[Hair Transplantation] #3.Consultation Process for Hair Transplantation

Transplanted hair starts growing again 3-5 months after temporary hair loss and shows maximum aesthetic effect by 1 year after the transplantation. Such delayed effect for several days or weeks is the difference of hair transplantation from general plastic surgeries that shows immediate effect. Compared to permanent growth of transplanted hair, loss of the existing hair continues over time, making the appearance even worse than before the transplantation or aesthetically unnatural. Since patients cannot accept such condition easily, clinicians may often experience various difficulties if they don’t provide full explanation on the subject in the course of consultation.



During the last 15 years of experience in hair transplantation, I would meet patients who could not satisfy with relatively good result and those who could satisfy with objectively not very good result. Patient’s satisfaction on the outcome may be expected by overall consideration of the patient’s accurate condition and expectation during a consultation, which is why consultation before a surgery is as important as the surgery itself. In addition, appropriate behavior to establish a good rapport between the clinician and patient is most important, because inappropriate behavior of the clinician or other medical staffs may lead to the patient’s disappointment, and even to a medical dispute for a not very bad surgical outcome.

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Consultation process for establishing good rapport with patients

1. Preliminary phase

Patients often wait for months or years before visiting the hospital, rather than receiving a care immediately, even if they had known the hospital and the medical staff in advance. They also tend to make an inquiry by telephone before visiting the hospital in person. The attitude of the person who answers the phone call may play as a key factor in determining whether or not to visit the hospital. Since telephone answering contributes to the first impression of the hospital, good telephone answering may have influence on the clinician-patient consultation. Staffs who answer telephones need to have enough knowledge on hair transplantation and answer the caller’s question sincerely. Warm-hearted response is effective not only for patients but also for a third person, including parents, wife or friends, who made a phone call instead of the patient, also contributing to the establishment of better rapport.



2. Consultation phase between the clinician and patient

It is very important to welcome a new patient warmly with a smile. Patients who visited for hair loss should be questioned kindly about the present medical history, family history and past medical history. Information about the patient’s job, family, hobby and sports may be also helpful for understanding the patient’s psychological, social and financial status and even for determining the possibility of hair transplantation, the number of hair strands to be transplanted, and the cost of transplantation.



Clinicians should keep in mind that the patient visited the hospital not just due to the lack of hair and that the patient might feel withdrawal and defensive at the same time due to the hair loss. Clinicians are recommended not to use direct phrases such as “you will look much younger with more hair after transplantation’ or ‘you will feel more confident’, because such expression might stir negative emotions about the patient’s appearance in his/her mind and hurt the patient’s feeling. Patients often ask ‘what are the processes of the surgery?’ not because he/she wants detailed explanation of the surgical process but because he/she is afraid of the hospital, hemorrhage, surgery or pain. Thus, the clinician needs to answer the patient’s question in a way that could reduce the patient’s fear. Patients can learn detailed surgical process from a pamphlet; excessively detailed explanation by the clinician using photos and such may rather increase the patient’s fear about the surgery.



3. Patient factors to be determined during consultation

Various patient factors, including age, the degree of hair loss and the characteristics of the donor hair, may have influence on the satisfaction and objective outcome of the surgery. Even a highly experienced clinician needs to review various patient factors sufficiently during a consultation.



(1) Age: Male pattern hair loss develops after adolescence and even early 20s often ask for hair transplantation due to progressive hair loss. Surgery would be inevitable if hair loss has progressed a lot even in young patients; however, if hair loss is not severe, hair transplantation needs to be delayed as long as possible or only minimum donor hair should be collected and the donor hair should be preserved for later in case the hair loss progresses (Figure 1). Generally, young male patients in their early- to mid-20s tend to have less satisfaction than middle-aged (40-50s) patients due to higher expectation about the outcome. Care should be taken as well because younger patients tend to have donor site scar more frequently than middle aged patients (Figure 2). Older patients in their 60-70s have lower expectation and thus higher satisfaction about the outcome, if they have no other physical condition. They also tend to experience donor site scar less frequently, making them more appropriate for hair transplantation (Figure 3).

Figure 1. Son before the surgery (26 years old, left) and father 1 year after surgery (56 years old, right). The son needs to preserve the donor site because he is highly likely to develop hair loss as his father.

Figure 2. Care should be taken in young patients in their 20-30s, who tend to experience a larger scar than middle aged or older patients due to their active wound healing process.

Figure 3. A 75-year-old male patient before (left) and 1 year after (right) 2,500 strands of hair transplantation. Hair transplantation is relatively more satisfactory among middle aged patients in general.

(2) Thickness of the donor hair: According to western standard, hair is considered as thick at ≥80㎛ thickness and as thin at ≤60㎛. Thicker donor hair contributes to increased volume of the transplanted hair and thus better outcome (Figure 4). Thin donor hair leads to less hair volume and less coverage of the scalp, resulting in decreased aesthetic effect (Figure 5). It is important, therefore, to measure the donor hair thickness to predict surgical outcome. Hair thickness can be measured by using a microscope or more recent computerized devices for easier measurement.

