Periorbital Rejuvenation: A Review of Dermatologic Treatments

Background. The periorbital region serves as a barometer of chronologic and environmental age and, as such, patients often seek its cosmetic rejuvenation.
Objective. The purpose of this article was to review the dermatologic treatments available for periorbital skin rejuvenation.
Methods. Topical retinoic and glycolic acid preparations, chemical peels, botulinum and collagen injections, dermabrasion, and laser resurfacing procedures for periorbital skin rejuvenation were reviewed. The relative benefits and risks of each treatment were detailed.
Results. Minimal photodamage with mild rhytides should be responsibe to topical acid therapy and superficial peels, whereas moderate wrinkling and photodamage generally require medium-depth peels, collagen injections, or erbium:YAG laser resurfacing. Deeper rhytides and more extensive cutaneous photodamage usually necessitate CO₂ laser resurfacing and botulinum injections.
Conclusions. Proper patient selection and assessment of aging severity are critical to determine the best therapeutic option.     

Effect of Pretreatment on the Incidence of Hyperpigmentation Following Cutaneous CO2 Laser Resurfacing

Background. Transient hyperpigmentation is the most common complication seen following cutaneous carbon dioxide (CO₂) laser resurfacing.
Objective. The purpose of this study was to determine whether the use of a topical skin lightening regimen prior to cutaneous laser resurfacing reduces the incidence of post-laser resurfacing hyperpigmentation.
Methods. One hundred consecutive CO₂ laser resurfacing patients (skin types I–III) were randomized to receive preoperative treatment with 10% glycolic acid cream twice daily (n = 25), hydroquinone 4% cream qHS and tretinoin 0.025% cream twice daily (n = 25) or no pretreatment (n = 50, control) for at least 2 weeks. Clinical and photographic assessments were performed prior to laser resurfacing and at 4 and 12 weeks following treatment.
Results. There was no significant difference in the incidence of post-CO₂ laser resurfacing hyperpigmentation between subjects who received pretreatment with either topical glycolic acid cream or combination tretinoin/hydroquinone creams and those who received no pretreatment regimen.
Conclusion. It is postulated that reepithelialization after cutaneous laser resurfacing includes follicular melanocytes that have not been affected by topical pretreatment. When instituted as a component of the skin care regimen postoperatively, topical hydroquinone, tretinoin and/or glycolic acid preparations may be helpful in reducing post-laser resurfacing hyperpigmentation.     

Treatment of Upper Lip Wrinkles: A Comparison of the 950 μsec Dwell Time Carbon Dioxide Laser to Manual Tumescent Dermabrasion

Background. High-energy pulsed or computer-scanned continuous-wave carbon dioxide (CO₂) laser resurfacing has gained popularity as a wrinkle treatment because of its minimal thermal injury and precise control of tissue vaporization depth. Manual tumescent dermabrasion has also been effective for treating facial wrinkles. This is, to our knowledge, the first study comparing the use of CO₂ laser to manual tumescent dermabrasion for the treatment of wrinkles on the upper lip.
Objective. To compare prospectively the clinical efficacy of the 950 μsec dwell time CO₂ laser to that of manual tumescent dermabrasion in the treatment of upper lip wrinkles.
Methods. Twenty female subjects with moderate to severe upper lip wrinkles were randomly treated with the 950 μsec dwell time CO₂ laser on one side of the upper lip and manual tumescent dermabrasion on the other.
Results . The average upper lip laser-treated wrinkle score (0 = none to 5 = severe) decreased from 4.3 ± 0.2 before treatment to 1.8 ± 0.3 at 6 months after treatment. The average upper lip dermabrasion-treated wrinkle score decreased from 4.4 ± 0.2 to 1.5 ± 0.3. The degree to which the wrinkle score improved after laser treatment compared with that after dermabrasion was not statistically significant ( P = .216).
Conclusion. Manual tumescent dermabrasion and 950 μsec dwell time CO₂ laser resurfacing are equally effective for the treatment of upper lip wrinkles.     

The significance of orbital anatomy and periocular wrinkling when performing laser skin resurfacing.

