1. 2002 2007

2. Contour TM 2940nm Er:YAG ThermaScan TM 1319nm Nd:YAG ClearScan TM 1064nm Nd:YAG BBL TM 410-1400nm Intense Pulsed Light Personalized For Your Practice New Modules 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

3. Sciton Profile Hair Removal Sciton Profile Hair Removal

4. Hair Removal Hair Removal Electrolysis Electrolysis Creams Creams Laser Laser Microwave Microwave Ideally only destroys source of keratin in hair-bearing skin

5. Regrowth and Removal With Electrolysis Regrowth and Removal With Electrolysis Patient: Age, Race, Sex % of Hair Killed 21 yr. old white female 30 yr. old black female 40 yr. old white male 53 yr. old white female 41 yr. old white female 27 hairs of 46% 35 hairs or 30% 23 hairs or 54% 36 hairs or 38% 30 hairs or 40% 19 hairs or 62% 22 hairs or 56% 17 hairs or 66% 18 hairs or 64% 22 hairs or 56% Average Percent Killed: Needle = 40%, Tweezer = 60% NeedleTweezer

6. 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

7. Target Isolation Can we target over other similar targets? Can we target over other similar targets? (Can we seek melanin in hair over skin?) (Can we seek melanin in hair over skin?) Selective Photothermolysis

8. 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

9. 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

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

11. Features Wavelength: nm Power: watts Fluence:power/cm2 Spotsize: mm Overlap: % Pulsetime: ms Pulse interval: ms or freq Features Wavelength: nm Power: watts Fluence:power/cm2 Spotsize: mm Overlap: % Pulsetime: ms Pulse interval: ms or freq

12. Thermal Containment Time(TCT) re: The Target The specific time for energy to create reaction without dispersion The specific time for energy to create reaction without dispersion too short: will not heat to 70 C too long: complete dispersion cooling Determined by pulse width=duration

13. Thermal Relaxation Time(TRT) RE: avoid injury to competing chromophores Determines the shortest interval between pulses Determines the shortest interval between pulses The time for 51% of heat reduction by The time for 51% of heat reduction by dispersion and cooling cooling proportional to: proportional to: 1. the square of spot size 2. pulse duration, providing it is > TCT

14. Time of the pulse Pulse duration should be longer than TCT and Pulse duration should be longer than TCT and Pulse interval longer than TRT Pulse interval longer than TRT This commonly protects other components with competing chromophores. This commonly protects other components with competing chromophores.

15. Hair Hand Pieces w/cooling

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

17. Skin Cool Technology

19. Energy Distribution Energy Distribution Comparison of a 10 mm diameter Gaussian spot with a 6.4 mm diameter square (Top Hat) spot. The square distribution delivers useful energy to a larger spot.

20. When pulses are applied next to one another, the epidermis heated by the first pulse may still be warm when the second pulse arrives. The “double hit” or “pulse stacking” can result in blisters. The problem will vary with the amount of overlap, which is not well controlled with hand delivery. A model of this effect is shown in the next slide. This is another reason to use a scanner with a large area cooler. With a small fixed window or plate cooler, there is no cooling of the previous spot. Pulse Stacking: A Problem With Hand Delivery of Pulses

21. 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.

22. Pulse time? Pulse time? Treat hair shaft Treat hair shaft –TCT 6-10 milliseconds Treat hair follicle Treat hair follicle –TCT 18-25 milliseconds, ie > 15 ms –TRT 35-60 milliseconds, ie > 35 ms

23. Keys for success Keys for success Wavelength: >690 nm (>wavelength=depth)Wavelength: >690 nm (>wavelength=depth) (shorter -> competing chromophores) (shorter -> competing chromophores) Spot size: at least 5 millimetersSpot size: at least 5 millimeters Pulse time: 18 or > millisecondsPulse time: 18 or > milliseconds Pulse interval of 35 or > millisecondsPulse interval of 35 or > milliseconds

24. When do you treat? During Anagen cycle During Anagen cycle Not during telogen Not during telogen Cycle time determined by Cycle time determined by Richard-Merhag chart Richard-Merhag chart

25. Richards-Merhag

26. Fitzpatrick Types OK: Fitzparick IV/VI:Nd-YAG non-confluent scanner >15 ms Continuous cooling

28. Consultation Patient history Patient history Any previous hair methods Any previous hair methods Expectations Expectations Treatment explanation Treatment explanation Photographs Photographs Consent Consent Periprocedure instructions Periprocedure instructions

29. Contraindications Contraindications Pregnancy Pregnancy Recent sun exposure Recent sun exposure Sun tan Sun tan Suspicious lesions Suspicious lesions What about the orbit?

30. Before Treatment Shave 1-3 days before treatment (stubble) Shave 1-3 days before treatment (stubble) Avoid other methods for 30 days Avoid other methods for 30 days SPF 15+ for 4-6 weeks SPF 15+ for 4-6 weeks Avoid tanning creams Avoid tanning creams Hydroquinone if necessary Hydroquinone if necessary

31. Treatment Safety Test cooling plate, check < 5 C Test cooling plate, check < 5 C Test spot: and wait 4 weeks Test spot: and wait 4 weeks No overlap No overlap Mark landmarks with red pen Mark landmarks with red pen Protect gums with Al foil if over area Protect gums with Al foil if over area

32. What is the endpoint ? Small contact spark/flash Small contact spark/flash Smell of burnt hair Smell of burnt hair Perifollicular edema Perifollicular edema Sensation of light sunburn Sensation of light sunburn One in three hairs extrude One in three hairs extrude

