Agnesian HealthCare Know & Go Showcase: Cutera Genesis Plus Laser

Know & Go!

Cutera Genesis Plus Laser For Treatment of

Nail Fungus, Warts and Scars

Thomas Sheridan, DPM

Agnesian Foot Clinic

Spot Size

Nd:YAG - Spot size affects depth of penetration

Spot size is the laser beam diameter (in mm) where the laser beam meets the skin

Smaller spot sizes reduce penetration at a given wavelength, due to increased impact of scatter

Energy is lost from the edges (scatter), and concentrated in the center cone shape

GenesisPlus has 1 mm and 5 mm spot sizes

GenesisPlus

GenesisPlus

The Cutera GenesisPlus is an Nd:YAG (1064nm) laser with a patented pulse structure designed for safe and effective treatment on all skin types and tanned skin.

It can be safely used on all body parts (excluding the eye and surrounding area).

GenesisPlus, cont’d.

Common uses include:

Temporary increase in clear nail in patients with onychomycosis

Warts

Scar reduction - including reduction in hypertrophic and keloid scars

Treatment of wrinkles

Rosacea/diffuse redness

Poikiloderma of civatte

Treatment of Nails

Baseline

Infected area = 42% Nine months post final treatment

Infected area = 5%

Avoiding Complications

Nerve blocks are not recommended as patient feedback is required

Patients with neuropathy may not be able to provide feedback

Increased risk of adverse events

Remove nail polish and clean toes

Do not treat over or close to tattoos

Remove or cover any jewelry

Avoiding Complications

No self-tanners for at least two to four weeks prior to treatment

Implants

Reaction to metal implants is unknown

Pacemaker - Stay at least six inches away from implant

Ice should not be applied directly to a suspected burn

Cold gel packs or cool compresses can be used

Treatment Technique

Recommend to debride nail if thicker than 2mm (normal thickness)

Do not use gel

Pre-treatment photographs recommended

Treatment Technique, cont’d.

Treat the entire nail bed, matrix and lateral folds, extending approximately 2mm past the nail

Treatment of Nails With 5mm Spot Size

5mm Spot Size

Treatment Steps

Treat one foot at a time

Hallux/big toe

600+ pulses using multiple passes

Lesser toes

100+ pulses per toe using multiple passes

5mm Spot Size

Pulse Placement

Hold hand piece perpendicular to nail’s surface (4cm away)

Ensure the distance beam (small red dot) is centered in the laser beam (large red dot)

This will confirm the correct distance from the tissue (3 to 4cm)

Treatment area is the laser beam (not the smaller distance beam)

5mm Spot Size

Treatment Steps

Pulses should be placed adjacent to each other with slight overlap

Adjacent pulses should be of the larger beam, NOT the smaller distance beam

Do NOT stack pulses

One pulse directly on top of another with no cooling time

Try not to overlap pulses

May cause more patient discomfort

5mm Spot Size

Treatment Steps

Alternate between vertical and horizontal passes

Move line positions on successive passes to ensure uniform coverage

Movement should be controlled

Start with slow repetition rate (2 Hz)

White flashes or sparks can occur during treatment

Ensure nail is clean

5mm Spot Size

Treatment Endpoint

Endpoint is total number of pulses Though the goal temperature is NOT the endpoint, it can help

indicate if enough heat is being delivered to the tissue

It is recommended that all 10 toes are treated Recommended treating one foot at a time

Number of treatments will depend on severity of fungal infection The average time interval between treatments is four to

six weeks

5mm Spot Size

Treatment Technique

Importance of good technique

Goal of treatment is even bulk heating

Pulses should be placed adjacent to each other with minimal overlap to prevent hot spots

5mm Spot Size

Pain Tolerance

Pain tolerance lowers with each pass due to accumulated heat

The number of passes may change from patient to patient depending on patient tolerance

Pause the treatment for five to 10 seconds in between passes for patient comfort

Treatment of Warts

Treatment of Warts

Before treatment One month after one treatment

Warts -

Avoiding Complications

Deep tissue injury and prolonged wound healing may occur

Diseases such as diabetes may impede wound healing

Darker skin types have an increased risk of complications and/or pigmentary issues

Do not treat over or close to tattoos or permanent make-up

Possible hair loss may occur

Warts - Avoiding

Complications, cont’d.

