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Year : 2020  |  Volume : 28  |  Issue : 4  |  Page : 205-213

Dye laser and long-pulsed Nd: YAG laser treatment of vascular lesions: Clinical experience

Department of Plastic, Reconstructive and Aesthetic Surgery, Abant Izzet Baysal University, Gölköy, Bolu, Turkey

Date of Submission10-Jan-2020
Date of Acceptance13-Jan-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Metin Gorgu
Department of Plastic, Reconstructive and Aesthetic Surgery, Abant Izzet Baysal University, Golkoy, Bolu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_89_19

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Introduction: Hemangiomas and vascular malformations are common vascular lesions. Although various methods have been described in the treatment of vascular lesions, the place of lasers is very important. Today, dye laser and Nd: YAG lasers are most commonly used in the laser treatment of vascular lesions. Materials and Methods: A total of 137 patients treated with 585–600 nm flashlamp pulsed dye laser and 1064-nm long-pulsed Nd: YAG laser in three laser units were searched, and laser setups and the number of sessions used were evaluated. Evaluations were made by three plastic surgeons over photographs. According to the discoloration and decrease in height of the lesion, it was classified as 0%–25% (poor), 25–50 (average), 50–75 (good), and 75–100 (excellent). The age of the patients ranged from 2 months to 55 years. 53 port-wine stain, 18 telangiectasia, 8 cherry angioma, 12 spider angioma, 18 hemangioma, 8 venous lake, 11 intraoral hemangioma, and 9 other vascular lesions constituted the distribution of diagnoses between patients. Laser power used in dye laser treatments ranged between 7 and 19 J/cm2, the mean sequence was 6.4, and duration ranged between 1.5 and 20 msec. Nd:YAG l laser power ranged between 120 and 240 J/cm2, the mean sequence was 2.8, and duration ranged between 10 and 50 msec. Results: Seventy patients (51.1%) achieved excellent results, 32 patients (23.36%) achieved good results, 14 patients (10.21%) achieved average clearance, and 21 patients (15.33%) showed low or no removal of their lesion. High success was achieved with minimal complications. Conclusion: Today, dye laser and Nd: YAG lasers provide a satisfactory aesthetic result, low morbidity, and effective treatment for many vascular lesions in terms of patient comfort. In order to optimize results and reduce negative effects, it is necessary to master the properties of the laser and have sufficient knowledge of the interactions of the laser with tissue.

Keywords: Dye laser, hemangioma, Nd:YAG laser, port-wine stain, vascular lesion

How to cite this article:
Gokkaya A, Gorgu M. Dye laser and long-pulsed Nd: YAG laser treatment of vascular lesions: Clinical experience. Turk J Plast Surg 2020;28:205-13

How to cite this URL:
Gokkaya A, Gorgu M. Dye laser and long-pulsed Nd: YAG laser treatment of vascular lesions: Clinical experience. Turk J Plast Surg [serial online] 2020 [cited 2022 Oct 5];28:205-13. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/4/205/296478

  Introduction Top

Vascular lesions are varied; Mülliken and, more recently, ISSVA classification[1] are being used [Table 1]. Common vascular lesions include infantile and congenital hemangiomas, various vascular malformations (such as port-wine stain [PWS], arteriovenous malformations, and venous malformations), and angiofibromas.[2],[3] Cutaneous vascular anomalies are seen in 5%–10% of children and are the most common tumors of infancy,[4] and hemangiomas affect 10%–12% of children under 1 year of age.[5] PWSs are benign congenital vascular malformations which are not spontaneous involusive and their incidence range between 0.3% and 0.5%.[4] Nearly 20% of the vascular lesions may cause bleeding, pain, ulceration, and infection, and also depending on the location and growth pattern, they may cause visual obstruction, feeding, and breathing problems.[4] In addition, they cause cosmetic disfigurement, especially facial lesions and psychological problems in both the family and the patient.[4]
Table 1: ISSVA classification of vascular anomalies

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Because of the progressive properties of hemangiomas and malformations, their treatment options are different. Therefore, the differential diagnosis of hemangiomas and vascular malformations is significant. Infantile hemangiomas (IHs) occur in the first few weeks of life, but vascular malformations are present at birth even if they are not visible. IHs spontaneously regress over time, whereas vascular malformations never disappear and usually grow over time. Besides congenital hemangiomas, which started to develop intrauterinely and started regression with birth and resolved completely within a few months there are with normal developed and lifelong remaining hemangiomas.[6] These are almost always solitary lesions located in the head-and-neck region, histologically having glucose-transporter-1 negativity, which can be miscible with vascular malformations.[6]

Vascular lesions are generally considered insignificant tumors and do not require treatment except in a few special cases. They become aesthetic rather than medical problems and the psychological impact it creates on the family can sometimes be more prominent.

