of treatment area coverage.
6. The velocity meter displays visual feedback on the proper velocity of handpiece
movement.
7. The target energy to be delivered is displayed here, calculated based on the
target % coverage selected.
8. The energy display is where the total energy delivered is displayed.
9. The Skin Temp indicator displays the skin temperature automatically during
treatment.
10. Touching the Treatment Summary soft key takes the user to the Treatment
Summary screen, which displays the treatment area, target/delivered energy,
and 1470 depth/coverage for the five treatment zones.
11. Adapter Life Time Indicator: The indicator shows how long the disposable
adapter has been used. The disposable adapter has a 90-minute life span. The
indicator will track the amount of time spent.
12. Preset Depth (m)/Coverage (percent) soft key for HALO 1, HALO 2, and
HALO 3: Touching one of these three soft keys allows the user to choose
between the predefined depth (m), coverage, and density (percent).
HALO1 Depth ( µ m ) / Coverage ( % ) is 300 / 5

HALO 2  Depth ( µ m ) / Coverage ( % ) is 300 / 10

HALO 3  Depth ( µ m ) / Coverage ( % ) is 350 / 10

13. The depth and coverage indicator displays the depth and % coverage selected
for treatment with HALO 1, HALO 2, or HALO 3.
14. Scan Width displays the HALO disposable adapter width in mm.
15. When raising the density, consider the patient’s skin type and history of pig-
mentary disorders, such as hyper- or hypopigmentation.
16. Standby soft key: The system is in idle or standby mode. Pressing this soft key
will bring the user to Ready mode, and the system will be active.
17. The user will be returned to the 1470 nm/2940 nm apps by pressing this soft key.
Fractional Ablative Lasers (FAL)
Light absorption in water increases about 100 times as the wavelength increases
from 1550 nm with Er:Glass laser to 2940 nm with Er:YAG laser. This is why abla-
tive lasers evaporate water as well as certain epidermal layers. The only FALs on the
market are the 2790 nm Cr:YSGG, the 2940 Er:YAG, and the 10,600 CO2 lasers.
Lasers 85
The 2940 nm laser has the greatest affinity for water, ten times that of CO2 and three
times that of Cr:YSGG. Cold (Er:YAG), warm (Cr:YSGG), and hot lasers are the
most common (CO2). Figure 2.24 depicts how all three lasers may produce the
same ablation but with varying degrees of thermal diffusion [96].
These lasers are used in hyper-/hypopigmentation, rejuvenation, and acne.
However, they are usually reserved for deep wrinkles and scars [94, 97]. FAL usu-
ally offers a combination of ablation and coagulation based on its water affinity.
This is called the ablation/coagulation ratio. Over the last two decades, several tech-
nological advancements improved the ability to control and customize the ablation/
coagulation ratio for different indications. Most platforms are equipped with a basic
stationary stamp handpiece to be upgraded to a full scanner if required.
What Is Stacking
Stacking is essential in all laser treatments, especially ablative lasers. Similar to the
train of pulses (sequential pulses) in the IPL, ablative laser platforms repeat the laser
shot at the same MTZ several times. Practitioners might use stacking to achieve
deeper ablation or coagulation without the undesired thermal diffusion associated
with greater pulse width. This technique significantly improved the safety and toler-
ability of FAL and reduced erythema and downtime.
Practitioners should consult the manufacturer to understand how they used the
term “stacking” in their publications. In some manuals, stacking means that the
same pulse is divided into micro-pulses, but the same total energy would be deliv-
ered during the same pulse width, as shown in Fig. 2.25 [98]. Higher stacking is
usually related to lower erythema and downtime. It is important to refer to the user
manual for each laser machine, as stacking might be interpreted differently.
Repetition rate refers to the interval between every pulse and is related to overlap-
ping the practitioner technique in moving the handpiece. In others, stacking is used
interchangeably with repetition and the number of passes [99].
ABLATION DEPTH
0-5 µ m 6-20 µ m 21-100 µ m

Er:YAG
3-7 µ m
THERMAL DEPTH
“Er:YAG’’
8-15µ m 16-30µ m
“CO2’’
Fig. 2.24 Difference between the Er:YAG and CO2 lasers in terms of ablation/coagulation
ratio [96]
Decreasing Erythmea
Power
Power
Smart Smart Smart Smart
stack 1 stack 2 stack 3 stack 5
Time Time
Dwell Time: Dwell Time: Dwell Time: Dwell Time:
1000µs 500µs 300µs 200µs E= 5×6 mJ = 30mJ
E= 1×30 mJ DOT Energy: DOT Energy: DOT Energy: DOT Energy:
30mJ 30mJ 27mJ 30mJ
Fig. 2.25 Difference between five stacking modes in the SmartXide DOT CO2 laser from
Deka [98]
2940 ER:YAG and CR:YSGG 2790 nm Laser

These two wavelengths have the highest affinity to water and, thus, the highest abla-
tion properties. The Er:YAG is the most ablative laser, referred to as a cold laser due
to minimal thermal diffusion, followed by the 2790 nm laser (the warm laser).
The first generation of Er:YAG systems had a stationary pulse width between
0.25 and 0.3 ms, with a single indication of resurfacing without significant coagula-
tion and remodelling. This feature has had fewer side effects, such as
PIH. Nevertheless, the 2940 and 2790 nm laser’s versatility was limited in the aes-
thetic field by its high ablation/coagulation ratio.
The second generation of the Er:YAG laser systems overcame this problem by
presenting a variable pulse width. With this, practitioners can achieve an adequate
ablation/coagulation ratio by controlling the pulse width. The high-peak short pulse
is usually purely ablative. The coagulation increases as we increase the pulse width
allowing more thermal diffusion. Besides, the shape of the pulse width has improved,
to exclude the long tail and reduce energy waste, as shown in Fig. 2.26 [49].
The Fotona Dynamis and Joule are the only fully functional Er:YAG systems
with variable pulse width and scanner attachment.
This video shows the Fotona Dynamis laser and discusses different parameters
for the fractional ablative treatment: https://drive.google.com/file/d/1IW-
FQO8mNYyHlTTUlf2v7S0OE_BZgFhf/view?usp=share_link
This video shows the relations between the pulse width and the application of
Er:Yag laser applications: https://drive.google.com/file/d/1JzNlu2NUwbUB8NOfk
15Qs7JIRxR5afEm/view?usp=share_link.
Comparison
Table 2.19 compares four Er:YAG laser systems in terms of available wavelength,
maximum ablation depth, pulse width, stacking, handpieces, and other features.
Lasers 87
STANDARD LASER TECHNOLOGY FOTONA VSP TECHNOLOGY
VSP
SP
LASER PULSE POWER
LP
Slow rise time VLP
Long tail
0
0 400 800 1200 1600 0 400 800 1200 1600
TIME (micro seconds)
Fig. 2.26 Difference between standard Er:YAG pulse technology and the variable square pulse
(VSP) technology in the Fotona laser platform, courtesy of Fotona
Table 2.19 Comparison of four Er:YAG laser systems

System Ablation Pulse
name Wavelength depth width Stacking handpieces Features
Fotona 2940 nm 400 μm 175–800 Yes Fully ablative, Full control over
Dynamis μs fractional, ablation/
scanner, coagulation ratio to
vaginal expand treatment
options.
Actual variable
square pulse (VSP)
The Dynamis
platform is
integrated with a
variable pulse
1064 nm ND:YAG
laser
Joule from 2940 nm 400 μm Variable, Yes Fully ablative, The platform comes
Sciton actual fractional, with several
data not scanner, additional options,
revealed vaginal, including a hybrid
hybrid 1470/2940 NM
Halo handpiece,
1064 nm, and IPL
(extra charge)
(continued)
System Ablation Pulse
name Wavelength depth width Stacking handpieces Features
iPixel 2940 nm 90 μm Fixed 2 No Handpiece Add-on to the
2940 from ms for with a 7 × 7 Harmony platform
Harmony 7 × 7 fractional zone
Alma Variable Handpiece
for the with 7 × 1
roller roller
10 mm
thermal
tip
2940 2940 nm No 0.25, 3.7, No One handpiece Add-on to the Icon
fractional revealed and 5 ms with two platform
from Icon fractional
zones of
10 × 10 and
6 × 6 mm
xeo Pearl 2790 nm 100 μm 600 μs No Fully ablative It can be used in
fractional handpiece and skin types I–III
from a fractional only
Cutera handpiece
Fotona Dynamis
The operator interface for Fotona Er:YAG is interactive and intuitive. The opera-
tor can choose the level of ablation and coagulation, and the computing system
will suggest a suitable setting, including fluence and pulse width, as shown
in Fig. 2.27.
iPixel ER:YAG 2940 nm 2 Hz Applicator; 7 × 1 iPixel Roller

Table 2.20 shows the treatment parameters using iPixel Er:YAG from Alma.
10,600 nm CO2 Laser

The CO2 laser systems have evolved in aesthetics and dermatology since the 1990s.
The first generation of CO2 laser systems has a continuous wave (CW) mode. This
delivers low but continuous energy. In contrast, the CW mode has unfavorable ther-
mal diffusion to the surrounding tissue and its ablation/coagulation ratio. Therefore,
their use in the aesthetic field was limited due to adverse effects, mainly PIH.
The second generation of CO2 laser introduced the super pulse principle, in
which the energy is delivered in a discrete, intense pulse. The super pulse mode,
with its sharp peak and short tails, has significantly improved the ablation/coagula-
tion ratio and reduced thermal diffusion to the surrounding tissue.
The latest generation uses the ultra pulse concept, where the energy pulse has a
more consistent rectangle shape without tails. We use the term Char-Free due to its
Lasers 89
Fig. 2.27 Operator interface window for the variable square pulse (VSP) in the Fotona laser plat-
form. By choosing the level of ablation and coagulation on the left, the system will suggest the
setting for a given handpiece to reach the treatment goals
Table 2.20 Treatment parameters using iPixel Er:YAG from Alma

Fitzpatrick skin Treatment Pulse Energy Interval between
type intensity mode (mJ/P) # Passes passes
I–III Mild Short <600 1-2 5–10 s
IV Mild Short <600
I–III Moderate Medium <800 1-2
IV Moderate Medium <800
I–III Aggressive Long <1000 1-2
IV Aggressive Long <1000
precise ablation and low thermal diffusion zone. Figure 2.28 shows the difference
between the three pulse modes of CO2 lasers: A, continuous wave (CW); B, super
pulse; and C, ultra pulse.
Indications
The ability to control the ablation/coagulation ratio and fractional density has made
the CO2 laser a versatile tool in dermatology and the aesthetic field. Its indication
includes skin remodelling, photorejuvenation, pigmentation, and scar removal. If
Fig. 2.28 Difference between (a) continuous wave (CW), (b) super pulse, and (c) ultra pulse in
terms of energy shape and skin effect
Lasers 91
you are not a dermatologist, this would be the last laser system you would add to
your practice. Figure 2.29 shows the different indications of the CO2 laser accord-
ing to the spot size and energy.
Comparison
Table 2.21 compares light-, medium-, and heavy-duty CO2 laser systems. They are
ranked according to alphabet.
Smaller Beam Size Larger Beam Size &

& HIGH ENERGY Low ENERGY
Penetrste deeply in dermal layer Weakly ablate epidermal layer
Skin tone, texture, pores,

Scar, wrinkles, laxity
fine wrinkles
Skin tightening+ Alike to efficacy of slight shemical

Collagen remodelling peeling
Major serious skin reaction, downtime (erythema could Minor skin reaction, less downtime, no anesthesia,
last for 1 month). pain (pain and downtime are able to be (does not high energy to penetrate into dermis)
overcome by adjustment of scan size
Fig. 2.29 Different indications of the CO2 laser according to the spot size and energy
Table 2.21 Comparison of three CO2 laser systems

Max
ablation Max
System name depth peak Stacking handpieces Features
eCO2 by 2.5 mm 30 Yes 120/300/500/1000 Variable MTZ size
Lutronic
The only CO2 with a
dynamic option
Easy-to-use interface
CO2RE by Less than 60 No Single handpiece (150 Four simple
Candela 1 mm μm spot size) operating mode
Disposable handpiece
Easy-to-use interface
Light and easy to
move
UltraPulse by 4 mm 240 Yes ActiveFX/DeepFX/ Powerful CO2 laser,
Lumenis SCAARFX heavy-duty
Require experienced
user
Advanced practice
In-depth control
interface
eCO2 by Lutronic
This is a simple CO2 laser system that provides all the benefits of a modern system
but with limited operator control (Fig. 2.30, Table 2.22).
Total Energy
Pulse Width Coverage%
Regulation of
Peek Power
Fig. 2.30 Operator interface window for the eCO2 by Lutronic
Table 2.22 eCO2 Plus system specifications

Laser Wavelength 10.6 μm
CO2 module maximum power Maximum 30 watts at continuous wave
Fractional scanner handpiece User mode Static (stamping)/dynamic (air brushing)
Tip 120, 300, and 500 μm spot sizes
Pulse energy 2–240 mJ
Pulse rate 10–200 Hz
Density 25–400 spots/cm2
Scan area 18 × 18 mm
Scan shapes Different shapes
Normal handpiece User mode Char-free (ultra pulse)/super pulse/CW
Pulse rate Char-free (ultra pulse) 1–700 Hz
Super pulse 1–550 Hz
Pulse width Char-free (ultra pulse) 40–1000 μs
Super pulse 1–5 ms
Lasers 93
CO2RE by Candela
An advanced system with full operator control (Fig. 2.31, Tables 2.23 and 2.24).
Fig. 2.31 Operator interface window for the CO2RE by Candela. This platform has advanced set-
tings that allow the operator to adjust the ring and the core size
Table 2.23 CO2RE four modes

Mode Energy settings Fractional coverage Estimated ablation depth
CO2RE Light 30–60 mJ 30–50% 30–60 μm
CO2RE Mid 60–90 mJ 20–40% 60–100 μm
CO2RE Deep 50–80 mJ 1–5% 500–750 μm
CO2RE Fusion 60–90 mJ 20–40% 60–100 μm and 500–750 μm
Classic Ablative 1–10 mJ Full 100–200 μm
Surgical 10–50 mJ n/a Line: 6 × 0.2 mm
Table 2.24 CO2RE system specifications

Lasers 95
ULT Rapulse by Lumenis (Fig. 2.32, Table 2.25)
Fig. 2.32 Operator interface window for the UltraPulse by Lumenis
Table 2.25 UltraPulse system specifications

Handpieces UltraPulse DeepFX™, ActiveFX™, TotalFX™
Wavelength 10,600 nm
Laser type UltraPulse and CW
Power to tissue 60 W
Peak power 240 W
Spot size Microscanner 120 μm
UltraScan™ CPG 1.3 mm
Depth Microscanner 100–3500 μm
UltraScan™ 10–300 μm
Density per scan Fractional, 1–82%; full ablative, >100%
Cooling Self-contained, closed cycle
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Chapter 3
Hair Removal
In this chapter, we shall refer to laser and IPL hair removal as “laser hair removal.”
The reader should have built a solid understanding of the difference between both
technologies, as explained in detail in the first two chapters, and any further differ-
entiation would be redundant.
Since 1996, when the first laser hair removal (LHR) platform was FDA cleared,
hair removal platforms have gone a long way [1]. The early technologies created
could only postpone hair growth by 3 months on average [2]. However, due to the
capacity to target the germinative cells in the hair follicle bulge and root via heat
created by light thermolysis, today’s LHR therapy gives longer-lasting benefits
(5–10 years) [3]. To this day, there is a controversy about the nomenclature of hair
removal/hair reduction and long-term/permanent; scientifically, we feel that long-
term hair reduction is more appropriate; nonetheless, practitioners adopted the
phrase “permanent laser hair removal” for marketing purposes. In this book, we
shall use both phrases interchangeably to keep within market norms while avoiding
marketing jargon.
For an effective LHR, the photothermolysis effect should reach the pigment-free
(they do not contain melanin) stem cells at two locations, the primary bulge region
and secondary germinative cells layers at the dermal papillary matrix, to achieve
long-term hair reduction [4]. As a result, the pulse width should be long enough to
generate heat in the hair shaft, cause photothermolysis to damage the hair strand,
and cause necrosis in the germinative layer of the follicle [5]. In other words, the
targeted germinative cells are affected by the bystander effect of the photothermoly-
sis, but not directly. Moreover, a reserve of stem cells in the bulge region should also
be disrupted, as shown in Fig. 3.1.
It has recently been claimed that delivering laser in successive pulses allows hair
follicles to absorb it more efficiently (similar to the stacking concept with FAL in
Chap. 2). Following each laser pulse, there was increased laser absorption at the hair
follicle level, known as the avalanche effect. The new hair removal technology
involves sending a series of laser pulses to the same skin area while optimizing the

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27632-3_3
102 3 Hair Removal
Fig. 3.1 Two different

locations for the stem cells
in the hair follicle: primary Epidermis Hair Sebaceous gland
in blue and secondary
in red
Outer root sheath
Inner root sheath
Connective
tissue sheath
Proliferating
Bulb
progenitor
cells
Dermal
papilla
laser pulse parameters for maximum avalanche impact. This method differs from a
standard “stamping” technique in which the laser handpiece is moved from spot to
spot across the treated skin with no overlap, and single high fluence pulses are deliv-
ered to each location [6, 7].
Hair removal’s effective lasers and IPL should have a pulse width in the millisec-
onds range (20–40 ms) as the TRT for hair follicles is between 10 and 100 ms,
depending on the hair’s color thickness and client skin type [3].
Laser pulses shorter than 5 ms cause thinning and lightening of the hair and delay
re-growth for 3–6 months by damaging the hair bulb. However, such pulse width
would not be enough to induce the bystander effect of photothermolysis in both the
germinative and bulge regions [8]. Therefore, to achieve long-term hair removal,
practitioners should choose the correct combination of wavelength, fluence, pulse
width, and spot size to deliver enough energy at the appropriate depth and location
without adverse effects. The epidermis is the main barrier to using very high energy
Hair Follicles 103
and long pulse width, as photo energy does not differentiate between melanin in the
epidermis or hair follicles. If the pulse time chosen is too short, the high energy
intensity may cause epidermal damage such as burns and hyperpigmentation [9].
Following a laser pulse, practitioners may notice that the hair partially vaporizes
and flies out of the follicle, indicating high unrecommended parameters (high flu-
ence and short pulse width). This is especially true for thick, dark hairs in the axillae
or bikini line. The expelled hairs become trapped in the gel, making it simple to
check. On the other hand, if the pulse time is too long, the hair may not heat up
enough to destroy the target chromophore. Rather, the hair may be damaged or
unaffected.
Hair Follicles
Each of us has two types of hair follicles: vellus and terminal. The relative percent-
age between the two types in an individual depends on sex, age, ethnicity, and other
factors [10]. Vellus hairs are predominant at an early age until puberty. It ranges in
diameter between 20 and 50 μm (thin and fine) and is lightly colored [11]. During
puberty, vellus hairs are replaced by terminal hairs due to the increase in androgenic
hormones. The newly developed hair type (terminal) is coarse (i.e., thick), usually
with a diameter of 150–300 μm, and is darkly colored. However, higher testosterone
levels (at a later age) may replace the terminal hair with a vellus one (androgenic
alopecia) [12].
Anatomy
The hair follicle is a complete mini organ comprising more than 20 different cell
populations.
An open cavity makes the space for the follicle in the dermal papilla (DP), the
home of the hair bulb. Extensions of the epidermal layer line the top two-thirds of
this cavity. The connective tissues of the dermal layer surround the cavity from the
sides and infiltrate it in the lower center to form the “papilla,” which provides the
necessary circulation to the follicle. The hair matrix is directly located on the top of
the DP, including the secondary germinative cells that divide rapidly to form the
hair strand. As mentioned previously, the primary stem cells are located at the bulge.
The keratinized cell in the hair strand (shaft) arranges itself in three layers: a central
medulla, cortex, and peripheral cuticle layer, as shown in Fig. 3.2. The medulla is
only present in thick hair, while the cortex is found in all hair and is responsible for
producing keratin. Melanocytes at different locations of the hair follicle are respon-
sible for hair pigment and color [13]. The activity of melanocyte depends on loca-
tion in the hair follicle and the growth phase.
104 3 Hair Removal
Hair shaft
Cuticle Medulla
IRS Huxley’s layer Cortex
Henle’s layer Cuticle
ORS
Hair bulb
Precortex
Melanocytes
Hair matrix
Follicular papilla
Dermal sheath
Fig. 3.2 Different layers and cellular clusters in the hair bulb region hair inner root sheath (IRS),
outer root sheath (ORS)
Growth
Hair follicles alternate between the growing and resting phases. The growth phase
is the anagen phase, where hair synthesis takes place. The length of this phase varies
between different hair follicles according to the body area of the same individual
[14]. At a set time, an average of 20% of body hair is in the anagen phase. Moreover,
this phase may last up to 7 years in the scalp area but only between 20 and 90 days
on a female face or extremities, respectively [15]. The second stage is the catagen
phase, which represents a transitional period that lasts about 2 weeks, during which
the hair detaches from its blood supply and the skin absorbs the lower third of the
follicle [16]. The final stage is the telogen phase, which results in hair shedding; The
hair bulb no longer exists, and the new hair strand will push out the old one. The
three consequent phases in the growth cycle are shown in Figs. 3.3 and 3.4.
The LHR affects mainly the hair follicles in the anagen phase, which explains the
need for multiple sessions to achieve long-term laser hair removal. Therefore, prac-
titioners should space subsequent sessions following the anagen phase length, as
shown in Table 3.1.
Four different responses can be detected after LHR depending on the chosen
parameters and the hair follicle life cycle [18].
• The photothermolysis effect is exclusive to the hair shaft without affecting the
germinative cells; this will cause the hair to fall or even explode. However, a new
hair follicle will replace it after 3–6 months.
Hair Follicles 105
Fig. 3.3 Growth cycle of

hair follicles adapted
e)
from [17] has
thP
w
o
Gr
N(
ANAGE
Repeating Cycle
CATAGEN
of
Hair Growth and Rest
t in g )
EN (Res
ELOG
T
Shedding
of Hair
Anagen Catagen Telogen
Fig. 3.4 Changes associated with the different phases in hair follicles’ life circle
• Photothermolysis affects the germinative layer and the stem cells at the bulge
partially, which results in finer and thinner hair.
• Photothermolysis affects both the hair shaft and secondary germinative layer,
resulting in a shock response and extended telogen dropout phase, but the anagen
phase will eventually resume after 12 to 16 months.
106 3 Hair Removal
Table 3.1 Richards-Merhag table showing full information growth rate for each body area [17]
Phases of cycle Phase duration in The average length of developed anagen hair
Region % weeks follicle
Thin Anagen Telogen Anagen Telogen mm
Lip 65 35 8–10 6–7 1.8
Chin 70 30 48–50 10–12 3
Cheek 50–70 30–50 N/A N/A 3
Bikini 30–40 54–70 16–18 12–14 4
Axillae 30–40 54–70 16 12 4
Arm 20–30 69–80 3–13 11–18 3
Leg 20–40 54–80 16–22 11–24 3.2
• Photothermolysis affects the hair shaft, the germinative layer, and the primary
stem cells at the bulge region, resulting in long-term (permanent) hair removal.
Assessment
Hair Color
Hair color, like skin color, is a result of the melanin produced by the melanocytes.
Therefore, hair color depends on melanin’s form, pheomelanin (red or yellow) and
eumelanin (brown or black) [19]. Hair color is essential to photothermolysis; there-
fore, individuals with blond and red hair are not candidates for LHR [20].
Texture and Coarseness
Hair coarseness is related to hair diameter and is best assessed 24 hours after shav-
ing. This can be evaluated visually (using a magnifying lens) or by touching the
shaved hair using the glove test.
The TRT for a hair follicle is mainly related to its diameter [21], as shown in
Fig. 3.5.
A practitioner should use a longer pulse width (for the same fluence) with coarse
hair as it has a longer TRT, as illustrated in Fig. 3.6.
Glove Test
The client should shave the area not waxed 24 hours before the treatment session.
To begin, practitioners should put on a tightly fitting glove, usually one size smaller
than what they normally use for the procedure. Following that, practitioners should
press their fingers firmly against the shaved target area in the opposite direction of
hair growth. Fine hair should be classified if the finger moves smoothly over the
area without resistance. The coarseness is medium if the area shows resistance by
Hair Follicles 107
Fig. 3.5 Estimated Thermal relaxation time (TRT)

relaxation as a function of 60
the target diameter 50
Time / [ms]
40
30
20
10
0
0 0.1 0.2 0.3 0.4 0.5
Diameter / [mm]
Fig. 3.6 Required change in pulse width in terms of hair coarseness
catching on the glove without feeling the pokes in the hair. Finally, coarse hair
results in a high resistance with a noticeable feel.
Hair Density
A practitioner should assess the hair density in the treatment areas visually and
assign a score using a consistent method such as the modified Ferriman-Gallwey
score [22].
Extremities and Face
0 = absence of terminal hair.

1 = a few scattered hairs (less than 10 hair/cm2).
2 = visible growth scattered over a wide area or localized in small groups (10–29
hair/cm2).
3 = vigorous growth of densely packed hair over most of the region or prolific
growth in large areas (30–40 hair/cm2).
Abdomen
0 = absence of terminal hair.

1 = ranging from a few scattered hairs to a thin midline streak.
2 = marked growth limited to the linea alba.
3 = considerable midline band of hair as well as scattered hairs in the region.
108 3 Hair Removal
Pubic Region
0 = horizontal limitation with no growth beyond the genitofemoral fold.

1 = a horizontal limit with growth not exceeding 2 cm beyond the genitofemo-
ral fold.
2 = same as 1, but with some hair beyond the 2 cm limit.
3 = pronounced growth extending down the thighs.
Higher hair density results in a more intense photothermolysis process and
higher thermal diffusing to the surrounding tissues. A practitioner should consider
decreasing the fluence in areas with a score of 3 by 2–5 J/cm2 of the recommended
settings, especially when using a relatively short pulse width, less than 20 ms [20,
23, 24].
Skin Phototype
Fitzpatrick Assessment
The improved Fitzpatrick assessment is still the most used tool to determine skin
phototype. Most newly adapted skin type assessment forms have four fields: genetic
background and deposition, genetic deposition, reaction to sun exposure, and tan-
ning habits with 12 multiple-choice questions, as shown in Table 3.2. The practitio-
ner should help the client choose one of the four suggested answers and grade each
question accordingly. The client’s skin phototype is directly related to the total score
of the questionnaire. A higher score is related to higher skin type and risks with
photo treatments such as epidermis burns and post-inflammatory pigmentation.
More information on other assessments can be found in Chap. 1.
Table 3.2 Genetic deposition

Available Technology 109
Skin Reflectance Colorimeter
The new handheld colorimeters emit light of a specific spectrum and measure the
light’s wavelength and intensity reflected by the skin [25]. This data is converted
into a colorimetric value and suggests skin color. One deficiency of these devices is
that they measure only a small skin area. Therefore, the practitioner should perform
multiple tests and ensure to include the darker spots if they exist.
Older devices, such as Mexameter MX 18 (Courage+Khazakauses, Germany),
only use a narrow band reflectance spectrophotometer, Other devices, such as
Antera 3D (Miravex Limited, Ireland), use seven different wavelengths. However,
these devices’ data is not absolute and may change according to external variables
such as previous tanning and room temperature. Some new LHR platforms’ hand-
piece is integrated with an internal skin colorimeter to help practitioners choose the
best treatment settings.
Other than the Mexameter and Antera 3D, we are aware of three handheld devices
to assess skin color: Chromameter (Minolta, Japan), DSM III (Cortex technology,
Denmark), and Skintel (Cynosure). More information is available in Chap. 1.
Wavelength
Melanin is not exclusive to hair but exists in other dermal and epidermal components.
Therefore, epidermal melanin will absorb part of the laser energy directed toward
hair follicles. Practitioners should assess hair characteristics and skin type before
choosing the appropriate wavelength. The rest of the parameters would follow after.
Melanin shows a higher light absorption with shorter wavelengths. However, exceed-
ing 500 nm would result in shallow skin penetration and higher competition with
oxyhemoglobin. Therefore, available laser wavelengths for long-term hair removal
are 755 nm, 810 nm, 1064 nm, and IPL spectrum between 590 and 1200 nm [26].
Available Technology
IPL
Most practitioners own and use IPL extensively due to the platforms’ versatility and
broad indications. All IPL platforms emit light between 400 and 1200, but they are
equipped with either different handpieces or several filters to filter the light spec-
trum according to the indication [27]. We will provide several examples of hair
removal IPL platforms: IPL-Sq by Vydence, M22 by Lumenis, Nordlys Ellipse by
110 3 Hair Removal
Fig. 3.7 Decreased blood

flow effect of applying
pressure on the treated area
when using IPL for laser Pressure
hair removal
Candela, Forever BARE by Sciton, and Icon Palomar by Cynosure. IPL platforms
use single or double filters to produce a light band spectrum according to the indica-
tion. First-generation IPL platforms have a single filter to cut off the lower unwanted
wavelengths. Some more advanced second-generation models have dual filters to
cut off lower, middle, or upper unwanted wavelengths for a higher efficacy and
safety profile in different indications [27].
For more efficient treatment, most IPL hair removal protocols recommend apply-
ing pressure on the treatment area, as shown in Fig. 3.7, to decrease blood flow and
depth of the hair follicle’s targeted area and reduce the treatment discomfort.
However, practitioners should consult the manufacturer’s instructions.
IPL Equipped with a Single Filter
Most IPL platforms have one applicator (handpiece) with changeable filters. These
filters limit specific light bands according to the indication. Most frequently used
filters cut off light lower than a specific wavelength. For example, a 580 nm filter
eliminates light with a wavelength lower than 580 nm and produces a light spectrum
of 580–1200 nm. As discussed in the coming section, some IPL platforms are
equipped with dual filters to produce a more specific light band.
IPL-SQ from Vydence
The IPL-Sq by Vydence is equipped with a handpiece and five filters for the lower
wavelength light. The transparent filter allows the applicator to emit light in the full
range between 400 and 1200 nm [28]. The handpiece comes with an adapter to
change the treatment size, with three possible sizes 14 × 12, 12 × 12, and 8 × 8.
As we notice in Table 3.3, each skin type and hair coarseness has a combination
of a specific filter, range of fluence, and pulse width. Darker skin and thicker hair
should be treated with a narrower band, lower fluence, and longer pulse width.
Table 3.3 IPL-SQ (A) specification and suggested parameters for hair removal as reported by the
manufacturer (B)
(A) The specification of IPL-SQ
IPL wavelength 400–1200 nm
Cutoff filters 400, 540, 580, 640, and 695 nm
Spot size 40 × 12 mm
VascuTip 8 mm and 12 × 12 mm
Maximum energy 33 J/cm2
Pulse width 5 to 100 ms
Repetition rate up to 2 Hz
(B) Suggested parameters for hair removal
Hair color Hair type Fluence (J/cm2) Wavelength (nm) Pulse width (ms) Cooling
Black Normal, thick 16–22 640 nm 20 ms V
Black Thick, deep 15–19 695 nm 30 ms V
White Think, normal 12–16 580 nm 30 ms V
Practitioners should observe the clinical response and balance between conservative
settings to enhance safety and intense setting to provide results.
This IPL is part of the ETHEREA platform, which could be upgraded to include
different modalities such as Q-switch nanosecond and fractional Er-YAG hand-
piece [29].
Lumenis M22 IPL
Lumenis M22 IPL has the advantage of dividing the pulse into a train of sequential
pulses (multiple-sequential pulsing, MSP™) to allow cooling of the epidermis,
improving safety and patient comfort. The train of pulses concept is thoroughly
explained in Chap. 1 (Table 3.4).
The M22 IPL interface is intuitive, as shown in Fig. 3.8a and b. The practitioner
starts by choosing the application and then feeding the skin and hair characteristics
to the system. The system processes the patient information and chosen handpiece
to suggest specific parameters for the user, including fluency, pulse width, and spot
size for best results.
Experts can manually override the suggested parameters if required, as shown in
Fig. 3.9. M22 uses a contact cooling mechanism that can be turned on and off but
does not give the practitioner the option of controlling the actual temperature [30].
112 3 Hair Removal
Table 3.4 Parameters for hair removal using the Lumenis M22 IPL
Skin Hair Pulse # of Pulse
type texture Wavelength Fluence Wavelength duration pulses delay Cooling
I Fine 640 nm 23 J/ 640 nm 4.5 ms Double 10 ms On
cm2
Coarse 695 nm 21 J/ 695 nm 5 ms Double 15 ms On
cm2
Dense 695 nm 22 J/ 695 nm 5.5 ms Double 20 ms On
cm2
II Fine 640 nm 22 J/ 640 nm 4.5 ms Double 10 ms On
cm2
Coarse 695 nm 21 J/ 695 nm 5 ms Double 20 ms On
cm2
Dense 695 nm 21 J/ 695 nm 5.5 ms Double 25 ms On
cm2
III Fine 640 nm 20 J/ 640 nm 5 ms Double 20 ms On
cm2
Coarse 695 nm 20 J/ 695 nm 3.5 ms Triple 25 ms On
cm2
Dense 695 nm 19 J/ 695 nm 3.5 ms Triple 30 ms On
cm2
IV Fine 640 nm 18 J/ 640 nm 5.5 ms Double 55 ms On
cm2
Coarse 695 nm 19 J/ 695 nm 3.5 ms Triple 60 ms On
cm2
Dense 695 nm 18 J/ 695 nm 3.5 ms Triple 80 ms On
cm2
V Fine 695 nm 17 J/ 695 nm 5.5 ms Double 80 ms On
cm2
M22 is a customizable platform that can be upgraded to include Q-switch, long-

pulsed ND:YAG, and resurfacing laser [31].
Forever BARE by BBL Sciton
This IPL is equipped with a dual flash lamp and uses static and in-motion modes for
hair removal. The in-motion mode delivers a low fluence in multiple high-repetitive
pulses to provide gradual heat accumulation for higher safety and less discomfort
during the treatment. This treatment model is popular in 810 nm diode laser and, as
it shows a lower pain score, is marketed as painless hair removal [32]. The applica-
tor is a 15 × 45 mm spot size with different adaptors [33]. Practitioners do not have
control over the pulse width in the dynamic (in-motion) mode, so it is one less
parameter to worry about; however, they have to assess the skin phototype and the
treated area’s size, so the system suggests the total energy for the treated area.
The area size is measured in increments of 25 cm2 using a template, as shown in
Fig. 3.10. The size of the treatment area is important to calculate the total energy
required for the laser hair removal session.
Return to Treatment screen

a
Select new
application
b
Clinical indications screen for ET handpiece
Clinical Indications
Select the skin type Skin Type: I II III IV V VI
Select the hair color Hair color: Blond/Red Light Brown Dark Brown Black
Hair Texture:
Select the hair texture Fine Coarse Dense
Treatment parameters
OptiPulse Auto Fluence 40 J/cm2
Load Physician L Rate (Hz) Fast ChillTip On
recommended presets
OK Cancel
Load use presets

Presets for currently selected
clinical indications
Fig. 3.8 (a) Indication window of the M22 IPL interface. (b) Skin and hair characteristics window
of the M22 IPL interface
After choosing the Forever BARE function, the practitioner should feed in the
following information, also shown in Fig. 3.11:
1. The size of the area
2. Skin type
114 3 Hair Removal
Pulse (ms)
Number of pulses
per trigger
Duration of
3.8 3.2 3.0
pulses in ms
Duration of pulse
delay in ms 2.6 2.4
Increase/Decrease
Buttons
‘Same’ Button
Pulse Characteristics
Fig. 3.9 Interface of the M22 IPL with manual control over all parameters in the expert mode
Treatment Size Template Squares Number of Crystal Widths
25 cm2 1 3
50 cm2 2 6
75 cm2 3 9
100 cm2 4 12, or 2 rows of 6
125 cm2 5 15
150 cm2 6 18, or 2 rows of 9
Each square is 25 sq cm.

Use 1-6 squares
depending on size of
treatment area. 3 crystal
widths fit in 1 square.
Fig. 3.10 Template to measure the number of squares in the treatment area
Fig. 3.11 Interface of the

Forever Bare BBL for hair
removal
Fig. 3.12 Treatment
interface of the Forever
BARE BBL for hair
removal. (1) Main window.
(2) Filter wavelength. (3)
Size of the area. (4) Hair
and skin characteristics
that the practitioner entered
in the previous step. (5)
Repetition rates. (6)
Sapphire temperature. (7)
Energy delivered. (8)
Energy required
3. Hair color
4. Hair coarseness
5. Hair density
The next interface window has the following parameters, as shown in Fig. 3.12.
The practitioner should keep moving the applicator over the treated area until the
total energy is delivered, indicated by an audible beep. It takes about 1 min to deliver
the 2000 J required for the 50 cm2 area. According to Sciton, Forever BARE BBL™
achieves extremely even heating of hair follicles by sending multiple lower fluence
pulses at a high repetition rate. The technology is claimed to reduce missed areas
caused by traditional hair removal devices [34]. This IPL can be used in motion or
static modes [35].
116 3 Hair Removal
IPL Equipped with Different Applicators
These platforms use a specific handpiece with fixed filters to produce a specific light
spectrum for certain indications. Therefore, the practitioner should change the
applicator to obtain different light spectrums to treat certain conditions. Changing
the handpiece is usually a simple process, and the platform recognizes the con-
nected applicator automatically (plug and play).
Icon Palomar by Cynosure
Icon is an example of a versatile IPL platform equipped with six different hand-
pieces. Each has a single or dual filter.
MaxR, MaxG MaxYs 1540 2940 1064+

APPLICATION MaxRs
Hair Removal–All Skin

Types
•
Hair Removal, small
areas, All Skin Types • •
Hair Removal,
including
Lighter, Finer Hair •
Skin Type I-IV
Leg Veins •
Photofacials
(Pigmented and
Vascular Lesions)
•
Vascular Lesions • •
•
Fractional Non-
Ablative Skin
Resurfacing
Striae •
Acne Scars and
Surgical Scars •
Fractional Ablative
Skin Resurfacing •
Wrinkles, Fine Lines
•
If practitioners wish to change the wavelength, they should change the hand-
piece, a simple plug-and-play process. Three of these handpieces can be used for
hair removal, as shown in Fig. 3.13:
• Max Y (yellow) produces a 525–1200 light band. It is the handpiece of choice for
light and fine hair and some pigmentation lesions as it produces a lower
wavelength.
• Max R & Rs (red) produces a 650 to 1200 nm light band. The R has a larger spot
size, 16 × 46; Max Rs handpiece on the other hand provides the same spectrum
but with smaller spot size, 12 × 28 mm (for underarm and bikini lines).
Generally, the R handpiece is safer for everyday hair removal procedures as it
has a narrower spectrum and lower fluence. Max Y should be reserved for fine and
light hair or the last two treatment sessions when the R handpiece is not a clinical
endpoint.
Table 3.5 shows the recommended treatment parameters for Max Y and R hair
reduction from Cynosure user manual [36].
When using Max R and Y, the operator can choose between two pulse modes:
SurePulse and SmoothPulse. When SurePulse is enabled, the handpiece will emit
two rapid-succession pulses with a single handpiece triggering. The first pulse width
is 20 ms, and the second pulse width is 10 ms. The total fluence is divided into a
60/40 energy ratio between the two pulses. Because of its shorter TRT, SurePulse is
best suited for light and fine hair [37]. When SurePulse is turned off, SmoothPulse
mode is activated, and the practitioner can manually adjust the pulse width based on
skin type, hair density, and coarseness, as shown in Fig. 3.14.
According to Cynosure literature, the traditional SmoothPulse has higher safety
in the epidermis than a train of pulses, as shown in Fig. 3.14. However, we do not
agree with this explanation due to the short TRT for the epidermis melanocyte
(1–2 ms) compared to TRT’s hair follicles (10–50 ms). In other words, the
Fig. 3.13 Max Y and Max

R with their parameters
(Courtesy of
Cynosure) [36]
118 3 Hair Removal
Table 3.5 Recommended handpiece and recommended setting for hair removal for Max Y and R
Treatment
Skin
Indication or Target Interval Suggested Settings
Type
(weeks)
MaxR™ Hair Removal

Pulse width msec
100 20 SurePulse
I-III Face, neck, ears 2-4

Fluence
Arms, underarms, bikini 4-6 Range 46-48 20-28 42-44
(J/cm2)
Legs, back 8-10
Pulse width msec

100 20 SurePulse
Face, neck, ears 2-4

IV Fluence
Arms, underarms, bikini 4-6 Range 36-48 18-28 32-44
(J/cm2)
Legs, back 8-10
Pulse width msec

100
Face, neck, ears 4

V
Fluence
Arms, underarms, bikini 4-6 Range 14-40
(J/cm2)
Legs, back 8-10
Pulse width msec
100
VI Face, neck, ears 4

Fluence
Arms, underarms, bikini 4-6 Range 14-18
(J/cm2)
Legs, back 8-10
epidermis will reach thermal equilibrium 5–25 times faster than hair follicles. In our
experience, most epidermal burns in IPL hair removal are due to high fluence
accompanied by short pulse width and lack of cooling due to practitioners’ inexperi-
ence in choosing the starting point (Fig. 3.15).
The Icon platform could be upgraded to include ND:YAG and fractional ablative
2940 nm and non-ablative 1540 lasers [38].
IPL Equipped with a Dual Filter
The dual-filter concept is a newer technology, as the applicators are equipped with
two filters to eliminate light lower and higher than the required wavelengths.
Therefore, they produce a narrower light band to increase efficacy and safety. We
will provide two examples.
Fig. 3.14 Icon interface after connecting a Max Y (up) and Max R (down) [37]
Fig. 3.15 Max R and Max Y with their parameters reported by Cynosure [37]
Nordlys Ellipse by Candela
The IL part of the Nordlys platform is widely known as Ellipse. This IPL has two
different hair removal light handpieces, HR 600 and HRD 645 [39]. Figure 3.16
shows all available handpieces on the Ellipse and their light spectrum reported in
the machine manual [40].
Ellipse HR and HRD applicator emit light with 600–950 nm and 645–950 nm. In
addition to the lower cutoff, the handpiece filters light with a wavelength greater
than 950 to target melanin optimally [41]. The penetration depth of this light band
120 3 Hair Removal
418 542 577

PL+ 400-720 nm
Absorption (Linear scale)
PR+ 530-750 nm
VL+ 555-950 nm
HR+ 600-950 nm
HR-D+ 645-950 nm
300 400 500 600 700 800 900 1000 1100 1200
wavelength (nm)
Fig. 3.16 Available handpieces on the Ellipse and their light spectrum reported in the machine
user manual; HR and HR-D are the ones assigned for hair removal [40]
Table 3.6 Optimal Skin type HR+ 600–950 nm HR-D+ 645–950 nm

handpiece for hair removal in I Yes Not optimum
different skin types
II Yes Not optimum
III Yes Not optimum
IV Yes Yes
V Yes, with caution Yes
VI Do not use Yes
Table 3.7 Default pulse time Hair thickness HR+/HR-L+ HR-D+

for HR and HR-D applicators Thin 15 ms 17.5 ms
Normal 20 ms 30 ms
Thick 40 ms 55 ms
is still enough to reach even the deeper hair follicles. Ellipse HR-D applicator emits
light with wavelength of 645–950 nm for skin types IV and V (D stands for dark)
with multiple sequential sub-pulse modes (1, 2, 3, and 4 pulses) with a total pulse
duration between 0.5 and 700 ms, which makes it safer for darker skin types [42].
Table 3.6 shows the recommended handpiece for hair removal in each skin type
using this IPL, as reported in the clinical manual [40].
The practitioner should input the skin type and hair thickness, and the system
would suggest the default pulse width of 15 J/cm2 according to the handpiece of HR
or HR-D. As shown in Table 3.7.
Practitioners can overcome system recommendations and adjust the settings
manually.
Harmony by Alma
Like Ellipse, Harmony and Harmony Pro has a dual filter to produce light between
650 and 950 (Red applicator). The available fluence is between 5 and 20 J/cm2, with
three different pulse widths (20,30 and 40 ms) and 16 × 40 mm spot size, as shown
in Fig. 3.17 [43].
The dual filter combined with Advanced Fluence Technology (AFT) made it pos-
sible to use low fluence to remove hair in darker skin types, as shown in Fig. 3.18.
This IPL is not the only one that offers a square pulse shape, but almost all IPLs
widely used in the cosmetic field have this feature.
The interface of the hair removal module is simple, as shown in Fig. 3.19.
Table 3.8 presents the spot test settings and waiting time reported in the clinical
manual for Harmony IPL [43].
Fig. 3.17 Older AFT HR

handpiece with its
specifications (Courtesy of
Alma laser)
Fig. 3.18 Advanced
Fluence Technology (AFT)
compared with other
pulsed lights [40]
Fig. 3.19 Alma’s hair

removal module for
Harmony XL IPL [40]
122 3 Hair Removal
Table 3.8 Spot test settings and the waiting time as reported in the clinical manual for Harmony IPL
Skin type Handpiece Pulse width (ms) Fluence (J/cm2) Waiting period
I AFT HR 650–950 nm (Red) 30 15 30 min
II AFT HR 650–950 nm (Red) 30 15 30 min
III AFT HR 650–950 nm (Red) 40 12 30 min
IV AFT HR 650–950 nm (Red) 50 9 24–48 h
V AFT HR 650–950 nm (Red) 50 7 24–48 h
VI AFT HR 650–950 nm (Red) 50 5 24–48 h
Table 3.9 Recommended settings for the HR handpiece and hair removal indication
Skin type Hair texture Wavelength Fluence (J/cm2) Pulse duration (ms)
I Light AFT HR 650–950 nm (Red) 15–20 30
Dark AFT HR 650–950 nm (Red) 10–20 30
II Light AFT HR 650–950 nm (Red) 15–20 40
Dark AFT HR 650–950 nm (Red) 10–20 30
III Light AFT HR 650–950 nm (Red) 15–20 40
Dark AFT HR 650–950 nm (Red) 10–17 40
IV Light AFT HR 650–950 nm (Red) 15–17 50
Dark AFT HR 650–950 nm (Red) 10–15 40
V Light AFT HR 650–950 nm (Red) Up to 15 50
Dark AFT HR 650–950 nm (Red) Up to 13 50
VI Light NA NA NA
Dark AFT HR 650–950 nm (Red) Up to 12 50
Table 3.10 Settings for Super Hair Removal (SHR) using the Speed AFT 700 cooled applicators
Fitzpatrick skin type Fluence (J/cm2) Cycle duration time (s) Total energy (kJ) Cooling (%)
I–III 7 30 12–15 100
IV 6 30 12–15 100
V–VI 5 30 12–15 100
Table 3.9 present the recommended parameters for hair removal with the red
applicator [43]. There are only three pulse widths available for the HR module, 30,
40, and 50 ms (default), and fluence is between 5 and 20 J/cm2, as shown in Fig. 3.17.
The new Alma’s Super Hair Removal (SHR) using the Speed AFT 700 cooled
applicator works by progressively heating the dermis to the degree that efficiently
destroys hair follicles and prevents re-growth while causing no harm to the sur-
rounding tissue. With SHR, the sweeping In-Motion™ approach includes repeat-
edly moving the applicator over the treatment region, delivering energy over a broad
grid, which promotes uniform covering throughout the treatment, which increases
outcomes dramatically (Table 3.10).
elos Pulse with Motif HR Applicator
This device combines IPL with radio frequency (RF) to reduce required fluence due
to RF energy. The lower IPL fluence allows for safer treatment of higher skin
phototypes.
Choosing IPL for Your Practice
When choosing an IPL for your practice for hair removal and other treatments, con-
sider the following: dual filter to eliminate light over 950 nm, adjustable sapphire
contact cooling, multiple sequential pulse mode, and square pulse delivery.
Moreover, the machine should be customizable to include other indications and
modalities in the future.
Service contracts and availability of customer service and maintenance could be
overlooked. However, you should be aware that a technician visit might cost about
$2000 in labor if the machine is out of manufacture warranty.
IPL machine is a level 3 machine, according to Health Canada. Therefore, as it
might be tempting to buy a cheap IPL machine from certain markets, you will not
be able to register the machine with the proper authority or regulatory body, and you
cannot legally use it.
Practitioners should arrange to meet their clients for a full consultation, assess-
ment, and a test spot at least 1 week before the treatment.
Pre-treatment Instruction
Medical History
During the consultation visit, practitioners should collect medical information rel-
evant to IPL treatments, such as the client’s list of medications, chronic diseases,
and skin disorders. Some medications increase skin photosensitivity. According to
a recent study, patients who took vitamin D supplements had a higher risk of burns
after laser hair removal [44]. Table 3.11 displays a list of medications associated
with increased photosensitivity [45].
Uncontrolled chronic diseases such as diabetes and hypertension might result in
delayed healing and other complication [47]. Here is a list of possible but not exten-
sive contraindications that require the intervention of the medical director:
• Current or history of cancer, especially malignant melanoma or recurrent non-
melanoma skin cancer or pre-cancerous lesions.
• Any active infection.
• History of recurrent herpes simplex, systemic lupus erythematosus, or porphyria.
124 3 Hair Removal
Table 3.11 A compendium of 393 photosensitizing medications. The number in brackets is the
number of agents assigned to each drug class and subclass. The agents in italics have substantial
evidence of their photosensitizing effects (n 15 articles). Asterisks denote agents for which a recent
report on their photosensitizing properties has been published (2005 and later) [46]
Cardiovascular (60)
Diuretics (25) Hydrochlorothiazide Bendroflumethiazide Indapamide
Furosemide Benzthiazide Triamterene
Chlorothiazide Bumetanide Chlorothiazide
Hydroflumethiazide Butizide Amiloride
Methyclothiazide Cyclothiazide Torasemide
Piretanide Chlorthalidone Xipamide
Polythiazide Metolazone Ethacrynic acid
Trichlormethiazide Quinethazone Acetazolamide
Bemetizide
RAAS effecting (15) Enalapril Benazepril Spironolactone
Ramipril Lisinopril Losartan
Quinapril Moexipril Olmesartan*
Captopril Valsartan Telmisartan*
Fosinopril Candesartan* Irbesartan*
Antiarrhythmics (11) Amiodarone Diltiazem Quinidine
Dronedarone*c Verapamil Propranolol
Disopyramide Carvedilol Sotalol
Procainamide Tilisolol
Ca2±-channel antagonists (2) Amlodipine Nifedipine
Antihypertensives (4) Hydralazine Diazoxide Methyldopa
Rilmenidine Oxerutins
Others (3) Clopidogrel Triflusal
Anti-inflammatory (38)
NSAIDs (28) Naproxen Bexaprofen Benoxafen
Ketoprofen Diflunisal Indoprofen
Tiaprofenic acid Nabumetone Indomethacin
Piroxicam Benzydamine Fenoprofen
Carprofen Flurbiprofen Sulindac
Aceclofenac Ketorolac* Suprofen
Diclofenac Meclofenamate Ibuprofen
Mefenamic acid Nalidixic Acid Tolmetin
Phenylbutazone Oxaprozin Mesalazine
Leflunomide
COX-2 inhibitors (6) Celecoxib Rofecoxib Nimesulide
Etodolac Meloxicam Valdecoxib
Others (4) Heroin Pentosan polysulfate Achillea
millefolium
Gold
Antineoplastic (47)
Alkylating (4) Hydroxyurea Dacarbazine Chlorambucil
Procarbazine
Antimetabolite (9) Methotrexate Pentostatin Thioguanine
Mercaptopurine Tegafur/Uracil Tegafur/gimeracil/
oteracil
Capecitabine Tegafur Fluorouracil
Anti-microtubule (3) Vinblastine Docetaxel Paclitaxel
Anthracycline (1) Epirubicin
Small-molecule inhibitors Vemurafenib* Cobimetinib Regorafenib*
(14) Vandetanib* Crizotinib* Erlotinib*
Dabrafenib* Dasatinib* Imatinib*
Gefitinib* Canartinib* Alectinib
Lapatinib* Trametinib*
Topoisomerase inhibitor (1) Irinotecan
Monoclonal antibodies (6) Nivolumab* Cetuximab* Trastuzumab*
Eculizumab* Panitumumab* Mogamulizumab*
Others (9) Flutamide Bicalutamide* Rucaparib
Midostaurin Mitomycin Anagrelide
PEG Interferon* Interferon alpha Arsenic
Anti-infectious (70)
Fluoroquinolones (16) Lomefloxacin Ulifloxacin Ofloxacin
Enoxacin Grepafloxacin Trovafloxacin
Ciprofloxacin Gemifloxacin Gatifloxacin
Clinafloxacin Levofloxacin Moxifloxacin
Sparfloxacin Fleroxacin Norfloxacin
Pefloxacin
Tetracyclines (7) Tetracycline Minocycline Chlortetracycline
Doxycycline Oxytetracycline Lymecycline
Demeclocycline
Sulfonamides (5) Sulfamethoxazole Sulfadiazine Sulfasalazine
Cotrimoxazole Sulfisoxazole
Cephalosporins (3) Cefazolin Ceftazidime Cefotaxime
Aminoglycosides (3) Kanamycin Streptomycin Gentamicin
Antimycotics (6) Griseofulvin Terbinafine Itraconazole
Voriconazole Ketoconazole Rosemary
Antituberculosis (6) Isoniazid Ethionamide Clofazamine
Pyrazinamide Ethambutol Aminosalicylate
Antiviral (11) Efavirenz Daclatasvir* sodium
Ritonavir Amantadine (Val-)Aciclovir
Saquinavir (Val-)Ganciclovir Simeprevir*
Zalcitabine Tenofovir Ribavirin
Others (13) Quinine Mefloquine Dapsone
Chloroquine Pyrimethamine Furazolidone
Hydroxychloroquine Quinacrine Methenamine
Azithromycin Sulfadoxine Flucytosine
Atoraquone/
proguanil
(continued)
126 3 Hair Removal
Nervous system (80)
Antidepressants (23) Hypericum Escitalopram Duloxetine*
Amitriptyline Paroxetine Isocarboxazid
Imipramine Protriptyline Phenelzine
Clomipramine Fluvoxamine Tranylcypromine
Desipramine Fluoxetine Amoxapine
Trimipramine Sertraline* Trazodone
Nortriptyline Citalopram Nefazodone
Doxepin Venlafaxine*
Antipsychotics (34) Promethazine Olanzapine* Chlorprothixene
Thioridazine Clozapine Chlorpromazine
Fluphenazine Haloperidol Perazine
Perphenazine Thioxene Loxapine
Flupentixol Trimeprazine Mesoridazine
Molindone Prochlorperazine Quetiapine
Pimozide Trifluoperazine Risperidone
Thiothixene Alprazolam Eszopiclone
Ziprasidone Chlordiazepoxide Zaleplon
Meprobamate Clorazepate Maprotiline
Zolpidem Triazolam Carisoprodol
Aripiprazole
Anticonvulsants/ Carbamazepine Topiramate Butabarbital
barbiturates (11) Lamotrigine Valproic Acid Butalbital
Phenytoin* Trimethadione Pentobarbital
Felbamate Phenobarbital
Triptans (4) Sumatriptan Zolmitriptan Almotriptan
Naratriptan
Others (8) Cevimeline Bupropion Procyclidine
Methylphenidate Danazol Trihexyphenidyl
Ropinirole Acamprosate
Metabolism/endocrinologic (53)
Statins (5) Simvastatin Pravastati* Rosuvastatin*
Atorvastatin* Pitavastatin*
Fibrates (3) Fenofibrate Bezafibrate Clofibrate
Antidiabetics (12) Chlorpropamide Gliquidone Canagliflozin
Tolbutamide Glymidine Sitagliptin*
Glyburide Acetohexamide Metformin*
Glipizide Glimepiride Tolazamide
Proton-pump inhibitor (3) Esomeprazole* Pantoprazole Rabeprazole
Xanthine-oxidase inhibitor Allopurinol Febuxostat
(2)
Hormones (6) Melatonin Estrogen Progesterone
Hydrocortisone Epoetin Alpha Ethinyl estradiol
Antihistamines (19) Mequitazine Clemastine Dimenhydrinate
Repirinast Dexchlorpheniramine Cyproheptadine
Astemizole Hydroxyzine Diphenhydramine
Azatadine Meclizine Loratadine
Brompheniramine Tripelennamine Cetirizine
Chlorpheniramine Triprolidine Terfenadine
Ranitidine
Antithyroid (1) Propylthiouracil
Others (1) Bergamot
Others (45)
Antiseptic (1) Thimerosal
Anticholinergic (6) Scopolamine Benzatropine Atropine sulphate
Hyoscyamine Glycopyrrolate Tiotropium*
Cholinergic (1) Pilocarpine
PDE5 inhibitors (2) Sildenafil Vardenafil
Photosensitizers (11) Porfimer sodium Aminolevulinic acid Dihematoporphyrin
8-Methoxypsoralen Temoporfin Ether
5-Methoxypsoralen Verteporfin Trioxsalen
Anthracene Protoporphyrin Hematoporphyrin
• Use of photosensitive medication or herbs that may cause sensitivity to

