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Cosmetic and asthetic gynaecology by Dr Narendra Malhotra
1. PROF.NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.
• Prof. Dubrovnick International University
• V.P. WAPM(world association of prenatal medicinne)
• President ISAR
• Presiddent Elect ISPAT
• Sec Gen SAFOG
• Member FIGO guidelines committee
• President FOGSI (2008-2009)
• Dean I.C.M.U. (2008)
• Director Ian Donald School of Ultrasound
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Managing Director GLOBAL RAINBOW HEALTH CARE
• Director ART-RAINBOW –IVF
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy
and Infertility, ART & Genetics
• Member and Fellow of many Indian and international organisations
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,
Corion award, Man of the year award, Best Citizens of India award
• Over 50 published and 200 presented papers
• Over 100 guest lectures given in India & Abroad and 24 ORATIONS
• Organised many workshops, training programmes, travel seminars and conferences
• Editor 18 books, many chapters, on editorial board of many journals
• Editor of series of STEP by STEP books
• Revising editor for Jeatcoate’s Textbook of Gynaecology 7th and 8th edition (2015)
• Very active Sports man, Rotarian and Social worker
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE,AGRA
84, M.G. Road, Agra-282 010
Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194
4. HER UNSPOKEN PROBLEMS
NARENDRA MALHOTRA
MANPREET SHARMA
JAIDEEP MALHOTRA
NEHARIKA MALHOTRA BORA
SHEMI BANSAL
GLOBAL RAINBOW HEALTH CARE AGRA
mnmhagra3@gmail.com
Cosmetic and Asthetic Gynaecology
5. Common UNSPOKEN problems
• Pelvic organ prolapse—symptomatic /
Asymptomatic
• Urinary dysfunction
• Stress urinary incontinence
• Sexual dysfunction
• Overactive bladder
• Faecal incontinence
• Pelvic pain
• Vulval /vaginal itching and pain
• Abnormal Vaginal discharge
12. Stress incontinence
A QOL Problem!
urine leakage
triggered by
coughing,
sneezing,
laughing, lifting,
exercising,
straining
Pads for incontinence – world market
P&G's -incontinence an attractive $7 billion
global
category growing 7% annually.
Compared baby diapers, feminine care products
and tissue
incontinence demonstrates the fastest
growth
Age and Parity
Pelvic floor muscle
denervation and
endopelvic fascial
disruption
Physical activity level
Individual impact is
variable
20. Kegel Master ?
• Helps a woman perform proper and effective Keigel
exercises by applying adjustable targeted resistance
against the muscles of the female pelvic floor.
• The Kegelmaster™ has 15 levels of resistance with a
maximum of 4.5lbs of pressure required to close the
unit.
• The Advanced Kegelmaster has 64 levels of
resistance with a maximum of 9.5lbs of pressure
required to close the unit.
20
24. STRESS URINARY INCONTINENCE
minimal invasive surgery
TVT
Ulmsten, 1996
“Integral theory”
Monofilament
Prolene
Midurethral support
No fixation of the
tape
25. Tension-free vaginal
tape
Cure rate 60 - 90%
Indications
• Primary and failed surgery
• Concomitant prolapse
surgery
Complications
• Bladder perforation
• Retention
• Urgency
26. Bladder injury at TVT
Bladder perforation rates 2 - 10%
Rates with previous retropubic
surgery
Remove TVT and site more laterally no
IDC required
28. IMPLANTS UNWANTED
EFFECTS
• UTI
• Urinary retention 1.9%
• Urge incontinence 12.6%
(21% did not respond to
anticholinergics)
• Haematuria 5%
Stothers L et al J Urol (1998)
29.