Figure 4. A 25-year-old male patient before (left) and 1 year after (right) 2,500 strands of hair transplantation. Thick hair contributes to a better aesthetic outcome even with a small amount.

Figure 5. A 55-year-old male patient 1 year after 2,000 strands of hair transplantation. Thin donor hair results in poorer aesthetic outcome.

(3) Density of donor hair: The average number of hair strands in the occipital region is around 130/cm² in Koreans, and 90% of them are terminal hair. The density can be considered as high if the number of hair strands is higher than this; higher density is associated with higher frequency of 2 hair Follicular Unit (FU) and 3 hair FU, as well as the tendency of better outcome (Figure 6). On the other hand, lower density or higher frequency of 1-hair FU is associated with poorer outcome (Figure 7). People generally think that male pattern hair loss develops only at the forehead or the crown of the head and not at the occipital region, which is not true. Occasionally, hair loss occurs at the lower region of the occipital region at the occipital region, in which case the donor hair becomes thin, ultimately resulting in the hair loss of the donor site. Hair transplantation should not be performed in this case (Figure 8).

Figure 6. High frequency of 2-3 hair follicular unit or high density of donor hair contributes to good aesthetic outcome.

Figure 7. High frequency of 1 hair follicular unit and low density of donor hair results in relatively poorer outcome.

Figure 8. Hair loss may develop at the occipital region, which is the donor site. Transplantation should not be performed in this case because the hair collected in this condition will fall out immediately after transplantation.

(4) Extent of hair loss progression: The extent of male patter hair loss is determined by the widely used Norwood classification. Patients in early phase of hair loss, such as in Norwood 1, 2 and 3, generally have higher expectation to have abundant hair at the transplanted area, and thus tend to feel less satisfaction. In addition, the transplanted hair will grow in place while the loss of the existing hair continues over time, making the appearance even worse than before the transplantation (Figure 9). On the other hand, patients in Norwood 5-7 stages tend to have lower expectation and thereby higher satisfaction (Figure 10). Hair transplantation should be avoided in male patients in their 20s with early phase hair loss (Figure 11). However, male patients in their 50s with early phase hair loss are less likely to develop to severe hair loss in the future. Therefore, hair transplantation can be performed in such patients, but they need to use a hair restorer, such as finasteride, for aesthetic purpose, because the transplanted hair will continue to grow and the hair loss of the existing hair will continue.

Figure 9. In young patients with early phase hair loss, transplanted hair will continue to grow while the hair loss of the existing hair will continue, resulting in serious outcome. Medication therapy should be used first while observing the prognosis before determining the time of surgery in young patients with early phase hair loss.

Figure 10. Patients with advanced hair loss tend to have high satisfaction and good surgical outcome after hair transplantation.

Figure 11. Compared to young patients (left), middle aged patients with early phase hair loss (right) are less likely to develop severe hair loss in the future and are safe to perform hair transplantation.

(5) Patient’s expectation: It is very important to confirm the patient’s level of expectation on hair transplantation during the consultation. Patients with unrealistic expectation generally do not satisfy with the outcome and often complain to the clinician. Patients with body dysmorphic disorder also tend to express dissatisfaction about the surgical outcome. It would be wise not to perform a surgery, if possible, for patients who seem overly obsessed with their appearance or are likely to have body dismorphic disorder during the course of consultation for a sufficient time.



(6) Present medical history: Hair transplantation is a relatively safe procedure, but care should be taken when there is another physical condition, as with any other surgery. Patients with a hemorrhagic disease that interferes with blood coagulation or those who are currently taking drugs that might interfere with hemostasis (such as aspirin, warfarin, etc.) need to have a consultation with their doctor before determining the surgery. Vitamin E products or other popular supplements, such as garlic juice, onion juice, ginseng juice and green vegetable juice, are advised to be discontinued from 2-3 weeks before the surgery because they dilute the blood and delays hemostasis. Patients with hypertension need to take an antihypertensive drug to lower the blood pressure because bleeding occurs a lot during the surgery. Propranolol and β-Blocker, among antihypertensive drugs, should be changed to another drug by consulting with the patient’s doctor, because these drugs may interact with epinephrine. Patients may also need to consult with their doctor for other physical conditions.



Both patients and clinicians will be satisfied with the outcome if the above factors are reviewed comprehensively before determining whether or not to perform hair transplantation.

- To be continued -

▶ Previous Artlcle : #2. Combination of Medical and Surgical Treatments for Male Pattern and Female Pattern Hair Loss

[Understanding Images by Filler and Cases Studies] #3.T zone Procedures and Other Case Types

Images by filler is the procedure of injecting standard 5ml of filler into every correctable area, including forehead, glabella, temple, nose, tear trough, Indian band, nasolabial fold, cheek, marionette line and chin. The cost can be increased when the amount exceeds 5ml. Of course, the treatment sites are determined by consultation with the patient. Both the patient’s requests as well as doctor’s recommendation are considered in the process.

