Lasers in Medicine 4.2 - The Millennium Laser Book Edition

LASERS IN MEDICINE
SURGERY AND DENTISTRY
WITH SPECIAL CHAPTERS ABOUT VETERINARY
UPDATE OF BASIC SCIENCE, OPERATIVE TECHNIQUE
AND A CLINICAL APPLICATION GUIDELINES

Quatenus nobis denegatum diu vivere,
relinquamus aliquid, quo nos vixisse testemur.
How long we live is not defined,
what we leave behind defines that we lived
Pro futuro
Stay up to date - Apply Laser
in Medicine
Primum nihil nocere
Fiat lux

CONTENTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Introductory remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Few words to readers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Legal Disclaimer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Basic of laser science - physics and biology
I F. Frank, E. Rohde, E. E. Schelle, G. Müller:
Technical aspects of medical laser application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
II H. Moseley: Characteristic features of light source for photodynamic therapy . . . . .37
III L. Pokora: Practical aspects lasers in physics and biology . . . . . . . . . . . . . . . . . . . . .47
IV T. I. Karu: Cellular mechanisms of low power laser therapy: new questions . . . . . .63
V T. C. Y. Liu:
Membrane Mechanism of Low intensity Laser biostimulation on a cell . . . . . . . . . .83
VI S. Korraa: Role of Free Radicals in Low Energy Laser - Irradiation (LELI)
Induced Photobiological Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
General Surgery
VII K. Dowlatshahi: Interstitial laser treatment of small breast cancers . . . . . . . . . . . . .133
VIII G. Bandieramonte, B. Stefanon, G. Martelli, L. Costa, B. Muraglia:
Excisional use of CO2 laser and association with the operating microscope
for superficial lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
IX R. Hoffmann, W. Zimmerli, H. P. Brütsch: Lasers for varicosis . . . . . . . . . . . . . .161
X F. D. Yanes: Surgical techniques in CO2 Swift laser assisted proctology . . . . . . . .167
XI Z. Simunovic, A. D. Ivankovich, A. Depolo:
Wound healing in animals and humans with use of Low Level Laser Therapy . . . .191
XII K. O. Greulich, A. Rapp:
Possible damages to DNA by straylight effect during laser surgery . . . . . . . . . . . . .211

6 CONTENTS
Paediatric Surgery
XIII J. Waldschmidt:
Congenital vascular disorders (CVD) of the thorax and abdomen . . . . . . . . . . . . . .221
Neurosurgery
XIV J. Paladino, G. Mrak: Clinical application of laser in oncological neurosurgery . .259
XV S. Rochkind: Intraoperative use of low-power irradition during microsurgical repair of
the injured peripheral nerve to protect and improve nerve function . . . . . . . . . . . . .277
XVI A. Muacevic, M. Peller, L. Ruprecht, D. Berg, L. Fend, R. Sroka, H. J. Reulen,
F. W. Kreth, J. Ch. Tonn: Image guided interstitial laser thermotherapy: An animal
model for neuroimaging, morphological and physiological brain research . . . . . . .285
Orthopaedy
XVII M. Knight, A. Goswami: Endoscopic Laser Foraminoplasty in the Treatment of
Spondylolytic Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293
XVIII A. Elborno, S. Stamelos, A. D. Ivankovich:
Percutaneous laser disc decompression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .313
XIX Z. Simunovic: Non-Thermal Laser applications in orthopaedy . . . . . . . . . . . . . . . .323
Otorhinolaryngology
XX S. Jovanovic, K. Waltmann:
Endoscopic CO2 laser surgery for Zenker's diverticulum . . . . . . . . . . . . . . . . . . . . .337
XXI M. Hopf, J. U. G. Hopf, E. Rohde, G. Müller E. E. Scheller, H. Scherer:
Diode laser treatment of recurrent epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .347
XXII J. Tunér & A. Bjorne: Somatosensory Tinnitus - a case for the laser dentist . . . . .361
Gynaecology
XXIII R. Chapman: Laser Surgical Techniques in Gynaecology . . . . . . . . . . . . . . . . . . . .371
XXIV M. Menton: Lasers in Gynaecology today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395
XXV P. Wyss: Clinical application of Photomedical Techniques in Gynaecology:
Breast Cancer Recurrences and Dysfunctional Uterine Bleeding . . . . . . . . . . . . . . .409
Urology
XXVI D. Zaak, U. Müller-Lisse, A. Hofstetter:
Fluorescence diagnosis of bladder cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .417
XXVII T. Sulser, S. Wyler, R. Ruszat, A. Bachmann: Photoselective Vaporization of the
Prostate (PVP) with high-power KTP Laser: First clinical results . . . . . . . . . . . . . .425
XXVIII H. John, D.M.Schmid, D. Hauri:
Urologic laser surgery in the urethra and ureter . . . . . . . . . . . . . . . . . . . . . . . . . . . .437
XXIX K. Matsuoka: Applications of Holmium:YAG laser in Urology - Laser lithotripsy,
Laser prostatectomy, Laser ablation of the urinary tract carcinoma and Laser incision
of the urinary tract stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445

