- Email: [email protected]
Cutaneous laser resurfacing
CUTANEOUS LASER RESURFACING W. GREGORY CHERNOFF, BSc, MD, FRCS, LARRY D. SCHOENROCK, MD, FACS
The art of selective photothermoepidermolysis continues to evolve into a science as applicable laser physics expands. N e w techniques are constantly evolving in medicine. For a n e w technique to be accepted, it must prove to be at least as effective as established, time-tested procedures. Hopefully, the new procedure will offer greater benefit to the patient. Patient safety must always be at the forefront of the mind of any surgeon offering alternative therapy. Before clinical application research, protocols must be developed and tested to assure clinical reproducibility. In our youth-oriented society, patients are constantly challenging facial plastic surgeons to improve methods geared toward maintaining an esthetically pleasing appearance as well as repairing skin changes reflective of actinic, solar, and senile damage. Although chemexfoliation and dermabrasion are timetested, reliable procedures, they are not without their respective shortfalls. The ability to exfoliate facial zones selectively and precisely, taking into account skin type variability from zone to zone and from patient to patient, is the ultimate goal.
HISTORY Exfoliation of the skin dates back to the ancient Egyptians who used salt, animal oils, and alabaster to improve skin texture.1 Various poultices using sulphur, mustard, and limestone were also applied. Other methods, using fire to singe the skin and exfoliate it, were introduced by the Turks. Early in the twentieth century, MacKee administered phenol for treatment of acne scars. 2 Gross practiced lay phenol peeling in Los Angeles in the 1930s. 3 In 1941, Eller and Wolff reviewed various exfoliation regimes. These included the use of pumice on the skin as well as sulphur and resorcinol pastes. 4 In 1966, Urkov described methods using phenol. 5 In the 1960s, Ayres 6'7 compared his results with those of Morash, s citing histologies of trichloracetic acid (TCA) and phenol. Brown et al reported their phenol formula, the histological changes it produced, and its potential toxicity. 9 In 1962, Litton 1~ and Baker 11 published their respective nonsaponized and saponized formulas. The 1970s and 1980s saw further advancements in full-face phenol application or TCA peels in combination with dermabrasion. 12 Stegman compared the histological From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology--Head and Neck Surgery, University of California, San Francisco, CA; and Midwest Cosmetic Surgery, Indianapolis, IN. Address reprint requests to Lawrence D. Schoenrock, MD, 830 Second St, Suite A, Santa Rosa, CA 95404. Copyright 9 1994 by W.B. Saunders Company 1043-1810/94/0504-0008505.00/0
depth of wounding of various chemical agents and dermabrasion. 13 This study was instrumental in developing concepts used in the techniques of the 1990s (Table 1). The history of dermabrasion is equally fascinating. Whereas variations in skin abrasion date back to the Egyptians in 1500 BC, Kromayer in 1905 was the first to report the use of a power-driven instrument in cutaneous surgery. 14 In 1947, Iverson reported the surgical removal of traumatic tattoos of the face using sandpaper of grit sizes 0 to 00. is In 1953, Kurtin 16 and Robbins-17 developed surgical wire brushes for tattoo removal. Lowenthal introduced the technique of using skin punches to remove ice pick scars with subsequent replacement with punch grafts, followed by dermabrasion. TM Noel Robbins is credited with the development of the wire brush and diamond fraise. 17 Yarborough introduced the concept of early_ dermabrasion for amelioration of posttraumatic scars. 19 Pinski contributed significantly to the study of the effects of biological dressings on dermabrasion w o u n d healing. 2~ Chemical peeling and dermabrasion have continued to be considered work horses in the facial plastic surgeon's armamentarium for the treatment of various conditions (Table 2). However, each modality has its limitations and variable success rates from lesion to lesion.
