(51) Int. Cl. A61N 5/06 A618 18/18 (52) U. S. Cl... (57)

Transcription

1 &19~ Unitd Stats lliililllililillilillillilliillliilillillliillliililillillilllliiillillilliiiiiiiiiiiiiiii US AI (12) Patnt Application Publication (Io) Pub. No. : US 2008/ A1 Franginas t al. (43) Pub. Dat: Mar. 6, 2008 (54) METHOD AND APPARATUS FOR MONITORING AND CONTROLLING DENSITY OF FRACTIONAL TISSUE TREATMENTS (75) Invntors: Gorg Franginas, Frmont, CA (US); Lonard C. DBndictis, Palo Alto, CA (US); Kin F. Chan, San Jos, CA (US); Robrt Khl Sink, Mountain Viw, CA (US) Corrspondnc Addrss: RELIANT / FENWICK c/o FENWICK 4 WEST, LLP 801 CALIFORNIA STREET MOUNTAIN VIEW, CA (73) Assign: Rliant Tchnologis, Inc., Mountain Viw, CA (US) (21) Appl. No. : 11/737, 696 (22) Fild: Apr. 19, 2007 Rlatd U. S. Application Data (63) Continuation-in-part of application No. 11/468, 275, fild on Aug. 29, (51) Int. Cl. A61N 5/06 A618 18/18 (52) U. S. Cl..... (57) Publication ClassiTication ( ) ( ) /9; 606/33; 606/38 ABSTRACT A mthod and apparatus for fractional tratmnt of skin by irradiating th skin with lctromagntic nrgy is disclosd. Sourcs of th lctromagntic nrgy can includ radio frquncy (RF) gnrators, lasrs, and flashlamps. Th apparatus includs at last on snsor configurd to dtct a positional paramtr, a skin charactristic, a skin rspons, or combinations throf. Th snsor provids fdback to a controllr. Th controllr controls th tratmnt paramtrs, including th tratmnt dnsity. By snsing th positional paramtr, skin charactristic and/or skin rspons to a tratmnt, th controllr automatically adjusts tratmnt dnsity in ral-tim in rspons to th snsd positional paramtr, skin charactristic and/or skin rspons. 100 scanr controllr 110 sourc 120 scanning dlivry unit 101 controllr skin snsor 180 ~ snsor positional 1 0

2 Patnt Application Publication Mar. 6, 2008 Sht 1 of 11 US 2008/ A1 100 scanr controllr 110 SOUrc scgnnlng dlivry Unit 101 controllr skin snsot 160 posltlonal sllsol

3 Patnt Application Publication Mar. 6, 2008 Sht 2 of 11 US 2008/ A controllr positional srasol 285~ 287~

4 Patnt Application Publication Mar. 6, 2008 Sht 3 of 11 US 2008/ A1 x 250 Figur A C D D D o Q c cp a o o 0 o 0 a c o 0 Q o 0 0 ' 0 0 a o o o 0 0 cl Q c o o 0 o 0' c Q 0 0 Q a 0 a 0 o a 0 o 0 a o o 0 o 0 0 o

5 Patnt Application Publication Mar. 6, 2008 Sht 4 of 11 US 2008/ A1 lik, kkkklkl ikkkkkkk, kk kkkkk, 4k', kk kklkllkkkk Figur 3A 392A Figur

6 Patnt Application Publication Mar. 6, 2008 Sht 5 of 11 US 2008/ A C 4808, 4818

7 Patnt Application Publication Mar. 6, 2008 Sht 6 of 11 US 2008/ A1 580A 580B C

8 Patnt Application Publication Mar. 6, 2008 Sht 7 of 11 US 2008/ A1

9 Patnt Application Publication Mar. 6, 2008 Sht 8 of 11 US 2008/ A1

10 Patnt Application Publication Mar. 6, 2008 Sht 9 of 11 US 2008/ A1

11 Patnt Application Publication Mar. 6, 2008 Sht 10 of 11 US 2008/ A1

12 Patnt Application Publication Mar. 6, 2008 Sht 11 of 11 US 2008/ A1

13 US 2008/ A1 Mar. 6, 2008 METHOD AND APPARATUS FOR MONITORING AND CONTROLLING DENSITY OF FRACTIONAL TISSUE TREATMENTS CROSS-REFERENCE TO RELATED APPLICATIONS [0001] This application is a continuation-in-part of copnding U. S. patnt application Sr. No. 11/468, 275, "Mthod and Apparatus for Monitoring " and Controlling Thrmally Inducd Tissu Tratmnt, by Kin F. Chan, Gorg Franginas, Lonard C. DBndictis, and Robrt Khl Sink, Aug. 29, 2006, from which priority is claimd and which is incorporatd by rfrnc in its ntirty. BACKGROUND OF THE INVENTION [0002] 1. Fild of th Invntion [0003] Th prsnt invntion rlats to a mthod and apparatus for providing fractional drmatological tissu tratmnt, and mor particularly, to controlling tratmnt dnsity as providd by an lctromagntic sourc basd on masurmnts of positional paramtrs, skin rsponss, and/ or skin charactristics. [0004] 2. Dscription of th Rlatd Art [0005] Many lctromagntic drmatological tratmnt systms rquir xtnsiv training bfor physicians and nurss dvlop th skills to dlivr nrgy uniformly ovr a targt rgion, such as th fac, nck, chst, or back. In many cass, physicians and nurss do not trat uniformly, rsulting in unvn tratmnt, ovr-tratmnt, or undr-tratmnt. Thr is a nd to crat mor uniform photothrmal and/or radio-frquncy (RF) tratmnt, particularly for larg aras. [0006] Howvr, not all patints rspond th sam way to th sam lvl of tratmnt. So vn if prcisly th sam lasr nrgy dos is dlivrd to two difirnt patints, th rspons of ach patint can b substantially difirnt. Within a singl patint, th skin rspons can vary from rgion to rgion. Tratmnt of th forhad can rspond difi'rntly than tratmnt of th nck, for xampl. Whn using fractional tratmnt mthods, if uniform tratmnt dnsitis ar usd for all patints or for all rgions, thn th tratmnt dnsitis will typically b dsignd for th most snsitiv patint or th most snsitiv rgion in ordr to avoid undsirabl sid fi'cts. Dsigning for th most snsitiv rgion or patint will frquntly lad to undr-tratmnt of othr rgions or patints. Thrfor, thr is also a nd to crat fractional photothrmal and/or RF tratmnts which can b modifid in ral tim basd on th typ of tratmnt dsird by th patint, th rspons of th patint to th tratmnt, and/or th rgion undrgoing tratmnt. Thus, thr is a nd for fractional dvics and mthods which can control and adjust th dnsity of th tratmnt during th tratmnt procss. Such a systm would hav th capability to provid both tratmnts of uniform dnsity and tratmnts whr th tratmnt dnsity is modifid in ral tim basd on th typ of tratmnt dsird, th patint' s rspons to th tratmnt, and th rgion undrgoing tratmnt. [0007] Many mdical lasr systms for th tratmnt of drmatological skin conditions function by prssing a foot pdal to triggr th dlivry of a singl puls of tratmnt nrgy. This typ of tratmnt apparatus is slow and has a lot of rptitiv motions, which can b tiring to th oprator. Othr lasr tratmnt systms fir idntical pulss at a constant puls rptition rat as th usr movs th handpic across th tissu. This systm rquirs skill and incrass th risks of ovr- or undr-tratmnt in th hands of an unskilld oprator. Thrfor, thr is also a nd for an approach to fractional lctromagntic tratmnt that provids controlld tratmnt dnsity and adjusts th tratmnt dnsity in ral tim to prvnt ovr- and/or undrtratmnt. For fractional tratmnts, such an approach could control tratmnt dnsity by adjusting th dnsity in ral tim in rspons to at last on positional paramtr, skin rspons and/or skin charactristic. Wckwrth U. S. Pat. No. 6, 758, 845 dscribs th us of optical masurmnts of rgularly spacd indicia that ar placd on or adjacnt to th targt rgion, but th concpt is limitd by th application of rgularly spacd indicia that ar countd to masur distanc travld by a handpic. This rquirs th prcis positioning of indicia to avoid rrors. In addition, th visibl indicia can b difficult to rmov following tratmnt, and can lav an unsightly pattrn on th skin following tratmnt. [0008] Wckwrth '845 and Talpalriu U. S. Pat. No. 6, 171, 302 dscrib mchanical rollr systms for tracking handpic travl. Ths can b unrliabl, for xampl, whn usd with gl du to a lack of friction btwn th mchani- cal rollr and th skin surfac. This lads to drop outs and rrors inmasurmnts ofpositional paramtrs. In addition, mchanical rollrs can bcom rustd or gummd up so that thy no longr spin asily, which maks dropouts and rrors mor likly. Waring out of mchanical parts lads to similar rrors. [0009] Wckwrth '845 dscribs othr systms that masur position of th handpic indirctly, through th intraction with rfrnc plans or points outsid th targt ara, rathr than masuring th targt ara dirctly. With this approach, th location of th targt surfac rlativ to th rfrnc surfac must b masurd or controlld. In addition, ths systms only masur on coordinat for th handpic, which mans that motion of th handpic across th targt tissu du to chang in orintation of th handpic can not b accountd for by th snsor systms. This lads to inaccuracis. [0010] For tratmnt of larg aras, an automatic lasr control systm is ndd for adjusting lasr tratmnt dnsity in ral tim in rspons to positional paramtrs such as th handpic position, vlocity, and/or acclration or in rspons to th lasr tratmnt itslf. To provid th most fictiv fractional tratmnt, to provid a tratmnt with fw sid fi'cts, as wll as for tratmnt of particular skin faturs such as blood vssls or pigmntd lsions, an automatic lasr control systm is ndd for adjusting tratmnt dnsity in ral tim in rspons to skin charactristics and/or skin rsponss. Thus, thr is a nd for an apparatus and mthod for a fdback loop that incrass th fictivnss of fractional tratmnt by controllably rsponding to tratmnt variabls such as tratmnt spd, handpic angl, handpic acclration, patint to patint variability, rgion to rgion variability within th sam patint, tc. Thr is a nd for fractional apparatus and mthods which includ a fdback loop that controllably rsponds to positional paramtrs, skin rspons and/or skin charactristics by adjusting th dnsity of th fractional tratmnt (L., altring th dnsity of tratmnt zons producd in a portion of skin) in ral tim.

