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Potential devices to treat spider veins
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Although many lasers and light devices have been attempted to clear legs veins, the majority of those tried have been unsuccessful This chapter reviews the laser or light sources with the most reported ef cacy These devices have wavelengths that are close to the hemoglobin absorption peaks at 541 nm and 800 to 1000 nm These light sources include potassium titanyl phosphate (KTP) laser or frequency doubled neodymium:yttrium aluminum garnet (Nd:YAG) laser (532 nm), pulsed dye laser (PDL) (595 nm), intense pulsed light (IPL) (560 1200 nm), and Nd:YAG laser (1064 nm) Diode and alexandrite lasers also have wavelengths within the hemoglobin absorption spectrum and have been used to treat leg veins, but these would not be our rst choice to treat blood vessels 532-nm lasers The 532-nm wavelength is absorbed by hemoglobin and penetrates just as well as 585-nm light, which is well known to treat vascular lesions For leg
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LASER AND LIGHT TREATMENTS Patient Selection
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In general, treatment with lasers and light sources is more expensive, less predictable, associated with inconsistent responses, and more painful than sclerotherapy However, these devices are occasionally used in certain circumstances For example, lasers or light sources may be used if the patient is afraid of needles, not interested in wearing postsclerotherapy compression hose, has telangiectatic matting that cannot be cannulated with a needle, or is nonresponsive to sclerotherapy The basic requirement for a laser or light source used for the treatment of leg veins is a wavelength that is proportionately better absorbed by the target (hemoglobin)
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9: Leg Rejuvenation
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vessels less than 1 mm in diameter that are not directly connected to a feeding reticular vein, and with use of contact cooling to protect the epidermis, this laser can be quite effective Two to three treatments are necessary for maximal vessel improvement although some have reported 100% resolution of the treated leg vein with one treatment16 Patients with darker or tanned skin should avoid this type of treatment secondary to a relatively high risk of temporary hypopigmentation in our experience Pulsed dye laser The traditional PDL (585 nm), with a 450- sec pulse duration, can penetrate 12 mm to reach the typical depths of leg telangiectasia17 However, the pulse duration is too short to effectively damage all vessels; it can damage only the most super cial ne vessels Theoretically, the new PDL devices, which have long pulse durations, some up to 40 milliseconds, should be more effective However, in general, veins treated with traditional or long-pulse PDLs are less responsive and more prone to posttherapy hyperpigmentation than when treated with sclerotherapy18 Intense pulsed light The initial report on treating leg telangiectasias with IPL was very optimistic; clearance of 75% to 100% was achieved in 79% of treated lesions and better than 50% clearance was achieved in 94% of cases19 However, this data was obtained from dozens of centers with widely different techniques of treatment and data recording and therefore could not be reproduced on
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a regular basis by some users20 For many years, we have treated several thousand patients with multiple parameters using multiple combinations of short and long pulses in an attempt to obtain the most consistent results We have found IPL to be most useful for the telangiectatic matting that occurs on the inner thighs following sclerotherapy Nd:YAG laser The rst report of 1064-nm Nd:YAG laser indicated that 75% improvement was possible after a single treatment at 3 months21 These ndings were con rmed and the mechanism of action was explained as heat-induced vessel damage and subsequent brosis22 The primary bene t of this wavelength is deep penetration and the absence of absorption in melanin thus allowing treatment even in deeply pigmented individuals However, high energies must be utilized for adequate penetration and heat dissipation to affect the posterior wall of a larger diameter (1 2 mm) vessel lled with deoxygenated hemoglobin The larger the vein, the more painful would be the treatment, due to increased absorption of infrared energy23 For patient comfort, epidermal cooling must be provided Contact and cryogen cooling are both effective means of protecting the skin and reducing pain Using smaller spot sizes with moderate uences to reduce excess dermal heating and pain has also been reported to be an effective way to treat leg veins with the 1064-nm laser24 A clinical photograph of leg vein response before and after treatment with a 1064-nm laser is shown in Figure 96
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Figure 96 Clinical results with 1064-nm laser A small isolated group of telangiectasias is treated with 1064-nm laser, (Vasculight, Lumenis, Santa Clara, CA) (A) Before and (B) 3 months after treatment Treatment parameters are a single 16-millisecond pulse, 6-mm spot size, and uence of 120 J/cm2
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