Laser Rejuvenation of Nonfacial Skin: A Review and a Personal Approach.

BACKGROUND: Laser skin rejuvenation historically has emphasized facial photodamage. In this review, we examine energy-based rejuvenation for nonfacial skin. OBJECTIVE: The purpose of this review is to summarize past and current energy-based rejuvenation off the face. RESULTS: Many energy-based interventions can address pigment, tone, and texture irregularities of nonfacial skin. CONCLUSION: With conservative settings, current devices can be applied safely for nonfacial skin rejuvenation.

A Combination Approach to Surgical Scars.

BACKGROUND: Scar formation from surgical procedures is an unavoidable risk. Despite measures taken by both the surgeon and patient during the perioperative and postoperative periods to maximize cosmesis, some patients will wish to pursue surgical or laser scar revision. OBJECTIVE: The authors propose a treatment algorithm to assist in approaching surgical scar revision with combination treatments. MATERIALS AND METHODS: A PubMed search was performed on various surgical scar revision techniques. The authors augment these findings with their own personal experiences. RESULTS: Reports of surgical excision, intralesional corticosteroid injection, intralesional 5-fluorouracil injection, pulse dye laser treatment, nonablative fractional laser resurfacing, ablative fractional laser resurfacing, and microneedling and fractional needle radiofrequency, used in isolation or combination, were found. The authors also provide clinical photographs documenting improvement in appearance of surgical scars using these treatments. CONCLUSION: Surgical scars are best treated with a combination approach to address various features of the scar. The authors propose a treatment algorithm with multiple treatment options and how to combine them safely and effectively.

Consensus statement regarding storage and reuse of previously reconstituted neuromodulators.

BACKGROUND: Legacy recommendations suggest that vials of botulinum toxin be used within 24 hours of reconstitution and in a single patient. Current standard of care is consistent with storage after reconstitution and use of a single vial for several patients. OBJECTIVE: To develop expert consensus regarding the effectiveness and safety of storage and reuse of botulinum toxin. MATERIALS AND METHODS: The American Society for Dermatologic Surgery authorized a task force of content experts to review the literature and provide guidance. Data extraction was followed by clinical question review, a consensus Delphi process, and validation of the results by peer review. RESULTS: After 2 rounds of Delphi process, the task force concluded by unanimous consensus and with the highest level of confidence that a vial of toxin reconstituted appropriately can, for facial muscle indications, be (1) refrigerated or refrozen for at least 4 weeks before injection without significant risk for contamination or decreased effectiveness and (2) used to treat multiple patients, assuming appropriate handling. CONCLUSION: The standard of care, which allows for use of botulinum toxin more than 24 hours after reconstitution and in more than 1 patient per vial, is appropriate and consistent with the safe and effective practice of medicine.

Pulsed dye laser and pulsed dye laser-mediated photodynamic therapy in the treatment of dermatologic disorders.

BACKGROUND: The pulsed dye laser (PDL) is used for treating cutaneous vascular disorders. Recent reports have also shown its effectiveness in conditions of other etiologies, although the precise mechanisms of action are unknown. PDL has also been used in photodynamic therapy (PDT) for many dermatologic conditions. We review the broad array of disorders that can be effectively managed using the PDL. OBJECTIVES AND METHODS: A review of the literature on the application of the PDL and PDL-mediated PDT in dermatologic disorders. A literature-based search was performed using PubMed from 1997 to 2010. Search terms included: "pulsed dye laser," "pulsed dye laser photodynamic therapy," and "pulsed dye laser indications." RESULTS: The PDL was initially designed for cutaneous vascular disorders. Recent investigations have demonstrated successful results when treating malignant, inflammatory, viral, and collagenous conditions. Side effects, including pain, purpura, edema, and postinflammatory hyperpigmentation, were mild, well tolerated, and transient. CONCLUSIONS: PDL is accepted as first-line therapy for vascular disorders including port-wine stains, telangiectasias, and hemangiomas. PDL causes selective photothermolysis of dermal vasculature. This mechanism also allows it to be applicable for disorders of other etiologies. Recent studies suggest that the PDL may induce cytokine expression and collagen formation, further increasing its applicability in dermatology.