33. Hair Chronology Redness: 4-6 hours after treatment Redness: 4-6 hours after treatment Hair appears to grow for several days Hair appears to grow for several days Hair falls out: day 10-14 Hair falls out: day 10-14 Hair reappears, next phase: >3-6 weeks Hair reappears, next phase: >3-6 weeks Treat again: >= 6 weeks later Treat again: >= 6 weeks later

34. Complications of Laser Hair Removal Blistering Blistering Hypopigmentation Hypopigmentation Hyperpigmentation Hyperpigmentation Scarring Scarring

35. Profile System Features Pulse Length: 0.1 to 200 milliseconds Pulse Length: 0.1 to 200 milliseconds Wavelength: 1064nm Wavelength: 1064nm Fluence: 20 to 120 Joules/cm 2 - Hair Fluence: 20 to 120 Joules/cm 2 - Hair 30 to 400 Joules/cm 2 - Vascular 30 to 400 Joules/cm 2 - Vascular Contact Cooling: Pre, During, Post Contact Cooling: Pre, During, Post Power Capacity:200 watts Power Capacity:200 watts Scanning: Computer Controlled, Scanning: Computer Controlled, Non-sequential Non-sequential

36. Profile Clinical Advantages Maximum Hair Count Reduction Per Treatment Maximum Hair Count Reduction Per Treatment Treats All Skin Types Treats All Skin Types Minimal Pain Minimal Pain Designed for Safe Operation Designed for Safe Operation Highest Speed Highest Speed No overlap required: Top hat pattern of injury No overlap required: Top hat pattern of injury

37. Summary of Factors Influencing Success Versus Safety of Therapy Appropriate settings: fluence ( > 40 J/cm2 ), Appropriate settings: fluence ( > 40 J/cm2 ), spot size ( 5mm or greater ), spot size ( 5mm or greater ), pulse duration ( >18msec ) & pulse duration ( >18msec ) & pulse interval ( >35msec ) pulse interval ( >35msec ) ‘top-hat’ non-sequential scanning ‘top-hat’ non-sequential scanning Percentage and density of anagenic hairs Percentage and density of anagenic hairs Fitzpatrick skin type: competing chromophore Fitzpatrick skin type: competing chromophore Percentage of Eumelanin versus red, grey or blond hair Percentage of Eumelanin versus red, grey or blond hair Cooling for at least 3 seconds Cooling for at least 3 seconds Angle of hair follicle ? 1/15 patients, beware of promises Angle of hair follicle ? 1/15 patients, beware of promises

38. Patient Instructions Patient Instructions Pretreatment Avoid sun exposure 4-6 weeks prior to laser Avoid sun exposure 4-6 weeks prior to laser Avoid bleaching, plucking, waxing for 4-6 weeks Avoid bleaching, plucking, waxing for 4-6 weeks Start bleaching regimen 4 weeks prior if tan easily or prone to pigmentation Start bleaching regimen 4 weeks prior if tan easily or prone to pigmentation Avoid laser interacting medications for at least 10 days prior to laser ( see list ) Avoid laser interacting medications for at least 10 days prior to laser ( see list ) At time of Laser Prep and shave skin with hibiclens Prep and shave skin with hibiclens Protect upper teeth with saline soaked gauze Protect upper teeth with saline soaked gauze Protective external eye shields is used Protective external eye shields is used No oxygen to be used in same room No oxygen to be used in same room Cooling device is applied to all areas lased: 3 second rule Cooling device is applied to all areas lased: 3 second rule After Laser Redness to the skin may last a few hours Redness to the skin may last a few hours Then resume bleach cream o: 4% hydroquinone with or without sunscreen Then resume bleach cream o: 4% hydroquinone with or without sunscreen Makeup may be used Makeup may be used Avoid sun exposure for 6 weeks Avoid sun exposure for 6 weeks Follow-up and or pretreatment in 4-8 weeks Follow-up and or pretreatment in 4-8 weeks Up to 5 treatments to each site may be necessary for permanent hair removal Up to 5 treatments to each site may be necessary for permanent hair removal

39. Preoperative Laser Safety Check List Equipment Check marking pen marking pen pattern sheet pattern sheet head light head light cooling device to 4 degrees C: no bubbles cooling device to 4 degrees C: no bubblesProcedure: adjust ceiling lights adjust ceiling lights confirm laser hazard sign on door light and lock door confirm laser hazard sign on door light and lock door place protective glasses on pt and all in room place protective glasses on pt and all in room gum protection: moist gauze and Al foil gum protection: moist gauze and Al foil move laser with arm in locked position to correct position move laser with arm in locked position to correct position take key to laser and turn on laser take key to laser and turn on laser turn on fan turn on fan place on standby place on standby dial desired settings dial desired settings release arm from lock release arm from lock perform procedure: maintaining>= 3 second skin contact with cooling devise perform procedure: maintaining>= 3 second skin contact with cooling devise

40. Examples of Clinical Results SiteFitzpatrickHair Settings Treatments Color Quality rate fluence width to satisfaction Color Quality rate fluence width to satisfaction Axilla 4 black course 5.8 46 35 5 Axilla/bikini 3 black course 5.9 45 35 5 Bikini/thigh 2dk brown course 4.46035 7 3.47835 7 Bikini 4 black course4.63635 5 Axilla 5 black course7.73035 5

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42. Anticipated Income Anticipated Income Income:LowHigh ½ day examples: 95 sideburn 125 underarms 250 thighs 250 forearms 500 lower legs n=10 patients75 test patch 105 bikini400 250 neck 500 lower legs 75 test patch ½ day collection$2225$5000+ Full day* collection$3560$7120+ * n=16 patients * n=16 patients