The nature and evolution of port wine stains: a computer-assisted study.

In an attempt to understand the histogenesis and evolution of port wine stains (PWS), 100 patients with PWS were biopsied; the gross features of each lesion and the patient's associated clinical characteristics were recorded. A detailed analysis of each biopsy including both vessel and nonvessel parameters was made with the assistance of a computer. The central abnormalities characterizing port wine stains are an increase in vessel number (vascular profiles) and ectasia. Vessel number is highest in the immediate subepidermal area and then rapidly diminishes; mean vessel depth is .46 +/- .17 mm. In contrast mean vessel area shows less variation throughout the dermis, ectatic vessels being present when vessel number is very low. The product of both factors determines the percent of dermis occupied by vessels, but the mean vessel area is the major determinant. While age correlates poorly with vessel number, it correlates well with both progressive vessel ectasia and color shifts (pink to purple). Each of multiple vessel parameters analyzed (vessel number, mean vessel area, wall thickness, angulation, and luminal erythrocyte content) exhibited strong layer to layer correlation within the first .8 mm of tissue beneath the epidermis, indicating homogeneity of vessel characteristics within the lesion. The size of the lesion and facial quadrant distribution do not change with age nor are they related to any histological parameters. However the PWS lesion is found most often on the right side and lower quadrants, with a distinctive pattern being present in patients with glaucoma and mental retardation.

Low-fluence CO2 laser irradiation: selective epidermal damage to human skin.

The interaction of normal human skin with low-fluence CO2 laser irradiation was studied using a three-phase approach. In phase one, freshly excised skin was observed immediately after impact. In phase two, skin irradiated 2 h prior to excision was studied. In phase three, human volunteers were irradiated and biopsied at time zero, 24 h and 48 h. Seventy-five sites were exposed and 60 biopsies were performed. The earliest histologic changes were observed in the 6-10 J/cm2 fluence (radiant exposure) range and these changes included spindle and vacuolar changes in the basal layer of the epidermis. Papillary dermal coagulation was present to a maximum of 0.03 mm. At fluences of 10-25 J/cm2, superficial dermal necrosis (0.06-0.08 mm) was observed. At fluences above 25 J/cm2, transepidermal necrosis was present with increasing papillary dermal necrosis that was in proportion to the energy density delivered. At 2h, basal vacuolar changes were accompanied by diffuse keratinocytic cell death where contact was maintained between the epidermis and dermis, while where separation occurred limited keratinocytic death was observed. The earliest changes occurred at lower threshold fluences (4-6 J/cm2). After 24 h, these doses resulted in extensive epidermal necrosis with focal acute inflammatory infiltrates. At 48 h, the degree of epidermal "slough" was proportional to the energy density delivered and was maximal with a fluence of 5.7 J/cm2 delivered whereas with a fluence of 3.8 J/cm2 thin slough (0.02 mm) was observed. These findings suggest that low-dose CO2 laser irradiation may provide a new approach to selectively damage the epidermis with minimal dermal damage.

In vivo spectrophotometric evaluation of normal, lesional, and laser-treated skin in patients with port-wine stains.

The influence of patient age and argon laser therapy on port-wine stains (PWS) was studied quantitatively in 16 patients aged 15-64 years using a spectrophotometer and computer graphics/statistics program. Normalized reflectance curves revealed a 10-20% decrease with age in the reflectance of normal skin from 400 nm to 650 nm, with an even more pronounced reflectance decrease in the region of peak deoxyhemoglobin absorption at approximately 555 nm. In each patient, PWS reflectance was less than that in the normal skin, as expected, and the average discrepancy increased with age from approximately 25% to 50%, with further reduction at 555 nm. The data suggest that with advancing age, both normal skin and PWS have a greater total hemoglobin content and an increased proportion of deoxyhemoglobin, consistent with increasing vascular dilation and tortuosity; and that the age-associated changes in PWS are an exaggeration of those in normal skin. Laser-treated PWS in both young and old patients had reflectance curves indistinguishable from those of untreated PWS in young patients. This implies, contrary to published clinical impressions, that in the absence of scarring the results of argon laser therapy are the same in young and old patients, but that only older patients experience a significant color shift in the lesion.

Port-wine stains. Morphologic variations and developmental lesions.

