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for Dermatology
& Cosmetic Surgery
SmartXide DOT
Clinical User Manual
Index
1
Disclaimer ............................................................................... 1
Introduction............................................................................. 2
2.1.1
2.1.2
2.1.3
4.1.1
4.1.2
4.1.3
5.1.1
5.1.2
5.1.3
Infection prevention.........................................................12
5.2
Anaesthesia Indications..........................................................13
5.2.1
5.2.2
5.2.3
5.3
5.3.1
5.3.2
5.3.3
5.4
6
6.2
Wrinkles ...........................................................................32
6.3
6.4
Keloid..............................................................................35
6.5
6.6
6.7
6.8
Beckers Nevus....................................................................37
6.9
Melasma...........................................................................38
II II
1 Disclaimer
While the information contained in these pages has been compiled from sources believed to
be current and reliable, DEKA cannot be held responsible for any errors, omissions, defects
in, or the accuracy, completeness, timeliness or usefulness of, the information supplied to
users on this document.
The following materials are presented for educational purposes only. Methods described may
not be the only or best method in every case. DEKA specifically disclaims any and all liability
for injury or other damages of any kind for any and all claims that may arise out of the use of
any drug, device or technique described in these pages, whether such claims are asserted by
a physician or any other persons.
Information on this document may contain technical inaccuracies or typographical errors.
DEKA takes no responsibility for the consequences of error or for any loss or damage suffered
by users of any of the information published on any of these pages. Such information does not
form any basis of contract with readers or users of these pages.
Furthermore, DEKA will not be liable to users of any for any damages, claims, demands or
causes of action, direct or indirect, special, incidental, consequential or punitive, as a result
of the use of this document or any information obtained from it.
Information may be changed or updated without notice. DEKA may also make improvements
and/or changes in this document at any time without notice.
All information contained within this document is the property of DEKA. Copyright 2008.
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SmartXide DOT Clinical User Manual- Version 2.2 - September 2008
2 Introduction
The natural ageing process together with exposure to the sun and pollution
leads to a gradual deterioration of the skins structure and function. This is
mainly evident at the level of the epidermis and the upper papillary dermis,
with a tissue laxity and skin that appears more lined, often accompanied by
telangiectasias, wrinkles, and dark spots.
2.1.1
Resurfacing with pulsed CO2 laser has always been considered the first choice of
1-6
treatment for rhytids and photo-damaged facial skin . However, due to the
7-8
lengthy recovery times and frequent complications , not all patients agree to
undergo this type of operation
9-10
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SmartXide DOT Clinical User Manual- Version 2.2 - September 2008
Besides the usual recovery time required for oedema, burning, scabs and
erythema which may often last for months
11-12
13-18
Cases of HSV infection and outbreaks of acne, after traditional resurfacing with pulsed CO2
laser.
2.1.2
Non-Ablative Photorejuvenation
Over recent years, the market has therefore been orientated towards less
invasive and less problematic systems and methods. This has led to a wide-scale
production of a myriad of non-ablative devices for reducing wrinkles and
improving photo-damaged skin with the consequent passing over from skin
resurfacing to skin rejuvenation. However, a critical review of the literature
inherent to these methods has revealed that in terms of efficacy, none of the
results obtained with these non-ablative methods can be compared with the
resurfacing results achieved with the CO2 laser19-23. Moreover, these types of
treatment are usually quite expensive for the patient, the devices themselves
are also costly for the medical practitioners, and the results obtained are not
always satisfactory.
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2.1.3
Fractional Photothermolysis
This situation has stimulated the search for new methods and protocols that are
more efficient in combining quick recovery and minimal post-op risks with
greater treatment efficacy. The advent of Fractional Photothermolysis, initially
introduced with non-ablative methods, has given rise to the development of a
new method that manages to effectively combine all the needs of both medical
practitioners and patients, and namely, the Fractional Laser Skin Resurfacing
with CO2 laser
24-28
remarkable
results
with
minimal downtime.
The CO2 laser energy, applied in a
fractional way, creates very thin and
spaced columns of thermal damage
which
penetrate
deep
into
the
Manuskiatti W et al. Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin. J Am
Acad Dermatol. 1999;40:401-11.
