[Choroidal haemangioma worsens after laser therapy for skin port-wine nevus and improves with photodynamic therapy in the eye]

A young man with facial port-wine nevus on one side of his face underwent skin laser treatment on his facial lesions and experienced worsening visual acuity from 0.9 to 0.4 and metamorphosis afterwards in the ipsilateral eye. He was found to have a choroidal haemangioma with an exudative retinal detachment. He received photodynamic therapy resulting in resolution of subretinal fluid and shrinkage of the haemangioma. Visual acuity decreased to 0.1 one week following photodynamic treatment, but improved steadily after that. Nine months following the treatment the visual acuity is 0.5 and metamorphosis is absent.

[Lasers in plastic surgery--vascular lasers]

Laser treatment of the cutaneous vascular lesions gained approbation and well-established position among plastic surgery techniques. Rapidly evolving laser market delivers us modem and safer devices. In the paper we discuss the most common vascular lesions and available lasers used to treat them. Described indications and safety rules might be useful for many specialists for their patient therapy choice.

Treatment of cutaneous vascular lesions using multiple-intermittent cryogen spurts and two-wavelength laser pulses: Numerical and animal studies

BACKGROUND AND OBJECTIVES

Presently, cutaneous vascular lesions are treated using a single cryogen spurt and single laser pulse (SCS-SLP), which do not necessarily produce complete lesion removal in the majority of patients. In this study, the feasibility of applying multiple cryogen spurts intermittently with multiple two-wavelength laser pulses (MCS-MTWLP) was studied using numerical and animal models.

STUDY DESIGN/MATERIALS AND METHODS

Two treatment procedures were simulated: (1) SCS+532 nm SLP; and (2) MCS+532/1064 nm MTWLP. Light transport and heat diffusion in human skin were simulated with the Monte Carlo method and finite element model, respectively. Possible epidermal damage and blood vessel photocoagulation were evaluated with an Arrhenius-type kinetic model. Blood vessels in the rodent window chamber model (RWCM) were irradiated with either SLP or MTWLP. Laser-induced structural and functional changes in the vessels were documented by digital photography and laser speckle imaging (LSI).

RESULTS

The numerical results show that the MCS-MTWLP approach can provide sufficient epidermal protection while simultaneously achieving photocoagulation of larger blood vessels as compared to SCS-SLP. Animal studies show that MTWLP has significant advantages over SLP by inducing irreversible damage to larger blood vessels without adverse effects.

CONCLUSIONS

MCS-MTWLP may be a promising approach to improve therapeutic outcome for patients with cutaneous vascular lesions featuring large blood vessels.

[Port wine stains and laser treatments]

Port wine stains correspond to cutaneous congenital capillary dysplasias and are undergoing broad clinical appearances as far as size, colour, and anatomical areas are concerned together with several possible associations to other vascular pathology. Laser treatment started by the end of the 70's with, at that time moderate scientific production, followed by a very "explosive" period till mid 90's, leading to a progressive decrease till today. Therefore, everything has been reported several times and, in some occasions with some kind of artlessness and/or without follow-up. Author will try in this paper to report a 25 years experience, with as much objectivity as possible.

Láser y otras fuentes de luz en el tratamiento de manchas en vino de Oporto

Laser treatment of vascular skin lesions is rapidly improving. Port wine stain (PWS) is one of the first lesions successfully treated with laser. The pulsed dye laser (PDL) has been developed on the concept of selective photothermolysis and has revolutionized PWS treatment. Even though the response is variable, substantial blanching can be obtained after several sessions. Greater selectivity and better response have been achieved by modifying PDL parameters such as longer pulse width, longer wavelength, or higher energy fluencies with cooling skin devices. It is known that thick, deep or raised lesions present poor response to conventional treatments. The aim of this study is to review the different lasers and other light sources which are developing for the treatment of PWS and other vascular lesions.

Traitement chirurgical des malformations capillaires

Capillary malformations do not demand mostly any therapeutics. For aesthetic reasons, family or child can demand a treatment to ease even to remove the unsightly character of the lesion. In this context, the means employees must be simple and not engender aftereffects more unaesthetic than the lesion. The pulsed dye laser fulfils perfectly this conditions by improving the color of the lesion without touching the texture of the skin. However it's a treatment requiring many sessions over 2-3 years. Surgery keeps an interest for the treatment of capillary malformations resistant to laser (in particular on the limbs) or to treat soft tissues hyperplasia met in certain cervicofacial locations. The surgery uses the whole techniques of plastic surgery classified from the most simple to the most complicated: excision-suture in one time or iterative, excision and coverage by a skin graft, use of skin expansion techniques with local flaps.

