Claude S. Burton III, MD, Director
Answers to Commonly Asked Questions About Laser Treatment of Vascular Lesions
How does the laser work on vascular lesions? Laser light penetrates the outer layers of skin reaching the blood vessels below. Targeted blood vessels soak up all of the energy in the beam and are destroyed by the brief but intense heat. The body removes the damaged tissue naturally and the resulting bruise fades normally.
What kind of laser do you use? For vascular lesions we most often employ flashlamp-pumped dye lasers manufactured by Candela Laser Corporation. The models we use, the V-Beam Sclerolaser™ and the Sclerolaser Plus™, are the latest and most sophisticated lasers produced for the treatment of vascular lesions.
Why doesn’t the laser damage the skin and tissues around the blood vessel? Three carefully designed strategies are used to avoid injury to adjacent tissue. First, the color of light used is selectively absorbed by the vascular target. The hemoglobin within the vessel soaks up the light energy much better than anything else in the tissue. Second, the brief pulses are just long enough to heat the desired target. The energy is automatically turned off before there is time enough for the surrounding area to heat up above the threshold for damage. Third, a skilled operator determines the optimal energy density for each individual at each session. While the laser is extremely safe there is no substitute for years of experience. Dr. Burton helped pioneer this technology and has treated thousands of patients since founding the Duke Dermatology Laser clinic in 1986.
Does it hurt? Yes. But a new cooling spray has been added which sprays the skin with a cooling agent immediately before the laser impact, decreasing the discomfort SIGNIFICANTLY! Most patients say the discomfort isn’t as bad as they expected. Everyone should feel one of these “zaps” and decide for him or herself. I liken the sensation to a rubber band snapping against the skin. I am often asked how far I pull back the rubber band! Certainly different areas of the skin are more sensitive than others. Many patients have found topical anesthetic creams (such as 30% Xylocaine) somewhat helpful. On thin skin and on the inside of the lip and elsewhere in the mouth, the creams work especially well. Other patients, instead of or in addition to the topical anesthetic creams, prefer acetaminophen (Tylenol), ibuprofen (Motrin, Advil), and other “pain pills”. (Many small children do better with a “general” anesthetic.) In most cases, the pain usually does not last very long after treatment. Most children do not complain at all of post-treatment discomfort and usually refuse our ice packs. Adults and some children find the cold pack quickly takes away any discomfort. An information sheet prepared by our Anesthesia service is available upon request.How much does it cost? A fee schedule is attached; however, the fees have a tendency to change at the beginning of every fiscal year (July). The fees listed include the professional fee for the services of the laser surgeon and staff, and a technical charge from the hospital for the equipment. These are the “charges” as listed in the price book and the actual invoice amount may vary where Duke provides services on a contractual basis with managed care companies. There is an additional charge for anesthesia services, if required. Fees listed are per treatment. Typically, once the size of the lesion gets smaller, the fee goes down.
Will my insurance cover this type of treatment? Currently the majority of our patients receive coverage for congenital lesions, and for lesions that cause symptoms such as bleeding, pain, or growth. Read your insurance contract carefully before signing up for coverage. Some policies are now written to exclude coverage for congenital problems including portwine stains (PWS) even if medically necessary. Telangiectatic leg veins are never covered. Patients or the parents of patients are held responsible for any amounts not paid by insurance. Duke will bill the insurance company for treatments we feel are medically necessary and make every effort to collect on your behalf. You will be asked to pay any deductible or co-payment at the time of each treatment. Duke representatives in the business office are available to discuss payment plans with you.
It may not be easy to determine in advance if the treatments are covered. If you or your child belongs to a managed care company (HMO), we attempt to obtain prior approval for your visit and treatment. While we do not consider treatment of congenital malformations and hemangiomas a “cosmetic” procedure, some companies do consider these treatments cosmetic. Nevertheless, many companies do provide “cosmetic” coverage for repair of congenital problems. An insurance policy is a contract with a lot of fine print. Some fine print may be used to deny coverage for this as well as many other therapies.
