S T E P H E N W I R YA M D

WORKSHO
P FOTONA
PQX
 CV
MEDICAL Airlangga University​
DOCTOR​
DERMATOLOG BOSTON MEDICAL CENTER, USA​
Y​
MEMBERSHIPS​ PERDOSKI, IMCAS, ISDS, ASLMS
(fellow), BMC Center for
Ethnic Skin/Cosmetic/Laser center​
PUBLICATIONS​ Journal of the American
Academy of Dermatology (JAAD),
JAMA Dermatology, American Journal of
Clinical Dermatology (AJCD), Journal of 
Pediatric Health Care, Clinical Experience
in Dermatology, Journal of Cosmetic
and Laser Therapy. ​
SPEAKING  ASLMS 2022 Annual Meeting​
ACTIVITIES​ IMCAS Faculty​
ISDS Faculty​
Teoxane KOL​
W H AT I S A P I C O S E C O N D L A S E R
• We heard about it! A lot!
• The magical Laser that will solve all pigmentary issues
• The best of the best that can do it all!
W H AT I S A P I C O S E C O N D L A S E R

Is it true?
W H AT I S A P I C O S E C O N D L A S E R
• First commercially available Picosecond Laser in 2012  for Tattoo removal
• Picosecond Laser: Laser that emits energy with pulse durations between 300-900 picoseconds
• The basis of development is the TRT (Thermal Relaxation Time)
• TRT  time taken to cool down to half the temperature to the originally intended
temperature
• Best target destruction is to have as little collateral damage as possible
• Thus, by utilizing the correct wavelength absorbed by the target, but with extremely short
duration (less than the TRT) we can destroy the target without damage to the
surroundings)
WHY BUY A
PICOSECOND
LASER?
• So? How is a Picosecond Laser better?
• Current picosecond Lasers have pulse durations
between 300-900ps, whereas nanosecond Lasers
have pulse duration of 5ns (5000ps)
• Remember that this Laser was originally intended to
clear Tattoos
• Tattoo particles are smaller than many epidermal
components
• Need at least nanosecond Lasers

• Is Picosecond an “overkill”?
WHY BUY A
PICOSECOND
LASER?
• If nanosecond is theoretically enough in accordance with the TRT, then why buy it?
• Shorter pulse duration  shorter heat  less photothermal effect, more
photomechanical effect  more effective clearance, with less risk of PIH
W H AT A R E T H E M A N Y
PICOSECOND LASERS ON
THE MARKET
 • PICO – Laser
W H AT I S
FOTONA
PQX? • NdYAG 1064 nm

• KTP 532 nm
BACK TO BASICS
• Why 532 and 1064nm?
• Good absorption at both
wavelengths and different depths
C O M PA R I S O N V S
OTHER BRANDS
• Making a true
picosecond Laser is
NOT EASY
• Shorter pulse  less
time to generate energy
• Tend to have smaller
spot sizes  more
scattering
W H AT C A N
THE
F  O T O N A
PQX DO? Most powerful Picolaser with one of the shortest
duration in the market for optimal tx of

PIGMENTED LESIONS TATTOOS

W H AT C A N T H E
FOTONA PQX DO?
• Multiple specific handpieces to deliver
specific wavelength / energy / spot
size / spot shape
 
W H AT C A N T H E
FOTONA PQX DO?
• DO NOT BE ALARMED

 
W H AT C A N T H E
FOTONA PQX DO?
• DO NOT BE ALARMED

 
W H AT C A N T H E
FOTONA PQX DO?

