Publications by authors named "Tina S Alster"

85 Publications

Reply to: Cohen and Ross: "Laser-Induced Chrysiasis: A Unique Adverse Event Associated with Q-Switched Lasers".

Am J Clin Dermatol 2021 Mar 27;22(2):291. Epub 2021 Feb 27.

City Medical Aesthetics Center, Vancouver, BC, USA.

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http://dx.doi.org/10.1007/s40257-021-00589-5DOI Listing
March 2021

Alternative Clinical Indications of Botulinum Toxin.

Am J Clin Dermatol 2020 Dec;21(6):855-880

Washington Institute of Dermatologic Laser Surgery, 1430 K St NW, Suite 200, Washington, DC, 20005, USA.

Botulinum toxin type A (BoNTA) is a powerful neurotoxin that inhibits acetylcholine release from presynaptic vesicles. The potency and safety profile of BoNTA grant the toxin vast therapeutic potential. It has been used off-label for a variety of dermatologic conditions. This review aims to analyze published literature regarding the benefits and risks of the off-label use of BoNTA beyond facial lines, including eccrine hidrocystomas, enlarged pores, keloids and hypertrophic scars, hidradenitis suppurativa, hyperhidrosis, masseter muscle hypertrophy, and salivary gland hypertrophy, among others. A MEDLINE search from January 2000 to December 2019 was conducted on the off-label uses of botulinum toxin in dermatology.
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http://dx.doi.org/10.1007/s40257-020-00532-0DOI Listing
December 2020

Dermatologic Laser Side Effects and Complications: Prevention and Management.

Am J Clin Dermatol 2020 Oct;21(5):711-723

City Medical Aesthetics Center, Vancouver, BC, Canada.

The evolution of modern laser and light-based systems has mirrored the demand for clinically effective treatments and the need for safer technologies with reduced postoperative recovery, side effects, and complications. With each new generation of lasers, more selective tissue destruction can be achieved with reduced unwanted sequelae. Patient selection and preparation, operator technique, and expeditious recognition and management of post-treatment side effects are paramount in avoiding complications and patient dissatisfaction. An overview of important variables to consider for dermatologic laser treatments are presented in order to provide a framework to reduce the severity and duration of possible post-treatment side effects and complications.
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http://dx.doi.org/10.1007/s40257-020-00530-2DOI Listing
October 2020

Microneedling of Scars: A Large Prospective Study with Long-Term Follow-Up.

Plast Reconstr Surg 2020 02;145(2):358-364

From the Washington Institute of Dermatologic Laser Surgery.

Background: In recent years, microneedling has been increasingly used to treat a number of dermatologic conditions, including scars. Although initial studies demonstrated improvement of (mostly) atrophic scars with microneedling, the number of patients evaluated was relatively small, and the devices and treatment protocols used and posttreatment follow-up varied widely. Through this prospective observational study, the results of microneedling on 120 patients with a variety of scars are described.

Methods: One hundred twenty consecutive patients (skin phototypes I through VI) with facial and nonfacial scars from a variety of etiologic sources (acne, trauma, surgery) were treated using a mechanical microneedling device. No additional treatments (topical or intralesional) were applied. Two assessors blinded to treatment protocol rated clinical improvement of scars 1, 3, 6, and 12 months after treatment on a five-point scale. Side effects were monitored and tabulated.

Results: Patients received one to six consecutive monthly microneedling treatments. All scars improved at least 50 percent after an average of 2.5 treatments. Over 80 percent of patients had 50 to 75 percent improvement, and 65 percent of patients demonstrated over 75 percent improvement. No significant clinical differences were observed in treatment responses of facial scars versus nonfacial scars nor between responses of atrophic acne scars and traumatic or surgical scars.

Conclusions: This study supports the use of microneedling for various facial and nonfacial scars across a broad range of skin phototypes with minimal risk of adverse effects. Further studies will help to establish standardized protocols to optimize treatment outcomes for different scar types.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000006462DOI Listing
February 2020

Microneedling Treatment of Striae Distensae in Light and Dark Skin With Long-Term Follow-Up.

Dermatol Surg 2020 04;46(4):459-464

MKL Dermatology, Vancouver, British Columbia, Canada.

Background: Striae distensae have notoriously been difficult to treat due to their extensive involvement of nonfacial skin. Microneedling with its lack of thermal injury during microneedling treatment renders it a viable treatment option in darker skin tones and nonfacial regions due to the reduced risk of postinflammatory hyperpigmentation.

Objective: To describe the clinical results and side effects of microneedling in a series of 25 individuals with striae distensae.

Materials And Methods: Twenty-five consecutive adults (SPT I-V) with striae distensae involving the trunk and extremities were treated using a microneedling device. No additional treatments (topical or intralesional) were applied. Two assessors blinded to treatment protocol rated clinical improvement of striae on a 5-point scale. Side effects were monitored and tabulated.

Results: Patients received 1 to 3 consecutive monthly treatments. All striae improved at least 50% after an average of 1.8 treatments, and 28% of patients demonstrated more than 75% clinical improvement. Striae in thicker skin regions (e.g., buttocks/thighs) showed comparable clinical improvement than those in thinner skin areas (e.g., breasts) and did not require additional treatment sessions. Side effects were limited to transient erythema in all skin phototypes. No infections or dyspigmentation were observed.

