2016 aad hands-on laser workshop handouts final sp dynamis m. christine lee, m.d. • the skin and...

M. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA

Hands-On Laser Workshop

M. Christine Lee, MD, MPHThe Skin and Laser Treatment Institute

Walnut Creek, CAwww.skinandlasertreatment.com • [email protected]

JULY 30, 2016

2016 Summer MeetingBoston, MAJuly 28-31, 2016Hynes Convention Center

DISCLOSURE OF RELEVANTRELATIONSHIPS WITH INDUSTRY

M. Christine Lee, M.D. Hands-On Laser Workshop

Investigator– Lumenis, Cutera, Syneron, Iridex, Solta, Ulthera, Cynosure, Fotona, BTL


2016 Summer MeetingBoston, MAJuly 28-31, 2016Hynes Convention Center


Ablative and Fractional Resurfacing


Carbon dioxide (CO2) laser appeared in 1964 and became the most widely used laser in derm. CO2 emits invisible infrared beam at 10,600 nm wavelength, targeting both intracellular and extracellular water. When light energy is absorbed by water-containing tissue, skin vaporization occurs with production of coagulative necrosis in the remaining dermis.Removes the deepest layer of epidermis (100 µm for CO2 compared to 30 µm for Erbium) which results in the best results. Disadvantage is that it also results in longest downtime, greater discomfort and inconvenience, greater risk of side-effects and complications compared to less invasive options. Limited to use on face whereas fractional and Erbium can be used all over the body.Down time and clinical effect varies based on energy applied, number of passes delivered, degree of pulse or scan overlap, complete/incomplete removal of partially desiccated tissue between each laser passResults are also affected by pre-op and post-op care

Laser Resurfacing


Fractional photothermolysis was developed in 2004 by Manstein and colleagues. A pixilated pattern of full-thickness columns of coagulation is created in this process. These columns of coagulation are termed micro thermal zone (MTZ). Shorter recovery time and rapid healing are attributable to the healthy tissue that surrounds the MTZs.

Advantage of fractional resurfacing is less downtime, faster recovery, less pain, and less side-effects and complications compared to traditional ablative resurfacing. Disadvantage is need for multiple treatments to achieve optimal results.

Gold standard for wrinkles is CO2 laser resurfacing. But new gold standard for acne scarring is probably fractional resurfacing.

Tradeoff for wrinkles: Longer downtime = more invasive = better results

Laser Resurfacing


Erbium:YAG ablative resurfacing (2940 nm wavelength) is more superficial in its level of ablation compared to CO2. These short pulsed lasers with stronger water absorption were less injurious to deeper tissues; they ablate the superficial tissue but leave little residual thermal damage. However, these lasers were good for smoothing the surface but did not have the same tightening effect as CO2 lasers. The next level of advancement entailed increasing the pulse width of the Erbium lasers to include some deposition of heat (increased thermal coagulation) which would allow tightening.

Erbium lasers vary greatly in their efficacy due to whether they possess the ability to do just pure ablation (shorter pulse) vs. ablation plus thermal coagulation (longer pulse). Erbium lasers which have longer pulse width such as Fotona and Sciton are capable of achieving more “CO2-like” results.

Laser Resurfacing


Downtime with Erbium can vary greatly from 2 to 7 days depending on the fluence used, number of passes, overlap (as opposed to 10-14 days with CO2 laser).

Because of faster recovery, greater tolerability, and minimal side effects, Erbium and fractional resurfacing have become the most popular and sought after resurfacing procedures and have largely replaced CO2 ablative resurfacing.

Very few cosmetic derm or plastic surgery practices perform CO2 laser despite the excellent results due to the “high hassle” factor. Almost all aesthetic practices perform many Erbium and fractional laser resurfacing procedures and they are considered essential workhorses for any aesthetic laser practice.

