Rex Moulton-Barrett, MDRex Moulton-Barrett, MD Lisa Derita, RN Lisa Derita, RN Alameda & Brentwood, CAAlameda & Brentwood, CA

ScitonSciton ProfileProfile

HairHair Removal Removal Nd-YAG Nd-YAG 1064 nm 1064 nm VesselVessel Reduction Reduction Nd-Nd-YAG 1064 nm YAG 1064 nm MicroLaserPeel &MicroLaserPeel & Er-YAG Er-YAG 2940 nm2940 nmResurfacingResurfacing Er-YAG 2940 nm Er-YAG 2940 nm

2002

2007

ContourTM

2940nm Er:YAG

ThermaScanTM

1319nm Nd:YAG

ClearScanTM

1064nm Nd:YAG

BBLTM

410-1400nm

Intense Pulsed Light

Personalized For Your Personalized For Your PracticePractice

New Modules

2007Ablative:MLP, resurface

Non-Ablative: acne, vessels Pro-V

Non-ablative: collagen

Ablative: hair, vessels

Non-ablative: collagen

Ablative: hair, vessels, pigment

Non-ablative collagen, acne

ProFractional: micro-ablative

ScitonSciton ProfileProfile

Hair Removal Hair Removal

Hair RemovalHair Removal

• ElectrolysisElectrolysis

• CreamsCreams

• LaserLaser

• MicrowaveMicrowave

Ideally only destroys source Ideally only destroys source

of keratin in hair-bearing skinof keratin in hair-bearing skin

Regrowth and Removal With Regrowth and Removal With

ElectrolysisElectrolysis

Patient: Age, Race, Sex % of Hair Killed

21 yr. old white female21 yr. old white female

30 yr. old black female30 yr. old black female

40 yr. old white male40 yr. old white male

53 yr. old white female53 yr. old white female

41 yr. old white female41 yr. old white female

27 hairs of 46%27 hairs of 46%

35 hairs or 30%35 hairs or 30%

23 hairs or 54%23 hairs or 54%

36 hairs or 38%36 hairs or 38%

30 hairs or 40%30 hairs or 40%

19 hairs or 62%19 hairs or 62%

22 hairs or 56%22 hairs or 56%

17 hairs or 66%17 hairs or 66%

18 hairs or 64%18 hairs or 64%

22 hairs or 56%22 hairs or 56%

Average Percent Killed: Needle = 40%, Tweezer = 60%

Needle Tweezer

Laser Hair ReductionLaser Hair Reduction

Epidermis: 40 - 150 microns

Dermis: 140 - 400 microns

E & D: 180 >/= 550 microns

1.Papilla: neurovascular tuft

2. Bulge: at Erector Pili

3.Matrix cells:>= 2 mm

Anagen> Catogen> Telogen

Target IsolationTarget Isolation

• Can we target over other similar targets?Can we target over other similar targets?

(Can we seek melanin in hair over skin?)(Can we seek melanin in hair over skin?)

Selective Selective PhotothermolysisPhotothermolysis

What is the Target ?What is the Target ?

• EumelaninEumelanin: : brown or black hairbrown or black hair Best absorption of lightBest absorption of light

• PheoPheomelaninmelanin: : red or blond red or blond hairhair

Poor absorptionPoor absorption

• Gray hairGray hair: : pigment-freepigment-freeWhite hair White hair

No absorptionNo absorption

Hair Removal LasersHair Removal Lasers

• Nd:YAGNd:YAG 10641064 nm nm• FlashlampFlashlamp575/ 515-1200575/ 515-1200 nmnm• DiodeDiode 800/810800/810 nmnm• AlexandriteAlexandrite 755755 nmnm• RubyRuby 694694 nmnm

Relative Absorption of Laser Relative Absorption of Laser LightLight & Competing Chromophores & Competing Chromophores

1064nm

FeaturesFeatures

Wavelength: Wavelength: nmnmPower: Power: wattswattsFluence:Fluence: power/cm2power/cm2Spotsize: Spotsize: mmmmOverlap: Overlap: %%Pulsetime: Pulsetime: msmsPulse interval: Pulse interval: ms or ms or freqfreq