CONTENTS
XXX H. Hainz: Inexpensive prostate laser operation with 0.6 mm bare fibre -
Report on 1,296 cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .465
XXXI B. Aeikens: New Experiences in TUR-P with a laser based therapy . . . . . . . . . . . .471
Endoscopic Laser Therapy
XXXII Z. Tudjman, V. Ostojic, M. Samija:
Surgical laser in tracheobronchial pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .477
XXXIII B. K. Rau, S. Krishna: Laser Application in tracheo bronchial tumors . . . . . . . . . .491
XXXIV P. Spinelli, A. Mancini, G. Calarco, A. Spinelli:
The use of laser in surgical oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .499
Laser Treatments in Plastic Surgery and Dermatology
XXXV D. J. Goldberg: Ablative and Non-ablative Skin Resurfacing . . . . . . . . . . . . . . . . .511
XXXVI G. Ginsbach: Some technique by means of KTP 532 Laser . . . . . . . . . . . . . . . . . .525
XXXVII M. A. Trelles: Ablative Photorejunevation with a single console system combining the
erbium: YAG and CO2 lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535
XXXVIII T. Ohshiro, K. Sasaki, S. Yasuda, S. Fujii, T. Ohshiro:
Application of Combined Laser Treatment (CLT) for tattoo removal . . . . . . . . . . .549
XXXIX R. Dummer, P. Graf: Variable Pulse Width Frequency Doubled Neodymium:YAG
Laser for vascular skin lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .569
XL J. Kubota: The application of laser surgery and medicine in anti-ageing . . . . . . . .577
XLI F. Soriano:
Dermatologic surgery techniques with CO2 laser and scanning system . . . . . . . . . .589
XLII F. A. H. Al-Watban, Z. Zhang, B. L. Andres, M. V. D. Gonzaga:
Laser as a Wound healer - In comparision with Pharmacological Drugs, LED and
Conventional Light Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .617
XLIII Z. Simunovic, K. Simunovic:
Treatment of the haematoma with Low-Level Laser . . . . . . . . . . . . . . . . . . . . . . . .651
XLIV L. Maturo: Complications in the use of lasers in dermatologic surgery . . . . . . . . .659
Interventional Radiology
XLV T. J. Vogl, R. Straub, K. Eichler, M. Mack: Laser-induced interstitial thermotherapy
(LITT) of liver lesions - technique and application data-clinical data . . . . . . . . . . .671
Ophtalmology
XLVI R. M. E. Smets, M. J. Tassignon:
Photodynamic therapy application in Ophtalmology . . . . . . . . . . . . . . . . . . . . . . . .693
XLVII V. De Groot, M. J. Tassignon: The use of lasers in the treatment of glaucoma . . .701
XLVIII M. Mrochen, M Bueeler, H. P. Iseli:
Customized corneal laser surgery for refractive corrections . . . . . . . . . . . . . . . . . . .717
7

8 CONTENTS
Laser Applications in Diagnostic
XLIX U. Bindig, E. Rohde, E. E. Scheller, G. Müller:
Laser enabled Optical Diagnostic in Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . .727
L K. K. Rapp, K. S. Kochanek, R. Steiner:
Optical Coherence Tomography in Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . .771
Dentistry and Maxillofacial Surgery
LI G. K.H. Eyrich, K. W. Grätz: Laser treatment of lesions in the oral cavity . . . . . .783
LII A. Moritz, W. Kluger: Laser-assisted Pulp Capping: Procedures and Review . . . .803
LIII M. Cortes: The Photo/Thermal Dynamics of Lasers in the Destruciton of Oral
Biofilms In Periodontics, Endodontics and Necrotic-Osteomyelitis
of the Jawbone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .811
LIV D. A. Dovsak, A. Vesnaver: Treatment of leukoplakias and vascular malformations of
the oral cavity using laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .825
LV R. J. Bensadoun, G. Ciais: Low Level Laser Therapy: A real Hope in Management of
Chemo-induced and Radiation-induced Mucositis in Oncology? Updating results of
multicenter phase III studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .843
LVI P. Bradley:
Low intensity laser therapy (LILT) for temporomandibular joint disorder pain . . .853
LVII L. Pokora: Lasers in Dentistry (Treating cancer using PDT, lasers applied
in prosthetics, laser teeth whitening) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .857
Veterinary
LVIII U. Petermann: LLLT and laser acupuncture in chronic equine back pain . . . . . . . .867
LIX U. Petermann: LLLT and laser acupuncture in wound healing disturbances
in common wounds and post operative complications . . . . . . . . . . . . . . . . . . . . . . .873
LX W. Brehm: Laser in Veterinary Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .883
LXI A. Roesti: Holistic Cybernetic Medicine Complementary Healing Method . . . . . . .907
The Millennium laser book part one
(few words about the first book, authors and their topic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .923
The Millennium laser book part two
(few words about the second book, authors and their topic) . . . . . . . . . . . . . . . . . . . . . . . . . . . .929
From EMLA statute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .939
Laser Companies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .941
Safety and laser nursing
P. J. Smalley, Z. Simunovic: Laser hazards, risks, and control measures:
A perioperative perspective on standards and safety management
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .see second book of trilogy page 813
Treatment of laser Surgery Side Effects
J. Kubota: Management of laser surgery-related side effects with infrared diode laser
therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .see second book of trilogy page 829

