Know & Go!
Cutera Genesis Plus Laser
For Treatment of
Nail Fungus, Warts and Scars
Thomas Sheridan, DPM
Agnesian Foot Clin...
Spot Size
Nd:YAG - Spot size affects depth of penetration
Spot size is the laser beam diameter (in mm)
where the laser b...
GenesisPlus
GenesisPlus
The Cutera GenesisPlus is an Nd:YAG (1064nm)
laser with a patented pulse structure designed
for safe and effe...
GenesisPlus, cont’d.
Common uses include:
Temporary increase in clear nail in patients with
onychomycosis
Warts
Scar r...
Treatment of Nails

 Baseline
 Infected area = 42%

 Nine months post final treatment
 Infected area = 5%
Avoiding Complications
Nerve blocks are not recommended as patient
feedback is required
Patients with neuropathy may not...
Avoiding Complications
No self-tanners for at least two to four weeks
prior to treatment
Implants
 Reaction to metal im...
Treatment Technique
Recommend to debride nail if thicker than
2mm (normal thickness)
Do not use gel
Pre-treatment photo...
Treatment Technique, cont’d.
Treat the entire nail bed, matrix and lateral
folds, extending approximately 2mm past the
na...
Treatment of Nails
With 5mm Spot Size
5mm Spot Size
Treatment Steps
Treat one foot at a time
Hallux/big toe
 600+ pulses using multiple passes

Lesser toes
...
5mm Spot Size
Pulse Placement
Hold hand piece perpendicular
to nail’s surface (4cm away)
Ensure the distance beam (small...
5mm Spot Size
Treatment Steps
Pulses should be placed adjacent to
each other with slight overlap
Adjacent pulses should ...
5mm Spot Size
Treatment Steps
Alternate between vertical and horizontal passes
 Move line positions on successive passes...
5mm Spot Size
Treatment Endpoint
Endpoint is total number of pulses
 Though the goal temperature is NOT the endpoint, it...
5mm Spot Size
Treatment Technique
Importance of good technique
Goal of treatment is even bulk heating
Pulses should be ...
5mm Spot Size
Pain Tolerance
Pain tolerance lowers with each pass due to
accumulated heat
The number of passes may chang...
Treatment of Warts
Treatment of Warts
Before treatment

One month after
one treatment
Warts Avoiding Complications
Deep tissue injury and prolonged wound healing
may occur
 Diseases such as diabetes may imp...
Warts - Avoiding
Complications, cont’d.
No self-tanners for at least two to four weeks prior to
treatment
Implants
 Rea...
Warts Treatment Technique
Pre-treatment photographs should be taken prior to
the initial treatment for future reference
...
Wart Treatment Parameters
Selecting Pulse Duration
Parameters need to be selected according to
location, size, and/or col...
Wart Treatment Parameters
Selecting Pulse Duration, cont’d.
Longer pulse duration (less aggressive
treatment)
 Larger, d...
Wart Treatment Technique
Hand piece should be held 2cm away from skin
instead of 4cm recommended for other indications
 ...
Wart Treatment Technique,
contd.
Some warts may require more than one pulse
Pause for a few seconds between pulses
Cool...
End Point
Check for endpoint after first pulse
Desired endpoint
 Slight ashen color should occur immediately after puls...
Treating Individual Warts
 If wart is smaller than laser beam:
 Assess the surrounding tissue before
placing additional ...
Treating Mosaic Warts
 Usually require multiple treatments
 Treatment Steps:
 Use less aggressive parameters
 Do NOT t...
Post Treatment Care
 Warts usually have a black or crusty appearance within
24 hours after treatment
 May apply ointment...
Warts Treatment Example
 Before

 Four weeks s/p treatment
Treatment of Scars
Scar Treatment
 Before Treatment

 Post Treatment
References
 Cutera - GenesisPlus. (n.d.). Retrieved January 22, 2014,
from Cutera: cutera.com/technology/ndyag laser/gene...
Thank You!
Know & Go!
Total Ankle Replacement
Alyssa Stephenson, DPM
Agnesian Foot Clinic
Ankle Anatomy
 The ankle is formed by the union of three

bones
 Talus
 Tibia

 Fibula
Ankle Anatomy
 The ankle has muscular origins above it and

tendons below it to help with movement.
 Contains cartilage ...
Ankle Joint Function
 Ankle joint acts like a hinge.
 It is one of the most flexible, free moving

joints in the body.
...
Ankle Joint Function
 When an ankle joint is functioning

normally, it is pain free.
 Abnormal function can cause pain.
...
Arthritis
 Arthritis - wearing away of the joint

surfaces.
 Three categories:
 Osteoarthritis

 Traumatic arthritis
...
Osteoarthritis
 Primary arthritis, degenerative arthritis
 Most common
 May be due to activity or family history,

wear...
Traumatic Arthritis
 Arthritis that develops after an injury to a

joint.
 Can cause pain, swelling, weakness,
trouble w...
Inflammatory Arthritis
 Occurs when a disease process causes

cartilage in the joint to wear away.
 Example: Rheumatoid ...
Symptoms of Arthritis
Pain - especially with first steps in the
morning or if have been sitting and get up to
ambulate ag...
Tests
X-ray
MRI
CT
Blood work
Diagnostic injections
Non-Surgical Treatment
 Orthotics

