The erbium micropeel: a prospective, randomized trial of the effects of two fluence settings on facial photoaging.

BACKGROUND: Recent studies have suggested that a series of low-energy, single-pass ablative laser resurfacing micropeels can reduce photoaging with decreased downtime. This randomized, prospective single-blinded trial sought to determine the ideal settings of sequential erbium:yttrium-aluminum-garnet (Er:YAG) laser treatments that maximize efficacy and patient satisfaction. METHODS: Forty-six subjects with mild-to-moderate facial dyschromia and rhytides were evenly randomized to two Er:YAG treatment arms. Patients in the lower fluence (LF) (2.5 J/cm2) and higher fluence (HF) (3.8 J/cm2) groups each received three one-pass, full-face treatments one month apart. Patient and investigator assessments of rhytides, dyschromia and global appearance were performed at baseline and at four, eight and 20 weeks using a nominal scale from 1­4. Adverse events and patient satisfaction were also evaluated. RESULTS: Patient scores showed rhytid improvement only with HF treatments. Investigator scores at three months post-treatment showed dyschromia was significantly improved in both study arms, with a 24 and 36 percent reduction for the LF and HF groups, respectively. Global appearance scores improved by 25 and 32 percent, respectively. A trend towards greater post-procedure erythema and time-to-erythema resolution was observed in the HF group. Mild peeling was the most common adverse event. Individuals who underwent LF treatments were more likely to pursue future treatments. CONCLUSION: Both settings resulted in moderate but significant improvement in dyschromia, although only HF treatment improved rhytides. The decreased downtime of LF treatments made this the preferred choice of patients.

Dual transposition flaps for the reconstruction of large scalp defects.

BACKGROUND: Large scalp defects can be challenging to repair because of the inelasticity of the scalp. While there are several methods to close this type of wound, they result in either alopecia or unacceptable scarring. We present a dual transposition flap to close a large defect following Mohs surgery for a basal cell carcinoma on the scalp. METHODS: We describe and report the case of a man with a basal cell carcinoma on the scalp vertex who had been referred for Mohs micrographic surgery. The surgery resulted in a large scalp defect. RESULTS: A dual transposition flap performed with tumescent anesthesia was used in a delayed closure of a 78.5-cm2 defect. It resulted in minimal alopecia, minimal distortion of the hair orientation, and minimal scar stretch-back. LIMITATIONS: The limitation of this study is that this technique is based on one case report. CONCLUSIONS: This dual transposition flap is a good reconstructive option for large, immobile scalp defects. It can be performed under local anesthesia with minimal alopecia and camouflaged scars.

Radiofrequency ablation of facial nerve branches controlling glabellar frowning.

BACKGROUND: Hyperdynamic activity of the corrugator supercilii and procerus muscles causes glabellar furrows. Recently, a novel radiofrequency device has become available that can effectively ablate the efferent nerves controlling corrugator and procerus contraction, producing clinical results that are similar to those of botulinum toxin. OBJECTIVE: To assess the efficacy, longevity of effect, and side effects of the radiofrequency ablation device in the treatment of hyperdynamic glabellar furrows. MATERIALS AND METHODS: Four probe entry points were used to access branches of the temporal and angular nerves. Seven and two ablations, respectively, were delivered to each temporal branch and angular nerve. RESULTS: Twenty-nine patients underwent bilateral radiofrequency ablation of temporal branches of the facial nerve and the angular nerves. Abrogation of glabellar furrowing was achieved in 90% of patients. No major adverse events were observed. All patients developed mild to moderate swelling, and nine patients (31%) developed purpura in the treated areas. Sixty-nine percent of patients had effects that lasted 4 months or longer, 41% had effects that lasted 6 months or longer, and 10% had effects lasting longer than 12 months. CONCLUSION: Radiofrequency ablation of efferent branches of the temporal and angular nerves effectively eliminates corrugator and procerus contraction and concomitant glabellar furrowing.

Dual nasal sidewall and lip defects combined into a single arcuate advancement flap.