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This chapter, we will focus on T zone images by filler procedures and other case types. <Case 1> is a 24-year-old female patient who received T zone images by filler procedure. Forehead, glabella, nasal root and chin were the main points, with additional procedures on zygoma, nasolabial fold, cheek and Marionette line. T zone images by filler is a procedure that makes the profile view as well as the front view more beautiful (Fig. 1, 2).

Figure 1. Case 1, F/24, Front view; before and after the procedure.

(Treatment sites; forehead, glabella, nasal root, zygoma, nasolabial fold, cheek, marionette line, and chin)

Figure 2. Case 1, F/24, Profile view; before and after the procedure.

(Treatment sites; forehead, glabella, nasal root, zygoma, nasolabial fold, cheek, marionette line, and chin)

In the same context, <Case 2> is a 28-year-old female patient, who received the procedure on the forehead, glabella, nasal root, supratip break point and chin as the main points, with additional procedure for Indian band. She did not express any special complaint about her face, but the face was not harmonious and attractive either. As most of patients who visit the clinic already have some level of information about images by filler, most of them agree with my advice on the sites requiring procedure and participates in the consultation with much hope for change after the procedure. This patient was satisfied a lot with front as well as profile view (Fig. 3, 4)

Figure 3. Case 2, F/28, Front view; before and after the procedure.

(Treatment sites; forehead, glabella, nasal root, supratip break point, chin and Indian band)

Figure 4. Case 2, F/28, Profile photos before and after the procedure.

(Treatment sites; forehead, glabella, nasal root, supratip break point, chin and Indian band)

Images by filler is also appropriate for people who complain of sagging cheek after facial contouring surgery. The patients who received zygoma contour surgery, among others, often experience soft tissue sagging. Facial contouring surgery may considerably reduce the actual size of the face, but the face in the picture or screen still does not appear young and small.



One of such case is <Case 3>, a 27-year-old female patient. She received procedure on Indian band, nasolabial fold and sagging cheek. The perioral mound formed at the right side of the lips also required special attention. The patient had to be informed of the presence of the perioral mound. And the procedure was planned to fill the surrounding area evenly, without injecting filler into that area, so as to make it look flat. You may see in the photos below that the patient’s face has become smaller and more beautiful with balanced U-line along the facial outline (Fig. 5, 6).

Figure 5. Case 3, F/27, front view; before and after the procedure.

(Treatment sites; Indian band, nasolabial fold and sunken cheek)

Figure 6. Case 3, F/27, Rt. 45° view; before and after the procedure.

(Treatment sites; Indian band, nasolabial fold and sunken cheek)

<Case 4> did not have apparent wrinkles, furrows or other facial problems, but fillers injected evenly to appropriate areas made the face look more elegant and sophisticated. The procedure was performed at zygoma, marionette lines and chin. The corrected chin changed the facial impression from weary to bright and healthy image and gave the patient a favorable impression (Fig. 7, 8). The chin is the closing area of the face. Most patients do not pay much attention to the chin unless they have severe micrognathia. Quite many patients also misunderstand that filler injection into the chin might make the face look longer.

Figure 7. Case 4, F/29, Right profile view; before and after the procedure.

(Treatment sites; Indian band, marionette line and chin)

Figure 8. Case 4, F/29, Rt. 45° view; before and after the procedure.

(Treatment sites; Indian band, marionette line and chin)

I think that the chin is a very important area so much so to describe it as the finishing touch of an artwork. In most cases, filler injection into the chin area makes the face look smaller, not longer. It is also an indispensable area when making V-line or U-line.



We have discussed the facial types and main procedure sites of the patients appropriate for images by filler so far. In the next part, the final chapter for images by filler, we will look into the overall designs required before a procedure and relevant cases, as well as patients not appropriate for images by filler procedure. In addition, I will introduce my future vision for filler procedure before closing this series.

- To be continued -

▶ Previous Artlcle : #2. Patients Appropriate for Filler and Filler Selection

[New Aspects of Burn Management] #3.Management of Minor Burns

The Goals of Therapy

1.Minimize pain and prevent infection.

2.Create moist conditions to facilitate speedy restoration of the wounded area using various, recently-developed dressing materials such as hydrophilic polyurethane that is air-permeable but inhibits passage of water.

3.Help sustain physical functions.

4.Minimize hyper- or hypo-pigmentation and burn scar formation (Figure 1).

Figure 1. As burns may cause hyperpigmentation, hypopigmentation and irregular, shiny scars, it is important to shorten the treatment period to the early stages of a burn as much as possible to minimize such scarring.

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Emergency care

Firstly, the source of heat should be separated or eliminated from the patient.

Cool down the burn immediately by holding it under running water for about 15-20 minutes, at 8℃. For children, extended exposure to cold water should particularly be avoided to prevent the risk of hypothermia.

- Advantages of a cooling procedure applied immediately after being burned:

- Stabilization of the mast cells in the skin

- Reduced histamine release

- Decreased edema development in the burned area

- Reduced pain

- The wound should be covered with sterilized, clean gauze or dressing to prevent the burn from deepening. Referral to a specialized burn center is recommended.