Conclusion: The clinical results obtained in this study support the safe and effective treatment of striae distensae with microneedling in light and dark skin tones in various body locations. Standardization of treatment protocols are anticipated with further (ongoing) studies.
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http://dx.doi.org/10.1097/DSS.0000000000002081DOI Listing
April 2020

An Observational Study of the Safety and Efficacy of Tissue Stabilized-Guided Subcision.

Dermatol Surg 2019 08;45(8):1057-1062

Ulthera, Inc.

Background: Cellulite is a common female cosmetic concern for which there are few treatment options with long-term effectiveness data. The aim of this multisite prospective registry study was to collect observational data on the real-life clinical use of a tissue stabilized-guided subcision (TS-GS) system for long-term improvement of cellulite appearance.

Methods: Fifty-three subjects were enrolled and received a single treatment using the TS-GS system. Physicians treated the subjects according to their standard of care. Global Aesthetic Improvement Scale (GAIS) was completed by the patient and clinician assessing overall aesthetic improvement after 180 days. Treatment parameters, pain scores, quality of life data, and expected treatment effects and adverse events were also recorded throughout the study.

Results: The patient and physician GAIS scores at Day 180 revealed an overall improvement in 91% and 96% of patients, respectively. Quality of life and self-confidence scores also improved through 180 days. No serious adverse events were reported. Expected treatment effects were similar to those reported in the pivotal trial supporting FDA clearance.

Conclusion: This study demonstrated significant improvement in the appearance of cellulite after a single treatment session in patients with moderate-to-severe cellulite. These results are consistent with the previously published the pivotal study data.
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http://dx.doi.org/10.1097/DSS.0000000000001911DOI Listing
August 2019

Treatment of Cosmetic Tattoos: A Review and Case Analysis.

Dermatol Surg 2018 12;44(12):1565-1570

Washington Institute of Dermatologic Laser Surgery, Washington, District of Columbia.

Background: Cosmetic tattoos such as eyeliner, brow liner, and lip liner have become increasingly popular in the United States and throughout the world. For a variety of reasons, patients frequently regret their tattoos and request their removal; however, removal is often complicated by the aesthetically sensitive location of these specialized tattoos and the fact that they often contain white metallic compounds that darken on pigment-specific laser irradiation.

Objective: To review the clinical use, effectiveness, and safety of an ablative laser technique for cosmetic tattoos.

Materials And Methods: A thorough literature review pertaining to laser treatment of cosmetic tattoos and a discussion of illustrative patient cases showcasing the successful use of ablative carbon dioxide (CO2) laser to treat cosmetic tattoos is presented.

Results: Cosmetic eyeliner and lip liner tattoos were significantly improved after CO2 laser vaporization. Side effects were limited to erythema, edema, and serosanguinous drainage. No infection, scarring, nor tattoo ink darkening was observed.

Conclusion: Because ablative lasers do not target specific tattoo inks, they do not pose a risk of paradoxical tattoo ink darkening and, thus, can be applied successfully in the treatment of iron oxide- or titanium dioxide-containing cosmetic tattoos.
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http://dx.doi.org/10.1097/DSS.0000000000001572DOI Listing
December 2018

Safety and Efficacy of a 1550nm/1927nm Dual Wavelength Laser for the Treatment of Photodamaged Skin.

J Drugs Dermatol 2018 Jan;17(1):41-46

BACKGROUND: Fractional photothermolysis (FP) is a popular treatment option for photodamaged skin and addresses shortcomings of ablative skin resurfacing and nonablative dermal remodeling. Previous studies have demonstrated that FP using the 1550nm wavelength has led to improvement of ultrastructural changes and clinical effects associated with photodamaged skin in the deeper dermal structures, while treatment with the 1927nm wavelength has shown clinical effects in the superficial dermis. Both wavelengths produce precise microscopic treatment zones (MTZs) in the skin. The two wavelengths used in combination may optimize the delivery of fractional nonablative resurfacing intended for dermal and epidermal coagulation of photodamage skin.

OBJECTIVES: To evaluate the safety and efficacy of a 1550/1927 Laser System (Fraxel Dual, Solta), using both 1550nm and 1927nm wavelengths in combination for treatment of facial and non-facial photodamage.

METHODS: Prospective, multi-center, post-market study in subjects with clinically identifiable photodamage (N=35) (Fitzpatrick skin types I-IV). Both 1550nm and 1927nm wavelengths were used at each treatment visit. Investigator assessment of the affected area(s) occurred at one week, one month and 3 months after a series of up to four treatments. Severity of adverse events (AEs) were assessed using a 4-point scale (where 0=none and 3=marked). Assessments included erythema, edema, hyperkeratosis, hyper- and hypo-pigmentation, scarring, itchiness, dryness, and flaking. Severity of photoaging, fine and coarse wrinkling, mottled hyperpigmentation, sallowness, and tactile roughness at baseline was assessed using the same scale. Investigators and subjects assessed overall appearance of photodamage and pigmentation based on a 5-point quartile improvement scale at all follow-up visits (where 0=no improvement and 4=very significant improvement [76%-100%]).

