Laser Skin Resurfacing MedArt ® 456 scanner MedArt ® 450 CO 2 laser

1. LaserSkinResurfacing MedArt® 456 scannerMedArt® 450 CO2 laser

2. Table of contents • What is laser skin resurfacing • Why choose laser skin resurfacing • Considerations in laser skin resurfacing • Patient and procedure • Recommended reading

3. What is laser skin resurfacing ? • It is a well-known and controlled wrinkle removal procedure. • It is an ablative technique that will partially evaporate upper skin layers. • New healthy collagen will develop and existing collagen fibres will shrink. This will smoothen out wrinkles and soften the skin texture. • New epidermal skin will form after 4-7 days.

4. Why choose laser skin resurfacing ? • It is the most efficient tool to produce dramatic wrinkle reduction. • It will improve but not completely eliminate all wrinkles. • It gives long-lasting results.

5. Considerations in laser skin resurfacing • Precise and reproduceable control of tissue vaporization. • Minimization of residual thermal damage. • Intraoperative hemostasis. • The above is achieved by: • A continuous wave laser resurfacing energy controlled and distributed by a scanner. The MedArt 456 scanner is a perfect means to control the above requirements.

6. Table of contents • Patient and procedure • Skin type candidates • Patient expectations • Treatment preparation • Patient preparation • Anaesthesia • Laser settings • Procedure • Postop expectations and care • Results

7. Type 1Light skin, red hair Ideal candidates. Type 2Medium skin, blond hair Type 3Medium skin, brown hair 17-27% develop transient inflammatory hyperpigmentation.*) Type 4Medium dark skin, brown-black hair Extreme caution must be excersiced during treatment due to high risk of dyspigmentation. Often, a special pre-procedure skin preparation is performed. Type 5 Dark skin, black hair Type 6 Black skin, black hair Skin type candidates *) Preoperative and Postoperative Considerations for Carbon Dioxide Laser Resurfacing Lasers in dermatology, vol. 64, december 1999

8. Patient expectations Patients treated: 195Women: 171 (88%)Men: 24 (12%)Age distribution:Women: 52.5 yearsMen: 36.7 yearsFull face treatments: 69 (35%)Lower half of face: 30 (15%)Perioral: 36 (18%)Periorbital: 16 (8%)Other areas: 44 (24%) Source:Peter Bjerring, Marselisborg Hospital University, Aarhus, Denmark, 2001Hans Lybecker, The Private Hospital Mølholm, Vejle, Denmark, 2001

9. Patient expectations Results:Based on patients’ evaluation on scale:poor, moderate, good, execellent Excellent: 45%Good: 35%Moderate: 16%Poor: 4% Side effects at follow-up after 1 year:Hyperpigmentation: 15%Hypopigmentation: 12%Infection: 2%Scars: 2% Source:Peter Bjerring, Marselisborg Hospital University, Aarhus, Denmark, 2001Hans Lybecker, The Private Hospital Mølholm, Vejle, Denmark, 2001

10. Treatment preparation • Exclusion criteria: • Pregnancy. • Keloid scar tissue former. • Previous history of radiation treatment. • Previous history of scleroderma. • Acquired immunodeficiency syndrome. • Prior organ transplant receiver. • Patient with Koebnerizing*) conditions. *) the outbreak of a specific dermal disorder after mechanical skin lesion, e.g. psoriasis, verrucae, vitiligo.

11. Treatment preparation • Carefully consider the following: • Determine patient skin type. • Medical history related to the necessary anaesthesia. • Make sure there is no scarring, wounds or local infections. • Determine use of medication at the time of treatment. • Determine need and involved risks in taking patients off medication. • Avoid acetylsalicylic acid containing medication (e.g. Aspirin). two weeks prior to treatment. • Avoid Isotretinoin intakes 6-24 months prior and post treatment. • Consider necessity of taking patient off any medication before treatment. • Determine risk of allergic reactions. • Inflammatory acne must be under control. • Inform patient of potential side effects. • Carefully instruct patient in postoperative care. • Pre-medication regime. *) *) Detailed information can be found in the ”Facial Skin Resurfacing” manual for the MedArt 456

12. Patient preparation • Patient preparation: • Remove all make-up and closely shave off any facial hair the day before treatment. • Do not use hairspray on the day of treatment. • Wear loosely fitting clothes on the day of treatment. • Make sure to arrange home transportation. • Be sure to have any recommended post-treatment remedies at home.

