Elizabeth K. Hale

Successful treatment of acneiform scarring with CO2 ablative fractional resurfacing

Acneiform scarring after severe episodes of acne is a common cosmetic concern, treatable by a variety of modalities with varying degrees of success. Ablative CO2 laser resurfacing, while effective, is associated with an undesirable side effects profile, lengthy recovery period, and risk of infection as well as potential pigmentary alterations. Newer modalities using the principles of fractional photothermolysis (FP) create patterns of tiny microscopic wounds surrounded by undamaged tissue beneath the skin with an erbium‐doped 1,550 nm laser. These devices produce more modest results in many cases than traditional carbon dioxide (CO2) lasers but with fewer side effects and shorter recovery periods. A novel ablative 30 W CO2 laser device uses a technique called ablative fractional resurfacing (AFR), combines CO2 ablation with a FP system.

Successful and Rapid Treatment of Blue and Green Tattoo Pigment With a Novel Picosecond Laser

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.

Outcomes of Childhood Hemangiomas Treated with the Pulsed-Dye Laser with Dynamic Cooling: A Retrospective Chart Analysis

BACKGROUND Laser treatment of childhood hemangiomas remains controversial. Previous studies have used outdated technology, resulting in a potential overrepresentation of adverse outcomes. OBJECTIVE To evaluate outcomes of hemangiomas treated with the most current laser technology. METHODS A retrospective chart analysis of 90 patients with a median age of 3.0 months and a total of 105 hemangiomas were enrolled over a 2.5‐year period. All were treated with the 595‐nm long‐pulse pulsed‐dye laser (LP‐PDL) with dynamic epidermal cooling at 2‐ to 8‐week intervals depending on the stage of growth. Exclusion criteria were previous laser, surgical, or corticosteroid treatment. Three reviewers assessed outcomes. RESULTS Near‐complete or complete clearance in color were achieved for 85 (81%) and in thickness for 67 (64%) hemangiomas. There was no scarring or atrophy. Ulceration occurred in one case and resolved during treatment. Hyperpigmentation and hypopigmentation occurred in 4% and 14% of hemangiomas, respectively. CONCLUSION Early treatment of childhood hemangiomas with the 595‐nm LP‐PDL with dynamic cooling may reduce the proliferative phase and result in excellent rates of clearing and few adverse events. Dr. Geronemus serves on the Advisory Board for Candela Corporation.

Successful Treatment of Atrophic Postoperative and Traumatic Scarring With Carbon Dioxide Ablative Fractional Resurfacing Quantitative Volumetric Scar Improvement

OBJECTIVE To assess the safety and efficacy of ablative fractional resurfacing (AFR) for nonacne atrophic scarring. DESIGN In this before-and-after trial, each scar received 3 AFR treatments and 6 months of follow-up. SETTING Private academic practice. PATIENTS Fifteen women with Fitzpatrick skin types I to IV, aged 21 to 66 years, presented with 22 nonacne atrophic scars between June 1 and November 30, 2007. Three patients (3 scars) were excluded from the study after receiving 1 AFR treatment and not returning for follow-up visits. The remaining 12 patients (19 scars) completed all 3 treatments and 6 months of follow-up. INTERVENTIONS Each scar received 3 AFR treatments at 1- to 4-month intervals. MAIN OUTCOME MEASURES Erythema, edema, petechiae, scarring, crusting, and dyschromia were graded after treatment and through 6 months of follow-up. Skin texture, pigmentation, atrophy, and overall appearance were evaluated after treatment and through 6 months of follow-up by the patient and a nonblinded investigator. A 3-dimensional optical profiling system generated high-resolution topographic representations of atrophic scars for objective measurement of changes in scar volume and depth. RESULTS Adverse effects of treatment were mild to moderate, and no scarring or delayed-onset hypopigmentation was observed. At the 6-month follow-up visit, patient and investigator scores demonstrated improvements in skin texture for all scars (patient range, 1-4 [mean, 2.79]; investigator range, 2-4 [mean, 2.95]), pigmentation for all scars (patient range, 1-4 [mean, 2.32]; investigator range, 1-4 [mean, 2.21]), atrophy for all scars (patient range, 1-4 [mean, 2.26]; investigator range, 2-4 [mean, 2.95]), and overall scar appearance for all scars (patient range, 2-4 [mean, 2.89]; investigator range, 2-4 [mean, 3.05]). Image analysis revealed a 38.0% mean reduction of volume and 35.6% mean reduction of maximum scar depth. CONCLUSION The AFR treatments represent a safe, effective treatment modality for improving atrophic scarring due to surgery or trauma.

Ablative and Fractional Ablative Lasers

The field of nonsurgical laser resurfacing for aesthetic enhancement continues to improve with new research and technological advances. Since its beginnings in the 1980s, the laser-resurfacing industry has produced a multitude of devices employing ablative, nonablative, and fractional ablative technologies. The three approaches largely differ in their method of thermal damage, weighing degrees of efficacy, downtime, and side effect profiles against each other. Nonablative technologies generate some interest, although only for those patient populations seeking mild improvements. Fractional technologies, however, have gained dramatic ground on fully ablative resurfacing. Fractional laser resurfacing, while exhibiting results that fall just short of the ideal outcomes of fully ablative treatments, is an increasingly attractive alternative because of its far more favorable side effect profile, reduced recovery time, and significant clinical outcome.