RESULTS: There was a positive treatment effect at all study visits, with moderate improvement (average reduction in severity of 21%-43%) observed 3-months after final treatment. Greatest reduction in severity of other benefit areas was at the 3-month follow-up visit, with a 21% and 30% decrease in severity in fine wrinkling and tactile roughness. No AEs or serious AEs were reported. Pain sensation during treatment was tolerable. Anticipated moderate erythema (mean score 1.6±0.5) and mild edema (mean score 0.8±0.7) were transient and resolved within 7-10 days. Anticipated and transient mild dryness (52% of subjects) and flaking (30%) were reported at the 1-week follow-up. There were no incidences of hyperkeratosis, scarring, or itchiness.

CONCLUSION: Treatments using both wavelengths associated with the combined 1550/1927 Laser System were well tolerated with limited, transient anticipated side effects and no serious AEs. Clinical efficacy in the appearance of photodamage and pigmentation was greatest following a series of up to 3 treatments.

J Drugs Dermatol. 2018;17(1):41-46.

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January 2018

Microneedling: A Review and Practical Guide.

Dermatol Surg 2018 Mar;44(3):397-404

Department of Dermatology, St. Joseph Mercy Hospital, Ann Arbor, Michigan.

Background: Microneedling is a relatively new treatment option in dermatology and has been touted for a broad range of applications including skin rejuvenation, acne scarring, rhytides, surgical scars, dyschromia, melasma, enlarged pores, and transdermal drug delivery. The significant increase in minimally invasive procedures that has been reported over the past several years suggest that microneedling may occupy a specific niche for patients who desire measurable clinical results from treatments with little to no recovery.

Objective: To review the published medical literature relating to microneedling in dermatology and provide a practical guide for its use in clinical practice.

Materials And Methods: A thorough literature search of microneedling in dermatology using PubMed was conducted, and all references pertaining to skin scarring and rejuvenation were reviewed. Based on the information presented in these publications and the authors' clinical experience, a microneedling technique is outlined for clinical practice. Pretreatment recommendations, intraoperative technique and treatment end points, and postoperative considerations are outlined.

Results: Microneedling produces substantial clinical improvement of scars, striae, and rhytides with expedient recovery and limited side effects. Controlled dermal wounding and stimulation of the wound healing cascade enhances collagen production and is likely responsible for the clinical results obtained.

Conclusion: Microneedling is a safe, minimally invasive, and effective esthetic treatment for several different dermatologic conditions including acne and other scars, rhytides, and striae. Given its expedient post-treatment recovery, limited side effect profile, and significant clinical results, microneedling is a valuable alternative to more invasive procedures such as laser skin resurfacing and deep chemical peeling.
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http://dx.doi.org/10.1097/DSS.0000000000001248DOI Listing
March 2018

Laser Tattoo Removal: An Update.

Am J Clin Dermatol 2017 Feb;18(1):59-65

Washington Institute of Dermatologic Laser Surgery, 1430 K Street NW Suite 200, Washington, DC, 20005, USA.

Tattoo art has been around for thousands of years in every culture and is currently flourishing in all age groups, social classes, and occupations. Despite the rising popularity of tattoos, demand for their removal has also increased. While various treatments, including surgical excision, dermabrasion, and chemical destruction have historically been applied, over the past 2 decades, lasers have revolutionized the way tattoos are treated and have become the gold standard of treatment. To achieve optimal cosmetic outcome of treatment, lasers emitting high energies and short pulses are required to adequately destroy tattoo ink. We review the history of laser tattoo removal, outlining the challenges inherent in developing lasers that can most effectively remove tattoo particles while safely protecting skin from unwanted injury.
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http://dx.doi.org/10.1007/s40257-016-0227-zDOI Listing
February 2017

The role of lasers and intense pulsed light technology in dermatology.

Clin Cosmet Investig Dermatol 2016 4;9:29-40. Epub 2016 Feb 4.

Department of Dermatology, Georgetown University Hospital, Washington, DC, USA; Washington Institute of Dermatologic Laser Surgery, Washington, DC, USA.

The role of light-based technologies in dermatology has expanded dramatically in recent years. Lasers and intense pulsed light have been used to safely and effectively treat a diverse array of cutaneous conditions, including vascular and pigmented lesions, tattoos, scars, and undesired hair, while also providing extensive therapeutic options for cosmetic rejuvenation and other dermatologic conditions. Dermatologic laser procedures are becoming increasingly popular worldwide, and demand for them has fueled new innovations and clinical applications. These systems continue to evolve and provide enhanced therapeutic outcomes with improved safety profiles. This review highlights the important roles and varied clinical applications that lasers and intense pulsed light play in the dermatologic practice.
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http://dx.doi.org/10.2147/CCID.S69106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4745852PMC
February 2016

A Randomized, Double-Blind Trial to Investigate the Equivalence of IncobotulinumtoxinA and OnabotulinumtoxinA for Glabellar Frown Lines.

