This thread is for physicians (or other medical professionals) who are users of the recently-introduced ablative fractional CO2 lasers, who wish to discuss indications, settings, comparisons between manufacturers, anesthesia issues, pre and post-treatment care, or other helpful tips.

eg: Lumenis Active FX, Lasering Mixto, Ellipse Juvia, Reliant Re:pair, etc.

TF,

Do you have the ActiveFX?

I am currently researching the market, and comparing what's available. From your screen name, I presume that you do....tell us why you favor that machine. What technological advantages do you think it has over its competition.

I have used ActiveFx for 10 mos. Most of those treated p't with severe acne, post-tramatic scar,and nevus extirpation. Comparing with my prior Sharplan CO2 experience, ActiveFx has a shorter erythema period and better results. But still very painful!The main issue of ActiveFx user is no available or useful parameters can be traced, including fluence & CPG.Its operator manual help only a little.In term of the outcome, it is worthwhile.

Nice white paper on the mixto sx here:
derm.md/dev/lasering/White%20paper.pdf

I have been a C02 fan since 1995, and am very interested in the new fractional C02 lasers. I have seen but not used the Fraxel repair, and the research is excellent. Have spoken to very respected docs who have experience with it and they love it. Recently used the SmartXide dot laser by Deka(italian), and while it was very easy to use, i am not certain it will do enough to warrant the purchase.Of course, it is half the cost of the Fraxel repair.

I've looked at both the Fraxel Repair and SmartXide Dot, and I have to say I like SmartXide more. My reasons: Fraxel can only be done with either option A or B. The physician is also held back because they can only go where the roller goes. The machine doesn't allow for full ablative laser, and it has a need for replaceable tips. (More costs)

SmartXide Dot allowed me to use lots of customizable options, from shapes, energy level, dwell time, etc to get the "perfect" combo for each patient. So, for example, areas around the nose or corners of the eyes are now easier to treat, as opposed to when trying it with Fraxel.

I'm posting a link to a video of SmartXide being performed. The doctor explains the different options the laser can do. I hope this helps.

http://uncutvideo.aol.com/videos/0adbeb721f19a977f78928eeb4ef4ced

Tell me more about your experience with the smartXide machine.

What are the machine's parameters for the power, size of the MTZ, and patterns? - it looks like a 17 x 17 pattern on the website. What is the cost of the machine? Is the reticulated arm hard to position? What are your favorite settings? How many days are the patients down for?

I'm currently investigating the Ellipse Juvia - it has a flexible fiberoptic waveguide, rather than a reticulated arm. Power is 15 watts, up to 7 ms pulse width, with variable pattern densities. Mtz size is 500 microns. A full-ablative handpiece is an option, according to the company. Like the smartXide, there are no consumables.

TF:

Power 5-30 watts
MTZ 300 microns
Pattern Variable up to 1.5x1.5 cm

Cost: ?? need to call the rep, I don't know what the cost will be for your area, but I can tell you right now it wont be as much as Re:pair.
Articulating arm. Some trouble initially with transferring between offices. Now works well
Settings: There is an entire list of settings depending on what you are treating.
Patients are down for 1-3 days. Red up to 10 days

Roseville: what settings have you tried for a) dyschromias, b) fine wrinkles c) heavy wrinkles and acne scars? How long does it take the final result to evolve?
Are you pre-treating with retin-A, hydroquinone or not?

I've been using the Juvia with 15 Watts and 6-7 milliseconds dwell time. The MTZ "dots" peel around day #4.

