Pearl Fusion Technique Combined Treatment Advanced Technique
General Considerations The Pearl Fusion Technique is an advanced procedure intended for operators with previous knowledge and experience with Pearl and Pearl Fractional devices, and is in no way complete. Please consult the Clinical Training CD for each of these devices for more complete information. The decision to treat with light therapy should be based upon appropriate diagnostic evaluation and consideration of all patient factors. The Pearl and Pearl Fractional lasers should only be operated by qualified practitioners who have received appropriate training and have thoroughly read the operator manual. It is important to observe tissue reaction during treatment. Excessive thermal damage to the skin, or excessive depth of treatment, can result in unwanted adverse effects such as blistering, burns, erosion, hyperpigmentation, and/or hypopigmentation; some of which may result in scarring. 2
Why Combine Treatments? Customize treatments depending on patient concerns Surface epidermal combined with deep dermal ablation provides dual benefit Treatments are better tolerated than comparable individual treatments Short recovery time, about 5-7 days Improved efficacy Fewer residual lentigines Overall improvement in photo-aging Rhytids Texture Mild Laxity Scarring 3
Patient Selection Patients with moderate photoaging Lentigines Wrinkles Peri-oral and peri-ocular Diffuse facial Textural concerns Laxity Also younger patients Acne or surgical scarring Minimal photoaging 4
Pre-Op Medical History The following conditions are not contraindications but should be considered before treating: Current medications (both routine and occasional use) Accutane (Isotretinoin) do not treat if taken in the last 6 months Anti-Coagulants may increase post treatment oozing Gold Therapy May cause blue-gray discoloration History of vitiligo Heat from the treatment could induce a flare-up in patients with pre-existing vitiligo. Wound Infections 5
Pre-Op Medical History The following conditions are not contraindications but should be considered before treating: Herpes Pre-treatment with an antiviral. Some physicians prescribe antivirals for all patients regardless of history Outbreak may impede wound healing and increase risk of scarring Tattoos, including permanent make-up, in treatment area Do not treat over tattoos or permanent make-up Keloids or Hypertrophic Scarring Coagulopathies/bleeding disorders Implants or surgeries in treatment area Do not treat over dysplastic nevi or any questionable pigmented lesions Evaluate lesion(s) for potential skin cancer warning signs and treat only if diagnosed as benign Online Melanoma Resources www.aad.org www.cancer.org 6
Determine Skin Type Fitzpatrick Skin Type Scale I II III IV V VI White White White - Light Brown Light Brown - Olive Moderate - Dark Brown Black Burns easily, never tans Burns easily, tans minimally with difficulty Burns moderately; tans moderately and uniformly Burns minimally, tans easily and moderately Rarely burns; tans profusely Never burns; tans profusely Current combination guidelines are for skin types I III. 7
Pre-Op Patient Consent Patient Consent Provide treatment information. Inform of expected and unexpected side effects. Set realistic patient expectations regarding downtime, usually 5-7 days, and potential results. 8
Patient Prep - Clean Remove all make-up, sunscreen, etc. Any creams or products left on the skin may interfere with the light and may cause irregular results or unwanted side-effects. 9
Patient Prep - Hair The beard area should be closely shaven prior to treatment. Excess hair will interfere with the light and may cause irregular results. 10
Pre-Op - Photos Pre-op photos are your MOST valuable tool and protection. You only have one chance to obtain good pre-op photos. Document baseline condition Use for comparison purposes later on in treatment Consistent technique is important for useful, comparable photos. Matched patient positioning Camera settings Lighting Cutera Photography Blog http://blog.cutera.com/blog/clinical-photography-tips 11
Commonly Used Supplies Topical anesthetic e.g. lidocaine; benzocaine and/or tetracaine Some patients are offered an oral anti-anxiety or mild narcotic pre-op in addition to topical. A cooling device, such as Zimmer, can be used during treatment. Acetone (medical grade). 4x4 gauze pads Wood cotton-tipped applicators Tongue depressors Gloves Laser masks that filter to 0.1 µm Smoke evacuator Eye protection for patient and provider Occlusive ointment such as plain Vaseline or Aquaphor ointment 12
Anesthetic Application and Removal A topical anesthetic should be applied liberally to the entire area to be treated for a minimum of 45 minutes. Avoid getting topical anesthetic into the eyes. CAUTION: Toxicity may result with the overuse of topical anesthesia. Consult the manufacturer s labeling. Anesthetic must be completely removed before treatment. Following removal of anesthetic, wipe the skin with medical grade acetone or alcohol, to remove any residual anesthetic. Residual anesthetic will absorb light and may cause irregular results. Allow the skin to dry before treating with the laser. 13