Dermatol Surg 2015 Nov;41(11):1310-9

*Manhattan Eye, Ear & Throat Hospital, New York, New York; †Tennessee Clinical Research Center, Nashville, Tennessee; ‡Tulane Health Sciences Center, New Orleans, Louisiana; §Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California; ‖Center for Dermatology and Laser Surgery, Sacramento, California; ¶Washington Institute of Dermatologic Laser Surgery, Georgetown University Hospital, Washington, DC; #Skin Care Physicians, Chestnut Hill, Massachusetts; **Center for Dermatology and Dermatologic Surgery, Washington, DC; ††University of California Los Angeles, Los Angeles, California; ‡‡Complete Medical Communications, Macclesfield, United Kingdom.

Background: IncobotulinumtoxinA and onabotulinumtoxinA are indicated for the temporary improvement in the appearance of glabellar frown lines (GFL). This is the first randomized direct comparator study to date, at the Food and Drug Administration-recommended dose of 20 units (U), for the treatment of GFL.

Objective: To investigate the dose equivalence of incobotulinumtoxinA (20 U) and onabotulinumtoxinA (20 U) for the treatment of moderate-to-severe GFL.

Materials And Methods: Prospective, randomized (1:1), double-blinded, parallel-group study in 250 females (18-50 years), employing a single treatment with incobotulinumtoxinA or onabotulinumtoxinA, followed by a 4-month observational period.

Results: At the primary efficacy endpoint (1 month after treatment), incobotulinumtoxinA was equivalent to onabotulinumtoxinA in the treatment of GFL at the 20 U dose within the prespecified ± 15% margin of equivalence. Efficacy remained similar between treatment groups through 4 months after treatment as assessed by the independent masked panel and the masked treating physicians. Patient satisfaction ratings were similar between groups and favorable (>90%) throughout. Both treatments were well tolerated.

Conclusion: Equivalence was demonstrated at the primary endpoint between incobotulinumtoxinA and onabotulinumtoxinA in the treatment of GFL at the 20 U dose at 1 month. Similar efficacy and tolerability profiles were observed through 4 months after treatment.
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http://dx.doi.org/10.1097/DSS.0000000000000531DOI Listing
November 2015

Delayed Onset Pain Associated With Cryolipolysis Treatment: A Retrospective Study With Treatment Recommendations.

Dermatol Surg 2015 Nov;41(11):1296-9

Washington Institute of Dermatologic Laser Surgery, Washington, DC.

Background: Cryolipolysis has become a popular treatment for noninvasive destruction of unwanted subcutaneous fat. It is a generally well-tolerated treatment with mild transient side effects. Delayed posttreatment pain has been sporadically reported, but its incidence, etiology, and treatment have not been elucidated in a large series of patients.

Methods: A retrospective review of 125 patients who received 554 cryolipolysis procedures over a 1-year period was conducted. Demographic data were obtained to determine specific variables that influenced development of delayed posttreatment pain.

Results: Young women (mean age, 39 years) undergoing abdominal cryolipolysis were at greatest risk of experiencing delayed posttreatment pain. The pain was self-limited (duration, 3-11 days) and resolved completely without long-term sequelae. The number of treatment cycles did not impact the development of this side effect.

Conclusion: Delayed posttreatment pain is a not uncommon adverse effect after cryolipolysis. Patients should be counseled on the possibility of its occurrence, and timely intervention should be instituted to reduce its impact.
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http://dx.doi.org/10.1097/DSS.0000000000000502DOI Listing
November 2015

Multicenter prospective cohort study of the incidence of adverse events associated with cosmetic dermatologic procedures: lasers, energy devices, and injectable neurotoxins and fillers.

JAMA Dermatol 2015 Mar;151(3):271-7

Department of Dermatology, Brown University School of Medicine, Providence, Rhode Island11Department of Dermatology, Harvard University School of Medicine, Boston, Massachusetts20Department of Dermatology, Yale School of Medicine, New Haven, Connecticut21.

Importance: Common noninvasive to minimally invasive cosmetic dermatologic procedures are widely believed to be safe given the low incidence of reported adverse events, but reliable incidence data regarding adverse event rates are unavailable to date.

Objective: To assess the incidence of adverse events associated with noninvasive to minimally invasive cosmetic dermatologic procedures, including those involving laser and energy devices, as well as injectable neurotoxins and fillers.

Design, Setting, And Participants: A multicenter prospective cohort study (March 28, 2011, to December 30, 2011) of procedures performed using laser and energy devices, as well as injectable neurotoxins and soft-tissue augmentation materials, among 8 geographically dispersed US private and institutional dermatology outpatient clinical practices focused on cosmetic dermatology, with a total of 23 dermatologists. Participants represented a consecutive sample of 20 399 cosmetic procedures. Data acquisition was for 3 months (13 weeks) per center, with staggered start dates to account for seasonal variation.

Exposures: Web-based data collection daily at each center to record relevant procedures, by category type and subtype. Adverse events were detected by (1) initial observation by participating physicians or staff; (2) active ascertainment from patients, who were encouraged to self-report after their procedure; and (3) follow-up postprocedural phone calls to patients by staff, if appropriate. When adverse events were not observed by physicians but were suspected, follow-up visits were scheduled within 24 hours to characterize these events. Detailed information regarding each adverse event was entered into an online form.

Main Outcomes And Measures: The main outcome was the total incidence of procedure-related adverse events (total adverse events divided by total procedures performed), as verified by clinical examination.

