Jain Dermatology Chapter 6: Cosmetic Surgery (Botox, Fillers, Lasers) – Flashcards

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Chemical peels and isotretinoin
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Do not resurface if patient with recent (6-12 months) isotretinoin; Accutane causes atrophy of the pilosebaceous unit, which is where re-epithelialization after peel originates from possible impaired wound healing with ↑ scar formation
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Antiviral prophylaxis for what level of chemical peels
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Medium and deep peels
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Frost intensity and peel level
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Level 1: Irregular light frost (erythema with streaky frosting): Superficial Epidermis; Level 2: Uniform white frost with underlying erythema: Papillary Dermis; Level 3: Solid white enamel frosting: Reticular Dermis
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Superficial peels
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Epidermis only: Glycolic acid or other alpha-hydroxyl acids, Jessner's, TCA 10-30%, Salicylic acid, Tretinoin solution
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Medium peels
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Papillary dermis: 35-40% TCA, 70% glycolic acid + 35% TCA, Jessner's solution + 35% TCA, 88% phenol (rarely used)
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Deep peels
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Reticular dermis: TCA>50%, Phenol/Baker's formula; Complications: prolonged erythema (most common), scarring, permanent hypopigmentation, hyperpigmentation, milia, acne
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TCA for peels
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10-20% concentration for very light superficial peels, 25-30% concentration for light superficial peels, 35% concentration with glycolic acid or Jessner's for medium peels 40% concentration when used alone for medium peels, >50% for deep peels
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Salicylic acid for peels
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Used for superficial peels; Keratolytic and comedolytic
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Which of the following chemical peel solutions need neutralization: Glycolic acid, Jessner's solution, Salicylic acid, TCA
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Glycolic acid needs to be neutralized with sodium bicarbonate; Jessner's, TCA, Salicylic acid do not need neutralization
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Jessner's solution is used for superficial or medium (with 35% TCA) chemical peels and composed of
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Salicylic acid, Lactic acid, Resorcinol, Ethanol
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Phenol
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Keratocoagulant, Must use IV sedation with full face procedure, Cardiotoxic (do not exceed 60-90 minutes) and need cardiac monitoring, Hepatotoxic, Nephrotoxic
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Baker formula - Used for deep peels
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Phenol, Distilled water, Croton Oil (active ingredient), Liquid Hexachlorophene,
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What level chemical peel used for AK, SK, Lentigines, dyschromia, Rhytides
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Medium peel
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Botox A vs B are clostridium purified protein derivatives that cause temporary paralysis of striated muscle by inhibiting Ach release: Mechanism of Action
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BTX A light chain cleaves SNAP25, BTX B light chain cleaves synaptoBrevin
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Botox A FDA approved for
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Glabellar rhytides, Hyperhidrosis, Most effective at reducing dynamic facial lines
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Botox and saline reconstitution
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Instructions recommend reconstitution in sterile, non-preserved saline but preserved saline results in less pain on injection and does not reduce stability of toxin
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Botox contraindications
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Neuromuscular disorder, Infection/Inflammation at injection site, Known hypersensitivity to product, Pregnancy category C
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Botox for glabellar rhytides
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Stay 1 cm above orbital rim, Toxin can cause eyelid ptosis (starts within 2-14 days, lasts 2-12 weeks) if it diffuses to levator palpebrae muscle, Apraclonidine 0.5% eyedrops (a-agonist) may help lift lid by 1-2 mm by causing Muller's muscle contraction to compensate for levator palpebrae weakness
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Botox for horizontal forehead lines
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Weakens frontalis muscle; Too much botox results in unopposed action of eyebrow depressors and angry expression, Injecting lateral but not superficial frontalis fibers results in quizzical appearance, If narrow brow fewer injection sites (4 instead of 5)
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Botox for Crow's Feet (horizontal to oblique lines radiating from lateral canthus)
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Weakens orbicularis oculi muscle, Do not inject while patient smiling as toxin may affect ipsilateral zygomaticus complex, causing ptosis of upper lip
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Botox for Perioral Rhytides
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Weakens orbicularis oris muscle, Vertical lines radiating outward from vermilion border; 8 doses (1-2 units per lip quadrant) sufficient for cosmesis and to avoid paresis and speech interference
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Botox for Bunny Lines
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Weakens nasalis muscle, Inject anterior to nasofacial groove on lateral wall of nose; Avoid angular vein, Avoid nasofacial groove as this can affect levator labii superiorir and levator superior alaeque nasi
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Botox for depressor anguli oris (DAO)
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Weakening DAO eliminates downward pull and negative facial expression; Inject 3-5 units at level of posterior margin of mangible close to anterior margin of masseter; Complications: Asymmetric smile and flaccid cheek. Patients who use perioral muscles intensely not good candidates
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Soft tissue augmentation locations
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Used on: Lips, Nasolabial folds, Wrinkles