560–1200 nm light exposure, such as isotretinoin, tetracycline, or St. John’s
wort. A study has shown that in patients undergoing systemic isotretinoin, laser
hair removal using alexandrite, diode, and Nd:YAG lasers is a safe technique [48].
• Immunosuppressive diseases, including AIDS and HIV infection, or the use of
immunosuppressive medications.
• Patient history of hormonal or endocrine disorders, such as polycystic ovary syn-
drome or diabetes, unless under control.
• History of bleeding disorders or current use of anticoagulants.
• History of keloid scarring and vertigo [49].
• Very dry skin.
• Treatment areas with nevi (moles) [50].
• Exposure to the sun or artificial tanning 3–4 weeks before treatment.
• Pregnancy and nursing.
Managing Clients’ Expectations

Clients should be aware of the expected number of sessions and total hair removal
costs [51].
128 3 Hair Removal
# of treatments
Body part 755 nm 1064 nm Interval
Lip 2–3 5–7 4 weeks
Face 4–6 5–7 4–6 weeks
Bikini line 4–5 5–8 4–6 weeks
Arms 4–5 5–8 4–6 weeks
Underarms 4–5 5–8 4–6 weeks
Back 4–6 6–9 8–10 weeks
Legs 6–8 6–9 8–10 weeks
Moreover, practitioners should inform their clients that this is a long-term hair
reduction rather than permanent hair removal. All clients will experience some dis-
comfort of a certain degree, such as redness and swelling that disappear within
24 hours.
Possible Side Effects and Adverse Reactions

All photo-based treatments could be associated with a certain risk of adverse reac-
tions such as skin texture and pigmentation changes. Clients have to sign a consent
form acknowledging the possibility of having one of these rare complications:
• Damage to the epidermal layer, such as burns and blisters: therefore, it is impor-
tant to follow all treatment instructions carefully and, in particular, to perform
test patches.
• Change of pigmentation: Most hypo- or hyperpigmentation cases occur in peo-
ple with darker skin or when the treated area has been exposed to sunlight before
or after treatment. In some patients, hyperpigmentation occurs despite protection
from the sun. This discoloration usually fades in 3 to 6 months, but in rare cases,
mainly hypopigmentation, pigment changes may last longer or permanently.
• Scarring: There is a very small chance of scarring, such as enlarged hypertrophic
scars. In rare cases, abnormal, large, raised keloid scars may appear. To reduce
the chance of scarring, it is important to carefully collect the client’s history,
follow all post-treatment instructions, and exclude patients with a scarring

genetic tendency.
• A blue-purple bruise (purpura) may appear on the treated area. It may last from
5 to 15 days. As the bruise fades, this skin may have a rust-brown discoloration,
which fades in 1 to 3 months.
Procedure
Here are some broad guidelines for using IPL in hair removal:
• Some practitioners (even the expert ones) start by marking the treatment area and
dividing it into a small area equal to 4 × 4 inches squares. This technique has the
benefit of better tracking and results in fewer untreated/overtreated areas.
• Ensure that the amount of gel is appropriate to the treatment. The amount should
be sufficient to ensure that it does not dry out during the treatment but is not so
great as to cause a gel buildup on the crystal side. It is recommended to use a gel
warmer to avoid air bubbles and improve treatment comfort.
• Always place the crystal perpendicular to the skin surface to ensure that most of
the crystal surface is in contact with the gel. Therefore, the maximum amount of
light energy penetrates the skin’s surface. It also reduces the risk of leaving
untreated strips on the skin.
• Remove gel buildups on the one crystal side to reduce the energy waste from the
crystal sides.
• Start with less sensitive areas; areas close to the nose and upper lip are most
sensitive for the face. Bonny areas are more sensitive than others on the same
body part to lower the energy—most often by 1–1.5 J/cm2 when treating areas
close to the bones (jawlines and shoulders).
• Do not treat the same area immediately if you did not notice the clinical endpoint
during the first shot, but move to the next area after adjusting the parameters. The
minimum rest is 1 min before retreating to the same spot.
• Some adverse events take time to be apparent; for example, skin types IV and V
might take several hours to see signs of skin burn after a treatment. Therefore, be
careful not to select high settings.
• Use manual IPL triggering mode for the first few shots, and examine the skin
closely for clinical response. The skin reaction might take some time and remain
fairly constant throughout the treatment; once you have established the treatment
parameters required for clinical response, you may use the auto-repetition trig-
gering mode. Continue to observe the skin reaction throughout the treatment, and
adjust the treatment parameters if the reaction changes.
• During the treatment, patient response and pain level are a good indication, but it
varies from one patient to another. It is recommended to ask the patient to “score”
any discomfort—using a system of 0–10, where 0 is no discomfort and 10 is the
worst possible pain imaginable. After the first few shots’ initial surprise, the
score should normalize (at a figure that often reflects patient sensitivity). The
patient should always be asked to report if the score changes during the treatment
and adjust the parameter accordingly.
• Insufficient contact with cold sapphire systems might result in skin burns. When
a piece of burnt hair sticks to a contact window device during laser/IPL hair
removal, energy is substantially absorbed by the charred tissue with each laser
pulse. Each succeeding pulse might result in a “stamping” burn pattern, as shown
in Fig. 3.20a. This potentially harmful impact may be avoided simply by clean-
ing the window before and after treatment [52, 53].
• Avoid treating pigmented lesions for hair removal by the applicator so that the
pigmented lesion is not within the spot size or adjust the energy used. Covering
the pigmented area with a wet white cloth, wet gauze, or non-absorbent white
paper may be possible.
• Remove the gel, dry the skin after the final shot with a soft cloth, and apply a cold
compress against the skin immediately after the treatment.
130 3 Hair Removal
Fig. 3.20 (a) Illustration of the “stamping” burn pattern caused by a piece of burnt hair adhering
to a contact window device during laser/IPL hair removal. The charred tissue absorbs a significant
amount of energy with each laser pulse, leading to an increased risk of burns. (b) Depiction of the
treatment area for the Icon Palomar laser/IPL system, highlighting the 20% overlapping require-
ment in older generations to ensure effective hair removal [37]
Unfortunately, all IPL applicators lose photo energy on the edges and concen-
trate the light energy at the treatment head center. Therefore, the peripheral area will
receive less than enough light to produce clinical changes. The concept of overlap-
ping was developed to overcome the shortcoming of all IPL systems. Older genera-
tions, such as Icon Palomar, required 20% overlapping. Newer systems decrease the
need for overlapping to less than 10% or 1 mm. Figure 3.20b suggests overlapping
Cynosure training material for the Icon Palomar large Max Y handpiece [37].
Endpoint
Practitioners should adjust the treatment parameter until they notice changes in the
skin around the hair follicles. These changes are slight erythema and edema in the
proximity of the treated hair follicles. If there is no visible clinical endpoint, the
practitioner should consider increasing the fluence by incrementing 1 J/cm2 until a
satisfactory response.
Figure 3.21 shows perifollicular erythema and edema after hair removal using an
IPL equipped with a single 600 nm filter [52].
Fig. 3.21 Immediate skin

responses after hair
removal using a 600 nm
filter
Post-treatment Instruction
• Sunscreen should be applied every 2 weeks (not only on sunny days). It would
help if you offered your clients to show them how to effectively apply sun-
block—in terms of the amount to be used and the need for reapplication through-
out the day.
• Most clients will report that their skin feels dry after the treatments. Therefore,
you might suggest a hydrating sunscreen to start with, as it will deal with dry
skin and sun exposure. A good moisturizer is especially useful if the weather is
likely to change after treatment (especially if the cold wind will dry out exposed
skin) is forecast.
Long-Pulsed Alexandrite 755 nm
Alex is the shortest wavelength laser used in LHR, with the least penetration and the
greatest affinity for melanin. In terms of efficacy, the 755 mm is comparable (or
better) to a diode laser for hair removal on skin types I through III and outperforms
132 3 Hair Removal
the ND:YAG systems in terms of results and tolerability. However, using this
755 nm wavelength is difficult in skin types IV or darker due to the high competition
between melanin in the hair and epidermis and the low pulse-width range compared
to the Nd:YAG laser [26]. As a result, practitioners should only use it on skin types
I, II, and III and adjust the fluence, pulse width, and spot size as needed. Some expe-
rienced practitioners may use the 755 nm laser with enhanced cooling in skin types
IV–V [54]. Table 3.12 displays the average fluence used in Alex LHR treatment
based on skin type.
Note that alexandrite crystal is not the only source for the 755 nm laser, but the
diode can produce the same wavelength; for example, Soprano Ice by Alma pro-
vides three different wavelengths (755, 808, 1064) from a diode source. We will
consider the laser source insignificant for the same wavelength [55].
Practitioners should start with longer pulse widths (20 ms) and low fluence at the
first session and observe the clinical endpoint. If the current settings were ineffec-
tive, practitioners should increase the fluence by 1–2 J/cm2. Practitioners should
consider reducing the fluence when changing to a larger spot size [56].
A widely used Alex platform is the GentleMax Pro from Candela, with is inte-
grated with the dynamic cooling device (DCD), a patented cryogen spray cooling
device. The GentleMax Pro has a more intuitive treatment interface, as shown in
Fig. 3.22 [57].
DCD is introduced as an advanced cooling method. However, it is considered an
additional consumable cost and might be associated with issues such as epidermal
damage and crescent-shaped or ring-shaped PIH. To avoid excessive cryogen spray
cooling, which may result in cutaneous freezing, as shown in Fig. 3.23, we recom-
mend that the skin be spot-tested with 100 ms of cryogen spray. If the halo frost lasts
longer than a few seconds, freeze injury is likely, and the cryogen spray’s duration
should be reduced.
These issues are primarily caused by the practitioner’s lack of experience in not
holding the laser handpiece perpendicular to the skin, as shown in Fig. 3.24 [58]. To
avoid excessive cryogen spray cooling, which may result in cutaneous freezing, we
recommend that the skin be spot-tested with 100 ms of cryogen spray. If the halo
frost lasts longer than a few seconds, freeze injury is likely, and the cryogen spray’s
duration should be reduced.
Table 3.12 Average fluence Skin type Average fluence (J/cm2)

used in Alex LHR treatment I 30.9
based on skin type
II 37.7
III 36.6
IV 31.3
VI 23
Fig. 3.22 GentleMax Pro interface for using Alex in hair removal [57]
134 3 Hair Removal
Fig. 3.23 Excessive
cryogen spray cooling with
cutaneous freezing [52]
a b
Fig. 3.24 (a) Excessive cutaneous freezing after 100 ms of cryogen spurt, (b) cryogen spurt angle
of 20°, intended to keep the laser spot cool when the handle is perpendicular to the skin, (c) laser
treatment performed at a 22.5° angle (angled toward the cryogen nozzle). The cooled area is
reduced at this angle, and only about 52% of the treatment area is protected from thermal
damage [58]
Pre-treatment Instruction
This section is identical to what was reported under the IPL section, including medi-
cal history, managing client expectations, and possible side effects.
Procedure
As reported in the parameter section, the highest safe energy density determined
through test spots should be utilized. A slight increase in influence (1 J/cm2 for the
755 nm laser) should be tolerated for each consecutive treatment. When treating
areas where the hair density is high, the fluence should be lowered based on the
treatment area and patient tolerance. Pulse width should be determined based on the
patient skin type and hair type. Longer pulse durations should be used to treat darker
skin types. In patients with skin types I–III, the pulse duration may be reduced to
10 ms or less to treat finer, thinner hair. The number and length of treatment sessions
depend on the treatment area’s size, the success rate, and the patient’s tolerance of
the treatment. A white or yellow washable marker can be used to outline the area to
be treated. Warning: Do not use blue, black, or brown markers to outline the treat-
ment area; these colors will absorb the laser energy and result in epidermal injury.
Pulses are delivered linearly with no more than a 10% overlap between pulses.
The use of an air-cooling system is recommended during treatment. The air-
cooling system allows for the continuous flow of cold air in the treatment area to
ease the sensation from the laser pulse. A thin coating of gel, aqueous or surgical
lubricant, clear aloe, clear ultrasonic gel, or water can be used in conjunction with
the system as a conduit for the laser energy and to increase the cooling efficiency of
the treatment site. A clear ultrasonic gel chilled to a slushy consistency can be
applied to the treatment area. A decreased influence may be necessary for sensitive
areas, such as the upper lip, chin, ankle, and bikini areas.
Topical anesthetics may be applied to the treatment area before treatment. Be
sure to wipe the area clean before laser treatment. Double pulsing at the same spot
is not recommended and can increase the chances of complications. Monitor skin
reaction or repeat test spots when changing pulse duration or fluence. Following the
treatment, the SmartCool air-cooling system or an ice pack can be applied to the
treated area to ease the sensation from the laser pulses. Treatments are scheduled at
4–8-week intervals for most body areas or when hair is actively growing. It is not
recommended to re-treat any sooner than 3 weeks.
Parameters
The practitioner should use the highest tolerable laser fluence but without compro-
mising safety depending on skin type, hair coarseness, and hair density in the treat-
ment area. Therefore, as explained later, clients should undergo spot tests before full
treatment, especially with larger spot sizes. For 755 nm, we recommend adjusting
136 3 Hair Removal
both pulse widths and fluences together (decrease the fluences by 1 J/cm2 for every
5 ms decrease in pulse width for the same area). In terms of area and hair coarse-
ness, most practitioners use the same spot sizes for the test spot as intended for the
treatment. Most practitioners use 8–12 mm spot size for facial hair removal, and
larger ones (20–24) are usually reserved for medium-to-coarse body hair. Remember
that a practitioner should decrease the fluency when changing to a larger spot size
to limit the penetration. In some areas, such as facial hair, practitioners should alter-
nate the treatments between long and short pulse width for the best results. This
treatment is contraindicated in tanned skin, even if the skin is slightly tanned.
Table 3.13 shows the recommended treatment settings with Alex laser for hair
removal according to skin and hair type, reported in the operator manual of Elite+
from Cynosure [56]. The Elite+ is a robust Alex/YAG laser platform with a forced
chilled air as a cooling mechanism.
Endpoint
proximity of the treated hair follicles, as shown in Fig. 3.25.
Table 3.13 Treatment settings with Alex laser for hair removal according to skin and hair type,
reported in the operator manual of Elite+ from Cynosure [56]
Skin typea Hair type Spot size Fluence Pulse widthb
I–III Coarse 10 mm 16–30 J/cm2 20 ms
Medium 16–35 J/cm2 15 ms
Fine 16–35 J/cm2 10–15 ms
Fine 16–35 J/cm2 10–15 ms
Fine 16–35 J/cm2 10–15 ms
Fine 16–35 J/cm2 10–15 ms
Fine 15–20 J/cm2 10–15 ms
Medium 10–14 J/cm2 5–15 ms
Medium 7–11 J/cm2 5–15 ms
a
Only pigmented hair for skin type I
b
Reduce pulse width based on the hair diameter
Fig. 3.25 (a) Skin

condition before treatment
a
with Alex laser, (b) Skin
condition directly after
treatment, demonstrating a
good clinical endpoint
marked by perifollicular
erythema and edema [52]
An extreme reaction such as a loud zapping sound and severe erythema indicates
high fluence. Tanned skin might respond aggressively to the 755 nm with blue-gray
discoloration (purpuric response) and blistering. A practitioner should immediately
end the treatment and consider waiting for the tan to fade or choose a different
wavelength (1064 ND:YAG). If there is no visible clinical endpoint, the practitioner
should consider increasing the fluence by 1–2 J/cm2 until a satisfactory response.
Long-Pulsed Diode 810 nm
Diode 810 nm laser has a higher safety profile than 755 nm alexandrite due to less
epidermal melanin absorption. Therefore, the diode laser is frequently used to treat
patients with skin types III to V using 300 and 450 ms pulse widths, respectively.
However, it is worth mentioning that long-term hair reduction is not possible in skin
type VI due to the tolerable fluence limitation. Diode lasers are available in high-
fluence single pass and low fluence with multiple passes.
High-Fluence Single Pass
The platforms rely on the same traditional “selective photothermolysis” concept

on hair follicles. Practitioners should select the appropriate parameters according
to skin phototype and hair texture. Notably, spot size is not adjustable on the diode
138 3 Hair Removal
laser handpiece. Practitioners should determine skin phototype, hair color, and
texture like all LHR platforms. The fluence decreases by 5 J/cm2 when moving to
a higher skip phototype, starting with 35 at skin type I. When using an LHR diode
laser, the thumps rule sets the pulse width to half the fluence (between 10 to 60 J/
cm2). The following is the suggested parameter in the LightSheer Duet from
LUMENIS as an example of a high-fluence single pass platform [59]. The plat-
form provides two applicators: the HS with a large aperture, negative pneumatic
(vacuum), and a standard ET chilled handpiece. Both handpieces are shown in
Fig. 3.26.
When the HS handpiece is placed on the treatment area, it creates suction and
draws the skin into the treatment handpiece, thus reducing stray light while increas-
ing the therapeutic effectiveness. Therefore, the treatment parameters are signifi-
cantly lower than the regular handpiece. The interface for the HS and ET handpiece
is shown in Fig. 3.27a and b.
Fig. 3.26 HS and ET

handpieces from the
LightSheer Duet diode
laser, courtesy of Lumenis
Fig. 3.27 (a) The interface of the HS handpieces from the LightSheer Duet diode laser. (b) The
interface of the ET handpieces from the LightSheer Duet diode laser [59]
140 3 Hair Removal
Endpoint
proximity of the treated hair follicles, as shown in Fig. 3.28. If there is no visible
clinical endpoint, the practitioner should consider increasing the fluence by 1–2 J/
cm2 until a satisfactory response [52].
Low Fluence with Multiple Passes
These platforms are relatively new and use multiple passes of low-level fluence
laser [60]. Therefore, instead of zapping the targeted hair follicle with one pulse of
laser to induce thermolysis, this diode laser induces incipient necrosis and perifol-
licular edema via a high repetition rate of short pulses. The gradual heat buildup in
the dermis is claimed to damage the hair follicles and prevents re-growth while
avoiding injury to the surrounding tissue. This approach significantly decreases the
treatment discomfort by delivering average high energy over a large area
(10 × 10 cm2) by continuously moving the handpiece over the treatment area (mul-
tiple passes or in motion) [61]. Areas of 100 cm2 should be treated with multiple
in-motion passes to reach a cumulative energy dose between 6 and 10 kJ. This tech-
nology is proven less effective than the Alex in skin types I–III. However, it shows
fewer side effects in darker skin types than the Alex laser [60].
Another observation is that hair grows back into finer and lighter follicles that are
more challenging to remove by laser [62]. Therefore, Alma laser introduced the
Soprano Ice platform with an additional alexandrite handpiece to deal with fine hair.
Later, Alma laser introduced the Soprano Ice, which offers three diode wavelengths,
755, 810, and 1064 [63]. The applicator emits one wavelength during the treatment
according to the attached tip.
Fig. 3.28 Diode laser

showed perifollicular
erythema and edema
several minutes after laser
treatment
The more advanced Soprano Platinum and Titanium systems emit three different
wavelengths simultaneously, 755, 810 and 1064, to heat the hair follicles on its
entire epidermal and dermal depths [64]. The technology was introduced in 2016; a
published paper showed the following treatment parament: fluence levels of 7–9 J/
cm2 and pulse repetition rate of 9–10 Hz (SHR mode). Spot sizes were either 2 cm2
or 4 cm2. Accumulated energy was either 16 kJ (for 2 cm2 spot size) or 28 kJ (for
4 cm2 spot size). The total number of treatment sessions was six, 6–8 weeks apart
[61] (Table 3.14).
Here are the treatment steps as reported in the user manual:
• Shave the treatment site to remove any surface hair that could interfere with the
therapy; use adhesive tape to remove any hair debris.
• Remove fragrances, cosmetics, and sunscreen from the skin.
• Make a grid (with a red pen) on a 10 × 10 cm treatment area (mark as many
neighboring grids as needed depending on the treatment area size).
• The enclosed treatment room provides suitable eye protection (OD > 5) goggles
for the patient and crew.
• Apply a thin layer of refrigerated (43–50°F/6–10°C) cooling ultrasonic gel to the
treatment site (typically 1–2 mm thick). The gel will act as a thermal sink for
absorbed and reflected energy, giving some cooling to the patient during treat-
ment and reducing friction during the in-motion procedure.
• Set the initial fluence and operation time interval (1, 3, or 30 ms) based on the
skin test findings and the size of the treatment area.
• In most circumstances, operation time intervals for big areas should be set to 30
s; for extremely small portions of the face, such as the upper lip and chin, inter-
vals of 1 and 3 s should be used (using the stationary technique rather than the
in-motion technique).
• To establish a good seal, place the module perpendicular to the skin, and have it
make contact with the skin. Avoid putting too much pressure on the skin.
• Within the grid region, use an in-motion approach with the appropriate parame-
ters and passes.
• Move the module across the skin’s surface, and activate the footswitch only
when the module is fully in touch and “in motion.”
Table 3.14 Recommended total energy for Soprano Prolight in different skin types to treat a gird
of 10 × 10 cm2 in SHR mode
1.2 cm² handpiece 2 cm² handpiece
Skin Type
Fluence Grid Accumulative Grid Accumulative
Fitzpatrick I-
(J/cm²) Size (cm²) Energy (kJ) Size (cm²) Energy (kJ)
VI*
I-III 8-10 150 8-10 300 12-20
IV 6-8 150 8-10 300 12-20
V 5-7 150 7-9 300 12-18
VI
*Must patch 5 150 7-9 300 12-18
test
142 3 Hair Removal
• Move the module in continuous linear or circular motions to cover the grid area.
Depending on the recommended total energy (kJ) you desire to distribute in the
grid region, this repetitive pattern may last several minutes.
• After finishing a single interval, remove the module from the skin, reposition it
at the spot where you started treatment in this grid, and repeat the procedure on
the full grid area.
• After completing the appropriate intervals, switch to the opposite side, and con-
tinue the process.
• Examine the skin reaction; if none is seen, repeat the procedure. Repeat until
clinical endpoints can be seen.
• For patients with skin types I–IV who have thin, vellus, light-colored hair, it is
recommended to raise the fluence to greater than 10 J/cm2 to cause maximum
damage to this hair type. For patients with light skin types, the recommended
fluence (J/cm2) should be greater the lighter the hair color and the thinner the hair
in the treatment region. The operator should be aware that the pulse repetition
rate decreases when the fluence increases from 10 to 20 J/cm2. At values between
10 and 20 J/cm2, the pulse repetition rate decreases as the fluence rises.
Endpoint
There is no visible clinical response to be considered as a treatment endpoint. The

platform suggests a total time according to the client’s sex (male/female) and treated
area. The interface does not require any other information, such as skin type, hair
texture, or density.
Long-Pulsed ND:YAG 1064 nm
In terms of pulse width, the 1064 nm ND:YAG is the most versatile laser, with dif-
ferent indications and treatment options. The millisecond range, ND:YAG laser can
be used for LHR, vascular, and superficial pigmentation lesions. However, it is
essential to point out that this laser in a long-pulsed form is unsuitable for PIH and
melasma treatment [65].
1064 nm is the safest laser wavelength for darker skin types with the least side
effects, especially with low fluence, small spot size, and long pulse width. In con-
trast to the diode laser, Nd:YAG would provide better long-term hair removal results
due to its lower affinity to melanin and the similarity between its pulse width and
coarse hair TRT, 30 ms. As mentioned before, the lower absorbance of melanin will
allow practitioners to use higher fluences (up to 60 J/cm2) with a small spot size (10
mm) and shorter pulse width (20 ms). However, the ND:YAG laser is less effective
in fine hair for the same reason. For example, in skin types IV and V with coarse
hair, the recommended settings are spot size 10 mm, fluence 45, and 40 ms pulse
width. It is recommended to decrease the fluence by 10 J/cm2 with every 2 mm
increase in the spot size. We advise the practitioner to start with a low fluence/longer
pulse width at the initial treatment, especially on facial hair. ND-YAG is widely
used for hair reduction on skin types I and II, but its efficacy is less than the 755 nm
alexandrite laser. Therefore, new platforms provide alexandrite/ND:YAG combo to
offer all skin types of best hair reduction efficacy.
Procedure
The safest energy density, as determined by test spots, should be used. Each subse-
quent treatment should be tolerated with a little increase in fluence (5 J/cm2 for the
1064 nm laser). When treating areas with dense hair, the fluence should be reduced
based on the treatment area and the patient’s tolerance. The pulse width should be
decided by the patient’s skin and hair type. To treat darker skin types, longer pulse
durations should be used. To treat finer, thinner hair in patients with skin types I–III,
the pulse length may be lowered to 10 ms or less. The number and duration of
therapy sessions are determined by the size of the treated area, the success rate, and
the patient’s tolerance of the treatment. Outline the area to be treated with a white
or yellow washable marker. Blue, black, or brown markers should not be used to
outline the treatment area because they absorb the laser energy and cause epidermal
damage. The pulses are given in a linear pattern, with no more than 10% overlap
between pulses.
During treatment, an air-cooling system is recommended. The air-cooling sys-
tem provides a continuous flow of cold air over the treatment area to alleviate the
sensation caused by the laser pulse. In conjunction with the system, a thin coating
of gel, aqueous or surgical lubricant, clear aloe, clear ultrasonic gel, or water can be
used as a conduit for the laser energy and to increase the cooling efficiency of the
treatment site. A clear ultrasonic gel chilled to a slushy consistency can be applied
to the treatment area. Fluence reduction may be required for sensitive areas such as
the upper lip, chin, ankle, and bikini.
Topical anesthetics may be applied to the treatment area before treatment. Be
sure to wipe the area clean before laser treatment.
Double pulsing at the same spot is not recommended and can increase the
chances of complications. Monitor skin reaction or repeat test spots when changing
pulse duration or fluence. Following the treatment, the SmartCool air-cooling sys-
tem or an ice pack can be applied to the treated area to ease the sensation from the
laser pulses.
Treatments are scheduled at 4–8 weeks intervals for most body areas or when
hair is actively growing. It is not recommended to re-treat any sooner than 3 weeks.
144 3 Hair Removal
Parameters (Tables 3.15 and 3.16)
Table 3.15 Recommended Nd:YAG treatment parameters using the Elite+ from Cynosure
and [56]
Skin typea Hair type Spot size (mm) Fluence (J/cm2) Pulse widthb (ms)
I–III Coarse 10 45–60 20
Medium–Fine 15–10
IV–VI Coarse 45–60 40
I–III Coarse 12 35–50 20
IV–VI Coarse 35–50 40
I–II Coarse 15 30–35 20
II–IV Coarse 30–35 40
V–VI Coarse 30–35 40
Medium–Fine 30
I–II Coarse–Fine 18 15–24 20–10
III–IV Coarse 40
V–VI Coarse 15–24 40
Medium–Fine 30
I–IV Coarse (body) 20 16–19 40
Medium–Fine (body) 30–20
V–VI Coarse (body) 40
Medium–Fine (body) 30
I–IV Coarse (body) 22 13–16 40
V–VI Coarse (body) 40
I–IV Coarse 24 10–13 40
V–VI Coarse 40
Notes: Longer pulse widths should be used at initial treatment. Pulse widths may be shortened
based on skin type, hair diameter, and hair density. Facial hair may need a longer pulse width for
first 1–2 treatments and lower fluence range. Due to the depth of penetration of the larger spot
sizes, test spots are recommended. Fluence should be reduced if changing from a smaller to a
larger spot size
Maximum fluence is dependent on the repetition rate
a
Only pigmented hair for Skin type I
b
Reduce pulse width based on the hair diameter
Table 3.16 Treatment parameter for the Cooled LP Nd:YAG 1064 nm applicator; 6 mm and
10 mm tips from Alma Harmony Pro platform
Fitzpatrick skin type Hair type Spot size Fluence (J/cm2) Pulse width (ms)
I–III Light 6 mm <150 15, 45
Dark 6 mm <150 15, 45
Light 6 mm <120 45
IV Light 10 mm 40–50 15
Dark 10 mm 40–50 15
V–VI Light 10 mm 40–50 15
Dark 10 mm 30–40 15
Endpoint
skin around the hair follicles and perifollicular edema, as shown in Figs. 3.29 and
3.30 [52]. These changes are slight erythema and edema in the proximity of the
treated hair follicles. However, these changes might be more challenging to detect
in darker skin types. The zapping sounds are noticeable, less than the 755 nm alex-
andrite when using similar parameters due to YAG’s lower melanin affinity. If there
is no visible clinical endpoint, the practitioner should consider increasing the flu-
ence by incrementing one J/cm2 until a satisfactory response (Fig. 3.29).
Practitioners should be vigilant for signs of aggressive treatment parameters
(high fluence or short pulse). These include many hairs exploding out of the follicle
or charred directly after the laser exposure (Fig. 3.30).
146 3 Hair Removal
Fig. 3.29 Several minutes

after laser treatment with
ND:YAG showing
perifollicular erythema and
edema
Fig. 3.30 Several minutes

after laser treatment with
ND:YAG laser showing
perifollicular erythema and
edema
Blended Blend Wavelengths
New laser devices emit a single high-energy simultaneous triple-wavelength

(810 nm, 940 nm, and 1064 nm) pulse as well as a single high-energy single-
wavelength pulse (either 755 nm, 810 nm, or 1064 nm) [66, 67]. New hybrid sys-
tems, such as SPLENDOR X from Lumenis and Duetto Evo from Quanta, can be
synchronized to be fired at both 755 and 1064 nm wavelengths individually or
simultaneously, as shown in Fig. 3.31 [68]. It is important to note that, unlike the
Alma Soprano series, these two systems have two separate laser sources. On the
other hand, the Soprano series uses a modified diode laser source for the 755, 810,
and 1064 nm lasers. The blended mode is safe and effective in skin types IV and V
[55]. Splendor X handpiece provides some features such as square spot size, a
Fig. 3.31 BLEND X

technology targets the hair
follicle in two depths for
greater efficacy
built-in plume evacuator with HEPA filter, and a dual cooling system that combines
cryo-touch and cryo-air [69].
However, we could not locate any articles that supported high-efficacy blended
wavelength laser devices. A clinical trial to assess the efficacy of Splendor X started
in 2019 and is expected to finalize in 2023 [70].
Electro-optical Synergy
The technique of electro-optical synergy (eLOS) combines electrical (radio-

frequency (RF)) and laser energy. eLOS is based on the premise that the photo-
energy component heats the hair shaft, which helps concentrate the bipolar RF
energy on the hair follicle. Based on this combination, lower laser fluence can be
used, indicating that all Fitzpatrick skin phototypes may tolerate it and successfully
eradicate white and light-colored hair [33]. As the theory is attractive, the clinical
application of the technology was not successful, at least from a marketing
perspective.
148 3 Hair Removal
How to Choose a System for Hair Removal
It all depends on the type of practice and your strategic plan. Before deciding which
system you wish to acquire for hair removal, the practitioner answer the following
questions:
1. Is this the first investment in aesthetic machines?
2. What is the expected share of hair removal out of the total business?
3. What qualifications do they have?
4. Do they plan to offer other services?
5. How much physical space do they have?
Skin type Versatility Upgrade Dimension

Alex/YAG combo I–V ++ No +++
IPL/Platform I–V +++ Yes ++
Diode stand-alone I–V + No +
If this is the practitioner’s first machine, choosing a platform with an IPL source
is best. Therefore, the practitioner would be able to provide hair removal, along with
other photo-based treatments. Moreover, the relatively small dimension and the
inclusive contact cool would allow practitioners to provide aesthetic services in the
normal-size treatment room. It is highly recommended not to invest in a stand-alone
IPL but in an upgradeable platform, moreover, to invest in adding the Nd:YAG
modality from the beginning. This way, practitioners could ethically advertise for
LHR since they are equipped with a laser modality.
We recommend an Alex/Tag modality if space is not an issue. These systems are
stable and steady, with long life and many indications. Moreover, spare parts are
available along with plenty of service depots once out of the service contracts.
However, the practitioner should consider that these systems are heavy and not por-
table and require an external force refrigerated air source. Some platforms, such as
GentleMax Pro, are equipped with cryogen spray and forced air-cooling options.
The intuitive interface in new systems is a significant advantage, especially for new
practitioners.
Diode systems, especially the SHR, are very handy for LHR due to their ease of
use and painless treatment option. However, they cannot be used for any other indi-
cations. Therefore, practitioners should be sure that the LHR venue is lucrative
enough to invest in such a system.
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laser hair removal with cryogen spray cooling. Lasers Med Sci. 2022;37:3613–9.
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show/record/NCT04152707.
Chapter 4
Acne Vulguris
Active Acne Vulgaris
Acne vulgaris and its prognosis are caused by several factors; the problem begins
with the pilosebaceous unit, the subepidermal part of a hair follicle [1]. The pilose-
baceous unit consists of the hair strand, the sebaceous gland, and the erector pili
muscle [2].
The Cutibacterium acnes (C. acnes) bacterial growth contributes to the multifac-
torial nature of acne vulgaris (anaerobic strain). The process begins with increased
sebaceous gland activity and a lack of desquamation (the natural process of losing
dead keratinocyte cells) [3]. The hair follicle cavity is clogged with dead skin and
filled with sebum, making it ideal for C. acnes (used to be called P. acnes) colonies
to multiply and form the closed comedones (whitehead) [4]. The hair follicle cavity
is clogged with dead skin and sebum, making it ideal for P. acnes colonies to multi-
ply and form closed comedones (whiteheads) [5]. If the acne lesion is not treated, it
expands and opens to form a blackhead; the oxidation of sebum and melanin causes
the back color of the lesion [6]. As shown in Fig. 4.1, the rupture of the lesion allows
white blood cells to migrate into the inflammatory sac and form more severe acne
manifestations such as papules, pustules, and cysts.
During anti-acne therapy, practitioners typically focus solely on shrinking acne
lesions, overlooking the importance of skincare and hygiene in the efficacy of acne
treatment. Acne-prone skin can be stabilized by maintaining enough moisture and
controlling sebum excretion. It is critical to understand the impact of treatment pro-
cesses on skin parameters to select the optimal care for a given skin and achieve the
greatest treatment effect [7]. In general, the evidence that supports the use of laser
and IPL for acne treatment as a monotherapy is not considered strong [8].

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27632-3_4
154 4 Acne Vulguris
a Normal hair follicle b Whitehead comedone
Hair
Follicular Whitehead
orifice
Skin
surface Enlargement
of follicle
Sebaceous opening
gland Bacteria
Follicle
c Blackhead comedone d Papule
Blackhead Inflammation
White
blood cells
e Pustule f Nodule or cyst
g h i
Fig. 4.1 Different stages of acne lesions. (a) A normal state of a normal sebaceous unit. (b) A
closed or whitehead comedone. (c) An open or blackhead comedone. (d) A papule. (e) A pustule.
(f) A cyst. (g) A histological image of a sebaceous unit. (h) A histological image of a comedone.
(i) A histological image of an inflammatory lesion
Acne Assessment 155
Acne Assessment
Subjective Tools and Questioners
Several tools are available to assess acne severity and treatment efficacy, including
the Leeds and Michelson’s acne severity scores (MASS) [9]. Table 4.1 is a straight-
forward and useful tool published in the British Journal of Family Medicine [10].
Another simple photographic scale has been used extensively since 1979 [11].
See Table 4.2 and Fig. 4.2 to produce a photographic acne assessment.
Objective Tools and Skin Analyzers
Multiple skin analyzers and thermal infrared cameras can be used to assess the
severity of acne and the efficacy of the chosen treatment.
Table 4.1 Assessment of acne with the comprehensive acne severity scale
Grade Description Face Back Chest
Clear No lesion/barely noticeable—a few comedones and papules
Almost Hardly visible from 2.5 m—a few comedones, papules, and
clear pustules
Mild Easily recognizable—less than half the affected area—many
comedones, papules, and pustules
Moderate More than half the affected area—numerous comedones,
papules, and pustules
Sever The entire area—is covered with comedones, papules, and
pustules. A few nodules and cysts
Every Highly inflamed acne that covers the affected area with many
severe nodules and cysts
Table 4.2 Form for global acne grading system

Location Factor F Severity S Local score (F * S) Acne severity
Forehead 2 Nil = 0 1–18 mild
Right cheek 2 Comedone = 1 19–30 moderate
Left cheek 2 Papule = 2 31–38 severe
Nose 1 Pustule = 3 >39 very severe
Chine 1 Nodule = 4
Chest and upper back 3
156 4 Acne Vulguris
Fig. 4.2 (a) Distinctive

facial location for acne a
assessment. (b) Six
locations (I–VI) of the
global acne grading
system [12]
Treatment Options
In this chapter, we will not discuss the underlying causes of acne and its treatments,
as it is not within the scope of this book.
Acne treatments may target one or more of the contributing factors. Several
books and review articles on acne topical and oral treatment have been published.
As a result, we will concentrate on light-based therapies in this section. However,
Treatment Options 157
practitioners should be aware that a single laser or IPL would not be sufficient to
treat mild-to-moderate acne. They are effective when combined with other topical
and systemic preparations [13].
Although lasers have been widely used to treat acne scarring, researchers and prac-
titioners have also investigated laser efficacy in active acne management [14]. In
theory, light-based therapies target bacterial growth, decrease inflammation levels,
disrupt sebum production, and remove dead layers of keratinocytes. However, a
systematic review in 2009 showed that clinical trials did not support the clinical
efficacy of laser in acne treatment [15].
All photo-based treatments we will discuss in this chapter are for mild-to-
moderate acne. Severe cases might require more in-depth analysis or topical or sys-
temic medication.
Mechanism of Action
Photo-based treatments work through photosensitization chemical reactions, down-

grading inflammation, and improving resurfacing [16]. Porphyrins are naturally
occurring organic compounds essential for hemoglobin’s (Hgb) biological function.
However, P. acnes in pustular acne produces high amounts of intercellular porphy-
rins with peak absorbance between 400 and 650 nm [17]. Photo energy turns these
compounds to free radicals with an antibacterial effect [18].
P. acnes is an anaerobic strain that flourishes under the confined inflammatory
environment of acne. Moreover, the anaerobic environment is exacerbated by the
lack of desquamation. Therefore, helping the skin restore its natural development
cycle would help minimize acne lesions [19].
The second target is the enhanced blood supply to inflamed acne, mainly to the
sebaceous gland. IPL targets oxy-Hgb (predominantly found in clinically red lesions
with an absorption peak wavelength of 542 nm). The mechanism of action with
oxy-Hgb is the photothermolysis we discussed previously. Moreover, decreasing
vascularity would also reduce lesion infiltration with inflammatory agents [20].
IPL
As mentioned earlier, inflamed acne lesions contain two chromophores to mediate

the IPL treatment effect: porphyrins and oxy-Hgb. These two chromophores show
absorption peaks at short wavelengths (between 400 and 600 nm). Therefore, IPL
acne treatments focus on short light bands. Moreover, due to restrictions on wave-
length, acne treatment with IPL is mainly indicated for lighter skin types (I–III).
158 4 Acne Vulguris
However, experienced practitioners can use it effectively and safely by adjusting the
treatment parameters such as the cutoff filter, fluence, enhanced cooling methods,
and multi sub-pulses [21]. Although IPL can be used alone, it is more effective
when combined with other agents such as alpha-hydroxy acid, minocycline, and
vitamin A derivatives [22]. It was suggested that IPL could improve acne lesions by
targeting both inflammation and sebaceous glands, as shown in Fig. 4.3 [23].
Wavelengths to Be Used
P. acnes bacteria release porphyrins as part of their active metaplasm cycle.

Porphyrins have four absorption peaks at 410, 540, 580, and 635 nm, and the absorp-
tion decreases as the wavelength increases [24]. Upon light absorption, porphyrins
transfer energy to a nearby oxygen molecule, causing it to transform into a single
oxygen molecule (free radical) that causes local cellular damage, sufficient to kill
P. acnes bacteria.
Similarly, oxy-Hgb shows significant light absorption between 400 and 600, with
three absorption peaks at 418, 542, and 577 nm, as shown in Fig. 4.4a [25, 26].
Since both chromophores have higher absorption at the shorter wavelength, we
should consider the risk of high melanin absorption at the short wavelength and the
significant depth of the targeted lesions. As shown in Fig. 4.4b, the effective wave-
length’s penetration depth does not exceed 1 mm.
IPL systems provide different acne options, such as full-unfiltered intensive blue
light pulse (400–1200) and single or dual cutoff filters. Different IPL systems and
technologies are extensively discussed in Chap. 1.
The unfiltered blue light and the single cutoff filters are available in all IPL sys-
tems. However, dual filtration technology is only available in the newer generation.
The Pulse Time
Blood vessels supplying the sebaceous glands are usually microcapillaries.