Results: Forty-eight adverse events were reported, for a rate of 0.24% (95% CI, 0.18%-0.31%). Overall, 36 procedures resulted in at least 1 adverse event, for a rate of 0.18% (95% CI, 0.13%-0.25%). No serious adverse events were reported. Adverse events were infrequently associated with known risk factors.

Conclusions And Relevance: Noninvasive to minimally invasive cosmetic dermatologic procedures, including energy, neurotoxin, and filler procedures, are safe when performed by experienced board-certified dermatologists. Adverse events occur in less than 1% of patients, and most of these are minor and transient.
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http://dx.doi.org/10.1001/jamadermatol.2014.2494DOI Listing
March 2015

Evolution of laser skin resurfacing: from scanning to fractional technology.

Dermatol Surg 2014 Nov;40(11):1163-72

*Department of Dermatology, Salford Royal NHS Foundation Trust, Salford, Manchester; †Washington Institute of Dermatologic Laser Surgery, Washington, DC.

Background: Laser skin resurfacing was popularized for photoaged and scarred skin 2 decades ago. Since then, several technologic advancements have led to a new generation of delivery systems that produce excellent clinical outcomes with reduced treatment risks and faster recovery times.

Objectives: To review the evolution of laser skin resurfacing from pulsed and scanned infrared laser technology to the latest techniques of nonablative and ablative fractional photothermolysis.

Materials And Methods: All published literature regarding laser skin resurfacing was analyzed and collated.

Results: A comprehensive review of laser skin resurfacing was outlined and future developments in the field of fractionated laser skin treatment were introduced.

Conclusion: Laser skin resurfacing has evolved such that excellent clinical outcomes in photodamaged and scarred skin are achieved with rapid wound healing. As newer devices are developed, the applications of this technology will have a dramatic effect on the delivery of medical and aesthetic dermatology.
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http://dx.doi.org/10.1097/01.DSS.0000452648.22012.a0DOI Listing
November 2014

Botulinum toxin in men: review of relevant anatomy and clinical trial data.

Dermatol Surg 2013 Oct;39(10):1434-43

Washington Institute of Dermatologic Laser Surgery, Washington, District of Columbia.

Background: Botulinum toxin is widely used for facial aesthetics, and its use in men continues to increase.

Objective: To provide a review of pertinent male anatomic features and updated clinical information on the use of botulinum toxin in men.

Methods: A Medline search was performed for publications on sex differences in facial anatomy and on clinical studies examining the role of sex in botulinum toxin treatment.

Results: There are substantial facial anatomic differences between the sexes, with men having increased cranial size, unique cranial shape, greater skeletal muscle mass, higher density of facial blood vessels, and more-severe facial rhytides. A review of sex and botulinum toxin treatment identified 17 clinical studies with 5,646 total participants, of whom 629 (11.1%) were male. Only two studies accounted for sex in study design or subgroup analysis. Both studies found abobotulinumtoxinA to be less effective in men. An additional study examining onabotulinumtoxinA dosing in men found that higher doses than typically used in women were more efficacious. There were not more adverse events in male participants in any study.

Conclusion: Despite sex differences in facial anatomy, the use of botulinum toxin in men is inadequately studied with regard to dosing, efficacy, and safety.
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http://dx.doi.org/10.1111/dsu.12302DOI Listing
October 2013

Laser earlobe revision.

Dermatol Surg 2013 Jul 29;39(7):1056-61. Epub 2013 Apr 29.

Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.

Background: Earlobe tears and disfigurement often result from prolonged pierced earring use and trauma. They are a common cosmetic complaint for which surgical reconstruction has often been advocated.

Materials And Methods: A series of 10 patients with earlobe tears or disfigurement treated using straight-line closure, carbon dioxide (CO2 ) laser ablation, or both are described. A succinct literature review of torn earlobe repair is provided.

Results: Successful repair with excellent cosmesis of torn and disfigured earlobes was obtained after straight-line surgical closure, CO2 laser ablation, or both.

Conclusion: A minimally invasive earlobe repair technique that involves concomitant surgical closure and CO2 laser skin vaporization produces excellent cosmetic results for torn or disfigured earlobes.
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http://dx.doi.org/10.1111/dsu.12223DOI Listing
July 2013

Vascular skin lesions in children: a review of laser surgical and medical treatments.

Dermatol Surg 2013 Aug 4;39(8):1137-46. Epub 2013 Feb 4.

Washington Institute of Dermatologic Laser Surgery, Washington, District of Columbia 20005, USA.

Vascular anomalies are a common finding in children. Although most of these lesions are benign, they can be a severe cosmetic problem and cause structural and functional damage to nearby tissues. As a result, physicians are tasked with developing effective treatment options with superior safety profiles. Vascular anomalies may be divided into tumors and malformations. Vascular tumors, such as infantile hemangiomas, typically appear a few months after birth, whereas the majority of vascular malformations, such as port-wine stains, are present at birth. Although these lesions vary in appearance, etiology, and disease course, many are treated in a similar fashion. In this review, we focus on treatment modalities for some of the more-prevalent childhood vascular lesions, including port-wine stains, primary telangiectasias, infantile hemangiomas, pyogenic granulomas, and angiomas.
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http://dx.doi.org/10.1111/dsu.12129DOI Listing
August 2013

Management of acne scarring, part I: a comparative review of laser surgical approaches.

