Keith Ash

Treatment of stretch marks with the 585-nm flashlamp-pumped pulsed dye laser

BACKGROUND Striae, or stretch marks, are very common skin disorders that do not impair bodily function, but are of considerable cosmetic concern to many patients. Traditionally, treatment options have been very limited. This study examines the results of treating striae using the 585‐nm pulsed dye laser. Stimulation of a variety of wound healing processes has been attributed to low energy laser therapy. Clinically, improvement of hypertrophic and erythematous scars with the 585‐nm pulsed dye laser at energy densities of 6–7 J/cm2 is well established. Since striae are dermal scars, evaluation of this same therapy to treat striae was undertaken. OBJECTIVE To evaluate the effectiveness of the 585‐nm flashlamp‐pumped pulse dye laser in treating cutaneous striae. METHODS Thirty‐nine striae were treated with four treatment protocols. These treated striae were compared with untreated striae controls in the same patient. The patients ages ranged from 23 to 52 years, with an average age of 36 years. The average age of the treated striae prior to initial treatment was 14 years (range, 8 months to 32 years). Treatment parameters included spot sizes of 7 and 10 mm and fluences of 2.0, 2.5, 3.0, and 4.0 J/cm2. Response to therapy was evaluated through clinical grading, sequential photography, and optical profilometry at a blinded laboratory. Skin biopsies were also examined with light microscopy from two of the 39 striae that were treated. RESULTS Subjectively, striae appeared to return toward the appearance of normal skin with all protocols. However, the protocol with 10‐mm spot size using 3.0 J/cm2 fluence improved the appearance of striae better than the other treatment protocols. Objectively, shadow profilometry revealed that all treatment protocols reduced skin shadowing in striae. This result corresponds with surface patterns of striae returning to that closely resembling adjacent normal skin surface patterns. Histologically, using hematoxylin and eosin stains as well as elastin strains, striae treated with a low fluence pulsed dye laser treatment protocol regained normal appearing elastin content when compared with normal (non‐striae) skin adjacent to the treated striae. CONCLUSION Treatment with the 585‐nm pulsed dye laser at low energy densities was shown to improve the appearance of striae. Apparent increased dermal elastin was also observed 8 weeks posttherapy and possibly contributed to the improvement seen in the study patients.

Comparison of Topical Therapy for Striae Alba (20% Glycolic Acid/0.05% Tretinoin Versus 20% Glycolic Acid/ 10% L-Ascorbic Acid)

background. Topical treatment of striae rubra with 0.1% tretinoin and laser treatment of striae rubra and alba with the 585‐nnt pulsed dye laser are proven therapeutic options. However, little efficacy has been shown for treatment of striae alba topically, and the laser is currently not a suitable treatment option for darker ethnic skin types. objective. The purpose of this study was to demonstrate that selected commercial topical agents can improve the appearance of striae alba. methods. Ten patients of varying skin types (I‐V) having striae distensae alba on the abdomen or thighs were selected to evaluate the effectiveness of two topical treatment regimens. Patients were placed on daily topical application of 20% glycolic acid (MD Forte) to the entire treatment area. In addition, the patients applied 10% L‐ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine to half to the treatment area and 0.05% tretinoin emollient cream (Renova) to the other half of the treatment area. The creams were applied on a daily basis for 12 weeks. Improvement was evaluated at 4 and 12 weeks in an objective unblinded fashion at the follow‐up visits, a objective blinded fashion by visual grading at the conclusion of the study, and in an objective blinded fashion with profilometry. Additionally, histopathologic analysis was performed. results. Analysis of these data reveals: 1) both regimens can improve the appearance of stretch marks; 2) these topical therapy regimens are safe and effective in study patients with minimal irritation; 3) elastin content within the reticular and papillary dermis can increase with topical 20% glycolic acid combined with 0.05% tretinoin emollient cream therapy; 4) both regimens increased epidermal thickness and decreased papillary dermal thickness in treated stretch marks when compared with untreated stretch marks; 5) combined epidermal and papillary dermal thickness in stretch marks treated with either topical regimen approaches that of normal skin; and 6) profilometry can objectively measure differences in skin texture associated with striae treatments when compared to controls, however, it is not sensitive enough to justify comparison or quantitative improvements between similarly effective treatments.

