pilot laser- surgical procedures with the pilot laser

8/2/2019 Pilot Laser- Surgical Procedures With the Pilot Laser

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Table O Contents

Clinical Research #1: The Histo-Path of Laser vs. Scalpel Incision 4

Clinical Research #2: Laser-Assisted Incision Options 5

Clinical Case #1: Feline Declaw 6

Clinical Case #2: Feline Castration 7

Clinical Case #3: Owl Wing Wound 8

Clinical Case #4: Canine Excisional Biopsy 9

Clinical Case #5: Musk Deer Nasal Mass 10

Clinical Case #6: Canine Staphylectomy 11

Clinical Case #7: Tinkerbird Chronic Scalp Wound 12

Clinical Case #8: Endoscopic Laser Tumor Ablation 13

Clinical Case #9: Barking Tree Frog Red Leg 14

Clinical Case #10: Hogfish Cutaneous Ulcer 15

Clinical Case #11: Canine Foreign Body Tract 16

Clinical Case #12: Feline Prepucial Surgery 17

Clinical Case #13: Canine Abscess Repair 18

Clinical Case #14: Oral Mass Removal 19

C L I N I C A L P R O C E D U R E G U I D E


4/22

Case Studies

4

PROCEDURE: Comparison of Laser Incision vs. Scalpel Incision.

Both pre-treated with 3LT for Hemostasis.

ANESTHESIA: N/A

EQUIPMENT: #15 Scalpel blade, 9.0 Watt Pilot Laser set at 8.5 watt in

both continuous and pulsed modes.

COMMENTS: Figure CR-1-1 Abdominal hernia repair provided an

opportunity to prepare these photo-micrographs of the histopathologic

sections the thin sliver of skin to compare Pilot Laser Incision with scalpel

incision.

Figure CR-1-2 & CR-1-3 Compares the laser incision seen along the topof both images with the scalpel incision seen only along the lower right

corner of the CR-1-2 image. Notice that there is no cellular charring in

the laser incision, and only a minimal cellular depth in the zone of tissue

vaporization and coagulation.

Figure CR-1-4: Diagrammatically represents the tissue impact zone

surrounding the end of the Optical Fiber Tip with each pulsed emission of

laser beam energy. It is essential to note that in each clinical application,

every layer of tissue has a different laser Energy Absorption Coefcient,

and the laser beam generates a well dened sphere of diffusing energy

levels as the thermal energy wave expands away form the optical bertip into the surrounding cellular matter. The direction of the laser beam

is rarely perpendicular to the surface of the skin, so the refracted portion

of laser energy varies constantly at the tissue surface as a function of the

contour irregularities along the surface of the target tissue.

The surgeon quickly learns to intuitively compensate for these variables

by adjusting the position of the laser hand-piece to achieve the desired

effect.

Clinical Research

The Histopathology o Laser vs. Scalpel Incision

Figure CR -1-1

Figure CR -1-2

Figure CR -1-3

Figure CR -1-4


5/22

Case Studie

5

PROCEDURE: Laser assisted incision options for any surgical candidat

include: Pre-treatment of incision site for biostimulation, decontamination

and hemostasis, as well as the post-treatment of incision site for additiona

biostimulation and decontamination.

EQUIPMENT: 9.0 Watt Pilot Laser at various settings.

COMMENTS:

Figure CR-2-1: Shows pre-operative laser treatment of incision site fo

biostimulation, decontamination, collagen contraction and hemostasis.

Figure CR-2-2: Shows incomplete laser incision, despite presence o

dark green pigmented dye. Char results from both remaining hair an

insufcient power setting. The red arrow identies a small plume of debrielimination by vacuum source at right margin of image. Notice that ther

is no bleeding.

Figure CR-2-3: Shows completed incision using a steel scalpel blade wit

essentially no bleeding.

Figure CR-2-4: Shows the pre-treatment of an incision site with lase

energy without photosensitive dye. In this instance, only the right o

the proposed Incision site received pre-operative laser treatment.

Figure CR-2-5: This image was captured immediately after the incisiowas made using a steel scalpel blade, clearly shows that only the non

treated half of the incision is freely bleeding with no hemostatic effec

The laser treated portion of the incision shows effective hemostasis.