14 US 2008/ A1 Mar. 6, 2008 [0011] Thr is also a nd for an apparatus and mthod that nabl fastr and mor rproducibl fractional tratmnts, that rquir lss training and skill by th oprator and/or that controllably rspond to tratmnt variabls, positional paramtrs, skin rspons and/or skin charactristics by controlling tratmnt dnsity. Th apparatus and mthod can also incras fictivnss without incrasing sid ficts or invasivnss, trat with lowr pain and sid ficts, dirctly masur tratmnt fficacy and/or progrss for us in a fdback loop ithr alon or with othr inputs instad of rlying primarily on accurat dlivry of a prdtrmind tratmnt dnsity or on masurmnt of handpic positional paramtrs, monitor biological rspons of th skin to th tratmnt, monitor inhrnt skin charactristics and tratmnt variabls for improvd biological prdictability, fficacy, and safty, and/or to prmit bttr control of tratmnt dnsity, for xampl for photo-dynamic thrapy (PDT) tratmnts, lasr hair rmoval, or fractional lasr rsurfacing. Fractional apparatus and mthods can achiv such tratmnts by automatically controlling tratmnt dnsity. SUMMARY OF THE INVENTION [0012] In gnral, th prsnt invntion compriss an apparatus and a mthod for fractional tratmnt of skin using fdback from on or mor snsors that ar usd to masur handpic positional paramtrs, charactristics or faturs of th skin that is to b tratd, and/or th skin rspons to thrmal or ablativ tratmnt that is causd by th dlivry of lctromagntic nrgy in a fractional mannr. Th lctromagntic nrgy can b radio frquncy (RF) or optical nrgy. Th positional snsors, skin rspons snsors and skin charactristic snsors can b usd sparatly or thy can b advantagously combind to allow th fractional tratmnt to vary in rspons to a combination of on or mor handpic positional paramtrs, on or mor skin charac- tristics, and/or on or mor skin rsponss. [0013] In on xampl, th invntion is dirctd to a mthod for controlld fractional skin tratmnt, comprising manually moving a handpic across a targt rgion of skin; dircting lctromagntic nrgy via th handpic toward th targt rgion in a mannr so as to provid a fractional tratmnt, snsing at last on positional paramtr, skin rspons and/or skin charactristic in th targt rgion; and automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd at last on positional paramtr, skin charactristic and/or skin rspons. In on xampl, th fractional tratmnt is dlivrd whil th handpic is in motion. In anothr xampl, th fractional tratmnt is dlivrd whil th handpic is not in motion. [0014] In anothr xampl, th invntion is dirctd to a mthod for controlld fractional skin tratmnt comprising th stps dscribd abov, whrin th snsing stp compriss snsing th at last on positional paramtr, and th automatically adjusting stp compriss automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snss at last on positional paramtr. In anothr xampl, th invntion is dirctd to a mthod as dscribd in th prcding sntnc, whrin th ordr of th stps in th mthod compriss: I) manually moving a handpic across a targt rgion of skin; 2) snsing a positional paramtr of th handpic; 3) dircting lctromagntic nrgy via th handpic toward th targt rgion in a mannr so as to provid a fractional tratmnt; and 4) automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd positional paramtr. [0015] In anothr xampl, th invntion is dirctd to th prviously dscribd mthod for controlld fractional skin tratmnt, whrin th snsing stp compriss snsing th at last on skin charactristic, and th automatically adjusting stp compris automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd at last on skin charactristic. In anothr xampl, th invntion is dirctd to a mthod as dscribd in th prcding sntnc, whrin th ordr of th stps in th mthod compriss: I) manually moving a handpic across a targt rgion of skin; 2) dircting lctromagntic nrgy via th handpic toward th targt rgion in a mannr so as to provid a fractional tratmnt; 3) snsing a skin rspons to th fractional tratmnt in th targt rgion; and 4) automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd skin rspons. [0016] In anothr xampl, th invntion is dirctd to th prviously dscribd mthod for controlld fractional skin tratmnt, whrin th snsing stp compriss snsing th at last on skin rspons, and th automatically adjusting stp compriss automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd at last on skin rspons. In anothr xampl, th invntion is dirctd to a mthod as dscribd in th prcding sntnc, whrin th ordr of th stps in th mthod compriss: I) manually moving a handpic across a targt rgion of skin; 2) snsing a skin charactristic of th targt rgion; 3) automatically dtrmining an appropriat tratmnt dnsity of a fractional tratmnt in ral-tim in rspons to th snsd skin charactristic; and 4) dircting lctromagntic nrgy via th handpic toward th targt rgion in a mannr so as to provid th fractional tratmnt of th appropriat tratmnt dnsity. [0017] In yt anothr xampl, th invntion is dirctd to an apparatus for controlld fractional skin tratmnt comprising: at last on lctromagntic sourc configurd to gnrat lctromagntic tratmnt nrgy capabl of trating skin whn dlivrd in a fractional mannr; a manually movabl handpic oprably coupld to th lctromagntic sourc, whrin th handpic is configurd to dlivr th lctromagntic tratmnt nrgy in a fractional mannr to a targt rgion of skin so as to provid a fractional skin tratmnt; a controllr oprably coupld to th lctromagntic sourc, whrin th controllr is configurd to activat or adjust on or mor paramtrs of th lctromagntic sourc, and a snsor oprably coupld to th controllr, whrin th snsor is configurd to sns at last on positional paramtr, skin rspons and/or skin charactristic in th targt rgion; whrin positional, skin rspons and/or skin charactristic fdback from th snsor is usd by th controllr to control dnsity of th fractional tratmnt by activation or adjustmnt of th on or mor paramtrs of th lctromagntic sourc and/or handpic. [001S] In on xampl, a combination of rlativ and absolut handpic positional masurmnts is masurd to dtrmin th positional changs of th handpic rlativ to th targt rgion of skin. [0019] In on xampl, skin shrinkag is masurd with a skin charactristic snsor and/or a skin rspons snsor. In othr xampls of th invntion, on or mor masurd

15 US 2008/ A1 3 Mar. 6, 2008 charactristics or faturs of th skin can includ on or mor of th following: skin birfringnc, skin watr contnt, skin lasticity, skin mchanical damping paramtrs, skin color, skin faturs such as blood vssls and pigmntd lsions, skin thicknss, skin txtur, and wrinkls. In othr xampls of th invntion, on or mor masurd rsponss of th skin can includ changs in on or mor of th following: skin birfringnc, skin watr contnt, skin lasticity, skin mchanical damping paramtrs, skin color, skin faturs such as blood vssls and pigmntd lsions, skin thicknss, skin txtur, and wrinkls. Ths and othr skin charactristics and/or skin rsponss can b masurd using on or mor typs of tchnology such as capacitiv snsors, (hypr-) spctral imaging, trahrtz imaging, optical cohrnc tomography, confocal microscopy, ultrasonic imaging, cohrnt dtction, thrmal dtctors, thrmal imaging systms, tc. Othr skin charactristics and/or skin rsponss and masurmnts can also b usd. [0020] In on xampl, th output of an rbium dopd fibr lasr is collimatd and dflctd by a scanning dlivry unit such as a galvanomtr scannr or a starburst scannr as dscribd in th co-pnding and co-ownd U. S. application Sr. No. 11/158, 907, which is incorporatd by rfrnc hrin, to crat a sris of figurs at th targt rgion. [0021] In anothr xampl, th scanning rat of th scanning dlivry unit is controlld by a controllr to dlivr a prdfind pattrn or dosag vn if th handpic vlocity changs within a chosn rang. [0022] In on xampl, a contrast nhancing agnt is usd to nhanc th signal to nois ratio of th positional snsor. For xampl, Food, Drug & Cosmtic (FD&C) Blu ¹I can b applid to th surfac of th skin to crat an improvd signal for a positional snsor comprising an optical mous chip, charg-coupld dvic (CCD) array, or othr dtctor array, with, for xampl, at last 25 lmnts. Using at last 25 lmnts as a Sx5 array allows suflicint imag rsolution to obsrv th changs in positional paramtrs, skin rspons, skin charactristics and/or dosag rspons. If fwr dtctor lmnts ar usd, a mor sophisticatd algorithm and/or mor sophisticatd lctronics gnrally will b typically rquird in ordr to distinguish changs in handpic positional paramtrs, skin rspons and/or skin charactristics. Othr contrast nhancing agnts ar fluorscnt or provid maximum contrast nhancmnt with infrard (IR) or ultra-violt (UV) illumination. Wavlngth slctiv coatings on th optical lmnts of th systm can b usd in conjunction with fluorscnt contrast nhancing agnts to filtr out on or mor illumination wavlngths. For xampl, th wavlngth slctiv coatings can b dsignd to filtr out light that is usd to nhanc th rspons of an optical positional snsor in ordr to improv th signal to nois ratio for a fluorscnt mission signal at a difl'rnt wavlngth. [0023] Th contrast nhancing agnt can b applid as a uniform or non-uniform pattrn of similar or dissimilar shaps. This pattrn of contrast nhancing agnt can b applid using rollrs, stamps, sprays, and/or stncils, for xampl. Th contrast nhancing agnt can also b applid onto or into an adhsiv substanc such as usd in a tmporary tattoo. [0024] In othr xampls, th positional snsor compriss on or mor of th following: a mchanical mous whl or rollr ball, non-concntric coils, an acclromtr, a gyro- scop, transmittr(s) and rcivr(s) that can b usd to masur distanc, a Dopplr radar systm, an ultrasonic tim of flight masurmnt, tc. [0025] In anothr xampl, lading and trailing dosag valuation snsors ar usd to masur th diflrntial skin rspons du to thrmal tratmnt. [0026] In anothr xampl, th scanning motion of a scanning dlivry unit is not changd, but th puls rat or puls timing of th lctromagntic sourc is changd by th controllr so as to chang tratmnt dnsity in rspons to masurmnts by at last on positional snsor, skin rspons snsor and/or skin charactristic snsor. Additionally, th puls timing and scannr pattrns can b chosn such that th bam is intntionally draggd across th targt rgion to rduc th tratmnt intnsity and/or to incras th siz of ach tratmnt zon cratd by ach nrgy puls. [0027] In fractional tratmnt, halthy skin is spard in rgions btwn individual tratmnt zons to crat a tratmnt with a givn tratmnt dnsity. Th spard tissu hlps to promot rapid haling of th woundd ara, prvnt scarring, and allow highr tratmnt lvls than ar othrwis possibl without sid flcts. Th masurmnt of positional paramtrs, skin rspons and/or skin charactristics can b usd to control th numbr of tratmnt zons cratd and/or to accuratly spac th tratmnt zons from on anothr so that tratmnt dnsity can b proprly controlld. Th dnsity of th fractional tratmnt can b controlld through th us of fdback from positional, skin rspons, and/or skin charactristic snsors. [0028] Othr aspcts of th invntion includ mthods, dvics, and systms corrsponding to th approachs dscribd abov, as wll as applications of th forgoing. BRIEF DESCRIPTION OF THE DRAWINGS [0029] Th invntion has othr advantags and faturs which will b mor radily apparnt from th following dtaild dscription of th invntion and th appndd claims, whn takn in conjunction with th accompanying drawings, in which: [0030] FIG. 1 is a diagram of an xampl of th invntion that incorporats a positional snsor and a skin snsor (k., a skin rspons snsor and/or a skin charactristic snsor). [0031] FIGS. 2A, 2B, and 2C ar diagrams of an xampl of th invntion that incorporats an optical sourc, a starburst scannr whl, and an optical positional snsor. FIG. 2C also dpicts on possibl tratmnt pattrn cratd by this xampl. [0032] FIGS. 3A, 3B, and 3C ar illustrations of pattrns that can b applid to th targt rgion or to rgions adjacnt to th targt rgion to nhanc th masurmnts of th optical positional snsor shown in FIG. 1. [0033] FIG. 4 is a diagram of an xampl of th invntion whrin on or mor acclromtrs ar attachd to th handpic to masur positional paramtrs of th handpic in up to thr dimnsions and/or up to thr angular orintations. [0034] FIG. 5 is a diagram of an xampl of th invntion whrin transmittrs and rcivrs ar usd to triangulat th position of th handpic to masur positional paramtrs in up to thr dimnsions and/or up to thr angular orintations. [0035] FIGS. 6 and 7 ar diagrams of xampls of th invntion whrin at last on ultrasonic transmittr and at last on ultrasonic rcivr ar mchanically coupld to th