Laser Resurfacing


Invasive Laser Ablation

Deep Acne Scars Severe Rhytids & Actinic Damage

Sebaceous Hyperplasia Benign Adnexal Neoplasms (Syringomas)

Xanthelasmas/Xanthomas

Rhinophyma Tattoos

CO2, Er:YAG, Fractional Resurfacing


Wrinkle Reduction LasersDevice Type

Wrinkle Reduction DowntimeGrade After 1

TreatmentAfter 6

Treatments Wound Redness

CO2 Laser A+ 70% N/A 7-10 Days 1-3 Months

ActiveFX A- 40% 80% 60% After 3 Treatments

3 Days 5-7 Days

re:Pair B+ 30% 60% 3 Days 5-7 Days

Erbium B+ With Multiple Treatments

30% 60% 1-2 Days 4-7 Days

Plasma B- With Multiple Treatments

25% 50% 1-2 Days 4-7 Days

Fractional Resurfacing

C+ With Multiple Treatments

20% 40% Minimal to None

4-7 Days(but more severe

than Erbium)

CoolTouch D+ With Multiple Treatments

<10% <20% Minimal to None 1-3 Days

M. Christine Lee, M.D. •The Skin and Laser Treatment Institute • Walnut Creek, CA

Wrinkle Reduction Lasers

CO2 > ActiveFX > Erbium > Plasma > Fractional > Non-Ablative(Fractional CO2)


Ablative Resurfacing

“Gold Standard” for wrinkle reduction Risks

Hypopigmentation Infection and scarring Unnatural sheen to skin Complex aftercare Prolonged erythema Limited to face (CO2)



ActiveFX, DeepFX & TotalFX & MaxFX (Lumenis)

• UltraPulse Encore

• Multi-application System for Incisional, Excisional and Skin Resurfacing Procedures

• C02 technology w/ scanner

• Ablative resurfacing, 4-7 days downtime

• Adjust depth, deep or superficial

• Unit cost $80-100,000

• 1 treatment, no disposables


Fractional CO2 ResurfacingActiveFX & DeepFX (Lumenis) CO2RE (Syneron) Fraxel re:pair (Solta Medical) Mixto SX (Lasering USA) Ellipse Juvia (Ellipse) Affirm CO2 (Cynosure) DOT Therapy (Eclipsemed) Pixel CO2 (Alma) Pixel CO2 OMNIFIT Handle (Alma)


Fractional ResurfacingFraxel Re:store (Solta/Valeant) Fraxel Re:fine (Solta/Valeant) Profractional (Sciton) Lux 1440 and Lux 1540 (Palomar/Cynosure) Affirm 1440 (Cynosure) M22 ResurFx (Lumenis) Clear & Brilliant (Solta/Valeant) Erbium fractional (Fotona) eMatrix and ePrime (Syneron)


UltraPulse Fractional CO2

How does Fractional CO2 work?• Small “bridges” of healthy tissue are left

intact for faster healing• Allows for thermal relaxation between

ablated spotsAblated Column

Intact “Bridge”

Heat in the Dermis



Ability to specify exact healing zone (density)

Leave 0 to 95% of skin in tactM. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA


Ablation Volume:Volume is varied by adjusting spot size

Spot size1.3 and 0.12

Depth


Trading lower down-time for more

modest results

ActiveFX™MaxFX™

ActiveFX vs. MaxFX


ActiveFX vs. Traditional CO2:

Leaves bridges intact Allows for thermal relaxation between ablated spots

Lower density in the pattern

“Traditional” Settings (spots touch or even overlap)

ActiveFX™ Settings (small “bridges” of

healthy tissue left intact for faster healing)

Photo courtesy of Greg Chernoff, M.D.


Erbium Resurfacing

Pearl YSGG (Cutera) Lux2940 (Palomar/Cynosure) Lux1540 (Palomar/Cynosure) Contour (Sciton) Venus-i (Cutera) SP Dynamis (Fotona/Lumenis) Pixel 2940 (Alma) PixelRF (Alma)

SP Dynamis (Fotona)


Introducing SP Dynamis


A non-disposable combination Erb:YAG Nd:YAG laser system that can deliver both ablative and non-ablative therapies via variable spot sizes and scanning patterns that utilize Piano and Frac3 modes, six unique adjustable pulse durations and a tissue effect indicator

Key Technical Specifications


Spec Er:YAG Nd:YAG

Wavelength 2940nm 1064nm

Max Energy 3000 mJ 50J

Max Power (W) 20W 80W

Pulse (ms) MSP, SP, LP, VLP, XLP, Smooth 0.1 to 50ms

Fluence (J/cm2) 0.1 to 95 J/cm2 10 to 600 J/cm2

Frequency 2 to 50 Hz 0.5 to 100 Hz

QCW Yes

KEY LASER TREATMENTS PER TYPE OF LASER

Skin Modifiers ★ Wrinkles★ Stretch marks★ Scars★ Tightening & texture★ Pigmented lesions★ Benign lesions