PREFACE
Today's world challenges technology and even medicine. Laser technology and
the variety of medical applications at the beginning of the third millennium reach
all continents; globalizing the field and achieving worldwide acceptance of laser
medicine. Fiction became reality!
The use of different lasers requires us to understand the physics and biology in
the new fields of diagnostic and therapeutic laser application in medicine, surgery,
dentistry and veterinary medicine.
Z. Simunovic
My intentions with The Millennium Laser Book Trilogy are to assemble recent
scientific and clinical works of respected laser specialists from every continent, because science as
an art form has no boundaries. Both areas are beneficial to the well-being of all peoples of all nations.
Contrary to specialized laser literature, The Millennium Laser Trilogy is a cooperative endeavor
compiled like a small encyclopedia, offering insight in every area of medicine, where lasers enjoy
success. However, this is not the last act of laser application in medicine. The road to ultimate
achievement and perfection is long and demanding, paved with optimism and confidence.
For example, take photodynamic therapy (PDT). New photosensitizes developments and new
light sources brought major, positive advances for malignant diseases and viral infections, as well as
diminishing the side effects. The methodology and technology used for PDT are rapidly unfolding.
PDT is expected to improve significantly in the future. Recent findings indicate that the laser enables
optical diagnostic in medicine and antiaging treatment.
In reading through The Millennium Laser Book Trilogy, you become aware of the variety of
authors and the diversity of opinions, methods, and experiences. All based on an intricate mixture of
schooling and patients with their individual traits, influenced by race, religion, nationality, mentality,
geography and climate.
Regardless of the differing factors, our common goal is the welfare of Homo sapiens accomplished
with laser medicine. Negligible side effects and tissue trauma, good patient toleration and
improved post-operative healing contribute to the popularity of laser medicine today. In particular,
general acceptance among patients is due to the painless, bloodless and aseptic treatment.
Limitless diversity makes it necessary to establish an individual approach to each patient. By
building up gradually, the treatment program and applied energy densities optimal irradiation doses
are achieved in each particular treatment and thereby the therapeutic program.

10 PREFACE
One should be aware of the impossibility in medicine to claim that two and two are four. It can
also be two, three or five, contrary to mathematics and physics. In medicine, one must take into
account the entire photobiology, biochemistry and pathophysiology of the human body, a wide
range of medicaments and the influence of many laser devices with wave lengths and energy densities.
Therefore, before employing any approach, it is necessary to respect Primum nihil nocere.
Contraindications in laser medicine are minimal, but cannot be underestimated. There is no
medical procedure without contraindications. As in life, it is the same in laser medicine: nothing and
no one is perfect. Remembering that, laser medicine is an integral part of the classic medical
approach, often complementing other fields of medicine to achieve better patient health care.
With more than 200 global laser specialists contributing to The Millennium Laser Trilogy, their
techniques and methods are sometimes not reproducible in your clinical environment without prior
consultation with the author. The publisher does not assume any responsibility for complications
arising from the application of any published laser techniques. The responsibility remains with the
authors and their presentations.
One should not forget that knowledge and experience is the best combination for success. Do
not hesitate to make timely contacts for instructions or advice! A list of the prominent laser specialists
is included in the book. Our authors' team guarantees quality and certified educational programs.
This was not always the case in laser medicine.
Marketing became an integral part of this field as well. Exercise caution and periodic controls
before subscribing to courses or education programs. Some institutions and so-called "academies"
do not hold the necessary credentials from governmental authorities. Often, laser organizations are
unregistered and unrecognized by their own officials and remain a privately managed group of people.
Many autodidacts claim to offer knowledge and experience. However, the professional growth
of an autodidact is hard and slow compared with those who strive to share their experiences.
United and governed by laws and regulations, we are stronger. Therefore, I strongly recommend
joining recognized laser organizations. Acupuncture passed through the same obstacles. By
introducing "law, order and ethics", it evolved into a recognized, respectable field of medicine,
which also employs the laser.
LASER is often employed in veterinary medicine, bringing ample benefits to laser therapy.
Typically, its effects on animals are not influenced by placebo or similar methods. Simply, animals
cannot act or pretend. No matter what area of laser medicine is applied, we should never neglect the
safety of medical personnel and patients.
Viribus unitis was our guide from the start. Let us continue this way. The frontiers in theory and
practice are unknown, so the research continues. All hypotheses require verification before serving
clinical medicine.
I would like to express my gratitude to the authors for their confidence and belief in me and my
idea and for their valuable support in promoting lasers in medicine.
My sincere thanks to everyone who helped make this book a reality: my collaborators and
graphic designers.
Ass. Prof. Zlatko Simunovic, MD, FMH
Specialist in Anesthesiology, Switzerland
Former Head of Dept. of Anesthesiology and Intensive Care Unit, Pain Clinic - Laser Center.
President of European Medical Laser Association - EMLA