Am J Clin Dermatol 2012 Oct;13(5):319-30

Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA.

Acne scarring is the result of a deviation in the orderly pattern of healing and can have profound psychosocial implications for patients. While the most effective means of addressing acne scarring is to prevent its formation through good acne control, there are a number of therapeutic interventions that improve the appearance of acne scars. Many of these procedural modalities have flaws and are limited by operator skill and experience. Laser scar revision, on the other hand, is a precise, well tolerated procedure with clinically demonstrable efficacy and minimal adverse effects that may be used alone or in combination with other scar treatments. The last 20 years has seen a dramatic evolution in laser treatment of acne scars, spanning ablative and nonablative technologies, to the current popularity of fractional laser scar revision. Determining which laser system to use depends upon the type and severity of acne scarring, the amount of recovery a patient can tolerate, and the ultimate goals and expectations of each patient. The importance of proper acne scar classification, laser scar revision techniques, and the evidence that addresses each laser system is reviewed in this article.
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http://dx.doi.org/10.2165/11598910-000000000-00000DOI Listing
October 2012

Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound.

Dermatol Surg 2012 May 23;38(5):754-9. Epub 2012 Jan 23.

Washington Institute of Dermatologic Laser Surgery, Washington, District of Columbia 20005, USA.

Background: Transcutaneous intense focused ultrasound is a novel Food and Drug Administration-approved technology for noninvasive skin tightening of the face and neck. No studies have reported on its safety and effectiveness on nonfacial areas.

Materials And Methods: Eighteen paired areas (6 each) on the upper arms, medial thighs, and extensor knees were randomly treated with two different transducers (4.0 MHz, 4.5-mm focal depth and 7.0 MHz, 3.0-mm focal depth). One side was randomly assigned to receive a single pass (single plane) of microthermal coagulation zones over the involved area with the 4.0 MHz, 4.5-mm-depth transducer, and the contralateral side was assigned to receive consecutive single passes (dual plane) using both transducers (4.0 MHz, 4.5-mm depth followed by 7.0 MHz, 3.0-mm depth). Two independent masked assessors determined clinical improvement scores using comparative standardized photographs obtained at baseline and 3 and 6 months after treatment. Subjective assessments of clinical improvement and side effects of treatment were obtained.

Results: Global assessment scores revealed significant improvement in all treated areas, with the upper arms and knees demonstrating more skin lifting and tightening than the thighs. Areas receiving dual-plane treatment had slightly better clinical scores than those receiving single-plane treatment in all three sites. Clinical scores from single-plane and dual-plane treated areas continued to improve between 3 and 6 months after treatment. Side effects were mild and transient and included erythema, warmth, and skin tenderness. Rare focal bruising was noted in two patients on the upper arms that resolved within 7 days. No other side effects were reported or observed.

Conclusions: Transcutaneous intense focused ultrasound can be safely and effectively used to improve the clinical appearance (texture and contour) of the upper arms, extensor knees, and medial thighs.
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http://dx.doi.org/10.1111/j.1524-4725.2012.02338.xDOI Listing
May 2012

Topical anesthetics for dermatologic procedures: a review.

Dermatol Surg 2012 May 13;38(5):709-21. Epub 2012 Jan 13.

Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Practitioners are increasingly using topical anesthetics to decrease the pain associated with superficial dermatologic, aesthetic, and laser procedures. Numerous lidocaine-containing products are available, but comprehensive reviews are lacking regarding their relative safety profiles and appropriate dermatologic uses.

Materials And Methods: A literature review of currently available topical anesthetics, their safety profiles, and dermatologic uses was conducted.

Results: Factors that should be considered to reduce the risk of side effects associated with the use of topical anesthetics include the amount of product used, body location, size of the surface area, and duration of product application. Many case reports document adverse outcomes associated with the use of compounded products that the Food and Drug Administration has not approved that have inappropriately high anesthetic concentrations and from the use of topical anesthetics on excessively large skin surface areas during laser treatments.

Conclusions: Lidocaine-containing products play an integral role in cutaneous anesthesia by providing patient comfort with minimal side effects. Careful attention must be paid to the particular anatomic location, the total surface area covered, and the duration of anesthetic skin contact.
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http://dx.doi.org/10.1111/j.1524-4725.2011.02271.xDOI Listing
May 2012

Rising concern over cosmetic tattoos.

Dermatol Surg 2012 Mar 2;38(3):424-9. Epub 2011 Nov 2.

Department of Dermatology, University of California at Irvine, Irvine, California, USA.

Background: A rise in popularity of cosmetic tattoos has led to an increase in adverse reactions. Due to more pressing concerns, the Food and Drug Administration (FDA) has not traditionally enforced its authority over tattoo inks.

Objective: To raise awareness of the dangers of cosmetic tattoos.

Materials And Methods: We reviewed FDA policies regarding tattoo ink, different ink components, adverse reactions, and various treatment options for cosmetic tattoo removal.

Results And Conclusion: An increase in consumer complaints has prompted FDA investigation into tattoo inks and their safety. It is important that further complications be reported to the FDA to promote regulation of cosmetic tattoo inks.
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http://dx.doi.org/10.1111/j.1524-4725.2011.02202.xDOI Listing
March 2012

Laser treatment for improvement and minimization of facial scars.

