Safety practices.

2. “If a patient sues for malpractice,
any healthcare professional
involved with the patient is fair

3. Do Not Look into the Laser Beam with your
remaining good eye!

4. O.D 1.0 = only 1/10th
(.1) of the light gets
through.
O.D. 2.0 = only 1/100th
(.01) of the light
gets through.
O.D 3.0 = only 1/1000th
(.001%) of the light
gets through.
Etc.
• A logarithmic formula (factor of 10) which
determines amount of light attenuation

5. O.D. and wavelength might be written on the in-
side

6. O.D 7 @ 190-380 nm (UVB &UVA) O.D. 6 @ 10600-11100 nm (IRA)
Safety Glasses for CO2 ( an example):

7. If the wavelength or OD happens to wear off over
time, the eye wear must be disposed off.
Using a pen to just write the information on is not
allowed.

8. Some final words about Laser Safety Glasses:
• Remember: The laser safety glasses appropriate
for your area may not provide protection against
other lasers (e.g. CO2 safety glasses will not
protect against visible light such as those in Ion
lasers).
• NEVER place your eye in the direct path of a laser,
even if you are wearing safety glasses.
• Laser safety glasses are for diffuse light.
• Laser safety glasses will give some protection from
a direct laser hit in the eye, but not full protection.

10. Avoid flammable preps or topical skin
applications such as alcohol, or acetone.
Alcohol-containing solutions
such as Hibiclens and
Duraprep are flammable, and
great care is required when
using them during laser
procedures.
Duraprep needs to dry
completely before firing the
laser; rinsing or blotting can
destroy the bacteriostatic
properties.
Hibiclens can be safely rinsed
or blotted dry before firing the
laser.

11. “Laser and Electro-surgery Plume”
is
Poisonous, Toxic, Noxious!

14. 1. CO2 light is applied to tissue.
2. The water in the tissue absorbs the light.
3. Absorbed light is converted to heat and
conducted to cooler regions.
4. Heat creates the following tissue effects
based on the specific parameters used:
• Coagulation
• Ablation
• Vaporization
• Incision

15. When the water inside the
cell reaches 100° C, the
water boils and the cells
explode!
The water in the tissue
vaporizes and carries the
remaining constituents of
the ablated tissue with it in a
plume of vapor and debris.
All soft tissue is made up of 80 to 95% water (with the
exception of bone which is only 45% water).
This includes neural, muscular, vascular, skin, and
connective tissue.

16. C02 Laser Resurfacing
• Rhytids
• Acne Scars
• Trauma Scars
• Dyschromia
• Striae
• Lax Tissue

17. Controllable Variables
• Depth of Ablation
• Deposition of HEAT at the selected depth
commonly referred to as Conduction
• First we’ll discuss getting to depth and
then we’ll discuss conducting heat to
adjacent tissue(s).

19. Energy is a quantity of electromagnetic radiation.
Energy is expressed in Joules.
1 Watt for 1 sec = 1 Joule
-----------------------------------------------------------------------
Power is the rate at which energy is delivered.
Power is expressed in Watts.
1 Joule for 1 second = 1 Watt

20. is a
quantity.
is the
rate at which
is used.
The amount of
water in a bucket
is an example of
The rate at
which water is
emptied from a
bucket is an
example of
.
.

22. Continuous
Irradiance at
High Power
Continuous
Irradiance at
Low Power
Intermittent
Irradiance, High
Power
100 J
100 J
100 J100 W 100 W 100 W
10 W
1 sec.
pulse
10 sec.
pulse
1/10
sec.
pulsesTime
Although all three scenarios deliver an equal amount of
energy to tissue, each will produce a different clinical
result.

