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Monday
Jun162008

DeepFx Forum (Exclusively for Encore UltraPulse Users)

Reliant UltraPulse Fractional CO2 Laser

 

DeepFx Webinar:  Notes and Analysis - Tuesday May 19, 2008
Reliant UltraPulse Fractional CO2 Laser

Introduction

Many Laser Companies offer regular Webinars for marketing and education (mostly marketing). These companies include, but are not limited to: Cutera, Lumenis, Reliant and Cynosure. These Webinars are available live or on the companies’ websites in their Webinar Archive Area. 

                                                                                     

We have produced these notes for several reasons. We want to generate a clinical discussion of these Webinars so we can all learn more from the Webinars and learn even more from the discussion. We want to clarify certain points that were not clear during the Webinar. We want to ask and answer questions that were not asked and answered during the live Webinar (there is never enough time to ask and answer all questions). It takes 2 hours to sit through a Webinar, most are for marketing purposes and not worth our time, these notes will help us decide which Webinars we want to watch. Hopefully many times we will not have to watch the Marketing Webinar once we have read the summary and participated in the resulting discussion. This will enable us to get the information without sitting at our computer watching a Webinar for 2 hours. 

 

The bottom line is that we all need to become better providers of services and get better results which generate happy patients who refer friends and family to our practices. By having easier, more convenient access to the information in the Webinars and sharing our thoughts and experiences, we all learn more quickly and we avoid making the same mistakes made by others.  In this manner, we gain access to “best practices” more quickly and the whole field evolves more rapidly. We want to use these Webinars as “Seminal Events” to stimulate meaningful “Clinical Exchange” of important information.

 

We hope to get the industry “Luminaries” to participate in these discussions. We also hope the Laser Companies will start to host these type of “On-Line” discussions after their Webinars and we hope the Laser Companies will start to host more “Continuing Education” Webinars rather than just “Marketing Webinars”.

 

The first set of notes is from a Lumenis Webinar about the DeepFx treatment with The UltraPulse Fractionated CO2 Laser. This was a Round Table Discussion with some of the top Cosmetic Physicians in the field. It was very good, but had its flaws and requires further discussion and clarification on points made. The participants (Luminaries) were James Heinrich, MD, Robert Weiss, MD, E. Victor Ross, MD and Jeffrey Dover, MD.

 

If you are considering using the information in this summary, please view the Webinar to make sure you are comfortable with the parameters! If you view the Webinar and find any inaccuracies in my notes, please correct them in our discussion on MedicalSpaMD. I am hoping Lumenis and “The Luminaries” will review these notes and comment.

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TotalFX Notes

 

Basic Facts & Theory:

  1. ActiveFx plus DeepFx gives you a TotalFx Treatment
  2. ActiveFx ablates 1.3 mm columns and can go 300 microns or 0.3 mm deep
  3. DeepFx ablates 0.12 mm columns and can go 2000 microns or 2.0 mm deep
    1. 1000 microns = 1.0 mm
  4. 125 mj of energy with ActiveFx penetrates 300 microns deep
  5. 30 mj of energy with DeepFx penetrates 1.9 mm deep (1900 microns)
  6. Most photoaging occurs in the papillary dermis (the worse “solar elastosis” in elderly farmers is at a depth of 800 microns), so there is no need to go deeper.  Therefore our panel recommended a max DeepFx strength of 20 mj (1 mm deep?).  Going deeper gets you more tightening because of more tissue ablation and volume loss.   
  7. Using 30 mj of energy and going to 2.0 mm deep has caused scarring around the eyes in one provider’s experience.  They do not recommend going this deep.
  8. How long does the tightening last?  No one knows for sure.
  9. ActiveFx:  Density 1:  75%; Density 2:  80%;  Density 3:  85%;  Density 4:  95%;  Density 5:  100%
  10. MaxFx is ActiveFx at Density 5:  100%.
  11. The MaxFx now is somewhat different than CO2 treatments done in the 1990s because only one pass is done.  In the 1990’s 3 passes were done wiping off the epidermis in between passes.
  12. DeepFx:  Density 1:  5%;  Density 2:  10%;  Density 3:  15%;  Density 4: 20%;  Density 5: 25%.
  13. Stronger treatments are done with the TotalFx on the West Coast.  Why?  In California the people have greater solar damage so you need higher settings OR the people in California are more demanding and want more dramatic results.  Interesting question!  What do you think?
  14. Healing is slower off the face.  Dr. Weiss says 2-3 times longer, did he mean 2-3 days longer?
  15. Doing Upper Lip Treatments with TotalFx can cause more vermillion lip border to “show”.  This is good

 

Clinical Tips:

  1. Do the DeepFx first and then do the ActiveFx
  2. If the DeepFx causes bleeding, wait until the bleeding stops before doing the ActiveFx (blood will absorb the energy from the ActiveFx pulses)
  3. The experts said that they did a second treatment one month after first treatment.  I was told to wait 3 months.  This one month interval is new information to me. My big question to Lumenis is “when were you going to tell me and your other users about this change?  How do you keep us up to date about changes like this?”  I am pissed off, I am angry.  I want an answer and I want it NOW!
  4. Dr. Ross sometimes uses thrombin spray (from Baxter) to stop the bleeding.
  5. With DeepFx, you treat lower face first and move upwards so blood won’t drip down into your treatment field.  “South to North”
  6. Do DeepFx before you do fillers.  The DeepFx may go deep enough to disrupt the fillers.
  7. You can do fillers and then ActiveFx because ActiveFx only goes 100 - 300 microns deep.  Fillers are placed deeper than this.
  8. Anesthesia:  Atavan or Valium (5 mg), IM Torodol 60 mg, Zimmer Cooler, Pliaglis Topical or Topical Lidocaine.  Is po Torodol ok? What about Percocet or Vicodan?
  9. You may need to use a nerve block for upper lip treatment.  Dr. Weiss, “Do you do the Infraorbital Nerve Block or 5 short injections near the upper lip gingiva?”
  10. Use intraocular eyeshields for upper eyelids.  You might be able to use tongue blade wrapped in moist gauze for lower lids
  11. Segmental Resurfacing:  Do IPL on cheeks for pigment and do ActiveFx in peri-occular areas for fine lines and tightening.  Get the most out of your hour with the patient.  This sounds like a great idea-Segmental Resurfacing!
  12. Dr. Heinrich does DeepFx only and then Deep plus Active one month later.  He says the patient’s skin gets used to treatment the first time, so downtime is less the second time.  This is my question:  what is the downtime with the first treatment and what is the downtime with the second treatment?  Do patients have to have two 4 day periods of downtime within 30 days?  I am not sure this makes much sense.
  13. Some older patients (your mother-in-law) really need traditional CO2 or a facelift.  Give them that option.
  14. Class 4 Wrinkles:  The best option is traditional CO2 with two weeks or downtime OR do TotalFx  2-3 times at one month intervals (Dr. Heinrich)

 

Treating Specific Conditions:

  1. DeepFx is best for vertical lip lines, deep wrinkles, acne scars.  It goes deep and stimulates more collagen and ablates more tissue for more tightening.
  2. ActiveFx is better for pigment and more superficial textural problems
  3. Stretch Marks (Stria):  Use ActiveFx:  80-100 mj, density 1-2 (use Density 2 for thicker Stria).  Do NOT use DeepFx for Stria.
  4. Melasma:  Experts are not sure it will work.  They do not recommend at this time.  They are doing test spots and experimenting with it.  Melasma is a whole topic unto itself.  Look for a specific blog about this in the future.
  5. Tattoos:  DeepFx might be good for resistant Tattoos

 

ActiveFx, DeepFx & Total Fx Settings:

  1. The experts usually treat with DeepFx in the range of 15 mj – 20 mj
  2. Most experts would not go higher than density 3 with DeepFx (15%).
  3. Recommended Settings: 
    1. DeepFx:  15 mj, density 3, one pass. 
    2. ActiveFx:  100 mj, density 3, one pass. 
    3. You can go to 20 mj with DeepFx
    4. You can to to 125 mj with ActiveFx. 
    5. Density 3 seems to be highest density used with DeepFx (Dr. Ross goes higher, but he is very experience, an expert and he has experience with the full CO2).  Don’t go higher than Density 3 with DeepFx. 
    6. For ActiveFx:  Higher density with one pass is better than lower density with two passes (Dr. Weiss).
  4. To stay out of trouble with ActiveFx off the face, use Density 1 and 70-80 mj

 

Treating Specific Areas:

  1. Eyes:  Use ActiveFx. Don’t do DeepFx around eyes (skin too thin?)
  2. Eyes:  ActiveFx:  90-100 mj, density 2-3.  Downtime:  7-8 days of downtime (what TYPE of downtime?)
  3. Eyes:  Upper Lid:  ActiveFx:  60-70 mj, density 1
  4. Eyes:  Might consider using DeepFx for low lids:  5-10 mj with density 2?  This was the experts thinking outloud.  They are not recommending this!
  5. Eyes:  Treat to the lid margins with ActiveFx:  Density 4-5, one pass (for greater tightening and because this is where much of the problem lines reside?)  This seems strong.  Listen to Webinar for yourself before doing this!
  6. Neck:  Necklass lines are done with DeepFx, the rest of the neck is done with ActiveFx. 
    1. DeepFx on the Neck:  15 mg, density 2 or 3. 
    2. ActiveFx on Neck:  90 mj, Density 1 or 2. 
    3. Neck with the above settings:  10-14 Days of downtime (what TYPE of downtime?)
  7. Neck:  ActiveFx:  100 mj and density 3 was too strong.  Produced prolonged erythema.
  8. Chest: 
    1. ActiveFx:  100 mj, Density 1. 
    2. DeepFx for sagging and wrinkling on Chest?  I think the experts recommending doing DeepFx.  Perhaps 15 mg, density 2?  Check the Webinar.
  9. DeepFx can be done on neck, chest and hands

 

Pigment Changes, Post Inflammatory Hyperpigmentation, Melasma

  1. Don’t treat Melasma (Dr. Ross)
  2. Dr. Weiss has never seen PIH with ActiveFx.  The company has told a friend of mine that they don’t get PIH with ActiveFx.  This is complete and utter bull!  I have gotten PIH with skin types 4 (Italian, Greek). We need an open and honest discussion of this.  Dr. Weiss may only be treating skin types 1-3.  If this is the case, he and the company need to be much more transparent, open and honest when they talk about PIH.  What they say (you don’t get PIH with ActiveFx) is misleading, false and dangerous.  To just dismiss the PIH problem with ActiveFx is irresponsible and dishonest!  This type of cavalier attitude pisses me off!  This view (no PIH with ActiveFx is parroted by others (company reps and clinical advisors) and this type of dishonesty will get YOU & ME into trouble!  If PIH is not a problem, why isn’t ActiveFx used in darker skin types?  A friend of mine has posted his PIH pictures at www.geocities.com/pih_pih/.  Go to this site to see PIH after ActiveFx.  Dr. Weiss, I am looking forward to your comments about these pictures.  Please don’t talk about PIH if you only treat skin types 1-3!  I would also like to hear from the other Luminaries and Lumenis who claim that PIH is not a problem.  Let’s move on . . . I am calming down now.
  3. None of the presenters use Hydroquinone to prevent or treat PIH.  This is because they say they don’t get PIH with ActiveFx, DeepFx or TotalFx.  Either I am an idiot or they are not being honest or they are not treating the patients that I am treating.  I am not treating any skin types 5 or 6 and I am being very careful with skin type 4.  I use Hydroquinone, RetinA and Hydrocortisone pre and post treatment on my skin type 4 patients.  Maybe I should not treat skin type 4?  Not treating skin type 4-6 eliminates about 40% of my patient population (so why should anyone buy the machine unless they live in Sweden or Finland?).  Let’s discuss this PIH issue!  Is “bronzing” PIH?  You can go to www.geocities.com/pih_pih/ to see my photos of PIH after ActiveFx.  I am interested in your comments (and I hope Drs. Weiss, Ross, Dover and Henrich will comment as well).  I think this is another case of “The Emperor Has No Clothes” (Everyone thinks that they will be called “stupid” if they don’t see what everyone says they are supposed to see. This is the question, “Do you get PIH with ActiveFx?”  If so, how do you prevent it, how do you treat it, who do you have to be careful with?  This is THE “cop out” answer that I do not want to hear, “I only have skin type 1-3 in my practice”.  This is bull (almost 50% of our population is now “patients of color” and if this is true, then YOU are not an expert using this technology!  (Just my opinion) (Sorry about the emotion, but I am fed up with the dishonest bull that comes from the companies and their luminaries.  I am on the front lines and it is me and my patients who get screwed by this type of pandering and dishonesty - hopefully one of the benefits of this type of blog will be to get the “experts” to be more thorough and honest in their presentations, you can’t be dishonest when everyone is watching and talking about your presentation!).
  4. Dr. Ross uses Hydroquinone once he sees PIH.  You generally start to see PIH 15-28 days after procedure.  Wouldn’t it be better to prevent the PIH, Dr. Ross?  Can you prevent it?  Do you know who is at greatest risk for PIH?
  5. Patients are generally not allergic to Hydroquinone (HQ), they can be sensitive to it.  15% of patients get irritated with HQ – contact irritation.  This is not a true allergy.  You can change the HQ to 2% OTC Hydroquinone.  Other options are to use it less frequently (every other day), use if for less time (3 hours per day rather than overnight), or use it with Hydrocortisone 1%.   (These other options are from me, not the experts).  There are also other bleaching agents like Azelaic Acid and Kojic Acid (see The Supplement to the September 2005 Skin & Aging Magazine on www.geocities.com/foxydog1064 for a Hyperpigmentation Round Table Discussion). 
  6. In skin types 4 and higher (Persians and Hispanics) go a little lighter (less density, less energy).  Density is % coverage; Energy is depth of treatment.  I think both matter.  Perhaps % coverage matters more (it matters more when you do a Fraxel Treatment).
  7. No one is treating skin types 5 and 6 with ActiveFx or DeepFx.  This includes Aftrican-Americans, East Asians (Japan, China) and Southern Asians (India, Middle East).  You can use Fraxel Re:store 1550 for these patients.  Be very careful to avoid PIH when you treat these darker skin types with the Fraxel. 
  8. Experts:  “PIH clears very quickly”.  Me:  I have read that it can last 6 months to 2 years.  In my opinion, you should not minimize PIH by saying it clears so quickly.  Just read www.realself.com to see patients with long standing PIH.
  9. Experts:  “Koreans are skin type 4”. Me:  I would treat them as skin type 5!  I wonder what Dr. Eliot Battle would say?

