Use of the Novel Frax 1940 Non-Ablative Fractional Laser Handpiece in Clinical Practice

April 21st
PATIENTS DESIRE TREATMENTS FOR THE SKIN TO IMPROVE A range of vascular, pigmentary, and textural irregularities that produce an overall rejuvenated appearance with minimal time away from their normal activities. Laser-based devices, specifically non-ablative lasers in the mid-infrared (IR) spectrum, that are selectively absorbed in water are capable of delivering heat sufficient to coagulate and resurface skin in the epidermal and dermal layers of the skin by stimulating collagen production1. Nonablative fractional lasers deliver energy to the skin in arrays that create microscopic treatment zones (MTZ’s) of treated skin with micro-epidermal necrotic debris (MENDS) located at the margins of the MTZ’s. Zones of healthy tissue between these areas contribute to the more rapid wound-healing response and the epidermal stratum corneum is preserved as compared to ablative therapies or full-beam laser treatments2–3. The 1940 nm wavelength is highly absorbed in water and can create focal damage to approximately 200 microns in depth. The peak absorption of water in this region is at 1935 nm. As such, the 1940 wavelength is a useful tool for treating the more superficial layers of the skin, including treating abnormalities in the epidermis and superficial dermis. It can be used independently and also in combination with the 1550 nm wavelength to create a layered approach to treatment. The 1550 nm wavelength penetrates more deeply to at least 800 microns and is also less highly absorbed in water, creating a different pattern of thermal coagulation than the 1940 nm wavelength. The 1550 nm wavelength remodels skin on a deeper level and can be used for treating deeper tissue or scarring. The 1940 nm wavelength is a useful tool for resurfacing the superficial layers to yield clinical improvements in overall texture and pigmentation and also an improved appearance of fine, smooth skin. Other combination treatments can include treatment of redness with VBeam 595 nm pulsed dye laser or IPL, such as the PR 530 or VL 555 handpieces.Additionally, the treatment of blue vessels with the NdYag wavelength can also be used as required for an overall rejuvenation treatment approach. The Handpiece The Frax 1940 handpiece is equipped with a replaceable roller tip and motion sensor, which allows control of the rate at which the laser delivers the MTZ arrays to the skin. Scan widths range from 4–12 mm and energy per MTZ and percent coverage are adjusted based upon the desired effect. For larger and more generalized resurfacing, the 10–12 mm scan width is preferred in multiple passes depending upon the skin type and skin condition to be treated. The Frax 1940 has the ability to digitally control the scan width without replacing the treatment tip. The scan width can be minimized to 4 mm, allowing for the treatment of epidermal skin abnormalities such as small, linear scars or benign epidermal pigmented lesions for which the clinician may wish to spare the surrounding tissue. The laser only operates in motion, providing a safeguard to overlapping energy deposition. Integrated air cooling improves patient comfort. Treatments Patients well-suited to treatment with the Frax 1940 handpiece are those who desire improvement of overall tone and texture due to photoaging. The face, decollete and hands area ideally suitable locations for treatment. The wavelength is also being studied for its use in the treatment of pigmented lesions and is also being shown to have an effect on the treatment of hyperpigmented skin. As with any laser treatment, protection from the sun, both pre- and post-treatment is important. There should be no active infection or irritation of the skin in the area being treated and there should be no significant medical abnormality that would impair wound healing. Prior to treatment, a topical anaesthetic is typically applied (lidocaine 23%/tetracaine 7%) for 30 minutes under occlusion and then completely removed. The skin is thoroughly cleaned and dried prior to treatment. Initial parameters for full area treatment of the face in skin types I–III generally begin with 3–4 passes at scan width of 10–12 mm, 14–18 MJ per MTZ and densities of 35–45%. Scan width is then reduced to 4 mm to treat individual lesions with 2–3 additional passes using increased densities up to 50%. Treatments off the face may require fewer passes or decreased fractional coverage. In darker skin types, the fractional coverage and number of passes are reduced to 20% or below and 2–4 passes, respectively. Treatments are performed monthly at approximately 4-week intervals for a total of 3 sessions. Post-treatment patients will experience erythema, oedema and possibly crusting depending upon the number of passes and density of treatment. In general, 2–3 days of redness and downtime are visible for mild to moderate treatments with an increasing number of days for more intensive, multipass, higher energy and higher density treatments. Post care involves strict sun protection and ample barrier moisturization. The Frax 1940 treatment provides a high degree of patient satisfaction when performed alone. It can also be performed in combination with the Frax 1550 and/or intense pulsed light (IPL) to further treat pigment, redness or for coagulation of tissue at increased depths.
