The role of dermatologists in the evolution of laser surgery.

The role dermatologists have played throughout the history of laser development is an extremely vital one. The initial interests of Dr. Leon Goldman stimulated many other individual dermatologists to further his work and develop surgical techniques using newer laser systems to provide more effective treatment for patients with a variety of skin diseases. The long list of current cutaneous laser applications developed by dermatologists makes it virtually certain that members of our specialty will continue to play a significant future role in the refinement of laser instrumentation and operative techniques that are inevitable to occur.

Topical suspension-assisted Q-switched Nd:YAG laser hair removal.

BACKGROUND: Many individuals seek to decrease facial and body hair density. Although a variety of epilating methods are available, improved techniques would be of interest to patients and physicians alike. OBJECTIVE: To determine the safety and clinical efficacy of a new laser-based method of hair removal. METHODS: A Q-switched Nd:YAG laser was used to scan skin with increased hair after applying a topical carbon-based solution. Thirty-five healthy, adult volunteers were treated with a single treatment to selected facial, neck, and axillary sites. RESULTS: Twelve weeks after a single treatment, integrated site scores revealed that the majority of patients had over 25% fewer hairs. The 12-week mean percentage of hair reduction, based on anatomic sites, ranged up to 66% and 44% as judged by physicians and subjects, respectively. Adverse events were minimal and temporary. CONCLUSION: Topical suspension-assisted Q-switched Nd:YAG laser therapy reduces hair density after a single treatment. Advantages include its speed, technical ease, and minimal adverse effects.

Laser-assisted hair removal.

The use of lasers in the treatment of a number of different skin disorders and diseases has become commonplace. This tremendous acceptance by both physicians and patients is a direct reflection of the high degree of precision and selectivity provided by lasers, which helps to minimize the risk of side effects and complications while simultaneously maximizing the opportunity for obtaining a satisfactory outcome. In an attempt to remove unwanted or excess hair, the principles of selective photothermolysis have been employed with several different laser and light devices that permit the effective treatment of large areas of hair-bearing skin with minimal discomfort and with low risk of scarring or other complications. It is possible using current laser technology to permanently remove some hair and induce a prolonged delay in the regrowth of many hairs. With additional experience and an improved understanding of how light can influence the rate and quality of hair growth, it is anticipated that permanent hair removal will be achieved in the near future.

Cosmetic use of lasers.

During the 35 years of their existence, lasers have assumed an ever-expanding role in cosmetic surgery due to their reproducible precision in effectively managing a number of cutaneous conditions and disorders for which no acceptable form of treatment has been developed. Current medical lasers can be used to fade or remove many vascular and pigmented birthmarks, decorative and traumatic tattoos, solar and rosacea telangiectasia, and many acquired pigmentary disorders, without a visible scar or change in texture. In order to provide their patients with the best possible aesthetic result, cosmetic surgeons should be familiar with the advantages, disadvantages, and potential complications of lasers.

Clinical uses of lasers in dermatology.

The accessibility of the skin to examination and study has permitted dermatologists to play an extremely important role in defining the clinical usefulness and limitations of many laser systems as well as developing innovative concepts, techniques and devices that further improved the effectiveness of laser treatment. As new laser technology evolved over the years, dermatologists have also helped define the specificity of laser-tissue interaction and employed the newly developed laser technologies in innovative ways which further expanded the usefulness of these devices. One of the most important concepts to be developed by dermatologists--selective photothermolysis--has led to the creation of a series of laser systems which have provided numerous unique advantages in the management of many common vascular and pigmented conditions of the skin and mucous membranes, even in infants and children. The net result of these technologic advances has been the creation of new and effective treatment techniques which have been so profoundly superior to existing technology that they have been rapidly incorporated into the daily practice of most dermatologists.

Treatment of epidermal pigmented lesions with the frequency-doubled Q-switched Nd:YAG laser. A controlled, single-impact, dose-response, multicenter trial.

BACKGROUND AND DESIGN: The removal of benign, aesthetically important, pigmented lesions can be effectively treated with multiple modalities. Selective removal of the pigment by lasers is becoming increasingly popular. A three-center trial evaluated the effectiveness of the frequency-doubled Q-switched neodymium (Nd):YAG laser (532 nm, 2.0-mm spot size, 10 nanoseconds) in removing benign epidermal pigmented lesions with a single treatment. Forty-nine patients were treated for multiple lentigines (n = 37), for cafe au lait macules (n = 7), and for miscellaneous lesions (n = 5). Treatment areas were divided into four quadrants, irradiated with fluences of 2, 3, 4, or 5 J/cm2 and evaluated at 1- and 3-month intervals following treatment. RESULTS: For lentigines, response was related to dose with a greater than 75% pigment removal achieved in 60% of those lesions treated at higher energy fluences. Responses were more variable with other lesions, with fair-to-good improvement noted in most cases. Mild, transient erythema; hypopigmentation; and hyperpigmentation were noted in several patients, but resolved spontaneously within 3 months. No other textural changes, scarring, or other side effects were noted. CONCLUSION: The frequency-doubled Q-switched Nd: YAG laser (532 nm) safely and effectively treats benign epidermal pigmented lesions.

Precise ablation of skin with reduced collateral damage using the femtosecond-pulsed, terawatt titanium-sapphire laser.

