International Journal of

Environmental Research
and Public Health

Article
Aesthetic Treatment Outcomes of Capillary
Hemangioma, Venous Lake, and Venous
Malformation of the Lip Using Different Surgical
Procedures and Laser Wavelengths (Nd:YAG,
Er,Cr:YSGG, CO2, and Diode 980 nm)
Samir Nammour 1, * , Marwan El Mobadder 1 , Melanie Namour 1 , Amaury Namour 1 ,
Josep Arnabat-Dominguez 2 , Kinga Grzech-Leśniak 3 , Alain Vanheusden 1 and
Paolo Vescovi 4
1 Department of Dental Science, Faculty of Medicine, University of Liege, 4000 Liege, Belgium;
marwan.mobader@gmail.com (M.E.M.); melanienamour@gmail.com (M.N.);
amaurynamour@gmail.com (A.N.); alain.vanheusden@chu.ulg.ac.be (A.V.)
2 School of Dentistry, University of Barcelona, 08907 Barcelona, Spain; 16324jad@comb.cat
3 Dental Surgery Department, Medical University of Wroclaw, 50-425 Wroclaw, Poland; kgl@periocare.pl
4 Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy; paolo.vescovi@unipr.it
* Correspondence: S.Namour@ulg.ac.be




Received: 20 October 2020; Accepted: 20 November 2020; Published: 22 November 2020


Abstract: Different approaches with different clinical outcomes have been found in treating capillary
hemangioma (CH), venous lake (VL), or venous malformations (VM) of the lips. This retrospective
study aims to assess scar quality, recurrence rate, and patient satisfaction after different surgeries with
different laser wavelengths. A total of 143 patients with CH or VM were included. Nd:YAG laser
was used for 47 patients, diode 980 nm laser was used for 32 patients (treatments by transmucosal
photo-thermo-coagulation), Er,Cr:YSSG laser was used for 12 patients (treatments by excision), and
CO2 laser was used for 52 patients (treatments by photo-vaporization). The Manchester scar scale
was used by practitioners to assess the scar quality. The recurrence rate and patients’ satisfaction were
noted at different follow-ups during 12 months. Our retrospective study showed that laser-assisted
aesthetic treatment of vascular lesions (CH, VL, and VM) of the lips can be considered effective
regardless of the wavelength used (Er,Cr:YSGG, CO2 , Nd:YAG, and diode 980 nm) or the treatment
procedure (transmucosal photo-thermo-coagulation, photo-vaporization, and surgical excision).
There was no significant difference in patient and practitioner satisfaction with aesthetic outcome at 6
months follow-up. Furthermore, the treatments of lip vascular lesions performed using Er,Cr:YSGG
and CO2 lasers did not show any recurrence during the 12 months of follow-up, while recurrence
rates of 11% ± 1.4% and 8% ± 0.9% were seen in the diode and Nd:YAG groups, respectively.

Keywords: capillary hemangioma; lasers; lip; oral pathology; oral surgery; venous lake;
venous malformation

1. Introduction
Vascular lesions of the head and neck present a broad pathological spectrum, with a diversity
of tumors and malformations including simple capillary irregularities and complex irregularities of
the arteries, veins, and lymphatics [1]. In the literature, numerous classifications have been found to
describe the vascular lesions; one of the most admitted classifications is that of the International Society
for the Study of Vascular Anomalies (ISSVA) updated in 2014 [2]. According to this classification, these

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lesions are grouped as either vascular tumors, characterized by a proliferation of blood vessels, or
vascular malformations, characterized by vessels with abnormal structure [2].
Capillary hemangioma (CH) is a benign vascular tumor that appears clinically as a raised, red
area found anywhere in the body with a prevalence of 83% in the head and neck region [2,3]. On the
other hand, venous malformations (VM) represent another frequent vascular lesion of the head and
neck region with a prevalence of 50% and with a clinical aspect of soft, compressible, non-pulsatile
blue-violaceous papules or nodules that can increase in size [2,3]. Furthermore, venous lake (VL) is a
common benign vascular lesion defined as vascular ectasias formed from dilated venules located in
the upper dermis [2–4].
Patients with capillary hemangioma and venous lip malformation usually seek treatment for
at least one of the following reasons: aesthetic alteration, functional limitations, and psychological
concerns. These vascular lesions can sometimes be subjected to a tendency of spontaneous regression;
thus, the treatment approach depends largely on several factors that characterize each case. These
factors are essentially size, location, and behavior of the lesion, as well as age and systematic condition
of the patient [5,6].
The total excision of localized, small, and discrete capillary hemangioma and venous malformation
is considered as the treatment of choice [5,6]. During surgical removal of these lesions, special care
and precautions must be taken into consideration in order to avoid recurrence, as it has been found
that these lesions have a tendency of recanalization. On the other hand, care must likewise be taken
in order to avoid any irreversible unaesthetic outcomes, especially when these vascular lesions are
localized in aesthetically sensible areas [6,7].
One of the first indications of laser in dermatology and dentistry is the management of vascular
lesions [8]. Wavelengths with selective tissue absorption and deeper penetrations such as near-infrared
lasers, specifically, Nd:YAG and diode lasers, are generally indicated for CH and VM [8,9]. In addition,
the application of photo-selective absorption wavelengths [10–13] such as alexandrite lasers and other
devices were reported to have a promising aesthetic outcome [14].
Despite the promising approach of these lasers toward the vascular lesions, there is not enough
literature concerning the best-indicated wavelength commonly used in dentistry, the long-term aesthetic
results, and the optimal treatment modality (excision, transmucosal photo-thermo-coagulation, and
photo-vaporization).
The aim of this retrospective study was to evaluate the aesthetic outcome and the recurrence rates
of capillary hemangioma, venous lake, and venous malformations of the lip performed using different
surgical procedures and different laser wavelengths (Nd:YAG, Er,Cr:YSGG, CO2 , and diode 980 nm
lasers). The null hypothesis was that there is a difference in the long-term aesthetic outcome across
different protocols.

