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Thread: My 1st VBeam...with some purpuric

  1. #11
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    Quote Originally Posted by DukeCity View Post
    Hi Lookout,
    Glad that everything went well for you, just to confirm, the price was $375.00? -- They filed an insurance claim for you? -- They did your entire face, forehead, cheeks, chin, temples, ect.? You're going for at least one more treatment? -- Keep us informed on how long before your bruises are cleared up... Thx!

    It's $325...entire face...and I mean every single spot on your face is done! Then she goes over that if needed in spot treatments to get it all. They only will bill my insurance for the doc's office visit...I would have to try to get my insurance co to pay for the VBeam.

    I am planning on 1 more for sure and if needed another one. At the price and what you get done I feel it is well worth it IF it works for me...I figure by treatment #2 I should really see alot of improvement.
    Dx 1998

  2. #12
    Senior Member Lauren 007's Avatar
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    I'm glad things went well, Lookout, best of luck!!

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    http://www.medscape.com/viewarticle/511189_3

    Interesting article regarding the purpuric and subpurpuric treatment of broken vessels and background redness.
    Why do we fall? So that we can learn to pick ourselves up again..

  4. #14
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    Dermatology, August 2005 Journal Scan

    From
    Dermatologic Surgery
    August 2005 ( Volume 31, Number 8 )

    Long-Pulsed Dye Laser Treatment for Facial Telangiectasias and Erythema: Evaluation of Single Purpuric Pass Versus Multiple Subpurpuric Passes
    Iyer S, Fitzpatrick RE
    Dermatologic Surgery. 2005;31(8):898-903
    The pulsed dye laser (PDL) is the gold-standard treatment for vascular lesions, including facial telangiectasias, port-wine stains, hemangiomas of infancy, and acquired hemangiomas. The first generation of PDLs produced selective photothermolysis of target vessels containing the chromophore hemoglobin, inducing vessel rupture and purpura. In contrast, second-generation PDLs (eg, Vbeam; Candela Corporation; Wayland, Massachusetts) allow for the variation of multiple laser parameters, including fluence, pulse duration, spot size, and dynamic (cryogen spray) cooling. These versatile lasers can induce vessel injury and ablation with or without rupture, depending on the selected fluence and pulse duration, thereby allowing the laser surgeon to "dial up" or "dial down" the level of treatment-induced purpura and edema. Does one need to induce purpura to achieve optimal vessel clearance, or can similar results be obtained using multiple subpurpuragenic passes?

    To address this important question, Iyer and colleagues conducted a small split-face study using a common pulsed dye laser (Vbeam) to treat facial telangiectasias with either a single purpuragenic pass (7 mm spot, 12 J/cm2 fluence, 6 msec pulse duration, 20/10 DCD setting) or multiple subpurpuragenic passes (10 mm spot, 6 J/cm2, 6 msec pulse duration, 20/10 DCD setting). The investigators used a simple study design, enrolling 9 subjects (6 females, 3 males; skin phototypes I or II) with facial telangiectasia and cheek erythema. Each patient received single-pass purpuragenic treatment on 1 cheek and multiple-pass (4 passes) subpurpuragenic treatment on the contralateral cheek, and treatments were confined to matching 5 x 5 cm areas. Study exclusion criteria included recent isotretinoin use, recent tanning, use of anticoagulant medications, or known coagulopathy. Study outcome measures included evaluation of erythema, vessel diameter, density/surface area of telangiectasias, and level of vessel arborization. Patients were evaluated at baseline and 3-week follow-up, including assessment of all adverse events (eg, prolonged purpura, edema, pigment alterations, scarring).

    All subjects completed the study, and only 1 individual developed transient hyperpigmentation on the single purpuragenic pass side. In general, both purpuragenic and subpurpuragenic treatments yielded comparable reduction in the surface area covered by telangiectasia (43.4% reduction vs 35.9% reduction respectively). The purpuragenic treatment was slightly better at reducing vessel diameter and extent of vessel arborization, while the subpurpuragenic treatment was better at reducing background erythema. As expected, the subpurpuragenic treatment produced less edema.

    Comment
    In this study, Iyer and colleagues test the hypothesis that similar clearance of facial telangiectasia and erythema can be achieved using the pulsed dye laser in a single purpuragenic pass vs multiple (4) nonstacked, nonoverlapping subpurpuragenic passes. Their observations build on previously reports[1,2] and show the following interesting trends:

    Both treatments appear to yield similar reduction in the surface area covered by facial telangiectasia.


    Purpuragenic treatment is more effective at treating highly arborized and larger-caliber vessels. Because such vessels have a higher blood flow, it seems plausible that vessel rupture is necessary to achieve optimal ablation.


