Vascular lesions

Vascular lesions are a common occurrence in all age groups. Most vascular anomalies can be classified into three categories: malformations, benign neoplasms, and dilatations of vessels.

Malformations are congenital lesions that are always present at birth and never regress. Although malformations do not exhibit cellular proliferation, they expand as patients age because of change in body contour and size and progressive ectasia of vessels. Port wine stains (PWS) are a type of vascular malformation, consisting of ectatic venules within the dermis.

Hemangiomas are the most common benign vascular neoplasm in infancy and childhood. These lesions usually appear several weeks after birth, grow rapidly during the first year of life, and then usually spontaneously involute over years as fibrous tissue replaces vascular parenchyma.

Vascular dilations have normal endothelial turnover but demonstrate ectasia of vessels. This category includes telangiectases, which represent permanent dilatations of end vessels, primarily venules. Telangiectases may be seen in numerous conditions, or may appear secondary to trauma, radiation therapy, sun damage, endocrine factors, or high venous pressure.

Prior to the advent of laser technology, treatment options for vascular lesions were limited to surgical excision, electrosurgery, cryosurgery, radiation therapy, dermabrasion, or overtattooing. These techniques were largely ineffective and carried an unacceptably high risk of scarring and pigmentary change.

Port Wine Stains

The pulsed dye laser is currently the treatment of choice for most PWS, especially those that are macular, mildly hypertrophic, or present in children.

Facial Telangiectases and Other Small Vessel Disorders

The most appropriate treatment modality for telangiectases depends on the diameter of the vessel, its anatomic location, and the age of the patient. Small diameter vessels on the face usually respond favorably to many types of lasers. The PDL represents an excellent treatment modality for facial telangiectases.

Spider and cherry angiomas typically respond after one or two treatments with the PDL.

Due to their large size and greater depth, larger blue vessels respond least well to the PDL. They may respond to treatment with long-pulsed alexandrite laser, long-pulsed Nd: YAG laser.

Hemangiomas

Hemangiomas are the most common benign neoplasms of infancy. They may appear anywhere on the skin but affect the head and neck most commonly.

Cutaneous hemangiomas may be superficial (capillary) or deep (cavernous).

Whereas superficial hemangiomas usually exhibit a bright red color, deeper lesions typically appear as subcutaneous nodules with normal overlying skin or with an overlying blue hue. Hemangiomas often exhibit combined superficial and deep components.

Treatment of hemangiomas has long been a source of controversy. In the past, most hemangiomas were left untreated because of their natural history of involution. However, increased sensitivity to the psychosocial trauma suffered by children, as well as the availability of newer treatment modalities, have forced a reevaluation of traditional dogma.

Choice of treatment modality depends on many factors, including anatomic location, type of hemangioma (superficial vs. deep), size and extent of lesion, phase of the lesion (preproliferation, growth, plateau, or involution), whether functional impairment is present, and level of parental concern.

The pulsed dye laser is the treatment of choice for almost all superficial hemangiomas and many mixed lesions. Small, superficial lesions and some large, plaquelike lesions respond well, provided that treatment is started early enough.

Leg Veins

Unsightly or symptomatic venulectasia or telangiectasia on the legs occurs in 29% to 41% of women and 6% to 15% of men. These smaller vessels are most often directly or indirectly connected to larger reticular or varicose "feeding" veins. Even though up to 53% of patients with leg telangiectases have associated symptoms, the most common reason patients seek consultation is cosmetic.

Sclerotherapy remains the gold standard for treatment of leg veins and telangiectases. Public interest in laser treatment of leg veins is high, and under the right circumstances they can produce excellent results.

In many patients, a combination of treatments is necessary.

Various devices have been utilized in an effort to enhance clinical efficacy and minimize the adverse sequelae of telangiectasia treatment.

Pigmented Lesions ( Lentigines )

Lentigines are extremely common hyperpigmented macules that most often result from chronic sun exposure. All three Q-switched lasers and the 510 nm pulsed dye laser are highly effective in the treatment of lentigines. After one treatment, at least 50% clearing is expected.

Café au Lait Macules

Café au lait macules (CALMs) are well circumscribed, light brown macules that may occur as isolated lesions in the general population or as multiple lesions.

The efficacy of lasers in the removal of CALMs is variable, and results are often unpredictable. Short-term lightening or clearing is frequently achieved after multiple treatments. However, recurrences are common, seen in up to 50% of treated lesions, even when complete clearing has occurred initially.

Ephelides

Ephelides (freckles) are small hyperpigmented macules located on sun-exposed skin. These lesions uniformly respond well to Q-switched laser treatment.

Becker's nevus

Becker's nevus is a large, hyperpigmented, slightly verrucous plaque that occurs most commonly on the shoulder area of males. These lesions are reported to be similar to café au lait macules in their response to laser treatment.

Nevus of Ota

Nevus of Ota is a mottled, bluish or gray-brown patch that is usually located unilaterally within the distribution of the first and second branches of the trigeminal nerve.

Nevus of Ota may affect mucosal surfaces such as cornea, sclera, nasal and buccal mucosa, and tympanic membrane. The lesions is present at birth in about 50% of cases, while the remainder usually appear by the second decade of life. Asians are most commonly affected, with an incidence of 1 in 500 reported in Japan . Women are five times more likely to be affected than men.

