Table Of ContentAesthetic Applications of Intense
Pulsed Light
Lucian Fodor (cid:129) Yehuda Ullmann
Monica Elman
Aesthetic Applications
of Intense Pulsed
Light
Authors
Lucian Fodor, MD, PhD Yehuda Ullmann, MD
Plastic Surgery Unit Professor and Chief of Plastic and Aesthetic
Emergency District Hospital Surgery
Cluj-Napoca, Romania Rambam Health Care Campus
and 8 Ha’Aliyah Street
Plastic Surgeon Haifa 35254
Rambam Health Care Campus Israel
Haifa, Israel
and Monica Elman, MD
Chirurgie I Private Practice Dermatology, Lasers
Str. Clinicilor 3-5 and Lights
Cluj-Napoca 400006 Maccabbi Insurance, Haifa & Tel Aviv,
Romania 14 Recanati Street
and Tel-Aviv, 69494
Rambam Health Care Campus Israel
8 Ha’Aliyah Street
Haifa 35254
Israel
ISBN 978-1-84996-455-5 e-ISBN 978-1-84996-456-2
DOI: 10.1007/978-1-84996-456-2
Springer London Dordrecht Heidelberg New York
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Library of Congress Control Number: 2010937624
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To my wonderful wife, Adriana Fodor
And my son Radu,
For fi lling my life with love and happiness
To my parents, Rozalea and Marian Fodor,
And my brother Marius and his wife Dana
For their encouragement of all my efforts
Lucian Fodor
This book is a small thank to my supportive and loved family:
Tami, Liran, Shachaf, and Yotam
Yehuda Ullmann
This book is dedicated to my lovely family
Arie Karin Dana Shay and my mother Marietta,
for their love and unconditional belief and support to me
Monica Elman
Foreword I
There are countless books written on cosmetic laser treatments. In many of these
books there is either a chapter written about Intense Pulsed Light (IPL) treatment or
minimal discussion of IPL treatments as part of a laser chapter. Finally there is now
a book solely dedicated to IPL treatments. Drs. Fodor, Ullmann and Elman dedicate
distinct chapters to Intense Pulsed Light treatment for skin rejuvenation, hair removal
and vascular lesions. Equally as important the book describes in depth the unique IPL
tissue interaction, IPL patient selection and complications that can occur from treat-
ments. This book is a must read for anyone dedicated to optimizing results and mini-
mizing risks of IPL treatment.
New York, NY, USA David J. Goldberg
Foreword II
One of the most controversial light based technologies, which had its birthplace in
San Diego, California (CA), USA in 1992, and cleared by the US FDA in late 1995
as the Photoderm™ (ESC/Sharplan, Norwood, MA, now Lumenis, Santa Clara, CA),
is the non-coherent polychromatic fi ltered fl ashlamp intense pulsed light (IPL) source.
It was initially launched and promoted as a radical improvement over existing meth-
ods for elimination of leg telangiectasia due to pressure from venture capital groups
that funded its development. While the treatment of leg telangiectasia was possible,
additional advantages recognized early on was the IPL’s ability as a specifi c modality
to minimize the possibility of purpura common to pulsed dye lasers (PDL), as well as
the elimination of hair and lentigines. Continued use proved that the device was of far
greater utility for other indications than leg telangiectasias (Weiss et al. 2000a ; Bitter
2000 ; Goldberg and Cutler 2000 ; Raulin et al. 1999 ; Jay and Borek 1998; Weiss et al.
1999 ; Raulin et al. 1997b –d; Schroeter et al. 1997 ) . The road to usability, reproduc-
ibility and effi cacy was a long one with some clinical users and many “laser experts”
dismissing the IPL as a harmful and useless form of technology. The term “PhotoBurn”
was coming used. It is ironic that the IPL is now considered the gold standard for
treatment of vascular lesions in addition to the many of the signs of photoaging (Weiss
et al. 2000a ; Bitter 2 000 ; Goldberg and Cutler 2000 ; Sadick et al. 2000 ; Weiss and
Sadick 2000 ) . Testimony to the acceptance of the IPL as a valid effi cacious techno-
logical break-through is evidenced by dozens of different manufacturers producing
various forms of IPL with the estimated sale of 30,000 IPL devises worldwide in the
last 18 years. It is thus fi tting that after 18 years of clinical use a textbook solely
devoted to Aesthetic Application of the IPL come into print. Drs. Fodor, Ullmann and
Elman are to be commended for their outstanding work.
