(Note, the first article in this series can be found here.)
The Players
Michael’s Birthmark: Facial, grade 2-3, 20 laser treatments with various PDL, test spots with ruby, argon, IPL, Nd:Yag. Resistant bugger.
Martin Kassir, MD, FAAD (Dermatologist) with Mona Lisa Dermatology, Dallas, TX: Educated, worldly, urbane, man with the plan.
Norma Baer (Clinical Nurse Manager): Cynosure laser training specialist, global traveler, cheerleader and confidence booster.
Cynosure Cynergy wih MultiPlex: Hot-rod multiplexing laser, new kid on the block; is the phrase “no pain, no gain” now antiquated?
Zimmer C3 air machine: Focused cold air delivery system, white noise.
The Experience
After Dr. Kassir delivered the first pulse of the Cynergy to my face I thought to myself, “You have to be kidding! I didn’t feel a thing!” It turned out the Cynergy actually had misfired on the first pulse, and not delivered the Nd:Yag zap after the low-energy PDL zap, so my remark was well founded. So, I steeled myself for the second zap. Much to my amazement it didn’t hurt nor did subsequent zaps change my opinion. By far this was the easiest, smoothest laser treatment I have ever had – and I’ve been through the wringer in this area. The doctor was quite pleased, because though he was using conservative settings, my skin was showing purpuric response. Purpura now appears to be a good thing with most doctors. My postop has been basically zero since walking out of Dr. Kassir’s office on Friday July 7, 2006, and as of this writing only 2-3 days out, I am seeing areas of slight fading on the most resistant areas of my birthmark. Hallelujah! Dr. Kassir said one week out is when he expects to see fading.
Much to Cynosure’s credit, both in their literature and conveyed to me verbally and by email from different members of their organization, the pulse dye laser is still considered the gold standard and the first course of recommended treatment. The Cynergy's multiplexing abilty comes in once the PDL no longer has any effect. From what I understand, the Cynergy Nd:Yag portion penetrates about twice as deep as the PDL, but is most effective after a PDL has been used and the more surface blood vessels have been eradicated. As of this writing, Cynosure is not recommending the MultiPlex feature for infants and children.
The June/July issue of the Birthmarks.com newsletter contains my first article about the Cynergy. It has a link to the Cynergy FAQ which delves into the technical aspects of how the new laser works so I won’t repeat all of that here, but in case you missed that excellent issue of our newsletter here is the link: Getting treated with the Cynergy Laser (Part 1). The Cynergy's two lasers CAN be used independently during any particular treatment (ie. The PDL alone for virgin port wine stains, Nd:YAG for hair removal). When the two wavelengths are used together, in a sequential manner, the MultiPlex capability is being used. There is a cynergistic effect (misspelling intended) which is supposed to make the lasers work better together than apart for the eradication of deeper vessels. I’d be remiss not to mention how much I liked the Zimmer air machine. It’s like a concentrated stream of cold air that comes out of a handpiece which the laser attaches to so it all works as a unit. The DCD (Dynamic Cooling Device), as used on Candela’s Vbeam and other lasers, has been a huge leap forward in laser treatments, providing both pain relief and the ability of the practitioner to deliver higher energies because the skin is cooled down dramatically at the point of impact. As someone who has had a handpiece next to my ear countless times, I am still startled due to the popping sound of the cryogen spray being delivered just before each laser zap. It has always made me jump and I'm unable to relax completely during a treatment. The Zimmer delivers continuous cooling which is nice. My face never felt hot during the treatment because Norma and Dr. Kassir kept running the air stream back and forth across it between zaps. That was nice as was the white noise created by the Zimmer. There wasn’t any popping, just a steady hiss which I found relaxing. I didn’t jump once the entire session.
(I should note that other members of our community have reported they still prefer the DCD to the Zimmer so there is definitely personal preference when it comes to cooling devices).
As I mentioned earlier, Dr. Kassir used conservative settings for the first of what will be a total of three treatments in all. He was delighted with my skin’s response since he still has a lot of energy and pulse width left to play with if needed. In part one of my article I mentioned how I hoped the doctor would treat a small telengactesia on my chin (which has stubbornly resisted several treatments from the Vbeam). Dr. Kassir and Norma both said telengactesias are tough to treat. Well, I just checked myself in the mirror and it is definitely lighter as well. Maybe because of all my previous PDL treatments I am the ideal candidate for the Cynergy and will experience additional fading. That would certainly be welcome. Fading means the progression of the lesion has been halted and that’s good news in my book!
My next Cynergy treatment is scheduled for August 25th. Dr. Kassir will review the changes in my birthmark and possibly use higher energies then. Stay tuned!
July 14, 2006 Follow-up Note: I am definitely seeing lightening of the most resistant area of my PWS after one week! The telengactesia has continued to lighten as well. I'm really looking forward to my next treatment.
Commentary by J. Stuart Nelson, MD, Ph.D. Dr. Nelson is the inventor of the Dynamic Cooling Device and a member of the Birthmarks.com Medical Advisory Board as well as a long-time Medical Sponsor of Birthmarks.com.
As pointed out, the Cynergy MultiPlex device has two wavelengths, PDL 595 and Nd:YAG 1064 nm. The 595 nm is used to target hemoglobin inside the targeted PWS blood vessels. The 1064 nm wavelength targets methemoglobin, which is produced as a result of the interaction of 595 nm light and hemoglobin. Methemoglobin formation in response to 595 nm laser irradiation is transient, hence the need to deliver the second 1064 nm laser pulse within a fraction of a second after the first pulse.
Nd:YAG laser light can penetrate 4-6 mm into human skin (as compared to 1.0-1.5 mm for 595 nm light). Although the Nd:YAG offers the opportunity to target deeper PWS blood vessels, the use of this device can also lead to skin ulceration if the laser-induced heating is not properly controlled. Therefore, this is a device that needs to be respected and should only be used by practitioners with considerable experience in PWS laser therapy. Until a more detailed understanding of the effects of this dual-wavelength Cynergy MultiPlex device have been developed, caution and the use of conservative laser treatment parameters should be the order of the day (bolding added by editor).
I have seen very good fading of PWS after Cynergy MultiPlex treatment in lesions which had become unresponsive to conventional PDL treatment. I have also seen patients whose PWS lesions responded poorly to Cynergy MultiPlex treatment. However, I have consistently seen excellent flattening and smoothening out of lumps and bumps (vascular nodules) on PWS lesions in adult patients. PWS patients with such pathology would seem to be excellent candidates for Cynergy MultiPlex treatment.
In summary, at this point in time, as with conventional PDL treatment it is very difficult to give patients an estimate of how many treatments will be required to achieve the desired level of improvement using the Cynergy MultiPlex device. Prospective, comparative and well-controlled clinical studies on a multicenter basis comparing this device with accepted conventional PDL treatment regimens are required so that the role of the Cynergy MultiPlex for PWS laser therapy can be fully defined.
