Advanced Techniques in Dermatologic Surgery - part 10 ppt

and amount of tumescent anesthesia placed around the vein. A uniform layer of blood circumferentially around the fiber will yield the best results with the hemoglobin targeting wavelengths. One in vitro study model has predicted that therm al gas production by laser heating of blood in a 6 mm tube results in 6 mm of thermal damage (23,24). These authors used a 940 nm diode laser with multiple 15-J, 1 sec pulses to treat the GSV. An median of 80 pulses (range, 22– 116) were applied along the treated vein every 5–7 mm. Histologic exam- ination of one excised vein demonstrated thermal damage along the entire treated vein with evidence of perforations at the point of laser application described as ‘‘explosive-like’’ photo-disruption of the vein wall. This produced the homogeneous thrombotic occlusion of the vessel. Since optical properties of a 940 nm laser beam within circulating blood is that it can only penetrate 0.3 mm, the formation of steam bubbles is the mechanism of action of heating surrounding tissue (24). Initial reports have shown this technique with an 810 nm diode laser to have good short-term efficacy in the treatment of the incompetent GSV, with 96% or higher occlusion at 9 months with a less than 1% incidence of transient paresthsia (25,26). Most patients, however, experience major degrees of post-operative ecchymosis and discomfort. Skin burns have observed by one of the authors (RAW). Deep venous thrombosis extending into the femoral vein have also been recently reported with endovenous laser treatment (27). Our patients treated with an 810 nm diode laser have shown an increase in post-treatment purpura and tenderness. Most of our patients do not return to complete functional normality for 2–7 days as opposed to the 1 day ‘‘downtime’’ with RF Closure TM of the GSV. There is even less downtime with CTEV TM , discussed in the next section. Recent studies suggest that pulsed 810 nm diode laser treatment with its increased risk for perforation of the vein (as opposed to continuous treatment which does not have intermittent vein perfor ations but may have irregular areas of perforation) may be responsible for the increase symptoms with 810 nm laser vs. RF treatment (28). Our experience wi th trying to vary the fluence and treating with a continuous laser pull back vs. pulsed pull back has not resulted in an elimination of vein perforation using an 810 nm diode laser. A longer wavelength such as 940 nm has been hypothesized to penetrate deeper into the vein wall with resulting increased efficacy. A report of 280 patients with 350 treated limbs with 18 month follow-up demonstrated complet e closure in 96% (29). Twenty vein segments were exam- ined histologically. Veins were treated with 1 sec duration pulses at 12 J. Perforations were not present. When the fluence was increased to 15 J with 1.2- and 1.3-sec pulses, microperforations did occur and were said to be self-sealing. The author suggests that his use of tumescent anesthesia as well as the above mentioned laser parameters are responsible for the lack of significant perforations and enhanced efficacy. A clinical study using an endoluminal 1064 nm Nd:YAG laser in the treatment of incompetent GSV in 151 men and women with 252 treated limbs was reported (30). Unfortunately, the surgeons also ligated the SFJ, 358 Weiss and Goldman which did not allow for a determination of the efficacy of SFJ ablation. Spinal anesthesia was used and the laser was used at 10–15 W of energy with 10 sec pulses with manual retraction of the laser fiber at a rate of 10 sec/cm. Skin overlying the treated vein was cooled with cold water. Unfortunately, this resulted in superficial burns in 4.8% of patients, paresthesia in 36.5%, superficial phlebitis in 1.6%, and localized hematomas in 0.8%. COOLTOUCH CTEV TM ENDOVENOUS TREATMENT In an attempt to bypass the problems associated with laser wavelength absorption of hemoglobin, we have developed a 1320 nm endolumenal laser. At this wavelength, tissue water is the target and the presence or absence of red blood cells within the vessels is