Split-face treatment of facial dyschromia: pulsed dye laser with a compression handpiece versus intense pulsed light.

BACKGROUND: Many visible light lasers and intense pulsed light (IPL) devices are available to treat photodamaged skin. OBJECTIVES: The objective was to perform a multiple-treatment split-face comparison evaluating a pulsed dye laser (PDL) with a compression handpiece versus IPL for photorejuvenation. METHODS: Ten subjects were treated three times at 3- to 4-week intervals. One side of the face was treated with the PDL with compression handpiece, and the other with IPL. One month after final treatment, blinded evaluation assessed for improvements in dyschromias and texture. Patients provided self-assessment of improvement in dyschromias and texture. Time to complete final treatments and pain during all treatments were recorded for each device. RESULTS: Improvement of the PDL was (mean) 86.5, 65, 85, 38, and 40% for dark lentigines, light lentigines, vessels <0.6 mm, vessels >0.6 mm, and texture, respectively, versus 82, 62.5, 78.5, 32.5, and 32%, respectively, for the IPL side. Patient-evaluated difference in improvement for vascular lesions significantly favored the PDL (p=.011). Mean third treatment times were 7.7 minutes for PDL versus 4.6 minutes for the IPL (p=.005). Mean pain ratings were 5.8 for the PDL and 3.1 for the IPL (p=.007). Purpura-free procedures depended on proper technical use of the compression handpiece when treating lentigines with the PDL. CONCLUSIONS: The PDL with compression handpiece and IPL are highly effective for photorejuvenation.

In vitro spectral analysis of tattoo pigments.

BACKGROUND: Absorption spectra of common tattoo pigments, their reaction to irradiation at 532 and 752 nm, and correlation with their titanium and iron component are important to the selection of an optimal laser device. OBJECTIVE: The objectives were (1) to establish the absorption spectra of common tattoo pigments and India ink and (2) to determine their response to laser irradiation at 532 and 752 nm and correlate this to their composition. MATERIALS AND METHODS: Samples of 28 tattoo pigments and India ink were mixed in agar and analyzed with a spectrophotometer. These agar plates were irradiated with Q-switched wavelengths of 532 and 752 nm. RESULTS: The highest absorbance of red was in the complementary spectrum, while blue, yellow, and orange had peaks in the adjacent portion of the visible light spectrum. There is great variability in the absorbance of green tattoo material. Pigment darkening was noted at both wavelengths in all iron-containing pigments except black. It was variable in those containing titanium. Pigments tested responded with either clearance or darkening at 532 nm; however, response at 752 nm was more limited. CONCLUSION: (1) Tattoo pigment absorption spectra can explain why some colors are more resistant to removal. (2) Pigment darkening is a complex process.

A pulsed dye laser with a 10-mm beam diameter and a pigmented lesion window for purpura-free photorejuvenation.

BACKGROUND AND OBJECTIVES: In traditional pulsed dye lasers (PDLs), power limitations and pulse characteristics have compromised purpura-free procedures. This study evaluated a new PDL with a modified pulse structure and a 10-mm beam diameter for purpura-free photorejuvenation. A compression handpiece was used for targeting lentigines. MATERIALS AND METHODS: Twenty patients with skin types I to III were treated three times at 3- to 4-week intervals. The first pass was delivered through a 10-mm compression handpiece to target pigment dyschromias using fluences between 6.5 and 8.0 J/cm(2) with a 1.5-ms pulse duration. A second pass was then performed with a 10-mm spot with fluences between 9.5 and 10 J/cm(2), a 20-ms pulse duration, and cryogen spray enabled. Improvement was evaluated by comparing pre- and posttreatment photographs and live subjects 1 month after the third treatment. RESULTS: In the majority of patients, >90% reduction of fine telangiectasias (<0.6 mm) and dark lentigines was achieved. Pigmented dyschromias improved proportional to the degree of pigment at presentation. Avoidance of purpura with the compression handpiece was dependent on obtaining proper compression before laser emission. Mean textural improvement was 34%. CONCLUSIONS: The new 595-nm PDL is highly effective for two-pass purpura-free improvement of telangiectases, pigment dyschromias, and texture.

