The Role of the Sciton Profile Nd-Yag Laser in the Reduction of Cutaneous Varicosities, a Pilot Study

The current pilot study reports a 19 patient case series to determine the effectiveness of the Sciton Profile NdYAG laser in the reduction of cutaneous vessels. Documentation was made of vessel characteristics including color, size, location, percentage reduction and laser settings including pulse width, fluence, numbers of synchronous passes and frequency of applications. We conclude that for vessels less than 4mm in diameter, using between 120350 Joules/cm2, 15-20millisecond duration and 1-3 passes, resulted in greater than 50% clearance without, complication for both red and blue-black vessels.


Introduction
The precise role of the Nd-Yag in the treatment of cutaneous varicosities remains controversial. Treatment choices include sclerotherapy [1,2], laser [3], dual wavelength laser [4], combination sclerotherapy /laser [5,6,7], end-venous laser [8] or radiofrequency [9] and microsurgical or conventional phlebectomy [10]. The vascular literature supports the primary use of sclerotherapy for vessels less than 5mm [7]. Some unattractive features of sclerotherapy include the need of the operator to be comfortable using an end-venous injectable. The latter requires a greater degree of dexterity and longer clinical experience than for the use of most lasers in order to achieve a satisfactory result [4].
Laser therapy is also an attractive adjunct or alternative in patients with needle phobia, post-sclerotherapy complications such as neovascularization, otherwise known as matting, the rare person with sclerosant allergy and hemosiderin / brown staining [1]. The latter can be avoided by aspiration of a superficial coagulated vessel, also requiring specific operator skill [2]. Postsclerotherapy complication rates are variable and in part seem dependent on the concentration of a sclerosant used [11]. Variables There are at least 6 commercially available wavelengths (532-1064nms), 50 laser machines from over 25 manufacturers in the United States today [13,14]. The Nd-Yag has several advantages over other laser devises available to treat cutaneous varicosities.
The longer 1064nm wavelength, provides a relative sparing of the competing chromophore-melanin, including safe usage on Fitzpatrick III-IV skin types. The laser energy is more likely to pass through the epidermis and dermis to be absorbed by oxy and reduced hemoglobin within larger diameter and deeper vessels than for shorter wavelength devices [15]. Important parameters, which must be acknowledged, include a pulse interval in excess of the thermal relaxation time of skin. The thermal relaxation time is dependent the size of the vessel. Vessel coagulation occurs at greater than 62C and vaporization over 100C [7]. The latter leads to bubble formation within the vessel wall and collapse. The clinical correlation of the latter is termed vessel 'clearing'. A longer pulse width leads to slower heating of the vessel, which in turn avoids vessel rupture [16].
Shorter wavelength lasers, while providing greater selectivity for the vascular chromophore, also have a greater propensity towards ablative injury to the vessel wall, which leads to rupture, ecchymosis and potential staining. Superficial varicosities of less than 1mm are generally lighter in color and are called spider telangiectasia / veins. Vessels 1-2 mm in size are termed venectasia and the deeper/darker varicosities of 2-4mm diameter are termed reticular vessels [12]. Previous studies using the Nd-Yag to reduce cutaneous vessels have provided a spectrum of recommended parameters from 40-350 J/cm 2 fluence and pulse widths from 1-55 milliseconds (see Table 1). Most authors have reported greater success with reticular vessels than for spider telangiectasia [4,12].

Objective
The purpose of the current pilot study is to report our experience of the most appropriate parameters as well as the effectiveness of the Sciton Profile Nd-Yag laser in the treatment of cutaneous vessels of 0.1-and 4.0-mm's diameter.  Standardized photographs were taken before, 1 and 2 months and as long as 3 months after treatment using a Lumex-Panasonic macro-digital camera with standardized lighting. Response to treatment was rated on a quartile system: 0 (no clearing), 1 (1%-25% clearing), 2 (26%-50% clearing), 3 (51%-75% clearing), and 4 (76%-100% clearing). The average number of passes was 2. We defined a significant improvement at the time of the treatment was greater than or equal to a 50% clearing. Side effects were documented and subsequently rated as: none,1 (mild), 2 (moderate), 3 (severe). Response to treatment was assessed by two treating physicians and one Registered Laser Nurse.

Results
19 pts received 27 treatments, with intervals of at least 6 weeks, the most common laser site was the lower leg. No compressive garments were applied after treatment, no topical anesthetic or antibacterial agents were applied before or after treatment.
Significant vessel clearance was seen in over 80% of patients at 3month follow-up. The best response for 1mm vessels was noted using a short pulse 20ms or less; with a fluence of greater than 150 J/cm 2 (see Figure 1). Reticular vessels required a longer pulse width: 30-50 ms and a fluence of 150 J/cm 2 (see Figure 2). Pain was the limiting factor when using shorter pulse widths or higher fluences. Treatment of vessels 4mm or greater was limited by the sensation of pain. A lower fluence and longer pulse was associated with a reduction of absence of pain, but without appreciable vessel clearance. Following treatment, no pigmentary changes were noted. There were no reported burns. Matting was not seen, and the commonest complaint was the sensation of heat at higher fluences and short pulse widths. Firm contact cooling with jel was very important in reducing this heat sensation and preventing the complication of burns or pigmentary changes.

Discussion
The current report indicates that the Sciton profile Nd-Yag is a useful laser modality in the reduction of cutaneous vessels of less than 4mm in size. Our experience was consistent with other reports [12] concerning Nd-Yag parameters, a shorter pulse duration (15 milliseconds) with higher fluence (>150 J/cm 2 ) was effective in closing smaller vessels (<1mm). Reticular vessels responded well to a longer pulse duration (30-50 milliseconds) with a fluence of 150J/cm 2 . Because of the relatively long wavelength, and continuous skin cooling there were no injuries to the skin and no changes in pigmentation as perceived by either patient or our group. Patient tolerance was a limiting factor when we attempted to reduce or collapse vessels in excess of 4mm. A recent investigator found that that a single treatment with a Nd-Yag and sclerotherapy provided comparative results for vessels < or equal to 2mm [5]. Other authors have reported that vessels greater than 4mm are more easily and effectively treated with sclerotherapy [7]. One author reported a