Laser Treatment of Vascular Birthmarks

Laser treatment of vascular birthmarks remains one of the more common applications of dermatologic lasers and is the treatment of choice for port-wine stains (PWS) and superficial capillary hemangiomas. Before the development of laser technology, these lesions were treated with radiation, surgical excision and grafting, cryosurgery, and camouflage with cosmetics or tattoos. All of these techniques produced unsatisfactory results or poor aesthetic outcomes. The development of the pulsed dye laser in the 1980s permitted selective photocoagulation and destruction of lesional blood vessels without damage to the surrounding normal skin, thereby producing dramatic clearing of PWS and hemangiomas with minimal risk of scarring.

The Effect of Varying Pulse Duration, Wavelength, Spot Size, and Fluence on the Response of Previously Treated Capillary Vascular Malformations to Pulsed-Dye Laser Treatment

Modern lasers allow different parameters to be altered in an effort to gain further improvement in otherwise resistant capillary vascular malformations (CMs). The aim of this study was to examine the effect of changing the pulse duration, wavelength, spot size, and fluence on the color and capillary architecture of 585-nm pulsed-dye, laser-resistant CMs. Eighteen patients were assessed with a depth measurement videomicroscope (DMV) before and after 12 test patches with ScleroPlus and V-Beam lasers at specified parameters. In the majority of the test patch areas, there was little improvement after treatment. However, 44% of patients had greater than 75% clearance in at least 1 test patch site. This study demonstrates that both lasers can achieve further lightening in 585 nm 0.45 msec pulsed-dye laser-resistant CMs. However, in CMs consisting of small-diameter deep vessels, further improvement is unlikely.

Evaluation of the treatment of port-wine stains with the 595-nm long pulsed dye laser: a large prospective study in adult Japanese patients

BACKGROUND

Treatments of port-wine stains with conventional pulsed dye laser yield inconsistent results.

OBJECTIVE

We evaluated the efficacy and safety of the longer pulse duration 595-nm dye laser.

METHODS

Sixty-six adult Japanese patients were enrolled in this prospective study. The laser treatment with a cooling device was repeated 4 times at 8-week intervals with a consistent setting of 10-ms pulse duration and an energy fluence of 12 J/cm2, using 7-mm spot size.

RESULTS

Improvement of port-wine stains was observed after multiple treatments, and 67% of the patients achieved either good or excellent response after the fourth treatment. Transient purpura, edema, or both were noted immediately after each treatment (76%-79% and 58%-67%, respectively). Hyperpigmentation (8%-17%) and hypopigmentation (6%-14%) were also mild and their occurrence did not increase by repeating treatments.

LIMITATIONS

Eighty five percent of the patients were classified as having Fitzpatrick skin type IV.

CONCLUSION

Our study indicated that the 595-nm dye laser with 10-ms pulse duration may be effective and well tolerated in the treatment of port-wine stains in adult Asians.

Treatment of Port Wine Stains With the Pulse Dye Laser

The pulsed dye lasers (PDL) are the gold standard in the treatment of port wine stains (PWS). However, clearance rates vary widely, and many lesions are not completely cleared with laser treatment. This article reviews the use of different types of PDL for the treatment of PWS. Longer pulse durations and higher fluences in conjunction with skin cooling are required for larger vessels. Controversy still exists as to which wavelength induces greater photothermal damage to the blood vessels in PWS. The incomplete response of PWS to the conventional PDL is due to the suboptimal irradiation parameters of energy fluence, pulse duration, and wavelength currently used in clinical settings. New-generation PDL are more effective than conventional PDL, but vessels smaller than 30-50 microm appear resistant to all kinds of PDL treatment.

Umbilical endometriosis

A 40-year-old woman with a history of a growing erythematous nodule in the umbilicus was diagnosed histopathologically with endometriosis. This umbilical endometriosis occurred spontaneously without any previous surgical procedures. The lesion was partially removed surgically; she then entered menopause with a spontaneous involution of the residuum during the following months so that further invention was not required. Umbilical endometriosis is very rare with an estimated incidence of 0.5 to 1% of all patients with endometrial ectopia. As the clinical appearance of umbilical endometriosis may share features with a variety of other disorders, we discuss the clinical picture and differential diagnostic considerations in detail.

Improvement of port wine stain laser therapy by skin preheating prior to cryogen spray cooling: A numerical simulation

BACKGROUND AND OBJECTIVES

Although cryogen spray cooling (CSC) in conjunction with laser therapy has become the clinical standard for treatment of port wine stain (PWS) birthmarks, the current approach does not produce complete lesion blanching in the vast majority of patients. The objectives of this study are to: (1) experimentally determine the dynamic CSC heat flux when a skin phantom is preheated, and (2) numerically study the feasibility of using skin preheating prior to CSC to improve PWS laser therapeutic outcome.

STUDY DESIGN/MATERIALS AND METHODS

A fast-response thin-foil thermocouple was used to measure the surface temperature and thus heat flux of an epoxy skin phantom during CSC. Using the heat flux as a boundary condition, PWS laser therapy was simulated with finite element heat diffusion and Monte Carlo light distribution models. Epidermal and PWS blood vessel thermal damage were calculated with an Arrhenius-type kinetic model.

