Daniel Cassuto

Treatment of facial telangiectasias with a diode-pumped Nd:YAG laser at 532nm

OBJECTIVE : Facial telangiectasias are a common cause of cosmetic concern. Current treatment modalities present various untoward effects and limits. The pulsed dye laser has been considered the gold standard in efficacy and safety; unfortunately it causes postoperative intracutaneous hematomata, discouraging many patients from undergoing this treatment. Several other vascular lasers (argon, tunable dye, copper, krypton, etc.) are disadvantaged by the risk of hypopigmented and atrophic scars. MATERIALS AND METHODS : We assessed a recent powerful version of the potassium titanyl phosphate (KTP) 532 nm laser, which delivers sufficient energy in single pulses lasting 10-50 msec (DioLite 532; IRIDEX, Mountain View, CA, USA). Collateral damage is reduced while the heating of the vessel is slow enough to avoid explosive photothermolysis with its associated purpura. Sixty six patients with facial telangiectasias were treated. RESULTS : In 62/66 patients (93.9%) we achieved a 75-100% clearance of the lesions, while two treatments were needed to reach an acceptable clearance in the remaining 4/66 patients (6.1%). The eventual need for more sessions was well tolerated because the acceptable postoperative appearance allowed patients to continue normal business and social activities between treatments. No permanent complications or undesired effects were noted. CONCLUSION : We conclude that this diode-pumped frequency-doubled Nd:YAG laser is an effective device for the treatment of facial telangiectasias, with a low profile of undesired effects that can be well tolerated by patients.

Advanced Laser Techniques for Filler‐Induced Complications

BACKGROUND The increasing use of injectable fillers has been increasing the occurrence of disfiguring anaerobic infection or granulomas. This study presents two types of laser‐assisted evacuation of filler material and inflammatory and necrotic tissue that were used to treat disfiguring facial nodules after different types of gel fillers. MATERIALS AND METHODS Infectious lesions after hydrogels were drained using a lithium triborate laser at 532 nm, with subsequent removal of infected gel and pus (laser assisted evacuation). Granuloma after gels containing microparticles were treated using an 808‐nm diode laser using intralesional laser technique. The latter melted and liquefied the organic and synthetic components of the granulomas, facilitating subsequent evacuation. Both lasers had an easily controllable thin laser beam, which enabled the physician to control tissue damage and minimize discomfort and pain. RESULTS All 20 patients experienced reduction or complete resolution, the latter increasing with repeated treatments. CONCLUSION Laser‐assisted treatment offers a successful solution for patients who have been suffering from disfiguring nodules from injected fillers—often for many years. The procedure broadens the range of treatment options in cases of untoward reactions to fillers, in line with surgical removal but with lower morbidity and less cosmetic disfigurement. The authors have indicated no significant interest with commercial supporters.

Clinical results of skin remodeling using a novel pneumatic technology

Background  A myriad of technologies are available for the treatment of aging skin. These, however, still lack the ability to combine immediate, short‐term and long‐term aesthetic results with no downtime. Furthermore, the treatment of fine wrinkles on large surfaces remains challenging, as does the treatment of delicate regions, such as the dorsal hand, neck, and chest.

Treatment of hypertrophic scars and keloids with an LBO laser (532 nm) and silicone gel sheeting

Abstract Background: Keloid scars continue to be a complex and poorly understood subject. The main problem faced by researchers is the lack of an animal model because keloids affect only humans. Traditional techniques for keloids and hypertrophic scars are still availble. More recently, lasers have gained an increasing role in the treatment of hypertrophic scars and keloids. Methods: A total of 37 consecutive patients (31 females and six males; F:M=5:1 ratio) with 48 scars (34 hypertrophic and 14 keloids) were included in this study. Patients ranged in age from 8 to 67 years (mean age 34 years) with Fitzpatrick skin types II–IV. The age of scars ranged from 3 to 35 months (average 9 months). The scars were classified according to the Vancouver Scars Scale (VSS). Clinical digital photography was performed under standard and cross-polarized illumination. Laser treatment was performed in association with silicone gel sheeting. Results: Overall, excellent resolution of the scars was achieved, with an initial average VSS score of 12.6 and a mean VSS final score of 3.3. Conclusion: The combined use of silicone gel sheeting and a 532-nm millisecond laser is an effective and safe treatment for hypertrophic scars and keloids.