Developmental History
This is the story of the development of the IPL by one of the developers. I began my
research into laser treatment of leg veins with the very fi rst production model of the
Candela pulsed dye laser purchased in March 1987. This research on rabbit ear veins
(Goldman et al. 1990 ) and then human leg veins (Goldman and Fitzpatrick 1990 )
demonstrated that a 585 nm laser pulsed at 0.45 ms could effectively cause thermal
coagulation of blood vessels <0.4 mm in diameter. The problem (in human leg veins)
was prolonged purpura and post-treatment hyperpigmentation and hypopigmenta-
tion. After a lecture given at the Westwood Conference on Clinical Dermatology in
Foreword II
Rancho Mirage, CA on “Management of Leg Veins” in April 1992, I was approached
by Dr. Shimon Eckhouse, an aerospace engineer from Israel, who was working in San
Diego. He told me he had an idea to treat leg veins with a fl ash-lamp devise used to
vaporize paint off of fi ghter jets. We fi rst discussed his idea in the hotel bar with my
partner, Richard Fitzpatrick, MD. Over a few beers, we hypothesized the ideal param-
eters for such a devise. Dr. Fitzpatrick and I initially requested an IPL that could vary
both the pulse duration as well as the wavelength cut-off fi lter between pulses. Our
idea was to thermocoagulate the vessel and protect the skin. The reason for multiple
sequential cut-off fi lters was to take advantage of the potential interaction with both
oxygenated and deoxygenated hemoglobin. Unfortunately, that exact devise could
not be produced and interesting, over 10 years later, the Cynosure laser company
came out with such a devise using multiple sequential pulsing of a 595 and 1,064 nm
laser to treat blood vessels (a project that I too was asked to investigate) (Larson and
Goldman 2007). After our meeting, Dr. Eckhouse said that he would make the devise
we requested and deliver it to us in San Diego by the end of the summer. I was to
arrange for an animal research facility to test the devise on the rabbit dorsal marginal
ear vein model system that I had been using to evaluate the effect of different types
and concentrations of sclerosing solutions on blood vessels.
The initial study using a prototype devise was performed on rabbit ear veins at the
HTI animal research center in Ramona, California in September 1992. Dr. Fitzpatrick
and I treated ten rabbits with a variety of pulse durations and energies ranging from 1
to 15 ms and 10 to 20 J/cm2 , all with a 515-nm cut-off fi lter with one pulse. We also
“inadvertently” treated an ankle telangiectasia on Dr. Fitzpatrick. The rabbit ears
were photographed and biopsied from 1 h to 30 days later. Many of the dorsal mar-
ginal ear veins had disappeared. Histologically, many veins were thermocoagulated
and most of the overlying epidermis was not damaged. The theoretical concept was
proven and human studies (in addition to Dr. Fitzpatrick’s ankle) could begin. I pre-
sented the results of this trial at the 6th Annual Congress of the American College of
Phlebology in Orlando on February 1993 in a lecture titled: “Clinical and Histologic
Evaluation of the ESC Vascular Lesion, Pulsed Light Source on the Dorsal Marginal
Rabbit Ear Vein.” (Dr. Robert Weiss, who was a moderator of the lecture session was
very interested in my presentation and would later become one of the leading inves-
tigators and innovators of the IPL.)
