1、激光美容存在的问题与对策(摘要) 高天文 孙林潮 李承新第四军医大学西京医院全军皮肤病中心 (陕西西安 71003)激光作为 20 世纪最重大的科技成就之一已载入史册。激光美容具有效果好、副作用小、安全性高等特点，然而激光美容中仍存在不少问题。我们应用 VersaPulse 多波长激光、VascuLight(Photo Dream)强光、LightSheer 半导体激光、Quanturn 嫩肤仪、Sharp1080S 超脉冲 CO2 激光、1030C 超脉冲 CO2 激光 Sharplan 铒激光、Sharplan 红宝石激光、 LaserscopeOrion 激光、连续和脉冲式Nd：YAG
2、激光、连续 Nd：YAP 激光、调 Q1064532 二合激光及 ClearTouch 痤疮治疗仪等治疗各种皮肤疾患数万例。本文就我们的应用体会对激光美容存在的问题进行分析并提出对策。1.鲜红斑痣的激光治疗问题，鲜红斑痣激光治疗的最大问题是治愈率低，以往各种机器治愈率均未超过 20，VascuLtght 强光与 VersaPulse 联合使用可提高治愈率。波长 595nm 的 V-Beam 能使疗效显著提高。2。色痣激光治疗问题：色(素)痣或黑痣是良性黑素细胞肿瘤的俗称，而不是一个疾病的诊断名称。激光治疗色痣可出现下列问题：1)不易彻底，常复发；2)过度治疗可致瘢痕；3)早期黑素瘤被误诊为色痣
3、，激光治疗造成严重后果。为此我们主张不论出于预防恶变还是美容需要，色痣的正确治疗方法是手术切除并作病理检查。3嫩肤除皱问题：我们有以下体会：1)效果：超脉冲 CO2铒激强光；2)超脉冲 CO2 疗效好，但色素沉着重，不适于有色人种；3)粗皱纹选铒激光；4)铒激光致色素沉着风险小于人们的预计；5) 光嫩肤只宜看作一种高级护肤设备，未发现有明显的除皱效果。4。强光嫩肤及治疗问题：目前强光被市场过度炒作，由于以次充好的机器的出现，市场混乱，致治疗无效，强光嫩肤的声誉已受到严重影响。Current Lasers in the Skin Cosmetic -Problems and SolutionsT
4、ian wenGao Lin chaoSun Cheng xinLiDepartment of Dermatology, Xijing Hospital, the Fourth Military Medical University,Xlan 710032, P.R.ChinaThe approach to skin cosmetic, especially to facial skin cosmetic, has been dramatically enhanced by theapplication of current lasers over the past decade. Curre
5、nt lasers have raised a lot of interest, and it has already been widely employed in the treatment of many kinds skin disorders, for instance, vascular lesions, pigmented diseases, hypertrichosis and skin resurfacing. However, there still exist some problems. Firstly, the Q-switch-mode laser is very
6、succeful in completely removing naevi of Ota, naevi of Ito, lentigos, freckles, and tattoos without any scarring or pigmentary disturbance, however, following Q-switched-mode laser treatment, many patients with pigmented uaevi have partial repigmentation within several months after discontinuation o
7、f therapy. In addition, it has been found that the number of recurrent pigmented macules increase and benign naevus even become malignant melanoma in some patients. Secondly, although current lasers are very effective in the treatment of angiomas, telangiectasias, vascular lesions of a few patients
8、can not be completely removed even after several years treatment. Finally, laser skin resurfacing has become a popular therapeutic modality for the correction of acne scars, but it is not always effective in all types of acne scars. How to prevent the side-effect and how to improve the treatment eff
