Gordon H. Sasaki

Fractional CO2 laser resurfacing of photoaged facial and non-facial skin: Histologic and clinical results and side effects

Abstract Background: CO2 fractional ablation offers the potential for facial and non-facial skin resurfacing with minimal downtime and rapid recovery. Objectives: The purpose of this study was (i) to document the average depths and density of adnexal structures in non-lasered facial and non-facial body skin; (ii) to determine injury in ex vivo human thigh skin with varying fractional laser modes; and (iii) to evaluate the clinical safety and efficacy of treatments. Methods: Histologies were obtained from non-lasered facial and non-facial skin from 121 patients and from 14 samples of excised lasered thigh skin. Seventy-one patients were evaluated after varying energy (mJ) and density settings by superficial ablation, deeper penetration, and combined treatment. Results: Skin thickness and adnexal density in non-lasered skin exhibited variable ranges: epidermis (47–105 μm); papillary dermis (61–105 μm); reticular dermis (983–1986 μm); hair follicles (2–14/ HPF); sebaceous glands (2–23/HPF); sweat glands (2–7/HPF). Histological studies of samples from human thigh skin demonstrated that increased fluencies in the superficial, deep and combined mode resulted in predictable deeper levels of ablations and thermal injury. An increase in density settings results in total ablation of the epidermis. Clinical improvement of rhytids and pigmentations in facial and non-facial skin was proportional to increasing energy and density settings. Patient assessments and clinical gradings by the Wilcoxons test of outcomes correlated with more aggressive settings. Conclusions: Prior knowledge of normal skin depths and adnexal densities, as well as ex vivo skin laser-injury profiles at varying fluencies and densities, improve the safety and efficiency of fractional CO2 for photorejuvenation of facial and non-facial skin.

The effectiveness and safety of topical PhotoActif phosphatidylcholine-based anti-cellulite gel and LED (red and near-infrared) light on Grade II-III thigh cellulite: a randomized, double-blinded study.

Background: Cellulite of the upper lateral and posterior thighs and lower buttocks represents a common, physiological and unwanted condition whose etiologies and effective management are subjects of continued debate. Objective: The purpose of this controlled, double‐blinded study is to evaluate the efficacy and safety of a novel phosphatidylcholine‐based, cosmeceutical anti‐cellulite gel combined with a light‐emitting diode (LED) array at the wavelengths of red (660 nm) and near‐infrared (950 nm), designed to counter the possible mechanisms that purportedly accentuate the presence of thigh cellulite. Methods: Nine healthy female volunteers with Grade II–III thigh cellulite were randomly treated twice daily with an active gel on one thigh and a placebo gel on the control thigh for 3 months. Twice weekly, each thigh was exposed for a 15‐minute treatment with LED light for a total of 24 treatments. At 0, 6, and 12 weeks of the study the following clinical determinants were obtained: standardized digital photography, height and weight measurements, standardized thigh circumference tape measurements, pinch testing, body mass index (kg/m2), body fat analysis (Futrex‐5500/XL near‐infrared analyzer), and digital high‐resolution ultrasound imaging of the dermal–adiposal border. In selected patients, full‐thickness biopsies of the placebo and active‐treated sites were obtained. At 18 months, repeat standardized digital photography, height and weight measurements, and body mass index measurements were obtained. Results: At the end of 3 months, eight of nine thighs treated with the phosphatidylcholine‐based, anti‐cellulite gel and LED treatments were downgraded to a lower cellulite grade by clinical examination, digital photography, and pinch test assessment. Digital ultrasound at the dermal‐adiposal interface demonstrated not only a statistically significant reduction of immediate hypodermal depth, but also less echo‐like intrusions into the dermal layer. Three of six biopsies from thighs treated for 3 months with the active gel and LED treatments demonstrated less intrusion of subcutaneous fat into the papillary and reticular dermis. In nine placebo and LED‐treated thighs and one of the actively treated thighs, minimal clinical changes were observed or measured by the clinical determinants throughout the 3‐month study. At the month‐18 evaluation period for the eight responsive thighs, five thighs reverted back to their original cellulite grading, while three thighs continued to maintain their improved status. Patients experienced minimal and transient side effects that included puritus, erythema and swelling. Conclusions: The results of this small but well‐documented, randomized, double‐blinded study affirms that eight of nine thighs with Grade II–III cellulite responded positively to a novel, combined 3‐month treatment program of a phosphatidylcholine‐based, anti‐cellulite gel and LED exposure, as determined by the clinical determinants obtained. Patients experienced minimal and transient side effects. At the month‐18 evaluation period (15 months after treatment), five responsive thighs reverted back to their original cellulite grading, indicating a need for maintenance treatment. Future studies are needed to verify these tentative positive observations.

