Chapter 37: Laser Applications in Podiatric Surgery

Lasers and Laser Physics

Fundamentals
Tissue Interraction
Laser Safety

Clinical Applications in Podiatric Surgery

The CO2 Laser
The Nd: YAG Laser
The ARGON Laser
The KTP Laser
Other Surgical Lasers
 LASER APPLICATIONS IN PODIATRIC SURGERY
Applications of lasers to medicine and surgery have increased exponentially over
the past decade. This technology has become established in the medical community
and has become the standard of care for many procedures. Lasers have justified their
utilization by the improved clinical outcome in the delivery of comparably more traumatic
and invasive procedures. Some procedures are not possible without the precision or
uniqueness of this modality.
There are a great variety of laser types and delivery systems, each having
indications unique to the desired tissue response. Fundamental to the surgeon in
selecting the wavelength, power and control to produce the intended effect, with safe
handling of the instrument, is a knowledge of laser physics for this tissue interaction.

LASERS AND LASER PHYSICS

HISTORY
1. The Quantum Theory:
Max Planck
1910
Light is quantified in Photon units
the basic unit of light (6.625 x 10-27 erg sec (cm2/sec))
2. Stimulated Emission Theory:
Albert Einstein
1917
Basis of laser light
3. First laser developed, demonstrated and patented
Theodore Maiman
Ruby Laser
1960

UNITS OF MEASUREMENT
1. Frequency Expressed in Cycles per Second (CPS)
Hertz (Hz)
2. Wavelength The measurement of one crest to another of a particular frequency

3. Length Meter = the basic measurement unit

Prefix
centi (cm) = 1 x 10-2 meters = .01 meters
-3
mili (mm) = 1 x 10 meters = .001 meters
micro (um) "micron" = 1 x 10-6 meters = .000001 meters
-9
nano (nm) = 1 x 10 meters = .000000001 meters
4. Time Second = the basic measurement unit
Prefix
mili (ms) = 1 x 10-3 seconds = .001 seconds
micro (us) = 1 x 10-6 seconds = .000001 seconds
-9
nano (ns) = 1 x 10 seconds = .000000001 sec
pico (ps) = 1 x 10-12 seconds = .000000000001 sec
5. Power Watts (W) = The basic measurement unit
Power density = Watts per centimeter squared (W/cm2)
Joules (J) = Watts x Seconds of power on tissue
FUNDAMENTALS
1. The wavelength is the key to tissue absorption, laser delivery systems and to laser
safety.
2. Comparison with other modalities:
Scalpel --> Mechanical pressure. Local effect. Controlled crushing.
Electrocautery --> Electrons. Conduction through isotherms. Global effect.
Radiosurgery --> Radio Frequency transmission. Local effect.
Laser --> Photon absorption. Specific to tissue content. Thermal precision.
3. The mnemonic "LASER":
L ight
A mplification by
S timulated
E mission of
R adiation
4. Laser frequencies most commonly used are in the infrared and visible spectra.
5. These are non-ionizing photonic radiation.
6. No lead shielding is required.
7. Exception: Excimer (UV) lasers are ionizing.
8. Laser light is NOT a natural phenomena.

UNIQUE CHARACTERISTICS OF LASER LIGHT

Coherent
Monochromatic
Collimated

Coherent = All crests of wavelengths line up. Crests and troughs are equidistant in
time and space. This eliminates wavelengths canceling each other out and producing
interference patterns which would decrease its intensity. This enables very efficient
power production. Coherent light, (compared with incoherent, conventional light) can be
focused to an exact single point. ie: 200 W of incoherent conventional light will illuminate
a room. 200 W of coherent laser light will rapidly carve through the cement wall of the
room.

Monochromatic = Pure, single color. Responsible for the interaction of tissue

chromophores producing a specific effect. ie: CO2 laser to incise and ablate amelanotic
tissue, Nd:YAG for deep tissue penetration, Argon penetrates epidermis.

Collimated = Emitted stream of photons is linear, and does not diverge. This also
eliminates wavelengths producing interference patterns reducing power.

COMPONENTS OF A LASER
1. Partially reflecting mirror 97%
2. Fully reflecting mirror 100%
3. Lasing media
4. Xenon flash lamp
5. high frequency Switching system
6. High voltage power supply
7. Delivery system - Articulating Arm, Fiberoptic, waveguide 8. Lense
9. Aiming Laser (HeNe), if required, depends on laser type

Conventional light radiation Laser light

radiation
+ Multiwavelength - polychromatic + Pure -
monochromatic
+ Divergent + Collimated
+ Coherent + In phase
+ Spontaneous Emission + Stimulated
Emission

THEORY of LASER OPERATION

1. Spontaneous Emission (conventional)
2. Stimulated Emission (laser)

CREATION OF LASER LIGHT V. CONVENTIONAL LIGHT

1. Lasers are classified by the type of active media used in the laser tube.
ie: CO2 laser tube filled with CO2 (excitable media), N2, and He gasses.
Nd:YAG is a Yttrium, Aluminum and Garnet crystal
doped with Neodymium as the excitable media.
2. Atoms are stimulated to rise from a lower energy shell to a higher shell,
3. Then fall back to emit a specific monochromatic wavelength of light.
4. These waves reflect in the laser media randomly at first, then become coherent
together by being amplified by reflecting between the mirrors.
5. Once their energy exceeds the threshold of transmission through the partially
reflecting mirror, laser radiation is emitted in a linear, collimated, array.
6. Frequency doubling media is also used to change laser wavelength.
ie: Tunable dye or KTP (Potassium, Titanium, Phosphate) laser.
The KTP crystal pumps a KTP crystal. Efficiency drops to about 30% of input.

Nd:YAG Laser -----------> KTP Crystal------------> output

1060 nm 532 nm

DELIVERY MECHANISMS
1. Low frequencies = longer wavelengths = far- and mid-infrared.
Articulating arms, or internally reflecting waveguides are used.
2. At near-infrared, 2100 nm and above (Ho:YAG laser) fiberoptics contain these
frequencies having a higher index of refraction.
3. Fiberoptics are constructed of quartz (Aluminum dioxide), silicon dioxide or silver
halides, coated with a plastic sheath.
4. Lenses, or contact light scalpels of selective focal lengths, can be integrated into the
terminal end of the fiberoptic system.
5. The bare fiber is also used for free beam ablation work.

TRANSMISSION MODES
1. Desirable laser energy distribution energy follows a Gaussian curve.
2. Energy decay falls exponentially on either side of the curve.

TEM00 has a narrow spot size TEM01 small spot 0.3 mm at best
true Gaussian
curve.
called "near
Gaussian"
0.2 mm diameter
spots
not desirable
appropriate for
cutting
can be used
for ablation.

TISSUE
INTERACTION
1. This is THE most important aspect of lasers in medical science.
2. Tissue interaction with the specific laser wavelength is the KEY to laser selection.

TRANSMISSION CHARACTERISTICS THROUGH TISSUE

1. reflection
2. transmission
3. scattering
4. adsorption

** Absorption of specific wave-length by specific chromophores is key.

CLINICAL TISSUE INTERACTION PHENOMENA

The effect on tissue by thermal lasers commonly used in Podiatry is both:
1. power and
2. time dependent:

POWER DENSITY
1. Is the standard of expression in documenting laser power to tissue.
2. Expressed in W/cm2.
3. P.D. maybe constant while tissue spot size and power varies.
This allows physicians to communicate standard terminology, allows for preference. It is
the STANDARD OF CARE: in operative reports describing laser use
It is necessary for communicating standard measurement in the scientific community.

