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About:
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Laser and Light Treatment of Acquired and Congenital Vascular Lesions
IPL treatment of PWS
IPL devices are broadband filtered xenon flashlamps that work based on the principles of selective photothermolysis. The emission spectrum of 515–1200 nm is adjusted with the use of a series of cut-off filters, and the pulse duration ranges from approximately 0.5 to 100 msec, depending on the technology. The first commercial system, Photoderm VL (Lumenis, Yokneam, Israel) became available in 1994, and has been used to treat vascular anamolies. Another, IPL Technology (Danish Dermatologic Development [DDD] Hoersholm, Denmark) with a dual mode light filtering has also been used to treat PWS. Many other IPL system have recently been developed, and the appropriate parameters for congenital vascular lesions are being developed. The IPL has been used successfully to treat PWS (Fig. 39.7),78–80 but pulsed dye laser remains the treatment of choice.
IPL technology has also been used to treat pulsed dye laser-resistant PWS. In the study by Bjerring and associates seven of 15 patients achieved over 50% lesional lightening after four IPL treatments. Most of these patients had lesions involving the V2 dermatome (medial cheek and nose), which are relatively more difficult to lighten. Six of seven of these patients showed over 75% clearance of their PWS. A 550–950-nm filter was used with 8–30-msec pulse durations and fluences of 13–22 J/cm2 to achieve tissue purpura. The 530–750-nm filter can also be used with double 2.5-msec pulses, with a 10-msec delay and fluence of 8–10 J/cm2. Epidermal cooling was not required. Treatment resulted in immediate erythema and edema, and occasional crusting. Hypopigmentation was observed in three patients, hyperpigmentation in one patient, and epidermal atrophy in one patient.
The basics of body fat
Let’s start with the basics. Not all fat is created equal. We have two distinct types of fat in our bodies: subcutaneous fat (the kind that may roll over the waistband of your pants) and visceral fat (the stuff that lines your organs and is associated with diabetes and heart disease).
From here on out, when we refer to fat, we are talking about subcutaneous fat, as this is the type of fat that cryolipolysis targets. A recent study showed that the body’s ability to remove subcutaneous fat decreases with age, which means we are fighting an uphill battle with each birthday we celebrate.
From popsicles to freezing fat
Cryolipolysis machine — which literally translates into cold (cryo) fat (lipo) destruction (lysis) — was invented, in part, by observing what can happen when kids eat popsicles. No kidding here. The cofounders of this process were intrigued by something called “cold-induced fat necrosis” that was reported to occur after young children ate popsicles that were inadvertently left resting on the cheek for several minutes. Skin samples taken from pediatric patients like these showed inflammation in the fat, but normal overlying skin. Thus, it appeared that fat may be more sensitive to cold injury that other tissue types.
HOW DOES IT WORK?
Coolplas Fat Freeze Machine uses rounded paddles in one of four sizes to suction your skin and fat “like a vacuum,” says Roostaeian. While you sit in a reclined chair for up to two hours, cooling panels set to work crystallizing your fat cells. “It’s a mild discomfort that people seem to tolerate pretty well," he says. "[You experience] suction and cooling sensations that eventually go numb.” In fact, the procedural setting is so relaxed that patients can bring laptops to do work, enjoy a movie, or simply nap while the machine goes to work.
WHO IS IT FOR?
Above all, emphasizes Roostaeian, CoolSculpting is “for someone who is looking for mild improvements,” explaining that it’s not designed for one-stop-shop major fat removal like liposuction. When clients come to Astarita for a consultation, she considers “their age, skin quality—will it rebound? Will it look good after volume is removed?—and how thick or pinchable their tissue is,” before approving them for treatment, because the suction panels can only treat the tissue it can access. “If someone has thick, firm tissue,” explains Astarita, “I won’t be able to give them a wow result.
WHAT ARE THE RESULTS?
“It often takes a few treatments to get to your optimum results,” says Roostaeian, who admits that a single treatment will yield very minimal change, sometimes imperceptible to clients. “One of the downsides of [CoolSculpting] is there’s a range for any one person. I’ve seen people look at before and after pictures and not be able to see the results.” All hope is not lost, however, because both experts agree that the more treatments you have, the more results you will see. What will happen eventually is an up to 25 percent fat reduction in a treatment area. “At best you get mild fat reduction—a slightly improved waistline, less bulging of any particular area that’s concerning. I would emphasize the word mild.”
WILL IT MAKE YOU LOSE WEIGHT?
"None of these devices shed pounds,” says Astarita, reminding potential patients that muscle weighs more than fat. When you’re shedding 25 percent of fat in a handful of tissue, it won’t add up to much on the scale, but, she counters, “When [you lose] what’s spilling over the top of your pants or your bra, it counts.” Her clients come to her in search of better proportions at their current weight, and may leave having dropped “one or two sizes in clothing.”
Although the mechanism of cryolipolysis is not completely understood, it is believed that vacuum suction with regulated cooling, impedes blood flow and induces crystallisation of the targeted adipose tissue with no permanent effect on the overlying dermis and epidermis. This cold induced ischaemia may promote cellular injury in adipose tissue via cellular oedema and mitochondrial free radical release. Another theory is that the initial insult of crystallisation and cold ischaemic injury is further perpetuated by ischaemia reperfusion injury, causing generation of reactive oxygen species, elevation of cytosolic calcium levels, and activation of apoptotic pathways.
Whichever the mechanism of injury, adipocytes undergo apoptosis, followed by a pronounced inflammatory response, resulting in their eventual removal from the treatment site within the following weeks. The inflammatory process sees an influx of inflammatory cells at 14 days post treatment, as adipocytes become surrounded by histiocytes, neutrophils, lymphocytes, and other mononuclear cells. At 14-30 days after treatment, macrophages and other phagocytes envelope and digest the lipid cells as part of the body’s natural response to injury. Initial concern was that cholesterol, triglycerides, low density lipoproteins (LDLs) and high density lipoproteins (HDLs), bilirubin and glucose levels were affected, however these have been shown to all stay within normal limits following the procedure.
Four weeks later, the inflammation lessens and the adipocyte volume decreases. Two to three months after treatment, the interlobular septa are distinctly thickened and the inflammatory process further subsides. Fat volume in the targeted area is apparently decreased and the septa account for the majority of the tissue volume.
Patients and treatment areas
Although all studies show reduction in every area examined, it is still unknown what areas are most responsive to cryolipolysis. Various factors may play a role in the degree of fat reduction observed after cryolipolysis. The vascularity, local cytoarchitecture, and metabolic activity of the specific fat depots in questions may play a role.
There is lack of substantial research to identify the ideal patient or even the ideal area to be treated. Given a modest (yet significant improvement of up to 25% reduction in subcutaneous fat), it is thought that the best candidates are those within their ideal weight range and those who engage in regular exercise, eat a heal
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