  Materials and Methods Top

A total of 137 patients (76 females and 61 males) were treated with 585-590-595-600 nm pulsed dye lasers (ScleroPLUS and Perfecta, Candela, USA) in two private clinics and 1064-nm long-pulsed Nd: YAG lasers (Epicare Duo, Lightage, USA) in the Department of Plastic Reconstructive and Aesthetic Surgery at Abant Izzet Baysal University [Figure 1]. The dose and number of sessions used were analyzed. The age of the patients ranged from 2 months to 55 years, and follow-up ranged from 1 year to 20 years. Fifty-three PWS, 18 telangiectasia, 8 cherry angioma, 12 spider angioma, 18 hemangioma, 8 venous lake, 11 intraoral hemangioma, and 9 other vascular lesions were evaluated. Laser spot used in the dye laser treatments ranged between 5 mm and 12 mm, laser power ranged between 7 and 19 J/cm2, the mean sequence was 6.4 (ranged between 1 and 12), and duration ranged between 1.5 and 20 msec. Nd: YAG laser spot size was 1.5 mm; the power ranged between 120 and 240 J/cm2, the mean sequence was 2.8, and duration ranged between 10 and 50 msec. The results were scored as 75%–100% as excellent, 75%–50% as good, 25%–50% as average, and 0%–25% as poor. Dye laser was mostly used for PWS and facial telangiectasia, and Nd:YAG laser was used for hemangioma, leg and trunk telangiectasias, and venous lake treatment [Table 2].
Figure 1: Laser application

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Table 2: Laser treatment results

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Epidermis was protected by applying cold air during laser treatments. EMLA cream (AstraZeneca PLC, England) was used before treatment in patients with low pain threshold. Session intervals ranged from 4 to 8 weeks. The minimum interval was 4 months between sessions but allowed to be longer when needed. Cold compresses and corticosteroid creams were used after the application and recommendations were made for sun protection.

  Results Top

Evaluations were made by three plastic surgeons over photographs. The evaluators were asked to classify the results as 0%–25% (poor), 25–50 (average), 50–75 (good), and 75–100 (excellent) depending on the discoloration and decrease in the height of the lesion. The sessions of some of the patients were in progress. Seventy-one patients (51.8%) achieved excellent clearance [Figure 2], 32 patients (23.3%) achieved good-moderate clearance [Figure 3], 13 patients (13.8%) achieved average clearance [Figure 4], and 21 patients (15.3%) had low or no removal of their lesion.
Figure 2: Complete clearance of face port-wine stain after multiple dye laser treatment

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Figure 3: Good clearance of neck port-wine stain after three sequences of dye laser treatment

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Figure 4: Average clearance of neck hemangioma after four sequences of Nd:YAG laser treatment

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Complications were scar, blistering, first-degree burn, hypopigmentation, and hyperpigmentation, but because most of them were transient, there were no enough records. One patient had permanent hypopigmentation [Figure 5], one patient had hypertrophic scarring [Figure 5], and one patient had atrophic scarring. Both of the patients with scars were Nd: YAG-treated patients.
Figure 5: Complication: Face hypertrophic scar after Nd:YAG, leg hypopigmentation after dye laser