unimportant. The CoolTouch CTEV TM treatment is an endovenous ablation method using a special laser fiber coupled to the intraluminal use of an infrared 1320nm wavelength with an automatic pullback device pre-set to pullback at 1 mm/sec (Fig. 5). This 1.32 micron wavelength is unique among endovenous ablation lasers in that this wavelength is absorbed only by water and not by hemoglobin. This makes it significantly different from the other (hemoglobin targeting) wavelengths u sed for en dovenous laser treatments. In our opinion and ex peri- ence, the CoolTouch CTEV TM at 1320 nm is significantly superior to the other endovenous laser methods both by v i rtue of the water absorption and the automatic pullback device (31). When using a wavelength strongly absorbed by hemoglobin, such as 810 nm, there i s a lot of intraluminal b lood hea ting w ith t ransmission of heat to the surrounding tissue through long heating times. Temperatures in animal models have been reported as high as 1200  C (28). When we have tried ex vivo vein treatment w ithout blood w ith the fiber in contac t with the vein wall, the 810 nm wavelength simply chars the inside of the vein. When blood is added to exvivo veins and is then treated with 810 nm, numerous vein explo- sions ar e observed (personal communication, Dr. M. Hirokawa, T ok yo, Japan, 200 5). Minimizing direct contact with the vein wall for hemoglobin-depen- dent methods minimizes the charring of the vein wall and probably lowers the post-operative pain levels. Ideally for a hemoglobin absorbed wavelength to work, it would be best to have a well-defined layer of hemoglobin between the fiber and the vein wall. In the real world, however, varicose veins are saccular and irregular pockets of hemoglobin are frequently encountered leading to sharp rises in temperature and vein perforations when using hemoglobin absorbing wavelengths such as 810 nm. Using tumescent anesthesia with a hemoglobin targeting wavelength, it can be very difficult to gauge the correct amount to compress the vein since some hemoglobin is necessary for the mechanism of action. If too much tumescence is used, there can be charring of the inner wall of the vein without heating of the vein wall, with resulting pain and failure to close the v ein. For all these potential obstacles to ideal treatment conditions for 810 nm, 940 nm, or 980 nm, it makes far more sense to use a water absorbing Endovenous Elimination with Radiofrequency or Laser 359 wavelength once cannulated within the vein. Therefore, the 1320 nm wavelength for use in endovenous ablation was explored and clinical trials performed resulting in FDA clearance in September 2004 for treatment of the greater saphenous vein. By August 2005, sufficient data for approval for obliteration of reflux in the lesser saphenous vein were cleared by the FDA. Percutaneous approaches to smaller leg telangiectasias indicate that deeply penetrating laser wavelengths with significant deoxyhemoglobin absorption, such as 1064 nm Nd:YAG, have the most utility. When veins are targeted through the skin, one exploits the concept of selective photothermolysis. By targeting deoxyhemoglobin, cutaneous Figure 5 CoolTouch CTEV TM 1320 nm laser and automatic pullback device. 360 Weiss and Goldman leg vessels absorb preferentially to surrounding water, collagen, and other structures. This allows selective destruction of tiny blood vessels without heating surrounding structures. The mechanism of this destruction by 1064 nm laser must be clearly understood by the user. The clinical observation is immediate photodarkening and coagulation. Histologi- cally this is represented by perivascular hemorrhage and thrombi with vessels fragmentation (32). This ultimately leads to vessel clearance in about 75% of targeted areas over a 3-month time frame (33). For the cutaneous approach, this is clearly state-of-the-art but this is not the best approach for endov enous laser ablation in which selective photother mo- lysis is not a factor. Endovenous ablation requires maximizing vein shrinkage and closure with the least amount of blood coagulation and the maximum amount