3Patient ConsultToday’s 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.
4Fitzpatrick Skin Types Skin Type is race dependent and DOES NOT CHANGE.Suntan alters the degree of pigmentation NOT the skin type.
5Fitzpatrick Skin Types Typical Skin Type DefinitionSkin Reaction on over exposure to UV light1Red-blonde Hair/ Blue-green Eyes Very light SkinAlways Burns / Never Tans2Light to Medium Hair / Light to Medium Eyes/ Light to Medium SkinUsually Burns / Seldom Tans3Medium Hair / Medium to Dark Eyes Medium to Olive SkinModerate Burns / Usually Tans4Dark Hair / Dark Eyes Dark Olive to Brown SkinBurns Mildly / Moderate Browning5Dark Hair / Dark Eyes Dark SkinSeldom Burns / Deep Browning6Dark Hair / Dark Eyes Very Dark SkinDoes Not Burn / No Change in Color
6Test SpotsWhen 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.
7F.A.Q. Can cancer survivors be treated? Can children 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.
8F.A.Q. Can patients use “sunless” tanning products? With the 1064 nm wavelength…YES!With the 755 nm wavelength…NO!Can you treat a man’s head?Yes, but make sure he understands that it is permanent and signs an informed consent.
9F.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.
10F.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.
11F.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.
12F.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.This slide is to prompt discussion.
13Contraindications Accutane Sun exposure 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 exposureRecent 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.
14Contraindications Pregnancy Pregnant practitioners should check with their physicianDO NOT TREAT Expecting mothersLiability reasonsHormones are “out of whack”
15Contraindications 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.
16Patient ConsultDuring consultation explain and obtain an INFORMED CONSENTDocument, Document, Document. Remember to chart the treatment procedure i.e. (Energy, Pulse Duration, Spot size, DCD)
17Patient 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.
19Patient 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.
20Permanent Hair Reduction “long-term stable reduction in the number of hairs re-growing after a treatment regime”The FDA allows us this definitionThis is the FDA’s definition of “Permanent Hair Reduction.” Electrolysis is the only methodology that can claim “Permanent Hair Removal” although those who wrote the regulations do not differentiate between the two terms. Setting patient expectations is the key, as “Permanent Hair Reduction” or “Removal” does not mean 100% elimination of hair forever.
21IMPORTANT… Write This Down The GentleMax will NOT treat white, blonde, or gray hairs! Patients should be informed upfront.Red Hair may not respond well.
22Bulb / bulge are critical structures responsible for hair re-growth Hair AnatomyEpidermisSebaceous GlandBulgeFollicleVascular Supply(matrix)BulbStill, these lasers are primarily hair removal lasers and should be purchased on the basis of their hair removal capabilities.So how does laser hair removal work? Current research suggests the two critical areas of the hair follicle that need to be destroyed to demonstrate permanent hair reduction are the the bulge area (located mm deep in the skin) and the bulb/vascular supply area of the hair follicle (located 3-5 mm deep within the skin).Bulb / bulge are critical structures responsible for hair re-growth
23Patient Consult Anagen: Hair is actively growing What are the 3 cycles of hair growth?Anagen: Hair is actively growingCatagen: Hair is dormantTelagen: Hair is falling out
25Patient 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%
26Hair Growth Information Body Area% Anagen Hair% Telogen HairTelogen DurationFollicles density/cm2Depth of follicleAxillae30%70%3 months65mmBrow and Ears10-15%85-90%502-2.5 mmBeard10 weeks5002-4 mmUpper Lip65%35%6 weeks1-2.5 mmScalp80-90%13%3-4 months3503-5 mmTrunk10-20%4 months702-4.5 mmPubic Area20-30%Arms20%80%18 weeks80Legs & Thighs6 months602.5-4 mmBreast3-4.5 mm
27Patient ConsultFor 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.
28Treatment Protocol For Hair Removal Pre-Treatment- Shave hair 24 hours prior to treatment.- If history of cold sores, an antiviral can be prescribed.Post TreatmentAloe vera (with Solarcaine and menthol) gel may be applied.- Sunblock of spf 30 if treated area is exposed to the sun.
29Treatment Protocol NO Plucking – 6 weeks prior or after NO Waxing – 6 weeks prior or afterNO Tweezing – 6 weeks prior or afterPatients should only shave.
30Treatment Protocol3 Things to ALWAYS remember while treating“FLUSH”“PERPENDICULAR”NO MORE THAN 30% OVERLAPSay it with me…..”FLUSH, PERPENDICULAR, NO MORE THAN 30% OVERLAP”
31ComplicationsThere are risks and complications that can occur from laser treatment.Use of conservative DCD settings are important.Complications are rare!BlisterHeat rashBruisingScarringInfectionHyperpigmentationHypopigmentationSwellingWelting
32Treatment of Vascular Lesions Leg Veins & Facial Telangiectasia
33Leg Telangiectasias or “Spider Veins” Sclerotherapy is the GOLD STANDARDGentleMax can clean up what Sclerotherapy does notVeins < 3mm in size are treatable
35Facial Telangiectasia 1064 nm is the preferred wavelength1.5 mm is the preferred spot sizeALWAYS use lower fluence if using the 3mm spot size
36Treating VesselsAlways palpate the vessel to see dynamics of blood flowMost will begin distally and move proximally while treating vesselsTrace vessel as you treat
37Clinical Endpoints Vessel disappears and then comes back (vasospasm) Vessel shrinks in size (vasoconstriction)Vessel contents darkenVessel looks like a cat’s scratch (Wheal and flare)NO OVERLAPPING!
