E. Victor Ross

Laser Treatment of Traumatic Scars With an Emphasis on Ablative Fractional Laser Resurfacing: Consensus Report

IMPORTANCE Despite expert wound care and assiduous management with traditional therapy, poor cosmetic outcomes, restricted motion, and symptoms such as pain and itch are a pervasive problem of disfiguring and debilitating scars. The advent of ablative fractional photothermolysis within the past decade and its application to the treatment of traumatic scars represents a breakthrough in the restoration of function and cosmetic appearance for injured patients, but the procedure is not widely used. OBJECTIVE To provide a synthesis of our current clinical experience and available literature regarding the laser treatment of traumatic scars with an emphasis on fractional resurfacing. EVIDENCE REVIEW Eight independent, self-selected academic and military dermatology and plastic surgery physicians with extensive experience in the use of lasers for scar treatment assembled for a 2-day ad hoc meeting on January 19 and 20, 2012. Consensus was based largely on expert opinion, but relevant literature was cited where it exists. FINDINGS After consensus was appraised, we drafted the manuscript in sections during the course of several months. The draft was then circulated among all panel members for final review and comment. Our consensus is that laser treatment, particularly ablative fractional resurfacing, deserves a prominent role in future scar treatment paradigms, with the possible inclusion of early intervention for contracture avoidance and assistance with wound healing. CONCLUSIONS AND RELEVANCE Laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars. Changes to existing scar treatment paradigms should include extensive integration of fractional resurfacing and other combination therapies guided by future research.

Blood flow dynamics after laser therapy of port wine stain birthmarks

During laser therapy of port wine stain (PWS) birthmarks, regions of perfusion may persist. We hypothesize that such regions are not readily observable even when laser surgery is performed by highly experienced clinicians. The objective of this study was to use objective feedback to assess the acute vascular response to laser therapy.

Treatment of acne scars using the plasma skin regeneration (PSR) system

Acne scarring is a common and difficult to treat condition. The plasma skin regeneration (PSR) system is a novel device that causes delayed ablation of the epidermis and controlled thermal modification to the underlying dermis. PSR has previously been shown to be a safe and effective treatment for facial rhytides and benign skin lesions. In this study, we investigated the safety and efficacy of single‐treatment, high‐energy, double‐pass PSR for the treatment of acne scarring.

Characterization of an optimized light source and comparison to pulsed dye laser for superficial and deep vessel clearance

An arc lamp‐based device providing optimized spectrum and pulse shape was characterized and compared with two pulsed dye laser (PDL) systems using a vascular phantom. Safety and effectiveness for facial telangiectasia are presented in clinical case studies.

En coup de sabre presenting as a port-wine stain previously treated with pulsed dye laser.

We report the case of a patient with en coup de sabre (ECDS) who was given an initial diagnosis of acquired port-wine stain (PWS) and treated with pulsed dye laser (PDL). Treatment yielded unanticipated blistering despite the use of conservative settings. This case illustrates that the early stages of linear scleroderma can present with intense erythema and can be mistaken for a vascular malformation. Additionally, we believe that an exaggerated response to PDL treatment should be a clinical clue to treating the early hyperemic response of localized scleroderma and not a true vascular malformation.

Laser-Tissue Interactions

The best gauge of laser interactions is the tissue response, and experiment is the most realistic manner to address medical treatment challenges. However, theoretical models are helpful in planning treatment approaches and laser parameters. In this chapter we discuss basics of lasers, their non laser counterparts, and laser-tissue interactions.

A split face study to document the safety and efficacy of clearance of melasma with a 5 ns q switched Nd YAG laser versus a 50 ns q switched Nd YAG laser

To determine the safety and efficacy of a 50 ns Q switched Nd YAG laser vs. a 5 ns Q switched Nd YAG laser for clearance of melasma. To compare subject satisfaction, efficacy, and comfort level between the two lasers.

