Clinical Experience in the Treatment of Different VascularLesions Using a Neodymium-Doped Yttrium AluminumGarnet Laser

EKREM CIVAS, MD,� EROL KOC, MD,y BERNA AKSOY, MD,z AND HASAN METE AKSOY, MDy

BACKGROUND A neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has been used with goodresults for the treatment of various vascular lesions.

OBJECTIVE To report our experience with a variable long-pulsed Nd:YAG laser for the treatment ofdifferent vascular lesions.

MATERIALS AND METHODS One hundred ten patients with different vascular skin lesions were in-cluded. Patients were examined before the treatment; 1 week after each treatment session; and 1, 2, and3 months after the last treatment session. Improvement was judged according to clinical examination ofthe patients and by comparing pre- and post-treatment photographs. Results were graded in four groupsusing percentage resolution (0–25%, 26–50%, 51–75%, and 76–100%.

RESULTS One hundred five patients (19 port wine stains, 48 telangiectasias, 25 hemangiomas, and 13other vascular lesions) completed the study; 71.5% of patients showed greater than 50% improvement.Good to excellent (more than 50%) results were achieved in 63.2% of patients with port wine stain, 80.0%of patients with hemangioma, 66.7% of patients with telangiectasia, and 84.6% of patients with othervascular lesions; 71.5% of all patients were very satisfied or satisfied with the results.

CONCLUSION A variable long-pulsed Nd:YAG laser was found to be effective in the treatment ofdifferent vascular lesions ranging from easy to difficult to treat.

The authors have indicated no significant interest with commercial supporters.

In the treatment of vascular lesions, many

therapeutic approaches such as cryosurgery,

embolization, pharmacological therapy, surgical ex-

cision, electrodessication, and laser therapy have

been employed.1–4 Various laser systems are now

being widely used for the treatment of vascular

skin lesions in dermatology practice.1,2,5

Neodymium-doped yttrium aluminum garnet

(Nd:YAG) laser offers a valuable treatment modality

in vascular tumors, especially large ones.1,3,5

The Nd:YAG laser system emits a continuous-

wave infrared light with a wavelength of 1,064 nm.1

Laser light at this wavelength penetrates the tissue

up to 4 to 5 mm.2 Water absorbs Nd:YAG laser

light poorly; hemoglobin predominantly absorbs

it, leading to selective photocoagulation within

blood vessels.1,2 The advantages of Nd:YAG

laser over other lasers are weaker melanin

absorption and deeper penetration with

protection of the epidermis using a cooling

effect.3,6,7 The Nd:YAG laser is capable of

photothermal coagulation of large, deeply located

blood vessels (venulectasia and reticular veins) in

the mid-dermis, which are not very responsive to

other laser systems.3,6

In this study, a series of 110 patients with

hemangiomas, port wine stains, telangiectasias,

and other vascular lesions were treated using

the Nd:YAG laser. The purpose of this study was

to report our experience with the use of a

single-wavelength Nd:YAG laser in the treatment

of vascular lesions and to evaluate long-term

results.

& 2009 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. �ISSN: 1076-0512 � Dermatol Surg 2009;35:1933–1941 � DOI: 10.1111/j.1524-4725.2009.01355.x

1 9 3 3

�Civas Clinic, Ankara, Turkey; yDepartment of Dermatology, Gulhane School of Medicine, Ankara, Turkey;zDermatology Clinic and yPlastic and Reconstructive Surgery Clinic, 29 Mayis Private Hospital, Ankara, Turkey

Materials and Methods

Laser Equipment

A high-peak-power, long-pulsed Nd:YAG laser sys-

tem (Coolglide, Vantage, Cutera Inc., Brisbane, CA)

was used. This Nd:YAG laser has a wavelength of

1,064 nm and pulse duration ranging from 0.1 to

300 ms. The maximum fluence that this system can

deliver is 300 J/cm2. Spot sizes are adjustable from 3

to 10 mm at the level of the handpiece. Epidermal

cooling is achieved using a self-contained internal

cooling system that is administered to tissue through

the handpiece.

