Chapter 19: FotoFacial RF Pro Parameters

Transcription

1 Chapter 19: FotoFacial RF Pro Parameters Definitions: Like most good ideas, the FotoFacial RF Pro concept is simple: A full face pass (or full anatomic part in FotoBody RF ) of combined broad spectrum IPL and RF energy in each pulse, treating every millimeter of skin and improving overall pink and brown discoloration, wrinkles, laxity, texture, pores and tone. In some patients, particularly with stubborn pink, ruddy-red and brown discoloration or deeper wrinkles and skin laxity, one full face pass will not be enough and additional regional passes (FFII, Laxity Vector therapy and WrinkleLite ) may be required with either the Aurora TM SR head or the Polaris WR/LV heads, if you own the system, with each visit to achieve the optimal FotoFacial RF Pro outcome. (A) FotoFacial RF Pro Procedure for Chromophores and Discoloration 94 One full pass of FotoFacial RF Pro I in all patients and a regional pass of FotoFacial RF Pro II in the more severe, resistant to FFI rosacea/stubborn pink or erythematous or stubborn brown/melanin regions of the face. FotoFacial RF Pro I and II settings use the low wavelength cut-off filter (470 nm or 580 nm). The FotoFacial RF Pro therapy program involves 5-7 visits (average 5 visits), every three weeks. Non-vasconstrictive topical anaesthetic cream is applied mins prior to each treatment. Each treatment visit lasts from minutes. Patients can put makeup on after each treatment and return to work immediately. FotoFacial RF Pro Indications: 1. Erythema, rosacea, flushing and blushing (vascular based chromophores) 2. Hyperpigmentation and dyschromia (melanin-based chromophores)

2 3. Photoaging and solar elastosis 4. Non-Facial FotoBody RF therapy (chest, neck, forearms and hands) 5. Treatment of inflammatory erythema post surgical, post laser resurfacing 6. The FotoFacial RF Pro treatment of wrinkles and skin laxity: The combination of intense pulsed optical and bi-polar radio frequency energy allows the physician to achieve wrinkle, skin laxity, pore size and skin texture improvements that were impossible to achieve with any degree of consistency with the IPL (Vasculight, Quantum or Prolite device) or YAG (Vasculight, Quantum DL, CoolTouch or SmoothBeam ) systems. (B) FotoFacial RF Pro Procedure for Chromophores, Wrinkles, Texture and Laxity The FotoFacial RF Pro incorporates the short wavelength FotoFacial RF Pro I and/or II settings, along with longer wavelength laxity vector and wrinkle parameters and settings. For FotoFacial RF Pro Galaxy TM or Polaris TM users, the Aurora TM FFI/FFII remains the same, but the Wrinklite TM and laxity vector is performed using the Polaris TM WR head and large vessels and lower lid dark circles with the LV head. All passes of the FotoFacial RF Pro are performed during the same sitting. In most FotoFacial RF Pro patients, there will be three separate passes of photons and RF across the skin. FotoFacial RF Pro addresses all the clinical issues of pure IPL systems (pink and brown discoloration) but, in addition, focuses on additional collagen and ground substance production with multiple pass laxity and wrinkle treatments. A non-vasconstrictive topical anaesthetic cream is applied minutes prior to each treatment. Depending upon the speed (recycle time) of the technology, each treatment visit lasts from minutes. The FotoFacial RF Pro therapy program involves 5-7 visits, every 3 weeks. 95

3 FotoFacial RF Pro Indications: Includes all the indications for a FotoFacial RF Pro I and II, with the addition of: 1. Skin Laxity: cheek-jowl, brow and neck laxity vectors 2. Wrinkles: Class I and II (very little effect on class III) 3. Textural Depressions: scars (acne, chicken pox), stretch marks STEP ONE: FotoFacial RF Pro e-light TM, e-max TM, Aurora TM & Galaxy TM users uses the SR head (580 nm) / SRA head (470 nm) A. FotoFacial RF Pro I Setting (FFI) FFI effects are primarily on the deep epidermis and superficial mid-dermal levels. 1. Improves uneven pigmentation, dyschromia and hyperpigmentation 2. Reduces erythema, flushing, fine telangiectasias 3. Reduces pore size 4. Smoothes texture 5. Stimulates collagen and ground substance production and will provide moderate skin laxity tightening 6. Slightly softens fine lines and wrinkles 7. Produces more even skin color and tone 96

