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Lasers in
Dermatology
and Medicine
Dermatologic Applications
Keyvan Nouri
Editor
Second Edition

123
Lasers in Dermatology and Medicine
Keyvan Nouri
Editor

Lasers in Dermatology
and Medicine
Dermatologic Applications

Second Edition
Editor
Keyvan Nouri
Leonard M. Miller School of Medicine
University of Miami
Miami, FL
USA

ISBN 978-3-319-76116-9    ISBN 978-3-319-76118-3 (eBook)

https://doi.org/10.1007/978-3-319-76118-3

Library of Congress Control Number: 2018950469

© Springer International Publishing AG, part of Springer Nature 2011, 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword—And Forward!

This, Nouri’s book, is a thorough, recent, practical, and refreshing one that
puts “laser dermatology” into a broader perspective; it is a pleasure to update
my brief contribution for this edition. Almost immediately after the first laser
was created in 1960, a handful of visionary physicians recognized the poten-
tial for surgical applications, starting with the organ systems readily accessi-
ble to light. Lasers in laryngology, ophthalmology, and dermatology are so
fully adopted now that the standards of care have forever been changed. Now,
light is marching inside the body. Laser lithotripsy is widely practiced all over
the world. Know-how about lasers and biomedical optics is jumping between
medical specialties. Optical coherence tomography, a rapid form of live
microscopy invented for retinal imaging, is starting to impact dermatology
while making a larger splash for upper GI tract and coronary artery diagnostic
imaging. Dermatology was the first to figure out how to target individual
pigmented cells with laser pulses, a capability later adopted into ophthalmol-
ogy for glaucoma treatment. Recently, the various optical nanoparticles
developed for laser photo-thermal cancer therapy are being used in dermatol-
ogy for acne treatment.
How did we get such a wide, almost dazzling, variety of treatment lasers
in dermatology? (Because, we need them for different uses in various practice
settings; lasers are the most tissue-specific surgical tools in existence.) Do we
really need so many? (Well, we need most all of them. Only a few are inter-
changeable.) Are the mechanistic, clinical, safety, ethical, and practice-related
chapters of this book worthy of study? (Yes.) Can’t we just learn which but-
tons to push, in courses provided by the more reputable device manufacturers
just after a laser is purchased? (This approach is foolish beyond words, yet
such fools exist). Even more foolish are those who purchase a used laser and
start using it without any training whatsoever.
A great asset of this book is the breadth of its practical, clinical discus-
sions. There is no substitute for hands-on training, which cannot be obtained
even from this practical book. If you use lasers in practice, talk with your
colleagues and attend medical laser conferences in which you are free to ask
questions to faculty who are not trying to sell something. Many laser compa-
nies provide useful information, but are inherently biased. Laser companies
are restricted from discussing off-label indications. FDA clearance of a device
for a particular indication cannot be taken as assurance that it will work safely
and effectively enough to satisfy you and your patients, while lack of FDA
clearance for a specific indication cannot be taken as assurance that it will not

v
vi Foreword—And Forward!

work safely and effectively. Some of the best uses for dermatological lasers
are not FDA-labeled indications, and probably never will be.
It is remarkable what lasers already can do for our patients, yet this field is
clearly still in its youth. What comes next? With the advent of fiber laser
technology, various industries and telecommunications now have extremely
powerful, efficient, wavelength-versatile lasers that operate reliably for
decades with little or no maintenance. Those have begun to make their way
into dermatology, and may ultimately do better what we do now, plus add
wholly new capabilities. Fractional lasers have taught us how amazingly tol-
erant skin is, to a large volume of micro-injury. Up to 30% of skin can be
killed or removed in random, full-thickness wounds that heal rapidly without
scarring. The caveat is that every little wound must be less than about 0.4 mm
wide. Given that, is it possible to “target” anything in the skin that can be
localized, regardless of its optical or thermal properties? If we knew where
various things are in the skin, can’t we just aim at them? Yes, we could!
Image-guided smart fractional lasers will be used to selectively treat struc-
tures and lesions not now addressed with lasers—and with that, we will have
software-programmable laser targeting. For example, all three cutaneous
glands—eccrine, sebaceous, and apocrine—are reasonable targets, as well as
nerves, lymphatics, sensory end organs, mast cells, antigen-presenting cells,
and other components of normal skin. Microscopy-driven ablative lasers may
even rival conventional microscopic margin-controlled tumor surgery, some
day. When laser microscopy and laser tissue ablation are finally married, sur-
gical oncology in general may be impacted. This new era is coming sooner
than you think.
I have been fortunate to play a role in launching many aspects of laser
dermatology, starting with some fundamental understanding of skin optics,
the concept of selective photothermolysis, lasers specifically designed for
dermatological use, permanent laser hair removal, scanning confocal laser
microscopy, and “fractional” laser treatments. Each of these arose from try-
ing to understand or solve one clinical problem, but now the panoply of clini-
cal laser applications far exceeds the initial effort. For example, fractional
lasers arose as a safer alternative to fully ablative laser skin resurfacing, a
safer way to induce skin remodeling. We had no idea that tissue so grossly
abnormal as a hypertrophic wound scar could be stimulated to normalize
itself this way. Fractional ablative lasers also offer a new way for delivery of
topical agents, including very high molecular weight macromolecules, parti-
cles, and even cells. The current widespread and diverse use of lasers in der-
matology attests not so much to new technology, as to the extreme value of
astute clinical observations made by dedicated dermatologists. Nouri’s text is
aimed exactly at achieving that. So please be a gourmet laser chef, not a
short-order cook. Contribute to an amazing and evolving part of
dermatology.
Thank you, Dr. Nouri and the many authors involved in this text, for your
excellent contribution.

R. Rox Anderson

Preface

Laser technology is quickly evolving with the presence of newer lasers, along
with new indications, that are constantly being introduced. The use of lasers
has become a major discipline and is currently practiced in a variety of fields
of medicine today. This book specifically offers a comprehensive literature
covering the different ways lasers are being used in the field of dermatology.
The authors of Lasers in Dermatology and Medicine are well known in their
respective fields and have attempted to cover each topic in the most compre-
hensive, readable, and understandable format. Each chapter consists of an
introduction and summary boxes in bulleted formats with up-to-date informa-
tion highlighting the importance of each respective section, enabling the
reader to have an easy approach towards reading and understanding the vari-
ous topics on lasers. This book has been written with the sincere hope of the
editors and the authors to serve as a cornerstone of laser usage in dermatol-
ogy, ultimately leading to better patient care and treatments. Lasers in derma-
tology have clearly expanded. The areas or laser treatments include port wine
stains, vascular anomalies and lesions, pigmented lesions and tattoos, hair
removal and hair re-growth, acne, facial rejuvenation, psoriasis, hypopig-
mented lesions and vitiligo, and treatment of fat and cellulites, among others.
The lasers are also being used for treatment and diagnosis of skin cancers.
We anticipate that this book will be of interest to all the physicians in the
field of dermatology who use or are interested in using lasers in their practice.
We are extremely grateful to our contributing authors. This book will serve as
a potential study source for physicians that would like to expand their knowl-
edge in lasers and light devices.

Miami, FL, USA Keyvan Nouri

vii
Acknowledgements

I would like to sincerely thank my family for their support and encourage-
ment throughout my life. Special thanks to Dr. William H. Eaglestein, Dr.
Lawrence A. Schachner (former Chairman of Dermatology at the University
of Miami School of Medicine), and Dr. Robert Kirsner (Chairman of the
Department of Dermatology and Cutaneous Surgery at the University of
Miami Miller School of Medicine). They have given me great support and
have served as mentors throughout my professional career. Their guidance
and encouragement over the years has been greatly appreciated. Dr. Dr. Perry
Robins, Dr. Robin Ashinoff, Dr. Vicki Levine, Dr. Seth Orlow, the late Dr.
Irvin Freedberg, Dr. Hideko Kamino, and the entire faculty and staff at
New York University School of Medicine Department of Dermatology:
Thank you all for the wonderful learning and friendship during my surgery
fellowship.
I would like to thank the faculty and dermatology residents, and the staff
of the Department of Dermatology and Cutaneous Surgery at the University
of Miami Miller School of Medicine, for their teaching, expertise, and friend-
ship. Special acknowledgements to the Mohs and Laser Center staff at the
Sylvester Cancer Center for their dedication, hard work, and support on a
daily basis. I would also like to thank Dr. Ali Rajabi-Estarabadi, my research
fellow, for his diligence and hard work and the rest of the Mohs staff, includ-
ing Cathy Mamas, Juana Alonso, Gladys Quintero, Destini M. Adkins, and
Ileana P. Reyes.
Special thanks to my clinical research fellows in dermatologic surgery,
Sofia Iglesia, Ariel Eva Eber, Sebastian H. Verne, Marina Perper, Robert
Magno, Alaleh Dormishian, and Samuel C. Smith, for all their hard work and
contributions to this book.
I would also like to acknowledge the publishing staff Mr. Grant Weston,
Ms. Tracy Marton, Mr. Leo Johnson, and the entire Springer Publishing team
for having done a superb job with the publication. It has been a pleasure
working with them and this excellent project to compile the textbook.
Lastly, I would like to sincerely thank all the authors of this textbook.
These individuals are world-renowned in their respective specialties and
without their time and energy, writing this book would have not been possi-
ble. These individuals have made this a comprehensive, up-to-date, and reli-
able source on Lasers in Dermatology and Medicine. I truly appreciate their
hard work and thank them for their contributions.
Keyvan Nouri

ix
Contents

1 Laser-Tissue Interactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    1

Amanda Abramson Lloyd, Michael S. Graves, and Edward
Victor Ross
2 Laser Safety: Regulations, Standards
and Practice Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   37
Brienne D. Cressey, Ashley Keyes, and Murad Alam
3 Lasers for Treatment of Vascular Lesions . . . . . . . . . . . . . . . . .   49
Jayne Joo, Daniel Michael, and Suzanne Kilmer
4 Laser for Scars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   63
Voraphol Vejjabhinanta, Shalu S. Patel, and Keyvan Nouri
5 Laser Treatment of Leg Veins . . . . . . . . . . . . . . . . . . . . . . . . . . .   73
Julie K. Karen and Shields Callahan
6 Lasers and Lights for Treating Pigmented Lesions. . . . . . . . . .   83
Emmy M. Graber and Jeffrey S. Dover
7 Laser Treatment of Tattoos . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  109
Voraphol Vejjabhinanta, Caroline V. Caperton,
Christopher Wong, Rawat Charoensawad, and Keyvan Nouri
8 Laser for Hair Removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  121
Voraphol Vejjabhinanta, Keyvan Nouri, Anita Singh,
Ran Huo, Rawat Charoensawad, Isabella Camacho, and Ali
Rajabi-Estarabadi
9 Lasers for Resurfacing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  137
Rungsima Wanitphakdeedecha and Tina S. Alster
10 Fractional Photothermolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . .  165
Dieter Manstein, Hans-Joachim Laubac, Sofia Iglesia,
Alaleh Dormishian, Ali Rajabi-­Estarabadi, and Keyvan Nouri
11 Sub-surfacing Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  197
Michael Howard Gold
12 Non-invasive Rejuvenation/Skin Tightening:
Light-Based Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  213
Marina Perper, John Tsatalis, Ariel E. Eber, and Keyvan Nouri

xi
xii Contents

13 Laser and Light Therapies for Acne. . . . . . . . . . . . . . . . . . . . . .  227

Ali Rajabi-Estarabadi, Ariel E. Eber, and Keyvan Nouri
14 Lasers for Psoriasis and Hypopigmentation. . . . . . . . . . . . . . . .  237
Laura Jordan, Summer Moon, and James M. Spencer
15 Lasers for Adipose Tissue and Cellulite . . . . . . . . . . . . . . . . . . .  247
Molly Wanner and Mathew M. Avram
16 Photodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  261
Ariel E. Eber, Marina Perper, Sebastian H. Verne,
Robert Magno, Ibrahim Abdullah Omair ALOmair,
Mana ALHarbi, and Keyvan Nouri
17 Intense Pulsed Light (IPL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  275
Sanjana Iyengar, Keyvan Nouri, Peter Bjerring,
Kåre Christiansen, Robert A. Weiss, Girish S. Munavalli,
Sonal Choudhary, and Angel Leiva
18 Current Status of Light-Emitting Diode Phototherapy
in Dermatological Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  285
R. Glen Calderhead
19 Laser and Light for Wound Healing Stimulation . . . . . . . . . . .  339
Ehsan Azimi, Navid Bouzari, and Keyvan Nouri
20 Lasers in Hair Growth and Hair Transplantation. . . . . . . . . . .  351
Nicole E. Rogers, Marc R. Avram, Isabella Camacho,
and Ali Rajabi-Estarabadi
21 Photobiomodulation and Hair Growth. . . . . . . . . . . . . . . . . . . .  367
Molly B. Hirt and Ronda S. Farah
22 Reflectance Confocal Microscopy
in Oncological Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  375
Pablo Fernández-Crehuet Serrano,
Gonzalo Segurado-Miravalles, and Salvador González
23 Laser Clinical and Practice Pearls . . . . . . . . . . . . . . . . . . . . . . .  401
Hana Jeon, Lori A. Brightman, and Roy G. Geronemus
24 The Selection and Education of Laser Patients. . . . . . . . . . . . .  415
Murad Alam and Meghan Dubina
25 Anesthesia for Laser Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . .  427
Marina Perper, Ali Rajabi-Estarabadi, Ariel E. Eber,
Voraphol Vejjabhinanta, Ran Huo, Keyvan Nouri,
and John Tsatalis
26 Lasers in Skin of Color. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  437
Heather Woolery-Lloyd and Nkanyezi Ferguson
27 Laser Applications in Children. . . . . . . . . . . . . . . . . . . . . . . . . .  449
Jessica Cervantes, Sebastian H. Verne,
and Mercedes E. Gonzalez
Contents xiii

28 Dressing/Wound Care for Laser Treatment. . . . . . . . . . . . . . . .  467

Ariel E. Eber, Vincent M. Hsu, Stephen C. Davis,
and Keyvan Nouri
29 Prevention and Treatment of Laser Complications. . . . . . . . . .  475
Rachael L. Moore, Juan-Carlos Martinez, Ken K. Lee,
Yun Ehrlich, Brian Simmons, and Keyvan Nouri
30 Ethical Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  493
Abel Torres, Tejas Desai, Alpesh Desai, William T. Kirby,
and Maren C. Locke
31 Medicolegal Issues (Documentation/Informed
Consent/Non-physician Operators). . . . . . . . . . . . . . . . . . . . . . .  499
Abel Torres, Tejas Desai, Sailesh Konda, Alpesh Desai,
and William T. Kirby
32 Photography of Dermatological Laser Treatment. . . . . . . . . . .  505
Shraddha Desai and Ashish C. Bhatia
33 Online Resources of Dermatologic Laser Therapies. . . . . . . . .  517
Shraddha Desai, Elizabeth Uhlenhake, and Ashish C. Bhatia
34 Starting a Laser Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  523
Vic A. Narurkar
35 Research and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . .  527
Yakir S. Levin, Fernanda Hidemi Sakamoto,
and R. Rox Anderson

Index�������������������������������������������������������������������������������������������������������� 541
Contributors

Murad Alam Department of Dermatology, Otolaryngology, and Surgery,

Northwestern University, Chicago, IL, USA
Department of Dermatology, Northwestern University, Chicago, IL, USA
Mana ALHarbi Department of Dermatology, College of Medicine, Al
Imam Muhammad Ibn Saud Islamic University (IMSIU), Riyadh, Kingdom
of Saudi Arabia
Ibrahim Abdullah Omair ALOmair Department of Dermatology, College
of Medicine, Al Imam Muhammad Ibn Saud Islamic University (IMSIU),
Riyadh, Kingdom of Saudi Arabia
Tina S. Alster Georgetown University Medical Center, Washington Institute
of Dermatologic Laser Surgery, Washington, DC, USA
Marc R. Avram Department of Dermatology, Massachusetts General
Hospital, Harvard Medical School, Boston, MA, USA
Mathew M. Avram Department of Dermatology, Massachusetts General
Hospital, Harvard Medical School, Boston, MA, USA
Ehsan Azimi Department of Dermatology, Cutaneous Biology Research
Center, Massachusetts General Hospital, Charlestown, MA, USA
Ashish C. Bhatia Department of Dermatology, Northwestern University –
Feinberg School of Medicine, Chicago, IL, USA
Oak Dermatology, Schaumburg, IL, USA
Peter Bjerring Department of Dermatology, Swansea University, Swansea,
Wales, UK
Navid Bouzari South Shore Skin Center, Plymouth, MA, USA
Lori A. Brightman Laser & Skin Surgery Center of New York, New York,
NY, USA
R. Glen Calderhead Research Division, VP Medicoscientific Affairs,
Clinique L, Goyang-shi, Gyeonggi-Do, South Korea
Shields Callahan Department of Dermatology, Virginia Commonwealth
University School of Medicine, Richmond, VA, USA

xv
xvi Contributors

Isabella Camacho School of Medicine, Georgetown University, Washington,

DC, USA
Caroline V. Caperton Miller School of Medicine, University of Miami,
Miami, FL, USA
Jessica Cervantes Department of Dermatology, University of Miami Miller
School of Medicine, Miami, FL, USA
Rawat Charoensawad Rawat Clinic, Bangkok, Thailand
Biophile Training Center, Bangkok, Thailand
Sonal Choudhary Department of Dermatology and Cutaneous Surgery,
Miller School of Medicine, University of Miami, Miami, FL, USA
Kåre Christiansen Molholm Research, Molholm Hospital, Vejle, Denmark
Brienne D. Cressey Department of Dermatology, New York Presbyterian-
Weill Cornell Hospital, New York, NY, USA
Stephen C. Davis Department of Dermatology and Cutaneous Surgery,
University of Miami, Miami, FL, USA
Alpesh Desai Heights Dermatology and Aesthetic Center, Houston,
TX, USA
Shraddha Desai Dermatology Institute, DuPage Medical Group, Naperville,
IL, USA
Tejas Desai Heights Dermatology and Aesthetic Center, Houston, TX, USA
Roberto Diaz Department of Neurosurgery, University of Miami, Miami,
FL, USA
Alaleh Dormishian Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, FL, USA
Jeffrey S. Dover Department of Dermatology, Yale University School of
Medicine and Brown University, Chestnut Hill, MA, USA
Meghan Dubina Department of Dermatology, Northwestern University,
Chicago, IL, USA
Ariel E. Eber Department of Dermatology and Cutaneous Surgery,
University of Miami, Miller School of Medicine, Miami, FL, USA
Yun Ehrlich Department of Dermatology and Cutaneous Surgery, University
of Miami, Miami, FL, USA
Ronda S. Farah Department of Dermatology, University of Minnesota,
Minneapolis, MN, USA
Nkanyezi Ferguson Department of Dermatology, University of Iowa
Hospital and Clinics, Iowa City, IA, USA
Elizabeth A. M. Frost Mount Sinai Medical Center, New York, NY, USA
Julie A. Gayle Department of Anesthesiology, LSUHSC School of Medicine,
New Orleans, LA, USA
Contributors xvii

