Aesthetic Applications of Intense Pulsed Light

Lucian Fodor • Yehuda Ullmann Monica Elman

Aesthetic Applications of Intense Pulsed Light

ISBN 978-1-84996-455-5 e-ISBN 978-1-84996-456-2DOI: 10.1007/978-1-84996-456-2Springer London Dordrecht Heidelberg New York

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AuthorsLucian Fodor, MD, PhDPlastic Surgery Unit Emergency District HospitalCluj-Napoca, RomaniaandPlastic SurgeonRambam Health Care CampusHaifa, IsraelandChirurgie IStr. Clinicilor 3-5 Cluj-Napoca 400006 RomaniaandRambam Health Care Campus8 Ha’Aliyah StreetHaifa 35254Israel

Yehuda Ullmann, MDProfessor and Chief of Plastic and Aesthetic SurgeryRambam Health Care Campus8 Ha’Aliyah StreetHaifa 35254Israel

Monica Elman, MDPrivate Practice Dermatology, Lasers and LightsMaccabbi Insurance, Haifa & Tel Aviv,14 Recanati StreetTel-Aviv, 69494Israel

To my wonderful wife, Adriana Fodor And my son Radu, For fi lling my life with love and happiness

To my parents, Rozalea and Marian Fodor, And my brother Marius and his wife Dana For their encouragement of all my efforts

Lucian Fodor

This book is a small thank to my supportive and loved family: Tami, Liran, Shachaf, and Yotam

Yehuda Ullmann

This book is dedicated to my lovely family Arie Karin Dana Shay and my mother Marietta, for their love and unconditional belief and support to me

Monica Elman

There are countless books written on cosmetic laser treatments. In many of these books there is either a chapter written about Intense Pulsed Light (IPL) treatment or minimal discussion of IPL treatments as part of a laser chapter. Finally there is now a book solely dedicated to IPL treatments. Drs. Fodor, Ullmann and Elman dedicate distinct chapters to Intense Pulsed Light treatment for skin rejuvenation, hair removal and vascular lesions. Equally as important the book describes in depth the unique IPL tissue interaction, IPL patient selection and complications that can occur from treat-ments. This book is a must read for anyone dedicated to optimizing results and mini-mizing risks of IPL treatment.

New York, NY, USA David J. Goldberg

Foreword I

One of the most controversial light based technologies, which had its birthplace in San Diego, California (CA), USA in 1992, and cleared by the US FDA in late 1995 as the Photoderm™ (ESC/Sharplan, Norwood, MA, now Lumenis, Santa Clara, CA), is the non-coherent polychromatic fi ltered fl ashlamp intense pulsed light (IPL) source. It was initially launched and promoted as a radical improvement over existing meth-ods for elimination of leg telangiectasia due to pressure from venture capital groups that funded its development. While the treatment of leg telangiectasia was possible, additional advantages recognized early on was the IPL’s ability as a specifi c modality to minimize the possibility of purpura common to pulsed dye lasers (PDL), as well as the elimination of hair and lentigines. Continued use proved that the device was of far greater utility for other indications than leg telangiectasias (Weiss et al. 2000a ; Bitter 2000 ; Goldberg and Cutler 2000 ; Raulin et al. 1999 ; Jay and Borek 1998; Weiss et al. 1999 ; Raulin et al. 1997b –d; Schroeter et al. 1997 ) . The road to usability, reproduc-ibility and effi cacy was a long one with some clinical users and many “laser experts” dismissing the IPL as a harmful and useless form of technology. The term “PhotoBurn” was coming used. It is ironic that the IPL is now considered the gold standard for treatment of vascular lesions in addition to the many of the signs of photoaging (Weiss et al. 2000a ; Bitter 2000 ; Goldberg and Cutler 2000 ; Sadick et al. 2000 ; Weiss and Sadick 2000 ) . Testimony to the acceptance of the IPL as a valid effi cacious techno-logical break-through is evidenced by dozens of different manufacturers producing various forms of IPL with the estimated sale of 30,000 IPL devises worldwide in the last 18 years. It is thus fi tting that after 18 years of clinical use a textbook solely devoted to Aesthetic Application of the IPL come into print. Drs. Fodor, Ullmann and Elman are to be commended for their outstanding work.

