Laser treatment of facial vascular lesions.

For years, the traditional 577 to 585-nm pulsed dye laser has provided safe and effective treatment for many facial vascular lesions. Currently, interest is focused on how selective epidermal cooling, longer wavelengths, and varied pulse durations may expand the pulsed dye laser's therapeutic range to include treatment-resistant port wine stains, nonablative wrinkle reduction, scar revision, and nonsurgical flap delay. Despite these manipulations, the generation of objectionable purpura remains a concern to patients with limited lesions. To this effect, a long pulsed 532-nm laser has recently become available. This laser is effective for the treatment of facial telangiectasias and does not cause any purpura. It has had minimal complications in two series.

Dermabrasion.

Dermabrasion is a time-tested and cost-effective resurfacing technique for scars, wrinkles, and photodamage with a track record of moderate efficacy and well-known safety profile. The risk of bloodborne pathogens to the operator is far greater with dermabrasion than other resurfacing techniques. The learning curve is significantly longer with dermabrasion than laser resurfacing or chemical peels. In expert hands, dermabrasion can achieve results comparable with laser resurfacing. When performed by an infrequent user of the procedure, however, the results achieved can be expected to be far less predictable than laser resurfacing.

Immediate postoperative laser resurfacing improves second intention healing on the nose: 5-year experience.

BACKGROUND: Mohs surgery defects on convex nasal surfaces do not reliably heal well by second intention. Prior to the availability of laser resurfacing we found that immediate postoperative dermabrasion improved the predicted outcome from second intention healing for these defects. OBJECTIVE: To determine the ability of immediate postoperative CO2 and Er:YAG laser resurfacing to improve predicted healing by second intention. METHODS: Seventy-four patients with Mohs surgical defects on the nose underwent immediate postoperative resurfacing with either a scanned CO2 or long-pulsed Er:YAG laser. Thirty patients had photographs of appropriate quality and follow-up for evaluation by a panel of nine objective physicians. RESULTS: All 74 patients were satisfied with their result and none have requested scar revision. Of the 30 patients evaluated by the panel, all were scored acceptable to excellent. CONCLUSION: Immediate laser resurfacing can improve the predicted outcome from second intention healing on the nose and should be considered for select patients.

Lasers in skin resurfacing.

The development of short-pulse high-peak power and rapidly scanned focused beam carbon dioxide lasers and normal mode erbium:yttrium aluminum garnet lasers, which can remove photodamaged skin layer by layer in a precisely controlled manner while leaving behind a very narrow zone of thermal damage, has revolutionized skin rejuvenation and enhanced our ability to treat scars. This review highlights laser-tissue interactions; the laser used for resurfacing; preoperative, operative, and postoperative issues and how to choose a candidate for the procedure; uses of resurfacing; adverse effects and complications of the procedure; and new developments in the field.

Laser treatment of warts and other epidermal and dermal lesions.

The CO2 laser is a versatile and effective tool for the treatment of warts and various other epidermal and dermal lesions where there is no easily targeted chromophore other than water. The development of high peak power, short-pulse, or rapidly scanned resurfacing CO2 lasers has significantly improved the safety and efficacy of using the CO2 laser. Many lesions amenable to CO2 laser vaporization can be treated by other far less expensive treatment modalities, however, and it is the laser surgeon's responsibility to use the CO2 laser only in cases in which it is demonstrably the best treatment option. The pulsed dye laser may replace the CO2 laser for the treatment of recalcitrant warts if the impressive early cure rates reported are borne out over time. Newer laser systems such as the Er:YAG laser with its extremely small zone of thermal damage may supplant the CO2 laser in the treatment of other epidermal and dermal lesions in the future.

Laser skin resurfacing.

There has always been interest in looking younger, but recently there seems to have been an explosion of public interest in facial rejuvenation. Physicians have been treating photodamaged skin for many years by removing the epidermis and a variable thickness of dermis with dermabrasion or chemical peels, with the expectation that reepithialization and collagen remodeling will result in a more youthful appearance. With the recent development of short-pulsed high-peak power and rapidly scanned carbon dioxide (CO2) lasers, the ability to remove photodamaged skin in a precise and reproducible manner while leaving behind a narrow zone of thermal damage has been achieved. This development has generated tremendous interest in laser skin resurfacing as a technique to reverse photoaging.

Nonmelanoma skin cancer. Risks, treatment options, and tips on prevention.

The incidence of nonmelanoma skin cancer is rapidly increasing. With early diagnosis and treatment, almost all basal cell and squamous cell carcinomas can be cured. Premalignant actinic keratoses are treated with cryosurgery; the CO2 laser is the treatment of choice for actinic cheilitis. Generally, nonmelanoma skin cancer can be effectively treated with excision, electrodesiccation and curettage, cryosurgery, or radiation therapy; 5-year cure rates are over 90%. Large, locally recurrent, and aggressive lesions, as well as lesions located in the central face, are best managed with Mohs' surgery; 5-year cure rates as high as 99% have been reported. Patient education about the dangers of sun exposure and tanning salons can potentially reduce the incidence of nonmelanoma skin cancer. The use of sunscreens starting early in life should be stressed.

