Experts describe the gold standard in medical and aesthetic by rtu13707

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									            Christopher Zachary, MBBS, FRCP                          Experts describe the gold standard in
            Professor and Chair
            Department of Dermatology                                medical and aesthetic laser therapy,
            University of California-Irvine                          sharing their experiences using clinically-
                                                                     effective, time-proven technologies.




L
         asers have without question revolutionized the practice     Expanding the Level of Service and
         of dermatology, permitting clinicians to treat conditions   Patient Satisfaction with Gemini®
         for which no medical therapies exist or offering results    Efficient Management of Rosacea and Photodamage
         that exceed those of conventional therapeutics. From        with the Gemini Laser
         medical conditions like acne and rosacea to cosmetic
rejuvenation, laser systems can address a variety of the most        Photorejuvenation in Asian Skin Tones:
common presentations that bring patients to the dermatolo-           Role of the Gemini Laser
gist’s office.
                                                                     Gemini for Photorejuvenation:
   Given their remarkable utility, well-designed and manufac-        A Cornerstone of the Cosmetic Practice
tured lasers can be a tremendous asset to dermatologists. Yet,
often physicians are overwhelmed by the prospect of incorpo-         Targeting Patients’ Aesthetic Goals with the VariLite™
rating laser procedures into practice. Technology is costly, and
                                                                     The VariLite for Fundamental Cosmetic Applications
there may be a tremendous sense of pressure to attract
patients and, as important, provide treatment that meets their       VariLite: A Reliable, Predictable Tool for Vascular and
goals. There may also be a learning curve, as residency pro-         Pigmented Lesions
grams currently offer little training in aesthetic dermatology,

                                              Continued on page 3
Expert Contributors
              William Baugh, MD                                    C. William Hanke, MD, MPH
              Assistant Clinical Professor,                        Visiting Professor of Dermatology,
              Western School of Medicine                           University of Iowa, Carver College of Medicine
              Medical Director                                     Clinical Professor of Otolaryngology Head and
              Full Spectrum Dermatology,                           Neck Surgery,
              Fullerton, CA                                        Indiana University School of Medicine
                                                                   Carmel, IN




              Henry H. Lin Chan, MD, PhD                           Arielle N. B. Kauvar, MD
              Hon. Professor, Li Ka Shing Faculty of Medicine,     Clinical Associate Professor of Dermatology,
              University of Hong Kong                              NYU School of Medicine
              Hon. Consultant Dermatologist,                       Director, New York Laser & Skin Care
              Queen Mary Hospital                                  New York, NY
              HKSAR Visiting Scientist,
              Wellman Center for Photomedicine, Massachusetts
              General Hospital, Harvard Medical School, Boston
              Additional titles: USAMBBS (London), FRCP (London,
              Edinburgh, Glasgow), FHKCP, FHKAM (Medicine)



              Jerome Garden, MD                                    E. Victor Ross, MD
              Professor of Clinical Dermatology                    Director, Scripps Clinic Laser and Cosmetic
              and Biomedical Engineering,                          Dermatology Center,
              Northwestern University, Chicago, IL                 Carmel Valley, CA
              Private Practice, Chicago, IL                        Past President of the American Society for Laser
                                                                   Medicine and Surgery (ASLMS)
                                                                   Member of the Board of the American Society of
                                                                   Dermatologic Surgery




              David J. Goldberg, MD, JD                            Christopher Zachary, MBBS, FRCP
              Clinical Professor of Dermatology,                   Professor and Chair, Department of Dermatology
              Director of Laser Research, Department of            University of California-Irvine
              Dermatology, Mount Sinai School of Medicine          Irvine, CA
              Director, Skin Laser & Surgery Specialists of New
              York and New Jersey
              New York, NY




2 | June 2010 | Supplement to Practical Dermatology
Photoaging, Vascular Lesions, and Pigmentation:
The Cornerstone of Any Cosmetic Laser Practice
Continued from page 1



and such training was virtually non-existent even 10                                                        practice development standpoint, it comes down to
years ago.                                                                                                  weighing the costs—upfront and ongoing/financial and
   Clinicians seeking to initiate or expand a laser der-                                                    timewise—against the likely returns. It rarely makes
matology practice must assess their own interests and                                                       sense for a physician to take a gamble on costly new
skills, patient demand, and the key considerations that                                                     technologies with uncertain efficacy and appeal, when
guide device selection and purchase.                                                                        tried and true systems can be
    Many dermatologists find success by focusing on                                                         acquired (often for less).
medical as well as cosmetic indications, such as acne                                                       Alternatively, low-priced
and rosacea, dyschromia, erythema, telangiectases, and                                                      systems can appeal to
fine wrinkling. With this broader approach, the clinician                                                   the frugal practice,
                                                                                                                                                    “As thousands of
is able to keep her or his practice flexible. Many of the                                                   but if a system is
best-respected names in aesthetic medicine will tell you                                                    underpriced, it                  physicians have learned,
that a portion of their practice remains focused on tradi-                                                  probably under-                           success in laser
tional medical dermatology. A flexible approach may                                                         performs.
                                                                                                                                                  medicine is built on
suit the clinician’s interest, and it likely reflects the level                                                The initial
of demand for service on the local level.                                                                   investment in a                   a strong foundation of
   Selecting a laser system can be a challenge. Key to                                                      system purchase                tried-and-true procedures
success is to disregard the hype. Many lasers have                                                          is an important
                                                                                                                                                 using tried-and-true
come to the market backed with flashy campaigns to                                                          consideration, but
the public and the medical community, making exag-                                                          it doesn’t account                         laser systems.”
gerated claims of efficacy and applicability. From a                                                        for everything. How
                                                                                                            much time do proce-
 Contents                                                                                                   dures take? How many
 Expanding the Level of Service and
                                                                                                            patients can be treated in a
 Patient Satisfaction with Gemini . . . . . . . . . . . . . . . . . . . . . . . . . . . 4                   period of time? Will time be
                                                                                                            wasted on set up? Will consumables and maintenance
 Efficient Management of Rosacea and Photodamage with the                                                   lead to costly bills?
 Gemini Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6          Dermatologists establishing or growing their laser
 Photorejuvenation in Asian Skin Tones:                                                                     practices can benefit significantly from the wisdom of
 Role of the Gemini Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8               their experienced and successful colleagues. That’s
                                                                                                            what the following pages provide. Some of the best-
 Gemini for Photorejuvenation:
                                                                                                            respected minds in aesthetic dermatology share their
 A Cornerstone of the Cosmetic Practice . . . . . . . . . . . . . . . . . . . . 10
                                                                                                            expertise about two laser systems—Gemini® and
 Targeting Patients’ Aesthetic Goals with the VariLite . . . . . . . . . 12                                 VariLite™—from an established market leader in laser
 The VariLite for Fundamental Cosmetic Applications . . . . . . . . . 13                                    aesthetics: IRIDEX. As thousands of physicians have
                                                                                                            learned, success in laser medicine is built on a strong
 VariLite: A Reliable, Predictable Tool for Vascular and Pigmented
                                                                                                            foundation of tried-and-true procedures using tried-
 Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
                                                                                                            and-true laser systems. q



