Good morning everybody!
Can anyone tell me how can i treat a 35 y.o. patient with an PWS (since his birth) that covers 90% of the face and neck area, using a Sciton Profile MP Nd:yag 1064 Laser?
How can i treat his nose, ears and eyelids, without riks and unplesant surprises?

I think the max pulse width would be 10msec and the clinical endpoint would be darkening or bruising of light color areas of PWS.I don't think there is any risk in treating the nose but in eyelids and ears maybe you should use lower fluence.

I think you need a good pulse-dye laser for port-wine staining. Although the target of the Nd:Yag 1064 is heme [red], I'm not sure you'll get a great result with that laser at all. Any dermatologist care to lend your expertise regarding this matter?

The "Cutaneous Laser Surgery" textbook by Goldman and Fitzpatrick agrees that PDL is the primary device for treating PWS. They also mention the Nd:YAG laser but using the 532 nm wavelength. They indicate that most PWS are superficial (mean vessel depth of only .46 mm) which would also be a reason NOT to use the 1064 nm wavelength.

The 1064 can be used for PWS and it will work. I have used it on adults. The biggest issue is scarring. You will see more scarring because of the deeper penetration using the 1064. The goal with PWS is to do as little damage to surrounding tissue as possible. That is why it takes so many treatments. I think you get more heat generated in the deeper tissues with the 1064. As of right now the gold standard is to use the PDL. I have seen some studies with 532 that looked promising.

I don't understand why if a PWS is superficial it can not be treated by a 1064nm wavelength.It's crazy!!The photons by the 1064nm are NOT jumping over the PWS!!

A wavelength moves up and down as it travels, as opposed to in a straight line. A longer wavelength penetrates deeper... not sure how the photons manage to pass through; I just know the 1064 likes deep things and big things... if only I could remember more physics!

The scattering in 532nm (KTP laser) and 585-595nm (PDL) is much higher than 1064nm.It's not the issue how deeper goes the 1064nm but what pulse width and fluence has the 1064nm laser.If has the appropriate pulse width and fluence the 1064 is better that PDL for PWS.

I don't think you're correct, but I'm not sure what the answer to the question is. I mean, longer wavelengths do penetrate more deeply, just as a longer pulse width penetrates more deeply. If a PWS is superficial, it only makes sense that you need to use a PDL. I look forward to hearing the answer from someone who knows more than I do... ;)

Pulse Duration (pulse width) is defined as: amount of time over which the fluence contained in one laser pulse is delivered to the surface of the skin.
A longer pulse duration (pulse width) does NOT penetrate more deeply, it "spreads" the fluence more horizontally thus less intensely. To influence "depth of penetration" you would use higher fluency AND/OR bigger spot size.
In hair removal for example, you want start out with a longer Pulse duration (10-20ms) to treat coarser hair AND to see if there would be any untoward side effects. Afterward, you shorten the PD to 5, then maybe 3 to treat the "finer hair" since a a shorter PD will lead to more sufficient(intense) heating of the targeted chromophore. The PD has to be SHORTER than the thermal relaxation time of hairs which is from 3 to 10ms.
In treating vascular objects, you want a longer PD to thermally damage the entire vessels completely.
TO use 1064nm in PWS, I would suggest using a smaller spot size (1.5 or 3.0) to keep the delivered fluence mostly superficial.Extrapolating guidelines from superficial vein treatment, For 1.5 spot size, PD 20-40ms, 260J/cm or for 3.0 spot size, 40-60ms PD, 180 J/cm2 With post cooling settings. Your endpoint goal is immediate purpura (dark blue bruise like appearance) If you don't see it, then increase the fluency OR decrease pulse duration.
Your patient will experience bruise like spots since these signify sufficient treatment due to the HEME (iron) reaction to laser.No overlaps and 8 weeks interval.I hope this helps

This answers my question on the treatment progression for brown spots posting too...thanks...

I have had great results with PWS with IPL (Lumenis One). I have a pt that has had 85% clearance with 8 sessions of IPL. Can't treat directly over the eyelid but otherwise she is thrilled with results. I started with 590 wavelength and double pulses at low fluence (15-17J). Now I am finishing with 560 and higher J (18-19). She has only had purpura once in the one year time and she is thrilled.
DC

DC:
Be careful. With the shorter wavelength, you probably need to go lower on fluency, especially with a darker skin type. Good luck. At which pulse width do you use, just curious???

pmdoc,
The standard parameters from the Lum One is 4.0ms pulse width. I usually leave it at that, although I have dropped it to 3.5 in areas where the residual is so superficial and very light. She is skin type 1 so its been easier to work with her.
The Lum One parameters are always conservative and I find that I usually have to go up just a little as you make progress.
It has been so rewarding for her (and me!).
dc

Dear all,

Can you please describe the exact setting of pulse and pulse width during IPL therapy for hair removal, pigment reduction and photo rejuvenation. What is the basis of these parameters

Great Info at Dr. Anderson's Harvard Conference on Port Wine Stains.

Port Wine Stains: 20% clear completely (that means that 80% do not clear completely)
99% get lighter
Pulse Dye Laser is the laser of choice (577 - 600 nm)
Be very careful with 1064 because it goes deep and can cause scarring
Alexandrite (755 nm) can be used. It goes deeper and is better for Hemangiomas. Must be careful with pigment
when using Alexandrite.
PDL: 0.4 - 10 ms; 7-10 mm spot size; 6-15 j/cm2; 6-12 treatments
Light Pink PWS are VERY difficult
Setting expectations is very important
Recent Study showed that IPL can work: 650 nm; 8.0 ms; 14-19j/cm2. Medical Laser Application 2008;23;133-140.