2. Material and Methods

2.1. Study Design

This multicenter retrospective study was carried out using data collected in the period between
2004 and 2019. The data collection was made for all capillary hemangiomas (CHs) of the lip, as well
as all venous lake and venous malformations (VMs) of the lip, treated with one of the following
laser wavelengths: neodymium-doped yttrium, aluminum, and garnet laser (Nd:YAG; 1064 nm),
erbium/chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG laser; 2790 nm),
carbon dioxide laser (CO2 ; 10,600 nm), and diode laser (980 nm). Furthermore, according to the
ethical committee recommendations of our university hospitals, the decision for surgery was made
after informing all participating patients about the steps of the surgery, the risks, and the possible
postoperative discomfort and complications. The surgery was performed after receiving a written
informed consent form signed by the patient. Concerning data collection for retrospective analysis
Int. J. Environ. Res. Public Health 2020, 17, 8665 3 of 17

this was not considered as a new clinical study and did not require any approval from the ethical
committee of the University of Liege.

2.2. Participants
A total of 143 patients participated in this retrospective study; the mean age of the patients was
48 (43–74), with 56% females (n = 81) and 44% males (n = 62). The average size of the lesions was
6 mm with a maximum of 15 and a minimum of three (Table 1). Specifically, 46 patients were treated
with the Nd:YAG laser (n = 47), 12 were treated with the Er,Cr:YSSG laser (n = 12), 52 were treated
with the CO2 laser (n = 52), and 32 were treated with the diode laser (n = 32) (Table 2). Diagnosis of
the included capillary hemangioma and venous lake or venous malformation of the lip was based
on a meticulous clinical exam and detailed medical history (date of appearance, growth, associated
symptoms). In addition, in 29 cases, color Doppler ultrasonography was used to obtain additional
information related to the vascularization, the flow type, the location, the three-dimensional (3D) profile,
the type of vascular pedicles, and the lesion volume. A graded periodontal probe was used to evaluate
the size of the lesions. The data were retrospectively entered into the database including patient
demographics (age, gender, anatomical region, dimension of the lesion), type of lesion (i.e., capillary
hemangioma or venous lip malformation), type of laser used (Nd:YAG, Er,Cr: YSGG, CO2 , or diode),
and the Manchester scar score (MSS) used in the postoperative follow-up (Table 3) [15]. Additionally,
the visual analogue scale (VAS) was used in order to assess patient satisfaction. The VAS consisted of
numbers from 0–10, where 0 represented “the worst satisfaction possible” and 10 represented “the
greatest satisfaction possible”. All data were eventually collected. The follow-up periods for additional
assessments of MSS and VAS were carried out at 2 weeks, 1 month, 6 months, and 12 months after
the treatments.

Table 1. Clinical features of the treated patients.

Gender Age Range Lesion Diameter (mm)

Total (years)
Female Male Average Minimum Maximum
56% 44% 48
143 6 3 15
(min: 43;
(n = 81) (n = 62)
max: 74)
Age in years; lesion diameter in millimeters; min = minimum; max = maximum.

Table 2. Repartition of the type of laser used for each patient.

Laser Wavelength (nm) Number of Patients

Nd:YAG, 1064 nm 47
Er,Cr:YSSG, 2780 nm 12
CO2 , 10,600 nm 52
Diode laser, 980 nm 32
143

Table 3. Description of the Manchester scar scale [15].

Description Score
Color
Perfect 1
Slight mismatch 2
Obvious mismatch 3
Gross mismatch 4
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Table 3. Cont.

Description Score
Matte vs. Shiny
Matte 1
Shiny 2
Contour
Flush with surrounding skin 1
Slightly proud/indented 2
Hypertrophic 3
Keloid 4
Distortion
None 1
Mild 2
Moderate 3
Severe 4
Texture
Normal 1
Just palpable 2
Firm 3
Hard 4

Inclusion and Exclusion Criteria

Patients complaining of an unaesthetic capillary hemangioma, venous lake, and/or venous lip
malformation were included. The exclusion criteria were chronic diseases, diabetes, immunosuppressed
patients, and the existence of other benign or malign tumors in the same area.

2.3. Surgical Techniques

Each treatment was made with one of the following lasers: Nd:YAG, Er,Cr:YSGG, CO2 , and
diode. Local infiltration of anesthesia covering the area of the lesion was made before any surgical
treatment. Prior to surgery, the operator, assistants, and patient wore specific eyeglasses for each
wavelength, and all safety measures for the use of lasers were taken. After the treatment, all wounds
were left to heal without any sutures. The collected data were divided into treatments performed
by transmucosal photo-thermo-coagulation, photo-vaporization, and surgical excision. Specifically,
nonsurgical procedures of photocoagulation were performed using the diode and Nd:YAG lasers,
while photo-vaporization of the lesions was carried out using the CO2 laser, and excision of the lesions
was performed using the Er:YAG laser because of its explosive mechanism and its difficulty to vaporize
blood without destroying the mucosal layer covering blood cisterns.

