Nonablative cutaneous remodeling using radiofrequency devices.

In recent years, several new radiofrequency devices have been introduced for treatment of a variety of skin conditions, particularly, skin wrinkling and laxity. These nonsurgical systems induce tissue tightening and contour changes through dermal collagen remodeling without disruption of the overlying epidermis, obviating a significant recovery period or risk of serious adverse sequelae. As such, radiofrequency-based systems have been used successfully for nonablative skin rejuvenation, atrophic scar revision, and treatment of unwanted hair, vascular lesions, and inflammatory acne.

Lasers in dermatology: four decades of progress.

Advances in laser technology have progressed so rapidly during the past decade that successful treatment of many cutaneous concerns and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair-can be achieved. The demand for laser surgery has increased substantially by patients and dermatologists alike as a result of the relative ease with which many of these lesions can be removed, combined with a low incidence of adverse postoperative sequelae. Refinements in laser technology and technique have provided patients and practitioners with more therapeutic choices and improved clinical results. In this review, the currently available laser systems with cutaneous applications are outlined, with primary focus placed on recent advancements and modifications in laser technology that have greatly expanded the cutaneous laser surgeon's armamentarium and improved overall treatment efficacy and safety.

Lasers in dermatology: four decades of progress

Advances in laser technology have progressed so rapidly during the past decade that successful treatment of many cutaneous concerns and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair-can be achieved. The demand for laser surgery has increased substantially by patients and dermatologists alike as a result of the relative ease with which many of these lesions can be removed, combined with a low incidence of adverse postoperative sequelae. Refinements in laser technology and technique have provided patients and practitioners with more therapeutic choices and improved clinical results. In this review, the currently available laser systems with cutaneous applications are outlined, with primary focus placed on recent advancements and modifications in laser technology that have greatly expanded the cutaneous laser surgeon's armamentarium and improved overall treatment efficacy and safety.

Botulinum toxin type B for dynamic glabellar rhytides refractory to botulinum toxin type A.

BACKGROUND: Botulinum toxin type B (BTX-B; Myobloc) has recently been introduced for the treatment of dynamic rhytides. This serotype is structurally similar to botulinum toxin type A (BTX-A; Botox) and appears to produce equivalent muscular paralysis. Because of the fact that some patients may become resistant to the effects of BTX-A with its continued use or may require large doses of type A to exert adequate muscular paralysis, the use of BTX-B may prove beneficial in these cases. OBJECTIVE: To determine the effect of BTX-B on glabellar rhytides refractory or showing decreased clinical effect to treatment with BTX-A. METHODS: Twenty females (mean age, 43 years) with vertical glabellar rhytides showing decreased or negligible clinical effect to BTX-A were treated with intramuscular injections of BTX-B. Five standardized intramuscular sites (procerus, inferomedial corrugator muscles, superior middle corrugator muscles) received a total dose of 2,500 U. Patients were evaluated at pretreatment and 48 to 72 hours, 1 week, and 2 and 4 months after injection. RESULTS: All glabellar rhytides improved after treatment with BTX-B injections. Peak clinical effect was noted 1 month after treatment, with 50% of peak effect evident at the 2-month follow-up. Near complete dissolution of effect was seen at 4 months after treatment. Side effects were transient and were limited to moderate injectional pain and rare bruising and frontal brow tightness. CONCLUSIONS: BTX-B is an effective treatment modality for glabellar rhytides refractory or exhibiting decreased clinical effect to BTX-A. The duration of effect using the 2,500 U dosing schedule described herein was shorter than that typically achieved after equivalent BTX-A injection.

Evaluation of a novel topical anesthetic agent for cutaneous laser resurfacing: a randomized comparison study.