Therefore, practitioners should use short pulses to counteract the short thermal
relaxation time (TRT).
The Correct Energy
Most clinical research achieved significant improvement with low fluence around
10 J/cm2. There is a consensus that acne treatment requires multiple sessions (prob-
ably eight weekly). However, treatment should be personalized according to acne
severity, skin type, treatment area, and co-therapies such as topical preparation.
a b
c d
e f
Fig. 4.3 Skin biopsy specimens before and after 6 IPL sessions at a 1-week interval, using an IPL
system with a 400 nm cutoff filter, triple IPL pulse, and fluence of 15–30 J/cm2. The inflammatory
infiltrate after IPL is significantly decreased (b, d, f) compared to baseline biopsies (a, c, e).
Histology of skin biopsy specimens (e, f) shows a significant decrease in surface area of sebaceous
glands after IPL (f) when compared to baseline biopsies (e) (H&E; ×100) [23]
160 4 Acne Vulguris
b
AR VR+ SR PL HR DS+
Blue Green Yellow Orange Red Red
420-1200nm 515-1200nm 535-1200nm 550-1200nm 620-1200nm 690-1200nm
0.1mm
2mm
5mm
Fig. 4.4 (a) Absorption peak of Hgb, melanin, and water for lasers between 400 and 1400 nm. (b)
The depth of penetration for different IPL light spectrums produced by different filters between
400 and 1200 nm
Single Cutoff Filter

The 400 nm filter is the most effective single cutoff for acne treatment. However, it
is associated with a higher risk of side effects in skin type III and up. Recent studies
demonstrated that IPL is an effective therapy for mild papulo-pustulous acne of the
face using the following parameters: wavelength 400 nm, fluence 8–9 J/cm2, and
single pulse mode of 30 ms duration. The protocol used was at least one session and
at most five sessions separated by 2 weeks’ interval, as shown in Fig. 4.5 [27].
Another study by the same authors used IPL to treat moderate-to-severe acne on
the back. The treatment parameters were 400 nm wavelength, 8–9 J/cm2 fluence,
and 30 ms single-pulse mode, as shown in Fig. 4.6 [28].
Table 4.3 lists the recommended acne treatment parameter with a traditional IPL
with a low-cutoff filter and without sub-pulses. The 400 nm filter targets the porphy-
rins in pustulated acne, while the 640 nm works mainly on inflammation.
a b
Fig. 4.5 Nodulocystic acne before (a) and after (b) five sessions of IPL treatment (wavelength
400 nm) [27]
a b
Fig. 4.6 (a) Skin condition before eight sessions of IPL treatment using 400 nm wavelength, 8–9
J/cm² fluence, and 30 ms single pulse mode, and (b) Skin condition after completing the treatment,
showcasing the results of IPL treatment and its effectiveness in hair removal [28]
162 4 Acne Vulguris
Table 4.3 Treatment parameter for inflammatory acne with single cutoff filter, single pulse mode
Skin type Lesion types Passes Fluence (J/cm2) Filter (nm) Pulse width Cooling
I–II Inflammatory 1° 10–18 640–695 100 ms High
I–II Pustular 2° 9–12 400 30–40 ms High
III–IV Inflammatory 1° 9–17 640–695 100 ms High
III–IV Pustular 2° 8–10 400 40–50 ms High
V–VI Inflammatory 1° 8–16 695 100 ms High
V–VI Pustular 2° 6–10 400 50 ms High
One study showed promising results using IPL as monotherapy for acne in skin
type IV. The protocol included at least one session and a maximum of five ses-
sions separated by 2 weeks. IPL therapy was performed in continuous mode with
a cutoff filter ranging from 530 to 1200 nm wavelengths, a fluence of 7.0 J/cm2,
and a pulse width of 3 ms. Six passes of 14.2 J/cm2 (two sub-pulses of 7.1 J/cm2)
fluence were performed over the entire face, followed by six passes of two sub-
pulses (double mode) over the lesion only [29]. A more aggressive protocol
includes using 400 filters with six passes of 7.1 J/cm2 using the continuous mode,
followed by passes using 3.4 J/cm2 over the active lesions, every 2 weeks and then
monthly [30]. Table 4.3 lists the recommended acne treatment parameter with a
traditional IPL with a low-cutoff filter and without sub-pulses. The 400 nm filter
targets the porphyrins in pustulated acne, while the 640 nm works mainly on
inflammation.
Icon Palomar by Cynosure

Handpiece: Max V (purple) with two light bands, 400–700 nm and 870–1200 nm.
Practitioners could target the acne lesion with two consequent shots to reach the
clinical response. Cynosure has discontinued this handpiece.
Fluence and Pulse Width

Skin type I–II: 10–20 J/cm2 and 40–60 ms. It is recommended to reduce the pulse
width to 100 ms with the 20 J/cm2.
Skin type III–IV: 10–15 J/cm2 and 60–100 ms. It is recommended to use a pulse
width of 100 ms with skin type IV.
Skin type V: 10 J/cm2 and 100 ms.
Negative Pneumatic Pressure IPL

Isolaz from Valeant is a unique IPL for acne treatment, along with several other
indications. Its handpiece integrates vacuum and intense pulse light. The vacuum
provides deep cleaning of pores and helps clear the clogged pores. The IPL com-
ponent works similarly to other IPL through broadband between 400 and 1200 nm.
Moreover, the vacuum isolates the treatment area and brings the acne lesion closer
to the light source. This platform is equipped with disposable tips of different
sizes (small, medium, and large) and comes as non-filtered (for skin types I–III)
and filtered (for skin types IV and V). While this device provides advantages in
acne treatment, practitioners should consider the extra cost of disposable
patient tips.
A Dual-Filter IPL
Nordlys by Candela
The PR applicator has dual filters and provides a 530–750 nm light band to target
Hgb and its derivatives (oxy and deoxy) [31]. Moreover, P. acnes produces por-
phyrins as part of its reproduction and metabolism processes, which absorbs light
in the 400–700 nm range and contains five absorption peaks at 410, 505, 540,
580, and 635 nm. The shortest wavelength absorbs the most, while higher wave-
lengths absorb less. Porphyrins react to intense light and produce single oxygen
molecules (free radicals), causing cellular damage at a local level. This level of
damage is adequate to destroy the P. acnes bacteria. The light emitted from the
PR+ applicator includes three of the five wavelengths that cause this effect, 540,
580, and 635 nm. Therefore, the capillaries that supply the acne sebaceous gland
undergo the photothermolysis process. Since the capillaries that supply the blood
to the capillary glands are small, we recommend using two sub-pulses of 2.5 ms
(with a sub-pulse delay of 10 ms) with low fluence 7–9 J/cm2 according to the
skin phototype. The treatment protocol includes 3–4 sessions of IPL, 3 to 4
weeks apart.
Harmony by Alma
The blue non-cooled handpiece of Harmony provides a lower wavelength starting
from 420 nm to better target porphyrins. Table 4.4 shows the recommended settings
for acne treatment using the Alma Harmony.
Treatment instructions:
• Apply ultrasound gel as a coupling medium.
• Position the applicator perpendicular to the skin, and cover the treatment area
with minimal overlap. Use a plastic stencil for individual lesions.
• Endpoint: mild erythema.
• The number of treatments: 8–16.
• Treatment intervals: twice a week over a 4–8-week period.
Table 4.4 Recommended settings for acne treatment using the Alma Harmony
Skin type Handpiece Fluence (J/cm2) Pulse width (ms)
I–III AFT Acne 420–950 nm 8–10 30–40
IV–VI AFT Acne 420–950 nm 7–8 40–50
164 4 Acne Vulguris
M22 Form Lumenis

A recent study showed that a combination of a dual-filter IPL with minocycline was
safe and effective in skin types III and IV. Lumenis’ acne filter sets the spectrum of
400–600 and 800–1200 nm [32, 33]. In one study, the fluence ranged from 10 to
13 J/cm2; pulse width ranged from 4.5 to 5 ms divided into three multi-sequential
pulses; and the pulse delay was kept at 30 ms [34]. Another study found that utiliz-
ing a dual-band filter with fluences ranging from 11 to 13 J/cm2, pulse widths of
4.0–5.0 ms, and pulse delays of 25–40 ms produced significant results, as seen in
Fig. 4.7 [35]. A comparable protocol was used in a double-pulse mode at 3.5–4.0 ms
with a delay of 30–40 ms, and the fluence of the first and second pulses for the
therapy was 9 and 6 J/cm2, respectively. During the therapy, adjustments were made
based on each patient’s age, gender, skin tone, acne and skin type, lesion location,
and level of discomfort [33].
Fig. 4.7 Clinical photos of a male patient showing improvement in acne lesions after treatment.
(a) Before treatment. (b) After five treatment sessions [35]
Comparison of Dual-Filter IPL for Acne
Table 4.5 compares three different IPL systems equipped with dual-filter technol-
ogy for acne treatment.
532 nm KTP Laser
In theory, the 532-nm KTP laser induces photodynamic stimulation of porphyrins

generated by P. acnes and the non-specific collateral thermal to sebaceous glands.
Furthermore, this wavelength is highly absorbed by oxy-Hgb of acne vulgaris
dilated vascular components [36, 37]. However, poor penetration and high melanin
absorption make it difficult to use this acne treatment wavelength. Therefore, most
commercially available 532 nm laser platforms are in the nanosecond and picosec-
ond pulse widths for tattoo removal and are not recommended for acne treatment. A
small study compared the difference between the results of once- and twice-weekly
treatment with the 532 nm KTP laser using 4 mm spot size, 20–40 ms pulse dura-
tion, and 5–12 J/cm2 fluence according to the skin type with significant improve-
ment, as shown in Fig. 4.8 [38].
However, the Q-switch 532 nm laser can offer a superficial peel in skin types I–
II. The treatment uses a 532 nm ns laser with low fluence (0.4–1 J/cm2) and a large
(6.9 mm) spot size.
Table 4.5 A comparison of three different IPL systems equipped with dual-filter technology for
acne treatment
System Handpiece Settings
Harmony Use the blue handpiece Pulse width (30–40-50 ms), fluence (5–8 J/cm2)
from Alma (420–950 nm)
M22 from Special acne dual cutoff 14–20 J/cm2, 3.5 ms double pulse, with 30 ms
Lumenis Filter (500–600, 800– delay
1200 nm) or 560 nm filter 10 to 13 J/cm2; pulse width ranged from 4.5 to
5 ms divided into three multi-sequential pulses,
and the pulse delay was kept at 30 ms
Fluences ranging from 11 to 13 J/cm2, pulse
widths of 4.0–5.0 ms, and pulse delays of
25–40 ms
A double-pulse mode at 3.5–4.0 ms with a delay of
30–40 ms, and the energy density of the first and
second pulses for the therapy was 9 and 6 J/cm2
Nordlys The PR+ handpiece has a 7–10 J/cm2, 2 × 2.5 ms pulses, separated by a
Ellipse wavelength band of 10 ms delay
Candela 530–750 nm
166 4 Acne Vulguris
a b
Fig. 4.8 Appearance of the lesions: (a) at the second control after 532 nm KTP laser treatment, (b)
untreated side of the face [38]
Fig. 4.9 Difference
between the pulse width of
purpuric (0.45 ms) and
non-purpuric (40 ms)
pulsed dye laser
585 and 595 nm Pulsed Dye Laser
While it is the golden standard for vascular lesions, the pulsed dye laser’s acne treat-
ment results are still controversial. PDL treatment can be classified as purpuric or
non-purpuric according to parameters and mechanism of action; the traditional high
fluence and short pulse width causes blood vessel rupture and possibly bruising.
The new systems can heat the targeted blood vessels slowly and include blood coag-
ulation instead, as shown in Fig. 4.9.
Long-Pulsed PDL
Long-pulsed PDL is an effective treatment for inflammatory acne. The treatment

should consist of four or more sessions or longer-pulse duration to decrease the
severity of inflammatory acne [39]. Here are some of the recommended settings
from randomized controlled trials:
1. Low fluence of 3 J/cm2, pulse duration of 350 μs, a spot size of 5–7 mm every 4
weeks for 12 weeks [40, 41].
2. Moderate fluence of 4.5 J/cm2, pulse duration of 3–6 ms, 10 mm spot size; results
are shown in Fig. 4.10 [14, 42].
3. High fluences of 8–10 J/cm2, long pulse duration of 40 ms, 10 mm spot size
[20, 43].
A study showed that combining a standard-dose isotretinoin with PDL was safe
and effective in managing acne-related erythema. Patients received 6 months of oral
isotretinoin (0.25 mg/kg/day) and five sessions of PDL at 2 weeks’ interval utilizing
4.5–5.5 J/cm2, 3 ms pulse duration, and 10 mm spot size. The treatment was admin-
istered in a single pass across the lesions. Mild erythema over acne lesions should
be the preferred outcome [44].
Short Pulse Duration
Gold Toning handpiece of Lutronic Spectra provides low-fluence Q-switched

Nd:YAG laser using the 585 nm (5 mm spot size, 5–10 ns). It is useful for erythema
lesions, inflammatory acne (papules, pustules), and post-acne erythema.
a b c d
Fig. 4.10 Acne improvement. The subject shows improvement from baseline to 12 weeks after the
last treatment under the 7.5 J/cm2 settings (a and b) and the 4 J/cm2 settings (c and d) [42]
168 4 Acne Vulguris
Recommended treatment parameters are 2–4 passes of 0.30–0.55 J/cm2 to three

biweekly sessions. The low fluence penetrates deeply enough into the skin to reach
the targeted minuscule vessels that cause diffuse redness while sparing the deeper
and larger blood vessels, which reduces bruising risk, as shown in Fig. 4.11 [45, 46].
A white paper offered the following protocol using low-fluence Gold Toning ses-
sions (Q-switched, 585 nm, 5–10 ns, 5 mm spot, 0.25–0.40 J/cm2) [47].
a b
c d
Fig. 4.11 Baseline (a and c) and 6 weeks after three sessions of Gold Toning (b and d).
Improvement of acne erythema is better visualized with enhanced red images (c and d) [45]
A new report suggested that the combination of 585 nm Q-switched Nd:YAG

laser therapy with systemic isotretinoin in treating post-acne erythema is safe and
tolerable [48].
1064 Nd:YAG Laser
The 1064 nm Nd:YAG is the most versatile laser in Laser hair removal and the aes-
thetic field. Most Nd:YAG platforms produce 1064 and 532 nm, and all pulse width
is available (ps, ns, μs, and ms) for different applications and indications.
Long and Quasi-long Pulse Width in Millisecond
There is no clear indication for acne treatment for the 1064 nm in acne treatment.
However, it has been suggested that the therapeutic effects of long-pulsed 1064 nm
Nd:YAG laser in acne were due to sebum output reduction associated with seba-
ceous gland thermal damage, gene expression modulation of inflammation, and
reductions of cytokines and inflammatory modulators [49, 50]. There are several
protocols mentioned in the literature using low, intermediate, and high fluence for
acne treatment:
1. Low fluence 2 J/cm2, pulse width 0.3–0.4 ms and 5–7 mm spot
2. Moderate fluence 10 J/cm2, pulse width 30 ms, 12 mm spot size
3. High fluence 30 J/cm2, pulse duration of 5 ms, a spot size of 7 mm
4. High fluence 40–50 J/cm2, pulse duration of 20 ms, Spot size 15 mm [51]
5. Combination of moderate fluence (10 mm spot size, 13 J/cm2 fluence with
0.3 ms) using feathering (painting motion without epidermis cooling) and a
10 mm spot size, 30 J/cm2 fluences with 30 ms focus on the lesion [52]
Short-Pulsed Laser
To use the Q-switched nanosecond 1064 nm, practitioners should utilize an exoge-
nous chromophore such as colloidal carbon suspension; this treatment is called
Hollywood peel or carbon peel. The practitioner should apply the carbon suspen-
sion long enough to allow the carbon particles with the stratum corneum to enter
inside hair follicles. Treatments usually consist of two phases:
1. One pass with a quasi-long laser using a low fluence (1–2.5 J/cm2) with no
overlapping
2. Four passes of 1064 nm Q-switch nanosecond laser with 50% overlap until the
carbon lotion is gone
A recent study found that combining long- and short-pulsed Nd:YAG lasers pro-
vided long-term benefits. The long-pulsed 1064 nm laser had a 10 mm spot size, a
170 4 Acne Vulguris
Fig. 4.12 A 37-year-old woman, with skin type III, received 11 treatments. The lower two pictures
are 12 months after laser therapy was completed [53]
60 ms pulse duration, and energy fluences ranging from 20 to 23 J/cm2, depending

on skin type. The 1064 nm Q-switched Nd:YAG lasers had a 6 mm spot size and
energy fluences ranging from 1.1 to 1.3 J/cm2, depending on the patient’s skin type.
The sessions were scheduled 2 to 4 weeks apart, with longer intervals as the patient
responded. Patients had to receive at least eight treatments. A representative set of
results is shown in Fig. 4.12 [53].
Non-ablative Fractional Lasers
As explained earlier, these lasers target water and do not have any specific acne
chromophore. However, they are associated with the best results in acne treatment.
1450 nm Diode Laser
In a pilot study, the 1450 nm Diode was safe and effective for acne treatment. The
treatment fluences varied from 11 to 14 J/cm2, with 6 mm spot size. The dynamic
cooling device was adjusted to 40 ms to cool the epidermis. A moisturizing lotion
and sunscreen were administered to the affected skin immediately after the therapy.
Treatments were separated by a 4- to 6-week period. Another small study (20
patients) showed that even in Fitzpatrick skin types IV–VI, the 1450 nm diode laser
(a 6 mm spot size; the dynamic cooling device setting was 40 ms at 14 J/cm2 and 45
a b c
Fig. 4.13 Multiple inflammatory papules and a few scattered pustules on the right cheek before
1450 nm laser treatment (a), after three treatments (b), and at the 12-month follow-up (c)
ms at 16 J/cm2) was safe and effective with a significant reduction in the number of
acne lesions seen after the first laser treatment, and this improvement was sustained
12 months after the third treatment, demonstrating significant long-term clinical
remission; results are shown in Fig. 4.13 [54]. Smoothbeam from Candela used to
be available in the North American market. However, it is not available on their
website anymore and has been replaced with the Frax Pro diode laser system with
highly targeted 1550 nm and 1940 nm wavelengths.
1540 and 1550 nm ER: Glass Laser
We discussed the use of the FNAL 1550 nm in melasma treatment. However, it is

also useful in active acne, particularly inflamed acne [35]. One protocol that we
frequently use is the fractional 1550 nm, 150 spot density, and 20–30 mJ/cm2, for a
total of four monthly treatments. The treatment interface widow for Fraxel Dual is
shown in Fig. 4.14.
Practitioners can choose to combine the 1550 nm laser with IPL or Q-switch
laser to help with redness and inflammation.
Fraxel Dual from Solta

Practitioners should follow the general resurfacing parameters for a total of four
sessions. The interval between sessions could be monthly or biweekly, according to
individual healing processes. Most of the 1550 nm applicator uses a rolling wheel
to deliver laser MTZs. To our knowledge, Fraxel Dual from Solta is the only plat-
form that can simultaneously provide both 1550 and 1927 nm lasers during the
172 4 Acne Vulguris
Fig. 4.14 Treatment
interface for Fraxel
1550 nm fractional laser
same pass. The 1927 nm has better resurfacing efficacy, which is much needed in
acne treatment.
The Fraxel applicator has a revolving wheel for easy and continuous movement.
The system suggests the number of passes to achieve the treatment level (MTZ
density). We observed the best results with the coagulation depth of 1–1.5 mm.
Fraxel Dual is an expensive stand-alone system with an extra cost of consumables.
Therefore, new practitioners should consider upgrading their existing systems, if
they have one, before investing in a stand-alone system. On the other hand, the
Fraxel brand name is one of the most established laser brands in the market and
could be used as a marketing tool.
Icon 1540 Fractional Laser from Cynosure

Different applicators have different stamping tips with different spot sizes and treat-
ment dentistry: XD Microlens (12 × 12 mm) provides 25 MTZ/cm2, XF Microlens
applicator provides 115 MTZ/cm2, and the 15 mm tip provides 320 MTZ/cm2.
Table 4.6 shows the specifications of Icon® 1540 fractional laser handpiece and two
different tips XD and XF Microlens.
Table 4.7 lists the average depth of 1540 nm fractional treatment tips for Cynosure
Icon and how applicators differ in terms of microbeam (mB) energy and dimension.
We recommend the following acne treatment parameter: the standard 15 mm XF
(extra fast) with a 50 mJ/microbeam fluence and a pulse width of 15 ms with two
passes with 50% overlap. A total of two treatments, 2–4 weeks apart, is recom-
mended. As the 1540 nm option is an excellent option on the Icon platform, the
1540 nm treatments require multiple passes (1–6) overlapping and rotating to
achieve the recommended density. One study used a similar 1550 nm laser in low-
energy mode (20 mJ/cm2 and 100–169 points per area) in combination with isotreti-
noin to treat acne vulgaris [55].
Table 4.6 Icon® 1540 fractional laser specification

1540 fractional laser
Wavelength: 1540 nm
Pulse width: 10–15 ms
Spot size: 10 and 15 mm
Energy: Up to 70 J/cm2
XD Microlens
Spot size: 12 × 12 mm
Microbeams: 49
Pitch: 2 mm
Microbeam energy: Up to
70 J/cm2
Density: 25 mB/cm2
Depth of coagulation:
1050 μm
Width of coagulation:
300 μm
XF Microlens
Microbeams: 175
Pitch: 1 mm
Microbeam energy: Up to
50 J/cm2
Density: 115 mB/cm2
Depth of coagulation:
700 μm
Width of coagulation:
260 μm
Table 4.7 A list of the average depth of 1540 nm fractional treatment tips for Cynosure Icon®
10 mm tip XD Microlens 15 mm tip XF Microlens
Histology orientation 70 mJ/mB 70 mJ/mB 10 mJ/mB 50 mJ/mB
Average column depth of the 725 1060 600 750
thermal damage
Average column width of the 200 230 125 270
thermal damage
174 4 Acne Vulguris
Alma Harmony XL Pro ClearSkin Pro Er:Glass 1540 nm

Due to restricted penetration depth, visible and mid-infrared laser light may fail to
affect the pilosebaceous units. ClearSkin® radially stretches the acne-affected skin
using an external vacuum (pneumatic) to increase penetration depth. A concurrent
contact cooling of the treated skin may reduce local thermal side effects [56]. This
system might work well for spot treatment, but it would be time-consuming to treat
the full face. Figure 4.15 shows one of the results using ClearSkin®.
Table 4.8 lists the recommended treatment parameters for ClearSkin® acne/acne
scars treatment.
Frax Pro® 1550 from Candela

Frax Pro (Formerly Ydun) is a non-ablative fractional diode laser recently introduced
by Candela to the market. It has similar indications and operations instructions to the
Fraxel Dual, with a more advanced interface that allows users to set the pulse dura-
tion and energy independently. However, practitioners should switch the handpiece
when changing the wavelength. Table 4.9 lists the Frax Pro® specifications.
Table 4.10 compares non-ablative color-blind laser platform settings that might
be used for active acne treatment.
a b
Fig. 4.15 (a) Face of a 25-year-old female patient before treatment. (b) Face of a 25-year-old
female patient 1 month after completing three treatment sessions with ClearSkin®
Table 4.8 A list of the recommended parameters for ClearSkin® acne/acne scars treatment
Fitzpatrick skin Energy Pulse repetition rate # Stacked
type Tip (mJ/P) (Hz) pulses #Passes
I–III 4 mm 400–500 2 2–3 2–3
10 mm 500–600
IV–VI 4 mm 300 1 1–2 1–2
10 mm 400–500
Table 4.9 A list of Frax Pro® specifications

Handpiece Frax Pro® 1550 Frax Pro® 1940
Wavelength 1550 1940
Energy/MTZ 5–100 mJ 5–20 mJ
Pulse duration 1–20 ms 1.5–20 ms
Depth Up to 800 μm Up to 200 μm
Scan width/spot sizes 4–12 mm 4–12 mm
Skin cooling SoftCool™ Integrated Air Cooling SoftCool™ Integrated Air Cooling
Table 4.10 A comparison of non-ablative color-blind laser platform settings that might be used
for active acne treatment
Max Beam
System coagulation (MTZ) Treatment
name Wavelength depth diameter mode Handpieces Features
Fraxel 1550/1927 nm 1.5 mm 63 μm Roller One A stand-alone
Dual® (in-motion) handpiece system, two
Solta with two FNAL
different tip wavelengths,
sizes dynamic
in-motion
treatment mode
only, has
substantial
consumable
use
Microlens® 1540 nm 1 mm 230 μm Static Deep (XD) Part of the Icon
Cynosure (Stamp) and fast platform
(XF) alongside IPL,
handpieces long-pulsed
Nd:YAG and
fractional
2930 nm
ablative laser
ResurFX® 1540 0.15 mm 400 μm Static CoolScan A stand-alone
from (scanner) scanner or part of the
Lumenis M22 platform,
a scanner with
contact cooling
Halo® 1470 NA 205, 370 Roller One Halo Pro was
Sciton and 500 (in-motion) handpiece the first Hybrid
μm with two 1470/2940
fractional fractional
zones of non-ablative/
10 × 10 and ablative
6 × 6 mm handpiece
(continued)
176 4 Acne Vulguris
Max Beam
System coagulation (MTZ) Treatment
name Wavelength depth diameter mode Handpieces Features
Frax Pro 1550 Up to 800 NA Roller (in Frax Pro SoftCool™
Candela μm motion) 1550 Integrated Air
Cooling, diode
laser,
stand-alone
system or part
of the Nordlys
platform
enables the
user to set the
pulse duration
and energy
independently
Hybrid® q 1 mm 400 μm Static Scanner contact
Alma (Scanner) with cooling,
contact Hybrid
cooling 1570/10600
fractional
non-ablative/
ablative
handpiece with
radio
frequency
ClearSkin® 1540 nm NA 600– Static 2 mm Integrated
in Er:Glass 100 mJ/P cooling
Harmony vacuum
Alma The vacuum
can be turned
on/off
Pixel® 1320 nm 2–4 mm Not Static 7 × 7 mm Variable pulse
1320 nm revealed handpiece widths
Nd:YAG with two 30–40–50 ms
from Alma Pixel for darker skin
counts (49 types
and 81)
Choosing a Device for Acne Treatment
Acne is a complex condition, and the evidence supporting the use of IPL and laser
as monotherapy in acne management is as strong as those supporting antibiotics and
vitamin A derivatives. The device of choice is determined by the size of the practice
and the additional benefits that a device may provide in terms of other treatments.
PDL and IPL have the most consensus in terms of efficacy. However, unless you
have a sophisticated dermatology practice with a large number of vascular condi-
tions to treat, you should not add a PDL device solely for acne treatment. For
References 177
practitioners starting a new practice, we recommend starting with an advanced IPL

platform that can be upgraded and customized later based on practice needs and
patient conditions.
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Chapter 5
Hyperpigmentation
The presence of pigments in the epidermis and dermis determines the color of the
skin [1]. The essential pigments in the human skin are melanin in both its types,
eumelanin and pheomelanin [2]. Moreover, other chromophores, such as hemoglo-
bin and bilirubin, also contribute to skin color [3]. Most pigmentary diseases are
caused by abnormalities in the generation or deposition of melanin, either quantita-
tively or qualitatively. However, aberrant fluctuations of other endogenous pigments
and the deposition of foreign pigments can contribute to the development of dys-
chromic lesions [4]. Before proposing a therapeutic approach in general and laser
treatment in particular, it is necessary to consider the underlying pathophysiological
processes that lead to these pigmentary disorders, as well as the location of these
pigments within the skin and their types of distinct chromophores. This chapter will
concentrate on hyperpigmented lesions since these are the most common cosmetic
concerns addressed daily.
Pigmented lesions may be treated using a variety of laser types. The majority of
lasers used for these indications operate based on selective photothermolysis.
Therefore, the ideal wavelengths will target the pigment (in most cases, melanin)
with little absorption by hemoglobin or water. To accomplish a selective laser
action, the pulse duration must be ten times shorter than the thermal relaxation
period of the target. Melanosomes containing melanin are the target lesions for the
majority of hyperpigmented conditions. Their size is around 0.5 μm, resulting in
relaxation times between 1 and 10 μs. The ideal duration of a pulse should be less
than 100 ns. Therefore, most lasers used to treat hyperpigmented lesions are
Q-switched (QS), allowing for short-pulsed durations. The most studied laser for
hyperpigmentation treatment is the Q-switched Nd:YAG laser at 1064 nm. The
595 nm pulsed dye laser (PDL) with compression handpiece reduces the presence
of hemoglobin and allows targeting of melanin. Picosecond lasers for tattoo removal
were introduced almost a decade ago. Several case reports and research have shown
different levels of success in treating pigmentary diseases. The new generation of

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27632-3_5
182 5 Hyperpigmentation
intense pulsed light (IPL) with dual filters and pulse sequencing can also be utilized
to treat pigmented lesions.
Select the wavelength based on the indication being treated.
Step 2: Determine the target’s depth, and adjust the fluence and spot size
accordingly.
Step 3. Determine the patient, and employ a more conservative setting with a
darker skin tone. Consider reducing the fluence and expanding the size of the spot
while treating off the face.
pidermal Pigmented Lesions: Actinic Lentigines

E
and Ephelides
Unprotected sun exposure may cause actinic lentigines, benign hyperpigmented

spots (liver spots or age spots). These localized kinds of benign, flat, uniform
acquired hyperpigmented spots are darker than ephelides and are not affected by
sun exposure. Typically, their size (1 cm) exceeds that of ordinary lentigines
(2–5 mm in diameter). Actinic lentigine histology is shown in Fig. 5.1.
Ephelides, often known as freckles, are tiny, pigmented macules with uneven but
well-defined borders, typically ranging in color from reddish to light brown. They
are mostly sized and distributed uniformly.
Fig. 5.1 Fontana-Masson
staining of normal skin
(top) and actinic lentigine
lesion (bottom), showing
the accumulation of
melanin in the basal layer
of the epidermis [5]
Epidermal Pigmented Lesions: Actinic Lentigines and Ephelides 183
Frequent use of high SPF sunscreens, avoidance of sun exposure during high-
irradiance hours, frequent skin washing, and epidermal barrier protection may pre-
vent the development of new pigmented lesions and may result in the spontaneous
regression of some existing ones. The two primary therapeutic approaches for
actinic lentigines are photochemical and topical treatments. Cryotherapy, laser, IPL,
and chemical peels are examples of photochemical therapies. Not without potential
adverse effects, topical treatment with active ingredients aim to restrict melanin
formation, stop melanocyte bio-stimulation, and reduce melanin distribution to ulti-
mate acceptor cells.
IPL
The IPL spectrum should be chosen according to the depth of the lesion, if possible.
Due to lower penetration, a practitioner should use a lower cutoff point (540 nm) for
epidermal melasma. The deeper lesions at the dermal level are treated with a nar-
rower band (cutoff of 580 nm). The practitioner should use more conservative
parameters when treating melasma, especially with type V and IV, fluence signifi-
cantly lower than what is recommended with LHR. Tables 5.1 and 5.2 compare
selected IPL machines with and without interchangeable filters, respectively.
Moreover, if the platform is equipped with two different handpieces with two
different spot sizes, the practitioner should use the larger spot size when possible. If
the pigmented lesion is smaller than the IPL spot size, it is recommended to use a
shorter pulse width. The recommended fluence is between 10 and 15 J/cm2 and
pulse width between 10 and 20 ms. Then practitioners should adjust the fluence and
pulse width according to the skin type and lesion’s depth.
Pre-treatment Instructions
It is critical to educate patients on the entire treatment process. The information

raises awareness of the treatment procedure and provides the patient with realistic
expectations of what is possible. Remember that the patient is a part of the process
and can impact the outcome, either positively or negatively. Patient satisfaction will
be higher if the patient has the right expectations before treatment. It is critical to
notify the patient of the following:
1. The expected number of treatments required and the expected outcome.
2. The treatment procedure’s timetable, the immediate clinical effects, the visible
effects over the next day or so, and when the final result will be visible.
3. The importance of avoiding sun exposure before and after treatment. Recent sun
exposure by a tanned or darker-skinned patient can easily conceal erythema
(redness), but all patients should be aware that both active sunbathing and unin-
tentional sunbathing (from any outdoor activity) should be avoided.
Table 5.1 Comparison of different IPL systems with interchangeable handpieces
184
System Pulse width Fluence (J/ Train of

name Filter technology (ms) cm2) sequential pulses Cooling Features
®
Nordlys SWT (Selective 0.5–99.5 2–26 Yes (1, 2, 3, and 4 Continuous The workstation can be equipped with
Ellipse Waveband Technology)a, pulses) duration contact cooling long-pulsed Nd:YAG 1064 nm, 1550 nm,
Candela which means that all filters of pulse train (not adjustable) and 1940 nm lasers and five IPL handpieces
are dual cutoff to eliminate 0.5–700 ms for a wide range of applications
light over 950 nm, as
shown in Fig. 5.3a
Icon Palomar MaxG is the only filter 1–100 Up to 81 SurePulse for hair Adjustable It comes with SkinIntel for skin phototype.
Cynosure with a dual cutoff, as removal (20 ms continuous It has three optional laser handpieces: 2940
shown in Fig. 5.3b laser on, 100 ms contact cooling fractional ablative laser, 1540 fractional
SmoothPulse™ b delay, 10 ms laser non-ablative, 1064+ laser handpiece
on) with a Advanced contact cooling that maintains
high-power peak constant 5° temperature during treatments
Harmony All handpieces are Each Static and NA Continuous Advanced Fluorescence Technology (AFT),
Alma equipped with a dual cutoff handpiece has dynamic contact cooling pulsed UVB for hypopigmentation. The
to eliminate light over 950 three pulse (not adjustable) platform can be equipped with a long-pulsed
nm, as shown in Fig. 5.3dc widths to Nd:YAG 1064 nm, fractional Q-switched
choose from 1064 nm, fractional 1540, and 2940 nm laser
under different trademark names such as
ClearSkin, ClearLift, etc.
a
According to Candela, the SWT is a narrowband technology defined by dual filters and sub-millisecond pulses. Table 5.2.1 lists the Nordlys system specifica-
tion. The system has eight Ellipse IPL Handpieces, Frax 1550, Frax 1940, and Nd:YAG 1064 nm with different indications
b
According to Cynosure, the SmoothPulse™ technology avoids energy spikes often used by competing systems to deliver treatment—patient skin stays cooler
and more comfortable without sacrificing efficacy
c
The new platform has several IPL handpieces such as Dye VL PRO 450–600 nm cooled applicator, Dye VL 500–600 nm cooled applicator in a stationary and
in-motion mode, cooled VL-PL 540 nm applicator, and cooled and non-cooled SR 570 nm applicator [6]. According to Alma, Advanced Fluorescence
Technology (AFT) is the new generation of IPL that enables continuous square-shaped pulsing with moderate peak power throughout the entire pulse.
However, a 2007 study did not show a significant difference in results between Lumenis and Harmony IPL
5 Hyperpigmentation
Table 5.2 Comparison of different IPL systems with interchangeable filters

Pulse Train of
IPL-Sq Square pulse 5–100 Static No Continuous A second-
Vydence technologya contact generation IPL that
cooling (not can be added to the
adjustable) Ethera platform
M22 Optimal Pulse 4–20 Static Yes (1, 2, Continuous M22 is a
Lumenis Technology and 3 contact comprehensive
OPT™) and pulses) cooling (not workstation that
Multiple pulse delay adjustable) could be custom
Sequential 5–150 ms built with
Pulsing Q-switched YAG
(MSP™)b and 1565 nm
fractional laser
OPT thin filters,
dual brand filters
for acne and
vascular lesion
BBL Smart Filter 5–200 Static and No Continuous The only IPL with
Joule with Finesse dynamic contact dynamic mode;
Sciton Spot cooling, offers a no-pain
Adapters™ c adjustable, option. SkinTyte
0–30 °C (ST) special filters,
part of the Joule
comprehensive
platform
a
effective therapeutic outcome; and (3) increases the procedure’s safety and efficacy
b
Lumenis claims that OPT provides gentler, more comfortable, patient-friendly procedures with
lower effective fluences • High peak power, shorter pulses—ideal for IPL skin treatments using
photorejuvenation and treatment of benign pigmented lesions • Advanced OPT will also allow
determining the specific fluence per sub-pulse when using Multiple Sequential Pulsing (MSP), for
fine-tuned treatment settings [7]. Lumenis launched the Stellar M22 with three SapphireCool™
lightguides to provide better continuous contact cooling for patient comfort. At the time of writing,
a new version of the M22 with advanced OPT (AOPT) had just been released in China. The ben-
efits of AOPT over OPT are not yet clear
c
According to Sciton, Smart Filter with Finesse Spot Adapters™ provide an easy and quick way to
change filters and reach difficult spots [8]
Other Pre- and Post-treatment Options
We recommend using a bleaching cream before treating skin types IV and V to

reduce the risk of PIH. This reduces light energy absorption in the epidermis (i.e.,
absorption by background melanin) during treatment.
An Accurate Medical History
This should include current and previous medical conditions and information about
any prescription or proprietary medicines and health supplements the patient
intakes. The main reason for doing this is to ensure that none of the conditions or
medications cause hypersensitivity, increase erythema, or interfere with the treat-
ment procedure.
Test Spot
Test shots aid in determining the best therapy settings. They should be produced in
a non-prominent location relevant to the treated region. Examine the patient’s dis-
comfort and the instant skin reaction (clinical endpoint). The predicted therapeutic
outcome is a gradual darkening of the pigment within 1–10 min of light emission
(clinical endpoint). Skin types I and II normally respond within 2 min, whereas skin
types III to V take longer. It is important to note that the pigment will continue to
darken for the next 12 h and will only clear from the skin in 7–12 days. A lack of
skin reaction does not necessarily signal poor treatment settings but rather that a
more effective outcome might be obtained by raising the energy somewhat. If the
skin turns grayish or if the pigment can be wiped off the skin’s surface soon after the
test shot, the energy setting is too high and should be decreased.
Treatment
Push the applicator forcefully on the skin’s surface when treating pigmented lesions.
The curved point of the crystal light guide will press blood out of the superficial
blood vessels as a result. This reduces light absorption by hemoglobin which is
competing chromophores. Because of the utilization of pressure, only a tiny layer of
optical coupling gel is required. When treating over bony areas like the cheekbones,
forehead, collarbone, or sternum, energy should be lowered by 1–2 J/cm2 compared
to a non-bony area. This is because light may be reflected from the bone in these
thin-skinned places, resulting in increased light absorption. Sensitive parts, such as
the neck and throat, should be addressed with similar caution. The expected number
of treatments is 3–6, repeated every 2–3 weeks.
Treatment Parameters
Here are the recommended treatment parameters for epidermal pigmentated lesions
using different IPLs, along with a comprehensive comparison.
Vydence IPL-Sq
This recommendation is for a 540 nm single cutoff filter with a single pulse mode
shown in Table 5.3.
Lumenis M22® IPL
For epidermal pigmented lesions, Lumenis M22® has three different filters. For skin
types I–IV, a single pulse mode is recommended. However, for safety, double sub-
pulses are recommended with skin type V, as shown in Table 5.4.
Table 5.3 A list of recommended treatment settings using IPL-sq® for epidermal pigmented lesions
Skin type Spot size Lesion type Fluence Wavelength Pulse width
I–II 40 × 12 mm Superficial 13–17 J/cm2 540 nm 10 ms
I–II 8 mm Superficial 14–18 J/cm2 540 nm 10 ms
I–II 8 mm Superficial 14–19 J/cm2 540 nm 15 ms
III 40 × 12 mm Superficial 12–17 J/cm2 540 nm 15 ms
III 12 × 12 mm Superficial 13–17 J/cm2 540 nm 15 ms
III 8 mm Superficial 13–18 J/cm2 540 nm 15 ms
IV 40 × 12 mm Superficial 10–16 J/cm2 540 nm 15–20 ms
IV 12 × 12 mm Superficial 13–18 J/cm2 540 nm 15–20 ms
IV 8 mm Superficial 13–17 J/cm2 540 nm 15–20 ms
Table 5.4 A list of recommended treatment settings using Lumenis M22® for epidermal
pigmented lesions
Lesion Pulse Pulse
Skin Fluence Filter # of duration delay Chiller
Type Depth type (J/cm2) (nm) pulses (ms) (ms) default
Lentigines Light Epidermal I 15 515 Single 4 – On
II 15 515 Single 4 – On
III 14 560 Single 4 – On
IV 12 590 Single 4 – On
V 17 590 Double 3 30 On
Dark I 14 560 Single 4 – On
II 14 560 Single 4 – On
III 13 560 Single 4 – On
IV 17 590 Double 4 25 On
V 16 590 Double 3.5 35 On
Harmony
Harmony PRO includes several handpieces that can be used to treat epidermal pig-
mented lesions. We reported the two most commonly used applicators, Dye PRO
and Dye SR, as shown in Table 5.5.
Icon®
Icon is a versatile IPL platform with six different handpieces, each with a single or
dual filter. If practitioners wish to change the wavelength, they should change the
handpiece, a simple plug-and-play process. Practitioners should start with the Lux
Y (Yellow) handpiece with a 525–1200 nm light band. The Lux Y (yellow) hand-
piece has the following parameters:
• Wavelength: 525–1200 nm
• Spot size: 16 × 46 mm
• Fluence: up to 35 J/cm2
• Pulse width: 1–500 ms
• Repetition rate: up to 2 Hz
MaxY®
MaxY® is a single cutoff filter 525–1200 nm with a single pulse mode, pulse width
1–100 ms, spot size 12 × 28 mm, and fluence up to 81 J/cm2. The recommended
setting for the MAXY handpiece is listed in Table 5.6.
MaxG®
MaxG® is a dual cutoff filter that eliminates light between 670 and 870 (wavelength,
500–670 nm and 870–1200 nm), a single pulse mode with pulse width 1–100 ms,
spot size 10 × 15 mm, and fluence up to 80 J/cm2. The recommended setting for the
MAXY handpiece is listed in Table 5.7.
Table 5.5 A list of recommended treatment settings using Harmony PRO® for epidermal
pigmented lesions
Handpiece Fitzpatrick skin type Pulse width (ms) Fluence (J/cm2)
Cooled Dye PRO 500–600 nm I–II 10, 12 10–13
III 10, 12 8–11
IV 12, 15 5–7
Cooled Dye SR 550–650 nm I–III 10, 12 8–12
IV 10, 12 8–11
V 12, 15 5–7
Table 5.6 A list of recommended treatment settings using Icon MaxY® for epidermal
pigmented lesions
Table 5: A list of recommended treatment settings using Icon MaxY® for epidermal pigmented
lesions
Treatment
Skin Indication or Target Suggested Settings
Interval
Type
(weeks)
Pigmented Lesions
Pulse width
15 msec
Face, arms, body 3-4 Fluence 28-36

I-II
Range
Chest, neck, legs, hands 3-4 28-36
(J/cm2)
Pulse width
15 msec
Face, arms, body 3-4 Fluence 20-30

III
Range
Chest, neck, legs, hands 3-4 20-30
(J/cm2)
Pulse width
Shorter pulse widths

40 msec 20 msec
may help treat
Face, arms, body 3-4 resistant lighter

Fluence
IV pigment. As always,
Range 24-36 14-26
Chest, neck, legs, hands 3-4
perform test spots to
(J/cm2)
ensure skin can
tolerate.
Table 5.7 A list of recommended treatment settings using Icon MaxG® for epidermal
pigmented lesions
Table 6: A list of recommended treatment settings using Icon MaxG® for epidermal pigmented lesions
Skin Interval
Indication or Target Suggested Settings
Type (weeks)
Pigmented Lesions
Face
Pulse width msec
Darker, denser pigment
may require a longer
pulse duration; lighter 20 15 10

Longer pulse widths yield milder
pigment may require
Fluence treatments; shorter pulse widths
shorter pulse durations. 3-4
Range 38-50 36-46 34-42 yield more aggressive treatments.
(J/cm2)
Chest, neck, legs, hands,

Pulsewidth msec
arms & body Shorter pulses may help treat
resistant lighter pigment.

I-II
30 20
Fluence
3-4
Range
32-38 30-36
(J/cm2)
Face Pulse width msec

30
pulse duration; lighter
3-4 Fluence
pigment may require
Range 32-44
shorter pulse durations.
(J/cm2)
Chest, neck, legs, hands, Pulse width msec
III arms & body
Shorter pulses may be

30
helpful for treating Fluence
resistant lighter Range

3-4 28-36
pigment. (J/cm2)
Face Pulse width msec

40 30
pulse duration; lighter
pigment may require 4-6 Fluence
shorter pulse durations. Range 30-38 28-36
(J/cm2)
Chest, neck, legs, Pulse width
hands, arms & body. msec

IV
Shorter pulses may
help treat resistant

40 30
lighter pigment.
Fluence
4-6
Range 28-36 26-32
(J/cm2)
Post-treatment Care
The optical coupling gel must be removed after the last shot, and the skin surface
must be dried using a soft towel. To alleviate pain, a cold compress or calming gel
can be administered (but check that the patient has no intolerance to the contents of
the gel). If the chosen energy setting is close to the upper limit, consider immedi-
ately following the treatment with a powerful (group IV) topical glucocorticoste-
roid, such as clobetasol propionate ointment. Erythema will develop and will go
away in a day or so. Additional crusting on the site of the lesion may occur with
shorter-wavelength applicators and dissipate in 1–2 weeks without additional treat-
ment. After treatment, the treated area should not be exposed to sunlight for a few
weeks, and sun protection lotion should be worn (SPF minimum 30, applied several
times per day). The longer this phase lasts, the better the outcome (Fig. 5.2).
Effective IPL treatment for pigmented lesions results in histological changes, as
shown in Fig. 5.3.
a b
c d
Fig. 5.2 Progression of skin reaction with IPL. (a) Before treatment. (b) One day after treatment.
(c) Two weeks after treatment. (d) One month after treatment
a b c d
e f g h
i j k l
Fig. 5.3 Visual and histological changes of a pigment spot of solar lentigines. Pigment spots at
pre-irradiation (a, e, i), 30 min (b, f, j), 24 h (c, g, k), and 7 days (d, h, l) after irradiation of intense
pulsed light were shown (e–h, hematoxylin-eosin staining; i–l, Masson-Fontana staining; ×200).
Masson-Fontana staining methods (i). Sequential histological images revealed a subepidermal
cleft, vacuolization of pigmented basal keratinocytes and melanocytes and the disappearance of
pigmentary incontinence in the papillary dermis at 30 m (f), lymphocytic infiltration in the upper
dermis at 6 h (not shown), degenerated epidermis and cleft enlargement at 24 h (g). Masson-
Fontana staining revealed vacuolated basal keratinocytes and melanocytes (j), degenerated epider-
mis with melanin pigments (k), and crust formation containing abundant melanin with a decrease
in basal cell melanin (l) [9]
Care Following Laser/Light Treatment for Vascular/Pigmented Lesions

1. Use caution when handling hot water, and avoid bathing in extremely hot water
until healed.
2. Apply aloe vera gel or Aquaphor Healing Ointment to the affected area, and keep
it moist until the inflammation subsides and the wound heals.
3. Keep the treated area out of direct sunlight. If exposure to the sun is unavoidable,
use SPF 40 or higher for at least 4 weeks after treatment.
4. Avoid rubbing the treated area with clothing and other sources of irritation.
5. Avoid using hairspray on or near the treated area.
6. Report any prolonged redness, excessive puffiness, or other unusual side effects
to the clinic.
Important facts to remember:

a. The treated areas will experience redness and, on occasion, mild blistering for
several hours to 3–14 days.
b. The treated area may “crust” or “flake” or appear to be a “cat scratch.” This
should be resolved in 3–14 days.
c. Each area to be treated typically necessitates two or more treatments spaced
2–12 weeks apart.
d. Permanent removal of the lesion may be impossible. Even if the lesion is reduced
or “disappears” for long periods (3–6 months), it may reappear in the future.
Because the lesion responded to treatment and was disabled for an extended
period, it almost always means it will respond to future treatment.
e.
e. Medications Dispensed:
use as directed.
Signature of Patient:
Print Name of Patient:
Signature of Person Authorized to Consent for Patient:
Print Name :
Relationship:
Date:
Witness:
Laser
Color-Sensitive Lasers
Long-Pulsed Lasers
Pulsed Dye Laser

PDL is not the optimal laser for pigmentation. However, it can be used for epider-
mal lesions using the parameters reported in Table 5.8.
Table 5.8 A list of recommended treatment settings using 595 nm PDL

Spot Pulse
size duration Fluence Cryogen Retreat
(mm) (ms) (J/cm2) spray (weeks) Comments
7 10 7–8 Off 4–6 Press the lens firmly onto the skin until the
10 10 5–7 Off 4–6 skin turns pale. Clinical
endpoint = darkening or color change at
the treatment site. Observe tissue response
Always start with the lowest fluence, and
observe the lesion for several minutes
before adjusting the fluence
Darker lesions may require lower fluences.
Peri-lesional erythema may occur
Table 5.9 Treatment parameters, pigmented lesions with Alex (755 nm) for Elite+®
Skin types I, II, and III (cooling required only post-treatment)
Skin type Spot size (mm) Fluence (J/cm2) Pulse width (ms)
I–II 5 18–25 0.5
III 5 15–25 0.5
I–II 7, 10 20–24 5.0
III 7, 10 18–24 5.0
Alex 755
The energy density with the highest energy density determined by test spots should
be used. Pulses are delivered linearly, with no more than 10% overlap between
pulses. A second pass over each lesion is advised. Cooling should not be used dur-
ing treatment; however, cooling may be used for patient comfort after treatment.
The parameters to target pigmented lesion with the Alex laser using Elite+ and
GentleMax Pro are reported in Tables 5.9 and 5.10, respectively.
When treating near the eyes, use extreme caution to avoid laser light injury.
Ascertain that the patient is wearing proper eye protection for the wavelength used.
When treating near the eye, always direct the laser beam away from the eye, and
only treat the skin outside of the orbital rim. The skin at the orbital rim can be pulled
away from the eye while the eye shield is held, allowing treatment to take place
outside the orbital rim. Be aware that improper eye protection poses a significant
risk of acute anterior uveitis and possible retinal damage.
Because treatment in the ocular region (below the eyes, the bridge of the nose,
and the temples) requires special attention, it may be easier to treat this area first.
Other sensitive areas, such as just beneath the nose and around the beard, may
necessitate fewer pulses or lower fluences for some patients. Patients should be
instructed to close their mouths when treatments are performed near the mouth to
avoid accidental exposure of their teeth to the laser beam. There will be an ery-
thematous flare, edema, and hyperpigmentation around the treated pigmented
lesions within 5–10 min of treatment, but no bruising. Erythema and edema can last
for several hours. After treatment, lesions should change color within 5–10 min.
Table 5.10 Treatment parameters, pigmented lesions with Alex (755 nm) for GentleMax Pro®
Spot Pulse
Lesion/skin size duration Fluence
type (mm) (ms) (J/cm2) Comment
Seborrheic Treatment of skin types V or VI is not
Keratoses recommended
Skin types 8 3 60–80 Start at the lowest fluence for treatment 1, and
I–IV observe tissue response. Start by treating the
Lentigines, 10 darkest lesions, which require lower fluence.
ephelides Lighter spots may require higher fluence
Skin types 3 30–60 Clinical endpoint: darkening of the lesion and
V–IV 12 3 30–40 perilesional erythema
Cryogen is generally not used for the treatment of
benign pigmented lesions. For some patients,
some cryogens may be beneficial. A cooling
method such as a cool gel pack or cold compress
may be used for brief pre- and post-laser
epidermal cooling
Lentigines, 12, 15 3 12–30 Endpoint: typically, slight popping of the skin and
ephelides 18 3 12–20 slight white-to-gray discoloration immediately
Skin types post-laser pulse, followed by slight erythema
I–III The distance of the handpiece to the skin should be
varied dependent upon the laser-tissue interaction
observed, starting at 1–2 cm off of the skin
Q-Switched Short-Pulsed Lasers
The pulse width gets 1,000,000 shorter as we move from the millisecond to the
nanosecond range (5–7 nm). As a result, the nanosecond range pulses have a much
higher energy peak [10]. The nanosecond laser is suitable to heat small targets with
a short thermal relaxation time. The heat buildup is rapid enough to overcome the
TRT and reach a clinically significant temperature. The indications of the Q-switch
lasers are simple and advanced pigmentation correction, photorejuvenation, and tat-
too removal. More importantly, as discussed before, laser shows significant photo-
acoustic properties at this short pulse width. Some systems have the quick
pulse-to-pulse mode (Q-PTP), enabling greater energy delivery by shooting two
pulses 80 μs apart to enhance the laser’s safety and tolerability [11].
The most commonly used laser for treating dermal and epidermal pigmentation
is the 532 and 1064-nm Q-switched Nd:YAG laser.
Table 5.11 list names of selected Q-switched laser devices, along with their
parameters.
Some modular platforms can be equipped with a Q-switched nanosecond appli-
cator, such as Lumenis M22® and Harmony PRO®, as shown in Tables 5.12 and
5.13, respectively.
We recommend the following treatment settings:
• Dermal lesions: 1064 nm, up to 5–7 J/cm2 and 7 mm spot size
• Epidermal lesions: 532 nm, spot size with a fluence of 1.2–1.5 J/cm2, a pulse a
3 mm spot size
Table 5.11 Comparison of four different 1064 nm Q-switched laser systems

System Fluence
name Wavelength Pulse width range Handpieces Features
Alma Q 532, 585, 640, Q-switched, Max single Zoom (1–7 mm), Long-pulsed and
and 1064 nm long and pulse collimated quasi-long-
quasi-long energy is (8 mm), square pulsed, fractional
0.45 J and (5 × 5 mm), and handpiece
1.2 J for fractional (add-on), Q-PTP
532 and (7 × 7 mm)
1064
Lutronic 532, 585, 640, Q-switched, Max single Collimated Q-PTP
Spectra and 1064 nm and pulse (2–8 mm), gold
quasi-long energy is toning 5 mm
0.45 J and handpiece
1.2 J for
532 and
1064
Fotona 532, 585, 640, Q-switched, Max single Collimated Adaptive
StarWalker and 1064 nm long and pulse (2–8 mm), Structured Pulse
quasi-long energy is fractional (ASP)
10 J for 532
and 1064
Cynosure 532, 585, 640, 300 ps Max single Collimated Q-PTP
RevLite and 1064 nm pulse (3–8 mm)
energy is
0.45 J and
1.2 J for
532 and
1064
Table 5.12 A list of specification of Harmony PRO ClearLift®

Spot size Pulse Pulse frequency
Wavelength (nm) (mm) width (Hz) Energy density/fluence/depth
1064 1, 2, 3, 4, 20 ns 1, 2, 4 600–1200 mJ/p
5, 6
1064 5 × 5 pixel 20 ns 1, 2, 4
532 2, 3, 4 KTP 20 ns 1, 2, 4
1064 5 × 5 pixel 20 ns 1, 2, 4
532 2, 3, 4 mm 20 ns 1, 2, 4
KTP
1064 5 × 5 roller 20 ns N/A
1064 7 × 1 roller
Table 5.13 A list of Wavelength 1064 nm

specifications for Lumenis
M22 Q-switched applicator
Spot size 2, 2.5, 3.5, 4, 5, 6, and 8 mm
Melasma 197
Melasma
Dyschromia is a major cause of aesthetic consultation, especially in people of

diverse hereditary [12]. Melasma and PIH count for almost half of the consultations
in our daily practice. They are common chronic hyperpigmentation condition that
primarily affects female patients in sun-exposed areas [13]. It manifests as symmet-
ric, with brownish-gray patches on the face, mainly the forehead and cheeks and
less frequently on the neck, chest, and forearm, as shown in Fig. 5.4 [14]. Melasma
is also known as “the mask of pregnancy,” as its first signs are safe and commonly
associated with pregnancy or relapse during pregnancy [15].
Melasma is a cosmetic concern without any medical prognosis; however, it might
impact self-perception. It mainly affects females with skin type IV, which makes
treatment even more challenging [16].
Assessment
The mMASI is the most common melasma assessment method. The calculation of
mMASI is shown in Fig. 5.5.
In the above formula, A represents lesioned area: when the cumulative lesion
area is <10%, 1 point is assigned; 10% to 29%, 2 points; 30% to 49%, 3 points; 50%
to 69%, 4 points; 70% to 89%, 5 points; ≥90%, 6 points. D represents color depth:
none, 0; mild depth, 1; moderate depth, 2; obvious depth, 3; and severe depth, 4. lm
indicates the left cheek; rm., the right cheek; f, the forehead; and c, the chin.
Fig. 5.4 Melasma
manifestation on the
forehead
Fig. 5.5 mMASI calculations
Managing Patient Expectation
Melasma treatment is challenging, with a high relapse rate. While light-based treat-
ments for melasma are promising, rebound hyperpigmentation and PIH are reported
in more than half of the clients treated [17]. Therefore, we highly recommend not
using light-based treatments as monotherapy but as a part of a comprehensive proto-
col that includes lightening topical preparations, antioxidants, and gentle resurfacing.
I have met many practitioners and patients frustrated with melasma management
after following protocols reported in many laser platform operation manuals.
Therefore, it is essential to do your research and cite trusted peer-reviewed proto-
cols. Moreover, it is crucial to inform the clients that you can cure their melasma but
can help to blend it with the rest of the skin on the face for a limited time. Sooner or
later, most clients will notice that melasma patches have reappeared. Therefore,
practitioners should manage melasma patient expectations in terms of results, cost,
length of treatment, and maintenance.
Etiology
Without a definitive etiology, melasma results from multiple factors, including sun
exposure, hormonal alterations, and genetic predisposition [18]. These factors
induce changes in the affected melanin production and distribution and vascularity
around the lesion [19], as seen in Fig. 5.6 [20]. The intensity of the discoloration is
not constant but usually changes over time. Moreover, patients with melasma might
experience relapses after treatment due to recurrent exposure to the inducing factors
such as UV exposure, heat, and stress.
Melasma 199
Fig. 5.6 Histology of

melasma shows an increase
in epidermal melanin in the
basal and suprabasal cells
as pigmentary caps [20]
Classification
Melanosome production and transfer can increase at different depths [21].