2.3.1. Er,Cr:YSGG Laser

An Er,Cr:YSGG laser with a wavelength of 2790 nm (Waterlase, Biolase Inc., Foothill Ranch, CA,
USA) was used. After the injection of local anesthesia, the excision areal limit was delimited by the laser
beam without air–water spray with an output power of 0.25 W and 20 Hz (Figures 1–3). An excision
was made for all lesions with an output power of 1.5 to 2 W (27 J/cm2 ), a fiber diameter of 600 µm, and
pulsed mode (20 Hz, 60 µs). In addition, a defocused (noncontact) mode without air–water spray was
used for the coagulation of the bottom of the wound at the end of the excision to ensure a primary
coagulation. The wound was left to heal in the second intention, and no sutures were made.
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Figure 1. Clinical
Figure 1. Clinical aspect
aspect of
of venous
venous malformation
malformation (VM)
(VM) on
on the
the lower lip.
lower lip.
Clinical aspect of venous malformation

Figure
Figure 2.
2. The
The lesion’s
lesion’s resection
resection limit
limit is
is indicated
indicated by
by the
the Er,Cr:YSGG laser
Er,Cr:YSGG laser around
laser around the
around the surgical
the surgical site.
surgical site.
site.
Figure 2. The
The lesion’s
lesion’s resection
resection limit is indicated by the Er,Cr:YSGG surgical site.

Figure 3.
3. Bleeding
Figure 3. Bleeding which
which appeared
appeared after
after lesion
lesion excision.
excision.
Figure
Figure 3. Bleeding
Bleeding which
which appeared
appeared after
after lesion
lesion excision.
excision.
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2.3.2.Int.
CO 2 LaserRes. Public Health 2020, 17, x FOR PEER REVIEW
J. Environ. 6 of 17

A COCO
2.3.2. 2 laser with a wavelength of 10,600 nm (Smart US20 D Laser, High Tech Laser, Herzele,
2 Laser
Belgium) was used. After injection of local anesthesia, the vascular lesion was photo-vaporized in a
A CO2 laser with a wavelength of 10,600 nm (Smart US20 D Laser, High Tech Laser, Herzele,
defocused (noncontact), continuous wave (CW), with an output power of 1 W (149.1 J/cm2 at focal
Belgium) was used. After injection of local anesthesia, the vascular lesion was photo-vaporized in a
point). The beam diameter was adapted to the diameter of each lesion minus 1 mm (−1 mm) in order
defocused (noncontact), continuous wave (CW), with an output power of 1 W (149.1 J/cm2 at focal
to avoid
point). The beam diameter was adapted to the diameter of each lesion minus 1 mm (−1 mm) in orderinside
irradiation of healthy tissue surrounding the lesion. The purpose was to generate heat
tumors to vaporize
to avoid the of
irradiation water inside
healthy the
tissue lesion, without
surrounding allowing
the lesion. vaporization
The purpose of the superficial
was to generate heat insidelayer
of thetumors
mucosa coveringthe
to vaporize the blood
water citterns
inside (Figure
the lesion, 4a,b and
without Figure
allowing 5). After complete
vaporization vaporization
of the superficial layer of
the blood
of theinside
mucosa the lesion, the
covering theblood
external layer
citterns of the 4a,b
(Figures mucosaand was vaporized
5). After completeand removed in
vaporization of focused
the
blood inside the lesion, the external layer of the mucosa was vaporized and removed
mode until complete exposure of the tumor cavity. The blood coagulation at the bottom of the citterns in focused mode
until complete
was performed in exposure
defocused of the
modetumor cavity.6).
(Figure TheThe
blood coagulation
surgical at the bottom
procedure of the citterns
was considered was after
done
performed in defocused mode (Figure 6). The surgical procedure was considered
verification of hemostasis via simple pressure on the operated site. The wound was left to heal in the done after
verification of hemostasis via simple pressure on the operated site. The wound was left to heal in the
second intention, and no sutures were made.
second intention, and no sutures were made.

b
Figure 4. (a,b) Clinical aspects of capillary hemangioma (CH) of the upper lip. The lesion was a result
Figure 4. (a,b) Clinical aspects of capillary hemangioma (CH) of the upper lip. The lesion was a result
of a trauma.
of a trauma.
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Figure 5. Vaporization
Figure 5. of the
Vaporization of the lesion
lesion in
in defocused
defocused mode
defocused mode using
mode using the
using the CO
CO222 laser.
the CO laser.

Figure 6.
6. The
Figure 6. The mucosal layer covering the blood cittern
cittern was
was vaporized
vaporized and
and removed in focused mode
Figure The mucosal
mucosal layer
layer covering
covering the
the blood
blood cittern was vaporized and removed in
removed in focused
focused mode
mode
using
using the
the CO
CO 2 laser.
2 laser.
using the CO2 laser.

2.3.3. Nd:YAG
2.3.3. Laser Irradiation
Nd:YAG Laser Irradiation
Irradiation
An Nd:YAG
An Nd:YAGlaser
Nd:YAG laserwith
laser with
with aa wavelength
a wavelength
wavelength of
of 1064
of nm
1064 1064(Fidelus
nm plus,
plus, Fotona
nm (Fidelus
(Fidelus plus,medical
Fotona Fotonalaser,
medical Ljubljana,
medical
laser, laser,
Ljubljana,
Slovenia)
Slovenia) was
Ljubljana, used.
used. After
Slovenia)
was topical
was used.
After application
topical After topicalof
application local
local anesthesia,
ofapplication aa transmucosal
of local
anesthesia, anesthesia, a photo-thermo-
transmucosal transmucosal
photo-thermo-
coagulation
coagulation was was made
made in
photo-thermo-coagulation in noncontact
was mademode,
noncontact with
with an
in noncontact
mode, an output power
mode, with
output power anof 22 Watts,
ofoutput fiber
power
Watts, fiberof diameter
2 Watts,of
diameter 320
offiber
320
μm, pulsed
diameter
μm, pulsed mode
of 320
mode µm,(15 Hz),
(15pulsed pulse duration
modeduration
Hz), pulse (15 Hz), ofof 320
pulse μs (LP
320duration mode), and
of 320 and
μs (LP mode), an
µs (LP energy
an mode), density
energy and of
an energy
density 11.94 J/cm
J/cm2..
of 11.94density
2

