Page 3 Patient Consult Todays patient is better educated than ever thanks to the internet. –Before any treatment, ALWAYS sit down with the client to explain the entire process. –They should know exactly what is expected of them. –They should know what to expect as far as outcomes.
Page 4 Fitzpatrick Skin Types Skin Type is race dependent and DOES NOT CHANGE. Suntan alters the degree of pigmentation NOT the skin type.
Page 5 Fitzpatrick Skin Types Skin TypeTypical Skin Type DefinitionSkin Reaction on over exposure to UV light 1 Red-blonde Hair/ Blue-green Eyes Very light Skin Always Burns / Never Tans 2 Light to Medium Hair / Light to Medium Eyes/ Light to Medium Skin Usually Burns / Seldom Tans 3 Medium Hair / Medium to Dark Eyes Medium to Olive Skin Moderate Burns / Usually Tans 4 Dark Hair / Dark Eyes Dark Olive to Brown Skin Burns Mildly / Moderate Browning 5 Dark Hair / Dark Eyes Dark Skin Seldom Burns / Deep Browning 6 Dark Hair / Dark Eyes Very Dark Skin Does Not Burn / No Change in Color
Page 6 Test Spots When skin reaction is a concern, always perform a test spot at a couple of different, lower fluences in an inconspicuous site. Untoward skin responses may occur if there is sun exposure within 1-2 days of treatment.
Page 7 F.A.Q. Can cancer survivors be treated? –Yes, but if there is concern get clearance from their treating physician. Can children be treated? –Yes, but more treatments maybe required later due to hormonal changes.
Page 8 F.A.Q. Can patients use sunless tanning products? –With the 1064 nm wavelength…YES! –With the 755 nm wavelength…NO! Can you treat a mans head? –Yes, but make sure he understands that it is permanent and signs an informed consent.
Page 9 F.A.Q. What areas of the body can you treat? –All areas are treatable with the exception of inside the orbital rim. Can treatments be done over implants? –Yes.
Page 10 F.A.Q. Can treatments be performed over orthopedic hardware? –Yes, however some patients may notice more discomfort in those areas. Pacemakers and other cardiac implants? –Patients with pacemakers may have treatment once cleared by their physician. Treatments are not typically performed directly over implant.
Page 11 F.A.Q. What about braces or other dental work? -Yes. Frequently gauze is placed between the cheek and gum for those patients who experience a tingling sensation on their teeth.
Page 12 F.A.Q. Can treatment be done over injectibles? - Probably not a good idea to treat directly over the injectible. Patients can have laser treatment and injections done...But, only in different areas.
Page 13 Contraindications Accutane –Most physicians recommend that patients should cease usage for at least 6 months. However, many physicians are treating while patient is on medication provided the primary chromophore is NOT water. Sun exposure –Recent tanning is an absolute contraindication. Skin with underlying redness is more susceptible to pigmentation changes. –With the 1064 nm wavelength AVOID the Sun for at least 1 week. –With the 755 nm wavelength AVOID the Sun for two or more weeks.
Page 14 Contraindications Pregnancy –Pregnant practitioners should check with their physician –DO NOT TREAT Expecting mothers –Liability reasons –Hormones are out of whack
Page 15 Contraindications What about Tattoos? –Tattoos and permanent make-up should be avoided. While these wavelengths can sometime be used for the removal of tattoos, the GentleMax has the WRONG pulse duration to safely and effectively remove tattoos. –Areas with permanent make-up should be covered or avoided.
Page 16 Patient Consult During consultation explain and obtain an INFORMED CONSENT Document, Document, Document. Remember to chart the treatment procedure i.e. (Energy, Pulse Duration, Spot size, DCD)
Page 17 Patient Consult Photo-Document –It is important to take pictures of the area to be treated. –Patients will sometimes forget what they looked like at the starting point. –Having before and after photos will allow you to market to potential clients using your own photographs.
Page 18 GentleMax for the treatment of unwanted hair
Page 19 Patient Consult Laser Hair Removal – – Targets the pigment in the hair follicle. –Heat is absorbed and destroys the cells lining the hair follicle specifically around the bulb, bulge, and vascular supply.
Page 20 Permanent Hair Reduction long-term stable reduction in the number of hairs re-growing after a treatment regime The FDA allows us this definition
Page 21 IMPORTANT… Write This Down The GentleMax will NOT treat white, blonde, or gray hairs! Patients should be informed upfront. Red Hair may not respond well.