30. Treatment of Pelvic Prolapse
Lifestyle Changes
Bladder Training
Physical Therapy
Pessary
Vaginal Mesh
Surgery
NEW: Laser Vaginal Rejuvenation
40. Atrophic Vaginitis
• Pre-pubertal – lactating –
postmenopausal
• Reduced endogenous estrogen
• Causing thinning of the vaginal
epithelium
• Vaginal epithelium susceptible
to trauma and infection
• pH high
pH 5-7 d/t reduction in lactic acid
production and decrease in
lactobacilli decreasing h2o2
43. Treatment for Atrophic Vaginitis
• Treated with estrogen replacement (vaginal/oral)
• Oral BCP (ethinyl estradiol up to 50ug)
• Conjugated estrogen up to 1.25mg in combo
w/medroxyprogesterone acetate to prevent
endometrial hyperplasia
• Vaginal cream 1g daily qhs x1m then ½ dose
2X/week (1g vaginal cream=.625mg conjugated
estrogen)
–should give w/ 2.5mg medrxyprogesterone
x14d
• Estrogen vaginal ring (change q3m) (Estring)
delivers 6-9ug estrodiol daily
• Vagifem 1tab intravaginally x2w then 3x/w for 3-6m
44. VRS – Vaginal Relaxation
Syndrome
it is a quite common
medical condition
described as a loss of
optimal vaginal
structure and is
usually associated
with vaginal delivery
and natural aging..
45. VRS leads to…….
• Sexual dysfunction
• Urinary incontinence
(Specially stress urinary
incontinence)
• Urogenital syndrome of
menopause
47. Lichen sclerosus
• Comprises 70% of benign epithelial disorders
→ epithelial thinning, inflammation &
histological changes in the dermis.
• Aetiology: unknown
• Sx: Itching (commonest), vaginal soreness +
Dyspareunia. Burning and pain are uncommon.
• Signs: crinkled skin, L. minora atrophy,
constriction of V. orifice, adhesions,
ecchymoses & fissures.
• Dx: Biopsy is mandatory
• Rx: - emollients, topical steroids.
- Testosterone: not effective than petroleum jelly
& → pruritus, pain & virilization.
- Surgery: avoided unless malignant changes
48. Lichen Planus
• General Appearance
– Erosive lesions at
vestibule w/without
adhesions resulting in
stenosis
– May have associated oral
mucotaneous lesions and
desquamative vaginitis
– Patient c/o irritating
vaginal , vulvar soreness,
intense burning, pruritus,
and dyspareunia w/post-
coital bleeding
– Types: Papulosquamous
LP/Hypertrophophic LP
/Errosive LP
49. Treatment
• Intravaginal
hydrocortisone
suppositories BID x 2m
• Steroid creams (medium-
high potency)
• Vaginal estrogen cream if
atrophic epithelium
present
• Vaginal dilators for
stenosis
• Surgery for severe vaginal
synechiae
• Vulvar hygiene
• Emotional support
51. Squamous Cell Hyperplasia
(Atopic Eczema/Neurodermatitis)
Physical Appearance
Benign epithelial thickening and
hyperkeratosis
◦ Acute phase with red/moist
lesions
◦ Causing pruritus leading to
rubbing & scratching
◦ Circumscribed, single or
unifocal
◦ Raised white lesions on vulva
or labia majora and clitoris
Treatment: Sitz baths,
lubricants, oral
antihistamines, Medium
potency topical steroid twice
daily
52. Lichen Simplex Chronicus
• Physical Appearance
– Thickened white
epithelium on vulva
– Generally unilateral
and localized
• Treatment:
Medium potency
steroid twice daily
prn
53. Benign Vulval lumps
• Bartholin’s cyst.
• Epidermal inclusion cyst.
• Skene’s duct cyst.
• Congenital mucous cysts: arise from mesonephric ducts remnants.
• Cyst of the canal of Nuck: can give rise to hydrocele in labia maqjora.
• Sebaceous cyst.
• Papillomatosis (solid).
• Fibroma (solid).
• Lipoma (solid).
• Condylomata (solid).
Cysts are either congenital or arise from obstructed glands.
Manifestations arise from the cysts (cosmotic) or from infection.
56. WHAT IS THERMI Va
• It’s a Non-invasive temperature controlled
radiofrequency device .