RESULTS

Experimental results show that the skin phantom surface can be cooled to a similar minimum temperature regardless of the initial temperature. Numerical simulation indicates that upon laser irradiation, the epidermal temperature increase is virtually unaffected by preheating, while higher PWS blood vessel temperatures can be achieved. Based on the damage criterion we assumed, the depth and maximum diameter of PWS vessels that can be destroyed irreversibly with skin preheating are greater than those without.

CONCLUSIONS

Skin preheating prior to CSC can maintain epidermal cooling while increasing PWS blood vessel temperature before laser irradiation. Numerical models have been developed to show that patients may benefit from the skin preheating approach, depending on PWS vessel diameter and depth.

Thickness of Healthy and Affected Skin of Children with Port Wine Stains: Potential Repercussions on Response to Pulsed Dye Laser Treatment

BACKGROUND

Response of port wine stain to pulsed dye laser therapy is variable and dependent on treatment settings used and anatomic site as well as on size and depth of ectatic vessels.

OBJECTIVE

Our purpose was to evaluate skin thickness in different anatomic areas and in port wine stain to thus assess its possible role in the response to pulsed dye laser.

MATERIALS AND METHODS

Twenty-one children with port wine stain underwent high-frequency ultrasound evaluation (20 MHz). Eighteen unaffected areas were considered in each patient and an additional measure was taken from the symmetric affected skin when present (50 areas).

RESULTS

Skin was thicker in the centrofacial area, dermatome V1 (followed by dermatome V2, dermatome V3, and dermatomes C1-2), and with increasing age. No substantial difference between affected and symmetric nonaffected skin was found.

CONCLUSION

Thicker cutaneous areas fit with those that typically respond worse to pulsed dye laser. Differences in skin thickness related to age support the fact that better responses are achieved in younger patients.

The Relationship Between Location, Color, and Vessel Structure Within Capillary Vascular Malformations

The treatment of capillary vascular malformations by laser is well established. Despite this, only a minority of patients obtain full clearance of their lesion after treatment. Both anatomic location and color have been proposed as prognostic factors determining the amount of improvement seen after laser treatment. This study uses the technique of depth measuring video microscopy to examine the hypothesis that smaller and more deeply placed capillaries may be responsible for the poorer response seen in certain anatomic locations. Fifty sites on 44 previously untreated patients were examined resting in a temperature-controlled room at 28 degrees C. No statistically significant correlation was found between color, based on a Munsell color chart recording and capillary depth or diameter. Also, no correlation was found between diameter, depth, or type of capillary ectasia and anatomic site. The authors believe that other factors, such as alteration in blood flow between different anatomic regions, and not vessel morphology alone, may be responsible for this variation in response.

Multifocal Basal Cell Carcinoma Developing in a Facial Port Wine Stain Treated with Argon and Pulsed Dye Laser: A Possible Role for Previous Radiotherapy

BACKGROUND

Basal cell carcinoma occurring in port wine stain is extremely rare but has been reported after radiotherapy for port wine stain.

OBJECTIVE

The objective was to present 55-year-old man with a facial port wine stain who had multiple treatment sessions with both the argon laser and the pulsed dye laser and subsequently developed a recurrent multifocal basal cell carcinoma and highlight the treatment carried out and its effects on the outcome.

METHODS

We describe the history of the patient's port wine stain treatment, the development of skin cancer within it, and the different modalities of therapy carried out.

RESULTS

The patient developed basal cell carcinoma in his port wine stain. The possibility of a causal link between laser treatment and this skin cancer was considered but it was discovered that he had had radiotherapy treatment of his birthmark at age 9. The basal cell carcinoma was successfully treated.

CONCLUSION

This case of a clinically indistinct multifocal basal cell carcinoma arising within facial port wine stain was most likely due to previous radiotherapy treatment as a child, rather than laser treatment. Careful treatment history should identify such patients who should be followed-up for development of skin cancer.

Lower Lip Hypertrophy Secondary to Port-Wine Stain: Combined Surgical and Carbon Dioxide Laser Treatment

BACKGROUND

Port-wine stains (PWSs) are capillary malformations that usually show progressive stasis of the vascular channels and cause slow hyperplasia of the soft and hard tissues. When these lesions involve the lower lip, macrocheilia may be developed along the time. Vascular-specific lasers are not adequate to correct these three-dimensional tissue deformities, and surgical management becomes necessary, resulting in considerable morbidity and aesthetic disturbances.

OBJECTIVE

To report a case of macrocheilia secondary to PWS treated by combination of surgery and carbon dioxide laser.

METHODS

A 51-year-old man with macrocheilia of the lower lip and severe functional impairment, secondary to long evolution PWS, received treatment with carbon dioxide laser vaporization and minimal surgical correction, resulting in significant improvement of the lower lip hypertrophy, good aesthetic and functional status, and preservation of the muscular function.