Roy G. Geronemus Laser & Skin Surgery Center of New York, New York,
NY, USA
Department of Dermatology, New York University Medical Center,
New York, NY, USA
Michael C. Giovingo Department of Ophthalmology, Stroger Hospital of
Cook County, Chicago, IL, USA
Michael Howard Gold Gold Skin Care Center and Tennessee Clinical
Research Center, Nashville, TN, USA
Mercedes E. Gonzalez Department of Dermatology, University of Miami
Miller School of Medicine, Miami, FL, USA
Salvador González Department of Medicine and Medical Specialities,
Alcalá University, Madrid, Spain
Department of Dermatology, Memorial Sloan-Kettering Cancer Center, New
York, NY, USA
Hospital Ramón y Cajal, Alcala University, Madrid, Spain
Emmy M. Graber Dermatology Institute of Boston, PC, Boston, MA, USA
Michael S. Graves Southwest Skin Cancer & Vein Clinic, Austin, TX, USA
Ramez I. Haddadin Department of Ophthalmology, Feinberg School of
Medicine, Northwestern University, Chicago, IL, USA
Molly B. Hirt Department of Dermatology, University of Minnesota,
Minneapolis, MN, USA
Vincent M. Hsu Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, FL, USA
Ran Huo Broward Dermatology Clinic, Pembroke Pines, FL, USA
Sofia Iglesia Department of Dermatology and Cutaneous Surgery, University
of Miami Miller School of Medicine, Miami, FL, USA
Viacheslav Iremashvili Department of Urology, Jackson Memorial
Hospital, Miami, FL, USA
Michael E. Ivan Department of Neurological Surgery, University of Miami
Hospital, Jackson Memorial Hospital, and Jackson South Hospital, Miami,
FL, USA
Sanjana Iyengar Department of Dermatology, Feinberg School of Medicine,
Northwestern University, Chicago, IL, USA
Hana Jeon Laser & Skin Surgery Center of New York, New York, NY, USA
Jayne Joo Department of Dermatology, Davis and Sacramento VA Medical
Center, University of California, Sacramento, CA, USA
Laura Jordan Kansas City University Consortium, Tri-County Dermatology
Residency Program, Cuyahoga Falls, OH, USA
xviii Contributors

Julie K. Karen Department of Dermatology, CompleteSkinMD, NYU

Langone Medical Center, New York, NY, USA
Alan David Kaye Department of Anesthesiology, Louisiana Health Sciences
Center, School of Medicine, New Orleans, LA, USA
Ashley Keyes Department of Dermatology, Weill Cornell Medicine, Lincoln
Medical Center, Bronx, NY, USA
Suzanne Kilmer Laser & Skin Surgery Center of Northern California,
Sacramento, CA, USA
Department of Dermatology, Davis Medical Center, University of California,
Sacramento, CA, USA
William T. Kirby Laseraway Hermosa Beach, Hermosa Beach, CA, USA
Ricardo J. Komotar Department of Neurosurgery, University of Miami,
Miami, FL, USA
Sailesh Konda Department of Dermatology, University of Florida College
of Medicine, Gainesville, FL, USA
Raymond J. Lanzafame Raymond J. Lanzafame, MD PLLC, Buffalo,
NY, USA
School of Dental Medicine, State University of New York at Buffalo, Buffalo,
NY, USA
Hans-Joachim Laubac Dermatologische Abteilung, Universitäre
Krankenhäuser von Gen, Genf, Schweiz
Ken K. Lee Dermatologic and Laser Surgery, Oregon Health and Sciences
University, Portland, OR, USA
Angel Leiva Department of Dermatology and Cutaneous Surgery, Miller
School of Medicine, University of Miami, Miami, FL, USA
Yakir S. Levin Department of Dermatology, Massachusetts General
Hospital, Boston, MA, USA
Wellman Center for Photomedicine, Massachusetts General Hospital, Boston,
MA, USA
Amanda Abramson Lloyd Skin and Vein Institute, Encinitas, CA, USA
Maren C. Locke Department of Dermatology, MetroHealth System,
Cleveland, OH, USA
Robert Magno Department of Dermatology, University of Miami, Toms
River, NJ, USA
Dieter Manstein Wellman Center for Photomedicine, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
Robert Marcovich Department of Urology, University of Miami, Miami,
FL, USA
Juan-Carlos Martinez Dermatologic and Laser Surgery, Oregon Health
and Sciences University, Portland, OR, USA
Contributors xix

Daniel Michael Department of Dermatology, Laser and Skin Surgery Center

of Northern California, University of California, Davis, Medical Center,
Sacramento, CA, USA
Summer Moon Dermatology Specialists of West Florida, FL, USA
Rachael L. Moore Dermatology Specialists of West Florida, Oregon Health
and Sciences University, Portland, OR, USA
Girish S. Munavalli Dermatology, Laser, and Vein Specialists of the
Carolinas, Charlotte, NC, USA
Timothy G. Murray Department of Ophthalmology/Ocular Oncology,
Retina Vitreous Diseases/Pediatric Ophthalmology, Medical Arts Surgery
Center Baptist, Nicklaus Children’s Hospital, Miami, FL, USA
Vic A. Narurkar Bay Area Laser Institute, San Francisco, CA, USA
Keyvan Nouri Dermatology, University of Miami, Miami, FL, USA
Ophthalmology, University of Miami, Miami, FL, USA
Otolaryngology, University of Miami, Miami, FL, USA
Dermatologic Surgery, University of Miami, Miami, FL, USA
Department of Dermatology and Cutaneous Surgery, University of Miami
Medical Group, University of Miami, Miami, FL, USA
Dermatology Services at Sylvester Comprehensive Cancer Center, University
of Miami Hospital and Clinics, Miami, FL, USA
MOHS, Dermatologic and Laser Surgery, University of Miami, Miami, FL,
USA
Surgical Training, University of Miami, Miami, FL, USA
Mahnaz Nouri Boston Eye Group, Brookline, MA, USA
Peter O’Kane Dorset Heart Centre, Royal Bournemouth Hospital,
Bournemouth, Dorset, UK
Carolyn Orgain Department of Otolaryngology, University of California,
Irvine, Orange, CA, USA
Steven Parker , Harrogate, North Yorkshire, UK
Krishna B. Patel Department of Ophthalmology, John H. Stroger Hospital
of Cook County, Lombard, IL, USA
Shalu S. Patel Department of Dermatology and Cutaneous Surgery, Miller
School of Medicine, University of Miami, Miami, FL, USA
Robert Perez Department of Dermatology and Cutaneous Surgery, Miller
School of Medicine, University of Miami, Miami, FL, USA
Marina Perper Department of Dermatology and Cutaneous Surgery,
University of Miami Hospital, Miller School of Medicine, Miami, FL, USA
xx Contributors

Roberto Pineda Department of Ophthalmology, Massachusetts Ear and Eye

Hospital, Boston, MA, USA
Ali Rajabi-Estarabadi Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, FL, USA
John Rawlins Dorset Heart Centre, Royal Bournemouth Hospital,
Bournemouth, UK
Douglas J. Rhee Department of Ophthalmology and Visual Science,
University Hospitals, Cleveland, OH, USA
Department of Ophthalmology and Visual Sciences, Case Western Reserve
University School of Medicine, Cleveland, OH, USA
Cornelia Selma de Riese Department of Obstetrics and Gynecology, Texas
Tech University Health Sciences Center, Lubbock, TX, USA
Nicole E. Rogers Hair Restoration of the South, Metairie, LA, USA
Edward Victor Ross Department of Dermatology, Scripps Clinic, San
Diego, CA, USA
Vanessa Rothholtz Pacific Coast Ear Nose and Throat, Beverly Hills,
CA, USA
R. Rox Anderson Department of Dermatology, Massachusetts General
Hospital, Harvard Medical School, Boston, MA, USA
Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard
Medical School, Boston, MA, USA
Ryan Rubin Department of Anesthesiology, Louisiana Health Sciences
Center, New Orleans, LA, USA
Fernanda Hidemi Sakamoto Department of Dermatology, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard
Medical School, Boston, MA, USA
Amy C. Schefler Department of Ophthalmology, Bascom Palmer Eye
Institute, Miami, FL, USA
Gonzalo Segurado-Miravalles Department of Dermatology, Ramón y
Cajal Hospital, Madrid, Spain
Pablo Fernández-Crehuet Serrano Department of Dermatology, Alto
Guadalquivir de Andújar, Andújar, Jaén, Spain
Brian Simmons Department of Dermatology and Cutaneous Surgery,
University of Miami, Miami, FL, USA
Anita Singh Montefiore Medical Center, Albert Einstein College of
Medicine, Bronx, NY, USA
James M. Spencer Spencer Dermatology and Skin Surgery Center (Spencer
Dermatology, Carillon Outpatient Center), St. Petersburg, FL, USA
Contributors xxi

Joseph Stuto Department of Dermatology, Weill Cornell Medical Center,

New York, NY, USA
Amit Todani Department of Ophthalmology, Goodman Eye Medical &
Surgical Center, Milford, MA, USA
Allyne Topaz Hackensack University Medical Center, Hackensack,
NJ, USA
On Topaz Asheville VA Medical Center, Asheville, NC, USA
Abel Torres Department of Dermatology, Loma Linda University School of
Medicine, Loma linda, CA, USA
John Tsatalis Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, FL, USA
Elizabeth Uhlenhake The Dermatology Group, Mason, OH, USA
Voraphol Vejjabhinanta Department of Dermatology and Cutaneous
Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami,
FL, USA
Department of Dermatology, Siriraj Hospital, Mahidol University, Bangkok,
Thailand
Sebastian H. Verne Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, FL, USA
Victor M. Villegas Bascom Palmer Eye Institute, Miami, FL, USA
Rungsima Wanitphakdeedecha Department of Dermatology, Faculty of
Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Molly Wanner Department of Dermatology, Massachusetts General
Hospital, Harvard Medical School, Boston, MA, USA
Robert A. Weiss Department of Dermatology, Maryland Dermatology
Laser Skin and Vein Institute, University of Maryland School of Medicine,
Hunt Valley, MD, USA
Andrew Whittaker Department of Cardiology, Dorset Heart Centre, Royal
Bournemouth Hospital, Bournemouth, Dorset, UK
Heather Woolery-Lloyd Department of Dermatology and Cutaneous
Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
Brian J. F. Wong Department of Otolaryngology, University of California,
Irvine, Orange, CA, USA
Christopher Wong Miller School of Medicine, University of Miami, Miami,
FL, USA
Charles C. Wykoff Department of Ophthalmology, Bascom Palmer Eye
Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
Roger B. Yandell Department of Obstetrics and Gynecology, Texas Tech
University Health Sciences Center, Lubbock, TX, USA
 Laser-Tissue Interactions
1
Amanda Abramson Lloyd, Michael S. Graves,
and Edward Victor Ross

Abstract driving a car (where the operator may have no

The best gauge of laser interactions is the tis- idea about nature of the drive train compo-
sue response, and experiment is the most real- nents), successful laser operation does not
istic manner to address medical treatment demand a complete understanding of the
challenges. However, theoretical models are machine or the details of the light-tissue inter-
helpful in planning treatment approaches and action. However, a comprehension of first
laser parameters. In this chapter we discuss principles allows for a logical analysis of final
basics of lasers, their non laser counterparts, clinical outcomes—furthermore, more cre-
and laser-tissue interactions. ative uses of equipment should follow. For
Many physicians choose laser settings out example, with an education in laser tissue
of habit (or reading it off of a label attached to interactions (LTIs) and tissue cooling, one can
the side of the machine—a “cheat” sheet with deploy the alexandrite (long pulse) laser either
skin-type specific parameters), using tissue as a hair removal device, vascular laser, or to
endpoints to confirm the appropriateness of remove lentigines.
the parameters. For example, when treating a The reader should note that although the
tattoo with a Q-switched laser, the operator title of this chapter is “Laser Tissue
looks for immediate frosty whitening. Like Interactions”, the introduction of many new
and diverse technologies make the term some-
what obsolete. We will continue to use the
term, but a more appropriate term is “energy–
A. A. Lloyd tissue interactions.” As both radiofrequency
Skin and Vein Institute, and ultrasound are increasingly applied in
Encinitas, CA, USA
medicine. We will use both terms interchange-
M. S. Graves ably in the remainder of the text.
Southwest Skin Cancer and Vein Clinic,
Austin, TX, USA
Keywords
E. V. Ross (*)
Laser · Radiofrequency · Ultrasound · Skin ·
Laser and Cosmetic Dermatology, Scripps Clinic,
San Diego, CA, USA Lentigines · Hair removal · Vascular ·
e-mail: [email protected] Dermatology

© Springer International Publishing AG, part of Springer Nature 2018 1

K. Nouri (ed.), Lasers in Dermatology and Medicine, https://doi.org/10.1007/978-3-319-76118-3_1
2 A. A. Lloyd et al.

Introduction with an education in laser tissue interactions

(LTIs) and tissue cooling, one can deploy the
1. Light represents one portion of a broader elec- alexandrite (long pulse) laser either as a hair
tromagnetic spectrum. removal device, vascular laser, or to remove len-
2. Light-tissue interactions involve the complex tigines [2].
topics of tissue optics, absorption, heat gen- The reader should note that although the title
eration, and heat diffusion of this chapter is “Laser Tissue Interactions”, the
3. Lasers are a special type of light with the char- introduction of many new and diverse technolo-
acteristics of monochromaticity, directional- gies make the term somewhat obsolete. We will
ity, and coherence. continue to use the term, but a more appropriate
4. Coagulation/denaturation is time and temper- term is “energy–tissue interactions.” As both
ature dependent radiofrequency and ultrasound are increasingly
5. Proper selection of light parameters is based applied in medicine. We will use both terms
on the color, size, and geometry of the target interchangeably in the remainder of the text.
6. Wound healing is the final but not least impor-
tant part of the laser tissue sequence (the
epilogue) Light
7. Laser-tissue interactions are fluid—the opera-
tor should closely examine the skin surface Light represents one portion of a much broader
during all aspects of the procedure electromagnetic spectrum. Light can be divided
8. Pulse duration and light doses are often as into the UV (200–400 nm), VIS (400–700 nm),
important as wavelength in predicting tissue NIR “I” (755–810 nm), NIR “II” (940–1064 nm),
responses to laser to irradiation MIR (1.3–3 μm), and Far IR (3 μm and beyond).
On a macroscopic level, light is adequately char-
The best gauge of laser interactions is the tis- acterized as waves. The amplitude of the wave is
sue response, and experiment is the most realistic perpendicular to the propagation direction. Light
manner to address medical treatment challenges. waves behave according to our “eyeball” obser-
However, theoretical models are helpful in plan- vations in day-to-day life. For example, we are
ning treatment approaches and laser parameters. familiar with refraction and reflection. The sur-
In this chapter we discuss basics of lasers, their face of a pond is a partial mirror (reflection); a
non-laser counterparts, and laser-tissue interac- fish seen in the pond is actually deeper than it
tions [1]. appears (refraction) [3]. Normally, the percent-
Many physicians choose laser settings out of age of incident light reflected from the skin sur-
habit (or reading it off of a label attached to the face is determined by the index of refraction
side of the machine—a “cheat” sheet with skin-­ difference between the skin surface (stratum cor-
type specific parameters), using tissue endpoints neum n = 1.55) and air (n = 1) [4]. This regular
to confirm the appropriateness of the parameters. reflectance is about 4–7% for light incident at
For example, when treating a tattoo with a right angles to the skin [3, 5]. The angle between
Q-switched laser, the operator looks for immedi- the light beam and the skin surface determines
ate frosty whitening. Like driving a car (where the % of reflected light. More light is reflected at
the operator may have no idea about nature of the “grazing” angles of incidence. It follows that, to
drive train components), successful laser opera- minimize surface losses, in most laser applica-
tion does not demand a complete understanding tions, one should deliver light approximately per-
of the machine or the details of the light-tissue pendicular to the skin [3, 6]. One can deliberately
interaction. However, a comprehension of first angle the beam, on the other hand, to decrease
principles allows for a logical analysis of final penetration depth and also attenuate the surface
clinical outcomes—furthermore, more creative fluence by “spreading” the beam. One can reduce
uses of equipment should follow. For example, interface losses by applying an alcohol solution
1 Laser-Tissue Interactions 3

