OVERVIEW SKIN ANATOMY SKIN ANATOMY by pengxiuhui

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									30th Annual Educational Meeting of the
CANP




                                                                            Topics
                                                           • Anatomy and Physiology of Skin and Hair
                An Introduction to                         • Hair Growth and Removal Options
            Medical Aesthetics: What you                   • Laser Physics and Light Technology
                   Need to Know                            • Safety, Pre/Post Treatment Guidelines, and
                                                             Complications
                 Cecily Cosby, FNP, PA-C, PhD
                                                           • Aesthetic Trends
                   Beth Haney, FNP-C, MSN
                                                           • Aesthetic Regulatory Issues
                       Donna Wilson, RN
                                                           • Basic Business for the Aesthetic Practice




                                                                     OVERVIEW
                                                           • To familiarize you with the essential
                                                             structures of the skin and hair
          Anatomy and Physiology of                        • To review relevant biology of the skin and
               Skin and Hair                                 hair
                                                           • Overview of common normal skin
                                                             presentations




                SKIN ANATOMY                                    SKIN ANATOMY
          • Skin is a highly specialized structure
            – Prevents invasion of microorganisms
            – Regulates fluid loss
            – Monitors temperature control
            – Protects against injury from radiation and
              electricity
            – Immunologic surveillance




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                SKIN ANATOMY                                                            SKIN ANATOMY
          • Skin thickness generally 1.2 mm but varies                    • Epidermis
            from 0.5 mm to 6 mm                                             – Outermost layer is the
          • Two layers                                                        stratum corneum
                                                                            – Nonviable layer of dry
             – Epidermis
                                                                              keratinized cells
                • measures 0.06 – 0.8 mm
                                                                            – 10-15 cell layers thick
                • Further divided by levels of specialization
                                                                            – Melanin is added to these
             – Dermis                                                         cells at the basal layer of the
                • Divided into papillary and reticular dermis                 epidermis by melanocytes




                SKIN ANATOMY                                                            SKIN ANATOMY
                                                                          • Dermis
         • Melanocytes produce melanin                                      – 20-30 times thicker than the
           – Melanin is the primary absorber of Ultraviolet light and         epidermis
             responsible for pigmentation of the skin                       – Divided into
           – Responsible for scavenging photochemical free radicals             • Papillary
           – Melanocytes exist within in the dermis but are confined to         • Reticular
             the basal layer of the epidermis                               – Contains
           – Transfer melanin to the keratinocytes                              •   Nervous
           – Between the basal layer and the outer stratum corneum              •   Vascular
             cells live in various stages of differentiation                    •   Lymphatic
                                                                                •   Epidermal appendages




                SKIN ANATOMY                                                            SKIN ANATOMY
          • Papillary Dermis                                                  • Reticular Dermis
             – Only slightly thicker than the epidermis                             – Major component of the dermis
             – Separated from the reticular dermis by a                             – Epidermal appendages terminate within
               vascular plexus                                                        the lower level of the reticular dermis
             – More commonly altered by                                             – Hair follicles and blood vessels penetrate
               environmental influences than by                                       deeper into the subcutaneous tissue
               inherited diseases of connective tissue




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                                                        PATIENT
                  SKIN ANATOMY
                                                      ASSESSMENT
          • Epidermal Appendages
                                          • History and Physical Exam
            – Sebaceous glands            • Particular attention to
            – Hair                          –   History of Skin conditions ie Acne, Roseacea
                                            –   Smoking
            – Sweat glands                  –   Alcohol Consumption
            – Nails                         –   Hormonal fluctuations- pregnancy, menopause
                                            –   Skin Care Products Used
                                            –   History of Herpes Simplex (Fever Blisters, Cold
                                                Sores)




                             TREATMENT
                             MODALITIES
          • SKIN
            –   OINTMENTS
                  •   RETINOIC ACID
                  •   HYDROQUINONE

            –   Microdermabrasion

            –   IPL

            –   PEELS
                  • GLYCOLIC ACID
                  • TCA,PHENOL

            –   TIGHTENING
                  • LASER
                  • RADIOFREQUENCY

            –   LASER RESURFACING




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                                                       HAIR
                                         • Three Main Functions
                                           – Thermoregulation
                                           – Photoprotection
                                           – Dry Lubrication




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                HAIR ANATOMY                               HAIR ANATOMY
          • Three distinct regions
             – Bulb                                   • Hair Bulb
             – Isthmus                                 – Approx 4 mm below the skin surface within the
                                                         subcutaneous layer
             – Infundibulum                            – Along with the Bulge-Site of Pluripotential cells of
                                                         the hair follicle which cause growth of each hair
                                                       – High concentration of Melanocytes present in
                                                         about these areas
                                                       – Location of Follicular papilla site of attachment
                                                         and blood supply




                    HAIR CYCLE                                  HAIR CYCLE
                                                      • Anagen- Growth Phase
         • All Hairs go through                         – Hair Matrix cells divide rapidly and migrate
           a cycle of                                     outward towards the shaft
           – Anagen- Hair                               – Capillary nourishment is greatly enhanced
             Growth                                     – Highest concentration of melanin during this
           – Catagen- Regression                          phase
           – Telogen- Resting                           – Follicle most sensitive to thermal effects of the
                                                          laser




                    HAIR CYCLE                                  HAIR CYCLE
          • Catagen- Regression                       • Telogen- Resting
             – Cessation of Mitosis                     – Follicle detaches from the papilla
             – Hair matrix cells regress                – Follicle contracts to one third of its
             – Papilla retracts to a place near the       original depth
               bulge                                    – Quiescent club hair eventually falls out
             – Capillary nourishment is greatly         – Phase length varies with body location
               reduced




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                      HAIR CYCLE
          • The length of hair at different body sites is
            governed by the duration of anagen
          • All hair bearing regions have differing hair
            cycles with great variability between length
            and duration of the phases
          • Laser hair removal most effective during
            anagen




                                                                                    Hair
                                                            • I have it where I don’t want it..
                          Hair Growth &                     • I don’t have it where I want it…
                         Removal Options                    • It’s too thin or too thick, too coarse or too fine,
                                                              too straight or too curly, too dark or too light
                                                              (gray) or the wrong color……..