Thermal Containment Thermal Containment Time(TCT)Time(TCT) re: The Target re: The Target

• The specific time for energy to The specific time for energy to create reaction without dispersioncreate reaction without dispersion

too short: will not heat to 70 Ctoo short: will not heat to 70 C

too long: complete dispersion too long: complete dispersion coolingcooling

Determined by pulse width=durationDetermined by pulse width=duration

Thermal Relaxation Thermal Relaxation Time(TRT)Time(TRT) RE: avoid injury to competing RE: avoid injury to competing chromophoreschromophores

• Determines the shortest interval between Determines the shortest interval between pulsespulses

• The time for 51% of heat reduction byThe time for 51% of heat reduction bydispersion and dispersion and

coolingcooling• proportional to:proportional to:1. the square of spot size1. the square of spot size2. pulse duration, providing it is > TCT2. pulse duration, providing it is > TCT

Time of the pulseTime of the pulse

• Pulse Pulse durationduration should be longer than should be longer than TCT TCT andand

• Pulse Pulse intervalinterval longer than TRT longer than TRT

• This commonly protects other This commonly protects other components with components with competing competing chromophoreschromophores..

Hair Hand Pieces w/cooling

Temperature in the Region Near Temperature in the Region Near thethe D/E Junction Versus Cooling D/E Junction Versus Cooling TimeTime

0

5

10

15

20

25

30

35

40

0 100 200 300 400

Depth-microns

Temperature

0.1 Sec

0.3

1

3

D/E JunctionSkin Surface

X

x

Skin Cool Technology

0

0.2

0.4

0.6

0.8

1

-6 -4 -2 0 2 4 6

Gaussian

Top Hat

Energy DistributionEnergy Distribution

Comparison of a 10 mm diameter Gaussian spot with a 6.4 mm diameter square (Top Hat) spot. The square distribution delivers useful energy to a larger spot.

When pulses are applied next to one another, the epidermis heated by the first pulse may still be warm when the second pulse arrives. The “double hit” or “pulse stacking” can result in blisters. The problem will vary with the amount of overlap, which is not well controlled with hand delivery. A model of this effect is shown in the next slide.

This is another reason to use a scanner with a large area cooler . With a small fixed window or plate cooler, there is no cooling of the previous spot.

Pulse Stacking: A Problem With Hand Delivery of Pulses

Non-sequential scanNon-sequential scan

• The non-sequential scan extends the time between two The non-sequential scan extends the time between two adjacent pulses to four times the interval of a sequential scan. adjacent pulses to four times the interval of a sequential scan. In combination with the post-pulse cooling, there is adequate In combination with the post-pulse cooling, there is adequate time for epidermal cooling.time for epidermal cooling.

Pulse time?Pulse time?

• Treat hair shaft Treat hair shaft – TCT 6-10 millisecondsTCT 6-10 milliseconds

• Treat hair follicle Treat hair follicle – TCT TCT 18-25 milliseconds18-25 milliseconds, ie > 15 ms, ie > 15 ms– TRT 35-60 milliseconds, ie > 35 msTRT 35-60 milliseconds, ie > 35 ms

Keys for successKeys for success

•Wavelength: >690 nm (>wavelength=depth)Wavelength: >690 nm (>wavelength=depth) (shorter -> competing (shorter -> competing

chromophores)chromophores)

•Spot size: at least 5 millimetersSpot size: at least 5 millimeters

•Pulse time: 18 or > millisecondsPulse time: 18 or > milliseconds

•Pulse interval of 35 or > millisecondsPulse interval of 35 or > milliseconds

When do you treat?When do you treat?

• During Anagen cycleDuring Anagen cycle

• Not during telogenNot during telogen

• Cycle time determined by Cycle time determined by

Richard-Merhag chartRichard-Merhag chart

Richards-MerhagRichards-Merhag

Fitzpatrick TypesFitzpatrick Types

OK: Fitzparick IV/VI: Nd-YAG

non-confluent scanner

>15 ms

Continuous cooling

ConsultationConsultation

• Patient historyPatient history

• Any previous hair methodsAny previous hair methods

• ExpectationsExpectations

• Treatment explanationTreatment explanation

• PhotographsPhotographs

• ConsentConsent

• Periprocedure instructionsPeriprocedure instructions

ContraindicationsContraindications

• PregnancyPregnancy

• Recent sun exposureRecent sun exposure

• Sun tanSun tan

• Suspicious lesionsSuspicious lesions

What about the orbit?What about the orbit?

