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Indexed by the US National Library of Medicine and PubMed
EDITOR-IN-CHIEF
Stuart Maddin, MD
University of British Columbia, Vancouver, Canada
ASSOCIATE EDITORS
Hugo Degreef, MD, PhD - Medical Dermatology
Catholic University, Leuven, Belgium
Jason Rivers, MD - Medical Dermatology
Treatment of Hyperhidrosis with
Botulinum Toxin A
S. Läuchli, MD and G. Burg, MD
Department of Dermatology, University Hospital, Zurich, Switzerland
University of British Columbia, Vancouver, Canada
Jeffrey S. Dover, MD - Surgical Dermatology
Yale University School of Medicine, New Haven, USA
Dartmouth Medical School, Hanover, USA
Jan D. Bos, MD
ABSTRACT
Focal hyperhidrosis of axillae, palms or soles is a frequent, socially debilitating
condition, triggered by various emotional stimuli. There are several treatment
options such as local application of metal salts (aluminum chloride) or tap water
iontophoresis, which provide temporary relief for some patients. More recently, local
intradermal injections of botulinum toxin A (BTX-A), a neurotoxin blocking the
cholinergic stimulus of eccrine sweat glands, offer an effective treatment option with
few side-effects. Patient satisfaction rates are high, although treatment effects only
last a few months. For definite cure, surgical procedures have to be considered.
Enno Christophers, MD
KEY WORDS: hyperhidrosis, botulinum toxin, BTX-A
ASSISTANT ASSOCIATE EDITOR
Murad Alam, MD - Surgical Dermatology
Northwestern University Medical School, Chicago, USA
EDITORIAL ADVISORY BOARD
Kenneth A. Arndt, MD
Beth Israel Hospital
Harvard Medical School, Boston, USA
Wilma Fowler Bergfeld, MD
Cleveland Clinic, Cleveland, USA
University of Amsterdam, Amsterdam, Holland
Universitäts-Hautklinik, Kiel, Germany
Richard L. Dobson, MD
Medical University of South Carolina, Charleston, USA
Boni E. Elewski, MD
University of Alabama, Birmingham, USA
Barbara A. Gilchrest, MD
Boston University School of Medicine, Boston, USA
W. Andrew Griffiths, MD
St. Johns Institute of Dermatology, London, UK
Aditya K. Gupta, MD, PhD
University of Toronto, Toronto, Canada
Vincent C. Y. Ho, MD
University of British Columbia, Vancouver, Canada
Mark Lebwohl, MD
Mt. Sinai Medical Center, New York, USA
James J. Leydon, MD
University of Pennsylvania, Philadelphia, USA
Harvey Lui, MD
University of British Columbia, Vancouver, Canada
Hyperhidrosis is a condition with a tremendous psychosocial and occupational
impact for the patients affected. In axillary hyperhidrosis, the slightest emotional
or mental activity leads to wet armpits, showing up as stains on clothes, which can
be socially embarrassing. Furthermore, skin maceration and subsequent microbial
infection lead to discomfort, and body odors can impede social contacts. Palmar
hyperhidrosis leads to a slippery grip and to a cold, wet handshake. Certain
occupations are impossible because of staining of paper or other materials
handled. There also is an increased risk for developing delayed type
hypersensitivity to nickel and other contact allergens. Patients spend large
amounts of their time and energy hiding their condition in social contexts.
Howard I. Maibach, MD
University of California Hospital, San Francisco, USA
Larry E. Millikan, MD
Tulane University Medical Center, New Orleans, USA
Takeji Nishikawa, MD
Keio University School of Medicine, Tokyo, Japan
Constantin E. Orfanos, MD
Freie Universitäts Berlin
Univeritätsklinikum Benjamin Franklin, Berlin, Germany
Stephen L. Sacks, MD
Viridae Clinic Sciences, Vancouver, Canada
Alan R. Shalita, MD
Several treatments have been offered to patients suffering from hyperhidrosis but
they were either of limited effectiveness or had numerous side-effects. With the
discovery of botulinum toxin A for the treatment of hyperhidrosis, a treatment is
available which relieves the symptoms in a relatively simple and safe fashion,
although only for a limited time.
