Christopher Zachary, MBBS, FRCP Experts describe the gold ... · Christopher Zachary, MBBS, FRCP Professor and Chair, Department of Dermatology University of California-Irvine Irvine,

Experts describe the gold standard in

medical and aesthetic laser therapy,

sharing their experiences using clinically-

effective, time-proven technologies.

Expanding the Level of Service and Patient Satisfaction with Gemini®

Efficient Management of Rosacea and Photodamagewith the Gemini Laser

Photorejuvenation in Asian Skin Tones: Role of the Gemini Laser

Gemini for Photorejuvenation: A Cornerstone of the Cosmetic Practice

Targeting Patients’ Aesthetic Goals with the VariLite™

The VariLite for Fundamental Cosmetic Applications

VariLite: A Reliable, Predictable Tool for Vascular andPigmented Lesions

Christopher Zachary, MBBS, FRCPProfessor and ChairDepartment of Dermatology University of California-Irvine

Lasers have without question revolutionized the practiceof dermatology, permitting clinicians to treat conditionsfor which no medical therapies exist or offering resultsthat exceed those of conventional therapeutics. Frommedical conditions like acne and rosacea to cosmetic

rejuvenation, laser systems can address a variety of the mostcommon presentations that bring patients to the dermatolo-gist’s office.

Given their remarkable utility, well-designed and manufac-tured lasers can be a tremendous asset to dermatologists. Yet,often physicians are overwhelmed by the prospect of incorpo-rating laser procedures into practice. Technology is costly, andthere may be a tremendous sense of pressure to attractpatients and, as important, provide treatment that meets theirgoals. There may also be a learning curve, as residency pro-grams currently offer little training in aesthetic dermatology,

Continued on page 3

Expert Contributors

2 | June 2010 | Supplement to Practical Dermatology

William Baugh, MDAssistant Clinical Professor,Western School of Medicine Medical DirectorFull Spectrum Dermatology, Fullerton, CA

Henry H. Lin Chan, MD, PhDHon. Professor, Li Ka Shing Faculty of Medicine,University of Hong Kong Hon. Consultant Dermatologist, Queen Mary Hospital HKSAR Visiting Scientist, Wellman Center for Photomedicine, MassachusettsGeneral Hospital, Harvard Medical School, BostonAdditional titles: USAMBBS (London), FRCP (London,Edinburgh, Glasgow), FHKCP, FHKAM (Medicine)

Jerome Garden, MDProfessor of Clinical Dermatology and Biomedical Engineering,Northwestern University, Chicago, ILPrivate Practice, Chicago, IL

David J. Goldberg, MD, JDClinical Professor of Dermatology, Director of Laser Research, Department ofDermatology, Mount Sinai School of MedicineDirector, Skin Laser & Surgery Specialists of NewYork and New JerseyNew York, NY

C. William Hanke, MD, MPHVisiting Professor of Dermatology, University of Iowa, Carver College of MedicineClinical Professor of Otolaryngology Head andNeck Surgery, Indiana University School of MedicineCarmel, IN

Arielle N. B. Kauvar, MDClinical Associate Professor of Dermatology, NYU School of Medicine Director, New York Laser & Skin CareNew York, NY

E. Victor Ross, MD Director, Scripps Clinic Laser and CosmeticDermatology Center,Carmel Valley, CAPast President of the American Society for LaserMedicine and Surgery (ASLMS)Member of the Board of the American Society ofDermatologic Surgery

Christopher Zachary, MBBS, FRCPProfessor and Chair, Department of DermatologyUniversity of California-Irvine Irvine, CA

and such training was virtually non-existent even 10years ago.

Clinicians seeking to initiate or expand a laser der-matology practice must assess their own interests andskills, patient demand, and the key considerations thatguide device selection and purchase.

Many dermatologists find success by focusing onmedical as well as cosmetic indications, such as acneand rosacea, dyschromia, erythema, telangiectases, andfine wrinkling. With this broader approach, the clinicianis able to keep her or his practice flexible. Many of thebest-respected names in aesthetic medicine will tell youthat a portion of their practice remains focused on tradi-tional medical dermatology. A flexible approach maysuit the clinician’s interest, and it likely reflects the levelof demand for service on the local level.

Selecting a laser system can be a challenge. Key tosuccess is to disregard the hype. Many lasers havecome to the market backed with flashy campaigns tothe public and the medical community, making exag-gerated claims of efficacy and applicability. From a

practice development standpoint, it comes down toweighing the costs—upfront and ongoing/financial andtimewise—against the likely returns. It rarely makessense for a physician to take a gamble on costly newtechnologies with uncertain efficacy and appeal, whentried and true systems can beacquired (often for less).Alternatively, low-pricedsystems can appeal tothe frugal practice,but if a system isunderpriced, itprobably under-performs.

The initialinvestment in asystem purchaseis an importantconsideration, butit doesn’t accountfor everything. Howmuch time do proce-dures take? How manypatients can be treated in aperiod of time? Will time bewasted on set up? Will consumables and maintenancelead to costly bills?