CONCLUSIONS

Combined carbon dioxide laser and surgery treatment may constitute a valuable alternative in treatment of macrocheilia secondary to PWS because bleeding risk is minimized and improves the preservation of muscular function and aesthetic results in relationship to conventional surgical approaches.

Treatment of resistant port wine stains with the V Beam® pulsed dye laser

BACKGROUND AND OBJECTIVES

Pulsed dye lasers (PDL; 585 nm, 0.45 millisecond) are the treatment of choice for port wine stains (PWS). However, clearance rates vary widely and are in many patients incomplete. The objective of this prospective pilot study was to investigate the effects of a long pulse-duration 595 nm PDL (V Beam, Candela Laser Corporation, Wayland, MA) on previously treated PWS to ascertain whether further lightening can be obtained. Treatment response was assessed subjectively (photographs) and objectively with noninvasive techniques (reflectance spectrophotometer and spectrophotometric intracutaneous analysis scope (SIAscope)).

STUDY DESIGN/MATERIALS AND METHODS

Twelve adult patients with congenital PWS each had four test patches with different spot sizes, fluences, and pulse widths carried out. The test area with the best response was selected and two laser treatments were performed at weeks 8 and 16. Photographs and measurements with a reflectance spectrophotometer and SIAscope (Astron Clinica, Cambridge, UK) were performed at baseline, before each treatment and at final review at week 24.

RESULTS

Of the nine patients who completed the study three patients showed a good response (51-75% lightening), which was supported by measurements with the reflectance spectrophotometer and the SIAscope. A further three patients had fair improvement (26-50% lightening) and three patients had a minor or no response (0-25% lightening). In two patients a discrepancy between the degree of clinical response and some of the objective measurements was noticed.

CONCLUSIONS

The 595 nm V Beam PDL appears to achieve further lightening of therapy-resistant PWS in the majority of patients (67%). Both reflectance spectrophotometer and SIAscope appear to permit assessment of objective treatment responses. Results require confirmation in larger studies.

Pyogenic granuloma arising in port-wine stain after cryotherapy

Pyogenic granuloma is a reactive vascular tumor that rarely arises in association with port-wine stain, either spontaneously or after trauma. A 21-year-old woman, presented here, developed a pyogenic granuloma within a facial port-wine stain after treatment with cryotherapy.

Pediatric vascular lesions

The seminal work of Mulliken and Glowacki in 1982 elucidated the histological differences between hemangiomas and vascular malformations: the former are characterized by endothelial cell proliferation, whereas the latter contain mature endothelial cells. Hemangiomas proliferate and then involute, whereas malformations remain stable in size, growing proportionally with the child. Vascular malformations are classified by the predominant vessel type within the lesion (capillary, venous, arterial, and lymphatic). Histological classification therefore correlates with clinical behavior. Treatment of hemangiomas is generally conservative; however, intervention may be required as a result of cosmetically concerning, function-threatening (e.g., interference with eyesight), or life-threatening (e.g., airway obstruction) lesions. Options include steroid therapy, laser treatment, and/or surgical excision. Vascular malformations do not involute and are more likely to require treatment. Treatment options include embolization and surgical resection. Understanding the clinical course of pediatric vascular lesions allows the surgeon to find an appropriate balance between watchful observation, providing reassurance when appropriate, and intervention when needed.

Treatment of phacomatosis pigmentovascularis: a combined multiple laser approach

BACKGROUND

Phacomatosis pigmentovascularis (PPV) consists of a capillary malformation with a variety of melanocytic lesions, which involve various regions of the body and are difficult to treat with conventional therapeutic tools.

OBJECTIVE

We described two cases with PPV (type IIa and IIb) that were successfully treated with different lasers.

METHODS

The areas involved by both melanocytic lesions and port-wine stains were treated using the Q-switched ruby laser, the Q-switched Alexandrite laser, and the flashlamp pumped pulsed-dye laser.

RESULTS

Removal of a good portion of cutaneous and vascular lesions using combined multiple laser approach was achieved after 6 sessions in the first case under general anesthesia and after 31 sessions under local anesthesia in the second case.

CONCLUSION

PPV type II can be treated successfully by laser treatment. We prefer to start combined multiple laser treatment of PPV in childhood period under general anesthesia because it will reduce the number of treatment, improve the patient's quality of life, and increase the cost-effectiveness of the treatment.

Laser surgery: new applications for pediatric skin and airway lesions

Recent research pertaining to laser applications for the treatment of capillary malformations (port wine stains) and cutaneous and subglottic hemangiomas is reviewed within the context of advances in laser technology and current therapeutic practices and controversies. Although laser advances have resulted in the concomitant growth of new clinical applications, research over the past year has focused on refining and improving existing applications, with the ultimate goal of being able to individualize treatment. Research initiatives aimed at improving the outcomes of pulse dye laser treatment for capillary malformations have illustrated the complexity of the interaction between laser characteristics, methods of laser application, variations in human skin and tissue, and morphologic parameters of involved blood vessels. Investigations of cutaneous hemangioma have addressed the issue of early pulse dye laser intervention, and results of a significant prospective study clearly demonstrate that this offers no benefit. Studies of subglottic hemangioma have compared the outcomes of treatment with carbon dioxide (CO(2)) and the potassium-titanyl-phosphate lasers, concluding that the latter results in superior outcomes, with less risk of posttreatment subglottic stenosis.