Types and Diagnosis of Hyperhidrosis
SUNY Health Sciences Center, Brooklyn, USA
Richard Thomas, MD
University of British Columbia, Vancouver, Canada
Stephen K. Tyring, MD, PhD
University of Texas Medical Branch, Galveston, USA
John Voorhees, MD
University of Michigan, Ann Arbor, USA
Klaus Wolff, MD
University of Vienna, Vienna, Austria
MANAGING EDITOR
Penelope Gray-Allan
Hyperhidrosis can be focal (axillary, palmar, plantar or forehead) or generalized.
It can be classified according to the stimuli inducing the sweating response. These
stimuli correlate with the sites of origin of the neuronal impulses for sweating—
emotional, mental or sensory hyperhidrosis (cortical reflex), thermoregulatory
sweating (hypothalamic), gustatory sweating (medullary), hyperhidrosis
following spinal cord transsection, injury or disease (spinal), and localized
sweating (axon reflex).
The most frequent triggers of focal hyperhidrosis affecting
axillae or palmoplantar areas are emotional (cortical)
stimuli. Hyperhidrosis is usually idiopathic, resulting from
a neurogenic overactivity of the sweat glands.1 Only rarely
is it associated with psychiatric disorders such as social
anxiety disorder.2 Generalized hyperhidrosis can be
secondary to a number of causes such as diabetes,
hyperthyroidism, chronic infections or malignancy.
Emotional sweating is always diurnal whereas
thermoregulatory sweating may be diurnal or nocturnal.3 A
history of “night sweats” always points to secondary
hyperhidrosis.
The sweat glands responsible for focal hyperhidrosis are
eccrine glands innervated with anatomically sympathetic,
but functionally cholinergic fibers. The neurotransmitter
involved is therefore acetylcholine.
The diagnosis of primary focal hyperhidrosis can usually
readily be made based upon the patient’s history of
wet armpits and massive sweating of the palms and soles
after emotional stress. Causes of secondary hyperhidrosis
should be excluded by
careful history and
appropriate laboratory
investigations.
The
areas affected can be
visualized with Minor’s
Iodine starch test
(Fig. 1). The extent of
hyperhidrosis can be
quantified
with
gravimetric methods,
but this is usually
unnecessary, as the
diagnosis is obvious and
Fig. 1: Axillary hyperhidrosis.
the decision to treat is
Area of excessive sweating is
based on the subjective
made visible with Minor’s
perception of the
Iodine-starch test.
suffering by the patient.
Treatment
There are various treatment modalities for hyperhidrosis.
Medications for generalized hyperhidrosis, such as
anticholinergics and antidepressants, are often
disappointing because the dose necessary to inhibit
2
sweating is high enough to cause substantial side effects
(see Table 1).
A first line treatment for localized hyperhidrosis, both
axillary and palmoplantar, is the local application of metal
salts, usually aluminum chloride or zirconium salts, in an
aqueous or ethanolic solution.4 These metal salts penetrate
the acrosyringium of the sweat glands and form a plug,
thereby reducing the amount of sweat. They are best applied
in the evening, before a period of relative inactivity of the
sweat glands. Applications are initially needed daily,
followed by a maintenance therapy with once or twice
weekly applications. The effect only lasts as long as the
maintenance dose is applied, although the sweat glands may
definitively involute after prolonged application.5
Another form of treatment achieving a substantial reduction
of sweating, particularly for palmoplantar hyperhidrosis, is
tap water iontophoresis.6 The hands or feet are immersed in
tap water and a low current is applied for approximately ten
minutes. Treatments should initially be performed 3-5 times
per week. For maintenance therapy, which can be
performed 1-3 times per week, patients sometimes prefer to
buy their own iontophoresis equipment.
