雷射光電學在皮膚科的最新發展 Emerging Technologies in Lasers in Dermatology

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1 雷射光電學在皮膚科的最新發展 Emerging Technologies in Lasers in Dermatology 台大醫院皮膚部主治醫師美麗境界診所醫學美容中心曾忠仁醫師

2 江山代有才人出 Laser Selective photothermolysis IPL Photorejuvenation Non-laser/Non-IPL Tissue remodeling

3 Emerging Technology in Laser in Dermatology High EFFECTIVENESS Low SAFETY High

4 Emerging Technologies in Lasers/Non-lasers in Dermatology Fractional Photothermolysis New Non-Laser/non-IPL Devices Improvement of IPL Photodynamic Therapy Lipolysis

5 Fraxel Fractional Photothermolysis

6 Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Anderson RR, Parrish JA. Science Apr 29;220(4596):524-7.

7 Extended theory of selective photothermolysis Altshuler GB, Anderson RR, Manstein D, Zenzie HH, Smirnov MZ. Lasers Surg Med. 2001;29(5):

8 Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR Lasers Surg Med. 2004;34(5):

9 Traditional Ablative Laser

10 Fraxel Laser

11 Fraxel SR Laser 1550nm Erbium-Doped Fiber Laser 2003 FDA clearance for soft tissue coagulation 2004 FDA clearance for correction of periorbital wrinkles and pigmented lesions, including age spots, sun spots and skin discoloration 2005 FDA clearance for skin resurfacing

12 Fraxel

13 FRAXEL LASER TREATMENT Human Tissue Cross Section Microscopic Epidermal Necrotic Debris (MEND) Controlled Zones of Denatured Collagen in the Dermis Courtesy from Henry Chan

14 MENDs CLINICAL HEALING RESPONSE Microscopic Epidermal Necrotic Debris Visible Light: 4mm Scale Each 20mJ, 1480nm, 4x6 pattern, 500 µm pitch Courtesy from Henry Chan

15 Advantage of Fractional Photothermolysis Relative safety procedure Less, or even no downtime Rapid healing process Similar result with CO 2 laser

16 Non-laser/Non-IPL Devices

17 Non-Laser/Non-IPL Devices Deep penetrating devices Radiofrequency, unipolar Radiofrequency, bipolar plus Diode laser Near Infra-Red Nitrogen plasma

18 Deep Penetrating Devices Unipolar RF ThermaCool Bipolar RF + Diode Laser Polaris Near Infra-Red Titan

19 ThermaCool Unipolar Radiofrequency

20 Depth of Heating 63% of energy deposited within these depths ThermaTip Deep ThermaTip Medium ThermaTip ThermaTip Shallow Superficial Pulse Dye 465 nm Diode 830 nm Nd:Yag 1064 nm CO2 SmoothBeam nm 1450 nm CoolTouch 1320 nm N-Lite Treatment Depth (microns) Current Laser data from Optical-Thermal Response of Laser-Irradiated Tissue by Welch and van Gemert. Thermage data by Thermage Research based on a single-layer homogenous tissue model. Thermage Deep, Shallow, Superficial and ¼ cm 2 tips are under development.

21 ThermaCool System Heating/Cooling Schematic

22 Computer Model of Temperature Profile 1.5 cm 2 Medium Treatment Tip Temp ( C) Depth (mm) Single-Layer Finite Element Analysis

23 Treatment Algorithm with Fast Tips Improved Clinical Outcomes Prior to March 2004 Now Degree and Predictability of Results Single pass algorithm yielded less predictable results Current multiple-pass/clinical endpoint algorithm improves both degree and predictability of results Patient Comfort Higher settings caused excessive patient discomfort Moderate settings with current multiple-pass algorithm and Fast Tip provide a more comfortable procedure for the patient

24 Treatment Algorithm with Fast Tips Improved Clinical Outcomes Time of Procedure Prior to March 2004 Standard Tip and multiple passes were lengthy and tedious for MD and patient Now Fast Tip enables time efficient completion of multiple pass/endpoint algorithm, which improves patient outcomes Adverse Events Rare idiosyncratic surface irregularities were noted Greatly reduced reported incidence of a surface irregularity using current multiple-pass algorithm with moderate settings

25 ThermaCool Today Significantly improved patient outcomes Immediate tightening in many patients More predictable and reproducible results Less discomfort Reduced procedure time Rare and declining side effects Treatment Guideline & Big Fast Tip Make the Difference

26 TEM Research by Brian Zelickson, MD Immediate collagen change with 3 passes at moderate Tx levels exceeds that of a single pass at higher Tx levels % IRREVERSIBLE COLLAGEN CHANGE MULTIPLE PASSES 3 Passes at x x 3 Study by Brian Zelickson, MD LEVEL (and Passes) 1 Pass at