Clinical Research

Laser-Assisted Incision Options

Figure CR -2-1

Figure CR -2-2

Figure CR -2-3

Figure CR -2-5Figure CR -2-4


6/22

Case Studies

6

BREED: 1 year old male Domestic Calico in good health.

PROCEDURE: Feline Onychectomy (Declaw)

ANESTHESIA: The cat was placed under general anesthesia

for the surgery (Figure CC-1-1).

EQUIPMENT: 9.0 Watt Pilot Diode Laser.

TECHNIQUE: The laser was set at 9 watts and was used

as a scalpel, with very light surface contact. There was no

carbonization (char) on the tip of the optical ber. The ber

tip was maintained in gentle contact at the cartilaginous

tissue margin, following the contour of the joint to preciselydissect the third phalanx and facilitate the coagulation of the

associated vascular structures (Figure CC-1-2). The laser was

used without any other surgical instruments. Several passes

were required to complete the amputation (Figure CC-1-3).

COMMENTS: The diode laser performed very similar to

the CO2

laser, except the laser tip is in contact mode almost

as though one were using a scalpel to incise the tissue. The

technique, hand speed, ber tip orientation, etc. was described

by the surgeon as exactly as a scalpel would be used. The

incision was clean with very little charring, except for anoccasional hair. No bleeding was present along the margins,

and there was no need to deal with stray bleeders. The

procedure progressed very swiftly, with a timely closure and

clean-up.

CLOSURE: Closure was completed with a surgical

cyanoacrylate adhesive.

Clinical Case #1

Feline Declaw

Figure CC-1-1

Figure CC-1-2

Figure CC-1-3


7/22

Case Studie

7

BREED: 1 year old male Domestic Calico in good health

PROCEDURE: Castration.

ANESTHESIA: The cat was placed under general anesthesi

for the surgery.


TECHNIQUE: Patient was immobilized, shaved and preppe

(Figure CC-2-1). The laser was set at 1 watt, and several slow

passes over the intended incision site were made, producin

collagen contraction with vascular constriction and effectiv

hemostasis. The laser was then set at 7 watts and used as scalpel with very light surface contact to create a full-thicknes

skin incision. Several passes were made to penetrate the layer

of tissue and membranes. The rst testicle was removed an

then the laser was used to surgically access the second testicle

Testicle removal was completed per standard protocol.

COMMENTS: The laser incision was very scalpel like

Technique, hand speed, etc. was exactly as a scalpel woul

be used. The incision was very clean, with no bleeding at th

incision. The procedure went very swiftly and closure an

clean-up was very fast.

CLOSURE: Closure was completed with sutures and

surgical cyanoacrylate adhesive.

Clinical Case #2

Feline Castration

Figure CC-2-1

Figure CC-2-2

Figure CC-2-3


8/22

Case Studies

8

BREED: Adult male Barn Owl.

PROCEDURE: Supercial cutaneous trauma (degloving) of

the ventral surface of the wing after being caught in a soccernet overnight.

ANESTHESIA: The owl was restrained, but not sedated.


TECHNIQUE: The wound was abraded repeatedly during the

night while the bird struggled to escape, leaving no soft tissue

covering the bone (Figure CC-3-1). The wound was cleaned

and debrided, but could not be closed surgically because therewas no tissue remaining over the denuded bone to provide

primary closure. No additional feathers were removed. The

laser was set at 2.o watts and held about 2 cm distance from the

damaged tissue (Figure CC-3-2). Operator hand movement was

slow but steady for approximately 2 minutes to slowly paint

the entire wound and marginal area, using the red aiming light

for guidance for biostimulation and decontamination (Figure

CC-3-3). Treatment was administered once every other day for

2 weeks.

COMMENTS: The wound healed faster than expected.Surprisingly, the wound healed without the usual scabbing

or crusting, which generally occurs with degloving injuries

(Figure CC-3-4). From day one, the owl was able to spread

its wing without disturbing, cracking or reopening the healing

wound. In two weeks the healed wing was completely

functional, and the owl was released back into the wild.

CLOSURE: Healing by second intention.

