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Background: Multiple exposures to general anesthesia may be neurotoxic to the developing brain. This relationship has not been evaluated in children undergoing laser surgery for vascular anomalies., Objective: To evaluate the prevalence of neurodevelopmental abnormalities in children who received multiple laser procedures under general anesthesia before the age of 4 years for the treatment of vascular anomalies., Methods and Materials: Retrospective chart review of patients with contact of parents for telephone interview., Results: Thirty-three patients were eligible. Average age at the time of survey was 7.8 years. Twenty-three (84.8%) patients were female, with average age at the time of first treatment at 1.9 years. Average number of treatments received before the age of 4 years was 6.7. Anesthetics included inhalational nitrous oxide and isoflurane and intravenous propofol. Seven patients carried one or more of the following diagnoses: attention-deficit hyperactivity disorder (3.0%), anxiety (6.1%), behavioral disorder (3.0%), language disorder (3.0%), speech disorder (3.0%), and motor disorder (6.1%). These prevalence rates are similar to those found in the US population., Conclusion: This is the first report on the prevalence of neurodevelopmental disorders in children undergoing multiple laser treatments under general anesthesia. Although the study sample is small, no increased risks when comparing with prevalence rates reported in the literature were noted.

Background: Topical anesthetics remain a powerful, new advance for pain relief prior to cutaneous procedures. They are frequently used by dermatologists to decrease the pain associated with laser pulses, surgical procedures, or soft tissue augmentation. EMLA is the most commonly used agent, however, several new topical anesthetic agents have been released recently that claim increased efficacy and a faster onset of action., Objective: We review and compare the efficacy of several commonly used topical anesthetics and provide a look into the future., Conclusion: EMLA remains the most widely used topical anesthetic given its proven efficacy and safety by several clinical trials. There has been a recent release of several new topical anesthetic agents with some demonstrating efficacy after a 30-minute application time. A reservoir of anesthetic is located and stored in the upper skin layers during application, providing additional anesthetic benefit 30 minutes after removal. As the options for the practitioner continue to grow, the demand for faster onset, comparative efficacy, and safety trials will continue to be of paramount importance.

Background: Hemangiomas are common skin tumors of infancy that have undergone recent changes in nomenclature, methods of evaluation, and treatment., Objective: To review the nomenclature, epidemiology, evaluation, and treatment of common hemangiomas., Methods: A literature search was conducted utilizing MEDLINE and the Cochrane library databases. Text search words used were "hemangioma" and "infancy." The clinical experience of the authors was also used to formulate the review., Results: There have been many advances in nomenclature and therapeutic options for children with hemangiomas. Hemangiomas are proliferative tumors of infancy that should be distinguished from structural malformations, such as port-wine stains and lymphangiomas., Conclusion: Natural involution remains a viable treatment option for the majority of patients with uncomplicated hemangiomas. Excisional surgery, laser, and pharmacologic remedies are indicated for a subset of complicated hemangioma patients.

The role dermatologists have played throughout the history of laser development is an extremely vital one. The initial interests of Dr. Leon Goldman stimulated many other individual dermatologists to further his work and develop surgical techniques using newer laser systems to provide more effective treatment for patients with a variety of skin diseases. The long list of current cutaneous laser applications developed by dermatologists makes it virtually certain that members of our specialty will continue to play a significant future role in the refinement of laser instrumentation and operative techniques that are inevitable to occur.

Background: Multiple laser systems are available for the purpose of hair removal., Objective: The purpose of this study was to determine the safety and long-term efficacy of the 800 nm, pulsed diode laser at reducing hair count., Methods: Fifty volunteers, primarily Fitzpatrick skin types II and III, with dark brown or black hair, were treated with a diode laser (800 nm, 10-40 J/cm2, 5-30 msec, 9 mm 9 mm, 5 degrees C chilled handpiece). Each subject had eight treatment sites at varying fluences and pulse durations, as well as a varying number of treatments and pulses. Hair counts were obtained at each site at baseline, 1, 3, 6, 9, and an average of 20 months after treatment., Results: After one treatment, hair regrowths ranged from 22 to 31% at the 1-month follow-up visit, then remained stable between 65 and 75% from the 3-month to the averaged 20-month follow-up. After two treatments there were relatively longer growth delays, with hair regrowths plateauing beginning at 6 months after treatment and ranging from 47 to 66% for the remainder of the follow-up evaluations. Side effects were limited to pigmentary changes, transient in subjects with skin types II and III., Conclusions: This 800 nm diode laser with a chilled sapphire tip and variable pulse duration is safe and effective for long-term hair reduction in individuals with skin types II and III.

