Joel M. Noe

Port wine stains and the response to argon laser therapy: successful treatment and the predictive role of color, age, and biopsy.

To date, no criteria exist for anticipating the response of a port wine stain to argon laser therapy. In an effort to determine such predictive factors, the preceding study was undertaken. Sixty-two patients, ages 7 to 66 years, with port wine stains were biopsied, had a small test area treated, and were evaluated after 4 months. A desirable result, defined by marked lightening of the lesion without scarring, occurred in 73 percent of the patients. Factors favoring a desirable result included age greater than 37 years, purple color, fraction of dermis occupied by vessels greater than 5 percent, mean vessel area greater than 2500 micrometers2, and percent of vessels containing erythrocytes greater than 15 percent. Furthermore, the degree of color change strongly correlated with these indices. Factors indicating an undesirable result included age less than 17 years, pink color, vascular area less than 2 percent, mean vessel area less than 1500 micrometers2, and percent of vessels containing erythrocytes less than 3 percent, Thus, if appropriate clinical and histological criteria are met port wine stains can successfully treated with argon laser therapy.

Chilling Port Wine Stains Improves the Response to Argon Laser Therapy

Twenty-three patients with facial port wine stains were studied to determine whether chilling lesional skin at the time of treatment could improve the outcome of argon laser therapy and whether this effect could be attributed to increased hemoglobin content of chilled sites, as hypothesized on clinical grounds. Each patient was biopsied in two representative and clinically identical sites, once at room temperature and once immediately after application of ice to the skin surface for 2 to 3 minutes. Two additional identical sites were treated with an argon laser in the same manner. Histologic sections of the port wine stain after application of ice tended to have a higher percentage of erythrocyte-filled vessels, but the effect of chilling on the dermal vasculature varied greatly among patients and was not statistically significant. In contrast, chilling of lesional skin prior to laser therapy resulted in a significantly better average outcome (p = 0.0002), with 57 percent of chilled sites superior to the paired room temperature control and none inferior. In nearly all instances of differential response, the site treated at room temperature manifested scarring, while the chilled site did not. Overall, after an average evaluation period of 4.8 months, 65 percent of the patients achieved a good or excellent result in the control site, and 87 percent achieved this result in the chilled site. These data establish the potential benefit of lesional modification prior to argon laser therapy and suggest that in the case of port wine stain chilling, this benefit is due to reduced heat injury of nonvascular elements in the skin.

Minimizing the pain of local anesthesia.

We studied the effect of depth of lidocaine injection into the skin, rate of injection, and temperature of the solution on pain experienced. The intervals of onset and duration of anesthesia were also evaluated. Intracutaneous instillation of lidocaine at body temperature (37 degrees C) is no less painful than injection at room temperature (21 degrees C), but superficial wheal-producing dermal injection is uniformly much more painful than that into the deep dermal-subcutaneous tissue region. Rapid injection almost always hurts more than slow. Full anesthesia to pinprick is produced immediately with superficial injection and is present 5 to 6 minutes after deep injection. We suggest that the best method for minimizing the discomfort of inducing local anesthesia is to use a syringe fitted with a No. 30 needle and to inject the smallest amount necessary slowly into the deep dermal-subcutaneous tissue as the needle is being slowly withdrawn.

Laser therapy: Basic concepts and nomenclature

Laser therapy has been demonstrated to be effective in treating many types of cutaneous vascular and pigmented lesions. Clinical and investigative studies on lasers are being published with increasing frequency, but is difficult to interpret and compare results because of lack of use of appropriate nomenclature regarding laser energy. We suggest that scientific communication in this expanding field will be improved if all future studies state: (1) irradiance (laser flux density) at the irradiated surface in watts/cm2, (2) laser beam cross-sectional area and shape at the irradiated surface, (3) laser pulse duration or exposure time in seconds, (4) pulse repetition rate (pulsed lasers) in pulses per second, (5) treatment time segments and intervals between treatment times, (6) total treated skin area in cm2, (7) total number of applied laser pulses or exposures, and (8) the type of laser used and its spectral distribution.

