Fraxel Technology & Protocols

Chat Transcript recorded on December 16th, 2008: Fraxel Protocols

Start Time: Tue December 16th, 2008 08:36:27 PM
Jeff: Hello! If i don't answer right away, i will be right back. Welcome to the Fraxel 1550 Chat.
Jeff: Hi Kiki
kikimarks: hello
Jeff: Do you have the Fraxel Re
kikimarks: yes
Jeff: Did you see the list of topics for this chat?
kikimarks: briefly
Jeff: How did you hear about this?
kikimarks: stephanie (he owner of Radiance medspa) emailed me an invitation to this chat
Jeff: Great. Glad you joined us. i like you because you are early. We should have a few more joining us soon.
Jeff: Are you a doctor? Nurse? np? pa? Aesthetician?
kikimarks: arnp
Jeff: What state do you practice in?
kikimarks: clearwater florida
Jeff: i love Clearwater! i want to retire there, but my wife didn't like it. i have a few more years to convince her!
kikimarks: i do too...why did your wife not love this beautiful area
Jeff: She doesn't like anything i like. Opposites attract, i guess. We do both agree that our kids are great.
Jeff: Hey Kevin
kevin do: hi Jeff
Jeff: Kevin, meet KiKi
kevin do: hi Kiki
kevin do: i am in Los Angeles
kikimarks: hello
Jeff: Kevin is one of the Top Thermage doctors in the country (maybe world).
kevin do: not that good
kevin do:
kevin do: hey Jeff, have you done more thermage lately?
kevin do: i will be in ny on the 23rd
Jeff: i will send you my before and after pictures. 6 months after my Thermage. We are doing a fair number, not sure how many. Kerry is doing most of them.
kevin do: ah, i see
kevin do: good
Jeff: Hi Greg
kevin do: hi Greg
Greg: Hi guys greg sikorski pa
Jeff: Kiki, Greg is one of the top Fraxel Providers in the country
Jeff: Greg, you are 7 minutes late! KiKi was here 5 minutes early.
Greg: had to get some beer ready
kevin do: did you know that Sella 1550 is now fda approved??
Jeff: Kiki, we have some of the top guys with us now. Do you have any questions? How long have you been using the Fraxel?
kevin do: it is the one from Korea that
Greg: i was talking with peer today and we said like technology should yield like results with a standard deviation
kevin do: agreed
kevin do: that was impressive about this Sellas was that you can customize the "pattern" of the beams
Greg: what do u mean Kevin?
Jeff: what is the utility of customizing the pattern of the beams?
Jeff: Hi mc
kevin do: u can use a stylus to "draw" on the screen the pattern of the "scanning"
Jeff: mc, what state is your clinic in and are you a md, do, np, pa ,etc
kevin do: based on the shape of the area you want to zoom on
mc: Hi Jeff,
mc: it's mitch chasin
kevin do: hi mc
Greg: can u control spot size to surface area?
kevin do: in a sense
Jeff: Mitch!!!!! Glad you could make it. i want to introduce you to Kevin and Greg. Kevin was at our Meeting and Greg is the top Fraxel Expert in the usa
kevin do: the handpiece is big but you can "draw down" the treated areas
kevin do: using the stylus
mc: Hi All
Jeff: KiKi is a np from Clearwater Florida. She uses the Fraxel.
Greg: kiki hot bed area for cosmetics!!
Jeff: KiKi, how long have you had the Fraxel?
Jeff: Hey Tom
mc: Who uses Botox on the same day as a Fraxel Restore treatment?
kikimarks: 1 year although i am new to the technology
kevin do: i have not done that
Greg: i do , or 2 wks before is better
kevin do: Greg??
kevin do: but not same day thu??
Greg: same day is ok
TF: Hey everyone. While i don't have the fraxel - i just wanted to see what's going on....
Jeff: KiKi. Greg is a Fraxel Expert. mc is an expert. If you have any questions, these are the guys to ask.
kevin do: Dr. tf, you have the Co2 by Eclipse?
Greg: 1-2 wks before botox is in effect already
TF: Kevin
kevin do: do u like it??
kevin do: they wanted to sell one to me
Jeff: Tom is the national expert on Juvia Fractional co2. We have quite a group tonight! Tom, mc has the Fraxel Re
TF: It's fine for the activeFX-like treatments. It's not set-up to drill deep holes like the deepFX or the Reliant unit
kevin do: i figured that
kevin do: i tested the repair last month
Greg: re
kevin do: Mitch, do u like the repair??
mc: i have performed split face using Ellispe on one side and Repair on other; Repair was superior (for rhytids and laxity)
kevin do: Mitch, is there anything the repair can do that the restore cannot??