Knowledge of orbital anatomy and the interaction of muscle contractions, gravitational forces and photoagingis fundamental in understanding the limitations of carbon dioxide (CO2) laser skin resurfacing when rejuvenating the skin of the periocular area. Laser resurfacing does not change the mimetic behavior of the facial muscles nor does it influence gravitational forces. When resurfacing periocular tissue, the creation of scleral show and ectropion are a potential consequence when there is an over zealous attempt at improving the sagging malar fat pad and eyelid laxity by performing an excess amount of laser passes at the lateral portion of the lower eyelid. This results in an inadvertent widening of the palpebral fissure due to the lateral pull of the Orbicularis oculi. Retrospectively, 85 patients were studied, who had undergone periorbital resurfacing with a CO2 laser using anew treatment approach. The Sharplan 40C CO2 Feather Touchlaser was programmed with a circular scanning pattern and used just for the shoulders of the wrinkles. A final laser pass was performed with the same program over the entire lower eyelid skin surface, excluding the outer lateral portion (e.g. a truncated triangle-like area),corresponding to the lateral canthus. Only a single laser pass was delivered to the lateral canthal triangle to avoid widening the lateral opening of the eyelid, which might lead to the potential complications of scleral show and ectropion. When the area of the crows' feet is to be treated, three passes on the skin of this entire lateral orbital surface are completed by moving laterally and upward toward the hairline. Patients examined on days 1, 7, 15, 30, 60, and one year after laser resurfacing showed good results. At two months after treatment, the clinical improvement was rated by the patient and physician as being "very good" in 81 of the 85 patients reviewed. These patients underwent laser resurfacing without complications. The proposed technique of periocular resurfacing prevents complications of scleral show and laxity in the lateral eyelid opening and even ectropion, because treatment conforms to the osseo-muscular anatomical relationship of eyelid structures. KEYWORDS: Laser resurfacing, blepharoplasty, periocular resurfacing, wrinkles, crows' feet     

Superpulsed CO2 Laser Treatment of Basal Cell Carcinoma With Intraoperatory Histopathologic and Cytologic Examination

background. CO₂ laser is currently one of the most versatile and useful laser devices in dermatologic practice in the fields of both cosmetology and oncology. The CO₂ laser in a superpulsed mode enables the operator to effect precise and adequate vaporization of the affected area, with the possibility to appreciate visually the depth achieved, and, when necessary, to perform histologic and cytologic examination of the surrounding skin.
objective. To show superpulsed CO₂ laser treatment of basal cell carcinoma.
methods. One hundred forty patients presenting single, multiple, superficial, or nodular basal cell carcinoma (BCC) have been treated with the superpulsed CO₂ laser. Before the laser treatment the lesion was subjected to cytologic examination by scraping; this examination was then repeated when the papillary dermis was clinically detectable, and again when the operator considered the BCC completely vaporized. In selected subjects, histopathologic examination was done three times (biopsies were obtained at the same time as the samples for the cytologic examination).
results. Recovery time was fast, with good healing outcomes. After 3 years follow-up no recurrences were seen. The cytologic and histopathologic examinations showed BCC in the specimens obtained prior to and during laser therapy, but not in those obtained after laser therapy.
conclusion. This technique causes minimal thermal cellular damage and no severe morphologic cellular alterations. Thus it permits an intraoperatory cytologic and histopathologic examination. Finally, this technique enables the operator to recognize the different skin levels removed by vaporization and to stop the vaporization as soon as unaffected dermis has been reached, as shown by intraoperatory cytologic and histopathologic examination.     