Capillary Hemangioma (Strawberry Mark) of Infancy: Comparison of Argon and Nd

Capillary hemangioma of infancy (strawberry mark) is a self-limiting problem, and conservative treatment is recommended. These birthmarks can be associated with a great deal of morbidity. There is definitely a role for a palliative form of treatment without systemic complications or destruction of adjacent tissue. In a 6-year period, 55 patients received 57 Nd:YAG or argon laser treatments. Thirty patients received 31 argon treatments, and 25 patients received 26 Nd:YAG treatments; and 2 received first argon with subsequent Nd:YAG treatments. Although more dramatic successes were noted in the Nd:YAG laser, complications were more frequent and severe. Complications included delayed healing, postoperative bleeding, and some hypertrophic scarring. Complications were seen in 12 percent of all patients, 9 percent of these associated with the Nd:YAG laser.

Perineal Hernias After Proctectomy A New Approach to Repair

Perineal herniation of pelvic organs rarely occurs after abdominoperineal resection of the rectum, but it does present a difficult surgical dilemma. The case of a patient with perineal herniation of the small bowel and urinary bladder into a proctectomy wound has been described. This was repaired using a transabdominal pelvic sling with Marlex followed by gracilis muscle transplantation. Review of the literature yielded 18 previous case reports of perineal hernia after proctectomy, and the results of various surgical approaches have been detailed and discussed. The technique of gracilis muscle transplantation offers a definite advantage when the hernia occurs in a contaminated perineal wound.

Nasal bone hemangiomas: a review of clinical, radiologic, and operative experience.

A case of hemangioma of the nasal bones is reported. Clinical and radiologic findings, including CT scan, are presented and the literature reviewed. Although rare, the lesion often has a characteristic clinical and radiologic presentation that can be recognized preoperatively. CT scanning is helpful in defining tumor characteristics and extent. Surgery appears curative in most cases without significant disfigurement. For smaller lesions, bone graft of the defect appears unnecessary and the presence of intact periosteum may actually contribute to regeneration of normal bone.

Acral Lentiginous Melanoma

Acral lentiginous melanoma occurs on the hands and feet, with a particular predilection for the fingers, toes, subungual areas, and heels. It is characterized by a lateral growth phase followed by a vertical growth phase. Despite the small number of reported cases it would appear that, as in other melanomas, prognosis is inversely related to depth of invasion at the time of diagnosis. The need for several biopsies or for total excision to make a definitive diagnosis of suspicious pigmented lesions of the hands or feet is noted both in a review of the literature and in the case presented.

Unexpected vascular response to epinephrine in port wine stains.

Success of argon laser therapy as a therapeutic modality for port wine stains has been correlated with the degree of vascular congestion within the lesions. Epinephrine causes vasoconstriction and erythrocyte stasis within normally innervated vessels. We tested the hypothesis that subcutaneous injection of epinephrine would cause vasoconstriction, altered hemodynamics, and increased red cell mass in port wine stains and thus allow more directed and less nonspecific damage and a better cosmetic result. Two clinically similar and adjacent areas within port wine stains were biopsied from 10 patients following subcutaneous injection of either Xylocaine or Xylocaine with epinephrine. Erythrocytes within vessels of the superficial cutaneous vascular plexus were increased in areas pretreated with Xylocaine plus epinephrine (55.3 versus 45.9 percent; p less than 0.09). This increase was seen in 9 of 10 patients studied (p less than 0.05). Epinephrine appears to increase erythrocytes within ectatic vessels of port wine stains and thus would likely improve laser energy absorption and cosmetic results.

Where should the knot be placed

When suturing a wound the surgeon should consider where to locate the knot. Suture placement and removal, patient comfort, wound healing, and cosmetic result can be facilitated by proper knot placement