Surgical Planning for Mohs Defect Reconstruction in the Digital Age.

Planning for Mohs defect reconstruction is an integral part of fellowship training. Use of a digital drawing program prior to the procedure can be a time-saving and cost-efficient method for surgical planning. It also fosters active engagement in learning through a collaborative and comprehensive discussion of reconstructive options.

Midface lift using a minimally invasive technique and a novel absorbable suture.

BACKGROUND: Midface rejuvenation is a minimally invasive procedure designed to correct early ptosis of the cheeks and deepening nasolabial folds. Implementation of this technique requires a detailed understanding of the anatomy of this region in addition to recognizing the vectors of change that occur over time as one matures. Finally, aesthetic competence and requisite surgical skills are required to restore the midface in a minimally invasive fashion. OBJECTIVE: To describe a new minimally invasive approach to facial rejuvenation using a novel absorbable suture with segmented stabilizers that allows for a superolateral reversal of the senescent changes of the midface. METHODS: In a case series study, 30 patients with aging changes of the midface signed informed consent to have this procedure done. An incision was made in the preauricular area, followed by hydrodissection with tumescent anesthesia and blunt dissection with the aid of a 4-mm spatula cannula. Two angiocatheters (14GA 3.25 IN, 2.1 x 83 mm, 14 gauge) were tunneled through the malar fat pad and pierced the skin just lateral to the nasolabial fold. The angiocatheter was then removed and the suture tethered to facilitate the proper amount of lifting entirely in the subcutaneous supra-SMAS plane and anchored superolaterally to the temporalis fascia. The segmented stabilizers anchored themselves in multiple directions but ultimately lifted the tissues of the midface. RESULTS AND CONCLUSION: This technique uses the multidirectional segmented stabilizers of the Monograms to counteract the downward displacement of the malar fat pad while simultaneously softening the nasolabial fold. This is a minimally invasive technique that addresses the multiple factors involved in the senescent changes of the midface. Proper patient selection, good aesthetic judgment, and surgical competence are required to restore the midface in a minimally invasive fashion. The objective of this study was to report a novel approach to midfacial rejuvenation using the Monograms. This cross-hatched suture achieves simultaneous malar fat pad elevation and nasolabial fold effacement. The midface lift adds another vital dimension to panfacial augmentation.

A novel specialized suture and inserting device for the resuspension of ptotic facial tissues: early results.

BACKGROUND: In the past decade, the popularity of minimally invasive procedures for facial rejuvenation has increased. OBJECTIVE: To describe a new specialized suture, and its associated technique, used to elevate sagging tissues of the face and neck. METHODS: A detailed description of the technique and the results obtained in 20 patients in whom we have used this novel approach. Attention was given to appropriate patient selection. The primary focus was on the correction of the jowl, jawline, and neck subunits. It involves the percutaneous introduction of a novel 3-0 polypropylene suture that has 10 absorbable hollow cones along its axis that are equally interspersed with knots. Once the absorbable cones are resorbed into the surrounding tissues, the non-absorbable suture component can be removed without compromising the aesthetic outcome. RESULTS: All patients demonstrated improvement in these areas, with minimal complications. One patient required resuspension using the open technique. (Excessive ptotic tissue was later excised for an optimal cosmetic result.) CONCLUSION: The suture and technique described in this article provide a major contribution to the correction of ptosis of facial tissues. When done in conjunction with other procedures, such as neck and jowl microliposuction, this technique has proven to be a useful addition to facial rejuvenation.

Atrophic and a mixed pattern of acne scars improved with a 1320-nm Nd:YAG laser.

BACKGROUND: Acne scar correction remains a challenge to the dermatologic surgeon. With nonablative laser resurfacing, this correction is imputed to dermal collagen remodeling and acne scar reorganization. Although atrophic acne scars tend to respond to laser treatment, the deeper ice pick and boxcar scars tend to be laser resistant. OBJECTIVE: To investigate the treatment of atrophic and a mixed pattern of facial acne scars, we evaluated a 1320-nm Nd:YAG laser. Twelve subjects with atrophic facial acne scars (N=6) or a combination of atrophic and pitted, sclerotic, or boxcar scars (N=6) received three laser treatments. Physician and patient acne scar ratings were performed at baseline and at 6 months after the last treatment. Acne scars were rated with a 10-point severity scale. RESULTS: Mean acne scar improvement was 1.5 points on physician assessments (P=0.002) and 2.2 points on patient assessments (P=0.01). Acne scars were rated more severely by patients than by the physician at all intervals. There were no noted complications at 6 months. CONCLUSION: The 1320-nm Nd:YAG laser is a safe and effective nonablative modality for the improvement of atrophic and a mixed pattern of facial acne scars.

Evaluation of a long-pulsed Nd:YAG laser at different parameters: an analysis of both fluence and pulse duration.

