Benign Pigmented Lesions in Cosmetic Surgery

The cosmetic impact of pigmented lesions in the maxillofacial region can be significant. A lesion may be considered unaesthetic due to any number of specific considerations including size, color, location, or number. Laser treatments provide an excellent option to treat localized dyschromias, cafe´ au lait macules, lentigines, nevus of Ota, and other pig¬mented lesions. Differentiating between epidermal and dermal lesions is important in achieving an optimal treatment outcome. Epidermal hyperpigmen¬tation is due to an increased rate of melanogenisis or an increased number of melanocytes. Dermal hyper-pigmentation is due to excess melanin deposits in the dermis. An excess of melanin contained within melanosomes will cause hyperpigmentation.
In fact, even carbon-dioxide lasers, with their much longer wavelength, may be used to treat superficial pigmented lesions of the skin by simple coagulation of the epidermis. Epidermal lesions may be treated in numerous ways.Lesions confined to the epidermis can be removed by any method that removes the epithelium, such as a carbon-dioxide laser.
Coagulation of the endothelial layer alone is not sufficient for resolution. As the depth of mural damage progresses from the endothelial layer through the intima and the media to the adventitia, greater success is seen. The absorption spectrum of hemoglobin and oxyhemoglobin has several peaks. Lasers that emit energy absorbed by hemoglobin and oxyhemoglobin (approximately 570 590 nm) will be best suited for treatment of vascular lesions. This group of lasers includes argon, krypton, potassium titanyl phosphate, pulsed dye, and IPL. Use of the long-pulse Nd:YAG laser (1064 nm) also is gaining popularity. This laser takes advantage of a smaller peak of absorption in hemoglobin near this wave-length. This peak also coincides with diminished absorption by the melanin chromophore and, there-fore, better penetration to the hemaglobin target.
All vessels from lower leg varicosities to pe¬ripheral angiomascan be treated with laser technology. The maxillofacial surgeon who primarily treats lesions of the head and neck, however, will encounter mainly facial telangectasias, hemangiomas, port wine stains, or rosacea.
Telangiectasias (‘‘spider veins’’) comprise 90% of the vascular lesions treated in the author’s practice. Telangectasias most commonly are seen in patients with Fitzpatrick I or II skin types. Telangiectasias can be grouped into four categories: arborized, papular, simple, and spider. These vessels are found most often to be less than 1 mm in diameter. They represent dilated arterioles, venules, or capillaries. Arteriolar vessels are flat, bright-red lesions, whereas venules are blue and may protrude above the skin’s surface. Capillary lesions are smallest in diameter and red. They may become larger and change to blue or purple as venous backflow increases hydrostatic pressure. The nose, cheeks (malar eminence), and chin are the most common sites for patients presenting for treatment. Interestingly, all of these sites are near bony foramina of the skull transmitting named vessels.
Using the 3-mm spot size of laser, cutaneous vessels can be removed quickly and comfortably. The Photoderm IPL will also remove facial telangiesctasias; however, because the smallest IPL quartz filter measures 12 or 8 mm, the surrounding normal tissue must be covered to avoid damage. Cutting a slit or hole in a self adhesive label or sheet of paper or cardboard is effective in isolating specific sites and minimizing adjacent erythema, purpura, or dyspigmentation. To prevent these undesirable side effects of vascular laser therapy, equipment manufacturers have developed methods for cooling the epidermis. Gel is commonly used, especially with the IPL devices. Lasers with cooling devices come in two varieties:
(1) contact cooling, whereby the laser tip maintains contact with the skin;
(2) spray cooling, in which a refrigerant medium is delivered to the target area immediately before the laser pulse.

In conjunction with routine skin care, a number of noninvasive cosmetic laser procedures have become available to further improve the skin’s health and appearance as explained in medicina estetica