Lasers in Maxillofacial Surgery and Dentistry 0865775664 PDF

Contents
Contributors
ix
Preface
xi
Foreword
1.
xiii
Physical C o n s i d e r a t i o n s of S u r g i c a l Lasers
Terry A. Fuller
2.
P r a c t i c a l Laser Safety i n O r a l a n d M a x i l l o f a c i a l Surgery . . . .
11
Lawrence M. Elson
3.
Specific G u i d e t o t h e Use o f Lasers
19
Lewis dayman, Richard Reid
4.
Preneoplasia of the O r a l Cavity

Lewis
5.
37
dayman
Papillomas and H u m a n Papillomavirus
55
Richard Reid. Myron Slrasser
6.
Soft Tissue Excision T e c h n i q u e s
63
Lewis dayman. Paul Kuo
7.
Transoral R e s e c t i o n o f O r a l C a n c e r
Lewis
8.
85
dayman
O u t p a t i e n t T r e a t m e n t o f S n o r i n g a n d Sleep A p n e a S y n d r o m e
w i t h C 0 Laser: Laser-Assisted U v u l o p a l a t o p l a s t y
2
111
Yves-Victor Kamami. James W. Woolen
9.
T h e C a r b o n D i o x i d e Laser i n Laryngeal Surgery
121
Robert J. Meleca
10.
Uses o f Lasers i n D e n t i s t r y
Harvey Wigdor
127
viii
Contents
11.
P h o t o t h e r a p y w i t h Lasers a n d D y e s
137
Dan J. Castro. Romaine E. Saxlon, Jacques Soudanl
12.
Laser P h o t o t h e r m a l T h e r a p y f o r Cancer T r e a t m e n t
143
Dan J. Castro. Romaine E. Saxlon. Jacques Soudant
13.
Laser-Assisted T e m p o r o m a n d i b u l a r Joint Surgery
151
Steven J. Butler
14.
E n d o s c o p i c Sinus S u r g e r y : A S i g n i f i c a n t A d j u n c t to
M a x i l l o f a c i a l Surgery
157
Jeffrey J. Moses. Claus R. l^ange
15.
Laser B i o s t i m u l a t i o n : P h o t o b i o a c t i v a t i o n , a M o d u l a t i o n o f
B i o l o g i c Processes by L o w - I n t e n s i t y Laser R a d i a t i o n
165
Joseph S. Rosenshein
16.
Laser Tissue Fusion
175
PaulKuo
17.
Laser A p p l i c a t i o n i n M i c r o g r a v i t y , A e r o s p a c e , a n d
Military Operations
179
I'aul Kuo. Michael D. Colvard
Appendix
181
Glossary
183
Index
185
Physical Considerations of Surgical Lasers
Terry A. Fuller
HISTORY
A laser, an acronym lor light amplification by stimulated
emission of radiation, is a device for generating a high-intensity, ostensibly parallel beam of monochromatic (single
wavelength) electromagnetic radiation. The possibility of
stimulated emission was predicted by Einstein in I9I7;
based on the work of Gordon in 1955 and Schawlow and
Townes in 1958, Maiman created the first operational laser
in 1960, a ruby laser emitting a brilliant red beam of light.
This was followed within 3 years by the development of the
argon, carbon dioxide ( C 0 ) , and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers, which remain the most
widely used lasers in medicine.
In 1963 the ruby laser was employed in the treatment of
pigmented dermatologic lesions and for photocoagulation
of the retina. Early applications of lasers in oral and maxillofacial surgery began to appear in the mid- to late 1970s.
Potential advantages of surgical lasers were clear from the
beginning, but the cost, unreliability, and operational complexity of the early machines greatly limited the actual use
of lasers, except in the fields of ophthalmology and dermatology, until the past 15 to 18 years. In recent years improved understanding of light-tissue interactions and, of
greatest importance to the surgeon, new technologies for
delivering laser light to (he tissue, has transformed lasers
into versatile and valuable surgical instruments. This chapter presents the fundamentals of laser physics and introduces the reader to the interactions between light and tissue.
Full appreciation of the uses, limitations, benefits, and
risks of surgical lasers requires a basic understanding of
laser physics and the biologic action of light.
2
the radiation in the visible region of the spectrum (Fig. 1-1)

defines the color of the light.
Atoms (ions or molecules) at their lowest energy or
ground state possess an intrinsic amount of energy. When
excited through the process of absorption by the input of
thermal, electromagnetic, or other forms of energy, they are
raised to one of several distinct higher energy levels. The
absorbed energy is subsequently and spontaneously released (spontaneous emission) in the form of a quantum of
energy corresponding to the difference between the ground
and excited states (E, E = E ) . All particles making the
transition between the same two energy levels will emit
light of identical energy and wavelength (Fig. 1-2).
Ordinary sunlight or lamplight consists of many wavelengths; even light, colored from passing through a filter,
represents a broad spectrum of many wavelengths. Such
light emanates in all directions from its source. The intensity diminishes as the inverse square of the distance from
the source. As discussed below, a laser uses the principle of
stimulated emission to produce light of a markedly different
quality.
The spontaneous emission of photons from an excited
atom may occur at any time and in any direction. If, however, a photon of E strikes an atom already in an upper energy stale E , it stimulates the emission of a second photon
of light. This second photon has precisely the same energy
or wavelength and is spatially and temporally synchronous
with and traveling in exactly the same direction as the initial photon. If these two photons strike additional atoms in
the excited state E-j, they will yield an amplifying cascade
of photonslaser lightthat is monochromatic (a single
wavelength), coherent (synchronous waves), and collimated
(parallel rays).
2
LIGHT
THE LASER
Electromagnetic radiation is energy transmitted through
space. It can be viewed either as propagated waves of characteristic energies, or as discrete (and the smallest) parcels
of energy called photons. Electromagnetic radiation is
quantified in terms of two reciprocal forms of measurement: frequency (v), expressed in Hertz (Hz) or cycles per
second, and wavelength (\), expressed in metric units of
length. Which units are employed in any particular application is largely a matter of convention. The wavelength of
Lasers consist of a small number of basic components as

shown in Figure 1-3. An active lasing medium, which can
be a solid, liquid, or gas, is enclosed within a laser cavity
bounded by two perfectly parallel reflectors (mirrors).
High-energy radiation is pumped into the active medium by
means of a pump source. The pump source is energy generally provided by an intense optical or electrical discharge.
The energy from the pump source is absorbed by the active
1
Lasers in M a x i l l o f a c i a l Surgery a n d Dentistry
Figure 1-1.
Electromagnetic spectrum.
Figure 1-2.
medium until the majority of atoms, ions, or molecules are
raised to their upper energy state. This is a condition known
as a population inversion and is a necessary condition to
generate laser light. The two parallel reflectors are situated
at the ends of the laser cavity and act to constrain the light
along and within the axis of the cavity. Thus, the light is repeatedly bounced between the reflectors. This will stimulate the emission of even more photons (amplification) in
that axial direction. Light traveling in other directions escapes the cavity and is lost as heal. One of the mirrors is
only partially reflective, enabling some of the light to escape the cavity as a beam of laser light.
Different lasing media, because of their particular
atomic, molecular, or ionic structure and energy levels, emit
Energy slate diagram.

light of characteristic wavelengths. The properties of the
most common surgical lasers are listed in Table 1-1.
CO? Laser
Carbon dioxide lasers employ carbon dioxide gas (in addition to other gases required for sustained stimulated emission of radiation) as a lasing or active medium. The gases
are either sealed in a tube or are circulated from a tank.
When excited by direct current (DC) or radio-frequency
(RF) voltage, the carbon dioxide absorbs a portion of this
energy and raises the CO> molecule to an upper energy
state. The excited C 0 molecule spontaneously decays and
emits mid-infrared photons at a wavelength of 10.6(H) nm
2
Figure 1-3.
Table 1-1.
LASER TYPE
C0
Holmium
Nd:YAG
Diode
KTP/KDP
Argon
Excimer ArF
-XcCI
Erbium: YAG(Er: YAG)
2
Basic laser components.
Characteristics of Surgical Lasers
WAVELENGTH
SPECTRAL
REGION
10.600 nm
2.100 nm
1,064 nm
800-890 nm
532 nm
488/514 nm.
190 nm
308 nm
Mid-Infrared
Near Infrared
Near Infrared
Near Infrared
Visible
Visible
Ultraviolet
Ultraviolet
MODE
TYPICAL MAX
POWER
I00W CW
l5Wavg.
IO0W CW
> 50W
25Wavg.
20W
SSOmJ
250mJ
CW & Gated & Superpulsed

Pulsed
CW & Pulsed
CW
Pulsed
CW
Pulsed
Pulsed
Reproduced with permission of T.A.F.. modified from Fuller TA. Thermal Surgical Lasers. Philadelphia: Surgical Laser Technologies. Inc.. 1992.
(10.6 pm). Power (measured in units of watts, W) is the

lime function of energy (measured in joules, J) and can be
delivered either continuously (continuous wave, CW) or in
a train of pulses. The carbon dioxide laser can be pulsed in
a manner thai results in high energy, rapidly repeating
pulses typically referred to as superpulses. In contrast to
CW surgical lasers, which generate power up to 100 W, the
superpulsed C 0 laser generates power up to 10,000 W in a
repeating train of pulses. There are substantial differences
in clinical effect between CW, conventional pulsing, and
superpulsed modes of operation (see Chapter 3).
2
Infrared light is in a region of the electromagnetic spectrum that is not visible to the human eye. Therefore, a second low-power visible laser [typically a red beam from a
helium-neon (HeNe) laser or visible diode laser) beam is
precisely aligned and coaxial with the C 0 laser beam for
aiming purposes. The delivery system used to carry Ihe laser
light to the lissue is of critical importance to the surgeon.
The C 0 laser generally uses an articulated arm as its principal delivery system. An articulated arm is a series of hollow tubes connected together through a series of six to eight
articulating mirrors. This is in contrast to very thin, continu2
Lasers in M a x i l l o f a c i a l Surgery and Dentistry
ously flexible, glass (fused silica) fiber optics generally

used for near infrared and visible lasers. Glass is opaque to
10,600 nm light and thus is not suitable for C O laser transmission. The C O laser is primarily used for cutting and vaporizing tissue in open procedures or in procedures where
rigid endoscopy is acceptable.
used in ophthalmology to disrupt the posterior capsule in

secondary cataracts or in shock-wave lithotripsy.
Argon
and
Frequency-Doubled
Nd.YAG
Lasers
Argon and frequency-doubled Nd:YAG laser (also referred

to as a KTP laser), although technologically very different
from each other, are devices that generate laser energy in
the green region of the electromagnetic spectrum. The
argon laser employs an electrically excited ionized argon
gas as a lasing medium. The high heat transfer requires a
water-jacketed cooling system, which permits power outputs of up to 25 W. More portable, air-cooled units arc limited to power outputs of 5 to 10 W. This laser emits bluegreen light at 488 and 514 nm. The KTP laser uses a
Nd:YAG laser in combination with a potassium titanyl sulfate (KTP) crystal. The Nd:YAG portion of this laser system generates a wavelength of 1064-nm energy whose frequency is doubled (wavelength is halved) on passing
through the KTP crystal. The result is a beam of green light
at 530 nm. The emission from both the argon and KTP
lasers can be transmitted through flexible glass fiber optics
thai can carry the light to the surgical site. Since the light is
visible, no secondary aiming beam is required. Safety
glasses are required to protect the patient and operating
room personnel from the therapeutic beam of all surgical
lasers. However, glasses used for the green lasers necessarily block green light and thus tend to obscure the overall visualization of the surgical field.
Nd.YAG
Laser
The neodymium.yttrium-aluminum-garnet (Nd:YAG) laser

is a solid-state device that generates light in the near infrared region of the spectrum at 1064 nm. The active
medium of this laser is the neodymium atoms doped into a
matrix of yttrium, aluminum, and garnet. The neodymium
atoms are optically excited by way of a bright arc lamp.
This relatively efficient laser generates a wavelength of
1064 nm and is outside the visible region of the spectrum.
Therefore, the Nd:YAG laser requires an aiming beam similar to that used by C 0 lasers. Safety glasses for this laser
are transparent to visible light and do not obscure the surgeon's surgical view. The surgical Nd:YAG lasers commonly deliver continuous (CW) power up to KM) W and can
be passed easily through inexpensive flexible fiber optics.
In addition to the CW mode of operation, the Nd:YAG laser
can be configured to operate in a special pulsed mode referred to as Q-switched. The Q-switched laser emits pulses
of pico- to nanoseconds in duration. This mode is often
2
Holmium:
YAG
The holmium:YAG laser is technologically associated with

the Nd:YAG laser. This solid-state laser uses holmium as
its active medium doped into a matrix of yttrium, aluminum, and garnet. Due to its inherently inefficient operation and certain thermal design considerations, this laser is
pulsed. It emits rapid pulses of energy at 2100 nm in the
mid-infrared part of the spectrum. Like the NdiYAG laser,
this laser requires an aiming beam. The holmium:YAG
beam can be delivered through fiber optics. However, such
fibers must be made of low OH (hydroxyl radical) glass
due to the high absorption of this wavelength to water.
Diode
Laser
In contrast to the gas and solid-state lasers discussed thus

far. diode lasers are in a category of devices that emit light
from semiconductor materials. They are operated in a manner similar to a transistor in which an electric potential is
applied to dissimilar semiconductor materials. In contrast to
gas, solid state, and liquid lasers, semiconductor lasers require no high voltages or currents, no arc lamps or optical
pump sources, and have no required moving parts. They are
very efficient (typically >3035%), but arc capable of generating only relatively low power levels. Individual "highpower" laser diodes typically generate only 1 to 1^ W per
diode. To gain useful power from the laser, multiple devices must be used in concert. Linear (one-dimensional) arrays or two-dimensional arrays are being developed to gain
sufficient power for surgery. Additionally, ganging individual diodes in various optical configurations are being explored: each approach carries its own benefits and drawbacks. Both commercial and prototype surgical diode laser
systems are able to deliver 20 to 50 W. There are currently
severe fiber optic size and maximum power limitations as
well as diode and system warranty and lifetime issues. Currently, the most popular diode lasers emit light in the 800to 890-nm range. Lasers in the shorter wavelength range
provide biologic effects similar to those of the Nd:YAG
lasers. Longer wavelengths have higher tissue absorption
characteristics.
The technological specifications of a given laser type and
model indicate how much power (or in the case of a pulsed
laser, energy) can be practically delivered to tissue and the
means by which the power can be conveyed to tissue. When
laser energy interacts with tissue its output power is distributed over the area of an illuminated spot. This distribution
or power density or fluence (power/area. W/cnr) is intimately related to the tissue effect. The power density can be
altered by changing either the power of the laser or spot size

of the laser beam. The effect that a particular laser emission
has on tissue, and thus the surgeon's ability to effectively
utilize that emission, depends upon power density and other
specifications as well as the characteristics of tissue. Only
by matching the characteristics of the laser beam and the
tissue can one begin to accurately predict the effect that the
laser will have in surgery.
THERMAL LASERTISSUE EFFECTS

The focus of this book is on the interactions of laser energy
and tissue that result in an elevation of the tissue temperature. These so-called thermal lasers represent the majority
of all applications of lasers in medicine. Thus, lasers that
are Q-switched or lasers that operate at low powers for
biostimulation or photodynamic therapy (PDT) interactions
are excluded herein from discussion. This section presents
an outline of the principal variables affecting the clinical
end point.
The utility of the thermal laser resides with its capability
of providing the surgeon the ability to accurately predict the
nature and extent of a thermally induced laser lesion in tissue. The goal of laser surgery is thus to create a temperature gradient (Fig. 1-4) or profile in tissue that will result in
coagulation or vaporization of tissue. Coagulation provides
hemostasis and. if desired, necrosis of tissue. Vaporization
(the conversion of solid and liquid phase tissue components
into gaseous phase components) provides the ability to cut,

incise, excise, resect or ablate tissue.
Coagulation and vaporization are two different effects
created by the same process: heating of tissue. Coagulation
generally occurs when the temperature is elevated from
60C to <100C. Obvious changes occur in the tissue at
these temperatures resulting from the thermal denaturation
of tissue protein, and include blanching and shrinkage as
well as puckering due to dehydration. When the temperature is elevated near and above the boiling point of water
(100C), vaporization of liquid and solid components occur.
A frank defect is left that includes a zone of char (carbon, as
a result of the combustion of tissue) surrounded by coagulated tissue. The extent of the area of vaporization, char,
and coagulation (as well as a heat-affected zone surrounding the coagulation, which can cause edema) is defined by
the temperature gradient. Thus, by altering the gradient, the
surgical effect can be altered. There are several variables
that determine the gradient. They include the laser parameters such as power density, duration of exposure, wavelength, and method of delivery of laser energy as well as
tissue parameters.
Light can be absorbed, transmitted, scattered, or reflected
by tissue (Fig. 1-5). Only light that has been absorbed can
yield a therapeutic result. Light that is transmitted through
or reflected from tissue yields no effect until and unless it is
absorbed. The measure of the degree to which tissue absorbs light is the absorption coefficient, a (measured in
units of c m ) . It is a measure of the amount of energy ab- 1
Figure 1-4. Temperature gradients in tissue.
OW?3SLT.INC./T.A.r
Figure 1-5.
Interactions of light and tissue.
sorbed through a distance of the absorbing material. The

penetration depth of the laser in a given tissue is proportional to the inverse of the absorption coefficient . The
more highly absorbed the light (high a), the shallower the
penetration. As can be seen in Figure I - 6 , this results in the
light energy being converted to heat energy within a shallow layer of tissue, and therefore results in intense surface
heat. A tissue with a high will create a steep temperature
gradient.
Figure 1-7 illustrates the absorption of light by tissue at
different wavelengths. The y-axis indicates greater absorption (less penetration) and thus higher resulting temperatures. It can be readily seen that the C 0 and erbium
(Er).YAG lasers would create high surface temperature and
very steep temperature gradients in the tissue. Both the C 0
and EnYAG laser beams are preferentially absorbed by
water, and because water is by far the largest component of
most tissue, this results in the rapid transformation of light
into heal within about 0.2 to 1.0 mm of the tissue surface.
The intense thermal response quickly evaporates the water
and vaporizes tissue. The temperature gradient is so steep
that it has relatively poor coagulation properties. The duration of exposure is another key variable in determining the
extent of a laser-induced lesion. Long exposure times result
in conduction of heat into surrounding lissue and thus improve hemostasis and increase coagulation necrosis. In contrast, techniques exist to diminish coagulation necrosis. The
superpulse C O laser is one such example. This laser uses
rapidly repeating, high peak power pulses with pulse energy
2
in the range of 50 to 120 mJ/pulse. The result of application

of the superpulsed laser is the reduction of coagulation
necrosis by 50% over the CW laser operating at the same
average power. By way of contrast, Ihe Nd:YAG laser will
penelrate deeply in tissue with a relatively low surface temperature and shallow temperature gradient.
Scatter of light by tissue spreads the laser beam in a diffuse pattern defined by the tissue's scatter coefficient. B.
Once the light is scattered, if it is absorbed, it will affect a
volume of tissue larger than Ihe laser's optical spot size. In
some instances scatter is an attribute desired by the surgeon.
For example, when Nd:YAG laser energy is used to thermally destroy a tumor, the deep penetration of the laser
beam coupled with the high scatter coefficient affects a
deep and wide volume of tissue. In contrast, scatter can also
be detrimental if one is attempting to localize the effect of
the laser.
The green light from the argon and KTP lasers is both
scattered and absorbed by tissue. The degree of absorption is heavily dependent on the concentration of the
chromophores hemoglobin and melanin. Thus, heavily
pigmented skin or vascular areas such as a hemangioma
will result in high absorption (low penetration). The scatter of the green lasers are greater than that of the C 0
laser.
The method of delivering the laser light to the tissue also
acts as a variable affecting the tissue response. In general
terms this delivery of energy falls into two broad classes:
free-beam lasers and lasers lor use in contact with tissue.
2
Figure 1-6.
Figure 1-7.
Power/depth and temperature/deplh.
Light absorption by composite tissue.
FREE-BEAM LASERS
Free-beam (sometimes referred to as noncontact) lasers are
devices that permit laser energy alone (without influence by
the delivery device) to interact with tissue, causing the final
clinical result. The interactions between laser light and tissue described above are specific for free-beam lasers. They
result from interactions between the native laser wavelength
and tissue alone. Typical free-beam delivery systems include articulating arms, micromanipulators used in conjunction with surgical microscopes, and conventional fiber optics. Characteristic of these devices is that the effect on
tissue is principally that of the laser emission alone. This is
typically what occurs when there is no contact between the
fiber optic end of the delivery device and the target tissue.
Consider the laser beam exiting a laser delivery system
used in a free-beam mode (Fig. 1-8, left). The beam will
converge (or diverge) as it exits the focusing lens and some
portion of the energy will be reflected from the tissue on
impact. Should the distance from the fiber to the tissue be
altered, the power density at the tissue will change, changing the clinical effect. Substantial energy is reflected (Qf)
or lost as heat and in smoke (Q)The free-beam method of delivery provides certain advantages over conventional surgery by providing a method
for "non-touch" surgery, but suffers from the loss of tactile
feedback. The techniques for learning and using the freebeam laser are substantially different from those of conven-
Figure 1-8.
tional instruments. Perhaps the most limiting feature of the

free-beam laser is that different laser sources are required
for different surgical maneuvers, e.g., Nd:YAG for coagulation and hembstasis and CO for incision and excision.
:
Modification
of Free-Beam
Laser
Contact Laser Surgery
Surgery:
Despite the benefits of free-beam laser surgery, certain limitations and drawbacks exist. Perhaps the most significant is
that to substantially change the tissue's temperature gradient (clinical effect), one must choose different laser sources,
an expensive and intraoperatively difficult task. Contact
Laser surgery has been developed to augment and overcome this and other fundamental deficiencies in free-beam
surgery. Contact Laser surgery works by altering the tissue
temperature gradient through changes in the laser delivery
system, rather than by alteration in wavelength.
A decade ago researchers developed a delivery system in
which an optical device is placed in direct contact with the
tissue during laser surgery to increase the delivered power
density and reduce changes in power density due to changes
in distance to the tissue. This is accomplished by use of interchangeable contact laser probes and scalpels (tips) made
from synthetic sapphire or fused silica. The tips have several different sizes and shapes and can be easily affixed to
the end of fiber optics. Several benefits result from the use
of these tips (Fig. 1-8. right). In addition to providing the
Noncontact vs. contact laser surgery.
Figure 1-9.
Changes in temperature gradient and tissue effect by wavelength conversion effect surface treatments.
surgeon with tactile feedback, a sense lost in free-beam

surgery, and controlling power density, the reflection of
light from the tissue is significantly reduced. The improved
efficiency in coupling of light into the tissue results in the
requirement of less power, in most cases a reduction of 40
to 50% (Fig. 1-8, right).
Altering the tip configuration of a probe and scalpel
makes it possible to change not only the spot size (and thus
power density), but the angle of divergence of the beam. A
frustroconical tip, for example, concentrates the laser light
on a small, precisely defined distal area from which light
splays out at a wide angle, creating a region of high power
density that drops rapidly with distance. Alterations in the
tip's shape can result in a low divergence angle. In addition
to placing tips onto the ends of fiber optics, the ends of fiber
optics themselves can also be shaped, although they lack
the mechanical strength and thermal resistance required for
extended and precision use.
The Contact Laser attributes thus far described, still result in a tissue effect that is solely dependent on the absorption of the laser emission by the tissue to generate the temperature gradient. It is a major attribute of Contact Laser
surgery to have the temperature gradient altered by the
Contact Laser tip. By placing a small amount of light ab-
sorbing material integrally between the contact tip and the

tissue, a portion of the energy will be absorbed by that material. The energy absorbed will be converted to heat and
will result in a very high temperature. Since the absorbing
material is in contact with the probe and the tissue, it will
elevate the temperature of the tissue by thermal combustion
in addition to the radiation heating caused by the native
wavelength. Thus, as can be seen in Figure 1-9, by use of
this absorbing material the tissue temperature gradient induced by the laser emission has been altered. Depending
upon the quantity and distribution of the absorbing material
the contact tip can mimic the effect of other laser wavelengths. This event is referred to as the Wavelength Conversion Effect. The wavelength conversion effect does not result in changing the wavelength of the laser; rather, it
changes the effect the wavelength has in the surgical
situation.
By adjusting the Wavelength Conversion Effect material
on the probe tip, one can titrate the amount of laser light exiting the tip in comparison to the amount of heat generated
by absorption at the tip. This means, in essence, that a single laser in combination with different interchangeable tips,
can mimic the tissue temperature profile and effect of various lasers.
Practical Laser Safety in Oral and

Maxillofacial Surgery
Lawrence M. El son
A laser is a device thai produces an intense, highly parallel

beam of coherent light. It is named after the composition of
the excitable medium from which the laser beam emanates
[e.g., carbon dioxide (CO,), argon (Ar), helium-neon
(HeNe). etc.). Since the late 1970s, lasers have been studied
in oral and maxillofacial surgery for the treatment of soft
tissue lesions and occasionally for the cutting of bone.
Light emitted by these surgical lasers is generally in the visible and infrared regions of the electromagnetic spectrum
and is nonionizing. This radiation must be clearly differentiated from ionizing radiation exemplified by x-rays and
gamma rays, which may produce deleterious effects on living tissue. Therefore, patients, medical personnel and particularly pregnant women working with or around lasers
may do so without the risks- associated with x-rays.
Each different type of laser produces a different wavelength (color) of light that is absorbed by specific target
chromophores within tissues. The biologic effect of this
light on tissue is dependent upon wavelength, energy level
of the beam, and absorption characteristics of the tissue receiving this energy. For example, the carbon dioxide laser
(10,600 nmmiddle infrared) light is absorbed heavily by
water. Since human tissue is mostly water, it absorbs virtually all of the laser energy without significant reflection or
backscatter from the surgical site. However, when this
same light comes into contact with shiny surgical instruments, reflection will occur. In tissue, the depth of this
laser's photovaporization or photocoagulation effect is directly dependent on the power density (watts/cm ), which
is determined by the intensity of the focused beam, and the
energy density (joules/cm ), which determines the rate at
which energy is delivered to the tissue. The thermal damage produced adjacent to the surgical site by diffusion of
heal can be reduced to a range of micrometers, depending
on the energy density used. Irreversible thermal damage
adjacent to (he zone of photovaporization is minimized by
using the highest controllable power density for the shortest amount of application time. Prior to patient use a "test
spot" is made on a moistened wooden tongue blade to assess the coaxial HeNe aiming beam, spot size contour,
power, and mode of operation [continuous wave (CW) or
pulsed|. Hazards of the carbon dioxide laser in oral and
maxillofacial surgery (OMFS) include corneal, scleral, and
cutaneous injury ranging from transient pain to severe
burns. Both the patient and the medical personnel are at
risk for these injuries.
1
The argon laser emits a blue-green light of 488 and 514

nm, which is selectively absorbed by the red chromophore.
oxyhemoglobin at 488 and 540/577 nm (double absorption
peak). It is delivered to the target tissue by an optical fiber.
This laser, depending on its spot size, power, time of application, and resulting energy density, can photovaporize or
coagulate tissue with up to several millimeters of thermal
damage adjacent to the zone of clinical laser treatment. The
optical hazards of the argon laser include retinal and
skin burns.
The neodymium:yttrium-aluminum-garnet (Nd:YAG)
laser emits an invisible 1060-nm (near-infrared) light that is
heavily absorbed by pigmented tissue. It can photovaporize
or photocoagulate almost all biologic tissue with which it
comes in contact. The zone of thermal damage of the
Nd:YAG laser may extend as much as I cm beyond the surgical target site consequent to a deep penetrating effect that
is not observable at the time of treatment. This powerful
laser is delivered to the surgical site by an optical fiber or
contact probe. Optical hazards of this laser are similar to
that of the argon laser and include retinal and skin hazards
(Fig. 2-1).
HAZARDS OF LASER SURGERY

Judgment
Errors
As is the case with surgery, judgment error may be as harmful as the use of inappropriate surgical technique. Of the
several types of judgment errors, the most severe is misdiagnosis or misinterpretion of the disease state being treated.
After having appropriately decided to use a laser, it becomes necessary to match the wavelength, power, and energy densities to the target tissue absorptive characteristics
to best eradicate the lesion. This mandates that the surgeon
understand the applied laser physics and laser-tissue interactions at the selected wavelength. The technical skill to
manipulate the laser delivery system safely to protect patient, surgeon, and operating room personnel must be acquired through instructional courses resulting in proper credentialing for each wavelength used. Ultimately, each
surgeon should be proctored by a properly credentialed
laser clinician at (he hospital in which the surgeon practices
for each type of procedure for which privileges are desired.
In some cases, residency training may substitute for a laser
11
12
Figure 2 - 1 . Nd:YAG-induced relinal burns

in a rabbit retina.
Figure 2 - 1 . Nd:YAG-induced retinal burns

in a rabbit retina.
course, but the preceplorship credentialing program is still
required. It is also very important to remember that improper use converts the laser into an expensive electro
cautery unit. Failing to limit the extent of the laser's lateral
heat conduction by the untrained clinician may produce a
conduction burn that extends well beyond the laser surgical
site. This might well prove disastrous.
Optical
Hazards
Since the clinical lasers utilized in oral, maxillofacial, and
head and neck surgery photovaporize or photocoagulate tissue, they all have the potential to damage the eye. Depending on the laser's wavelength, different tissue effects will
occur. Visible light laser radiation [argon, potassium titanyl
phosphate (KTP). HeNe. gold vapor, pulsed dye, etc.], and
the near-infrared Nd:YAG laser's energy will easily be
transmitted through the eye directly into the retina where
absorption may produce a burn (Fig. 2-2) and partial loss of
vision or even blindness. Laser light that is focused through
the lens of the eye will increase its effective power up to
l(K).(KM) times! The eye must always be protected to prevent
visual field defects or blindness. Other near-infrared lasers
[erbium (Br):YAG and holmium (Ho):YAG[ and middle infrared lasers such as the C O laser are absorbed by the
water in the cornea, scleral epithelium, or eyelid and have
the potential to burn or damage these areas.
Therefore, it is imperative that all individuals in the operating room, i.e.. surgeons, nurses, technicians, and patients,
wear adequate eye protection while the laser is being used.
This will protect their eyes from direct exposure to misaimed laser light as well as from specular reflections from
instruments or tissues at the surgical site. All facilities using
lasers must therefore have available appropriate wavelength-specific goggles (Fig. 2-3) or glasses with side
shields to be worn by all personnel whenever the laser is
:
operating. These laser protection devices should have an

optical density (OD) stamped or imprinted on them along
with the wavelength and/or name of the laser for which they
arc to be used. The material coating the lenses of these goggles or glasses absorbs and disperses the incident laser energy, preventing damage to the eye. For protecting the patient, in addition to wavelength-specific glasses or goggles,
it is also acceptable to place wet gauze or eye pads across
the closed eyelids and, depending upon the procedure (i.e.,
Nd:YAG laser procedures), an aluminum-metal type of eye
shield should be placed over the gauze or pads.
Skin
Hazards
Even though, from a laser usage standpoint, skin hazards

are regarded as a minor nuisance, they are painful and may
be damaging. The most common mishap occurs when the
laser operator's or assistant's hands pass in front of the
working laser beam causing a burn. This happens when the
laser is either misfired during the course of surgery or
when an assistant carelessly places a hand in contact with
the laser beam. The resulting injury may potentially be
substantial. It is therefore most important for the clinician
to keep his foot off the foot pedal until ready to fire the
laser. Simultaneously, the laser technician must be ready to
change the laser to the "standby" mode whenever an interruption in laser use is encountered. The clinician should
also inform the support staff of the danger of laser injuries
to tissue, and must warn them to keep their hands away
from the surgical site when the laser is in operation. Other
important locations at risk of exposure in oral and maxillofacial surgery include the patient's facial skin, teeth, and
soft tissues. Wet drapes or gauze sponges should also be
placed over the patient's skin and teeth outside of the surgical site. A laser impact on a tooth has the potential to
damage the enamel, penetrate into the pulp chamber, and
Practical Laser Safety in O r a l and M a x i l l o f a c i a l Surgery
13
Figure 2-2. Absorption site of (A)

visible and near-infrared radiation; ( B )
middle, far-infrared radiation and middle ultraviolet radiation; (C) and nearultraviolet radiation. (Reproduced from
Laser Institute of America*s Laser
Safety Guide.)
14

shatter the tooth. A tooth damaged by the laser is caries resistant but unsightly.
Fire
Figure 2-3. Goggles that are wavelength specific.
Figure 24. Laser burns in combustible materials present at surgery: gauze, wooden
tongue blade, cotton, tipped applicators, and
rubber glove.
Hazards
All lasers used in the operating suite have the potential to

ignite materials on the surgical site and produce a fire hazard. Examples of these combustible materials include disposable drapes made from wood pulp, dry cotton swabs,
gauze sponges, wooden tongue blades, and plastic instruments (Fig. 2-4). To reduce the potential for igniting the
draping material by the laser, this author advocates the use
of polypropylene surgical drapes because in my experience
when hit by an incident laser beam they melt rather than
burst into flame.
The greatest source of danger in surgery of the oral cavity is the endotracheal tube itself. Special care must be
taken to prevent the tube from coming into contact with the
laser during surgery because ignition of the endotracheal
tube produces a tire with a blowtorch effect inside the patient's airway (Figs. 2-5 and 2-6). New "laser safe" endotracheal devices are available for use during laser surgery.
It is important to have an airtight endotracheal tube with a
metal reflective exterior. The cuff at the distal end of the
tube should be tilled with a saline and methylene blue dye.
If the laser beam penetrates the cuff during surgery, the
blue solution will spill, indicating to the surgeon and anes
thesiologist that a laser-related puncture of the cuff has
occurred. The stainless steel body of the armored endotracheal tubes will resist perforation by the laser. Foilwrapped endotracheal tubes are not recommended because
of the possibility that hand wrapping may leave an uncovered area that is susceptible to a laser burn, causing
ignition.
Other safety-enhancing techniques to reduce tire risk include reducing the oxygen content of the anesthetic mixture
15
Figure 2-5. Cuff of endotracheal tube penetrated by C O 2 laser beam. Methylene blue liquid lilling cuff escapes,
Figure 2-6. Ignition of oxygen-filled endotracheal tube results in ignition and creation of
a blowtorch-like effect. Covered foot pedal.
to 30%, and insertion of wet cottonoids or gauze sponges

as a hypopharyngeal throat pack. These serve as additional
protection for the endotracheal tube by absorbing laser light
and ensuring greater protection for the patient. However, it
should also be remembered that the surgeon must remove
these wet packs from the patient's throat upon completion
of the procedure. As for all throat packs, the anesthesiologist should record the time of placement and removal of the
pack. At the end of the case, he should ask the surgeon, "Is
the pack removed?" The anesthesiologist must understand
the surgical procedure being performed as if he himself
were performing the operation. Simultaneously, the surgeon
must know of any potential anesthetic problems so that both
the surgeon and anesthesiologist may foresee and avoid
mishaps. As always, communication between surgeon,
anesthesiologist, laser technician, and nursing staff in a
safety-oriented environment is essential for successful and

safe surgery.
The surgeon, anesthesiologist, and operating room staff
must always be prepared and have a written plan of action
should an airway fire occur. In the event of this dramatic
and frightening complication, rapid planned intervention
may be lifesaving. The following protocol is recommended
for an airway fire: simultaneously stop lasing. cease ventilation, turn off all anesthetic gases, including oxygen, extinguish flames using saline solution from a nearby basin, deflate the cuff, and remove the endotracheal tube. Make sure
the entire tube is removed. Next, ventilate the patient's
lungs with l(K)% oxygen by bag and mask, assess the airway for burns and foreign bodies (e.g.. tracheal tube and
packing materials) by using a bronchoscope. If the damage
is minimal, it may be possible to continue with the proce-
16
dure. However, extreme caution is advised in regard to proceeding even in the case of minimal observed damage. If
the damage is extensive, it may be necessary to control airway ventilation by inserting an endotracheal tube or performing a tracheostomy, ventilation proceeds using humidified gases. Antibiotics and large dose steroids should also
be given. Lastly, the laser safety officer and the surgeon
must report the incident to the appropriate hospital quality
improvement and risk management departments, as well as
to the laser companies and fiber-optic manufacturers, and a
report must be filed with the Food and Drug Administration.
4
Electrical
Hazards
Of all the laser surgical-related hazards, electrical hazards

have the greatest potential to be lethal, with several fatalities having been reported since the initiation of the use
of lasers in surgery. These incidents have occurred as a result of either untrained and/or unauthorized individuals
opening the closed laser cabinet or by technicians who did
not follow prescribed electrical safety procedures. Contact
with the fully charged capacitor located inside the laser
cabinet may result in electrical shock or even death by electrocution.
It is mandatory that inspection, evaluation, and repair of
electrical components in these specialized lasers be performed only by factory-trained technicians. Most surgical
lasers use high voltage and high current electricity. The
laser's direct current (DC) capacitors also have the ability
to remain charged for hours after the laser has been turned
off and unplugged and, therefore, remain a reservoir of
lethal electrical current. Consequently, if the electrical malfunction indicator light goes on during a procedure, the
laser should be turned off and a service representative
should be called in immediately to evaluate the extent of the
problem. If a service representative is not available, the
laser aspect of the procedure must be immediately terminated (unless a standby laser is available).
Plume
Hazards
One of the few negative aspects of using lasers in surgery is

the resulting smoke or laser plumea by-product of laser
surgery. The laser plume is primarily composed of vaporized water (steam), carbon particles, and cellular products,
which combine to produce a malodorous scent. This smoke
has been found to be irritating to those operating room personnel who come in contact with it. It has also been reported that laser smoke contains many toxic substances,
such as formaldehyde, hydrogen cyanide, hydrocarbons,
and other airborne mutagens. The particles have an average size of slightly larger than 0.3 u.m.
4
Unfortunately, human papilloma virus DNA has been

identified in the plume during the surgery for removal of
papillomas. The initial observers of this phenomenon cau5
tioned against overreaction because it could not be proven

that these particles could seed themselves in unsuspecting
human hosts. Jn 1993 these researchers reported the first
transmission of laser plume-related disease in cows. Currently, additional research is being conducted nationally regarding this issue. As a result of the uncertainty surrounding the seeding ability of this plume material in humans, a
proactive stance should be adopted. Use of a high-volume
laser smoke evacuation apparatus that filters smoke particles to 0.1 u.m is recommended. Maintaining the suction
wand within 4 cm of the surgical site to remove as much of
the plume as possible is recommended. Disposable gloves
and sterile technique should be used to change evacuation
filters, which are treated as hazardous waste and disposed
of in biohazard bags. The laser-charred material should be
wiped from the surgical site and the cloth and paper products used during the laser procedure disposed of using
proper biohazard handling. When working with infected patients or those at high risk for HIV/hepatitis, etc., goggles
and face masks should be worn to prevent the splattering of
tissue from the surgical site onto the eyes and noses of those
performing or assisting during the procedure. Lastly, all
surgical instruments, e.g., microscopes, operating room tables, etc., should be wiped with a hospital-approved sterilizing solution after each laser procedure.
6
ADDITIONAL LASER SAFETY

INFORMATION
Each institution that uses lasers clinically should appoint a
laser safety officer (LSO) to oversee and ensure the safe use
of lasers in its facility. The LSO should attend a laser safety
officer course to assist in the proper performance of his/her
duties. The LSO evaluates all laser use policies and procedures, identifies potential laser-related hazards, and serves
as the resource person for the education of hospital staff,
medical staff, and nursing staff, and answers questions regarding laser capabilities.
It is recommended that a laser safety policy and procedure be written in each institution using laser to treat patients. Once approved by the laser committee, this information should be disseminated to the employees of the
operating room staff and to all laser surgeons, dentists,
physicians, podiatrists, etc., and should be followed, as
written.
All lasers must have their keys removed when not in use
and, if possible, they should be kept in a locked room
to maintain equipment safety and security. Only LSOapproved personnel should have access to operate the laser
equipment.
Laser safety warning signs should be placed on the door
of any operating room using lasers prior to usage. These
signs should include the type and power of the laser being
used. All operating room windows should be covered with

an opaque material while lasers are being used so no laser
light can escape and harm an unsuspecting bystander. This
is not necessary during C O | laser procedures because its
emission is absorbed by plastic and glass. An extra pair of
laser goggles should also be placed on the door handle of
the operating room so that a person entering the room will
have adequate eye protection.
All clinical lasers should be examined weekly and their
power output should be monitored regularly with a power
meter. This data should be recorded for the LSO's monthly
quality assurance reports and for medical/legal record-keeping.
Remember foot pedal safety: When the laser is not in
use, the clinician's foot should be removed from the pedal.
If the laser is not being used for a substantial period of time,
the laser should be placed in the standby mode with the approval of the clinician. The covered design of the foot pedal
helps prevent accidental activation of the laser.
A basin of saline should be available to be utilized in
the event of fire for each laser procedure. Remember: In
Case of fire, use the laser fire safety protocol and act
quickly. Do not use water to extinguish fires on electrical
equipment.
17
All operating room personnel should know where and

how to use the fire extinguishers located near the operating
room. Remember: P.A.S.S.pull, aim, squeeze, sweep.
REFERENCES
1. dayman L, Fuller T. Bcckman H. Healing of continuous-wave
rapid superpulsed. carbon dioxide, laser-induced bone defects.
J Oral Surg 1978:36:932-937.
2. Reid R. Elson L, Absten G. A practical guide to laser safety.

Colposc Gynecol Laser Surg
1986:2(3): 121 -132.
3. Rontal M. Rontal E. Wenokur M. Elson L. Anesthetic management for tracheobronchial laser surgery. Ann Owl Rhinol
Laryngol 1986:95:556-560.
4. Sosis MB. ed. Problems in Anesthesia: Anesthesia for Laser
Surgery. Philadelphia: J.B. Lippincott; 1993.

5. Intact viruses in C 0 laser plume spur safety concern. Clin
Laser Month I987;5(9): 101-103.
6. New research confirms laser plume can transmit disease. Clin
Laser Month 1993;! l(6):8l-84.
7. Recommended practices for laser safety in the practice setting.
AORNJ 1989:155-158.
8. American National Standard: For the safe use of lasers in
health care facilities. ANSI 2136.3. 1988.
2
specific guide to the Use of Lasers

Lewis dayman,
Richard Reid
CARBON DIOXIDE LASER
Why Use a Co2 Laser?

The C 0 laser emits a coherent light beam in the mid-IR region at 10,600 nm which is near a major spectroscopic absorption peak for water. Because the target chromophore is
water and all tissues contain water, all tissues have the capability of interacting with the C 0 beam. The extent to
which this interaction will occur, and therefore the extent to
which it may be controlled, is determined by the water content of the tissue and the irradiance, fluence, and geometry
of the C 0 laser beam (also see Chapter 1). This laser has
unique application in the evaporative ablation (photovaporization) of superficial mucosal disease of the oral cavity. It
can also function as a precise thermal knife for the excision
of soft tissue lesions affecting mucosa or skin (Chapter 6).
Properly used, the C 0 laser will produce results either superior to or not achievable with a scalpel or electrocautery.
The following are the advantages and disadvantages of the
C 0 laser.
2
The carbon dioxide ( C 0 ) laser, which is the workhorse of

contemporary laser surgery, is a molecular gas laser emitting in the mid-infrared (IR) range configured in either
flowing gas or sealed tube form. In the former, the continuously degrading active medium is replenished with fresh
gas and the laser consistently produces power outputs of
up to 100 watts (W). It is noisy but reliable. The sealed
tube laser is of smaller size and lower output power. Its
lower maintenance requirements make it suitable for office use.
To bring the laser light to the target tissue, two basic delivery systems have been developed: an articulated ann and
a waveguide. At present, there is no commercially available
fiber-optic delivery system, although feasibility for one was
demonstrated when a prototype was developed by Terry A.
Fuller in 1982.
The articulated arm consists of a series of metal tubes,
linked by freely movable joints containing precisely aligned
mirrors that maintain the laser beam in the center of each
segment of the arm. This prevents degradation of beam integrity within the articulated arm. The distal end of the articulated arm is attached to a handpiece containing a focusing lens, or to a micromanipulator attached to an operating
microscope (Figs. 3-1 and 3-2).
A flexible hollow waveguide, consisting of a small diameter metal tube coated with a highly reflective material applied to its interior, is available for some C 0 lasers, generally with maximum power outputs of less than 20 W. The
laser beam bounces from point to point within the waveguide to reach the handpiece. The greater flexibility of this
delivery system permits increased freedom of movement,
allowing the operator to reach less accessible areas of the
oral cavity and oropharynx. Additional flexibility is
achieved by outfitting the waveguide with curved or contraangled lips. In contradistinction to the articulated arm system that attaches to either a handpiece containing a focusing lens or a microscope, the waveguide system does not
transmit the laser beam through a lens system. The beam, as
it emerges from the latter, immediately begins to diverge.
Therefore, the focal point is considered to be at the tip of
the waveguide. Divergence is rapid, resulting in a more
rapid decrease in power density than is the case for an articulated arm-focusing handpiece system.
2
Advantages
1. Improved operating conditions:
Rapid incision or ablation (evaporative photovaporization of tissue).
Minimal damage to normal tissue adjacent to the area of
treatment.
Preservation of histologically readable "margins."
Good intraoperative hemostasis.
"Quiet field" secondary to lack of muscle contraction of
the target tissue during laser surgery.
Sterilizing action of the beam at its point of application
to the tissue.
No need for elaborate "prep" of the operative field.
"No touch" technique permits surgery in difficult to
reach locations (vocal cords, esophagus, paranasal sinuses).
2. Improved patient benefits:
Minimal postoperative swelling.
Very low infection rates.
Minimal scar formation.
Elimination of the need for skin grafting in floor of
mouth surgery.
Healed tissue is supple and maintains normal healing capability if repeat surgery is required.
19
20

Possible source of unexpected injury to patient, staff, or
surgeon.
Laser-specific education and credentialling required for
surgeons.
High cost of equipment.
Rational Basis for the
Use of the
C0 Laser
2
Electromagnetic radiation reaching the target tissue is reflected, transmitted, scattered, or absorbed. Ultimately, absorption determines the effect of the laser on the tissue. For
the C 0 laser, absorption is proportional to water content.
Therefore, tissues with high aqueous content like epithelium, connective tissue, or muscle readily absorb the incident beam. This is especially true for corneal epithelium,
which, because of its high water content, completely absorbs the laser energy within 50 |xm of the epithelial surface. Therefore, the corneal thermal lesion is very superficial.' Tissues like muscle and skin, which have less water
content, suffer greater thermal damage of respective depths
of 0.055 mm and 0.25 mm in response to continuous wave
(CW) C 0 at low power density (PD). In comparison, nonaqueous tissues like bone, tendon, or fat are poor absorbers
that may sustain more heat damage. Using a rapid superpulsed (RSP) beam instead of CW will minimize the heat
effects. In addition, bone will rapidly melt thereby becoming even more anhydrous, resulting in excessive heating
even to the point of incandescence followed by actual flaming with continued application of the beam. For anhydrous
tissue like bone, one must use a shorter wavelength laser
like the erbium:yttrium-aluminum-garnet (Er:YAG) (2.92
|xm) or the holmium (Ho):YAG (2.127 u.m) to avoid the
excessive heating occurring with C 0 . The other commonly
used lasers in head and neck surgery, neodymium (Nd):
YAG and argon, respectively, have pigmented chromophores for targets. Argon has affinity for the red pigment
of hemoglobin, whereas Nd.YAG is selective for the dark
pigments of melanin and protein. Nd:YAG is usually used
for excision as a contact laser with a sapphire or silica tip.
Argon, on the other hand, is used for photocoagulation of
vascular lesions with a fiberoptic or handpiece deliver)' system. The intensity of the tissue interaction also depends on
the energy of the incident beam.
2
Figure 3 - 1 .
Handpiece and articulated arm.
Figure 3-2.
Microslad.
Healing is more rapid than for other thermal instruments

(diathermy, cryoprobe " ).
Minimal tissue handling is required.
1
Disadvantages
Operative:
Loss of tactile sense with which surgeon is most familiar
and comfortable.
Additional safety requirements for use in the operating
theater.
Laser safety personnel (laser technician) required in operating theater.
Anterior floor of mouth surgery is complicated by microstomia, limited mouth opening, or other anatomic abnormalities.
Special attention required to avoid contact with the endotracheal tube.
5
Beam energy is inversely proportional to wavelength.

Hence, wavelength determines whether a laser beam will
produce ionization (excimer lasers) or thermal interactions
(dye. argon, potassium titanyl sulfate (KTP), Nd:YAG,
EnYAG, Ho:YAG, and C 0 lasers). In addition, wavelength also determines whether absorption will be color dependent (dye and Nd:YAG) or color independent (excimer
and C 0 ) . Thermal damage is a function of the optical properties of the incident energy as well as of effects induced by
the absorbed irradiation.
2
7,9
As the incident beam is absorbed, some heat is generated

within the medium unless the application time is so short
and the fluence is so low that there is no useful effect on the
target tissue. Therefore, some heat effects must be accepted
Specific Guide to the Use of Lasers

in the course of the performance of useful work by most
lasers. During healing the optical properties of the target tissue do change. For water, as the temperature increases the
absorption coefficient decreases. This becomes more pronounced with repeated laser "hits" particularly at the base
of the vaporization crater. Recent studies have shown that
even a single pulse will change the absorption coefficient of
water. Therefore, as the temperature increases during the
pulse, so does the depth of absorption. For mid-IR lasers,
which emit near the 1940-nm absorption peak for water, the
absorption peak decreases, which results in a slightly
greater depth of penetration than was predicted. The effect
is more pronounced for the C 0 laser at 10,600 nm. At conditions of vaporization the absorption coefficient may
change by a factor of 10\ Therefore, as the energy from repeated laser pulses accumulates, thermal damage extends
progressively deeper into the tissue."' This effect is further
exaggerated if the tissue has become charred, which radically alters its optical and absorptive properties.
How is it possible for a thermal instrument to remove the
target tissue without having excessive heating cause destruction of the surrounding normal tissue?
Tissue interaction with a laser beam is defined by the volume of absorption of the laser beam by the target tissue.
This is the fraction of the incident light absorbed by (he tissue. This becomes understandable by considering Beer's
law according to which the incident light transmitted
through the target tissue (I1) is inversely proportional to the
absorption coefficient (u) and the thickness of the irradiated
tissue (X), thus:
21
I1 = I0 10-A*
This equation may be simplified by setting tissue thickness
{X) equal to 1/ot so that
/, = / ( 1 0 - ' ) o r / , = / / 1 0 .
0
The incident transmission /, now becomes reduced to

10% of its initial intensity. Therefore, the critical volume
of tissue required to absorb 90% of the incident radiation
is defined by the reciprocal of the absorption coefficient.''" It is this extremely high absorption of the thermal energy of the laser beam within a small volume of tissue lhat permits the laser to selectively remove the target
tissue while having minimal heal effects on the surrounding tissue. This extreme containment of the energy within
a small volume of tissue results in instantaneous boiling of
water within the tissue, which causes the formation of
steam. This, in turn, results in explosive disruption of tissue at the impact site. The resultant crater consists of a vaporized area surrounded by a zone of carbonization (charring), which is in turn bordered by a zone of sublethal, and
therefore potentially reversible, thermal injury "" (Fig.
3-3). The damaged tissue zone adjacent to the vaporization crater represents a thickness of only 50 to 200 L U I I
measured from the histologic tissue specimen. This is
somewhat greater than the volume of absorption of water
in laboratory studies.
12
13
Figure 3-3. Zones of damage. H & F..

The clinical significance of the above property is that the
amount of tissue removed under direct visual observation
represents nearly the entire amount of vaporized and damaged tissue actually removed.
Using a superpulsed laser of adequate fluence, coagulation necrosis is limited to a narrow, sharply defined zone at
the crater margin, in which energy levels do not reach the
vaporization threshold (Fig. 3-4). Under these circumstances, crater depth conforms closely to the true level of
thermal destruction.
With the superpulsed C 0 laser, basically, what you sec
is what you get! This is its great difference compared with
the Nd:YAG laser, in which, because of extensive scatter,
the volume of tissue injury is approximately 40 to 50 times
greater than that for C 0 . ' ' ' " ' ' In addition, with YAG there
is no immediately visible change in the tissue surrounding
the zone of vaporization, so it is very difficult to estimate
the true extent of thermal necrosis. Studies of laser-target
interactions for the C O , laser in water demonstrate an intense heating effect that is restricted to a small volume of
water. The entire energy of the impact beam was absorbed
in a depth of water of only 39 to 90 u.m. To minimize lateral heat conduction, the pulse width for CO, must be less
than approximately 1 ms. For a free-beam Nd:YAG delivered by optical fiber in the same water model the absorption
depth was 4 to 6 m m . " This great differential in the water
absorption model predicts events occurring in soil (issue.
The C O , beam is complc(ely absorbed, with an intense
heating effect in a small volume of water, whereas Nd:YAG
is absorbed in a much larger volume of water but with less
vaporization. Using a contact tip converts Nd:YAG into a
predominantly thermal instrument with reduced depth of absorption compared with free-beam Nd:YAG. Argon effects
arc intermediate, with a depth of absorption of 0.5 to 2.0
m m . However, this advantage for C 0 may readily be lost
2
16
22
Figure 3-4. Gaussian distribution curve. Tissue removed occurs within the area delined by the "vaporization threshold."
(Courtesy T.A. Fuller. Ph. D.)
if used inexpertly. Therefore, one must understand that the
COi laser is an instrument that works by thermal destruction
(Table 33) as do conventional instruments like the electrocautery or the Shaw scalpel. For conventional thermal instruments to work, they must maintain contact with the tissue during a lag phase until the target tissue is heated to the
necessary temperature. During this time, lateral heat conduction results in absorption of heat in a progressively larger
area of tissue. In short, the tissue is burned.
Healing postoperatively will not occur until the damaged
tissue is repaired, which is a slow process. On the other
hand, the C 0 laser, as previously discussed, can be administered as a series of pulses that remove tissue through explosive vaporization by the direct thermal effects of the
laser radiation, but not by lateral heat conduction from the
laser crater. Therefore, heat-damage adjacent to the vaporization crater is generally restricted to a zone less than 100
to 200 u.m wide. The actual volume of heat necrosis is
largely dependent on the application time of the laser.
Consequently, healing begins quickly after laser surgery
and reepithelialization occurs before excessive collagen
(scar) is deposited. " '' There are also fewer myofibroblasts
in the healing laser wound than in the conventional wound,
which may also contribute to reduced wound contraction
and scarring. ''"
2
17
21
Irradiance
(Power
Density)
Once again, to achieve the desired wound characteristics

listed above, optimization of tissue effects must occur. This
is partly a function of the duty cycle in the pulsed mode of

operation. A short pulse duration is chosen to permit photovaporization effects to predominate over photocoagulation
thereby minimizing lateral heat transfer. This is accomplished by using high-power densities at pulse widths
shorter than the thermal relaxation time of the target tissue.
In addition, an interpulse interval at least twice as long as
the pulse width permits significant, but not complete, tissue
cooling between pulses. Unfortunately, rapid superpulse
has one major disadvantage: the choice of a short duty cycle
will reduce power output accordingly, which slows down
the rate of tissue removal. Hence, in practice, rapid superpulse is generally reserved for situations in which small tissue volumes need to be treated with maximal precision.
A handy compromise between the high precision of rapid
superpulse and the high power of continuous wave is obtained from the chopped mode (actually chopped CW
mode; see Chapter 4, Fig. 4-15), in which the laser tube is
electrically pulsed to emit broader, flatter pulses with a
shortened interval between pulses. Consider, for example,
the electrical pulsing of a 120-W laser tube, governed such
that the ratio of on/off time (duty cycle) will never exceed
5:1. When used at the highest duty cycle, maximal output
would be 100 W (i.e.. 120 X 5/6). Conversely, selecting a
1:9 duty cycle would produce an output of only 12 W (i.e.,
120 X 1/10). Because the peak power of each pulse is not
amplified, an electronically pulsed laser tube does not have
a refractory phase when used in the chopped mode. Hence,
repetition rate can be increased to virtually any frequency.
However, as pulse frequency approaches a duty cycle of

2:1, heat will accumulate at the impact site, and the clinical
effects will resemble those of a continuous wave laser.
Thus, the best compromise is a duty cycle of about 1:1 producing 60 W of power output, while preserving about half
of the intcrpulse cooling. Physical cooling of the tissue with
iced saline also helps reduce unwanted heat transfer during
lasing.
Fluence
(Energy
Density)
In addition to power density, one must also consider the fluence (energy density), which is the rate at which energy is
delivered. It must exceed the vaporization (ablation) threshold for mucosa (4 J/cm per pulse) or skin (5 J/cm per
pulse). The fluence may be delivered in continuous or
pulsed modes. The pulses themselves may be delivered in
two different modes: superpulse, in which pulsing occurs
within the laser tube (rapid superpulse, RSP) or "chopped"
(gated) continuous wave, in which the beam is interrupted
by a shutter. RSP lasers may produce peak pulse powers of
individual pulses that exceed 500 W. A typical pulse duration is 150 to 300 u.s at approximately 50 to 150 mJ/pulse
with an intcrpulse interval of several milliseconds. This
provides excellent control of a cool beam, which will ablate
small volumes of tissue very precisely. However, the very
short duration of the pulse reduces power output compared
with continuous wave function. The actual average power
output for a pulsed laser corresponds with the duty cycle
during which the pulse is actually occurring.
2
3. Irradiating a bleeding point at low PD, which heals the

blood at the surface but does not coagulate the cut blood
vessel. This causes cooking, not coagulation! Remember
that soft tissues suffer coagulation necrosis at temperatures above 58C and bone is even more sensitive, succumbing at 47C.
22
23
Consequently, cooling the operative field with iced saline

before lasing and prior to each raster is helpful in reducing
unwanted heat damage.
Power Density
(PD)
(W/cm )
To calculate PD, a reasonable approximation is given by

2
PD = - ^ 3 - ^ = 100 W/cm
where VV is power, in watts, of the exit beam, measured by

the laser power meter, and d is the measured diameter in
millimeters of the imprint left by a 10-W, 0.1-second pulse
on a moistened wooden tongue depressor. Since the inverse square law of light applies here, changing the spot
size will affect PD exponentially, whereas changing the inline laser power output will affect PD only linearly. Therefore, the greatest control by the operator on laser effects
will be by altering power density through changes in focus
and beam geometry, not by changing power output at the
beam source (Table 3-1).
24
Learner's
Energy
23
Curve
Table 3-2 represents the early experience of the section of

oral and maxillofacial surgery during the first year of C 0
laser use at Sinai Hospital of Detroit in 1979-1980. There is
a wide distribution of power densities used for photovaporization. As experience was gained. PD clustered around
several restricted ranges, as it became apparent that there
was a specific relationship between PD and clinical effect.
Consequently, one may now select the appropriate PD for
2
Energy (joules) = Power (watts) X Time/(sec)

A given amount of energy will destroy the same volume
of tissue independent of the rate at which that energy is delivered. However, the effects on the target tissue as well as
on the surrounding tissue differ greatly depending upon the
rate of energy delivery. With a superpulsed laser of adequate fluence emitting pulses shorter than the thermal relaxation lime of the target tissue, thermal damage becomes a
function of the optical properties of the incident energy. In
contrast, when pulse duration exceeds thermal relaxation
time, heat accumulates at the surface of the impact crater
and lateral heat conduction begins. It is this technique error
of prolonged time of application that causes thermal damage. This results in the loss of the major benefit of laser use:
selective tissue removal.
The following errors most commonly lead to unwanted
heat damage:
Table 3-1.
POWER DENSITY
2
< 100 W/cm

> 100 W/cm
600-2500 W/cm
> 10,000 W/cm

1. Use of low irradiance by excessively defocusing the
beam, resulting in PD <50O-60() W/cm for keratinized
tissue. The same applies for nonkeratinized oral mucosa
at PD < 350-400 W/cm .
2. Failure to remove carbonized debris from the wound before using the laser for its second application.
2
>50,000 W/cm
> 10* W/cm
Power Density and Tissue Effects

17
EFFECT -
25
Desiccation, denaturation. warming

Photovaporization, carbonization (carbon
appears as target tissue temperature
reaches approximately 150C)
Photovaporization (ablation), minimal
carbonization, superficial hemostasis;
target tissue temperatures may reach 3(X)C
Ultrarapid photovaporization,
thermal incision
Incision of tissue, approximately same
rate of cutting as for a scalpel
Plasma formation, acoustic shock
waves: tissue destruction by mechanical
disruption rather than thermal denaturation
24
Table 3-2.
Learner's curve.
ablative vaporization or incision and rapidly learn how

quickly to move the beam across the target tissue to achieve
the desired effect.
Beam
Geometry:
Gaussian
Distribution
of Energy
The energy within the laser beam follows a Gaussian distribution pattern with the usable component occupying the
Figure 3-5.
central 86% of the beam. This is the working "spot size" of

the beam. However, the peripheral 14% still heats the tissue, thereby contributing to thermal conduction, denaturation and subthreshold heating. Irradiance (PD) must be kept
high enough to vaporize tissue quickly because low irradiance results in desiccation. Anhydrous conditions can cause
excessive heating, carbonization, and even flaming. Consequently, temperatures at the impact crater may increase
Beam profile: transverse and cross section. (Courtesy T. A. Fuller. Ph.D.)
Specific G u i d e to the Use of Lasers
25
the energy profile of the incident beam (Fig. 3-5). A highly

focused beam, providing high PD that is suitable for incision, will produce a beam contour as seen in (Fig. 3-6). Defocusing the beam either by moving the handpiece away
from the tissue or by adjusting the microslad device on the
microscope by rotating its tuning dial to alter spot size will
flatten out the beam. One wishes to flatten the beam profile
until the amplitude of the beam is about half that of the spot
diameter (Fig. 3-7).
Figure 3-6. Beam profile in bone: cross section of C 0 beam:

RSP mode, in focus at high PD (left and center) and lower PD
(right) (frozen ox femur). (Courtesy L. dayman, DMD, MD and
Carlo Clauser, MD.)
2
The characteristics of the beam are also modified by the

delivery system. Both systems destroy collimation, so that
at the tissue the beam is slightly divergent. Both spot size
and depth of field at any given wavelength will vary with
the focal length of the objective lens. The operating microscope of long focal length objective (300-400 mm) produces a relatively large minimum spot size (approximately
0.6 mm) with excellent depth of field, while the handpiece
objective (125 mm) produces a very small spot (0.3 mm)
with a shallow depth of field. The maximum power density
is higher, and the beam geometry is therefore sharper for
the handpiece compared with the microscope at maximum
power densities. This is the intrinsic difference that makes
the handpiece the instrument of choice for rapid incision.
However, the microscope is most suitable for ablation if target anatomy permits its use because it provides these advantages: (1) keeping the beam normal to the tissue maintains a circular spot size of constant PD (using the
defocused handpiece in a "pencil grip" is more likely to
permit obliquity and an oval spot size of nonuniform PD);
(2) enhanced visual resolution increases both beam control
and monitoring of direct tissue effects.
THE PLANES OF TISSUE DESTRUCTION

IN ABLATION
First
Figure 3-7.
Amplitude beam 5 spot diameter.
The objective of ablation is to selectively remove part or all

of the mucosa according to the operator's choice. Destruction of the first plane removes only the surface epithelium.
Removal stops at about the level of the basement membrane. Therefore, the vaporization crater is placed deep in
the parabasal layer of mucosa or skin. To achieve proper
depth, the laser spot is manipulated to describe a series of
parallel lines, overlapping by about one third. Each pass of
the C 0 laser beam will cause a bubbling effect at the surface wherein the target tissue becomes opalescent, and actual bubbles occur on its surface (Fig. 3-8). This is accompanied by a crackling sound similar to that of pulmonary
rales, or to the sound of Rice Krispies in milk. The presumed mechanism is that flash boiling of both intra- and extracellular water occurs, which ruptures the epithelium at
the level of attachment of keratinocytes to the basement
membrane. This first layer of removal is also referred to as
the first raster. Either of these two distinctive signs (opalescence and bubbling) can be lost if deep penetration beyond
2
from 100C to >600C. This increased heating causes a

burn, which is similar to, or even worse than, that caused by
electrocautery.' '
Recall that the exit beam, particularly after being modified by the lenses within a handpiece, or by the microscope's objective lenses, does not contain energy of uniform density. There is variation within the beam profile that
follows a Gaussian distribution and is readily seen at the
target site where the shape of the impact crater replicates
1 16
Plane
26
Figure 3-8. Surface bubbling and opalescence after treatment of

buccal mucosa.
Figure 3-10. Visual end point: appearance of treatment area

after second and linal raster has been applied perpendicular to the
initial raster.
higher PD may be used initially and the first raster will penetrate directly to plane II. After wiping away debris, the surgical site will show a roughened surface of yellow color.
There is minimal heat damage to the deeper submucosa (or
reticular dermis for skin). If thermal relaxation time is exceeded, then deeper transmission and wider scattering of
the incident laser beam causes a larger, but predictable zone
of coagulation necrosis. The extent of necrosis is directly
proportional to the duration of irradiation, which elevates
tissue temperature above 55C. The sublethal zone of thermal injury remains small. Healing is rapid but slightly delayed compared with plane I. and there will be no scar contracture.
Third
Figure 3-9. Magnified view (I6X) of collagen network deep to

ablated epithelium after wiping away epithelial debris.
the basement membrane occurs. Wiping away the altered
tissue will expose the pink, shining, smooth intact surface
of the basement membrane overlying the submucosa (Fig.
3-9). There will be no bleeding. Healing is complete by
reepithelialization in less than 14 days for moderate-sized
lesions and in approximately 3 weeks for large lesions. No
scarring occurs.
Second
Plane
Thermal destruction to the second plane removes all of the

epithelium and some of the upper submucosa, or for skin
the papillary dermis. This is achieved by applying a second
raster, at the same PD as the first but perpendicular in direction. This time there will be no opalescence, but some bubbling will still occur (Fig. 3-10). Alternatively, a slightly
Plane
Plane III is rarely used for mucosa since it will obliterate

the entire submucosa. following which there will be delayed healing and some scar formation. In ablative oral and
maxillofacial surgery, this will be limited in use to removal
or recontouring of intraoral skin grafts, for removing cutaneous scars or keloids, or for debulking nonresectable cancers.
Correct depth control is most likely obtained with use of
the microscope, which allows one to recognize these landmarks in skin: (1) coarse collagen bundles appearing as
gray-white fibers after epithelial ablation: and (2) a network
of arterioles and venules running parallel to the epithelial
surface (Fig. 3-11). There will also be drops of blood from
transected blood vessels in either the reticular dermis or the
deep submucosa. Good surgical technique requires slower
movement of the beam guided by visual recognition of a
"fibrous grain" within the crater base. Therefore, this type
of lesion extends deeply enough to create a burn. Regeneration of mucosa starts from the mucosal edge and from
minor salivary gland epithelium. It is somewhat delayed because the heat-damaged tissue must be removed by phagocytosis before reepithelialization begins. This delay occurs
consequent to thermal damage. Excess heat may cause
Figure 311.
27
Reticular dermis: collagen fibrils exposed, blood vessels visible.
"mummification" of collagen within the submucosa (or dermis), where it further delays healing and promotes fibrosis.
This is the deepest plane from which optimal healing may
occur.
less well absorbed by intracellular water than is the C 0

beam. As a consequence, free-beam Nd:YAG energy
causes more extensive scattering and transmission of the incident beam through the target tissue. Therefore, as expected, absorption length for water is 2 to 4 mm in a large
volume of fluid' compared with <90 u-m for Co . More
heating of tissue occurs at lower contact temperatures than
for the C 0 laser, thereby producing a deep coagulation effect that increases with power and time of application.
The volume of tissue destruction is 40 to 50 times greater
than for a similar exposure to an equal diameter incident
beam from a C 0 laser. The clinical consequence of this is
that the volume of tissue destruction greatly exceeds the
volume of visible laser effect between the beam and the tissue. Precise control of tissue effects is therefore difficult.
Consequently, the YAG laser is most useful for ablation of
large volumes of tissue, particularly when strict hemostasis
is required (e.g., hepatic resection). On the other hand, C 0
will be most useful for superficial ablation of surface disease or for incision where the need for hemostasis is moderate.
As mentioned above, the Nd:YAG laser is useful in situations where coagulation is essential, particularly when the
underlying tissue can tolerate thermal damage, as in larger,
deeply sited vascular tumors. The YAG laser's ability to
seal large blood vessels greatly enhances its utility for treatment of vascular lesions. The C 0 laser, which can be used
to excise small capillary hemangiomas, is not suitable as a
2
Postoperative
Care
For oral mucosa, care is very simple. The patient uses warm
dilute saline rinses four to six times per day on the first day.
After that, the saline is mixed 1:1 with 3% hydrogen peroxide and used as a rinse until the mouth feels comfortable.
No antibiotics are used and nonsteroidal anti-inflammatory
agents are given orally to control pain.
For skin, or for postablation care of the vermilion border
of the lips, an antibiotic cream or ointment is applied three
times a day. Skin lesions are occluded for the first 24 to 48
hours.
25
26
Nd:YAG
Neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are
solid-state devices emitting at 1060 nm in the infrared region of the electromagnetic spectrum. This is a more highly
energetic beam than that of the C 0 laser because of its
shorter wavelength. (Energy is inversely proportional to
wavelength.) Its target chromophores are pigmented molecules (melanin, hemoglobin, and other proteins) and it is
2
28
surgical instrument to treat these larger lesions, nor is

scalpel excision, which may cause aesthetic and functional
disabilities.
The most recent development permitting an increase in
the range of applications of the NdrYAG laser has been the
development of contact probe tips (Fig. 3-12), which control and also limit thermal injury. This alters laser-tissue interactions without changing wavelength of the incident
beam (see Chapter I).
In considering treatment of cavernous hemangiomas and
vascular malformations (AVMs) using the Nd:YAG laser,
one must be cognizant of potential overtreatment, which
may lead to rupture and hemorrhage of the lesions. A conservative approach is to employ a target spot technique
using a 2-mm spot size free beam in single pulses at 20 to
25 W and 0.5 sec pulse width. The laser spots are placed 2
to 3 mm apart from one another to avoid overlapping of
scattered laser energy. The resultant photocoagulation
necrosis obliterates the pigmented or vascular lesion with
preservation of normal tissue, leading to resolution of
bleeding and swelling as well as improved function. One
expects retreatment to be necessary to ablate residual
tumor. Patients are usually reevaluated in 4 to 6 weeks for
further treatment. Staged treatment helps to reduce overenthusiaslic single-stage therapy, which might result in tissue
sloughing and compromised healing.
The C 0 laser resembles the electrocautery unit, the electrodiathermy, and the cryosurgical probe, in that all are instruments of thermal destruction. With conventional devices, lateral heal propagation declines along a slow, linear
gradient. Adjacent tissues must recover from the ill effects
of a diffuse conduction burn from thermal instruments or
frostbite from cryoprobes before the healing response can
begin. Moreover, collagen damaged by inept laser surgery
can remain "mummified" in the dermis for many months,
where it acts to delay healing and promote cicatrization.
The noncontact C 0 laser consistently minimizes collateral
heat damage when used properly. The Nd:YAG contact
lasers act similarly and also provide tactile feedback
through tissue contact.
2
Table 3-3. Typical Laser Use

CO, Laser (10,600nm)
Handpiece: Spot: 0.3 mm at focal point
A = 10.6 (j-m
Output power: 5-80 watts
Ablation: PD: 475-750 w/cm
Incision: PD: 10,000 to >50,000 w/cm
Pulsed average power: up to 25 W
Duty cycle: up to 15%
Fluence: 120-600 mJ/pulse
Pulse width: 0.85-6.4 ms
Maximum peak power: 500 w/pulse
CW: Same as output power at exit lube
For both: PD * IOO(W)/spot (cm)
2
Contact Nd-.YAG (1060nm)

Silica tips: varied
Typical power
(a) to mark tumor periphery: up to 10 W
(b) to incise: 12-20 W
Argon Laser (488 to 514 nm)
Handpiece or fiber: 2-4 W CW mode.
ILP-fiber: 2-4 W CW mode.
C 0 : Scanner Handpiece
X = 10.6 urn
Spot size: 26mm. Varied by handpiece
P: < 20 W
E: 200-500 mJ/pulse
Fluence = 5 - > 15 J/cm"
Cycle = approx. 0.2 sec
PRR set by computer with limits defined by length Of cycle
2
Note: 2-4 "passes" are required to ablate skin wrinkles

Pulse width < I msec
Note: All lasers require protective eyewear and high-speed laser suction to
evacuate plume particles.
27
Figure 3-12.
Nd:YAG contact laser probe tip.
Figure 3-13.
Argon laser: end point is "whitening" of lesion.
29
Argon laser
The argon laser is a continuous wave laser emitting bluegreen light between 488 and 514 nm (Table 3-3). Its depth
of penetration is 0.5 to 2.0 mm and the energy is absorbed
mainly by hemoglobin. The depth of absorption is a function both of power density and heating effects. The effect
on soft tissue is to create an initial pallor (Fig. 3-13) followed by blanching (whitening), liventually, the epithelial
surface elevates, and a vesicle forms that then ruptures to
reveal the effect of the laser on the subjacent deeper tissue.
This vesicle itself may form from the vaporization of water
into steam. This results in elevation of the epithelium away
from the subepithelial plane due to dispersion and absorption of the beam within this deeper plane.
For superficial coagulation a pulsed argon laser beam at
2-W output power with a 0.2-mm spot size and a 10-ms
pulse width will be absorbed to a depth less than 1.0 mm.
Using such a low irradiance it is possible to treat cutaneous
telangiectasias without topical anesthesia by using a spot
target technique of single-spot applications to the target
vessels. Up to 500 vessels may be treated in a single 20minute session this way. For extensive telangiectasias, multiple sessions, averaging between four and five in number,
are required. The sessions are repealed at 3 to 4-week intervals. Slightly longer pulse duration at higher power densities will permit photocoagulation to occur to a deeper level
in thicker vascular lesions. However, at higher outputs
some cutaneous absorption will occur and the probability of
scarring increases. Therefore, for superficial cutaneous vascular lesions like port-wine stains or telangiectasias, other
lasers like flashlamp-pumped dye lasers or copper vapor
lasers emitting closer to the H b - 0 second absorption peak
of 577 nm should be used. For intramucosal vascular malformations or for those thicker malformations involving
critical anatomic regions like the vermilion border of the
lip, a higher dose of argon may be used either to reduce the
size of the lesion and devasculari/e the ensuing scar prior to
surgery or as definitive treatment.
26
Figurc 3-14.
Vascular malformation of labiobuccal vestibule.
Figure 3-15. Argon laser applied by liber to glass slide compressing the lesion. Laser beam may be used al its focal point or
defocused.
TECHNIQUE
To maximize the effectiveness of the argon laser for the
treatment of thicker vascular lesions (Fig. 3-14) one may
employ physical adjuncts to convert a thick lesion to a thin
one with a reduced rate of blood How. This may be
achieved by reducing the local blood How by the application of ice to the lesion and by infiltration of local anesthetic containing vasoconstrictor around the lesion. At this
point the argon laser is applied to the surface of a glass slide
placed over the lesion to compress it (diascopy). The spot
size and power is adjusted and the application time in CW
is prolonged until the test target tissue turns white. The optical fiber is now used to trace a series of decreasing concentric circles from the periphery to the center of the lesion
until the entire field turns white (Figs. 3-15 and 3-16). During the procedure, which takes about 1 minute, the glass
slide is maintained in constant position under finger presFigure 3-16.
Completion of treatment: entire lesion is white.
30
sure. At the conclusion of the initial treatment, the slide is

removed and blood flow through the lesion is visually assessed. If the lesion is still quite red. ice is reapplied and the
treatment is repeated. Antibiotic ointment is applied and the
patient is given wound care instructions. Swelling and discoloration at the operative site are to be anticipated.
The size of the acute lesion increases over 48 to 72 hours.
Edema peaks at 72 hours and persists for several days.
Wound healing, which is delayed initially, is apparent at the
end of the first week. '' Analgesics, usually in the form of
nonsteroidal anti-inflammatory agents, are prescribed. The
patient is seen at 5 to 7 days to monitor wound healing followed by monthly reevaluations. The healed wound is generally 20 to 30% larger than is the vascular lesion. If resolution is incomplete, the lesion is retreated after 2 months.
Two or three treatment sessions may be required until the
lesion is eradicated (Fig. 3-17).
2
ALTERNATE TECHNIQUE: INTRALESIONAL

PHOTOCOAGULATION
For thicker vascular lesions, particularly for intraoral hemangiomata a more aggressive technique for photocoagulation is intralesional photocoagulation (ILP). For this technique to be effective one depends on both selective
photoabsorption by the H b - 0 chromophore and a nonspecific heat effect. After anesthetizing the lesion with local
anesthetic containing vasoconstrictor, ice is applied to help
reduce blood How. thereby diminishing the capability of a
well-vascularized lesion to function as a heat sink. The optical fiber is then activated usually starting at 3 W. Using diascopy technique the lesion is compressed and photocoagulated (Figs. 3-18 and 3-19). After the tip is heated it is
brought into contact with the mucosal surface of the lesion
(Fig. 3-20). Using only gentle pressure, the fiber is advanced into the substance of the vascular malformation.
Care is taken to ensure that the tip does not enter the surrounding normal tissue.
Figure 3-18. Diascopy: mucosa compressed. Lesion outlined

with argon in C'W mode.
Figure 3-17. Similar case of vascular malformation of buccal

mucosa eliminated. Mucosa stable at 18 months recall.
Figure 3-19. Center of lesion "filled in'" with argon applied in

decreasing concentric circles.
Figure 3-20. For intralesional photocoagulation the fiber tip is

introduced into the lesion. First, the laser is activated and then
using very gentle finger pressure so that the fiber is introduced "on
its own weight.'" the lesion is entered. Note that entry is almost
completely bloodless.
31
Figure 3-21. With the laser activated the fiber is brought back
and forth across the lesion in a series of passes in the same manner
as performance of a fine needle aspiration biopsy.
Figure 3-22. Thirty-four days after surgery healing has been

complete. There is no vascular malformation present and the
tongue has a full range of motion.
With the laser in active mode the fiber tip is advanced to

the periphery of the lesion opposite the point of entry and is
then withdrawn to a point just deep to the mucosa but still
within the lesion. It is then redirected and the same action is
repeated. It is the same technique used for fine needle aspiration technique to sample a mass for cytologic assessment
(Fig. 3-21). Generally, four to six such passes are required.
After the last pass the lesion should have become depressed
and there should be little or no venous oozing from the lesion. If gentle pressure is not adequate to control bleeding,
another series of ILP passes will be required. The power
should be adjusted so that with each pass one hears a gentle
crackling sound, indicating that absorption and some heating
is occurring. If a second ILP is required, the lesion should be

iced for 3 to 5 minutes between ILPs. Postoperatively a nonsteroidal analgesic is given for pain, and the patient is instructed to rinse with dilute warm saline four to six times per
day. Moderate edema is expected but the amount of postoperative pain is unpredictable. The patient is recalled in 5 to 7
days for interim reexamination and then at monthly intervals
to assess regression. If regression is incomplete or progression occurs at the monthly recalls, then retreatment is suggested. If more than three treatments are required, then another treatment option should be chosen. Patient acceptance
is generally quite high and significant improvement is usually
seen within two treatment sessions (Fig. 3-22).
32
ARGON: NONCONTACT
For very small lesions, the handpiece may be used to provide adequate energy to photocoagulate superficial lesions.
In the following case of superficial vascular malformations
of the lateral tongue border the argon laser was used at a
power output of 2.5 W and a spot size of 2.0 mm in continuous wave function (Figs. 3-23 to 3-26).
Figure 3-25.
tongue.
Figure 3-23.
of tongue.
Six months postoperative. Full range of motion of
Superficial vascular malformation of free border
Figure 326.
Figure 3-24.
Handpiece delivery system: dcfocused. CW: 2.5 W.
No recurrence and no tear.
33
ARGON: COMPLICATIONS
COMPLICATION I: INADVERTENT SKIN PENETRATION
Figure 3-30. Skin damage. Fiber approached skin surface too

closely during subcutaneous and submucosal photocoagulation.
Figure 3-27.
Vascular malformation of labiobuccal sulcus.
Figure 3-28.
Figure 3-29.
coagulation.
Figure 3-31.
site in skin.
First postoperative day. Eschar forming at burn
Figure 3-32.
skin injury.
Thirteen months: depressed scar present at site of
Patient properly protected with goggles.
Lesion photocoagulated using intralesional photo-
34
Lasers in M a x i l l o f a c i a l Surgery and Dentistry.

