A. Jay Burns

Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases.

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

Consensus Recommendations on the Use of an Erbium‐Doped 1,550‐nm Fractionated Laser and Its Applications in Dermatologic Laser Surgery

BACKGROUND Nonablative fractional photothermolysis has revolutionized the way we treat a number of common skin conditions with laser technology. OBJECTIVE A comprehensive guide is needed for clinicians using this technology to treat specific skin conditions in various skin types. MATERIALS AND METHODS Recommendations were made from a recent round table discussion among experienced physicians and a review of recent literature findings. RESULTS Optimal laser parameters are dependent on patient skin type and condition. We recommended guidelines for the successful treatment of several common skin conditions on and off the face using nonablative fractional photothermolysis. Specific conditions were dyschromia, rhytides, acne scars, surgical scars, melasma, and striae distensae. CONCLUSIONS We developed reproducible guidelines to most effectively treat a variety of skin types and conditions using nonablative fractional photothermolysis. Future large, multicenter trials are indicated for further optimization of treatment parameters. Reliant Technologies paid travel expenses and honorariums to all authors.

Safety and efficacy of cryolipolysis for non-invasive reduction of submental fat.

Cryolipolysis has previously received FDA clearance for fat reduction in the abdomen, flanks, and thighs. There is also interest in small volume fat reduction for areas such as the chin, knees, and axilla. This article reports the results of a cryolipolysis pivotal IDE study for reduction of submental fullness.

Cryolipolysis for Safe and Effective Inner Thigh Fat Reduction

While cryolipolysis initially received FDA clearance for fat reduction in the abdomen and flanks, there was significant interest in non‐surgical fat reduction for other sites, such as the inner and outer thighs. This article reports the results of an inner thigh study which contributed to FDA clearance of cryolipolysis for treatment of thighs.

Classification of vascular anomalies and the comprehensive treatment of hemangiomas.

Background: The purpose of this article is to review the biological classification system of vascular anomalies and present a comprehensive treatment approach to hemangiomas. Methods: An extensive literature review was performed for the classification of vascular anomalies. Emphasis was placed on the epidemiology, pathogenesis, diagnosis, and treatment of hemangiomas, including the authors’ preferred algorithm. Results: The authors’ comprehensive management of vascular anomalies as described in this article has resulted in high patient satisfaction and an excellent outcome in a majority of patients. Conclusions: The authors believe that knowledge of proper classification is not just their personal preference but a functional necessity to aid in the treatment of these complex and large lesions. Proper use of the biological classification is inherent to understanding and treating these common vascular lesions optimally.

Total soft-tissue reconstruction of the middle and lower face with multiple simultaneous free flaps in a pediatric patient.

A 2-year-old boy sustained a massive facial soft-tissue wound secondary to a dog attack. Essentially all the soft tissues of the face were absent, including innervation and intraoral lining. We describe the reconstruction of this defect with five simultaneous free tissue transfers. To our knowledge, this is the first report of five simultaneous free flaps in any patient.

Role of laser therapy in pediatric patients.

Background: Laser applications have revolutionized the treatment of many cutaneous vascular anomalies. Because most of these lesions are congenital, the pediatric population has benefited primarily. In this article, the authors focus primarily on laser treatment options, realizing that this modality is but one part of an overall comprehensive plan of management options for these affected children. Methods: The literature was reviewed and interjected into the authors’ 20 years of experience in the use of lasers in the pediatric population. Results: The use of different therapy modalities, such as the neodymium:yttrium-aluminum-garnet laser, pulsed dye laser, erbium:yttrium-aluminum-garnet laser, and intense pulsed light systems, is discussed. Outcomes, risks, benefits, and treatment protocols vary for each entity and for each laser. The authors’ results and those of others are presented. Conclusions: Lasers play a vital role as an adjunctive therapy or definitive therapy in many of the authors’ pediatric patients. Anyone treating such patients should be well aware of lasers as a valuable tool.

