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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).