For a more definitive cure, surgical treatments have to be
considered. Local excision of axillary sweat glands can be
performed in tumescence local anesthesia and usually
shows good results.7 Thoracal sympathectomy reduces
palmar hyperhidrosis effectively but carries the risk of
compensatory sweating.8
Botulinum Toxin A
Botulinum toxin (BTX) is a neurotoxin produced by the
anaerobic bacterium clostridium botulinum. It inhibits the
release of acetylcholine at the presynaptic nerve endings of
the motor endplates. At the end of the 18th century, it was
recognized as the cause of botulism, a frequently fatal form
of food poisoning.9 Therapeutic use of the poison started in
the 1960s, when ophthalmologists recognized that minute
amounts of BTX could effectively paralyze eye muscles in
patients with strabism and blepharospasm. Clinical use for
other muscle disorders, such as cramped sphincters in anal
fissures and urogenital dystonias followed quickly. In the
early 1990s, after clinicians observed that patients treated
with BTX for hemifacial spasms no longer sweated in the
treated area, the idea arose to use the toxin to treat
Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 7 • November-December 2003
Mode
of application
Mechanism
of action
Duration
of effect
Major
advantages
Major
drawbacks
Metal salts
(aluminum
chloride,
zirconium)
Local application
under oclusion at
bedtime
Plugging of
sweat glands
As long as applied
Easy application,
few side effects
Limited
effectiveness
Tap water
iontophoresis
Immersion of
affected sites 3-5
times weekly for
10 minutes
Unknown
As long as applied
Few side effects
Availability and
cost of equipment,
time consuming
Botulinum
toxin A
Intradermal
injection
Inhibition of
exocytosis of
acetylcholine
Several (3-17)
months
Very effective
Costs, repetitive
treatments necessary,
anesthesia
Surgical
procedures
Local excision of
Reduction of
axillary sweat
sweat glands
glands in tumescence
anesthesia
Lasting
Long term
effectiveness
Complications of
surgery
Thoracal
sympathectomy
Lasting
Long term
effectiveness
Compensatory
sweating, (rarely)
complications
Denervation of
sweat glands
Table 1: Summary of available treatments for focal hyperhidrosis
hyperhidrosis. In the meantime, BTX has become widely
established for the treatment of hyperhidrosis and
hyperfunctional facial lines.
Seven serotypes of BTX exist; of these, serotype A is the
one most often used to treat hyperhidrosis. By preventing
the exocytosis of acetylcholine, BTX-A exerts an inhibitory
effect on the cholinergically innervated eccrine secretory
cells and thus reduces sweat production. BTX-A is
available in two commercial forms (BOTOX® [Allergan] in
the USA and Europe and Dysport® [Ipsen] in Europe),
whereby 1 unit of BOTOX® is about equal to 3-4 units of
Dysport®. The affected area is first visualized with Iodine
starch staining (Minor test). Then 50-200 units of BOTOX®
are injected intradermally; the dose is divided into 10-15
aliquots injected at spatial intervals of approximately 2 cm,
enough to cover the entire affected area. Injection in the
axillae is usually well tolerated without anesthesia.
Injections in palms and soles can be very painful and are
therefore best performed under regional anesthesia (median
and ulnar nerve block for palms, sural and posterior tibial
nerve block for soles). Alternatively, the area can be
rendered relatively pain free by prior application of
anesthetic cream (EMLA, AstraZeneca) under occlusion,
iontophoretic application of lidocaine, or cryospray.
The anhidrotic effect of BTX-A, which can be perceived
after 2-4 days, is usually very satisfying. Several studies
have reported it to be effective in more than 90%
of patients, compared to response rates around 35%
for placebo. This is true both for axillary10-12
and palmoplantar13,14 hyperhidrosis. Quality-of-life
assessments showed a substantial reduction of the adverse
impact of hyperhidrosis.15,16 Although apocrine sweat
glands are innervated by adrenergic fibers, treatment with
BTX-A showed marked improvement of unpleasant body
odor (bromhidrosis).17 The mechanism of action for this
effect may be a reduction of the moist environment
favorable for bacterial growth, or the inhibition of
cholinergic apocrine glands. In patients with dyshidrotic
hand dermatitis, treatment of the palms with BTX-A may
reduce the severity of the eczema, as hyperhidrosis is
considered to be a precipitating factor in this condition.18
A drawback of the treatment with BTX-A when compared
to surgical approaches is the limited duration of its effect.
After one treatment, anhidrosis lasts between 3 and 17
months with a median duration of approximately 7 months.
