Effectively treating vascular and pigmented lesions — from common facial telangiectasias to more challenging hemangiomas — relies on identifying the appropriate tools and then honing one’s technique to achieve the best results. However, more often than not, patients want to make the most of their sessions by undergoing concomitant facial resurfacing to improve wrinkles and texture changes related to repeated sun exposure, according to William F. Groff, D.O., who practices alongside aesthetic laser pioneer, Richard Fitzpatrick, M.D., at the La Jolla Cosmetic Surgery Centre, in La Jolla, Calif. In these cases, Dr. Groff tells Cosmetic Surgery Times, a combination of two or more lasers is often the best approach. Here, Dr. Groff offers tips and perspective on wrinkle and vascular and pigmented lesion treatment strategies that result in patients whose post-procedure appearance is ultimately the best form of marketing.

RESULTS DELIVERED The most common facial lesions that patients request treatment for are wrinkles, telangiectasias and solar lentigines according to Dr. Groff, who adds that these are followed in frequency by rosacea, melasma, cherry angiomas and spider angiomas.

“Facial telangiectasias, cherry angiomas and spider angiomas are fairly easy to treat if you have the right tools,” says Dr. Groff. They can all be treated very safely and effectively with pulsed dye lasers (PDLs) in just one or two sessions. “PDL has a long track record and is certainly considered the gold standard, so if the practitioner wants to treat both vascular and pigmented lesions, the PDL is one unit that can be counted on to deliver reliable, predictable and safe results. We have about 20 lasers in our practice and the PDL is probably the safest. The chance of having a problem or complication is extremely rare.”

Dr. Groff’s technique for facial telangiectasias comprises the use of a Candela V-beam Perfecta PDL, using the 10 mm spot size with 7.5 to 10 J/cm2. “I would usually use a 6, 10 or 20 ms pulse duration [depending on the size of the vessels], and it could take anywhere from one to three sessions at the most,” he explains. Larger vessels require treatment with longer pulse durations. David J. Goldberg, M.D., J.D., adds that, “A variety of other lasers and light sources can also be successfully and safely used to treat such vascular lesions. Among the more popular wavelengths besides the 595 PDL are the 532, 940, 980 and 1064 nm wavelengths.” Dr. Goldberg is director of Skin Laser & Surgery Specialists of NY/NJ, and clinical professor of dermatology/director of laser research at the Mount Sinai School of Medicine in NYC.

There is a high demand for facial laser resurfacing in Dr. Groff’s practice and almost every person who comes in for resurfacing has brown spots and telangiectasias. “But no matter what kind of fractional resurfacing device you use, most telangiectasias and some brown spots remain.” To get the best results, Dr. Groff recommends using a combination of lasers. “There’s not one box that does it all and does it all the best,” he says.

For a patient who has facial telangiectasias, solar lentigines and wrinkles, Dr. Groff recommends using the PDL to remove the capillaries, the PDL or Q-switched alexandrite to remove the lentigines, then immediately treating with fractional CO2 resurfacing all in one session. “The results are much better than if you use any of these technologies alone,” he says. “Dr. Fitzpatrick and I have been doing these combination treatments for years, and we’ve never had any complications from combining lasers in one session. Our results are excellent and patients appreciate not having to come back for separate treatments, which would incur more social downtime. There’s a synergistic effect where the results are much better when these treatments are done at the same time, in comparison to doing them separately,” he adds.

Taking the synergistic effect one step further, Dr. Groff recommends pretreating with BOTOX around the glabella, the forehead and the crow’s feet area one to two weeks before performing fractional resurfacing. “If you do this, those muscles are relaxed so they’re not contracting and etching lines into freshly resurfaced skin,” he explains.

STACKING TREATMENTS In the majority of these cases, patients who are seeking resurfacing and treatment for telangiectasias also want to be rid of the vertical upper lip “smokers’ lines” that are commonplace among women over the age of 40. “The gold standard for erasing these lines is still traditional multiple pass CO2 laser resurfacing in combination with erbium laser resurfacing. So even though fractionated CO2 will soften the lines, if the patient wants those lines to be gone you still need multiple pass CO2 and erbium laser resurfacing,” he explains. “In our practice, if we’re going to resurface a woman’s facial skin, we’ll use a fractional CO2 over the entire face with the exception of the upper lip where we’ll perform traditional multiple pass CO2 and erbium resurfacing in addition to using the PDL and the Q-switched alexandrite laser to address the telangiectasias and brown spots, respectively. We use these lasers back to back in the same treatment session. That’s really the way to get the best results,” Dr. Groff says. With regard to these challenging upper lip lines, Dr. Goldberg adds that, “Although fractional nonablative lasers do not typically lead to improvement of upper lip lines, many clinicians have also seen great results from ablative fractional lasers emitting 2790, 2940 and 10,600 nm wavelengths.”

For pigmented lesions, Dr. Groff opts for Candela’s TriVantage, a Q-switched alexandrite laser, which delivers energy through a fiber optic cable, giving it a homogeneous result with less variation from pulse to pulse. “We consider this laser the workhorse of our practice. It’s fast and extremely effective,” he says. The TriVantage offers Q-switched 1064 nm and 532 nm wavelengths, as well as a 755 nm wavelength, so, in addition to treating pigmented lesions, it is also effective for tattoo removal of many colors. “Previously removing multicolor tattoos meant using multiple lasers, but with the TRiVantage we’re able to remove all colors except for white, yellow and fluorescents,” he says.