- Prescriptions available for pain relief:

- A small amount of IV morphine

- Acetaminophen

- Short-acting benzodiazepines

Elevation of the Burned Area

- Efforts should be made to prevent continuous edema of a burned area as it may increase the chances of infection.

- In order to reduce edema, have the patient practice regular exercise and elevate the burned area to a level slightly above that of the heart. The upper limbs may be elevated appropriately using a sling.

- Such precautions can help to prevent burn-induced edema from lasting longer than 3 days.

- As lower limb burns cause more severe edema and pain due to walking, elastic bandages such as Ace bandages may be used to reduce the edema and pain.

Local Burn Wound Care

Blisters

There is controversy over whether to eliminate blisters immediately to prevent infection in the early stage of a burn or to drain the blisters while leaving the separated epidermis in place to protect the wound and stimulate the healing process.

According to my clinical experience, preserving the separated epidermis of blisters is very helpful for maintaining moist condition, preventing drying out of the wound, protecting the wound, and relieving pain. Therefore, good therapeutic effects may be obtained by drainage and preserving the blistered epidermis in place, if possible (Figure 2).

Figure 2. 2^nd degree burn caused by hot water, forming large blisters the next day. I broke the blisters and preserved the epidermis in an effort to protect the wound and to take advantage of biological dressings. Just applying a topical agent on the blisters is not helpful for treatment.

Immediate removal:

According to the results of analyzing exudate from inside blisters, immunosuppression due to impaired polymorphonuclear cells (PMNs) and lymphocytes, interference with neutrophil chemotaxis, opsonization due to arachidonic acid in the blister fluids, and detrimental factors causing inflammation were present, indicating the benefit of removing the exudate (Figure 3).

Figure 3. Removing blisters completely from 2^nd degree burns causes the wound to dry and partially deepen. Often the patient complains of pain, thus complete removal is not helpful for treatment. Recently, cultured epithelial cell has been proven useful for burn wound care. However the high price of the material and the resultant financial burden comes as a drawback to the usage of cultured epithelial cells.

Intact maintenance of blisters:

Blisters occur at the level of the stratum spinosum and, if preserved well, most mid-2^nd degree burns may recover within two to three weeks. If blisters are completely removed, most wounds dry up, causing pain (as the zone of stasis transitions to the zone of necrosis, possibly deepening the burn). Thus exudate should first be removed while keeping the epidermal flap, and the wound should be dressed with dry gauze or an absorptive sponge-type dressing to absorb additional exudate until the epidermal flap adheres and dries completely for recovery (Figure 4). If a deep burn oozes fluid continuously for more than one week or the fluid becomes murky and smelly, this is an indication that the epidermis has lost the natural capability of serving as biological dressing. In this case, it should be removed immediately and replaced by a cultured epithelial homograft or synthetic biological dressing according to the latest views on burn management.

Figure 4a. Day 1 of sustaining a scalding burn on the right thigh.

Figure 4b, 4c. On Day 3, the blisters were preserved as far as possible and cultured epithelial homograft was performed on the exposed areas.

Figure 4d. On Day 6, the wound was already epithelized on the area where blisters were preserved, while epithelialization was still in progress on the areas where cultured epithelial homograft was performed.

Figure 4e. On Day 7, epithelialization was still in progress in parts of the areas where cultured epithelial homograft was performed.

Figure 4f. On Day 12, after complete recovery on Day 8, the wounds appear less severe on the areas where the blisters were preserved.

Cleansing the Burn Wound

- Pollutants remaining on a burned area should be removed.

- Tepid or room temperature normal saline, chlorhexidine gluconate soap, or non-irritating soap may be used for gentle cleansing.

- When removing materials such as tar or asphalt, which will not come off easily, the burn should be first cooled with cold water. The materials can then be removed by dissolving them with mineral oil, sunflower seed oil or solvent (Figure 5).

Figure 5. A facial burn by tar was cooled with cold water and then mineral oil was applied to cleanly remove the tar without inflicting additional wounds.

Topical agents

Recently the use of topical agents has decreased, with the exception of special cases such as with severe burn patients, as most agents may cause unwanted local or systemic side effects or delay the process of wound healing. If a topical agent must be utilized, sulfadiazine ointment is often a reliable option, with the fewest side effects and reduced pain. However, because silver sulfadiazine cream interferes with the process of epithelialization, it is not recommended for use once reepithelialization starts after necrotic tissue or eschar has been eliminated. Sulfamylon (mafenamic acid) may be used for ear burns which can pass through thick eschar and often cause chondritis. Additionally sulfamylon may be used to treat pseoudomonas infections or for the prevention of wound sepsis caused by deep tissue necrosis and accompanying infections. However, one should take into account that sulfamylon also causes severe pain in the burn victim.



It is not advisable to apply topical agents unconditionally to every burn as topical agents thickly applied to 2^nd degree burns with large blisters may penetrate the blisters, leaving no choice but to remove the epidermis, which plays an important role in protecting the wound. Applying topical agents to the facial area should also be avoided as it may irritate the eyes (Figure 6).

Figure 6. Sulfadiazine ointment should be avoided for facial burns since it may irritate the eyes and interfere with the protective action of blisters, hindering the progress of treatment.

