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PRACTICE PEARLS | melanin resulting in clearance of the


pigmented lesion. While proper choice of parameters is


essential to effectively treat pigmented and vascular lesions, treatment technique is equally important. Interestingly, most published papers on pulsed light treatments do not detail treatment technique. Either the authors assume that all pulsed light practitioners employ the same technique (i.e. a single pulse or a single pass over target lesions) or there is no consistent technique used from patient to patient. From nearly thirty thousand pulsed light treatments performed by this author, it is clear that how the treatment is performed is key to the final result. Given the same parameters, there can be markedly different results depending on exactly how the treatment is done. When reading scientific papers on pulsed light treatments, readers should always inquire and expect to be informed of exactly what technique the author used. Treatments with pulsed light are essentially


carried out with the practitioner’s choice of parameters, applicator spot size, total number of pulses, number of passes, amount of overlap between pulses, and number of pulses over a given target. The other variables that influence the end result is whether a cooling device is used during treatment and the total number of treatments. The author’s preferred technique for


pigmented and vascular lesions is to perform pulsed light treatments using a two-step process. The first step is to perform one or two passes over the entire cosmetic unit with milder more conservative parameters. The second step is to select a more aggressive parameter using a smaller spot size and focusing these pulses over the vascular or pigmented target. The purpose behind this two-step technique is that the first two passes over the entire cosmetic unit serve to first improve the appearance of skin in the entire


cosmetic unit and second, prime the vascular or pigmented lesion to be more sensitive to the more aggressive parameter used in the second step. By treating the entire cosmetic unit there is a blending of areas of lesser target with a more pleasing overall result for the patient. Also, by treating the entire cosmetic unit there is much less likelihood of a contrast between the treated and untreated skin. Contrast between treated skin and untreated areas may produce an obvious pattern in the shape of the crystal. This has been referred to as ‘tiger striping’ and has been a common


and


undesirable side-effect of pulsed light treatments. Tiger striping is a result of partial treatment of an area when more aggressive parameters are used. The use of higher


fluence Treatments with


practitioner’s choice of parameters, applicator


pulsed light are essentially carried out with the


spot size, total number of pulses, number of passes, amount of overlap between pulses, and


number of pulses over a given target.


parameters and lower wavelength cut off filters has been the most commonly employed technique in the past with pulsed light treatments. This technique has had the common and undesirable side effect of tiger striping. Tiger striping never occurs with the two-step treatment process described in this article.


Techniques For the purposes of clarity it is important to distinguish between multiple pulses or passes and stacking of pulses. Stacking a pulse is when serial pulses are given over the same


target area without pausing between pulses. The effect of stacking pulses is to create increasing epidermal and dermal heat with each subsequent pulse. Stacking of pulses creates a high likelihood of an epidermal or dermal burn and subsequent wound. Multiple pulses are pulses delivered with a pause between pulses. The pause may be the time to treat the entire cosmetic unit with a first pass before going back over the area a second time, or it may be just enough time to examine the target before the next pulse is delivered. This momentary pause of a few seconds to a minute is sufficient to allow cooling of the treatment site enough so as to avoid the thermal burns that may occur by stacking pulses. This author recommends


against


stacking pulses with pulsed light treatments. Lastly, it is essential to record precisely the


parameters and technique employed with each treatment. Each treatment record should record, as a minimum, not only the pulsed light device used and choice of filter, fluence, pulse duration spot size and contact cooling, but also the number of pulses and passes over a given area. Reporting the parameters but not reporting the technique is analogous to reporting the concentration of botulinum toxin used, but not reporting the amount and exact location of each injection. Without this information the reader would not really know how the treatment was performed and would be unlikely to duplicate the results. By carefully recording parameters and technique, the practitioner learns what is effective, as well as what is too aggressive or too conservative a treatment for each patient. Others can learn from experienced practitioners who record and report the details of both parameters and technique advancing our knowledge of pulsed light and how to treat a wide variety of conditions in patients with all skin types safely and effectively.


Figure 1 A) Before, and B) after 2 treatments with FotoFacial® broadband light and SkinTyte (Sciton inc., Palo Alto) in combination for the treatment of photo damage/dyschromia


52 ❚ January/February 2015 | prime-journal.com


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