FRONTIERS IN DERMATOLOGIC SURGERY

Jun
2012
Vol. 31. No. 2

Introduction

In this issue, we hope to explore the history of dermatologic
surgery and also delve into new discoveries in the field. In
the 1930s, Frederick Mohs introduced chemosurgery to
dermatology and expanded the way in which dermatologists
treated skin cancers. Although Mohs micrographic
surgery has become an indispensable treatment modality
for skin cancer, enhancements have been made in the
medical management of advanced skin cancers. Dermatologists
have further expanded their skill set in surgery to
encompass cosmetic surgery with injectables, peels, laser
surgery, tumescent liposuction, hair transplant surgery,
and beyond. Many of the advancements in dermatologic
surgery have come within the past decade. We have seen
the emergence of fractionated laser technology and a burgeoning
field of noninvasive body contouring, which has
revolutionized our ability to offer nonsurgical options to our
patients. We have also witnessed clever applications of old
technologies and materials to treat difficult, recalcitrant conditions.
As the field continues to grow, dermatologic surgeons
are expanding their skill set, and the horizon looks
bright for dermatologic surgery. We have sought to compile
an exciting array of articles from thought leaders in the field
that highlight the past, present, and future of dermatologic
surgery.
Bill Hanke opens the issue reviewing key moments in the
history of dermatologic surgery. Next, Kelley Redbord and
Bill were able to assemble a unique well-illustrated biography
of the late Samuel Stegman. Bill has access to all of Dr Stegman’s
papers, and thus, he was able to compile a fascinating
article on one of the specialties’ pioneering dermatologic surgeons.
The past and future of soft tissue fillers is then reviewed
by Rick Glogau. Doru Alexandrescu and Vic Ross
follow with a discussion of the manifold current and future
uses of lasers in cutaneous medicine and surgery. Cutaneous
vascular lesions have long been treated with lasers and light
sources but complete removal of many vascular lesions and
malformations remains a difficult task. The future for the
treatment of such lesions is reviewed by Kristen Kelly and
colleagues. The use of fractionation in delivery of laser energy
has brought about rapid and dramatic conceptual and practical
changes in how we can deliver care, and Nazanin Saedi
and colleagues review fractional laser use in the treatment of
esthetic and medical disorders. One of the most exciting observations
in recent years has been the dramatic effectiveness
of ablative fractional resurfacing in the treatment of traumatic
scars and contractures in wounded warriors. These studies
have been carried out at the Naval Medical Center in San
Diego and are described by Nathan Uebelhoer, Vic Ross, and
Peter Shumaker.
Body contouring and sculpting is one of the great areas of
most intense current interest in esthetic medicine and dermatology.
Noninvasive fat removal, an important aspect of
this field, is discussed by Ray Jalian and Matthew Avram.
Arielle Kauvar treats us to a discussion of a new approach to
the treatment of melasma using low-fluence Q-switched neodymium-
doped yttrium aluminium garnet lasers to target
melanosomes. Low-level laser therapy has long been used
with some success in Asia and other parts of the world and is
now finding broad application for a variety of pigmented and
textural problems. The treatment of hyperpigmentation in
skin of color is very challenging, and this topic is nicely
reviewed in-depth by Sailesh Konda, Aanand Geria, and Rebat
Halder. Lastly, there is a short discussion of the cutting
edge in cutaneous oncology treatments by Kim Chong and
colleagues.
We sincerely hope that you find this issue informative and
enlightening.

Ablative Fractional Resurfacing for the Treatment of Traumatic Scars and Contractures

E. Victor Ross, MD | Nathan S Uebelhoer, DO

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.

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Fractionation: Past, Present, Future

H Ray Jalian, MD | Nazanin Saedi, MD | Anthony Petelin, MD | Christopher Zachary, MBBS, FRCP

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.

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Body Contouring: The Skinny on Noninvasive Fat Removal

H Ray Jalian, MD

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.

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The Evolution of Melasma Therapy: Targeting Melanosomes Using Low-Fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet Lasers

Arielle N.B. Kauvar, MD

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.

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New Horizons in Treating Disorders of Hyperpigmentation in Skin of Color

Aanand N. Geria, MD | Rebat M. Halder, MD

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.

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