COMPLICATION 2: SCARRING AFTER T R E A T M E N T OF
TELANGIECTASIAS
The argon laser has been used to treat superficial telangiectasias of the skin, but because of a high rate of unfavorable
scarring postoperatively. Ilashlamp pumped dye lasers and
copper vapor lasers have largely replaced argon for this use.
In this illustrative case facial telangiectasias (Fig. 3-33)
occurring along with intraoral hemangiomata in a young
girl were treated by direct "tracing" by the argon fiber over
the telangiectasia that was compressed by a glass slide (Fig.
3-34). Argon at 2 W CW was used at the focal point of the
laser fiber. Application of energy was continued until the lesion blanched (Fig. 3-35). One year later (Fig. 3-36) there
was slight skin surface scarring, although the vascularity of
the telangiectasia was significantly diminished.
Figure 3-33.
Facial telangiectasias.
Figure 3-34. Lesion compressed (diascopy) and treated to end

point of blanching.
Figure 3-35. Posttreatment: feeding vessels and. especially,

central part of telangiectasia has been blanched.
Figure 3-36. One year later, vascularity of the telangiectasia has

been greatly reduced but some skin scarring has occurred.

H()I.MIUM:YTRIUM-ALUMINUM-GARNi: IT (HO: YAG)
H o l m i u m : Y A G laser, by virtue of its ability to vaporize tissue within a Quid m e d i u m , h a s p r o v e n most useful for intraarticular surgery of the t e m p o r o m a n d i b u l a r j o i n t ( T M J ) .
During a r t h r o s c o p i c s u r g e r y of the T M J this laser is used at
low power to m a k e releasing incisions in the rctro-discal
tissue. At higher p o w e r it is c a p a b l e of resecting fibrocartilage or bone. H o w e v e r , it is rare to require p o w e r greater
than 10 W. In general, pulse repetition rates (PRR) of
less than 10 W are sufficient. Useful characteristics of the
Ho:YAG pulsed T M J laser a r e listed in T a b l e 3 - 1 .
Table 3-4.
Tabic
3 - 4 . Suitable energy levels for the Ho: YAG pulsed
TMJ unit
5. Guerry TL, Silverman S Jr. Dedo HH. Carbon dioxide laser

resection of superficial carcinoma: indications, techniques
and results. Ann Oiol Rhinol iMryngol 1986;95:547-555.
6. Catone G. leaser technology in oral and maxillofacial surgery.
Part II: Applications. Selected Readings Oral Maxillofac Surg
l994;3(5):l-35.
7. Thomson S. Medical Lasers: How they work and how they
affect tissue. Cancer Bull I989;4I(4):203-211.
8. Hall RR. The healing of (issues incised by a carbon dioxide
laser. Br J Surg 1971 ;58(3):222-225.
9. Jacques SL. Laser tissue interaction. Cancer Bull
I989;41(4):211-218.
10. Jansen ED, van Lecuwen TO, Motamedi M. Borst C, Welch
AJ. Temperature dependence of the absorption coefficient of
water for incident infrared radiation. Lasers Surg Med
1994;14:258-268.
11. Polanyi TG. Laser physics: medical applications. Otolaryngol
Clin North Am 1983; 16:753-774.
12. Anderson R, Parrish K. Selective photothermolysis: precise
microsurgery by selective absorption of pulsed radiaiion. Science 1983;220:524-527.
13. l i c k in.in H, Barraco R, Sugar S, Gaynes E, Blau R. I-ascr irridectomies. Am J Ophthomal 1971 ;72(2):393-402.
14. Armon E, Laufcr G. The response of living tissue to pulse of
a surgical C 0 laser: transections of the ASME. J Biomech
F.ng 1985;107:286-290.
15. Reid R, Elfont GA, Zirkin RM, Fuller TA. Superficial laser
vulvectomy II. The anatomic and biophysical principles permitting accurate control of (hernial destruction with carbon
dioxide laser. Am J Ohstet Gynecol 1985;152:261-271.
16. Absten GT. Physics of light and lasers. Obstet Gynecol Clin
North Am 199l;18(3):407-427.
17. Walsh JT. Flotte TJ. Anderson RR. Deutsch T. Pulsed C O ,
laser tissue ablation: effect of tissue type and pulse duration
on thermal damage. Lasers Surg Med 1988;8:108-118.
18. Dobry MM, Padilla RS, Pennino RP. Hunt WC. Carbon dioxide laser vaporization: relationship of.scar formation to power
density. J Invest Dermatol 1989;93( 1 ):75-77.
19. Mihashi S, Jako GJ, Ine/.e J, et al. Laser surgery in otolaryngology interactions of C0 laser and soft tissue. Ann NY Acad
Sci 1976;267:263-294.
20. Gabbiani G, Ryan G B . Majno G. Presence of modified fibroblasts in granulation (issue and their possible role in wound
contraction. Experientia l97l;27(5):549-550.
2 1 . Loumanen M. Lehto V-P, Mem man JH. Myofibroblasts in
healing laser wounds of rat tongue mucosa. Arch Oral Biol
1988:33(1): 17-23.
22. Reid R. Dorsey JH. Physical and surgical principles of carbon
dioxide laser surgery in the lower genital tract. In: Coppleson
M, Monaghan JM, Morrow C P , Tattersall MHN, cds. Gynecologic Oncology. 2nd ed. London: Churchill-Livingstone;
1992:1087-1132!
23. Eriksson RA. Albrektsson T. Temperature threshold levels
for heat-induced bone tissue injury: a vital microscopic study
in the rabbit. J Prosthet Dent 1983;50:101-107.
24. Fuller TA. Laser tissue interaction: (he influence of power
density. In Baggish M. cd. Basic and Advanced Ixiser
Surgery and Gynecology: New York: Appleton-CemuryCrof(s;"l985.
25. Reid R. Physical and surgical principles governing expertise
wild (he carbon dioxide laser. Obstet Gynecol Clin North Am
1987;14:513-535.
26. Gillis TM, Strong MS. Surgical lasers and soft tissue interactions. Otolaryngol Clin North Am 1983:16(4):775-784.
27. Kamat BR. Carney JM. Arndt KA. et al. Cutaneous (issue repair following C O , laser irradiation. J Invest Dermatol
1986:87:268-271.
2
Average poweractual use in TMJ arthroscopic surgery:

Aiming Beam0.6-1.0 J/pulse at 8-12 Hz: Avg P = 6-12 W.
Peak Power|up to 5 J/pulse: Surgilase Ho:YAG].
ERBIUERBILM:YTRIUM-ALUMINUM-GARNETT (ER:YAG)
The E r b i u m : Y A G laser e m i t s at 2 . 9 4 n m and b e c a u s e of its
shorter w a v e l e n g t h it is a laser of inherently h i g h e r e n e r g y
than C O . or N d : Y A G lasers. Not only is it highly a b s o r b e d
by water, being c l o s e r to t h e h i g h e s t a b s o r p t i o n p e a k than
than is
C 0 , but it is also m o d e r a t e l y well a b s o r b e d by h y d r o x y a p atite, which is a major
m a j o r constituent of b o n e , d e n t i n , a n d
enamel. C o n s e q u e n t l y E r : Y A G h a s potential suitability for
laser-assisted s u r g e r y of hard tissues.
:
Er:YAG
X = 2.91nm
2.9lnm
E= 125-625mJ/pulse
PRR = Variable, usually < 2 0 H z
P=
P
= <ISW
<1SW
chromophore: water, h y d r o x y a p a t i t e
REFERENCES
1. Filmar S. Jetha N. McComb P. Gomel V, et al. A comparative
histologic study on the healing process after tissue transection. I. Carbon dioxide laser and clectromicrosurgery.
clectromierosurgery. Am J
Obstet Gynecol 1989:160(5.
1989;160(5, part 1): 1063-1067.
2. Sako K. Marchctta
Marchetta FC.
FC, Hayes RL. Cryotherapy of intraoral
leukoplakia. Am J Surg 1972; 124:482-484.
3. Pospisil OA. MacDonald DG. The tumor potentiating effect
of cryosurgery on carcinogen treated hamster cheek pouch.
Br J Oral Surg 1981; 19:96-104.
4. Poswillo DE. Cryosurgery and electrosurgery compared in
the treatment of experimentally induced oral carcinomas. Br
Dent J 1971; 131 (8):347-352.
35
4
Lewis
Preneoplasia of the Oral Cavity

dayman
Successful treatment of superficial mucosal disease of the

oral cavity mandates selective ablation of the abnormal epithelium including the parabasal layer attached to the basement membrane. The carbon dioxide laser does not impart
magical properties to the tissues, but it does provide a selective therapeutic advantage for the treatment of intramucosal
preneoplasia by avoiding damage to subjacent tissue,
thereby eliminating scar formation and the creation of oral
deformities.
Preneoplastic lesions of the oral mucosa include leukoplakia, erythroplakia, and oral submucous fibrosis, with
85% of the preneoplasias being accounted for by leukoplakia. The erosive variant of lichen planus has stimulated a
great deal of debate in regard to its malignant potential;
however, because this proclivity is still uncertain, erosive
lichen planus will not be considered, particularly as C 0
laser treatment of lichen planus does not alter its natural
history and is therefore ineffective. High risk of malignant
transformation is associated with dysplasia, multicentricity,
and anatomic site of the leukoplakias. " In regard to dysplasia the risk of malignant transformation is related to its
presence but not necessarily its grade. The most recent
World Health Organization (WHO) classification of leukoplakia will now include dysplasia as an indicator of risk of
transformation." The areas at highest risk for transformation
are the floor of the mouth, buccal mucosa, soft palate/anterior tonsillar pillar, tongue, and lip v e r m i l i o n . ' " Overall,
the transformation rate ranges from 0.13 to 28% with cancer being detected on average 2.5 years after the diagnosis
of the index leukoplakia.
Leukoplakias are categorized as homogeneous (Fig. 4-1),
nodular (Fig. 4-2), or speckled (Fig. 4-3). The latter occurs
on the buccal mucosa adjacent to the oral commissure,
which is a particularly notorious site for malignant transformation. Also worrisome are leukoplakias located on the anterior floor of the mouth covering the orifice of Wharton's
duct. In this location both dysplasia and invasive carcinoma
have the capability of invading directly into the lumen of
the salivary ducts. Different varieties of leukoplakia may
also occur simultaneously in the same patient (Fig. 4-4).
The snuff dipper's lesion is usually homogeneous but
may include areas of nodularity. Most commonly it is found
on the area of mucosa with which the smokeless tobacco
product is placed in contact. The buccal mucosa and the
2
13
VITAL STAINING
14
4-7
12
mandibular labiobuccal vestibule are the areas most likely

to be affected (Fig. 4-5).
Erythroplakias are erythematous, are often severely dysplastic, and may include microinvasive cancer at the time of
detection. Dysplasias are sharply demarcated from adjacent
zones of normal mucosa and they tend to be velvety in appearance. When the oral mucosal surface is dried with a
gauze sponge, the alteration in the reflective surface of the
oral mucosa becomes readily apparent (Fig. 4-6).
The clinical diagnosis of the subset of lesions at high
risk, the dysplastic leukoplakia, is facilitated by the application of a vital dye to the mucosal surface. The principle is
similar to that supporting the use of vital staining of the
uterine cervix as a method for detecting an abnormal transformation zone in cervical intraepithelial neoplasia (C1N),
which is the gynecologic equivalent of leukoplakia with severe dysplasia or erythroplakia.
39-
Toluidine blue (TN), a metachromatic vital dye, selectively

stains cytoplasmic sulfated mucopolysaccharides and nuclear DNA and RNA in rapidly dividing cells. Because it is
the transformed (premalignant or malignant) epithelial cell
that has escaped regulation by feedback inhibition of its
replication, possibly by alteration of one or more tumor
suppressor genes, this rapidly dividing cell, which accepts
the stain, is an abnormal cell. The specificity of vital staining with 1% toluidine blue dye ranges from 87 to 100%,
and the sensitivity ranges from 96 to 1 0 0 % . " False-positive rates are usually reported as being approximately 2.0%
and false-negatives as 2.5%. The basic technique for vital
staining requires removal of saliva from the area to be examined by washing with saline or dilute (3%) acetic acid
followed by drying of the suspicious mucosa with a gauze
sponge (Fig. 4-7). The TN is applied with cotton-tipped applicators and is allowed to remain in situ for 60 seconds
(Fig. 48). The area is now rinsed with acetic acid followed
by a water rinse (Fig. 4-9). Any remaining blue stain is subjectively ranked as being mildly (Fig. 4-9), moderately
(Fig. 4-10), or strongly (Fig. 4-11) positive. The examiner
is now guided directly to the site of most heavy staining as
being representative of the "worst" area of the lesion. In
this way, a directed (by the stain) biopsy of the lesion is
1 5
37
38
Figure 4-1. Homogeneous leukoplakia of ihe ventral tongue

and floor of mouth.
Figure 4-2.
Nodular luekoplakia of Ihe buccal mucosa.
Figure 4-3. Speckled leukoplakia occurring at its most common

location, the oral commissure. This is frequently accompanied by
Colonization with Candida albicans.
Figure 4-4. Multicentricity. Simultaneous occurrence of leukoplakia on the floor of mouth, ventral tongue and mandibular alveolar ridge. This patient also had leukoplakia of the hard and soft
palate, maxillary alveolar ridge, and buccal mucosa.
Figure 45. Typical snuff dippers leukoplakia at site of application of the tobacco product. Note staining of the teeth, which is
also typical. In Scandinavia, these lesions rarely, if ever, progress
to cancer, but in the United States, where snuff is formulated differently, they frequently do become malignant after a very long latency period.
Figure 4-6. F.rythroplakia of the ventral tongue. The lesion is

red, slightly raised and sharply demarcated from surrounding normal mucosa.
Figure 4-7. A new oral cancer of the alveolar ridge-buccal mucosa arising in a field of dysplasia 41 months after removal of a
primary tumor at the same site.
Figure 4-10. Moderately positive stain with toluidine blue: buccal mucosa, retromolar pad. and anterior tonsillar pillar.
Figure 411.
Figure 4-8. Alter application of 1% toluidine blue, there is

dense staining of the cancer as well as the peripheral tissue.
39
Strongly positive stain with toluidine blue.
performed, subsequent to which a definitive treatment plan

is formulated. Because oral precancer and cancer is frequently multicentric, it is wisest to stain in this way all of
Ihe high-risk mucosa of the tongue, floor of mouth, soft
palate-retromolar pad area, and the buccal mucosa. Staining of the more posterior area of the mouth may be carried
out at the time of planned surgery of the index lesion, when
the patient is sedated or anesthetized.
SURGICAL TREATMENT: C 0 LASER

2
Conventional surgical treatment, which consists of excision

with a scalpel, is successful and adequate for limited local
disease. The literature reports control rates of around
90%.
Failure becomes likely when this local treatment
is applied to extensive disease. Because the multicentric nature of precancer (the condemned mucosa concept) manifests itself as multifocal disease by occurring at multiple
sites in the oral cavity and oropharynx, a more global treatment concept than local excision is required. Failure rates
6 1 8 1 9
Figure 4-9. After washing with saline. Ihe residual blue slain
demarcates ihe area at the periphery of the lesion, which is most
likely to contain areas of dysplasia. This is a mildly positive stain.
40

4
following local surgical excision are as high as 3 3 % . Muliicentricity demands excision of topographically large areas
of mucosa. However, the denudation of large areas of oral
mucosae results in scarring and wound contraction as well
as postoperative pain, edema, and nutritional depletion. Despite the greatest care, the minimum thickness of tissue removed with a scalpel results in exposure and removal of the
submucosa. Both scarring and incomplete epithelial regeneration OCCIir. The traditional solution to this problem is to
replace the mucosa with a split-thickness skin graft. This,
however, is an unsatisfactory solution because skin dews not
function as well as mucosa. The graft ultimately contracts
as time passes, and the grafted skin covers remaining elements of regenerated mucosa that may be unstable. Lastly,
even for local treatment, site-specific consequences may
dictate against locally invasive surgery that induces scarring. For example, removal of the thinnest layer of mucosa
over the opening of Wharton's or Stensen's duct may cause
scarring, glandular obstruction, and infection. Excision of
large lesions at the oral commissure causes deformity of the
oral stoma.
The advantage of replacing traditional excisional techniques with C 0 laser photoablation is that the laser permits removal of the damaged epithelium with as little as 0.1
to 0.2 mm of reversible thermal injury to the submucosa.
Precise control of thermal damage makes it possible to remove even the epithelium directly over the salivary duct
orifices without inducing sialodochitis and glandular obstruction (Figs. 412 and 413). Extensive areas of mucosa
may be ablated without skin grafting because epithelium is
regenerated from normal tissue at the wound periphery in
no more than 5 weeks for lesions as large as 40 c m . After
healing, the mucosa al risk is still observable by direct visual inspection during recall examination. Of equal importance, there is little postoperative swelling and patients may
take oral fluids immediately after surgery. These patients
may be operated upon as outpatients, and there is usually
no bleeding or swelling. Pain, which is highly variable, is
easily managed with oral analgesics, rarely lasts more than
a few days, and only occasionally shows a secondary in2
crease in intensity on days 3 to 5, which then abruptly terminates. "

The CO, laser beam itself is delivered either by a handpiece (Chapter 3, Fig. 3-1) or a microscope (Chapter 3, Fig.
3-2) delivery system. The power density is controlled by
enlarging the spot size (defocusing the beam) either by direct observation of the coaxial red helium-neon (HeNe)
laser aiming beam or by direct observation of the tissue effect. An estimation of the laser effect is gauged by a pretest
in which a wooden tongue blade is exposed to individual
pulses from the laser and then the spot size is directly measured (Fig. 4-14). In this way. the spot size, power, and application time for each of the pulses to be used during
surgery are "calibrated" on a wooden tongue blade. The
power density is approximately equal to the exit power of
the laser (generally 15 to 40 W), divided by the square of
the spot size (in cm ). Using this rough approximation, one
can achieve a power density of 500 to 1250 W/cm for ablation by evaporative vaporization (ablative vaporization).
Modes of application include continuous wave (CW) or
variations of a pulsed mode. These latter may be gated or
"chopped" CW or, preferably, rapid superpulsed (RSP)
(Fig. 4-15). For ablation, RSP is most desirable because the
19
21
Figure 4 - 1 2 .
Lesion over duct.
Figure 4 - 1 3 .
Vaporization of tissue over duct without damaging
duct. No sclerosis or submandibular gland obstruction occurred
postoperatively.
Figure 4 - 1 4 .
Tongue blade: spot size.
Figure 417.
TIME (msec)
Figure 4-15.
Fibrin coagulum day I.
From the viewpoint of the microscopist, the laser wound

(Fig. 4-16) has the following c h a r a c t e r i s t i c s . ' The superficial epithelium is homogeneously carbonized. Interspersed in the zone of thermal damage are "boiled away
vesicles." The deeper layers of epithelial cells show intercellular voids as a sign of thermal damage. Denatured protein is found in the form of a coagulum near the wound surface. However, there is minimal damage to adjacent tissue
across an area of potentially reversible thermal injury of
150 to 300 u-m. The amount of collagen found in the wound
is diminished and epithelial regeneration is somewhat delayed and irregular. " However, during healing there is minimal inflammatory response, and compared with scalpel or
cautery wounds, there are fewer myofibroblasts and very
little wound contraction. - - In vivo, reepithelialization
occurs within 4 to 6 weeks, but may be as brief as 2 weeks
in cases having ablation of less than 2 c m of mucosa. During the entire healing process, tissues remain soft and
pliable.
Not only are small blood vessels and lymphatics sealed
by the laser, but nerve endings are "rounded off." This latter
may account for some of the diminution in postoperative
pain anecdotally reported, but this is not uniformly consistent. A fibrin coagulum forms in the first 24 hours (Fig.
4-17), which is slowly replaced without the occurrence of
significant wound contraction.
712
CW (chopped or gated) and RSP profiles. (Courtesy of Lara d a y m a n . )
41
8,22
23
I8
24
25
Figure 4 - 1 6 .
Laser wound: soft tissue.
pulse width may be designed to be as brief as 250 to 950

u,s. which is shorter than the thermal relaxation time of oral
soft tissues. At these power densities of 500 to 1250 W/cm ,
and using the pulsed mode at 50 to 250 pps, with a peak
pulse power of 500 to 1000 W per pulse, in the range of 120
to 600 mJ/pulse the fluence actually applied to the target tissues is adequate to ablate them while limiting thermal injury
to the subjacent normal tissue to less than 200 p.m. As the
pulse width lengthens beyond I msec, thereby exceeding the
thermal relaxation time of the target tissue, the region of lateral thermal damage exceeds 200 u-m.
2
SURGICAL TECHNIQUE
The oral mucosa is assessed and the requisite biopsies are
obtained in the manner previously described. At the time of
laser surgery, the vital staining is repeated. Local anesthesia
is used unless the patient receives a general anesthetic. No
pre- or perioperative antibiotics are given and no antiseptic
preparation solution is used for the mouth. The face is protected with wet surgical drapes and the eyes are covered. If
endotracheal intubation is utilized, the hypopharynx is
packed with a wet gauze.
42
Lasers i n M a x i l l o f a c i a l S u r g e r y a n d D e n t i s t r y
After identifying the extent of the pathology, the laser is

set at an average power of 20 to 30 W for pulsed modes,
and 15 to 20 W for CW mode. The spot size will vary between 2 and 3 mm in diameter. The clinical end point for
ablation of the mucosa is to cause a "rapid bubbling of the
epithelium which is opalescent in color and is accompanied
by a crackling noise." The lesion (Fig. 4-18) is outlined
with a suitable margin of several millimeters and then parallel lines of application of the laser are placed within the
marginal outline (Fig. 4-19). This is called rastering. After
completion of this first layer of lasing, there should be almost no carbonization. If the wound appears blackened,
there has been excessive heat conduction because of prolonged contact between the laser beam and the tissue as a
result of excessively slow hand speed in moving the handpiece or microscope joystick-directed laser beam across the
lesion. The more heat conducted, the greater the desiccation
occurring at surgery.
A moist gauze is now used to wipe away the treated area
of mucosa. This allows one to assess the depth of penetration of the laser. A pale pink base that does not bleed indicates removal of the epithelium at the level of the basement
membrane (Fig. 4-20). If there are scattered droplets of
blood, then the superficial aspect of the submucosal plane
has been breached. If the depth of penetration is too superficial, a second raster is applied to reach the required depth,
which results in removal of the entire thickness of the epithelium (Figs. 4-21 and 4-22). In areas of thick hyperplasia as for nicotine stomatitis or fibroepithelial hyperplasia of
the palate (see Chapter 6), several layers of rastering may be
required. The submucosal layer is identified both by the appearance of blood vessels and by the appearance of tissue of
granular appearance and yellow color. At the conclusion of
surgery the abnormal (issue has been removed and there
should be no bleeding except where it was necessary to extend tissue removal into the submucosa. as may be required
in this case of papillary hyperplasia of the palate where four
rasters are needed for complete tissue removal. The fibrin coagulum that formed within the first 24 hours is still present at
one week (Fig. 4-23). Complete mucosal reepithelialization
and healing has occurred within 5 weeks (Fig. 424).
21
Figure 4-18.
Lesion: papillary hyperplasia of the palate (I0X).
Figure 4-19.
Outline of lesion with RSP. CO, laser.
Figure 4-20. First layer of treated tissue wiped away with a

moistened gauze sponge (16X).
Figure 4-21.
Second raster (16X).
43
HEALING
Epithelial resurfacing is rapid. A fibrinous coagulum tonus
within the first 24 hours, which is progressively replaced by
epithelium originating from the wound edge. Ablation of
less than 2.0 c m of mucosa uniformly results in complete
epithelial resurfacing in less than 3 weeks. Larger mucosal
ablations (5.0 c m or more) require between 4 and 5 weeks.
However, in one patient, even an extensive insult of more
than 60 c m still required only 6 weeks for complete resurfacing. The major cause for delayed healing is from the creation of charring (carbonization) of the tissue. This occurs
as a function of time of contact of the laser beam with the
target tissue. Repeated application of the laser without removing the char from the previous exposure will dramatically increase heat transfer to the nontarget tissue. This will
retard healing. Postoperative complications potentially include bleeding, infection and damage to teeth, lips. etc.. or
ignition of the endotracheal tube by laser "mishaps." In the
treatment of 148 leukoplakias by ablation technique in the
series from Sinai Hospital of Detroit, there were three cases
of inadvertent single pulse laser hits to teeth (1) and lip (2).
There were no serious complications.
2
Figure 4-22. Residual lesion after wiping away tissue treated by

second raster* I6X).
RESULTS
Reports from the literature on the subject of recurrence alter
laser ablation of leukoplakia (dysplasia not specified),
range from 4.5 to 22% at 3-year follow-up to 10 to 22% at
37- to 55-month f o l l o w - u p .
Series with less than 2year follow-up may report spectacular results of lack of
recurrence; however, this attenuates with time. Therefore,
these patients require long-term surveillance, particularly if
they continue to smoke and drink. There are no reports in
the literature that laser treatment enhances malignant trans
formation of oral preneoplasia. One report reported recurrence in five of seven cases of leukoplakia, a frequency
that is not substantiated by reports of series with significant
numbers o f c a s e s .
"' '
2 5 1 5 1 8 2 6
26
Figure 4-23. Fibrin coagulum still present after one week.

Reepithelialization commencing from wound periphery.
27
2 1 4 1 8 1
2 6
2 7
LEUKOPLAKIA
Figure 4-24. Reepithelialization complete after 5 weeks. Condition remained stable for the next 28 months when the patient was
lost to recall examination.
The most important subset of oral preneoplasia (precancer)

is leukoplakia, a clinical term describing a white lesion of
the oral cavity that cannot be removed by wiping the
mucosa with a gauze sponge, and to which no other specific
diagnostic category may be assigned. Histologically
leukoplakias may range from simple hyperkeratosis to
intramucosal dysplasia or neoplasia. The ideal treatment is
by free-beam C 0 laser because ablation will completely
remove the lesion. Furthermore, the mucosa will almost always reepithelialize in less than 4 to 6 weeks, with no scar2
44
ring. There is no reduction of oral opening and the oral mucosa remains soft, moist, and pliable. This is particularly
important because leukoplakia may affect many different
locations within the oral cavity, may well recur, and may
ultimately affect a large surface area of mucosa. Therefore,
it is a great advantage to have the mucosa return to an undamaged state because retrcatment may be necessary.
Although a recurrence rate of zero was reported from
Scmmelweis University in Budapest for a selected group of
126 patients with leukoplakias treated by ablative vaporization at 10 to 15 W |power density (PD) not specified] or by
excision at 20 to 25 W (PD not specified), clinical followup had been quite brief, at only 16 to 28 months. This suggests that there is certainly no enhancement of malignant
transformation by laser treatment during the early postoperative observation period. However, one must be mindful of
the fact that most of the recurrences, which also may include progression to carcinoma, won't appear for about 30
months after identification of the index leukoplakia."
My own series of 114 mucosal precancers occurring in
70 patients included 41 simple leukoplakias and 73 dysplasias that were treated by laser vaporization and followed
for a minimum of 2 years to a maximum of 8 years. Of the
dysplasias, 68% were located in the most dangerous sites
for malignant transformation: floor of mouth, tongue, soft
palate, anterior tonsillar pillar, and retromolar pad. This series is very heavily skewed toward high-risk leukoplakias,
with 64% of all the index leukoplakias being dysplastic.
Seventeen lesions in 70 patients escaped control after laser
treatment, with eight relapsing as leukoplakias and nine
transforming into cancer. Therefore, the overall failure rate
(relapse, progression, or development of new lesions) during the 8-year period was 24.2% of which 12.9% (9/70) developed cancer and 11.3% relapsed as leukoplakias. Of the
cancer occurrences, eight of the nine (88.9%) arose from
areas of previous dysplasias. From the point of view of the

individual lesions rather than patients, the failure rate was
only 9.6% (11/114) during the first 6 years of observation,
which compares favorably with laser success rates of 10 to
22% reported in the literature after 37 to 55 months' surveillance.
5 ls
Horch et al. had a 22 to 28% recurrence rate for lesions

treated by ablation with a handpiece. Roodcnburg et al.'"'
followed 70 patients with 103 leukoplakias. 33 of which
were dysplastic and therefore probably at higher risk for recurrence or malignant transformation. Laser ablation was
carried out using the microscopic technique al 10 to 15 W
output (PD unspecified but probably approximately 375
w/cnr). A recurrence rate of only 10% in 103 leukoplakias
observed from 7 to 55 months after ablation was reported.
There was no degeneration of any case into cancer and recurrence could not be correlated with degree of dysplasia.
Postoperatively, in all scries listed above (over 700 patients) reepithelialization occurred within 3 weeks for all
lesions smaller than 2 c m and within 5 weeks for larger
lesions. There was no scarring and no postoperative
swelling, although soreness occasionally interfered with
food intake. About one third of patients required analgesics
for the first 24 hours after surgery, and only the rare patient
required analgesics after day 5* However, there was an
unpredictable subset of patients that required no analgesics
immediately after surgery, but that later required two or
three days' use of analgesics, generally between days 3 and
5. Narcotics are rarely required, with nonsteroidal analgesics being the drug of choice. All patients were treated as
outpatients, using local or general anesthesia or intravenous sedation, as dictated by site and extent of lesions,
by patient emotional needs, and by the need to use the microscope.
2
Five case reports demonstrate the technique.
Preneoplasia o f the O r a l Cavity
CASE 1: LIP LEUKOPLAKIA WITH

DYSPLASIA
A 59-year-old white man with a leukoplakia containing
areas of dysplasia of the lower lip was referred for removal
of his lesion (Fig. 4-25). Vital staining with TN (Fig.
4-26) resulted in a mildly positive stain. The handpiece delivery system (Fig. 4-27) was chosen using a spot size of
2.5 mm (1.8-mm vaporization spot), 92 PPS superpulsed
mode, PD = 617 W/cm , 216 mJ/pulse, P = 20 W, superpulsed by the 125-mm handpiece, T E M (transverse electromagnetic mode). Note the guide tip extension of the
handpiece, which indicates that the laser is at its focal point
at the tip of the handpiece. Moving the tip away from the
target tissue results in reduction of the power density. The
initial raster (Fig. 4-28) results in crackling and bubbling
of the epithelium with slight brown discoloration of the
treated mucosa. After wiping away the treated mucosa
(Fig. 4-29) one may judge the thickness of tissue removal
by observing the border of the untreated mucosa. The
slightly yellow color of the base of the treated area indi2
0 0
Figure 4-25.
Figure 4-26.
Dysplastic leukoplakia of lower lip.
Vital staining with TN is mildly positive.
45
cates that tissue removal has included the basement membrane.

Any residual area requiring biopsy for assessment may
be excised with the scalpel (Fig. 4-30) and bleeding from
the base of the biopsy site may be controlled with the laser.
A biopsy from an area of laser treatment at a magnification
of I00X (Fig. 4-31) demonstrates that heat artifact is restricted to a thickness of approximately 0.21 mm. Note that
the epithelium has been completely removed as was desired. At the conclusion of surgery, wiping away the treated
mucosa (Fig. 4-32) demonstrates a clear demarcation between the normal epithelial border and the de-epithelialized
treatment region. The dark brown area on the left of the illustration shows the discoloration secondary to the heat effect from application of the laser to control bleeding at the
base of the area excised by the scalpel. At 13 days postoperative (Fig. 433) fibrin is present covering the wound surface and there are some signs of reepithelialization occurring. By 22 days (Fig. 4-34) healing is about 50% complete
and by one month (Fig. 4-35) reepithelialization has been
completed and maturation is occurring. At 5 months the lip
looks normal (Fig. 4-36).
Figure 4-27.
Laser handpiece in position to start treatment.
Figure 4-28. First raster at PD = 460 W/cm (2.5 mm HeNe

guide spot, 1.8-mm vaporization spot, 92 PPS superpulsed. average power of 20W, 216 mJ/pulse l.l-ms pulse width with 125-mm
handpiece).
46
Figure 4-29. Tissue treated by first raster removed by wiping

with wet gauze. Note sharp border of untreated mucosa. Full
thickness of mucosa has been removed.
Figure 4-30.
biopsy.
Selected, TN stained tissue sampled by excisional
Figure 4 - 3 1 . Heat effect at base of treated area at edge of

biopsy sample: depth of thermal damage is 0.21 mm.
Figure 4 - 3 2 . Completion of treatment. Dark color on right from

coagulation of base of biopsy area with laser.
Figure 4 - 3 3 .
Figure 4 - 3 4 .
nent.
Healing at 13 days. Fibrin still covers wound.
Healing ai 22 days. Reepitheliali/ation is promi-
Figure 4-35. Thirty-three days. Reepithelialization has been

completed and mucosa has started to mature.
47
Figure 4-36. Five months. Maturation completed during second

month. Mucosa has been stable for 12 months.
48
CASE 2: LEUKOPLAKIA, ANTERIOR FLOOR

OF MOUTH AND LINGUAL GINGIVA
A 56-year-old man presented with a very subtle erythroleukoplakia of the anterior floor of the mouth centered on
the lingual frenulum and extending onto the lingual gingiva
(Fig. 437). Staining with TN was mildly positive. Treatment: The lesion was ablated with a C 0 laser using the
handpiece (125 mm focal length), average output power 15
W. RSP at 104 PPS. and PD approximately 375 w/cnr. To
ablate the lingual gingiva a front surface mirror was used to
change the direction of the beam (Fig. 4-38). Spot size was
between 2.5 and 3.0 mm. average output power 20 W at 58
PPS. The "slower" beam was used to permit easier coordination of energy delivery between the handpiece, mirror,
and target tissue.
Ablation of the mucosa included the region directly adjacent to the orifices of the submandibular ducts. Note the ab2
solute absence of charring of the native tissue at the site of

ablation after removal of the layer of treated tissue (Fig.
4-39). Consequently uncomplicated complete epithelialization occurred within 30 days (Figs. 440 to 4-43). There
was no transient obstruction of the submandibular salivary
glands, no loss of attached gingiva, and no recurrence at 6
years' follow-up examination (Fig. 4-44).
Six years after treatment, an erythroplakia reappeared
that was restricted to the lingual frenulum and the same
laser vaporization procedure was repeated to remove the
second erythroleukoplakia. Again, healing was uncomplicated, with complete epithelial resurfacing having occurred
in approximately 30 days. At reoperation the tissue both of
the floor of the mouth and of the lingual gingiva was noted
to have the same characteristics of plasticity and response
to the laser energy as had been the case for treatment of the
index lesion, i.e., there was no long-term damage to the native tissue from the first operation 6 years before.
Figure 4-37. Subtle erythroleukoplakiu of floor of the mouth

originating at the base of the frenulum and extending over the submandibular duct orifices across the lingual sulcus and onto the lingual gingiva.
Figure 439.
lated.
Lingual gingiva, sulcus, and area over ducts ab-
Figure 4-38. Use of front surface mirror to redirect the beam.

Spot size is enlarged until PD is low enough not to damage the
mirror.
Figure 4-40. Note sharp demarcation between normal epithelium and ablated area. Few areas of pinpoint bleeding indicate
deeper penetration of beam. Note absolute absence of charring of
base of ablation region.
Figure 441. First postoperative day. Note deposition of fibrin

within the wound.
Figure 4-42 postoperative: 10 days. Reepethilialization well
established.
49
Figure 4 - 4 3 . Postoperative: 30 days. Epithelialization complete.
Figure 4-44.
tached gingiva.
Postoperative II months. No loss of lingual al-
50
CASE 3: BUCCAL MUCOSA

A 54-year-old white woman with a 35-pack-year cigarette
smoking habit who did not drink alcohol presented with a
leukoplakia of the buccal mucosa. The preoperative biopsy
was interpreted as hyperkeratosis with mild atypia. The left
buccal mucosa demonstrated a 2 X 3 cm area of leukoplakia that stained mildly positive with toluidine blue (TN).
The microscope-guided superpulsed C 0 laser was used
2
with the power density adjusted to achieve the desired e:

feet of creating opalescent crackling of the mucosa. This n
quired an estimated average power density of approx
mately 585 W/cnr (15 W) average beam output powe
HcNe aiming beam spot size approximately 2 mm, and
true spot size of 1.6 mm. 46 PPS with a pulse width of 4.
ms. The worst area of the mucosa was excised for anothe
histologic interpretation. The mucosa had completely resui
faced in 4 weeks (Figs. 4-45 to 4-48).
Figure 4-45. Buccal mucosa: area of mildly positive staining

with TN indicates "worst" area of lesion (I0X).
Figure 4-47. Tissue subject to first raster removed. Note lack of

bleeding after ablation of epithelium only. Note sharp demarcation
between normal epithelium and treated area ( 1 6 X ) .
Figure 4-46. First raster completed. Mildly stained area saved

for excisional biopsy (6X).
F'igure 4-48. Mucosa completely healed at 4 weeks. Patient still

is disease free at 4.5 years.
CASE 4: BUCCAL MUCOSA

A 58-year-old while man with erosive lichen planus and
lichenoid dysplasia of both buccal mucosae. Protocol:
Vital staining with TN resulted in a mildly positive result.
51
Lesion removed in two rasters at an average power of 15

W, true RSP mode, HeNe spot of 2.5 mm (true vaporization spot size of 1.8 mm), giving an estimated PD of 463
W/cm at 150 mJ/pulse at PRR = 118 Hz (Figs. 4 - 4 9 to
4-54).
2
Figure 4-49. Mildly positive staining with TN. Red HeNe aiming beam centered on stained tissue (6X).
Figure 4-52. Second raster halfway completed. Note color

change in upper one half of treatment field. The yellow color indicates second plane of ablation has been achieved al the level of the
submucosa.
Figure 4-50. First raster completed, Note symmetry of "rows"

of tissue ablated. There is no charring. Note distinct boundary between normal mucosa and treated area.
Figure 4-53. Epilhelialization quite pronounced at 7 days. Epithelialization 80 to 90% complete at 13 days. Process complete
within 28 days.
Figure 4-51. Rastered area wiped away with moist gauze

sponge. A few areas of bleeding noted indicating extension of
laser effect into submucosa.
Figure 4-54.
norma].
Two years. Mucosa is supple. Treated area appears
52
CASE 5: LEUKOPLAKIA OF TONGUE

This 28-year-old white woman with no risk factors developed a TINOMO squamous cell carcinoma of the left posterolateral tongue border and a dense leukoplakia simplex
covering much of the anterior dorsal tongue surface (Fig.
4-55). Three previous biopsies of the "worsf'-appearing
areas of her dorsal tongue demonstrated hyperkeratosis with
mild atypia. Incisional biopsy of the tongue cancer was inlerpretated as well-differentiated squamous cell carcinoma.
Examination under anesthesia and vital staining also revealed a third white lesion of the left buccal mucosa. This
stained only faintly with toluidine blue. No prophylactic antibiotics were administered.
The dorsal tongue lesion was vaporized with a true rapid
superpulsed C 0 laser and 46 PPS, average power of 20 W,
spot size of 2.0 mm at a fluence of approximately 435
mJ/pulse width, a peak pulse power of 500 W, at a pulse
width of approximately 4.2 ms, and an interpulse distance
of 19 ms. Two rasters were applied with the target tissue
being wiped free of debris between applications. There was
almost no char and no bleeding (Figs. 4 - 5 6 to 4-58). The

cancer was then removed with the same laser at 30 W average power using the handpiece in focus at 0.3 mm spot size
for incision and defocused to control bleeding. The partial
glosscctomy wound was sutured closed. Estimated blood
loss for the resection was 15 mL. Reepithelialization of the
surface of the tongue was 100% complete at 27 days. Mild
hyperkeratosis was present immediately after healing was
completed.
Figure 4-57. Debris removed by wiping with gauze sponge.

Note yellow color in central portion where vaporization was deeper
especially in center area which had stained positively with TN.
Figure 4-55. Leukoplakia affecting majority of surface area of

dorsal tongue.
Figure 4-56. First, horizontal, raster used to remove surface epithelium. Note HeNe aiming spot of approximately 2.0-mm diameter. Rastering half completed.
Figure 4-58. Surface reepitheliali/.ed at 3 weeks. Mature mucosa shown at 9 weeks.
Papillomas and Human Papillomavirus
Richard Reid, Myron Strasser
Although controversial, evidence from immunoperoxidase

and DNA hybridization studies have implicated human papillomavirus (HPV) as the etiologic agent for many diseases within the oral cavity. The possible relationship of
HPV to the development of squamous cell cancer (SCC) of
the head and neck merits an expanded discussion of HPV in
this chapter. Well-established association of HPV with oral
cavity disease includes condyloma acuminatum (HPV
45), 1,2 verruca vulgaris (HPV 6 and 1 6 ) , 2 - 4 squamous papilloma (HPV 6, I I ) , 2 5 focal epithelial hyperplasia (HPV 13
and 32) 1 , 2 ' 4 and squamous cell carcinoma (HPV 16 and
18) . 1 , 2 , 6-12 Human papilloma virus has also been detected in
diseases that do not show obvious viral stigmata, such as
ameloblastoma (HPV 16, 1 8 ) , 1 3 - 1 S leukoplakia (HPV
16)1,2.9.12,16 lichen planus ( HPV 16 )1.2.12 w h j t e s p o n g e
nevus (HPV I 6 ) , 1 7 and odontogenic keratocyst (HPV 16) 18
In head and neck surgery as in other specialties, carbon
dioxide ( C 0 ) laser surgery is gaining increasing acceptance in the treatment of such HPV-associated lesions as
condyloma acuminatum, verruca vulgaris, squamous papilloma, and leukoplakia. The use of the C 0 laser as an alternative instrument for excision is also useful in the resection
of oral squamous cell c a n c e r . 1 7 , 1 9 , 2 0
base pairs and a molecular weight of 5200 d. The viral

DNA is combined with histones (derived from the cellular
pool of the natural host) to form a small chromosome of
which the viral DNA constitutes only 12% of the virion by
weight.
When the nuclear proteins are stripped away, the viral
DNA assumes a supercoiled shape (form I). Supercoiling is
visible on electron microscopy and is also detectable by
electrophoretic migration because of the relatively rapid
mobility of these tight circular molecules. Cleavage of only
one DNA strand by bacterial enzymes (restriction endonucleases) results in a relaxed circle, form 11 (Fig. 5-2), while
cleavage of both strands at a single site produces a linear
molecule form III, 20 which migrates more slowly in electrophoresis gels (Fig. 5-2C).
BASIC VIROLOGY
Taxonomy
Papillomaviruses are small, double-stranded DNA viruses 12,21,22 that manifest qualitatively similar biologic
characteristics. All papillomaviruses exhibit a similar pattern of genetic organization. DNA sequencing studies have
shown that broadly equivalent areas of protein coding potential, known as open reading frames (ORFs), are preserved through the genome. 2 2 However, the actual nucleotide sequences within these ORFs are widely disparate;
hence, individual papillomaviruses show enormous differences in species specificity, site predilection, and degree of
oncogenicity. Human papillomaviruses compose the largest
group, with more than 50 known t y p e s 3 , 6 , 2 3 (Fig. 5-1).
DNA
Organization
The papillomavirus genome is a closed, circular, doublestranded DNA molecule, with a molecular length of 7,900
Viral
Genetic
Function
As previously mentioned, alignment of sequenced papillomavirus DNAs revealed a highly conserved pattern of protein-coding potentialthe ORFs. In essence, each of these
ORFs represents a viral gene. Virus-specified proteins apparently determine such characteristics as host range, tissue
tropism, and the clinicopathologic consequences of infection.
The papillomavirus genome can be subdivided into
three functional portions. The "early" or " E " region is the
longest segment, representing about 4 5 % of the viral
genome. This region contains five ORFs that code for proteins; these either induce cell transformation or control
viral DNA replication. The "late" or " L " region, which
comprises about 4 0 % of the viral genome, contains two
ORFs that are essential to vegetative viral replication. The
third region of the genome is the upstream regulatory region (URR). This is a noncoding segment, representing
about 15% of the viral genome. It contains the origin of
DNA replication, several promoters (sequences needed to
initiate viral RNA synthesis), and several enhancers (sequences that increase the rate of RNA transcription). The
URR is located between the end of the LI ORF and the
beginning of the E5 ORF. The URR is the genetic interval
most likely to be divergent among viral types, and some of
these differences have been correlated with changes in virulence and oncogenicity. 2 1 , 2 2
55
Figure 5-1. Genome organization of human papillomaviruses (HPV) la. 6b, 8, 16, bovine papillomavirus (BPV) I,
cottontail rabbit papillomavirus (CRPV), and deer papillomavirus (DPV). Open reading frames were displayed by
means of the computer program FRAMES and are indicated by open bars. Dotted lines within the frames represent
the first methionine codon, which could serve as a start point of translation. In HPV 16 the El frame appeared to be
split in the originally published sequence. A continuous El, which was found in four new isolates, is indicated by
dotted lines. Stippled areas of the genome bar represent coding sequences and black regions stand for so-called noncoding regions. (From reference 35, with permission.)
94
35
Papillomas a n d H u m a n Papillomavirus
57
Figure 5-2. (A) Structure, (B) genomic DNA, and (C) protein pattern of papillomavirus particles. Capsids were
stained with phosphotungstic acid. DNA was extracted by phenol treatment. DNA of phage PM2 was included as a size
standard (97 kd). The molecules appear as supertwisted covalently closed circles (CCC) or open circles (OC). Proteins
were separated by polyacrylamide gel electrophoresis after disruption of viral particles by sodium dodecyl sulfate
(SDS). VP1 and VP2@ represent structural proteins of the capsid shell. Histones H3, H2b, H2a, and H4 are associated
with the viral DNA and appear in preparations of DNA-containing capsids. (From reference 35, with permission.)
PATHOPHYSIOLOGY OF INFECTION
Inoculation
Inoculation occurs when material containing relatively
large numbers of virus particles (e.g., exfoliated superficial
cells or keratin fragments) lodge in sites of microtrauma
within a susceptible epithelium. HPV virions penetrate to
the basal layer of the damaged epidermis, where they then
shed their outer protein capsid. The viral genome crosses
the cell membrane and is then transported to the cell nucleus. There the infecting genome is translated and transcribed, thereby producing various virus-specific proteins.
Transforming proteins induce conducive host cell functions,
while regulatory proteins control viral gene expression.
may lead to active viral expression. Capture of the host cell

results in pronounced alteration in cell growth in the basal
layers, increased replication of the viral genome in the middle layers, and viral cytopathic effects in maturing cells.
Such progression from episomal to productive viral replication depends upon the interplay of cell permissiveness, viral
type, host susceptibility, and cofactor activity. Two basic
types of cell-virus interaction are recognized: vegetative
(productive) and transforming (nonproductive). Patients
with high-grade dysplasia and those in whom oncogenic
HPV subtypes are identified are at risk for higher recurrence rates after treatment.
22
Incubation
Phase
Initially the virus exists as a self-replicating extrachromosomal plasmid, termed an episome. Proteins specified by the
early viral genes result in an initial burst of episomal replication, producing additional viral genomes that will gradually transfect neighboring cells. Because these episomal
viral plasmids are programmed to replicate with each cell
division, there is little dilution of viral copy numbers over
the succeeding years.
22
Active
Expression
Phase
Many exposed individuals will remain in long-term latent

infection; however, in susceptible hosts, viral colonization
CLINICAL AND LABORATORY

EVALUATION
Comprehensive history-taking can help in establishing the
diagnosis of HPV-related oral lesions. Consider, for example, a patient presenting with multiple painless, sessile, soft
whitish papules on the lower labial mucosa and lateral
tongue border (Fig. 5-3). Knowledge that such a patient has
an limit ancestry would raise a high degree of suspicion for
focal epithelial hyperplasia. When a definitive diagnosis
cannot be established by history and clinical examination, a
specimen must be obtained for microscopic and/or other
laboratory evaluation. The decision to perform incisional
versus excisional biopsy depends on such considerations as
lesion size, location, and possible diagnosis of cancer.
58

margins that are clear of cytopathic changes. The pathologist is able to examine the margins of the specimen because
the laser destroys tissue in a precise manner, causing a central /one of tissue vaporization, and only 100 to 200 u.m of
tissue necrosis adjacent to the points of impact." - In contrast, during vaporization strategic tissue biopsies need to
be obtained prior to vaporization. Laser vaporization (ablation) or painting away of the oral lesions are performed in a
layer by layer method (rastering). Carbonization produced
by vaporization should be wiped away to improve visualization of the lased areas and to decrease crater temperature,
thereby decreasing thermal conduction into the adjacent tissue. Tissue irradiance of this carbonized material raises the
temperature from I00C (the boiling point of water) to
more than 600C (the temperature of a red-hot coal). After
the surgeon is confident that the lesion has been completelyremoved, a carbonized layer should remain to help maintain
hemostasis of the small vessels that have been sealed by the
laser " if the depth of removal extends into the submucosa.
A fibrous coagulum replaces the carbonized layer after approximately 24 hours. Epithelialization of the laser wound
occurs at approximately I week if its surface area is less
than 1.0 c m . Larger wounds take 4 to 5 weeks to reepithelialize. Many authors have noted that laser wounds heal
slower than scalpel wounds, being delayed from 2 to 4
days. There will be slight but pathologically unimportant
shrinkage at the base of the specimen being removed for
biopsy.
Disadvantages of using the C 0 laser include higher cost
for the equipment, limited availability, slower healing of
the laser wound, and the possibility of the HPV DNA being
liberated in the plume of laser vapors. It is mandatory to
use a high-speed suction system to evacuate the vaporized
material. The potential infectivity of virus panicles found in
the effluent plume is under intense investigation at present.
WARNING: If you smell the plume through the mask,
there is a chance of inhaling particulate matter that may
carry virus particles or whole virions. Although there is lack
of consistent proof of the infectivity of these particles, prudence in regard to mask selection is strongly recommended.
8
29
30
Figure 5-3. Focal epithelial hyperplasia of lateral tongue.

(Photo courtesy of Scott Boyd. D.D.S.. Ph. D.)
If the area under investigation is large or if one suspects

malignancy, incisional biopsy is preferred. Conversely,
small lesions that appear clinically benign may be excised.
For both cases, tissue is sent to the pathology laboratory for
routine processing. In the majority of cases, an oral pathologist will make a firm diagnosis with the light microscope,
aided by clinical description and historical details. In difficult cases, if identification of the specific HPV is needed,
ancillary testing is available. Viral analysis of formalin
fixed tissue is done by either polymerase chain reaction or
in situ DNA hybridization . 2,3,8,9,14 ' 24-27 Greater sensitivity
can be achieved by filter hybridization of fresh tissue (e.g.,
a cellulose swab or a frozen biopsy sample). Virus testing is
still expensive and is not available for routine use.
31
19
32
33
CARBON DIOXIDE LASER

Excision and vaporization are the two techniques employed
in soft tissue surgery. Excision is the preferable mode for
removal of oral lesions, because this method permits histologic confirmation of the diagnosis and establishment of
Papillomas a n d H u m a n Papillomavirus
2
CASE 1: PAPILLOMAS
(Courtesy Lewis dayman, D.M.D., M.D.)
A 5-year-old African-American girl presents to her family
doctor because of recurrent lip biting. Examination shows a
5-mm "wart" on the inner aspect of the mucosal surface of
her left lower lip. With the lip in repose, this abuts a second
similar lesion affecting the interproximal papilla between the
left lateral incisor and canine teeth (Fig. 5-4). These are
"kissing" lesions. A similar lesion is also noted adjacent to
the upper right lateral incisor. A clinical diagnosis of oral papillomas is made. The parents are reported to be free of oral
or genital papillomas by report from their family physician.
The patient is brought to the operating theater for photoablation by vaporization with the C 0 laser. General
anesthesia with oral endotracheal intubation was chosen because of the patient's age. The lip lesion was treated first
with a true superpulsed beam with a peak power of 500 W
delivering an average power of 10 W at 58 pulses per second with an average power density (PD) of 440 W/cm at a
spot size of 1.5 mm. The first raster removed the superficial
mucosa. Part of the lower lip papilloma was excised with
2
Figure 5 - 4 . Five-year-old girl with contact papillomas of left

mucosal surface of lower lip and left interproximal gingiva between left lower lateral incisor and canine.
Figure 5-5.
Lip site after wiping away char.
59
the laser in a focused mode (PD = 1250 W/cm ) at a spot

size of 0.3 mm. The remainder of the lesion was vaporized
using two rasters to ablate just below the basement membrane. Figure 5-5 illustrates the depth achieved after wiping
away the remainder of the treated mucosa. The lower incisor was protected with a metal matrix band (of the type
used for placing interproximal amalgam restorations), and
the interproximal gingiva was ablated at a power density of
500 W/cm (Fig. 5-6). An additional 1 x 3 mm lesion of
the left buccal mucosa was similarly ablated. Estimated
blood loss was nil. Histopathologic and viral studies
demonstrated oral papillomas positive for HPV 6 and 11. At
3-month follow-up assessment, the "kissing" lesions of the
left lower lip and gingiva had recurred. The gingival lesion
was now 7 mm in maximum dimension and a 5 X 2 mm
plantar papilloma had recurred on the left lower lip. These
were retreated using the same laser parameters as before. At
14 days, the mucosa had completely resurfaced with normal
epithelium. One year later, there was no recurrence (Fig.
5-7). However, 2 years later, there was reactivation or
reinoculation of the left lower lip lesion. The gingival lesion
had not recurred.
2
Figure 5 - 6 .
Gingival site after wiping away treated tissue.
Figure 5-7. Lip: no recurrence at one year. Gingival site: no recurrence at one year, even after trauma of eruption of the succedaneous tooth.
60
CASE 2: EXTENSIVE ORAL

PAPILLOMATOSIS ON A RENAL
TRANSPLANT RECIPIENT
(Courtesy Lewis dayman, D.M.D.,
maxilla and tongue in a defocused superpulsed mode with a

3.0-mm spot size at 90 W average output power at 60 pulses
per second. The PD was approximately 1280 W/cm . The
treatment field included the entire maxillary and mandibular
ridge, labiobuccal sulci, and palate for a total treatment area
of approximately 60 cm (Fig. 5-9). The entire dorsal tongue
was similarly treated over an area of approximately 28 cm .
The buccal mucosae, commissures, and upper and lower lips
were treated at an average output power of 20 W superpulsed, using the handpiece delivery system with a spot size
of approximately 1.6 mm at 120 pulses per second for an average power density of 780 W/cm . Estimated blood loss
was 250 mL and operating time was 130 minutes.
Postoperatively, the patient took only two analgesic pills
during the first 8 days after treatment. On day 8 there was
epithelial resurfacing of about 20 to 30% of the mucosa.
The most uncomfortable area of his mouth was the palate.
By day 19 there were signs of regrowth of hyperplastic tis2
M.D.)
This 56-year-old African-American man presented with a

chief complaint of inability to wear dentures because of
"growths" in his mouth (Fig. 5-8).
Twenty years earlier, maxillary split-thickness skin grafting and vestibuloplasty had been performed to aid in denture
retention. Since then, progressive maxillary ridge resorption
had resulted in the loss of all alveolar bone. The anterior
nasal spine was now the most prominent feature of the residual ridge. Eighteen months before, his chronic renal failure
had been successfully treated by a cadaver renal transplant.
Following the institution of cyclosporine immunosuppression
therapy, he developed extensive papillary hyperplasia of all
of his oral mucosae, which precluded his ability to wear dentures. His list of illnesses active at the time of consultation included diabetes mellitus, hypertension, glaucoma, gout, and
hypothyroidism. His transplanted kidney was functioning
well. Current medications included: cyclosporine, prednisone, Imuran, lente insulin, Cardizem, Synthroid, Zantac,
colchicine, potassium iodide, and ferrous sulfate. He was
HIV negative. The histopathologic diagnosis of a representative biopsy of the papillomas of the maxillary alveolar ridge
was verruciform hyperplasia. This sample was positive for
HPV 6 and 11. The treatment recommendation for removal
of the diseased oral mucosa by C 0 laser in several stages
was explained to the patient, and he agreed to therapy.
The first treatment was performed using general anesthesia and nasoendotracheal intubation. Aerodigestive endoscopy demonstrated mucosal changes extending into the
pyriform recesses bilaterally, but not involving either the
true or false vocal cords. Antibiotic prophylaxis with
cephalothin was administered because of the renal transplant. No local anesthetics were used. The Sharplan 743 C 0
laser with the microscope delivery system was used for the
Figure 5-8. Extensive papillomatosis and verrucous hyperplasia

of maxilla, buccal mucosa, alveolar ridges, and tongue. Palate and
commissures also affected.
Figure 5-9. After first treatment using the microscope delivery

system with a defocused beam in the superpulsed mode at an average power output of 90 W delivered at 60 pulses per second at 150
mJ/pulse with a spot size of 3.0 mm. the PD was 1280 W/cm . Estimated blood loss was 250 mL for treatment of more than 120
cm of oral mucosae.
2
Figure 5-10.
ment.
Maxillary alveolus and palate 19 days after treat-
Papillomas and H u m a n Papillomavirus

sue in the maxilla (Fig. 5-I0). The mandible had recpithelialized to about 60% of normal, and he was completely
pain-free. By day 25 epithelialization was 80% complete.
By day 40 resurfacing was more than 9 0 % complete, but
there was approximately a 2 0 % recurrence level of mucosal
hyperplasia. At this stage the patient developed an attack of
Herpes zoster in a left thoracic dermatome. By day 70 there
was approximately 50% recurrence in the maxilla and there
were minor areas of recurrence in the retromolar pad bilaterally, the oral commissures, and the floor of the mouth
(Fig. 5-11). The areas of recurrence were treated as before.
The total surface area of the treatment field was 53 cm ,
which represented approximately half of the surface area of
the initial treatment (Fig. 5-12).
Examination and palpation under anesthesia did not
demonstrate any scarring or loss of resiliency of the oral
mucosa. Reepithelialization covered approximately 30% of
the treatment area by day 14. The entire retreatment area
was about 80% reepithelialized 31 days after treatment.
There was slight scarring at the commissures but none intraorally. The patient remained disease free for 3 months, at
which time minor recurrences were noted at the right
mandibular alveolar ridge and left oral commissure. Using
61
Figure 5-13. One year after treatment and 5 months after maxillary ridge augmentation with corticocancellous block iliac crestal
bone.
local anesthesia and intravenous sedation at a PD of 796

W/cm (parameters: HeNe guide spot size = 2.0 mm; average output power = 25 w, PRR = 156 PPS with defocused
125-mm handpiece), these two areas were retreated. After 2
months, small recurrences were observed at the left commissure ( 2 X 7 mm) and the midline of the hard palate (3 X
4 mm). These areas were completely reepithelialized in 24
days after a third retreatment cycle. One year later the patient remained disease free in the palate but had a minor recurrence in the lateral tongue and left oral commissure (Fig.
5-13).
2
REFERENCES
1. Pogrel M, Yen C, Hansen L. A comparison of carbon dioxide
laser, liquid nitrogren cryosurgery, and scalpel wound in
healing. Oral Surg Oral Med Oral Pathol 1990:69:269-273.
Figure 5-11.
Recurrent disease 70 days after initial treatment.
2. Shroycr K, Gree R. Detection of human papillomavirus DNA

by in situ DNA hybridization and polymerase chain reaction
in premalignant and malignant oral lesions. Oral Surg Oral
Med Oral Pathol 1991 ;71:708-713.
3. Pecaro B. Garehim W. The C 0 laser in oral and maxillofacial surgery../ Oral Maxillofac S'urg 1983;41:725-728.
4. Duncavage J. Ossoff R. Use of the C 0 laser for malignant
disease of the oral cavity. Lasers Surg Med 1986:6:442-444.
5. Eversole L. Viral infections of the head and neck among
2
HIV-seropositive patients. Oral Surg Oral Med Oral Pathol
1992:73:155-163.
6. Greer R, Eversole L, Crosby L. Detection of human papillomavirus-genomic DNA in oral epithelial dysplasias, oral
smokeless tobacco associated leukoplakias, and epithelial malignancies. J Oral Maxillofac Surg 1990:48:1201 -1205.
7. Reid R. Physical and surgical principles of laser surgery in
the lower genital tract. Obstet Gynecol Clin North Am
Figure 5-12. Retreatment again using the microscope delivery

system, superpulsed at a PD of 780 W/cm .
2
1991;18:429-474.
8. Sachs S, Borden G. The utilization of the carbon dioxide laser
in the treatment of recurrent papillomatosis: report of the
case. J Oral Surg 1981 ;39:299-300.
9. Scully C, Cox M, Prime S, Maitland N. Papillomaviruses: the
current status in relation to oral disease. Oral Surg Oral Med
Oral Pathol
1988;65:526-532.
Soft Tissue Excision Techniques
Lewis dayman, Paul C. Kuo
GENERAL PRINCIPLES OF CLINICAL

LASER APPLICATION
USE OF C 0 LASER IN INCISIONAL

PROCEDURES
Surgical lasers are instruments with their own specific indications for applications. Consideration must be given to
ihe nature of the lesion to be treated, its anatomic location
and functional implications after laser treatment, as well
as the benefits, risks, and alternate modes of treatment
available.
Careful observation of the target tissue is well advised
during laser application, particularly with the free-beam
C 0 laser where there is no tactile feedback and the depth
of penetration is shallow. The beam should be directed
perpendicular to the target tissue unless dissection of tissue underlying the lesion is desired. When using the continuous or rapid pulse modes, the surgeon should work
expeditiously and with even strokes. Both the power density and the fluence may change with small variations in
operative technique and may affect clinical outcome
in sensitive areas, such as facial skin. Be aware of tissue
that is in the path of the laser beam beyond the target tissue. Protection of the underlying tissue should be provided in anticipation of any laser beam that may "escape"
inadvertently after cutting through the target. Recall that
the width of the laser cut corresponds to the beam diameter, the depth depends in part on the power set, and the
degree of coagulation necrosis on the duration of laser exposure.
The no-touch technique with a free-beam laser theoretically offers the added advantage of limiting transplantation
of malignant or infected cells because in the process of
thermovaporization and thermocoagulation, the heat produced sterilizes the surgical field. In addition, blood vessels
and lymphatics adjacent to a target tumor are also sealed.
Some controversy may exist on the subject of tumor promotion by C 0 laser since there is a report of seven cases of
oral leukoplakia being treated by C 0 laser of which five
recurred. However, this is not supported by more substantial series with longer follow-up where the rate of recurrence or progression of leukoplakia is reported as to be as
high as 28%. The C 0 laser was also not found to promote
tumor growth in a mouse-melanoma model, nor was it
found to promote metastases in a mouse adenocarcinoma
model."
To use the C 0 laser as a precise cutting instrument, the

spot size at its focal point should be small, approximately
0.2 to 0.3 mm. A focus guide probe, along with a coaxial
helium-neon (HeNe) guide beam are helpful in acquiring
evenness in the cut when a laser handpiece is used. A
pulsed C 0 laser with a fluence of greater than 4 J/cm delivered with a pulse width shorter than the thermal relaxation time of approximately 950 ms, allows precise tissue
ablation with minimal lateral thermal damage. This can
best be achieved with a minimum energy of approximately
150 mJ/pulse. Where the target tissue can tolerate a wider
zone of coagulation necrosis, such as incisions made in oral
mucosa, a continuous wave (CW) laser may be used. At
higher power densities the surgeon will have to work
rapidly to minimize unwanted thermal damage. Charring
will inevitably occur in inverse relationship to incisional
speed. This char must be wiped away with wet sponges or
cotton swabs as intentional or inadvertent second exposures
on the desiccated charred tissue cause severe heat transfer.
This results in creation of a burn in the target tissue. Traction and countertraction of tissue with sponges, forceps, or
sutures will facilitate precise surgery just as it does for conventional technique. The target tissue should be examined
to see if the desired depth is reached. As with a scalpel, several passes may be necessary to achieve this. Although this
is a "no-touch" technique, the loss of tactile sensation with
which surgeons are so familiar with traditional surgical instruments is easily overcome by visual feedback and a bit of
practice.
3,4
6-7
Frenectomy
(Maxillary,
Mandibular,
Lingual)
Maxillary frenectomy can be accomplished using incision

and/or ablation. Either CW mode at 3 to 5 W with a 0.2-mm
spot size for incision or a pulsed mode at 20 W, 50 to 60
pps, and 2.0-mm spot for ablation size can be used. Topical
anesthetic is usually adequate but infiltration technique may
be preferred. With the upper lip everted and the frenum
stretched taut (Fig. 6-1), a short (3-5 mm), vertical incision
is made through the mucosa of the midportion of the
frenum. Horizontal releasing incisions are then developed
63
64
Figure 6-1.
through the mucosa on both sides of the frenum, which may

extend to the periosteum. A diamond-shaped mucosal
wound is developed as the lip-mucosal attachment is released. The fibrous band between the central incisors, if
present, is then vaporized. The field should be dry (Fig.
6-2). Any small bleeding vessels encountered can be vaporized or welded closed by withdrawing the handpiece to increase the spot size and decrease the irradiance. Any char
that develops should be wiped away with a wet gauze to
prevent heat accumulation that may cause excessive lateral
thermal damage on reapplication of the laser beam. Warm
saline with hydrogen peroxide rinses are prescribed. No
dressing is necessary. The wound develops a fibrinous coagulum in 24 hours and reepithelialization occurs in 5 to 3
weeks (Fig. 6-3). Alternatively, a contact Nd:YAG laser
using a fine scalpel tip at 8 to 12W CW may be used, following the same surgical technique.
Low attachment of maxillary frenum.
Vestibuloplasty
Figure 6-2. After 3- to 5-mm vertical incision and superior and

inferior horizontal incisions a diamond-shaped dissection is created. Notice absence of char after use of rapid superpulsed C 0
laser.
2
Figure 6-3.
Treatment area healed at 24 days.
Other incisional procedures include vestibuloplasty and sulcus extension. Submucous vestibuloplasty is more commonly performed for the atrophic mandible, where denture
adherence and stability is problematic. With the lower lip
retracted and the mucosa stretched, the junction of the attached gingiva and the alveolar mucosa is noted. Using a
focused, small beam spot of 0.2 mm at 6 W CW, an incision
is made along the junction from the midline of the mandible
posteriorly to the first molar areas bilaterally. Attempts
should be made to identify the position of the mental foramen from where the mental nerves emerge. Supraperiosteal
dissection can be carried out with the laser to the desired
depth. Care should be taken to avoid the mental nerves. Because of the shallow depth of penetration of the laser, the
soft tissue overlying these nerves can be dissected precisely, thereby avoiding damage to the mental nerves in
their extraosseous course. The use of a split-thickness skin
graft to surface the wound and inhibit vestibular loss from
upward migration of the mimetic muscles during healing is
Figure 6-4.
High frenal attachment in mandible.
65
advisable. The flanges of the existing denture are extended

and relined to use as a surgical stent for 7 to 10 days. Routine oral hygiene is adequate thereafter (Figs. 6-4 to 6-6).
USE OF THE CO, LASER IN EXCISIONAL

PROCEDURES
The C 0 laser offers a number of advantages when used as
an excisional instrument, particularly for small to moderatesized mucosal, submucosal and cutaneous lesions. The procedure is usually simple and straightforward. The excisional depth can be easily controlled. A good specimen can
be obtained with little damage to the margins, although one
must include an additional I to 2 mm of marginal tissue
more than would otherwise be adequate with conventional
scalpel excision, to allow for tissue lost by vaporization or
damaged by coagulation necrosis. The surgical wound usually does not need to be sutured. An outline is rapidly made
using repeated single pulses (175 mJ/pulse, 0.2-mm spot at
5 W) to circumscribe the desired target tissue. Following
this outline, a laser incision is then made to the desired
depth using the same method and laser setting as described
previously. One edge of the cut margin can then be elevated
with forceps and the lesion undermined and harvested at the
correct depth of dissection with the laser. With the laser
beam defocused. the surgical wound is briskly "painted"
over in one pass (raster) to seal off lymphatic vessels and
nerve endings and left open to heal by second intention. A
fibrinous wound surface results and cellular infiltration begins after 3 days. Larger wounds can be packed with an antiseptic ointment (Balsam of Peru, Bips paste, neomycin,
bacitracin, etc.) applied to ribbon gauze for 2 to 7 days.
2
Figure 6-5. Linear dissection using 0.2-mm spot at 6 W CW

function. Expanding dissection to compensate lor expected regression after submucosal vestibuloplasty technique.
Figure 6-6. Healed treatment area at 5 weeks. High frenal attachment has been lowered, but as expected without mucosal free
grafting, some loss of vestibular depth has occurred.
66

FIBROMA
Fibromas commonly appear on the buccal mucosae, inner

surface of the lip or lateral surfaces of the tongue. Presumably their origin is from trauma, particularly lip or cheek
biting, although they may result as the final involutional
form of a pyogenic granuloma (Figs. 6-7 to 6-9).
Figure 6-8. Defect left to heal by secondary intention after removing lesion with RSP CO laser at 58 pps, 150 mJ/pulse, 0.2mm spot size delivered with a handpiece at 6 W average output
power (PD = 15,000 W/cm ).
:
Figure 6-7. Large fibroma of cheek, quite close to commissure,

probably initiated by repeat cheek biting.
Figure 6-9. Cheek well healed by the I month recall visit.
67
FIBROEPITHELIAL POLYP
Removal of a libroepilhelial polyp Of the tongue in a
neonate is illustrated in Figures 6-10 to 6 - 1 3 . The polyp
arising from the dorsal midline of the anterior tongue was
both interfering with suckling and causing consternation for
the parents and the pediatrician. At approximately 7 weeks
of age the patient was brought to the operating room where,
using general anesthesia delivered by an oral endotracheal
tube and without supplemental local anesthesia, the polyp
was bloodlessly removed in one minute of operating time.
Laser parameters were handheld C O rapid superpulsed
laser at 50 pps. evaporative spot si/.e of 0.3 mm, average
power output of 10 W [power density (PD) approximately
20,000 W/cm ].
:
Figure 6-12. Transection almost complete, cotton swab placed

behind target area to prevent unwanted laser contact with adjacent
tissue as transection is completed. No bleeding occurred during
surgery.
Figure 6-10.
Fibrocpithelial polyp of dorsal midline of tongue.
Figure 6-11. Lesion placed under traction as incision commences across base of lesion. Note HeNe guiding beam in center
of incision.
Figure 6-13.
ture.
Primary closure of surgical site with resorbable su-
68
Iasers in M a x i l l o f a c i a l Surgery and Dentistry
EAR TAG
Skin tags occasionally occur in newborns as well as adults.
In this illustrative case a consultation was received from the
newborn nursery to remove an ear tag. Otologic and auditory examinations were normal.
The baby was brought to the laser lab where he was first
fed. Then, after falling asleep the base of the lesion was inliltrated with 0.25 mL of 2% lidocaine. The lesion was then
removed with the superpulsed CO, laser at 6 W average
output power, 0.3-mm spot size using a handpiece at 118
pps. The operation required less than a minute and there
was no blood loss (Figs. 6-14 to 6-15).
Figure 6-14. Ear lag lifted away from underlying normal skin
by a cotton tipped applicator, which also protected the underlying
normal skin.
Figure 6-15. Surgical site at conclusion of laser surgery. Area

was resurfaced in approximately 10 days.
Figure 6-16.
Skin lag along periphery of ihe helix of the right car.
A similar case in an adult man from India is illustrated in

Figures 6-16 to 6-18.
Figure 6-17. Base of treatment of area after excision of skin tag.