9、iciency? Here we bring forward some principles for the application of current lasers in the skin cosmetic. As laser technology is refined, we can ensure the optimal outcome for our patients and advance the field of cosmetic dermatology.激光作为 20 世纪最重大的科技成就之一己载入史册。激光真正步入美容医学仅 10 年左右，然而其如同魔光，使丑变美、老变少、黑变
10、白、糙变嫩，创造了大量令人难以置信的奇迹。美容激光的发展不仅提高了人们的生活质量、提供了大量就业机会、创造了巨大的财富，而且在一定程度上提高了人们认识自然.崇尚科学.创造奇迹的科学态度。激光美容具有效果好、副作用小，安全性高等特点，然而激光美容中仍存在不少问题。我们应用 VersaPulse 多波长激光、VascuLight(PhotoDerm)强光、LightSheer 半导体激光、Qunntum 嫩肤仪、Sharplan10805 超脉冲 CO2 激光、1030C 超脉冲 002 激光Sharplan 铒激光、Slarplan 红宝石激光、LaserscopeOrion 激光、连续和脉冲式
11、 Nd：YAG 激光、连续 Nd：YAP 激光、调 Q1064532二合一激光及 ClearTouch 痤疮治疗仪等治疗各种皮肤疾患上万例。本文就我们的应用体会对激光美容存在的问题进行分析并提出对策。1 鲜红斑痣的激光治疗问题鲜红斑痣激光治疗的最大问题是治愈率低，我们先后用过Laserscope 公司的 Orion 激光器、ESC 公司的 VaseuLight 强光及科以人公司的 VersaPulse 等设备，治疗均有效，但治愈率均未超过20。激光治疗的疗效与病变的血管的管径大小、位置的深浅、病变所在的部位以及表皮色素的深浅等有关。一般说来，患者年龄小、皮损颜色较淡并呈粉红色、分布较弥散、病变
12、血管间有正常组织相间隔的类型，治愈率较高；而病变颜色深、组织厚、血管密集的类型较难治疗：下肢皮损可能因重力的原因，血管易再通。对于管径较小和较浅的血管性病变用较短的波长和脉宽治疗即可获理想的疗效，如用 VPW532nm 治疗，脉冲宽度采用5ms30ms，能量采用 10-20Jcm2。而对于管径较大和较深的血管性病变则要用较长的波长和脉宽，我们常配合使用 VascuLigat 强光，以 570nm、590nm 的滤光晶体进行治疗，其作用深度可大大加深。通过计算机控制，VascuLight 强光和激光的脉宽在 0.5ms50ms 间可调；且每次击发可选择 13 个脉冲，因此，VascuLight
13、强光在治疗管径较粗、部位较深的血管性病变有一定优势。激光与 VaseuLight强光联合治疗可使血管性疾病的疗效有一定的提高。近年推出的595nm 激光，由于其波长、脉宽设置非常合理，疗效较以往的机器有明显的提高，是目前最理想的治疗血管性疾病的激光仪。另外，治疗的间隔适当缩短，可使疗效有所提高，在保证表皮能够顺利愈合的情况下，治疗间隔可缩短至 4 周左右。因疗效差，常需尽量增大能量以减少患者的治疗次数，然而由于个体差异大，增大能量几乎难以避免出现一些治疗的副反应，包括水肿、水疱形成、色素沉着、色素减退、瘢痕形成等。对策:初次治疗时最好先进行“光斑试验” ，以确定最佳治疗剂量，组织反应以红色变暗
14、变紫为宜，明显发白则说明能量过高。治疗参数选择一般应由低能量开始，然后逐渐加大。特别要注意眼周及儿童的治疗，因皮肤娇嫩，极易损伤，所用能量应相应减低。术中应同步采取冷却措施。术后立即用冰袋冰敷。早期形成的粉红色的增生性瘢痕可用 VPW532nm 的激光或用 PhotoDerm 强光治疗(使用570nm，590nm 滤光晶体)。可以使瘢痕变软、变平，颜色恢复近似正常肤色。色素沉着和色素减退一般为暂时性，可不予处理。长久性的色素减退为能量过高所致，较难处理，应以预防为主。2 色痣激光治疗问题色(素)痣或黑痣是良性黑素细胞肿瘤的俗称，指由各种增生的黑素细胞构成的非恶性肿瘤，而不是一个疾病的诊断名称。
15、目前的中文专著中将普通后天性色痣及小的先天性色痣混为一体，均称色痣。严格说来，宜用普通后天性色痣替代色痣、痣细胞痣等概念不清的名称。此种名称可将易恶变的先天性色痣、争议中的后天性发育不良性色痣明确加以区分。最近我们统计了西京医院皮肤科以色痣相关名称行切除的 1024 个病例，病理符合色痣相关疾病包括雀斑样痣的病例 870 例，诊断不符及未作诊断的共 154 例，主要有恶性黑素瘤及色痣恶变 6 例、基底细胞癌 13 例，脂溢性角化病 75 例、表皮囊肿 13 例、皮肤纤维瘤 7 例等。以病理诊断皮内痣、混合痣、交界痣、蓝痣等色痣相关疾病进行检索共查出 9.54 例，临床诊断色痣相关疾病者 867
16、 例，其中诊断不符的主要有皮赘 11 例，皮脂腺痣 10例，黑素瘤及色痣恶变 9 例，脂溢性角化病 9 例等。两组诊断错误病例总计 210 例，错误率约 20。其中一些错误诊断是由具有丰富经验的教授做出的。对于早期的黑素瘤，由于诊断错误行激光治疗必然造成严重后果，我们的病例中有 6 位患者治疗前仅考虑到色痣，病理确诊为黑素瘤，若以激光去除而未做病理检查，后果可想而知。皮内痣组织病理的一个特点是有“痣细胞成熟现象” ，即深部的痣细胞体积变小、不成巢，色素消失。以 CO2 激光治疗色痣时，凭肉眼观察去除所见的黑色组织，深部无色素的痣细胞仍残留导致复发，而且可能因受刺激而恶变，我们目前已有 3 个因
17、 CO2 激光除“痣”恶变的病例。若去除过深则可能因胶原增生修复形成瘢痕。Q 开关 1064nm 激光及 755nm 激光对不含色素的痣细胞毫无作用，治疗不彻底及复发是必然的结局。所以我们近年在不同的场合反复呼吁，不论出于预防恶变还是美容需要，色痣的正确治疗方法是手术切除并作病理检查。3 黑子的治疗问题黑子即雀斑样痣，为 1mm 至 3mm 的点状黑斑点，常被误称为黑痣。黑子虽小，治疗失败者颇多，常因其疗效差而影响激光治疗的声誉。其疗效差的原因可能是黑子表皮突明显延长，且增生的黑素细胞主要位于表皮突深部，加之肉眼看似浅表易治而措施不力。治疗可任选长脉冲 532nm、Q 开关 532nm、Q 开