Treated with:Erbium YAG


Others ★ Hair removal★ Vascular lesions ★ Active acne★ Onychomycosis★ Warts★ Keloids

Treated with:Neodymium:YAG

Location of Delivery Devices


Nd:YAG Scanner

Nd:YAG Handpiece

Erbium:YAG Delivery Device

Fotona SP Dynamis


Fotona SP Dynamis


Modalitiesnon-ablative

full beamnon-ablative

fractionalablative

full beamsurgical

Lipo and Endosurgical

Lipo and EndoWavelenth Nd:YAG 1064 nm Nd:YAG 1064 nm Er:YAG 2940 nm Nd:YAG 1064 nm

Modalities Long pulse FRAC3 Stamping, Scanning QCW mode

Max. Power 65 W 65 W 20 W 30 W

Max. Energy 50 J 18 J 3.000 mJ 5 J

Max Fluence 600 J/cm2

@ 2 mm spot 550 J/cm

2

@ 2 mm spot 95 J/cm 2 n / a

Pulse length 2 - 50 msec 0,1 - 1,0 msec0,1 - 1,5 msec, 150 . 250 msec

0,1 - 2,0 msec

Max. Frequency 100 Hz 100 Hz 50 Hz 100 Hz

Handpieces, Scanners

R31, R33; S-11 R31, R33; S-11 R04, R11, S-Runner

R27 - cannulas

Spot size - stamping

2 - 10 mm 2 - 10 mm 2 - 12 mm bare fibers 600um and 945 nm

Spot size- scanning 3 and 6 mm 3 and 6 mm 4 mm scan up to 40 x 40 mm

/

Special features

Wireless Footswitch - comfort in sysetm usage

VSP - Variable Square Pulse

EFC - Energy Feedback Control, unique automatic selfcalibration per each pulse

FRAC3®

mode - unique, 3D non-ablative fractional treatments with Accelera pulses

Smooth mode - non ablative thermal ErYAG modality

Erbium:YAG

M. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA M. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA

Erbium YAG Laser

Can be applied as: ABLATIVE (remove tissue and pigmentation) NON ABLATIVE (heat deposit – tightening)

Can operate in : FULL SPOT = Total area coverageFRACTIONAL= Microspot minimizing aggression

Can be applied with: HANDPIECE SCANNER

What is Erbium YAG Smooth Mode ?


• Special TRAIN of long pulses that create a unique Extra Long Pulse that can generate deep heat deposition with no necrosis, bleeding or pain

100 µm

Heating depth of + 1500 µmSmooth mode in stretch marks

Nasogenian Grooves & Nasolabial Folds

M. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA15 Minute Procedure – Requires No Anesthesia

Intraoral Application: Fractional – Non ablative – Smooth mode Erbium:YAG


Fotona Laser 4D

★ Intraoral (fractional nonablative Erbium Smooth mode with super long-pulsed 250 msec)

★ Frac3 (fractional Nd:YAG with high peak power)★ Piano mode (extra super long-pulsed 6 sec

Nd:YAG)★ Ablative Erbium (substitute nonablative Erbium

Smooth mode for this step if want to keep it noninvasive)

M. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA M. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA

Neodymium YAG with Adjustable Pulse Duration

Microseconds Miliseconds Seconds

Watts

LONG

PULSE

FRAC3

PIANO MODE

Kilowatts

QCW

Peak Power

Pulse duration

!FRAC 3 : fractional, deep, high peak power pulses = Skin tightening, pigment removal, hair removal

!QCW: Quasi Continuous Wave - small packets of pulses at high repetition = Laserlipolysis, tissue cutting and coagulation

!Long Pulse : Heat deposition for coagulation and bactericidal effect = Acne, onychomycosis, vascular tx, warts

!PIANO Mode: Homogeneous deep heating = Bulk tissue heating, pain treatments

SP Dynamis (Fotona) Nd:YAG


Neodymium:YAG


• Hair removal

• Vascular lesions

• Active acne

• Warts

• Onychomycosis

• KeloidsM. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA

Indications for UsePort Wine Stains Mod Acne Vulgaris Warts Telangiectasia

Treatment of WrinklesSpider VeinsLeg VeinsVenus LakeRosacea

Hemangiomae Vascular LesionsProcedures

★ Leg Veins★ Telangiectasias★ Spider veins★ Venous lakes★ Port Wine Stains★ Facial veins★ Hemangiomas★ Rosacea


Key Benefits ★ Immediate visible results★ Good patient tolerance★ Low incidence of secondary

effects★ Highly effective treatment

Nd:YAG


Tattoo Removal


Tattoo Removal• Based on theory of selective photothermolysis. Energy is absorbed by the ink particles in a

very short time, typically nanoseconds or picoseconds. Sufficient energy must be delivered and absorbed by the tattoo ink to break up the pigment. The shock wave created by this energy causes the pigment to fragment or shatter.