The use of Dermicol-P35 dermal filler for nonsurgical rhinoplasty.

A growing number of patients with congenital or acquired nasal defects is seeking nonsurgical procedures to correct the appearance of their nose. The use of fillers for the correction of nasal deformities is expanding because of their low risk and reversibility compared with surgery. Dermicol-P35 (Evolence; Ortho Dermatologics, Skillman, NJ) is a novel crosslinked, fibrillar type I collagen isolated from porcine tendons that has not been associated with the same degree of immunogenicity as bovine collagen. The use of Dermicol-P35 in this study of 12 subjects was associated with high tolerance, as well as a high degree of satisfaction.

Non‐ablative scar revision using a long pulsed frequency doubled Nd:YAG laser

OBJECTIVE: Unsightly scars often are the only reminder of a previous surgical or traumatic wound. Surgical or ablative scar revision is sought by patients, sometimes unnecessarily. When the aesthetic drawback is mainly a result of hypervascularity or hyperpigmentation, these problems can be specifically targeted with a wavelength that is well absorbed by the two above mentioned chromophores. Some degree of epidermal tightening can also be achieved, which is sometimes useful in slightly atrophic scars. The average improvement after 2–3 sessions was 81% (75%–100%) clearance, as judged by an independent observer who reviewed pre‐ and post‐treatment photographs. No undesired effects were reported. All our patients were satisfied and required no further treatment. METHODS: Selective photothermolysis by means of a long pulsed frequency doubled Nd:YAG laser (DioLite™ 532, IRIDEX Corporation, Mountain View, CA, USA) was used to eliminate the unsightly vascular and pigmented components of 23 mature scars (scars older than 2 years) in 22 consecutive patients. Energy densities of 17–22 j/cm2 were used with a 500 micron spot, or 65–90 j/cm2 with a 200 micron spot. RESULTS: overall scar clearance averaged 81% after 2.4 treatments. Facial scars showed the best clearance averaging 94% after 2 treatments. Inframammary scars were the most difficult to clear averaging 46%. Postoperative undesired effects were immediate erythema and swelling that subsided within 2–10 hours and microcrusting on 19/22 (88%) patients that resolved within one week. No other temporary or permanent undesired effects such purpura, hypo‐ or hyperpigmentation were noticed, even in patients with darker skin types.

Management of Complications Caused by Permanent Fillers in the Face: A Treatment Algorithm.

Background: Nonresorbable substances are still injected to enhance soft-tissue volumes and fill subcutaneous defects. Inflammatory reactions (often termed granulomas) to these materials can be functionally and socially disabling. Most therapeutic options used until now are nonspecific antiinflammatory treatments, targeting an ill-defined immune reaction of undefined cause. The minimally invasive intralesional laser treatment can remove the foreign substance and the inflammatory reaction with an 808-nm diode laser. Methods: Two hundred nineteen consecutive patients referred from September of 2006 until June of 2013 for inflammatory reactions to permanent facial fillers and treated with this technique at the authors’ institution with a minimum 6-month follow-up were studied. All patients were screened with an ultrasound soft-tissue examination and the lesions were classified as either cystic (implants inserted by bolus injections) or infiltrating (as in microdeposit injection). The authors’ therapeutic approach is summarized in an algorithm: infiltrating patterns were treated with intralesional laser treatment alone, whereas cystic distribution cases were also drained through stab wound incisions. The mean patient age was 49 years (range, 23 to 72 years); 204 patients were women. Results: Partial improvement was obtained in 30 percent of patients, whereas 8 percent discontinued the treatment because of a lack of satisfaction. Lesions disappeared completely in 62 percent. Complications included transient swelling in all cases, hematoma in 2 percent, secondary sterile abscess in 9.5 percent, and minimal scarring in 10 percent. Conclusion: A problem-oriented systematic approach to inflammatory complications from permanent fillers is proposed, based on the comprehensive work from the past 7 years, with an overall improvement rate of 92 percent. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

An Innovative Device for Fractional CO 2 Laser Resurfacing: A Preliminary Clinical Study

