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        Buyers Guide                The Le a ding C o s metic P ractice Resou rce ™

                                                                                                                       Clinical Roundtable Supplement

Fraxel Evolves Beyond Limits of
Ablative and Non-Ablative Technologies
Editor’s Note: Roy Geronemus, M.D., served as mod-                                       Ron Moy, M.D. – We think there is some tightening, but
                                                                                         it is modest. However, there is more tightening than
erator for this very timely clinical roundtable of experts
                                                                                         with other non-ablative technologies. I suspect colla-
discussing the broad applications of the Fraxel laser                                    gen healing and collagen remodeling occurs. It is anal-
technology developed by Reliant Technologies. Fraxel                                     ogous to the tightening that we observe after resurfac-
                                                                                         ing treatment with the CO2 laser.
treatment, which is based on the novel principle of
high-speed scanning of thousands of microthermal                                         Elizabeth Tanzi, M.D. – I’ve been most impressed with
spots on the skin surface, produces significant clinical                                 the tissue tightening in the perioral area, particularly
                                                                                         the lower nasolabial folds and mesolabial folds. The
results without serious complications.                                                   tightening effect is cumulative with additional treat-
                                                                                         ments. I presume the clinical effect is caused by neo-
                                                                                         collagenesis and collagen remodeling. However, addi-
   Do you notice a tissue tightening effect with                                         tional research is needed to clarify the process.
   Fraxel treatments? If so, what do you think
   causes this effect?                                                                   Jean-Michel Mazer, M.D. – You do not see as rapid a
                                                                                         tightening effect during treatment as with the CO2
                                                                                         laser. With Fraxel, it takes between one and two
Robert Weiss, M.D. – We absolute-                                                        months to begin to notice a visible tissue tightening
ly notice an effect. The effect is                                                       effect.
caused by collagen contraction,
which is induced by the normal                                                           Roy Geronemus, M.D. – There is some tightening in
response to the Fraxel microther-                                                        many patients, primarily in the lower third of the face
mal zones.                                                                               and the neck and upper eyelids. The depth of the
                                                                                         microthermal zones extends fairly deep into the der-
Steven Struck, M.D. – Mostly it is                                                       mis. This creates a healing response that probably
the more youthful patients – 30 to       Robert Weiss, M.D.                              leads to some tightening of the skin.
40 years old – that notice the great-
est effect. At one week follow-up after only one treat-                                  David McDaniel, M.D. – In some patients we’ve
ment, these patients comment that there is tightening of                                 observed a tissue tightening effect. As more months
pores around the nose area and some tightening of fine                                   pass after final Fraxel treatment, we are seeing a little
lines. I think some of the collagen growth is stimulated                                 bit more tightening. This effect is probably related to
via the heat generated by treatment of surrounding skin.                                 new collagen and dermal matrix synthesis.

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       Fraxel Clinical Roundtable

      What are your clinical results when treating acne
      scars and your typical treatment protocol?

    Elizabeth Rostan, M.D. – So far, I have seen truly

                                                                                                                             Photos courtesy of Elizabeth Rostan, M.D.
    amazing results. I have observed both a dermal remod-
    eling effect resulting in decreased depth of scars and a
    resurfacing effect on the edges of the scars. This resur-
    facing effect is particularly important in scars with
    sharp edges, such as ice pick or boxcar-type scars. I’ve
    been very happy with improvement in these geometric
    types of scars because historically they have not
    responded as well to other non-ablative modalities.
    Additionally, the Fraxel laser can improve the pigment
                                                                Before Tx                     After five treatments
    alterations that may occur with acne scars.

