Preliminary report on use of the neodymium-YAG laser in plastic surgery

Laser and light-based treatment of Keloids--a review

BACKGROUND

Keloids are an overgrowth of fibrotic tissue outside the original boundaries of an injury and occur secondary to defective wound healing. Keloids often have a functional, aesthetic, or psychosocial impact on patients as highlighted by quality-of-life studies.

OBJECTIVES

Our goal is to provide clinicians and scientists an overview of the data available on laser and light-based therapies for treatment of keloids, and highlight emerging light-based therapeutic technologies and the evidence available to support their use.

METHODS

We employed the following search strategy to identify the clinical evidence reported in the biomedical literature: in November 2012, we searched PubMed.gov, Ovid MEDLINE, Embase and Cochrane Reviews (1980-present) for published randomized clinical trials, clinical studies, case series and case reports related to the treatment of keloids. The search terms we utilized were 'keloid(s)' AND 'laser' OR 'light-emitting diode' (LED) OR 'photodynamic therapy' (PDT) OR 'intense pulsed light' OR 'low level light' OR 'phototherapy.'

RESULTS

Our search yielded 347 unique articles. Of these, 33 articles met our inclusion and exclusion criteria.

CONCLUSION

We qualitatively conclude that laser and light-based treatment modalities may achieve favourable patient outcomes. Clinical studies using CO2 laser are more prevalent in current literature and a combination regimen may be an adequate ablative approach. Adding light-based treatments, such as LED phototherapy or PDT, to laser treatment regimens may enhance patient outcomes. Lasers and other light-based technology have introduced new ways to manage keloids that may result in improved aesthetic and symptomatic outcomes and decreased keloid recurrence.

Lasers and adjunctive treatments for facial scars: a review

A variety of facial scars--erythematous, pigmented, atrophic and hypertrophic--may occur as a result of trauma, surgery, burns and skin disease such as acne. Surgery with other adjunctive methods including radiotherapy, intralesional steroids and pressure therapy have shown variable results. Laser treatment has been attempted for scar revision since the 1980s. The continuous wave lasers, including continuous wave carbon dioxide (CO2), argon and Nd:YAG achieved some improvement; however, their use was limited by the inherent problems of continuous mode lasers. The pulsed dye laser has been successfully used in erythematous and hypertrophic scars. Pigment-specific Q-switched lasers have shown a good improvement for pigmented scars. Skin resurfacing lasers (both CO2 and erbium-YAG) have been used successfully to improve selected atrophic facial scars. The results may be improved by using lasers together with scar subcision and injectable or implantable fillers.

Lasers in periodontics

Publicity about the use of lasers in dentistry has generated considerable interest in both professional and lay audiences. The purpose of this report is to provide information for members of the dental profession about the current and potential application of laser technology to periodontal practice. This report was prepared by the Research, Science and Therapy Committee of the American Academy of Periodontology.

Laser treatment of hypertrophic scars, keloids, and striae

The successful use of the 585-nm pulsed dye laser for the treatment of hypertrophic scars has been well established over the past decade. Although 5 years ago this treatment option might have been considered as a viable choice only after all other methods failed, it is now generally recognized as an excellent first-line treatment option. Early scar treatment with pulsed dye laser irradiation effectively prevents scar formation or worsening and yields a better and more prolonged clinical improvement. The concomitant use of corticosteroids, 5-fluorouracil, or other treatments is proving to be of particular importance in reducing scar bulk and symptoms of more proliferative scars. Although optimal management for keloids and striae has yet to be determined, pulsed dye laser irradiation will no doubt continue to play a role in their treatment.

Sclerotherapy for treatment of hemangiomas

BACKGROUND

While sclerotherapy in chronic venous insufficiency and in hemorrhoids is well established, the use of sclerotherapy for hemangiomas of the skin is widely unknown.

OBJECTIVE

The aim of the study was to analyze the clinical value of sclerotherapy with polidocanol in a larger population.

METHODS

Over a period of 20 years (1975-1995) we performed sclerotherapy of hemangiomas and vascular malformations in a total of 157 patients. Their ages ranged from 3 months to 75 years. Among these were 87 (55.4%) children and adolescents (up to the age of 18). Sclerotherapy with polidocanol was carried out mostly at monstrous or rapidly growing cavernous hemangiomas mainly localized in the face.

RESULTS

One to three injections was usually sufficient to obtain the sclerosis effect; aesthetically, long-term results were convincing. Severe complications were not observed.

CONCLUSION

Sclerotherapy of hemangiomas is a relatively simple, effective, and inexpensive method that is a valuable and promising treatment.