Developmental History

This is the story of the development of the IPL by one of the developers. I began my research into laser treatment of leg veins with the very fi rst production model of the Candela pulsed dye laser purchased in March 1987. This research on rabbit ear veins (Goldman et al. 1990 ) and then human leg veins (Goldman and Fitzpatrick 1990 ) demonstrated that a 585 nm laser pulsed at 0.45 ms could effectively cause thermal coagulation of blood vessels <0.4 mm in diameter. The problem (in human leg veins) was prolonged purpura and post-treatment hyperpigmentation and hypopigmenta-tion. After a lecture given at the Westwood Conference on Clinical Dermatology in

Foreword II

Foreword II

Rancho Mirage, CA on “Management of Leg Veins” in April 1992, I was approached by Dr. Shimon Eckhouse, an aerospace engineer from Israel, who was working in San Diego. He told me he had an idea to treat leg veins with a fl ash-lamp devise used to vaporize paint off of fi ghter jets. We fi rst discussed his idea in the hotel bar with my partner, Richard Fitzpatrick, MD. Over a few beers, we hypothesized the ideal param-eters for such a devise. Dr. Fitzpatrick and I initially requested an IPL that could vary both the pulse duration as well as the wavelength cut-off fi lter between pulses. Our idea was to thermocoagulate the vessel and protect the skin. The reason for multiple sequential cut-off fi lters was to take advantage of the potential interaction with both oxygenated and deoxygenated hemoglobin. Unfortunately, that exact devise could not be produced and interesting, over 10 years later, the Cynosure laser company came out with such a devise using multiple sequential pulsing of a 595 and 1,064 nm laser to treat blood vessels (a project that I too was asked to investigate) (Larson and Goldman 2007). After our meeting, Dr. Eckhouse said that he would make the devise we requested and deliver it to us in San Diego by the end of the summer. I was to arrange for an animal research facility to test the devise on the rabbit dorsal marginal ear vein model system that I had been using to evaluate the effect of different types and concentrations of sclerosing solutions on blood vessels.

The initial study using a prototype devise was performed on rabbit ear veins at the HTI animal research center in Ramona, California in September 1992. Dr. Fitzpatrick and I treated ten rabbits with a variety of pulse durations and energies ranging from 1 to 15 ms and 10 to 20 J/cm 2 , all with a 515-nm cut-off fi lter with one pulse. We also “inadvertently” treated an ankle telangiectasia on Dr. Fitzpatrick. The rabbit ears were photographed and biopsied from 1 h to 30 days later. Many of the dorsal mar-ginal ear veins had disappeared. Histologically, many veins were thermocoagulated and most of the overlying epidermis was not damaged. The theoretical concept was proven and human studies (in addition to Dr. Fitzpatrick’s ankle) could begin. I pre-sented the results of this trial at the 6th Annual Congress of the American College of Phlebology in Orlando on February 1993 in a lecture titled: “Clinical and Histologic Evaluation of the ESC Vascular Lesion, Pulsed Light Source on the Dorsal Marginal Rabbit Ear Vein.” (Dr. Robert Weiss, who was a moderator of the lecture session was very interested in my presentation and would later become one of the leading inves-tigators and innovators of the IPL.)

The fi rst human pilot study was performed on seven leg vein patients and four PWS patients at our dermatology offi ce in Encinitas, CA, on November 17 and 18, 1992. Single pulses, again with a 515 nm cut-off fi lter without cooling and without a light-guide were used on leg veins ranging from 0.2 to 1 mm in diameter. Energies of 10–20 J/cm 2 were used with single pulses of 3–15 ms. Leg vein patients were fol-lowed for 6 weeks and PWS patients followed for 4 weeks. Excellent resolution was seen in 60% of veins and PWS with epidermal burning occurring in 40% and scar formation in 20%. It was clear that much more work needed to be done.