18、关 755nm、Q 开关1064nm，能量 48Jcm2，至皮损发白，重复 34 个脉冲。亦可用超脉冲 C02 激光 UltraPulse(或 SilkTouch)，治疗时宜略深。由于黑子浅表，至今无发生恶变的报告，除激光治疗外，亦可选用药物腐蚀、电烙，高频电、普通 CO2 激光等治疗。此外，一些早期小的交界痣临床上无法与黑子相区别，因其浅表易彻底去除，可按黑子处理。因黑子仅 1-3mm，无需担心治疗过度，即便暂时遗留小的凹陷，数月后即可恢复。4 嫩肤除皱问题 激光除皱是随着超脉冲 CO2 激光的诞生而开始的，兴起于 1993 年。激光除皱效果好、安全性高、操作较简便，使其迅速风靡西方世界。通
19、过一次全面部除皱，通常能年轻 5 岁左右。超脉冲 CO2，激光引入中国后，由于肤色的差异出现了无法接受的色素沉着。1996 年前后出现了损伤小，色素沉着轻的铒激光。我们应用后获得了较好的效果，除皱后有 1 月左右的潮红，未发生过严重的或超过半年的色素沉着，未出现过因效果或副反应方面的纠纷。尽管其未出现无法接受的副作用，但其属于有创性美容，除皱后需休假 10 天左右，加之需麻醉师协助等一些问题，此技术未在国内大量展开。强光除皱虽被炒得沸沸扬扬，我们作为国内最早开展此治疗的激光美容中心之一，至今未见真正达到除皱效果的案例，但强光确实能使皮肤变得光滑细嫩，达到较好的美容效果。Nlite、 CoolT
20、ouch、Smooth-Beam 等“深除皱”设备已上市多年，但其确切效果尚待评价。5 强光嫩肤及治疗问题强光(Intensivepulselight，IPL)即一种强脉冲光是在低能量密度下进行的非剥脱方式的治疗。强脉冲光是经滤过的多光谱光，较短的波长用于治疗血管性病变和色素性病变(斑记) ，而较长的波长治疗后可促进皮肤胶原再生及重新排列，实现光嫩肤。强光治疗范围包括毛细血管扩张、面部发红、酒糟鼻、雀斑、色素沉着、毛孔粗大及细小皱纹等，治疗后皮肤会变得光滑细腻而富有弹性。目前强光被市场过度炒作，强光治疗仪被称为“光子”嫩肤仪，近期一些强光嫩肤仪又被炒做成“比光子更先进”的“光量子” 。不论冠以
21、“光子”还是“光量子” ，实质均为强脉冲光，有效光波波长范围为 560nm 至 1200nm，治疗的有效能量密度约 2535Jcm2，机器需有先进的计算机控制系统，高质量的滤光晶体，有高效的冷却系统，配以优质耦合冷凝胶，需由训练有素的专业人员操作。然而目前市场上的一些机器仅几万元甚至几千元即可购买，有的能量密度不足 20Jcm2，有的无任何冷却系统。由于以次充好的机器的出现，市场混乱，致治疗无效，强光嫩肤的声誉已受到严重影响。有的医院及美容院购入劣质强光治疗仪后，为了使其产生一定的效果，使用了接近优质机器的能量密度，导致严重色素沉着、严重色素脱失。正常情况下光子嫩肤术后除了短暂的红斑反应外，一
22、般无明显的其它副反应。但参数选择过高、操作不当，即便优质强光嫩肤仪，仍可发生诸如水肿、水疱、色素沉着等伤害。其对策是：治疗先从耳前开始，以能量密度 25Jcm2 照射 2-3 个光斑后立即进行皮肤即刻反应的观察。皮肤反应不明显需增加能量，但每次增加能量密度不超过 2Jcm2。选择照射后轻微发红、患者略有疼痛感的能量进行治疗。如果有重度红斑出现，应适当减少能量密度。冷凝胶厚度应为西方白种人的 2 倍，使滤光晶体离开皮肤表面约 2 mm。对于敏感部位应抬高至约 3mm，如下眼睑，唇周等，对于皮下组织较少的部位，如额部，则在抬高治疗头的同时，还应将能员降低10。操作时始终保持滤光晶体与皮肤平行，使在
23、同区域内滤光晶体离皮面的高度始终一致。照射后色素斑可能出现轻微的变黑，对肤色较黑的病人，可能会出现延迟的皮肤反应。能量不可过高，不能因为即刻反应不明显而贸然增加能量。不同肤色和皮肤质地的参数调整：皮肤越厚，病变分布越深，脉宽调长，延长脉宽时，可适当提高能量，皮肤越黑越敏感，能量密度宜调小，脉冲延时调长，采用三次脉冲时，第 2 个脉冲延时略长于第 1 个，由三次脉冲切换到两次脉冲时，能量降低 20。使治疗部位术后冷却至少 15 分钟，直到热敏感减退。术后避免使用热水，应使用冷水柔和清洁皮肤，可以使用保湿润肤的化妆品。对黄褐斑患者的治疗，最好先 在 wood 氏灯下判断病变的深浅，表皮型的黑素主要
24、沉积在表皮基底层，wood 氏灯下色素程度加深，颜色更明显：真皮型表现为真皮中上部有噬黑素细胞，wood 氏灯下颜色不明显加深。对于真皮型的患者治疗应慎重；对于表皮型的患者可做小面积的试验性治疗，疗效理想者再大面积治疗，术后应严格防晒，可同时可配合其它治疗，如内服调理内分泌的药物、维生素 C、维生素 E 等，外用氢醌霜等。40 年前人类发明了激光，20 年前人们能想象的激光是烧灼破坏所指向的一切病变组织(包括周围正常组织 )。20 世纪末，激光已能够将组织内异常的黑色素、病变血管破坏而不损伤所透过的正常皮肤，能在毫无损伤的情况下使真皮组织中的胶原恢复活力，皱纹消除、老化的皮肤变细嫩，能随意去除
25、多余的毛发、消除痤疮、去除银屑病皮损、恢复白癜风皮损激光能为人类的健康服务，能使人类变得更美，但也会给人类造成伤害，关键在于我们去很好地认识它、驾驭它。Current Lasers in the skin Cosmetic-Problem and SolutionTianwen GAO Linchao Sun Chengxin LiDepartment of Dermatology, Xijing Hospital, the Fourth Military Medical University,Xian, Shaanxi710032, P.R.ChinaThe current laser as