                                                                                                                         Supplement to Practical Dermatology | July 2010 | 3
Expanding the Level of Service and
Patient Satisfaction with Gemini®
               By E. Victor Ross, MD
               Director,
               Scripps Clinic Laser and
               Cosmetic Dermatology Center
               Carmel Valley, CA




P
        hotodamage is one of the most common com-          Ideal Combination Systems
        plaints among patients presenting for cosmetic     A significant benefit of the Gemini for a cosmetic der-
        laser therapy. Specifically, patients frequently   matology practice is that it combines two different
        seek treatment for mottled pigmentation,           laser systems into one single device. While the notion
        melasma, lentigines, broken capillaries, telang-   of dual-system devices is well-established, the reality
iectases, and surface roughness. Despite anecdotal         is that combinations are not always optimal, or they
reports of decreased demand in some areas, hair            may not be as convenient as they seem upon first con-
reduction and leg vein removal continue to be com-         sideration. For example, some systems may pair con-
mon requests in the cosmetic dermatology clinic, as        stituents that have similar indications. As such, the
well.                                                      combination system may provide clinical utility for
   Various laser and light sources available on the mar-   specific patient presentations but may not permit the
ket offer a range of wavelengths and penetration           practice to expand the service menu or appeal to a
depths necessary to address these various patient con-     wider base of patients. By combining the 532nm and
cerns. Ranging from intense pulsed light sources (IPLs)    the 1064nm wavelengths, the Gemini expands the
to fractional resurfacing lasers, the number of treat-     number of indications—and likely the
ment options has become remarkably wide. Yet to effi-      number of patients—the clini-
ciently treat a majority of patients presenting with       cian can treat.
these common complaints, a single system offering             With some dual sys-
dual wavelengths and a variety of spot sizes, Gemini       tems, switching from                   REEL TALK*
(532nm KTP/1064nm Nd:YAG, IRIDEX) may be appro-            one wavelength to                  “There are a lot of new
priate.                                                    another can be a               technologies out there, but
   Gemini features the long-pulse 532nm KTP laser          time-consuming            one of the tried-and-true tech-
and the 1064nm Nd:YAG, providing the versatility to        and difficult
                                                                                        nologies is KTP laser and the
target a variety of chromophores and enabling the cli-     process for the
nician to provide up to about 80 percent of the treat-     operator. With             long-pulse YAG laser. And the
ments commonly sought in a typical laser practice.         Gemini, the               Gemini fits the bill for both of
Although other two-in-one systems are available,           operator can            those wavelengths. So in a sense
Gemini is unique in the wavelengths it offers. The         quickly and            the Gemini is a time-tested prod-
shorter 532nm wavelength effectively targets superfi-      easily switch
                                                                                    uct. It has served us well at our
cial red and brown lesions (lentigines, broken capillar-   from one wave-
ies, mottled pigmentation, melasma), while the longer      length to another          clinic, both at the Navy and at
1064 wavelength effectively targets deeper vessels in      (just a tap on the          Scripps Clinic over the last 10
the face and the legs, permits hair reduction, and pro-    screen), allowing                     years roughly now.”
vides some mild skin tightening.                           the clinician to easi-
                                                               See Dr. Ross discuss his experience with the Gemini laser.