INTRODUCTORY REMARKS
INTRODUCTORY REMARKS
“Whenever something is new, people say it is not true. As time goes on and it
is proven to be true, people say it is not important. As time goes on and it is proven
to be important, people say it is not new any more.” …Voltaire.
Man is as much a creature of habit as a creature of change. The intellectual
curiosity of the scientist and clinician undoubtedly has its origins in the wide-eyed
R. Lanzafame
wonderment of the child. Curiosity and the constant probing and testing the environment
are integral components of learning. The dissemination of the collective learning or information,
whether formally through the educational process of formal schooling, or informally
through a variety of media and the spoken word, helps to satiate this quest for knowledge. We continue
to learn and sometimes relearn throughout our lifetimes. There is unquestionably much to
experience and learn in the process. Learning is, or should be, an active process. We must gather relevant
information; question its significance, attempt to understand its applicability and test its veracity
by discussion with those familiar with the topic.
Lasers have occupied our fancy since their development in 1960. The stuff of science fiction
and cinema has become a powerful tool in our daily lives. CD players, other electronic systems,
telecommunications, science and industry have been transformed by this amazing technology.
Medicine was one of the first disciplines to embrace the potential of lasers, with opthalmology and
dermatology taking the lead. Early on, clinicians and academicians began to experiment with and
apply these devices to solve some of their most difficult problems. It became practical to treat the
retina and a variety of cutaneous diseases, which had been impossible or cumbersome to treat by
conventional means. New devices, improved technologies, were coupled with a pioneering spirit
and a thirst to expand the boundaries of understanding and application. Better understanding of laser
tissue interactions, wound healing, and the microanatomic, molecular, and more recently, the genetic
basis of disease are continuing to expand our horizons. Lasers have provided an entire lexicon of
knowledge and application for those willing to explore, learn and apply.
The body of knowledge on lasers rests on an ever-increasing scientific basis. Many questions
remain, and skeptics continue to rally around the few cases of quackery and charlatanism that have
marred the medical landscape and have clouded the perceptions and the expectations of our patients.
General surgery is just one example of the deleterious effects of unrealistic claims and poor training
11

12 INTRODUCTORY REMARKS
during the rapid development of laparoscopic cholecystectomy and minimally invasive surgery. Few
general surgeons today use or have had the opportunity to learn about lasers as compared to the
masses seeking training in the early 1990’s. This does not diminish the potential of these devices in
general surgery however. Other examples exist in still other disciplines. Still others, like urology,
have come full circle by using lasers for lithotripsy, ablation of bladder lesions, and more recently
high-power ablation of hypertrophic prostatic tissues. Each of these applications was pioneered with
arguably rudimentary technology relative to devices and delivery systems created for these specific
applications. Our colleagues in dermatology and opthalmology continue to push our capabilities
forward at a staggering pace.
Dr. Z. Simunovic has assembled a retinue of the current leading authorities in photobiology,
photomedicine, each of whom has contributed to this volume and its earlier two predecessors.
Together, this trilogy represents a robust and diverse compendium for the student, scientist and clinician
alike. Great care has been taken to provide a thorough scientific basis for the content and suggested
therapeutic techniques. An ample bibliography and listing of each author’s credentials is coupled
with clear text and excellent graphics. These features give the reader the ability to understand
and, hopefully to apply this wealth of knowledge to the clinic or the laboratory. It has been an honor
and a privilege to be included with such an august group of distinguished colleagues and friends and
to have had the opportunity to contribute to our understanding of lasers and their applications in a
small way.
Voltaire’s insight may be apt to describe the uninformed or the skeptic. This third volume of
the trilogy is a true testimony to our basic human nature. A remarkable tool continues to evolve
through the work and curiosity of many. Knowledge and its application having become commonplace,
loses its mystery and is relegated to the mundane for the masses. We continue to make great
strides in understanding lasers and using them both appropriately and rationally. The only limits that
we have are the boundaries of our collective imaginations. There is mounting evidence that photobiomodulation
is indeed real and results from a true photo-reaction with tissue. Dermatologists are
beginning to embrace these concepts and to apply them to nonablative facial rejuvenation based on
the stimulation of collagen production in the dermis. Much is being proven, yet much more is new
or yet to be discovered! We must have the willingness to learn and the tenacity to explore. This text
and its companions move us well ahead in our journey.
Prof. Raymond J. Lanzafame, MD, MBA, FACS
Director Laser Medicine and Surgery
Laser Center
Rochester General Hospital
Rochester, New York, USA.

