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.