Christopher Zachary, MBBS, FRCP Experts describe the gold standard in Professor and Chair Department of Dermatology medical and aesthetic therapy, University of California-Irvine sharing their experiences using clinically- effective, time-proven technologies.

asers have without question revolutionized the practice Expanding the Level of Service and ® of dermatology, permitting clinicians to treat conditions Patient Satisfaction with Gemini for which no medical therapies exist or offering results Efficient Management of and Photodamage that exceed those of conventional therapeutics. From with the Gemini Laser medical conditions like acne and rosacea to cosmetic Lrejuvenation, laser systems can address a variety of the most in Asian Skin Tones: common presentations that bring patients to the dermatolo- Role of the Gemini Laser gist’s office. Gemini for Photorejuvenation: Given their remarkable utility, well-designed and manufac- A Cornerstone of the Cosmetic Practice tured can be a tremendous asset to dermatologists. Yet, often physicians are overwhelmed by the prospect of incorpo- Targeting Patients’ Aesthetic Goals with the VariLite™ rating laser procedures into practice. Technology is costly, and there may be a tremendous sense of pressure to attract The VariLite for Fundamental Cosmetic Applications patients and, as important, provide treatment that meets their VariLite: A Reliable, Predictable Tool for Vascular and goals. There may also be a learning curve, as residency pro- Pigmented Lesions grams currently offer little training in aesthetic dermatology,

Continued on page 3 Expert Contributors

William Baugh, MD C. William Hanke, MD, MPH Assistant Clinical Professor, Visiting Professor of Dermatology, Western School of Medicine University of Iowa, Carver College of Medicine Medical Director Clinical Professor of Otolaryngology Head and Full Spectrum Dermatology, Neck , Fullerton, CA Indiana University School of Medicine Carmel, IN

Henry H. Lin Chan, MD, PhD Arielle N. B. Kauvar, MD Hon. Professor, Li Ka Shing Faculty of Medicine, Clinical Associate Professor of Dermatology, University of Hong Kong NYU School of Medicine Hon. Consultant Dermatologist, Director, New York Laser & Skin Care Queen Mary Hospital New York, NY HKSAR Visiting Scientist, Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston Additional titles: USAMBBS (London), FRCP (London, Edinburgh, Glasgow), FHKCP, FHKAM (Medicine)

Jerome Garden, MD E. Victor Ross, MD Professor of Clinical Dermatology Director, Scripps Clinic Laser and Cosmetic and Biomedical Engineering, Dermatology Center, Northwestern University, Chicago, IL Carmel Valley, CA Private Practice, Chicago, IL Past President of the American Society for and Surgery (ASLMS) Member of the Board of the American Society of Dermatologic Surgery

David J. Goldberg, MD, JD Christopher Zachary, MBBS, FRCP Clinical Professor of Dermatology, Professor and Chair, Department of Dermatology Director of Laser Research, Department of University of California-Irvine Dermatology, Mount Sinai School of Medicine Irvine, CA Director, Skin Laser & Surgery Specialists of New York and New Jersey New York, NY

2 | June 2010 | Supplement to Practical Dermatology Photoaging, Vascular Lesions, and Pigmentation: The Cornerstone of Any Cosmetic Laser Practice

Continued from page 1

and such training was virtually non-existent even 10 practice development standpoint, it comes down to years ago. weighing the costs—upfront and ongoing/financial and Clinicians seeking to initiate or expand a laser der- timewise—against the likely returns. It rarely makes matology practice must assess their own interests and sense for a physician to take a gamble on costly new skills, patient demand, and the key considerations that technologies with uncertain efficacy and appeal, when guide device selection and purchase. tried and true systems can be Many dermatologists find success by focusing on acquired (often for less). medical as well as cosmetic indications, such as acne Alternatively, low-priced and rosacea, dyschromia, erythema, telangiectases, and systems can appeal to fine wrinkling. With this broader approach, the clinician the frugal practice, “As thousands of is able to keep her or his practice flexible. Many of the but if a system is best-respected names in aesthetic medicine will tell you underpriced, it physicians have learned, that a portion of their practice remains focused on tradi- probably under- success in laser tional medical dermatology. A flexible approach may performs. medicine is built on suit the clinician’s interest, and it likely reflects the level The initial of demand for service on the local level. investment in a a strong foundation of Selecting a laser system can be a challenge. Key to system purchase tried-and-true procedures success is to disregard the hype. Many lasers have is an important using tried-and-true come to the market backed with flashy campaigns to consideration, but the public and the medical community, making exag- it doesn’t account laser systems.” gerated claims of efficacy and applicability. From a for everything. How much time do proce- Contents dures take? How many Expanding the Level of Service and patients can be treated in a Patient Satisfaction with Gemini ...... 4 period of time? Will time be wasted on set up? Will consumables and maintenance Efficient Management of Rosacea and Photodamage with the lead to costly bills? Gemini Laser ...... 6 Dermatologists establishing or growing their laser Photorejuvenation in Asian Skin Tones: practices can benefit significantly from the wisdom of Role of the Gemini Laser ...... 8 their experienced and successful colleagues. That’s what the following pages provide. Some of the best- Gemini for Photorejuvenation: respected minds in aesthetic dermatology share their A Cornerstone of the Cosmetic Practice ...... 10 expertise about two laser systems—Gemini® and Targeting Patients’ Aesthetic Goals with the VariLite ...... 12 VariLite™—from an established market leader in laser The VariLite for Fundamental Cosmetic Applications ...... 13 aesthetics: IRIDEX. As thousands of physicians have learned, success in laser medicine is built on a strong VariLite: A Reliable, Predictable Tool for Vascular and Pigmented foundation of tried-and-true procedures using tried- Lesions ...... 14 and-true laser systems. ●