• Different lasers are used for different tattoo colors. Consequently, multi-color tattoo removal almost always requires the use of two or more laser wavelengths.

• Types of lasers used:

• Q-switched frequency doubled Nd:YAG: 532 nm - creates a green light which is highly absorbed by red and orange. This wavelength is highly absorbed by melanin which makes it effective for brown spot removal.

• Q-switched Ruby: 694 nm - creates a red light which is highly absorbed by green and dark tattoo pigment. This is the best wavelength for blue ink.

• Q-switched Alexandrite: 755 nm - creates a red light which is highly absorbed by green and dark tattoo pigment. Works well on green tattoo but because of its weaker peak power (it is the weakest of all the Q-switched devices) it works only moderately well on black and blue ink.

• Q-switched Nd:YAG: 1064 nm - creates a near-infrared light absorbed by all dark tattoo pigments and is the safest wavelength to use on tissue due to the low melanin and low hemoglobin absorption.


Tattoo Removal

• Dye modules are available for some lasers to convert 532 nm to 650 nm or 585 nm light which allows one laser system to safely and effectively treat multi-color tattoo inks. (the QX-Max by Fotona which we are using in today’s laser workshop is one of those lasers.)

• Multiple treatments usually spaced at least 7 weeks apart are required to remove tattoos.

• Certain colors are more difficult to remove than others. Green and blue are more resistant.

• Picosecond lasers using 755 nm, 532 nm, and 1064 nm wavelengths have been developed and are reported to be more effective in treating resistant colors like green.


Tattoo Lasers• RevLite (ConBio/Cynosure) - QS Nd:YAG, KTP, 585, 650 nm

• MedLite C6 (ConBio/Cynosure) - QS Nd:YAG, KTP

• Picosure (Cynosure) - Picosec 755 nm

• QX-MAX (Fotona) - QS Nd:YAG, KTP, 585, 650 nm• Picoway (Syneron) - Picosec Nd:YAG and KTP• Enlighten (Cutera) - Picosec Nd:YAG and KTP

• Trivantage (Syneron) - QS Nd:YAG, KTP and Alex

• Harmony (Alma) - QS Nd:YAG, KTP handpiece

• Duality (Astanza) - QS Nd:YAG, KTP

• Eternity (Astanza) - QS Ruby


QX-MAX(Fotona)

QX-Max (FOTONA)

Q-switched KTP (532 nm) and Nd:YAG (1064 nm)

585 nm and 650 nm wavelengths

Variable spot size, pulse duration, and fluence

Better beam profile


Q-Switched Laser Wavelengths: 1064 nm, 755 nm, 694 nm and 532 nm


Q-switched lasers wavelengths:1064 nm, 755 nm, 694 nm and 532 nm

1,064 mm

0.755 mm 0.694 mm

0.532 mm

Efficacy

Safety

KTP used only for red, orange, purple Ruby and alexandrite

may cause hypopigmentation

Nd:YAG most safe for all skins

Depth of Penetration

Influencing factors: 1. Depth

1. Wavelength -1064 deepest2. Spot size - larger better

2. Peak power 1. High Power - (1,600 mj)2. Speed - (6 ns pulse)


Deep High Peak Powers

QX-Max Effect

QX-MAX shatters deep inks, and then the bodies own phagocytes can absorb and remove ink particles

Low powered devices will leave a shadow and never clear the tattoo as the laser will not effectively reach deep enough


Large Spot at High Peak Powers (short pulse + high fluence) = Success


Response to Laser Exposure (Electron Microscopy)Untreated tissue

Q-Switched laser

Courtesy H. R. Jalian, M.D.


Response to Laser Exposure

Untreated tissue

Q-Switched laser

Courtesy H. R. Jalian, M.D.