Clinical Case #3

Owl Wing Wound

Figure CC-3-1

Figure CC-3-2

Figure CC-3-3

Figure CC-3-4


9/22

Case Studie

9

Figure CC-4-3

Figure CC-4-1

Figure CC-4-2

Figure CC-4-4

BREED: 16-year-old spayed female Pomeranian.

PROCEDURE: Surgical excision of chronic dermal mass.

ANESTHESIA: Owner declined general anesthesia, an

elected to restrain the patient for the procedure. Local anesthesi

provided with infused 2% lidocaine (without epinephrine).

EQUIPMENT: 5.0 Watt Pilot Diode Laser (prototype).

TECHNIQUE: Surgical site was clipped but no pre

op surgical scrub applied. Only the laser was utilized fo

decontamination, biostimulation, and also initial pre-operativ

photo-paresthesia (Figure CC-4-1). Laser was set at 2.0 watwith dime-sized impact zone. Using the laser hand-piec

directed perpendicular to the surface of the skin around th

mass; the diode laser energy was directed into the dermal laye

to induce parasthesia. Then, the 2% lidocaine was injecte

for deeper subcutaneous anesthesia. Photo-contraction an

hemostasis along the proposed incision line was achieved wit

the addition of laser intensifying dye. The scalpel was used t

nish the incision through the skin to the subcutaneous layer

(Figure CC-4-2). Scissors were used for sharp/blunt dissectio

of the mass. Laser decontamination and biostimulation of th

surgical site was repeated following mass removal (FigurCC-4-3).

COMMENTS: The area healed extremely well and rapidly

This laser assisted technique provided moderate parasthesia

excellent hemostasis and excellent decontamination

Furthermore this combination with tissue biostimulatio

effects of the laser produced minimal tissue reaction wit

no visible erythema, infammation, thickening of the woun

margins or discharge. Three months post-operatively the sca

was wider than expected but there was no palpable brosi

There was also a noticeable increase in pigmentation of th

surrounding hair. Its suspected that these sequelae were th

result of inadequate wattage and would not have occurred wit

the 9-0 watt laser.

CLOSURE: A continuous subcutaneous suture (Figure CC

04-04) was followed by simple interrupted skin suture

Biostimulation and decontaminated were performed twic

daily for 1 week post-op.

Clinical Case #4

Canine Excisional Biopsy


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Case Studies

10

BREED: 3-year-old intact male Siberian Musk Deer.

PROCEDURE: Laser Treatment of chronic, cryptococcal

nasal lesion.

ANESTHESIA: General.

EQUIPMENT: 5.0 Watt Pilot Diode Laser (prototype).

TECHNIQUE: The deer (Figure CC-5-1) was immobilized

for re-evaluation following itraconazole treatment; modest

improvement was noted. However, there was residual

thickening of the region surrounding the right nares. (Figure

CC-5-2) A small area of mucosal ulceration (~8 mm diameter)was noted approximately 12 mm inside the right nasal passage.

The laser was used to decontaminate and biostimulate the ulcer

(1.0 watts for 2 seconds for each eraser-sized application).

The surrounding tissues where thickening was noted were also

biostimulated (0.7 watts for 2 seconds for each eraser-sized

application). (Figure CC-5-3).

COMMENTS:This deer had been treated with fuconazole with

poor success followed by itraconazole with some improvement,

but still incomplete success. The nasal inammation reduced

rapidly following laser therapy (Figure CC-5-4). It is difcultto determine the exact relationship between the treatment

factors to the resolution in this case, as nasal cryptococcus is

an uncommon presentation of cryptococcosis in musk deer.

However, the overall outcome was rapid and good following

the application of the laser therapy.

CLOSURE: Not applicable.

Clinical Case #5

Musk Deer Inected Nasal Lesion

Figure CC-5-1

Figure CC-5-2

Figure CC-5-3

Figure CC-5-4


11/22

Case Studie

11

BREED: 8-month-old neutered male Boston Terrier presente

with a history of difculty breathing, especially during period

of excitement. (Figure CC-6-1).

PROCEDURE: Excision of excessive soft palate tissu

obstructing the laryngeal airway.