of vein wall contraction. We know from earlier methods involving electrosurgical blood coagu lation that the long-term success rates based on coagulation of blood are very low (34,35). On the contrary, success rates for radiofrequency vein shrinkage specifically avoiding coagulation of blood are very high (5,13,36). Recently, Proebstle and col- leagues designed a study that answers the question of whether endovenous ablation is best accomplished by hemoglobin heating or the approach of using water around the collagen in the vein wall as a target (37). He has had extensive experience with the 940 nm wavelength for endovenous ablation (38). As shown by Proebstle et al., there is a clear advantage of targeting water over hemoglobin when performing endovenous laser. There is a statistically reduced rate of pain post-operatively with a higher rate of success while at the same time applying lower energy. This results in greater safety and efficacy for the patient, our own experience reflects this, with a reduction in pain and bruising of 80% when switching from 810 nm endovenous to 1320 nm endovenous. Having treated over 200 greater saphenous veins with 1320 nm, our incidence of mild pain is 5%. No significant pain interfering with walking has been observed. A typical clinical result is shown in (Fig. 6). Based on our experience we believe that there is reduced pain reported with 1320 nm vs 940 nm probably due to less vein perforations and more uniform heating by 1320 nm targeting water in the vein wall. Rarely, patients experience mild pain after 1320 nm, but this is probably related to heat dissipated into surrounding tissue, not vein perforations. This might be minimized by using the minimal effective energy to shrink the vein. In our own unpublished studies we have found that emitting 5W of 1320 nm through a 600-m fiber moving at 1 mm/sec in a 2-mm thick vein wall, the highest temperature recorded on the exterior of the vein wall was 48  C. Unfortunately in a saphenous vein, for effective sealing and shrinkage, higher energies must sometimes be utilized. In the Proebste et al. (37) study, 8 W of 1320 nm were employed to have the highest intraluminal occlusion and shrinkage but probably accounted for the post-operative pain incidence. We believe that effective energy for vein sealing in our practice is mostly between 5 and 6, thus minimizing post-operative pain to less than 5%. In summary, our experience Endovenous Elimination with Radiofrequency or Laser 361 and those of others indicate that 1320 nm water targeting vs. 810 nm, 940 nm, or 980 nm hemoglobin targeting endovenous occlusion is gentler, leading to far less bruising and post-operative pain. TECHNIQUE OF COOLTOUCH CTEV TM ENDOVENOUS TREATMENT The patient is evaluated and marked in an identical manner as with RF Closure TM of the GSV. An appropriate entry point is selected similar to RF. This is usually just below where reflux is no longer seen in the greater saphenous vein. For the majority of patients in our series this is at a point just above or below the knee along the course of the GSV. A sheath is placed in the entire length of the vein to be treated up to the saphenofemoral junction. Tumescent anesthesia is then injected along the vein and injected subfacially to separate and dissect the targeted vein, and to provide a layer of thermal protection around the vein. Some blood is always in the vein and that gets gently heated from its water content. Direct fiber contact with the vein wall is not important as the energy for heating water is propelled in an arcing field from the distal end of Figure 6 Clinical result seen with CoolTouch CTEV TM 1320 nm laser. (A) Before treatment. (B) After 6 weeks. There is marked improvement of a varicosity associated with reflux of the greater saphenous vein. 362 Weiss and Goldman the fiber facing into the lumen proximally. Once tumescent anesthesia is achieved and totally surrounds the targeted vein, a 600 um laser fiber is inserted with CTEV TM . A helium neon aiming beam that is continuously illuminated when the laser is on ensures that the laser fiber is in the superficial venous