Laser Tissue Laser Tissue Laser Tissue Laser Tissue Interaction Interaction ––Interaction Interaction ––

Technology Technology Technology Technology meets medicinemeets medicinemeets medicinemeets medicine

Aesthetic Laser Aesthetic Laser Aesthetic Laser Aesthetic Laser IndustryIndustryIndustryIndustry

Why the excitement?

Laser Aesthetic Market GrowthLaser Aesthetic Market GrowthLaser Aesthetic Market GrowthLaser Aesthetic Market Growth

71% of patients who have cosmetic

Affordabilitywho have cosmetic surgery earn less than $60,000 per Year*

AcceptanceAll ages and incomes consider cosmetic procedures**

$60,000 per Year

34.8 million light-based equipment procedures performed in 2006***

procedures**

in 2006***

More than $17.24 billion spent in 2006 on aesthetic procedures

Market

3

worldwide***

Sources: * People Magazine, June 2008. **American Society for Aesthetic Plastic Surgery, 2006; Forbes 2006. ***Medical Insights, 2006.

The media is fueling the antiThe media is fueling the anti--aging buzzaging buzzThe media is fueling the antiThe media is fueling the anti--aging buzzaging buzz

More?

The Latest Breakthroughs inReducing the Signs of Aging

Lunchtime Facelifts AreThe Newest Skin Treatment

4

g g g g

Procedure volume for light based skin Procedure volume for light based skin procedures continues to growprocedures continues to growProcedure volume for light based skin Procedure volume for light based skin procedures continues to growprocedures continues to grow

5

Industry InformationIndustry InformationIndustry InformationIndustry Information

Cutera Websitet– www.cutera.com

American Society of Aesthetic Plastic Surgery (ASAPS)(ASAPS)– www.surgery.org

American Academy of Dermatology (AAD)American Academy of Dermatology (AAD)– www.aad.org

American Academy of Ophthalmology (AAO)y p gy ( )– www.aao.org

American Society for Laser Medicine and Surgery

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(ASLMS)– www.aslms.org

Industry CompetitionIndustry CompetitionIndustry CompetitionIndustry Competition

Highly competitive Market

Many competitors in this industry – the following are several major competitors– Cutera– Cutera– Lumenis– Sciton– Syneron– Alma– PalomarPalomar– Cynosure– Candela

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Laser Tissue Laser Tissue Laser Tissue Laser Tissue InteractionInteractionInteractionInteraction

Goal of Lasers in Aesthetics / Goal of Lasers in Aesthetics / MedicineMedicineGoal of Lasers in Aesthetics / Goal of Lasers in Aesthetics / MedicineMedicine

Target specific structures without damaging surrounding tissuesurrounding tissue

Enable less invasive procedures with lower risk of complicationcomplication– Lentigines– Glaucoma

Dermatology and Ophthalmology– Accessibility

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Anatomy of the SkinAnatomy of the Skin

10

Normal Skin HistologyNormal Skin HistologyNormal Skin HistologyNormal Skin Histology

A

BC

Epidermis (5 Primary Layers)– Stratum Corneum at top– Varies in thickness by body

D

part

Dermis (2 Primary Layers)– Papillary Dermis

s

Papillary Dermis– Reticular Dermis– ~2mm thick (varies)

H d i b l D i

Hypodermis below Dermis– Adipose tissue / connective

tissue0 30 h k

11

E – 10-30mm thick

Skin Histology Cont.Skin Histology Cont.Skin Histology Cont.Skin Histology Cont.

12http://www.lab.anhb.uwa.edu.au/mb140/corepages/integumentary/Images/skthick0021he.jpg

http://upload.wikimedia.org/wikipedia/commons/2/20/Skinlayers.png

Mechanisms of Laser InteractionMechanisms of Laser InteractionMechanisms of Laser InteractionMechanisms of Laser Interaction

Photo Chemical– Acne – PDT (Photo Dynamic

Therapy)

Photo Thermal– Vascular (Face and Leg

Veins– Rejuvenation

(Wrinkles, texture, age spots)Resurfacing – Resurfacing

– Hair Removal, etc.