(n = 1.4), water (n = 1.33), or a sapphire crystal are controlling the device–tissue interaction time
(n = 1.55 μm). This allows for optical coupling to allow for precise heating (vide infra).
(vide infra). On the other hand, the surface of dry Lasers are useful because they allow for pre-
skin reflects more light because of multiple skin– cise control of where and how much one heats
air interfaces (hence the white appearance of a [10]. There are four properties that are common
psoriasis plaque). to all laser types (1) Beam directionality (colli-
Light penetrates into the epidermis according mation), (2) Monochromaticity, (3) Spatial and
to wavelength dependent absorption and scatter- temporal coherence of the beam, and (4) High
ing (vide infra) [1, 6–8]. Because of scattering, intensity of the beam [11]. The intensity, direc-
much incident light is remitted (remittance refers tionality, and monochromaticity of laser light
to the total light returned to the environment due allow the beam to be expanded, or focused quite
to multiple scattering in the epidermis and der- easily. With non-laser sources like flashlamps
mis, as well as the regular reflection from the sur- directed toward the skin surface, the light inten-
face). In laser surgery, light reflected from the sity at the skin surface cannot exceed the bright-
surface is typically “wasted”. This “lost” energy ness of the source lamp. With many lasers, a lamp
varies from 15% to as much as 70% depending similar to the intense pulsed light (IPL) flashlamp
on wavelength and skin type. For example, for pumps the laser cavity [12]. The amplification of
1064 nm, 60% of an incident laser beam may be light within the laser cavity sets laser light apart
remitted. One can easily verify this by holding a from other sources.
finger just adjacent to the beam near the skin sur- For most visible light applications, laser rep-
face. Warmth can be felt from the remitted por- resents a conversion from lamplight to an ampli-
tion of the beam. fied monochromatic form [13]. The high power
To describe laser tissue interactions at the possible with lasers (especially peak power) is
molecular/microscopic level, light is considered achieved through resonance in the laser cavity.
as a stream of “particles” called photons, where For many dermatology applications requiring ms
the photon energy depends on the wavelength of or longer pulses delivered to large skin areas,
light. IPLs are either adequate or preferable to lasers.
The scientific principle on which lasers are based
E photon = hc / l (1.1)
is stimulated emission. With spontaneous emis-
Where h is Plank’s constant (6.6 × 10−34 J -s), sion, electrons transition to the lower level in a
and c is the speed of light (3 × 1010 cm/s) [9]. random process. With stimulated emission, the
emission occurs only in the presence of photons
of a certain energy. The critical point is maintain-
Types of Light Devices ing a condition where the population of photons
in a higher state is larger than that in the lower
In principle, many non-laser devices could be state. To create this population inversion, a pump-
used for heating skin [9]. Most properties of laser ing energy must be directed either with electric-
light (i.e., coherence) are unimportant insofar as ity, light, or chemical energy.
the way light interacts with tissue in therapeutic All lasers contain four main components, the
applications. And although collimation (lack of lasing medium, the excitation source, feedback
divergence) of the incident beam might increase apparatus, and an output coupler. With respect to
the % of transmitted light with laser versus IPL, lasing media, there are diode lasers, solid-state
the increasing use of filtered flash lamps in der- lasers, dye, and gas lasers. Most solid state and
matology suggests that losses from IPL beam dye lasers use optical exciters (lamps), whereas
divergence are not critical. In lieu of lasers, some gas and diode lasers use electrical excitation (i.e.,
thermal sources can be used in skin surgery (i.e., CO2 and RF). The feedback mechanism consists
nitrogen plasma device) for resurfacing (Portrait, of mirrors where one mirror reflects 100% and
Rhytec, MA). The critical features of any device the other transmits a small fraction of light [14].
4 A. A. Lloyd et al.

An example of a solid-state laser is the alexan-

drite laser. A solid-state laser consists of a rod
that is pumped by a flashlamp. The lamp pumps
the rod for stimulated emission. The rod and
lamp assembly must also be designed for ade-
quate cooling. Lasers typically are finicky
because all of the components are driven near
their damage thresholds (like redlining your car
all the time). As an example of this concept, con-
sider the pulsed dye laser (PDL). As the dye
degrades, the lamps must work harder to generate
higher pulse energies from the dye. Also, mirrors Fig. 1.1 A red LED (OmniLux, Phototherapeutics, Inc.)
become contaminated over time such that the
lamps must work harder and harder. These is no oscillation and the semiconductor LASER
demands stress the power supply. Thus, eventu- acts like an LED. This emission is very similar to
ally, the dye kit, the power supply, lamps, and dye the visible emission of light emitting diodes. If
are all working at their maximal output. Often one adds mirrors it operates as a tiny laser instead
people speak of a tunable dye laser. In fact many of an LED. The overall efficiency of semiconduc-
dye lasers are tunable; the manufacturers have tor lasers is quite high, approximately 30% and
simply chosen one wavelength. An example of a among the highest available for any laser types.
tunable laser was the Sclero-plus pulsed dye laser Most semiconductor (diode) lasers are operated in
(tunable from 585 to 600 nm in 5 nm increments) CW mode but can be pulsed. New visible
from Candela (Candela, Wayland, MA). light semiconductor lasers are available, and also
Laser systems differ with regard to duration laser diode arrays are available where scientists
and power of the emitted laser radiation. In con- have created large numbers of semiconductor
tinuous wave lasers (CW mode) with power out- lasers on one substrate. Some diode lasers are
puts of up to 103 W, the lasing medium is excited housed separate from the handpiece and delivered
continuously. With pulsed lasers, excitation is by fiber optics. Others are configured with the
effected in a single pulse or in on-line pulses laser diodes in the handpiece as arrays. Modern
(free-running mode). Peak powers of 105 W can diode lasers achieve higher powers than in the
be developed for a duration of 100 μs–10 ms. past, but their peak powers are still lag behind
Storing the excitation energy and releasing it sud- most pulsed solidstate lasers [14].
denly (Q-switch mode or mode-locking) leads to Excimer lasers emit UV light and are used for
a peak power increase of up to 1010–1012 W, and a photomodulation of the immune system. They
pulse duration of 10 ps–100 ns [13]. have also been used in surgery. The possible muta-
Light emitting diodes (LEDs) are becoming genicity of these lasers has not been well studied.
commonplace in dermatology (Fig. 1.1). Primarily Materials such as the KTP crystal can be used to
used as a PDT light source, they are also used in generate harmonics with lasers. The KTP crystal is
biostimulation. LEDs are similar to semiconduc- used to convert 1064 nm radiation to 532 green
tor (aka diode) lasers in that they use electrical light. Also quality (Q) switching is used for gener-
current placed between two types of semiconduc- ating short pulses. Much of the electrical energy
tors. However, they lack an amplification process used to create laser emissions is wasted as heat,
(no mirrors). LEDs do not produce coherent which is why water is used for cooling most lasers.
beams but can produce monochromatic light. Air cooling is used for some high-powered flash
Semiconductor (diode) lasers contain an LED as lamps and many diode lasers. In the future, free
the active gain medium. A current passes through electron lasers might be useful but presently they
a sandwich of two layers consisting of compounds are too cumbersome and only generate small
(called p type and n type). Below threshold, there amounts of energy per unit wavelength.
1 Laser-Tissue Interactions 5

Intense pulsed light devices are becoming cost of both laser and flashlamp technology are
increasingly comparable to lasers that emit ms steadily decreasing.
domain pulses [15]. Absorption spectra of skin
chromophores show multiple peaks (HgB) or can
be broad (melanin) [16], and therefore a broad- Light Device Terminology
band light source is a logical alternative to lasers.
Proper filtration of a xenon lamp tailors the out- Basic parameters for light sources are power,
put spectrum for a particular application. Some time, and spot size for continuous wave lasers,
concessions are made with direct use of lamp- and for pulsed sources, the energy per pulse,
light. For example, rapid beam divergence pulse duration, spot size, fluence, repetition rate,
obliges that the lamp source be near the skin sur- and the total number of pulses [17]. Energy is
face. This subsequent requirement makes for a measured in joules (J). The amount of energy
typically heavier handpiece compared with most delivered per unit area is the fluence, sometimes
lasers (Fig. 1.2) (the exception being some diode called the dose or radiant exposure, given in
arrays where the light source is also housed in the J/cm2. The rate of energy delivery is called power,
handpiece-(i.e., Light Sheer, Lumenis, CA)). measured in watts (W). One watt is one joule per
Also IPL cannot be adapted to fibers for subsur- second (W = J/s). The power delivered per unit
face delivery. High energy short pulses area is called the irradiance or power density,
(Q-switched ns pulses) are not possible with usually given in W/cm2. Laser exposure duration
flashlamps. They can, however, be used to pump (called pulse width for pulsed lasers) is the time
a laser, and some modern IPLs feature a laser over which energy is delivered. Fluence is equal
attachment where the flashlamp and laser rod are to the irradiance times the exposure duration
in the handpiece. In general, the size, weight, and [10]. Power density is a critical parameter, for it

Fig. 1.2 IPL and green light laser—note smaller size of laser handpiece
6 A. A. Lloyd et al.

often determines the action mechanism in cuta- physician can control spot size and tissue effects
neous applications. For example, a very low irra- simply by moving the handpiece tip toward or
diance emission (typical range of 2–10 mW/cm2) away from the skin. The subsequent rapid
does not heat tissue and is associated with diag- changes in power density offer “on the fly” flexi-
nostic applications, photochemical processes, bility and control.
and biostimulation. On the other extreme, a very A thorough knowledge of a specific laser’s
short ns pulse can generate high peak power den- operation and quirks is imperative for optimal and
sities associated with shock waves and even “safe” lasering. Vendors are creating lasers that
plasma formation [18]. Plasma is a “spark” due are more intuitive to operate. Increasingly, manu-
to ionization of matter. facturers have added touch screen interfaces with
Another factor is the laser exposure spot size application-driven menus and skin-­type specific
(which can greatly affect the beam strength inside preset parameters. Some devices permit patient
the skin). Other characteristics of importance are laser parameters to be stored for future reference.
whether the incident light is convergent, diver- Most lasers are designed such that the handpiece
gent, or diffuse, and the uniformity of irradiance and instrument panels are electronically inter-
over the exposure area (spatial beam profile). The faced. It follows that the laser control module
pulse profile, that is, the character of the pulse “knows” what spot size is being used. Typically
shapes in time (instantaneous power versus time) this “handshake” occurs when one inserts the
also affects the tissue response [19]. handpiece into the calibration port, or through a
Many lasers in dermatology are pulsed, and control cable from the handpiece to the laser
the user interface shows pulse duration, fluence, “main frame”. With others, one selects the spot-
spot size and fluence. Some multi-wavelength size on the display, and the laser calculates the flu-
lasers also allow for wavelength selection. Some ence accordingly. For example, one of our erbium
older lasers, for example a popular CO2 laser, YAG lasers possesses interchangeable lenses for
showed only the pulse energy on the instrument 1, 3, 5, and 7 mm spots. However, there is no feed-
panel, or in continuous wave (CW) mode, the back from the handpiece to the laser control
number of watts. In these cases one uses the board. The user “tells” the laser which lens cell is
exposure area and exposure time to calculate the inserted, and the laser calculates the fluence based
total light dose (fluence). on the selected spot and selected pulse energy. In
this case, if one changes the spot size (for exam-
Power ´ time
Fluence = (1.2) ple, by exchanging the 7 mm for the 3 mm lens
area cell), the laser still “thinks” the 7 mm spot is being
With the exception of PDT sources and CW used, and the actual surface fluence is now ~5×
CO2 lasers, most aesthetic lasers create pulsed the fluence on the panel. The resulting impact on
light. In many CW applications (i.e., wart treat- the skin surface (the wound depth and diameter)
ment with a CO2 laser), the fluence is not of great should alert the enlightened user to reassess his
importance in characterizing the overall tissue parameter selection.
effect. A more important parameter is power den- Most lasers calibrate through a system where
sity (where higher power densities achieve abla- the end of the handpiece is placed in a portal on
tion and lower power densities cause charring), the base unit (Fig. 1.3). This configuration allows
and the physician stops the procedure when an for interrogation of the entire system, from the
appropriate endpoint is reached. On the other “pumping” lamps to the fiber/articulated arm to
hand, in PDT applications with CW light where the handpiece optics. For example, if a fiber is
the clinical endpoint might be delayed, the total damaged, the laser will fail calibration, and an
fluence and power density are important predic- error message appears. Other systems measure
tors of the tissue response. the output within the distal end of the handpiece
In CW mode, CO2 lasers are used with a using a small calibration module that “picks off”
focusing (noncollimated) handpiece such that the a portion of the beam.
1 Laser-Tissue Interactions 7

a b

Calibration port
Handpiece
tip

Fig. 1.3 Figures show handpiece before and during insertion into calibration port of a Q switched alexandrite laser

There are some simple ways to interrogate for damental optimized “mode” of the laser. This
system integrity. One can examine the aiming shape is usually observed when the beam has
beam as it illuminates a piece of white paper, been delivered through an articulated arm. For
checking that the beam edges are sharp—this some wavelengths, this is an effective way to
suggests that the treatment beam is also sharp and deliver energy (CO2 and erbium). The disadvan-
the profile is according to the manufacturer’s tage of the rigid arm is limited flexibility, the
specifications. Also, burn paper can be used— typically short arm length, the possibility of mis-
here the laser is used with a low energy and the alignment from even minor impact, and a ten-
spot is checked for uniformity from beam edge to dency for non-­uniform heating across the spot
edge. By checking the impact pattern, one can [20]. For example, in treating a lentigo with a
uncover damaged mirrors in the knuckle of the Q-switched alexandrite laser equipped with a
articulated arm, or a damaged focusing lens that rigid articulated arm, one may observe complete
renders the laser unstable or unsafe. Likewise, for ablation of the epidermis at the center of the
scanners, one can ensure that skin coverage will “spot”, but only whitening at the periphery. On
be uniform. the other hand, sometimes a bell-shaped profile
is desirable, for example, when applying a small
1. LEDs are becoming commonplace in biomed- spot FIR beam with a scanner. In this scenario,
ical applications the wings of the beam allows for some overlap
2. Solid state lasers generally achieve the largest without delivering “too much” energy at points
peak powers among laser types of overlap.
3. The laser operator should know every nook The Gaussian profile can be modified outside
and cranny of a laser’s features to optimize the cavity, which is desirable in many applica-
patient outcomes and safety tions. With a fiber equipped delivery system, the
4. Power density determines the mechanism for beam is mixed within the fiber and can be shaped
many LTIs to be more flat-topped. The lentigo then is more
likely to be uniformly heated (so long as the
lesion itself if uniformly colored!). Although
 eam Profiles: Top Hat Versus
B fiber delivery systems are usually preferred by
Gaussian physicians, some laser beams are difficult to
deliver through a fiber. Examples include far IR
Laser beam profiles vary based on intercavity wavelengths and very short pulses (i.e., few ns
design, lasing medium, and the delivery system. with typical Q switched Nd YAG lasers whose
A common profile is Gaussian or bell-shaped. high peak power exceeds the damage threshold
For many lasers, this profile represents the fun- of most fibers).
8 A. A. Lloyd et al.

Palomar smooth pulse technology Competing system

30 30
Skin temperature
25 25

Power, au; ∆ Tepi, °C

Power, au; ∆ Tepi, °C

Skin safety level Skin safety level

20 20
Skin temperature
15 15

10 10

5 5

0 0
–5 0 5 10 15 20 25 –5 0 5 10 15 20 25
Time, ms Time, ms

Fig. 1.4 Figure shows spiky versus smooth pulse and effect on epidermal temperature

Pulse Profiles: Square Versus Spiky 193 nm have been used for skin and corneal
ablation.
The pulse profile is the temporal shape of the 2. Violet IPL emissions, low power 410 nm
laser pulse (Fig. 1.4) [21]. In many pulsed laser LED, and fluorescent lamps are used either
applications, the “macro pulse” is comprised of alone or with ALA. Alone, the devices take
several shorter micropulses [22]. Depending on advantage of endogenous porphyrins and kill
the application, the temporal pulse profile may P. acnes [24]. After application, of ALA, this
impact the tissue effect. For example, simply by wavelength range is highly effective in creat-
increasing the pulse number from four to six ing singlet O2 after absorption by PpIX. Uses
pulselets, the purpura threshold is increased with include treatment of actinic keratoses, actinic
the PDL. Also, highly energetic spikes tend to cheilitis, and basal cell carcinomas [25].
increase the epidermal to dermal damage ratio in 3. Visible light (green yellow) - VIS (GY). These
applications such as laser hair reduction. This is wavelengths are highly absorbed by HgB and
especially true with green-yellow light in vascu- melanin and are especially useful in treating
lar applications. epidermal pigmented lesions and superficial
vessels [26–28]. Their relatively poor penetra-
tion in skin (and the even poorer penetration
Summary of Wavelength Ranges in blood—see Table 1.1) make them poor
choices for treatment of deeper pigmented
In this section we examine wavelength ranges lesions or deeper larger vessels. Their shallow
that are useful for cutaneous surgery. penetration depths preclude their use in per-
manent hair reduction (with the possible
1. UV laser and light sources have been used pri- exception of very large spots (i.e., IPL) that
marily for treatment of inflammatory skin dis- enhance light depth). The effective portions of
eases and/or vitiligo, as well as striae. The many IPL spectra include the GY range.
presumed action is immunomodulatory. The By the proper manipulation a laser delivery
XeCl excimer laser emits at 308 nm, near the device, one can optimize parameters for selec-
peak action spectrum for psoriasis. Other UV tive heating of pigmented versus vascular
non-laser sources have also been used for lesions. For example, by applying a compres-
hypopigmentation, striae, and various inflam- sion handpiece without cooling with 595 nm,
matory diseases [22, 23]. Excimer lasers at blood is depleted as a target and pigment is
1 Laser-Tissue Interactions 9

Table 1.1 Absorption coefficients (cm−1) for various chromophores

Wavelength (nm) 410 532 595 694 755 810 940 1064
Oxy HgB (40% Hct) 1990 187 35 1.2 2.3 3.6 5.2 2.2
Deoxy HgB 1296 138 96 6.6 5.2 2.7 3.0 0.6
Melanina 140 56 38 23 17 13 7 5.7
Water 6.7 × 10−5 0.00044 0.0017 0.005 0.03 0.02 0.27 0.15
Bloodless dermis 10 3 2 1.2 0.8 0.6 0.5 0.4
OPD in skin (μm) 100 350 550 750 1000 1200 1500 1700
(net epidermis) for moderately pigmented adult—10% mel. volume fraction in epidermis [7, 29]
a

a b In “sun” mode T
is increased

Fig. 1.5 Figure shows user controllable temperature change with an IPL. By increasing the handpiece tip temperature,
pigmented lesion heating is favored over vascular heating

preferentially heated [30]. Also, by (see lime- lengths useful for PDT (i.e., sodium lamp,
light desert mode—Fig. 1.5), one can increase IPL, frequency doubled Nd YAG, or PDL)
or decrease the sapphire window temperature [31, 32]. On the other hand, all visible light
to enhance epidermal versus vascular heating. can be used for PDT, as the Soret band and
By reducing the pulsewidth into the nanosec- smaller “Q-bands” can all create singlet O2 on
ond range, melanosomes are preferentially irradiation of PpIX. Therefore the 532, 595,
heated over vessels. For example, extremely and IPL devices, when used adjunctively with
short Q-switched 532 nm pulses will cause ALA, can all augment the cosmetic result
fine vessels to rupture, but inadequate heat dif- through both photothermal and photochemi-
fusion to the vessel wall precludes long term cal effects.
vessel destruction. On the other hand, melano- 4. Red and Near IR (I) (630, 694, 755, 810 nm).
somes are sufficiently heated for single-­ Deeply penetrating red light (630 nm) contin-
session lentigo destruction. By choosing uous wave devices are efficient activators of
specific wavelengths with respect to HgB and PpIX after topical application of ALA. The
melanin, one can achieve some degree of 694 nm (ruby) laser is optimized for pigment
selective melanin or HgB heating. For exam- reduction and hair reduction in lighter skin
ple, if one wanted to avoid HgB in heating a types. The 810 nm diode and 755 nm alexan-
lentigo, 694 nm (ruby) represents a better drite laser, depending on spot size, cooling,
choice than 532 or 595 nm. This choice might pulse duration, and fluence can be configured
decrease inflammation by unintended heating to optimize outcomes for hair reduction, len-
of normal vessels in the dermis. tigines, or blood vessels [33]. They are posi-
There are absorption peaks for PpIX in the tioned in the absorption spectrum for blood
green–yellow range, making these wave- and melanin between the GY wavelengths and
10 A. A. Lloyd et al.