    Dr. Weiss – We’ve seen some really great results. We        Dr. Moy – We are also seeing good improvement.
    like to perform about four or five treatments, but at       Results approach the outcomes of the CO2 laser, but
    longer intervals – three to four weeks apart. Our typi-     without the side effects. We schedule five treatments
    cal settings are 8 to 10 J/cm2 with a microthermal zone     with the Fraxel laser normally one month apart.
    density of 250, and anywhere from eight to ten passes.
                                                                Dr. Geronemus – We are doing very well with acne
    Dr. Tanzi – Overall, I’ve been pleased with the treat-      scars. However, they do require multiple treatment
    ment of atrophic facial scars. Fraxel has allowed me to     sessions. A variety of scars,
    treat skin types III and IV, without the high incidence     including broad atrophic scars
                                                                and deeper pitted scars, tend to
    “The Fraxel laser does not cure scars, but                  respond nicely to this treatment.
                                                                The Fraxel laser does not cure
    it works as well as any other treatment I’ve                scars, but it works as well as any
    seen, and probably better, including the                    other treatment I’ve seen, and
                                                                probably better, including the
    ablative technologies.”                                     ablative technologies.
                                                                    Our protocol consists of           Roy Geronemus, M.D.

    of post-inflammatory hypopigmentation that I was see-       approximately five treatment ses-
    ing with ablative resurfacing procedures.                   sions, generally spaced two to three weeks apart. We
         Typically, patients receive two to three consecutive   then wait several months to assess the benefit. There
    monthly Fraxel treatments, depending on the severity        appears to be continued improvement of acne scars for
    of their acne. I then like to evaluate patients two to      a period of time after discontinuing treatment.
    three months later to allow for collagen remodeling. So
    far, these patients have not needed additional treat-       Dr. McDaniel – My typical patient treatment protocol is
    ment. However, my follow-up time is relatively short,       four sessions at 10 to 14 day intervals. Three months
    only out to about six months. Nonetheless, I’ve been        after completing final treatment, the results have been
    observing more consistent improvement with Fraxel           quite nice, but not complete resolution. Some of the old,
    compared to the purely non-ablative lasers.                 deep moon-crater-type acne scars have improved, as
                                                                well as the more superficial pits.

2       Aesthetic Buyers Guide March/April 2005 www.miinews.com
                                                                   Fraxel Clinical Roundtable                                i

                                                                  at least four treatments, normally once a week. We are
  How are your outcomes when treating for melas-                  also experimenting with slightly lower fluences (about
  ma? Which type of patient responds the best?                    6 J/cm2) and focusing the beam more superficially.
  Have you treated Asians?                                        Furthermore, we have doubled the number of
                                                                  microthermal zones from about 2,000 per square cen-
                                                                  timeter to 4,000. We are also doing multiple passes.
Steven Cohen, M.D. – Outcomes                                          The best patient response is in solar damage and
have been good, although patients                                 lentigines with fine lines. I have also done well when
require multiple treatments. We                                   treating Asians, as well as black skin.
are seeing lightening, not neces-
sarily complete elimination. We
are also seeing a favorable                                         Have you treated striae? What effects have you
response in Asians.                                                 observed?

Dr. Weiss – We’ve also seen some        Steven Cohen, M.D.
very good initial response in                                     Dr. Tanzi – I’ve treated mature striae, the white silvery
patients. We expect to use the Fraxel laser a lot for             striae. However, my patients are still in follow-up. So
melasma as the warmer weather approaches. Patients                far I’ve been pleased, but the results are preliminary.
with skin type III to V respond the best. To date, we’ve
treated one Asian patient, with a good response.                  Dr. Mazer – I have also seen some improvement in stri-
                                                                  ae after one month. I was very surprised because I was
Dr. Geronemus – We are doing very well with melas-                quite skeptical at first for this indication. I had tried
ma. We have seen significant improvement. We are                  several other lasers in the past, but none showed
able to treat a wide variety of skin types, including the         results.
darker skin types, which includes Asians. With Asians,
I was concerned that we would observe some increased
pigmentation around the treated area. This has not
been the case, though. Nor have we seen pigmentary                  What clinical results are you achieving for perioral
loss in terms of hypopigmentation.                                  wrinkles?
    For the most part, up to skin type V, we are doing
very nice. Both the epidermal and dermal components
of melasma tend to respond. However, the real issue is            Dr. Tanzi – This is one of the areas that I’ve been most
how long results will remain beneficial. From what we             impressed with. Patients obtain
have seen so far, the benefit appears to be as long last-         much more consistent results
ing as any other treatment I have seen, and probably              than with purely non-ablative
lasts longer.                                                     systems. Depending on wrinkle
                                                                  severity, I usually perform two
Dr. Rostan – I have treated a few patients with mild              consecutive Fraxel treatments,
melasma that have responded well to the Fraxel laser.             then assess the need for addition-
One Asian patient with significant post-inflammatory              al treatment. I normally tell a
hyperpigmentation from acne and a burn responded                  patient to expect anywhere from
very well, with about 70% lightening of both the acne             two to four treatments, depending      Elizabeth Tanzi, M.D.
and large burn scar.                                              on the severity of the wrinkles at
                                                                  baseline. Sessions are typically spaced at three to four
Dr. Struck – I am seeing greater improvement with                 week intervals.
melasma than I expected. Results are good. I schedule

