Return Of The Scientific Methodthe Charge For The Future

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An alternative approach to perioral rhytides

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Industrial hyperbole and the seeming need by many cutaneous laser surgeons to be the first "kid on the block" by presenting anecdotal evidence for a new use of a particular laser (148), whether justifiable biologically or financially for the patient, swung the pendulum of laser activity and continues to do so at a violent pace toward the nonsense pole antithetical to Leon Goldman's maxim. In recently reviewing laser skin resurfacing, Kauvar (324) bemoaned and warned that "rapid development of novel instrumentation is outpacing our ability to study fully their biological effects in tissue."

The immense cost of purchasing several similar lasers to compare their efficacy and the unlikely provision of loaned or free competing lasers by a laser manufacturer (anxious to market a new product) complicated interpretation of new data and even made those presented for one laser system only suspect and continued to foster divisiveness and antagonism even in the public arena. Even with panels of experts presenting their data, too often listeners would query, "Well, which of these very expensive instruments should I purchase?" Fortunately, a number of laser surgeons could occasionally swing the pendulum back toward "sense" science by doing side-by-side or randomized comparisons (Fig. 1.20) (186,192,197,205,207,208,329,337,352-356,415,459,460). For example, Schliftman and

Figure 1.20 Two comparative side-by-side studies of argon, copper vapor, and continuous dye lasers on a port-wine stain by Drs. Schliftman and Brauner.

Brauner (205,207) in 1990 showed that equivalently dosed copper vapor laser was more effective than continuous wave dye laser or argon laser on side-by-side test areas of port-wine stain after one treatment. In 1993 Waner et al. (208) compared two yellow lasers, the copper vapor and pulsed dye, for facial telangiectases. Upon side-by-side comparison the former laser healed more quickly and was more cosmetically acceptable to the patients but both gave equivalent clinical improvement. In 1995 Dover et al. (186) compared port-wine stains treated with hexascan-assisted continuous dye laser with those treated with matched side-by-side pulsed dye laser and found both lasers effective, with the pulsed dye more so. A minimal and equivalent side effect profile for both sites was shown. Waldorf et al. (197) compared dynamically cooled sites with uncooled sites on pulsed dye laser-treated paired sites in port-wine stains, illustrating the epidermal sparing and pain relief effects of this device. Adrian and Tanghetti (192) paired pulsed dye laser and sapphire-tip-chilled 532 nm Nd:YAG laser for facial telangiectasia. Leuen-berger et al. (460) had better results with Q-switched ruby laser on black tattoos than side-by-side Q-switched Nd:YAG and Q-switched alexandrite, although all worked well. McDaniel et al. (356) compared CO2 laser for perioral rhytid resurfacing to combined sequential CO2 and then Er:YAG resurfacing and found no significant clinical differences. Alster et al. (337) found no significant clinical differences in four randomized simultaneous CO2 resurfacing lasers and in a second study (355), in six randomized Er:YAG resurfacing systems. Khatri et al. (353) found quicker recovery but lesser therapeutic effect in Er:YAG than in CO2-laser-resurfaced areas. Goldberg and Whitworth (415) compared side-by-side char-free CO2 lasers and QS Nd:YAG laser for periorbital rhytid removal. Grossman et al. (461) studied side-by side flashlamp-pulsed light source, two types of long-pulsed ruby laser, long-pulsed alexandrite, and long-pulsed diode lasers for hair removal.

Determining optimal intervals for therapies requiring multiple treatments (as mentioned previously concerning pigmented lesion removal) requires paired side-by-side comparisons as well, but the rush to publication and for rapid treatment obscured the need for understanding the biology of laser healing and tissue restoration.

The emergence of on-line Internet laser discussion groups and even journals such as lasernews.net (http://lasernews.net) and Dermatology Online Journal (http://matrix. ucdavis.edu/DOJdesk/desk.html) fosters rapid communication and helps disseminates more quickly new insights and possible complications but accelerates the speed of what we think is laser "science" perhaps faster than the biology of healing and repair is willing to provide us with correct information. Time tempers judgment but accelerated internet time may only interfere with a cautious laser surgeon's perspective.

In a similar vein, hyperbole (308-338) masked the true incidence of complications. Some cautious but perhaps courageous laser surgeons did report side effects and preached thoughtful reflection and methodology (222,319,349,355,462-469). This author raised the question of underreporting of scarring and the role of wound dressings in preventing hypertrophic scarring in 1984 (75). In a 1987 review Olbricht et al. (463) surveyed laser surgeons, 69% of whom had seen at least one case of hypertrophic scarring after argon laser and 64% after CO2 laser surgery, but no true incidence of scarring was tabulated. Lent and David (464) noted hyperpigmentation in 16% of laser-resurfaced patients postoperatively and Fitzpatrick et al. (319), 25%. Nanni and Alster (466) found a 37% incidence, more common in darker patients (up to 100% of Fitzpatrick type IV and V patients) (355,466), but this is reversible particularly with postoperative hydroquinones. Bernstein et al. (349) first made known the previously unreported late onset of hypo-pigmentation with CO2-laser-resurfaced patients, which may have represented both mela-nocyte destruction and delayed opacification. This delayed side effect, which seemed to correlate with prolonged erythema, was largely responsible for the shift to Er:YAG laser resurfacing systems. Rendon-Pellerano et al. (467) reviewed the rare but expectable early and late complications seen after laser resurfacing but reported four worrisome unpredictable outcomes, disseminated herpes simplex without prior clinical history of herpes, delayed wound healing with spontaneous breakdown of previously healed skin and protracted healing with scarring thereafter, granulomatous response of the lip margins, and a case of staphylococcal parapharyngeal abscess.

Our past history, short as it has been in cutaneous laser surgery, has been one of brilliance, bringing unimaginable benefits to our patients with deformity, as well as convenience and safety for cosmetic surgery. Our future will undoubtedly continue in a similar vein. In an era of high technology we can only expect more extraordinary technical innovations and new seminal events. Hopefully, as physicians first, we will be mindful of the cautions laid down by Leon Goldman and by our sense of honest scientific inquiry and our ethos of "primum non nocere." Hopefully, we will continue to view the potential of cutaneous laser surgery with the same excitement and joy that Leon Goldman did at laser's very inception in 1960 as a potential for healing. Hopefully, future historians of cutaneous laser surgery will not record how our professionalism was swept away by a tidal wave of marketing hyperbole.

Timeline of the Development of Cutaneous Laser Surgery

Early 20th century 1906-1917 1920s

1960s 1960

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