The fi rst human pilot study was performed on seven leg vein patients and four
PWS patients at our dermatology offi ce in Encinitas, CA, on November 17 and 18,
1992. Single pulses, again with a 515 nm cut-off fi lter without cooling and without a
light-guide were used on leg veins ranging from 0.2 to 1 mm in diameter. Energies of
10–20 J/cm 2 were used with single pulses of 3–15 ms. Leg vein patients were fol-
lowed for 6 weeks and PWS patients followed for 4 weeks. Excellent resolution was
seen in 60% of veins and PWS with epidermal burning occurring in 40% and scar
formation in 20%. It was clear that much more work needed to be done.
We then began a formal IRB-approved human study on leg veins every Tuesday
afternoon for many months developing fi rst the multiple sequential pulsing technol-
ogy then procuring a variety of cut-off fi lters ranging from 550 to 570 to 590 nm that
would not crack. But it was not until we incorporated a quartz (later changed to a
sapphire) light guide used in conjunction with ice-cold clear ultrasonic gel which
would be stable with rapid heating and transmit light without distortion that repro-
ducible effi cacy with minimal epidermal damage could be obtained. The results from
this human leg vein trial were fi rst presented in May 1993 to the Israel Dermatologic
Foreword II
Society in Hertzilia, Israel, in a lecture titled, “Treatment of Varicose and Telangiectatic
Leg Veins: Sclerotherapy and Lasers” and in June 1993 at the Pacifi c Vascular
Symposium: Controversies in the Management of Venous Disorders on the Kohala
Coast, Hawaii, in a lecture titled, “Laser Treatment of Leg Veins.” The entire study
was presented in December 1993 at the 53rd Annual Meeting of the American
Academy of Dermatology in New Orleans, LA, titled, “Can Light Be Useful in the
Management of Lower Extremity Telangiectasia and Reticular Veins.” Finally, the
theoretical basis for using the IPL in treating benign vascular lesions was presented
and hypothesized in our textbook, C utaneous Laser Surgery: The Art and Science of
Selective Photothermolysis . Goldman, Fitzpatrick RE. Mosby-Year Book Inc., St.
Louis, MO, 1994. After concluding our leg vein trials, we fi rst began treating facial
telangiectasia throughout 1994 and hemangiomas, venous malformations, and hyper-
trophic scars in May 1995 all with excellent results.
A multicenter study was begun in 1993 with United States FDA approval of the
fi rst systems in late August 1995. At the time of FDA approval, over 20 Photoderm
systems were in use in “clinical trials” within the USA with another 20 IPLs in use in
Europe and Canada. While some doctors were reporting outstanding results, others
reported that the devise was fraught with complications. In August 1995 at the
Controversies in Cutaneous Laser Surgery meeting in Bermuda, I presented a lecture,
“Laser & Light Source Treatment of Spider Leg Veins.” In the discussion that fol-
lowed, Rox Anderson, MD, claimed that the devise was fraught with complications
and predicted that patients would be seriously harmed and even die from the hand-
piece which was bound to explode. Needless to say, it was diffi cult to debate someone
of Dr. Anderson’s stature and the IPL fell into disrepute.
Fortunately, I and many others continued to pursue development of the IPL and
the fi rst large-scale publication appeared in D ermatologic Surgery and Cosmetic
Dermatology in 1996 detailing the excellent results of our multicenter leg vein study
(Goldman and Eckhouse 1996 ; Goldman 1995 ) . An accompanying editorial by Drs.
Robert and Margaret Weiss attest to the diffi culty of performing treatment with the
IPL and to the advances in treatment techniques that came with experience (Weiss
and Weiss 1996 ) .
A variety of benign vascular lesions were treated with multiple case reports and
studies attesting to the effi cacy of the IPL on these conditions (Raulin et al. 1997a ) .
In fact, the treatment of leg veins with the IPL decreased in extent due to variable
results (Dover et al. 1999 ) , while the treatment of both pigmented and vascular lesions
with “rejuvenation” of the skin gained in popularity (Nestor et al. 2000; Weiss et al.
2000b ; Goldman and Weiss 2001 ) .