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  Discussion Top

Lasers are more important in the treatment of permanent vascular malformations and a group of permanent or long-term hemangiomas. IH usually presents as a macular lesion in the postnatal period and draws a typical pattern, grows first, enters a stabilization period, and then undergoes spontaneous involution, leaving an atrophic scar behind.[7],[8] IHs are the proliferation of embryonal tumors that can originate from placenta tissue and are caused by excessive proliferation of endothelial cells, and their control is always challenging for all experts because of the heterogeneous behavior of their lesions, with approximately 20% of cases causing side effects and complications.[7],[9] Congenital hemangioma develops prenatally and is obvious at birth, may show different patterns of development after birth, may spontaneously involve (rapidly involuting congenital hemangioma), may be permanent (noninvoluting congenital hemangioma), may be intermediate form, and partially goes to involution (partially involuting congenital hemangioma).[1],[8] The psychology of both patients and their families is affected in patients with vascular birthmarks, and patients eagerly await the results of laser treatments.[10] Patient selection should be made after detailing the course of the lesions, different treatment options, possible outcomes, cost, multiple treatment requirements, and possible postoperative complications.[11] In the presence of active local infection and severe skin diseases, laser treatments should not be used, and in the presence of vitiligo, psoriasis, keloid, and keloidal tendencies, isotretinoin and noncompliant or unrealistic expectation lasers should be used selectively.[11]

Prevention and reduction of aesthetic and functional risks, pain, ulceration, treatment, and elimination of life-threatening risks are the main factors to be addressed in vascular lesions.[11] Unless associated with serious complications, vascular anomalies are usually benign disorders and are not life threatening.[12] Patients with vascular lesions should be carefully evaluated in order not to miss complex anomalies and syndromes.[12] Medical treatment of vascular lesions has topical, intralesional, and systemic options. Oral corticosteroids were the most important medical treatment option until 2008. Propranolol, which is a nonselective beta-blocker in the following period, has replaced steroids, with more effect, less complications, and an increase in usage every year.[2],[3],[4],[8],[12] Treatment options for vascular lesions include interferon, topical and/or intralesional steroids, vincristine, imiquimod, waiting for follow-up and involution, sclerotherapy, radiotherapy, plastic surgery, constraint treatment, photodynamic therapy, laser applications, and surgical resection. Endovascular treatment may also be performed in certain cases according to specific conditions.[2],[3],[4],[8] In vascular anomalies, sclerotherapy can be used safely and effectively in appropriate patients.[13] It has been reported that topical beta-blockers inhibit the growth of small, superficial hemangiomas and accelerate involution. Topical imiquimod and subcutaneous interferon are among other medical treatment options.[8] Ball et al. stated that Total Reflection Amplification of Spontaneous Emission of Radiation can be used effectively in vascular lesions and epilation.[14] Liu et al. reported the use of ultrasound-guided intralesional diode laser in congenital extratruncular venous malformations.[15] Surgical treatment has very limited indication in IHs. If the proliferative stage is not controlled by other methods, Surgery may be considered, if the proliferative stage is not controlled by other methods and involution cannot be waited because of complications such as bleeding, amblyopia, and astigmatism.[8] In general, surgical intervention will be needed some time for large scalp, forehead, nasal type, and auricular hemangiomas. There is no consensus for surgical decision and timing. In the treatment of vascular malformations with lasers even after multiple sessions, full clearance is not always achieved and sometimes relapse is encountered; rapamycin, imiquimod, and axitinib may be added to the treatment to obtain better results.[16] Dementieva and Jones found that the combination of systemic propranolol and 940 nm diode laser in the treatment of severe IHs was effective and reliable, and reported that they achieved a cosmetic-positive result.[5] Cheon et al. used flash lamp pulsed dye laser (FPDL) and timolol in combination, but did not see an extra benefit of timolol.[16] Asilian et al. reported that they achieved high efficacy, cost advantage, and short treatment time when the combination of FPDL and topical timolol was used in the treatment of IH.[7] Greveling et al. used FPDL, Er: YAG, and rapamycin (Rapamune® 0.1%) in various combinations in the treatment of PWS, and they did not see a positive effect of PWS blanching FPDL treatment.[17] Separate use and sometimes combined use of β-blocking drugs with laser has been reported, and further improvement in lesion size with β-blockers and laser combination has been reported to increase the effect of lasers in superficial and deep mixed IHs.[18] Lasers have an important role in the treatment of residual and refractory lesions during or after β-blocking therapy.[18]