CUTANEOUS LASER RESURFAClNG With the growth of experience in any procedure comes an invaluable sense of the limitation of its use and/or appreciation of its benefit. It is this knowledge of application of dermabrasion and chemical peel that has led investigators to search for improvements. There exists an inherent lack of precision of chemical peel and dermabrasion with respect to exact exfoliation depth, combined with danger to nearby mucous membranes from peeling solutions and rotary hazards near the mouth and eyes. The knowledge pertaining to w o u n d healing, specific to these modalities, gave valuable insight toward the implementation of new techniques. The early concept for medical lasers was to use pigmented tissue as a selective absorption target resulting in thermal necrosis of the targeted tissue, sparing the immediately adjacent nonpigmented tissue.2r An in-depth knowledge of laser physics as well as laser-tissue interaction is necessary for the surgeon contemplating this exciting field. This discussion is beyond the realm of this article; however, additional information is easily obtained in the literature. The past two decades have yielded numerous studies on CO2 laser surgery. These have focused on improving delivery systems as well as expanding our understanding of cutaneous tissue repair after CO 2 laser irradiation. 22'23 The early use of the CO 2 laser in cutaneous surgery was as an excisional or destructive tool in treating malignan-
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 5, NO 4 (DEC), 1994: PP 281-283
281
TABLE 1. Types of Chemical Peels Light (superficial) Wound to papillary dermis TCA (10%-25%) Jessners solution: Resorcinol 14 gm Salicyclic acid 14gm Lactic acid 14 gm Q.S. ethanol 100 cc Medium depth Wound to upper reticular dermis TCA (35%-50% unoccluded or occluded) Full-strength phenol (88% unoccluded)
TABLE 3. C02 Laser Resurfacing Indications Rhytids Lip vermilion Vertical perioral Periorbital Glabellar Enhancement of filling substances Scars Postsurgical incisions, flaps Posttraumatic Acne Small pox Warts
Deep peel Wound to mid reticular dermis Bakers formula: 3 cc phenol 2 cc tap water 8 drops soap 3 drops cotton oil (occluded or unoccluded)
cies, 24'25 in the management of burns, 26 and for the debridement of decubitus ulcers. Increasing availability and ease of use further diversified its application. This was primarily because of increased surgical speed, a bloodless field, and reduced postoperative pain. Those practitioners who gained experience soon became disenchanted with CO 2 cutaneous surgery because of the realization that thermal damage to surrounding tissue was difficult to control. Disappointing clinical results and unacceptably high rates of scarrin~ posed serious questions a s t o theircontinued use. 28'2~ This was related to the effects of heat diffusion into surrounding tissue resulting in unwanted thermal necrosis. When laser energy interacts with tissue, it obeys Beer's Law. This law states that tissue damage at the absorption site decreases exponentially with increasing distance from the laser crater edge. This allows epidermal cells at the wound edge as well as epidermal appendages at the wound depth to remain viable and subsequently participate in wound healing. 3~ According to the above law, laser energy heats a critical tissue volume until the tissue temperature exceeds the vaporization threshold. If fluence is sufficient to deliver adequate energy during a pulse, and if that pulse is less than the thermal relaxation TABLE 2. Common Indications for Chemical Peel and Dermabrasion Chemical peel Aging skin rhytids Elastosis Actinic keratosis Pigmentary dyschromias Superficial scarring Acne bulgaris and rosacea Dermabrasion Postacne scars Traumatic scars Surgical scars Smallpox scars Traumatic tatoo Melasma Epidermal nevi Adenoma sebaceum Actinic keratosis Syringomas Rhytids
Milia 282
Note: see Table 2 for other applications.
