THE CUTTING EDGE

SECTION EDITOR: GEORGE J. HRUZA, MD; ASSISTANT SECTION EDITORS: MICHAEL P. HEFFERNAN, MD; CHRISTIE AMMIRATI, MD Fractional Photothermolysis for Involuted Infantile

Hans-Joachim Laubach, MD; Richard Rox Anderson, MD; Thomas Luger, MD; Dieter Manstein, MD; Klinik und Poliklinik fu¨r Haut- und Geschlechtskrankheiten, Universität Münster, Münster, Germany (Drs Laubach and Luger); Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston (Drs Laubach, Anderson, and Manstein)

The Cutting Edge: Challenges in Medical and Surgical Therapeutics

REPORT OF A CASE ried out. The skin spontaneously resolved over the following years leaving the residual skin changes. The An otherwise healthy 14-year-old white girl presented to skin lesion had remained unchanged for the last 4 years our dermatologic laser clinic with a protruding tumor without further improvement in appearance. above the right nasolabial fold. The patient’s parents re- Physical examination revealed a protruding subcuta- ported that the patient had a fast-growing red tumor dur- neous tumor, abnormally lax overlying skin with several ing the first months after birth in the same area. The le- linear indentations, and a soft atrophic scarlike surface tex- sion at that time was diagnosed as infantile hemangioma ture (Figure 1A and Figure 2A). Several telangiecta- by the pediatrician, and no further intervention was car- sias were discernable within the skin lesion and in its im- mediate surrounding skin. The oral mucosa of the patient appeared to be free of any alterations. Findings of the gen- A B eral skin examination were unremarkable: no other simi- larly protruding skin were found.

THERAPEUTIC CHALLENGE

The patient was referred for consideration of treatment alternatives to the proposed surgical intervention for the removal of the involuted facial infantile hemangioma. Of special concern for the patient was the irregular surface structure of the skin lesion rendering the application of make-up in an attempt to mask the lesion impossible. In- Figure 1. Close-up photographs taken at a 45° angled view to emphasize the vasive ablative procedures including traditional laser re- rough surface structure before (A) and 4 weeks after (B) 5 fractional surfacing were also deemed to be too aggressive and risky photothermolysis treatment sessions. The same photographic and flash setup by the patient’s parents. Less invasive procedures to im- was used for the before and after pictures, assuring constant light and prove the cosmetic appearance of the skin lesion were photography angles. sought.

A B SOLUTION

The patient consulted our department for treatment alter- natives to surgical excision of the involuted facial infantile hemangioma. The patient and her parents agreed to a trial of nonablative fractional photothermolysis (nFP) as a first treatment because of its favorable adverse effect profile, its demonstrated efficacy in treating atrophic scar tissue,1-4 and its reported improvement of telangiectasias.5-7 We advised the parents that several nFP treatment sessions would likely Figure 2. Close-up photographs taken at 90° angled view (profile) to emphasize be needed and that additional liposuction might be nec- the herniation of the skin lesion before (A) and 4 weeks after (B) 5 fractional essary to reduce the residual fibro-fatty mass.8-10 photothermolysis treatment sessions. The same photographic and flash setup was used for the before and after pictures, assuring constant light and For the nFP treatments, 2 different 1550-nm glass- photography angles. fiber lasers were used (Fraxel 750 and Fraxel re:store; Re-