The most important armature are lasers in the treatment of vascular lesions, especially the correction of cosmetic appearance. Lasers are an effective therapeutic tool for congenital and acquired vascular lesions; technological advances in laser technology reduced adverse effects and increased efficacy.[11] The use of lasers in vascular lesions has provided significant superiority to classical methods such as embolization, steroid treatment, cryosurgery, electrodesiccation, and sclerosing agent injection.[10] The laser treatment of vascular lesions is the most requested and performed cutaneous laser procedures and among the laser devices used in the treatment of IHs, the most commonly used is FPDL.[9],[11] Early laser treatment can prevent various complications due to the enlargement of the hemangioma and may provide psychological relief for pediatric patients and their parents.[9] FPDL is the most commonly used and highly successful laser in the treatment of vascular malformation with its hemoglobin specificity of wavelength (585–600 nm) and noninvasive technology.[11],[18],[19],[20],[21] It is known as a safe and effective treatment for dermatological lesions in which skin microvessels play a key role in the pathogenesis or development.[20] FPDL is considered the gold standard in the treatment of PWS, superficial hemangiomas, and telangiectasias.[4],[16],[19] In general, the number of treatment sessions ranged from 2 to 12 and sometimes more with 4–8-week intervals. In some cases, even after several sessions, the lesions may not completely disappear, so a realistic expectation and correct recommendations are very important.[11]

Nd:YAG laser (1064 nm) has the second choice for the treatment of vascular lesions. The Nd: YAG laser can be used with a small spot size (1.5–3 mm) as high-energy doses are required. Nd:YAG laser is used effectively in the deep component of hemangioma and leg telangiectasias. Because the wavelength of 1064 nm hemoglobin absorption coefficient is lower than that of the dye laser, high-energy doses are required, and it is more likely to cause heat damage to epidermis and dermis. Although diode laser is also used in vascular lesions, the reason for the high level of pain and its high affinity for melanin causes it to stay behind these two lasers. The copper vapor and copper bromide lasers (511 nm and 578 nm, respectively; the yellow light of 578 nm wavelength is thought to be effective in acne, rosacea, hemotelangiosis, freckles, liverspots, warts, and some vascular lesions),[22] KTP laser (potassium titanyl phosphate, 532 nm), krypton laser (568 nm), argon laser (514 nm), alexandrite laser (755 nm), diode laser (800–810 nm), and intense pulsed light (IPL) (nonlaser, 500–1200 nm) are the other vascular lasers [Table 3]. Abukawa et al. used KTP laser in the treatment of oral and perioral vascular lesions intralesionally.[23] The most common laser that is used intralesionally is Nd:YAG laser.[18]
Table 3: Vascular lasers

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The preference of the laser to be used is determined by the characteristics of the lesion (the thickness of the vessels, hypertrophy, and the depth attained) and the variables of the laser. Skin properties, skin type, and laser variables are evaluated considering the characteristics of the lesion. It is accepted that there will be no tissue damage by laser beam when the pulse duration is below the thermal relaxation time (TRT). For superficially located, especially telangiectatic lesions, short-wavelength lasers (e.g. 532 nm and 595 nm) are more effective. Longer wavelengths (800 nm and 1064 nm) should be preferred for deeply located telangiectatic lesions. Our priority when choosing wavelength is based on the absorption coefficient, but will not be effective if it does not reach the target. For an effective and uncomplicated treatment, the laser must generate the therapeutic heat in the lesion and deliver the energy amount (J/cm2) with pulse width (millisecond) that does not conflict with the principles of TRT. There is no universally accepted protocol for the treatment of hemangiomas and vascular malformations.[24] Professionalism is important in the use of lasers. Doctors should know the properties of the laser well and should evaluate the required energy correctly, should use a sufficient number of pulses, and should adjust the session intervals according to the condition of the skin.[10]

With noninvasive lasers, we can treat various vascular lesions such as PWS, hemangioma, telangectasis (facial leg and trunk), rosacea, spider angioma, pyogenic granuloma (PG), venous lake (VL), and different lesions such as keloid, hypertrophic scar, and wart.[11] In our practice, for treatment of PWS lesions only FPDL was used and for treatment of hemangioma with deeper components, venous lakes in the lips and intraoral locations, and leg telangiectasias Nd:YAG laser was used. In face and trunk telangectasis, various angiomas, superficial hemangiomas both of the lasers have been used depending on the availability. The standard laser for PWS is FPDL; other treatment options and other lasers should be considered only if the lesion is resistant to FPDL. Different applications of laser and combinations with drugs can be considered in resistant lesions. Jia et al. stressed the importance of multiple laser pulses to increase blood vessel photocoagulation to improve the therapeutic efficacy of the laser for PWS.[25] When single laser pulse is inadequate in erasing the lesion completely, a better performance can be obtained by using a lower dose of multiple laser pulses.[25] Klapman et al. reported that they applied pressure to skin with glass in the treatment of thick PWS and venous malformations with 595-nm FPDL; reducing the thickness of the lesion may allow the laser beam to reach deeper.[26] They pointed out that while using 30 ms pulse duration with a power of 7.5–18 J/cm2 and different diametered spots, pain was more intense and reported that blistering may occur if adequate cooling is not present.[26] In laser applications, various methods are applied to increase the effectiveness of the laser such as increasing the oxygenation of the lesion to retain more heat of the oxyhemoglobin, thinning the surface of the lesion, laser overlapping, or drug combining. Although these methods have the advantage, they should not conflict with principles of selective photothermolysis. Epidermal damage from excessive heat in the environment can result in burns. Yu et al. used 595 nm, 12 J/cm2, 1.5-ms pulse duration, 7-mm spot size laser treatment in patients with PWS, and they reported that the results were worse in the central lesions of the face than that of the lateral lesions, and also noted that there may be regional differences in terms of laser response.[27]

