the fotofacial rf galaxy: the fotofirm proceduremulhollandmd.com › mdu › disciplinefiles › 2...

SpaMedica® Franchisee Clinical Training ManualX – 35.1 INITIALS

The FotoFacial RF® Galaxy: The FotoFirm™ Procedure• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Evolution of the FotoFacial RF® Galaxy (The FotoFirm™)The FotoFacial® has grown to become one of the most commonly performed optical based skinrejuvenation procedures in the world. On any given day in the United States, there are over10,000 FotoFacial® procedures performed. The FotoFacial® procedure initially evolved from beinga single pass, full face, Intense Pulsed Light treatment, multiple IPL cutoff filter passes. Theoriginal IPL FotoFacial® is very good at removing melanin and hemoglobin based chromophores.However, original IPL FotoFacial® therapy alone was only modest at best at improving wrinkles,tightening skin and smoothing texture. The addition of Nd.YAG (1064 nm, 1340 nm or 1450 nm)was the next advance of the FotoFacial® procedure and was called the FotoFacial Plus®. Theaddition of multiple, segmental passes of long pulsed YAG treatments over areas of wrinkles andlaxity, in combination with the Full Face and segmental IPL treatments improved the degree ofdermal enhancement, wrinkle and texture improvement that could be achieved with a series ofFotoFacial® treatments. The recent introduction of conducted, Bipolar radiofrequency energy intothe aesthetic marketplace has resulted in a significantly enhanced ability to tighten skin andimprove fine to moderate wrinkles, as well as remove vascular and melanin based chromophoretargets with less inflammation and downtime.

With the introduction of the Aurora by Syneron of IPL and RF in the same pulse profile, a conceptcalled ELOS™ (electrical-optical synergy), the FotoFacial RF® procedure was born. The addition of 25 J/cm2 of radiofrequency energy pulsed synchronously with the IPL has allowed us to achievea much greater degree of skin tightening, texture enhancement and wrinkle improvement thanever before.

The FotoFacial RF® FotoFirm™ procedure using the Galaxy represents an evolution in the pulsed-optical-RF technique and is the most advanced non-invasive skin enhancement ever introduced intothe market. The FotoFacial® FotoFirm™ produces by far the most impressive improvements inchromophore resolution, skin tightening, skin laxity, texture and wrinkles that we have ever beenable to achieve with any other non-ablative technology. By combing the Aurora platform withPolaris operating systems into one device and procedure, called the FotoFirm™, the Galaxyphysicians now have at their disposal the most advanced IPL-RF and high Fluence RF and PulsedOptical Diode energy to non invasively rejuvenate the skin.

The Galaxy Operating PlatformsTo perform the FotoFirm™, a physician user must be familiar with the various technology platforms,that have been incorporated by Syneron. The Galaxy series of devices incorporates the Aurora®

technology, whose treatment heads combine Lower fluence bipolar radiofrequency energy and

Intense Pulsed Light in the same treatment profile. The Aurora Heads include the SR (Skin Removal),DS (Hair Removal) and AC (Acne) head, the specifications of which are outlined below:

Aurora Treatment Heads

Head Application Wavelength Fluence Pulse Profile

1. SR Head Skin Rejuvenation 580–980 nm up to 45 J/cm2 25 ms Short

25 J/cm3 RF Double Long

2. DS Head Hair Removal 680–980 nm up to 30 J/cm2 25 ms Short

25 J/cm3 RF Triple Long

3. AC Head Acne Head 400–600 nm up to 16 J/cm2 10 Pulse train

20 J/cm3 RF 2 ms on/30 ms off

Polaris Treatment Heads

Whereas the Aurora platform combines only Intense Pulse Light and Radiofrequency energy in the same treatment profile, and, depending upon the exact configuration of your Aurora and thenumber of heads you purchase you may have IPL-RF Skin Rejuvenation head, DS-Hair Removalhead and/or and AC acne head. The Polaris does not employ Intense Pulsed Light, but incorporatesPulsed Diode Laser energy combined with Radiofrequency energy in the same pulse profile todeliver therapy. This pulsed laser diode, RF ELOS™ technology is configured in an LV (Leg Vein)Head, and a WR (Wrinkle Reduction).