INTRODUCTORY REMARKS
The Third Millennium Laser Book, which like the other two contains contributions
from laser scientists and experts from all parts of the world, is about to be
born. Together they form a unique account of laser science, laser medicine, laser
surgery and laser dentistry as it is at the beginning of the twenty first century, and
it is due to the vision, courage and perseverance of Dr. Med. Zlatko Simunovic
FMH that this has been made possible. It is to be hoped that these volumes will
M. S. Plouzhnikov soon be found in all medical libraries around the world, and will encourage the
younger generation of scientists, physicians, surgeons, dentists and veterinarians to make even
greater contributions to laser science and practice in the years to come.
Surprisingly, little is known in the West of Russian laser medicine in spite of the fact that
Russia was among the first countries which discovered the physical phenomena of lasers. as well as
developing the first laser and ancillary instruments. Alexander Gurwitsch in 1923 published “The
Phenomenon of Biological Induction”. He observed that living cells emit a non-thermal electromagnetic
irradiation which stimulates cell mitosis. The use of semiconductors in lasers was proposed
by N. G. Basov in 1955. He and the physicist A. M. Prokhorov, who independently invented
the maser in 1955, were awarded Nobel Prizes for physics in 1964 together with C. H. Townes of
the U. S. A. Finally, more recently, Tiina Karu has for many years contributed many papers on the
effects of low power laser at the cellular level.
Basically at first Universities in Russia started doing laser research, but in 1984 the Moscow
Research Institute of Laser Medicine was founded which united administratively 14 Laser Centres
scattered all over the vast territory of Russia. The Institute co-ordinates research in local regional
centres. It holds annual conferences and issues proceedings. The Institute periodically organizes
symposia on pressing problems of laser medicine and regularly holds discussions at the sittings of
its Scientific Council on practical and theoretical activities of ‘laser medicals’.
In 1995 the Government founded the Russian Academy of Laser Sciences in Kaluga. The
Academy started training specialists in all aspects of laser design and application.
I am personally of the opinion that apriori it might have been supposed prior to all the experiments
that therapeutic laser might have been especially effective in the tissues of deeply located
cavities well hidden under natural conditions from light, e.g. nasal and oral cavities, nasopharynx,
tympanic cavity, paranasal sinuses, larynx, trachea, bronchi, gastrointestinal tract and female sexual
organs. Later many investigators corroborated clinically that presumption.
The exclusive use, initially, of the Carbon Dioxide (CO2) Laser in laser surgery was confined
to its employment through the open wound, and O. K. Skobelkin and his team in Moscow designed
many instruments for use in the abdomen, including a flattened, light occlusion bowel clamp with a
slit anteriorly to allow for the accurate application of the laser beam while the posterior portion acted
as a back-stop, thus permitting rapid excision, followed by tissue welding in a dry surgical field.
However, the domination of the CO2 laser in surgery became, to my mind, the factor which
somewhat delayed the application of lasers in endosurgery. All the attempts to transmit the CO2 laser
beam via fibre-optics failed until the Neodymium: Yttrium Aluminium Garnet (Nd:YAG), Argon,
Diode, Potassium Titanyl Phosphate (KTP), and other lasers appeared to fill the gap which had been
apparent. The new lasers, however, turned out to be not so beneficial as to their ‘biological’ properties
in comparison with the carbon dioxide laser scalpel. They induced rather deep tissue damage
with poor healing and even led to the formation of ulcers. Immediately certain problems in their use
were created. Naturally, the apparently negative properties of this new class of lasers might be useful
in oncology providing ablation, but still formation of ulcers with following cicatrization com-
13

14 INTRODUCTORY REMARKS
plicated the situation in many aspects.
In 1984 in Russia a communication was made of fibre-optic lasers applied in ‘contact’ mode.
The contact technique practically excluded off-the-target hits, creating very ergonomic and adequate
conditions for surgery performed endoscopically by permitting direct contact of the cutting instrument
with the tissue, thus giving a feeling for the surgeon of tissue resistance and borders of the
tumour. Moreover, the time taken by the surgery was shortened which was very beneficial for the
surgeon who inevitably inhaled plume in the operating room. Marker systems for aiming the laser
beam in contact technique became superfluous which commercially made the laser set cheaper.
It seems reasonable to assume that not all the useful properties of contact mode had been
exhausted. This might be vividly illustrated by introducing into clinical practice the method of laser
interstitial thermo-destruction entirely based on contact laser technique. It is broadly known now,
thanks to the pioneering works of Roxana Chapman from the U. K. .and other clinicians, what a
great benefit laser interstitial thermo-destruction has been in endosurgery, not only for gynaecology,
but for other surgical disciplines as well.
Photodynamic therapy, which was born in the West, has brought many hopes and disillusions.
Destruction of tumours by haematoporphyrin derivatives (HPD) with the mechanism of singlet oxygen
produced under the influence of low energy laser light in advanced stages of cancer, when alternative
methods of treatment are useless, represents an intriguing prospect, but, unfortunately, there
do not exist as yet photosensitizers possessing the properties of targeted selective accumulation in
malignant tumours. A very important, but expensive, technique has been introduced to couple monoclonal
antibodies to sensitizers. Another idea has also been suggested to couple sensitizers to iron
molecules and then gather the sensitizer in the tumour by means of a magnetic field, but this suggestion
is still hypothetical because no practical means has been found as to how to realize this technique.
Laser medicine, with its dominant trends of therapeutic laser, laser surgery and photodynamic
therapy, still contains many undiscovered possibilities and potentials and is waiting for more
research.
Professor Marius S. Plouzhnikov, MD
Director of the Otorhinolaryngology - Head and Neck Surgery Department,
I. P. Pavlov Medical University, Saint Petersburg, Russia.
President of the International Academy of Otolaryngology - Head and Neck Surgery.