24. Depth of Ablation
High
Fluence
Medium
Fluence
Low
Fluence
Low
Medium
High
Tissue
Depth of ablation can be varied by a
change in fluence while maintaining
distance from tissue.
Same
Distance

25. High
Fluence
Depth of AblationDepth of ablation can be varied by a
change in distance from tissue while
maintaining fluence.
High
Fluence
High
Fluence
Low
Medium
High
Tissue

26. Focused
Defocused
When used as a conventional CO2
laser,
the MiXto SX® can treat a large variety of
dermal lesions using any one of several
easily attachable handpieces; small spot
“focused’ for cutting or larger spot
“defocused” for more superficial ablation.
Removal of dermal lesions is done by
either cutting them off (as in skin tags) or
by slowly ablating the lesion down layer
by layer until the desired depth is reached.
If a larger spot sized handpiece is
unavailable, a small spot focused
handpiece can alternatively be used in a
defocused fashion by holding the tip of the
handpiece further away from the lesion
creating a larger less ablative spot.

27. 300 µm Spot 180 µm Spot
Slide comparing histology of the 300 µm spot size vs. 180 µm
spot when using equal fluence and pulse width.
MiXto SX® Scanner Handpiece Histology
Note: actual ablation depth will vary according to specific parameters chosen.

28. How to Control Depth
• Spot size – 180um or 300um
Bier’s Law – the 180um will ablate
almost 4 times as deep as
the 300um hand piece at
the same wattage.
• Power – Wattage selected
the higher the wattage the deeper
albated column

29. Heat energy
moves from hot
regions of spoon
to cooler handle.

30. Controlling Conduction
•Index – equates to pulse width (time on tissue)
nominal 1 through 8 – 16ms to 2.5ms,
respectively.
• Density – 5% to 40% when fractionated
100% when in traditional mode
• Scanned Area – smaller = LESS bulk heating
larger = MORE bulk heating

32. th of thermal damage increases with time
12
6
39
Hot object
Thermal
damage
Time

33. A short pulsed laser beam
with sufficient fluence
instantly heats and ablates
radiated tissue.
If the laser beam is applied
over a longer time, heat
will flow from ablated area
to adjacent tissue.
Two ways that a laser beam can generate
heat in tissue.

34. Adjusting the laser pulse width (dwell
time) to be less than a target’s TRT will
allow for heating of the target without
conducting much of it’s heat to the
dissimilar surrounding tissues.

35. At a certain point in time after a target is heated
by a laser beam it begins to cool off by
dissipating heat to the surrounding tissue via a
process called ‘thermal diffusion’.
After heating up, the time it takes the tissue to
cool to 50% of its initial peak temperature is
called the “Thermal Relaxation Time” or TRT.
If the laser pulse is interrupted (turned off)
before the target can substantially cool off, then
the majority of heat that was initially absorbed
will be confined to the tissue for which it is
intended.

36. Increasing
Fluence By
Increasing
Peak Power
Increasing
Fluence By
Increasing
Pulse Width
More
Pronounced
Increase In
Ablation Depth
More Pronounced
Increase In
Residual Thermal
Damage

37. SP/UP pulsed lasers can drill a deep hole, but cannot
produce the high degree of RTD like a CW pulsed laser!
CO2 Laser PulseSame Pulse
Width
Same Peak
Power
More pronounced increase in depth!
More pronounced increase in RTD!
Less pronounced increase in RTD!
Less pronounced increase in depth!
Incremental
increase in
power
Incremental
increase in
pulse width
SP/UP
CW

38. With similar parameters the CW CO2 laser pulse will produce slightly less
ablation than the shorter pulsed SP/UP CO2 lasers, but slightly more RTD (more
tissue tightening and greater collagen production) with an added thin layer of
coag.
This thin layer of highly coagulated tissue will provide for a dryer, safer
Depth
Coag
RTD
Ablatio
n
SP/UP CW

39. Ablation
Due to the fact that Er:YAG is absorbed 12 – 18
times more into water than CO2, it ablates much
more superficially and deposits much less heat.
CO2 Er:YAG
Reversible Thermal Damage
Coagulation
Carbonization

40. K
rypton
416
C
O
2
10,600
A
rgon488
K
TP
532D
ye577
D
ye585
R
uby694
A
lex755
N
d:Y
A
G
1,064
Erbium
2,900
Wavelength (nm)

41. Short Pulse
Er:YAG
Long Pulse
Er:YAG
UltraPulse –
Superpulse CO2
Continuous
Wave (CW) CO2
(250 – 350 µs) (1 – 4 ms) (50 µs – 500 µs) (2.5 – 16 ms)
= Residual Thermal Damage (RTD)
Note: The above diagram is not drawn to scale but is shown for
comparison purposes only.
Spot size, depth of ablation, and degree of residual damage is
dependent on the specific parameters chosen by the user.