Use of a novel pulse dye laser for rapid single-pass purpura-free treatment of telangiectases.

BACKGROUND: Purpura-free elimination of telangiectases with a single pass of a pulsed dye laser with a large spot has proved difficult. OBJECTIVE: The purpose of this report was to define parameters that achieve single-pass purpura-free telangiectasia reduction. MATERIALS: Thirty patients between the ages of 23 and 78 years were treated with a pulsed dye laser with a 10-mm spot and fluences ranging from 9 to 10 J/cm2. The macropulse width was 20 ms. Each macropulse was composed of eight pulselets. Treatments were carried out over facial areas with discrete telangiectases. RESULTS: Smaller telangiectases (<600 microm) showed transient bluing followed by stenosis. Larger vessels (600-10,000 microm) showed bluing but inconsistent closure. A second pass typically resulted in closure. CONCLUSION: A modified pulsed dye laser was capable of single-pass purpura-free reduction with a 10-mm spot size.

Use of a long-pulse alexandrite laser in the treatment of superficial pigmented lesions.

BACKGROUND/OBJECTIVE: Although the alexandrite 755-nm-wavelength laser is effective in the treatment of unwanted hair, there are no published studies gauging the efficacy of the variable long-pulse alexandrite laser in the treatment of superficial pigmented lesions. STUDY DESIGN/METHODS: Eighteen patients underwent a single treatment session using a variable pulse-width alexandrite laser. Test sites were performed using a 10-mm spot size and up to four pulse widths (3, 20, 40, 60 ms) with and without epidermal cooling. Full treatments were performed 3 weeks later using optimum test parameters. The patients were evaluated at 3 and 6 weeks. RESULTS: Patients with darker lentigines had greater lesion clearance than those patients with lighter colored lentigines. Shorter pulse widths and treatment without cryogen cooling both, independently, lowered the fluence threshold for lentigo clearance. CONCLUSION: A long-pulse alexandrite laser is effective in clearing solar lentigines in a single pass with minimal adverse effects.

Laser treatment of leg veins: Physical mechanisms and theoretical considerations.

BACKGROUND AND OBJECTIVES: A discussion of laser treatment of leg veins is based on a review of the literature, theoretical analysis, and the clinical experiences of the authors. Theoretical computations are discussed within the context of clinical observations. STUDY DESIGN/MATERIALS AND METHODS: A Monte Carlo model is used to examine volumetric heat production, fluence rate, and temperature profiles in blood vessels at 1,064 and 532 nm wavelengths with various beam diameters, vessel diameters, and pulse durations. RESULTS: Clinical observations, Monte Carlo results, and a review of the literature suggest that longer wavelengths and longer pulses durations favor vessel contraction over intraluminal thrombosis. Monte Carlo simulations show that longer wavelengths are more likely to uniformly heat the vessel compared to highly absorbing wavelengths. Methemoglobin production causes deeply penetrating wavelengths to generate more volumetric heat for the same input radiant exposure. CONCLUSIONS: Clinical observations and models support the role of long wavelengths and long pulses in optimal clearance of most leg telangiectasias.

Nonfacial laser rejuvenation.

With continuing developments in laser rejuvenation of nonfacial skin, dermatology nurses and support staff need to stay abreast of procedural, preoperative, and postoperative aspects of new therapies.