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©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 liant Technologies Inc, Clear View, California). The first It has been clearly established that 3 treatments were done with the Fraxel 750 device at a and/or pulsed-dye laser treatments can cause early invo- microbeam energy of 16 mJ per microthermal treatment lution of infantile . These early treatments zone (MTZ) and a final MTZ density of 1250 MTZ/cm2 might reduce the need for corrective procedures after natu- delivered in 10 passes at 125 MTZ/cm2 per pass. Two sub- ral involution has occurred. sequent treatments were executed with a Fraxel restore To avoid psychosocial functional impairment, addi- device, an upgraded instrument model from the same tional treatment of these residual lesions is often carried manufacturer, at a fluence of 35 and 40 mJ/MTZ, treat- out. More than 80% of these common tumors are located ment level 8, and 8 passes. Local anesthesia was achieved in the head and neck region.19 Of 100 cases of parotidal by 60-minute incubation without occlusion of a custom- hemangioma retrospectively studied by Greene et al,17 66% made topical anesthetic cream containing lidocaine, 23%, were deemed to need reconstructive after natural tetracaine hydrochloride, 3.5%, and tetracaine base, 3.5%. regression had occurred. Ninety-two percent of these pa- Furthermore, a forced-air cooling device (Zimmer Cool- tients underwent preauricular excision of redundant skin ing Device; Medizin Systems, Irvine, California) was used and/or fibrofatty tissue, and 37% of patients needed au- on a setting of 3 during the laser exposure to reduce dis- ricular revision. Surgical excision of excess tissue and/or comfort and the potential risk of bulk heating. local tissue flaps and grafts often result in an extra wide The patient tolerated each procedure with mild to mod- scar. The classic surgical approach of elliptical excision has eratediscomfort.Treatmentintervalsvariedbetween4weeks been improved by Mulliken et al20 and Vlahovic et al,21 who and 4 months. Immediately after each treatment there was proposed a circular excision and purse-string closure confluent and edema typical for nFP treatments. technique. With this technique, the residual scar size is A cold compress was applied to the area immediately after approximately 70% the size of the scar resulting from stan- each laser treatment to reduce edema and patient discom- dard lenticular excisions. Another advantage of the purse- fort, and the patient was instructed to continue to cool the string closure technique is minimal distortion of surround- treatmentareatoreduceposttreatmentedemaanderythema. ing structures.20,21 One month after the fifth treatment, the involuted he- However, even this improved technique results in a sig- mangioma showed a clear improvement in the cutaneous nificant residual surgical scarring and might not be appli- texture and laxity and surprisingly an apparent reduc- cable in cases with a larger affected area. Surgical proce- tion in volume of the lesion (Figure 1B and Figure 2B). dures are also associated with all the risks of general The patient and her parents were very satisfied with the anesthesia and common surgical adverse effects of infec- result. The patient herself was especially pleased with the tion, tissue necrosis, and nerve damage. Another less in- ability to camouflage the lesion with make-up, which had vasive technique to change the appearance of the invo- been impossible before the nFP treatments. luted lesion is the volumetric reduction of the fibro-fatty tissue mass by different liposuction techniques.8-10 Al- though beneficial in volumetric reduction, this method does COMMENT not resolve the overlying dermal and epidermal changes. Traditional ablative laser resurfacing or dermabrasion Infantile hemangioma is a benign vascular proliferation can be used,22,23 but these techniques cause wounds with showing some similarities to placental vasculature.11 With the risk of permanent hypopigmentation, infection, and scar- an incidence of approximately 10%, this is the most com- ring. The potential for these adverse effects was strictly re- mon neoplasia in childhood.12,13 Common infantile hem- jected by our patient and her parents. We therefore de- have a distinct evolution consisting of a pro- cided to use nFP. liferative phase during the first year of life, followed by The principle behind the nFP technique is to create an gradual and often very slow regression with softening of array of small thermal lesions within the skin called MTZs the tumoral mass taking up to a decade or more. using focused laser microbeams.3 The tissue within those During the time of rapid proliferation and growth, in- MTZs is completely denatured, but the skin can recruit fantile hemangiomas can displace the surrounding tissue the surrounding unharmed tissue to regenerate very quickly, in a manner similar to that of a tissue expander. The nor- thus reducing adverse effects significantly.5 In addition, mal dermal architecture is commonly destroyed result- nFP has been shown to improve the appearance of atro- ing in an abnormal cutaneous laxity. The phic scars as well as surgical scars.1,4,6,24,25 Facial tel- mass is frequently not entirely absorbed during involu- angiectasias and postinflammatory erythema have also been tion, but is replaced partly by a loose fibro-fatty stroma reported to respond to treatment with nFP.6,7,26 Figure 1B with lobular architecture.14,15 This leads to a residual tu- and Figure 2B demonstrate improvement of the invo- mor in the affected area even after the vascular tumor has luted infantile hemangioma after nFP. completely regressed (Figure 1A and Figure 2A).16,17 In ad- Changes in skin surface structure due to nFP treatment dition, ulceration of the rapidly growing lesion occurs fre- were expected and can be explained by a dermal remod- quently and can lead to further scarring of the affected tis- eling process.5,27 However, the apparent volumetric changes sue.18 Remaining telangiectasias also contribute to the oftheinvolutedskinlesionweresurprisingandtoourknowl- typical heterogeneous clinical presentation of involuted edge have not been described previously. A likely explana- infantile hemangiomas. Hence, important tion for these 3-dimensional changes is an increase in der- persists in approximately 25% of the cases even after the mal strength and elasticity due to the laser treatment. This natural involution process of the infantile hemangiomas dermal “tissue tightening” then could decrease the appar- is completed.16 ent herniation of the protruding fibro-fatty tissue.