                                                             Aesthetic Buyers Guide March/April 2005 www.miinews.com             3
       Fraxel Clinical Roundtable

    Dr. Weiss – Patients are really pleased with the results      of the wrinkles, at one week intervals. But for really
    they achieve with perioral wrinkles. There is about a         tenacious wrinkles, an additional session may be
    50% improvement after three to five treatments.               required. We treat patients up to approximately 18 to
    Compared to acne, we set our energy levels slightly           20 J/cm2. Most patients, though, are treated at about 12
    lower, at 7 or 8 J/cm2. However, we still treat at a          J/cm2 around the eyelids. The microthermal zone den-
    microthermal zone density of 250, and anywhere from           sity is 250, along with typically four passes.
    six to eight passes.                                              Following a series of treatments, non-surgical
                                                                  patients can expect quite a bit of improvement. We are
    Dr. Rostan – By using higher fluences (14 or 16 J/cm2),       very pleased with what we are seeing. Results appear
    I am able to achieve fairly good improvement, even in         to be approaching a CO2 laser.
    deeper perioral wrinkles. However, the very deep
    rhytides are slow to respond and may require more ses-        Dr. Struck – If you think of CO2 as kind of the gold
    sions than other areas.                                       standard, Fraxel can deliver about 50% of those
                                                                  results. I think that is a fair assessment. The key is not
    Dr. Mazer – I begin to see some results six weeks after       overselling the device. But the Fraxel definitely deliv-
    the first treatment. I believe outcomes will improve          ers. I have high patient satisfaction.
    with the passing of time.

    Dr. Geronemus – The static lines tend to improve.               Do you use the Fraxel laser in combination with
    However, I think you still need to use Botox for those          other therapies? Please explain your favorite com-
    dynamic lines that are the consequence of muscle                bination approaches.

    Dr. McDaniel – Perioral wrinkles                              Dr. Moy – Often, we combine Fraxel with the
    have thus far probably been the                               ThermaCool TC System (Thermage, Inc.) or the Titan
    most challenging part of photo-                               (Cutera) for additional tightening
    aging with the Fraxel laser. We                               of the skin. Botox or facial fillers
    have treated numerous faces,                                  is also a popular combination.
    necks, chests, arms and hands.                                 Our favorite combination is prob-
    The area that seems the slowest to                            ably Fraxel and ThermaCool. I
    respond and is somewhat more                                  don’t think it makes a difference if
    variable is the really deep perioral   David McDaniel, M.D.
                                                                  the ThermaCool is applied before
    lines. In contrast, the fine lines                            or after Fraxel. One session is
    seem to respond pretty quickly.                               often all that is required. When
        We have gone back to some of our first cases and          using facial fillers, however, we       Ron Moy, M.D.
    retreated only the perioral area with a new protocol. I       perform Fraxel first because it
    think originally we did not use enough energy. By             may destroy the fillers by punching tiny holes into
    using the Zimmer cold air machine, we are able to use         them. Fillers also provide immediate improvement,
    higher energy levels. We pre-cool the perioral area for       whereas Fraxel has delayed gratification.
    about one minute before starting treatment. Our new
    settings are 16 to 20 J/cm2 with a microthermal zone          Dr. Geronemus – Besides using Fraxel in conjunction
    density of 125 and three to four passes. As a result, we      with Botox and other filler substances, we frequently
    are seeing more improvement.                                  use other lasers in combination with Fraxel. For exam-
                                                                  ple, significant redness can be treated with other lasers
    Dr. Cohen – In the non-surgical patient, we usually           such as pulsed dye or a 532 nm KTP laser. If a patient
    schedule three to five sessions, depending on the depth       has large discreet blood vessels, the Fraxel laser may