We then began a formal IRB-approved human study on leg veins every Tuesday afternoon for many months developing fi rst the multiple sequential pulsing technol-ogy then procuring a variety of cut-off fi lters ranging from 550 to 570 to 590 nm that would not crack. But it was not until we incorporated a quartz (later changed to a sapphire) light guide used in conjunction with ice-cold clear ultrasonic gel which would be stable with rapid heating and transmit light without distortion that repro-ducible effi cacy with minimal epidermal damage could be obtained. The results from this human leg vein trial were fi rst presented in May 1993 to the Israel Dermatologic

Foreword II

Society in Hertzilia, Israel, in a lecture titled, “Treatment of Varicose and Telangiectatic Leg Veins: Sclerotherapy and Lasers” and in June 1993 at the Pacifi c Vascular Symposium: Controversies in the Management of Venous Disorders on the Kohala Coast, Hawaii, in a lecture titled, “Laser Treatment of Leg Veins.” The entire study was presented in December 1993 at the 53rd Annual Meeting of the American Academy of Dermatology in New Orleans, LA, titled, “Can Light Be Useful in the Management of Lower Extremity Telangiectasia and Reticular Veins.” Finally, the theoretical basis for using the IPL in treating benign vascular lesions was presented and hypothesized in our textbook, Cutaneous Laser Surgery: The Art and Science of Selective Photothermolysis . Goldman, Fitzpatrick RE. Mosby-Year Book Inc., St. Louis, MO, 1994. After concluding our leg vein trials, we fi rst began treating facial telangiectasia throughout 1994 and hemangiomas, venous malformations, and hyper-trophic scars in May 1995 all with excellent results.

A multicenter study was begun in 1993 with United States FDA approval of the fi rst systems in late August 1995. At the time of FDA approval, over 20 Photoderm systems were in use in “clinical trials” within the USA with another 20 IPLs in use in Europe and Canada. While some doctors were reporting outstanding results, others reported that the devise was fraught with complications. In August 1995 at the Controversies in Cutaneous Laser Surgery meeting in Bermuda, I presented a lecture, “Laser & Light Source Treatment of Spider Leg Veins.” In the discussion that fol-lowed, Rox Anderson, MD, claimed that the devise was fraught with complications and predicted that patients would be seriously harmed and even die from the hand-piece which was bound to explode. Needless to say, it was diffi cult to debate someone of Dr. Anderson’s stature and the IPL fell into disrepute.

Fortunately, I and many others continued to pursue development of the IPL and the fi rst large-scale publication appeared in Dermatologic Surgery and Cosmetic Dermatology in 1996 detailing the excellent results of our multicenter leg vein study (Goldman and Eckhouse 1996 ; Goldman 1995 ) . An accompanying editorial by Drs. Robert and Margaret Weiss attest to the diffi culty of performing treatment with the IPL and to the advances in treatment techniques that came with experience (Weiss and Weiss 1996 ) .

A variety of benign vascular lesions were treated with multiple case reports and studies attesting to the effi cacy of the IPL on these conditions (Raulin et al. 1997a ) . In fact, the treatment of leg veins with the IPL decreased in extent due to variable results (Dover et al. 1999 ) , while the treatment of both pigmented and vascular lesions with “rejuvenation” of the skin gained in popularity (Nestor et al. 2000; Weiss et al. 2000b ; Goldman and Weiss 2001 ) .

The fi rst evidence of the ability to remove hair with the IPL came in August 1996 after I treated a facial port wine stain (PWS) in a man whose PWS extended to his moustache area. While the PWS cleared over 50% with one IPL treatment, the patient’s moustache only grew back 50%. This was reported to the ESC Company as a complication, but Hillel Bachrach, the Vice President of Sales and Marketing at ESC recognized this not as a complication, but as a new indication for the IPL. My back was then treated in November 1996 with biopsies demonstrating effective ther-mocoagulation of hair follicles, clinical studies were performed on male transvestites in Berlin, Germany and the IPL, with a higher power and faster recharging time was launched as the Epilyte™.

