Next-Generation Fractional CO2 Emerges. Annual Practice Survey Results Review of Autologous Treatments AAD 2011 Exhibitor Highlights THE

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1 THE Next-Generation Fractional CO2 Emerges Annual Practice Survey Results Review of Autologous Treatments AAD 2011 Exhibitor Highlights The CO2 laser is a mainstay of many aesthetic practices. Originally held in the highest esteem, aggressive treatments brought CO2 a reputation for pigmentation issues and risks that outweighed the unequalled resurfacing results it achieved. However, the emergence of fractional techniques rushed CO2 back to the forefront, with physicians still swearing by its power. While current trends favor low risk, low downtime and low discomfort, a new CO2 laser technology stands out due to its ability to offer both gentle, as well as aggressive treatments for a variety of indications. continued on page 3 January/February 2011 Circulation 30,000

2 CO 2 RE Delivers Complete Spectrum of CO 2 Tx By Kevin A. Wilson, Contributing Editor CO 2 RE from Syneron, Inc. (Irvine, Calif.) and Candela Corporation (Wayland, Mass.), brings aesthetic physicians the entire spectrum of CO 2 laser therapies together in a single powerful, versatile platform to suit the needs of any aesthetic practice. This easy-to-use system not only offers fractional and ablative CO 2 treatments through a lightweight handpiece, it can be effortlessly moved from room to room. Unique software and scanning technology make CO 2 RE easily upgradable as well. The CO 2 laser is still the gold standard for resurfacing the skin, stated dermatologist Vince Afsahi, M.D., medical director of South Coast Dermatology Institute (Tustin and Newport Beach, Calif.). The advent of fractional technology allowed us to treat more patients by reducing downtime and improving the safety profile, even if results were less impressive. While many new technologies grab the headlines, CO 2 is still a workhorse. Vince Afsahi, M.D. Medical Director South Coast Dermatology Institute Tustin and Newport Beach, CA For Dr. Afsahi what stands out most about CO 2 RE is its versatility. When you think of the aesthetic CO 2 laser you think about full ablation, surgical laser excision and most recently, fractional treatment. Offering four fractional modes, along with other ablative modes, CO 2 RE combines all this into one system. CO 2 RE s digital SuperPulsed 10,600 nm CO 2 laser can quickly deliver ablative pulses with precision and rapid variability. This laser is synchronized with CO 2 RE s high precision inboard scanner, which can change the position and depth of injury hundreds of times per second. Creation of micro-wounds in the fractional modes is basically random in order to prevent untoward buildup of thermal energy. As well, different parts of the scan matrix can be placed at various depths. Beam energy is variable from 1 mj to 70 mj with repetition rate reaching as high as 16.7 Hz, and a pulse duration varying from 20 to 1,166 microseconds. The result, according to Dr. Afsahi, is an ability to draw a variety of patterns at multiple depths in one stamp, without having to recalibrate the machine or change handpieces. This carefully calculated and controlled pattern stamp allows precise, powerful single-pass treatment, thus reducing treatment times. Dr. Afsahi feels the design of this device is ideal for any office environment. The platform, mounted on castors, is relatively slim and has a small footprint (listed dimensions 40 x 44 x 177 cm, weighing 26 kg). CO 2 RE is also extremely quiet because it is air cooled. In addition to this there are no disposables needed with CO 2 RE, although a disposable sterile-pack handpiece is available for convenience in a plastic surgery setting. According to the manufacturer, CO 2 RE is optimal for treating skin types I though III. The old rules still apply; you have to be careful and know what you re doing, especially when considering darker skin types are more likely to experience hyperpigmentation. There are many fractional and CO 2 lasers out there, and the issues involved with CO 2 therapy are well While many new technologies grab the headlines, CO 2 is still a workhorse. Periorbital area before Tx Periorbital area five weeks after one CO 2RE Tx THE Aesthetic Guide January/February