4 | June 2010 | Supplement to Practical Dermatology
Photos courtesy of E. Victor Ross, MD




                                         Before                                                         After

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


                                        ly use both systems for a single patient in one brief         within a single treatment. For example, it is not
                                        visit. An intuitive interface permits the operator to set     uncommon to treat diffuse pigmentation on the face
                                        and change treatment parameters with ease.                    and chest with the 532nm wavelength using the 10mm
                                           When combining systems, manufacturers may be               spot, then to switch to a 2mm handpiece to address
                                        forced to sacrifice certain elements of functionality in      telangiectases on the face, and then to use the 1064nm
                                        order to merge the two components. This is not the            wavelength to target a deep vessel on the face.
                                        case with the Gemini®, which provides a wide range            Alternatively, a treatment session dedicated largely to
                                        of spot sizes (42 different sizes), permitting operators      the face could culminate with the physician applying
                                        to customize treatment, whether the goal is full-face         the laser to the legs to treat a grouping of small, mat-
                                        rejuvenation or eradication of small, discrete lesions        ted vessels.
                                        on the face, chest, or hands. With the 10mm spot size,
                                        a full-face treatment can be completed in about 10            The Patient’s Perspective
                                        minutes.                                                      In addition to the ease and convenience of treatment
                                           Probably the most challenging areas to treat with          for the operator, the Gemini is associated with signifi-
                                        any laser system are convex and concave areas, such           cant benefits for the patient. Elements essential to
                                        as the sides of the nose. However, through the selec-         overall patient satisfaction are minimal downtime and
                                        tion of appropriate small handpieces and spot sizes,          low risk of adverse events. The speed of treatment is a
                                        the clinician can effectively treat these areas with the      bonus for patients, as are rapid results—small telang-
                                        Gemini.                                                       iectases disappear in real time. Non-ablative rejuvena-
                                                                                                      tion is considered a no-downtime procedure, but it is
                                        The Operator’s Perspective                                    important that patients and physicians know what to
                                        Because of the ease with which the operator can               expect in the hours after therapy. With full-face treat-
                                        change the wavelength and spot sizes as well as cus-          ment, patients may actually experience a temporary
                                        tomize treatment parameters, it is possible to target a       increase in erythema (that may be likened to a mild to
                                        range of cosmetic concerns on various anatomic sites          moderate sunburn) that will resolve over several days.
                                                                                                      There is no weeping, oozing, or peeling associated
                                        * Reel Talk: To see laser specialists discuss their laser     with treatment. However, swelling may occur;
                                        systems, log on to DermTube.com.                              swelling can be minimized with icing. Many patients



                                                                                                                    Supplement to Practical Dermatology | July 2010 | 5
can usually return to work following Gemini sessions,         to the ease of system use and the efficiency of treat-
however it is best to provide treatments a minimum of         ment, the Gemini allows the physician to rapidly treat
several days prior to a social engagement.                    a range of patient complaints, optimizing the level of
                                                              care without reducing the number of patients that can
Broad Application                                             be seen in a given day. Patients respond favorably to
The Gemini is a versatile and easy to use laser               this high level of physician involvement and are gen-
system that can address a majority of the common              erally pleased with the comfort and results of treat-
patient requests in a cosmetic dermatology practice.          ment as well as the lack of significant downtime.
(Probably the only common complaint is an operator            These are the foundations for patient satisfaction and
cannot use Gemini for tattoos and resurfacing.) Due           loyalty. q




Efficient Management of Rosacea and Photodamage
with the Gemini® Laser
               Arielle N. B. Kauvar, MD
               Clinical Associate Professor of Dermatology,
               NYU School of Medicine
               Director, New York Laser & Skin Care
               New York, NY




A
             mong the first clinical indications for lasers   Laser Management of Rosacea
             in dermatology was treatment of vascular         Rosacea is a significant medical and cosmetic concern,
             lesions, particularly port wine stains, with     affecting up to 16 million Americans, according to esti-
             the pulsed dye laser (585-595nm). While          mates from the National Rosacea Society. Among fair-
             early pulsed dye laser systems provided          skinned patients, symptoms of rosacea—telangiectases,
notable efficacy, treatment was associated with pupura        broken capillaries, diffuse erythema—are nearly ubiqui-
lasting as long as two weeks and occasional crusting.         tous. Despite the availability of several topical and oral
With time, refinements in laser technology have made          treatments that can address the inflammatory compo-
it possible to treat vascular targets with decreased risk     nents of rosacea, such as papules and pustules, no med-
of adverse events and little to no downtime, expanding        ication effectively addresses diffuse erythema, telangiec-
the clinical use of laser systems to treat vascular           tases, or broken capillaries.
lesions and vascular-mediated diseases, like rosacea.            The Gemini is a single system that permits treatment
The pulsed dye laser, the 532nm KTP laser, and                of both superficial and deep vessels/vascular lesions, dif-
intense-pulsed light systems (IPL) are available to treat     fuse erythema, lentigines, and non-vascular pigmented
vascular lesions and rosacea. Among these, the Gemini         lesions, with minimal risk and virtually no downtime.
(532nm KTP/1064nm Nd:YAG, IRIDEX) laser system is             To treat individual telangiectases, the 532nm laser can be
an attractive option that facilitates efficient, no-down-     used with one of various smaller spot sizes to trace out
time treatment. The laser is versatile and easy-to-use,       vessels. Typically, a 2-3mm spot size is suitable to treat
providing convenience for the operator and safe, com-         individual fine vessels, with resolution seen after two to
fortable, and reliable results for the patient.               three treatment sessions. Gemini offers additional versa-



6 | June 2010 | Supplement to Practical Dermatology
Photos courtesy of Arielle N. B. Kauvar, MD




                                               Before                                                       After

                                              The patient is shown before and one year post two treatments with the Gemini 532nm laser. Treatment was provided with
                                              10mm spot, 30ms pulse, fluence 8 J/cm2, followed by 3mm spot, 30ms, 12 J/cm2.