Supplement to Practical Dermatology | July 2010 | 3 Expanding the Level of Service and Patient Satisfaction with Gemini®

By E. Victor Ross, MD Director, Scripps Clinic Laser and Cosmetic Dermatology Center Carmel Valley, CA

hotodamage is one of the most common com- Ideal Combination Systems plaints among patients presenting for cosmetic A significant benefit of the Gemini for a cosmetic der- laser therapy. Specifically, patients frequently matology practice is that it combines two different seek treatment for mottled pigmentation, laser systems into one single device. While the notion melasma, lentigines, broken capillaries, telang- of dual-system devices is well-established, the reality Piectases, and surface roughness. Despite anecdotal is that combinations are not always optimal, or they reports of decreased demand in some areas, hair may not be as convenient as they seem upon first con- reduction and leg vein removal continue to be com- sideration. For example, some systems may pair con- mon requests in the cosmetic dermatology clinic, as stituents that have similar indications. As such, the well. combination system may provide clinical utility for Various laser and light sources available on the mar- specific patient presentations but may not permit the ket offer a range of wavelengths and penetration practice to expand the service menu or appeal to a depths necessary to address these various patient con- wider base of patients. By combining the 532nm and cerns. Ranging from intense pulsed light sources (IPLs) the 1064nm wavelengths, the Gemini expands the to fractional resurfacing lasers, the number of treat- number of indications—and likely the ment options has become remarkably wide. Yet to effi- number of patients—the clini- ciently treat a majority of patients presenting with cian can treat. these common complaints, a single system offering With some dual sys- dual wavelengths and a variety of spot sizes, Gemini tems, switching from REEL TALK* (532nm KTP/1064nm Nd:YAG, IRIDEX) may be appro- one wavelength to “There are a lot of new priate. another can be a technologies out there, but Gemini features the long-pulse 532nm KTP laser time-consuming one of the tried-and-true tech- and the 1064nm Nd:YAG, providing the versatility to and difficult nologies is KTP laser and the target a variety of chromophores and enabling the cli- process for the nician to provide up to about 80 percent of the treat- operator. With long-pulse YAG laser. And the ments commonly sought in a typical laser practice. Gemini, the Gemini fits the bill for both of Although other two-in-one systems are available, operator can those wavelengths. So in a sense Gemini is unique in the wavelengths it offers. The quickly and the Gemini is a time-tested prod- shorter 532nm wavelength effectively targets superfi- easily switch uct. It has served us well at our cial red and brown lesions (lentigines, broken capillar- from one wave- ies, mottled pigmentation, melasma), while the longer length to another clinic, both at the Navy and at 1064 wavelength effectively targets deeper vessels in (just a tap on the Scripps Clinic over the last 10 the face and the legs, permits hair reduction, and pro- screen), allowing years roughly now.” vides some mild skin tightening. the clinician to easi-

See Dr. Ross discuss his experience with the Gemini laser.

4 | June 2010 | Supplement to Practical Dermatology D M

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. E f o y s e t r u o c s o t o Before After h P This patient is shown before and immediately after treatment with 532nm laser at 10 J/cm2, 24ms, using the 5mm spot with contact cooling.

