After a decade of military conflict, thousands of wounded warriors have suffered debilitating
and cosmetically disfiguring scars and scar contractures. Clearly, there is a need for
effective scar treatment regimens to assist in the functional and cosmetic rehabilitation of
these patients. Traditional treatments, including aggressive physical and occupational
therapy and dedicated wound care, are essential. Adjunctive treatments with established
laser technologies, such as vascular lasers and full-field ablative lasers, have had a
somewhat limited role in scar contractures due to modest efficacy and/or an unacceptable
side effect profile in compromised skin. Refractory scar contractures often require surgical
revision, which can be effective, but is associated with additional surgical morbidity and a
significant risk of recurrence. Furthermore, current scar treatment paradigms often dictate
scar maturation for approximately a year to allow for spontaneous improvement before
surgical intervention. Since 2009, the Dermatology Clinic at the Naval Medical Center San
Diego has been treating scars and scar contractures in wounded warriors and others using
ablative fractionated laser technology. Although traditionally associated with the rejuvenation
of aged and photo-damaged skin, our clinical experience and a handful of early reports
indicate that laser ablative fractional resurfacing demonstrates promising efficacy and an
excellent side effect profile when applied to the functional and cosmetic enhancement of
traumatic scars and contractures. This article discusses our clinical experience with
ablative fractional resurfacing and its potential prominent role in rehabilitation from traumatic
injuries, including a possible shift in scar treatment paradigms toward earlier procedural
intervention. Potential benefits include the optimization of scar trajectory and higher
levels of full or adapted function in a more favorable time course.
Semin Cutan Med Surg 31:110-120 © 2012 Published by Elsevier Inc.
The development of fractional photothermolysis is a milestone in the history of laser technology and cutaneous resurfacing. Based on the concept that skin is treated in a fractional manner, where narrow cylinders of tissue are thermally heated and normal adjacent skin is left unaffected, the fractional devices have shown effectiveness in treating a variety of conditions. Since its development, we are becoming more adept at using optimal parameters to induce near carbon dioxide laser benefits with a much more comfortable postoperative period and fewer complications. The future remains bright for fractionated laser devices and with new devices and wavelengths, the applications of this technology continue to grow.
Semin Cutan Med Surg 31:105-109 © 2012 Elsevier Inc. All rights reserved.
Historically, the approach to body contouring has largely involved invasive procedures,
such as liposuction. Recently, several new devices for noninvasive fat removal have
received clearance by the Food and Drug Administration for the treatment of focal adiposity.
Modalities are aimed primarily at targeting the physical properties of fat that differentiate
it from the overlying epidermis and dermis, thus selectively resulting in removal. This
review will focus on 3 novel approaches to noninvasive selective destruction of fat.
Semin Cutan Med Surg 31:121-125 © 2012 Published by Elsevier Inc.
The Evolution of Melasma Therapy: Targeting Melanosomes Using Low-Fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet Lasers
Melasma is an acquired disorder of pigmentation that commonly affects women with
phototypes III-V, and it has a negative impact on the quality of life in affected individuals.
It presents clinically as symmetric tan or brown patches on the face, most often involving
the forehead, cheeks, perioral region, and periorbital region. On histologic examination,
there is increased melanin in the epidermis and/or an increased number of melanosomes
in the dermis, with a normal number of highly melanized and dendritic melanocytes. The
mainstay of treatment is the use of sunscreen along with topical medications that suppress
melanogenesis. Clearance is usually incomplete and recurrences or exacerbations are
frequent, probably because of the poor efficacy in clearing dermal melanosomes. Treatment
with high-energy pigment-specific lasers, ablative resurfacing lasers, and fractional lasers
results in an unacceptably high rate of postinflammatory hyper- and hypopigmentation and
rebound melasma. Recently, promising results have been achieved with low-fluence Qswitched
neodymium-doped yttrium aluminium garnet laser treatment, which can selectively
target dermal melanosomes without producing inflammation or epidermal damage, in
all skin phototypes. This article reviews the current treatment modalities for melasma, the
rationale for using and the clinical results of combination therapy with low-fluence Qswitched
neodymium-doped yttrium aluminium garnet lasers.
Semin Cutan Med Surg 31:126-132 © 2012 Elsevier Inc. All rights reserved.
Pigmentary abnormalities are among the most common reasons why patients with skin of
color visit a dermatologist. Hydroquinone has been a cornerstone for the treatment of
hyperpigmentation; however, concerns regarding adverse effects have prompted a search
for alternative agents. Some promising topical treatments include soy, licorice, rucinol,
mulberry, niacinamide, ellagic acid, resveratrol, and dioic acid. Oral agents, primarily used
for the prevention of postprocedural hyperpigmentation, include procyanidins, tranexamic
acid, and Polypodium leucotomos. Advances in Q-switched lasers, intense pulse light,
fractional photothermolysis, and the advent of tretinoin peeling add to the clinician’s
armamentarium for treating hyperpigmentation.
Semin Cutan Med Surg 31:133-139 © 2012 Elsevier Inc. All rights reserved.