                      Hair Growth                                Methods of Hair Removal
          • Three phases of
            normal hair growth:
             – Anagen (active)
                                                                –   Shaving
             – Catagen (regression)                             –   Waxing / plucking
             – Telogen (resting)                                –   Depilatories and creams (bleaches)
          • Multiple variables                                  –   Electrolysis / electrothermolysis
             –   Age                                            –   Laser hair removal
             –   Hormones, stress
             –   Medications, illness
             –   Pregnancy




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               How Laser Hair Removal
                                                                             Who is a Candidate?
                       Works
                                 • Laser energy is selectively   • Works best on darker hair
                                   absorbed by the melanin in
                                                                     – Blonde, gray and white hair do not contain
                                   the hair follicle and
                                                                       much melanin so any effects are short term
                                   converted to heat, injuring
                                   the follicle.                 • Can treat any area of the body
                                                                     – For safety avoid treating within ocular
                                 • Many hairs are permanently
                                                                       socket/orbit or on mucous membrane
                                   removed. Hair that does
                                   regrow is finer and lighter
                                   than before.




                     Before You Start..                                 Fitzpatrick Skin Types
          • Safety                                                     I      Always burns, never tans
          • Screening                                                  II     Always burns, sometimes tans
              – Medications, HSV, tanning                              III    Sometimes burns, always tans
          •   Assessment                                               IV     Rarely burns, always tans
          •   Preparation                                              V      Moderately pigmented
          •   Comfort                                                  VI     Black skin
          •   Safety
          •   Post-treatment care




                  Managing Discomfort                                        Topical Anesthetics
          •   Safety first                                       • Prescription strength
          •   Create positive experience                             – Benzocaine 20%, Lidocaine 6%, Tetracaine 4%
          •   Pain thresholds and influences                     •   Application
          •   Anticipate needs                                   •   Toxicity
                                                                 •   Instructions
                                                                 •   Consent




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          Benefits of Laser Hair Removal                                                  Potential Risks
                                                                        • Perifollicular edema/erythema
         • Treats a large area quickly                                      – Favorable post-treatment response
         • Some patients describe as similar to a rubber band               – Usually resolves w/in 24 hours
           snap                                                         • Local blisters - too high fluence, dark skin
         • Low risk of side-effects                                     • Hyper/Hypopigmentation
         • Temporary hair reduction for all hair types                      – Transient, should clear within 2-12 months,
         • Long-term growth delay                                           – Fluence and skin type dependent
         • Permanent hair reduction                                     • Scarring – Extremely rare




                           Terminology                                    Appropriate Pulse Durations
          •   Chromophores
                                                                     • Pulse duration selected shorter than the thermal relaxation time
          •   Pulse duration                                           (TRT) of target
          •   Thermal relaxation time                                   – Thermal confinement to target structure
                                                                        – Results in injury/damage to target structure
          •   Wavelength, fluences, joules (j/cm2)                   • The larger the target, the longer the thermal relaxation time.
                                                                        – Finer hair has shorter TRT.
                                                                        – Coarser hair has longer TRT.
                                                                     • Longer pulses allow heat to safely spread from the epidermis,
                                                                       especially important with darker skin types.
                                                                     • Select pulse duration appropriate for skin type and hair diameter.




                           Pre-Treatment                                                  Pre-Treatment
                                                                        • Patient selection
          • Pt. cannot wax, pluck or undergo electrolysis for 6            – Gray or blond hair not good candidates
            weeks beforehand                                               – Avoid treating if history of pronounced keloids
              – Can shave or trim                                          – Avoid treating over tattoos or permanent make-up
          • Avoid active tanning in area to be treated for 4 weeks         – History of HSV - pretreat with antiviral medication
            prior to treatment                                             – Stop Accutane for at least 6 months
                                                                           – Caution if patient on photosensitizing medications
          • No self-tanning products 2 weeks prior to treatment
                                                                           – Caution if history of hyper- or hypopigmentation
          • Obtain photographs




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             Laser Hair Removal Technique
                                                                                        Number of Treatments
                                                                              • Three phases of normal hair growth:
         • Treatment is simple and straightforward                               – Anagen (active)
            –   Set patient expectations                                         – Catagen (regression)
            –   Obtain health history                                            – Telogen (resting)
            –   Informed consent signed
                                                                              • Follicle most susceptible during anagen phase
            –   Area clean and shaved prior to treatment
            –   If desired, topical anesthetic cream applied 30-60 minutes    • Multiple treatments required
                before treatment                                                 – 3-6 treatments for lighter skin patients
                    • Caution if lidocaine allergy
                                                                                 – 4-8 treatments for darker skin patients
            – Settings chosen based on skin type and hair density
            – Look for the presence of a tan                                  • Permanent reduction typically 50-90% following
            – Test spotting recommended                                         multiple treatments




                                Post-Treatment                                                         Case One
           • Sunburn sensation is normal
                                                                                                                              • 33 year old requests
           • If desired, cold compress, aloe or hydrocortisone
             cream applied after treatment                                                                                      treatment of axila and
                                                                                                                                bikini area for hair
           • Gently clean area twice daily
                                                                                                                                removal
           • Avoid irritants for several days (glycolics,
             retinoids etc…)
           • Sunscreen for 6 weeks over the area                                                                              • Where do you start?
           • Describe singed hair and shedding process
           • Patient returns in 6-8 weeks for next treatment




                •   Inform, educate                                                                    Case Two
                •   Screen
                •   Treatment Plan                                           • 35 year old requests
                                                                               evaluation for laser hair
                •   Consent                                                    removal of upper lip
                •   Preparation                                                and full legs
                •   Treatment                                                • Currently waxing
                •   Instructions                                             • Plans trip to Mexico
                •   Follow-up                                                • History HSV