Unfortunately, during the early days of the IPL, many physicians, especially those with important ties to laser companies were extremely vocal in their opposition to this

Foreword II

new technology. The fact that the early IPL machines took some technical expertise and were not just “point and shoot” systems also proved to provide adverse results in those physicians who did not grasp the concept of multiple sequential pulsing, epi-dermal cooling and the use of cold coupling gel as an interface between the IPL fl ashlamp, light-guide crystal and the skin. The New York Times published a one sided negative article on June 23, 1996, titled “Unsightly Veins? Zap Wall St. Woes? Zap.” This was countered by a Letter to the Editor from Harvey Jay, MD, an early adopter and innovator of the IPL, explaining that the IPL is like a scalpel, a trained surgeon will get great results and a novice will not get acceptable results (Jay 1996). Next, a particularly strong article against the IPL was published in the Journal of the American Academy of Dermatology by Dr. David Green (Green 1998 ) . Dr. Green observed a high degree of adverse effects and patient dissatisfaction. In a subsequent panel dis-cussion at the Annual Meeting of the American Society of Laser Medicine and Surgery in San Diego, April, I was asked to explain why I disagreed with Dr. Green’s statements. I responded, like Dr. Jay did to the New York Times , that it is all based on the expertise of the physician. For that I was sued for libel in San Diego Superior Criminal Court by Dr. Green. The case was tried before a jury and no damages were awarded to Dr. Green but at a cost of over $40,000 to me in legal fees to defend my remarks (Goldman 2001 ) . Such was the climate in the early life of the IPL.

However, it has been my belief over the last 15 years that the IPL is the most ver-satile machine available for the cosmetic surgeon (Goldman 2002 ) . The IPL is not only highly effective for benign vascular and many pigmented lesions but has also been incorporated into photodynamic therapy treatment of superfi cial non-melanoma skin cancer, acne and photodamage (Gold and Goldman 2004 ; Goldman et al. 2005 ; Nootheti and Goldman 2006 ) .

Final Thoughts

The one question I am most commonly asked is: If I can only afford to purchase one laser, which one do you recommend? I must fi rst begin with the disclaimer that I am or have been a consultant, lectured for, performed workshops for and/or received discounted equipment and/or research support from many different laser companies: Lumenis (formerly ESC, Sharplan and Coherent), CoolTouch, ICN, Altus Medical, Cynosure, Candela, ConBio, Diomed, Wavelight, Laserscope, Deka, Sciton and Syneron. I have also been instrumental in the development and/or initial clinical test-ing of the pulse dye laser, Q-switched alexandrite laser, Ultrapulse CO

2 laser, intense

pulsed light, long pulsed 1,064 nm Nd:YAG Vasculite, CoolTouch Varia, CoolGlide (now Cutera), CoolTouch I, II and III, Clearlight, Relume, Aluma, Wavelight Alexandrite and Ruby Lasers, Active FX, Deep FX, CoolLipo, CTEV, Cynosure Affi rm and Affi rm Multiplex, Smart Lipo and Smart Lipo Multiplex, Cynosure Cynergy, Triactive, Velashape, Smoothshape, GentleWaves, Laserscope Solis, and a few more that never went into mass production. My practice also presently owns lasers from all of these companies that are used every day. With this background one can see that my answer will upset the majority of laser companies, but the question is valid and deserves an answer.

One can argue that almost any laser can be used to treat a variety of conditions by changing various parameters of the laser or using the laser in conjunction with some

Foreword II

other technique, such as epidermal cooling, dying an epidermal lesion a certain color, or applying a chemical that is photoactivated. If this was true, the least expense laser is the one you should buy. However, if you wish to be a bit more specifi c and acquire a specialized laser, which one is best? The answer to this question depends on the type of practice you have. Is it a primarily cosmetic practice, a general dermatology practice, hair removal practice/Spa, or one concerned with Phlebology, etc.?