BACKGROUND: Effective hair removal continues to pose a challenge to the physician. The use of lasers represents a significant advance in epilation, but still requires further refinement. The long-pulsed Nd:YAG laser may offer advantages over other systems because of its significant depth of penetration and minimal absorption by epidermal melanin, but ideal parameters need to be determined. OBJECTIVE: To evaluate the efficacy of a long-pulsed Nd:YAG laser system and determine the optimal parameters for hair removal. METHODS: Twenty-two subjects were treated with a cryogen spray-cooled long-pulsed Nd:YAG laser. Four adjacent sites were assigned to each subject, where the following sets of parameters were utilized: 50 J/cm2 with a 25-msec pulse duration, 60 J/cm2 with a 50-msec pulse duration, 80 J/cm2 with a 50-msec pulse duration, and control. Hair counts were obtained immediately, 1 week, 1 month, and 3 months after treatment, and multivariate regression analysis was used to determine the significance of hair reduction. Acute reactions and adverse events were also evaluated. RESULTS: Treatment at all three sets of parameters resulted in significant mean hair reductions immediately, at 1 week, and at 1 month (P <.001). At 3 months, the higher settings of 60 J/cm2 and 50 msec and 80 J/cm2 and 50 msec were statistically significant for reduced mean hair counts (P =.014, P =.042, respectively), while the lowest setting at 50 J/cm2 and 25 msec was not significant (P =.079). Patient and physician assessments suggested optimal hair reduction at the highest fluence (80 J/cm2) and longest pulse duration (50 msec). The most common acute reactions were pain during treatment, erythema, and perifollicular edema, all of which were more severe with higher fluences. CONCLUSION: The long-pulsed Nd:YAG laser is a safe and effective method of hair removal. Increased fluence (60-80 J/cm2) and longer pulse duration (50 msec) settings were generally correlated with reduced hair counts and improved clinical outcome.

Evaluation of a new super-long-pulsed 810 nm diode laser for the removal of unwanted hair: the concept of thermal damage time.

BACKGROUND: Laser hair removal is based on the dual concepts of selective photothermolysis and thermal relaxation time. In most laser hair removal systems, light with emitted pulse durations of 2-50 msec targets hair follicles. A novel concept of laser hair removal uses the thermal damage time rather than the thermal relaxation time of the hair follicle. The follicle's thermal damage time is the amount of time required for diffusion of delivered laser energy from the treated hair to follicular-associated hair stem cells. This can range from 170 to 1000 msec. OBJECTIVE: To investigate the theory of thermal damage time, we performed a pilot study to evaluate the clinical efficacy and side effect profile of a modified 810 nm diode laser device operating in a super-long-pulse mode (200-1000 msec). METHODS: Ten female subjects with Fitzpatrick skin types I-VI received either one or two laser treatments at eight test sites. Super-long pulse durations of 200-1000 msec were evaluated with delivered fluences ranging from 23 to 115 J/cm2. Subjects were followed for 6 months after the first treatment. Subjects were evaluated for hair removal efficiency, optimal pulse duration and delivered fluence, and associated complication rate. RESULTS: The clinical results show that safe hair removal in all skin types can be accomplished with an 810 nm diode laser delivering super-long pulse durations. Pain and complications were greatest at the highest pulse duration (1000 msec) and the highest fluence (115 J/cm2). Optimal hair reduction at 6 months (31%) was achieved at a thermal diffusion time of 400 msec (46 J/cm2). CONCLUSION: The super-long pulsed 810 nm diode laser can safely remove unwanted hair in a full variety of skin types. Pain and increased risk of complications may preclude the use of the laser at very high fluences and pulse duration in the range of 1000 msec.

Nd:YAG laser (1064 nm) irradiation for lower extremity telangiectases and small reticular veins: efficacy as measured by vessel color and size.

BACKGROUND: Laser treatment of lower extremity telangiectases and small reticular veins has remained difficult because of vessel color, diameter, depth, and associated high-pressure flow. Traditionally, larger-caliber blue leg veins do not respond well to laser treatment. Nd:YAG laser (1064 nm) irradiation is absorbed by oxyhemoglobin and reduced hemoglobin and is associated with greater depth of penetration than other previously studied vascular lasers. OBJECTIVE: To evaluate a millisecond contact-cooled 1064 nm Nd:YAG laser for the treatment of telangiectases and small reticular veins. METHODS: Twenty-one lower extremity sites, with Fitzpatrick skin types I-IV, received two laser treatments separated by a 4 to 6-week period. Blue and red vessels, ranging in size from 0.25 to 4.0 mm were treated. Pulse durations of 10-50 msec were utilized at fluences of 90-187 J/cm2. Three months after the last treatment, patients were evaluated for vessel improvement and complications. RESULTS: Seventy-one percent of lower extremity vessels had improvement graded as significant. All vessel colors and sizes were successfully treated. The only complication at 3 months was postinflammatory hyperpigmentation. CONCLUSION: 1064 nm Nd:YAG laser irradiation with associated contact cooling is a safe and effective treatment for telangiectases and small reticular veins of the lower extremities.

Non-ablative laser treatment of facial rhytides: a comparison of 1450-nm diode laser treatment with dynamic cooling as opposed to treatment with dynamic cooling alone.

BACKGROUND AND OBJECTIVE: Non-ablative dermal remodeling has been shown to create new dermal collagen. This is thought to occur secondary to a laser-induced injury to the skin. Other mechanisms of injury may lead to similar results. The aim of this study was to evaluate the efficacy and complication rate of a 1450-nm diode laser and compare clinical effect when the laser is used in conjunction with cryogen cooling as compared to the use of cryogen cooling alone. STUDY DESIGN/MATERIALS AND METHODS: Twenty subjects, skin types I-IV, age range 42-70 years, with Class I and II rhytides were enrolled in the study. Subjects were treated with 2-4 laser treatments and cryogen cooling on one side of their face, while the contralateral side was treated with cryogen cooling alone. Subjects were evaluated six months after their final treatment. RESULTS: Thirteen subjects showed clinical improvement on the laser/cryogen treated side. No subjects were noted to have any improvement at the cryogen alone side. CONCLUSION: The 1450-nm diode laser can lead to non-ablative improvement of rhytides. This effect appears to be a direct laser induced effect.