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                 •   Inform, educate                                                        Eye Safety
                 •   Screen                                                • Can cause severe retinal injury
                 •   Treatment Plan                                        • No treatment within bony orbit of eye (outer
                 •   Consent                                                 canthus). Treatment of eyebrows not
                                                                             recommended.
                 •   Preparation
                                                                           • Ocular Hazard Zone:
                 •   Treatment                                                – 164 feet / 50 m
                 •   Instructions                                          • Use occlusive goggles when treating the face
                 •   Follow-up




                                         Safety                                                Safety

         •   Enclosed room, windows covered                            •   Footswitch clean and out of way when not in use
         •   Laser safety sign posted outside door                     •   Do not treat over paper or cloth
         •   Laser in standby when not actively used                   •   Do not store flammables in the room
         •   Key removed when not in use                               •   Available fire extinguisher
         •   Laser beam directed only at target or calibration port    •   Follow ANSI standards for Class IV laser
                                                                            – Contact Laser Institute of America (LIA)
                                                                              (800) 34LASER for current ANSI and OSHA standards




                       Operator Technique                                    Positive Clinical Endpoints
                                                                      • Perifollicular erythema and edema
         •Secure wrist strap                                               – Bumps around follicle several minutes after
         •Pick and place                                                     treatment
             –Most effective in smaller areas
                                                                           – Less pronounced on darker skin types
         •Slide and glide
             –Allows more rapid coverage on larger areas
             –Thin (< 1 mm) layer of gel facilitates gliding
             –Pattern in gel enables tracking of treated areas
         •Apply slight compression
         •ChillTip™ flat on the skin surface at a 90o angle
         •Inspect and clean tip frequently during treatment!
         •Caution if treating over moles or suspicious lesions




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                             Results                                                 Results

         • Female, Skin type III - Chin                         • Female, Skin type IV - Axila




                                        36 months after 5 Tx
                     Pre                                                    Pre            4 months after 3 Tx




                             Results                                                 Results
          • Female, Skin type II - Bikini
                                                                 • Female, Skin type III - Leg




                                                                          Pre                24 months after 3 Tx

                    Pre                   8 months after 3 Tx




                             Results                                                 Results
         • Male, Skin type IV - Beard                            • Female, Skin type V - Chin




                                   5 months after 3 Tx                     Pre                   4 months after 5 Tx
                    Pre




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                         Summary
          • Appropriate candidate
          • Careful screening
          • Fully informed, consented & prepared
          • Precise treatment (following recommended
            parameters and safety guidelines)
          • Reinforce post-treatment care
          • Close follow-up
          • Pleased client with a good outcome.




                                                       Laser Physics and Technology
                                                                           • LASER

               Laser Physics and Light                 •   L – Light
                     Technology                        •   A - Amplification by
                                                       •   S – Stimulated
                                                       •   E – Emission of
                                                       •   R - Radiation




          Laser Physics and Technology                 Laser Physics and Technology
               Components of a laser system                      • Components of a laser system
               A.  Active medium
                   1.    gas
                   2.    liquid
                   3.    solid state
               B.  Excitation source
               C.  Laser head
               D.  Ancillary components
               E.  Control panel
               F.  Mirrors
               G.  Delivery system




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          Laser Physics and Technology              Laser Physics and Technology
                   Characteristics of laser light                Laser Light Spectrum
                    Coherent vs. Incoherent




          Laser Physics and Technology              Laser Physics and Technology
                                                        Intense Pulsed Light Device – IPL
          The laser system – output                     A. Flash lamp energized
               A. Lasing medium                         B. Produces multiple wavelengths
               B. Wavelength                            C. Output controlled by filters
               C. Temporal characteristics              D. Can produce a spectrum of
                     1.   Continuous wave (CW)               wavelengths simultaneously
                     2.   Pulsed




          Laser Physics and Technology              Laser Physics and Technology
                 Intense Pulsed Light Device         Types of medical lasers
                                                        A.    Gas
                                                              1.    Argon, Krypton
                                                                    a.     Ophthalmology
                                                              2.    Carbon Dioxide (CO2)
                                                                    a.     General procedures
                                                              3.    Excimer
                                                                    a.     Ophthalmology




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          Laser Physics and Technology                              Laser Physics and Technology
                   Types of medical lasers                                     Medical Laser Wavelengths
                   B.   Liquid
                        1.    Dye lasers
                   C.   Solid State
                        1.    Diode
                        2.    Nd:YAG
                        3.    Ho:YAG
                        4.    Er:YAG
                        5.    KTP
                        6.    Ruby
                        7.    Alexandrite




          Laser Physics and Technology                              Laser Physics and Technology
              Laser tissue interaction                                   Factors related to heat generation
              A.   Reflection                                            A.    Wavelength of the light source
              B.   Absorption                                            B.    Absorption characteristic of target
              C.   Transmission                                          C.    Power density of light source
              D.   Scatter                                               D.    Exposure time
                                                                         E.    Mode
                                                                               1. Pulsed
                                                                               2. Continuous
                                                                               3. Other




          Laser Physics and Technology                                               Summary
                   Laser Terminology                                • Physics of lasers and light-based devices is
                   A.    Frequency – the number of waves that         very complex
                         pass a point in space during any time
                         interval                                   • Laser energy is a coherent stream of light
                   B.    Wavelength – the distance between any to     and precise
                         corresponding points of successive waves
                                                                    • IPL energy is a broad spectrum light that
                   C.    Power density – Irradiance (Watts/cm2)       effects many different targets
                   D.    Energy density – Fluence (Joules/cm2)
                                                                    • The wavelengths that are commonly used
                   E.    Joules = Watts x seconds                     for aesthetic purposes are in the visible to
                   F.    Watts = Joule/sec                            near infra-red spectrum




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                                                                            Basic Safety and
                                                                          Equipment Operation




                          Basic Safety                                        Eye Protection
                                                                  • Safety goggles are required for each of the
          • Eye Protection                                          technologies used: Nd:Yag, Diode, and IPL.
                                                                  • The lasers are at the visible light range and
          • Treatment Room                                          present a significant hazard to the retina.
                                                                  • The Optical Density (OD) and the
          • Treatment Protocol                                      appropriate wavelength are noted on the
                                                                    lens or arms of the goggles and it is
          • Equipment                                               imperative the correct OD and wavelength
            Operation                                               is used.