In a cosmetic practice, non-invasive rejuvenation and laser hair removal are per-haps the two most popular procedures and my choice for the one best machine is the IPL. Only an IPL can treat both superfi cial vascular and melanocytic lesions as well as hair. The IPL can be manipulated so that many different wavelengths can be pro-duced along with an infi nite number of combinations and lengths of pulse durations. The IPL can therefore be targeted to many different sizes of blood vessels, pigmented lesions and hair follicles. Other vascular lasers like the pulse dye lasers and long-pulsed 532nm Nd:YAG lasers can do a great job at eliminating vascular ectasia and telangiectasia as well as possibly some lentigines through non-specifi c thermal effects when used without epidermal cooling, but they cannot treat hair.

Another benefi t of IPL and vascular-specifi c lasers is the ability to soften superfi -cial wrinkles. Some physicians believe that collagen stimulation can occur through irritation of endothelial cells lining capillaries with release of growth factors or through direct stimulation of fi broblasts. I have not been signifi cantly impressed with minimizing wrinkles or striae with ANY vascular-specifi c, pigment-specifi c laser or IPL but do not entirely discount the opinions of these experts. My opinion is that certain subsets of patients at certain geographic latitudes under specifi c and as yet poorly defi ned parameters can have collagen stimulation with these lasers and IPLs. In my opinion, published studies have not looked long enough at treated patients to accurately evaluate wrinkle resolution since collagen remodeling may take nearly a year to occur. In my practice, it is common for both the patient and me to be less than enthusiastic with the treatment of their wrinkles only to be surprised when they return a year later looking better. I look forward to learning the optimal parameters for treat-ing wrinkles in the future. My choice of the IPL for the one best machine is that it can treat both vascular and pigmented lesions as well as hair and perhaps collagen remod-eling. However, as many physicians have learned, the IPL is not “idiot-proof” and needs to be learned. I liken it to a musical instrument. When you fi rst use it you get a bunch of squeaks and only with practice does it sound beautiful.

That is why this text is so important to so many physicians and I applaud the authors in fulfi lling the task of putting everything you need to know about the IPL into one, easy to understand text.

San Diego, CA, USA Mitchel P. Goldman

References

Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg . 2000;26(9):835-842.

Dover JS, Sadick NS, Goldman MP. The role of lasers and light sources in the treatment of leg veins. Dermatol Surg . 1999;25:328-336.

Gold MH, Goldman MP. ALA-PDT: where we have been and where will we are going. Dermatol Surg . 2004;30:1077-1084.

Foreword II

Goldberg DJ, Cutler KB. Nonablative treatment of rhytids with intense pulsed light. Lasers Surg Med . 2000;26(2):196-200.

Goldman MP. Laser and non-coherent pulsed light treatment of leg telangiectasia and venules. Cosmet Dermatol . 1995;8:43-44.

Goldman MP. The right to disagree and the loss of academic freedom: a personal experience. Cosmet Dermatol . 2001;14:61-65.

Goldman MP. One laser for a cosmetic dermatologic practice. Cosmet Dermatol . 2002;15:49-50. Goldman MP, Eckhouse S. Photothermal sclerosis of leg veins. Dermatol Surg . 1996;22:323-330. Goldman MP, Fitzpatrick RE. Pulsed-dye laser treatment of leg telangiectasia: with and without

simultaneous sclerotherapy. J Dermatol Surg Oncol . 1990;16:338-344. Goldman MP, Weiss RA. Treatment of poikiloderma of Civatte on the neck with an intense pulsed

light source. Plast Reconstr Surg . 2001;107:1376-1381. Goldman MP, Martin DE, Fitzpatrick RE, Ruiz-Esparza J. Pulse dye laser treatment of telangi-

ectases with and without sub-therapeutic sclerotherapy: clinical and histologic examination of the rabbit ear vein model. J Am Acad Dermatol . 1990;23:23-30.

