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    Lip Depigmentation (Pinkification) Using 810nm Diode Laser, Kassem’s Protocol, Initial Case Report

     

    Islam Kassem - BDS, MSc, FDS RCS
    Consultant Maxillofacial Surgeon
    Private practice, Doha – Qatar | ikassem@dr.com


    Mohammed Adib Al-Agha - BDS
    Private practice, Dubai – UAE

     

    ABSTRACT
    Oral depigmentation is considered a complementary part in aesthetic dentistry , gingival depigmentation is well by a lot of practitioner especially whom deal with dark skin patient. Lip depigmenation or pinkification is considered a novel approach which desired by many patient to get an atractive smile.


    We present a first case in English literature using diode 808nm with details parameter to ensure patient safety and avoid any further complications.


    KEYWORDS
    Lip depigmentation, Diode laser, Lip pinkification, Lip hyperpigmentation laser treatment.

     

     

     

    INTRODUCTION
    Oral Mucosa is normally pink, although the color varies depending on location, function and underlying structures. The final color is depending upon accumulation of materials inside the epithelium layer mostly melanin.


    Lip color varies depending on the ethnic group and there is an increase in aesthetic demand for lip depigmentation.


    Beside a huge rise in aesthetic dentistry the lips are a frame for the smile and have a great importance for aesthetic rehabilitation.


    Several techniques for lip depigmentation either cosmetically or medically exist.


    DIFFERENT TECHNIQUES FOR LIP DEPIGMENTATION
    Permanent makeup by Pinkification dates back at least to the start of the 20th century, though its nature was often concealed in its early days.


    The tattooist George Burchett, a major developer of the technique when it became fashionable in the 1930s, described in his memoirs how beauty salons tattooed many women without their knowledge, offering it as a “complexion treatment” of injecting vegetable dyes under the top layer of the lip skin.


    Lasers are widely used for depigmentation utilizing the chromophore theory (Figure 1). This is aimed at the causative factor for pigmentation; in our scenario the Chromophore is melanin.

     

    (Fig. 1) Notice that Diode Lasers (GaAsAl) both 810nm and 980nm have higher absorption rates in both melanin and Haemoglobin

     

     

    Different laser wavelengths were used starting from Carbon Dioxide (10,600nm), Q-Switched laser, Nd YAG laser (1,060nm) and finally, in this case, (GaAsAl) diode lasers (810nm).


    Using Diode laser can be a challenge for the clinician to avoid scaring and improper results. The technique by the author aims to decrease the complexity of the procedure and enhance patient safety and the final result.


    CRITERIA FOR CASE SELECTION
    The patient must be able to sign a consent form and be medically free from any hematological disorders. Normal skin pigmentation must be considered please note that Melanocytes stimulating hormones lesions should be excluded.


    This technique is applicable in hereditary melanin hyperpigmentation

     

    (Fig. 2) Notice the Great Contrast between upper and lower lips showing excessive hereditary accumulation of Melanin in the upper lip posing a cosmetic concern to the patient, forcing her to use brighter lipstick colors to mask the difference and make it look homogenous

     

     

     

    Referencing the color of the mucosa of the inside of the lower lip should be a good guide for the expected outcome of the treatment.


    A detailed discussion with the patient of all the expected outcomes and postoperative precautions is mandatory as this is an elective cosmetic procedure.


    The author prefers to show the patient example of cases both video and pre and post operative.


    Anesthesia options are also discussed for the technique as some patients like to have sedation with local anesthesia.


    KASSEM’S TECHNIQUE
    Lip Depigmentation is a cosmetic technique to improve lip color in persons of darker skin colour, an informed consent is mandatory before starting operative steps and detailed explanation of the expected post operative events should be covered.

     

    Anesthesia depends on the operator as well as the patient preference, the author prefers bilateral infra orbital nerve block from extra oral approach (Figure 3) to avoid unnecessary anesthesia to the muscle elevating xupper lip hence avoiding lip drop.

     

    (Fig. 3a) Extraoral Approach for infraorbital nerve block was the anesthesia of choice

     

     

    (Fig. 3b) LLLT application pre-operative 100mW for 1 min helps reducing pain and increases comfort

     

     

    A laser safety check should be carried out, before starting the procedure.


    The operating room should be closed off with a laser-in-use sign posted outside.


    All personnel and the patient should be issued with appropriate (wavelength specific) protective glasses (L6). This is equivalent to an optical density of 6.