ANESTHESIA: General anesthesia achieved with morphine

acepromazine, Ketamine and diazepam. An endotracheal tub

was placed and the patient was maintained on oxygen an

isofurane.

EQUIPMENT: 9.0 Watt Pilot Diode Laser, 4-0 Monocry

suture, and curved metzenbaum scissors.

TECHNIQUE: Stay sutures were placed laterally jus

above the line of resection and at the distal midline of th

elongated soft palate (Figure CC-6-2). A visual estimation o

the tissue to be removed was made. Tissue coagulation an

vaporization began at the left margin with the laser set at 7.

watts. Gradual lasing was continued two-thirds of the wa

across toward the right lateral margin. (Figure CC-6-3) Tissu

coagulation followed by cutting with curved metzenbaum

scissors was used to remove the remaining tissue. An injectio

of dexamethasone SP was given at the anti-infammatory dosimmediately following surgery to reduce potential tissu

swelling. The patient recovered well and had limited strido

overnight. A noticeable decrease in respiratory effort and nois

was noted the following day and the patient began eating sof

food.

COMMENTS: The goal is for the soft palate to just meet th

epiglottis, providing complete separation from the nasopharyn

without obstructing the pathway of air through the oropharynx

Surgical bleeding and post-operative swelling increase patien

morbidity and mortality associated with the surgery.

CLOSURE: Given that no bleeding occurred with eithe

laser cutting or laser coagulation followed by scissors, closur

was likely not required. However, the surgical site was ove

sewn in a simple continuous pattern using 4-0 Monocryl as

precautionary measure.

Clinical Case #6

Canine Staphylectomy (Reduction o Sot Palate

Figure CC-6-1

Figure CC-6-2

Figure CC-6-3


12/22

Case Studies

12

BREED: 2-year-old male Tinkerbird (Figure CC-7-1) with a

chronic wound from scalp trauma (Figure CC-7-2).

PROCEDURE: Laser biostimulation of Chronic wound fromscalp trauma.

ANESTHESIA: None; manual restraint.


TECHNIQUE: Laser was set at 0.7 watts for each of four,

two-second, eraser-sized applications. A Duoderm paste cap

was also applied over the wound. The caudal edge of the

Duoderm cap was sealed to the skin with tissue glue. Additionalbiostimulation was performed 24 hours later, and the lesion

was covered with a Duoderm paste cap again at that time. This

same process was repeated for subsequent treatments every

two days for 3 more treatments.

COMMENTS: The laser was noted to be easy and fast to use

for all treatments. The extent of lesion healing was profound

and estimated to be reduced by 60% within 24 hours. Figure

CC-7-3 shows the progression of healing. The outer drawn

red line shows the margins of the lesion pre-treatment. Theinner drawn green line shows the margins of the lesion at 24

hours. Figure CC-7-4 is an unmarked photo of the wound at

48 hours, and Figure CC-7-5 shows the wound on day seven.


Clinical Case #7

Tinkerbird Chronic Scalp Wound

Figure CC-7-1

Figure CC-7-2

Figure CC-7-3

Figure CC-7-4Figure CC-7-5


13/22

Case Studie

13

Figure CC-8-1

BREED: 5-year-old female spayed Domestic Short Hair ca

presented for ablation of a nasal tumor at the nasal choana

(posterior nasal aperture).

PROCEDURE: Endoscopically guided laser ablation of th

mass.

ANESTHESIA: Induction with an intravenous injection o

Propofol and maintenance with isourane via oxygen and a

endotracheal tube.

EQUIPMENT: 5-Watt Pilot Diode Laser (prototype), Penta

6 mm diameter exible video endoscope.

TECHNIQUE: The endoscope was passed through the mout

and retroexed above the soft palate. It was then guide

anteriorly to the level of the internal nasal choanae to allow

visualization of the mass. The laser ber was passed throug

the working channel of the endoscope and the mass wa

visualized (Figure CC-8-2). Power was set at 0.5 watt at pulse

mode and near contact with the tip of the optical ber in ver

close quarters (Figure CC-8-3). The laser was red for only

few seconds at a time. The smoke plume was evacuated usin

suction to allow visual evaluation. (An 8 French red rubbe

catheter was placed into the nares and inserted to the level othe choanae. Suction was applied to the catheter to remove th

smoke produced in the confned area of the nose). The ablatio

was completed (Figure CC-8-4).