BACKGROUND: A variety of topical anesthetic compounds are available for use prior to minimally or moderately painful cutaneous laser procedures. A novel lidocaine/tetracaine-based peel has recently been developed that is applied to the skin as a cream and, once air dried, is removed as a flexible film that may prove useful in providing adequate dermal anesthesia for dermatologic laser surgery. OBJECTIVE: To evaluate the clinical efficacy of a novel topical anesthetic peel preparation for induction of local anesthesia prior to full-face cutaneous laser resurfacing. METHODS: A series of 20 patients undergoing full-face single-pass CO2 laser resurfacing were enrolled in a double-blind institutional review board (IRB)-approved study protocol in which two different topical anesthetic products were compared. A 4 cm x 4 cm area of one cheek was randomized to receive the novel lidocaine/tetracaine-based cream peel (S-Caine) while a 4 cm x 4 cm area on the contralateral side received EMLA cream with occlusion for 30 minutes prior to laser treatment. Patients rated the level of pain experienced during laser treatment on each side using a visual analog scale. Independent assessments of observed discomfort and side effects were recorded RESULTS: Pain scores were significantly lower using the novel lidocaine/tetracaine-based cream peel formulation compared with the EMLA cream. Side effects associated with application of the anesthetic peel were limited to mild transient erythema and skin blanching. CONCLUSION: A novel topical lidocaine/tetracaine-based cream peel provides safe and effective dermal anesthesia for single-pass CO2 laser skin resurfacing.

Nonablative laser skin resurfacing using a 1540 nm erbium glass laser: a clinical and histologic analysis.

BACKGROUND: A variety of laser systems have recently become available that allow for selective dermal remodeling without disruption of the epidermal surface. Modest clinical improvement in mild to moderate photoinduced facial rhytides with minimal morbidity is typical of these nonablative lasers, providing a significant advantage over traditional ablative laser systems. OBJECTIVE: To determine the clinical and histologic effects of a novel 1540 nm erbium glass laser on facial rhytides. METHODS: Patients with mild to moderate periorbital and perioral rhytides received a series of three monthly treatments with a 1540-nm erbium-doped phosphate glass laser by a single operator. Photographic and clinical evaluations were independently conducted by the patient and a masked medical observer at each treatment visit and at 1, 3, and 6 months following the final treatment session. Skin biopsies were obtained for histologic analysis by a board-certified dermatopathologist at baseline, immediately following laser irradiation, and at one and six months post-treatment. RESULTS: Slow, progressive clinical improvement of rhytides was noted in all patients after each treatment and continued throughout the extended follow-up period. Side effects of treatment were limited to transient erythema and edema immediately following laser irradiation. No serious adverse effects were noted. Histologic skin changes were not apparent until several months following treatment, when an increase in dermal collagen was noted. CONCLUSIONS: The nonablative 1540 nm erbium glass laser system with contact cooling produces gradual clinical and histologic improvement in mild to moderate facial rhytides with minimal risk of serious adverse sequelae.

Clinical comparison of sclerotherapy versus long-pulsed Nd:YAG laser treatment for lower extremity telangiectases.

BACKGROUND: Sclerotherapy has traditionally been considered the gold standard of treatment for leg veins, but patient fear of multiple needle injections and side effects of treatment have fueled investigation into other treatment alternatives. As a result, vascular-specific laser and light sources have been developed in an effort to treat these vessels with minimal morbidity and improved efficacy. OBJECTIVE: To compare the clinical efficacy of leg telangiectasia treatment with sodium tetradecyl sulfate sclerotherapy to long-pulsed 1064 nm Nd:YAG laser irradiation. METHODS: A series of 20 patients with size-matched superficial telangiectases of the lower extremities were randomly assigned to receive two consecutive monthly treatments with injectable sodium tetradecyl sulfate on one leg and long-pulsed 1064 nm Nd:YAG laser irradiation on the other. Patients were evaluated by two masked assessors at each treatment visit and at 1 and 3 months after treatment to assess clinical improvement within matched sites. RESULTS: Leg telangiectases responded best to sclerotherapy in fewer treatment sessions than to long-pulsed 1064 nm Nd:YAG laser irradiation. The incidence of adverse sequelae was minimal and equivocal in both treatment groups. CONCLUSION: Despite recent advances in laser technology for treatment of lower extremity telangiectases, sclerotherapy continues to offer superior clinical effect in the majority of cases. Laser leg vein treatment appears to be most beneficial in patients with telangiectatic matting, needle phobia, or sclerosant allergy.