Background: Pulsed dye laser treatments usually result in purpura. Any topical application that eliminates or shortens the duration of purpura would be extremely useful., Objective: The purpose of this prospective study was to determine the safety and efficacy of topical vitamin K cream in shortening the duration of laser-induced purpura., Methods: Twenty adult subjects were enrolled. Each subject had five 1.5 cm sites treated with a pulsed dye laser at 585 nm, 450 nsec, 7 mm spot size at each subject's respective threshold fluence. Each subject had a control site where no topical application was used and four other sites where a different formulation was applied to each for 2 weeks before and for 2 weeks after laser irradiation. Five vitamin K formulations with or without retinol were studied: 3% vitamin K in acrylates copolymer cream, 5% vitamin K in acrylates copolymer cream, 1% vitamin K and 0.3% retinol in acrylates copolymer cream, 1% vitamin K and 0.15% retinol in acrylates copolymer cream, 1% free vitamin K cream. Purpuric discoloration at each site was rated on days 0, 1, 3, 7, 10, and 14 after laser treatment on a quartile scale. Each site was assigned 100% discoloration on day 0 after laser irradiation., Results: Laser-induced purpuric discoloration resolved faster with 1% vitamin K and 0.3% retinol in acrylates copolymer cream than with no topical application. The difference is statistically significant from day 3 onward., Conclusion: A combination of 1% vitamin K and 0.3% retinol in acrylates copolymer cream hastened the resolution of laser-induced purpura.

Background: Scars have a significant effect on a person's physical and social being. Many treatment modalities for scar improvement such as surgical scar revision, electrosurgical planing, chemical peeling, filler substance implantation, and dermabrasion have been developed. Recently, the resurfacing carbon dioxide (CO2) laser systems have proven to be a useful and safe treatment in the treatment of facial rhytides and acne scarring., Objective: The purpose of this study was to evaluate the resurfacing CO2 lasers in the treatment of various surgical, traumatic, acne, and varicella scars., Methods: Thirty subjects, aging between 14 and 84 years, with surgical, traumatic, acne, or varicella scars were evaluated. Two types of resurfacing laser systems were utilized in this study, a high-energy, short-pulsed CO2 laser and a continuous wave CO2 laser with an optico-mechanical computer flash-scanner. Post-surgical scars were treated with laser resurfacing between 4 and 6 weeks after scar formation. Traumatic, acne, and varicella scars were treated after scar maturation (range, 1-10 years). Scar improvement was evaluated by photographic analysis of before and after images by four independent health care workers using a quartile scale of improvement (< 25%, 25-49%, 50-74%, > 75%) as well as optical profilometry using silicone surface impressions in 12 scars., Results: Twenty of 24 surgical scars had greater than 75% improvement, and 24 of 24 had greater than 50% improvement by photographic analysis. All six traumatic, acne and varicella scars had greater than 50% improvement. Optical profilometry and surface topography maps reveal a significant flattening of related and depressed scars., Conclusion: The high-energy, short-pulsed CO2 laser and the continuous wave CO2 laser with flash-scanning attachment are safe and effective as a treatment modality for scar revision. In general, elevated scars improve more dramatically than depressed scars.

Background and Objective: The objective of this study was to determine the effectiveness of a dynamic cooling device (DCD), spraying the skin with a brief spurt of cryogen prior to the laser pulse, in reducing transient pain associated with 585-nm pulsed dye laser (PDL) treatment of port-wine stains (PWS), and reducing epidermal damage (hypo/hyperpigmentation) caused by this laser during PWS treatment., Materials and Methods: Matched treatment sites were compared with and without the use of the cryogen spray in 47 patients at two investigational sites. Pain ratings, clearance of the PWS, and pigmentation changes were assessed. The results were analyzed by skin type and patient age., Results: A statistically significant reduction in pain ratings was found in all patient groups using the DCD without changing the efficacy of PWS clearance. Pain reduction was most remarkable in patients with darker skin types. Dynamic cooling prevented the occurrence of epidermal damage or pigmentation change in most cases., Conclusions: This study suggests that dynamic cooling can dramatically diminish pain during PWS treatment with the 585-nm PDL without reducing treatment efficacy. The absence of epidermal damage in most patients suggests that precooling with the DCD may allow the use of higher laser fluences to expedite clearance without inducing epidermal change. Dynamic cooling has potential use with other lasers and different lesions where discomfort and epidermal effects limit therapy.