 
W H AT C A N T H E
FOTONA PQX DO?
• DO NOT BE ALARMED

 
W H AT C A N T H E
FOTONA PQX DO?
• DO NOT BE ALARMED

 
 W H AT C A N T H E
FOTONA PQX DO?
• MELASMA
• One of the most common treatments include
Laser toning using nanosecond QS:NdYAG
Laser
• Higher safety profile (more photomechanical
effect than photothermal effect)
• Fractional handpiece may further increase
safety profile as lower cumulative energy is
delivered
Subcellular selective photothermolysis

Wong CSM, Chan MWM, Shek SYN, Yeung CK, Chan HHL. Fractional 1064 nm Picosecond Laser in Treatment of Melasma and Skin Rejuvenation in Asians, A Prospective Study. Lasers Surg Med. 2021;53(8):1032
Kim DG, Nam SM, Shin JS, Park ES. Effectiveness of the Pico-toning Technique for the Treatment of Melasma with a Low Fluence 1,064-nm Nd:YAG Laser in Asian Patients. Medical Lasers. 2020 Dec
W H AT C A N T H E F O T O N A P Q X D O ?

Parameter: 1064nm 8mm 0.7-1.0 J/cm2 5hz two passes q2-4weekly

MELASMA
 W H AT C A N T H E
FOTONA PQX DO?
• SOLAR LENTIGO
• Currently, nanosecond 532nm and 755nm Alex Lasers with nanosecond pulse
are commonly used
• However, risk of PIH is often high, between 25-47%
• Picosecond Laser has much lower rate of PIH around 4-5%
• Shorter pulse width  photoacoustic > photothermal effects  more efficient
and effective destruction

Wu DC, Goldman MP, Wat H, Chan HHL. A Systematic Review of Picosecond Laser in Dermatology: Evidence and Recommendations. Vol. 53, Lasers in Surgery and Medicine. John Wiley and Sons Inc; 2021. p. 9–49.
Kasai K. Picosecond laser treatment for tattoos and benign cutaneous pigmented lesions (Secondary publication). Laser Ther. 2017;26(4):274–81.
W H AT C A N T H E F O T O N A P Q X D O ?

Parameter: 532nm 3mm 0.5 J/cm2

SOLAR/SENILE LENTIGO
 W H AT C A N T H E
FOTONA PQX DO?
• HORI’S NEVUS
• Common in Asians
• Very difficult condition to treat due to depth of melanocytes in papillary
and mid dermis
• Risk of PIH is high due to melanocytes dispersed in a perivascular
fashion
• Shorter pulse width  photoacoustic > photothermal effects  less
fluence required  less disruption of DEJ
• More uniform removal of pigment
Park JM, Tsao H, Tsao S. Acquired bilateral nevus of Ota-like macules (Hori nevus): Etiologic and therapeutic considerations. J Am Acad Dermatol [Internet]. 2009;61(1):88–93.
Kim SY, Park J, Kim H, Cho S bin. Long-Term Follow-Up of 1,064-nm Picosecond-Domain Neodymium:Yttrium-Aluminum-Garnet Laser Treatment for Acquired Bilateral Nevus of Ota-Like Macules. Medical Lasers. 2017 Dec
W H AT C A N T H E F O T O N A P Q X D O ?

Parameter: 1064nm 4mm 2-4 J/cm2 0.5hz 3 tx q4weekly

HORI’S NEVUS
 W H AT C A N T H E
FOTONA PQX DO?
• ACNE SCAR
• Current gold standard is Ablative
Laser, but risk of complications is high
 

• F9 Handpiece is equipped with DOE

(Diffractive Optical Element)  Laser-
Induced Optical Breakdown (LIOBs)

Lee CH, Jin EM, Seo HS, Ryu TU, Hong SP. Efficacy and safety of treatment with fractional 1,064-nm picosecond laser with diffractive optic element for wrinkles and acne scars: A clinical study. Ann Dermatol.
2021;33(3):254–
Manuskiatti W, Punyaratabandhu P, Tantrapornpong P, Yan C, Cembrano KAG. Objective and Long-Term Evaluation of the Efficacy and Safety of a 1064-nm Picosecond Laser With Fractionated Microlens Array for the Treatment of
Atrophic Acne Scar in Asians. Lasers Surg Med. 2021;53(7):899–905.
W H AT C A N T H E
FOTONA PQX DO?
Typical Picosecond LIOBs PQX LIOBs

VS
 W H AT C A N T H E
FOTONA PQX DO?
• ACNE SCAR
• Compared to other
  modalities?
• At least as effective or better
compared to Fractional CO2
and Erbium Lasers