Before TreatmentBefore Treatment

• Shave 1-3 days before Shave 1-3 days before treatment treatment (stubble) (stubble)

• Avoid other methods for 30 Avoid other methods for 30 daysdays

• SPF 15+ for 4-6 weeksSPF 15+ for 4-6 weeks

• Avoid tanning creamsAvoid tanning creams

• Hydroquinone if necessaryHydroquinone if necessary

Treatment SafetyTreatment Safety

• Test cooling plate, check < 5 CTest cooling plate, check < 5 C

• Test spot: and wait 4 weeksTest spot: and wait 4 weeks

• No overlapNo overlap

• Mark landmarks with red penMark landmarks with red pen

• Protect gums with Al foil if over Protect gums with Al foil if over areaarea

What is the endpoint ?What is the endpoint ?

• Small contact spark/flashSmall contact spark/flash

• Smell of burnt hair Smell of burnt hair

• Perifollicular edemaPerifollicular edema

• Sensation of light sunburnSensation of light sunburn

• One in three hairs extrudeOne in three hairs extrude

Hair ChronologyHair Chronology

• Redness: 4-6 hours after treatmentRedness: 4-6 hours after treatment

• Hair appears to grow for several daysHair appears to grow for several days

• Hair falls out: day 10-14Hair falls out: day 10-14

• Hair reappears, next phase: >3-6 Hair reappears, next phase: >3-6 weeksweeks

• Treat again: >= 6 weeks laterTreat again: >= 6 weeks later

Complications of Laser Hair Complications of Laser Hair RemovalRemoval

• BlisteringBlistering

• HypopigmentationHypopigmentation

• HyperpigmentationHyperpigmentation

• ScarringScarring

ProfileProfile System Features System Features

• Pulse Length: 0.1 to 200 millisecondsPulse Length: 0.1 to 200 milliseconds• Wavelength: 1064nmWavelength: 1064nm• Fluence: Fluence: 20 to 120 Joules/cm 20 to 120 Joules/cm2 2 - Hair - Hair 30 to 400 Joules/cm30 to 400 Joules/cm2 2 - Vascular - Vascular• Contact CoolingContact Cooling: : Pre, During, Post Pre, During, Post • Power Capacity:Power Capacity: 200 watts200 watts• ScanningScanning: : Computer Controlled,Computer Controlled, Non-sequentialNon-sequential

Profile Clinical AdvantagesProfile Clinical Advantages

• Maximum Hair Count Reduction Per TreatmentMaximum Hair Count Reduction Per Treatment

• Treats All Skin TypesTreats All Skin Types

• Minimal PainMinimal Pain

• Designed for Safe OperationDesigned for Safe Operation

• Highest SpeedHighest Speed

• No overlap required: No overlap required: Top hat pattern of injuryTop hat pattern of injury

Summary of Factors Influencing Summary of Factors Influencing SuccessSuccess Versus Versus SafetySafety of Therapy of Therapy

•Appropriate settings: fluence ( > 40 J/cm2 ), Appropriate settings: fluence ( > 40 J/cm2 ),

spot size ( 5mm or greater ), spot size ( 5mm or greater ),

pulse duration ( >18msec ) & pulse duration ( >18msec ) &

pulse interval ( >35msec )pulse interval ( >35msec )

‘ ‘top-hat’ non-sequential top-hat’ non-sequential scanningscanning

•Percentage and density of anagenic hairsPercentage and density of anagenic hairs•Fitzpatrick skin type: competing chromophoreFitzpatrick skin type: competing chromophore•Percentage of Eumelanin versus red, grey or blond Percentage of Eumelanin versus red, grey or blond hairhair•Cooling for at least 3 secondsCooling for at least 3 seconds•Angle of hair follicle ? 1/15 patients, beware of Angle of hair follicle ? 1/15 patients, beware of promisespromises