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Treatment of pigmentation and melasma

April 21st
Uneven tone and pigmentation disorders are frequent problems that motivate patients to seek help. The gold standard for treating the majority of these hyperpigmentation changes is the use of a picosecond laser, as the effect is predominantly photomechanical and photochemical, thus we can achieve optimal results with almost no downtime and side effects. Medical Management The first step, as with any other medical condition, is to diagnose properly the pigmentation disorder presented by the patient. Dermoscopy and standardized photos with UV analysis should be performed. The most common diagnosis cover senile and solar lentigos, ephelides and melasma. On patients with diffuse patterns of pigmentation, the skin should be preconditioned for at least 3 weeks with soft depigmentation agents (e.g. kojic acid 4% 2id), chemoexfoliant actives (e.g. AHA 10%) and sunscreen. In the case of melasma, the patient education and medical care is the cornerstone of the treatment. Beside the behavioral intervention, a full topical regimen should be prescribed, and the laser treatment should only be initiated after 4-8 weeks of patient compliance. This regimen comprehends photoprotection (UVA/UVB/IR/HEV) and depigmentation, antioxidant, anti-inflammatory and chemoexfoliating agents and tranexamic acid. One should consider adding oral tranexamic acid and P. Leucotomos when suitable. Isolated pigmented lesions For lentigos, our way to go is the new 730nm Picoway handpiece. The precise balance of the PicoWay 730 nm handpiece efficiently targets pigment while minimizing risk of hypo- or hyperpigmentation and impact on surrounding tissues 1,2 The handpiece has the shortest pulse duration – only 250 picoseconds* - to reduce thermal impact and boost photoacoustic effect3. After thoroughly cleansing the area to be treated, we use the 4mm spot, with fluences ranging between 0.8-1.0J/cm2, covering all lesions. The endpoint is the darkening of the lesion and a perilesional erythema. Sometimes one may have a slight frosting effect, but it is not mandatory. For a complete clearance of the lentigo, 1-2 sessions, minimum 4 weeks apart are needed. As aftercare, we recommend topical hydrocortisone 3id for 5 days and sunscreen. The usual evolution is the lesion fading in 10-14 days. Diffuse pigmentation For diffuse pigmentation, we start treating the bigger lesions as we’ve described before. Afterwards, we use the 532nm Resolve Fusion fractional handpiece to cover all the area, doing 2 passes crosshatch. This handpiece is a proven picosecond know-how that builds new collagen and elastin4-6 - now integrates blended light technology, reaching more skin surface area. And, with a short pulse duration (375 ps) creates more photoacoustic and less thermal effect.3 The usual energy setup is 0.35-0.50mj/px at 7Hz, needing about 3500-4000 shots to cover the whole face. After the laser treatment, we apply a soothing mask to improve patient comfort. The aftercare is similar as described before. The typical post procedure is a mild redness that lasts up to 5 days. The pigmented lesions will darken, form a very thin crust and scab after about 7 days. For a complete treatment, 2-3 sessions are needed, at a minimum interval of 4 weeks. Melasma Laser therapy is an important adjunctive resource to deal with dermal pigmentation deposits and vascular component and to perform laser drug delivery. The first step is to control the vascular component, using Vbeam Prima at 595nm (15mm, 4.00-4.50J/cm2, 3ms, DCD 30/20). After, we perform a melanocyte dendridectomy, using the Picoway Zoom handpiece, 8mm spotsize, 0.60-0.75J/cm2, doing two general passes and an extra double pass on the pigmented area. Then, we target again the melanosome and perform a fibroblast stimulation using the 1064 Resolve handpiece, with energy 1.3-1.5mj/px, full face double pass with an extra double pass on the pigmented areas. This also increases the skin permeability, allowing to perform laser drug delivery with tranexamic acid. The typical post is a mild erythema lasting up to 48h. As aftercare, we recommend topical hydrocortisone 3id for 5 days and sunscreen. The number of sessions is variable from patient, but the average is 4. The recommended minimum interval between them is 4 weeks. Conclusions The Picoway and its picosecond technology is the front end for treating pigmentation disorders efficiently. The use of holographic fractionated handpieces expands the traditional use of these types of lasers, with its regenerative (and, thus, rejuvenation) capabilities. References *Based on published manufacturer specifications at the date of publication. Candela - data on file, 2020 1. Artzi O et al. Lasers Med Sci. 2018;33(4):693-697. 2. Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases. Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 113 -123 (DOI: 10.1159/000450812). 3. Kung KY, Shek SY, Yeung CK, Chan HH. Lasers Surg Med. 2019 Jan;51(1):14-22. doi: 10.1002/lsm.23028. Epub 2018 Oct 25 4. Brauer JA, Kazlouskaya V, Alabdulrazzaq H, et al. Use of a picosecond pulse duration laser with specialized optic for treatment of facial acne scarring. JAMA Dermatol. 2015;151(3):278-284. 5. Tanghetti EA, Tartar DM. Comparison of the cutaneous thermal signatures over twenty-four hours with a picosecond alexandrite laser using a flat or fractional optic. J Drugs Dermatol. 2016;15(11):1347-1352. 6. Tanghetti EA. The histology of skin treated with a picosecond alexandrite laser and a fractional lens array. Lasers Surg Med. 2016. Sep;48(7):646-52. doi: 10.1002/lsm.22540. Epub 2016 Jun 1.
