pearl fusion technique

© 2008 Cutera, Inc. D0760_Rev. B Pearl/ Pearl Fractional Advanced Technique

Pearl Fusion Technique

Pearl Fusion Technique

Combined TreatmentAdvanced Technique

2© 2008 Cutera, Inc. D0760_Rev. B Pearl/ Pearl Fractional Advanced Technique

General ConsiderationsGeneral Considerations

The Pearl Fusion Technique is an advanced procedure intended foroperators with previous knowledge and experience with Pearl and Pearl Fractional devices, and is in no way complete. Please consult the Clinical Training CD for each of these devices for more complete information.

The decision to treat with light therapy should be based upon appropriate diagnostic evaluation and consideration of all patient factors.

The Pearl and Pearl Fractional lasers should only be operated byqualified practitioners who have received appropriate training and have thoroughly read the operator manual.

It is important to observe tissue reaction during treatment. Excessive thermal damage to the skin, or excessive depth of treatment, can result in unwanted adverse effects such as blistering, burns, erosion, hyperpigmentation, and/or hypopigmentation; some of which may result in scarring.


Why Combine Treatments?Why Combine Treatments?

Customize treatments depending on patient concerns

Surface epidermal combined with deep dermal ablation provides dual benefit

Treatments are better tolerated than comparable individual treatments

Short recovery time, about 5-7 days

Improved efficacy– Fewer residual lentigines– Overall improvement in photo-aging

• Rhytids• Texture• Mild Laxity • Scarring


Patient SelectionPatient Selection

Patients with moderate photoaging– Lentigines– Wrinkles

• Peri-oral and peri-ocular• Diffuse facial

– Textural concerns– Laxity

Also younger patients – Acne or surgical scarring – Minimal photoaging


Pre-Op – Medical HistoryPre-Op – Medical History

The following conditions are not contraindications but should be considered before treating:– Current medications (both routine and occasional use)

• Accutane (Isotretinoin) – do not treat if taken in the last 6 months

• Anti-Coagulants – may increase post treatment oozing

• Gold Therapy– May cause blue-gray discoloration

– History of vitiligo• Heat from the treatment could induce a flare-up in

patients with pre-existing vitiligo.– Wound Infections


Pre-Op – Medical HistoryPre-Op – Medical History

The following conditions are not contraindications but should beconsidered before treating:– Herpes

• Pre-treatment with an antiviral. Some physicians prescribe antivirals for all patients regardless of history

• Outbreak may impede wound healing and increase risk of scarring

– Tattoos, including permanent make-up, in treatment area• Do not treat over tattoos or permanent make-up

– Keloids or Hypertrophic Scarring– Coagulopathies/bleeding disorders– Implants or surgeries in treatment area– Do not treat over dysplastic nevi or any questionable pigmented

lesions• Evaluate lesion(s) for potential skin cancer warning signs and treat

only if diagnosed as benign• Online Melanoma Resources

– www.aad.org– www.cancer.org


Determine Skin TypeDetermine Skin Type

Fitzpatrick Skin Type ScaleI II III IV V VI

White White White - Light Brown

Light Brown - Olive

Moderate - Dark Brown

Black

Burns easily,

never tans

Burns easily, tans

minimally with difficulty

Burns moderately;

tans moderately and

uniformly

Burns minimally, tans

easily and moderately

Rarely burns; tans profusely

Never burns; tans

profusely

Current combination guidelines are for skin types I – III.


Patient Consent

Provide treatment information.– Inform of expected and

unexpected side effects.– Set realistic patient

expectations regarding downtime, usually 5-7 days, and potential results.

Pre-Op – Patient ConsentPre-Op – Patient Consent


Remove all make-up, sunscreen, etc. – Any creams or products left on the skin may interfere with the

light and may cause irregular results or unwanted side-effects.

Patient Prep - CleanPatient Prep - Clean


Patient Prep - HairPatient Prep - Hair

The beard area should be closely shaven prior to treatment.– Excess hair will interfere with the light and may cause

irregular results.


Pre-op photos are your MOST valuable tool and protection. You only have one chance to obtain good pre-op photos.

– Document baseline condition– Use for comparison purposes later on in treatment– Consistent technique is important for useful, comparable

photos.• Matched patient positioning• Camera settings• Lighting

– Cutera Photography Blog• http://blog.cutera.com/blog/clinical-photography-tips

Pre-Op - PhotosPre-Op - Photos

http://blog.cutera.com/blog/clinical-photography-tips


Commonly Used SuppliesCommonly Used Supplies

Topical anesthetic

– e.g. lidocaine; benzocaine and/or tetracaine

Some patients are offered an oral anti-anxiety or mild narcotic pre-op in addition to topical.

A cooling device, such as Zimmer, can be used during treatment.

Acetone (medical grade).

4x4 gauze pads

Wood cotton-tipped applicators

Tongue depressors

Gloves

Laser masks that filter to 0.1 µm

Smoke evacuator

Eye protection for patient and provider

Occlusive ointment – such as plain Vaseline or Aquaphor ointment


Anesthetic Application and Removal Anesthetic Application and Removal

A topical anesthetic should be applied liberally to the entire area to be treated for a minimum of 45 minutes.– Avoid getting topical anesthetic into the eyes.– CAUTION: Toxicity may result with the overuse of topical

anesthesia. Consult the manufacturer’s labeling.