                                              tility in the management of rosacea, because the 1064nm       A First-line Option
                                              Nd:YAG laser can be used to target larger, deeper vessels.    Laser therapy for rosacea should not be considered a sec-
                                                  More diffuse redness consistent with flushing and         ond-line intervention. As noted, the 532nm KTP laser tar-
                                              blushing will respond to the 532nm laser when used with       gets discrete telengiectases, diffuse erythema, and acne-
                                              a larger spot size—usually 10mm—to rapidly treat the          like lesions. In addition, it targets other signs of photodam-
                                              entire face. Full-face treatment can take as little as five   age, such as red and brown spots, that accompany
                                              minutes. By offering a variety of spot sizes from 1mm up      rosacea. Treatment can also improve overall skin texture
                                              to 10mm, Gemini® facilitates efficient treatment of specif-   and improve the appearance of enlarged pores. Rosacea is
                                              ic targets as well as background erythema in a single,        a multifactorial disease, and laser therapy
                                              brief treatment session.                                      is a multi-targeted treatment. As
                                                  Patients with a few telangiectases may require only       such, laser therapy often yields
                                              one to two laser treatments. Those with moderate to           clearance for patients who                      REEL TALK
                                              severe rosacea should see optimal improvement in indi-        have been managed unsat-                   “Treating with the
                                              vidual lesions and overall erythema and skin tone fol-        isfactorily with pharma-                   Gemini is very well
                                              lowing three to five laser treatment sessions. In addition    cologic therapies.                       accepted by patients
                                              to improvement of their appearance, patients report a         Patients previously dis-
                                              reduction in rosacea symptoms like flushing and               satisfied with medical          because both components of
                                              warmth. Results of treatment are long-lasting but not         rosacea management             the Gemini, the 1064 and the
                                              permanent; maintenance treatments may be required             become satisfied and         532nm, are non-invasive lasers.
                                              every six to 12 months.                                       loyal laser patients.        So there's really no real down-
                                                  The 532nm laser provides short-term improvement in           Despite the poten-
                                              erythema, vascular lesions, and overall signs of photo-       tial limitations of con-      time and no recuperation, and
                                              damage and may have long-term effects on the inflamma-        ventional rosacea                the results are predictable in
                                              tory component of rosacea. Addressing the underlying          drugs, they and other                 our hands, and patients
                                              vasculature seems to reduce papules and pustules over         therapies may be incorpo-              are very satisfied with
                                              the long-term for many patients.                              rated into the overall
                                                                                                                                                        their treatments.”
                                                                                                             See Dr. Kauvar discuss her experience with the Gemini laser.

                                                                                                                          Supplement to Practical Dermatology | July 2010 | 7
patient management plan. Standard rosacea therapies can
be used to help uphold results in between maintenance
laser sessions. Depending on the initial presentation, other                Common Uses for the Gemini
treatments that may be used in conjunction with laser                          in a Rosacea Practice
therapy include those that target pigmentation, such as
kojic acid or hydroquinone, and topical antioxidant-con-          • The 532nm KTP laser effectively targets brown spots,
taining compounds. All patients must use sunscreens on a          red scars, and port wine stains (and infantile
consistent basis to arrest photoaging and prevent further         hemangiomas), and venous lakes.
damage from developing.
                                                                  • KTP can also be used for melasma, provides an
An Important Option                                               improvement in overall skin texture, and may help
Laser therapy can be an important option for the manage-          reduce the appearance of large pores.
ment of rosacea and associated signs of photodamage. For
any dermatology practice that treats a significant propor-        • In addition to full-face treatments, the 532nm KTP
tion of rosacea patients, investment in a versatile and effi-     laser can be used to treat the neck and chest for a
cient laser system, such as the Gemini, may be a cost-            comprehensive cosmetic effect.
effective option. In addition to treating rosacea, the
Gemini can be used for general rejuvenation procedures            • Although needle sclerotherapy is the gold-standard
and hair removal (See sidebar, at right, for some tips on         for leg veins, fine and matted vessels respond very well
other common uses for Gemini in my practice), allowing            to 532nm laser, making the laser an ideal tool for post-
the practice to offer a range of laser therapies through the      sclerotherapy “clean-up” procedures.
addition of a single system. q




Photorejuvenation in Asian Skin Tones:
Role of the Gemini® Laser
               By Professor Henry Chan
               Hon. Professor, Li Ka Shing Faculty of Medicine,
               University of Hong Kong
               Hon. Consultant Dermatologist,
               Queen Mary Hospital




L
       aser rejuvenation in darker skin tones requires            “ideal” candidate has dark hair and very light skin.
       special considerations. From a photophysical               Dark hair selectively absorbs the laser energy while
       standpoint, epidermal melanin in darker skin               the minimally pigmented surrounding skin provides
       potentially competes with the target chro-                 minimal “competition” for absorption.
       mophore of the laser. This optical competition                From a clinical standpoint, clinicians should recog-
may inhibit the efficacy of treatment by decreasing the           nize differences in photoaging depending on skin type.
amount of energy deposited to the target. At the same             Development of wrinkling and laxity in darker skin
time, if too much energy is absorbed by the normal                tones may be delayed by one to two decades, com-
melanin, excessive heating of the non-target tissue               pared to lighter skinned patients. A “typical”
may occur and could produce scarring. To illustrate               Caucasian individual has a natural SPF of 0, while an
this point, consider laser hair reduction, where the              Asian patient may have an SPF of about 3—equivalent