Kwon HH, Yang SH, Cho YJ, Shin E, Choi M, Bae Y, et al. Comparison of a 1064-nm neodymium-doped yttrium aluminum garnet picosecond laser using a diffractive optical element vs. a nonablative 1550-nm erbium-glass laser for the
treatment of facial acne scarring in Asian patients: a 17-week prospective, randomize. Journal of the European Academy of Dermatology and Venereology. 2020;34(12):2907–13.
Sirithanabadeekul P, Tantrapornpong P, Rattakul B, Sutthipisal N, Thanasarnaksorn W. Comparison of Fractional Picosecond 1064-nm Laser and Fractional Carbon Dioxide Laser for Treating Atrophic Acne Scars: A Randomized Split-Face
Trial. Dermatol Surg. 2021;47(2):e58–65.
Chayavichitsilp P, Limtong P, Triyangkulsri K, Pratumchart N. Comparison of fractional neodymium-doped yttrium aluminum garnet (Nd:YAG) 1064-nm picosecond laser and fractional 1550-nm erbium fiber laser in facial acne scar
treatment. Lasers Med Sci. 2020 Apr 1;35(3):695–700
W H AT C A N T H E F O T O N A P Q X D O ?

Parameter: FracTAT 1064nm 9x9mm 5mJ/pix 5hz two passes q4weekly

ACNE SCAR
 W H AT C A N T H E
FOTONA PQX DO?
• Facial Rejuvenation Strategy
FULL BEAM F9 Handpiece

Zhang M, Huang Y, Wu Q, Lin T, Gong X, Chen H, et al. Comparison of 1064-nm and Dual-Wavelength (532/1064-nm) Picosecond-Domain Nd:YAG Lasers in the Treatment of Facial Photoaging: A Randomized
Controlled Split-Face Study. Lasers Surg Med. 2021;
Lee HC, Childs J, Chung HJ, Park J, Hong J, bin Cho S. Pattern analysis of 532- and 1,064-nm picosecond-domain laser-induced immediate tissue reactions in ex vivo pigmented micropig skin. Sci Rep. 2019 Dec 1;9(1).
Yeh YT, Peng JH, Peng P. Histology of ex vivo skin after treatment with fractionated picosecond Nd:YAG laser in high and low-energy settings. Journal of Cosmetic and Laser Therapy [Internet]. 2020;22(1):43–7.
Available from: https://doi.org/10.1080/14764172.2019.1710536
W H AT C A N T H E F O T O N A P Q X D O ?

STEP1: 1064nm 8mm 0.7-1J/cm2 5hz two passes

STEP2: FracTAT 1064nm 9x9mm 0.9-2.5mJ/pix 5hz two passes q4weekly
P H O T O R E J U V E N AT I O N
 W H AT C A N T H E
FOTONA PQX DO?
• TATTOOS
• Picosecond vs Nanosecond Laser
• Why is one better than the others?
• Vast majority of tattoo inks contain
significant amounts of nanoparticles
• Lower rate of paradoxical darkening in
some tattoos containing titanium dioxide

Lorgeou A, Perrillat Y, Gral N, Lagrange S, Lacour J, Passeron T. Comparison of two picosecond lasers to a nanosecond laser for treating tattoos : a prospective randomized study on 49
patients. J Eur Acad Dermatol Venereol. 2018;32:265–70.
W H AT C A N T H E
FOTONA PQX DO?
• TATTOOS
• Full beam
• Fractional ablative Lasers + QS Lasers
• FracTAT + full beam
• The idea is to prepare channels to allow pressure release
• Create a new pathway of transepidermal elimination of
tattoo ink
• Improvement scores were significantly greater in the
combination side at week 8 and 12
• Combined treatment can decrease both blistering and
subsequent scar formation
Sirithanabadeekul P, Vongchansathapat P, Sutthipisal N, Thanasarnaksorn W, Suwanchinda A. Outcomes of 1064-nm picosecond laser alone and in combination with fractional 1064-nm
picosecond laser in tattoo removal. J Cosmet Dermatol. 2022
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