Management of adult facial vascular anomalies

Vascular anomalies are best classified by biologic behavior-active hemangiomas, and inactive vascular malformations. Hemangioma growth is restricted to infancy, but residual deformity may persist to adult life in the form of redundant skin, bulky fibrofatty tissue, and ectatic cutaneous vessels. Treatment largely consists of scar revision and laser photocoagulation of residual vascular pigmentation. Vascular malformations are present throughout life and can cause increasing facial distortion and disfigurement as capillaries, veins, lymphatics, and/or arteries further dilate and the facial features hypertrophy. A variety of treatment options include laser photocoagulation, sclerotherapy, embolization, and direct surgical excision, and often a combination of techniques yields improved results. In many cases, however, therapy is only palliative, and patients should be advised of the limitations of each treatment option to avoid unrealistic expectations and disappointing results.

Cryogen spray cooling efficiency: improvement of port wine stain laser therapy through multiple-intermittent cryogen spurts and laser pulses

BACKGROUND AND OBJECTIVES

Cryogen spray cooling (CSC) is used to minimize the risk of epidermal damage during laser treatment of port wine stain (PWS) birthmarks. Unfortunately, CSC may not provide the necessary protection for patients with high concentrations of epidermal melanin. The objectives of this study are to: (1) provide a definition of cooling efficiency (eta) based on the amount of heat removed per unit area of skin for a given cooling time; (2) using this definition, establish the eta of previously reported spray nozzles; (3) identify the maximum benefit expected in PWS laser therapy based solely on improvement of eta; and (4) study the feasibility of using multiple-intermittent cryogen spurts and laser pulses to improve PWS laser therapy.

STUDY DESIGN/MATERIALS AND METHODS

A theoretical definition to quantify eta is introduced. Subsequently, finite difference heat diffusion and Monte Carlo light distribution models are used to study the spatial and temporal temperature distributions in PWS skin considering: (1) the current approach to PWS laser therapy consisting of a single cryogen spurt followed by a single pulsed dye laser exposure (SCS-SLP approach); and (2) multiple cryogen spurts and laser pulses (MCS-MLP approach). At the same time, an Arrhenius-type kinetic model is used to compute the epidermal and PWS thermal damages (Omega(E) and Omega(PWS), respectively) for a high epidermal melanin concentration (20%), corresponding to skin types V-VI.

RESULTS

The eta corresponding to a wide range of heat transfer coefficients (h) is quantified. For reported CSC nozzle devices eta varies from 40 to 98%. Using the SCS-SLP approach, it is shown that even eta = 100% cannot prevent excessive Omega(E) for a skin types V-VI. In contrast, the MCS-MLP approach provides adequate epidermal protection while permitting PWS photocoagulation for the same skin types.

CONCLUSIONS

The new proposed definition allows to compute the cooling efficiency of CSC nozzle devices. Computer models have been developed and used to show that the SCS-SLP approach will not provide adequate epidermal protection for darker skin patients (skin types V-VI), even for eta = 100%. In contrast, the MCS-MLP approach may be a viable solution to improve PWS laser therapy for darker skin patients.

Algorithm for using a long-pulsed Nd:YAG laser in the treatment of deep cutaneous vascular lesions

BACKGROUND

Conventional therapies for deep cutaneous vascular anomalies have demonstrated poor efficacy and many side effects. New laser systems offer greater potential to treat these difficult lesions, but the lack of specific treatment guidelines has restricted consistent success.

OBJECTIVE

To establish a rational, user-friendly algorithm that incorporates basic components of deep vascular lesions to define the correct laser settings required for safe, effective, and reproducible treatment.

METHODS

Within 18 months, 162 deep vascular lesions of various types and anatomic sites were evaluated for vessel size, depth, color, and pressure. An algorithm incorporating these characteristics was employed to determine laser parameter settings. Using a high-peak power, long-pulse 1064-nm Nd:YAG laser system, the vascular lesions were then treated.

RESULTS

Within 6 months of follow-up, 80% of treated areas demonstrated a 50% or greater resolution after a single treatment session, with complete clearance shown in 19%. Only minimal and transient side effects were observed. Of note, 74% of areas on the extremities and 83% within the oral cavity showed a 50% or greater resolution after one treatment.

CONCLUSION

Previously challenging deep cutaneous vascular anomalies may be safely reduced or cleared with the use of an appropriate laser system and this algorithm-directed technique. This represents a significant breakthrough in the management of vascular lesions.