The
of
The lesion
11.94 J/cm
lesion was
2 treated
was. The
treated by
by transmucosal
lesion was treated byphoto-thermo-coagulation,
transmucosal and
and the
transmucosal photo-thermo-coagulation,
photo-thermo-coagulation, the treatment
treatment andwas
wastheconsidered
treatment
considered
completed
was considered
completed when
when a blanching
completed
a blanching when and visible
a blanching
and shrinkage
and visible
visible shrinkage of the blood
shrinkage
of the blood ofappeared
the blood
appeared inside the
appeared
inside CV
the CV or
or VM
inside the
VM
(Figures
CV or VM
(Figures 7 and 8).
(Figures
7 and When
8). When necessary,
7 andnecessary, a second
8). When anecessary, passage
a second
second passage of the photo-vaporization
of passage cycle
of the photo-vaporization
the photo-vaporization was performed
cycle was
cycle was performed
after
after 22 weeks
performedweeks in
in 2cases
after weeks
cases of persistence
of in or
or recurrence
cases of persistence
persistence of
of the
the lesion.
or recurrence
recurrence The
of the
lesion. wound
lesion.
The wound Thewas
wound
was left
left to heal
was
to leftwithout
heal to heal
without
any other
without
any other anytreatment, and
other treatment,
treatment, no sutures were
and no were
and no sutures made.
sutures were made.
made.
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Figure
Figure 7.
7. Clinical
Clinical aspect
aspect of
of the
the lesion
lesion VM
VM on
on the
the lower
lower lip.
lip.

Figure 8.
8. The
Figure 8. The lesion
lesion was treated
was treated by
treated by transmucosal
by transmucosal photo-thermo-coagulation
photo-thermo-coagulation after
transmucosal photo-thermo-coagulation after topical
topical anesthesia
anesthesia
Figure The lesion was after topical anesthesia
application.
application. An
An Nd:YAG
Nd:YAG laser
laser was
was used.
used.
application. An Nd:YAG laser was used.

2.3.4.
2.3.4. Diode
Diode Laser
Laser
A
A diode
diode laser
laser with
with aa wavelength
wavelength of of 980
980 nm
nm (Smart
(Smart M M Pro,
Pro, Lasotronix,
Lasotronix, Poland)
Poland) waswas used.
used. In
In order
order
toto avoid
avoid irradiation
irradiation of of healthy
healthy tissue
tissue surrounding
surrounding the the lesion,
lesion, the
the diameter
diameter of of the
the laser
laser beam
beam waswas
changed
changed depending
depending on
on the
thesize
size of the
of lesion
the so
lesion that
so the
that diameter
the of
diameter theofbeam
the was
beam
depending on the size of the lesion so that the diameter of the beam was always about 1 mm always
was about
always 1 mm
about
less
1 mm
less than
than lessthe
than
the diameter of
of the
the diameter
diameter the lesion. After
After topical
of the lesion.
lesion. application
After topical
topical of
of local
application
application anesthesia,
local of the
the laser’s
local anesthesia,
anesthesia, thetip
laser’s was
laser’s
tip was
not
tip activated,
was not and the
activated, irradiation
and the was carried
irradiation was out in
carriednoncontact
out in mode
noncontact at an average
mode
not activated, and the irradiation was carried out in noncontact mode at an average distance of almost at andistance
average of almost
distance
2of
2 mm
almost
mm in
in aa2continuous wave
wave (CW).
mm in a continuous
continuous (CW). waveThe irradiation
The(CW). conditions
The irradiation
irradiation were
were anan output
conditions conditions were power
output an output
power of
of 44 power
W
W (248.5of
(248.5
J/cm )) and fiber 2
fiber )diameter
and fiber of 320
320 μm. of Similarly to
to the
the Nd:YAG procedure, transmucosal photo-
2
4J/cm
W 2(248.5and J/cm diameter diameter
of μm. 320 µm. Similarly
Similarly to the Nd:YAG
Nd:YAG procedure,procedure, transmucosal
transmucosal photo-
thermo-coagulation
thermo-coagulation was
photo-thermo-coagulation was carried
was carried
carried out
out after the
out after
after topical
the the application
topical
topical application
application of local
of of localanesthesia.
local anesthesia.In
anesthesia. Incases
In cases of
cases of
persistence or recurrence of a reduced size of the lesion, repetition of the
persistence or recurrence of a reduced size of the lesion, repetition of the treatment was performed treatment was performed
after
after 11 oror 22 weeks.
weeks. TheThe wound
wound was was left
left to
to heal
heal without
without sutures.
sutures.

2.3.5. Postoperative Instructions

2.3.5. Postoperative
Postoperative Instructions and
Instructions and Recommendations
Recommendations
After
After each
each treatment,
treatment, each
each patient
patient was
was prescribed
prescribed aa painkiller and aa topical
painkiller and topical oral
oral disinfecting
disinfecting
solution. In
In addition,
addition, instructions
solution. In addition, instructions were given to patients to avoid eating hard or hot foods for
instructions were given to patients to avoid eating hard or hot foods for the
the first
first
55 days after the procedure.
days after the procedure.
Int. J. Environ. Res. Public Health 2020, 17, 8665 9 of 17

2.4. Evaluation of the Aesthetic Results

In order to evaluate the aesthetic outcome of the treatment and in order to transcribe any potential
complications or compromise in the aesthetic outcome after wound healing, the Manchester scar scale
(MSS) was used for practitioners’ evaluations (Table 1). On the other hand, in order to evaluate patient
satisfaction, a visual analogue scale was used with values from 0–10 where 0 represented “the worst
satisfaction possible” and 10 represented “the highest satisfaction possible”. The follow-up periods
were assigned 2 weeks, 1 month, 6 months, and 12 months after the treatment.