                 Eye Protection (cont.)                                 Eye Protection (cont.)
          • The IPL light is extremely bright and can be          • Never look directly into light or laser beam
            irritating to the unprotected eye.                      even when using protective eyewear.
          • Optical density (OD) of 5 is sufficient for the IPL   • Do not treat eyebrows, eyelashes, or other
            patient and OD of 3 for the user.
                                                                    areas within the bony area surrounding the
          • Small opaque goggles or adhesive eye shields can
                                                                    orbit with diode or Nd:Yag.
            be used for facial skin treatments using IPL for
            photorejuvenation.                                    • The light emitted is capable of causing
          • A pair of each type of eyewear should be attached       serious eye damage or BLINDNESS.
            to the outside of the treatment rooms so that
            anyone entering will be properly protected.




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                Eye protection (cont.)                              Treatment Room
                                                          • Treatment rooms must be labeled with
          • Eyewear must have side guards to protect        regulation DANGER signs indicating the
            eyes from lateral exposure.                     laser/ high intense pulsed light is being
                                                            used.
          • Do not allow reflective objects such as
            jewelry, watches, surgical instruments, or    • These signs should be posted at eye level on
            mirrors to reflect laser or pulsed light.       all doors that access a room where Class 3b
                                                            and/or Class 4 lasers will be operated.




              Treatment Room (cont.)                          Treatment Room (cont.)
          • Glass windows and mirrors should be           • Do not store flammable liquids in the
            covered to prevent unintentional reflection     immediate proximity of the laser/IPL
            or injury.                                      equipment.
          • No one can be allowed into a laser room       • Do not store oxygen in the same room as
            unless properly authorized and protected.       the laser/IPL equipment.
          • All laser keys should be kept in a secured    • Do not use laser/IPL equipment in the
            area and signed out only by those               presence of explosive anesthetics.
            authorized to use them.




                  Treatment Protocol                        Treatment Protocol (cont.)
          • Written policies and procedures should        • Only qualified staff and authorized
            cover laser and non-laser hazards and           personnel may operate the laser/ IPL
            should be available within the practice         equipment.
            setting.                                      • Once the patient is assessed and the site is
                                                            photographed, the treatment area should be
          • These protocols should be reviewed              cleansed with a non-alcoholic cleanser and
            annually, and revised if warranted, to          shaved if applicable.
            conform with current standards and            • Photography of the treatment site is very
            procedures.                                     important for subjective documentation of
                                                            results.




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            Treatment Protocol (cont.)                             Calibration/Settings
          • Patients should be required to consent for      • Settings and operator’s manual should be
            photography since the photographs will not        reviewed and understood prior to any
            be for public use.                                procedure.
          • Explain to the patient their photographs will   • The settings on IPL machines vary
            remain a confidential part of their chart and     according to the energy delivery method
            are strictly used for before and after            used.
            treatment comparison.                           • For example some machines use different
                                                              pulse lengths or pulse widths depending on
                                                              parameters selected by the clinician.




                                                                  Equipment Operation
                                                            • All equipment should be calibrated in
                                                              accordance with the manufacturer’s
                                                              directions.
                   Equipment Operation                      • Appropriate eyewear must be worn during
                                                              calibration.
                                                            • Lasers and IPL equipment should be placed
                                                              in stand-by mode when not in use to prevent
                                                              inadvertent exposure to the light source.




           Equipment Operation (cont.)                      Equipment Operation (cont.)
          • An emergency shut-off switch must be
            available to the operator or the assistant to   • Know location and operation of nearest fire
            rapidly shutdown the equipment.                   extinguisher.
          • Foot pedals must be kept clean and out of       • Keep hands away from treatment heads
            the way when not in use.                          during the start-up phase of laser/IPL
                                                              equipment.
          • Do not use alcohol near the area where the
                                                            • Examine all light guides and filters for
            laser is being fired.                             breakage or damage and, if present, do not
                                                              use.




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                                                                   Treatment Guidelines
           Patient Preparation, Pre/Post
             Treatment Guidelines and                       •   Patient Preparation
                   Complications                            •   Contraindications
                                                            •   Pre - treatment guidelines
                                                            •   Post – treatment guidelines
                                                            •   Possible complications




                  Patient Preparation

          • Important to counsel patient prior to
            treatment in order to promote realistic
            expectations for skin rejuvenation, vein
            treatments, and/or hair removal.

          • Take a detailed history including previous
            treatments and determine patient suitability.




            Patient Preparation (cont.)                         Patient Preparation (cont.)
          • Determine why patient is seeking treatment      1. Some discomfort associated with
            and understand/manage his/her                      treatment.
            expectations.                                   2. Transient erythema/edema immediately
          • Discuss treatment plan with the patient.           after treatment.
          • During the first visit the clinician should     3. Pigmented lesions may become darker for
            inform the patient of the following:               up to 14 days after treatment.
                                                            4. Acceptable results will likely take a
                                                               number of treatments, usually 4 - 6.




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            Patient Preparation (cont.)                         Patient Preparation (cont.)
          5. Small risk of adverse side effects.            • Patients need to understand the IPL
          6. Anesthesia is usually not required.              treatment is not intended to substitute for
          7. For laser hair removal – no plucking,            surgical face lift, ablative skin resurfacing,
             waxing, electrolysis, or use of depilatories     or procedures for deep wrinkles and sagging
             for 6 weeks prior to treatment. No tanning       skin.
             2-4 weeks prior, including self tanners.       • IPL is intended for patients who desire
                                                              evenness of skin color or want to
                                                              reverse/reduce sun damage and photo-
                                                              aging.