According to the hyperpigmented patches depth, we can classify melasma into
three categories: epidermal, dermal, or mixed. Knowing the depth of melasma
would help formulate a complete treatment protocol [22]. Wood’s lamp is an
easy and inexpensive method to determine the depth of melasma. This lamp is a
handheld device that emits long-wave UV light. The interaction between the
melasma lesion and the UV light differs according to the depth of melasma. If
the melasma is epidermal, the discolored patches glow under the lamp with a
distinguished boundary from the rest of the skin (light accentuation), as shown
in Fig. 5.2 [20].
However, dermal depth melasma does not glow any more than the rest of the
skin. Mixed melasma is harder to diagnose with Wood’s lamp, and practitioners
might need to use a more advanced skin analyzer [23]. The depth of melasma is a
crucial factor in determining the treatment protocol.
Treatment
The first step toward treatment protocol is to collect melasma information, such as
the first occurrence, risk factors, other comorbidities, and treatment history. The
second step is eliminating risk factors such as sun exposure [24] (Fig. 5.7).
Epidermal melasma is usually easier to handle than dermal and mixed melasma.
However, it is essential to manage clients’ expectations, as we do not permanently
correct melasma’s underlying cause. Therefore, they should expect a relapse some-
time in the future.
Fig. 5.7 Three different cases of melasma diagnosed with Wood’s lamp and correlated with der-
moscopy; (a) epidermal, (b) dermal, (c) mixed [20]
Topical Agents
Most clients usually start OTC topical bleaching formulae before seeking profes-
sional help. This topical preparation may temporarily improve the condition, but
melasma patches often return [25]. Moreover, it is necessary to discuss the risk of
prolonged and frequent use of bleaching cream, such as hypopigmentation in the
surrounding skin and loss of effectiveness (tolerance or tachyphylaxis). Moreover,
Melasma 201
most clients experience a rebound effect after prolonged topical preparations, as the
discoloration gets worse and more resistant.
Active Ingredients and Mechanism of Actions
Most melasma topical preparations contain a combination of different active ingredi-

ents with different mechanisms of action. Hydroquinone (with or without steroids) is
the primary active ingredient in all lightning preparation [26, 27]. It is a tyrosinase
inhibitor that disrupts the enzymatic processes of pigment production within melano-
cytes. The principles of therapy include the inhibition of pathways. Other agents that
inhibit melanin production include arbutin, azelaic acid, and kojic acid. Ascorbic acid
is also another inhibitor of melanogenesis through its antioxidant effects [28]. These
ingredients can be used alone or with a peeling agent that increases skin turnover,
such as retinoic acid. Some less frequently used agents downsize the interaction
between melanocytes and keratinocytes, thus transferring melanosomes. Kligman’s
formula is frequently used in the field of hyperpigmentation; it contains 0.1% treti-
noin, 5.0% hydroquinone, and 0.1% dexamethasone in a hydrophilic ointment [29].
Indication
Bleaching topical treatment is used alone or with photo treatment for correcting
melasma lesions. While it might be effective independently in epidermal melasma,
topical therapy is less likely to be effective in dermal melasma. However, different
studies showed that photo treatment of melasma showed better results and less
rebound effect when proceeded with a topical lightening agent [30]. Therefore,
practitioners should provide clients with lightening cream to use for at least 2 weeks
before the laser treatment for three reasons:
1. Minimizing the rebound effect after laser exposure
2. Improving the contrast between melasma lesions and the surrounding skin
3. Decreasing the density of the chromophore, especially in darker skin types
There are numerous topical preparations with single or multiple active ingredi-
ents of different efficacies. The practitioner should choose the potency and concen-
tration of the topical preparations relative to the whole protocol and treatment plans,
such as length of treatment, skin type, depth of melasma, and combination.
This book will focus on the triple combination cream (TCC) that contains 4%
hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide. We recommend
using the TCC cream once daily, starting 2 weeks before the first IPL treatment and
4 weeks after the last one. The practitioner should provide the following instructions:
1. Apply once daily at bedtime starting 2 weeks before the treatment.
2. A client can increase the application time gradually to avoid any side effects.
Stop the cream if you notice itchiness and redness, and contact your healthcare
provider.
3. Clean and dry the face before the application and first thing in the morning.
4. Apply a thin layer on the pigmented lesion, and spread sparingly to the surround-
ing skin.
5. Stop for 1 day before and after the IPL treatment.
6. Keep using the cream for 4 weeks after the last IPL treatment.
7. Please do not stop the cream abruptly, and wean it off over 2 weeks.
Light-Based Treatments
IPL
Intense pulse light carries several advantages over single-wavelength laser in

melasma treatments. The broad spectrum of IPL allows targeting both vascular and
pigment components of melasma. Due to the gradient depth penetration, the IPL
also targets the pigmented lesion at the epidermal and dermal depths. IPL’s main
disadvantage in melasma treatment is the pulse width of the millisecond range. As
discussed earlier, melanosome’s TRT is in the nanosecond range. Therefore, the
IPL might deliver an unnecessarily heating effect, which results in bulk heating and
PIH, especially in darker skin types (VI and V). However, a study showed that
using a low fluence of 10 J/cm2 with nanosecond pulse duration was safe and effec-
tive in skin types VI and V (this technology is not available in North America
yet) [31].
Lumenis M22®
Lumenis M22 has the advantage of using the double-pulse technique (Multi
Sequential Pulsing). It is recommended to use a 3 ms pulse duration, with a 30–40 ms
delay and a fluence of 14–18 J/cm [32]. A recent case study employed the M22® IPL
at 640 nm, with an initial pulse width of 6.0 ms /6.0 ms /7.0 ms and initial fluence
of 5 J/cm2–5 J/cm2–5 J/cm2. The patient got a total of eight treatments, and the
mMASI and satisfaction levels were measured before, after, and 4 months following
the end of the entire treatment cycle. The patient was instructed to use sunscreen and
a topical human-like collagen repair dressing. The pigmentation lightened, and the
general skin tone brightened after three treatments; the pulse width was modified to
6.0 ms and the fluence to 6 J/cm2–6 J/cm2–5 J/cm2. After two further treatments with
the altered settings (for a total of five treatments), the affected region was substan-
tially lighter, the area of melasma lesions was reduced by almost 80%, the mMASI
score was lowered to 9.0 points, and the satisfaction score was 6 points. The pulse
width increased to 5.0 ms–6.0 ms–5.0 ms and the fluence to 7 J/cm2–7 J/cm2–6 J/
cm2. After eight treatments, the area of melasma lesions decreased by approximately
88%, the complexion seemed lighter, the mMASI score dropped to 6 points, and the
satisfaction level increased to 9 points. Four months after the end of the entire
Melasma 203
a b c d
Fig. 5.8 Progression of melasma treatment using combined IPL with AOPT and a skin barrier
repair agent, employing the M22/AOPT instrument. The images display the patient’s skin at differ-
ent stages of the treatment: (a) before treatment, (b) after the fifth session, (c) after the eighth ses-
sion, and (d) four months after completing the treatment. A wavelength of 640nm was used, an
initial pulse width of 6.0ms/6.0ms/7.0ms and an initial energy of about 5 J·cm-2/5 J·cm-2/5 J·cm-2.
After 2 courses, the pigmentation became lighter and the overall skin tone was brightened, the
pulse width was adjusted to 5.0ms/6.0ms/6.0ms and the energy to 6 J·cm-2/5 J·cm-2/5 J·cm-2. After
3 more courses under the adjusted parameters (ie, after a total of 5 times of treatments), the pulse
width was further adjusted to 5.0ms/5.0ms/5.0ms and the energy to 6 J·cm-2/6 J·cm-2/6 J·cm-2.
AOPT advanced optimal pulse technology [33]
treatment period, the area of melasma lesions had not expanded, and the mMASI
and satisfaction scores remained at 6 and 9, respectively, as shown in Fig. 5.8 [33].
Lumecca from InMode
The standard IPL delivery is only 10% within the 500–600 nm range. However,
Lumecca IPL from InMode provides 40% of the pulse energy between 500 and
600 nm with a minimum of 1.5 ms pulse widths for better efficacy and safety. The
515 SR applicator is used for vascular lesions and the 580 SR for pigmentation and
melasma.
Specifications
515 SR 515 SR
Lumecca
Wavelength 515-1200 nm 580-1200 nm Standard IPL
Absorption(1/cm)
Spot size 30 mmx10 30 mmx10

mm mm
Fluence 5.30j/cm2 5.30j/cm2
Pulse duration 1.5-15 msec 1.5-15 msec
Light cooling
10-20°C 10-20°C
Guide
300 400 500 600 700 800 900 1000
Repetition rate 1 PPS 1 PPS
Wavelenght,nm
418 542 577

PL+ 400-720 nm
Absorption (Linear scale)
PR+ 530-750 nm
VL+ 555-950 nm
HR+ 600-950 nm
HR-D+ 645-950 nm
300 400 500 600 700 800 900 1000 1100 1200
wavelength (nm)
Fig. 5.9 Different filter characteristic of Nordlys Ellipse
Nordlys Ellipse by Candela

The IPL part of the Nordlys platform is the Ellipse with PR 530 applicator that emits
530–750 nm (peak wavelength of 661 nm) with a relativity short 2.5 ms dual pulse
with a 10 ms delay time. According to the skin type, the recommended interval between
treatments is 4 weeks, with an average fluence between 5 and 8 J/cm2. The low fluence
with a narrower band could allow treatment without active cooling (Fig. 5.9).
One study reported using the Ellipse IPL with 2.5 ms double pulse and 10 ms
pulse delay and low fluence of 8.0–9.4 J/cm2 with topical preparation of tranexamic
acid 2% to be safe and effective.
Cooling
We recommend using an external cooling device (a chiller) to cool down the lesion
area for 5 min before the treatment. Moreover, keeping the external cooling tool to
aid the internal IPL sapphire reduces PIH is recommended.
The Treatment Parameter

We recommend increasing the fluence rather than the pulse width to achieve the
clinical endpoint. After the treatment, the lesion will get darker and crust and then
shed off in 2 weeks.
Clinical Endpoint
Practitioners should notice a darkening or color change at the treatment site, which
might take up to 15 min. Always start with the lowest fluence, and observe the lesion
for several minutes before adjusting the fluence. Darker lesions may take 24 h to
show a clinical response, so be patient, and start with low fluence.
The clinical endpoint is a slight color change, which might take up to 15 min
after skin type I–III treatment. However, it might take up to 24 h in skin types
IV–V. Therefore, practitioners should deliver the first shot and observe the clinical
manifestations patiently before adjusting. Reactions considered normal immedi-
ately after the treatment are moderate erythema around the lesion and darkening of
Melasma 205
the lesion with no change to adjacent skin. On the other hand, the absence of these
effects does not imply inefficacy of the set parameters.
Q-Switched Nanosecond Lasers
The nanosecond pulse width is more suited to the melanosomes’ TRT. Multiple
lasers are now available as Q-switched nanosecond lasers, such as 694 nm ruby,
755 nm alexandrite, 585 nm pulsed dye, and 532 nm or 1064 nm Nd:YAG. The
main advantage of the Q-switched laser is the ability to produce high-intensity laser
beams with short pulse durations, a one-million fraction of the IPL pulse. Moreover,
at nanosecond pulse widths, lasers exert photoacoustic vibration. The vibration
oscillates, and fragments targeted lesions into smaller particles, enhancing elimina-
tion (particularly effective tattoo removal). Despite the appealing theory, studies
have shown that Q-switched nanosecond lasers (except the 1064 nm) are ineffective
in melasma. The only Q-switch penetrating deep enough to treat dermal melasma is
the 1064 nm Nd:YAG. Other Q-switched lasers are only useful in epidermal
melasma due to superficial penetration. Until 2012, the only Q-switched nanosec-
ond laser that was FDA approved for melasma treatment was the dual-pulsed (532,
1064 nm) low-fluence Q-switched 5 ns Lutronic Spectra. Using a Q-switched nano-
second laser is not recommended to treat melasma in a patient with a skin phototype
higher than IV. Even with the low-fluence 1064 nm Q-switched nanosecond laser,
the melasma recurrence after 3 months is higher than 80% if used as a monotherapy.
Therefore, similar to IPL, we highly recommend topical lightening preparations
starting 2 weeks before the laser treatment. One main disadvantage of using
Q-switched nanosecond lasers is that it requires weekly sessions over 3 months (12
sessions). It has been shown that adding oral tranexamic acid may enhance efficacy
and reduce PIH risk [34]. A recent meta-analysis assessed the efficacy of low-
fluence 1064 nm Q-switched Nd:YAG laser for treating melasma and recommended
a combination over laser monotherapy [35]. Laser toning (subcellular selective pho-
tothermolysis) has replaced the traditional Q-switched laser in the last decade. The
treatment protocol included a low fluence (<3 J/cm2), 1–2 weeks’ treatment inter-
vals, and large spot size and leads. Laser toning degrades intracellular melanosomes
while leaving melanocytes intact, resulting in reduced inflammation and undesir-
able consequences such as guttate hypopigmentation and PIH. As a result, low-
fluence laser treatment is preferred to typical Q-switched protocols for melasma,
particularly in dark skin phototypes [36, 37].
Another recent research involved 40 Polish ladies with Fitzpatrick skin photo-
type II–III and melasma treated with a 1064 nm Q-switched laser (pulse duration 5
ns; spot size 6–8 mm; fluence 1.7–3.2 J/cm2; 2–8 passes) of a total of nine treat-
ments. The whole face was treated with two passes; then pigmentation patches were
treated with extra four to eight passes. Treatments were repeated at weekly or
biweekly intervals. Seventy percent of participants said the laser met their expecta-
tions for treating melasma. One year of clinical follow-up revealed that the decreased
melasma impact was still present. Patients also reported better skin conditions (radi-
ance, smoothness, brightness, hydration, regeneration), as shown in Fig. 5.10 [38].
One study suggested combining the Q-switched 1064 nm with a quasi-long pass
of the same wavelength as follows: The first pass was performed with a Q-switched
B1 B2
Fig. 5.10 36-year-old female with melasma (Fitzpatrick type III) who received nine laser treat-
ments. (b1) Before treatment and (b2) 1 year after the last treatment [38]
low fluence of 2.1–2.5 J/cm2 at 10 Hz and then with a pass with 7 mm spot size,
0.3 ms, and fluence of 15–17 J/cm2 at 5 Hz [39].
Endpoint
The clinical responses are mild erythema and slight color change. The practitioner
should know that the clinical response may not appear directly after the treatment,
especially with skin types V and IV; the clinical manifestation delay could be up to
15 min. Therefore, practitioners should give enough time between the passes to
observe the treatment endpoints.
Treatment Parameters
Q-switched nanosecond lasers have a fixed pulse width. However, these are the
parameters as reported in the Lutronic Spectra operating manual:
• Wavelength: 1064 nm Nd:YAG
• Spot size: 7–8 mm (we highly recommend using only the 8 mm spot size with
darker skin type)
• Fluence: according to the skin type, skin types I–II should be treated with fluence
between 1.5 and 1.8 J/cm2. Skin types III to V should be treated with fluence
between 1 and 1.5 J/cm2
One protocol repeatedly mentioned in the literature is the following: 1064 nm
Q-switched Nd:YAG laser of pulse energy of 1.6–2.0 J/cm2, pulse duration of 5–10-ns,
7 mm spot size, 10 Hz, and 2000 shots with appropriate overlapping. The energy was
not delivered in one go but using a train of two pulses 0.8–1.0 J/cm2 and 80 μs intervals.
Melasma 207
Do not use the nanosecond lasers as monotherapy due to the higher risk of PIH
and rebound rate 3 months after the treatment. Do not treat melasma with nanosecond
laser as a monotherapy, and always supply the patient with the TCC to be used for
2 weeks before the first sessions. Moreover, we found it very useful to perform soft
peels every other week to help resurface the skin. It would be beneficial to alternate
the nanosecond laser with an FNAL if practitioners access different laser platforms.
Combination with Tranexamic Acid

Several studies investigated Q-switched nanosecond lasers to complement
tranexamic acid (TXA) treatment [40]. One study compared the combination of
Q-switched Nd:YAG laser with oral TXA delivery to laser therapy alone. The
mMASI improved considerably in both groups, with better results in the combina-
tion group. Furthermore, the laser monotherapy group showed a lower dropout rate.
Treatment parameters included a fluence of 2.0 J/cm2 and a spot size of 7 mm [41].
Picosecond Lasers
These platforms exert their effect via photothermolysis and photoacoustic vibration.
Using the term “Pico” in the terminology has more marketing than practical bene-
fits. The first picosecond laser has a pulse width of 750 ps, closer to the nanosecond
range. Therefore, most experts do not recognize PicoSure from Cynosure as an
actual picosecond laser. PicoWay, a second-generation picosecond laser from
Candela, has half the pulse width, between 350 and 450 ps. Yet, the pulse width is
still shy of an actual single-digit picosecond pulse width. Like the nanosecond laser,
the 1064 nm Nd:YAG is the most used wavelength in melasma. Other available
wavelengths are 532 and 755.
Our experience and literature search showed that the picosecond laser is promis-
ing in tattoo removal and general skin rejuvenation. However, it has very little to
add to melasma treatment over the Q-switched nanosecond lasers. In our opinion,
practitioners should not use short-pulsed lasers (nano- and picosecond) as melasma
monotherapy due to the high risk of rebound hyperpigmentation and PIH (over 50%
of treated patients).
In 2019, a panel of experts published guidelines for using PicoWay laser in skin
color. The guidelines were published as a supplement to practical dermatology and
sponsored by Candela (PicoWay). Here are the recommendations related to melasma
and PIH treatment:
Wavelength: 1064 nm
Fluence: 0.16–1.2 J/cm2
Spot size: 6 mm
We recommend using a single pulse, waiting enough time before firing the next
shot, and utilizing proper cooling techniques to reduce heating, making treatments
more comfortable and possible hyperpigmentation. A study found that using a frac-
tional picosecond 1064 nm laser in conjunction with 4% hydroquinone was more
effective and much better than using 4% hydroquinone alone to treat melasma. The
participants were subsequently treated with the following settings using a non-
ablative fractional picosecond 1064 nm laser (PicoWay®): 1064 nm laser, resolve
fractional mode, 100 dots per 6 mm diameter, fluence 1.3–1.5 mJ per microbeam,
pulse duration 450 ps, and 4% coverage per pass. Each patient received two passes
until mild erythema occurred as an endpoint with a total of 400–1000 shots [42]
(Fig. 5.11).
a
29 patients with Fitzpatrick skin type IV enrolled
All Taiwanese female with melasma
Randomly assigned for interventions
Informed consent signed
Group A1 Group A2 Group B

9 patients 11 patients 9 patients
Group A1 Group A2 Group B

9 patients completed 11 patients completed 6 patients completed
the study the study the study
b
Baseline
evaluation 1st evaluation 2nd evaluation
W0 W4 W8 W12 W20
A1
1st Laser 2nd Laser 3rd Laser
Baseline
evaluation 1st evaluation 2nd evaluation
W0 W4 W8 W12 W16 W20
A2
1st Laser 2nd Laser 3rd Laser 4th Laser 5th Laser
Fig. 5.11 (a) Study design. (b) Both laser groups had laser sessions every 4 weeks and Melasma
Area and Severity Index (MASI) score and VISIA® evaluations at baseline week 12 and week 20
Melasma 209
Recent research proposed using a fractional 755 nm picosecond laser (diffractive

lens array) with a fluence of 0.4 J/cm2, an 8 mm spot size, and a pulse duration of
750 ps to cure melasma in darker skin types. The fluence of high-energy zones
(microbeams, 10% of tissue) was projected to be around 2.8 J/cm2, while 90% of
tissue (low fluence background) got only 0.13 J/cm2 [43]. The study design and
representative results are shown in Figs. 5.12 and 5.13, respectively.
A similar controlled trial compared traditional flat and refractory lenses utilizing
PicoSure devices. A pulse duration of 750 ps was supplied through an 8 mm spot
size with an average fluence of 0.40 J/cm2 at 2.5 Hz for two passes without pulse
overlapping under a cold air-cooling system. Over the flat laser, the ultrashort laser
showed significant improvement without any benefit for a refractory lens, as shown
in Fig. 5.13 [30]. Table 5.14 shows results of a 2020 systemic review of using ultra-
short pulse laser in melasma treatment.
Fractional Non-ablative Laser (FNAL)
These lasers have become the treatment of choice for several aesthetic indications,
including melasma. If used with optimal parameters, these lasers can be used safely
in skin types V and VI. Fractional platforms divide the laser beam into microscopic
thermal zones (MTZ) that range in diameter between 100 and 400 μm. We have
mentioned that the smaller spot size results in less penetration due to scattering (mm
range). However, this is not applicable in the μm range. The depth of the penetration
of an FNAL depends mainly on the fluence and wavelength. The MTZs are sepa-
rated by untreated skin areas, which help fasten skin regeneration and reduce down-
time. Some platforms have fixed MTZ density (15 or 25%); others allow the
a b c
Fig. 5.12 Melasma in a 40-year-old woman. Front view. (a) Baseline MASI score, 4.7. (b) After
three sessions of picosecond 755 nm alexandrite laser with diffractive arrays. MASI score, 3.0. (c)
Three-month follow-up after the third laser session. MASI score, 2.4
a b
c d
Fig. 5.13 55-year-old woman (skin type V) with mixed-type melasma (a) at baseline on the left
side, (b) at 1 month after five treatments with 755 nm picosecond laser without DLA (flat optics),
(c) 3 months after treatment, and (d) 6 months after treatment; (e) at baseline on the right side, (f)
at 1 month after five treatments with 755 nm picosecond laser coupled with DLA, (g) 3 months
after treatment, and (h) 6 months after treatment. Note the continued improvement from 1 to
6 months after the final treatment. DLA Diffractive lens array; FST Fitzpatrick skin types
Melasma 211
e f
g h
Table 5.14 A result of a 2020 systemic review of using ultrashort pulse laser in melasma
treatment [44]
Author/date Lesion N Study type Skin type Settings Results Complications Device Fractionated
Lee Melasma 3 Case series IV 755 nm 550 ps Fair to good No post- Picosure No
et al. [56] 6 mm spot improvement treatment
erythema noted
0.57 J
6–14 sessions
spaced 2 weeks
apart
Choi Melasma 39 PRLC III–V Split face with 2% Colorimeter: No incidence of Pico+4 No
et al. [57] HQ as control significantly more rebound or PIH
lightening on the
laser side 1 week,
1 month,
2 months, and
3 months after
treatment
1064 nm: MASI: significant Dermatitis 5%
7–10 mm spot 0.2–1.5 improvement on
J laser-treated side
2–4 passes only at 1 week
595 nm:
5 mm spot 1–2
passes 0.1–0.55 J
750 ps
5 treatments,
1-week interval 1-,
2-, 3-month follow-
up
Chalermchai Melasma 30 PRLC III–IV Full face—4% 4-week follow-up: Mild erythema Picoway Yes
et al. [58] (prosp, split HQ; random half- Significant (6.7%), mild
face, rando, face—fractionated improvement in desquamation
eval blind) 1064 nm MASI with laser 6.7%), mild
6 × 6 mm treatment vs. HQ burning
1.3–1.5 mJ/beam 450 control side sensation (3.3%)
ps (absolute
8–12% coverage difference 3.52
400–1,000 pulses 4 vs 4.18)
Hz
Endpoint mild
erythema
Follow-up evaluation
4 weeks after final

laser treatment
Lee et al. [59] Melasma 12 PRLC III–IV PSAL vs. QS YAG Pigment No unexpected Picosure vs. No
clearance was adverse events Medlite
PSAL: 4.4–5.1 mm faster and No report of
spot, 0.88–1.18 significantly rebound
J/cm2, 650 ps, better on the pigmentation
3 passes, 1,000 PSAL side in both
pulses physician and
QS YAG: patient
5 ns assessments
Pass 1: 8 mm spot,
2 J/cm2
Pass 2: 6 mm spot,
3.5 J/cm2
Pass 3: 4 mm spot,
3.2 J/cm2
Endpoint: mild
erythema with
edema but no
petechiae
4 treatments at 1-
month intervals 3-
month follow-up
after final
treatment
Wang Melasma 26 Random- Group A1: 755 nm Significant Everyone applied Picosure Yes
et al. [60] ized single- diffractive lens improvement noted SPF50 + Q2H for
blind array in MASI score in all the duration of
comparison three groups at the the study—no
final evaluation control group to
time point; no exclude the
significant possibility that
differences between improvements
groups were not due to
increased sun
protection alone
8 mm spot VISA analysis Baseline MASI
Melasma 213
Author/date Lesion N Study type Skin type Settings Results Complications Device Fractionated
suggested improvement in spots, pores, wrinkles in both laser groups scores were 3–4
points lower in
group A1 vs. A2
and B—claimed to
be non-significant
difference but used
parametric testing
with ANOVA,
which is
questionable at
such small sample
sizes
0.4 J/cm2 A2 had a follow-
up evaluation at 1 month but not 3 months—not comparable
750 ps VISIA analysis
only done on laser groups—why not analyze TCC group as well?
2 passes, 2,500 pulses, endpoint mild erythema 3 treatment 18.2% PIH rate in A2; 33.3%
sessions at 4-week intervals irritation in B
Group A2: 755 nm diffractive lens array
8 mm spot
0.4 J/cm 750 ps
2
2 passes, 2,500 pulses, endpoint mild erythema 5 treatment

sessions at 4-week intervals
Group B: TCC
consisting of
fluocinolone
acetonide 0.01%,
hydroquinone 4%,
and tretinoin
0.05% applied
QHS for 8 weeks,
then twice weekly
for 6 weeks, then
once weekly for
6 weeks
All subjects
evaluated at
1 month following
the final
treatment for
group A2
Chen Melasma 20 OLT IV 755 nm MASI: Significant 5% PIH Picosure Yes
et al. [61] improvement from baseline (9.0 ±

4.8
vs. 6.5 ± 3.7)
8 mm spot VISIA: Significant
improvement in spots and
porphyrins
0.4 J/cm2
10 Hz
2 passes,
2,000–2,500
pulses
3 treatments at 4–6-week
intervals
4-week follow-up
II–IV 9
Lyons Melasma 10 PRLC vs. weekly treatments to More None PiQo4 N
et al. [62] 6% HQ randomized facial improvement on
the treated side
practitioner to choose the density of the MTZ in the treated area, between 5 and
75%, according to the wavelength. Higher MTZ density is associated with more
extended downtime and delayed healing. Due to wavelengths ranging from 1320 to
1927 nm, these lasers target the water molecule as chromophores. The affinity to
water within this range is mild; therefore, the stratum corneum stays without signifi-
cant histology changes due to low water content.
Water as a Chromophore
As discussed earlier, the targeted chromophore is the skin’s water. To our knowl-
edge, there is no difference in the water content between pigmented and unpig-
mented skin areas. Therefore, these lasers are considered unselective as they interact
with the skin equally. The skin’s upper layer generally has the lowest water activity,
while the deeper layers are abundant with water as they are closer to physiologi-
cal water.
Wavelength
Even though several wavelengths are available, most aesthetic practices use 1550 nm
Er:Glass and 1927 nm thulium fiber laser. Some platforms, such as Fraxel Dual
from Valeant, provide both wavelengths as a combination for the best results. The
platform offers in-motion techniques as the handpiece delivers the laser MTZ via a
revolving wheel’s continuous movement. Therefore, we will use the term (pulse
energy) instead of fluence.
1550 nm
There are two sources for the 1550 nm laser: Er:Glass (Fraxel Dual from Solta) and
diode (Frax Pro from Candela). This wavelength has less affinity to water, thus a
deeper penetration, which is particularly useful in dermal and mixed melasma. The
penetration depth increases according to the pulse energy; however, practitioners
can achieve a considerable depth of 400 μm with pulse energy as low as 6 mJ. The
maximum depth of 1550 nm is around 1400 with 70 mJ pulse energy.
The density of the MTZ can be controlled according to the treatment level.
Higher treatment levels correlated with higher MTZ density and more aggressive
treatment. The minimum MTZ density can be as low as 5% and increase to 48%
after the recommended eight passes.
The Fraxel Dual operation manual suggests the following for melasma treatment:
Skin types I–III, 6–15 mJ (440–600 μm) with 5–8 treatment levels (14–24%):
lighter skin (lower skin type) allows the practitioner to use higher energy and den-
sity. Due to higher liability, the operation manual does not include directions on
treatment for skin type VI.
Skin type IV–VI, 6–15 mJ (440–600 μm) with 3–7 treatment levels (9–20%):
practitioners should be more conservative as the skin gets darker by setting lower
energy and density.
As the reader notices, skin types III and IV might share treatment parameters.
Therefore, practitioners should use their clinical judgement when choosing the
treatment setting. We always recommend starting low and increasing the parameters
when possible.
The 1550 nm has better coagulation properties than the 1927 nm, especially at a
deeper level, but without a significant resurfacing effect. Table 5.15 shows the rec-
ommended settings of using the 1550 nm laser for different pigmented lesions.
Like all pigmentation treatments, we recommend treating the pigmented lesions
with lightning preparation before and after laser treatment. However, the patient
should stop the topical treatment 1 day before and after treatment. Authorized prac-
titioners may use other techniques to deal with clients with low pain threshold or
high pain perception, such as subcutaneous lidocaine 2% injection or nitrous gas.
Melasma 215
Table 5.15 Recommended treatment settings for investigational applications of the 1550 nm
erbium-doped laser
TABLE 14: The recommended Treatment Settings for Investigational Applications of the 1,550 nm Erbium-Doped Laser
Pulse Energy, Treatment Level Passes, Treatments, Treatment Interval,
Application mJ (Coverage, %) N N Wk
Becker’s nevus* 8–40 5–10 (14%–29%) 8 5–10 6–8
Hypopigmentation associated
with poikiloderma
Facial 10–20 8 (23%) 8 5† 4–6‡
Non-facial rea 10–20 5 (14%) 8 5† 4–6‡
Post inflammatory erythema 10–25 3–7 (5%–20%) 6–8§ 3–5 4–6
Residual hemangioma 20–40 7–10 (20%–29%) 8 3–5 4–6
Scars, traumatic10,11 40–70 6–13 (17%–38%) 8 5 4
Striae rubra 30 6 (17%) 8 4–6 4–8
Recalcitrant tattoo removal 50 6 (17%) 8 Variable{ 6–8{
Wrinkles, non-periorbital location 20–55# 5 (14%) 6–8 $5† 4–6‡
* Laser hair removal performed on the same day before 1,550 nm laser treatment.
† Initial treatment series followed by a yearly maintenance session.
‡ Treatment interval is 6 to 8 weeks for patients with a history of post inflammatory pigment alteration.
§ Skin cooling between every 2 passes.
k Recommended adjunct treatment for tattoos with persistent pigment after 10 treatment sessions and those with overlying textur
al changes or scarring. Laser tattoo
removal devices commonly used immediately before the 1,550 nm laser include Q-switch and picosecond lasers. Skin cooling between the different laser modalities is
imperative.
{ Number of treatments dependent on the response per treatment and pigment density.
# Pulse energy level dependent on the wrinkle depth.
Test Spot
A test spot is a must with all melasma laser treatments. We recommend performing
the test spot in a hidden area, not on the face. Our favorite location for the test spot
is behind the ear. Practitioners should complete the test spot using the highest pos-
sible setting and take pictures before treatment, directly after treatment, and 10 days
later. This test helps the practitioner to establish treatment safety and pain level.
Pain Level and Redness

Due to the deep penetration of the 1550 nm Er:Glass, the treatment is associated
with a higher pain level. External cooling is usually insufficient to provide patients
with enough comfort to complete the eight passes required to complete the treat-
ment. Therefore, we recommend applying topical anesthetic preparation such as
lidocaine 5% ointment. We recommend multiple applications over 3 h that precede
the laser treatment or one application using an occlusive film, such as plastic wrap.
After treatment, the swelling and redness are highest at 1550 nm, especially with
high MTZ density (high treatment level), similar to severe sunburn. It takes 72 h for
these manifestations to reside after the treatment. Before starting the treatment, the
practitioner should discuss that with the clients and provide them with post-procedure
instructions and products to minimize the itchiness and shorten the downtime.
1927 nm
Due to the longer wavelength, this laser has a higher affinity to water than 1550 nm.
Therefore, some practitioners classify it as semi-ablative, especially with a high
treatment level (high MTZ density). There are two sources for the 1927 nm laser:
thulium fiber (Fraxel Dual from Solta and diode (Frax Pro from Candela).
While the 1927 nm laser provides some coagulation effect, it is not as significant
in level and depth as the 1550 nm. Therefore, both wavelengths complete each other
to deliver the coagulation and resurfacing required for effective treatment. Table 5.16
shows the recommended settings of using the 1927 nm laser for different skin
lesions [45].
The MTZ concept is precisely similar to the 1550 nm. Therefore, we will not
cover it again here. Fraxel Dual manual does not provide parameters specific to
melasma treatment. Therefore, we will report the settings of face general resurfacing.
Skin types I–III, 5–20 mJ with 3–7 treatment levels (30–50%): lighter skin
(lower skin type) allows the practitioner to use higher energy and density.
Skin types IV–V, 5–20 mJ with 1–5 treatment levels (20–40%): due to higher
liability, the operation manual does not include skin type VI treatment directions.
thulium [45]
TABLE 14: The recommended Treatment Settings for Investigational Applications of the 1,927 nm Thulium
Laser
Puls Treatment Level P Trea Treatment
e Energy, mJ (Coverage, %) asses, tments, Interval, Wk
Application
N N
FST I–III
Actinic keratosis, 10 5–10 (40%–65%) 8 3–5 4–6
advanced Dyschromia
Lichen planus 5– 4–5 (35%–40%) 3 1–2 4–8
pigmentosus Melasma/PIH 15 1–4 (20%–35%) –4 1–2 6–12
Enlarged pores 5– 3–5 (30%–40%) 4 4–6 4
Hypopigmentation 10 –8
10 4 (35%) 8 6
Facial 4
Non 3 (30%) 6 4
10 8
facial area
10 8
Associated with
poikiloderma 7 (50%) 3–5 4–6
Facial 3–4 (30%–35%) 3–5 4–6
20 6
Non facial area –8
Scars, hypopigmentation, 20
6
or hyperpigmentation 5–7 (40%–50%) –8 5–6 4
Facial* 3 (30%) 6 4
Non facial area 10
10
8
8
FST IV–VI
Hypopigmentation
Facial
5– 3 (30%) 8 3–4 4–6
10
* Total energy for full face, 1.0 to 1.5 mJ; the total energy for small
hypopigmented scar, 0.1 mJ. FST, Fitzpatrick skin type; PIH, post inflammatory
hyperpigmentation.
Melasma 217
One study showed that after four 1927 nm laser treatments, there was a statisti-
cally significant improvement using the Fraxel Dual laser.
• Treatment 1 was carried out at a 10 mJ energy level, with six to eight passes and
a surface area coverage of 20–45% for a total density of 252–672 MTZ/cm2.
During Treatment 1, the average total energy utilized was 1.42 kJ.
• Treatment 2 was carried out at 10–15 mJ for eight passes, resulting in a total
density of 328–672 MTZ/cm2. During Treatment 2, the average total energy uti-
lized was 1.61 kJ.
• Treatment 3 was carried out at 10–20 mJ for eight passes, with a total density of
372–784 MTZ/cm2 and average total energy of 1.77 kJ.
• Treatment 4 was carried out at 10–15 mJ for eight passes, with a total density of
520–584 MTZ/cm2 and average total energy of 2.44 kJ [46].
A similar study used the 1927 nm fractionated thulium laser at 10 or 20 mJ/cm2,
with 60–70% surface area coverage and total energies from 1.72 to 4.42 kJ, as
shown in Fig. 5.14 [47].
Combination
A study combined 595 nm pulsed dye with 1927 nm fractional low-powered
diode laser to treat melasma lesions with a significant vascular component. First,
patients received the 595 nm pulsed dye laser set to the following parameters:
10 mm spot size, 10–20 ms pulse duration, and 7.5–8.5 J/cm2 fluence. After 30
min, the patients received the 1927 nm fractional low-powered diode laser
Fig. 5.14 Before and 4 weeks after treatment. Laser settings used were 20 mJ, 70% coverage,
and 4.30 kJ
(Clear + Brilliant®). The entire face was treated with eight passes on the “low”
treatment level. A low treatment level equates to 5 mJ energy, 170 m depth, and
5% coverages.
The 1927 nm laser was combined with local TXA 1.2% locally [48]. The TXA
solution was applied directly after the laser treatment for better penetration. The
laser output power was 3 W (5 mJ fluence with exposure time per pulse of 1.7 ms)
with MTZ of 100 μm in diameter. The whole face was treated with two laser passes
and then covered with 1 ml of TXA solution on one side of the face and saline
(NSS) on the other. The treatment was repeated weekly for 4 weeks, and the results
are shown in Fig. 5.15 [48].
Test Spot
A test spot is a must with all melasma laser treatments. We recommend performing
the test spot in a hidden area, not on the face. Our favorite location for the test spot
is behind the ear. Practitioners should complete the test spot using the highest pos-
sible setting and take pictures before treatment, directly after treatment, and 10 days
later. This test helps the practitioner to establish treatment safety and pain level.
Baseline 1 week 1 month 3 months 6 months
NSS
(control)
TXA
NSS
(control)
TXA
Fig. 5.15 Representative clinical findings of two patients with views focused on the malar areas.
A progressive decrease in darkness, areas, and homogeneity of patches is noted in both NSS and
TXA groups from 1 week until 3 months after completion of treatment. At 6 months, there is some
darkening and increase in area and homogeneity compared with 3 months after; however, these
changes appear less obvious in the TXA group. https://pubmed.ncbi.nlm.nih.gov/32506227/
Melasma 219
Pain Level
Treatment with 1927 nm alone is more tolerable than the 1550 nm laser. External
cooling is usually enough to provide enough comfort to complete the eight passes
required to complete the treatment. If the practitioner plans to use the 1550/1927
combo, we recommend applying topical anesthetic preparation such as lidocaine
5% ointment. We recommend multiple applications over 3 h that precede the laser
treatment or one application using an occlusive film, such as plastic wrap. 1927 nm
laser is associated with less swelling and redness if used alone. However, the swell-
ing and redness are significant when using the 1927/1550 nm combo, especially
with high MTZ density (high treatment level), similar to severe sunburn. It takes
72 h for these manifestations to reside after the treatment. Before starting the treat-
ment, the practitioner should discuss that with the clients and provide them with
post-procedure instructions and products to minimize the itchiness and shorten the
downtime.
Ablative Fractionated Resurfacing Lasers
10,600 nm CO2 and 2940 nm Er:YAG are the main ablative fraction resurfacing
lasers in aesthetic practice. The water absorption of light increases almost 100 times
when the wavelength rises from 1550 nm with Er:Glass laser to 2940 nm Er:YAG
laser. Therefore, FAL vaporizes the water and some layers of the epidermis. FAL is
not frequently used to treat hyperpigmented lesions compared to FNALs.
Experienced practitioners should operate these lasers, reserved for deep wrinkles
and scars, unless practitioners wish to achieve extensive resurfacing. Older FAL
usually offers ablation with minimal coagulation. Newer platforms were engineers
to provide a satisfactory level of coagulation if needed. However, the coagulation
points would not exceed 40 μm in depth. We do not recommend using the non-
fractional ablative lasers due to PIH’s high risk, infections, extreme light exposure
restriction, and extended downtime.
One studied protocol used cold fractional ablative 2940 nm Er:YAG laser in
short pulse mode with a lower fluence of 250–300 mJ, 30–40 μm ablation depth,
and a spot size of 7 mm. The laser treatment was followed by a topical 4% HQ
cream application. Each patient received two passes without overlapping [49]. A
similar study used Fotona ablative fractional laser system Er:YAG 2940 nm at a flu-
ence of 700 mJ/cm2 via the short pulse mode and 5 mm spot size [50].
Some protocols suggest following the ablative laser treatment with a Q-switched
nanosecond 1064 nm laser pass. However, 50% of the treated patient developed PIH
that lasted up to 3 months. Therefore, due to the significantly high risk-benefit ratio,
we do not recommend this modality as an option for melasma. One protocol pub-
lished in 2018 showed that combining Er:YAG and Q-switched nanosecond Nd:YAG
was more effective than the Nd:YAG alone. The protocol was as follows: Q-switched
1064 nm was used in 0.769 to 0.995 J/cm2 fluence and 8 mm spot size. After cooling
the area, the patient went through Er:YAG ablative session with the following
parameters: short pulse; 400 m and 7 mm spot (fluence, 1.040 J/cm2). Patients must
use a topical bleaching cream before and after the treatment [51].
A small recent study of 12 patients suggests that ablative CO2 laser treatment
may be a viable option for refractory melasma in patients with dark skin. The treat-
ment protocol included a combination of laser toning, oral TXA, and CO2 laser, as
shown in Table 5.17 [52].
Table 5.17 A list of treatment characteristics and results for 12 patients with refractory melasma
who received different combinations that included CO2 laser
Laser type TXA Initial Final
Skin (no. of CO2 laser treatment mMASI mMASI
type sessions) parameters (duration) score score Complications
III CO2a (2) 24 mJ, 50/cm No 2.15∗ 0.5∗ Swelling
CO2a 22 mJ, 75/cm No 0.75 0.6 No
III CO2a (3) 22 mJ, 75/cm Yes (7 wk) 6.7b 3.55b No
CO2a then 24 mJ, 75/cm Yes (11 wk) 3.7 2.75 No
laser toningc
(1)
CO2a 24 mJ, 75/cm Yes (16 wk) 3.05 1.95 No
IV CO2a (1) 22 mJ, 100/ Yes (2.4 wk) 6.45 5.25 No
cm
III CO2a (1) then 28 mJ, 50/cm Yes (2 wk) 2.7 2.1 No
laser toningc
(1)
III CO2a (1) then 24 mJ, 100/ Yes (1 wk) 0.9 1.8 No
laser toningc cm
(1)
III CO2a (1) then 22 mJ, 75/cm Yes (4.9 wk) 0.75∗ 1.95b PIH
laser toningc
(1)
III CO2a (1) then 26 mJ, 50/cm Yes (4 wk) 2.1 0.75 No
laser toningc
(1)
IV CO2a (1) 50 mJ, 50/cm No 1.65∗ 0.6b No
IV CO2a (1) then 26 mJ, 50/cm Yes (16 wk) 7.2 5.55 No
laser toningc
(1)
III CO2a (1) 24 mJ, 75/cm No 3.45 2.25 No
III CO2a (1) then 24 mJ, 100/ No 3.75 4.2 No
laser toningc cm
(1)
III CO2a (2) then 24 mJ, 75/cm No 0.6 0.75 No
laser toningc
(1)
CO2a 30 mJ, 50/cm No 1.05∗ 0.3b No
a
Lutronic eCO2
b
P < 0.05
c
Lutronic PicoPlus/Spectra
Melasma 221
a b
c d
e f
Fig. 5.16 Results of using a combination of CO2 laser and TXA, Comparison of facial appearance
before and after treatment from various angles: (a) Frontal view before treatment (b) Frontal view
after treatment (c) Right-side view at 45° rotation before treatment (d) Right-side view at 45° rota-
tion after treatment (e) Left-side view at 45° rotation before treatment (f) Left-side view at 45°
rotation after treatment
Another study had 29 patients and used a TXA and low-power, low-density frac-
tional CO2 laser (12 watts, 800 μm spacing, 7.3% density, and 300 μs dwell time
with TXA); representative results are shown in Fig. 5.16 [53].
Conclusion
Simple hyperpigmentation is a good start for new practitioners dealing with this
issue. You do not need additional investments to address these concerns because
existing devices can be used. Make no large investments, such as in picosecond
lasers, because the return on investment is low. Before investing in stand-alone
devices, practitioners should upgrade their current modular platform with a
Q-switched and fractional non-ablative laser to expand their practice to include
melasma.
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Chapter 6
Scar Revision
A scar is a wound that did not heal correctly for various reasons. Wound healing is
a complex biological process involving soluble chemical mediators, extracellular
matrix components, parenchymal resident cells such as keratinocytes, fibroblasts,
endothelial cells, nerve cells, and infiltrating blood such as lymphocytes, mono-
cytes, and neutrophils, all of which are referred to as immunoinflammatory cells.
Scars form at the location of tissue damage and can be atrophic or hypertrophic. The
wound healing process is divided into three stages: (1) inflammation, (2) develop-
ment of granulation tissue, and (3) matrix remodelling [1].
Scars are classified into two categories based on whether there is a net loss or
increase of collagen (atrophic and hypertrophic scars). Eighty to ninety percent of
patients with scars have depressed atrophic scars (collagen loss), whereas a few
have raised hypertrophic scars and keloids (collagen overproduction) [2].
Scar Assessment and Types
Different tools and questionnaires are available for scar assessment. The Vancouver
scale is widely accepted in the aesthetic and dermatology field due to its simplicity.
Table 6.1 shows the Vancouver scale for scar assessment.