Water-Assisted Liposuction for Body Contouring and Lipoharvesting: Safety and Efficacy in 41 Consecutive Patients

BACKGROUND Water-assisted liposuction (WAL) is a new technique for body contouring and fat harvesting that relies on a fan-shaped jet of tumescent solution to anesthetize fatty for liposuction and grafting. As with any new technology, safety and efficacy are paramount. OBJECTIVE The author evaluates the technique and outcomes for small-to-moderate volume liposuction cases treated with WAL in an office setting. METHODS Forty-one consecutive patients were treated with WAL (Body-Jet; Human Med, Eclipse Ltd., Dallas, Texas) in the authors private practice for mild-to-moderate body contouring. Patients were given local anesthesia (standardized tumescent solutions) during all three phases of the surgery. During the latter two phases, irrigation of tumescent solution was accompanied simultaneously by suction aspiration. Fat harvesting was accomplished by collecting and separating the aspirated adipose tissue in a sterile container, without need for washing or centrifugation. Fat grafting by microdroplet technique was performed within two hours of collection. Fat aliquots from five randomly-selected patients were assessed with a trypan blue dye exclusion test within one hour and again six to eight hours after collection. RESULTS A total of 37 females and four males underwent WAL in this series; average body mass index (BMI) was 25.5. Among the 41 patients, 166 areas involving twelve anatomic sites were treated. Patients were divided into two groups based on the volume of treatment: Group 1 contained 19 patients with small-volume WAL and Group 2 had 22 cases of moderate-volume WAL. All patients experienced uneventful recovery periods with minimal side effects and no significant complications. Although large volumes of tumescent solution were required during the three phases of the technique, the total volume of infiltration almost equaled the final volume of aspiration. The average infiltration-to-aspiration ratio was 1.1 to 1.0 in all cases over both groups. On the other hand, the average infiltration-to-fat ratio was 2.8 to 1.0 in Group l and 2.4 to 1.0 in Group 2. Lidocaine dosage averaged 10.5mg/kg in Group 1 and 20.0mg/kg in Group 2. Patients were monitored for at least 24 hours without adverse signs or symptoms that required fluid resuscitation, blood transfusions, or interventional treatments for lidocaine side effects or toxicity. Twenty-three patients elected to save their fat for autologous fat grafting in nine anatomical sites with thirty-nine procedures. The augmented sites were clinically assessed between three and eight months postoperatively. Trypan blue dye exclusion testing indicated that about 90% of adipocytes expelled the dye after one hour of extraction, while an estimated 10% of cells per patient were observed to be free of dye six to eight hours after removal. CONCLUSIONS The amount of instilled tumescent fluid, lidocaine dosage, and aspiration volumes appeared to be safe, with minimal blood loss in small and moderate volume liposuction cases. The early experience with fat grafting was encouraging, but requires more sophisticated evaluation, longer follow-up, and a larger number of cases.

Quantification of Human Abdominal Tissue Tightening and Contraction After Component Treatments With 1064-nm/1320-nm Laser-Assisted Lipolysis: Clinical Implications