I think we are going to find that it is a combination that works. The 1064 works well for the thicker PWS that have deeper vasculature. This is an area that the PDL has a problem with. Then the PDL to clean up the middle and more superficial vasculature and then finish off with an IPL device as they tend to work better on the very fine superficial vessels.

LH

Try the combination of BBL and Nd YAG 1064.It works great!!

I already do and I agree.

Thanks

LH and Charry,

What BBL settings do you use for PWS??? Do you look for greying as an endpoint with the BBL treatment?

JEE

Try the combination of BBL and Nd YAG 1064.
1)For deep (blue color or purple color) PWS begin with 6mm and pulse width 10msec.After the 1st or 2nd session and as the color of PWS is becoming more red change the spot (3mm),keep the pulse width at 10msec and adjust the fluence up to level that you could see a little purpura.You can do a trial shot for adjustment the Fluence.
As the color is becoming more and more light (red or light red) you can use first the BBL with 560nm filter 11J/cm2 ,20msec for type III skin and then the Nd YAG (3mm spot, >150J/cm2 ,pulse width:10msec).
2)For superficial (red or light red color) PWS you can use the combination of BBL +Nd YAG as i said above.
Yes i am looking for greying as an endpoint with the BBL treatment.

I agree with Charry but I use a Cutera 1064 (the only thing they make that is worth it) and the BBL so my 1064 settings a re a little different but very similar.

We have plugged along for the last several years and built a quality and profitable aesthetic practice along with our Internal Medicine practice. We thank Empire and MedSurge for initially showing us the way however we were naive and uniformed and I would recommened a different path for anyone else trying to enter the business.

May I ask for your advice please?
I am a patient getting coolglide treatment for my facial port wine stain. There is some improvement after 3 treatments (spot size 5mm face, 3mm around eyes, 100j fluence) but some parts still look blue/purplish. Is it safe to increase the spot size to 7mm for the purplish part (area to the side of the nose where the elevated part ends) and use 100j, and increase spot size to 5mm and use 100 j around the eye? I am afraid of closing important veins. Thank you for your insight.

Port wine stains can take numerous treatments. You want to be cautious so you do not scar. It sounds like they are doing fine if you are seeing improvement. I would generally use the 3 to 5 mm spot but with higher energy settings. I would tend to use energy settings in the 130 to 150J range. Remember, this depends on what I am seeing and the response in the skin. Do NOT rush the process as you will be more likely to have scarring.

Thank you LH! I have just had another treament. As you pointed out, I continue to see results using 5m spot size and going up on fluence (140J now). I do 1064 (coolglide) every four weeks and do IPL(limelight setting B, fluence 20) in between (two weeks after 1064). There seems to be some parts that remain dark despite repeated treatment. The funny thing is Visia scan does not show these parts as *red spot* or *brown spot*. I am suspecting whether these parts are so deep that Visia cannot detect. After a couple of more 1064 treatments, I might ask my doctor to use 7m spot size. If anyone has insights as to how deep 7m 1064 treatment would go, whether it would be safe on the face, and what would be the appropraite fluence, it would be much appreciated. Thank you.

I have used the 7mm spot on the face just be cautious but remember the only reason to go larger on the spot size is to go deeper for penetration. If what you are seeing is superficial then do not use the 7mm spot. Remember that there are some larger veins under the skin that can feed these things and that may be what you are seeing. These are the areas that tend to scar and I believe mostly from collapse of the vessels in the area. The skin can become depressed because it does not have the continued support of the underlying vessels.

I hope this helps. Keep us updated on your progress.

LH

Lornell E. Hansen II, M.D.
www.LazaDerm.com

I have used the 7mm spot on the face just be cautious but remember the only reason to go larger on the spot size is to go deeper for penetration. If what you are seeing is superficial then do not use the 7mm spot. Remember that there are some larger veins under the skin that can feed these things and that may be what you are seeing. These are the areas that tend to scar and I believe mostly from collapse of the vessels in the area. The skin can become depressed because it does not have the continued support of the underlying vessels.

I hope this helps. Keep us updated on your progress.

LH

Lornell E. Hansen II, M.D.
www.LazaDerm.com

LH

Thank you for your further advice. I tried another Cutera 1064 treatment, this time at 8ms/150j/5mm spot size. For the area above upper lip, where I can see the vascularity from inside the mouth, 7mm spot size was used at 110j and the result there was great. It's funny how the impact I feel correlates with the result I see. I am wondering if I should go higher on fluence, b/c there was a bit of purpura this time. There won't be improvement, if I keep the setting as is and do more treatments?

I also had one more IPL (Limelight setting B 22). It's interesting how I developed purpura in parts where I never had purpura before with Vbeam.

zh

LH

Thank you for your further advice. I tried another Cutera 1064 treatment, this time at 8ms/150j/5mm spot size. For the area above upper lip, where I can see the vascularity from inside the mouth, 7mm spot size was used at 110j and the result there was great. It's funny how the impact I feel correlates with the result I see. I am wondering if I should go higher on fluence, b/c there was a bit of purpura this time. There won't be improvement, if I keep the setting as is and do more treatments?

I also had one more IPL (Limelight setting B 22). It's interesting how I developed purpura in parts where I never had purpura before with Vbeam.

zh

What settings would you use for Light Asian with PWS on neck with BBL? Her PWS is darker red.

Has anyone had significant improvement using Palomar Starlux?