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Laserscope Aura
Laser Treatment of Facial Veins and Vascular
Lesions
The KTP laser is very effective at treating veins. The
laser emits a powerful light that is well absorbed by the color in the
veins.
As the light is absorbed it is turned into heat and the
veins are gone. The flash of light is so short that the heat does not
have time to spread into your skin, and because there are no injections
or scalpels scarring is most unlikely.
Facial Spider Veins or Telangiectasia
These are one of the most common facial skin conditions
for which patients seek treatment. These unsightly dilated blood vessels
are seen almost exclusively in patients with fair skin, and are often
associated with chronic sun exposure, rosacea, overuse of cortisone
creams and certain autoimmune diseases, and occasionally they may be
hereditary. In many cases, the exact cause is unknown. Contrary to
popular opinion, facial telangiectasia are not associated with alcohol
abuse.
Unlike leg veins, which are induced and aggravated by
gravity, facial telangiectasia are usually capillaries or small arteries
(arterioles) in the papillary dermis with weakened elastic fibers in
their walls which allow them to dilate and become visible, and despite
their common name, they are not true "veins". They can be
classified according to their appearance as linear, arborizing
(branching), spider, or punctate telangiectasia. The linear and
arborizing type occur most commonly around the nose, and the spider type
are most common on the cheeks.
Telangiectasia-linear (left), arborizing (center
left), punctate (center right), spider (right)
Background:
Before medical lasers were developed, facial
telangiectasia were usually treated with pinpoint electrocauterization
("electric needle"). Besides being uncomfortable,
cauterization often caused pinpoint scarring and discoloration,
especially in the thick, oily facial skin areas where telangiectasia
commonly occur. In the late 1970's and early 1980's, the continous wave
(CW) CO2 laser was used, although results were little better than with
electrocautery. The Argon Laser's blue-green light is effective for
superficial vessels, but its shallow penetration and non-specific
thermal effect limits its use on deeper vessels and dark skinned
patients. In the late 1980's the Pulsed Dye Laser, emitting short pulses
of yellow light was developed, and although it's effective, its short
pulse duration (less than 1 millisecond) ruptures the telangiectasia,
causing purpura, or black and blue marks, which can take up to 2 weeks
to resolve. In the 90's the Copper Vapor Laser, Copper Bromide, and
Krypton lasers were also used to treat facial telangeictasia. Later, the
Frequency Doubled Q-Switched Nd:YAG laser, which is usually used to
treat certain tattoo colors, was noted to be effective, but the short
Q-Switched pulse also caused vessel rupture with purpura.
 
Arborizing nasal telangiectasia preoperative,
left, and 3 months postop single treatment with Argon Laser
In the last few years, the "long pulsed"
frequency doubled Nd:YAG laser (KTP Laser) has become the laser of
choice for the treatment of facial telangiectasia.
Treatment of Facial Telangiectasia:
Like most other lasers, the KTP laser makes use of the
principle of selective photothermolysis to coagulate abnormal blood
vessels while sparing the surrounding tissue. The KTP laser emits a
brilliant green light at 532nm, close to a major absorption peak of
hemoglobin in blood. The blood absorbs the laser energy more than the
surrounding tissue, and by selecting a pulse width less than the thermal
relaxation time of the blood vessel, the blood vessel can be selectively
coagulated without causing purpura or damaging the skin.
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No anesthesia is needed for treatment of facial
telangiectasia-the laser pulses feel like little "snaps",
and can be easily tolerated by most patients. In most cases a
transparent cooling gel is applied to the skin to increase comfort
and decrease superficial blistering. After the proper laser setting
are made, the individual vessels are "traced" with
individual laser pulses. If vessels are too small or to numerous to
trace, a scanner can be used to treat entire areas. In some cases,
the skin may be cooled with ice packs prior to treatment.
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In some cases, especially in larger, high flow
telangiectasia around the nose, there may be an improvement instead
of complete resolution. Occasionally, the telangiectasia may
at first appear worse than before treatment, and then disappear
within a few weeks or months. It is much safer to re-treat than
to run the risk of scarring... Anticipate a re-treatment about a
month after the initial treatment for best results.