2.5. Evaluation of the Recurrence Rate

A qualitative visual evaluation was made for the recurrence of CH and VM after the treatment.
The patients were asked to immediately contact the proper practitioners if any aspect of capillary lesion
or abnormality was seen on the treated lip. Any reappearance or recurrence of the lesion was noted.

2.6. Statistical Analysis

For statistical analysis, Prism 5® software (GraphPad Software, Inc., San Diego, CA, USA) was used.
The confidence level of the study was proposed to be 95% with a p-value < 0.05 considered as statistically
significant for the analysis. Descriptive statistics, including the means and standard deviations, were
also calculated. One-way ANOVA coupled with a Newman–Keuls multiple comparison test (post hoc
test) was used.

3. Results

3.1. Results of the Manchester Scar Scale Evaluation

The global mean average of the Manchester scar scale after 12 months was significantly lower
(p < 0.05) compared to the results obtained just after 2 weeks of treatment for all wavelengths.
Furthermore, regardless of the laser wavelength and regardless of the surgical approach (transmucosal
photo-thermo-coagulation, photo-vaporization, and surgical excision), the healing process (the quality
of the scar) was acceptable and satisfactory after 6 months of follow-up in all groups (Table 4).

Table 4. Global mean value of the Manchester scar score at different follow-ups as a function of the
laser type.

Laser Wavelength MSS at Different Time of Follow-Up

2 Weeks 1 Month 6 Months 12 Months
Er,Cr:YSSG 1.71 ± 0.16 A 1. 16 ± 0.18 B 1 B 1B
CO2 1.8 ± 0.42 A 1.5 ± 0.27 C 1B 1B
Diode 2.9 ± 0.22 D 2.2 ± 0.74 E 1B 1B
Nd:YAG 2.8 ± 0.30 D 2.5 ± 0.62 E 1B 1B
The scale is based on a score from 1–4 where 1 represents an excellent result and 4 represents a poor. Identical
superscript letters indicate no statistically significant difference, and different superscript letters indicate a statistically
significant difference (p < 0.05). Refer to Table 1 for a descriptive explanation of the Manchester Scar Score.

After 2 weeks of follow-up, the Er,Cr:YSSG (1.71 ± 0.16) and the CO2 (1.8 ± 0.42) lasers resulted in
significantly better scar quality compared to the Nd:YAG laser (2.8 ± 0.30) and diode laser (2.9 ± 0.22)
(Figure 9). Only the Er,Cr:YSSG group showed no statistically significant difference at 1 month of
follow-up (1.16 ± 0.18) and above (1).
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Mancheter Scar Scale