2.
Fitzpatrick RE et al. Pulsed carbon dioxide laser resurfacing of photo-aged facial skin. Arch Dermatol 1996;132:395402.3.Schwartz
RJ et al. Long term assesment of CO2 facial laser resurfacing: Aesthetic results and complications. Plast Reconstr Surg. 1999;
103:592-601.
4.
Lent WM, David LM. Laser resurfacing: a safe and predictable method of skin resurfacing. J Cutan Laser Ther. 1999;1:87-94.
5.
Fitzpatrick RE. Maximizing benefits and minimizing risk with CO2 laser resurfacing. Dermatol Clin. 2002;20:7786.
6.
Hruza GJ, Dover JS. Laser skin resurfacing. Arch Dermatol 1996;132:451455.
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SmartXide DOT Clinical User Manual- Version 2.2 - September 2008
7.
Bernstein L et al. The short and long term side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997;23:519525.8.Alster
T, Hirsch R. Single-pass CO2 laser skin resurfacing of light and dark skin: Extended experience with 52 patients.J Cosmet Laser
Ther 2003;5:3942.
9.
Trelles MA, et al. The origin and role of erythema after carbon dioxide laser resurfacing: a clinical and histologic study. Dermatol
Surg. 1998;24:25-30.
10. Burkhardt BR, Maw R. Are more passes better? safety versus efficacy with the pulsed CO2 laser. Plast Reconstr Surg. 1997;99:15311534.
11. Sullivan SA, Dailey RA. Complications of laser resurfacing and their management. Ophthal Plast Reconstr Surg.2000;16:41726.
12. Berwald C et al.. Complications of the resurfacing laser: Retrospective study of 749 patients. Ann Chir Plast Esthet. 2004;49:3605.
13. Alster TS. Cutaneous resurfacing with CO2 and erbium: YAG lasers: preoperative, intraoperative, and postoperative
considerations. Plast Reconstr Surg. Feb 1999;103(2):619-32.
14. Alster TS. Side effects and complications of laser surgery. In Alster TS: Manual of Cutaneous Laser Techniques, ed 2. Philadelphia,
Lippinco. 2000;pp 175-187.
15. Alster TS, Lupton JR. Treatment of complications of laser skin resurfacing. Arch Facial Plast Surg. Oct-Dec 2000;2(4):279-84.
16. Sriprachya-Anunt S et al. Infections complicating pulsed carbon dioxide laser resurfacing for photoaged facial skin. Dermatol Surg.
1997;23:527-36.
17. Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing. An evaluation of 500 patients. Dermatol Surg 1998;24:315
320.
18. Sadick NS. Update on non-ablative light therapy for rejuvenation: A review. Lasers Surg Med. 2003;32:1208.
19. Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing. An evaluation of 500 patients. Dermatol Surg 1998;24:315
320.
20. Sadick NS. Update on non-ablative light therapy for rejuvenation: A review. Lasers Surg Med. 2003;32:1208.
21. Williams EF III, Dahiya R. Review of nonablative laser resurfacing modalities. Facial Plast Surg Clin North Am. 2004;12:30510.
22. Grema H et al. Facial rhytides subsurfacing or resurfacing? A review. Lasers Surg Med. 2003;32:40512.
23. Bjerring P. Photorejuvenation an overview. Med LaserAppl. 2004;19:18695.
24. Le Pillouer-Prost A, Zerbinati N. Fractional laser skin resurfacing with SmartXide DOT. Initial Results. J Cosmc and Laser Ther,
2008;10(2):in press.
25. Matteo Tretti Clementoni et al. Non sequential fractional ultrapulsed C02 resurfacing of photoaged skin. J Cosmc and Laser Ther,
2007;9(4):21822.
26. Hantash BM et al. Ex vivo histological characterization of a novel ablative fractional resurfacing device. Laser Surg Med.
2007;39:87-95.
27. Hantash BM et al. In vivo histological evaluation of a novel ablative fractional device. Laser Surg Med. 2007;39:96-107.