 

Downtime:

  1. The experts discussed “Downtime” and “Quality of Downtime”.  Absolute Downtime, Relative Downtime & Social Downtime.  Absolute Downtime would be when you can’t go out (the day after an ActiveFx).  Social downtime would be when you don’t want to go out but can go to work (after the peeling, ActiveFx:  days 5-7). Days 2-4 are Relative Downtime, when you feel fine but don’t look to good.  You don’t want to go to work, but you can work at home and pick the kids up from school (stay in the car).     
  2. We should come up with some words and definitions for the different types of downtimes so we can communicate this to our patients.  What are your thoughts on how to categorize downtime?
  3. There is a big difference between 3-4 days of downtime and 5-7 days of downtime.  With 3-4 days, you can have procedure on Thursday and be back to work by Monday.  With 5-7 days of downtime, you have to take the week off.
  4. The experts prefer to do TotalFx over Fraxel Re:store (1550).  They do the Fraxel when the patient prefers to give one day of downtime x 5 rather than 4 days of downtime once.

 

ActiveFx, DeepFx, TotalFx vs other Lasers:

  1.  DeepFx and Fraxel Re:pair CO2 are the only lasers that go deep and ablate.  The others ablate shallow and then coagulate deep.  They also have spot sizes which are macro (1.3mm)  rather than micro (0.12mm)
  2. The best results for deep wrinkles, vertical lip lines and acne scars can only be obtained with deep ablation
  3. Experts:  It is nice to have a CO2 Laser because it has an ablative handpiece that can treat syringomas, sebaceous hyperplasia, warts and moles.  We need to start a blog which discusses how to treat these conditions and avoid scarring.  Feel free to blog on sryingomas, sebaceous hyperplasia, warts and moles!  How do you treat them with the ablative handpiece of the Encore?
  4. Why Deepfx?  People were disappointed in Perioral wrinkles and lines.  DeepFx does a better job.  You may have to do 2-3 treatments, one month apart!  How much downtime would this be?  What type of downtime (absolute, relative, social)?  How do we explain this to our patients? 

 

Pre and Post Treatment Tips:

  1. Mild moisturizers avoid acne flare-ups
  2. You don’t have to use aquaphor or vasoline.  Mild moisturizers are good enough (personal communication from company reps).
  3. Be careful of the lanolin in the aquaphor.
  4. Using Aveeno Water Gel gets you one less day of Downtime!  (From Dr. Weiss).  What is Aveeno Water Gel?  How do we get it?
  5. Post TotalFx Care:  Use “Soaks” every 3-4 hours.  (What type of soaks?  Saline Soaks (saline and gauze)?  How long do you soak every 3-4 hours?) 
  6. Post Care:  Cold packs or Zimmer Cooler for 30-45 min after treatment
  7. Valtrex for everyone.  One case of disseminated herpes on the face is not good.  Can we use Acyclovir?  It costs less, much less (Four Dollars at Walmart!).
  8. Check all patients the next day, this makes you and them feel better.
  9. Don’t give pain meds after treatment.  If they have pain, you want to know about it and see them.  They should not have pain for more than a few hours after treatment.  Prolonged pain suggests infection:  bacterial, viral, fungal.  Can we discuss post procedure infections and how to treat them? 
  10. Pliaglis can be mixed with cetaphil cleanser or cetaphil moisturizer.  90% Pliaglis and 10% cleanser or moisturizer.
  11. Experts worry about Lidocaine toxicity.  Compounded Lidocaine works as well or better than Pliaglis.  Pliaglis costs $60 per treatment.  Compounded Lidocaine costs about $6 per treatment.  Do the experts have a financial interest in Pliaglas?  Are the experts afraid that they will be sued if they talk about compounded lidocaine?  The discussion on this topic did not seem to be open, honest and complete!
  12. Experts do not routinely use oral antibiotics unless indicated for acne outbreak prevention:   Keflex 500 mg TID, Doxycycline 100 mg BID, Erythromycin can be used to prevent acne outbreak.
  13. Sunscreens:  Use everyday after skin is healed up.  Wear hat and stay out of sun until healed.
  14. Use a good UVA blockers:  Neutrogena, Helioplex or Loreal Products.

 

The Opinions of the Transcriber (CHMD) & Other Misc Issues:

  1. These experts have only been using the DeepFx and TotalFx for 6 months, so their use is evolving.  It will be very important for Lumenis to keep us informed about changes in these expert’s opinions as they get more experience.  We must all advocate very loudly and strongly for a Newsletter from the company which keeps us up to date (not just Webinars which take 2 hours to watch and are mostly for marketing and selling lasers).  Go to www.geocities.com/FoxyDog1064  for more information about Advocacy for Better Clinical Education and Clinical Exchange Programs. 
  2. We must also make sure the company picks experts that have significant experience using their laser in skin type 4!!!  To say, “I don’t have the problem because I don’t have patients with skin type 4” is bull.  It is a big cop out and is counterproductive.  Plus, I don’t believe it or accept it.  Skin type 4 is Italians, Greeks and others who don’t burn but tan easily and get dark easily when exposed to the sun.  If you are not treating skin type 4, patients I am not sure you are practicing in the USA!
  3. If you want to contact Lumenis directly, address all questions and comments to Amy Easterly, Product Manager.  Her email is: amy.easterly@lumenis.com.  Perhaps she can ask the Drs. Heinrich, Weiss, Ross and Dover to participate in this discussion, read this blog and comment and clarify.  I believe that they get paid a lot of money to do the Webinar.  I believe their job has been done incompletely when they leave us with unanswered questions and incomplete thoughts.  Remember, we are treating patients.  Real patients with real faces that can be scarred and hyperpigmented!!!  We want excellent outcomes with very few complications.  Lumenis owes it to us!
  4. This Webinar will be available soon in Aesthetics Buyers Guide.  When?  Let’s see how good the Aesthetics Buyer Guide Version is.  I bet it will be edited to sell lasers!  Lumenis, it’s ok to do a version to sell your laser, but you should also do a version for your Encore UltraPulse Users as Continuing Education.  Let’s see if you step up to the plate for your Users!

Now let’s blog.  Let’s get it on!!!  Let’s get what we need (more self support and more company support).