The authors have indicated no significant interest with commercial supporters.

Colloid milium: a review and update.

Colloid milium (CM) is a rare cutaneous deposition disease with at least 3 distinct subtypes. The exact histogenesis of the condition is still unresolved and awaits definitive elucidation. Electron microscopy and immunohistochemical analysis have allowed the distinction of CM from clinically similar conditions such as amyloidosis. Successful treatment has been achieved with dermabrasion and, more recently, with ablative and fractional laser resurfacing of affected skin.

Systemic toxicity from topically applied lidocaine in conjunction with fractional photothermolysis.

BACKGROUND: Topical anesthetics, unlike injectable anesthetics, can be applied painlessly and can provide sufficient pain control to maintain patient comfort throughout a variety of laser procedures. Although the use of topical lidocaine is considered relatively safe, instances of cardiotoxic and neurotoxic adverse events have been reported to occur. OBSERVATIONS: A 52-year-old woman underwent fractional photothermolysis for management of severe hypopigmentation and scarring of several years' duration. Shortly after termination of treatment to her face and neck, which required prolonged exposure to a 30% lidocaine gel compound both before and during surgery, she developed clinical signs and symptoms consistent with systemic lidocaine toxicity. The results of laboratory studies confirmed serum lidocaine levels within the toxic range. We postulate that the combination of the high concentration of topical lidocaine required to achieve sufficient anesthesia, together with the laser-induced disruption in epidermal barrier function, may have been responsible for this phenomenon. CONCLUSIONS: Application of a 30% topical lidocaine gel to a limited area in conjunction with fractional photothermolysis may generate serum lidocaine levels high enough to elicit systemic toxicity. Laser surgeons should be alert to this phenomenon, particularly in patients with underlying hepatic, endocrine, cardiac, or central nervous system/psychiatric dysfunction; in patients with a low body mass index; and in patients who are taking medications that may interfere with hepatic lidocaine metabolism.

Cosmetic blepharoplasty.

Cosmetic blepharoplasty provides a satisfying solution to correct undesirable changes and provides substantial rejuvenation to the patient. The ability to perform procedures under local anesthesia combined with a relatively short recovery time makes blepharoplasty surgery highly satisfying for the patient. Detailed knowledge of the orbital anatomy, meticulous planning, and surgical technique are the keys to achieving the ideal outcome and meeting patient expectations.

Poly-L-lactic acid for the aesthetic correction of facial volume loss.

Sculptra (poly-L-lactic acid), a new injectable soft tissue filler designed to stimulate neocollagenesis, increase dermal thickness, and enhance volume, is most commonly used for the midface and temporal fossa, with more limited use in the mental and prejowl areas. In the authors' practice, Sculptra injections have virtually replaced autologous fat transfer, yielding excellent results for patients with mild to moderate midface and jowl laxity.

Use of a dual-mode erbium:YAG laser for the surgical correction of rhinophyma.

Rhinophyma is a cosmetically deforming disorder characterized by nodular hypertrophy of the nasal soft tissue. Treatment of rhinophyma usually consists of laser ablation or surgical excision for correction of the associated tissue deformity. We describe 6 patients with mild to severe rhinophyma who were treated with a dual-mode erbium:YAG (Er:YAG) laser, which provides the advantages of controlled ablative energy for tissue reduction and excellent intraoperative hemostasis. Outcome measures included patient satisfaction, clinician observer ratings, and an assessment of complications, including scarring, pigment abnormalities, and postoperative bleeding. All patients were satisfied with their outcomes, and no complications were detected during follow-up. All treatment outcomes were rated as very good to excellent at a 3-month follow-up visit. The flexibility of the dual-mode Er:YAG laser provides both controlled ablation and hemostasis, making it an ideal laser for the surgical treatment of rhinophyma.

Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbon dioxide laser.