16 US 2008/ A1 Mar. 6, 2008 handpic. Th xampl dpictd in FIG. 6 utilizs an ultrasonic tim-of-flight masurmnt. Th xampl in FIG. 7 utilizs an ultrasonic rflction masurmnt. [0036] FIG. S illustrats an xampl of th invntion whrin polarizd imaging is usd to masur changs in th birfringnc of th skin. [0037] FIG. 9 is a diagram showing th us of lading and trailing dosag valuation snsors in accordanc with th invntion for th masurmnt of th diflrntial skin rspons to particular tratmnt paramtrs. [003S] FIGS. 10 and 11 illustrat xampls of th invntion that masur th skin rspons to particular tratmnt paramtrs by masuring th signatur of a shock wav cratd by an nrgy puls incidnt on th skin. FIG. 10 illustrats an apparatus for masuring th shock wav signatur with a pizo-lctric matrial. FIG. 11 illustrats an apparatus for masuring th shock wav signatur with a rflctd prob bam. [0039] FIG. 12 is a diagram of an xampl of th invntion whrin on or mor coil snsors ar usd to masur positional paramtrs of th handpic. [0040] FIG. 13 illustrats masurmnts cratd by a systm according to FIG. 12. DETAILED DESCRIPTION [0041] This invntion dscribs an lctromagntic systm with automatic adaptiv control of fractional (photothrmal and/or RF) tratmnt dnsity, as wll as a mthod of trating tissu in a fractional mannr using an lctromagntic systm with automatic adaptiv control of tratmnt dnsity. Tratmnt dnsity is th numbr of tratmnt zons producd pr unit surfac ara in a targt rgion of skin or portion throf. A nominal pattrn and tratmnt dnsity can b dfind whn th systm bgins tratmnt and this tratmnt dnsity can b modifid basd on a masurd position of th handpic, an intrinsic charactristic of th tissu undrgoing tratmnt and/or a chang in an intrinsic charactristics of th tissu, a skin rspons to th tratmnt and/or a chang in a skin rspons to th tratmnt. Snsors of various typs can b usd to dtrmin th masurd position paramtr, skin charactristic and/or skin rspons. Algorithms that dscrib th positional paramtr, skin charactristic and/or skin rspons to tratmnt ar usd to control th dnsity of th fractional tratmnt. [0042] As dscribd hrin, handpic positional paramtrs includ paramtrs rlating to th position, vlocity and/or acclration of th handpic usd to dlivr th fractional tratmnt. Skin charactristics includ inhrnt charactristics, biological proprtis and/or faturs of th skin, such as, for xampl, skin ton, birfringnc, tmpratur, watr contnt, ph, lasticity, color, thicknss, txtur, mchanical damping proprtis, blood vssls, pigmntd lsions, hairs, hair follicls, wrinkls, tc. Skin charactristics can includ changs in ths inhrnt charactristics, biological proprtis and/or faturs of th skin which ar not brought about by or in rspons to th tratmnt. Skin rsponss includ changs in inhrnt charactristics, biological proprtis and/or faturs of th skin which occur in rspons to th tratmnt, such as, for xampl, skin shrinkag, birfringnc, tmpratur, watr contnt, ph, lasticity, color, thicknss, txtur, mchanical damping proprtis, blood vssls, pigmntd lsions, hairs, hair follicls, wrinkls, tc. [0043] Which positional paramtr masurmnts, skin charactristic masurmnts and/or skin rspons masurmnts ar mad can dpnd upon particular masurmnt rsults or tratmnt rquirmnts. For xampl, if th handpic is moving vry rapidly across th skin and tratmnt powr is proportional to rlativ handpic spd, thn bulk hating of th tissu can b a concrn. In this cas, th snsors can b instructd by th controllr to masur skin paramtrs that ar associatd with blistring du to ovr tratmnt. If movmnt is slow, bulk hating and blistring can b lss of a concrn and mor of th procssing powr of th controllr can b usd to mak mor accurat masurmnts of vlocity with th snsors instad. Dtaild xampls of th invntion ar dscribd blow. [0044] In som xampls, a distinction can b mad btwn micro-dosimtry and macro-dosimtry masurmnts. Micro-dosimtry masurmnts ar substantially limitd to on or mor zons that ar about to b tratd or hav bn tratd by a puls, a st of squntial pulss, or a st of simultanous pulss. For xampl, masurmnt of an approximatly 1. 2 mm diamtr ara that is co-cntrd with an approximatly I mm diamtr ara that is about to b tratd is micro-dosimtry bcaus th masurmnt is substantially limitd to th rgion that is about to b tratd with a futur puls or a futur st of ssntially simultanous pulss. In contrast, macro-dosimtry masurmnts ar usd to valuat largr aras of skin to produc an avrag masurmnt of rgions that includ both aras that ar about to b tratd (or that hav just bn tratd) and adjacnt rgions. In som xampls, a snsor is usd to produc micro-dosimtry or macro-dosimtry masurmnts in accordanc with th fdback loops of this invntion. [0045] FIG. 1 is a diagram of an xampl of th invntion showing a manually movabl handpic 100 that is configurd to dlivr lctromagntic tratmnt nrgy in a fractional mannr to th skin 150 in th targt rgion. Th lctromagntic sourc 110 gnrats lctromagntic nrgy 130 that trats th skin. Th controllr 115 activats or adjusts on or mor paramtrs of th lctromagntic sourc for th purpos of afl'cting tratmnt dnsity. Th handpic 100 can contain a controllr 115 that can compris a computr, a radio frquncy gnrator, and/or lasr drivr lctronics. In othr configurations, th controllr 115 is locatd xtrnal to th handpic 100 and is oprably connctd to th handpic 100 to control tratmnt paramtrs so as to adjust tratmnt dnsity. Th systm can also includ an optional scanning dlivry unit 120 that is oprably coupld to a scannr control 125 that scans th lctromagntic nrgy 130 ovr th targt rgion of th skin 150. An optional contact plat 139 that is mchanically coupld to th handpic 100 can b usd to mak good lctrical or optical contact with th skin 150 to nhanc controlld dlivry of th lctromagntic tratmnt nrgy 130, or to nhanc th opration of a skin snsor 160 or a positional snsor 1SO. A positional snsor 1SO masurs positional paramtrs of th handpic and a skin snsor 160 masurs a skin rspons to tratmnt and/or a skin charactristic. Additional snsors for dtcting positional paramtrs, skin rsponss and/or skin charactristics can b includd in th systm in ordr to masur difl'rnt paramtrs, rsponss and/or charactristics, or in ordr to mak multipl masurmnts of paramtrs, rsponss and/or charactristics in diflrnt parts of th targt rgion of skin,

17 US 2008/ A1 Mar. 6, 2008 or at difl'rnt parts of th tratmnt procss (. g., on on th lading dg in front of th tratmnt bam and on on th trailing dg bhind th tratmnt bam). Ths additional snsors ar oprably coupld to th controllr so as to nabl positional, rspons and/or charactristic fdback from th snsors to b usd to control th tratmnt dnsity. [0046] Whil th oprator manually movs th handpic 100 in dirction 101 or aftr th oprator has manually movd th handpic 100, th positional snsor 1SO masurs on or mor positional paramtrs of th handpic 100 and th skin snsor 160 masurs a skin rspons to th tratmnt and/or a skin charactristic. Th positional snsor 1SO and th skin snsor 160 communicat with th controllr 115 and/or with th scannr control 125. [0047] In anothr xampl, whil th oprator manually movs th handpic 100 in dirction 101 or aftr th oprator has manually movd th handpic 100, on or mor skin rspons snsors masur on or mor skin rsponss to th tratmnt within th rang of th snsor. Th skin rspons snsor(s) communicat with th controllr 115, th handpic 100 and/or with th scannr control 125 in ordr for th controllr 115, handpic 100 and/or scannr control 125 to adjust th tratmnt dnsity in ral-tim basd on th skin rspons fdback. In yt anothr xampl, whil th oprator manually movs th handpic 100 in dirction 101 or aftr th oprator has manually movd th handpic 100, on or mor skin charactristic snsors masur on or mor skin charactristics of th skin within th rang of th snsor. Th skin charactristic snsor(s) communicat with th controllr 115, handpic 100 and/or with th scannr control 125 in ordr for th controllr 115, handpic 100 and/or scannr control 125 to adjust th tratmnt dnsity in ral-tim basd on th skin charactristic fdback. [004S] Th controllr 115, th handpic 100 and/or th scannr control 125 matrially altr th tratmnt in raltim in rspons to th positional paramtr masurmnts, skin charactristic masurmnts and/or skin rspons masurmnts providd by th snsors by adjusting th tratmnt dnsity. Altrnativly, th controllr 115, handpic 100 and/or th scannr control 125 can matrially altr th tratmnt in ral-tim by adjusting (k., incrasing or dcrasing) th numbr of tratmnt zons cratd, th spacing of th tratmnt zons cratd, and/or th siz of th tratmnt zons cratd. This adjustmnt of tratmnt zon numbr, spacing or siz can b mad in rspons to a positional paramtr, a skin rspons, and/or a skin charactristic. An adjustmnt of tratmnt zon numbr, spacing or siz can b mad alon or in conjunction with an adjustmnt in tratmnt zon dnsity. [0049] In som xampls, th fdback loops comprising th controllr 115 and/or th scannr control 125 in combination with on or mor snsors (. g., th positional snsor 1SO, th skin snsor 160, tc. ) can b usd to provid automatd control of tratmnt dnsity, as wll as to provid automatd control of othr tratmnt variabls which may or may not afl'ct tratmnt dnsity, such as, for xampl, tratmnt location, tratmnt zon ovrlap, tratmnt nrgy, tratmnt dpth, tratmnt powr, tratmnt zon siz, tratmnt zon pattrn, tratmnt cooling (including pr-cooling and post-cooling), tc. Th tratmnt dnsity and/or th othr tratmnt variabls (. g., tratmnt location, tratmnt zon ovrlap, tc. ) can b controlld through adjustmnt of dvic paramtrs, such as optical focus, spot siz, tratmnt pattrn, puls width, puls nrgy, puls timing, puls frquncy, lasr powr, lasr wavlngth, spray cooling volum, spray cooling timing, tc. [0050] Optionally, th controllr 115 can b oprably connctd to th scannr control 125, which can b hlpful for rducing th numbr of wiring connctions from th snsors. Th controllr 115 can srv th function ofboth th controllr 115 and th scannr control 125 as shown in th xampl of FIG. 2A. For xampl, th functions of both th controllr 115 and th scannr control 125 can b prformd by a computr or a CPU oprably coupld to a mmory that stors a computr program. Th snsors, including th positional snsor 1SO and th skin snsor 160 can also b oprably coupld or can b combind in a singl componnt. For xampl, a CCD chip can b usd to masur shifts in movmnt, skin charactristics and skin rsponss. [0051] Dtaild xampls of svral componnts in FIG. 1 ar dscribd in th xampls givn blow. In on xampl, th lctromagntic sourc 110 dlivrs RF nrgy and th scanning dlivry unit 120 compriss an lctrical switching ntwork comprising lctrically controlld rlays connctd to multipl lctrical contact pads in th contact plat 139 that is mad of a nonconductiv substanc such as moldd plastic. Th scanning dlivry systm 120 can dlivr a fractional tratmnt by dlivring pattrns of nrgy across th targt rgion squntially, or multipl rlays can b activatd to nrgiz a plurality of tratmnt bams simultanously so as to produc a plurality of tratmnt zons simultanously. [0052] In gnral, an lctromagntic sourc 110 is a radio frquncy (RF) sourc, an optical sourc, or a combination of th two. A RF sourc gnrats lctromagntic nrgy with a frquncy in th rang of about 0. 1 MHz to about 20 MHz, or in th rang of about 0. 5 MHz to about 8 MHz. An optical sourc gnrats light, which is dfind for this application as lctromagntic nrgy with a wavlngth in th rang of about 300 nm to about 12, 000 nm. In som xampls, us of optical nrgy prmits th nrgy to b dirctd accuratly and asily to th dsird targt rgions of th skin so as to dlivr a fractional tratmnt. RF nrgy can also b usd, particularly for applications whr dpr pntration or targting of particular burid layrs of skin is dsird. Th choic of RF or optical nrgy can also b mad to rduc intrfrnc with a chosn typ of position snsor, skin charactristic snsor, and/or skin rspons snsor. [0053] In on xampl, th lctromagntic sourc 110 is a lasr and th lctromagntic nrgy 130 is a lasr bam. Exampls of lasrs ar Nd: YAG lasrs, diod lasrs, rbium fibr lasrs, CO~ lasrs, Er:YAG lasrs, Er:glass lasrs, flashlamp-pumpd lasrs, fr lctron lasrs, thulium fibr lasrs, Raman shiftd fibr lasrs, dy lasrs, gas lasrs, Argon lasrs, and yttrbium fibr lasrs. [0054] Th skin charactristic and/or skin rspons can b masurd by on or mor skin snsors 160 mploying on or mor typs of tchnology such as capacitiv snsors, (hypr-) spctral imaging, trahrtz imaging, optical cohrnc tomography, confocal microscopy, ultrasonic imaging, cohrnt dtction, thrmal dtctors, thrmal imaging, tc. In addition, on or mor skin snsor(s) 160 can masur skin birfringnc, skin watr contnt, skin lasticity, skin mchanical damping paramtrs, skin color, skin faturs such as blood vssls and pigmntd lsions, skin thicknss, skin txtur, wrinkls, tc. Othr typs of masurmnt