4       Aesthetic Buyers Guide March/April 2005 www.miinews.com
                                                                          Fraxel Clinical Roundtable                              i

                          Photos courtesy of David McDaniel, M.D.

                                                                         improvement of fine lines and wrinkles. It is a great
                                                                         rejuvenation technique.

                                                                         Dr. Rostan – Apart from Botox for dynamic lines, I’ve used
                                                                         cryotherapy for larger seborrheic keratoses that are not
                                                                         completely removed with a series of Fraxel treatments.

                                                                         Dr. McDaniel – All our patients receive GentleWaves
Arm before Tx
                                                                         LED Photomodulation (Light BioScience) both before
                                                                         and after Fraxel treatment. We conducted some split-face
                                                                         and split-hand studies that showed the efficacy of this
                                                                         regimen. On the hands, we observed reduced swelling
                                                                         and redness for two to three days after each treatment.

                                                                         Dr. Weiss – GentleWaves is a popular combination for
                                                                         us as well. By performing GentleWaves immediately
Arm eight weeks after four treatments                                    after Fraxel treatment, patients say they have far less
                                                                         swelling and redness. But I don’t schedule it before-
help some with redness, but it is not going to make a                    hand like Dr. McDaniel. I believe GentleWaves after
very significant difference in individual veins. You                     Fraxel is more important.
need to combine therapies.                                                   We’ve also alternated between Fraxel and IPL pho-
                                                                         torejuvenation. We might start with two IPL sessions
Dr. Mazer – I’ve also seen good                                          spaced one month apart. Then one month later, sched-
results combining the Fraxel laser                                       ule a series of three Fraxel treatments at two to three
with Botox. We use Botox to treat                                        week intervals.
the rhytides of the forehead. Botox
is scheduled one week after Fraxel.                                      Dr. Cohen – I’ve pretreated with Fraxel prior to a sur-
                                                                         gical facelift. We combine Fraxel with oxygen therapy,
Dr. Tanzi – For static and dynam-                                        and after surgery repeat Fraxel. It’s early on, but I
ic wrinkles, Fraxel plus Botox and                                       think we are going to see some really excellent results.
cosmeceuticals works beautifully.       Jean-Michel, Mazer, M.D.
In addition, dermal fillers such as                                      Dr. Struck – By combining Fraxel with a facelift, you
Restylane or other hyaluronic acids can be used for the                  achieve good neck-skin rejuvenation and hand-skin
correction of nasolabial folds.                                          rejuvenation. I also offer photofacial Nd:YAG laser
    But for those patients who have both wrinkling                       treatments in conjunction with Fraxel for broken capil-
and some jowling and lower-face laxity, I like to use the                laries because Fraxel by itself does not do much for red.
ThermaCool, followed by a series of Fraxel treatments.
For the patient who is looking for minimally invasive
rejuvenation – short of a facelift – Fraxel and the                        Can you provide some helpful treatment sugges-
ThermaCool together provides a really nice tightening                      tions for your colleagues who are beginning to
and rejuvenation effect, with minimal patient down-                        use the Fraxel laser?
time. I typically schedule the ThermaCool first, as a
separate session. I then start Fraxel in as soon as a
week later. I tell patients to plan on two to four Fraxel                Dr. Tanzi – Dermasurgeons need to prepare their
treatments. After a series, patients usually notice skin                 patients for multiple treatments for the best results. I
tightening, overall improved skin tone and texture, and                  would also start out with conservative settings because