            Patient Preparation (cont.)                         Patient Preparation (cont.)
          • Hair removal patients need to understand                         Side effects
            that laser treatments result in permanent       1. Pain during treatment
            hair reduction and not complete hair            2. Crust or blister
            removal.
                                                            3. Pigment changes –
          • The skin harbors many hair cells that do not       hypo/hyperpigmentation
            become active until later stages of life,
            therefore touch-ups may be necessary            4. Scarring
            although infrequent.                            5. Swelling




            Patient Preparation (cont.)                               Contraindications
                       Side Effects (cont.)                 •   Pregnancy
                                                            •   Breast-feeding
          5. Fragile skin                                   •   Recently tanned < 4 weeks (IPL only)
          6. Bruising                                       •   Inflammatory skin conditions
          7. No effect                                      •   Active cold sores, open wounds on
                                                                treatment area.




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              Contraindications (cont.)                        Contraindications (cont).
          • Use of isotretinoin (Accutane) within the      • Current or history of cancer or skin cancers;
            last 6 – 12 months.                              especially malignant melanoma or recurrent
          • Isotretinoin is not the same drug as topical     non-melanoma skin cancer.
            tretinoin (Retin-A).                           • Any active infection.
          • Use of medications causing photosensitivity    • Diseases that may be stimulated by light at
            within 2 weeks of initial treatment.             515nm – 1200nm such as HSV or SLE.
          • Bleeding disorder (physician discretion).




              Contraindications (cont.)                                Pre-Treatment
          • AIDS or HIV or use of immunosuppressive        • Patient assessment and counseling.
            medications.                                   • Consent form signed.
          • History of hormonal or endocrine disorders     • Skin type assigned if applicable.
            such as polycystic ovarian syndrome or         • Contact lenses removed.
            diabetes unless controlled.
                                                           • Treatment area to be cleansed with non-
          • History of keloid scarring.                      alcohol cleanser.
          • Extremely dry skin.                            • Shave treatment area if applicable.




                Pre-Treatment (cont.)                            Pre-Treatment (cont.)
          • Never treat mucous membranes.
          • Ensure proper eye protection is used by all    • Test spot performed in an inconspicuous
            persons in treatment room.                       area in treatment site.
          • Photographs taken.
          • Explanation of side effects reviewed.          • Treat the patient according to recommended
          • Questions answered to patient satisfaction.      guidelines.
          • Gel applied to treatment area for skin
            protection.




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                     Post-Treatment                                Post-Treatment (cont.)
          • Explain to patients after treatment with laser   • Tell patients to avoid irritants such as
            or IPL there may be some temporary                 glycolic, salicylic, and lactic acids or
            redness and/or mild swelling.                      retinoids.
          • Most patients describe the sensation as a        • Discourage vigorous exercise for 24 - 48
            slight sunburn.                                    hours to prevent further swelling if present.
          • Application of hydrocortisone twice a day if     • Encourage at least 30 SPF sun-block during
            necessary for inflammation.                        treatments and ultimately indefinitely (for
          • Gentle cleansing twice a day.                      skin health).




               Post- Treatment (cont.)                             Post-Treatment (cont.)
          • Inform patient not to pluck or tweeze during     • Quick, warm showers are recommended –
            laser hair removal series because this             hot baths are discouraged for 24 hours.
            prevents the laser light/heat from traveling     • In the rare case of broken skin or if a blister
            down the hair shaft to damage the follicle.        appears, the area should be kept moist with
          • Sun avoidance ensures the most effective           an antibiotic ointment to prevent crusting or
            and efficient treatment because a high             scabbing.
            energy level may be used safely.                 • Aloe vera and cold packs may ease any
                                                               discomfort.




                Post-Treatment (cont.)                             Post-Treatment (cont.)
          • Typically, IPL treatments are spaced no          • Make-up may be applied as long as the skin
            more often than every three weeks.                 is not broken.
          • This is due to the skin cell turn-over rate of   • Inform the patient sun exposure can cause
            21 days.                                           minor complications, (i.e. burns and/or
          • Larger intervals do not appear to adversely        hyperpigmentation), and this should be
            influence IPL treatment results.                   discussed with the patient.
          • Laser hair removal intervals range from 4 to     • Any questions or concerns should be
            16 weeks depending on area treated.                addressed with the Doctor or Nurse.




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                      Complications                               Complications (cont.)

          • Sun avoidance is crucial.                              Two types of complications:

          • Complications such as latent burning of
            exposed skin and skin darkening occur due
                                                                          1. Temporary
            to sun exposure after treatment.                              2. Permanent




                                                                Temporary Complications
             Temporary Complications
                                                                        (cont.)
          • Pain – during and after treatment with IPL
            and/or laser.                                   • Hyperpigmentation – resolves itself but
          • Swelling – after treatments, usually resolves     may take up to 12 months.
            within one hour or up to two days.              • Blistering – Most painful but usually
                                                              resolves in 3 – 7 days.
          • Redness - usually transient lasting minutes
            to 24 hours depending on body area treated.     • Bruising – may appear on the treated area,
                                                              usually lasts 5 – 15 days. As the bruise
          • Fragile skin – do not rub as this may tear        fades a possible rust-brown discoloration
            the skin.                                         may last for up to three months.




              Temporary Complications
                                                               Permanent Complications
                      (cont.)
          • Folliculitis – LHR may cause a temporary                         Very rare
            case of folliculitis especially when the        • Burns – usually occur with less
            patient has a history of the symptoms. Many       experienced or very aggressive technicians.
            times recurrent folliculitis or “ingrown          Severe burns may lead to disfigurement
            hairs” will bring the patient in to seek          especially if performed on mucous
            treatment. Antibiotics may lessen the             membranes.
            symptoms until the hairs are reduced.           • Scarring – usually occurs from a burn.
            Mechanical exfoliation is an additional         • Hypopigmentation – usually on darker
            remedy.                                           skinned patients.




