Whether you use ablative, vaporizing, or Q-switched lasers, human particles are released into the air via nano- or picosecond pulses. Even when you use conventional methods such as an Erbotome or a soldering iron to burn tissue, smoke is produced, and human tissue—often contaminated with viral genomes—is atomized into the air, where it can be inhaled.

Surgical smoke is just as harmful as cigarette smoke. The ablation of 1 gram of tissue produces smoke whose mutagenicity is equivalent to that of 6 unfiltered cigarettes. When using monopolar diathermy in a plastic surgery room, the daily smoke production is equivalent to that of approximately 27–30 cigarettes. Therefore, the Control of Substances Hazardous to Health Regulations (COSHH) in the UK, the Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege in Germany, and the Occupational Safety and Health Administration in the US recommend the use of smoke evacuators.

Sources: https://www.hse.gov.uk/healthservices/diathermy-emissions.htm, Surgical smoke – a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units – PubMed (nih.gov), The Control of Substances Hazardous to Health Regulations (Northern Ireland) (COSHH) 2003 | Department of Health (health-ni.gov.uk), Experiences and Perception of Risk Among Surgeons and Surgical Assistants – On the Prevention of Surgical Smoke in the Operating Room (asu-arbeitsmedizin.com), Surgical Smoke – Hazards and Protective Measures – bgw-online, Laser/Electrosurgery Plume – Overview | Occupational Safety and Health Administration (osha.gov)

In this matter, you have a dual obligation, including a duty to your patients. Consumer protection laws require that you ensure the highest possible level of patient safety to guarantee that the patient does not suffer any harm as a result of your treatment. Harm can result not only from medical malpractice, such as improper laser treatment, but also if the patient inhales or absorbs substances that may be carcinogenic or infectious. Therefore, it is of the utmost importance that you exercise the utmost care.

The workers’ compensation association is showing increased interest in ensuring workplace safety and health protection. As the practice operator, you are obligated to protect both your employees and yourself by preventing the inhalation of HPV viruses, which can lead to laryngeal papillomas or laryngeal cancer over the long term. Therefore, it is now essential to use a suction device.

As a doctor, the safety of patients and staff is essential. The risk assessment required by the Occupational Safety and Health Act helps identify risks and implement protective measures to prevent health hazards and accidents. This boosts staff motivation and performance, as well as the quality of your practice. Documentation provides legal certainty. For guidance and support, visit Risk Assessment in Medical Practices (bgw-online.de)

An excerpt from the BG Risk Assessment brochure states:

“High-Frequency SURGERY or Lasers:

During HF or laser surgery, there may be increased contamination of the indoor air due to vaporized or burned body tissue as well as evaporating disinfectants. The fumes may contain infectious pathogens. Protection goal: Avoid inhaling fumes and vapors generated during the use of HF surgical devices and lasers.

T-O-P Measures (Selection)

Technical: • Procure and set up equipment that complies with safety standards • Use equipment with fume extraction • Have equipment maintained by experts every two years

Organizational: • Ensure adequate ventilation

Personal: • Train employees • Wear appropriate protective equipment: – Insulating gloves – Safety goggles – Type P2 respirator

A 44-year-old surgeon who had treated anogenital condylomas and cancerous lesions with an Nd:YAG laser for many years was diagnosed with laryngeal papillomatosis caused by HPV types 6 and 11, with no other known sources of HPV exposure aside from his occupational exposure. A 28-year-old surgical nurse developed recurrent laryngeal papillomatosis due to an HPV infection, recognized as an occupational disease, after repeatedly assisting in CO2 laser and electrocautery surgeries for anogenital condylomas.

A 62-year-old gynecologist with HPV-16-positive oropharyngeal carcinoma had over 30 years of experience in the removal of cervical and vulvar lesions using CO2 laser and LEEP and had no other risk factors. The same study described a 53-year-old gynecologist with HPV-16-positive tonsillar carcinoma who had performed laser ablations and LEEPs for over 20 years without adequate ventilation or protective measures, with no other risk factors identified.

HPV DNA has been detected multiple times in laser smoke during the removal of papillomas and condylomas; however, its infectivity has not yet been conclusively proven. The exposure risk for medical personnel is low when protective measures are followed; however, in the gynecological field, it is significantly higher than in the ENT field due to the larger volume of tissue to be removed.

Source: Frauenarzt-0898-0903-FORT_Willems_03.pdf (ag-cpc.de) and Thieme E-Journals – Laryngo-Rhino-Otology / Abstract (thieme-connect.de)

All occupational safety guidelines, such as TRBA 250, DGUV Rule 109-002, and those issued by the professional associations, primarily require an exhaust system and, as a supplement, PPE (personal protective equipment).
Only an exhaust system with HEPA filters certified to meet the filtration efficiency standards of EN 1822 guarantees optimal protection for patients, medical staff, and physicians.

Laser treatment of virus-infected tissue can lead to the release of respirable aerosols containing infectious particles such as viruses or their genomes. Temperatures are lower at the edge of the ablation crater; a sterilizing effect is achieved only at high temperatures. If large fragments of virus-infected cells are torn from the tissue, intact viruses may be present in the aerosol, e.g., HPV in warts, condylomas, and papillomas, or adenoviruses in tear fluid during ophthalmic surgeries.
To minimize risk, thermal vaporization techniques, e.g., using an Nd:YAG laser, should be preferred for such treatments. Plastics used during treatment can catch fire. PVC produces hazardous gases such as HCl. If these come into contact with mucous membranes, the resulting hydrochloric acid can cause tissue burns, and if inhaled, can lead to alveolar collapse. Technical safety measures, such as standard-compliant laser equipment, proper extraction of combustion products, the use of activated carbon or HEPA filters, and the safe handling of chemicals, are essential to protect staff and ensure safety.
Source: FA Info_005_Lasers in Medicine_151109 (bgetem.de)

Exposure during laser treatment involves a mixture of biological, cellular particles, which may also be in gaseous or vapor form. In addition to papillomaviruses and multidrug-resistant pathogens, researchers have also detected benzene, toluene, and xylene, hydrogen cyanide (prussic acid), formaldehyde, acetaldehyde, acrolein, cresols, and phenol in laser smoke. Depending on the energy input, the particles can be larger than 200 micrometers or smaller than 10 nanometers. The combustion of the cooling agent sprayed onto the skin during laser hair removal produces highly toxic vapors. The patented InLine filter, a pre-filter in the collection element, ensures high protection against these dangerous particles.
Source: Eickmann U, Falcy M, Fokuhl I, Rüegger M, Bloch M, Merz B. Surgical Fumes: Hazards and Protective Measures. Edited by: International Section of the ISSA for the Prevention of Occupational Accidents and Diseases in the Health Sector. 2011

The collection component of a filtration and extraction system must be tailored to the process. An InLine filter located within the collection system acts as a pre-filter, capturing the coarsest particles directly at the source, thereby preventing them from entering the extraction arm and reaching the filters in the system. This minimizes the cleaning effort.

The effectiveness of the TBH hygiene concept for the residue-free removal of contaminants in the system has been tested and confirmed by the accredited testing laboratory CleanControlling Medical GmbH & Co. KG in Emmingen-Liptingen. The system, including all accessories, can be effectively cleaned in just a few simple steps. The InLine filter should be replaced daily depending on usage, but at least once a week.

Video: TBH Health Series – Cleaning Instructions on YouTube