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SmartXide DOT Clinical User Manual- Version 2.2 - September 2008
CO2
Wavelength
10.6 m
Power to Tissue
30 W (max)
Repetition Rate
from 5 to 100 Hz
Pulse Length
from 0.2 to 80 ms
Delivery System
Aiming Beam
Scanning Mode
User Interface
Aiming Beam
Power Supply
Dimensions
Weight
30 Kg
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Scanning Area
Min: 1 x 4 mm
Spot Size
Stimulative Effect
350 m
Ablative Effect
120 m
Scanning Mode
Pulse Emission
from 0.2 to 2 ms (DOT)
Dwell Time
DOT Pitch
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4.1.1
Scanning Areas
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4.1.2
Scanning Modes
Normal
Interlaced
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4.1.3
The first part of the pulse has high peak power for few tens of microseconds
that allows for rapid ablation of the epidermis and the first layers of the derma,
while the second part of the pulse has low peak power allowing for targeted
heating of the deeper areas of the skin.
P o w er
Ablation
Pulse Duration
Smart Pulse Emission
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5 Clinical Procedure
5.1 Pre Treatment Care
5.1.1
First of all it is important to proceed with the visit and the anamnesis of the
patient.
A persons history should be compiled by establishing the following:
Sun and UV lamp exposure: avoid them before (at least 1 month), during and
after treatment. Apply SPF50 sunblock before and after the treatment.
Make sure that the patient is not taking incompatible drugs as:
o Anticoagulants (as acetylsalicylic acid, heparin, etc),
o Retinoids these drugs can cause problems in the healing process
with possible scar results - (as isotretinoin, etc),
o Photo-sensitizers (as tetracycline [antibiotic], naproxen [NSAD],
auranofin
[antirheumatic],
estrogens
and
progestins
[oral
5.1.2
PIH prevention
Especially with darker phototypes (III, IV, V and VI) and Asian phototypes, it is
recommended to apply a topical cream every day for four weeks before the
treatment for inhibiting melanin production.
It is possible to use cream containing hydroquinone or, as alternative lighteners,
arbutin, azelaic acid, kojic acid or stabilized vitamin C.
This procedure is highly recommended with darker and Asian skin types, while
for photo type I and II it is just a suggestion.
5.1.3
Infection prevention
The anaesthetic protection for CO2 laser skin therapies becomes necessary in specific cases,
such as:
Traditional CO2 laser skin resurfacing;
The treatment of extensive skin areas;
The treatment of deep lesions;
Patients with a low pain threshold;
Non-compliant patients;
Paediatric patients.
5.2.1
Anaesthesia Techniques
Irrespective of the anaesthetic method used, several indispensable precautions are necessary:
A careful clinical assessment (if an anaesthetist is necessary this will be their exclusive
responsibility), with particular attention to cardiovascular, pulmonary, and neurological
pathologies, hypertension, diabetes, allergic phenomena and/or any idiosyncratic
reactions to the medicinal products to be administered;
Instrumental assessment (ECG, chest X-ray, etc.) wherever indicated;
Detailed indications regarding the administration, modification or discontinuation of
therapies in progress (in the current condition and in relation to the type of
intervention/treatment, the assessment will mainly concern the anticoagulant therapy);
Pre-op fasting (6 hours for solids, 2 hours for liquids);
Informed consent;
Outpatient safety devices;
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Infiltrative Anaesthesia
While the use of this type of anaesthetic does not necessarily require the presence of the
anaesthetist, monitoring of the vital parameters is obligatory, as well as the presence of all
the aids for coping with possible emergency situations. Any type of local anaesthetic may be
used for the infiltration. The onset of the action is extremely rapid with nearly all agents,
irrespective of whether used intradermically or subcutaneously. Epinephrine considerably
prolongs the duration of the block via infiltration.
Both intradermal and subcutaneous infiltration may be painful, above all due to the acid pH
that characterises all local anaesthetics. The problem can be attenuated with suitable
administration techniques and the addition of NaHCO3 in a 10-15% ratio.
The intradermal and subcutaneous infiltration techniques foresee the use of fine needles (30
G) for the initial pomphus, after which larger gauge needles can be used (25-23 G) for
achieving an optimal anaesthesia in the area to be treated, and by always taking care to
inject the preselected solution very slowly.