Dear all

All the different ways of comparision are just adding more confusion, could we kind of standardise the variables? I can think of the followings, please comment , love to learn more experience from you:
1. Continuous wave vs super-pulsed (the one I use is super-pulsed)
2. Overall power output ( max for mine = 30W)
3. Energy per MTZ (i.e. spot) ( mine range from 10mJ - 160mJ)
4. Densities of MTZ ( max for mine = full ablation, then 550 MTZ /cm2, then 250, 120, 50, ........total 10 choices )
5. % of skin ablation ( that depends on the densities of course)
6. Beam size ( mine is similar to the deep fx, ~ 0.1 -0.12mm)
7. Pulsing frequency ( mine range from 1 - 10, i.e pulsing 2 , 3 or 4 times in each MTZ before next beam )
8. Pulsing pattern and size ( mine square or round, 1mm - 20mm each dimension)
9. Pulsing sequence : random or continuous ( mine is continuous across )
10. Dwell time (Don't know about mine)
11. Depth of penetration ( that depends on the energy used of course )

Any more addition?

For pigmentation of face, I use 10-20mJ, Frequency 1, density ~120 - 70MTZ/cm2, 1 -2 passes

For eyelids tightening, I use 30mJ, frequency 1 -2, density 120MTZ/cm2, 1-2 passes

For facial tightening, I use 30-40mJ, frequency 2-3, dencity 120MTZ/cm2

For acne scar, I use 20-40mJ, frequency 2-3, density 250 -120 MTZ

Have to say, brilliant results so far. Scabs come off around day 3 -7. No cases of PIH. But I use a cool down treatment for 15 mins afterwards, it can be simple icy cold towel, or a cooling machine with cold head of -10C. There is a talk about using copper peptides mask too and I am experiencing this. Copper peptide is well know to improve skin healing.

dr stephen I

That's great stuff, dr. stephen! Dwell times apply to the continuous-wave machines - rather than your pulsed machine. What is the pulse-width on your machine?

I'm just about to start playing with multiple passes and stacked passes on my machine, so I've got a few questions for you. When you do stacked pulses (frequency = 2-3), what do you see clinically? Does re-epithelialization or erythema clearance take longer? Do you see more char? Is it more painful for the patient? Do you turn the power down for those - half power if you are doing 2 pulses, etc.?

Which gives you a better clinical outcome - increasing the frequency, or doing multiple passes - or are they about the same? Does a second pass look much the same as doubling the MTZ density?

Thanks!

I am interested in a fractionated CO2 lase. However, I am wondering how many paople I will have that want the service. I looked at the results of the Erbium Fraxel, but the before and after photos were just not impressive. I felt I could get pigmentation off with IPL just as well. When treating superficial to deep wrinkles, what is a typical fee to the patient that one would expect? I am in a rather small area and need to keep costs down. I don't have a lot of cash for procedures that may not come around every day. Thank you in advance.

Reliant just released their fully ablative and cutting handpieces at ASLMS. I have 3 lasers from Reliant (the real Fraxel) and have been with them from the beginning. All the big wigs are from Coherent and know what they are doing. The build products on science.

I will not purchase another Reliant until they get rid of the consumables. The consumables have nothing to do with science they only have to do with cash. They are having financial trouble and from what I have heard they are looking to be bought. I have heard a rumor that Thermage is looking at them.

ESC,Coherent,Sharplan ---- merged with Lumenis.

Sorry for disappearing for some days.

Dr K, you seem to be praising fraxel re:pair here and in another bolg, without substantiating yourself with figures. What is so awesome? You haven't got round to say further in the other blog. If you work for Reliant, identify yourself!

TF,

I may be wrong, but I thought you refer dwell time to the time a laser beam spend in 1 MTZ. In that case, even a super pulsed laser can have a dwell time. To achieve the scanning pattern, it is either :

Laser operation mode : Continuous wave (in each MTZ) + tissue exposure mode : repeat ( to complete all MTZs) , i.e. one continue pulse repeat many times OR

Laser operation mode : Super pulses (in each MTZ) + tissue exposure mode : Single, i.e. one single pulse broken down to many super pulses.

I don't know how much time a laser beam spends in the MTZ for my laser. I don't know the pulse wide either.