4

Scale (1- 4)
3

Er,Cr:YSSG
CO2
2 Diode (980 nm)
Nd:YAG

s
s
k

th

th
ee

ee

on
on
W

m
m
2

12
Time

Figure 9. Global mean values of the Manchester scar scale for the different laser wavelengths and at
Figure 9. follow-ups.
different Global mean values of the Manchester scar scale for the different laser wavelengths and at
different follow-ups.
3.2. Recurrence Rate
3.2. Recurrence Rate
It was necessary to have a second treatment session in groups treated with the diode and Nd:YAG
It Recurrence
lasers. was necessarywithto have a second
obligation treatment
to perform a secondsession in groups
treatment sessiontreated with the
was observed diode
in 11% and
± 1.4%
Nd:YAG lasers.inRecurrence
of cases treated withgroup
the diode laser obligation
and 8%to perform
± 0.9% ofacases
second treatment
treated in the session
Nd:YAGwaslaserobserved in
group. On
11% ± 1.4%
the other of cases
hand, treated
in the in the and
Er,Cr:YSSG diode
COlaser
2 group
groups, noand 8% ± 0.9%
recurrence of
was cases
noted treated
after thein the
first Nd:YAG
treatment
laser group.
sessions On5).
(Table the other hand, in the Er,Cr:YSSG and CO2 groups, no recurrence was noted after the
first treatment sessions (Table 5).
Table 5. Recurrence rate of different surgical procedures.
Table 5. Recurrence rate of different surgical
Diode
procedures. Nd:YAG
Er,Cr:YSSG CO2
Laser Wavelength (Transmucosal (Transmucosal
(Excision) (Photo-Vaporization)
CO2 Diode Nd:YAG
Photo-Thermo-Coagulation) Photo-Thermo-Coagulation)
Laser Er,Cr:YSSG
Recurrence rate (%) 0A (Photo-
0A (Transmucosal
11% ±1.4% Photo-
B (Transmucosal
8% ± 0.9% C Photo-
Wavelength (Excision)
Vaporization) Thermo-Coagulation) Thermo-Coagulation)
Identical superscript letters indicate no statistically significant difference and different superscript letters indicate a
statistically significant difference (p < 0.05).
Recurrence
0A 0A 11% ±1.4% B 8% ± 0.9% C
rate (%)
3.3. Patient Satisfaction
Identical superscript letters indicate no statistically significant difference and different superscript
letters
After 2indicate
weeks,athe
statistically significant
highest values difference (p
of satisfaction < 0.05).
was obtained with the Er,Cr:YSSG laser (8.9 ± 0.23),
followed by the diode laser (7.8 ± 1.58), CO2 laser (7.4 ± 0.7), and Nd:YAG laser (7.10 ± 0.86) (Table 6).
3.3.
The Patient Satisfaction
difference between the values of each group was statistically significant (p < 0.05). The values
significantly increased
After 2 weeks, the with follow-up
highest values offorsatisfaction
all groups,was
attaining thewith
obtained highest
the satisfactory
Er,Cr:YSSG score (±10)
laser (8.9 ±
at 6 months. Therefore, it can be considered that, regardless of the wavelength, patients
0.23), followed by the diode laser (7.8 ± 1.58), CO2 laser (7.4 ± 0.7), and Nd:YAG laser (7.10 ± 0.86) showed
satisfaction
(Table with
6). The regard tobetween
difference the aesthetic outcome
the values within
of each 6 months
group of follow-upsignificant
was statistically (±10) (Table
(p6,< Figure 10).
0.05). The
values significantly increased with follow-up for all groups, attaining the highest satisfactory score
Table 6. Visual analogue scale of patient satisfaction at different follow-ups.
(±10) at 6 months. Therefore, it can be considered that, regardless of the wavelength, patients showed
satisfaction
Laser Wavelength to the aesthetic
with regard outcome
Visual within
Analogue 6 monthsTime
at Different of follow-up (±10) (Table 6, Figure
of Follow-Up
10).
2 Weeks 1 Month 6 Months 12 Months
Er,Cr:YSSG ± 0.23 scale of patient
9 ± 0.82 A BA B
Table 6. Visual 8.9
analogue 10
satisfaction at different follow-ups. 10
CO2 7.4 ± 0.7 C 8.4 ± 0.6 D 10 B 10 B
Diode E A 10 of Follow-Up10 B
B
Laser Wavelength Visual Analogue
7.8 ± 1.58 8.85 ± at Different Time
0.85
Nd:YAG 7.10 ± 0.86 F 8.30 ± 0.36 D B B
2 Weeks 1 Month 6 Months 12 Months10
10
Zero representsEr,Cr:YSSG
the worst satisfaction8.9 possible,
± 0.23 and
A 109represents
± 0.82 A the highest10 B satisfaction10possible.
B Identical
superscript letters indicate no statistically significant difference, and different superscript letters indicate a statistically
significant differenceCO
(p <2 0.05). 7.4 ± 0.7 C 8.4 ± 0.6 D 10 B 10 B
Diode 7.8 ± 1.58 E 8.85 ± 0.85 A 10 B 10 B
Nd:YAG 7.10 ± 0.86 F 8.30 ± 0.36 D 10 B 10 B
Zero represents the worst satisfaction possible, and 10 represents the highest satisfaction possible.
Identical superscript letters indicate no statistically significant difference, and different superscript
letters indicate a statistically significant difference (p < 0.05).
Int. J. Environ. Res. Public Health 2020, 17, 8665 11 of 17
Int.J.J.Environ.
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The
Theaesthetic
The aesthetic
aesthetic appearance
appearance
appearance of the
of scarred treatedtreated
the scarred
scarred areas varied
areasdepending on the surgery
varied depending
depending performed
on the surgery
The aesthetic appearanceofofthethe scarred treated areas
treated areas varied
varied depending on on
the the surgery
surgery
at each wavelength
performed
performed atateach
each (Figures 11–15).
wavelength
wavelength (Figures
(Figures 11–15).
performed at each wavelength (Figures11–15).
11–15).

Figure 11. The aspect of healing at 2 weeks post operation. The excision was performed using an
Er,Cr:YSSG
Figure 11.The laser.
Theaspect
aspectof
Figure
Figure 11.
11. The aspect ofofhealing
healingat
healing atat222weeks
weekspost
weeks postoperation.
post operation.The
operation. Theexcision
The excisionwas
excision wasperformed
was performedusing
performed usingan
using an
an
Er,Cr:YSSGlaser.
Er,Cr:YSSG
Er,Cr:YSSG laser.
laser.

Figure 12. View of the healed area at 2 weeks post operation. The vaporization was performed using a
CO2 laser.
Int. J.
Int. J. Environ.
Environ. Res.
Res. Public
Public Health
Health 2020,
2020, 17,
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REVIEW 12 of
12 of 17
17

Int. J. Environ.
Figure Res.View
Figure 12.
12. Publicof
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the 2020, 17,
the healed
healed 8665at
area
area at 22 weeks
weeks post
post operation.
operation. The
The vaporization
vaporization was
was performed 12 of 17
performed using
using
aa CO
CO22 laser.
laser.

Figure 13.
Figure 13.Clinical
13. Clinicalaspect
Clinical aspect
aspect of the
of
of the the healed
healed
healed area
area
area at at 44 post
at
4 weeks weeks
weeks post operation.
post operation.
operation. The vaporization
The vaporization
The vaporization was
was
was performed
performed
performed
using using
laser.aa CO
a CO2using laser.
CO22 laser.

Figure 14.
Figure 14. The aesthetic
aesthetic aspect
aspect at
at 6 months
months post
post operation.
operation. The
The vaporization was
was performed
performed using
using a
Figure 14. The
The aesthetic aspect at 66 months post operation. The vaporization
vaporization was performed using aa
CO22 laser.
CO laser.
CO 2 laser.
Int. J. Environ. Res. Public Health 2020, 17, 8665 13 of 17
Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 13 of 17

Figure 15.
Figure 15.Clinical
Clinical aspect
aspect of healing
of healing at 2 post
at 2 weeks weeks post operation.
operation. Transmucosal
Transmucosal photo-thermo-
photo-thermo-coagulation
coagulation was performed using
was performed using an Nd:>YAG laser.an Nd:>YAG laser.