26、 one of the most important scientific achievements has been recorded in the history. There are only 10 years or so after the laser was brought in the medical cosmetology. It just like a magical light which create plenty of remarkable wonders to change ugly into beautiful, old into young, rough into
27、delicate. The development of the laser cosmetic therapy does not only enhanced the quality of peoples life, supplied many jobs, created massive wealth, but also enhanced the scientific attitude of people to study the nature, believe in science and create wonders.The current laser cosmetic therapy ha
28、s many advantages like good effect, slight side effect and high safety; however, there are still some problems. We have treated thousands of patients with skin disease by different equipments such as the VersaPulse multiple-wavelength lasers, VascuLight (PhotoDerm) intensive light, LightSheer Semico
29、nductor lasers, Quantum skin-refining equipment, Sharplan 1080s ultra-pulse carbon dioxide lasers, 1030s ultra-pulse carbon dioxide lasers, Sharplan erbium lasers and ruby lasers, Laserscope Orion lasers, continual and pulsative Nd:YAG lasers, Q-switched-mode 1064/532 lasers and ClearTouch acne equi
30、pment. Now we will analyze the problems and give solutions.1. The problems of the treatment on nevus FlammeusThe biggest problem of the therapy of the nevus flammeus is the low cure rate, we have used the Orion laser equipment of Laserscope Company, The VascuLight intensive light of ESC Company and
31、the VersaPulse equipment, they are all effective, but the cure rate is below 20%. The effect is related to the size of the vessel, the depth of the position, the location of the pathologic change and the depth of the epidermal pigment. If the patient is young, the color of the damaged skin will be l
32、ight and pink, the distribution will be wide-spread, the cure rate of the disease with septum in normal tissues which is in the pathological blood-vessels will be high, and the disease with deep-colored pathologic change, thick tissues and concentrated blood-vessels is hard to cure. The skin damage
33、of lower limb may be caused of gravity, the vessels of this disease is easy to recuperate.For the vascular pathologic change with narrow and shallow caliber, we can use the VPW532nm,the pulse width is between 5ms30ms,the energy is between 1020J/c.For the one with wide and deep caliber, we can use lo