Yes, if I do a frequency 2 or 3, it is more painful, and the downtime is longer. I think there is more lateral heat expansion if you hit the same MTZ few times before moving to the next. To do a second pass is different, in that there is more time to cool down in the MTZs. Not too difficult to understand : 1,1,1; 2,2,2; 3,3,3....... vs 1,2,3,....1,2,3,......1,2,3,.....

Whether to increase the frequency or to do multiple passes, depends on whether you want to go deeper, or to cover more. Increasing the energy or the frequency has similar but different result, both go deeper. More passes just increase the MTZs, covering more, without going deeper.

So I juggle around with energy / frequency / density / pass, as I suggested in my parameters above.

Cheers.

Hey Dr. Stephen - good to hear from you. I agree with you - there is a difference between increasing the energy and increasing the frequency. With a higher energy, the beam naturally goes deeper, but the lateral thermal damage only increases a little. With a repeated stacked pulse, you have the second pulse hitting the char from the first pulse - so you'll get much more lateral heating, and only a little more ablation depth.

Clinically, which do you think works better for the deeper wrinkles and acne scars?

just got a smartxide
could do with a good protocol for eye tighting?
any offers
thanks

I had quite a few cases of good results in tightening the upper eyelids. Moderate result in 1 month which progressed to excellent result in 3 months, after 1 single treatment.

You can have a look at 1 case at www.drhealthbeauty.com

Patient skin type : II - III
Parameters used on my machine: 60mJ, pulse stacking 3, ~ 100 MTZ/cm2

For chinese people with skin type IV, I used 30-40mJ with good result but no PIH (so far).

drstephen

I also use 60mJ (15W x 4 ms) per MTZ for the lower lids, but at only 49 MTZ / cm2, using the Juvia.

thank you both

dr stephen
looked at your case and yes very good result. you stack the pulse 3 times, and so i take it that is not a 3 passes. What is the down time? with that.
do you find stacking increases down time significantly more and do you stack routinely for all areas of the face or scarring or just up the energy? if you use 60mj, what watt and dwell time does that break down into.
This term mtz is not a term very familar with me and has caused me confusion. Sorry for sounding slightly stupid but i take 100 MTZ/cm2 to be 1mm or 100um spacing.

TF
so what spacing would 49 be?
is that a single treatment and whats your down time like.

Thank you both for your help with this

The parameters on each machine are slightly different. You probably won't be able to transfer exactly what somebody else does on a different machine.
7 x 7 zones per cm2 works out to a spacing of 1.25 mm between the center of each spot, I believe.

I'll do 2 passes. Downtime is about 5-6 days. Hope that helps.

Has anyone compared the Mixto and the Smartxide-dot? Seems that the dot has more flexibility. I demo'ed the Mixto and felt it was a great technology , and will demo the dot in 2 wks and post here. thanks

I think the major difference is the dwell time. SmartXide's scanner goes up to 2 ms at 30W, while the Mixto's scanner can have longer dwell times, up to 16 ms, IIRC.

Demo'd the SmartXide dot fractional CO2 today; The settings were more user friendly than the Mixto, the controls were on the hand piece (very-nice) and it appeared to be faster. There was more controlability in the settings such at power, spot size and dwell time; the Mixto had 2 settings such as 8 & 8. We'll see how the results are in a week...as we know its all about the results. Also, the SmartXide was heavier and harder to move ( for those of us w/ more than 1 location. Anyone else had similar experiences?

TF: what was the pricing you got on the Juvia; as we know CO2 is CO2 is Co2? thanks (also any extended warranty?? thanks

The Juvia MSRP is $90K, IIRC.