ly use both systems for a single patient in one brief within a single treatment. For example, it is not visit. An intuitive interface permits the operator to set uncommon to treat diffuse pigmentation on the face and change treatment parameters with ease. and chest with the 532nm wavelength using the 10mm When combining systems, manufacturers may be spot, then to switch to a 2mm handpiece to address forced to sacrifice certain elements of functionality in telangiectases on the face, and then to use the 1064nm order to merge the two components. This is not the wavelength to target a deep vessel on the face. case with the Gemini®, which provides a wide range Alternatively, a treatment session dedicated largely to of spot sizes (42 different sizes), permitting operators the face could culminate with the physician applying to customize treatment, whether the goal is full-face the laser to the legs to treat a grouping of small, mat- rejuvenation or eradication of small, discrete lesions ted vessels. on the face, chest, or hands. With the 10mm spot size, a full-face treatment can be completed in about 10 The Patient’s Perspective minutes. In addition to the ease and convenience of treatment Probably the most challenging areas to treat with for the operator, the Gemini is associated with signifi- any laser system are convex and concave areas, such cant benefits for the patient. Elements essential to as the sides of the nose. However, through the selec- overall patient satisfaction are minimal downtime and tion of appropriate small handpieces and spot sizes, low risk of adverse events. The speed of treatment is a the clinician can effectively treat these areas with the bonus for patients, as are rapid results—small telang- Gemini. iectases disappear in real time. Non-ablative rejuvena- tion is considered a no-downtime procedure, but it is The Operator’s Perspective important that patients and physicians know what to Because of the ease with which the operator can expect in the hours after therapy. With full-face treat- change the wavelength and spot sizes as well as cus- ment, patients may actually experience a temporary tomize treatment parameters, it is possible to target a increase in erythema (that may be likened to a mild to range of cosmetic concerns on various anatomic sites moderate sunburn) that will resolve over several days. There is no weeping, oozing, or peeling associated * Reel Talk: To see laser specialists discuss their laser with treatment. However, swelling may occur; systems, log on to DermTube.com. swelling can be minimized with icing. Many patients

Supplement to Practical Dermatology | July 2010 | 5 can usually return to work following Gemini sessions, to the ease of system use and the efficiency of treat- however it is best to provide treatments a minimum of ment, the Gemini allows the physician to rapidly treat several days prior to a social engagement. a range of patient complaints, optimizing the level of care without reducing the number of patients that can Broad Application be seen in a given day. Patients respond favorably to The Gemini is a versatile and easy to use laser this high level of physician involvement and are gen- system that can address a majority of the common erally pleased with the comfort and results of treat- patient requests in a cosmetic dermatology practice. ment as well as the lack of significant downtime. (Probably the only common complaint is an operator These are the foundations for patient satisfaction and cannot use Gemini for tattoos and resurfacing.) Due loyalty. ●

Efficient Management of Rosacea and Photodamage with the Gemini® Laser

Arielle N. B. Kauvar, MD Clinical Associate Professor of Dermatology, NYU School of Medicine Director, New York Laser & Skin Care New York, NY

mong the first clinical indications for lasers Laser Management of Rosacea in dermatology was treatment of vascular Rosacea is a significant medical and cosmetic concern, lesions, particularly port wine stains, with affecting up to 16 million Americans, according to esti- the pulsed (585-595nm). While mates from the National Rosacea Society. Among fair- early pulsed dye laser systems provided skinned patients, symptoms of rosacea—telangiectases, Anotable efficacy, treatment was associated with pupura broken capillaries, diffuse erythema—are nearly ubiqui- lasting as long as two weeks and occasional crusting. tous. Despite the availability of several topical and oral With time, refinements in laser technology have made treatments that can address the inflammatory compo- it possible to treat vascular targets with decreased risk nents of rosacea, such as papules and pustules, no med- of adverse events and little to no downtime, expanding ication effectively addresses diffuse erythema, telangiec- the clinical use of laser systems to treat vascular tases, or broken capillaries. lesions and vascular-mediated diseases, like rosacea. The Gemini is a single system that permits treatment The pulsed dye laser, the 532nm KTP laser, and of both superficial and deep vessels/vascular lesions, dif- intense-pulsed light systems (IPL) are available to treat fuse erythema, lentigines, and non-vascular pigmented vascular lesions and rosacea. Among these, the Gemini lesions, with minimal risk and virtually no downtime. (532nm KTP/1064nm Nd:YAG, IRIDEX) laser system is To treat individual telangiectases, the 532nm laser can be an attractive option that facilitates efficient, no-down- used with one of various smaller spot sizes to trace out time treatment. The laser is versatile and easy-to-use, vessels. Typically, a 2-3mm spot size is suitable to treat providing convenience for the operator and safe, com- individual fine vessels, with resolution seen after two to fortable, and reliable results for the patient. three treatment sessions. Gemini offers additional versa-

6 | June 2010 | Supplement to Practical Dermatology

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. N e l l e i r A f o y s e t r u o c s o t Before After o h P The patient is shown before and one year post two treatments with the Gemini 532nm laser. Treatment was provided with 10mm spot, 30ms pulse, fluence 8 J/cm2, followed by 3mm spot, 30ms, 12 J/cm2.