The basic principles of dressing

- Do not expose wounds to air for a long time until they are well dried (Figure 7).

- Use hydrogel-type dressing materials for the first one or two days to cool down the wound and relieve pain.

- When it is difficult to maintain dressing properly, such as on areas like the face, apply a non-irritating ointment continuously as required, to prevent wound drying.

- Blister exudate may be absorbed by using normal, saline-soaked mesh gauze, changed twice a day, for two to three days; this method also reduces inflammation and edema.

- For dressing, apply an elastic bandage with appropriate tightness that does not interfere with the blood circulation (soft splints).

Figure 7. The above wound has been exposed in the air for a long time, partially deepening the burn on the inner thigh.

Burn Wound Care

2^nd Degree burns, Partial Thickness Burns

The epidermis plays an important role as a physical barrier against microorganisms and, because it is composed of lipid components, it is also important for inhibiting moisture evaporation. When treating partial thickness burns, the focus is to induce reepithelialization as soon as possible from dermal appendages mostly distributed in the reticular dermis. This allows minimization of the hypertrophic scar or dyspigmentation within 3 weeks for better functional and aesthetic results (Figure 8).

Figure 8. Day 12 after sustaining 2^nd degree burn on the right thigh. Dotted white spots represent epithelialization of cells proliferated from the pilosebaceous unit, including from hair follicles, sebaceous glands and sweat glands, distributed in the dermis

For the treatment of such burns, therefore, it is important to induce epithelialization by using an appropriate dressing material for maintaining moist conditions. There are also many studies investigating materials that promote epithelial cell regeneration, such as various cytokines, peptide growth factor (of which recombinant FGF is currently available), protease and growth hormone, based on genetic engineering.



3^rd Degree Burns, Full-Thickness Burns

Generally, the mechanisms of wound healing in 3^rd degree burns involve mostly wound contracture and epithelialization of the surrounding tissues, although the effect of epithelialization is weak because most of the dermal appendages, which are the main sources of epithelialization, are lost. Eschars made of necrotic tissues prevent wound healing and are generally separated by microorganisms present in the skin or are spontaneously separated by epithelialization from the dermal appendages under the eschars. Since eschars prevent wound healing, they should be surgically removed as soon as possible to induce wound healing before conducting wound closure.



Initial Assessment

Since the depth of a burn changes much within the first week of sustaining the burn, it is very difficult to predict the general depth during the early phase of the burn. However, blood vessels around the wound may be injured and edema caused by burn or fluid resuscitation may compress dermal vessels, impairing the blood circulation and thereby causing the zone of stasis to convert to the zone of necrosis, deepenuing the burn.

These variables contribute to the over 30% error rate of predicting the burn depth in the early phase. It is important, therefore, to accumulate enough personal experience to establish a proper management plan within 1 day of the burn’s occurrence. For example, in the case of hand burns, erroneous measurement of burn depth often leads to unnecessary surgery or omission of a surgery necessary for functional improvement.

If a patient requires surgery, systematic planning, such as selection of the graft type and donor site, should be established and wound closure via a one-step procedure should be also considered, as it is beneficial for a good postoperative outcome. The burn care team should try to deliver coordinated and reliable treatments for the patient’s mental stability.



The Roles of Bandaging

Burn dressing plays the following principal functions:

Protection: A bandage is a protective barrier for the injured skin against microorganisms.

Metabolism: Bandages reduce evaporative heat loss and minimize cold stress and shivering. Burn patients have an evaporation rate several times greater than that of the normal people (150ml/24 hours), causing a 10 times greater caloric demand and need for fluid replacement.

Comfort: 2^nd degree burn wounds are very sensitive to exposure to the air and deep thermal burns cause severe pain due to reeinnervation with time, which is why occlusive dressing should be utilized.



Pruritus

Most burn patients complain of pruritus, which occurs more often in children and on the legs than the arms. The etiology is still unknown, although it is suspected that increased bradykinin and endopeptide due to burn inflammation might be the cause. For management of pruritus, antihistamine administration, cool compression, application of aloe or alcohol-free lotion with an astringent effect as well as oily lotion may be used.



Protocol for the treatment of itching:

Step 1: Use a moisturizing body wash and lotions

Step 2: Schedule Diphenhydramine 1.25 mg/kg/POq4h

Step 3: Hydroxyzine 0.5mg/kg/PO q 6h and Diphenhydramine 1.25 mg/kg/PO q 6h should be administered alternatively every 3 hours

Step 4: Hydroxyzine 0.5mg/kg/PO q 6h, Cyproheptadine 0.1mg/kg/dose PO6h, and Diphenhydramine 1.25 mg/kg/PO q 6h should be administered alternatively every 2 hours while the patient is awake.

- To be continued -

▶ Previous Artlcle : #2. Emergency Care of Burn

[Laser Resurfacing] #3.Lasers for Skin Resurfacing and Their Effects

Ablation-type and Contraction-type Lasers

Lasers are widely used for medical purposes; especially when a surgical knife cannot be used for a skin lesion, laser alone can yield excellent therapeutic effects. With the discovery of selective photothermolysis (SPTL) of laser on the skin, it has become available to choose an appropriate laser for effective treatment of various skin diseases, without many side effects.

