HYBRID FRACTIONAL LASER RESURFACING FOR SKIN AND VAGINAL MUCOSA. Robert Aycock, MD, FACS

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1 HYBRID FRACTIONAL LASER RESURFACING FOR SKIN AND VAGINAL MUCOSA Robert Aycock, MD, FACS

2 DISCLOSURES Sciton Clinical Investigator and Physician Educator BOTOX Trainer

3 OUTLINE Background Hybrid Fractional Laser (HFL) HFL Effects & Results on Skin HFL Effects & Results on Vaginal Mucosa

4 BACKGROUND Robert Bobby Aycock, MD, FACS Board-certified in Plastic & Reconstructive Surgery Specialize in facial rejuvenation, abdominoplasty, breast augmentation and body contouring Offices in San Francisco Bay Area Founder and medical director, Greenbrae Surgery Center and Bon Air Surgery Center Member of

5 HYBRID FRACTIONAL LASER (HFL) What? How? Why?

6 WHAT IS A HYBRID FRACTIONAL LASER (HFL)? System that delivers ablative and non-ablative laser wavelengths consecutively and coincidently

7 HFL EFFECTS ON SKIN UV correction, melasma, wrinkles, texture improvement, pores

8 WHAT IS THE HYBRID FRACTIONAL LASER DOING IN SKIN? 2940 nm Er:YAG to ablate ( μm) Targets the epidermis (or top layer) of skin to address texture issues and pores 1470 nm diode to coagulate ( μm) Targets the dermis to stimulate collagenesis and address deeper sun damage and other dermal pigmentary issues

9 HOW IS HFL DELIVERED TO SKIN?

10 HOW IS HFL DELIVERED TO SKIN?

11 HOW IS HFL DELIVERED TO SKIN?

12 Consecutive Delivery HFL ON SKIN ILLUSTRATIONS 2940 nm 1st Coincident Delivery Top View Spot Size = Approx 1:1 Ratio Depth:Diameter Side View 1470 nm 2nd

13 HFL ON SKIN HISTOLOGY Superficial Ablation (2940 nm) Coagulation Zone (1470 nm) Coagulation Zone (1470 nm)

14 INTEGRATED COOLING Keeps the skin cool and comfortable throughout the treatment. INTEGRATED SUCTION Integrated smoke evacuation keeps the air clear from debris during ablation. INTEGRATED COOLING AND SUCTION

15 DTO TECHNOLOGY Dynamic Thermal Optimization continually measures skin temperature and automatically changes energy density and pulse width to ensure the laser is always tuned to your specifications. OPTICAL NAVIGATION Delivery device measures the speed that the handpiece is moving relative to the skin and adjusts the scanning speed to guarantee an even treatment. PRECISION CONTROLLED

16 Without DTO, as skin temperature warms or cools the size of the MTZ will change leading to overtreatment or undertreatment DTO continually measures the temperature of the skin and automatically changes the energy density to ensure uniform and predictable treatments DTO ENSURES CONSISTENT TREATMENT

17 RESEARCH SUPPORTS SKIN TEMPERATURE MONITORING Conclusion: The skin temperature affects the size of epidermal MTZ during fractional photothermolysis The control of skin temperature is necessary to provide a consisten outcome...

18 WHY USE A HYBRID FRACTIONAL LASER? Ablative-like results with non-ablative downtime in 1-2 treatments Each wavelength can be tuned independently for precise coverage and depth Customize treatments for patients with multiple conditions: Pigmentary issues Fine lines and wrinkles Enlarged pores Observed benefits include: High levels of comfort Reduced downtime Consistent results

19 RESEARCH SUPPORTS THE HYBRID APPROACH Conclusion: combination treatment of fractional ablative 2,940 and nonablative 1,440 lasers provides improvement in wrinkles and pigment similar to conservative purely ablative approaches... Reduced side effects make the combined procedure an attractive option for facial rejuvenation.

20 HEALING OF HFL ON SKIN Average healing progression for medium to aggressive treatments: Before Day 1 Day 2 Day 3 Day 4 Photos courtesy of Dr. Chris Robb, MD, PhD

21 HEALING OF HFL ON SKIN Day 1 Fine Peeling Photo courtesy of Dr. Chris Robb, MD, PhD

22 HEALING OF HFL ON SKIN Day 2 Medium Peeling Photo courtesy of Dr. Chris Robb, MD, PhD

23 HEALING OF HFL ON SKIN Day 3 Coarse Peeling Photo courtesy of Dr. Chris Robb, MD, PhD

24 NON-ABLATIVE HEALING ON SKIN Immediate Tissue within MTZs is destroyed and becomes non-viable Collagen is thermally altered/denatured 1 day Within 1 day, the epidermis is repaired and MENDs form Dermal tissue is still non-viable and collagen is still thermally altered Days 2 7 MENDs become trapped in Stratum Corneum Dermal tissue becomes more viable each day

25 NON-ABLATIVE HEALING ON SKIN 1 Hour Post Treatment Immediately post, microthermal zones (MTZ) are formed The MTZs are areas of in which the skin has been heated to a temperature that necrosis the cells and denatures the collagen