The Polaris platform, like the Aurora, emits synchronous pulses of pulsedoptical energy (a pulsed diode laser) and RF (Radiofrequency) in the same pulse profile. The diode array has its wavelength at 910 nm2, in the rear infared spectrum and its prime chromophore is deoxygeneted hemoglobin andsome interstitial water Nd:YAG like effects. The head has two contact,conductive radiofrequency electrodes on either side of an Optical Diode crystal.The handpiece is water cooled to 5 degrees Celsius. The technique for thePolaris heads is exactly like the contact technique with the Aurora in that thetwo diode electrodes stay in flat contact with the skin and contact couplingmedium of the treatment area and the pulsed optical head is slightly recessed to minimize direct contact. The dimensions of the Aurora heads are 9 mm wide(between the electrodes) and 26 nm long. The Polaris WR bipolarelectrodesystem is larger, with the WR electrodes being the WR, is 14 mm wide and26 mm long, while the LV head is more like the Aurora, measuring 8 mm by 26 mm.


The Polaris

Polaris Head

Head Application Wavelength Fluence Pulse Profile

1. LV Leg Veins 910 nm 50–140 J/cm2 Diode up to 300 ms

10–100 J/cm3 RF

2. WR Wrinkle Reduction 910 nm 10–50 J/cm2 Diode up to 200 ms

10–100 J/cm3 RF


The Polaris WR (Wrinkle Reduction) Head

The Polaris LV (Leg Vein) Head

The Galaxy

The FotoFirm™ procedure incorporates the Galaxy platform. TheGalaxy platform is the newest of the Syneron ELOS™ based platformsto be FDA cleared and it combines the Aurora and Polaris platformsand heads into one system. On one side of the Galaxy is an Auroraport where the Aurora IPL-RF heads may be inserted, including theSR, DS or AC heads. On the other side of the Galaxy is the Polarisport, into which the Polaris heads may be inserted, including theDiode-RF heads, either the WR or the LV.

The Polaris Physics: Dermal Matrix Heating

The physics, pulse profile, depth of penetration and level and degree ofdermal matrix heating is quite different from that of the Aurora andhence, so is the technique. The Polaris, like the Aurora, still relies on Syneron’s patented ELOStechnology, that is an electrical-optical synergy. For the WR (wrinkle reduction) head thefollowing pulse profile occurs:

The FotoFacial RF® FotoFirm™ Procedure

The are three basic steps to the FotoFacial® FotoFirm™ procedure. As with any FotoFacial®

patient, the patient’s medical health history must be taken, contraindications disclosed and thenthe patient’s aesthetic skin concerns enumerated and a clear understanding of the patient’s goalsoutlined, ensuring that the patient’s expectations match the likely outcome of the FotoFacial RF®

FotoFirm™ Galaxy program.

Polaris Selective RadioPhotothermolysis ELOS Physics Review

The Polaris Platform (present, along with the Aurora platform on the Galaxy, or, the Polaris canbe a stand alone system) comes with a WR (wrinkle reduction head) and LV (leg vein head). The WR head emits a 910 nm wavelength laser diode and synchronous Radiofrequency energy(slides 1 and 2).


The Galaxy – 2 port, Aurora &Polaris System

Slides 1 and 2

The laser diode heats the microvasculature maximally to a dermal depth of approximately 2.5–3 mmThe 910 nm infrared diode warms the dermal tissue, lowers the impedance and results in augmentedRadioFrequency current density (RF preferentially travels the path of least resistance, or lowestimpedance). Thus, similar to the Aurora, where IPL creates the optimal environment for a specific,localized RF heating, the Polaris 910 nm diode focuses and concentrates the WR RF energy for a specific and controlled dermal RF heating.