PWS is a capillary malformation, with congenital spots in the form of patches extending from pink to erythematous; PWS is seen in 0.3%–0.5% of cases and remains lifelong. The most important problem is the psychological effect of local lesions, especially on the face and neck, unless it is syndromic. The clearance rate with FPDL reaches 75.1% overall (excellent and good) in our series, which is consistent with the results obtained in literature in general [Figure 2], [Figure 3], and [Figure 6]. Laser energy levels, spot size, and pulse width range are well standardized for PWS treatment with FPDL all over the world.
Figure 6: Port-wine stain; 8 weeks after a single dye laser treatment; note the clearance of the lesions at laser spots

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PG is a benign vascular reactive proliferation and appears as a small erythematous papule on the skin or oral mucosal surface.[28],[29] PG is a capillary hemangioma and named as lobular capillary hemangioma.[29] Lesions can be removed by eliminating the underlying causes or surgically. Lasers with different laser wavelengths are used in PG treatment. Al-Mohaya and Al-Malik used a 940-nm diode laser for oral, soft-tissue PG treatment.[28] Akamatsu et al. have proposed CO2 laser ablation following surgical excision in the treatment of PG.[29] PGs respond well to almost all vascular laser applications with their vascular lobular structures. While the dye laser is effective with a large spot diameter and specific wavelength, the Nd: YAG laser with long wavelength is used in deeply located lesions. In our cases, we used Nd: YAG laser more in PGs. The success rate of both lasers was high. Surgical scraping in PGs and nitrate stick cauterization are also effective treatment alternatives.

VL is a vascular lesion that occurs in the enlargement of the venules and lies in the superficial layer of the papillary dermis, in the form of a dark blue-violet pressurized papule that occurs more commonly in the elderly.[30],[31] VL is seen in sun-exposed areas such as face, neck, helix of the ears, lips, and oral mucosa; it is seen most frequently on the ventral surface of the tongue, buccal mucosa, and retrocommissural mucosa.[31] VL mostly causes esthetical problems to patients. Especially lesions in oral localization and bleeding are more problematic; surgical excision, selective photocoagulation, cryotherapy, sclerotherapy, and electrodessication are used in the treatment of various degrees of success which are partially discomforting. Most vascular lasers are suitable for VL treatment, and laser treatment is a safer and more effective alternative. Although FPDL may be effective, long-pulsed Nd: YAG and diode lasers are more preferred because of the depth of the lesion[30],[31] [Figure 7] and [Figure 8]. Voynov et al. used a 980-nm diode laser for VL treatment and obtained successful results.[30] In our cases, we used Nd: YAG laser more commonly for VL. Although it is possible to obtain partial results with FPDL in superficial VLs, they respond better to Nd: YAG and diode laser treatment unless they have large and deep components. Intralesional laser treatment with diode and Nd: YAG laser can be planned for deep and wide VLs. As our cases were selected, Nd: YAG laser treatment was sufficient and the clearance rate was satisfactory. High-power lasers in intraoral vascular lesions with coagulative properties can be used without the risk of bleeding, better healing pattern, and differentiated postoperative appearance, which offer an important therapeutic option.[24]
Figure 7: Intraoral venous lake treated with Nd: YAG laser, at 1-year follow-up

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Figure 8: Venous lake treated with Nd: YAG laser, at 2-year follow-up