Higher doses of BTX-A seem to lead to a slightly longer
duration of effect,19 outweighed by the higher costs and the
higher risk of antibody formation. Repeat treatments can be
performed at intervals guided by the patient’s requests and
lead to sustained good results.10 For many patients this may
be preferable to the ongoing treatments required by metal
salts and tap water iontophoresis. However, a definitive
Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 7 • November-December 2003
3
cessation of the symptoms has not been observed even after
multiple treatments, and histological examination of sweat
glands shows no involution due to inactivity. A treatment
algorithm for axillary and palmoplantar hyperhidrosis is
proposed in Fig. 2.
AXILLARY
BTX-A
1. Sato K, Kang WH, Saga K, Sato KT. Biology of sweat glands and their
disorders. I. Normal sweat gland function. J Am Acad Dermatol
20(4):537-63 (1989 Apr).
2. Davidson JR, Foa EB, Connor KM, Churchill LE. Hyperhidrosis in
social anxiety disorder. Prog Neuropsychopharmacol Biol Psychiatry
26(7-8):1327-31 (2002 Dec).
3. Sato K, Kang WH, Saga K, Sato KT. Biology of sweat glands and their
disorders. II. Disorders of sweat gland function. J Am Acad Dermatol
20(5 Pt 1):713-26 (1989 May).
Focal Hyperhidrosis
Topical antiperspirants
(Metal salts)
References
PALMOPLANTAR
Tap water iontophoresis
4. Scholes KT, Crow KD, Ellis JP, Harman RR, Saihan EM. Axillary
hyperhidrosis treated with alcoholic solution of aluminium chloride
hexahydrate. Br Med J 2(6130):84-5 (1978 Jul).
5. Holzle E, Braun-Falco O. Structural changes in axillary eccrine glands
following long-term treatment with aluminium chloride hexahydrate
solution. Br J Dermatol 110(4):399-403 (1984 Apr).
6. Anliker MD, Kreyden OP. Tap water iontophoresis. Curr Probl
Dermatol 30:48-56 (2002).
Tap water iontophoresis
BTX-A
Local excision of sweat
glands (or Thoracal
sympathectomy)
Thoracal
sympathectomy
Fig. 2: Treatment Algorithm for focal hyperhidrosis. Steps
may be omitted based on availability and patient preferences.
Adverse effects of the treatment with BTX-A are minor and
very rare. Hematomas at injection sites are usually of little
concern. Injection into the palms can lead, by diffusion of
the toxin, to a transient weakness of the small muscles in
the hand. Subjectively increased sweating at non-treated
sites has been reported. Especially when higher doses of
BTX-A are used, antibody formation (leading to
ineffectiveness of the treatment) can theoretically occur, but
this has been observed only very rarely. Contraindications
include pregnancy and lactation, and special precautions
should be applied in patients with motor neuron disease,
myasthenia gravis, Eaton-Lambert syndrome, patients on
aminoglycoside antibiotics or with hypersensitivity to
BTX-A or any ingredient in the formulation.
Conclusion
Intradermal application of Botulinum toxin A (BTX-A) has
added a valuable and very effective option to the hitherto
available treatments of focal hyperhidrosis. While the effect
is only of limited duration and repetitive treatments are
necessary, it has a very good safety profile. It can add
significantly to patients’ quality of life, especially when
other treatment options have proven ineffective.
4
7. Hafner J, Beer GM. Axillary sweat gland excision. Curr Probl
Dermatol 30:57-63 (2002).
8. Lin TS, Kuo SJ, Chou MC. Uniportal endoscopic thoracic
sympathectomy for treatment of palmar and axillary hyperhidrosis:
analysis of 2000 cases. Neurosurgery 51(5 Suppl):84-7 (2002 Nov).
9. Geiges ML. The history of botulism. Curr Probl Dermatol 30:77-93
(2002).
10. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of
bilateral primary axillary hyperhidrosis: randomised, parallel group,
double blind, placebo controlled trial. BMJ 323(7313):596-9 (2001
Sep).
11. Salmanpoor R, Rahmanian MJ. Treatment of axillary hyperhidrosis
with botulinum-A toxin. Int J Dermatol 41(7):428-30 (2002 Jul).
12. Heckmann M, Ceballos-Baumann AO, Plewig G; Hyperhidrosis Study
Group. Botulinum toxin A for axillary hyperhidrosis (excessive
sweating). N Engl J Med 344(7):488-93 (2001 Feb).