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©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Treatment depth of nFP is presently limited to 1.5 mm, 9. Fisher MD, Bridges M, Lin KY. The use of -assisted liposuction in the and the MTZ depth varies with micropulse energy. We treatment of an involuted hemangioma. J Craniofac Surg. 1999;10(6):500-502. 10. Spinowitz AL. The treatment of multiple by liposuction surgery. J Der- observed good improvement after the first 3 treatments matol Surg Oncol. 1989;15(5):538-540. and much greater apparent amelioration after the fourth 11. Barne´s CM, Huang S, Kaipainen A, et al. Evidence by molecular profiling for a and fifth treatments. This was also reflected by the ob- placental origin of infantile hemangioma. Proc Natl Acad SciUSA. 2005;102 servation of the patient herself, suggesting that an en- (52):19097-19102. 12. Mulliken JB. Cutaneous vascular anomalies. Semin Vasc Surg. 1993;6(4):204-218. ergy response study for these lesions is warranted. 13. Mulliken JB, Fishman SJ, Burrows PE. Vascular anomalies. Curr Probl Surg. 2000; Nonablative fractional photothermolysis appears to be 37(8):517-584. an effective treatment technique for involuted facial in- 14. De´gardin-Capon N, Martinot-Duquennoy V, Patenotre P, Breviere GM, Piette F, fantile hemangiomas. It is a valid alternative to surgical Pellerin P. Early surgical treatment of cutaneous hemangiomas [in French]. Ann excision and other more invasive procedures. Chir Plast Esthet. 2006;51(4-5):321-329. 15. Yu Y, Fuhr J, Boye E, et al. Mesenchymal stem cells and adipogenesis in heman- gioma involution. Stem Cells. 2006;24(6):1605-1612. 16. Fishman SJ, Mulliken JB. Hemangiomas and vascular malformations of infancy Accepted for Publication: June 21, 2008. and childhood. Pediatr Clin North Am. 1993;40(6):1177-1200. Correspondence: Hans-Joachim Laubach, MD, Massa- 17. Greene AK, Rogers GF, Mulliken JB. Management of parotid hemangioma in 100 chusetts General Hospital, Wellman Center for Photo- children. Plast Reconstr Surg. 2004;113(1):53-60. medicine, BAR No. 305, 50 Blossom St, Boston, MA 02114 18. Kane WJ, Morris S, Jackson IT, Woods JE. Significant hemangiomas and vas- cular malformations of the head and neck: clinical management and treatment ([email protected]). outcomes. Ann Plast Surg. 1995;35(2):133-143. Author Contributions: Dr Laubach had full access to all 19. Adouani A, Bouguila J, Abdelali MA, et al. Place of the precocious surgical treat- of the data in the study and takes responsibility for the in- ment in facial hemangioma [in French]. Ann Chir Plast Esthet. 2008;53(5): tegrity of the data and the accuracy of the data analysis. 435-440. Study concept and design: Laubach and Manstein. Acquisi- 20. Mulliken JB, Rogers GF, Marler JJ. Circular excision of hemangioma and purse- string closure: the smallest possible scar. Plast Reconstr Surg. 2002;109(5): tion of data: Laubach. Analysis and interpretation of data: 1544-1555. Laubach, Anderson, Luger, and Manstein. Drafting of the 21. Vlahovic A, Simic R, Kravljanac D. Circular excision and purse-string suture tech- manuscript: Laubach and Manstein. Critical revision of the nique in the management of facial hemangiomas. Int J Pediatr Otorhinolaryngol. manuscript for important intellectual content: Anderson and 2007;71(8):1311-1315. 22. Be´nateau H, Labbe D, Dompmartin A, Boon L. Sequelae of haemangiomas: sur- Luger. Obtained funding: Laubach and Manstein. Admin- gical treatment [in French]. Ann Chir Plast Esthet. 2006;51(4-5):330-338. istrative, technical, and material support: Luger and Man- 23. Bechu S, Labbe D, Barrelier MT, et al. Multidisciplinary approach to treat a large stein. Study supervision: Anderson and Luger. involuted haemangioma. J Plast Reconstr Aesthet Surg. 2007;60(10):1097-1102. Financial Disclosure: Dr Laubach has received travel ex- 24. Hasegawa T, Matsukura T, Mizuno Y, Suga Y, Ogawa H, Ikeda S. Clinical trial of penses and research funding from Reliant Technologies a laser device called fractional photothermolysis system for acne scars. J Dermatol. 2006;33(9):623-627. Inc; Dr Manstein has received honoraria, research fund- 25. Glaich AS, Rahman Z, Goldberg LH, Friedman PM. Fractional resurfacing for the ing, and royalties from Reliant Technologies Inc; Dr Luger treatment of hypopigmented scars: a pilot study. Dermatol Surg. 2007;33(3): has received research funding form Reliant Technolo- 289-294. gies Inc; Dr Anderson has received honoraria, research 26. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis: treatment of facial and nonfacial cutaneous photodamage with a 1,550-nm erbium-doped fiber laser. funding, and royalties from Reliant Technologies Inc. Dermatol Surg. 2007;33(1):23-28. Funding/Support: Reliant Technologies Inc provided a con- 27. Hantash BM, Bedi VP, Sudireddy V, Struck SK, Herron GS, Chan KF. Laser- sumable part of their laser device free of cost for this study. induced transepidermal elimination of dermal content by fractional Additional Contributions: The professional photogra- photothermolysis. J Biomed Opt. 2006;11(4):041115. phers Jutta Bueckmann and Peter Wissel assisted with the acquisition of the patient photographs. Submissions