18 US 2008/ A1 Mar. 6, 2008 tchnology and othr drmatological faturs and tissu proprtis that can b masurd will b apparnt to thos skilld in th art. [0055] A mchanical mous or rollr whl with an ncodr can also b usd as a positional snsor 1SO. Altrnativly, a non-mchanical positional snsor which dos not rly primarily on moving parts to masur positional paramtrs can b usd. Non-mchanical positional snsors advantagously improv masurmnt rliability on slippry surfacs and rduc th chanc of mchanical failur in comparison to mchanical positional snsors. [0056] In on xampl of a non-mchanical positional snsor 1SO, coil snsors ar usd as dscribd by Bn-Haim t al in U. S. Pat. No. 6, 788, 967, which is hrin incorporatd by rfrnc. Thr snsor coils that ar mchanically coupld to th handpic 100 in th appropriat orintations can b usd to masur positional information, for xampl up to thr dimnsions and/or up to thr angular orintations for th handpic whn th snsor coils ar placd in th magntic fild gnratd by at last two radiators. Othr gomtris and numbrs of radiators and snsor coils ar possibl for masurmnt of on-dimnsional to six-dimnsional positional paramtrs of th handpic. Othr nonmchanical positional snsors such as optical positional snsors ar dscribd blow and can b dtachabl from th handpic. [0057] On xampl of th us of coil snsors is shown in mor dtail in FIG. 12. In FIG. 12, a magntic positional snsor 12SO is locatd outsid th handpic 1200 and th magntic sourc 12S1 is attachd to th handpic Th magntic sourc 12S1 can compris thr magntic fild sourc lmnts 12S5A-C. Th magntic fild sourc lmnts ar arrangd such that thir axs span thr-dimnsional spac. Th axs can, for xampl, b dirctd in thr mutually orthogonal dirctions. Th magntic positional snsor can compris thr magntic snsor lmnts 12S4A-C that can b locatd at a rfrnc point and ar arrangd to span thr-dimnsional spac. [005S] In on xampl, ach of th magntic fild sourc lmnts 12S5A-C and ach of th magntic fild snsor lmnts 12S4A-C compris a loop antnna that is tund to a dsird frquncy, for xampl a frquncy of about 10 khz. Th loop antnnas 12S5A-C for th magntic fild sourc lmnts 12S2 can ach b drivn with a currnt sourc, for xampl an op-amp currnt sourc. Altrnatly, a singl currnt sourc 12SS can b lctronically switchd to powr ach of th loop antnnas of th magntic fild sourc lmnts 12S5A-C squntially. Th systm can b opratd in th nar fild of ach of th magntic fild sourc lmnts 12S5A-C and ach of th magntic fild snsor lmnts 12S4A-C, but opration in th far fild is also possibl. Th sourc lmnts 12S4A-C can b squntially powrd in ordr to tim division multiplx th sourc signals. Th controllr 1215 compriss rcivr lctronics for masuring th rspons dtctd by th magntic fild snsors. Th rcivr lctronics portion of th controllr can b collocatd with th magntic fild snsor lmnts 12S4A-C or can b intgratd with th othr lctronics of th controllr Th controllr compriss appropriat lctronics to d-multiplx th rcivd signals to idntify th masurd magntic fild intnsity du to ach of th sourc lmnts. To synchroniz th systms, particularly in th cas of tim division multiplxing, a common clock can b usd for th sourc and rcivr lctronics. Othr configurations of sourc, rcivr, multiplxing/d-multiplxing, and lctronic systms will b apparnt. For xampl, additional xampls and rfinmnts of appropriat magntic fild systms can b found in U. S. Pat. Nos. 4, 613, 866, 4, 737, 794, 4, 742, 356, and 5, 307, 072, ach of which is incorporatd hrin by rfrnc. [0059] In anothr xampl, th magntic fild sourc lmnts 12S5A-C ar locatd at on or mor rfrnc points outsid th handpic and th magntic fild snsor lmnts 12S4A-C ar attachd to th handpic. Th location of and dirction of th tratmnt bam(s) mittd from th handpic rlativ to th rfrnc coordinat systm is thn masurd. For tratmnt on th fac, th handpic 1200 can includ th magntic sourc 12S1, and a small arbud that is placd within th ar of th patint can contain th magntic positional snsor 12SO. To improv accuracy and to dtrmin whthr th arbud has falln out or shiftd, a scond magntic positional snsor (not picturd) can b usd, for xampl in th opposit ar of th patint. If thr is a discrpancy btwn th rdundant snsors, th systm can alrt th physician, using, for xampl, an audibl alarm. [0060] Th choic of which of th magntic sourc 12S1 and th magntic positional snsor 12SO is locatd at th rfrnc point(s) and which is locatd at th handpic 1200 can b chosn basd on th sourcs of lctromagntic intrfrnc and objcts of lctromagntic fild distortion, such as mtal plats. For th xampl abov, it is anticipatd that thr is a scanning motor lmnt, such as for xampl usd in FIG. 2 to spin th scannr whl 220 around axis 221 that gnrats a significant magntic fild. Th ficts of a scanning motor lmnt on th masurmnt systm can b rducd by locating th sourc in th handpic instad of th snsor. In an altrnat configuration, thr can b no lctromagntic lmnts in th handpic, for xampl, and th snsor can b optimally locatd in th handpic and th sourc locatd at a rfrnc point. In addition, th systm can b calibratd mpirically to compnsat at last partially for any fixd lmnts that distort th magntic fild. [0061] In on xampl of a magntic fild systm as dscribd in FIG. 12, a Polhmus Patriot digital trackr systm (availabl from Polhmus, Colchstr, Vt., USA) is usd to masur th position of th handpic rlativ to a rfrnc point. An xampl of masurmnts cratd using this systm ar shown in FIG. 13, which shows a two dimnsional (2D) projction 1301 of a thr dimnsional (3D) data st for half of a fac. [0062] In on xampl, on or mor masurd handpic positional paramtrs includ handpic position or handpic angl (angular orintation) or th tim drivativs of ths two paramtrs including handpic vlocity, handpic acclration, handpic angular vlocity, and handpic angular acclration. Handpic positional paramtrs can b absolut or can b rlativ to th targt rgion. [0063] To nhanc th srvicability of th apparatus and to allow handpics to b intrchangd and thus shar xpnsiv componnts, th handpic can b dtachabl from on or mor of th following: th lctromagntic sourc 110, th controllr 115, and th scannr controllr 125. To rduc th wight of th handpic, ths componnts can b locatd outsid th handpic. Altrnativly, to nhanc portability of th apparatus, ths componnts can b includd insid th handpic. [0064] Th scanning dlivry unit is configurd to rciv th lctromagntic nrgy 130 and dlivr th lctromag-

19 US 2008/ A1 Mar. 6, 2008 ntic nrgy 130 to th skin 150 rgardlss of whr th othr componnts ar housd. For xampl, th lctromagntic sourc 110 can b a lasr. Th lctromagntic radiation can b coupld into an optical fibr, optical wavguid, or articulating arm for dlivry to th handpic. Th handpic can accpt optical nrgy by using a fibr coupling or a fibr collimator. Similarly, it will b vidnt to thos skilld in th art that th snsors 160 and 1SO can b oprably coupld to th controllr 115, but do not nd to b locatd insid th handpic. [0065] Th controllr 115 and scannr control 125 can b sparat componnts as in FIG. 1 or can b combind as a singl controllr as shown in FIG. 2A. [0066] In th xampl of FIG. 2A, a lasr sourc 210 is usd as th lctromagntic sourc. In this xampl, a manually movabl handpic 200 is configurd to dlivr an optical bam 230 of lctromagntic nrgy to th targt rgion of th skin 250. Th handpic 200 contains a controllr 215 comprising a computr and/or lasr drivr lctronics. Th controllr 215 controls an optical sourc 210 and a scanning dlivry unit 220 to afl'ct on or mor paramtrs such that tratmnt dnsity is matrially aflctd. Th optical sourc 210 gnrats an optical bam 230 that is dirctd to an optional scanning dlivry unit 220. Th scanning dlivry unit 220 dflcts th lasr bam 230 to difl'rnt tratmnt zons on or within th skin 250 as will b dscribd in gratr dtail blow. For clarity, only on bam position is shown in FIG. 2A. A dichroic mirror 232 and a contact plat 239 that ar substantially transparnt at th wavlngth of th lasr bam 230 can advantagously b includd in particular xampls. Th dflctd lasr bam 230 is dlivrd through th dichroic mirror 232 and contact plat 239 to th skin 250. A bam dlivry lns 231 can b usd to focus th dflctd bam 230 within th pidrmis 251, drmis 252, or othr layrs of th skin 250. Th focal point of th optical bam 230 can b blow th skin surfac or th bam can b divrging or collimatd as it ntrs th skin 250. Th skin snsor 260 (k., skin charactristic snsor and/or skin rspons snsor) is mchanically coupld to th handpic 200 and masurs a skin charactristic and/or a skin rspons to tratmnt. [0067] In th xampl of FIG. 2, th positional snsor 2SO masurs th position of th handpic rlativ to th surfac of th skin 250. In altrnat xampls, th positional snsor 2SO can masur position, vlocity, and/or acclration of th handpic rlativ to th surfac of th skin 250. An illumination sourc 2S2 mits illumination 2S3 that is collimatd by an illumination dlivry lns 2S4 for dlivry to th surfac of th skin 250. Collimating th illumination 2S3 incrass alignmnt tolrancs, improvs uniformity of th illumination on th skin surfac, and allows th illumination sourc 2S2 to b placd furthr from th targt rgion than would othrwis produc a uniform profil of illumination 2S3 at th surfac of th skin 250. Th illumination 2S3 is scattrd from th surfac of th skin 250 or from a contrast nhancing agnt 290 that is placd into or onto th skin 250. Th spctral rflctivity of th dichroic mirror 232 and th rflctiv prism 2S7 ar dsignd to substantially rflct th wavlngth of th scattrd illumination 2S5. A dtctor lns 2S6 is placd in th optical path from th skin to th positional snsor 2SO to imag th surfac of th skin 250 on th optical positional snsor 2SO. Exampls of optical positional snsors 2SO includ an optical mous chip (Agilnt Tchnologis, Palo Alto, Calif., USA), a CCD camra, or an optical snsor array of at last two snsor lmnts. Th optical snsor array can hav at last 25 snsor lmnts, arrangd as a Sx5 array in ordr to hav sufficint rsolution to accuratly quantify a rang of vlocity rsolutions asily. In on xampl, this optical positional snsor can b siliconbasd so that it can b manufacturd chaply using bulk manufacturing procsss and chap matrial sourcs that hav bn dvlopd for th lctronics industry. Othr configurations will b vidnt to thos skilld in th art. [006S] In FIG. 2A, th dirction 201 of handpic motion (not shown) is ssntially prpndicular to th plan of th pag. FIG. 2B illustrats a sid viw of th handpic that shows th dirction of motion 201 of th handpic 200. For simplicity, intrnal lmnts of th handpic 200 ar not shown in FIG. 2B. Th handpic 200 is manually movd by th oprator in dirction 201 whil th positional snsor 2SO masurs on or mor positional paramtrs of th handpic and th skin snsor 260 masurs on or mor skin charactristics and/or skin rsponss to tratmnt. Th positional snsor 2SO and th skin snsor 260 communicat with th controllr 215. Altrnativly or additionally, mor than on skin snsor can communicat with th controllr 215. In rspons to th masurmnts providd by th snsor(s), th controllr 215 adjusts th optical tratmnt paramtrs so as to adjust th tratmnt dnsity in ral tim to matrially aflct th photothrmal tratmnt. For xampl, th rat of lasr firing can b adjustd to b proportion to th vlocity of th handpic 200 to crat a prdfind tratmnt dnsity. As a furthr xampl, th dnsity of tratmnt zons producd in a portion of skin can b adjustd in rspons to th masurmnts, such as, for xampl, to rduc th dnsity of tratmnt zons producd in th skin nar a blood vssl so as to rduc sid flcts such as blding. As yt a furthr xampl, th dnsity of tratmnt zons producd, as wll as th tratmnt zon siz, numbr, pattrn, spacing, tc., can b adjustd in rspons to th masurmnts. [0069] An xampl of a skin snsor 260 (k., a skin rspons snsor and/or a skin charactristic snsor) is a capacitiv snsor as shown in FIGS. 2A, 2B, and 2C. Th capacitiv snsor 260 can masur th lvl of dsiccation of slctd layrs of th skin du to tratmnt. Th masurmnts from th capacitiv snsor 260 can b usd to calculat th propr tratmnt paramtrs for th tratmnt and mak adjustmnts to th tratmnt dnsity using th controllr 215. Th capacitiv snsor 260 can also b usd to valuat whthr a rgion of skin has blistrd. By imaging th junction btwn th drmis and th pidrmis, th capacitiv snsor can dtrmin whthr sparation of th drmis and pidrmis has occurrd. In othr xampls, snsors for masuring or imaging skin rsistivity can b usd as skin snsors 260 to valuat blistring and skin moistur contnt. A capacitiv snsor array that is commonly usd for fingrprint masurmnts is an xampl of a snsor that can b usd as a capacitiv snsor 260. [0070] FIG. 2C shows a tratmnt pattrn comprising sparatd microscopic tratmnt zons 256 that can b cratd with this approach as th handpic 200 is movd across th targt rgion 257 in th dirction 201. In this xampl, sparatd microscopic tratmnt zons 256A, 256B, and 256C can b cratd in th skin as dscribd in th co-pnding and co-ownd U. S. application Sr. Nos. 10/367, 582, 10/751, 041, 10/888, 356, and 11/158, 907, which ar hrin incorporatd by rfrnc. In on xampl, th tratmnt zons 256 can b cratd in a prdfind pattrn