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Injectactable filler composition
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Hyaluronic acid, Collagen, Fat, Calcium hyroxylapatite
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Filler side-effects
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Bruising, Granuloma formation, Hematoma, Infection
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Hair transplant follicular unit composed of
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1-4 terminal hairs, 1-2 vellus hairs, Associated glands, Arrector pili, Adventitial collagen
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Hair transplant: Follicular units taken out intact through stereomicroscopic dissection, follicular unit density is
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Typically >30 follicular units/cm2
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FDA-approved medical treatments for male-pattern alopecia
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Minoxidil (Rogaine), Finasteride (Propecia)
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Finasteride MOA, SE
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MOA - 5a-reductase inhibitor, decreases convertion of T to DHT; SE - Decreased libido, Gynecomastia, Decreased prostate-specific antigen (PSA) level
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Filler made from neonatal foreskin that lasts 3-4 months
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Cosmoderm I - Human collagen + plain lidocaine, Injected in superficial to mid-dermis, No pretesting
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Filler made from bovine collagen + lidocaine that is injected into superficial to mid-dermis
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Zyderm - Requires pretesting (two tests, two weeks apart, Zyderm lasts 3-4 months, Zyderm II lasts 3-6 months
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Filler made from hyaluronic acid product of bacterial fermentation lasting 4-6 months
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Restylane - No pretesting, Mid-dermis
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Filler made from hyaluronic acid product from rooster comb lasting 3-6 months
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Hylaform/Hylaform plus - No pretesting, Mid-dermis
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Filler made of collagen from patients own skin lasting 4-9 months
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Autologen - No pretesting, Mid-dermis
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Filler made of polymethylmethacrylate beads in bovine collagen suspension that is permanent
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Artecoll- Pretesting, Deep dermis
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Filler made of human collagen cross-linked with glutaraldehyde + plain lidocaine that lasts 3-4 months
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Cosmoplast
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Filler made of hyaluronic acid (bacterial fermentation) lasting 3-9 months
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Perlane - Deep dermis
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Filler made of bovine collagen cross-linked with glutaraldehyde + plain lidocaine lasting 3-5 months
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Zyplast - Deep dermis, Pretesting
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Filler made of cultured autologous human fibroblasts with unclear duration
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Isolagen - Versatile implantation level
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Filler made of hyaluronic acid lasting 3-6 months
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Juvederm - Dermis, Level varies if ultra or plus
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Filler made of calcium hydroxylapatite microspheres in polysaccharide gel lasting 9 months - 5 years
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Radiesse - Subdermal, Can be seen on x-ray
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Filler made of Poly-L-lactic acid lasting 24 months and FDA approved for HIV lipodystrophy
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New-Fill, Sculptra, Subdermal
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Filler made of acellular human cadaveri dermis lasting 3-6 months
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Alloderm - Subdermal implant
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Filler made of fat harvested from patient lasting 6-24 months
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Autologous graft
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Fillers requiring pretesting
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Zyderm I/II, Artecoll, Zyplast
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Fillers made from hyaluronic acid
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Juvederm; Hylaform - Rooster comb; Restylane, Perlane - Bacterial fermentation
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Fillers made from bovine collagen
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Zyderm I/II - lidocaine; Artecoll - Polymethylmethacrylate beads; Zyplast - cross-linked with glutaraldehyde + plain lidocaine
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Fillers made from human collagen
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Cosmoderm I - plain lidocaine, Autologen - Patient's own skin, Cosmoplast - cross-linked with glutaraldehyde + plain lidocaine
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Laser light characteristics
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Monochromatic - Single, discrete wavelength; Spatially coherent - Light in phase; Collimated - Light in parallel fashion
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Laser: Selective thermolysis
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Targeted lesion may be destroyed by chromophore absorption of laser light without significant thermal damage to surrounding normal tissue
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Laser: Pulse duration and thermal relaxation time time) < or equal to target thermal relaxation time (TRT, cooling time or time for target to lose 50% heat) to confine thermal damage
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Pulse duration (exposure
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Laser: Pulse Duration and Thermal Damage Time (TDT)
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Pulse duration < or equal to TDT allows for efficacy with ↓ epidermal damage
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Chomophores
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Components of skin which absorb laser light; Endogenous - Hemoglobin, Melanin, Water; Exogenous - Tattoo ink
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Fluence vs Power
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Fluence - J/cm2; Power - J/s