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We achieved good results with both lasers in our patients with spider angioma [Figure 9]. Sivarajan et al. stated that while treating patients with single- or double-pulse technique using 585-nm pulsed dye laser, 95% of patients with spider nevi had successful results with 1.8 sessions of treatment[32] and 36% of patients had recurrent spider nevi in the same place. There was no correlation between recurrence and site risk, number of treatments, size and characteristics of spider nevus, and treatment protocol. The risk of recurrence increased with age and was higher in peripheral facial lesions.[32] Fordyce angiokeratomas are asymptomatic vascular lesions on the scrotum, characterized by a blue-to-red papule with a scale surface. Although considered benign, the lesions bleed spontaneously or rupture, which may cause anxiety and social embarrassment.[33] Lapidoth et al. used pulsed dye laser in the treatment of Fordyce angiokeratomas and found that two to six sessions were enough (5.5–8.0 J/cm2) for excellent or good results. Pulsed dye laser is an effective and reliable therapy option with minimum side effects in the treatment of Fordyce angiokeratoma.[33]
Figure 9: Spider angioma treated with dye laser, at 5-year follow-up

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CO2 laser may be useful in the treatment of superficial oral mucosal lesions such as vascular malformations, precancerous lesions, and verrucous nevus.[34] Laser over scalpel provides advantages such as reduced bleeding, a clear view during surgery, and a shorter operative time.[34] Favia et al. treated intraoral vascular lesions in patients with PHACE syndrome using diode laser (noncontact and intralesional).[35] Azevedo and Migliari used diode laser in the treatment of perioral and intraoral vascular lesions.[10] Jasper et al. reported that they obtained good results in three patients using diode laser with intraoral hemangioma and that laser treatment of these lesions was well tolerated by the patients and prevented recurrence.[24] Choi et al. stated that sclerotherapy using sodium tetradecyl sulfate for intra/perioral vascular lesions is advantageous compared to surgery, especially the advantage of providing nonbleeding and aesthetic results.[36] The advantages of sclerotherapy in lesions with deep components are obvious, but sclerotherapy has no priority if there is a lesion that can be treated with noninvasive lasers. Cannarozzo et al. stated that FPDL applications are effective in hypertrophic scars and keloid.[20]

Telangiectasias are chronic dilated blood vessels that have become visible in the upper layer of the skin. Telangiectasias are dilatations (expansion and stretching) of preexisting vessels. Redisch and Pelzer divided telangiectasia into four subgroups according to clinical appearance as follows: (1) sinus or simple (linear), (2) arborizing, (3) spider or star, and (4) punctiform (papular).[37]

Telangiectasia can occur at any age and has no known etiology, but autosomal dominant inheritance has been described in familial cases. Telangiectasias are common in healthy people. They may occur spontaneously as well as due to excessive ultraviolet exposure, aging, hormonal changes, smoking, alcohol use, menopause, hypertension, and corticosteroid use.[38],[39] They may also be associated with certain diseases such as collagen tissue diseases, and roscea and some syndromic diseases such as ataxi telangiectasia and hereditary hemorrhagic telangiectasia.[38],[39] Telangiectasias can occur anywhere in the body, but more often on the face (nose, cheek, and chin) and legs (especially thighs, just below the knees and wrists). They are 1–3 mm wide, several millimeters to centimeters long, red, blue or purple, linear lesions which are temporarily disappeared by pressure, and telangiectasias are treated usually due to aesthetic concern.

The treatment of telangiectasia varies according to the diameter of the vessels. Noninvasive laser treatment is usually used for the treatment of vessels with a diameter of <1 mm. KTP laser, FPDL, alexandrite laser, diode lasers, long-pulsed Nd:YAG (1064 nm) laser and various IPL sources have been used for telangiectasia treatments.[38],[39] In the present study, FPDL and Nd:YAG laser were used in the treatment of telangiectasia with a high success rate [Figure 10] and [Figure 11]. While dye laser treatment is sufficient in facial telangiectasias, Nd:YAG laser is more effective with long wavelength, especially in deep located lesions in leg telangiectasia.
Figure 10: Long-pulsed 1064 nm Nd: YAG laser treatment of foot telengiectasia

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Figure 11: Complete clearance of leg telengiectasia after two sequences of dye laser, at 5-year follow-up