1064 nm. They will penetrate deeply enough

in blood to coagulate vessels up to 2 mm [34–
36]; also, they are reasonably tolerant of epi-
dermal pigment in hair reduction (with surface
cooling) so long as very dark skin is not
treated [37]. By decreasing the pulsewidth
into the nanosecond range, the alexandrite
laser is a first line treatment for many tattoo
colors.
5. Near IR (II). 940 and Nd YAG (1064 nm).
These two wavelengths have been used for a
broad range of vessel sizes on the leg and face
[38]. They occupy a unique place in the
absorption spectrum of our “big 3” chromo-
phores, that is blood, melanin, and water.
Because of the depth of penetration (on the
order of mm), they are especially useful for
hair reduction and coagulation of deeper
blood vessels. By varying fluence and spot
size, reticular ectatic veins, as well as those
associated with nodular port wine stains or
hemangiomas, can be safely targeted. On the Fig. 1.6 Note scar after 1064 nm irradiation of a nodule
other hand, they are not well suited for within a port wine stain
epidermal-­pigmented lesions. Also, although
water absorption is poor, it exceeds that of the
VIS and near VIS wavelengths. The result is absorbing wavelengths. Without surface cool-
that 940 and 1064 nm achieve large volume ing, unless very small fluences are applied, a
temperature elevation in the skin, and with top to bottom thermal injury occurs. The
repeated laser impacts, because of the slow absorption coefficients for the 1320 nm,
cooling of this volume (large τ–vide infra), 1450 nm, and 1540 nm systems are ~3 cm−1,
catastrophic pan-cutaneous thermal damage is 20 cm−1, and 8 cm−1 respectively [39], while
possible. This wavelength (1064 nm) repre- the effective scattering coefficients are about
sents the extreme example of a “what you 14, 12, and 11 cm−1. The corresponding pene-
don’t see can hurt you laser” [18] (Fig. 1.6). tration depths are ~1500, 300, and 700 μm. It
The Q-switched YAG laser plays an expand- follows that for equal surface cooling and
ing role in the treatment of tattoos, nevus of equal fluences, the most superficial heating
Ota, and even melasma. will occur with the 1450 nm laser, followed by
6. MIR-lasers and deeply penetrating halogen the 1540 and 1320 nm lasers. Newer deeply
lamps. These lasers and lamps heat tissue penetrating lamps have been introduced (Titan,
water. With macrowounding (>1 mm) spot Cutera, Brisbane, CA). They emit light over a
sizes, depending on where we want to heat, we 1–2 μm wavelength band with relatively low
can “choreograph” our laser and/or cooling power densities and long exposures (several
settings to maximize the skin temperature in seconds). In a typical scenario, the irradiation
certain skin layers. In general, with more begins after a roughly 2 s period of cooling. At
deeply penetrating wavelengths, larger vol- this point, a band of tissue from roughly 700–
umes are heated. On the other hand, achieving 1.5 μm deep in the skin is heated. By varying
temperature elevations in the volume will the fluence, this relatively large volume can be
require higher fluences than with highly heated to different peak temperatures. As part
1 Laser-Tissue Interactions 11

of each iteration, post pulse cooling is impera-  eam Propagation: How the Laser
B
tive because such a large volume of skin is Energy Gets to the Target
heated that a “thermal wake” advances toward
the skin surface. If one removes the handpiece Skin optical properties determine the penetration,
prematurely, heat accumulates near the skin absorption, and internal dosimetry of laser light.
surface with the risks of pain, dermal thermal The laser surgeon can divide the skin into two
injury, and scarring [40]. The 1320 nm components, (1) the epidermis (primarily an
Nd:YAG has been used in the endovenous absorber of visible light due to melanin) and (2)
ablation of the deep saphenous venous system The dermis (which can be envisioned as a carton
as well as laser liposculpture. Recently the of milk with red dots in it). Light tissue interac-
MIR spectral subset has become the mainstay tions can be broken down into A. The transport of
for fractional non-ablative technologies. light in tissue, B. Absorption of light and heat
7. Far infrared systems. The major lasers are the generation in tissue, C. Localized temperature
CO2, erbium YAG, and erbium YSGG elevation in the target tissue (and denaturation of
(chromium:yttrium-scandiumgallium-garnet) proteins), and D. Heat diffusion away from the
lasers. Overall, the ratio of ablation to heating target [17, 45].
is much higher with the erbium YAG laser. The optical properties of the skin mimic a tur-
However, one can enhance the thermal effects bid medium intermixed with focal discrete visi-
of the Er YAG laser by extending the pulse or ble and infrared light absorbers (blood, melanin,
increasing the repetition rate, and likewise one bilirubin, and dry collagen) [46]. The thermal or
can decrease residual thermal damage (RTD) photochemical effects depend on the local energy
of the CO2 laser by decreasing pw [41, 42]. density at the target. Once the light penetrates the
Where precision is required in ablation, Er surface, it undergoes a series of absorbing and
YAG is preferred. On the other hand, depend- scattering events. Photons statistically are either
ing on settings, the CO2 laser enjoys a desir- scattered or absorbed in a wavelength dependent
able blend of ablation and heating. The fashion [1, 47]. Scattering is affected by the shape
thresholds for ablation for CO2 and erbium or size of the particle and the index of refraction
lasers vary inversely with their optical pene- mismatch between the particle and medium. For
tration depths in tissue (20 μm and 1 μm most tissues, for λ > 2.5 μm or < 250 nm, absorp-
respectively). This assumes thermal confine- tion dominates over scattering. For the remainder
ment. It follows that less surface fluence is of the EM spectrum, scattering is the primary
required for ablation with the erbium laser. attenuator of light in tissue with the exception of
The CO2 laser at typical operating “pulsed” focal discrete absorbers (melanosome, HgB, etc.)
parameters performs self-limited controlled The probabilities of absorption or scattering
heating of the skin [43, 44], whereas the (designated μa and μs respectively, Table 1.1) are
erbium laser operates in an almost purely determined by experiment. For example, for a μa
ablative regime. The erbium YSGG (2.79 μm) of 0.3 cm−1, the mean free path before absorption
laser has recently been applied to LSR and its is 1/μa or 3.3 cm. Generally, light is attenuated as
absorption coefficient makes it a kind of it propagates through tissue. In turbid tissue (i.e.,
hybrid between CO2 and erbium YAG insofar the dermis, where collagen acts as the major scat-
as the ratios of heating to ablation. All three terer), the fluence attenuation can be described
wavelengths (2.79, 2.94, and 10.6 μm) have by:
recently been integrated into fractional deliv-
I ( z ) = I o ke (
-z /d )
ery systems. (1.3)

There are four key components in the sequence where I(z) is the local subsurface fluence at
of most photothermal laser-tissue interactions some depth z, k is a constant that accounts for
(Sects. 7.1–7.4). backscattered light and δ is the wavelength
12 A. A. Lloyd et al.

dependent optical penetration depth of light, or most tissues [10]. Various skin pigments can play
the depth at which there is attenuation to 37% of optical “tricks” on the cutaneous surgeon. For
the surface value (37% = l/e, where e = 2.7, the example, poikiloderma appears to be a mix of
base of the natural logarithm). This depth is hyperpigmentation and hypervascularity. In fact,
determined by absorption and scattering coeffi- although there is some melanin influence in the
cients, as related by the simple equation below red-brown appearance, the dyschromia is by far
[1, 47]: more a disorder of matted telangiectasia. This is
confirmed by the good response of the condition
1
d= (1.4) to the PDL, even with aggressive surface cooling
3m a ( ma + m s (1 - g ) ) that should preclude any impact on superficial
cutaneous hyperpigmentation. Additionally, with
Where g is the anisotropy coefficient (a mea- diascopy, “poikilodermatous” skin often appears
sure of the “mean” direction of the scattered pho- no browner than the surrounding apparently nor-
tons). g = 0.9 for the skin. As μa and μs increase, δ mal skin. The explanation is that deoxy-Hb con-
decreases accordingly. For example, for hair tributes to a “pigmented skin appearance”. This
removal, based solely on depth of penetration, finding follows from the absorption spectrum of
longer wavelengths such as 800 and 1064 nm deoxy-Hb in the 630–700 nm range, which is
should be preferable to 694 and 755 nm. In the very similar to the absorption spectrum of epider-
visible light range, this is why red light can pen- mal melanin. The size of the vessels in the super-
etrate one’s hand when shining a flash light on ficial venous plexus is such that the transmitted
the surface. Scattering decreases roughly propor- light through these vessels is approximately 50%
tional to λ3/2, so that, for example, an 800-nm lower than the incident intensity. These vessels
photon will on average travel about 1.3 times as therefore appear dark [49].
far in tissue as a 700-nm photon without being In most biological systems, tissue constituents
scattered. It follows that for “more” scattering show broad absorption bands with only a few dis-
wavelengths, there will be greater accumulation tinct absorption peaks. From 200 to 290 nm
of photons near the surface. In addition to scatter- (UVC), all biological objects (cells and tissue)
ing, this superficial convergence of photons is absorb energy very strongly. From 290 to 320
based on index of refraction mismatches between (UVB) nm, only a limited number of biomole-
air and tissue [1]. Accordingly, light must be cules show absorption (aromatic amino acids and
deposited more slowly with shorter wavelengths nucleic acids). For UVA 320–400 nm, light is
to avoid overheating the superficial tissue. weakly absorbed by colorless skin parts. From
There is backscattered light that can yield a 400 to 1000 nm mainly pigments—bilirubin,
higher fluence beneath the tissue than at the tis- blood, and melanin absorb light. The heterogene-
sue surface [48]. This paradox of tissue optics is ity of the skin allows for discrete heating over
that the internal fluence can actually exceed that this range, and therefore selective photothermol-
at the surface, as below: ysis (SPT) is exploited in this band. For
>1100 nm, all biomolecules have specific strong
I = I o (1 + 6 R ) (1.5)
vibrational absorption bands. Tissue water is the
primary determiner of the response to laser in this
Where I is the subsurface energy density, Io is wavelength range [9].
the surface fluence, R = the surface remittance The absorption coefficient (μa) is the relative
(0.3, 0.6, and 0.7 for 585 nm, 694 nm, and “probability” per unit path length that a photon at
1064 nm respectively). (personal communication a particular wavelength will be absorbed. It is
from RR Anderson, 1994) therefore measured in units of 1/distance and is
Since neither macromolecules nor water typically designated μa, given as cm−1. The
strongly absorb in the red light and near IR (600– absorption coefficient is chromophore and wave-
1200 nm) this range allows deeper penetration in length dependent. For larger heterogeneous vol-
1 Laser-Tissue Interactions 13

umes, μa can be weighted according to the Melanin: Most pigmented lesions result from
fraction of a specific chromophore. For example, excessive melanin in the epidermis. By choosing
for a dermis a typical blood fraction (f.blood) is almost any wavelength (<800 nm), one can pref-
0.2%, assuming that the blood is uniformly dis- erentially heat epidermal melanin. Shorter wave-
tributed in the skin [7]. lengths will create very high superficial epidermal
Following the descriptive convention of temperatures, whereas longer wavelengths tend
describing an equivalent average homogeneous to bypass epidermal melanin (i.e., 1064 nm).
f.blood, the net absorption of the dermis, μa.derm, Fat: Fat shows strong absorption at 1200 and
is calculated: 1700 nm [51]. Although the ratios of fat to water
absorption are small, the small differences are
ma .derm = ( f .blood )( m a .blood )
(1.6) exploited with the proper choice of parameters.
+ (1 - f .blood )( m a .skinbaseline ) 1200 nm might represent the best choice due to
decreased overall water absorption and therefore
Scattering is responsible for much of light’s increased penetration. Sebum is similar to fat but
behavior in skin (beam dispersion, spot size also is comprised of wax esters and squalene.
effects, etc.). The dermis appears white because Carbon: Carbon is a product of prolonged
of light scatter. The main scattering wavelengths skin heating. Once carbon is formed at the skin
(relative to absorption) are between 400 and surface, the skin becomes “opaque” to most laser
1200 nm. Absorption occurs where the laser fre- wavelengths (that is, most energy will be
quency equals the natural frequency of the free absorbed very superficially). It follows that the
vibrations of the particles (absorption is associ- dynamics of surface heating changes immedi-
ated with resonance) [50]. Scattering occurs at ately once carbon is formed. This can be used
frequencies not corresponding to those natural creatively as an advantage. For example, one can
frequencies of particles. Scattering is decreased convert a deeply penetrating laser to one that
as wavelength increases [7]. would only affect the surface by using a carbon
There are four major chromophores (water, dye. This has been accomplished with a laser peel
blood, tattoo ink, and melanin) in cutaneous laser using a Q Switched Nd YAG laser.
medicine [50]. Water makes up about 65% of the Collagen: Dry collagen has absorption peaks
dermis and lower epidermis. There is some water near 6 and 7 μm. With a free electron laser oper-
absorption in the UV. Between 400 and 800 nm, ating at these wavelengths, collagen can be
water absorption is quite small (which is consis- directly heated. Ellis et al. found that this
tent with our real world experience that light approach might allow for less tissue irradiation
propagates quite readily through a glass of water). and less thermal damage than CO2 laser [52].
Beyond 800 nm, there is a small peak at 980 nm,
followed by larger peaks at 1480 and 10,600 nm.
The water absorption maximum is 2940 nm Heat Generation
(erbium YAG).
Hemoglobin: There is a large HgBO2 (oxyhe-  elective Photothermolysis (SPT)
S
moglobin) peak at 415 nm, followed by smaller Non-bulk skin heating is based on selective
peaks at 540 and 577 nm. An even smaller peak is absorption by discrete chromophores of rela-
at 940 nm. For deoxyhemoglobin (HgB), the tively low concentration (i.e., melanin, hemoglo-
peaks are at 430 and 555 nm. The discrete peaks bin). Dr. Leon Goldman showed that color
of hemoglobin absorption allow for selective ves- contrast allowed for selective damage of dermal
sel heating. Although the 410 nm peak achieves targets as early as 1963 [53]. However, it was Dr.
the greatest theoretical vascular to pigment dam- RR Anderson who elegantly described the con-
age ratio among the other peaks, scattering is too cept of selective photothermolysis [26]. Selective
strong for violet light to be a viable option for photothermolysis offered a mathematically rigor-
vascular applications. ous rationale for tissue-selective lasers. As
14 A. A. Lloyd et al.

described by Dr. Anderson, extreme localized assume instantaneous heating of the target, so
heating relies on: (1) a wavelength that reaches that τ is the time for cooling after the pulse. If the
and is preferentially absorbed by the desired tar- pulse is too long, the target cools during the
get structures; (2) an exposure duration less than pulse, akin to one pouring water slowly into a
or equal to the time necessary for cooling of the leaky bucket. If the water represents heat, one
target structures; and (3) sufficient energy to observes that the bucket never fills (akin to a tar-
damage the target. The heterogeneity of the skin get never becoming very hot). If one wants to
allows for selective injury in microscopic targets. spatially confine heating one chooses a short
The focal nature of the heating decreases the like- pulse less than τ of the chromophore. For the
lihood of catastrophic pancutaneous thermal same volume, a sphere will cool faster than a cyl-
damage. For example, one can apply a 4 mm inder, which will cool faster than a slab. When
laser beam and observe only a 1 mm wide tattoo defining thermal relaxation time, the target size
line “whiten” with Q switched Nd YAG laser and geometry are important. Normally, τ is
with a larger round spot (Fig. 1.7)—the skin out- defined by:
side the tattoo but within the spot will appear nor-
d 2 / gk (1.7)
mal. Also, a darker lentigo will become white but
a lighter lentigo will remain unchanged. The pri- where δ is the optical penetration depth for
mary areas where SPT is helpful in dermatology homogeneously absorbing layers (such as tissue
is in the treatment of vascular lesions, tattoos, water for IR applications), and κ is the thermal
and pigmented lesions. However, even in applica- diffusivity (a measure of heat capacity and con-
tions where water is the chromophore, the prin- ductivity—for tissue, κ ~ 1.3 × 10−3 cm2/s). For
ciples of SPT are useful, as one can design precise discrete absorbers, i.e., the melanosome or a
heating and ablation protocols based on wave- blood vessel, τ is defined in terms of the particle
length and pulse duration [54]. size, and δ represents the diameter of the particle.
κ is the thermal diffusivity, a quantity based on
Thermal Relaxation Time the thermal conductivity and specific heat of the
The thermal relaxation time (τ) is the interval medium, and “g” is a constant based on the
necessary for a target to cool to a certain percent- geometry of the target (slab, cylinder, or sphere)
age of its peak temperature [28]. Larger objects [26]. See Table 1.2 for sample thermal relaxation
require longer times than smaller volumes to times for common targets in skin.
cool. For example, a tubful of warm bathwater The often-used term “thermal relaxation time
requires much longer than a thimbleful to cool to of the skin” is meaningful only when used for
room temperature. With laser irradiation, we specific wavelengths (or specific skin structures,
i.e., the epidermis). With a ubiquitous absorber
such as tissue water, τ should be considered
within the context of the wavelength dependent
optical penetration depth (δ) and the laser source,
not the dimensions of the skin constituents. For