Dermatologists establishing or growing their laserpractices can benefit significantly from the wisdom oftheir experienced and successful colleagues. That’swhat the following pages provide. Some of the best-respected minds in aesthetic dermatology share theirexpertise about two laser systems—Gemini® andVariLite™—from an established market leader in laseraesthetics: IRIDEX. As thousands of physicians havelearned, success in laser medicine is built on a strongfoundation of tried-and-true procedures using tried-and-true laser systems. ●

Supplement to Practical Dermatology | July 2010 | 3

Photoaging, Vascular Lesions, and Pigmentation: The Cornerstone of Any Cosmetic Laser Practice

Contents

Expanding the Level of Service and Patient Satisfaction with Gemini . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Efficient Management of Rosacea and Photodamage with theGemini Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Photorejuvenation in Asian Skin Tones: Role of the Gemini Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Gemini for Photorejuvenation: A Cornerstone of the Cosmetic Practice . . . . . . . . . . . . . . . . . . . . 10

Targeting Patients’ Aesthetic Goals with the VariLite . . . . . . . . . 12

The VariLite for Fundamental Cosmetic Applications . . . . . . . . . 13

VariLite: A Reliable, Predictable Tool for Vascular and PigmentedLesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

“As thousands of

physicians have learned,

success in laser

medicine is built on

a strong foundation of

tried-and-true procedures

using tried-and-true

laser systems.”

Continued from page 1

Photodamage is one of the most common com-plaints among patients presenting for cosmeticlaser therapy. Specifically, patients frequentlyseek treatment for mottled pigmentation,melasma, lentigines, broken capillaries, telang-

iectases, and surface roughness. Despite anecdotalreports of decreased demand in some areas, hairreduction and leg vein removal continue to be com-mon requests in the cosmetic dermatology clinic, aswell.

Various laser and light sources available on the mar-ket offer a range of wavelengths and penetrationdepths necessary to address these various patient con-cerns. Ranging from intense pulsed light sources (IPLs)to fractional resurfacing lasers, the number of treat-ment options has become remarkably wide. Yet to effi-ciently treat a majority of patients presenting withthese common complaints, a single system offeringdual wavelengths and a variety of spot sizes, Gemini(532nm KTP/1064nm Nd:YAG, IRIDEX) may be appro-priate.

Gemini features the long-pulse 532nm KTP laserand the 1064nm Nd:YAG, providing the versatility totarget a variety of chromophores and enabling the cli-nician to provide up to about 80 percent of the treat-ments commonly sought in a typical laser practice.Although other two-in-one systems are available,Gemini is unique in the wavelengths it offers. Theshorter 532nm wavelength effectively targets superfi-cial red and brown lesions (lentigines, broken capillar-ies, mottled pigmentation, melasma), while the longer1064 wavelength effectively targets deeper vessels inthe face and the legs, permits hair reduction, and pro-vides some mild skin tightening.

Ideal Combination SystemsA significant benefit of the Gemini for a cosmetic der-matology practice is that it combines two differentlaser systems into one single device. While the notionof dual-system devices is well-established, the realityis that combinations are not always optimal, or theymay not be as convenient as they seem upon first con-sideration. For example, some systems may pair con-stituents that have similar indications. As such, thecombination system may provide clinical utility forspecific patient presentations but may not permit thepractice to expand the service menu or appeal to awider base of patients. By combining the 532nm andthe 1064nm wavelengths, the Gemini expands thenumber of indications—and likely thenumber of patients—the clini-cian can treat.

With some dual sys-tems, switching fromone wavelength toanother can be atime-consumingand difficultprocess for theoperator. WithGemini, theoperator canquickly andeasily switchfrom one wave-length to another(just a tap on thescreen), allowingthe clinician to easi-

Expanding the Level of Service and Patient Satisfaction with Gemini®

By E. Victor Ross, MDDirector, Scripps Clinic Laser and Cosmetic Dermatology CenterCarmel Valley, CA

“There are a lot of newtechnologies out there, but

one of the tried-and-true tech-nologies is KTP laser and the

long-pulse YAG laser. And theGemini fits the bill for both of

those wavelengths. So in a sensethe Gemini is a time-tested prod-

uct. It has served us well at ourclinic, both at the Navy and at

Scripps Clinic over the last 10years roughly now.”

REEL TALK*


See Dr. Ross discuss his experience with the Gemini laser.

http://dermtube.com/video/dr-ross-discusses-experience-with-gemini-laser/


ly use both systems for a single patient in one briefvisit. An intuitive interface permits the operator to setand change treatment parameters with ease.

When combining systems, manufacturers may beforced to sacrifice certain elements of functionality inorder to merge the two components. This is not thecase with the Gemini®, which provides a wide rangeof spot sizes (42 different sizes), permitting operatorsto customize treatment, whether the goal is full-facerejuvenation or eradication of small, discrete lesionson the face, chest, or hands. With the 10mm spot size,a full-face treatment can be completed in about 10minutes.

Probably the most challenging areas to treat withany laser system are convex and concave areas, suchas the sides of the nose. However, through the selec-tion of appropriate small handpieces and spot sizes,the clinician can effectively treat these areas with theGemini.