OBJECTIVE: To assess mature burn scars treated with a fractional carbon dioxide laser for changes in histological architecture, type I to III collagen ratios, density of elastic tissue, and subjective measures of clinical improvements. DESIGN: Uncontrolled, prospective study of patients with mature burn scars, from a clinical and histological perspective. Biopsy specimens were obtained before and 2 months after 3 treatment sessions. The tissue was prepared with Verhoff von Giesen (VVG) stain to discern elastic tissue and Herovici stain to differentiate types I and III collagen. SETTING: Subjects were recruited from the Grossman Burn Centers. PARTICIPANTS: Of 18 patients with mature burn scars, 10 completed the entire treatment protocol. INTERVENTION: Participants received 3 treatments with a fractional carbon dioxide laser. MAIN OUTCOME MEASURES: Vancouver Scar Scale and Patient and Observer Scar Assessment Scale survey scores. In histological analysis, imaging software was used to measure changes in collagen subtype and elastic tissue. A rating scale was developed to assess normal vs scar architecture. RESULTS: The first hypothesis that significant histological improvement would occur and the second hypothesis of a statistically significant increase in type III collagen expression or a decrease in type I collagen expression were confirmed. There were no significant changes in elastic tissue. Statistically significant improvements were seen in all survey data. CONCLUSIONS: Treatment with a fractional carbon dioxide laser improved the appearance of mature burn scars and resulted in a significant improvement in collagen architecture following treatment. Furthermore, in treated skin specimens, a collagen subtype (types I and III collagen) profile resembling that of nonwounded skin was found.

Advances in plasma skin regeneration.

Plasma skin regeneration (PSR) is a novel method of resurfacing that uses plasma energy to create a thermal effect on the skin. PSR is different from lasers, light sources, and ablative lasers in that it is not chromophore dependent and does not vaporize tissue, but leaves a layer of intact, desiccated epidermis that acts as a natural biologic dressing and promotes wound healing and rapid recovery. Histological studies performed on plasma resurfacing patients have confirmed continued collagen production, reduction of elastosis, and progressive skin rejuvenation beyond 1 year after treatment. PSR has received US Food and Drug Administration 510 (k) clearance for treatment of rhytides of the body, superficial skin lesions, actinic keratoses, viral papillomata, and seborrheic keratoses. PSR also has beneficial effects in the treatment of other conditions including dyschromias, photoaging, skin laxity, and acne scars. The safety profile of PSR is excellent, and there have been no reports of demarcation lines in perioral, periorbital, or jawline areas, as can sometimes be observed following CO2 resurfacing. PSR is effective in improving facial and periorbital rhytides and can be used on nonfacial sites, including the hands, neck, and chest. Numerous treatment protocols with variable energy settings allow for individualized treatments and provide the operator with fine control over the degree of injury and length of subsequent recovery time.

Targeting a tumor-specific laminin domain critical for human carcinogenesis.

Laminin-332 is critical for squamous cell carcinoma (SCC) tumorigenesis, but targeting it for cancer therapy has been unachievable due to key role of laminin-332 in promoting tissue integrity. Here, we show that a portion of laminin-332, termed G45, which is proteolytically removed and absent in normal tissues, is prominently expressed in most human SCC tumors and plays an important role in human SCC tumorigenesis. Primary human keratinocytes lacking G45 (DeltaG45) showed alterations of basal receptor organization, impaired matrix deposition, and increased migration. After SCC transformation, the absence of G45 domain in DeltaG45 cells was associated with deficient extracellular signal-regulated kinase and phosphotidylinositol 3-kinase (PI3K) pathway activation, impaired invasion, deficient metalloproteinase activity, and absent tumorgenicity in vivo. Expression of G45 or activated PI3K subunit in DeltaG45 cells reversed these abnormalities. G45 antibody treatment induced SCC tumor apoptosis, decreased SCC tumor proliferation, and markedly impaired human SCC tumorigenesis in vivo without affecting normal tissue adhesion. These results show a remarkable selectivity of expression and function for laminin-332 G45 in human SCC tumorigenesis and implicate it as a specific target for anticancer therapy.