Patient Profile

One hundred ten patients (57 male, 53 female) with

Fitzpatrick skin phototypes II to III and aged 7 to 71

were enrolled in this study. Informed consent was

obtained from each patient. In all cases, the diag-

nosis of vascular lesions was decided clinically.

Treated lesions were categorized as vascular tumors

(e.g., hemangiomas: flat or tuberous); vascular mal-

formations (e.g., port wine stains: flat or elevated);

ectasias, classified as small (e.g., telangiectasias) or

large (e.g., leg or facial veins); and other vascular

lesions (e.g., spider angiomas, venous lakes). Patients

with a history of deep vein thrombosis, pregnancy or

lactation, diseases associated with poor wound

healing, hypercoagulability, connective tissue

disease, predisposition to hypertrophic scars and

keloids, oral isotretinoin treatment in the previous

2 months, or immunosuppression were excluded.

Pre- and Intraoperative Considerations

Topical anaesthesia with 2.5% lidocaine and 2.5%

prilocaine cream was used for patients with port

wine stains and tuberous hemangiomas 1 hour be-

fore treatment. There was no need for any anesthesia

for other patients. The entire lesion was treated with

the 1,064-nm Nd:YAG laser. In some cases, laser

parameters were altered according to the results

obtained from a test site. Special effort was made to

direct laser energy away from vital structures such as

the eyes. All patients were required to wear protec-

tive eye gear. Each vascular lesion was assessed for

vessel size, depth, and color. Laser settings (fluence,

pulse duration, and spot size) were carefully deter-

mined according to personal experience of the

treating physician and the manufacturer’s recom-

mendations. A 3- or 5-mm spot size was used for

superficial vascular lesions (e.g., telangiectasias, flat

hemangiomas), and a 5- or 7-mm spot size was se-

lected for deeper or larger lesions (e.g., tuberous

hemangiomas, port wine stains, large or deep leg

veins). Pulse durations were selected according to the

estimated vessel size for each lesion: 10 to 20 ms for

thin, 10 to 25 ms for medium, and 10 to 30 ms for

thick vessels. Variable fluences (60–210 J/cm2) were

used for the treatment. Selection of fluence was

based on estimated vessel size, vessel depth, vessel

color, and spot size setting.

Postoperative Considerations

All patients were informed that some degree of ery-

thema, swelling, burning, and rarely skin erosion

would be experienced after the procedure. In these

cases, patients were instructed to apply mupirocin

ointment twice daily for 1 week. Affected areas of

skin were treated with mupirocin ointment after

each treatment session. Patients were advised to take

analgesics such as paracetamol if they felt it was

necessary. Treatment was repeated in some patients

considering the rate of clearance of their lesions,

with an interval of 6 weeks or longer between the

sessions. Patients were examined 1 week after each

treatment session and 1, 2, and 3 months after the

last treatment session. Photographs were taken

before and after each treatment session.

Evaluation

An experienced laser dermatologist (EC) judged re-

sults using direct visual patient examination and by

comparing before and after photographs. Results

were categorized into four groups based on resolu-

tion (0–25%, no improvement = poor; 26–50%, mild

improvement = fair; 51–75%, moderate improve-

ment = good; and 76–100%, significant improve-

ment = excellent). At the final visit, the patients were

D E R M AT O L O G I C S U R G E RY1 9 3 4

N D : YA G L A S E R & VA S C U L A R L E S I O N S

asked to rate their satisfaction with the procedure

(1 = not satisfied, 2 = little satisfied, 3 = somewhat

satisfied, 4 = satisfied, 5 = very satisfied).

Statistical Analysis

Statistical analysis was performed using SPSS, ver-

sion 10.0 (SPSS Inc., Chigaco, IL). The chi-square

test and t-test were used for statistical analysis. A t-

test was used to compare the relationship between

clinical responses. The statistical level of significance

was set at po.05.