Fotona QxMax Technical Specifications


Wavelength Nd:YAG 1064nm KTP 532nm Yellow 585nm Red 650nm

Modalities Single Pulse, Q-Switched Mode

Single Pulse, Q-Switched Mode



Max. Energy 1.600 mJ 600 mJ 300 mJ 220 mJ

Max. Available Fuluence 51 J/cm2 19 J/cm2 9,5 J/cm2 7.0 J/cm2

Max. Usable Fluence 12,7 J/cm2@ 4 mm Spot

6.5 J/cm2@ 3 mm Spot

9,5 J/cm2@ 2 mm Spot

6,5 J/cm2@ 2 mm Spot

Pulse Length 5-20 nsec 5-20 nsec 5-20 nsec 5-20 nsec

Max. Frequency 5 nsec at max output energy 10 Hz 2 Hz 2 Hz

Spot Size 2 - 8 mm 2 - 8 mm 2, 3, 4 mm 2, 3, 4 mm

Special Features

EFC - Energy Feedback Control, unique automatic self-calibration per each pulse

Beam Profile - Unique, patent pending solution for generation of ideal beam profile

Optoflex Arm - Unique, 3D non-ablative fractional treatments with Accelera pulses

Wireless Footswitch - comfort in system usage

QxMax: Four-Wavelength Laser


Much longer life time than any other solid dye converter on the market

Wavelenth 585 nm 650 nm

Color removed Sky blue Green

Max. Energy 300 mJ 220 mJ

Max Fluence 9,5 J/cm2 6,5 J/cm2

Max Frequency 2 Hz 2 Hz

Spot size 2, 3, 4 mm 2, 3, 4 mm

Two Additional Solid Dye Inserts: Yellow (585 nm) and Red (650 nm)


Tattoo removal: Sky blue hues, Vascular lesions

585nm

Treatment of Complementary Colors

Tattoo removal: Green hues

Q-switched Beam Converter 585nm

Q-switched Beam Converter 650nm

650nm


26

System Technical Specifications:

Fotona QX Max

Wavelenth Nd:YAG 1064 nm KTP 532 nm Yellow 585 nm Red 650 nmAccelera

Nd:YAG 1064 nm

ModalitiesSingle pulse,

Q-Switched mode

Single pulse, Q-

Switched mode

Single pulse, Q-

Switched mode

Single pulse, Q-

Switched modeFree-running

mode

Max. Energy 1.600 mJ 600 mJ 300 mJ 220 mJ 5.000 mJ

Max available Fluence 51 J/cm

219 J/cm

29,5 J/cm

27.0 J/cm

2160 J/cm

2

Max usable Fluence 12,7 J/cm2

@ 4 mm spot

6,5 J/cm2

@ 3 mm spot

9,5 J/cm2

@ 2 mm spot

6,5 J/cm2

@ 2 mm spot

160 J/cm2

@ 2 mm spot

Pulse length 5-20 nsec 5-20 nsec 5-20 nsec 5-20 nsec 250 μsec

Max. Frequency 10 Hz 10 Hz 2 Hz 2 Hz 0,5 - 2,2 Hz

Spot size 2 - 8 mm 2 - 8 mm 2, 3, 4 mm 2, 3, 4 mm 2 - 8 mm

Special features

EFC - Energy Feedback Control, unique automatic selfcalibration per each pulse

Beam Profiler - unique, patent pending solution for generation of ideal beam profile

Optoflex Arm - unique, patent pending solution for beam delivery and handling

Wireless Footswitch - comfort in sysetm usage

FRAC3® mode - unique, 3D non-ablative fractional treatments with Accelera pulses


Results


PEAK POWERPicoWay

(Syneron)PicoSure

(Cynosure)enlighten (Cutera)

ConBio RevLite

(Cynosure)

QX Max (Fotona)

Wavelength 1064 / 532 nm 755 nm 1064 / 532 nm 1064, 532, 585, 650 nm 1064, 532, 585, 650 nm

Maximum energy 400mJ / 200 mJ 165-200 mJ 600 mJ / 300 mJ

850 mJ @ 1064 nm 350 mJ @ 532 nm 310 mJ @ 585 nm 200 mJ @ 650 nm

1600 mJ @ 1064 nm 600 mJ @ 532 nm 300 mJ @ 585 nm 220 mJ @ 650 nm

Pulse width 450 ps / 375 ps 550 – 750 ps 750 ps & 2 ns 5-20 ns 5-20 ns

Peak power (GW)0.9 Gigawatts / 0.53 Gigawatts 0.36 Gigawatts

0.8 Gigawatts/ 0.4 Gigawatts

0.16 GW @ 1064 nm 0.07 GW @ 532 nm 0.06 GW @ 585 nm 0.04 GW @650 nm

0.32 GW @ 1064 nm 0.12 GW @ 532 nm 0.06 GW @ 585 nm 0.04 GW @650 nm

Peak power (W)900,000,000 Watts 530,000,000 Watts 360,000,000 Watts

800,000,000 Watts 400,000,000 Watts

160,000,000 W @ 1064 nm 70,000,000 W@ 532 nm

60,000,000 W @ 585 nm 40,000,000 W @650 nm

320,000,000 W @ 1064 nm 120,000,000 W@ 532 nm 60,000,000 W @ 585 nm 40,400,000 W @650 nm