Photo Acoustic

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– Tattoo

Photochemical ActionPhotochemical ActionPhotochemical ActionPhotochemical Action

Light induced chemical reaction

Uses Endogenous or Exogenous ChromophoresUses Endogenous or Exogenous Chromophores

PDT (Photo Dynamic Therapy)Spectral absorption curve determines optimal light – Spectral absorption curve determines optimal light sources

– Typical action is a chemical reaction that releases a free radical oxygenradical oxygen

– Free radical oxygen is highly volatile

Used for Acne (one example)Used for Acne (one example)– P.Acne Bacteria also has an absorption spectrum with a

photochemical reactionP t f th t d t l ft ti t

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– Part of the reason acne tends to clear up after time at the beach

Photo AcousticPhoto AcousticPhoto AcousticPhoto Acoustic

Uses shockwaves to destroy tissue or target structures

Dermatology examples:– Q-switched lasers (~50ns pulse duration)

• Little to no thermal damage• Target ink particles in the upper dermis

– Tattoo Removal Tattoo Removal • Targeting requires wavelengths that absorb in ink colors• Typically requires 3 distinct wavelengths (multiple color

tattoos)tattoos)– YAG, Ruby, KTP

Ophthalmology examples

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– Secondary Cataracts (Q-YAG)– Vision correction (Excimer laser)

Photo ThermalPhoto ThermalPhoto ThermalPhoto Thermal

Most common application of lasers in Dermatology and Ophthalmology (retinal)Dermatology and Ophthalmology (retinal)

Very dependant upon the use of the Theory of Selective PhotothermolysisSelective Photothermolysis

Lasers and Light used typically range from ~400nm to 10,600 nm,

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Theory of Selective PhotothermolysisTheory of Selective PhotothermolysisTheory of Selective PhotothermolysisTheory of Selective Photothermolysis

Photothermolysis (Greek)

– Photo meaning light

– Thermo meaning heat

– Lysis meaning destruction.Lysis meaning destruction.

Translation: Selective PhotothermolysisTranslation: Selective Photothermolysis

– Using light to selectively heat an object, resulting in its destruction, while preserving surrounding tissue

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Goal of PhotoGoal of Photo--Thermal TreatmentsThermal TreatmentsGoal of PhotoGoal of Photo--Thermal TreatmentsThermal Treatments

Regardless of IPL (Intense Pulsed Light) or Laser, the goal is to:to:– Heat the desired targets …

• In the case of hair and vessels, to the point of destruction

ith t i h ti d d t di ti– …without excessive heating, and damage, to surrounding tissue

Selective Photothermolysis requires the right combination of ALL of the following parameters safety and consistently achieve the desired target response.

– Wavelength

– Pulse Duration

– Power

– Spot Size

– Cooling (consistent safety)

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g ( y)

– … all selected to treat a specific patient and condition

Primary Chromophores for Primary Chromophores for Thermal TxThermal TxPrimary Chromophores for Primary Chromophores for Thermal TxThermal Tx

Reduced & Oxy-hemoglobin– vascular lesions

Melanin– pigmented lesions, hair– Primarily in hair and epidermis

• some dermal pigmentsome dermal pigment

Water– General tissue incision excision ablation volumetric General tissue incision, excision, ablation, volumetric

heating– Water exists in every cell

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Light Sources: Lasers and LampsLight Sources: Lasers and LampsLight Sources: Lasers and LampsLight Sources: Lasers and Lamps

LaserLampRange of Wavelengths

Single Wavelength or “Color”

Controllable beam: Can be delivered via fiber

g g

Highly divergent light: Lamp placed near target tissue

Fixed treatment areaAdjustable Spot Sizes

Typically smaller treatment area

Fixed treatment area(based on size of window)