Sample Cases

Case 1

A 41-year-old man applied for the treatment of

hemangioma of the forehead present for approxi-

mately 10 years (Figure 1). His lesion was treated

using a one-session treatment with a 1,064-nm

Nd:YAG laser set at pulse duration of 20 ms and a

fluence of 150 J/cm2 with a 5-mm handpiece. The

result after one treatment session was excellent

(Figure 2).

Case 2

A 43-year-old man applied for treatment of a con-

genital port wine stain lesion overlying the right side

of his neck and right lower cheek (Figure 3). He

received three treatment sessions separated by

6-week intervals. The settings for the 1,064-nm

Nd:YAG laser treatment for all three sessions (1/2/3)

were pulse duration 10 to 15/10 to 20/10 to

20 ms and a fluence of 65 to 135/90 to 150/100 to

160 J/cm2, with 5- to 7-mm spot sizes. After three

treatment sessions, 51% to 75% resolution was

achieved (Figure 4).

Case 3

A 41-year-old woman applied for treatment of a

congenital hemangioma lesion on her right

Figure 1. Sample case 1 before treatment: clinical appear-ance of the hemangioma present for 10 years.

Figure 2. Sample case 1: disappearance of the hemangiomaafter one treatment session.

Figure 3. Sample case 2: clinical appearance of port winestain before treatment.

3 5 : 1 2 : D E C E M B E R 2 0 0 9 1 9 3 5

C I VA S E T A L

cheek (Figure 5). She had undergone an unsuccessful

surgical treatment of her lesion 20 years before.

She received three treatment sessions separated by

6-week intervals. The settings of the 1,064-nm

Nd:YAG laser treatment for all three sessions (1/2/3)

were pulse duration 20 to 35/15 to 20/10 to 20 ms

and fluence of 80 to 135/90 to 150/100 to 170 J/cm2,

with 5- to 7-mm spot sizes. After three treatment

sessions, 76% to 100% resolution was achieved

(Figure 6).

Results

Of the 110 patients (53 male (50.4%), 52

female (49.6%)), 105 completed the study. The pa-

tients’ mean age was 33.1 (range 7–71). Five patients

received the treatments but had only a single

follow-up visit and failed to return for the final

evaluation. The mean fluence was 95.8 J/cm2 (range

60–210 J/cm2), the pulse duration ranged from

10 to 30 ms. The number of treatments ranged from

one to five, and the average number of treatments

for each patient was 2.5. Table 1 summarizes

patient characteristics, type and anatomic

distribution of the lesions, fluence, and number of

treatments.

Nineteen patients (14 male, 5 female) were treated

for port wine stains. Mean age was 27.1 (range 9–

43). The average number of treatments was 2.9. A

good to excellent response was achieved in 63.2% of

the patients (450% improvement), and this was

statistically significant (po.05).

Twenty-five patients (19 male, 6 female) were

treated for hemangiomas. Mean age was 35.1 (range

7–61). The average number of treatments was 2.6. A

good to excellent response was achieved in 80% of

the patients, and this was statistically significant

(po.05).

Figure 4. Sample case 2: 51% to 75% resolution of port winestain after three neodymium-doped yttrium aluminum gar-net laser treatment sessions.

Figure 5. Sample case 3: clinical appearance of congenitalhemangioma located over the right mandibular region be-fore treatment.

Figure 6. Sample case 3: 76% to 100% resolution of congen-ital facial hemangioma after three neodymium-doped yt-trium aluminum garnet laser treatment sessions.

D E R M AT O L O G I C S U R G E RY1 9 3 6

N D : YA G L A S E R & VA S C U L A R L E S I O N S

Forty-eight patients (11 male, 37 female) were

treated for telangiectasias. Of these, 13 had facial

telangiectasias, and 35 had leg venulectasias. Mean

age was 41.2 (range 17–71). The average number of

treatments was 2.4. A good to excellent response

was achieved in 66.7% of the patients, and this was

statistically significant (po.05).

Thirteen patients (9 male, 4 female) were treated

for other vascular lesions. Of these, five had

spider angiomas, five had venous lakes, two had

poikiloderma of Civatte, and one had angiokera-

toma. Mean age was 29.2 (range 11–57). The

average number of treatments was 2.1. A good to

excellent response was achieved in 84.6% of

the patients, and this was statistically significant

(po.05).