No self-tanners for at least two to four weeks prior to

treatment

Implants

Reaction to metal implants or fillers is unknown

Pacemaker - Stay at least six inches away from implant

Ice should not be applied directly to a suspected burn

Cold gel packs or cool compresses can be used for

patient comfort

Warts Treatment Technique

Pre-treatment photographs should be taken prior to the initial treatment for future reference

Clean skin

Shave excess hair in the treatment area

Warts may need to be debrided prior to treatment

Anesthetics may be used for patient comfort

Local anesthesia (lidocaine without epinephrine) is optional

Gel is not used

Wart Treatment Parameters

Selecting Pulse Duration

Parameters need to be selected according to location, size, and/or color of wart

Pulse duration - measured in milliseconds (ms)

Shorter pulse duration (more aggressive treatment)

Small, lighter targets

Treating over bottom of foot or calloused area

Wart Treatment Parameters

Selecting Pulse Duration, cont’d.

Longer pulse duration (less aggressive

treatment)

Larger, darker target

Darker skin

Treating over bony areas, near joints or cuticles

Pulse duration options:

20ms, 15ms, 10ms, 9ms, 8ms, 7ms, 6ms

Wart Treatment Technique

Hand piece should be held 2cm away from skin instead of 4cm recommended for other indications

Only the larger aiming beam will be visible

Smaller working distance beam and the temperature readout will not be activated

Stay within the wart border

Wart may spark when treated

Ensure skin is clean

Wart Treatment Technique,

contd.

Some warts may require more than one pulse

Pause for a few seconds between pulses

Cool with ice/frozen gel pack in between pulses

End Point

Check for endpoint after first pulse

Desired endpoint

Slight ashen color should occur immediately after pulse

Can be a subtle color change

If surrounding skin becomes white or edematous, it was probably over-treated

Treat as a wound

Treating Individual Warts

If wart is smaller than laser beam:

Assess the surrounding tissue before placing additional pulses to avoid over-treatment of normal tissue

If wart is larger than the laser beam:

Use less aggressive parameters

May require multiple treatments

Treat small sections over multiple visits

Place pulses with approximately 10 to 50 percent overlap

Lighter/smaller warts = more overlap

Larger/darker warts = less overlap

Treating Mosaic Warts

Usually require multiple treatments

Treatment Steps:

Use less aggressive parameters

Do NOT treat entire area of mosaic wart in one session

Only treat the darker/thicker area; usually near center of wart

Do not overlap pulses; pulses should be placed adjacent or spaced out

Cool treatment area in between pulses

Post Treatment Care

Warts usually have a black or crusty appearance within

24 hours after treatment

May apply ointment of choice and non-stick dressing for

patient comfort

If a blister develops, treat as a wound

Treated tissue usually sloughs within one to four weeks

Deep tissue injury and prolonged wound healing may occur

More than one treatment may be necessary (four to six

weeks apart)

Warts Treatment Example

Before Four weeks s/p treatment

Treatment of Scars

Scar Treatment

Before Treatment Post Treatment

References

Cutera - GenesisPlus. (n.d.). Retrieved January 22, 2014,

from Cutera: cutera.com/technology/ndyag laser/genesis-

plus/

Cutera Clinical Education. (n.d.). Retrieved January 22,

2014, from Cutera:

cutera.com/education/index.php#tv

GenesisPlus Laser. (n.d.). Retrieved January 22, 2014,

from YouTube: www.youtube.com/watch?v=6HWWyE9R

vBk#t=36

Thank You!

