Meet the Ultimate Skin Resurfacing System - (Sam) Rizk

A SUPPLEMENT TO PSPMeet theUltimate SkinResurfacingSystemThe Cortex combines CO 2plusErbium:YAG laser energiesBY WENDY LEWISO 2lasers have been widely consideredthe gold standard forCskin resurfacing since the 1990s,and they remain so today. Butdue to the anesthesia, prolongeddowntime, and potential risks offully ablative resurfacing, manypatients have opted for less invasivemethods of skin renewal. Fractional technology haschanged the way energy-based systems are used inclinical practice today, giving both patients and physiciansmore treatment options with minimal downtime.The two workhorses of ablative technology are CO 2and Erbium:YAG. The Sandstone Cortex from EllmanInternational is the only skin-resurfacing laser system toinclude both CO 2and Erbium:YAG wavelengths in thesame console. This innovative device offers fractionalCO 2with an adjustable density for up to 95% coverageplus full-coverage Erbium:YAG. The dual wavelengthsallow practitioners to perform resurfacing procedures ona wide range of skin types and for multiple indications.The CO 2laser penetrates deeply and provides heat tostimulate collagen, while the Erbium:YAG laser helps tosoften the texture of the epidermis and remove pigmentationfrom the superficial layers of the skin. The Cortexis widely recognized as the only laser that offers suchflexibility with numerous treatment parameter options.February 2013 PlasticSurgeryPractice.com 19

BEFOREAFTERCO 2and Erbium:YAG, 2 months post treatment.CO 2FRACTIONAL CAPABILITIESWith the Cortex System, physicianscan select multiple settings, includingsize, shape, density and duration, totailor the treatment to each patient foroptimal dermal penetration, healing andpost-treatment results. Clinical indicationsthat can be treated include rhytides,fine lines, acne scars, photo damage,textural irregularities and pigmentedlesions.SOLID-STATE ERBIUM FORSUPERFICIAL RESURFACINGThe Erbium:YAG modality allows forfiner control of the energy and precisesuperficial tissue ablation. Clinical indicationsthat can be addressed includephoto damage, mild to moderate rhytides,uneven pigmentation and seborrheickeratosis. By combining a proprietary fluencelevel with an extra-long pulse width,the Erbium precisely ablates the epidermiswithout exposing the underlyingdermis. The gentler nature of the Erbiumwavelength allows the physician to treathighly sensitive areas on the neck, dorsalhands, perioral and periorbital areaswithout the need for anesthesia.FACIAL RENEWAL PARADIGMAccording to New York City facialplastic surgeon Sam Rizk, MD, FACS, “Iprefer the Cortex laser due to its efficientcombination of fractionated CO 2andErbium. In most patients, I use the fractionatedCO 2first with one or two passes,and then I do an Erbium pass as a buffer,which serves the dual purpose ofremoving the grid residue of the CO 2andhelps to deliver a smoother result. It islike going through a car wash where youhave different brushes, with finer brushesused toward the end of the wash to adda finishing touch.”Speed and manageable downtime areamong the key advantages of the Cortex.“The treatment takes 30 minutes or less.Patients look good within 7 to 10 days,and they can use makeup in a week,”Rizk says. He also uses the Cortex laserat the same time as a face and neck lift toadd the benefits of skin resurfacing to hissurgical results. “I almost always use theCortex with a facelift or under the eyeswith a transconjunctival blepharoplasty. Ialso like it for dealing with sun damage,fine skin wrinkles and enlarged pores. Irarely do it as a stand-alone procedureexcept in the cases of severe acne scarring.In the acne patients I have used iton, there was a noticeable improvementwith only a few passes,” Rizk says.Facial plastic surgeon Paul J. Carniol,MD, FACS, who practices in Summit, NJ,has extensive experience with fractionalresurfacing using the Cortex System. “Ifind that the fractionated lasers use a gridpattern of laser spots, which I refer to as‘micro spots.’ The micro spots producedby the Cortex System are smaller thansome other systems, about 150 microns,providing some major advantages.“When treating a patient, we use atopical anesthetic cream which contains6% lidocaine and 6% tetracaine, andduring the procedure, a chiller to blowcool air. We believe that it is most importantto keep the patient comfortable,” hesays. “We apply the topical anesthesiafor 20 to 30 minutes prior to the procedure.With this combination, patientsdon’t need sedation or local anesthesiainjections. We only treat the face andupper neck, and only apply the topicalanesthetic to the limited areas we aretreating.”All in all, “it becomes a very pleasantprocedure. Patients are very comfortable,so it is not a traumatic experience,”he says.Another advantage of the smallerCortex micro spots, according to Carniol,is the relatively quick and easy recoveryfor patients. “Within a week, they arepretty much healed. After the procedurethey only have some pinkness, minimalswelling, without a lot of discomfort.Usually, Tylenol ® is adequate. For these20 PlasticSurgeryPractice.com February 2013