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Time required to irreversibly damage target with sparing of surrounding tissue
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Target Damage Time (TDT)
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Time for target to lose 50% heat
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Target Thermal Relaxation Time (TRT); Proportional to square of target diameter (shortest TRT in chromophore with smallest size)
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Gain medium
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Determines wavelength of light; Liquid (Dye Lasers), Gas (Argon, CO2, helium-neon), Solid (Nd:Yag, ruby)
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Pulse duration (Exposure time of laser)
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Best if pulse duration less or equal to TRT and TDT
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Spot size
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Larger size allows for deeper energy penetration (less scattering)
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Cooling Types
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Different types of cooling minimizes epidermal damage; Passive (aqueous gel); Active contact cooling (water encased in sapphire or glass housing); Dynamic active cooling (cryogen spray); Forced air cooling
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Q-switch - Quality switched
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Allows accumulation of excessive energy in laser cavity prior to emission; Extremely short pulses of very high power (nanosecond range); Used mainly for removal of tattoo pigment and superficial pigmented lesions
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Laser Hair Removal Target
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Bulge of hair follicle and dermal papilla
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Laser Hair Removal pulse duration
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Optimum pulse duration 10-50 ms; or equal to TRT of epidermis (3-10 ms)
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Pigmented lesions (epidermal pigment)
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Q-switched lasers with very short pulse duration; QS KTP, QS ruby, QS Nd:Yag; Endpoint: Uniform but faint whitening, no epidermal disruption (higher fluences will have solid whitening with epidermal disruption and pinpoint bleeding)
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Second harmonic generation (SHG)
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Frequency doubled
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Type of lasers used to remove tattoo pigment
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Q-switched
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Reason why white/peach/pink/flesh-toned tattoo color may turn dark gray immediately after treatment with Q-Switched laser
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Ferric oxide reduced to ferrous oxide
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Number of treatments to clear amateur vs professional tattoo with Q-Switched laser
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Amateur - 3 to 5 treatments; Professional - 10 or more treatments
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Best lasers for pigmented lesions, hair and tattoo removal (melanosome absorption range: 300-1000 nm - peak 335 nm)
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Nd:Yag - 532nm, KTP - 532nm, PDL - 585-595nm, Ruby - 694nm, Alexandrite - 755nm, Diode - 800-810nm
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Best lasers for ablative and non-ablative remodeling, actinic cheilitis (water aborption peaks at 1450 nm, 1950 nm, 3000 nm)
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Nd:Yag - 1320 nm, Diode - 1450 nm, Erbium - 2940nm, CO2 - 10,600nm,
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Reason why higher wavelength lasers used for hair removal and pigmented lesions despite melanin peak aborption in 300-600nm range
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Increased scattering, decreased penetration and competing chromophores (Hgb) occur with lower wavelength
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Best laser for psoriasis (Chromophore: Protein)
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Excimer (XeCl) 308nm
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Best lasers for vascular lesions (Hemoglobin absorption peaks at 418 nm, 542 nm, 577 nm)
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Argon - 488nm, Copper vapor - 511/578nm, KTP - 532nm, PDL - 585-595nm
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Best lasers for hair removal (melanosome absorption range: 300-1000 nm (peak 335 nm)
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Ruby - 694nm, Alexandrite - 755nm, Diode - 800-810nm, ND:Yag (long-pulsed) - 1064nm, IPL - 515-1200nm
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Best laser for red/orange/yellow, purple tattoos
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QS ND:Yag - green light (frequency doubled) - 532 nm; Pulsed dye - green light (short wavelength) - 510 nm
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Best lasers for blue/black/green tattoos
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QS Ruby - 694 nm (red light); QS Alexandrite - 755nm (red light)
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Best laser for blue/black tattoos
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QS Nd:Yag (long-pulsed) - 1064nm
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Best laser for nevus of Ota
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Ruby - 694 nm
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Best laser for verrucae
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PDL - 585-595nm
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Best laser for actinic cheilitis
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CO2 - 10,600nm
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Best laser for hypertrophic scars
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PDL - 585-595 nm
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Best lasers for blond, red, white, gray, brown hair removal
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Ruby - 694nm - significant dose-related side effects vs alexandrite or Nd:Yag (crusting, dychromia 2/2 increased melanin aborption)
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Best lasers for red, gray, brown hair removal
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Alexandrite
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Best laser for brown/black hair removal
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Diode - 810nm
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Laser which can cause retinal damage
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Ng: Yag (long pulsed) - 1064 nm (Long wavelength with deep penetration and invisible radiation)
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