Reader Comments (95)

Excellent post and commentary. This is exactly the type of information I love to see on this site. Informative but without the usual hype that the usual advertising site's and magazines provide. There are actual differences in IPL's and lasers. Loving it.

06.17 | Unregistered CommenterDermgal

CHMD, is there a reason you're not identifying yourself? I'm just curious. This is great information but it would be better if we knew who was behind the commentary. I wouldn't put it past a company to use this site to build up a reputation and then trash the competitors.

06.17 | Unregistered CommenterGrumpy MD

Great work with this post, CHMD. Here are some questions I'm looking for answers to:

Any discussion on the effects of pulse stacking vs. multiple individual pulses?

At what settings does an activeFX treatment essentially become indistinguishable from a fully ablative traditional CO2 laser treatment?

Aren't most wrinkles at 300-500 microns, not 800?

Interesting that they recommend essentially the same parameters for chest and for the neck....any comments on scarring problems there?

06.17 | Unregistered CommenterTF

I am a MD. I work full-time in a Cosmetic Skin Care Center. I am board certified in Internal Medicine. I am doing this because I want to share what I have learned and I want to learn more as others comment on the material that I have summerized.

My attitude is, put it out there, be open and honest and let the truth perolate to the top. My post may not be the truth, but after you guys have finished commenting on it, the truth will be evident!

I don't identify myself because I have to deal with these laser companies and these luminaries and I want to be able to be completely open and honest and I want to be able to be pissed off without having to worry about retribution.

I am also a terrible speller, so I don't want anyone to think that I am stupid!

06.17 | Unregistered CommenterCHMD

CHMD: I think you are doing a great job. Keep it up. Everyone is pretty much in the same boat out there, but some of us have more arrows in our back than others. If I can help even one person avoid some of the pitfalls I have encountered- and mistakes I have made (and there have been MANY) -- I will feel that I have done a mighty good deed. Hopefully there is such a thing as karma....

some of questions you pose are representative of someone who wants a cookbook answer. ie: can you use vicodin with treatment? as a medical professional if you can't answer this question yourself, you should consider if you should be prescribing this ever. it dangerous to expect a particular setting or practice method to be handed to you as a license to peform any laser procedure you desire. your analysis is somewhat 1 dimensional in this respect. to say you should never treat the eyelids with deep fx is another example of misinformation.

06.18 | Unregistered Commenterreader1

Reader 1, you are the type of doctor who really pisses me off.

The "cookbook argument" is used repeatedly by doctors who are too lazy or too stupid to sit down and figure out how they do things.

(or they are too stingy and greedy and don't want to share what they know or what they have learned).

All great cooks first learned to cook from a cookbook and then they take it to the next level once they understand the basics. This is how great doctors learn as well.

To argue that you cannot write a cookbook is to misunderstand how everyone learns medicine and how everyone learns any other difficult disipline. Reader 1, how do you learn? How did you learn medicine? Were you just born brilliant?

Most of us are not as brilliant as you. We have to learn it somewhere. It starts with something like a "cookbook".

I would suggest that you are not as smart as you think you are and I would suggest that you are not a very good physician if you don't know WHY you do things and you don't know HOW you learned to do the things you do.

How do you know you are doing things correctly? I guess you just know because you are so brilliant!

btw, giving vidan could be a bad thing if you are supposed to monitor the patient for pain. So the question is a good question and it is relevant. Therefore the whole premise for your critisism shows YOUR lack of understanding and your lack of expertise and your one dimentional knowledge of this field.

ps. 99% of what CHMD wrote is his/her summary was from the experts who gave the webinar (it is a summary of a webinar). CHMD was not the person who said not to treat the eyelids with deepfx. It was Dr. Weiss. So if you have a problem with that, take it up with Dr. Weiss. If you want to treat the eyelids with DeepFx, go right ahead.

pss. the whole point of this blog is to counter idiots like you who think that we cannot be instructed and taught to provider better and safer treatments. What is your alternative to simplistic, 1 dimentional intruction? to let everyone figure it out for themselves?

Reader 1, you hit a very sensitive nerve. The "cookbook argument" is just a big cop-out meant to shut down discussion and learning. In every instance that I have encountered it, it has come from an idiot who just doesn't understand and they THINK they are smart.

Sorry for the emotion. I am better now.

06.18 | Unregistered CommenterMDR

Let me explain:

The intent of the vicodan question was to understand why Dr. Ross used IV toradol when he could use po toradol or use vicodan or percocet. It seems that IV meds for this procedure is another level of invasiveness. I don't want to use IV toredol, so I am wondering if po meds are just as good? I think they are, but am I missing something?

The intent of the DeepFx around the eyes comment was to alert everyone that the experts felt that you probably should not do DeepFx around the eyes. They did speculate on possibly safe parameters you could use if you want to treat around the eyes.

I don't think this summary is "cookbook". It is the opinions of four very knowledgeable and experience physicians.

To be a master chef you need to read lots of cookbooks and have great mentors. After you master the basics, you take it to the next level and do your own thing. You should not skip the "cookbook" stage. Unfortunately in cosmetic medicine it is hard to find an experienced and knowledgeable mentor.

My goal is writing this summary is to generate discussion of the methods that these doctors use. I want to know if people agree or disagree and I want to know how everyone does their treatments. The more ways that I know to do something, the better I will be.

There are 100 ways to skin a cat. 10 are correct and 90 are incorrect. You want to be exposed to all 100 methods so you can choose the method you will use. If you are not exposed to all these methods you are doomed to repeat the mistakes of the past and you probably won't hit upon the best way without a lot of trial and error. I prefer to skip the trial and error phase. I want to learn from other's mistakes.

Remember to listen to the webinar if you are really interested in being the best DeepFx provider you can be. My summary is just a summary. Go to the original souce.

06.19 | Unregistered CommenterCHMD

CHMD and MDR: I just came across another interesting example of what you are all blogging about. Palomar has a one hour webinar on their web site by Dr. Weiss on the subject of using the 1064 laser for leg veins. After listening to Weiss's webinar, I have come to the conclusion that a physician should probably not even be attempting this until he/she has mastered sclerotherapy. Without being knowledgeable about the entire subject of the venous anatomy and physiology of the legs, laser treatments may siomply not work in many cases (unless the primary cause of the visible problem veins is first resolved, etc.). Weiss said his workshop for laser treatment is usually a full day, which would have to be in addition to a full course on sclerotherapy. There are also possible complications such as ulcerations which may be encountered. The bottom line is that many of what some consider "simple" med spa procedures are really pretty sophisticated medical procedures requiring extensive training and considerable expertise for first rate outcomes....

CHMD,

When I go to your website on PIH I have a problem loading the pics. Is it me?

06.19 | Unregistered Commenterdexter

CHMD,

Not to be controversial, but isn't is possible that you shouldn't be doing skin resurfacing on skin type 4 with CO2 and if you are going to then you have to expect the incidence of PIH is pretty high. Does Lumenis recommend skin type 4? Frankly, even if they do they are probably pushing it. They did the same thing with the Lightsheer and people got into trouble.