Table 1.2 Thermal relaxation time of some potential

targets
Erythrocyte—2 μs
200 μm hair follicle—40 ms
Melanosome (0.5 μm)—0.25 μs
Nevus cell (10 μm)—0.1 ms
0.1 mm diameter vessel—10 ms
Fig. 1.7 Tattoo treated with 4 mm spot Q YAG laser; note
0.4 mm diameter vessel—80 ms
only 1 mm linear tattoo is heated (indicated by immediate
frosty whitening) 0.8 mm diameter vessel—300 ms
1 Laser-Tissue Interactions 15

example, if one uses the 1540 nm laser, the entire wave of heat diffuses from this cylinder, the tem-
epidermis and large portions of the dermis are perature decreases.
heated, and τ is on the order of seconds, because Spatially selective temperature elevation is
δ is several hundred micrometer. So even though possible when (1) the absorption coefficient of
τ of the epidermis is about 10 ms based on its the target exceeds that of collateral tissue (selec-
thickness, a thicker slab of skin is heated at tive photothermolysis), or (2) when the “innocent
1540 nm, the epidermis will take several seconds bystander” tissues are cooled so their peak tem-
to cool because there is little temperature gradi- peratures do not exceed some damage threshold
ent between it and that of the dermis. or (3) with very small microwounds (fractional).
For most targets a simple rule can be used: the Localized heating, for example, in telangiectasia
thermal relaxation time in seconds is about equal and lentigines, follows from the concentrations
to the square of the target dimension in millime- of blood and melanin there, respectively, such
ters. Thus a 0.5 μm melanosome (5 × 10−4 mm) that μa is focally increased. Verification of the
should cool in about 25 × 10−8 s, or 250 ns, models can be made by real-time measurements,
whereas a 0.1 mm PWS vessel should cool in thermocouple needles, thermal cameras, etc.
about 10−2 s, or 10 ms. Recall that τ is derived The geometry (and therefore the microscopic
from a solution of a differential equation and characteristics) of lesions is important—for
does not represent an absolute cooling time, but example in the treatment for a nevus versus a len-
rather provides approximate pulsewidths for tigo, the nevus is composed of melanocytes in
varying degrees of thermal confinement [13]. aggregates as nodules (collectively the nodules
Once the local subsurface energy density has are often several hundred micrometer in diame-
been determined (Eq. 3), heat generation can be ter) whereas the lentigo is a mere sheet of mela-
predicted by energy balance (conservation of nocytes some 10 μm thick. For example, in
energy), pulse duration, thermal relaxation time, treating nevus with a long pulsed alexandrite
and the wavelength specific absorption for that laser with a high fluence, the TRT will approach
target. a second. From the above equation, it follows that
The temperature increase of a desired target thermal confinement will be high, and the peak
can be roughly calculated by knowing the absorp- temperature will rise accordingly. More impor-
tion and scattering coefficients, surface light tantly, the thick slab of melanocytes will take
dose, size of the target, and the length of the long to cool, such that the will be considerable
pulse, as follows: heat diffusion away from the target. On the other
g/2 hand, the lentigo represents a slab only tens of
Fm æ tr ö microns thick; there will be heat diffusion during
DT = z a çç ÷÷ (1.8)
rc ètr +t p ø the long pulse and rapid cooling after the pulse.
Thus, with ms-domain fluences, the nevus case
where Fz is the local subsurface fluence, ρ is might result in scarring, and a lighter lentigo
the density, c is the specific heat “g” is a geomet- might not become hot enough for clearance. If
ric factor (“1” for planes, “2” for cylinders, and one applies ns pulses to the two lesion types, the
“3” for spheres), τp is the laser pulse duration, lentigo shows a good response with possibly
and τr is the thermal relaxation time of the target complete clearing, whereas the nevus will require
(time for target to cool to 37% of peak tempera- multiple sessions, as each laser application will
ture), defined by Eq. 1.7. Thus one can perform result in heat confined to the most superficial part
some quick algebraic calculations to estimate the of the lesion.
peak temperatures of local targets in the skin. The Two “offshoots” of SPT are the concepts of
temperature generally decays as a function of thermal damage time and thermokinetic selectiv-
diameter and time from the target. For ex, in hair ity (TKS).
removal the shaft and bulb, heavily invested with Thermal damage time. In some applications
melanin, reach high temperatures, and as the the immediate absorber and the intended target
16 A. A. Lloyd et al.

are not collocated (i.e., hair shaft and hair bulb/ state, followed by a complete relaxation into
bulge). Thermal damage time is defined as the vibrational modes (internal conversion).
pulsewidth that achieves irreversible target dam- However, NIR wavelengths and beyond are
age with sparing of the surrounding tissue. The absorbed via rotational and vibrational excita-
thermal damage time represents the interval tions in biomolecules (all of which are hydrocar-
when the outermost part of the target reaches the bons with the exception of pigments). These
target damage temperature through heat diffusion reactions can be considered a two-step process.
from the heater. In this case the eventual target In the first the molecule is “pumped” to an excited
and the heater (for example, hair shaft) are differ- state. Then, through a process known as non-­
ent and at a considerable distance from each radiative decay, there are inelastic collisions with
other [55]. Using this model, the thermal damage nearby molecules [50]. The temperature rise
time can be many times longer than the thermal results from the transfer of photon energy to
relaxation time. For example, for laser hair kinetic energy.
removal, with a 100 μm shaft and 30 μm follicle, For thermal reactions to occur, the energy
the TDT can approach several hundred millisec- must be randomized with a large ensemble of
onds [55]. molecules through statistical processes. With
Thermokinetic selectivity: Along the same HgB, the electronic excited state gives way to
lines is the concept of thermal kinetic selectivity vibrational modes. With longer wavelengths, the
(TKS). Using this principle, one selects larger or quantized energy packets correlate with vibra-
smaller targets for heating based on pulse dura- tional transitions from NIR and MIR.
tion. For example, if one wants to damage larger
targets while sparing relatively smaller ones, the
pulse duration is extended beyond the thermal Reaction Types and Effects of Heating
relaxation time of the smaller target. In this man-
ner, i.e., a melanosome will be heated to a lower • Photochemical effects (usually 10–1000 s;
temperature than the subjacent vessel. 10−3–10 W/cm2)
• Photothermal effects (1 ms–100 s; 1–106 W/
 olecular Basis of LTI
M cm2)
Most devices for cosmetic rejuvenation are based • Photomechanical and photoionizing effects
on photothermal or “electrothermal” mecha- (10 ps–100 ns; 108–1012 W/cm2)
nisms, that is, the conversion of light or electrical
energy to heat. Two fundamental processes gov- Photothermal Effects
ern all interactions of light with matter: absorp- Photothermal processes depend on type and
tion and scattering. Absorption and excitation are degree of heating, from coagulation to vaporiza-
necessary for all photobiologic effects and laser-­ tion. With a very short pulsewidths (pw), lasers
tissue interactions. Energy is proportional to fre- vaporize targets. For example, in treating blood
quency and inversely proportional to wavelength. vessels, rapid heating results in acute vessel wall
Thus a 532 nm photon (532 nm is the distance damage and petechial hemorrhage (with Q
between two of the transverse waves in a stream switched 532 nm) [56–58]. With intermediate
of light) is twice as energetic as a 1064 nm length pulses (0.1–1.5 ms), one can gently heat
photon. targets without immediate rupture of the vessels.
Macroscopically, the atomic events in LTIs Still intravascular thrombosis can create purpura
are not identifiable, but on the molecular level, and delayed hemorrhage. With still longer pulses
EMR exchanges energy only in discrete quanti- (6–100 ms), the ratio of contraction to thrombo-
ties (photons). The molecular basis of LTIs is sis increases and side effects are less likely. On
based on electronic transitions for the ultraviolet the other hand, too long pulses with very small
(UV) and visible (VIS) wavelengths. For exam- targets can create two problems. With highly
ple, hemoglobin is excited to a higher electronic absorbing targets, (i.e., tattoo inks)—the heat
1 Laser-Tissue Interactions 17

shorter wavelengths and are therefore preferable

for treatment. In fact, as the blood temperature
rises during laser irradiation, 532 nm light trans-
mission increases and longer wavelength (i.e.
595 nm) transmission decreases [29, 60].
Even after the heating source is removed,
whole blood optical properties change. A macro-
scopic coagulum emerges comprised of dena-
tured HgB, cell membranes of erythrocytes and
plasma proteins. Met HgB formation is also
important, with absorption peaks near 630–
635 nm. With increasing met HgB and deoxy
production, 755–1064 nm lasers penetrate less
Fig. 1.8 Figure shows extensive damage from long
pulsed 1064 nm irradiation of tattoo particle and will generate more heat in vessels. This is
one argument for sequential pulses with 1064 nm
lasers. One potential downside of this is that an
generation is so great and long-lived that signifi- abrupt increase in absorption, particularly with
cant diffusion occurs to the surrounding dermis 940–1064 nm, causes too much collateral
(Fig. 1.8). On the other hand, using a long pulse damage.
YAG for a nevus of Ota results in an insufficient
temperature rise as the pigmented nevus cells Thermal Injury to Cells
cool off too fast during the delivery of the pulses There is a range of measurable effects on skin
(also melanin absorption is much weaker than based on temperature. Below 43 °C, the skin
black ink). remains intact, even for very long exposures [45,
A mild–moderate temperature increase results 61]. The first change is a conformational change
in denaturation of enzymes and function. If the in the molecular structure that occurs at tempera-
heating is very fast, a phase change occurs [50, tures from 43 to 50 °C. After several minutes,
59]. Depending on the rate of energy delivery, there will be tissue necrosis as described by the
photovaporization occurs with or without inertial Arrhenius equation (an equation that quantita-
confinement (vide infra), where time is short tively describes conversion of tissue from a native
compared to the time for pressure relaxation. to denatured state). Thermal denaturation is a rate
Here the laser induced pressure causes compres- process: temperature increases the rate at which
sive stresses in tissue. Microcracks in the tissue molecules denature, depending on the specific
are the result of these large stress gradients [13]. molecule. For example, at 45 °C, cultured human
Whitening after ns irradiation is thought be gas fibroblasts die after about 20 min. However, the
vacuoles with scattering that resolve as the as the same cells can withstand over 100 °C for 10−3 s.
“spaces” are refilled with interstitial fluid. In general, a temperature of >60° lasting for at
Hemoglobin undergoes a complex set of reac- least 6 s leads to irreversible damage.
tions when heated. Formation of met HgB and
deoxy HgB occur during irradiation on the order Coagulation
of ms, representing a real-time change in tissue Temperature, directly related to the average
optics. During the heating phase, hemoglobin kinetic energy of molecules, is a critical factor in
absorption undergoes a bathochromic (red) shift tissue coagulation. Denaturation depends on time
of the 580 nm absorption peak (the 540 nm peak and temperature, and at least for exposures >1 s,
does not shift). This has important implications conforms to a rate process as described by the
for designing optimal blood vessel protocols. For Arrhenius equation. The characteristic behavior
example, it has been suggested that 585 nm of the Arrhenius-type kinetic damage model is
though 600 nm should penetrate deeper than that, below a threshold temperature, the rate of
18 A. A. Lloyd et al.

damage accumulation is negligible; and it away from the skin. The evaporation of tissue
increases precipitously when this value is water acts as a sort of buffer, reducing the peak T
exceeded. An example of coagulation is the cook- to just over 100 °C. When there is vaporization
ing of an egg white. Thermal denaturation is both there is also increasing pressure as the water tries
temperature and time dependent, yet it usually to expand in volume. The expansion leads to
shows an all or none like behavior. Most denatur- localized microexplosions. At the surface, parti-
ation reactions follow first order rate kinetics. For cles are ejected at supersonic velocities. At tem-
a given heating time there is usually a narrow peratures beyond 100 °C (without further
temperature region above which complete dena- vaporization), carbonization takes place, which is
turation occurs. As a rule, for denaturation of obvious by blackening of adjacent tissue and the
most proteins, one must increase the temperature escape of smoke. Carbon is the ultimate end
by about 10 °C for every decade of decrease in product of all living tissues being heated and car-
the heating time to achieve the same amount of bon temperatures often reach up to 300 °C. When
thermal coagulation [13]. treating a wart at low power densities with the
An absolute temperature for coagulation-­ CO2 laser, one can observe almost simultane-
denaturation does not exist. For very short times, ously incandescence and combustion. In water
higher temperatures than the oft-quoted “62– free structures, such as char, temperatures can
65 °C” should be required. Early signs of micro- reach 1000 °C, and incandescence can be
scopic damage are vacuolization, nuclear observed with continued irradiation of char at
hyperchromasia and protein denaturation (recog- long pulse cw CO2 lasers. Normally, this should
nized as a birefringence loss for collagen). be avoided, because the depth of tissue injury
Moderate temperature-induced damage phenom- will extend well beyond the blackened skin sur-
ena in tissue are difficult to assess with conven- face [50]. This is particularly true, for example,
tional light microscopy. In fact, histology when treating a rhinophyma or performing laser
represents and conveys the overall reactions of a skin resurfacing.
complex system and cannot be related to molecu-
lar species. Specimens obtained 24 h after irradi- Photomechanical Effects
ation tend to be more sensitive than those obtained With very short pulses, there is insufficient time
immediately after treatment, as often a day is for pressure relaxation. Mechanical damage is
required to show sign of necrosis; also, an inflam- observed with high-energy, submicrosecond
matory response might be the most sensitive indi- lasers for tattoo and pigmented lesion removal.
cator of injury. Particularly in light of newer large The time threshold for inertial confinement is
volume low intensity heating devices for rejuve- predicted by the relation [1]:
nation, more sensitive tools might be required to d /v (1.9)
characterize subtle thermal effects. Beckham
et al. [62]. found that over a narrow temperature where δ is the target diameter and v is the
range, heat shock protein (HSP) expression cor- velocity of sound in tissue.
related with laser induced heat stress, and that the Inertially confined ablation occurs when there
HSP production followed the Arrhenius integral. is high-pressure at constant volume. In a very
Thus HSP expression (in addition to tissue ultra- short pulse, the energy is invested so quickly one
structure, i.e., EM) might be an excellent tool to that there is no time for the pressure to be relieved.
examine low intensity high volume heat injury. Under these conditions of inertial confinement,
there’s not enough time for material to move—
Vaporization this can lead to the generation of tremendous
At a certain threshold power density, coagulation pressures and relief through shock waves. For
gives way to photovaporization (ablation). Water example, one can feel the recoil during laser tat-
expands as it is converted to steam. Vaporization too treatment if one touches the skin surface near
is beneficial in that much of the heat is carried the impact site.
1 Laser-Tissue Interactions 19

Photochemical Effects light (DUSA, Vahalla, NY) or Omni Lux

The absorption of light in tissue does not always (Phototherapeutics, CA, USA) will outperform a
generate heat. A term luminescence describes pulsed source (IPL, KTP, or PDL) for AKs with
cases where absorbed light causes emission of one treatment. However, largely because most
light of a different color. This occurs after elec- practitioners posses at least one pulsed visible
trons are excited from some lower (ground) state, light source, they have been widely used in PDT
to an upper level, excited state. If the process is and shown to be useful in a range of PDT-­
fast, fluorescence occurs. If the is an intermediary responsive skin disorders [64, 65]. Because
reaction and longer decay time, phosphorescence pulsed light sources in dermatology do not meet
occurs. Most photochemical reactions occur in the theoretical PDT saturation threshold
the UV and violet portion of the spectrum as the (4 × 108 W/m2) [66], in theory there should be
electronic transitions demand highly energetic significant PDT activity [67].
photons. Most photochemical activity is observed
Photochemical reactions are governed by spe- between 320 and 630 nm. The main absorption
cific reaction pathways, whereas thermal reac- peaks for PpIX are 415, 504, 538, 576, and
tions tend to be non specific. Photochemical 630 nm. Beyond 800 nm, photochemistry, even
reactions include fluorescence, phosphorescence with exogenous photosensitizers or pro-drugs, is
and photodynamic action. The former two unlikely. PDT reactions are complex; for exam-
involve the reemission of light after absorption at ple, with ALA, optimization require an under-
lesser wavelengths. Fluorescence spectra are standing of skin pharmacokinetics, conversion
increasingly used in diagnostic applications. An kinetics of ALA to PpIX, and proper delivery of
example is PpIX fluorescence to determine the light dose (including power density, wavelength,
amount of photosensitizer (PS) in the skin after etc.). A new development is a possible role for
application of ALA. Fluorescence spectra can vascular specific therapy with PDT. Both with
also be used to assess collagen content in the hematoporphyrin and benzoporphyrin deriva-
skin. Also, keratin fluoresces such that a milium tives, this approach is being investigated for
will display a bright yellow color during irradia- refractory deeper vascular lesions [68].
tion with a green light laser. We have occasion-
ally used this technique to distinguish a Photodisruption or Photodecomposition
deep-seated milium from a small pearly This reaction type is usually observed at 107–
BCC. Endogenous fluorescence applications are 108 W/cm2 in the UV range. Usually there is little
increasing and have included assays of NADH, residual thermal damage (RTD).
collagen, and amino acids [63]. Rather than heating water directly as their FIR
In photodynamic reactions, a photosensitizer counterparts, these lasers can exceed the bond
(acting as a catalyst) is excited by a certain wave- energies of many organic compounds. Among the
length of light. The PS then undergoes several available wavelengths (193, 241 and 308 nm)
sequential decays, forming singlet O2. In the XeCl (308 nm) is more likely to be more thermal
presence of oxygen, oxygen is transformed from because of the lowered energy per photon.
its triplet state, which is its normal ground state,
to an excited singlet state. The excited singlet Excimer Laser (308 nm)
state oxygen reacts with biological molecules The mechanism of action for the excimer laser
and attacks plasma and intracellular membranes (XeCl) is thought to be the same as narrow band
(type II PDT reactions). The most common pho- UV therapy. A reduction in cellular proliferation
tosensitizer (PS) in dermatology is PpIX. This PS most likely plays a role in epidermal cellular
is formed by skin cells by the pro-drug, ami- DNA synthesis and mitosis. In Parrish’s original
nolevulinic acid (ALA). Most photochemical study in 1981, he showed that wavelengths
reactions proceed more efficiently with lower between 300 and 313 nm were most effective
power densities, such that for example, the Blu-U [69]. It appears that the excimer laser works
20 A. A. Lloyd et al.