 Ankle braces
 AFO

 Shoe modifications
 Medication

 NSAIDS, steroids, corticost...
Surgical Treatment
 Debridment
 Allograft arthroplasty
 Distraction arthroplasty
 Arthrodesis (fusion)
 Total ankle r...
Ankle Debridment
 “Cleaning up” the joint

 Arthroscopically
 Open

 Removal of the inflamed synovial

tissue, removal...
Allograft Arthroplasty
 Uses cadaver donated bone and

cartilage
 Tissue is transplanted in the ankle to
replace the dam...
Talar Dome Lesion
Corrected Talar Dome Lesion
Talar Dome Lesion
Graft Arthroplasty
Distraction Arthroplasty
Ankle is debrided of loose cartilage and
bone spurs
Then a wire frame is applied through the
bo...
Ankle Arthrodesis
Remaining cartilage is removed from the
ankle
Bone surfaces are approximated and
corrected for any def...
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Surgical Options
Motion

No Motion

Debridment
Allograft arthroplasty
Distraction
arthroplasty
Total ankle
replacement...
Total Ankle Replacement
 A surgical cut is made in the front of the ankle
 The tendons, nerves and blood vessels are gen...
Post-Op
 A cast or boot is worn for a few weeks to

keep the ankle from moving while the
incision heals.
Risks
Bleeding
Temporary or permanent nerve damage
Allergic reaction
Infection
Device loosening
Increased pain
Devi...
Post-Op Total Ankle
Replacement
Thank You!
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser
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Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser

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Members of the Agnesian HealthCare Podiatry team present on the new Cutera Genesis Plus Laser, which is for treatment of nail fungus, warts and scars

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Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser

  1. 1. Know & Go! Cutera Genesis Plus Laser For Treatment of Nail Fungus, Warts and Scars Thomas Sheridan, DPM Agnesian Foot Clinic
  2. 2. Spot Size Nd:YAG - Spot size affects depth of penetration Spot size is the laser beam diameter (in mm) where the laser beam meets the skin Smaller spot sizes reduce penetration at a given wavelength, due to increased impact of scatter Energy is lost from the edges (scatter), and concentrated in the center cone shape  GenesisPlus has 1 mm and 5 mm spot sizes
  3. 3. GenesisPlus
  4. 4. GenesisPlus The Cutera GenesisPlus is an Nd:YAG (1064nm) laser with a patented pulse structure designed for safe and effective treatment on all skin types and tanned skin. It can be safely used on all body parts (excluding the eye and surrounding area).
  5. 5. GenesisPlus, cont’d. Common uses include: Temporary increase in clear nail in patients with onychomycosis Warts Scar reduction - including reduction in hypertrophic and keloid scars Treatment of wrinkles Rosacea/diffuse redness Poikiloderma of civatte
  6. 6. Treatment of Nails  Baseline  Infected area = 42%  Nine months post final treatment  Infected area = 5%
  7. 7. Avoiding Complications Nerve blocks are not recommended as patient feedback is required Patients with neuropathy may not be able to provide feedback  Increased risk of adverse events Remove nail polish and clean toes Do not treat over or close to tattoos Remove or cover any jewelry
  8. 8. Avoiding Complications No self-tanners for at least two to four weeks prior to treatment Implants  Reaction to metal implants is unknown  Pacemaker - Stay at least six inches away from implant Ice should not be applied directly to a suspected burn  Cold gel packs or cool compresses can be used
  9. 9. Treatment Technique Recommend to debride nail if thicker than 2mm (normal thickness) Do not use gel Pre-treatment photographs recommended
  10. 10. Treatment Technique, cont’d. Treat the entire nail bed, matrix and lateral folds, extending approximately 2mm past the nail
  11. 11. Treatment of Nails With 5mm Spot Size
  12. 12. 5mm Spot Size Treatment Steps Treat one foot at a time Hallux/big toe  600+ pulses using multiple passes Lesser toes  100+ pulses per toe using multiple passes
  13. 13. 5mm Spot Size Pulse Placement Hold hand piece perpendicular to nail’s surface (4cm away) Ensure the distance beam (small red dot) is centered in the laser beam (large red dot)  This will confirm the correct distance from the tissue (3 to 4cm) Treatment area is the laser beam (not the smaller distance beam)
  14. 14. 5mm Spot Size Treatment Steps Pulses should be placed adjacent to each other with slight overlap Adjacent pulses should be of the larger beam, NOT the smaller distance beam Do NOT stack pulses  One pulse directly on top of another with no cooling time Try not to overlap pulses  May cause more patient discomfort
  15. 15. 5mm Spot Size Treatment Steps Alternate between vertical and horizontal passes  Move line positions on successive passes to ensure uniform coverage Movement should be controlled Start with slow repetition rate (2 Hz) White flashes or sparks can occur during treatment  Ensure nail is clean
  16. 16. 5mm Spot Size Treatment Endpoint Endpoint is total number of pulses  Though the goal temperature is NOT the endpoint, it can help indicate if enough heat is being delivered to the tissue It is recommended that all 10 toes are treated  Recommended treating one foot at a time Number of treatments will depend on severity of fungal infection  The average time interval between treatments is four to six weeks
  17. 17. 5mm Spot Size Treatment Technique Importance of good technique Goal of treatment is even bulk heating Pulses should be placed adjacent to each other with minimal overlap to prevent hot spots
  18. 18. 5mm Spot Size Pain Tolerance Pain tolerance lowers with each pass due to accumulated heat The number of passes may change from patient to patient depending on patient tolerance Pause the treatment for five to 10 seconds in between passes for patient comfort
  19. 19. Treatment of Warts
  20. 20. Treatment of Warts Before treatment One month after one treatment
  21. 21. Warts Avoiding Complications Deep tissue injury and prolonged wound healing may occur  Diseases such as diabetes may impede wound healing Darker skin types have an increased risk of complications and/or pigmentary issues Do not treat over or close to tattoos or permanent make-up Possible hair loss may occur
  22. 22. Warts - Avoiding Complications, cont’d. No self-tanners for at least two to four weeks prior to treatment Implants  Reaction to metal implants or fillers is unknown  Pacemaker - Stay at least six inches away from implant Ice should not be applied directly to a suspected burn Cold gel packs or cool compresses can be used for patient comfort
  23. 23. Warts Treatment Technique Pre-treatment photographs should be taken prior to the initial treatment for future reference Clean skin Shave excess hair in the treatment area Warts may need to be debrided prior to treatment Anesthetics may be used for patient comfort  Local anesthesia (lidocaine without epinephrine) is optional Gel is not used
  24. 24. Wart Treatment Parameters Selecting Pulse Duration Parameters need to be selected according to location, size, and/or color of wart Pulse duration - measured in milliseconds (ms) Shorter pulse duration (more aggressive treatment)  Small, lighter targets  Treating over bottom of foot or calloused area
  25. 25. Wart Treatment Parameters Selecting Pulse Duration, cont’d. Longer pulse duration (less aggressive treatment)  Larger, darker target  Darker skin  Treating over bony areas, near joints or cuticles Pulse duration options:  20ms, 15ms, 10ms, 9ms, 8ms, 7ms, 6ms
  26. 26. Wart Treatment Technique Hand piece should be held 2cm away from skin instead of 4cm recommended for other indications  Only the larger aiming beam will be visible  Smaller working distance beam and the temperature readout will not be activated Stay within the wart border Wart may spark when treated  Ensure skin is clean
  27. 27. Wart Treatment Technique, contd. Some warts may require more than one pulse Pause for a few seconds between pulses Cool with ice/frozen gel pack in between pulses