A Multicenter Study for a Single, Three-Step Laser Treatment for Cellulite Using a 1440-nm Nd:YAG Laser, a Novel Side-Firing Fiber, and a Temperature-Sensing Cannula

BACKGROUND Historically, treatments for cellulite have not been able to address all of its physiological components and require multiple sessions. OBJECTIVE The authors evaluate the safety and efficacy of a single, subdermal procedure to treat the underlying structure of cellulite. METHODS Fifty-seven patients underwent a 3-step cellulite treatment with a 1440-nm Nd:YAG laser with a side-firing fiber and temperature-sensing cannula. Efficacy was measured by the ability of blinded evaluators to distinguish baseline photos from those taken at 3 and 6 months posttreatment, as well as their rating of the results on a 5-point, 2-category ordinal photonumeric scale when comparing baseline photos to those taken at 2, 3, and 6 months posttreatment. Patient and physician satisfaction was assessed based on completion of a satisfaction survey at 2, 3, and 6 months posttreatment. Adverse events (AE) were recorded throughout the study. RESULTS At 6 months posttreatment, blinded evaluators rated at least a 1-point improvement in the appearance of cellulite in 96% of treated sites. Blinded evaluators were also able to correctly identify baseline versus posttreatment photos in 95% of cases. At least 90% of patients and physicians reported satisfaction with the results of treatment throughout 6 months. AE were mild in intensity and transient to treatment. CONCLUSIONS A single, 3-step, minimally invasive laser treatment using a 1440-nm Nd:YAG laser, side-firing fiber, and temperature-sensing cannula to treat the underlying structure of cellulite proved to be safe and maintained effectiveness at least 6 months posttreatment. LEVEL OF EVIDENCE 2.

A Multicenter Study for Cellulite Treatment Using a 1440-nm Nd:YAG Wavelength Laser with Side-Firing Fiber

BACKGROUND Treatment of cellulite using a 1440-nm YAG wavelength laser with side-firing fiber has proven safe and effective, lasting at least 6 months. OBJECTIVES The authors evaluate the safety and efficacy of a single, subdermal procedure to treat the underlying structure of cellulite for at least 1 year. METHODS Fifty-seven patients underwent a 3-step cellulite treatment with a 1440-nm Nd:YAG laser with a side-firing fiber and temperature-sensing cannula. Efficacy was measured by the blinded evaluators to distinguish baseline photos from those taken at 12 months posttreatment, with results on a 5-point, 2-category ordinal photonumeric scale when comparing baseline photos to 12 months posttreatment. Subject and physician satisfaction was assessed based on completion of a satisfaction survey. Adverse events (AE) were recorded throughout the study. Twelve month data were analyzed and compared to 6 month data. RESULTS Evaluators chose baseline photographs 97% on average from 6 (-1, +2) months and 91% from the 12 (-3, +2) months posttreatment photographs. At 6 (-1, +2) months, the average improvement score was 1.7 for dimples and 1.1 for contour irregularities. At 12 (-3, +2) months, the average improvement score was 1.4 for dimples and 1.0 for contour irregularities. The average satisfaction score for the physician was 5.6 and the patient was 5.3 on a 6-point scale. CONCLUSIONS A single, 3-step, minimally invasive laser treatment using a 1440-nm Nd:YAG laser, side-firing fiber, and temperature-sensing cannula to treat the underlying structure of cellulite proved to be safe and maintained effectiveness at least 1 year post treatment. LEVEL OF EVIDENCE 2: Therapeutic.

A Personal Approach to Laser Resurfacing

Recommendations based on 2 years’ experience with CO2 laser skin resurfacing of more than 600 treatment areas are presented. The two different CO2 laser systems used are reviewed and compared. The mechanism of action of the CO2 laser, indications, treatment protocol, preoperative and postoperative guidelines, complications, and results are outlined. There is no question that laser resurfacing (LRS) is effective, and at times the results are spectacular. This enthusiasm must be countered with the realization that a certain morbidity is associated with this procedure and the longevity of the results is uncertain. Nevertheless, this technique can be used safely with proper training and experience. LRS became a reasonable treatment option with the advent of the new high-energy, short-pulse CO2 lasers. A detailed discussion of laser physics is beyond the scope of this article. However, with all laser technology, the emphasis is on “selective” injury. There are many mechanisms to achieve “selectivity,” but one basic concept common to all selective systems is that with delivery of high energy to the target tissue (i.e., skin, pigment, and blood vessels) this energy needs to “dwell” on the tissue for a shorter time to accomplish its goal. In theory, with infinitely high energy there would be an infinitely short dwell time so that only the specific target would be heated and destroyed with very little residual damage. This concept is termed “selective photothermolysis.”1 With LRS the target is the superficial portion of the skin to the level of the upper to mid reticular dermis, although the ideal depth has yet to be determined. 2,3 Selectivity has currently been accomplished with the new pulsed CO2 lasers in which powers as high as 400 to 500 mJ per pulse can be delivered in 1 msec or less. Keeping …