Almost three-quarters (71.5%) of the patients

achieved good to excellent results (450% improve-

ment). Table 2 summarizes the clinical responses of

the treated patients.

Some patients experienced only partial clearing of

their lesions and had two or more treatment sessions

to any given area. Patients required one to five

treatment sessions depending on response of their

lesions to treatment. In general, darker lesions re-

sponded better than lighter ones. Port wine stains

with elevated components and purplish color

responded better than flat and pink ones.

Sixty-one patients (58.1%) were satisfied or very

satisfied, 21 (20%) were somewhat satisfied, 10

(9.5%) were little satisfied, and 13 (12.4%) were not

satisfied with the clinical results of Nd:YAG laser

treatment.

Transient side effects such as erythema, erosions,

burning, and crusting were observed infrequently

during the treatment sessions. These side effects were

not specifically recorded and added to the evaluation

because they did not lead to cessation of laser ther-

apy. The incidence of development of vesiculation

and erosion was higher in patients treated with

TABLE 1. Patient and Treatment Characteristics

Characteristic

Port Wine Stains

(n = 19)

Hemangiomas

(n = 25)

Telangiectasias

(n = 48)

Other Vascular

Lesions (n = 13)

Total

(N = 105)

Sex, n (%)

Male 14 (73.7) 19 (76) 11 (22.9) 9 (69.2) 53 (50.4)

Female 5 (26.3) 6 (24) 37 (77.1) 4 (30.8) 52 (49.6)

Age, mean (range) 27.1 (9–43) 35.1 (7–61) 41.2 (17–71) 29.2 (11–57) 33.1 (7–

71)

Fitzpatrick phototype, n (%)

II 13 (68.4) 14 (56) 26 (54.1) 7 (53.8) 60 (57.1)

III 6 (31.6) 11 (44) 22 (45.9) 6 (46.2) 45 (42.9)

Location, n (%)

Head and neck 17 (89.4) 16 (64) 13 (27.1) 11 (84.6) 57 (54.3)

Other 2 (10.6) 9 (36) 35 (72.9) 2 (15.4) 48 (45.7)

Size, cm2, n (%)

o10 4 (21) 12 (48) 21 (43.8) 13 (100) 50 (47.6)

10–99 13 (68.4) 13 (52) 27 (56.2) F 53 (50.5)

� 100 2 (10.6) F F F 2 (1.9)

Fluence, J/cm2, range 60–120 90–140 140–210 60–160 60–210

Spot size, mm, range 5–7 3–5 3–5 5–7 5–7

Pulse duration, ms,

range

10–30 10–25 10–15 10–20 10–30

Number of

treatments, average

2.9 2.6 2.4 2.1 2.5

3 5 : 1 2 : D E C E M B E R 2 0 0 9 1 9 3 7

C I VA S E T A L

higher fluence and lower pulse duration laser ther-

apy and in patients with darker skin type (e.g., type

III). Erosions healed in the early postoperative period

after treatment with mupirocin ointment. Some

erosions healed with pigmentary changes and scar-

ring. Postoperative atrophic scar formation was seen

in patients with deeper erosions. We observed

hyperpigmentation in six patients, hypopigmenta-

tion in three patients, and atrophic scars in four

patients, as shown in Table 3. We observed these side

effects in only 13 patients (12.4%).

Discussion

The use of laser energy as a therapeutic option in the

treatment of vascular lesions offers a conservative,

effective approach.2,3 Although Nd:YAG laser has

been shown to be effective in the treatment of large

or deep vascular lesions, total eradication has been

rare and infrequently reproducible in the literature.3

We think that it is now possible to treat large and

deep vascular lesions effectively and satisfactorily

with new Nd:YAG laser systems that supply the re-

quired fluence and pulse duration parameters. The

1,064-nm Nd:YAG laser is able to create a coagu-

lation effect at a depth of 6 to 10 mm and therefore is

capable of treating moderately deep, large-caliber

vessels and feeding reticular veins of the skin and

mucosa.1,3 The 1,064-nm Nd:YAG laser offers an

effective, well-established method for treating deep

and large vascular lesions.1,2 In most skin types, the

Nd:YAG laser allows for effective treatment of a

broad range of vessel diameters.3,8 There are several

studies with use of Nd:YAG laser for treating vas-

cular lesions in the literature.1–3,8

Groot and colleagues3 described an algorithm to

select the parameters for using the 1,064-nm

Nd:YAG laser for a variety of deep vascular lesions.