  28. 28. End Point Check for endpoint after first pulse Desired endpoint  Slight ashen color should occur immediately after pulse  Can be a subtle color change If surrounding skin becomes white or edematous, it was probably over-treated  Treat as a wound
  29. 29. Treating Individual Warts  If wart is smaller than laser beam:  Assess the surrounding tissue before placing additional pulses to avoid overtreatment of normal tissue  If wart is larger than the laser beam:  Use less aggressive parameters  May require multiple treatments  Treat small sections over multiple visits  Place pulses with approximately 10 to 50 percent overlap  Lighter/smaller warts = more overlap  Larger/darker warts = less overlap
  30. 30. Treating Mosaic Warts  Usually require multiple treatments  Treatment Steps:  Use less aggressive parameters  Do NOT treat entire area of mosaic wart in one session  Only treat the darker/thicker area; usually near center of wart  Do not overlap pulses; pulses should be placed adjacent or spaced out  Cool treatment area in between pulses
  31. 31. Post Treatment Care  Warts usually have a black or crusty appearance within 24 hours after treatment  May apply ointment of choice and non-stick dressing for patient comfort  If a blister develops, treat as a wound  Treated tissue usually sloughs within one to four weeks  Deep tissue injury and prolonged wound healing may occur  More than one treatment may be necessary (four to six weeks apart)
  32. 32. Warts Treatment Example  Before  Four weeks s/p treatment
  33. 33. Treatment of Scars
  34. 34. Scar Treatment  Before Treatment  Post Treatment
  35. 35. References  Cutera - GenesisPlus. (n.d.). Retrieved January 22, 2014, from Cutera: cutera.com/technology/ndyag laser/genesisplus/  Cutera Clinical Education. (n.d.). Retrieved January 22, 2014, from Cutera: cutera.com/education/index.php#tv  GenesisPlus Laser. (n.d.). Retrieved January 22, 2014, from YouTube: www.youtube.com/watch?v=6HWWyE9R vBk#t=36
  36. 36. Thank You!
  37. 37. Know & Go! Total Ankle Replacement Alyssa Stephenson, DPM Agnesian Foot Clinic
  38. 38. Ankle Anatomy  The ankle is formed by the union of three bones  Talus  Tibia  Fibula
  39. 39. Ankle Anatomy  The ankle has muscular origins above it and tendons below it to help with movement.  Contains cartilage which acts as a shock absorber.  Contains ligaments, or straps of tough tissue, which help prevent the joint from dislocating.  Contains synovial fluid, a clear smooth oil-like lubricating liquid, which makes it easier for the joint to move.
  40. 40. Ankle Joint Function  Ankle joint acts like a hinge.  It is one of the most flexible, free moving joints in the body.  The ankle can move forward, from side to side and twist.
  41. 41. Ankle Joint Function  When an ankle joint is functioning normally, it is pain free.  Abnormal function can cause pain.  Deformity - congenital or acquired  Injury  Arthritis
  42. 42. Arthritis  Arthritis - wearing away of the joint surfaces.  Three categories:  Osteoarthritis  Traumatic arthritis  Inflammatory
  43. 43. Osteoarthritis  Primary arthritis, degenerative arthritis  Most common  May be due to activity or family history, wear and tear, age
  44. 44. Traumatic Arthritis  Arthritis that develops after an injury to a joint.  Can cause pain, swelling, weakness, trouble walking.  Can affect activity level and lifestyle.
  45. 45. Inflammatory Arthritis  Occurs when a disease process causes cartilage in the joint to wear away.  Example: Rheumatoid arthritis, where the body’s immune system attacks the joint lining.
  46. 46. Symptoms of Arthritis Pain - especially with first steps in the morning or if have been sitting and get up to ambulate again Swelling Extra bone formation - spurring Decreased range of motion of the joint Cracking or crepitus with movement of the joint
  47. 47. Tests X-ray MRI CT Blood work Diagnostic injections
  48. 48. Non-Surgical Treatment  Orthotics  Ankle braces  AFO  Shoe modifications  Medication  NSAIDS, steroids, corticosteroid injections
  49. 49. Surgical Treatment  Debridment  Allograft arthroplasty  Distraction arthroplasty  Arthrodesis (fusion)  Total ankle replacement
  50. 50. Ankle Debridment  “Cleaning up” the joint  Arthroscopically  Open  Removal of the inflamed synovial tissue, removal of loose cartilage and removal of bone spurs
  51. 51. Allograft Arthroplasty  Uses cadaver donated bone and cartilage  Tissue is transplanted in the ankle to replace the damaged tissue
  52. 52. Talar Dome Lesion
  53. 53. Corrected Talar Dome Lesion
  54. 54. Talar Dome Lesion
  55. 55. Graft Arthroplasty
  56. 56. Distraction Arthroplasty Ankle is debrided of loose cartilage and bone spurs Then a wire frame is applied through the bones above and below the ankle and is distracted This holds the ankle stiff and separated Allows cartilage healing to occur
  57. 57. Ankle Arthrodesis Remaining cartilage is removed from the ankle Bone surfaces are approximated and corrected for any deformity Fused together using plates and screws or large nails No motion, eliminate pain
  58. 58. Case Study
  59. 59. Case Study
  60. 60. Case Study
  61. 61. Case Study
  62. 62. Case Study
  63. 63. Case Study
  64. 64. Surgical Options Motion No Motion Debridment Allograft arthroplasty Distraction arthroplasty Total ankle replacement Arthrodesis (fusion)
  65. 65. Total Ankle Replacement  A surgical cut is made in the front of the ankle  The tendons, nerves and blood vessels are gently moved aside  Bone spurs and damaged bone and cartilage are removed  The parts of the new artificial joint are then attached to the cut bony surfaces  Special glue is used to hold them in place  New joint is closed with sutures, and tendons, nerves and blood vessels are put back in place, and the wound is closed with stitches or staples
  66. 66. Post-Op  A cast or boot is worn for a few weeks to keep the ankle from moving while the incision heals.
  67. 67. Risks Bleeding Temporary or permanent nerve damage Allergic reaction Infection Device loosening Increased pain Device noise Bone breakage Blood clots
  68. 68. Post-Op Total Ankle Replacement
  69. 69. Thank You!

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