Background and Objective: Use of CO2 laser resurfacing is a powerful tool for the treatment of several skin conditions, such as fine and coarse wrinkles, scars of various origin, uneven pigmentation, and dilated pores. Some major drawbacks have progressively limited its use: the need for effective anesthesia, the downtime associated with treatment, the risk of hyperpigmentation and scarring, the need for intensive postoperative care, the long-lasting erythema, and the need to avoid sun exposure for extended periods. Fractional laser resurfacing with a 1540-nm laser can avoid some of these disadvantages, but pain and cost still serve as barriers. A new CO2 laser system with a fractional modality added to a traditional though potentially very rapid scanner was tested as a tool for skin rejuvenation. It can perform traditional and fractional resurfacing at depths ranging from 20 to 500 μm and treating 20%, 40%, or 100% of the scanned area. Materials and Methods: A series of 24 consecutive patients (Fitzpatrick skin types II–IV) were treated with one pass of the aforementioned fractional CO2 laser (18 faces, 2 necks, 8 hands). No anesthesia was used. The power used was between 8 and 15 W, with SX index values of 4 to 8, according to patient tolerance. SX index indicates pulse width: the shorter the pulse the higher the SX index value. Postoperative management included a thermal water-based cream and makeup provided free of charge. Digital clinical macrophotography was used to assess the results and a subjective pain and satisfaction evaluation was also done. Results: All patients showed improvement in skin texture and color after one treatment. Undesired postoperative effects were immediate erythema, and swelling that subsided within 24 hours. Fine pinpoint microcrusting occurred in all cases, but it resolved within 1 week on the face and 10 days on the other body areas. The treatment was well tolerated. With makeup it looked like a tan. No long-term side effects were observed after 6 months of follow-up. Conclusions: The evaluated system is an effective and safe tool for skin rejuvenation by fractional laser resurfacing.

Right–left comparison study of hydrogel pad versus transparent fluid gel in patients with dermo‐cosmetic lesions undergoing non‐ablative laser therapy

Objective: The aim of this study was to compare the cooling properties of a transparent hydrogel pad and a fluid gel in patients with dermo‐cosmetic lesions undergoing non‐ablative laser therapy. Methods: Patients enrolled in this prospective, open, randomized study had vascular or pigmented lesions in the face, v‐neck or hands. The assigned test product was applied to the skin on the left side of the lesion whereas the other product was applied to the opposite side. Primary endpoints were the maximal pain intensity during laser treatment and the number of blisters and crusts after laser treatment. Results: Twenty‐one patients were enrolled and underwent laser procedures using a hydrogel pad and fluid gel (16 patients with vascular and five with pigmented lesions). Maximal local pain severity was lower in all 21 patients on the side where the transparent hydrogel pad was applied (p<0.001); the transparent hydrogel pad was associated with a more cooling effect (p<0.001) and less erythema (p = 0.027). The number of crusts was similar for both test products. Conclusion: Overall, laser therapy was more convenient for the patients on the side where the transparent hydrogel pad was applied. The transparent hydrogel pad offers an alternative skin cooling method worth considering for non‐ablative laser therapy.

Treatment of facial telangiectasias with a diode-pumped Nd:YAG laser at 532 nm

Facial telangiectasias are a common cause of cosmetic concern. Current treatment modalities present various effects and limits. The pulsed dye laser has been considered the golden standard in efficacy and safety. Unfortunately it causes postoperative intracutaneous hematomata that discourage many patients form undergoing this treatment. Several other vascular lasers are disadvantaged by the risk of hypopigmented and atrophic scars. We assessed a recent powerful version of the potassium titanyl phosphate 532 nm laser, that can deliver sufficient energy in single pulses lasting 10-50 msec. Collateral damage is reduced while the heating of the vessel is slow enough to avoid explosive photothermolysis with its associated purpura. Sixty-six patients with facial telangiectasias were treated. In 62/66 patients, we achieved a 75 percent-100 percent clearance of the lesions, while two treatments were needed to reach an acceptable clearance in the remaining 4/66 patients. The overall need for more sessions was well tolerated, because the acceptable postoperative appearance allowed patients to continue normal business and social activities between treatments. No permanent complications or undesired effects were noted. The KTP/532nm laser is also being tested in combined laser-sclerotherapy of fine leg capillary telangiectasias with encouraging results.