8 | June 2010 | Supplement to Practical Dermatology
to almost 10-times the level of protection from UV            not contrast significantly with the target lesion.
radiation. This natural level of protection is demon-         Therefore, a small spot size is important to efficiently
strated by lower rates of skin cancer in ethnic skin.         deliver energy directly to the target lesion without
For example, one study found that Japanese individu-          irradiating the normal surrounding tissue with its com-
als living in Hawaii had about a 10-time lower inci-          petitive chromophore of normal melanin.
dence of skin cancer compared to Caucasians. Despite             Other features of Gemini enhance its usefulness to
this natural SPF, Asian patients develop other common         treat lentigines and freckles in Asian skin. To mini-
signs of photodamage, such as freckles, lentigines, and       mize the risks of hyperpigmentation and scarring, epi-
seborrheic keratoses in their 30s through 50s, after          dermal cooling is critical throughout the laser treat-
which time wrinkling tends to become a prevalent              ment session, and Gemini has a very effective continu-
complaint, as well.                                           ous cooling system (Parallel Contact Cooling).
                                                              Additionally, Gemini’s compression handpiece
Gemini® for Lentigines                                        improves treatment results. Hemoglobin in the blood
We recently demonstrated the benefits of Gemini for           is also a target chromophore for the 532nm wave-
management of lentigines in Asian skin in a study             length. The compression handpiece empties blood
sponsored by Johnson & Johnson that compared the              from vessels at the target treatment site, thus eliminat-
Gemini 532nm long-pulse KTP laser, 595nm long pulse           ing this competitive chromophore and ensuring maxi-
dye laser (LPDL), 755nm LP Alexandrite, and 532nm             mum thermal injury to the lentigines.
QS Nd:YAG in the treatment of 40 Chinese patients                The Gemini system is a long-pulse laser with a pre-
with Fitzpatrick skin types III and IV.* Subjects were        dominantly photothermal effect. This method of action
randomized 10 to each laser and received one to four          on a molecular level is considered gentler than the Q-
sessions provided four to six weeks apart. Subjects           switched laser, which has a photothermal as well as
were assessed three to 12 months after their last treat-      photoacoustic effect. The latter is associated with
ment. A majority of subjects (70 percent) treated with        higher rates of inflammation and associated sequelae,
the Gemini had optimal improvement after six to 12            including post-inflammatory hyperpigmentation.
months, compared to 50 percent of LPDL patients
after three months and 60 percent of QS Nd:YAG                Optimal Therapy
patients after three to 12 months. Alexandrite laser          Because we have numerous lasers available in our
therapy did not provide statistically significant             center, we often use multiple lasers for each patient.
improvement. There was no risk for post-inflammatory          We believe that this is an ideal way to optimize the
hyperpigmentation in the Gemini group.                        benefits of all the available systems
   A “typical” protocol for Gemini treatment for pho-         while minimizing risks.
torejuvenation in Asian patients begins with a single         However, if I could use only
pass of the full face using the 532nm wavelength              one laser for rejuvenation
                                                                                                      REEL TALK
(10mm spot, 20ms pulse, 7-8J/cm2 fluence). This is            in Asian skin, it would          “Gemini is an extremely
then followed by two full-face passes with the 1064nm         be the Gemini. As
                                                                                             effective non-ablative skin
wavelength (10mm spot, 45ms pulse, 4J/cm2 fluence).           noted, the large
Note that when treating the forehead or any other             10mm spot size facil-          rejuvenation laser. And by
bony area, the energy is decreased by 10 percent to           itates rapid treat-     combining the 532 KTP lasers
improve patient comfort.                                      ment of the full       with the long pulse 1064 YAG,
   Following the initial full-face passes, specific lesions   face, while the
                                                                                        we can achieve non-ablative
can be addressed. Just as the large 10mm spot size            smaller available
allows for rapid treatment of the full face, the numer-       spot sizes permit       skin rejuvenations in terms of
ous small spot sizes available are critical to the safe       direct delivery of       reductions of pigmentations,
and effective treatment of discrete lesions. Typically,       laser energy to target        fine lines, pore size and
the 2mm spot size is used (2ms pulse, 12-14J/cm2 flu-         pigmented lesions
                                                                                               vessel improvement.”
ence) to treat individual lesions. As noted, a high con-      while by-passing com-
trast between the target and normal skin is preferred.        petitive chromophores.
However, the Asian patient’s normal skin tone may             The compression handpiece

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

                                                                           Supplement to Practical Dermatology | July 2010 | 9
and contact cooling improve outcomes and enhance                   *Study sponsored by Johnson & Johnson. Data presented at
safety, ensuring that treatment is satisfying for clini-        the American Society for Laser Medicine and Surgery, April
cians as well as patients. q                                    2010. (Abstract No. 136).




Gemini® for Photorejuvenation:
A Cornerstone of the Cosmetic Practice
              By William Baugh, MD
              Assistant Clinical Professor,
              Western School of Medicine
              Medical Director
              Full Spectrum Dermatology,
              Fullerton, CA