tility in the management of rosacea, because the 1064nm A First-line Option Nd:YAG laser can be used to target larger, deeper vessels. Laser therapy for rosacea should not be considered a sec- More diffuse redness consistent with flushing and ond-line intervention. As noted, the 532nm KTP laser tar- blushing will respond to the 532nm laser when used with gets discrete telengiectases, diffuse erythema, and acne- a larger spot size—usually 10mm—to rapidly treat the like lesions. In addition, it targets other signs of photodam- entire face. Full-face treatment can take as little as five age, such as red and brown spots, that accompany minutes. By offering a variety of spot sizes from 1mm up rosacea. Treatment can also improve overall skin texture to 10mm, Gemini® facilitates efficient treatment of specif- and improve the appearance of enlarged pores. Rosacea is ic targets as well as background erythema in a single, a multifactorial disease, and laser therapy brief treatment session. is a multi-targeted treatment. As Patients with a few telangiectases may require only such, laser therapy often yields one to two laser treatments. Those with moderate to clearance for patients who REEL TALK severe rosacea should see optimal improvement in indi- have been managed unsat- “Treating with the vidual lesions and overall erythema and skin tone fol- isfactorily with pharma- Gemini is very well lowing three to five laser treatment sessions. In addition cologic therapies. accepted by patients to improvement of their appearance, patients report a Patients previously dis- reduction in rosacea symptoms like flushing and satisfied with medical because both components of warmth. Results of treatment are long-lasting but not rosacea management the Gemini, the 1064 and the permanent; maintenance treatments may be required become satisfied and 532nm, are non-invasive lasers. every six to 12 months. loyal laser patients. So there's really no real down- The 532nm laser provides short-term improvement in Despite the poten- erythema, vascular lesions, and overall signs of photo- tial limitations of con- time and no recuperation, and damage and may have long-term effects on the inflamma- ventional rosacea the results are predictable in tory component of rosacea. Addressing the underlying drugs, they and other our hands, and patients vasculature seems to reduce papules and pustules over therapies may be incorpo- are very satisfied with the long-term for many patients. rated into the overall their treatments.” See Dr. Kauvar discuss her experience with the Gemini laser.

Supplement to Practical Dermatology | July 2010 | 7 patient management plan. Standard rosacea therapies can be used to help uphold results in between maintenance laser sessions. Depending on the initial presentation, other Common Uses for the Gemini treatments that may be used in conjunction with laser in a Rosacea Practice therapy include those that target pigmentation, such as kojic acid or hydroquinone, and topical antioxidant-con- • The 532nm KTP laser effectively targets brown spots, taining compounds. All patients must use sunscreens on a red scars, and port wine stains (and infantile consistent basis to arrest photoaging and prevent further hemangiomas), and venous lakes. damage from developing. • KTP can also be used for melasma, provides an An Important Option improvement in overall skin texture, and may help Laser therapy can be an important option for the manage- reduce the appearance of large pores. ment of rosacea and associated signs of photodamage. For any dermatology practice that treats a significant propor- • In addition to full-face treatments, the 532nm KTP tion of rosacea patients, investment in a versatile and effi- laser can be used to treat the neck and chest for a cient laser system, such as the Gemini, may be a cost- comprehensive cosmetic effect. effective option. In addition to treating rosacea, the Gemini can be used for general rejuvenation procedures • Although needle is the gold-standard and hair removal (See sidebar, at right, for some tips on for leg veins, fine and matted vessels respond very well other common uses for Gemini in my practice), allowing to 532nm laser, making the laser an ideal tool for post- the practice to offer a range of laser therapies through the sclerotherapy “clean-up” procedures. addition of a single system. ●

Photorejuvenation in Asian Skin Tones: Role of the Gemini® Laser

By Professor Henry Chan Hon. Professor, Li Ka Shing Faculty of Medicine, University of Hong Kong Hon. Consultant Dermatologist, Queen Mary Hospital

aser rejuvenation in darker skin tones requires “ideal” candidate has dark hair and very light skin. special considerations. From a photophysical Dark hair selectively absorbs the laser energy while standpoint, epidermal melanin in darker skin the minimally pigmented surrounding skin provides potentially competes with the target chro- minimal “competition” for absorption. mophore of the laser. This optical competition From a clinical standpoint, clinicians should recog- Lmay inhibit the efficacy of treatment by decreasing the nize differences in photoaging depending on skin type. amount of energy deposited to the target. At the same Development of wrinkling and laxity in darker skin time, if too much energy is absorbed by the normal tones may be delayed by one to two decades, com- melanin, excessive heating of the non-target tissue pared to lighter skinned patients. A “typical” may occur and could produce scarring. To illustrate Caucasian individual has a natural SPF of 0, while an this point, consider laser hair reduction, where the Asian patient may have an SPF of about 3—equivalent