Spot size 2-10 mm2.0 – 6.0 mm Zoom 6, 8, 10 mm Fixed 2-8 mm

1064 nm – 3, 4, 6 & 8 mm 532 nm – 2, 3, 4 & 6 mm

585 nm - 2 & 3 mm 650 nm - 2 & 3 mm

1064 nm – 2-8 mm 532 nm – 2-8mm

585 nm - 2, 3 & 4 mm 650 nm - 2 , 3 & 4 mm

Repetition rate Single to 10 Hz 1, 2, 5, 10 Hz Single to 10 Hz 10 Hz Nd:YAG / 1 Hz Dye Cart

0.5 - 10 Hz Nd:YAG /KTP 2 Hz Dye Cart


Fluences vs spot sizes QX Max and Pico systemsQX Max has up to 8x higher fluences

Due to such low fluences pico has to work with small spots – in PicoSure max 3.5 mm was reported as used in tattoo removal treatments so far.

0

3.5

7

10.5

14

2 3 4 5 6 7 8

QXMaxPicoSurePicoWayenLighten

NdYAG

Spots QX Max PicoSure PicoWay enLighten

2 12,7 6,37 12,7 12,7

3 12,7 2,83 5,7 8,5

4 12,7 1,59 3,2 4,8

5 8,2 1,02 2,04 3,06

6 5,7 0,71 1,6 2,4

7 4,2 0,52 1,04 1,56

8 3,2 0,40 0,8 1,19


Skin Tightening


Non-Invasive Skin TighteningUltherapy (Merz) - High Intensity Focused Ultrasound

Exilis Elite (BTL) - RadiofrequencyThermage (Solta) - RadiofrequencyTitan (Cutera) - Deep Heating Infrared Heating

Invasive Skin TighteningS-Lift & Mid-Face Suspensions

Sagging Skin


BODY CONTOURING

Thermage for Body (Solta)

Titan (Cutera)

truSculpt (Cutera)

Exilis Elite (BTL Industries)

Cellutone (BTL)

Z Wave (Zimmer)

iLipo (Chromogenex)

Venus Freeze (Venus Concept)

Vaser Shape (Sound Surgical)

VelaShape (Syneron)

SmoothShapes (previously Eleme, now Cynosure)

Refit (Viora)

Bella Contour (Real Aesthetics)

Legend (Lumenis)


Exilis EliteBTL Aesthetics


Key Advantages

• Focused, Continuous • Monopolar RF • Controlled Cooling • Real-Time Temperature • Monitoring • EFC (Energy Flow Control) • Impedance Intelligence • Body and Face

Applicators • No Costly Consumables


Focused Monopolar RF• Uniform Volumetric Heating

• Consistent collagen and fat response • Deep

• Reach depths up to 2.5 cm • Flexible

• Customize treatments by targetingspecific depths of tissue

• Safe • No hot spots • Closed loop system widely used in aesthetics


Real Time Temp. Monitoring

Adjust energy to ensure patient comfort without sacrificing efficacy.


Controlled Cooling

• Ability to treat various layers of tissue- dermis to full subcutaneous fatM. Christine Lee, M.D. • The Skin and Laser Treatment Institute • Walnut Creek, CA

Body & Face Applicators

Built in Temp Monitor• Abdomen • Love Handles • Back Fat • Arms • Thighs/Knees • Four Treatments

90 Watt Applicator• Full Face • Neck/ Decollete • Periorbital • Elbows • Hands • Two Treatments


Mechanism of Action

• RF energy- volumetric heating of tissue by exciting molecules rapidly (3 million times per second)

• Tissue resistance (impedance) to movement creates heat

• RF energy is color blind – treats all skin types


Collagen RemodelingMonopolar RF Mechanism of Action

• Initial Clinical Response • Immediate collagen contraction • Water molecules separated from collagen molecules cause collagen to