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27632-3_6
226 6 Scar Revision
Table 6.1 Vancouver Scar characteristic

scar scale
Vascularity Normal 0
Pink 1
Red 2
Purple 3
Pigmentation Normal 0
Hypo 1
Hyper 2
Pliability Normal 0
Supple 1
Yielding 2
Firm 3
Ropes 4
Contracture 5
Height Flat 0
<2 mm 1
2–5 mm 2
>5 mm 3
Atrophic Scars
Different treatments for atrophic scars include energy and non-energy based [3].
The most common cause of facial atrophic scars is acne. As a result, we will con-
centrate on using IPL and laser to treat atrophic acne scars.
Atrophic acne scars can be categorized into three types: icepick, rolling, and
boxcar. Figure 6.1 depicts the shape and depth of various acne scar types. The ice-
pick type accounts for 60–70% of atrophic scars, the boxcar type 20–30%, and the
rolling type 15–25%.
Icepick scars are deep, thin (2 mm) epithelial tracts that extend vertically to the
deep dermis or subcutaneous tissue. As the scar tapers from the surface to its deep-
est peak, the surface aperture is frequently, but not always, bigger than the deeper
infundibulum.
Rolling scars are caused by dermal tethering of apparently normal-looking skin
and are often broader than 4–5 mm. Surface shadowing and a rolling or undulating
look of the overlaying skin is caused by abnormal fibrous anchoring of the dermis
to the subcutis.
Boxcar scars, like varicella scars, are round to oval depressions with highly
marked vertical edges. They are clinically broader than icepick scars at the surface
and do not taper to a point at the base. They might be shallow (0.1–0.5 mm) or deep
(0.5 mm), and their diameter is usually 1.5–4.0 mm. Most patients present with a
combination of three scar types, as illustrated in Fig. 6.2.
These three scar forms are frequently found in the same person, making differ-
entiation difficult. On the one hand, this categorization system enabled a uniform
Atrophic Scars 227
Acne Scar Subtypes
Iceplck Rolling Boxcar

Skin
Surface
Laser
SMAS
Fig. 6.1 Icepick, rolling, and boxcar scars are the most common (superficial and deep). Yellow
reference line indicates the CO2 laser’s depth of ablation and resurfacing capability. Green line
represents the superficial musculoaponeurotic system, to which fibrous bands cling, resulting in
rolling scars [4]
Fig. 6.2 Three different

scar types (boxcar in the
rectangle, icepicks in a
triangle, and rolling scars
in the circle)
and defined characterization of acne scars, which was accepted in clinical research
and assisted in treatment regimens. On the other hand, clinical evaluation of scars
shows substantial heterogeneity among assessors, and the lack of a globally
acknowledged quantitative or qualitative rating methodology makes comparing
scarring therapies problematic. Furthermore, any preceding scar types may mani-
fest as macular acne scar type, characterized by clinically visible erythematous,
hyperpigmented, or hypopigmented flat markings [5].
228 6 Scar Revision
The top three photorejuvenation mechanisms, not including ablation, are [6]:
• Photorejuvenation via thermal damage, followed by wound healing
• Inflammatory cytokines which promote photorejuvenation
• Photobiomodulation photorejuvenation
These three photorejuvenation methods will be discussed briefly. First, thermal
injury, followed by wound healing, is thought to be the fundamental mechanism of
photorejuvenation. Although the specific mechanism is uncertain, heat stress to the
skin is thought to degrade collagen, resulting in the recruitment and activation of
fibroblasts for new collagen production. This method exemplifies the contradiction
that collagen breakdown must precede new collagen formation. This is because par-
tial collagen denaturation is assumed to act as a trigger or scaffolding for new col-
lagen synthesis. The goal is to raise the skin temperature to 50–70 °C [7].
This thermal injury might be limited to specific dermis levels, allowing deeper
scars or wrinkles to be treated by a higher heating intensity, while deeper penetra-
tion into ligaments, fascia, or subcutaneous fat could tighten entire skin regions. The
generation of thermal energy, whether through lasers, light sources such as IPL,
radio frequency, ultrasound, or microwave energy, would result in collagen denatur-
ation and contraction. Many believe that thermal stress to the dermis causes fibro-
blasts to create collagen and affects glycosaminoglycans (GAG) and the dermal
matrix, resulting in dermal matrix remodelling. Table 6.2 lists different skin tissue
responses according to the tissue’s temperature [8].
Second, inflammatory cytokines from diverse sources alter the expression of
extracellular matrix proteins in human skin fibroblasts, such as type I collagen and
fibronectin. These inflammatory cytokines are also produced during cell injury and
wound repair processes and contribute to photorejuvenation’ s first mechanism
(thermal injury with subsequent wound healing). Some speculate that these inflam-
matory cytokines are generated by immune system cells, which subsequently infil-
trate the capillaries when they are damaged. It has been shown that patients treated
with pulsed-dye laser showed no histological change. However, dermal collagen
Table 6.2 Skin tissue responses to temperature

Temperature
(°C) Thermal reaction
42–45 Beginning of hyperthermia, conformational changes and shrinkage of
collagen
50 Reduction of enzymatic activity
60 Denaturation of proteins, coagulation of the collagens, membrane
permeabilization
100 Tissue drying and formation of vacuoles
>100 Beginning of vaporization and tissue carbonization
300–1000 Thermal ablation of tissue, photoablation, and disruption
Atrophic Scars 229
levels increased at 2, 4, and 5 weeks following laser exposure. This shows that vas-
cular laser therapy could be beneficial for photorejuvenation.
This mechanism also involves heat shock proteins (HSP) and matrix metallopro-
teinases (MMP). Another study discovered that temperatures above 60 °C for more
than 1 s cause collagen denaturation, but temperatures below 50 °C are insufficient
for thermal change but sufficient for activating HSP, resulting in increased collagen
production. MMP was assumed to have a negative influence on skin regeneration
because of its collagen breakdown characteristics. However, the contrary has been
discovered to be true. It was also discovered that the buildup of partially degraded
collagen in photodamaged skin might limit collagen synthesis by skin fibroblasts.
Finally, photobiomodulation is also referred to as bio-stimulation or low-level
light therapy (LLLT). Photochemical effects can be classified based on their mecha-
nism, such as photobiomodulation or photodynamic treatment (PDT), which this
book will not cover.
A recent international consensus recommendation was published about using
energy-base devices, including IPL and lasers, on the treatment of acne scars [9]:
• The scar type (e.g., boxcar, icepick, rolling) and location (i.e., face, body) of acne
scarring affected treatment choices the most, followed by Fitzpatrick skin type
and scar severity.
• With ablative lasers, one consideration may be the relative tolerability of frac-
tional devices for the complete spectrum of skin types.
• Boxcar scars are the most susceptible to AFL. Table 6.3 shows the platforms that
were chosen for each acne scar subtype.
• In terms of the expected degree of maximum improvement following the end of
a standard treatment course: ablative 51–70% improvement, non-ablative
31–70% improvement, and vascular devices 31–70% improvement (in erythema).
• For fractional ablative and non-ablative lasers, the most commonly used setting
combinations for typical atrophic acne scars were high energy and low-moderate
density.
Intense Pulse Light
Scar treatment with IPL alone is less successful than scar treatment with lasers. One
possible reason for this result is that the energy emitted by IPL decreases from the
center to the periphery of the light spectrum, yet the light energy of the most helpful
segment of the IPL spectrum is just a fraction of the overall emitted energy. As a
result, the efficacy of IPL looks disappointing [11]. However, it can be a beneficial
addition with ablative lasers such as Er:YAG and CO2.
IPL is a valuable combination to improve new scars with flat, raised, or depressed
erythema, particularly with an ablative laser. Elevated scars will flatten, depressed
scars will rise, and erythema will diminish. The sooner IPL therapy on a fresh surgi-
cal scar is started, the faster and better the result. It is believed that early IPL scar
therapy might help lessen the probability of keloid or hypertrophic scarring
230 6 Scar Revision
Table 6.3 Efficacy of all modalities per atrophic scar type [10]
Table 3: Efficacy of modalities per atrophic scar type
Type of Modality Rolling Shallow Deep

Icepick
treatment scars Boxcar Boxcar
scars
scars scars
Microdermabrasio
n
Dermabrasion
Peels
Resurfacing
CROSS
Micro Needling
Ablative laser
Lifting-related Subcision
Fillers
Volume-related Platelet rich
plasma
Fractional non-
Skin tightening
ablative laser
Fractional
Radiofrequency
Less
Ineffective effecti Effective
ve
developing. The author’s chosen scar criteria are the same as those utilized to treat
rosacea erythema. Two or three passes over the scar with a spot adapter that approx-
imates the size of the scar are indicated, followed by three or more treatments at
2-to-4-week intervals. IPL therapy for cosmetic surgery scars on the face can begin
at 2 weeks, while treatment for body scars can begin at 3–4 weeks. However, IPL
does not improve pitted acne scars or hypopigmented scars. Striae that are young
and still erythematous or purple can be improved using the same method as scars
and erythema, as shown in Fig. 6.3 (Table 6.4) [12].
Atrophic Scars 231
a b
Fig. 6.3 (a) A skin type II patient with erythematous rolling and boxcar scars. (b) Erythema
resolved with IPL (MaxG, ICON, Palomar) and scars improved with 1540 nm Er:Glass laser
(ICON, Palomar). IPL intense pulsed light
Table 6.4 shows recommended IPL scar reconstruction values for a single cutoff filter and single
pulse mode
Skin type Fluence Wavelength Pulse width Cooling
I–II 14–16 J/cm2 540 nm 15–20 ms High
I–II 14–18 J/cm2 580 nm 15–20 ms High
III–IV 14–16 J/cm2 540 nm 20 ms High
III–IV 14–18 J/cm2 580 nm 15–20 ms High
Long Pulse
Pulsed dye laser has been extensively studied in macular atrophic scars with signifi-
cant improvement. However, most of these studies were small in number. One study
reported using the 585 nm with 0.45 ms pulse, average fluence 6.5 J/cm2, and 7 mm
spot size erythematous atrophic scars [13]. Another study used a shorter pulse
(0.350 ms), with a lower fluence of 1.9–2.4 J/cm2 and spot size (5 mm). Patients
reported visible cosmetic improvement with a 47.8% reduction in scar depth, as
shown in Fig. 6.4 [14]. A more recent study used a higher setting; spot size 7 mm,
10 m, 9.5–11 J/cm2. Patients received two treatments 4 weeks apart, and 90% of
patients experienced clinical improvement [15]. The 2022 international consensus
recommended 7–10 mm, 6–10 ms, and 7–10 J/cm2.
Other long-pulsed lasers, such as 1064 nm Nd:YAG and 755 nm Alex, can be
used for general skin rejuvenation, with little benefits in scar revision. One study
showed that the “YAG 50/50 technique” (10 mm spot, 50 ms, 50 J/cm2) was effec-
tive and safe for general skin rejuvenation [16].
232 6 Scar Revision
a b
Fig. 6.4 (a) 30-year-old female (skin type II) with erythematous boxcar scars before and (b) 6
months after three treatments with PDL (585 nm, 12 J/cm2, 10–30 mm spot size, 5 ms)
Short-Pulsed Q-Switched Nanosecond Lasers
Most of the recent research focused on investigating the efficacy of the fractional
Nd:YAG 1064 nm laser for atrophic scars [17–19]. The traditional 532 and 1064 nm
Q-switched nanosecond nm lasers can be effective in post-acne erythema [20, 21].
One report showed the benefit of using a high-energy fractional nanosecond
Q-switched 1064 nm laser. The treatment was delivered with the nanosecond
1064 nm Nd:YAG laser with a fractional 1064 nm handpiece at an energy level of
30–75 mJ/pixel, as shown in Fig. 6.5 [22].
Ultrashort
Several studies have shown that the ultrashort pulsed laser is helpful for acne scars
and ethnic skin. The picosecond laser (ps) in fractional mode is well tolerated, with
minimal downtime, and it might be considered as another effective acne scar revi-
sion option (Table 6.5).
One study found that using a 9 mm fractionated handpiece and 0.7–0.8 J/cm2
fluence, with 5 Hz repetition rate and 450 ps pulse width, yielded promising results
for scar revision. Each patient received three treatments with a fractionated micro-
lens array handpiece every 8 weeks. The desired clinical endpoint was immediate
mild oozing and moderate erythema, both of which indicate epidermal ablation [23].
Histological Changes
Pico lasers can cause intraepidermal and dermal vacuoles at high fluences via a pro-
cess known as a laser-induced optical breakdown. Laser-induced optical breakdown
occurs when a chromophore, most often melanin, absorbs enough energy to exceed
Atrophic Scars 233
Fig. 6.5 Picture of a patient before and 2 weeks after the second procedure using a high-energy
fractional nanosecond Q-switched 1064 nm laser [22]
Table 6.5 Comparison of five different picosecond laser systems

System Laser Fluence
name wavelength Handpieces range Passes Rate
Discovery 532, 694, Round zoom 0.16–2.9 J/ 3 Up to 8
by Quanta 1064 nm (2–10 mm), cm2
fractional
(7 × 7 mm), and
square (5 × 5 mm)
PicoWay by 1064 nm Resolve 6 × 6 mm 0.16–2.9 J/ 3 8
Candela cm2
PicoSure by 1064 nm diffractive lens 0.57 J/cm2 3 10
Cynosure (DLA) 6 × 6
Pico clear 532, 585, 640 Round (2–10 mm), 450 mJ (1.3 Second generation,
by Alma and 1064 nm fractional (7 × 7 mm) GW) for the PTP, four
and square 1064 nm wavelengths
(5 × 5 mm)
PicoPlus by 532, 585, Round zoom 800 mJ (2.2 Second generation,
Lutronic 660, and (2–10 mm), round GW) for the focus lens,
1064 nm collimated (2–6 mm) 1064 nm distributes energy
into microbeams
234 6 Scar Revision
a b
c d
Fig. 6.6 Tissue reactions after 1064 nm fractional picosecond laser treatment. Single-pulse,
1064 nm picosecond laser treatment at a 7 mm spot size and a fluence of 1.9 J/cm2 generated the
fractionated appearance of cystic cavitation lesions (asterisks) throughout the lower epidermis and
upper papillary dermis at regular intervals. Microscopic perinuclear vacuolar changes (arrows)
were found around the areas of cystic cavitation. (a, b) Single-pulse mode and (c, d) dual-pulse
mode treatment. H&E stain at original magnification (a, c) ×100 and (b, d) ×400 [25]
its irradiance threshold. When the irradiance threshold is exceeded, the chromo-
phore releases a free electron, which starts the creation of more free electrons and
the development of localized ionized plasma. The extremely intense ionized plasma
can induce a fast rise in the water temperature within the tissue, resulting in the for-
mation of steam bubbles. Cavitation occurs when tissue expands and contracts,
causing pressure fluctuations in the epidermis and dermis, as shown in Fig. 6.6 [24].
Color-Blind Lasers
Non-ablative Fractional Laser (FNAL)
The fractionation 1550 nm Er:Glass is the most studied laser for scars management,
particularly in pigmented scars. The thulium 1927 nm laser with a mid-infrared
wavelength is a superficial, non-ablative, fractional laser useful for treating post-
inflammatory hyperpigmentation and melasma, which typically emphasize pig-
mented scarring. The same is applicable.
Atrophic Scars 235
Histology Changes
A column-like denaturation of the epidermis and dermis, a distortion of the dermo-

epidermal junction, subepidermal coagulation within the MTZ, and an intact stra-
tum corneum can be seen in the non-ablative version, as shown in Fig. 6.7. The
surrounding tissue is not damaged. Within 24 h, keratinocytes migrate from the
surrounding healthy tissue to replace the thermally injured tissue [26].
Clinical Endpoint
• Endpoint transient erythema (redness) and edema (swelling) shortly after ther-
apy are acceptable clinical endpoints for skin types I–III.
• Treat skin types IV–VI below the erythema threshold. The clinical endpoint is
edema (swelling) shortly following therapy.
• Bronzing, or brown debris on the skin’s surface, is a desired therapeutic endpoint.
Test Spot
• Before each treatment, on each candidate for treatment and at each appointment,
test spots should always be applied. Before treating big areas, wait for clinical
outcomes from test areas.
• The test spot approach is intended to simulate the tissue effect of a larger treat-
ment area in a small test area as closely as possible.
• Because skin sensitivities vary, the placement of the test spot affects evaluation.
The reactions are stronger and stay longer on the periphery of the face and thin-
skinned areas than on the face. Off-face sites will also have far longer-lasting
skin reactions than on-face sites. To measure test area response, conduct test
spots adjacent to the anticipated treatment area.
• To minimize rapid stacking of microbeams of test spot pulses, test spots should
involve lifting and rotation of the handpiece (explained below and on the follow-
ing page).
a b
Fig. 6.7 Fractional non-ablative laser. (a) Focal coagulation of the epidermis and dermis with
preservation of the stratum corneum after fractional 1540 nm laser (H&E ×100). (b) Focal coagu-
lation of the epidermis and papillary dermis with preservation of the stratum corneum after frac-
tional 1927 nm laser (H&E ×100) [27]
236 6 Scar Revision
• Begin with low settings for the handpiece tip you have chosen.
• Before trying higher levels, evaluate discomfort and skin reactions immediately
and 10 min after delivering test spots with lower energy settings. It is important
to note that substantial swelling (sometimes accompanied by blanching) is an
expected reaction within a few minutes of therapy.
• To best assist in treatment decisions, skin reactions should be examined 24 h and
up to 1 week after test spots. Blistering or signs of overtreatment 24–48 h after
test pulse administration suggest that the settings are above skin tolerance.
Excessive redness may be a sign of post-inflammatory hyperpigmentation.
• Test spot settings require repeated passes per area to get the appropriate cover-
age. For example, if you intend to treat at maximum fluence with two passes with
50% overlap in the horizontal direction and minimum overlap in the vertical
direction, four pulse test spots in a single area will best match treatment coverage.
Post-treatment
• Applying cool gel packs and appropriate topical lotions soon after treatment
might help relieve any irritation or stinging that may arise.
• Edema and sometimes blanching are common soon after therapy and usually
resolve within 24–48 h. Some consumers may experience it for up to 3–5 days.
• Those receiving therapy may have considerable redness, burst capillaries, and
bronzing in the treatment area for 1–3 days following treatment. This may last
for several weeks in a mild form, especially in locations other than the face.
• Following a more vigorous treatment, it may be beneficial to apply an occlusive
ointment to the skin following treatment to assist limit trans-epidermal water
loss, which can cause significant desquamation or crusting.
• To assist, remove debris and bronzing of the skin that may emerge 1–4 days after
treatment, soak treated areas in water for 5–15 min, and then gently remove
debris. Picking or scrubbing the treated areas is not permitted.
• Following treatment, gentle washing and the use of non-irritating cosmetics is
authorized. Retinoids should be avoided for 1–2 weeks before the first treatment
and for the duration of the treatment. The use of retinoids during the course of
treatment may result in unwanted side effects and protracted recovery.
• Those who are prone to acne outbreaks should refrain from using heavy makeup
or moisturizers for 24 h after therapy.
• After treating striae (stretch marks) with the 1540 laser handpiece, it is advised
to avoid wearing clothing that is too tight around the treated regions for 3 months.
• As healing occurs, clients should avoid injury and sun exposure for at least 2
weeks following treatments, and it is strongly advised that clients use a sun-
screen with SPF 45 or higher that contains UVA/UVB protection, as well as a
sun blocker such as zinc oxide or titanium dioxide, between treatments.
• Those receiving treatment should continue to apply SPF 45 or higher whenever
they go outside for the next 6 months.
• Itching or dryness may occur after the treatment area has healed. This will clean
up with time. Moisturizers that are non-irritating may provide some relief.
Atrophic Scars 237
• Instruct the person being treated to contact the treatment provider if any prob-
lems or concerns arise as a result of the treatment.
One study showed that the 1550 nm laser is more effective than the 595 nm pulsed
dye laser for treating facial erythema resulting from acne. The 1550 nm Er:Glass
fractional laser treatments were performed at densities of 100 MTZ/cm2 and fluences
of 14 mJ/cm2. The following parameters were used for PDL treatments: wavelength
595 nm, spot size 7 mm, pulse duration 10 ms, and fluence 9–11 J/cm2 [28].
Fraxel Dual
The Fraxel Dual laser system is a non-ablative laser system that includes a single
handpiece with wavelengths of 1550 and 1927 nm with various indicators for each
wavelength. The erbium-doped laser at 1550 nm is indicated for soft tissue coagula-
tion, skin resurfacing procedures, and the treatment of dyschromia, epidermal
lesions (e.g., lentigines and actinic keratoses [AK]), dermal pigmentary disorders
(e.g., melasma), periorbital wrinkles, acne scars, and surgical scars. The 1927 nm
thulium laser is used for dermatological treatments that require soft tissue coagula-
tion and the treatment of AK and dyschromia. Tables 6.6, 6.7, and 6.8 focus on best
practices of different applications of the 1550 and 1927 nm twin laser systems [29].
Table 6.6 Recommended treatment settings for approved indications of the 1550 nm erbium-
doped and 1927 nm thulium laser system and treatment settings for combination treatment [29]
TABLE 8.1. Recommended Treatment Settings for Approved Indications of the 1,550 nm Erbium-Doped and 1,927 nm
Thulium Laser System and Treatment Settings for Combination Treatment [29]
Treatment Level (Coverage, %)
Treatment
Approved Indication Pulse Energy, mJ FST I-III FST IV-VI Passes, N Treatments, N Interval, wk
1,550 nm wavelength
General skin resurfacing*
Facial 35–70 7 (20%) 3–7 (9%–20%) 8 3–5 4–6
Periorbital area 35–70 7 (20%) 3–6 (9%–17%) 3–4 3–5 4–6
Nonfacial area 35–70 #8 (#23%) 3–6 (9%–17%) 8 3–5 4–6
1,927 nm wavelength
Actinic keratosis 20 10 (65%) 1–3 (20%–30%)† 8 3–5 8–12
Dyschromia 10 10 (50%) 2–5 (25%–40%) 8 2–4 4–8
Combination of 1,550 nm and 1,927 nm Wavelength

1,550 nm 1,927 nm
Combination Pulse Treatment Level Passes, Pulse Treatment Level Passes, Treatment
Use Energy, mJ (Coverage, %) N Energy, mJ (Coverage, %) N Interval, Wk
General skin
resurfacing*
Facial 25–50 5–8 (14%–23%) 4 10 4–6 (35%–45%) 4 4–6
Nonfacial area 15–45 3–8 (9%–23%) 4–5 10 3–6 (30%–45%) 4 4–6
Traumatic, 12–40 4–7 (11%–20%) 8 10 3 (30%) 8 4–6
surgical scars
Striae distensae 30 6 (17%) 4–6 10 3 (30%) 8‡ 4–6
* Treatment for pigmented lesions, uneven skin texture, and fine wrinkles.
† For some experts, preferred treatments were topical chemotherapeutics (e.g., topical 5-fluorouracil or retinoids).
‡ Skin cooling between every 2 passes.
FST, Fitzpatrick skin type.
238 6 Scar Revision
erbium-doped laser
TABLE 8.2. Recommended Treatment Settings for Investigational Applications of the 1,550 nm Erbium-Doped Laser
Pulse Energy, Treatment Level Passes, Treatments, Treatment Interval,
Application mJ (Coverage, %) N N Wk
Becker’s nevus* 8–40 5–10 (14%–29%) 8 5–10 6–8
Hypopigmentation associated
with poikiloderma
Facial 10–20 8 (23%) 8 5† 4–6‡
Non-facial rea 10–20 5 (14%) 8 5† 4–6‡
Post inflammatory erythema 10–25 3–7 (5%–20%) 6–8§ 3–5 4–6
Residual hemangioma 20–40 7–10 (20%–29%) 8 3–5 4–6
Scars, traumatic10,11 40–70 6–13 (17%–38%) 8 5 4
Striae rubra 30 6 (17%) 8 4–6 4–8
Recalcitrant tattoo removal 50 6 (17%) 8 Variable{ 6–8{
Wrinkles, non-periorbital location 20–55# 5 (14%) 6–8 $5† 4–6‡
* Laser hair removal performed on the same day before 1,550 nm laser treatment.
† Initial treatment series followed by a yearly maintenance session.
‡ Treatment interval is 6 to 8 weeks for patients with a history of post inflammatory pigment alteration.
§ Skin cooling between every 2 passes.
k Recommended adjunct treatment for tattoos with persistent pigment after 10 treatment sessions and those with overlying textural changes or scarring. Laser tattoo
removal devices commonly used immediately before the 1,550 nm laser include Q-switch and picosecond lasers. Skin cooling between the different laser modalities is
imperative.
{ Number of treatments dependent on the response per treatment and pigment density.
# Pulse energy level dependent on the wrinkle depth.
thulium laser
TABLE 8.3. Recommended Treatment Settings for Investigational Applications of the 1,927 nm Thulium Laser
Pulse Treatment Level Passes, Treatments, Treatment Interval,
Application Energy, mJ (Coverage, %) N N Wk
FST I–III
Actinic keratosis, advanced 10 5–10 (40%–65%) 8 3–5 4–6
Dyschromia
Lichen planus pigmentosus 5–15 4–5 (35%–40%) 3–4 1–2 4–8
Melasma/PIH 5–10 1–4 (20%–35%) 4–8 1–2 6–12
Enlarged pores 10 3–5 (30%–40%) 8 4–6 4
Hypopigmentation
Facial 10 4 (35%) 8 6 4
Non facial area 10 3 (30%) 8 6 4
Associated with
poikiloderma
Facial 20 7 (50%) 6–8 3–5 4–6
Non facial area 20 3–4 (30%–35%) 6–8 3–5 4–6
Scars, hypopigmentation,
or hyperpigmentation
Facial* 10 5–7 (40%–50%) 8 5–6 4
Non facial area 10 3 (30%) 8 6 4
FST IV–VI
Hypopigmentation
Facial 5–10 3 (30%) 8 3–4 4–6
* Total energy for full face, 1.0 to 1.5 mJ; the total energy for small hypopigmented scar,
0.1 mJ. FST, Fitzpatrick skin type; PIH, post inflammatory hyperpigmentation.
Atrophic Scars 239
It was suggested that reducing the total density (MTZ/cm2) in each treatment
session would help to lower the risk of PIH linked with FNAL. However, this
approach would mean that the total number of treatment sessions would double [30]
(Tables 6.9 and 6.10).
Icon® 1540 Fractional Laser

This handpiece is part of the modular Icon platform. It comes with two essential tips
(10 and 15 mm) and two non-essential tips (XD Microlens and XF Microlens)
(Fig. 6.8; Tables 6.11, 6.12, and 6.13).
Table 6.9 Recommended parameter for atrophic scars in patients with low risk of pigmentation
Parameter for eight passes (total of four sessions) Recommended Minimum Maximum
Energy, mJ 55 25 70
Total energy, kJ 7 0.5 9.6
Depth, μm 1.2 400 1400
Treatment level 9.5 6 11
Coverage, % 27 17 32
Total density (MTZ/cm2) 445 250 1000
Density/pass (MTZ/cm2) 55 40 120
Table 6.10 Recommended parameter for atrophic scars in patients with high risk of pigmentation
Parameter for four passes (total of eight sessions) Recommended Minimum Maximum
Energy, mJ 44 16 60
Total energy, kJ 4 0.5 6
Depth, μm 1.2 400 1400
Treatment level 9 4 11
Coverage, % 25 11 32
Total density (MTZ/cm2) 220 150 500
Density/pass (MTZ/cm2) 55 40 120
Fig. 6.8 Overlapping
technique suggested by
Cynosure when using
Icon® 1540 fractional laser
240 6 Scar Revision
Table 6.11 Icon® 1540 fractional laser specification

1540 Fractional laser
Wavelength: 1540 nm
Pulse width: 10–15 ms
Spot size: 10 and 15 mm
XD Microlens
Microbeams: 49 Pitch: 2 mm
Microbeam energy: Up to 70 J/cm2
Density: 25 mB/cm2
Depth of coagulation: 1050 μm
Width of coagulation: 300 μm
XF Microlens
Microbeams: 175 Pitch: 1 mm
Microbeam energy: Up to 50 J/cm2
Density: 115 mB/cm2
Depth of coagulation: 700 μm
Width of coagulation: 260 μm
Table 6.12 A list of Icon® 1540 skin resurfacing and coagulation of soft tissue
15 mm tip XD Microlens™ XF Microlens™
Energy (millijoules per microbeam) 10–15 mJ/mB 40–70 mJ/mB 30–50 mJ/mB
Pulse width 10–15 ms 15 ms 10–15 ms
Number of passes (10–50% overlap) 3–4 3–6 1–2
Number of treatments 2–5 2–5 1–2
Treatment interval 3–4 weeks 3–4 weeks 3–4 weeks
For skin types IV–VI, use lower energy and pass settings, or consider using the 15 mm tip with one
to three passes with lower energies, increasing energy based on test spots. Treating darker skin
types below the visible erythema level reduces the risk of post-inflammatory hyperpigmenta-
tion (PIH)
Atrophic Scars 241
Table 6.13 A list of Icon® 1540 acne scars and surgical scars
15 mm Tip XD Microlens™ XF Microlens™
Energy (millijoules per microbeam) 10–15 mJ/mB 40–70 mJ/mB 30–50 mJ/mB
Pulse width 10–15 ms 15 ms 10–15 ms
Number of passes (10–50% overlap) 3–4 3–6 1–2
Number of treatments 3–7 3–7 3–7
Treatment interval 3–4 weeks 3–4 weeks 3–4 weeks
For skin types IV–VI, use lower energy and pass settings or consider using the 15 mm tip with one
to three passes with lower energies, increasing energy based on test spots
Treating darker skin types below the visible erythema level reduces the risk of post-inflammatory
hyperpigmentation (PIH)
Table 6.14 Recommended parameter for atrophic scars using the ClearSkin Pro
Skin Energy Repetition # Stacked #
type Tip (mJ/P) rate (Hz) pulses Passes
ClearSkin PRO Er:Glass I–III 4 mm 400–500 2 2–3 2–3
1540 nm Cooled applicator; 4 10 mm 500–600
and 10 mm tips IV– 4 mm 300 1 1–2 1–2
VI 10 mm 400–500
ClearSkin Pro
This is a cooled Er:Glass laser with vacuum treatment. This technology to combine
a non-ablative laser with contact cooling and vacuum. The recommended parame-
ters are listed in Table 6.14.
Ablative Fractional Laser
CO2
Most of the suggested protocols suggested using high energy with low density for
effective scar revision treatment [31, 32].
1. Energy
I. High energy: >30 mJ (ablation depth > 0.9 mm, use only with low density)
II. Moderate energy: 15–30 mJ (0.45–0.9 mm ablation depth, only when using
low or moderate density)
III. Low energy: 15 mJ (ablation depth of 0.45 mm, use moderate density)
2. Density
I. High ≥15% (use with caution and only with low pulse energy)
II. Moderate = 10%
III. Low ≤5%
CO2 will be discussed in more details in the hypertrophic scars section.
242 6 Scar Revision
CO2 laser creates microarrays of ablative and thermal damage; the ablation depth is
related to the laser energy. Tissue ablation zones were bordered by tissue coagula-
tion zones that spanned the epidermis and a portion of the dermis. A thin condensed
lining was found on the inside wall of the lesion cavity, as seen in Fig. 6.9.
a b
c d
Fig. 6.9 Depth of ablation of hematoxylin-eosin-stained sections of ex vivo human abdominal
tissue treated with the 30 W, 10.6 mm, CO2 laser at 9.2 mJ (a), 13.8 mJ (b), 18.0 mJ (c), and 23.3
mJ (d). The arrows outline the extent of coagulation collagen zones [33]
Hypertrophic Scars and Keloids 243
ER:YAG
The Er:YAG laser, with a wavelength of 2940 nm, corresponds to the peak absorp-
tion coefficient of water and is absorbed 12–18 times more efficiently by cutaneous
water-containing tissue than the CO2 laser, which has a wavelength of 10,600 nm.
It has been shown that fractional Er:YAG and CO2 lasers provided comparable
scar treatment outcomes, but fractional CO2 laser was associated with greater treat-
ment discomfort. The Er:YAG laser was set to deliver at a pulse duration of 350 ms
and mean energy of 13.75 (12.5–15) mJ; the CO2 laser was set to deliver at a pulse
duration of 950 μs and mean energy of 13.75 (12.5–15) mJ. Both lasers were pro-
grammed to treat an average of 5% of the skin’s surface coverage [34]. The addition
of variable pulse to the Er;YAG lasers enhances the widespread of using this laser
in the aesthetic field. One report suggested advanced techniques by treating the
scarred areas with an ablative fractional erbium laser (SP Dynamis, Fotona,
Slovenia). The treatment parameters included using the FS01 handpiece (1 cm
fixed-focused fractional handpiece with 81 microbeams in a 1 cm2 fixed-focused
area). The author suggested setting the laser to an R11 handpiece setting with a
7 mm spot size (although the handpiece used for treatment was the FS01 hand-
piece), 22.8 J/cm2, long pulse, 1 Hz, and turbo 6 (six stacked pulses) double stacked
to deliver 12 pulses per spot, and five to six intersecting passes were among the laser
parameters used [35].
Fully ablative lasers result in a full-thickness epidermal injury with partial denuda-
tion of the epidermis. The depth of the epidermal injury depends on the laser energy.
At high laser fluence, full vaporization of the epidermis and superficial dermis could
be achieved, as seen in Fig. 6.10 [36].
Summary of Suggested Treatments
Table 6.15 is a summary of systemic review of using different IPL and lasers devices
for atrophic scars treatment [37].
Hypertrophic Scars and Keloids
Hypertrophic scars and keloids have been extensively documented to form follow-
ing skin damage or inflammation, in most cases months or even years after the ini-
tial trauma. As a result, damage to the skin is a required and significant inciting
event. Specific skin regions, such as the ear lobes, anterior chest wall, and shoul-
ders, are more prone to keloid formation because they are more prone to trauma,
244 6 Scar Revision
a b
Fig. 6.10 Routine histology after fully ablative Er:YAG laser. (a) Full vaporization of the epider-
mis and superficial dermis (H&E ×100). (b) Magnified (H&E ×200) [27]
either iatrogenically (e.g., ear piercing or surgery) or as a result of an inflammatory

condition (e.g., acne) [38]. Keloid grows in size to exceed the original injury,
whereas hypertrophic scars are restricted to the injury boundaries as shown in
Fig. 6.11 [37].
Over the last decade, there has been substantial progress in operations’ incision
care. However, surgical scars, which cause significant and long-lasting negative
impacts on patients’ looks, are common in all procedures involving an incision.
Inflammation, proliferation, and remodeling occur from surgical incision until
wound healing. Chemotaxis and neovascularization of inflammatory cells are
caused by inflammation, which drives fibroblast proliferation and collagen forma-
tion. This series of events finally leads to scar hypertrophy. Scars have a negative
impact on a patient’s quality of life. Patients with surgical scars have a worse quality
of life due to persistent symptoms such as itching, pressure, and discomfort.
These scars are most frequent in African, Hispanic, and Asian people, who are
also prone to pigmentation disorders [39]. Risk factors other than genetic predispo-
sition are either local or systemic. Repeated injury, such as repeated attaching and
detaching a piercing, is considered the prominent local risk factor [40]. Improper
treatment of local infection is another local risk factor. Systemic risk factors include
normal and abnormal hormonal changes due to puberty, pregnancy, or some syn-
dromes [41].
Keloid differs from hypertrophic scars histologically, so they have a different
appearance [42]. For simplicity, we could consider the keloids as extreme hypertro-
phic scar with scar tissues extending beyond the border of the original injury and a
more intense red or purple color.
Table 6.15 Systemic review of using different IPL and lasers devices for atrophic scars treatment
Settings and Fitzpatrick

Ablative vs Fractionated vs Wavelength, Additional Skin Type
Device Company Nonablative Nonfractionated nm Energy Spot Size, mm Information (I-VI)
IPL M22; Lumenis Ltd., NA NF 560 cutoff filter 16-18J/cm2 15 x 35 mm Double pulsed: 3.5 I-III (560
Yokneam, Israel millisecond pulse filter)
duration with a 20
millisecond pulse delay
IV-V(590
Filter)
PDL Vbeam Perfecta; NA NF 595 6-8 J/cm2 10 mm 6 millisecond pulse I-V
Syneron Candela, duration
Wayland, MA
QS alexandrite Accolade; Cynosure, NA NF 755 1.5-2 J/cm2 3-4 mm I-IV
laser Westford, MA
Pico laser 755 nm Picosure; Cynosure, NA NF 755 1.59J/cm2 4 mm Energy is automatically I-IV (focus
Westford, MA selected based on spot fractional
size in V-VI)
QS Nd:YAG laser Spectra; Lutronic NA NF 1,064 1-2 J/cm2 8 mm 2-3 passes until mild I-VI
Corporation, South erythema develops
Korea
2 treatments at a 4-wk
interval
CO2 laser Fraxel re:pair; Solta, A F 10,600 30-55 mj Roller tip 40%-50% density-face I-IV
Hayward, CA (face) (Type I-III skin, 20%-
30% density Type IV)\
25-30 mJ 25%-30% density
periorbital periorbital 4 passes
up to .1.6 mm penetration
DERMATOLOGIC SURGERY
depth
CO2 laser Deep Fx, Ultra Pulse; A F 10,600 22.5-25 mJ 10 mm 15% density (face) I-IV
Lumenis Ltd.,
Yokneam, Israel
10% density (forehead)
0.3 seconds delay
Settings and Fitzpatrick

Ablative vs Fractionated vs Wavelength, Additional Skin Type
Device Company Nonablative Nonfractionated nm Energy Spot Size, mm Information (I-VI)
Er:YAG laser Fotona SP Dynamis; A F 2,940 Turbo 6 with 2 passes; I-VI
Ljublijana, Slovenia long pulsed
22.8 J/cm2 7 mm Rolling scars: fixed
fractional handpiece
22.8 J/cm2 7 mm Many boxcar scars:
variable focus handpiece
5-7 J/cm2 1-2 mm A few boxcar scars:
variable focus
handpiece; shot
tangentially across the
skin as a single pass
Erbium/CO2 laser Derma K, ESC; A NF 2,940, 10,600 1.4 4 mm 40% density, 12 Hz, 6 W; I-VI
Sharplan-no longer 3 passes
in production
Erbium glass Fraxel re:store; Solta, A F 1,550 35-70 mJ Intelligent 20%-32% density Type I-VI
1,550 nm Hayward, CA optical tracking I-III skin
system
14%-20% density Type IV
skin
30-35 mJ 17% density Type V-VI
skin 4 passes (M.T)
3-5 treatments at 1 mo
intervals
≤ 1.4 mm penetration
depth
Erbium glass Palomar Icon; NA F 1,540 60 mJ/mb 15 mm XD handpiece; 15 I-IV
1,540 nm Cynosure, Westford, millisecond pulse
MA duration
intervals
Erbium 1,565 nm ResurFX; Lumenis, NA F 1,565 35-70 mJ 17 mm 350-500 microbeams/cm2, I-IV
Yokneam, Israel Type I-III skin, rectangle

shape, precision tip; 50-
250 microbeams/cm2
Type IV skin
intervals
246 6 Scar Revision
Hypertrophic Scar Keloid Scar
Original Injury Margins Original Injury Margins
Fig. 6.11 Difference between hypertrophic and keloidal acne scars [37]
Etiology
These scars form as a result of cutaneous trauma and dysregulated wound healing
process [43]. The trauma could be as little as an insect bite. The normal wound heal-
ing process is tightly regulated to control the inflammation and balance collagen
production and degradation. This process is disrupted in people prone to have keloid
scars [44]. Thus, at the dermis level, the continuous and localized inflammation
status in the extracellular matrix results in over vascularization of the lesion and an
imbalance between building collagen and degrading it. This imbalance results in a
less than proper job closing the wound by a thick layer of tissue (abnormal wound
healing). This newly constructed tissue extends beyond the damaged area and rises
higher than the skin surface, as shown in Fig. 6.12 [45].
Normal skin presented random and relaxed collagen bundle arrangement,
whereas keloid and hypertrophic tissues present more stretched and thicker collagen
bundles. Abundant cellular islands were found in both the papillary and the reticular
dermis of hypertrophic scar tissue. K keratin layer, EP epidermis, PD papillary der-
mis, RD reticular dermis.
Similar to other treatments that use photon energy, practitioners should be aware of
the targeted chromophores. For keloid and hypertrophic scars, practitioners should
utilize the available tool to target enhanced vascularity (oxyhemoglobin) and the
extracellular matrix (water).
Intense Pulse Light
IPL treatment is effective in keloids and hypertrophic scars with lower cutoff filter
filters of 550–590 nm according to the skin type, similar to that used in vascular
lesion treatment. The fluence can be adjusted between 30 and 40 J/cm2, starting with
10 ms pulse widths down to 2; results of such protocol are shown in Fig. 6.12.
Practitioners should keep in mind skin type and comfort, before intensifying the
treatment by decreasing the pulse width [46] (Fig. 6.13).
Fig. 6.12 Different mechanisms that contribute to keloid formation
a b
Fig. 6.13 Scar in the left anterior thigh region following a burn. (a) Preoperative view. (b)
Postoperative view after nine sessions [46]
248 6 Scar Revision
Table 6.16 Successive treatment to treat vascular component

Number of Pulse Number of
Filters pulses duration Delay Fluence sessions
Pigmented 550 2 5–10 ms 10 ms 10–12 J/ Up to 5
component cm2
Vascular 500 2 5–10 ms 10 ms 14–17 J/ Up to 6
component cm2
Another protocol is a combination between IPL devices and local corticosteroid

injections; the fluence varies between 8 and 14 J/cm2; it is recommended to use
double- or triple-pulse mode with pulse durations of 2.5–5 ms and pulse delays of
10–20 ms [47].
According to one report, keloids were treated with handpieces with wavelengths
of 500 nm (vascular component) and 550 nm (pigmented component). The pig-
mented component was treated first with the 550 nm handpiece where it was pres-
ent. Following that, successive treatments with the 500 nm handpiece were
performed to treat the vascular component as shown in Table 6.16 [48].
Long-Pulsed Lasers
532 nm KTP laser can be used for the treatment of red scars. This laser can be used
up to skin type IV. Practitioners could offer this treatment only if the 595 pulsed dye
laser is not available. To our knowledge, the only platform that provides this wave-
length in the millisecond range is the Excel V from Cutera. This platform emits both
the 532 nm and 1064 in ms pulse widths. The Excel V platform is equipped with two
different handpieces: Coolview with chilled sapphire and Genesis V with a tempera-
ture sensor. This laser can be used in skin types I–IV with 7 mm spot size and flu-
ence between 5.5 and 7 J/cm2 and pulse duration between 3 and 10 ms [49].
585 and 595 nm pulsed dye lasers are the golden standard for vascular lesions,
including keloids and hypertrophic scars in skin types I–IV. The flam-lamp-equipped
platforms provide laser in the millisecond range (long and quasi-long), making it
perfect for highly vascular scars. Low-fluence high-intensity 595 proved effective in
scars with significant vascularity, 1–3 on the Vancouver scale. The treatment effi-
cacy depends on the scar’s stage, as it is most vascular and red during the early stage
of formation (within 1 year). This treatment should have little to no effect on older
scars with no color difference from the surrounding tissues. The suggested protocol
is two treatments with 6-week intervals using a fluence of 4.5–5.5 J/cm2, 1.5 ms
pulse width, and 10 mm spot size [50]. The laser should be applied to the length of
the scar with no overlapping and external cooling. The practitioner should set the
machine at 2 Hz to allow enough cooling time. Eligible practitioners could consider
corticosteroid injected after the laser treatment, not before, to maximize the effect.
The interval between sessions should be shortened if the scar is still fresh (1–2
months old) to utilize the high color intensity and lower thickness. The suggested
protocol uses a fluence of 6 J/cm2, a spot size of 7 mm, and a pulse duration of 3 ms
every 4 weeks for a total of 5 treatments.
Another effective protocol for correcting red hypertrophic scars with less thick-
ness is 3.5 J/cm2, 0.45 ms pulse duration, and a 10 mm spot size. The treatment
should be repeated every 4 weeks for a total of five sessions [51].
Practitioners should consider the scar’s thickness, as the previous setting does
not penetrate deeper than 0.5 mm. Therefore, the laser parameter could be adjusted
for deeper penetration by increasing the laser’s fluence and spot size or combine it
with a fractional laser. As we will explain later, both lasers can be used at the same
session or on different ones.
Quasi-long-Pulsed Nd:YAG 1064 nm (Millisecond Range)
The 1064 nm laser offers deeper penetration than the 595 pulsed dye lasers. This
laser is effective in dark and thick keloid and hypertrophic scars. The protocol
includes monthly treatment over 1 year with the following parameters: a spot size
diameter of 5 mm, an energy density of 65–75 J/cm2, an exposure time per pulse of
250 μs (0.25 ms), and a repetition rate of 2 Hz with high-intensity cooling.
Practitioners should use lower fluence with very dark keloid. The session is 2–3
passes with no overlapping, depending on patient comfort and pain tolerance. It is
essential to point out that most traditional laser hair removal machines might not be
able to provide the required quasi-long pulse for this treatment.
Q-Switched Nanosecond Laser
This laser might be an option for clients with higher skin phototypes. The principle
of targeting high vascularity is similar. The recommended setting is fluence
between 3 and 5 J/cm2 and 5 mm spot size. Gold toning handpiece provides low-
fluence Q-switched Nd:YAG laser using the 585 nm (5 mm spot size, 5–10 ns)
[52]. It is useful for erythema lesions, inflammatory acne (papules, pustules), and
post-acne erythema. The recommended treatment parameters are 2–4 passes of
0.30–0.55 J/cm2, a total of three biweekly sessions [53–55]. The low fluence pen-
etrates deeply enough into the skin to reach the target very tiny vessels that cause
diffuse redness while sparing the deeper and larger blood vessels, reducing bruis-
ing risk.
Practitioners could offer the 532 nm if the 595 nm pulsed dye laser is not avail-
able. The parameter is as follows: fluence of 3–3.5 J/cm2 and 3–4 mm spot size,
every 4–6 weeks. Practitioners could reach better depth with a bigger spot with
higher fluence after the first treatment [56].
250 6 Scar Revision
Ultrashort Picosecond Lasers
Color-Blind Lasers
Non-ablative Fractional Laser
Non-ablative fractional lasers induce coagulation and stimulate a wound-healing

process. The 1550 Er:Glass fractional laser is more effective in correcting the appear-
ance of the Keloids. It can be used alone or in combination with pulsed dye laser.
A total of four biweekly treatments with the following parameters for Fraxel: flu-
ences of 70 mJ, treatment level 8 (coverage 23%) with 16 passes for a total of 0.5–0.8
KJ. A similar treatment can be delivered using the 1540 Icon platform using the XD
Microlens applicator with a 50–70 mJ/microbeam fluence and a pulse width of 15
ms 3–6 passes with 50% overlap, total 4–6 treatments, 2–4 weeks apart [57–59].
An example of the combined treatment parameters was fluence of 6 J/cm2, spot
size 7 mm, and pulse duration of 3 ms for 595 nm, along with the deep 1550 nm
treatment [60].
Ablative Fractional Laser
The rule of ablative laser comes secondary to the erythema treatment plan. In our
opinion, an ablative fractional laser should not be used as a monotherapy in correct-
ing keloids and hypertrophic scars [61]. However, these lasers have a role in improv-
ing the appearance and reducing the scars’ thickness and restrictive tissues. However,
these lasers (especially the older models) do not provide enough thermal coagula-
tion. For example, the 1550 nm could provide thermal coagulation as deep as 1.5
mm, but Er:YAG would reach a max of 50 μm in coagulation but 0.5 mm in abla-
tion. Therefore, the 2970 nm Er:YAG is referred to as the cold laser. In general,
more passes are required at the scar edges to achieve even results.
Two fractional ablative wavelengths are widely used in the aesthetic and derma-
tology field: the 2970 nm Er:YAG and 10,600 CO2 lasers. It is recommended to
apply topical lightening preparation on the scar and surrounding area for 2–4 weeks
before laser treatment to avoid PIH, especially on skin type III and higher.
CO2 Laser
The CO2 laser systems have evolved in aesthetics and dermatology since the 1990s.
The first generation of CO2 laser systems has a continuous wave (CW) mode. This
delivers low but continuous energy. In contrast, the CW mode has unfavorable ther-
mal diffusion to the surrounding tissue and its ablation/coagulation ratio. Therefore,
their use in the aesthetic field was limited due to adverse effects, mainly PIH.
The second generation of CO2 laser introduced the SuperPulse principle, in
which the energy is delivered in a discrete, intense pulse. The SuperPulse mode,
with its sharp peak and short tails, has significantly improved the ablation/coagula-
tion ratio and reduced thermal diffusion to the surrounding tissue.
The latest generation uses the UltraPulse concept, where the energy pulse has a
more consistent rectangle shape without tails. We use the term char-free due to its
a Continuous Wavelength lasers
Time 1.0 ms
b SuperPlus Lasers
p
o
w
e
r
Time 1.0 ms
c SuperPlus Lasers
p
o
w
e
r
Time 1.0 ms
Fig. 6.14 Difference between (a) continuous wave (CW), (b) SuperPulse, and (c) UltraPulse in
terms of energy shape and skin effect
252 6 Scar Revision
precise ablation and low thermal diffusion zone. Figure 6.14 shows the difference
between the three pulse modes of CO2 lasers: (a) continuous wave (CW), (b)
SuperPulse, and (c) UltraPulse.
Indications
The ability to control the ablation/coagulation ratio and fractional density has made
the CO2 laser a versatile tool in dermatology and the aesthetic field. Its indication
includes skin remodelling, photorejuvenation, pigmentation, and scar removal. If
you are not a dermatologist, this would be the last laser system you would add to
your practice. Figure 6.15 shows the different indications of the CO2 laser according
to spot size and energy.
Comparison
Table 6.17 compares light-, medium-, and heavy-duty CO2 laser systems. They are
ranked alphabetically.
Smaller Beam Size Larger Beam Size &

& HIGH ENERGY LOW ENERGY
Penetrste deeply in dermal layer Weakly ablate epidermal layer
Skin tone, texture, pores,

Scar, wrinkles, laxity
fine wrinkles
Skin tightening+ Alike to efficacy of slight shemical

Collagen remodelling peeling
Major serious skin reaction, downtime (erythema could Minor skin reaction, less downtime, no anesthesia,
last for 1 month), pain (pain and downtime are able to be (does not high energy to penetrate into dermis)
overcome by adjustment of scan size
Fig. 6.15 Different indications of the CO2 laser according to spot size and energy
Table 6.17 Comparison of three CO2 laser systems

Max
ablation Max
System name depth peak Stacking Handpieces Features
eCO2 by 2.5 mm 30 Yes 120/300/500/1000 Variable MTZ size
Lutronic
The only CO2 with a
dynamic option
Easy-to-use
interface
CO2RE by Less than 60 No Single handpiece (150 Four simple
Candela 1 mm μm spot size) operating mode
Disposable handpiece
Easy-to-use
interface
Light and easy to
move
UltraPulse by 4 mm 240 Yes ActiveFX/DeepFX/ Powerful CO2 laser,
Lumenis SCAARFX heavy-duty
Require experienced
user
Advanced practice
In-depth control
interface
Fig. 6.16 Operator interface window for the eCO2 by Lutronic

254 6 Scar Revision
eCO2 by Lutronic
This is a simple CO2 laser system that provides all the benefits of a modern system
but with limited operator control (Fig. 6.16; Table 6.18).
Table 6.18 eCO2 plus system specifications

Laser wavelength 10.6 μm
CO2 module maximum power Maximum 30 watts at continuous wave
Fractional scanner handpiece User mode Static (stamping)/dynamic (air brushing)
Tip 120, 300, and 500 μm spot sizes
Pulse energy 2–240 mJ
Pulse rate 10–200 Hz
Density 25–400 spots/cm2
Scan area 18 × 18 mm
Scan shapes Different shapes
Normal handpiece User mode Char-free (UltraPulse)/SuperPulse/CW
Pulse rate Char-free (UltraPulse) 1–700 Hz
SuperPulse 1–550 Hz
Pulse width Char-free (UltraPulse) 40–1000 μs
SuperPulse 1–5 ms
Fig. 6.17 Operator interface window for the CO2RE by Candela. This platform has advanced set-
tings that allow the operator to adjust the ring and the core size
Table 6.19 CO2RE four modes

Mode Energy settings Fractional coverage Estimated ablation depth
CO2RE light 30–60 mJ 30–50% 30–60 μm
CO2RE mid 60–90 mJ 20–40% 60–100 μm
CO2RE deep 50–80 mJ 1–5% 500–750 μm
CO2RE fusion 60–90 mJ 20–40% 60–100 μm and 500–750 μm
Classic ablative 1–10 mJ Full 100–200 μm
Surgical 10–50 mJ n/a Line: 6 × 0.2 mm
Table 6.20 CO2RE system specifications

256 6 Scar Revision
CO2RE by Candela
An advanced system with full operator control (Fig. 6.17; Tables 6.19 and 6.20).
Fig. 6.18 Operator interface window for UltraPulse by Lumenis
Table 6.21 UltraPulse system specifications

Handpieces UltraPulse DeepFX™, ActiveFX™, TotalFX™
Wavelength 10,600 nm
Laser type UltraPulse and CW
Power to tissue 60 W
Peak power 240 W
Spot size Microscanner 120 μm
UltraScan™ CPG 1.3 mm
Depth Microscanner 100–3500 μm
UltraScan™ 10–300 μm
Density per scan Fractional: 1–82%, full ablative: >100%
Cooling Self-contained, closed cycle
UltraPulse by Lumenis (Fig. 6.18; Table 6.21)

The treatment parameters depend on the scar’s thickness; in general, CO2 does not
penetrate more than 1 mm into the skin due to high water affinity. A useful three-
stage protocol was reported:
1. One pass of deep fractional ablation with high energy between 70 and 120 mJ
and low density and short pulse width
2. Two passes of superficial ablation and considerable coagulation using energy 40
mJ, high density, and long pulse duration
3. Lastly, one pass of high energy 100–120 mJ, low density, and long pulse width
This protocol provides the right balance between the ablation and coagulation
effect of the CO2 laser [62]. The previous setting could be achieved in all current
CO2 laser systems by changing the pulse mode and the handpiece [63]. However,
some platforms grant practitioners much liberty to adjust treatment parameters. One
study showed that the combination of IPL and CO2 was effective.
For example, the UltraPulse Encore CO2 laser from Lumenis has two energy
delivery modes: UltraPulse with short pulse duration and continuous wave (CW)
with a long pulse. Within each mode, there are different modules for different hand-
pieces to reach the required depth and coagulation. This protocol provides the right
balance between the ablation and coagulation effect of the CO2 laser. Practitioners
should generally adjust the energy to over 500 μm in ablation depth, with 5–10%
microbeam density.
IPL or PDL lasers can enhance the effect of CO2 lasers. According to one study,
combining the CO2 laser with IPL was statistically more significant in terms of
color and texture than the CO2 laser alone, as shown in Fig. 6.19 [64] (Table 6.22).
In a recent study, the 595 nm PDL was used to treat red hypertrophic scars first;
the treatment parameters were 7–15 J/cm2 fluence, 1.5–3 ms pulse widths, 7 mm
spot size, 30 ms spray, and dynamic cooling device delay of 20 ms (DCD). Purpura
in the treated region was the treatment’s endpoint. The scar was then treated with the
UltraPulse fractional CO2 laser’s DeepFX model, with 3050 mJ energy, frequency
of 300 Hz, and density of 5% After 3 months, the combined laser treatment was
repeated; results are shown in Fig. 6.20 [65].
ER:YAG
The older Er:YAG platforms have a fixed pulse width of 0.25–0.35 ms, producing
purely ablative results without coagulation. However, the newly developed Er:YAG
platforms allow the Er:YAG to produce both ablation and coagulation effect by
introducing a variable square pulse mode that extends from 0.2 to 1.6 ms. The long-
pulsed-duration Er:YAG ablates the upper skin layers and creates coagulation in the
deep layers. The downtime of the traditional Er:YAG treatment is also significantly
shortened by utilizing the stacking technique. Instead of delivering the energy in
one pulse, the system delivers the same energy in a burst of five to six consecutive
pulses with short intra-pulse time (0.025 ms) [66]. In general, the Er:YAG laser does
258 6 Scar Revision
Fig. 6.19 Before and after images of the subject treated with the CO2 fractional ablative laser in
conjunction with intense pulsed light (IPL), the CO2 fractional ablative laser alone, and the con-
trol [64]
Table 6.22 Treatment setting guidelines of the CO2 laser and the M22 intense pulsed light
Fig. 6.20 Pulsed dye laser (PDL) combined with fractional CO2 laser treat middle and low face
scar [65]
Fig. 6.21 Depth of

ablation and coagulation
not penetrate more than 0.5 mm in the skin due to extreme water affinity. Figure 6.21
show the effect of five different modes of Fotona Er:YAG:
1. With coagulation (medium peel, deep peel, and smooth mode)
2. With out coagulation (light peel and deep cold peel)
Practitioners should choose the parameter according to the thickness of the scar.
For example, for thick scars, we wish to provide a profound ablation effect. The
following are the suggested parameters to reach a deep level of ablation and variable
coagulation using the FS10 fractional handpiece (Table 6.23).
The coagulation level depends on both the energy and pulse width—the more
extended pulse width of the same fluence results in deeper coagulation. Practitioners
260 6 Scar Revision
Table 6.23 General parameters for fractional Er:YAG resurfacing using the Fotona laser machine
Fractional skin resurfacing
Handpiece Fluence Depth Frequency User mode
FS01 80 J/cm2 274 μm Turbo 5 SP Mode (add 9 μm of coagulation)
90 J/cm2 309 μm LP Mode (add 11 μm of coagulation)
VLP (add 13 μm of coagulation)
XLP (add 16 μm of coagulation)
should always use shorter pulses with darker skin types. We recommend 4–5 passes
to reach 20% MTZ density, and practitioners could follow a similar protocol to what
we reported under the CO2 laser to balance ablation and coagulation.
The debris should be removed using a soft cloth that emerged in normal saline to
enhance ablation. The pinpoint bleeding might decrease the laser ablation effect.
Therefore, practitioners should increase the fluence or apply a vasoconstrictor solu-
tion topically with the first sign of bleeding (2% lidocaine with norepinephrine 20
μg/mL or a corticosteroid solution). Two passes of 595 nm pulsed dye laser before
the ablative laser would significantly decrease pinpoint bleeding.
The coagulation level should be reduced to the minimum if the treatment plan
includes a fractional non-ablative laser. The number of treatments depends on the
scar thickness and client satisfaction level. The treatment could be repeated after
12 weeks if required. The second treatment setting could be adjusted according to
the required outcomes; for general smoothing, a practitioner should adjust the set-
ting to achieve superficial ablation (low energy, short pulse width, and low density).
Stacking
Ablative laser platforms repeat the laser shot at the same MTZ several times.
Practitioners might use stacking to achieve deeper ablation or coagulation without
the undesired thermal diffusion associated with greater pulse width. This technique
significantly improved the safety and tolerability of FAL and reduced erythema and
downtime.
Practitioners should consult the manufacturer to understand how they used the
term “stacking” in their publications. In some manuals, stacking means that the
same pulse is divided into micro-pulses, but the same total energy would be deliv-
ered during the same pulse width, as shown in Fig. 6.21 [67]. Higher stacking is
usually related to lower erythema and downtime. It is important to refer to the user
References 261
Power Decreasing Erythmea
Power
Smart Smart Smart Smart
stack 1 stack 2 stack 3 stack 5
Time Time
Dwell Time: Dwell Time: Dwell Time: Dwell Time:
1000μs 500μs 300μs 200μs
E=1x30 mJ DOT Energy: DOT Energy: DOT Energy: DOT Energy: E=5x6 mJ = 30mJ
30mJ 30mJ 27mJ 30mJ
Fig. 6.22 Difference between five stacking modes in the SmartXide DOT CO2 laser from
Deka [67]
manual for each laser machine, as stacking might be interpreted differently.