34、nger wave length and pulse width, and the VascuLight and the light-filtering crystal of 570nm、590nm to cooperate. Through the control of computer, the pulse width of the VascuLight intensive light and the lasers can be adjusted between 0.5ms50ms, each percussion can 13 pulses, so the VascuLight inte
35、nsive light has certain advantage on this aspect. The combined treatment of the VascuLight intensive light and the lasers can improve the effect of vascular pathologic change. The lasers with 595nm are the ideal equipment because of the reasonable installation of wavelength and pulse width. Besides,
36、 reducing the interval of the treatment can enhance the effect; the interval can be to 4 weeks or so under the condition that the epidermis was healed up smoothly.To reduce the time of the treatment, we often need to increase the energy because of the poor effect, but there is great difference betwe
37、en different individuals. Its hard to avoid some side-effect such as hydrops、vesiculation、pigmentation、reduce of pigment and cicatrisation. SOLUTION:At first, use“the test of light spots” to decide the best dosage of the treatment. The tissue reaction is better to become dark and purple from red. If
38、 the color is obvious white less, it means the energy is over-high. The therapeutic parameter should be added gradually. Especially pay attention to the therapy of the children and the periophthalmic skin which is tender and easy to hurt.During the operation, take the cooling measure at the same tim
39、e.After the operation, give an ice compress.Treat the early hyper plastic pink scar by VPW532nm lasers or the PhotoDerm intensive light (570nm, 590nm light-filtering crystal) which can soften and flatten the scar and make the skin normal.Usually, the pigmentation and the pigment decreasing are tempo
40、rary and the long-term pigment decreasing is caused by the over-high energy, so focus on prevention.2. The problem of treatment on pigmented nevusThe pigmented nevus or the melanotic nevi are the popular name of the benign malanocyloma. It is a non-malignancy tumor that was composed of different kin
41、ds of melanocyte rather than a diagnostic name of a disease. Nowadays, in some Chinese special works, the common acquired pigmented nevus and the small congenital pigmented nevus are mixed and called pigmented nevus. Strictly, we should use the common acquired pigmented nevus instead of the pigmente