A typical example using 14 Watts with a 0.2 mm diameter contact tip or spot size (which
is 0.1 mm radius)
Traditional Algebraic:
WATTS 14 4.46 446
----------- = --------------------- = ----------------- = --------------------- = 44,600
pi x r2 0.12 0.01 0.01
3.14 x ----- -----
102 100

where: 0.1 is the radius

10 is the conversion factor of 10 mm/cm

a shortcut algebraic:
WATTS 14
127 x ----------- = 127 x --------- = 44,450
d2 0.22
WATTS PER CM2 Chart

WATTS TIP DIAMETER (mm) or CO2 Spot Size (mm)

0.1 0.2 0.4 0.6 0.8 1.0 2.0 3.0
-----------------------------------------------------------------------------------------------------------------------
4 50,955 12,739 3,185 1,415 796 510 127 57
5 63,694 15,924 3,981 1,769 995 637 159 71
6 76,433 19,108 4,777 2,123 1,194 764 191 85
7 89,172 22,293 5,573 2,477 1,393 892 223 99
8 101,911 25,478 6,369 2,831 1,592 1,019 255 113
9 114,650 28,662 7,166 3,185 1,791 1,146 287 127
10 127,389 31,847 7,962 3,539 1,990 1,274 318 142
11 140,127 35,032 8,758 3,892 2,189 1,401 350 156
12 152,866 38,217 9,554 4,246 2,389 1,529 382 170
13 165,605 41,401 10,350 4,600 2,588 1,656 414 184
14 178,344 44,586 11,146 4,954 2,787 1,783 446 198
15 191,083 47,771 11,943 5,308 2,986 1,911 478 212
16 203,822 50,955 12,739 5,662 3,185 2,038 510 226
17 216,561 54,140 13,535 6,016 3,384 2,166 541 241
18 229,299 57,325 14,331 6,369 3,583 2,293 573 255
19 242,038 60,510 15,127 6,723 3,782 2,420 605 269
20 254,777 63,694 15,924 7,077 3,981 2,548 637 283
21 267,516 66,879 16,720 7,431 4,180 2,675 669 297
22 280,255 70,064 17,516 7,785 4,379 2,803 701 311
23 292,994 73,248 18,312 8,139 4,578 2,930 732 326

TIME
The gating of the flash lamp may be:
1. C.W. Continuous Wave - Continuously on
2. Single Pulsed - Continuous on for a preset period
3. Superpulsed - Rapid pulsing at peak power at 250 - 1000 Hz.
Average power is determined by
1. pulse width and
2. repetition rate
This allows tissue to undergo "thermal relaxation"
4. Ultrapulsed - Much higher RF (Radio Frequency) switching
nanosecond pulse width.
More thermal precision.
5. Q-switched - Very high peak power with picosecond pulse width

THERMAL RELAXATION = Interval between pulses to allow dissipation of energy.

Minimum interval is 1:10 ratio on-off.
LASERS APPLICABLE TO PODIATRIC SURGERY

WAVELENGTH USE IN PODIATRY DEPTH OF PENETRATION FUNCTION

10,600 um CO2 Noncontact: 0.1 mm Cutting
Far IR Dissection Ablation
Derm.Pathologies Coagulation
Nail Pathologies
1,060 um Nd:YAG Bare Fiber 6-8 mm Ablation
Near IR Deep tumor destr. Coagulation

Nd:YAG Contact-tip: 50-200 u Cutting

Dissection

2,100 um Ho:YAG Near-contact: 0.4-0.6 mm Ablation

Mid IR Cartilage and bone

4881514 um Argon Noncontact Dermal vessels Photoablation

Verruca

532 um KTP Noncontact: Dermal vessels Photoablation

Cutaneous vascular Cutting
Verruca
Contact: 1-2 mm
Dissection

478 urn Copper- Noncontact: Dermal vessels Photoablation

Vapor Cutaneous vasc.
lesions

ie: CO2 is strongly absorbed by water, therefore superficial penetration.

Holmium is absorbed by water but not as much as C02, so deeper tissue penetration.
Argon and KTP are absorbed by Hb and chromophores.
Nd:YAG (bare fiber) is not absorbed by anything, so it penetrates.
LASER SAFETY
1. Reference: "ANSI 136.3 Publication" on laser safety
2. Four Classes of Lasers:
Class I - No ocular damage with direct viewing
Class II - Ocular damage with prolonged exposure
Class III - Ocular damage to the eye before the eye can blink
Class IV - Medical lasers. Great potential and hazard to the eye
and skin. Ignites combustible materials. Beam = fire hazard.
3. Dedicated laser nurse in O.R. controlling use and monitoring laser safety
4. Key operated, controlled access.
5. Room shields to outside personnel.
6. Eye protection for patient and all OR personnel.
7. Wavelength specific eye protection hung outside the door
so that people can enter the room safely.
8. Adequate smoke evacuation appropriate to tissue atomization.
9. Dual stage filtration, carbon and 0.2 um filter.
10 Coaxial visible aiming beam for use with invisible light lasers.
11 Proper filtering mask.

EYE PROTECTION
1. Impact is direct or reflective.
2. Minimal hazard zone is determined to be 6 feet away from the reflected zone.
3. O. D. = Optical Density, expressed as an exponent of power of 10.
ie: O. D. of 5 is 100 x as absorbent as O. D. of 3
4. Always expressed as an O.D. at a specific wavelength
5. Recommended to surgeon (direct viewing field) - minimum O.D. of 5 @ wavelength.
6. Recommended to OR personnel (indirect) - minimum O.D. of 3 @ wavelength.
7. Conventional glass or plastic glasses will stop CO2
8. Recommend UV coating to stop the ultraviolet fluorescence off carbonization.
9. Eye protection still necessary for endoscopic procedures, fibers could break.
10. High density filters on endoscopes, arthroscopes, waveguides.
11. The reflected light transmits directly back to the surgeon.

CO2 - corneal burn.

Surgeon's cornea replaceable. Argon, KTP - retinal damage,
Irreversible.

Nd:YAG absorbed in the vitreous humor causing posterior cataract formation.

Reversible? Doubtful.

DRAPING FOR LASER SURGERY

1. Surgical site draping for CO2 laser use should be wet towels.
2. Drapes should be dry for the Nd:YAG procedures.
(Water is a transmitter at the YAG frequency and absorbed at CO2 frequency.)
3. Laser nurse - laser on standby when not immediately using the instrument avoids
accidental discharge.
4. Multiple foot switches - Bovey, power saws, table, can be confused with the laser.
5. A defocused beam has more of a tendency to start fires.
6. A focused beam will have a tendency to drill.
7. A prefocused beam will have a tendency to accelerate the hole it is drilling.
The power density increases approaching the focal point.
8. Always have water on hand, to extinguish a potential flame.
9. Anodized instruments (blackened or roughened) are helpful to diffuse the beam,
minimizes reflections but does not eliminate.
10. Endotracheal tubes should be coated with Mirasil (noncombustible material).

HAZARDS OF THE LASER SMOKE PLUME

1. Epidermis with the CO2 laser creates a great deal of smoke.
2. The shock waves backscatter verrucoid particles which can be inhaled.
3. Vaporized tissue and debris is liberated by tissue atomization
4. Studies show live intact DNA recovered from the laser plume.
5. Hazard in AIDS and hepatitis patients
Hazard in patients with infectious lesions, i.e. warts.
6. Lesions have been reported by Dermatologists, Podiatrists, and Gynecologists.
7. Formaldehyde also produced, large number of other carcinogens.

High power plume evacuators are required with dual stage filters.
1. Charcoal filter for carcinogens, smell.
2. Filtering down to 0.2 microns to filter out virus
a. The key is good technique in smoke evacuation.
b. Keep the smoke evacuator close to the area of surgery.
c. A laser mask will filter down to 0.3 microns.
d. These measures reduce nearly all of the hazards of the viral particles

II - CLINICAL LASER APPLICATIONS IN PODIATRIC SURGERY

STANDARD OF CARE
1. OPERATIVE REPORT - Include laser type power density calculation.
ie: "Procedure: Austin Bunionectomy, left foot (Soft tissue with CO2 laser): With the CO2
laser set at 33,000 W/cm2 power density, a linear incision was ..."

2. CONSENT FORM - Include the laser type or wavelength used and the intended
application of the laser if there is conventional instrumentation used. ie: "(Usual
description of surgery), soft tissue with CO2 laser"

3. ETHICS IN ADVERTISING - Differentiate the application of the laser ie: "Laser

assisted" bunionectomy, or "Laser for soft tissue"

Advertise straightforward what laser procedures (warts, nails) are done if also
advertising conventional procedures (bunionectomy) that are not performed with laser
assistance.