C
            O2 and Er:YAG resurfacing represent the             tions. Whereas ablative resurfacing is typically
            gold standard of facial resurfacing, but the        reserved for those patients with the most extensive
            excellent cosmetic improvement of deep              photodamage and historically has been considered an
            rhytides and extensive photodamage that             alternative to surgical facelifts, non-ablative rejuvena-
            these systems provide comes with the                tion is appropriate for rejuvenation in patients with
trade-off of significant downtime and patient discom-           early signs of photodamage and therefore appeals to a
             fort. Ablative fractional resurfacing has          very wide range of patients, beginning with those in
                     become a popular alternative for           their late 30s. For the majority of photorejuvenation
       The                resurfacing with good efficacy        procedures in my practice, I use the Gemini combina-
Gemini has many              for deep rhytides and photo-       tion 532nm KTP/1064nm Nd:YAG laser (IRIDEX).
                                damage but with less               The 532nm component allows for high affinity treat-
potential advantages
                                 downtime and improved          ments of solar lentigos and facial telangiectasias (two
over other lasers. The             comfort. A third option      of the most common changes seen with photodamage).
combination of the two              for photorejuvenation       The Gemini has also been shown to stimulate new col-
commonly-used wave-                  is minimal downtime,       lagen formation within the papillary dermis, and thus
                                     non-ablative rejuvena-     a subtle smoothing effect can be appreciated in many
lengths makes the device
                                     tion that provides great   cases.
very versatile. Furthermore,         tolerability and modest
the Gemini system is excep-         improvement of wrin-        Photorejuvenation Procedures
tionally easy to operate           kling and other signs of     The Gemini has many potential advantages over other
                                  photodamage, including        lasers. The combination of the two commonly-used
and can be used on vir-
                                solar lentigos and facial       wavelengths makes the device very versatile. The
tually any skin type.         telangiectases. Non-ablative      Gemini system is exceptionally easy to operate and
                           rejuvenation can literally be a      can be used on virtually any skin type. The 1064nm
                      “lunchtime procedure,” with mini-         component allows for treatment of dark skin with
                 mal patient discomfort and little risk of      minimal risk of post-inflammatory hyperpigmentation.
adverse events.                                                    I perform a variety of treatments with the Gemini,
   Non-ablative rejuvenation can have broad applica-            some as stand-alone treatments, others in combination.



10 | June 2010 | Supplement to Practical Dermatology
                                                               patients in a given period of time. For the end-user, it
                                                               is a user-friendly, high-performance system.
                                                                  There are a variety of potential settings available
                                                               with the Gemini, which is an important feature, as no
                                                               one 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 2mm
                                                               spot size and specifically treat individual lentigos and
                                                               blood vessels with pulse durations ranging from 6-
                                                               20ms and fluences ranging from 6-16J, depending
                                                               upon 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 is
                                                               introduced, with focal spot treatments over dominant
                                                               lentigos, followed by a single pass utilizing a 2-7mm
                                                               spot, 300-600mJ at around 10pps.
                                                                  Specific customization and sculpting can be per-
                                                               formed for each patient according to his/her desires
                                                               and specific problem areas. Overall, I can complete
The large viewing window allows visualization of target ves-   this entire treatment in about 30 minutes for an aver-
sels treated with the Gemini.
                                                               age patient. Most patients peel in about a week and
                                                               then marvel at the reduction in the appearance of sun
Combination photorejuvenation with Venus i™ (2940nm            damage.
Erbium laser, IRIDEX) laser mini-peel is very popular
in my practice. In this case, I usually perform the stan-      Weighing the Options
dard Gemini-based photorejuvenation immediately fol-           Of course, every device has limitations, and there is
lowed by the addition of a light Erbium laser peel. The        no perfect laser. However, I believe the Gemini has
advantage to this procedure is increased uniformity of         some of the fewest limitations. With the 1064nm com-
the treatment, since the entire face will be induced to        ponent I am not significantly limited to treating only
peel together as opposed to focal spot peeling which           lighter skin but can treat virtually any skin type. The
can occur with purely non-ablative procedures. Once            Gemini has a large range of spot sizes available at the
the patient stops peeling (usually in about seven days         operator’s finger tips. Simply dialing a knob allows the
depending upon the depth of the peel), increased uni-          operator to change from a 1mm spot size incremental-
formity and smoothness of the complexion can be                ly through to a 5mm spot size with any specific size
appreciated.                                                   available in between. With a quick cord change of the
                                                               hand piece, I can change to the 10mm spot size in a
Advantages of Gemini®                                          matter of seconds. The Gemini has the largest spot
The Gemini offers many features that make it prac-             size—10mm—available for a 532nm laser.
tice-friendly and easy to operate. It has a clear sap-            The Gemini’s greatest strength is its versatility. A
phire window through which the laser beam is emit-             physician or practice considering purchasing any sys-
ted, permitting visualization of anatomic targets. The         tem may be most concerned with costs. Systems vary
Gemini cooling method is called "parallel contact cool-        in price; most are expensive, but some low-cost
ing," which in my experience is the best available             options are available. I firmly believe you get what
method. It provides cooling of targets before, during,         you pay for. In my experience, the Gemini has been
and after energy output. The handpiece configuration           well worth the investment. It offers an excellent safety
is simple to use, and the manual touchscreen allows            profile, predictable results, and reliable performance
for quick and easy treatments. In a healthcare envi-           (repairs, though rarely needed, are provided quickly in
ronment where time is money, this laser facilitates            your office by IRIDEX technicians). It has been a cor-
rapid treatments, enabling the physician to treat more         nerstone of my cosmetic dermatology practice. q



                                                                           Supplement to Practical Dermatology | July 2010 | 11
Treatment of Facial Vascular and Pigmented Conditions
with the VariLiteTM Laser System
              Jerome Garden, MD
              Professor of Clinical Dermatology
              and Biomedical Engineering,
              Northwestern University, Chicago, IL