                                                                    Aesthetic Buyers Guide March/April 2005 www.miinews.com           5
       Fraxel Clinical Roundtable

    there is benefit even in a light manner with very min-        Dr. Struck – You want to make sure that the treatment
    imal downtime. Start slowly, then increase the aggres-        head is in contact with the skin at all times. You don’t
    siveness as your experience increases.                        want to lift the head off the skin while you are doing
                                                                  treatment. Otherwise, the beam will focus on the skin
    Dr. Rostan – I have found that I                              surface, resulting in a slight burn and scratch.
    achieve the best results with a                                   There is also a slight ablative component to good
    more thorough treatment: multi-                               treatment, so patients should plan on being bronzed
    ple passes and higher fluences for                            and amber colored for the first 24 hours. But I have
    deeper rhytides or scars. We have                             patients who attend school soccer games or go out for
    also discovered that perioral                                 dinner the same day.
    mini-blocks and forehead nerve
    blocks significantly help with                                Dr. McDaniel – I think using the Zimmer cold-air
    pain tolerance during treatment.     Elizabeth Rostan, M.D.   machine is very important. We have also made treat-
    Massaging the area immediately                                ment dramatically more comfortable by applying a
    after laser passes helps tremendously, too.                   water-based topical anesthetic prior to the blue dye.
                                                                  This also makes it easier to remove the dye.
    Dr. Moy – I think the main issue from the patient’s
    standpoint is the discomfort. We are also now applying        Dr. Weiss – There is a slight learning curve with the
    more regional pain blocks. We are only treating limited       technology, such as the rate in which you move the
    areas in one session. We are also scheduling treat-           handpiece. There is skill involved.
    ments closer together. Instead of once a month, we are            Moreover, we have also found that topical anes-
    treating every two weeks. Patients appreciate the             thetic alone in most patients is not adequate. We need
    quicker timetable. Results appear just as good.               to use Zimmer forced air cooling as well. Now many
                                                                  patients find Fraxel treatment a very pleasant experi-
    Dr. Geronemus – It is important to understand the tech-       ence. After removing the blue dye, we apply a topical
    nology and to have an appreciation of how the various         anesthetic.
    parameters will affect different conditions in the skin.
    Although the Fraxel laser is relatively simple to use,        Dr. Cohen – I would advise that novices persevere with
    there are ways to optimize outcomes by selecting the          Fraxel technology and not be discouraged if some of the
                                                                  initial results don’t look quite as good. Initially, there is
                                                                  a tendency to treat at lower joules. You should progress
    “I would also start out with conservative                     at your rate, eventually becoming more comfortable
    settings because there is benefit even in a                   treating at higher fluences. This likely will improve
    light manner with very minimal downtime.
    Start slowly, then increase the aggressive-
                                                                    How does the Fraxel laser fit into your practice?
    ness as your experience increases.”                             Who benefits the most?

    appropriate parameters for a particular patient. Forced
    air cooling has also significantly minimized patient          Dr. Weiss – Right now, Fraxel is the number one
    pain, using the Zimmer device or an equivalent device.        requested new procedure at our office. Our Fraxel laser
    By enhancing comfort, we are able to achieve a complete       is used nearly all day. Many patients can benefit from
    and thorough treatment with patient acceptance.               treatment, ranging from pigmentation disorders to
    Additionally, we are able to use higher energy levels.        photo-aging to acne scarring.

