Fractional Ablation Course V Ver 1.0 VENUS CONCEPT Welcome to Course V, Fractional Ablation. This course is designed to give you a basic understanding of fractional ablative techniques and what you will need to know when using Venus Concept devices. Fractional Ablation Course V Ver 1.0

DISCLAIMER The purpose of this course is to review basic skin anatomy and to provide general guidelines to safely and effectively determine the correct Venus Concept Device to select for your patients aesthetic goals. The clinical education in this presentation is for review purposes and does not substitute the clinical judgment of the physician nor is it intended to replace formal training in aesthetic medicine procedures.

Contents In this course you will learn: The history of fractional ablation How to choose the right ablative technology Proper settings for the Venus Viva Fractional Side effects and

What is the ideal device? Able to control ablation and coagulation ration Considerable dermal heating (but avoiding bulk heating) Reduced pain Safe - low occurrence of side effects (such as PIH) Low operating cost Fast treatment time The ideal device for fractional ablation would offer a combination of ablation and coagulation – allowing the physician to choose how much of each is necessary for each condition. The dermal heating pattern would be consistent but not so intense as to cause incidences of PIH. The pain would be tolerable and controlable as well, the cost would not be prohibitive. Speed in treatment would be a necessity.

Why Do We Need Coagulation? Coagulation – denaturation of the damaged proteins when they are exposed to high temperatures. The high temperatures affect the bonding within the protein's structure, causing them to lose their normal shapes and leading them to the cell death pathways. Thus making our body to produce a new protein  firmer skin  rejuvenation. Recently it has been shown that repetitive, controlled pulsed heat exposures can stimulate an increased synthesis of pro-collagen I and pro-collagen III by fibroblasts in vitro. Two seconds heat shocks exposures to 45°C were able to induce fibroblasts to produce pro-collagen I and III with a peak synthesis at 35 days, slowly decreasing after 90 days. Repetitive mild thermal stress has proven effective in providing an hormetic tool to be used in skin rejuvenation, maintaining a good intracellular stress protein profile responsible for reducing accumulation of oxidatively and glyco-oxidatively damaged proteins while stimulating proteasomal activities aiming to degrade damaged proteins and improving cellular resistance to other stressful conditions. Coagulation will denature collagen and assist in the regeneration process.

Why Do We Need Ablation? Ablation – removal of tissue by vaporization (a phase transition from the liquid phase to gas phase) For a laser to ablate tissues, the power density or fluence must be high, otherwise thermocoagulation occurs, which is simply thermal vaporization of the tissues. With an ablative device we can treat both the epidermis and the dermis to remove various lesions, age spots, aged skin, wrinkles, and thus rejuvenating the skin. Ablation is necessary to remove the tissue that we want to regenerate and resurface. The heat caused by the RF allows for the tissue to be vaporized and coagulation to begin. Ablation is both epidermal and dermal. Epidermal ablation assists with the pigment and visible vascular concerns and the dermal ablation addresses surface irregularities as well as vascular lesions, pigment and overall skin rejuvenation.

Ablation, Coagulation and Dermal Heating FractionalNeedle RF 3rd Generation Fractional RF 2nd Generation Fractional RF Er:Glass Both coagulation and ablation are needed and the degree of which is oted by the indication being treated. As you can see, each device has it’s “specialty” or area which it is best in as it will address the most important features of that particular indication. However, no deice combines the options of all the levels of ablation and coagulation as the venus viva does. Local coagulation and minimal dermal heating Marginal ablation and full dermal heating Ablation, Coagulation and marginal dermal heating Coagulation and marginal dermal heating Ablation, coagulation and full dermal heating

CO2 Laser – Introduced in 1970 In the 1970’s CO2 laser made a debut and it was the gold standard for ablation. Today we still use CO2 full ablation as common practice in surgery environments as an aggressive means to resurface the skin. In this process both the epidermal and first strata of the dermis are completely removed, leaving the skin with a global wound. The healing and downtime are signifgant as is the discomfort. It is challenging to treat darker skin types and the complications that arise are signifigant in their presentation. Hyper / hypo pigmentation, demarcation lines, infection and scarring are just a few of the common concerns that occur post treatment. Since most patients do not have skin concerns that require this aggressive a solution nor do the challenges and downtime satisfy their needs, the evolution of fractional treatments was born.

Fractional Lasers – Introduced in 2004 Around 2004 the laser market grew to include fractional ablation. Fractional ablation means that a portion of the skin is ablated / vaporized, while another portion is left in tact to assist in healing the damaged tissue. Fractional lasers deploy columns of energy into the skin and partially wounded the tissue allowing for healthy, intact tissue to surround the columns of damaged tissue. The healthy tissue would encourage faster healing time and less of the epidermis / dermis would be compromised. This allowed for less pain, less downtime and less risks. The main issues we faced were that the columns of energy allowed only for specific pin points of damage and did not allow us to spread the damage under the epidermal layers without compromizing the epidemis. As well, laser energy can be challenging to use on darker skins as the attraction to melanin can cause hyperpigmentation in the lesions that were created. Many patients saw incidents of PIH (post inflammatory pigmentation) to the treated areas.

Fractional RF – Introduced in 2008 2008 bore the first RF (radio frequency) fractional ablation technology. The design was simple and allowed the majority of the damage that was created to be present in the dermis leaving the epidermis mostly in tact. The common concerns were blisters and burns as the arcing issues with RF were not resolved, the contact with the tissue was challenging over areas of bony prominence or oily skin. Keeping the tissue very dry became an issue as the moisture caused impedance of the energy. The RF delivered to the tissue in a pulse and this large amount of energy in one pulse was still very uncomfortable.