Background: Carbon dioxide (CO2) laser resurfacing has become a very popular method of rhytide and scar removal in the recent past. Preliminary studies have been published describing the method, histology, and clinical results of CO2 laser resurfacing. However, none of these studies has dealt with long-term follow-up results., Objective: To review all side effects resulting from CO2 laser resurfacing with regard to both short- and long-term effects., Method: Retrospective analysis of 104 patients who have undergone CO2 laser resurfacing for either facial rhytides and/or scarring with follow-up periods of 4-23 months (average, 8.2 months)., Results: The incidence of side effects are generally very low for CO2 laser resurfacing, including scarring, postinflammatory hyperpigmentation, and infection. However, there is a significant and previously unreported risk of hypopigmentation in an area of the population who often seek improvement in the appearance., Conclusions: CO2 laser resurfacing of facial rhytides and acne scars can be a very safe procedure by an experienced laser operator. However, careful patient selection, thorough patient instruction, and proper aesthetic analysis of treatment sites must be followed to insure the most favorable outcomes with CO2 laser resurfacing.

Background: Traumatic tattoos result from accidental or unintentional deposition of exogenous pigment within injured skin. Pigments may consist of heavy metals, vegetable matter, or commercial dyes., Objective: The clinical and histologic description of a traumatic tattoo resulting from a surgical procedure using undyed, braided, synthetic, absorbable suture material and its removal with the Q-switched ruby laser (694 nm, 28 nsec)., Methods: The pigmented linear lesion was biopsied and processed using standard histological methods. Subsequently, the area was treated on two occasions with the Q-switched ruby laser., Results: The pigmented lesion was completely removed with the Q-switched laser treatments., Conclusion: We report on the occurrence of a traumatic tattoo resulting from synthetic suture material and complete removal with the Q-switched ruby laser.

Background: New "char-free" carbon dioxide lasers are capable of precise tissue vaporization with minimal residual thermal damage. These lasers operate either by producing high energy, rapid pulses or by scanning a highly focused continuous mode beam., Objective: To determine the depth of ablation and the depth of residual thermal injury produced with one to three passes of the pulsed and scanned systems., Methods: The distal ends of preauricular donor skin from 12 patients requiring full-thickness skin grafts following Mohs micrographic surgery were treated with zero to three passes of each of the lasers, and fixed for histopathological analysis., Results: The three lasers tested produced vaporization of thin (20-50 microns) layers of tissue and narrow (20-150 microns) zones of thermal injury following one, two, or three passes on intact skin., Conclusion: The pulsed and scanned technologies are capable of producing "char-free" tissue ablation with minimal residual thermal damage.

Background: Recent advances in carbon dioxide (CO2) laser technology have resulted in the development of lasers that can precisely remove thin layers of skin with minimal thermal damage to the surrounding tissue. These lasers rely on rapid pulsing or scanning of the laser beam. The effects of these lasers are predictable and reproducible, making them ideal for skin resurfacing. Clinical results have been promising, however, to date, no published series exist., Objective: To evaluate the effectiveness and side effect profile of laser resurfacing utilizing a CO2 laser with a scanning device, and make recommendations for patient selection and treatment protocol., Methods: Patients with perioral, periorbital, and glabellar rhytides were treated with a CO2 laser with a scanning device. Utilizing chart review and photographic evaluation, patients treated between November 1994 and April 1995 were retrospectively evaluated for effectiveness of therapy, healing time, and complication rates., Results: A total of 47 patients were evaluated. Photographic evaluation or chart review revealed good to excellent cosmetic results in all anatomic areas studied. All patients experienced posttreatment erythema lasting 1-6 months. Other minor complications were limited to contact dermatitis to topical preparations, transient postinflammatory hyperpigmentation, and milia formation. One patient experienced a primary herpes simplex virus infection during reepithelialization and required intravenous therapy. Minor focal atrophy was seen in one patient. No hypertrophic scarring or permanent pigmentation changes were seen., Conclusions: A CO2 laser system with a scanning beam can effectively and safely improve or remove glabellar, perioral, and periorbital rhytides.

Background: Approximately 50-75% lightening of port-wine stains is achieved within two to three treatments with pulsed dye laser therapy, but the incidence of complete clearing is variable., Objective: This study was designed to: 1) assess the ability of continued repetitive pulsed dye laser treatments to further lighten persistent port-wine stains; 2) evaluate the factors contributing to the resistance of port-wine stains to laser therapy; and 3) determine the relative risk of adverse effects following repetitive treatments to the same area., Methods: A retrospective photographic analysis was performed of 69 patients that failed to achieve greater than 75% lesional lightening within nine treatment sessions. The percentage improvement was assessed by comparing the degree of lightening at the last treatment to that of the midway point of treatment., Results: Significant improvement in port-wine stain lightening, from the midway to last treatment, was seen in patients who had 10-25 repetitive treatments., Conclusion: Repetitive treatments with the pulsed dye laser can lead to improvement in the overall lightening of persistent port-wine stains without an increased risk of adverse effects.