4. Discussion
The use of laser beams for the management of vascular lesions lesions dates
dates backback toto the
the 1960s
1960s [16–18].
[16–18].
Back then, ruby and argon lasers were introduced to improve the color
Back then, ruby and argon lasers were introduced to improve the color of hemangiomas and post- of hemangiomas and post-wine
stains. However,
wine stains. However, theirtheir
nonselective
nonselective photothermolysis
photothermolysis of of
thethetargeted
targetedtissue tissueresulted
resultedin in frequent
frequent
negative postoperative scarring and pigmentation changes [19–22]. After the vast development of
lasers and after improvements in the understanding of laser–tissue interactions interactions and laser physics, the
treatment of vascular
vascular lesions
lesions isis considered
considered as as one
one of
of the
the most
most common
common indications
indications of oflaser
laser[23–27].
[23–27].
This multicentric retrospective study showed that the treatment
multicentric retrospective study showed that the treatment outcome of capillary outcome of capillary hemangioma,
venous
hemangioma,lake, and venous
venous lake,malformation
and venous of the lip withof
malformation different
the lip wavelengths
with differentwas reported towas
wavelengths be
successful,
reported toand be both patientsand
successful, andbothoperators
patients reported satisfactionreported
and operators concerning the aesthetic
satisfaction outcomethe
concerning at
6aesthetic
months outcome
and above of follow-up. In addition, it was revealed that the
at 6 months and above of follow-up. In addition, it was revealed that the quality of the scar (the quality
of the
the healing)
scar (theafter 4 weeks
quality was
of the higher after
healing) in the4 group
weekstreated
was higherusing in thetheEr,Cr:YSSG
group treatedand CO 2 lasers
using the
showing
Er,Cr:YSSG an MSS
and COof 1.16 ± 0.18
2 lasers and 1.5an
showing ± 0.27,
MSSrespectively.
of 1.16 ± 0.18The andaesthetic
1.5 ± 0.27, outcome values obtained
respectively. The aestheticwith
the Er,Cr:YSSG
outcome values(incision)
obtained and withCO (total photo-vaporization
the2 Er,Cr:YSSG (incision) andof CO lesions)
2 (total lasers were significantly
photo-vaporization better
of lesions)
than
lasersthose
were obtained with the
significantly diodethan
better and thethoseNd:YAG laserswith
obtained (transmucosal
the diodephoto-thermo-coagulation).
and the Nd:YAG lasers
Consequently, the Er,Cr:YSSG
(transmucosal photo-thermo-coagulation). and CO 2 lasers gave better scar quality
Consequently, the Er,Cr:YSSG and at 2 weeksCO2andlasers4 weeks after
gave better
treatment.
scar qualityHowever,
at 2 weeks at 6and
months
4 weeksand after
above, all surgical
treatment. procedures
However, at 6and wavelengths
months and above, showed similar
all surgical
satisfactory
procedures quality of the scar. showed
and wavelengths Furthermore, similar thesatisfactory
aesthetic quality
quality of of
scarstheresulting from the diode
scar. Furthermore, the
and Nd:YAG lasers was low until 1 month of follow-up, but gave satisfactory
aesthetic quality of scars resulting from the diode and Nd:YAG lasers was low until 1 month of results similar to other
wavelengths
follow-up, but after
gave6 months of follow-up.
satisfactory results similar to other wavelengths after 6 months of follow-up.
In this retrospective study, study, the
the Manchester scar scale (MSS), proposed in 1998 by Beausang et et al.
al.
was used because
because of ofits
itsdetailed
detailedand andrelevant
relevantdescription
description ofof
thethe color,
color, texture,
texture, size,
size, andand margin
margin of
of the
the
scarscar
andand its association
its association withwith the surrounding
the surrounding tissuetissue [15].
[15]. In In addition
addition to the to the aMSS,
MSS, a patient-based
patient-based visual
visual
analogue analogue scale
scale was wastoused
used to assess
assess the patient’s
the patient’s perception
perception of the healing
of the healing aspect.aspect. Furthermore,
Furthermore, it was
it was noted
noted that there
that there is practically
is practically no no standardized
standardized methodology
methodology and andsystematic
systematicapproach
approach for for the
assessment of scars and the the quality
quality of of healing
healing in in post-operative
post-operative surgical
surgical sitessites [28].
[28].
The nonsurgical procedure of transmucosal transmucosal photo-thermo-coagulation applied using the diode
and Nd:YAG lasers lasers consists
consists of of targeting
targeting the the chromophores
chromophores inside inside the the vascular
vascular lesions,
lesions, essentially
hemoglobin [29–31]. These chromophores absorb the laser’s energy and convert it into heat, which is
transferred to the vessel wall, causing coagulation and vessel closure and, finally, thrombosis of the
blood vessels [32]. [32]. Concerning
Concerningphoto-vaporization
photo-vaporizationusing usingthetheCO CO 2 laser,
2 laser, thethe absorption
absorption of photons
of photons by
by the water content of the tumor provokes a sudden
the water content of the tumor provokes a sudden local increase in temperaturelocal increase in temperature resulting from
vaporization of the blood cittern. At the end of the surgery, the mucosal layer covering the blood
cittern is totally vaporized, exposing the bottom of the tumor cavity [33–35]. On the other hand, the
Int. J. Environ. Res. Public Health 2020, 17, 8665 14 of 17