Laser resurfacing is available in ablation mode, where the irradiated laser vaporizes the moisture in the skin exfoliating the skin surface, or in contraction mode, where thermal activity induces skin contraction, thereby improving wrinkles and scars.



Lasers for skin resurfacing targets the moisture in the skin (chromophore) and uses CO₂ laser (10,600nm) and Er:YAG laser (2,940nm), which are in infrared region that absorbs well in the moisture.

Laser resurfacing in ablation mode is useful for epidermal lesions, including various keratosis and nevi, as it exfoliates the skin surface. In this case, it is recommended to maximize the ablation on the skin surface so as to reduce thermal injury of the skin. As for the laser setting, the power should be increased (400-500mJ) and the pass number should be lowered for less thermal injury and maximal tissue ablation.

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Laser resurfacing in contraction mode is skin remodeling for skin contraction and increased resilience, not for exfoliating the skin. It induces collagen contraction in the dermis, thereby increasing the resilience of the aged skin and straightening wrinkles. The contraction mode is also available for various scar remodeling. In this case, lower output (250-300mJ) with multiple irradiation (2-3 passes) setting can induce stronger resilience effect.

	Ablation mode	Contraction mode
Purpose	skin lesions	wrinkle, scar
Vaporization	maximum	minimum
Thermal damage	minimum	moderate
Power(mJ)	high(400~500)	lower(250~300)
Pass	1-2 pass	multiple

Table 1. Comparison between ablation mode and contraction mode

CO₂ Laser and Er:YAG Laser

Early CO₂ lasers in continuous mode created scars more frequently from thermal injury. Pulse frequency was developed later and then the later ultra-high frequency Ultrapulse mode is capable of yielding maximum skin ablation and papillary dermis contraction at the same time by high output (500mJ) for a short period of time (1/1,000 sec).

Figure 1. Removal of skin lesion using ablation mode of resurfacing laser.

Figure 2. Improvement of wrinkles using contraction mode of resurfacing laser.

High power CO₂ laser is useful for skin resurfacing but may interfere with the patient’s social life due to long-lasting erythema and frequent pigmentation (postinflammatory hyperpigmentation; PIH) after resurfacing.

Er:YAG laser is favorable for skin ablation due to 10 times stronger water absorption coefficiency than CO₂ laser. Early Er:YAG lasers have short irradiation time (pulse) on the skin, resulting in less thermal injury, but the lack of hemostasis and the hemorrhage absorbing laser energy prevents deeper resurfacing. In order to prevent such disadvantages, Er:YAG lasers with longer pulse has been used with CO₂ laser for skin resurfacing.



The ablation threshold is 0.5-1.5J/cm² for Er:YAG lasers, which is lower than 4.5-5J/cm² for CO₂ lasers.

Er:YAG lasers cause less thermal injury, induces faster wound healing, causes less erythema and pigmentation, and provides more safety and comfort for patients, making it more appropriate for shallow laser resurfacing.



I used Ultrapulse CO₂ laser in the 1990s, and from the 2000s, when the device was no longer any use, I have been using Er:YAG laser. In order to achieve deep skin resurfacing as the CO₂ laser, Er:YAG laser needs 2-3 times more irradiation for 2-3 times longer period of time. Therefore, I personally prefer Ultrapulse CO₂ laser for full facial resurfacing.



Patients often question about the difference between CO­₂ laser and Er:YAG laser; I would explain to them that how to use the devices, rather than the difference of laser models, is more important. I would also describe CO₂ laser as a sharp knife, which is effective when used well but may accompany side effects when used wrong, and Er:YAG laser as a relatively dull knife, which is safe but requires multiple use for deeper procedure.

Lasers Characteristics	Er:YAG	CO2
wave length	2,940nm	16,000nm
water absorption coefficient	12,800cm-1	800cm-1
pulse duration	200~300μsec	-950μsec
albation depth / pass	2~5μm	20~30μm
thermal damage	10μm	25~70μm
usual power setting	5~15J/㎠	250~500mJ/pulse
immediate collagen shrinkage	12%	25%
late collagen contraction	-14%	-43%
epithelization period	3~5days	5~10days
erythema lasting	1~2week	1~3month
hyperpigmentation	30~50%	50~80%
delayed hypopigmentation	rare(in Caucacian)	none
infection	less than CO2	2~7%

Table 2. Comparison between CO₂ laser and Er:YAG laser

For some clinicians who ask which laser is more beneficial for resurfacing, I remark the fact that the purpose of resurfacing is more important and that a specialized costly laser is not a necessity simply for removing nevus. Lasers recently developed in Korea also seem to have excellent cost efficiency.



Reference: Laser Plastic Surgery, Koonja Publishing, 2008, Seoul

- To be continued -

▶ Previous Artlcle : #2. Total Rejuvenation

[Case Series in Dermatologic Surgery] #3. The Most Effective Method for Surgical Treatment of Earlobe Keloid and Prevention of Its Recurrence

CASE

▶ Patient: a 21-year-old woman

▶ Chief complaint: The patient visited the hospital for hard nodular lumps accompanying pain in bilateral earlobes growing bigger in size (duration: for 1 year).