Topical steroids implicated in postoperative infection following ablative laser resurfacing

Carbon dioxide (CO2) lasers are associated with complications that include postoperative erythema and hyperpigmentation. More rarely, hypopigmentation, scarring, and infections are observed [1]. Generally, CO2 resurfacing complication rates increase with increasing lesion depth. Likewise, deeper burn wounds increase the risk of hypertrophic scarring with prolonged inflammation, delayed reepithelialization, and bacterial colonization [2]. We report two cases of CO2 laser resurfacing complicated by postoperative infections. Our first patient presented for resurfacing of facial rhytids (Fig. 1). She was prepped with an antimicrobial wash (70% isopropyl alcohol) and the procedure was performed under clean conditions. Pain control was achieved via nerve blocks, intramuscular sedation, and 5% lidocaine cream (Numb and Number, Los Angeles, CA) (prepared under sterile conditions according to the manufacturer). An external cooling device (Zimmer Chiller, LaserMed, Monroe, CT) was applied just adjacent to the laser impact site for additional pain control. Prophylaxis with oral dicloxacillin 250mg QID and acyclovir 400mg QID was started on the day prior to the procedure. The patient was treated with a CO2 laser (Ultrapulse Encore, Lumenis, Santa Clara, CA) with one pass at 100% coverage (1.3mm microspot size, 100mJ, density settings ranging 5–7). The patient returned the following day with no evidence of infection; moreover, edema was milder than expected. On postoperative day 4, she reported a rapid increase in pain and was prescribed hydrocodone/acetaminophen 5/500 over the phone by the covering on-call physician. She returned to the clinic on postoperative day 6 with yellow–green malodorous crusts over the cheeks (Fig. 2). Although she was afebrile, she complained of pain and malaise. Cultures for fungi, bacteria, and herpes simplex virus (HSV) were obtained. Dicloxacillin was discontinued and she was started on oral doxycycline 100mg BID and ciprofloxacin 750mg BID for empiric methicillin-resistant Staphylococcus aureus and pseudomonal coverage, respectively. She also received one dose of diflucan 150mg for empiric fungal coverage. On postoperative day 7, she showed minimal improvement. Accordingly, she was started on intravenous vancomycin 1.5 g daily for 3 days as per infectious disease (ID) recommendations. After her first dose of vancomycin, the patient showed decreased edema and the crust was about 80% improved. She returned to the clinic daily for wound debridement until postoperative day 9, when her pain was replaced by mild pruritus. That day she received 1 g of intramuscular ceftriaxoneasper IDrecommendations. The skin culture grew out Klebsiella which was resistant to ampicillin, but sensitive to levofloxacin, and S. aureus which was pansensitive excluding penicillin. Fungal and HSV cultures were negative. After resolution of the infection, she was treated with a 13 day course of topical corticosteroids (fluocinonide 0.05% ointment) beginning on postoperative day 10 to reduce the risk of scarring. On postoperative day 11, all antibioticswere discontinued. The patient was completely repithelialized by day 16 without any skin textural changes. The patient’s cosmetic outcome was excellent 1 month later (Fig. 3) and continues to show no adverse effects 6 months postoperatively. Our second patient was treated that same week in a similar manner with a CO2 laser (Ultrapulse Encore) for facial resurfacing at 80% coverage. The patient was on dicloxacillin 250mg QID and acyclovir 400mg QID for empiric prophylaxis. She returned 5 days after the procedure with severe facial pain and reticulated crusts over the forehead and lateral cheeks. Dicloxacillin was discontinued and she was started on ciprofloxacin 750mg BID. The patient quickly improved and all antimicrobials were discontinued on postoperative day 8. She was started on desonide 0.05% ointment to prevent any postinfection scarring. This patient was also culture positive for S. aureus (resistant only to penicillin). HSV and fungal cultures were negative. Approximately 72 ablative resurfacing procedures are performed at our institution per year. Of these cases, only these two patients developed postoperative bacterial

Nonablative laser rejuvenation in men.

ABSTRACT:  As our culture increasingly emphasizes youth and virility in the workplace, men have become interested in enhancing their appearance. Once confined to a small number of “progressive” urban patients, the ever‐enlarging buffet of minimally invasive procedures has broadened the appeal for laser rejuvenation. Although most procedures are gender neutral, there are sex‐specific characteristics that should be considered in designing logical laser strategies for men. In this review, the major categories of rejuvenation are examined in a modality‐ and application‐specific manner. When possible, settings are discussed for particular devices. The reader should be aware, however, that “go‐by” recipes, although enticing for the novice, should only be applied within the context of identifiable tissue endpoints and with properly functioning equipment. The best settings are those that achieve desired results for a specific device, and ultimately, experience is the best guide for optimal parameter selection.

Pulsed dye laser treatment of pigmented lesions: a randomized clinical pilot study comparison of 607‐ and 595‐nm wavelength lasers

The 595‐nm pulsed dye laser has been used for the treatment of benign epidermal pigmented lesions (EPLs), but there is a risk of inducing undesirable purpura with treatment.