Richard M. Dwyer

Control of connective tissue metabolism by lasers: Recent developments and future prospects

Various laser modalities are currently in extensive use in dermatology and plastic surgery, particularly for treatment of vascular and pigmented lesions. A relatively new area of laser utilization involves the possible biologic effects of the lasers. In this overview, we are summarizing our recent studies, which indicate that lasers at specific wavelengths and energy densities modulate the connective tissue metabolism by skin fibroblasts both in vitro and in vivo. Specifically, the neodymium-yttrium-aluminum-garnet (Nd: YAG) laser was shown to selectively suppress collagen production both in fibroblast cultures and in normal skin in vivo, thus suggesting that this laser modality may be useful for the treatment of fibrotic conditions such as keloids and hypertrophic scars. Furthermore, two low-energy lasers, helium-neon (He-Ne) and gallium-arsenide (Ga-As), were shown to stimulate collagen production in human skin fibroblast cultures, suggesting that these lasers could be used for enhancement of wound healing processes. These experimental approaches illustrate the future possibilities for applying lasers for the modulation of various biologic functions of cells in tissues and attest to the potential role of lasers in the treatment of cutaneous disorders.

Biostimulation of Wound Healing in Vivo by a Helium-neon Laser

Clinical observations have suggested that low-energy lasers might stimulate wound healing. To understand the mechanism of the biostimulation, we previously examined the effects of low-energy lasers on collagen production by human skin fibroblasts and reported an increase of collagen synthesis in vitro. To examine the effects of low-energy lasers in vivo, hairless mice were experimentally wounded, sutured, and subjected to laser irradiation by a helium-neon laser with a power output of 1.56 mW and an energy fluence of 1.22 Joules/cm2. Experimental wounds were subjected to laser treatment every other day for 2 months; control wounds remained untreated. Specimens from the wounds were then examined for histological findings, tensile strength, and total collagen content. Results demonstrated a considerable improvement in the tensile strength of the laser-irradiated wounds at 1 and 2 weeks. Furthermore, the total collagen content was significantly increased at 2 months when compared with control wounds. These results suggest a beneficial effect of the helium-neon laser on wound healing in vivo.

Effects of the Nd:YAG laser on DNA synthesis and collagen production in human skin fibroblast cultures

Human skin fibroblasts were subjected to treatment with a Neodymium:YAG laser at 1060 nm with varying levels of energy determined by a reproducible method of dosimetry. DNA synthesis in the cells was measured by the incorporation of [3H]thymidine, and collagen production was monitored by the synthesis of nondialyzable [3H]hydmxyprohne after incubation of cells with [3H]proline. Using energy levels equal to 1.7 × 103 l/cm2, a significant reduction in DNA synthesis was noted, while the cells remained viable as tested by the trypan blue exclusion lest. With energy levels higher or equal to 2.3 × 10 l/cm2, the suppression of DNA synthesis was accompanied by cell nonviability. The collagen production, when measured immediately following the treatment with 1.7 × 103 l/cm2, was markedly reduced, and similar effects were observed with higher energy levels. However, when the cells were tested for collagen production at 20 hours following laser treatment, there was a significant decrease in collagen production at energy levels as low as 1.1 × 103 l/cm2, a dose that did not affect DNA synthesis or cell viability. Thus, the results indicate that the Nd:YAG laser can selectively suppress collagen production without affecting cell proliferation. These observations suggest that laser treatment could potentially be used to reduce collagen deposition in conditions such as keloids and hyperlrophic scars.

Skin closure by Nd: YAG laser welding

Skin incisions 6 mm in length were made on the backs of hairless mice. Control wounds were closed with interrupted 5-0 Prolene sutures, and experimental wounds were approximated and closed by laser welding using a Nd:YAG laser. The wounds were examined daily, and specimens were excised at weekly intervals for histopathologic study, transmission electron microscopy, tensile strength determination, and type I collagen-specific messenger ribonucleic acid measurements. The laser-welded wounds demonstrated rapid healing. Histologic study showed a functional scar tissue at day 7 and a minimal residue of the original wound at day 14. Tensile strength of the control and experimental wounds was similar at all time points. The levels of collagen-specific messenger ribonucleic acid were significantly higher in the sutured group in comparison with the laser group or with normal control skin. This study suggests that laser welding might have advantages over suturing, since the former is sterile and nontactile, does not require introduction of foreign material into the wound, and provides subjectively improved cosmetic results.

Wound healing: biological effects of Nd:YAG laser on collagen metabolism in pig skin in comparison to thermal burn

Pig skin was treated with the Nd:YAG laser at 1,060 nm or electrocautery, at energy densities of 649 ± 20 J/cm2 and 612 J/cm2, respectively. Biopsies of treated areas and of normal skin were performed at 7, 14, and 60 days after treatment and processed for histology, electron microscopy and biochemical assays. Wound healing, as shown histologically, was similar in both treated groups. Depth of injury appeared to reach reticular dermis at day 7 in each treated group. However, thermal burn was more destructive of regular collagen, whereas the laser appeared to damage deep dermal blood vessels without destroying surrounding connective tissue. Biochemical assays revealed increased collagen production and increased collagenolytic activity 7 days after laser injury. However, by day 60, there was a reduction in total collagen content in laser treated skin below that of normal skin, which correlated with decreased collagen synthesis and unchanged collagenolytic activity. In burn specimens there was an initial decrease in total collagen content which reverted to normal by day 60. Active collagen degradation occurred at all 3 time points, but a marked increase in synthetic activity occurred as the burn scar was laid down. Laser treatment resulted in reduction of the amount of collagen below that in burn scarred or normal skin, suggesting that classical scar formation may be inhibited. These results indicate that the Nd:YAG laser may be useful for the treatment of keloids and hypertrophic scars.