Goldman MP, Weiss RA, Weiss MA. Intense pulsed light as a non ablative approach to photoaging. Dermatol Surg . 2005;31:1179-1187.

Green D. Photothermal removal of telangiectases of the lower extremities with the Photoderm VL. J Am Acad Dermatol . 1998;38:61-68.

Nootheti PK, Goldman MP. Advances in photorejuvenation and the current status of photodynamic therapy. Expert Rev Dermatol . 2006;1:51-61.

Raulin C, Goldman MP, Weiss MA, Weiss RA. Treatment of adult portwine stains using intense pulse light therapy (Photoderm™ VL): Initial clinical report. Dermatol Surg . 1997a;23:594-601.

Raulin C, Schroeter C, Maushagen-Schnaas E. [Treatment possibilities with a high-energy pulsed light source (PhotoDerm VL)]. Hautarzt . 1997c;48(12):886-893.

Raulin C, Weiss RA, Schonermark MP. Treatment of essential telangiectasias with an intense pulsed light source (PhotoDerm VL). Dermatol Surg . 1997d;23(10):941-945.

Raulin C, Schroeter CA, Weiss RA, Keiner M, Werner S. Treatment of port-wine stains with a non-coherent pulsed light source: a retrospective study. Arch Dermatol . 1999;135(6):679-683.

Sadick NS, Weiss RA, Shea CR, Nagel H, Nicholson J, Prieto VG. Long-term photoepilation using a broad-spectrum intense pulsed light source [In process citation]. Arch Dermatol . 2000;136(11):1336-1340.

Schroeter C, Wilder D, Reineke T, et al. Clinical signifi cance of an intense, pulsed light source on leg telangiectasias of up to 1 mm diameter. Eur J Dermatol . 1997;7:38-42.

Sommer A, Van MP, Neumann HA, Kessels AG. Red and blue telangiectasias. Differences in oxy-genation? Dermatol Surg . 1997;23(1):55-59.

Weiss RA, Sadick NS. Epidermal cooling crystal collar device for improved results and reduced side effects on leg telangiectasias using intense pulsed light. Dermatol Surg . 2000;26(11):1015-1018.

Weiss RA, Weiss MA. New treatment for telangiectases and venulectases: status of intense pulsed light therapy. Dermatol Surg . 1996;22:322.

Weiss RA, Weiss MA, Marwaha S, Harrington AC. Hair removal with a non-coherent fi ltered fl ash-lamp intense pulsed light source. Lasers Surg Med . 1999;24(2):128-132.

Weiss RA, Goldman MP, Weiss MA. Treatment of poikiloderma of Civatte with an intense pulsed light source. Dermatol Surg . 2000a;26(9):823-827.

v

There is a steady increase in aesthetic procedures nowadays. Many patients desire a minimally invasive procedure with long-lasting results. The Intense Pulsed Light (IPL) technology has proved to be of real benefi t in satisfying patient demands. The main advantages of this noninvasive technology are the minimal recovery downtime, fast and easy performance and long-term improvement. The fi eld of light therapy has grown and the literature must refl ect the advancement and direction of the light fi eld. However, not much has been written about IPL applications.

This book is written in a format to allow not only physicians dealing with IPL cosmetic procedures but also mid-level providers to understand and perform this treatment. The topics covered in this book are the main cosmetic applications of IPL. The book is structured around nine chapters.

Skin anatomy. This chapter describes the pertinent anatomy related to IPL appli-cations. In addition to the main structural elements of the skin described, the chapter contains important points about skin aging and histological aspects which can help the reader to a better understanding of the etiology of skin lesions and the need for IPL treatment.

Light-tissue interaction. This chapter describes the interaction between IPL and different skin structures. Target skin structures (chromophores) are described in detail. The results of this interaction are described as being important to understand-ing the goals and principles of treatment.