The Operator’s PerspectiveBecause of the ease with which the operator canchange the wavelength and spot sizes as well as cus-tomize treatment parameters, it is possible to target arange of cosmetic concerns on various anatomic sites

within a single treatment. For example, it is notuncommon to treat diffuse pigmentation on the faceand chest with the 532nm wavelength using the 10mmspot, then to switch to a 2mm handpiece to addresstelangiectases on the face, and then to use the 1064nmwavelength to target a deep vessel on the face.Alternatively, a treatment session dedicated largely tothe face could culminate with the physician applyingthe laser to the legs to treat a grouping of small, mat-ted vessels.

The Patient’s PerspectiveIn addition to the ease and convenience of treatmentfor the operator, the Gemini is associated with signifi-cant benefits for the patient. Elements essential tooverall patient satisfaction are minimal downtime andlow risk of adverse events. The speed of treatment is abonus for patients, as are rapid results—small telang-iectases disappear in real time. Non-ablative rejuvena-tion is considered a no-downtime procedure, but it isimportant that patients and physicians know what toexpect in the hours after therapy. With full-face treat-ment, patients may actually experience a temporaryincrease in erythema (that may be likened to a mild tomoderate sunburn) that will resolve over several days.There is no weeping, oozing, or peeling associatedwith treatment. However, swelling may occur;swelling can be minimized with icing. Many patients

Before After

This patient is shown before and immediately after treatment with 532nm laser at 10 J/cm2, 24ms, using the 5mm spotwith contact cooling.

* Reel Talk: To see laser specialists discuss their lasersystems, log on to DermTube.com.

Phot

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. Vic

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Ross

, M

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Among the first clinical indications for lasersin dermatology was treatment of vascularlesions, particularly port wine stains, withthe pulsed dye laser (585-595nm). Whileearly pulsed dye laser systems provided

notable efficacy, treatment was associated with pupuralasting as long as two weeks and occasional crusting.With time, refinements in laser technology have madeit possible to treat vascular targets with decreased riskof adverse events and little to no downtime, expandingthe clinical use of laser systems to treat vascularlesions and vascular-mediated diseases, like rosacea.The pulsed dye laser, the 532nm KTP laser, andintense-pulsed light systems (IPL) are available to treatvascular lesions and rosacea. Among these, the Gemini(532nm KTP/1064nm Nd:YAG, IRIDEX) laser system isan attractive option that facilitates efficient, no-down-time treatment. The laser is versatile and easy-to-use,providing convenience for the operator and safe, com-fortable, and reliable results for the patient.

Laser Management of RosaceaRosacea is a significant medical and cosmetic concern,affecting up to 16 million Americans, according to esti-mates from the National Rosacea Society. Among fair-skinned patients, symptoms of rosacea—telangiectases,broken capillaries, diffuse erythema—are nearly ubiqui-tous. Despite the availability of several topical and oraltreatments that can address the inflammatory compo-nents of rosacea, such as papules and pustules, no med-ication effectively addresses diffuse erythema, telangiec-tases, or broken capillaries.

The Gemini is a single system that permits treatmentof both superficial and deep vessels/vascular lesions, dif-fuse erythema, lentigines, and non-vascular pigmentedlesions, with minimal risk and virtually no downtime. To treat individual telangiectases, the 532nm laser can beused with one of various smaller spot sizes to trace outvessels. Typically, a 2-3mm spot size is suitable to treatindividual fine vessels, with resolution seen after two tothree treatment sessions. Gemini offers additional versa-

can usually return to work following Gemini sessions,however it is best to provide treatments a minimum ofseveral days prior to a social engagement.

Broad ApplicationThe Gemini is a versatile and easy to use laser system that can address a majority of the commonpatient requests in a cosmetic dermatology practice.(Probably the only common complaint is an operatorcannot use Gemini for tattoos and resurfacing.) Due

to the ease of system use and the efficiency of treat-ment, the Gemini allows the physician to rapidly treata range of patient complaints, optimizing the level ofcare without reducing the number of patients that canbe seen in a given day. Patients respond favorably tothis high level of physician involvement and are gen-erally pleased with the comfort and results of treat-ment as well as the lack of significant downtime.These are the foundations for patient satisfaction andloyalty. ●

Efficient Management of Rosacea and Photodamagewith the Gemini® Laser

Arielle N. B. Kauvar, MDClinical Associate Professor of Dermatology, NYU School of Medicine Director, New York Laser & Skin CareNew York, NY


tility in the management of rosacea, because the 1064nmNd:YAG laser can be used to target larger, deeper vessels.

More diffuse redness consistent with flushing andblushing will respond to the 532nm laser when used witha larger spot size—usually 10mm—to rapidly treat theentire face. Full-face treatment can take as little as fiveminutes. By offering a variety of spot sizes from 1mm upto 10mm, Gemini® facilitates efficient treatment of specif-ic targets as well as background erythema in a single,brief treatment session.

Patients with a few telangiectases may require onlyone to two laser treatments. Those with moderate tosevere rosacea should see optimal improvement in indi-vidual lesions and overall erythema and skin tone fol-lowing three to five laser treatment sessions. In additionto improvement of their appearance, patients report areduction in rosacea symptoms like flushing andwarmth. Results of treatment are long-lasting but notpermanent; maintenance treatments may be requiredevery six to 12 months.