Laser welding: An alternative method of venous repair

This study compared the histology, biochemistry, tensile strength, and extensibility of Nd:YAG laser-welded and sutured venotomies. Two-centimeter-length bilateral canine femoral or jugular venotomies were evaluated with one vessel (control) closed with interrupted 6-0 polypropylene sutures, and the contralateral vessel (experimental) welded with the Nd:YAG laser (1 W power and 30- to 40-sec exposure). Specimens were removed and examined immediately after fashioning (t0) and at 1, 4, or 5 weeks post-operatively to compare the progression of healing. Histologic examination of the 4- and 5-week sutured wounds had granulomatous reaction around the sutures with areas of excessive collagen accumulation. In contrast, the laser-welded wounds had minimal inflammatory response, near normal collagen content, and minimal residual disorientation and break in the elastic fiber continuity. The rate of collagen synthesis in laser-welded wounds was approximately twice that of sutured wounds at 1, 4, and 5 weeks, and correlated with increased tensile strengths of lasered wounds. The extensibility of the 5-week specimens was 0.19 for sutured and 0.29 for laser-welded wounds as compared to 0.29 for normal vein. These preliminary data suggest that laser welding of venotomies may have several advantages over conventional suture techniques.

Preliminary report: a new technique of enterotomy closure using Nd:YAG laser welding compared to suture repair

This study compared the histology and tensile strength of Nd:YAG laser welded and sutured small bowel enterotomies in Sprague-Dawley rats. Enterotomies (0.5 cm long) were either welded with the Nd:YAG laser (1 W and 10.6 sec pulses) or repaired with interrupted, simple 6-O silk sutures. Group I consisted of seven animals; five with enterotomies repaired by laser welding and two repaired by suturing. Group II consisted of eight animals with each having both laser and suture repairs. Animals were killed and specimens were removed and examined at 1 day, and at 1, 2, and 3 weeks postoperatively to compare the progression of healing. On macroscopic examination the laser welded enterotomies were closed 84% of the time and only 23% had adhesion formation while 90% of sutured repairs were closed and 100% had adhesion formation. Histologic examination of both suture and laser welded enterotomies demonstrated active healing at 1 week with minimal collagen bridging the enterotomies. At 2 and 3 weeks the sutured enterotomies had granulomatous reaction around the sutures while the laser welded enterotomies had minimal inflammatory response and near normal small bowel histology. The tensile strength of the 3-week specimens from both the suture and laser welded enterotomies were 50% of normal bowel. These findings suggest that the laser welding of small bowel enterotomies is comparable in closure and tensile strength to suture repair. The time required to repair the enterotomy is significantly decreased, the procedure is easily performed, and there is a marked decrease in adhesion formation following laser repair.

A new method of dosimetry-a study of comparative laser-induced tissue damage.

The use of lasers in medicine and surgery has increased slowly—its effectiveness based on trial-and-error clinical experience. Very little comprehensive data has been published that scientifically presents dosage, energy, absorption, and comparisons between types of lasers. Our laboratory has developed a method for taking the guesswork out of laser dosage using scientific data to optimize therapy and give reproducible responses. Experiments were conducted using an argon laser, a neodymium:YAG laser, and a broad-band infrared light source. This preliminary study uses a beam scan technique, which for the first time permits accurate measurement of the laser intensity incident on tissue. Therefore, this protocol allows the standardization of dosage measurements with good experimental reproducibility in biological models. By using this accurate method of measuring the intensity delivered to pigskin, we are able to reproduce for the first time similar histological damage with the different energy sources.

Clinical Applications in Gastrointestinal Bleeding

As recently as 1981, fewer than 12 medical centers in the United States were using lasers in the treatment of gastrointestinal (GI) disease. By 1984, 200 hospitals were using lasers for this purpose,1 and by the end of 1986,2 there were approximately 1,000. The reasons for such proliferation include increased applications of the use of lasers in GI problems, the relative ease with which they can be used, and the recent ruling by the Food and Drug Administration that the Nd:YAG laser is safe and effective and is therefore no longer considered to be an investigational device. Furthermore, lasers provide a multidisciplinary and multispecialty modality as well as therapeutic options where such choices did not exist or were limited previously.3 More importantly, they have been found to be safe, efficient, and cost-effective in most cases.

Vascular Welding Using The Argon Laser

This study compared the histology, biochemistry, and tensile strength of laser welded and sutured canine venotomies, arteriotomies and arteriovenous fistulas. Bilateral femoral, carotid or jugular vessels were studied with one repair (control) closed with interrupted 6-0 polypropylene sutures, and the contralatral repair (experimental) welded with the argon laser. Specimens were examined at weekly intervals from 1 to 4 weeks for each type of repair and evaluated histologically by hematoxylineosin, elastin and trichrome stains, biochemically by the formation of [3H] hyaroxyproline as an index of collagen synthesis, ana mechanically by tensile strength determinations. At removal, all experimental closures were patent without hematomas, aneurysms or luminal dilatation. Histologic and biochemical examination and tensile strength determinations suggest that laser welaing may be an alternative to sutures for repair of large diameter venotomies, arteriotomies and arteriovenous fistulas, as they heal comparable to suture repairs up to 4 weeks postoperatively.