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Because melanin in skin also absorbs green 532nm
light, darker skin can absorb some laser energy, and in some cases,
cause mild superficial blistering and crusting ("chicken
scratches"), which usually resolves in a few days. Temporary
redness and lightening of the skin can occur, especially with higher
fluences in darker skinned patients. Scarring is extremely rare with
the energy settings used on the face.
Telangiectasia of nose before (left), and 1 month
after one KTP laser treatment
 
Arborizing Telangiectasia of Nose, pre-treatment
(left), post-treatment (right)
Matted telangiectasia of nose before treatment
(left), after 2 KTP laser treatments with a scanning device (right)
Arborizing and matted telangiectasia of cheek,
pretreatment (left), and after 2 KTP laser treatments, the first for the
large individual vessels, the second with a scanning device for the
small, matted vessels (right).
Hemangiomas and Vascular Malformations: Hemangioma
is used as a generic term to describe an abnormal growth or
proliferation of blood vessels. More properly, the term hemangioma
refers to lesions not present at birth, that appear and proliferate at
some time after birth, and usually disappear, or involute. Growths
present at birth that remain unchanged or that grow slowly are more
properly referred to as a Vascular Malformation.
Hemangiomas occur in about 2-7% of newborns,
more commonly in females and multiple births. They present as whitish,
flat patches surrounded by dilated blood vessels, but enlarge over the
first year of life. Most hemangiomas will begin to regress by age 4,
eventually leaving a small, barely visible patch of slightly irregular
skin, although incomplete regression is common. In a very few cases,
these lesions may enlarge rapidly , become irritated and bleed, and even
affect vital structures. Occasionally they may be associated with
similar lesions inside the body, especially the larynx and trachea. Most
of these lesions require no treatment-more aggressive growths can be
treated with oral or injected cortisone, or even with Interferon. Laser
treatment of these lesions is controversial. Some authorities recommend
early treatment in infancy with the Pulsed Dye or KTP laser, which may
limit the growth and encourage early regression of these unsightly
lesions. Others reserve treatment for those lesions than have not begun
to regress spontaneously after age 3 or 4. In either case multiple
treatments are necessary.
Cherry Hemangioma (angioma) is the most common
of all the vascular malformations. These smooth red-to-purple   papules
will rarely grow larger than about 1/4 inch, and occur mostly on the
trunk in persons over 30. Their exact cause is unknown, but they can be
treated with a variety of methods, including the CO2, Argon, or KTP
lasers. Occasionally, they may mistaken for nodular melanoma-note the
large, dark cherry hemangioma on the right.
 Venous
Lake: Venous Lakes are most common on sun-exposed areas in older
individuals, especially on the vermilion of the lip and on the ears.
These smooth, easily compressible lesions are simply a dilated or
"varicose" vein. Because of their deep purple, almost black
color, they may be mistaken by patients for melanoma, and bleeding
following trauma or irritation may occur. Venous lakes are easily
treated by needle point electrocautery, or with the CO2, argon, or KTP
lasers.
Unilateral Telangiectasia Syndrome can either be
congenital or acquired; the acquired form often begins with increasing
blood levels of estrogen, such as with oral contraceptives or pregnancy.
Usually, the telangiectasia will occur on the face or neck, and follows
the distribution of an underlying nerve. These lesions can be treated
with the Pulsed Dye or KTP lasers.
Hereditary Hemorrhagic Telangiectasia:
Also known as Rendu-Weber-Osler Disease, this is an
inherited malformation of blood vessels. Small, flat or punctate
telangiectasias appear in childhood and gradually become more visible in
adulthood, mostly on the lips, tongue, nasal mucosa, and forearms,
although any area of the body may be involved. These telangiectasias are
delicate and can bleed easily, which at times may be severe and require
transfusion. Nosebleeds are especially common and severe in these
patients. Treatment is with electrocautery, argon, KTP or CO2 lasers.
Persistent nosebleeds may be treated with skin grafts to affected areas
inside the nose.
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