Internal lipoplasty (iLAL) represents an evolving procedure that depends on delivery of sufficient and controlled thermal energy for lipolysis and collagen denaturation. Of the two outcomes, the particular advantage of iLAL may exist in its capability to selectively denature, remodel, and contract collagen and elastin fibers for eventual skin contraction. Despite the practice of sound laser principles and clinical outcomes, laser lipolysis has not been readily accepted because of its yet unproven advantages over other liposuction devices. This limited clinical research study on the lower abdomen of three female subjects provides objective data by Vectra 3D analysis (Canfield Scientific, Fairfield, New Jersey) of significant skin contraction (average, 9.1% at three months; average, 7.6% at six months) as a consequence of the application of sequential wavelengths of 8 W 1064 nm/8 W 1320 nm within the shallow but not the deep subdermal layers. The application of sustained and confluent thermal injury within the targeted 4 x 10-cm rectangular panel (zone 5) was continually monitored by an internal temperature-sensing cannula (45-47 degrees C) and by an external surface temperature-sensing infrared camera, recording surface skin temperatures to 40-42 degrees C threshold levels. Minimal skin contraction was measured at three months in panels that were treated by tumescence (1.1%, zone 1) and cannulation (1.5%, zone 2). Of interest, the slight increase in skin contraction in zones treated by volume reduction after liposuction (3.6%, zone 3) or deep lasing plus liposuction (3.6%, zone 4) may be due more to skin accommodation than active skin contraction. The second highest amount of skin contraction was observed in zone 6 (4.2%), which was treated by shallow lasing, liposuction, and deep lasing. Further quantitative clinical studies will be needed to validate these findings.

Comparison of results of wire subcision performed alone, with fills, and/or with adjacent surgical procedures.

BACKGROUND Because of the fixed attachments (or muscle-superficial musculoaponeurotic system [SMAS] insertions) to the undersurface of wrinkles, folds, and retracted scars, the use of fills alone has resulted in unpredictable and unsatisfactory improvements. OBJECTIVE To demonstrate that use of a wire dissector to completely release these attachments, accompanied by an immediate fill and/or an adjacent aesthetic surgical procedure, may optimize final results, improving deep wrinkles, folds, and scars. METHODS The subcision wire was positioned under various wrinkles, folds, and scars in a triangulated outline and then zigzagged to uniformly release any subdermal attachments. Patients were divided into 4 categories based on the treatment received: group 1, wire subcision only; group 2, wire subcision plus immediate fill with a strip of autogenous filler or xenograft material; group 3, wire subcision without fill but with an adjacent aesthetic surgical procedure; and group 4, wire subcision, fill, and an adjacent surgical procedure. Results were rated with a photographic wrinkle/fold assessment scale (mean +/- standard deviation) by 2 blinded evaluators after at least 6 months. Assessment was based on a quartile grading scale that indicated improvement (0= <25% improvement; 1=25-50% improvement; 2=51-75% improvement; and 3= >75% improvement). RESULTS Eighty-five patients experienced 338 wire subcisions at 8 facial, 1 posterior neck, and 4 thigh (cellulite) sites. The longest follow-up was 1.5 years (mean, 6.3 mos). The cumulative quartile grading scale was recorded as follows: group 1 (1+/-1.5 SD); group 2 (3.1+/-0.1 SD); group 3 (2.5 +/- 0.2 SD); and group 4 (3.6+/-0.2 SD). When fills were employed as spacers under the release tracts in group 2 and 4 sites, strips of SMAS, dermis, and microfat droplets were the favored fills in the areas of nasolabial and marionette folds because of the capacity of the grafts volume and tissue acceptance. For shallower depressions, such as the glabellar frown lines and crows feet, strips of deep temporal fascia or muscle were more effective. Complications after wire subcision with or without fill were few and transient. CONCLUSIONS The use of wire subcision for resistant wrinkles, folds, or scars can result in a satisfactory outcome with minimal complications when used as a solitary procedure. Results may be further optimized with the immediate addition of fill into the released tract. An adjacent aesthetic surgical procedure that impacts at the subcised site may provide additional benefit to the site, but not as much as observed with the usage of an immediate fill. Autogenous fills that are substantitive provide longer lasting effects because of volume and tissue acceptance.

An Objective Comparison of Holding, Slippage, and Pull-Out Tensions for Eight Suspension Sutures in the Malar Fat Pads of Fresh-Frozen Human Cadavers

