Richard E. Fitzpatrick

Cutaneous laser resurfacing

UNLABELLED Cutaneous resurfacing with the new generation of carbon dioxide and erbium lasers has recently come into favor for the treatment of facial rhytides, photodamage, and scarring. The precise control of these resurfacing lasers over the extent of tissue vaporization minimizes thermal damage to the skin while maximizing therapeutic efficacy. Proper use of resurfacing lasers is contingent upon a complete understanding of their clinical, histologic, and ultrastructural effects, as well as an appreciation of the principles of laser safety. An organized approach to the preoperative, intraoperative, and postoperative management of the patient undergoing laser resurfacing will be provided, including a discussion of prevention and treatment of postoperative side effects and complications. (J Am Acad Dermatol 1999;41:365-89.) LEARNING OBJECTIVE At the conclusion of this learning activity, participants should be familiar with the clinical, histologic, and ultrastructural effects of resurfacing lasers and be able to discuss the preoperative, intraoperative, and postoperative management of patients undergoing laser resurfacing.

Laser treatment of erythematous/hypertrophic and pigmented scars in 26 patients.

Fifteen patients with erythematous/hypertrophic scars and 11 patients with postinflammatory hyperpigmentation were treated with a flashlamp pumped pulsed-dye laser at 585 nm or a flashlamp pulsed-dye laser at 510 nm. An average of 1.8 treatments resulted in an average improvement of 77 percent. Forty-seven percent of the patients had 100 percent improvement after one to three treatments. Eleven patients with postinflammatory hyperpigmentation were treated with the flashlamp pumped pulsed-dye laser at 510 nm with a pulse width of 300 ns. There was an average of 80 percent improvement with 1.45 treatments. Forty-five percent of the patients had 100 percent improvement after one or two treatments. The pathophysiology of postoperative scarring is reviewed. Theoretical reasons for the efficacy of laser treatment are detailed.

Laser Treatment of Scars

BACKGROUND Erythematous and hypertrophic scars may occur after surgical procedures. This paper describes a novel technique for their resolution. OBJECTIVE The purpose of this paper is to describe long‐term results of treating erythematous, hypertrophic scars with the flashlamp‐pumped pulsed dye laser (FLPDL). METHODS Forty‐eight patients who presented with erythematous/hypertrophic scars were treated with the FLPDL with or without intralesional triamcinolone. Patients were evaluated by physicians on a 25% increment of objective improvement. RESULTS Seventy‐three percent of scars appearing on the face for less than 1 year totally resolved in an average of 2.3 treatments. Twenty percent of scars on the face for greater than 1 year had a total resolution in 4.4 treatments with an average improvement of 88%. Scars on nonfacial areas for less than 1 year had a 25% incidence of total resolution over an average of 2.5 treatments with an average improvement of 81%. Scars in nonfadal distributions over 1 year of age had a 12% total resolution with an average 62% improvement over 2.2 treatments. CONCLUSION The FLPDL is a useful adjuvant in the treatment of erythematous, hypertrophic scars.

Complications of fractional CO2 laser resurfacing: Four cases

Fractional ablative laser therapy is a new modality which will likely be widely used due to its efficacy and limited side‐effect profile. It is critical to recognize, characterize, and report complications in order to acknowledge the limits of therapeutic efficacy and to improve the safety of these devices.

Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin.

BACKGROUND Laser resurfacing has been used for treatment of photoaged facial skin since late 1993. Very few long-term follow-up studies regarding the effectiveness and side effects of this procedure have been reported. METHOD Patients who received carbon dioxide laser resurfacing for facial photoaging and wrinkling from Dec 17, 1993, to Nov 30, 1996, were followed up with clinical evaluation and patient questionnaires. Histologic study was also performed in 10 representative patients who had had preoperative biopsies. All treatments were performed by 2 experienced laser surgeons (R. E. F. and M. P. G.). RESULTS One hundred four patients were examined and interviewed with an average 24-month postoperative follow-up (range 12 to 44 months). We observed high patient satisfaction ratings and significant persistence of wrinkle score improvement. Long-term histologic features confirmed the long-lasting nature of the clinical improvement and demonstrated continuing, progressive improvement in solar clastosis deep in the dermis for an average follow-up period of 2 years. Prolonged use of topical tretinoin (retinoic acid) postoperatively may contribute to continued improvement. The incidence of long-term side effects, including pigmentary changes and scarring, was generally very low and these side effects were usually not noticed by the patients. CONCLUSION Improvement from cutaneous laser resurfacing has persisted for an average 24-month postoperative period with a low incidence of side effects. Hypopigmentation is the most common long-term side effect and appears to be related to the degree of pre-existing photodamage as it contrasts with the newly healed undamaged skin.

Treatment of port-wine stains (capillary malformation) with the flashlamp-pumped pulsed dye laser

Forty-three children with 49 separate port-wine stain vascular malformations were treated with the flashlamp-pumped pulsed dye laser at 585 nm. The patients ranged in age from 2 weeks to 14 years. Overall, 16% of patients had more than 95% resolution of their port-wine stains after an average of 4.8 (1 to 11) treatments. There was an average improvement of 69% in those lesions not clearing completely (average of 3.7 treatments). Lesions in patients less than 4 years of age were almost twice as likely to clear than were those in older children (20% vs 12%), and in fewer treatments (3.8 vs 6.5). An approximate 50% clearing was obtained with one treatment. Subsequent treatments resulted in an additional 10% clearing. There were no episodes of scarring or persistent pigmentary changes in any of the patients. Lesions on the hand and arm responded less well than lesions on the face, neck, and torso. The flashlamp-pumped pulsed dye laser has proved to be a safe and effective treatment modality for port-wine stain capillary malformations in infants and children.