The 532nm laser provides short-term improvement inerythema, vascular lesions, and overall signs of photo-damage and may have long-term effects on the inflamma-tory component of rosacea. Addressing the underlyingvasculature seems to reduce papules and pustules overthe long-term for many patients.

A First-line OptionLaser therapy for rosacea should not be considered a sec-ond-line intervention. As noted, the 532nm KTP laser tar-gets discrete telengiectases, diffuse erythema, and acne-like lesions. In addition, it targets other signs of photodam-age, such as red and brown spots, that accompanyrosacea. Treatment can also improve overall skin textureand improve the appearance of enlarged pores. Rosacea isa multifactorial disease, and laser therapyis a multi-targeted treatment. Assuch, laser therapy often yieldsclearance for patients whohave been managed unsat-isfactorily with pharma-cologic therapies.Patients previously dis-satisfied with medicalrosacea managementbecome satisfied andloyal laser patients.

Despite the poten-tial limitations of con-ventional rosaceadrugs, they and othertherapies may be incorpo-rated into the overall

Before After

The patient is shown before and one year post two treatments with the Gemini 532nm laser. Treatment was provided with10mm spot, 30ms pulse, fluence 8 J/cm2, followed by 3mm spot, 30ms, 12 J/cm2.

“Treating with the

Gemini is very well

accepted by patients

because both components of

the Gemini, the 1064 and the

532nm, are non-invasive lasers.

So there's really no real down-

time and no recuperation, and

the results are predictable in

our hands, and patients

are very satisfied with

their treatments.”

REEL TALK


Phot

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of A

rielle

N.

B. K

auva

r, M

D

See Dr. Kauvar discuss her experience with the Gemini laser.

http://dermtube.com/video/dr-kauvar-discusses-experience-with-gemini-laser/

Laser rejuvenation in darker skin tones requiresspecial considerations. From a photophysicalstandpoint, epidermal melanin in darker skinpotentially competes with the target chro-mophore of the laser. This optical competition

may inhibit the efficacy of treatment by decreasing theamount of energy deposited to the target. At the sametime, if too much energy is absorbed by the normalmelanin, excessive heating of the non-target tissuemay occur and could produce scarring. To illustratethis point, consider laser hair reduction, where the

“ideal” candidate has dark hair and very light skin.Dark hair selectively absorbs the laser energy whilethe minimally pigmented surrounding skin providesminimal “competition” for absorption.

From a clinical standpoint, clinicians should recog-nize differences in photoaging depending on skin type.Development of wrinkling and laxity in darker skintones may be delayed by one to two decades, com-pared to lighter skinned patients. A “typical”Caucasian individual has a natural SPF of 0, while anAsian patient may have an SPF of about 3—equivalent

Photorejuvenation in Asian Skin Tones: Role of the Gemini® Laser

By Professor Henry ChanHon. Professor, Li Ka Shing Faculty of Medicine,University of Hong Kong Hon. Consultant Dermatologist, Queen Mary Hospital


patient management plan. Standard rosacea therapies canbe used to help uphold results in between maintenancelaser sessions. Depending on the initial presentation, othertreatments that may be used in conjunction with lasertherapy include those that target pigmentation, such askojic acid or hydroquinone, and topical antioxidant-con-taining compounds. All patients must use sunscreens on aconsistent basis to arrest photoaging and prevent furtherdamage from developing.

An Important OptionLaser therapy can be an important option for the manage-ment of rosacea and associated signs of photodamage. Forany dermatology practice that treats a significant propor-tion of rosacea patients, investment in a versatile and effi-cient laser system, such as the Gemini, may be a cost-effective option. In addition to treating rosacea, theGemini can be used for general rejuvenation proceduresand hair removal (See sidebar, at right, for some tips onother common uses for Gemini in my practice), allowingthe practice to offer a range of laser therapies through theaddition of a single system. ●

• The 532nm KTP laser effectively targets brown spots,red scars, and port wine stains (and infantile hemangiomas), and venous lakes.

• KTP can also be used for melasma, provides animprovement in overall skin texture, and may helpreduce the appearance of large pores.

• In addition to full-face treatments, the 532nm KTPlaser can be used to treat the neck and chest for acomprehensive cosmetic effect.

• Although needle sclerotherapy is the gold-standardfor leg veins, fine and matted vessels respond very wellto 532nm laser, making the laser an ideal tool for post-sclerotherapy “clean-up” procedures.

Common Uses for the Geminiin a Rosacea Practice

to almost 10-times the level of protection from UVradiation. This natural level of protection is demon-strated by lower rates of skin cancer in ethnic skin.For example, one study found that Japanese individu-als living in Hawaii had about a 10-time lower inci-dence of skin cancer compared to Caucasians. Despitethis natural SPF, Asian patients develop other commonsigns of photodamage, such as freckles, lentigines, andseborrheic keratoses in their 30s through 50s, afterwhich time wrinkling tends to become a prevalentcomplaint, as well.