INTRODUCTORY REMARKS
At a time a method begins to establish itself in the area of scientific research
the consolidation of knowledge, results and ideas is an essential part of scientific
development in terms of evidence based medicine.
However this can only be the first step. For a further substantiation of knowledge
and findings of the laser, investigations are required which exceed the expert
opinions and agreements of the consensus conferences. An approved advancement
W. Banzer
of therapeutic interventions is only to be expected on this basis. Thus the efficacy
of laser therapy could easily be assessed by randomized studies. In the different volumes of this trilogy,
there have already been authors getting the word, whose empirical studies match these
demands.
New and important laser application areas are developing. In particular the domain of sports
medicine has to be mentioned. A growing number of people is spending its leisure time in physical
activity and sports. The application of laser suits excellent for the appearing medical complaints. For
the medical attendance of numerous high-class and professional athletes the laser has become indispensable.
Likewise, in needle acupuncture an increasing interest in the use of the laser is obvious. Its
effects are beyond controversy for the practitioner. But how about the dosage? What are the effects
of laser applications on a peripheral and central level compared to needles? These are only a few
fundamental questions and concerns requiring future research.
A medicine which is confined to therapeutic targets does not have any perspective in respect of
content and economical reasons. Especially for secondary prevention the laser application provides
excellent presuppositions.
To be able to release a trilogy to a subject is only possible for a few people, especially if it is
filled with worth reading content. Providing an overview of the current scientific-medical discussion
the acknowledgement becomes even higher.
In this regard my Compliments to the Editor Dr. Zlatko Simunovic, M.D. FMH and his associates
who have made this book possible. I hope it will receive a broad distribution among the various
groups of interest.
Prof. Dr. Med. Dr. Phil. Winfried E. Banzer
Goethe Universitat Frankfurt am Main, Germany
Institut fur Sportwissenschaften Abt. Sportmedizin
15

16 INTRODUCTORY REMARKS
Since T. Maiman and his team from the Hughes Aircraft Company research
laboratories in Malibu (California) built the first laser apparatus in 1960, and
Townes Basor and Prokhorov received the Nobel Prize for their work on laser
physics, much research has been done. Leon Goldman (1961) treated human skin
disease and supervised laser application in surgery. Fava and Veronesi (1968)
applied lasers in the surgical treatment of melanoma. Following the research done
S. Giavelli by these pioneers, a number of physicians have tried to use lasers in different specialised
types of surgery, in order to reduce haemorrhage side effects and to obtain
the best possible results from therapy. Physicists, biologists and photobiologists have also planned
many experiments in order to examine the effect of laser light on enzymes, chromosomes, mytochondria,
cells, tissues, bacteria, yeast and animals.
When laser biostimulation was demonstrated, physicians tried to use it in medicine, particularly
with the aim of relieving pain, healing wounds, rehabilitating geriatric patients afflicted with
osteoarticular disease, and treating people suffering from sports injuries.
Given the strong demand from researchers and users, physicists and engineers studied and modified
laser device technology in order to provide researchers, surgeons and clinicians with more suitable
apparatuses that would enable them to obtain the best possible results.
However we may note that researchers studying basic laser effects and physicians using lasers
for clinical or surgical purposes are divided as they follow three or four different groups of study
and they work separately. Thus they need to know each other’s work better and to communicate and
discuss the results of either basic research carried out ,or clinical and surgical usage, while never forgetting
safety-related problems.
Professor Zlatko Simunovic, M.D. has well understood today’s needs, as he has planned
“Lasers in Surgery and Medicine” to include the reports from all the above mentioned groups of
researchers and laser users, including veterinary, dentistry and safety groups.
It is a pleasure and an honour for me to congratulate him on his work and to wish him all the
best with his book!
Prof. Sandra Giavelli, M.D. - Radiologist
Chairman Emeritus, Dep. Laser Therapy and Radiology
Pio Albergo Trivulzio Geriatric Institute
Milan, Italy
Chief Editor “Laser & Technology”
Official Journal of Emla

INTRODUCTORY REMARKS
In medicine, dentistry included, every diagnostic and therapeutic method
should be evidence based, particulary in our time. This demand, coming from the
quality thinking of many suppliers of medical services and health insurers, leads to
a flood of scientific investigations and professional publi-cations. The practitioner
is not able to follow all and to discriminate between the essential results for his
clinical work. It is therefore very helpful to concentrate essential informations with
G. Pajarola clinical relevance in a book like the trilogy of Lasers in Medicine and Dentistry
with this present third volume. The Editor, Dr. Zlatko Simunovic succeeded in
motivating experts in the field of laser therapy in the orofacial region, to contribute their clinical
experiences. So in a surplus to scientifically elaborated knowledge and documented clinical observations,
we may reach real evidence for successful Laser protocols for particular proceedings. As a
pleasing deviation from many publications in this field, the editor does not discriminate Low Level
Laser Therapy from Power Laser Application. This contributes to the idea, that Laser therapy of
both energy levels is not contrary, but complementary. In the seven chapters dealing with Lasers in
the maxillofacial area we find the group along Prof. Grätz and Dr. Eyrich from the Maxillofacial
Clinic of the University Hospital Zurich, contributing to the application of Laser in lesions of the
oral cavity, A. Moritz and W. Kluger from the Dental School, University of Vienna about Laserassisted
Pulp Capping: Procedures and review, Mrs. M. Cortes from the Mount Sinai Medical
Center N.Y. about Laser effects in bacterial jaw infections and D. Dovsak and coworkers from the
Faculty of Medicine University Ljubliana about treatment of leukoplakia and vascular alterations in
the oral mucosa. As the above mentioned autors deale with Power Laser equipments, the following
contributions describe clinical effects of Low Level Laser applications. The team of Prof.
Bensadoun from the Department of Radiation Oncology in Nice presents the clinical importance of
LLLT in chemo- and radiation- induced mucositis. The most experienced Prof. emeritus P. Bradley
from the Royal London School of Medicine and Dentistry presents his observations about Low
Level Intensity Laser Therapy in TMJ pain. The last contribution by Prof. L. Pokora from the Center
of Laser Technology in Warsaw, an expert with immense physical and clinical knowledge, deals
with Laser application in dental treatment. I’m sure, the reader will be extremely well informed
about modern Laser technology and its clinical outcome for the welfare of our patients.
17
Gion F. Pajarola, M. D., D.M.D.
Head of the Policlinic for oral surgery
of the University Hospital Zürich
Switzerland