through in an immunomodulatory way much like  eat Conduction Away

H
standard non coherent UVB “light boxes”. There from the Chromophore
may be a thermal component as well at fluences
>800 mJ/cm2. This final “physical” step in LTIs in important in
characterizing collateral damage. Once heat is
Biostimulation generated, heat losses are based on heat conduc-
Biostimulation belongs to the group of photo- tion, heat convection, or radiation. Radiation can
chemical interactions. Increasingly this field is be neglected in most types of laser applications.
validated by the number of well-executed investi- A good example of heat convection is transfer
gations. Typical fluences are in the range of from blood flow. Heat conduction is the primary
1–10 J/cm2, and temperature elevation is absent. mechanism by which heat is transferred to unex-
Potentially positive reactions include (1) Increase posed tissue structures.
in phagocytic activity (2) Depression in rate of
bacteria replication (3) Increase in repair of skin, Cooling
and (4) Stimulation of wound healing. We should Surface cooling enhances efficacy and safety in
not debunk these applications—certainly they are skin laser surgery, especially for visible light tech-
being studied more and we are witnessing a tran- nologies, (i.e., green–yellow light sources such
sition from lab to bedside. One example of a “bio- as IPL, KTP laser, and PDL) that are popular in
stimulation” device is the Gentlewaves LED cutaneous laser surgery. They are also the wave-
Photomodulation unit (Light BioScience, LLC, length ranges where epidermal damage is most
Virginia Beach, VA). This device uses 590 nm likely. The epidermis is an innocent bystander in
light in a high repetition rate and low power den- cutaneous laser applications where the intended
sity to increase collagen synthesis and enhance targets, such as hair follicles or blood vessels, are
facial tone. Cell culture work supports this con- located in the dermis. Specifically, absorption of
cept [70]. Newer LED devices (800 nm) also sup- light by epidermal melanin causes skin surface
port a role for photorejuvenation and even hair heating.
growth. It is unknown if any special features of The first goal is of surface cooling is preserva-
laser light are relevant for biostimulation, although tion of the epidermis. The second and related
at least one study supports coherence as a possible goal of surface cooling permits higher fluences to
factor in photomodulation. Some investigators the intended target (i.e., the hair bulb and/or
have shown that laser showed the best effect while bulge or a subsurface blood vessel). Another ben-
the non-coherent LED light showed the poorest. efit of surface cooling is analgesia, as almost all
Coherence does not influence the transmission; cooling strategies will provide some pain relief
rather, because of interference in the scattered [71–79].
light field, coherency influences the microscopic The timing of the cooling relative to the
light distribution into tissue. laser pulse is important. Cooling can be pre,
during the pulse (parallel), or after the pulse
Plasma Induced Ablation (post) [79]. Post cooling may prevent retro-
With very high power densities exceeding 108 W/ grade heating (i.e., from the vessel back to the
cm2, optical breakdown occurs. Plasma removes epidermis) from damaging the skin surface. A
skin without evidence of mechanical or thermal cooling protection factor (CPF) has been pro-
damage when choosing appropriate parameters. posed by Dr. Rox Anderson. The cooling pro-
Plasmas are sometimes produced by laser tattoo tection factor is the ratio of fluence, with and
removal, where one can observe a spark [13]. without surface cooling, that spares the epider-
There is a new resurfacing system that uses mis. It is defined by:
plasma created by an RF excited N2 gas. Unlike Tc - Tic
laser-induced plasma, this flame heats tissue by CPF = (1.10)
Tc - Ti
direct heat transfer from the plasma edge.
1 Laser-Tissue Interactions 21

In the above equation, Tic and Ti are basal layer in macrophages of the dermis—the combination
temperatures before laser irradiation with and of gold and Q-switched lasers produces a
without cooling, respectively. Tc is the critical photothermal-­ photochemical conversion such
temperature at which thermal injury occurs. The that the gold darkens to a light blue or grey color
detailed calculations described later indicate that (Fig. 1.9). This reaction is a good teaching tool in
if the initial skin temperature is 30 °C, contact that it points out the role of pulse duration on the
cooling reduces the temperature of the basal layer laser tissue interaction [80, 81]. As noted earlier,
to about 20 °C. If Tc is assumed to be 60 °C (it is some reactions are dependent on power den-
actually somewhat higher for the brief laser sity—with higher power densities, multi-photon
exposure times in this analysis), this would give interactions are possible, that is, the energy is
the CPF as (60–20)/(60–30) or 1.33. Similarly, condensed into such a short duration, that simul-
cryogen cooling reduces the temperature to about taneous “arrival” of two photons at the same
0 °C, thus giving a CPF value as (60–0)/(60–30) locale can result in two-photon absorption. In the
or 2.0. Finally, there is convective air cooling, case of gold, the chemical compound structure
where cold air is commonly used in skin chilling. can be changed (from crystalline to elemental).
The Zimmer (Cyro5, Zimmer Medizin Systeme, Once the reaction occurs, one can apply longer
Ulm, Germany) directs −10 °C air at the skin at a pulses to diminish the dyspigmentation (even
rapid rate (1000 L/min). This system proves for with the same wavelength!). This reaction also
good bulk cooling but spatial localization of the underscores the importance of beam scattering,
cooling is poor. The CPF, depending on the air as the “gold” Q-switched laser reaction extends
temperature and nozzle velocity, is near that of beyond the diameter of the beam with each pulse.
contact cooling.

 ome Interesting Concepts

S
and Ideas in Laser Tissue
Interactions

With Q switched lasers, one might hear a loud

“pop” accompanied by a spark-like emission at
the skin surface. Normally this is the result of
inorganic compounds (make-up) remaining in
the skin during irradiation. Thorough cleaning of
the skin will remove this distraction. One should
ensure that any dark markers are off the skin,
especially when using long pulsed visible light
technologies. For example, one of our trainees
placed a black marking pen to outline an area for
a test spot for laser hair removal. During irradia-
tion, the beam was absorbed almost completely
by the ink—the hot ink cooled at the expense of
the skin surface, such that a very superficial burn
occurred.
Also, one should consider oral medications
both in the genesis of treatable lesions (i.e.,
­minocycline hyperpigmentation), and in the cau-
sation of pigmentation disturbances (i.e., gold).
In the case of gold, the medication is sequestered Fig. 1.9 Note blue macules
22 A. A. Lloyd et al.

Focusing the laser beam: A trick to increase with similar microvolumes of injury, that is, even
the dermal to epidermal damage ratio is use of a when the same total volume is observed, wound
convergent lens. This tool increases the local healing proceeds differently.
radiant exposure in the dermis (targeting the hair In the most common approach, 75–150 μm
bulb, a blood vessel, or dermal water). wide microwounds are created in the skin
Theoretically, one should be able to use smaller (Fig. 1.10) with densities ranging from 100 to
incident fluences, therefore achieving some pro- 1500 microwounds/cm2. By spatially confining
tection of the epidermis.
Vacuuming the target in the laser beam: A
company (Aesthera, Livermore, CA) has created
a pneumatic device whereby the skin is vacu-
umed into the light path such that the light pene-
tration in skin is enhanced. In this way more
energetic high frequency photons can be deliv-
ered, for example, to the hair follicle, with rela-
tive epidermal sparing. By applying suction, the
absorption coefficient of the epidermis can be
reduced by up to 25%. The technologies have
also been used for acne and pain reduction.
By proper timing of the suction with respect to
irradiation, selective targeting of various chromo-
phores can be achieved, for example, to increase
the dermal blood fraction in pale PWS (and
increase the blood vessel diameter). The very
small vessels in paler PWS have too small vessel
diameters for thermal confinement—that is, the
vessels cool too quickly to reach a critical tem-
perature. By applying suction, the blood volume
fraction increases, not simply a result of the
mechanical force but a physiologic response as
well [82, 83].
Pixilated Injury (aka fractional photothermol-
ysis): One can use a “pixilated” injury with water
as a chromophore in what is called fractional
photothermolysis. Roughly 100 μm spots have
been used with 250–500 μm spacing [84]. The
tissue can recover from this fractional injury
without the widespread epidermal loss observed
after traditional resurfacing applications. A num-
ber of technologies have been introduced. Despite
a wide range of devices, the pitch, wound diam-
eter, wound depth, and other wound features have
not been optimized. Ideally one would design
devices that maximize downtime while maximiz-
ing cosmetic enhancement. One can consider
ablative and non ablative approaches. Early evi-
dence suggests that there is a difference between
ablative and non ablative wound healing even Fig. 1.10 Note damage pattern with 1540 nm microbeam
1 Laser-Tissue Interactions 23

the micro-lesions, deeper wounds can be created ers on routine histology. Particularly for the erbium
than with a “slab-like” approach, while still man- YAG laser, there is immediate water loss through
aging a larger measure of safety. There are both these portals of entry [85], and postoperative dis-
ablative and nonablative approaches. Ablative comfort is often severe for an hour after the proce-
devices include the Profractional laser (Sciton), dure. Pinpoint bleeding is sometime observed,
equipped with a scanned microbeam, the Pixel particularly with higher-­pulse energies and shorter
erbium YAG laser from Alma (Alma lasers, pulsed erbium YAG applications.
Buffalo Grove, IL), and a newly introduced Optical damping: Replacing air (n = 1.0) with a
2940 nm technology from Palomar. Reliant higherindex medium at the skin surface such as
Technologies manufactures a fractional CO2 laser glass (n = 1.5) or sapphire (n = 1.7) tends to spare
system (Re Pair) that creates 125 μm diameter the epidermis. This effect has nothing to do with
“ablative” wounds as deep as 1 mm. Early inves- heat transfer, but rather is a consequence of optical
tigations have shown immediate superficial skin scattering behavior. At wavelengths from about
tightening. 600–1200 nm, most light in Caucasian epidermis is
“Macrowound” fractional technologies create back- and multiply-scattered light. By providing a
wounds >300 μm in diameter. These include the match to the skin’s refractive index, internal reflec-
KTP laser with a scanner (with approximately tion of the back-scattered light is greatly reduced,
700 μm wounds) as well as the active FX CO2 sys- decreasing the natural convergence of photons at
tem (Lumenis, Santa Clara, CA), which creates an the skin surface. This version of optical epidermal
array of 1.3 mm wounds and covers approxi- sparing requires a physically thick external medium
mately 60% of the surface area per session. such as a sapphire window or heavy layer of gel.
Wound depths range from 80 to 150 μm depend-
ing on pulse energy. Fluences with these
approaches range from 5 to 15 J/cm2. The applied Compacting the Dermis
fluences are another means (besides wound diam-
eter) to differentiate microwound injuries from One can decrease the depth photons must propa-
macrowound injuries. With ablative micro- gate by applying pressure over the treated area.
wounds, fluences tends to exceed 30× the ablation This maneuver may, for example, decrease the
threshold, whereas with traditional resurfacing relative depth of the bulb and bulge of the hair
laser applications (CO2 and erbium) fluences follicle up to 30% relative to the skin surface.
range from 0.8 to 10× ablation threshold per pass. Disadvantages include variability in the amount
The original non ablative fractional laser was of pressure, such that adjacent treatment areas are
(Reliant Technologies, Mountain View, CA), exposed to different subsurface fluences. Also, it
deploying a 1550 nm scanned microbeam that is unclear if compacting the dermis might alter its
required a surface blue dye for proper tracking scattering properties. In theory compression
along the skin. The newer Fraxel technology should decrease water content and improve der-
achieves deeper wounds and does not require the mal transmission [86].
dye. Palomar introduced a fractional 1540-nm sys- Spot diameter: In general the spot size should
tem. This device uses a “stamping” approach, be 3–4× > δ (for wavelengths where scattering
where each 10 mm macro-spot is comprised of dominates absorption), as larger spots make it
100 beamlets. With progressive passes, an increas- more likely that photons will be scattered back
ing skin surface area is covered. Another nonabla- into the incident collimated beam [13]. Photons
tive example is a 1440-nm/1320-nm Nd YAG laser scattered out of the beam are essentially wasted.
(Affirm, Cynosure, Chelmsford, MA) that delivers Traveling “alone”, they carry insufficient energy
hundreds of beamlets interspersed with a relatively to cause macroscopic thermal responses. The
uniform low-fluence background irradiation. consequences of spot size can be explained best
After high-fluence fractional CO2 and erbium on surface to volume arguments. Larger beams
YAG laser (50–200 J/cm2), one observes microcrat- (with the same surface fluence as smaller beams)
24 A. A. Lloyd et al.

create deeper subsurface cylinders of injury ple, can increase local blood flow, as can applying
because there is less surface versus volume for heating pad or simply placing a patient in
photons to escape. Basically, for small beams Trendelenburg position. One of our patients actu-
(narrow), scattered photons are carried out of the ally performs jumping jacks prior to her rosacea
beam path after only a few scattering events. As a laser therapy to increase the response [87].
clinical example of the effect of spot size, we Most laser tissue interactions are threshold-­
have found for 3 mm vs. 6 mm spots with the based, that is, a certain amount of energy must be
YAG laser that roughly ½ the fluence is required invested over a specific time to achieve the
with the larger spot for leg vein clearance. For desired efficacy. For example, to lighten a lentigo
shallow penetrating lasers such as CO2 and on the nose, even ten very–low-fluence passes, so
erbium where the δ ≪ spotsize (all cases except long as the interval between passes is long enough
for fractional devices), the diameter of the beam to preclude cumulative heating, will not result in
does not affect the tissue response. That is why clearance. The analogy is a smallish man trying
equivalent results can be obtained for skin resur- to push a car up a hill. Even if the man were to
facing using pulsed CO2 lasers versus scanned, arrive every day at 6 AM to push the heavy car,
tightly focused cw CO2 lasers [44]. Although the vehicle will remain stationary. There is no
studies suggest that large spots increase the ratio incremental car movement each day. One “laser”
of dermal to epidermal damage (usually desir- exception to this analogy is perhaps tissue tight-
able, for example, when treating a hair bulb), ening and protein denaturation over large vol-
there are instances where small spots are desir- umes with complex molecules (i.e., collagen),
able. For example, when treating a smaller vessel where repeated low impact low fluence passes
with an Nd YAG laser, a small spot with higher have been shown to increase the percentage of
fluence will result in a higher percentage of the denatured collagen fibers recruited in to the tight-
energy being invested in vessel heating versus ening process. Part of this phenomenon might be
larger spots. For any turbid medium, even if the secondary to differential denaturation tempera-
spot is “top hat”, there will be an accumulation of tures of older versus younger fibers.
photons near the center of the beam such that a When treating vascular lesions, multiple
greater clinical effect will often be noted at the “low” fluence passes can achieve cumulative
center of the spot. improvement. For example, a second pass even
Changing optical properties in real-time: seconds after an initial pass with the YAG laser or
Chromophore concentrations can change during a PDL will achieve additional bluing of an angi-
treatment session. One should never consider each oma. The dynamics of vascular heating is some-
laser tissue interaction as an independent event, but what different than for water and melanin. In
rather a cumulative process where visual endpoints vascular applications, dynamic changes in blood
are the most important ally for the physician. properties play a role. Met-Hg is produced by
Optical properties of the skin are like the weather one pass so that additional passes can result in an
[3], and one must accommodate the changes in increase in absorption. Also the partial clot
real-time. For example, the dermal blood fraction enhances absorption venous red blood.
increases after one pass of the PDL, such that for a With pigment lesions, repeated laser pulses
second pass, the skin temperature will increase due delivered over short periods (0.25–1 s) intervals
to the higher μa. The phenomenon will, for exam- results in progressive graying or darkening of the
ple, lower the purpura threshold on a second pass. lesions. On the other hand, repeated passes (after
On the other hand, general anesthesia can decrease >1 min) will result in cumulative extent.
the blood flow in PWS and require a higher light Both immediate and delayed pigmented dark-
dose. A failure to respond to these real-time ening (seconds to minute after irradiation) after
changes accounts for many laser treatment short- application is most likely due to optical property
comings. In treating a PWS, tetracaine, for exam- changes in melanin as well as erythema deep to
1 Laser-Tissue Interactions 25

the lesions that might add to the darkening per- a more superficially penetrating laser by having a
ception of (Fig. 1.11). fine carbon layer at the surface. For example, one
Optical clearing with hyperosmolar solutions: can “convert” a 694 nm ruby laser into a laser
Transparency of the skin is enhanced by topical with CO2 laser like effects by applying a fine
application or intradermal injection of solutions layer of graphite from a copy machine to the skin
such as glycerin [88]. Water and collagen become surface. In this way the 694 nm laser energy is
less bound such that the effective scattering coef- confined to the surface by the almost 100%
ficient of the dermis is reduced. Already this con- absorption by carbon. This fine layer of heated
cept has been applied to increase the visibility of materiel then cools much like a superficial layer
blood vessels from the surface. Possible applica- of tissue heated by a CO2 laser alone.
tions include tattoo removal, where particles Photon recycling: The remittance of human
often are found several mm deep in tissue. More skin is wavelength dependent (vide supra). These
recently Perfluorodecalin has been applied topi- reflected photons are scattered into the environ-
cally to accelerate the clearing of the immediate ment and “wasted” in surgical laser applications.
tissue whitening response after tattoo removal. One can design a simple hemispherical reflector
Once the whitening response has diminished to return reflected light to the incident spot on the
(usually about 5 min after the application), a sec- skin. In theory the gain in total energy available
ond treatment can be applied in the same session 1
to skin is a factor of , where RS is the
without the tissue scattering created by the first (1 - R S R M )
pass [89].
“Carbonization” at the surface: Carbon will skin reflectance, and RM is that of a hemispherical
cause all wavelengths to increase absorption such
that one can convert a deeply penetrating laser to mirror. For example, if RS is 0.7, and RM is 0.9, a
1
gain of , or almost threefold, can be
(1 - 0.63)
Darkening
after IPL achieved.
Photothermal responses in individual cells.
Most of our characterization of laser-tissue
responses is based on “macroscopic” responses.
That is, individual cells are rarely examined dur-
ing and after laser irradiation. When focal cell
damage has been examined, the following consid-
erations are made. (1) Heterogeneity of cell struc-
ture can lead to extreme localized light absorption
and temperature elevation different from that of a
homogenous medium. (2) Localized overheating
may cause cell damage, even in the absence of
average thermal effects over larger volumes [90].
After absorption of a laser pulse, non-radia-
tive relaxation of optical energy occurs within
10−11 s. Thus heating at the site of absorption is
Whitening instantaneous. On the other hand, heat diffusion
after Q alex is much slower and characterized by the TRT. In
experiment, not unexpectedly, it was found that
Fig. 1.11 Figure shows immediate pigment response that temperature fields in cells were more uni-
after IPL and Q switched alexandrite laser form with longer pulses. It follows that short
26 A. A. Lloyd et al.