Repetition rate refers to the interval between every pulse and is related to overlap-
ping the practitioner technique in moving the handpiece. In others, stacking is used
interchangeably with repetition and the number of passes [68]. For example,
TURBO mode in Fotona Dynamis is an Er:YAG treatment modality that enables
larger ablation depths to be achieved by stacking multiple pulses on the same treat-
ment area (Fig. 6.22).
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with a 10,600-nm carbon dioxide fractional laser system: a split-face, evaluator-blinded study.
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32. Hedelund L, et al. Fractional CO2 laser resurfacing for atrophic acne scars: a randomized con-
trolled trial with blinded response evaluation. Lasers Surg Med. 2012;44(6):447–52.
2011;38(3):449–61.
34. Manuskiatti W, et al. Comparison of fractional erbium-doped yttrium aluminum garnet
and carbon dioxide lasers in resurfacing of atrophic acne scars in Asians. Dermatol Surg.
2013;39(1pt1):111–20.
35. Taylor MB, Koron N. Combined treatment of rolling acne scars in ethnic skin using exten-
sive subcision, trichloracetic acid peel, and fractional ablative erbium laser. Dermatol Surg.
2021;47(4):496–9.
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histological evaluation. Lasers Surg Med. 2004;35(2):146–51.
37. Zaleski-Larsen LA, et al. Acne scar treatment: a multimodality approach tailored to scar type.
Dermatol Surg. 2016;42:S139–49.
38. Andrews JP, et al. Keloids: the paradigm of skin fibrosis—pathomechanisms and treatment.
Matrix Biol. 2016;51:37–46.
39. Taylor SC. Skin of color: biology, structure, function, and implications for dermatologic dis-
ease. J Am Acad Dermatol. 2002;46(2):S41–62.
40. Slemp AE, Kirschner RE. Keloids and scars: a review of keloids and scars, their pathogenesis,
risk factors, and management. Curr Opin Pediatr. 2006;18(4):396–402.
41. Park TH, Chang CH. Keloid recurrence in pregnancy. Aesthet Plast Surg. 2012;36(5):1271.
42. Moshref SS, Mufti ST. Keloid and hypertrophic scars: comparative histopathological and
immunohistochemical study. Med Sci. 2010;17(3):3–22.
43. Appleton I, Brown NJ, Willoughby DA. Apoptosis, necrosis, and proliferation: possible impli-
cations in the etiology of keloids. Am J Pathol. 1996;149(5):1441.
44. Murray JC, Pollack SV, Pinnell SR. Keloids: a review. J Am Acad Dermatol. 1981;4(4):461–70.
45. Ogawa R, Akaishi S, Izumi M. Histologic analysis of keloids and hypertrophic scars. Ann Plast
Surg. 2009;62(1):104–5.
46. Erol OO, et al. Treatment of hypertrophic scars and keloids using intense pulsed light (IPL).
Aesthet Plast Surg. 2008;32(6):902–9.
47. Kim DY, et al. Efficacy of IPL device combined with intralesional corticosteroid injection for
the treatment of keloids and hypertrophic scars with regards to the recovery of skin barrier
function: a pilot study. J Dermatol Treat. 2015;26(5):481–4.
48. Piccolo D, et al. Unconventional use of intense pulsed light. Biomed Res Int. 2014;2014:618206.
49. Excel V Clinical Training Guide. https://mycutera.com/getattachment/31f5e9ef-80d9-4c0e-
ba82-c061b0b68c9f/Clinical-Training-Guide.aspx.aspx.
50. Raulin C, Karsai S. Laser and IPL technology in dermatology and aesthetic medicine. Springer
51. Chan HH, et al. The use of pulsed dye laser for the prevention and treatment of hypertrophic
scars in Chinese persons. Dermatol Surg. 2004;30(7):987–94.
52. Cho S, et al. Efficacy and safety of 1064-nm Q-switched Nd:YAG laser with low fluence for
keloids and hypertrophic scars. J Eur Acad Dermatol Venereol. 2010;24(9):1070–4.
53. Manuskiatti W, Fitzpatrick RE. Treatment response of keloidal and hypertrophic sternotomy
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54. Paquet P, Hermanns JF, Piérard GE. Effect of the 585 nm flashlamp-pumped pulsed dye laser
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molysis on scar remodeling. Lasers Surg Med. 2011;43(4):265–72.
58. Verhaeghe E, et al. Nonablative fractional laser resurfacing for the treatment of hypertrophic
scars: a randomized controlled trial. Dermatol Surg. 2013;39(3pt1):426–34.
59. Issa MC, et al. Topical delivery of triamcinolone via skin pretreated with ablative radiofre-
quency: a new method in hypertrophic scar treatment. Int J Dermatol. 2013;52(3):367–70.
60. Niwa ABM, et al. Fractional photothermolysis for the treatment of hypertrophic scars: clinical
experience of eight cases. Dermatol Surg. 2009;35(5):773–8.
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264 6 Scar Revision
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Chapter 7
Stretch Marks (Striae Distensae)
Treatment settings could be adjusted to target one or more chromophores to correct the
stretch marks’ appearance. These chromophores are water, hemoglobin and its deriva-
tives, and melanin. The treatment goal on stretch marks is to correct their appearance
and make them less distinctive in color or appearance and eventually blend with the
surrounding skin [1]. The correction can be achieved by different protocols that include
both ablative and non-ablative lasers by smoothing the surface, enhancing collagen
production, decreasing vascularity, and correcting melanin pigmentation [2].
Etiology
Stretch marks generally develop in various stages such as pregnancy, puberty, or recur-
rent abrupt changes in weight. However, they are also observed in some syndromes
such as Cushing or as a side effect of topical or systemic pharmaceutical therapies.
Similar to keloids, their pathology is multifactorial and still controversial.
However, there is a consensus that abnormal production of proteins and imbalance
of extracellular matrix components (ECM) alter the dermal connective tissue qual-
ity and appearance. However, stretch marks are the extreme opposite of keloids’
hypertrophic scar, where the enzyme activities are higher than connective tissue
formation. Therefore, some practitioners classify stretch marks as atrophic scars.
Stretch marks are initially red and raised with signs of swelling (striae rubra).
They then go aging process in which the dermis loses its elasticity, becomes thin
and atrophic, and loses its color to become pale (striae alba) (Fig. 7.1).
The normal epidermis has a basketweave appearance and well-formed rete
ridges. In contrast, SD shows a loss of the rete ridge pattern. Additionally, the nor-
mal dermis demonstrates parallel collagen bundles to the surface, evenly spaced,
which contrasts with the SD dermis; ED, epidermis; PD, papillary dermis; and RD,
reticular dermis [3].

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266 7 Stretch Marks (Striae Distensae)
Fig. 7.1 Histological
differences between
normal skin and stretch
marks [3]
Light Base Treatment
The treatment goal on stretch marks is to correct the appearance on three domains:
color (redness or loss of pigment), texture, and size. Practitioners should manage
clients’ expectations regarding the results and number of sessions [4].
IPL
Practitioners should choose the treatment wavelength band according to the stretch
mark status and the patient skin type. IPL treatment is significantly more effective
in the early stages of the stretch marks (red and raised) before the hypertrophic
stage. IPL treatment has two goals: decreasing vascularity (540 nm and 580 bands)
and connective tissue rejuvenation (640 nm and 695 nm bands). As for fluency, it is
generally recommended to reduce it on the fatty area (abdomen, buttocks, and
breasts) due to high heat retention [5].
Here are the setting reported by Vydence for monthly treatment, with an average
of 5 sessions (3–7 sessions) to improve the color and overall appearance.
Table 7.1 shows the recommended settings for stretch mark treatment [6].
The following parameters are recommended for red stretch marks when a
sequential delivery mode is available.
Table 7.2 shows the stretch mark treatment settings when using the M22 IPL [7].
Practitioners could use the 645 filters on pale stretch marks to enhance tissue
remodelling due to higher safety and lack of vascularity. This protocol is reported
using the Lumenis M22, 645 nm filter, starting fluence of 30 J/cm2 and then increased
in each session according to skin response (edema and erythema at the end of each
Light Base Treatment 267
Table 7.1 Parameters used in IPL stretch mark treatment

Skin Spot size Fluence Wavelength Pulse width
type (mm) Passes (J/cm2) (nm) (ms) Cooling
I–II 40 × 12 1 10–16 640 100 High
I–II 40 × 12 2 14–18 540 15–20 ms High
III–IV 40 × 12 1 9–17 640–695 100 ms High
III–IV 40 × 12 2 14–18 580 15–20 ms High
Table 7.2 Parameters in M22 IPL for stretch mark treatment

Skin type Fluence (J/cm2) Wavelength (nm) Pulse width (ms) Pulse delay (ms) # of pulses
I 19 560 3.5 10 Triple
II 19 560 nm 3 15 Triple
III 18 560 nm 3.5 20 Triple
IV 19 590 nm 3.5 30 Triple
V 17 590 nm 4.5 35 Triple
treatment). The energy was delivered in a train of two sub-pulses (2.7 and 4 ms)
separated by a 20 ms delay. The protocol had a total of biweekly sessions.
Another protocol reported using a traditional IPL with the 595 nm filter, the
pulse duration of 0.5 ms, and a fluence of 2.5 J/cm2. The protocol includes five ses-
sions with 4-week intervals between the sessions.
Pulsed Dye Laser
In the first 6–12 months of formation, stretch marks are distinguished with erythema
due to the presence of dilated blood vessels. Therefore, it would be logical to use a
pulsed dye laser to target oxyhemoglobin [8]. However, this treatment might cast a
challenge in darker skin-type clients (IV–V) due to a higher risk of hyperpigmenta-
tion and PIH. Therefore, pulsed dye laser was mostly used (fluence 3 J/cm2, 0.5 ms
pulse width, and 10 mm spot size) combined with other lasers such as fractional
lasers for best results [9].
1064 nm ND:YAG
This wavelength has an affinity to all three chromophores (hemoglobin, water, and
melanin), which is considered an advantage in stretch mark treatment. Nd:YAG
significantly improves dyschromia issues (hypopigmentation and redness) but has
less effect on the texture.
Treatment using Nd:YAG involves high energy (75–100 J/cm2) with a short pulse
duration (15 ms) and small spot size (3–5 mm) in red stretch marks. Therefore, only
a b
Fig. 7.2 Stretch marks before (a) and after (b) a single session of 1064 nm long pulsed Nd:YAG
laser [11]
practitioners with enough experience should attempt to use the 1064 nm laser for
stretch marks, as shown in Fig. 7.2. The recommended number of treatments is
monthly with a total of four treatments. Moreover, intense settings can be used
when ND:YAG is used in combination with fractional lasers [10].
A recent study showed that the therapeutic efficacy of the Nd-YAG laser outper-
formed that of the fractional CO2 laser in the treatment of white stretch marks with
better tolerability, as shown in Fig. 7.3. The Nd:YAG treatment parameters employed
were fluence of 80 J/cm2, spot size of 4 mm, and pulse duration of 15 ms [12].
Fractional Non-ablative Lasers
Due to lower water affinity, these lasers would significantly affect coagulation and
dermis remodelling at more extended depth. These are the most effective in reduc-
ing stretch mark dimension but less on color and texture. In our opinion, these are
most effective in correcting stretch mark dimension and texture and dyschromia.
1540 Fractional Laser
The Icon from cynosure is equipped with several applicators that have different
stamping tips with different spot sizes and treatment density; XD Microlens (12 × 12
mm) provide 25 microbeam/cm2, XF Microlens applicator provides 115 MTZ/cm2,
and the 15 mm tip provides 320 MTZ/cm2. The applicators differ in terms of the
microbeam energy and dimension.
Practitioners should benefit from deep XD (extra deep) and superficial XF (extra
fast) handpiece properties. Stretch marks showed significant improvement after fol-
lowing this protocol: XD, 50 J/cm2, 15 ms, two passes, and XF, 50 J/cm2, 15 ms, two
passes, for a total of 25% density. Most clients will need four monthly treatments.
The system relies on the traditional stamping technique during the treatment.
Light Base Treatment 269
a b
c d
Fig. 7.3 (a) Right arm of a 29-year-old female patient before Nd:YAG treatment, (b) after three
Nd:YAG treatment sessions; (c) left arm of the same patient before fractional CO2 laser treatment,
(d) after three fractional CO2 laser sessions [12]
1550 nm Er:Glass Laser
The relevantly low affinity of the 1550 nm laser provides deep coagulation that
reaches 1.5 mm. The following settings effectively correct stretch mark dimension
and texture using Fraxel 1550 system: 50 mJ, level 7, and eight passes at 4-week
intervals [13]. The suggested stretch mark treatment parameters are usually associ-
ated with a high level of discomfort and could be painful [14]. Therefore,
Table 7.3 General recommendation for Fraxel dual lasers in different indications
Power Treatment Number of
Wavelength (mJ) level passes Intervals
Stretch marks 1550 25–40 5 6 4 weeks
Resurfacing 1927 20–45 6 3 6 weeks
Scars 1550/1927 35–50 7 6 4 weeks
Melasma and 1550/1927 10–15 4 3 8 weeks
hyperpigmentation
Alopecia 1550 20 5 6 4 weeks
practitioners should direct the clients to apply topical anesthetic preparations. Fraxel
is equipped with a revolving wheel, and the laser will be delivered through a con-
tinuous moving pattern. The moving wheel is considered consumable and is an
extra cost that a practitioner should consider. These settings can be interpreted to
1000 MTZ/cm2 when using other 1550 nm laser platforms such as Frax 1550 (part
of the Nordlys platform) and Ydun by Candela (Frax Pro) (Table 7.3).
1565 nm Laser
Another non-ablative laser is the 1565 nm laser by the ResurFX from Lumenis.
Practitioners could adjust the treatment level (density) between 50 and 500 MTZ/
cm2 per pass, with adjustable spot shape and size 5 to 18 mm, with an energy of up
to 70 mJ/MTZ. This treatment is effective in correcting stretch marks. Each treat-
ment involves two passes: the first is 300 MTZ/cm2 with 40–44 mJ/cm2, with a
focus on the center of the stretch marks; the second pass treats the full area, includ-
ing stretch marks’ margins (settings 150 MTZ/cm2 and 50–55 mJ/cm2) [15].
ResurFX form Lumenis generates an array of focused microbeams for each shot
(each microbeam has a diameter of 110–200 and can determine a column of dena-
turation inside the dermis of 800 of depth using the maximum energy of 70 mJ) that
the operator can vary from a density of 50–500 beams/cm2. The practitioner can
select from six different forms, with spot sizes ranging from 5 to 18 mm (depending
on the shape and density of the microbeams) and delivering up to 70 mJ/spot. The
reusable tip incorporates contact cooling and a window through which the operator
may precisely observe the aiming beam and, thus, the treatment target. The micro-
beams are emitted in a nonsequential way and distributed uniformly, and this non-
sequential pattern prevents overheating [16].
Fractional Ablative Lasers
Ablative lasers have an extreme affinity to water molecules in the skin tissues,
which results in skin cell vaporization. Like hypertrophic scars, the most commonly
used fractional ablative lasers for stretch marks are 10,600 nm CO2 and 2940 nm
References 271
Er:YAG lasers. The goal of fractional ablative laser is to ablate, coagulate, and
induce connective tissue remodelling. Therefore, fractional ablative lasers have less
role in stretch mark treatment, especially in the early stages. However, these are
effective in smoothing the texture, especially old pale stretch marks.
10,064 nm CO2 Laser
Fractional CO2 lasers are more effective in mature pale stretch marks than in new
red ones. The CO2 laser should be combined with a pulsed dye laser to target the
vascularity in red stretch marks. Practitioners should balance ablation and coagula-
tion when correcting stretch marks with a CO2 laser. This balance can be achieved
by choosing the pulse shape and duration, treatment density, energy, and stacking.
Treatment density should achieve 20% after all passes are delivered (usually 2–4
passes); energy is usually set between 10 and 20 W, depending on the skin type;
stacking is between 2 and 3. This protocol showed significant improvement when
using DEKA SmartXide DOT. The first pass only focuses on the stretch marks with
the following parameters: power 20 W, spacing 800 μm, dwell time 800 μs, and
three stacks.
The second pass was done on the whole area (e.g., the whole abdomen) using the
following parameters: power 20 W, spacing 800 μm, dwell time 800 μs, and
two stacks.
Fractional Er:YAG Laser
The new variable pulse Er:YAG laser has made it possible to balance the treatment’s
ablative/coagulation results. Most new Er:YAG platforms also provide the Er:YAG
for a dual treatment in skin types I–IV and as a monotherapy for skin type IV.
The following is a protocol of dual Nd:YAG/Er:YAG treatment using the Fotona
platform.
• Nd:YAG 15 J/cm2, 0.6 ms pulse width, and 9 mm spot size with 6 Hz. Practitioners
should apply laser in continuous movement to reach a skin temperature of 42 and
maintain it for 2–3 min.
• Er:YAG fractional handpiece with 4 J/cm2 at micro-short pulse duration to
achieve 11 microns of ablation and 12 μm of coagulation [17].
References
1. Borrelli MR, et al. Striae distensae: scars without wounds. Plast Reconstr Surg.
2021;148(1):77–87.
2. Oakley AM, Patel BC. Stretch marks (striae). StatPearls; 2020.
3. Ud-Din S, McGeorge D, Bayat A. Topical management of striae distensae (stretch

marks): prevention and therapy of striae rubrae and albae. J Eur Acad Dermatol Venereol.
2016;30(2):211–22.
4. Nepomuceno AC, Da-Silva LC. Laser treatment for stretch marks: a literature review. Revista
Brasileira de Cirurgia Plástica. 2001;33(4):580–5.
5. Hernández-Pérez E, Colombo-Charrier E, Valencia-Ibiett E. Intense pulsed light in the treat-
ment of striae distensae. Dermatol Surg. 2002;28(12):1124–30.
6. IPL-sq handpieces. 2021. https://shop.salientmed.com/en/aesthetics/hair-removal/
vyd018077-ipl-sq-handpiece.
7. Lumenis M22 operator manual. 2021. https://www.medwrench.com/documents/view/7211/
lumenis-m22-operator-s-manual.
8. Jimeénez GP, et al. Treatment of striae rubra and striae alba with the 585-nm pulsed-dye laser.
Dermatol Surg. 2003;29(4):362–5.
9. Karsai S, et al. Pulsed dye laser: what’s new in non-vascular lesions? J Eur Acad Dermatol
Venereol. 2007;21(7):877–90.
10. Goldman A, Rossato F, Prati C. Stretch marks: treatment using the 1,064-nm Nd:YAG laser.
Dermatol Surg. 2008;34(5):686–91; discussion 691–2.
11. Wollina U, Goldman A. Management of stretch marks (with a focus on striae rubrae). J Cutan
Aesthet Surg. 2017;10(3):124.
12. Hendawy AF, et al. Comparative study between the efficacy of long-pulsed neodymium-
YAG laser and fractional CO2 laser in the treatment of striae distensae. J Lasers Med Sci.
2021;12:e57.
13. Gokalp H. Long-term results of the treatment of pregnancy-induced striae distensae using a
1550-nm non-ablative fractional laser. J Cosmet Laser Ther. 2017;19(7):378–82.
14. Kim BJ, et al. Fractional photothermolysis for the treatment of striae distensae in Asian skin.
Am J Clin Dermatol. 2008;9(1):33–7.
15. Tretti Clementoni M, Lavagno R. A novel 1565 nm non-ablative fractional device for stretch
marks: a preliminary report. J Cosmet Laser Ther. 2015;17(3):148–55.
16. Clementoni MT, et al. Striae distensae. In: Energy for the skin. Springer; 2022. p. 301–13.
17. Wanitphakdeedecha R, Meeprathom W, Manuskiatti W. A pilot study of treatment of striae
distensae with variable square pulse Erbium: YAG laser resurfacing. J Cosmet Dermatol.
2017;16(4):466–70.
Chapter 8
Laser Vaginal Rejuvenation
Vaginal relaxation syndrome (VRS) is a broad term that has been recently intro-
duced. It describes various disorders that can result from relaxation of the vaginal
wall. Aging, childbirth, and hormonal changes post-menopause are considered risk
factors that can aggravate the signs and symptoms of VRS. Women with VRS can
suffer from one or multiple problems including sexual dysfunction due to loosening
of the vaginal wall, vulvovaginal atrophy (VVA), and stress urinary incontinence
(SUI). While VRS can affect women at any age, postmenopausal women are at
higher risk of experiencing VRS due to decrease in their estrogen levels, which is
referred to as genitourinary syndrome of menopause (GSM). GSM symptoms
include vaginal pain, dryness, itchiness, and dyspareunia. Women with GSM also
suffer from urological symptoms such as urinary urgency and frequency, frequent
urinary tract infection, and urinary incontinence. Signs of GSM include changes of
the vaginal wall lining, thinning of superficial cells, and increase in the parabasal
and intermediate cells. The signs and symptoms of GSM do not resolve without
treatment; in fact, if left untreated, GSM can progress, and symptoms can become
worse over time.
Lasers, radiofrequency (RF), high-intensity focused ultrasound (HIFU), and the
newer high-intensity focused electromagnetic (HIFEM) technology are the most
recent technologies used in managing some vaginal symptoms, non-surgically,
which is widely referred to as vaginal rejuvenation.
On July 13, 2018, the FDA released a statement in regard to deceptive health
claims and significant risks related to devices marketed for use in medical proce-
dures for “vaginal rejuvenation.” Their statement is as follows:
As part of our efforts to promote women’s health, the FDA has cleared or approved laser
and energy-based devices for the treatment of serious conditions like the destruction of
abnormal or pre-cancerous cervical or vaginal tissue, as well as condylomas (genital warts).
But the safety and effectiveness of these devices hasn’t been evaluated or confirmed by the
FDA for “vaginal rejuvenation.” In addition to the deceptive health claims being made with
respect to these uses, the “vaginal rejuvenation” procedures have serious risks. [1]

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274 8 Laser Vaginal Rejuvenation
Health Canada followed the FDA’s lead and issued “It Has Come To Our
Attention Letters” (IHCTOA) to all major manufacturers and distributors, request-
ing that the term “vaginal rejuvenation” be removed from their websites and mar-
keting materials. The majority of CO2 and Er:YAG lasers have been approved by
health agencies for specific indications such as GSM, SUI, and VVA. In this chapter,
we will refer to the intravaginal use of lasers to treat GSM, SUI, or VVA symptoms
as laser vaginal rejuvenation (LVR).
Laser Vaginal Rejuvenation
This chapter will discuss vaginal application of laser only and will not include other
technologies such as RF, HIFU, nor HIFEM that are cleared for the same indication.
The CO2 and Er:YAG lasers have traditionally been employed in gynecological
surgery that includes but is not limited to labiaplasty and the excision of genital
warts. The most recent nonsurgical application for vaginal lasers includes soft tissue
ablation and coagulation, which is widely referred to as laser vaginal rejuvenation
(LVR). LVR is a very general term that includes management of various gyneco-
logical conditions, such as lichen sclerosus, GSM, and VRS. Table 8.1 provides a
list with the laser devices that can be used intravaginally [2].
Literature has shown conflicting results in terms of the efficacy of intravaginal
laser application. For example, a recent study was unable to show an improvement
in stress urinary incontinence after CO2 vaginal laser therapy [3]. However, a recent
meta-analysis concluded that “CO2 laser treatment may be effective for postmeno-
pausal women with VVA symptoms in improving quality of life and sexual func-
tion” [4]. Another study added “There are no contraindications to vaginal laser
therapy except for its high cost. The evidence reviewed shows that laser therapy can
be used for the treatment of GSM symptoms and does not show any adverse effects.
However, there does not appear to be sufficient evidence of its long-term efficacy
and other effects” [5].
Table 8.1 Laser devices for vaginal applications

Device Technology type
CO2RE Intima (Syneron) Digital Superpulse CO2 laser (RF-excited,
10,600 nm)
diVa (Sciton) Hybrid fractional laser (1470/2940 nm)
diVaTyte (Sciton) Intense pulsed light (500–1400 nm)
DivaTight (Quanta System) Dual-wavelength laser (1540 and 10,600 nm)
FemiLift (Alma Lasers) Superpulse CO2 laser (10,600 nm)
FemTouch (Lumenis) Superpulse CO2 laser (10,600 nm)
IntimaLase (Fotona) Er:YAG laser (2940 nm)
MonaLisa Touch (Cynosure) Digital Superpulse, fractional CO2 laser (10,600 nm)
Laser Vaginal Rejuvenation 275
Fractional CO2
Most of the protocols suggest a series of three sessions, 4–6 weeks apart. A study
suggested two CO2 laser passes with an energy of 50–70 mJ and a fluence of
300–400 J/cm2 [6, 7]. The valvular area is usually treated with one pass of lower
fluence, around 40 mJ, and lower density 5% [8]. Tables 8.2 and 8.3 list the treat-
ment setting using the FemTouch from Lumenis according to the severity evaluated
by the Vaginal Health Index Score (VHIS) [9].
Table 8.2 Treatment parameter using FemTouch CO2 intravaginally

Treatment Atrophy level First treatment Second treatment Third treatment
Intravaginal Severe Energy: Energy: 10 mJ Energy: 10 mJ
(FemTouch™) (5< VHIS <15) 7.5/10 mJ Density: 10% Density: 10%
Density: 10%
Moderate Energy: 10 mJ Energy: 10/12.5 mJ Energy: 10/12.5 mJ
(15< VHIS <20) Density: 10% Density: 10/15% Density: 10/15%
Non atrophic Energy: 10 mJ Energy: 12.5 mJ Energy: 12.5 mJ
(VHIS>20) Density: 10% Density: 10/15% Density: 15%
Table 8.3 Treatment parameter using FemTouch CO2 in the valvular area
Treatment First Second Third
Treatment area Laser Type treatment treatment treatment
External (AcuScan 120 Vaginal CW Energy: Energy: Energy:
Microscanner, Deep mode) introitus 10 mJ 10 mJ 10 mJ
Density: Density: Density:
5% 5/10% 5/10%
Labia CW Energy: Energy: Energy:
Minora 10 mJ 10 mJ 10 mJ
Density: Density: 5% Density:
5% 5%
Labia Superpulse Energy: Energy: Energy:
Majora 10 mJ 10 mJ 10 mJ
Density: Density: Density:
5–10% 5–10% 5–10%
Non-ablative Er:YAG
Fotona has introduced a non-ablative mode of Er:YAG. This therapeutic effect of

FotonaSmooth relied on the thermal effect on human soft tissue without ablation
[10]. The non-ablative SMOOTH mode can be used on the skin and internal muco-
sal tissue. The initial attempts at targeting mucosal tissue were made intraorally.
When the SMOOTH mode is applied to the soft palate, tissue contraction occurs,
making it a suitable noninvasive way for treating snoring and sleep apnea difficul-
ties [11]. The use of FotonaSmooth expanded to include vaginal treatment. Currently,
two protocols available for minimally invasive, nonsurgical, and non-ablative pro-
cedures have been developed: IntimaLase (for VRS) and IncontiLase (for SUI).
These regimens contain two therapy sessions at a 4–6-week interval based on heat-
ing the vaginal wall mucosa to around 65 °C. The IntimaLase protocol takes around
8 minutes to complete, while IncontiLase takes about 15 minutes.
Another protocol which is available for treating pelvic organ prolapse is based on
the same sample basis as the protocols for vaginal tightening and SUI but with a
change in treatment intensity (increased) and location of the principal area treated
(the prolapsed part of the vaginal wall). This regimen necessitates three to five ses-
sions spaced 4–6 weeks apart. The number of sessions required is proportional to
the severity (grade) of the prolapse. The vaginal atrophy protocol is based on a
slightly different notion of milder hyperthermia, in which the mucosa is warmed up
to 45 °C, stimulating cell proliferation through heat shock protein activation, colla-
gen formation, and anti-inflammatory activity. This treatment consists of three ses-
sions spaced 3 weeks apart. Following initial tissue shrinking, the neocollagenisis
process could take up to 6 months to complete.
A recent study suggests a three-phase protocol with favorable outcome of sexual
function partly related to the tightening of the vagina:
• Phase 1: Full-beam FotonaSmooth mode using a fluence of 10 J/cm2 and repeti-
tion of 1.6 Hz
• Phase 2: Fractional laser beam in a perpendicular position to the front wall for
five passes using the same setting as phase 1
• Phase 3: Fractional laser beam to target the introitus and vestibule
Laser Vaginal Rejuvenation 277
Fig. 8.1 Left The G kit required for Fotona vaginal treatment. Right Optional G runner
The study recommended three treatment sessions separated by 4 weeks. The

handpiece needed to perform this protocol is shown in Fig. 8.1.
Hybrid Fractional Laser
The theory behind using the combination of 2940 nm and 1470 nm is to allow for
the creation of a very controlled column of ablation surrounded by a tunable layer
of coagulation [12]. Our literature search yielded no studies comparing the efficacy
of one laser versus the hybrid. The required diVa attachments to the joule system
and the suggested parameters for diVa vaginal treatment are shown Fig. 8.2 and
Table 8.4, respectively.
High Precision Automated (HPA) Handpiece
Guide rings
Dual wavelength energy delivery window
Single-Use Strengthened Quartz Dilator (SQD)
SQD handle
SQD tip
Fig. 8.2 The required diVa attachment for vaginal treatment
Table 8.4 diVa laser vaginal therapy

1470 nm (non-ablative) 2940 nm (ablative)
Application Treatment number Depth (μm) Density (%) Depth (μm) Density (%)
Premenopausal 1 500 6 300 7
2 600 15 350 14
3 700 18 400 14
Postmenopausal 1 400 4 200 7
2 500 12 250 14
3 600 15 300 14
Treatment Procedures 279
Treatment Procedures
A topical anesthetic was administered extra- and intravaginally for 20 minutes
before treatment, and remnants then should be subsequently removed using gauze
to reduce moisture from the mucosa, resulting in more heat energy absorption.
During laser therapy, the vaginal applicator should be inserted into the vaginal canal
to a depth of approximately 10 cm and put in contact with the vaginal wall (a tiny
quantity of mineral oil was added to the handpiece to ease application).
The interior region should be initially laser-passed, with the first laser shot aimed
upward (12 o’clock), and the following rounds were spun at a 30°–60° angle to
complete a 360° revolution. The handpiece should then be partially retracted 1 cm
(as indicated by the engraved notches), and the shot rotation was repeated to achieve
a uniform treatment of the whole vaginal canal with no pulse repeats in the same
place. Reinsertion and a second pass spanning an angle of 120° of the front area
(from 10 to 2 o’clock) should be undertaken to reinforce the bladder region, turning
the hand device 30°–60° each time and releasing it 1 cm after the area was finished
treated, encompassing the whole canal length, as shown in Fig. 8.3.
Fig. 8.3 General steps for laser vaginal rejuvenations

The vulvar could also be treated with one pass of factional handpiece with the
same fluence. Patients were instructed to refrain from strenuous physical activity,
use of a swimming pool or sauna, vaginal douches or lubricants, and intercourse for
5 days following therapy.
Evaluation, Consultation, and Follow-Up
Consultation/Education
A consultation is required to set realistic expectations and acquire a thorough under-

standing of the patient and her treatment goals. Before initiating any treatment, the
patient must comprehend the procedure, pre- and after-care instructions, expecta-
tions, contraindications, and potential complications.
Medical History
Prior to treatment, a full medical history should be collected, including any previous
or current medical condition or medication that is contraindicated or that may alter
the result of the treatment. Before initiating any further treatment, it is recom-
mended that a brief medical history be taken by evaluating clinical information such
as any new medications, relevant changes from previous treatment, pregnancy,
and so on.
Informed Consent
Prior to treatment, the patient must examine, understand, and sign the process of
accepting and confirming the treatment. This document shall summarize the themes
covered during the consultation. It certifies that the patient understands the proce-
dure, the risks, and the problems and that all queries have been addressed.
Medication
It is suggested that an antiviral medicine be provided to avoid the activation of a

herpes simplex virus infection.
Contraindications 281
Follow-Up
At each visit, treatment outcomes and overall patient improvement should be evalu-
ated by physical examination or using validated tools such as the International
Consultation on Incontinence Questionnaire (ICIQ-IU) [13], the Sandvik severity
index [14], and Vaginal Health Index Score (VHIS) [15]. The Female Sexual
Functioning Index (FSFI) questionnaire could be also used to assess the impact and
improvements of UI on the quality of sexual interactions in patients [16]. Other
tools focus on the sexuality aspects such as Female Sexual Distress Scale-Revised
(FSDS-R) [17].
Possible Side Effects
Minor to severe discomfort may occur during therapy, particularly in the introitus
and vulva areas. Short-term, more acute discomfort is possible at times, although it
fades rapidly when the application is interrupted.
A greater frequency and number of pulse stacking than those specified in the
therapy procedure might result in increased discomfort and burns.
When using and removing a lattice speculum, mechanical injuries are possible.
When the adaptor is moved forward or back, a protrusion of the ventral (in cysto-
cele) or dorsal wall (in rectocele) wall and prominent rugae might generate resis-
tance. This problem can be solved by tilting the speculum and adaptor vertically or
horizontally, dorsally, or ventrally. When using the lattice speculum, care should be
given with cautious handling, taking into consideration specific anatomical charac-
teristics to avoid injuries such as abrasions or bruises.
Small discomfort, a slight tugging, distinct spotting, and increased discharge
may occur after the therapy. Occasionally, brief distress symptomatology lasting a
few days to 3 weeks was noted.
Contraindications
• Infectious illness patients

• Patients suffering from connective tissue disease
• Patients that are prone to keloid development
• Immunocompromised or healing-compromised patients
• Patients who have been using systemic steroids for a long time (e.g., prednisone,
dexamethasone)
• Patients who are pregnant or breastfeeding
• Patients who have recently used isotretinoin (e.g., Accutane)

• Patients suffering from a medical condition that may impair wound healing
• Patients who do not use a medically recommended method of contraception
• Patients with acute or recurring urinary tract infections, active sexually transmit-
ted illnesses, or recent use of vaginal topical antibiotics or antifungal drugs
• Patients with a known collagen disorder, vascular disease, scleroderma, a history
of immunosuppression, a history of bleeding disorder, or a substantial concurrent
illness such as diabetes
• Patients who are using drugs that have been shown to impair sexual function and
have clinically significant anxiety, depression, or psychosexual dysfunction
• Patients who have been unable to certify a clean pelvic exam by a gyn in the
previous year
• Patients who had a pelvic exam in the previous year that revealed any contrain-
dication or associated condition
References
1. Gottlieb S. Statement from FDA Commissioner Scott Gottlieb M.D., on efforts to safeguard
women’s health from deceptive health claims and significant risks related to devices mar-
keted for use in medical procedures for “vaginal rejuvenation”. 2018. https://www.fda.gov/
news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-efforts-
safeguard-womens-health-deceptive-health-claims.
2. Qureshi AA, Tenenbaum MM, Myckatyn TM. Nonsurgical vulvovaginal rejuvenation with
radiofrequency and laser devices: a literature review and comprehensive update for aesthetic
surgeons. Aesthet Surg J. 2018;38(3):302–11.
3. Alexander JW, et al. CO2 surgical laser for treatment of stress urinary incontinence in women:
a randomized controlled trial. Am J Obstet Gynecol. 2022;227(3):473.e1–473.e12.
4. Liu M, et al. Efficacy of CO2 laser treatment in postmenopausal women with vulvovaginal
atrophy: a meta-analysis. Int J Gynecol Obstet. 2022;158(2):241–51.
5. Arunkalaivanan A, Kaur H, Onuma O. Laser therapy as a treatment modality for genitourinary
syndrome of menopause: a critical appraisal of evidence. Int Urogynecol J. 2017;28(5):681–5.
6. Palacios S, Ramirez M. Efficacy of the use of fractional CO2RE intima laser treatment in stress
and mixed urinary incontinence. Eur J Obstet Gynecol Reprod Biol. 2020;244:95–100.
7. Alexiades MR. Fractional CO2 laser treatment of the vulva and vagina and the effect of post-
menopausal duration on efficacy. Lasers Surg Med. 2021;53(2):185–98.
8. Arroyo C. Fractional CO2 laser treatment for vulvovaginal atrophy symptoms and vaginal
rejuvenation in perimenopausal women. Int J Women's Health. 2017;9:591.
9. Eder S, Darush M. FemTouch clinical guide. https://medavenu.by/wp-content/uploads/2022/08/
femtouch-clinical-treatment-guide-web-pb-2005717-rev-c.pdf.
10. Gambacciani M, et al. Sexual function after vaginal erbium laser: the results of a large, multi-
centric, prospective study. Climacteric. 2020;23(sup1):S24–7.
11. Gaspar A, et al. Smooth resurfacing by hyper stacking of Er:YAG laser pulses; a histological
and clinical study. J Laser Health Acad. 2021;2021(1).
12. Peet JJ. Evaluation of the safety and efficacy of hybrid fractional 2940 nm and 1470 nm lasers
for treatment of vaginal tissue: pilot study. J Med Life. 2011;4(1):75–81.
13. The International Consultation on Incontinence Questionnaire. https://iciq.net/.
References 283
14. Sandvik H, et al. Validation of a severity index in female urinary incontinence and its imple-
mentation in an epidemiological survey. J Epidemiol Community Health. 1993;47(6):497–9.
15. Alvisi S, et al. Vaginal health in menopausal women. Medicina. 2019;55(10):615.
16. Rosen CB, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D, D’Agostino R. R,
The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the
assessment of female sexual function. J Sex Marital Ther. 2000;26(2):191–208.
17. Carpenter JS, et al. Using an FSDS-R item to screen for sexually related distress: a MsFLASH
analysis. Sex Med. 2015;3(1):7–13.
Chapter 9
Buying a New Laser or IPL Devices
Photo energy devices are becoming an essential element of cosmetic dermatological

treatment. With the advancement of new technologies, more sophisticated devices
that are relatively safe and effective, especially for darker skin types, are being pro-
duced. With an expanding number of devices to select, deciding which system to
purchase has become a complex and frequently complicated chore for physicians.
Several technologies are available, including lasers, lights, and non-light energy
devices. Choosing a laser system, maintaining the equipment, and providing after-
sales support are all critical components of a successful laser practice.
Similarly, devices from many manufacturers with differing features and costs are
available, making it difficult for practitioners to decide which to purchase.
Furthermore, there is a lot of hype in the marketing and overblown promotional
material utilized by laser businesses, with each claiming that their system is the
greatest. There is a great deal of uncertainty regarding post-sales maintenance pro-
cedures. Most buyers are ignorant of the many types of insurance and other terms
and conditions that must be considered for their equipment. The purpose of this
essay is to concentrate on practical considerations before acquiring a laser. It is criti-
cal to carefully plan the type of machine, specifications, financial aspects, mainte-
nance, and warranties.
Before purchasing a laser, the buyer and seller should sign a contract or agree-
ment that covers key aspects of installation, after-sales service, and machine main-
tenance. Adequate training is required; understanding laser physics and laser-tissue
interaction will help you get the most out of your machine. To ensure after-sales
service, the credibility of the dealer and company should be established. Buying a
refurbished machine is never a good option, and we highly advise against it.

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27632-3_9
286 9 Buying a New Laser or IPL Devices
Stand-Alone Versus Modular Platforms
Laser systems are available in both stand-alone and platform configurations. In gen-
eral, stand-alone systems consist of a single wavelength with a single handpiece
designed for a specific purpose, such as a long-pulsed alexandrite 755 nm laser for
laser hair removal. Multiple handpieces can be attached to a platform system’s
machine, and the system can handle various indications. The handpieces may be a
hair removal handpiece, an IPL handpiece for treating vascular lesions, or a near-
infrared handpiece offering skin tightening treatments, among others. One or two
handpieces can be attached to the system at any given time and can be swapped out
as desired. The software of the system recognizes the attached handpiece, allowing
settings to be modified as necessary. The advantages and disadvantages of each of
these two systems are detailed in Table 9.1.
Obviously, stand-alone systems are better suited for large practices and estab-
lished practitioners with large budgets, whereas platforms are better suited for
beginners, those with multiple clinics, and if multiple doctors wish to share the
machine [1].
Table 9.1 Comparison of stand-alone versus modular platforms

Pros cons
Stand-alone Robust and reliable systems Multiple systems take up more
Have better peak power and options for the space and are more expensive to
dedicated treatment own
The ability to treat multiple patients at the Increased service visits if
same time if more than one stand-alone system systems are of different brands
is available in the clinic Increased maintenance costs
Modular Less expensive to acquire and able to treat a In the event of platform failure,
platforms variety of conditions all handpieces may dysfunction
Takes up less office space; requires fewer Only one patient at a time can be
service calls; probably reduces maintenance treated
costs Not as robust and comparatively
Greater mobility between rooms less effective than stand-alone
systems
Planning Your Next Device Purchase 287
Planning Your Next Device Purchase
Certain lasers are the gold standard in dermatology and aesthetics, despite the fact
that selecting a device is frequently challenging.
The most prevalent laser systems consist of the following:
• Laser hair removal utilizing diode laser 810 nm and long-pulsed Nd:YAG laser
1064 nm.
• Er:YAG 2940 nm and CO2 ablative and fractional lasers are utilized for the treat-
ment of benign skin lesions, resurfacing, and scars.
• The Q-switched Nd:YAG laser is used to treat pigmented lesions and tattoos.
• In addition, non-ablative 1550 nm fractional erbium glass laser and 585 and
595 nm pulsed dye laser for vascular lesions.
• Variables of pulse duration, spot size, energy, fluence, consumables, and cost
must be considered when selecting a laser system from the available models in
these technologies.
Here are the most important factors to consider before purchasing a device:
1. Socioeconomic factors: The first stage in the purchasing procedure is to examine
your unique customer demographic to determine which therapies would be most
enticing. Several socioeconomic factors may play a substantial role in the
decision-making process, including, but not limited to:
• Population age: Younger customers often seek laser hair removal, whereas
more senior clients may prefer photofacials, skin rejuvenation, and fractional
laser wrinkle reduction. Client skin type should also be considered.
• Population ethnicity: If most of your patients have darker skin—Fitzpatrick
skin type classification 4, 5, or 6—then practitioners should avoid investing in
shorter wavelengths such as Alex 755 nm. Darker skin types are more com-
patible with Nd:YAG and color-blind lasers.
• Average yearly income: Before investing in costly aesthetic equipment, prac-
titioners should examine the average annual income of their neighborhood.
The initial investment and ongoing overhead costs, such as consumables,
would affect the service pricing and patients’ capacity to pay for the service,
as cosmetic and aesthetic treatments are usually out-of-pocket expenses.
2. Type of practice: It is needless to say that the type of practice and the available
space are also important factors. For example, practitioners such as MD with an
established general practice wish to start providing aesthetic services. The initial
laser purchased is either a laser for hair removal or a fractional ablative laser. The
widespread prevalence of hirsutism increased awareness among women and
broader acceptance of the technology. Therefore, practitioners should consider
the following factors:
• Indications: Some devices provide a single indication, but the majority pro-
vide multiple indications based on the type of light source, wavelength, and
add-ons.
–– If the device’s only purpose is laser hair removal, we recommend an
808 nm diode laser with both in-motion and stamping modes. It is critical
to understand that this device can only be used for laser hair removal.
Table 9.1 compares some 808 nm diode laser devices available in North
America.
–– IPL: In general, a device that can be used for multiple indications, such as
modular IPL, would be advantageous. Modular IPL devices can be cus-
tomized and upgraded to meet the practice’s needs. However, each mod-
ule’s capability will fall short of a stand-alone device of the same
wavelength. For example, a stand-alone Q-switch nanosecond Nd:YAG
laser device would be more capable than an added Q-switch nanosecond
Nd:YAG handpiece in a modular device. Another disadvantage of modular
systems is that all models are connected as shown in Table 9.1. That is, if
the device experiences technical difficulties, all modes will be unavailable.
There are several important characteristics in a good IPL device: dual-cut
filters, short pulse width (5 ms), and sequential train of pulses. Table 9.2
compares some modular IPL systems available in North America.
–– Nd:YAG/Alex combo devices: these are versatile, efficient, and depend-
able devices, but they are bulky and may necessitate external cooling.
Table 9.3 compares some Nd:YAG/Alex combo devices in North America.
–– Fractional lasers, specially the non-ablative ones, are a valuable tool in
most aesthetic concerns excluding laser hair removal.
• Treatment delegation: If practitioners are medical professionals and want to
delegate treatment to an assistant, they should first consult with their licens-
ing entity. IPL devices are less restricted and easier to delegate to other
assistants.
• Competition: The prevalence of laser hair removal and the availability of the
service from various practice outsets make it more difficult to launch a busi-
ness based on this indication alone. Practitioners should conduct a market
analysis and attempt to fill a need in their practice or in the neighborhood.
Table 9.2 Comparison of five different diode laser systems in SHR mode
System Pulse Treatment
name wavelength width Handpiece Max fluence mode Features
LightSheer 808 nm 5–400 ms Vacuum Up to 12.5 J Static, Standard and
Duet handpiece and in the with or vacuum
9 × 9 mm vacuum without handpieces
standard handpiece vacuum
handpieces with and 100 J/
continuous cm2 in the
contact cooling 9 × 9
contact
handpiece
LightSheer 805 nm 5–400 ms Vacuum Up to 12.5 J Static, Standard and
Desire handpiece in the with or vacuum
12 × 12 and vacuum without handpieces
9 × 9 mm handpiece vacuum
standard and 100 J/
the 12 × 12
contact
handpieces
LightSheer 805 and 5–400 ms Vacuum Up to 12.5 J Static, Dual-
Quadro 1060 nm handpiece in the with or wavelength,
12 × 12 and vacuum without standard, and
9 × 9 mm handpiece vacuum vacuum
standard and 100 J/ handpieces
the 12 × 12
contact
handpieces
Soprano 755, 810, It has three Dynamic Three diode
ICE 1064 nm different wavelengths,
platinum separate handpieces, one special 3D
and and in trio for each handpiece,
Titanium technology wavelength and handpiece for
from Alma (3D) a 3D handpiece ear and
that emits the nostril hair
three removal
wavelengths
simultaneously
3. Publications: Look for publication in peer-reviewed journals on laser technol-

ogy—to gain insight into a given system’s efficacy and side effect profile. The
articles can provide information about the parameters used, serving as a starting
point for new users. White papers carry little to no value.
Table 9.3 Comparison of several modular IPL systems

Pulse Train of
System width sequential
name Filter technology (ms) pulses Cooling Features
IPL-Sq Square Pulse 5–100 No Continuous A second-generation IPL
Vydence technologya contact that can be added to the
cooling Ethera platform
(not
adjustable)
M22 Optimal Pulse 4–20 Yes (1, 2, Continuous The M22 is a
Lumenis Technology and 3 contact comprehensive workstation
OPT™) and pulses). cooling that could be custom-built
Multiple Pulse (not with Q-switch YAG and a
Sequential delay adjustable) 1565 nm fractional laser
Pulsing 5–150 ms OPT thin filters, dual brand
(MSP™)b filters for acne and vascular
lesion
BBL Smart Filter with 5–200 No Continuous The only IPL with dynamic
Joule Finesse Spot contact mode offers a No-pain
Sciton Adapters™ c cooling option. SkinTyte (ST)
Adjustable, special filters, part of the
0 °C to Joule comprehensive
30 °C platform
Nordlys SWT® (Selective 0.5–99.5 Yes (1, 2, Continuous The workstation can be
Ellipse Waveband 3, and 4 contact equipped with long-pulsed
Candela Technology)d, pulses) cooling Nd:YAG1064 nm,1550 nm
which means duration (not and 1940 nm lasers and five
that all filters are of pulse adjustable) IPL handpieces for a wide
dual cutoff to train range of applications
eliminate light 0.5–
over 950 nm, as 700 ms
shown in
Fig. 9.1
Icon MaxG is the 1–100 SurePulse Adjustable It comes with SkinIntel for
Palomar only filter with a for hair continuous skin phototype. It has three
Cynosure dual cut-off, as removal contact optional laser handpieces:
shown table (20 ms cooling 2940 fractional ablative
SmoothPulse™e laser on, laser, 1540 fractional
100 ms non-ablative, and 1064+
delay, laser handpiece
10 ms Advanced contact cooling
laser on) that maintains a constant 5°
with a temperature during
high- treatments
power
peak
Pulse Train of
System width sequential
name Filter technology (ms) pulses Cooling Features
Harmony All handpieces Each NA Continuous Advanced Fluorescence
Alma are equipped handpiece contact Technology (AFT) as shown
with a dual has three cooling in Fig. 9.2. The platform
cutoff to pulse (not can be equipped with a
eliminate light widths to adjustable) long-pulsed Nd:YAG
over 950 nmf choose 1064 nm, fractional
from q-switched 1064 nm,
fractional 1540, and
2940 nm laser under
different trademarks such as
ClearSkin, ClearLift, etc.
a
effective therapeutic outcome; and (3) increases the procedure’s safety and efficacy. This technol-
ogy is not exclusive to Vydence, as all second-generation IPL systems are equipped with the
square pulse feature. Table 9.4 lists the technical specifications for IPL-Sq
b
Lumenis claims that OPT provides gentler, more comfortable, patient-friendly procedures with
lower effective fluences • High peak power, shorter pulses—ideal for IPL skin treatments using
photorejuvenation and treatment of benign pigmented lesions • Advanced OPT will also allow
determining the specific fluence per sub-pulse when using multiple-sequential pulsing (MSP), for
fine-tuned treatment settings [2]. Lumenis launched the Stellar M22 with three SapphireCool™
lightguides to provide better continuous contact cooling for patient comfort. At the time of writing,
a new version of the M22 with advanced OPT (AOPT) had just been released in China. The ben-
efits of AOPT over OPT are not yet clear. Table 9.5 lists the M22 system specifications
c
According to Sciton, Smart Filter with Finesse Spot Adapters™ provides an easy and quick way
to change filters and reach difficult spots [3]. Table 9.6 lists different handpieces for the Joule
system and their indications. Table 9.5 lists the indications of different handpieces from
Joule systems
d
According to Candela, the SWT is a narrowband technology defined by dual filters and sub-
millisecond pulses. Table 9.7 lists the Nordlys system specification. The system has eight Ellipse
IPL handpieces, Frax 1550, Frax 1940, and Nd:YAG 1064 nm with different indications, as shown
in Table 9.7
e
According to Cynosure, the SmoothPulse™ technology avoids energy spikes often used by com-
peting systems to deliver treatment—patient skin stays cooler and more comfortable without sac-
rificing efficacy. Full technical specification for Cynosure Icon and the light spectrum of the Max
G handpiece is in Table 9.8
f
The new platform has several IPL handpieces such as Dye VL PRO 450–600 nm Cooled
Applicator, Dye VL 500–600 nm Cooled Applicator in a stationary and in-motion mode, Cooled
VL-PL 540 nm Applicator, and Cooled and non-cooled SR 570 nm Applicator [4]. According to
Alma, Advanced Fluorescence Technology (AFT) is the new generation of IPL that enables con-
tinuous square-shaped pulsing with moderate peak power throughout the entire pulse. However, a
2007 study did not show a significant difference in results between Lumenis and Harmony IPL [5].
The full technical specification for Alma Harmony XL Pro is listed in Table 9.9
Fig. 9.1 SWT® (Selective