Typically, large treatment areaSkiarea Skin

Lamp

Skin

Laser Handpiece

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Selective PhotothermolysisSelective PhotothermolysisSelective PhotothermolysisSelective Photothermolysis

Desired Response:

1. Sufficient light reaches targetReflection

2. Light absorbed by target (chromophore)

3. Absorbed light converts to heatTarget

Scatter

3. Absorbed light converts to heat

4. Temperature rise in target sufficient toprovide desired effect

Transmission

Absorption

provide desired effect

5. Minimal heating of surrounding tissue

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Key Parameters of Light SourcesKey Parameters of Light SourcesKey Parameters of Light SourcesKey Parameters of Light Sources

Wavelength– What is the absorbing target?

Spot SizeSpot Size– How large and how deep is the

target?

Pulse DurationPulse Duration– What is the size of the target?

FluenceHow much energy is necessary – How much energy is necessary to thermally treat the target?

Cooling– Can enough energy be delivered – Can enough energy be delivered

to the target while protecting the epidermis

Selective Photothermolysis requires

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Selective Photothermolysis requiresthe right combination of parametersfor safe and effective treatments.

Absorption Absorption (Melanin and Hemoglobin)(Melanin and Hemoglobin)Absorption Absorption (Melanin and Hemoglobin)(Melanin and Hemoglobin)

Absorption Spectrum(Logarithmic)

1000

Different Targets are absorbed differently according to wavelength

1000

100

tion

(1/c

m)

HemoglobinMelanin

10Abs

orp

1

500 550 600 650 700 750 800 850 900 950 1000

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500 550 600 650 700 750 800 850 900 950 1000

Wavelength (nm)532 KTP 585 Pulsed Dye 755

Alexandrite694

Ruby

808Diode

1064YAG

940Diode

AbsorptionAbsorption(Melanin, Hemoglobin, and Water)(Melanin, Hemoglobin, and Water)AbsorptionAbsorption(Melanin, Hemoglobin, and Water)(Melanin, Hemoglobin, and Water)

Absorption Spectra

10001000

100

1/cm

)

Hemoglobin

10

Abs

orpt

ion

(

Deoxy HemoglobinWaterMelanin

1500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000

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0.1

Wavelength

Absorption (Water)Absorption (Water)Absorption (Water)Absorption (Water)

Water Absorption by WavelengthWater Absorption by Wavelength

10000

100000

10

100

1000

n (1

/cm

)

0.1

1

10

500 2500 4500 6500 8500 10500

Abs

orpt

ion

0.0001

0.001

0.01

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Wavelength (nm)

Wavelength: Effect on Depth of Wavelength: Effect on Depth of PenetrationPenetrationWavelength: Effect on Depth of Wavelength: Effect on Depth of PenetrationPenetration

Wavelength and depth of penetration (given comparable fluence)– In visible to near IR, depth of penetration increases with wavelength

over the range absorbed by melanin and hemoglobin.over the range absorbed by melanin and hemoglobin.• Shorter wavelengths experience more scattering.• More of the longer wavelengths reach deeper targets.

– Water absorption limits depth of longer wavelengths Wavelength (nm): 532 585 694 755 810 1,064 2790 2940 10600

Laser Type: FD Nd:YAG PDL Ruby Alex Diode Nd:YAG YSGG Erbium CO2

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Visible Infrared

Selection of Spot SizeSelection of Spot SizeSelection of Spot SizeSelection of Spot Size

Smaller spot sizes reduce penetration at a given wavelength, due to increased i f impact of scatter.