13. Lowe NJ, Yamauchi PS, Lask GP, Patnaik R, Iyer S. Efficacy and
safety of botulinum toxin type a in the treatment of palmar
hyperhidrosis: a double-blind, randomized, placebo-controlled study.
Dermatol Surg 28(9):822-7 (2002 Sep).
14. Wollina U, KaramÞlov T. Botulinum toxin A for palmar hyperhidrosis.
J Eur Acad Dermatol Venereol 15(6):555-8 (2001 Nov).
15. Tan SR, Solish N. Long-term efficacy and quality of life in the
treatment of focal hyperhidrosis with botulinum toxin A. Dermatol Surg
28(6):495-9 (2002 Jun).
16. Naumann MK, Hamm H, Lowe NJ; Botox Hyperhidrosis Clinical
Study Group. Effect of botulinum toxin type A on quality of life
measures in patients with excessive axillary sweating: a randomized
controlled trial. Br J Dermatol 147(6):1218-26 (2002 Dec).
17. Heckmann M, Teichmann B, Pause BM, Plewig G. Amelioration of
body odor after intracutaneous axillary injection of botulinum toxin A.
Arch Dermatol 139(1):57-9 (2003 Jan).
18. Swartling C, Naver H, Lindberg M, Anveden I. Treatment of
dyshidrotic hand dermatitis with intradermal botulinum toxin. J Am
Acad Dermatol 47(5):667-71 (2002 Nov).
19. Wollina U, KaramÞlov T, Konrad H. High-dose botulinum toxin type
A therapy for axillary hyperhidrosis markedly prolongs the relapsefree interval. J Am Acad Dermatol 46(4):536-40 (2002 Apr).
Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 7 • November-December 2003
ADVANCES IN DERMATOLOGIC SURGERY
Editors: Jeffrey S. Dover, MD and Murad Alam, MD
Blepharoplasty: Laser or Cold Steel?
B. S. Biesman, MD
Vanderbilt University Medical Center, Nashville, TN, University of Tennessee Health Sciences Center, Memphis, TN, USA
ABSTRACT
Blepharoplasty of the upper and/or lower eyelids can restore a youthful appearance to the aging face. This is a minimally invasive procedure that can be accomplished with little bleeding and a small incision. Laser-assisted blepharoplasty was pioneered
in 1980, with the technique simplified after the subsequent introduction of the pulsed carbon dioxide laser. Laser-assistance
helps mitigate bleeding during blepharoplasty. In ideal circumstances, the laser can be used as a multipurpose device that
simultaneously offers cutting, cautery and blunt dissection capabilities. However, there is little experimental evidence
confirming the superiority of laser-assisted blepharoplasty over more traditional scalpel surgery. For some procedures coldsteel may be preferable, and some surgeons prefer to use a knife for initial incisions and then laser for its coagulative properties. Patient factors and physician skill should guide the selection of the ideal blepharoplasty technique.
KEY WORDS: blepharoplasty, facial aging, laser
Over the past two decades, western society has placed
increasing demands on physicians to perform procedures
with greater speed and efficiency and shortened recovery
times. Perhaps no discipline has been more affected by
these demands than aesthetic surgery. Once considered a
luxury available only to the extremely wealthy and long
considered a “taboo” topic, aesthetic surgery has become
a part of mainstream Western culture. Fashion magazines,
the internet, and television shows feature aesthetic surgery
topics that are so current that they discuss the use of
products not yet approved for use by the US FDA.
Cosmetic surgery has consequently become a part of
mainstream Western culture.
Some of the earliest changes of facial aging are reflected
in the periorbital region. These changes may include
excess skin on the upper and/or lower eyelids
(dermatochalasis), prominent upper or lower eyelid fat
pads, and loosening of the lower eyelids due to laxity of
the canthal tendons. It is thus not surprising that
blepharoplasty is one of today’s most popular aesthetic
surgical procedures.