Laser techniques associated with facial aesthetic and reparative surgery

Chronological aging is a natural biological event that is seen particularly in the face. Attempts to correct the results of this facial loss of structural form are sometimes successful. The skin itself is usually neglected, and surgery sometimes fails to achieve the goals expected by the patient. The surgical laser offers an extremely elegant and powerful solution to this problem to complement or enhance the results of selected surgical facial aesthetic procedures as follows: (1) ablative full-face CO2 laser resurfacing in combination with facelifting; (2) laser surgical technique for upper eyelid ptosis; (3) lower eyelid blepharoplasty with the aid of the CO2 laser; (4) full-face resurfacing following minilifting of the lower part of the face; (5) endoscopic eyebrow lifting combined with laser resurfacing; (6) perioral CO2 laser resurfacing in combination with facelifting; and (7) several miscellaneous procedures (e.g., treatment of upper and lower xanthelasma with laser upper blepharoplasty, laser resurfacing in combination with fillers, and laser resurfacing of periocular wrinkles after surgical blepharoplasty). In the hands of the authors, the combination of laser and standard surgical procedures presented herein has consistently produced good results and high patient satisfaction. The complication rate is low and the recovery rate is excellent. Laser treatment enhances the natural look obtained by conventional surgeries.     

Novel approach with fractional ultrapulse CO2 laser for the treatment of upper eyelid dermatochalasis and periorbital rejuvenation

Fractional ultrapulse CO₂ laser resurfacing improves photodamage, wrinkles, and acne scarring by ablation of damaged tissue with subsequent regeneration and remodeling of collagen. In this study, the authors examined the efficacy and safety of fractional CO₂ laser and introduce a novel approach to the treatment of upper eyelid dermatochalasis. We treated 20 patients with low and moderate upper eyelid dermatochalasis. We did photographic analysis of results by measuring distance of upper eyelid fold and lateral eyebrow in vertical axis from a horizontal line joining medial and lateral canthi. All patients underwent UltraPulse CO₂ laser (Microxel MX 7000) resurfacing at upper eyelid, superior to eyebrow, and in periorbital area. Measurements were taken before and at 3 and 6 months after the laser treatment. We evaluated results at 3 and 6 months after laser treatment and found that the UltraPulse CO₂ laser induced elevation of eyelid crease and brow position (1.62?±?0.69 and 2.110?±?0.66 mm at 3 months; 1.63?±?0.68 and 2.300?±?0.67 mm at 6 months, respectively) as compared to before the treatment. Side effects were mild, patients reported minor crusting and oozing that resolved within 48 to 72 h, edema (1–2 days), and moderate postoperative erythema resolved within 4 days. These data illustrate the safety and efficacy of fractional ultrapulse CO₂ laser in the treatment of low and moderate upper eyelid dermatochalasis with added advantage of nonsurgical brow lift.     

Atypical Mycobacterial Infection Following Blepharoplasty and Full-Face Skin Resurfacing With CO2 Laser

background. With the popularity of laser skin resurfacing for the correction of photoaging and the improvement of acne scarring, it is important to note complications that may result from this procedure. Infections must be recognized and treated early, as some can result in permanent local destruction and systemic spread to other body sites.
objective. To increase the awareness of an unusual infection that may result from laser resurfacing.
methods. We report the case of a 52-year-old woman who presented with two symmetrical nodules 1 month after full-face skin resurfacing with CO₂ laser. These were found to be abscesses caused by Mycobacterium fortuitum infection.
results. The diagnosis was established following surgical debridement and subsequent culture grown from the exudate. Oral antibiotic treatment guided by organism sensitivity resulted in complete clearance of the infection with no recurrence or sequelae after 3 years of follow-up.
conclusion. This case demonstrates that atypical mycobacterial infections may arise after laser resurfacing procedures, despite proper technique, sterile instrumentation, and appropriate perioperative medications and postoperative wound care. If diagnosed and treated early, this potentially disastrous complication can be cured with no permanent sequelae.     

Histological Comparison of Postoperative Wound Care Regimens for Laser Resurfacing in a Porcine Model

Background . The use of short-pulsed CO₂ lasers for skin resurfacing is routinely performed, but few studies have examined postsurgical care.
Objective To determine which postoperative treatments are most beneficial in promoting optimal healing after laser resurfacing.
Methods . Four pigs received laser resurfacing. The laser sites were randomly left untreated or treated with petroleum-based ointment or dressed with 1 of the following occlusive dressings: hydrocolloid, hydrogel or foam. Biopsies were taken from each treatment group on Days 2, 3, 4, 5, 8, 12, and 19. All samples were stained with hematoxylin and eosin. Each histological slide was evaluated by a blinded investigator.
Results . Differences were observed between treatment groups in the amount of cellular infiltrate, presence of necrotic tissue, progression of the epidermal sheet, maturation of the epidermis, presence of rete ridges, and appearance of new collagen.
Conclusion . Postoperative treatments after laser resurfacing vary in their ability to influence the quality of healing.     