In their report, complete clinical resolution was

achieved in many lesions treated, with few reported

side effects. This algorithm has been proposed to

represent a safe, effective, systematic, sequential yet

simple guideline for laser surgeons to achieve re-

producible and consistent clinical results. We also

used Nd:YAG laser treatment for our patients by

following this algorithm.

Grantzow and coworkers9 reported 77% to 98%

size reduction in hemangiomas after percutaneous

Nd:YAG laser therapy, depending on the number of

treatments. In another study, 20 patients with hem-

angiomas and venous malformations were treated

with Nd:YAG laser and followed up for 8 years.1 In

TABLE 2. Clinical Response of Patients

Clinical

Response, %

n (%)

Port Wine

Stains Hemangiomas Telangiectasias

Other Vascular

Lesions Total

0–25 3 (15.8) 2 (8.0) 6 (12.5) 1 (7.7) 12 (11.4)

26–50 4 (21.0) 3 (12.0) 10 (20.8) 1 (7.7) 18 (17.1)

51–75 9 (47.4) 12 (48.0) 24 (50) 8 (61.5) 53 (50.5)

76–100 3 (15.8) 8 (32.0) 8 (16.7) 3 (23.1) 22 (21.0)

Total 19 (100.0) 25 (100.0) 48 (100.0) 13 (100.0) 105 (100.0)

TABLE 3. Incidence of Side Effects

Side Effect

n (%)

Port Wine Stains Hemangiomas Telangiectasias Other Vascular Lesions Total

Hyperpigmentation 0 (0) 0 (0) 6 (12.5) 0 (0) 6 (5.7)

Hypopigmentation 0 (0) 0 (0) 2 (4.2) 1 (7.7) 3 (2.9)

Atrophic scar 3 (15.8) 1 (4) 0 (0) 0 (0) 4 (3.8)

D E R M AT O L O G I C S U R G E RY1 9 3 8

N D : YA G L A S E R & VA S C U L A R L E S I O N S

this study 20% of hemangiomas underwent near

complete remission, more than 25% partial im-

provement was observed in 66% of the cases with

hemangiomas, and more than 90% excellent re-

sponse was achieved in two of five cases (40%) with

venous malformations. Only 30% of the patients

were not satisfied with the treatment and underwent

surgical excision.1 We achieved more than 50%

clinical response in 80% of 25 patients with hem-

angiomas. Ulrich and colleagues1 observed scars

(40%), hyper- and hypopigmentation (23%), mild

atrophy (20%), and wrinkled texture (17%) as ad-

verse effects after complete regression. We observed

atrophic scars only in one (4%) of cases with hem-

angiomas. Ulrich and colleagues1 have proposed that

percutaneous or intralesional Nd:YAG laser is sug-

gested to be valuable in the treatment of venous

malformations or deeper hemangiomas, especially

those with rapid uncontrollable growth or affecting

functional areas. They have suggested that the use of

this laser is a minimally invasive technique in the

treatment of patients with hemangiomas and venous

malformations with good aesthetic and functional

results. Clymer and colleagues treated 10 patients

with hemangiomas or vascular malformations using

interstitial Nd:YAG laser. They reported an overall

mean reduction in size of 53% and more than 50%

reduction in size in six patients. Vlachakis and

coworkers5 have found that the Nd:YAG laser is

capable of successfully treating massive and deep

hemangiomas in children. We achieved a good to

excellent response in 80% of patients with hem-

angiomas who were treated with Nd:YAG laser, and

there was only one case with a side effect of atrophic

scarring in this group of patients. The use of higher

fluence parameters than needed could explain this

side effect. An ulcer formed and healed with an

atrophic scar in this case.