syst em and can be used to monitor automatic pullback visually. The sheath acts to protect the vein during the insertion of the optical fiber. However, the sheath must be completely removed from the vein prior to application of laser energy. This is performed so that the automatic pullback device may pullback the fiber unimpeded. If the laser fiber retracts within the sheath thermal destruction of the sheath occurs with no energy transmission to the vein wall. Correct placement of the laser fibe r tip 2 cm distal to the SFJ is con- firmed through Duplex visualization of the fiberoptic in the tumescent anesthesia compressed saphenous vein combined with viewing the aiming beam through the skin. Pullback is set for 1 mm/sec and the laser is set for 5–6 W at 50 Hz. The laser is fired for 2–3 sec to visualize sealing of the targeted vein on Duplex. The laser is then stopped for a moment while the pullback device is turned on. Once the laser fiber is seen to be getting pulled back on Duplex, the laser is immediately switched on. Vein shrinkage can be monitored visually by Duplex ultrasound as the water is heated circumferentially. Having the fiber pointed directly at a vein wall should be avoided. The progress can be monitored by Duplex or visually by the aiming beam reaching the skin surface from within the vein. As the fiber approaches the entry site, the laser is stopped. SUMMARY The latest techniques for endovenous occlusion using radiofrequency ablation catheters or endoluminal laser targeting water are our preferred methods to treat saphenous related varicose veins. These methods are well proven to offer a less invasive alternative to ligation and stripping and can be supplemented by sclerotherapy, particularly foamed sclero- sant scler otherapy. Clinical experience with endovenous techniques in over 1000 patients shows a high degree of success with minimal side effects, most of which can be prevented or minimized with use of tumescent anesthesia. Tumescent anesthesia is critical to the safety of endovenous techniques. Within the next 5 years, these minimally invasive endovenous ablative procedures involving saphenous trunks should have virtually replaced open surgical strippings. Already over 100,000 patients have been treated worldwide. Endovenous Elimination with Radiofrequency or Laser 363 REFERENCES 1. 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J Vasc Surg 2002 Jun; 35(6):1190–1196. 16. Weiss RA, Goldman MP. Transillumination mapping prior to ambulatory phlebectomy. Dermatol Surg 1998; 24:447–450. 17. Smith SR, Goldman MP. Tumescent anesthesia in ambulatory phlebectomy. Dermatol Surg 1998 Apr; 24(4):453–456. 18. Goldman MP. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: preliminary 6-month follow-up. Dermatol Surg 2000 May; 26(5):452–456. 19. Chandler JG, Pichot O, Sessa C, Schuller-Petrovic S, Osse FJ, Bergan JJ. Defining the role of extended saphenofemoral junction ligation: a prospective comparative study. J Vasc Surg 2000 Nov; 32(5):941–953. 364 Weiss and Goldman 20. Manfrini S, Gasbarro V, Danielsson G, Norgren L, Chandler JG, Lennox AF, et al. Endovenous management of saphenous vein reflux. Endovenous Reflux Management Study Group. J Vasc Surg 2000 Aug; 32(2):330–342. 21. Sybrandy JE, Wittens CH. Initial experiences in endovenous treatment of saphenous vein reflux. J Vasc Surg 2002 Dec; 36(6):1207–1212. 22. Komenaka IK, Nguyen ET. Is there an increased risk for DVT with the VNUS closure procedure? J Vasc Surg 2002 Dec; 36(6):1311. 23. Proebstle TM, Sandhofer M, Kargl A, Gul D, Rother W, Knop J, et al. Thermal damage of the inner vein wall during endovenous laser treatment: key role of energy absorption by intravascular blood. Dermatol Surg 2002 Jul; 28(7):596–600. 24. Proebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge S, et al. Endo- venous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles. J Vasc Surg 2002 Apr; 35(4):729–736. 25. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the incompetent greater saphenous vein. J Vasc Interv Radiol 2001 Oct; 12(10):1167–1171. 26. Navarro L, Min RJ, Bone C. 