It is at the intersection of the laser diode and RF that the dermalheating is maximal. The RF in the Polaris platform would bevery diffuse and less effective a wrinkle reduction and tissuetightening and lifting force if the laser diode were not present to create a focused microenvironment of low impedance tofocus and maximize the current density. Thus, the Polarisplatforms exhibit classic ELOS™ physics, a true electric-opticalsynergy, whereby the laser or the RF energy unto themselves is less effective than the two energy sources combined (similarto the IPL-RF of the Aurora) (see slide 3).

These 3 dimensional graphics show the ELOS effect of the Polaris platform. In slide 3, the 910 nmlaser diode is depicted in red and the RF in green. The intersection of the two represents the areaof the dermis where the 910 nm laser diode has heated the dermis (2.5–3mm deep) and the RFcurrent, which was initially diffuse, becomes concentrated in the laser heated dermal tissue withlowered impedance.

The 910 nm wavelength, like all infrared lasers, acts optimallyon deoxygenated hemoglobin.

The pulse profile of the Polaris is quite different (slide 4) fromthe Aurora. With the Aurora, the relatively low level conductedbipolar energy was present throughout the 200 ms pulseduration (assuming the ISL was not reached) and the PulsedOptical or IPL energy was only on for a brief period of time (25 ms in short pulse and a double pulse of IPL in the Longpulse mode). The brief period of IPL heated the dermis and

lowered the impedance enough for the relatively low level RF to act for 175 ms. In the Polarisplatform, the conducted bipolar RF energy is very strong with energy levels up to 100 J/cm3.Because of the high energy nature of the RF in the WR head, the pulse duration of the WR RF is quite short. The entire pulse duration of the WR head is approximately 300 ms. The RF energyis on as soon as the Polaris WR button is depressed. The first 10 ms, the contact cooling, couplingadequacy and an average impedance calibrations is performed. Then, for the next 70 ms the high energy RF is released. However, in the absence of a 910 nm laser infrared diode energy, theRF is quite diffuse and less effective. After approximately 10 ms, the 910 nm infrared, laser diodeis released concurrent with the high energy RF. As the 910 nm laser begins to bind with the


Slide 3

Slide 4

microvasculature and vessels (its prime target is deoxygenated and oxygenated Hemoglobin in the deep dermis, 2.5 mm–3.0 mm deep) causing a selective photothermolytic heating of the vesselsand the adjacent dermis. The dermal heating drops the impedance and the RF current densityincreases exponentially in the laser heated dermis. For 80 ms the 910 nm laser diode is focusingthe high energy WR handpiece RF in the narrow band of the dermis. By approximately 100 ms,the high energy has acted for about 80 ms in the selective environment created by the laser and,because of its very high energy nature, the RF must be turned off to avoid overheating the dermis and causing a thermal injury. The post-heating period in the Polaris is then delivered bythe 910 nm laser diode, that continues to heat the dermis for another 200 ms (see slide 4).

The unique long wavelength of the 910 nm diode, large spot size and high energy, result in a deep dermal heating. In addition, the wide distance between the bipolar electrodes ensures a deepdermal RF delivery, where it can be concentrated by the diode impedance drop (slides 5–10). The round edges of the WR electrodes avoid area of excessive RF heating, minimizing the risk ofburns at the edges of the electrode, a significant risk of monopolar RF systems. The differencebetween the WR and LV heads lies in the size of the electrodes (the LV electrodes are closertogether and not as long, as well as the relative fluencies for each of the modalities, where the WR head has up to 100 J/cm3 of RF and 50 J/cm2 of the 910 nm diode, the LV has up to 100 J/cm3 of RF and up to 140 J/cm2 of the 910 nm diode, a feature which gives the LV head morereticular and larger spider vessels specificity.


Slide 7 Slide 8

Slide 6Slide 5

Shows the depth of heating of the deep dermis with the WR head and the protection of theepidermis provided for by the dynamically cooled hand piece and the rounded configuration ofthe electrodes.