Chapter XLIV
COMPLICATIONS IN THE USE OF LASERS IN
DERMATOLOGIC SURGERY
Lucio Maturo
Orthopaedics Division in Nursing Home Hospital Milan, Italy
The results gathered from the use of different sources of lasers, from the small diode that was
used in 1979 to the present excimer laser, have had in some cases negative and unsatisfactory applications
simply because its operators have probably used it wrongly.
The errors originating from the wrong use of a laser source, especially if surgical and affecting
a patient whose treatment was recommended, should be mainly evaluated from an aesthetic point of
view.
In this case we wish to identify the negative results of a series of treatments involving the dermatologic
surgery of the face, body, and the upper and lower limbs.
We therefore will not examine the errors due to lack of attention for the safety of both the operator
and the patient.
We are talking about the safety measures related to the use of special polished and sandblasted
instruments, the use of particular and specific safety glasses, the pedal, which should be protected
and equipped with a double mechanism that allows the discharge of the ray and prevents the pedal
from being accidentally pressed during inactive times of the surgery, thus causing lesions to the
patient or hitting fixtures of the operating room such as the bed, paper products, pieces of cloth or
worse still the patient’s clothing.
These are all accidents that can occur with some frequency but which fortunately do not produce
major damages.
The important damages, those that leave hypertrophic scars or keloid scars, some hyperchromic
or depressed scars, downright second degree burns, are the result of the wrong use of laser powers
and lack of knowledge of the parameters that relate to the complementarity of the colours and the
different degree of penetration in organic tissues by the different wavelengths.
The absorption of laser radiation results in damages because the transfer of energy, which is
absorbed by the surrounding medium, produces an increase in the local temperature and causes thermal
modifications, downright damages to the cellular constituents.
The determination of the absorption coefficient of the different tissues and the study of the penetration
in them are crucial factors for the identification of the possible thermal effects produced by

Chapter XLIV L. Maturo
661
In this case, however, the dehydrated tissues are carbonised, something that occurs at 300°C
because the thermostatic effect is lacking and, consequently, there will be greater thermal damage
to the surrounding tissues.
The processes that determine the extent of the thermal damage are as follows:
• evaporation of the tissue that digs and widens the crater
• thermal damage due to direct absorption of the beam of laser light
• thermal conduction from the edges of the crater towards adjacent tissues
The thermal damage in the adjacent tissues after the use of surgical lasers is a function of the
exposure time and, therefore, is not dependent on the output power.
On the other hand, next to the harmful effects originating from the wrong use of high-power
laser radiations in surgery, we have not detected any anomalies from the biostimulation effects
caused by exposure to low-power lasers. In fact, they have had and continue to have great positive
results on several painful musculoskeletal and musculotendineous pathologies.
Only one patient, a case that will be described further on, has had some second degree burns on
a finger because of the wrong use of a therapeutic CO2 laser, a finger that had been previously
anaesthetised for minor surgery and that a few days earlier had suffered a distortion of the proximal
interphalangeal joint.
Obviously the patient could not detect the high temperature emitted by the laser source and thus
suffered without noticing the enormous energy density that produced on its skin the lesions shown
in photographs number 1 and 2.
Fig. No. 1
This is a burn caused by a therapeutic CO2 laser on the
dorsal surface of a finger. Several minutes earlier the
patient had been subjected to a brief surgical operation
in local anaesthesia for the removal of a wart on the
same finger that, a few days earlier, had accidentally
suffered a distortion at the proximal interphalangeal
level. Speaking with a collaborator of the medical practice
where the laser surgery had been carried out, this
patient complained that in the previous days he had
experience some sharp pain and oedema at that same
joint. At this point the physiotherapist at the surgery,
ignoring that that finger was still anaesthetised, carried
out a therapeutic CO2 laser application either holding
it too close to the skin or doing some very scanning
movements. The patient, being therefore under local
anaesthesia, could not notice the high temperature
being released by the laser beam and consequently suffered
a burn on his finger.
Fig. No. 2
After five days of treatment one can see an eschar and
more distally a phlyctena. The patient recovered after
25 days.