8 | June 2010 | Supplement to Practical Dermatology to almost 10-times the level of protection from UV not contrast significantly with the target lesion. radiation. This natural level of protection is demon- Therefore, a small spot size is important to efficiently strated by lower rates of skin cancer in ethnic skin. deliver energy directly to the target lesion without For example, one study found that Japanese individu- irradiating the normal surrounding tissue with its com- als living in Hawaii had about a 10-time lower inci- petitive chromophore of normal melanin. dence of skin cancer compared to Caucasians. Despite Other features of Gemini enhance its usefulness to this natural SPF, Asian patients develop other common treat lentigines and freckles in Asian skin. To mini- signs of photodamage, such as freckles, lentigines, and mize the risks of hyperpigmentation and scarring, epi- seborrheic keratoses in their 30s through 50s, after dermal cooling is critical throughout the laser treat- which time wrinkling tends to become a prevalent ment session, and Gemini has a very effective continu- complaint, as well. ous cooling system (Parallel Contact Cooling). Additionally, Gemini’s compression handpiece Gemini® for Lentigines improves treatment results. Hemoglobin in the blood We recently demonstrated the benefits of Gemini for is also a target chromophore for the 532nm wave- management of lentigines in Asian skin in a study length. The compression handpiece empties blood sponsored by Johnson & Johnson that compared the from vessels at the target treatment site, thus eliminat- Gemini 532nm long-pulse KTP laser, 595nm long pulse ing this competitive chromophore and ensuring maxi- dye laser (LPDL), 755nm LP Alexandrite, and 532nm mum thermal injury to the lentigines. QS Nd:YAG in the treatment of 40 Chinese patients The Gemini system is a long-pulse laser with a pre- with Fitzpatrick skin types III and IV.* Subjects were dominantly photothermal effect. This method of action randomized 10 to each laser and received one to four on a molecular level is considered gentler than the Q- sessions provided four to six weeks apart. Subjects switched laser, which has a photothermal as well as were assessed three to 12 months after their last treat- photoacoustic effect. The latter is associated with ment. A majority of subjects (70 percent) treated with higher rates of inflammation and associated sequelae, the Gemini had optimal improvement after six to 12 including post-inflammatory hyperpigmentation. months, compared to 50 percent of LPDL patients after three months and 60 percent of QS Nd:YAG Optimal Therapy patients after three to 12 months. Alexandrite laser Because we have numerous lasers available in our therapy did not provide statistically significant center, we often use multiple lasers for each patient. improvement. There was no risk for post-inflammatory We believe that this is an ideal way to optimize the hyperpigmentation in the Gemini group. benefits of all the available systems A “typical” protocol for Gemini treatment for pho- while minimizing risks. torejuvenation in Asian patients begins with a single However, if I could use only REEL TALK pass of the full face using the 532nm wavelength one laser for rejuvenation (10mm spot, 20ms pulse, 7-8J/cm2 fluence). This is in Asian skin, it would “Gemini is an extremely then followed by two full-face passes with the 1064nm be the Gemini. As effective non-ablative skin wavelength (10mm spot, 45ms pulse, 4J/cm2 fluence). noted, the large Note that when treating the forehead or any other 10mm spot size facil- rejuvenation laser. And by bony area, the energy is decreased by 10 percent to itates rapid treat- combining the 532 KTP lasers improve patient comfort. ment of the full with the long pulse 1064 YAG, Following the initial full-face passes, specific lesions face, while the we can achieve non-ablative can be addressed. Just as the large 10mm spot size smaller available allows for rapid treatment of the full face, the numer- spot sizes permit skin rejuvenations in terms of ous small spot sizes available are critical to the safe direct delivery of reductions of pigmentations, and effective treatment of discrete lesions. Typically, laser energy to target fine lines, pore size and 2 the 2mm spot size is used (2ms pulse, 12-14J/cm flu- pigmented lesions vessel improvement.” ence) to treat individual lesions. As noted, a high con- while by-passing com- trast between the target and normal skin is preferred. petitive chromophores. However, the Asian patient’s normal skin tone may The compression handpiece

See Dr. Chan discuss his experience with the Gemini laser.

Supplement to Practical Dermatology | July 2010 | 9 and contact cooling improve outcomes and enhance *Study sponsored by Johnson & Johnson. Data presented at safety, ensuring that treatment is satisfying for clini- the American Society for Laser Medicine and Surgery, April cians as well as patients. ● 2010. (Abstract No. 136).

Gemini® for Photorejuvenation: A Cornerstone of the Cosmetic Practice

By William Baugh, MD Assistant Clinical Professor, Western School of Medicine Medical Director Full Spectrum Dermatology, Fullerton, CA

O2 and Er:YAG resurfacing represent the tions. Whereas ablative resurfacing is typically gold standard of facial resurfacing, but the reserved for those patients with the most extensive excellent cosmetic improvement of deep photodamage and historically has been considered an rhytides and extensive photodamage that alternative to surgical facelifts, non-ablative rejuvena- these systems provide comes with the tion is appropriate for rejuvenation in patients with Ctrade-off of significant downtime and patient discom- early signs of photodamage and therefore appeals to a fort. Ablative fractional resurfacing has very wide range of patients, beginning with those in become a popular alternative for their late 30s. For the majority of photorejuvenation The resurfacing with good efficacy procedures in my practice, I use the Gemini combina- Gemini has many for deep rhytides and photo- tion 532nm KTP/1064nm Nd:YAG laser (IRIDEX). potential advantages damage but with less The 532nm component allows for high affinity treat- downtime and improved ments of solar lentigos and facial telangiectasias (two over other lasers. The comfort. A third option of the most common changes seen with photodamage). combination of the two for photorejuvenation The Gemini has also been shown to stimulate new col- commonly-used wave- is minimal downtime, lagen formation within the papillary dermis, and thus lengths makes the device non-ablative rejuvena- a subtle smoothing effect can be appreciated in many tion that provides great cases. very versatile. Furthermore, tolerability and modest the Gemini system is excep- improvement of wrin- Photorejuvenation Procedures tionally easy to operate kling and other signs of The Gemini has many potential advantages over other and can be used on vir- photodamage, including lasers. The combination of the two commonly-used solar lentigos and facial wavelengths makes the device very versatile. The tually any skin type. telangiectases. Non-ablative Gemini system is exceptionally easy to operate and rejuvenation can literally be a can be used on virtually any skin type. The 1064nm “lunchtime procedure,” with mini- component allows for treatment of dark skin with mal patient discomfort and little risk of minimal risk of post-inflammatory hyperpigmentation. adverse events. I perform a variety of treatments with the Gemini, Non-ablative rejuvenation can have broad applica- some as stand-alone treatments, others in combination.