COMMENTS: The conned nature of the cats nasal passage

renders aiming of the laser ber very difcult. However, wit

persistence, most of the mass was ablated.

FOLLOW-UP: Two months after the initial procedure, nasa

obstruction recurred due to re-growth of the mass. It wa

ablated a second time. The use of a laser intensifying dy

applied to the mass might facilitate ablation and should b

considered.

Clinical Case #8

Endoscopic Laser Tumor Ablation

Figure CC-8-2

Figure CC-8-3

Figure CC-8-4


14/22

Case Studies

14

BREED: Barking Tree Frog presenting for swelling and

inammation attributed to Red Leg Syndrome.

PROCEDURE: The infection had been non-responsive totreatment with standard therapy, so laser decontamination and

biostimulation were instituted.

ANESTHESIA: None.


TECHNIQUE: A long standing infectious dermatitis in this

animal had been non-responsive to both antibiotic baths and

topical antibiotic treatments (Figure CC-9-1). Prior to lasertreatment, the prognosis was terminally poor. All previous

treatment was discontinued, and laser therapy was introduced

to achieve decontamination and biostimulation of the infection

site. Laser therapy was applied at 2.0 watts for 2 seconds, twice

weekly for four weeks.

COMMENTS: Figure CC-9-2 shows reduction in swelling

at two weeks. Marked improvement was noted at three weeks

(Figure CC-9-3), and at four weeks the Red Leg was clinically

resolved (Figure CC-9-4). Swelling and redness reduced

consistently and signicantly throughout therapy. Ultimately,two frogs were involved and treated simultaneously. One frog

died one week after therapy was discontinued due to unrelated

causes. In this frog, no leg lesions were present at necropsy.

CLOSURE: Not Indicated.

Clinical Case #9

Barking Tree Frog Red Leg

Figure CC-9-1

Figure CC-9-2

Figure CC-9-3

Figure CC-9-4


15/22

Case Studie

15

Figure CC-10-3

BREED: Hogsh.

PROCEDURE: Treatment of long-standing non-responsiv

with Low-Level Laser Therapy (3LT).

ANESTHESIA: MS-222 on early procedures; none used o

later procedures.


TECHNIQUE: Laser therapy was applied at 1.0 watts fo

2 seconds, at a distance of approximately 1.0 cm to achiev

decontamination and biostimulation. Treatment was repeate

once weekly for eight weeks.

COMMENTS: This is a lesion that had not responded t

parenteral antibiotics over several weeks of treatment. (Figur

CC-10-1) The wound was actually getting worse with th

antibiotic treatment alone. Figure CC-10-2 shows a close-u

of the lesion. Antibiotic treatment was stopped when lase

treatment was initiated. Steady improvement was seen wit

laser therapy and is resolving better than with any previou

conventional therapy. Weekly laser treatments will continu

and resolution of lesion is expected. Figure CC-10-3 show

near resolution at eight weeks of once weekly 3LT therapy.


Clinical Case #10

Hogsh Cutaneous Ulcer

Figure CC-10-1

Figure CC-10-2


16/22

Case Studies

16

BREED: 4-year-old spayed female German Shorthaired

Pointer (Figure CC-11-1).

PROCEDURE: Non-healing foreign body (foxtail) tract.

ANESTHESIA: None, Laser set at 2.0 Watts and avg. 7 cm

for nerve desensitization. Light manual restraint.


TECHNIQUE: Laser set at 2.0 watts at approximately 7

cm for pre-operative nerve desensitization. Tract opened

and probed with sterile mosquito forceps, negative ndings,

ushed with dilute chlorhexidine solution. Laser set a 4.0watts at an average 5 cm distance, three passes once daily for

three days was used for decontamination and biostimulation

of the wound.