The Use of the 1.0 mm Handpiece in High Energy, Pulsed CO2 Laser Destruction of Facial Adnexal Tumors

Background. The treatment of syringoma and trichoepithelioma has included punch and shave biopsy, excision, electrodessication, as well as continuous wave and superpulsed carbon dioxide laser ablation. More recently, high-energy pulsed CO₂ lasers have been reported to be effective with standard available handpieces that deliver collimated beams.
Objective. To report our experience using a focusing handpiece (1.0mm spot at focus) with a high energy pulsed CO₂ laser.
Methods. Four patients with syringoma and two with multiple trichoepithelioma were treated with a high energy pulsed CO₂ laser using a 1mm spot size focusing handpiece. Pulse energies ranged from 125 to 250 mJ. All patients were followed 2 weeks after treatment and then for variable periods ranging from 8 to 18 months (mean = 13.3 months).
Results. The 1mm spot focusing handpiece permitted rapid tumor ablation with optimal matching of lesion size and laser spot diameter. Recurrence of tumor was associated with superficial ablation while complications such as hypopigmentation and atrophy were associated with deeper ablation.
Conclusion. Facial adnexal tumors such as syringoma and trichoepithelioma can be successfully treated with the 1.0mm handpiece in tandem with high energy pulsed CO₂ lasers.     

Novel Use of Erbium:YAG (2,940-nm) Laser for Fractional Ablative Photothermolysis in the Treatment of Photodamaged Facial Skin: A Pilot Study

BACKGROUND The use of CO₂ or conventional erbium laser ablation or more recent nonablative laser photothermolysis for skin rejuvenation is associated with significant disadvantages.
OBJECTIVE The objective was to assess the efficacy of the erbium:YAG laser (2,940 nm) using the "ablative" fractional resurfacing mode to improve photodamaged skin.
METHODS A total of 28 patients, 27 women and 1 man, aged 28 to 72 years (mean age, 54.2 years), with Fitzpatrick Skin Types II to IV, were treated for mild to moderate actinic damage using fractional erbium:YAG laser (2,940 nm) combined with Pixel technology. Sessions were scheduled at 4-week intervals. Response to treatment was evaluated by two physicians on a five-tiered scale.
RESULTS Patients underwent one to four treatment sessions (mean, 3.2). The initial reaction consisted of erythema and minimal swelling. On clinical assessment 2 months after the final treatment, the results were rated excellent by 21 patients (75%) and good by 7 (25%). Nineteen of the 21 were also evaluated 6 to 9 months after final treatment without any significant change in the results.
CONCLUSIONS Fractional ablative photothermolysis using erbium:YAG laser (2,940 nm) is a promising option for skin resurfacing with reduced risk and downtime compared to existing laser methods.     

Treatment of Basal Cell Carcinoma with the Pulsed Carbon Dioxide Laser: A Retrospective Analysis

Background and Objective. Treatment options for basal cell carcinoma include surgical excision, cryotherapy, radiation, photodynamic therapy, Moh's micrographic surgery, and topical treatment with 5-fluorouracil and immunomodulators such as imiquimod. Resurfacing and ablation with a CO₂ laser (UltraPulse, Coherent Inc.) may present an attractive and effective treatment option in the management of these cutaneous cancers. We demonstrate the efficacy and safety of the UltraPulse CO₂ in the treatment of basal cell carcinomas of the skin.
Methods. We performed a retrospective chart review of 23 patients treated with the UltraPulse CO₂ laser. A total of 61 biopsy-proven superficial and nodular basal cell carcinomas without prior treatment were included in the study. The patients were followed postoperatively for a period of 15 to 85 months (mean 41.7 months) and assessed for clinical recurrence.
Results. Of the 61 tumors treated, clinical recurrence was observed in two cases (3.2%). Adverse effects included significant hypertrophic scarring in one patient and hypopigmentation in one patient.
Conclusions. Destruction of superficial and nodular basal cell carcinomas may be accomplished successfully and safely with the UltraPulse CO₂ laser with a cure rate of 97%.     