Gemini® for LentiginesWe recently demonstrated the benefits of Gemini formanagement of lentigines in Asian skin in a studysponsored by Johnson & Johnson that compared theGemini 532nm long-pulse KTP laser, 595nm long pulsedye laser (LPDL), 755nm LP Alexandrite, and 532nmQS Nd:YAG in the treatment of 40 Chinese patientswith Fitzpatrick skin types III and IV.* Subjects wererandomized 10 to each laser and received one to foursessions provided four to six weeks apart. Subjectswere assessed three to 12 months after their last treat-ment. A majority of subjects (70 percent) treated withthe Gemini had optimal improvement after six to 12months, compared to 50 percent of LPDL patientsafter three months and 60 percent of QS Nd:YAGpatients after three to 12 months. Alexandrite lasertherapy did not provide statistically significantimprovement. There was no risk for post-inflammatoryhyperpigmentation in the Gemini group.

A “typical” protocol for Gemini treatment for pho-torejuvenation in Asian patients begins with a singlepass of the full face using the 532nm wavelength(10mm spot, 20ms pulse, 7-8J/cm2 fluence). This isthen followed by two full-face passes with the 1064nmwavelength (10mm spot, 45ms pulse, 4J/cm2 fluence).Note that when treating the forehead or any otherbony area, the energy is decreased by 10 percent toimprove patient comfort.

Following the initial full-face passes, specific lesionscan be addressed. Just as the large 10mm spot sizeallows for rapid treatment of the full face, the numer-ous small spot sizes available are critical to the safeand effective treatment of discrete lesions. Typically,the 2mm spot size is used (2ms pulse, 12-14J/cm2 flu-ence) to treat individual lesions. As noted, a high con-trast between the target and normal skin is preferred.However, the Asian patient’s normal skin tone may

not contrast significantly with the target lesion.Therefore, a small spot size is important to efficientlydeliver energy directly to the target lesion withoutirradiating the normal surrounding tissue with its com-petitive chromophore of normal melanin.

Other features of Gemini enhance its usefulness totreat lentigines and freckles in Asian skin. To mini-mize the risks of hyperpigmentation and scarring, epi-dermal cooling is critical throughout the laser treat-ment session, and Gemini has a very effective continu-ous cooling system (Parallel Contact Cooling).Additionally, Gemini’s compression handpieceimproves treatment results. Hemoglobin in the bloodis also a target chromophore for the 532nm wave-length. The compression handpiece empties bloodfrom vessels at the target treatment site, thus eliminat-ing this competitive chromophore and ensuring maxi-mum thermal injury to the lentigines.

The Gemini system is a long-pulse laser with a pre-dominantly photothermal effect. This method of actionon a molecular level is considered gentler than the Q-switched laser, which has a photothermal as well asphotoacoustic effect. The latter is associated withhigher rates of inflammation and associated sequelae,including post-inflammatory hyperpigmentation.

Optimal TherapyBecause we have numerous lasers available in ourcenter, we often use multiple lasers for each patient.We believe that this is an ideal way to optimize thebenefits of all the available systemswhile minimizing risks.However, if I could use onlyone laser for rejuvenationin Asian skin, it wouldbe the Gemini. Asnoted, the large10mm spot size facil-itates rapid treat-ment of the fullface, while thesmaller availablespot sizes permitdirect delivery oflaser energy to targetpigmented lesionswhile by-passing com-petitive chromophores.The compression handpiece

“Gemini is an extremely

effective non-ablative skin

rejuvenation laser. And by

combining the 532 KTP lasers

with the long pulse 1064 YAG,

we can achieve non-ablative

skin rejuvenations in terms of

reductions of pigmentations,

fine lines, pore size and

vessel improvement.”

REEL TALK


See Dr. Chan discuss his experience with the Gemini laser.

http://dermtube.com/video/dr-chan-discusses-experience-with-gemini-laser/


CO2 and Er:YAG resurfacing represent thegold standard of facial resurfacing, but theexcellent cosmetic improvement of deeprhytides and extensive photodamage thatthese systems provide comes with the

trade-off of significant downtime and patient discom-fort. Ablative fractional resurfacing has

become a popular alternative forresurfacing with good efficacy

for deep rhytides and photo-damage but with less

downtime and improvedcomfort. A third optionfor photorejuvenationis minimal downtime,non-ablative rejuvena-tion that provides greattolerability and modestimprovement of wrin-

kling and other signs ofphotodamage, including

solar lentigos and facialtelangiectases. Non-ablative

rejuvenation can literally be a“lunchtime procedure,” with mini-

mal patient discomfort and little risk ofadverse events.

Non-ablative rejuvenation can have broad applica-

tions. Whereas ablative resurfacing is typicallyreserved for those patients with the most extensivephotodamage and historically has been considered analternative to surgical facelifts, non-ablative rejuvena-tion is appropriate for rejuvenation in patients withearly signs of photodamage and therefore appeals to avery wide range of patients, beginning with those intheir late 30s. For the majority of photorejuvenationprocedures in my practice, I use the Gemini combina-tion 532nm KTP/1064nm Nd:YAG laser (IRIDEX).

The 532nm component allows for high affinity treat-ments of solar lentigos and facial telangiectasias (twoof the most common changes seen with photodamage).The Gemini has also been shown to stimulate new col-lagen formation within the papillary dermis, and thusa subtle smoothing effect can be appreciated in manycases.