Variable pulse erbium:YAG Laser skin resurfacing of perioral rhytides and side-by-side comparison with carbon dioxide Laser

Laser resurfacing of facial rhytides has become a popular treatment option for many patients with wrinkles, photoaging, and acne scarring. Laser wavelength/pulse duration options and new techniques continue to shorten the healing phase associated with laser skin resurfacing while maintaining clinical efficacy. Variable pulse erbium:YAG (Er:YAG) laser systems are now available that offer the surgeon the ability to vary the Er:YAG pulse duration from a pulse that is primarily ablative to one that is more thermal. The objective of this study was to evaluate the histologic effects created with a variable pulse Er:YAG laser. To study prospectively the clinical effects on upper lip rhytides with a variable pulse Er:YAG laser when compared side by side with pulsed carbon dioxide (CO2) laser resurfacing.

The erbium: YAG laser: a review and preliminary report on resurfacing of the face, neck, and hands.

The use of short-pulsed or flash-scanned CO(2) lasers to resurface skin has rapidly joined chemical peels and dermabrasion as an accepted procedure. The purpose of this study was to evaluate a mid-infrared pulsed Erbium: YAG laser prospectively to determine its clinical efficacy for resurfacing of the face, neck, and hands. Postoperative changes and recovery period were also evaluated. A total of 21 patients were evaluated on a prospective basis with Er: YAG laser resurfacing (12 crows feet, five upper lips, three hands, and one neck). Additional nonstudy clinical experience is also reported. Posttreatment crusting or scabbing lasted an average of 2.7 days, pain an average of 3 days, erythema an average of 5.2 days, and swelling an average of 3 days. Blinded subjective grading was performed 2 months postoperatively. This grading revealed a 52% combined improvement from all areas. The appearance of crows feet was improved by 58%; upper lip, 43%; dorsal hand, 48%; and neck, 44%. Overall the Er: YAG laser consistently produced reduction in rhytids and improvement in the appearance of sun-damaged skin. The times for reepithelialization and duration of erythema were strikingly shorter than those typically observed with current CO(2) laser resurfacing. This report details the study, reviews Er: YAG laser technology, and compares our findings with those observed with standard CO(2) laser resurfacing.

The gracilis free flap revisited: A review of 25 cases of transfer to traumatic extremity wounds

Trauma to the extremities often results in a complex bony and soft-tissue injury requiring free flap reconstruction. Muscles from various body sites have been used in extremity reconstruction since the early 1970s. The gracilis muscle is usually not considered the first choice for free flap reconstruction of these defects. It is usually relegated to small defects or used to reanimate the face. Our purpose is to present our experience with the gracilis muscle as a first-choice flap in reconstruction of traumatic extremity defects. A retrospective review of all gracilis muscle free flap transfers for traumatic extremity wounds between 1988 and 1995 at the Naval Medical Center Portsmouth was performed. Twenty-five patients age 20 to 71 years (mean, 29.7 years) underwent 26 free flaps to the lower leg, ankle, foot, or forearm to cover traumatic wounds. Defects ranged in size from 3 x 3 cm (9 cm2) to 13 x 18 cm (234 cm2), with a mean of 75.5 cm2. There were no flap losses and all wounds healed. Nine patients experienced 11 complications, which consisted of minor wound separation (16%), wound infection (12%), partial or complete loss of split-thickness skin graft (8%), thrombosis of graft with successful revascularization (4%), and nonunion of an underlying fracture (4%). Our overall success rate for gracilis free flap reconstruction of traumatic wounds is 100%. The gracilis free muscle flap has become our first option for tissue coverage in traumatized extremities. It leaves minimal functional defect limited to the side of the primary injury and provides a good cosmetic result. It can cover large defects when the epimysium is cut, and allows an epidural block to be performed for sympathectomy effect and pain control in the affected extremity during the immediate postoperative period.

Accelerated Laser Resurfacing Wound Healing Using a Triad of Topical Antioxidants

background. The speed of wound healing and the duration of erythema are the primary complaints after laser skin resurfacing. Antioxidants have been shown to enhance the healing of wounds by reducing free radical damage. Reepithelialization is also enhanced by the moist environment produced by occlusive dressings. objective. This study was conducted to compare two occlusive agents: white petrolatum and “melting” petrolatum. Another arm of the study evaluated the use of melting petrolatum with and without a triad of topical antioxidants (TTA). results. Plain white petrolatum proved superior to melting petrolatum in time required for reepithelialization as well as in discomfort. Crusting and pain were decreased with white petrolatum but duration of erythema was equivalent. Wound healing was enhanced when TTA was added. Time for reepithelialization, duration of crusting and scabbing, pain, redness, and swelling were decreased when TTA was added to topical therapy. conclusion. TTA compound enhances and hastens wound healing. White petrolatum as a base occlusive vehicle shortens reepithelialization compared with “melting” petrolatum.