Dissection performed after injection of local anesthetic at 6 W,
0.3-mm spot size, 118 pps in RSP mode. Note complete absence
of char. Skin was completely healed by 17 days.
Figure 6-18.
Long-term appearance 4 years later.
EXPOSURE OF IMPACTED TEETH

Although exposure of impacted teeth (soft tissue impaction) is easily accomplished in the dental operatory
using local anesthesia and a loop cautery, there is less
swelling, less postoperative pain, and less chance of thermal injury to the exposed tooth if the free beam C 0 or the
contact heodymium:yttrium-aluminum-garnet (Nd:YAG)
laser is used (Figs. 6-19 and 6-20).
The C 0 laser may be used at PD of approximately
10,000 W/cm at 50 PPS, 10 W average output power and
0.3 mm spot size to incise around the impacted crown of the
tooth. As dissection proceeds, the mucosal flap is elevated
2
Figure 6-19.
of bleeding.
Crown of impacted tooth exposed. Note absence
69
with tissue forceps until the underlying crown is identified. Al this point, the handpiece is moved away from
the tissue to diminish PD, thereby permitting dissection of the mucosa away from the crown without marring Ihe enamel surface from inadvertent laser strikes
at high PD.
Alternatively, as illustrated in Figures 6-19 and
6-20, the Nd.YAG laser in contact mode using a short
scalpel tip at 5 to 10 W average output power is used to
excise the gingival cuff. Rapid identification of the
crown permits the operator to avoid inadvertently damaging it by excessive heating from the scalpel tip.
There is no bleeding.
Figure 6-20. Mucosa well healed at 3 weeks. Bonded bracket

ready to be used to start tooth movement.
70
FREE GINGIVAL GRAFTING

Lack of attached gingiva was treated by first dissecting
away the alveolar mucosa with the C 0 laser at 5 W average power, pulsed mode. 50 pps. 0.2-mm spot size. A completely bloodless and char-free base was obtained (Fig.
6-21). A free palatal graft was obtained with scalpel dissection and thinned with scissors to the correct thickness. This
was secured to the recipient site with sutures (Fig. 6-22).
The donor site was "sealed" to stop bleeding with one raster
in the defocused mode. The graft was readily accepted and
the mature graft is demonstrated at 6 weeks recall examination (Fig. 6-23).
2
Figure 6-22.
Figure 6-21. Recipient site prepared with RSP CO> laser with
P SW, PRR = 50 Hz. spot size = 0.2 nun.
Figure 6-23.
Free palatal graft secured in position.
Mature graft. Complete "take" at 6 weeks.
HEMANGIOMAS AND VASCULAR

MALFORMATIONS
Hemangiomas in the oral cavity are most effectively treated
with the argon laser (see Chapter 3) by direct application
after compressing the lesion with a glass slide or for larger
figure 6-24.
Small vascular malformation of labial sulcus.
Figure 6-25. Dissection of the inferior mucosal flap. An absolutely dry field was achieved with RSP C 0 laser, handheld at
IIS pps. 150 mJ/pulse. at 10 W average output power. 0.3-mm
spot size which was defocused when necessary to control small
bleeding points.
2
71
lesions by intralesional introduction of the liber. Large,

higher-flow lesions are occasionally treated with the
Nd:YAG laser. However, small, localized, low-flow lesions
may be excised with the C 0 laser. In the illustrated case
(Figs. 6-24 to 6-27) a small vascular malformation of the
labial sulcus was excised with the C 0 laser.
2
Figure 6-26.
Dissection of the lesion itself.
Figure 6-27. Two weeks postoperative, the wound was nearly

healed with some contraction of the surgical site, which had been
left open to heal by secondary intention. The surgical site was
completely healed in an additional 2 weeks. Ten years later there
was no recurrence.
72
Lasers in Maxillofacial Surgery and Dentistry
USE OF THE CO, LASER AS A

VAPORIZATION INSTRUMENT
Vaporization with the C O , laser is used when ablation of
localized, superficial strips of tissue is desired. It works in a
similar manner to incisional and excisional techniques except that a larger beam size is preferred. The PD used,
which is best adjusted by varying the distance of the incident beam to target tissue, depends on the preference and
experience of the surgeon. Slow vaporization with lower
PD causes greater coagulation necrosis, increases pain and
delays healing. On the other hand, vaporization can be
achieved at a higher PD with little charring and minimal
thermal effect on the adjacent tissue but also less photocoagulation for good hemostasis. In general, the power can be
set from 15 to 30 W average power at 50 to 150 pps at 50 to
650 mJ/pulse. Usually approximately 100 to 150 mJ/pulse
is used. A defocused spot size of 1 to 5 mm at the target is
used. The target tissue is vaporized with a defocused beam

in a "painting" (rastering) fashion. With deeper lesions it is
better to ablate the entire surface of the lesion to the same
shallow depth in layers, repeating the process until the desired depth is reached. Each treated layer is wiped away
with a gauze sponge before applying the next raster. This
prevents excessive overlapping of laser crater margins,
which results in increased thermal damage, as can be the
case when narrower areas are first vaporized to the desired
depth. This is because of the Gaussian distribution of the
laser energy curve (see Chapter 1) such that a laser crater
may be clean in the center but charred at its periphery, especially when multiple passes are performed. This procedure
is performed most accurately when the laser is used in conjunction with the microscope and efforts are taken to maintain a perpendicular relationship between the laser and the
target tissue. However, careful use of the handpiece will
usually produce satisfactory results. (For detailed examples
of clinical use, see Chapter 4.)
73
GINGIVAL HYPERTROPHY
A 34-year-old African-American male recipient of a cadaver renal transplant receiving azathioprine. prednisone,
diltiazem. doxazosin, captopril, clonidine, and cyclosporine
was treated for hypertrophic gingivae. Key elements of
laser technique for gingivoplasty include the use of a superpulsed C O laser with the handpiece at a PD of 500 to 625
W/cm by varying the spot size between 2.0 and 2.5 mm at
58 pps 600 mJ/pulse at an average power output of 25 W. A
matrix band is secured around the cervical margin of the
tooth below the free margin of the gingiva to protect the
enamel and cementum from injury by the laser beam. Gingiva removed by each raster is wiped away to remove the
carbonization prior to applying additional rasters with the
laser (Figs. 6-28 to 6-32).
:
Figure 6-30. Series of test spots hi assess for suitable I'D to produce opalescent bubbling of lirst layer of tissue to be removed.
Note red HeNe aiming beam adjusted to approximately 2.0-mm
spot size.
Figure 6-28. Gingival hypertrophy. Loss of normal interproximal gingival contour. Bulbous papillae and hypertrophy of marginal and attached gingiva.
Figure 6-31. Gingiveclomy complete: charred area consequent

to defocused beam application to control bleeding.
Figure 6-29. Toftlemire-type metal matrix band applied snugly

around tooth at or below cervicoenamel junction.
Figure 6-32. Six months follow-up. Patient has not received

recommended dental prophylaxis every 3 months. Still on cyclosporine. Some recurrent hyperplasia present between the lower
central incisors.
74
SEVERE GINGIVAL HYPERTROPHY

A 35-year-old woman with epilepsy has been taking
diphenyl hydantoin in a stable dose for many years to control her seizure disorder. Gingival hypertrophy was extensive and was much more fibrotic than was the hypertrophy
induced by cyclosporine illustrated in the previous case. A

superpulsed C 0 laser at 30 W average output power, with
a 2- to 3-mm spot size was used. Blood loss was less than 5
mL and four quadrant gingivectomy, without the use of
local anesthetic, required 60 minutes under general anesthesia (Figs. 6-33 to 6-36).
Figure 6-33. Severe gingival hypertrophy induced by phenytoin

(diphenyl hydantoin).
Figure 6-35. Healing gingivae at 1 week. At 2 weeks the wound

was 50% epithelialized.
Figure 5-34. Removal of excess gingivae. Bone exposure was

studiously avoided. Note placement of self-retained matrix bands.
Figure 6-36.
Two years postoperative.
FIBROEPITHELIAL HYPERPLASIA
OF PALATE
A 65-year-old while woman with a history of rheumatoid
arthritis, emphysema, and colon resection for adenocarcinoma presented with a complaint of a sore mouth under her
upper denture. She smoked two packs of cigarettes per day,
and took 2.5 g of aspirin per day, having completed a full
course of gold therapy for her rheumatoid arthritis 8 months
ago. She had a family history of an undefined "bleeding disease." Her coagulation profile was normal.
She has a 1.5-cm raised, reddish, irregular midline palatal
lesion that, when biopsied, is reported to be representative
of fibroepithelial hyperplasia of the palate. Ablation by vaporization with the C 0 laser is chosen as the treatment of
choice. Consequent to her medical history, this patient is
admitted to the hospital on the morning of surgery and discharged the following day. She is treated under general
anesthesia with nasoendotrachcal intubation, no prophylactic antibiotics are used, and the surgical site is not prepared
with antiseptic solutions. Local anesthetic with vasoconstrictor is administered for postoperative pain relief. At
surgery, the C O laser is used in the CW mode specifically
2
Figure 6-37.
Fibroepithelial hyperplasia of palate.
Figure 6-38. Completion of tirst raster. CO\ laser in CW mode

at 20 to 30 W.
75
to induce a greater than customary amount of lateral heat

conduction to minimize bleeding. The parameters for the
laser treatment are spot size 2.0 mm, power output 20 and
30 W, CW function, at average PDs, respectively, of 500
W/cm and 750 W/cm . Surgical treatment requires two
rasters at 750 W/cm to remove all of the abnormal tissue
followed by a third exposure at 500 W/cm to coagulate the
base of the lesion. Observation for 10 minutes by the clock
at the conclusion of surgery shows no bleeding. Total surgical time including the period of observation is 27 minutes,
and the estimated blood loss, measured prospectively, was
18 mL. The area ablated measured just over 15 cm".
Postoperatively, a single diflunisal tablet was taken for
pain control on the evening of surgery. However, on days I.
2. and 3 the patient required four analgesics (Synalgos) per
day and a single dose of acetaminophen (500 mg), with 300
mg of codeine on the evening of day 3. She required similar
analgesics for the next 4 days, and none thereafter.
By day 21, the operative site was 90% resurfaced with
epithelium despite the heavy charring created at the base of
the lesion by the coagulation of the base with the 30 W
beam. Epithelialization was complete on day 26. There was
no recurrence when she was discharged from follow-up observation 28 months after surgery (Figs. 6-37 to 6-46).
2
Figure 6-39.
First raster after wiping away the char.
Figure 6-40.
Last raster (third application of laser).
76
Figure 6-41. Last raster after wiping away the char. Note general yellow color as submucosa deep to minor salivary glands has
been excised.
Figure 6 - 4 2 . First postoperative day. Characteristic appearance

of fibrin covering the wound.
Figure 6 - 4 3 .
Figure 6-44.
Day 6.
Day 19.
Figure 6-45. Day 26. Treatment area has become completely

reepithelialized.
77
Figure 6-46. Long-term results; 15 months postoperatively mucosa has been stable.
78
FACIAL NEVI
A 38-year-old white woman sought consultation for removal of a nodular facial nevus present for the past 10
years. Vaporization technique with rapid superpulsed (RSP)
C 0 laser was chosen to reduce scarring. Laser parameters:
RSP C 0 laser (110 mJ/pulse) at 108 pps using the microscopic and microslad system. The laser spot size was 2.0
mm at an output power of 15 W and a PD of approximately
450 W/cm . The target site was anesthetized by infiltration
of 1% lidocaine local anesthetic. No skin preparation was
performed (Fig. 6-47). Two rasters were administered
under 10X magnification and the surface of the target tissue
was debrided with a wet gauze sponge after the first and
second raster (Fig. 6-48). One year later there was only a
faint depression at the treatment site and there was no
change in skin color (Fig. 649).
2
Figure 6-47.
Facial nevus.
Figure 6-48. Treatment of nevus. After two rasters at PD = 450

W/cm , RSP CO, with microscope at I OX magnification.
2
Figure 6-49. Result at one year. Very minor depression. Perfect

skin color at treatment site.
79
SKIN RESURFACING IN AESTHETIC

SURGERY
,Skin wrinkles, or rhylidcs from excessive sun exposure,
particularly those occurring on and around the lips and
eyes, may be reduced by treatment with the COs laser using
an automated scanner such as the SilkTouch flash-scanner
(Sharplan Lasers). This microprocessor controlled device
creates char-free ablation by moving a high-irradiance
beam at a rapid rate, thereby preventing the dwelling time
at any one point scanned to be greater than the thermal relaxation time of the skin. The scanner can be attached to
any C 0 laser that provides a CW, collimated beam, and is
capable of removing very shallow skin craters whose penetration level is restricted to the epidermis and upper dermis.
The subjacent papillary and reticular dermis receives no
3
Figure 6-50. 62-year-old female with line wrinkles in

lower lid. lateral and infraorbital areas.
Figure 6-54. 18-yearold male with small area

of burn scar, mildly
raised, sustained 2 years
prior, over right temporal
area.
figure 6-51. C02 lasers resurfacing with Coherent Ultrapulse

5000C CPG scanner at 225 ml,
60W. with one pass at moderate
density over lower lid and 2-3
passes over lateral and infraorbital/malar areas.
Figure 6-55. CO. laser resurfacing with the Coherent Ultrapulse 5000C CPG scanner at 300
ml, I (WW with 2 passes at moderate density.
thermal damage. The wrinkle is treated by ablating the area

adjacent to the deepest point of the wrinkle fold with the
laser set at 7 W average output power in the pulsed mode at
0.2-s cycles. This permits assessment of the laser effect
after completion of a single cycle (one complete revolution
of the flash scanner within its target circle). As always, the
target tissue is removed with a saline moistened gauze
sponge (Figs. 6-50 to 6-57). Pending the area to be treated,
a second and third pass may be necessary to penetrate into
or through the papillary dermis. Alternatively, a Computer
Pattern Generator (Coherent Lasers) can be used with an ultrapulse C 0 laser at 175 to 300 mJ/pulse and an average
power of between 60 and 100 W. Benign cutaneous
growths and atrophic scars and pits can be treated similarly
(see chapter 4, White Lesions of the Lip.) Postoperative results are consistently good.
2
Figure 6-52. 3 weeks post

surgery
Note
resolving
edema and erythema.
Figure 6-56.
post surgery.
I week
Figure 6-53. 6 months post

surgery.
Figure 6-57. 2 months

post surgery. Note smoothened area with the slight
hypo-pigmentation, which
is expected to improve in
time.
80
COMBINATION USES
A combination of excision and vaporization techniques can be
used in the treatment of certain diseases. In fact, the versatility
of the C 0 laser in its ability to incise, coagulate, and ablate
by simply moving the laser handpiece into and out of focus is
a major advantage of the instrument in its medical applications. As long as laser-tissue interaction principles are understood and adhered to, the desired tissue effect can be obtained.
2
Rhinophyma
plete, whereas electrocautery would leave significant scars.

Recontouring with a scalpel is complicated and also difficult because of excessive hemorrhage. The CO, laser allows good precision and a dry field for easier sculpting.
Thermal damage using the CW beam should be avoided.
Excision with a small spot size at 5 W of power can be used
in combination with vaporization in the defocused mode
with multiple passes for recontouring. The presence of intact sebaceous glands should be noted on the deep margin
to minimize scarring. Reepithelialization takes place in 3 to
5 weeks (Fig. 6-59).
Treatment of rhinophyma is an example. (Fig. 6-58) Previous treatment methods with dermabrasion was often incom-
Figure 6-58. Rhinophyma. (Courtesy of Dr. Andrew Van

Hassel.)
Figure 6-59. Postoperative result at 5 weeks.
EPULIS FISSURATUM
Epulis fissuratum, which consists of hyperplastic mucogingival folds from fibroepithelial proliferation secondary to
ill-fitting dentures, prevents proper denture seating on a
stable base. It responds well to laser excision with minimal
postoperative discomfort and swelling. In this case, a defo-
Figure 6-60.
Fpulis
fissuratum
secondary to a poorly fitting
81
cused beam at 5 to 10 W CW is used to aid hemostasis and

promote a dry field. Alternatively, a pulsed waveform at 20
W, PRR = 50-200 pps at 2.0 to 3.0-mm spot size may be
used. The existing denture is relined with soft denture
liner. The wound re-epithelializes in about 3 weeks with
little loss or no loss of sulcus depth (Figs. 6-60 to 6-63).
Figure 6-62.
After treatment and wiping away treated area.
maxillary denture.
Figure 6-61. CO, handpiece. Focus mode used to excise much

of the redundant tissue.
Figure 6-63. Three weeks. Sulcus deepened approximately

5 mm after frenectomy. Stability was maintained at a 6 month recall visit.
82
MUCOCELE
Mucoceles can be excised after mucoepidermoid carcinoma
has been ruled out. At 6 to 8 W CW, the lesion is first unroofed. The gland is then propped up and excised in toto to
prevent recurrence. Large ranulae are marsupialized by
having the " r o o f excised. The wound margin is then sealed
with a defocused beam. Reepithelialization is complete in 2
or 3 weeks depending on the size of the wounds (Figs. 6-64
to 6-67).
Benign
Pigmented
Lesions
The C 0 laser used in combination with scalpel surgery

facilitates wound management and healing. Skin moles
can be excised sharply with a scalpel flush to the skin. A
pulsed laser at 3 W of power output with 200 mJ/pulse of
energy using a 1- to 2.5-mm spot size can then be used to
"paint" over the surgical wound to a slightly grayish
color. The center of the wound may become slightly concave due to contraction of collagen fibers. The periphery
2
or rim of the wound is then recontoured with the larger

spot size and adequate energy/pulse to level raised areas.
If residual pigment is present in the deep dermis, it can be
left alone until such pigment rises to the surface of the
dermis during healing. The area can then be resurfaced
again.
Aphthous
Stomatitis
A similar technique with the C 0 laser can be used to primarily desensitize oral wounds. Mucosal donor sites in the
palate can be glazed over to provide a thin layer of fibrinous
coagulation. CW and defocused mode using a char and
wipe technique is adequate here, as occasional minimal
scarring can be well tolerated. Similarly, painful, ulcerative
lesions can be removed and treated palliatively. Aphthous
and traumatic ulcers are first painted over with topical anesthetic. A lower power, defocused C 0 beam is then passed
over the entire lesion including the red halo rim. The lesion
heals in 2 to 3 weeks without pain. Likewise, lichen planus
that causes burning and itching sensations can be treated
with passes of C 0 laser beam at lower power settings in
2
Figure 6-64.
Recurrent mucocele of floor of mouth.
Figure 6-65. Hene guide beam beyond periphery of "roof" of

mucocele, the central portion of the lesion is lifted with a forceps.
F'igure 6-66.
Part of sublingual gland ablated.
F'igure 6-67. Three months. Slight scar at surgical site. No submandibular gland obstruction.

the defocused mode until the mucosal tissue begins to blister and turn white. This tissue can be peeled away with a
hemostat and the underlying tissue assessed. Any remaining
disease can be treated with a second pass. Improvement of
symptoms varies from patient to patient. In general, some
improvements can be expected with smaller lesions. The ultimate late of the lesion, however, will be determined by the
natural history of lichen planus.
WOUND CARE
The objective of postoperative wound care is to protect the
wound, provide patient comfort, and promote healing.
Wound care ideally should be simple such that the patient
can perform the tasks at home. Smaller oral and pharyngeal
wounds are left open, covered only with coagulum, which
is the intermediate zone of coagulation necrosis. Carbonized eschar (char) should be wiped and removed. The
coagulation necrosis widens in the first few postoperative
days and sloughs, accounting for the delay in initial wound
healing and possibly some increase in patient discomfort at
thai time. Larger oral wounds may be covered initially with
gauze packing impregnated with a topical agent like Balsam of Peru, Whitehead's varnish, Bips paste, or an antibiotic ointment. Warm saline rinses four to six times daily
and general oral hygiene care should be instituted. Skin
wounds should be cleansed gently twice daily with a mild
soap solution and topical antibiotic ointment applied. Extra
protection with a dressing such as Duoderm is advisable
until new epithelium is formed in 4 to 6 weeks. Sun exposure should be avoided for 6 to 12 months.
83
Charring is expected with laser burn. Charring promotes hemostasis but also can act as a heat sink and mask
the depth of laser effect on tissues. The degree of thermal
damage tolerance of the target tissue should be understood.
Long-term complications are related to regeneration of
wound tissue. This includes granulation tissue, hypertrophic
scar, wound contracture, and hypo- and hyperpigmentation.
Management of these complications is similar to those resulting from scalpel or electrocautery surgery. Prevention
of their formation by choosing the proper wavelength and
parameters is paramount. Postoperative edema is usually
minimal. However, both edema and pain will increase if
poor technique results in excessive heating of the tissues
during surgery.
The advantage of C O laser usage is evident, particularly
in treatment of widespread, superficial diseases, bloody
procedures, and vascular tissues. It is useful as a surgical instrument in patients with bleeding disorders, patients who
arc on anticoagulants, patients in whom the use of epinephrine vasoconstriction is contraindicated, and in those patients who are on monitoring or pacemaker devices. It can
also be helpful in infected surgical sites as it theoretically
sterilizes during application.
;
REFERENCES
1. Oosterhuis JW. Tumor Surgery with the CO, Laser. Studies
with the Cloudman S9I Mouse Melanoma. Groningen. Nether-
lands: Rijksuniversiteit; 1977:1 II.

2. Braun RE. Leibow C. Clinical evaluation of tumor promotion
by C 0 laser. In: SPIE vol 1424: Lasers in Orthopedic. Dental,
and Veterinary Medicine. 1991:138-144.
2
3. Roodenburg JL. Panders AK. Vermey A. Carbon dioxide laser
COMPLICATIONS
Laser-related complications in the orofacial area are minimal if proper precautions are taken. Many of the laser procedures are minor and can be performed under local or topical anesthesia. With the latter, care should be taken to
monitor the pain tolerance of the patient and prevent patient
movement. Supplemental 0 should be avoided unless delivered through an endotracheal tube. Unintentional burns
should be diligently avoided.
2
surgery of oral leukoplakia. Oral Surg Oral Med Oral Pathol
1991:71:670-674.
4. dayman L. Management of mucosal premalignant lesions.
Oral Maxillofac Clin North Am I994;6(3):431^143.
5. Ammirati M, Rao LN, Morthy Ms, Buchmann T. Goldschmidt

RA. Scanlon BF. Partial nephrectomy in mice with milliwatt
carbon dioxide laser and its influence on experimental metastasis. J Surg Oncol 1989;41:153-159.
6. Absten GT. Physics of light and lasers. Obstet Gynecol Clin

North Am l99I;18(3):407-427.
7. Rox Anderson R, Parrish JA. Selective photolhermolysis: precise microsurgery by selective absorption of pulsed radiation.
Science 1983;220:524-527.
Transoral Resection of Oral Cancer
Lewis dayman
The most s e r i o u s , life-threatening d i s e a s e o r i g i n a t i n g from

the oral cavity is s q u a m o u s cell c a r c i n o m a . Despite the p o tential for early detection, m o s t oral c a n c e r s are still d i s c o v ered in their late s t a g e s (stages III and I V ) . In the United
States this results in a p p r o x i m a t e l y 8 0 0 0 d e a t h s per y e a r .
The rate of n e w c a s e formation is a p p r o x i m a t e l y 3 0 , 0 0 0 per
year. M o r b i d i t y and late detection remain high largely b e cause of the l o w rate of clinical e x a m i n a t i o n by health care
workers. T h e C e n t e r s for D i s e a s e C o n t r o l (Atlanta, G A ) e s timates that in 1993 less than 1 4 . 3 % of adults had e v e r had
any t y p e of s i m p l e s c r e e n i n g e x a m i n a t i o n for oral c a n c e r .
Of those p e o p l e e v e r h a v i n g been e x a m i n e d for oral c a n c e r
5 4 . 4 % had received this e x a m i n a t i o n as part of a dental e x amination and 3 5 % as part of a r o u t i n e p h y s i c a l e x a m i n a tion."
1
Transoral resection of stages I and II oral c a n c e r is a

well-accepted treatment m e t h o d in o n c o l o g i c s u r g e r y . T h e
specific surgical t e c h n i q u e is less important than is t h e
sound application of o n c o l o g i c p r i n c i p l e s to a c h i e v e adequate resection of the tumor. T h e gold s t a n d a r d for o u t c o m e
is the result a c h i e v e d by scalpel resection. A n y o t h e r t e c h nique such as e l e c t r o s u r g e r y , c r y o s u r g e r y , or laser s u r g e r y
must p r o d u c e c o m p a r a b l e o r i m p r o v e d c u r e r a t e s . C u r e
rates a c h i e v a b l e with the surgical laser match those attributed to scalpel or e l e c t r o s u r g e r y , and also p r o v i d e the significant a d v a n t a g e s of better h e m o s t a s i s , less p o s t o p e r a t i v e
e d e m a , shorter hospital stay, d i m i n i s h e d infection rates, a n d
elimination of the need for s p l i t - t h i c k n e s s skin grafting. In
addition, in t h e o r y , b e c a u s e of t h e l a s e r ' s ability to seal
small blood vessels and l y m p h a t i c s , there is a r e d u c e d likelihood of i n d u c i n g t u m o r m i c r o e m b o l i d u r i n g surgical extirpation of the t u m o r , w h i c h in turn r e d u c e s the c h a n c e s of
" s e e d i n g " the surgical site or the v a s c u l a r or the l y m p h a t i c
system.
SURVIVAL
T h e most r e c e n t survival statistics a p p l i c a b l e t o oral c a n c e r
a r e those p u b l i s h e d in 1994 by t h e N a t i o n a l C a n c e r Institute of t h e United S t a t e s N a t i o n a l Institutes of Health for
the period 1973 to 1 9 9 1 . ' F o r the m o s t r e c e n t interval in
this series ( 1 9 8 3 to 1990) t h e 5 - y e a r r e l a t i v e s u r v i v a l rate
for oral cavity a n d p h a r y n x i s 5 2 . 3 % . A s e x p e c t e d , the sur-
vival is w o r s e for r e g i o n a l d i s e a s e ( p r i m a r y and neck inv o l v e m e n t ) at 4 1 . 5 % a n d it is better for local d i s e a s e

(tumor, node, metastasis tumor stagingstage I: T 1 N 0 M 0 ,
s t a g e II: T 2 N 0 M 0 ) a t 7 8 . 9 % . T h e r e f o r e , for transoral r e s e c tion w i t h t h e s u r g i c a l laser t o b e c o m e a c c e p t a b l e , 5-year
s u r v i v a l for local d i s e a s e ( s t a g e I or II) must equal or e x ceed 7 8 . 9 % .
R e p o r t s in t h e literature- 3-6 r e g a r d i n g survival after transoral resection o f localized oral c a v i t y c a n c e r using the C 0
laser q u o t e r e l a t i v e survival rates of 81 to 8 9 % for previo u s l y untreated l e s i o n s . C o l l e c t i v e l y , 178 patients w e r e
studied, of w h o m 22 w e r e m o n i t o r e d for 2 years and 156
w e r e m o n i t o r e d for 5 y e a r s . As reported later in this c h a p ter, in my o w n e x p e r i e n c e at Sinai Hospital of Detroit, 106
p a t i e n t s h a v e been treated by transoral resection with the
free-beam C 0 laser. O f this g r o u p , 4 3 patients with 5 1
stage I or II oral c a n c e r s h a v e been u n d e r surveillance for
m o r e than 5 y e a r s . T h e d e t e r m i n a t e 5 - y e a r survival rate is
9 2 . 3 % . S e r e n d i p i t o u s l y , it is noted that for T glottic c a n cer, a n o n o r a l head and neck site, e n d o s c o p i c e x c i s i o n with
the free-beam C 0 laser resulted in a 5-year local control
rate of 9 4 % with a 5 - y e a r survival rate of 7 8 % with deaths
attributable to e i t h e r a s e c o n d p r i m a r y c a n c e r or intercurrent
disease.
O n e o f the q u e s t i o n s t o c o n s i d e r that c o u l d t h e o r e t i c a l l y h a v e a n e g a t i v e effect on local r e c u r r e n c e is t h e p o s sibility that c a n c e r c e l l s t h a t a r e n o t c l i n i c a l l y a p p a r e n t
d u r i n g s u r g e r y c o u l d b e c o m e b u r i e d and m a i n t a i n their
v i a b i l i t y after l o s i n g c o n t i n u i t y with t h e e p i t h e l i a l s u r f a c e
from w h i c h t h e y a r o s e . T h i s q u e s t i o n w a s c o n s i d e r e d and
i n v e s t i g a t e d d u r i n g s t u d i e s o f C 0 l a s e r a b l a t i o n o f the
transformation z o n e in c a s e s of cervical intraepithelial
neoplasia. During colposcopic and histopathologic assessment it was noted that recurrent lesions did maintain
c o n t a c t with t h e s u r f a c e e p i t h e l i u m . T h e y d i d not lie
d o r m a n t a s b u r i e d c r y p t s o f a b n o r m a l e p i t h e l i u m that
w o u l d t h e n h a v e t h e p o t e n t i a l t o g r o w into n e o p l a s m s
later.
C o m p a r e d with p a t i e n t s h a v i n g s t a g e s I and II oral c a v ity t u m o r s that w e r e t r e a t e d b y c o n v e n t i o n a l s u r g e r y
using transoral resection technique, the laser-treated cases
d i d not s h o w i n c r e a s e d local r e c u r r e n c e o r r e g i o n a l
m e t a s t a s e s . I n c o n c o r d a n c e w i t h t h e N a t i o n a l C a n c e r Institute data individual studies from the literature reporting
c u r e r a t e s for c o n v e n t i o n a l s u r g e r y o f p r e v i o u s l y u n 2
85
86
treated l o c a l i z e d t o n g u e a n d floor o f m o u t h c a n c e r r a n g e d
from 8 6 % t o a s h i g h a s 9 4 % for 2 y e a r s for T j l e s i o n s a n d
6 9 t o 8 6 % for T l e s i o n s . 1 ' 5 , 1 0 - 1 2 A t 5 y e a r s , t h e s u r v i v a l
rate for T , floor o f m o u t h c a n c e r fell t o 6 7 t o 9 6 % d e p e n d i n g on whether the patients had originally been
treated b y r a d i o t h e r a p y o r s u r g e r y , r e s p e c t i v e l y . 1 1 - 1 3 F o r
T | and T oral t o n g u e c a n c e r t r e a t e d b y r e s e c t i o n t h e 5 year survival was 7 7 % and 6 5 % , respectively, with no
significant d i f f e r e n c e r e p o r t e d for t r a n s o r a l r e s e c t i o n
alone vs. transoral resection with elective neck dissect i o n . T h e s e s u r v i v a l s t a t i s t i c s s u p p o r t t h e u s e o f t h e surg i c a l laser for t r a n s o r a l r e s e c t i o n of l o c a l i z e d ( s t a g e s I
and II) oral c a n c e r w i t h o u t i n c r e a s i n g t h e risk o f local recurrence or regional spread.
W h e n used a s a n a l t e r n a t i v e o r a s a n a d j u n c t t o c o n v e n tional s u r g e r y for larger T a n d T l e s i o n s , t h e r e w e r e n o
a d v e r s e effects o n e i t h e r w o u n d h e a l i n g o r t u m o r c o n trol.3,l5,16
T h e most i m p o r t a n t n e g a t i v e a s p e c t t o c o n s i d e r i n e v a l u a t i n g l a s e r s u r g e r y i s w h e t h e r t h e l a s e r b e a m itself m i g h t
h a v e a n y t u m o r - p r o m o t i n g effects that m i g h t e n h a n c e r e c u r r e n c e o r s p r e a d t o l o c o - r e g i o n a l o r distant s i t e s . B e c a u s e the b e a m i s a p p l i e d o n l y t o c l i n i c a l l y n o r m a l t i s s u e
at t h e resection m a r g i n and not on t h e t u m o r itself, any e n h a n c e m e n t of s p r e a d w o u l d be e x p e c t e d to be a c o n s e q u e n c e o f direct h a n d l i n g o f t h e n e o p l a s t i c t i s s u e b y retraction i n s t r u m e n t s . T h i s b e i n g t h e c a s e , o n e w o u l d not
e x p e c t to find a d i m i n i s h e d c o n t r o l r a t e with l a s e r u s e a n d ,
in fact, t h e literature d o e s not s u p p o r t s u c h a n e g a t i v e o u t c o m e i n s u r g i c a l l a s e r t r e a t m e n t o f h u m a n oral m a l i g n a n c i e s . 3 , 1 7-1 9 A p r o s p e c t i v e c l i n i c a l trial t o e v a l u a t e s u c h a n
effect for T , l e s i o n s w h e r e t h e l a s e r c u r e rate e x c e e d s 9 0 %
w o u l d r e q u i r e 3 4 2 c a s e s in e a c h a r m of a s t u d y ( c o n v e n tional and laser) to d e t e c t a 5% s u r v i v a l d i f f e r e n c e at a
p < . 0 5 (at 8 0 % p o w e r ) ( p e r s o n a l c o m m u n i c a t i o n : Y
D a o u d , b i o s t a t i s t i c i a n , Sinai H o s p i t a l , D e t r o i t ) . S u c h a
study h a s n e v e r b e e n d o n e .
T h e issue r e g a r d i n g t u m o r p r o m o t i o n b y direct a p p l i c a tion of laser light to t h e t u m o r itself is m o r e c o n t r o v e r s i a l .
R e v i e w of t h e literature of t h e b i o s t i m u l a t o r y effects of
low-level laser light on fibroblasts and epithelial cells in tissue c u l t u r e generally s h o w s s t i m u l a t o r y effects at e n e r g y
d e n s i t i e s b e l o w 3.0 t o 4 . 0 m J / c m a n d inhibitory effects
a b o v e 4 . 0 m J / c m 2 (see C h a p t e r 15). A n i m a l solid t u m o r
m o d e l s h a v e d e m o n s t r a t e d conflicting results with h a m s t e r
c h e e k pouch c a r c i n o m a r e s p o n d i n g b y increasing t u m o r
s p r e a d 2 0 and m o u s e m e l a n o m a s not b e i n g affected b y laser
light. 21 C a r c i n o m a s in a rat liver m o d e l w e r e not subject to
increased m e t a s t a s e s w h e n e x p o s e d t o milliwatt C 0
l a s e r s . 2 2 M o u s e m a m m a r y c a r c i n o m a s treated b y c o n t a c t
n e o d y m i u m : y t t r i u m - a l u m i n u m - g a r n e t ( N d : Y A G ) laser
scalpel had l o w e r local r e c u r r e n c e rates c o m p a r e d with c o n ventional resection with a steel scalpel. 23 T h e r e a r e no a n i mal data on s q u a m o u s cell c a r c i n o m a r e s p o n s e to irradiation with 10.6-u.m laser light ( C 0 ) .
2
14
FREE-BEAM C0
T h e transoral resection of oral c a n c e r w a s first reported by

S t r o n g et a l . 2 4 ' 2 5 in 1979. T h e y e s t a b l i s h e d the safety of mic r o s c o p e - g u i d e d C 0 laser surgery c o u p l e d with the use o f
vital s t a i n i n g with t o l u i d i n e b l u e and the use of frozen sections to control m a r g i n s . T h i s c o n c e p t received further support by t h e early 1980s, particularly from Panjer et a l . and
C a r r u t h . T w o t e c h n i q u e s w e r e e m p l o y e d : h a n d - h e l d probe
and j o y s t i c k m i c r o m a n i p u l a t o r c o u p l e d to an o p e r a t i n g mic r o s c o p e . F o r both t e c h n i q u e s i r r a d i a n c e must exceed 5,000
to 10,000 W / c m . H e m o s t a s i s requires a l o n g e r duty cycle
than d o e s ablation as d i s c u s s e d in the p r e c e d i n g c h a p t e r bec a u s e a m o d e r a t e a m o u n t of lateral thermal c o n d u c t i o n is
required to seal t h e m i c r o v a s c u l a t u r e . T h i s can be achieved
by u s i n g a c h o p p e d c o n t i n u o u s w a v e ( C W ) m o d e rather
than rapid s u p e r p u l s e d ( R S P ) . T h e c h o p p e d m o d e provides
a r e a s o n a b l e c o m p r o m i s e b e t w e e n a " c o o l " b e a m and the
heat transfer to t i s s u e required for h e m o s t a s i s . T h i s usually
m e a n s a c c e p t a n c e of a z o n e of heat d a m a g e at the depth of
t h e crater as well as a l o n g its side walls of about 0.5 to 1.0
mm.
U s i n g a s u p e r p u l s e d C 0 laser with a fluence of approximately 3 J / c m 2 at 2 Hz an e s t i m a t e d z o n e of tissue d a m a g e
of nonablated t i s s u e of 40 to 50 u,m width is o b t a i n a b l e in a
g u i n e a pig skin m o d e l . In v i v o , at m o r e realistic ablation
rates of 50 to 150 pulses per s e c o n d it is consistently noted
that t h e z o n e of d a m a g e is less than 2 0 0 u-m (see Fig. 7 - 8 ) .
T h i s e x t e n t of heat d a m a g e of tissue adjacent to the b e a m in
c a n c e r resection is quite a c c e p t a b l e . In addition, its extent is
m u c h m o r e c o n t r o l l a b l e than is heat d a m a g e associated
with e l e c t r o s u r g e r y . Both t h e h a n d h e l d p r o b e and the j o y stick m i c r o m a n i p u l a t o r result in safe excisional surgery;
h o w e v e r , t h e m i c r o s c o p e e n h a n c e s control b y magnifying
t h e surgical field a n d thereby a d d i n g precision to the
m e t h o d o f tissue r e m o v a l .
2
2 6
DRY FIELD
M a i n t e n a n c e of a dry field d e p e n d s on laser-tissue interactions as well as o t h e r tissue factors. T h e former is a timed e p e n d e n t function o f e n e r g y a b s o r p t i o n and thermal c o n d u c t i o n , and therefore h e m o s t a s i s i s e n h a n c e d b y C W o r
c h o p p e d C W free-beam lasers c o m p a r e d with R S P lasers.
S i m i l a r l y , N d : Y A G delivered by c o n v e n t i o n a l sapphire tip
or by the silica c o n t a c t p r o b e of the Surgical Laser T e c h n o l o g i e s ( S L T ) 2 7 - 2 9 laser i m p r o v e s h e m o s t a s i s significantly
w h i l e still a v o i d i n g e x c e s s i v e heat d a m a g e (see Fig. 7 - 4 4 ) .
E n h a n c i n g h e m o s t a s i s in tissue is a b e t t e d by the use of local
a n e s t h e t i c solution c o n t a i n i n g d i l u t e ( 1 : 2 0 0 , 0 0 0 ) e p i n e p h rine or Pitressin ( 1 . 0 u n i t s / m L ) . It is well advised to wait 5
to 7 m i n u t e s for m a x i m u m vasoconstriction to o c c u r prior

to Operating. T h e s e latter adjuncts add the benefit of intraoperative and p o s t o p e r a t i v e analgesia in addition to the
vasoconstriction that facilitates a c c u r a t e surgery by maintaining a dry field.
O p e r a t i n g c o n d i t i o n s a r e further i m p r o v e d by using t h e
laser. T h e application of the laser e n e r g y to the tissue d o e s
not c a u s e any m o v e m e n t of the tissue, particularly m u s c l e ,
as is the c a s e with e l e c t r o c a u t e r y w h o s e application induces
strong m u s c l e c o n t r a c t i o n s . T h i s is most a p p a r e n t during
surgery on the t o n g u e . T h e result is that the target tissue lies
passively during e n e r g y application, which e n h a n c e s t h e
precision of resection.
87
did not r e c e i v e v a s o c o n s t r i c t o r w h o s e b l o o d loss w a s 9 0

m L and three w h o did r e c e i v e v a s o c o n s t r i c t o r w h o s e avera g e b l o o d loss w a s 3 8 m L for t h e s a m e o p e r a t i o n . T h e
trend w a s t o w a r d r e d u c e d b l o o d loss for t h e laser-treated
p a t i e n t s . T h e Boor of m o u t h r e s e c t i o n s for both g r o u p s did
not i n c l u d e r e m o v a l of b o n e . All o p e r a t i o n s for t o n g u e
and floor of m o u t h w e r e p e r f o r m e d on p a t i e n t s having
g e n e r a l a n e s t h e s i a with t h e a i r w a y m a i n t a i n e d b y n a s o e n dotrachcal intubation.
AVOIDING GENERAL ANESTHESIA

Surgical
CO, AND CONTACT Nd:YAG
For transoral c a n c e r resection, the t w o lasers of greatest
value are the free-beam C O , and the v a r i o u s c o n t a c t
N d : Y A G lasers. T h e i r utility b e c o m e s progressively m o r e
important as m o r e a g e d patients c o m e to surgery for r e s e c tion of their oral c a n c e r s . Most of these patients h a v e significant intercurrent d i s e a s e s , particularly c a r d i o v a s c u l a r , pulmonary, and c e r e b r o v a s c u l a r , which m a k e it preferable to
perform their surgery using local a n d / o r regional a n e s t h e s i a
techniques a c c o m p a n i e d by i n t r a v e n o u s s e d a t i o n . B e c a u s e
operating in the oral cavity u n d e r these c o n d i t i o n s places
the airway at risk for obstruction from b l e e d i n g during
surgery, m a i n t a i n i n g a dry field b e c o m e s essential to the
maintenance of a patent a i r w a y . Both the C O and the Y A G
lasers permit the safe c o n d u c t of surgery u n d e r these circumstances. I n c o m p a r i s o n with the role o f free-beam C 0
the contact N d : Y A G laser w h e n used at 15 to 25 W output
power with an 8 0 0 - p m conical tip w a s found to reduce
bleeding and not to i m p a i r w o u n d healing. W h e n used for
the resection of a d v a n c e d - s t a g e oral c a n c e r that had been
previously treated by radiation it w a s e v e n found to reduce
infectious c o m p l i c a t i o n s , fistula formation, and distant flap
complications.
:
29
A p r o s p e c t i v e study of t h e u s e of f r e e - b e a m C O in t h e
D e p a r t m e n t o f D e n t i s t r y / O r a l and M a x i l l o f a c i a l S u r g e r y
at Sinai H o s p i t a l w a s initiated in 1988 to e v a l u a t e its efficacy for the transoral resection of s t a g e s I a n d II oral c a n cer. T h e first p a r a m e t e r to be e x a m i n e d w a s b l o o d loss resulting from partial g l o s s e c t o m y and floor of m o u t h
resection. T h e r e w e r e 12 t o n g u e l e s i o n s treated with the
free-beam C 0 laser ( s t u d y g r o u p ) and 1 0 treated with
scalpel o r e l e c t r o s u r g e r y ( c o n v e n t i o n a l g r o u p ) . T h e average blood loss for the c o n v e n t i o n a l g r o u p w a s 122 mL and
that for the laser-treated g r o u p w a s 6 0 m L . Both g r o u p s
received local infiltration a n e s t h e s i a with l i d o c a i n e 0 . 5 %
and e p i n e p h r i n e 1:200,000. F o r B o o r o f m o u t h c a n c e r , the
10 p a t i e n t s treated c o n v e n t i o n a l l y all had local a n e s t h e t i c
with v a s o c o n s t r i c t o r , and their a v e r a g e b l o o d loss w a s 190
m L . T h e laser-treated g r o u p c o n s i s t e d o f five p a t i e n t s w h o
:
Protocol
T h e a n a t o m i c site w a s injected with lidocaine or bupivacaine c o n t a i n i n g e p i n e p h r i n e 1:200,000. For floor of mouth

c a s e s . Pitressin (1.0 unitvmL) w a s also added to the local
a n e s t h e t i c . T h e c a n c e r itself w a s not m a n i p u l a t e d but the
area a r o u n d t h e t u m o r that would later constitute the margin
w a s intiltrated with the a n e s t h e t i c solution. T h e drapes w e r e
then a p p l i e d and a h y p o p h a r y n g e a l g a u z e pack w a s inserted. For o p e r a t i o n s p e r f o r m e d using sedation instead of
g e n e r a l a n e s t h e s i a , a g a u z e pack w a s placed as a throat
screen rather than as a h y p o p h a r y n g e a l pack. No " p r e p " solutions w e r e used and no preoperative or intraoperative antibiotics w e r e given unless they w e r e required for p r o p h y laxis b e c a u s e of c a r d i a c v a l v u l a r d i s e a s e or the presence of
metallic o r t h o p e d i c i m p l a n t s . N e i t h e r systemic nor locally
a p p l i e d steroids w e r e g i v e n . T r a c t i o n using sutures or ins t r u m e n t s to aid visibility d u r i n g s u r g e r y w a s applied as
n e c e s s a r y . ( S e e c a s e reports for details.)
S i n c e 1988, there h a v e been 13 patients with T, or T mal
c a r c i n o m a s , s e v e n of w h i c h w e r e floor of mouth ami
t o n g u e , w h i c h w e r e treated by laser resection using local
a n e s t h e t i c and i n t r a v e n o u s sedation. Unfavorable airway incidents did not o c c u r during surgery and no c a s e required a
c h a n g e in a n e s t h e t i c m a n a g e m e n t to control the airway during surgery. In no c a s e w a s it necessary to excessively
d e e p e n sedation to meet the n e e d s of patient comfort. N o n e
of these p a t i e n t s required p o s t o p e r a t i v e ICU for surgical
site m a n a g e m e n t and n o n e of t h e m required hospitalization
for m o r e than 48 hours.
CONSEQUENCES
P o s t o p e r a t i v e l y there w a s a high level of patient accept a n c e . O b j e c t i v e l y , they had m u c h less e d e m a and also res u m e d oral feedings m o r e rapidly than did those patients
with similar lesions w h o w e r e treated by c o n v e n t i o n a l
s u r g e r y , particularly with electrocautery.
During f o l l o w - u p e x a m i n a t i o n s the use of postoperative
a n a l g e s i c s w a s r e c o r d e d . As noted in the literature" " and
1,1
88
c o n f i r m e d i n o u r o w n p r o s p e c t i v e and o n g o i n g a s s e s s m e n t
of p o s t o p e r a t i v e pain, the d e g r e e of pain to be anticipated is
unpredictable.
F u r t h e r m o r e , a p p r o x i m a t e l y o n e third o f
patients will h a v e less p o s t o p e r a t i v e pain w h i l e a n o t h e r
third will h a v e m o r e p o s t o p e r a t i v e pain than do t h o s e patients h a v i n g c o n v e n t i o n a l s u r g e r y . A m o n g those with less
pain, a s u b g r o u p will e x p e r i e n c e a 2- or 3-day interval of
s u d d e n l y increasing pain starting on p o s t o p e r a t i v e day 4 or
5 . G a s p a r and S z a b o reported o n 5 4 8 o p e r a t i o n s o f different types in the oral cavity and found that only 3 1 . 2 % of
their patients required a n a l g e s i c s o n t h e d a y o f s u r g e r y .
After day 5, only t w o patients required a n a l g e s i c s b e c a u s e
of pain from e x p o s e d b o n e .
11
w e r e t w o c a s e s o f p o s t o p e r a t i v e infection requiring treatm e n t with s y s t e m i c antibiotics, but there w e r e no cases of

significantly d e l a y e d h e a l i n g . S i m i l a r f i n d i n g s h a v e also
b e e n reported for u s e of the c o n t a c t N d : Y A G (sapphire
t i p ) . 2 9 S t r o n g et a l . ' s 2 4 ' 2 5 original 1979 study of 57 oral canc e r s o f unspecified stage r e m o v e d using m i c r o s c o p i c control b y C W C 0 laser did not report any postoperative infections.
2
1 8
All of o u r patients w e r e seen on a w e e k l y basis until

h e a l i n g w a s c o m p l e t e . I n d e p e n d e n t o f oral a n a t o m i c r e g i o n ,
all patients w e r e c o m p l e t e l y h e a l e d by t h e fifth p o s t o p e r a tive w e e k . T h i s consistent epithelialization of t h e laser-ind u c e d w o u n d i n h u m a n s c o n f i r m s t h e results o f a n i m a l e x p e r i m e n t s in which reepithelialization from t h e peripheral
b o r d e r of a laser w o u n d took place within 4 w e e k s . T h e s e
treatment areas in h u m a n s , as in d o g s , w e r e a l m o s t t h e s a m e
c o l o r and t e x t u r e within 4 to 5 w e e k s , a n d after m a t u r a t i o n
w e r e indistinguishable from n o r m a l m u c o s a . In addition,
the healed oral m u c o s a p r e s e r v e s its elastic properties. T h i s
m a y be related to the m i n i m a l increase in m u c o s a l t h i c k n e s s
after C 0 laser treatment c o m p a r e d with scalpel i n c i s i o n s
or it could be related to d i m i n i s h e d activity of m y o f i b r o blasts i n t h e h e a l i n g w o u n d . 3 2
3 0
U s i n g these t e c h n i q u e s to r e m o v e 106 c a n c e r s d u r i n g the

past 5 y e a r s , we h a v e not had any patients stay in t h e hospital l o n g e r than 2 d a y s . For larger T lesions and those with
p o s t e r i o r defects r e q u i r i n g insertion of a surgical pack, all
s t a y e d an a v e r a g e of 2 d a y s . H o w e v e r , b e c a u s e of the consistent m i n i m a l p o s t o p e r a t i v e e d e m a , n o n e o f these 9 0 patients from w h o m 106 t u m o r s w e r e r e m o v e d required
o v e r n i g h t intubation or a d m i s s i o n to an intensive care unit
after s u r g e r y .
2
A l t h o u g h Panje et a l . reported s w a l l o w i n g difficulties in

2 1 % o f their c a s e s treated b y transoral resection with the
C 0 laser, w e did not specifically m o n i t o r s w a l l o w i n g difficulties. All patients c o u l d eat a soft or n o r m a l diet by the
t i m e epithelial resurfacing w a s c o m p l e t e at 4 to 5 w e e k s .
D u r i n g this initial period n o n e of these patients required intubation of t h e gastrointestinal tract to maintain their nutrition.
2
30
TIME AT OPERATION
COMPLICATIONS
N o s p l i t - t h i c k n e s s skin grafts w e r e p l a c e d for a n y lasertreated c a s e s . P o s t o p e r a t i v e s c a r r i n g w a s m i n i m a l , although t w o p a t i e n t s from a m o n g 2 6 p a t i e n t s with floor o f
m o u t h o r ventral t o n g u e r e s e c t i o n r e q u i r e d s c a r r e l e a s e
( 7 . 7 % ) t o i m p r o v e t o n g u e m o b i l i t y a n d o n e patient with
w i d e local e x c i s i o n of t h e t o n g u e , floor of the m o u t h , a n d
O n c e the " l e a r n i n g c u r v e " delay is o v e r c o m e by clinical exp e r i e n c e , laser c a s e s go quite quickly. In fact, t h e average
t i m e d u r i n g t h e past 5 y e a r s for resection of T, or T oral les i o n s is less than 45 to 50 m i n u t e s including injection of
local a n e s t h e t i c , vital s t a i n i n g with toluidine b l u e , and a
m a n d a t o r y 5 - m i n u t e (by t h e clock) h e m o s t a s i s c h e c k prior
to terminating the operation.
2
m a n d i b u l a r a l v e o l u s a l o n g with s u p r a o m o h y o i d n e c k diss e c t i o n had a mild s p e e c h i m p e d i m e n t for w h i c h he d i d not

seek t r e a t m e n t .
THE SUBMANDIBULAR DUCT
A m o n g the 106 p a t i e n t s treated by transoral resection

with t h e free-beam C 0 laser, p o s t o p e r a t i v e b l e e d i n g w h i l e
in hospital w a s limited to five e v e n t s . T w o o c c u r r e d in patients with c i r r h o s i s of t h e liver, w h o " o o z e d " for 2 to 3
d a y s after s u r g e r y . T h e r e w e r e t w o c a s e s o f d e l a y e d b l e e d ing necessitating r e a d m i s s i o n to the o p e r a t i n g r o o m to c o n trol b l e e d i n g , both o c c u r r i n g on the first p o s t o p e r a t i v e
e v e n i n g , and there w a s o n e patient w h o bled a t t h e c o n c l u sion of s u r g e r y d u r i n g e m e r g e n c e from a n e s t h e s i a w h i l e
still intubated, w h o required r e c o a g u l a t i o n of t h e floor of
the m o u t h . T h e r e w a s also o n e c a s e o f d e l a y e d h e m a t o m a
d e v e l o p i n g 10 d a y s after resection of the ventral t o n g u e and
floor of m o u t h in a patient with c i r r h o s i s of t h e liver. T h e r e
F o r anterior floor of m o u t h resection, no special care is

taken in regard to W h a r t o n ' s duct. In fact, they are c o m pletely i g n o r e d . 3 3 T h e laser is used to transect the duct if
this is required to " c l e a r the field" of cancer. B e c a u s e of the
k n o w n possibility of d o w n g r o w t h into the duct of oral s q u a m o u s cell c a n c e r located o v e r the d u c t , 3 4 it is w i s e to be
q u i t e liberal in regard to t h e indications for r e m o v i n g the
duct as part of t h e en b l o c resection. No sialodochoplasty of
t h e part of t h e p r o x i m a l duct r e m a i n i n g in situ is performed.
P o s t o p e r a t i v e l y the rate of significant s u b m a n d i b u l a r gland
e n l a r g e m e n t s e c o n d a r y to obstruction requiring removal of
the g l a n d i s 4 % i n o u r s e r i e s .

SURGICAL CASES
89
Both the free-beam C 0 laser and t h e c o n t a c t N d : Y A G

laser a r e a p p l i c a b l e to t h e transoral resection of oral c a n c e r .
The major a d v a n t a g e s for t h e u s e of lasers a r e m i n i m a l
postoperative e d e m a , w h i c h is usually but not a l w a y s less
than that e n c o u n t e r e d with e l e c t r o s u r g e r y ; a dry o p e r a t i v e
f i e l d ; and a b s e n c e o f m u s c u l a r fasciculations, particularly
of the t o n g u e , w h i c h p r o v i d e s a " q u i e t " o p e r a t i v e field.
Most patients are d i s c h a r g e d within 2 4 t o 4 8 h o u r s a n d patient a c c e p t a n c e is very high.
Surgery itself g o e s q u i c k l y , usually lasting less than I
hour, and either g e n e r a l a n e s t h e s i a or s e d a t i o n t e c h n i q u e s
may be used a l o n g with local a n e s t h e s i a . B l o o d loss is m i n imized. H o w e v e r , r e m e m b e r t o rapidly c l a m p and tie o r c o -
larly simplified by the lack of need for split-thickness skin

grafts. P o s t o p e r a t i v e scar contraction is mild and persistent
restricted oral o p e n i n g following resection of posteriorly located lesions of t h e buccal m u c o s a , retromolar pad, or anter i o r tonsillar pillar is u n c o m m o n . S o m e patients will lose
a b o u t 1 0 t o 2 0 % o f their m a x i m a l incisal o p e n i n g .
T h e free-beam C 0 laser i n c h o p p e d C W o r R S P m o d e s
c a u s e s t h e least s c a r r i n g b e c a u s e it c a u s e s t h e least heat
d a m a g e . As a corollary it is also less h e m o s t a t i c than either
C W C 0 o r c o n t a c t N d : Y A G . O n t h e o t h e r hand, these latter t w o o p t i o n s c r e a t e m o r e u n w a n t e d heat effects both to
the m a r g i n o f t h e s p e c i m e n and t o t h e native tissue. T h e
C 0 laser d o e s not p r o v i d e tactile sensation t o t h e operator,
a n d for u s e in t h e area of t h e lingual anterior m a n d i b u l a r
g i n g i v a o n e m u s t use a front surface d e n t a l m i r r o r to c h a n g e
t h e b e a m d i r e c t i o n . T h i s r e q u i r e s a bit of practice for surg e o n s w i t h o u t dental training. T h e c o n t a c t N d : Y A G pro-
agulate vessels if t h e laser d o e s not s t o p t h e b l e e d i n g . T h e

return rate to the o p e r a t i n g theater to c o n t r o l d e l a y e d bleeding is about 4 % .
Reconstruction after floor of m o u t h resection is particu-
vides tactile sensation and better h e m o s t a s i s , but heat d a m a g e m a y e x c e e d 3.6 m m w h e r e a s R S P C 0 heat d a m a g e i s

usually less than 0.3 m m . F r e e - b e a m C 0 w o u n d s heal
slightly faster but this is not clinically significant.
General Comments: Free-Beam C0

Contact Nd: YAG
vs.
90
Lasers in Maxillofacial Surgery a n d Dentistry
TRANSORAL CASE 1: FLOOR OF MOUTH

A 5 4 - y c a r - o l d A f r i c a n - A m e r i c a n w o m a n , with a 2 5 - y e a r
history of daily s m o k i n g of t w o p a c k s of cigarettes and of
drinking four b e e r s , presents with a 2 - m o n t h history of an
"irritation u n d e r m y t o n g u e . " E x a m i n a t i o n , incisional
b i o p s y , and s y s t e m i c e v a l u a t i o n d e m o n s t r a t e a T | N ( ) M ( )
m o d e r a t e l y well-differentiated s q u a m o u s cell c a r c i n o m a o f
the anterior floor of m o u t h ( F O M ) that e n c r o a c h e s upon t h e
t e r m i n u s o f W h a r t o n ' s duct ( F i g s . 7 - 1 a n d 7 - 2 ) . S h e i s also
noted to h a v e mild von W i l l e b r a n d ' s disease, c h r o n i c
obstructive lung d i s e a s e , stable c o r o n a r y artery d i s e a s e , and
insulin-controlled d i a b e t e s mellitus. T h e free-beam CC2
laser is c h o s e n as the instrument of c h o i c e for r e m o v a l of
her tumor.
Figure 7 - 2 .
During operation, tongue properly retracted.
TECHNIQUE
After the c o m p l e t i o n of a e r o d i g e s t i v e e n d o s c o p y with the

patient r e c e i v i n g a general a n e s t h e t i c , the a i r w a y is secured
with a n a s o e n d o t r a c h e a l t u b e . T h e face is protected with
moist saline e y e p a t c h e s and facial d r a p e s , and the
h y p o p h a r y n x is packed with a wet throat pack. Local
a n e s t h e t i c solution c o n t a i n i n g 1:200,000 e p i n e p h r i n e and
Pitressin 1.0 U / m L is injected along t h e p l a n n e d lines of
resection into t h e d e p t h of the w o u n d . W h i l e a w a i t i n g
m a x i m u m vasoconstrictor effect, the oral m u c o s a is stained
with toluidine blue. ( S e e C h a p t e r 4.) T h i s is very helpful in
a s s e s s i n g subclinical extent of spread of t h e m u c o s a l t u m o r .
After w a s h i n g the field with saline, the areas retaining
the stain a r e noted (Fig. 7 - 3 ) and the peripheral resection
margin is m a r k e d with t h e laser in the d e f o c u s e d m o d e ( F i g .
7 - 4 ) . T h e tip of the t o n g u e is g r a s p e d with a towel clip to
facilitate retraction. T h e h a n d p i e c e for the free-beam C O 2
laser is n o w placed in c o n t a c t (i.e., at the focal point) with
the tissue to be e x c i s e d to start the e x c i s i o n . T h e laser is
adjusted s o that i n c h o p p e d C W o r R S P m o d e a n a v e r a g e
p o w e r o u t p u t of 20 to 30 W is d e l i v e r e d . By v a r y i n g the
h a n d p i e c e distance from the tissue h e l i u m - n e o n ( H e N e )
g u i d e b e a m spot size is varied from 0 . 3 to 3.0 m m . T h e true
Figure 7 - 1 .
T | N()M() SCC of anterior floor of mouth.
Figure 7 - 3 . Lesion retains toluidine blue vital slain after aectk

acid rinse. HeNe guide beam placed into contact with tissue ai
focal point of probe demonstrating 0.3-mm guide spot size foi
incision.
Figure 7-4. Defocused spots to mark resection margin.