Anesthetic must be completely removed before treatment.

Following removal of anesthetic, wipe the skin with medical grade acetone or alcohol, to remove any residual anesthetic.– Residual anesthetic will absorb light and may cause

irregular results.

Allow the skin to dry before treating with the laser.


Patient Eye SafetyPatient Eye Safety

Patient eye protection must be used.– Metal, laser-safe, light-

blocking patient goggles are recommended.

When treating eyelids internal corneal shields (metal, laser-safe) should be used.


Patient Prep – MarkingPatient Prep – Marking

If you want to avoid treatment of the neck, the skin may be marked along the mandible using a surgical marker. This provides a reminder during treatment not to treat beyond the marked line.

The surgical marker can also be used to mark areas that you want to treat only with Pearl Fractional, such as around the perioralarea.


Safety EyewearSafety Eyewear

Safety eyewear must be worn by all persons in the treatment room

Appropriate safety eyewear must have an optical density (O.D.) of 2.5 or greater at the wavelength of 2,790nm


Pre-treatmentPre-treatment

Laser masks with filtration of 0.1µm should be worn by all personnel in the treatment room to minimize exposure to laser generated airborne contaminants.– Note: Standard surgical masks are not designed to

provide protection from plume contents.


*Parameter Selection*Parameter Selection

Treatment Area Fluence Pulse Duration Overlap

Face 3 – 3.5J/cm2 0.3ms 10% - 20%

SINGLE PASS PEARL SETTINGS

Treatment Area Energy Density Passes

Eyelids 80 - 120mJ 2-3 2

Crow’s Feet

Peri-Oral

Other areas as required

120mJ 3 2 - 3

Scarring 120 -160mJ 3 - 4 2 – 3

PEARL FRACTIONAL SETTINGS

*For advanced procedure only. Consult Pearl and Pearl Fractional Clinical CD for complete treatment information.

Treatment parameters for treatment of the neck as well as off the face have not yet been developed.

Skin types IV-VI are at higher risk for side effects, specifically post-inflammatory pigment alteration. Treatment recommendations have not yet been developed for these patients.


Parameter Selection (cont.)Parameter Selection (cont.)

Higher energy may be selected for deeper lines and/or areas of scarring which may result in greater efficacy.– May increase downtime and risk of unwanted side

effects.

Lower energy and/or density may be selected to increase patient comfort


Treatment OrderTreatment Order

Always begin with Pearl first, followed by Pearl Fractional to areas of concern. This order is important to ensure that Pearl is performed on clean, dry, skin, following an acetone wipe. Oozingfrom Pearl Fractional prevents Pearl from being properly absorbed.

1. Pearl full face, single pass– Overlap may be decreased to 10% when combining lasers to reduce

thermal impact.

2. Pearl Fractional– Immediately follow with Pearl Fractional to peri-orbital and peri-oral

areas and, if indicated, other areas with significant wrinkles or scarring

– Minimum 2 passes• 2nd pass at a 30-45° angle to the first pass

– 2-pass limit over lids to lash line– Optional 3rd pass over crow’s feet, peri-oral, and other indicated

areas


Smoke EvacuatorSmoke Evacuator

A smoke evacuator is required for both Pearl and Pearl Fractional.

Attach smoke evacuator hose to the laser handpiece or have an assistant hold it next to the treatment site.

Ensure that the suction is set high enough to capture the laser generated airborne contaminants to prevent plume odor

Ensure that the tube is not making contact with the filter inside the smoke evacuator.


Post Treatment – ImmediatePost Treatment – Immediate

Immediately after treatment apply an occlusive ointment such as new, plain Vaseline or Aquaphor ointment.

Some patients experience a burning sensation immediately after treatment. This usually resolves a few minutes after the application of an occlusive ointment.– Vinegar soaks can help relieve these

symptoms


Post TreatmentPost Treatment

Provide the patient with a post-treatment instruction sheet for proper post-treatment care.

– An example set of post-treatment instructions is provided on the Pearl and Pearl Fractional Clinical Training CD.

Erythema is a normal reaction to treatment, with deeper treatments resulting in longer lasting erythema which resolves with time.

Minimal oozing from micro spots during and after treatment may occur.

Edema (swelling) may occur in some patients. While this is temporary, sleeping with the head elevated may help to minimize this effect.

The coagulated skin will slough off at 3 to 7 days after treatment for most patients.

If repeat treatments are performed, the recommended treatment interval is 3 weeks or longer.


Example Patient – Female 56yr

Pre-Tx 5 weeks post

Pearl: Full Face, Single pass at 3.5J/cm² - 0.4ms with 20% overlap. (Peri-orbital not tx)Pearl Fractional: Cheeks, periorbital (no upper lid) and perioral, 2 passes at 160 mJ with Density 2

Photos courtesy of Adele Makow,MD


Pearl: Full Face, Single Pass at 3.0J/cm² - 0.3ms with 10% overlapPearl Fractional: Full Face, Single Pass at 160 mJ with Density 4

Photos courtesy of Brian Biesman, MD

Example Patient – Female 58yr

Pre-Tx 5 weeks post

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