3 Even in a crowded space a number of features make CO 2 RE stand out, such as the multiple scanning patterns and wound depth options in a single pass, as well as the portability, quiet operation and the easyto-use handpiece. Before Tx Five weeks after one CO 2RE Tx known, said dermatologist E. Victor Ross, M.D., medical director of Scripps Clinic Carmel Valley Laser and Cosmetic Dermatology (San Diego, Calif.). However, even in a crowded space a number of features make CO 2 RE stand out, such as the multiple scanning patterns and wound depth options in a single pass, as well as the portability, quiet operation and the easy-to-use handpiece. CO 2 RE s utility and versatility give it a lot of potential. E. Victor Ross, M.D. Medical Director Scripps Clinic Carmel Valley Laser and Cosmetic Dermatology San Diego, CA In Dr. Ross s opinion, one of the most distinct features of CO 2 RE is the scanning technology. The scanner is not in the handpiece, as it is with many other CO 2 platforms. Instead it s located in the device housing itself. This configuration makes the handpiece remarkably light and relatively small the size of a large felt-tip marker. Most others are at least the size of your palm, and outweigh the CO 2RE handpiece. Owing to the scanner s design, increased scanning capabilities can be achieved by a simple software upgrade, Dr. Ross added. CO 2 RE s autoclavable aluminum handpiece reduces operator fatigue considerably, Dr. Ross highlighted. From a practitioner s perspective the handpiece itself may be the most important feature of this device because it is so light and easy-to-use, he explained. If you have a lot of laser experience then you ll know what I m talking about. You re not holding the scanner in your hand; therefore it s a lot easier to manipulate during treatment. In addition, the handpiece is fixed to a lightweight, seven-joint, pneumatically balanced arm that rotates 360 on the horizontal plane. There are also a wide-range of scanning patterns with multiple treatment modes accessible via the graphical user interface (GUI) without having to change handpieces. Dr. Ross specifically called attention to the GUI s side view representation of skin that demonstrates the thermal wound profile to the user as they change modes and treatment parameters. It shows, what I believe to be, a very accurate representation of what the effect will be. It s very helpful for visualizing what is supposed to happen before you apply the energy. The interactive GUI also helps the user save treatment preferences to facilitate easy recall. Dr. Afsahi echoed this opinion: This new device is very programmable. You can vary spot shape and density, as well as energy and other treatment parameters to influence downtime, among other things. The GUI makes each variation easy to conceptualize. Downtime, he added, is mostly linked to wound pattern density and energy levels; superficial treatments with lower energy levels will have less downtime, and deeper treatments with higher energies will bring more downtime. Additionally, CO 2 RE can actually combine placement of deep, pinpoint wounds within the wider, more superficial ring-shaped fractional wounds deposited in the same spot, covering the area in less than a half-second. You can basically lay down two different modes in the same scan, replicating 6 THE Aesthetic Guide January/February