time of the tissue, then clear vaporization without thermal damage beyond the impact site will occur. Slow heating of tissue yields burning, desiccation, and charring. This correlates with extensive peripheral thermal damage secondary to thermal diffusion with subsequent scarring. Much work has been performed by the current investigators over the past 2 years that will be released in forthcoming publications. This has been geared toward defining and refining specific parameters required for the precise selective photothermoepidermolysis of specific cutaneous problems (Table 3). The refinements in surgical laser systems, including superpulse modes, ultrapulse modes, and laser scanning systems, have opened new frontiers for laser cutaneous surgeons. The ideal CO2 laser for cutaneous surgery should incise or vaporize tissue rapidly and efficiently, coagulate blood vessels, and most importantly, allow for rapid, normal healing from both adjacent nontreated epidermis and adnexal structures. The first stage of our multicentered study involved the examination of over 400 h u m a n histological specimens. These specimens were treated with various delivery systems at different power levels. This created a vast knowledge as to the capabilities of the systems, and more importantly, allowed us to correlate fluence levels with exfoliation depths, proportional to skin type (Table 4). Also included in this study was a comparison of cutting abilities and hole punch capabilities for the purposes of
TABLE 4. Classifications of Skin Type in Study Group Complexion pattern Light skin Red hair Blue or green eyes Light skin Blond hair Blue eyes Medium skin Brown hair and eyes Medium to dark skin Brown to black hair and eyes Dark skin Black hair and eyes Black skin Black hair and eyes
CUTANEOUS LASER RESURFAClNG
hair transplantation. A n i n - d e p t h s e r i e s of m u l t i c e n tered studies with follow-up are also pending in future publications. It m u s t b e e m p h a s i z e d t h a t a l t h o u g h t h i s t e c h n i q u e offers e x t r e m e p r e c i s i o n , t h e r e e x i s t s a d e f i n i t e l e a r n i n g c u r v e for a c q u i s i t i o n of t h e skills n e c e s s a r y to a d m i n i s t e r t h e t e c h n o l o g y s a f e l y to p a t i e n t s . P a r a m e t e r s t h a t m u s t b e m a s t e r e d i n c l u d e a w o r k i n g k n o w l e d g e of w h i c h p r o b l e m to t r e a t a n d w h e n . Effecting appropriate spot sizes, s c a n n i n g s p e e d s , a n d r e p e t i t i o n r a t e s is i n s t r u m e n t a l to successful outcomes. T h e clinical a p p l i c a t i o n o f l a s e r r e s u r f a c i n g is l i m i t e d only by the user's imagination. We have performed studies combining conventional resurfacing and subcutaneous defect-filling techniques with laser cutaneous surgery. Although important results have been obtained, t h e f u t u r e s u c c e s s of t h i s v a l u a b l e t e c h n o l o g y w i l l d e p e n d o n t h e c o n t i n u e d r e s e a r c h a n d d e v e l o p m e n t of d e l i v e r y s y s t e m s t h a t w i l l i n c r e a s e t h e s a f e t y m a r g i n a v a i l a b l e to the user.
10. 11.
I2. 13.
14.
15. 16. 17. 18. 19.
20. 21.
REFERENCES 1. Marmelzat WL: A historical review of chemical rejuvenation of the face, in Kotter R (ed): Chemical Rejuvenation of the Face. St Louis, MO, Mosby, 1992, pp 1-39 2. MacKee GM, Karp FL: The treatment of post-acne scars with phenol. Br J Dermatol 64:456, 1952 3. Gross BG, Mescheck F: Phenol chemosurgery for removal of deep facial wrinkles. Int J Dermatol 19:159, 1980 4. Eller JJ, Wolff S: Skin peeling and scarification. JAMA 116:934, 1941 5. Urkov JG: Surface defects of skin: Treatment by controlled exfoliation. IL Med J 89:75, 1946 6. Ayres S: Dermal changes following application of chemical counterants to aging skin. Arch Dermatol 82:578, 1960 7. Ayres S: Superficial chemosurgery in treating aging skin. Arch Dermatol 85:125, 1962 8. Morash S: The uses of diluted trichloracetic acid in dermatology. Urol Cutan Rev 49:119, 1949 9. Brown AM, Kaplan LM, Brown ME: Phenol induced histological
CHERNOFF AND SCHOENROCK
22. 23. 24. 25. 26. 27.