The S-Caine peel: a novel topical anesthetic for cutaneous laser surgery

BACKGROUND

The S-Caine peel (Zars, Inc., Salt Lake City, UT) is a novel eutectic lidocaine/tetracaine mixture that is applied as a cream, drying upon exposure to air to form a flexible film that can be peeled off easily. The patented formulation can be used to anesthetize the skin prior to a variety of cutaneous procedures.

OBJECTIVE

To examine the clinical efficacy of the S-Caine peel as a topical anesthetic for pulsed dye laser (PDL) treatment and to determine the optimal application time for adequate cutaneous anesthesia.

METHODS

Sixty patients were enrolled in one of three separate double-blind, placebo-controlled protocols in which the active product or a placebo was applied to the skin and left intact for 20, 30, or 60 minutes prior to laser treatment. A 585 nm or 595 nm PDL was used to treat facial telangiectases or port-wine stains in each protocol. Patients rated the level of pain experienced during laser treatment on a visual analog scale (VAS). Independent assessments of observed discomfort and side effects were recorded.

RESULTS

All patients experienced significant pain reduction with the S-Caine peel as their sole topical anesthetic. An application time of 20 or 30 minutes was as effective as 60 minutes in achieving anesthesia. Side effects of the peel application were limited to transient mild erythema.

CONCLUSION

The S-Caine peel is a rapid, safe, and effective method of topical anesthesia for cutaneous PDL treatment.

Clinical testing of a photoacoustic probe for port wine stain depth determination

BACKGROUND AND OBJECTIVE

Successful laser treatment of port wine stain (PWS) birthmarks requires knowledge of lesion geometry. Laser parameters, such as pulse duration, wavelength, and radiant exposure, and other treatment parameters, such as cryogen spurt duration, need to be optimized according to epidermal melanin content and lesion depth. We designed, constructed, and clinically tested a photoacoustic probe for PWS depth determination.

STUDY DESIGN/MATERIALS AND METHODS

Energy from a frequency-doubled, Nd:YAG laser (lambda=532 nm, tau(p)=4 nanoseconds) was coupled into two 1,500 mum optical fibers fitted into an acrylic handpiece containing a piezoelectric acoustic detector. Laser light induced photoacoustic waves in tissue phantoms and a patient's PWS. The photoacoustic propagation time was used to calculate the depth of the embedded absorbers and PWS lesion.

RESULTS

Calculated chromophore depths in tissue phantoms were within 10% of the actual depths of the phantoms. PWS depths were calculated as the sum of the epidermal thickness, determined by optical coherence tomography (OCT), and the epidermal-to-PWS thickness, determined photoacoustically. PWS depths were all in the range of 310-570 microm. The experimentally determined PWS depths were within 20% of those measured by optical Doppler tomography (ODT).

CONCLUSIONS

PWS lesion depth can be determined by a photoacoustic method that utilizes acoustic propagation time.

Clinical application of lasers in Asians

BACKGROUND

Laser surgery for Asians differs from that for Caucasians in several important respects. In Asians, some conditions such as nevus of Ota are frequently seen and certain adverse reactions, especially postinflammatory hyperpigmentation, tend to be more common.

OBJECTIVE

This article reviews the use of different types of lasers and intense pulsed light (IPL) sources for the treatment of Asian patients.

METHODS

Various cutaneous conditions amenable to laser treatment, including lentigines, nevus of Ota, acquired bilateral nevus of Ota-like macules, port-wine stains, and acne scarring, are discussed. Strategies for the management of postinflammatory hyperpigmentation are offered.

RESULTS

Appropriate selection and careful planning of the treatment can lead to excellent clinical outcome.

CONCLUSION

Lasers and intense pulsed light sources are important tools for the treatment of a wide range of cutaneous conditions in Asians.

Flashlamp pulsed dye laser and argon-pumped dye laser in the treatment of port-wine stains: a clinical and histological comparison

BACKGROUND

Port-wine stains (PWS) are congenital vascular malformations occurring in 0.3% of children. The pulsed dye laser is a well established treatment for PWS.

OBJECTIVES

To compare, clinically and histologically, the effects of the flashlamp pulsed dye laser with the argon-pumped dye laser in the treatment of PWS.

METHODS

Thirty patients were treated on two to four test areas with both laser types using different energy fluences. A flashlamp pulsed dye laser with 0.45 ms pulse duration and a spot size of 5 mm was compared with an argon-pumped dye laser, with a spot size of 1 mm delivered with a robotic scanning laser handpiece (Hexascan) and 70-190 ms pulse duration. Both were tuned to 585 nm. Twelve weeks later the degree of lightening was evaluated and biopsies were taken. To count the vessels the skin sections were stained with CD34 using an immunohistochemical technique. The vessels were divided into three groups by diameter (d): d < 10 microm, 10 < or = d < 20 microm, d > or = 20 microm.

RESULTS

The clinical results showed a significantly better lightening using the flashlamp pulsed dye laser than with the argon-pumped dye laser. The histological results showed a significant decrease in the number of vessels of diameter larger than 20 microm in treated compared with untreated lesions. We found no histological difference in the number of vessels between the two laser treatments. However, there was a tendency towards more small vessels (diameter < 10 microm) after one treatment with the flashlamp pulsed dye laser compared with untreated PWS.