“denature” and therefore contract • Clinical Result – wound healing response

• Collagen deposition and remodeling • Dermal contraction results in tightening • Fibrous septae contraction results in contouring

+ HEAT

Collagen Triple Helix Molecule Denatured Collagen Fibers

Source: “Histological and Ultrastructural Evaluation of the Effects of a Radiofrequency- Based Non-ablative Dermal Remodeling Device” Archives of Dermatology February 2004, B.Zelickson, M.D. et al


ClinicallyProven

Safe&Efficacious

CustomizableTreatment

TreatallBodyArea

VirtuallyPainless

MinimalConsumables


92cents/line;800–900lines/Tx

Roughly$700consumable15Tx/Monthfor12months=$126,000

Roughly$125-$150/Tx15Tx/Monthfor12months=$22,500

$4/treatmentforground15Tx/Monthfor12months=$720


Current Market Pricing & Costs• $400-$600 per area for 4 body Tx’s• $800-$1200 per area for 2 face Tx’s• Average time of treatment is 30-50 min.

• Minimal consumables• Disposable ground electrode at $4 per treatment• Baby oil or ultrasound gel for conduction• The device is paid in full after only 35 patients


Summary

• Face and Body Applicators can be used all over the face, neck and body

• Patient comfort with controlled cooling

• No costly consumables

• Easy to delegate


Fat Melting


Fat Contouring DevicesHigh-Frequency Focused Ultrasound (HIFU)(Thermal)

Liposonix (Solta/Valeant) Pulsed Focused Ultrasound (Nonthermal)

UltraShape (Syneron) Cryolipolysis

CoolSculpt (Zeltiq) Multipolar Selective Radiofrequency

Vanquish ME (BTL) 1064 nm Diode Laser

SculpSure (Cynosure)


VanquishMEBTLAesthetics


The world’s first: • Operator Independent • Multipolar, • Selective RF™ treatment,

• That eliminates fat non-invasively

• Without downtime, discomfort, or consumables.


• Multiple + & - electrodes emitted simultaneously create the world’s first and

only non-contact, Selective RF™ energy field.

• First and only true multipolar design.

Multipolar, Selective RF


• Vanquish delivers RF energy, selectively absorbed by Fat which heats it to the point of permanent reduction

• Skin and Muscle are not affected

• Think of a traditional light bulb – the copper wires on either side conduct energy

• The filament in between is not conductive but receives the energy which gets hot and gives light

Mechanism of Action


Lightbulb Conductive and Resistive Properties


Muscle and skinare extremely polarized

Fat is not effectively polarized

Vector of Electrical Intensity

• Fat tissue is not easily polarized due to its low water content & low relative permittivity

• This creates a high internal electric field measured by the Vector of Electrical Intensity

• Vector of electrical Intensity Efat is approx 10 x higher than Emuscle, skin


Depth of Penetration

• Focal point is Approx. 10mm below the surface

• Uniformly heats Approx. 5mm - 15mm to 43 - 45ºC

10mm5mm

15mm

43-45ºC


• Core Applicator • Articulating Arm • Generator and

Operator Interface • Small Footprint • Easy to Move • Easy to Operate

Device Component Summary


Vanquish Device



Homogenous Thermal Profile

With the largest spot size in it’s category


Skin surface temperature 40° post treatment. At 1cm deep temperature is 44° for 26 minutes.

BTL Vanquish: Homogenous Heating of Skin and Fat Tissues


Apoptosis/pseudoinflammationof the fat cells


Histology

After 1st treatment

After 4th treatment


Gross Pathologic Examination

Volume of the fat layer – treated area

Volume of the fat layer untreated area


The Results: Volumetric Reduction

measured in fat layer

Approximately a 60% Reduction

Before Thickness of subcutaneous

fat tissue 7.6 mm

After 4 weeks Thickness of subcutaneous

fat tissue 2.9 mm


DemographicsSex, n (%) 22 (91.7)

Female 2 (8.3)

Male

Age, y

Mean (SD) 47.9 (11.2)

Median (range) 47 (30-69)

BMI

Mean (SD) baseline 23.9 (2.1)

Mean (SD) 3 months f/u 23.6 (2.3)

Race, n (%)

White 19 (79.1)

African American 1 (4.2)

Other 4 (16.7)