BEFOREreasons, there is a high acceptance rateby patients.”Carniol has expanded his uses forthe Cortex System. “Another advantageis that you can use just fractional CO 2or just Erbium for dyschromia and lentigines,”he says. “When I complete thefractional laser treatment, I often go backwith the Erbium laser for the lentigines,rather than treat the whole face.”He adds: “One thing that is reallyimportant if you are going to treat anypigmented lesions with a laser is tocheck that they are really lentigines andnot atypical melanocytic lesions. If youare not sure what it is, take a 2 mm punchbiopsy before you treat. I do a biopsyfor anything of question at the time ofconsultation prior to the procedure, so if Iam treating a lentigine, I know what it is.”Like Rizk, Carniol does all Cortextreatments himself. He believes that aresurfacing laser should not be delegatedto non-physicians. “I wear magnifierswhen I do the treatment because I wantto see how it is affecting the skin at amagnifying level to minimize potentialcomplications.”AFTERCO 2and Erbium:YAG, 2 months post treatment.UNPARALLELED VERSATILITYAccording to oculoplastic surgeonMichael Ehrlich, MD, who practices inDanbury, Conn, “The Cortex featuresthree different modalities: incisional CO 2,fractional CO 2, as well as Erbium:YAGresurfacing, which provide the opportunityto truly customize each treatment.I can address deeper rhytideswith fractional CO 2and also utilize theErbium:YAG handpiece for more superficialrhytides with less overall thermalspread. This allows faster recovery forthe patients, reduced chance of pigmentarycomplications and is a space-saverin my office.“The incisional CO 2features a superpulsemode that varies the duty-cyclewhile maintaining a continuous wave.While performing transconjunctival laserblepharoplasty, I can decrease theamount of energy that enters the orbitwhile maintaining a bloodless surgicalfield. Less energy means less postoperativeedema and an easier recovery,” hesays.Most of Ehrlich’s patients seek periorbitalrejuvenation, which makes theCortex an ideal fit for his practice. “I havefound that two passes with the fractionatedCO 2at 22 watts, pulse durationof 2 ms and density of 35%, followedby a single Erbium:YAG pass at 600mJ, achieves excellent and consistentresults. This treatment algorithm takesless than 10 minutes,” he says.Because of its versatility, the Cortex isemerging as the efficient laser of choicefor both periorbital and full facial renewal.According to Ehrlich, “My preferred techniqueis to use a laser for both a surgicalprocedure and skin resurfacing. I canuse the same laser for a 35 year old withearly superficial rhytides and for a 65 yearold who needs surgical intervention andmultiple types of resurfacing treatments.I don’t need 12 different lasers taking upspace in the office.”A proponent of the Pellevé ® WrinkleReduction System from Ellman, HeidiPHOTOS COURTESY OF HARRISON PUTNAM, MDWorth, MD, who practices in Frisco,Colo, was looking to bring in a CO 2system for patients with deeper wrinklesaround their mouth and eyes. “I wantedto offer my patients a deeper treatmentwith the wound response that occurswithin the skin with CO 2. The dual heads(both Erbium and CO 2) and the pricing ofthe Cortex System were very compelling.So far, I have found it intuitively easy tooperate. Patients are very comfortablepost procedure, and the recovery is prettyeasy, which is a big plus,” she says.The deciding factor for Worth was thedual wavelengths. “For people who wantthat precise depth micro laser peel, it’sgreat to have that option to offer them.The Erbium is so precise, and it is almostpainless,” she says. “We offer it as astand-alone treatment and tell patientsFebruary 2013 PlasticSurgeryPractice.com 21

that they will have 3 days of downtime,depending on the depth.”Ideally, she says, “We do three treatmentsspaced 1 month apart, but theywill get some improvement with eachtreatment. We also use it for youngerpeople with acne scars. For diffuse rollingacne scars, atrophic scars, this offersgreat improvement. I typically do twotreatments with fractional CO 2. The easeof use with the Cortex is wonderful, and ithas been very simple to learn,” she says.She also uses the Cortex Systemfor 40 to 60 year old patients who havedeeper wrinkles and want the best resultsthey can get with the least amount of timeout of their lives. According to Worth,“There are none of the CO 2complicationsof prolonged downtime and the risksof hypo and hyperpigmentation line ofdemarcation are eliminated. For peoplewith deeper wrinkles and severe acnescars, they may need more sessions. Or Iwill frequently do a deeper treatment andthen, for some extra brightness with littledowntime