The fi rst evidence of the ability to remove hair with the IPL came in August 1996
after I treated a facial port wine stain (PWS) in a man whose PWS extended to his
moustache area. While the PWS cleared over 50% with one IPL treatment, the
patient’s moustache only grew back 50%. This was reported to the ESC Company as
a complication, but Hillel Bachrach, the Vice President of Sales and Marketing at
ESC recognized this not as a complication, but as a new indication for the IPL. My
back was then treated in November 1996 with biopsies demonstrating effective ther-
mocoagulation of hair follicles, clinical studies were performed on male transvestites
in Berlin, Germany and the IPL, with a higher power and faster recharging time was
launched as the Epilyte™.
Unfortunately, during the early days of the IPL, many physicians, especially those
with important ties to laser companies were extremely vocal in their opposition to this
Foreword II
new technology. The fact that the early IPL machines took some technical expertise
and were not just “point and shoot” systems also proved to provide adverse results in
those physicians who did not grasp the concept of multiple sequential pulsing, epi-
dermal cooling and the use of cold coupling gel as an interface between the IPL
fl ashlamp, light-guide crystal and the skin. T he New York Times published a one sided
negative article on June 23, 1996, titled “Unsightly Veins? Zap Wall St. Woes? Zap.”
This was countered by a Letter to the Editor from Harvey Jay, MD, an early adopter
and innovator of the IPL, explaining that the IPL is like a scalpel, a trained surgeon
will get great results and a novice will not get acceptable results (Jay 1996). Next, a
particularly strong article against the IPL was published in the J ournal of the American
Academy of Dermatology by Dr. David Green (Green 1998 ) . Dr. Green observed a
high degree of adverse effects and patient dissatisfaction. In a subsequent panel dis-
cussion at the Annual Meeting of the American Society of Laser Medicine and
Surgery in San Diego, April, I was asked to explain why I disagreed with Dr. Green’s
statements. I responded, like Dr. Jay did to the N ew York Times , that it is all based on
the expertise of the physician. For that I was sued for libel in San Diego Superior
Criminal Court by Dr. Green. The case was tried before a jury and no damages were
awarded to Dr. Green but at a cost of over $40,000 to me in legal fees to defend my
remarks (Goldman 2 001 ) . Such was the climate in the early life of the IPL.
However, it has been my belief over the last 15 years that the IPL is the most ver-
satile machine available for the cosmetic surgeon (Goldman 2002 ) . The IPL is not
only highly effective for benign vascular and many pigmented lesions but has also
been incorporated into photodynamic therapy treatment of superfi cial non-melanoma
skin cancer, acne and photodamage (Gold and Goldman 2004 ; Goldman et al. 2005 ;
Nootheti and Goldman 2006 ) .
Final Thoughts
The one question I am most commonly asked is: If I can only afford to purchase one
laser, which one do you recommend? I must fi rst begin with the disclaimer that I am
or have been a consultant, lectured for, performed workshops for and/or received
discounted equipment and/or research support from many different laser companies:
Lumenis (formerly ESC, Sharplan and Coherent), CoolTouch, ICN, Altus Medical,
Cynosure, Candela, ConBio, Diomed, Wavelight, Laserscope, Deka, Sciton and
Syneron. I have also been instrumental in the development and/or initial clinical test-
ing of the pulse dye laser, Q-switched alexandrite laser, Ultrapulse CO laser, intense
2
pulsed light, long pulsed 1,064 nm Nd:YAG Vasculite, CoolTouch Varia, CoolGlide
(now Cutera), CoolTouch I, II and III, Clearlight, Relume, Aluma, Wavelight
Alexandrite and Ruby Lasers, Active FX, Deep FX, CoolLipo, CTEV, Cynosure
Affi rm and Affi rm Multiplex, Smart Lipo and Smart Lipo Multiplex, Cynosure
Cynergy, Triactive, Velashape, Smoothshape, GentleWaves, Laserscope Solis, and a
few more that never went into mass production. My practice also presently owns
lasers from all of these companies that are used every day. With this background one
can see that my answer will upset the majority of laser companies, but the question is
valid and deserves an answer.
One can argue that almost any laser can be used to treat a variety of conditions by
changing various parameters of the laser or using the laser in conjunction with some