Lymphoepithelioma-like carcinoma of the skin treated by Mohs micrographic surgery.

BACKGROUND: Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare malignant tumor thought to be of adnexal origin. Because of its rarity, treatment parameters have not been defined. OBJECTIVE: To examine the role and success of Mohs micrographic surgery in the treatment of LELCS versus other forms of treatment previously documented in the literature. METHODS/RESULTS: A review of the previous reported cases and their treatment outcomes was compared with the present case. Three of the 12 previously reported cases were incompletely treated with initial surgical management, with one patient subsequently dying of metastatic tumor. The present case was treated with Mohs micrographic surgery for recurrent LELCS, following initial treatment with electrodessication and curettage, and is without evidence of disease 20 months postoperatively. CONCLUSION: LELCS may be successfully treated by Mohs micrographic surgery.

Facial reconstruction with prefabricated induced expanded (PIE) supraclavicular skin flaps.

The prefabricated induced expanded (PIE) supraclavicular flap refers to the staged transfer of an expanded supraclavicular skin with a fascia flap used as the carrier. In three patients, we utilized PIE supraclavicular flaps to successfully reconstruct a total forehead and two major nasal defects. Our first PIE flap confirmed the feasibility of the method but necessitated two microvascular free flaps. In the ensuing two patients, we reduced the need for microvascular anastomoses by using simple pedicled flap transfers in either or both stages. Whenever feasible, the preferred method consists of transferring a temporoparietal fascia flap to a subcutaneous pocket in the ipsilateral supraclavicular fossa and simultaneously placing a skin expander under both the fascia flap and the supraclavicular skin. After adequate expansion, the fascia becomes incorporated within the capsule of the expander, and the composite capsulofasciocutaneous flap can be safely transferred to the facial defect as the PIE flap. These patients show that supraclavicular PIE flaps can provide ample amounts of vascularized cutaneous tissue for the reconstruction of major facial defects. The necessary tissue is generated by expanding the most desirable tissue type available, and a selected vascular pedicle is induced to perfuse and carry that generated tissue. Compared with conventional expansion and adjacent flap transfers, PIE flaps allow the transfer of expanded skin to distant sites as island or free flaps perfused by the induced vascular pedicles.

Mohs micrographic surgery local recurrences.

BACKGROUND: Even though 5-year cure rates are as high as 99% for Mohs micrographic surgery (MMS) of cutaneous carcinomas, theoretically 100% cure rates of unifocal carcinomas should be possible. OBJECTIVE: To determine why cutaneous malignancies recur locally (persist) after MMS. METHODS: A retrospective study of all cutaneous malignancies treated with MMS during a 4-year period at Washington University School of Medicine was made. All lesions that were locally recurrent after previous MMS were analyzed for any possible cause of the recurrence. RESULTS: Of 2,414 cutaneous malignancies treated, 33 (1.4%) were locally recurrent after previous MMS by four different Mohs surgeons and five separate technicians. Technical or interpretation problems that could have accounted for the local recurrence were identified in 77% of the lesions. The mean time to recurrence was 38.5 months, with 20% developing more than 5 years after the initial MMS. CONCLUSION: MMS local recurrences are rare with procedural errors representing a majority of them. Five-year cure rates for basal cell carcinoma may somewhat overestimate the ultimate cure rate.

Squamous cell carcinoma developing within lichen planus of the penis. Treatment with Mohs micrographic surgery.

BACKGROUND: Lichen planus is a common disease, with a low malignant potential. There are several case reports in the literature of squamous cell carcinoma (SCC) developing in cutaneous lichen planuse. However, SCC developing in penile lichen planus is extremely rare. OBJECTIVE: To report a case of SCC developing within penile lichen planus, to discuss treatment with Mohs micrographic surgery, and to review the literature. METHOD: The diagnosis of lichen planus and SCC were made by biopsy of the lesion. RESULTS: We present the first case in the English literature of SCC developing within lichen planus of the penis. The lesion was treated with Mohs surgery and the patient's penis is functional and free of tumor 2 years postoperatively. CONCLUSION: Squamous cell carcinoma may develop within lichen planus. Treatment-resistant longstanding cases of lichen planus should be biopsied. Mohs micrographic surgery is a precise treatment for penile SCC, it avoids penectomy, and preserves normal function.

Management of a young patient with xeroderma pigmentosum.

Xeroderma pigmentosum is a group of rare autosomal recessive disorders with defective DNA repair that provide insight into the basic mechanism of carcinogenesis. It is the best human model linking clinical abnormalities and neoplasia to carcinogen exposure. We describe a patient with xeroderma pigmentosum and numerous basal cell carcinomas, squamous cell carcinomas, and melanomas treated with radiation therapy, Mohs micrographic surgery, dermabrasion, and isotretinoin prophylaxis.