"1927-nm Fractional resurfacing of facial actinic keratoses: A promising new therapeutic option"Weiss, Elliot T; Brauer, Jeremy A; Anolik, Robert; Reddy, Kavitha K; KAREN, JULIE K; Hale, Elizabeth K; Brightman, Lori A; Bernstein, Leonard; Geronemus, Roy G
BACKGROUND: Actinic keratoses (AK) are precancerous epidermal proliferations commonly present on chronically sun-damaged skin. These lesions are among the most often treated dermatologic conditions. OBJECTIVE: We sought to investigate the 6-month safety, tolerance, and efficacy of nonablative 1927-nm fractional resurfacing of facial AK. METHODS: This was a prospective clinical trial of 24 individuals with facial photodamage and AK receiving up to 4 treatments with the fractionated 1927-nm nonablative thulium laser. RESULTS: At 6 months, an 86.6% reduction in absolute number of lesions was noted by independent physician assessment. In addition, at this same time point, patients reported marked or noticeable improvement in overall photodamage. LIMITATIONS: This prospective study does not provide safety, tolerance, and efficacy data beyond 6 months of follow-up, nor does it identify the precise mechanism of action involved in AK clearance after 1927-nm resurfacing. CONCLUSION: The clinical and histologic findings, as well as the reported patient satisfaction and safety, suggest that the treatment of AK and photodamage with a fractionated 1927-nm nonablative thulium laser is a promising new therapeutic option..
"Investigation into optimal treatment intervals of facial port-wine stains using the pulsed dye laser"Anolik, R; Newlove, T; Weiss, ET; Brightman, L; Hale, EK; KAREN, JK; Bernstein, L; Geronemus, RG
BACKGROUND: Port-wine stains (PWS) affect 0.3% to 0.5% of newborns and pulsed dye laser (PDL) remains the treatment of choice. Optimal treatment intervals have not been established. OBJECTIVE: We sought to validate the optimal treatment intervals for the management of facial PWS with PDL. METHODS: In all, 24 infants with facial PWS who received at least 5 treatments with the PDL at 2-, 3-, and 4-week intervals at a private laser and skin surgery center from 2009 to 2010 were identified by a retrospective chart review. Safety and efficacy were compared by blinded investigators. RESULTS: Side effects were equivalent in all interval groups and included only expected short-term erythema, edema, purpura, and mild postinflammatory hyperpigmentation. No patient developed hypopigmentation, scarring, or infection. All interval groups showed 50% to 100% clearance of their PWS after 5 treatments. Complete or near-complete clearance was seen in 6 of 8 (75%) and 7 of 8 (87.5%) patients in the 2- and 3-week interval groups, respectively, as compared with 3 of 8 (37.5%) patients in the 4-week interval group. LIMITATIONS: This was a retrospective chart review from a single institution. Long-term side effects and recurrence rates were not assessed. CONCLUSION: We conclude that PDL treatments at 2-, 3-, and 4-week intervals are effective for the management of facial PWS in infants with minimal short-term side effects. Shorter treatment intervals may allow for relatively more rapid and more effective treatment..
"Successful and rapid treatment of blue and green tattoo pigment with a novel picosecond laser"Brauer, Jeremy A; Reddy, Kavitha K; Anolik, Robert; Weiss, Elliot T; KAREN, JULIE K; Hale, Elizabeth K; Brightman, Lori A; Bernstein, Leonard; Geronemus, Roy G
BACKGROUND While the understanding and technology of laser tattoo removal has advanced much over the last 5 decades, treatments and results remain far from perfect. With currently available devices, treatment courses are often painful and prolonged with mixed results. We describe the successful and rapid treatment of 12 tattoos containing blue and/or green pigment with a novel, picosecond, 755-nm alexandrite laser. OBSERVATIONS All previously untreated multicolored tattoos as well as tattoos recalcitrant to treatment demonstrated at least 75% clearance of blue and green pigment after 1 or 2 treatments with a novel, picosecond, 755-nm alexandrite laser. More than two-thirds of these tattoos approached closer to 100% clearance. CONCLUSIONS While additional future studies are needed, we believe that this new technology is more effective in targeting blue and green pigment, resulting in expedited clearance with less collateral injury to surrounding tissue..