Improvement in Arm and Post-Partum Abdominal and Flank Subcutaneous Fat Deposits and Skin Laxity Using a Bipolar Radiofrequency, Infrared, Vacuum and Mechanical Massage Device

Skin laxity of the body is a growing cosmetic concern. Laxity can result from chronological or photoaging and changes in body dimensions during pregnancy or weight loss. The end result is loose, sagging skin, and localized fat deposits. Liposuction and abdominoplasty or brachioplasty are established approaches to these issues. Patient desire for alternatives to surgical correction has spawned the development of non‐invasive body contouring devices. The combination of infrared light (IR), bipolar radiofrequency (RF), vacuum and mechanical massage (Velashape, Syneron Medical Ltd, Israel) has demonstrated efficacy in improving skin appearance and circumference of the thighs [Goldberg et al., Derm Surg 2008; 34:204–209; Fisher et al., Derm Surg 2005; 31:1237–1241; Arnoczky and Aksan, J Am Acad Orthop Surg 2000; 8:305–313; Alster and Tanzi, J Cosmetic Laser Therapy 2005; 7:81–85; Wanitphakdeedecha and Manuskiatti, J Cosmet Dermatol 2006; 5:284–288; Nootheti et al., Lasers Surg Med 2006; 38: 908–912], but only anecdotal evidence has supported its use on other anatomic locations. This study was designed to evaluate the efficacy and safety of Velashape on additional body sites and more rigorously examine the technologys impact on upper arm as well as abdominal and flank circumference.

Procedural dermatology training during dermatology residency: A survey of third-year dermatology residents

BACKGROUND Given the expanding role of multiple surgical procedures in dermatology, resident training in procedural dermatology must be continually assessed to keep pace with changes in the specialty. OBJECTIVE We sought to assess the third-year resident experience in procedural dermatology during residency training. METHODS This survey study was mailed to third-year dermatology residents at 107 Accreditation Council for Graduate Medical Education (ACGME)-approved dermatology residency programs in 2009. RESULTS A total of 240 residents responded (66%), representing 89% of programs surveyed. Residents assume the role of primary surgeon most commonly in excisional surgery (95%) and flap and graft reconstruction (49%) and least often in Mohs micrographic surgery (18%). In laser and cosmetic procedures, the resident role varies greatly. Residents believed they were most prepared in excisional surgery, botulinum toxin, and laser surgery. Residents believed it was sufficient to have only knowledge of less commonly performed procedures such as hair transplantation, tumescent liposuction, and ambulatory phlebectomy. Of responding residents, 55% were very satisfied with their procedural dermatology training during residency. LIMITATIONS Individual responses from residents may be biased. Neither residency program nor dermatologic surgery directors were surveyed. CONCLUSION This survey confirms dermatology residents received broad training in procedural dermatology in 2009, in keeping with ACGME/Residency Review Committee program guidelines. The results provide feedback to dermatology residency programs and are an invaluable tool for assessing, modifying, and strengthening the current procedural dermatology curriculum.

Adverse Events Associated With Mohs Micrographic Surgery Multicenter Prospective Cohort Study of 20 821 Cases at 23 Centers

IMPORTANCE Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Eyelid Tightening and Improved Eyelid Aperture through Nonablative Fractional Resurfacing

BACKGROUND AND OBJECTIVE The effects of fractional resurfacing on eyelid tightening and aperture are unknown. Our purpose was to retrospectively examine the potential for eyelid tightening and eye-aperture opening in patients treated with nonablative fractional resurfacing for facial photorejuvenation. STUDY DESIGN/MATERIALS AND METHODS Fractional laser treatments using a 1,550-nm erbium-doped fiber laser system on the upper and lower eyelids were given at a pulse energy of 17 to 20 mJ at 125 micro-thermal zones (MTZ)/cm2 to a final density of 500 to 750 MTZ/cm2. Each patient had 3 to 7 treatments. Standard pre- and post-treatment photographs were taken at each visit. Physicians who graded 31 preselected patient photographs using a 4-point scale evaluated eyelid tightening. Increase in eyelid aperture was also evaluated. RESULTS All patients had some degree of eyelid tightening; 19% achieved 1% to 25% tightening, 26% achieved 25% to 50%, 26% achieved 50% to 75%, and 29% achieved 75% to 100%. Increase in eyelid aperture was seen in 55.9% of patients. Postoperative wounding, hypopigmentation, hyperpigmentation, persistent erythema, and scarring were not observed. All patients experienced mild or no edema for a few days after treatment. CONCLUSION Fractional resurfacing tightens and increases eyelid aperture without wounding, downtime, or long-term complications.

Port Wine Stain Progression: A Potential Consequence of Delayed and Inadequate Treatment?

Port wine stains are congenital low‐flow vascular malformations of the skin. Unlike hemangiomas, PWS do not involute with time, but rather if left untreated can hypertrophy and develop nodularity. Laser therapy of PWS particularly with pulsed‐dye lasers, is a safe, well‐established treatment that is successful in the majority of patients, especially for younger patients. Patients that fail to receive treatment early in life may subsequent develop lesions more likely to progress.