Waveband Technology)
with dual cutoff filters that
eliminate light over
950 nm
Fig. 9.2 Advanced
Fluorescence Technology
(AFT) with continuous
square-shaped pulsing with
moderate peak power
throughout the entire pulse
in Alma Harmony AFT
Table 9.4 IPL-Sq® technical IPL spectrum 400–1200 nm

specifications
Filters 400, 540, 580, 640, and 695 nm
Spot size 40 × 12 nm
Vascutip TM 8 mm and 12 × 12 mm
Pulse width 5–100 ms
4. Feedback: Seek feedback from other users of the system above. Make it a habit
to inquire about users’ experiences with the machine. For an honest assessment,
asking a competitor company for their opinion on the machine may be useful.
5. Demonstration: Before purchasing a system, always request a demonstration.
The machine should be kept in the clinic for at least two treatment sessions and
tested on various patient types.
Table 9.5 M22® technical specifications

IPL spectrum 400–1200 nm
Filters Acne (400–600 and 800–1200); 515 nm; vascular
(530–650 and 900–1200); 560 nm; 590 nm,
615 nm; 640 nm; 695 nm; 755 nm
Fluence 8 × 15 mm—up to 35 J/cm2
15 × 35 mm—up to 35 J/cm2 6 mm round—up to 56 J/cm2
Pulse characteristic Multiple sequential pulsing
Spot size 35 × 15 mm2; 15 × 8 mm2, 6 mm
ResurFX™
Wavelength 1565 nm
Pulse energy 10–70 mJ per microbeam
Pulse characteristic CoolScan™ Scanner
Pattern shapes Line, square, rectangle, circle, doughnut, hexagon
Beam density Up to 500 microbeams/cm2
Repetition rate 0.5–2 Hz
Tip Sapphire; precision
Spot size Up to 18 mm
MultiSpot™ Nd:YAG
Wavelength 1064 nm
Fluence 10–225 J/cm2
Pulse characteristic Multiple sequential pulsing
Spot size 6 mm; 2 × 4 mm2; 9 mm
Q-Switched Nd:YAG
Wavelength 1064 nm
Pulse characteristic Top-Hat
Spot size 2; 2.5; 3.5; 4; 5; 6 and 8 mm
Table 9.6 BBL® technical specifications

IPL spectrum 20 – 1400 nm
Filter 420 nm, 515 nm, 560 nm, 590 nm, 640 nm, 695
nm, 800 nm
Pulse Width Up to 200 msec
Repetition Rate Up to 1 pulse -per-second
Cooling Method Skin Cooling Continuous thermoelectric sapphire plates
Adjustable from 0 - 30 ˚C
Spot Size 15 x 45 mm
Finesse Adapters 15 x 15 mm square, 11 mm & 7 mm round
Handpiece FIBER BBL
Forever Bare BBL™

ProFractional-XC™
ClearScan YAG™
ClearScan ALX™
ThermaScan™
CelluSmooth™
™
Contour TRL™
ClearSense™
ProLipo PLUS
SkinTyte™
JOULE Module
Pro-V™
Halo™
diVa®
BBL™
1064 Nd:YAG
1319 Nd:YAG
1064 Nd:YAG
1319 Nd:YAG
1319 Nd:YAG
2940 Er:YAG
2940 Er:YAG
2940 Er:YAG
2940 Er:YAG
1470 Diode &
1470 Diode &
Smart Filters
Smart Filters
Smart Filters
1064 / 1319
590 to 1400
420 to 1400
590 to 695
755 Alex.
Nd:YAG
Wavelength (nm)
Acne • •
Acne Scars •
SKIN
Scar Revision • • •
Skin Resurfacing • • •
Skin Texture Improvement • • • • •
FY BBL Concept •
Wrinkles • •
Vascular Lesions • • •
VASCULAR
Telangiectasia • •
Reticular/Spider Veins • •
Endovenous Ablation •
HAIR & SPECIALTIES
Permanent Hair Reduction • • • •
Onychomycosis • •
Warts • • •
Vaginal Therapy •
Table 9.7 Nordlys applicator specifications

ELLIPSE IPL
Type/Wavelength HRD 645 (645-950 nm) PR/PRS 530 (530-750 nm)
Band HR/HRL 600 (600-950 nm) PL 400 (400-720 nm)
VL/VLS 555 (555-950 nm)
Fluence Range 2-26 J/cm 2
Pulse Time 0.5-99.5 msec (depending on applicator)
Pulse Delay 1.5-99.55 msec
Number of Pulses 1-4
Duration of 0.5-700 msec

Pulse Train
Spot Size HR 600, HRD HRL 600 VLS 555, PRS 530
645, VL 555, PR 18 mm x 48 mm Hexagonal: 90 mm2
530, PL 400
10 mm x 48 mm
FRAX 1550 ND:YAG 1064

Laser 1550 nm 1064 nm
Wavelength
Fluence Range/ 5-100 mJ 20-500 J/cm2

Energy 6-40 J/cm2 (onychomycosis)
Pulse Duration 1-20 msec 2.5-90 msec

0.3-0.9 msec (onychomycosis)
Scan Width/ 4-12 mm 1.5-5.0 mm

Spot Sizes
Skin Cooling Soft CoolTM Integrated Air Cooling
Frax 1550 Frax 1940 Nd:YAG 1064 PL 400 PR (530 -950) HR (600 -950) HDR
nm VL (555 -950) (645 -950)
Skin resurfacing. Skin resurfacing. Leg vessels (0.1-3 mm Benign epidermal Telangiectasias Permanent hair reduction
Coagulation of soft tissue Coagulation of soft tissue. in diameter) pigmented lesions Port wine stains
Benign pigmented lesions Benign vascular lesions (e.g., solar lentigines) Benign pigmented lesions
(including but not limited to Port wine stains Benign vascular lesions
lentigines (age spots), solar Venous lakes (e.g., Diffuse Redness)
lentigines (sunspots), and Epidermal pigmented Rosacea
ephelides (freckles) for lesions Poikiloderma of Civatte
Fitzpatrick Skin Types I-IV Inflammatory acne vulgaris
(PR 530)
Table 9.8 Icon applicator specifications
MaxG MaxR MaxRs

Wavelength: 500-670 nm Wavelength: 650-1200 nm Wavelength: 650-1200 nm
and 870-1200 nm Pulse width: 1-100 msec Pulse width: 1-100 msec
Pulse width: 1-100 msec Spot size: 16 x 46 mm Spot size: 12 x 28 mm
Spot size: 10 x 15 mm Energy: Up to 46 J/cm2 Energy: Up to 70 J/cm2
MaxYs 2940 fractional ablative laser The light spectrum of Max G handpiece
Wavelength: 525-1200 nm Wavelength: 2940 nm
Pulse width: 1-100 msec Treatment
Spot size: 12 x 28 mm zone-fractional: 10 x 10, 6 x 6 mm
Energy: Up to 81 J/cm2 Flatbeam: 6 x 6 mm
Microbeam density: Up to 1000 cm2
Pulse width: 0.25-5 msec
Max. repetition rate: Up to 6 Hz
Table 9.9 Harmony XL Pro system specifications

Spot Pulse Energy
Light size Wavelength Pulse widths/ repetition density (J/
SHR Pro Flash 5 650–950 HR 30, 40, 50 ms 1/2 5–20
(5) lamp SHR Timer: 1,3,30 s 3 3–7
Cooled
SVL Flash 3 515–950 10, 12, 15 ms 2/3 5–30
Cooled lamp
VL/PL Flash 3 440–950 10, 12, 15 ms 2/3 5–30
Cooled lamp
SR Flash 3 570–950 10, 12, 15 ms 2/3 5–30
Cooled lamp
Dye-SR Flash 3 550–650 Dye-SR 10, 12, 15 ms 1/2 Up to 14
Pro lamp Dye-SSR Timer: 1,3, 30 s 3 1–4
Dye Flash 3 450–600 Dye-VL 10, 12, 15 ms 1/2 Up to 15
VL-Pro lamp Dye- Timer: 1,3, 30 s 3 1–4
SVL
SHR Pro Flash 3 650–950 HR 30, 40, 50 ms 1/2 5–25
(3) lamp SHR Timer: 1,3,30 s 3 3–7
Cooled
SSR Flash 3 540–950 Timer: 1,3,30 s 2 1–15
Cooled lamp
SST Flash 3 780–950 Timer: 1,3,30 s 5 0.5–3.5
Cooled lamp
Non-cooled IPL Module 6.4 cm2 spot size
SVL Flash 6.4 515–950 10, 12, 15 ms 2/3 5–25
lamp
VL/PL Flash 6.4 440–950 10, 12, 15 ms 2/3 5–25
lamp
SR Flash 6.4 570–950 10, 12, 15 ms 2/3 5–25
lamp
HR Flash 6.4 650–950 30, 40, 50 ms 1/2 5–25
lamp
ST Flash 6.4 780–950 Timer: 2 1–7
lamp 10,30,90 s
Acne Flash 6.4 420–950 Acne 30, 40, 50 ms 1/2 5–25
lamp S-Acne 2 ms 10 0.3–1.2
(continued)
Pulse
Wavelength Spot size Pulse frequency Energy density/
Module Technology (nm) (mm) width (Hz) fluence/depth
Laser Nd:YAG cooled module
Cooled Long Nd:YAG 1064 2 10 ms 1 30–450 J/cm2
Pulse 6 15, 45, 1 30–150 J/cm2
1064 nm 60 ms
Nd:YAG 10 15 ms 1 20–50 J/cm2
5 × 5 pixel 10 ms 1 3–25 J/cm2
Cooled Long Nd:YAG 1320 6 30, 40, 1 5–40 J/cm2
Pulse 50 ms
1320 nm 5 × 5 pixel 30, 40, 1 1–11 J/cm2
Nd:YAG 50 ms
Laser Nd:YAG non-cooled module
Q-Switched Q-Switched 1064 1,2,3,4,5,6 20 ns 1, 2, 4 600–1200 mJ/p
1064 nm Nd:YAG 1064 5 × 5 pixel 20 ns 1, 2, 4
Nd:YAG 532 2, 3, 4 20 ns 1, 2, 4
KTP
High Power Q-Switched 1064 1, 2, 3, 4, 20 ns 1, 2, 4 600–1200 mJ/p
Q-Switched Nd:YAG 5, 6
1064 nm 1064 5 × 5 pixel 20 ns 1, 2, 4
Nd:YAG 532 2, 3, 4 mm 20 ns 1, 2, 4
KTP
1064 5 × 5 roller 20 ns N/A
1064 7 × 1 roller
6. Engineer education and experience: Examine whether the company’s marketing

person or engineer has some basic scientific knowledge about the laser machine,
what training they received from the parent manufacturer abroad, and so on. This
is critical because technical knowledge is the key to maintenance. Many laser
manufacturers train service personnel in their facilities. This must be confirmed.
7. Contract: It is critical to have a written laser purchase contract signed by both the
buyer and the distributor. Many distributors accept a one-page purchase order
(PO) from the customer, but this is insufficient because the full terms of the deal
are not stated. The following items should be included in the purchase contract:
(a) The company seeks an advance amount after negotiating a price and signing
a contract. In general, this should not exceed 25% of the total amount. A
proper receipt must be obtained, clearly stating the cheque number and amount.
(b) Balance payment clause, with repayment date; instalments, if any, must be
specified.
(c) Dollar/foreign currency exchange rate: Because many machines are
imported, the price is frequently determined by the value of the dollar/other
currency, which is subject to market fluctuations. This should be thoroughly
discussed, and a proper understanding should be reached regarding currency
market fluctuations.
(d) Examine the price of the machine mentioned, and note any undervaluation.
For any reason, do not undervalue the machine.
(e) Check to see if all costs are listed: Taxes, customs, transportation, insurance,
and instalment costs are all included.
(f) Warranty: The warranty should cover all laser parts; read the fine print to see
if there are any exclusion clauses. Check to see if the warranty is contingent
on any laser room specifications or associated devices, such as a vacuum
evacuator or air conditioner. Check the frequency of servicing and, if neces-
sary, the need for distilled water replacement. Sometimes the company or
parent organization will provide an extended warranty or additional service,
which should be documented and mentioned in the contract.
(g) Repair clause: Determine how many hours/days it will take to attend to the
breakdown. What is an approximate time frame for repairing/replacing
parts? Installation of a standby system while the machine is being repaired
should be requested so that work is not disrupted. Moreover, it is important
to ask if there is local support after the warranty is expired. Practitioners
might end up paying $3000 in transportation fees to replace a pert that cost
$200 if local support is not available.
8. Cost of consumables: Try to avoid devices that charge per cycle or associated
with high consumable cost.
9. The device’s goodwill and established market share: Due to an excellent market-
ing strategy and a good reputation, some companies were able to establish a
market share. This is especially important for new practices because patients
may prefer a specific device over a specific treatment.
Refurbished Devices
We do not recommend buying a refurbished laser, but if you feel confident about
your decision, please consider the following points:
• Check with the original manufacturer to see if they will service the machine after
buying it.
• The 1-year warranty that most systems come with is typically worthless if the
laser is sold to another individual since the guarantee is non-transferable. The
new buyer may be required to pay a recertification fee to the manufacturer for the
distributor to service it and provide an extended warranty.
• Examine the shot count, past service reports, system age, and spare availability.
• Ensure the system during transit to avoid any harm that may occur.
• When purchasing a secondhand system, be sure that the laser safety eyeglasses
and corneal shields are included and in good shape.
• Always insist on the original user guide.
• Videos captured by the original owner while doing treatments provide an excel-
lent insight into the system’s performance and approach.
This topic is extensively discussed in Chap. 10 (Table 9.10).
Table 9.10 Comparison between different laser systems that have Alex lasers
Name/maker Emission Cooling Interface Energy Pulse with Spot size Features
Elite + Combo Forced air as a Mono-color, 45 J Alex, 0.5– Up to 24 mm No consumables
Cynosure separate unit non-intuitive 63 J 100 ms
Nd:YAG
Refurbished Devices
Elite Iq Combo Forced air as a Digital LCD, 45 J Alex, 0.5– Up to 24 mm No consumables, equipped with Skintel
Cynosure separate unit intuitive and 63 J 300 ms Melanin Reader
user friendly Nd:YAG
Arion 755 nm Forced air Mono-color, 70 J Alex 2–100 ms Up to 16 mm Scanner for large areas (add-on), special
Alma non-intuitive burst mode (each laser pulse is split up into
several short, quick sub-pulses*
The skin surface can cool down between
the sub-pulses
The risk of side effects is minimized) and
does not require gel
GentleMax Combo Cryogen spray Digital LCD, 53 J Alex, 0.35– Up to 18 mm Cryogen spray needs to replace the cryogen
Pro intuitive and 79.2 J 300 ms canister
Candela user friendly Nd:YAG
AvalancheLase Combo DMC™ (Dry Digital LCD, 53 J Alex, 0.6 ms to Up to 30 mm Scanner for large areas (add-on), avalanche
Fotona Molecular spray intuitive and 79.2 J 1 s effect**
Cooling) user friendly Nd:YAG DMC™ (Dry Spray Molecular Cooling)
***
Light A 755 Contact or forced LCD 100 J Alex 2–100 ms Up to 16 mm The practitioner can configure the platform
Quanta air to add IPL, 1064 nm, 2940 nm, and
1320 nm
SPLENDOR Combo, Cryogen spray Digital LCD, 55 J Alex, 3–100 20 × 20 mm, Simultaneous Alex-Nd:YAG hybrid laser
X hybrid and forced air intuitive and 80 J 24 × 24 mm shots, integrated smoke evacuate
Lumenis user friendly Nd:YAG square technology, square and round treatment
area for easy treatment
299
References
1. Aurangabadkar SJ, Mysore V, Ahmed ES. Buying a laser—tips and pearls. J Cutan Aesthet
Surg. 2014;7(2):124.
3. Sciton. BBL® Family of Brands. 2022. https://sciton.com/wp-content/uploads/2022/04/BBL-
4. Harmony XL Pro; Quick reference guide. 2020. https://www.almalasers.com/wp-content/
5. Braun M. Intense pulsed light versus advanced fluorescent technology pulsed light for photo-
damaged skin: a split-face pilot comparison. J Drugs Dermatol. 2007;6(10):1024–8.
Chapter 10
Buying a Refurbished Laser Device
Aesthetic Plastic Surgery National Databank showed that surgical and nonsurgical
cosmetic and aesthetic procedures are a $14.625 billion industry [1]. According to
the same report, the nonsurgical procedure constituted a little over 30% of the total
revenue, and skin tightening and fat reduction showed a 128% increase between
2020 and 2021. The previous statistic reflects only the physician-led facilities and
does not include non-physician settings such as medical spas [2].
With the aging of the US population, the market for medical aesthetic devices is
anticipated to expand rapidly. This is also associated with increased marketing
efforts by leading industry players that target both the professional and general pop-
ulation [3]. Concerns have been raised concerning the use of deceptive or mislead-
ing language in advertising, a lack of proof of efficacy and safety, and a lack of
public and professional awareness of the FDA’s oversight of medical devices [4].
Well-established aesthetic device manufacturers could be held to minimum ethical
standards. However, most issues stem from unlicensed aesthetic devices and resell-
ers of refurbished medical and aesthetic devices. Therefore, this chapter focuses on
the issues posed by the unorganized selling of refurbished aesthetic devices on the
US market, as well as how these businesses can circumvent and manipulate rules.
Understanding the difference between “remanufacturing” and “service” is cru-
cial. Remanufacturing is the act of processing, conditioning, renovating, repackag-
ing, or restoring a piece of completed equipment in a way that substantially modifies
its performance, safety criteria, or intended purpose. Servicing is the repair and
preventative or regular maintenance of one or more components of a completed
product after it has been distributed to restore it to the safety and performance stan-
dards specified by the original equipment manufacturer (OEM) and to its original
intended usage. Regardless of whether a business self-identifies as a “servicer” or
“remanufacturer,” the FDA focuses on the precise actions an entity conducts on a
certain device. The classification of an entity’s actions as remanufacturing impacts
the application and enforcement of regulatory obligations under the Federal Food,
Drug, and Cosmetic Act (FD&C Act) and its related regulations. Remanufacturing

Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27632-3_10
302 10 Buying a Refurbished Laser Device
entities are subject to the obligations of the FD&C Act and its implementing rules,
including but not limited to registration and listing, adverse event reporting, the
quality system (QS) regulation, and marketing submissions.
Maintenance and repair of medical devices that are timely, cost-effective, and of
high quality are essential to the proper operation of the US healthcare system and
the continuous quality, safety, and efficacy of medical devices sold in the United
States. This is crucial for devices used on several patients over extended periods.
Poor service may result in subpar device performance, failure, and adverse events [5].
Medical Device Regulations in the United States
Marketing or Selling a New Medical Device
Device Classifications
A manufacturer (or seller) must go through a process, the intricacy of which depends
on the device classification, to register a device with the FDA. The objective is to
locate a precedent or something similar to your previously evaluated device. The
database component of the FDA/CDRH website (http://www.fda.gov/
MedicalDevices/default.htm) is the first stop. This is the product classification data-
base maintained by the FDA, where you can look for equivalent devices [6].
FDA Medical Device Approval Pathways
In the United States, Product Development Protocol (PMA) approval is required for
the majority of class III and new devices that are not substantially identical to a law-
fully marketed product that does not need a premarket approval (PMA) application.
A new medical or aesthetic device has to go through distinct stages from concep-
tion to disposal, as shown in Fig. 10.1. It takes 3–7 years to get a technology to
market, compared to 12 years for pharmaceuticals. Concerns exist, however, that
Food and Drug Administration methods may not be enough to provide the necessary
guarantees of safety and effectiveness [7].
The majority of class II and certain class I devices need premarket entry notice
(known as 510(k), an FDA information package subject to a less strict evaluation
than the PMA procedure). The 510(k) submission must establish that the
Fig. 10.1 Seven traditional phases of medical device development

Medical Device Regulations in the United States 303
proposed medical device is substantially identical to an already-marketed medi-

cal device in the United States. Most class I and a few class II (low-risk) devices
are exempt from 510(k) filing before sale but are subject to general control
requirements [8]. Figure 10.2 illustrates FDA medical device approval pathways
adapted from [7].
Is your product a device? Determine if the product

(Consult the FDA Device Determination Officer) NO is covered by the FFDCA
YES
Is the device anticipated to be used

Submit HDE Application
to treat a condition that affects YES Obtain local IRB Approval
<4000 U.S. patients annually?
NO
CLASSIFY THE DEVICE
Low Risk Moderate Risk High Risk High Risk

(Class I)? (Class II)? (Class III: classification (Class III: based on default
based on clinical risk)? classification of a new device)?
YES YES YES YES
75% may be “exempt” Most need PMN Submit PMA and IDE
from requiring any (also known as 501[k]) applications in anticipation
clinical trials application. of conductiing clinical trials.
Consult with FDA Consult early with FDA
about possible modular regarding need for and type
or streamlined PMN. of clinical studies
YES
Approved as de novo? NO
NO
Submit 513(g) application Is the device

Does the device
to reclassify the device YES actually only low NO have a predicate?
as a de novo device or moderate risk?
YES
Submit PMN
Fig. 10.2 FDA medical device approval pathways. Early consultation with Food and Drug
Administration (FDA) through pre-submission meetings is strongly encouraged; the FDA can help
determine which pathways and applications are needed and whether clinical trials are necessary.
FFDCA Federal Food, Drug, and Cosmetics Act; HDE human device exemption; IDE investiga-
tional device exemption; IRB Institutional Review Board; PMA premarket approval; PMN premar-
ket notification
The only premarket submission number they have is K213554, which is a class
II device with a GEX code. According to the FDA, a GEX code refers to:
A laser (light amplification by stimulated emission of radiation) based device having
coherence, collimated and typically monochromatic radiation. Typically indicated to cut,
destroy, remove, or coagulate tissue, generally soft tissue, for general surgical purposes in
medical specialties of general and plastic surgery, dermatology/aesthetic, podiatry, otolar-
yngology (ent), gynecology, neurosurgery, orthopedics (soft tissue), dental and oral sur-
gery, and dentistry. The classification regulation 21 car 878.4810 describes a carbon
dioxide or argon laser device intended to cut, destroy, remove or coagulate tissue by the
light. [9]
Marketing or Selling a Refurbished Medical Device
The situation has drastically altered in the last decade due to diminishing healthcare
resources and significant technological advancements [10]. Used medical equip-
ment is becoming more popular in the United States and other developed nations.
As bigger hospitals acquire newer models, they trade in their obsolete equipment,
which is often still in excellent shape. Large worldwide producers of medical
devices are now engaged in the refurbishing industry. This equipment may continue
to be used in various settings, including urban and rural hospitals. The increased
usage of reconditioned and refurbished equipment in developed nations raises the
issue of safety and efficacy, as repair does not qualify as manufacture until the
device has been completely reconditioned or refurbished [11]. As shown in
Fig. 10.3, service providers and third-party resellers open a side loop that begins
with the sale phase and spills over into the advertising phase. Moreover, resellers
are not uncommon to sell a brand-new medical or aesthetic device before it is
used [12].
Fig. 10.3 Modern medical device development cycle with reservicing and refurbishing side loop
Medical Device Regulations in the United States 305
FDA Control of Refurbished Device Trading in the United States
Used or refurbished medical and aesthetic devices were mainly traded to developing
countries, mainly by third parties, and the vendors were often opportunistic mer-
chants with no technical expertise or ethical obligation. Many recipient countries
had bad experiences with used equipment because there was no after-sale technical
support or spare parts. By 2002, at least five countries had imposed a total ban on
the import of used equipment, and 17 others had partial bans depending on the type
of equipment [8]. Therefore, vendors focused on the highly opportunistic market
inside the United States and specialized in aesthetic devices as it has even less con-
trol and regulations. The sales term and condition often refer to the medical device
“AS IS” to make it harder for the buyers to initiate legal claim. In addition, the new
owner of the medical equipment has full legal responsibility for trademark infringe-
ment since third-party resellers lack the authority to transfer the right to use the
device’s trademarks. In 2021, the FDA gave more attention to refurbishing, remanu-
facturing, and servicing medical and aesthetic devices and started seeking input on
this issue [5]. FDA suggests using the following guiding principles when utilizing
this advice to assess whether an activity constitutes remanufacturing [5]:
• Whether maintenance aims to restore the device to the safety and performance
criteria provided by the OEM and to satisfy its original intended use, any modi-
fication to the intended use should be examined to determine whether the action
constitutes remanufacturing.
• Assess if the activities, individually and collectively, significantly alter the safety
or performance specifications of a finished device—According to CFR 820.3(w),
remanufacturing includes activities that significantly alter the performance or
safety specifications of the finished device. The FDA considers efforts that
enhance the device to be “change.” However, activities that are not intended to
alter the performance or safety standards must nonetheless be reviewed to see if
they significantly alter the performance and safety criteria of the completed
device. The cumulative effect of many revisions on the performance or safety
standards of a lawfully marketed medical device should be examined.
• Assess whether any changes to a device require a new marketing submission—
regardless of whether changes made to a legally marketed device are remanufac-
turing, such changes should be evaluated to determine whether a premarket
notification (510(k)) or other marketing submission is required under the FD&C
Act and applicable regulations. Entities should consult relevant guidance for
FDA’s recommendations on the topic. For example, a modification to a device
subject to 510(k) and special controls 185 should be assessed about the criteria
in CFR 807.81, specifying whether a new 186,510(k) submission is necessary
and any special controls under the appropriate device classification rule,
respectively.
• Assess component/part/material dimensions and performance standards—the

evaluation of modifications to dimensional and performance criteria may help
determine whether the operation constitutes remanufacturing. The effect of com-
ponent/part/material modifications may be assessed by comparing them to the
specifications of the original components/parts/materials or by conducting veri-
fication and validation testing. Deviations in component/part/material specifica-
tions from the OEM’s legally marketed device may result in substantial changes
to the device’s performance or safety specifications, necessitating a closer evalu-
ation (such as testing or a risk-based assessment) and consideration of the regula-
tory criteria describing when a new marketing submission is required.
Obligation in Terms of Reservicing a Medical Device
Unfortunately, the FDA does not impose a minimum obligation on the parties clas-
sified as servicers. The only assurance a health professional can get is a market-
ing slogan.
Problem with Buying Refurbished Laser Device
Purchasing a new laser or IPL device is a significant investment. As a result, many

practitioners try to save money by purchasing a refurbished aesthetic device from a
third party. However, this is a significant risk that we strongly warn against for the
following reasons:
• Trademark infringement: Third parties do not have the right to transfer owner-
ship of most aesthetic and laser devices. This is a delicate and complex legal
problem, which more practitioners realize after the fact. For example, a practitio-
ner who purchases a refurbished Fraxel dual laser may advertise that they use a
1550/1927 nm laser for resurfacing, but they may not advertise that they offer
Fraxel dual service. Otherwise, they would be at risk of infringing on trademarks
owned and registered by the device’s producer, Solta, in this case. Many practi-
tioners have received cease-and-desist letters and had to involve legal counsellors.
• Consumables: Cost is another key reason that should dissuade practitioners from
investing in refurbished devices. Most modern cosmetic devices include con-
sumables that must be replaced after each use. Using the Fraxel Dual example,
practitioners must purchase tips to perform therapy. However, Solta will not pro-
vide consumables to a clinic that purchased a Fraxel Dual from a third party
unless the clinic pays a high recertification price.
• Calibration and maintenance: Health agencies mandated that lasers and IPL be
regularly maintained and calibrated. You cannot use the manufacturer’s calibra-
tion and maintenance services if you purchase a laser device from a third party.
On the other hand, owners of refurbished devices will need to find a certified
technician, which is not easy, or ship the machine to a third party and carry the
extra expenses.
References 307
• Contract: Most third parties sell the device “AS IS.”

• Training and support: Third-party providers do not provide access to training and
support, which could be extremely beneficial to new practitioners.
• Dispute: Every contract contains a clause that refers to the procedures that should
be followed in a dispute. As a result, practitioners who disagree with a third-party
seller or distributor may find themselves in a difficult situation. Some contracts
include mediation and arbitration, which are complicated and expensive pro-
cesses that significantly impact practitioners and their businesses.
• Finance: Leasing refurbished devices is very difficult and known to be a tough
process.
• It is important to read the sale agreement carefully and consult legal counsel
before signing any agreement.
References
1. Aesthetic Plastic Surgery National Databank Statistics 2021, in Aesthetic Plastic Surgery
National Databank Statistics 2021: The Aesthetic Society.
2. Valiga A, et al. Medical spa facilities and non-physician operators in aesthetics. Clin Dermatol.
2022;40(3):239–43.
3. Swanepoel YW. The Perceived Competency of Somatologists Working in the Medical
Aesthetic Industry. 2017: University of Johannesburg (South Africa).
4. Hagopian CO. Ethical challenges with non-surgical medical aesthetic devices. Plast Surg
Nurs. 2019;39(1):5–9.
5. Remanufacturing and Servicing Medical Devices. https://www.
f d a . g o v / m e d i c a l -d e v i c e s / q u a l i t y -a n d -c o m p l i a n c e -m e d i c a l -d e v i c e s /
remanufacturing-and-servicing-medical-devices#papers.
6. The Section 513(g) Mechanism Explained. 2015. https://www.thefdagroup.com/blog/2015/08/
the-section-513g-mechanism-explained.
7. Van Norman GA. Drugs, devices, and the FDA: part 2: an overview of approval processes:
FDA approval of medical devices. JACC: Basic to Translational. Science. 2016;1(4):277–87.
8. Cheng M. Medical device regulations: global overview and guiding principles. 2003.
9. GEX Product Classification. CFR—Code of Federal Regulations Title 21. https://www.access-
data.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm?ID=5887.
10. Haleem A, et al. Medical 4.0 technologies for healthcare: Features, capabilities, and applica-
tions. Internet Things Cyber-Phys Syst. 2022;2:12–30.
11. Green JIJ. Medical Device Regulations for custom-made devices: answers to ten important
questions. BDJ Team. 2022;9(1):39–48.
12. SPOTLIGHT SYSTEM OF THE WEEK- NEW - BTL EMSCULPT SYSTEM. https://app.
robly.com/archive?id=cd6d894a6aa4185bacc0f0aac8df6390&v=true.
Appendix
General Laser Consent Form
Instructions: This informed consent document has been prepared to assist you in
learning more about laser skin treatment procedures, risks, and alternative
treatments.
You must carefully and thoroughly read this information. Please initial each page
to indicate that you have read it and signed the consent form for the procedure as
recommended by your doctor.
Introduction: For many years, physicians have used lasers. There are numerous
methods for using lasers in the procedure. Laser energy can cut, vaporize, and selec-
tively remove skin and deeper tissues. The laser can be used to treat wrinkles, sun
damage, scars, and some types of skin lesions/disorders. The laser may be used as a
cutting instrument in certain surgical procedures. In some cases, laser treatments
may be used in conjunction with other surgical procedures. Specific skin care prod-
ucts can be used before and after laser skin treatments to improve the results.
Alternative Treatment: Alternative treatments include not having the proposed
laser skin treatment procedure performed. Other forms of skin treatment (chemical
peels) or surgical procedures (dermabrasion or excisional procedure) may be used
in place of excisional procedures. In some cases, the laser may provide a therapeutic
advantage over other forms of treatment.
In some cases, alternative laser treatment procedures may not be a better option
than other procedures or skin treatment forms. Alternative forms of treatment, such
as skin treatments or surgical procedures, are associated with risks and potential
complications.
Risks of Laser Skin Treatment: There are risks and complications associated
with all laser skin treatment procedures. There are risks associated with using laser
energy as a form of surgical therapy and the specific procedure performed. An indi-
vidual’s decision to undergo a procedure is based on a risk-benefit analysis. Although
© The Editor(s) (if applicable) and The Author(s), under exclusive license to 309
Springer Nature Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27632-3
310 Appendix
most patients do not experience any of these complications, you should discuss
them with your doctor to ensure you understand the risks, potential complications,
and consequences of laser skin treatment.
Infection: Although bacterial, fungal, and viral infections are uncommon after
laser skin treatment, they can occur. Following laser treatment, herpes simplex virus
infections around the mouth or other areas of the face can occur. This applies to
people who have a history of herpes simplex virus infections in the mouth and
people with no known history of herpes simplex virus infections in the mouth. To
suppress an infection caused by this virus, specific medications may be prescribed
and taken both before and after the laser treatment procedure. Additional treatment,
including antibiotics, may be required if a skin infection develops.
Scarring: Although normal healing is expected after the procedure, abnormal
scarring in the skin and deeper tissues is possible. Keloid scars can form in rare
cases. Scars can be unsightly and differ in color from the surrounding skin. Scarring
may necessitate additional treatments.
Burns: Laser energy has the potential to cause burns. The laser beam may injure
or permanently damage adjacent structures, including the eyes. Burns are uncom-
mon but result from heat produced within the tissues by laser energy. Laser bums
may necessitate additional treatment.
Pigmentation: Laser treatments may cause your skin’s natural color to change.
Skin redness usually lasts 2–12 weeks but can last up to 6 months after laser skin
treatment. There is a chance that the skin will have irregular color variations, includ-
ing lighter and darker areas. There may be a line of demarcation between normal
skin and laser-treated skin.
Accutane (Isotretinoin) is a prescription medication used to treat various skin
conditions. This medication may impair the skin’s ability to heal after treatments or
procedure for an unknown period, even after the patient has stopped taking it.
Individuals who have taken the medication should give their skin time to recover
before undergoing laser skin treatment procedures.
Laser energy has the potential to ignite flammable agents, surgical drapes and
tubing, hair, and clothing. When the laser energy is used in the presence of supple-
mental oxygen, the risk of fire increases and some anesthetic gases may contribute
to combustion.
Laser Smoke (plume): Laser smoke is toxic to those exposed. This smoke could
be a potential biohazard.
Laser energy directed at skin lesions has the potential to vaporize the lesion. A
laboratory examination of the tissue specimen may be impossible.
Visible Skin Patterns: Laser treatment procedures may result in visible skin
patterns. This is not a predictable occurrence.
Patient Noncompliance: Patient noncompliance after a laser skin treatment pro-
cedure is critical. To avoid potential complications, increased pain, and unsatisfac-
tory results, post-operative instructions regarding appropriate activity restriction,
use of dressings, and use of sun protection must be followed. Your doctor may
advise you to use a long-term skin care program to improve healing after a laser skin
treatment.
Appendix 311
Damaged Skin: Skin that has previously been treated with chemical peels or
dermabrasion or that has been damaged by bums, electrolysis (hair removal treat-
ments), or radiation therapy, may heal abnormally or slowly after treatment with
lasers or other surgical techniques. This is not a predictable occurrence. Additional
treatment may be required.
Anatomical Features Distortion: Laser skin treatments can distort the appear-
ance of the eyelids, mouth, and other visible anatomic landmarks. This is not a
predictable occurrence. If this occurs, additional treatment, including procedure,
may be required.
Unsatisfactory Outcome: These procedures may produce an unsatisfactory out-
come. Laser procedures may cause unacceptable visible deformities, skin slough-
ing, loss of function, and permanent skin color changes. You may be dissatisfied
with the result of laser treatments.
Chronic pain may occur very rarely after laser skin treatment procedures.
Allergic Reactions: Local allergies to tape, preservatives used in cosmetics, or
topical preparations have been reported in rare cases. Drugs used during medical
procedures and prescription medications can cause more serious systemic reactions.
Allergic reactions may necessitate additional therapy.
Inadequate Long-Term Results: Laser or other treatments may not completely
improve or prevent future skin disorders, lesions, or wrinkles. Additional proce-
dures or procedure may be required to tighten loose skin further.
Delayed Healing: Healing after laser treatments may take longer than expected.
Skin that heals more slowly than usual may develop thin, easily injured skin. This is
distinct from the normal redness of the skin following a laser treatment.
Unknown Risks: It is possible to discover additional risks associated with laser
skin treatments.
Surgical Anesthesia: Both local and general anesthesia are risky procedures—
all forms of surgical anesthesia and sedation risk complications, injury, and
even death.
Additional Treatment or Procedure Required—Numerous variables influence the
long-term outcome of laser skin treatments. Even though risks and complications
are uncommon, the risks listed are specifically associated with these procedures.
Other complications and risks are possible, but they are uncommon. Procedures,
procedure, or other treatments may be required if complications arise. Medical and
surgical practice is not an exact science. Although good results are expected, there
is no express or implied guarantee or warranty on the results that may be obtained.
Financial Responsibilities: The cost of laser skin treatment includes several
fees for the services rendered. Fees charged by your doctor, pre- and post-operative
skin care medications, surgical supplies, laser equipment and personnel, laboratory
tests, and possible outpatient hospital charges, depending on where the procedure is
performed, are all included. Cosmetic procedure costs are unlikely to be covered by
an insurance policy. Even if you have insurance, you will be responsible for any co-
payments, deductibles, or charges that are not covered. If complications arise due to
the treatment, additional costs may be incurred.
312 Appendix
Disclaimer: Informed consent documents are used to communicate information

about a disease or condition’s proposed treatment and disclosure of risks and alter-
native forms of treatment. The procedure for obtaining informed consent. Attempts
to define risk disclosure principles should generally meet most patients’ needs in
most situations. However, informed consent documents should not be used to define
all other methods of care and risks encountered. Your doctor may give you addi-
tional or different information based on the facts in your specific case and the cur-
rent state of medical knowledge.
Documents containing informed consent are not intended to define or serve as
the standard of medical care. Medical care standards are determined based on all of
the facts involved in a specific case and are subject to change as scientific knowl-
edge and technology advance and practice patterns evolve.
Before signing the consent, you must carefully read the preceding information
and have all your questions answered.
1. I, as a result of this, authorize _____________to perform the following proce-
dure or treatment.
2. I understand that unforeseen conditions may necessitate different procedures
than those listed above during the procedure and medical treatment or anesthe-
sia. As a result, I authorize the above physician and assistants, or designees, to
perform any other necessary and desirable procedures to exercise their profes-
sional judgment. This paragraph’s authority extends to all conditions that require
treatment but are unknown to my physician when the procedure is initiated.
3. I agree to administer any anesthetics deemed necessary or advisable. All forms
of anesthesia carry risk and the possibility of complications, injury, and, in some
cases, death.
4. I acknowledge that anyone regarding the outcome has made no guarantee.
5. I agree to photograph or televise the operation(s) or procedure(s) to be per-
formed, including appropriate portions of my body, for medical, scientific, or
educational purposes, provided that the photograph does not reveal my identity.
6. I agree to admit observers to the operating room to further medical education.
7. I agree to dispose of any tissue, medical devices, or body parts removed.
8. I authorize the release of my Social Security number to appropriate agencies for
legal reporting and, if applicable, medical-device registration.
9. IT HAS BEEN EXPLAINED TO ME IN AN ACCURATE MANNER:
(a) THE ABOVE TREATMENT OR PROCEDURE IS TO BE PERFORMED.
(b) ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
MAY EXIST.
(c) THE PROPOSED PROCEDURE OR TREATMENT HAS RISKS.
I AGREE TO THE TREATMENT, PROCEDURE, AND ITEMS MENTIONED
ABOVE (1–9). THE EXPLANATION HAS SATISFIED ME.
Appendix 313
Patient or Authorized Signing Representative: Initials of the Patient

Date of Witness: Date:
General Post-Care
What to Expect After Treatment
Laser treatment may produce side effects. The intensity and duration of your side
effects depends on the treatment aggressiveness and your individual healing charac-
teristics. Generally, patients who are treated more aggressively experience more
intense and longer lasting side effects; however, some patients who receive a less
aggressive treatment may experience side effects of greater-than-expected magni-
tude, while others receiving more aggressive treatments may experience side effects
of less-than-expected magnitude. Notify your physician if the severity of your side
effects becomes a problem for you.
What You May Feel and Look Like
Immediately after the treatment, you will experience redness, swelling, and some-
times pinpoint bleeding. You will notice most of the swelling on the first morning
after treatment, particularly under the eyes. Swelling usually lasts 2–3 days. To
minimize swelling, do the following:
Apply cold compresses to the treatment area for 10 min of every hour on the day
of treatment, until you go to bed.
Sleep elevated the first night. Use as many pillows as you can tolerate.
Heat sensation can be intense for the following 2–3 h. Occasionally oozing can
occur in isolated areas for a few days as well.
Over the next few days, redness may worsen. Swelling may be significant and
cause some discomfort.
You may also notice that your skin appears bronzed or little dark dots will appear
on the treated area. Your skin may feel dry, peel, or flake. You may notice a “sand-
paper” texture a few days after treatment. This is the treated tissue working its way
out of your body as new fresh skin is regenerated.
This dead skin is a normal result of laser treatment and should start sloughing off
3–4 days after the treatment. Most patients complete this process 5–7 days after a
treatment on the face. (On off-face areas, such as hands/arms, where healing is
slower, the process may take up to 2 weeks.)
Once the sloughing is complete, you may notice some pinkness over the next few
weeks. Most redness resolves during the first week after treatment, but a rosy “glow”
314 Appendix
can remain for several weeks. If you wish, you can apply makeup to minimize the
redness.
Some patients have also experienced itching.
How to Care for Your Skin After Treatment
Congratulations! You have taken the first step toward more healthy and radiant look-
ing skin by having a laser treatment. Now it is important to help your skin heal
quickly and protect your skin investment.
Your after-treatment skin care regimen is tailored to the treatment you received
today. Follow the instructions as checked below:
Immediately After Treatment. Use a bland moisturizer (i.e., Cetaphil® cream) or
a very thin layer of petrolatum ointment (i.e., Aquaphor®). Use petrolatum ointment
to cover any area with oozing and keep moist. Use of icepacks helps alleviate the
heat sensation. You may also cleanse your face with a mild cleanser.
First Few Days. Continue cleansing and moisturizing over the next few days.
Once the sloughing starts, please allow your skin to heal and DO NOT scrub, rub,
or use exfoliants. Keep clothing away from treated body parts as much as possible
to avoid irritation.
First Week of Healing. Keep treated area clean; avoid smoking, excessive alco-
hol consumption, excessive exercise, perspiring, swimming, or exposing skin to
heat and sun.
Skin Care Products. All of your skin care products should be non-irritating and
non-clogging for the first week or so after a laser treatment. Examples of brands that
offer very gentle and inexpensive products that are ideal to use: Aveeno®, Dove®,
Neutrogena®, and Cetaphil®.
Scrubs, Toners, Glycolic Acid, and Retin A. Your skin will be sensitive for the
first week or so after treatment. Do not use products that will cause irritation during
this time. Do not use abrasive scrubs, toners, or products that contain glycolic acids
or Retin A. Read the product labels.
Normal Skin Care Regimen. Once the sloughing is complete, you may resume
your routine skin care and makeup products, as long as they are tolerable to you.
Sunscreen. It is very important that you use sunscreen to prevent sun damage to
the skin. Sunscreen should offer broadband protection (UVA and UVB) and have a
sun protection factor (SPF) of 30 or more. Once sloughing is complete, use sun-
screen daily for at least 3 months after your last treatment. Apply sunscreen 20 min
before going outside, and again, immediately before. Reapply sunscreen every 2 h.
If direct sun exposure is necessary, wear a hat and clothing that covers the treated
area. Your practice of diligent sunscreen use may lower the risk of laser-induced
hyperpigmentation (darker color).
Moisturizer. Remember that peeling and/or flaking is normal during the healing
process. Therefore, the moisturizer you use should be non-irritating and non-
clogging, or else you could develop breakouts. During the healing period, your nor-
mal moisturizer may be too occlusive, so consider products from the brands listed
Appendix 315
above. Instead of using two separate products, use moisturizers that contain SPF30+.
Reapply whenever your skin feels dry.
Bleaching Creams. Discontinue use of your bleaching cream while your skin
is tender.
Resume your normal skin care regimen when your skin has fully healed.
Cold Sores. If you have a history of cold sores, ask your doctor about care!
Abnormal Healing. If you notice any blisters, cuts, bruises, crusting/scabs, areas
of raw skin, ulcerations, active bleeding, increased discomfort or pain, pigment
changes (lighter or darker than usual complexion), or any other problems, please
contact us as soon as possible.
Questions/Concerns. Post-treatment healing varies from patient to patient. If you
have any questions or concerns, please contact the office.
I was instructed on the above post laser treatment post care and a copy was given to
me.

Laser Hair Removal
Consent Form
I hereby authorize my practitioner, or any delegated associates, to perform laser hair

removal on me. I understand this procedure works on growing hairs, not dormant
ones. For this reason, complete destruction of all hair follicles from any one treat-
ment is unlikely, and I understand that I will require several treatments to obtain a
significant, long-term reduction of hair growth. I also understand some people may
not experience complete hair loss even with multiple treatments and that it is only
effective on hair with color and does not treat white, grey, blonde, or red hair. I
understand that genetics, hormones, and hair color may interfere with hair loss, and
I may not respond at all.
I am aware of the following possible experiences/risks:
DISCOMFORT—Some discomfort may be experienced during treatment.
REDNESS/SWELLING/BRUISING—Short-term redness or swelling of the
treated area is common and may occur. There also may be some bruising.
PIGMENT CHANGES (Skin Color)—During the healing process, there is a
possibility that the treated area can become either lighter (hypopigmentation) or
darker (hyperpigmentation) in color compared to the surrounding skin. This is usu-
ally temporary, but it may be permanent on rare occasions.
WOUNDS—Treatment can result in burning or blistering of the treated areas. If
any of these occur, please call our office.
INFECTION—Infection is possible whenever the skin surface is disrupted
although proper wound care should prevent this. If signs of infection develop, such
as pain, heat, or surrounding redness, please call our office.
SCARRING—Scarring is rare, but it is possible if the skin surface is disrupted.
To minimize the chances of scarring, you must follow all post-treatment instruc-
tions carefully.
https://doi.org/10.1007/978-3-031-27632-3
318 Laser Hair Removal
EYE EXPOSURE—Protective eyewear or shields will be provided. It is impor-

tant to keep these shields on at all times during treatment to protect your eyes
from injury.
The following points have been discussed with me:
Potential benefits of the proposed procedure.
Possible alternative procedures such as electrolysis, waxing, tweezing, and
depilatories.
Probability of success.
Reasonably anticipated consequences if the procedure is not performed.
Most likely possible complications/risks involved with the proposed procedure and
subsequent healing period.
Post-treatment instructions.
For women of childbearing age: I indicate that I am not pregnant by signing
below. Furthermore, I agree to keep my practitioner informed should I become
pregnant during treatment.
Photographic documentation will be taken. I hereby authorize the use of my
photographs for teaching purposes.
BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I, Client
Name, HAVE READ AND UNDERSTAND THE “CONSENT, RELEASE AND
INDEMNITY AGREEMENT” FOR THIS PROCEDURE, AND THAT I AM
SIGNING IT VOLUNTARILY.
PLEASE SIGN YOUR FULL NAME BELOW IF YOU AGREE

Pre- and Post-Care
Pre-Care
You must shave the hair of the body part to be treated. If you cannot shave, then
advise the technician and our staff prior to treatment in order to schedule extra time
in the appointment, and we can do it for you for a fee of $50 per area per occurrence.
Do not wax, pluck, or use depilatories during your series of laser hair reductions.
Avoid sun exposure for 1–2 weeks prior to treatment and use SPF 30 daily to
ensure coverage against UVB and UVA rays.
Do not use self-tanning products for 1–2 weeks prior to and/or post-treatment.
Discontinue use of Tretinoin-type products (Renova, Tretinoin, Retin A, Retin A
Micro, Tri-Luma, Solage, etc.) or Hydroquinone at least 2 or 3 days prior to
treatment.
Laser Hair Removal 319
Many medications that are sun sensitive will also make you more sensitive to the
laser. Please disclose any medications that you may be taking.
If you have a history of cold sores, begin prophylactic treatment with Valtrex or
similar no later than the day prior to your laser hair treatment.
Notify the center if you develop a cold sore, acne, open lesions in the area being
treated, or experience any type of illness prior to your treatment.
Longevity of Botox and fillers are done any time within 6 months prior to face
treatment may be affected. Botox done within 2 weeks prior to treatment is not
recommended.
REMEMBER—Laser hair reduction is never 100%. The industry standard is a
75 to 90% reduction in hairs. Not all hairs will be destroyed. Hormones can cause
hair to grow back.
Post-Care
You may experience small red bumps around the hair follicle. This is normal and
expected. Do not pick, rub, or scratch these until they have cleared. Your skin over-
all may be sensitive for several days following your laser hair removal treatment.
If your skin scabs or crusts or you experience a burn, do not pick, rub, or scratch
these areas. Doing so can result in infection, permanent pigment changes in your
skin or even scarring. Gently cleanse the area and apply hydrocortisone cream sev-
eral times a day for 1 week. If the area is open, also apply a layer of antibiotic oint-
ment over the hydrocortisone cream. Please contact us immediately if you experience
any burns.
Do not sunbathe or use a tanning bed for at least 2 weeks following your treat-
ment. If you need to be out in the sun, wear an SPF 30 minimum.
Avoid swimming, hot tubs and saunas for several days following your treatment.
It can take several weeks for the hair in the treated area to “fall out” (push up and
out of the follicle). This time frame is normal. Do not expect your hair to “not grow
back” after a single session. Laser hair removal is a process. Subsequent treatment
sessions should be 6 to 8 weeks if done on the face and 8–12 weeks if done on the
body. Although rare, infection in the treated area is possible. Signs of infection may
include redness and tenderness in the infected area and fever. Should you develop
an infection, antibiotics may be necessary. Please contact us should you have any
concerns. Please call our office during normal business hours if you have ANY
questions or concerns.
I understand that these pre-/post-care instructions are important to my overall
treatment. I agree that I have read and understand what is required of me to have my
treatment.
320 Laser Hair Removal

Non-ablative Fractional Laser
Consent Form
Do not sign this form without reading and understanding its contents.
The nature of the non-ablative fractional laser procedure has been explained to
me. I understand that just as there may be benefits from the procedure, all proce-
dures involve risk to some degree.
I understand that the following are among the expected side effects of the non-
ablative fractional laser procedure:
Discomfort—Most people will feel some heat-related discomfort (pain) associ-
ated with the treatment. This discomfort is usually temporary during the procedure
and localized within the treatment area. A small number of patients have reported
tenderness in the treatment area lasting up to several weeks.
Redness and Swelling—Laser treatment will cause varying degrees of redness
and swelling in the treatment area. These common side effects last from several
days to a couple of weeks, depending upon the aggressiveness of the treatments.
Itching—This can occur as part of the normal wound-healing process or may
occur as part of the infection, poor wound-healing, or contact dermatitis.
Acne or Milia Formation—A flare-up of acne or milia formation (tiny white
bumps or small cysts on the skin) may occur. These symptoms usually resolve
completely.
Herpes Simplex Reactivation—Herpes simplex virus (cold sore) eruption may
result in rare cases in a treated area that has previously been infected with the virus.
I understand that the following are among the possible risks or complications
associated with the
Laser procedure:
Bleeding; Oozing; Crusting—Aggressive treatment may cause pinpoint bleed-
ing, petechiae (small red dots under the skin surface), and oozing. Crusting or scab-
bing may form if the clear fluid or blood dries.
https://doi.org/10.1007/978-3-031-27632-3
322 Non-ablative Fractional Laser
Blisters; Burns; Scabbing—Heating in the upper layers of the skin may cause
blisters or burns and subsequent scab formation. Steam from the heating may create
a separation between the skin’s upper and middle layers, resulting in blister forma-
tion. The blisters usually disappear within 2–4 days. A scab may be present after a
blister forms but typically will disappear during the natural wound-healing process
of the skin.
Scarring—Scarring is possible due to the disruption to the skin’s surface and
abnormal healing. Scars, which can be permanent, may be raised or depressed, and
scarring could lead to loss of pigment (“hypopigmentation”) in the scarred area.
Pigment Changes—The treated area may appear darker during the healing phase.
This is called PIH, post-inflammatory hyperpigmentation. You may have experi-
enced this type of reaction before and noticed it with minor cuts or abrasions. PIH
occurs as a part of the normal skin reaction to injury. The skin functions become
hyperactive during the healing process, including cells that produce pigment. PIH
occurs more frequently with darker-colored skin, after sun exposure to the treatment
area, or with patients who already have a tan. To reduce the risk of PIH, the treated
area must be protected from exposure to the sun (sunscreen for 6 months after treat-
ment); however, in some patients, increased skin coloring may occur even if the area
has been protected from the sun. This pigmentation usually fades in 3–6 months.
Hypopigmentation—In some patients who experience pigment changes, the
treated area loses pigmentation (hypopigmentation) and becomes a lighter color
than the surrounding skin. This type of reaction may also be permanent.
Infection—If blisters or bleeding are present, an infection of the wound is possi-
ble. Scarring and associated pigment changes may result from an infection.
Eye Injury—Eye injuries may result from numbing cream into the eyes. Your
eyes will be covered with protective goggles during treatment and should remain
closed during the treatment. The laser could cause direct eye injury in the absence
of these precautions.
Efficacy—Because all individuals are different, it is impossible to predict who
will benefit from the procedure. Some patients will have noticeable improvement,
while others may have little or no improvement. A series of treatments are usually
needed for maximum results.
Contraindications—Non-ablative fractional laser cannot be performed on
patients who are currently undergoing or have had Accutane treatment within the
past 6 months, have a predisposition to keloid formation or excessive scarring, or
have suspicious legions.
I am aware that other unexpected risks or complications may occur and that no
guarantees or promises have been made to me concerning the results of the proce-
dure. It has also been explained that during the course of the proposed procedure,
unforeseen conditions may be revealed, requiring the performance of additional
procedures. My questions regarding this treatment, its alternatives, its complica-
tions, and risks have been answered by my doctor and/or his or her staff.
DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND BELIEVE
THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE
BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE
Non-ablative Fractional Laser 323
TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES

OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I have read this form and understand it, and I request the performance of the
procedure.