Laser blepharoplasty in Asians

Traditional blepharoplasty removes periorbital wrinkles by cutting and stretching the skin. However, this method has a substantial risk of producing ectropion or scleral show. In addition, fine periocular wrinkles may persist because this method does not change skin texture. The pulsed CO2 laser has recently become a primary surgical tool in treating aging eyelids. Periorbital wrinkles vary in depth not only from person to person, but also among different races. Compared with whites, most Asians have a thicker dermis, so more laser passes and a higher power may be required to remove periorbital wrinkles, but concerns about hyperpigmentation and prolonged erythema have limited its use on Asian skin. In this study, 346 patients underwent laser blepharoplasty at the Korea University Medical Center and at Dr Choi's Aesthetic Clinic. They were followed for 12 months on average from September 1995 to September 1999. The CO2 laser was used in resurfacing periorbital wrinkles, transcutaneous skin excision, and transconjunctival blepharoplasty, including fat removal. The authors assessed the benefit of using the UltraPulse CO2 laser in Asian blepharoplasty. They found that 291 patients (84%) had good to excellent results. The incidence of side effects was very low. Prolonged erythema occurred in 19 patients (5%) and hyperpigmentation occurred in 35 patients (10%), but the erythema disappeared spontaneously within 2 months and the hyperpigmentation could be managed readily by the topical use of retinoids and hydroquinone cream. Therefore, the authors conclude that postoperative hyperpigmentation is no longer a problem limiting laser resurfacing in Asian blepharoplasty. The UltraPulse CO2 laser is a safe and effective rejuvenation method for treating aging eyelids in Asians.     

Prolonged Erythema After Facial Laser Resurfacing or Phenol Peel Secondary to Corticosteroid Addiction

Background. Prolonged persistent erythema postprocedure using phenol or carbon dioxide (CO₂) lasers occurs frequently and the reasons have not been fully ascertained.
Objective. To describe patients whose postoperative care consisted of prolonged use of topical corticosteroids and to assess the outcome of cessation of this medicine.
Methods. Twelve patients who underwent CO₂ laser resurfacing or phenol peels to their face are presented. All patients were seen between 3 and 30 months after the procedures were performed. All dressings, wound care, and other medicaments had been stopped prior to being seen. Most were patch tested to a wide variety of chemicals including corticosteroids, topical medications, and preservatives. They were observed during the poststeroid cessation period and the clinical response is described.
Results. All patch testing showed insignificant results. All postpeel patients cleared within 6 months of steroid cessation, experiencing several flares of erythema before the end result. Three of the six laser resurfacing patients cleared fully within 12 months and three are still being followed. The erythema and severe burning in the patients that cleared stayed clear during long-term follow-up. No scars or atrophy were seen.
Conclusion. The use of topical corticosteroid preparations postoperatively in peel and resurfacing patients is believed to be a major cause of prolonged erythema, dermatitis, burning, and telangiectasias in these patients. The mechanism is believed to be one of vasoconstriction/vasodilatation secondary to the corticosteroids through a nonintact barrier.     