T
         he unique combination of the 532nm and the        variously sized facial vessels, background redness, and
         940nm diode laser in the VariLite Laser           pigmented lesions, the VariLite is well tolerated and
         System (IRIDEX) and its application in either     the post-procedural reactions are temporary and
         a single pulse or scan delivery mode provides     acceptable.
         the clinician a unique opportunity to treat          Vessels generally respond well after one to three
individual vessels and pigmented lesions as well as dif-   treatments. These treatments are typically spaced at
fuse erythema of the face. The distinctive 940nm           least six weeks apart. Lentigines respond to one to two
wavelength is particularly useful for larger vessels,      treatments. All patients develop some post-procedural
including those with a blue rather than red tone.          erythema, which can last from
                                                           one to four days, while
Patient-Focused Cosmetic Care                              lentigines become tran-
There are two basic elements to enhancing success in       siently darker after                    REEL TALK
the management of patients. First, the clinician must      treatment. These                   “The VariLite system is a
understand the patient's individualized goals and con-     changes gener-         wonderful choice for those people
cerns—accomplished through an in-depth consultation        ally do not
with the patient allowing for the necessary amount of      prevent                 who want to enter into the laser
time. Second, the clinician must be able to effectively    patients            arena. Because many, many patients
meet those goals. Without doubt, correction of photo-      from               have vessels which naturally occur as
damage is a very common request from patients, with        resuming        they grow older or especially those who
many patients seeking specifically to remove telang-       their daily
iectatic vessels and lentigines. Another related com-      activities,           develop rosacea later in life, this is
mon request is treatment for rosacea, where the            but             something that many practices have the
emphasis again is on vessels in addition to diffuse ery-   patients         need for treatment. And because there
thema.                                                     should             is such ease of use and it is a reliable
   The patient's clinical outcome is just one element to   forego
consider, as patients also have practical expectations     treatments        system, I always suggest to those who
about procedures and recovery. Increasingly, patients      before a sig-     ask me, what system should I start off
will poorly tolerate significant downtime, intra- or       nificant social          with, I feel that this is definitely
post-operative pain, or notable side effects, such as      engagement.                one of them that they should
purpura, crusting, scarring, etc.
   The VariLite, with the combination of 532nm and         VariLite Laser                          strongly consider.”
940nm wavelengths, allows the clinician to customize       System
treatment to meet the aesthetic and practical goals of     Dual wavelength hand-
many patients. In addition to its efficacy in treating     pieces are available with the

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

12 | June 2010 | Supplement to Practical Dermatology
                                     VariLite with 0.7, 1.0,       discrete thermal zones over large treatment areas. By
                                     1.4, 2.0, and 2.8mm           leaving zones of untreated tissue, this method of ener-
                                     spot sizes, allowing          gy delivery allows for thermal dissipation, which
                                     the operator to trace         reduces the risks of side effects associated with exces-
                                     out fine vessels or           sive thermal damage. The ScanLiteXP is suitable for
                                       rapidly treat larger        treating larger areas.
                                       areas. The VariLite            The VariLite is a user-friendly, portable laser system
                                       offers the                  that provides clinicians a great deal of versatility to
                                       ScanLiteXP, an opti-        optimize and customize the treatment approach to
                                       cal scanning hand-          each individual patient. The distinctive 940nm wave-
                                       piece, for use with         length—able to treat darker skin types, as it does not
                                       the 532nm wave-             compete with melanin as much as the 532nm wave-
                                       length. The                 length—is effective for the treatment of larger vessels.
                                       ScanLiteXP offers           Combined with the 532nm wavelength, the VariLite
                                       MicroSpot™ precise          laser system allows the clinician to treat a variety of
                                       energy delivery in          the more common facial photodamage concerns. q

                                      Rendering of MicroSpot energy deposition made possible with the ScanLiteXP
                                      handpiece.




The VariLiteTM for Fundamental Cosmetic Applications
              David J. Goldberg, MD, JD
              Clinical Professor of Dermatology,
              Director of Laser Research, Department of
              Dermatology, Mount Sinai School of Medicine
              Director, Skin Laser & Surgery Specialists of New
              York and New Jersey




F
        or many patients and some clinicians, the notion of        one machine allows the clinician to treat
        treating “vascular lesions” typically calls to mind red    a sizable proportion of cosmetic derma-
        telangiectases, diffuse erythema, and deeper red           tology patients. The clinical reality is
        vessels. Yet, for a number of patients, visible blue       that a majority of patients present
        vessels can be just as troubling as red ones. Until        to the dermatologist for treatment
recently, the only laser that provided any possible utility        of both red and blue vessels,
for the treatment of blue vessels or purpura was the               lentigines and freckles, diffuse
1064nm Nd:YAG laser. However, treatment was associated             erythema, and dyschromia. Treat-
with a significant incidence of pitting. The 940nm wave-           ment for these common presenta-
length—available in the VariLite (532nm KTP/940nm diode            tions can now be provided with a
laser, IRIDEX)—efficiently targets blue vessels with a sig-        single laser. VariLite is unique in
nificantly decreased incidence of pitting.                         the combination of wavelengths

Meeting Patient Demand                                            Rendering of the 940nm wavelength
The combination of the 532nm and 940nm wavelength in                               destroying a vessel.



                                                                                Supplement to Practical Dermatology | July 2010 | 13
See Dr. Goldberg discuss his experience with the VariLite laser.


