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I. Hamlar, M.A., M.D.

Assistant Professor, Case Western Reserve University School of Medicine

Results: A marked reduction in fat volume and more oil vacuoles and giant cells in histology were identified with the 1,444 nm wavelength compared to the 1,064 nm wavelength. Human fat in the in vitro experiments also revealed more oil production following the use of the 1,444 nm laser. Biopsy samples were taken and histologically analyzed immediately after biopsy and at 1, 2, 4, and 12 weeks postoperatively. With a fluence setting above 3000 J/100 cmІ, inflammation was severe and remained by the 3-month follow-up, resulting in severe scarring of the fat tissue. Below this energy level, mild lobular inflammation in the early phase biopsy had resolved with no scarring by the 3-month follow-up. This study suggested that controlling the energy level is important for clinical applications of laser lipolysis with no significant complications. In this study, wavelength-dependence measurements of laser lipolysis effect were performed using different lasers at 1,064, 1,320, and 1,444 nm wavelengths that are currently used clinically. Materials and Methods: Fresh porcine skin with fatty tissue was used for the experiments with radiant exposure of 5-8Wwith the same parameters (beam diameter 600 мm, peak power 200 mJ, and pulse rate 40 Hz) for 1,064, 1,320 and 1,444 nm laser wavelengths. After laser irradiation, ablation crater depth and width and tissue mass loss were measured using spectral optical coherence tomography and a micro-analytical balance, respectively. In addition, thermal temporal monitoring was performed with a thermal imaging camera placed over ex vivo porcine fat tissue; temperature changes were recorded for each wavelength. Results: this study demonstrated greatest ablation crater depth and width and mass removal in fatty tissue at the 1,444 nm wavelength followed by, in order, 1,320 and 1,064 nm. In the evaluation of heat distribution at different wavelengths, reduced heat diffusion was observed at 1,444 nm. Conclusions: the ablation efficiency was found to be dependent upon wavelength, and the 1,444 nm wavelength was found to provide both the highest efficiency for fatty tissue ablation and the greatest thermal confinement. The same approaches might also result in an unbalanced appearance unless the changes evoked by intrinsic and extrinsic aging are not taken into consideration. Effects of Time: Time does not stand still, and improvements delivered by the surgical lifting techniques alone generally diminish over time as tissues undergo natural postoperative changes which are typically greater in older patients, those with severely photoaged skin or who tend to be heavier built, in smokers or those who have undergone significant weight loss. Rationale for Adjunctive Surgery: the optimum approach would therefore appear to be ensure first of all absolute precision in performing the selected surgical techniques, and then to employ adjunctive nonsurgical or minimally invasive approaches which might offer a more natural appearance overall and which may be longer lasting. The same system can then be employed to achieve deep dermal heating for eventual skin tightening through collagen remodeling. The optical fiber-delivered 1444 nm energy also provides an ideal undermining technique to enhance the usual lifting approaches. Conclusions: the plastic surgeon must therefore be familiar with and take these new minimally-invasive adjunctive procedures into careful consideration in order to maximize and prolong the aesthetic effect of an excellentlyperformed facelift. Along with clinical assessment, study parameters evaluated among "original" and "modified" (where protocol updates included deep dermal soft tissue coagulation as an optional step) protocol groups included laser power, pulse energy, and total energy delivery as well as lipoaspirate volume at each treatment site. Results: Mean power and pulse energy were similar (within 5%) and total -5 energy use was greater (70% higher for mid- and lower face) in the original protocol group. Lipoaspirate volume was similar for both groups for the midface (within 10%) but elevated w in the modified protocol group for the lower face (40% higher). Treatment complications were observed in 47 of 363 treatment sites (13%) in the original and in 12 of 915 treatment sites (1%) in the modified protocol group with the majority (63%) of the complications comprising over- versus undercorrections of desired tissue contour. Clinical efficacy varied with improvements of mid- and/or lower facial contour ranging from marginal to subtle to very apparent. In particular, accentuated nasolabial folds and loss of elasticity are early signs of skin aging. Two blinded physicians evaluated clinical improvement by rating comparative photographs on a 5-point scale. Skin biopsies were performed on five volunteers before treatment and 3 months after treatment. Epidermal proliferation was stimulated as demonstrated by increases in epidermal thickness and Ki-67 expression (p <.