13. Anaesthesia For full skin resurfacing: • General or light anaesthesia is recommended. For all other treatments: • Local anaesthesia – infiltration and regional blockage. The objective is to make the patient feel comfortable and each doctor will chose the method depending on his preferences related to the extent of the treatment. See ref.: ”Anesthesia for the dermatologic surgeon”Scarborough D, Bisaccia E, Schuen W, Swensen R. Int J Dermatol 1989 Dec;28(10):629-37

14. Laser settings Laser parametres: • Output power: 8.5 – 10 W • Frequency range: 99 s Scan parametres: • Spot size: 0.3 mm • Dwell time: 0.9 ms • Scan area: 1 cm2 • Scan time: 1.1 s • Pattern: square or circle

15. Procedure • Mark treatment area. • Apply anaesthesia. • Wipe skin with a damp clothbefore treatment – stretch out all wrinkles during wiping. • Activate scanner for 1st pass. • Remove debris after each scanning pass *). • Activate scanner for 2nd pass (if needed). • Cover the treated area with a wound dressing. • After a week the dressing can safelybe removed. *) Number of passes determined by treatment area – see treatment manual for the MedArt® 456 scanner.

16. Procedure Thermal damage level after 1st pass was on average 31µ (abdominal skin).

17. Procedure After 1st pass wipe treated area with a wet gauze.

18. Procedure Thermal damage level after 2 passes was on average 51µ (abdominal skin).

19. Procedure After treatment use a wound dressing to provide an artifical skin barrier. Open wound dressing: pure Vaseline and other ointments.Closed wound dressing: Silon®, 2nd Skin®, etc.

20. Procedure After 1 week the dressing can be removed, as new epithelium has formed.

21. Postop expectations and care • Normal expectations: • Pain and swelling – worst the first 2-3 days. • Itching 3-10 days after treatment. • Erythema from day 8-10 until 6-8 weeks postop. Care: • Do only wash from the third day onwards if petrolatum is used. • Do not wash if treatment area is covered by dressings. • Do not use soap. • Apply a cold dressing to reduce itching. • From day 8-10 a light makeup can be used to conceal erythema. • Avoid sun – or use heavy sunblocking and shade with a hat or umbrella.

22. Results Upper lip

23. Results Full face

24. Recommended reading ”Fast Healing after Laser Skin Resurfacing” (362) Laurence David, MD, Javier Ruiz-Esparza, MD Dermatol Surg 1997;23:359-361 ”The Short- and Long-Term Side Effects of Carbon Dioxide Laser Resurfacing” (366) Leonard J. Bernstein, MD, Arielle N.B. Kauvar, MD, Melanie C. Grossman, MD, et al. Dermatol Surg 1997;23:519-525 ”A new patient classification for laser resurfacing and peels: Predicting responses, risks, and results” (407) Nabil Fanous Aesth. Plast. Surg. 26:99-104, 2002 ”Valacyclovir Prophylaxis for Herpes Simplex Virus Infection or Infection Recurrence Following Laser Skin Resurfacing” (409) William H. Beeson, MD and John D. Rachel, MD Dermatol Surg 2002;28:331-336 ”The use of hydroquinone with facial laser resurfacing” (410) Mitchel P. Goldman Journal of Cutaneous Laser Therapy 2000;2:73-77 ”Anesthesia for the Dermatologic Surgeon” (400) Dwight Scarborough, MD, Emil Bisaccia, MD, Wendy Schuen, MD, Rick Swensen, CRNA International Journal of Dermatology, December 1989 Vol. 28. ”Preoperative and Postoperative Considerations for Carbon Dioxide Laser Resurfacing” (408) Sharon Horton, MD, Tina S. Alster, MD Lasers in dermatology, vol. 64, december 1999