BACKGROUND In recent years, a number of designed suspension sutures have been rapidly introduced into clinical practice. OBJECTIVE This study compares the holding tension, slippage tension, and pull-out tension for each of 8 suspension suture systems randomly positioned in the midface soft tissue in 4 fresh-frozen cadaver heads. METHODS For each suture suspension system, a suture was positioned and set within the soft tissue of the cheek adjacent to the nasolabial line and attached to a tensiometer. A reference point was marked on the skin at the point where the suture first engaged the tissue. Holding tension was defined as the ounces of tension required to obtain a 5-mm superolateral displacement of the reference point. Slippage tension was determined by pulling further until the suture experienced its first slippage. Pull-out tension was defined as the ounces of tension required to pull the entire suture from its exit site. Photomicrographs of the fixation sites on the extracted sutures were examined and compared to their preinsertion state. RESULTS Holding tension was statistically higher for the expanded polytetrafluoroethylene (ePTFE) knotted looped suture (W.L. Gore & Associates, Flagstaff, AZ) than for other systems. Slippage tension was greatest for the ePTFE suture; among other sutures, the tension profiles for the Silhouette (Kolster Methods, Inc., Corona, CA) and Woffles suture technique were higher than the others. In 3 of 5 cases, the ePTFE sutures demonstrated the highest pull-out tension, followed by the Silhouette and Woffles sutures. About 50% of barbs or cogs of polypropylene and polydioxanone sutures demonstrated bending, curling, or stripping away from the suture body after extraction. No morphologic flaws were found for suture knots, free-standing cones, or anchor pulleys. CONCLUSIONS The various suture suspension systems currently available have differing efficacy and safety profiles. The results of this cadaver study clarify our understanding of the safety, benefits, and limitations of these systems. The higher ounces of tension for the ePTFE and Woffles sutures were to be expected, because these systems employ double suture strands that grasp a wider area than single-suture systems. Limitations of the study include the small number of samples, possible departures from clinical technique, and the inherent differences of the elastic and suture-holding properties between fresh-frozen cadaveric versus living tissue.

Clinical Parameters for Predicting Efficacy and Safety With Nonablative Monopolar Radiofrequency Treatments to the Forehead, Face, and Neck

BACKGROUND Patient selection is key to obtaining a successful outcome after nonablative monopolar radiofrequency (NMRF) treatments to the forehead, face, and neck. OBJECTIVE The purpose of this study was to discover at baseline from patient demographics, skin and fat characteristics, measurable degrees of tissue mobility and photoaging, any predictors of a positive result under a standardized treatment algorithm. METHODS Twenty-five patients (22 females, 3 males; average age 52.3 years) were selected randomly for NMRF treatments (2 nonoverlapping passes, additional passes for vectored contraction and contouring) between 350 and 450 firings with 1.5-cm tips to the forehead, periorbitum, face, and upper neck. Patients were evaluated at baseline and monitored for outcomes beyond 1 year by a number of quantitative assessments. RESULTS At baseline and 3, 6, and l2 months, measurements of skin thickness, subcutaneous fat depth, tissue mobility, and wrinkle and fold depth were obtained at 9 different reference sites on each patient. Nineteen patients (76%) who progressively responded to NMRF energy over 12 months were observed at baseline to have a global mobility score (mean +/- SD) of 3.4 +/- 0.27 mm; 6 patients who were assessed to be nonresponders over l year of evaluation began with more tissue laxity and exhibited at baseline a larger global mobility score (mean +/- SD) of 4.4 +/- 0.60 mm. Other factors that were more likely to be associated with a positive response to NMRF treatment included minimal degrees of photoaging and shallower wrinkle/fold development. The variables of skin thickness and fat depth did not play significant roles in predicting positive responses to treatment. Side effects and complications were minimal throughout the study. CONCLUSIONS This study represents one of the first investigations that attempts to identify systematically objective baseline parameters that are more likely to be associated with positive responses to NMRF treatments to the forehead, face, and neck. Longer follow-up of our patients and further studies will be required to verify our preliminary findings.

Micro-Needling Depth Penetration, Presence of Pigment Particles, and Fluorescein-Stained Platelets: Clinical Usage for Aesthetic Concerns