COMMENTS: Foreign body (i.e. foxtail/grass awn) tracts are

commonly found on dogs, especially in the feet (Figure CC-

11-2). This dogs abscess was surgically probed under heavy

sedation and local anesthesia three days prior and she was put

on systemic non-steroidal anti-infammatory and antibiotic

medications at that time. A presumptive exit-wound was

identifed on the plantar surface of the inter-digital webbing.Never-the-less, the tract healed over and re-abscessed. Often

foreign body tracts must be reopened to drain multiple times.

Foot soaks and bandaging may also be used to help the wound

healing.

In one day, this tract was dry and swelling was signifcantly

reduced (Figure CC-11-3). By day four the tract was

approximately 50% smaller and remained dry. No bandaging

or other treatment changes were made. The tract was resolved

with residual scar tissue ten days after the onset of laser

treatment.


Clinical Case #11

Canine Foreign Body Tract

Figure CC-11-1

Figure CC-11-2

Figure CC-11-3


17/22

Case Studie

17

Figure CC-12-3

Figure CC-12-1

Figure CC-12-2

Figure CC-12-4

BREED: 6-week-old male Domestic Long Hair feline.

PROCEDURE: Corrective surgery of prepuce damag

secondary to genital suckling. Because general anesthesia warequired, the kitten was also neutered at this time.

ANESTHESIA: General anesthesia using bupreorphin

and Sevofurane. Post-operatively, applied 1% lidocaine an

dexamethasone SP topically.


TECHNIQUE: Laser set at 6.5 Watts following standar

surgical preparation. Gentle traction applied to elevate prepucaway from end of penis. Laser ablated granulation tissu

covering (Figure CC-12-1), creating a new orice (Figur

CC-12-2). 1% lidocaine and dexamethasone SP were applie

topically. RX: systemic meloxicam and bupreorphine, topica

triple antibiotic ointment twice daily.

COMMENTS: Genital suckling is common among neonata

orphan kittens and causes signicant genital damage. Often

the result is urinary tract obstruction by granulation tissue

produced in attempt to heal the injury. Typically, the kitte

then requires perineal urethrostomy (PU), a major surgicare-plumbing of the urinary system to allow urination. Thi

laser facilitated surgery to re-open the prepuce has prevente

this kitten from undergoing such a traumatic procedure. In thi

group of six orphans, all four males were suckled excessively

Three required surgical attention. Of these three, one kitte

underwent PU surgery and is still dealing with mino

incontinence issues. Two were successfully treated by lase

surgery. The laser was set at 8 Watts on the rst kitten, causin

both charring and scabbing that required warm packing. Th

surgery was perfected for this, the second kitten. Figure CC

12-3 shows a completely healed new prepuce opening at 1

days post-op. Figure CC-12-4 shows the kitten that underwen

PU surgery. This may have been avoided with the earl

application of 3LT, and here the healing remains in progres

at 28 days post-op.

CLOSURE: Not indicated.

Clinical Case #12

Feline Prepucial Surgery


18/22

Case Studies

18

BREED: 6-week-old intact female Border Collie mix.

PROCEDURE: Second repair of an injection site abscess.

(First repair dehisced after ve days).

ANESTHESIA: General anesthesia with morphine, ketamine-

valium and isourane.


TECHNIQUE: Routine surgical repair, Penrose drain

placement, laser decontamination and biostimulation at 4.0

Watts. Three passes of the laser at approximately 5 cm distance

over the caudal half of incision only, once daily for four days

(Figure CC-13-1) Rx: Clavamox, meloxicam, buprenorphine.

COMMENTS: Initial surgical debridement and treatment with

a systemic cephalosporin was deemed inadequate to resolve

the infection when the site dehisced. E. coli was cultured,

indicating fecal contamination of the site following the initial

repair. Additionally, abscess cavitation had increased by the

time of the second surgery.

The second surgical repair included both drain placement,

and laser decontamination/biostimulation, followed by an

antibiotic change. It is apparent in only three days that thetreated half of the incision has better epithelialization and

less scabbing following low level laser therapy (3LT) than the

untreated half (Figure CC-13-2).