To enhance efficiency, hasten a return to routine activities
and reduce morbidity associated with a surgical
procedure, efforts are typically made to minimize incision
size, limit the amount of dissection, and shorten the
operative time. Applying these concepts to blepharoplasty,
the variable most amenable to change is duration of the
operative procedure. Operative times may be shortened
through operator skill and experience, and via use of a
device to enhance intraoperative hemostasis.
Numerous devices permit soft tissue incisions to be made
with little or no bleeding. Some examples include sapphire
tips heated by an Nd:YAG laser, needle-tipped
radiofrequency devices, fine-tipped monopolar cautery,
CO2 laser-heated ultra-sharp diamond knife, and free
beam CO2 laser. While hemostasis is important, when one
is evaluating these devices the amount of thermal damage
produced along the wound edges must also be considered,
as excessive thermal effect will produce delayed wound
healing, dehiscence, or even hypertrophic scarring.
Laser assisted blepharoplasty was first performed by
Baker in 1980. He reported the results of his first 40 cases
in 1984, concluding that this technique held promise.1
Despite Baker's optimism, the prevailing opinion in the
1980s was that CO2 lasers produced too much thermal
damage to be useful in cutaneous, much less aesthetic,
surgical procedures.2
Interest in laser-assisted blepharoplasty was renewed in
the early 1990s with the introduction of a high-energy
pulsed CO2 laser. This device, known by the trade name
UltraPulse® (Lumenis, Palo Alto, CA), produced a high
frequency pulsed beam that made incisions with a smaller
zone of thermal injury than was previously possible. This
Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 7 • November-December 2003
5
ADVANCES IN DERMATOLOGIC SURGERY
Editors: Jeffrey S. Dover, MD and Murad Alam, MD
laser cut soft tissue with a pulsed beam whose frequency
and energy could be independently varied to achieve the
ideal blend of cutting and coagulation. Even when operated
in “continuous wave” mode, this laser produced a pulsed
beam with a frequency of 1000-3000 Hz. The UltraPulse®
also produced a small (0.2mm) diameter beam that made it
more useful for working in the periorbital region. When
used properly, surgery could be performed quickly,
intraoperative hemostasis and visualization of delicate
anatomic structures was dramatically improved, and the
zone of thermal injury surrounding the laser incisions was
only about 115µm.3 Consequently, when these wounds
healed they were usually indistinguishable in appearance
from cold steel wounds. Similar devices subsequently
produced by other manufacturers (e.g., Unipulse®‚ Nidek
Incorporated, Fremont, CA, 0.2mm spot, peak power = 40
W) yielded equally satisfactory results, leading to more
widespread acceptance of laser incisional surgery as a
viable technique in certain clinical settings. In an effort to
further reduce the risk of complications, in 1998 Sciton
(Palo Alto, CA) began adapting an Er:YAG laser to
produce soft tissue incisions. Unfortunately the Er:YAG
laser was unable to produce sufficient hemostasis to make
it practical for use in soft tissue incisional surgery.
Clinical Perspective
Proponents of laser incisional surgery find that soft tissue
surgery may be performed more efficiently and, in some
cases, more effectively with lasers than with standard
techniques. There are several reasons for this. First, when
used properly, the laser handpiece acts as three instruments:
a cutting tool, a cautery, and a blunt dissection device. The
intraoperative transfer of instruments and therefore total
operating time is thus decreased. Second, intraoperative
efficiency is increased further by the near absolute
hemostasis that is often achieved when working in areas
such as the periorbital region where most blood vessels
have an internal diameter of 0.5mm or less. For this reason,
the CO2 laser has found its greatest incisional applications
in the periorbital region. Third, dissection with the CO2
laser in the eyelids and periorbital region allows surgery to
be performed on delicate vascular structures such as the
levator palpebrae superioris and the superior tarsal
(Müller’s) muscle with a lower risk of tissue distortion,
6
functional impairment, or hematoma formation.
Consequently, the use of lasers allows certain incisional
procedures such as blepharoptosis repair or correction of
eyelid retraction to be performed with greater precision.
One of the most important questions is whether using lasers
to perform incisional procedures benefits the surgeon, the
patient, both, or neither. The literature is decidedly unclear
in attempts to answer this question. Anecdotal reports and
small unmasked studies offer conflicting conclusions as to
the benefit of lasers in blepharoplasty, the aesthetic
procedure performed most often with lasers rather than
traditional instrumentation.4-7 Some authors report that the
CO2 laser offers little advantage over the scalpel,8 while a
recent survey comparing scalpel versus CO2 laser
blepharoplasty indicated that the benefits of using a laser
included quicker recovery time to usual activities (6.3 vs.
