Dermatology Reports 2019; volume 11(s1):8076

Hair removal treatment using of the complex anatomy of the external ear, 1,064 nm long-pulsed Nd:YAG towards the necessity to provide good pro- Correspondence: Erika Dewi Essary, jection and symmetry.1 Unwanted is Department of Dermatology and Venereology, laser in auricular post apparent in microtia patients with a low Faculty of Medicine, Universitas Padjadjaran reconstruction of microtia hairline after auricular reconstruction pro- - Dr. Hasan Sadikin Hospital, Bandung 40161 patient: Two case reports cedure.2 In addition, the majority of patients Indonesia. have a low retroauricular hairline. Although Tel.: +62222032426 ext. 3449. E-mail: [email protected] 1 ear reconstruction technology has been Kartika Ruchiatan, 3 1 1 highly developed in techniques and results Acknowledgments: The authors would like to Erika Dewi Essary, Reti Hindritiani, 4 1 of surgeries, hair growth on the reconstruc- extend our gratitude to the staff of the RM Rendy Ariezal Effendi, tion ear has plagued both surgeons and 2 1 Department of Dermatology and Venereology, Rani Septrina, Hendra Gunawan, patients.3 Unwanted hair growth of the 1 Faculty of Medicine, Universitas Padjadjaran Oki Suwarsa reconstructed ears of microtia patients can who contributed to this work. 1Department of Dermatology and cause cosmetic problems,4 physiological 5 Venereology, Faculty of Medicine, distress, and known to be a therapeutic Key words: Auricular reconstruction; hair 6 Universitas Padjadjaran - Dr. Hasan challenge. There is a need for an effective, removal; microtia; Nd:YAG; unwanted hair safe, and non-invasive treatment modality Sadikin Hospital, Bandung 40161, West Contributions: All the authors contributed Java; 2Department of Plastic Surgery, capable of removing on a longterm 7 equally. Faculty of Medicine, Universitas basis. Lasers known for its long-term Padjadjaran - Dr. Hasan Sadikin results, non-invasive nature, minimal treat- Conflict of interests: the authors declare no ment discomfort, and the speed and ease Hospital, Bandung 40161, West Java, potential conflict of interest. with which procedures can be performed.8 Indonesia Therefore, lasers are now viewed as the Funding sources: None gold standard for .2 A variety of laser systems with varying wavelengths, Receivedonly for publication: 1 February 2019. Abstract pulse durations, spot size, and energy flu- Accepted for publication: 20 February 2019. ences are currently used for hair removal. Microtia is a congenital anomaly of the This work is licensed under a Creative Successful hair removal treatment require external and middle ear with various Commons Attribution-NonCommercial 4.0 light to penetrate deep into the because degrees of severity. The hair growth on the International License (CC BY-NC 4.0). it is necessary to obliterate the entire folli-use reconstructed auricle causes aesthetic prob- cle.8 Hair removal treatment using 1,064 nm lems. We describe two cases about the suc- ©Copyright K. Ruchiatan et al., 2019 long-pulsed neodymium: ytrium-alumuni- Licensee PAGEPress, Italy cessful epilation of unwanted hair in um-garnet (LP Nd:YAG) laser combined Dermatology Reports 2019; 11(s1):8076 postauricular reconstruction of microtia doi:10.4081/dr.2019.8076 patients using 1,064 nm long-pulsed the wavelength advantage of the Nd:YAG neodymium: ytrium-alumunium-garnet (LP and the longer pulse duration advantage of 9 Appropriate parameters were chosen in Nd:YAG) laser in Fitzpatrick skin type IV the other long-pulsed systems. The aim of accordance with Fitzpatrick skin type IV. A patients, using 6x6 mm tip, 35 J/cm2 flu- these two case reports were to show the suc- spot size of 6x6 mm, a fluence of 35 J/cm2, ence, 10 ms pulse, and 1 Hz frequency with cessful hair removal treatment using 1,064 a pulse duration of 10 ms, and 1 Hz fre- burnt of hair as an endpoint. On the follow nm LP Nd:YAG laser in auricular postre- quency with burnt of hair as an endpoint. up day 11 of case one and day 7 of case two, construction microtia patients. The observation of epilation was performed the hair reductions on treated auricles were at 11 days after the irradiation (Figure 1C). 46% and 58%, respectively, with no adverse The post-treatment region was examined by effects. Minimal 6 repeated sessions are Case Reports dermoscopy and showed 46% reduction recommended for optimal result. In these Case #1 rate of unwanted hair (Figure 1D). There case reports, LP Nd:YAG laser treatment is A 37-year-old male who had congenital were no side effects such as inflammation, considered effective for the unwantedNon-commercial hair microtia of the right ear was referred to our oedema, ulcer, , and folliculitis of the growth on the reconstructed auricle in dark department, with a complaint of excessive epilated skin after irradiation. skin type patients with minimal risk of adverse effect. hair growth on the right ear two months after the second ear reconstruction surgery. Case #2 The surgery using the skin of the scalp and A 18-year-old female complaint with an the groin as donor sites. He was clinically Introduction excessive hair growth on the left ear. The examined and photo-documented before patient had undergone stage I-II auricular Microtia known as a congenital malfor- receiving the first laser treatment (Figure reconstruction using the Nagata technique, mation that is characterized by unorganized 1A). The physical examination showed with obvious hair growth in helix area of the cartilage remnants and a malpositioned - unwanted hair growth on reconstructed reconstructed auricle two weeks after the ule, with the various degrees of severity auricular region (the right auricle). surgery. She was referred to our department from mild structural abnormalities to the Dermoscopy examination revealed 147 vel- for opinion regarding hair removal at this complete absence of the external and mid- lus and terminal hairs (Figure 1B). Hairs unusual site. The skin of the scalp was used dle ear. The prevalence varies among coun- were trimmed using a scissor immediately as a donor site. The physical examination of tries from 0.83 to 17.4 per 10,000 births, prior to laser therapy. The therapy session the left ear showed long, thick, and coarse and males are more often affected than took place under topical anesthesia on the hairs (Figure 2A). Dermoscopy examina- females. Auricular reconstruction is a chal- therapeutic area. A LP Nd:YAG with a tion revealed 152 vellus and terminal hairs lenging reconstructive procedure, because wavelength of 1,064 nm was used. (Figure 2B). The patient had Fitzpatrick