Hexokinase is widely distributed in tissues, whereas glucokinase is found only in hepatocytes and pancreatic ~- islet cells. These coincide with the differences in Km values for the glucose transporters in these tissues listed in Table 1-12-1. Note Arsenate inhibits the conversion of glyceraldehyde 3-phosphate to 1,3bisphosphoglycerate by mimicking phosphate in the reaction. Glucokinase Hepatocytes and pancreatic ~-islet cells High Km (10 mM) Induced by insulin in hepatocytes! The consequent intracellular acidosis can cause proteins to denature and precipitate, leading to coagulation necrosis. Near-complete deficiency of glucokinase activity is associated with permanent neonatal type 1 diabetes. Glyceraldehyde 3-phosphate dehydrogenase: catalyzes an oxidation and addition of inorganic phosphate (P) to its substrate. Glycolysis Is Irreversible Three enzymes in the pathway catalyze reactions that are irreversible. The rightward shift in the curve is sufficient to allow unloading of oxygen in tissues, but still allows 100% saturation in the lungs. Glucose 1-P Glucose 6-P Glycolysis Gal 1-P uridyltransferase deficiency · Cataracts early in life · Vomiting, diarrhea following lactose ingestion · Lethargy · Liver damage, hyperbilirubinemia · Mental retardation In the well-fed state, galactose can enter glycolysis or contribute to glycogen storage Administration of galactose during hypoglycemia induces an increase in blood glucose Glucose Figure 1-12-5. Along with other monosaccharides, galactose reaches the liver through the portal blood. Once transported into tissues, galactose is phosphorylated (galactokinase), trapping it in the cell. Galactose l-phosphate is converted to glucose l-phosphate by galactose I-P uridyltransferase and an epimerase. The pathway is shown in Figure 1-12-5; important enzymes to remember are: Galactokinase · Galactose l-phosphate uridyltransferase Clinical Correlate Primary lactose intolerance is caused by a hereditary deficiency of lactase, most commonly found in persons of Asian and African descent. Secondary lactose intolerance can be precipitated at any age by gastrointestinal disturbances such as celiac sprue, colitis, or viral-induced damage to intestinal mucosa. Common symptoms of lactose intolerance include vomiting, bloating, explosive and watery diarrhea, cramps, and dehydration. The acids are osmotically active and result in the movement of water into the intestinal lumen. Treatment is by dietary restriction of milk and milk products (except unpasteurized yogurt, which contains active Ladobacillus) or by lactase pills. Cataracts, a characteristic finding in patients with galactosemia, result from conversion of the excess galactose in peripheral blood to galactitol in the lens of the eye, which has aldose reductase. The same mechanism accounts for the cataracts in diabetics because aldose reductase also converts glucose to sorbitol, which causes osmotic damage. Deficiency of galactose I-phosphate uridyltransferase produces a more severe disease because, in addition to galactosemia, galactose 1-P accumulates in the liver, brain, and other tissues. Galactosemia Galactosemia is an autosomal recessive trait that results from a defective gene encoding either the galactokinase gene or the galactose 1-P uridyltransferase gene. There are over 100 heritable mutations that can cause galactosemia, and the incidence is approximately 1 in 60,000 births. Galactose will be present in elevated amounts in the blood and urine and can result in decreased glucose synthesis and hypoglycemia. The parents of a z-week-old infant who was being breast-fed returned to the hospital because the infant frequently vomited, had a persistent fever, and looked yellow since birth. The physician quickly observed that the infant had early hepatomegaly and cataracts. Blood and urine tests were performed, and it was determined that the infant had elevated sugar (galactose and, to a smaller extent, galactitol) in the blood and urine. The doctor told the parents to bottle-feed the infant with lactose-free formula supplemented with sucrose. Galactosemia symptoms often begin around day 3 in a newborn and include the hallmark cataracts. Jaundice and hyperbilirubinemia do not resolve if the infant is treated with phototherapy. In the galactosemic infant, the liver, which is the site of bilirubin conjugation, develops cirrhosis. Vomiting and diarrhea occur after milk ingestion because although lactose in milk is hydrolyzed to glucose and galactose by lactase in the intestine, the galactose is not properly metabolized.