TF: mc
TF: I'd be interested to hear what you used on the Juvia side...
mc: Differences between the restore and repair are the significant skin tightening and improvement in deep rhytids that repair can achieve.
Jeff: restore coagulates and repair ablates. Big difference
Greg: tf what are limits? st 4-6? Off face & neck?
kevin do: i agreed with you, Mitch. i have the restore and thermage
kevin do: i used thermage for tightening
Jeff: KiKi, do you have any questions about how to use the Fraxel Re
Jeff: how come i am green and you all are blue?
kevin do: byt he way, starting next month, ur rep will represent both fraxel and thermage
Greg: restore is under utilized, has alot of untapped potential but not a tightening laser
kevin do: very true
Jeff: i get great results with both.
TF: Jeff
kevin do: it might have a new company name
TF: What's going on with the thermage & fraxel merger?
mc: anyone upgrade thermage for the large body tip
Jeff: i use restore when the patient wants 5 treatments with one day of downtime each treatment and i use DeepFx when they want best results and can tolerate 5 days of downtime. i use Fraxel Re
mc: done deal!
kevin do: the rep locally will be responsible both for thermage and fraxel
kevin do: the combined company might have a new name next month
Greg: jeff go to r1, r2 and do 2 tx and you are to goal
TF: Jeff
Jeff: 50/50
kevin do: i still believe most patients prefer no downtme
Greg: tf it does not have to be used that way
TF: How do you really know how deep your treatments are going - and how do you adjust for the skin thickness in the area of treatment?
Jeff: for the fraxel 1550?
kevin do: u can with restore
Greg: i go to the or and lay 2-3 tx in one
TF: Sorry- referring to the repair.
Jeff: i dont have the repair. mitch has the repair. i have the ultrapulse deepfx
Greg: 30-40% coverage and 1.2 mm depth
kevin do: u can up to 20% with repair and 1.4mm, i think
kevin do: is it right, mitch??
TF: ok - well, same question then for the deepFX. Do you worry about subdermal scarring - 1.2 mm is a lot!? WHat are your thoughts on the bloggers who describe deepFX related injuries?
mc: 40 percent
Greg: i think repair goes max 2mm!!!
kevin do: don't think so
kevin do: mitch??
Greg: kevin i saw that on a chart. makes no sense skin 1.5-2.5 total
Jeff: I use 17.5 j with DeepFx. This goes 900 microns deep. I go less deep on the neck and I only use the activefx around the eyes (300 microns deep).
Greg: jeff how much ablation/coagulation in the 900 microns?
Jeff: if you go to you will find a nice chart which shows thickness of skin in different areas of the face and body.
Jeff: 95% ablation
kevin do: Jeff, the table is a bit confusing to me
kevin do: about thickness
Jeff: skin thickness table?
kevin do: yes
Greg: kevin i will send u a good chart
Jeff: i will go there and check it out.
Jeff: send me that chart too, greg
Greg: ok
kevin do: for example, what is the depth of the skin all the way thru the dermal layer for the neck and eyes??
mc: The truth about depth is that no study has actually demonstrated the efficacy to be greater with increasing depth..... so dont get too caught up in that....
Greg: neck around1.5mm lower lids 700 microns
TF: So, you ablate down to 900 microns depth...and then there is coagulation beyond that? It sounds very aggressive...even on thicker facial skin (not eyelids).
Jeff: upper eyelid area is .6 mm thick
kevin do: is it 1.5mm from top of skin to bottom of the dermal layer??
Greg: u would coag sq not good
Greg: aprox but yes kevin
Greg: males are thicker collagen all over
TF: Sounds like the fluence is too high...
Jeff: deeper is probably better. too deep not good. More ablation, more tightening. Nothing proven.
kevin do: true with males
TF: i would also expect the complication rate to rise with depth, just like it does with chemical peels.
Greg: depth is important with fractional and limits traditional co2, erbium
Jeff: i set it at 17.5 j because that is what Dr. Dover, Dr. Ross, Dr. Weiss and Dr. Goldman set their DeepFx.
Jeff: if you go too deep you get scarring. not good.
Greg: deep scar i go 1.4mm with up to 40% surface area with nice results
Greg: coag is straight down in columns
Greg: too deep ablation is a problem but not coag
TF: Do you think you see a significantly different clinical result if you ablate to only 600 microns versus 1000+ microns?
Greg: deeper ablation increase % of scarring
TF: Yes - exactly. So why do it?
Jeff: i have tried 600 microns. i think damage is to 800 microns. 12.5 j would go 600 microns deep.