REFERENCES Clinicians, residents, and fellows are invited to submit cases of challenges in management and therapeutics to 1. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser photothermolysis for this section. Cases should follow the established pat- the treatment of atrophic scars. Dermatol Surg. 2007;33(3):295-299. 2. Behroozan DS, Goldberg LH, Dai T, Geronemus RG, Friedman PM. Fractional pho- tern. Manuscripts should be prepared double-spaced with tothermolysis for the treatment of surgical scars: a case report. J Cosmet Laser right margins nonjustified. Pages should be numbered Ther. 2006;8(1):35-38. consecutively with the title page separated from the text 3. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photother- (see Instructions for Authors [http://archderm.ama-assn molysis: a new concept for cutaneous remodeling using microscopic patterns .org/misc/ifora.dtl] for information about preparation of of thermal injury. Lasers Surg Med. 2004;34(5):426-438. the title page). Clinical photographs, photomicro- 4. Rahman Z, Alam M, Dover JS. Fractional laser treatment for pigmentation and graphs, and illustrations must be sharply focused and sub- texture improvement. Skin Therapy Lett. 2006;11(9):7-11. mitted as separate JPG files with each file numbered with 5. Laubach HJ, Tannous Z, Anderson RR, Manstein D. Skin responses to fractional the figure number. Material must be accompanied by the photothermolysis. Lasers Surg Med. 2006;38(2):142-149. 6. Behroozan DS, Goldberg LH, Glaich AS, Dai T, Friedman PM. Fractional photo- required copyright transfer statement (see authorship thermolysis for treatment of poikiloderma of Civatte. Dermatol Surg. 2006; form [http://archderm.ama-assn.org/misc/auinst_crit 32(2):298-301. .pdf]). Preliminary inquiries regarding submissions for 7. Glaich AS, Goldberg LH, Dai T, Friedman PM. Fractional photothermolysis for the this feature may be submitted to George J. Hruza, MD treatment of telangiectatic matting: a case report. J Cosmet Laser Ther. 2007; ([email protected]). Manuscripts should be submitted via 9(2):101-103. our online manuscript submission and review system 8. Berenguer B, De Salamanca JE, Gonzalez B, Rodriguez P, Zambrano A, Higueras (http://manuscripts.archdermatol.com). AP. Large involuted facial hemangioma treated with syringe liposuction. Plast Reconstr Surg. 2003;111(1):314-318.

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