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Such livers of the normal size and form exhibit numerous blue-black spots which become violet-red after lying for a long time and which occupy a deeper position than the normal liver surface. The spots are of the size of a 25-cent piece, soft, and show a net- In cattle like structure on cross section. The meshes are furnished with an endothelium the lacunae are therefore to be considered as enlarged capillaries and the whole anomaly a formation due to arrested development in consequence of the occasional failure of the liver cell cylinders to grow into the supporting substance. Saake the younger, in connection with the publication of his angiomata and came to the conclusion that the disease in question is characterized by " multiple bloody, infiltrated, blue-red areas varying in size from that of a millet seed to that of a cherry or even a walnut, and permeating the whole liver substance without changing the unaffected parts of the liver tissue. In many cases alterations were observed in the blood vessels in the form of thrombi (eight out of eleven cases), liver cell emboli (six cases), rupture of the blood vessel (one case), infiltrations of the vascular father, investigated ten cases of hepatic walls with eosinophilous cells (five cases); also disintegration of the nuclei in the connective tissue cells of the walls into granular masses (two cases), transparent spherules in the blood masses and almost always proliferation phenomena in the connective tissue elements in the surrounding tissue. In four of the cases it was demonstrated that they had calved and the other was killed in consequence of parturient paresis. Saake, accordingly, does not agree with the interpretation of Kitt that we are dealing with congenital angioma, and he is strengthened in his dissenting opinion by the fact that, according to the experience of veterinarians engaged in meat inspection, the disease is not observed in virgin heifers. Finally, Stockmann is disposed to consider the hepatic alterations in question as the sequela of distomatous cirrhosis of the liver and as a simple enlargement of the hepatic capillaries. This view, however, is opposed to the fact that angioma of the liver is also observed without coexistent cirrhosis. Livers affected with the above described alterations must be considered unfit for food, whether the affection is of the^ Special restrictions on the sale-nature of angioma or hemorrhage. Ruptures of the liver arise from the effect of violent mechanical shocks in the anterior abdominal region. A necessary condition, however, is an unusual discerptibility which usually is brought about by a strong fatty infiltration, as, for example, in fattened lambs. The meat of animals dead of rupture of the liver is - is be considered the equal of that of animals slaughtered in the ordinary way, if evisceration occurs immediately after death. Atrophy of the liver in old animals (horses and cows) has been discussed in the description of the normal structure Furthermore, the so-called nutmeg liver occurs in of these organs. This alteration is due to obstruction of the blood, in consequence of cardiac or pulmonary disturbances. The central veins of the acini of the liver become distended by the persistent obstruction, and bring about atrophy of the neighboring liver cells. The interior of the acini appears dark in color and the cortical zone is red-brown or yellow-brown. Simultaneously, a slight shrinking or enlargement of the liver occurs (atrophic and hypertrophic nut- - meg liver). This pigmentation is due to a pronounced distention of the smaller bile ducts with thickened In fresh preparations bile plugs of a Y form are conspicuous. With regard to the distinction between fatty metamorphosis and fatty infiltration, compare page 256. Rarely, amyloid degeneration of the liver is met with in food the domestic hen has already been mentioned as the only animals. Livers affected with amyloid degeneration become enlarged, harder than normal, and of a dull gray color (spotted liver). Rabe, is In the horse, the firmness of the amyloid liver, according to about the same as that of wax while cooling, and later of the crumbling, soft consistency of half dried mortar. The livers of fowls affected with amyloid degeneration are friable, light yellowish red and to the touch are granular sandy (Kitt). Traumatic hemorrhages terminate, as a rule, after resorption of the blood, in atrophic cir- rhosis of the liver or in abscess of the liver, are carried into the liver tissue when pyogenic bacteria by the fluke worm. The flukes which cause traumatic hemorrhages are usually found only after considerable search, for the reason that they are constantly moving through the liver tissue by means of the peculiar arrangement of spines on their integument. Necrotic processes, however, may occur ") in the liver as idiopathic local affections. Occasionally the disease is associated with inflammation of the navel (the author). The liver tissue lying between the necrotic foci is usually discolored as in Later the necrotic areas become delimited from the neighicterus. The necrosis bacillus has a decided tendency to It belongs to the anaerobic bacteria and loses its. Nevertheless, the sale of this meat must take place under declaration if the animal was slaughtered during the febrile stage of the disease, or if the icterus has developed in consequence of the necrosis. This represents a chronic productive inflammation of the interacinous tissue which may lead to a considerable increase in volume (hypertrophic cirrhosis of the liver), or to a striking decrease in volume (atrophic cirrhosis of the liver).