6       Aesthetic Buyers Guide March/April 2005 www.miinews.com
                                                               Fraxel Clinical Roundtable                             i

Dr. Rostan – The ability to treat more significant sun        Dr. Geronemus – The Fraxel laser has been widely
damage and rhytides without downtime has filled a             accepted by patients in our practice. We are using it for
huge niche in my practice.                                    a wide variety of conditions: photorejuvenation, acne
                                                              scarring and melasma. Our most popular indication is
Dr. Tanzi – Fraxel has been a boon for the practice and       for overall photorejuvenation, although acne and
the downtime is manageable for patients. People who           melasma patients can be very happy, too.
do not want seven to ten days of raw skin with the                Many patients benefit from treatment, including
ablative procedures find Fraxel treatment highly              the 40 year old who has sun damage, early wrinkling,
desirable. I think patients with mild-to-moderate pho-        dsychromia and/or loss of skin tone. Surgical scars also
todamage and wrinkles benefit the most. Our one               improve. In addition, we are treating actinic keratoses.
Fraxel laser is used daily on multiple patients.              These patients tend to respond quite nicely. We now
    Fraxel is bringing new and returning patients back        have a non-ablative approach for actinic keratoses
to the practice who were waiting for the next greatest        without the downtime and with a cosmetic improve-
                                                              ment. Extensive areas can be treated.
“People who do not want seven to ten
                                                              Dr. Mazer – I use the Fraxel laser two days a week.
days of raw skin with the ablative                            Recently, I treated 12 patients in those two days. The
procedures find Fraxel treatment highly                       technology is without risk and without downtime.
                                                              Patients between the ages of 40 and 55 appear to ben-
desirable.”                                                   efit the most. They don’t want to take time off work like
                                                              with the CO2. I believe that Fraxel represents a new
thing, without having all the downtime associated with        generation of laser. It is very efficacious technology
an ablative procedure. Typically with Fraxel, there are       without risk. Practitioners need to make a choice
three to four days of redness, potentially slight             between risk and efficacy.
swelling, and a little rough skin. But this is manage-
able for the vast majority of patients. Makeup coverage       Dr. Cohen – An office nurse devotes 70% of her time to
is perfectly safe for returning to work the next day.         Fraxel treatments. This will soon be 100%. Two types
                                                              of patients benefit: those who are trying to stay away
Dr. Moy – The Fraxel laser has become a huge part of          from surgery by doing something proactive and those
our practice. We are very busy with it and there is a big     who use Fraxel in concert with a surgical facelift. In
demand for it. In fact, Fraxel has perhaps become the         the latter group, you’re presenting a more global
ideal way of resurfacing the skin now. I believe the          approach to treating facial aging.
patient with moderate wrinkles and moderate blotchi-
ness will be the most pleased with
results. Obviously, really deep                                 What future applications do you envision for Fraxel
wrinkles are harder to treat.                                   technology, based on your experience so far?

Dr. Struck – Recently, I treated 13
patients in one day with the                                  Dr. Moy – Although we are primarily concentrating on
Fraxel laser. And I schedule at                               the face, other surface areas such as the chest, arms
least 20 to 30 people a week. This                            and back may represent growing future applications.
is all through word-of-mouth
advertising. The 30 to 40 year old     Steven Struck, M.D.    Dr. Tanzi – Fraxel is very exciting and versatile
patient with moderate solar dam-                              because some of the other lasers in the past have not
age responds the best. Fraxel can also effectively treat      been able to be used other than on the face. I expect to
the fine lines in these patients.                             see more treatment of stretch marks or striae. There is