• RF energy delivered deeply into vulva ,vagina
• Tissue tightening immediately
• Newer and tighter collagen stimulation – new
softer and smoother skin
57. THERMI Va
Non – surgical
No anesthesia
Painless
OPD procedure
Immediate results
58. No pain
Treat outside
(labia)
Treat inside
(vagina)
No downtime
For any age
For loose vagina
For loose labia
For dry vagina
For leaky bladder
For orgasmic
problems
59. Heating of the skin and mucosa promotes 3 different kinds
of effect:
• Immediate contraction of collagen
• Immediate collagen remodeling and elasticity
• Long term stimulation of production of new collagen
HOW WORKS
61. TREATMENT TIME : what it takes ??
• External labia : 5-10 min, atrophy/lax
• Full vagina : 30 min
• SUI &OAB :10-15min
• Atrophic vaginitis: 10 min
• Cystocele : 7-10 min
• Rectocele : 7-10min
• Orgasmic dysfunction : 15-20 min
64. Alma FemiLift
Key Differentiator: Treatment Time and Efficiency
The Alma FemiLift allows Selective Targeted
Treatment Areas meaning practitioners can
target specific areas or zones 45 degrees at a
time i.e. protocol choosing between 11 o’clock
and 2 o’clock for maximum thermal efficacy and
penetration depth.
ThermiVA
ThermiVA uses a disposable wand to deliver RF
energy to the external and internal vagina. Requires
time to increase temperature into the “therapeutic
range” of 40-45° C. Thermal reaction only, no
ablative reaction reduces long term neocollagenisis.
Requires topical numbing cream for external use
(30-45 min)
65. 3. ThermiVA has a single use probe which times
out after 1 treatment and can’t be reused on the
same patient for treatments 2 & 3. Per patient
costs are $450 vs $120 for Femilift. Femilift has a
much better ROI.
ThermiVA is Monopolar and also requires a
grounding pad. Push downside of “old” mono RF
technology and importance of positioning
grounding pad in the correct spot.
How are we different?
66. FemiLift Probe
Key Differentiator
ThermiVA Wand
Small shape – can’t be reused – slow
with small spot size
Slim Shape – ease of use. Comfortable
for practitioner and patient.
67. Femilift™ is an FDA-approved pixel CO2 laser designed and
invented by Alma Lasers™ to treat
vulvo-vaginal dryness,
vaginal laxity
mild to moderate urinary incontinence,
mild prolapse
Vulval diseases
Definition
68. Rationale for using laser therapy
• 1970
• Late 80s’-90s’
Full field ablation for facial rejuvenation
• 2004
Fractional phothermolysis
• 2009
Vaginal Fractional phothermolysis
• 2014
FDA approves vaginal fractional co2 for:
Skin tightening
Vaginal atrophy
69. Effect of Laser on
Tissues
Photostimulation
Photodianamic Reaction
Photothermolytic Action
70. What is Vaginal Laser
• Vaginal Laser Stimulates
Production Of Collagen,
Elastin And Fibroblast
Activity.
• Treat And Improve: Stress
Urinary Incontinence ,
Vaginal Laxity And
Dryness.
71. Er:YAG laser
• 2940 Nm Wavelength
• Maximum Absorption By
Water
• Minimal Penetration Depth
• Short Thermal Relaxation
Time
• A Short Pulse Width Can
Provide Precise Control With
Minimum Damag
• Can Be Used To Be Ablative In
High Fluence Ranges –Either
Very Superficial Or Very
Aggressive And Deep In Turbo
Mode
73. What is
• vaginal CO2 laser stimulates production of collagen,
elastin and fibroblast activity.
• Treat and improve: stress urinary incontinence ,
vaginal laxity and dryness.
• Utilizing CO2 Pixel Laser Technology:
Long term thermal effect
Micro ablative effect
Gold standard in Face Treatment & Skin
Tightening
74. 74
The Technology
of FEMILIFT
BEING USED WIDELY IN INDIA BY DEMRA
ABOUT 10 GYNAECS USING FEMILIFT IN INIDA
KOLKATA
BANGLORE
JAIPUR
AGRA
SURAT
DELHI
NASIK
NELLORE
MUMBAI
75. 75
Pixel CO2 laser
Deep Thermal Heating
and Micro-ablation
• Laser energy is delivered to the
vaginal tissue through a DOE -
Diffractive Optical Element
• DOE pixelates the beam to 81
microscopic pixels in a 9x9
pattern
• Pixel pattern promoting faster
healing
• Deep thermal effect for
vaginal collagen remodeling,
without causing aggressive
77. 77
Pixel CO2 laser vs. Scanner
1 Laser Beam81 Micro Beams
At the same fluence the
Pixel CO2 is 81 times longer than the
Scanner
30W * T = 100
mj/Pixel
T=100/30
T=3.33 msec
(Pick Power ;
Ablative)
30W/81 Pixel * T =
100 mj/Pixel
T=100*81/30
T=270 msec
Thermal Effect
Treatment Energy 80-120 mj/Pixel
Enhanced thermal effect
78. 78
Pixel CO2 laser
Strong and Impactful
Thermal Effect
• High-powered laser
• Utilization of much higher energy levels by longer
pulse duration
• Microscopic columns of thermal zone penetrates deep
into the submucosa, leaving the surrounding tissue intact,
with minimal ablation
79. structural support
How does the FemiLift Pixel CO2 Works?