and pigment improvement, Ido the Erbium micro laser peel.”The skin improvements may also continuefor several months as the laserstimulates the patient’s own collagenremodeling. As Carniol says, “Fractionallasers have been shown to stimulatecollagen and there is a histochemicaleffect that improves the skin. In 3 to 6months, they look better than they lookat 3 weeks.”Ehrlich takes a slightly differentapproach. “In my hands, the CortexSystem is most useful for 50 to 65year old patients who have upper andlower dermatochalasis and have moderatedyschromia and rhytides but aren’tready for a facelift,” he says. “In thesepatients I perform an upper laser blepharoplasty,lower laser transconjunctivalblepharoplasty and full-face dual-modeCO 2and Erbium:YAG resurfacing. Withthe Cortex, I can perform all of theseprocedures with a single unit.”POSTPROCEDURE PEARLSAs with any energy-based resurfacingtreatment, it does not end when thepatient leaves the office. Patient educationon good postprocedure care andmaintenance will go a long way to minimizecomplications and achieve the bestpossible long-term results.“Diligent attention to aftercare isimportant. We put patients on a strictprotocol of sun avoidance for 4 weekswith daily use of a broad-spectrum SPFKEY BENEFITS OFTHE CORTEX LASERn Quick and efficient treatment(15 to 30 minutes)n Dual platform of CO 2andErbium:YAGn Large treatment area (18 x18 cm)n Small spot size (150 microns)n Versatilityn Cost-effective equipmentn Minimal downtimen High patient satisfactionn Results continue to improvefor 3 to 6 months30,” Rizk says. “It is beneficial to be on agood skin care regimen to enhance theresults.”Worth uses a light petrolatum creampost procedure, such as EltaMD ® IntenseMoisturizer, and has patients use it forseveral days until most of their peelingis complete and the skin is not so tight.She also recommends Avene ® ThermalSpring Water Spray to reduce the heat inthe skin. Vinegar water soaks are anotheroption. “We allow patients to go backto using their own moisturizer at aboutday 4 or 5 to encourage peeling,” shesays. “In daylight, they should be using asunscreen with SPF 40-50, and we recommendNeova ® Ti-Silc or EltaMD. Theyhave to wait until the peeling is done, andthen they can use mineral makeup over aheavier moisturizer.”Carniol’s postprocedure program consistsof applying Aquaphor ® immediatelyand for 3 to 5 days for some areas of theface that need it. “If the area is healed,they don’t need to use Aquaphor on thatarea. Wherever it is pink or there aremicrocrusts, they should use it.”Carniol also insists upon good sunprotection. “They must use UVA protectionto prevent dyschromia. I tell patientsthat before you get in your car in themorning, put on your SPF. Micronizedzinc is preferable because if you put it oncorrectly, it goes on clear, and you cansee through it,” he says. “They can usefoundation on top, and it will lie on theskin very evenly. The way they put it onis the way it stays.”Within 1 week, Carniol lets hispatients use mineral makeup, but theyare restricted from using normal foundationuntil they are completely healed.“For the average patient, if we do it ona Wednesday or Thursday, they can beback to work on Monday or Tuesday. Ifthey have plans for the weekend, we doit on a Monday,” he says.According to Ehrlich, the novice physicianshould keep a close eye on thepostoperative course. “I place all fullfaceresurfacing patients on 500 mg ofAcyclovir twice a day, and ask themto call if they develop a cold sore,” hesays. “I prefer the protocol I learnedin fellowship with Julie Woodward,MD.” The patient cleans her face every3 hours with a paper towel dipped into amixture containing a teaspoon of householdwhite vinegar in a cup of water.“This is followed by a thin application ofAquaphor generally until postop day 5,when I switch to a micronized zinc-basedsunscreen,” he says. “This regimen isinexpensive and easy for the patient toperform.”DOCTOR AND PATIENTSATISFACTIONThe Cortex combines the two mostpopular wavelengths for skin resurfacing:CO 2and Erbium:YAG. The CO 2laser canbe used for deep resurfacing while theErbium:YAG laser can be used for superficialtreatment, which offers greater versatilityfor the physician.Having no consumable costs positionsCortex as a smart choice for practitioners.An added benefit that makesthe Cortex System particularly attractiveis that it is affordably priced, whichallows physicians the ability to realizetheir return on investment in a shortperiod of time.Finally, nothing beats happy patientswho see a noticeable improvement andsing your praises to their friends andfamily. “Patients are happy because theirskin is smoother, it contracts so there istightening, rhytides are diminished anddyschromia is lessened. They appreciatethat they are going to look in the mirrorand their skin looks better,” Carniol says.FOR MORE INFO,VISIT WWW.ELLMAN.COM22 PlasticSurgeryPractice.com February 2013