pulses have smaller thermal fields but higher 1. LTIs are usually based on varying degrees of
localized T elevations. The shorter the laser light absorption by tissue HgB, melanin, and
pulse, the more the final tissue response will water.
depend on the properties of the local absorbing 2. Wavelength ranges should be chosen to
components. One interesting phenomenon is that achieve as much specificity as possible in tis-
on a localized level, an initial thermal field does sue heating
not provide the maximum amplitude of the inte-
gral photothermal response inside a cell. Rather,
the T response reaches its maximum as a result Radiofrequency (RF) Technology
of the multiple secondary thermal fields as they
emerge. With R radiofrequency energy, local heat gener-
Using a polarizing lamp to enhance illumina- ation depends on the local electrical resistance
tion. Laser treatment can be enhanced by using a and current density. The distribution of the cur-
polarizing lamp during procedures to treat vascu- rent density is determined by the configuration of
lar and pigmented lesions. This is particularly the electrodes with respect to the skin anatomy.
helpful, for ex. when treating PWS in kids using There are multiple types of electrode deploy-
general anesthetic, the lamp is [91] helpful to ments [94–97].
delineate the edges of the PWS prior to treat-
ment. Also, the visual enhancement tends to
result in more complete elimination of vessels, Monopolar vs. Bipolar
therefore patients are more satisfied.
Selective cell targeting. A process called Radiofrequency energy induces tissue heating in
selected cell targeting has been examined as a multiple ways, one by creating bulk heating of
way to destroy selected cells. This precise energy the dermis while sparing the epidermis via cool-
deposition is achieved by using laser pulses and ing mechanisms, and alternatively, micro needles
light absorbing immunoconjugates tagged to the can be placed in the skin to deliver small coagula-
respective cells. The investigators in one study tive injuries [98, 99].
showed, for example, that lymphocytes could be Since radiofrequency energy stimulates the
selectively damaged by attaching iron oxide mic- generation of new collagen and elastin, most
roparticles absorbing 565 nm radiation at those devices require at least three treatments and
sites [92]. One can imagine, in the future, using effects are not typically fully seen until 1–3 months
this type of modality to treat T-cell mediated dis- after the last treatment. One benefit to using radio-
eases such as atopic dermatitis or psoriasis. In frequency devices is that the energy is colorblind
this way, one makes the “bad guy” more notice- and passes through the melanin and hemoglobin
able to the laser. present in the tissue; therefore, all skin types can
Scatter limited therapy—using small micro- be treated. One should note that there is attenua-
beams. Reinisch [93] proposed the use of beam tion of the electrical field as a function of depth
diameter to titrate the depth of penetration, For (like light and lasers); however, the specific equa-
example, we have studied a fractional 1064 nm tions that guide the specifics of the attenuation are
ms laser (100 μm diameter microbeam and beyond the scope of this chapter.
100 mb/cm2) technology to achieve superficial There are four broad types of RF interventions
vessel heating with relative epidermal sparing in the skin. One is a monopolar system where
with just such a device to limit penetration into a capacitive coupling device is placed on the
the dermis. By using the aforementioned spot surface and heat is delivered for a few ­seconds.
size arguments, one can exploit the properties of Simultaneously and just after the “pulse”, the
small spots to change the way particular wave- surface is cooled. The second is a bipolar sys-
lengths behave in the skin. For example, one can tem comprised of metal rails on the skin surface
tailor a 1064 nm laser to heat progressively larger where the current is alternated in a rapid manner
depths of skin by increasing the spot size. (300 kHz–1 MHz) between the superficial skin
1 Laser-Tissue Interactions 27

layers. Generally, in this configuration, the depth [99]. The theory predicts that once the selectively
of the heating is roughly ½ the distance between targeted chromophores are heated by the visible
the electrodes. In the third type of intervention, light, their impedance decreases and the subse-
an array of needle or pin electrodes is placed in quent RF energy will preferentially heat those tar-
the skin such that very focal heating zones are geted tissues (i.e. hair and vessels). A purported
created at predetermined depths. A final type advantage of the treatment is that lower optical
of RF heating is capacitive far field heating, energies can be used to selectively heat sub-sur-
where a system of electrodes delivers energy at face targets than if a light source were used alone
27.12 MHz to create apoptosis in fat. (thus enhancing epidermal preservation).
For monopolar radiofrequency, the delivery In microneedling fractional radiofrequency
electrode is in the hand piece and the return elec- devices, the needles become the delivery and return
trode is placed elsewhere on the patient’s body electrodes and the electric power and current is
whereas with bipolar radiofrequency, the deliv- divided among the needles. In this configuration,
ery and return electrodes are both incorporated the device fractionates the radiofrequency energy
into the hand piece. Therefore, with monopolar among several delivery and return ­electrodes. With
radiofrequency the area of heating is a column/ uninsulated needles as electrodes, the entire needle
cylinder extending from the epidermis towards conducts heat, and wounds are created along the
the subcutaneous tissue. The electrical energy is entire length of the needle. Insulated needles only
most concentrated near the tip of the delivery allow the tip of the needle to heat and therefore
electrode and decreases rapidly with distance, the epidermis is preserved. There are also devices
with the penetration depth about half the size of where the needles (or “pins”) are deployed very
the delivery electrode. However, the behavior of superficially (only down to 100–300 μm) where
the current as it passes through the body to the both fine lines and pigment can be reduced with
return electrode is somewhat unpredictable. multiple treatment sessions.
Monopolar skin rejuvenation systems create
large-volume heating. Electrical energy is distrib-
uted uniformly over the electrode surface through How RF Creates Dermal Heating
“capacitive coupling”. This type of coupling
reduces the natural accumulation of electrical Skin has inherent impedance, which is the resis-
energy at the electrode edge [100]. The first non-­ tance to electric current, and when an electric
ablative RF device (Therma Cool TC, Solta current meets resistance it generates heat in
Medical, Hayward, CA) uses cryogen spray cool- accordance with Joule’s law,
ing (CSC), where the spray is started before the
RF current. Interestingly, if an electric field is Q = I2Rt
induced perpendicular to the skin-fat interface, a
monopolar device can selectively heat large areas where Q is the heat generated in joules, I is the
of fat while sparing the skin and muscle [98]. electric current, R is the resistance and t is the
With bipolar radiofrequency, a U shaped area time of application. Ohm’s law is V = IR where V
of heating is created between the delivery and is the voltage, I is the electric current and R is the
return electrodes in the hand piece and thus the resistance. Ultimately, it is the local current dis-
current travels a fixed distance. The depth of the tribution, time, and resistance (impedance) that
“U” is limited to one half of the fixed distance determine the local heat generation.
between the electrodes. Therefore, the distribution One can envision local RF effects as P = GV2
of, as well as the location of the radiofrequency where P is the power loss in the tissue, G is the
current, is controlled and predictable within the local conductivity of the tissue, and V is the voltage
tissue. In one scenario, cooled bipolar electrodes drop across the target. If one examines Fig. 1.12,
are combined with a diode laser, halogen lamp, or the local heat generation can always be determined
intense pulsed light device. In this configuration, if one knows the microenvironment of the electrical
there is synergy between the two energy sources system. Oftentimes, we must simplify the a­ nalysis
Other documents randomly have
different content
of Aiken for twenty years, and at last the fact leaked out and the
people became frantic and the board of health, very much excited,
attempted to confine her ill a loathsome pest house situated outside
of the city limits, where only some negroes had been quarantined
with small pox, and Mr. Sawyer, assisted only by Mr. G. W. Croft, a
very young attorney just admitted to the bar, enjoined' the board.
The case was strenuously fought but he won out in the Supreme
Court and saved his client, who was also blind. Mr. Sawyer served in
the local militia and was also an aide to Governor Wade Hampton.
Though a young man at the time, he took part in the exciting
campaign to restore white government during the '70s, and was
elected in 1S76 a member of the Legislature, at the time Wade
Hampton was elected governor. He was again chosen in 1880. For a
time he served as a director of the State Penitentiary. In 18S8 he
was cliosen presidential elector and cast his vote for Grover
Cleveland. For many years past Air. Sawyer has served as trustee of
the State College at CJrangeburg and has held many minor offices.
Politically he is a democrat with strong prohibition leanings, and has
always believed in honesty regardless of partj'. He has taken a stand
against universal suffrage, and in view of recent conditions is
opposed to immigration from foreign countries except from England,
France, Holland and Belgium. Mr. Sawyer has held every ofl'ice in his
Masonic lodge from steward, except secretary and treasurer, has
been district deputy, up to grand master of the state from December,
1894, to December, 1S96. He is also a Knight of Pythias. A Unitarian
in religious belief, he belongs to no church, since the nearest
organization of Unitarians is at Charleston. Mr. Sawyer has never
married. That has not been from a high regard of the marriage tie
and an exalted opinion of woman, but rather due to ill health. As
noted above, Mr. Saw3'er took an active part in the campaign of
1S76, helping rouse the people of his part of Aiken County to their
proper duties. He was nominated for the Legi5,lature and elected,
and in the famous legislative assembly that followed he voted
against evacuating the State House and camped in the hall of the
House four days and nights without sleep or any food e.xcept what
could be smuggled in. He stood by and supported Governor
Hampton throughout his administration. Everj-thing done in the
"Wallace House" had to be decided in the caucus of both houses,
and he was appointed one of the secretaries and never missed a
caucus. He called the roll hundreds of times, and worked until long
after midnight, and then would be in his seat next morning at the
beginning of the day's duties. --\11 that time he was a sufferer from
chronic appendicitis and frequently had to be lifted from his chair. In
later years he was for several terms county chairman of tlie
democratic party of Aiken and presided over county judicial and
congressional conventions. He was thoroughly opposed to Tillman,
and when the Tillman faction became dominant he was deposed
from authority. }vlr. Sawyer was a member of the national
convention that met in St. Louis in 1904, where he voted for Parker,
but has always been opposed to Bryanism, but being a democrat, he
always supported the nominees. In all his political dealings he has
been straightforward and outspoken, and this alone has stood in the
way of political advancement corresponding with his abilities. As
early as 1880, while he was a member of the Legislature, he
proposed that the constitution should be amended to require every
voter to possess the qualification of being able to read and write,
with an additional property qualification, and allowing two or three
years for the electorate to adjust themselves to such conditions.
These were the very provisions carried out by the Tillman
constitutional convention of 1895. When the captain of the National
Guard company had failed, Mr. Saw>'er took it upon himself to raise
a company in 189S, and succeeded, bj' deserving the confidence and
esteem of his men, in making his company second to none in the
regiment. But politics played a part and the regiment was ordered
home and mustered out on the loth day of
 56 HISTORY OF SOUTH CAROLINA November, 1898. Only
five of Captain Sawyer's men signed the petition, or "round robin,"
gotten up by the disaffected for discharge, while all the otiiers
present drew up another jietition without Captain Sawyer's
knowledge and sent it to the secretary of war praying thai the
company be transferred and kept in the service. Captain Sawyer has
always regarded that as the best and highest compliment ever, paid
him. The company of which he was captain was Company L of the
First South Carolina \'olunteers, commanded by Col. Joseph .Mston,
who died in the service. In iSgq he was appointed by President
McKinloy one of two captains from South Carolina and was assigned
to the Thirty- I^ighth Infantry, commanded by Col. George S.
Anderson. Under the plan of organization of that army all the field
officers above captain, and some of the captains, were regulars, and
all but one in this regiment were West Pointers, so that the
conditions were in all respects those of the regular establishment,
and the army was very efficient, so far as the officers and men could
make it so, but Congress was derelict in its duly and tlie soldiers in
the Philippines suffered hardships seldom exceeded. Captain Sawyer
was in the Philippine insurrection from 1899 to June 30, 1901,
during which time he was in many engagements and was
recommended by his commanding officers for brevet for his
meritorious services. He acted as major, commanded a number of
expeditions; and was in command of a fort for two months and
commanded a post and large military district for four months, served
as provost judge and in his district he organized civil government,
established schools and taught the Filipinos the meaning of liberty.
Though he turned over his command of the post and left his
headquarters, at midnight a large concourse of natives came to see
him off, expressed every degree of affection and grief at his
departure. Through his experience and intimate contact with the
Filipinos Captain Sawyer wrote a letter to Senator McLaurin to
oppose the giving up of the Philippine?, since the islands and the
people needed a long period of education and training before they
were ready for self-government. This letter got into public hands and
w'as published, and Roosevelt in his Baltimore speecli in 191^0 used
it as an argument of particular value as coming from a democrat.
Then some of the people of South Carolina abused Captain Sawyer
and declared he was a republican, and caused his defeat for state
senator in 1902. At the time of the World war Captain Sawyer was
too old for service, but gave nearly all his time to local work without
a cent of remuneration. His law partner, Herbert E. Gyles, was made
food administrator and at the time of the second draft became
naturalization examiner. The firm's stenographer was taken, and in
the endeavor to handle the business of the firm and other duties
Captain Sawyer was under a strain from which today he is suffering
almost physical incapacity. In April, 1917, he organized a patriotic
league in Aiken. Many of the qualified leaders of the community
were not allowing their voice to be heard on one side or the other,
but Captain Sawyer appointed ittee to interview every man and
explain that only two kinds of people could exist in such a national
crisis, and each side must show his true colors. Through Captain
Sawyer was held the great patriotic parade of May I, 1917, and after
that rousing demonstration men who hitherto had been quiet
assumed the conventional leadership and, as is the way with popular
opinion, much of tlie credit for local war work goes to them. Such
arc some of the more notable facts in the lifetime of a man who will
receive greater honor and esteem in after years than in his own
immediate generation. EuGiXE MvKKr.i.i. Pkkpi.ks. One of the worthy
native sons of HamiUon County, South Carolina, is Eugene M.
Peeplcs, the popular and efficient clerk of courts of Hampton County,
who is easily the peer of any of his fellows in the qualities that
constitute correct manhood and good citizenship. He is what he is
from natural endowment and self-culture, having attained his jircsent
standing solely throu.gh the impelling force of his own strong
nature. Ko possesses not only those pow-ers that render men
cfiicient in the material affairs of the community, but also the gentler
traits that mark genial and helpful social intercourse. In his daily
affairs he manifests a generous regard for his fellows, and he
therefore commands the good will of the people of his community,
where he has spent his entire life. Eugene ^furrell Peeples was born
in Hampton County, South Carolina, on October 10, 1871, and is the
son of A. McB, and Carrie Julia (Murrell) Peeples. The father, who
was also a native of Hampton County, was a man of much local
pronii.nence and served as treasurer of the old Beaufort District. He
followed the mercantile business and was the first settler at
Varnville. He erected the raHroad depot at that place and was
appointed the first railroad agent there. In 1883 he retired from
active business on account of the failure of his eyesight. During the
Civil war he was an oflicer in the Confederate army and was severely
wounded at the battle of Pocateligo. His father, W. W. Peeples, was a
farmer all his life and lived to the advanced age of ninety-three
years. He was born in Cedar Grove, Hampton County, and was of
English descent. The subject's mother was a native of Charleston,
South Carolina, and the daughter of Walter Murrell, who was a
soldier in the Confederate army during the Civil war and was killed in
the service. The subject is the eldest of the nine children born to his
parents. Eugene M. Peeples is indebted to the common schools for
his educational training, though he has all through his life been a
close reader, a deep thinker and keen observer of men and events,
so that today he is considered a well informed man on general
topics. At the age of sixteen years he, was appointed station agent
at Varnville, also acting as express agent and ojicrator. He held this
position for eight years, wheii he was transferred to Hampton in
1894, and assigned to similar duties. After nine years faithful service
in that position M^r. Peeples was appointed postmaster of Hampton,
filling the position for seven years to the entire satisfaction of the
postofl'ice department and the patrons of the office. During this
period he was also engaged
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r^yuiaiwv^ffW't-' »~jti."'!OT-a-»j«n fp/jiyi^Kl'g^w^iig''*