20 US 2008/ A1 Mar. 6, 2008 that is invariant with th rlativ vlocity or acclration of th handpic 100. Othr pattrns will b vidnt to thos skilld in th art. Substantially uniform tratmnt dnsity can b cratd by appropriatly choosing optics, tratmnt paramtrs, and lasr puls timing. Altrnativly, th capacitiv snsor 260 (L., skin rspons snsor and/or skin charactristic snsor) can provid fdback to th controllr 215 so that th tratmnt dnsity can b adjustd in rspons to masurmnts providd by th snsor(s). For xampl, th capacitanc snsor 260 can function as a skin rspons snsor to provid fdback to th controllr 215 to incras or rduc th dnsity of microscopic tratmnt zons 256 or to incras or rduc th tratmnt powr in rspons to undr-tratmnt or ovr-tratmnt. [0071] In an altrnativ xampl, th tratmnt pattrn can b intntionally varid according to a prdfind algorithm whr tratmnt dnsity is varid in ral tim in rspons to changs in th vlocity or acclration of th handpic and whr th tratmnt pattrn is not prdfind. For xampl, th tratmnt dnsity can b controlld in ral tim by th usr by appropriatly adjusting th position, vlocity, or acclration of th handpic. In som tratmnts, it is dsirabl to allow th oprator to hav control ovr th tratmnt dnsity through th us of vlocity. For xampl, if th usr trats quickly, th systm can b configurd to allow a highr tratmnt dnsity, which in turn can b masurd by th skin snsor 260. If th usr trats slowly, thn th tratmnt dnsity can b rducd. Thus, th usr is abl to control th tratmnt dnsity simply by changing positional paramtrs of th handpic. Thus, th tratmnt dnsity, as wll as tratmnt pattrn, tratmnt intnsity, and othr tratmnt paramtrs ar not prdfind, but can b dfind through an automatd rspons to masurd positional paramtrs, to masurd skin rspons, to masurd skin charactristics, or to combinations throf. An lctronic or computr intrfac (not picturd) can b providd to allow switching on or ofl' difl'rnt mods of usr control. [0072] In anothr xampl, a tratmnt status map is displayd on a monitor (not shown) for th usr or th patint to obsrv. Th positional snsor 280 can b usd to masur th location within th targt rgion of th tissu rspons that is masurd by th skin snsor 260. In this way, a map can display which parts of th targt rgion hav bn tratd and how ach part of th targt rgion has rspondd to tratmnt. Th usr can tak th information on this map to mak tratmnt uniform ovr th ntir targt rgion or to hav tratmnt vary in a dsirabl mannr such as trating aras with dp wrinkls mor dnsly than lss wrinkld aras. Altrnativly, th systm can b configurd to automatically rduc tratmnt dnsity or disabl tratmnt in th rgions that hav alrady bn adquatly tratd as th usr continus to mov th handpic ovr th targt rgion. A pictur or schmatic rprsntation of th targt rgion, such as a lin drawing of a fac for tratmnt of wrinkls on th fac, can b usd as a background for a computr display of th map of th tratmnt rspons masurmnts. [0073] Th us of a positional snsor 280 and/or a skin snsor 260 (L., a skin rspons snsor and/or a skin charactristic snsor) to crat a map can b usd bnficially, particularly with small bam sizs lss than 1 mm in thir smallst dimnsion. Using such a map, tratmnt can b turnd on or ofl; or th dnsity of tratmnt incrasd or dcrasd, basd on whthr tratmnt has covrd that ara or not, basd on th prsnc or absnc of skin faturs such as wrinkls, blood vssls, pigmntd lsions, tc., or basd on th prsnc or absnc of an xognous pigmnt. Th advantag of using a bam siz of lss than I mm is that th granularity of th bam siz for tratmnts that ar visually apparnt aftr tratmnt will b lss noticabl for such small bam sizs. Thus, th us of a positional snsor 280 and/or a skin snsor 260 is particularly suitd to fractional tratmnt and/or tratmnts with a small bam siz of lss than I mm. [0074] Controllr 215, optical sourc 210, and othr componnts can b xtrnal to th handpic 200 instad of bing includd insid th handpic as illustratd in FIG. 2A. Th optical bam 230 can propagat to th handpic through fr spac, through an articulatd arm, or through a wavguid, such as an optical fibr. Th handpic 200 can b mchanically sparabl from or mchanically sparat from th xtrnal componnts and th handpic 200 can b configurd to rciv th optical bam 230 and/or th signal from th controllr 215. [0075] In on xampl, th lctromagntic sourc 210 is a singl mod pulsd rbium dopd fibr lasr with a pak output powr in th rang of about 5 W to about 50 W and a wavlngth in th rang of pm. This lasr sourc can b focusd to an optical spot siz in th rang of about 30 pm to about 600 pm or about 60 pm to about 300 pm on th surfac of th skin. Puls nrgis in th rang of about 2 mj to about 100 mj or in th rang of about 8 mj to about 20 mj can b usd for ths rangs of optical spot siz, wavlngth, and powr. This xampl dos not includ surfac skin cooling, but such cooling can b includd if dsird to rduc damag to th pidrmis and drmalpidrmal junction. [0076] Th scanning dlivry unit 220 usd in this xampl is a scannr whl rotating at last 360' around an axis 221 as dscribd in dtail in U. S. application Sr. No. 11/158, 907, which is incorporatd by rfrnc hrin. Othr scannr typs will b apparnt to thos skilld in th art. For xampl, galvanomtr scannrs, psudo stationary dflction (PSD) scannrs as dscribd in co-pnding and co-ownd U. S. application Sr. No. 10/750, 790, which is also incorporatd by rfrnc hrin, polygonal scannrs, light valvs, liquid crystal display (LCD) scrns, microlctromchanical systm (MEMS) basd rflctiv scannrs, and translation stags can b usd for th scanning dlivry unit for dlivry of optical nrgy. Multipl scanning dlivry units can b usd in such systms to control multipl axs of dflction. For xampl, two galvanomtr scannrs can b usd in sris to scan th lasr bam in two dirctions to covr an ara on th surfac of th skin 250. Altrnativly, singl scanning units can caus bam dflction in two dirctions as dscribd in dtail in U. S. application Sr. No. 11/158, 907. [0077] On algorithm that can b usd to control oprational paramtrs of th scanning dlivry unit 220 is to adjust th rotational spd of a doubl or singl whl PSD scannr and th lasr firing rat in proportion to th vlocity of th handpic. This allows microscopic tratmnt zons of fractional rsurfacing to b placd in a prdfind dnsity on th skin. [0078] Anothr algorithm for controlling tratmnt is to adjust th firing of th lasr in approximat proportion to th rlativ vlocity of th handpic to crat a prdfind tratmnt dnsity. A uniform dnsity of tratmnt zons

21 US 2008/ A1 Mar. 6, 2008 distributd across a targt rgion by ovrlapping or abutting tratmnt zons can also b achivd. For xampl, if th scannr 220 shown in FIG. 2A is controlld to spin at a constant angular vlocity as th handpic 200 is moving across th surfac of th skin 250, th lasr firing can b pulsd to crat th dsird tratmnt dnsity by firing th lasr only whn it is alignd with a particular fact of th scannr that crats th dsird tratmnt dnsity. Not vry fact nds to b usd. For a particular vlocity, vry fact can b usd. If th vlocity is rducd by a factor of thr from this vlocity, thn only vry third fact can b usd to kp th sam dnsity. In on xampl, th algorithm maintains a uniform dnsity of tratmnt zons within th targt rgion. Configurations which spin th scanning whl 220 at a constant angular vlocity can b usd. Altrnativly, configurations which rquir th angular vlocity of th scanning whl 220 to b proportional to th spd of th handpic 200 can b usd, although such configurations can incras th complxity of th motors, associatd driv lctronics, and ncodrs that ar usd to accuratly control th angular vlocity of th scanning whl 220. [0079] In anothr xampl, th scannr whl 220 can b run at a vlocity that drags th optical bam 230 across th targt rgion. This whl vlocity can vn b in th opposit dirction of th dirction that would compnsat for movmnt of th handpic. This intntional dragging of th optical bam 230 across th surfac of th skin 250 can b cratd with ithr variabl-vlocity or fixd-vlocity scannr systms. With th fixd-vlocity systm, for xampl, th puls duration of th lasr bam can b adjustd according to th vlocity of th handpic 200 such that th optical bam is draggd across th skin by approximatly th sam distanc with ach puls. By changing th angular vlocity of th scannr whl 220 or by changing th puls duration for th optical bam 230, th distanc ovr which th optical tratmnt occurs for ach puls can b changd. Th controlld dragging of th optical bam can, for xampl, b usd to incras th fill factor for a fractional rsurfacing tratmnt by making ach microscopic tratmnt zon largr by incrasing th distanc ovr which optical tratmnt occurs. Similarly, th controlld dragging of th optical bam can, for xampl, b usd to incras th tratmnt dnsity for a fractional tratmnt by incrasing th numbr of tratmnt zons cratd in th targt rgion of skin. As th vlocity of th handpic 200 is rducd, th incrasd puls duration prscribd by this algorithm can caus a rduction in tratmnt dnsity as masurd by th skin snsor 260. Thrfor, it can b dsirabl to incras th puls nrgy to kp th tissu rspons th sam. [OOSO] Th contact plat 239 bnficially rducs optical scattring from th skin surfac for th tratmnt bam by crating a smooth surfac that can b usd to prcisly and rproducibly position th skin rlativ to th focus dpth of th optical bam 230. Th contact plat 239 can also act as a thrmal hat spradr or can conduct hat away from th surfac to activly cool th skin whn connctd to a cooling sourc (not shown). Th contact plat 239 and dichroic mirror 232 can compris sapphir, fusd silica, borosilicat glass, transparnt plastic, or othr transparnt matrials. Th contact plat 239, dichroic mirror 232, and othr optical componnts can hav optical coatings applid on on or mor sids to incras th flicincy of nrgy dlivry into th skin or to nhanc th rflctivity or transmission of th illumination 2S3 from th illumination sourc 2S2. [OOS1] In som xampls, th contact plat 239 can b undsirabl and can b omittd. For xampl, in ablativ lasr tratmnts, it can b dsirabl to hav th surfac of th skin b mchanically fr to nhanc th ablation rspons o f tratmnt. [OOS2] To nhanc th ability of th optical positional snsor 2SO to rad th positional paramtrs of th handpic 200, a contrast nhancing agnt 290 can b applid onto or into th skin 250. For xampl, uniform application of a dy to th surfac of th skin 250 can prfrntially dcorat crtain faturs, such as skin wrinkls or hair follicls, to crat shaps that can b dtctd as objcts by th positional snsor 2SO. Th contrast nhancing agnt 290 must b non-toxic whn applid onto or into a patint's skin in amounts suitabl for adquatly nhancing masurmnts by th positional snsor 2SO. In on xampl, th contrast nhancing agnt and th matrials and gomtry chosn for th handpic 200 and contact window 239 allow th handpic 200 to slid asily ovr th surfac of th skin 250. [OOS3] Exampls of contrast nhancing agnts 290 ar carbon particls, India ink, and FD&C Blu ¹1. Many othr dys, inks, particulats, tc., can b usd as contrast nhancing agnts whn applid to th skin and whn usd with th appropriat positional snsor 2SO. Th wavlngth illumination sourc 2S2 can b chosn to maximiz th signal to nois ratio of th masurmnt of th positional paramtrs of th handpic 200. For xampl, a rd LED with a pak wavlngth in th rang of about 600 nm to about 640 nm can b usd with FD&C Blu ¹1. [OOS4] In many cass, th contrast nhancing agnt can b chosn such that it has a low absorption of th tratmnt nrgy or of th tratmnt wavlngth in th cas of optical tratmnt nrgy. In this way, th contrast nhancing agnt will not intrfr with th dposition of th tratmnt nrgy in th targt rgion. In som cass, th contrast nhancing agnt is chosn such that a masurabl or obsrvabl paramtr changs in rspons to th tratmnt nrgy. A chang in th contrast nhancing agnt can b usd to dtrmin whr tratmnt has occurrd, which allows th tratmnt to b touchd up in aras whr it is not vn or uniform. [OOS5] It is dsirabl to choos a contrast nhancing agnt 290 that can b rmovd without abrasiv or harsh scrubbing. Altrnativly, a rmoval facilitation substanc (not shown) can b applid prior to application of th contrast nhancing agnt 290 to allow th dy to b rmovd mor asily. Dimthicon, ura, and arginin ar xampls of rmoval facilitation substancs. Ths substancs can b applid prior to th contrast nhancing agnt 290 to facilitat subsqunt rmoval of th contrast nhancing agnt 290. Ths substancs can b applid using common solvnts such as watr, alcohol, or oil. Concntrations of th rmoval facilitation substanc can b usd, for xampl, in th rang of about M to about O. IM. [OOS6] It is dsirabl to choos a contrast nhancing agnt 290 that is not clarly visibl whn illuminatd with typical room light and/or sunlight. Contrast nhancing agnts 290 ar said to b "hypo-visibl" if and only if th contrast nhancing agnt is not radily visibl on othrwis bar skin with th nakd y whn illuminatd with about 400 nm to about 650 nm light whn th contrast nhancing agnt 290 is applid such that th rspons of th dtctor 2SO is bnficially and substantially nhancd whn using an illumination wavlngth from about 300 nm to about 400 nm or