Page 23 Patient Consult –What are the 3 cycles of hair growth? Anagen: Hair is actively growing Catagen: Hair is dormant Telagen: Hair is falling out
Page 24 Hair Biology AnagenTelogenCatagen
Page 25 Patient Consult When do you re-treat? –Within 7 days of when re-growth is observed. –Different areas have different percentages of hair in the Anagen phase. Face, Axilla, Bikini are approximately 20-35% Trunk and Extremities have approximately 10-20%
Page 26 Hair Growth Information Body Area % Anagen Hair % Telogen HairTelogen DurationFollicles density/cm2Depth of follicle Axillae30%70%3 months mm Brow and Ears10-15%85-90%3 months mm Beard70%30%10 weeks mm Upper Lip65%35%6 weeks mm Scalp80-90%13%3-4 months mm Trunk10-20%80-90%4 months mm Pubic Area20-30%70%3 months mm Arms20%80%18 weeks mm Legs & Thighs20%80%6 months mm Breast30%70%3 months mm
Page 27 Patient Consult For best results, multiple treatments will be needed. For most areas 4-6 treatments are necessary to achieve desired hair clearance. One may need more or less than 6 treatments depending on hair type, previous methods of hair removal, and skin color. Results will vary from patient to patient and to various degrees of efficacy.
Page 28 Treatment Protocol For Hair Removal Pre-Treatment - Shave hair 24 hours prior to treatment. - If history of cold sores, an antiviral can be prescribed. Post Treatment –Aloe vera (with Solarcaine and menthol) gel may be applied. - Sunblock of spf 30 if treated area is exposed to the sun.
Page 29 Treatment Protocol –NO Plucking – 6 weeks prior or after –NO Waxing – 6 weeks prior or after –NO Tweezing – 6 weeks prior or after –Patients should only shave.
Page 30 Treatment Protocol 3 Things to ALWAYS remember while treating –FLUSH –PERPENDICULAR –NO MORE THAN 30% OVERLAP Say it with me…..FLUSH, PERPENDICULAR, NO MORE THAN 30% OVERLAP
Page 31 Complications There are risks and complications that can occur from laser treatment. Use of conservative DCD settings are important. Complications are rare! Blister Heat rash Bruising Scarring Infection Hyperpigmentation Hypopigmentation Swelling Welting
Page 32 Treatment of Vascular Lesions Leg Veins & Facial Telangiectasia
Page 33 Leg Telangiectasias or Spider Veins Sclerotherapy is the GOLD STANDARD GentleMax can clean up what Sclerotherapy does not Veins < 3mm in size are treatable
Page 34 Leg Veins
Page 35 Facial Telangiectasia 1064 nm is the preferred wavelength 1.5 mm is the preferred spot size ALWAYS use lower fluence if using the 3mm spot size
Page 36 Treating Vessels Always palpate the vessel to see dynamics of blood flow Most will begin distally and move proximally while treating vessels Trace vessel as you treat
Page 37 Clinical Endpoints Vessel disappears and then comes back (vasospasm) Vessel shrinks in size (vasoconstriction) Vessel contents darken Vessel looks like a cats scratch (Wheal and flare) NO OVERLAPPING!
Page 38 Special considerations Vitamin E, Aspirin, Ibuprofen or other Blood thinners may increase the likelihood of bruising. Avoid for several days if possible, if not, should do test spots Diabetic patients should have clearance from their primary physicians
Page 39 Pre-Treatment Squeaky clean skin! No tanned skin! No Topical anesthetics Measure vessel size
Page 40 Post-Treatment Apply pressure to treated area after a few pulses May apply aloe vera gel with Solarcaine and menthol Encourage sun block 30+ spf Avoid activities that cause vasodilatation or increase blood pressure for 3-5 days Inform the vessel area will gradual fade over several weeks.
Page 41 Treatment of Pigmented Lesions **Using the 755 nm Wavelength
Page 42 Pigmented Lesions A pigmented lesion is caused by an abnormal production of melanin which makes it visible on the skins surface
Page 43 Pigmented Lesions The following benign pigmented lesions can be treated with the GentleLase: –Mottled or hyperpigmentation –Lentigines –Ephelides (freckles) –Epidermal melasma –Café au lait
Page 44 Pigmented Lesions Lentigines : –Are small, tan to medium brown lesions that are located on the skins surface –Usually caused by excessive sun exposure –Need to be differentiated from the potential skin cancers. (i.e., have it checked off by a physician)
Page 45 Lentigines
Page 46 Pigmented Lesions Ephelides : –Also known as freckles –Commonly seen on fairer skinned patients
Page 47 Ephelides
Page 48 Pigmented Lesions Café au lait: –Are typically light tan to pale brown patches that are seen at birth or soon after.
Page 49 Café Au Lait
Page 50 Pigmented Lesions Remember that this will treat Epidermal pigmentation issues. –NOT LIKELY TO RESPOND Nevi of Oto or Ito Melanocytic Nevi –Should only be treated by dermatologist Blue Nevi
Page 51 Pigmented Lesions Method of Treatment: –Treat only on Skin Types I-III (and Asian skin) –No DCD is used. –May require multiple treatments (2 – 3 TX) –For treatment of smaller lesions a small spot size should be used.