Public misconceptions: No incision, laser cuts bone.

You will never lose a patient because of an honest disclosure of a procedure.

THE CO2 LASER

PROPERTIES OF THE CO2 LASER
1. Active media is C02, helium, nitrogen
Carbon dioxide is the excited media
Helium and neon are catalysts
2. High absorption in water, Tissue mostly water
therefore superficial absorption
"What-you-see-is-what-you-get"
Low scattering in tissues
3. Invisible beam at 10,600 nm far-infrared, helium-neon aiming beam necessary

ADVANTAGES OF USING THE CO2 LASER

1. Thermal precision
Maximum impact on target and minimum damage to adjacent tissue
2. Absolute hemostasis minimizing postoperative edema. Coagulates small blood
vessels, lymphatics (<0.5 mm diameter) Minimizes pathways spreading malignant cells
3. Accelerated healing of internal tissue
because of lack of mechanical trauma.
Fibroblasts are less stimulated.
therefore skin sutures need to be left in tissue a few days longer, however internal
scarring is less
tissue remodeling is minimized due to little scar formation. earlier joint range of motion.
4. Minimal postoperative pain
sealing axonal tubules in small cutaneous nerves
5. Pain may increase several days postoperatively if patient weightbearing sealed
exoplasm from nerve endings is under increased hydrostatic
pressure
electrolytes stimulate neural discharge
6. Sterilization of the target sight
Inactivate any bacteria, fungi, or virus
7. No foreign body reaction
8. Versatile - Operates in CW or pulse mode to vaporize or incise tissue
9. Portable and inexpensive relative to other lasers
10. Minimal amount and cost of disposable laser items per case.
11. Handpieces easily sterilizable
12. Least expensive laser
SELECTION OF LASER PARAMETERS
1. Appropriate power, spot size, power duration, and angle to tissue
2. Ablational work: spot size less than 2-3 mm in diameter
3. Incisional work: spot size less than 0.3 mm in diameter

DISADVANTAGES
1. Cost, power, alignment, control, additional informed consent
2. Smoke evacuation system
3. Combustible materials risk, extra drapes, higher protection
4. Special training for physician/staff
5. Learning curve
6. Credentialling process/extension of privileges if hospital use

PROCEDURES PERFORMED USING THE CO2 LASER ASSIST

1. Plantar Verruca Ablation
2. Porokeratoma Ablation
3. Nail Matrixectomy Ablation
4. Fungal Nail Treatment - Drilling through nail plate
5. Heel Fissure Debridement
6. Ulcer Debridement/Sterilization
7. Incisional Procedures for soft tissue component (of neuroma, bunion, etc.)

THEORY OF CO2 LASER TISSUE INTERACTION

1. Controlled, highly localized vaporization.
2. Energy is absorbed by water.
3. High conductivity minimal to adjacent tissue damage.
4. Avoid tissue carbonization - increases and conducts thermal effects Immediately
seen. Worse problem at low power densities. Global tissue temperature and thermal
conductivity. Wipe this off with a damp gauze.

CO2 LASER PROCEDURES

TECHNIQUE OF CO2 LASER ABLATION
1. Power Density over 1000 W/cm2
2. Larger spot size- 2-3 mm

The following diagrams, illustrate two methods: linear and circular overlap.
The goal is an evenly ablated surface.
1. Circumscribe lesion by 2 mm peripherally
2. Curette representative area and send biopsy for pathology.
3. Deep channels should be avoided.
4. Do not penetrate dermis in verrucoid lesions.
5. If you have a 0.2 mm spot size at focal point, defocus to 1.0 mm.
For example, 20 watts with a 1 mm spot size equals 2540 watts/cm2 power density.
Scarring results from dermal penetration
IPK's and porokeratosis are focally penetrated to the dermis.
1. Need to lase to subdermal fat.
2. 75% cure rate, somewhat higher than conventional applications.
3. Little scarring.
4. More focal treatment is required at higher power levels.
5. Remove char by lavage or sponge

TECHNIQUE OF CO2 LASER FOR INCISION/EXCISION

1. Power density greater than 6,000 watts/cm2 preferred
2. Small spot size, maximum 0.3 mm diameter,
3. TEM01 lasers are not able to produce less than 0.3 mm spot at focal point.
Thus they are not appropriate for making incisions.
4. TEM00 lasers are available to deliver 0.1 mm, but commonly 0.2 mm.
Example:
a. 20 watts with 0.2 mm spot size equals 63,500 watts/cm2 power density.
b. Technique: smooth rapid continuous motion
c. In focus
d. Traction and countertraction perpendicular to incision.
5. Traction/countertraction of the incised area will enable smooth tissue plane
delineation.
6. Retrace path to achieve desired depth.
7. Important: Characteristics of individual lasers vary greatly.
8. Test on a tongue blade first.
Depth should be a little over halfway through with minimal charring.

NOTES:
1. A TEM00 laser produces a very different effect compared to a TEM01 machine
2. A superpulsed laser has a variety of pulse settings to achieve the same P. D.
3. The ultrapulsed lasers cut faster at lower power settings.
4. These are characterized by very short duration RF pulsed power supplies

Power densities are a general rule of thumb and should be adjusted to

1. each wavelength,
2. the particular instrument and
3. the type of tissue undergoing surgery.

HEMOSTASIS
1. By Coagulation:
Defocus to a spot size greater than twice the vessel diameter
Use a Power density less than 1500 watts/cm2
Technique: defocus beam to increase spot size and direct beam at site
2. By Dessication (thermal contraction):
Spot size 1 mm
Power density as with coagulation
Technique: direct beam to tissue immediately adjacent

FOCUSED, FREE BEAM LASER APPLICATIONS

1. In Focus: Incision
2. Defocus: Debulking
3. Greatly defocused: Coagulating
4. Prefocused: Avoid altogether

OVERLASING
Significant problem to inexperienced user is "Overlasing"
Definition: delivery of an inappropriate amount of laser energy to target tissue
or to the surrounding tissues
producing unintended tissue destruction.
(Immediately visualized with CO2 lasers.)

CAVERNOUS HEMANGIOMA
1. Considered ablative surgery requiring high power densities.
2. This is a highly vascular tumor.
3. Nd:YAG (bare fiber) is appropriate for deep penetration
4. Causes deep thermal vascular stenosis.
5. CO2 is not good for coagulation for these tumors, but it can be used.
6. KTP and Argon are more appropriate for superficial vascular lesions.

KELOID AND HYPERTROPHIC SCAR

1. Excellent indication for CO2 laser excision because of lack of fibroblast stimulation.
2. Superficial epidermal incision with the CO2 laser, NOT with the steel scalpel.
3. Avoid charring, will delay healing.
4. Refer to technique for incision/excision

LASER ASSISTED OSSEOUS PROCEDURES

1. Advertise as laser assisted bunionectomy.
2. Lasers used for soft tissue dissection only.
3. Not FDA approved for osseous work.
4. Used for incision, soft tissue dissection and capsular work.
5. Result is less postoperative pain, edema, and earlier range of motion.
6. Fascial layers - very little water content
therefore is more transmissible at this wavelength
7. Excellent for capsular incision. Earlier ROM.
contraindicated for periosteal dissection hemostasis of ALL vessels.
This seals the metaphyseal arteries and slows periosteal healing
8. Remember the delayed skin healing effect
9. Leave the sutures in a few days longer
10. Fibroblast stimulation is minimal thus scar formation is minimal
11. Better cosmetic result.