Chapter XLIV L. Maturo
663
Fig. No. 7
The volar surface of the forearm, where this black
amateurish tattoo was localised, is to be considered as
an area at risk of keloids. This is exactly the result
obtained by the author after employing a 25-Watt
CO2 laser in one sitting. The thermal damage was
considerable and so the result is necessarily a keloid.
This type of tattoo should be treated during sittings a
few months apart by making a superficial abrasion
that allows the resulting eschar to transport on the
surface, in the granulation tissue, part of the coloured
pigments.
Fig. No. 9
This is a large keloid on the abdomen resulting from
a series of applications with a CO2 laser. The tattoo
represented the head of a tiger, the colour was black
and the treatment was concluded in four sittings. It is
possible that the colleague who carried out the laser
treatment either used a very low power or treated
areas that were too large. The second hypothesis is
probably more likely since the sittings were only four
and, therefore, it is possible that very large cutaneous
areas were vaporised. This patient was recommended
a topical treatment with allantoin for several months.
Fig. No. 8
This is another case, also carried out by the author, of
an amateurish tattoo located on the volar surface of
the forearm. A CO2 laser was utilised and the treatment
procedure was also carried out in one sitting,
something that damaged the derma so much that a
keloid was left as scar.
Fig. No. 10
Two small keloids localised on the deltoid region as a
result of the treatment with a CO2 laser of two small
amateurish black tattoos carried out with China ink.
This patient told me that he was subjected to the second
treatment, which was carried out like the first one
over the whole surface of the two tattoos, after only
fifteen days. This patient was also prescribed a topical
treatment of allantoin cream.

Chapter XLIV L. Maturo
667
Fig. No. 23
Another case of treatment for dilated capillaries of
the lower limbs carried out in this case with a CO2
laser. The CO2 laser source was never indicated as
being useful for the treatment of vascular lesions,
especially of an aesthetic nature and especially if
localised on the lower limbs where, as is well known,
the cicatrisation process can lead to failures.
Fig. No. 25
This is an intravasal coagulation of dilated capillaries
of the thigh after utilisation of an Argon laser. It is not
an irreversible alteration because after three-four
months these lesions tend to disappear. In this case
the power of the green beam of the Argon laser
utilised was too low and the translation of the knob
was too slow.
Fig. No. 24
Another case of wrong use of the Argon laser for
dilated capillaries of the lower limbs. One can see
some hyperpigmented points interpolated among
hypopigmentation areas. The hyperpigmentations
resulting from an Argon laser are not irreversible.
After some time (even three to four years) they tend
to diminish and then almost completely disappear. It
is possible that in this case the power used was too
high and inadequate for the type of skin.
Fig. No. 26
Treatment of dilated capillaries of the lower limbs
using an Nd:Yag laser, which left hyperpigmentation
and intravasal coagulation as an irreversible residue
of the treatment. The Nd:Yag laser is not recommended
as a vascular laser even though there is
presently talk of very thin intravasal fibre optics for
achieving the retrograde coagulation of the vasal
lumen.

668 L. Maturo
Chapter XLIV
Fig. No. 27
This is a series of small areas of dilated capillaries on
the dorsal surface of a foot treated with an Nd:Yag
laser. As it can be observed in the area immediately
above the larger eschar, the laser beam followed the
outline of the small vessels and this caused a series of
burn lesions and a series of hyperpigmentations.
Fig. No. 28
This is a patient who after a sclerosing treatment for
small dilated capillaries of the lower limbs noted in
some areas of the legs the appearance of yellowbrown
pigmentations, which an eager user of laser
sources decided to treat with a CO2 laser in the hope
that they would disappear. Not only the wished-for
result was not achieved but also vast areas of round,
hyperchromic, and irreversible hyperpigmentations
have appeared. We saw this patient three years after
the treatment with the surgical laser.
Fig. No. 30
This picture shows the same patient with some lesions on the
medial surface of the knee where one can see a depressed scar
resulting from too much power.
Fig. No. 29
This is a patient who came to our attention six months after treatment with an Nd:Yag laser of some dilated capillaries
of the lower limbs. The result is absolutely not satisfactory because one can observe some hyperchromic
areas associated with hypochromic points and an enlargement of the vascular canals, which appear augmented and
enriched with minute new vascular formations.

Chapter XLIV L. Maturo
669
L. Maturo
Curriculum Vitae
Lucio Maturo, M.D. has specialised in Plastic Surgery, Orthopaedics and
Traumatology, and Hand Surgery. He lives and practices medicine in Milan. He has
been the first in Italy and among the first worldwide to apply laser technologies, both
therapeutically and surgically, in orthopaedic pathologies, face dermato-surgery, and
hand surgery.
Among his publications:
Lasertherapy Manual I.R., 1981
Lasertherapy: clinical and rehabilitive experience, 1984
Carbon dioxide and argon lasers in dermatological surgery, 1986
Therapeutic carbon dioxide laser, 1988
Therapeutic laser in painful hand patology, 1989
Atlas Text of Laser Surgery, (Hand Surgery), 1992
Lasertherapy Atlas, 1998
It’s forbidden to grow old, 1999
Minor Traumatology Manual, 2000
He is presently head of the Orthopaedics Division in a Nursing Home in Milan