22 US 2008/ A1 10 Mar. 6, 2008 from about 700 nm to about 1100 nm. Th us of hypovisibl contrast nhancing agnts 290 is dsirabl bcaus th contrast nhancing agnt 290 will b lss visibl aftr tratmnt vn if not all of th contrast nhancing agnt 290 is rmovd from th targt rgion. [0087] Many fluorscnt inks, laks, dys, and particulats ar xampls of hypo-visibl contrast nhancing agnts 290. Fluorscing agnts ar dsirabl bcaus th wavlngth of illumination can b filtrd by th dichroic mirror 232 or by othr optical componnts or coatings whil th throughput of th fluorscnt mission wavlngth is maximizd to improv th signal to nois ratio of th positional snsor 290. Polymr (PMMA) ncapsulatd fluorscnt dys ar commrcially manufacturd by NwWst Tchnologis (Santa Rosa, Calif., USA). Othr fluorscnt matrials includ collagn, lastin, FD&C Orang No. 5, flavin adnin dinuclotid, flavin adnin mononuclotid, folic acid, niacin, nicotinamid, rducd nicotinamid adnin dinuclotid (NADH), porphyrins, pyranin (FD&C Grn No. 7), pyridocin hydrochlorid, quinin sulfat, riboflavin, riboflavin phosphat, tryptophan, uranin (fluorscin), or combinations throf. Th absorption and mission spctra for ths substancs ar wll publishd in th art. Othr fluorscnt matrials that ar wll known in th art can also b usd as th contrast nhancing agnt 290, for xampl Carbazin, Coumarin, Stilbn 3, Kiton Rd, tc. [00SS] As th intnsity of fluorscnt mission of pyranin varis with ph, pyranin can b usd to valuat changs in barrir function and alrt th usr or automatically stop tratmnt or rduc tratmnt intnsity if a brak in th stratum cornum or a ruptur of th skin occurs during tratmnt. Thus, th contrast nhancing agnt 290 can also b usd to improv th signal to nois ratio of th skin snsor 260. [0089] Indocyanin grn (ICG) is an xampl of a contrast nhancing agnt 290. Most contrast nhancing agnts 165 can b dilutd with watr or othr solvnts to mak thm asir to apply or chapr to us. Th pak wavlngth of ICG varis dpnding on th solvnt and th concntration of ICG. For xampl, in watr, ICG has an IR absorption pak at approximatly 700 nm for high concntrations (. g. about 129 pm to about 1290 pm) and at approximatly 780 nm for low concntrations (. g. about 6. 5 pm to about 65 pm). For ICG in blood plasma, thr is an absorption pak in th rang of approximatly 790 nm to approximatly 810 nm across a broad rang of concntrations (about 6. 5 pm to about 1290 pm). In gnral, ICG typically has an absorption pak in th rang of about 650 nm to about 850 nm for most solvnts. ICG also has absorption paks in th UV rang. ICG dos not hav a strong absorption pak in th rang of about 400 nm to about 650 nm, which maks it diflicult to s with th nakd y. Thus, ICG is an xampl of a contrast nhancing agnt that has low visibility to th human y, but is asily discrnabl to a silicon basd optical dtctor whn illuminatd appropriatly. In non-fluorscing contrast nhancing agnts, th wavlngth (or wavlngth rang) of illumination can b chosn to b in a rgion whr th pak absorption of th contrasting agnt is at last about 3 tims, or at last about 10 tims, strongr or wakr than that of skin. It is also dsirabl to hav th pak absorption of th contrasting agnt in th chosn wavlngth (or wavlngth rang) to b at last about 3 tims, or at last about 10 tims, strongr than th pak absorption within th wavlngth rang of about 400 nm to about 650 nm. [0090] Th contrast nhancing agnt can also b applid in a pattrn. Th pattrn can compris a uniform grid of idntical FIGS. 391 in th targt rgion 357 as illustratd in FIG. 3A. Th pattrn can compris a non-uniform pattrn of idntical FIGS. 392 in th targt rgion 357 as illustratd in FIG. 3B. Th pattrn can compris a non-uniform pattrn of a plurality of diflrnt FIG. 393 in th targt rgion 357 as illustratd in FIG. 3C. Contrast nhancing agnts can b applid using stamps, rollrs, sprays, stncils, or with agntsoakd gauz pads. [0091] Pattrns of contrast nhancing agnts can also b attachd to th skin using adhsivs as usd in tmporary tattoos. As in a tmporary tattoo, a pattrn can b cratd by printing a contrast nhancing agnt on or mbdding a contrast nhancing agnt in an adhsiv that attachs to th skin. Th adhsiv has th advantag of bing asir to rmov than many of th contrast nhancing agnts that can b includd in or on th adhsiv. Laks of Food and Drug Administration (FDA) approvd colors such as FD&C Blu ¹I (also packagd as Optiguid Blu by Rliant Tchnologis, Mountain Viw, Calif., USA) can b mbddd in a polymr-basd tattoo adhsiv and paintd onto th skin. Following tratmnt, ths adhsiv basd pattrns can b rmovd with alcohol and light scrubbing. Th us of adhsiv also allows th us of contrast nhancing agnts in doss that would othrwis b toxic to th skin bcaus th adhsiv can b dsignd to provid a barrir btwn th skin and th contrast nhancing agnt. [0092] Altrnativly, contrast nhancing agnts can b suspndd in sugar-basd or gl basd solutions without pattrning. Ths solutions can dsirably b mad viscous so that thy do not drip outsid th targt rgion. [0093] Instad of applying a pattrn of figurs with a contrast nhancing agnt, th lasr tratmnt zons can form a pattrn of figurs that is usd to nhanc th rspons of th positional snsor 280. For xampl, a CO~ lasr can ablat portions of th skin to crat a pattrn of ablatd aras intrsprsd insid non-ablatd aras. This pattrn can b illuminatd with a light mitting diod (LED) to provid visibl faturs that nhanc th signal to nois ratio of an optical mous chip functioning as a positional snsor 280. [0094] Othr xampls of positional snsor 280 ar illustratd in FIGS Othr xampls of skin snsor(s) 260, (L., skin rspons snsor(s) and/or skin charactristic snsor(s)) ar illustratd in FIGS. S-11. Using on or mor of ths snsors, (L., positional snsors, skin rspons snsors, and/or skin charactristic snsors), difl'rnt masurmnts can b mad to optimiz tissu tratmnt dnsity. Tratmnt dnsity can b kpt constant or maintaind within dfind rangs by th controllr 215 which appropriatly adjusts tratmnt paramtrs of th lctromagntic sourc 210 and th scanning dlivry unit 220. Altrnativly, tratmnt dnsity can b changd by th controllr 215 basd on fdback from th snsor(s). [0095] Th positional snsors and skin snsors shown in FIGS can b addd to or substitutd into th xampl shown in FIGS. 1 and 2. As will b apparnt to on skilld in th art, many of ths systms can b asily dsignd such that th rgion snsd by th skin snsor is coincidnt with th rgion masurd by th positional snsor and th targt rgion bing tratd. In situations whr it is not dsirabl to hav multipl snsors coincidnt or whr ths multipl typs of snsors intrfr, th skin snsor(s), can b displacd along th x, y, or z dirctions rlativ to ach othr.

23 US 2008/ A1 Mar. 6, 2008 [0096] Whil th xampls illustratd in FIG. 2 shows dlivry of optical nrgy to th targt rgion, monopolar or bipolar radio frquncy (RF) nrgy can also b usd in plac of optical nrgy by rplacing th contact plat 239 with a contact plat, contact lctrods, or ndl lctrods that ar configurd to dlivr RF nrgy to a dsird targt rgion undr th control of a controllr 215 that compriss a RF gnrator. [0097] FIG. 4 illustrats anothr xampl of th invntion. In this xampl, th positional snsor is implmntd as on or mor sts of acclromtrs 4SO and 4S1 that ar mchanically coupld to th handpic 400. Th sts of acclromtrs 4SO and 4S1 can b attachd to th insid or outsid of th handpic 400. A st of thr acclromtrs 4SOA, 4SOB, and 4SOC can b usd to masur changs in vlocity in ach of th thr coordinat plans. Th on or mor sts of acclromtrs 4SO and 4S1 can communicat with a controllr 415 that controls th oprational paramtrs of an lctromagntic sourc 410. Th lctromagntic sourc 410 mits lctromagntic nrgy 430, which is dlivrd to th skin 450 through a contact plat 439. Th configuration illustratd in FIG. 4 can also includ a scanning dlivry unit (not shown), as illustratd in FIGS. 1 and 2. [009S] As shown in FIG. 4, a pair of acclromtrs can b usd to masur angular acclration in ach of th thr rotational dirctions. For xampl, acclromtrs 4SOA and 4S 1A masur th angular acclration around a rotational axis paralll to th z axis, acclromtrs 4SOB and 4S1B masur th angular acclration around a rotational axis paralll to th x axis, and acclromtrs 4SOC and 4S1 C masur th angular acclration around a rotational axis paralll to th y axis. Acclromtrs 4SOB and 4S1B ar displacd from ach othr along th z axis dirction and ar drawn as ovrlapping in FIG. 4. Altrnativly, gyroscops can b usd to masur angular acclration of th handpic. MEMS basd acclromtrs and gyroscops ar sold by svral supplirs (. g. Kionix, Inc., Ithaca, N. Y. ). [0099] Masurmnts of acclration or angular acclration can b intgratd in tim to produc masurmnts of vlocity and position or angular vlocity and angular position. In many configurations, an initial calibration and priodic rcalibrations can b rquird to rst th rfrnc vlocity, angular vlocity, position, and/or angular position. [0100] Acclromtrs masur absolut positional paramtrs of th handpic 400 rathr than rlativ positional paramtrs of th handpic 400 with rspct to th targt rgion of th skin 450. If rlativ positional paramtrs ar dsird, acclromtrs can b usd whn th targt rgion is immobilizd or whn absolut movmnt of th targt rgion is insignificant. Altrnativly, th absolut movmnt of th targt rgion of th skin 450 and th absolut movmnt of th handpic 400 can both b masurd and th rlativ motion btwn th handpic 400 and th targt rgion of th skin 450 can b calculatd. [0101] Rlativ masurmnts of angular position can b usd to provid fdback to th systm and disabl th lasr unlss th rlativ angl of th handpic is within a crtain angular rang rlativ to th surfac normal from th surfac of th targt rgion. This can b usful, for xampl, to align proprly a cooling spray and a tratmnt lasr bam on a targt rgion. Absolut masurmnts of angular position ar usful if th handpic 400 has componnts that ar snsitiv to gravity, such as fluid-filld cavitis that lak if turnd upsid down. Rlativ masurmnts of position can b usd to masur distanc btwn locations for pulsing th lctromagntic sourc 410. [0102] Absolut or rlativ masurmnts of vlocity, acclration, angular vlocity, and angular acclration ar usful for valuating whthr th handpic has bn droppd or has suddnly slippd in an uncontrolld way, which might lad to undsird tratmnt outsid th dsird targt rgion. A combination of rlativ positional paramtr masurmnts and absolut positional paramtr masurmnts can b usd to masur movmnt of th patint. For xampl, if th patint suddnly movs, th difl'rnc btwn th rlativ acclration and th absolut acclration masurmnts can b significant. In any of th situations dscribd in this paragraph, th controllr 415 can tmporarily disabl th lctromagntic sourc 410 to prvnt tratmnt in aras that ar not dsird by th usr. [0103] FIG. 5 illustrats anothr xampl of th invntion. In this xampl, th positional snsor compriss at last two pairings of transmittr and rcivr that conduct ithr unidirctional or bidirctional wirlss communication. Th transmittrs 5SOA-C ar positiond to transmit signals to on or mor rcivrs 5S1A-B that ar mchanically coupld to th handpic 500. Th signals from th rcivrs ar rcivd by th controllr 515, which uss tim of flight masurmnts or phas masurmnts to calculat th distanc btwn ach pairing of transmittr and rcivr. Ths distancs can b usd to calculat slctd positional paramtrs of th handpic, which can b don by th controllr 515. Th controllr 515 can b oprably connctd to othr componnts of th handpic such as th lctromagntic sourc 110, th scannr control 125, or th scanning dlivry unit 120 as shown in FIG. 1. Ths can b locatd insid or outsid th handpic 500 and, for simplicity, ar not shown. [0104] Th numbr and location of transmittrs and rcivrs dtrmins th positional paramtrs that can b masurd. For masuring th position of th handpic in thr dimnsions, thr transmittrs and on rcivr can b usd. For masuring th position of th handpic in up to thr dimnsions and also masuring th angular position for up to thr indpndnt angular dirctions, a scond rcivr can b usd. For masuring all thr dimnsions and all thr handpic angls, thr transmittrs and thr rcivrs can b usd in ordr to hav rdundancy. A simpl apparatus compriss two transmittrs and on rcivr. This apparatus can b usd to masur th positional paramtrs of a handpic in two dimnsions along a prdfind surfac. In an altrnat configuration, two rcivrs ar usd with on transmittr to produc th sam masurmnt. Th particular gomtry and locations of transmittrs and rcivrs can b gnralizd by on skilld in th art. [0105] For simplicity in th xampls dscribd blow, rcivrs ar locatd on th handpic and transmittrs ar locatd insid th targt rgion 557 or ar mchanically coupld to th targt rgion 557 such that th masurd positional paramtrs of th handpic will b rlativ to th targt rgion and not absolut masurmnts. Othr configurations can b usd if absolut masurmnts ar dsird. Light basd or othr lctromagntic communications systms can b usd for ths typs of systms as wll. [0106] In on xampl, thr radio frquncy transmittrs ar attachd to a cap, such as, for xampl, mad of cloth or latx for as of us and low cost. For xampl, transmittrs