BONE AND CARTILAGE

1. Accidentally hitting the bone cortex will take 16-20 weeks to heal. Solution: Debride
damaged cortex immediately. Damage is usually superficial.
2. Carbonization in a joint will set up severe chronic inflammation. Solution: Lighten up
on capsular dissection in this area Irrigate thoroughly postoperatively, as always
3. Excellent application for subchondrodesis procedures
Instead of using K-wire to drill use CO2 at high P.D. for 0.5 seconds. Space closer
together with less mechanical disturbance to cartilage

LASER TREATMENT OF VERRUCA

1. CO2, Nd:YAG, Argon, KTP 532 can be used.
2. Selection or combination treatments depend upon clinical presentation.

The technique is to ablate in a layering method

1. Anesthesia, avoid epinephrine.
Avoid directly sublesional.
2. Drape area using moist towels or laser safe drapes.
3. Power density CO2 laser: 6,000 to 21,000 watts/cm2.
Decrease for light skinned and thin skinned individuals
Also reduce power density for thin areas on dorsal areas of the foot
4. Circumscribe lesion taking 2 mm min border of normal appearing tissue
at the periphery. Viable verruca in this tissue.
5. Do this in focus.
6. Submit representative biopsies.
7. Plow multiple interspersing furrows and crosshatch these to an even base.
8. Next wipe area with a sterile, moist gauze to remove char. Avoid relasing char.
9. Repeat lasing and wiping until dermal/epidermal separation occurs. Epidermis will
appear to peel away from the dermis.
10. Several passes are required on the plantar surface of the foot. Desired depth is
papillary dermis.
11. Healing will occur from basal cells in the dermal papillae.
12. Relase superficial areas until an homogeneous depth is encountered
to rete ridges.
13. Photocoagulate in a defocused mode.
Coagulate the surface to a very light haze.
This also sterilizes the surgical bed of viral particles.
14. Work is complete. Do not revaporize. Inspect with magnification.
15. Silvadene cream and sterile dressing for 24 hours.
Avoid occlusive dressings.
Extra strength Tylenol for small lesions
Hydrocodone 2.5 mg i-ii Q 4 h prn for large masses
16. Expect moderate drainage for 3 days to 1 week.
Wound closes completely in 1 month entirely healed.
In 2 months no signs of treatment are usually visible.

* Treat lesions less than 1 cm from each other as one lesion

* Do not leave a bridge of healthy skin between.

Handling large lesions:

i.e. large, mosaic verruca.
1. Keep depth of penetration even.
2. Circumscribe and divide the lesion into quadrants.
3. Lase each quadrant individually.
4. If the patient is supine, work from posterior to the anterior
If bleeding is encountered be sure it does not drain over the surgical site.
5. Be prepared with extra smoke evacuation filters.

To accomplish hemostasis, if needed::

1. reduce the power density and "brush" hemorrhagic area.
2. Power density can be reduced by backing off to a defocused mode.
3. Suction blood away first - laser does not coagulate free blood

Postoperative Care:
1. Patient seen 3 days to 1 week
2. Patient allowed to clean twice daily with H202 and bandaid
exception: large lesions require redressing until drainage decreases.
3. Normal bathing after first redressing.
Accommodative pad if needed.
4. Stop dressing when drainage ceases, no dressing at night.
5. Monitor patient for at least 6 months due to the nature of HPV.
6. Success rate easily 90% after learning curve reached.

Complications:
1. Infection--rare, laser sterilizes the bed.
2. Overlasing

NOTES:
3. Increased pain--result of overlasing.
4. Increased bleeding--result of overlasing
5. Increased scarring--result of overlasing
6. Scarring--Penetration of dermis

LASER NAIL MATRIXECTOMY

1. No epinephrine
2. No tourniquet - will have good hemostasis
3. Avulse the nail, do not ablate with laser
4. Power settings: 0.2 mm spot size, 125 mm focal length lense, 10 watts CW
5. Aim at 45 degrees, under proximal nail fold for acisional technique
6. Outline matrix and circumscribe to periphery of distal phalanx condyle avoid lasing
bone.
7. Lase the matrix in layers achieving a uniform layer of desiccated tissue. Debride with
a dermal curette to the next layer of matrix. Stop when coming close to bone. Several
passes are necessary
8. Keep site very dry and free from blood.
9. Dilute phenol may be used as an adjunct, but the laser replaces the blade.

1. Techniques for missing part of the matrix are just a probable with laser or blade
2. Characterized as a blind procedure.
3. Burning bone may result in periostitis, very rare.
4. Recurrence after learning curve partial permanent procedure, hallux, 0.5%.
5. These rate of results after learning curve reached.
6. Usually recurrence is keloid, hypertrophic scar formers, and psoriatic patients
7. Patients with high epidermal growth turnover
8. Total permanent if recurrent in these patients

POSTOPERATIVE CARE
1. Leave sterile dressing on 24 h
Patient to change at home
Patient to clean twice daily with H202. No soaks.
2. Some tissue necrosis 1 week
3. Patient to keep dry for 3 days
4. Patients seen 24 hours - 3
days postop
5. Bandaid dressing
6. Normal healing
7. Discontinue dressing and soaks
when drainage ceases, generally 2 weeks
8. Allow it to drain 1-3 weeks until it stops draining spontaneously.
9. Total permanent drain more on the 3 week margin, lesser digit partials for a week or
so.
COMPLICATIONS
1. Increased pain
2. Increased drainage
3. Delayed healing
4. Soft tissue infection
5. Thermal osteitis
6. Osteomyelitis
7. Overlasing is generally the culprit of all those complications.
PREVENTION OF COMPLICATIONS
1. Use appropriate power density
2. Keep the hand piece moving or apply power with periodicity
3. Keep exposure time on a given spot to a minimum
4. Don't relase over char
5. Always know where the beam is going, especially these blind procedures

FROST AND WINOGRAD TECHNIQUE

1. Do not use lasers to cut the nail- excessive heat.
Use incisional power densities as described for incisional procedures
2. Laser is 90 degrees to the skin, P.D.= 40,000 W/cm2
Then decrease when performing matrixectomy
3. Incision would be the same otherwise as the Winograd
please refer to that section within this review book
4. Laser incision is made straight back past the eponychium
Second curvlinear incision around soft tissue pathology
Remove hypertrophied nail lip and granuloma tissue.
5. Closure with 4-0 Nylon suture.
6. Tourniquet is not necessary.

LASER TREATMENT OF ONYCHOMYCOSIS

1. No anesthesia required
2. Laser "mottling" techniques
3. Object is to punching holes in the top nail plate
4. This allows topical medications to penetrate
a. Laser settings to just barely fire through a tongue depressor.
b. These settings should be just subthreshold for patient feeling any heat
c. Laser must be in a pulsed mode
d. holes drilled 4-5 mm apart
e. Three separate treatments 6 weeks apart.
f. Topical antifungal applied BID

SUBTOTAL MATRIXECTOMY
1. Anesthesia as before
2. The plate is always removed conventionally
3. Lasing is performed on the total matrix
4. however only scanned to 50% of the depth
5. The idea is to remove only part of the nail matrix to result in a thinner nail

SUBUNGUAL HEMATOMA
1. No anesthesia
2. Same procedure as mottling technique
3. Slightly higher power Density may be used
4. Lase a couple of holes until the nail plate is penetrated.
5. Hematoma will isolate thermal effects.

LASER TREATMENT OF GRANULOMAS

These respond very well to laser treatment
1. Ablate the granuloma in a crisscross pattern, the same as verruca
2. Alternate with a moist gauze until normal tissue is encountered
3. Good hemostasis should be encountered throughout the procedure
4. No chemocautery, bovey, or hemostatic solutions are necessary
5. Once the granuloma is gone the minimal bleeding encountered stops
6. Defocus, relase, apply sterile dressing.
7. Home treatment and followup as with verruca.

CAUTION IN REVISIONAL PROCEDURES

Scar tissue, if encountered, has less water content.
Therefore reduce power density when you relase this type of tissues. Otherwise excess
vaporization penetrating tissue planes may occur.

THE Nd:YAG LASER

GENERAL DESCRIPTION
1. 1060 nm, near-infrared, separate HeNe aiming beam
2. Most frequently used laser besides the CO2 laser
3. This is a general surgical instrument used most of the time by general, thoracic,
plastic, and urologic surgeons
4. See absorption chart - Nd:YAG is centered between other common medical lasers
5. Unique characteristic - the "window" of low absorption
and high transmissibility
YAG is poorly absorbed by hemoglobin, chromophores, protein, or water.
6. 99% of Podiatric use is with contact laser scalpels
7. Able to coagulate vessels < 0.2 mm diameter
8. User friendly, but tip selection, type and size must be understood
9. Power settings are very important
10. Endoscopically/arthroscopically compatible

MODES OF OPERATION
1. Non-contact mode - used for debulking and treating deep tumors.
higher power levels required ie: 40 W
2. Contact-tip mode - highly localized scalpel form similar to CO2 laser
lower power ie: 12-16 W (frosted tip)
4-6 W (nonfrosted)
3. Contact-tip is very superficial absorption, cutting only at the tip.
"What-you-see-is-what-you-get"

Noncontact is indicated for deep

Contact is used for incision and tumors.
excisional work.

