Faculty Bibliography

BACKGROUND AND OBJECTIVE: Pulsed dye laser treatment often results in port-wine stain (PWS) improvement; however, results vary. A frequency-doubled neodymium-doped yttrium aluminum garnet (Nd:YAG) laser that allows for shorter pulse widths along with large spot sizes and high fluences has been developed for the treatment of cutaneous vascular lesions. STUDY DESIGN: A prospective, controlled study was performed in 5 adults with PWS using a frequency-doubled Nd:YAG laser (Excel V; Cutera Inc, Brisbane, CA) in 4 quadrants, using spot sizes of 6 to 10 mm, fluences of 4.8 to 9 J/cm2, and pulse durations of 3 to 6 ms. An adjacent control area was not treated. Each was assessed immediately posttreatment for purpura and edema and at 1 month for PWS color, size, texture, and thickness. Skin biopsies obtained immediately after and at 1 month posttreatment were evaluated. RESULTS: All treatment quadrants displayed purpura. At 1-month follow-up, all treatment quadrants showed at least 1 grade of color improvement, from a minimum of 1% to 25% to a maximum of 51% to 75% improvement (12/20 quadrants with 1%-25% improvement, 3/20 with 26%-50%, 5/20 with 51%-75%, and 0/20 with 76%-100%). Histologic evaluation of treatment quadrants revealed vascular changes ranging 0.35 to 4 mm in depth. Immediately posttreatment, thrombi and extravasated red blood cells were observed in treatment quadrants. Histology at 1 month revealed decreased number and diameter of vessels in treatment quadrants (superficial vessels decreased by mean 1.1 vessels per section [13%], and diameter by 3.0 mum [47%], midlevel vessels decreased in number by 2.3 [20%], diameter by 2.42 mum [25%], and deep vessels decreased in number by 1.5 [83%], and diameter by 7.44 mum [88%]). CONCLUSIONS: A single treatment with a short pulse width, frequency-doubled Nd:YAG laser resulted in safe and effective improvement of PWS, with up to 75% improvement in color observed at 1 month. Histologic evaluation demonstrated vascular injury at depths of 0.35 to 4 mm with a reduction in vessel number and size at multiple dermal levels.

BACKGROUND: Infantile hemangioma (IH) clearance may be slow or incomplete in response to pulsed dye laser (PDL) or propranolol alone. OBJECTIVES: To evaluate whether IH treated with PDL and propranolol displayed more rapid and complete clearance than IH treated with propranolol alone. MATERIALS AND METHODS: Retrospective review of facial-segmental IH treated with propranolol and PDL and controls treated with propranolol was conducted. Blinded physicians used patient photographs to select clearance level and the earliest date of near-complete clearance. Days of propranolol, PDL sessions, and propranolol dose, each until date of near-complete clearance; total days of propranolol; and total propranolol dose were recorded. RESULTS: Infantile hemangiomas treated concurrently with propranolol and PDL achieved complete clearance (6/12) more often than IH treated with propranolol followed by PDL (2/5) or IH treated with propranolol alone (1/8; difference in clearance scores p = .01) and achieved near-complete clearance after fewer days of propranolol (mean 92 days for concurrent propranolol and PDL vs 288 days for propranolol; p < .001). Cumulative propranolol dose until near-complete clearance was lowest in the concurrent propranolol and PDL group (149.16 vs 401.25 mg/kg for propranolol; p < .001). CONCLUSION: Facial-segmental IH treated with propranolol and PDL displayed morerapid and complete clearance and required a lower cumulative propranolol dose to achieve near-complete clearance.

Vascular lesions encountered in dermatology can be divided into vascular malformations and vascular tumors, namely infantile hemangiomas (IH). Vascular malformations can further be subdivided by their flow characteristics and vessel type. Slow, or low-flow lesions are either capillary vascular malformations (CVMs), venous malformations, or lymphatic malformations. Fast, or high-flow lesions include an arterial component, and are categorized as arteriovenous malformations. IH and CVMs are among the most common benign vascular lesions seen and treated in dermatology. CVMs are present at birth and grow as the individual does, whereas IH usually appear days to weeks later and may rapidly enlarge for a period of months to a year before gradually involuting. As the technology has evolved, early and often laser treatment with the pulsed dye 595-nm laser has become our standard therapy of choice. More recently, we have started more patients on combination therapy for IH with the topical beta blocker timolol. If left untreated, CVMs darken and thicken, making them increasingly difficult to successfully treat with lasers. IH involute, sometimes resulting in fibrofatty, atrophic plaques. These individuals can undergo ablative fractional resurfacing with a fractional CO2 laser to improve the texture and appearance of these lesions.