vaporization of the blood cittern. At the end of the surgery, the mucosal layer covering the blood
cittern is totally vaporized, exposing the bottom of the tumor cavity [33–35]. On the other hand, the
Er,Cr:YSSG laser procedure consists of complete excision of the vascular lesion, followed by coagulation
of the bottom of the wound for primary hemostasis [36,37].
A large number of approaches are described in literature for the management of vascular
lesions [8,38–40]. These methods principally depend on the type, severity, size, location, and possible
complications of the vascular lesion [14,38–43].
John et al. conducted a study on the treatment of venous lesions of the lips with a long-pulsed
Nd:YAG laser. The study included 31 patients with venous lesions of the lip [44]. The parameters
used were spot size depending on the size of the lesion, variable energy density with an average of 80
J/cm2 , and pulse width of 20. They concluded that the treatment was effective with 87% of patients
having no recurrence and one patient having a small, contracted scar [44]. In contrast to John et al., the
recurrence rate in our study was lower (only ±8%) with the Nd:YAG laser and no contracted scar was
seen. Scherer et al. also studied the use of the Nd:YAG laser for venous malformations of the face,
including 146 patients [45]. In their study, the Nd:YAG laser was used alone if the lesion was considered
relatively small or followed by a surgical excision if the lesion was considered deep. In addition, a
retrospective study by Mungnirandr et al. assessed the safety and effectiveness of the Nd:YAG laser
for venous malformation in the oral cavity [46]. The study included 10 children with inoperable VM
and established that the Nd:YAG laser is a promising alternative treatment in pediatric patients with
venous malformations in the oral cavity, whereby oral complications mostly seen involved mild to
moderate scarring [46]. Interestingly, the treatment protocol used in their study included the use of
the Nd:YAG in contact mode, in noncontact mode, and using interstitial techniques. The choice of
each technique depended essentially on the size and depth of the lesions. Specifically, the contact
technique involved placement of the fiber-optic end of the laser handpiece directly against the mucosal
surface during laser irradiation. The noncontact process, however, involved the laser beam being
emitted through a clear ice cube for purposes of minimizing epidermal injury [47]. The interstitial
technique required the insertion of the fiber-optic end of the handpiece during laser irradiation inside
the lesion [46].
It can be found in the literature that most treatments for vascular lesions were performed with
the Nd:YAG laser, albeit using different wavelengths. Del Pozo et al. conducted a study with a
CO2 laser on five cases of venous malformations with lip involvement [47]. The study revealed that
vaporization with the carbon dioxide laser was able to flatten the surface of the lip and, therefore,
was considered an effective palliative treatment of lip venous malformations [47]. Compared to our
study, the treatment protocol with the CO2 laser was different. Del Pozo et al. irradiated the treatment
area with several passages in contact mode to achieve a contraction and immediate flattering of
the lesion surface. However, in our study, noncontact mode was used in order to generate heat to
vaporize the water inside the vascular lesion; then, the external layer of the mucosa was vaporized
and removed in focused mode until complete exposure of the lesion bottom. Unlike our study, there
was no recurrence noted in Del Pozo’s study; however, their purpose was not to completely remove
the venous malformation but to shrink its size. Bacci et al. performed a retrospective study on the
use of a diode laser to treat small oral vascular malformations. The study included 59 patients, which
showed that the only complication related to the surgery was modest pain. This pain 30 days after the
reduction of the lesions, however, was considered as excellent or good in 52 cases and fair or poor in
seven cases, whereas six patients required a second diode laser application [48]. The study revealed
that the diode laser is considered acceptable for the treatment of small oral venous malformations and
venous lakes with shorter postoperative complications and shorter operating times when compared to
the conventional scalpel surgery [48]. Furthermore, Angiero et al. conducted a study on head and neck
vascular lesions in pediatric patients treated with an endolesional 980 nm diode laser [48]. The study
included 160 patients with hemangiomas, 50 with vascular malformations, and 40 with lymphatic
malformations. The treatment results were analyzed by evaluating the decrease in lesion size and its
Int. J. Environ. Res. Public Health 2020, 17, 8665 15 of 17

complete clinical disappearance. All patients had a complete resolution of the vascular lesion except
for 38, for which an additional session was required [48].
Topical therapy such as timolol, high-potency topical corticosteroids, imiquimod, and becaplermin
gel are also recommended for superficial hemangiomas [40–42]. In fact, timolol has emerged as the
preferred topical treatment. On the other hand, Lee et al. concluded, in a study on 11 patients with lip
hemangioma, that the use of Dermabond after surgical excision prevents wound contamination and
yields acceptable aesthetic results [43].
Since different operators used the Manchester scar scale (MSS) to assess the aesthetic outcome, a
possible limitation of our study was the slight subjectivity obtained when different operators used
the MSS.
Our retrospective study compared four laser wavelengths in the management of venous
malformation and capillary hemangioma of the lip with three different surgical approaches (excision,
photo-vaporization, and transmucosal photo-thermo-coagulation). Further studies are necessary to
compare the aesthetic outcome, the recurrence rates, and the possible postoperative complications of
different protocols.
The null hypothesis was rejected because no statistical difference in the aesthetic outcome at
the end of follow-up was obtained by the three different surgical procedures, i.e., transmucosal
photo-thermo-coagulation (Nd:YAG and diode lasers), photo-vaporization (CO2 laser), and surgical
excision (Er,Cr:YSGG laser).

5. Conclusions
Our retrospective study showed that laser-assisted aesthetic treatment of vascular lesions of the
lips can be considered effective regardless of the wavelength used (Er,Cr:YSGG, CO2 , Nd:YAG, and
diode lasers) or the treatment procedure (transmucosal photo-thermo-coagulation, photo-vaporization,
and surgical excision). There was no significant difference in patient and practitioner satisfaction
with aesthetic outcome at 6 months follow-up. Furthermore, the treatments of lip vascular lesions
performed using Er,Cr:YSGG and CO2 lasers did not show any recurrence during the 12 months of
follow-up, while recurrence rates of 11% ± 1.4% and 8% ± 0.9% were seen in the diode and Nd:YAG
groups, respectively.

Author Contributions: Conceptualization, S.N.; methodology, S.N., M.E.M., P.V., and A.V.; investigation, A.N.,
M.N., P.V., K.G.-L., and J.A.-D.; writing—original draft preparation, S.N. and M.E.M.; writing—review and
editing, S.N., M.N., and A.N.; supervision, S.N. and A.V. All authors read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: Page: 15The authors declare no conflict of interest.

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