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Novel picosecond handpieces for the treatment of pigmentation

April 21st
Introduction: Pigmentary disorders are common with several treatment modalities available ranging from topical therapy to chemical peels and lasers. The advent of ultrashort pulsed picosecond lasers (PSL) transformed the way tattoos and benign pigmented lesions are treated. Unlike long-pulsed lasers (milli to microsecond domain) and Q-switched lasers (nano second domain), the PSL deliver very short pulse durations in one trillionth of a second ( range) giving a predominantly photomechanical effect rather than a photothermal one. This in turn has increased safety on the tissue with less complications, particularly in the higher skin types1. Several PSL exist with different pulse durations and wavelengths. In this article I will explain the way I use two new handpieces of the Candela PSL called Picoway™. The Picoway™ system is a PSL with a total of 6 handpieces spanning across 4 wavelengths (532, 730, 785 and 1064 nm). The non-fractional handpieces are called zoom (532 and 1064nm) or full beam (730 an 785nm), the fractional handpieces called Resolve (532 and 1064nm), and the newer Resolve Fusion handpiece (532nm) merges in one pass one the benefits of fractional and full beam treatments. There are 2 new handpieces for which I was the first doctor in Europe to work on; namely the unique 730 nm titanium sapphire generated wavelength and the 532 Resolve Fusion fractional handpiece. Below are 2 cases detailing how I integrate these handpieces in the treatment of pigmentation. Cases report: In the first case I have a 53-year old woman with skin type 3 and photodamage with benign lentigines and freckles on the face. The novel 730 nm handpiece was used first as a spot treatment for the individual benign lesions. The spot size of 4 mm was used with a fluence of around 1 J/cm2 adjusted down to the use of 2 mm between 2.6 and 3 J/cm2 depending on the achievement of the clinical endpoint which is light whitening of the lesions preserving the surrounding tissue. In the light-coloured lesions an additional pass was performed. Subsequently, the 532 nm Resolve Fusion handpiece was used with a fluence of 0.5 mJ in 2 passes over the entire face with erythema as a clinical endpoint. Post care moisturizer and sunblock were advised. Marked improvement in the pigmentation was noted during her second visit in 4 weeks follow-up (figure 1). In the second case a 45-year old Chinese woman with skin type 4 presented with discrete lentigines on the zygomatic area of her right cheek which she was keen to get rid of. The 730 nm handpiece was used with both the 2 and 3 mm spot with fluences ranging between 1.6 to 2.6 J/cm2 until the desired endpoint of mild whitening was achieved. A potent topical corticosteroid cream was prescribed to use twice daily for 3 days together with meticulous sun protection. Clearance of the lesions was achieved with no adverse effects (figure 2). Conclusion: The treatment of benign pigmented lesion with lasers require the selection of the right wavelength and parameters to ensure a high clinical clearance with low complications, particularly in higher skin types. The novel 730 nm wavelength is unique in that it is highly absorbed by melanin (more than both 755 and 785 nm) with very low haemoglobin (less than both 755 and 785 nm) absorption. It also has the shortest pulse duration of any PSL wavelength available at 250 ps2. This is important as it is shorter than the stress relaxation time of the melanosomes leading to a predominantly photoacoustic method of pigment clearance with little collateral damage. The 532 nm Resolve Fusion provides an array of microbeams which combines a high fluence central beam with a low fluence peripheral rim allowing for greater coverage per pass with less impact in the central beam leading to less side-effects such as petechiae in higher skin types3. This fractionated beam gives a distinct microscopic injury termed light-induced optical breakdown with cell-signalling for rejuvenation and a mechanical destruction of melanosomes leading to enhanced clearance of diffuse pigmentation with little downtime. References: 1. Wu DC, Goldman MP, Wat H, Chan HHL. A Systematic Review of Picosecond Laser in Dermatology: Evidence and Recommendations. Lasers Surg Med. 2020 Apr 13. doi: 10.1002/lsm.23244. Epub ahead of print. PMID: 32282094. 2. Lipp MB, Angra K, Wu DC. Safety and Efficacy of a Novel 730?nm Picosecond Titanium Sapphire Laser for the Treatment of Benign Pigmented Lesions. Lasers Surg Med. 2020 Sep 1. doi: 10.1002/lsm.23314. Epub ahead of print. PMID: 32869883. 3. Miyata N. Picoway clinical insights: innovative picosecond laser with 4 wavelengths. Candela corporate white paper 2020.
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