Laser resurfacing of darkly pigmented patients.

Hyperpigmentation following laser resurfacing in darker-skinned individuals is common but treatable. This pigmentation is usually heralded by persistent erythema and can be prevented in most patients if aggressive laser resurfacing is curtailed and conservative or single-pass techniques are applied. Avoiding excessive intraoperative frictional trauma when removing the desiccated tissue Avoiding excessive intraoperative frictional trauma when removing the desiccated tissue and potentially irritating agents or infections in the pre- or postoperative period is also instrumental in avoiding long-term complications.

Regional anesthesia with monitored anesthesia care for dermatologic laser surgery.

This article describes an anesthetic technique that the authors have found useful for cutaneous laser surgery in keeping with the standards for office-based anesthesia practice. Although still in its infancy, office-based anesthesia for dermatologic laser procedures has become one of the most challenging yet rewarding fields of anesthesia today. As laser procedures continue to flourish, with seemingly endless technologic advances, surgeons, anesthesia providers, and other medical personnel must work collaboratively in developing appropriate office-based practice. The authors' experience using the anesthetic technique described here has demonstrated that cutaneous laser resurfacing can be conducted safely and efficiently using a combination of facial nerve blocks with intravenous sedation.

Laser scar revision.

A variety of lasers can be used to treat scars and striae effectively. It is of paramount importance that the type of scar be properly classified on initial examination so that the most appropriate method of treatment can be chosen. Classification also allows the laser surgeon to discuss with the patient the anticipated response to treatment. The 585-nm pulsed dye laser (PDL) is the most appropriate system for treating hypertrophic scars, keloids, erythematous scars, and striae. The PDL carries a low risk of side effects and complications when operated at appropriate treatment parameters and time intervals. Atrophic scars are best treated with ablative CO2 and Er:YAG lasers; however, proliferative keloids and hypertrophic scars should not be vaporized because of the high risk of scar recurrence or progression. The appropriate choice and use of lasers can significantly improve most scars. As research in laser-skin interaction continues, further refinements in laser technology coupled with the addition of alternate treatment procedures will allow improved clinical efficacy and predictability.

Cutaneous metastasis from an intracranial glioblastoma multiforme.

A 34-year-old white man with a history of an intracranial glioblastoma multiforme was treated with surgical excision and radiotherapy. Five months later, the patient had a rapidly growing scalp mass develop. This lesion was excised, and the histology revealed a tumor that was similar to the originally resected intracranial glioblastoma. Immunohistochemistry for general neuroepithelial derivation (S-100 protein) and for glial fibrillary acidic protein (GFAP) was positive, whereas mesenchymal, epithelial, and neuronal markers were negative. This immunohistochemistry pattern was identical to the original tumor. Although metastasis of this tumor is not uncommon, metastasis to the skin has never been reported. To our knowledge, this is the first reported case of cutaneous metastasis from glioblastoma in the world literature.

Are all infrared lasers equally effective in skin rejuvenation.

In an attempt to limit the prolonged postoperative healing associated with ablative laser skin resurfacing and in response to growing public interest in less invasive treatment modalities, nonablative laser and light source technology was developed. Over the past few years, several clinical and histologic research studies have been conducted to determine the relative efficacy of these nonablative systems. These systems stimulate dermal collagen remodeling using wavelengths and concomitant tissue cooling that limit injury to the epidermis, thereby minimizing or eliminating postoperative sequelae. While nonablative lasers do not supersede already established ablative laser technologies, they supplement the treatment armamentarium, making a wider range of treatment options available and enhancing the ability to correlate the needs of individual patients more closely with the specific advantages offered by a particular modality.