THE INSTRUMENT
1. Instrument is portable, conventional nondedicated power OK
2. C.W. mode only
3. Flashlamp excites Neodymium-doped crystal of Yttrium, Aluminum, Garnet
4. Fiberoptic delivery system, air or water cooled within the sheath
5. Large variety of handpieces, general surgical one is used
6. Large variety of contact tips, fiber and handpiece combinations

THE CONTACT TIP

1. Developed for 3-dimensional feedback, feels similar to a conventional scalpel Better
control of dissection
2. Converts light energy from a laser into heat energy.
3. Very precise hot knives, tissue effect 50-200 microns
4. Types of conical tips: Frosted, clear, ceramic, titanium coated

There are many combinations of tips:

1. Sapphire scalpels interchangeable - screw onto handpiece
2. Integrated quartz tips with fiber and handpiece also used
3. Scalpel must be in contact with tissue when power on
or flare out of expensive tip will occur
4. Flare-out threshold temperature:
Sapphire scalpel - 2000 degrees F
Quartz scalpel - 1000 degrees F
5. Tip shapes - Chisel, flat, round, cylindrical, hook
a. Long or short conical used in Podiatry
b. Tapered conical tip concentrates energy
c. Polished lense at distal end
d. Available radii are 0.2-1.2 mm diameter
i. when calculating P.D. don't forget diameter -> radius
ii. and mm to cm conversions
6. Frosted and nonfrosted available
a. Frosted - distal end roughened to allow lateral radiation except at lense and allows
coagulation during dissection
b. Nonfrosted - tip is clear
i. radiation only at distal lense
ii. appropriate for very fine dissection at low power levels
c. Procedures are scalpel specific

SURGICAL APPLICATIONS

LASER SCALPEL STEEL SCALPEL

Rapid dessication
Seals small nerves
Seals small vessels
Cell necrosis is small
Cuts with Light Energy
High precision
Controlled crushing
Smears small nerve endings
No microcoagulation
Cell necrosis is moderate
Cuts with physical pressure
Normal tactile feedback

ADVANTAGES OF Nd:YAG OVER SCALPEL

1. Less postoperative pain
2. Less bleeding of smaller vessels/lymphatics - less swelling
3. Sterilizes surgical site reducing chance of infection
4. Less cell necroses
5. Less fibroblastic stimulation - faster tissue remodeling

Nd:YAG MEDICAL INDICATIONS

1. Situations contraindicating tourniquet
particularly where a dry field is essential
2. Dissection of delicate tissue planes in all axis requiring contact
3. Patients where surgical trauma may stimulate adverse reactions
Collagen-vascular disease (ie: SLE), gout, R.A., etc.
3. Patients with platelet, hematogenous and vessel disease,
sickle cell, phlebitis
4. Elderly patient exhibiting capillary fragility

PODIATRIC MEDICAL INDICATIONS FOR Nd:YAG SCALPEL

1. The Nd:YAG laser scalpel decreases the surgical pathophysiology of
a. edema in a dependent extremity
b. leakage of intravascular fluid in the surgical site
of the foot from hydrostatic pressure
c. nerve microtrauma and axonal depolarization
d. local surgical cell necroses (v blade)
e. scar formation
f. nosocomial infection
2. Extremity surgery
a. Hydrostatic pressure, terminal perfusion. weightbearing
b. structure undergoing reconstructive surgery are all
c. factors complicating foot and ankle surgery
3. Hypertensive patient with peripheral edema
4. Plastic reconstruction
5. Wet cases
6. Cases where visualization must be optimized
ie: Nerve decompression within ganglion complex
7. Any situation where cell necrosis must be minimized

CONTRAINDICATIONS
Defer these cases until the learning curve plateau is reached
1. Digital surgery - cannot justify utilization
Instrument overkill for procedure
2. Revisional surgery - actually indicated
but these surgeries carry a higher risk by default
If successful laser gets the credit
If not successful surgeon gets blammed
Public expectations of lasers are high
3. Any bone work - not FDA approved
This is not a wavelength for this
4. Medical-Legal cases - Same idea as revisional Surgery
5. Amputation - Same idea as revisional surgery
6. PVC cases - Same idea
7. Acute Trauma cases - no time to call in laser team
INDICATIONS FOR FROSTED AND NONFROSTED CONTACT TIPS

PROCEDURE CONTACT-TIP COMMENT

Nerve releases and Neuroma Nonfrosted Thermal Radiation
Neurectomy Nonfrosted Lateral Radiation
Bunionectomy (soft tissue) Frosted Limit capsular dissection
Ganglions Nonfrosted Particularly those
adjacent to muscle
Tendon transplants/lengthening Nonfrosted Long remodeling time
Heel spur (soft tissue) Frosted Excellent visualization
Plantar Fasciotomy Nonfrosted Around calcaneus only
General Podiatric Surgery Frosted Coagulation during
dissection

INAPPROPRIATE Nd:YAG PROCEDURES

1. Wrong tip = wrong procedure
ie Neuroma sx with frosted tip
Induces thermal periostitis in adjacent metatarsals
This can be done with frosted at short power applications
2. Nail matrixectomy = burns periosteum
use CO2
3. Warts = can use, but it's more easily treated with CO2
4. See contraindications

GENERAL CONSIDERATIONS IN APPLICATION OF THE Nd:YAG LASER

1. Drapes are dry. Water transmits this wavelength.
2. Separate mayo stand for fiberoptics with expensive tips and power equip
3. Notch filter glasses are the best eyewear protection, best visibility
4. Select general surgery handpiece
5. Select tip size and frosting based on presurgical plan
6. Laser nurse will connect fiberoptics to launch pad on laser
7. Calibrate instrument and hand off calibration cone, now contaminated
Select power level, C.W. mode
8. Incision is made with a steel blade only to the dermis
When you see the whiteness of the dermis - stop
Contact tip is held 45 degrees to tissue
New frosted tips need 2 seconds at full power to "age"
9. Traction - countertraction throughout procedure
10. Room suction be used for the minimal smoke plume
much less than CO2 laser
11. Deeper dissection now before using forceps Use traction - countertraction
12. Dissect in linear strokes. Avoid burying the tip.
This laser needs less pressure than a steel blade Tactile feel is like a hot knife through
butter So let the laser do the work
13. Repeat dissection strokes until each plane of tissue complete
14. Dissection may be adjacent to vessels, stay 3-4 mm from nerves at high power
levels 14-16 W
15. Hemostasis of larger vessels can be with the laser
alternate on either side, observe coagulation
16. Capsular dissection may be made right over cartilage
with no damage to cartilage
17. Dissect only the periosteum/capsule you intend to discard
Good hemostasis, but seals off periosteal vessels
18. Remainder of capsule/periosteum done with blade
19. Bone work with conventional power instrumentation
20. Watch on-time during intermetatarsal neuroma surgery
Avoid thermal periostitis in adjacent metatarsals
21. Seal nerve endings in neuroma sx. with the contact tip
Prevents stump neuroma formation
22. Minimal char formation seen
Very dry and atraumatic surgical site seen
23. Closure is conventional, dressings conventional
24. Sutures remain in a few days longer
Expect macroscopic bleeding due to tourniquet reflux hyperemia

REALISTIC EXPECTATIONS
1. Learning curve is steeper than CO2 Laser
2. Postoperative bruising still seen
3. Swelling, and pain still seen - although diminished
4. Macroscopic bleeding present but diminished
5. Be ready for the unexpected -
New technology presents new situations
6. Do simple cases first
THE ARGON LASER