[page 142] [Dermatology Reports 2019; 11(s1):8076] Case Report skin type IV. Before hair removal, the treat- ment area was trimmed with scissor (Figure 2C). The patient was set in a supine position and the head was turned to expose the involved ear. The 1,064 nm LP Nd:YAG laser was used under topical anaesthesia. A spot size of 6x6 mm, a fluence of 35 J/cm2, a pulse duration of 10 ms, and 1 Hz fre- quency with burnt of hair as an endpoint. A significant reduction of unwanted hair (58% reduction hair amount) was observed 7 days after only one session compared to that observed before the treatment (Figure 2D). No adverse effects occured during the treat- ment.

Discussion A two-step auricular reconstruction was planned in microtia patients. The first stage, the ipsilateral coatal cartilages are harvested to construct all anatomical segments. The second stage is generally carried out 6 months after the first1 and skin grafting commonly used.3 Although the techniques only and results of surgeries for microtia have improved, microtia patients with low hair- lines have aesthetic problems of hair growth when scalp skin is usually used for ear use reconstruction.4 Unwanted hair may only Figure 1. Clinical appearance. A. Before therapy. B. Dermoscopy examination before become apparent in the later stages of a therapy. C. Day 11 after therapy. D. Dermoscopy examination day 11 after therapy. reconstruction, sometimes hair begins to grow on the rim after a second stage release, and sometimes a full thickness graft from the groin begin to grow hair when a child progresses beyond . The cells that responsible for hair growth are not actually located in the bulb but located in the the buldge zones. Thus, grafts with a substantial dermal component will grow hair.2 Our cases showed that the use of skin graft taken from scalp and groin skin can lead to the undesired side effect of unwanted hair growth. A variety of conventional methodsNon-commercial are available for hair removal, such as , , , chemicals,3,6 and elec- trolysis6 which provide temporary effects3,6 and often involve adverse reactions.3 Lasers are now viewed as the gold standard for hair removal,2 and considered as the most effi- cient method for the reduction of unwanted hair.5 Lasers have been used both to treat hairs prior to reconstruction and to treat the ears after reconstruction.2 systems are typically grouped into the following 3 categories on the basis of the type of laser or light source each uses: red light systems (694 nm ruby), infrared light systems (755 nm alexandrite, 800 nm diode, and 1,064 nm Nd:YAG), and intense 10 Figure 2. Clinical appearance. A. Before therapy. B. Dermoscopy examination before pulsed light sources (590 to 1200 nm). therapy. C. Trimmed area before therapy. D. Day 7 after therapy. Lasers require an effective fluence, appro-