28. 29. 30.
skin changes: Hazards, techniques and uses. Br J Plast Surg 13:158, 1960 Litton C: Chemical face lifting. Plast Reconstr Surg 29:371, 1962 Baker TJ: Chemical face peeling and rhytidectomy: A combined approach for facial rejuvenation. Plast Reconstr Surg 29:199, 1962 Stegman SJ: Chemabrasion. J Dermatol Surg Oncol 3:217, 1977 Stegman SJ: A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sun damaged skin. Aesthetic Plast Surg 6:123, 1982 Kromayer E: Rotationsinstrumente: Ein neues technisches verfahren in der dermatologischen flemcherurgie. Dermatol Z 12:26, 1905 Iverson PC: Further developments in the treatment of skin lesions by surgical abrasion. Plast Reconstruct Surg, 12:27, 1953 Kurtin A: Corrective surgical planning of the skin. Arch Dermatol Suppl 68:389, 1953 Robbins N: Abner Kurter, father of ambulatory dermabrasion. J Dermabrasion 14:425, 1988 Lowenthal L: Punch biopsy with autograft. Arch Dermatol 67:629, 1953 (suppl) Yarborough J: Dermabrasive surgery. Clin Dermatol 5:75, 1987 Pinski JB: Dressings for dermabrasion: New aspects. J Dermatol Surg Oncol 13:673, 1987 Goldman L: Laser treatments of melanoma, in Goldman L (ed): Laser Cancer Research. New York, NY, Springer-Verlag, 1966 Kamat BR, Carney JM, Goldman L, et al: Cutaneous tissue repair following CO2 laser irradiation. J Invest Dermatol 87:2, 1986 Hishimoto K, Rockwell JR, Goldman L, et al: Laser wound healing compared with other surgical modalities. Burns 1:13-22, 1973 Kirschner RA: Cutaneous plastic surgery with the CO2 laser. Surg Clin North Am 64:871, 1984 Goldman L: CO2 laser surgery for cancer of man. Laser J 3:21, 1971 Stellar S, Ger R: CO 2 laser for excision of burn eschars. Lancet 1:945, 1971 Stellar S, Meijer R: CO 2 Laser debridement of decubitus ulcers: Followed by immediate rotation flap or skin graft closure. Ann Surg 79:230, 1974 Friedman M, Gal D: Keloid scars as a result of CO2 laser for molluscum contagiosum. Obstet Gynecol 70:394, 1987 Shapskay SM, Rebeiz EE: Benign lesions of the larynx: Should the laser be used? Laryngoscope 100:953, 1990 Reid R: Physical and surgical principles governing CO 2 laser surgery on the skin. Dermatol Clin 9:297, 1969
283
The art of selective photothermoepidermolysis continues to evolve into a science as applicable laser physics expands. N e w techniques are constantly evolving in medicine. For a n e w technique to be accepted, it must prove to be at least as effective as established, time-tested procedures. Hopefully, the new procedure will offer greater benefit to the patient. Patient safety must always be at the forefront of the mind of any surgeon offering alternative therapy. Before clinical application research, protocols must be developed and tested to assure clinical reproducibility. In our youth-oriented society, patients are constantly challenging facial plastic surgeons to improve methods geared toward maintaining an esthetically pleasing appearance as well as repairing skin changes reflective of actinic, solar, and senile damage. Although chemexfoliation and dermabrasion are timetested, reliable procedures, they are not without their respective shortfalls. The ability to exfoliate facial zones selectively and precisely, taking into account skin type variability from zone to zone and from patient to patient, is the ultimate goal.