The Penrose drain was pulled on day four. At this time, 3LT was

applied to the entire affected area, including subcutaneously

via the drain sites. At 15 days post-op, the entire wound

was nicely healed (Figure CC-13-3) with an atypically large

amount of new hair growth. The difference in healing suggests

that 3LT is benecial for all surgical procedures. A sibling who

was not treated with 3LT is also pictured (Figure CC-13-4) for

overall comparison.

CLOSURE: 3-0 nylon, horizontal mattress and simple

interrupted patterns.

Clinical Case #13

Canine Injection Site Abscess Repair

Figure CC-13-1

Figure CC-13-2

Figure CC-13-3

Figure CC-13-4


19/22

Case Studie

19

Figure CC-14-3

Figure CC-14-1

Figure CC-14-2

Figure CC-14-4

BREED: Two year-old female Domestic Long Hair feline i

good health.

PROCEDURE: Oral mass removal from ventral surface otongue.

ANESTHESIA: General anesthesia with morphine ketamine

valium and isourane.

EQUIPMENT: 9.0 Watt Pilot Diode Laser at various setting

TECHNIQUE: Patient was immobilized, and the ventra

surface of the tongue including a very vascular, raised tissu

mass was surgically prepped (Figure CC-14-1). The lasewas set at 4.0 watt, and several slow passes over the intende

incision site were made, producing collagen contractio

with conspicuous localized blanching of the surroundin

tissue indicating vascular constriction producing an effectiv

Hemostasis. Upon completion of the circumferential excisio

of the mass a slight degree of tissue charing was observe

(Figure CC-14-3). Closure of the Excisional wound wa

completed with three individual sutures using 4-0 Monocry

as a precautionary measure (Figure CC-14-4). The laser wa

then set at 2 watts and used to biostimulate the entire ventra

surface of the tongue.

COMMENTS: Keeping in mind that the rate of ablatio

varies with the composition of the tissue at the surgical site, th

clinician should be careful not to tear any structures but rathe

allow the laser energy to do all the work (Figure CC-14-2

Although open excisional wounds utilizing the Pilot diode lase

generally do not bleed, it is always a good idea to gently clos

all open mucosal wounds as a precautionary measure (Figur

CC-14-4). Immediate post operative 3LT treatment seems t

improve not only the rate of healing, but demonstrates marke

residual photo-induced-paresthesia producing noticeabl

reduction of post operative oral discomfort. This surgica

patient was comfortably lapping up fresh water shortly after fu

recovery something not commonly seen with traditional ora

surgery procedures involving lingual tissues or musculature

The patient healed uneventfully.

Clinical Case #14

Oral Mass Removal


20/22

20

HOW LASER STIMULATES TISSUE REGENERATION, REDUCES INFLAMMATION

AND RELIEVES PAIN IN MUSCULOSKELETAL DISORDERS

James Carroll FRSM AInstP

Low Level Laser Therapy (LLLT) had been used as a therapy for pain and tissue repair for over thirty years despite

a lack of published scienEc evidence, but in the last decade scientists have been busy publishing over 1,000

laboratory studies and 100 randomised double blind placebo controlled clinical trials in peer reviewed medicaljournals. This is a brief summary of the photobiological mechanism that leads to reduction of inammation, tissue

regeneration and analgesia in musculoskeletal injuries.

The Mechanism Can Be Described In Three Steps:

Primary Eect: Light is absorbed by chromophores and porphyrins in mitochondria and cell membranes causing

an increase in Adenosine Triphosphate (ATP), modulaEon of Reactive Oxygen Species (ROS) and release of

Nitric Oxide (NO).

Secondary Eect: The primary effects leads to a cascade of indirect effects on cell signalling such as exchange of

calcium ions, secretion of growth factors, activation of enzymes and other secondary messengers.

Tertiary Eect: Neutrophils, macrophages, mast cells, broblasts, endothelial cells, keratinocytes and leukocyteshave all been shown to be inuenced by LLLT in-vivo. This is true for all cells with mitochondria, but results

depend on the local environment. Healthy cells show little or no response whereas cells in hypoxic or other

stressed states are more likely to show some change. There are also measurable changes in blood ow, a reduction

in apoptosis and protection of cells after ischemic injury.

The Three Main Clinical Benets In Musculoskeletal Injuries And Wounds Are:

Tissue Repair: Rapid regeneration of skin, muscle, tendon, ligament, bone and neural tissue.