    Subpurpuragenic treatments may produce a greater reduction in background erythema. This is likely due to the unwanted effects of vessel rupture when using purpuragenic settings, including perivascular inflammation and hemosiderin deposition.




    These general guidelines should aid laser surgeons in their search for optimal treatment results with minimal adverse effects. Patients with large-bore or heavily arborized facial telangiectasia should be warned that these vessels may require purpuragenic treatment to achieve optimal clearance. In contrast, patients with fine telangiectatic mats and extensive background erythema may benefit more from subpurpuragenic treatment, especially if they have darker skin phototypes prone to postinflammatory hyperpigmentation.

    One main limitation of the above study is the short follow-up period of 3 weeks, since it is possible that the results from the 2 types of PDL treatment will diverge over time. For instance, vessel recurrence may be greater in the areas of purpura-free treatment. Furthermore, background erythema due to extravasated red blood cells should be expected to fade over time in the sides treated with purpuragenic laser settings, and longer follow-up would likely show further improvement in these areas. Finally, the study does not address the role of pulse stacking -- a technique that Rohrer and colleagues[3] have reported to produce excellent vessel clearance without inducing significant purpura. This technique uses stacked subpurpuragenic PDL pulses to ablate vessels without causing vessel rupture.

    References
    Alam M, Dover JS, Arndt KA. Treatment of facial telangiectasia with variable pulse high fluence pulsed-dye laser: comparison of efficacy with fluences immediately above and below the purpura threshold. Dermatol Surg. 2003;29:681-685.
    Tanghetti E, Sherr E. Treatment of telangiectasia using the multi-pass technique with the extended pulse width, pulsed dye laser. J Cosmet Laser Ther. 2003;5:71-75.
    Rohrer TE, Chatrath V, Iyengar V. Does pulse stacking improve the results of treatment with variable-pulse pulsed dye lasers? Dermatol Surg. 2004;30:163-167
    Why do we fall? So that we can learn to pick ourselves up again..

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    Quote Originally Posted by melissawohl View Post
    Hey Francois,
    These were my settings:
    The spot size she used was 10
    The pulse width was 6
    The energy used was 8 Joules
    The # of pulses was 34

    Best wishes,
    Melissa
    Melissa,

    Is this the settings of your last treatment or all of them? Did you have any purpura with these settings? Did she double pass?
    Why do we fall? So that we can learn to pick ourselves up again..

  6. #16
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    That article was really informative...Thanks for posting Francois!

    I wasn't able to get my settings....I'll have to remember for next time I go. I am gonna print out this info to take with me also!

    Melissa, your settings say # of pulses is 34....does that mean each time they zap you it's like getting 34 zaps in one zap? Hope I asked that correctly!
    Dx 1998

  7. #17
    Moderator Melissa W's Avatar
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    Thanks for that article Francois!
    Really informative.

    These are the settings she uses on me each VBeam give or take whatever she adjusts depending on my reaction at the time. She is thoughtful as she's doing the VBeam. The VBeam before this one she did a double pass on my left cheek and I noticed no difference but since I flush asymmetrically anyway I'm not sure I would be able to tell.

    At this most recent VBeam she only went over each cheek once but she covered a lot of areas and included part of my jaw line. She preflushes me (at my request) by putting the heat on in the exam room at full blast and my whole face was red including the sides of my face and not just my central cheeks which is usually the area she confines the treatment to. I did not let her do my forehead or chin this time as I don't usually flush there but I do sometimes. I find that when she treats just my face it also improves my ears. Weird.

    I don't get purple bruises Francois but my face gets covered in red swollen circles where the swelling lasts for at least 3 days (I am still a bit swollen and it is day 4 now) and the red patches last for a few weeks albeit fading each week a bit more. Impossible to cover with makeup for at least a full week afterwards.

    Darlene, I do not know what the 34 means. She also uses DCD settings (no clue what that is either) 20/10. I would be curious to know but the reason I never asked her is that I don't want to be too high maintenance a patient if you know what I mean. If I'm going to her I better trust her at least to determine the treatment parameters etc. but at my next VBeam I'll try and remember and ask her.

    How are you guys doing in terms of healing/symptoms?
    Darlene, do you have any swelling left? How do your bruises look?

    Best wishes,
    Melissa

    BTW It hurts a lot each Vbeam pulse. i thought it would get easier over time but no, not really.