10 | June 2010 | Supplement to Practical Dermatology patients in a given period of time. For the end-user, it is a user-friendly, high-performance system. There are a variety of potential settings available with the Gemini, which is an important feature, as no one protocol fits all patients. With that caveat, a “typi- cal” protocol might be as follows. For photorejuvena- tion with the Gemini laser, I might begin with a 2mm spot size and specifically treat individual lentigos and blood vessels with pulse durations ranging from 6- 20ms and fluences ranging from 6-16J, depending upon what is treated. This is often followed by treat- ing with a 4mm spot size at 30ms, and 12J in a "paint- ing" technique over the face. The Venus i laser then is introduced, with focal spot treatments over dominant lentigos, followed by a single pass utilizing a 2-7mm spot, 300-600mJ at around 10pps. Specific customization and sculpting can be per- formed for each patient according to his/her desires and specific problem areas. Overall, I can complete The large viewing window allows visualization of target ves- this entire treatment in about 30 minutes for an aver- sels treated with the Gemini. age patient. Most patients peel in about a week and then marvel at the reduction in the appearance of sun Combination photorejuvenation with Venus i™ (2940nm damage. Erbium laser, IRIDEX) laser mini-peel is very popular in my practice. In this case, I usually perform the stan- Weighing the Options dard Gemini-based photorejuvenation immediately fol- Of course, every device has limitations, and there is lowed by the addition of a light Erbium laser peel. The no perfect laser. However, I believe the Gemini has advantage to this procedure is increased uniformity of some of the fewest limitations. With the 1064nm com- the treatment, since the entire face will be induced to ponent I am not significantly limited to treating only peel together as opposed to focal spot peeling which lighter skin but can treat virtually any skin type. The can occur with purely non-ablative procedures. Once Gemini has a large range of spot sizes available at the the patient stops peeling (usually in about seven days operator’s finger tips. Simply dialing a knob allows the depending upon the depth of the peel), increased uni- operator to change from a 1mm spot size incremental- formity and smoothness of the complexion can be ly through to a 5mm spot size with any specific size appreciated. available in between. With a quick cord change of the hand piece, I can change to the 10mm spot size in a Advantages of Gemini® matter of seconds. The Gemini has the largest spot The Gemini offers many features that make it prac- size—10mm—available for a 532nm laser. tice-friendly and easy to operate. It has a clear sap- The Gemini’s greatest strength is its versatility. A phire window through which the laser beam is emit- physician or practice considering purchasing any sys- ted, permitting visualization of anatomic targets. The tem may be most concerned with costs. Systems vary Gemini cooling method is called "parallel contact cool- in price; most are expensive, but some low-cost ing," which in my experience is the best available options are available. I firmly believe you get what method. It provides cooling of targets before, during, you pay for. In my experience, the Gemini has been and after energy output. The handpiece configuration well worth the investment. It offers an excellent safety is simple to use, and the manual touchscreen allows profile, predictable results, and reliable performance for quick and easy treatments. In a healthcare envi- (repairs, though rarely needed, are provided quickly in ronment where time is money, this laser facilitates your office by IRIDEX technicians). It has been a cor- rapid treatments, enabling the physician to treat more nerstone of my cosmetic dermatology practice. ●

Supplement to Practical Dermatology | July 2010 | 11 Treatment of Facial Vascular and Pigmented Conditions with the VariLiteTM Laser System