Page 52 Pigmented Lesions Some factors that could trigger re- occurrence of pigmented lesions are: Hormonal Imbalance Pregnancy Medications Menopause Sun Exposure
Page 53 Pigmented Lesions Potential Side Effects: –Discomfort –Bruising –Swelling –Scabs –Hyper-pigmentation –Hypo-pigmentation –Infection –Scarring –Lesion Recurrence Side effects are quite rare!
Page 54 Pigmented Lesions Clinical Endpoint –You may hear a Snap while treating. –The darker the lesion, the louder the Snap –It is not uncommon to see a Frosting of the lesion –Single Pulse Only!
Page 55 Pigmented Lesions Clinical Endpoint: –The lesion will darken within minutes after treatment and may remain so until the lesions forms a micro-crust. Use of an ointment is recommended. Aquaphor, bacitracin or even vaseline can be used to keep area moist until the crust falls off. The skin underneath will be pink. There is a gradual return to normal skin color over time.
Page 56 Pigmented Lesions Avoidance of direct and indirect sun exposure for at least 2 weeks after the laser treatment is advisable. Sunblock of at least SPF 30 on the treated area daily. Sun exposure may contribute to hyperpigmentation in treated area.
Page 57 Photorejuvenation Skin Tightening/Wrinkle Reduction/Scarring/Stretch Marks
Page 58 Photorejuvenation Consult Inform patient that collagen remodeling is a slow process and that they can continue to see improvement up to 6 months after their final treatment Inform patient that they will need 4-6 treatments one month apart
Page 59 Special Considerations Using the 1064 nm wavelength –Please refer to Clinical Bulletin #8 created by Dr. Mark Taylor for treatment photos, parameters and technique. Using the 755 nm wavelength –Use good judgment when selecting the patients skin type. No skin types over lighter skin type IV should be treated. –Avoid sun exposure.
Page 60 Pre-Treatment Photo-Document Face/Neck should be squeaky clean Shave any facial hair –Facial hair may be reduced. Male patients should be informed. No recently tanned skin May use topical anesthetics
Page 61 Post-Treatment Mild erythema is clinical endpoint May apply aloe vera gel with Solarcaine and menthol. Apply and instruct on daily use of spf 30 Inform patient fine lines may appear more enhanced for a few days and their face may feel tight and dry Encourage extra moisturizer
Page 62 Photorejuvenation
Page 63 Stretch Marks
Page 64 Stretch Marks
Page 65 GentleMAX Interface How to choose wavelength How to adjust parameters Using the Guided Mode
Page 66 Warning During Warm-Up
Page 67 Standard Alex Screen
Page 68 Standard Alex Screen Self Adjust Able to adjust all parameters –Fluence (J/cm2) –Pulse duration (Candela recommends 3ms exclusively) –Able to adjust DCD
Page 77 Switch to YAG Simply press YAG wavelength
Page 78 Standard YAG Screen
Page 79 YAG Applications
Page 80 YAG Guided Mode
Page 81 YAG - Guided Mode Treatment Selection
Page 82 YAG - Guided Mode Parameter Selection
Page 83 Switch to Alex Simply press Alex wavelength
Page 84 What is DCD?
Page 85 Dynamic Cooling Device Cryogen spray milliseconds before laser pulse -Cools / protects epidermis from thermal damage -Protects darker skin types -Good visibility / does not slow treatment -No messy gels
Page 86 Dynamic Cooling Short spray of cryogen onto skin milliseconds before laser pulse Rapid, efficient cooling of epidermal layers only Does not cool subsurface targeted structures Does not impede visibility or treatment speed
Page 87 Operation, Maintenance & Safety
Page 88 Operative Checklist –Put laser in ready mode and calibrated to correct energy with proper hand piece –Squeaky Clean Skin –Safety goggles or glasses on clinician and patient –No flammable substances in operating area –Hair protected with headband –Written post-operative instructions given to the patient
Page 89 Maintenance Refer to section 6 of the operators manual User verification tests Policy for the cleaning of distance gauges and lenses.
Page 90 Laser Safety Checklist Issue Policy Flammability Fire Extinguisher Water and Wet Cloths Non-reflective Instruments No alcohol preparations Keep Laser in standby when not in use Ocular Safety Appropriate eyewear without reflective metal Electrical Hazards Dedicated outlets for laser use No extension cords No defects in laser cord No water or other solutions near laser Controlled access to laser suite Warning and Danger signs posted on doors Opaque material on windows Laser keys locked when not in use Laser plume Smoke evacuator with clean filter and tubing Laser masks