It would seem to make sense that if you are going to use CO2 you need to do the fractional form with the lowest density possible. You results won't be great but you won't be flirting with that delicate line between good results and complications.

Maybe these practitioners see skin type 4 or greater but they don't use CO2 on them even in the fractional form? Ross and Weiss both have erbium (2940) fraxel lasers. Maybe they use the erbium on darker skin types, but a Lumenis forum is not the place to talk about that.

The main factors of damage are simple: Depth which is obvious, Density because the more coverage the more damage. If there's more coverage then the body has to work harder to heal. And finally the type of damage. CO2 inherently damages by vaporization and coagulation. That coagulated tissue has to be dealt with by the body. This is why the healing times are longer than erbium. Erbium is 90-95 percent pure ablation. I'm not trying to promote erbium. I believe there is a good cause to have coagulation in many instances. But dark skin types may not be it. Erbium lasers can cause PIH in asian skin types, so you can be assured CO2 will cause PIH at a higher rate. That is it's limitation.

You mention that you consider asian skin types a 5. If you believe that (and I think it's a good thought) then CO2 may not be the best tool for those patients.

When see patients with skin types 4-6 we use our erbium laser and don't add coag. If they are 1-3 then we are comfortable adding coagulation (which makes it CO2 like).

Sorry for intruding on your forum, but I couldn't resist. I love talking resurfacing.

06.19 | Unregistered Commenterdexter

Problem fixed. Sorry.

go to: www.geocities.com/pih_pih to see PIH pictures after ActiveFx

06.19 | Unregistered CommenterCHMD

Thanks, Dexter. Love your imput. BTW, contact pmdoc about the forum he is helping put together in November. I think you would like to be there and you would be a great asset.

I think that we need to talk about ethnicity when we talk about skin types. I am curiou what others think.

For example, Asians act like skin type 5 in my experience. Italians & Greeks act like skin type 4. African-Americans act like skin type 6.

It is almost more helpful to talk about ethnicity than skin type in my opinion. For example, if you tell me you have an asian patient, this tells me more then if you tell me you have a patient with skin type 4 or skin type 5. What do you all think?

06.19 | Unregistered CommenterCHMD

Adverse rxn's is the reason people stopped using the "gold standard" in the first place. Fractional CO2 science followed fractional erbium. I think this happened because laser companies saw an opportunity to sell "new technology".

I agree with dexter maybe the best for the darker skin types is traditional and fractional erbium. Even in lighter skin types maybe the fractional CO2 would be better for spot treating (areas with mild laxity, deep rhytids) and the rest is done with fractional erbium. The reason I say this is if the face is to be treated as a whole coagulation everywhere is not a good thing if you are trying to reverse age related changes. The thinking in the past few years is about adding collagen and volume to the reticular layer to reverse these age changes. This is why there are so many new dermal fillers. CO2 in any form coagulates with the thermal component, denaturing protein (collagen) this causes a macrophage rxn as well as other immune/repair response. This is why CO2 tightening fades after 18 months or so. Granted there is some new collagen growth but not as much as with fractional erbium. Why would you want to leave the dermal layer thinner then when you started if youthful appearance is about density and depth of collagen as a whole.

06.19 | Unregistered CommenterFlorida PA

Regarding the ethnicity point, take a look at this study and let me know what you take away from it.

http://network.nature.com/forums/jidclub/1610

Since epidermal healing partially comes from the hair follicle and sebaceous gland would it be fair to speculate that if you have lower hair density in a certain ethnicity then healing may be delayed. What got me thinking about this is that it seems apparent that hispanics heal better than asians although they can be claimed as similar fitz. types. Frankly, I remember discussing this somewhere back in my co2 days but it just reoccurred to me.

06.19 | Unregistered Commenterdexter

An interesting point that some might not know but fractional CO2 has been around for a long time. coherent (now lumenis) used this technique when developing a CO2 hair transplant scanner with the old ultrapulse. the hope was to eliminate bleeding, but the CO2 caused too much coagulation for the hair follicle to take.

I agree with Florida PA. Fraxel has simply given every CO2 manufacturer from the 1990's a new lease on life. Same laser just different scanner and software. The CO2 market was dead and now it is revitalized thanks to Reliant. Ironically, they gave life to the market and will end up being the ones punished because they choose to deliver CO2 with a consumable while every CO2 company in japan, china and europe do it without and at much less cost.

06.19 | Unregistered Commenterdexter

reliant's co2 is superpulsed and not ultrapulsed as with lumenis. most other "fractional" co2 devices are continuous (mixto, etc) and are not at a micro spot .12 um.

06.20 | Unregistered Commenterrexfx

If Superman fought Ultraman, would Superman win? Does this make superpulsed better than ultrapulsed?

rexfx, what is the difference between superpulsed and ultrapulsed?

06.20 | Unregistered CommenterMDR

I think there are differences in the response to Fraxel amoung ethnicities. Asia acne scars and pigment responds very well to low treatment levels (TL: 4-6)- 10-15%. They also hyperpigment very easily.

Whether this difference is due to differences in hair density or the hair follicle complex or it is due to differences in their melanocytes or something else, I do not know.

I do know from the ASLMS Meeting that melanocytes are different and fibroblasts act differently in different ethnicities.

Excellent point Dexter. Hopefully Dr. Eliote Battle is trying to work out the reasons for these ethnic differences as we blog!

06.20 | Unregistered CommenterCHMD

MDR,
There is a difference in the physics of how the energy is delivered as well as consistency of depth of penetration. Ultrapulse: flat topped energy delivery, Continuous - constant but harder to control, Superpulsed - peaks and slowly tapers. All are CO2 whether fractional or not however this will affect depth of penetration, thermal relaxation time, and secondary clinical seqeule. One study reveals differences in collagen production and coagulation. More is on the way. We are beginning an independent study comparing depth and coag ratio's with Deep(ultrapulsed) , Re:pair (superpulsed) and Mixto (continuous wave). Will it make a huge difference clinically ? Collagen/Coagulation production difference? Not sure.. We will see.


Dermatologic Surgery
Volume 25 Issue 3 Page 153-159, March 1999

To cite this article: Tina S. Alster MD, Christopher A. Nanni MD, Carmen M. Williams MD (1999) Comparison of Four Carbon Dioxide Resurfacing Lasers A Clinical and Histopathologic Evaluation
Dermatologic Surgery 25 (3) , 153–159 doi:10.1046/j.1524-4725.1999.08126.x


Abstract
Comparison of Four Carbon Dioxide Resurfacing Lasers A Clinical and Histopathologic Evaluation
Tina S. Alster MD, Christopher A. Nanni MD & Carmen M. Williams MD1 Washington Institute of Dermatologic Laser Surgery, Washington, DC
Correspondence to: Tina S. Alster MD , 2311 M Street, NW, Suite 200, Washington, DC 20037.