Photorejuvenation ProceduresThe Gemini has many potential advantages over otherlasers. The combination of the two commonly-usedwavelengths makes the device very versatile. TheGemini system is exceptionally easy to operate andcan be used on virtually any skin type. The 1064nmcomponent allows for treatment of dark skin withminimal risk of post-inflammatory hyperpigmentation.

I perform a variety of treatments with the Gemini,some as stand-alone treatments, others in combination.

Gemini® for Photorejuvenation: A Cornerstone of the Cosmetic Practice

By William Baugh, MDAssistant Clinical Professor,Western School of Medicine Medical DirectorFull Spectrum Dermatology, Fullerton, CA

The

Gemini has many

potential advantages

over other lasers. The

combination of the two

commonly-used wave-

lengths makes the device

very versatile. Furthermore,

the Gemini system is excep-

tionally easy to operate

and can be used on vir-

tually any skin type.

and contact cooling improve outcomes and enhancesafety, ensuring that treatment is satisfying for clini-cians as well as patients. ●

*Study sponsored by Johnson & Johnson. Data presented atthe American Society for Laser Medicine and Surgery, April2010. (Abstract No. 136).


Combination photorejuvenation with Venus i™ (2940nmErbium laser, IRIDEX) laser mini-peel is very popularin my practice. In this case, I usually perform the stan-dard Gemini-based photorejuvenation immediately fol-lowed by the addition of a light Erbium laser peel. Theadvantage to this procedure is increased uniformity ofthe treatment, since the entire face will be induced topeel together as opposed to focal spot peeling whichcan occur with purely non-ablative procedures. Oncethe patient stops peeling (usually in about seven daysdepending upon the depth of the peel), increased uni-formity and smoothness of the complexion can beappreciated.

Advantages of Gemini®

The Gemini offers many features that make it prac-tice-friendly and easy to operate. It has a clear sap-phire window through which the laser beam is emit-ted, permitting visualization of anatomic targets. TheGemini cooling method is called "parallel contact cool-ing," which in my experience is the best availablemethod. It provides cooling of targets before, during,and after energy output. The handpiece configurationis simple to use, and the manual touchscreen allowsfor quick and easy treatments. In a healthcare envi-ronment where time is money, this laser facilitatesrapid treatments, enabling the physician to treat more

patients in a given period of time. For the end-user, itis a user-friendly, high-performance system.

There are a variety of potential settings availablewith the Gemini, which is an important feature, as noone protocol fits all patients. With that caveat, a “typi-cal” protocol might be as follows. For photorejuvena-tion with the Gemini laser, I might begin with a 2mmspot size and specifically treat individual lentigos andblood vessels with pulse durations ranging from 6-20ms and fluences ranging from 6-16J, dependingupon what is treated. This is often followed by treat-ing with a 4mm spot size at 30ms, and 12J in a "paint-ing" technique over the face. The Venus i laser then isintroduced, with focal spot treatments over dominantlentigos, followed by a single pass utilizing a 2-7mmspot, 300-600mJ at around 10pps.

Specific customization and sculpting can be per-formed for each patient according to his/her desiresand specific problem areas. Overall, I can completethis entire treatment in about 30 minutes for an aver-age patient. Most patients peel in about a week andthen marvel at the reduction in the appearance of sundamage.

Weighing the OptionsOf course, every device has limitations, and there isno perfect laser. However, I believe the Gemini hassome of the fewest limitations. With the 1064nm com-ponent I am not significantly limited to treating onlylighter skin but can treat virtually any skin type. TheGemini has a large range of spot sizes available at theoperator’s finger tips. Simply dialing a knob allows theoperator to change from a 1mm spot size incremental-ly through to a 5mm spot size with any specific sizeavailable in between. With a quick cord change of thehand piece, I can change to the 10mm spot size in amatter of seconds. The Gemini has the largest spotsize—10mm—available for a 532nm laser.

The Gemini’s greatest strength is its versatility. Aphysician or practice considering purchasing any sys-tem may be most concerned with costs. Systems varyin price; most are expensive, but some low-costoptions are available. I firmly believe you get whatyou pay for. In my experience, the Gemini has beenwell worth the investment. It offers an excellent safetyprofile, predictable results, and reliable performance(repairs, though rarely needed, are provided quickly inyour office by IRIDEX technicians). It has been a cor-nerstone of my cosmetic dermatology practice. ●

The large viewing window allows visualization of target ves-sels treated with the Gemini.

The unique combination of the 532nm and the940nm diode laser in the VariLite LaserSystem (IRIDEX) and its application in eithera single pulse or scan delivery mode providesthe clinician a unique opportunity to treat

individual vessels and pigmented lesions as well as dif-fuse erythema of the face. The distinctive 940nmwavelength is particularly useful for larger vessels,including those with a blue rather than red tone.

Patient-Focused Cosmetic Care There are two basic elements to enhancing success inthe management of patients. First, the clinician mustunderstand the patient's individualized goals and con-cerns—accomplished through an in-depth consultationwith the patient allowing for the necessary amount oftime. Second, the clinician must be able to effectivelymeet those goals. Without doubt, correction of photo-damage is a very common request from patients, withmany patients seeking specifically to remove telang-iectatic vessels and lentigines. Another related com-mon request is treatment for rosacea, where theemphasis again is on vessels in addition to diffuse ery-thema.