GENERAL DESCRIPTION
1. Dual wavelength output:
Blue 488 nm
Green 514 nm very close to KTP 532 nm (pure green)
2. 1 to 2 mm depth of penetration.
3. Operates as a coagulation device, not used for cutting
4. Argon and KTP pass epidermis to absorb in the dermal hemoglobin selectively
Nd:YAG and CO2 do not absorb in the region of the Hb curve
5. Fiberoptic delivery system
6. collimated handpiece, freebeam fiber, contact
7. Aiming beam is a low power argon beam, hard to see through OD 3 or 5 glasses
8. 30 degree divergence on the KTP fiber, 2 degree divergence on the Argon fiber.
9. 488 nm filter is used to filter out green component
10. Hemoglobin Absorption is a bimodal curve
11. Ideally the wavelength should fall on the peak absorption of this curve and be
maximally transmissible through other tissues

MECHANISM OF ACTION
1. Chromophores on the bottom of the foot are minimal
2. They pose little problem because the epidermis, dermis
basal layer is transparent to this wavelength
3. Absorption at this wavelength is low
first absorbed in the hemoglobin within the vessels of the reticular dermis
4. vessels are stenosed via selective photoablation.
a. Able to coagulate vessels less than 1 mm in diameter.
b. Indicated for tissue coagulation and necrosis procedures (acisional)
c. KTP laser, 532 nm can be used also for vascular stenosis.
d. Deeper dermal structures, such as capillary hemangioma, other lasers are indicated
for this such as the free beam Nd:YAG.

EYE PROTECTION
1. Optical Density (O.D.) minimum of 5 at 488 nm.
2. Unfortunately, these glasses block out the aiming beam
The aiming beam is a low level intensity treatment beam.
3. Visible light eye protection radically alters the colors of the surgical field

SURGICAL APPLICATIONS
INDICATIONS FOR THE ARGON LASER
1. This treatment is very useful for incisionless surgery
It is highly favored by the patient,
particularly in the large verrucae on the plantar aspect of the foot and the posterior
aspect of the heel normally a CO2 laser would leave an ulcerative defect Immediate
shoe gear
2. Multiple disseminating lesions or mosaic warts on the plantar foot
3. Vascular lesions of a superficial nature

4. Patients having communicable diseases when a bloodless field is desired

5. It is not indicated for highly fibrotic and scarred verrucoid lesions. Scar tissue
transmits this frequency giving a painful result

ADVANTAGES
1. Minimal exposure to blood--this is an incisionless procedure.
2. Decreased laser plume about 5% of that with CO2 laser A smoke evacuator is still
required
3. Good treatment for immunocompromised patients
4. Faster than CO2 laser, i.e. a 45 minute procedure for the CO2 laser for
verruca plantaris would take 5 minutes with the Argon laser
5. It is repeatable
6. Sterile preparation unnecessary.
Surgeon still should be gloved for isolation from lesion contaminants.

ARGON LASER DESTRUCTION OF VERRUCA

1. Object = delivery of energy to the superficial dermis - papillary plexus These are the
vessels feeding the wart.
The wart is an epidermal structure, not a dermal structure. It is however fed by vessels
from the dermis.
2. Anesthesia peripheral to lesions and without epinephrine
3. Thick sections of epidermis should be debrided previous to treatment This minimizes
epidermal carbonization.
4. Inject peripherally - do not blanch skin from the injection pressure
5. Collimated handpiece is used with 600 nm to 1 mm diameter fiber
6. 5 degree to 30 degree divergence. Focusing handpieces are available.
7. Bare fiber is held 1-2 cm from tissue
8.2-4 mm spot, 5.5 watts, 0.5 seconds for the plantar foot.
May be used continuous mode and brushed when a good technique is adapted.
9. Selection of appropriate power density is very important.
3 watts for thin skin, 6.5 watts for thick skin
10. Include 2 - 3 mm border peripheral to the wart,
11. Carefully check this tissue for a "blanching effect".
12. Allow for a 3 to 5 second delay in this blanching
13. This is a result of the coagulation
of the superficial dermal vessels. No vaporization occurs

NOTES:
1. Some carbonization is normal in thick epidermis
Avoid charring this by continuous circular motions.
2. When blanching occurs, this is the proper setting.
Also the proper rate of hand piece movement.
3. This is a time dependent phenomena.
4. After the vasculature is coagulated the chromophores have absorbed the wavelength.
5. If blanching is not encountered, do not increase power,
do not slow down handpiece movement.
6. Repeat the same movement of the handpiece over the area.
7. When proper parameters are determined, continue treatment beyond the test area.
8. The result is not only power and spot size, giving P.D., but time dependent.

POSTOPERATIVE CARE
1. Accommodative pad prn
No dressing necessary.
Patient can put his shoe and sock on and walk out of the operating room.
2. Hydrocodone 2.5 mg i-ii Q 4-6 h prn pain
3. Blistering likely to occur in 3 to 5 days.
Patient may incise and drain this at home.
After I&D, patient is to leave the skin on, for a protective barrier.
4. At one week a black necrotic skin component will form
This lasts 3 weeks and spontaneously sheds.
5. Check patient in 3-4. Recheck in 10 weeks.
6. Should fully heal within 4 to 5 weeks.
No scarring should be seen.
A slight hypopigmentation may be observed.
7. Ulceration is not possible with this laser as the chromophores, hemoglobin
and oxyhemoglobin stops the absorption in the superficial papillary plexus.

THE KTP LASER

GENERAL CHARACTERISTICS
1. Very similar to Argon laser. Single wavelength 532 nm (v. 514 nm Argon).
2. Difference: KTP can cut tissue, contact mode
3. Very useful in selected tissue (below)
4. A frequency doubled Nd:YAG laser
5. Blanching of the skin also seen similar to the Argon laser
6. Note indications for vascular tumors:
Argon superficial
KTP moderate
Nd:YAG (bare fiber) deep
7. Absorption coefficient is slightly increased over the Argon
A.C. - The distance it takes for the radiation to diminish 90% in tissue.
8. Contraindicated in surgery in close proximity (0.5 cm) to thin cortical bone
Vessels of the bone will absorb this wavelength, necrose vascular supply
9. Contact mode and free beam mode

FIBER PREPARATION
Fiber preparation is done previous to each case
1. Fiber must be cleaved:
a. Optical fibers have a crystalline nature
b. A cleaver is used to penetrate the sheath and score the fiber cortex this sets up a
stress riser so the fiber can be snapped
c. the end of the fiber is inspected for a flat, even surface
emitted laser light should be circular and symmetrical
d. The sheath must be stripped.
e. 4 mm recommended by manufacturer, but emits too much lateral light
f. so strip 2-3 mm instead, but enough so the sheath doesn't melt
g. So leave it to Cleaver to strip off the sheath for fiber preparation

SURGICAL APPLICATIONS
KTP TREATMENT OF VERRUCA
1. Same as for Argon
2. Treatment is slightly deeper
3. Blanching is similar but has more significance of penetration depth

KTP APPLICATIONS TO PLANTAR FASCIOTOMY

1. MECHANISM OF ACTION
a. KTP is a nonthermal laser
b. Selective wavelength absorption
c. Operates in contact mode by specific photoablation of protein and hemoglobin.
d. Pericalcaneal tissue = adipose, muscle, and plantar fascia
Advantage - transmission through clear adipose.
Advantage - plantar muscle contact - very little bleeding
e. Muscle is highly vascular and plantar fascia is separated off
Usually muscular bleeding is considerable
Absorption in muscle is superficial - stopped by Hb
f. Lower power levels required

2.. THERMAL LASER PROBLEMS INDICATING KTP LASER

a. Thermal lasers, C02, Nd:YAG --> adipose photohydrolysis and liquefaction
b. This water and fat liquefaction interferes with laser cutting
c. Disadvantage CO2 laser - strongly absorbed by water and no cutting occurs
d. Disadvantage Nd:YAG laser - water transmits and energy is disseminated.
e. Surgical site in heel spur work is deep and visibility must be optimized
Particularly with endoscopic size incisions
3. DISADVANTAGES OF KTP LASER
a. Retinal hazard
b. Fiber preparation before every case
c. Cannot dissect in close proximity to bone
d. Inefficient laser - requires dedicated 220 V 50 A line
e. Larger zone of necrotic damage and zone of coagulation than the CO2
f. Takes a long time to dissect through vertical septa and plantar fascia
g. Must take care not to deliver much energy into muscle (well absorbed)
h. Learning curve
OTHER SURGICAL LASERS
Other medical lasers available with properties, delivery systems unique to each Podiatry
is already using these, but be familiar with basic lasers first