Abstract
Background. Several high-energy, pulsed and scanned carbon dioxide (CO2) lasers are currently available for cutaneous resurfacing. Although each laser system adheres to the same basic principles of selective photothermolysis, there are significant differences between lasers with respect to tissue dwell time, energy output, and laser beam profile. These differences may result in variable clinical and histologic tissue effects.

Objective. The purpose of this study was to examine the in vivo clinical and histopathologic effects of four different high-energy, pulsed or scanned CO2 resurfacing lasers.

Methods. A prospective study using four different CO2 resurfacing lasers (Coherent UltraPulse, Tissue Technologies TruPulse, Sharplan FeatherTouch, and Luxar NovaPulse) was performed. The cheeks of seven patients were divided into four quadrants. Each quadrant was randomly assigned to receive treatment with one of four CO2 lasers. Skin biopsies were obtained intraoperatively from each quadrant, after each of three laser passes, and at 1 and 3 months postoperatively. Blinded clinical assessments of each laser quadrant were made at 1, 3, and 6 months postoperatively by three physicians. Degree of lesional improvement as well as erythema severity, re-epithelialization rates, and presence of side effects were recorded. Blinded histologic examination of laser-treated quadrants was performed to determine the amount of tissue ablation, residual thermal damage, inflammation, and new collagen synthesis.

Results. The four CO2 lasers produced equivalent clinical improvement of rhytides and scars. Re-epithelialization occurred in all laser quadrants by day 7. Postoperative erythema was most intense in the quadrants treated by UltraPulse and NovaPulse; however, overall duration of erythema was equivalent for all four laser systems (3 months). Postinflammatory hyperpigmentation was the most frequently encountered side effect and occurred with equal frequency in each quadrant. No scarring, hypopigmentation, or infections were observed. After one laser pass, histologic examination revealed partial ablation of the epidermis with the TruPulse laser and complete epidermal ablation using the UltraPulse, NovaPulse, and FeatherTouch laser systems. The greatest degree of residual thermal damage was seen after FeatherTouch and NovaPulse laser irradiation. New collagen formation was greatest in the UltraPulse and FeatherTouch laser-irradiated quadrants.

Conclusions. Equivalent clinical results were observed using the FeatherTouch, NovaPulse, TruPulse, and UltraPulse CO2 lasers. While postoperative erythema intensity differed between laser systems, total duration of erythema was equivalent. The four lasers under study resulted in minimal residual thermal damage and stimulated new collagen formation within 6 months after treatment

06.20 | Unregistered Commenterrexfx

Interesting study on PIH after laser resurfacing with traditional methods - abstract posted below. Now we just have to determine whether fractional devices cause the same thing....

Take away points:
Choice of laser made no difference
Pre-post treatment protocol made no difference
PIH in 68% of type IV skin

Now we just have to determine whether fractional devices cause the same thing....
---------------------------------------------------------------------


Facial resurfacing in patients with Fitzpatrick skin type IV.

Sriprachya-anunt S, Marchell NL, Fitzpatrick RE, Goldman MP, Rostan EF.

BACKGROUND AND OBJECTIVES: Though post-inflammatory hyperpigmentation (PIH) is probably the most common complication of laser resurfacing and appears to correlate directly with the intensity of the patient's natural pigmentation, there is very little data that specifically addresses the risks of dyspigmentation in more darkly pigmented patients (Fitzpatrick skin types IV and above). The objective of this study was to evaluate the long-term dyspigmentation of patients with skin type IV having radial laser resurfacing.

STUDY DESIGN/MATERIALS AND METHODS: A retrospective review of the clinical efficacy, incidence of dyspigmentation and other adverse effects, as well as the pre/post-operative protocol of 22 patients with Fitzpatrick skin type IV who were a minimum of 1 year post-operative following facial laser resurfacing.

RESULTS: The average patient achieved greater than 50% improvement, indicating adequate treatment being delivered. PIH occurred in 68% of patients, starting 1 month post-operative and lasting 3.8 months. There was no correlation to pre-treatment or type of laser used as far as incidence of PIH. True hypopigmentation was not seen in this group of 22 patients.

CONCLUSIONS: PIH is the most common complication of facial resurfacing in patients with skin type IV. It is not preventable by choice of laser or skin care regimen pre-operative, but appears to respond to appropriate treatment once it has developed. Copyright 2002 Wiley-Liss, Inc.

06.21 | Unregistered CommenterTF

Did anyone hear the very latest webinar from Dr. M. Goldman re: Deep FX / Active FX states that he has NEVER had hyperpigmentation on type 4 asian or hispanic skin. Mitch, please stop by our office and Ill show you > 95% PIH in all of our patients at very low settings. About 50 patients and we are also in California ! I don't think this is a realistic representation of what is happening. Maybe all the medical residents are doing his treatments or everyone in La Jolla CA is type 1-2 ????

06.28 | Unregistered Commenterco2md

No hyperpigmentation is bull! This type of dishonesty is really wrong. I want to call Dr. Goldman out right now and debate me (us) on this forum. I HAVE seen PIH FREQUENTLY in skin type 4.

Is he full of Bull or am I an idiot? Is he the FOOL who is telling us all that the Emporer has clothes? Are we going to believe him or believe our own eyes?

What has been YOUR experience?

Dr. Goldman. Come on this blog and tell US how you avoid PIH.

How much did Lumenis PAY you to do that webinar?????

Are you being honest? Why don't you get PIH and why do I get it all the time???? I am using the SAME SETTINGS!!!

Something is rotten in Denmark!

06.28 | Unregistered CommenterMDR

go to: www.geocities.com/pih_pih to see PIH pictures after ActiveFx

06.28 | Unregistered CommenterCHMD

Is anyone else sick and tired???
Being mislead by the experts is getting old.
I am sick and tired of it!

Dr. Mitch Goldman tells us that he sees no PIH with ActiveFx in skin type 4 (Asian or Hispanic). That is because he is trying to sell lasers for Lumenis. That is what he is getting PAID for.

Being lied to and mislead is getting old.

I no longer believe ANYTHING Dr. Mitch Goldman says.

Lumenis should start looking for another spokesperson, because word is getting around that Dr. Goldman will say anything if you PAY him!

It is time the "experts" stop prostituting themselves for the laser companies. It hurts other doctors and it ultimately hurts patients.

I am tired of being the one who gets hurt. My patients are not happy when we tell them something the experts told us (no PIH) and then it happens differently (they get PIH).

Dr. Goldman, it is time you start being honest with us and with prospects. Do you remember the Hippocratic Oath ("Do no harm"?). Well, you do lots of harm when you mislead other doctors and prospects. You harm patients indirectly and you harm other doctors.

I hope I am wrong about you, but I have heard about you before and it seems you have done it again in this webinar.

I am not even going to listen to the webinar because as far as I am concerned, everything that comes out of your mouth is suspect.

co2md said that you said you NEVER had PIH in a skin type 4 and I believe him. I don't believe you. I too have seen PIH with ActiveFx.

Good night, Dr. Goldman!