"Ablative Fractional Resurfacing for Involuted Hemangioma Residuum"Brightman, Lori A; Brauer, Jeremy A; Terushkin, Vitaly; Hunzeker, Christopher; Reddy, Kavitha K; Weiss, Elliot T; KAREN, JULIE K; Hale, Elizabeth K; Anolik, Robert; Bernstein, Leonard; Geronemus, Roy G
BACKGROUND Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas. OBSERVATIONS All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance. CONCLUSION While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas..
"Calcium Hydroxylapatite Nodule Resolution After Fractional Carbon Dioxide Laser Therapy"Reddy, KK; Brauer, JA; Anolik, R; Bernstein, L; Brightman, LA; Hale, E; KAREN, J; Weiss, E; Geronemus, RG
BACKGROUND: Injection of calcium hydroxylapatite filler may result in nodule formation owing to superficial placement of the filler. Calcium hydroxylapatite nodules are difficult to reverse. Previously reported therapeutic options are limited and include intralesional triamcinolone, massage, needling, and excision, each with inconsistent results or potential for scarring. Observation We have observed complete resolution of calcium hydroxylapatite nodules after a single treatment with fractional carbon dioxide laser. CONCLUSIONS: A single session of fractional carbon dioxide laser treatment may resolve selected cases of calcium hydroxylapatite nodules. The mechanism of action may involve conversion of the product into tricalcium phosphates which dissolve readily. This novel therapeutic technique may enhance treatment options for a difficult clinical problem..
"Reduction of thickened flap using fractional carbon dioxide laser"Brightman, Lori A; Brauer, Jeremy A; Anolik, Robert; Weiss, Elliot T; KAREN, JULIE; Chapas, Anne; Hale, Elizabeth; Bernstein, Leonard; Geronemus, Roy G
BACKGROUND AND OBJECTIVE: The paramedian forehead flap is an excellent choice when repairing a large nasal defect. However, even when carefully thinned, the flap may develop a bulky appearance, an ill-fitting contour, or trap door deformity. When on the face, these suboptimal results can be quite distressing. Surgical and non-surgical options for improvement exist. Surgical options include additional debulking and reorientation of the flap. Non-surgical options include intralesional corticosteroids or 5-flourouracil, dermabrasion, and ablative and non-ablative laser resurfacing. Each option has limited benefit as well potential side effects. STUDY DESIGN/MATERIALS AND METHODS: Case report. RESULTS: In this report, we present dramatic improvement of a thickened paramedian forehead flap using the Fraxel Re:pair, a fractional carbon dioxide (CO(2) ) laser (Solta Medical, Inc. Hayward, CA). CONCLUSION: To our knowledge, this is the first case in the literature demonstrating successful reduction of a bulky flap using a fractional ablative laser..