Large Spot Sizes for:D T t– Deep Targets

• Hair removal, deep reticular veins

– Large Area Coverage• Epidermal melanin

Large Spot Sizep

• Bulk dermal heating

Small Spot Sizes for:ll h ll– Small, shallow targets

– Where high fluences are required (such as telangiestasia)

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Small Spot Size

Selection of Pulse DurationSelection of Pulse DurationSelection of Pulse DurationSelection of Pulse Duration

Thermal Relaxation Time (TRT)

The time it takes for an object to cool to 50% of h h d d l f lthe temperature achieved immediately after laser

exposure

Thermal relaxation time also affects the time that it takes for an object to heat it takes for an object to heat. – Short thermal relaxation times cool and heat rapidly– Long thermal relaxation times cool and heat slowly

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“The Goal” When Selecting a Pulse Duration (Width)“The Goal” When Selecting a Pulse Duration (Width)“The Goal” When Selecting a Pulse Duration (Width)“The Goal” When Selecting a Pulse Duration (Width)

Utilize a pulse width short enough to confine heating to the desired target without excessive heating to the desired target without excessive heating of adjacent tissue (pulse width shorter than the target’s TRT)

YET

long enough to minimize epidermal heating g g p g(pulse width longer than epidermal TRT)

Nominal pulse duration = ½ TRT to TRT

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Selection of Pulse DurationSelection of Pulse DurationSelection of Pulse DurationSelection of Pulse Duration

Target ObjectLight

OnPulse Duration

Light

TimeOff

Prior to the light exposure, the target is approximately the same temperature as the surrounding tissue.

Light

The target object is heated during the pulse of light.– As light is absorbed, the temperature of the target increases.

As the target becomes hotter than the surrounding tissue As the target becomes hotter than the surrounding tissue, heat will begin to flow from the target to the surrounding skin. (Conduction)

Light

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Selection of Pulse DurationSelection of Pulse DurationSelection of Pulse DurationSelection of Pulse Duration

Small objects in the skin cool off faster than large objects.

– Greater surface area relative to absorption area

Lightarea

– Tea cup vs. large pot of hot water. • Tea cup cools off much faster, but also heats up

much faster• Tea cup has a short thermal relaxation time

Small objects lose heat more rapidly, so optimal pulse duration will be p

relative to a large pot of water

For maximum heating efficiency, heating should occur rapidly enough so that most of the heat is confined to the target. Light

shorter.

the heat is confined to the target.

In order to provide efficient heating of the target, the optimal pulse duration for a small object is usually shorter than for a l bj t

Large objects lose heat more slowly, so pulse duration can be longer.

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large object. be longer.

Commonly Used Laser Pulse Durations Commonly Used Laser Pulse Durations by Applicationby ApplicationCommonly Used Laser Pulse Durations Commonly Used Laser Pulse Durations by Applicationby Application

The pulse durations listed below are short enough to efficiently heat the target but long enough to provide minimal heating of the epidermis

• Microvasculature (capillary loops, blush) Laser Genesis procedure: 0.3 ms

– Estimates (each hair, vein, etc. must be evaluated independently)

• Fine telangiectasia / fine hair: 10-20 ms

• Spider veins / medium hair: 20-30 ms

Reticular leg veins / coarse hair: 40 60 ms• Reticular leg veins / coarse hair: 40-60 ms

• Epidermis: ~5-10msp• Longer than this allows heat to exit the epidermis, reducing risk of burns

• Much shorter prevents the epidermis from heating. Pulses must be less than ~0 4 ms to provide safety

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Pulses must be less than ~0.4 ms to provide safety.

• For bulk heating of dermis with Titan, common pulse durations are 3-5 seconds.

FluenceFluenceFluenceFluence

Fluence = J / cm2

Describes the average energy density of the entire pulse

Fluence is typically the final parameter adjusted, based on clinical response

Fluence is ONLY significant once pulse duration, Fluence is ONLY significant once pulse duration, wavelength and spot size are all set correctly

Multiple systems with equal fluence, but different pulse durations / spot sizes will result in significantly different durations / spot sizes will result in significantly different clinical outcomes

– Can range from safe and efficacious treatments to high rate of complications even though fluence is the same

– Joules is time and power dependent, but the body and selectivity require specific pulse durations for targeting and efficacy

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Fluence, Pulse Duration & Spot Size Fluence, Pulse Duration & Spot Size CombinationsCombinationsFluence, Pulse Duration & Spot Size Fluence, Pulse Duration & Spot Size CombinationsCombinations

Peak Power (Beam Intensity)

1500020 J/cm2 with 5 mm spot – The graph below shows some commonly used Cutera settings and

peak powerpeak power.

