1. Polaris WR Clinical Review and Technique Michael Kreindel, Ph.D. Thomas Goslau

2. Part I Mechanism of Collagen Remodeling

3. WR Mechanism of Collagen Remodeling Before  Collagen has high density with small intrafibrilar spacing that prevents growth of new fibers and limits the blood supply.

4. WR Mechanism of Collagen Remodeling Immediately After  Deep edema, intrafibrilar spacing is increased due to release of liquids from lymphatic and vascular systems.  Fibers are separated and oriented chaotically.  Edema and erythema appear.

5. WR Mechanism of Collagen Remodeling 3-weeks After  After edema decreases the collagen maintains enlarged intrafibrilar spacing which is filled with new collagen.

6. Before 3-weeks After Side by Side Comparison

7. Before 3-weeks after Collagen fiber has more chaotic orientation at a depth of 0.5-2mm. -0.5 -0.0 -1.5 mm Remodeling Depth

8. What is the end point?  Erythema is responsible for superficial improvements: fine lines, skin texture  Edema is required for deep wrinkle improvement and change of shape

9. Part II Treatment Tips and Parameters

10. Treatment Targets - Polaris WR  Skin Tightening (face and body)  Laugh Line (nasalabial fold)  Enlarged Pores  Acne Scars  Peri-orbital Wrinkles  Eyebrow Position  Skin Tone (lighter color)

11. Facial Treatment Zones 1.Forehead and Cheek Bone - over bone area, sensitive to RF energy. 2.Cheeks, Nasalabial Folds - soft part of face, easy coupling, tolerates well to higher energy levels. 3.Lower Eye Area - can be treated when tissue is pulled down over cheek bone. 4.Upper Lips – sensitive to pain. 5.Chin – semi-soft area with high curvature; careful placement of electrodes. 6.Nose – RF sensitivity and curvature; careful placement of electrodes. 1 2 3 4 5 6

12. Parameters (1) Parameters (1) Starting Points  1 – Over-bone sensitive area RF 45-55 / Laser 24-28  2 – Soft part of face RF 75-85 / Laser 28-34  3 – Under eye area RF 60-70 / Light 24-26 Pulled down to over-bone area, single pulsing  4 & 5 – Semi-soft area RF 60-70 / Laser 26-30  6 – Difficult contact area RF 45-55 / Laser 22-26 strong pressing, single pulsing  Neck RF 70-80 / Laser 20  Body (soft area) RF 80-90 / Laser 28-34 1 2 3 4 5 6

13. Parameters (2) Parameters (2) Adjustments  If EMLA is used then parameters should be 5-10% higher because of vasospasms created by lidocain.  Energy can be increased by 5% during 2 nd and 3 rd treatments.  Lower laser energy for neck should be used to avoid any damage of superficial arteries.

14. Anchor Points  Anchor points contribute to better skin tightening and face shaping.  Anchor points should be treated with more passes to reach stronger edema.

15. Treatment Procedure (1)  Remove make-up from patient.  (If needed) Apply topical anesthetic approximately 1 hour prior to treatment.  Put on patient protective eyewear.  Apply thick layer of gel (2-3mm).  Set treatment parameters for most sensitive area (low settings).  Treat first over sensitive and difficult to access areas.  Repeat passes until erythema appears on treated area.

16. Treatment Procedure (2)  Set parameters for soft tissue (higher settings) areas.  Repeat passes until erythema and edema appear in treatment area.  Do more passes on anchor points  Repeat procedure every 2-3 weeks. Recommend at least 3 treatment sessions, maximum 5 sessions.

17. Treatment Tips (1)  To be safe ALWAYS use lower energy over bone areas (e.g. forehead, temple, and cheek bone).  Use single pulsing for face treatments and automatic pulse mode for body treatments.  Press firmly on skin surface with applicator, ensuring good electrode contact to skin.  If full contact of electrodes cannot be achieved, reduce RF energy by 40% (e.g. nose).

18. Treatment Tips (2)  Don’t treat in the orbital area; pull peri-orbital tissue over bone for treatment (careful to keep eye shields in place).  Stacking of pulses is dangerous and may burn.  Delay at least 30 sec between passes when treating the same area.  Pigmentation does not effect settings and results.  Some patients and areas require only single pass to achieve proper skin response, while some cases require up to 5 passes.

19. Post-treatment Care  Apply sun-protective cream after treatment.  Recommend patient to protect skin from direct sunlight for up to one week after the treatment.  Recommend alcohol-free skin care products (alcohol dries the skin).  Recommend use of skin moisturizer.

20. Part III Management of Patient Expectations

21. Patient Expectations (1)  BUILD REALISTIC PATIENT EXPECTATIONS. Wrinkle reduction (not disappearance). Skin tightening. Skin texture improvement (reduction of pores / smoother and brighter skin).  AVOID OVER-PROMISSING. Results appear gradually. Sometimes more than 3 treatments are required. Wrinkles will not disappear, but will be shorter and more shallow. Not a surgical face lift.

22. Patient Expectations (2)  The best responding patients are women from 30-45 years old with normal skin thickness (2-3 session is enough for good results).  Thin skin patients usually require up to 5 treatments with more passes (typically with settings 10% lower).  Customer satisfaction according to Japan user survey: 57% very satisfied 30% satisfied 10% see results but expected more 3% see some results but not satisfied 1% of patients had transient adverse effects during first 2 weeks that decreased to zero with improvement of treatment technique

23. Patient Expectations (3)  Clinical indications according to treatment efficiency: 1.Nasalabial folds 2.Skin tone 3.Pore size 4.Acne scars 5.Neck 6.Peri-orbital and peri-oral wrinkles 7.Eyebrow positions

24. Combination Treatments  Treat 2-weeks after and/or before injections of Botox, Retinol, etc.  Users of both Aurora and Polaris have reported that satisfaction of customers from combined treatment is much higher than from one system only.

25. Treatment Economics  90% of doctors using Polaris in Asia-Pacific region sell a package of 5 treatments for average price of US$ 2,500.  Selling a package of treatments (3-5) improves management of customer expectations.

26. Dr. A. Del Giglio, Italy – Neck Treatment

27. Dr. A. Del Giglio, Italy – Peri-orbital Lines

28. Dr. M. Kulick, CA, USA, Face Treatment

29. Dr. M. Kulick, CA, USA – Face Treatment

30. Dr. M. Kulik, CA, USA – Peri-oral Wrinkles

31. Dr. Hidemi Akai, Japan – Face Tightening

32. Dr. H. Akai, Japan – Skin Tightening (“Hip Lift”) After 3rd treatment After 1st treatmentBefore

33. Dr. E. Mihara, Japan, Face Treatment

34. Dr. E. Mihara, Japan – Acne Scars & Pores

36. Dr. E. Mihara, Japan – Skin Tightening (Hip “Lift”)