Ho:YAG LASER
1. a near-contact laser being used for resecting calcaneal spurs
2. good for endoscopic and arthroscopic work
3. transmits through water
4. also indicated for cartilage ablative procedures for joint restoration

COPPER VAPOR LASER

1. Known largely for treating port wine stain
and congenital cutaneous vascular pathologies
2. Two wavelengths - yellow and green
3. yellow for superficial vascular
4. green for deeper vascular
5. dermatological surgery
6. very inefficient, large laser, long warmup period

Q-SWITCHED LASERS
1. used to be used in ophthalmic procedures
2. Q-switched Ruby and Q-switched Nd:YAG for tatoo removal
3. no anesthesia necessary
4. multiple treatments necessary
5. little scarring results, mild hypopigmentation

EXCIMER LASER
1. UV laser, 0.2 mm absorption
2. Ionizing radiation
3. Cardiac catheterization, osteotomy, corneal sculpting
4. High frequency, short wavelength means high precision

Er:YAG LASER
1. Mid infrared, 0.1 mm absorption
2. Bone surgery
3. Difficulty in fiberoptic delivery - fragile and toxic
BIBLIOGRAPHY

1. Arndt, Kenneth A., "Argon Laser Therapy of Small Cutaneous Vascular Lesions",
Journal of the American Academy of Dermatology, vol. 118, April 1982, pp. 220-224.

2. Borovoy, Mathew; Fuller, Terry A.; Elson, Lawrence M.; Laser Safety in Podiatry", The
Journal of Foot Surgery, 1985, vol. 24, no. 2, pp. 136-138.

3. Borovoy, Mathew; Klein, Jeffery T.; Fuller, Terry A.; "Carbon Dioxide Laser
Methodology for Ablation of Plantar Verrucae", vol. 24, no. 6, 1985, pp. 431-437.

4. Cacciaglia, G.B.: Reigelhaupt, R.W.; "Effectiveness of Lasers on Plantar Papillomas:

A Preliminary Study", Journal of Foot Surgery, vol. 24, no. 1, 1985, pp. 477-481.

5. Carlson, Bruce A., and Pyrcz, Robert A., "Lasers in Podiatry and Orthopaedics",
Nursing Clinics of North America, v. 25, No. 3, September 1990, Pg. 719-723.

6. Carlson, Bruce A.; Pyrcz, Robert; "Human Papilloma Virus-Induced Lesions: Their
Treatment and the Evolution of an Alternative Laser Application", Current Podiatric
Medicine, November 1989, pp.9-12.

7. Carlson, Bruce A., "Complications Associated with Laser Surgery", Clinics in Podiatric
Medicine and Surgery, vol. 4, no. 4, October 1987, pp. 823-828.

8. Chromey, Paul A., "The Significance of Power Density in Applying the CO2 Laser",
Current Podiatric Medicine, September 1986, pp. 20-22.

9. Chromey, Paul A., "The Application of CO2 Laser to Soft Tissue Tumors", Current
Podiatric Medicine, May 1986, pp.24-27.

10. Collis, Sheldon; Rowland, Roberta N.; "Lasers For Podiatry Principles and
Language", Current Podiatry, April 1984, pp. 33-34.

11. Kaplan, Isaac, "The CO2 Laser In Clinical Surgery: Past, Present, and Future",
Journal of Clinical Laser Medicine and Surgery, pp. 341-343, vol. 9, no. 5, 1991.

12. Kelly, Peter F.; "Nd:YAG Contact-Tip Laser Reduces Pain from Foot Surgery",
Clinical Laser Monthly, Volume 10, No. 1, January, 1992.

13. Kelly, Peter F., "Nd:YAG Contact Tip V. Cold Steel Applications in Podiatric Foot and
Ankle Surgery", American Society for Laser Medicine and Surgery, Supplement 4, 1992.

14. Kelly, Peter F.; "The Light Scalpel - Nd:YAG Laser Contact-Tip", Issue 24, 1992, The
Laser Letter, International Society of Podiatric Laser Surgery, Doylestown, PA.

15. Kelly, Peter F.; "The Nd:YAG Laser for the Podiatric Surgeon", The Laser Letter,
Issue 25, 1992, International Society of Podiatric Laser Surgery, Doylestown, PA.
16. Kelly, Peter F.; "KTP Laser Application to Calcaneal Spur Surgery", Clinical Laser
Monthly; Volume 11, No. 3, April, 1993.

17. Kelly, Peter F., "KTP Laser Application to Calcaneal Spur Resection and Plantar
Fasciectomy", American Society for Laser Medicine and Surgery, Supplement 5, 1993

18. Landsman, Mark J.; Mancuso, John E.; Abramow, Steven P.; "Laser's Use in Bone
and Joint Surgery, Clinics in Podiatric Medicine and Surgery, vol. 9, no. 3, July 1992, pp.
721-737

19. McDowell, Brian A., "Carbon Dioxide Laser Excision of Benign Pedal Lesions,
Clinics in Podiatric Medicine and Surgery, vol. 9, no. 3, July 1992, pp. 617-632.

20. Mueller, Terrance J.; Carlson, Bruce A.; Lindy, Marc P.; "The Use of the Carbon
Dioxide Surgical Laser for the Treatment of Verrucae", Journal of the American Podiatry
Association, vol. 70, no. 3, March 1980, pp. 136-141.

21. Nicholson, Ronald A., "Two Techniques Described using C02 Laser for
Matrixectomy", Laser Practice Report, vol. 7, no. 7, pp. 1 S-2S.

22. Pyrcz, Robert A.; Carlson, Bruce A.; "Lasers in Podiatry and Orthopedics", Nursing
Clinics of North America, vol. 25, no. 3, September 1990, pp. 719-723.

23. Wasserman, Gerald, "Treatment of Morton's Neuroma with the Carbon Dioxide
Laser", Clinics in Podiatric Medicine and Surgery, vol. 9, no. 3, July 1992.

SPEED-READING BIBLIOGRAPHY

1. "Continued efforts to enhance the utilization of laser technology and the ability of laser
education at teaching hospitals are key for the future." Lanzafame, Raymond, J.;
Hinshaw, Raymond, J.; "Laser Education, Laser Usage, and Surgical Attitudes: A
Challenge for the Future", Pg. 279-81, Journal of Clinical Laser Medicine and Surgery,
Volume 10, No. 4, 1992.

2. "It (the CO2 laser) routinely provides a bloodless surgical field as well as unusual
surgical precision." Fairhurst, Mark V.; Roenick, Randall K.; Brodland, David G.;
Subspecialty Clinics: Dermatology, "Carbon Dioxide Laser Surgery for Skin Disease",
Mayo Clinical Proceedings, Vol. 67, Pg. 49-58, 1992.

3. "Thermally induced tissue destruction is accurate with little damage to surrounding

normal tissue because the coherent, collimated, monochromatic beam of light can be
focused to a very tiny point using an optical lens system. Histologically, the area of
tissue necrosis adjacent to the laser incision is less than 0.1 mm, usually 50-70 microns.
This facilitates healing with reduced scarring. The zone of cellular damage varies from
0.3 to 0.5 mm." Chromey, Paul A., Current Podiatric Medicine, September 1986, Pg. 20-
22.
4. "Carbon dioxide laser offers many advantages demonstrated in this study, including
minimal bleeding, improved healing, reduced edema, improved postoperative
discomfort, minimal scarring and minimal infection." Cacciaglia, G.B., Reigelhaupt, R.W.,
"Effectiveness of Lasers on Plantar Papillomas: A Preliminary Study", Journal of Foot
Surgery, Vol. 24, No. 1, 1985, Pg. 477-481.