Patient Eye Safety Patient eye protection must be used. Metal, laser-safe, lightblocking patient goggles are recommended. When treating eyelids internal corneal shields (metal, lasersafe) should be used. 14
Patient Prep Marking If you want to avoid treatment of the neck, the skin may be marked along the mandible using a surgical marker. This provides a reminder during treatment not to treat beyond the marked line. The surgical marker can also be used to mark areas that you want to treat only with Pearl Fractional, such as around the perioral area. 15
Safety Eyewear Safety eyewear must be worn by all persons in the treatment room Appropriate safety eyewear must have an optical density (O.D.) of 2.5 or greater at the wavelength of 2,790nm 16
Pre-treatment Laser masks with filtration of 0.1µm should be worn by all personnel in the treatment room to minimize exposure to laser generated airborne contaminants. Note: Standard surgical masks are not designed to provide protection from plume contents. 17
*Parameter Selection *For advanced procedure only. Consult Pearl and Pearl Fractional Clinical CD for complete treatment information. SINGLE PASS PEARL SETTINGS Treatment Area Fluence Pulse Duration Overlap Face 3 3.5J/cm 2 0.3ms 10% - 20% Treatment Area Energy Density Passes Eyelids 80-120mJ 2-3 2 Crow s Feet Peri-Oral Other areas as required PEARL FRACTIONAL SETTINGS 120mJ 3 2-3 Scarring 120-160mJ 3-4 2 3 Treatment parameters for treatment of the neck as well as off the face have not yet been developed. Skin types IV-VI are at higher risk for side effects, specifically post-inflammatory pigment alteration. Treatment recommendations have not yet been developed for these patients. 18
Parameter Selection (cont.) Higher energy may be selected for deeper lines and/or areas of scarring which may result in greater efficacy. May increase downtime and risk of unwanted side effects. Lower energy and/or density may be selected to increase patient comfort 19
Treatment Order Always begin with Pearl first, followed by Pearl Fractional to areas of concern. This order is important to ensure that Pearl is performed on clean, dry, skin, following an acetone wipe. Oozing from Pearl Fractional prevents Pearl from being properly absorbed. 1. Pearl full face, single pass Overlap may be decreased to 10% when combining lasers to reduce thermal impact. 2. Pearl Fractional Immediately follow with Pearl Fractional to peri-orbital and peri-oral areas and, if indicated, other areas with significant wrinkles or scarring Minimum 2 passes 2 nd pass at a 30-45 angle to the first pass 2-pass limit over lids to lash line Optional 3 rd pass over crow s feet, peri-oral, and other indicated areas 20
Smoke Evacuator A smoke evacuator is required for both Pearl and Pearl Fractional. Attach smoke evacuator hose to the laser handpiece or have an assistant hold it next to the treatment site. Ensure that the suction is set high enough to capture the laser generated airborne contaminants to prevent plume odor Ensure that the tube is not making contact with the filter inside the smoke evacuator. 21
Post Treatment Immediate Immediately after treatment apply an occlusive ointment such as new, plain Vaseline or Aquaphor ointment. Some patients experience a burning sensation immediately after treatment. This usually resolves a few minutes after the application of an occlusive ointment. Vinegar soaks can help relieve these symptoms 22
Post Treatment Provide the patient with a post-treatment instruction sheet for proper post-treatment care. An example set of post-treatment instructions is provided on the Pearl and Pearl Fractional Clinical Training CD. Erythema is a normal reaction to treatment, with deeper treatments resulting in longer lasting erythema which resolves with time. Minimal oozing from micro spots during and after treatment may occur. Edema (swelling) may occur in some patients. While this is temporary, sleeping with the head elevated may help to minimize this effect. The coagulated skin will slough off at 3 to 7 days after treatment for most patients. If repeat treatments are performed, the recommended treatment interval is 3 weeks or longer. 23
Example Patient Female 56yr Pre-Tx 5 weeks post Photos courtesy of Adele Makow,MD Pearl: Full Face, Single pass at 3.5J/cm² - 0.4ms with 20% overlap. (Peri-orbital not tx) Pearl Fractional: Cheeks, periorbital (no upper lid) and perioral, 2 passes at 160 mj with Density 2 24
Example Patient Female 58yr Pre-Tx 5 weeks post Photos courtesy of Brian Biesman, MD Pearl: Full Face, Single Pass at 3.0J/cm² - 0.3ms with 10% overlap Pearl Fractional: Full Face, Single Pass at 160 mj with Density 4 25