Handpiece is moved away from focal point until 2- to 3-mm spot
size is obtained. Bloodless markings are made with single pulses
(PD <500 W / c m ) .
2

vaporization spot size a v e r a g e s a p p r o x i m a t e l y 8 0 % o f the
HeNe spot size. T h e r e f o r e , the p o w e r d e n s i t y ( P D ) will
range from 3 5 , 0 0 0 W / c m 2 t o 3 5 0 W / c m 2 a t 2 0 - W o u t p u t
and from 5 2 , 0 0 0 W / c m 2 t o 5 2 5 W / c m 2 a t 3 0 - W output.
The former values a r e used for e x c i s i o n and t h e latter for
coagulation.
Surgical principles of traction-countertraction a r e used to
facilitate dissection (Fig. 7 - 5 ) and c a u t e r y or suture ligatures are used liberally to q u i c k l y s t o p b l e e d i n g . T h e s u b mandibular ducts are transected at will at high PD in the
pulsed m o d e , and n o s i a l o d o c h o p l a s t i e s a r e p e r f o r m e d .
After d e t e r m i n i n g the d e p t h of resection anteriorly, d i s s e c tion w a s c o n t i n u e d posteriorly until an a d e q u a t e m a r g i n
was established. T h e posterior dissection w a s then m a d e
from the m u c o s a to the d e p t h of t h e r e s e c t i o n . T h e b a s e of
the resection w a s free of c h a r e x c e p t w h e r e d e l i b e r a t e c o a g ulation w a s used (Fig. 7 - 6 ) . T h e s p e c i m e n w a s oriented and
91
Figure 7 - 6 . Base coagulated in CW mode al 30 to 40 W, defocused for maximum hemostasis. Note that both resection and coagulation violate the submandibular ducts.
pinned on a w o o d e n t o n g u e blade to be s e n t to the p a t h o l ogy laboratory (Fig. 7 - 7 ) . N o t e that t h e extent of the thermal d a m a g e on t h e d e e p side of the resection m a r g i n w a s
only 0.16 m m (Fig. 7 - 8 ) . E s t i m a t e d b l o o d loss w a s 5.0 m L
and operating t i m e w a s 4 0 m i n u t e s .
The patient w a s d i s c h a r g e d in the m o r n i n g with a p r e scription for a narcotic and a nonsteroidal anti-inflammatory analgesic. (If used, an oral p a c k is r e m o v e d either at
bedside prior to d i s c h a r g e , or in t h e office on the f o l l o w i n g
day.) T h e day after s u r g e r y , t h e b a s e o f t h e w o u n d w a s f i b rin covered. T h e patient rinsed twice a d a y with c h l o r h e x i dine for t h e next 7 to 10 d a y s . P r o g r e s s of h e a l i n g w a s
checked a p p r o x i m a t e l y w e e k l y ( F i g s . 7 - 9 t o 7 - 1 4 ) until
reepithelialization w a s c o m p l e t e , at which t i m e p o s t o p e r a tive observation w a s m a i n t a i n e d a c c o r d i n g to the c a n c e r
surveillance protocol. At 1-year recall ( F i g s . 7 - 1 5 to 7 - 1 7 )
speech, s w a l l o w i n g , and r a n g e o f motion o f t h e t o n g u e
were all n o r m a l . T h e r e w a s no e v i d e n c e of recurrent d i s e a s e
at 3 years.
Figure 7 - 7 .
pathologist.
Figure 7 - 5 . Specimen mobilized. Dissection made to base of

deep resection margin. Note instruments retracting both tongue
and specimen to provide traction-countertraction for good surgical
exposure.
F'igure 7 - 8 . Histology: Note zone of thermal necrosis on base of

specimen is only 0.16 mm (100X).
Specimen oriented and pinned for transfer to the
92
Figure 7-9. Fibrinous coagulum appears within the first 24

hours. still present at 1 week.
Figure 7-10. Two weeks. Note that reepithelialization occurs

from the periphery. Note the exposed area of lingual plate of
mandible on the patient's left side.
Figure 7-11. Twenty-two days. Note that most of oral floor is

covered by new epithelium. Bone is still exposed.
Figure 7-12 twenty-two days. mirror demonestrate area of

exposed bone. one will expect squestrum, but not progressive
osteomyelitis to develop. The patient has received no antibiotics.
Figure 7-13. Thirty-two days. Most of the surgical site has

reepithelialized.
Figure 7-14.
Forty-six days. Completely healed.
94

TRANSORAL CASE 2: FOM
A 5 6 - y e a r - o l d w h i t e m a n with a 2 5 - y e a r history of daily

smoking of two packs of cigarettes and drinking four
w h i s k e y e q u i v a l e n t s of b e e r p e r d a y p r e s e n t s with a
2 - m o n t h history o f a n "irritation u n d e r m y t o n g u e . " E x a m i nation, incisional biopsy, and s y s t e m i c evaluation d e m o n strate a T | N M well-differentiated m i c r o i n v a s i v e s q u a m o u s cell c a r c i n o m a o f t h e anterior floor o f m o u t h ( F O M )
that e n c r o a c h e s upon the t e r m i n u s of W h a r t o n ' s d u c t ( F i g .
7 - 1 8 ) . H e i s also noted t o h a v e c h r o n i c o b s t r u c t i v e lung
disease and c o r o n a r y artery d i s e a s e w i t h o u t recent anginal
chest pain. T h e free-beam C 0 laser i s c h o s e n a s t h e instrument of c h o i c e for r e m o v a l of h i s t u m o r .
0
d e l i b e r a t e c o a g u l a t i o n w a s used. E s t i m a t e d blood loss w a s

15 mL and o p e r a t i n g t i m e w a s 20 m i n u t e s . If hemostasis is
satisfactory after 5 to 10 m i n u t e s of observation, t h e patient
is b r o u g h t to t h e recovery r o o m . On (he o t h e r hand, if h e m o s t a s i s is imperfect, a b o v i n e c o l l a g e n pad is placed o v e r
the resection bed a n d an iodoform g a u z e pack is secured for
o v e r n i g h t insertion. T h e patient is e x t u b a t e d in t h e recovery
r o o m w h e n fully a w a k e .
TECHNIQUE
After i n d u c i n g general a n e s t h e s i a and s e c u r i n g t h e airw a y with a n oral e n d o t r a c h e a l t u b e , a e r o d i g e s t i v e e n d o s c o p y is p e r f o r m e d . T h e tube is then c h a n g e d to a nas o e n d o t r a c h e a l t u b e . T h e face i s p r o t e c t e d with moist s a l i n e
e y e p a t c h e s and facial d r a p e s , and the h y p o p h a r y n x is
p a c k e d with a wet throat pack. Local a n e s t h e t i c solution of
0 . 5 % b u p i v a c a i n e c o n t a i n i n g 1:200,000 e p i n e p h r i n e and
Pitressin 1.0 U / m L ( 1 . 0 m L o f Pitressin a d d e d t o 3 0 m L o f
b u p i v a c a i n e ) is injected a l o n g the p l a n n e d lines of resection
t o t h e depth o f t h e m u s c u l a t u r e o f t h e oral floor. N o p r e p a ration solution is used and neither p r o p h y l a c t i c antibiotics
n o r steroids a r e g i v e n . W h i l e a w a i t i n g m a x i m u m v a s o c o n strictor effect, the oral m u c o s a is stained with t o l u i d i n e b l u e
(see C h a p t e r 4 ) t o assess a n y subclinical m u c o s a l s p r e a d o f
the t u m o r .
T h e s u b m a n d i b u l a r d u c t s are t r a n s e c t e d at will at high
PD in the p u l s e d m o d e , and no s i a l o d o c h o p l a s t i e s a r e performed. After d e t e r m i n i n g the d e p t h of resection a n t e r i o r l y ,
dissection c o n t i n u e s posteriorly until an a d e q u a t e margin
guided by the initial m a r k i n g out of t h e resection is e s t a b lished. T h e vertical c o m p o n e n t o f t h e resection from m u cosa to the depth of the resection is then c o m p l e t e d . T h e
b a s e of the resection should be free of c h a r e x c e p t w h e r e
Figure 7 - 1 8 . Microinvasive T|N M squamous cell carcinoma

of anterior oral floor arising in proximity to Wharton's duct.
0
PROBLEM AREA: LINGUAL ANTERIOR MANDIBULAR GINGIVA

T h e most difficult area to a d e q u a t e l y control is the region of the lingual g i n g i v a , w h e r e it is often important to
r e m o v e t h e soft tissue lining t h e lingual surface of the
m a n d i b l e in a s u p r a p e r i o s t e a l p l a n e . T h i s m a y be d o n e in
several w a y s . E i t h e r t h e scalpel is used to incise to b o n e ,
w h i c h u n f o r t u n a t e l y c a u s e s b l e e d i n g , o r t h e laser must b e
redirected a n t e r i o r l y s o t h e incision can b e carried d o w n t o
t h e p e r i o s t e u m . T h i s latter m a n e u v e r r e q u i r e s the u s e of an
a d j u s t a b l e front surface m i r r o r ( F i g . 7 - 1 9 ) to redirect the
b e a m . A l t e r n a t i v e l y , s o m e o f the s u p r a p e r i o s t e a l dissection
m a y be p e r f o r m e d with a periosteal e l e v a t o r . Or, if using
t h e laser, a c o n t r a - a n g l e h a n d p i e c e m a y be used instead of
a front surface m i r r o r d e p e n d i n g on availability. T h e final
incision of p e r i o s t e u m is best p e r f o r m e d with a scalpel to
a v o i d d a m a g i n g t h e b o n e with the laser i m p a c t s . H o w e v e r ,
s h o u l d t h e latter o c c u r to a mild d e g r e e , e p i t h e l i u m will
still c o m p l e t e l y c o v e r l a s e r d a m a g e d b o n e in about 4
w e e k s . It is not, h o w e v e r , u n c o m m o n for a s m a l l , thin seq u e s t r u m of part of the lingual plate of the m a n d i b l e to be
formed.
After r e m o v i n g t h e s p e c i m e n (Fig. 7 - 2 0 ) , m a r g i n s w e r e
harvested from the patient for frozen section. T h e defect
w a s p a c k e d with i o d o f o r m g a u z e and a n antibacterial ointment. T h e patient w a s transferred to the recovery r o o m
w h e r e e x t u b a t i o n w a s p e r f o r m e d only w h e n h e w a s fully
awake.
Figure 7 - 1 9 . (From another patient) Note that a front surface

mirror may be used to reflect the laser beam to reach the lingual
aspect of the mucosa or gingiva lining the lingual surface of the
mandible.

AFTER CARE
Oral fluids are a d m i n i s t e r e d that night and narcotics a r e
prescribed i n t r a m u s c u l a r l y or i n t r a v e n o u s l y that night. T h e
patient is discharged in the m o r n i n g with a prescription for
a narcotic and a nonsteroidal anti-inflammatory a n a l g e s i c .
The oral p a c k is r e m o v e d either at b e d s i d e p r i o r to discharge, or in the office on t h e following d a y . At this t i m e ,
(he base of the w o u n d is fibrin c o v e r e d ( F i g . 7 - 2 1 ) . T h e patient rinses twice a day with c h l o r h e x i d i n e for the n e x t 7 to
10 days. H y d r o g e n peroxide/salt w a t e r rinses m i x e d 1:1 a r e
95
used e v e r y few h o u r s . P r o g r e s s of healing is c h e c k e d

w e e k l y until reepithelialization is c o m p l e t e ( F i g s . 7 - 2 2 and
7 - 2 3 ) , a t w h i c h t i m e p o s t o p e r a t i v e observation i s m a i n tained a c c o r d i n g t o t h e c a n c e r s u r v e i l l a n c e protocol. For a n terior floor of m o u t h r e s e c t i o n s , there is no interference
with n o r m a l s w a l l o w i n g . S p e e c h usually returns t o normal
within 2 to 3 m o n t h s and is a c c o m p a n i e d by a n o r m a l r a n g e
o f m o t i o n o f t h e t o n g u e . R e s e c t i o n s o f t h e posterolateral
floor of the m o u t h a r e m o r e likely to be associated with
minor speech impediments.
Figure 7-20. The specimen is pinned onto a wooden tongue

blade, marked for orientation and demonstrated to the pathologist
in the operating room. Frozen sections are obtained from the palient as required.
Figure 7 - 2 2 . Oral floor well healed. Wound was reepithelialized

in 25 days. Mature, pliable mucosa present (10 weeks).
Figure 7 - 2 1 . Fibrin coagulum still present at floor of resection,

postoperative day 10.
Figure 7 - 2 3 . Lingual gingiva stripped at surgery has recovered

completely (10 weeks). Recover)' of tongue range of motion was
complete.
96

period of 4 to 5 m i n u t e s lo m i n i m i z e t h e h y p e r t e n s i v e effect
C A S E 3: T O N G U E F R E E - B E A M C 0
T h i s 8 2 - y e a r - o l d w h i t e w o m a n with h y p e r t e n s i o n and a
of the e p i n e p h r i n e . Essentially, the entire right lower lip and

oral c a v i t y w a s anesthetized to p r o v i d e comfort d u r i n g re-
9 - c m a b d o m i n a l aortic a n e u r y s m p r e s e n t e d with a T 2 N 0 M 0
traction as well as pain p r e v e n l i o n for the actual a r e a s of in-
m o d e r a t e l y well-differentiated c a r c i n o m a of the right lateral
cision.
t o n g u e (Fig. 7 - 2 4 ) . After r e v i e w b y t h e head and n e c k c a n -
T h e p e r i p h e r y of the p l a n n e d resection w a s m a r k e d using
cer t e a m , surgical r e m o v a l o f the t u m o r w a s r e c o m m e n d e d
the laser h a n d p i e c e in t h e d e f o c u s e d m o d e at a PD of about
as the t r e a t m e n t of c h o i c e . E x t e n s i v e p r e o p e r a t i v e c o u n s e l -
5 0 0 W / c m . After a s s e s s i n g for a d e q u a c y of m a r g i n s , the
ing in regard to risks as well as the details of t r e a t m e n t s e -
resection c o m m e n c e d at an a p p r o x i m a t e PD of > 5 0 , 0 0 0
W / c m 2 ( A v g . P = 3 0 W , p p s = 1 1 8 , H e N e spot = 0.3 m m .
cured her c o n s e n t to r e m o v e the t u m o r u s i n g local a n e s t h e sia with s u p p l e m e n t a l i n t r a v e n o u s s e d a t i o n .
pulse w i d t h = 2 . 4 m s , intcrpulsc d i s t a n c e = 9.9 m s , 11 u-
At s u r g e r y , after p r o v i d i n g s e d a t i o n , the t o n g u e w a s
e n c e = 2 9 0 m J / p u l s e ) starting lateral to the m i d l i n e to pre-
anesthetized by lingual, inferior a l v e o l a r and long b u c c a l
s e r v e the m a x i m u m a m o u n t of u s a b l e t o n g u e tip with the
b l o c k s as well as by direct infiltration in the m i d l i n e of t h e
incision, then p r o c e e d i n g o b l i q u e l y to reach the midline
t o n g u e and in the lateral oral floor with 0 . 5 % b u p i v a c a i n e
(Fig. 7 - 2 5 ) . N o w d i s s e c t i o n w a s c o n t i n u e d posteriorly i n
with 1:200,000 e p i n e p h r i n e . T h i s w a s given slowly o v e r a
the relatively b l o o d l e s s p l a n e of the m i d l i n e of the tongue.
Figure 7-24. T NM,i moderately well-differentialed squamous

cell carcinoma of mobile tongue.
Figure 7-26.
4.3 X 1.5 cm.
Figure 7 - 2 5 . Margins marked. Superpulsed mode, defocused

handpiece. PD = 450 W / e n r .
Figure 7 - 2 7 . Deep resection margin of specimen. Note relative

lack of charring. Approximately 5 mm of additional "marginal"
tissue was vaporized at the depth of resection. (PD approximately
52.000 W/cm for resection.)
Oral side of specimen. Specimen measured 4.7 X
97
At the p o s t e r i o r limit of t h e resection, the incision w a s e x tended laterally to j o i n t h e line of resection at the oral floor.
This latter w a s n o w joined by the anterior resection line at
the level of t h e floor of t h e m o u t h and t h e s p e c i m e n w a s
delivered (Figs. 7 - 2 6 and 7 - 2 7 ) . T h e b a s e w a s c o a g u l a t e d
at 30 W in CW m o d e with a 3 - m m spot s i z e , d e f o c u s e d to
provide a PD = 4 2 5 W / c m . T h e b a s e w a s d e l i b e r a t e l y left
slightly c h a r r e d to r e d u c e the likelihood of p o s t o p e r a t i v e
bleeding (Fig. 7 - 2 8 ) . N o t e the contrast to F i g u r e 7 - 2 7 in
which the d e e p surface of t h e s p e c i m e n r e m o v e d by the
laser in s u p e r p u l s e d m o d e s h o w s a l m o s t no c h a r and t h e r e fore minimal heat effects. A s i m p l e g a u z e s p o n g e w a s
placed o v e r the w o u n d and t h e patient w a s a s k e d to bite on
it. Estimated blood loss w a s less than 50 m L , and o p e r a t i n g
t i m e i n c l u d i n g a d m i n i s t r a t i o n of local a n e s t h e t i c w a s 48
minutes.
P o s t o p e r a t i v e l y , narcotic a n a l g e s i c s w e r e required for 4
d a y s . T h e patient started a c l e a r liquid diet on t h e day of
s u r g e r y and full liquids on t h e first p o s t o p e r a t i v e d a y . T h e r e
w a s n o p o s t o p e r a t i v e b l e e d i n g , and s h e w a s discharged o n
p o s t o p e r a t i v e day 2. T h e s e q u e n c e of healing from the first
p o s t o p e r a t i v e visit to c o m p l e t e reepithelialization is d e m o n strated i n F i g u r e s 7 - 2 9 t o 7 - 3 3 . F u n c t i o n a l l y , speech and
s w a l l o w i n g w e r e c o m p l e t e l y n o r m a l within 9 w e e k s of the
c o m p l e t i o n o f s u r g e r y . T h e r e w a s n o postoperative s u b m a n d i b u l a r g l a n d o b s t r u c t i o n , and the patient r e m a i n e d dise a s e free for 3 years until s h e died from a m y o c a r d i a l infarction.
Figure 7-28. Base of resection. CW effect causing char left in

situ to inhibit bleeding.
Figure 7 - 3 0 . Day 10. Most of fibrin has been replaced by immature epithelium.
Figure 7 - 2 9 . Day 4. Fibrin covering of laser wound left to heal

by second intention. This forms during the first 24 to 48 hours
after wounding and is gradually replaced by epithelial tissue.
F'igure 7 - 3 1 . Day 18. Some wound contraction has occurred

and most of wound is covered by new epithelium.
98
Figure 7 - 3 2 . Day 25. All except one small area representing

less than 10% of the total surface area of the wound has been replaced by new epithelium.
Figure 7 - 3 3 . Eight weeks. Complete epithelialization occurred

by day 3 1 ; 24 days later the surface is unchanged and the range of
motion of the tongue is very good but slightly restricted.
99
CASE 4: T O N G U E CANCERPRIMARY
CLOSURE
A 53-year-old w h i t e w o m a n with a T 1 N 0 M 0 well-differentiated s q u a m o u s cell c a r c i n o m a of t h e m i d d l e third of the lateral border of the m o b i l e t o n g u e ( F i g s . 7 - 3 4 to 7 - 3 7 ) .
Figure 7 - 3 6 .
Figure 7-34.
tongue.
T,N M
n
Primary closure of wound.
squamous cell carcinoma of mobile
Figure 7-37. Normal tongue protrusion at 33 months. Patient

had no evidence of disease at 8 years.
Figure 7-35. Starting the incision with the laser handpiece tip
adjacent the tissue at the focal point. PD approximately 30,(X)0 W,
superpulsed mode. Note HeNe aiming beam just below tip within
incision. Field is dry.
100
C A S E 5: T O N G U E C O N T A C T ND:YAG
LASER SCALPEL
T h i s 8 3 - y e a r - o l d w h i t e m a n p r e s e n t e d with a well-differentiated T 1 N 0 M 0 s q u a m o u s cell c a r c i n o m a o f the posterior
third of the m o b i l e t o n g u e located along its ventrolateral
surface. S e v e n t e e n years before he had had a w i d e local e x cision of the m i d p o r t i o n of t h e left lateral t o n g u e for a w e l l differentiated T | N M s q u a m o u s cell c a r c i n o m a . H e had
d i s c o n t i n u e d s m o k i n g cigarettes after the t r e a t m e n t of h i s
index c a n c e r , but c o n t i n u e d to c o n s u m e four w h i s k e y
e q u i v a l e n t s of gin per d a y . Liver function s t u d i e s a n d q u a n titative platelet c o u n t s w e r e n o r m a l . T h e c o l l e c t i v e r e c o m m e n d a t i o n of the head and neck t u m o r c o n f e r e n c e w a s to
resect the t u m o r . T h e c o n t a c t N d : Y A G l a s e r ( S L T ) w a s
c h o s e n as t h e instrument of c h o i c e b e c a u s e of the need to
e x t e n d the posterior limit of t h e resection a l o n g t h e lingual
0
( )
gutter into the u p p e r h y p o p h a r y n x . an area w h e r e control of

the free-beam C 0 b e c o m e s a bit difficult e v e n with the u s e
of a front surface m i r r o r to alter t h e incident a n g l e of t h e
b e a m . In addition, the increased h e m o s t a s i s of the c o n t a c t
Y A G w a s c o n s i d e r e d t o b e o f a d e q u a t e benefit t o a c c e p t the
slight increase in thermal n e c r o s i s a t t e n d a n t to t h e c o n t a c t
laser c o m p a r e d with t h e free-beam C 0 . T h e silica c o n t a c t
scalpel p r o b e s (Fig. 7 - 3 8 ) w e r e selected b a s e d upon their
g e o m e t r y for tissue e x c i s i o n in this highly v a s c u l a r area.
F'igure 7 - 3 9 . Laser is activated prior to touching probe against

tissue. When probe tip reaches operating temperature, it is gently
stroked along the path of incision. Tactile sense regulates rate and
depth of incision. Dissection proceeding into depth of tongue.
Note absence of bleeding.
At operation, g e n e r a l a n e s t h e s i a with n a s o e n d o t r a c h e a l
intubation t o secure t h e a i r w a y w a s c h o s e n . B u p i v a c a i n e
0 . 5 % with e p i n e p h r i n e 1:200.000 w a s a d m i n i s t e r e d w i t h i n
the s u b s t a n c e of the t o n g u e both to e n h a n c e h e m o s t a s i s and
t o p r o v i d e p o s t o p e r a t i v e a n a l g e s i a . T h e f i e l d w a s stained
with toluidinc blue to assess for areas of subclinical n e o p l a sia a n d / o r areas o f p r e n e o p l a s t i c c h a n g e ( d y s p l a s i a ) . T h e
h y p o p h a r y n x w a s o c c l u d e d with a wet g a u z e throat pack.
An Allis c l a m p w a s p l a c e d in t h e left anterolateral t o n g u e to
facilitate retraction. W i t h the c o n t a c t Y A G l a s e r set at an
Figure 7 - 3 8 . Silica scalpel tips for the contact Nd:YAG laser.

(Scalpel tip number 6 used for incision at 15 W.)
Figure 7 - 4 0 . Posterolateral aspect of tongue adjacent to tongue

base retracted laterally to demonstrate extent of posterior element
of the excision. Note proximity of high-speed laser suction to laser
probe tip.
Figure 7 - 4 1 .
Depth of resection in residual mobile tongue.
Figure 7 - 4 2 .
Specimen.
Figure 7 - 4 3 . Bovine collagen dressing sutured in place lo facilitate hemostasis (from a similar case).
Figure 7-44. Histology of resection margin. Note that depth of

coagulation necrosis from the contact YAG tip is only 0.22 mm.
(Depending upon area examined it ranged from 0.22 mm to 0.67
mm.)(H&E200X.)
101
o u t p u t p o w e r of 15 W, and using the n u m b e r 6 scalpel tip

probe, the prospective margin was gently scribed approximately 1 cm b e y o n d the visible a n d / o r p a l p a b l e t u m o r e d g e .
N o w , the p r o b e tip w a s c h a n g e d to a n u m b e r 8 scalpel tip,
t h e laser t u r n e d o n , a n d the pedal w a s d e p r e s s e d to permit
h e a t i n g of the p r o b e tip, w h i c h w a s only then inserted into
t h e t i s s u e to begin the e x c i s i o n . W i t h slight c h a r r i n g of the
tip o c c u r r i n g , heat transfer w a s n o w kept constant by periodically w i p i n g the p r o b e tip to m a i n t a i n a consistent level
of c a r b o n i z a t i o n . In this w a y , the dissection w a s c o m p l e t e d
( F i g s . 7 - 3 9 t o 7 - 4 1 ) u s i n g tactile c u e s very similar t o those
used for e l e c t r o c a u t e r y in " c u t " m o d e . G e n t l e pressure on
t h e hand p r o b e p e r m i t t e d unforced penetration of t h e tiss u e s . T h i s p r e v e n t e d e x c e s s i v e b u i l d u p of c h a r r e d tissue on
t h e p r o b e tip, w h i c h w o u l d o t h e r w i s e h a v e c h a n g e d t h e output p o w e r (heat) a n d b e a m g e o m e t r y .
At t h e c o n c l u s i o n of this subtotal posterolateral g l o s s e c t o m y , e s t i m a t e d blood loss w a s 125 m L and operation time
w a s 4 0 m i n u t e s . T h e s p e c i m e n (Fig. 7 - 4 2 ) w a s reviewed
with t h e p a t h o l o g i s t in the o p e r a t i n g r o o m . T h e entire
t o n g u e w o u n d w a s left to heal by s e c o n d a r y intention, and
p o s t o p e r a t i v e h e m o s t a s i s w a s e n h a n c e d by a p p l y i n g a
b o v i n e c o l l a g e n patch to t h e surface of the t o n g u e , which
w a s sutured a l o n g its p e r i p h e r y (Fig. 7 - 4 3 ) . T h e histologic
s p e c i m e n (Fig. 7 ^ 1 4 ) s h o w e d t h e r m a l n e c r o s i s limited t o
0 . 3 to 0.7 m m . After s u r g e r y , the patient applied p r e s s u r e
until t h e f o l l o w i n g m o r n i n g . He r e s u m e d oral intake the
next m o r n i n g , and h e w a s d i s c h a r g e d t h e following d a y . H i s
s p e e c h w a s intelligible on t h e d a y after surgery, and it returned to n o r m a l d u r i n g p o s t o p e r a t i v e w e e k 5 (Fig. 1-AA).
P o s t o p e r a t i v e n a r c o t i c a n a l g e s i c s w e r e required for 6 d a y s
after s u r g e r y . H o w e v e r , there w a s m i n i m a l postoperative
e d e m a and there w a s n o p o s t o p e r a t i v e bleeding. S w a l l o w ing w a s n o r m a l by w e e k 8. At 18 w e e k s the r a n g e of motion
of the t o n g u e w a s n o r m a l , as w a s s w a l l o w i n g (Fig. 745).
M e t a s t a t i c d i s e a s e a p p e a r e d in the ipsilateral neck d u r i n g
the fifth m o n t h after s u r g e r y .
Figure 7 - 4 5 . At 18 weeks. Range of motion of tongue good.

Mild speech impediment. Normal swallowing.
102

CASE 6: BUCCAL M U C O S A
the family would not permit a full-thickness cheek resection

if indicated at surgery. T h e lesion w a s staged as T N M
m o d e r a t e l y well-differentiated s q u a m o u s cell carcinoma.
Surgical resection w a s the r e c o m m e n d e d treatment by the
head and neck t u m o r board.
2
fl
An 86-year-old d i v o r c e d A f r i c a n - A m e r i c a n w o m a n with a
I - m o n t h history of a m a s s in her left buccal m u c o s a p r e sented for e v a l u a t i o n . S h e h a s been c h e w i n g t o b a c c o for 75
years with the quid usually being held in the left buccal
p o u c h . T h e r e has been no pain or bleeding but the m a s s interfered with her u p p e r d e n t u r e . Her past m e d i c a l history
w a s significant for insulin-dependent d i a b e t e s mcllitus a n d
she was blind as a c o n s e q u e n c e of proliferative diabetic
retinopathy.
On oral e x a m i n a t i o n , a globular e x o p h y t i c m a s s m e a s u r ing 3.2 cm at its widest d i m e n s i o n w a s p r e s e n t (Fig. 7-46).
It o c c u p i e d the most dorsal aspect of the left buccal m u c o s a
e x t e n d i n g from the apex of the buccal v e s t i b u l e to the inferior aspect of the buccal m u c o s a . On b i m a n u a l palpation, it
was estimated to be 1.5 cm thick but to be freely m o v a b l e
R e s e c t i o n w a s p e r f o r m e d with the patient receiving a

general a n e s t h e t i c with n a s o e n d o t r a c h e a l intubation. The
c h e e k w a s infiltrated with 8 mL of 0 . 5 % b u p i v a c a i n e containing 1:200.000 e p i n e p h r i n e . Scrutiny of the oral cavity
did not reveal additional m u c o s a l lesions and vital staining
with toluidine b l u e w a s positive only for the area of carcinoma.
R e s e c t i o n w a s p e r f o r m e d with t h e c o n t a c t N d : Y A G
laser with a n u m b e r 4 s c a l p e l silica tip at 15-W output
p o w e r . R e s e c t i o n i n c l u d e d a 1.0-cm m a r g i n w h e n e v e r
p o s s i b l e and the d e p t h of resection was e s t a b l i s h e d bey o n d the b u c c i n a t o r m u s c l e so that the d e p t h of t h e resec-
and not a d h e r e n t to skin or s u b c u t a n e o u s tissue. T h e surface

of the lesion a p p e a r e d to be c o r r u g a t e d . T h e r e w a s no l y m p h a d e n o p a t h y . F i b e r o p t i c n a s e n d o s c o p y w a s n e g a t i v e and
tion w a s w i t h i n t h e s u b c u t a n e o u s fat of the c h e e k . Histologic a s s e s s m e n t o f the r e s e c t i o n s h o w e d t h e z o n e o f

t h e r m a l n e c r o s i s at t h e b a s e of the resection s p e c i m e n to
T N M well-differentiated squamous cell cancer.
Figure 7-48. Buccal fat pad graft is partially epithelialized (6

days). By 16 days it was approximately 50% reepithelialized.
Figure 7-47. Development of buccal fat pad for partial coverage

of surgical defect.
Figure 7 - 4 9 . Thirty-six days. Completely reepithelialized. By

15 weeks the wound was mature and maximum oral opening was
50 mm.
Figure 7-46.
((

range from 0 . 3 2 t o 0.34 m m i n t h i c k n e s s . E s t i m a t e d b l o o d
loss w a s 150 mL and o p e r a t i v e t i m e r e q u i r e d for this
subtotal e x c i s i o n o f the c h e e k w a s 9 0 m i n u t e s . Partial c l o sure of t h e d e f e c t w a s o b t a i n e d by a d v a n c e m e n t of t h e
buccal fat pad ( F i g . 7 - 4 7 ) . At e x a m i n a t i o n 6 d a y s after
surgery t h e r e w a s significant e p i t h e l i a l c o v e r i n g of t h e
buccal fat pad a n d there w a s slight e p i t h e l i a l i z a t i o n of the
depth of the u n c o v e r e d part of t h e w o u n d ( F i g . 7 - 4 8 ) . At
103
1 5 d a y s , h e a l i n g w a s p r o g r e s s i n g with m o d e r a t e s c a r c o n traction o c c u r r i n g and a p p r o x i m a t e l y 5 0 % e p i t h e l i a l i z a tion h a v i n g o c c u r r e d . A t 3 6 d a y s , t h e w o u n d w a s c o m pletely e p i t h e l i a l i z e d ( F i g . 7 - 4 9 ) . A t 1 0 w e e k s there w a s

slight t r i s m u s with a m a x i m u m interridge o p e n i n g of 42
m m . A t 1 5 w e e k s t h e patient o p e n e d 5 0 m m . S h e had res u m e d her n o r m a l d i e t , w a s m a i n t a i n i n g her w e i g h t , and
had n o p a i n .
104

COMPLICATIONS
Case
7: PalatePostoperative Tonsillar Hypertrophy
T h i s 4 9 - y e a r - o l d w h i t e m a n presented with h i s s e c o n d prim a r y s q u a m o u s cell c a r c i n o m a . T h e index lesion w a s a

T 1 N 0 M 0 m o d e r a t e l y well-differentiated s q u a m o u s cell carc i n o m a of the left ventrolateral t o n g u e treated by free-beam
laser e x c i s i o n 1 2 m o n t h s p r e v i o u s l y . H e c o n t i n u e d t o
s m o k e o n e and a half p a c k s of cigarettes per d a y , and to
drink t w o or three beers per d a y . A s e c o n d p r i m a r y t u m o r , a
T1N0M0 well-differentiated s q u a m o u s cell c a r c i n o m a , d e veloped on the left soft palate and a n e w l e u k o p l a k i a d e v e l oped on the right soft p a l a t e . T h e treatment plan c a l l e d for
w i d e local e x c i s i o n o f the n e w p r i m a r y c a n c e r a n d e v a p o r a tive ablation of the leukoplakia after directed b i o p s y g u i d e d
by vital s t a i n i n g with t o l u i d i n e b l u e .
T h e r e w e r e no unexpected extensions of the palatal cancer.

Resection c o m m e n c e d with the S L T contact N d : Y A G laser
silica p r o b e tip. Output p o w e r w a s 12 to 20 W. Dissection
w a s carried full thickness through the levator veli palatini
m u s c l e after first marking the periphery for margins with the
n u m b e r 4 scalpel tip used at 20 W. N o w using the number 8
scalpel tip at 15 W, the tip w a s angled to maintain proper position in t h e depth of the resection. In this c a s e s o m e palatal
m u s c l e w a s preserved and there w a s no perforation of the nasopharyngeal m u c o s a . Histopathologic assessment of the
specimen confirmed adequacy of resection. T h e margins
w e r e s o m e w h a t affected by heat artifact from the Y A G contact laser with the d e e p margin s h o w i n g 1.6 mm of thermal
necrosis. H o w e v e r , hemostasis was excellent and the more
e x t e n s i v e heat d a m a g e w a s not clinically significant.
An u n e x p e c t e d l y e x u b e r a n t host r e s p o n s e to t h e palatal
resection o c c u r r e d d u r i n g the s e c o n d m o n t h of observation.
Figure 7 - 5 2 .
Figure 7 - 5 0 . Outlining the mass: SLT contact YAG: number 6

scalpel tip at 15 W.
Figure 7 - 5 1 . Traction as dissection reaches depth of tonsillar

crypt. No bleeding. Note smoke generation. The high-speed laser
smoke evacuation system still must be used, just as it is for the
free-beam C 0 laser.
2
Figure 7 - 5 3 .
weeks.
Specimen.
Complete reepithelialization and healing at 3

Unilateral h y p e r t o p h y of tonsillar tissue d e v e l o p e d adjacent to the resection site (Fig. 7 - 5 0 ) . T h i s w a s r e m o v e d for
histopathologic a s s e s s m e n t using the b l o o d l e s s t e c h n i q u e of
the c o n t a c t : Y A G laser. T h e c o n t a c t : Y A G p r o v i d e d the security of tactile feedback while p e r f o r m i n g surgery at the
depth of the tonsillar fossa. T h e lesion w a s easily delivered
from a bloodless field ( F i g s . 7 - 5 1 and 7 - 5 2 ) . Significant
laser s m o k e w a s g e n e r a t e d by the Y A G tip in c o n t a c t with
105
the tissue. As a l w a y s it w a s m a n d a t o r y to u s e the highspeed laser suction.

T h e tonsillar fossa w a s not b l e e d i n g at the c o n c l u s i o n of
surgery and r a w surface a r e a w a s reduced by partially closing the fossa. T h e surgical site w a s reepithelialized and
c o m p l e t e l y healed in 3 w e e k s ( F i g . 7 - 5 3 ) . Postoperatively,
s p e e c h and s w a l l o w i n g w e r e c o m p l e t e l y n o r m a l within 6
w e e k s after s u r g e r y .
106
C A S E 8: FOM C O M P L I C A T I O N RESTRICTED TONGUE MOTION

A 72-year-old w h i t e w o m a n with T | N M m o d e r a t e l y well
differentiated s q u a m o u s cell c a r c i n o m a . A n t e r i o r floor of
mouth. Limitation of r a n g e of motion of t o n g u e o c c u r r e d
requiring scar release (Figs. 7 - 5 4 and 7 - 5 5 ) .
0
Figure 7 - 5 5 . Restricting scar band: Pseudoankyloglossia at 19

months. Release of wide and thick scar band causing pseudoankyloglossia. RSP, 118 pps. PD approximately 500 to 6(H) W/cm .
1
Figure 7-54.
of mouth.
T1N0M0 squamous cell carcinoma of anterior floor

C A S E 9: BUCCAL M U C O S A WITH
PROLIFERATIVE GRANULATION TISSUE
A 58-year-old w o m a n with a verrucous carcinoma,
T 2 N 0 M 0 of the right buccal m u c o s a , w a s treated by w i d e
local e x c i s i o n with the free-beam R S P C 0 laser at an average p o w e r of 25 W, 0 . 3 - m m spot size for incision, d e f o cused spot size of 2 . 0 to 2.5 mm for coagulation at 86
pps, 2 9 0 mJ/pulse ( F i g s . 7 - 5 6 t o 7 - 5 9 ) . A l t h o u g h , m o s t
of the treated area reepithelialized normally, a 1.5-cm-diameter mass of granulation tissue persisted at the proxi2
Figure 7-56.
cosa.
T2N0M0 verrucous carcinoma of righl buccal mu-
Figure 7-57. Proliferative granulation tissue arose, at proximal

edge of resection margin. Matured lesion now appeared as a large
pedunculated polyp. Excised with the RSP C 0 laser.
2
107
mal e d g e of the resection margin. Trauma from her m o lars o c c l u d i n g into the proliferative scar prevented its resolution. After an additional 2 months of maturation the
l e s i o n persisted. It w a s , therefore, e x c i s e d using the same
parameters described a b o v e . A maxillary acrylic prosthesis with a buccal flange w a s worn for 1 month to prevent
o c c l u s a l trauma to any granulation tissue that might have
proliferated at the treatment site. Within 1 month of e x c i s i o n , the buccal m u c o s a had healed c o m p l e t e l y and maxim u m incisal o p e n i n g w a s normal. S h e has been cancer
free and the proliferative lesion has not returned.
Figure 7-58.
Maxillary prosthesis to protect cheek.
Figure 7-59. Buccal mucosa, 9 months after excision of polyp.

Three years later there is still no recurrence of the polyp or the
cancer; mouth opening and buccal mucosa are both normal.
108
C A S E 10: A D J U N C T I V E U S E O F T H E C 0
LASERTUMOR DEBULKING
When treating patients with head and neck cancer w h o have

failed definitive therapy, o n e is confronted with the problem
of designing compassionate palliative treatment to debulk
recurrence at the primary site. Satisfactory palliation should
provide pain relief, create a wound that is easy to clean, and
reduce the smell of necrotic tissue, and the palliative procedure should be brief. The high-powered free-beam C 0
laser serves this purpose well.
A 68-year-old man developed recurrent squamous cell
carcinoma under his pectoralis major myocutaneous flap
that extended into the submental triangle (Figs. 7 - 6 0 to
2
Figure 7-60. Recurrent carcinoma of anterior neck and floor of

mouth occurring inferior to a myocutaneous flap 27 months after
resection of a T 3 N 3 M 0 squamous cell carcinoma of the tongue.
7 - 6 3 ) . The original tumor was a stage IV, T 3 N 3 M 0 squamous cell carcinoma of the tongue and his recurrence developed 27 months after treatment of the index tumor by a combined regimen of chemotherapy, radiotherapy, and surgical
resection with immediate soft tissue reconstruction. The C 0
laser with a handheld probe was used in the defocused mode
at an output power of 90 W CW with a spot size of 2 . 0 to 3.0
mm giving an average PD of 3 5 0 0 W / c m to 1560 W / c m .
This provided adequate hemostasis while permitting debulking of the tumor. General anesthesia was used and the operation required less than 30 minutes. A collagen hemostatic
dressing w a s applied to the depth of the wound to aid in hemostasis. The wound remained clean and without an offensive odor until the patient's death 3 months later.
2
Figure 7 - 6 2 .
Tumor bed is clean 3 weeks after treatment.
Figure 7 - 6 1 . Ablation of recurrent tumor. Free-beam C 0 , 90

W, 2- to 3-mm spot size. Note HeNe aiming beam in upper left
comer of wound. Significant plume production occurred at this
power density.
2
Figure 7 - 6 3 . Three months after treatment just before death.

The treated area remains quite clean.
Section 1: Outpatient Treatment of Snoring and

Sleep Apnea Syndrome with C 0
Assisted
Laser: Laser-
Uvulopalatoplasty
Yves-Victor Kamami
The laser-assisted uvulopalatoplasty ( L A U P ) is a surgical

technique d e s i g n e d to correct b r e a t h i n g a b n o r m a l i t i e s d u r i n g
sleep that result in snoring or mild to m o d e r a t e obstructive
sleep apnea s y n d r o m e ( O S A S ) . 1 , 2 T h i s is a short operation,
performed in the office using local anesthesia a n d a surgical
laser. T h e objective is to reduce p h a r y n g e a l a i r w a y o b s t r u c tion by reducing tissue v o l u m e in the uvula, the v e l u m , and
the superior part of the posterior p h a r y n g e a l pillars.
INDICATIONS
It has been d e m o n s t r a t e d that t h e majority of s n o r e r s benefit
from L A U P a s d o m a n y p a t i e n t s with O S A S w h o s e r e s p i ratory distress index ( R D I ) is less than 5 0 . F o r t h o s e w i t h
severe O S A S ( R D I > 7 5 ) , w h o h a v e s e v e r e m a n d i b u l a r retrognathia or nasal tract o b s t r u c t i o n , o t h e r t r e a t m e n t m e t h ods, particularly c o n t i n u o u s p o s i t i v e a i r w a y p r e s s u r e
(CPAP) o r m a n d i b u l a r a d v a n c e m e n t o s t e o t o m y , a r e required. H o w e v e r , e v e n i n s o m e c a s e s o f s e v e r e O S A S with
obstruction at the p h a r y n g e a l level w h o do not r e s p o n d to
C P A P , L A U P m a y b e o f limited benefit i n i n c r e a s i n g p h a ryngeal a i r w a y c o m p l i a n c e .
1
Further c o n t r a i n d i c a t i o n s t o L A U P a r e s e v e r e m a e r o g l o s sia and morbid obesity with h y p o p h a r y n g e a l o b s t r u c t i o n at

the t o n g u e b a s e . In t h e rare c o n d i t i o n of floppy epiglottis,
L A U P is also not of benefit.
of u n c o n t r o l l e d scar f o r m a t i o n . B e c a u s e of the h e m o s t a t i c
a c t i o n of the laser, t h e p r o c e d u r e m a y be performed using
local a n e s t h e s i a with minimal b l e e d i n g d e s p i t e the highly
vascular tissue o f the oral m u c o s a . U n l i k e U P P P , the L A U P
is a limited o p e r a t i o n with l o w m o r b i d i t y that d o e s not req u i r e general a n e s t h e s i a and m a y be performed in an office
o r d a y s u r g e r y c e n t e r . T h e lack o f m o r b i d i t y from L A U P all o w s p a t i e n t s to return to work i m m e d i a t e l y after surgery.
T h e L A U P a l l o w s m o r e precise tissue r e m o v a l , less tissue
l o s s , and better overall c o n t r o l of s u r g e r y . It is m o r e attractive t o s u r g e o n s w h o q u e s t i o n traditional U P P P b e c a u s e
of its a n e s t h e t i c risk a n d increased p o s t o p e r a t i v e pain,
s w e l l i n g , and potential risk of d e v e l o p i n g v e l o p h a r y n g e a l
incompetence (VPI).
L A U P m a y a l s o b e useful w h e n U P P P h a s failed d u e t o
o b s t r u c t i o n of t h e h y p o p h a r y n x from fatty and r e d u n d a n t
tissue on t h e p o s t e r o l a t e r a l p h a r y n g e a l walls. It is also a
g o o d a l t e r n a t i v e for patients w h o present with major surgical a n d a n e s t h e s i a - r e l a t e d risks. In all c a s e s , t h e h e a l i n g of
t h e l a s e r - i n d u c e d w o u n d s is faster than after standard
U P P P , e x c e p t in t h e c a s e s of alcohol or t o b a c c o use. In
these c a s e s , the d u r a t i o n of p o s t o p e r a t i v e pain is p r o l o n g e d .
A s i s t h e c a s e for U P P P , s n o r i n g and O S A S m a y also
r e c u r after L A U P . T h i s i s d u e t o v e l o p h a r y n g e a l h y p o t o n i a
s e c o n d a r y t o a g e , o b e s i t y , t o b a c c o and a l c o h o l use, e x c e s sive c o n s u m p t i o n o f s e d a t i v e - h y p n o t i c d r u g s o r tranquilize r s , or untreated h y p o t h y r o i d i s m . If s y m p t o m s of snoring or
O S A S recur, a s e c o n d treatment directed at t h e palate may
i n d u c e r e m i s s i o n . T h e C 0 laser o r c o n t a c t n e o d y m i u m : y t t r i u m - a l u m i n u m - g a r n e t ( N d : Y A G ) l a s e r i s preferred t o the
u s e of t h e N d : Y A G fiber-delivered laser in this p r o c e d u r e
b e c a u s e o f the l o w v o l u m e o f absorption o f the C 0 laser
b e a m o r c o n t a c t N d : Y A G i n tissue. T h i s property p r e v e n t s
e x c e s s i v e thermal n e c r o s i s o f t h e target tissue. T h e Y A G
laser a l s o d o e s not h a v e a b a c k s t o p , a l t h o u g h this problem
is e l i m i n a t e d for c o n t a c t Y A G lasers. An additional a d v a n tage o f t h e C 0 laser i s its u s e a s a " n o - t o u c h " t e c h n i q u e ,
thereby e l i m i n a t i n g c o n t a c t with t h e palate and p h a r y n g e a l
w a l l s . T h i s p r o p e r t y r e d u c e s g a g g i n g , especially for the hyp e r s e n s i t i v e individual w h o s e g a g g i n g o c c u r s on a p s y c h o logical basis despite h a v i n g a d e q u a t e a n e s t h e s i a at t h e surgical site.
2
COMPARISON TO
UVULOPALATOPHARYNGOPLASTY
(UPPP)
The p r o p e r use o f the t h e r m a l p r o p e r t i e s o f the C 0 laser
provides technical a d v a n t a g e s o v e r scalpel t e c h n i q u e s for
the surgical treatment of s n o r i n g . T h e accessibility of t h e
velum, uvula, a n d posterior tonsillar pillar to direct s c u l p t ing by t h e laser a l l o w s the o p e r a t o r to selectively r e g u l a t e
tissue r e m o v a l . After t r e a t m e n t , p o s t o p e r a t i v e e d e m a a n d
pain are m i n i m a l and healing is rapid, p r e d i c t a b l e , a n d free
2
111
112

DESCRIPTION OF THE PROCEDURE
L A U P is performed with a free-beam C O , laser with a

b a c k s t o p . B e a m g u i d a n c e is p r o v i d e d by a coaxial h e l i u m neon ( H e N e ) laser. Standard C O laser safety p r e c a u t i o n s
h a v e to be followed. T h e o u t p u t p o w e r is set at 20 to 30 W
a v e r a g e p o w e r in a pulsed m o d e , d e p e n d i n g on the thickness of tissue that is to be incised. A specific s n o r i n g h a n d piece is used with a variable spot size of 0.6 to 3.51 mm at a
focal length of 3 0 0 m m . T h i s h a n d p i e c e h a s a focus-defocus
ring: focus to cut. and defocus to c o a g u l a t e .
The patient is p r e m e d i c a t e d with an oral a n a l g e s i c and
antiemetic. Blood pressure is m o n i t o r e d d u r i n g the operation. At the time of the session, the patient is placed in a
scaled position with the m o u t h o p e n . T h e e y e s a r e protected
with g o g g l e s or wet g a u z e s p o n g e s . T h e patient then is
given breathing instructions: to take a d e e p breath and very
slowly let it out. Local anesthesia is then a d m i n i s t e r e d using
a lidocaine 1 5 % spray followed by an injection of 2% lidocaine with e p i n e p h r i n e (1.25 mg in 2 . 0 g of lidocaine) into
the base of the uvula on both sides. B e t w e e n I and 2 mL are
infiltrated on e a c h side.
:
The
Kinure 8 - 1 . Laser-assisted UPPP (LAUP) in four to five sessions. Illustration demonstrates the vertical and horizontal incision
cutting of the soft palate, laterally to the root of the uvula, at the
left, then at the right side of the uvula.
"Multiple-Stage " Technique
T h i s p r o c e d u r e is d e s i g n e d to r e m o v e the minimal a m o u n t
of tissue consistent with t h e reduction of snoring. Usually
the surgery is repeated a s e c o n d or a third t i m e . T h i s c o n servative a p p r o a c h to tissue r e m o v a l essentially e l i m i n a t e s
the d e v e l o p m e n t of VPI as a c o m p l i c a t i o n of L A U P . Bilateral vertical incisions a r c m a d e lateral to the u v u l a , s p a r i n g
the uvula itself. T h e s e are full-thickness " t r e n c h e s " on either side of the uvula (Fig. 8 - 1 ) . T h e uvula is then shortened by a p p r o x i m a t e l y 5 0 % of its length and " r e s h a p e d . " A
" n e o - u v u l a " is created, with further d e b u l k i n g of the inferior and lateral sides of t h e uvula. Its anterior and p o s t e r i o r
sides must be preserved, leaving the m u c o s a intact to prevent g r a n u l o m a formation and facilitate reepithclialization.
T h i s is d o n e by vaporization al the point of focus (0.6 m m )
using a pulsed m o d e " S w i f l l a s e " a t t a c h m e n t for t h e S h a p lan laser, which p r o d u c e s minimal char w h i l e a b l a t i n g the
tissue rapidly and bloodlcsslv. T h e slightly d e f o c u s e d b e a m
w h e n applied to t h e area of incision a d e q u a t e l y c o n t r o l s
b l e e d i n g from any discrete area that still bleeds after m a k ing the incision. No s u t u r e s are r e q u i r e d . At e a c h of the
p l a n n e d s e s s i o n s , about 5 to 8 mm of the v e l u m is r e m o v e d .
Extending t h e incisions m u c h h i g h e r o n t o t h e soft palate
will usually result in increased p o s t o p e r a t i v e pain. In this
w a y the n e o - u v u l a will gradually a s s u m e a m o r e s u p e r i o r
position following each treatment until it reaches t h e level
of P a s s a v a n t ' s ridge (Figs. 8 - 2 and 8 - 3 ) .
A h a n d p i e c e specifically d e s i g n e d for this p r o c e d u r e inc o r p o r a t e s a b a c k s t o p and a s m o k e e v a c u a t o r . T h e b a c k s t o p
protects the posterior p h a r y n g e a l wall and the s m o k e e v a c u ator m a i n t a i n s clear visibility in the o p e r a t i v e field.
Figure 8 - 2 .
of uvula.
LAUP in multiple sessions: reducing lateral aspect
S u b s e q u e n t s e s s i o n s are basically the s a m e as the first

o n e . T h e e n d point is d e t e r m i n e d w h e n the patient or bed
partner stops c o m p l a i n i n g a b o u t snoring. In patients with a
narrow n a s o p h a r y n g e a l orifice, a horizontal section is performed on t h e u p p e r part of the posterior tonsillar pillars, to
e n l a r g e the aperture. T h i s r e m o v a l of the upper part of the
Outpatient Treatment of Snoring and Sleep Apnea Syndrome
113
In t h e m u l t i s t a g e t e c h n i q u e , three to four sessions of 5

m i n u t e s e a c h a r e p e r f o r m e d , generally s p a c e d at monthly
intervals. T h e length and n u m b e r of t h e s e s s i o n s will vary
a c c o r d i n g to t h e t h i c k n e s s of the arch and soft palate and
t h e h y p e r t r o p h y o f t h e tonsils. T h e a v e r a g e n u m b e r o f sess i o n s is 3.77 in n o n a p n e i c snorers and 4 . 3 in O S A S patients.
The
"Single-Stage" Technique
To facilitate rapidity of t h e c o r r e c t i o n of s n o r i n g , a " s i n g l e s t a g e " t e c h n i q u e h a s n o w been d e v e l o p e d . T h i s should only

be p e r f o r m e d by s u r g e o n s e x p e r i e n c e d in the multistage
t e c h n i q u e . T w o p a r a m e d i a n vertical incisions o r transfixing
" t r e n c h e s " a r e m a d e to a h e i g h t of 2 to 3 c m . T h e s e incisions a r e lateral to t h e root of the u v u l a and e x t e n d superiorly up to t h e j u n c t i o n of the soft a n d hard palate at the
Kigure 8 - 3 . LAUP: multiple sessions. Creation of a "neouvula," by debulking of the inferior and the lateral sides of the
uvula. Repeat sessions will gradually result in the "nco-uvula" assuming a more superior and dorsal position, closer to Passavant's
ridge.
tonsillar pillar is usually d o n e in the last s e s s i o n , c a u s i n g an

anterior and superior m o t i o n of the n e o - u v u l a , as retraction
occurs.
In the O S A S p a t i e n t s , t h e uvula is u s u a l l y thicker and
longer than in p a t i e n t s with s i m p l e s n o r i n g . T h e o p e r a t i o n s
are therefore l o n g e r for apneic s n o r e r s than for n o n a p n e i c
snorers b e c a u s e of the l o n g e r t i m e n e e d e d to transfix and
trim the uvula. If there is h y p e r t r o p h y of t h e lingual tonsils,
it is possible to perform a tonsil ablation with e i t h e r a fixed
90 or an adjustable front surface m i r r o r h a n d p i e c e , w h i c h
permits o n e to redirect t h e laser b e a m to the p o s t e r i o r third
of the t o n g u e .
Five watts of c o n t i n u o u s p o w e r and a local a n e s t h e t i c
spray a r e used. B l e e d i n g is u s u a l l y m i n i m a l or m o r e likely
nonexistent. W h e n there is b l e e d i n g , it is controlled with
the defocused b e a m , w h i c h c o a g u l a t e s vessels less than 0.5
mm in d i a m e t e r . If b l e e d i n g c o n t i n u e s , it is c o n t r o l l e d with
bipolar electrocautery. S m o k e is e v a c u a t e d by a h i g h - s p e e d
dedicated laser e v a c u a t i o n s y s t e m , w h i c h is c o n n e c t e d to
the laser h a n d p i e c e .
Palatine or lingual tonsillar h y p e r t r o p h y is treated by
laser-assisted tonsil ablation ( L A T A ) with t h e " S w i f t l a s e " if
tonsillar size is contributing to the O S A S by obstructing the
oropharynx. In c a s e s of nasal obstruction c a u s e d by
turbinate h y p e r t r o p h y or septal deviation, a C 0 laserassisted partial inferior turbinectomy ( L A P T ) or a septoplasty
may have to be performed. Actually, most patients m a y h a v e
a L A P T about 1 m o n t h after the c o m p l e t i o n of the L A U P
procedure to ensure better n a s o p h a r y n g e a l air flow.
" d i m p l e point." T h e b a s e of t h e uvula is then held with a

K o c h e r c l a m p to pull it laterally to facilitate a horizontal inc i s i o n j u s t u n d e r the b a s e of t h e uvula (Fig. 8 - 4 ) . R e s h a p i n g
of the u v u l a at t h e apex of the soft palate is carried out, resulting in a s m a l l " n e o - u v u l a . " T h i s n e o - u v u l a h a n g s from
t h e r e a r of the hard palate, p r e v e n t i n g centripetal s c a r fibrosis, b e c a u s e of t h e specific m a k e u p of its m u s c l e fibers
( w h i c h s e e m s to be different from n o n - s n o r e r s ) (Fig. 8 - 5 ) .
In a d d i t i o n , t h e u p p e r part of the posterior pillars a r e d e b u l k e d and both t h e s u p e r i o r portion of the vertical incisions and the n e o - u v u l a are m a d e into a U s h a p e using the
Swiftlase a t t a c h m e n t (Fig. 8 - 5 ) . It c o n t a i n s a portion of the
a z y g o s m u s c l e that can still contract and prevent V P I from
o c c u r r i n g , like a m a i n m a s t s u p p o r t i n g the palatine arch, a
Figure 8-4.
neo-uvula.
LAUP: one-stage vertical incisions and creation of
114

u n n e c e s s a r y . T h e r e a r e no clinically identifiable c h a n g e s in
s p e e c h o r v e l o p h a r y n g e a l function. N o f i b r o s i s c a u s i n g narr o w i n g of the n a s o p h a r y n g e a l a p e r t u r e has been o b s e r v e d as
s o m e t i m e s h a s b e e n seen after U P P P . Nasal regurgitation
h a s not been reported after t h e laser surgery. Infections
w e r e rare e x c e p t for o c c a s i o n a l oral c a n d i d i a s i s .
OSAS PATIENTS
T o e n s u r e p h y s i o l o g i c night ventilation i n s e v e r e O S A S patients, nasal c o n t i n u o u s p o s i t i v e airway p r e s s u r e ( N - C P A P )
is utilized for t h e d u r a t i o n of t h e laser t r e a t m e n t . Following
c o m p l e t i o n o f the L A U P t r e a t m e n t , p o l y s o m n o g r a p h y i s rep e a t e d . C P A P i s d i s c o n t i n u e d w h e n t h e p o l y s o m n o g r a m becomes normal.
RESULTS OF A PERSONAL SERIES

Figure 8 - 5 . LAUP: one stage. Debulking the superior part of
the posterior pillars to create a U shape.
s t u b m i d d l e pillar s i m i l a r to t h o s e of t h e ribbed vault of a

c h u r c h , flanked by t h e t w o lateral p o s t e r i o r pillars. T h e
m a i n m a s t of the u v u l a is m a d e by t h e p a l a t o s t a p h y l i n u s or
uvula a z y g o s m u s c l e . T h i s s m a l l , s p i n d l e - s h a p e d , vertical
m u s c l e is entirely e n c l o s e d in t h e v e l u m ; its m a i n action is
to raise t h e uvula, and this m u s c l e is only attached to t h e
posterior side of the hard palate at its u p p e r e d g e . So it is
very important to partially p r e s e r v e this m a i n m a s t as a s u p port of the m i d d l e of the v e l u m . 3
OPERATIVE OUTCOME
After the p r o c e d u r e , t h e p a t i e n t s a r e g i v e n a prescription inc l u d i n g mild a n a l g e s i c s , p e r o x i d e and w a t e r g a r g l e s , topical
a n e s t h e t i c throat l o z e n g e s , a n e s t h e t i c m o u t h s p r a y s , a n d
viscous l i d o c a i n e to relieve throat p a i n . T h e y a r e instructed
to avoid d r i n k i n g a l c o h o l , e a t i n g food with vinegar, l e m o n ,
o r spices a n d t a k i n g aspirin a n d nonsteroidal anti-inflammatory d r u g s ( N S A I D s ) for 10 d a y s after t h e o p e r a t i o n .
Patients c o m p l a i n only of a m o d e r a t e to s e v e r e " s w a l l o w i n g p a i n " similar to a " s o r e t h r o a t " for a b o u t 10 d a y s .
Pain intensity r e a c h e s its peak 3 to 5 d a y s p o s t o p e r a t i v e l y ,
but d o e s n ' t inhibit e a t i n g food or d r i n k i n g , s p e a k i n g , or
w o r k i n g i m m e d i a t e l y afterward. R a r e l y , spitting o f b l o o d
m a y o c c u r either d u r i n g t h e f i r s t 4 8 h o u r s o r a p p r o x i m a t e l y
8 d a y s after the s e s s i o n , but c a n easily be s t o p p e d in minutes with p e r o x i d e and w a t e r g a r g l e s .
U s u a l l y , n o s e r i o u s c o m p l i c a t i o n s o c c u r d u r i n g the operation o r d u r i n g the i m m e d i a t e p o s t o p e r a t i v e p h a s e after
L A U P . P o s t o p e r a t i v e o b s e r v a t i o n in a medical c a r e unit is
Nonapneic
Snorers
F r o m D e c e m b e r 1988 t o July 1994, 8 5 6 patients were

treated with L A U P b y t h e author. T h e r e w e r e 7 1 5 m e n and
141 w o m e n , with a m e a n a g e of 4 9 . 2 years ( r a n g e : 25 to
8 0 ) . T h e m e a n b o d y m a s s index ( B M I ) w a s 2 5 . 9 (range:
17.1 to 4 5 ) . No r e c o r d i n g s of s n o r i n g w e r e carried out, as
t h e d i a g n o s i n g and treatment indications w e r e based on the
s p o u s e ' s c o m p l a i n t and not on a m e a s u r e d level or character of n o i s e .
After t r e a t m e n t , 7 0 . 4 % of patients ( 6 0 3 patients) had a
c o m p l e t e or n e a r e l i m i n a t i o n of s n o r i n g , with no long-term
r e c u r r e n c e ; 2 4 . 4 % ( 2 0 9 p a t i e n t s ) had i m p r o v e m e n t in their
s n o r i n g , w i t h o u t d i s t u r b i n g t h e s p o u s e , and 5.1 % ( 4 4 patients) s h o w e d no r e s p o n s e after L A U P . In these "failures"
there w a s a l w a y s a d i m i n u t i o n of s n o r i n g but t h e bed partner w a s still u n h a p p y a b o u t the intensity of snoring. Of the
6 4 4 p a t i e n t s treated with the m u l t i s t a g e t e c h n i q u e , results
s h o w e d clinical i m p r o v e m e n t by the second or third L A U P
s e s s i o n . A c l e a r d e c r e a s e of s n o r i n g w a s seen, and t h e mean
s e s s i o n n u m b e r w a s 3.77. A m o n g t h e 2 1 2 patients cured
with t h e o n e - s t a g e t e c h n i q u e , there w e r e only seven patients
w h o n e e d e d a s e c o n d s e s s i o n , 1 m o n t h later. T h e mean duration t i m e of p o s t o p e r a t i v e pain w a s 11.2 d a y s .
Early p o s t o p e r a t i v e results w e r e better than for the classic U P P P , but longer follow-up s h o w e d reduced success.
After several m o n t h s , s n o r i n g had reappeared in a few
c a s e s , but with m u c h less d i s t u r b a n c e than before. A further
study of l o n g - t e r m results by t e l e p h o n e interview is currently in p r o g r e s s to d e t e r m i n e t h e e x a c t p e r c e n t a g e of snoring r e c u r r e n c e several years after L A U P . Levin and B e c k e r
h a v e s h o w n that s n o r i n g recurred in m o s t patients 6 to 12
m o n t h s after U P P P ; 2 8 % o f patients with initial complete
abolition of s n o r i n g had returned to preoperative levels
(after U P P P ) . U s u a l l y , after L A U P , t h e rare patients who
c a m e back again for a n o t h e r session b e c a u s e of snoring re4
115
currence h a v e been cured of their d i s c o m f o r t . T h e most frequent c a u s e of r e c u r r e n c e is t o b a c c o s m o k i n g . Of the 25
cases of c o n v e n t i o n a l U P P P failures treated by L A U P . there
were 14 c o m p l e t e c u r e s , 10 w e r e i m p r o v e d , and I failed. In
the majority of the patients, there w a s also a significant reduction of d a y t i m e s o m n o l e n c e , sleep a w a k e n i n g s , m o r n i n g
tiredness, m o r n i n g h e a d a c h e s , and sexual p r o b l e m s (erectile
dysfunction).
Obstructive Sleep Apnea Syndrome

F r o m D e c e m b e r 1988 t o M a y 1994, 7 0 adult p a t i e n t s w e r e
included in this study as " O S A S s n o r e r s , " 64 m e n and 6
w o m e n , with a m e a n age of 5 3 . 9 ( r a n g e : 2 3 - 7 2 ) . T h e m e a n
BMI w a s 29.2 ( r a n g e : 2 2 . 3 - 4 0 ) and t h e B M I w a s found t o
be m o r e than 30 in 23 c a s e s . All had pre- and p o s t o p e r a t i v e
evaluation by p o l y s o m n o g r a p h y and d e m o n s t r a t e d e v i d e n c e
of repeated obstructive respiratory e v e n t s d u r i n g sleep on
presurgical p o l y s o m n o g r a p h y .
For severe O S A S , C P A P w a s initiated before L A U P .
P o l y s o m n o g r a p h y w a s carried out before and after L A U P .
After L A U P , there w a s an i m p r o v e m e n t of sleep efficiency
as measured by nocturnal E E C , which d e m o n s t r a t e d longer
periods spent in stages III to IV and R E M sleep. In 56 patients ( 8 0 % ) . there w a s c o m p l e t e or n e a r - c o m p l e t e elimination of snoring, with no recurrence. In 11 patients ( 1 5 . 7 % ) ,
there w a s i m p r o v e m e n t of snoring, but still a small a m o u n t
of occasional noise persisted. In three patients ( 4 . 3 % ) there
was a d e c r e a s e in snoring, but the noise w a s still disturbing
to the s p o u s e . D a y t i m e s l e e p i n e s s disappeared in 8 2 % of
cases, decreased in 1 5 % of cases, and w a s u n c h a n g e d in 3%
of cases. M o r n i n g tiredness disappeared in 9 4 % of cases and
decreased in 6% of c a s e s . A m o n g the 26 patients w h o suffered from m o r n i n g h e a d a c h e s , this s y m p t o m d i s a p p e a r e d in
25 cases, and r e m a i n e d u n c h a n g e d in o n e case. A m o n g the
56 patients with frequent sleep a w a k e n i n g s , this s y m p t o m
disappeared in 30 c a s e s , d e c r e a s e d in 18 c a s e s , and r e m a i n e d
as before L A U P in eight cases. A m o n g the 27 patients w h o
suffered sexual p r o b l e m s (erectile dysfunction, loss of libido), 23 said that their sex life w a s i m p r o v e d after L A U P .
S l e e p efficiency (total s l e e p t i m e X 100/total sleep p e riod) w a s i m p r o v e d i n 6 3 % o f patients a m o n g patients with

pre- and p o s t o p e r a t i v e nocturnal E E G studies. A l s o s h o w n
w a s an i n c r e a s e in d e e p sleep t i m e (stages III to IV and
R E M ) , in 63%> of p a t i e n t s confirmed by nocturnal E E G
s t u d i e s . F u r t h e r m o r e . 44 patients noticed a r e a p p e a r a n c e of
d r e a m i n g . A c o m p l e t e c u r e of O S A S w a s a c h i e v e d in 36
patients ( 5 1 . 4 % ) , and a c l e a r i m p r o v e m e n t of O S A S in 26
p a t i e n t s ( 3 7 . 1 % ) , with at least a 5 0 % reduction in both the
p r e o p e r a t i v e o x y g e n d e s a t u r a t i o n index and of the duration
of the a p n e a s . Eight patients ( 1 1 . 4 % ) w e r e u n i m p r o v e d .
H o w e v e r , these patients had better long-term a c c e p t a n c e of
C P A P b e c a u s e of the reduction of the u p p e r respiratory
t r a d obstruction.
As for U P P P , high RDI and sleep a p n e a indices and morbid o b e s i t y a l s o predicted a p o o r r e s p o n s e to L A U P .
A m o n g 6 2 p a t i e n t s classified a s successful r e s p o n d e r s .
t h e r e s p i r a t o r y d i s t u r b a n c e index ( R D I ) w a s reduced by
m o r e t h a n 5 0 % . T h e r e d u c t i o n o f a p n e a length and o f preo p e r a t i v e o x y g e n d e s a t u r a t i o n index w a s greater than
5 0 % . T h e m e a n r e s p o n d e r R D I d e c r e a s e d from 37.6 t o
15.9, a n d t h e m e a n a p n e a index from 2 3 . 3 to 6.2, w h i l e the
m e a n a p n e a index for t h e n o n r e s p o n d e r s d e c r e a s e d from
2 3 . 8 t o 17.5. T h e r e w e r e n o c o m p l i c a t i o n s r e p o r t e d . For
all 70 p a t i e n t s , t h e m e a n R D I d e c r e a s e d from 3 7 . 8 to 19.
T h e i r m e a n a p n e a index d e c r e a s e d from 2 3 . 3 t o 7.7. O n e
very significant result is that t h e a p n e a s h a v e been transf o r m e d t o h y p o p n e a s . w h i c h are less d a n g e r o u s for these
p a t i e n t s . T h e m e a n S a O for t h e 7 0 p a t i e n t s i m p r o v e d
from 9 3 . 1 % p r e o p e r a t i v e l y t o 9 3 . 9 % p o s t o p e r a t i v e l y . T h e
m e a n l o w e s t S a O c h a n g e d from 7 7 . 3 % t o 8 0 . 5 % p o s t o p eratively.
F o u r patients w e r e surgical U P P P failures corrected by
L A U P . After L A U P , t h e results w e r e t w o c o m p l e t e recoveries and t w o failures. T h i r t e e n patients w e r e also cured of
nasal o b s t r u c t i o n by laser-assisted partial t u r b i n e c t o m y
c o m b i n e d with t h e L A U P . It is essential to c o n v i n c e our
treated patients to maintain l o n g - t e r m follow-up e x a m i n a tion and to repeat a full sleep study several m o n t h s after
s u r g e r y to confirm the efficacy of the L A U P o p e r a t i o n .
;
116

CASE 1
CASE 2
A 55-year-old o b e s e ( 1 0 2 k g . or 2 2 5 lbs) m a n , 1.73 m (5

feet. 8 inches) tall, presented with a 3 0 - y e a r history of snoring and m o d e r a t e sleep a p n e a . E x a m i n a t i o n r e v e a l e d that
the tip of the soft palate e x t e n d e d to the inferior b a s e of the
t o n g u e , p r e d i s p o s i n g t o p h a r y n g e a l collapse. N o maxillofacial a b n o r m a l i t y w a s found. His initial p o l y s o m n o g r a p h y
c o n f i r m e d the d i a g n o s i s o f O S A S , with a n R D I o f
6 2 . 8 / h o u r and a sleep a p n e a index of 4 6 . 6 / h o u r , and a total
duration time of a p n e a s of 126 m i n u t e s 14 s e c o n d s ; 4 8 % of
sleep registering t i m e o c c u r r e d in association with a S a 0
of less than 9 5 % . Nasal C P A P w a s initiated 10 d a y s later at
a pressure o f + 1 1 c m o f H 0 , resulting i n R E M positive
sleep. A strict weight reduction diet w a s started. T h e patient
w a n t e d t o d i s c o n t i n u e the N - C P A P and agreed t o u n d e r g o
L A U P in several s e s s i o n s . T h e first and s e c o n d s e s s i o n s
performed 2 m o n t h s apart still required c o n t i n u e d use of NC P A P . P o l y s o m n o g r a p h y w a s r e p e a t e d 3 w e e k s later,
which found significant i m p r o v e m e n t of the O S A S , with an
RDI of 2 2 . 6 and an a p n e a index of 12.5, a m e a n S a 0 of
9 3 . 9 . and a lowest S a 0 of 6 1 . 6 % . T h e total d u r a t i o n of a p neas w a s 41 m i n u t e s 12 s e c o n d s . T h e patient noticed a c l e a r
i m p r o v e m e n t of clinical s y m p t o m s , i n c l u d i n g a reduction of
weight to 98 kg ( 2 1 6 p o u n d s ) .
Four m o n t h s after the initial L A U P , a third o p e r a t i o n w a s
performed. This was followed 3 w e e k s later by p o l y s o m n o graphy s h o w i n g an RDI of 13/hour. and an a p n e a index of
7.3/hour. T h e m e a n S a 0 w a s 9 2 . 9 % and the lowest S a 0
was 7 2 . 5 % . The N - C P A P was decreased to 7 cm H 0 . A
fourth and fifth session w a s d o n e , r e s p e c t i v e l y . 7 and 8
m o n t h s after initial treatment. A repeat p o l y s o m n o g r a m 9
m o n t h s after initial treatment c o n f i r m e d the e l i m i n a t i o n of
O S A S and the C P A P w a s stopped. T h e patient later com
plained of nasal o b s t r u c t i o n , and a laser-assisted partial turb i n e c t o m y of the left inferior and m i d d l e turbinate w a s performed 14 m o n t h s after initial t r e a t m e n t . T h e right
turbinates w e r e treated by L A P T 3 w e e k s later. T h e patient
returned for e x a m i n a t i o n 4 m o n t h s later with no m o r e
m o r n i n g tiredness o r d a y t i m e s o m n o l e n c e , i m p r o v e m e n t o f
sexual p r o b l e m s and of s l e e p efficiency, and o n l y o c c a sional soft s n o r i n g , still a bit d i s t u r b i n g to h i s wife.
2
A 5 0 - y c a r - o l d medical d o c t o r presented with a 1-year history of snoring, m o r n i n g tiredness, sexual p r o b l e m s , no

d a y t i m e s o m n o l e n c e , and a BMI of 24.6. He underwent a
o n e - s t a g e L A U P and returned for r e e x a m i n a t i o n I month
later at which l i m e there w a s cessation of snoring, although
he c o m p l a i n e d of c h r o n i c nasal obstruction. E x a m i n a t i o n of
his n o s e d e m o n s t r a t e d a mild septal deviation and hypertrop h y of the turbinates. Laser-assisted turbinectomy of the
left inferior and m i d d l e turbinates, w a s carried out in two
s e s s i o n s . W h e n reevaluated 4 m o n t h s later, he had no more
m o r n i n g tiredness and there w a s i m p r o v e m e n t of his sexual
d y s f u n c t i o n and of s l e e p efficiency with the reappearance
o f d r e a m i n g . T h e r e w a s n o m o r e snoring.
CONCLUSION
L A U P can lift the d r o o p i n g soft palate on both sides of the
uvula, similar to the w a y a theater curtain rises. After 5
years of e x p e r i e n c e with L A U P , this technique h a s imp r o v e d or e l i m i n a t e d O S A S in most cases and probably
shall be routinely used in O S A S s u r g e r y in a few years if
the results are c o n f i r m e d by other investigators. It would
b e c o m e a valuable alternative technique to conventional
U P P P , with its great potential to r e d u c e morbidity and cost
to patients.
P o p u l a r i z a t i o n of t h e L A U P will r e q u i r e serious training
of s u r g e o n s and further study with special e m p h a s i s on
l o n g - t e r m a s s e s s m e n t , especially in surgery for O S A S ,
which is m o r e difficult to treat b e c a u s e of the thickness of
t h e soft palate. In these patients, long-term p o l y s o m n o g r a p h y c o n t r o l s are n e c e s s a r y to study long-term results.
REFERENCES
1. Kamami YV. Laser C 0 for snoring, preliminary results. Ada
Otorhtnolaryngol Belg 1990;44:451-456.
2. Kamami YV. Outpatient treatment of sleep apnea syndrome
with C 0 laser, LAUP: laser-assisted UPPP results on 46 patients. J Clin User Med Surg 1994;12:215-219.
2
Section 2: Further Comments on the