4 the thermal effect of different, well known technologies to create injuries that are almost 1 mm wide and a hundred microns deep in the same scan as an injury that s 120 microns wide and several hundred microns deep, Dr. Ross noted. You can also control the density at which the microwounds are placed. I don t think any other existing device does that in a single pass. According to Dr. Afsahi, CO 2 RE offers four fractional treatment modes: CO 2 RE Light, CO 2 RE Mid, CO 2 RE Deep and CO 2 RE Fusion. CO 2 RE Light mode creates a pattern of unique ring-shaped wounds providing the most superficial fractional ablative treatment from 20 μm to 40 μm deep. Treatment is limited to the epidermis to increase epidermal cell proliferation. As a purely epidermal treatment, you re looking to treat dyschromias, maybe fine lines or textural issues. Depth is uniform, precise and reproducible. This will represent the lower end of the downtime spectrum, maybe four days or so. A similar pattern of ring-shaped wounds is produced by CO 2 RE Mid, which penetrates more deeply to coagulate tissue beneath the dermalepidermal junction between 100 μm and 200 μm. The deepest effect is seen with CO 2 RE Deep, which creates a pattern of pinpoint wounds that penetrate through the dermis to depths of up to 750 μm. With CO 2 RE Mid and CO 2 RE Deep modes you re penetrating through the epidermis into the dermis, to about 1 mm in depth, Dr. Afsahi advised. This will move toward acne scarring, tightening and overall collagen stimulation. You ll see downtime in the range of seven days or so. CO 2 RE Fusion mode, which combines CO 2 RE Mid and CO 2 RE Deep modes in a single pass, optimizes treatment of the dermal and epidermal zones simultaneously. What this does is cause a ring of more superficial thermal damage, with a single pulse driving a column of deeper penetrating energy in the center of the ring. For someone presenting with both superficial and deep issues, problems such as dyschromia in conjunction with skin laxity and deeper pathologies, this mode is best but will result in more downtime. Whatever mode is chosen, the theory behind treatment is still based on the fractional model. The objective is to cause precise patterns of wounds surrounded by zones of undamaged tissue to promote relatively quick reepithelialization and rapid healing, thus facilitating recovery and reducing risk in comparison to full ablation, Dr. Afsahi explained. Due to the unique character of the wound pattern and delivery of laser energy, fractional treatment with CO 2 RE is performed in a single pass. This promotes consistency and reproducibility, Dr. Afsahi continued. If you put down a pass with CO 2 RE Mid followed by a separate pass with CO 2 RE Deep, there would inevitably be some overlap. Doing it all in one pass prevents this, meaning that every time you treat, it will be the same and you ll know what to expect. If a patient presented with a variety of manifestations and levels of photodamage, for example, you could treat the face with CO 2 RE using different modes throughout, making changes with the push of a button wherever CO 2RE Variable Treatment Modes CO 2RE Light CO 2RE Mid CO 2RE Deep THE Aesthetic Guide January/February

5 As we continue to use CO 2 RE, the physician community can suggest new scanning ideas that could be implemented with relative ease. We don t know what this might mean in the future. 60 mj at 0 days 75 mj at 10 days and whenever necessary, said Dr. Afsahi. You can control everything from depth to density to energy, based on the patient s needs. When you consider the ubiquity of CO 2 technology, this is still quite revolutionary. CO 2 RE can also do what CO 2 lasers have long been famous for. You can still use the continuous wave mode for warts or syringomas, discrete lesions a dermatologist might often treat, or resurfacing, plus excision mode for surgical applications, Dr. Ross added. So in addition to the novel technologies this could easily be your workhorse CO 2 laser. Dr. Afsahi agreed that there is still a need for fully ablative CO 2 resurfacing. In traditional resurfacing mode the scanner will create a spot in one of three shapes: circle, rectangle or square. Some patients will present with extensive photodamage or scarring. In these cases you must be as aggressive as possible. The advantage of these different shapes allows you to more easily navigate the intricate contour of the face, which promotes precision, especially in places like the corner of the eye or mouth. You can make these changes easily during treatment with the user-friendly GUI. Different shapes improve precision in the surgical excision mode as well, he added, which is further enhanced by the unit s continuous aiming beam. Dr. Ross believes that the bright future of CO 2 RE is owed to the novel, advanced scanner technology and its unique placement on the unit housing instead of in the handpiece. The scanning potential of CO 2 RE is limited only by the capabilities of the software engineers, he explained. Whenever it s necessary, a technician can come in with a USB flash drive or similar device and add many new scanning options. As we continue to use CO 2 RE, the physician community can suggest new scanning ideas that could be implemented with relative ease. We don t know what this might mean in the future. This technology has evolved even since I ve been involved with it. As a powerful laser capable of superpulsed and continuous wave output, flexible software implementation and a full range of multiple depth fractionated and fully ablative treatment parameters, Syneron is calling CO 2 RE a CO 2 resurfacing workstation. As the first system born of the 2009 merger of Syneron and Candela, there is much attention on CO 2 RE. Candela s reputation was based on producing solid, reliable core technologies backed by strong science, said Dr. Afsahi. They were well-established in the aesthetic medical community with devices that stood the test of time. Syneron brought a complementary product portfolio and a spirit of technological innovation to the table. 8 THE Aesthetic Guide January/February