Q-switched lasers provide an extremely effective means of treating this condition.

Tattoos

Tattoos are produced when an exogenous prigment is implanted traumatically or intentionally into the dermis. In most amateur tattoos, a crude instrument is used to drive a carbon-based pigment such as India ink into the skin. Pigment is usually lightly concentrated within various levels of the dermis. In contrast, professional tattoos are made with an electric tattoo machine that uses rapidly vibrating needles to repeatedly puncture the skin. Pigment is densely concentrated primarily at the junction of the papillary and reticular dermis. Professional tattoo pigments are composed of mixtures of metallic salts and organic dyes.

Q-switched lasers can lighten almost all tattoos, but the degree of clearing depends on pigment density, color, and composition. Black amateur tattoos generally respond well, typically clearing within 3 to 6 treatment sessions. The response of densely prigmented, multicolored professional tattoos is far more variable. These tattoos typically require 6 to 12 treatment sessions for clearing but may require up to 20 sessions.

Hirsutism and Unwanted Hair

Hirsutism is characterized by the growth of terminal hair in women on androgen-dependent areas of the body such as the upper lip, chin, or chest. Often the result of androgen excess, hirsutism may be accompanied by acne, androgenetic alopecia, and acanthosis nigricans. The most common hormonal cause of hirsutism is polycystic ovary disease, estimated to occur in 1% to 4% of the female population of reproductive age.

The presence of unwanted hair continues to plague many individuals for whom traditional methods of hair removal remain unsatisfactory. Laser and flashlamp technology now offers the potential for rapid, safe, and effective treatment of unwanted hair.

Liposuction

Adipose tissue is deposited in human subcutaneous tissue as an energy reservoir and serves to provide the body with temperature and vibratory insulation. Its sites of deposition are in large part genetically predetermined. Two general body shapes are known to exist: gynecoid and android. The gynecoid body type is the usual female shape, with fat preferentially deposited peripherally in locations such as the thighs and hips. The male android body type tends to deposit fat centrally in the intraabdominal region. There are certainly exceptions to both.

Liposuction is the aesthetic removal of undesirable localized collections of subcutaneous adipose tissue.

The evolution of liposuction over the past decade has been driven by the desire to increase safety and allow the procedure to be performed in an outpatient setting.

Liposuction is one of the most commonly performed aesthetic surgical procedures.

Indications for liposuction are cosmetic body contouring, diseases involving the subcutaneous tissue (lipomas, lipodystrophy, axillary hyperhidrosis), and reconstruction. Ideally, liposuction should be used in conjunction with an exercise program and not as a substitution for weight loss by diet control. Many patients pursue liposuction for specific body locations that disturb them.

Hair Transplantation

Male pattern baldness (MPB) is a progressive disorder that in men usually begins in the frontotemporal triangles. Frontal area hair loss progresses medially while in the temporal area it moves posteriorly so that the alopecic frontotemporal triangle gradually becomes larger. Either at the same time, before, or after the frontotemporal thinning, a similar process may begin in the vertex area. With the passage of time the latter also enlarges until it finally may reach the hair loss progressing from the frontal area.

Androgenetic alopecia in females usually occurs in a different form than that described for males, although there are some females who thin in a similar fashion.

Maintenance of at least some hair in the hairline zone while thinning occurs more posteriorly and small round alopecic areas that are scattered throughout the diffuse thinning are hallmarks of MPB in nearly all females.

Numerous medical treatments for MPB have been tried, and at least three are quite helpful in slowing down the rate of hair loss or in fact growing some hair: 1 mg finasteride orally per day, 2% to 5% minoxidil applied twice a day to the scalp, and 0.025% estradiol applied once every 1 to 2 days.

All of these medications must be continued indefinitely or any benefits disappear quite quickly.

If medications are not effective, surgical methods such as hair transplant can be tried.

Lasers in Skin Resurfacing

Laser skin resurfacing has revolutionized the approach to facial skin rejuvenation over the last decade. It has also added an approach to managing both atrophic and hypertrophic scars. There has always been a great interest in facial rejuvenation.

In the 1980s and early 1990s continuous wave carbon dioxide lasers were used in an effort to resurface photoaged skin. Although the results of this procedure performed by a few were quite impressive, the risk/benefit ratio of the procedure was very high.

However, with the development of short-pulse high peak power and rapidly scanned focused beam carbon dioxide lasers and normal mode erbium:yttrium aluminum garnet (Er:YAG) lasers, the ability to remove photodamaged skin layer by layer in a precisely controlled manner while leaving behind a very narrow zone of thermal damage became possible. There has been an explosion of interest in the use of this new technology to resurface photoaged skin, as well as for the treatment of scars.

Other Indications

Laser skin resurfacing is used for a variety of other conditions apart from treating photoaged skin. Acne scars traditionally have been treated with dermabrasion. Moderate improvement can be achieved, but the procedure is quite bloody and the blood microdroplets can hang suspended in the air for several hours, posing a threat to the physician, staff, and other patients. Laser resurfacing can achieve improvement in acne scars with much less risk to the surgical team. In addition, the procedure is very precise.

Crateriform varicella scars can be improved with spot laser resurfacing. The area around and over the scar is vaporized with one pass of the laser.

Postsurgical and traumatic scars can be dramatically improved, especially if resurfaced 6 to 10 weeks after the surgery or injury.