Alma Pixel CO2 surgical laser utilizes fractional technology to
create micro-ablation and thermal damage to the mucosa and sub-mucosa
• fractional laser through holographic lenses
pixelating the beam to 81 microscopic beams (pixels)
• ablated mucosa and microscopic columns
of thermal damage that penetrate deep into the sub-
mucosa
• Strongly stimulates the growth of new collagen
• Collagen remodeling allows tissue re- firming, causing
CO2 Laser
81. Collagen Remodeling & Stimulation-
Mechanism of Action
Acute Thermal Damage Phase (48-72 hours)
Edema
Release of Chemical Mediators
Collagen Shrinkage
Proliferation Phase (30 days)
Fibroblastic Recruiting
New Dermal Molecular Matrix
New Collagen Fibers
Remodeling Phase (? months)
Mature Collagen Fibers
New Elastic Fibers
82. Beam Splitter – Alma’s CO2 Pixel Solution
• Fractional CO2 combines
micro-ablative approach
with longer pulse for deep
thermal effect
• Allows short, easy and
efficient treatment protocol
reducing procedure time
83. 83
Mechanism of Action
The Action Process Has Three Phases:
Edema
Release of chemical mediators
Shrinkage of collagen and elastic fibers
Early thermal
effect
Phase I
Within 48-72
hr.
Fibroblastic recruiting
New extracellular matrix
New collagen fibers
Proliferation
Phase II
In the
following 30
days
Mature collagen fibers
Increase of collagen fiber strain
Neovascularization: new blood vessel
formation
Improved lubrication, pH (acidity)
Remodelling
Phase III
After 30- 40
days
Physiologic and functional recovery of the vaginal
mucosa.
84. + Normal tissue is comprised of a thin
top layer (the epidermis) that rests on a
deeper layer (the dermis). The dermis
contains a matrix of collagen (the basic
building block of skin) and elastin that
provides structure and support to the
vaginal tissue.
Dermis
Epidermis
Elastin Fibers Collagen Fibers
+ Aging and obesity degrades the
vaginal tissue’s normal collagen and
replaces it with abnormal tissue that
does not stretch and recoil. This
creates tissue laxity.
Elastosis
+ CO2 laser removes the abnormal
upper tissue layers, and stimulates
new collagen growth in the dermis
to effectively restructure and restore
it to a state that resembles
undamaged tissue.
New
Collagen
Collagen
Remodeling Process
86. Micro Ablative Effect
Colposcopic picture of vaginal wall post FemiLift treatment
•
Smooth
treatment
without
damages
or
carbonizat
ion
Immediately post
treatment
Two weeks post
treatment
87. Histology
histological HE samples
from the time just after the ablative effect (A), the
filling of the
vaporized space" as a column shape (B) at 72-96 h,
the progress of
healing in the vaporized area (C) (D) at 14 and 28
days
respectively, and finally the rejuvenated fascia at two
months (E).
89. 89
Histologies
Thick vaginal epithelium, rich in
glycogen
Atrophic vaginal mucosa.