Laser-Assisted Uvulopalatoplasty
lames W. Wooten
The laser-assisted uvulopalatoplasty ( L A U P ) to e l i m i n a t e

snoring first described by K a m a m i , 1 has b e c o m e a low m o r bidity operation that m a y safely be p e r f o r m e d in an a m b u l a tory setting (office or s u r g i c e n t e r ) . T h e operation is c o n ducted using local anesthesia with optional s e d a t i o n in a
series of o n e to five surgeries staged 3 to 5 w e e k s apart. R e covery is relatively uneventful. L o n g - t e r m s u c c e s s rates a r e
high with elimination of snoring being rated as c o m p l e t e in
7 0 . 4 % of c a s e s , satisfactory in 2 4 . 4 % , and u n i m p r o v e d in
5.2%. 2
Second
Procedure
T h r e e t o f i v e w e e k s p o s t o p e r a t i v e l y the p a t i e n t ' s snoring

status should be reevaluated. If s n o r i n g persists or if the patient can still snort, then the p r o c e d u r e can be repeated. Ordinarily a less e x t e n s i v e p r o c e d u r e is a c c o m p l i s h e d on repeat L A U P s . If l o w palatal w e b b i n g persists, thereby giving
a c o n s t r i c t e d a p p e a r a n c e to the v e l o p h a r y n g e a l ring, an additional vertical release of 3 to 5 mm is placed laterally to
t h e original vertical incisions.
O n e p r o c e d u r e is successful a p p r o x i m a t e l y 7 5 % of the
time. M o r e than t w o p r o c e d u r e s are s e l d o m required.
Procedure1,2,5-7
Case Report
Vertical full-thickness i n c i s i o n s are m a d e bilaterally adjacent to the u v u l a e x t e n d i n g from t h e free e d g e of t h e soft
palate s u p e r i o r l y for a p p r o x i m a t e l y 1 to 2 cm ( F i g . 8 - 6 a ) .
The s u p e r i o r e x t e n t of the incision l e n g t h is m a r k e d by the
attachment o f t h e levator veli palatini m u s c l e s . T h e s u p e rior extent of t h e incision is limited by an i m a g i n a r y line
located at t h e p o s t e r i o r / i n f e r i o r b o r d e r of t h e l e v a t o r ' s insertion. T h e p o s i t i o n of its a t t a c h m e n t is in t h e m i d l i n e ,
anterior and s u p e r i o r to the b a s e of the u v u l a . It is r e c o g nized by h a v i n g the patient forcefully s a y . " H a ! , H a ! " A
d i m p l e will briefly a p p e a r on the oral s u r f a c e of t h e soft
palate. T h i s d i m p l e i s m a r k e d b y either silver nitrate
( A g N O , ) or by a l a s e r e t c h i n g of t h e m u c o s a ( F i g . 8 - 6 b ) .
A 3 9 - y e a r - o l d m a n w a s referred from the sleep laboratory

for e v a l u a t i o n of snoring and h y p o x e m i a . He is 6 feet tall.
W A R N I N G : E x t e n s i o n o f t h e vertical i n c i s i o n s a b o v e
the level of t h e d i m p l e m a y c a u s e v e l o p h a r y n g e a l i n c o m petence ( V P I ) , r e s u l t i n g in nasal reflux of fluids and hypernasal s p e e c h . T h i s must b e a v o i d e d . After t h e vertical
incisions a r e p e r f o r m e d b i l a t e r a l l y , t h e u v u l a is g e n e r a l l y
reduced b y o n e half ( F i g . 8 - 6 c ) . T h i s will v a r y a c c o r d i n g
to the length of t h e u v u l a .
In most cases the laser is next used to create a 2 mm d e e p
and 4 mm w i d e trench on the anterior m u c o s a l surface of
the posterior tonsillar pillars bilaterally. T h i s incision e x tends from the start of the initial vertical palatal incision
and e x t e n d s laterally and interiorly to t h e b a s e of t h e p o s t e rior tonsillar pillar (Fig. 8 - 6 d ) . T h e s e a r e generally less
than 3 cm in length.
Figure 8-6. (A) Vertical incisions are made on each side of the
uvula. (B) Superior extension of incision is detemiined by the position of attachment of the levator palati. (C) The uvula is generally reduced the same length as the vertical incisions. (D) lateral
trenches are created on the anterior surface of the posterior pharyngeal pillars.
118
w e i g h s 2 4 5 lbs. ( 1 1 4 k g ) a n d has a history of s e v e r e c o n t i n u o u s snoring. S l e e p studies indicated an a p n e a index of 1

and a n o x y g e n desaturation index o f 3 1 . D u r i n g 1 8 % o f his
sleep time, o x y g e n saturation w a s less than 8 0 % . A lateral
c e p h a l o m e t r i c r a d i o g r a p h s h o w e d a d e q u a t e p o s t e r i o r airw a y s p a c e in the h y p o p h a r y n g e a l region. A n a s o p h a r y n g o s c o p y d e m o n s t r a t e d a n a r r o w i n g of t h e a i r w a y from e a c h
side and a c l o s u r e of the retropalatal area d u r i n g M i d l e r ' s
m a n e u v e r . Oral e x a m i n a t i o n r e v e a l e d a low w e b b e d soft
palate and a long uvula. T h e lateral p h a r y n g e a l walls w e r e
thickened (Fig. 8 - 7 ) . T h e s l e e p laboratory w o r k u p included
r e c o m m e n d a t i o n s t o use C P A P a n d lose w e i g h t , but t h e p a tient w a s u n w i l l i n g t o d o either. T h e r e f o r e , t h e L A U P w a s
r e c o m m e n d e d as a c o n s e r v a t i v e surgical treatment b e c a u s e
the n a s o p h a r y n g o s c o p y d e m o n s t r a t e d a retropalatal c l o s u r e .
After c o u n s e l i n g and o b t a i n i n g informed c o n s e n t , the p a tient agreed to h a v e t h e o p e r a t i o n s .
Topical anesthesia o f t h e nasal and o r o p h a r y n g e a l t i s s u e s
w a s a c c o m p l i s h e d b y nasal insufflation o f 2 % l i d o c a i n e / 2 %
N e o - S y n e p h r i n e solution and by s p r a y i n g of t h e o r o p h a r y n x
with C e t a c a i n e . S e d a t i o n w a s initiated and m a i n t a i n e d with
3 m g m i d a z o l a m , w h i c h w a s eventually s u p p l e m e n t e d b y
three additional 1-mg i n c r e m e n t s . Local a n e s t h e s i a w a s o b tained with 0 . 5 % b u p i v a c a i n e using 0.2 to 0.3 mL to the
right and left sides of t h e a t t a c h m e n t of t h e levator p a l a t i n i ,
into the c e n t e r of t h e u v u l a and then bilaterally into t h e m i d position o f the posterior p h a r y n g e a l pillars. T h e d i m p l e w a s
then m a r k e d with the laser using 10-W p u l s e s to etch the
mucosal surface lying directly o v e r t h e d i m p l e m a r k i n g the
attachment o f t h e levator palatini ( F i g . 8 - 8 ) . U s i n g a C 0
laser adjusted to 15 W o u t p u t p o w e r with a b a c k s t o p p e d
h a n d p i e c e , 13-mm t h r o u g h - a n d - t h r o u g h vertical i n c i s i o n s
w e r e m a d e o n e a c h side o f t h e uvula. T h e inferior a s p e c t o f
8
Figure 8-7. Prcoperatively the patient has a long uvula and a

low webbed soft palate.
the uvula w a s shortened 13 mm by e x c i s i n g it with a nonb a c k s t o p p e d h a n d p i e c e . D u r i n g the p r o c e d u r e t h e uvula

w a s stabilized with a wet w o o d e n t o n g u e blade. W i t h the
s a m e h a n d p i e c e , a 4 mm w i d e , 2 mm d e e p , and 15 mm long
trench w a s c r e a t e d on both the right and left sides e x t e n d i n g
laterally a n d inferiorly on t h e a n t e r i o r surface of the posterior p h a r y n g e a l pillar (Fig. 8 - 8 ) . T h i s w a s all a c c o m p l i s h e d
w i t h o u t difficulty and w i t h o u t physical discomfort to the
patient.
Postoperative medications were ketorolac Irimethamine
( T o r a d o l ) 6 0 m g i.m. and liquid o x y c o d o n e 5 m g / a c e t a minophen 5 0 0 m g . A topical anesthetic solution containing a m i x t u r e o f 9 0 % d i p h e n h y d r a m i n e HC1 s y r u p , 9 %
t e t r a c y c l i n e or d o x y c y c l i n e s u s p e n s i o n , a n d 1% of a 1%
b e t a m e t h a s o n e lotion t o b e g a r g l e d a n d e x p e c t o r a t e d four
t i m e s a d a y a n d p.r.n. w a s g i v e n . A nystatin s u s p e n s i o n
was prescribed with 1 mL to be gargled and expectorated
q.i.d.
T h e p o s t o p e r a t i v e c o u r s e w a s benign and t h e m u c o s a e
w e r e well healed at 3 w e e k s ( F i g . 8 - 9 ) . T h e patient returned
to h i s n o r m a l w o r k on an offshore oil rig 2 d a y s after
s u r g e r y . At 4 w e e k s t h e patient stated that h i s d o r m i t o r y
m a t e s c o m m e n t e d that his s n o r i n g w a s m u c h less severe, alt h o u g h it still persisted. U p o n retesling, the patient could
still snort and t h e s e c o n d stage w a s then p l a n n e d .
S e v e n w e e k s after t h e initial s u r g e r y , a s e c o n d p r o c e d u r e
w a s d o n e t o c o m p l e t e l y s t o p t h e snoring. U s i n g the s a m e
i.v. s e d a t i o n and a n e s t h e s i a p r o t o c o l , t h e patient w a s anxiety and pain-free yet a w a k e and c o o p e r a t i v e . T h e d i m p l e
w a s m a r k e d and vertical incisions w e r e m a d e on the right
and left sides of the u v u l a e x t e n d i n g vertically 6 to 7 mm
Figure 88. Vertical incisions of 13 mm length were placed on

each side of the uvula. The uvula was shortened the same distance.
Lateral trenches 4 mm wide, 2 mm deep, and 15 mm long were
created on the anterior surface of the posterior pharyngeal pillar.
Further Comments on the Laser-Assisted Uvulopalatoplasty

using 15 W output power. Additional vertical incisions of 4
to 5 mm in length were placed 3 to 4 mm lateral to the original cuts. The uvula was then shortened 4 mm and lateral
trenches 1 cm long, 4 mm wide, and 2 mm deep were created on the anterior surface of the posterior pharyngeal arch
(Fig. 8 - 1 0 ) . The postoperative regime was the same as for
the first procedure and the recovery was uncomplicated.
Three months after the original surgery, a repeat sleep
study demonstrated an apnea index of 1 and an o x y g e n desaturation index of 2 3 . Most impressively, the patient's
lowest o x y g e n saturation was 7 2 % and only 1.7% of his
sleep time was associated with an o x y g e n saturation of less
than 80%. His dormitory mates reported c o m p l e t e cessation
of snoring.
Four months after the initial surgery, the palate has g o o d
form with a less constrictive velopharyngeal ring and a
shorter uvula (Fig. 8 - 1 1 ) . The patient is very satisfied. In-
119
clear line of sight along the handpiece. After positioning the

high v o l u m e s m o k e evacuator at the corner of the mouth the
operation c o m m e n c e s . A scalpel-type probe tip (see Fig.
7 - 3 8 ) is chosen for the incisions that are made as recommended by Kamami earlier in this chapter. After creating
the general U-shaped form for the neo-uvula as illustrated
by Kamami and W o o t e n in Figs. 8 - 4 , 8 - 6 and 8 - 1 0 ) , final
adjustments of contour as well as deepening of the superior
part of the incisions may be performed with the rounded
structions to lose 15 to 2 0 % body weight were o n c e again

given to the patient.
CONTACT ND:YAG
An alternative technique for L A U P is to use a contact
N d : Y A G laser instead of the free-beam C O . Preoperative
assessment and the technique for adequately anesthetizing
the operative site remain the same. With the patient seated
and the mouth open, a black (nonreflective) metal tongue
blade is used to depress the tongue. T h e patient's mouth is
conveniently held open by a bite block or side action mouth
prop. The long contra-angle handpiece is used to provide a
z
Figure 8-9. At 3 weeks the mucosa was healed but, some snoring persisted.
Figure 8-10. The secondary procedure was less extensive when

performed at 7 weeks after initial surgery.
Figure 8-11. Four months after original surgery, the patient has
a well-contoured soft palate and is sleeping without snoring.
120
tips that, by d e l i v e r i n g a flatter b e a m profile, permit s u b t l e

s u e . A n y b l e e d i n g p o i n t s a r e e a s i l y c o a g u l a t e d with the
probe.
3.
4.
O u t p u t p o w e r o f the N d : Y A G s h o u l d b e i n t h e r a n g e o f
12 to 15 W u s i n g a n u m b e r 6 S L T c o n t a c t p r o b e for rapid
5.
operating time, excellent hemostasis, and predictable results.
REFERENCES
1. Kamami YV. Laser C 0 for snoring, preliminary results. Acta
Otorhinolaiyngol Belg f99<);44:451-456.
2. Kamami YV. Outpatient treatment of sleep apnea syndrome
2
with C 0 laser. LAUP: laser-assisted UPPP results on 46 patients. J Clin Laser Med Surg 1994; 12:215-219.
Couly G. Analomie Maxillo-faciale 25 questions pour la preparation des examens et concours. Paris: Pr6lat J; 1974.
Levin BC, Becker GD. Uvulopalalopharyngoplasty for snoring: long term results. Laryngoscope 1994; 104(9): 1150-1152.
Krespi Y, el al. The efficacy of laser assisted uvulopalatoplasty
in the management of obstructive sleep apnea and upper airway resistance syndrome. Operative Tech Otolayrngol Head
Neck Surg l994;5(4):235-243.
Cornay WJ III. Personal communication.
Krespi YP, Keidar A. Laser-assisted uvulopalatoplasty for the
treatment of snoring. Operative Tech Otolaryngol Head Neck
Surg l994;5(4):228-234.
Sher AE, Thorpy MJ, Sphrintzen RJ, Spielman AJ. et al. Predictive value of Muller's maneuver in selection of patient for uvulopalatopharyngoplasty. Laryngoscope 1985;95( 12): 1483-1487.
2
c o n t o u r i n g with only m i n o r t h e r m a l d a m a g e t o n a t i v e tis-
6.
7.
8.
The Carbon Dioxide Laser in Laryngeal

Surgery
Robert). Meleca
Coupling (he o p e r a t i n g m i c r o s c o p e with the C 0 2 laser

launched a n e w era in the field of laryngeal m i c r o s u r g e r y .
With the d e v e l o p m e n t of microsurgical i n s t r u m e n t a t i o n a n d
a m i c r o m a n i p u l a t o r laser a t t a c h m e n t that p r o d u c e s a reduced spot size d i a m e t e r of 0.25 mm at a 4 0 0 - m m w o r k i n g
distance, the C 0 2 laser c o m b i n e s surgical m i c r o p r e c i s i o n
with capillary h e m o s t a t i c capability and h a s b e c o m e t h e instrument of c h o i c e for a n u m b e r of laryngeal p a t h o l o g i e s .
The glottis is an ideal structure for the use of a C 0 2 laser
because of its high tissue w a t e r c o n t e n t , especially in
R e i n k e ' s s p a c e , a l l o w i n g for diffusion of t h e r m a l e n e r g y
away from the impact site of the b e a m and resulting in less
surrounding tissue injury. T h e benefit of m i n i m a l thermal
d a m a g e from C 0 laser s u r g e r y results i n less p o s t o p e r a t i v e
tissue e d e m a , m i n i m a l s c a r r i n g , and rapid w o u n d h e a l i n g .
It is ideally suited for r e m o v a l of recurrent laryngeal papillomas, vascular lesions of the larynx such as h e m a n g i o m a s
and h e m o r r h a g i c p o l y p s , laryngeal c y s t s , g r a n u l o m a s , a n d
early glottic c a r c i n o m a s . T h e C O 2 laser m a y also b e utilized
alone or in c o m b i n a t i o n with c o n v e n t i o n a l surgical techniques for r e m o v a l of vocal fold cysts or t r e a t m e n t of
Reinke's edema.
1
W h e n used properly t h e C O 2 laser is an effective and safe

instrument for laryngeal s u r g e r y , but d e s p i t e m e t i c u l o u s
safety p r e c a u t i o n s c o m p l i c a t i o n s will o c c u r . T h e s e m a y include cuff rupture, e n d o t r a c h e a l tube ignition, ignition of
pledgets or d r a p e s , b u r n s to t h e skin or m u c o s a of t h e patient or o p e r a t i n g r o o m p e r s o n n e l , corneal injury, p n e u mothorax, s u b c u t a n e o u s e m p h y s e m a , and h e m o r r h a g e (see
Chapter 2 for m o r e details).
Several e x p e r i m e n t a l studies h a v e d e m o n s t r a t e d d e l a y e d
healing and increased s c a r r i n g w h e n the C 0 2 laser i s
used.
H o w e v e r , the d e v e l o p m e n t of n e w m i c r o s u r g i c a l
instrumentation, r e d u c e d b e a m spot size, and better o p e r a tor t e c h n i q u e s h a v e led to e q u i v a l e n t , or i m p r o v e d , vocal
fold mucosal healing a n d voice q u a l i t y . 5
2
Laser p a r a m e t e r s and laryngeal surgical t e c h n i q u e s that

will d e c r e a s e s u r r o u n d i n g soft tissue thermal injury include
( I ) using a m i c r o m a n i p u l a t o r that p r o d u c e s a spot size of
0.25 mm with a 4 0 0 mm focal length lens; (2) utilizing l o w
power settings (0.5 to 6 W ) ; (3) using short pulse d u r a t i o n s
in a s u p e r p u l s e m o d e to d e c r e a s e the t i m e o v e r which thermal energy b u i l d u p o c c u r s in the tissues (0.1 to 1.0 s e c o n d s
in a 1 0 % duty c y c l e ) ; (4) s u c t i o n i n g the v a p o r p l u m e from

the o p e r a t i v e field, w h i c h will limit t h e a m o u n t of heat
b u i l d u p a n d d e c r e a s e thermal injury to s u r r o u n d i n g tissues;
(5) frequently r e m o v i n g c a r b o n a c e o u s debris (char) from
the soft tissue laser e x c i s i o n site with laryngeal suction to
d e c r e a s e heat transfer; and (6) k e e p i n g tension at the laser
e x c i s i o n line by stretching the tissues with microsurgical
forceps: this p r o d u c e s a cleaner incision by m i n i m i z i n g
c h a r formation, t h u s p r e v e n t i n g h e a t - i n d u c e d soft tissue
damage.6
T h e f o l l o w i n g sections d e s c r i b e the p a t h o p h y s i o l o g y of
specific laryngeal lesions, indications for their r e m o v a l , and
C O 2 laser t e c h n i q u e s . G e n e r a l l y , for all p r o c e d u r e s d e scribed b e l o w the patient is intubated with a small ( 6 . 0 to
6.5 m m i n n e r d i a m e t e r ) laser-resistant e n d o t r a c h e a l tube
(jet ventilation m a y be used to avoid p l a c e m e n t of an e n d o tracheal t u b e ) . T h e e n d o t r a c h e a l tube cuff is filled with
m e t h y l e n e blue to allow for rapid detection of a cuff leak
from a m i s d i r e c t e d laser "hit." U s e of o x y g e n concentrations b e t w e e n 3 0 and 4 0 % will d e c r e a s e the c h a n c e o f end o t r a c h e a l tube ignition. S u s p e n s i o n m i c r o l a r y n g o s c o p y is
p e r f o r m e d using a l a r g e - b o r e l a r y n g o s c o p e with 10X to
2 5 X magnification, a m o i s t u r i z e d pledget is placed o v e r the
cuff to protect t h e cuff and distal tissues, and t h e e y e s and
face a r e protected with d a m p e n e d e y e p a d s and a head
d r a p e , respectively (Figs. 9 - 1 a n d 9 - 2 ) .
LARYNGEAL PAPILLOMAS
Laryngeal papillomas are cauliflower-like lesions caused by
infection with t h e h u m a n papilloma virus ( H P V ) (Figs. 9 - 3
and 9 - 4 ) . T h i s lesion is t h e most c o m m o n benign neoplasm
of the larynx. During infancy or adulthood its presenting
s y m p t o m s are hoarseness o r airway obstruction. T h e natural
history of this disease is o n e of multiple recurrences, especially with the j u v e n i l e onset type; therefore, C O 2 laser vaporization of these lesions, although the accepted procedure
of choice today, is thought to be only palliative in most cases.
Multiple recurrences are thought to be caused by persistent
g r o w t h of H P V in subclinically infected normal-appearing
tissue bordering the area of treatment. 7 T h e goal of laser va-
121
122
Figure 9 - 1 . Intraoperative view demonstrating the equipment used for a patient undergoing suspension microlaryngoscopy and C O , laser excision of subglottic granulation tissue. The microscope is coupled to a C 0 laser micromanipulator. This allows for a magnified and binocular view of the lesion, which is exposed using a laryngoscope placed in
suspension. Note that a 4(X)-mm lens on the microscope provides adequate working distance between the microscope
and the laryngoscope.
2
porization is to eradicate this lesion and establish an adequate

airway and functional voice without causing submucosal
d a m a g e that m a y result in vocal fold scarring and fibrosis. Simultaneous removal of papillomas from both sides of the anterior or posterior c o m m i s s u r e should be avoided, as this maneuver often results in c o m m i s s u r e w e b formation.8 Typical
C 0 2 laser settings for such a procedure include using a 0 . 2 5 mm spot size at a working distance of 4 0 0 m m , 2- to 3-W
power, and 0 . 5 - to 1.0-second pulse durations.
Figure 9 - 2 . Iixample of the view obtained through the subglottiscope used for the patient in Fig. 9 - 1 . Note the red beam of the
C 0 laser located at the inferior boundary of the lesion.
2
LARYNGEAL AND SUBGLOTTIC

HEMANGIOMAS
H e m a n g i o m a s are u n c o m m o n n e o p l a s m s that m a y occur
a n y w h e r e in the larynx and histologically are capillary, cave r n o u s , or mixed c a p i l l a r y / c a v e r n o u s lesions. T h e y may
present in a pediatric or adult form; the pediatric form is
p r e d o m i n a n t l y capillary in nature and the adult form more
often mixed or c a v e r n o u s . 6 T h e pediatric h e m a n g i o m a char-
Figure 9 - 3 . Preoperative view of a 27-year-old patient with laryngeal papillomas involving both true vocal folds and the anterior
false fold on the right. (Photo courtesy of Robert W. Bastian,
M.D., Loyola University, Chicago.)
The Carbon Dioxide Laser in Laryngeal Surgery
123
and the incision site i s then carefully outlined with the C 0

laser. U s i n g microsurgical i n s t r u m e n t a t i o n the lesion is retracted m e d i a l l y , t h u s p l a c i n g t h e area to be incised under
tension. T h i s a l l o w s for less c h a r formation and d e c r e a s e d
peripheral thermal tissue d a m a g e . T h e lesion is r e m o v e d at
its b a s e with c a r e taken not to induce t h e r m a l d a m a g e d e e p
to the superficial l a m i n a propria. A p p r o p r i a t e laser settings
for such a p r o c e d u r e m i g h t include using a 0 . 2 5 - m m spot
size with a 4 0 0 - m m lens, 0 . 5 - to 2 - W p o w e r , and pulse durations of 0.1 to 0.5 s e c o n d .
LARYNGEAL CYSTS
Figure 9-4. Two-week postoperative view demonstrating mild
vocal fold edema, but the voice is significantly improved. (Photo
courtesy of Robert W. Bastian. M.D., Loyola University,
Chicago.)
acteristically p r e s e n t s shortly after birth, h a s a proliferative

phase that m a y last up to 1 y e a r followed by an involutional
phase o c c u r r i n g from 1 to 7 y e a r s of a g e . T h e s e l e s i o n s
often o c c u r subglottically and m a y p r o g r e s s in size, resulting i n a i r w a y obstruction. C 0 2 laser t r e a t m e n t m a y b e used
safely to r e m o v e these lesions w h i l e s i m u l t a n e o u s l y m a i n taining a patent a i r w a y and thereby a v o i d i n g need for a tracheotomy.'' W i t h the use of a s u b g l o t t o s c o p e and a laser
with increased pulse d u r a t i o n settings to a l l o w for m o r e
thermal diffusion and better c o a g u l a t i o n of small v e s s e l s ,
capillary h e m a n g i o m a s m a y b e effectively t r e a t e d . T h e s e
lesions can be m a n a g e d u s i n g a laser with a 0 . 2 5 - m m spot
size at a 4 0 0 - m m focal d i s t a n c e , 2- to 3 - W p o w e r , and 0 . 5 to 1.0-second pulse d u r a t i o n s . C a v e r n o u s lesions often present bleeding p r o b l e m s d u r i n g r e m o v a l that a r e not effectively controlled using t h e C 0 2 laser, t h e r e b y r e q u i r i n g t h e
use of o t h e r forms of therapy.
6
REINKE'S EDEMA AND VOCAL

FOLD POLYPS
R e i n k e ' s e d e m a a n d vocal fold p o l y p s r e p r e s e n t a d i s e a s e
process induced by c h r o n i c irritation to t h e vocal folds with
resultant fluid a c c u m u l a t i o n in t h e superficial l a y e r of the
lamina propria. T h i s fluid a c c u m u l a t i o n usually o c c u r s bilaterally and m a y b e diffuse ( R e i n k e ' s e d e m a ) o r localized
(vocal fold p o l y p ) . P o l y p s m a y be fusiform, p e d u n c u l a t e d ,
hemorrhagic, o r g e n e r a l i z e d . T h e irritating stimuli p r o d u c ing these p a t h o l o g i c c h a n g e s include vocal a b u s e , c h r o n i c
throat c l e a r i n g or c o u g h , cigarette s m o k e , or gastric acid a s sociated with g a s t r o e s o p h a g e a l reflux. Surgical intervention
is r e c o m m e n d e d for i m m a t u r e , soft lesions failing c o n s e r v ative t h e r a p y , or for p o l y p s d e m o n s t r a t i n g fusiform, p e d u n culated, o r h e m o r r h a g i c c h a r a c t e r i s t i c s . T h e C 0 laser i s
particularly useful for r e m o v a l of p e d u n c u l a t e d , h e m o r rhagic p o l y p s . Vessels leading to the p o l y p a r e c o a g u l a t e d .
M u c u s - r e t e n t i o n c y s t s m a y o c c u r in the supraglottis w h e r e
m u c u s - s e c r e t i n g g l a n d s exist in a b u n d a n c e . C o n g e n i t a l sacc u l a r c y s t s or l a r y n g o c e l e s a r e rare and m a y present with
voice c h a n g e o r airway c o m p r o m i s e . T h e C O 2 laser i s ideal
for c o m p l e t e r e m o v a l of these lesions e n d o s c o p i c a l l y . M a r supialization and ablation of the cysts lining m a y be att e m p t e d ; h o w e v e r , r e c u r r e n c e i s not u n c o m m o n . Laser
settings for such a p r o c e d u r e include a 0 . 2 5 - m m spot size,
0 . 5 to 2 W, and a 0 . 1 - to 0 . 5 - s e c o n d pulse d u r a t i o n .
10
GRANULOMA
L a r y n g e a l g r a n u l o m a s typically arise in t h e posterior glottis, o v e r t h e medial aspect of the vocal p r o c e s s . Etiologies
include p r e v i o u s t r a u m a from e n d o t r a c h e a l intubation, g a s t r o e s o p h a g e a l reflux, or vocal a b u s e . T h e s e lesions often
begin as ulcerations with p r o g r e s s i o n toward granulation
formation. T h e y characteristically p r e s e n t with s y m p t o m s
of h o a r s e n e s s , c h r o n i c throat c l e a r i n g , sore throat, or a
g l o b u s s e n s a t i o n . Effective treatment usually includes rem o v a l o f t h e irritating s o u r c e , a d m i n i s t e r i n g antibiotics and
antireflux m e d i c a t i o n s , a s well a s s p e e c h therapy. W i t h
l o n g - t e r m c o n s e r v a t i v e therapy most g r a n u l o m a s will resolve in an o r d e r l y fashion by p r o g r e s s i n g from an ulcerative state to a b r o a d - b a s e d g r a n u l o m a , and finally to a p e d u n c u l a t e d m a s s that will e v e n t u a l l y fall off. W h e n
c o n s e r v a t i v e t r e a t m e n t fails, t h e C 0 laser i s ideal for surgical e x c i s i o n . T h e laser is used to precisely e x c i s e the g r a n u loma w i t h o u t e x p o s i n g u n d e r l y i n g c a r t i l a g e . 6 A n y r e m a i n ing g r a n u l a t i o n tissue can be spot v a p o r i z e d . T y p i c a l laser
s e t t i n g s for r e m o v a l of such lesions include using a 0 . 2 5 mm spot size with a 4 0 0 - m m lens, 0 . 5 - to 2 - W p o w e r , and a
0 . 1 - t o 0 . 5 - s e c o n d pulse d u r a t i o n .
2
MALIGNANT NEOPLASMS
V o c a l fold h y p e r k e r a t o s i s , e r y t h r o p l a s i a , c a r c i n o m a in situ,
or e a r l y i n v a s i v e c a r c i n o m a can all be effectively treated
124
using the C O , laser ( F i g s . 9 - 5 t o 9 - 9 ) . 2 W h e n c o m p a r i n g

C 0 laser resection with irradiation for T , c a r c i n o m a s o f t h e
glottis, t h e cure rates a r e e q u i v a l e n t . 1 1 - 1 3 V o i c e quality in
select patients with T , c a r c i n o m a s treated with C 0 laser resection e q u a l s that for similarly staged patients treated with
radiation t h e r a p y , but w h e n m o r e than 5 0 % o f t h e vocal
fold width is resected using t h e laser, voice quality d e t e r i o r a t e s . S u g g e s t e d criteria for C 0 laser r e m o v a l o f a glottic
c a r c i n o m a include T , lesions i n v o l v i n g t h e m i d c o r d , w i t h out i n v o l v e m e n t o f t h e a n t e r i o r c o m m i s s u r e o r vocal
process o f the arytenoid. C 0 laser excision i s a n e x c e l l e n t
alternative to irradiation b e c a u s e it a l l o w s for a s i m u l t a n e o u s staging excisional biopsy and definitive t h e r a p y , all in
an outpatient setting. T y p i c a l s e t t i n g s used for laser e x c i sion of T, glottic c a r c i n o m a s include a 0 . 2 5 - m m spot size at
2
14
a w o r k i n g d i s t a n c e of 4 0 0 m m , 4- to 6 - W power, with a 0.5to 1.0-second p u l s e duration.

I n s u m m a r y , t h e C 0 laser c o m b i n e s surgical microprecision with h e m o s t a s i s of capillary size blood vessels. T h e s e
qualities result in less postoperative tissue e d e m a , minimal
s c a r r i n g , a n d rapid w o u n d h e a l i n g w h e n c o m p a r e d with
o t h e r surgical t e c h n i q u e s . T h e laser m a y be used to treat a
n u m b e r of b e n i g n , p r e m a l i g n a n t , and malignant lesions of
t h e larynx, i n c l u d i n g laryngeal p a p i l l o m a s , h e m a n g i o m a s
and cysts, vocal fold p o l y p s and g r a n u l o m a s , as well as
vocal fold h y p e r k e r a t o s i s , erythroplasia, c a r c i n o m a in situ,
and i n v a s i v e s q u a m o u s cell c a r c i n o m a . With the developm e n t of m o r e sophisticated instrumentation, c o m b i n e d with
o p e r a t o r e x p e r t i s e , t h e field of m i c r o l a r y n g e a l surgery will
c o n t i n u e to e v o l v e at an accelerated p a c e .
2
Figure 9 - 5 . Preoperative view of a 57-year-old patient with a T,

squamous cell carcinoma involving the left true vocal fold after
biopsy at an outside institute. This lesion is ideal for laser removal
because of its position on the midcord, without involvement of the
anterior commissure or vocal process. (Photo courtesy of Robert
W. Bastian. M.D., Loyola University, Chicago.)
Figure 9 - 7 . Six-week postoperative view with near complete

healing of the left vocal fold. (Photo courtesy of Robert W. Bastian, M.D., Loyola University, Chicago.)
Figure 9-6. Intraoperative view after removal of the lesion. The

laser was used to outline the carcinoma with a 2- to 3-mm margin.
After frozen section confirmation of clear margins the final defect included removal of the medial one third of the vocalis muscle. (Photo
courtesy of Robert W. Bastian, M.D., Loyola University, Chicago.)
F i g u r e 9 - 8 . Six-month postoperative view with a mucosalized

scar band extending across the original excision site. (Photo
courtesy of Robert W. Bastian, M.D., Loyola University,
Chicago.)
The Carbon Dioxide Laser in Laryngeal Surgery

HEALING SEQUENCE
T w o w e e k s p o s t o p e r a t i v e l y ( F i g . 9 - 4 ) this
mild true vocal fold e d e m a , but t h e voice is
i m p r o v e d , both subjectively and objectively.
focus of residual disease j u s t anterior to the
process.
125
patient h a s
significantly
N o t e small
right vocal
T, Glottic Carcinoma
HISTORY
T h i s is a 5 7 - y e a r - o l d m a n with a significant history of
s m o k i n g and ethanol use w h o presented with a 3-month history o f p r o g r e s s i v e h o a r s e n e s s and a n e p i s o d e o f h e m o p t y sis ( F i g s . 9 - 5 t o 9 - 8 ) .
Figure 9 - 9 . Example of how the laser is utilized to outline a
small glottic carcinoma prior to removal. (Photo courtesy of
Robert W. Bastian, M.D., Loyola University. Chicago.)
CASE PRESENTATIONS
T h e following c a s e p r e s e n t a t i o n s h a v e been selected b e cause they represent lesions that a r e ideally suited for C 0
laser e x c i s i o n . T h e c a s e s presented include laryngeal p a p i l loma and T | glottic c a r c i n o m a .
2
Laryngeal
Papilloma
HISTORY
This 2 7 - y e a r - o l d patient w i t h o u t a s m o k i n g history presented with 4 m o n t h s of p r o g r e s s i v e h o a r s e n e s s ( F i g s . 9 - 3
and
9-4).
EXAMINATION FINDINGS
P a p i l l o m a s involving the true vocal folds bilaterally with

involvement of t h e a n t e r i o r false vocal fold on the right
(Fig. 9 - 3 ) . T h e a r y t e n o i d and anterior c o m m i s s u r e r e g i o n s
are free of d i s e a s e .
EXAMINATION FINDINGS
T h i s is a b i o p s y - p r o v e n s q u a m o u s cell c a r c i n o m a of the
left true vocal fold i n v o l v i n g t h e m i d c o r d region (Fig. 9 - 5 ) .
T h e left vocal fold m o v e s freely and the anterior c o m m i s s u r e , vocal p r o c e s s , ventricle, and subglottic regions are
free of d i s e a s e .
TREATMENT
Laser Type
C a r b o n d i o x i d e laser with m i c r o m a n i p u l a t o r
c o u p l e d to an o p e r a t i n g m i c r o s c o p e at 10X magnification,
c o n t a i n i n g a 4 0 0 - m m lens.
Parameters
A 0 . 2 5 - m m spot size. 4 - W average power, 0.5second pulse duration in a 10% duty cycle (superpulse mode).
COMMENTS
T h e lesion is carefully outlined (Fig. 9 - 9 ) with the laser,
a small cuff of n o r m a l tissue is taken with t h e t u m o r , and
frozen section c o n f i r m a t i o n of free m a r g i n s is obtained
( F i g . 9 - 6 ) . Patients with glottic c a r c i n o m a should be seen
o n c e a m o n t h for t h e first p o s t o p e r a t i v e year, every 2
m o n t h s for t h e next year, and regularly thereafter for a total
of 5 years so that recurrent d i s e a s e can be detected early
and further t h e r a p y instituted p r o m p t l y .
TREATMENT
HEALING SEQUENCE
Laser Type
C a r b o n d i o x i d e laser with m i c r o m a n i p u l a t o r
coupled to an o p e r a t i n g m i c r o s c o p e at 10X m a g n i f i c a t i o n .
A 4 0 0 - m m lens on the m i c r o s c o p e p r o v i d e s e n o u g h w o r k ing d i s t a n c e for m i c r o l a r y n g e a l i n s t r u m e n t a t i o n .
band forms across the area of excision (Figs. 9 - 7 and 9 - 8 ) .
Parameters
A 0 . 2 5 - m m spot size, 2 - W a v e r a g e p o w e r ,
0.5- to 1.0-second pulse d u r a t i o n in a 1 0 % duty c y c l e ( s u perpulse m o d e ) .
ACKNOWLEDGMENT
T h e a u t h o r w o u l d like t o t h a n k R o b e r t W . Bastian, M . D . ,
from L o y o l a University, C h i c a g o , for u s e of the c a s e illustrations.
COMMENTS
L a r y n g e a l p a p i l l o m a s g r o w superficially and s h o u l d b e
ablated at the m u c o s a or s u b m u c o s a level without penetration into t h e vocal l i g a m e n t or vocalis m u s c l e . C l o s e postoperative follow-up is i m p o r t a n t as the natural history of
this d i s e a s e is o n e of m u l t i p l e recurrences.
After resection of a midcord c a r c i n o m a a mucosalized scar
REFERENCES
1. Freche C, Jakobowitz M, Bastian RW. The carbon dioxide
laser in laryngeal surgery. Ear Nose Throat J 1988;67:436-445.
2. Crockett DM, Reynolds BN. Laryngeal laser surgery. Otolaryngol Clin North Am 1990;23(l):49-66.
10
Uses of Lasers in Dentistry
Harvey Wigdor
T h e c o n c e p t of using lasers in dentistry is as old as t h e first

laser d e v e l o p e d by M a i m a n in I 9 6 0 . S o o n afterward Stern
and S o g n n a e s ' 2 b e c a m e t h e f i r s t t o s t u d y potential dental
hard tissue a p p l i c a t i o n s and reported their results in 1964.
They evaluated t h e p o s s i b l e u s e of t h e r u b y laser to fuse t h e
caries susceptible o c c l u s a l pits on t h e c h e w i n g surface of
teeth. T h e y also investigated the u s e of t h e s e lasers to alter
the smooth surfaces of teeth to r e d u c e their susceptibility to
decay. P r o g r e s s w a s slow in d e v e l o p i n g laser a p p l i c a t i o n s
in cutting dental hard tissues b e c a u s e of the thermal d a m a g e
caused by t h e laser w a v e l e n g t h s a v a i l a b l e at the t i m e . Although investigational activity w a s s p a r s e t h e r e w e r e s o m e
published research p a p e r s that e v a l u a t e d t h e effect of lasers
on hard dental t i s s u e s . " A d r i a n et a l . e x a m i n e d t h e effects
of the ruby laser on the dental p u l p and found that t h e r m a l
d a m a g e w a s significant. H o w e v e r , i t w a s the d e v e l o p m e n t
of the C 0 laser that s t i m u l a t e d an i n c r e a s e in activity investigating the tissue-altering effects of lasers on e n a m e l
and dentin.
3
Recent y e a r s h a v e seen t h e d e v e l o p m e n t o f lasers w h o s e

manufacturers h a v e s u g g e s t e d their u s e t o c u t hard d e n tal tissues. Unfortunately, m a r k e t i n g efforts o u t s t r i p p e d
research activity and the training m a n u a l s of s o m e of
the n e o d y m i u m : y t t r i u m - a l u m i n u m - g a r n e t ( N d : Y A G ) laser
manufacturers s u g g e s t e d u s e s i n c l u d i n g r e m o v a l o f s m a l l
carious lesions of e n a m e l , r e m o v a l of s u b g i n g i v a l c a l c u l u s ,
a p i c o e c t o m y , and treatment o f small c a r i o u s c e r v i c a l lesions in teeth. All of these p u b l i s h e d s u g g e s t e d a p p l i c a t i o n s
were a d v o c a t e d p r i o r to t h e Food and D r u g A d m i n i s t r a tion's ( F D A ) c l e a r a n c e of hard tissue a p p l i c a t i o n s in d e n tistry. Regrettably these r e c o m m e n d a t i o n s a r e largely unwarranted b e c a u s e thermal d a m a g e t o t h e treated tissues
continues to be p r o b l e m a t i c .
8
LASER HARD DENTAL TISSUE

ABLATION RESEARCH
During t h e last few y e a r s research performed by Hibst and
Keller
has shed s o m e light o n t h e u s e o f a n e r b i u m
( E r ) : Y A G laser with a w a v e l e n g t h of 2 . 9 4 pm for c u t t i n g
hard dental tissues. T h e y s h o w e d that this laser c o u l d effectively cut teeth to m a k e cavity p r e p a r a t i o n s for s i m p l e d e n tal restorations. T h e i r thermal studies s h o w e d little or no effect on teeth i n c l u d i n g dental p u l p w h e n this laser w a s used.
9 1 0
As with any light s o u r c e irrespective of w a v e l e n g t h the

material that is b e i n g irradiated m a y either a b s o r b , transmit,
scatter, or reflect the light e n e r g y . T h e s u m m a t i o n of the
light-tissue interaction will d e t e r m i n e the effect of the laser
(see C h a p t e r 1).
Clinical effects a r e p r e d o m i n a n t l y t h e result of the a b sorption of t h e laser light in t h e tissues being treated. S o m e
of the u n a b s o r b e d light can also scatter c a u s i n g a m o r e diffuse effect in t h e tissue. T h e d e s i r e d clinical effects in
s u r g e r y a r e mostly c o n t r o l l e d b y the absorption and s o m e w h a t by t h e scatter of t h e light in the tissue. T h e p o w e r of
t h e l a s e r used and t h e t i m e that t h e e n e r g y is in c o n t a c t with
t h e tissue being treated a r e very important p a r a m e t e r s that
d e t e r m i n e the o b s e r v e d clinical effect.
After u n d e r s t a n d i n g t h e effects lasers m a y h a v e o n any
material i n c l u d i n g dental hard tissues an u n d e r s t a n d i n g of
the optical p r o p e r t i e s of dental hard tissues is in order. Fried
e t a l . " ' d e t e r m i n e d t h e absorption and scattering coefficients, u s i n g w a v e l e n g t h s of 5 4 3 , 6 3 2 and 1053 nm. T h e s e
coefficients a r e t h e quantifiable a m o u n t s of absorption and
scatter in e n a m e l and d e n t i n . At these w a v e l e n g t h s their results s h o w e d that light in the visible ( 5 4 3 , 6 3 2 n m ) and the
n e a r infrared ( 1 0 5 3 n m ) a r e only negligibly a b s o r b e d by
e n a m e l and dentin. Visible light is scattered s o m e w h a t but
the near infrared is strongly transmitted straight t h r o u g h
t h e s e tissues and only w e a k l y scattered.
Fried et al. p l a c e d t h e e n a m e l s a m p l e , as well as d e n t i n ,
i n a n optically m a t c h e d solution. T h e s a m p l e w a s then s u b j e c t e d to s p e c t r o s c o p i c analysis. U s i n g an integrating
s p h e r e of a s p e c t r o p h o t o m e t e r the light from t h e s a m p l e
w a s collected and a d e t e r m i n a t i o n w a s m a d e that quantified
the a m o u n t of light a b s o r b e d by the s a m p l e . Integrating
s p h e r e s a r e totally e n c l o s e d d e t e c t o r s that receive and c o n tain t h e light from t h e s a m p l e for e v a l u a t i o n . T h e internal
surface of t h e s p h e r e s are highly reflective, a l l o w i n g the
light to r e m a i n in the s p h e r e until hitting the detector. T h e
optically m a t c h e d solution, which h a s t h e s a m e optical
p r o p e r t i e s as t h e s a m p l e s , a l l o w e d uniformity b e t w e e n the
light and the s a m p l e . If it had not been used, t h e a i r - s a m p l e
interface that t h e light w o u l d p a s s through would act as t w o
different optical materials. T h i s w o u l d c a u s e the s a m p l e t o
reflect s o m e of t h e incident light, thereby r e d u c i n g the
transmitted light d e t e c t e d i n t h e integrating s p h e r e . T h e o p tically m a t c h e d solution g i v e s m o r e accurate values of the
true optical p r o p e r t i e s of these tissues w h e n it is used.
1 2
W h e n d e n t i n s a m p l e s i n a n optically m a t c h e d solution
127
1 28
w e r e studied using t h e s a m e w a v e l e n g t h s as in the e n a m e l

there w a s s o m e variability in t h e scattering coefficient
based on tubule d e n s i t y and orientation. It w a s found that
e v e n t h o u g h the a b s o r p t i o n coefficient w a s low, if e n o u g h
e n e r g y is d e p o s i t e d on the tissue o v e r the visible a n d n e a r
infrared s p e c t r a it is a b s o r b e d by dentin. U n f o r t u n a t e l y , t h e
high a m o u n t of e n e r g y n e c e s s a r y at these w a v e l e n g t h s to
c a u s e clinical effects can also c a u s e very d a m a g i n g thermal
side effects. H o w e v e r , if l o w e r e n e r g y levels a r e used, most
of the light is transmitted a n d / o r scattered, being a b s o r b e d
as it passes into d e e p e r r e g i o n s of t h e d e n t i n . Clinically this
is significant, for if a laser w e r e used that h a s the potential
for d e e p e r penetration, the u n d e r l y i n g tissues b e n e a t h the
area of treatment m a y be a d v e r s e l y affected by the laser.
It s e e m s that al the present m o m e n t the optimal laser for
oral hard tissue ablation is o n e that h a s high a b s o r p t i o n
within t h e v o l u m e of tissue b e i n g treated, thereby r e d u c i n g
both t h e depth of penetration ( a b l a t i o n ) and thermal injury.
Both of t h e s e characteristics are essential w h e n c o n s i d e r i n g
that tissues b e i n g treated by d e n t i s t s are usually thin a n d
very susceptible to thermal d a m a g e .
T h e m o s t efficient ablation with the lowest thermal effect
o c c u r s w h e n the laser e n e r g y is highly a b s o r b e d in a small
v o l u m e o f tissue. T h i s requires c l o s e m a t c h i n g o f the w a v e length of t h e incident b e a m to the target c h r o m o p h o r e . Sim u l t a n e o u s l y , the energy d e n s i t y must be a d e q u a t e to ind u c e t h e desired tissue effect d u r i n g an a p p l i c a t i o n t i m e
short e n o u g h to p r e c l u d e lateral thermal c o n d u c t i o n (see
C h a p t e r 3 ) . T h e inverse effect o c c u r s if the laser w a v e length is not well a b s o r b e d , w h i c h requires a longer t i m e of
e x p o s u r e on the tissue. T h i s l o n g e r e x p o s u r e w o u l d c a u s e a
d e e p e r z o n e o f d a m a g e and m o r e thermal effect. F r o m Fried
et a l . ' s 1 1 ' 1 2 r e s e a r c h , laser light from the n o n c o n t a c t
N d : Y A G laser (1.06 u.m) c a u s e s significant h e a t i n g in hard
tissue ( d e n t i n , e n a m e l , and b o n e ) , w h i l e t h e c o n t a c t
N d : Y A G h a s less heat effect.
For hard tissue ablation a laser that is h i g h l y a b s o r b e d by
one or m o r e of the c o m p o n e n t s in t h e hard tissue w o u l d be
most a d v a n t a g e o u s . T h e recent interest in the suitability of
the E r : Y A G l a s e r ' s effects on hard dental tissues is based
upon t h e characteristic of its 2 . 9 4 - n m w a v e l e n g t h . It is very
highly a b s o r b e d by w a t e r and m o d e r a t e l y well a b s o r b e d by
h y d r o x y a p a t i t e , a major c o n s t i t u e n t of both d e n t i n and
e n a m e l . B e c a u s e of the high a b s o r p t i o n c h a r a c t e r i s t i c of
ihis laser in both dentin and e n a m e l , it can ablate these hard
(issues efficiently with very little heat production, thereby
a v o i d i n g d a m a g e to t h e dental p u l p , which h a s very little
heat tolerance. It must be the goal of any laser that is to be
used in dentistry to p r o d u c e minimal heat as it cuts t h r o u g h
the hard dental tissues.
T h e precise m e c h a n i s m o f the ablation o f hard tissues
with t h e E r : Y A G laser r e m a i n s unclear. O n e theory s u g gests that w h e n the laser interacts with t h e hard tissue it is
a b s o r b e d by the water and h y d r o x y a p a t i t e . T h e laser heats
the w a t e r c a u s i n g it to b e c o m e s t e a m . T h i s e x p a n s i o n during t h e c h a n g e of state of w a t e r c a u s e s c r a c k i n g of the tis-
sue. As t h e s t e a m e x p a n d s it also forces the cracked material a w a y from the ablation zone. B e c a u s e this is a very
rapid action, it is e x p l o s i v e in n a t u r e . T h e effect of this laser
is s o m e w h a t different in e n a m e l c o m p a r e d with dentin. As
d i s c u s s e d by Hibst and Keller 9 the E r : Y A G laser energy is
a b s o r b e d about twice as intensely in dentin as in enamel.
T h e y suggest that the relative ratio of water to hydroxyapatite is t h e r e a s o n for this difference. T h e y calculated the
absorption of the Er: Y A G laser in dentin to be in the order
of 2 0 0 0 c m - 1 and in e n a m e l to be 1000 cm-1 . Further work
by Hibst and K e l l e r " using ultrashort flash photography to
e v a l u a t e the p l u m e arising from the ablation of denial hard
i issues w a s p u b l i s h e d in 1993. T h e i r results substantiate the
theory of the E r : Y A G laser m e c h a n i s m o b s e r v e d on dental
hard tissues. T h e y further suggest that the g l o w observed in
front of the tissue surface is c a u s e d by the particles being
heated after ejection from the tissue (see Fig. 1 0 - 1 6 ) . This
heating c a u s e s a c o n s i d e r a b l e e n e r g y loss, which prevents
the e x p e c t e d linear increase in crater d e p t h with time of exp o s u r e . In addition the velocity of the ejection p l u m e for
e n a m e l is less than that for dentin. T h e differential ratio of
the w a t e r and h y d r o x y a p a t i t e content in these t w o tissues
a p p e a r s to be the reason for this difference.
Recent studies included histologic and scanning electron
m i c r o s c o p i c ( S E M ) evaluation of the effect of E n Y A G
lasers on teeth. W i g d o r et a l . 1 4 evaluated the effect of the
E r : Y A G laser on d o g teeth in v i v o a n d in vitro (extracted
teeth). E n Y A G h o l e s w e r e m a d e in the teeth. T h e output
p o w e r of the laser w a s 1.5 W with an e n e r g y of 5 0 0 mJ per
pulse at 3 Hz. A m a l g a m restorations were then placed in
the ablation h o l e s . After 4 d a y s the teeth w e r e extracted and
decalcified. F i g u r e 10-1 is a p h o t o g r a p h of the holes created by the laser in the c a n i n e teeth. After decalcification
t h e teeth w e r e sectioned and stained with h e m a t o x a l i n and
eosin. Figure 1 0 - 2 is a p h o t o m i c r o g r a p h of an untreated
c o n t r o l tooth. N o t e the loose c o n n e c t i v e tissue in the pulp
and the n o r m a l a p p e a r a n c e of the o d o n t o b l a s t s lining the
dentin. Figure 1 0 - 3 is a p h o t o m i c r o g r a p h of a tooth that
had been irradiated by the E n Y A G laser. T h e laser defect
can be seen as a depression in the dentin. Note that the pulp-
Figure 1 0 - 1 .
Er:YAG laser holes on dog canine teeth.

al tissue a p p e a r s n o r m a l . H i g h e r magnification failed to
d e m o n s t r a t e any harmful effects of the E r : Y A G laser on the
pulpal tissue. T h e lack of increased vascularity or of inflammatory cells and the a b s e n c e o f disruption o f t h e o d o n t o blastic layer s u g g e s t s no h a r m to t h e p u l p in this tooth.
A n o t h e r tooth treated with the E r : Y A G laser s h o w e d a
t h i c k e n i n g of t h e dentin b e n e a t h t h e laser defect. F i g u r e
1 0 - 4 s h o w s a p h o t o m i c r o g r a p h of the p u l p j u s t beneath t h e
E r : Y A G l a s e r - i n d u c e d defect. N o t e that there a p p e a r s to be
an i n c r e a s e in the d e n t i n adjacent to t h e defect. After j u s t 4
d a y s this c h a n g e w o u l d not b e e x p e c t e d . T h e c a u s e o f this
increased layer of dentin is not k n o w n .
T h e death o f o n e d o g from a n e s t h e t i c c o m p l i c a t i o n s j u s t
after the teeth w e r e irradiated permitted the a s s e s s m e n t of
the a c u t e effects of this laser on teeth. T h e teeth w e r e rem o v e d just after t h e d o g died and decalcified a n d stained.
On a h i g h - p o w e r view ( F i g . 1 0 - 5 ) t h e predentin layer j u s t
beneath the laser defect s h o w s d a r k i n c l u s i o n s that are
probably cellular c o m p o n e n t s o f o d o n t o b l a s t s . T h e s e inclusions can also be seen in the d e n t i n a l tubules j u s t a b o v e t h e
predentin layer. F i g u r e 1 0 - 6 is a view distant from the laser
ablation in the s a m e tooth s h o w i n g n o r m a l predentin and
dentin w h e r e n o i n c l u s i o n s are present. T h e e x a c t c a u s e o f
129
these c h a n g e s is u n k n o w n but o n e consideration is that the

p r e s s u r e from the E n Y A G ablation e x p l o s i o n m a y b e traveling d o w n the d e n t i n a l t u b u l e s c a u s i n g these c h a n g e s .
Extracted h u m a n teeth s t o r e d i n 5 % s o d i u m h y p o c h l o r a t e
solution w e r e also irradiated b y t h e E r Y A G laser using the
s a m e p a r a m e t e r s a s a b o v e i n t h e d o g study and evaluated
with S E M . F i g u r e 1 0 - 7 i s a n S E M p h o t o m i c r o g r a p h o f the
surface of d e n t i n that w a s cut with a high-speed dental
h a n d p i e c e : n o t e t h e patent dentinal t u b u l e s . A representative selection s h o w i n g a typical z o n e of E n Y A G irradiation
can be seen in F i g u r e 1 0 - 8 . It is e v i d e n t that the dentinal
t u b u l e s h a v e retained their patency after t h e E n Y A G laser
irradiation. T h e similarity o f t h e S E M ' s p h o t o m i c r o g r a p h s
Figure 1 0 - 4 . Photomicrograph of the dentin just beneath the

E r Y A G laser hole. Note the increased dentin in the area beneath
the laser hole. (X 100 H&E.)
Figure 10-2.
stain.)
Normal pulpal and dentin histology. (X100 H&E
Figure 1 0 - 3 . Pulpal histology beneath an Er:YAG laser hole

(right). (X100 H&E.)
Figure 10-5. Higher power view of the predentin layer just beneath the laser hole. Note the dark inclusions in the predentin.
( X 4 0 0 H&E.)
130
Figure 10-6. Higher power view of the predentin layer in an

area not affected by the laser. (X400 H&E.)
Figure 10-8. SEM photomicrograph of dentin ablated with an

EnYAG laser (X 1200 longitudinal section).
Figure 10-7. SEM photomicrograph of dentin cut with a highspeed dental drill (X1000 longitudinal section). (All SEM photographs are courtesy of Dr. S. Ashrafi.)
Figure 10-9. SEM photomicrograph of dentin ablated with an

EnYAG laser (X500 cross section).
of the dental h a n d p i e c e and laser-treated dentin m a y suggest that t h e laser affects dentin in a w a y similar to c o n v e n tional high-speed turbine tissue r e m o v a l . F i g u r e 1 0 - 9 is a
cross section o f dentin treated with the E n Y A G laser.
A g a i n , the patent d e n t i n a l t u b u l e s a r e o b v i o u s . R e s e a r c h
p e r f o r m e d by Visuri et al. from N o r t h w e s t e r n University
(Evanston, II) and the a u t h o r have repeated s o m e of the projects p e r f o r m e d by Hibst and Keller with w a t e r a d d e d as a
coolant.
O u r studies s h o w e d that a t t h e p o w e r n e c e s s a r y
for effective ablation of teeth and dental m a t e r i a l s ( 1 5 0 - 6 5 0
m J / p u l s e ) s o m e heat i s p r o d u c e d b y the E n Y A G laser. T o
prevent this i n c r e a s e in t e m p e r a t u r e , w a t e r w a s used as a
c o o l a n t . B e c a u s e w a t e r a b s o r b s the 2 9 4 0 - n m w a v e l e n g t h
very efficiently, there w a s c o n c e r n a b o u t h o w t h e w a t e r
might affect ablation efficiency.
T h e first series of studies w a s d e s i g n e d to e v a l u a t e t h e
ablation efficiency o f t h e E n Y A G laser. T o a c c o m p l i s h this
holes w e r e c r e a t e d with t h e E n Y A G laser and then dental
i m p r e s s i o n s w e r e taken o f these holes. T h e silhouettes o f
these i m p r e s s i o n s w e r e then projected on a grid for quantifi-
c a t i o n . Extracted m o l a r teeth w e r e used and t h e buccal surfaces w e r e irradiated with the b e a m p e r p e n d i c u l a r to the
surface. T h e e n e r g y p e r pulse w a s varied and a pulse width
of 2 5 0 u,s with an 800-p.m spot size w a s used. Figure 1 0 - 1 0
is a p h o t o g r a p h of t h e ablation holes created in t h e enamel
of the buccal surface of an extracted m o l a r tooth. T h e lack
of c h a r is evident. A p h o t o m i c r o g r a p h of the S E M (Fig.
1 0 - 1 1 ) of similar holes s h o w s well-defined holes in the
e n a m e l . F i g u r e 1 0 - 1 2 is an i m p r e s s i o n of the ablation holes
and F i g u r e 1 0 - 1 3 is t h e projected i m a g e of t h e impressions
o f t h e s e holes. T h e results s h o w e d that t h e a m o u n t o f material r e m o v a l is directly proportional to the e n e r g y deposited
on the tooth. As noted in t h e g r a p h (Fig. 1 0 - 1 4 ) at high energy ( 6 2 6 m J / p u l s e ) 115 u.m of material w a s r e m o v e d per
p u l s e . A t l o w e r e n e r g y ( 1 8 7 m J / p u l s e ) 2 2 p m o f material
w a s r e m o v e d . T h e next study e v a l u a t e d the ablation effic i e n c y and t e m p e r a t u r e c h a n g e s o f the E n Y A G laser o n
d e n t a l h a r d tissues. S e c t i o n s of extracted h u m a n teeth were
c u t into k n o w n t h i c k n e s s e s and ablated with the E n Y A G
laser. A t h e r m o c o u p l e w a s placed on the side o p p o s i t e the
Figure 10-10.
lack of char.
Ablation holes from an extracted tooth. Note the
Figure 10-13.
10-12.
131
Projected image of the impression from Figure
MEAN DEPTH
PER PULSE
pm/ pulse
Figure 1 0 - 1 1 . SEM photomicrograph of Er:YAG laser holes in

the buccal surface of an extracted tooth.
Figure 10-14. Table of ablation efficiency from the impression

method in Figure 10-13.
Figure 10-12.
ablation holes.
ablation surface. Figure 1 0 - 1 5 is a p h o t o g r a p h of the setup

design of the e x p e r i m e n t . A stream of w a t e r w a s directed to
t h e area of the laser b e a m and t h e How rate of w a t e r v o l u m e
w a s controlled. D u r i n g the ablation process the t e m p e r a t u r e
of the tooth w a s d e t e r m i n e d without w a t e r flow and then
with w a t e r directed at the spot of the ablation. Figure 1 0 - 1 6
is a p h o t o g r a p h of the ablation p l u m e during the ablation of
dentin with t h e laser b e a m c o m i n g from t h e left and Figure
1 0 - 1 7 is a p h o t o g r a p h of the holes that w e r e created by the
laser in t h e c r o s s - s e c t i o n a l slice of d e n t i n .
In o u r s t u d i e s the effect of t h e E r : Y A G laser on dental
a m a l g a m and c o m p o s i t e m a t e r i a l s w a s also studied. Dental
a m a l g a m is a mixture of a n u m b e r of m e t a l s , including
silver, z i n c , c o p p e r , and tin, that a r e mixed with m e r c u r y to
form a material that hardens a short t i m e after m i x i n g .
Dental impression from a tooth after Er:YAG
1 32
Figure 10-15. Laboratory setup for the study of dentin ablation.
Figure 1(1-17. Ablation holes created in dentin sections from

extracted teeth with the E n Y A G laser.
Figure 10-16.
laser.
Plume from dentin ablation with the E n Y A G
Figure 10-18. Ablation holes created in amalgam sections with

the E n Y A G laser.
C o m p o s i t e s are tooth-colored dental materials that are used

as restorative materials for dental restorations w h e n aesthetics are a c o n c e r n . T h e y are a blend of acrylic and q u a r t z
particles that are placed in cavity preparations in teeth to restore defects c a u s e d by dental d e c a y . A n y laser that will be
used to cut dental hard tissues must also r e m o v e the existing materials in teeth being p r e p a r e d for r e s t o r a t i o n s .
For this study c o r e s of these m a t e r i a l s w e r e a b l a t e d by an
E n Y A G laser. T h e ablation efficiency o f the laser w a s d e termined with and without water. T h e m e t h o d used w a s
similar to that for the dentin ablation study s h o w n in Figure
1 0 - 1 5 . T h e a m a l g a m ablation p l u m e w a s rather large and
similar in size with and without water. Of great interest for
study a r e the p r o d u c t s c r e a t e d w h e n a m a l g a m is a b l a t e d .
Studies a r e n o w u n d e r w a y t o a n a l y z e the p l u m e b y - p r o d ucts and to e v a l u a t e their possible toxic effect to patient and
treatment team m e m b e r s . Figure 1 0 - 1 8 is a p h o t o g r a p h of
the ablation holes created by the E n Y A G laser. T h e three
holes w e r e created at different p o w e r s and t h e effect w a s
not influenced by the water coolant.
Figure 1 0 - 1 9 is a p h o t o g r a p h of the ablation holes created in dental c o m p o s i t e restorative material with and without w a t e r c o o l a n t . T h e hole on the right was cut without
water. N o t e the char that was caused by the laser. T h e hole
on the left w a s created with the laser using water as a
c o o l a n t . It has a well-defined b o r d e r and no char is evident.
It is a p p a r e n t that t h e w a t e r m a d e a d r a m a t i c difference
w h e n it w a s used in the c o m p o s i t e ablation studies
T h e results of the ablation efficiency and the thermal effects on t h e different materials tested (dentin, e n a m e l , amalg a m , and c o m p o s i t e ) w e r e very similar. Therefore, the composite ablation results are presented here as a s u m m a r y of
the laser effects on the materials tested. Figure 1 0 - 2 0 is a
graph of the t e m p e r a t u r e c h a n g e s that o c c u r r e d as the ablation p r o g r e s s e d t h r o u g h the s a m p l e . As the ablation progressed the hole b e c a m e d e e p e r and closer to the thermoc o u p l e . T w o e n e r g y levels w e r e used with and without
water. T h e results s h o w that as the ablation hole deepens
the t e m p e r a t u r e rises w h e n w a t e r is not used. T h e rate of
this rise is a l m o s t the s a m e for the t w o e n e r g y levels. The
Figure 10-19. Ablution holes created in composite sections with

the Er:YAG laser. With water (L); without water (R).
133
Figure 1 0 - 2 1 . Graph of the ablation rate as the fluence and

water are varied.
other, s u g g e s t i n g that water has very little effect at the

h i g h e r fluences.
F r o m a patient s u r v e y , in this a u t h o r ' s practice, 7 0 %
would like a laser to be d e v e l o p e d that could replace the
dental drill. T h e ultimate q u e s t i o n is w h e t h e r a laser can be
d e v e l o p e d that can ablate at a s p e e d similar to the highs p e e d air t u r b i n e dental h a n d p i e c e (drill) that is used by
d e n t i s t s t o d a y , a n d w h e t h e r a laser will be better tolerated
by patients.
DENTAL CARIES SUSCEPTIBILITY
Figure 10-20. Graph of the temperature changes as the ablation

progressed through the sample with and without water.
m a x i m u m t e m p e r a t u r e of a b o u t I 7 C o c c u r r e d j u s t as the
laser penetrates t h r o u g h the s a m p l e . W o r k by Z a c h and
C o h e n h a s s h o w n that if t h e t e m p e r a t u r e of the tooth rises
more than 5C the p u l p m a y b e h a r m e d . W h e n w a t e r w a s
used during ablation the t e m p e r a t u r e did not rise by m o r e
that 3C.
Figure 10-21 is a graph of the ablation rate as the e n e r g y
(fluence) and w a t e r flow w e r e varied. T h e a m o u n t of ablation w a s r e c o r d e d as the increase in depth of the hole per
pulse. As can be seen in the g r a p h , w a t e r slightly r e d u c e s
the c o m p o s i t e ablation efficiency at l o w e r fluences. T h e
graph s h o w s that at h i g h e r flow rates m o r e e n e r g y w a s n e c essary for equal a b l a t i o n . H o w e v e r , after r e a c h i n g a fluence
of 60 J / c m 2 there is a c o n v e r g e n c e of the water How lines
on the g r a p h and they a p p e a r to be s u p e r i m p o s e d o v e r each
1 9
T h e effects of the infrared laser (9.0 to 11 p m ) on dental

hard tissues and on denial c a r i e s susceptibility has been investigated. 2 0 - 2 3 T w o c o m p o n e n t s o f dental hard tissues,
w a t e r and h y d r o x y a p a t i t e , h a v e a m o d e r a t e to high a b s o r p tion in this area of the s p e c t r u m . B e c a u s e of the moderate to
high absorption in these s u b s t a n c e s infrared lasers h a v e
been s h o w n to c a u s e less t h e r m a l d a m a g e to hard tissues.
For h y d r o x y a p a t i t e there a r e strong spectral absorption
p e a k s a t 9 3 0 0 and 9 6 0 0 n m , which a r e close t o the main
C O , e m i s s i o n of 10.6(H) nm. B e c a u s e o n e of the major c o m p o n e n t s of dental hard tissues is h y d r o x y a p a t i t e , it s e e m s
that there is a potential for these laser w a v e l e n g t h s lo cut
hard tissues efficiently. C o m b i n e d with t h e high water a b sorption of h y d r o x y a p a t i l e in the 9 . 3 - to 1 0 . 6 - p m region, it
s e e m s that this area of the s p e c t r u m m a y have a role to play
in hard tissue ablation. F e a t h e r s t o n e and N e l s o n 2 4 and othe r s u s e a l o w - p o w e r e d C 0 2 laser preferably tuned t o the
highly a b s o r b e d 9 . 3 - and 9 . 6 - p m w a v e l e n g t h s o n extracted
teeth leading to a reduction in the acid d e m o r a l i z a t i o n in
s e c t i o n s of e n a m e l . T h e y s u g g e s t that the l o w - p o w e r laser
h a s an effect on the c a r b o n a t e ion in e n a m e l by dramatically
r e d u c i n g its c o n t e n t in the h y d r o x y a p a t i t e crystal in e n a m e l ,
t h e r e b y m a k i n g this crystal less susceptible to d e m i n e r a l i z a -
134
tion by bacterial acids. T h e s e c h a n g e s are c a u s e d by a thermal effect; h o w e v e r , the authors state that the actual m e c h a nism of action is still not clear. W h e t h e r this s a m e effect
will be seen in v i v o has yet to be d e t e r m i n e d .
LASER DENTAL DECAY DETECTION AND

OPTICAL PROPERTIES OF TEETH
2 h
Z a c h a r i a s e n et a l .
and K o n i g et a l . investigated t h e use
of lasers to d i a g n o s e e n a m e l d e c a y . T h e y found that w h e n a
laser is used to irradiate the e n a m e l of teeth c a r i o u s lesions
will fluoresce. It is not u n d e r s t o o d w h y this o c c u r s , but the
authors suggest it m a y be d u e lo the bacteria present in the
lesion. Certain bacteria contain p o r p h y r i n s in their cell
walls that fluoresce w h e n certain w a v e l e n g t h s of light are
used. T h i s characteristic may play a role in d i a g n o s i n g
caries before the lesions are d e t e c t a b l e clinically. In a n o t h e r
related study on hard-tissue laser effects A l t s c h u l e r et a l .
r e v i e w e d the optical p r o p e r t i e s of teeth. T h e i r m o d e l suggests thai the e n a m e l p r i s m s and d e n t i n a l tubules may affect
laser light before the light is a b s o r b e d by t h e tissues. For instance, the dentinal tubules may act as g u i d e s directing the
laser e n e r g y to the p u l p of the tooth being treated. T h i s directed and possibly c o n c e n t r a t e d laser e n e r g y m a y c a u s e
d a m a g e to the pulpal tissue instead of to the hard tissues at
which the e n e r g y is being directed. T h e optical p r o p e r t i e s of
teeth m a y c a u s e u n w a n t e d d a m a g e t o teeth and require
m o r e study for a better u n d e r s t a n d i n g of their possible influence.
2 7
LASER DENTAL MATERIALS PROCESSING

A n o t h e r clinical application of lasers is in c u r i n g dental
c o m p o s i t e restorative materials. R e s e a r c h by Powell et al.
s h o w e d that c o m p o s i t e materials e x p o s e d lo argon laser
light ( 4 8 8 nm) required shorter c u r i n g t i m e s than for c o n ventional w h i t e light s o u r c e s . T h e laser-cured m a t e r i a l s also
had a better bond strength to dentin at its interface with t h e
c o m p o s i t e . Kelsey et al.
investigated t h e physical properties of the c o m p o s i t e materials c u r e d with t h e a r g o n laser
and found them to be e n h a n c e d o v e r c o n v e n t i o n a l m e t h o d s .
B l a n k e n a u et a l , reported c o n s i d e r a b l e difference in the
physical properties as the t i m e b e t w e e n c u r i n g and testing
increased. T h e y s u g g e s t e d that the a u t o p o l y m e r i z a t i o n of
the c o m p o s i t e w a s a factor in t h e differences s e e n . T h e
F D A has cleared t h e use of the argon laser as a light source
for the p h o t o p o l y m e r i z a t i o n of dental c o m p o s i t e materials.
T h e r e is s o m e c o n t r o v e r s y r e g a r d i n g w h e t h e r the laser provides a d e q u a t e benefit to c o m p e n s a t e for its m u c h h i g h e r
cost.
b u r g , S w e d e n ) for the welding of dental implant supported

bridges with a N d : Y A G laser. T h e m e t h o d thai is presently
being used by dental laboratories for bridge assembly is eit h e r c a s t i n g of a bridge in total or soldering c o m p o n e n t s to
fabricate the b r i d g e . Both of these t e c h n i q u e s can cause
s h r i n k a g e of t h e metal and distortion of the bridge. Using
the m e t h o d d e v e l o p e d by N o b e l p h a r m a . twin N d : Y A G
laser b e a m s weld the c o m p o n e n t s on either side of the joint
at the s a m e t i m e , thereby a v o i d i n g the differential shrinkage
that n o r m a l l y o c c u r s w h e n w e l d i n g is performed sequentially instead of s i m u l t a n e o u s l y . T h e s i m u l t a n e o u s welding
of t h e t i t a n i u m pieces e n h a n c e s the precise adaptation of
these implant bridges to the underlying implants. This
method r e d u c e s distortion and therefore increases accuracy
o f fit."
T h e laser s y s t e m , d e v e l o p e d by N o b e l p h a r m a Industries,
is a flashlamp p u m p e d N d : Y A G laser in which t w o laser
b e a m s are directed to t h e titanium bridge, which is then
w e l d e d by t h e laser. B e c a u s e of the t e n d e n c y for the titan i u m to d e v e l o p an o x i d e layer, the welding must occur
u n d e r an a t m o s p h e r e of argon gas. T h i s a t m o s p h e r e assures
that the weld joint is o x i d e free and of m a x i m u m strength.
W i t h the lens system and m i r r o r focal point used in this proprietary s y s t e m a weld 6 0 0 to 8 0 0 pm d e e p is generated at
t h e j o i n t . T h e e n e r g y p r o v i d e d from the laser melts each
piece of titanium on either side of the j o i n t . As the metal
c o o l s the t w o pieces of titanium j o i n together. T h i s method
is different from the s o l d e r i n g m e t h o d s presently used bec a u s e with the laser similar metals are w e l d e d , whereas in
s o l d e r i n g i m p u r i t i e s (flux) and dissimilar metals are soldered, w h i c h can lead to a w e a k e r j o i n t . T h i s welding technique may be a p p l i e d even to a c o m p l e t e arch bridge.
Preliminary investigational work s u g g e s t s exciting areas
of investigation for lasers in dentistry. Lasers h a v e the potential for d e t e r m i n i n g the vitality of a tooth based on the
c h a n g e s o b s e r v e d from laser irradiation on the buccal surface of a vital versus a nonvital tooth that can be detected
by a laser. N o n i o n i z i n g laser light has the potential for replacing the radiation n o w used to m a k e dental radiographs.
Lasers also m a y be used as a light source in conjunction
with a m i c r o s c o p e to e v a l u a t e the v a s c u l a t u r e of the ging i v a in v i v o to d i a g n o s e a c t i v e periodontal d i s e a s e . The
potential for laser a p p l i c a t i o n s in dentistry portends an exciting future.
3 0
Lasers h a v e been used extensively in industry for cutting

and w e l d i n g o f m e t a l s . N e w t e c h n o l o g y h a s been d e v e l o p e d
b y N o b e l p h a r m a Industries ( N o b e l p h a r m a A B . G o t h e n -
REFERENCES
1. Stem RH. Sognnaes RF. Laser beam effect on dental hard tissues. J Dent Res I964;43(suppl to no. 5):873 (abstract 307).
2. Stern RH, Sognnaes RF. Goodman F. Laser effect on in vitro
enamel permeabilily and solubility. J Am Dent Assoc
1966;78:838-843.
3. Lobene RR. Bhussry BR. Fine S. Interaction of carbon dioxide laser radiation with enamel and denlin. J Dent Rei
1968:47:311-317.
4. Goldman L. Hornby P. Meyer R, Goldman B. Impact of the
laser on dental caries. Nature 1964:203:417.
11
Phototherapy with Lasers and Dyes
Dan }. Castro, Romaine E. Saxton, Jacques Soudant
For years s u r g e r y a n d / o r radiation therapy h a v e been the

therapy of choice for the Successful treatment of superficial
malignancies. H o w e v e r , each of these m o d a l i t i e s is either
invasive or destructive with s o m e morbidity and restriction
of further therapeutic options if and w h e n recurrent d i s e a s e
occurs.
T h e p i o n e e r of m o d e r n p h o t o t h e r a p y in d e r m a t o l o g y w a s
F i n s e n in 1 9 0 1 , w h o s e e x t e n s i v e e x p e r i m e n t s on the treatment of skin t u b e r c u l o s i s with natural and artificial ultraviolet ( U V ) radiation stimulated the current interest in cutan e o u s p h o t o b i o l o g y . T h e first medical use of c h e m i c a l l y
e n h a n c e d p h o t o t h e r a p y (other than for restoration of pig-
Laser p h o t o t h e r a p y with d y e s (activated by specific

w a v e l e n g t h s of light) m a y b e c o m e an attractive adjunctive
modality for treatment of superficial m a l i g n a n c i e s w h e n
fluorochromes with high t u m o r specificity and low s y s temic toxicity are d e v e l o p e d . T h i s t e c h n i q u e is simple and
minimally invasive, with a potentially high effective c u r e
rate and l o w morbidity. M o s t of these t r e a t m e n t s can be
performed as outpatient p r o c e d u r e s thereby r e d u c i n g the
cost of hospitalization. B e c a u s e lasers are n o n i o n i z i n g
b e a m s , ' superficial t u m o r s can be treated repeatedly by e n doscopically delivered laser fiberoptics. T h i s is particularly
attractive because surgery a n d / o r radiation t h e r a p y m a y still
be used if and w h e n recurrent d i s e a s e o c c u r s .
In the last t w o d e c a d e s , the field of p h o l o d y n a m i c therapy ( P D T ) has regained popularity, specifically since the
introduction of lasers by M a i m a n , ' the recent clinical evaluation of h e m a t o p o r p h y r i n d e r i v a t i v e s , t h e current e x p e r i mental testing o f r h o d a m i n e - 1 2 3 , and m e r o c y a n i n e 5 4 0
as p h o t o s e n s i t i z e r s for the treatment of superficial m a l i g nancies.
m e n t a t i o n ) w a s reported by J e s i o n e k and T a p p e i n e r " in