▶ Past medical history and family history: She had received intralesional injection of triamcinolone for 1 year and pressure therapy for several months at a private clinic.

▶ Skin findings: Hard nodular lumps developed from ear piercing scars in bilateral earlobes (Figure 1).

▶ Diagnosis: Earlobe keloid solely based on clinical findings

▶ Treatment: Intramarginal excision (see Figure 5 below) immediately followed by radiation therapy (see the description below), resulting in full recovery without recurrence so far.

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Figure 1. Hard nodular lumps in bilateral earlobes.

Histology findings: Postoperative histological images and histopathologic findings (see Figure 2).

Figure 2. Histopathological findings of keloids (H & E, A, B, C)

Histopathologic findings of the keloids

1. Inside the scar tissue are thick hyaline collagen fibers, with homogeneous eosinophilic staining, proliferated disorderly and widely in bundle (A and B) compared to relatively normal collagens in the lower part (A and C).

2. Proliferation of skin fibroblasts and mucopolysaccharides, especially chondroitin-4-sulfate, is identified between collagen fibers.

3. The blood vessels are decreased unlike in hypertrophic scar or normal tissue recovered after injury.



Histopathologic findings of the keloids

1. Basic knowledge for earlobe surgery

• Skin in front of the ear: The skin is thin and directly attached to the cartilage without adipose layer.

• Local anesthetic injection induces a lot of pain. Tissue dissection and primary skin suture are difficult to perform.

• Skin behind the ear: Relatively thick and loosely attached to the lower cartilage.

• Cartilage: One cartilage shapes the ear. Cartilage injury should be monitored at all times because cartilage infection may develop to fulminant necrotic cartilage in rare cases.

• Auricular region: Wedge resection is available to approximately 1/4 of all, with tie-over dressing that passes through the cartilage.

• Occlusive treatment: Dressing should be removed within 3-4 days due to the risk of Pseudomonas aeruginosa infection, and complete occlusive treatment is contraindicated.

• When a large area of the soft tissue on top of the cartilage has been removed, making it hard to perform primary suture or to expect the formation of granulation tissue by secondary suture, the cartilage should be resected by punch (1.5-2mm) to induce granulation tissue from the soft tissue on the opposite side, or the punching should be immediately followed by skin graft directly to the defect.

• Find the anatomical structures of the ear and their names in the diagram below(Figure 3).

- Helix, Antehelix, Scaphoid Fossa, Triangular Fossa, Crus of Helix, Tragus, Antitragus, Concha, Symba.

 

Figure 3. Diagram.

2. Things to be considered before surgical treatment of earlobe keloids

1) Conventional local treatments include intralesional injection of steroid, bleomycin or 5-FU, silicone gel application or silicone pressure sheet, metal pressure earring such as magnets or splint and cryotherapy, which have limited effect on preventing recurrence.

2) Simple excision followed by pressure has been reported as successful in some cases, although there are few reports on long-term follow-up results. Simple surgical removal is not currently recommended due to high risks of recurrence and exacerbation, but intralesional resection (core, subtotal or intramarginal excision) entails less recurrence.

3) Perioperative steroid injection and postoperative imiquimod application have been attempted to prevent postoperative recurrence, although these methods are not recognized as effective methods due to weak prevention effect.

4) Radiation therapy was found as the most effective method in comparative studies on various treatments.

5) Uncontrolled cases by conventional treatments or recurrent cases after surgery require radiation therapy and should be transferred to a hospital that provides one.

6) Radiation therapy is most effective and successful when performed 3 times consecutively (low-dose fractionated radiotherapy: 12Gy in three fractions) within 24 hours after surgery.

3. Surgical techniques for treatment of keloids

1) Intra-marginal or Subtotal Excision.

Figure 4. Intra-marginal Excision. JAAD 2002;47:307~9.

2) Core Excision with Supra-keloidal Flap.

Figure 5. Core Excision with Supra-keloidal Flap.

3) Preop TRA + Core Excision + RT.

4) My Current Approach: Summary.

4-6 weeks before surgery: Intralesional triamcinolone injection 20mg/ml/2 weeks.

Surgery: core excision with suprakelidal flap under local anesthesia

Radiation therapy within 2 hours after surgery: fractionated RT(12Gy in three fractions).

Figure 6. Preop TRA + Core Excision + RT.

References

1. Dinh Q, Veness M, Richards S. Role of adjuvant radiotherapy in recurrent earlobe keloids. Australas J Dermatol. 2004 Aug;45(3):162~6. Review.

2. Sclafani AP, Gordon L, Chadha M, Romo T 3rd. Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature. Dermatol Surg. 1996 Jun;22(6):569~74.

3. Field LM. Subtotal keloid excision--a preferable preventative regarding recurrence. Dermatol Surg. 2001 Mar;27(3):323~4.