24 US 2008/ A1 12 Mar. 6, 2008 can b attachd to lctroncphalograph (EEG) caps for this purpos. This typ of cap is usful for locating th handpic whn trating wrinkls on th forhad or priorbital aras of th fac, for xampl, bcaus th transmittrs can b mchanically coupld to th targt rgion. This typ of cap can also b usd with th coil masurmnt systm dscribd in th txt for FIG. 1. In som xampls, singl chip rcivrs, similar to thos commonly usd in cll phons or global positioning satllit (GPS) tracking systms, ar attachd to th cap. Altrnativly, snsors or rcivrs can b attachd dirctly to th targt rgion or to othr aras of th body, such as th tth, ars, nos, chin, tc., using adhsivs. If th snsors ar placd accuratly in th sam plac for ach tratmnt, for xampl on th sam tooth, thn ovrlay maps can b cratd to illustrat th rgions that wr tratd with ach tratmnt in a sris. [0107] On advantag of th acclromtr, magntic, gyroscop, and transmittr-rcivr basd masurmnt systms is that thy can asily b usd in noncontact tratmnt mod (k., whr th handpic dos not com in dirct contact with th skin), which rducs th chanc of skin movmnt during tratmnt and allows th handpic to b hld at diflrnt distancs from th skin in ordr to manually adjust th bam siz that is incidnt on th skin surfac. [010S] Multipl positional snsors can also b usd, for xampl, to allow lowr quality signals from ach of th positional snsors. For xampl, an optical mous typ snsor can b usd with a magntic radiator coil masurmnt systm. Th combination of multipl snsors can also b usd to shut th systm down if larg discrpancis wr notd btwn or among th snsors. If diflrnt typs of snsors wr usd, discrpancis can b usd to provid additional information, for xampl, about whthr th skin is bing strtchd. This information can b usd to dtct situations whn th handpic is not sliding proprly and can b usd to provid fdback to th systm and rduc localizd ovr- and undr-tratmnts. [0109] FIG. 6 shows anothr xampl of th invntion whrin a manually movabl handpic 600 is configurd to dlivr optical nrgy to th skin. An ultrasonic transmittr 6SO is positiond on on sid of th contact plat 639 and an ultrasonic rcivr 6S2 is positiond on th opposit sid of th contact window. Tim-of-flight masurmnts or phas masurmnts ar rcordd to masur th distanc of propagation btwn th transmittr 6SO and rcivr 6S2. This can b usd to masur vlocity of th handpic 600 in th dirction 601 rlativ to th skin 650. [0110] FIG. 7 shows an xampl of th positional snsor and a handpic 700. A phasd array of ultrasonic transmittrs 7SO is positiond on on sid of th contact plat 739 and an ultrasonic rcivr 7S2 is positiond on th sam sid of th contact window. Th phasd array 7SO mits a dirctional ultrasonic bam that can b scattrd or rflctd from th surfac of th skin or from on or mor faturs 753 within th skin to th ultrasonic rcivr 7S2. Using phas shift, tim of flight, or Dopplr frquncy shift masurmnts, a controllr (not shown) can b usd to masur positional paramtrs of th handpic 700 as it movs in th dirction 701. [0111] Th ultrasonic transmittr-rcivr pairs shown in FIGS. 6 and 7 can also b usd as xampls of th skin snsor 160 from FIG. 1, or of mbodimnts of a skin rspons snsor and/or a skin charactristic snsor, with th propr choic of frquncy. Such a snsor can b usd in conjunction with a vlocity snsor to rmov th changs in th masurmnt du to vlocity. [0112] FIG. S shows an xampl of th skin snsor 160 from FIG. 1, or of a skin rspons snsor and/or skin charactristic snsor. In this xampl, a polarizd illumination sourc S62 is usd to illuminat th skin S50 through an illumination lns S64 and through an optional transparnt contact plat S39. A polarizd imaging systm comprising an imaging snsor S60, a polarizr S67, and an imaging lns S66 ar usd to imag th birfringnc of th targt rgion of th skin S50. Th imaging snsor S60 can thn b oprably coupld to th controllr 115 shown in FIG. 1. [0113] During crtain typs of photothrmal tratmnt, drmal collagn is coagulatd, which causs a loss of optical birfringnc for th collagn. This chang in birfringnc can b masurd by th imaging snsor S50 and can b usd, for xampl, as th ndpoint of a tratmnt puls to control th duration of a tratmnt puls. Additionally, this chang in birfringnc can b masurd by th imaging snsor S50 and can b usd to valuat a skin rspons or charactristic which can thn b usd by th controllr to control tratmnt dnsity as wll as othr tratmnt paramtrs. [0114] Th polarizr S67 can b adjustabl (automatically or manually) to mak alignmnt asir or mor prcis or to allow comparison of cross polarization and paralll polarization imags. [0115] Th xampl shown in FIG. S can also b usd to masur skin shrinkag, such as, for xampl, by masuring th sparation distanc btwn two faturs on th skin bfor and aftr tratmnt. On or mor imaging snsors S60 can b usd. Shrinkag can also b masurd using a singl masurmnt by masuring th sparation distanc btwn individual tratmnt zons that start at a known distanc. For xampl, an ablativ CO~ lasr can plac two marks at a st distanc of about 15 mm and thn th sparation btwn ths marks can b masurd to dtrmin skin shrinkag. Us of th polarizr S67 can b unncssary for ths masurmnts and th illumination sourc S62 can b unpolarizd. [0116] In anothr implmntation of th skin snsor illus- tratd in FIG. S, illumination can b usd to incras th signal lvl of an optical skin snsor (k., skin rspons snsor and/or skin charactristic snsor). Whit light illumination can b usd. Altrnativly, squntial illumination with difl'rnt color illumination sourcs can b usd to captur imags that ar digitally procssd to spctrally dtrmin th rspons and/or charactristics of th skin. For xampl, illumination from a rd LED at about 660 nm and grn LED at about 555 nm can b usd to captur, for which th absorption of mlanin and blood ar diffrnt. This will hlp to distinguish btwn tratmnt lightning rspons of pigmntd lsions and of blood vssls. This can also b usd to dtrmin th prsnc of skin faturs such as blood vssls and pigmntd lsions. Us of th polarizr S67 can b unncssary for ths masurmnts and th illumination sourc S62 can b unpolarizd. [0117] FIG. 9 shows an xampl of th invntion that uss a plurality of skin snsors (L., skin rspons snsors and/or skin charactristic snsors) 960 and 961 to provid mor information than is availabl from a singl snsor. For xampl, on skin snsor 961 can masur th skin prior to tratmnt and a scond skin snsor 960 can masur th skin aftr tratmnt. In this xampl, th two skin snsors 960 and 961 ar oprably coupld to a controllr 915 that

25 US 2008/ A1 13 Mar. 6, 2008 controls th tratmnt paramtrs of th lctromagntic sourc 910, including th tratmnt dnsity. Th lctromagntic sourc 910 gnrats lctromagntic nrgy 930 that is dlivrd in a fractional mannr to th targt rgions of th skin 950 through a contact plat 939 as th handpic is movd in a dirction 901. [0118] Using a skin rspons snsor 961 bfor tratmnt and anothr skin rspons snsor 960 aftr tratmnt allows th controllr 915 to calculat th tratmnt dnsity applid, or how th skin rspons has changd aftr tratmnt for a particular tratmnt dnsity stting. Th controllr 915 can thn mak adjustmnts as appropriat to adjust th tratmnt paramtrs of th lctromagntic sourc 910 in ordr to adjust th tratmnt dnsity. This fdback loop allows ral tim adjustmnt of tratmnt dnsity. [0119] An xampl of a fdback loop uss a first capacitiv snsor 961 and a scond capacitiv snsor 960. Each capacitiv snsor masurs th prcntag of skin that has bn tratd with a nonablativ fractional rsurfacing tratmnt. Th first and scond capacitiv snsors 961, 960 ar positiond in front of and bhind th tratmnt window such that th first capacitiv snsor 961 masurs th prcntag of skin that had bn tratd prior to th currnt pass of th handpic and th scond capacitiv snsor 960 masurs th prcntag of skin that has bn tratd aftr th currnt pass of th handpic ovr th targt rgion. Th difl'rnc btwn th masurmnts for th two snsors 960, 961 dscribs th prcntag of skin tratd during th currnt pass of th handpic ovr th tratmnt rgion. Th calculation of th prcntag of skin tratd during th currnt pass can b usd, for xampl, to avoid ovr-tratmnt causd by bulk hating of tissu by rducing th lasr tratmnt dnsity whn unusually high prcntags ar calculatd. Othr xampls of appropriat fdback snsors 960, 961 ar dscribd in U. S. application Sr. No. 10/868, 134, which is incorporatd by rfrnc hrin. [0120] FIGS. 10 and 11 show othr xampls of a skin snsor 1060/1160 that is oprably connctd to a controllr (not shown), which changs th tratmnt dnsity in rspons to th masurmnts from th snsor. In on xampl, th snsor 1060/1160 is locatd insid th handpic 1000/1100. In anothr xampl, th snsor 1060/1160 is not locatd insid th handpic 1000/1100. In FIG. 10, a prob radiation sourc 1062 gnrats a prob bam 1063, such as, for xampl, with a puls width of btwn about 0. 5 ns and about 1000 ns or btwn about 5 ns and about 100 ns, that is absorbd by th skin 1050 to crat a strss wav that propagats through th intrfac btwn a pizolctric matrial 1065 and th skin Th prob bam 1063 can pass through an optional prob bam dlivry lns 1064 to focus th prob bam 1063 onto or into th skin Th strss wav causs th pizo-lctric matrial 1065 to gnrat an lctrical signal that is masurd by th lctrical signal dtctor 1060 that is lctrically connctd to th pizo-lctric matrial [0121] Th charactristics of th gnratd strss wav vary basd on mchanical and optical charactristics of th skin. Th prob wavlngth can b chosn such that thr is a diflrnc in absorption within th skin btwn untratd and tratd skin. Altrnativly, th puls conditions ar chosn such that th mchanical rspons is difl'rnt for tratd and untratd skin. Thus, th strss wav that is cratd can b masurd to dtrmin whthr th probd skin is approaching, has rachd, or has xcdd a dsird dnsity of tratmnt. Exampls of mchanical charactristics of th skin that can b probd using a strss wav includ lasticity, tnsion, and mchanical damping of th skin. [0122] Th signatur of th strss wav that is gnratd can b masurd using svral difl'rnt tchniqus. On tchniqu is illustratd in FIG. 10 and is dscribd abov. In this tchniqu, a transparnt contact plat 1065 mad of a pizo-lctric matrial, such as lithium niobat, gnrats an lctrical signal in rspons to a mchanical strss wav. This lctrical signal can b masurd by an lctronic signal dtctor Appropriat lctronic signal dtctors 1060 ar wll dscribd in th art. Th prob radiation sourc 1062 can b a Q-switchd or mod-lockd lasrs. Th lasr can b a diod lasr, a solid stat lasr, an Nd: YAG lasr, a gas lasr, tc. [0123] A scond tchniqu for masuring th strss wav is to obsrv th chang in rflctanc pattrn from a bam incidnt on th surfac of th skin as shown in FIG. 11. In this configuration, a prob radiation sourc 1162 gnrats a prob bam 1163 that is absorbd by th skin 1150 to crat a strss wav that propagats along th surfac of th skin Th prob bam can, for xampl, hav a puls width of btwn about 0. 5 ns and about 1000 ns or btwn about 5 ns and about 100 ns. Th prob bam 1163 can pass through an optional prob bam dlivry lns 1164 and an optional contact plat 1165 if dsird for optical or mchanical purposs such as focusing th prob bam 1163 or mchanically nhancing th propagation of th strss wav. A cohrnt illumination sourc 1172 gnrats a cohrnt illumination bam 1173 that can b focusd or collimatd onto th surfac of th skin using an optional cohrnt illumination lns Th cohrnt illumination bam 1173 is diflractd from th surfac of th skin by th strss wav cratd on th surfac of th skin 1150 to crat a diflractd bam Th diflractd bam 1167 can b imagd using an imaging lns 1166 onto an imaging dtctor 1160, such as a CCD camra. [0124] Th componnts 1162, 1163, and 1164 ar similar to thir analogs in FIG , 1063, and 1064 and can b mad from th sam componnts as dscribd abov. [0125] Th optional contact window 1165 can b comprisd of a transparnt matrial, such as fusd silica or sapphir, through which th prob bam 1163 passs. [0126] Th prob bam 1163 is absorbd by th skin 1150 to crat a strss wav in th skin As dscribd abov for FIG. 10, th faturs of th strss wav dpnd on th optical and mchanical paramtrs of th skin. Crtain faturs, such as th priod and damping of th strss wav, can b valuatd by masuring th diflraction pattrn from th diflractd bam 1167 that is imagd on th surfac of th imaging dtctor [0127] Th cohrnt illumination sourc 1172 can b a cohrnt sourc, for xampl a HN lasr. Th angl of th cohrnt illumination bam 1173 rlativ to th surfac of th skin 1150 and th angl of th imaging systm rlativ to th surfac of th skin 1150 and rlativ to th cohrnt illumination bam 1173 can b alignd to maximiz th masurmnt signal. Onc a signal has bn masurd, th dcay constant and rsonant frquncy of th strss wav can b masurd with of th apparatii dscribd by FIGS. 10 and 11. DC filtring can also b usd to improv th signal to nois ratio of th dtctd signal. [0128] With th tchniqus dscribd in FIGS. 10 and 11, in on xampl, only th first rflctd wav is masurd and