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                  Common Remedies                            Common Remedies (cont.)
          • Aloe vera gel to soothe the skin after
            treatments.                                   • Aquafor helps soothe skin after treatments.
          • Hydrocortisone 1% OTC after treatments        • Cool packs.
            lessen inflammation.                          • Written post-care instructions – helps
          • Antibiotic ointments or creams help heal        ensure the best possible results of IPL and
            broken skin.                                    laser treatments.
          • Skin lightening creams may help with
            hyperpigmentation.




                         Summary                                          Summary
          • Eye protection is of the utmost importance    • Patient expectations and preparation are
            for clinician and client.                       paramount in obtaining great results.
          • Good understanding of equipment               • Contraindications must be addressed.
            operation, calibration, and settings ensure   • Proper training is essential to help prevent
            safe and effective treatment.                   side-effects or complications.
          • Practice protocols provide consistency in
            treatments regardless of which clinician
            performs the service.




                       Thank You!




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                Aesthetic Practice                                                            • Sexy, seductive and
                                                                                                60: Beauty trends
                     Trends                                                                     ignore age
                                                                                                 – Karen Thomas
                                                                                                   USA Today
                                                                                                   Aug. 11, 2006




                         FAQs                                                         Trends
                                                                     • > 10 million cosmetic surgery procedures in
            • What’s all the fuss?                                     2005:Increased by 43% since 2000
            • How does the                                           • Botox UP 409%
              consumer know
              where to start?                                        • Hair transplantation UP 102%
            • Who is best to                                         • Cellulite treatments UP 57%
              perform these                                          • Minimally invasive procedures UP 50%
              procedures?

                                                                     • Collagen injections DOWN 61%




                  What’s Out There?                                      ‘Rejuvenating’ Products
             • Products                                          •   Antioxidants
                                     • ‘Other’                   •   Retinols
             • Medical                 – Micropigmentation       •   Alpha-hydroxy acids
               Procedures              – Sclerotherapy           •   Glycolic acids
                “Minimally                • deep veins,          •   “Bleaching” agents
                 invasive”                  superficial veins,   •   Growth factor serums
                                            perforator veins,    •   Skin care lines
             • Surgical                     and spider veins
               Procedures              – Tattoo removal
                                                                 • Can generate revenue for a practice (~ 30%)




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                         Topical Agents for
                                                                               Minimally Invasive
                         Hyperpigmentation
         • Hydroquinone (hydroxyphenolic chemical)                  • Laser Hair Removal
         • Non- phenolic agents                                     • Light-based therapy
              –   Tretinoin                                         • Microdermabrasion (aluminum oxide)
              –   Adapalene
                                                                    • Thermage
              –   Topical corticosteroids
              –   Azelaic acid                                      • Injectables
              –   Arbutin
              –   Kojic acid
              –   Licorice extract




                                    2005                                                     2005
                  Top Five Minimally-Invasive for Women              • Top Five Minimally Invasive for Men
          •   Botox® (3.8 million)
          •   Chemical peel (1 million)                              •   Botox (314K)
          •   Microdermabrasion (838,000)                            •   Microdermabrasion (201K)
          •   Laser hair removal hair (783,000)                      •   Laser hair removal (173K)
          •   Sclerotherapy (590,000)                                •   Chemical peel (109K)
                  – Source: American Society of Plastic Surgeons®    •   Laser skin resurfacing (38K)
                                                                         – Source: American Society of Plastic Surgeons®




                  Surgical Procedures                                               Top Five 2005
                                                                     • Female                     • Male
                   --Liposuction             – Thread lift               – Breast Augmentation      – Nose reshaping (100K)
                   --Tummy Tuck              – Dermabrasion                (291 K)                  – Hair transplantation
                                                                         – Liposuction ((288)         (39K)
                   --Forehead lift           – Laser
                                               resurfacing               – Nose reshaping (199)     – Liposuction (36K)
                   --Hair transplantation
                                                                         – Eyelid surgery (198)     – Eyelid (33K)
                   --Rhytidectomy            – Deep chemical
                                               peels                     – Tummy tuck (129)         – Breast reduction (16K)
                   --Blepharoplasty
                   --Implants and Lifts




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                             Ballpark Cost                                           A Word about Cellulite…
                                                                                    80% of women have some, other 20% think
         • Laser Hair Removal                 • Botulinum toxin type A
           –   Bikini: $1K                         – $10-16 per unit
                                                                                    they do, some males as well.
           –   Full legs: $2.5K                    – Per area
           –   Chin: $800                              • Forehead $350
           –   Axilla: $800
                                                                                        •Thighs, buttocks, abdomen
                                              • Microdermabrasion                       •Develops in stages
         • Intense Pulsed Light                    – $100-150
           Face: $2K                                                                    •Pinch test positive for ‘mattress
                                              • Micropigmentation
         • Fillers                                 – Brows/Lips: $600 each              phenomenon’
                                                                                        phenomenon’ (dimpling)
           – Restylane 1cc: $475
                                              • Thermage                                •Common in thin women
           – Poly-L-Lactic acid: $1K per
             treatment                             – Lower/upper face: $1500 each                                      lymphatics,
                                                                                        •Diet, hydration, circulation, lymphatics,
           – Collagen 1cc: $325                                                         etc…
                                                                                        etc…




                          Cellulite Options                                             Don’t forget the hands….
          • Liposuction: poor cosmetic result
                                                                                     After the face, hands are
          • Topicals: small but real benefit
                                                                                    the second most visible,
          • Endermologie: suction/massage, studies show                             tell-tale sign of one’s age
            little benefit
          • Vela-Smooth:
                  • Medical device: radiofrequency, laser, mechanical massage to
                    break up and recontour, FDA approved 6/05
          • Mesotherapy:                                                            June issue of Plastic and Reconstructive Surgery®,
                  • Intradermal ‘homeopathic’ medicine to break down cellulite
                    and improve circ, lymphatic drainage: poorly defined