No hyperpigmentation is not a bull. “No” change to “May have” may be more comfortable to doctors experienced the fractional CO2 laser resurfacing. All my patients were skin type 4 to 5 skin with main concerns of sever facial acne scar.
My clinic sits at the southern of Taiwan without any association with Lumenis company. What I mostly used spot fluence was got to 8.5J/cm2 and more than 50% coverage and 2-3 runs on some scar areas. To tell the truth, so far, no PIH is noted for more than ActiveFX 60 cases and TotalFx 4 cases. I think the main point is the post-laser wound care. I use close wound care with Hydrocolloid (like Duoderm) coverage for a week with subsequent strict moisture and sunscreen skin care. I personally consider the PIH is the common sequel of any normal skin injury (esp. dryness following post-laser healing skin), so is fever in body infection. Dry casuses hurt with symptoms of itch and pain.

06.29 | Unregistered CommenterCLF

Like I noted before we have had significant PIH in our asian/latin american patients, we are in CA as well. I usually tell patients to expect it. It is manageable with hydroquinone, tretinoin, sunblock etc. however definetely not great for patients and lots of hand holding. Settings I have used was Deep FX 10mJ with Density 1 and Active 90mJ and Density 2 --- these are conservative so results will not be that dramastic especially for acne scarring common in Asian populations. My patient Type 4 --- very light Chinese and PIH that lasted for 6-8 months with minor residual PIH. Post care was aquaphor and hydroquinone, tretinoin after re-epithelization. IPL and microderm doesn't seen to help much.....

The big question would be at what conservative settings would you be at incresed risk of mild - moderate - severe -- PIH ??? Of course that would depend upon each individual patient and their unique skin type.

06.29 | Unregistered Commenterco2md

Are we talking about the same thing? Is PIH the same as post procedure "bronzing".

I agree with co2md. I get PIH frequently. I am going to tell my patients to expect some bronzing or PIH, or whatever.

By the way, when summer comes, you get tanning which looks like bronzing and/or PIH.

Can we define some terms so we can understand eachother?

PIH
Bronzing
Tan

Thanks

06.29 | Unregistered CommenterMDR

In my definition, post-procedure diffuse bronzing or tanning is PIH which is darker than pre-laser in color and makes patient unhappy. Of course, must rule out any sunburn accident or any contact dermatitis, eg. too early sunscreen applied. If PIH develops frequently, this Lumenis machine would become expensive garbage. It is a disaster for a private clinic! To choose a lower fluence setting is safe for a doctor himself, but is unfair for patients who pay a lot of money. In my clinic OPD, it is common seeing a very angry patient with severe acne scar, post-treated with a latest fashionable fractional Er laser resurfacing done at otherwise. In terms of spots or small-area patches of bronzing or tan, I prefer to use Kojic acid &/ Azelaic acid to care and lighten it. Iontophoresis or sonophoresis with liposomed Vit C is also very helpful.

06.29 | Unregistered CommenterCLF

CLF,

Your patients wear duoderm on their face for 1 week???

Do you use the ActiveFx?

My settings are 100 mj/cm2, Density 3 (85%) for ActiveFx. I am not sure what you mean when you say "spot fluence of 8.5 j/cm2).

Are we using similar settings? I do one pass when I do a density 3.

Density 1 on the ActiveFx is 75% coverage.

I am very interested to learn how you can do ActiveFx and do NOT GET PIH. Is it your after treatment care or is it your setting during treatment? You are clearly doing something different or you are very lucky!

06.30 | Unregistered CommenterMDR

ps. I'd like to see Dr. Goldman come on this blog and tell us how HE avoids the PIH that the rest of us are seeing FREQUENTLY.

06.30 | Unregistered CommenterMDR

Usually, change Duoderm bid or tid in the intitial PO 24hrs, then qd for 2~3 days, lastly left it on the treated face till PO 7th day. With open wound care, it is a hard burden for a treated patient and a being called doctor. I use DeepFx for hard scars (eg ice-pick), ActiveFx for soft scars. My received setting data show a little different from yours. ActiveFx setting: Density 1 --- 66% in line and rectangle shape; 55% in square and rhombus. Density 3 --- 80% in line and rectangle shape; 82% in square and rhombus. I often use your cited Active setting on some deep soft scars. PO wound care is everything. I closely follow each case, especially within 14 days of wound healing. No PIH is not lucky only!

06.30 | Unregistered CommenterCLF

co2md,

do you have your "CoolScan" ON?
Is your HZ 100 or less?

Delivering the energy too quickly or bulk heating (no coolscan) can lead to PIH.

CoolScan can turn off without you knowing (especially if you use the ablative handpiece). Check your options screen.

The pattern should be random and not organized when you fire a pulse. If pulses fire in a "row" pattern, then coolscan is not on.

Let me know what HZ you are using and if the coolscan is on or off.

Hope this helps.

CLF, any comments on coolscan or hz when you treat darker skin types?

07.1 | Unregistered CommenterJEE

Re: Active - Yes cool scan in on. (No brainer) I have turned down the hz to 50 - 75 hz , we use lots of Zimmer. before, during and after. Active FX on lighter settings does not cause as much "actinic bronzing" or PIH with Asian- Korean, Chinese, and Latin American however with Deep FX you will definetely see PIH once you go past 7.5 mj density 1. Ask medical offices with predominately ethinic skin offices you will see a high percentage of PIH. Its manageable however, as a precaution ALL ethnic skin type SHOULD expect it ALL the time and this should be noted in the consultation.

07.1 | Unregistered Commenterco2md

Sounds like good advice about PIH for anyone treating any type 4 skin with fractional CO2.

"Co2md" - have you had any patients where the PIH would not resolve with time and bleaching agents?

07.1 | Unregistered CommenterTF

PIH has resolved in all patients in our office. Longest duration about 4 months. +/- on IPL to treat it. I am not convinced to really does anything. I recommend starting immediately once skin has re-epithel. Hydroquinone,tretinoin,kojic acid,sunblock..... etc.

07.1 | Unregistered CommenterCo2md

.

07.1 | Unregistered Commenter.

co2md,

How do you explain no PIH with Dr. Goldman and Dr. Weiss's patients?

Are they lying, are they not paying attention, are they doing something different, are they calling it something eles?

Is PIH and Bronzing and Tanning the same thing? What is the difference?

How do you get the PIH to go away when summer comes and the patient gets a tan? Doesn't this look just like PIH?

07.1 | Unregistered CommenterJEE

Is PIH a problem for your patients for the 4 months they have it? Is it annoying for you to have to "hold their hands" for those 4 months? Can they easily cover it up with camoflage makeup?

07.1 | Unregistered CommenterJEE

So . . . we tell our skin type 4 patients that they will get actinic bronzing, but it will resolve in 4-6 months and afterwards their acne scarring will be better so it will be worth it. Is that what you say?

co2md, do you have Fraxel 1550?