– The combination of parameters is what is critical to determine clinical efficacy

– To provide 60 J/cm2 in 10ms (a setting used for hair removal), a10000

To provide 60 J/cm in 10ms (a setting used for hair removal), asystem must have a minimum power shown by the blue line

– With less power, a system can still achieve the required fluence, butonly at a pulse duration that is ineffective for some treatments.

C t ’ l id hi h k bilit id

5000

– Cutera’s lasers provide high peak power capability over a wide range of pulse durations for maximum versatility in parameter selection.

1000

60 J/cm2

with 10 mm spot 60 J/cm2 with

10 mm spot 60 J/cm2 with

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Pulse Duration (in ms)0.3 ms 10 ms

p

20 ms 30 ms 40 ms10 mm spot 60 J/cm2 with 10 mm spot

CoolingCoolingCoolingCooling

The epidermis has melanin– Melanin absorbs most wavelengths creating a competing chromophore– Without cooling, the epidermis will heat while the target heats

Primary types of coolingPrimary types of cooling– Contact Copper, Contact Sapphire, Cryogen Spray, Bulk air cooling

Pre-Cooling– Reduces initial temperature allowing safe temperature rise during Tx

• Copper Sapphire Cryogen Bulk Air• Copper, Sapphire, Cryogen, Bulk Air– Ideally pre-cooling controls the skin temp to achieve the same temperature prior

to every pulse (challenging with bulk air)

Post-Cooling– Extracts heat from tissue to prevent bloom and reduce time at elevated t acts eat o t ssue to p e e t b oo a d educe t e at e e ated

temperature• Copper, Sapphire, Bulk Air

Parallel Cooling– Cools during pulse delivery

• Sapphire– Most significant if pulse duration is long relative to thermal conduction time in

tissue (> ~100ms)• Thermal conduction time in tissue (essentially water with heat extraction from vessels)

increases with the square of distance4ms cools 30um

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– 4ms cools ~30um– 400ms cools ~300um

Lasers in UseLasers in UseLasers in UseLasers in UseLasers in UseLasers in UseLasers in UseLasers in Use

Hair RemovalHair RemovalHair RemovalHair Removal

Target: – Melanin in the hair

Wavelength:Wavelength:– Melanin absorption, low hemoglobin absorption and low water absorption– Low enough melanin absorption to penetrate through the epidermis

(>750nm)

Depth of Treatment– Must penetrate deeply to reach the hair bulb

Problems:– Melanin is the target for Selective Photothermolysis– The epidermis has melanin– Heat must be retained in the hair follicle to treat

Solution to Problem:– Must provide epidermal cooling– Pulse durations >5 ms to protect the epidermis

Pulse durations <100 ms to confine heat to the hair follicle

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– Pulse durations <100 ms to confine heat to the hair follicle– Smaller hairs require shorter pulse durations

Wavelength: Wavelength: Challenge of LightChallenge of Light--Based Hair RemovalBased Hair RemovalWavelength: Wavelength: Challenge of LightChallenge of Light--Based Hair RemovalBased Hair Removal

Melanin is in the epidermis & hair

Laser Light

The more melanin, the more heat

Epidermal safety is

Melanin

Epidermal safety is determined by the amount of melanin & laser parameters

– Skin type & tan– Wavelength – Fluence

Cooling

Targets

– Cooling

Growth Stage of the Hair– Anagen

C t

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– Catagen– Telogen

Anatomy of a Human Hair

Vascular LesionsVascular LesionsVascular LesionsVascular LesionsVascular LesionsVascular LesionsVascular LesionsVascular Lesions

Vascular (Leg and Facial Veins)

Spider Veins (0.5 – 1.5 mm)-blue purple or red-blue, purple or red

Fi S id V iFine Spider Veins (< 0.5 mm) -red

Deep Reticular Veins (1 – 4 mm)-blue

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Vascular TreatmentsVascular TreatmentsVascular TreatmentsVascular Treatments