IPL safety and legal issues. This chapter describes the needs of the environment for a safe treatment. The necessary equipment and how to avoid pitfalls which may lead to lawsuits are described. Several aspects of IPL legal issues are also discussed: how to avoid medical liabilities and how to manage them are also included in this chapter.

How to organize the IPL treatment room. This is a very important aspect since “the action” takes place in this setting. This topic describes the necessary equipment for performing the treatment; the possibilities of acquiring the equipment, and how to arrange the room. The room can be a “mess” or a friendly working environment when all the tools are available and ready to use.

Patient selection. This chapter is unique and describes the pearls and pitfalls in selecting patients for IPL treatment. This is not an easy task, and proper patient selec-tion is extremely important to have satisfi ed patients. Problematic patient types are also described here.

Skin rejuvenation. This chapter starts with a description of skin aging. Intrinsic and extrinsic mechanisms are detailed. The most common skin lesions related to aging that can benefi t from IPL treatment for rejuvenation are detailed. The chapter

Preface

vi Preface

continues with treatment protocols which describe strategies for achieving optimal results. A review of the literature is included, presenting the treatment parameters of different studies and their results.

Hair removal. This chapter starts with a description of the hair follicle cycle, hair types and important structures for treatment. Treatment strategies are emphasized and detailed, starting from choosing the right parameters to post-treatment recom-mendations. A literature review is presented regarding treatment parameters and results according to various authors.

Vascular lesions treatment. This chapter describes the types of vascular lesions that can benefi t from IPL treatment. The treatment protocol is emphasized and describes in detail all the steps for performing this application. A literature review is presented and different results are compared regarding treatment parameters.

Complications. It is inevitable that complications can result from any medical treatment. The possible complications of the most common IPL applications (skin rejuvenation, hair removal, pigmented and vascular lesion treatment) are detailed. How to avoid them and how to handle them is also described.

The practical points section ends each chapter and emphasizes the most important factors for achieving the best results.

The goal of this manuscript is to provide an up-to-date book which will help clini-cians, residents, fellows and mid-level providers to understand IPL and perform treat-ments for various cutaneous conditions. The way it is written, the in-depth analysis, and the practical approach make this text a useful reference and a teaching instrument for both beginner and experienced physician in the fi eld of aesthetic medicine.

Lucian Fodor, MD Yehuda Ullmann, MD

Monica Elman, MD

vii

I have learned life experience and medicine from many excellent doctors, but fi rst place among them belongs to Yehuda Ullmann, not only my teacher and a co-editor of this book, but also a sincere friend. Because I cannot repay him for all that he has given me, with this book I share my experience with beginners in this fi eld of medicine.

Lucian Fodor, MD

The editors would like to thank Myrna Perlmutter for her help in the preparation of the manuscript.

Grant Weston, Cate Rogers and the other people at Springer Publisher have been patient, helpful and very professional.

We are deeply grateful to Carmen Ciplea and Alina Vesa for the quality of dia-grams and pictures.

A special thanks goes to Adriana Fodor who was very helpful and typed the origi-nal manuscript.

Dr. Yoram Levi was always a great supporter of this book.

Lucian Fodor, MD Yehuda Ullmann, MD

Monica Elman, MD

Acknowledgements

ix

1 Skin Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Light Tissue Interactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3 Intense Pulsed Light Safety: Legal Issues . . . . . . . . . . . . . . . . . . . . . . . 21

4 How to Organize the IPL Treatment Room . . . . . . . . . . . . . . . . . . . . . 27

5 Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

6 Skin Photorejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

7 Hair Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

8 IPL Treatment for Vascular Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

9 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Contents

xi

ALA 5-aminolevulinic acid AM Arterial malformations AVF Arteriovenous fi stula BDD Body dysmorphic disorder CLM Capillary lymphatic malformation CM Capillary malformations EMR Electromagnetic radiation IPL Intense pulsed light MAL Methyl aminolevulinate PpIX Protoporphyrin IX PTD Photodynamic therapy PWS Port-wine stains TRT Thermal relaxation time VM Venous malformations VPL Variable pulsed light

List of Abbreviations