38Special 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 spotsDiabetic patients should have clearance from their primary physiciansYounger “healthy” diabetics should be okay. Older or more ill diabetics may have neuropathy which may inhibit their true tolerance to the treatment. Should a complication arise from the treatment with someone who has diabetic neuropathy, this may lead to delays in treatment of the complication.
39Pre-Treatment Squeaky clean skin! No tanned skin! No Topical anestheticsMeasure vessel sizeTanned skin and high fluences DO NOT MIX……..may scab/blister/hypopigment.
40Post-Treatment Apply pressure to treated area after a few pulses May apply aloe vera gel with Solarcaine and mentholEncourage sun block 30+ spfAvoid activities that cause vasodilatation or increase blood pressure for 3-5 daysInform the vessel area will gradual fade over several weeks.
41Treatment of Pigmented Lesions **Using the 755 nm Wavelength
42Pigmented LesionsA pigmented lesion is caused by an abnormal production of melanin which makes it visible on the skins surface
43Pigmented LesionsThe following benign pigmented lesions can be treated with the GentleLase:Mottled or hyperpigmentationLentiginesEphelides (freckles)Epidermal melasmaCafé’ au lait
44Pigmented Lesions Lentigines: Are small, tan to medium brown lesions that are located on the skins surfaceUsually caused by excessive sun exposureNeed to be differentiated from the potential skin cancers. (i.e., have it checked off by a physician)
50Pigmented LesionsRemember that this will treat Epidermal pigmentation issues.NOT LIKELY TO RESPONDNevi of Oto or ItoMelanocytic NeviShould only be treated by dermatologistBlue Nevi
51Pigmented 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.
52Pigmented LesionsSome factors that could trigger re-occurrence of pigmented lesions are:Hormonal ImbalancePregnancyMedicationsMenopauseSun Exposure
53Pigmented Lesions Potential Side Effects: Infection Discomfort BruisingSwellingScabsHyper-pigmentationHypo-pigmentationInfectionScarringLesion RecurrenceSide effects are quite rare!
54Pigmented Lesions Single Pulse Only! 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 lesionSingle Pulse Only!
55Pigmented 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.
56Pigmented LesionsAvoidance 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.
57Skin Tightening/Wrinkle Reduction/Scarring/Stretch Marks PhotorejuvenationSkin Tightening/Wrinkle Reduction/Scarring/Stretch Marks
58Photorejuvenation 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 treatmentInform patient that they will need 4-6 treatments one month apart
59Special Considerations Using the 1064 nm wavelengthPlease refer to Clinical Bulletin #8 created by Dr. Mark Taylor for treatment photos, parameters and technique.Using the 755 nm wavelengthUse good judgment when selecting the patients skin type. No skin types over lighter skin type IV should be treated.Avoid sun exposure.
60Pre-Treatment Photo-Document Face/Neck should be squeaky clean Shave any facial hairFacial hair may be reduced. Male patients should be informed.No recently tanned skinMay use topical anesthetics
61Post-Treatment Mild erythema is clinical endpoint May apply aloe vera gel with Solarcaine and menthol.Apply and instruct on daily use of spf 30Inform patient fine lines may appear more enhanced for a few days and their face may feel tight and dryEncourage extra moisturizer
85Dynamic 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 gelsThe real difference between lasers is in their ability to protect the skin from “collateral epidermal damage.” GentleLASE’s unique, integrated and patented Dynamic Cooling Device (DCD) selectively cools the epidermis during low and high fluence laser treatments. DCD delivers a short, pre-determined and re-producible burst of non-toxic cryogen spray onto the top of the patient’s skin milliseconds before the laser pulse, independent of operator technique or involvement. This evaporative coolant protects the epidermis without cooling the underlying targeted hair follicle or leg vein, providing maximum protection of the patient’s skin while ensuring maximum thermal energy is delivered to the targeted structure. Furthermore, DCD eliminate the need for cooling gels used with most other laser systems, allowing for increased visibility as well as faster treatment times. All of these DCD advantages further contribute to overall operator ease-of-use.
86Dynamic CoolingPictorially, the laser energy is delivered to the targeted structure through the patient’s epidermis, where any heat being generated from the absorption of that laser energy by competing epidermal melanin is cooled and effectively neutralized by DCD cryogen spray. This importance of skin cooling cannot be overstated, as laser energy is constant The consistency and constancy of your epidermal cooling must match the consistency and constancy of the energy being delivered. Insufficient cooling will result in epidermal damage (burns, hyper & hypo pigmentation) while TOO MUCH skin cooling will actually result in the targeted hair follicle or blood vessel being cooled, therefore reducing treatment efficacy, as is often the case with “contact cooling”.Short spray of cryogen onto skin milliseconds before laser pulseRapid, efficient cooling of epidermal layers onlyDoes not cool subsurface targeted structuresDoes not impede visibility or treatment speed
88Operative ChecklistPut laser in “ready” mode and calibrated to correct energy with proper hand piece“Squeaky Clean” SkinSafety goggles or glasses on clinician and patientNo flammable substances in operating areaHair protected with headbandWritten post-operative instructions given to the patient
89Maintenance Refer to section 6 of the operator’s manual User verification testsPolicy for the cleaning of distance gauges and lenses.
90Laser Safety Checklist Issue PolicyFlammability Fire ExtinguisherWater and Wet ClothsNon-reflective InstrumentsNo alcohol preparationsKeep Laser in “standby” when not in useOcular Safety Appropriate eyewear without reflective metalElectrical Hazards Dedicated outlets for laser useNo extension cordsNo defects in laser cordNo water or other solutions near laserControlled access to laser suite Warning and Danger signs posted on doorsOpaque material on windowsLaser keys locked when not in useLaser plume Smoke evacuator with clean filter and tubingLaser masks