In recent years, the demand for facial esthetic treatments has becoming increasingly acute especially among elderly patients, with the result that the clinicians are required to satisfy the patients’ requests by proposing less invasive, more cost-effective and safer approaches [17].
VL of the lips, a highly esthetic anatomical region, may impact on the self-confidence of affected patients, even causing psychological concerns. Additionally, some VL, depending on their dimension and location, may also cause functional interferences.
The use of laser-assisted therapy for the management of vascular lesions has been consistently proposed in the literature. Indeed, several laser machines, such as the CO2 laser, the Diode laser and the Er,Cr:YSGG laser, all based on invasive approaches ranging from surgical excision to photo-vaporization, have been widely used to treat different types of vascular lesions of the head and neck area [18-21]. Despite their proven efficacy, post-operative complications can occur, such as bleeding, swelling, textural alterations or healing with scars.
In this scenario, the non-invasive photo-thermo-coagulation approach, based on the application of the Nd:YAG laser, has attracted the interest of clinicians due to its safety, manageability, effectiveness and acceptance by patients. Indeed, the Nd:YAG laser allows the clinician to treat a variety of vascular lesions, such as venous malformations, hemangiomas and lymphatic malformations [22-23]. Moreover, the Nd:YAG seems to have a greater efficacy in the treatment of VL, compared to other lasers [12], thanks to the 1,064 nm wavelength pulse that has a high affinity for hemoglobin. This results in a thermal effect on the endothelium, meaning that it can penetrate about 7 mm into the tissue without interacting with the surface layers [14].
To the best of our knowledge, this is the first study which has evaluated the effectiveness of the Nd:YAG laser in a homogeneous sample of patients all affected by VL localized at the lips. Additionally, in this study, where the Nd:YAG laser was used with the lowest laser energy according to a non-surgical trans-epithelial photo-thermo-coagulation technique, the laser’s parameters were set differently in comparison with the majority of the studies. In the systematic review carried out by Mlacker et al. [12] the use of the Argon Laser [24-26], Pulsed Dye laser [18-21, 27, 28] and Nd:YAG laser [29-31] was reported. These lasers were set with a higher energy and with a shorter pulse duration, increasing the patient’s discomfort. Indeed, the Nd:YAG was used with an absolute low energy level of 4.9 J, setting the laser energy density at 100 J/cm2 and the spot size at 2.5 mm.
A total of 50 VL were treated according to this procedure, which allowed a complete clinical resolution of the lesions in all the cases at the one-month follow-up, without any recurrence at the 2-year follow-up. Moreover, all the VL, except one, healed with excellent esthetic outcomes with no visible scars, as evaluated by the MSS scores. These results are in line with those of Migliari et al [29], who treated 16 lip and oral VL with the Nd:YAG laser, achieving a complete resolution with no, or minimal, scarring. On the contrary, in the studies of Bekhor et al [30] and John et al [31], where 34 and 31 VL of the lips, cheeks and oral mucosa were treated with the Nd:YAG laser, the success rates were lower, 94% and 87% respectively. This could be attributable to the variability of the sample in terms of lesion size, including larger lesions, and on account of the fact that also patients with a prior treatment, such as excision, cryotherapy, sclerotherapy or pulsed dye laser, were included.
In the present study, the rate of clinical resolution, 100%, was even higher than that reported in the study of Neumann et al [26], where 51 VL of the lips were treated with the Argon Laser, achieving excellent cosmetic outcomes in 90% of the cases, although often requiring from one to four applications before showing a clearance of the lesions. These differences were probably due to the reduced ability of the Argon laser to penetrate into the tissue, compared with the Nd:YAG, which has a higher penetration performance.
Although there is no clear evidence of the superiority of one laser machine and approach over the others in the treatment of vascular malformations including VL [32], the Nd:YAG laser has been found to be more tolerable than other laser treatments [12].
In the present study, the patient’s acceptability of the laser application was explored by recording the oral discomfort through the NRS scale. No or little discomfort was recorded, as evidenced by the low scores of the NRS (range 0-3) and no patient needed any topical application of local anesthetic. This result may possibly be explained in terms of the use of the Nd:YAG laser with a low energy level, which produced less discomfort in comparison with other studies using the Nd:YAG with other parameters or other lasers [12].
Of note, besides the complete clinical resolution of all the VL, no severe or major complications, such as edema, bleeding, pain or infection, as described in the literature [12, 33, 34], were reported, except for one barely visible scar in one patient, thus demonstrating the safety of this procedure. While recurrences were reported in the other studies [12], no recurrences were recorded over the two-year follow-up period in the present sample of patients. This may be linked to the low energy level, which allows a targeting of the VL for a longer time, thus obtaining the clinical outcome of resolution without increasing the risk of scarring or complications