4 Principles of Safe FotoFacial RF Pro (FFI) treatments 1. Perform a test spot on each visit and on each site you will treat before proceeding with full face, or anatomic region treatments. 2. After each test spot, watch for the %ISM reading, this provides your pulse to pulse measurement in the drop in dermal impedance (or rise in dermal temperature) and is Active Dermal Monitoring ADM TM ). Your test spot should be slightly pink and the %ISM should be between 15-20% for skin types 1-3. If the %ISM is too low, raise the IPL 1-2 J/cm 2 and reassess. Conversly, decrease the IPL if the ISM is too high. 3. Assess closely the skin reaction as you move across the region, watching for evidence of over treatment or missed areas. 4. Ask the 6 important questions each time the patient presents for another treatment: (i) How did the last treatment go? Any complications or troubles with your skin after the last treatment? Down time (i.e. purpura, swelling, crusting, blistering, scabbing?) An answer of YES to any of these questions may modify your treatment parameters and approach for the next FotoFacial RF Pro treatment. (ii) Are you on any new medications since the last treatment? Look for new potentially photosensitizing medications. If yes, you may have to do a test spot and have the patient return. (iii) Have you had any significant sun exposure since your last treatment? If yes, you may have to send the patient away and come back in 2 weeks when the tan has faded. (iv) What differences do you see in your skin? (v) What things in your skin do you still want to see improved? 97

5 (vi) Has anyone spontaneously commented that your skin is looking better? Always record what has been said to the patients by others as a record of your outcomes. This will often be valuable when you have your completion consultation. 5. In general, increase the intense pulsed optical fluence by 1-2 J/cm 2 of optical energy each visit (as there is a diminishing chromophore target.) Hence the importance of the FotoFacial RF Pro software key. Without high optical intense pulsed light fluences, dermal optical heating will be insufficent, the impedence will not drop optimally and the RF will not be as selective as effective. Remember to test spot on each side of the face, on each visit and ensure that the %ISM stays between 15-20%. Once you are very proficient with FotoFacial RF Pro procedure, try to keep the pulse-to-pulse %ISM between 18-22%. Remember, you will need to go up in IPL each visit as your target chromophores are diminishing. In general, with each visit you will require more IPL to generate the same dermal, selective phothesmolytic heating with the IPL. Just like a domino effect, without critical optical dermal heating, you will not lower impedence enough to optimize dermal RF effects. That is why we usually raise the IPL setting 1-2 J/cm 2 each visit (if all went well during the previous treatment) and why the FotoFacial RF Pro key is needed.) 98

6 FotoFacial RF Pro Parameters Tables (for Step One) FotoFacial RF Pro Clinical Indications (i) (ii) (iii) (iv) (v) (vi) Rosacea, erythema, flushing, telangiectasia Dyschromia: hyperpigmentation, lentigines, ephilli, brown pigmentation Wrinkles: fine to moderate Texture: scars, irregularities Skin laxity Pore size The FotoFacial RF Pro Treatment Algorithm (i) (ii) (iii) (v) (vi) FotoFacial RF Pro anesthetic cream Num-It and Synercool TM (if you own it) Test spot with starting parameters based upon skin type and chromophore severity. Beside the ear, deltopectoral groove or proximal forearm. FFI Full face, then assess skin response for enhancement of brown and reds. Rotate handpiece 180 degrees and retreat. Laxity Vector therapy jowls, neck, cheek, eye and brow WrinkleLite for fine lines (vii) FotoFacial RF Pro Galaxy TM if you own a system (viii) Perform every three weeks 99

7 (ix) (x) Stratum corneum therapy in between each of the first three FotoFacial RF Pro treatments FotoFacial RF Pro skin care and procedure enhancement creams. Using the FotoFacial RF Pro Parameters Tables The following tables contain the initial parameters to use for a test spot. Depending upon the appearance of the test spot, the intensity of the parameters are adjusted, i.e. the fluence may be increased or decreased (most commonly manipulated parameter) or the IPL pulse duration may be adjusted, or the %ISL setting altered. To be safe, an accurate skin type determination must be made and a test spot used every treatment. The patient returns for a FotoFacial RF Pro every three weeks and, in general, with each new visit the IPL fluence is increased by 1-2 J/cm

8 FotoFacial RF Pro Parameters Skin type I-3 FFI Type nm J/cm 2 SP 25 J/cm 3 ISM% % 580 nm J/cm 2 SP 25 J/cm 3 ISM% % After one full face pass, access area. To enhance red or brown areas rotate handpiece 180 degrees and retreat. Full face total Pulses Skin type 4 Note: must pre-treat all skin type 4 patients with melanin/pigment suppressionbased skin care products for 4 weeks prior to treatment. FFI Type nm J/cm 2 SP 25 J/cm 3 ISM% % 580 nm J/cm 2 SP 25 J/cm 3 ISM% % Skin type 5 FFI Type nm J/cm 2 LP 25 J/cm 3 ISM% % 580 nm J/cm 2 LP 25 J/cm 3 ISM% % 680 nm J/cm 2 LP 25 J/cm 3 ISM% % FotoBody Treatment Parameters (Skin Types I, II, III, IV, V) For non-facial skin rejuvenation use the FotoFacial I setting starting with light fluence 2 Joules lower than face - two passes (Skin Types I, II, III, IV, V) Pulses: Neck: 200+ Chest: Hands:

9 Long pulse of optical energy, higher fluences 1. The long pulse setting for skin rejuvenation spreads the optical energy over a much longer period of on time. The long pulse is a double pulse and the long delays allow both the target and the epidermis to cool (12.5ms/50ms/12.5ms). The RF energy is lowered slightly. 2. Some basal layer epidermal effect, predominantly superficial dermal effect. 3. Generally a regional treatment only, performed after a full FFI, if the FFI is not improving the regional area of chromophore predominance. FFII is therefore a second pass over skin you have just immediately treated. Indications: 1. Improves larger resistant telangiectasias 2. Reduces deeper erythema 3. Improves stubborn or resistant brown discoloration 4. Improves skin texture 5. Tightens pores 6. Improves flushing, blushing 7. Stimulates collagen 8. Softens fine lines slightly 102

10 FotoFacial RF Pro SR Head Spot Welding Parameters Occasionally you will experience patients with stubborn vascular and melanin-based lesions that are not improving with FFI. Alternatively, you will have some patients who may not want to invest in full facial treatments and only want a small vascular blemish or pigmented lesion(s) treated. The spot welding parameters are for these patients. In these patients, and only after the full face FFI and treatments are proving unsuccessful, do you implement the Spot Treatment parameters. The Spot Treatment FotoFacial RF Pro parameters have much higher intense pulsed optical fluences and the risk of blisters, purpura, burns, scarring and post-treatment pigmentation disorders and complications are much higher. The spot treatments are isolated, single crystal sized, one pulse treatments initiated over larger telangiectasias or isolated melanin lesions that are resistant to FFI parameters and have not improved after at least two FotoFacial RF Pro treatments, the usual 3 weeks apart. For resistant erythema, telangiectasia and/or pigmentation, implement FFII protocol as follows - [Also refer to page 154 for treatment of larger spiders with LV (Polaris) applicator.] Skin type I-3 SRA Type nm J/cm 2 LP 25 J/cm 3 ISL 30% OR 470nm J/cm 2 SP 25 J/cm 3 ISL 30% *** Advanced Technique 1-2 additional partial passes Skin type 4 SRA Type 4 470nm J/cm 2 LP 25 J/cm 3 ISL 30% OR 580nm J/cm 2 LP 25 J/cm 3 ISL 30% *** Advanced Technique 1-2 additional partial passes Skin type 5 SRA Type 5 680nm J/cm 2 LP 25 J/cm 3 ISL 30% *** Advanced Technique 1-2 additional partial passes 103

11 Step Two: Laxity Vector Parameters e-light TM, e-max TM, Aurora TM & Galaxy TM users uses the DS & ST heads Laxity Vectors are the directions of loosening and laxity in the skin that occur as we age and the resulting brow, facial and neck ptosis that ensues. There are three primary laxity vectors that are treated. The Brow-lift Laxity Vector, the Cheek and Jowl-lift Laxity Vectors and the Neck-lift Laxity Vector (only if the patient is paying for FotoBody treatments of the neck.) Similar to the treatment of wrinkles, the histological and structural effect of the laxity vector therapy is to shorten existing collagen fibrils and to produce new collagen and ground substances (proteoglycans and glycosaminoglycans.) The clinical goal and effect is to tighten the laxity in the ptosis vectors and produce a noticable shrink wrap effect to the skin. Like WrinkleLite treatments (last section) successful Laxity Vector therapy will rely on dermal matrix heating or Dermal Thermesence and Heat Stacking in the dermis. The end result will be to heat the dermis to degrees celsius over the prolonged 200 ms pulse profile (can be more profused than 10 degrees celsius over 10 ms required for fibroblast activation and collagen shortening and production of collagen and ground substances.) Use the long wavelength intense pulsed optical head, the 680 nm HR head for the laxity vector therapy. The longer wavelength pulsed optical cut-off will ensure that the optical Selective Radiophotothermolysis will occur at a deeper level (5-8mm) of the dermis than the FFI and FFII passes with the 580 nm cut-off filter (2-4mm). The radio frequency energy during the Laxity Vector therapy will then stream to the lower and deeper regions of lowered impedance than during the FFI and FFII therapy. The result is the production of collagen and ground substances (proteoglycans and glycosaminoglycans) at a deeper dermal level than during the 580 nm FotoFacial RF Pro passes and, also, less likelihood of burns, blisters, thermal injuries and their sequela, scars and pigmentation disorders. 104