Indications:

The indications for a FotoFacial RF® FotoFirm™ Galaxy treatment are an absence of absolute andrelative contraindications (as in the FotoFacial RF® section) and skin concerns consisting of thetypical skin rejuvenation concerns of vascular concerns such as diffuse teleangiectasia, erythema,rosacea and melanin concerns of hyperpigmenation, lentigines, dyschromia and melasma. Inaddition, good FotoFacial RF® Galaxy candidates also complain of the fine to moderateperiocular or perioral rhytides, skin texutural roughness, acne scarring and laxity.

FotoFacial RF® FotoFirm™ Galaxy Indications1. Vascular Chromophore Concerns

Telangiectasia

Erythema

Rosacea

Flushing and Blushing

Lower lid dark circles of venous congestion origin

2. Pigmentation Melanin Chromophore Concerns

Lentigines

Hyperpigmentation

Dyschromia

Melasma, Cholasmo

Poikilodermo


Slide 9 Slide 10

3. Fine and Moderate Wrinkles

4. Skin Textural Issues

Acne Scars

Depressed Scars

5. MacroPores

6. Mild to Moderate Skin Laxity

Brow, Cheek, Neck laxity

Contraindications:

Standard FotoFacial RF® contraindications.

FotoFacial RF® FotoFirm™ Galaxy Technique• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Once the appropriate candidate has been selected with standard FotoFacial RF® approaches, thereis then a 3 step approach to each treatment visit:

Step One: Standard FotoFacial RF® Treatment (Aurora SR/WR Heads)

FFI and/or FFIIRequires 15–20 minutes

During step one, the SR head is inserted into the Galaxy. A full face FotoFacial®, using standard,Skin type specific FotoFacial One (FFI) fluence settings. A spot test is performed in the preauricularregion on each side, with each visit. The full face is treated, overlapping 20–25% each pulse. The%ISM should be between 15–20% on average with each pulse (for skin type I–III). The patientshould be treated every 3 weeks and each visit the IPL fluence should be raised 1–2 J/cm2 everytreatment session (this will be required each treatment to keep the %ISM between the 15–20%range (as the degree of chromophore will diminish after each treatment and increased IPL fluencewill be required to create the heat during selective photothermolysis enough to drop the impedanceenough to lower the RF impedence and facilitate optimal RF current density). After one of two


treatment sessions (6–9 weeks) into the FotoFacial RF® Galaxy program, one may have to addFotoFacial RF® Two (FFII) over areas of stubborn pink or brown discoloration immediately afterFFI and/or FFII the WR Polaris head is employed. Like the WrinkleLite® and Vector Laxity in aAurora FotoFacial®, the WR and LV Polaris treatments are performed on the same skin that wasjust treated with FFI/FFII.

Step Two: WR Polaris Passes (FotoFirm™)

Requires 15 minutes

The FotoFacial RF® Galaxy is ideally suited for those patients with wrinkle,laxity, skin textural concerns and/or macropores. For these patients step two isperformed immediately after the FFI and/or FFII. The WR head is inserted intothe Polaris head ports in the Galaxy. The Polaris WR head replaces the multipleWrinkleLite® with the SR head and laxity pass with the DS head used with theAurora only FotoFacial RF®. The following WR fluence settings are then used:

WR Head Settings

Skin Type Pulsed Diode Fluence RF Fluence

I–III 50 J/cm2 100 J/cm3

IV 30 J/cm2 100 J/cm3

V 20 J/cm2 100 J/cm3

During each WR treatment the following steps should be taken:

A. Wrinkles

1. Apply a thin layer of conductive medium to the area to be treated

2. Apply the WR head to treatment area with full contact of the electrodes

3. Ensure full electrode contact

4. Deliver treatment

5. Assess patient’s level of discomfort

6. Without moving the headpiece, wait 1–2 seconds and deliver a second, stacked pulse

7. Move to the area adjacent to the one just treated with 20% overlap and repeat the double technique

8. Once you have completed one pass of the wrinkled area or laxity, assess the skin condition.Watch for blisters, welts or skin discoloration