BTL Vanquish ME: Evaluation and Safety of Selective RF

Results

Average Circumference Reduction

4.22cm at 3 month F/U

3 Independent Evaluator’s Assesment

88% Accuracy

Safe & Efficacious Yes


Vanquish Leg Applicator Protocol• Treatment Parameters

• 4 Treatments

• 30 minutes (each leg)

• Start power: 80W titrate PRN

• Patient positioning

• Sitting or semi-reclined position

• Edge of bed closest to device

• Bolster inner or outer thigh, if necessary

• Drape the pubic bone with a towel


Vanquish Leg Applicator


BODY CONTOURING

Thermage for Body (Solta)

Titan (Cutera)

truSculpt (Cutera)

Exilis Elite (BTL Industries)

Cellutone (BTL)

Z Wave (Zimmer)

iLipo (Chromogenex)

Venus Freeze (Venus Concept)

Vaser Shape (Sound Surgical)

VelaShape (Syneron)

SmoothShapes (previously Eleme, now Cynosure)

Refit (Viora)

Bella Contour (Real Aesthetics)

Accent V-Shape (Alma)

Legend (Lumenis)


Comparison Between Liposonix, Ultrashape, Zeltiq, Trusculpt

Treatment of Love Handles:Liposonix: 20 minutes x 1 treatment to lose 2.5 cm to 4 cm (results seen at 3 months after 1 Rx)

Ultrashape: 20-30 minutes x 2-3 sessions to lose 2.5 to 4 cm (results seen at 2 weeks after 2-3 Rx’s)Zeltiq: 2-4 hours x 2-3 sessions to lose < 2 cm (results seen at 3-4 months after 2-3 Rx’s)

TruSculpt: 1 hour x 2 sessions to lose < 1 cm (results seen at 2 months after 2 Rx’s)


Comparative Analysis Tissue Response To Different Modalities

1UltraShape research – data on file, 2Liposonix published data, 3Zeltiq published data

Acute 2 Weeks 4 WeeksUltraShape- Focused Pulsed Ultrasound1 (Immediate mechanical effect)

No InflammationNo Inflammation

CoolSculpting-Cryo3 (freeze-thaw necrosis) 1hr. induction

Inflammation Inflammation

Liposonix-HIFU2 (Thermal necrosis)

Inflammation


Comparison of Devices


Vanquish vs. Coolsculpt

Clinical Proven

Safe & Efficacious

Patient Selection

Treat Multiple Areas Simultaneously

Treatment Time

Comfortable, Non-Painful Procedure

Downtime

Ability to Tighten

No Consumables


Treatment to Transformation (6 small @ $125/ea & 1 large @ $275/ea applicators = $1025) 15 Tx/Month for 12 months = $184,500

$0/Tx 15 Tx/Month for 12 months = $0


Liposonix = Pain & Bruising


TruSculpt- 4” square for 4 min


Homogenous Thermal Profile

With the largest spot size in it’s category


Summary• Non-contact

• Largest Treatment area

• Energy is selectively absorbed in fat

• Pain free

• Ease of use for clinician

• Short focused sessions

• Low consumable costs


Cellutone (BTL)• Acoustic shock wave device similar to

Zimmer Z wave

• Cellulite reduction and lymphatic drainage

• Accelerates results of body contouring devices

• Pain free, Ease of use for clinician

• Short focused sessions

• No consumable costs


Fat Contouring Devices

Suction MassageEndermologie

Suction/Massage/ThermalTriActive (Cynosure) Smoothshapes (Cynosure)

Radiofrequency Energy VelaSmooth, VelaShape (Syneron) Thermage (Solta/Valeant) TruSculpt (Cutera)Accent (Alma) Exilis Elite (BTL)

Reaction (Viora)TiteFX (Invasix)

High-Frequency Focused Ultrasound Energy

UltraShape (Syneron)LipoSonix (Solta/Valeant)

CryolipolysisCoolSculpt (Zeltiq)

Low-Level Light Laser Therapy

Zerona (Erchonia Medical)


Fat Contouring Devices

High-Frequency Focused Ultrasound Energy

UltraShape (Syneron)LipoSonix (Solta/Valeant)

CryolipolysisCoolSculpt (Zeltiq)

Multipolar Selective Radiofrequency

Vanquish ME (BTL)1064 nm Diode Laser

SculpSure (Cynosure)

Acoustic Shock WaveCellutone (BTL)Z Wave (Zimmer)

2016 aad hands-on laser workshop handouts final sp dynamis m. christine lee, m.d. • the skin and...

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