The patient's clinical outcome is just one element toconsider, as patients also have practical expectationsabout procedures and recovery. Increasingly, patientswill poorly tolerate significant downtime, intra- orpost-operative pain, or notable side effects, such aspurpura, crusting, scarring, etc.

The VariLite, with the combination of 532nm and940nm wavelengths, allows the clinician to customizetreatment to meet the aesthetic and practical goals ofmany patients. In addition to its efficacy in treating

variously sized facial vessels, background redness, andpigmented lesions, the VariLite is well tolerated andthe post-procedural reactions are temporary andacceptable.

Vessels generally respond well after one to threetreatments. These treatments are typically spaced atleast six weeks apart. Lentigines respond to one to twotreatments. All patients develop some post-proceduralerythema, which can last fromone to four days, whilelentigines become tran-siently darker aftertreatment. Thesechanges gener-ally do notpreventpatientsfromresumingtheir dailyactivities,butpatientsshouldforegotreatmentsbefore a sig-nificant socialengagement.

VariLite LaserSystem Dual wavelength hand-pieces are available with the

Treatment of Facial Vascular and Pigmented Conditionswith the VariLiteTM Laser System

Jerome Garden, MDProfessor of Clinical Dermatology and Biomedical Engineering,Northwestern University, Chicago, IL

“The VariLite system is a

wonderful choice for those people

who want to enter into the laser

arena. Because many, many patients

have vessels which naturally occur as

they grow older or especially those who

develop rosacea later in life, this is

something that many practices have the

need for treatment. And because there

is such ease of use and it is a reliable

system, I always suggest to those who

ask me, what system should I start off

with, I feel that this is definitely

one of them that they should

strongly consider.”

REEL TALK


See Dr. Garden discuss his experience with the VariLite laser.

http://dermtube.com/video/dr-garden-discusses-experience-with-gemini-laser/

VariLite with 0.7, 1.0,1.4, 2.0, and 2.8mmspot sizes, allowingthe operator to traceout fine vessels or

rapidly treat largerareas. The VariLiteoffers theScanLiteXP, an opti-cal scanning hand-piece, for use withthe 532nm wave-length. TheScanLiteXP offersMicroSpot™ preciseenergy delivery in

discrete thermal zones over large treatment areas. Byleaving zones of untreated tissue, this method of ener-gy delivery allows for thermal dissipation, whichreduces the risks of side effects associated with exces-sive thermal damage. The ScanLiteXP is suitable fortreating larger areas.

The VariLite is a user-friendly, portable laser systemthat provides clinicians a great deal of versatility tooptimize and customize the treatment approach toeach individual patient. The distinctive 940nm wave-length—able to treat darker skin types, as it does notcompete with melanin as much as the 532nm wave-length—is effective for the treatment of larger vessels.Combined with the 532nm wavelength, the VariLitelaser system allows the clinician to treat a variety ofthe more common facial photodamage concerns. ●

Rendering of MicroSpot energy deposition made possible with the ScanLiteXP

handpiece.

For many patients and some clinicians, the notion oftreating “vascular lesions” typically calls to mind redtelangiectases, diffuse erythema, and deeper redvessels. Yet, for a number of patients, visible bluevessels can be just as troubling as red ones. Until

recently, the only laser that provided any possible utilityfor the treatment of blue vessels or purpura was the1064nm Nd:YAG laser. However, treatment was associatedwith a significant incidence of pitting. The 940nm wave-length—available in the VariLite (532nm KTP/940nm diodelaser, IRIDEX)—efficiently targets blue vessels with a sig-nificantly decreased incidence of pitting.

Meeting Patient DemandThe combination of the 532nm and 940nm wavelength in

one machine allows the clinician to treata sizable proportion of cosmetic derma-tology patients. The clinical reality isthat a majority of patients presentto the dermatologist for treatmentof both red and blue vessels,lentigines and freckles, diffuseerythema, and dyschromia. Treat-ment for these common presenta-tions can now be provided with asingle laser. VariLite is unique inthe combination of wavelengths

The VariLiteTM for Fundamental Cosmetic Applications

David J. Goldberg, MD, JDClinical Professor of Dermatology, Director of Laser Research, Department ofDermatology, Mount Sinai School of MedicineDirector, Skin Laser & Surgery Specialists of NewYork and New Jersey

Rendering of the 940nm wavelengthdestroying a vessel.


the system offers and,therefore, the diver-

sity of vessels andvascular and pig-mented lesionsit targets.

Treatmentwith theVariLite isassociatedwith a signif-icant level ofpatient com-fort. Patients

do not experi-ence pain or

notable discom-fort during treat-

ment, which can takeas little as five minutes

for discrete vessels. There isno downtime following treatment.

Patients should expect to undergo three treatments, pro-vided about a month apart. Vessels have a tendency toreturn, so patients should also anticipate maintenancetreatments at intervals (up to a year apart).

Meeting Clinicians’ NeedsIn addition to its versatility of applications, the VariLite

offers remarkable convenience for a practice. A variety ofhandpieces and spot sizes are available. The device is smalland lightweight, allowing it to be moved easily from roomto room or even from one practice location to another.