Fractional Needle RF – Introduced in 2010 In 2010 the market expanded to include needle based solutions which gave the provider an opportunity to pierce the epidermis and then selectively heat just the dermis by delivering the RF at the base of the needles. The discomfort and complications with these systems was apparent and thus are not as widely used in the market today.

INTRODUCING THE NEW GOLD STANDARD IN FACIAL REJUVENATION TREATMENTS Venus Viva is a special technology – nano-fractional RF resurfacing. By using RF to resurface and partially or fractionally ablate the skin, we can safely treat all skin types and reslove the issues faced with previous resurfacing solutions. First, let’s look at the evolution of ablative and partially ablative technology.

160 pins per tip with 62 mJ/pin small footprint per pin (150X20 Microns) 1000 pulses Adjustable ablation 100-250 microns with dermal heating up to 500 microns SmartScan™ Pattern generator Enter the Venus Viva. Our system has 160 pins with a 150 micron pin size which is roughly half of any pin size on the market. Why is this important? The smaller the pin, the smaller the wound and the less that the downtime and pain will be. The footprint is ergonomic and creates a shape that fits perfectly on areas of bony prominence. The depth we can acieve is between 100 – 500 microns. Between 500-700 microns is where the most activity is for collagen rejuvenation so the depth we are achieving is optimal to allow for maximum results with less downtime. The SmartScan refers to how we deliver our RF. When four pins are active, the other 156 pins act as a return. Then the next four pins and so on. As the energy moves through this algorythm, we reduce the bulk heating caused by other systems. This reduces the incidents of PIH and also allows for a more comfortable treatment. The pattern generator technology provides an opportunity for the provider to select what areas they wish to treat and how many pins will be active. This is excellent for more gentle treatments and for small areas such as the upper lip or nose.

This is a tip displaying the 160 pins and ergonomic shape This is a tip displaying the 160 pins and ergonomic shape. By selecting partial pins you are essentially “shutting off” groups (4 pins in a group) at a time and allowing for the energy to be emitted from just the pins that are active. In pattern mode you can select to have half the pins active (every second group of four are shut off), the right or left three columns, and / or the upper two rows.

Highest current density is below the pins, then the current expands to larger volume of the skin. Since the outermost layer of skin is less conductive, more current will flow in the inner more conductive layer. Our RF heating pattern allows for deep dermal heating while preserving the integrity of the epidermis. The heat generated from RF begins a the surface and spreads much like an ellipse under the skin. Depending on the setting chosen, the greatest degree of heating damage will be either relatively superficial (100 microns) or more aggressive and deep (500 microns). Both leave the epidermis mainly in tact with only a portion of the damage visible to the naked eye.

Better Control of Clinical Effects Basic Mode MD Mode Treatment Depth, Coagulation The Venus Viva Fractional offers two screen choices, basic and MD. The Basic mode offer 270 volts as a constant means and changes the ms to allow for higher % of overall energy. The advanced screen offers the variable of 220 – 280 volts over 5-30 ms. MD mode is the screen preferred by most clinicians as you have control over the amount of ablation (volts) vs coagulation (ms) you wish to attain with your patient. Ablation & imprints Working area Working line Power Power Pulse duration Pulse duration E = Power x Pulse Duration (msec)

Ablation & Coagulation 220V 280V 5ms 30ms Ablation Coagulation Longer ms will deliver more coagulation while higher volts will equate to more ablation. Often it is a combinationof both ablation and coagulation that you will wish to deliver to the patient as you will increase your overall energy delivered per treatment by 10% in total. So if you offered 50% energy in the first treatment, you will offer 60% in the second by increasing the ms and volts according to the indication you wish to treat. A full description of indications is included on the treatment parameters sheet. Use this sheet to determine beginning parameters and test spots for each of your patients. It is recommended that you perform three test spots on each patient prior to treatment. Wait 24 – 48 hours post the test spots to determine what your settings will be for their first treatment. A test spot will aloow you to see some erythema and edema immediately post treatment. Some patients may have pin point bleeding in the area which will resolve immediately. After the 24-48 hour period of time has passed, the patient should have a visible lesion in the area that is light to moderate borwn =, crusted over with a tiny series of scabs which may be visible to the naked eye. If erythema and edema remain in the area, there is excessive pain, bleeding or blistering, do not administer the treatment and investigate the cause of the patient response. If there is no response to the test spots, the settings chosen were too mild and it is advised that you increase the setting on your first treatment slightly to anticipate a response from the tissue. Power Pulse duration TOTAL ENERGY E = ƒ(power,time)

Although the system is completely flexible allowing you more options that low, medium and high, we want you to observe the difference between a mild to more impactful test spot / treatment one day post. This is seem with a magnifier. The most aggressive area will have more visible demarcations seen at a conversational distance but certainly it can be concealed with regular make up if desired. After 3 – 7 days the skin lesions seen will flake off and the tissue will appear smooth and free of any damage. Low Medium High

Pre-clinical Biopsy immediately post treatment Highest setting Lowest setting The system allows you to select volts and ms which roughly co-related between ablation and coagulation. The reason one might want a more shallow wound is for maintenance treatments, patients desiring less downtime, and pigmentation lesions which mainly reside in the epidermal layers. The deeper layers containing acne scarring and surface irregularities will require more ablative treatments. The ablation and coagulation can be seen in this histological slide.

THANK YOU!!! www.venusconcept.com www.venustreatments.com Fractional treatments will deliver a solution for patients wishing to address their pigmentation lesions, scarring, vascular lesion and deep / fine wrinkles. With safely delivered nano-fractional treatments you will be able to treat all skin types for a variety of conditions with little to no downtime.