"Successful treatment of atrophic postoperative and traumatic scarring with carbon dioxide ablative fractional resurfacing: quantitative volumetric scar improvement"Weiss, Elliot T; Chapas, Anne; Brightman, Lori; Hunzeker, Christopher; Hale, Elizabeth K; KAREN, JULIE K; Bernstein, Leonard; Geronemus, Roy G
OBJECTIVE: To assess the safety and efficacy of ablative fractional resurfacing (AFR) for nonacne atrophic scarring. DESIGN: In this before-and-after trial, each scar received 3 AFR treatments and 6 months of follow-up. SETTING: Private academic practice. PATIENTS: Fifteen women with Fitzpatrick skin types I to IV, aged 21 to 66 years, presented with 22 nonacne atrophic scars between June 1 and November 30, 2007. Three patients (3 scars) were excluded from the study after receiving 1 AFR treatment and not returning for follow-up visits. The remaining 12 patients (19 scars) completed all 3 treatments and 6 months of follow-up. INTERVENTIONS: Each scar received 3 AFR treatments at 1- to 4-month intervals. MAIN OUTCOME MEASURES: Erythema, edema, petechiae, scarring, crusting, and dyschromia were graded after treatment and through 6 months of follow-up. Skin texture, pigmentation, atrophy, and overall appearance were evaluated after treatment and through 6 months of follow-up by the patient and a nonblinded investigator. A 3-dimensional optical profiling system generated high-resolution topographic representations of atrophic scars for objective measurement of changes in scar volume and depth. RESULTS: Adverse effects of treatment were mild to moderate, and no scarring or delayed-onset hypopigmentation was observed. At the 6-month follow-up visit, patient and investigator scores demonstrated improvements in skin texture for all scars (patient range, 1-4 [mean, 2.79]; investigator range, 2-4 [mean, 2.95]), pigmentation for all scars (patient range, 1-4 [mean, 2.32]; investigator range, 1-4 [mean, 2.21]), atrophy for all scars (patient range, 1-4 [mean, 2.26]; investigator range, 2-4 [mean, 2.95]), and overall scar appearance for all scars (patient range, 2-4 [mean, 2.89]; investigator range, 2-4 [mean, 3.05]). Image analysis revealed a 38.0% mean reduction of volume and 35.6% mean reduction of maximum scar depth. CONCLUSION: The AFR treatments represent a safe, effective treatment modality for improving atrophic scarring due to surgery or trauma..
"Ablative and fractional ablative lasers"Brightman, Lori A; Brauer, Jeremy A; Anolik, Robert; Weiss, Elliot; KAREN, JULIE; Chapas, Anne; Hale, Elizabeth; Bernstein, Leonard; Geronemus, Roy G
The field of nonsurgical laser resurfacing for aesthetic enhancement continues to improve with new research and technological advances. Since its beginnings in the 1980s, the laser-resurfacing industry has produced a multitude of devices employing ablative, nonablative, and fractional ablative technologies. The three approaches largely differ in their method of thermal damage, weighing degrees of efficacy, downtime, and side effect profiles against each other. Nonablative technologies generate some interest, although only for those patient populations seeking mild improvements. Fractional technologies, however, have gained dramatic ground on fully ablative resurfacing. Fractional laser resurfacing, while exhibiting results that fall just short of the ideal outcomes of fully ablative treatments, is an increasingly attractive alternative because of its far more favorable side effect profile, reduced recovery time, and significant clinical outcome..
"Improvement in arm and post-partum abdominal and flank subcutaneous fat deposits and skin laxity using a bipolar radiofrequency, infrared, vacuum and mechanical massage device"Brightman, Lori; Weiss, Elliot; Chapas, Anne M; KAREN, JULIE; Hale, Elizabeth; Bernstein, Leonard; Geronemus, Roy G
BACKGROUND AND OBJECTIVES: Skin laxity of the body is a growing cosmetic concern. Laxity can result from chronological or photoaging and changes in body dimensions during pregnancy or weight loss. The end result is loose, sagging skin, and localized fat deposits. Liposuction and abdominoplasty or brachioplasty are established approaches to these issues. Patient desire for alternatives to surgical correction has spawned the development of non-invasive body contouring devices. The combination of infrared light (IR), bipolar radiofrequency (RF), vacuum and mechanical massage (Velashape, Syneron Medical Ltd, Israel) has demonstrated efficacy in improving skin appearance and circumference of the thighs [Goldberg et al., Derm Surg 2008; 34:204-209; Fisher et al., Derm Surg 2005; 31:1237-1241; Arnoczky and Aksan, J Am Acad Orthop Surg 2000; 8:305-313; Alster and Tanzi, J Cosmetic Laser Therapy 2005; 7:81-85; Wanitphakdeedecha and Manuskiatti, J Cosmet Dermatol 2006; 5:284-288; Nootheti et al., Lasers Surg Med 2006; 38: 908-912], but only anecdotal evidence has supported its use on other anatomic locations. This study was designed to evaluate the efficacy and safety of Velashape on additional body sites and more rigorously examine the technology's impact on upper arm as well as abdominal and flank circumference. STUDY DESIGN AND METHODS: Subjects were 28-70 years old, skin types I-V. Nineteen subjects underwent 5 weekly treatments of the upper arms, and 10 subjects underwent 4 weekly treatments of the abdomen and flanks. Treatments were performed using Velashape. Circumference measurements, photographs, and subject weights were performed prior to treatment and at 1- and 3-month follow-ups. Subjects were asked to record their treatment satisfaction level. RESULTS: Change in arm circumference, at the 5th treatment was statistically significant with a mean loss of 0.625 cm. At 1- and 3-month follow-ups, mean loss was 0.71 and 0.597 cm respectively. Reduction of abdominal circumference at 3rd treatment was statistically significant with a 1.25 cm mean loss. At 1- and 3-month follow-ups, average loss was 1.43 and 1.82 cm respectively. CONCLUSIONS: This study demonstrates with statistical significance, sustainable reduction in circumference and improvement in appearance of arms and abdomen following treatment with Velashape..