Target: Hemoglobin

Wavelength– Anything from 500-600– Not between 600-900– Anything from 900-1064

Pulse Duration– Maintain thermal confinement to target vessels (5-60 ms)– Shorter pulse durations for small diameter, longer for large diameter

Problem– Melanin is more highly absorbed than hemoglobin– Larger vessels tend to be deeper– Multiple sized vessels

Solution– Wavelength Selection for high hemoglobin to melanin contrast

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g g g– Cooling to protect the epidermis– Multiple spot sizes to match vessel size and depth

Review of Absorption by Review of Absorption by WavelengthWavelengthReview of Absorption by Review of Absorption by WavelengthWavelength

AbsorptionOptimal vascular results

100

Melanin

Optimal vascular results require sufficient hemoglobin but minimal melanin absorption

10

H l bi

1

Hemoglobin

Important for vascular

Wavelength (nm)

532 1064585 694 810755FD

Nd:YAGRuby Alex Diode Nd:YAG

treatments

42

Nd:YAG Pulsed Dye

Ratio of Hemoglobin to Melanin Ratio of Hemoglobin to Melanin AbsorptionAbsorptionRatio of Hemoglobin to Melanin Ratio of Hemoglobin to Melanin AbsorptionAbsorption

Hemoglobin/Melanin Absorption

Vascular treatment:

• Hemoglobin absorption (blood vessels) is good

• Melanin absorption (epidermis) is bad

• 500 ― 600 nm and 940-1064 nm lasers are best for vascular treatments

Wavelength (nm)

532 1064585 694 810755FD

Nd:YAG Pulsed Ruby Alex Diode Nd:YAG

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Pulsed Dye

Pigmented Pigmented Pigmented Pigmented LesionsLesionsLesionsLesions

Pigmented Lesion TreatmentsPigmented Lesion TreatmentsPigmented Lesion TreatmentsPigmented Lesion Treatments

Target: Melanin

WavelengthWavelength– 500-700 nm (High melanin absorption)

Pulse Duration– Shorter pulses are more aggressive– Longer pulses allow for more gradual heating – safer for darker

skin types and low contrast pigmented lesions

Problem– Cooling reduces the efficacy when treating pigment because the

treatment intentionally heats the epidermisy p

Solution– On-Demand Skin Cooling

Pulse Duration Selection

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– Pulse Duration Selection

Laser GenesisLaser GenesisLaser GenesisLaser GenesisLaser GenesisLaser GenesisLaser GenesisLaser Genesis

Laser GenesisLaser GenesisLaser GenesisLaser Genesis

Target: Hemoglobin in microvasculature (papillary dermis) and bulk heating

Wavelength– 1064 nm Nd:YAG

Pulse Duration– Very short microsecond pulses

Problem– Melanin is more highly absorbed than hemoglobing g

Solution– Microsecond pulses thermally confine heat to targets smaller in size than

the epidermisTh id i i b l l d i h d d – The epidermis is subsequently a large target and is not heated to damage levels making the laser modality safe for all skin types and tanned skin

– High frequency pulsing cumulatively heats the papillary dermis and upper reticular dermis

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Targets for Laser Genesis Targets for Laser Genesis ProcedureProcedureTargets for Laser Genesis Targets for Laser Genesis ProcedureProcedure

Hemoglobin absorption used to heat (not damage) fine upper vascular plexus

Water absorption used to conduct heat into upper dermisdermis

Results in reduction of diffuse redness and

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diffuse redness and stimulation of new collagen production

TitanTitanTitanTitanTitanTitanTitanTitanTreating Skin LaxityTreating Skin Laxity

Skin LaxitySkin LaxitySkin LaxitySkin Laxity

Target: Water

Wavelength1100 1800 nm– 1100-1800 nm

– Wavelengths below 1100 nm absorb in melanin and hemoglobin increasing risk to the epidermis

