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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!