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CERVICAL PLEXUS
Central blocks:
Superficial C.P.
- ophthalmic bundle-branch
Deep C.P.
- maxillary bundle-branch
- mandibular bundle-branch
Peripheral blocks:
- supraorbital nerve
- infraorbital nerve
- mental nerve
The local anaesthetics used for peripheral nerve blocks are the same as those used for the
infiltrative techniques.
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ANALGESICS:
SEDATIVES:
Benzodiazepine
Ketorolac
Ketamine
Tramadol
Major sedatives
Opiates
Hypnotics
Anaesthetics
General anaesthesia
The indications for general anaesthesia are restricted to paediatric and non-compliant
patients. The presence of the anaesthetist is indispensable, and the anaesthetic may be
performed in authorised structures including outpatients.
5.2.2
5.2.3
Patient discomfort can vary widely in case of traditional laser skin resurfacing.
Many patients find the topical application applied one or two hours prior to the
treatment and combined with regional nerve blocks provides appropriate
analgesia.
Other patients prefer to undergo intravenous sedation because they find laser
resurfacing to be uncomfortable.
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and
traditional)
full
face
5.3.1
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Fluence
(J/cm2) =
As a simple result of the formula above, reducing the Power and/or the Dwell
Time and/or increasing the Spacing, it is possible to reduce the fluence and to
control the thermal effect on the skin.
5.3.1.1
Skin Resurfacing
Phototype
Power (W)
Dwell Time
(s)
Spacing
(m)
Nr. of
Sessions
Nr. of
Passages
30
2000
750
II
30
2000
1000
III
30
2000
1200
IV
25
2000
1200
V-VI
25
1500
1200
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5.3.1.2
Chronoaging
Phototype
Power (W)
Dwell Time
(s)
Spacing
(m)
Nr. of
Sessions
Nr. of
Passages
30
1000
750
II
30
1000
1000
III
30
1000
1200
IV
25
1000
1200
V-VI
25
750
1200
Fair Asian
Skin type
30
300
300
Dark Asian
Skin Type
25
300
350
5.3.1.3
Phototype
Power (W)
Dwell Time
(s)
Spacing
(m)
Nr. of
Sessions
Nr. of
Passages
30
2000
1000
2-3
II
30
1500
1000
III
30
1000
1000
3-4
IV-VI
30
750
1000
3-4
Fair Asian
Skin type
30
800
800
Dark Asian
Skin Type
25
800
800
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5.3.1.4
Keloid
Phototype
Power (W)
Dwell Time
(s)
Spacing
(m)
Nr. of
Sessions
Nr. of
Passages
30
2000
800
2-3
II
30
1500
800
III
30
1000
800
3-4
IV-VI
25
1000
800
3-4
Fair Asian
Skin type
30
800
700
Dark Asian
Skin Type
25
800
700
5.3.1.5
Phototype
Power (W)
Dwell Time
(s)
Spacing
(m)
Nr. of
Sessions
Nr. of
Passages
30
500
500
1-2
II
30
400
500
1-2
III
30
300
500
1-2
IV
25
300
600
1-2
20
300
800
1-2
Fair Asian
Skin type
25
300
650
1-2
Dark Asian
Skin Type
20
250
650
1-2
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5.3.1.6
Melasma
Phototype
Power (W)
Dwell Time
(s)
Spacing
(m)
Nr. of
Sessions
Nr. of
Passages
20
500
500
II
20
400
500
III
20
300
500
IV
15
400
500
Fair Asian
Skin type
20
400
500
Dark Asian
Skin Type
20
300
500
5.3.1.7
Dwell Time
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5.3.1.8
post
treatment
scars
is
higher.
It
is
Dwell Time
5.3.1.9
Power
Dwell Time
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5.3.2
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Malar areas
For these areas the suggested setting is: Power= 17 W and Dwell Time= 400 s.
Normally a second laser pass is used to treat the malar area, this should be done
transversely with respect to the previous one.
Perioral Area
In the perioral area, laser resurfacing is carried on to the vermilion border.
Great care is taken to avoid allowing the laser beam to strike teeth. Some
surgeons prefer to use a protective mouth-piece. Be careful because it could
distort the perioral tissue. Initial parameters should be: Power=13 W and Dwell
Time= 400 s.