Pre- and Post-Care
Pre-Care
Stop using Retin-A (and other retinoids) or glycolic acids 3 days before treatment.
Retin-A and other regular skin care regimens can be resumed 1 week after treatment
or as directed.
Sun Protection: If you have a suntan, you will not be able to undergo the proce-
dure. It is critical to wear a broad-spectrum sunscreen before and after your treat-
ment. SPF 30 or higher is advised.
You should take antiviral medication the day before, the day of, and 3 days after
your fractional laser procedure if you have a history of herpes. You will need to
reschedule if you have cold sores during your procedure.
Please refrain from wearing makeup to your treatment session. It may, however,
be used immediately following treatment. Mineral-based makeup is advised.
Please arrive at least 60 min before your appointment for topical anesthesia or
pick it up 1 day before your treatment.
Please make arrangements for a ride home.
Suggested Post-Procedure Products to Have at Home:
Post-Care 1
What to Expect Following Treatment
The non-ablative fractional laser treatment has side effects. The severity and dura-
tion of your side effects are determined by the aggressiveness of the treatment and
your healing characteristics. In general, patients treated more aggressively
experience more intense and long-lasting side effects; however, some patients who
receive a less aggressive treatment may experience side effects of greater magnitude
than expected, while others receiving more aggressive treatments may experience
side effects of lesser magnitude. Inform your doctor if the severity of your side
effects becomes an issue.
What You May Feel and Appear to Be
You will experience redness, swelling, and sometimes pinpoint bleeding immedi-
ately following the treatment. Most of the swelling will be visible the first morning
after treatment, particularly under the eyes. Typically, swelling lasts 2–3 days. To
reduce swelling, do the following:
On the day of treatment, apply cold compresses to the treatment area for 10 min
every hour until you go to bed.
The first night, I slept well. Utilize as many pillows as you can stand. The heat
sensation may be intense for the next 2–3 h. Oozing can also occur in isolated areas
for a few days. The redness may worsen over the next few days. Swelling can be
severe and cause discomfort. Your skin may also appear bronzed, or small dark dots
may appear on the treated area. Your skin may feel dry, flaky, or peeling. You may
notice a “sandpaper” texture a few days after treatment. This is the treated tissue
exiting your body as new fresh skin regenerates.
This dead skin is a normal side effect of laser treatment and should start peeling
off 3–4 days after the procedure. Most patients complete this process 5–7 days after
a facial treatment. (The process may take up to 2 weeks in off-face areas, such as
hands and arms, where healing is slower.)
When the sloughing is finished, you may notice some pinkness for a few weeks.
Most redness fades within the first week of treatment, but a rosy “glow” can last for
several weeks. If you want, you can conceal the redness with makeup.
Some patients have also reported itching.
How to Take Care of Your Skin Following Treatment
Congratulations! Having a non-ablative fractional laser treatment has taken the first
step toward healthier, more radiant skin. It is now critical to assist your skin in heal-
ing quickly and to protect your skin investment.
Your skin care regimen after treatment is tailored to the treatment you received
today. Please follow the steps outlined below:
Immediately the following treatment. Apply a light moisturizer (such as Cetaphil®
cream) or a very thin layer of petrolatum ointment (such as Aquaphor®). Cover any
oozing areas with petrolatum ointment and keep moist. The use of ice packs helps
to relieve the sensation of heat. You can also use a gentle cleanser to clean your face.
The First Few Days Continue to cleanse and moisturize for the next few days.
Allow your skin to heal, and DO NOT scrub, rub, or use exfoliants once the slough-
ing begins. Keep clothing as far away from treated body parts as possible to avoid
irritation.
The First Week of Recovery Avoid smoking, excessive alcohol consumption,
excessive exercise, sweating, swimming, or exposing skin to heat and sun.
Skin Care Items. For the first week or so after the treatment, all of your skin care
products should be non-irritating and non-clogging. Aveeno®, Dove®, Neutrogena®,
and Cetaphil® are examples of brands that provide very gentle and inexpensive
products that are ideal for use.
Scrubs, Toners, Glycolic Acid, and Retin A are all available. Your skin will be
sensitive for the first week or so after treatment. During this time, avoid using prod-
ucts that will irritate your skin. Avoid using abrasive scrubs, toners, or products
containing glycolic acids or Retin A. Examine the product labels.
Normal Skin Care Routine After the sloughing process is finished, you can
resume using your regular skin care and makeup products as long as they are
tolerable.
Sunscreen. It is critical to use sunscreen to protect your skin from sun damage.
Sunscreen should provide broad UVA and UVB protection and have an SPF of 30
or higher. After sloughing is complete, apply sunscreen daily for at least 3 months
after your last treatment. Apply sunscreen 20 min before going outside and then
again right before. Every 2 h, reapply sunscreen. Wear a hat and clothing that covers
the treated area if direct sun exposure is required. Your diligent use of sunscreen
may reduce your risk of laser-induced hyperpigmentation (darker color).
Moisturizer. It is important to remember that peeling and flaking is normal dur-
ing the healing process. As a result, the moisturizer you use should be non-irritating
and non-clogging, or you may experience breakouts. Your regular moisturizer may
be too occlusive during the healing period, so consider products from the brands
listed above. Instead of using two separate products, use SPF30+ moisturizers.
Reapply as needed if your skin becomes dry. Creams for bleaching. While your skin
is tender, stop using your bleaching cream. You can resume your normal skin care
routine when your skin has healed completely. Sores from the cold. Consult your
doctor if you have a history of cold sores!
Healing that is abnormal. Please get in touch with us as soon as possible if you
notice any blisters, cuts, bruises, crusting/scabs, areas of raw skin, ulcerations,
active bleeding, increased discomfort or pain, pigment changes (lighter or darker
than usual complexion), or other problems.
Questions/Concerns. Healing after treatment varies from patient to patient.
Please get in touch with the office if you have any questions or concerns.
I was given a copy of the above post-laser treatment post-care instructions.
Name, READ AND UNDERSTAND THE “CONSENT, RELEASE, AND
INDEMNITY AGREEMENT” FOR THIS PROCEDURE AND AM SIGNING IT
VOLUNTARILY.
IF YOU AGREE, PLEASE SIGN YOUR FULL NAME BELOW.

Post-Care 2
For many years, physicians have used lasers. There are numerous methods for using
lasers in surgery. The fractional laser may use one or more wavelength or a hybrid
technology of 1470 nm non-ablative laser and 2940 nm ablative laser to create con-
trolled zones of coagulation to selected depths into the dermis, stimulating neocol-
lagenesis and fractionally vaporize (ablate) micro laser channels in the epidermis,
addressing skin tone and texture. It does not vaporize the skin when used with the
non-ablative laser.
The fractional laser treatment produces results based on the treatment’s aggres-
siveness, considering your skin concerns, skin health, and individual healing ability.
As a result, patient response to fractional treatment may vary. The desired responses
are erythema (redness) and possibly edema (swelling) within a few minutes of the
procedure’s completion. The depth and coverage of the procedure will increase the
degree of redness and the length of healing time.
Following Treatment
The presence of redness is normal and expected. The intensity of redness generally
increases in the first few days after treatment, with day 3 being the most intense.
Depending on how aggressive the treatment is, redness can last up to 7 days.
Pinpoint bleeding is possible. Depending on the treatment depth, this can last
anywhere from a few hours to 12 h, and it may be limited to specific treated areas.
Swelling is common and expected immediately after treatment. A cold compress
or ice packs will help to reduce swelling. To avoid further swelling, sleep upright the
first night following treatment. The first morning after treatment is when swelling is
most noticeable, particularly under the eyes. Depending on how aggressive the
treatment is, swelling may last 2–4 days.
After the treatment, the area may feel warm for 12–24 h. During this time, cold
compresses or ice packs may provide relief.
On the second or third day following treatment, you will notice tiny dark spots
and a bronzed appearance to the treated skin. This is known as the MENDS (micro-
scopic epidermal necrotic debris). The microscopic wounds known as MENDS con-
tain a lot of melanin in people with dark skin or areas where sun damage has caused
pigmented lesions. Because there are so many MENDS, they can bronze the skin
and make small areas crusted (do not try to scratch them off). This is a part of the
healing process in which treated tissue is expelled from your body as new fresh skin
regenerates. During this time, your skin will be extremely dry, with a sandpaper
texture, and flake and peel. The peeling process may take 5–7 days to complete if
the face is treated. This process could take up to 2 weeks if the neck, chest, or other
body parts were treated.
After the peeling is finished, your skin will have a rosy, pink glow that will
gradually fade. Your clinician will inform you and advise you when and how to
use makeup.
If you were prescribed an antiviral, continue to take it as directed.
Post-treatment discomfort may be relieved by over-the-counter oral pain reliev-
ers, such as Extra Strength Tylenol, or by doctor-ordered pain medication.
Itching is common during the healing process and is completely normal. Oral
Benadryl may relieve itching, but it can also cause drowsiness. DO NOT scratch the
treated area, as this can result in scarring and pigmentation issues.
Keep your skin moisturized with Medical Barrier Cream, Restoracalm, or
another moisturizing cream recommended by your practitioner. It should be reap-
plied as needed if your skin becomes dry. A petroleum-based moisturizer may be
appropriate for individuals who require more graduated coverage, whereas a cream
may suffice for less aggressive treatments.
Cleanse the skin twice a day, beginning the morning after the treatment, with
plain, lukewarm water and a gentle cleanser, such as Cetaphil. Apply the cleanser
and water gently with your hands, then pat dry with a soft cloth. DO NOT rub,
scrub, or use an exfoliant or a skin care brush, such as Clarisonic, in the treated area.
This could result in scarring and pigmentation issues.
Peeling and flaking are common within 24 h of treatment and should be allowed
to fade naturally. DURING THE HEALING PROCESS, DO NOT PICK, RUB, OR
FORCE OFF ANY SKIN, AS THIS MAY RESULT IN SCARRING,
PIGMENTATION COMPLICATIONS, AND INFECTION! Washing the skin gen-
tly more frequently will aid in the peeling process.
Sunscreen is a must and should be used daily beginning the day of treatment and
up to 3 months after the procedure. Use recommended sunscreen with broad UVA
and UVB protection and an SPF of 30. Apply sunscreen 20 min before going out in
the sun. Every 2 h, reapply sunscreen. Wear a hat and clothing that covers the treated
area if direct sun exposure is required. Blistering, scarring, hyperpigmentation, or
hypopigmentation may occur if the treated area is exposed to sunlight (direct or
indirect). Sun exposure should be avoided for at least 2 weeks after treatment.
Makeup can usually be worn after the peeling process is finished.
Avoid getting shampoo directly on the treated area when showering in the com-
ing days. To avoid directly hitting your face with the full force of the water stream,
take your shower with your back to the water.
Exercising and sweating should be avoided until the skin has healed.
There may be some swelling immediately following treatment; however, if you
have excessive swelling or any of the following signs of infection, please get in
touch with the office right away:
Drainage that looks like pus.
Increased warmth at or around the treated area.
Fever of 101.5 or higher.
Extreme itching.
Rosacea and Spider Vein Removal
Consent Form
I give my practitioner permission to perform the procedure. The pulsed light system
has the potential to reduce darkly pigmented sunspots and spider veins significantly.
More than one laser session may be required to achieve the desired results. Other
treatments, such as skin care products, are frequently required to blend color, reduce
sun damage, and achieve the best results. The FDA has approved the removal of
brown spots, spider veins, and rosacea.
The skin will be red and swollen, and fine, thin scabs will form. Continue to
apply Polysporin and Aquaphor to the treated areas until the thin scabs fall off. This
procedure will take between 1 and 3 weeks. It could take up to 3–6 months in some
rare cases. Scratching the scabs can result in scarring.
We cannot treat clients who are taking ACCUTANE or PHOTOSENSITIZING
medications. Clients who use ANTICOAGULANTS should be identified.
The following issues may arise during treatment:
Scarring: The pulsed light system can cause bruising and a mild burn or blister
on the skin. The power (joules) must be just below the blistering point for an effec-
tive treatment, which means the skin will be red. Scarring is a possibility.
After treatment, hyperpigmentation (browning) and hypopigmentation (whiten-
ing) have been observed, particularly in people with darker skin. This usually
resolves within a few weeks, but it can sometimes take up to 3–6 months. The risk
of permanent color change is uncommon. If you have a lot of color in your skin, a
skin-lightening cream will be recommended before the treatment to reduce the mel-
anin in your skin. It is critical to avoid sun exposure after the treatment to reduce the
risk of color change.
Infection: Although bacterial, fungal, and viral infections are uncommon after
pulsed light treatment, they can occur. Following laser treatment, herpes simplex
virus infections in the mouth can occur. Individuals with a history of herpes simplex
virus infections in the mouth are at risk. Additional treatment, including antibiotics,
https://doi.org/10.1007/978-3-031-27632-3
330 Rosacea and Spider Vein Removal
may be required if a skin infection develops. We recommend preventative therapy if

you have a history of herpes simplex virus in the treated area.
Pinpoint bleeding is uncommon but can occur after brown spot and spider vein
treatment procedures. If bleeding occurs, additional treatment may be required.
Pathology of Skin Tissue: Energy directed at skin lesions has the potential to
vaporize them. A laboratory examination of the tissue specimen may be impossible.
Only pigmented lesions that are clearly benign can be treated. Consult your doctor
before beginning treatment.
In rare cases, local allergies to tape and preservatives used in cosmetics or topical
preparations have been reported. Prescription medications can cause systemic reac-
tions (which are more serious). Allergic reactions may necessitate additional
therapy.
Wear SPF 25 or higher sunscreen before and after treatment to protect your skin.
I understand that multiple treatments may be required to achieve the desired result.
I am aware that prolonged exposure to light may harm my vision. I will always
wear my eye protection.
Following the aftercare instructions is critical for healing and preventing scar-
ring, hyperpigmentation, and hypopigmentation.
Unexpected mechanical problems may arise from time to time, necessitating a
rescheduling of your appointment. We will make every effort to notify you before
you arrive at the office. Please accept our apologies if we have caused you any
inconvenience.
Name, HAVE READ AND UNDERSTAND THE “CONSENT, RELEASE, AND
INDEMNITY AGREEMENT” FOR THIS PROCEDURE AND AM SIGNING
VOLUNTARILY.

Post-Treatment Instructions
Immediately after the treatments, you should apply an ice pack, as there may be
mild swelling. It is normal for the treated area to feel like sunburn for a few hours.
You should use a cold compress if needed. Avoid any trauma to the skin for up to
2–5 days, such as bathing with very hot water, strenuous exercise, or massage.
Avoid picking or scratching the treated skin to achieve your best results. If any
crusting, apply antibiotic cream. Some physicians recommend Aloe Vera gel or
some other after sunburn treatment such as Desitin. Darker pigmented people may
have more discomfort than lighter skin people and may require the Aloe Vera gel or
Rosacea and Spider Vein Removal 331
an antibiotic ointment longer. Follow instructions as specified by your laser

professional.
Makeup may be used after the treatment has quit swelling unless there is epider-
mal bleeding. It is recommended to use new makeup to reduce the possibility of
infection. Keep the area moist. Any moisturizer without alpha-hydroxy acids
will work.
You may shower after the laser treatments in tepid water. The treated area may
be washed gently with a mild soap. Skin should be patted dry and NOT rubbed.
You will experience redness and bruising from 5 to 14 days at the treatment.
Avoid direct sun exposure and tanning beds for 1–2 months and throughout the
course of the treatment so as to reduce the chance of dark or light spots. Use sun-
screen SPF 25 or higher at all times throughout the treatment when going outside.
Avoid tweezing, waxing, bleaching, or chemical peels during the course of the
treatment. Do not use any irritants such as Retin-A, Benzoyl Peroxide, or astringents.
If work on the leg has been done, wear compression stockings for 48 h and then
during the day while on feet for up to 2 weeks.
Call your physician’s office with any questions or concerns you may have after
the treatment.
CO2 Laser
My practitioner has told me that I am a good candidate for CO2 Fractional Laser
Resurfacing treatment and that, while laser surgery is highly effective, there are no
guarantees I will benefit from it. I understand that the following are the most com-
mon side effects and complications of this laser treatment:
Pain: Each laser pulse’s sharp, burning sensation may cause moderate to severe
discomfort. Topical anesthetics, anesthetic injections, or intravenous sedation may
alleviate pain during the procedure. For the post-treatment period, oral pain medica-
tion may be prescribed.
Swelling and Oozing: Swelling is most common around the eyes and neck.
Clear fluid may accumulate and form a crust (or scab) if the lased areas are not
moist. Within 2 days, you may notice an exaggerated tan with slight micro crusting
lasting up to 2 weeks. During this time, a healing ointment should be applied to
the skin.
Prolonged Skin Redness: At first, the laser-treated areas will appear bright red.
The redness can be concealed with opaque makeup after the first few days. The red-
ness will fade to pink over the next few weeks and then to normal skin color over
the next few months.
Skin Darkening (Hyperpigmentation): “Tanning” of the skin can occur in treated
areas and fade after a few months. This reaction occurs more frequently in patients
with olive or dark skin tones and can worsen if the laser-treated area is exposed to
sunlight.
Skin lightening (hypopigmentation): Light spots can appear in areas of skin that
have previously been treated or as a delayed response to laser surgery. The pale
areas may darken or pigment over time, but they may be permanent.
Scarring: Although the risk of scarring is low, it can occur whenever the skin’s
surface is disrupted. Strict adherence to all post-operative instructions will reduce
the likelihood of this occurring.
Infection: A post-operative skin infection is possible. The risk is reduced by
using antibiotics appropriately and practicing good skin care, including frequent
hand washing.
Allergic Reaction: An allergic reaction to an anesthetic, topical cream, or oral
medication is possible.
Ectropion: A downward pull of the eyelids can occur in rare cases after peri-
orbital laser resurfacing.
Acne or milia formation: Acne flare-ups or milia formation can occur
post-treatment.
By signing below, I certify that I have read and comprehended all of the informa-
tion written above and contained in the information sheet. I believe I have been
adequately informed about my alternative treatment options, the risks of the pro-
posed surgery, and the risks of failing to treat my condition. I freely consent to my
practitioner performing laser surgery on me and authorize the taking of clinical
photographs to document my clinical process.
VOLUNTARILY.

Pre- and Post-Care
Pre-Care
Avoid prolonged sun exposure for 1–2 weeks before treatment and use SPF 30 daily
to ensure UVB and UBA ray protection.
Do not use self-tanning products for at least 2 weeks before and after treatment.
Exfoliants should be avoided for 1 week before and 2 weeks after treatment.
Tretinoin-type products (Renova, Tretinoin, Retin A, Retin A Micro, Tri-Luma,
Solage, etc.) should be stopped at least 2 or 3 days before treatment.
Rosacea and Spider Vein Removal 333
Sometimes, you may be asked to “pre-treat” with lightning agents. Your techni-
cian will advise you whether or not to use lightning agents before treatment and for
how long. If you are using or have been told to use lightning agents, stop using them
2 or 3 days before your treatment.
If you have a history of cold sores, start prophylactic treatment with Valtrex or
similar the day before CO2.
Notify the center if you develop a cold sore, acne, or open lesions in the area
being treated or if you become ill before your treatment.
Ibuprofen and nonsteroidal anti-inflammatories should be avoided for 1–2 weeks
before and after treatment.
Botox and fillers done within 6 months of facial treatment will have a shorter
lifespan and are not recommended.
Post-Care
You will feel sunburned, and your skin will turn pink immediately after treatment.
For up to 12 h after treatment, most people experience mild to severe discomfort.
Although less common, swelling is possible. If the “stacking” technique is used,
you will feel severely sunburned, your skin may be raw, swelling is expected, and
the area may ooze.
DO NOT wash your face for 24 h after the treatment. You can relieve discomfort
in the first 24 h with cool compresses and a mild/gentle moisturizer. Pinking or red-
ness of the skin and a burning sensation are normal within the first 24 h.
Tiny scabs or marks might appear one to several days after treatment if the face/
neck was treated and up to several weeks if “stacking” was used or treatment was
performed on the body. Use antibiotic ointment if any of the marks are raw or open.
Picking or scrubbing at the marks is not permitted. Cleanse the area and use a gentle
moisturizer the day after the treatment and several times throughout the day while
marks are present for most face/neck treatments. Please see the next bullet below if
the “stacking” technique is used or if treatment is being done on the body.
If the “stacking” technique is used (ask your technician if this will be done) or if
treatment is being done on the body, gently cleanse the area and apply hydrocorti-
sone cream followed by a thin layer of antibiotic ointment several times a day for
the first week or until the area heals.
Otherwise, you should be able to resume your normal facial skin care routine
after 3 days (or as otherwise advised by your technician). Perform a test spot first!
If exposed, apply SPF 30 or higher to the treated area daily. Makeup can generally
be applied the day after your treatment unless “stacking” is used, in which case
makeup should be avoided until the skin has healed.
I understand how important these pre/post-care instructions are to my overall
treatment. I agree that I have read and understand what is expected of me to receive
my treatment. My signature is valid for future pre-/post-care for CO2 treatments.

VOLUNTARILY.
Date of Client Signature
Acne Treatments
Consent Form 1
Acne develops when your skin’s pores become clogged with oil, dead skin, or bac-
teria. Each pore on your skin is a follicle opening. The follicle is composed of hair
and an oil gland. The oil gland secretes sebum (oil), which travels up the hair shaft,
out the pore, and onto the skin. Fotona provides a laser acne treatment protocol that
comprehensively solves the acne problem. Through photo-selective absorption and
controlled heating effects, the treatment precisely controlled laser or IPL light safely
penetrates the skin to target overactive sebaceous glands and reduce acne inflamma-
tion. The high-powered laser or IPL safely penetrates the skin to an optimal treat-
ment depth, thermally and selectively destroying overactive sebaceous glands.
Aside from its thermal penetration effects, the laser or IPL acne treatment also
accelerates healing and stimulates collagen remodeling, which is an important step
in the long-term treatment of acne.
I voluntarily consent and authorize the staff of this center, including physicians,
technicians, associates, technical assistants, and other healthcare providers as
deemed necessary by the staff of this center, to perform this treatment. I hereby
release this center, its staff, and other participating healthcare providers from all
consequences of this treatment and related procedures.
I agree to have this center’s staff take close-up photographs of the involved
area(s) before, during, and after treatment to help document my treatment course. I
agree to have these photos published on the center’s website and social media. I
understand that my identity will be kept confidential.
I understand that this treatment is not an exact science, and I acknowledge that
no guarantees or assurances about the outcome have been made to me.
I am not on Accutane and have been off Accutane for at least 6 months.
I understand and acknowledge that I must have at least four treatments per week
and adhere to the skin care regimen prescribed by the center.
https://doi.org/10.1007/978-3-031-27632-3
336 Acne Treatments
I promise to give the center 3 months (using proper skin care and treatment
modalities) to resolve and reduce my acne.
By signing below, I certify that I have read and comprehended all the information
provided above. I have been fully informed of my alternative treatment options and
the risks of the proposed treatment, and all of my questions have been addressed and
answered satisfactorily. I freely agree to the laser acne treatment.
VOLUNTARILY.

Consent Form 2
Intense pulse light (IPL) for acne treatment uses light to kill or reduce P. acnes bac-
teria, inflammation, and overproduction of sebaceous oil glands. This therapy may
selectively employ multiple IPL filters (420 nm, 560 nm, and 590 nm) to target the
P. acnes bacteria and sebaceous oil glands. The goal is to pack enough light into the
skin to affect the entire pilosebaceous unit.
A Review of Light Therapy Facts
For the treatment of acne, IPL selected the following filters: 420 nm, 560 nm,
and 590 nm:
Porphyrins are effectively targeted by the 420 nm filter (blue light). Porphyrins
are produced by the bacteria Propionibacterium acnes (P. acnes). After being
exposed to blue light, these P. acnes porphyrins will undergo photoexcitation. This
process produces singlet oxygen within the microorganism, resulting in the bacte-
ria’s selective destruction.
Adding a 560 nm filter (yellow light) improves the treatment of mild to moderate
inflammatory acne lesions.
Adding a 590 nm filter (red light) effectively treats deeper lesions caused by the
sebaceous oil gland. The red light heats the gland to help it produce less oil.
Multiple consecutive sessions will be required to reduce acne and the severity of
lesions.
Pre- and post-care instructions and requirements must be followed.
The treatment course is expected to result in a 40–80% reduction in the number
of lesions and the prevention of new lesion formation.
Acne Treatments 337
Laser light can harm the eyes, so special safety eyewear must be worn during the
procedures.
IPL light is an intense burst of light, and even with the special safety eyewear on,
you will notice light emanating from the treatment area.
In some cases, the sensation of light can be unpleasant, resembling pinpricks or
bursts of heat. The use of topical anesthetic is typically avoided in light-based acne
procedures. Because there are known severe allergic reactions to ingredients in topi-
cal anesthetics, the use of topical anesthetics is at the practitioner’s discretion.
Patients who are allergic to anesthetics will notify the provider.
Common Risks and Side Effects
A mild sunburn sensation is to be expected. It can last anywhere from 2 to 24 h.

Acne flare-ups during the first and second sessions. This usually goes away after
a few sessions. Do not pick, scratch, or remove any blemishes that form scabs.
Erythema (redness) and kin edema (swelling) in the treated area could last hours.
The thermal light affecting the surrounding skin can also cause urticaria (itching) or
a hive-like appearance. Purpura (bruising) occurs when a blood vessel ruptures.
These symptoms usually go away after a few hours. A cool compress applied to the
affected area provides relief. For at least 12–24 h, the treated area should be handled
with care. Limited activity may be advised to reduce excessive perspiration and not
use a hot tub, steam room, sauna, or shower.
After treatment, a blister can form up to 48 h later. It is possible to use an antibi-
otic cream or ointment. Bruising, superficial crusting, and discomfort are also short-
term effects.
There has been hyperpigmentation (browning) and hypopigmentation (lighten-
ing) observed. The permanent color change is a rare risk with these conditions,
which usually resolve within 2–6 months. Sun exposure (including tanning beds)
must be avoided before and after treatments to reduce the risk of color change.
When sun exposure is required, apply sunscreen and/or sunblock.
Infection following uncommon treatments; however, herpes simplex virus infec-
tions around the mouth can occur. This applies to people with a history of the virus
and people with no known history. If an infection occurs, your clinician must be
notified so that appropriate medical care can be prescribed.
Treatment-induced allergic reactions are uncommon. As previously discussed,
some people may develop a hive-like appearance in the treated area. Cosmetics or
topical preparations can cause localized reactions in some people. Systemic reac-
tions are uncommon.
After hearing about the potential benefits of IPL Acne Treatment and other
options, I decided on IPL Acne Treatment.
I understand that following pre- and post-treatment instructions is critical to the
success of Acne Treatment and avoiding unnecessary side effects or
complications.
338 Acne Treatments
I am aware that Acne Therapy requires payment, and the fee structure has been
explained to me.
VOLUNTARILY.

Pre- and Post-Care
Pre-Care
Avoid sun exposure for 1–3 weeks before treatment and use SPF 30 daily to ensure
coverage against UVB and UBA rays.
Do not use self-tanning products for 1–3 weeks before and post treatment.
Discontinue use of Tretinoin type products (Renova, Tretinoin, Retin A, Retin A
Micro, Tri-Luma, Solage, etc.) at least 2 or 3 days before treatment.
Discontinue use of Hydroquinone 2 or 3 days before treatment.
If you have a history of cold sores, begin prophylactic treatment with Valtrex or
similar no later than the day before IPL.
Notify the center if you develop a cold sore, acne, open lesions in the area being
treated, or experience any illness before your treatment.
If possible, avoid Ibuprofen and non-steroidal anti-inflammatories for 3 days
before and after treatment.
Longevity of Botox and fillers done any time within 6 months before face treat-
ment may be affected. Botox and fillers within 2 weeks before IPL is not
recommended.
Post-Care
You may experience a sunburned sensation immediately following treatment.

Although rare, some light swelling is possible.
Darkening of freckles and other areas is normal. If this occurs, do not pick or
exfoliate the areas. They will flake off or lighten on their own over the next week if
on the face and over the next several weeks if on the body.
If you experience a burn, gently cleanse the area and use hydrocortisone cream
on the area several times a day for the next week. If the mark opens, also use
Acne Treatments 339
antibiotic ointment over the hydrocortisone cream. Please notify us immediately of

any burns.
Use SPF 30 or higher daily on treated area if exposed.
You may generally resume normal skin care regimen after 3 days following treat-
ment (or sooner if advised by your technician).
Makeup may be applied the day after your treatment (or sooner if your techni-
cian advises).
Please call our office during normal business hours if you have ANY questions
or concerns.
I understand that these pre-/post-care instructions are important to my overall
treatment. I agree that I have read and understand what is required of me to have my
treatment.
Name, READ AND UNDERSTAND THE “CONSENT, RELEASE AND
Client Signature Date
Melasma
Introduction: The nanosecond Q-switch laser is the golden standard for Melasma
treatment. The light beam produced by this laser is ideal for smooth and even lasing
with no “hot spots.” As a result, benign pigmented lesions can be treated quickly,
efficiently, and safely, with less risk of scarring, crusting, or pigment bio-stimulation.
This laser’s mechanism of action is to shatter small subcellular particles known as
melanosomes. Your natural skin color is usually unaffected by the wavelength used,
and all skin colors can be treated without difficulty.
The procedure: Although no anesthetic is required, you will be offered a topical
anesthetic cream or a lidocaine injection. Minor stinging may occur in the leased
areas. This stinging usually goes away shortly after the procedure. The laser treat-
ment is quick, and multiple brown spots can be treated in a single session. Following
your laser treatment, the brown spots will appear dark red, similar to a bruise. After
treatment, the brown spot pigment will peel away in 1–2 weeks. To avoid scarring,
apply a light layer of moisturizer to the brown spots during this period and avoid
picking or scratching the lesions. It is critical to stress that multiple treatments may
be required to lighten the lesion completely. Finally, some brown spots are extremely
resistant to treatment and may necessitate more invasive surgery to remove them.
Some brown spots are prone to recurrence.
Possible complications: Complications of pigment lasing are uncommon but can
occur. These complications include crusting, bruising, secondary infection, scar-
ring, and skin pigmentary changes. Bruising of varying degrees is expected, and it
should resolve without complications within 10–14 days of the laser procedure.
Follow-up: Re-treatments are scheduled every 4–6 weeks.
I have read and comprehended the above consent. The doctor/technician/nurse
has gone over the consent form with me and allowed me to ask questions about the
procedure and any potential risks. Alternative therapies have also been explained to
me by the doctor/nurse/technician. I understand that the outcome of this treatment
is not guaranteed and that complications, such as scarring, are possible. I understand
https://doi.org/10.1007/978-3-031-27632-3
342 Melasma
that multiple treatments, at my own expense, may be required, as well as the use of
bleaching creams.
VOLUNTARILY.

Pre- and Post-Care
Pre-Care
• Do not wear makeup on the day of treatment.

• No sun-tanning or self-tanners 4 weeks prior to treatment.
• Includes spray tans, tanning lotions, tanning beds, sun exposure, etc.
• Some medications or supplements may increase the risk bruising. Consult with
your physician.
• Avoid treatments that may irritate the skin for 1–2 weeks prior to treatment (wax-
ing, depilatories, etc.).
• Notify clinic with any changes to your health history or medications since your
last appointment.
• History of herpes or cold sores may require an antiviral prescription prior to
treatment.
Post-Care
• Avoid sun exposure and use a broad-spectrum (UVA/UVB) sunscreen to prevent

further sun damage.
• Bruising, redness, and swelling are common and resolve with time.
• Treated pigment will turn darker (brown to black) within 24–48 h.
• Do not pick at treated areas.
• Treated pigment will exfoliate off the face in approximately 1 week.
• Treated pigment will exfoliate off the body in approximately 2–3 weeks.
• Avoid heat—hot tubs, saunas, etc. for 1–2 days.
• Avoid skin irritants (examples below) a few days post-treatment.
• Products containing tretinoin, retinol, benzoyl peroxide, glycolic/salicylic acids,
astringents, etc.
• Notify clinic of any concerns (blistering, excessive redness/swelling, etc.)
• Consult with clinic about when to resume skin care regime.
Index
A C
Acne vulgaris, 153 Cavitation, 234
anti-acne therapy, 153 CO2 laser systems
Cutibacterium acnes, 153 A-Continuous Wave (C.W.), 252
device of choice, 176 B-Super pulse, 252
dual filter technology, 165 CO2ER by candela, 93–95, 254
harmony by alma, 163 comparsion, 91, 252
M22 form lumenis, 164–165 C-Ultra pulse, 252
nordyls by candela, 163 eCO2 by Lutronic, 92–93, 253
532-nm KTP laser, 165 indication, 89, 252
585 and 595 nm pulsed-dye laser, 166 pulsed dye laser (PDL), 259
icon palomar by cynosure, 162 Superpulse mode, 88
IPL treatment effect, 157, 158 treatment parameters, 256
long pulsed PDL, 167 UltraPulse by Lumenis, 95–96, 256
negative pneumatic pressure, 162–163 Coagulation, 79
non-ablative fractional lasers, 170 Cynosure Icon IPL, 34
Clearskin®, 174 Cynosure Icon technical
colour-blind laser platform, 174 specifications, 291
Fraxel 1550 nm fractional
laser, 172
Fraxel Dual from Solta, 171 D
Frax PRO®1550, 174 DEKA Smartxide DOT, 271
Icon® 1540 fractional laser, 172 Dermal Papilla (DP), 103
1450-nm Diode laser, 170
photo-based treatments, 157
short pulse duration, 168 E
single cut-off filter, 160 Electro-Optical Synergy (ELOS), 147
skin analyzers, 155 Ephelides, 182
1064 nm Nd: YAG, 169, 170 Epidermis (EP)
tools and questioners, 155 melanocyte, 3
Advanced Fluorescence Technology (AFT), stratum basale, 3
21, 48, 184, 291, 292 stratum corneum, 2
Anagen phase, 104 stratum granulosum, 3
Ascorbic acid, 201 stratum sріnоѕum, 3
Avalanche effect, 101 Erythema, 191
https://doi.org/10.1007/978-3-031-27632-3
344 Index
F MaxY®, 188
FDA Medical Device Approval Pathways, 303 melasma, 197
Federal Food, Drug, and Cosmetic assessment method, 197
Act (FD&C Act), 301 classification, 199
Female Sexual Functioning Index (FSFI), 281 etiology, 198
Finesse Spot Adapters™, 44, 291 MASI score, 209
patients expectation, 198
treatment, 199
G microscopic thermal zones (MTZ), 209
Genitourinary Syndrome of the 1927 nm laser, 216
Menopause (GSM), 273 Fraxel Dual laser, 217
Gentlmax interface, 66 treatment, 216
Glogau photoaging classification, 9 picosecond laser, 207
pigmented lesions, 181
pre-treatment process, 183
H Q-switch nsec lasers, 204
Hair removal, see Laser hair removal (LHR) clinical response, 205
Hyaluronic acid, 5 tranexamic acid (TXA) treatment, 207
Hyperpigmentation treatment parameter, 206
ablative fraction resurfacing lasers, test shots, 186
219, 220 topical agents, 200
actinic lentigines, 182 indication, 201
chromophore, 213 mechanisms of action, 201
colour-sensitive lasers treatment, 186
ALEX 755, 194 Vydence IPL-sq, 187
pulse-dye laser (PDL), 193 Hypertrophic scars and keloids, 243
Q-switch laser devices, 195 color-blind lasers
quick pulse-to-pulse mode ablative fractional laser, 250
(Q-PTP), 195 CO2 laser systems (see CO2 laser
combination of 595-nm and 1927 nm systems)
laser, 218 Er:Yag platforms, 257, 259, 260
pain level, 219 non-ablative fractional lasers, 250
test spot, 218 stacking, 260
1550 nm laser, 214 color-sensitive lasers
Erbium-Glass Doped Laser, 214 long pulsed lasers, 248
Fraxel Dual operation, 214 Q-Switch nsec laser, 249
pain level, 215 1064 nm laser, 249
swelling and redness, 215 differences, 246
test spot, 215 etiology, 246
fractional 755-nm psec laser, 209 IPL treatment, 247
glucocorticosteroid, 191 wound healing process, 246
Harmony PRO, 188
Icon®, 188
intense pulse light (IPL), 202 I
clinical endpoint, 204 Intense pulsed light (IPL), 40, 183, 290–291
cooling device, 204 interchangeable filters, 42
Lumecca IPL from Inmode, 203 comparison, 43
Lumines M22®, 202 IPL-Sq® technology, 44
Nordlys platform, 203 Joule systems, 44
IPL-Sq® technology, 185 light emission range, 42
Lumenis M22® IPL, 187 M22 system specifications, 44
Masson-Fontana staining methods, 192 train of sequential pulses, 42
MaxG®, 188 interchangeable handpieces, 47
Index 345
Alma Harmony XL Pro, 48 edema, 137

comparison, 47 GentlMaxPro, 132
Cynosure, the SmoothPulse™ parameters, 135
technology, 48 perifollicular erythema, 137
Dye VL PRO 450-600 nm Cooled pre-treatment, 135
Applicator, 48 procedure, 135
Nordlys system specification, 48 long-pulsed Diode 810 nm, 137
Isolaz IPL from Solta, 54 high-fluence single pass, 138
light characteristics, 41 low-fluence single pass, 140
skin lesions, 41 selective photothermolysis, 137
long-pulsed pass ND
parameters, 144, 145
L procedure, 143
Laser hair removal (LHR), 101 YAG 1064 NM, 142
avalanche effect, 101 photo-thermolysis effect, 101
blended blend wavelengths, 146 wavelength, 109
dermal papillary matrix, 101 Laser systems, 54
Electro-Optical Synergy (ELOS), 147 Alma Harmony XL Pro specifications, 291
hair follicles, 103 BBL® TECHNICAL
abdomen, 107 SPECIFICATIONS, 294
anatomy, 103 colour-blind lasers, 56
catagen phase, 104 ablative lasers, 56, 57
extremities and face, 107 coagulation, 56
Fitzpatrick assessment, 108 microthermal treatment zones, 56
glove test, 106 resurfacing lasers (see
growth phase, 104 Resurfacing lasers)
hair colour, 106 wavelength, 57
hair density, 107 colour sensitive, 54
photothermolysis effect, 104 diode laser, 55
public region, 108 532 nm laser, 55
skin reflectance colourimeters, 109 585 and 595 nm Pulsed-dye lasers, 55
telogen phase, 104 photothermolysis effect, 54
texture and coarseness, 106 755 nm Alexandrite, 55
IPL platforms, 109 694 nm Ruby laser, 55
blood flow effect, 110 1064 nm Nd:YAG laser, 55
clients expectations, 127 cost of consumables, 298
dual-filter concept, 118 demonstration, 292
ELOS Pulse, 123 dermatology and aesthetics, 287
erythema and edema, 130 engineer education and experience, 297
ForeverBARE function, 113 feedback, 292
guidelines, 128 IPL-Sq technical specifications, 291
Harmony and Harmony pro, 121 M22 system specifications, 291
Icon Palomar by Cynosure, 116 Nordlys system specification, 291
IPL-SQ by Vydence, 110 picosecond laser systems comparison, 78
Lumenis M22 IPL interface, 111 publications, 289
medical history, 123 purchase contract, 297
Nordlys platform, 119 refurbished devices, 298
post-treatment, 131 socioeconomic factors, 287
side effects and adverse reactions, 128 stand-alone versus modular platforms, 286
skin texture and pigmentation type of practice, 288
changes, 128 with Alex lasers, 299
long-pulsed Alexandrite 755 nm, 132 Light-based treatment, 10
cutaneous freezing, 134 Light-tissue interaction process, 10
346 Index
Long millisecond (msec) and quasi-long Q

microsecond (μsec) Q-switch nanosecond lasers, 207
diode laser, 68 Q-switch nsec applicator, 195
diode laser systems in SHR mode, 71 Q-switch nsec lasers, 204
532 nm KTP, 58, 59
585 and 595 nm wavelength, 60
GentleMax, 66 R
CDC malfunction, 66 Refurbished laser device
dynamic cooling device (DCD), 66 device classification, 302
hyperpigmentations, 66 FDA control, 305
LightSheer Duet from Lumenis, 68, 69 FDA Medical device approval
low-level fluence SHR mode, 70 pathways, 303
755 nm Alexandrite (Alex) laser, 63, 65 medical equipment, 304
1064 nm ND: YAG laser, 73 obligation, 306
Vbeam interface, 61 problems, 306
Vectus cynosure, 70 calibration and maintenance, 306
Lumenis, 138, 291 consumables, 306
contract, 307
dispute, 307
M finance, 307
Matrix metalloproteinases (MMP), 229 trademark infringement, 306
Medical aesthetic devices, 301 training and support, 307
Melanin, 103 remanufacturing, 301
Melasma Area and Severity Index (MASI) service providers and third-party
score, 208 resellers, 304
Michalson acne severity scores (MASS), 155 servicing, 301
Microthermal treatment zones (MTZs), 56 Resurfacing lasers
Multiple Sequential Pulsing Technology fractional ablative lasers (FAL), 84
(MSPTM), 20 comparison, 86
Fotona Er: YAG, 88
iPixel Er:YAG from Alma, 88
N stacking, 85
Nd-YAG laser, 268 10600 nm CO2 laser (see Co2 laser
systems)
2940 ER: YAG AND CR:YSGG 2790
O NM LASER, 86–88
Original equipment manufacturer (OEM), 301 UltraPulse by Lumenis, 95
fractional non-ablative lasers (FNAL), 79
coagulation, 79
P comparison, 82
Photoaging delivery patterns, 81
classification, 9 Er: Glass lasers, 79
dermis layer, 7 Halo laser, 83, 84
epidermis, 7 stratum corneum, 79
Photobiomodulation, 229 Richards-Merhag table, 106
Photo-energy devices, 285
Photorejuvenation, 10
Photothermolysis effect, 54, 104 S
Phototype assessment, 31 SapphireCool™, 291
Post-inflammatory hyperpigmentation Scars, 225
(PIH)., 17 ablative fractional laser, 241
Product Development Protocol (PMA) acne scars, 229
approval, 302 assessment, 225
Pulsed dye laser (PDL), 181 atrophic scars, 226
Index 347
atrophic scar type, 229 depth of the lesion, 35

boxcar scars, 226 phototype assessment, 31
Clearskin pro, 241 thermal relaxation time (TRT), 35
colour-blind lasers photoaging
clinical endpoints, 235 classification, 9
histology chages, 235 dermis layer, 7
non-ablative fractional laser, 234 epidermis, 7
post-treatment, 236 Skin chromophores, 11
test spot approach, 235 chemical photosensitization, 13
colour-sensitive lasers, 231–234 depth of laser penetration, 23
laser-induced optical breakdown, 232 Er: Yag Laser’s pulse, 18
long pulsed lasers, 231 fluence, 16
Nd:YAG 1064 nm laser, 232 photoacoustic effect, 13
ultrashort pulsed laser, 232 photo thermolysis, 12
Er:YAG laser, 243 pulse shape, 20
Fraxel Dual laser system, 237 Alma IPL systems, 21
heat shock proteins (HSP), 229 Superpulse mode, 21
icepick scars, 226 Ultrapulse, 21
Icon® 1540 fractional laser pulse width, 16
specification, 239 repetition rate, 25
inflammatory cytokines, 228 spot sizes, 21
intense pulse light (IPL), 229, 231 train of sequential sub-pulses
photodynamic treatment (PDT), 229 intra-pulse duration, 19
photorejuvenation methods, 228 Luminus M22, 20
rolling scars, 226 photo energy, 19
thermal injury, 228 wаvеlеngth, 13
treatment, 243 absorption coefficient, 14
vancouver scale, 225 intense pulsed light (IPL), 14
Short Q-switched nanosecond (nsec) laser, 73 Stacking, 85
comparison, 74 Stretch marks, 265
532 nm laser, 74 etiology, 265
585 and 595 nm pulsed-dye lasers fractional ablative lasers, 271
(PDL), 74 IPL treatment, 266
Lutronic Spectra interface, 75 pulsed-dye laser, 267
1064 NM ND: YAG LASER, 74–75 swelling (Striae Rubra)., 265
Skin 1064 nm laser, 268
anatomy XF Microlens applicator, 268
dermis, 5 1565 nm laser, 270
epidermis (EP) (see Epidermis (EP)) Fraxel 1550 system, 269
hypodermis, 6 Super hair removal (SHR), 122
changes after laser interaction, 25
CO2 fractional, 27
colour-sensitive laser, 25 T
Er:YAG fully ablative, 28 Three combination cream (TCC), 201
laser hair removal, 25
non-ablative colour-blind laser, 26
picosecond laser, 27 U
chromophores (see Skin chromophores) Ultra-short Picosecond (psec) laser, 75
hematoxylin-eosin, 6
intrinsic aging process, 7
lesion characteristics, 28 V
absorption and contrast, 30 Vaginal Health Index Score (VHIS), 275, 281
348 Index
Vaginal relaxation syndrome (VRS), 273 laser devices, 274

consultation, 280 medical history, 280
contraindications, 281–282 medical procedures, 273
diVa laser vaginal therapy, 277 medication, 280
FemTouch CO2, 275 non-ablative mode of Er:YAG, 276
follow up, 281 side effects, 281
GSM, 273 treatment, 279
informed consent, 280 Vulvovaginal atrophy (VVA), 273

Kamal Alhallak, Adel Abdulhafid, Salem Tomi, Dima Omran - The Ultimate Guide For Laser and IPL in The Aesthetic Field-Springer (2023)

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The

The Ultimate Guide

ISBN 978-3-031-27631-6 ISBN 978-3-031-27632-3 (eBook)

1  kin, Light, and Their Interactions�������������������������������������������������������� 1

Light-Based Treatment�������������������������������������������������������������������������� 246

Laser Hair Removal���������������������������������������������������������������������������������������� 317

Non-ablative Fractional Laser������������������������������������������������������������������������ 321

Rosacea and Spider Vein Removal ���������������������������������������������������������������� 329

It comprises approximately 15 layers of nonliving keratinocytes (corneocytes)

© The Author(s), under exclusive license to Springer Nature 1

Fig. 1.2 Structure of SC and SG layers

Fig. 1.5 Melanocyte connection with a keratinocyte cell

Histology of Normal Skin

Changes due to Intrinsic Aging

Fig. 1.10 Photo-numeric scale for photoaging [21]

Another system to objectively assess photoaging is the photonumeric scales

Fig. 1.11 Four different possible outcomes of the light-skin interaction

Our goal is to maximize the light absorption by a specific skin component at a

Fig. 1.12 Heat diffusion

2. We should use a specific wavelength to target that chromophore selectively.

Acne vulgaris light-based treatments rely, in part, on the photosensitization of por-

532 585 755 810 1064 1550 1927 2.94 10.6

Fig. 1.13 Relative penetration of the most commonly used wavelength

Pulse Widths (Fraction of a Second)

Fig. 1.16 A simple

The short-pulsed laser provides a concentrated, high-intensity laser pulse usually

Train of Sequential Sub-pulses

Duration of 3.8 3.2 3.0

Fig. 1.20 M22 IPL interface from Lumenis

Fig. 1.21 (a) (Top) Two a

This technology is mainly utilized in IPL platforms to provide a higher safety

Pulse 1 Pulse 2 Pulse 3

Sure Pulse 130ms 62 2,500

Short Pulse 20ms 40 2,000

Long Pulse 80ms 62 775

Spot Size (mm)

Fig. 1.23 Schematic representation of the spot-size-dependent depth of penetration, recreated

Fig. 1.25 Effect of

Repetition Rate (Hz) for the Device

Skin Histology Changes After Laser Interaction

Laser Hair Removal

Skin Rejuvenation with Color-Sensitive Laser

Non-ablative Color-Blind Laser

A column-like denaturation of the epidermis and dermis, a distortion of the dermo-­

Er:YAG Fully Ablative

Skin Lesion Characteristics

As we mentioned, laser-skin interaction depends on the laser parameters and objec-

Fig. 1.30 Depth of ablation of hematoxylin-eosin–stained sections of ex vivo human abdominal

Skin Reflectance Colorimeter

Do you have freckles on Many Several Few Incidental None

Total score for genetic disposition: 12

Reaction to Sun Exposure

Do you turn brown Never Seldom Sometimes Often Always

Total Score for reaction to sun exposure: 10

Total Score for tanning habits: 0

My Skin Type Score: 32

Skin Type Score Fitzpatrick Skin Type

Table 1.6 Simple skin-type assessment with ten multiple-choice questions

SAMPLE SKIN TYPING

Client Name: Date:

What is the color of your skin Pale with Light Dark

Do you have freckles on sun-exposed Many Several Few Incidental None

Hardly Turn dark

1 kin, Light, and Their Interactions�� 1

Light-Based Treatment�� 246

Laser Hair Removal�� 317

Non-ablative Fractional Laser�� 321

Rosacea and Spider Vein Removal �� 329

Histology of Normal Skin

Changes due to Intrinsic Aging

Pulse Widths (Fraction of a Second)

Train of Sequential Sub-pulses

Spot Size (mm)

Repetition Rate (Hz) for the Device

Skin Histology Changes After Laser Interaction

Laser Hair Removal

Skin Rejuvenation with Color-Sensitive Laser

Non-ablative Color-Blind Laser

A column-like denaturation of the epidermis and dermis, a distortion of the dermo-

Er:YAG Fully Ablative

Skin Lesion Characteristics

Thermal Relaxation Time (TRT) and Size

60. Icon Cynosure. 2021. https://www.cynosure.com/product/palomar-icon-aesthetic-system/.

IPL with Interchangeable Filters

IPL with Interchangeable Handpieces (Applicators)

Color Sensitive According to Pulse Width

Long Millisecond (ms) and Quasi-long Microsecond (μs) Laser