Journal of Cosmetic and Laser Therapy Comparison of the effectiveness of nonablative fractional laser versus ablative fractional laser in thyroidectomy scar prevention: A pilot study. Journal of Cosmetic and Laser Therapy Facial scars after a road accident: Combined treaent with fractional photothermolysis and alexandrite laser. Medical Lasers Comparison of non-ablative and ablative fractional laser treaents in a postoperative scar study. Journal of the European Academy of Dermatology and Venereology Platelet-rich plasma combined with fractional laser therapy for skin rejuvenation. International Journal of Dermatology the effect of a 1550 nm fractional erbium-glass laser in female pattern hair loss. Dermatologic Surgery Clinical effects of non-ablative and ablative fractional lasers on various hair disorders: A case series of 17 patients. Dermatologic Surgery Non-ablative 1550nm erbium-glass and ablative 10,600nm carbon dioxide fractional lasers for various types of scars in Asian people: Evaluation of 100 patients. Journal of Investigative Dermatology Low-fluence Q-switched neodymium-doped yttrium aluminum garnet laser for melasma with pre- or post-treaent triple combination cream. Journal of Cosmetic and Laser Therapy Histopathological study of the treaent of melasma lesions using a low-fluence Q-switched 1064-nm neodymium:yttrium­aluminium­garnet laser. International Journal of Dermatology Combination of 1064-nm Q-switched neodymium:yttrium­aluminum­garnet laserwith low fluence and 578-/511-nm copper bromide laser for nipple­areolar hyperpigmentation. Medical Lasers A randomized, split-face clinical trial of low-fluence Q-switched neodymium-doped yttrium aluminum garnet (1,064 nm) laser versus low-fluence Q-switched alexandrite laser (755nm) for the treaent of facial melasma. International Journal of Dermatology Erythema ab igne successfully treated using 1,064-nm Q-switched neodymium-doped yttrium aluminum garnet laser with low fluence. Using the same total energy and power settings (5,000 J, 8 W), both the 1,064 nm and 1,444 nm lasers were used to irradiate the two cephalic areas. The two caudal areas were irradiated with both lasers, using the maximum power settings (12 W with the 1,064 nm laser, 8 W with the 1,444 nm laser). Another minipig was administered a preoperative injection of tumescent solution and treated with the same condition. Measurements of fat volume with computed tomography and histological exams were conducted. Equal amounts of human fat, harvested by liposuction, were put into test tubes and irradiated with 1,064 nm and 1,444 nm lasers. Quantitative image analyses of pre- and post-treatment biopsies revealed that collagen fibers increased from baseline (p >. The present preliminary study was designed to assess the efficacy of the 1444 nm wavelength in facial and body contouring. Subjects and Methods: Twenty-four informed and consenting female patients (ages ranging from 23 yr to 59 yr, mean age 32. Following tumescent anesthesia, the tip of the optical fiber was placed in the subcutaneous fat via a cannula inserted through a small puncture wound, and lasing was commenced while the tissue over the end of the optical fiber was continuously palpated to check for excessive heat formation. Patients were followed for at least 2 months with clinical photography at baseline, immediately post-treatment and at subsequent assessment points. Patient subjective satisfaction was high, and an objective clinician assessment from the clinical photography showed good efficacy. Minor side effects were transitory, all resolved spontaneously and good results were maintained during a 2-3 month follow-up. The high absorption rate of 1444 nm in both fat and water, coupled with the 100 s pulse, was believed to contribute highly to the success of the study and the satisfaction of the patients. In collagen organization, fibroblast proliferation, and intensity of elastic fibers and mucopolysaccharides, the treatment groups were higher than those of the control group, overall. We conducted this study to evaluate whether this laser is effective in tightening the skin and causing histological alterations to dermal collagen fibers, fibroblasts, mucopolysaccharides, and elastin. Postoperatively, we evaluated the skin-tightening effect through histopathologic examination. Results: On histopathology examination, the thickness of the dermis had gradually increased following the 3-month treatment with laser irradiation. In the treatment groups on the abdomen, the collagen fibers were arranged in a more parallel pattern and became denser than those in the control group.