                                                         Aesthetic Buyers Guide March/April 2005 www.miinews.com          7
    also the potential to improve body surgical scars. We                         Fraxel and ThermaCool on the same day to achieve
    are just scratching the surface as to what we can do                          more rapid results.
    with the Fraxel laser. It’s a simple concept, but a bril-
    liant one. It has really changed the way we’re thinking                       Dr. McDaniel – Based on what we have seen clinically
    about rejuvenating the skin.                                                  and pathologically, Fraxel probably represents the next
                                                                                  wave in laser skin resurfacing. I believe this is the
    Dr. Cohen – I think combining Fraxel with a variety of                        breakthrough technology that will bridge the gap
    cosmeceuticals might be an exciting realm because I                           between IPL and traditional resurfacing, without any
    see increasing potential for drug delivery, if you will.                      downtime. I don’t believe we’ve had to apply camouflage
        Treatment combinations for facelift surgery should                        makeup on any Fraxel patient. Every single person has
    also be explored. I’m excited about pretreating these                         also shown some degree of visible improvement. This is
    patients with Fraxel because, in theory, you increase                         in stark contrast to most of the non-ablative therapies.
    new blood vessel formation and angioneogenesis. Such
    stimulation may cause these patients to heal faster.                          Dr. Geronemus – With the Fraxel laser, we don’t have
    Patients might also become more secure about under-                           a lot of the issues that we have with standard resur-
    going these procedures. With Fraxel, you can simulta-                         facing, such as wounding and all the risks that are
    neously treat textural changes.                                               associated with a wide post-operative wound. Early on,
                                                                                  we had some occasional scratches of the skin. But we
    Dr. Struck – Lately, with a tummy tuck, we have                               have been able to eliminate that by simply modifying
    focused the beam on the epidermis and significantly                           the technique. The Fraxel laser can also be used off the
    decreased the joules. We have tried to disrupt the epi-                       face quite easily, including the neck, chest, hands and
    dermal barrier, so we can introduce vitamin C and                             arms. Although this is still relatively new technology, a
    hydroquinones and other cosmeceuticals. This would                            database of experience is quickly accumulating which
    be a great way to treat melasma.                                              should lead to even wider acceptance.

    Dr. Weiss – I would like to use Fraxel in combination                         Dr. Cohen – Fraxel technology is a vast departure from
    with photodynamic therapy. It will also probably be                           old resurfacing techniques that basically create a burn.
    used with other tissue tightening technologies like the                       I think we are becoming more precise. That, to me, is
    ThermaCool. In fact, we might be able to perform both                         what science is all about.                            I

       Steven Cohen, M.D.                                David McDaniel, M.D.                            Steven Struck, M.D.
       Associate Clinical Professor of Plastic Surgery   Anti-aging Research Consultant                  Voluntary Clinical Faculty Member
       University of California, San Diego               Virginia Beach, Va.                             in Plastic Surgery
       voice (858) 453-7224                              voice (757) 437-8900                            Stanford University School of Medicine
       fax (858) 453-7268                                fax (757) 437-8200                              voice (650) 562-0587
       email: scohen@sdfaces.com                         email: dhm@lsvcv.com                            fax (650) 562-0581
                                                                                                         email: trishjarvis@aol.com
       Roy Geronemus, M.D.                               Ron Moy, M.D.
       Director of the Laser &                           Clinical Professor of Dermatology               Elizabeth Tanzi, M.D.
       Skin Surgery Center of New York                   University of California, Los Angeles           Co-director of Laser Surgery
       New York City                                     voice (310) 794-7422                            Washington Institute of
       voice (2112) 686-7306                             fax (310) 208-2158                              Dermatologic Laser Surgery
       fax (212) 686-7305                                email: rmoy@ucla.edu                            Washington, D.C.
       email: contact-mail@laserskinsurgery.com                                                          voice (202) 785-8855
                                                         Elizabeth Rostan, M.D.                          fax (202) 785-8858
       Jean-Michel Mazer, M.D.                           Dermatology and Cosmetic                        email: etanzi@skinlaser.net
       Dermatologist in private practice                 Surgery Center of Charlotte
       in Paris, France                                  Charlotte, N.C.                                 Robert Weiss, M.D.
       voice (33) 1 45 23 0448                           voice (704) 333-9113                            Assistant Professor of Dermatology
       fax (33) 1 42 46 6610                             fax (704) 333-9757                              Johns Hopkins University School of Medicine
       email: jmmazer@wanadoo.fr                         email: erostan@carolina.rr.com                  voice (410) 666-3960
                                                                                                         fax (410) 666-3981

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