9.1 days), and shorter operating times (four eyelid
blepharoplasty times of 58 vs. 94 minutes).9 Biesman and
colleagues have performed the only prospective,
multicenter, double-blind study to address this issue.
Ophthalmic plastic surgeons who were experienced in both
laser-assisted and traditional technique (at least 100 cases
of each over the preceding 2 years) performed
blepharoplasty procedures on 50 patients using laser on one
side and cold steel on the other. The side treated with laser
was randomly selected and the patients were blinded to the
surgeon's choice. Patients were examined 1, 2, and 4 weeks
after surgery. Results were assessed by patient
questionnaire and by evaluation of photographs by a
skilled, masked observer. Two weeks after surgery there
was no significant difference in the amount of swelling,
discoloration, or wound appearance. The surgeons
preferred performing surgery with the laser when possible
due to the improved intraoperative hemostasis. This study
did not evaluate surgical times.10
Despite these findings, after years of experience
performing periorbital surgery with an array of incisional
devices including cold steel, radiofrequency, monopolar
cautery, long-pulsed Er:YAG laser and CO2 laser, I
continue to prefer the CO2 laser when performing certain
incisional procedures, especially for most cases of upper
eyelid blepharoplasty, upper eyelid ptosis repair, and lower
eyelid transconjunctival blepharoplasty. I have even found
Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 7 • November-December 2003
ADVANCES IN DERMATOLOGIC SURGERY
Editors: Jeffrey S. Dover, MD and Murad Alam, MD
that the laser enables me to operate with a greater degree
of safety on certain anticoagulated patients who require
eyelid or orbital surgery but are unable to discontinue
anticoagulation without significant risk of an untoward
event.
unacceptable appearance. I prefer nylon or polypropylene
suture, and leave the sutures in place approximately 7 days
as opposed to the 3-4 days I leave sutures after cold steel
blepharoplasty. This gives the laser wounds an opportunity
to heal more completely prior to suture removal.
I do not advocate the use of laser in all cases of periorbital
surgery. Due to inconsistent results, I no longer use the
laser to make the initial skin incision when performing
upper blepharoplasty on patients with “tight” skin such as
young patients, Asians, or patients with prominent
epicanthal folds. I also prefer to make lower eyelid skin
incisions with sharp instruments. However, once the initial
incisions have been completed, I use the laser to complete
the remainder of the dissection.
Conclusion
The CO2 laser produces a zone of irreversible thermal
injury (coagulative necrosis) along the wound edge, an
observation that has been correlated with the well
recognized delay in the rate of laser wound healing,
postoperative wound dehiscence, and unacceptable
scarring. As long as these tissue effects are recognized and
understood, postoperative problems can be avoided. For
example, laser incisions should be made parallel to relaxed
skin tension lines. This will allow wounds to be closed
with the least amount of tension, thus reducing the risk of
unacceptable scarring. Similarly, cutaneous laser incisions
should be placed in areas such as the head and neck that
have a rich blood supply. When closing cutaneous laser
wounds, I believe that absorbable suture materials should
be avoided as the coagulative necrosis produced by the
laser, in conjunction with the inflammation stimulated by
the suture material can produce wounds with an
When used appropriately and judiciously, lasers can play
an important role in periorbital incisional surgery.
References
1. Baker SS, Muenzler WS, Small RG, Leonard JE. Carbon
dioxide laser blepharoplasty. Ophthalmology 91(3):238-43
(1984 Mar).
2. Wesley RE, Bond JB. Carbon dioxide laser in ophthalmic
plastic and orbital surgery. Ophthalmic Surg 16(10):631-3
(1985 Oct).
3. Biesman BS, Bernstein E. The Er:YAG laser as a soft tissue
incisional device. Lasers Surg Med Suppl 11:64 (1999).
4. David LM, Sanders G. CO2 laser blepharoplasty: a comparison
to cold steel and electrocautery. J Derm Surg Oncol 13(2):110
(1987 Feb).