Know & Go!

Total Ankle Replacement

Alyssa Stephenson, DPM

Agnesian Foot Clinic

Ankle Anatomy

The ankle is formed by the union of three bones

Talus

Tibia

Fibula

Ankle Anatomy

The ankle has muscular origins above it and tendons below it to help with movement.

Contains cartilage which acts as a shock absorber.

Contains ligaments, or straps of tough tissue, which help prevent the joint from dislocating.

Contains synovial fluid, a clear smooth oil-like lubricating liquid, which makes it easier for the joint to move.

Ankle Joint Function

Ankle joint acts like a hinge.

It is one of the most flexible, free moving joints in the body.

The ankle can move forward, from side to side and twist.

Ankle Joint Function

When an ankle joint is functioning normally, it is pain free.

Abnormal function can cause pain.

Deformity - congenital or acquired

Injury

Arthritis

Arthritis

Arthritis - wearing away of the joint surfaces.

Three categories:

Osteoarthritis

Traumatic arthritis

Inflammatory

Osteoarthritis

Primary arthritis, degenerative arthritis

Most common

May be due to activity or family history, wear and tear, age

Traumatic Arthritis

Arthritis that develops after an injury to a joint.

Can cause pain, swelling, weakness, trouble walking.

Can affect activity level and lifestyle.

Inflammatory Arthritis

Occurs when a disease process causes cartilage in the joint to wear away.

Example: Rheumatoid arthritis, where the body’s immune system attacks the joint lining.

Symptoms of Arthritis

Pain - especially with first steps in the morning or if have been sitting and get up to ambulate again

Swelling

Extra bone formation - spurring

Decreased range of motion of the joint

Cracking or crepitus with movement of the joint

Tests

X-ray

MRI

CT

Blood work

Diagnostic injections

Non-Surgical Treatment

Orthotics

Ankle braces

AFO

Shoe modifications

Medication

NSAIDS, steroids, corticosteroid injections

Surgical Treatment

Debridment

Allograft arthroplasty

Distraction arthroplasty

Arthrodesis (fusion)

Total ankle replacement

Ankle Debridment

“Cleaning up” the joint

Arthroscopically

Open

Removal of the inflamed synovial tissue, removal of loose cartilage and removal of bone spurs

Allograft Arthroplasty

Uses cadaver donated bone and cartilage

Tissue is transplanted in the ankle to replace the damaged tissue

Talar Dome Lesion

Corrected Talar Dome Lesion

Talar Dome Lesion

Graft Arthroplasty

Distraction Arthroplasty

Ankle is debrided of loose cartilage and

bone spurs

Then a wire frame is applied through the

bones above and below the ankle and is

distracted

This holds the ankle stiff and separated

Allows cartilage healing to occur

Ankle Arthrodesis

Remaining cartilage is removed from the ankle

Bone surfaces are approximated and corrected for any deformity

Fused together using plates and screws or large nails

No motion, eliminate pain

Case Study

Case Study

Case Study

Case Study

Case Study

Case Study

Surgical Options

Motion

Debridment

Allograft arthroplasty

Distraction arthroplasty

Total ankle replacement

No Motion

Arthrodesis (fusion)

Total Ankle Replacement

A surgical cut is made in the front of the ankle

The tendons, nerves and blood vessels are gently moved aside

Bone spurs and damaged bone and cartilage are removed

The parts of the new artificial joint are then attached to the cut bony surfaces

Special glue is used to hold them in place

New joint is closed with sutures, and tendons, nerves and blood vessels are put back in place, and the wound is closed with stitches or staples

Post-Op

A cast or boot is worn for a few weeks to keep the ankle from moving while the incision heals.

Risks

Bleeding

Temporary or permanent nerve damage

Allergic reaction

Infection

Device loosening

Increased pain

Device noise

Bone breakage

Blood clots

Post-Op Total Ankle

Replacement

Thank You!