HISTORY Exfoliation of the skin dates back to the ancient Egyptians who used salt, animal oils, and alabaster to improve skin texture.1 Various poultices using sulphur, mustard, and limestone were also applied. Other methods, using fire to singe the skin and exfoliate it, were introduced by the Turks. Early in the twentieth century, MacKee administered phenol for treatment of acne scars. 2 Gross practiced lay phenol peeling in Los Angeles in the 1930s. 3 In 1941, Eller and Wolff reviewed various exfoliation regimes. These included the use of pumice on the skin as well as sulphur and resorcinol pastes. 4 In 1966, Urkov described methods using phenol. 5 In the 1960s, Ayres 6'7 compared his results with those of Morash, s citing histologies of trichloracetic acid (TCA) and phenol. Brown et al reported their phenol formula, the histological changes it produced, and its potential toxicity. 9 In 1962, Litton 1~ and Baker 11 published their respective nonsaponized and saponized formulas. The 1970s and 1980s saw further advancements in full-face phenol application or TCA peels in combination with dermabrasion. 12 Stegman compared the histological From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology--Head and Neck Surgery, University of California, San Francisco, CA; and Midwest Cosmetic Surgery, Indianapolis, IN. Address reprint requests to Lawrence D. Schoenrock, MD, 830 Second St, Suite A, Santa Rosa, CA 95404. Copyright 9 1994 by W.B. Saunders Company 1043-1810/94/0504-0008505.00/0
depth of wounding of various chemical agents and dermabrasion. 13 This study was instrumental in developing concepts used in the techniques of the 1990s (Table 1). The history of dermabrasion is equally fascinating. Whereas variations in skin abrasion date back to the Egyptians in 1500 BC, Kromayer in 1905 was the first to report the use of a power-driven instrument in cutaneous surgery. 14 In 1947, Iverson reported the surgical removal of traumatic tattoos of the face using sandpaper of grit sizes 0 to 00. is In 1953, Kurtin 16 and Robbins-17 developed surgical wire brushes for tattoo removal. Lowenthal introduced the technique of using skin punches to remove ice pick scars with subsequent replacement with punch grafts, followed by dermabrasion. TM Noel Robbins is credited with the development of the wire brush and diamond fraise. 17 Yarborough introduced the concept of early_ dermabrasion for amelioration of posttraumatic scars. 19 Pinski contributed significantly to the study of the effects of biological dressings on dermabrasion w o u n d healing. 2~ Chemical peeling and dermabrasion have continued to be considered work horses in the facial plastic surgeon's armamentarium for the treatment of various conditions (Table 2). However, each modality has its limitations and variable success rates from lesion to lesion.
CUTANEOUS LASER RESURFAClNG With the growth of experience in any procedure comes an invaluable sense of the limitation of its use and/or appreciation of its benefit. It is this knowledge of application of dermabrasion and chemical peel that has led investigators to search for improvements. There exists an inherent lack of precision of chemical peel and dermabrasion with respect to exact exfoliation depth, combined with danger to nearby mucous membranes from peeling solutions and rotary hazards near the mouth and eyes. The knowledge pertaining to w o u n d healing, specific to these modalities, gave valuable insight toward the implementation of new techniques. The early concept for medical lasers was to use pigmented tissue as a selective absorption target resulting in thermal necrosis of the targeted tissue, sparing the immediately adjacent nonpigmented tissue.2r An in-depth knowledge of laser physics as well as laser-tissue interaction is necessary for the surgeon contemplating this exciting field. This discussion is beyond the realm of this article; however, additional information is easily obtained in the literature. The past two decades have yielded numerous studies on CO2 laser surgery. These have focused on improving delivery systems as well as expanding our understanding of cutaneous tissue repair after CO 2 laser irradiation. 22'23 The early use of the CO 2 laser in cutaneous surgery was as an excisional or destructive tool in treating malignan-
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 5, NO 4 (DEC), 1994: PP 281-283
281
TABLE 1. Types of Chemical Peels Light (superficial) Wound to papillary dermis TCA (10%-25%) Jessners solution: Resorcinol 14 gm Salicyclic acid 14gm Lactic acid 14 gm Q.S. ethanol 100 cc Medium depth Wound to upper reticular dermis TCA (35%-50% unoccluded or occluded) Full-strength phenol (88% unoccluded)
TABLE 3. C02 Laser Resurfacing Indications Rhytids Lip vermilion Vertical perioral Periorbital Glabellar Enhancement of filling substances Scars Postsurgical incisions, flaps Posttraumatic Acne Small pox Warts
Deep peel Wound to mid reticular dermis Bakers formula: 3 cc phenol 2 cc tap water 8 drops soap 3 drops cotton oil (occluded or unoccluded)
cies, 24'25 in the management of burns, 26 and for the debridement of decubitus ulcers. Increasing availability and ease of use further diversified its application. This was primarily because of increased surgical speed, a bloodless field, and reduced postoperative pain. Those practitioners who gained experience soon became disenchanted with CO 2 cutaneous surgery because of the realization that thermal damage to surrounding tissue was difficult to control. Disappointing clinical results and unacceptably high rates of scarrin~ posed serious questions a s t o theircontinued use. 28'2~ This was related to the effects of heat diffusion into surrounding tissue resulting in unwanted thermal necrosis. When laser energy interacts with tissue, it obeys Beer's Law. This law states that tissue damage at the absorption site decreases exponentially with increasing distance from the laser crater edge. This allows epidermal cells at the wound edge as well as epidermal appendages at the wound depth to remain viable and subsequently participate in wound healing. 3~ According to the above law, laser energy heats a critical tissue volume until the tissue temperature exceeds the vaporization threshold. If fluence is sufficient to deliver adequate energy during a pulse, and if that pulse is less than the thermal relaxation TABLE 2. Common Indications for Chemical Peel and Dermabrasion Chemical peel Aging skin rhytids Elastosis Actinic keratosis Pigmentary dyschromias Superficial scarring Acne bulgaris and rosacea Dermabrasion Postacne scars Traumatic scars Surgical scars Smallpox scars Traumatic tatoo Melasma Epidermal nevi Adenoma sebaceum Actinic keratosis Syringomas Rhytids
Milia 282
Note: see Table 2 for other applications.