Power of the pinch: pinch lower lid blepharoplasty

Lower lid blepharoplasty is performed with great variation in technique. Conventional lower lid blepharoplasty with anterior fat removal via the orbital septum has a potential lower lid malposition rate of 15% to 20%. Lower lid malposition and the stigma of obvious lower lid surgery have led plastic surgeons to continue to change their approach to lower lid rejuvenation. In recent years, some surgeons have come to rely on alternative procedures like laser resurfacing alone or in conjunction with transconjunctival fat removal and canthopexy in an effort to avoid such complications. The pinch blepharoplasty technique removes redundant skin without undermining. This allows for more controlled wound healing, predictable recovery, and potential for simultaneous laser resurfacing. The combination of pinch blepharoplasty with transconjunctival fat removal leaves the middle lamella intact and reduces the chance of scleral show or ectropion. The purpose of this series is to demonstrate that pinch excision of redundant lower eyelid skin can be safely performed and that it can be used with laser resurfacing and/or transconjunctival fat removal for optimal treatment of the aging eye. A retrospective review of 46 consecutive patients who underwent pinch blepharoplasty, either in isolation or with other periorbital procedures was performed. Follow-up was at least 4 months (range of 4-24 months). In addition, we performed a prospective study of 25 consecutive patients to quantify the amount of skin removed and evaluate results and complications. An average of 8 mm of skin was resected (range of 4-12 mm) with the pinch blepharoplasty technique. Of these patients, 5.6% also underwent transconjunctival blepharoplasty, laser resurfacing, and/or fat grafting of the nasojugal groove. Despite the addition of simultaneous laser resurfacing, we did not see an increase in lower lid malposition. Three of the 71 patients had temporary scleral show that resolved with lower lid massage. In total, only 4 patients had isolated pinch lower lid blepharoplasty. Twelve patients had orbicularis suspension and 15 had either canthopexy or canthoplasty. Five patients who had orbicularis suspension, canthopexy, or canthoplasty had periorbital edema. Two also had pronounced chemosis. Four patients had mild rounding of the lower lid. Pinch blepharoplasty is a versatile technique that produces consistent results. This study confirms that more skin from the lower lid can be resected than classically described. Pinch blepharoplasty can be performed safely in combination with other procedures to enhance lower lid appearance. The absence of skin undermining allows for safe simultaneous laser resurfacing. Preserving the middle lamella and supporting it when necessary allows one to resect significant amounts of lower lid skin without significant risk of scleral show, lower lid rounding, and ectropion. Patients with poor lid tone or laxity may benefit from supportive procedures such as the canthopexy or canthoplasty.     

Comparison of body temperature changes during laparoscopic and open cholecystectomy

Background: Prevention of hypothermia during abdominal surgery by insulating or heat-transferring methods has been the subject of numerous investigations. This study approaches the problem from a less discussed point of view, i.e. the effect of different surgical techniques on body temperature changes.
Methods: Body temperature was measured at 3 core and 6 skin points in 40 patients scheduled for cholecystectomy through open laparotomy or laparoscopy with pneumoperitoneum created and maintained with unwarmed carbon dioxide (CO₂) insufflation. End-tidal CO₂ was kept constant by adjustments of respiratory frequency. Anaesthesia, intravenous infusions, and draping of the patients were standardized.
Results: During the first 1 h of anaesthesia core temperatures decreased approximately by 0.7˚C and distal skin temperatures increased by 7˚C in both groups. At the end of surgery heat balance was similar in both groups. An increase of 2.5 1 min^-1 in respiratory minute volume was needed to control end-tidal CO₂ levels in the laparoscopy group during pneumoperitoneum, which was maintained with a CO₂ flow of 1.2 l-min^-1 through the abdominal cavity.
Conclusion: Laparoscopic technique with unwarmed carbon dioxide insufflation does not offer any advantage in terms of body temperature changes when compared to open surgery.     

Changes in delivered tidal volume with the addition of carbon dioxide to mechanical ventilation

Objective:  To determine discrepancies in delivered tidal volumes induced by the addition of carbon dioxide (CO₂) during mechanical ventilation.
Design:  Prospective, experimental, lung model study.
Setting:  Research laboratory at a University hospital.
Subjects:  Ventilator set-up using a mechanical lung model.
Interventions:  Tidal volumes were measured during pressure and volume limited ventilation at various pressures and volumes with the addition of inspired CO₂ concentrations of 0, 1, 2, and 4%. Three ventilator set-ups were used including the addition of CO₂ to the inspiratory limb (M1), the use of two external blenders to mix air, oxygen and CO₂ prior to entry to the ventilator (M2), and the use of one external blender to mix air and CO₂ prior to addition to the ventilator.
Measurements and main results:  Statistically significant increases in delivered tidal volume were noted with the addition of CO₂ with all three of the ventilator set-ups (M1, M2 and M3). However, the maximum increase was 2.4% above that of baseline (no CO₂ added). With the M2 set-up, there was also a significant discrepancy noted between the set and the delivered tidal volumes (16–17%) when using the volume limited mode even without the addition of CO₂.
Conclusions:  Either the M1 or the M3 set-up functioned efficiently without clinically significant alterations in ventilator performance. We prefer the M1 set-up as it is the one that is used most commonly in clinical practice and does not require significant alterations in the working configuration of the ventilator.     