Laser treatment of hypertrophic scars, keloids, and striae

Lasers are now being used successfully to improve various types of scars and striae. It is not only imperative to properly categorize the type of scars and striae present, but to determine which laser or lasers can best treat them. A 585-nm flashlamp pumped pulsed dye laser is preferred for the treatment of hypertrophic scars, keloids, and striae distensae. CO2 laser vaporization of scars that are proliferative, such as hypertrophic scars and keloids, is not advised due to the high rate of recurrence or worsening. When properly used, lasers can effect the best clinical responses in hypertrophic scars and keloids ever observed. Future laser technologic advances as well as the addition of concomitant lasers or other treatments may enhance clinical results. It appears evident that by promoting the remodeling phase of wound healing, abnormal scarring may be prevented or improved. Laser surgery may best be able to accomplish this by triggering regression of blood vessels and, therefore, fibroblasts within the scar. By so doing, further deposition of connective tissue may be halted.

Basic laser principles

Skin diseases have been treated with lasers since the early 1960s. The three principal chromophores in the skin--hemoglobin, melanin, and water--have different absorption spectra that selectively absorb certain wavelengths of electromagnetic radiation. A given wavelength and pulse duration will selectively treat a target containing a chromophore. The wide variety of lasers and their applications are discussed.

Nd:YAG laser irradiation in conjunction with cryogen spray cooling induces deep and spatially selective photocoagulation in animal models

Successful laser treatment of haemangiomas requires selective photocoagulation of subsurface targeted blood vessels without thermal damage to the overlying epidermis. We present an in vivo experimental procedure, using a chicken comb animal model, and an infrared feedback system to deliver repetitive cryogen spurts (of the order of milliseconds) during continuous Nd:YAG laser irradiation. Gross and histologic observations show deep-tissue photocoagulation is achieved, while superficial structures are protected from thermal injury due to cryogen spray cooling. Experimental observation of epidermis protection in chicken comb animal models suggests selective photocoagulation of subsurface targeted blood vessels for successful treatment of haemangiomas can be achieved by repetitive applications of a cryogen spurt during continuous Nd:YAG laser irradiation.

Spatially selective photocoagulation of biological tissues: feasibility study utilizing cryogen spray cooling

Successful laser treatment of selected dermatoses such as hemangiomas requires thermally induced damage to blood vessels while protecting the epidermis. We present and test a procedure in a rabbit liver tissue model that utilizes cryogen spray cooling during continuous Nd:YAG laser irradiation to induce deep photocoagulation necrosis while protecting superficial tissues from thermal injury. Gross and histologic observations are consistent with calculated thicknesses of protected and photocoagulated tissues and demonstrate the feasibility of inducing spatially selective photocoagulation when cryogen spray cooling is used in conjunction with laser irradiation. This procedure may be useful in the thermal treatment of some pathological conditions for which it is desired that deep photocoagulation be induced while protecting superficial tissues.

Improvement of facial acne scars by the 585 nm flashlamp-pumped pulsed dye laser

BACKGROUND

Hypertrophic or erythematous scars (or both) have remained notoriously difficult to treat because of their persistence or recurrence after traditional therapies. Recently, the 585 nm flashlamp-pumped pulsed dye laser has been shown to be effective in treating similar traumatic and surgical scars.

OBJECTIVE

Our purpose was to determine the effectiveness of the 585 nm flashlamp-pumped pulsed dye laser in the specific treatment of facial acne scars.

METHODS

Twenty-two patients with erythematous or hypertrophic facial acne scars were included in this Investigational Review Board-approved study. The 585 nm flashlamp-pumped pulsed-dye laser was used to treat scars on half of each patient's face, with the contralateral side used as control. Baseline, 6-week, and 6-month posttreatment photographs, erythema measurements made with reflectance spectrometry, and skin texture analyses were obtained from laser-irradiated and untreated scars. Clinical analyses were performed independently by two "blinded" observers.

RESULTS

Significant clinical improvement was observed in laser-irradiated acne scars compared with the untreated (control) scars after one or two 585 nm pulsed-dye laser treatments. Erythema measurements and skin texture analyses of laser-treated scars approximated those obtained in the adjacent normal skin.

CONCLUSION

The 585 nm flashlamp-pumped pulsed-dye laser can significantly improve the clinical appearance of erythematous or hypertrophic facial acne scars.

Nd:YAG laser turbinate surgery animal experimental study: preliminary report

The chronically hypertrophic nasal turbinate is a challenging problem for otolaryngologists. Although some success has been achieved with a number of medical and surgical methods, other forms of treatment are still needed. In this study, encouraging results were achieved using the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser on canine turbinates. Clinical and histological results showed that with Nd:YAG laser surgery, coagulation occurs in the deep cavernous vessels and submucosal glands of the turbinate, while the overlying mucosa remains intact.