Facial Plast Surg Clin North Am 2011 Aug;19(3):527-42

Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Room 1-330S, Philadelphia, PA 19104, USA.

Cutaneous injuries that result in scar formation are relatively common, leading patients to seek treatment for cosmetic or functional improvement. Treatments that have the potential to improve or eliminate scarring include radiation therapy, surgical excision, and intralesional injections of corticosteroids, 5-flourouracil, or bleomycin. Unfortunately, these methods are associated with high recurrence rates and untoward sequelae such as skin atrophy, dyspigmentation, and pain. Laser scar revision is a safe procedure with clinically demonstrable efficacy and minimal side effects when used alone or in combination with other scar treatments. The specifics of current laser scar revision techniques are addressed in this overview.
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http://dx.doi.org/10.1016/j.fsc.2011.06.006DOI Listing
August 2011

Laser treatment of dark skin: an updated review.

Am J Clin Dermatol 2010 Dec;11(6):389-97

Washington Institute of Dermatologic Laser Surgery, Washington, DC 20005, USA.

The growing diversification of the patient population coupled with the increasing demand for cosmetic laser rejuvenation has highlighted the need to develop cutaneous laser systems and establish treatment protocols for patients with a wide range of skin conditions and phototypes. Recent technologic advancements have provided viable treatment options to achieve clinical outcomes that were previously only attainable in patients with lighter skin tones. This review provides an updated discussion of the range of laser treatments available for pigmented skin and sets the stage for further advancements. Pigment-specific laser technology with green, red, or near-infrared light targets a variety of pigmented lesions such as lentigines, ephelides, café-au-lait macules, and melanocytic nevi as well as tattoos and unwanted hair. Short-pulsed alexandrite, ruby, and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are used for pigmented lesions and tattoos, whereas their longer pulse-width laser counterparts are used for laser-assisted hair removal. Vascular lesions and hypertrophic scars can be treated with a variety of vascular-specific lasers, but it is the pulsed dye laser (PDL) that has long been the gold standard treatment for these lesions due to its high specificity for hemoglobin and its ability to improve skin surface texture in children and adults. Laser skin resurfacing techniques for photodamaged skin and atrophic scars have been optimized with fractional technology to produce excellent clinical outcomes and minimal complication risks. Radiofrequency and nonablative lasers are also used to provide skin tightening and collagen remodeling with virtually no postoperative recovery.
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http://dx.doi.org/10.2165/11538940-000000000-00000DOI Listing
December 2010

Clinical efficacy of a novel sonic infusion system for periorbital rhytides.

J Drugs Dermatol 2010 Sep;9(9):1121-4

Washington Institute of Dermatologic Laser Surgery, Washington, DC 20005, USA.

Aging skin is a leading concern of most men and women seeking cosmetic dermatologic consultation. Various in-office procedures as well as topical at-home regimens, are generally prescribed to reduce the signs of aging, but relatively few provide immediate clinical benefit. A novel sonic infusion system that combines sonic micro-massage with an anti-aging serum was studied to determine its immediate effect on a wide range of patients with periocular rhytides. Clinical improvement of periocular rhytides was achieved after a single sonic infusion treatment (30 seconds/eye). Patients with more severe rhytides and those older than 40 years of age showed the best clinical results.
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September 2010

Fractionated laser skin resurfacing treatment complications: a review.

Dermatol Surg 2010 Mar 19;36(3):299-306. Epub 2010 Jan 19.

Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada.

Background: Fractional photothermolysis represents a new modality of laser skin resurfacing that was developed to provide a successful clinical response while minimizing postoperative recovery and limiting treatment complications.

Objectives: To review all of the reported complications that develop as a result of fractional ablative and nonablative laser skin resurfacing.

Methods: A literature review was based on a MEDLINE search (1998-2009) for English-language articles related to laser treatment complications and fractional skin resurfacing. Articles presenting the highest level of evidence and the most recent reports were preferentially selected.

Results: Complications with fractional laser skin resurfacing represent a full spectrum of severity and can be longlasting. In general, a greater likelihood of developing post-treatment complications is seen in sensitive cutaneous areas and in patients with intrinsically darker skin phototypes or predisposing medical risk factors.

Conclusions: Although the overall rate of complications associated with fractional laser skin resurfacing is much lower than with traditional ablative techniques, recent reports suggest that serious complications can develop. An appreciation of all of the complications associated with fractional laser skin resurfacing is important, especially given that many of them can be potentially prevented. The authors have indicated no significant interest with commercial supporters.
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http://dx.doi.org/10.1111/j.1524-4725.2009.01434.xDOI Listing
March 2010

Treatment of laser complications.

Facial Plast Surg 2009 Dec 18;25(5):316-23. Epub 2009 Dec 18.

Washington Institute of Dermatologic Laser Surgery, 1430 K Street, NW, Suite 200, Washington, DC 20005, USA.