CONCLUSIONS

The flashlamp pulsed dye laser is clinically superior to the argon-pumped dye laser in the treatment of PWS.

Naevus anaemicus with teleangiectatic vessels

We describe a 20-year-old man with naevus anaemicus on the chest where, after dermabrasion of the epidermis, enlarged teleangiectatic dark-red vessels were seen within the previously pale area. They were clearly different from those seen on dermabrasion at this site in normal skin and in patients with vitiligo where the area is lighter red with only small punctual bleedings from arterial capillaries. The naevus anaemicus and a port-wine stain (naevus flammeus) in the same location is a phenomenon of vascular twin spotting, which was revealed when the epidermis was removed. The area was transplanted with thin epidermal grafts and healed within 2 weeks. One year later the naevus looked the same as before grafting. Much thicker grafts than those used by us will be needed, but they are not cosmetically acceptable.

Pediatric plastic surgery revisited

Improvements in surgical technique and an ever improving understanding of the embryologic and cellular origin of many congenital anomalies marks the gains made during the last decade in pediatric plastic surgery. This contemporary review highlights many of these advancements in the diverse array of birth and surgical defects.

Laser pulse impact on rat mesenteric blood vessels in relation to laser treatment of port wine stain

BACKGROUND AND OBJECTIVE

To study the impact of laser pulses on animal microvasculature as a model for laser treatment of port wine stains.

STUDY DESIGN/MATERIALS AND METHODS

Rat mesenteric blood vessels were irradiated with a laser pulse (585 nm, 0.2-0.6 ms pulse duration, 0.5-30 J/cm(2) radiant exposure). Video microscopy was used to assess vessel dilation, formation of intravascular thrombi, bubble formation, and vessel rupture. Changes in reflection during a laser pulse were measured by simultaneously recording the temporal behavior of the incident and reflected signals.

RESULTS

A threshold radiant exposure of approximately 3 J/cm(2) was found for changes in optical properties of blood in vivo, confirming previous in vitro results. Often, laser exposure induced a significant increase in vessel diameter, up to three times the initial diameter for venules and four times for arterioles, within 200 ms after laser exposure. Arterioles were more likely to dilate than venules. Sometimes, immediately after the pulse, round structures, interpreted as being gas bubbles, were seen within the vessel lumen.

CONCLUSIONS

A variety of phenomena can occur when blood vessels of sizes comparable to those in port wine stains are irradiated with laser pulses as used in port wine stain treatment. Thrombus formation and vessel rupture have been described before from histological sections of laser-irradiated port wine stains. However, vessel dilation and formation of non-transient gas bubbles as found in this study have not been described before.

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.

Port-wine stain nodules in the adult: report of 20 cases treated by CO2 laser vaporization

BACKGROUND

Port-wine stain (PWS) is a congenital vascular malformation of the superficial dermal vessels. These vessels become progressively ectatic, with development of nodular and hypertrophic areas on the surface of the lesions.

OBJECTIVE

To determine the efficacy of CO2 laser vaporization in the treatment of nodules in PWS.

METHODS

Twenty adult patients with PWS who developed nodules and hypertrophy on the surface of the lesions were treated by CO2 laser vaporization. Only one pass was performed to each area of the lesions, using a continuous and defocused mode, with a power density of 10 W/cm2. When the treated lesion was very large, several sessions of treatment were necessary to vaporize its entire surface. Photographic controls were performed before and after treatment.

RESULTS

The nodules and hypertrophy were removed and the smooth surface of the lesions was reestablished. The color, usually violaceous, was transformed in a slight erythema.

CONCLUSION

CO2 laser is a good method for treatment of nodules and hypertrophy in PWS. With adequate precautions, excellent cosmetic results can be obtained. Other more-specific laser systems may be successively used to treat the remaining erythema.

Lasers in plastic surgery

The laser is a relatively new tool in many branches of medicine. In particular, in the field of plastic surgery, lasers have found numerous applications. Laser light is produced by the stimulated emission of photons from the lasing medium. Lasers may be classified according to the lasing medium employed, the wavelength of the emitted light and the pulse duration. One of the main uses of lasers is in the treatment of vascular lesions such as port wine stain (PWS). The 585 nm flashlamp pumped pulsed dye laser (FPPDL) is particularly effective in this role. The principle of selective photothermolysis has allowed highly specific targeting of different tissue components. Newer lasers have been developed to treat pigmented lesions as well as primary and metastatic cutaneous malignancies. In cosmetic surgery, lasers have been developed for skin resurfacing and removal of wrinkles, tattoos and unwanted hair. There has been recent interest in the use of lasers to promote wound healing. Laser therapy is not without complications and the safety of both patient and operator must remain paramount. The future is likely to hold greater advances in this rapidly developing field.