4. Lee Y, Minn KW, Baek RM, Hong JJ (2001) A new surgical treatment of keloid: Keloid core excision. Ann Plast Surg 46:135–140.

5. Brian B. Adams, Hugh M. Gloster. Surgical Pearl: Excision with suprakeloidal flap and radiation therapy for keloids. J Am Acad Dermatol 2002;47:307-9.

6. Berman B, Villa A. Imiquimod 5% cream for keloid management’ Dermatol Surg. 2003 Oct;29(10):1050~1.

- To be countinued -

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[Scar Treatment] #3. Drugs and Topical Agents for Hypertrophic Scar and Keloid Treatment I

1. Scar treatment by pressure, humidification and occlusion

Despite lack of controlled studies, pressure therapy is empirically considered as effective for scar treatment. Generally 25-40mmHg is required, but occlusive dressing of scar area with lower pressure tape is also known to be effective. It is therefore considered useful to some extent to apply pressure with currently available DuoDerm, MediForm and common Band Aids. The mechanism of treatment is suspected diversely from reduced dermal thickness to reduced edema, and reduced fibroblast activity and collagen production due to low oxygen in the skin.

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Figure 1. Example of skin pressure.

2. Silicone gel sheets

The effect of silicone gel on scar treatment has been published a lot in the literature. It is more useful for prevention of scar formation rather than for the treatment of scars already in place. For the purpose of preventing surgical scars, continuous occlusion for at least 12 hours a day for 3-6 months from 2 weeks after surgery is required. The mechanism of action is controversial, but it has been suggested that it is either the effect of silicone itself or associated with reduced secondary scar formation due to hydration induced by occlusion.

Figure 2. Silicone gel sheet.

3. Steroids

Steroids are most commonly used for scar treatment; among others, triamcinolone injection is most representative. The main mechanism of action includes reduced inflammatory response and inhibition of fibroblast growth and collagen synthesis. Recent studies have found the presence of inhibitory function of various growth factors and genes (TGF-beta, SMAD-1, etc.) associated with scar formation. Despite such effects, steroids are frequently associated with systemic (acne, hypertension and diabetes mellitus) and local (atrophoderma and vasodilation) side effects, requiring dose and concentration control depending on the scar.



4. 5-Fluorouracil (5-FU)

5-FU is a pyrimidine analog antimetabolite. It is generally one of antitumor agents used for solid tumors. The mechanism of action is prevention of DNA synthesis and fibroblast growth, thereby reducing collagen synthesis as an inhibitory action against TGF-beta. 5-FU combined with steroid can make up for the side effects of each other, rather than when 5-FU is used alone.

Figure 3. 5-FU injection for a keloid scar.

5. Bleomycin

Bleomycin is an antitumor agent as 5-FU, but is widely used for the treatment of warts in dermatology. The mechanism of action is similar to that of 5-FU, inhibiting DNA synthesis and fibroblast growth, thereby reducing collagen synthesis as an inhibitory action against TGF-beta. Systemic side effect has not been reported, but hyperpigmentation may occur as a local side effect.

Generally, 0.5~1ml/cm² with 1.5 international unit/ml is injected.

Figure 4. Bleomycin treatment of a keloid scar.

6. Calcium channel antagonist

Verapamin or trifluoperazine are often used, which have been already in use for contracture in other medical fields. The mechanism of action is the inhibition of production and secretion of extracellular matrix, including collagen, and increasing the production of collagenase. It is also known to reduce the synthesis of IL-6 and VEGF to inhibit scar formation. The therapeutic effect is not evident for clinically established scars but has been used for prevention of surgical scars in many reports.



7. Interferon

Interferon-alpha, beta and gamma can be used for scar treatment due to its inhibitory action of collagen synthesis. However, the price is high compared to the effect and the injection may cause flu-like symptoms. Generally, 1 million unit/cm² is injected.



8. Radiation therapy

Radiation therapy is used as an adjuvant therapy for prevention of recurrence after surgery, rather than as a monotherapy. It is hardly applicable to general scars, but is considered as the most effective method until now for inhibition of radiation therapy-induced recurrence after surgery in severe keloid patients.



9. Cryotherapy

Cryotherapy can induce the most rapid reduction of scar, as with steroid injection. The accurate mechanism of action of cryotherapy on scar treatment is not known, but low oxygen condition induced by freezing seems to reduce collagen synthesis. The advantages of cryotherapy include the possibility of treating wide area within a short period of time depending on various scar sizes and lack of the risk of systemic side effect. Having said that, cryotherapy is also associated with many side effects, such as injection site pain, blistering, coloring and worsening of scar. The lack of standardization and great dependence on the operator’s experience also makes it hard to predict accurate therapeutic effect.

Figure 5. (A) Cryotherapy for hypertrophic acne scar on the chin. (B) Intralesional cryotherpay for keloid scar of the ear.

10. Other topical agents

1) Retinoic acid

2) Vitamin E

3) Onion extract

4) Heparin

5) Imiquimod: Interferon-inducing topical agent, reported as effective for prevention of surgical scars, including keloids.

Figure 6. Various topical agents

- To be continued -

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