SureLase (Clinicon) http://www.clinicon.com/
Fraxel Re:Pair (Reliant Technologies) http://www.reliant-tech.com/fraxel-repair-laser.cfm
UltraPulse ActiveFX (Lumenis) http://www.aesthetic.lumenis.com/wt/page/ActiveFX
MiXto (Lasering USA) http://www.laseringusa.com/default.aspx?language=en
Mosaic eCO2 (Lutronic) http://www.lutronic.com/eng/product/mosaic-eco2-overview.html
FRx (MedArt) http://www.medart.dk/files/pdf/download/ysbroc001_frx.pdf
SmartXide (Deka Lasers) http://www.dekalasers.com/public_html/index.php?page=products&action=view&pid=13
Juvia (Ellipse) http://www.ellipse.org/us/Products/Ellipse+Juvia
Pixel CO2 (Alma Lasers) http://www.almalasers.com/pixel_co2.jsp
Exelo2 (Quantel Medical) http://www.quantel-medical.com/UK/produits/produits_detail.php?cat=derma&sscat=lasers&id=47

Dermarogue,
I am demoing the Mixto and Smartxide in the next two weeks. What results have you seen with your patients? What about treating the neck. This is the most difficult area to treat without doing surgery. I have a Sciton profile which the MLP works OK, but I am hoping the Fractionated CO2 will do much better. Let me know your thoughts. Did you purchase one yet?
Thanks

I have just started treating necks with my Juvia. 1 pass, no wiping, low density (49 Mtz / cm2), 40 mJ, no pulse stacking - seems to work so far. Significantly slower to heal than the face.

It seems that after reading the blogs the only reason why anyone would want to buy anything other than Reliant's re:pair or Lumenis Deep FX is price? Trying to do what they can do but cheaper with the "generic", is that correct?

Reliant and Lumenis have proved based on histology slides their .12 um micron spot size can penetrate to 500 - 700 mm depth level, have the other "generics" done this?

Interesting question, trem. Reliant certainly has ongoing disposable costs.

More importantly, it is yet unclear whether it is the depth of the "hole" drilled into the skin that is important, or whether it is the lateral thermal energy delivered to a particular depth that is the key point to get clinical results. I haven't seen any studies addressing this issue. Personally, I think it's the heat - which is why fractional CO2 gets a better response than a fractional erbium in fewer treatments.

Also, since most wrinkles are around 400-500 microns (not mm) depth, is it really clinically important to ablate past that depth? Nobody has these answers yet. It may be that these approaches are the best, but show me the science first, please.

Trem,
Thanks for the reply. My problem with Reliant is the disposable cost. Both Reliant and Lumenis are overpriced. Are both Fraxel and DeepFx 120 micron spot size? Mixto is 300microns and Smartxide is 350. Juvia is 500 microns. I also believe the results are from tissue contraction due to subablation threshold heating of tissue of each column/MTZ. This is inherent to CO2 in general, and it makes a great cutting tool. Any one else doing necks with fractionated CO2?
TF,
What settings are you using on the face? I haven't looked at the Juvia other than on the web. It looks like it ablates quite a bit more tissue than the others.
Thanks,
RAY

Hi Ray:

I'm still determining the "sweet spot" with the Juvia, in terms of results vs. down-time.

As you may be aware, it has a choice of 3 different pattern densities: 7 x 7 (=49 MTZ / cm2), 9 x 9, and 11 x 11. I started with the 7 x 7 pattern, initially only doing one pass. While this worked fine for superficial dyschromias, and pore size - it didn't really modify the wrinkles too much. So I've now gone to what I call a "multi-pass protocol", where I do up to 3 non-stacked passes at 15W, 6ms for facial rhytids (=90mJ/Mtz) I lower it down to 2 passes and 4 ms for the eyelids.

Now, I'm now working with the 9 x 9 pattern for the deeper wrinkles. Once I get the parameters dialed in, I'll share these with the community.

E mail me at drfiala@drfiala.com if you have specific Juvia questions.

TF you use a much larger dwell time on the juvia - 4-6ms. As you know the smartxide only goes to 2 ms. As the wattage on the xide goes up to 30 so using 2 ms will give the same mj value as yourself (on eyes). dwell time increases lateral thermal damage but does that change if you use a smaller dwell time with a higher power setting to deliver the same amount of energy? thanks

happy 4th everyone ! be safe and cool down.....