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Intravascular 1320-nm Laser Closure of the Great Saphenous Vein: A 6- to 12-Month Follow-up Study. Dermatol Surg 2004 Nov; 30(11):1380–1385. 32. Goldberg SN, Hahn PF, Tanabe KK, Mueller PR, Schima W, Athanasoulis CA, et al. Percutaneous radiofrequency tissue ablation: does perfusion-mediated tissue cooling limit coagulation necrosis? J Vasc Interv Radiol 1998 Jan; 9(1 Pt 1):101–111. 33. Weiss RA, Weiss MA. Early clinical results with a multiple synchronized pulse 1064 nm laser for leg telangiectasias and reticular veins. Dermatol Surg. In press 1998. 34. Lewin JS, Connell CF, Duerk JL, Chung YC, Clampitt ME, Spisak J, et al. Interactive MRI-guided radiofrequency interstitial thermal ablation of abdominal tumors: clinical trial for evaluation of safety and feasibility. J Magn Reson Imaging 1998 Jan; 8(1):40–47. 35. Otsu A, Mori N. Therapy of varicose veins of the lower limbs by light coagulator. Angiology 1971 Mar; 22(3):107–113. 36. Sofka CM. Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration. Ultrasound Q 2004 Jun; 20(2):66. 37. Proebstle TM. Comparison of 940 nm and 1320 nm endovenous ablation. Dermatol Surg. In press 2005. 38. Proebstle TM, Gul D, Kargl A, Knop J. Endovenous lasertreatment of the lesser saphenous vein with a 940-nm diode laser: early results. Dermatol Surg 2003 Apr; 29(4):357–361. Endovenous Elimination with Radiofrequency or Laser 365 19 Radiofrequency Tissue Tightening: Thermage Carolyn I. Jacob Northwestern Medical School, Department of Dermatology, Chicago Cosmetic Surgery and Dermatology, Chicago, Illinois, U.S.A. Michael S. Kaminer Department of Dermatology, Yale Medical School, Yale University, New Haven, Connecticut, U.S.A.; Department of Medicine (Dermatology), Dartmouth Medical School, Dartmouth College, Hanover, New Hampshire, U.S.A.; and SkinCare Physicians of Chestnut Hill, Chestnut Hill, Massachusetts, U.S.A. Video 22: Thermage INTRODUCTION Rapid advances in skin rejuvenation treatments have been seen in the new millennium, with patient demand and improved technology driving the development of treatments that require little or no recovery time. A new nonlaser procedure for tightening the skin uses radiofrequency to heat the dermis and potentially the subdermal tissues. The ThermaCool TC TM by Thermage has been recently cleared by the FDA for the noninvasive tightening of periorbital rhytides using this proven mechanism of tissue tightening. In this chapter we will outline the new radiofrequency technology and explore its place among the armamentarium of facial rejuvenation. We will also briefly discuss early stage work that uses this technology for acne treatment and body skin tightening. To meet the demands of aging baby boomers, who desire an ever-youthful appearance, many devices and drugs have been developed. Previously, carbon dioxide and Erbium:YAG lasers were developed to produce skin rejuvenation through epidermal ablation and dermal heating. Although effective, these ablative lasers require 5 to 10 days of epidermal healing and may cause erythema that lasted for weeks to months. Recently, nonablative lasers have been researched, tested, and proved to provide dermal neocollagenesis while protecting the epidermis. These less invasive lasers improve facial rhytides from 0% to 75%, by subjective evaluation (1). Unfortunately, these technologies often require multiple, time-consuming treatment sessi ons, use highly delicate optics, and can be quite costly to acquire and maintain. In addition, results from 367 [...]