Lasers in surgery

Leonardo Longo
MD
Institute of Laser Medicine Bordo Pinti
Florence, Italy
School of Specialisation in General Surgery
Siena University
Italy

Since the breakthrough in laser development by Ted Maiman in 1960,(1) laser beams have been used in all surgical sectors of medicine, especially in minimally invasive surgery (see Table 1). Plastic surgery is the sector where the laser is most frequently used. Leon Goldman and Richard Gregory (1987) were among the first in the world to develop the technique of laser resurfacing for wrinkle removal. The use of two kinds of lasers was established for this procedure: the CO2 laser and the Erbium:YAG laser.

The aim of laser resurfacing is not to replace facelifting but to compliment the procedure for some specific areas of wrinkles (periocular, perilabial and perinasal). In these areas the surgical procedure could be either too excessive or insufficient to correct wrinkles. The choice of laser is made after establishing the diagnosis of wrinkles, photoageing, skin type and general condition of the patient.(2) The CO2, UPW  or Silk-Touch laser is preferable when a light tissue contraction of the areas is desired; when there is poor haemostasis; or the patient cannot tolerate adrenaline associated with the local anaesthetic agent. The CO2 laser – with fragmented and robotised pulses (Fraxel and similar methods) – increases safety of use for the inexpert operator, but this procedure has its limitations in cases of asperity of the skin surface. The Erbium:YAG laser is a better choice in all other cases. The same procedure is used for surgical cleansing of skin ulcers and decubitus.

Dyschromias, or pigmentary abnormalities, are the most common side-effect of laser resurfacing; however, in the majority of cases these are reactive by nature and clear in a few months, spontaneously or with topical bleaching agents.

Specific applications
All hyperpigmented lesions of the skin can be treated with lasers, independent of their cause. It is necessary to have many kinds of different lasers, to be able to choose the laser colour complementary to the lesion colour with appropriate energy density. The same principle is valid for tattoo removal. However, the patient should be informed that it is not always possible to achieve the complete removal of a tattoo. If the tattoo pigment has changed the cytoarchitecture of the dermis, the selective elimination of the pigment itself will not be able to reconstitute the dermal fibrous tissue to the same original shape. This could give rise to the so-called “post-intervention phantasm tattoo”, resulting in a more or less light dyschromia, dependent not upon the skill of the laser operator, but on the accuracy with which the tattoo ink was placed in the dermis.

The skin striae can be modified and improved, but only in rare cases do they totally disappear. The pulsed-dye laser can successfully change the colour of the striae, making them less noticeable, but these lasers do not succeed in completely eliminating them. In our experience, the only stretchmarks that disappear completely are the ones seen after pregnancy, if treated immediately postpartum, and those of adolescents, if treated immediately after their appearance.

Acne and post-traumatic scars have, on the contrary, demonstrated an unexpected course. In previous years we proposed to treat these lesions with CO2 CW lasers in defocused mode with sub-burn doses, or with nonsurgical lasers (904 nm diodes), with doses of over 8 J/2sqcm, inhibiting the fibroblast activity in vitro. The results have been variable, independent of the method used: functionally positive in 60%, but often negative from the aesthetic point of view.(3)

The aesthetic improvement of pigmented and hypertrophic scars seems to be obtainable with flashlamp pumped dye lasers.(4)

In respect to vascular ectasias,(5) facial telangiectases disappear almost in all case when the right parameters are used for the treatment. In almost all cases there are no side-effects and/or permanent complications.

Telangiectasias of lower limbs should be treated after an accurate clinical, laboratory and instrumental diagnosis, which can verify the nature of the condition. It is estimated that on average only 30% of all the telangiectasias for which patients seek a physician’s advice are treatable with lasers. In most other cases lasers are not as effective or are contraindicated. On the other hand, the 30% of telangiectasias treatable by laser therapy cannot be treated otherwise without the risk of permanent complications.(6)

Today, many varices of lower limbs are treatable with endovenous lasers, but only after selected diagnosis and always with surgical procedures.(3)

Laser hair removal
Laser hair removal is the latest manifestation of laser use in cosmetic medicine, but it still requires some well-defined parameters. Lasers cannot guarantee total and irreversible hair elimination, because this depends in part upon the kind of hair and the area of treatment. This needs time, from a minimum of six months to a few years. The new growth and maturation of hair slows after laser depilation. The main advantage of laser use is the ability to treat very large areas in a short time, with minimum inflammations and/or other side-effects, with very little or no pain at all before, during and after the treatment. There are no parallel studies that prove one system of laser or luminous beam superior to the others in terms of effectiveness. 

Conclusion
Lasers occupy an important place in modern medicine and surgery, and their use is destined to grow exponentially. There are some factors that limit the use of lasers, such as the high costs, the need for continuous training in the use of new technologies, the rapid depreciation of the machines, poor technical assistance, the lack of specialisation in laser biotechnology and the widespread confusion at mass-media level. Overscrupulous doctors, as well as well-educated patients, are inclined to distrust the latest miraculous technology they see on the television or in other media, even when it is endorsed by colleagues of ours who are unknown in science but have experience in the field. Nevertheless, the technology is very sound if used in the right way.

These conclusions are justified when the doctor is well trained in laser surgery, has a suitable laser machine for each clinical entity and uses them only after an accurate diagnosis has been made. A specialisation in any field of medicine does not give the necessary knowledge to use lasers, as laser technology evolves continuously.

Greater specialisation and training in this field by all users of lasers would help scientific progress enormously.

References

1. Maiman T. Stimulated optical radiation in ruby. Nature 1960;187:483-94.
2. Goldman MP, Fitzpatrick RE. Cutaneous laser surgery: the art and the science of selective phototermolysis. St Louis: Mosby; 1994.
3. Marangoni O, Longo L. Lasers in phlebology. Trieste: IALMS; 2007.
4. Alster T. Laser treatment of scars. In: Alster T, Apfelberg D, editors. Cosmetic laser surgery. Wilmington: Wiley-Liss Inc; 1996. p. 81-93.
5. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220(4596):524-7.
6. Corcos L, Longo L. Combined laser and sclerotherapy for telangiectases of the lower limbs. Phlebology 1989;4:51-3.