Flashlamp pumped pulsed-dye laser (585 nm) was

thought to be the criterion standard in the treatment

of port wine stains. It penetrates the skin to ap-

proximately 1 to 2 mm, so it is less effective for

deeper vascular birthmarks.1,10 Most port wine

stains cannot be removed completely with pulsed-

dye laser treatment. Nd:YAG laser can penetrate

deeper (with a factor of 2.7 times) than pulsed-dye

laser into the dermis as far as deeper vessel damage is

concerned.10 Yang and colleagues10 compared a

595-nm pulsed-dye laser with a 1,064-nm Nd:YAG

laser in 17 patients with port wine stains and found

that the Nd:YAG laser performed at one minimum

purpura dose was safe and as effective as pulsed-dye

laser in fading of these lesions. They observed more

than 50% clearing of the lesions in 37% (6/16) of

patients. They observed hypertrophic scar develop-

ment in one patient treated with Nd:YAG laser. We

treated 19 patients with port wine stains and

achieved more than 50% improvement in 63.2%

(12/19) of the patients. These results are better than

results of Yang and colleagues. The only difference in

our Nd:YAG laser treatment protocol was pulse

duration, which was 10 to 30 ms, and this was

greater than Yang and colleagues’ 3- to 15-ms pulse

duration. This may have contributed to our better

clearing ratios. We observed atrophic scar develop-

ment in only three (15.8%) patients as an adverse

effect. Nd:YAG laser is safe and effective, especially

in the treatment of elevated and darker port wine

stains, but in lighter and flatter ones, it had higher

complication rates (e.g., atrophic scar) because short

pulse duration and high fluence levels are required.

Scars developed in some patients treated with laser at

the beginning. We think this was a result of lack of

experience because scars were not observed in other

cases treated later in our series. Atrophic scars are an

important cosmetic problem, so clinicians must be

careful when they treat port wine stains, especially

flat and pink ones, with Nd:YAG laser. In our ex-

perience, considering the number of patients with

scarring, Nd:YAG laser may not be the first choice

laser for treating port wine stains, although our ex-

perience shows that Nd:YAG laser can be a good

first choice in the treatment of port wine stains

with greater experience and the use of correct

parameters.