5. "Since the beam affects well defined areas of the skin, there is minimal necrosis of
adjacent tissue; consequently, postoperative pain, edema, and scarring are minimized."
Mueller, Terrance J.; Carlson, Bruce A.; Lindy, Mark P.; "The Use of the Carbon Dioxide
Surgical Laser for the Treatment of Verrucae", Journal of the American Podiatry
Association, Vol. 70, No. 3, March 1980, Pg. 136-141.

6. "Podiatry started using the laser for the excision of Morton's neuroma and for
incisional approaches to bunionectomy and other podiatric procedures." "The same
advantages were found to be present for incisional procedures: less bleeding, pain, and
postoperative edema." Peyrcz, Robert A., Carlson, Bruce A., "Lasers In Podiatry and
Orthopedics", Nursing Clinics of North America, Vol. 25, No. 3, September 1990, Pg.
719-723.

7. "Utilizing the CO2 laser in neuroma surgery for making incisions and sealing the nerve
stump decreases postoperative pain and healing, allowing patients to resume normal
ambulation faster than with conventional scalpel surgery." Wasserman, Gerald, Clinics
in Podiatric Medicine and Surgery, "Treatment of Morton's Neuroma With the Carbon
Dioxide Laser", Vol. 9, No. 3, July 1992, Pg. 671-686.

8. "The contact method of performing endoscopic and open surgery with the Nd:YAG
laser opens a new era in laser surgery ... with cutting capabilities previously only seen
with the CO2 laser." "The CO2 laser operating at a wavelength of 10,600 nm with energy
outputs of 100 watts is effective at cutting and coagulation of SUPERFICIAL blood
vessels." Joffe, Stephen N.; Schroder, Tom; Lasers in General Surgery, Year Book
Medical Publishers, Inc., Laser Center of America, Cincinnati, OH, Pg. 125-130, 1987.

9. "We concluded that CO2 laser surgery for hemophiliacs has a confirmed place for
modern laser technology." Santo-Dias, A.; "CO2 Laser Surgery in Hemophilia
Treatment", Journal of Clinical Laser Medicine and Surgery, Pg. 297-301, Volume 10,
No. 4, 1992.

10. "Because of the large amount of water in body tissue, this laser (CO2) will cause a
vaporization of the tissue at the focal point and seal the small blood vessels and
lymphatics. The laser creates an incision that leaves residual tissue undamaged."
Kaplan, Isaac; "Twenty Years of CO2 Laser Surgery: A Review and Update", Journal of
Clinical Laser Medicine and Surgery, Pg. 57-60, Volume 11, No. 2, 1993.

11. "Certain advantages of the use of the CO2 laser stand out: absence of hemorrhage
and cellular vaporization which permit, due to a perfect visibility, appreciation at every
moment of the quantity of tissue that needs to be removed." Dourov, Nicolas; Nammour,
Samir; "Removal of Benign Tumors Using the CO2 Laser", Journal of Clinical Laser
Medicine and Surgery, Pg. 109-113, Volume 10, No. 2, 1992.
12. "This action results in a fine hemostatic incision leaving the residual tissue relatively
undamaged." "The treated areas heal rapidly because the skin appendages escape
permanent damage." Kaplan, Isaac; "The CO2 Laser In Clinical Surgery: Past, Present,
and Future", Journal of Clinical Laser Medicine and Surgery, Pg. 341-343, Volume 9,
No. 5, 1991.

13. "Surgical laser technology has been available for nearly 30 years and is being used
increasingly in many surgical disciplines including orthopedic surgery." Cahill, Sandy;
Kopta, Joseph A.; Kosanke, Stanley D.; Rayan, Ghazi M.; Stanfield, Denver T.; "Effects
of Rapid Pulsed CO2 Laser Beam on Cortical Bone In Vivo", Lasers in Surgery and
Medicine, Pg. 615-620, Volume 12, No. 6, 1992.

14. "The lack of wound contraction, scarring, and good reepithelialization combined with
precise tissue destruction makes CO2 laser surgery ideal for this procedure when
compared with conventional techniques." Keng, S. B.; Loh, H. S.; "The Treatment of
Epulis Fissuratum of the Oral Cavity by CO2 Laser Surgery", Journal of Clinical Laser
Medicine and Surgery, Pg. 303-306, Volume 10, No. 4, 1992.

15. "The advantage of the CO2 laser technique was that it produced minimal thermal
damage to the surrounding tissues." Fallouh, Hayel; Sultan, Raymond A.; "Combined
CO2-Nd:YAG Radiation in Liver and Anorectal Diseases", Journal of Clinical Laser
Medicine and Surgery, Pg. 255-263, Volume 10, No. 4, 1992.

FURTHER READING

1. Sherk, Henry H., Editor, Lasers in Orthopaedics, J.B. Lippincott Company,

Philadelphia, PA, 1990.

2. Ballow, Edward B., D.P.M., Editor, Laser Surgery of the Foot, First Edition,
International Society of Podiatric Laser Surgery, Doylestown, PA, 1988.

3. Joffe, Stephen N.; Schroder, Tom; Lasers in General Surgery, Year Book Medical
Publishers, Inc., Laser Center of America, Cincinnati, OH, 1987.

4. "Lasers In Podiatry and Orthopedics", Nursing Clinics of North America, Vol. 25, No.
3, September 1990.
PHOTODYNAMIC THERAPY "PDT"

MECHANISM OF OPERATION
1. Requires an injection, dissemination and systemic absorption of protoporphyrins
2. Malignant cells take up the protoporphyrin
These can be visualized under UV light
Patient must remain away from all light during this treatment session and have a
photosensitivity up to six weeks post treatment
3. Laser radiation is applied at a specified frequency, usually red light area. and for a
specified time - result is Joules to tissue
4. Wavelength depends on protoporphyrin
5. Results is a single oxygen produced which destroys malignant tissue selectively

BIOSTIMULATION "BIOSTIM"
1. A few milliwatts hitting mitochondria stimulating thermal mechanism.
2. No heat is produced.
3. Mitochondrial chromophores.
4. This is FDA investigational.
5. Applied to wound healing, to nerve regeneration, and chronic pain--analgesic.
6. Elicits a systemic effects
7. 0 milliwatts, tunable dye, helium-neon, 12 joules per week for 30 weeks
8. Applied to rheumatoid arthritis, trigeminal neuralgia, osteoarthritis, sciatica, diabetic
neuropathy.
9. Has 60 to 85% of pain relief
10. 5-hydroxyindolacetic acid, 5-HIAA produced
Urinary HIAA output increase correlated with pain relief
11. Systemic effects:
stimulation of human lymphocytes
Decreased pain and inflammation of distant ion irradiated sites Increased urinary 5-
HIAA, product of serotonin metabolism
12. Dose:
50 milliwatts, tuneable dye or helium-neon laser, 12 joules per week for 30 weeks.
13. Proposed mechanism:
absorption of light by photoreceptor or chromophore in the mitochondria activates the
respiratory chain, resulting in a cellular response.
14. Primary process:
a. Electron train excitation
b. acceleration of electron transfer in redox pairs (activates and stimulates).
c. Transfer of excitation energy from oxygen
to single oxygen (oxidative effect inhibiting healing).
d. Respiratory chain components are probably the primary photoacceptors.
e. Flavins, cytochromes, cytochrome oxidase.
f. Respiratory chain in a unitary dynamic system can be acted upon
at various points causing change in the whole state of response.
Summary:
1. Effects are dose dependent. Higher energies seem to be damaging.
2. Coherent light is preferred versus non-coherent.
3. Narrowed band monochromatic light preferred, i.e. helium-neon coherent and
monochromatic light
4. Competing wavelengths cancel the effects, therefore coherent light is preferred.
5. Transcutaneous irradiation penetrates deeply enough to
produce generalized effect in many cases.
6. 4 joules/cm2 penetrates approximately 1 cm.
7. Local radiation with systemic effects.
i.e., 5-HIAA production from serotonin metabolism.
8. Depends upon the physiological status of cell before radiation.
9. The biostimulation effect is not always possible.