    Pre-operatively, Low Level Laser Therapy (LLLT) is initiated to both reduce the pain of the procedure and increase comfort for the patient. We use the same diode laser (of 810nm) but now with 100mW of energy, for 1 minute, covering all the lip area.


    SETTINGS AND PARAMETERS
    Device: Surgical Diode laser from elexxion AG Germany using 810nm – Claros Pico with 5W Peak Power


    Low Surgery Program was chosen under the following parameters:
    • Spot size: 600 μm tip initiated,
    • Peak Power: 5 W
    • Average Power: 1.5 W

     

    Tissue Exposure Mode:
    Digital Pulse 26μsec ON / 24μsec Off


    Wave type: chopped 12,000 Hz

     

    (Fig. 4) Wave Type and relationship to Tissue damage by heat accumulation.
    Red: Continuous Wave with red Line representing Great Heat Increase in very short Time.
    Orange and Yellow: Traditional Gated Pulse with Long Relaxation time still does not prevent Heat Accumulation
    Green: Digital Pulsed Laser allows heat dissipation without significant increase in tissue temperature.

     

     

    Tip is held parallel to the lip tissues (Figure 5) and not perpendicular to avoid unwanted tissue reaction in deeper layers. Please note that the diode laser at 810nm has tendency for high penetration rate.

     

    (Fig. 5) Tip Position parallel to the tissues to decrease penetration and collateral damage to unnecessary deeper tissues. Saline irrigation  increases comfort decreases smell, acts as a lubricant and reduces heat accumulation in the tissues reducing the chance for post operative pain and discomfort

     

    First step: Movement is done with feather light strokes starting vertically from the midline toward the periphery following Langer lines (relaxations lines of the lip) to prevent scarring.

     

    Second step: involves removal of tissue islands left between the first vertical cuts by moving horizontally.


    Care should be taken to avoid taking the laser energy to deeper layers. Coagulation of bleeding points will be noticed, but if wiped with wet saline gauze this will help to keep the field accessible and improve visibility.


    Additional saline irrigation is required for both lubrication and to prevent charring and excessive thermal insult to the tissues. It is also well accepted by the patient.


    Smell is considered as a major discomfort issue for the patient and it can be reduced by intermittent saline irrigation intra-operatively


    Tip cleaning is advisable, the author prefer to use a dry cotton roll for cleaning of the fibre, by firing the laser and embedding the tip into the circular surface of the cotton roll pulling the tip out completely clean without the need for reinitiating the laser tip.


    POST OPERATIVE CARE IS FOCUSED ON:
    Decreasing both edema and pain (Figure 6&7)
    1. Proper analgesic is prescribed and anti bruising cream and steroids,
    2. Cold fomentation is advised for one day followed by warm fomentation,
    3. Sun block should be used for lips until appropriate healing occurs.
    4. Patient should be advised to avoid alcoholic beverages, smoking, as well as spicy foods for one week post operatively.
    5. Additional Hyaluronic acid preparation can be added to aid faster healing.

     

    (Fig. 6) Immediate Post-operative mild swelling was noticed and patient was advised to use cold fomentation and ice pack compress, LLLT was also applied to help speed the healing process. 100mW was used for 1minute, over the entire lip surface

     

    (Fig. 7) LLLT application post-operative 100mW for 1 min helps reducing pain and attributes to faster healing

     

    (Fig. 8A) 10 Days post operative situation

     

    (Fig. 8B) 10 Days post-operative: favorable healing is noticed, patient did not report any complications. Pain disappeared after the first two days and she was able to practice regular daily activities without problems. Mild edema was noted and it subsided spontaneously

     

     

    DISCUSSION
    Lip Depigmentation is a cosmetic procedure for removing melanin pigments and dark color from the lips. Patient safety is ensured and a thorough briefing of the patient is essential to avoid post operative discomfort, informed consent with postoperative instruction is mandatory.

     

    (Fig. 9) Good reduction in the depth of the melanin pigments considering the initial situation except for deeper spots that require a second visit to  unnecessary prevent deep tissue damage

     

    (Fig. 10) Relapse in some areas after 7 months follow-up indicating the need for another review visit for touch up to maintain the result that is to last for few years

     

     

    REFERENCES
    1. Yousuf A et al. Removal of gingival melanin pigmentation with the semiconductor diode laser: A Case report. J Clin Laser Med Surg. 2000;18(5):263-6.
    2. Esen et al. Gingival melanin pigmentation and its treatment with carbon dioxide laser. Oral Surg Oral Med Oral Pathol Oral Rad Endod. 2004;98(5).