     REEL TALK                        the system offers and,        offers remarkable convenience for a practice. A variety of
“One of the great things                 therefore, the diver-      handpieces and spot sizes are available. The device is small
                                            sity of vessels and     and lightweight, allowing it to be moved easily from room
about being in the laser field is
                                              vascular and pig-     to room or even from one practice location to another.
there are new lasers that come out              mented lesions         The system is easy to use, with no difficulty associated
every day. It makes it a very exciting           it targets.        with swapping handpieces or changing spot sizes. Other
arena to be in. The problem is the pop-               Treatment     modular systems offer different wavelengths, but switch-
                                                   with the         ing from one wavelength to another can be a challenge.
ular machine of today, unfortunately,
                                                   VariLite is      With the VariLite, changing from one wavelength to anoth-
often becomes the machine that you                 associated       er can literally be done with one hand.
don't need a year from now. The VariLite           with a signif-
is tried and true. The wavelengths—532             icant level of   A Foundational System
                                                   patient com-     By combining into a single system the ability to treat both
nanometers, 940 nanometers—they
                                                  fort. Patients    red and blue vessels, and pigmented lesions, VariLite
work. We've had the machine for sev-            do not experi-      enables a clinician to treat a very wide range of fundamen-
eral years. It doesn't break down.             ence pain or         tal cosmetic concerns. As such, the 532nm KTP/940nm
Patients send their friends. It's a          notable discom-        diode laser may represent a reasonable option for a clini-
                                           fort during treat-       cian just starting out in cosmetic laser surgery. The VariLite
great machine to have in the
                                       ment, which can take         will not provide improvement in skin texture and wrin-
office.”                            as little as five minutes       kling, however, treatment pairs nicely with other popular
                                for discrete vessels. There is      cosmetic procedures, such as fillers and botulinum toxins.
                          no downtime following treatment.          These additional cosmetic services can be provided in the
    Patients should expect to undergo three treatments, pro-        same visit. The VariLite can provide a basis for building a
vided about a month apart. Vessels have a tendency to               cosmetic practice with ample opportunity to incorporate
return, so patients should also anticipate maintenance              additional complementary laser systems, such as one of the
treatments at intervals (up to a year apart).                       many that target texture, as demand grows. The VariLite is
                                                                    an affordable system that offers ample opportunity to make
Meeting Clinicians’ Needs                                           a return on the investment. It meets the demands of cos-
In addition to its versatility of applications, the VariLite        metic patients and needs of busy clinicians. q




VariLiteTM: A Reliable, Predictable Tool for Vascular
and Pigmented Lesions
               C. William Hanke, MD, MPH
               Visiting Professor of Dermatology,
               University of Iowa, Carver College of Medicine
               Clinical Professor of Otolaryngology Head and
               Neck Surgery,
               Indiana University School of Medicine




L
         ike many cosmetic laser surgeons, I treat a                been satisfied with the consistency of treatment out-
         number of patients seeking improvement of                  comes for any single device. The dual-wavelength
         fine linear vessels and larger vascular lesions.           532nm KTP/940nm diode VariLite laser (IRIDEX) is
         While different laser systems have proven use-             the first laser that facilitates reliable, effective, and
         ful for these different indications, I had not             efficient treatment of linear vessels of all sizes.



14 | June 2010 | Supplement to Practical Dermatology
Photos courtesy of C. William Hanke, MD, MPH




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


                                               A Problem Solved                                                 darker skin. We have utilized the VariLite for der-
                                               Historically, the argon laser (488-514nm) was first used         matosis papulosa nigra (DPN) with good results and
                                               for the treatment of linear vessels. However, mainte-            no complications.
                                               nance issues arose in our practice, and we had diffi-
                                               culty finding replacement parts, leading us to abandon           A Safe and
                                               the argon laser. The 532nm KTP laser is effective for            Reliable Option
                                               fine linear blood vessels, but some patients had dis-            The VariLite has become a
                                               comfort and post-operative crusting. An alternative,             frequently-used tool in
                                               the 595nm pulsed dye laser, lacks versatility. In my             our practice for the
                                               experience, PDL and KTP lasers are more effective for            management of ves-                 The VariLite 940nm
                                               smaller blood vessels than large linear ones.                    sels and pigment-          laser (and 532nm KTP dual
                                                  The VariLiteTM solved our clinical problem by allow-          ed lesions.                 system) solved our clinical
                                               ing us to change wavelengths to effectively treat small          Unlike some
                                                                                                                                            problem by allowing us to
                                               linear blood vessels as well as larger and deeper ves-           older lasers, it
                                               sels and other vascular and pigmented targets.                   is a reliable            effectively treat small linear
                                               Treatment of linear blood vessels with the 940nm                 system,                blood vessels as well as larger
                                               wavelength is relatively painless, and post-operative            requiring no            and deeper vessels and other
                                               crusting is non-existent. Results are instantaneous for          significant
                                                                                                                                     vascular and pigmented targets.
                                               most sites. Linear blood vessels on the nose, however,           maintenance
                                               may need to be retreated several times, with treat-              or consum-                  Treatment of linear blood
                                               ments administered at four-week intervals.                       ables. The                vessels is relatively painless,
                                                  With any treatment, patients usually have tempo-              532nm/940nm            and post-operative crusting is
                                               rary post-operative erythema, but there is no down-              system has pro-
                                                                                                                                              non-existent. Results are
                                               time. Many patients do not require anesthesia,                   vided consistent
                                               although patients can select topical anesthesia if they          results in patients of         instantaneous for most
                                               wish. For treatment of facial vessels, our most com-             various skin tones with                            sites.
                                               mon laser parameters are 1mm spot size, 140 J/cm2.               a high degree of patient
                                                  The VariLite is safe and effective for treatment of           comfort and satisfaction. q



                                                                                                                          Supplement to Practical Dermatology | July 2010 | 15
                                                     IRIDEX, IRIDEX logo, and Gemini are registered
                                                 trademarks; and VariLite, ScanLiteXP, MicroSpot, Venus i
                                                         are trademarks of IRIDEX Corporation.




IRIDEX ‚ 1212 Terra Bella Ave. ‚ Mountain View, CA 94043 ‚ 800.388.4747 (US inquiries) ‚ info@iridex.com (US & int’l inquiries ) ‚ www.iridex.com

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