Thin epithelium with mild
parakeratosis
Neovascularizatio
n in the
sub-epithelial,
lamina propria
Courtesy of Jorge Alberto Eias, MD , Buenos Aires,
Argentina
Pre-treatment Post laser treatment Post laser treatment
90. Menopause: The Journal of The North American Menopause
Society Vol. 22, No. 8
Histological study on the effects of
microablative fractional CO2 laser on
atrophic vaginal tissue: an ex vivo
study
Stefano Salvatore, Umberto Leone Roberti Maggiore,
,Stavros Athanasiou, et al
91. Advantages
• non invasive procedure
• Office procedure
• “coffee break” procedure -lasting approximately
between 10-20 min
• Easy and safe procedure
• Minimal discomfort and pain
• Effective
• Rapid healing
• Single use and hygienic vaginal
probe
92. To achieve safe and effective collagen
remodeling for vaginal tissue
rejuvenation, it is important to have
thermal effect and avoid ablative
damage.
FemiLift™ Safety
98. 98
Pixel CO2
Integrating Technology and
Convenience for Optimal Results
• Uses an 10,600 nm CO2
laser
• Power up to 30W/ 70W
• Intuitive, user friendly
interface
• Adaptable to most surgical
microscopes and
colposcopes
99. FemiLift Single Use Hygienic Vaginal Probe:
Femilift reusable hand-piece with a single-use sheath
100. All in One, Multi Package
FemiLift Probe FemiLift Slim Probe FemiLift Smart
FemiTight LiteScan FemiCam
101. Protocol
• Femilift probe
• Apply liquid lidocaine 2% on the
introitus, Waite 3 minutes
• The inner part of the introitus 25 mj/p ,
3 passages
• Outer part of the introitus. 15 mj/p , 3
passages
• Repeat if necessary after one month
103. 103
Vaginal Tightening
• Powerful thermal heating and micro-ablation is
applied to the various layers of the vaginal tissue in a
360 degree pattern
• Vaginal tissues remodelling
The Treatment
106. Collagen Remodeling process
Dermis
Epidermis
Collagen FibersElastin Fibers
+ Normal tissue is comprised of a thin
top layer (the epidermis) that rests on a
deeper layer (the dermis). The dermis
contains a matrix of collagen (the basic
building block of skin) and elastin that
provides structure and support to the
vaginal tissue.
+ Aging and overweight degrades the
vaginal tissue’s normal collagen and
replaces it with abnormal elastic
fibers that do not stretch and recoil.
This creates tissue laxity.
Elastosis
+ Co2 laser removes the abnormal
upper tissue layers, and stimulates
new collagen growth in the dermis
to effectively restructure and restore
it to a state that resembles
undamagedtissue.
New
Collagen
107. Fractional microablative CO2 laser
for vulvovaginal atrophy in women
treated with chemotherapy and/or
hormonal therapy for breast cancer:
a retrospective study.
Menopause 2016 Oct;23(10):1108-13
Pagano T et al
Fractional microablative CO2 laser treatment is associated
with a significant improvement of VVA symptoms in women
affected by hormone-driven breast cancer.
This procedure has the advantage of relieving
iatrogenic/physiological VVA symptoms without resorting to
contraindicated estrogen preparations, which have been the
most effective therapy thus far.
108. Urethra Support – can be
achieved with FemiLift
URINE URINE
Normalsupport
under the
muscle
URINARY INCONTINENCE
Loose collagen fibers
NO URINARY INCONTINENCE
Firmed collagen fibers
Loss of support
under the
muscle
109. The effect of microablative
fractional CO2 laser on
vaginal flora of
postmenopausal women
Climacteric 2016 Oct;19(5):512-8.