Facial and leg telangiectatic vessels are common

cosmetic problems.7 Although facial telangiectasias

are superficial and easy to treat, leg veins are deeper

3 5 : 1 2 : D E C E M B E R 2 0 0 9 1 9 3 9

C I VA S E T A L

and more difficult to treat.7,11 Initial efforts with the

1,064-nm Nd:YAG laser were focused on treatment

of deeper leg veins.8 Sadick12 demonstrated greater

than 75% clearance over a broad spectrum of leg

veins, 0.2 to 3 mm in diameter, increasing to 80% of

patients 6 months after 1,064-nm Nd:YAG laser

treatment. In this study, greater vessel clearing oc-

curred from follow-up months 3 through 6 without

any further treatment.12 Eremia and coworkers13

noted that, for treatment with Nd:YAG lasers,

sufficient fluence and proper choice of pulse width

were critical to obtaining good results in their com-

parative study with Nd:YAG, diode, and alexandrite

lasers for the treatment of leg veins 0.3 to 3 mm in

diameter. They observed more than 50% improve-

ment in 94% of Nd:YAG laser-treated sites but in

only 33% of 810-nm diode laser-treated sites and

58% of 755-nm alexandrite laser-treated sites. In

another study, Rogachefsky and colleagues6 found

significant improvement of leg veins after treatment

with Nd:YAG laser in 71% of sites treated. They

noted spontaneously resolving postinflammatory

hyperpigmentation in 62% of the cases who had

large blue reticular veins. They concluded that the

long-pulsed 1,064-nm Nd:YAG laser is effective and

safe for the treatment of lower extremity vessels,

especially large and blue ones. Major and

coworkers7 achieved good to excellent results in 29

of 32 cases with leg veins after one to five treatment

sessions with a Nd:YAG laser. They observed excel-

lent results, with 95% to 100% clearance of facial

telangiectasias.7 Eremia and Li11 reported a pro-

spective study involving 17 patients treated in one

session with a 1,064-nm Nd:YAG laser for facial

telangiectasias and reticular veins. They reported a

clearance rate of at least 75% at 1 month in 97% of

the sites that were treated and greater than 50%

improvement in all the sites treated. They proposed

that the efficacy of the Nd:YAG laser is similar to

expertly performed sclerotherapy. Sarradet and

colleagues14 demonstrated moderate to significant

improvement in 80% of patients 3 months after two

Nd:YAG laser treatment sessions for facial tel-

angiectasias. Bevin and colleagues8 reported good

results in 50% of the patients, with no adverse

effects reported in the long term with use of Nd:YAG

laser in the treatment of facial telangiectasias in eight

patients.

We treated 13 patients with facial telangiectasias and

35 patients with leg vein telangiectasias. We achieved

66.7% (32/48 patients) good to excellent results in

facial and leg vein telangiectasias. This is somewhat

lower than the results in the literature but higher

than Bevin and coworkers’ results. In our series, we

observed hyperpigmentation in six and hypopig-

mentation in two patients with telangiectasia. Our

practice of using lower pulse duration than required

for the high-pressure telangiectasia lesions may ex-

plain this. Hyperpigmentation may have developed

because of the use of high fluence and low pulse

duration in patients with dark skin types and large

vessels.

We also treated seven spider angiomas and five ve-

nous lakes with the Nd:YAG laser; 84.6% of these

lesions showed good to excellent response. The

effectiveness of Nd:YAG laser in these vascular le-

sions needs to be further examined.

Sixty-one of our patients (58.1%) were satisfied or

very satisfied with the results of Nd:YAG laser

treatment that they received. Patient satisfaction

from a laser procedure may not always parallel the

treating doctor’s assessment of success of laser

treatment.15 Gupta and Bilsland15 showed that psy-

chological distress decreases significantly after laser

treatment even in patients with minor vascular le-

sions, particularly telangiectasia and vascular spi-

ders. They demonstrated that 82% of patients found

laser treatment beneficial, whereas doctors’ assess-

ment of success rate was 79%15 so our patient sat-

isfaction percentages can be regarded as acceptable.

Nd:YAG lasers have the advantage of reaching

deeply located blood vessels while bypassing the

epidermis because of the minimal absorption by

melanin pigment at this wavelength. The disadvan-

tages of Nd:YAG laser include pain and the risk of

dermal damage associated with use of large spot

D E R M AT O L O G I C S U R G E RY1 9 4 0

N D : YA G L A S E R & VA S C U L A R L E S I O N S

sizes and high fluences. Many previously reported

complications related to Nd:YAG laser use were re-

lated to overheating as a result of inadequate contact

cooling of the skin.8 In our study, we failed to follow

up with five patients because they discontinued their

treatment due to pain and discomfort associated

with laser therapy. One may treat vascular lesions

with the same vessel diameter, depth, and color with

different spot sizes, fluences, and pulse durations.

Thus, discomfort and incidence of adverse effects

can be reduced by optimizing spot size, fluence, and

pulse duration. Smaller spot sizes deliver a greater

percentage of incident energy to the vessels and

avoid general dermal heating. Using spot sizes as

small as possible allowed us to minimize pain and

patient discomfort during treatment sessions and

reduced the risk of adverse effects.

The variable-pulsed 1,064-nm Nd:YAG laser with

different energy parameters was found to be effective

for several types of vascular skin lesions. Previously

challenging vascular lesions may be safely reduced in

size or cleared using the Nd:YAG laser. Our results

with the Nd:YAG laser with effective and appropri-

ate wavelength confirm that this laser can be safely

and repeatedly used for the treatment of different

types of vascular lesions. When used appropriately,

the Nd:YAG laser is a useful tool for removing and

ameliorating vascular lesions, but patients should be

aware of the limitations of the Nd:YAG laser in the

treatment of vascular lesions to avoid unrealistic

expectations. In conclusion, successful results were

achieved with the single 1,064-nm wavelength

Nd:YAG laser in the treatment of different vascular

lesions from easy to difficult to treat.