Background Aesthetic micro-needling (MN) has demonstrated skin permeability to cosmeceutical ingredients and platelet-rich plasma by creating reversible micro-channels in the skin. Objectives The purposes of this study were to determine: (1) actual needle depth-penetrations by adjusting needle lengths in a disposable tip of an electric MN device; (2) time-dependent passage of pigment and platelets; and (3) safety and efficacy profiles in patients. Methods Excised micro-needled pre-auricular skin was used to determine actual depths of tissue penetration with six needle lengths, and the presence of massaged pigment particles (histological examination) and fluorescein-labeled platelets (confocal laser microscopy) in 1 mm depth micro-channels over an hour. Patients were treated for wrinkles and skin laxity, scars, and alopecia with cosmeceuticals and plasma-rich platelets. Results Actual needle penetrations closely matched settings up to 1.0 mm, but were less consistent at settings from 1.5 to 2.5 mm. The optimal time for massaging pigment particles and labeled platelet-rich plasma (PRP) down 1.0 mm micro-channels was between 5 to 30 minutes after MN. Patients treated in the Skin Care Center (cosmeceuticals, 0.25-1 mm depth) and Surgical Center (PRP, 0.25-2.5 mm) demonstrated statistically significant improvements (P ⩽ .05) in wrinkle effacement, skin laxity, scar softening, and hair growth by Patient and Observer Satisfaction Scores at 12 months. The average hair count in a 10 mm spot size at baseline (88.3 ± 22.5) increased at the 12 month evaluation period (133.6 ± 13.8). All patients experienced minimal side-effects. Conclusions MN alone or in combination therapy resulted in safe and effective treatments from implemented guidelines. Level of Evidence 3 Therapeutic

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.

In Vivo Use of Human Fibrin Glue Under the Subperiosteal and Subcutaneous Planes in Holtzman Rats

BACKGROUND Commercial fibrin sealant has been increasingly used off-label in the United States for aesthetic surgical procedures to minimize postoperative drainage, hematoma and seroma collections, ecchymosis, and edema. OBJECTIVE We sought to determine the optimal concentrations of thrombin and fibrinogen to extend the sealant adhesion time and to maintain the maximal glue strength, respectively, in subperiosteal and subcutaneous planes in Holtzman rats. METHODS Three preparations of 2-component fibrin sealant from the Hemaseel APR kit (Haemacure Corp., Sarasota, FL) were formulated: standard fibrin sealant (fibrinogen 75-115 mg/mL, thrombin 500 IU/mL), half fibrinogen concentration (fibrinogen 37.5-57.5 mg/mL, thrombin 500 IU/mL), and 1/100 thrombin concentration (fibrinogen 75-115 mg/mL, thrombin 5 IU/mL). In 6 rats, paired standardized subperiosteal scalp pockets and subcutaneous abdominal pockets were elevated, leaving a retained septum between each pair. In experiment 1, 1 of the 3 fibrin sealant preparations was instilled into 1 side of each paired subperiosteal and subcutaneous pockets in 2 of the 6 rats, leaving the adjacent pocket as a control flap. Changes in force of flap displacement and in setup time for adherence within the treated and matched control flaps were measured at intervals over an hour. In experiment 2, the duration and strength of adherence in flaps treated only with the standard fibrin sealant preparation and their paired control flaps in 34 rats were measured weekly over 6 weeks. One of the 34 rats was sacrificed each week to examine the histologic changes at the tissue-glue interface. RESULTS In flaps treated with the half-concentration of fibrinogen, the grams of force needed to displace the scalp flaps by 5 mm and the abdominal flaps by 10 mm were significantly reduced compared with values obtained in similar flaps treated with the standard fibrin preparation over 1 hour of interval measurements (P < 0.05). In flaps treated with the 1/100 concentration of thrombin, the setup times before flap adherence were significantly extended to about 1 minute compared with the 15-second setup times observed in flaps treated with the standard fibrin preparation (P < 0.05). The use of the standard fibrin preparation in 34 rats resulted in up to 6 weeks of tissue adherence in the subperiosteal scalp flaps and up to 2 weeks of tissue adherence in the subcutaneous abdominal flaps over the paired control flaps, as measured weekly on the basis of force of flap displacement. Histologic examination demonstrated that glue material was absent at about 5 to 6 weeks in the subperiosteal space and 2 to 3 weeks in the subcutaneous space. CONCLUSIONS Any decrease in fibrinogen concentration from that found in the standard fibrin sealant results in suboptimal strength of adherence of flaps. The standard thrombin concentration (500 IU/mL) results in a rapid onset of adherence within 15 seconds that may prevent the surgeon from massaging the glue evenly throughout the pocket and may produce a premature seal on opposing surfaces, leading to a seroma cavity. A reduced thrombin concentration (5 IU/mL), on the other hand, extends the onset time to a minute before adherence occurs, optimizing the sealing of the surgical cavity. (Aesthetic Surg J 2003;23:458-463).