"Rapidly eruptive, treatment-resistant, nodular Kaposi's sarcoma in an acquired immunodeficiency syndrome (AIDS) patient on highly active antiretroviral therapy"Chang, Caroline A; Sanchez, Miguel R; KAREN, JULIE K; Rosenman, Karla S; Prystowsky, Stephen D
"Sensitivity and specificity for detecting basal cell carcinomas in Mohs excisions with confocal fluorescence mosaicing microscopy"Gareau, Daniel S; KAREN, JULIE K; Dusza, Stephen W; Tudisco, Marie; Nehal, Kishwer S; Rajadhyaksha, Milind
GRANTS:R01 EB002715/EB/NIBIB NIH HHS/United States;R01 EB002715-05/EB/NIBIB NIH HHS/United States;R01EB002715/EB/NIBIB NIH HHS/United States
Recent studies have demonstrated the ability of confocal fluorescence mosaicing microscopy to rapidly detect basal cell carcinomas (BCCs) directly in thick and fresh Mohs surgical excisions. Mosaics of confocal images display large areas of tissue with high resolution and magnification equivalent to 2x, which is the standard magnification when examining pathology. Comparison of mosaics to Mohs frozen histopathology was shown to be excellent for all types of BCCs. However, comparisons in the previous studies were visual and qualitative. In this work, we report the results of a semiquantitative preclinical study in which 45 confocal mosaics are blindly evaluated for the presence (or absence) of BCC tumor. The evaluations are made by two clinicians: a senior Mohs surgeon with prior expertise in interpreting confocal images, and a novice Mohs fellow with limited experience. The blinded evaluation is compared to the gold standard of frozen histopathology. BCCs are detected with an overall sensitivity of 96.6%, specificity of 89.2%, positive predictive value of 93.0%, and negative predictive value of 94.7%. The results demonstrate the potential clinical utility of confocal mosaicing microscopy toward rapid surgical pathology at the bedside to expedite and guide surgery.
