1. Rex Moulton-Barrett, MD Plastic & Reconstructive Surgery San Leandro Surgery Center

2. Botulinum A Botulinum A BoTox = Allergan BoTox = Allergan Dysport / Reloxan = Ipsen Pharm/Medicus Dysport / Reloxan = Ipsen Pharm/Medicus Mechanism of action: irreversible inhibition of acetyl choline Mechanism of action: irreversible inhibition of acetyl choline release from muscle release from muscle neuromuscular receptor neuromuscular receptor

3. Botulum Toxin Botulum Toxin Used since 1980 Used since 1980 FDA approved 2002 frown lines between eyes FDA approved 2002 frown lines between eyes FDA approves 2004 for arm pit sweating FDA approves 2004 for arm pit sweating ‘Off-label’ use since then elsewhere: forehead, lateral crows, corner mouth, neck, sweating hands, neck muscles/tension headaches ‘Off-label’ use since then elsewhere: forehead, lateral crows, corner mouth, neck, sweating hands, neck muscles/tension headaches Made in the USA bottled in Ireland: 100 U bottle Made in the USA bottled in Ireland: 100 U bottle Must be shipped cold in powder form Must be shipped cold in powder form Reconstituted in saline: 2-4 mls Reconstituted in saline: 2-4 mls Once reconstituted ? how long effective Once reconstituted ? how long effective

4. What is the End-Point ?: No wrinkles at rest or no lines of facial expression What is the End-Point ?: No wrinkles at rest or no lines of facial expression No wrinkles at rest: No wrinkles at rest: 6 treatments permanent 6 treatments permanent Must treat every 4-6 months Must treat every 4-6 months No lines of expression: requires 2 x more BoTox No lines of expression: requires 2 x more BoTox

5. Lasers Lasers Hair Reduction Hair Reduction Resurfacing: deep, superficial Resurfacing: deep, superficial Vessel Reduction Vessel Reduction Collagen remodeling Collagen remodeling Vessel Ablation: varicose veins Vessel Ablation: varicose veins Laser Liposuction Laser Liposuction

6. Contour TM 2940nm Er:YAG ThermaScan TM 1319nm Nd:YAG ClearScan TM 1064nm Nd:YAG BBL TM 410-1400nm Intense Pulsed Light Sciton Profile Laser Sciton Profile Laser New Modules:ProLipo 2007Ablative:MLP, resurface Non-Ablative: acne, vessels Pro-V Non-ablative: collagen Ablative: hair, vessels Non-ablative: collagen Ablative: hair, vessels, pigment Non-ablative collagen, acne ProFractional: micro-ablative

7. Sciton Profile Hair Removal Sciton Profile Hair Removal

8. Laser Hair Reduction Epidermis: 40 - 150 microns Dermis: 140 - 400 microns E & D: 180 >/= 550 microns 1.Papilla: neurovascular tuft 2. Bulge: at Erector Pili 3.Matrix cells:>= 2 mm Anagen> Catogen> Telogen

9. What is the Target ? What is the Target ? Eumelanin: brown or black hair Eumelanin: brown or black hair Best absorption of light Best absorption of light Pheomelanin: red or blond hair Pheomelanin: red or blond hair Poor absorption Poor absorption Gray hair: pigment-free Gray hair: pigment-free White hair No absorption

10. Hair Removal Lasers Hair Removal Lasers Nd:YAG1064 nm Nd:YAG1064 nm Flashlamp575/ 515-1200nm Flashlamp575/ 515-1200nm Diode800/810nm Diode800/810nm Alexandrite755nm Alexandrite755nm Ruby694nm Ruby694nm

11. Relative Absorption of Laser Light & Competing Chromophores 1064nm

13. Temperature in the Region Near the D/E Junction Versus Cooling Time Temperature in the Region Near the D/E Junction Versus Cooling Time D/E Junction Skin Surface X x

14. Non-sequential scan Non-sequential scan The non-sequential scan extends the time between two adjacent pulses to four times the interval of a sequential scan. In combination with the post- pulse cooling, there is adequate time for epidermal cooling. The non-sequential scan extends the time between two adjacent pulses to four times the interval of a sequential scan. In combination with the post- pulse cooling, there is adequate time for epidermal cooling.

15. Richards-Merhag

18. Relative Absorption of Laser Light

19. Vessel characteristics by size Superficial small vessels < 1 mm : telangectasia Superficial small vessels < 1 mm : telangectasia 1-2 mm, intermediate depth: venectasia 1-2 mm, intermediate depth: venectasia 2-4 mm, deeper: reticular vessels 2-4 mm, deeper: reticular vessels Definitions:

20. Photothermic effect of laser on vessel Vessel coagulation: > 62 C Vessel coagulation: > 62 C Vessel vaporization: >100 C Vessel vaporization: >100 C Vessel vaporization--> Bubble formation Vessel vaporization--> Bubble formation Bubble formation in vessel wall: collapse Bubble formation in vessel wall: collapse Vessel wall collapse: ‘Clearing’ Vessel wall collapse: ‘Clearing’ Photoacoustic effect: rupture, Pulse Dye Laser Photoacoustic effect: rupture, Pulse Dye Laser