Jerome Garden, MD Professor of Clinical Dermatology and Biomedical Engineering, Northwestern University, Chicago, IL

he unique combination of the 532nm and the variously sized facial vessels, background redness, and 940nm diode laser in the VariLite Laser pigmented lesions, the VariLite is well tolerated and System (IRIDEX) and its application in either the post-procedural reactions are temporary and a single pulse or scan delivery mode provides acceptable. the clinician a unique opportunity to treat Vessels generally respond well after one to three Tindividual vessels and pigmented lesions as well as dif- treatments. These treatments are typically spaced at fuse erythema of the face. The distinctive 940nm least six weeks apart. Lentigines respond to one to two wavelength is particularly useful for larger vessels, treatments. All patients develop some post-procedural including those with a blue rather than red tone. erythema, which can last from one to four days, while Patient-Focused Cosmetic Care lentigines become tran- There are two basic elements to enhancing success in siently darker after REEL TALK the management of patients. First, the clinician must treatment. These “The VariLite system is a understand the patient's individualized goals and con- changes gener- wonderful choice for those people cerns—accomplished through an in-depth consultation ally do not with the patient allowing for the necessary amount of prevent who want to enter into the laser time. Second, the clinician must be able to effectively patients arena. Because many, many patients meet those goals. Without doubt, correction of photo- from have vessels which naturally occur as damage is a very common request from patients, with resuming they grow older or especially those who many patients seeking specifically to remove telang- their daily iectatic vessels and lentigines. Another related com- activities, develop rosacea later in life, this is mon request is treatment for rosacea, where the but something that many practices have the emphasis again is on vessels in addition to diffuse ery- patients need for treatment. And because there thema. should is such ease of use and it is a reliable The patient's clinical outcome is just one element to forego consider, as patients also have practical expectations treatments system, I always suggest to those who about procedures and recovery. Increasingly, patients before a sig- ask me, what system should I start off will poorly tolerate significant downtime, intra- or nificant social with, I feel that this is definitely post-operative pain, or notable side effects, such as engagement. one of them that they should purpura, crusting, scarring, etc. The VariLite, with the combination of 532nm and VariLite Laser strongly consider.” 940nm wavelengths, allows the clinician to customize System treatment to meet the aesthetic and practical goals of Dual wavelength hand- many patients. In addition to its efficacy in treating pieces are available with the

See Dr. Garden discuss his experience with the VariLite laser.

12 | June 2010 | Supplement to Practical Dermatology VariLite with 0.7, 1.0, discrete thermal zones over large treatment areas. By 1.4, 2.0, and 2.8mm leaving zones of untreated tissue, this method of ener- spot sizes, allowing gy delivery allows for thermal dissipation, which the operator to trace reduces the risks of side effects associated with exces- out fine vessels or sive thermal damage. The ScanLiteXP is suitable for rapidly treat larger treating larger areas. areas. The VariLite The VariLite is a user-friendly, portable laser system offers the that provides clinicians a great deal of versatility to ScanLiteXP, an opti- optimize and customize the treatment approach to cal scanning hand- each individual patient. The distinctive 940nm wave- piece, for use with length—able to treat darker skin types, as it does not the 532nm wave- compete with melanin as much as the 532nm wave- length. The length—is effective for the treatment of larger vessels. ScanLiteXP offers Combined with the 532nm wavelength, the VariLite MicroSpot™ precise laser system allows the clinician to treat a variety of energy delivery in the more common facial photodamage concerns. ●

Rendering of MicroSpot energy deposition made possible with the ScanLiteXP handpiece.

The VariLiteTM for Fundamental Cosmetic Applications

David J. Goldberg, MD, JD Clinical Professor of Dermatology, Director of Laser Research, Department of Dermatology, Mount Sinai School of Medicine Director, Skin Laser & Surgery Specialists of New York and New Jersey

or many patients and some clinicians, the notion of one machine allows the clinician to treat treating “vascular lesions” typically calls to mind red a sizable proportion of cosmetic derma- telangiectases, diffuse erythema, and deeper red tology patients. The clinical reality is vessels. Yet, for a number of patients, visible blue that a majority of patients present vessels can be just as troubling as red ones. Until to the dermatologist for treatment Frecently, the only laser that provided any possible utility of both red and blue vessels, for the treatment of blue vessels or purpura was the lentigines and freckles, diffuse 1064nm Nd:YAG laser. However, treatment was associated erythema, and dyschromia. Treat- with a significant incidence of pitting. The 940nm wave- ment for these common presenta- length—available in the VariLite (532nm KTP/940nm diode tions can now be provided with a laser, IRIDEX)—efficiently targets blue vessels with a sig- single laser. VariLite is unique in nificantly decreased incidence of pitting. the combination of wavelengths

Meeting Patient Demand Rendering of the 940nm wavelength The combination of the 532nm and 940nm wavelength in destroying a vessel.

Supplement to Practical Dermatology | July 2010 | 13 See Dr. Goldberg discuss his experience with the VariLite laser.