The system is easy to use, with no difficulty associatedwith swapping handpieces or changing spot sizes. Othermodular systems offer different wavelengths, but switch-ing from one wavelength to another can be a challenge.With the VariLite, changing from one wavelength to anoth-er can literally be done with one hand.

A Foundational SystemBy combining into a single system the ability to treat bothred and blue vessels, and pigmented lesions, VariLiteenables a clinician to treat a very wide range of fundamen-tal cosmetic concerns. As such, the 532nm KTP/940nmdiode laser may represent a reasonable option for a clini-cian just starting out in cosmetic laser surgery. The VariLitewill not provide improvement in skin texture and wrin-kling, however, treatment pairs nicely with other popularcosmetic procedures, such as fillers and botulinum toxins.These additional cosmetic services can be provided in thesame visit. The VariLite can provide a basis for building acosmetic practice with ample opportunity to incorporateadditional complementary laser systems, such as one of themany that target texture, as demand grows. The VariLite isan affordable system that offers ample opportunity to makea return on the investment. It meets the demands of cos-metic patients and needs of busy clinicians. ●

“One of the great things

about being in the laser field is

there are new lasers that come out

every day. It makes it a very exciting

arena to be in. The problem is the pop-

ular machine of today, unfortunately,

often becomes the machine that you

don't need a year from now. The VariLite

is tried and true. The wavelengths—532

nanometers, 940 nanometers—they

work. We've had the machine for sev-

eral years. It doesn't break down.

Patients send their friends. It's a

great machine to have in the

office.”

REEL TALK


Like many cosmetic laser surgeons, I treat anumber of patients seeking improvement offine linear vessels and larger vascular lesions.While different laser systems have proven use-ful for these different indications, I had not

been satisfied with the consistency of treatment out-comes for any single device. The dual-wavelength532nm KTP/940nm diode VariLite laser (IRIDEX) isthe first laser that facilitates reliable, effective, andefficient treatment of linear vessels of all sizes.

VariLiteTM: A Reliable, Predictable Tool for Vascular and Pigmented Lesions

C. William Hanke, MD, MPHVisiting Professor of Dermatology, University of Iowa, Carver College of MedicineClinical Professor of Otolaryngology Head andNeck Surgery, Indiana University School of Medicine

See Dr. Goldberg discuss his experience with the VariLite laser.

http://dermtube.com/video/dr-goldberg-discusses-experience-with-gemini-laser/


A Problem SolvedHistorically, the argon laser (488-514nm) was first usedfor the treatment of linear vessels. However, mainte-nance issues arose in our practice, and we had diffi-culty finding replacement parts, leading us to abandonthe argon laser. The 532nm KTP laser is effective forfine linear blood vessels, but some patients had dis-comfort and post-operative crusting. An alternative,the 595nm pulsed dye laser, lacks versatility. In myexperience, PDL and KTP lasers are more effective forsmaller blood vessels than large linear ones.

The VariLiteTM solved our clinical problem by allow-ing us to change wavelengths to effectively treat smalllinear blood vessels as well as larger and deeper ves-sels and other vascular and pigmented targets.Treatment of linear blood vessels with the 940nmwavelength is relatively painless, and post-operativecrusting is non-existent. Results are instantaneous formost sites. Linear blood vessels on the nose, however,may need to be retreated several times, with treat-ments administered at four-week intervals.

With any treatment, patients usually have tempo-rary post-operative erythema, but there is no down-time. Many patients do not require anesthesia,although patients can select topical anesthesia if theywish. For treatment of facial vessels, our most com-mon laser parameters are 1mm spot size, 140 J/cm2.

The VariLite is safe and effective for treatment of

darker skin. We have utilized the VariLite for der-matosis papulosa nigra (DPN) with good results andno complications.

A Safe and Reliable OptionThe VariLite has become afrequently-used tool inour practice for themanagement of ves-sels and pigment-ed lesions.Unlike someolder lasers, itis a reliablesystem,requiring nosignificantmaintenanceor consum-ables. The532nm/940nmsystem has pro-vided consistentresults in patients ofvarious skin tones witha high degree of patientcomfort and satisfaction. ●

The VariLite 940nm

laser (and 532nm KTP dual

system) solved our clinical

problem by allowing us to

effectively treat small linear

blood vessels as well as larger

and deeper vessels and other

vascular and pigmented targets.

Treatment of linear blood

vessels is relatively painless,

and post-operative crusting is

non-existent. Results are

instantaneous for most

sites.

The patient above is shown before (left) and after (right) treatment with the VariLite.

Phot

os c

ourt

esy

of C

. Will

iam

Han

ke,

MD

, M

PH

LT0520

IRIDEX ❘ 1212 Terra Bella Ave. ❘ Mountain View, CA 94043 ❘ 800.388.4747 (US inquiries) ❘ [email protected] (US & int’l inquiries ) ❘ www.iridex.com

IRIDEX, IRIDEX logo, and Gemini are registered trademarks; and VariLite, ScanLiteXP, MicroSpot, Venus i

are trademarks of IRIDEX Corporation.

Documents

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