Introduction of the flash-lamp pulsed-dye laser treatment of facial port-wine stains in childhood: A case of health care technology assessment

BACKGROUND AND OBJECTIVE

Lasers have been used in the treatment of port-wine stains (PWS) for more than 30 years. With the introduction of the flash-lamp pulsed-dye laser (FPDL) it was assumed that infants could be treated safely, effectively, and probably more efficiently. Nowadays, FPDL treatment is an established form of treatment of PWS in childhood.

STUDY DESIGN/MATERIALS AND METHODS

On the basis of the iterative Health Care Technology Assessment (HCTA) loop, we examined whether sufficient evidence from evaluations has been present to support the introduction of FPDL treatment for facial PWS at an early age. Such an assessment requires an interdisciplinary approach focusing on aspects of safety, efficacy, effectiveness, quality of life, costs, and the ethical issues of treatment.

RESULTS

Assessment of the FPDL in PWS treatment of children did not follow the model of medical innovation and evaluation. Most assessments have been focused on laser applications that were already in clinical use. Efficacy and effectiveness of laser treatment have been the major concern in most assessments. Only a few studies have looked at costs and ethical aspects of treating children.

CONCLUSIONS

The introduction and diffusion of the use of the FPDL in the treatment of PWS in childhood were uncontrolled, and the field was not prepared to use this technique properly. We believe that this nonadherence to the iterative HCTA model reflects the gradual way by which innovations find their way into clinical practice.

[Pathological findings in the eye of children with facial nevus]

BACKGROUND

Port-wine stains distributed to the trigeminal area may be associated with eye and/or central nervous system complications. Visual loss may be prevented with screening for eye pathology at an early age with adequate intervention.

MATERIAL AND METHODS

45 children with port-wine stains in the trigeminal area were examined by an ophthalmologist under general anaesthesia.

RESULTS

Seven of 30 patients with one or both eyelids affected had a choroidal vascular anomaly. Four patients had glaucoma. These four patients had both eyelids affected. Two children with a vascular anomaly had only upper eyelid involvement.

INTERPRETATION

Patients with facial port-wine stains affecting the eyelids should be screened for eye pathology at an early age.

Videomicroscopy of port-wine stains: Correlation of location and depth of lesion

BACKGROUND

Anatomic location and depth of ectasia of port-wine stains (PWSs) are important prognostic indicators when evaluating treatment options for patients. Videomicroscopy permits subsurface evaluation of PWSs, thereby allowing determination of the depth of the ectatic vessels.

OBJECTIVE

Our purpose was to determine whether location of PWSs corresponds to the depth of the ectatic vessels.

METHODS

Seventeen patients presenting for evaluation or treatment of PWSs underwent videomicroscopy with a Video Loupe 7EX microscope. Data were recorded by location of the PWS as a type 1 lesion (blobs or globular structures) corresponding to ectasia of the superficial capillary loops, a type 2 lesion (rings) corresponding to ectasia of the deeper horizontal plexus, or a mixed pattern.

RESULTS

PWSs in areas that typically respond well to laser treatment (V3, neck, and trunk) were more likely to have a superficial type 1 pattern. PWSs in areas that have a poorer response to therapy (V2, distal extremities) were more likely to have a deeper type 2 pattern.

CONCLUSION

We found that patients with lesions in the V3 dermatome and on the trunk and neck have more superficially ectatic vessels, whereas those lesions in dermatome V2 and on the distal extremities have more deeply placed vessels. Further studies are needed to determine whether videomicroscopy can be used to preoperatively predict treatment results.

Basal cell carcinomata in port wine stains

The development of basal cell carcinoma (BCC) in a port wine stain is rare and the aetiology of these malignancies in this situation is the subject of some debate. Early treatment of port wine stains with ionising radiation has been implicated in the development of BCC. The use of the argon laser has not been implicated. We present four cases of BCC in port wine stains, one previously treated with an argon laser, and discuss the possible aetiological factors.

Unilateral acquired nevus flammeus in women

Congenital nevus flammeus is a benign vascular tumor characterized by pink to pale red patches that thicken as the patient ages, producing a dull red to reddish blue, cobblestone-textured plaque. We present the cases of 3 women with unilateral acquired nevus flammeus on the cheek whose lesions resolved after minimal treatment with a 585-nm pulsed dye laser. The etiology of acquired nevus flammeus is reviewed and tumor response rates to laser surgery are discussed.

Temperature distributions in laser-heated biological tissue with application to birthmark removal

The time-dependent temperature distributions produced within thermally homogeneous media heated by a moving laser beam with Gaussian and uniform power density profiles are examined using a time-domain method based on Green's functions. Regions of finite length, width, and depth within the medium having exponential power absorption are considered. The temperature distribution is written as a single integral with respect to time of simple functions and the resulting expressions have been used to model the heating of blood vessels for birthmark (port-wine stain) removal. The temperature distributions obtained are in good agreement with those produced using Monte Carlo optical and finite difference thermal models.