42、d nevus, the nevocytic nevus and so on. This name can be distinguished between the congenital pigmented nevus And the acquired pigmented nevus. Recently, we got a statistics of 1024 resection cases that were done in the Department of Dermatology, Xijing Hospital. In these cases, 870 cases tallied wi
43、th the related disease of pigmented nevus including freckling nevus, 154 cases were falling short of or under diagnose, mainly including 6 cases of the malignancy melanoma and the pigmented nevus canceration; 13 cases of basal cell carcinoma; 75 cases of seborrheic keratosis; 13 cases of epidermal c
44、yst; 7 cases of dermatofibroma etc.954 cases can be looked up with related pigmented nevus disease depend on pathological diagnosis such as junctional nevus, compound nevus, blue nevus etc.867 cases of that patients are related to the pigmented nevus by clinical diagnose, which are not according wit
45、h the diagnosis, mainly include 17 cases of superfluity of skin;10 cases of the sebaceous nevus;9 cases of melanoma and pigmented nevus canceration;9 cases of seborrheic keratosis and so on. These two groups of diagnostic errors amount to 210 cases, the error rate was about 20%, the experienced prof
46、essors made some of them.As for the early melanoma, using laser therapy must cause serious problems because of the diagnostic errors. There are 6 patients in our cases only considered the pigmented nevus before the treatment, which are actually confirmed as diagnosis .If we use laser to remove it wi
47、thout pathological examination, the result can be imagined. One of the pathological feature of intradermal tissues is“the maturation phenomenon of nevus cells” ,which means the volume of the nevus cells becomes small, it can not form a nest, and the pigments disappear in the deep part .When we were
48、using the carbon dioxide laser to cure the pigmented nevus, we removed the black tissues by observation, but the deep non-pigmented nevus cells were still remained, and they may cause recurrence even canceration. We had 3 cases of nevus canceration removed by using carbon dioxide laser. If we made a
49、n over-deep removal, it may form scar because of the repair of the collagen hyperplasia. The Q-switch-mode 1064nm laser and 755nm laser are ineffective to the non-pigmented nevus cell, and the result must be intensive therapy and recurrence, so we appealed repeatedly the effective therapy of pigmented nevus is resection operation with pathological examination.3. The problem of the treatment on black molesThe black mole is freckling nevus which is punctuating black spot between 13mm,always is miscalled as melanotic nevus. T