Collagen tightening induced by carbon dioxide laser versus erbium :YAG laser

Pulsed CO2 laser resurfacing improves photodamage and acne scarring by ablation of abnormal tissue with subsequent regeneration and remodeling of collagen and through heat induced collagen contraction. Whether collagen contraction persists long‐term and helps maintain the skin tightening observed after resurfacing is debated. One possible mechanism of long‐term clinical tightening is that of wound contracture that occurs as part of normal wound healing. If normal wound contracture, and not heat induced collagen contraction, is responsible for maintaining the initial skin tightening seen in CO2 laser resurfacing, then equal results would be expected from resurfacing with either CO2 or erbium lasers. The study was performed to determine whether there is a difference in skin tightening secondary to thermally mediated collagen contraction versus that which occurs secondary to tissue contraction of wound healing. The persistence of these changes over 6 months and the histologic characteristics were studied as well.

Reversal of photodamage with topical growth factors: a pilot study

BACKGROUND: Interest in the reversal of facial photodamage has increased significantly among patients and physicians in the past decade. Though surgical procedures may be very effective, the associated healing time and potential risks have spurred the development of non‐surgical treatments. There has also been an increasing depth of knowledge regarding wound healing and its control by growth factors as well as its modulation by the topical application of growth factors. Bioengineered tissue cultures have resulted in the ability to collect naturally occurring human growth factors in their tissue concentrations. OBJECTIVE: The objective of this study is to determine if the twice daily application of a combination of multiple growth factors to photodamaged facial skin results in any evidence of improvement after 60 days. METHODS: Fourteen patients applied a gel containing a mixture of eight different growth factors (Nouricel‐MD) to photodamaged facial skin twice daily. Prior to the study and at 60 days there were clinical evaluations of photodamage (Fitzpatrick scale), 3 mm punch biopsies and optical profilometry. Patient questionnaires were answered at 60 days. RESULTS: Eleven of 14 patients showed clinical improvement in at least one facial area. The peri‐orbital region showed a statistically significant improvement (p=0.0003). Optical profilometry showed a statistically significant reduction in Ra measurement (p=0.0075) and shadowing (p=0.02), both indicating a decrease in the depth and number of textural irregularities or fine lines. Biopsies revealed new collagen formation in the Grenz zone (37% increase in thickness) and thickening of the epidermis by 27%. Eight of 14 patients felt their wrinkles were improved, while 12 of 14 felt their skin texture was improved. CONCLUSIONS: The application of a mixture of topical growth factors may stimulate the repair of facial photodamage resulting in new collagen formation, epidermal thickening and the clinical appearance of smoother skin with less visible wrinkling.

Prophylactic antibiotics in patients undergoing laser resurfacing of the skin

BACKGROUND Carbon dioxide (CO2) laser resurfacing produces a superficial second-degree burn that needs to be protected from bacterial and fungal infections. OBJECTIVE We investigated the effects of various systemic and topical antimicrobial regimens. METHODS Four different regimens using oral ciprofloxacin, topical antibiotics (intranasal mupirocin ointment and otic solution), oral ketoconazole, and oral fluconazole were tested in four time periods. The frequency and types of the infections with various regimens was compared. RESULTS The study included 356 sequential patients who underwent facial CO2 laser resurfacing. Infections occurred in 27 patients (7.6%). Without antibiotic prophylaxis, 8.2% of patients had bacterial infections from days 3 to 12 after the procedure (average, day 5). With prophylactic ciprofloxacin only, 4.3% of patients had bacterial infections; these occurred almost exclusively after ciprofloxacin was discontinued. For 7 months, patients were randomly assigned to either receive or not receive mupirocin intranasally. All Staphylococcus aureus infections that occurred were seen in patients who had used intranasal mupirocin. Yeast infections were seen in 6 patients (1.7%), but mostly occurred more than 10 days after the procedure. Yeast infections were of approximately equal occurrence in the ciprofloxacin group (2.2%) and in the non-ciprofloxacin group (1.8%). No yeast infections occurred in patients who had undergone antifungal prophylaxis. CONCLUSION Post-CO2 resurfacing infections are not rare but can appear subtly and might only be noticeable in the second postoperative week. Prophylactic intranasal mupirocin is ineffective, but ciprofloxacin is effective in preventing infection with both gram-positive and gram-negative bacteria. Oral ketoconazole and fluconazole are effective in preventing yeast infections.

Consensus Recommendations on the Use of an Erbium‐Doped 1,550‐nm Fractionated Laser and Its Applications in Dermatologic Laser Surgery

BACKGROUND Nonablative fractional photothermolysis has revolutionized the way we treat a number of common skin conditions with laser technology. OBJECTIVE A comprehensive guide is needed for clinicians using this technology to treat specific skin conditions in various skin types. MATERIALS AND METHODS Recommendations were made from a recent round table discussion among experienced physicians and a review of recent literature findings. RESULTS Optimal laser parameters are dependent on patient skin type and condition. We recommended guidelines for the successful treatment of several common skin conditions on and off the face using nonablative fractional photothermolysis. Specific conditions were dyschromia, rhytides, acne scars, surgical scars, melasma, and striae distensae. CONCLUSIONS We developed reproducible guidelines to most effectively treat a variety of skin types and conditions using nonablative fractional photothermolysis. Future large, multicenter trials are indicated for further optimization of treatment parameters. Reliant Technologies paid travel expenses and honorariums to all authors.