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Minimal complications of laser therapy include pain, purpura, ecchymosis, edema, blister, bullae, bleeding, scarring, postinflammatory hyperpigmentation/hypopigmentation, and atrophy changes.[4],[11] Purpura occurs especially at short pulses (e.g. 1.5 ms) on the dye laser; the pulse duration can be kept long to reduce purpura. Dye laser treatment is very effective in superficial lesions and carries minimal risk. Nd: YAG laser treatment should be preferred over dye laser in lesions where dye laser cannot be effective, especially in deep lesions, and where the risk of burns and scar risk is higher. One of the most serious complications of the laser treatment is skin burn. Despite the advantages of laser use, it should be noted that if it is not used correctly, it can damage the normal tissues by causing thermal damage due to high heat generation. Laser parameters vary depending on the treatment area, type of lesion, skin color, depth of lesion, and machine used. When suspected, a single test pulse can be performed to determine individual specifications.[11] In the evaluation of our patients, we confronted temporary minor complications such as pain, pigmentation changes, blistering, and in two patients, permanent scarring occurred [Figure 5]. In order to avoid complications in laser applications, the correct wavelength should be chosen appropriate to the skin color of the patient, test should be performed first if doubt persists, adequate epidermal cooling should be provided during the application, and conservative treatment should be performed especially when selecting fluence and pulse durations. Furthermore, the same results are not guaranteed even if lasers with the same characteristics of different companies are used with the similar parameters.

It is not possible to evaluate the laser treatment results objectively. Visual evaluations are usually made on photographs, which may vary depending on the quality contrast and light adjustment of photographs and view point of the reviewer. The success rate of vascular lesions with laser treatment is relative and varies in literature,[4] and achieving total clearance in lesions is relatively low.[4] Garden et al. obtained clearance over 75% in 44% of patients and clearance over 50% in 29% of their patients.[40] Di Maio et al. reported that they achieved excellent results in 51%, good results in 39%, average results in 7%, and poor results in 3% of patients with vascular malformation with pulsed dye laser treatment.[41] Excellent results indicated that the pulsed dye laser proved its clinical efficacy in the treatment of dermal vascular malformations.[41] The current investigation results are generally consistent with those of literature, but there will always be question marks as the laser results are subjectively evaluated. However, lasers are accepted as the most effective and safe treatment modality in vascular lesions. Patients' satisfaction with the results is more important than subjective evaluations. Although complete clearance cannot always be achieved with laser, it is important for many patients that the lesion can be covered with a light makeup.

  Conclusion Top

Selective photocoagulation with laser is an effective application for many vascular lesions with a satisfactory aesthetic result, low morbidity, and patient comfort. To optimize results and reduce negative effects, it is necessary to have a basic knowledge of lasers and laser–tissue interactions.

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Conflicts of interest

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  References Top

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Patel AM, Chou EL, Findeiss L, Kelly KM. The horizon for treating cutaneous vascular lesions. Semin Cutan Med Surg 2012;31:98-104.  Back to cited text no. 2
Willenberg T, Baumgartner I. Vascular birthmarks. Vasa 2008;37:5-17.  Back to cited text no. 3
Sajan JA, Tibesar R, Jabbour N, Lander T, Hilger P, Sidman J. Assessment of pulsed-dye laser therapy for pediatric cutaneous vascular anomalies. JAMA Facial Plast Surg 2013;15:434-8.  Back to cited text no. 4
Dementieva N, Jones S. The treatment of problematic hemangiomas in children with propranolol and 940 nm diode laser. J Pediatr Surg 2016;51:863-8.  Back to cited text no. 5
Azevedo LH, Galletta VC, Eduardo Cde P, Migliari DA. Venous lake of the lips treated using photocoagulation with high-intensity diode laser. Photomed Laser Surg 2010;28:263-5.  Back to cited text no. 6
Asilian A, Mokhtari F, Kamali AS, Abtahi-Naeini B, Nilforoushzadeh MA, Mostafaie S. Pulsed dye laser and topical timolol gel versus pulse dye laser in treatment of infantile hemangioma: A double-blind randomized controlled trial. Adv Biomed Res 2015;4:257.  Back to cited text no. 7
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Blei F, Guarini A. Current workup and therapy of infantile hemangiomas. Clin Dermatol 2014;32:459-70.  Back to cited text no. 8
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

  [Table 1], [Table 2], [Table 3]


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