[Dermatology Reports 2019; 11(s1):8076] [page 143] Case Report priate spot size for the area being treated for less invasive and safer than other surgical Auricular reconstruction of congenital the successful treatment without complica- flap reconstructions and good cosmetic microtia: a personal experience in 225 5 tion. However, some lasers can be poorly results can be achieved. Current laser hair cases. Acta Otorhinolaryngol Ital. tolerated in dark skin type patients due to removal systems are designed to irradiate as 2015;35:191-7. 10 side effects of erythema, blistering, and much of the follicle as possible. In partic- 2. Gault D. Treatment of unwanted hair in post-inflammatory hyperpigmentation or ular, for those with congenital microtia who auricular reconstruction. Facial Plast hypopigmentation.9 LP Nd:YAG laser is a were diagnosed between the ages of 6 and Surg. 2009; 25: 175-80. safe treatment option for patients with the 18 years, the pain from laser hair removal 11 3 3. Guo Y, Shan J, Zhang T. Clinical appli- darkest skin phototypes (III-VI), and might not be tolerated. In our case reports, known to be superior in both short term and the patients had not done the presurgical cation of depilation long term studies.7 in a laser treatment. technology in total auricular reconstruc- cyclic pattern which consists of a growth or According to Guo et al.3 study, the hair tion. Lasers Med Sci. 2017;22: 1-8. anagen phase, followed by intermediate removal from the skin after the auricular 4. Takase M, Hashimoto I, Nakanishi H, degradation of a portion of the follicle framework was implanted had no negative Tanaka S, Matsumoto K, Matsuo S. known as the catagen phase, and then by a impact on the cartilage framework under- Reconstruction of microtia with laser 10 resting period when no growth occurs (the neath the skin. Alster et al. study conclud- hair removal before transplantation of telogen phase).11 Only lasers emitting ener- ed that 1,064 nm LP Nd:YAG can achieve costal cartilage. JPRAS. 2008;61:S86- gy with wavelengths ranging from 630 to rates of hair reduction equivalent to those of S91. 1,100 nm are potentially capable of irradiat- other LP red and infrared laser, and intense 5.Park MW, Baek SK, Jung KY. Laser epi- ing the entire length of anagen hair follicles, pulsed-light system. The study also showed lation for unwanted hair in the larynx. which typically extend 2 to 5 mm into the LP Nd:YAG laser can effectively treat .10 With most laser systems, a single Med Laser. 2012; 1(2): 31-33. patients with darker skin tones. There was ∅ treatment can reduce hair by 10-40%; three no post-therapy adverse effect on both 6. Haedersdal M, G tzsche PC. Laser and treatments by 30-70%; and repeated treat- cases. Multiple laser treatments are neces- photoepilation for unwanted hair 11 ments as much as 90%. Two cases of hair sary because laser only targets follicles in growth.only Cochrane Database Syst Rev. removal therapy in postreconstruction the anagen phase.5 As a general rule, 6 to 10 2006;(4):CD004684. auricular of microtia patients with laser sessions are required during the first 7. Haedersdal M, Wulf HC. Evidence- Fitzpatrick skin type IV using 1,064 nm LP year to achieve long-term epilation.11 based review of hair removal using Nd:YAG were reported. The laser using 6x6 lasers and light sources. JEADV. 2006; mm tip, 35 J/cm2 fluence, 10 ms pulse, and use 20: 9-20. 1 Hz frequency with burnt of hair as an end- Conclusions point. On the follow up day 11 (case one) 8. Grad L, Sult T, Sult R. Scientific evalu- and 7 (case two) hair reduction were 46% Our cases highlight this undesirable ation of VSP Nd:YAG lasers for hair and 58%, respectively. effect of auricular reconstruction surgery removal. J Laser Health Acad. The first report of reconstruction of where a dermatologist’s help is called for. 2007;2:1-12. microtia using laser hair removal was pre- We suggest that the 1,064 nm LP Nd:YAG 9.Chui CT, Grekin RC, Leboit PE, Zachary 4 sented by Brent in 1999. Takase et al. in laser is a non- invasive method that can CB. Long-pulsed Nd:YAG for hair 2007 experienced presurgical laser thera- resolve the problem of postoperative removal: early histological changes. pies of five microtia patients and examined unwanted hair on the reconstructed auricle, LaserNews.net. 1999. 1-6. these patients with quantitative analysis effective for hair reduction in darkly pig- 10. Alster TS, Bryan H, William C. Long- using video-microscope and histological mented skin patients, and furthermore pulsed Nd:YAG laser-assisted hair examination. The diode laser system and increasing patient statisfaction. the LP alexandrite laser system were used removal in pigmented skin. Arch every 1 to 3 months for 1 year before the Dermatol. 2001; 137: 885-9. 11. Lepselter J, Elman M. Biological and transplantation of costal cartilage. References Presurgical laser hair removal is aNon-commercial useful clinical aspects in laser hair removal. J technique for microtia patients because it is 1. Anghinoni M, Bailleul C, Magri AS. Dermatol Treat. 2004; 15: 72-83.

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