Acknowledgments The authors thank Baris Sur-

ucu for his contribution to the study by performing

statistical analyses.

References

1. Ulrich H, Baumler W, Hohenleutner U, Landthaler M. Neodym-

ium-YAG laser for hemangiomas and vascular malformationsFlong term results. J Dtsch Dermatol Ges 2005;3:436–40.

2. Vesnaver A, Dovsak DA. Treatment of vascular lesions in the head

and neck using Nd:YAG laser. J Craniomaxillofac Surg

2006;34:17–24.

3. Groot D, Rao J, Johnston P, Nakatsui T. Algorithm for using a

long-pulsed Nd:YAG laser in the treatment of deep cutaneous

vascular lesions. Dermatol Surg 2003;29:35–42.

4. Clymer MA, Fortune DS, Reinisch L, et al. Interstitial Nd:YAG

photocoagulation for vascular malformations and hemangiomas

in childhood. Arch Otolaryngol Head Neck Surg 1998;124:

431–6.

5. Vlachakis I, Gardikis S, Michailoudi E, Charissis G. Treatment of

hemangiomas in children using a Nd:YAG laser in conjunction

with ice cooling of the epidermis: techniques and results. BMC

Pediatr 2003;12:2.

6. Rogachefsky AS, Silapunt S, Goldberg DJ. Nd:YAG laser (1064

nm) irradiation for lower extremity telangiectases and small ret-

icular veins: efficacy as measured by vessel color and size.

Dermatol Surg 2002;28:220–3.

7. Major A, Brazzini B, Campolmi P, et al. Nd:YAG 1064 nm laser in

the treatment of facial and leg telangiectasias. J Eur Acad

Dermatol Venereol 2001;15:559–65.

8. Bevin AA, Parlette EC, Domankevitz Y, Ross EV. Variable-pulsed

Nd:YAG laser in the treatment of facial telangiectasias. Dermatol

Surg 2006;32:7–12.

9. Grantzow R, Schmittenbecher PP, Schuster T. Early treatment of

hemangiomas: laser therapy [in German]. Monatsschr Kinderhe-

ilkd 1995;143:369–74.

10. Yang MU, Yaroslavsky AN, Farinelli WA, et al. Long-pulsed

neodymium:yttrium-aluminum-garnet laser treatment for port-

wine stains. J Am Acad Dermatol 2005;52:480–90.

11. Eremia S, Li CY. Treatment of face veins with a cryogen spray

variable pulse width 1064 nm Nd:YAG laser: a prospective study

of 17 patients. Dermatol Surg 2002;28:244–7.

12. Sadick NS. Laser treatment with a 1064-nm laser for lower ex-

tremity class I-III veins employing variable spots and pulse width

parameters. Dermatol Surg 2003;29:916–9.

13. Eremia S, Li CY, Umar SH. A side-by-side comparative study of

1064 nm Nd:YAG, 810 nm diode and 755 nm alexandrite lasers

for treatment of 0.3-3 mm leg veins. Dermatol Surg 2002;28:

224–30.

14. Sarradet DM, Hussain M, Goldberg DJ. Millisecond 1064-nm

neodymium:YAG laser treatment of facial telangiectases. Derma-

tol Surg 2003;29:56–8.

15. Gupta G, Bilsland D. A prospective study of the impact of laser

treatment on vascular lesions. Br J Dermatol 2000;143:356–9.

Address correspondence and reprint requests to: BernaAksoy, MD, Private Konak Hospital, Yenisehir Mah.Donmez Sok. No: 53 BekirpasaFIzmit, 41050, Kocaeli,Turkey, or e-mail: bmaksoy@mynet.com

3 5 : 1 2 : D E C E M B E R 2 0 0 9 1 9 4 1

C I VA S E T A L