12 Laxity Vector Therapy Skin Types 1 5 Indications: 1. Production of collagen and ground substances along the lax cheek, jowl and brow vectors as well as the upper lip and lower lid, if there are wrinkles in these areas. 2. Performed after the FFI, FFII and/or spot welding passes. Laxity Vector Parameters Skin type I-3 Laxity Vector Type nm(DS) 30 J/cm 2 SP 25 J/cm 3 ISL 30% Skin type 4 * NOTE: Do not start laxity vector for skin type 4 until after the 3rd FF treatment. Do not initiate multiple passes if the skin shows adverse reaction signs (blistering, excessive edema or erythema, or persistently high ISM% or persistent patient pain.) Laxity Vector Type 4 680nm(DS) J/cm 2 SP 25 J/cm 3 ISL 15% Skin type 5 * NOTE: Do not start laxity vector for skin type 5 until after the 3rd FF treatment. Do not initiate multiple passes if the skin shows adverse reaction signs (blistering, excessive edema or erythema, or persistently high ISM% or persistent patient pain.) Laxity Vector Type 5 680nm(DS) J/cm 2 LP 25 J/cm 3 ISL 10% *** FOR NEW ST HEAD SETTINGS AND PROTOCOL SEE PAGE 84 *** 105

13 Step Three: WrinkleLite Parameters e-light TM, e-laser TM, e-max TM, Aurora TM, Galaxy TM & Polaris TM users uses the SR/DS head, WR head Whereas the FotoFacial RF Pro FFI +/- FFII treatments are directed primarily at facial chromophores and homogenization of color, the WrinkleLite component, like the laxity vector, is targeting the dermis and designed to create new collagen, as well as ground substances and shorten the collagen that is already there. The shortened fiber length of existing collagen and increased collagen and ground substance production in the dermis, provides structural filler under the fine to moderate wrinkles, acne scars, textural depressions and serves to tighten the loose skin envelope of the face. The innovative synergy of intense pulsed optical and RF energy in the same treatment are here to improve the wrinkle outcomes. For most IPL or YAG systems the goal of creating a maximum amount of dermal heating, and the resultant shortening of existing collagen and the production of new collagen, leads to very high fluences being used. Risk of epidermal reaction, in the wrong, or tanned, skin type can be significant. By using the synergy of intense pulsed optical and RF energy one can reduce the high risk IPL to allow RF streaming, thereby decreasing the IPL, pulsed optical exposure risk. It is the clinical intention with the step 2 WrinkleLite treatment to create a palpable dermal edema under each wrinkle or depressed textural irregularity, which reflects the inflammation following the dermal thermescence or dermal heat stacking that is occurring. Recall, at degrees celsius over 200 ms, the dermal heat energy will stimulate fibroblasts to become fibrocytes and produce type 1 collagen, in tight, organized fibrils. At this temperature there is also some reorganization and shortening of existing collagen fibrils. The endpoint of WrinkleLite treatment of slight dermal and epidermal edema under each wrinkle, is quite similar in look and feel to the palpable and visual appearance of injecting Zyderm 1 or any of the Hyaluronic acids. This end-point, like all of the finesse components of the FotoFacial RF Pro, is not something you can learn from a book and necessitates an advanced training and certification course. Use WrinkleLite with great caution in skin 106

14 types 4 and 5, as there is more melanin for the pulsed optical energy to interact with adversely and cause complications. The darker skinned patients rarely present with wrinkles and much more frequently desire improvement in brown discoloration. WrinkleLite Skin Types 1 5 Indications: 1. Wrinkles class Acne, chicken pox scars 3. Dark circles lower lids of venous congestion origin WrinkleLite Parameters Skin type I-3 Wrinkle Type nm(SR) 20 J/cm 2 LP 25 J/cm 3 ISL 30% Lite Type 1-3 WR head 40 J/cm J/cm 3 -- * Only skin types 1-3 would get WrinkleLite for fine neck or chest lines. Skin type 4 * NOTE: Do not initiate multiple passes if the skin shows adverse reaction signs (blistering, excessive edema or erythema, or persistently high ISM% or persistent patient pain.) Wrinkle Type 4 680nm(DS) J/cm 2 LP 25 J/cm 3 ISL 15% Lite Type 4 WR head 30 J/cm J/cm 3 -- Skin type 5 * NOTE: Do not start WrinkleLite for skin type 5 until after 3 full FF treatments. Do not initiate multiple passes if the skin shows adverse reaction signs (blistering, excessive edema or erythema, or persistently high ISM% or persistent patient pain.) Wrinkle Type 5 680nm(DS) J/cm 2 LP 25 J/cm 3 ISL 10% Lite Type 5 WR head 20 J/cm J/cm