42. ProFractional
Laser by Sciton

43. re:pair CO2 Fractional
Resurfacing 2 Hours Post-Op
Deep Tissue Ablation
using CO2
Short pulse width
provides poor blood
coagulation!

44. The MiXto SX®
Scanner utilizes a proprietary patent
pending algorithm producing a “non-sequential”
scanning pattern.
This unique pattern provides the longest amount of time
between adjacent pulses while filling in a given square
area of tissue.
This allows for the maximum amount of tissue cooling of
each laser spot before another spot is placed beside it
lowering the risk of side effects while maximizing patient
comfort.
This treatment delivers the best clinical results of any CO2
micro-fractional system on the market today.

45. (Maximum Cooling)
TraditionalTraditional Micro-FractionalMicro-Fractional
300 µm spots

46. 1 2
3 4
Following a “Z”
pattern, the
scanner will
deposit spots
sequentially in
each quartile of
the selected
scan area until
the entire area
is filled in to
the desired
tissue density.

47. 1 2
3 4
Completed
Scan

48. The diagram to
the left is not
true to scale
but is useful to
show spot
numeric
sequence.
Although there
is only one
aiming beam,
the fast moving
scanner makes
it appear as
though there
were four.
From this diagram one can see that a certain amount of
time occurs before an adjacent pulse is applied.

49. Scanning at a higher percentage of tissue coverage
(density) would be used when desiring a more aggressive
treatment, plus have the added benefit of a shorter overall
treatment time versus doing two or more passes at lower
density.
A disadvantage of using a higher density is that it will
deposit more heat, slightly increase patient pain during
treatment, slightly increase recovery time, and increase
the possibility blistering, scarring and PIH (in patients
with melasma, those more prone to PIH, or in those with a
darker skin type).
Use of a lower density (although increasing treatment
time if doing multiple passes), is less painful and lowers
the possibility of adverse side effects.

50. Doing 2 passes at 20% tissue coverage deposits slightly more
heat (due to some latent heat from the first pass adding to the
second pass) than 1 pass alone, but not as much heat as one
pass done at 40%.
Density 20% 20% 30 - 40% ? 40%
+ ≈ ≠
1st
Pass 2nd
Pass
Some Heat Some Heat More Heat Much Heat
1st
Pass- Result -
Heat
Level
Exact percentage of resultant tissue
coverage will depend on the degree of
scan overlap.
Using a lower density is also useful for feathering (the blending-
in of areas between regions of higher and lower density) or to
gradually tapper along the edge of a scanned area next to a non-
treated location.

51. 300 µm Spot Scan Sizes (in 2 mm² increments)
180 µm Spot Scan Sizes (in 1 mm² increments)
6
8
12
14
16
18
20
10
5 6 7 8 9 10 11 12

52. 5% Density
10% Density
15% Density
20% Density
40% Density

53. Most practitioners perform fractional laser resurfacing in a
systematic fashion, commonly laying down horizontal rows
across the forehead (the exact method is not important) and
then proceeding down either side of the face.
The same systematic method would be utilized a second
time if more passes are needed.
When less a less aggressive treatment is performed the
same parameters can generally be used for the entire face.
When doing a more aggressive treatment, there is an ever
increasing need to select specific settings for each different
region of tissue so as to not over treat thinner skinned or
more delicate areas.

