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Click here for Skin Therapy Letter online V o l u m e 8 • N u m b e r SkinCareGuide 7 • N o v e m b e r - D e c e m b e r 2 0 0 3 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. Go Online with www.AcneGuide.ca & www.AcneGuide.com At last, a comprehensive website offering acne informtion for physicians and their patients. Featuring content from • Jerry K.L. Tan, MD • Guy Webster, MD • Marianne O’Donoghue, MD Register today to receive updates about new online features! 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, Canada, V6C 2T8. Managing Editor: Penelope Gray-Allan, Tel: 604-926-4320, Fax: 604-926-5455, email: [email protected]. All rights reserved. Reproduction in whole or in part by any process is strictly forbidden without prior consent of the publisher in writing. While every effort is made to see that no inaccurate or misleading data, opinion or statement appears in the Skin Therapy Letter©, the Publishers and Editorial Board wish to make it clear that the data and opinions appearing in the articles herein are the responsibility of the contributor. Accordingly, the Publishers, the Editorial Committee and their respective employees, officers and agents accept no liability whatsoever for the consequences of any such inaccurate or misleading data, opinion or statement. While every effort is made to ensure that drug doses and other quantities are presented accurately, readers are advised that new methods and techniques involving drug usage, and described herein should only be followed in conjunction with the drug manufacturer’s own published literature. Printed on acid free paper effective with Volume 1, Issue 1, 1995. Subscription Information. Annual subscription: Canadian $94 individual; $171 institutional (plus GST); US $66 individual; $121 institutional. Outside North America: US$88 individual; $143 institutional. We sell reprints in bulk (100 copies of the same article or more). For individual reprints, we sell photocopies of the articles. The cost is $20 to fax and $15 to mail. Prepayment is required. Student rates available upon request. Sales inquiries: [email protected] 8 Skin Therapy Letter • Editor: Dr. Stuart Maddin • Vol. 8 No. 7 • November-December 2003 Click here for Skin Therapy Letter online SkinCareGuide