Patient InstructionsPatient Instructions

PretreatmentPretreatment

• • • Avoid sun exposure 4-6 weeks prior to laserAvoid sun exposure 4-6 weeks prior to laser

• • • Avoid bleaching, plucking, waxing for 4-6 weeksAvoid bleaching, plucking, waxing for 4-6 weeks

• • • Start bleaching regimen 4 weeks prior if tan easily or prone to pigmentationStart bleaching regimen 4 weeks prior if tan easily or prone to pigmentation

• • • Avoid laser interacting medications for at least 10 days prior to laser ( see list )Avoid laser interacting medications for at least 10 days prior to laser ( see list )

At time of LaserAt time of Laser

• • • Prep and shave skin with hibiclensPrep and shave skin with hibiclens

• • • Protect upper teeth with saline soaked gauzeProtect upper teeth with saline soaked gauze

• • • Protective external eye shields is usedProtective external eye shields is used

• • • No oxygen to be used in same room No oxygen to be used in same room

• • • Cooling device is applied to all areas lased: 3 second ruleCooling device is applied to all areas lased: 3 second rule

After LaserAfter Laser

• • • Redness to the skin may last a few hoursRedness to the skin may last a few hours

• • • Then resume bleach cream o: 4% hydroquinone with or without sunscreenThen resume bleach cream o: 4% hydroquinone with or without sunscreen

• • • Makeup may be usedMakeup may be used

• • • Avoid sun exposure for 6 weeksAvoid sun exposure for 6 weeks

• • • Follow-up and or pretreatment in 4-8 weeks Follow-up and or pretreatment in 4-8 weeks

• • • Up to 5 treatments to each site may be necessary for permanent hair removalUp to 5 treatments to each site may be necessary for permanent hair removal

Preoperative Laser Safety Check Preoperative Laser Safety Check ListList

Equipment CheckEquipment Check• marking pen marking pen • pattern sheetpattern sheet• head lighthead light• cooling device to 4 degrees C: no bubblescooling device to 4 degrees C: no bubbles

Procedure:Procedure:• adjust ceiling lightsadjust ceiling lights• confirm laser hazard sign on door light and lock doorconfirm laser hazard sign on door light and lock door• place protective glasses on pt and all in roomplace protective glasses on pt and all in room• gum protection: moist gauze and Al foilgum protection: moist gauze and Al foil• move laser with arm in locked position to correct positionmove laser with arm in locked position to correct position• take key to laser and turn on lasertake key to laser and turn on laser• turn on fan turn on fan • place on standbyplace on standby• dial desired settingsdial desired settings• release arm from lockrelease arm from lock• perform procedure: perform procedure: maintaining>= 3 second skin contact with cooling maintaining>= 3 second skin contact with cooling

devisedevise

Examples of Clinical Examples of Clinical ResultsResults

SiteSite FitzpatrickFitzpatrick HairHair Settings Settings TreatmentsTreatments

Color Quality rate fluence width Color Quality rate fluence width to satisfactionto satisfaction

AxillaAxilla 4 black course 4 black course 5.8 5.8 46 35 546 35 5

Axilla/bikiniAxilla/bikini 3 black course 3 black course 5.9 5.9 45 35 545 35 5

Bikini/thighBikini/thigh 2 2 dk brown course dk brown course 4.44.4 6060 3535 7 7

3.43.4 7878 3535 7 7

BikiniBikini 4 4 black course black course 4.64.6 3636 3535 5 5

AxillaAxilla 5 5 black course black course 7.77.7 3030 3535 5 5

Sample AdvertisementsSample Advertisements

400 % variation in local pricing

Anticipated IncomeAnticipated IncomeIncome:Income: LowLow HighHigh

½ day examples:½ day examples: 95 sideburn 95 sideburn

125 underarms125 underarms

250 thighs250 thighs

250 forearms250 forearms

500 lower legs500 lower legs

n=10 patientsn=10 patients 75 test patch75 test patch

105105 bikini bikini 400400

250 neck250 neck

500 lower legs500 lower legs

75 test patch75 test patch

½ day collection½ day collection $2225$2225 $5000+$5000+

Full day* collectionFull day* collection $3560$3560 $7120+$7120+

* n=16 patients* n=16 patients