How deep can one go on the nose with a fractional CO2 without damaging the cartilage? thanks

ukdoctor: if you decrease the dwell time, and increase the power, as you suggest - you should expect to see a deeper treatment (more ablation) with less lateral thermal damage. Specifically, whether this would be appropriate on your machine for the lower eyelids, I really can't say....let's see what other smartxide users are doing.

TF,

What does Smartxide use? CW or superpulse or ultrapulse?

& What 's the max pulse energy?

I was thinking whether smartxide 's larger beam size at 0.3mm would theroretically cause more PIH compare to the 0.12mm I am using?

Thanks.

dr stephen

According to their website, their spot size is 350 microns, max energy is 30W, and pulse width / dwell time is up to 2 ms - so 60mJ pulse energy at maximum.

While large spot sizes have been shown to be more painful for the patient, I'm not aware of literature showing that the spot size correlates directly with the incidence of PIH - although larger laser spots would certainly cause more bulk heating of tissue. Great question - and something to look into.

TF, so you are doing the calculation on the basis that the smartxide is a continuous wave? Can you please confirm this?

With a superpulse, even if the average power is at 30W over (on + off time), the peak power is pumped up to about 140 to 160W over (on time) only, and the average over this (on time) is 70-80W, and to get 60mJ, this superpulse only need to spend ~0.8ms in that spot to give a clean ablation, which is close to the TRT of dermis. This is my reasoning that superpulse is theoretically less risky in causing PIH.Does it make sense? (although somewhere here somebody quoted a paper which showed no difference in CW / superpulse / ultrapulse when doing full ablation).

Regarding the beam size, we are doing it fractionated because the conventional ablation is causing longer downtime and have higher chance of PIH, i.e. doing it by micro-spot is better than doing the whole 100% ablation, than the impression (only impression) would be a 0.12mm spot is better than a 0.35mm spot, as it is only at a fraction of about 1/10 in area.

dr stephen

Here's an interesting new study regarding PIH.....

The prevalence and risk factors of post-inflammatory hyperpigmentation after fractional resurfacing in Asians.Chan HH, Manstein D, Yu CS, Shek S, Kono T, Wei WI.
Division of Dermatology, Department of Medicine, University of Hong Kong, Hong Kong SAR, China. hhlchan@hku.hk

BACKGROUND: Ablative laser resurfacing is considered to be the main therapeutic option for the treatment of wrinkles and acne scarring. However, in Asians, post-inflammatory hyperpigmentation (PIH) is a common adverse effect of laser resurfacing. Fractional resurfacing is a new concept of skin rejuvenation whereby zones of micro thermal injury are generated in the skin with the use of a 1,540-nm laser. The risk and prevalence of hyperpigmentation in dark-skinned patients using this approach have not been studied.

OBJECTIVE: To assess the prevalence and risk factors of PIH that is associated with the use of fractional resurfacing in Asians. METHOD: A retrospective study of 37 Chinese patients who were treated with fractional resurfacing for acne scarring, skin rejuvenation, and pigmentation was carried out. In all of the cases, pre- and post-treatment clinical photographs (from standardized and cross-polarized views) were taken using the Canfield CR system. Two independent observers assessed the photographs. A prospective study of treatments of nine different density and energy levels that were applied to the forearms of 18 volunteers was also performed. Clinical photographs were assessed pre- and post-treatment for evidence of PIH.

RESULT: In the retrospective study, 119 treatment sessions were performed. Sixty-eight treatment sessions were high energy, low density; 51 sessions were low energy, high density. Patients who underwent a high energy but low-density treatment (range of energy 7-20 mJ; average energy 16.3 mJ, 1,000 MTZ) were associated with a lower prevalence of generalized PIH (7.1% vs. 12.4%) than those who underwent a low energy but high-density (range of energy 6-12 mJ; average energy 8.2 mJ, 2,000 MTZ) treatment. However, the difference was not statistically significant. Localized PIH occurred in the peri-oral area among patients who did not receive air cooling as an adjunctive therapy.

