GentleMax

GentleMAX Treatment Applications Hair Removal Venous Lake Wrinkles Telangiectasias Skin Rejuvenation Leg Veins Skin Tightening Age Spots Vascular Lesions Verrucae Pigmented Lesions Cherry Angiomas PFB Keratoses Freckles Melasma Café-au-Lait Striae Diffuse Redness Scars Hemangiomas Poikiloderma Sun Spots Laser Peels

Patient Consult Today’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.

Fitzpatrick Skin Types Skin Type is race dependent and DOES NOT CHANGE. Suntan alters the degree of pigmentation NOT the skin type.

Fitzpatrick Skin Types Typical Skin Type Definition Skin 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

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.

F.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.

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 man’s head? Yes, but make sure he understands that it is permanent and signs an informed consent.

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.

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.

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.

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. This slide is to prompt discussion.

Contraindications 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 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.

Contraindications Pregnancy Pregnant practitioners should check with their physician DO NOT TREAT Expecting mothers Liability reasons Hormones are “out of whack”

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.

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)

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.

GentleMax for the treatment of unwanted hair

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.

Permanent Hair Reduction “long-term stable reduction in the number of hairs re-growing after a treatment regime” The FDA allows us this definition This 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.

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.

Bulb / bulge are critical structures responsible for hair re-growth Hair Anatomy Epidermis Sebaceous Gland Bulge Follicle Vascular Supply (matrix) Bulb Still, 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 1-1.5 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

Patient Consult Anagen: Hair is actively growing What are the 3 cycles of hair growth? Anagen: Hair is actively growing Catagen: Hair is dormant Telagen: Hair is falling out

Hair Biology Anagen Catagen Telogen

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%

Hair Growth Information Body Area % Anagen Hair % Telogen Hair Telogen Duration Follicles density/cm2 Depth of follicle Axillae 30% 70% 3 months 65 3.5-4.5 mm Brow and Ears 10-15% 85-90% 50 2-2.5 mm Beard 10 weeks 500 2-4 mm Upper Lip 65% 35% 6 weeks 1-2.5 mm Scalp 80-90% 13% 3-4 months 350 3-5 mm Trunk 10-20% 4 months 70 2-4.5 mm Pubic Area 20-30% Arms 20% 80% 18 weeks 80 Legs & Thighs 6 months 60 2.5-4 mm Breast 3-4.5 mm

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.

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.

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.

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”

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

Treatment of Vascular Lesions Leg Veins & Facial Telangiectasia

Leg Telangiectasias or “Spider Veins” Sclerotherapy is the GOLD STANDARD GentleMax can clean up what Sclerotherapy does not Veins < 3mm in size are treatable

Leg Veins

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

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

Clinical Endpoints Vessel disappears and then comes back (vasospasm) Vessel shrinks in size (vasoconstriction) Vessel contents darken Vessel looks like a cat’s scratch (Wheal and flare) NO OVERLAPPING!

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 Younger “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.

Pre-Treatment Squeaky clean skin! No tanned skin! No Topical anesthetics Measure vessel size Tanned skin and high fluences DO NOT MIX……..may scab/blister/hypopigment.

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.

Treatment of Pigmented Lesions **Using the 755 nm Wavelength

Pigmented Lesions A pigmented lesion is caused by an abnormal production of melanin which makes it visible on the skins surface

Pigmented Lesions The following benign pigmented lesions can be treated with the GentleLase: Mottled or hyperpigmentation Lentigines Ephelides (freckles) Epidermal melasma Café’ au lait

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)

Lentigines

Pigmented Lesions Ephelides: Also known as freckles Commonly seen on fairer skinned patients

Ephelides

Pigmented Lesions Café’ au lait: Are typically light tan to pale brown patches that are seen at birth or soon after.

Café Au Lait

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

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.

Pigmented Lesions Some factors that could trigger re-occurrence of pigmented lesions are: Hormonal Imbalance Pregnancy Medications Menopause Sun Exposure

Pigmented Lesions Potential Side Effects: Infection Discomfort Bruising Swelling Scabs Hyper-pigmentation Hypo-pigmentation Infection Scarring Lesion Recurrence Side effects are quite rare!

Pigmented 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 lesion Single Pulse Only!

Pigmented Lesions Clinical Endpoint: The lesion will darken within 5 - 10 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.

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.

Skin Tightening/Wrinkle Reduction/Scarring/Stretch Marks Photorejuvenation Skin Tightening/Wrinkle Reduction/Scarring/Stretch Marks

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

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.

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

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

Photorejuvenation

Stretch Marks

Stretch Marks

GentleMAX Interface How to choose wavelength How to adjust parameters Using the Guided Mode

Warning During Warm-Up

Standard Alex Screen

Standard Alex Screen Self Adjust Able to adjust all parameters Fluence (J/cm2) Pulse duration (Candela recommends 3ms exclusively) Able to adjust DCD

Alexandrite Applications

Alex-Guided Mode Selection

Alexandrite - Guided Mode Treatment Selection

Alexandrite - Guided Mode Parameter Selection

Alexandrite - Guided Mode 2 Second Calculation

Alexandrite - Guided Mode Calculated Parameters

Alexandrite - Guided Mode Final Screen

Alexandrite - Guided Mode Warning Screen

Switch to YAG Simply press YAG wavelength

Standard YAG Screen

YAG Applications

YAG Guided Mode

YAG - Guided Mode Treatment Selection

YAG - Guided Mode Parameter Selection

Switch to Alex Simply press Alex wavelength

What is DCD?

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 The 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.

Dynamic Cooling Pictorially, 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 pulse Rapid, efficient cooling of epidermal layers only Does not cool subsurface targeted structures Does not impede visibility or treatment speed

Operation, Maintenance & Safety

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

Maintenance Refer to section 6 of the operator’s manual User verification tests Policy for the cleaning of distance gauges and lenses.

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

Thank You