AMAS 2020 Strategic Pigmentary Laser Procedures

AMAS 2020 Strategic Pigmentary Laser Procedures

On the 10th of October 2020, 1600 hrs, at the World Medical Center hospital, Renovia-ABLS Academy director, Dr. Staporn Jinaratana,MD., gave a live demonstration on the “Strategic Pigmentary Laser” procedures.
The principle concept ” The fundamental laser physics, Biological response of living tissue to irradiation energy , using the state of the arts of “Soft Lasing Technique “.

The aesthetic moral is ” Primum non nocero ” : first do no harm . This moral mindset together with the principle concept guide the laser doctors to the enlightenment of ” Immediate good effects without Complications ” to patients.

Soft Lasing Technique (SLT) is a way of life for aesthetic doctors as well as aesthetic practitioners could follow. There are guidelines, Not Protocol , for novices to climb up the art of skin laser procedures with ease and in short time.

The SLT Etiquettes are :
Heterogeneity of target tissue with variable fractional volume of chromophores.
Undetermined depth of target tissues.
Removing target tissues layer by layer while
Defining : Clinical Effective Signs & Early Complication Signs , orientating parameters
Testing lasing techniques, swept beam speed, and distant against clinical effective signs .

Issues in cosmetic laser surgery : Biological effects of laser on living tissue . Laser of every wavelengths could cause all the laser effects : photothermal, photochemical , phytoplasma and photoacoustic . Each effect will be explained elsewhere in this website.
Photoacoustic Effect  for  Solid Content of the Target 
Photothermal Effect for Liquid Content of the Target
Photochemical for Photo biomodulation to Rejuvenate .

There will be Cascades of events of biological response of living tissues to laser Irradiation : immediate, post-op, & delayed effects. The novices must learn how to recognize all these events and be able to explain the lase scenarios follow.

SLT Concept:  Clinical Effective Signs :
SLT does not have protocol of setting parameters as in other conventional protocol technique , but rather using laser physics , biological response of the tissue and look and feel of the doctor to adjust laser parameters according to what he(she) sees : clinical signs. Modern medical practice often looses track from the art of medicine which consist in seeing, palpating, percussion and listening to signs in physical examination. Today physicians rely more on laboratory and investigation than their own’s physical examination and experience.
In SLT aesthetic doctors listen to complete medical history, do the aesthetic examination and evaluation and then design management plan for the specific patient in front of him(her). Laser wavelengths and operating mode of the laser machine are chosen. Target tissues are evaluated in the 3 dimensional process ; physical consistency, depth, size . Then makes initial tentative parameters setting according to findings. Test the parameter for “Clinical Effective Signs” and ” Early Complication Signs” with him(her) self. Test “Effective Distance ( the distance from the handpiece to the skin surface). Test effect ” Effective Speed) , the hand moving swept beam delivery to the skin surface.

SLT defines ” Clinical Effective Signs” according to the biological response of the living tissue target to laser irradiation energy.
Solid targets : there is more histologic water in the target more than the solid (fractional volume) of the chromophores. Solid target areas look dull and dry . When the chromophores are deep in the skin , such as basement membrane , they are more water in them (70% of cells contain water). Moving upward to the outer surface of the skin , they loose water content and become dry when they are at the stratum coronium layer. Some of dead cells , pigments and other material form clumps , strongly attached to the surface of the skin. These targets need photoacoustic energy to break and evaporate them. After their removal from the surface of the skin , we can see ” Lightening & Brightening ” of the skin, because we exposed stratum lucidum layer which contains keratin and shinning materials. SLT defines ” Lightening & Brightening ” as the ” Clinical Effective Signs” for solid target.
” Mild Darkening” is the “Clinical Effective Signs ” for “Liquid Target” ( chromophores that have more water content in them). Histologic water in chromophores is essential for ” Phot thermolysis”. Tissues convert laser energy into heat , and heat boil water , bringing the intracellular water from 37 C to 100 C , then coverts water into vapor . Water vapor volume is 1600 times than its liquid phase. The tissue space is the same, so there is 1600 times more intracellular pressure. This pressure breaks the tissue and eject water and solid material into the air. This is a mechanism of “Laser Skin Resurfacing”, which is obsolete nowadays. We just need laser photo effect to bring the intracellular temperature to denaturation, either irreversible for target tissue or reversible for adjacent tissue. The color of the tissue is changed from light to dark ( becomes darker) , like when we put raw meat( light color) into a heated pan of oil. When the meat is cooked the color becomes yellowish, yellow brown ====> burn (dark) . In SLT
” mild darkening” of the target is an “Effective Clinical Signs” for liquid target.
For very hard solid target , we use photoacoustic effect of laser to break it. Then we see “Cavitation”, greyish-to-white , snow flaw area. If it is too white , excessive laser energy may penetrate to deeper skin layers , causing, pin-point bleeding or petechiae.

SLT Concept:  Clinical Early Complication Signs :

For superficial targets : most target tissues are dry . High laser energy may penetrate deep into dermis where there are dermal papillary vessels. Heat energy make them dilate and we find ” Mild erythema “. Mild erythema is the ” Clinical Early Complication Sign” . Moderate and severe degree of erythema may be impending signs of complications. Novices in cosmetic laser surgery should be beware and aware of these phenomena. Additional energy may effect permeability of the blood vessels and causes tissue edema. When we fine peri-lesion edema , we are warned of impending complications. Further energy delivery may induce
breaking of blood vessel walls causing intravascular mediators escape out. Hemosiderin deposition in the dermis as well as melanocyte stimulation by leaking Vascular Endothelial Growth Factors (VEVG) are proposed to be the cause of PIH(Post-inflammatory hyperpigmentation. PIH is a common complication in pigmentary laser procedure. Bleb, ulcers , scar are also found in cosmetic laser surgery practice.

SLT teaches novices in all cosmetic laser surgery practice. Be patient and learn how to choose, and use laser machine, how to think in a safe and effective way using SLT process. When you master the SLT , you could develop your own’s .

People say “Practice makes perfect “. My mentor told me ” Perfect practice makes perfect” .


SLT Steps in Q-Switched Nd:YAG Laser :

Step 1    
          : Remove Superficial Deal Keratinocytes & attached
            pigments .
Step 2
  : Breaking Rocky Superficial Target
Step 3
  : Boiling Histologic Water of the Deep Target

Step 4
  : Rejuvenating Dermis

See video

SLT Step 1

SLT Step 2

SLT Step 3 & 4

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