BACKGROUND: Actinic keratoses (AK) are precancerous epidermal proliferations commonly present on chronically sun-damaged skin. These lesions are among the most often treated dermatologic conditions. OBJECTIVE: We sought to investigate the 6-month safety, tolerance, and efficacy of nonablative 1927-nm fractional resurfacing of facial AK. METHODS: This was a prospective clinical trial of 24 individuals with facial photodamage and AK receiving up to 4 treatments with the fractionated 1927-nm nonablative thulium laser. RESULTS: At 6 months, an 86.6% reduction in absolute number of lesions was noted by independent physician assessment. In addition, at this same time point, patients reported marked or noticeable improvement in overall photodamage. LIMITATIONS: This prospective study does not provide safety, tolerance, and efficacy data beyond 6 months of follow-up, nor does it identify the precise mechanism of action involved in AK clearance after 1927-nm resurfacing. CONCLUSION: The clinical and histologic findings, as well as the reported patient satisfaction and safety, suggest that the treatment of AK and photodamage with a fractionated 1927-nm nonablative thulium laser is a promising new therapeutic option.

BACKGROUND: There are few objective techniques to accurately measure the outcome of liposuction. Consequently, there is also a paucity of data quantifying the results of this procedure. OBJECTIVES: The authors compare changes in abdominal volume and circumference with several objective measurement techniques in a relatively homogeneous group of individuals undergoing liposuction in a single, defined abdominal region. METHODS: This clinical study enrolled 23 patients with a body mass index (BMI) <25 kg/m(2) who had a localized anterior abdominal contour defect. Patients underwent standard suction-assisted tumescent liposuction. Changes in abdominal volume and circumference in the operative area (60 mm above to 80 mm below the umbilicus) preoperatively and 10 weeks postoperatively were assessed using a 3-dimensional (3D) digital photographic system and a standardized constant-tension manual tape measure procedure. RESULTS: The majority of the patients in this study were Caucasian women with a mean age of 42 years, a mean weight of 65.8 kg, and a mean BMI of 23.8 kg/m(2). In the study population, mean abdominal volume and umbilical circumference were reduced by 231.0 mL (~30% of subcutaneous fat) and 1.7 cm, respectively, at 10 weeks postoperatively as determined by 3D digital imaging. Fat volume in the surgical aspirate (mean = -183.3 mL) was a poor predictor of individual outcome, as assessed 10 weeks postoperatively by both the 3D digital imaging and multilevel constant-tension tape measure assessment tools. CONCLUSIONS: Both 3D digital photographic imaging and a standardized manual tape measurement procedure proved to be reliable tools for objectively assessing changes in abdominal circumference and volume produced by standard liposuction of a single, defined abdominal region.

BACKGROUND Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas. OBSERVATIONS All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance. CONCLUSION While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas.

BACKGROUND While the understanding and technology of laser tattoo removal has advanced much over the last 5 decades, treatments and results remain far from perfect. With currently available devices, treatment courses are often painful and prolonged with mixed results. We describe the successful and rapid treatment of 12 tattoos containing blue and/or green pigment with a novel, picosecond, 755-nm alexandrite laser. OBSERVATIONS All previously untreated multicolored tattoos as well as tattoos recalcitrant to treatment demonstrated at least 75% clearance of blue and green pigment after 1 or 2 treatments with a novel, picosecond, 755-nm alexandrite laser. More than two-thirds of these tattoos approached closer to 100% clearance. CONCLUSIONS While additional future studies are needed, we believe that this new technology is more effective in targeting blue and green pigment, resulting in expedited clearance with less collateral injury to surrounding tissue.