Detection of carbon dioxide in expired air after oesophageal intubation; the role of bystander mouth-to-mouth ventilation

Background: The identification of a correctly placed tube during anaesthesia routinely depends on the detection of carbon dioxide (CO₂) in the expired air.
Results: We describe a previously unreported cause of false-positive prediction in two patients with high initial values of CO₂ in expired air after oesophageal intubation. Both patients had received bystander cardiopulmonary resuscitation with mouth-to-mouth ventilation, and the CO₂ from the rescuers' expired air was trapped and subsequently detected after oesophageal intubation.     

The detection of carbon dioxide embolism during laparoscopy in pigs: a comparison of transesophageal Doppler and end-tidal carbon dioxide monitoring

Background: The aim of the study was to compare the value of transesophageal Doppler and end-tidal carbon dioxide monitoring to detect venous carbon dioxide embolism in pigs during laparoscopic cholecystectomy.
Method: Ten pigs were anesthetized under constant ventilation, and instrumented for laparoscopic cholecystectomy. CO₂ pneumoperitoneum was performed at 15 mmHg and then, successive increased intravenous gas boluses of 0.1 to 4 ml/ kg injectedthrough the femoral vein using a 55-mm long catheter. The responses indicative of embolism were defined as: 1) a change in Doppler tone placed facing the junction of the right atrium and inferior vena cava; 2)
Results: Doppler was more sensitive in detecting 0.1, 0.2 and 0.4 ml/mg of CO₂ embolism than end-tidal CO₂ ( P <0.05). Over 0.4 ml/mg no differences in sensitivity were found but the Doppler signal modifications occurred earlier than the changes in end-tidal CO₂. Moreover, these changes always consisted of a reduction of the value.
Conclusions: During laparoscopic cholecystectomy in pigs, transesophageal Doppler was a highly sensitive monitor which provided an earlier detection of CO₂ embolism and at lower doses than end-tidal CO₂ monitoring.     

Laser Resurfacing of the Neck with the Erbium:YAG Laser

Background.  Laser resurfacing of the face is widely used to correct the effects of photoaging. The neck also develops a similar degree of photoaging, but is not usually treated because a higher incidence of adverse effects can occur with laser treatment.
Objective.  To present a new method for treating photoaged skin of the neck with an erbium:yttrium aluminum garnet (Er:YAG) laser.
Methods.  Twenty patients underwent Er:YAG laser resurfacing of the neck with one of two methods. Method 1 consisted of using the Er:YAG with a 5-mm diameter collimated beam at a fluence of 8.7 J/cm² followed by a second pass using a 0.2 mm diameter non-collimated spot at 1.7 J in a defocused mode with spot sizes ranging from about 5 to 10 mm in diameter (fluences from 2–9 J/cm²). Method 2 consisted of treating the entire neck with a single pass of the Er:YAG laser with a 4 mm diameter non-collimated spot at 1.7 J (fluence of 13.5 J/cm²). A second pass at identical settings was made on the upper half of the neck with a more defocused pass using a 6–10 mm diameter spot (fluence of 2–6 J/cm²) on the lower half of the neck. Patients were evaluated by two nontreating physicians as to overall satisfaction and improvement in skin texture and color.
Results.  Overall, 51% of patients were satisfied with their results. Skin texture improved an average of 39%. Method 1 produced a 28% improvement, Method 2 a 48% improvement. Skin color improved an average of 37%. Method 1 produced a 28% improvement, Method 2 a 45% improvement.
Conclusion.  Photoaged skin of the neck can be effectively treated with the Er:Yag laser with minimal adverse effects.