07.1 | Unregistered CommenterJEE

JEE,
I use coolscan in every case. It is one of Lumenis’ patented characters. Have any contraindication ? Apply ActiveFx without CPG coolscan, only a treatment spot, will injury the lens located on the front of handpiece. (An engineer told me recently)
Hz Hurt!! If patient feels severe pain, just turn down the Hz a little, eg. Hz 100 down to Hz 75.

07.1 | Unregistered CommenterCLF

I am a cosmetic dermatologist in Taiwan. All my patients are Taiwanese/ Chinese, with Fitzpatrick Skin Types III to V. I have been using the Active FX for about a year. In the beginning of my Active FX treatment protocol, I was using more aggressive energy settings like, 80-100 mJ, 75-100 Hz, with density from 4-6 for acne scar patients. At the time, I get about 10% of PIH developed about a month after treatment. The PIH usually resolves within 3-4 months after applying 4%hydroquinone. However, the PIH was not only dependent on the energy settings, but on the patient's sun exposure as well. I had a patient who only had PIH on the left side of the face because he is a salesperson who drives around all day.

After about 6 months of experience, now I use more conservative settings, with energy like 80-100 mJ, 75-100 Hz, with density 1 for the whole face and with density 2-3 on acne scars. Up till now, I don't have patients developing PIH. I think density is the key in Asian patients. With lower density, I can still get at least 30% improvements in acne scars with each treatment.

Finally, in regarding to Dr. Mitch Goldman, I know him personally and professionally for more than 3 years. He is a knowledgeable laser surgeon and an amazing teacher. I spent several months in La Jolla SpaMD. He has at least 20% of patients being Skin type IV or above, Hispanics, Asians and Blacks. During my time there, I did not see any patients being treated with Active FX developing PIH. Also, he did at least 2-3 whole face Active FX resurfacing every week. He is a man with integrity and honor. I know that for a fact.

S. Lai

Thank you, Dr. Lai. Excellent advice. I will try it.

CLF, I didn't understand your point about the lens and not using cooltouch. I have used ActiveFx without coolscan and my lens was not damaged! The defaut setting for the ActiveFx is WITHOUT Coolscan. I bet many doctors are not using Coolscan and they don't know it.

Dr. Lai, I am sure you are correct about Dr. Goldman, but someone should tell him that PIH does occur and they should tell him how to avoid it and how to treat it. They should also tell him NOT to tell everyone that it does not occur with ActiveFX.

He should not be broadcasting the fact that it does not occur. I still hold him (and the other Lumenaries) personally responsible for spreading inaccuate information which CAN and WILL harm patients!

Perhaps we should all get his email address and suggest he read this blog. When doctors like Dr. Goldman (and Dr. Weiss) see their reputations being questioned because of what they say on Webinars, perhaps they will be more careful to be complete and accurate!

The question still remains: why does co2md have such a high rate of PIH? He seems very smart and experienced!!!!

For a PIH photo from ActiveFX see www.geocities.com/pih_pih

Does DeepFx produce more of less PIH than ActiveFx?

Dr. Lai, what exactly do you tell your patients about sun exposure after ActiveFx? How long before and after treatment to stay out of sun? How strict avoidance? Etc.

07.4 | Unregistered CommenterMDR

In a recent Webinar, Dr. Weiss said that PIH does NOT occur with Active or DeepFx. In a recent Webinar, Dr. Goldman said that PIH does NOT occur with Active or DeepFx. THE COMPNAY LINE is that PIH does NOT occur with ActiveFx or DeepFx.

THIS IS 1000% WRONG, UNTRUE AND MISLEADING!!!

We all need to forward the link to this blog to Lumenis, Dr. Weiss and Dr. Goldman so they can modify their incorrect information.

They need to acknowlege that it can and does occur. They need to incorporate into their webinars how to avoid it and how to treat it.

Please find these doctors' emails and forward. Let's overwhelme them with our displeasure at being mislead (or let's educate them).

Not doing this will lead to patients being damaged with PIH!!!

07.4 | Unregistered CommenterMDR

MDR, for the post treatment care for Active FX, I have my nursing staff to cool the whole face for at least an hour. After that, I usually apply duoderm all over the face for at least 3 days. I have my patients to come in the next day for follow up and to change the duoderm. I tell all my patients that they may not go out to the sun for 3-5 days. After that, they are required to apply sunscreen, SPF 50 every 2-3 hours if they choose to go out. I will have another follow up appointment at one week post treatment. If the patient has intense erythema at the time, then I would prescribe hydroquinone 4% before they develop PIH.

I have been communicating with other dermatologists throughout Asia (China and Thailand) with their experiences with Active FX and Deep FX. It seems that PIH is not a huge problem even in Type V skin, Thai people. Maybe we just need to use more conservative energy setting and more strick sun avoidance.

S. Lai

Thanks, Dr. Lai.

07.11 | Unregistered CommenterMDR

There is a handful of doctors that again and again promote new devices and
creams, but personally I would be vary of even buying a used car from them.

07.12 | Unregistered CommenterSceptic

Sceptic, are you talking about Dr. Goldman or Dr. Weiss?

I think in this forum we should name names!

If anyone has a specific opinion it helps us all be wary.

As you know, if Dr. Goldman said what it is reported he said, I still think he is very unethical (dispite what Dr. Lai says about him).

If he is going to be an expert and give webinars, it is incombent upon him to know what is happening with the laser and encorporate this into his opinion, not just rely on his personal experience (which I DON'T believe).

If he is hearing about PIH with the ActiveFX, he should be wondering why others are experiencing it and find out why it is happening. He should not tell the world that it does not occur! This is untrue, misleading and dishonest.

Does he really believe this, does he have his head up is Ivory Tower Ass or is he doing it because he is paid lots of money to be a lumenary for Lumenis.

Dr. Goldman! What say you?

07.13 | Unregistered CommenterMDR

In this blog, we should be open and honest about our experiences in Active FX and Deep FX. This should not be a forum for personal attacks. Like I said before, I believe Dr. Goldman is an expert in laser and cosmetic dermatology that we can all learn something from. He is also a man with intergrity and honor.

07.14 | Unregistered CommenterS. Lai, MD

If someone does Webinars and gets paid lots of money to help sell lasers and then does not tell us the complete story and misleads us and does not tell us about potential complications that we might have with our patients . . . in this situation, they set themselves up for personal attacks and in my opinion they SHOULD BE attacked!!!

What Dr. Goldman is doing, in my opinion, is beyond WRONG!

If he said that PIH does not occur with ActiveFX, then he SHOULD BE ATTACKED savagely and in an unrelenting manner until he starts to tell the complete truth.


He is NOT an honerable man if he is telling people that ActiveFX does not cause PIH.

This blog, unlike other areas of asthetic medicine, holds people accountable for what they say and what they do. This is the beauty of this blog.

Dr. Goldman, Dr. Weiss and other Lumenaries should know that they will be help accountable here. They better not mislead us in order to help laser companies sell lasers. We want the truth, the whole truth. We can handle it and we demand it. There is a new day dawning and it is just around the bend, a new day dawning . . .

07.14 | Unregistered CommenterMDR

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