  8. #18
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    Francois,
    You may also want to check out this link. This is another article that discusses purpuric level settings. Your article and the one I have linked are part of what I used to convince my Doc to try purpuric settings about a year ago. She had been of the opinion that the sub-pupuric levels were equal in benefit but now I believe she has come over to the dark side (pun intended).
    http://www.ingentaconnect.com/search...ize=20&index=2
    The link is slow but it does work. My computer skills aren't great so I couldn't figure out how to import the whole article and paste it on the post as you did. If someone else wants to, that'd be great.
    Melissa,
    The DCD settings are for the "dynamic cooling device" on the V-beam. The number delineates the delay and duration (in milliseconds) of the little spray of cryogen that comes with each pulse.
    Wish I knew more, but that's all I've got on that.
    Rob

  9. #19
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    Oh, one other thing-
    On the old Candela V-beam, each pulse is split into a 4 pulse burst. Cynosures PDL, the V-star is split into a 6 pulse burst. The V-beam Perfecta (the newest model) is split into an 8 pulse burst. Candela argues that 8 is better. Cynosure argues that splitting the pulse into anything more than 6 has no measurable benefit. Who knows who is right or wrong.
    I like the original V-beam. Some people have said that Perfecta wasn't as effective as the original and it is more difficult to induce purpura. I haven't had to cross that bridge as yet so I can't say.
    Rob

  10. #20
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    Hi Rob,
    That is very informative thank you.
    The article was written in 2003 before (I think) the VBeam Perfecta model was introduced. You are correct in that it is much harder to induce purpura with the Perfecta but you still can. The thing is, the Perfecta is more efficient (supposedly) than the previous VBeams and can deliver more power at subpurpuric treatment than the older models and hence decreases the need for bruising to get to the same result. What we need are more studies involving the newer models (including the Perfecta) comparing bruising vs non-bruising treatment. That would really help decide this matter.

    Here is the article you so kindly shared with us. I'm not sure if this is what you meant (to post it like this or you just meant to post the whole article which is unavailable to anyone who is not a subscriber unfortunately).
    Treatment of Facial Telangiectasia With Variable-Pulse High-Fluence Pulsed-Dye Laser: Comparison of Efficacy with Fluences Immediately Above and Below the Purpura Threshold



    Authors: Alam M.; Dover J.S.; Arndt K.A.
    Source: Dermatologic Surgery, Volume 29, Number 7, July 2003 , pp. 681-685(5)
    Publisher: Blackwell Publishing

    Abstract:
    Background.
    Pulsed-dye laser treatment has been shown to be highly effective for the treatment of facial telangiectasia. Posttreatment purpura after such treatment has limited patient acceptance of the procedure. Objective.
    To determine whether purpura-free treatment with recently introduced variable-pulsed pulsed-dye lasers can effectively reduce facial telangiectasia. Methods.
    This was a prospective, randomized, controlled, nonblinded trial. Eleven patients received variable-pulse pulsed-dye laser treatment with and without induction of purpura. Telangiectasia were graded on a “telangiectasia density scale,” on which a 1 signified extremely fine, sparsely distributed telangiectasia, and 5 referred to thick, ropelike telangiectasia covering the affected area. For each subject, two areas on either side of the facial midline with equivalent telangiectasia density ratings were randomized to the purpura and purpura-free treatment groups, respectively. All treatments used a 7-mm spot size and a 10-ms pulse duration. The fluence associated with the purpura threshold for each patient was determined in test areas. Purpura-free treatment entailed a fluence 1.0 J/cm2 less than the purpura threshold, and purpura-level treatment entailed a fluence 0.5 J/cm2 greater than the threshold. Results.
    Six weeks after a single purpura-free treatment, mean telangiectasia ratings were reduced from 2.7 to 2.4. Purpura-level treatments resulted in a decrease to 1.4 from the same baseline. Thicker, denser telangiectasia appeared to benefit more from purpura-level treatment (a mean telangiectasia density scale reduction of 1.7) than finer, sparser telangiectasia (a mean reduction of 0.8 ). In 81% of cases, both investigators and patients rated the side treated with purpura as undergoing a greater reduction in telangiectasia density. Conclusion.
    Although facial telangiectasia do improve after a single purpura-free treatment with the variable-pulse pulsed-dye laser, they improve more after purpura is induced. Purpura-free and purpura-level treatments may be close to equivalent for treating fine telangiectasia, but purpura-level treatments have a distinct advantage for treating thicker telangiectasia. Significantly, the variable-pulse pulsed-dye laser offers patients the option of effective treatment of some telangiectasia without bruising.
    M. ALAM, MD, J. S. DOVER, MD, FRCPC, AND K. A. ARNDT, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.
    Document Type: Research article
    DOI: 10.1046/j.1524-4725.2003.29181.x

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