27 Polaris Bipolar Radiofrequency + Diode Laser

28 ELOS Synergy (Polaris WR) Cooling Hot spot Conducted RF Diode Laser

29 The Polaris Concept Polaris is based on Syneron s ELOS technology Conducted RF High power diode laser Effective contact cooling Multiple applications WR: Wrinkle reduction and skin texture treatment LV: Leg vein treatment and vascular lesion

30 RF Current Distribution Unique curvature design of electrodes pushes RF into dermis. Maximum current density is at depth of 1.5mm

31 Polaris WR Pulse Structure Energy RF 70ms High intensity RF pulse is applied at the beginning of the pulse sequence Light energy is subsequently delivered over long duration to avoid overheating of epidermis. Laser 200ms Time

32 Polaris WR Heating Principle Ablative skin Resurfacing with CO 2 and Er:Yag lasers Non-ablative skin Resurfacing with 1.32μ Nd:Yag or 1.450μ diode Matrix skin Renewal with Polaris WR Ablation of epidermis and heating the upper dermis Cooling of epidermis and weak heating the dermis Cooling of skin surface and strong heating of the dermis in matrix way

33 Temperature Profile Hot Spot RF energy heats deep dermis mm Light heats dermis and epidermis. Cooling prevents over-heating of the skin surface.

34 ELOS Synergy Vessel Targeting 1- Set hand piece on skin with vessel 3 - RF goes through the pre-heated vessel 2 - Light is selectively absorbed by blood 4 - Combination of RF and light creates coagulation of vessel wall

35 Polaris LV Pulse Structure Energy 100ms Laser 200ms Time

36 Titan Infrared skin tightening

37 Infrared-- Titan The first light-based solution for tightening skin Clearances The Titan is cleared for the treatment of wrinkles in Europe, and for general dermatologic use in Canada. In the United States, the Titan is cleared for topical heating, for the purpose of elevating tissue temperature for temporary increase in local circulation where applied. Additional 510(k) clearances are pending in the United States. Titan Handpiece Wavelength nm with tailored spectrum Fluence 5 to 65 J/cm2 Spot Size 10 x 15 mm Energy Control Closed loop photometric Epidermal Cooling Continuous epidermal temperature regulation Treatment Cycle 4 to 10 seconds

38 Titan

39 Titan vs ThermaCool

40 Portrait Plasma Nitrogen Plasma Skin Resurfacing

41 The Portrait PSR³ System Plasma Skin Resurfacing (PSR) A Preliminary Report Of A New Technique For Skin Resurfacing Harrison R, Ramsden A, Penny K, Wilson, H, Andrews P, Gault D. Lasers in Surgery and Medicine, Supplement 15, 2003

42 The Portrait PSR³ System FDA-cleared for the treatment of Facial rhytides, Superficial skin lesions Actinic keratoses Easy to learn, 10 minute in-office procedure Proven clinical results with strong safety profile Continuing regeneration one year after treatment Rapid healing with minimal erythema Effectively treats perioral and periorbital areas High patient satisfaction and acceptance Reduced maintenance costs and durability

43 The Portrait PSR³ System Class II device for use by physicians only No need for laser qualified treatment room No special goggles to protect against laser emissions Non-contact delivery of energy at 5mm distance Energy settings range from 1 4 Joules Self-calibration feature to verify energy delivery

44 The Portrait PSR³ System Millisecond pulses of nitrogen plasma Uniform, predictable, soft impact Easy to feather treatment areas Unique surface microenvironment: No epidermal vaporization or charring Intact epithelium to speed healing Targeted thermal conduction into dermis No chromophore dependency Vacuolation of epidermis acts as insulator No scarring or hypopigmentation in clinical studies to date

45 Improvement of IPL

46 Improvement of IPL Improvement of the pulse width Improvement of the light spectrum Improvement of the skin cooling Combined with pneumatic suction

47 IPL Major side effect: Pain Burn Hyperpigmentation Hypopigmentation Chloasma-like dyschromia

48 StarLux

49 Improvement of the Pulse Width Skin temperature elevated Palomar 其他商品 Power, a.u.; Δ Tepi, 0 C Power, a.u.; Δ Tepi, 0 C Time, ms Same energy Time, ms

50 Improvement of the Light Spectrum

51 Simulate the absorption spectrum of the target chromophore

52 Improvement of the Skin Cooling System Ready mode: 12 C, Supercool mode: 4 C

53 Improvement of IPL Working as a platform Various handpieces Photorejuvenation Vascular lesions Hair removal Acne treatment Tissue remodeling