"Detection of basal cell carcinomas in Mohs excisions with fluorescence confocal mosaicing microscopy"KAREN, J K; Gareau, D S; Dusza, S W; Tudisco, M; Rajadhyaksha, M; Nehal, K S
GRANTS:R01 EB002715/EB/NIBIB NIH HHS/United States;R01 EB002715-05/EB/NIBIB NIH HHS/United States;R01EB002715/EB/NIBIB NIH HHS/United States
BACKGROUND: High-resolution real-time imaging of human skin is possible with a confocal microscope either in vivo or in freshly excised tissue ex vivo. Nuclear and cellular morphology is observed in thin optical sections, similar to that in conventional histology. Contrast agents such as acridine orange in fluorescence and acetic acid in reflectance have been used in ex vivo imaging to enhance nuclear contrast. OBJECTIVES: To evaluate the sensitivity and specificity of ex vivo real-time imaging with fluorescence confocal mosaicing microscopy, using acridine orange, for the detection of residual basal cell carcinoma (BCC) in Mohs fresh tissue excisions. METHODS: Forty-eight discarded skin excisions were collected following completion of Mohs surgery, consisting of excisions with and without residual BCC of all major subtypes. The tissue was stained with acridine orange and imaged with a fluorescent confocal mosaicing microscope. Confocal mosaics were matched to the corresponding haematoxylin and eosin-stained Mohs frozen sections. Each mosaic was divided into subsections, resulting in 149 submosaics for study. Two Mohs surgeons, who were blinded to the cases, independently assessed confocal submosaics and recorded the presence or absence of BCC, location, and histological subtype(s). Assessment of confocal mosaics was by comparison with corresponding Mohs surgery maps. RESULTS: The overall sensitivity and specificity of detecting residual BCC was 96.6% and 89.2%, respectively. The positive predictive value was 92.3% and the negative predictive value 94.7%. Very good correlation was observed between confocal mosaics and matched Mohs frozen sections for benign and malignant skin structures, overall tumour burden and location, and identification of all major histological subtypes of BCC. CONCLUSIONS: Fluorescent confocal mosaicing microscopy using acridine orange enables detection of residual BCC of all subtypes in Mohs fresh tissue excisions with high accuracy. This observation is an important step towards the long-term clinical goal of using a noninvasive imaging modality for potential real-time surgical pathology-at-the-bedside for skin and other tissues.
"Three-dimensional surface imaging for clinical trials: improved precision and reproducibility in circumference measurements of thighs and abdomens"Weiss, Elliot T; Barzilai, Ori; Brightman, Lori; Chapas, Anne; Hale, Elizabeth; KAREN, JULIE; Bernstein, Leonard; Geronemus, Roy G
BACKGROUND AND OBJECTIVES: Numerous body contouring and laser-assisted liposuction devices have recently obtained or are seeking FDA clearance, and assessment of efficacy of these devices is largely based upon qualitative comparisons of before and after photographs and measurable changes in patient circumference. The current standard for measuring body circumference in clinical trials involves the use of a standard measuring tape. These manual measurements introduce human error and may incorrectly support or refute a device or procedure's efficacy. A promising alternative to manual measurements is three-dimensional (3D) photography. This technology allows circumference measurements to be performed on 3D digital models. Our objective is to compare the precision and reproducibility of manual versus 3D photographic measurement of body circumference. STUDY DESIGN/MATERIALS AND METHODS: Thirty subjects completed this IRB approved study. Each subject's thighs and abdomen were measured twice by each of two blinded investigators and twice by the 3D system. RESULTS: For right and left thigh circumference, the variance of the replication errors [measurement 1-measurement 2] for the human investigators was 20.5% larger than the variance for the 3D photography system. For abdominal circumference, the variance for the human investigators was 231.3% larger than the variance for the 3D system. CONCLUSIONS: 3D photography is a valuable tool that enables investigators to reliably detect minute changes in body shape; consequently, 3D photography reduces the number of subjects needed to sufficiently power a clinical study. For studies involving abdominal circumference, utilizing 3D photography reduces the number of subjects needed by 1/2 to 2/3..
"Generalized essential telangiectasia"KAREN, JULIE K; Mengden, Stephanie J; Kamino, Hideko; Shupack, Jerome L
A 56-year-old woman presented with multiple, erythematous cutaneous vessels that blanched with diascopy and were symmetrically distributed over both lower and upper extremities. The lesions had been present for approximately 6 years and were asymptomatic. Generalized essential telangiectasia (GET) is an idiopathic syndrome of widespread, asymptomatic telangiectases of unknown cause. In our patient, an extensive laboratory evaluation showed low levels of circulating vitamin C as well as the presence of urinary matrix metalloproteinases. The relevance of these abnormal findings is unclear. No uniformly effective treatment exists for GET. Our patient was started on oral doxycycline and was referred for laser therapy.