26 US 2008/ A1 14 Mar. 6, 2008 subsqunt signals from scattring ar tmporally filtrd. This rducs confusion from multiply rflctd wavs. This is similar to optical cohrnc tomography systms in which only th first rflctd signal is usd. Dpnding on th particular gomtry of th apparatus, this apparatus can b usd to masur bulk or localizd optical and mchanical proprtis or charactristics of th skin, which ar changd by th tratmnt. Altrnativly, this apparatus can b usd to masur bulk or localizd optical and mchanical proprtis or charactristics of th skin, which ar not changd by th tratmnt. [0129] Th xampls prsntd hr hav all illustratd th us of ths tchniqus on human skin. This invntion is also applicabl to tratmnt of othr tissus of th body. For xampl, puncturing th surfac of tonails for tratmnt of nail fungus, altring th soft palat for tratmnt of disordrs such as slp apna and snoring, rmoving hair, dlivring pharmacuticals or nutricuticals through th skin or mucosa, or trating hart tissu can all bnfit from th us of this invntion. [0130] Although th dtaild dscription contains many spcifics, ths should not b construd as limiting th scop of th invntion but mrly as illustrating difl'rnt xampls and aspcts of th invntion. It should b apprciatd that th scop of th invntion includs othr mbodimnts not discussd in dtail abov. For xampl, in many of th xampls abov, lasrs ar usd as th mbodimnt, but ths can b gnralizd to RF, flashlamp, or othr lctromagntic nrgy basd tratmnts as wll. Various othr modifications, changs and variations which will b apparnt to thos skilld in th art may b mad in th arrangmnt, opration and dtails of th mthod and apparatus of th prsnt invntion disclosd hrin without dparting from th spirit and scop of th invntion as dfind in th appndd claims. Thrfor, th scop of th invntion should b dtrmind by th appndd claims and thir lgal quivalnts. Furthrmor, no lmnt, componnt or mthod stp is intndd to b ddicatd to th public rgardlss of whthr th lmnt, componnt or mthod stp is xplicitly rcitd in th claims. [0131] All publications, patnts and patnt applications citd hrin, whthr supra or infra, ar hrby incorporatd by rfrnc in thir ntirty. [0132] In th spcification and in th claims, rfrnc to an lmnt in th singular is not intndd to man "on and only on" unlss xplicitly statd, but rathr is mant to man "on " or mor. In addition, it is not ncssary for a dvic or mthod to addrss vry problm that is solvabl by difl'rnt mbodimnts of th invntion in ordr to b ncompassd by th claims. What is claimd is: 1. A mthod for controlld fractional skin tratmnt comprtstng: manually moving a handpic across a targt rgion of skin; dircting lctromagntic nrgy via th handpic toward th targt rgion in a mannr so as to provid a fractional tratmnt; snsing at last on positional paramtr, skin rspons and/or skin charactristic in th targt rgion; and automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd at last on positional paramtr, skin charactristic and/or skin rspons. 2. Th mthod of claim 1, whrin th fractional tratmnt is dlivrd whil th handpic is in motion. 3. Th mthod of claim 1, whrin th fractional tratmnt is dlivrd whil th handpic is not in motion. 4. Th mthod of claim 1, whrin th snsing compriss snsing th at last on positional paramtr, and th automatically adjusting compriss automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd at last on positional paramtr. 5. Th mthod of claim 4, whrin th ordr of stps in th mthod compriss: I) manually moving a handpic across a targt rgion of skin; 2) snsing a positional paramtr of th handpic; 3) dircting lctromagntic nrgy via th handpic toward th targt rgion in a mannr so as to provid a fractional tratmnt; and 4) automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd positional paramtr. 6. Th mthod of claim 1, whrin th snsing compriss snsing th at last on skin charactristic, and th automatically adjusting compriss automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd at last on skin charactristic. 7. Th mthod of claim 6, whrin th ordr of th stps in th mthod compriss: I) manually moving a handpic across a targt rgion of skin; 2) snsing a skin charactristic of th targt rgion; 3) automatically dtrmining an appropriat tratmnt dnsity o f a fractional tratmnt in ral-tim in rspons to th snsd skin charactristic; and 4) dircting lctromagntic nrgy via th handpic toward th targt rgion in a mannr so as to provid th fractional tratmnt of th appropriat tratmnt dnsity. S. Th mthod of claim 1, whrin th snsing compriss snsing th at last on skin rspons, and th automatically adjusting compriss automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd at last on skin rspons. 9. Th mthod of claim S, whrin th ordr of th stps in th mthod compriss: I) manually moving a handpic across a targt rgion of skin; 2) dircting lctromagntic nrgy via th handpic toward th targt rgion in a mannr so as to provid a fractional tratmnt; 3) snsing a skin rspons to th fractional tratmnt in th targt rgion; and automatically adjusting tratmnt dnsity of th fractional tratmnt in ral-tim in rspons to th snsd skin rspons. 10. Th mthod of claim 6, whrin said snsing a skin charactristic compriss snsing a skin rspons in th targt rgion prior to and/or following th fractional tratmnt or portion thro f. 11. Th mthod of claim 6, whrin said snsing a skin charactristic compriss gnrating, capturing and quantitativly comparing data corrsponding to th skin charactristic prior to and/or following th fractional tratmnt or portion thro f.

27 US 2008/ A1 15 Mar. 6, Th mthod of claim 6, whrin said snsing a skin charactristic compriss masuring th skin charactristic prior to at last on puls of a tratmnt nrgy, and said automatically adjusting compriss automatically adjusting said tratmnt dnsity for at last on puls of th tratmnt nrgy. 13. Th mthod of claim 6, whrin said snsing a skin charactristic compriss snsing skin birfringnc prior to dlivry of th fractional tratmnt or portion throf. 14. Th mthod of claim 6, whrin said snsing a skin charactristic compriss masuring skin tnsion prior to dlivry of th fractional tratmnt or portion throf. 15. Th mthod of claim 6, whrin said snsing a skin charactristic compriss capturing imags of th targt rgion whn illuminatd with light of diffrnt polarizations prior to dlivry of th fractional tratmnt or portion throf. 16. Th mthod of claim 6, whrin snsing a skin charactristic compriss capturing imags of th targt rgion whn illuminatd with light of diffrnt wavlngth rangs prior to dlivry of th fractional tratmnt or portion throf. 17. Th mthod of claim 6, whrin snsing a skin charactristic compriss masuring a chang in distanc btwn two faturs locatd in or on th targt portion of skin. 1S. Th mthod of claim 6, whrin snsing a skin charactristic compriss snsing a blood vssl in th targt portion of skin. 19. Th mthod of claim 6, whrin snsing a skin charactristic compriss snsing a lvl of pigmntation in th targt portion of skin. 20. Th mthod of claim S, whrin said automatically adjusting compriss adjusting dnsity of th tratmnt zons if a skin rspons indicativ of ovr-tratmnt or undrtratmnt is snsd. 21. Th mthod of claim S, whrin said snsing a skin rspons compriss snsing a skin rspons in th targt rgion prior to th fractional tratmnt or portion throf and following th fractional tratmnt or portion throf. 22. Th mthod of claim S, whrin said snsing a skin rspons compriss gnrating, capturing and quantitativly comparing data corrsponding to a skin condition prior to th fractional tratmnt or portion throf and following th fractional tratmnt or portion throf. 23. Th mthod of claim S, whrin said snsing a skin rspons compriss masuring th rspons to at last on prior puls of a tratmnt nrgy, and said automatically adjusting compriss automatically adjusting said tratmnt dnsity for at last on subsqunt puls of th tratmnt nrgy. 24. Th mthod of claim S, whrin said snsing a skin rspons compriss snsing changs in skin birfringnc du to th fractional tratmnt or portion throf. 25. Th mthod of claim S, whrin said snsing a skin rspons compriss masuring changs in skin tnsion du to th fractional tratmnt or portion throf. 26. Th mthod of claim S, whrin said snsing a skin rspons compriss capturing imags of th targt rgion whn illuminatd with light of diffrnt polarizations following th fractional tratmnt or portion throf. 27. Th mthod of claim S, whrin snsing a skin rspons compriss capturing imags of th targt rgion whn illuminatd with light of diffrnt wavlngth rangs following th fractional tratmnt or portion throf. 2S. Th mthod of claim 1, whrin th mthod furthr compriss automatically adjusting numbr of said tratmnt zons in ral-tim in rspons to said snsing. 29. Th mthod of claim 1, whrin th mthod furthr compriss automatically adjusting siz of said tratmnt zons in ral tim in rspons to said snsing. 30. Th mthod of claim 1, whrin th mthod furthr compriss automatically adjusting spacing of said tratmnt zons in ral tim in rspons to said snsing. 31. An apparatus for controlld fractional skin tratmnt comprising: at last on lctromagntic sourc configurd to gnrat lctromagntic tratmnt nrgy capabl of trating skin whn dlivrd in a fractional mannr; a manually movabl handpic oprably coupld to th lctromagntic sourc, whrin th handpic is configurd to dlivr th lctromagntic tratmnt nrgy in a fractional mannr to a targt rgion of skin so as to provid a fractional skin tratmnt; a controllr oprably coupld to th lctromagntic sourc, whrin th controllr is configurd to activat or adjust on or mor paramtrs of th lctromagntic sourc; and a snsor oprably coupld to th controllr, whrin th snsor is configurd to sns at last on positional paramtr, skin rspons and/or skin charactristic in th targt rgion; whrin positional, skin rspons and/or skin charactristic fdback from th snsor is usd by th controllr to control dnsity of th fractional tratmnt by activation or adjustmnt of th on or mor paramtrs of th lctromagntic sourc and/or handpic. 32. Th apparatus of claim 31, whrin th apparatus is configurd to dlivr th fractional skin tratmnt whil th handpic is in motion. 33. Th apparatus of claim 31, whrin th apparatus is configurd to dlivr th fractional skin tratmnt whil th handpic is not in motion. 34. Th apparatus of claim 31, whrin th apparatus furthr compriss a scanning dlivry unit oprably coupld to a scannr control that scans th lctromagntic tratmnt nrgy ovr th targt rgion of th skin, and whrin th positional, skin rspons and/or skin charactristic fdback from th snsor is usd by th controllr to control th dnsity of th fractional tratmnt by activation or adjustmnt of th on or mor paramtrs of th lctromagntic sourc, handpic, and/or scannr control. 35. Th apparatus of claim 31, whrin th apparatus furthr compriss a contact plat mchanically coupld to th handpic, whrin said contact plat is usd to mak good lctrical or optical contact with th targt rgion of skin to improv th opration of th snsor and/or to improv th dlivry of th lctromagntic tratmnt nrgy.