54

55 Lux IR for skin tightening Wave length: 800 1,800 nm (Near Infrared) Spot size: 12 X 28 mm Fluence: J/cm2 Pulse duration: sec. Contact cooling: 0 o C Pulsing with Skin Contact Pending FDA Approval

56 Altera Photopneumatic System

57 Photopneumatic therapy(ppx) Novel Photopneumatic Technology" (PPx): Delivering High Efficiency Photons to Dermal Targets Vic A Narurkar MD, Bay Area Laser Institute, San Francisco CA & Department of Dermatology, School of Medicine, University of California Davis Cosmetic Dermatology, February 2005 Combination of pneumatic energy and broadband light For the treatment of unwanted hair, unwanted pigment and unslightly veins

58 Handpiece of Altera Photopneumatic System

59 Photopneumatic therapy(ppx) Require No Pre-Treatments with Topical Anesthetics Painless treatment Faster treatment Safer: PPx therapy is upto 5 times more efficient in delivering energy to the target.

60 Photopneumatic therapy(ppx)

61 Photopneumatic therapy(ppx) After suction: Skin elevated Thinning of skin Decrease of melanin density Decrease of blood flow Less energy required Less side effect

62 Photopneumatic therapy(ppx) Conventional IPL therapy Photopneumatic therapy

63 Photopneumatic therapy(ppx)

64 Photopneumatic therapy(ppx) Evaporative cooling Under negative pressure in the handpiece, liquid on the skin's surface extracts large amounts of heat from the tissue and evaporates it at protective temperatures. This self regulated cooling process creates a safe environment of continual cooling providing protection to the skin.

65 Photodynamic Therapy

66 Photodynamic Therapy 5-ALA ( 5-aminolevulinic acid ) The most common drug used in topical PDT FDA approved indication for AK 20% 5-ALA hours drug incubation 16 minutes, 40 seconds blue light

67 Photodynamic Therapy Problems Long incubation time hours 3 hours under occlusion Pain associated with therapy PDT effect Downtime with healing of treated area required Up to 1 week or longer

68 Photodynamic Therapy Short contact, full face incubation minutes to 1 hour Reports show no difference in efficacy with longer incubation time No pain with the new vascular lasers and IPL Faster procedure than original blue light source Full face only require 10 minutes None or minimal downtime

69 Photodynamic Therapy Lasers or Light Sources being studied with 20% 5-ALA-PDT All IPL systems Quantum, VascuLight, Aurora, SkinStation, Ellipse All Vascular lasers V-beam, V-star Blue light sources Blu U, ClearLight

70 Photodynamic Therapy ALA-PDT with IPL fro Photorejuvenation Michael H. Gold 2003, ASLMS Dermatol Surg 2004; 30: Global improvement score 90% had greater than 75% improvement compared to baseline 90% improvement in crow s feet appearance 100% improvement in tactile skin roughness 90% improvement in mottled hyperpigmentation 70% improvement in facial erythema 83% of targeted AKs responded to therapy

71 Photodynamic Therapy ALA-PDT with V-Beam Vascular Laser Alexiades-Armenakas M, Geronemous R 2002 ASLMS, Arch Dermatol 2003; 139:

72 Photodynamic Therapy ALA-PDT for moderate to severe inflammatory acne vulgaris 2-4 treatments every other week Tolerated well by patients Short contact Full face Blue light or IPL Works quickly

73 Photodynamic Therapy ALA-PDT for Acne: Michael H. Gold 2003 AAD, Dermatol Surg 2004; 30: patients Short conact, full face ALA therapy Blue light Once a week for 4 weeks 4 and 12 week follow-up 58% decrease in inflammatory acne lesions 55% had 75% improvement in global severity score No adverse reactions

74 Photodynamic Therapy ALA-PDT for Acne Short contact ALA-PDT with blue light or other lasers/light sources provides a significant effect for moderate to severe acne vulgaris. Well tolerated by patients Works quickly No significant side effects

75 Lipolysis Laser-assisted lipolysis

76 Lipolysis Histologic evaluation of the pulsed Nd:YAG laser for laser lipolysis Kota Ichikawa, et al Tokai University School of Medicine and School of Engineering Pulsed 1064 nm Nd-YAG laser Optic fiber in 1 mm diameter cannula 150 mj, 100 ms pulse width, 40 Hz Direct application of the pulsed Nd:YAG laser is effective for destruction of human fat tissue. The results appeared to be achieved by the impulsed shockwave.

77 Lipolysis Low energy 1064 nm laser assisted lipolysis Karen H. Kim,, Roy G. Geronemus Laser and skin surgery center of New York 1064 nm Nd:YAG laser 100 micron optic fiber 1 mm diameter microcannula Laser lipolysis is a safe and effective treatment approach for the elimination of small quantities of unwanted fat without the need for fat aspiration.

78 Thank you for your attention.