Can the laser cause scarring? Yes! Scarring is very unlikely however. We will be happy to show you pictures of the scarring we have seen. Scars from dye laser surgery resemble chicken pox scars more than anything else and often fade over the course of a year. It appears that scars result from areas that blister or scab after treatment and become infected; therefore, we recommend a topical antibiotic as insurance against this complication. Scarring is also more likely to develop on darker skin and deeply tanned skin. For this reason we recommend continued coverage with sunscreens (SPF 30 or higher) throughout the course of therapy to prevent tanning during treatment. The treated area may lighten during treatment but the ability to tan is not affected. A recent  analysis of 500 patients treated elsewhere reported atrophic scarring in 0.8% of patients after a minimum of 8 treatments, increased pigment of a temporary nature in 1%, lightening of pigment in 2.6% of patients and temporary dermatitis in 2.2% (most of whom had eczema) that cleared with topical medication.
How will I know when to stop? There are a number of possible endpoints. We always stop if the treatment no longer produces improvement. Sometimes patients decide to stop sooner if they reach a satisfactory endpoint. We take lots of pictures to help you decide and to help us decide how things are going. The decision to treat is always left up to the patient and family.
How often will I be seen? How many treatments will I need? How long between treatments? Estimating the number of treatments is virtually impossible. Like looking at a lake, one can see the surface well but cannot define the depth. Only by treating can the speed at which a given area clears be discovered. Some birthmarks clear in three treatments but most require six to ten and we have some patients who have had over forty treatments. Fortunately, the most dramatic improvement is seen right away so one does not have to wait long to see good results. Very few patients achieve 100% clearing! While the results are dramatic, my patients are able to see some of the lesion even after maximal benefits have been achieved. At the time of your consultation we will show you pictures that illustrate the types of responses we see.
What will I look like after the treatment? The treated area is covered with little round bruises. These bruises are noticeable for 7-10 days on average and fade like any bruise. Bruises on the face fade more quickly than bruises on the arm or leg. You can expect to get a lot of strange looks if you are out and about the first few days after treatment. One can cover the spots with heavy makeup ( such as Dermablend, which can be found at Belks & other department stores) but it is not easy and one must exercise care in removing makeup to avoid trauma to the treated skin. The first several days you are better off to apply a thin layer of antibiotic ointment such as Polysporin and leave the area alone. If the skin around the eyelid, ear, or lip is treated, the area tends to swell quite a bit for the first day or so after treatment, worse in the morning and improving during the day. Children are less prone to have as much swelling.
A variety of strategies have been used for handling the bruised post-treatment appearance. Some children stay out of school and do their lessons at home. Others prepare the class in advance about what to expect and the child goes right back to school.
Can I talk to someone who has had this treatment? Yes. Several of our patients have agreed to talk with potential treatment candidates. If you would like to talk to a former or current patient let us know at the time of your consultation. We will put you in contact with one or more individuals that would closely approximate your situation.
Can I see pictures of all of this before I make up my mind about what to do?
Absolutely! Above all else, wherever you go, ask to see pictures that encompass a wide variety of situations and results. You should be sure the pictures you are shown are the work of the doctor you are seeing for treatment and not the work of another doctor being used to promote the treatment. There is no substitute for experience in obtaining the best possible results.
What about treatment of rosacea and other conditions? Rosacea and other telangiectatic or flushing syndromes also respond well to laser treatment. Laser is often required to treat patients that do not respond to medical therapy or who continue to have symptoms even after medical therapy has produced some improvement. Rosacea patients typically require two visits, and on some occasions three to achieve optimal improvement. 75% clearing is typically seen with the first session, and about 95% clearing with the second. If active inflammatory disease is present, medical treatment may be required before laser therapy is used. Persistent redness on the neck and upper chest (known as poikiloderma), along with discoloration in these areas, is ideally treated with this approach.
*If you have varicose veins, ankle swelling, or calf tenderness, laser treatment is probably not for you. Your legs should be evaluated first in the Duke Wound Management Institute. Call 919-684-4656 for appointments.
How long does it take to get an appointment? Dr. Burton is regarded as one of the premier laser surgeons in the world. It may take a while to get your first appointment. Once you are enrolled in the clinic, we have a much easier time arranging follow-up appointments to suit your schedule.