time of the tissue, then clear vaporization without thermal damage beyond the impact site will occur. Slow heating of tissue yields burning, desiccation, and charring. This correlates with extensive peripheral thermal damage secondary to thermal diffusion with subsequent scarring. Much work has been performed by the current investigators over the past 2 years that will be released in forthcoming publications. This has been geared toward defining and refining specific parameters required for the precise selective photothermoepidermolysis of specific cutaneous problems (Table 3). The refinements in surgical laser systems, including superpulse modes, ultrapulse modes, and laser scanning systems, have opened new frontiers for laser cutaneous surgeons. The ideal CO2 laser for cutaneous surgery should incise or vaporize tissue rapidly and efficiently, coagulate blood vessels, and most importantly, allow for rapid, normal healing from both adjacent nontreated epidermis and adnexal structures. The first stage of our multicentered study involved the examination of over 400 h u m a n histological specimens. These specimens were treated with various delivery systems at different power levels. This created a vast knowledge as to the capabilities of the systems, and more importantly, allowed us to correlate fluence levels with exfoliation depths, proportional to skin type (Table 4). Also included in this study was a comparison of cutting abilities and hole punch capabilities for the purposes of
TABLE 4. Classifications of Skin Type in Study Group Complexion pattern Light skin Red hair Blue or green eyes Light skin Blond hair Blue eyes Medium skin Brown hair and eyes Medium to dark skin Brown to black hair and eyes Dark skin Black hair and eyes Black skin Black hair and eyes
CUTANEOUS LASER RESURFAClNG
hair transplantation. A n i n - d e p t h s e r i e s of m u l t i c e n tered studies with follow-up are also pending in future publications. It m u s t b e e m p h a s i z e d t h a t a l t h o u g h t h i s t e c h n i q u e offers e x t r e m e p r e c i s i o n , t h e r e e x i s t s a d e f i n i t e l e a r n i n g c u r v e for a c q u i s i t i o n of t h e skills n e c e s s a r y to a d m i n i s t e r t h e t e c h n o l o g y s a f e l y to p a t i e n t s . P a r a m e t e r s t h a t m u s t b e m a s t e r e d i n c l u d e a w o r k i n g k n o w l e d g e of w h i c h p r o b l e m to t r e a t a n d w h e n . Effecting appropriate spot sizes, s c a n n i n g s p e e d s , a n d r e p e t i t i o n r a t e s is i n s t r u m e n t a l to successful outcomes. T h e clinical a p p l i c a t i o n o f l a s e r r e s u r f a c i n g is l i m i t e d only by the user's imagination. We have performed studies combining conventional resurfacing and subcutaneous defect-filling techniques with laser cutaneous surgery. Although important results have been obtained, t h e f u t u r e s u c c e s s of t h i s v a l u a b l e t e c h n o l o g y w i l l d e p e n d o n t h e c o n t i n u e d r e s e a r c h a n d d e v e l o p m e n t of d e l i v e r y s y s t e m s t h a t w i l l i n c r e a s e t h e s a f e t y m a r g i n a v a i l a b l e to the user.