                                  Resources
          • http://www.plasticsurgery.org/public_educa
            tion/loader.cfm?url=/commonspot/security/
            getfile.cfm&PageID=17864                                                          Regulatory Issues
                                                                                         Regarding Aesthetic Practice




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                 Regulation of Aesthetic                                                Regulation of Aesthetic
                      Procedures                                                             Procedures
          • Regulation of medical devices for all                                 • FDA Classification Systems
            applications are by:                                                    – Center for Devices and Radiological Health
            – Federal Government                                                       • Compliance (Bureau of Radiological Health)
               • Food and Drug Administration                                          • Product Clearance (Office of Device Evaluation)
            – State
               • Multiple regulatory boards
            – Municipalities
               • Usually for structure code requirements
            – Facilities
               • For device usage




                 Regulation of Aesthetic                                                Regulation of Aesthetic
                      Procedures                                                             Procedures
          • Classification Systems                                                • FDA Product clearance – 510(k)
            – Center for Devices and Radiological Health                               • All light emitting devices are cleared by the FDA
               • Office of Device Evaluation                                             for aesthetic laser procedures under Section
                                                                                         878.4810 as a Laser Instrument, Surgical, Powered
                  – Classify medical devices I-III
                                                                                          – Even though they are not all surgical devices, they have no
                      » Class I – General Controls – require no additional
                                                                                            other Section to clear them under
                        instruction to use safely (gloves, scissors)
                                                                                          – This includes Intense Pulsed Light (IPL) devices even
                      » Class II – Special Controls – Require additional
                                                                                            though they are not lasers
                        information to use safely (510k cleared)
                      » Class III – Premarket Approval – Must determine
                        safety and efficacy, and are used to sustain or support
                        life, and are new technology or applications




                 Regulation of Aesthetic                                                Regulation of Aesthetic
                      Procedures                                                             Procedures
          • FDA Regulation                                                        • FDA Regulation
            – Only controls the manufacturer                                           • All Class II medical devices cleared by the FDA
               • To whom they sell the product                                           carry the following labeling:
                                                                                          – Caution: Federal law restricts this device to sale by or on
               • What they may say regarding what the device may                            the order of a _______, the blank to be filled in with the
                 be used for (labeling)                                                     word “physician”, “dentist”, “veterinarian”, or with the
               • They do not control who may use it or how it may                           descriptive designation of any other practitioner licensed
                                                                                            by law of the State in which he practices to use of order
                 be used                                                                    the use of the device
            – Exceptions                                                                  – Most aesthetic products are all Class II medical devices
               • A physician comes under FDA jurisdiction if they                         – Lasers and IPL’s are classified under the same section of
                                                                                            the law by the FDA
                 promote off-label use




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                Regulation of Aesthetic                                        Regulation of Aesthetic
                     Procedures                                                     Procedures
          • State Regulatory Boards                                     • Although medical aesthetic procedures are
               • Control who may use the product and under what           controlled by professional regulatory
                 circumstances
               • Almost all states have determined that the use of a      agencies, they recognize that these
                 laser for all procedures, including hair removal, is     procedures are more of a “business
                 within the practice of medicine and must be either
                 used by the licensed practitioner or delegated by a
                                                                          opportunity”
                 licensed practitioner to someone appropriately         • They therefore are very interested in any
                 trained
               • This licensed practitioner (medical director) must       structure in which they are offered
                 either be an M.D. or D.O., or in some states a Nurse
                 Practitioner (NP)




                Regulation of Aesthetic                                        Regulation of Aesthetic
                     Procedures                                                     Procedures
          • Regulatory oversight                                        • Regulatory oversight
            – Most states have minimal personnel for                      – Because of limited personnel, investigations
              investigative activities                                      will most often only be initiated by:
            – Depending on the state, most of these activities               • A patient being hurt
              are provided by regulatory boards, state’s                     • A competitor reporting those facilities not in
              attorney general, or departments of consumer                     regulatory compliance
              affairs.                                                       • Disgruntled patients whose expectations have not
                                                                               been managed properly




                Regulation of Aesthetic                                        Regulation of Aesthetic
                     Procedures                                                     Procedures
          • Regulatory/Business Structures                              • Qualities of each structure
            – Physician + employee in their own practice                  – Physician + office employee
            – Physician partnering with a nurse outside their                • Most direct control of procedure
              practice                                                       • More patients using office and staff
            – Physician partnering with an electrologist or                  • Patients are from their own practice or from
              aesthetician in the physician’s practice                         aggressive internal or external marketing
            – Physician partnering with an electrologist or                  • Favored by regulatory agencies
              aesthetician in their practice
            – Physician partnering with a spa
            – Physician as a medical director only




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                   Regulation of Aesthetic                                       Regulation of Aesthetic
                        Procedures                                                    Procedures
          • Qualities of each structure                                 • Qualities of each structure
            – Physician + nurse outside physician’s practice              – Physician + electrologist or esthetician in the
               • Physician has less direct control                          electrologists or esthetician’s practice
               • Less impact on physician’s office and staff                 •   Less impact on physician’s office and staff
               • Requires higher level of marketing to assure patient        •   Less control
                 flow                                                        •   Less marketing required
               • Regulatory agencies do not favor this                       •   More aggressive marketing is possible
                                                                             •   Less physician investment
                                                                             •   A possible turn-key operation
                                                                             •   Frowned on by regulatory community




                   Regulation of Aesthetic                                       Regulation of Aesthetic
                        Procedures                                                    Procedures
          • Qualities of each structure                                 • Qualities of each structure
            – Physician + electrologist or esthetician in the             – Physician’s +entrepreneur (medispa)
              physician’s practice                                           • Less impact of physician’s office and staff
               •   More direct control                                       • Less control
               •   More patients using office and staff                      • Lower level of marketing required if already
               •   Less marketing required                                     established
               •   Immediate large patient flow                              • More aggressive marketing possible
               •   In states where these personnel can perform the           • Larger spectrum of procedural offerings
                   procedures, regulatory agencies approve                   • Immediate high level of potential patients
                                                                             • Most scrutinized by regulatory agencies




                               Summary
            Medical Aesthetics and Regulation
            - Varies state by state
            – Can be done effectively if the right regulatory                         Business Basics
              plan is used
            – It is not difficult, but it must be done right!!