BACKGROUND AND DESIGN: The precise ablation of skin was studied using an ultrashort-pulsed, high-intensity titanium-sapphire (Ti:Al2O3) laser capable of peak intensities of tens of terawatts (TW; 1 TW = 10(12) watts [W]) per square centimeter. Rat skin was exposed in vitro to femtosecond-pulsed Ti:Al2O3 laser radiation at 800 nm, while varying the number of pulses and the intensity up to 46 TW/cm2. Ablation was evaluated by monitoring the amount of tissue removed per pulse as a function of energy, and by light microscopic examination of damage to adjacent, nonirradiated tissue. OBSERVATIONS: Ablation depth per pulse was 0.1 micron at threshold intensity, and it was increased with both the energy per pulse and the number of pulses. Minimal damage to adjacent healthy tissue was observed, varying 0 to 30 microns. CONCLUSION: The results suggest that ablation of skin with femtosecond-pulsed, terawatt Ti:Al2O3 laser may have potential for precision cutaneous surgery, and in vivo studies are indicated.

Inflammatory carcinoma masquerading as erythema annulare centrifugum.

A case of inflammatory carcinoma, or carcinoma erysipelatodes, clinically resembling erythema annulare centrifugum is reported. The cutaneous inflammatory carcinoma was due to metastasis by a signet-ring cell adenocarcinoma, probably of gastrointestinal origin. This is the third reported case of inflammatory carcinoma with signet-ring cell infiltration. Cancer patients with atypical or unusual inflammatory dermatoses should be evaluated by skin biopsy because of the possible association with the internal neoplastic process.

Treatment of port-wine stains for the 1990s.

BACKGROUND: A dramatic improvement in the treatment of patients with port-wine stains has occurred over the past 20 years owing to the availability of a variety of different laser systems. The argon laser was the first system to offer an advantage over the older surgical techniques that had previously been used to manage these patients. However, many new lasers have since been developed that further improved the treatment results while simultaneously reducing the risks, even when treating children. OBJECTIVE: To present the current status of laser surgery for port-wine stains and describe how the many newer systems are being used to more effectively manage these patients. METHODS: A thorough review of the medical literature was conducted on the use of new lasers, delivery systems, and treatment techniques for the management of port-wine stains. RESULTS: The biggest advance in laser treatment of port-wine stains resulted from the development of systems that are capable of delivering yellow light. The improved precision provided by these lasers serves to minimize epidermal injury, limit nonspecific thermal damage, and permit treatment of newborns and young children without a significant risk of scarring. CONCLUSION: Major benefits in the treatment of port-wine stains have resulted from the recent development of many new laser systems and laser accessories that provide a more precise response with less potential for complications than had been previously attainable with older technologies.

Low-energy helium neon laser irradiation does not alter human keratinocyte differentiation.

There are reports that low-energy HeNe irradiation can enhance wound healing in vivo. We have previously demonstrated that HeNe irradiation increases the motility of human epidermally derived keratinocytes in vitro. Here we investigate whether HeNe irradiation alters normal keratinocyte differentiation, which is essential for the formation of a normal, functioning epidermis. Subconfluent keratinocyte cultures were irradiated three times within 24 h with either 0, 0.8, 3, or 7.2 J/cm2. After cultures reached post-confluence, parameters of growth and differentiation, such as cell number, cornified envelope (CE) formation, and transglutaminase activity were measured. No significant differences were found between the control (0 J) and irradiated cultures in these assays. We also examined the pattern of newly synthesized keratins in cultures irradiated with 7.2 J/cm2 three times within a 24-h period. Both control and irradiated cultures exhibited similar keratin patterns. These results provide evidence that HeNe irradiations of up to 7.2 J/cm2 have no direct deleterious effect on normal keratinocyte differentiation needed for the formation of a functional epidermis. Hence, it is anticipated that the clinical use of the HeNe laser irradiance that enhances keratinocyte migration in vitro (0.8 J/cm2) to promote wound healing in vivo will not alter the ultimate integrity or differentiated function of the epidermis that migrates to cover the wounded area.

Analysis of the carbon dioxide laser plume for simian immunodeficiency virus.

To determine the viability of the immunodeficiency virus in the laser plume after carbon dioxide (CO2) laser irradiation, multiple samples of culture medium containing concentrated simian immunodeficiency virus (SIVMAC at 1000 TCID50 cultured from HUT 78 cells) were irradiated with a continuous-wave CO2 laser at variable irradiances (from 400 W/cm2 for 5 seconds to 1600 W/cm2 for 300 seconds). The resultant plume was collected and cultured for the presence of SIV. A positive control consisted of handling an infected specimen identically to the test specimens, with the exception of CO2 laser irradiation. All test cultures remained negative over an 8 week incubation period, while the control was positive for viable SIV within 7 days. These results suggest that SIV is not viable in the laser plume after CO2 laser irradiation. Further investigation is necessary before extrapolating these results to the human immunodeficiency virus (HIV).

Use of the argon-pumped tunable dye laser for port-wine stains in children.

The authors reported previously a new technique using a low power argon-pumped tunable dye laser at a wave-length of 577nm (yellow light) to treat port-wine stains in adults. The authors report their results using this same technique as a form of treatment for 92 children with facial port-wine stains.

Current issues in the performance of Mohs micrographic surgery.

Recently, a survey was sent to all members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology concerning their performance of Mohs micrographic surgery. Responses to numerous questions regarding the daily practice of this technique revealed that many useful modifications have evolved over the years that serve to enhance the efficacy and the efficiency of the original Mohs surgical procedure. The results of this survey are presented and discussed.

Reconstruction of the lower lip and chin using local and random-pattern flaps.

Unlike the reconstruction of wounds found on more predictable and less variable anatomic subunits of the face, reconstruction of defects on the chin and lower lip often present special difficulties for the surgeon in accurately assessing and selecting the lines of incision that will provide the patient with the best cosmetic result. The author discusses the many factors which must be considered as part of that selection process and describes the uses of the most common local flaps for reconstructing wounds found in this anatomic location.