5. Morrow DM, Morrow LB. CO2 laser blepharoplasty. A
comparison with cold-steel surgery. J Dermatol Surg Oncol
18(4):307-13 (1992 Apr).
6. Apfelberg DB, Maser MR, Lash H, White DN. Sapphire tip
technology for the YAG laser excisions in plastic surgery. Plast
Reconst Surg 84(2):273-9 (1989 Aug).
7. Putterman A. Scalpel Neodymium:YAG laser in oculoplastic
surgery. Amer J Ophthalmol 109(5):581-4 (1990 May).
8. Mittelman H, Apfelberg DB. Carbon dioxide laser
blepharoplasty—advantages and disadvantages. Ann Plast
Surg 24(1):1-6 (1990 Jan).
9. Glassberg E, Babapour R, Lask G. Current trends in laser
blepharoplasty. Results of a survey. Dermatol Surg
21(12):1060-3 (1995 Dec).
10. Biesman BS, Buerger DE, Yeatts RP, Flaherty P. Presented at:
the meeting of the American Society of Ophthalmic Plastic and
Reconstructive Surgery, October, 2000.
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Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 7 • November-December 2003
7
Update on Drugs
Class
Antibacterial Agent
Name/Company
PA mAB
ABthrax™
Human Genome Sciences
Approval Dates and Comments
The US FDA approved a Fast Track Product designation in August 2003,
for the prevention and treatment of anthrax infections. A Phase I placebocontrolled, dose-escalation clinical trial has been initiated in healthy
adult volunteers to evaluate the safety, tolerability and pharmacokinetics
of this product.
Immuno-modulatory
Agent
Thalidomide
THALOMID®
Pharmion/Celgene
The Australian Drug Evaluation Committee recommended approval of
this product in August 2003, for the treatment of patients with relapsed
and refractory multiple myeloma, and for the treatment of cutaneous
manifestations of erythema nodosum leprosum.
Antiviral Agent
Valacyclovir Caplets
Valtrex®
GlaxoSmithKline
The US FDA approved a supplemental new drug application in August
2003, for this antiviral product for suppressive therapy in otherwise
healthy adults with genital herpes in order to reduce the risk of
heterosexual transmission of genital herpes.
Antibacterial Agent
Ertapenem Sodium
Invanz®
Merck Frosst Canada
TPP Canada approved this new once-daily monotherapy antibiotic in
September 2003, for the treatment of adults with moderate-to-severe
infections, caused by a wide range of bacteria. These include skin and
skin structure infections, intra-abdominal infections, and community
acquired pneumonia.
Antipsoriatic Agent
Efalizumab
Raptiva®
Genentech/XOMA
The US FDA Dermatologic and Ophthalmic Drug Advisory Committee
unanimously recommended approval of this product in September 2003,
for the treatment of moderate-to-severe plaque psoriasis in adults aged
>18 years.
Oncologic Agent
INGN 201
The US FDA granted Fast Track designation for this investigational
Advexin® Gene Therapy cancer therapy in September 2003, for the treatment of squamous cell
carcinoma of the nead and neck. This product combines the p53 gene
Introgen Therapeutics
with an adenoviral delivery system designed to kill cancer cells and stop
tumor growth without harming normal cells.
Drug News
Malignant Melanoma
According to a study published in the Journal of Foot and Ankle Surgery*, malignant melanoma is
increasing at a rate faster than any other cancer in the US, and the overall 5-year survival rate of patients
with a primary tumor on the foot is significantly higher than for patients with primary melanomas elsewhere
on the lower extremity (52% vs. 84% respectively). Melanoma can be more easily misdiagnosed than a
melanoma located elsewhere, and the authors recommend that patients with moles on their feet should
watch them carefully and have them removed if they change in color and shape.
*J Foot Ankle Surg 42(4):193-8 (2003 Jul-Aug)
Skin Therapy Letter®(ISSN 1201–5989) Copyright 2003 by SkinCareGuide.com. The Skin Therapy Letter© is published 10 times annually by SkinCareGuide.com Ltd, 1107 – 750 West Pender, Vancouver, British Columbia,
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Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 7 • November-December 2003
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