1905. T h e s e pioneers in the study of p h o t o d y n a m i c therapy
treated five basal cell c a r c i n o m a s by injecting eosin into the
t u m o r and e x p o s i n g it to light; three cures w e r e reported.
H a x t h a u s e n and H a u s m a n n ' " in 1908 w e r e the first to suggest that h e m a t o p o r p h y r i n w a s a p h o t o d y n a m i c photosensitizer. T h i s finding w a s c o n f i r m e d in 1913 by M e y e r - B e t z .
w h o injected h i m s e l f intravenously with h e m a t o p o r p h y r i n
and b e c a m e highly sensitive to light for 2 m o n t h s , proving
that these c o m p o u n d s can induce systemic pholosensitization in m a n . Filially, in 1925 G o e c k e r m a n successfully
used t h e p h o t o t o x i c effects of coal tar. together with U V radiation, to treat psoriasis.
U 7
12
ls
1 6
PHOTODYNAMIC THERAPY
Laser p h o t o t h e r a p y can be further s u b d i v i d e d into t w o

major areas: P D T and p h o t o d i a g n o s t i c i m a g i n g ( P D I ) . Both
are used for eradication and i m a g i n g of c a n c e r s . E a c h of
these potential applications will be r e v i e w e d .
HISTORY
This first use of light-sensitive s u b s t a n c e s ( p s o r a l e n s ) in the
treatment of d i s e a s e can be traced back o v e r 6 0 0 0 years to
the ancient Egyptians.'' C r u s h e d leaves from plants related
to parsley w e r e rubbed o v e r an area of d e p i g m e n t e d skin
before e x p o s u r e to t h e s u n ' s r a y s lo p r o d u c e a severe form
of sunburn only in the treated a r e a s . After resolution of the
sunburn the skin would return to its natural color. Reference
to the use of a plant extract for the restoration of skin pigmentation w a s m a d e in 1400 B . C . , ' " and p h o t o t o x i c effects
of psoralens w e r e described in 1250 A . D . "
Definitions
P h o t o d y n a m i c t h e r a p y c o n s i s t s of the administration of a
p h o t o s e n s i t i z i n g a g e n t , i.e., a c h e m i c a l at e x t r e m e l y low
and n o n t o x i c c o n c e n t r a t i o n s that is a b s o r b e d selectively by
living tissues. T h i s " s e n s i t i z e d " tissue is then e x p o s e d in the
p r e s e n c e of o x y g e n to a light source of a specific w a v e length, w h i c h results in the destruction of this tissue.
Mechanisms
of Photooxyfienulion
M a n y c h e m i c a l s , including natural cell constituents, can a b s o r b light and by p h o t o c h e m i c a l reactions d a m a g e Ihe org a n i s m . T h i s p r o c e s s , c a l l e d " p h o t o d y n a m i c a c t i o n " requires o x y g e n and it d a m a g e s biologic target m o l e c u l e s by
p h o t o o x i d a t i o n . B i o c h e m i c a l effects include e n z y m e d e a c t i vation ( t h r o u g h d e s t r u c t i o n of specific a m i n o a c i d s , particularly m e t h i o n i n e , histidine. and t r y p t o p h a n ) , nucleic acid
oxidation (primarily g u a n i n e ) , and m e m b r a n e d a m a g e (by
oxidation of unsaturated fatty acids and c h o l e s t e r o l ) . Photosensitized oxidation is initiated by t h e absorption of light by
a sensitizer, w h i c h can be a d y e or p i g m e n t , a ketone or
137
1 38
q u i n o n e . o r a n a r o m a t i c m o l e c u l e . T h e sensitizer ( S e n s ) , b y
c a p t u r i n g a photon, is elevated to a h i g h e r e n e r g y state
w h e r e it m a y n o w act as an oxidizer.
T h e r e are t w o m e c h a n i s m s of p h o t o s e n s i t i z e d o x i d a t i o n ,
t y p e I and t y p e II. that are a l w a y s in c o m p e t i t i o n . F a c t o r s
that govern the c o m p e t i t i o n include o x y g e n c o n c e n t r a t i o n ,
the reactivities of the substrate and sensitizer excited state,
substrate c o n c e n t r a t i o n , and singlet o x y g e n lifetime.
High sensitizer reactivity, high substrate reactivity and
c o n c e n t r a t i o n , l o w o x y g e n c o n c e n t r a t i o n , and short singlet
lifetimes favor the t y p e I m e c h a n i s m , w h i l e the o p p o s i t e
factors favor the t y p e II.
Hematoporphyrin Derivitives
of H P D and red light ( 6 3 0 n m ) , a w a v e l e n g t h selected for

optimal activation o f H P D , w h i c h also allowed m a x i m u m
penetration t h r o u g h tissue ( 1 - 2 c m ) as is necessary for this
m e t h o d to be useful for c a n c e r therapy. T h e most important
point c o m m o n to both the d i a g n o s t i c and therapeutic photoradiation s y s t e m s e m p l o y e d with H P D is the requirement
for sufficient a m o u n t s of light to reach t u m o r target sites. In
addition, detection of t u m o r fluorescence is simplified when
the e x c i t i n g light is both c o h e r e n t and of a different wavelength from the fluorescence e m i s s i o n of the tumor. Lasers
are o n e t y p e of light that can satisfy these conditions.
C u r r e n t clinical applications of H P D for P D T have foc u s e d on a c c e s s i b l e superficial m a l i g n a n c i e s , including canc e r o f t h e l u n g , 2 3 , 2 4 b l a d d e r , 25 vagina and cervix, gastrointestinal tract,26 p r i m a r y and metastatic skin c a n c e r s , and
t u m o r s of t h e head and neck (laryngeal b a s e of tongue,
palatal, and floor of m o u t h t u m o r s ) . 2 2 - 2 9 In a series of tum o r s treated with H P D and laser light, P D T has shown
therapeutic effects.
T h e depth of tissue d e g e n e r a t i o n d u e to this therapy was
influenced by the e n e r g y d o s e delivered to the treated
tumor. At the s a m e e n e r g y level, greater therapeutic effects
w e r e o b t a i n e d w h e n the light e x p o s u r e w a s performed 96 to
168 h o u r s after H P D a d m i n i s t r a t i o n than after 24 to 72
h o u r s . H o w e v e r , therapeutic effectiveness varies according
to e a c h lesion, e v e n in the s a m e patient. Thus the inconsistent r e s p o n s e implies that laser-tissue interactions and
d o s i m e t r y r e m a i n as areas r e q u i r i n g further study.
T h e initial e n t h u s i a s m g e n e r a t e d by the early successful
results o b s e r v e d in patients treated with H P D and laser light
w a s d i m i n i s h e d substantially by its side effects and other
treatment l i m i t a t i o n s . 3 0 Patients must be protected with adeq u a t e c l o t h i n g or s u n s c r e e n s against any sunlight and cannot even v e n t u r e o u t s i d e or sit near a w i n d o w d u r i n g this
period. Pain is a n o t h e r c o m m o n side effect, particularly involving t h e c a l v a r i u m , with patients frequently experiencing s e v e r e h e a d a c h e s after light a c t i v a t i o n . 30 In addition.
H P D has been s h o w n to exhibit nonspecific uptake by inflammatory cells and t r a u m a t i z e d tissues, which decreases
its potential as a " t u m o r specific fluorescent d y e . " A l s o the
l o w p o w e r (milliwatt r a n g e ) of the d y e lasers used for treatment h a v e limited effectiveness for t u m o r therapy because
of limited d e p t h of tissue p e n e t r a n c e . T h e s e side effects and
limitations of H P D will p r o b a b l y remain significant limiting
factors for its future clinical applications. A variety of other
p h o t o c h e m i c a l l y active d y e s , such a s acridine o r a n g e , merc u r o c h r o m e , nitro-red. m e t h y l e n e blue, p s o r a l e n s , rose bengal, and s o d i u m fluorescein h a v e been investigated as potential p h o t o s e n s i t i z i n g agents with s o m e a d v a n t a g e s . T h e y
h a v e not p r o v i d e d an a d v a n t a g e over the use of H P D .
17
H e m a t o p o r p h y r i n derivatives ( H P D s ) w e r e recently tested

as a photosensitizcr for specific laser treatment of superficial m a l i g n a n c i e s . T h i s w a s based on o b s e r v a t i o n s that
d e m o n s t r a t e d that H P D w a s retained l o n g e r by m a l i g n a n t
tissue than by m a n y s u r r o u n d i n g n o r m a l tissues and w a s d e tectable by t u m o r f l u o r e s c e n c e . 1 7 , 1 8 T h i s s u g g e s t e d that its
activation w o u l d selectively d a m a g e only the a b n o r m a l tissue to which it had been b o u n d .
T h e c h e m i c a l c o m p o s i t i o n o f H P D h a s been s h o w n t o b e
a mixture of several p o r p h y r i n s , but until recently, the a c tive c o m p o n e n t r e s p o n s i b l e for its action w a s u n k n o w n .
T h e structure of the active e l e m e n t d i h e m a t o p o r p h y r i n e t h e r
( D H E ) w a s elucidated b y D o u g h e r t y e t a l . 2 0 i n 1979. T h e
absorption s p e c t r u m of H P D in h u m a n serum s h o w s five
major absorption p e a k s , a t 4 0 2 , 5 0 7 . 5 4 0 , 5 7 3 . a n d 6 2 4 n m ,
all of w h i c h are in the visible s p e c t r u m of light. T h e least
tissue penetration and the highest H P D absorption are at
4 0 2 n m : the greatest tissue penetration and least absorption
are at 6 2 4 n m .
1 9
Attempts to d e m o n s t r a t e c l e a r differences in affinity of

porphyrins for n o r m a l or m a l i g n a n t cells in culture h a v e
given a m b i g u o u s results. C h a n g and D o u g h e r t y 2 0 e x a m i n e d
t w o cell lines derived from n o r m a l tissue and t w o from malignant tissue u n d e r identical tissue culture c o n d i t i o n s and
they found no differences in p o r p h y r i n affinity or p h o t o d y n a m i c killing for four cell lines of different o n c o g e n i c p o tential. H o w e v e r , these results m a y h a v e been c o m p r o m i s e d
by the p r e s e n c e of H P D i m p u r i t i e s , rather than b e i n g attributable to the H P D c o m p o n e n t r e s p o n s i b l e for the in v i v o effects. In fact, the result of studies by H e n d e r s o n et a l . 2 1 indicate that the uptake kinetics of the active c o m p o n e n t of
H P D ( D H E ) a r e quite different from t h e H P D m i x t u r e .
While n u m e r o u s early reports indicated that most n o r m a l
(issues d o retain H P D , recent s t u d i e s b y G o m e r and
D o u g h e r t y 2 2 d e m o n s t r a t e d that k i d n e y , liver, and spleen of
m i c e retain m o r e H P D than d o c s a transplanted m a m m a r y
tumor.
T h e current interest in p h o t o d y n a m i c t h e r a p y s t e m s from
studies begun in 1972 by D o u g h e r t y a n d c o l l e a g u e s at
Roswell Park M e m o r i a l Institute in Buffalo. In 1 9 7 8 1 7 a n d
1979 18 this g r o u p reported clinical studies s h o w i n g that skin
m e t a s t a s e s could be eradicated with the p r o p e r c o m b i n a t i o n
Current Status of Laser Dyes

A large n u m b e r of p h o t o s e n s i t i z e r s have been tested in labo r a t o r i e s a r o u n d the world with p r o m i s i n g results. M c r o c y a n i n e - 5 4 0 is currently used in p h a s e I clinical trials for
purging t u m o r cells from a u t o l o g o u s b o n e m a r r o w grafts in

patients with l e u k e m i a , l y m p h o m a , o r metastatic n e u r o b l a s t o m a . R h o d a m i n e - 1 2 3 ( R h - 1 2 3 ) ( F i g s . 11-1 and 1 1 - 2 ) h a s
recently been a p p r o v e d for p h a s e I clinical trials in patients
with recurrent head and neck c a r c i n o m a s in o u r o w n studies
at U C L A .
Recent w o r k d o n e b y R i e s / and K r i s h n a " d e m o n s t r a t e d
the potential of sulfonated p h t h a l o c y a n i n e s as c a n d i d a t e s
for p h o t o d y n a m i c therapy. P h o t o c y t o t o x i c i t y of p h t h a l o c y a nines in m a m m a l i a n cells h a s been d e m o n s t r a t e d for vario u s cell lines, and e v i d e n c e for s i n g l e t - o x y g e n induced cell
killings h a s been reported. A l t h o u g h t h e s e l e c t i v e retention
of p h t h a l o c y a n i n e in t u m o r m o d e l s a p p e a r s to be similar to
that of h e m a t o p o r p h y r i n d e r i v a t i v e s , a l o n g e r w a v e l e n g t h
8
139
( 6 0 0 n m ) with g r e a t e r penetrating p o w e r in tissues than for

h e m a t o p o r p h y r i n has been used.
T w o g r o u p s o f p h o t o s e n s i t i z e r s w e r e synthesized recently by M o r g a n et aL T h e s e p h o t o c h e m i c a l s include the
p u r p u r i n s and their metallo derivatives. U n l i k e H P D . they
are h o m o g e n e o u s p u r e d y e s of k n o w n structure. In addition,
the p u r p u r i n s h a v e major absorption p e a k s b e t w e e n 6 3 0 and
7 1 5 n m . which are w a v e l e n g t h s c a p a b l e of d e e p tissue penetration. F r o m histologic studies in transplanted urothelial
t u m o r s , it is clear that p u r p u r i n s and m e t a l l o p u r p u r i n s are
capable of causing extensive tumor necrosis when combined with visible light.
D e t t y 3 3 at the E a s t m a n K o d a k Laboratories recently
d e m o n s t r a t e d the potential usefulness of a n e w g r o u p of
p h o t o s e n s i t i z e r s , the c h a l c o g e n a p y r i l i u m d y e s , w h i c h a r e
w a t e r s o l u b l e c a t i o n i c c o m p o u n d s with various absorption
m a x i m a b e t w e e n 7 5 0 and 8 7 5 nm. T h e c h a l c o g e n a p y r i l i u m
d y e s represent a family of related c o m p o u n d s w h o s e properties as a c h r o m o p h o r c can be d e s i g n e d by proper choice
of o r g a n i c structural substitutions, w h i c h permit control of
their w a v e l e n g t h a b s o r p t i o n m a x i m a , redox properties, f l u o r e s c e n c e yields, and hydrolytic stability. T h e s e d y e s should
be c o m p a t i b l e with c o m m e r c i a l l y available g a l l i u m arsenide lasers. H o w e v e r , recent preliminary s t u d i e s s h o w
both relatively p o o r u p t a k e and significant toxicity of the
c h a l c o g e n a p y r i l i u m s in cell cultures,
T h e k r y p t o c y a n i n e d y e E D K C has been tested b y Ara
and O h u o h a 3 5 and exhibits preferential u p t a k e b y c a n c e r
cells of various o r i g i n s , with an absorption m a x i m u m at 7 0 0
nm in saline. K o d a k Q - S w i t c h II d y e (1051 n m ) h a s recently been e v a l u a t e d 3 6 in vitro in our laboratory as a nearinfrared laser d y e with p r o m i s i n g results. Several oxazine
d y e s 3 3 an d Nile b l u e A also h a v e been tested as fluorescent
cationic d y e s . P h e o p h o r b i d e , a chlorophyll derivative with a
peak a b s o r p t i o n a t 6 7 0 n m . h a s b e e n e x a m i n e d recently b y
Segclman.38
14
x
700.9
ABS
0.0527
Wfl
UisiMe
MODE
Scan
Figure 1 1 - 1 . Absorption spectrum of rhodamine dyes (Rh-123.

Rh-6G. Rh-3G).
Future Directions: Photosensitizers and

Light Sources
T h e field of p h o t o d y n a m i c therapy with d y e s and lasers for
t h e treatment of c a n c e r m a y b e c o m e clinically useful only
after p e r f o r m i n g e x t e n s i v e drug s c r e e n i n g similar to antibiotic culture and sensitivity testing for infectious diseases. It
is e v i d e n t that there is not o n e " m a g i c " antibiotic for all infectious p r o c e s s e s . By a n a l o g y , there m a y not be o n e
" m a g i c " d y e for all m a l i g n a n c i e s , but most likely many
d y e s will be suitable, each with a specific affinity for a specific c a n c e r , p e r h a p s based on the cell line of origin. For e x a m p l e , R h - 1 2 3 a p p e a r s to h a v e p r o m i s i n g effects as a p h o tosensitizer for argon laser treatment of s q u a m o u s cell
carcinoma
(Fig.
11-3),
melanoma,
adenocarcinoma,
l e u k e m i a , and l y m p h o m a cell lines."' but h a s poor response
in m e s o t h e l i o m a and s a r c o m a cell lines." M e r o c y a n i n e 5 4 0 , on the o t h e r hand, is e x t r e m e l y efficient in leukemias,
l y m p h o m a s , and n e u r o b l a s t o m a s , but s h o w s p o o r uptake
and effects in lung and ovarian c a r c i n o m a s .
1
RHODAMINE 123
Figure 11-2.
Molecular structure of rhodamine dyes.
37
140

A rapid technological a d v a n c e in the design of diode
lasers c o u l d also open a p r o d u c t i v e new approach for investigation and clinical a p p l i c a t i o n s of P D T for several reas o n s . First, d i o d e lasers are the most efficient and stable
lasers available. S e c o n d , this t e c h n o l o g y is b e c o m i n g less
e x p e n s i v e at the s a m e t i m e that the d i o d e lasers are being
m i n i a t u r i z e d and increasing in p o w e r output.
S o m e n e w d i o d e lasers h a v e a p o w e r output of nearly 25
W from a d e v i c e s m a l l e r than a Carousel slide tray. New
tunable d y e lasers with e m i s s i o n s from the visible to the
near-infrared s p e c t r u m are c o n t i n u o u s l y being developed.
T h e s e d i o d e lasers will certainly revolutionize the field of
laser t e c h n o l o g y , and might e v e n result in the d e v e l o p m e n t
of powerful p o c k e t - s i z e p o r t a b l e lasers that might even be
d i s p o s a b l e b e c a u s e of their l o w cost.
N e w light delivery s y s t e m s for p h o t o d y n a m i c therapy are
d e v e l o p i n g at a s t a g g e r i n g p a c e . Flexible fiberoptic cables
of 2 0 0 u,m and s m a l l e r d i a m e t e r a r c currently available.
N e w fiberoptic d e v i c e s for efficient laser light dosimetry
and delivery t o t u m o r during P D T a r e u n d e r d e v e l o p m e n t t o
o p t i m i z e t h e effectiveness of this t e c h n i q u e .
Photodiagnostic Imaging with Lasers

T h e ability to localize and m a p t u m o r s has o b v i o u s o n c o logic applications for the clinician for potential identification of occult t u m o r s as well as m o r e precise t u m o r rem o v a l . T h e field of p h o t o d i a g n o s t i c i m a g i n g with laser may
be further subdivided into several potential applications inc l u d i n g laser s p e c t r o s c o p y , laser d y e fluorescence, and d y e conjugated m o n o c l o n a l a n t i b o d y imaging.
CONCLUSIONS
Figure 11-3. Argon laser phototherapy of experimental P, squamous carcinoma tumors in nu/nu mice after sensitization with Rh123. Pretreatment (A2). immediately post-laser therapy (B2), I
week (C2). and 10 weeks (D2) post-laser therapy. Complete cure
is noted in the experimental tumors (Rh-123 + laser. D2) while
continued growth is noted for control tumors ( D l ) .
W i t h the collaboration of c l i n i c i a n s , c h e m i s t s , biologists,

and p h o t o c h e m i s t s , p h o t o c h e m i c a l d y e s m a y b e " d e s i g n e d "
in the laboratory, and then tested clinically. D y e s with
h i g h e r affinity for specific n e o p l a s m s , with rapid m e t a b o lism, short half-life, and lower s y s t e m i c toxicity can then be
d e v e l o p e d . D y e s with synergistic a n d / o r a n t a g o n i s t i c effects
on various n e o p l a s m s m a y be found, and o p t i m a l l l u o r o c h r o m e s for p h o t o d y n a m i c therapy a n d / o r p h o t o d i a g n o s tic i m a g i n g with lasers can then be classified. T h e c h a l c o g e n a p y r i l i u m d y e s are a good e x a m p l e of a " d y e d e s i g n "
s y s t e m , because their absorption w a v e l e n g t h m a x i m a fluor e s c e n c e versus singlet yields, redox p r o p e r t i e s , and a q u e o u s stability can be n o w modified by c h a n g i n g different
c h a l c o g e n a t o m s and substitutions in the d y e c h r o m o p h o r e .
A n e w and e x c i t i n g a p p r o a c h to c a n c e r d i a g n o s i s and therapy m a y be d e v e l o p e d using lasers and d y e s . A n a l o g o u s to

antibiotic t h e r a p y , t u m o r c u l t u r e s m a y be initiated in the
laboratory and then tested for sensitivity to m a n y photosens i t i z e s and laser w a v e l e n g t h s . T h e optimal tumoricidal effects of laser-dye c o m b i n a t i o n s for a specific t u m o r may be
defined and then a p p l i e d clinically. W i t h the collaboration
of p h o t o c h e m i s t s , physicists, t u m o r biologists, engineers,
and c l i n i c i a n s , m a n y different photosensitizers and n e w
laser w a v e l e n g t h s will be d e v e l o p e d . T h i s m a y result in
m o r e specific d y e u p t a k e by t u m o r s and longer retention in
the target t u m o r , l o w e r s y s t e m i c toxicity, and d e e p e r tissue
penetration. T h i s c o u l d lead lo the identification of n e w
d y e s with synergislic effects that e n h a n c e the tumoricidal
effect of laser light. T h e rapid technological revolution of
m a g n e t i c r e s o n a n c e i m a g i n g , laser fiberoptics, and m a g netic r e s o n a n c e - c o m p a t i b l e p r o b e s will allow t u m o r detection and real-time m o n i t o r i n g of interstitial laser phototherapy for treatment of l a r g e - v o l u m e t u m o r s using d y e s and
lasers in a w i d e r a n g e of the e l e c t r o m a g n e t i c spectrum.
A n e w era is d a w n i n g in the d i a g n o s t i c potential of laser

d y e fluorescence, and laser-induced fluorescence s p e c troscopy is s h o w i n g p r o m i s i n g results for detection of o c cult c a r c i n o m a s . M o n o c l o n a l a n t i b o d i e s can n o w be produced with specific a n t i t u m o r b i n d i n g c a p a c i t y , be linked to
photosensitizers, and then be injected into p a t i e n t s with
cancer. S o o n it m a y be possible for the clinician to e x a m i n e
and d i a g n o s e early r e c u r r e n c e s by l o w - p o w e r illumination
of dye-stained t u m o r n o d u l e s followed by treatment with
h i g h - p o w e r laser e m i s s i o n via interstitial fiberoptics.
Exploration is j u s t b e g i n n i n g in a m o s t p r o m i s i n g n e w
area that will require further c o l l a b o r a t i v e research b e t w e e n
the clinician and basic scientist to d e t e r m i n e the usefulness
of this exciting adjuctive m o d a l i t y for t h e treatment of c a n cer and other d i s e a s e s .
11.
12.
13.
14.
15.
16.
17.
A c k n o w l e d g m e n t s T h i s study w a s s u p p o r t e d b y the Division of Head and Neck S u r g e r y , and the J o n s s o n C o m p r e hensive C a n c e r C e n t e r C I C R A w a r d , U C L A School o f
Medicine. N I H grant # U S H H S D C 0 0 3 1 , a n d N I H grant
# C A 6 5 0 5 3 - O l R . the Elsa P a r d e e F o u n d a t i o n , t h e D u P o n t Merck, E - Z E M , Inc., L a s e r s c o p e , R e s o n a n c e T e c h n o l o g y ,
O h m c d a , Inc., T r i m e d y n e , Valley L a b . Inc., I n - V i v o R e search Inc., G E Medical S y s t e m s , and the A s s o c i a t i o n d c
Recherche stir le C a n c e r ( A . R . C . , BP 3-94801 Villejuif
Cedex, France).
18.
19.
20.
21.
REFERENCES
22.
1. Muiman TH. Stimulated optical radiation in ruby. Nature
1960; 187:493-494.
2. Policard A. Etudes sur les aspects offerts pas des lumeur experimentales examinee a la lumiere de woods. CR Sac Biol
(Paris) 1924:91:1423.
3. Castro DJ. Saxton RE. Fetterman HG. Castro DJ. Ward PH.
Rhodamine-123 as a new photochemosensitizing agent with
the argon laser: "Non-thermal'" and thermal effects on
human squamous carcinoma cells in-vitro. Laryngoscope
I987;97(5):554-56I.
4. Castro DJ, Saxton RE. Fetterman HR. Ward PH. The effects
Of argon lasers on human melanoma cells sensitized with
Rhodamine-123 in-vitro. Am J Otolaryngol 1988;9( I): 18-29.
5. Castro DJ. Saxton RE. Fetterman HR. Ward PH. Phototherapy with the argon laser on human melanoma cells "sensitized" with Rhodamine-123: a new method for tumor growth
inhibition. Laryngoscope 1988:98(4):369-376.
6. Castro DJ. Saxton RE, Fetterman HR. Castro DJ, Ward PH.
Biostimulalion of human carcinoma cells with the argon
laser: a previously unreported potential iatrogenic effect of
lasers. Laryngoscope 1987;98:109-116.
7. Castro DJ. Saxton RE, Fetterman HR. Castro DJ. Ward PH.
Biostimulative effects of Nd:YAG Q-switch dye on normal
fibroblast cultures: study of a new chemosensitizing agent for
the Nd:YAG laser. Laryngoscope 19K7:97( 12): 1454-1459.
8. Gaffncy DK. Sieber F. Binding of merocyanine 540 by cells
labeled with anthroyloxy fatty acids. Photochem Photoblol
1990;49 (suppl):315.
9. Forrest JB, Forrest HJ. Case report: malignant melanoma
arising during therapy for vitiligo. J Surg Oncol
1980;13:337-340.
10. Whitney WD. Atharva-veda Samhita. (Translation and notes).
23.
24.
25.
26.
27.
28.
141
Harvard Oriental Series, vol 7. Cambridge: Harvard University Press. 1905.

Ibn El-Bitar. Mofradai Al Adwiya. Cairo: Egyptian Government Press, 1877; 1:4.
Finscn NR. Neue untcrsuchugen uber die einwirkung dess
lichtcs auf die haut. Mitt Fisen Instil 1900; 1:8.
Jesionek A. Tappeiner HV. Zur behandlung de hautcarcinome
mil
fluoresierenden Stolle.
Dtsch Arch Klin Med
1905;82:223-227.
Haxthauscn H, Hausmann W. Die lichterkrankugen der haul.
Vienna: Urban and Schwur/enberg. 1929.
Meyer-Belz F. Untcrsuchugen iiber die biologische (photodynamische). Wirkung des Hamnloporphyrins und anderer derivate des blut-und gallenfarbstoffs. Dtsch Arch Klin Med
1913:112:476-503.
Gocckerman WH. Treatment of psoriasis. North West Med
1925;24:229-231.
Dougherty TJ. Kaufman JE. Goldfarb A. et al. Photoradiation
therapy for the treatment of malignant tumors. Canter Res
1978;38:2628-2635.
Dougherty TJ. Lawrence G. Kaufman JH. et al. Photoradiation in the treatment of recurrent breast carcinoma. J Nail
Cancer Inst 1979:62:231-237.
I lay ..ia Y. Dougherty TJ. Lasers and hematoporphyrin derivative in cancer. In: Hayata Y, Dougherty TJ. eds. Cancer.
Translation by Barron P. New York: Igaku-Shoin. Tokyo;
1982:1-114.
Chang CT. Dougherty TJ. Photoradiation therapy: kinetics ol
thermodynamics of porphyrin uptake and loss in normal and
malignant cells in culture. Radial Res 1978;74:498-499.
Henderson BW, Bellnier DA. Ziring B. Dougherty TJ. Aspects of the cellular uptake and retention of hematoporphyrin
derivative and their correlation with the biological response
to PRT in vitro. In: Kessel D. Dougherty TJ. eds. Porphyrin
Photosensitizaiion. New York: Plenum Press; 1983:129-138.
Gomer CJ. Dougherty TJ. Determination of | 3 H | and | I9C|
hematoporphyrin derivative distribution in malignant and
normal tissue. Cancer Res 1979:39:146-151.
Balchum OJ. Doiron DR. Huth GC. Photoradiation therapy of
endobronchial lung cancers employing the photodynamic action of hematoporphyrin derivative. Laser Surg Med
1984;4:13-30.
Hayata Y. Kato H. Konaka C. et al. Photoradiation therapy
with hematoporphyrin derivative in early and stage I lung
cancer. Chest 1984:86:169-177.
Benson RC. Kinsey JH, Cortese DA, et al. Treatment of transitional cell carcinoma of the bladder with hematoporphyrin
derivative phototherapy. J Urol 1983:130:1090-1094.
Hayata Y. Kato H. Okitsu H, et al. Photodynamic therapy
with hematoporphyrin derivative in cancer of the upper gastrointestinal tract. Semin Surg Oncol 1985:1:1-11.
Keller GS. Doiron DR. Fisher GU. Photodynamic therapy in
otolaryngologyhead and neck surgery. Arch Otolaryngol
1985:111:758-761.
Gluckman JL, Waner M. Shumrick K. Photodynamic therapy: a viable alternative to conventional therapy for early lesion of the upper aerodigestive tract. Presented at the Joint
Meeting of the American Society for Head and Neck Surgery
and the Society of Head and Neck Surgeons entitled, "Current
Research and Clinical Concepts in Head and Neck Cancer,"
Dorado. Puerto Rico. May 5. 1985.
29. Kinsey JH. Cortese DA. Neel HB. Thermal considerations in

murine tumor killing using hematoporphyrin derivative phototherapy. Cancer Res 1983;43:1562-1567.
30. Gregory RO. Goldman L. Application of photodynamic therapy in plastic surgery. Laser Surg Med 1986;6:62-66.
31. Ricsz P. Krishna M. Phthalocyanines und their sulfonated
derivatives as photosensitizers in photodynamic therapy.
12
Laser Photothermal Therapy for Cancer

Treatment
Dan J. Castro, Romaine E. Saxton, Jacques Soudant
T h e therapeutic value of heat w a s first r e c o g n i z e d and reported in the t i m e of the ancient E g y p t i a n s m o r e than 2 0 0 0
years a g o . Breast t u m o r s w e r e treated using t h e g l o w i n g tip
of a fire drill. 1 Classical R o m a n and G r e e k p h y s i c i a n s also
were a w a r e o f t h e h o m e o s t a t i c and d e s t r u c t i v e tissue c a p a bilities of heat and used it widely in m e d i c a l p r o c e d u r e s . 2
Laser light h a s been used in a w i d e s p e c t r u m of a p p l i c a t i o n s
both in m e d i c i n e and surgery since its introduction in t h e
early 1960s. B e c a u s e m o s t w a v e l e n g t h s a r e e m i t t e d via
fiber optics, laser e n e r g y can be delivered to target sites e n doscopically a n d / o r interslitially using the p r i n c i p l e of minimally invasive s u r g e r y , w h i c h r e d u c e s c o s t of t r e a t m e n t . In
addition, b e c a u s e its e n e r g y is rapidly a b s o r b e d in tissues,
its effects are p r e d i c t a b l e , r e p r o d u c i b l e , and c o n t r o l l a b l e . Its
nonionizing characteristic simplifies safety r e q u i r e m e n t s .
With the increasing cost of health c a r e d u r i n g t h e past 20
years, a great public interest in t h e r e l a t i o n s h i p b e t w e e n
cost and quality has d e v e l o p e d . L a s e r t e c h n o l o g y h a s b e e n
permissive in t h e d e v e l o p m e n t of less i n v a s i v e but h i g h l y
effective surgical p r o c e d u r e s that r e d u c e both m o r b i d i t y
and cost. T h i s is exemplified by l a p a r o s c o p i c s u r g e r y ,
which is r e p l a c i n g " o p e n " l a p a r a t o m y , resulting in r e d u c e d
morbidity, accelerated functional r e c o v e r y , and l o w e r i n g of
cost as a m b u l a t o r y s u r g e r y has b e c o m e a safe alternative to
inpatient surgery. I m a g e g u i d e d m i n i m a l l y i n v a s i v e s u r g e r y
is a n e w c o n c e p t that uses u l t r a s o u n d ( U T Z ) a n d / o r fast
magnetic r e s o n a n c e i m a g i n g ( M R I ) t o g u i d e v a r i o u s e n e r g y
sources such as lasers, radio frequency, and ultrasonic and
c r y o t h e r a p y d e v i c e s for t h e r a p y o f d e e p t u m o r s w h i l e m o n i toring tissue c h a n g e s d u r i n g e n e r g y d e p o s i t i o n ( F i g . 1 2 - 1 ) .
T h e use of lasers as a s o u r c e of p h o t o t h e r m a l e n e r g y for
treatment of c a n c e r and o t h e r d i s e a s e s , its p h y s i o l o g i c effects, and b a c k g r o u n d a r e r e v i e w e d in this c h a p t e r .
a v a i l a b l e s e v e r e l y limits its utility, b e c a u s e t h e lowest t e m p e r a t u r e a c h i e v e d in a t u m o r m a s s is the key predictor of

treatment r e s p o n s e . 3
O t h e r m e t h o d s for i n d u c i n g localized tissue necrosis such
as topical or interstitial c r y o t h e r a p y h a v e been tested by
R a v i k u m a r et a l . 4 and Z h o u et a l . for the treatment of liver
t u m o r s . In several c a s e s both t u m o r eradication and survival
t i m e s for o t h e r w i s e untreatable t u m o r s h a v e been
i n c r e a s e d . 4 , 5 D r i t c h i l o et a l . 6 used interstitial implantation of
radioactive s e e d s in t u m o r s to i n d u c e t u m o r necrosis, b u t
t h e effect on survival w a s not clear. Livraghi et a l . 7 an d
S h i n a e t a l . 8 injected 9 5 % alcohol into t h e c e n t e r o f t u m o r s
using u l t r a s o u n d g u i d a n c e , w h i c h w a s associated with few
complications and produced tumor necrosis. This method,
h o w e v e r , is rather i m p r e c i s e and treatment o u t c o m e s are
u n p r e d i c t a b l e . C l e a r l y t h e s e t e c h n i q u e s a r e not ideal;
c r y o t h e r a p y r e q u i r e s a l a p a r o t o m y for its application, which
limits r e p e a t e d treatment, and a l c o h o l injection is subject to
imprecision in a d m i n i s t r a t i o n a n d a requirement for repeat
t r e a t m e n t s . T h e r e is an o b v i o u s need to d e v e l o p better techn i q u e s to i n d u c e t u m o r n e c r o s i s in a m o r e predictable w a y ,
w h i l e u s i n g m i n i m a l l y i n v a s i v e surgical a c c e s s and improved "real" time monitoring systems.
5
Interstitial laser therapy of t u m o r s is a p r o m i s i n g n e w a p p r o a c h b e c a u s e it is m i n i m a l l y i n v a s i v e and allows precise

and controlled delivery of p h o t o t h e r m a l e n e r g y into tissues.
H o w e v e r , it will b e c o m e clinically useful only w h e n noninv a s i v e d o s i m e t r y s y s t e m s deliver the e n e r g y in an accurate
and r e p r o d u c i b l e w a y ( F i g . 1 2 - 2 ) . Invasive m e t h o d s currently a v a i l a b l e u s e t h e r m a l p r o b e s , infrared t h e r m o g r a p h y ,
and histologic a s s e s s m e n t ,
w h i c h a r e reliable but h a v e
limited clinical a p p l i c a t i o n s .
S i n c e t h e m i d - 1 9 7 0 s , interstitial p l a c e m e n t of laser
liberoptics h a s been a p p l i e d successfully in large s u b c u t a n e o u s m e t a s t a t i c t u m o r s . " I n 1985 S v a a s a n d e t a l . d e v e l o p e d p r e l i m i n a r y optical d o s i m e t r y for interstitial p h o totherapy o f m a l i g n a n t t u m o r s . B o w n
investigated the
interstitial u s e of the n e o d y m i u m : y t t r i u m - a l u m i n u m - g a r n e t
( N d : Y A G ) laser for h y p e r t h e r m i a . M a t t h e w s o n e t a l .
used a single N d : Y A G laser fiber at l o w p o w e r ( 1 - 2 W ) , to
p r o d u c e areas of t h e r m a l necrosis in the normal rat liver
( b e l o w t h e surface), and to e r a d i c a t e i n d u c e d rat colon tum o r s and i m p l a n t e d f i b r o s a r c o m a s . H a s h i m o t o e t a l . a p plied 5 to 15 W of N d : Y A G laser p o w e r with a modified
1 2
BACKGROUND
Localized h y p e r t h e r m i a m a y b e delivered externally a n d / o r
interstitially using r a d i o frequency, ultrasound, m i c r o w a v e ,
or laser e n e r g y . W i t h all of these t e c h n i q u e s the major p r o b lem is to precisely focus t h e e n e r g y on the target tissue to
predictably induce the required cell death. T h e u n e v e n heating a c h i e v e d by local h y p e r t h e r m i a t e c h n i q u e s presently
1 3
1 4
1 5 - 1 7
1 8
143
I 44
Figure 1 2 - 1 . (A) Interstitial Nd:YAG laser treatment of a recurrent midline neck squamous cell carcinoma guided by ultrasound.
(B) The 10-MHz transducer is placed on the skin while the laser
needle is introduced transcutaneously in the tumor and its position
confirmed by ultrasonography. (C) The Nd:YAG laser is then
turned on while the ultrasound monitors the tissue effects, demonstrating a transient hyperechoic signal during energy deposition.
difluser fiber tip to treat liver t u m o r s with evidence of reduction of t u m o r size. G o d l e w s k i et a l . 1 9 , 2 0 used high-powered
N d : Y A G of up to 100 W. of 1-second duration to produce
areas of vaporization and necrosis of 16 to 22 mm in the
porcine liver. However, the high power density at the distal
end of the optical fiber resulted in frequent tip d a m a g e , burning, nonuniform distribution of laser energy, and poorly reproducible tissue effects. T h e recent introduction of synthetic
sapphire p r o b e s , 2 1
which h a v e high melting points
(202O-2050C). greater tensile strength, and a uniform pattern
of laser b e a m delivery from the probe have allowed testing of
N d : Y A G l a s e r - i n d u c e d hyperthermia in a d o g m o d e l . 2 1 , 2 2
Daiku/.ono and J o f f e 2 1 further developed a computer-controlled N d : Y A G system for intcrstital local h y p e r t h e r m i a
To i n c r e a s e the area of n e c r o s i s that could be produced
using a single laser as the e n e r g y s o u r c e , S t e g e r and
B r o w n 2 2 e m p l o y e d f i b e r - o p t i c c o u p l i n g s y s t e m s , which
a l l o w t h e insertion of multiple fibers. T h i s c o n c e p t , while
attractive, has p r o v e d difficult to a c h i e v e in practice.
Figure 1 2 - 2 . T2-weighted image of three in vivo laser lesions

made at 2(X)() J in (he normal muscle of a rabbit. Lesions were produced using 5 W X 400 sec. 10 W X 200 sec. and 20 W X 400
sec. Concentric layers of signal intensity change correspond to coagulated (dark) and interstitial edema (bright and diffused) zones.
At the core of each lesion is the center filled with interstitial fluid.
Mood, or air.
LASER TISSUE EFFECTS

T h e p h o t o b i o l o g i c effects of laser light on tissue can be s e p arated into three c a t e g o r i e s : p h o t o c h e m i c a l , p h o t o m e c h a n i cal, and p h o t o t h e r m a l . P h o t o c h e m i c a l effects depend on the
a b s o r p t i o n of light to initiate c h e m i c a l reactions such as the
Laser Photothermal Therapy for Cancer Treatment

production of reactive c h e m i c a l s p e c i e s in p h o t o d y n a m i c
therapy. It is associated with low fluence rates that do not
produce a significant t e m p e r a t u r e increase in the treated tissue, but do interact with a natural or e x o g e n o u s p h o t o s e n s i li/er to p r o d u c e the desired reaction. P h o t o m e c h a n i c a l responses o c c u r d u r i n g application of e x t r e m e l y high t l u e n c e
rates (greater than 1 0 8 W / c m 2 ) , a n d short laser pulses ( 1 0 -6
second or less), which p r o d u c e shock w a v e s and p l a s m a s .
Such effects occur, for e x a m p l e , w h e n a laser is o p e r a t e d in
the Q - s w i t c h e d m o d e .
P h o t o t h e r m a l effects result from the t r a n s f o r m a t i o n of
absorbed light e n e r g y to heat. T h e s e p h o t o t h e r m a l effects
can be further subdivided into three c a t e g o r i e s : (1) laser hyperthermia, (2) p h o t o a b l a t i o n . and (3) p h o t o c a r b o n i z a t i o n
or p h o t o e v a p o r a t i o n . In h y p e r t h e r m i a cells that are heated
to t e m p e r a t u r e s r a n g i n g from 4 0 to 4 5 C c a n sustain reversible injury that b e c o m e s irreversible ( d e a t h ) after e x p o sure from 25 m i n u t e s to several h o u r s , d e p e n d i n g on the
type of tissue and e x p e r i m e n t a l or therapeutic c i r c u m stances. Both s y s t e m i c a n d local h y p e r t h e r m i a h a v e been
tested clinically with limited s u c c e s s , mainly b e c a u s e of the
difficulties in delivering a uniform level of e n e r g y throughout the t u m o r m a s s . In addition this t e c h n i q u e is slow, c u m bersome, and difficult to a p p l y .
In photoablation. t h e tissue is rapidly h e a t e d to a r a n g e of
60 to 100C w h e r e visible w h i t e n i n g is seen, indicating
thermal c o a g u l a t i o n . T h e r m a l c o a g u l a t i o n of tissues is d e fined as t h e r m a l l y i n d u c e d , irreversible alteration of proteins and other biologic m o l e c u l e s , o r g a n e l l e s , m e m b r a n e s ,
cells, and extracellular c o m p o n e n t s that are o b s e r v a b l e with
the naked eye a n d / o r m i c r o s c o p e . Most of these alterations
are due to thermal denaturation of structural p r o t e i n s , although m e m b r a n e rupture m a y result from alterations in
lipids. By this definition, thermal tissue c o a g u l a t i o n differs
from low t e m p e r a t u r e injury in that the a l w a y s lethal c o a g u lative lesions are m a r k e d by structural c h a n g e s seen i m m e diately after heating. T h i s p r o c e s s is easier and faster to d e liver and control in tissues.
W h e n tissue t e m p e r a t u r e is raised a b o v e
100C, t h e
process of p h o t o c a r b o n i z a t i o n a n d / o r p h o t o e v a p o r a t i o n will
occur with an e x p l o s i v e f r a g m e n t a t i o n of tissue loss. S u b surface heating g e n e r a t e s b u b b l e s that eventually e x p l o d e in
a series of e v e n t s called the " p o p c o r n effect." W a t e r loss results in tissue desiccation, which radically c h a n g e s the optical characteristics of tissues and their absorption efficiency
of infrared lasers. In addition, w a t e r loss reduces the thermal conductivity and specific heat of tissues. Black char,
yellow flames, and gray s m o k e are the p r o m i n e n t p h e n o m ena characterizing the clinical u s e of the process of p h o t o carbonization.
BIOLOGIC EFFECTS OF HYPERTHERMIA

A n u m b e r of biologic m e c h a n i s m s h a v e p r o v i d e d a rationale for c o n s i d e r i n g h y p e r t h e r m i a as an a n t i t u m o r agent. At
145
a t e m p e r a t u r e r a n g e b e t w e e n 4 0 and 4 2 . 5 C , heat can inc r e a s e cell killing in a synergistic w a y following e x p o s u r e

of a t u m o r to ionizing radiation or to c h e m o t h e r a p e u t i c
d r u g s . T h i s h e a t - i n d u c e d radiosensitization is probably seco n d a r y to the inhibited repair of radiation induced D N A
lesions. B i c h e r and B r u l e y , 2 3 Dethlefse n and Dewey. 24
D i e t z e l , 2 5 H o r n b a c k . 2 6 an d S t o r m 2 7 d e m o n s t r a t e d that the
action of b l e o m y c i n . A d r i a m y c i n . and cis-platinum is enh a n c e d by heat treatment (T = 4 0 - 4 2 . 5 C ) . H y p e r t h e r m i a
acts as a c y t o t o x i c agent at t e m p e r a t u r e s higher than 42.5C
b e c a u s e cells die after heating in a t i m e - t e m p e r a t u r e - and
cell c y c l e - d e p e n d e n t m a n n e r . T h e relationship b e t w e e n the
t e m p e r a t u r e and t i m e for w h i c h it is a p p l i e d is not a simple
linear product of these t w o variables. 28 Early o b s e r v a t i o n s
of tissue h y p e r t h e r m i a w e r e m a d e in the late 1920s by
W e s t e r m a r k 2 9 and P i n c u s a n d F i s c h e r . 3 0 Moritz and Henriques studied the effects of t h e r m a l b u r n s induced in pig
skin and h u m a n s after e x p o s u r e to t e m p e r a t u r e s above
4 4 C . with heating t i m e s b e t w e e n 1 second and several
h o u r s . P i n c u s and F i s c h e r " o b s e r v e d that a b o v e 4 4 C an inc r e a s e in t e m p e r a t u r e of 1C w a s equivalent to increasing
t h e t i m e of h e a t i n g by a factor of t w o and vice versa
O n e of t h e m a i n s u b c e l l u l a r targets for h y p e r t h e r m i a is
cell m e m b r a n e p r o t e i n . 3 2 I n addition, h y p e r t h e r m i a inhibits
D N A replication and D N A and protein synthesis, and leads
to c h a n g e s in m e t a b o l i c p r o c e s s e s . D u r i n g m o d e r a t e inc r e a s e s in tissue t e m p e r a t u r e , an elevated rate of m e t a b o lism is s e e n , w h i c h is followed by an inhibition in energy
production in m o s t c e l l s . T h i s a d e n o s i n e triphosphate
( A T P ) depletion plays an uncertain role during heat-ind u c e d cell killing, because the g l y c o l y t i c pathway remains
a l m o s t unaffected for a p r o l o n g e d time. T u m o r cells are
preferentially killed in the S-phase d u r i n g hyperthermia,
specifically if their m i c r o e n v i r o n m e n t is characterized by
h y p o x i a , acidity, and e n e r g y d e p r i v a t i o n . T h i s e n h a n c e d effect of heat on t u m o r cells m a y also be attributed to blood
flow, which m a y be p o o r and sluggish in t u m o r s . In addition, b e c a u s e the perfusion rate is r e d u c e d with increasing
size of a t u m o r , 3 3 , 3 4 it results in d e c r e a s e d heat dissipation
31
and h i g h e r local t e m p e r a t u r e s for a given e n e r g y . T h e Iherm a l distribution in tissues, t h e rate of t e m p e r a t u r e rise, and
the steady state t e m p e r a t u r e are d e t e r m i n e d by multiple par a m e t e r s including thermal c o n d u c t i v i t y , specific heat
s o u r c e , blood perfusion rate, tissue extinction coefficient,
h e a t losses at e x p o s e d surfaces, and incident energy density. F a c t o r s such as optical w a v e l e n g t h s , heating conditions at the surface, and e n e r g y density can be controlled to
shift the location of the m a x i m u m rise of tissue t e m p e r a t u r e
at v a r i o u s d e p t h s . C o o l i n g at t h e surface, for e x a m p l e , will
shift the location of the m a x i m u m t e m p e r a t u r e rise from the
surface to a d e e p e r layer, previously inaccessible to the o p tical p e n e t r a t i o n of the w a v e l e n g t h used.
In most t u m o r s , a significant reduction in blood flow will
be o b s e r v e d if a p p r o p r i a t e tissue t e m p e r a t u r e levels and
heat e x p o s u r e a r e c h o s e n . H o w e v e r , despite the fact that
blood flow inhibition m a y increase the cytocidal effects of
h y p e r t h e r m i a , it m a y reduce its c h e m o t h e r a p y a n d / o r ra-
146
diosensitizing effects b e c a u s e heat d i m i n i s h e s t h e rate of

d r u g delivery and m a k e s t h e t u m o r m o r e h y p o x i c . T h e r e fore, a p p r o p r i a t e timing and s e q u e n c i n g is required w h e n
using h y p e r t h e m i a in conjunction with c h e m o t h e r a p e u t i c
d r u g s a n d / o r radiation therapy. T h e d e c r e a s e d blood flow to
the t u m o r during h y p e r t h e m i a also g e n e r a t e s a cellular m i c r o e n v i r o n m e n t that can sensitize c a n c e r cells to heat. T h e
intercellular s p a c e b e c o m e s h y p o x i c , acidic and d e p r i v e d of
nutrients, which further e n h a n c e s the c y l o c i d a l effects of
hyperthermia, thereby inhibiting the repair of the thermal
d a m a g e and the d e v e l o p m e n t of t h e r m o t o l e r a n c e .
IMAGING-GUIDED MINIMALLY
INVASIVE THERAPY
T h e c o n c e p t of i m a g i n g - c o n t r o l l e d interstitial t u m o r therapy ( I T T ) e m p l o y s M R I a n d / o r U T Z s y s t e m s t o safely
g u i d e t r a n s c u t a n e o u s p l a c e m e n t of an e n e r g y s o u r c e in a
t u m o r w h i l e a v o i d i n g s u r r o u n d i n g o b s t a c l e s , then s e r v e s a s
a monitor for t u m o r destruction in real or " n e a r " real
time.32-41
In recent years M R I h a s p r o v e n to be o n e of t h e most
useful m o n i t o r i n g t e c h n i q u e s for interstitial t u m o r thera p y . 4 2- 5 2 T h e availability o f o b l i q u e and multiplanar i m a g ing capabilities, a lack of ionizing radiation, high tissue
contrast anil resolution, the a b s e n c e of b e a m - h a r d e n i n g artifacts from b o n e , and the recent d e v e l o p m e n t of ultrafast
MR pulse s e q u e n c e s m a k e M R I particularly useful d u r i n g
minimally invasive s u r g e r y (Fig. 1 2 - 3 ) . H o w e v e r , several
limitations of current MR s y s t e m s must be resolved for its
effective and safe u s e for interventional p r o c e d u r e s . T h e
high m a g n e t i c f i e l d (1.5 T ) o f the M R e n v i r o n m e n t and the
closed cylindrical s h a p e of the m a g n e t s e v e r e l y restrict both
physical access to the patient as well as a c c e s s to the m o n i toring and treatment d e v i c e s in u s e . W i t h t h e c o l l a b o r a t i o n
of a n u m b e r of different m a n u f a c t u r e r s a variety of n e w
M R - c o m p a l i b l e d e v i c e s w e r e introduced in a standard sup e r c o n d u c t i n g 1.5 T S i g n a ( G E Medical S y s t e m s , M i l w a u kee) MRI suite p e r m i t t i n g the use of practical interventional
p r o c e d u r e s in this r o o m (Fig. 1 2 - 4 ) .
A series of 55 p a t i e n t s w e r e treated o v e r a 6 - y e a r period
( 1 9 8 8 - 1 9 9 4 ) a t t h e U C L A School o f M e d i c i n e , u s i n g the
c o n c e p t of i m a g i n g - g u i d e d m i n i m a l l y i n v a s i v e therapy.
Most patients w e r e in the fifth and sixth d e c a d e of life and
w e r e treated for palliation in an a t t e m p t to c o n t r o l s y m p t o m s such as pain, d y s p h a g i a , d y s p n e a , and b l e e d i n g . Most
treated t u m o r s ( 9 0 % ) w e r e s q u a m o u s cell c a r c i n o m a s , l o cated in different a n a t o m i c sites within t h e head and neck.
Most patients ( 8 3 % ) w e r e treated in the o p e r a t i n g r o o m
using U T Z a s t h e g u i d i n g i m a g i n g m o d a l i t y ( F i g . 1 2 - 1 ) ,
w h i l e 1 7 % w e r e treated in an u p g r a d e d interventional M R I
suite (Fig. 12^+). In 9 0 % of the c a s e s the n e o d y m i u r m y l t r i u m - a l u m i n u m - g a r n e t ( N d r Y A G ) laser w a s used either externally o r interstitially ( 6 0 0 p m b a r e fiber optic) t o p h o -
Figurc 1 2 - 3 . (A) Presurgical 3D-MR1 of a patient with an unresectable recurrent submental carcinoma. Based on laser dosimetry
study presurgical planning of the needle, introduction and position
is made on the screen. (B) Presurgical MR images of the same patient showing the needles in the tumor during energy deposition.
toablate the t u m o r s , w h i l e the C 0 laser and ultrasonic energy w e r e used in the r e m a i n i n g c a s e s . Ninety percent of
the patients w e r e treated o n a n outpatient b a s i s , with 8 0 %
s h o w i n g i m p r o v e m e n t a n d / o r resolution of s y m p t o m s after
o n e to five sessions, with a m e a n of t w o treatments. In 50 to
8 0 % o f the patients, local t u m o r " c o n t r o l " o r " c u r e " w a s
o b s e r v e d (Fig. 1 2 - 5 ) . T h i s r e s p o n s e w a s linearly related to
t h e initial t u m o r v o l u m e , histology, and g r o w t h rate.
S m a l l e r , s l o w - g r o w i n g , m o r e differentiated t u m o r s were
2
Laser Photothermal Therapy for Cancer Treatment
147
Figure 12-4. Setting of the MR suite

showing the GE Signa MR magnet (A),
the operator console (B). the Laserscope KTP:YAG laser, which is kept
outside the magnet (C). the Coherent
power meter and detector head (I)), the
l.uxtron tluoroptic thermometer ().
palliated successfully and had a "better c h a n c e " for local

cure than did rapidly d i v i d i n g m a l i g n a n c i e s . O v e r 8 0 % of
the patients h a v e s h o w n significant functional a n d / o r c o s metic i m p r o v e m e n t and w e r e a b l e to r e s u m e daily activities
for periods of up to 4 years posttreatment with a m e a n of 18
months (range: 3 m o n t h s to 5 y e a r s ) . O n l y o n e major c o m plication w a s o b s e r v e d in a c a s e early in this series. A perioperative bleed o c c u r r e d during interstitial laser e n e r g y
deposition that required e m b o l i z a t i o n . E n d o t r a c h e a l intubation w a s required to protect t h e a i r w a y . T h i s patient did
well afterward and died of acute m y o c a r d i a l infarction 4
years after her initial palliative treatment. T h e only p r e m a ture death o c c u r r e d in the first patient 3 m o n t h s p o s t o p e r a tively of unrelated c a r d i o p u l m o n a r y d i s e a s e . T h e m e a n survival for the study g r o u p w a s 18 m o n t h s .
P r o c e d u r e s w e r e carried out on inpatients using the operating r o o m and on outpatients using an M R I unit specially
equipped with a v i d e o m o n i t o r i n g s y s t e m . After o b t a i n i n g
appropriate informed c o n s e n t , the patients w e r e p l a c e d on
continuous c a r d i a c and pulse o x i m e t r y m o n i t o r i n g and then
heavily sedated or placed u n d e r general anesthesia by an
ancsthesiologst. T h e surgical f i e l d w a s p r e p a r e d and d r a p e d
in a sterile fashion, a n d t h e skin o v e r l y i n g t h e t u m o r m a s s
was anesthetized with 1% l i d o c a i n e with 1:100,000 e p i nephrine. Based upon the t u m o r v o l u m e to be treated, a
variable n u m b e r of 16-gauge M R I - c o m p a t i b l e needles (EZ - E M . Inc.) w e r e then p a s s e d p c r c u t a n e o u s l y into the
t u m o r m a s s . MRI (5 patients) or U T Z (25 patients) (Fig.
1 2 - 1 ) w a s used to c o n f i r m the position of the tip of the
catheters within the t u m o r m a s s , with special attention
given to their p r o x i m i t y to t h e great vessels and to t u m o r
neovascularity.
A 6 0 0 p m f l e x i b l e N d : Y A G laser f i b e r o p t i c cable was

then passed t h r o u g h the lumen of the needle and into the
t u m o r m a s s . N d : Y A G laser e n e r g y ( 9 0 % o f c a s e s ) w a s a p plied interstially a n d / o r externally w h i l e using T2 fast spin
echo (FSE) MRI or U T Z as a monitoring technique. The
C 0 laser ( 7 % ) and ultrasonic ( 3 % ) e n e r g i e s w e r e used externally in the r e m a i n i n g c a s e s . As tissue photoablation o c c u r r e d , the t u m o r m a s s w a s frequently irrigated with normal
saline and suctioned ( F i g . 1 2 - 1 ) . During the p r o c e d u r e att e m p t s w e r e m a d e t o either excise the t u m o r with m a r g i n s ,
d e b u l k it, a n d / o r i n d u c e p h o t o c o a g u l a t i o n necrosis and suction the d e b r i s . T h e initial t u m o r v o l u m e as calculated by
3 D - M R I a n d / o r with U T Z d e t e r m i n e d the n u m b e r of treatm e n t sessions with larger t u m o r s r e q u i r i n g multiple treatm e n t s . At the end of e a c h p r o c e d u r e a pressure d r e s s i n g
w a s a p p l i e d and t h e patients w e r e a w a k e n e d from anesthesia.
2
CONCLUSION
T h e t e c h n i q u e o f interstitial t h e r a p y guided b y M R I a n d / o r
U T Z is likely to b e c o m e a m i n i m a l l y invasive m e t h o d for
initial treatment of b e n i g n t u m o r s of the head and neck,
breast, kidney, and prostate. B e c a u s e it is performed u n d e r
local a n e s t h e s i a on an outpatient basis using a single needle
stick, it will be m u c h less e x p e n s i v e than open p r o c e d u r e s .
In addition, b e c a u s e laser light is n o n i o n i z i n g , treatment
m a y be r e p e a t e d m a n y t i m e s w i t h o u t the morbidity of
surgery a n d / o r radiation therapy. O v e r three million " o p e n "
surgical p r o c e d u r e s per y e a r are p e r f o r m e d to r e m o v e tu-
148

radio frequency, m i c r o w a v e s , c r y o t h e r a p y , ethanol injection, or interstitial radioactive seed implantation. S u c h treatm e n t s h a v e the potential to p r o v i d e meaningful palliation
for patients with a d v a n c e d head and neck c a n c e r on a costefficient, o u t p a t i e n t basis.
Acknowledgments
T h i s study w a s s u p p o r t e d b y t h e Division of H e a d and N e c k S u r g e r y , and the J o n s s o n C o m p r e h e n s i v e C a n c e r C e n t e r C I C R A w a r d , U C L A School o f
M e d i c i n e , N I H grant # U S H H S D C 0 0 3 1 , and N I H grant
# C A 6 5 0 5 3 - O l R , t h e Elsa P a r d e e F o u n d a t i o n , DuPont
M e r c k , E - Z - E M , Inc., L a s e r s c o p e , R e s o n a n c e T e c h n o l o g y ,
O h m e d a , Inc., T r i m e d y n e , Valley L a b , Inc., In-Vivo Research Inc., G E Medical S y s t e m s , a n d the Association d e
R e c h e r c h e sur l e C a n c e r ( A . R . C . , B P 3-94801 Villejuif
Cedex, France).
REFERENCES
Figure 12-5. Pre- (A) and post- (B) 3D-MR images on a patient
with a large base of skull carcinoma that was treated using the
concept of imaging-guided surgery. The patient's tumor regressed
completely and remained free of local recurrence 2 years posttreatment
m o r s of t h e head and neck, breast, k i d n e y , prostatic m a s s e s ,

and single-level d i s k d i s e a s e s . If only 1 0 % of these patients
b e c o m e c a n d i d a t e s for this t e c h n i q u e of interstitial t h e r a p y
g u i d e d by i m a g i n g t e c h n i q u e s , it c o u l d lead to substantial
s a v i n g s and benefit m i l l i o n s of patients. In t h e future, this
t e c h n i q u e m a y b e e x t e n d e d t o o t h e r d i s e a s e s such a s brain
t u m o r s , liver, c h e s t , a b d o m e n , all t u m o r m e t a s t a s e s , and
other p a t h o l o g i c c o n d i t i o n s .
T h e t e c h n i q u e s d e v e l o p e d for N d : Y A G I T T m a y b e
a d a p t a b l e to o t h e r f o r m s of m i n i m a l l y i n v a s i v e interstitial
t u m o r t h e r a p y , e m p l o y i n g lasers o f o t h e r w a v e l e n g t h s .
1. Breasted JH. The Edwin Smith Surgical Papyrus, vol 1.

Chicago: University of Chicago: 1930.
2. Milne JS. Surgical Instruments in Greek and Roman Times.
Oxford: Clarendon Press; 1907.
3. Wagner von Jauregg J. Gutachten der Wiener Medizinischen
Fakultaet. Jahrb Psychiat Neurol 19I7-18;38:1^18.
4. Ravikumar TS. Kane R, Cady B, et al. Hepatic cryosurgery
with intraoperative ultrasound monitoring for metastatic
colon carcinoma. Arch Surg 1987; 122:403-409.
5. Zhou XD, Tang ZY, Yu YQ, Ma ZC. Clinical evaluation of
cryosurgery in the treatment of primary liver cancer (report of
60 cases). Cancer 1988;61:1889-1892.
6. Dritchilo AE, Grant EG, Harter KW, et al. Interstitial radiation therapy for hepatic metastases: sonographic guidance for
applicator placement. Am J Roentgenol 1986;164:275-278.
7. Livraghi T, Salmi A, Bolondi L, et al. Small hepatocellular
carcinoma: percutaneous alcohol injection results in 23 patients. Radiology 1988; 168:313-317.
8. Shiina S, Yasuda H, Muto H, et al. Percutaneous ethanol injection in the treatment of liver neoplasms. Am J Roentgenol
1987;149:949-952.
9. Cummins L, Nauenberg M. Thermal effects of laser radiation
in biological tissue. Biophys J 1983;42:99-102.
10. Welch AJ. The thermal response of laser irradiated tissue.
IEEE J Quant Electron 1984;20:1471-1484.
11. Dougherty TJ, Lawrence G, Kaufman JH, et al. Photoradiation in the treatment of recurrent breast carcinoma. J Natl
Cancer Inst 1979;62:231-237.
12. Dougherty TJ, Kaufman JE, Goldfarb A, et al. Photoradiation
therapy for the treatment of malignant tumors. Cancer Res.
1985;38:2628-2635.
13. Svassand LO, Boerslid T, Oeveraasen M. Thermal and optical properties of living tissue: application of laser-induced
hyperthermia. Lasers Surg Med. 1985;5:589-602.
14. Bown SG. Phototherapy to tumors. World J Surg
1983;7:700-709.
15. Matthevvson K. Barr H, Tralau C, Bown SG. Low power interstitial Nd-YAG laser photocoagulation; studies in a transplantable fibrosarcoma. Br J Surg 1989;76(4):378-381.
16. Matthewson K, Barton T, Lewin MR, et al. Low power interstitial Nd-YAG laser photocoagulation in normal and neoplastic rat colon. Gut 1988;29:27-34.
13
Laser-Assisted Temporomandibular Joint

Surgery
Steven ]. Butler
A d v a n c e s in arthroscopic i n s t r u m e n t a t i o n and t e c h n i q u e for

small joint surgery h a v e recently found application in
surgery for the t e m p o r o m a n d i b u l a r joint ( T M J ) . C o u p l e d
with the advent of high-resolution m a g n e t i c r e s o n a n c e
imaging ( M R I ) the a c c u r a c y o f d i a g n o s i s o f T M J d i s o r d e r s
has been greatly e n h a n c e d . A r t h r o s c o p y of the T M J h a s
consequently progressed from an instrument of d i a g n o s i s to
one of treatment. As its usefulness for the treatment of internal d e r a n g e m e n t s , particularly n o n r e d u c i n g d i s k displacement (closed lock), h a s b e c o m e generally a c c e p t e d ,
the search for i m p r o v e d i n s t r u m e n t a t i o n h a s resulted in t h e
d e v e l o p m e n t of various laser s y s t e m s for T M J surgery. As
the safety and early s u c c e s s of a r t h r o s c o p y of the T M J b e c a m e e s t a b l i s h e d , ' c o n t i n u e d technical d e v e l o p m e n t s resulted in the refinement of surgical t e c h n i q u e . T h e s e included predictable and r e p r o d u c i b l e joint entry a n d
distension, triangulalion, and the introduction of a r t h r o scopic hand i n s t r u m e n t s and m e c h a n i z e d s h a v e r s .
As a
c o n s e q u e n c e of predictable successful o u t c o m e s with diminished m o r b i d i t y in surgery of the u p p e r T M J s p a c e ,
arthroscopic surgery has b e c o m e an alternative to open
arthrotomy for the treatment of internal joint d e r a n g e m e n t
involving the m e n i s c u s (disk). Fortunately, the d e m a n d c r e ated by the refinement of surgical skills by the profession
has resulted in the rapid r e s p o n s e by industry to p r o d u c e
arthroscopes and high-resolution v i d e o s y s t e m s that a r e
specifically d e s i g n e d for use in the T M J . C o n s e q u e n t l y ,
n e w i n s t r u m e n t s h a v e been d e v e l o p e d that permit j o i n t
entry through c a n n u l a s less that 3 mm in d i a m e t e r . Instruments for incising, s c u l p t i n g , and c a u t e r i z a t i o n of j o i n t tissues h a v e been similarly refined. H o w e v e r , they r e m a i n e d
inefficient. T h e objective of incising of a t t a c h m e n t s of the
lateral pterygoid m u s c l e to the anterior b a n d or resecting
the m e n i s c u s w o u l d be a c h i e v e d with e l e c t r o c a u t e r y but
only at the e x p e n s e of e x c e s s i v e heat d a m a g e and carbonization ( c h a r r i n g ) of the target tissue and s y n o v i u m . T h e
surgical alternative of using a mechanical s h a v e r w a s unsatisfactory because of its inefficiency and u n p r e d i c t a b l e results o c c u r r i n g as a c o n s e q u e n c e of limited access and maneuverability within the restricted confines of a small j o i n t
space.
1
small joint arthroscopic s y s t e m s in o r t h o p e d i c s resulted in

their adaptation for use in t h e T M J . ' T h e i r ability to
b l o o d l e s s l y r e m o v e tissue in a p r e d i c t a b l e , r e p r o d u c i b l e
w a y with m i n i m a l u n w a n t e d heat d a m a g e in a fluid
m e d i u m c o m p a t i b l e with g o o d vision, excellent a c c e s s , and
c o n t r o l l a b l e tissue r e m o v a l h a s m a d e this an exciting area
for
surgical
development.
Lasers,
particularly
the
h o l m i u m : y t t r i u m - a l u m i n u m - g a r n e t ( H o : Y A G ) laser emitting at 2 1 9 2 n m , a r e in u s e currently to r e m o v e d e g e n e r ated f i b r o c a r t i l a g e , s y n o v i u m , o r b o n e . T h e y a l s o a r e c a p a ble of m a k i n g releasing incisions while cauterizing
b l e e d i n g b l o o d v e s s e l s o r p h o t o a b l a t i n g the n e o v a s c u l a r ization of s y n o v i t i s .
5
THE Ho:YAG LASER
3,4
T h e d e v e l o p m e n t of miniaturized laser delivery s y s t e m s

using optical fibers and " u s e r friendly" control s y s t e m s for
T h e H o : Y A G laser is a solid-state laser e m i t t i n g at 2 1 9 2

n m , w h i c h c l o s e l y c o r r e s p o n d s with a major spectral a b sorption p e a k for w a t e r in the infrared region of the electrom a g n e t i c s p e c t r u m . T h i s laser o p e r a t e s in a pulsed m o d e at
a pulse width of 3 5 0 p s , which is well below the thermal relaxation time for m o s t tissues with high w a t e r content.
T h e r e f o r e , o n e would not e x p e c t to e n c o u n t e r significant
heat effects. In fact, K o s l i n d e m o n s t r a t e d intraarticular
t e m p e r a t u r e e l e v a t i o n s of an a v e r a g e of I 0 F (range =
1.2-22.6F) m e a s u r e d with an intraarticular t h e r m o c o u p l e
d u r i n g H o : Y A G arthroscopic surgery.
T h e H o : Y A G laser configured for arthroscopic surgery
c o n s i s t s of a free-beam laser with a sterile fiber-optic delivery s y s t e m and the a p p r o p r i a t e l y a d a p t e d arthroscope and
v i d e o s y s t e m . B e c a u s e the H o : Y A G e m i s s i o n is highly abs o r b e d by w a t e r with an a v e r a g e depth of absorption of 0.3
m m . it r e m o v e s tissue precisely. B e c a u s e the target tissue
itself h a s a high w a t e r c o n t e n t and the laser o p e r a t e s within
7
a fluid m e d i u m , there is very little u n w a n t e d thermal d a m a g e lateral to the vaporization crater. N e v e r t h e l e s s , even
with m i n i m a l u n w a n t e d heat effects the actual thermal inj u r y m a y vary from 0.1 to 1.0 mm d e p e n d i n g on tissue t y p e
and the e x p o s u r e p a r a m e t e r s of the individual laser. T a r r o "
m e a s u r e d tissue necrosis with H o : Y A G and found it to be
0.4 to 0.6 m m , w h e r e a s e l e c t r o c a u t e r y p r o d u c e d necrosis of
151
1 52
0.7 to 1.8 m m . In addition to the t h e r m a l effects the short

pulse width of 3 5 0 ps associated with high fluence rates
m a y also induce p h o t o m e c h a n i c a l and p h o t o a c o u s t i c effects
that also c o n t r i b u t e to tissue ablation.
C o m m e r c i a l l y available l o w output H o : Y A G lasers a r e
quite a d a p t a b l e for T M J a r t h r o s c o p i c s u r g e r y . Several f i b e r
delivery m e t h o d s are available. T h e specific styles and
specifications vary a m o n g m a n u f a c t u r e r s . S o m e s u r g e o n s
prefer a side firing tip to a c c e s s t h e lateral a s p e c t s of t h e
joint w h i l e o t h e r s prefer to bend the fiber slightly or use alternate port p l a c e m e n t s to reach this area. It is rare to require an output p o w e r in e x c e s s of 10 W or a post-repetition
rate ( P R R ) e x c e e d i n g 10 Hz to resect fibrocartilage or rec o n t o u r b o n e . L o w e r settings are s u g g e s t e d for m a k i n g releasing incisions. T a b l e 13-1 s u m m a r i z e s suitable e n e r g y
levels for different p r o c e d u r e s .
Laser-Assisted Temporomandibular Joint Surgery

CASE 1
153
carried out u n d e r a g e n e r a l a n e s t h e t i c using c o n v e n t i o n a l

a r t h r o s c o p i c t e c h n i q u e s a s described b y M c C a i n . T h e
m e n i s c u s w a s found t o b e anteriorly and m e d i a l l y disloc a t e d ( F i g . 1 3 - 1 ) , a n d reduction with a blunt p r o b e prod u c e d a n a u d i b l e " s n a p . " T h e H o : Y A G laser w a s used for
a n t e r i o r release and p o s t e r i o r band cauterization. T h e
laser w a s set at 8 W o u t p u t p o w e r , pulsed m o d e at 5 Hz.
T h i s resulted in a b l o o d l e s s releasing incision (Fig. 1 3 - 2 ) .
T h e laser w a s d e f o c u s e d a t the s a m e settings and w a s
u s e d to c a u t e r i z e and shrink t h e posterior tissues. A res o r b a b l e s u t u r e , O - P D S E t h i c o n , w a s passed percutaneously t h r o u g h t h e posterior b a n d o f t h e disk. T h e
entire p r o c e d u r e lasted 32 m i n u t e s and t h e total laser u s a g e
w a s less than 5 m i n u t e s . P o s t o p e r a t i v e l y , recovery w a s
uneventful and physical t h e r a p y w a s given in six sessions.
A predicted right posterior o p e n bite w a s present after
s u r g e r y and this o c c l u s a l c h a n g e w a s maintained during
the p o s t o p e r a t i v e p h a s e u s i n g a prefabricated hard acrylic
o c c l u s a l splint. Within 3 w e e k s of h e r surgery she had
r e g a i n e d a m a x i m u m o p e n i n g o f 4 2 m m with n o detectable
o p e n i n g click and 8 mm of lateral e x c u r s i v e m o v e m e n t s .
S h e reported little o r n o discomfort with mastication o r
o p e n i n g but did notice o c c a s i o n a l a b n o r m a l noises in
t h e joint, w h i c h w e r e not p r o b l e m a t i c for her. T h e patient
ultimately c h o s e c o m p r e h e n s i v e o r t h o d o n t i c treatment
to correct h e r o c c l u s i o n . S h e r e m a i n s pain free and functional since t h e n .
2
A 26-year-old w o m a n with a 5-year history of p o p p i n g in

the right T M J d e v e l o p e d a s p o n t a n e o u s l y r e d u c i n g intermittent closed lock i m m e d i a t e l y after childbirth. T h r e e m o n t h s
later she d e v e l o p e d limitation on o p e n i n g of 32 m m , and a
diagnosis of nonreducing T M J disk displacement (closed
lock) w a s m a d e . H e r r e m o t e past history i n c l u d e d b r u x i s m
and u s e of a soft interocclusal night g u a r d . S h e c o m p l a i n e d
of severe pain in her right j o i n t w h e n a t t e m p t i n g to force
her m o u t h o p e n and described a dull tight feeling in t h e
joint "all the t i m e . " T h e patient d r e w a d i a g r a m that o u t lined her pain only in the p r e a u r i c u l a r area on t h e right side.
T h e r e w a s no pain on the left s i d e . H e r e x a m i n a t i o n s
s h o w e d a m a x i m u m interincisal o p e n i n g o f 3 2 m m with
significant deviation to the right w h e n her o p e n i n g r e a c h e d
28 mm. There were no joint sounds or crepitus. She had an
angle class I m o l a r o c c l u s i o n but t h e incisors w e r e retroclined and c r o w d e d . T h e masticatory m u s c l e s on the right
w e r e slightly m o r e t e n d e r than t h o s e on the left but e s s e n tially all of her pain w a s focused in and a r o u n d t h e right
T M J itself. Joint i m a g i n g s h o w e d an a n t e r i o r dislocation of
t h e right m e n i s c u s . T h e left j o i n t w a s n o r m a l . After d i s cussing nonsurgical and surgical t r e a t m e n t alternatives s h e
c h o s e the surgical o p t i o n .
A n arthroscopic release a n d r e p o s i t i o n i n g p r o c e d u r e w a s
Figure 1 3 - 1 . Anterior and medial dislocation of TMJ mensicus.