CONCLUSION: Both the density and energy of the treatment determines the risk of PIH in dark-skinned patients. Density may be of more important but further studies are necessary to determine this. Cooling to prevent bulk tissue heating is also important, especially in small anatomical areas. By using adequate parameters, the risk of PIH in dark-skinned patients can be significantly reduced.

Yes, Dr. Stephen, I was assuming that the smartXide performs as a CW machine with my previous calculations.

It's a little confusing on the website - it seems that the base laser (without the scanner) may indeed be a superpulse machine - but then you add their separate optico-mechanical scanner in front of it to get the parameters we mentioned earlier. It's not clear to me from their website how the combination of the two works together, regarding the characteristics of the energy pulse, and whether it is actually more like a CW machine, or a pulsed one. It would seem to vary depending on the combination of the laser setting and the scanner setting - you might actually have the scanner cutting off the beam, for example, if the scanner time is set to be shorted than the laser pulse width. But that's just me hazarding a guess...What are your thoughts?

No, the scanner cannot change the laser characteristics. The superpulses are created with a shutter inside the laser tube. The scanner just scans whatever comes into it, and may move the CW beam around, but will not change it into a superpulse.

I would love to post the diagram here but I cannot find how to do it.

dr stephen

Hi Dr Stephen,

I am a physician based in Singapore and is very keen to learn more about your experience in using fractional CO2 lasers because I believe we treat very similar patient base (Type III - V). I am currently looking for an effective laser for treatment of acne scars and have tried various ones and is now looking at the Lutronic's Eco2.
Some specs on the system:
Wavelength: CO2 10.6um
Power: 30W
Pulse energy: 2-240mJ
Spot Sizes: 120/200/1000 microns
Multiple scan shapes with random or regular beam patterns

Wondering if you have any experience in this machine?

Hi KC Sim

Just had a look at Lutronic 's web site and I have to say the eco2's spec are very impressive.

The max energy is very high at 240mJ ( but it also quoted 120mJ else where), anyway I think it is not needed to go beyond 80mJ which is very sufficient.

I like the random and regular mode choices.

That the spot size can be changed is very good too, like the Lumenis' total Fx!

Repetition at 5 is good enough, although mine offers 10.

I wonder how much it is asking for?

dr stephen

Hi Dr Stephen,

I have just tried the machine on 3 of my patients yesterday who has acne scarring (ice-picks and boxed scars). All had pre-treatment EMLA cream under occlusion for 45-60min.
First case had significant ice-picks scars over both cheeks and mild active acne. Used 35mJ with 50MTZ/cm2 for whole face excluding periorbital and peri-oral areas which I used 24mJ with 50MTZ/cm2, followed by 50mJ with 100MTZ/cm2 over both cheeks. He had mild oedema with erythema following treatment and pain level was moderate. Will review him again next week.
Second case had moderate boxed scars over both cheeks with no active acne. Used 35mJ with 100MTZ/cm2 for whole face excluding periorbital and perioral areas which was at 24mJ with 50MTZ/cm2, followed by 50mJ with 100MTZ/cm2 over both cheeks. Mild oedema and erythema following treatment. Pain level was low. Seeing him next week.
Last case has moderate boxed scars over cheeks and forehead. Used Used 35mJ with 100MTZ/cm2 for whole face excluding periorbital and perioral areas which was at 24mJ with 50MTZ/cm2, followed by 50mJ with 100MTZ/cm2 over both cheeks. Moderate oedema and erythema. Pain level moderate. Reviewing her today (my staff).

Will update on the progress. Selling for around $60,000 usd.

KC: Try pliaglis instead of EMLA. I think you will get better anesthesia, and no need for saran-wrap!

Can anyone let me know how much the Smartxide is asking for in the US?