26 Day 1 During the first day after a treatment, new epidermis proliferates underneath the necrotic epidermal tissue and Microscopic Epidermal Necrotic Debris (MEND) appears at the top of epidermis from the necrotic tissue. NON-ABLATIVE HEALING ON SKIN

27 1 Day Post Laser Using a stain to detect the presence of viable tissue, we can see a layer of viable epidermis 1 day post resurfacing, while the dermal tissue is still not viable. NON-ABLATIVE HEALING ON SKIN

28 HFL RESULTS ON SKIN

29 Before After 1 Treatment Photos courtesy of Dr. Chris Robb, MD, PhD

30 Before After 1 Treatment Photos courtesy of Dr. Chris Robb, MD, PhD

31 Before After Photos courtesy of Dr. Chris Robb, MD, PhD

32 Before After Photos courtesy of Dr. Chris Robb, MD, PhD

33 Before After 1 Treatment Photos courtesy of Dr. Rebecca Gelber, MD

34 Before After 1 Treatment Photos courtesy of Dr. Chris Robb, MD, PhD

35 Before UV PHOTOGRAPHY After 1 Treatment Photos courtesy of Dr. Chris Robb, MD, PhD

36 Before UV PHOTOGRAPHY After 1 Treatment Photos courtesy of Dr. Chris Robb, MD, PhD

37 Before PORE IMPROVEMENT After 2 Treatments Photos courtesy of Dr. Chris Robb, MD, PhD

38 Before VISIA SHOWS 60% REDUCTION After 2 Treatments Photos courtesy of Dr. Chris Robb, MD, PhD

39 HFL EFFECTS ON VAGINAL MUCOSA

40 WHAT IS THE HYBRID LASER DOING IN VAGINAL MUCOSA? 2940 nm Er:YAG to ablate ( μm) Targets the epithelial layer (or top layer) of vaginal mucosa to address dryness and pain during intercourse 1470 nm diode to coagulate ( μm) Targets the lamina propria to stimulate collagenesis and address vaginal relaxation, dryness, stress urinary incontinence

41 HISTOLOGY Before Treatment 3 mos Post 3 Treatments Figures showing increase in epithelial thickness 1-month after treatment. Collagen went from haphazard to denser with horizontal streaming after treatment. Photos courtesy of Johnny Peet, MD

42 HISTOLOGY Before Treatment Photos courtesy of Johnny Peet, MD 3 mos Post 3 Treatments The number of fibroblasts and activation increased after treatment with larger nuclei and open chromatin. Endothelial enlargement in the superficial lamina propria and small vessels appear more stented open suggesting increase in blood flow to the tissue.

43 Vaginal handpiece controlled by a motorized system Rotates, retracts, and fires laser pulses automatically Limits user-dependent treatment variability Ensures even distribution of energy 5-7 min procedure HOW IS HFL DELIVERED IN THE VAGINA?

44 Single-use strengthened quartz cover Expands the canal for increased treatment surface area Every laser pulse is fired through new zone in the cover Saves time Reduces risk of crosscontamination Prevents degradation of equipment HOW IS HFL DELIVERED IN THE VAGINA?

45 HFL RESULTS ON VAGINAL MUCOSA

46 PILOT CASE SERIES STUDY Principal Investigator: Johnny Peet, MD, FACOG Evaluation of the Safety and Efficacy of Hybrid Fractional 2940nm and 1470nm Lasers for Treatment of Vaginal Tissue: A Pilot Study 18 Caucasian premenopausal females (mean age 41 ± 4.3) with prior history of vaginal delivery Measures Female Sexual Function Index (FSFI) International Consultation of Incontinence-Urinary Incontinence Short Form (ICIQ-UI SF)

47 Mean FSFI Scores RESULTS - FSFI FSD Patient FSFI Scores Duration in Months FSD Patient Comparison Duration Comparison p-value 0 & 1 p= & 2 p= & 3 p= & 8 p=0.002 *p-value was presented as a result of Pair sample T-test **p-value was presented as a a result of Wilcoxon signed ranks test ***p<0.05 *FSFI Scores indicates Female Sexual Dysfunction (FSD) Paired sample T-test showed a significant difference in improvement in FSD during all visits including the third-month & eighth-month in comparison to month 0 measurements.

48 Mean ICIQ-SF Scores SUI Patient ICIQ-SF Scores Duration in Months RESULTS ICIQ-UI SF Duration Comparison SUI Patient Comparison p-value 0 & 1 p= & 2 p= & 3 p= & 8 p=0.066 *p-value was presented as a result of Wilcoxon signed ranks test **p<0.05 *ICIQ Scores > 0 indicates symptoms of urinary incontinence (UI) Wilcoxon signed ranks test showed No significant difference between month 0 and month 1. No significant difference between month 0 and month 2. Significant difference between month 0 and month 3 and month 8

49 HFL IN A NUTSHELL Comfortable and quick treatment for the patient Safe to delegate On Skin Consistent results with only 1-2 treatments Almost ZERO downtime Ability to treat darker skin types and a wide variety of patients & skin conditions On Vaginal Mucosa Ability to treat both premenopausal and postmenopausal vaginal conditions Effective for long-term improvement of vaginal dryness, ability to orgasm, pain with intercourse, and stress urinary incontinence

50 THANK YOU FOR YOUR ATTENTION! Questions?

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