Athanasiou S et al
MFCO2-Laser therapy increased Lactobacillus (p < 0.001)
and normal flora (p < 0.001) after the completion of the
therapeutic protocol, which decreased vaginal pH from a
mean of 5.5 ± 0.8 (initial value) to 4.7 ± 0.5 (p < 0.001). The
prevalence of Lactobacillus changed from 30% initially to
79%
110. 110
FemiTight
For Labia Majora Tightening
• Treatments conducted with
this probe use a low fluence
beam laser that gently heats
the tissue
• Effectively restoring and
reviving collagen growth
111. 111
LiteScan
For Labia Majora Rejuvenation
• Char-free tissue ablation with
multiple scanning patterns
• Promotes accelerated re-
epithelization, allowing for faster
healing and tissue regeneration
• Significantly improved overall skin
tone, elasticity and texture, and
reduced superficial pigmentation
112. 112
The System
Our
experienceUSING SINCE 6 MONTHS AGRA
35 SUI CASES
10 VAGINAL TIGHTENING :4 post delivery
5 GENITAL PROLAPSE UNFIT FOR SURGERY
1 WARTS
1 RESHAPING
1 LICHEN LIKE
3 VULVAL VAGINAL ITCHING
2 VAGINAL DRYNESS
ALSO BEING USED BY COSMETIC DEPPT
COLLECTIVE INDIAN EXPERIENCE OF OVER A YEAR WITH OVER 200 CASES OF SUI
113. Pre-Treatment Consultation
Complete Health History Questionnaire
Vaginal / Bladder Questionnaire
Complete OB/GYN History, Including Pap Smear Results
Pelvic Exam
114. Contraindications
Active HPV / Herpes
Abnormal Pap Smear
Active Vaginal Infection
GYN Cancer
Undiagnosed Vaginal Bleeding
Uncontrolled Diabetes
Pregnancy
Recent Vaginal Injury
Any Active Bleeding (Including Menses)
115. Treatment Protocol
Office Procedure
No Anesthesia
2-3 Passes of Entire Vaginal Canal
3 Sessions
1 Month Interval
1 Memory Session After 1 Year
May Repeat Full Course After 2 Years
116. NON GYN USES IN WOMEN
• PREGNANCY STRETCH MARKS
• FACIAL LASER
• WARTS ANYWHERE
• DARK SPOTS AND MOLES
• SCAR MARKS POST C.S. KELOIDS
• EVOLVING INDICATIONS
• OPERATIVE EXTERNAL ALSO WITH CUT LASER
117. Case 1
• 45 y, G3P2, nurse, patient zero
• Healthy, no operations
• For 2 years pain in the introitus on 12
o'clock. Affect work, avoidance from sex.
trial of various local treatment -failed.
Work up - no infection, normal
colposcopy, diverticula-ruled out
• Started femilift
• Before tx VAS 90, after first tx VAS 60 ,
after second tx VAS 40, after third tx VAS
1/2,resumed sexual activity
VISUAL ANALOG SCORE FOR PAIN SEVERE 75-100 45-74 MODERATE 5-44 MILD 0-4 NO PAIN
118. Case 2
• 32 y, G1 P1
• Healthy no operation
• Since delivery Vulvodynia , local tx,
behavioral tx, physiotherapy, local
anesthetics - no improvement . Infection-
ruled out, normal colposcopy
• Started femilift
• VAS before tx 10, after one tx 7/8, after
second tx,5 after. Third 3
119. Case 3
• 36 y G2P2
• Healthy no operations
• 2 years pain during intercourse, siting
• No infection normal colposcopy
• Vas before 9 after one tx 7 after second 4
120. Case 4
• 28 y G0
• Healthy no operations
• 5 y pain in introitus , no infection, normal
colposcopy
• Trial of various local tx , behavioral tx,
physiotherapy - no improvement refers for
vestibulectomy
• VAS before tx 9, after one tx 3 satisfied
121. • Vaginal tightening
• Post delivery
rehabilitation
• SUI
• Vaginal dryness
• Vulvar rejuvenation
• Scars
• Vulvodynia/
Vestibulitis
• Lichen sclerosis
• Vaginal infections
• Bleaching
THE NEED IS REAL
THE NEED …NEEDS TO BE RESPECTED
SHE SHOULD DECIDE
ITS HER WHICH MATTERS
WHY SHOULD SHE SUFFER IN SILENCE
122. Domestic & International
Experience
87% of patients report significant improvement
in Vaginal Rejuvenation and Tightening
78% of patients report improvement of Stress
Incontinence
88% reported complete dryness afterwards
12% have less leakage afterwards
22% with insignificant or no improvement
123. There is no such thing as
PERFECT or COMPLETE…
only continuous improvement.
GIVE H.E.R. WINGS AND LET H.E.R.SOAR
PRACTICE WITH QUALITY,ETHICS AND DIGNITY
126. Thank you
Acknowledgements to prof ronen gold,dr ruby ruprai,dr carolyn ,dr vidya pancholy
Dr rashmi chaar khandelwal,dr lila vyas and ALMA lasers
FOR HELPING TO MAKE THIS PRESENTATION AND SHARING DATE AND SLIDES