Infammation: Resolution of inammation at least equal to NSAIDS but without the side effects.

Analgesia: Temporary (48 hours) inhibition of nerve conduction in small and medium diameterperipheral nerve bres.

All effects are subject to total dose (energy / joules) and dose-rate effects (W/cm2). There is an intensity and

total energy threshold below which there is no effect, and there are limits beyond which cellular function is

temporarily inhibited.

Three Step Treatment Method

Local: Stimulation of a wound or injury with LLLT will promote repair and reduce inammation.

Lymphatics: Stimulation of lymphatics reduces oedema and stimulates the immune system.

Spine And Trigger Points: Treatment of the spinous processes and trigger points induces a 48-hour neural

blockade (analgesia) reducing central sensitisation (pain memory).

1. Lane N, Power Games. Nature 2006 Oct 26 443 901-03 2. Tafur et al Low-intensity light therapy: exploring the role of redox mechanisms. Photomed Laser Surg 2008 Aug 26(4) 323-8 3. Zhang Low-power laser irradiation activates Src tyrosine kinase through

reactive oxygen species-mediated signaling pathway. J Cell Physiol 2008 Jul 9 4. Oron et al Ga-As (808 nm) Laser Irradiation Enhances ATP Production in Human Neuronal Cells in Culture. Photomed Laser Surg 2007 Jun 25(3) 180-2 5. Saygun et al Effects of

laser irradiation on the release of basic broblast growth factor (bFGF), insulin like growth factor-1 (IGF-1), and receptor of IGF-1 (IGFBP3) from gingival broblasts. Lasers Med Sci. 2008 Apr;23(2):211-5 6. Arany et al Activation of latent TGF-beta1 by low-power

laser in vitro correlates with increased TGF-beta1 levels in laser-enhanced oral wound healing. Wound Repair Regen. 2007 Nov-Dec;15(6):866-74 7. Fujimaki et al Low-level laser irradiation attenuates production of reactive oxygen species by human neutrophils.J

Clin Laser Med Surg. 2003 Jun;21(3):165-70. 8. Gavish et al, Irradiation with 780 nm diode laser attenuates inammatory cytokines but upregulates nitric oxide in lipopolysaccharide-stimulated macrophages: implications for the prevention of aneurysm progression.

Lasers Surg Med. 2008 Jul;40(5):371-8 9. Chen et al Low-level laser irradiation promotes cell proliferation and mRNA expression of type I collagen and decorin in porcine achilles tendon broblasts In Vitro. J Orthop Res. 2008 Nov 7 10. Prado et al Effect of Ap-

plication Site of Low-Level Laser Therapy in Random Cutaneous Flap Viability in Rats. Photomed Laser Surg. 2008 Nov 23 11. Medrado et al, Inuence of laser photobiomodulation upon connective tissue remodeling during wound healing. J Photochem Photobiol

B. 2008 Sep 18;92(3):144-52 12. Stergioulas et al Effects of low-level laser therapy and eccentric exercises in the t reatment of recreational athletes with chronic achilles tendinopathy. Am J Sports Med. 2008 May;36(5): 881-7 13. Carrinho et al, Comparative study

using 685-nm and 830-nm lasers in the tissue repair of tenotomized tendons in the mouse. Photomed Laser Surg. 2006 Dec;24(6):754-8. 14. Markovic et al Postoperative analgesia aUer lower third molar surgery: contribution of the use of long-acting local anesthetics,

low-power laser, and diclofenac. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Nov;102(5):e4-8 15. Chow et al The effect of 300 mW, 830 nm laser on chronic neck pain: a double-blind, randomized, placebo-controlled study. Pain. 2006 Sep;124(1-

2):201-10 16. Chow et al, 830 nm laser irradiation induces varicosity formation, reduces mitochondrial membrane potential and blocks fast axonal ow in small and medium diameter rat dorsal root ganglion neurons: implications for the analgesic effects of 830 nm

laser. J Peripher Nerv Syst. 2007 Mar;12(1):28-39


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pilot laser- surgical procedures with the pilot laser

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