Retrodiscal tissues are shown stretched over posterior portion of
condylar head.
Figure 13-2. Bloodless releasing incision created through synovium and superior aspect of lateral pterygoid muscle using the
Holmium:YAG laser.
1 54

CASE 2
A 46-year-old w o m a n presented with pain in and a r o u n d

her right t e m p o r o m a n d i b u l a r j o i n t . S h e had c o m p l a i n e d of
noise in the joint and intermittent e p i s o d e s of locking that
had been treated o v e r several years with v a r i o u s t y p e s of
splints with s o m e i m p r o v e m e n t i n her s y m p t o m s . S h e d e nied a history of recent t r a u m a but noticed increasing c r e p i tus and pain o v e r the past 6 m o n t h s . S h e d e s c r i b e d h e r current pain as a periodic "jolt" in her right e a r and t e m p l e area
that would be followed by a h e a d a c h e and l i g h t n e s s in her
j a w . T w o w e e k s prior t o her presentation she noted t h e
onset of inability to open her m o u t h fully and slated that her
level of pain had greally increased. Physical e x a m i n a t i o n
s h o w e d a m a x i m a l interincisal o p e n i n g of 18 mm with e s sentially no translation to the left. S h e had m a n d i b u l a r retrognathia with a d e e p bite. Palpation of t h e right p r e a u r i c u lar area d e m o n s t r a t e d c r e p i t u s and t e n d e r n e s s w h i l e the left
side w a s n o r m a l . T h e r e w e r e no areas of defined m u s c l e
tenderness. T o m o g r a m s o f the t e m p o r o m a n d i b u l a r j o i n t s
s h o w e d a small flattened m a n d i b u l a r c o n d y l e on the right.
M R I c o n f i r m e d a g r a d e IV d i s l o c a t i o n of t h e right m e n i s c u s with p o s s i b l e f r a g m e n t a t i o n . T h e left s i d e w a s n o r mal.
Arthroscopic surgery w a s c h o s e n as the t r e a t m e n t of
choice with a d i a g n o s t i c suspicion of a perforated m e n i s c u s .
T h e right T M J w a s e n t e r e d without difficulty using standard triangulation t e c h n i q u e s . " A large disruption in the
m e n i s c u s w a s seen ( F i g . 1 3 - 3 ) . T h e anterior recess c o n tained a d h e s i o n s and areas of e c c h y m o s i s and a p r o m i n e n t
b o n y p r o t u b e r a n c e on the a n t e r o m e d i a l portion of the
c o n d y l a r h e a d . C o n s e q u e n t l y , t h e d e c i s i o n w a s m a d e t o rem o v e t h e m e n i s c u s using the H o : Y A G laser. T h e laser fiber
w a s placed in the anterior portal and serial sections of
m e n i s c u s w e r e r e m o v e d and t h e joint m e c h a n i c s e v a l u a t e d
(Fig. 1 3 - 4 ) . S o m e difficulty w a s e n c o u n t e r e d in a c c e s s i n g
the most lateral aspect of the anterior joint s p a c e , a n d a
m o n o p o l a r coagulation p r o b e w a s used to isolate several
large pieces of disk. Varied e n e r g y levels and pulse settings
w e r e used r a n g i n g from 5 to 8 p u l s e s per s e c o n d at an a v e r a g e p o w e r of 8 to 10 W. B l e e d i n g w a s m i n i m a l , e v e n with
resection of the a n t e r o m e d i a l portion of t h e m e n i s c u s . After
c o m p l e t i n g the m e n i s e c t o m y (Fig. 1 3 - 5 ) , the joint w a s inj e c t e d with a 0 . 5 % b u p i v a c a i n e with dilute e p i n e p h r i n e s o lution after removal of the c a n n u l a s , and the patient r e c o v ered uneventfully. A g g r e s s i v e physical therapy w a s
initiated on the s e c o n d postoperative day and no p o s t o p e r a tive c o m p l i c a t i o n s w e r e o b s e r v e d . H e r p o s t o p e r a t i v e interincisal o p e n i n g w a s 28 mm after 5 d a y s and 34 mm after 7
w e e k s . S h e c o n t i n u e d lo h a v e a mildly d e c r e a s e d left lateral
e x c u r s i v e m o v e m e n t of the m a n d i b l e but related that although she still had s o m e mild discomfort in the j o i n t her
pain was 9 0 % i m p r o v e d and she had no restrictions in her
diet. Her occlusion d e m o n s t r a t e d p r e m a t u r i t i e s on t h e right
side and o r t h o d o n t i c follow-up w a s r e c o m m e n d e d .
2
Figure 1 3 - 3 . Large perforation of meniscus with visible deformed condylar head.
Figure 13-4. Resection of residual perforated meniscus using

the Holmium:YAG laser.
Figure 13-5. Completed laser-assisted menisectomy: View of

intact cartilidge over deformed condylar head.
CONCLUSION
A r t h r o s c o p i c s u r g e r y of t h e t e m p o r o m a n d i b u l a r joint has
b e c o m e a valuable treatment modality that is rapidly replacing open joint p r o c e d u r e s for internal d e r a n g e m e n t . While
anterior releasing incision and posterior scarification can
easily be a c c o m p l i s h e d by t h e trained arthroscopist using
e l e c t r o c a u t e r y , removal of the m e n i s c u s with conventional
shavers, and rotary i n s t r u m e n t s is tedious and inaccurate. In
Laser-Assisted Temporomandibular Joint Surgery

contradistinction, use of the laser for arthroscopic s u r g e r y
permits precise intraarticular tissue removal with excellent
h e m o s t a s i s without the resultant heat d a m a g e to tissue that
electrocautery p r o d u c e s . In addition, b e c a u s e the fiber is
smaller and m o r e m a n e u v e r a b l e than c o n v e n t i o n a l rotary
instruments, it m i n i m i z e s scuffing of c o n d y l a r surfaces. B e c a u s e t h e depth of tissue penetration is usually only 0.4 to
0.6 m m . ablation is readily confined to the a b n o r m a l menisc u s , thereby m a x i m a l l y p r e s e r v i n g the n o r m a l areas of
m e n i s c u s . C o n s e q u e n t to its excellent h e m o s t a t i c properties, postoperative h e m a r t h r o s e s h a v e been e l i m i n a t e d as a
complication of intraarticular surgery. Lasers are safe and
effective w h e n standard p r e c a u t i o n s are taken. T h e
H o : Y A G laser is a m a z i n g l y versatile, p e r m i t t i n g the perform a n c e of a w i d e r a n g e of p r o c e d u r e s on v a r i o u s tissue
types. C o n t i n u e d study of the intraarticular a p p l i c a t i o n s of
lasers will result in the d e v e l o p m e n t of m o r e s o p h i s t i c a t e d
laser s y s t e m s p e r m i t t i n g the arthroscopist of the future even
more c h o i c e s w h e n treating the d i s e a s e d t e m p o r o m a n d i b u lar joint.
155
REFERENCES
1. McCain JP, De la Rua H. Principles: practices of operative
arthroscopy of the human temporomandibular joint. Oral Maxillofac Surg Clin North Am 1989:1:135-151.
2. McCain JP. Puncture technique and portals of entry for diagnostic and operative arthroscopy of the temporomandibular
joint. Arthroscopy 1991:2:221-232.
3. McCain JP. An Illustrated Guide to TMJ Arthroscopy. And o v e r . M D : Dyonics; 1987.
4. .Sanders B. TMJ Internal Derangement and Arthrosis: Surgical
Atlas. St. Louis: Mosby; 1985.
5. Hendler BH. Ciatcno J. Mooar P. et al. Holmiuin:YAG laser
arthroscopy of the temporomandibular joint. J Oral Maxillofac
Surg 1992:50:931-934.
6. Koslin MG. Martin JC. The use of the holmium laser for temporomandibular joint arthroscopic surgery. J Oral Maxillofac
Surg 1993:51:122-123.
7. Koslin MG. Arthroscopic Laser Debridement of Perforated
Articular Disc Using the Versa Pulse Surgical Laser. Palo
A l t o C A : Coherent. 1992.
8. Tarro AW. Arthroscopy: A Diagnostic and Surgical Atlas.
Philadelphia: J.B. Lippincott: 1993.
14
Endoscopic Sinus Surgery: A Significant

Adjunct to Maxillofacial Surgery
Jeffrey J. Moses, Claus R. Lange
With the use of Le Fort osteotomies for the correction of

skeletofacial deformities there has developed within the discipline of oral and maxillofacial surgery ( O M S ) a renewed interest in the management of sinonasal pathology. As enhanced
awareness of the importance of the patency of the osteomeatal
unit ( O M U ) grew, it has b e c o m e evident that some cases of
postoperative sinusitis occurred consequent to midfacial orthognathic surgery. High-level septal deviations could lead to
distortion of the middle turbinate on the convex side of the
septum, which laterali/.es the uncinate process and hiatus
semilunaris of the infundibular outflow pathway, which subsequently also b e c o m e s tortuous. T h e s e anatomic alterations
predispose to the development of postoperative sinusitis.
O c c a s i o n a l c a s e s w e r e noted with direct interruption of
infundibular patency attributable t o inadvertent m u c o u s
m e m b r a n e synechial w e b and wall formation, o r the c r e ation of n a r r o w e d or b l o c k e d ostia in conjunction with altered a i r w a y flow patterns o c c u r r i n g after high-level Le Fort
I o s t e o t o m y . If s y m p t o m s arise, direct d i a g n o s t i c a s s e s s ment of the maxillary sinus and e n d o n a s a l structures is n o w
possible with e n d o s c o p i c t e c h n i q u e s . T h i s p e r m i t s a s s e s s ment of the mucosal and b o n y r e s p o n s e to a u t o g e n o u s , allogeneic, and alloplastic materials placed adjacent to the sinus
during surgery. Most i m p o r t a n t l y , these t e c h n i q u e s also
permit c o m p l e t e evaluation of the e n d o n a s a l a n a t o m y , e s p e cially as it relates to its p e r m i s s i v e role in sinus a e r a t i o n .
majority o f o r t h o g n a t h i c s u r g e r y patients w h o have d e v e l o p e d sinusitis p o s t o p e r a t i v e l y , t h e M e s s e r k l i n g e r a p p r o a c h

p r o v i d e s a d e q u a t e t r e a t m e n t . W i t h increasing familiarity
and s o p h i s t i c a t i o n , the application of e n d o s c o p i c e v a l u a tion of the m i d d l e m e a t u s h a s given O M S a n e w diagnosticaid to predict patients at risk for the p o s t o p e r a t i v e d e v e l o p ment of sinusitis. T h o s e with p r e e x i s t i n g sinus disease also
m a y be c o n s i d e r e d for t r e a t m e n t p r i o r to o r t h o g n a t h i c
surgery.
T h e e s s e n c e of e n d o s c o p i c s u r g e r y is to restore aeration
and mucociliary flow patterns (Fig. 1 4 - I ) . Ciliary function
is both t e m p e r a t u r e and h u m i d i t y sensitive. B e l o w I 8 C
and 50% h u m i d i t y , i m p a i r m e n t o c c u r s . If contact occurs bet w e e n m u c o s a l surfaces, as can h a p p e n w h e n the infundibular m u c o s a s w e l l s , n o r m a l ciliary beats of I0 to 15 strikes
p e r m i n u t e c e a s e altogether. S i n c e these beats are required
to m o v e the thicker m u c i n o u s blanket along the less viscous
RATIONALE FOR ENDOSCOPIC

SINONASAL SURGERY
T h e c o n c e p t o f reversibility o f sinus d i s e a s e b a s e d upon
the restoration of n o r m a l d r a i n a g e p a t t e r n s and aeration led
t o the d e v e l o p m e n t o f several surgical t e c h n i q u e s . T w o o f
these in c o m m o n u s e are the M e s s e r k l i n g e r and W i c g a n d
techniques. Messerklinger (A, B) technique evaluates and
alters structure from an a n t e r i o r to p o s t e r i o r a p p r o a c h , c o n centrating on the m a x i l l a r y , e t h m o i d a l , and frontal s i n u s e s .
In contrast, W i e g a n d ( C ) d e v e l o p e d his p a n s i n u s e v a l u a tion and treatment from p o s t e r i o r to anterior s t r u c t u r e s a s sociated with m o r e a g g r e s s i v e eradication o f t h e s a m e sin u s e s , i n c l u d i n g e x t e n s i o n t o the s p h e n o i d s i n u s . For t h e
Figure 1 4 - 1 . Coronal view of paranasal sinuses. Arrows indicate direction of normal ciliary directed mucous flow toward natural ostea.
157
158
B
Figure 14-2. (A) Diagram of stylistic oslca lumen of greater than 2.5 mm diameter indicating healthy cilia and aeration. (B) Diagram of cross section of ostca lumen with less than 2.5 mm diameter indicating paralysis of ciliary motion
and inadequate aeration potential due to mucous stagnation.
Structurally, the infundibulum r e c e i v e s d r a i n a g e from the

e t h m o i d a l , frontal, and maxillary sinuses within the hiatus
s e m i l u n a r i s which, along with the middle turbinate, occupies the m i d d l e m e a t u s . O s t i a d i a m e t e r s less than 2.5 mm
a r e p r e d i s p o s e d to infections primarily b e c a u s e of the phen o m e n o n of cilia i m p a i r m e n t s e c o n d a r y to m u c o s a l approximation (Fig. I 4 - 2 A . B ) . A d d i t i o n a l l y , d e v i a t i o n s of the superior and m i d d l e a s p e c t s of the s e p t u m , swollen or
paradoxical turbinate positioning and a n a t o m i c variations
of the uncinate p r o c e s s all can lead to obstruction of the
O M U , resulting in c h r o n i c sinus disease.
T h e focus of e n d o s c o p i c sinonasal s u r g e r y is on the mucociliary and l o w e r c o n c h a s y s t e m , and location and patency of the ostia and O M U (Fig. 1 4 - 3 ) .
1.
2.
3.
4.
Lamina p a p y r a c e a
Anterior e t h m o i d
Infundibulum
Uncinate process
5.
6.
7.
8.
Maxillary o s t e u m
Middle m e a t u s
Middle t u r b i n a t e
Inferior t u r b i n a t e
Figure 14-3. Cross-sectional coronal diagram of normal structure in the nose and osteo-meatal complex.
layer i m m e d i a t e l y adjacent lo the cilia, stasis o c c u r s , p r o viding a culture m e d i u m for bacterial infections. T h u s , t h e
c o m m o n rhinitis o c c u r r i n g after a viral u p p e r respiratory
tract infection i n d u c e s m u c o s a l e d e m a and ciliary paralysis,
leading to m u c o s a l s e c o n d a r y bacterial infection within 24
to 48 hours. Infundibular m u c o s a l s w e l l i n g induced by alterations in airflow patterns, as m a y o c c a s i o n a l l y o c c u r
after Le Fort o s t e o t o m i e s in the lateral nasal wall, similarly
impairs mucociliary function.
PREOPERATIVE EXAMINATION
Preoperative e x a m i n a t i o n should include s p e c u l u m and
headlight-assisted inspection of t h e nasal cavity both before
and after the application of the d e c o n g e s t a n t spray. Additional tests such as those of M u e l l e r and Cottle (Smith and
N e p h e w Richard, Inc.. 7 4 5 0 B r o o k s Rd., M e m p h i s , T N
3 8 7 7 6 U S A ) to a s s e s s the nasal valve, and lateral wall airw a y resistance should also be d o n e before and after the dec o n g e s t a n t treatment.
A n y d e v i a t i o n s of t h e s e p t u m , laterally or in a vertical to
inferior S - s h a p e d fashion, should be noted. Of particular
i m p o r t a n c e is a visual c h e c k of the middle m e a t u s for the
p r e s e n c e of high septal d e v i a t i o n s or spurs and contralateral
c o m p e n s a t o r y turbinate hyperplasia. T h e convex side of the
s p u r or deviation can c a u s e a paradoxical form of the mid-
Endoscopic Sinus Surgery

d i e turbinate. T h i s m a y lead to a d e l i c a t e b a l a n c e b e t w e e n
O M U p a t e n c y and o b s t r u c t i o n . Le Fort I o s t e o t o m y m a y
alter airflow patterns, w h i c h induce c o m p e n s a t o r y m u c o s a l
r e s p o n s e s that block O M U p a t e n c y .
In addition, septal d e v i a t i o n s can lead to lateralization
and toruosity of the i n f u n d i b u l u m , with s u b s e q u e n t risk of
mucosal a p p r o x i m a t i o n and n a r r o w i n g of t h e m a x i l l a r y
ostia. M i n o r alterations in airflow c a u s e a p p r o x i m a t i o n of
the m u c o s a lining t h e ostia, thereby n a r r o w i n g its lumen to
less than 2.5 m m , which leads to a cessation of ciliary m o tion that blocks O M U function.
F o r patients with midfacial skeletal a s y m m e t r i e s or preexisting obstructive nasal respiration ( O N R ) as e x e m p l i f i e d
by those patients with a p e r t o g n a t h i a or " l o n g face s y n d r o m e " w h o are m o u t h b r e a t h e r s , p r e o p e r a t i v e c o m p u t e d
t o m o g r a p h y ( C T ) o f t h e s i n u s e s d o c u m e n t s d i s e a s e o r predisposition for p o s t o r t h o g n a t h i c s u r g e r y d e v e l o p m e n t of
O M U dysfunction. S u r g i c a l m a n a g e m e n t o f s i n o n a s a l d i s e a s e is tailored to e l i m i n a t e a b n o r m a l i t i e s s u c h as p o l y p s ,
h y p e r t r o p h i c t u r b i n a t e s , and s y m p t o m a t i c O M U b l o c k a g e .
Should these s y m p t o m s first a p p e a r p o s t o p e r a t i v e l y , then
CT s c a n n i n g b e c o m e s n e c e s s a r y as a first d i a g n o s t i c step in
establishing a d i a g n o s i s and treatment plan.
INSTRUMENTATION
T h e s e p r o c e d u r e s a r e usually a c c o m p l i s h e d u n d e r g e n e r a l
anesthesia with oral e n d o t r a c h e a l intubation. A R i c h a r d ' s
3 0 angled e n d o s c o p e o f 3 . 5 - o r 4 . 0 - m m d i a m e t e r i s u s e d ,
which is then attached to a S l r y k e r solid-state v i d e o opticale n h a n c e m e n t and m o n i t o r i n g c a m e r a s y s t e m . A s i m p l e
setup of instrumentation is preferred by t h e author; this s i m plifies m a i n t e n a n c e o f e q u i p m e n t a n d m i n i m i z e s t h e need
for assistance. M o s t of the s u r g e r y can be p e r f o r m e d with
straight and 4 5 a n g l e d W e i l - B l a k e s l e y forceps, a l o n g with
a s h a r p C o t t l e e l e v a t o r . If required, soft tissue r e s e c t i o n s a r e
performed with a m e d i u m " t h r u - c u t t e r " a n d m e d i u m r e verse biting instruments. A c u r v e d o s t i u r n - s e e k i n g p r o b e
and suction-assisted s o u n d a r e used to p a l p a t e t h e m a x i l l a r y
ostium. A d d i t i o n a l i n s t r u m e n t a t i o n for e n d o a n t r a l t r i a n g u l a tion p r o c e d u r e s o c c a s i o n a l l y r e q u i r e s u s e o f t h e S t o r z c a n nula trocar s y s t e m , # 1 0 F r e n c h c a t h e t e r t u b i n g , and irrigation. L a r g e r m u c i n o u s s t r u c t u r e s , such a s e n g o r g e d
turbinates o r intranasal p o l y p s , can readily b e r e m o v e d w i t h
the S t r y k e r " H u m m e r . "
Occasionally, mucosal h e m o r r h a g e is e n c o u n t e r e d despite
the injection of local anesthetic, 0 . 5 % b u p i v a c a i n e with e p i nephrine 1:1(X),000, and timed nasal cottonoid p a c k i n g
soaked with 4% c o c a i n e . It is therefore helpful to h a v e laserassisted carbon d i o x i d e ( C 0 ) o r H o I m i u m : y t t r i u m - a l u m i n u m - g a r n e t ( H o : Y A G ) p h o t o c o a g u l a t i o n available. If not
available, insulated e l e c t r o c a u t e r y should be accessible.
T h e H o : Y A G laser ( N e w S t a r L a s e r s , 7 7 8 0 2 K e m p e r
Rd., A u b u r n , C A 9 5 6 0 3 U S A ) with a q u a r t z f i b e r h a n d p i e c e
2
159
can be utilized for e n d o n a s a l soft tissue ablation, p h o t o c o a g u l a t i o n , a n d t u r b i n o p l a s t y w h e n indicated. Settings of 10

W of p o w e r and h i g h - s p e e d p l u m e e v a c u a t i o n a r e utilized.
T h e C 0 laser ( L u x a r C o r p o r a t i o n , 7 9 2 0 6 North C e n t e r
P a r k w a y , B o t h e l l , W A 9 0 8 7 7 - 8 2 0 5 ; L X S - B D 120-090
B e a m Deflector Sheath for L X 2 2 0 L a s e r S y s t e m ) can also
be used for these p r o c e d u r e s , and c o n v e n i e n t tips are availa b l e for directed b e a m localization.
On selected c a s e s , septoplasty is p e r f o r m e d first if there
is d e v i a t i o n or high posterior septal s p u r s . T h i s condition
p r e v e n t s a c c e s s t o t h e m i d d l e m e a t u s o r p u s h e s the m i d d l e
turbinate against the lateral nasal w a l l , inhibiting access to
the hiatus s e m i l u n a r i s , u n c i n a t e process, and infundibulum.
O t h e r w i s e , t h e septoplasty is p e r f o r m e d following the functional e n d o s c o p i c s i n u s s u r g e r y in o r d e r to reduce the incid e n c e o f h e m o r r h a g e , w h i c h o b s t r u c t s vision.
2
TECHNIQUE OF FUNCTIONAL
ENDOSCOPIC SINUS SURGERY (FESS)
I n t r o d u c i n g t h e e n d o s c o p e along the nasal f l o o r j u s t b e y o n d
t h e sill p e r m i t s better a c c e s s and control for instrumentation
and a i d s in visibility. First, the u n c i n a t e process is identified
and a vertical incision m a d e with t h e s h a r p e d g e of t h e C o t tle e l e v a t o r . T h e u n c i n a t e p r o c e s s is g r a s p e d at t h e superior
m a r g i n of this incision with t h e W e i l - B l a k e s l e y forceps and
p u l l e d inferiorly to t h e level of the m i d d l e turbinate. T h e s e
s a m e forceps a r e then u s e d to o p e n the bulla e t h m o i d a l i s ,
with care b e i n g taken to orient the b e a k s of the forceps vertically to p r e v e n t inadvertent e x t e n s i o n laterally through the
l a m i n a p a p y r a c e a and t h e r e b y e n t e r i n g t h e orbit.
D e c o m p r e s s i o n of t h e i n f u n d i b u l u m by this m a n e u v e r
frequently r e q u i r e s e n l a r g e m e n t of the maxillary o s t i u m , e s pecially in patients w h o h a v e had high-level Le Fort o s t e o t o m i e s with resultant a b n o r m a l b o n y architecture o r
s y n e c h i a ! w e b b i n g . U s e of a c u r v e d p r o b e is essential to
identify the m a x i l l a r y o s t i u m . After its identification, the
o s t i u m is e n l a r g e d with the r e v e r s e biting forceps working
anteriorly until sufficient d i a m e t e r (3.0 mm plus) is
a c h i e v e d . We h a v e found that a c u r v e d laser-delivering
p r o b e o r a b e a m - d e f l e c t i n g p r o b e ( C 0 L u x a r o r modified
H o : Y A G C o h e r e n t ) is useful in reestablishing a d e q u a t e patency o f this o s t i u m .
2
T h e indications for the j u d i c i o u s removal of portions of

t h e m i d d l e turbinate a r e c o n c h a b u l l o s a , turbinate hypertrop h y , o r p a r a d o x i c a l turbinate m o r p h o l o g y , o r e v e n n o r m a l
turbinates that h a v e been p u s h e d into o b s t r u c t i v e positioning within t h e O M U by posterior septal d e v i a t i o n s . In these
c a s e s , both the " t h r u - c u t " R i c h a r d s forceps and the laserassisted e n d o s c o p i c nasal t u r b i n o p l a s t y a r e indicated.
F o l l o w i n g these p r o c e d u r e s , a F E S S silicone stent, bacit r a c i n - c o a t e d Telfa strip, and nasal drip p a d s a r e applied to
p r e v e n t t h e f o r m a t i o n of lateral s y n e c h i a e and to aid m u cosal w o u n d healing. If s e p t o p l a s t y w a s p e r f o r m e d , its m u -
1 60
c o s a is r e a p p r o x i m a t c d with 4 - 0 c h r o m i c m a t t r e s s s u t u r e s to
prevent septal h e m a t o m a .
O t h e r areas of antral a c c e s s a r e s o m e t i m e s utilized, such
as t h e H o s a k a w i n d o w (Fig. 144). During t h e c o u r s e of
down-fracturing of the m a x i l l a in the Le Fort I operation,
patients with c h r o n i c sinusitis and obstructive nasal respiration u n d e r g o i n g rigid fixation receive nasoantral n o t c h i n g
procedures of t h e lateral nasal walls. T h e s e are placed at the
junction of the anterior m a x i l l a r y walls and the lateral nasal
walls at the anterior aspect of the maxillary a n t r u m . T h i s is
a c c o m p l i s h e d using an e n d - c u t t i n g b o n e r o n g e u r , t h e r e b y
allowing the drainage of the maxillary a n t r u m d u r i n g healing. Additionally, the a u t h o r utilizes this w i n d o w to place a
small e n d o s c o p e postoperatively t h r o u g h a S t o r z c a n n u l a
placed transnasally to view t h e sinus m u c o s a (Fig. 1 4 - 5 ) .
T h e status of b o n e healing, fixation h a r d w a r e , h y d r o x y a p atite, and b o n e grafts can also be e v a l u a t e d with this a c c e s s .
In certain c a s e s mucosal w e b s a n d / o r shelf-life plicae,

which m a y inhibit p h y s i o l o g i c m u c o u s flow, m a y also be
present and r e q u i r e lysis.
T h e m a x i l l a r y - a n t r a l t r o c h a r - c a n n u l a puncture can b e
utilized at the area of the c a n i n e fossa for surgical access,
transantral p o l y p , tooth or foreign b o d y r e m o v a l s , and end o s c o p i c a l l y assisted laser d e b r i d e m e n t of reactive m u c o s a .
P u n c t u r e s a r e usually left open to heal by s e c o n d a r y intention o n c e t h e i n s t r u m e n t a t i o n is r e m o v e d .
COMPLICATIONS AND POSTOPERATIVE

CONSIDERATIONS
O c c a s i o n a l l y , nasal irrigation and even steroid nasal sprays
a r e required in the postoperative period following pack and
stent r e m o v a l . F o l l o w - u p antibiotics are given routinely
with all patients. E n d o n a s a l e x a m i n a t i o n s are d o n e with a
headlight and s p e c u l u m to detect early synechial formation
since these can frequently be interrupted with antibioticc o a t e d c o t t o n applicators or with m i n i m a l l y invasive man i p u l a t i o n s . M o r e m a t u r e a d h e s i o n s m a y require surgical or
laser-assisted lysis.
CASE ILLUSTRATIONS
Case 1
Figure 14-4. Diagram of a down fractured maxilla at the Lc

Fort 1 level indicating view of notches (Hosaka Window) placed in
the lateral nasal wall.
Figure 14-5. Placement of endoantral cannula and endoscope

through a "Hosaka Window" approach.
T h i s is a 4 2 - y e a r - o l d m a n status p o s t - s e g m e n t a l Le Fort 1
o s t e o t o m y c o m b i n e d with m a n d i b u l a r o s t e o t o m y , septoplasty, and partial t u r b i n e c t o m i e s . T h e s e p r o c e d u r e s were
a c c o m p l i s h e d for treatment of facial skeletal asymmetry,
vertical m a x i l l a r y hyperplasia and retrognathism, as well as
o b s t r u c t i v e nasal respirations d u e to septal deviation and
h y p e r t r o p h i c turbinates. Significant findings at the time of
t h e Le Fort I r e v e a l e d a cyst of the left maxillary antrum,
and severe septal spurs and d e v i a t i o n s . Pathology reports
w e r e consistent with cholesterol g r a n u l o m a initially read
from tissue p a t h o l o g y s p e c i m e n s .
W i t h i n 2 to 3 w e e k s after surgery, the patient reported a
large tissue obstruction of the right nasal p a s s a g e w a y . Intranasal e x a m i n a t i o n r e v e a l e d a p o l y p o i d m a s s present and
nasal topical s t e r o i d s w e r e e m p l o y e d to assist m a n a g e m e n t .
T h e s e w e r e unsuccessful in reducing the size of the tissue
and a CT scan w a s ordered. A large ( 2 - 3 c m ) oblong soft
tissue m a s s w a s d i s c o v e r e d in the right lateral aspect of the
nasal c a v i t y (Fig. 1 4 - 6 ) . Functional e n d o s c o p i c a l l y assisted
nasal s u r g e r y w a s p e r f o r m e d with surgical r e m o v a l of the
p o l y p o s i s , followed by H o : Y A G laser ablation of soft tissue
tags r e m a i n i n g . Pathologic confirmation of p o l y p s and the
m u c o u s - r e t e n t i o n cyst p h e n o m e n o n with m u c o u s gland hyperplasia w e r e o b t a i n e d . P o s t o p e r a t i v e intranasal steroids
w e r e applied, and there h a v e been no r e c u r r e n c e s in the past
16 m o n t h s .
Endoscopic Sinus Surgery
161
Case 2
Figure 14-6. Coronal CT scan of patient (Case 1) having a large

Concha Bullosa and nasal polyp in right nasal parragenay.
T h i s is a 5 4 - y e a r - o l d w h i t e w o m a n w h o presented status
p o s t - m u l t i p l e facial o s t e o t o m i e s for correction of posterior
vertical maxillary hyperplasia with a p e r t o g n a t h i s m and retr o g n a l h i s m . S e g m e n t a l Le Fort I o s t e o t o m i e s , along with
m a n d i b u l a r o s t e o t o m i e s , w e r e a c c o m p l i s h e d without septoplasty or t u r b i n e c t o m i e s . T h e maxillary nasal sinuses had
p o l y p s p r e s e n t , w h i c h w e r e sent for p a t h o l o g i c confirmation of i n f l a m m a t o r y p o l y p s with increased n u m b e r of
e o s i n o p h i l s of the nasal m u c o s a .
S e v e r a l years later, the patient returned with a c o m p l a i n t
of h e a d a c h e s and c h r o n i c sinusitis resistant to medical mana g e m e n t . CT scan r e v e a l e d that the left maxillary sinus had
e x t e n s i v e inflammatory c h a n g e s that e x t e n d e d throughout
the e t h m o i d a l air cells. A d d i t i o n a l l y , the patient had nocturnal s n o r i n g and clinical e v i d e n c e of h y p e r t r o p h y of the
uvula and r e d u n d a n c y of the soft palate. B l o c k a g e of the
O M U w a s noted on the left side (Fig. 14-7). A surgical plan
for treatment i n v o l v e d F E S S with o p e n i n g of the maxillary
o s t i u m and O M U with anterior e t h m o i d e c t o m y . H o : Y A G
laser-assisted m i d d l e t u r b i n o p l a s t y . and C 0 laser-assisted
uvulopalatoplasty, which was accomplished.
2
Case 3
Figure 14-7. Coronal CT scan of patient (Case 2) showing Concha Bullosa, obstructed OMU. and evagination of inferior
turbinates into the maxillary antrum.
T h i s is a 3 5 - y e a r - o l d w h i t e w o m a n w h o w a s treated in 1987
with t e m p o r o m a n d i b u l a r joint ( T M J ) arthroscopic surgery
for t e m p o r o m a n d i b u l a r dysfunction ( T M D ) with internal
joint d e r a n g e m e n t ( I J D ) . and in 1989 with Le Fort I o s t e o t o m y with s u p e r i o r r e p o s i t i o n i n g , sagittal split r a m u s o s t e o t o m y , t u r b i n e c t o m i e s , and septoplasty. Her treatment
w a s related to m a n a g e m e n t of her posterior vertical maxillary h y p e r p l a s i a with resultant a p e r t o g n a t h i a . m a n d i b u l a r
a s y m m e t r i c p r o g n a t h i s m and concurrent h y p e r t r o p h i c
t u r b i n a t e s , and o b s t r u c t i v e nasal r e s p i r a t i o n s .
T h e patient returned in 1995 with a c o m p l a i n t of sinusitis
and c h r o n i c nasal r h i n o r r h e a . A c o m b i n a t i o n of e n d o s c o p i cally assisted e n d o n a s a l e x a m i n a t i o n s and C T scan analysis
r e v e a l e d s y n e c h i a l w e b b l o c k a g e o f the maxillary o s t i u m ,
resulting in p h y s i o l o g i c flow restriction of maxillary sinus
m u c o u s (Fig. 1 4 - 8 ) . T h i s w a s present despite the patency of
a large nasal antral w i n d o w placed at the t i m e of the original Le Fort I o s t e o t o m y ( H o s a k a w i n d o w ) .
F E S S treatment c o n s i s t e d of partial laser-assisted
t u r b i n o p l a s t y , s y n e c h i a l lysis, and e n l a r g e m e n t of t h e m a x illary o s t i u m on the left side.
DISCUSSION
Figure 14-8. Coronal CT scan of patient (Case 3) with OMU

blockage and synechial web obstruction of the maxillary oslea.
E x a m i n a t i o n of the maxillary antral walls through the

H o s a k a w i n d o w placed at t h e t i m e of the Le Fort o s t e o t o m y
in most c a s e s revealed a b s e n c e of d i s e a s e d m u c o s a next
to the rigid fixation h a r d w a r e protruding into the sinus.
162
T h i s w a s i n d e p e n d e n t of the type of metal used for the hardw a r e (Fig. 1 4 - 9 ) .

Utilization of the 7 0 e n d o s c o p e and careful rotation for
better visualization r e v e a l e d s y n c c h i a l w e b s and s h e l v e s in
s o m e patients at the Le Fort I o s t e o t o m y site in t h e m a x i l lary a n t r u m . T h i s p r o b a b l y led to a "fall b a c k " inhibition of
n o r m a l p h y s i o l o g i c m u c o u s f l o w t o w a r d t h e natural o s t i u m
(Fig. 1 4 - 1 0 ) . In o u r e x p e r i e n c e , several patients h a v e required lysis of s y n c c h i a l w e b s at the level of the m a x i l l a r y
ostium in o r d e r to restore aeration of the m a x i l l a r y s i n u s .
Other etiologic factors to c o n s i d e r include p r e d i s p o s i n g
anatomic variants, such a s c o n c h a b u l l o s a and e n l a r g e m e n t s
of the m i d d l e turbinate, c r e a t i n g the contact p h e n o m e n o n
that inhibits ciliary m o v e m e n t at t h e hiatus s e m i l u n a r i s and
i n f u n d i b u l u m . T h e p r e s e n c e o f high septal spurs and a s y m metric d e v i a t i o n s lead to a p r e d i s p o s i t i o n of t h e narrowed

airway p a s s a g e s and d r a i n a g e spaces to b e c o m e obstructed
after o r t h o g n a t h i c surgery. W h e r e a s n o r m a l airway anato m y and m u c o s a l health m i g h t h a v e been able to tolerate
these c h a n g e s , the i m p a i r e d m u c o s a and a i r w a y patencies of
patients with obstructive nasal respiration, such as those
with t h e classic a p e r t o g n a t h i a l o n g face s y n d r o m e w i t h
c o n c u r r e n t m o u t h b r e a t h i n g patterns, m a y not be able to
a d a p t r a p i d l y e n o u g h after Le Fort o s t e o t o m y to avoid these
airway problems.
SUMMARY
Figure 14-9. Endoscopic view of maxillary antral wall showing

step and hardware entrance into the maxillary sinus.
C e r t a i n patterns of facial skeletal a s y m m e t r i e s with highlevel septal d e v i a t i o n s and o t h e r s with obstructive nasal resp i r a t i o n / m o u t h b r e a t h i n g , and skeletal g r o w t h disturbances
such as long face s y n d r o m e or a p e r t o g n a t h i a m a y be predisp o s e d to the d e v e l o p m e n t of clinically significant sinonasal
d i s e a s e p o s t o p e r a t i v e l y . T h e s e m a y in part be d u e to the
O M U b l o c k a g e o r with s y n c c h i a l shelves and w e b s blocking n o r m a l m a x i l l a r y antral mucosal flow.
T h e use of nasoantral w i n d o w s placed in the anterolateral
nasal wall at the t i m e of Le Fort I d o w n - f r a c t u r e (Hosaka
w i n d o w ) d o e s not a p p e a r to e n h a n c e d r a i n a g e of the maxillary a n t r u m b e c a u s e the p h y s i o l o g i c flow pattern of the muc o u s b y p a s s e s this region.
With the a d v e n t of office-based e n d o s c o p i c instrumentation, the oral and maxillofacial s u r g e o n is better e q u i p p e d to
i m m e d i a t e l y e v a l u a t e and treat p o s t o p e r a t i v e untoward seq u e l a e such a s s y n e c h i a ] w e b s , p o l y p s , and O M U blockage,
as well as to view the h e a l i n g of t h e lateral nasal wall
within the m a x i l l a r y sinus. R e g i o n s e x p o s e d to sinus lift implants and interpositional h y d r o x y a p a t i t e or b o n e grafts can
be visualized and e v a l u a t e d . E v a l u a t i o n of patients by both
e n d o s c o p i c a l l y assisted intranasal e x a m i n a t i o n and axial
and c o r o n a l C T scan a n a l y s i s i s r e c o m m e n d e d . F E S S with
the m i n i m a l l y invasive M e s s e r k l i n g e r a p p r o a c h , combined
with intranasal u s e of laser-assisted turbinoplasty and soft
tissue lysis, has been successful in the m a n a g e m e n t of the
majority of these c a s e s .
REFERENCES
Figure 14-1(1. Cross-sectional coronal view diagram of steps

formed within the maxillary antrum and resultant potential for
redirected/inhibited ciliary mucous flow following Le Fort I osteotomy.
1. Heetderks DL. Observations on the reactions of normal nasal

mucous membrane. Am J Med Sci. 1927; 174:231.
2. Hilding AC. The role of respiratory mucosa in health and disease. Man Med. 1967; 50:915-919.
3. Holliday RA. Shiptner BA. Avoiding complications of endoscopic sinus surgery: analysis of coronal, axial, and sagittal
computed tomographic images. Operative Tech Otolaryngol
Head Neck Surg. 1995; (3):149-157.
15
Laser Biostimulation: Photobioactivation,

A Modulation of Biologic Processes by
Low-Intensity Laser Radiation
Joseph S. Rosenshein
BACKGROUND
Therapeutic Use of Light in Medicine
HELIOTHERAPY
Light therapy can be traced back to healing p r a c t i c e s of

the ancient E g y p t i a n s and G r e e k s w h o p r a i s e d R a o r Helios
as the god of light, sun, and healing. Greek and R o m a n
p h y s i c i a n s , C e l s u s and G a l e n for e x a m p l e , r e c o m m e n d e d
sunbathing as therapy for a variety of c o n d i t i o n s i n c l u d i n g
e p i l e p s y , arthritis, and a s t h m a . E x p o s u r e to sunlight w a s
considered to be p r e v e n t i v e m e d i c i n e and its effects on
bone growth w e r e recognized by the 6th c e n t u r y B.C. T h e
w o r s h i p of the sun w a s practiced throughout the R o m a n
E m p i r e until it w a s s u p p r e s s e d by early Christianity. As a
c o n s e q u e n c e of the Industrial R e v o l u t i o n , there w a s a large
transfer of rural p o p u l a t i o n s to cities with p o o r l y illuminated housing, poor diets, long h o u r s in dark w o r k p l a c e s ,
and few opportunities for a d e q u a t e e x p o s u r e to sunlight.
T h e s e c o n d i t i o n s resulted in o u t b r e a k s of s c u r v y , rickets,
e d e m a , r h e u m a t i c arthritis, and d e p r e s s i o n , for which s u n bathing w a s often prescribed as a c u r e . A n u m b e r of s c i e n tific investigations into the biologic effects of sunlight
eventually resulted in t h e d i s c o v e r y of its bactericidal effects and its role both in the prevention and treatment of
rickets by the end of the 19th century.
ULTRAVIOLET (UV) THERAPY
Al the turn of the 2()th c e n t u r y , a t t e m p t s to artificially d u plicate the s u n ' s radiation using artilicial light resulted in
the d e v e l o p m e n t of c o n v e n i e n t s o u r c e s of UV radiation that
were effective in treating the o p e n w o u n d s found in tuberculosis and rickets. By t h e 1930s, UV light t h e r a p y w a s
c l a i m e d to be successful in treating h u n d r e d s of c o n d i t i o n s
including nephritis, r h e u m a t o i d arthritis, h e m o p h i l i a , and
herpes zoster. T h e c o n d i t i o n s for which UV t h e r a p y w a s , at
that t i m e , the only effective treatment are t o d a y s u c c e s s fully treated by m e d i c a t i o n s , dietary s u p p l e m e n t s , etc. T h e
use of UV therapy h a s u n d e r g o n e alternating p e r i o d s of e n thusiastic e n d o r s e m e n t and d e n o u n c e m e n t . Despite the current c o n c e r n s r e g a r d i n g the p o o r findings from c o n t r o l l e d
clinical research and the potential for harmful effects from

UV e x p o s u r e , a c t i n o t h e r a p y is still r e c o m m e n d e d , although
not universally a c c e p t e d , for stimulation of w o u n d healing
in ulcers, boils, and c a r b u n c l e s , and for treatment of acne
vulgaris and neonatal j a u n d i c e w h e n used cautiously and
prudently.
1,2
L A S E R S I.N M E D I C I N E
T h e d e v e l o p m e n t of light s o u r c e s for medical p u r p o s e s

took a giant leap forward with the b u i l d i n g of the first laser
by T h e o d o r e M a i m a n in I960. S i n c e that time, medical a p plications of the intense, c o h e r e n t , m o n o c h r o m a t i c radiation
available from a variety of pulsed and c o n t i n u o u s w a v e
( C W ) solid-state, d y e , and g a s lasers h a v e multiplied.
Shortly after the introduction of this new source of light,
o p h t h a l m o l o g i s t s b e c a m e the first users of medical lasers by
a p p l y i n g the ruby laser to p h o t o c o a g u l a t i o n of the retina to
weld d e t a c h e d retinas back into place. With the availability
of o t h e r lasers, applications of the intense electromagneticradiation at different w a v e l e n g t h s b e c a m e possible. T h e foll o w i n g a r e s o m e e x a m p l e s o f medical laser applications:
T h e C 0 laser, a n infrared ( I R ) emitter a t 10,600-nm
w a v e l e n g t h , is used in both CW and pulsed m o d e s as a
surgical laser b e c a u s e of its excellent hemostasis and
s h a l l o w penetration depth in neurosurgery, d e r m a t o l o g y ,
plastic s u r g e r y , g y n e c o l o g y , o p h t h a l m o l o g y , oncology,
oral and maxillofacial s u r g e r y , o t o l a r y n g o l o g y , and general s u r g e r y .
2
The
neodymium:ytlrium-aluminum-garnet
(Nd:YAG)
laser p r o d u c e s IR radiation at a 1060-nm wavelength. It
is used in o p h t h a l m o l o g y to r e m o v e o p a c i t i e s that s o m e t i m e s d e v e l o p in the posterior c a p s u l e after removal of a
cataract and insertion of an intraocular lens and for transclcral destruction of p o r t i o n s of the ciliary b o d y in intractable cases of g l a u c o m a .
Solid-state lasers p r o d u c e w a v e l e n g t h s in the visible and
infrared r e g i o n s of the spectrum. A r r a y s of these lasers
c a n p r o d u c e p u l s e s with peak p o w e r s of 100 W or CW
radiation with an a v e r a g e p o w e r of tens of watts. M a n y
of the most c o m m o n of these solid-state near-IR lasers
165
166
arc constructed from g a l l i u m a r s e n i d e ( G a A s ) or g a l l i u m

a l u m i n u m a r s e n i d e ( G a A l A s ) , w h i c h p r o d u c e s radiation
of 8 2 0 - to 9 0 4 - n m w a v e l e n g t h s . T h e s e lasers p r o m i s e to
deliver even greater p o w e r d e n s i t i e s with greater reliability and lower cost as they c o m e into c o m m o n u s e in t h e
near future.
H e l i u m - n e o n ( H e N e ) g a s lasers are p e r h a p s the most
c o m m o n l y k n o w n visible light p r o d u c i n g lasers b e c a u s e
of their relatively l o w cost and availability. T h e s e lasers
emit light primarily at 6 3 2 . 8 - n m w a v e l e n g t h and c o m m o n l y are used as a i m i n g b e a m s for IR lasers.
A r g o n ion gas lasers p r o d u c e visible light w a v e l e n g t h s of
blue and blue-grecn. T h e s e lasers are e m p l o y e d in o p h t h a l m o l o g y to treat proliferative retinopathy and glauc o m a b e c a u s e their light is highly a b s o r b e d by v a s c u l a r ized tissue. Similarly, they a r e useful for the treatment of
vascular m a l f o r m a t i o n s and p o r t - w i n e stains. A n o t h e r recent application of argon lasers is in p h o t o d y n a m i c therapy ( P D T ) of c a n c e r .
T u n a b l e d y e lasers and m o r e recently t u n a b l e T k s a p p h i r e
lasers provide a w i d e r a n g e of visible and IR w a v e lengths for use in o p h t h a l m o l o g y and d e r m a t o l o g y .
Most recently argon fluoride e x c i m e r lasers p r o d u c i n g
e x t r e m e UV radiation of 193 nm h a v e been d e v e l o p e d
for use in p h o t o a b l a t i v e refractive k e r a t e c t o m y for correction of m y o p i a and a s t i g m a t i s m .
A l m o s t all the lasers used in surgical a p p l i c a t i o n s e m p l o y
the p h o t o t h e r m a l effects of light a b s o r p t i o n , which involve
protein d e n a t u r a t i o n , c o a g u l a t i o n , a n d v a p o r i z a t i o n with
the increased t e m p e r a t u r e s a s s o c i a t e d with e n e r g y a b s o r p tion. T h e e x t r e m e ultraviolet radiation of h i g h - e n e r g y p h o t o n s from t h e e x c i m e r laser disrupt m o l e c u l a r and a t o m i c
b o n d s , resulting in ablation relatively free of t h e r m a l effects.
LOW-INTENSITY
LASER THERAPY
T h e use of low-intensity laser radiation ( L I L R ) for therapy w a s p i o n e e r e d by E n d r e M e s l e r in B u d a p e s t in the late

1960s,
and i n d e p e n d e n t l y by Dr. Friedrich P l o g in
C a n a d a . T h e use of low-intensity laser light for therapy is
dislinct from the use of lasers in s u r g e r y in that t h e therapeutic effects apparently arise either directly or indirectly
from the e l e c t r o m a g n e t i c interaction of the light with tissue
and not from thermal effects. Early r e s e a r c h e r s used very
low p o w e r lasers of less than I milliwatt ( m W ) but present
research is b e i n g c o n d u c t e d at p o w e r s b e t w e e n 1 and 75
m W . T h e typical low-intensity l a s e r currently used in biostimulation research or in a clinical setting has a p o w e r of at
least 15 mW and may be as high as several h u n d r e d milliwatts. T r e a t m e n t t i m e s a r e typically short ( ^ 3 0 s e c ) , resulting in delivery of e n e r g i e s of only a few j o u l e s per
square c e n t i m e t e r to the treated s i t e .
4
A l t h o u g h laser therapy or laser b i o s t i m u l a t i o n is freq u e n t l y used in E u r o p e and Asia as a therapy for a variety
of d i s e a s e s , it has not been generally a c c e p t e d in t h e United
Slates d u e to the difficulty in g a i n i n g Food and D r u g A d -
ministration ( F D A ) approval for n e w medical d e v i c e s a s

safe and effective. T h e r e is no c l e a r e v i d e n c e that laser
b i o s t i m u l a t i o n is superior to e x i s t i n g therapy options. Until
such e v i d e n c e is p r e s e n t e d , it s e e m s unlikely that the F D A
will grant a p p r o v a l for use of this therapy in the United
States.
Clinical Areas of Application

L o w - i n t e n s i t y laser biostimulation has been applied to some
of the f o l l o w i n g a r e a s :
1. P h y s i o t h e r a p y
a. W o u n d h e a l i n g
b. Soft tissue injuries
C. Pain relief
d. Arthritis
2. Dentistry
a.
b.
c.
d.
R e d u c t i o n of e d e m a and h y p e r e m i a
Wound healing
Pain relief
T r e a t m e n t of herpes labialis and herpetic gingivostomatitis
e. Activation of bone growth
3. V e t e r i n a r y practice
a. Pain relief
b . W o u n d healing
c. T r e a t m e n t of respiratory tract infections
d. R e v e r s a l of n e u r o p r a x i a
e. I m p r o v e m e n t of foot g r o w t h in horses
4. Laser acupuncture
CONTROVERSY
S i n c e M e s t e r s initial work, there has been c o n s i d e r a b l e
c o n t r o v e r s y r e g a r d i n g t h e effectiveness and even the exist e n c e of low-intensity laser b i o s t i m u l a t i o n . T h e early reports of L I L R - i n d u c e d p h o t o b i o s l i m u l a t i o n w e r e published
in Russian and E a s t e r n E u r o p e a n j o u r n a l s ihat were inacc e s s i b l e to most r e s e a r c h e r s in A m e r i c a . E v e n w h e n translated, (he initial w o r k suffered from i n c o m p l e t e description
of e x p e r i m e n t a l p a r a m e t e r s , protocols that w e r e not blinded
or c o n t r o l l e d , and Hawed m e t h o d o l o g i e s . In particular, the
specifications of L I L R research w e r e inconsistently presented, m a k i n g c o m p a r i s o n s and replication of results difficult if not i m p o s s i b l e . As t h e field h a s m a t u r e d , the rigor of
reporting has i m p r o v e d , leading to m o r e credible and reliable results. M o d e r n r e s e a r c h in this field should specifically report:
78
In vitro v s . In v i v o s t u d i e s H o w do the cellular studies

c o m p a r e to a p p l i c a t i o n s in a n i m a l s or h u m a n s ?
L a s e r light s o u r c e s W h a t a r e the characteristics of the
light s o u r c e , including intensity, b e a m profiles, polarization, and stability? W a s t h e light pulsed or c o n t i n u o u s ? If
p u l s e d , what w e r e the pulse c h a r a c t e r i s t i c s ?
Laser Biostimulation
W a v e l e n g t h s W h a t a r e t h e w a v e l e n g t h s and b a n d w i d t h s of the light used in t h e r e s e a r c h ?
D o s i m e t r y H o w w a s t h e e n e r g y d e l i v e r e d ? O v e r what
a r e a ? W h a t w e r e t h e peak and a v e r a g e p o w e r s per unit
a r e a ? H o w long w a s the e x p o s u r e ?
T e c h n i q u e s W h a t w e r e t h e treatment s c h e d u l e s ? D e scribe t h e c o n t r o l s and limited b l i n d i n g b y r e s e a r c h e r s .
8,0
LASER PARAMETERS
167
c a u s e s " s h o w e d significant beneficial results. O t h e r i n v e s t i g a t o r s h a v e found n o benefit o f L I L R o n v e n o u s leg ulc e r s . T h e e x t e n t of the i n v e s t i g a t i o n of t h e effect of L I L R
on wound healing is shown in Table 1 5 - 1 . An overview of
t h e s e r e s u l t s indicates that L I L R m a y d e m o n s t r a t e effects of
p h o t o b i o s t i m u l a t i o n on w o u n d healing, particularly in its
e a r l y p h a s e s . T h e s e effects m a y d e p e n d o n the species o f
animal used. L o o s e - s k i n n e d a n i m a l s such a s rabbits, rats,
a n d m i c e s e e m to s h o w a p r o m i n e n t r e s p o n s e to L I L R , possibly d u e to e n h a n c e d c o l l a g e n a c c u m u l a t i o n in the
w o u n d e d a r e a . T h e r e a r e , h o w e v e r , n e g a t i v e results rep o r t e d for p i g s that are m o r e similar to h u m a n s .
12
14
1 5
T h e specific characteristics o f L I L R r e s e a r c h need t o b e

considered w h e n e v a l u a t i n g the effects p r o d u c e d .
A.
Inherent Laser Parameters
1. W a v e l e n g t h
2. Polarization
3 . B e a m m o d e and profile
a. TEM,,,,gaussian
b. Multimode
c. Homogeneous
4 . B e a m temporal t y p e
a. C W
b . Pulsed
B.
1.
2.
3.
4.
5.
6.
Adjustable Parameters
P o w e r density
E n e r g y density
Pulse width
Pulse repetition rate
Duration of e x p o s u r e
Exposure schedule
T h e s e p a r a m e t e r s a r e essential t o u n d e r s t a n d i n g the m e c h a nism u n d e r l y i n g t h e effects of p h o t o b i o s t i m u l a t i o n b e c a u s e

too l o w an e x p o s u r e will h a v e no effect and t o o high an e x posure can p r o d u c e d e t e r i o r a t i o n o r e v e n d e s t r u c t i o n o f t h e
cells and tissues. T h i s lack o f c o m p l e t e d e s c r i p t i o n o f t h e
L I L R p a r a m e t e r s used in research m a y a c c o u n t for the c o n fusion and c o n t r a d i c t i o n p r e s e n t in this field.
EXAMPLES OF LASER-MEDIATED ANALGESIA

Examples of laser-mediated analgesia shown in Table
1 5 - 2 a r e not e x h a u s t i v e but indicative of s c o p e of work
d o n e in this a r e a of clinical pain m a n a g e m e n t and therapy.
R h e u m a t o i d arthritis ( R A ) is t h e subject of c o n s i d e r a b l e
r e s e a r c h interest b e c a u s e of its p r e v a l e n c e in the general
p o p u l a t i o n . A n u m b e r of w e l l - d e s i g n e d and controlled studies find pain lessened, s w e l l i n g d i m i n i s h e d , medication u s e
r e d u c e d a n d m o r n i n g stiffness i m p r o v e d following multiw e e k c o u r s e s o f both visible a n d I R L I L R . H o w e v e r , b e n e f i t s m a y b e limited. A l t e r a t i o n s o f s e d i m e n t a t i o n rates,
l e u k o c y t e c o u n t s , platelet a g g r e g a t i o n , and C reactive protein c o n c e n t r a t i o n s , w h i c h m a y be associated with L I L R effects on t h e i m m u n e s y s t e m , a r e frequently reported but
o c c u r s p o r a d i c a l l y . T h e r e l a t i o n s h i p of these factors to clinical effectiveness is still unclear. A multicenter, multiyear
study involving HeNe LILR photobiostimulation of hands
with R A w a s presented t o a n F D A advisory c o m m i t t e e i n
1988. T h e s t u d y w a s not a p p r o v e d d u e t o c o n c e r n s about
d e s i g n limitations, patient selection, and benefit. A n o t h e r
w e l l - c o n t r o l l e d m u l t i c e n t e r s t u d y in 1990 and 1991 evaluated the effect of L I L R therapy on RA of the h a n d s with
c o n t r o l p a t i e n t s treated c o n v e n t i o n a l l y . T h e study w a s
s t o p p e d before c o m p l e t i o n d u e t o c o n c e r n s that i m p r o v e m e n t s , if a n y , w e r e t o o limited to justify c o n t i n u a t i o n .
6,8
CURRENT RESEARCH
Cellular
Parameters Used in Studies

WOUND HEALING
T h e early w o r k o f M e s t e r o n w o u n d h e a l i n g o f c h r o n i c
ulcers i n v o l v e d the effect of L I L R p h o t o b i o s t i m u l a t i o n on
ulcers that had been u n r e s p o n s i v e to o t h e r t r e a t m e n t m o d a l ities. After treating 1120 ulcers and o t h e r n o n h e a l i n g
w o u n d s with 4 J / c m of H e N e laser light and later with an
argon laser t w i c e p e r w e e k o n t h e entire w o u n d surface,
7 8 % healed and a n o t h e r 1 4 % w e r e i m p r o v e d , w h i l e only
8% remained unhealed. The average healing time was 12 to
16 w e e k s . O t h e r u n c o n t r o l l e d trials of the effect of L I L R on
healing of d e c u b i t u s u l c e r s ' " and of leg ulcers from various
2
Effects
R e s e a r c h on t h e effects of L I L R has been most e x t e n s i v e

a n d s y s t e m a t i c a l l y carried out in the area of cell p r o c e s s e s .
H o w e v e r , b e c a u s e o f the diversity o f e x p e r i m e n t a l protoc o l s a n d the n o n s t a n d a r d m e t h o d s of r e p o r t i n g the c o n d i t i o n s of e x p o s u r e a n d results, t h e interpretation of the p u b lished information p r e s e n t s difficulties. Photoactivation
a p p a r e n t l y o c c u r s at t w o levels in b i o l o g i c s y s t e m s : t h e cellular level, w h i c h is t h e localized p r i m a r y response, and
then o v e r a larger c o n t i g u o u s area, which is m o r e of a syst e m i c s e c o n d a r y r e s p o n s e . By radioactive labeling of cellular c o m p o n e n t s , M e s t e r and his s o n s , o v e r a 2 0 - y e a r p e riod, h a v e e x a m i n e d the influence of L I L R on the following:
8
16
168

I able 15-1.
WOUND
MITHOR
Mester
(1971)
ANIMAL
Mouse
EVALUATED
Diameter
Burn
Mester
(1973)
Rat
Open skin
Complete wound
and collagen
synthesis
Mester
(1975)"
Rat
Muscle
injury
Haina
(1981)
Rat
Kuna
(1981)"'
Rat
Surinchak
(1983)"
Rabbits
In v i v o animal e x p e r i m e n t s
LASER
WAVELENGTH
Ruby
694 nm
POWER
DENSITY
ImW/cnr)
ENI-RCi
DENSITY
(J/cm )
1 XI'OSURISCHEDULE
EFFECT
1 J/cnr
increased
healing
N/A
0.5. 1.4.
5. 10
2 X weekly
Ruby
694 nm
N/A
1
4
6
Day 5
Postop
Postop
Regeneration
of muscle
Ruby
694 nm
N/A
Every 3rd
day X 4
Open skin
Granulation
tissue formation
HeNe 633 nm
50
0.5. 1.5.
4. 1 0 . 2 0
Once daily
Increase up to
4 J/cnr. then
decrease
Open skin
Rate of wound
closure and
collagen synthesis
HeNe 633 nm
45
4 , 10. 20
Once daily
None but 4
J/cm
increased
3-12 days
Wound area, effect

of eschar removal.
tensile strength
HeNe 633 nm
Argon 488
and 514 nm
35
3 6
Open skin
Rats
Open skin
Wound area
Mashiko
(1983)
Guinea pig
Open skin
Wound area
Hunter
(1984)'"
Pig
Open skin
Wound area
McCaughan
(1985)*
Mesicr
(1985)
Guinea pig
Open '.km
Wound area
Mice
Open skin
Abergel
(1987)*
Mice
Abergel
(1987)*'
Lyons
(1987)
4 J/cm
increased
healing and
collagen
synthesis
Immediate:
increased
regeneration
but adverse
with repealed
treatment
Variable
Every 3rd day

2X daily
2X daily
1.1
22
4.5
None
After 4 days
None
then 2 x weekly
Increased rate
Every 2 days
of healing
50
200
1
4
17
HeNe 633 nm
64
0.96
N/A
None
Argon 488
and 514 nm
20
Every 2 - 3 days
None
Wound area.
Ruby 694 nm
cellular content
of granulation tissue
N/A
I.I
2 x weekly
Increased rale
of closure
Open skin
Wound area.
collagen content,
tensile strength
HeNe 633 nm
4.05
1.22
Every other
day
Increased
collagen and
tensile slrenglh
Pig
Open skin
Procollagen levels
HeNe 633 nm
1.56
0.6
3X weekly
Increased
levels
Mice
Open skin
Wound area, tensile

strength, collagen
content
HeNe 633 nm
4.05
1.22
Every other
day
Increased
collagen and
tensile strength
Rochkind
(I989) *
Rats
Open skin.
burns.
peripheral
andCNS
Wound area, action

potential, neuron
degeneration
HeNe 633 nm
N/A
7.6
10
10
Daily for
20-21days
Increased rale
of healing.
action potential
increased and
degeneralion
reduced
Braverman
(1989)*
Rabbils
Open skin
Wound area, tensile

Strength, epidermal
thickness, collagen
area
HeNe 633 nm
and infrared
N/A
1.65 HeNe
8.25 IR
N/A
None, except
increased
tensile strength
Enwemeka
(1990)'
Rabbits
Tendons
Size, tensile strength.

energy absorption.
strain
HeNe 633 nm
N/A
1.2.3.4,
5mJ/cm
Daily
Size decreased.
no other
difference, but
fibroblasts and
collagen
aligned
/arkovic
(1991)"
Mice
Open skin
Wound area, serum

lipoprotein content
GaAs 830 nm
50-W pulses
N/A
210 seconds
daily, 7 days
Increased rate
of healing.
decrease in
LDLs
Rossetti
(I99I)'
Rat
Brain
Superoxide dismulase
HeNe 633 nm
1.08
N/A
Increased SOD
' I I " '-I'..1
(1983)
41
830 nm
42
45
47
T a b l e 152.
169
Examples of laser-mediated analgesia
K i l l KI.NCI
LASER
TREATMENT
LIT
MEASURE
COMMENTS
\ 1 -.111111 ct Jl.
830
60 mW CW
and pulsed
RA pain
163
82%*
Report
4 0 % placebo
H.i.l.iid et ul.
(1987)
633
0.9 mW. 9 0 s.
CW X 3 pw.
3/52. T
OA thumb pain
81
ns
Numeric*
*+ROM. strength, etc.
Bicglio el al.
(1987)"
633
N + IR
Radicular pain
+ ve*
Report
inflamm phase:
?ncural/vasc
mechanisms
Bliddal el ill.
(1987)*'
633
10 mW, 5 min.
X 3 pw. 3/52. T
RA pain
17
ns
VAS*
+ EMG etc;
?systemic effect*
Burgudjieva et al.
(1985)"
633
Postop pain
(gynecologic)
179
+ve
Report
Choi cl al.
(I986) *
904
<1 mW.60s.
X 2 pw. Acu
Painful elbow
67*
Report*
*+glucocorticoid
excretion
Duhenko ct al.
(1976)"
Tri neuralgia
106
+ve
Report
[F1.AI
Emmanouilidis
820
and Diamantopoulos
(1986)
l5mW.90s.
CW. X 5 pw. 2/52.
T
Sports injuries
62
90%*
Scotl/VAS**
Cumulative effect
*25%; placebo.
** +thermography
England ct al.
3 mW. 5 min.
Tendinitis
30
+ve*
VAS**
*p<
(1987)"
54
60
904
1DIAGNOSIS
(1989)"'
4000 Hz, T.
x3pw.2/52
Galpcrti cl al
(1987)"'
633
< 6 0 s . <7.2J/cm
PA pain
60
IR
10-20 min,
X5pw,4/52.T
AS. PA, LBP.etc.
546
Glykofridis
633;
and Diamantopoulos 660- 950
(I987)
< 2 5 mW. vartime.

CW. x 5 p w , T
Locomotor pain
200
Gussetti el al.
(1986)"
904/633
5 - 2 0 min.
x5pw,T
PA shoulder
30
Jensen et al.
(1987) **
904
0.3 mW. 30 min.

250 Hz. X 5 pw. T
PA knee
29
IR
X URx.T
Various
60
Kalsclal. (1985)"" 633
Oral pain*
88
Krcc/i and Klinger

(1986)""
633
2 mW. 3 0 s.
100 Hz. 1 Rx. Acu
Radicular pain
21
1 .onaiiiT
633/IR*
10 min, 15/365. T
OA pain hand
40
633
PHN
CO,
5 mW. CW?.
<20min. X5pw.
3/52. N + T
Mastalgia
Mayordomo cl al.
(1986)"
co
< 2 5 W. scan. CW.

Locomotor pain
5 - 1 0 min, X2 pday
82
Mester and Mesicr

(1987)"
Clust
50 mW
Wound pain
Morselli el al.
(1985a)
CO,
< 2 5 W scan.
CW. 5 - 1 0 min.
X 3 pw
OA pain
Morselli et al.
(19856)'*
co
Roumeliotis et al.
(1985)
[FLA]
.001;
**+goniomelry
+ve
Quest
87%
Report*
* +functional;
cumulative effect
N*
+ve
Numeric
Comparative sludy:
.'analysis
SO' 'i
Report*
*+X-ray invest
nil
Report*
crossover study:
*+drug intake
79%*
Numeric
*46% "effective /
34% fair
+ve
Report
[FLA], 'sialadenitis
-l-ve*
Adapt V A S
*/><.00l, max post

1 h; effects 9.6 ii
+ve**
combination
preferable; ** +
grip strength, etc.
150
+ve*
Report
|FLA| 'versus
alternatives
50
32%
Keele/Lasa/
Map
[Ab]
;lt80%
Numeric*
* + thermography
+ve
200
>70%*
[Ab], *62% acute

effect; effects
cxlend>l h
< 2 5 W . scan. CW?;

Sports injuries
10-15 min. X2 pday
>I0
0
+ve
Report
[Ab]
820
15 m W . C W .
< 2 5 min. X5pw.
2/52. T
Snorts injuries
31
+ve
VAS*
|Ab|
*+thermography
Shiroto ct al.
(I986) '
830
< 3 0 s/pt, < 7 min.

T P + Acu
Various pain
160
0
85%
Report
[Ab]
Sicberl ct al.
(I987) *
633; 904
< 3 0 m W . 1200 Hz.