Greg: cause scar cascade instead of collagen remodeling
TF: Jeff
Jeff: i think you get better results if you go deeper. If you don't go too deep you get the benefit without the downside.
Jeff: Have not done 12.5.
Greg: kiki if you need some help get my email from jeff
Greg: tf do you know of ablation studies showing depth of collagen that grows back?
TF: Not for fractional co2. i think it's been done for traditional peels and fully ablative co2. It would be an important contribution.
Jeff: Kevin, See Facial Thickness Article at Foxydog1064. This article is very detailed.
kevin do: ok i will. Greg, you will send me one also??
Greg: yes sir kevin
Jeff: Kevin, print the article, read it and let me know what you think. The other chart is very simple.
Jeff: Kiki, Greg and Tom are in Orlando
kevin do: thx, Greg
TF: There's also a handy article in prs - about the relative facial skin thickness as a factor compared to the eyelid thickness. i can look up the citation if you want.
kevin do: sure, Tom. Would be great
Greg: if you could email it would be great. i think collagen regeneration holds all the answers to both modalities
kevin do: very true
Jeff: i have everyone's email except KiKi's. i will forward to all if you send to me. KiKi, my email is
kikimarks: thanks very appreciated!
TF: Which do you all think is more important for skin improvement - drilling a narrow deep hole, or getting some heat energy into the skin around the hole?
Jeff: what is your email?
kikimarks: thanks
kevin do: depending on what the intentions are
Jeff: Tom, great question. Since i have the DeepFx, i have a vested interest in it being deep and narrow.
kevin do: for thermae coag, it is the heat
Greg: depends on goal i will soon present theory both in conjunction will yield the best results and why
TF: Put that aside for a moment, and think scientifically
TF: ok, Greg- lay it on me. This is what fascinates me!
TF: i think it's the heating effect, more than the hole drilling effect.
Jeff: KiKi, you are now on the Fraxel User Group LIst. Welcome. You can join the Medical Aesthetic Practice Association by sending a one dollar bill to me at Cherry Hill Laser
TF: Otherwise, we could just do some percutaneous roller treatments, and call it a day for under $100!
kikimarks: one dollar what a deal
Jeff: Tom, Greg, Kevin and Mitch. i have not received your George Washington yet!
kevin do:
Greg: ablation is negative to long term dermal thickness coag has foreign body reaction and on histology increases dermal depth. ablation is needed for severe rhytids and age related change so co2 first then erbium in colmns for new thicker collagen growth and longevity of dermal layer
kevin do: ok, Jeff
Jeff: The dollar is symbolic. i just want a bunch of one dollar bills from you all.
kevin do: okidoki
Greg: tf u underestimate fractional erbium
Jeff: Greg, i think your statement is theory. We need histology studies.
TF: Greg
Greg: there are for frac erbium thats why i asked if any known for frac co2
Jeff: Kevin, could you stop your eyes from rolling?
Greg: tf the user did not know how to use it i can send u some pics
kevin do: part of my Asian slanted eyes..............LOL
Jeff: Hey guys, i have to go, you all can stay as long as you want. Let me know if you want any emails sent later.
TF: Greg
Jeff: welcome Jason and welcom guest 1. Enjoy. Good to have you.
kevin do: i have to run also, sorry,
Jason S. Lee: Hi, Jeff... Hi everyone....
Jeff: Jason is my buddy from North Jersey. He was at our conference.
kikimarks: thank you everyone
Jeff: See you all. Thanks for coming. We are doing this again in January. Tom and i will be hosting.
Greg: tf i will send you a few of my work. the reps give you crap parameters to use. i gained the info over time with trial and lack of results
TF: Greg
Jason S. Lee: i guess that i came too late....
Jason S. Lee: What did i miss?
Greg: dont get me wrong co2 is avalueble tool and i think the best results will come from a combination
TF: Going back to your theory, it sounds like you would like some long dwell times to get lots of coagulation / heat.
Greg: i have found "large" spot size and depth work the best and not overly aggressive surface area with frac erbium
Greg: the fraxel is a mere catalyst
Greg: co2 results are sooner frac erbium are hurry up and wait for collagen to reach the top for cosmetic results
TF: Sure - but don't you think that the co2, by the nature of the heat transfer, would give us more of the results that we want than the super-precise erbium?
Greg: i do not know for sure that is why i am looking for info on what happens to ablated areas
TF: Lots more basic science to be done - that's for sure!
Greg: good exchange Tom we will pick it later on email or med spa. i will send some pics by email . tell me what u think
TF: ok - goodnight everyone!
End Time: Tue December 16th, 2008 09:57:39 PM