Clinical uses of lasers in dermatology

The accessibility of the skin to examination and study has permitted dermatologists to play an extremely important role in defining the clinical usefulness and limitations of many laser systems as well as developing innovative concepts, techniques and devices that further improved the effectiveness of laser treatment. As new laser technology evolved over the years, dermatologists have also helped define the specificity of laser-tissue interaction and employed the newly developed laser technologies in innovative ways which further expanded the usefulness of these devices. One of the most important concepts to be developed by dermatologists--selective photothermolysis--has led to the creation of a series of laser systems which have provided numerous unique advantages in the management of many common vascular and pigmented conditions of the skin and mucous membranes, even in infants and children. The net result of these technologic advances has been the creation of new and effective treatment techniques which have been so profoundly superior to existing technology that they have been rapidly incorporated into the daily practice of most dermatologists.

The Nd:YAG laser treatment of hemangioma

An Nd:YAG laser was used in the treatment of 160 patients with hemangioma from January 1989 to January 1993. Irradiance was between 800 and 1600 W/cm 2 with energy between 400 and 1600 J/cm 2. The best results with almost total restoration were obtained in 21 of the 160 patients (13%). The size of the hemangioma was reduced by more than 50% in 88 cases (55%), by less than 50% in 56 cases (35%), and by a negligible amount in 3 cases (2%). Side effects as found in 160 patients or 10% included slow healing, superficial skin necrosis, and occurrence of scars. Most hemangiomas can shrink by themselves. However, the treatment is needed for cases with risk of various side effects including scar formation, sepsis, bleeding, or abnormal growth of an organ. We concluded that the Nd:YAG laser is a very useful instrument in the treatment of abnormality of blood vessels, such as hemangioma.

The contact Nd-YAG laser for oral and oropharyngeal malignant tumors

Nine oral and oropharyngeal squamous cell carcinomas were removed with a contact Nd-YAG laser. Clinical and morphological studies on wound healing and effects of the Nd-YAG laser were performed. The wounds were not sutured and patients did not complain of any severe symptoms. The wound healing was prolonged to 3-6 weeks. Cells and glands degenerated at a depth of 2-3 mm by the direct effects of the laser. The epithelium exhibited acantholysis 5 mm from the site of laser injury. Scanning electron microscopy showed no coagulation or other coated material in the wound created by a surgical knife, while the wound surface by laser consisted of carbonization, well-coated and non-coated areas. These findings varied with the laser power. The coagulation and thermal effects of the Nd-YAG laser resulted in autolysis of tumor cells at least within 5 mm of the cutting surface. The contact Nd-YAG laser was useful for the removal of the malignant tumor in the oral cavity and oropharynx where it is difficult to maintain a generous safety margin.

Treatment of port-wine stains for the 1990s

BACKGROUND

A dramatic improvement in the treatment of patients with port-wine stains has occurred over the past 20 years owing to the availability of a variety of different laser systems. The argon laser was the first system to offer an advantage over the older surgical techniques that had previously been used to manage these patients. However, many new lasers have since been developed that further improved the treatment results while simultaneously reducing the risks, even when treating children.

OBJECTIVE

To present the current status of laser surgery for port-wine stains and describe how the many newer systems are being used to more effectively manage these patients.

METHODS

A thorough review of the medical literature was conducted on the use of new lasers, delivery systems, and treatment techniques for the management of port-wine stains.

RESULTS

The biggest advance in laser treatment of port-wine stains resulted from the development of systems that are capable of delivering yellow light. The improved precision provided by these lasers serves to minimize epidermal injury, limit nonspecific thermal damage, and permit treatment of newborns and young children without a significant risk of scarring.

CONCLUSION

Major benefits in the treatment of port-wine stains have resulted from the recent development of many new laser systems and laser accessories that provide a more precise response with less potential for complications than had been previously attainable with older technologies.

Treatment of keloids with surgical excision and postoperative X-ray radiation

124 patients with keloids were treated with surgical excision followed by postoperative X-ray radiation, begun within 24 hours after surgery. Only patients with a two-year keloid history were included in this study. The treatment results were evaluated 6 and 24 months after treatment. There was good correlation agreement between subjective and objective evaluations. Good or excellent results were observed in 92% of the patients. Side effects were moderate. Slight hyperpigmentation was found in 31% of the patients and telangiectasis in 15%. It was concluded that excision and early postoperative irradiation constitute effective keloid treatment.

Failure of carbon dioxide laser excision of keloids

Seven patients with nine keloids have been treated by excision with the carbon dioxide laser. Eight of the nine keloids have recurred to their original or close to original size as early as 10 months following treatment and as late as 22 months. Keloids included in this study were located on the trunk, nuchal region, back, and earlobe. Only one patient (who underwent earlobe keloid excision) has greatly improved keloids after only 9 months follow-up, but this patient needs to wear pressure earrings continuously. The long-term benefits of keloid excision with the carbon dioxide laser is not demonstrated in this case study series.