• Increases variability across patients (limiting efficacy)• Limits skin types safely treated by the device

Pulse Duration– Long pulse durations to provide safe heating for collagen contraction

Problem– Bulk heating does not have thermal confinement yet the treatment needs to

spare the epidermis– There is no “specific” chromophore for the laser to target– Short pulse durations do not localize heating to the depths desired for efficiacy

and can create burnsand can create burns

Solution– Contact cooling over the entire epidermis being treated– Target water absorption and control the amount of absorption to control depth

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– Provide long pulses to heat and maintain volumetric heating

Treating Skin Laxity with TitanTreating Skin Laxity with TitanTreating Skin Laxity with TitanTreating Skin Laxity with Titan

Sustained heating of the dermis

Treatment Objectives– Collagen contraction

L t ti l ti f – Long-term: stimulation of collagen remodeling

– Epidermal protection

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Titan and Water Absorption Titan and Water Absorption Titan and Water Absorption Titan and Water Absorption

Absorption Spectra

Designed to absorb in water yet penetrate deeply for optimal results

1000

Titan Spectrum

100

1/cm

) Water Absorption

10

Abs

orpt

ion

(1

11000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000

52

0.1

Wavelength

Collagen Contraction Collagen Contraction Collagen Contraction Collagen Contraction

Heat disrupts the bonds linking the collagen

Collagen coil “relaxes” resulting in a shorter Collagen coil “relaxes” resulting in a shorter, thicker strand

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NeocollagenesisNeocollagenesisNeocollagenesisNeocollagenesis

New Collagen Growth – Long-termThermally induced wound response– Thermally induced wound response

– Happens gradually (3 – 6 months)– Improves skin texture

Collagen Matrix

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PearlPearlPearlPearlPearlPearlPearlPearlResurfacing LaserResurfacing Laser

complementarycomplementary——not not cannibalisticcannibalistic----productsproductscomplementarycomplementary——not not cannibalisticcannibalistic----productsproducts

• What are we trying to treat?

• How do we treat this best (from a physician and patient ti )?

Full Treatment vs. Fractional Treatment Decision Chartf f

perspective)?

Location Depth

# of Tx

Full Cover

Down

Time Full

# of Tx

Frac.

Down

Time Frac.

Full Coverage or Fractional?

Cutera Solution

<100 Lentigines Epiderm

is

<100 micron

s1-2 3-4

days 4-6 2-3 days

Full – best results in the

fewest treatments

with less days PearlTexture /

Fine lines Epidermis and <100 3-4 3-4 with less days

of total downtime.

Fine lines and wrinkles

is and Papillary Dermis

microns

1-2 3-4 days 4-6 3-4

days

Moderate to l

300 – Fractional Ablative– l

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Deep Wrinkles and Scars

Reticular Dermis

800 micron

s

1 30 days 1-2 5-7

days

AblativeDowntime and

healing are best

Pearl Fractional

Absorption (Water)Absorption (Water)Absorption (Water)Absorption (Water)

Water Absorption by WavelengthWater Absorption by Wavelength

10000

100000

10

100

1000

n (1

/cm

)

0.1

1

10

500 2500 4500 6500 8500 10500

Abs

orpt

ion

0.0001

0.001

0.01

57

Wavelength (nm)

Pearl’s Mechanism of ActionPearl’s Mechanism of ActionPearl’s Mechanism of ActionPearl’s Mechanism of Action

Top Down: • Full Epidermal Treatment p

through Ablation and Coagulation

Ablation: up to 1/3 of the

natural dressing

• Ablation: up to 1/3 of the epidermis ablated during treatment

• Coagulation: Up to 2/3 of the

Ablation removes tissue

residual heatgepidermis coagulated during treatment• Provides a natural dressing

that peels off in 3 5 days

residual heat

that peels off in 3-5 days

Bottom Up: Collagen Stimulation• Collagen Remodeling: Residual

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heat in dermis stimulates new collagen