An algorithmic approach to esthetic facial volume restoration.

The growing availability of treatment options for facial restoration has created a need for a more organized approach to combination treatments. This article presents considerations from one practice to assessing the aging face and tailoring treatments to specific deficiencies.

Alpha 6 beta 4 integrin regulates keratinocyte chemotaxis through differential GTPase activation and antagonism of alpha 3 beta 1 integrin.

Growth factor-induced cell migration and proliferation are essential for epithelial wound repair. Cell migration during wound repair also depends upon expression of laminin-5, a ligand for alpha 6 beta 4 integrin. We investigated the role of alpha 6 beta 4 integrin in laminin-5-dependent keratinocyte migration by re-expressing normal or attachment-defective beta 4 integrin in beta 4 integrin null keratinocytes. We found that expression of beta 4 integrin in either a ligand bound or ligand unbound state was necessary and sufficient for EGF-induced cell migration. In a ligand bound state, beta 4 integrin supported EGF-induced cell migration though sustained activation of Rac1. In the absence of alpha 6 beta 4 integrin ligation, Rac1 activation became tempered and EGF chemotaxis proceeded through an alternate mechanism that depended upon alpha 3 beta 1 integrin and was characterized by cell scattering. alpha 3 beta 1 integrin also relocalated from cell-cell contacts to sites of basal clustering where it displayed increased conformational activation. The aberrant distribution and activation of alpha 3 beta 1 integrin in attachment-defective beta 4 cells could be reversed by the activation of Rac1. Conversely, in WT beta 4 cells the normal cell-cell localization of alpha 3 beta 1 integrin became aberrant after the inhibition of Rac1. These studies indicate that the extracellular domain of beta 4 integrin, through its ability to bind ligand, functions to integrate the divergent effects of growth factors on the cytoskeleton and adhesion receptors so that coordinated keratinocyte migration can be achieved.

Continuous, noninvasive, and localized microvascular tissue oximetry using visible light spectroscopy.

BACKGROUND: The authors evaluated the ability of visible light spectroscopy (VLS) oximetry to detect hypoxemia and ischemia in human and animal subjects. Unlike near-infrared spectroscopy or pulse oximetry (SpO2), VLS tissue oximetry uses shallow-penetrating visible light to measure microvascular hemoglobin oxygen saturation (StO2) in small, thin tissue volumes. METHODS: In pigs, StO2 was measured in muscle and enteric mucosa during normoxia, hypoxemia (SpO2 = 40-96%), and ischemia (occlusion, arrest). In patients, StO2 was measured in skin, muscle, and oral/enteric mucosa during normoxia, hypoxemia (SpO2 = 60-99%), and ischemia (occlusion, compression, ventricular fibrillation). RESULTS: In pigs, normoxic StO2 was 71 +/- 4% (mean +/- SD), without differences between sites, and decreased during hypoxemia (muscle, 11 +/- 6%; P < 0.001) and ischemia (colon, 31 +/- 11%; P < 0.001). In patients, mean normoxic StO2 ranged from 68 to 77% at different sites (733 measures, 111 subjects); for each noninvasive site except skin, variance between subjects was low (e.g., colon, 69% +/- 4%, 40 subjects; buccal, 77% +/- 3%, 21 subjects). During hypoxemia, StO2 correlated with SpO2 (animals, r2 = 0.98; humans, r2 = 0.87). During ischemia, StO2 initially decreased at -1.3 +/- 0.2%/s and decreased to zero in 3-9 min (r2 = 0.94). Ischemia was distinguished from normoxia and hypoxemia by a widened pulse/VLS saturation difference (Delta < 30% during normoxia or hypoxemia vs. Delta > 35% during ischemia). CONCLUSIONS: VLS oximetry provides a continuous, noninvasive, and localized measurement of the StO2, sensitive to hypoxemia, regional, and global ischemia. The reproducible and narrow StO2 normal range for oral/enteric mucosa supports use of this site as an accessible and reliable reference point for the VLS monitoring of systemic flow.