Polaris WR Head

9. If the skin condition is acceptable, then a second pass of pulses is made. Again, watchcarefully for adverse skin reactions

10. Complete the second pass or double, stacked pulses. Again look carefully for adverse skin reactions

11. If there are no adverse skin effects, then proceed to a 3rd pass

12. If the patient complains of excessive pain during the first pulse, then avoid the second pulseof the stacked pulsed and just perform a single pulse, with three passes

13. After 3 passes, assess the wrinkles for signs of dermal edema (some plumping of the dermis,like zyderm II or Restylane™ has been injected). If there is edema then stop. If there is no edema, then proceed to a 4th, 5th or even a 6th pass. Stop after each successive pass toassess for edema or an adverse reaction. Stop after 6 passes

14. Pain control and the Polaris WR/LV: use topical cream and Synercool™

Standard WR treatment regions: FotoFirm™

1. Crow’s feet and lower lid rhytides

2. Upper lip wrinkles

3. Frown and forehead lines

4. Cheek laxity

5. Cervical laxity

6. Acne scars to the cheeks

B. Laxity and Tightening: FotoFirm™

1. After completing the wrinkle treatments, treat the lax areas of the patient’s face.

2. Jowls – Cheeks – Smile Lines

– orient the WR headpiece obliquely and start in the commissive region, in the jowl-commissive region and move north to the tragel region with 20% overlap

– no stacking of pulses

– move up to the alas base and treat across the malas eminence to the temporal hairline

– complete 3–6 passes in this fashion depending upon laxity and skin response


Brow and Lids

1. Orient horizontally, protecting the eyebrow

2. Treat superiorly to the harline, at the tail of the brow

3. Move to the middle column of the brow

4. 3–6 assessing skin response as the treatment proceeds

Special WR FotoFirm™ Treatment Areas

Lower Lid Technique

1. With the patient’s laser eye shields secured pull down the patient’s malar skin to expose theentire lower lid skin up to and including to the ciliary margin (same as with the standardFotoFacial RF® lower lid technique).

2. Place the superior electrode up adjacent to the laser eye shield, but ensure that the laser eye shields do not conduct RF energy, or leave a millimeter between the electrode and the eye shield.

3. Treat the lateral canthal region and then move medially towards the medial canthus with thedouble, stacked pulse technique. Use three passes.

Upper and Lower Lip Technique

1. Place one electrode on the red lip and the otherelectrode will then lie above the white roll. RF energywill be passing across the white roll and red lip.

2. Many patients will complain of teeth sensitivity. Forthese patients, place tongue depressor between theupper lip and teeth. Alternatively, you may use somegum or the patient may use gum.


Step Three: LV Head Passes

Requires 10 minutes

The last step (all 3 performed each time) of the FotoFacial RF® Galaxy is the LV head. The LVhead is a special vascular head that is used for large reticular vessels and the larger spidervaricosities of the facial region. After the FotoFacial® FFI and/or FFII and the WR treatment, theLV head is plugged into the Polaris port on the Galaxy and the LV head used to treatment visiblylarger vessels on the face. The larger vessels will generally be around the nose, cheeks and chin.Apply a thin layer of conductive gel and apply the electrodes. Ensure each electrode is fullycontacted and then deliver the treatment. Closely inspect the vessel to examine for evidence ofintravascular thrombosis. Between 1–3 pulses may be delivered for each visit.