10. 11.
I2. 13.
14.
15. 16. 17. 18. 19.
20. 21.
REFERENCES 1. Marmelzat WL: A historical review of chemical rejuvenation of the face, in Kotter R (ed): Chemical Rejuvenation of the Face. St Louis, MO, Mosby, 1992, pp 1-39 2. MacKee GM, Karp FL: The treatment of post-acne scars with phenol. Br J Dermatol 64:456, 1952 3. Gross BG, Mescheck F: Phenol chemosurgery for removal of deep facial wrinkles. Int J Dermatol 19:159, 1980 4. Eller JJ, Wolff S: Skin peeling and scarification. JAMA 116:934, 1941 5. Urkov JG: Surface defects of skin: Treatment by controlled exfoliation. IL Med J 89:75, 1946 6. Ayres S: Dermal changes following application of chemical counterants to aging skin. Arch Dermatol 82:578, 1960 7. Ayres S: Superficial chemosurgery in treating aging skin. Arch Dermatol 85:125, 1962 8. Morash S: The uses of diluted trichloracetic acid in dermatology. Urol Cutan Rev 49:119, 1949 9. Brown AM, Kaplan LM, Brown ME: Phenol induced histological
CHERNOFF AND SCHOENROCK
22. 23. 24. 25. 26. 27.
28. 29. 30.
skin changes: Hazards, techniques and uses. Br J Plast Surg 13:158, 1960 Litton C: Chemical face lifting. Plast Reconstr Surg 29:371, 1962 Baker TJ: Chemical face peeling and rhytidectomy: A combined approach for facial rejuvenation. Plast Reconstr Surg 29:199, 1962 Stegman SJ: Chemabrasion. J Dermatol Surg Oncol 3:217, 1977 Stegman SJ: A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sun damaged skin. Aesthetic Plast Surg 6:123, 1982 Kromayer E: Rotationsinstrumente: Ein neues technisches verfahren in der dermatologischen flemcherurgie. Dermatol Z 12:26, 1905 Iverson PC: Further developments in the treatment of skin lesions by surgical abrasion. Plast Reconstruct Surg, 12:27, 1953 Kurtin A: Corrective surgical planning of the skin. Arch Dermatol Suppl 68:389, 1953 Robbins N: Abner Kurter, father of ambulatory dermabrasion. J Dermabrasion 14:425, 1988 Lowenthal L: Punch biopsy with autograft. Arch Dermatol 67:629, 1953 (suppl) Yarborough J: Dermabrasive surgery. Clin Dermatol 5:75, 1987 Pinski JB: Dressings for dermabrasion: New aspects. J Dermatol Surg Oncol 13:673, 1987 Goldman L: Laser treatments of melanoma, in Goldman L (ed): Laser Cancer Research. New York, NY, Springer-Verlag, 1966 Kamat BR, Carney JM, Goldman L, et al: Cutaneous tissue repair following CO2 laser irradiation. J Invest Dermatol 87:2, 1986 Hishimoto K, Rockwell JR, Goldman L, et al: Laser wound healing compared with other surgical modalities. Burns 1:13-22, 1973 Kirschner RA: Cutaneous plastic surgery with the CO2 laser. Surg Clin North Am 64:871, 1984 Goldman L: CO2 laser surgery for cancer of man. Laser J 3:21, 1971 Stellar S, Ger R: CO 2 laser for excision of burn eschars. Lancet 1:945, 1971 Stellar S, Meijer R: CO 2 Laser debridement of decubitus ulcers: Followed by immediate rotation flap or skin graft closure. Ann Surg 79:230, 1974 Friedman M, Gal D: Keloid scars as a result of CO2 laser for molluscum contagiosum. Obstet Gynecol 70:394, 1987 Shapskay SM, Rebeiz EE: Benign lesions of the larynx: Should the laser be used? Laryngoscope 100:953, 1990 Reid R: Physical and surgical principles governing CO 2 laser surgery on the skin. Dermatol Clin 9:297, 1969
283