REEL TALK the system offers and, offers remarkable convenience for a practice. A variety of “One of the great things therefore, the diver- handpieces and spot sizes are available. The device is small about being in the laser field is sity of vessels and and lightweight, allowing it to be moved easily from room vascular and pig- to room or even from one practice location to another. there are new lasers that come out mented lesions The system is easy to use, with no difficulty associated every day. It makes it a very exciting it targets. with swapping handpieces or changing spot sizes. Other arena to be in. The problem is the pop- Treatment modular systems offer different wavelengths, but switch- ular machine of today, unfortunately, with the ing from one wavelength to another can be a challenge. VariLite is With the VariLite, changing from one wavelength to anoth- often becomes the machine that you associated er can literally be done with one hand. don't need a year from now. The VariLite with a signif- is tried and true. The wavelengths—532 icant level of A Foundational System nanometers, 940 nanometers—they patient com- By combining into a single system the ability to treat both fort. Patients red and blue vessels, and pigmented lesions, VariLite work. We've had the machine for sev- do not experi- enables a clinician to treat a very wide range of fundamen- eral years. It doesn't break down. ence pain or tal cosmetic concerns. As such, the 532nm KTP/940nm Patients send their friends. It's a notable discom- diode laser may represent a reasonable option for a clini- great machine to have in the fort during treat- cian just starting out in cosmetic laser surgery. The VariLite ment, which can take will not provide improvement in skin texture and wrin- office.” as little as five minutes kling, however, treatment pairs nicely with other popular for discrete vessels. There is cosmetic procedures, such as fillers and botulinum toxins. no downtime following treatment. These additional cosmetic services can be provided in the Patients should expect to undergo three treatments, pro- same visit. The VariLite can provide a basis for building a vided about a month apart. Vessels have a tendency to cosmetic practice with ample opportunity to incorporate return, so patients should also anticipate maintenance additional complementary laser systems, such as one of the treatments at intervals (up to a year apart). many that target texture, as demand grows. The VariLite is an affordable system that offers ample opportunity to make Meeting Clinicians’ Needs a return on the investment. It meets the demands of cos- In addition to its versatility of applications, the VariLite metic patients and needs of busy clinicians. ●

VariLiteTM: A Reliable, Predictable Tool for Vascular and Pigmented Lesions

C. William Hanke, MD, MPH Visiting Professor of Dermatology, University of Iowa, Carver College of Medicine Clinical Professor of Otolaryngology Head and Neck Surgery, Indiana University School of Medicine

ike many cosmetic laser surgeons, I treat a been satisfied with the consistency of treatment out- number of patients seeking improvement of comes for any single device. The dual-wavelength fine linear vessels and larger vascular lesions. 532nm KTP/940nm diode VariLite laser (IRIDEX) is While different laser systems have proven use- the first laser that facilitates reliable, effective, and L ful for these different indications, I had not efficient treatment of linear vessels of all sizes.

14 | June 2010 | Supplement to Practical Dermatology

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The patient above is shown before (left) and after (right) treatment with the VariLite.

A Problem Solved darker skin. We have utilized the VariLite for der- Historically, the argon laser (488-514nm) was first used matosis papulosa nigra (DPN) with good results and for the treatment of linear vessels. However, mainte- no complications. nance issues arose in our practice, and we had diffi- culty finding replacement parts, leading us to abandon A Safe and the argon laser. The 532nm KTP laser is effective for Reliable Option fine linear blood vessels, but some patients had dis- The VariLite has become a comfort and post-operative crusting. An alternative, frequently-used tool in the 595nm pulsed dye laser, lacks versatility. In my our practice for the experience, PDL and KTP lasers are more effective for management of ves- The VariLite 940nm smaller blood vessels than large linear ones. sels and pigment- laser (and 532nm KTP dual The VariLiteTM solved our clinical problem by allow- ed lesions. system) solved our clinical ing us to change wavelengths to effectively treat small Unlike some problem by allowing us to linear blood vessels as well as larger and deeper ves- older lasers, it sels and other vascular and pigmented targets. is a reliable effectively treat small linear Treatment of linear blood vessels with the 940nm system, blood vessels as well as larger wavelength is relatively painless, and post-operative requiring no and deeper vessels and other crusting is non-existent. Results are instantaneous for significant vascular and pigmented targets. most sites. Linear blood vessels on the nose, however, maintenance may need to be retreated several times, with treat- or consum- Treatment of linear blood ments administered at four-week intervals. ables. The vessels is relatively painless, With any treatment, patients usually have tempo- 532nm/940nm and post-operative crusting is rary post-operative erythema, but there is no down- system has pro- non-existent. Results are time. Many patients do not require anesthesia, vided consistent although patients can select topical anesthesia if they results in patients of instantaneous for most wish. For treatment of facial vessels, our most com- various skin tones with sites. mon laser parameters are 1mm spot size, 140 J/cm2. a high degree of patient The VariLite is safe and effective for treatment of comfort and satisfaction. ●

Supplement to Practical Dermatology | July 2010 | 15 IRIDEX, IRIDEX logo, and Gemini are registered trademarks; and VariLite, ScanLiteXP, MicroSpot, Venus i are trademarks of IRIDEX Corporation.

IRIDEX ❘ 1212 Terra Bella Ave. ❘ Mountain View, CA 94043 ❘ 800.388.4747 (US inquiries) ❘ [email protected] (US & int’l inquiries ) ❘ www.iridex.com

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