Modern lasers and light-based sources that were developed based on the theory of selective photothermolysis are capable of destroying specific tissue targets while minimizing the risk of scarring and pigmentary changes. This is accomplished through the use of a wavelength and pulse duration that is best absorbed by a specific chromophore such as melanin or hemoglobin. However, not all lasers and light sources adhere to this principle. Continuous wave (CW) lasers are least selective and may produce unwanted tissue damage and scarring through heat conduction to normal skin. Quasi-CW lasers limit excessive thermal destruction by delivery of a series of brief laser pulses but still pose a higher risk of nonspecific tissue damage and thermal injury. The pulsed and Q-switched (QS) systems adhere most closely to the principles of selective photothermolysis and result in the highest degree of selective destruction with the lowest risk of scarring from excessive thermal diffusion. Certainly, any laser system potentially can result in scarring and tissue damage when used incorrectly; therefore, adequate operator education and skill are essential. Side effects and complications that occur as a consequence of laser treatment can be significantly reduced if diagnosed and treated in an expeditious manner.
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http://dx.doi.org/10.1055/s-0029-1243080DOI Listing
December 2009

Laser treatment of dark skin: a review and update.

J Drugs Dermatol 2009 Sep;8(9):821-7

Georgetown University School of Medicine, USA.

Of the estimated 11.7 million cosmetic surgical and nonsurgical procedures performed in the United States (U.S.) in 2007, 22% were performed on racial and ethnic minorities. Laser and light treatments rank in the top five most requested procedures in annual surveys of cosmetic and dermatologic surgeons. Recent U.S. population statistics reveal dramatically shifting demographics that would anticipate a likely increase in this percentage. U.S. Census Bureau data projects that by 2050, people of color are expected to become the majority, comprising 54% of the U.S. population, with Latinos accounting for 30%, African Americans 15%, and Asians 9.2%. The rising popularity of cutaneous laser surgery as an accepted therapy for various skin pathologies, coupled with the diverse face of the patient population, has led to increased demand for laser treatment of darker skin tones. Although difficult, effective laser therapy in patients with darker skin phototypes can be achieved. When determining a treatment protocol for an individual patient, the proper laser energy and wavelength are important in ensuring a substantial margin of safety while still achieving satisfactory results.
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September 2009

Improvement of postfractional laser erythema with light-emitting diode photomodulation.

Dermatol Surg 2009 May 6;35(5):813-5. Epub 2009 Apr 6.

Washington Institute of Dermatologic Laser Surgery, District of Columbia, USA.

Background: The most common side effects of fractional laser skin treatment are erythema and edema. Low-level light therapy and light-emitting diode (LED) devices have been used to stimulate fibroblast activity and hasten wound healing.

Objective: To determine whether LED treatment immediately after fractional laser skin resurfacing affects the severity and duration of postoperative eythema.

Materials And Methods: Twenty patients received treatment with a 590-nm wavelength LED array to randomly selected facial halves immediately after undergoing full-face fractional laser skin resurfacing with a 1,550-nm erbium-doped fiber laser. Differences in erythema between LED-treated and untreated facial halves were recorded at 24, 48, and 96 hours post-treatment.

Results: The LED-treated facial halves were less erythematous in all 20 patients 24 hours postoperatively. The six patients who received the highest mean energy densities during fractional laser treatment continued to exhibit decreased erythema in the LED-treated areas at 48 hours. At 96 hours post-treatment, no discernible differences between facial halves were observed in any patient.

Conclusions: Photomodulation with a 590-nm-wavelength LED array can decrease the intensity and duration of postfractional laser treatment erythema.
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http://dx.doi.org/10.1111/j.1524-4725.2009.01137.xDOI Listing
May 2009

Combined 595-nm and 1,064-nm laser irradiation of recalcitrant and hypertrophic port-wine stains in children and adults.

Dermatol Surg 2009 Jun 9;35(6):914-8; discussion 918-9. Epub 2009 Apr 9.

Washington Institute of Dermatologic Laser Surgery, Washington, District of Columbia, USA.

Purpose: Although pulsed dye laser (PDL) treatment of port-wine stain (PWS) has long been proven safe and effective, incomplete clearance of these vascular malformations can be problematic. In addition, advanced PWS with deeper coloration and tissue hypertrophy can be particularly difficult to treat because of the superficial dermal penetration of 585- to 595-nm light. The purpose of this study was to evaluate the safety and efficacy of a novel device that delivers sequential pulses of 595- and 1,064-nm wavelengths in the treatment of recalcitrant and hypertrophic PWS.

Methods: Twenty-five children and adults (skin phototypes I-III) with recalcitrant or hypertrophic PWS showing incomplete clearance after 10 prior PDL treatments were included in the study. Successive treatments using a 595-nm PDL and a 1,064-nm neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser were delivered at 6- to 8-week intervals. Two masked assessors determined clinical improvement of treatment areas using independent evaluation of comparative photographs at baseline and 3 months after treatment using a standard quartile grading scale.

Results: The use of dual 595-/1,064-nm wavelengths provided continued improvement of PWS that were previously recalcitrant to ongoing PDL therapy. Side effects were limited to transient erythema, edema, and mild purpura. Rare vesicle formation was observed, with no subsequent scarring or undesirable pigmentary changes.

Conclusion: The novel dual 595-nm PDL and 1,064-nm Nd:YAG laser is an effective treatment for PWS that are recalcitrant to PDL therapy alone.
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http://dx.doi.org/10.1111/j.1524-4725.2009.01155.xDOI Listing
June 2009