»y«lgj[| ; 'f< ^' / / / . /1( 4k'a^i>tfi»Mafe;
^^.^^^^-.^^^I^^^^^J^Z^^
 HISTOID' OK SOUTH CAl^OJJXA 57 ill the mercantile
business, in wliicli lie demonstrcited business abilities of higli order.
In 191 1 Mr. Feepk-s sobl his business interests and resigned the
postmastership in order to make the raee. for the otlice of clerk of
courts at Hampton County. The election in 1912 was in his favor by a
very decided majority, he receiving 1,190 votes out of a total vote of
l,.S95, which was certainly a very marked and gratifying testimonial
to his popularity and the confidence of the people in liiin. At the end
of his first term of four 3 cars, lie was being a fornii:r c!- ':. \ i: •,: !
over 200. Mr. I' ' duties of his •• manner that nD u-nl. ,,; , ,, knou-
him. md good will of all who selected, his opponent heat by a
majority of barged the responsible in so satisfactory a jism have
been heard. even in the heat of a political campaign. Mr. Peeples has
for many years taken a very active interest in .Sunday school work,
and has done some very effective work in stimulating and
maintaining popular interest in the cause, lie has been president of
the Ilaptist Sunday School convention for the past eleven years, and
of the Hampton County Interdenominational Sunday School
Association, which he organized seven years ago. For the • past four
years Hampton County has retained the "Gold Star Banner," in this
work, being the first county in the state to reach the "gold star"
standard in Sunday school work. In connection with this work Mr.
Peeples has done a great deal of speaking all over the county and he
also "stumped" the county in the interest of the prohibition
movement. He served as chairman of the local war board and was
chairman of the district Red Cross drive during the days of the World
war activities, in which Hampton County made such a splendid
record, going way "over the'top." He was also chairman of the Young
Men's Christian Association drive, which was equally successful.
However, as a result of his long-continued activities along these
lines, with little or m rest, his health broke down and he was
compelled to go to the mountains for a while to recuperate. Mr.
Peeples is the only licensed embalraer in this section of the countrv
and does a general undertaking business, covering a wide radius of
the surrounding territor}', his place of business being at Hampton.
He is a m.cmber of the board of trustees of Coker College at
Hartsville. Mr. Peeples was married to Emma Johns, who was born in
Colleton County. South Carolina, the daughter of Jasper I. and
Rebecca E. (Folk) Johns. To their union have been born three
children, ."Mine, nineteen years old, Eugene M., seventeen years old,
and Earl F., eleven years old. Mr. Peeples is a member of the .Ancient
Free and Accepted Alasons, the Knights of Pythias and the Junior
Order of United .\merican ilechanics, and has held offices in the two
first named organizations. He has been successful in business,
faithful as a public ofl'icial, respected in social life and as a neighbor
he has discharged his duties in a manner becoming a liberal-minded,
intelligent citizen of a state where the essential qualities of manhood
have ever been duly recognized and prized at their true value. 'His
chief characteristics seem to be keenness of perception, a tireless
energy, honesty of purpose and motive and every-day common
sense, and because of these attributes and his genial disposition he
has Er.w.\i
 58 HISTORY OF SOUTH CAROLINA for membership in llie
Volunteer Medical Service of which organization be is still a member.
Fraternally he is a Mason and Odd Fellow, and also belongs to the
Red Men, the Knights of Pythias and the Order of Pocahontas.
During the years he has been in practice Doctor Meldau has jiroven
himself a man worthy of the highest consideration from the several
communities in which he has resided, and his professional success is
well deserved, as it is the logical results of careful training and
natural ability. Now at the age of sixty-two he is still actively
engaged in the practice of his profession, having made friends of the
entire population of McClelianville and tlio surrounding coimtry. His
religious conviction is with the Missionarv Baptists, but there being
no church of this denomination at McClelianville he still retains his
church connection at the First Church of Newberry. ■ Lkland Moore,
president of the Leland Moore Paint and Oil Company, one of the
biggest industries of its kind in the South, has been in this line of
business, beginning as an employe, for over thirty-nine years. He
was born in Spartanburg, South Carolina, January S, 1863, and is a
niember of a prominent family of the state. His father was J. O. A.
Aloore, a native of South Carolina, and a member of the
Constitutional Convention of the state. His grandfather was Rev.
George \V. Moore, a minister of the Methodist Episcopal Church and
a native of Charleston, who died about 1865. Mr. Moore's mother
was Eliza Hibbin Leland, also a native of South Carolina and
daughter of James Hibbin Leland, who was a son of Rev. A. W.
Leland. Rev. A. W. Leland was a minister of the Presbj-terian Church
and at one time pastor of tlie old Scotch Presbyterian Church at
Charleston when it was built. He also served as president of the
Presbyterian Seminary at Columbia. Leland Moore was third in a
family of seven children. He lived in !Marion County until he was si.x
j'cars of age, when his parents came to Charleston and he fmished
his education in the local public schools. He spent one year at sea
and followed various otlier occupations until 18S1, when he entered
the paint and oil business of William E. Holmes as an employe, and
in 18S6 he was admitted to partnership. In 1902 he severed his
connection with this firm and organized the Leland Aloore Paint and
Oil Company, of which he is president and treasurer. Under capable
and able management the business has steadily increased until
today the firm is widely known both as manufacturers of paint, as
well as wholesale distributors of paints, oils and kindred products. Li
1914 Mr. Moore was elected democratic county chairman, and in that
capacity he did mucli to reform and improve election methods in the
city and state and eliminate some of the evil influences from local
politics. Among the most important of these reforms was the
adoption of the Australian ballot system, and for this he is deserving
of nmch credit, since its use in the state today is the direct result of
earnest and continued effort on his part. He made a thorough and
careful study of this system and practically unaided and alone made
the early fight for its adoption. Getting copies of the ballot law, as
adopted and used in Massachusetts, New York and other slates, he
took the best from each and formulating a measure containing such
modifications and additions as were required to best meet the
conditions prevalent in South Carolina, he went before the
Legislature and sought the enactment of the necessary legislation to
make the measure effective. He was finally granted permission to
put tlie system into operation in Charleston County. There the great
benefits of this secret form of ballot were quickly demonstrated, with
the result that it was adopted by the Legislature as the only oflicial
system for use in the state primary elections, and thus it may
trutlifully be said that Mr. Moore is the fatlicr of this great reform in
South Carolina. He is president of the Young Men's Christian
Association. During the war with Germany he was^ district fuel
director for Charleston, and was chairman of the Registration Board
in 1917. He is one of the prominent laymen of the Methodist
Episcopal Church, South, being chairm.an of the Board of Stewards
of Trinity Church and a director for the South Carolina Conference in
the Centenary Missionary campaign. He is vice chairman of the
Board of Public Works of Charleston and a director of the Chamber
of Commerce. Is a director of the Charleston Museum, and a director
of the Commercial National Bank. He is a member of the South
Carolina Society and in the Masonic order is a member of Orange
Lodge No. 14. In 1885 he married Miss Lillian Alston Weber,
daughter of Rev. S. A. Weber. Her father is the oldest minister of the
South Carolina Conference in the Methodist Episcopal Church, South.
They had two daughters, Elizabeth, who died in infancy, and Dorothv
Alston. John Rich.'ird Parker has expended his forceful busmess
enterprise not only on his plantation and mines, but as a
constructive force in the general upbuilding of this section of Aiken
County. He is an especial friend of a modern public school system
and has been the leader and instrument in giving this county two of
its fine and most modern schools. Mr. Parker, who has a prominent
part in the kaolin mining industry of South Carolina, was born at
Richmond, Virginia, son of L. J. and Elizabeth (Odom) Parker. His
mother was twice married. Her first husliand was Colonel Lee, a
brother of Gen. Robert E. Lee. After his death she became the wife
of L. J. Parker. The latter was a Virginian and served in the
Confederate army with Lee in Northern Virginia. In 1883 he
established his home at Charleston, South Carolina, and died in
March, i9;o. John R_ichard Parker spent some of his early years in
Charleston. As a very young man he became a locomotive engineer,
and for about five years piloted an engine on the Charleston and
Western Carolina Railroad between Charleston and Augusta. . During
that time his home was at Edgefield. Mr. Parker has been a resident
of Aiken County since about 18S6. His home is one mile south of
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 HISTORY OF SOUTH CAROl.INA 59 Langley, on the National
Hislnvay. While he owns niid gives much attention to the
management of a hue farm there, liis principal business is kaolin
mining, an industry in wliich he has been active for a quarter of a
centurj-. His kaolin beds are on the Soutlicrn Railway about two
miles from W'arrenville and Graniteville. The industry is conducted as
the J. R. Parker Kaolin Works. This plant produces about 150 tons of
kaolin per week. ^lost of it is sliipped to paper manufacturers in the
North. Kaolin, it might be explained, is one of the essentials in tlic
manufacture of wood pulp paper, and tlie demand for the material
was never greater tlian at present on account of the mounting high
cost of neus print paper. Kaolin i> also used in the aluminum
industry, in the manufacture of tile and is an ingredient in rlie
manufacture of other commodities. The South Carolina kaolin has a
distinct superiority on account of the fact it requires no refining. It is
shipped ready for use direct from the chalk beds to the factory. For
fully twenty years ^Ir. Parker has given his influence, time and
means to the promotion of a worthy and adequate school fystem at
Langley and vicinity. He is president of tlie board of trustees of
Langley School District No. 29. Langley now has one of the finest
school buildings in the county, largely as a result of Mr. Parker's
effective leadersliip. His district also includes the Bath community,
and in the fall of 1919 he realized a distinct satisfaction when his
efforts resulted in the voting of appropriate ta.xation to provide for a
new school building to cost about $30,000. This school will be
particularly available to the people in the vicinity of Aiken Mills. Mr.
Parker was treasurer of the Aiken County Red Cross organization and
was a personal worker in other patriotic causes. He married Miss
Emma Foss, of Hepsibah, Georgia. She was born in the West Indies
of English parentage. Mr. and Mrs. Parker have .eight children : Their
son, John R., Jr., entered the Officers' Training Camp at Fort
Oglethorpe and went overseas as a member of the Fourth Division.
He was in all the fighting at the front from July to November, 1918,
and while in France was promoted to the rank of captain. William J.
Coxdon. The self-made man has every right to be proud of what he
has accomplished and his rising above conditions and placing himself
in better environments than those he had at the beginning of his
career. No man rises in this manner without hard and constant work,
but his rewards are abundant, and his honors many, and he de-
serves them all. William J. Condon, president of the large wholesale
and retail bakery which bears his name, is one of the prosperous
business men of Charleston who owes all he now possesses to his
industry, foresight and ability to grasp opportunities as they were
presented to him. \Villiam J. Condon is a twin brotlier of James F.
Condon, one of the leading merchants of the city, and these bovs
were born at Charleston on August 28, 1857. Their father, William
Condon, having come to the United States from his native Tipperarj-,
Ireland, left New York City, where he landed, after a short stav, and
came to South Carolina, and here was married to Fannie Scannell,
then visiting her brother, both of them also being natives of Ireland,
although they hailed from Cork. William Condon settled down to
work at his trade of merchant tailoring, and after the birth of his
twin sons planned a long and useful life to be spent in affording
them advantages denied hirii, but conditions aros^ which made his
plans void and took him from his family in 1S67, when he was only
forty-nine years of age, as the result of the service he gave the
section of his adopted country as a private in the Confederate arm\'.
The good mother, left widowed, did the best she could for her sons,
and lived to see them both prosperous, as she was eighty-two vears
of age when she passed away in 1S94. As mere lads the brothers
attended the public schools of Charleston, but when eleven years of
age started out, bravely determined to fight their battles, as had
their father the ones of the "Lost Cause," bravely and without
complaint. William J. Condon worked at different jobs assisting brick
masons and other laborers, and finallv in 1870 commenced to learn
the trade of a baker. This was a fortunate move, for in this line of
work he found congenial labor and a field for operations_ of his own.
After giving O. G. Margenhoff a faithful service, during that period
learning the details of the business, William J. Condon started m
l8vS5 a very small bakerv of his own, his sole capital being $500. In
spite of the fact of such small begmnings. so skillful had he become
and so impressed was he of the necessity for giving his customers
first class articles that it was not long before he had more than he
could handle in his small quarters and had to enlarge. Finally, in 191
1, his business had assumed such proportions that he decided to
incorporate it. taking into it at that time his two elder sons, the other
two coming into the company later on. .\bout seventyfive persons
are employed in the bakery, and in addition to the extensive
wholesale trade a retail department is maintained and is patronized
by careful buyers who appreciate the privilege of obtaining
dependable goods at prices as low as is consistent with their quality.
Mr. Condon is vice president of the Citizens liank, and president of
the Master Bakers' Association. Like his brother he belongs to the
Knights of Columbus, Catholic Knights of America, Woodmen of the
World. He is also a member of the Chamber of Commerce, and the
Fraternal Aid Union and is the vice president of the .Madin Motor &
Tire Company and a director of the Francis Marion Hotel, also of the
Camden Coke Company of which he is president and treasurer and is
president of the Quaker Realty & Investment Company. In 1880
William J. Condon was married to Eleanor F. Mooney, born at
Cliarleston. Mr. and Mrs. Condon have seven children, as follows :
William J., Henry G., James P., Frank E., all of whom are in business
with him; Marie, who is the wife of T. E. Powers, of Savannah,
Georgia; Ruth, who is the wife of Francis E. Conway, of Charleston;
and Ethel, who is at home.
 60 HISTORY OF SOUTJl CAROLINA KopERT FosTF.R MoRKis
for years lias bocii one of tlie most substantial citizens of the old
community of Willington, formerly in Abbeville County and now in
McCormick County. The old home place of the Morris family is five
miles from the town of Willington, and was included in that territory
taken to form the County of McCormick in 1916. Robert Foster Morris
was born there in i860, a son of James H. and Elizabeth (McCaslan)
Morris. He is of English ancestry tiirough his father, while his mother
was of Scotch descent. James H. Morris was a soldier in Hampton's
Legion, and was killed in the battle of Trevillian Station in Virginia in
1S64. Robert Foster Morris was a small child when his father lost his
life, and he grew up on the old homestead. One of the famous
schools of his day was the old Clear Spring Academj", not far from
his home. He finished his education there. He has always been a
farmer, but for the past twenty years he has also engaged in the
mercantile business at Willington, his farm adjoining that town.
Since 1906 he has also served as mayor of Willington. Mr. Morris is
an elder in the Presbyterian Church and IS a member of the Masonic
Order. During recent years Mr. Morris has acquired valuable and
extensive interests in the great oil fields of Texas. The principal
center of his investments is Clarendon on the edge of the Texas
Panhandle. Mr. Morris married Mary Elizabeth Cowan. They are the
parents of eiglit children, seven daughters and one son. The only
son is Lieut. James J. Morris, who entered the Oiticers' Training
Camp at Camp Sevier and Camp Gordon, was on duty throughout
the war, and since being mustered out has been in business with his
father. Alfred O. H.^lsey, president of the HaJscy Lumber Company
of Charleston, one of the leading concerns of its kind in the city,
belongs to one of the pioneer families of this country,
representatives of the Halsey family having come to the American
Colonies in 1640, locating at Southampton, Long Island, New York,
their original home being England. There the family remained until
Elisha L. Halsey, born on Long Island in 1800, left for the South and
came to Soutli Carolina. His son, Edwin L. Halsey, was born at
Charleston, was reared in the city and during the war between the
states served gallantly as a captain in the Confederate army. Upon
his return to civil life he embarked in a lumber business, and
conducted it until his death, October 12, 1903. He was married to
Maria T. Olney, a daughter of George W. Olney. The Olney family
also originated in England, from whence representatives of it came
to America, locating at Providence, Rhode Island, and later in South
Carolina. George \V. Olney died at Charleston. His father, Capt.
Stephen Olney, commanded a company of troops during the
American Revolution. Edwin L. Halsey and his wife had eleven
children born to them, of whom Alfred O. ILilsev is the second in
order of birth. Growing up at Charleston, Alfred O. Halsey first
attended its grammar and high schools, and then the University of
Georgia, from which he was graduated in 1S93. Upon his return to
Charleston, Mr. Halsey went into business with his father, and after
the latter's death the business was rc-organized in 1904 as the
Halsey Lumber Company, with liis son Alfred O. Halsey as president,
and he is still at the head of the concern. This is the oldest lumber
company of Charleston, and also one of the most reliable, and the
same honorable standards raised by the father are maintained under
the leadership of the son. On November 26, 1903, Alfred O. Halsey
was married to Lucile Bonuoitt, of Darlington, South Carolina. Mr.
and Mrs. Halsey have one daughter and two sons, namely: Lucile,
Alfred O., Jr.. and Marion B. Mr. Halsey belongs to the New England
Society and the South Carolina Society, licing active in both
organizations. Grace Ejjiscopal Church holds his membership and
receives his benefactions. He is a man possessed of sound qualities,
is genuine, broad and public spirited, and his influence upon his
comm.unity has always had a constructive trend. John ]\L\rsh.\ll. To
the true American the possession of ancestors who bore a part in
the founding and 'development of this government is the highest
possible honor. A man who can trace his descent from men whose
names are enrolled on the pages of his country's history has a
heritage no money can buy or political prestige supply. It has been
said that the southerner thinks more of his forebears than those of
the more northern states, but no one could be insensible to the
honor of belonging to the family which has as an immediate
ancestor the illustrious Chief Justice John Marshall, whose name is
accorded equal rank with that of Washington and Jefferson. One of
the descendants of this distinguished American bears his name and
is a resident of Charleston, John Marshall, his great-grandson. John
Marshall, of Charleston, was born in Fauquier County, Virginia,
January 10, 1865, and he also has the honor of tracing back to
another important factor in the history of the United States as a
great-grandfather, Robert Morris. Carefully educated, John ^larshall
first turned his attention toward scliolastic work, being professor of
French and German at WofTord College from 1886 to 1890, but the
confinement of the schoolroom irked him and he sought broader
fields of expression in the journalistic arena, forming connections
with the News and Courier of Charleston, first as reportorial writer,
then as city editor. His facile pen and fearless expression of tlie
policies of his paper caused him to be given charge of the editorial
page, and later he was made actijig managing editor, he continuing
with this newspaper from 1892 until 1906. Once more he sought a
change in occupation and established himself in business as a stock
and bond broker. His wide acquaintance and thorougli knowledge of
affairs, combined with excellent judgment and a reputation for
sterling honesty in every respect, brought him a large patronage of
those who seek sound and reliable investments with a concern in
which they can place implicit trust. During his life at Charleston Mr.
Marshall has become one of the well known men in politics, and not
only has he
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