Hair removal using a long-pulsed alexandrite laser.

The use of lasers for hair depilation has become a common modality for physicians in the recent past. As new lasers are developed, the complex mechanisms affecting this form of treatment are now under close investigation. The long-pulsed alexandrite laser functioning at a wavelength of 755 nm has recently been added to the armamentarium of health care providers to assist patients with unwanted body hair. A review of the embryology and anatomy of the hair follicle are discussed, as well as the findings of recent studies using this form of laser therapy. Using the suggested treatment protocols offered laser assisted depilation may be effectively achieved. The degree and duration of reduction vary with anatomic site and improve with multiple treatments.

Breast reduction under intravenous sedation: a review of 50 cases.

&NA; Breast reduction is a surgical procedure most commonly performed on an inpatient basis under general anesthesia. In the current climate of health care reform, we must evaluate such procedures to determine if there are alternate, less expensive, but equally safe means to perform them. Our purpose is to present our experience with 50 bilateral breast reductions performed under local anesthesia with intravenous sedation between October of 1991 and October of 1994. We have excluded bilateral reductions under 500 gm total, unilateral reductions, mastopexies, and gynecomastia procedures. Patients were sedated with intravenous Versed and fentanyl and a local solution consisting of marcaine, lidocaine, and 1:200,000 epinephrine. Intercostal blocks were not used routinely. Monitoring and sedation were performed by nonanesthesia personnel in 49 patients. There were no complications relating to the sedation or to the local solution. All reductions were performed by the inferior pedicle technique. The average patient age was 28.0 years (20 to 67 years). The average total breast tissue resected was 1372 gm (510 to 2948 gm), with 33 patients having resections greater than 1000 gm. Operative times averaged 3 hours (115 to 275 minutes). Forty‐nine of the 50 patients tolerated the procedure with little to no recall. Twenty‐eight patients were discharged on the same day as admission. One patient recalled some significant discomfort dining parts of the procedure. All staled that they would again have the procedure performed under local anesthesia with intravenous sedation. Our conclusions are as follows: (1) Breast reduction can be performed safely and comfortably under local anesthesia with intravenous sedation. (2) Patients should be chosen on their acceptability as intravenous sedation candidates and not with regard to the amount of breast tissue removed. (3) There will he a subset of patients who can be discharged on the same day. (Plast. Reconstr. Surg. 97: 952, 1996.)

Precautions in warming light therapy as an adjuvant to postoperative flap care

Warming lights, circulating-water blankets, space heaters, and the Bair Hugger are used by surgeons in the perioperative period to maintain a patients core body temperature. Warming lights in particular are often used by plastic surgeons to augment the postoperative vasodilatation of reconstructive flaps by increasing the ambient temperature of the area around the flap. A review of the literature fails to elucidate even anecdotal experience regarding the actual intensity of thermal energy directly imparted to tissues from these modalities with respect to distance. The purpose of our study was to quantify actual tissue temperatures generated, as a function of distance, with the Emerson warming light. Our interest in this is a result of a full-thickness burn which occurred to a portion of a pedicled TRAM flap used for breast reconstruction when a warming light was inadvertently positioned, during the course of the first postoperative night, at a distance less than that recommended by the manufacturer. A biological model was created simulating a sympathectomized flap and the temperature curves generated by Emerson warming lights were recorded by calibrated glass bulb thermometers at 15 min intervals for distances of 32 and 71 cm using both focused and defocused light beams. The distance of 32 cm was used as a parameter as it was the distance noted between the patient and the warming light when the TRAM flap burn occurred. Temperatures obtained at a distance of 32 cm rose to 120 degrees F (48.8 degrees C) within 30 min for the focused beam and 118 degrees F (48 degrees C) after 1 h for the defocused beam. This exceeds the temperature at which tissue necrosis is known to occur (111.2 degrees F/44 degrees C). However, temperatures obtained at 71 cm for the focused and defocused beams plateaued at 93.2 and 96.8 degrees F (34 and 36 degrees C) respectively, which is well within physiologic limits and below the temperature resulting in tissue necrosis. Our conclusion is that warming lights can be successfully used as a safe adjuvant in order to optimize flap vasodilatation without compromising the thermal threshold of tissue damage if maintained at the manufacturers minimum recommended distance of 71 cm. If this source of thermal energy is used, however, strict precautions and nursing guidelines must be instituted to maintain this minimum distance parameter and prevent patient morbidity.