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How to maximize your use of picosecond lasers

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Since the introduction of the picosecond laser within the aesthetic and dermatologic markets, it has become widely recognized as the safest and most effective solution for pigmented lesions and tattoo removal. Now, the PICOCARE Nd:YAG laser, developed and manufactured by Wontech, Ltd., Co. (Daejeon, South Korea), has expanded the scope of  picosecond technology to treat various types of scars, skin rejuvenation and nail disorders via a variety of handpieces (595 nm and 660 nm dye handpieces and HEXA MLA).

In this editorial, I will share my experience with PICOCARE and why it is my product of choice, as well as review the use of this technology to treat various cutaneous conditions.

Picosecond lasers deliver good therapeutic results and fast outcomes with only one-half to one-third of the energy used in a Q-switched laser. In addition, the incidence of side effects that are common in Q-switched lasers, such as post-inflammatory hyperpigmentation (PIH) or scarring, is much lower.

This is most evident when removing tattoos or treating pigmented lesions, such as freckles, lentigines, age spots, nevus of Ota, and other pigmentary disorders. After treatment with PICOCARE, patients with pigmented lesions are satisfied with the results and the gentle manner of the procedure, which provides less downtime and improved comfort via the lower energy. In addition, PICOCARE offers low fluence, enabling safe treatment of darker skin types.

Pigmented lesions

Depending on the location of the pigmented lesion, the 532 nm or 1064 nm wavelength may be selected (532 nm for epidermal pigments and 1064 nm for dermal pigments). However, to maximize effects when removing blemishes or brightening dull skin tone, I use both wavelengths in one session.

PICOCARE can also treat PIH stemming from laser treatment, surgery or other causes. I have many patients coming to my clinic to treat PIH resulting from post-liposuction via the popliteal fossa.
I deliver three to five passes of Pico-toning to the target area with a slight increase of energy from 1.0 to 1.2 J/cm2. Patients are quite pleased with the fast results and minimal pain.

As another example, I achieved great outcomes using these same parameters to treat a female patient with post-varicella PIH on the temple area and upper back. Thus, using PICOCARE to accelerate removal of PIH is a good option for those who cannot tolerate the side effects of bleaching cream.

For patients with melasma, I prefer to use PICOCARE treatment with oral medications. Since the factors of melasma vary between the different skin layers and hormones, it should be integrally managed. In my experience, low energy should be used to avoid hypopigmentation and/or deterioration of the lesion.

I use the Zoom handpiece to remove pigmentation and the HEXA MLA (micro lens array) fractional handpiece to improve the dermal environment. Then, I prescribe Transamine for improved outcomes.

Tattoo removal

Tattoo removal has been a major objective of the picosecond laser. The PICOCARE’s 532 nm and 1064 nm wavelengths effectively treat various tattoo colors. I have also found that using PICOCARE to remove tattoos is less painful, with fewer vesicles, bullae or scars, and quicker results.

In addition, I use the 595 nm and 660 nm dye handpieces due to their high absorption coefficient in blue, green and purple inks. See Figure 1.

Other indications

Interestingly, the PICOCARE’s 595 nm dye handpiece can also treat erythemato-telangiectatic rosacea and acne vulgaris. Although the exact mechanism of action is not known, it seems the wavelength’s characteristics can be effectively applied for the treatment of vascular lesions and acne.

Furthermore, the fractional handpiece with a picosecond laser system emits a unique energy, which generates laser-induced optical breakdown (LIOB). LIOB damages the target via plasma generation and cavitation creation, without effecting the stratum corneum and basal membrane. This produces collagen remodeling, which helps in scar treatment, skin rejuvenation and many more indications.

One such indication is acne scarring, which is frequently treated with HEXA MLA. After one treatment with HEXA MLA patients with depressed scars observed improvement. Another surprising discovery was its remarkable effectiveness on hard-to-treat rolling scars and icepick scars.

For patients who have acne scars with Systemic Lupus Erythematosus (SLE), telangiectasia or acne redness, I combine the HEXA MLA treatment with the 595 nm dye handpiece procedure.

To maximize the therapeutic effects, I deliver regenerating components, such as EGF, FGF, Tranexamic acid, Polydeoxyribonucleotide and y-polyglutamic acid, to the treatment site where microchannels have been created by the HEXA MLA procedure.

The most popular general procedure with HEXA MLA is skin rejuvenation. Compared to conventional fractional lasers, such as carbon dioxide and Er:YAG, procedural inconvenience and heat are low, but results are excellent.

Using relatively low or moderate energy levels provides a very short window of downtime, from a few hours to a maximum of one to two days. Patients have reported outstanding improvements on periorbital wrinkles, infraorbital fine lines, enlarged pores, skin firmness, skin texture, as well as skin tone. See Figure 2.

The addition of neurotoxin and/or filler injections after the rejuvenation procedure will further enhance the clinical outcomes. Dorsal hand rejuvenation can even be performed. Note that it is important to evaluate skin thickness in order to determine adequate fluence when treating the dorsal hand.

PICOCARE is also being used to treat melanonychia, a nevus in the nail bed. While long-pulsed lasers are sometimes used, the high fluence involves pain and deformation of the nail surface. Conversely, treatment with PICOCARE is more comfortable and offers satisfactory results. See Figure 3.

Prior to treatment, a Potassium hydroxide (KOH) test should be done to exclude possible mychomycosis.

As I have used PICOCARE to treat this wide range of indications with highly satisfying results, the device has now become the most popular one in my clinic.

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