15 min, 10/365. T
Tcndinopalhies
64
ns
Numeric*
* +thermography;
.'placebo: 10-citi
distance
Oral pain
Report
[Ab]
Locomotor pain
400
+ve
T + TP
+ve
Report*
[FLA]
Gartner cl al.
(1987)"
Kamikawa and
Kyoto (1985)
67
(I986) "
Lukashcvich
(1985)"
Martinof^S?)
72
75
77
Simunovic(l987)"" 633
TernovoylP^)"
633
|Ah|
170

T a b l e 15-2. Examples of laser-mediated analgesia (continued)
<; 11 K : \ i i
LASER
TREATMENT
DIAGNOSIS
El'T
Ml
Vidovich el al.
(1987)
co
1 mW
RA pain
272
75%
VAS*
|Ab] * + drug intake,

etc.
Walker (1983)
COMMENTS
A M Kl
633
1 mW, < 3 0 s . 20 Hz, Chronic pains

X 3 p w , 10/52.
N + T
36
73%
VAS*
Chronic effect, * + 5 IIIAA
Walker el al.
(1986)"
633
1 mW, X 3 pw.
10/52
RA pain
64
+ve*
VAS**
*/><.0()l. **+drug
intake
Willner e! al.
(1985)"
904
6 0 s , 1000 Hz.
OA pain hands
67
62%
MPQ*
| A b ] . *+drug intake
Zhou Yo Cheng
(1987)
C0
30 mW, Acu
Minor surgery
40
95%
Report*
[Abl. *+drug intake
D. double-blind; P. placebo-controlled; BIT, efficacy; Measure, pain measurement method used; RA. rheumatoid arthritis; |Ab|, abstract; pw, per week, e.g..
3/52 = 3 weeks; T. topically applied to lesion; ns, nonsignificant findings; ROM, range of movement; N, applied to nerves/nerve r<x>ts; VAS, visual
analogue scale; EMG, electromyography; |FLA|, foreign language abstract; Acu. applied to acupuncture points; Tri, trigeminal; PA, periarthrilic pain; AS,
ankylosing spondylitis; l.BP. low back pain; Rx, treatment; OA, osteoarthritis; PHN. postherpetic neuralgia; Scan laser used in conjunction with scanning
1. Protein s y n t h e s i s T h e effect of r u b y laser L I L R on

R N A and D N A protein s y n t h e s i s i n h u m a n f i b r o b l a s t
c u l t u r e s w a s studied. T h e r e w a s a significant i n c o r p o r a tion of t h y m i d i n e related to t h e n u m b e r of fibroblasts in
t h e S-stage of t h e cell c y c l e . T h e S - s t a g e is the stage of
D N A synthesis p r i o r t o cell d i v i s i o n . T h e i n c o r p o r a t i o n
of uridine and valine w a s only increased by a s m a l l
a m o u n t . T h i s implies an increase in t h e n u m b e r of cells
in t h e process of r e p r o d u c t i o n .
2 . C o l l a g e n s y n t h e s i s A series o f e x p e r i m e n t s i n v o l v i n g
ulcers and n o n h e a l i n g w o u n d s , u s i n g L I L R from H e N e
and argon ion lasers of a b o u t 4 J / c m , s h o w e d a significant increase in c o l l a g e n fibers, w h i c h increased with
s u b s e q u e n t e x p o s u r e s to L I L R . It w a s t h o u g h t that t h e
rates of incorporation of g l y c i n e and proline indicated
that the p r i m a r y effect of L I L R w a s in t h e s y n t h e s i s of
collagen d u r i n g t h e c o l l a g e n o u s p h a s e o f w o u n d healing.
T h e r e w a s also a n a p p e a r a n c e o f vesicles h a v i n g e l e c t r o n - d e n s e nuclei in both i n t r a c y t o p l a s m i c and intercellular material. T h e s e vesicles w e r e t h o u g h t t o r e l e a s e
bioactivc s u b s t a n c e s that p r o m o t e d h e a l i n g in nonirradiated areas of the w o u n d .
3 . D N A s y n t h e s i s H u m a n l y m p h o c y t e c u l t u r e s stimulated with p h y t o h e m a g g l u t i n i n ( P H A ) and treated with 1
J / c m of L I L R had a 2 0 % i n c r e a s e in t r a n s f o r m a t i o n of
l y m p h o c y t e s t o large-size, b l a s t - t y p e c e l l s c o m p a r e d
with cultures that w e r e only s t i m u l a t e d with P H A but
not treated with L I L R . T h i s w a s associated with an increase in t h e rate of s y n t h e s i s of D N A of t h e l y m p h o cytes. T h e r e w a s n o effect o f L I L R o n l y m p h o c y t e s that
had not been stimulated with P H A .
4 . Cell replication and p r o l i f e r a t i o n H e a l i n g o f artificially c r e a t e d skin defects in w h i t e m i c e w a s significantly accelerated w h e n treated by ruby l a s e r L I L R . In
t h e treated w o u n d s , there w a s a h i g h e r n u m b e r of dividing cells and the w o u n d s c l o s e d m o r e q u i c k l y . L I L R of 1
J / c m from a H e N e laser p r o d u c e d a significant a c c u m u lation of t h e E and F types of p r o s t a g l a n d i n in the first 4
d a y s after w o u n d i n g .
2
M a n y o t h e r r e s e a r c h e r s e x a m i n i n g t h e effects of L I L R on
cell function h a v e reported c h a n g e s in cell proliferation,
motility, p h a g o c y t o s i s , i m m u n e r e s p o n s e , and respiration.
Basford
h a s o b s e r v e d increases i n R N A s y n t h e s i s , cell
g r a n u l e r e l e a s e , cell motility, m e m b r a n e potential, cell
b i n d i n g affinities, n e u r o t r a n s m i t t e r release, o x y h e m o g l o b i n
d i s s o c i a t i o n , p h a g o c y t o s i s , a d e n o s i n e triphosphate ( A T P )
s y n t h e s i s , intercellular m a t r i x , and p r o s t a g l a n d i n synthesis.
R e c e n t l y , investigators h a v e s h o w n that a n e n h a n c e m e n t
o f cultured h u m a n k e r a t i n o c y t e m i g r a t i o n s u b s e q u e n t t o
L I L R e x p o s u r e c o u l d be attributed to an increase in kera t i n o c y t e motility, but not to p r o l i f e r a t i o n . T h e effect of
L I L R on c o l l a g e n and protein s y n t h e s i s and cell proliferation h a s b e e n found by s o m e r e s e a r c h e r s to p r o d u c e both inc r e a s e s and d e c r e a s e s in those p r o c e s s e s .
Irradiation of n o r m a l h u m a n m u c o s a l fibroblasts with infrared d i o d e lasers has been s h o w n to h a v e a biostimulative
effect on D N A s y n t h e s i s ' similar to that o b s e r v e d in H e L a
cells.
T h e s e effects generally a r e significant and a r e t o o wides p r e a d t o b e e a s i l y d i s m i s s e d . A l t h o u g h t h e effects o f L I L R
on cell function h a v e been repeatedly d e m o n s t r a t e d , to this
d a t e t h e r e has been n o elaboration o f t h e p r e c i s e m e c h a n i s m s by w h i c h these effects are p r o d u c e d . T h e r e h a s been
s p e c u l a t i o n that t h e respiratory chain c o m p o n e n t s of the mit o c h o n d r i a t h e c y t o c h r o m e s and the p r o p h y r i n s m i g h t
be t h e p r i m a r y p h o t o a b s o r b e r s in t h e visible and near-IR
wavelengths.
I t h a s b e e n s u g g e s t e d that L I L R may activate t h e e n z y m e s in the electron-transport chain directly,
alter cellular s i g n a l i n g , or increase production of A T P , foll o w e d b y the a u g m e n t a t i o n o f D N A s y n t h e s i s and cell proliferation. T h e action s p e c t r u m of L I L R for w a v e l e n g t h s
from 3 0 0 to 9 0 0 nm m e a s u r e d by t h e synthesis rate of nucleic acids in H e L a cell c u l t u r e s h a s been d e t e r m i n e d . T h e
action s p e c t r a reveal m a x i m a in the s y n t h e s i s of D N A and
R N A a t 4 0 0 , 6 3 0 , 6 8 0 , 7 6 0 , a n d 8 2 0 n m . H o w e v e r , the direct activation of e n z y m e s as t h e basis for increased D N A
s y n t h e s i s a n d c o n s e q u e n t therapeutic effects h a s not yet
been verified.
6,8
17
19
2 02 1
2 2
O n e of the most o b v i o u s c a n d i d a t e s for absorption of the
longer w a v e l e n g t h s is a h e m o p r o t e i n , p r o b a b l y o n e or m o r e
c o m p o n e n t s o f the mitochondrial o x i d a t i v e p h o s p h o r y l a t i o n
system and its constituent c y t o c h r o m e s . T h e formation o f
A T P following e x p o s u r e t o H e N e L I L R a t a n e n e r g y d e n sity of 5 J / c m points to t h e o x i d a t i v e p h o s p h o r y l a t i o n s y s tem in the inner m i t o c h o n d r i a l m e m b r a n e s . C y t o c h r o m e s
A - A 3 and c o p p e r c o m p l e x , or c y t o c h r o m e o x i d a s e , form a
functional c o m p o n e n t of the t e r m i n a l electron transport s y s t e m that a b s o r b s light e n e r g y in t h e r e d u c e d but not in t h e
oxidized s t a t e . C y t o c h r o m e o x i d a s e h a s a n absorption
peak a t 8 3 0 n m and also a t 6 0 5 n m . C y t o c h r o m e s o f the
mitochondrial o x i d a t i v e p h o s p h o r y l a t i o n s y s t e m might prod u c e a series of c h r o m o p h o r e s that a b s o r b light o v e r t h e
w i d e r a n g e of w a v e l e n g t h s in w h i c h L I L R p h o t o b i o s t i m u l a tion is o b s e r v e d to occur. B e c a u s e of the low a b s o r p l i v i t i e s ,
relatively high p o w e r m a y be required to initiate p h o t o n
23
171
sure. T h e s e factors only serve to further o b s c u r e an already

confused area of research. O n l y careful research in the future c a n e l u c i d a t e t h e m e c h a n i s m s r e s p o n s i b l e for t h e effects of L I L R on biologic m a t e r i a l s .
2 4
FURTHER RESEARCH
Effects of Repetition Rates
25
2 6
c o n v e r s i o n into h i g h - e n e r g y p h o s p h a t e ( A T P ) . B e c a u s e
ascorbic acid c r o s s e s the cell m e m b r a n e against a c o n c e n tration gradient t h r o u g h a p r o c e s s that can be b l o c k e d by
u n c o u p l i n g o x i d a t i v e p h o s p h o r y l a t i o n , inhibiting electron
transport, or a n a e r o b i o s i s , t h e c h a n g e in intracellular a s c o r bate c o n c e n t r a t i o n can selectively alter c o l l a g e n s y n t h e -
sis
27
T h u s , o n e h y p o t h e s i s p r o p o s e d for the basis of the p h o t o bioslimulative effects of L I L R h a s been the direct stimulation o f A T P p r o d u c t i o n . H o w e v e r , this h y p o t h e s i s s e e m s t o
be ruled out by the c o n t r a d i c t i n g o b s e r v a t i o n that b i o s t i m u lation by H e N e laser radiation of H e L a cells i n c r e a s e s t h e
stress from trypsinization and plating 5 m i n u t e s after e x p o sure; a significant d e g r a d a t i o n o c c u r r e d in the e x p o s e d cells
c o m p a r e d with the n o n i r r a d i a l e d c o n t r o l c e l l s . If t h e
trypsinization w a s d e l a y e d until 3 0 t o 2 4 0 m i n u t e s after e x posure to L I L R , the n u m b e r of irradiated cells increased
within the first w e e k and later d e c r e a s e d to b e l o w t h e level
of t h e control cells. T h u s , the initial and short-term effect of
LILR cannot be a result of direct stimulation of t h e A T P
production.
It has been s h o w n that free radicals are present after e x 18
28,2
posure o f biologic m a t e r i a l s t o L I L R . ' ' T h e p h o t o c h e m i cal or p h o t o d y n a m i c p r o d u c t i o n of free r a d i c a l s and o x i dants has been p r o p o s e d as t h e c a u s e of t h e effects on
cellular function p r o d u c e d by L I L R .
3 0 , 3 1
T h e r e h a v e been s u g g e s t i o n s that the effects of L I L R

may be d u e to the absorption of light in c h r o m o p h o r e s producing photophysical vibrational a n d local thermal eff e c t s . T h e c h a n g e s in the stereotaxic c o n f i g u r a t i o n of biologic m o l e c u l e s p r o d u c e d by excitation of vibrational slates
by the L I L R as well as by localized h e a t i n g c o u l d alter t h e
kinetics of b i o c h e m i c a l r e a c t i o n s at specific sites d u r i n g
those p h a s e s of cellular p r o c e s s e s that a r e particularly v u l nerable to alteration. T i m i n g of e x p o s u r e to t h e c e l l u l a r
p h a s e s w o u l d be critical a n d difficult to c o n t r o l unless c a r e ful s y n c h r o n i z a t i o n of the c u l t u r e s w e r e m a i n t a i n e d . T h e
variability of the effects of L I L R in s o m e of t h e s t u d i e s
cited m a y be explained by this sensitivity to t i m i n g of e x p o 32
In pulsed laser a p p l i c a t i o n , t h e pulse rate m a y be an important e x p e r i m e n t a l p a r a m e t e r t o e x a m i n e . T h e lifetime o f

s o m e e x c i t e d m o l e c u l a r states m a y b e l o n g e r than the p e riod of t h e p u l s e , a l l o w i n g for less efficient absorption of
e n e r g y . A l s o , there m a y be a relaxation lime for the bioc h e m i c a l p r o c e s s e s resulting from photon a b s o r p t i o n , which
m a y be longer than t h e pulse period that would reduce the
efficiency of e n e r g y transport into the cellular process.
Timing of Exposure to Cellular Processes

As m e n t i o n e d in the p r e v i o u s section, the t i m i n g of e x p o sure to L I L R m a y be critical in d e t e r m i n i n g the effectiven e s s o f the e x p o s u r e t o alter cellular p r o c e s s e s . For e x a m p l e , d u r i n g D N A s y n t h e s i s the b o n d s o f the D N A m o l e c u l e
are altered, p r o d u c i n g a c h a n g e in the m o l e c u l a r absorption
spectra. T h i s c h a n g e in a b s o r p t i o n s p e c t r a w o u l d d e p e n d on
the stage of replication in the cellular c y c l e . T h u s , maintaining a s y n c h r o n i z e d cell culture m a y e n h a n c e the effects o b s e r v e d in L I L R p h o t o b i o s l i m u l a t i o n .
Effects of Exposure to Simultaneous Multiple

Wavelengths
O n l y a f e w reports of m u l t i p l e w a v e l e n g t h e x p o s u r e to
L I L R b i o s t i m u l a t i o n can be found in the l i t e r a t u r e . ' T h e
c o m b i n e d effects o f multiple w a v e l e n g t h L I L R ( M W L 1 L R )
m a y result in e n h a n c e d p h o t o b i o s t i m u l a t i o n b e c a u s e of s y n ergistic a c t i o n . T h e a b s o r p t i o n of a p h o t o n of o n e w a v e 33
34
length by a c h r o m o p h o r e can e x c i t e that m o l e c u l e into a

long-lived state. T h e m o l e c u l e in t h e excited state m a y h a v e
e n h a n c e d a b s o r p t i o n of a p h o t o n with a w a v e l e n g t h that
w o u l d not be a b s o r b e d by the m o l e c u l e w e r e it in its unexcited s t a t e . T h e c o m b i n e d a b s o r p t i o n o f t w o sequential p h o t o n s c a n result in g r e a t e r e n e r g y transfer to the cell c o n t a i n ing t h e b i o m o l e c u l e than w o u l d be e x p e c t e d from the
absorptivity of e a c h p h o t o n individually. B e c a u s e laser
light i s highly m o n o c h r o m a t i c , M W L I L R e x p o s e s b i o l o g i c
m a t e r i a l s t o m u c h h i g h e r p h o t o n d e n s i t i e s a t specific w a v e lengths than w o u l d be e n c o u n t e r e d in light from o r d i n a r y ,
incoherent s o u r c e s . T h e p r o b l e m i s q u i t e c o m p l e x b e c a u s e
t h e action s p e c t r a of m u l t i p l e w a v e l e n g t h s in cellular
p r o c e s s e s a r e not easily m e a s u r e d . H o w e v e r , such information w o u l d e n a b l e t h e m e c h a n i s m s of p h o t o b i o s t i m u l a t i o n
t o b e m o r e precisely elucidated and p e r h a p s b e used m o r e
effectively.
16
Tissue Fusion
Paul Kuo
Laser t e c h n o l o g y h a s b l o s s o m e d in recent y e a r s , along with

the e m e r g e n c e of n e w , active media and w a v e l e n g t h s . In
addition, laser delivery s y s t e m s are being miniaturized and
h a v e b e c o m e m o r e flexible and c o n v e n i e n t t o use. W i t h
these i m p r e s s i v e a d v a n c e s , potential h a s increased for further clinical application of lasers in surgery and m e d i c i n e .
T w o such areas are laser tissue fusion and p h o t o a c t i v a t i o n .
Photoaclivation refers to the use of laser w a v e l e n g t h s to initiate solidification of protein tissue a d h e s i v e s and tissue
substrates, which facilitates laser t i s s u e - w e l d i n g .
Clinical u s e of lasers in s u r g e r y and dentistry has not yet
been universally a c c e p t e d for a n u m b e r of r e a s o n s . T h e s e
included the large size and cost of e q u i p m e n t , lack of portability, and the unfamiliarity of a n e w e r s y s t e m that requires
training and practice as c o m p a r e d with c o n v e n t i o n a l s u r g i cal instruments such as scalpel or e l e c t r o c a u t e r y . T h e myriad w a v e l e n g t h s and s y s t e m s a v a i l a b l e , each with its o w n
specific properties and h e n c e clinical a p p l i c a t i o n , a d d s to
the confusion in this field. For w i d e s p r e a d laser use in
surgery and m e d i c i n e , t h e s y s t e m s h o u l d be c o m p a c t , reliable, i n e x p e n s i v e , and easy t o use. T o a c h i e v e these ideals,
miniaturized m o d e l s of C O s laser with flexible w a v e g u i d e
delivery s y s t e m s and n e o d y m i u m : y t t r i u m - a l u m i n u m - g a r n e t
( N d : Y A G ) lasers w i t h o u t need for w a t e r c o o l i n g h a v e been
d e v e l o p e d . But the system that h a s the best p r o s p e c t for
w i d e a c c e p t a n c e in s u r g e r y and dentistry is that of t h e d i o d e
lasers. T h e s e are d e s k t o p and h a n d h e l d units that are s m a l l ,
portable, and relatively i n e x p e n s i v e . D y e - e n h a n c e d p h o toablation and p h o t o a c t i v a t i o n will facilitate the use of
these l o w e r - p o w e r lasers. At t h e s a m e t i m e , research is
being c o n d u c t e d to increase the p o w e r output of d i o d e
lasers with the e x p e c t a t i o n that they m a y b e c o m e the d o m i nant laser s y s t e m in surgery, especially for a e r o s p a c e and
military applications (see C h a p t e r 17).
Laser tissue fusion is being investigated as an alternative
to surgical closure with s u t u r e s . A l t h o u g h sutures a n d staple
h a v e w o r k e d well in g e n e r a l , laser tissue fusion t e c h n o l o g y
is particularly suited to e n d o s c o p i c and l a p a r o s c o p i c
1
surgery. Laser tissue fusion h a s the a d v a n t a g e of s m a l l e r

instrumentation, g r e a t e r speed, e a s e of u s e , and d e c r e a s e d
inflammatory r e s p o n s e with little or no foreign b o d y r e a c tion. It also a l l o w s w e l d e d tissue the ability to g r o w , as
c o m p a r e d with c o n v e n t i o n a l sutures that inhibit g r o w t h .
F u r t h e r m o r e , it offers a c o m p l e t e , circumferential seal of
the w o u n d for a watertight c l o s u r e and d e c r e a s e s l e a k a g e .
2
especially w h e n g l u e reinforcement is a d d e d . E x p e r i m e n t s
c o m p a r i n g bursting p r e s s u r e s of sutured versus laserg l u e - r e in forced a n a s t o m o s e s in a rabbit a o r t o t o m y model
s h o w e d greater early strength in t h e latter, using indocya
nine green d y e - t i b r i n o g e n g l u e e x p o s e d to 8 0 8 - n m diode
laser.*
DEVELOPING FRONTS
As with laser p h o t o a b l a t i o n . laser tissue fusion requires
training, and its s u c c e s s and reliability a r e d e p e n d e n t on o p erator skill and j u d g m e n t . D e w and c o w o r k e r s ' used c o m puter-controlled N d : Y A G laser w e l d i n g in 169 laser skin
c l o s u r e s in pigs. T h e y reported g o o d healing without dehisc e n c e with good c o s m e t i c results. T h e N d : Y A G provided
similar penetration depth regardless of tissue w e t n e s s or
p i g m e n t a t i o n . M o r e importantly, the a u t o m a t e d welding
with c o m p u t e r controlled laser d o s i m e t r y ( p o w e r density,
e x p o s u r e d u r a t i o n , duty cycle) tends to provide a more uniform result, a l t h o u g h it d o e s not entirely obviate operator
j u d g m e n t in the final o u t c o m e .
T i s s u e g l u e o r " s o l d e r " refers t o fibrinogen o r o t h e r protein c o m p o u n d s that a r e used to a b s o r b laser energy during
w e l d i n g . T h i s further p r o v i d e s selective localization of the
laser e n e r g y , t h u s s p a r i n g the u n d e r l y i n g host or native tissue from collateral thermal d a m a g e r e g a r d l e s s of w a t e r content or p i g m e n t a t i o n . In addition to forming stronger b o n d s ,
the p r e s e n c e of tissue g l u e requires less e n e r g y for welding
and allows t h e use of s i m p l e r laser s y s t e m s . M o r e o v e r , the
margin for error is greater as unsuccessful or imperfect
" w e l d s " m a y be adjusted by s e c o n d a r y t r e a t m e n t s without
ill effects to t h e host tissue.
T o a c h i e v e d y e - e n h a n c e d p h o t o a c t i v a t i o n , the laser/dye
pairs a r e c h o s e n so that their w a v e l e n g t h s / a b s o r p t i o n peaks
are closely m a i n t a i n e d . T h i s allows efficient target-specific
d e l i v e r y of laser e n e r g y and e n h a n c e m e n t of laser tissue fusion. O n e such laser/dye c o m b i n a t i o n u s e s fibrinogen e x tracts with i n d o c y a n i n e green and an 8 0 8 - n m solid-state
d i o d e l a s e r . T h e 8 0 8 - n m w a v e l e n g t h c o r r e s p o n d s to an o p tical window * for vascular and o t h e r tissues. In addition,
adding i n d o c y a n i n e green d y e permits selective tissue effects at the a r e a of d y e application w h i l e sparing adjacent
native tissue, b e c a u s e the latter d o e s not a b s o r b within the
7
175
176
8 0 8 - n m w i n d o w . C l e a r l y , this m i n i m i z e s d a m a g e t o t h e native host tissue. T h e physical a n d optical p r o p e r t i e s of tissue

g l u e are d e t e r m i n e d by the protein and carrier g r o u n d s u b stance as well as by the d y e . T h e o r e t i c a l l y , by m a n i p u l a t i n g
the p r o p o r t i o n s of these s u b s t a n c e s , p r o p e r t i e s of the tissue
g l u e can be altered to suit specific u s e s and r e q u i r e m e n t s .
H o w e v e r , o b t a i n i n g fibrinogen for clinical u s e is p r o b l e m atic, because h o m o l o g o u s s o u r c e s present a risk of a c q u i r e d
infection.
MECHANISM
T h e exact m e c h a n i s m of tissue fusion is not clear. It is g e n erally a c c e p t e d that fusion is a result of p h o t o t h e r m a l a c tion. T h e r e is also speculation as to w h e t h e r p h o t o c h e m i c a l
b o n d s are formed or c h a n g e d d u r i n g the fusion p r o c e s s .
Studies of the effect of laser w e l d i n g on structural protein
( c o l l a g e n ) a r e not c o n c l u s i v e . T h i s is in part d u e to t h e u s e
of different w a v e l e n g t h s and w e l d i n g p a r a m e t e r s . N e v e r t h e less, there a r e s o m e s u g g e s t i o n s of formation or d e g r a d a t i o n
of covalent b o n d s . O v e r a l l , a high e n o u g h e n e r g y or t e m perature is n e e d e d to c a u s e protein d e n a t u r a t i o n in target
tissues so that an a m o r p h o u s c o a g u l u m is formed that infiltrates the native tissue. In this s e n s e , t h e fibrin g l u e or s o l der constitutes a b i o d e g r a d a b l e scaffold on w h i c h tissue
edges heal.
9
IN VIVO STUDIES
In v i v o studies performed on blood vessels h a v e p r o v i d e d
s o m e insight into the process of laser a n n e a l i n g or c o a p t a tion. A s s e s s m e n t of these studies has been m a d e difficult by
the use of different laser w a v e l e n g t h s and p a r a m e t e r s in different studies. In g e n e r a l , l a s e r - b o n d e d vessels a r e found to
be s m o o t h e r and less rigid than sutured controls. T h e o r e t i cally this results in less turbulent (low d o w n s t r e a m and
h e n c e less t r a u m a to the intima. M o r e o v e r , fibrinogen g l u e
is reabsorbed w i t h o u t a foreign b o d y reaction, in c o n t r a d i s tinction to the c a s e w h e n sutures are used. S t u d i e s of stressstrain analyses reveal similar strength in laser-repaired v e s s e l s . ' The a d v a n t a g e of laser w e l d i n g is especially e v i d e n t
in small vessels a n a s t o m o s e s w h e r e s u t u r i n g is difficult.
T h e y are s i m p l e r to weld, particularly w h e n the use of tissue glue o b v i a t e s t h e need for precise tissue e d g e a p p r o x i mation w h i l e also p r e v e n t i n g e x c e s s i v e h e a t i n g of host tissues. Reapplication and retrial of fusion can also be carried
out w i t h o u t d a m a g e to native tissue, and w e l d e d vessel tissue has been o b s e r v e d to g r o w freely as c o m p a r e d with restricted g r o w t h of suture-repaired t i s s u e .
9
S i m i l a r o b s e r v a t i o n s of d e c r e a s e d foreign b o d y reaction
and e a s e of operation w a s noted for skin c l o s u r e . Increased
c o l l a g e n formation w a s found, with greater strength of
laser-fusion skin repair without any l o n g - t e r m w o u n d c o m p r o m i s e i n strength o r c o s m e s i s . " '

T h e first successful n e r v e regeneration of transected rat
sciatic n e r v e after epineurial repair using C O , laser was reported by D e w et a l . " in 1982. T h e e l e c t r o p h y s i o l o g y . a x o p l a s m i c transport, and light electron m i c r o s c o p i c studies of
t h e laser-repaired nerves d e m o n s t r a t e d c o m p a r a b i l i t y to
c o n v e n t i o n a l suture repairs.
R e g e n e r a t i o n of transected nerves is predicated upon successful a x o n a l g r o w t h into e n d o n e u r i a l tubes left patent by
wallerian d e g e n e r a t i o n of distal s e g m e n t s . C o a p t a t i o n of
transected n e r v e with s u t u r e s inherently d o e s not provide a
watertight seal. A x o n s sprout o u t s i d e the fascicular and
epineurial c o n f i n e s , forming a n e u r o m a with i n c o m p l e t e
reinnervation. I n v e s t i g a t o r s h a v e a t t e m p t e d to block such
aberrant a x o n a l g r o w t h by using different materials such as
c o l l a g e n sleeves, vein, silicon, g l a s s , and fibrin g l u e . Laser
tissue fusion p r o v i d e s a circumferential seal with less constriction at the repair site b e c a u s e of t h e lack of foreign
b o d y r e a c t i o n . C a m p i o n and c o w o r k e r s ' used a n argon
laser to repair transected p e r o n e a l n e r v e of rabbits ( p o w e r
density 100 W/cm*. pulse d u r a t i o n 2 0 0 m s . spot size 0.5
m m via m i c r o s c o p e with m i c r o m a n i p u l a t o r ) . T h e y noted
e n h a n c e d , parallel a l i g n m e n t of n e r v e libers at the laser
n e u r o r r h a p h y site w i t h o u t inflammatory reaction or carb o n a c e o u s d e b r i s . C h a n g e s in c o l l a g e n substructure were
a l s o e v i d e n t , with actual interdigilation of the layered fibrils
o c c u r r i n g , t h u s a l l o w i n g for a m o r e c o m p l e t e epineurial
seal than w a s possible by suture repair. M o r e o v e r , laser-assisted n e r v e c o a p t a t i o n c o u l d be p e r f o r m e d in difficult to
reach p l a c e s and c o u l d b e d o n e m o r e rapidly.
Bailes and c o w o r k e r s " studied laser-assisted anastom o s e s in p r i m a t e peroneal nerves using a u t o g e n o u s sural
interpositional fascicular grafts. T h e y used a single slay suture, w h i c h w a s later r e m o v e d , to aid in the repair and
found no difference b e t w e e n the laser e x p e r i m e n t a l g r o u p
as c o m p a r e d with the s u t u r e control g r o u p with respect to
c o n t i n u i t y of n e r v e , c o n d u c t i o n velocity, axon fiber density,
and d i s t a l / p r o x i m a l m y e l i n a t e d liber d e n s i t y . Notably, therew a s less a x o n a l e s c a p e into extrafascicular s p a c e in the
laser-assisted g r o u p , w h o s e sites of repair w e r e not disc e r n i b l e g r o s s l y or m i c r o s c o p i c a l l y at harvest. Other workers h a v e noted w e a k e r tensile strength at coaptation sites in
n e r v e treated with laser tissue f u s i o n . A g a i n , a wider a n g e of w a v e l e n g t h s and e n e r g y w e r e used in these studies
on peripheral n e r v e or interpositional grafts to decrease ten
sion at coaptation sites and support the laser fusion. Potentially, these a d a p t a t i o n s w o u l d c o m p r o m i s e n e r v e regeneration. A t t e m p t s t o c i r c u m v e n t p r o b l e m s with sutures and
additional a n a s t o m o s i s sites from interpositional grafts by
using o t h e r m e t h o d s such a s s u b c u t a n e o u s ( S Q ) w e l d i n g
with a SQ tissue s l e e v e " to boost strength of the anastom o s e s h a v e o n l y had limited success. Further work in this
a r e a is clearly n e e d e d , b e c a u s e t h e full potential for physically c o a p t i n g s e v e r e d n e r v e e n d s with s u t u r e s h a s seemingly been r e a c h e d ( F i g s . 16-1 to 1 6 - 4 ) .
2
Tissue Fusion
177
Figure 1 6 - 1 . Rat sciatic nerve. Nerve transected and then fused

with KIO-nm dye laser. CW at 680 mW for 20 seconds. 660-u.m
spot size. (I0X.) (Courtesy of Lewis dayman. D.M.D.. M.D.)
Figure 1 6 - 4 . Rat sciatic nerve. CW COo laser. 600-p.m spot

size, P = 0.4 W. PW = 0.2 sec. Six weeks: nerve continuous.
(S100 stain.) Partial neuroma at site of stay suture. (25X.)
(Courtesy of Lewis dayman. D.M.D.. M.D.)
Figure 116-2.
6 - 2 . Sciatic
Sciatic nerve
nerve at
at 66 weeks.
weeks. Dense
Dense staining
staining vertical
vertical
band indicates persistent scar. (50X.) (Courtesy of Lewis
dayman. D.M.D.. M.D.)
M.D.)
Figure 1 6 - 5 . Six weeks. Healing complete. Minor disturbance

of axonal architecture. (S100 stain.) (25X.) (Courtesy of Lewis
dayman. D.M.D., M.D.)
REFERENCES
1. Bass LS, Ozc MC. Auteri JS. et al. Laparoscopic applications
of laser-activated tissue glues. Proc SPIE 1991; 1421:
164-168.
2. Frazier OH, Painvin GA, Morris JR, et al. Laser-assisted
microvascular
anastomoses:
angiographic
and
anatomopathologic studies on growing microvascular
anastomoses: preliminary report. Surgery 1985;97:585-590.
3. Oz MC. Johnson JP. Parangi S, et al. Tissue soldering using
indocyanine green dye enhanced fibrinogen with the near
infrared diode laser. J Vase Surg 1980; 11:718-725.
4. Dew DK, Hsu TM, Hsu LS, ct al. Laser assisted skin closure
at 1.32 microns: The use of a software driven medical laser
system. Proc SPIE 1991; 1422:111 -115.
5. Grubbs PE, Wang S, Marini C. et al. Enhancement of C 0
laser microvascular anastomoses by fibrin glues. J Surg Res
1988;45:112-119.
6. Poppas DP, Schlossburg SM, Richmond IL, et al. Laser
welding in urethral surgery: improved results with a protein
solder. J Urol 1988:139:415-417.
2
Figure 1 6 - 3 . Same rat. Residual histologic signs of thermal

damage and incomplete nerve healing still present. (250X.)
(Courtesy of Lewis dayman. D.M.D.. M.D.)
17
Laser Application in Microgravity,

Aerospace, and Military Operations
Paul C. Kuo, Michael D. Colvard
Research in s p a c e m e d i c i n e s u g g e s t s thai t r a u m a t i c injuries

in space are reduced, but not e l i m i n a t e d , d u e to m i c r o g r a v ity. T h e need for surgical repair is clear. C o n v e n t i o n a l
Surgical t e c h n i q u e s arc possible in m i c r o g r a v i t y , but it is
difficult to c o n t r o l , c o n t a i n , and collect fluids, and there is a
tendency for arterial blood to scatter.
1,2
T h e first use of a C O , laser to perform facial and a b d o m i nal surgery on rats while a b o a r d an aircraft during high-altitude pressurized flight w a s r e c o r d e d in 1992. T h e e x p e r i ment d e m o n s t r a t e d that aircraft safely and o p e r a t i o n s are
not c o m p r o m i s e d by the u s e of a medical laser in flight.
Environmental c o n t a m i n a t i o n by tissues and fluids w a s
minimal with the use of laser p h o t o a b l a t i o n and p h o t o c o a g ulation for control and stabilization of b l e e d i n g w o u n d s .
Furthermore, the r e d u c e d flotsam and the reusable nature
of the portable laser a l l o w e d for a reduction in the quantity
of surgical materials required without c o m p r o m i s i n g p r o p e r
surgical and w o u n d care in e x p e r i m e n t a l rats. T h e investigators o b s e r v e d that surgical precision c o u l d be e n h a n c e d
by the use of a c o n t a c t laser to c o u n t e r to s o m e extent the
unpredictable nature of air t u r b u l e n c e . In this light, the
miniaturization of laser t e c h n o l o g y with s m a l l e r d i o d e
lasers of various w a v e l e n g t h s will p r o v i d e t h e flight surgeon with p o r t a b l e , reliable, r e - u s a b l e lasers for e x p e d i e n t
stabilization of w o u n d s in aviation and possibly in the z e r o gravity, weightless s p a c e e n v i r o n m e n t s .
7
Similar miniaturized and c o m p a c t laser units c a n be used

in trauma care and in field military o p e r a t i o n s by ( c o m b a t )
medics for w o u n d stabilization and e m e r g e n c y p r o c e d u r e s .
Early h e m o s t a s i s and w o u n d sealing r e d u c e s bacterial e x p o sure as well as b l o o d and fluid loss and i m p r o v e s w o u n d
healing. R e c e n t l y , a small, totally r e c h a r g e a b l e , N : - C a d
battery p o w e r e d d i o d e laser that e m i t s 7 W of energy al
81(1-900 nm c a p a b l e of c u t t i n g , c o a g u l a t i n g and c l o s i n g
wounds in the search and rescue e n v i r o m e n t h a s been d e veloped. To be effective, these miniaturized units s h o u l d
be configured with pre-set. c o n t r o l l e d p a r a m e t e r s for predictable w o u n d tissue r e s p o n s e . In addition, they must be
extremely lightweight, small, and rugged to withstand
8
w e a t h e r e x t r e m e s , vibration, and shock. T h e y must have

self-contained p o w e r s o u r c e s and be c o m p a t i b l e with an external p o w e r supply. Biological d r e s s i n g and d y e - e n h a n c e d
s u p c r s t r c n g t h tissue g l u e or s o l d e r c a p a b l e of photoactivation, w h e n d e v e l o p e d , will further e n h a n c e the potential for
rapid w o u n d closure using these laser s y s t e m s . As previously discussed, t h e u s e of tissue solder allows for a greater
margin of safety to native tissues as well as m o r e uniform,
r e p r o d u c i b l e results, particularly in unskilled h a n d s with
less surgical e x p e r t i s e . C u r r e n t l y , d i o d e lasers a r e the most
p r o m i s i n g in t e r m s of size and cost. A p p r o p r i a t e clinical
features a r e being d e v e l o p e d as m e n t i o n e d a b o v e , and the
introduction of d i o d e laser s y s t e m s with further i m p r o v e d
features and delivery p a r a m e t e r s s h o u l d be f o r t h c o m i n g .
REFERENCES
1. Gardener RM. Ostler DV. Nelson BD. et al. The role of smart
medical systems in the space station. Int J Monit Comp
1989:6:91.
2. Nelson BD. Gardener RM. Ostler V, et al. Medical impact
analysis for the space station. Avial Space Environ Med
1990:61:170.
3. Markham SM. R(xk JA. Deploying and testing an expandablesurgical chamber in microgravity. Avial Space Environ Med
1989:60:76.
4. Rock JA. An expandable surgical chamber for use in conditions
of weightlessness.
Avial Space
Environ
Med
1984:55:403.
5. Yaroshcnko. GL. Terentyn VG. Mokov MD. Characteristics of
surgical intervention under conditions of weightlessness.
Voen-MedZH 1967:10:69.
6. Space Life Sciences: A status report. Offices of Space Science
and Applications. NASA 1990;Feb:5.
7. Colvard MC. Kuo PC, Caleel R, et al. Laser surgery procedures in the operational KC-135 aviation environment. Avial
Space Environ Med I992;63:619.
8 Keipert AG. Garber DD, Colvard MD. Field Medical Laser
System (FMLS) for the Special Operations Command. Kirkland AFB. New Mexico. Phillips Laboratory Laser and Imaging Directorate, Airforce Material Command. 1994.
179
Figure 7-15.
One year. Hull range of motion of tongue. S p e e c h
is normal as it has been since the s e c o n d postoperative month.
Patient has been in regular c a n c e r surveillance protocol s i n c e
month 3.
Figure 7-17.
Figure 7-16.
Note
norma! range o f motion o n tongue
S p e e c h and s w a l l o w i n g were normal. Patient had
DO e v i d e n c e of disease at 3 years.
Appendix
C 0 X = 10.6 p m / 1 0 , 6 0 0 n m
P o w e r : C W u p t o 100 W .
RSPup to 25W
Pulse width 3 5 0 - 1 2 0 0 p s
Peak p o w e r 500-12(K) W / p u l s e
Pulsed: 1 0 - 6 0 0 m J / p u l s e ( u p t o 4 0 0 m J with S u r g i l a s e
150; 2 0 0 m J / p u l s e with Ultrapulse s y s t e m )
M i n i m u m spot size: 0 . 1 5 - 0 . 3 0 m m (0.3 m m with 125
mm focal length h a n d p i e c e )
0 . 6 - 0 . 8 m m for m i c r o s c o p e units with m i c r o s l a d
attachment
Delivery s y s t e m s
Waveguide
Articulated a r m (with coaxial H e N e a i m i n g b e a m )
Incision: spot size 0.3 m m : P D 1 0 W / c m ( 1 0 , 0 0 0
to >50,000 W / c m )
Contact N d : Y A G
Silica tips: varied
Typical power
Up to 10 W to mark periphery of t u m o r
To incise: 5 - 2 5 W d e p e n d i n g on tissue
N d : Y A G : free b e a m : X = 1064 nm
Aiming beam: HeNe: 5 mW

Power: l O O m W t o 100W
Pulse c a p a b i l i t y : 0.1 to 1.0 s e c and CW
fiber
delivery system
S L T Contact N d : Y A G
X = 1064 n m
Absorption characteristics
A b l a t i o n : spot size 2 . 0 - 2 . 5 m m P D
= 400-750
ABSORPTION
COEFFICIENT
W/cm
Estimation of PD = 100 W / d (d = d i a m e t e r of spot in
mm)
Representative Articulated A r m S y s t e m ( S h a r p l a n )
CW:0.I-I00W
RSP 0.5-2.0 W
Peak P = 4 3 0 W @ 4 5 0 m J / p u l s e
E n e r g y / p u l s e = 150 m J / 2 0 0 mJ
Pulse width = 7 7 0 ps
Aiming beam: 5 mW HeNe
Duty c y c l e : u p t o 1 5 %
C(>2 S c a n n i n g Lasers
PENETRATION
IN MEDIUM
co
Nd:YAG
Argon
water
(cm-')
blond
(cm-')
water
blood
(cm' )
778
0.40
800
4
330
0.001
2.5
10.000
0.001
0.25
0.0001
0.003
From Fuller TA. Chapter 1: Fundamentals of Laser Surgery (pp. I -17). In:
Surgical lasers: A Clinical Guide. New York. NY: Macmillan. 1987.
ErbiurmYAG
X = 2.94 nm
A r g o n / a r g o n :dye
X = 488, 514,585
U p to 5.0 W
Spot size: 5 0 p m t o 6 m m
A u t o m a t e d scanner: 1 7 5 - 3 0 0 mJ/pulse
Preset output for wrinkle r e m o v a l
T h e majority of the c a s e s presented in C h a p t e r s 4 and 7
w e r e performed with an R S P C O 2 laser with the following
characteristics:
CO2 Sharplan Laser Pulse Characteristics*

Actual (pulses per second
Avg. power (watts)
Pulse width (millisec)
Pulse period (millisec)
46
20
4.24
21.74
Duty cycle (%)

Avg. pulse power (watts)
Pulse energy (millijoules)
19.50
102.60
435
42
25
6.40
23.90
93.50
93.50
597
92
20
1.62
10.82
133.60
133.60
86
25
2.40
11.60
120.90
120.90
165
20
0.85
6.05
142.30
142.30
157
25
1.15
216
290
121
159
6.35
138.10
138.10
Note: Pulse characteristics measured from pulse generating circuitry. not from actual output. Data courtesy
J. Rosenshein. Ph.D.
181
182
Lasers in Oral and Maxillofacial Surgery
P = up to 5.0 W
Dye lasers
C a n d e l a S P T L vascular lesions laser
Pulsed d y e laser. I l a s h l a m p e x c i t e d
10J/cm
2 - m m spot size
AlexandriaPulsed d y e / a l e x a n d r i t e
4 J/cnr, 8 J/cm
3 - m m . 5 - m m spot size
G o l d v a p o r laser
2.0 W
X = 6 2 7 . 8 nm
For P D T
Copper vapor
Matching Laser to Chromophere

CHROMOPHORK
LASER
NAME
ArF
\\ A M . i
I:NC,TII(S)
193 nm
PEAK ABSORPTION
NAMH
Peptide bonds
220 nm
XeCI
308 nm
Bilirubin. Beta-carotene
-310nm
Ar
488 and 514 nm
Hemoglobin. Melanin. Bilirubin, Beta-carotene
400 - 500 nm
KTP (Nd:YAG freq. doubling)
532 nm
Hemoglobin. Melanin
550-600 nm
Cu vapor
511 & 5 7 8 nm
Hemoglobin.
Cytochrome a-a3.
Red & orange tattoos
550-600 nm.
=600 nm
510-532 nm
Au vapor
627.3 nm
HpD
350-630 nm
Kr
647 nm
Melanin
400-700 nm
Dye
500-800 nm
Hemoglobin. Tattoos. Melanin.

Cytochrome
PDT
550-600 nm
694.3 nm
Green/Blue/Black Tattoo ink
694, 755. 1064 nm
TLSapphire
600-1,100 nm
Cytochrome aa3
Green/Blue/Black Tait(x> ink
600 nm
694. 755. 1064 nm
Diode
670-1,550 nm
Green/Bluc/Black Tattoo ink
694, 755. 1064 nm
Alexandrite
720-800 nm
Green/Blue/Black Tattoo ink
694, 755. 1064 nm
Ruby
350-630 nm
Nd:YAG
1.064 nm
Non-specific
Th:YAG
2.010 nm
Water
> 1,400 nm
Ho: YAG
2.140 nm
Water
> 1.400 n m
ErYAG
2.940 nm
Water
Maximum at 2.940 nm
CO,
10,600 nm
Water
> 1.400 nm
Prmii: Roscnshoin J S . Ph.D. Physics oj''Surgical Lasers Oral and Maxillofacial Clinics of North America. I W 6 .
Glossary
Laser light o c c u p i e s several different positions within the

electromagnetic s p e c t r u m . T h e infrared e m i t t e r s a r e
arranged in the near infrared ( I R ) [ n e o d y m i u m : y t t r i u m - a l u m i n u m - g a r n e t ( N d : Y A G ) 1064 n m . H O : Y S G G / 2 0 8 0 n m ,
holmium (Ho):YAG/2100, erbium (Er):YAG/292() n m ] ,
mid I R ( C 0 : 10,600 n m ) ; the visible light g r o u p e n c o m passes all c o l o r s ( K T P / y e l l o w , a r g o n / g r e e n , h e l i u m neon/red, t u n a b l e flash p u m p - d y e / m a n y c o l o r s , and t h e ultraviolet g r o u p m a i n l y to 193 n m ) . All f o r m s of laser light
are properly c h a r a c t e r i z e d by the t e r m s listed b e l o w .
A b s o r p t i o n l e n g t h ( E x t i n c t i o n coefficient) A b s o r p t i o n
of the first 6 3 % of the delivered e n e r g y (rather than 9 0 % as
for extinction coefficient). T h i s 6 3 % absorption is m e a s u r e d
from the histologic s p e c i m e n c o r r e l a t i n g with the v a p o r i z e d
region of the target s p e c i m e n . T h e r e a r e a p p r o x i m a t e l y 2.3
absorption lengths in e a c h extinction length.
D u t y cycle D u t y cycle refers to the p e r c e n t a g e of t i m e
the laser is on per second w h e n used in a repeat-pulse
m o d e . It is the p r o d u c t of pulse width and repetition rate
multiplied by 100.
E n e r g y Energy is the c a p a c i t y to do w o r k or. in laser
terms, to v a p o r i z e tissue. It is m e a s u r e d in j o u l e s (J) and can
be looked upon as a m e a s u r e m e n t of d o s e . An important
concept to r e m e m b e r is that a finite a m o u n t of e n e r g y will
vaporize a finite v o l u m e of tissue. Studies h a v e s h o w n that
it takes 2.4 J of e n e r g y to vaporize 1 m m ' of soft tissue at a
fluence of a p p r o x i m a t e l y 4 J / c n r . Laser e n e r g y is a product
of power (watt) and t i m e of a p p l i c a t i o n (sec):
2
of e n e r g y delivery p e r unit area of target tissue. Practically

s p e a k i n g , it is a m e a s u r e of h o w intensely the b e a m is c o n c e n t r a t e d o v e r a g i v e n s u r f a c e area ( W / c m ) . T h e h i g h e r
t h e i r r a d i a n c e . t h e faster a g i v e n v o l u m e of t i s s u e is vaporized.
L a s e r p u l s e a n d p u l s e w i d t h ( P W ) D e p e n d i n g o n the
l a s e r m e d i u m , the laser light e m i t t e d m a y be c o n t i n u o u s or
pulsed. A c o n t i n u o u s w a v e laser b e a m (e.g., C 0 ) e m i t s a n
u n i n t e r r u p t e d b e a m at t h e output p o w e r set for as long as
the switch is turned on. It can also be c h o p p e d or gated to
form a train of p u l s e s . If t h e on-off duty cycle is controlled
by r e p e a t e d direct current c y c l i n g or by radio-frequency
c o n t r o l , rapid s u p e r p u l s e d output pulses of brief d u r a t i o n
occur. T h e s u p e r p u l s e b e a m h a s a p e a k p o w e r that far exc e e d s that set on the c o n s o l e p o w e r . U s u a l e n e r g y is 50 to
2 0 0 m J / p u l s e at p e a k p o w e r s up to 1200 W p e r p u l s e . Ultrap u l s e d lasers m a i n t a i n h i g h e r e n e r g y / p u l s e and produce
p u l s e s of 2 0 0 m J / p u l s e . T h e laser e x p o s u r e t i m e , called
p u l s e width or pulse d u r a t i o n , refers to t h e duration of an
individual pulse d u r i n g which e n e r g y is delivered. It has
been e s t i m a t e d that a pulse width as long as 6 5 0 ps is short
e n o u g h to p r e v e n t significant heat diffusion from the target
tissue to adjacent tissue, thereby p r e v e n t i n g significant unw a n t e d thermal d a m a g e .
2
P o w e r P o w e r is the rate of e n e r g y delivery, or h o w fast

e n e r g y flows. It can be t h o u g h t of as an instant m e a s u r e of
Energy (J) = Power (W) X Time

10 J = 1 W X 10 sec
10 J = I 0 W X sec
( T h e s a m e a m o u n t o f tissue i s r e m o v e d )
e n e r g y output. T h e unit of m e a s u r e m e n t is the watt ( W ) .

which is defined as o n e j o u l e per second. T h e line p o w e r
o u t p u t of a laser is the p o w e r of the laser b e a m at its exit
point from the laser.
P u l s e r e p e t i t i o n r a t e ( P R R ) Repetition rate i s the numb e r of laser p u l s e s p e r s e c o n d , m e a s u r e d in H e r t z ( H z ) .
E x t i n c t i o n l e n g t h Distance from the tissue surface at

which the incident b e a m has been r e d u c e d to 1 0 % of its initial intensity.
F l u e n c e ( E D ) F l u e n c e , or e n e r g y d e n s i t y , is the total
a m o u n t of e n e r g y delivered per unit area of the a p p l i e d
laser b e a m . It is the p r o d u c t of irradiance ( W / c m ) a n d t i m e
of laser application, e x p r e s s e d in J / c m . T h i s t i m e of laser
e x p o s u r e also d e t e r m i n e s t h e a m o u n t of heat c o n d u c t i o n to
cells i m m e d i a t e l y adjacent to the target tissue, referred to as
lateral thermal heat transfer.
I r r a d i a n c e ( P D ) Irradiance. or p o w e r density, is the rate
S p o t size Spot size refers to the d i a m e t e r of the laser

b e a m as m e a s u r e d by c r e a t i n g a laser impact of 0.1 sec at
10 W on a m o i s t e n e d w o o d e n t o n g u e blade. It varies with
the d i s t a n c e of the incident b e a m from the laser h a n d p i e c e
to the target tissue (see Fig. 3 - 7 ) . T h e e n e r g y distribution
within the b e a m s p o t is not uniform. R a t h e r , it follows a
G a u s s i a n c u r v e , b e i n g highest in t h e c e n t e r and t a p e r i n g off
t o w a r d the p e r i p h e r y , c r e a t i n g a laser crater as the b e a m hits
t h e target tissue (see Fig. 3 - 4 ) . A p p r o x i m a t e l y 8 6 % of this
b e a m is a v a i l a b l e to c r e a t e t h e v a p o r i z a t i o n crater. W h e n
the b e a m is in focus, the p o w e r d e n s i t y is at its h i g h e s t for
any given output p o w e r . B e c a u s e the a r e a of a circular spot
183
1 84
c h a n g e s with the square of its radius, a d o u b l i n g of the spot

size, w h e n the b e a m is d e f o c u s e d , will result in a fourfold
d e c r e a s e in p o w e r density. T h e r e f o r e , w h e n the laser is used
in the d e f o c u s e d m o d e , t h e b e a m g e o m e t r y is flattened out,
which permits controlled ablation of tissue to occur.
T h e r m a l r e l a x a t i o n t i m e T h e p r o c e s s b y which heat
diffuses through tissue by c o n d u c t i o n is referred to as thermal relaxation. T h e r m a l relaxation is the t i m e required for
tissue to dissipate 5 0 % of t h e heat a b s o r b e d from the laser
pulse by diffusion.
Z o n e o f c o a g u l a t i o n n e c r o s i s Lethally d a m a g e d tissue
s e c o n d a r y to lateral thermal d a m a g e (heat c o n d u c t i o n ) adjacent to t h e v a p o r i z a t i o n crater. M a y also be a carbonized
region.
/ o n e o f s u b l e t h a l i n j u r y Peripheral area injured b y lateral heat c o n d u c t i o n that has the capacity to recover.
Z o n e o f v a p o r i z a t i o n V o l u m e o c c u p i e d b y the vaporization crater. T h i s is the tissue actually r e m o v e d by the explosive vaporization of t h e laser pulse.
Index
Ablation
of dentin, 127-133
of recurrent tumor. I OK
tissue destruction, planes. 25-31
argon laser. 28. 29-31
technique. 29-30
diascopy. mucosa compressed. 30
first plane. 25-26
intralesional photocoagulation. 30-31
labiobuccal vestibule, vascular
malformation, 29
Nd:YAG, 27-28
contact laser probe tip. 28
postoperative care. 27
second plane, 26
third plane. 26-27
Absorption, of light, composite tissue, 7
Absorption length, defined, 183
Absorption spectrum, rluxlamine dyes, 139
Aerospace, laser application in. 179
Aesthetic surgery, skin resurfacing in, 79
Analgesia, laser-mediated. 167, I69t-170t
Anesthesia, general, avoiding, transoral resection.
oral cancer. 87
Argon laser, 28t. 29-31
complications, 33-35
telangiectasias, scarring after, 34
frequency-doubled Nd:YAG laser, 4
nonconlact. 32
skin penetration, inadvertent. 33
technique. 29-30
telangiectasias, scarring after treatment, 34
Bean profile. CO, laser, transverse, cross section,
24
Buccal mucosa
nodular leukoplakia, 38
prencoplasia. 50-51
cpithclialization, 51
first raster, 50, 51
mucosa, healing, 50
postoperative, 51
second raster. 51
proliferative granulation tissue. 107
transoral resection, oral cancer. 102-103
Carbon dioxide laser. See CO, laser
Caries, dental, susceptibility, lasers and. 133-134
Characteristics, of lasers, 3t
Chromophorc, laser, matched, 182
C 0 laser. 2-4, 19-25
advantages of. 19-20
articulated arm. 20
basis for use of, 20-22. 28t
beam
geometry. 24-25
profile, transverse, cross section, 24
disadvantages of, 20
energy, 23
cxcisional procedures. 65
Ouence. 23
2
Gaussian distribution, energy, 24-25

handpiece. 20
incisional procedures, 63-65
frenectomy, 63-64
vestibuloplasly, 64-65
irradiance, 22-23
laryngeal surgery. 121-126
Learner's curve. 23-24
microslad. 20
Nd:YAG, transoral resection, oral cancer, 87
power density, 23, 23t
tissue effects and, 23t
preneoplasia. oral cavity. 39-41
outline of lesion with. 42
transoral resection, oral cancer, 87
tumor debulking. transoral resection, oral
cancer. 108
uvulopalatoplasty. 111-120
as vaporization instrument, 72
W/cm2, 23.
Coagulation necrosis, zone of. defined. 182
Components, of lasers, 3
Contact laser surgery, overview, 8-9
Decay detection, dental, lasers and, 134
Dental caries, susceptibility, lasers and. 133-134
Dentin
ablation, laboratory setup, laser. 132
histology, 129
Dentistry, lasers in. 127-135
ablation. 127-133
decay detection. 134
dental caries, susceptibility, 133-134
dentin
ablation
Er:YAG laser, plume from. 132
laboratory setup. 132
histology. 129
ErYAG, canine teeth, hole. 128
extracted t<x>th. ablation holes, 131
hard dental tissue ablation, 127-133
materials processing, 134
pulpal histology, 129
Deoxyribonucleic acid. See DNA
Diascopy. mucosa compressed, 30
Diode laser. 4-5
DNA organization, papillomas, 55, 57
Duty cycle, defined, 183
Dyes, phototherapy with, 137-142. 139
definitions, 137
hematoporphyrin derivatives, 138
history. 137
light sources. 139-140
overview, 140-141
photodiagnostic imaging, 140
photodynamic therapy, 137-140
photooxygenation, mechanisms of, 137-138
photosensitizes. 139-140
rhodamine dyes
absorption spectrum, 139
molecular structure, 139
Ear tag, excision, 68

ED. Set Fluence
Electrical hazards, laser surgery, 16
Electromagnetic spectrum, 2
Endoscopic sinus surgery. 157-163
case study, 160-161
complications, 160
"Hosaka window" approach. 160
instrumentation. 159
overview. 161-162
paranasal sinuses, coronal view of, 157
postoperative considerations, 160
preoperative examination. 158-159
rationale. 157-158
technique, 159-160
Energy
defined. 183
density. See Fluence
Energy state, diagram. 2
Epulis fissuratum, 81
Erbium, yttrium-aluminum-garnetl. See Er:YAG
laser
Jt
Erthroplakia, ventral tongue, prencoplasia, 38
Er:YAG laser, 35 "
canine teeth. 128
dentin ablation, 132
Extinction
coefficient, defined. 183
length, defined, 183
Facial nevi, 78
Facial telangiectasias. 34
Fibrin coagulum. prencoplasia. oral cavity, 41.43
Fibrocpithelial hyperplasia, palate, 75-77
Fihroepithelial polyp, excision, 67
Fibroma, excision, 66
Fire hazards, laser surgery. 14-16
Fluence. defined. 183
Free-beam lasers. 8-9
contact laser surgery, vs. nonconlact. 8
modification, 8-9
transoral resection, oral cancer, 86
Frenectomy. with CO, laser. 63-64
General anesthesia, avoiding, transoral resection,
oral cancer, 87
Gingiva
grafting, 70
hypertrophy, 73
severe, 74
lingual, leukoplakia. 48-49
Goggles
patient protection with, 33
wavelength specific, 14
Handpiece, CO; laser. 20
Hazards, laser surgery. 11-16
electrical hazards, 16
fire hazards. 14-16
judgment errors. 11-12
optical hazards, 12, 13-14
185
186
Index
Hazards, laser surgery (Continued)

plume hazards. 16
skin hazards. 12-14
Heliotherapy. 165
Hemangioma
laryngeal, CO, laser. 122-126
malformation. 71
subglottic. CO, laser. 122-126
Hematoporphyrin derivatives, 138
Histology, pulpal. 129
History, of lasers, I
Holmium. yltrium-aluminum-garnctt. See
Ho: YAG laser
"Hosaka window" approach, endoscopic sinus
surgery. 160
Ho:YAG laser. 4, 35
temporomandibular joint surgery', energy levels
for, 35t
Human papillomavirus, 55-62
carbon dioxide laser. 58
epithelial hyperplasia, lateral tongue. 58
evaluation, clinical, laboratory, 57-58
infection, pathophysiology of, 57
active expression phase, 57
incubation phase. 57
inoculation. 57
virology, 55-56
DNA organization, 55,57
taxonomy, 55, 56
viral genetic function, 55
Hyperthermia, biologic effects. 145-146
Imaging-guidcd minimally invasive therapy.
photolhermal therapy. 146-148
Impacted teeth, exposure of, 69
Incubation phase, papillomas, human
papillomavirus. 57
Inoculation, papillomas, human papillomavirus,
57
Intralesional photocoagulation. 30-31
Irradiance
CO, laser, 22-23
defined, 183
Judgment errors, in laser surgery. 11-12
KTP laser. See Argon, frequencv-doublcd
Nd:YAG laser
I^ibiobuccal sulcus, vascular malformation of, 33
luibiobuccal vestibule, vascular malformation, 29
Laryngeal hemangiomas. CO. laser. 122-126
laryngeal surgery, CO, laser. 121-126
case presentations, 125
cysts, laryngeal, 123
granuloma. 123
hemangiomas, laryngeal, subglottic. 122-126
laryngeal hemangiomas, 122-126
neoplasms, malignant. 123-125
papilloma. 121-122, 125
examination findings, 122, 125
healing sequence, 123, 125
history. 122-123. 125
laser type. 125
parameters. 125
treatment. 125
Reinke's edema. 123
T, glottic carcinoma. 125
examination findings. 124. 125
healing sequence, 124, 125
history. 124. 125
laser type. 125
parameters, 125
treatment, 125
vocal Ibid polyps. 123
Laser, overview, 1-5

argon, frequency-doubled Nd:YAG laser, 4
characteristics, 3t
chromophorc, matched, 180
CO, laser, 2-4
components, 3
diode laser, 4-5
Ho:YAG laser. 4
Nd:YAG laser, 4
Laser biostimulation, 165-172
analgesia, laser-mediated, 167, I69t-I70t
background, 165-166
cellular effects, 167-171
cellular processes, exposure to, timing. 171
controversy, 166-167
current research, 167-171
exposure to cellular processes, timing, 171
heliotherapy. 165
laser parameters. 167
low-intensity laser therapy. 166
overview. 165-166
parameters. 167
repetition rates, effects of, 171
research, 171
ultraviolet therapy. 165
in vivo animal experiments. 168t
wavelengths, simultaneous, multiple, effects of
exposure to, 171
wound healing. 167, I68t
Laser handpiece, positioning, prencoplasia, oral
cavity, 45
Laser pulse, defined. 183
Laser tissue effects, photolhermal therapy,
144-145
Learner's curve. CO, laser, 23-24
Leukoplakia, prencoplasia. oral cavity, 43-44
Light
absorption, composite tissue, 7
lasers and. overview, 1, 2
in medicine, therapeutic use of. See also
Photobioactivation
overview, 165-166
sources of, phototherapy and. 139-140
tissue, interactions, 6
Lingual gingiva, leukoplakia. 48-49
ablation. 48
front surface mirror, to redirect beam, 48
postoperative, 49
sulcus, ablation, 48
Lip. dysplastic leukoplakia. 45-47
Meniscus, anterior, medial dislocation of,
temporomandibular joint surgery, 153
Microgravity, laser application. 179
Military operations, laser application, 179
Mouth, floor of. transoral resection, oral cancer,
90-93.94-95
aftercare. 95.
lingual anterior mandibular gingiva. 94-95
technique 90-93. 94
Mucocele, 82-83
aphthous stomatitis, 82-83
benign pigmented lesions, 82
Nd:YAG laser. 4, 27-28
argon, frequency-doubled, 4
CO, transoral resection, oral cancer, 87
contact laser probe tip, 28
retinal burns, 12
Necrosis, coagulation, zone of, defined, 184
Nonapneic snorers, 114-115
Obstructive sleep apnea syndrome, 115. See also
Sleep apnea syndrome
Optical hazards, in laser surgery, 12, 13-14
Oral cavity, preneoplasia, 37-53

buccal mucosa, 50-51
epithelialization, 51
first raster. 50. 51
mucosa, healing, 50
postoperative, 51
second raster. 51
CO, laser, 39-41
outline of lesion with, 42
duct, lesion over, 40
erthroplakia, ventral tongue, 38
fibrin coagulum. 41. 43
healing. 43
laser handpiece, positioning, 45
laser wound, soft tissue. 41
leukoplakia, 43-44, 48^*9
lingual gingiva, 48-49
lip
dysplastic leukoplakia, 45
leukoplakia, with dysplasia. 45-47
mouth, 48-49
lingual gingiva, ablation, 48
postoperative, 49
multicentricity, 38
nodular leukoplakia, buccal mucosa. 38
palate, papillary hyperplasia of. 42
reepithelialization complete. 43
results, 43
surgical technique, 41-42,43
tongue, leukoplakia, 52
debris removed, 52
surface reepithelialized, 52
tongue blade, spot size, 40
vaporization, tissue over duct. 40
vital staining. 37-39
Palate
papillary hyperplasia of. 42
postoperative tonsillar hypertrophy, 104,
104-105
Papilloma, 55-62
carbon dioxide laser. 58
clinical, laboratory evaluation, 57-58
epithelial hyperplasia, lateral tongue. 58
gingival site. 59
infection, pathophysiology of. 57
active expression phase. 57
inoculation, 57
laryngeal. CO, laser. 125
examination findings, 122. 125
healing sequence. 123. 125
history. 122-123, 125
laser type. 125
parameters, 125
treatment. 125
Up
no recurrence. 59
site, 59
virology, 55-56
DNA organization, 55, 57
taxonomy, 55, 56
viral genetic function. 55
Papillomatosis, renal transplant recipient.
(,l> 61
maxillary alveolus, palate, after treatment. 60

recurrent disease, 61
Paranasal sinuses, coronal view of, 157
Photobioactivation. 165-172
analgesia, laser-mediated, 167. 169-1701
background, 165-166
cellular effects, 167-171
controversy, 166-167
current research, 167-171
Index
exposure to cellular processes, liming. 171
heliotherapy. 165
laser parameters. 167
low-intensity laser therapy. 166
parameters. 167
repetition rates, effects of. 171
research. 171
ultraviolet therapy. 165
wavelengths, simultaneous multiple, effects of
exposure to, 171
wound healing. 167. I68t
Photodiagnostic imaging. 140
Pholodynamic therapy. 137-140
Photooxygenation. mechanisms of. 137-138
Photosensitizers. 139-140
Phototherapy with dyes. 137-142
definilions. 137
dyes. 138-139
hematoporphyrin derivatives. 138
history. 137
light sources. 139-140
overview. 140-141
photodiagnostic imaging. 140
pholodynamic therapy. 137-140
photooxygenation. mechanisms of. 137-138
photosensitizers. 139-140
rhodamine dyes
absorption spectrum. 139
Photothernial therapy, cancer. 143-149
background. 143-144
hyperthermia, biologic effects. 145-146
imaging-guided minimally invasive therapy.
146-147. 48
laser tissue effects, 144-145
overview. 147-148
Pigmented lesions, benign. 82
Plume hazards, in laser surgery. 16
Power, defined. 183
Prencoplasia, oral cavity. 37-53
buccal mucosa. 50-51
epithelialization, 51
first raster, 50,51
mucosa, healing, 50
postoperative. 51
second raster. 51
CO, laser. 39-41
outline of lesion with. 42
duel, lesion over. 40
erthroplakia. ventral tongue, 38
fibrin coagulum, 41, 43
healing. 43
laser handpiece, positioning. 45
laser wound, soft tissue. 41
leukoplakia. 43-44. 48-49
lingual gingiva. 48-49
lip
leukoplakia, with dysplasia. 45-47
mouth. 48-49
lingual gingiva, ablation. 48
postoperative. 49
multicentricity, 38
nodular leukoplakia, buccal mucosa. 38
palate, papillary hyperplasia of, 42
rccpitheliali/ation complete. 43
results. 43
surgical technique. 41-42,43
tongue, leukoplakia, 52
debris removed, 52
surface reepithelialized, 52
tongue blade, spot size. 40
vaporization, tissue over duct. 40
vital staining. 37-39
PRR. See Pulse repetition rale

Pulse
repetition rate, defined. 183
width, defined. 183
Reinke's edema. CO, laser, 123
Renal transplant recipient, papillomatosis,
60-61
maxillary alveolus, palate, after treatment.
60
recurrent disease. 61
Retinal burns. Nd:YAG-induced, 12
Rhinophyma, 80
Rhodamine dyes
absorption spectrum. 139
Safety, with laser. 11-17
goggles, wavelength specific, 14
hazards, laser surgery. 11-16
electrical hazards, 16
fire hazards, 14-16
judgment errors, 11-12
optical hazards. 12. 13-14
plume hazards. 16
skin hazards. 12-14
retinal burns, Nd:YAG-induced, 12
Sciatic nerve, tissue fusion, 177
Skin
hazards, in laser surgery, 12-14
resurfacing, in aesthetic surgery. 79
Sleep apnea syndrome, laser-assisted
uvulopalaloplasty. 111-120
contact Nd:YAG. 119
incisions. 117
indications, 111
multiple sessions. 113
"multiple-stage" technique. 112-113
one stage. 114
operative outcome. 114
overview, 116
procedure, description. 112-114
"single-stage" technique, 113-114
uvulopalatopharyngoplasty, compared. 111
Snoring, uvulopalatoplasly. 111-120
contact Nd:YAG, 119
indications, 111
laser-assisted UPPP. 112
LAUP
multiple sessions. 113
one stage. 114
nonapneic snorer. 114-115
overview. 116
procedure, description. 112-114
uvula, vertical incisions, 117
Soft tissue excision. 63-83
clinical laser application, overview. 63
CO, laser
excisional procedures, 65
incisional procedures, 63-65
frenectomy, 63-64
vcslibuloplasty, 64-65
as vaporization instrument. 72
combination uses. 80
rhinophyma. 80
complications. 83
ear tag. 68
epulis lissuratum. 81
facial nevi, 78
fibrocpilhelial hyperplasia, palate. 75-77
fibroepithelial polyp, 67
fibroma. 66
187
gingiva
grafting. 70
hypertrophy. 73
severe, 74
hemangiomas malformation. 71
impacted teelh, exposure of, 69
mucocele, 82-83
aphthous Momaritis, 82-83
benign pigmented lesions, 82
skin resurfacing, in aesthetic surgery, 79
vascular malformation, 71
wound care. 83
Spot size, defined. 183-184
Stomatitis, aphthous. 82-83
Subglottic hemangioma, CO, laser. 122-126
Sublethal unjury. zone of, defined, 184
Submandibular duct, transoral resection, oral
cancer. 88
Surgical lasers, physical considerations. 1 -9
contact laser surgery. 8-9
electromagnetic spectrum, 2
energy state, diagram, 2
free-beam lasers, 8-9
contact laser surgery, vs. noncontact. 8
modification. 8-9
history. I
light, 1,2
absorption, composite tissue, 7
tissue, interactions, 6
overview. 1-5
argon, 4
characteristics. 3t
CO, laser, 2-4
components, 3
diode laser, 4-5
Ho: YAG laser, 4
Nd:YAG laser, 4
power/depth, 7
temperature/depth. 7
temperature gradients, in tissue. 5
thermal laser-tissue effects. 5-7
T, glottic carcinoma, C 0 laser, 125
examination findings. 124, 125
healing sequence 124, 125
history, 124, 125
laser type. 125
parameters, 125
treatment. 125
Telangiectasias. 34
Temperature gradients, in tissue, 5
Temporomandibular joint surgery. 151-155
case study, 153. 154
Ho:YAG laser. 151-152
meniscus, anterior, medial dislocation of. 153
overview. 154-155
Thermal laser-tissue effects, laser, 5-7
Thermal relaxation time, defined. 184
Tissue
fusion. 173-176
mechanism. 174
sciatic nerve. 175
in vivo studies. 176-177
light
absorption, 7
interactions, 6
temperature gradients in. 5
Tongue, leukoplakia. 52
debris removed. 52
surface reepithelialized. 52
Tongue blade, spot size, 40
Tonsillar hypertrophy, postoperative, transoral
resection, oral cancer, 104-105
Tooth. See also Dentistry
impacted, exposure of. 69
2
188
Index
Transoral rcsoclion. oral cancer. 85-109

buccal mucosa. 102-103
with proliferative granulation tissue. 107
CO, laser. 87
vs. contact Nd:YAG. 87. 89
free beam. 86. 96-98
tumor debulking. 108
complications. 88
consequences, 87-88
contact Nd.YAG. 87
dry field. 86-87. 101
general anesthesia, avoiding. 87
surgical protocol, 87
mouth, floor of. 90-93.94-95
aftercare. 95
lingual anterior mandibular gingiva. 94-95
technique 90-93,94
palate, postoperative tonsillar hypertrophy.
104-105
proliferative granulation tissue buccal mucosa,
107
submandibular duct, 88
surgical cases. 89
survival. 85-86
time at operation. 88
tongue
cancer, primary closure. 99
contact Nd:YAG laser scalpel. 100-101
free beam CO 96-98
motion, restricted, 106
tonsillar hypertrophy, postoperative, 104-105
tumor debulking, CO, laser, 108
Tumor debulking. CO, laser, transoral resection,
oral cancer. 108
:
Ultraviolet therapy. 165

UV. See Ultraviolet therapy
Uvulopalatoplasty, 111-120
case study. 116
contact Nd:YAG, 119
incisions. 117
indications. 111
I.AUP
multiple sessions, 113
one stage, 114
nonapneic snorers. 114-115
obstructive sleep apnea syndrome. I IS

OSAS patients. 114
overview, 116
personal series, results of. 114-115
procedure description, 112-114
uvulopalatopharyngoplasty, compared. 111
Vaporization, zone of. defined. 184
Vascular malformation. 71
labiobuccal sulcus, 33
Vcstibuloplasty, with CO, laser. 64-65
Viral genetic function, papillomas. 55
Virology
human papillomavirus, 55-56
papillomas. 55-56
Vocal fold polyps, C 0 laser, 123
2
Wound healing, photobioactivation and, 167, I68t

Zones
of coagulation necrosis, defined. 184
of sublethal unjury. defined. 184
of vaporization, defined. 184

Lasers in Maxillofacial Surgery and Dentistry 0865775664 PDF

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Lasers in Maxillofacial Surgery and Dentistry 0865775664 PDF

Hochgeladen von

Copyright:

Verfügbare Formate

Contents

P r a c t i c a l Laser Safety i n O r a l a n d M a x i l l o f a c i a l Surgery . . . .

Specific G u i d e t o t h e Use o f Lasers

Lewis dayman, Richard Reid

Preneoplasia of the O r a l Cavity

Papillomas and H u m a n Papillomavirus

Richard Reid. Myron Slrasser

Soft Tissue Excision T e c h n i q u e s

Lewis dayman. Paul Kuo

Yves-Victor Kamami. James W. Woolen

T h e C a r b o n D i o x i d e Laser i n Laryngeal Surgery

Dan J. Castro. Romaine E. Saxlon, Jacques Soudanl

Dan J. Castro. Romaine E. Saxlon. Jacques Soudant

Laser-Assisted T e m p o r o m a n d i b u l a r Joint Surgery

Jeffrey J. Moses. Claus R. l^ange

Laser Tissue Fusion

I'aul Kuo. Michael D. Colvard

Physical Considerations of Surgical Lasers

the radiation in the visible region of the spectrum (Fig. 1-1)

Lasers consist of a small number of basic components as