... (BTX-B), 20 vs botulinum toxin type A, 20–21 storage and reconstitution, 21–22 Bovine collagen Koken AtelocollagenÕ , 47 RespolastÕ , 47 Bovine collagen soft-tissue fillers, temporary types, 45–47 ZydermÕ , 45–47 ZyplastÕ , 45–47 Brow lift, face treatment, 25 BTX-A See botulinum toxin type A BTX-B See Botulinum toxin type B BTXs See Botulinum neurotoxins Cannulas, 24 hole, for liposuction, 107 Chemodenervation... the treatment setting should be dropped to 61.0 to 62.0 Levels in all areas are adjusted to the patient’s comfort Radiofrequency Tissue Tightening 381 Figure 9 Multiple-pass treatment algorithm: (A) first pass (in purple), (B) second pass (in brown), and (C) third pass (in green) (Continued next page) 382 Jacob and Kaminer Figure 9 (Continued) Figure 10 Periorbital rejuvenation including brow lift Source:... Melting of fat and tissue tightening in the z-axis perpendicular to the skin which pulls tissue in, toward the bony underlying structures, 3 A combination of the two This z-axis effect appears to be an important element of the improved results seen recently in treatment of the lower face (Fig 15) Whether this comes from additional tightening in the x (horizontal) Figure 15 The x, y, and z planes of skin... 113.8 J/cm2 on the cheeks, decreasing to 99.7 J/cm2on the neck In post-treatment follow-up phone interviews, 36% of patients who 374 Jacob and Kaminer Table 2 The FWCS Class Wrinkling Score Degree of elastosis Mild (fine textural changes with subtly accentuated skin lines) Moderate [distinct popular elastosis (individual papules with yellow translucency under direct lighting) and dyschromia] Severe [multipapular... fat harvesting techniques, 73–77 preparation for, 72–73 fat injection techniques, 77–86 fat processing, 74 goals of, 82 Fat harvesting anesthesia, 73 preparation for, 72–73 site choice, 73 Fat injection techniques, 77–86 fat autograft muscle injection, 80–86 LipostructureTM, 78–79 modified LipostructureTM, 79–80 subcutaneous space, 77–78 Fat processing, fat harvesting techniques, 74 Flashlamp-pumped pulsed... demonstrated increased steady-state expression of collagen type I mRNA in treated tissue, an evidence that wound healing is initiated by the single treatment The secondary collagen synthesis in response to collagen injury is purported to occur over several (2–6) months Kilmer noted fibroplasia and signs of increased collagen formation in the papillary dermis and, less frequently, in the reticular dermis (10) ... treated on 68 cm2 of tissue with a single pass at settings ranging from 65 to 95 J/cm2 Twenty-two patients received a nerve block just superior to the eyebrows immediately before or shortly after initiation of treatment Independent scoring of blinded photographs taken six months after treatment resulted in Fitzpatrick wrinkle score improvement of at least one point in 83.2% (99/119) of treated periorbital... cheek laxity with a non-ablative radiofrequency device: a lifting experience In press 14 Ruiz-Esparza J, Gomez JB The medical face lift: a noninvasive, nonsurgical approach to tissue tightening in facial skin using non-ablative radiofrequency Dermatol Surg 2003; 29(4):325–332 15 Ruiz-Esparza J, Gomez JB Nonablative radiofrequency for active acne vulgaris: the use of deep dermal heat in the treatment of... fibrils with increased diameter and loss of distinct borders as deep as 6 mm Higher energy settings produced deeper and more extensive collagen changes (Fig 4) In a clinical study involving in vivo human skin, a similar pattern of immediate collagen fibril contraction was observed, an acute effect that has not been associated with nonablative lasers (9) In this same study of intact abdominal tissue,... 3 Younger age is a predictor of increased efficacy with the Thermage procedure These findings have direct implications for refining treatment algorithm guidelines Guidelines should include treating a broad surface area and carefully selecting patients in their 40s, 50s, or early 60s, who have medium quality skin thickness and mild to moderate jawline and neck laxity Treating areas on and adjacent to the . the post-operative pain incidence. We believe that effective energy for vein sealing in our practice is mostly between 5 and 6, thus minimizing post-operative pain to less than 5%. In summary,. yo, Japan, 200 5). Minimizing direct contact with the vein wall for hemoglobin-depen- dent methods minimizes the charring of the vein wall and probably lowers the post-operative pain levels. Ideally. dissipated into surrounding tissue, not vein perforations. This might be minimized by using the minimal effective energy to shrink the vein. In our own unpublished studies we have found that emitting

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