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             The most important thing                               Shaping a new practice
          • It’s not about you or how much money you           Some very important question to ask yourself:
            are going to make
                                                               How do I get started?
          • It’s about the patient                             Do I need a plan?
                                                               What technology should I choose?
          • It’s about the passion                             Do I need to expand our office space?
                                                               Will I need to hire more staff?




                              Facts
          You may be asking yourself why this is a             We see in magazines and newspapers all over
           good idea for your practice…                         the country it is safe to say these numbers
                                                                are continuing to skyrocket! If your asking
            Did you know that well over 2.7 million             yourself why this should be beneficial for
            procedures to erase wrinkles and rejuvenate         your practice, keep this in mind…
            the skin are performed annually. With the           Your practice has an established patient
            popularity of television shows such as “Dr.         base, so you are already ahead of the game.
            90210” and “Extreme Makeover” as well as            Chances are that most of your patients have
            the copious amounts of media coverage               had or are considering having aesthetic




                          Why Not?                                 What do patients demand?
            procedures. Why shouldn’t they get them
            from you. Patient trust and rapport has been                                  100% safety

            established. It is a win, win situation for all.               No pain

            Give your patients what they want! The
            procedures they want, in a familiar                               High Efficacy
            environment, by medical professionals they                         with: No
            trust!                                                             down time
                                                                        No lengthy
                                                                        treatment times      Affordability




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                   What do you need?                                    Getting started
          Clinically Proven          No complications
                                                             When considering starting your aesthetic
           Efficacy with:                                    practice it is vital that you have a plan.
                                                             Consider whether or not you will simply
                            Fast                             add aesthetic treatments to your existing
                       procedures                            practice or will you turn start a new
                                                             aesthetic practice? Whatever your goal,
                                                             you must have a plan.
                                    Satisfied
                    High return
                    on investment   patients




                     Getting started                                    Getting started
          Consider the following:                          If you have already asked yourself the previous
                                                           questions then you are ready to get started!
                                                              Purchasing technology is a big ticket item so do
          • What technology should I consider
                                                              your homework! Skin rejuvenation and hair
            purchasing                                        removal are an essential part to any practice.
          • Should I consider changing the look and           Light based technologies are best for skin
            feel of our practice?                             rejuvenation procedures. They offer your patients
          • Will we need to hire a nurse or aesthetician      great outcomes with little “down time”




                     Getting started                                    Getting started
            Don’t stop there! To better serve your
            patients you must consider providing full        What about injectables? Botox and fillers
            spectrum procedures. Microdermabrasion,          are a must! Over 2.6 million injections of
            chemical peels and skin care products only       Botox and fillers are performed annually! It
            potentiate the effects of your procedures.       is all part of the package! If your patients
            They go hand in hand! So many, so little         have not had it done, they are thinking
            time. Try them, consider cost to ALL of          about it!
            your customers.




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                     Getting Started                             Second Most Important
          Now that you have the big items out of the         • Marketing
            way, what’s next?
          Marketing, Marketing, Marketing                    • Don’t be an advertising victim!
          Consider your current patient base as the start.
          * Send an informative letter explaining the
            new and exciting procedures you have
            added to the practice. Perhaps a discounted
            rate existing patients.




                         To do List                          How to Market Your Practice
          • Find out everything you can                      • In person
          • Go to every course you can                       • In brochures
          • Find people in the industry you trust            • In a newsletter
                                                             • In a seminar
          Always remember – If it’s too good to be           • In a newsletter
           true – It is!                                     • In a newsletter
                                                             Hint: The more personal the better




                         Marketing                                         Remember
          • “In Office” is marketing is far superior to      • 80% of your business comes from 20% of
            any other means                                    your clients
          • Never think of your patient as a particular      • Your best client is the one you have
            type of patient (example)
                                                             • The second best is the one from your
          • You should cross market to everyone
                                                               existing client
          • You should get your existing clients to
            promote you
          • Don’t make assumptions about what
            patients want…Always ask




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                         Remember                                     Getting Started
          • The AVERAGE aesthetic practice knows         Plan an event.. “An evening of conversation”
            how to write a good press release            Wine, appetizers, gifts and information about
          • The GREAT aesthetic practice knows the       your new menu!
            editor                                       Offer an additional gift if they bring a friend.
                                                         Seek outside marketing assistance
                                                         Internal marketing is essential! All staff
                                                         members should have a good understanding of
                                                         the procedures being offered and the importance of
                                                         their role in marketing your aesthetic services.




                     Getting started                                  Getting started
          Once you have made it this far, think about    Very important! Consider a script for your front
            the                                          Receptionist. They should be prepared to
          following:                                     answer any general questions about your
            * Should we create a menu of services        services.

               (think about the look you are creating)
                                                         Consider a private consultation area
            * Patient brochures in the lobby
                                                         for your patients. Consultations should not be done
            * What is the room set-up                    at the counter of the reception area.
              (tables, carts, lighting, etc.)




                     Getting started                                  Getting Started
          Who should be doing consultations?             Other general questions:
          Doctors, nurses, aestheticians, patient
                                                           Do we need a camera?
          coordinators.
                                                           Where can I find treatment tables?
          Any person who has a true understanding of
                                                           What prices do we charge?
          your services and your technology.               How do we schedule treatments?
          Someone who has the ability to identify
          customer needs and expectations                Consider hiring a professional consultant




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                          More Skills                Make Your Staff a Team
          •   Dealing with difficult patients   •   On going process
          •   Dealing with disappointment       •   Must buy into your vision
          •   Making your staff a team          •   Regular meetings
          •   Dealing with competitors          •   Rewards
                                                •   Get rid of DEAD WOOD!
                                                •   Have a plan “B”




              The Last Important Thing
          Take Action!

                                                                  Thank you




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