LV Head Settings

Skin Type Pulsed Diode Fluence RF Fluence

I–III 140 J/cm2 80–100 J/cm3

IV 100 J/cm2 60–80 J/cm3

V 75 J/cm2 50–60 J/cm3

Special LV Lower lid Technique for Dark Circles

Some patients will complain of lower lid dark circles. Some of these lower lid dark circles will be a result of mid-deep dermal melanin or hyperpigmentation, for which little treatment can be offered. For those patients who complain of lower lid dark circles, and examination revealsvenous engorgement and large reticular vessels, treatment with the Polaris LV head can be offered.One can determine this venous engorgement by distracting the lower lid skin and the large venous vessels will be visible through the skin. In general, venous engorgement can be seen in skin types 1–3.

1. Distract the lower lid skin with the laser shields on, as per the WR lower lid technique.

2. Apply the lower lid LV head with the superior electrode adjacent the eye shield. Do notmake contact with the laser goggles unless they are protected against conduction of RFenergy or you risk burning the skin.

3. Perform a one pulse pass treating the entire lower lid complex, as per the WR lower lidtechnique. Once you have finished with the LV head, ensure you have made an Aurora FFIpass and/or FFII pass for the more superficial vesels starting with the lateral canthal region.

4. You may need to perform a second or third pass, but do not perform a double pulse.


Post FotoFacial RF® FotoFirm™ Galaxy Treatment

Similar to the standard FotoFacial RF® treatment on an Aurora, the patient can typically goimmediately to the restroom after completion, apply make-up and go home.

The FotoFacial RF® FotoFirm™ Galaxy treatment may require 35–45 minutes to complete. Thereis a much higher risk of temporary edema of the lower lid skin for 2–4 days and you will have towarn patients of this. The edema will be most noticeable in the fine skin of the lower lid and lipmucosa. There is also a higher risk of blisters, burns and scars (still less than 1%).

Similar to standard FotoFacial RF® treatments, the patient should stop skin care products, such as Retin A, hydroquinone, etc. for 48 hrs before and for 48 hrs after a FotoFacial RF® Galaxytreatment. Patients may use a standard FotoFacial RF® Galaxy moisturizer and sunblock.Treatments are performed every three weeks and the standard Aurora SR treatments will continueto increase in fluence every 2 weeks. The settings for the WR and LV heads will not increase ordecrease in fluence.

What to do if you only have the Polaris WR head?

First option, buy the Galaxy and Aurora platform. It is critical to understand the importance ofthe IPL-RF FotoFacial® treatment (FFI/FFII) to the overall sucess of the program and happiness of the patient.

The full face FFI and segmental FFII treatments are essential for every chromophore diode basedred, bown discoloration or to lessen pores and to blend texture and tone. Use of a WR head (orThormage) will certainly tighten skin and lessen wrinkles, but the skin may still not look verybright and attractive. Some of the most important things we can accomplish with the FotoFacial RF®

Galaxy is an improvement in the color, texture, wrinkles and laxity. It is critical to use a protocolthat incorporates IPL or pulsed optical.


Results

Just as with a standard Aurora only FotoFacial RF® patient, it is critical to create a realistic senseof outcome with the FotoFacial RF® Galaxy procedure. The FotoFacial RF® Galaxy can improvethe Class II wrinkle results seen by the Aurora by 25–20%. Thus, I tell our FotoFacial RF®

Galaxy patients that may expect to see anywhere between 30–80% fine wrinkle improvement(average 60%), a 25–50% improvement in moderate wrinkles and a noticeable 20% improvementin more severe wrinkles. In addition, passes over the cheeks, neck and brow will result inaugmented tightening of skin laxity and lax vectors.

Conclusion

The FotoFacial RF® FotoFirm™ procedure is the state of the art non-ablative skin rejuvenation. The results we have seen with this powerful and unique combination of IPL-RF and Diode-RF are tremendous. In the opinion of Dr. Bitter and myself, the Galaxy delivers the best possible skin rejuvenation recovery on the market today and the training and certification on the FotoFirm™

procedure is now part of our advanced training certification course.


Pre (right) and Post (left) FotoFacial RF® Galaxy program.Notice the very noticeable improvement in her perioral linesusing combined SR Aurora and WR Polaris heads.

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