54. When less aggressive parameters are utilized the amount of
overlap per scan is generally not important, but as settings are
increased it becomes more and more important that the degree
of overlap be minimized.
Also, careful attention needs to made throughout the treatment
watching for a difference in tissue effect (such as the degree of
skin tightening or amount of punctate bleeding) from one area
to another indicating a necessary increase or decrease in laser
parameters accordingly.
Performing resurfacing only in a single area without feathering
the margin between resurfaced and non-resurfaced tissue is
generally OK at lower settings, but blending in of the
surrounding area should be done when using higher parameters
during more aggressive treatments to avoid demarcation lines.
Feathering should also be done when doing full face resurfacing
along the jawline (and hairline if treating someone who is
balding on the forehead).

55. To minimize any missed areas of tissue, it is recommended
to slightly overlap each scan.
Scans are limited to the shape of a square in order to
maintain the proprietary algorithm to reduce heat buildup.
Perfect
(in theory only, not
attainable)
More Realistic
(slight overlap, 1 or 2 rows)

56. +
+ = Better
= OK
1st
Pass 2nd
Pass
45O
Rotation

57. ≈ 20% Coverage
≈ 40% Coverage
Scan Pattern Rotated 45°
Normal Scan Pattern
(Greater Clinical Effect!)

58. There is no cook book (one set of parameters for
each type of treatment fits all); there are no hard
dividing lines that separate mild, moderate, and
aggressive treatment settings. Experience is Key!
A treatment will gradually become more aggressive
as settings and the number of passes are increased.
In general, best cosmetic results are obtained using
the highest settings possible (and/or doing multiple
passes) while taking into consideration the patients
pain tolerance and possibility of adverse side effects
according to type of skin (thickness, skin type, age,
etc.)
Also, a patients expectations and willingness to
comply with post treatment care instructions can

59. More Superficial Peel
- 300 µm -
Greater Depth of Ablation
- 180 µm -
Combination
The 300 µm spot size, due to
it’s larger area will produce a
more complete peel for
treating sun damaged skin,
dyschromia, mild wrinkles or
scarring, and other
superficial skin conditions.
(less painful & less downtime
than 180 µm due to being
more superficial)
The 180 µm spot size due to
it’s smaller footprint produces
a fluence 2.74 times greater
than the 300 µm spot size.
This higher fluence will allow
for deeper tissue ablation
providing better treatment for
deeper wrinkles and scarring.
For patients with a combination of both superficial and deeper skin
conditions, a treatment using both spot sizes will often provide an
improved outcome.

60. An improved method in treating the face where there are
separate localized areas of more severe wrinkles or scarring is
to first use the 180 µm spot on these areas, then going over
those areas again along with the entire face using the 300 µm
spot.
It’s better to use the 180 µm spot size first because it’s harder
to visualize where the more damaged areas are once they are
covered with 300 µm treated spots.
If the patient has deeper wrinkles or scarring over the majority
of their face, then the preferred method would be to just treat
the entire face with 180 µm spots alone.
The 180 µm spot will give overall better tightening than the 300
µm spot due to it’s deeper penetration, although this will result
in slightly more post-operative edema and erythema.

69. Although one treatment is usually sufficient, several
additional treatments can be performed with a minimal
interval of one month between sessions to allow the skin
sufficient time to heal.
Since production of new collagen peaks from 3 to 6 months,
a better course of action would be to wait at least 3 months
or more to ascertain for sure whether another treatment is
necessary.
It is better to be conservative and under-treat if you are
unsure of what settings to use (since more treatments can
be done later) than risk having adverse side effects from
being initially over aggressive.

70. Thick
6
Deep Wrinkles / Scarring
More Aggressive Less Aggressive
Skin Type
Treatment Parameters
Dyschromia / Sun Damage
Skin Thickness
Thin
1

71. What does the patient want?
• Reduce wrinkles
• Improve skin tone
• Improve skin texture/feel
• Reduce brown spots
• More even skin color
• Reduce scars
• Some combination of the above

72. • Are patients expectations reasonable?
• Is the patient a perfectionist?
• Has the patient been dissatisfied elsewhere
and why?
• Is the patient litigious (sue happy)?
• Is the patient psychiatrically stable?
• Will the patient be happy with a modest or
less than perfect result?

73. Thank You!