Studies have shown that port-wine stains (PWSs) probably represent a progressive ectasia of the superficial cutaneous vascular plexus. During examination of approximately 500 patients with PWSs, seven lesions were identified that could be categorized into two groups. In one group (two patients), the typical superficial PWS was accompanied by a proliferation and ectasia of thin-walled vessels in the deeper dermis, subcutaneous adipose tissue, and skeletal muscle (cavernous hemangioma). In the other group (five patients), single or multiple polypoid tumors arose that consisted of a proliferation of vessels with walls of varying thickness, and intervascular stroma (arteriovenous malformation). These tumors appear to arise in both young patients with flat lesions as well as the older patients with pronounced surface irregularities. Two patients were specifically chosen because they represented the typical PWS cobblestone pattern. This vascular abnormality represents a localized exaggeration of the ectasia process. We conclude that a small number of PWSs are associated with an underlying cavernous hemangioma. Furthermore, besides the surface irregularities that characterize the older PWS, de novo vascular tumors arise that can be categorized as arteriovenous malformations.

Complications of cutaneous laser surgery. A survey.

We surveyed a selected group of 139 dermatologists and plastic surgeons about their experience with the complications of cutaneous laser surgery. Reported complication rates varied from 0% to 35%, with means of 3.2% for dermatologists and 6.2% for plastic surgeons using the argon laser, and 4.2% for dermatologists and 2.8% for plastic surgeons using the carbon dioxide laser. Hypertrophic scarring was the complication noted most frequently; 69% of physicians using the argon laser and 64% of physicians using the carbon dioxide laser have seen at least one case of hypertrophic scarring. Complications noted less frequently include infection, pain, atrophic scarring, intraoperative or postoperative hemorrhage, and prolonged wound healing. Environmental accidents were few. No procedure-related deaths, ocular damage, or secondary cutaneous malignant neoplasms were reported. We conclude that cutaneous laser surgery has an acceptable risk profile but that complications are not uncommon.

Healing of port-wine stains after argon laser therapy.

Studies have shown port-wine stains (PWSs) probably represent an aneurysmal dilation and ectasia of the cutaneous vascular plexus. The abnormal vessels are largely included within a 0.6-mm subepidermal zone, which is within the argon laser destruction range. Twenty-eight patients with PWSs underwent biopsies prior to argon laser treatment and repeated biopsies 4 1/2 months later. Those lesions (23) that contained large ectatic blood-filled vessels responded well to argon laser therapy in contrast to those (five) in which the vessels were relatively small and erythrocyte free. A similar histologic pattern was seen in the repeated biopsy specimens of both groups: the mean vessel area, the fraction of dermis occupied by vessels, vascular erythrocyte content, and vessel wall thickness sharply decreased, while the number of vessels tripled. Since lesion color strongly correlates with and probably is largely determined by erythrocyte content, the reason for the PWS lightening, despite increased vessel number, is the relative lack of erythrocytes in the newly formed vessels.

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.

Can stitches get wet?

This study was performed to answer the question of whether or not a patient can wet stitches after a minor soft-tissue surgical procedure without increasing the incidence of infection or disruption of the wound. One hundred consecutive patients underwent an excision of a skin or soft-tissue lesion closed either primarily or with a local flap. Monofilament nylon was used. There were 55 benign lesions and 45 malignant lesions. All procedures were performed using local anesthesia on an ambulatory basis. All patients were asked to wash the wounds with soap and water twice a day starting the morning after surgery. All wounds healed without any infections and without any disruption or dehiscence of the wounds.

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.

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.

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.

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.

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.

Postoperative hypertension as an etiological factor in hematoma after rhytidectomy. Prevention with chlorpromazine.

Our experience strongly implicates postoperative "reactive hypertension" as a major etiological factor in hematoma formation in the face lift patient. This autonomic lability to post-surgical and emotional stress may be prevented and treated by the appropriate and timely administration of chlorpromazine.

Postrhinoplasty "red nose": differential diagnosis and treatment by laser.

Prior to anticipated nasal surgery, the nasal and facial skin should be examined for any vascular lesions. The skin type should be ascertained. A history of any prior nasal surgery, particularly on the nasal dorsum, should be noted. If rosacea is a clinical possibility, a trial of 1.5 to 2.0 gm q.d. of tetracycline for 6 to 8 weeks is warranted. If, after rhinoplasty, a diffuse "redness" on the nasal dorsum results and one can exclude other diagnoses, then argon laser therapy should be considered. A 3-mm punch biopsy should be obtained to see whether superficial ectatic vessels are present, a finding that would be indicative of a good result from laser therapy.