Forehead
When treating the forehead area, the hair is moistened and metal shields or
moist towels are used to protect the eyes. Care is taken to avoid lasering the
hairline or eyebrows. Initial parameters are: Power= 15 W and Dwell time= 400
s.
Periorbital area
Because the eyelid tissue is so delicate, reduced fluence is used: Power=10 W
and Dwell Time= 400 s. The eye to be treated is anaesthetized with two drops
of tetracaine. A glass or metal eye shield is inserted under the lid to protect the
globe. It is better to use a spherical protector to be sure that the surface is
smooth and free of any irregularities. Resurfacing is carried no closer than 3 to 4
mm from the ciliary margin to minimize oedema and possible thermal irritation
to the meibomian glands in the eyelid area. Multiple passes may be used to
treat deep wrinkles in the lateral canthal area. For the upper eyelid, treatment
is carried down to the superior tarsal fold.
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5.3.3
Set the SmartXide DOT system according to the patient phototype, the area to
be treated and the application.
TREATMENT
EMISSION
LEVEL*
MODE
FREQUENCY
REMARKS
(Hz)
Acne Scar
PW
0.5-3
10-20
Actinic Cheilitis
PW
0.5-5
10-20
Topical anaesthesia.
Actinic Keratosis
(superficial)
PW
1.5
10
Actinic Keratosis
(tick)
PW
50
Angiokeratoma
PW
1.5-5
10-20
Balanitis Xerotic
Obliterans
PW
2.5
20
Basal Cell
Carcinoma
PW
0.5-8
10-50
Bowens Disease
PW
20
Chondrodermatitis
Nodularis Helicis
PW
1-2.5
20-50
Condyloma
Acuminatum
PW
1.5-10
10-20
Topical anaesthesia.
PW
4-7
50-100
Infiltrative anaesthesia.
Cyst
PW
2.5
20
Infiltrative anaesthesia.
Dermal Nevus
PW
0.5-4
10-20
Epidermal Nevus
PW
0.5-3
10-20
Facial
Telangiectasia
PW
3-8
80
Granuloma
Pyogenicum
PW
2.5-8
20-50
Infiltrative anaesthesia.
Haemangiofibroma
PW
1.5-3
10-20
Topical
anaesthesia.
Spiral
movements starting from the edges
to the centre.
Topical anaesthesia.
biopsy.
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TREATMENT
EMISSION
LEVEL*
MODE
FREQUENCY
REMARKS
(Hz)
Haemangioma
PW
4-10
80
Hidrocystoma
Apocrine
PW
0.5-2
10
Hypertrophic Scar
PW
0.5-3
10-20
Keloid
PW
0.5-3
10-20
Keratosis
(Seborrheic
Keratosis)
PW
0.5-3
10-20
Topical anaesthesia.
PW
0.5-2
10
Lentigo Maligna
PW
0.5-3
10-20
Leukoplakia
PW
0.5-5
10-50
Lymphangioma
PW
0.5-3
10-20
Molluscum Fibroma
PW
0.5-3
10-20
Topical anaesthesia.
Neurofibroma
PW
0.5-2.5
10-20
Nevus Sebaceus
PW
1.5-10
10-20
Infiltrative anaesthesia.
Pagets Disease
PW
0.5-3
10-50
Queyrats Disease**
PW
20
Rhinophyma 1
PW
2.5-10
50-100
Rhinophyma 2
PW
2.5-5
20
Finishing
phase.
anaesthesia.
Sebaceous
Adenoma*
PW
1.5-2.5
10-20
Topical anaesthesia.
Spider Nevus
PW
3-8
80
Spinocellular
Carcinoma
PW
2.5-8
20-50
Rough-shape
anaesthesia.
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phase.
biopsy.
Infiltrative
Infiltrative
TREATMENT
EMISSION
LEVEL*
MODE
FREQUENCY
REMARKS
(Hz)
Superficial
Pigmented
Lesions**
PW
1.5
10
Syringoma
PW
0.5-2.5
10-20
Infiltrative anaesthesia.
Trichoepitelioma
PW
0.5-5
10-50
Infiltrative anaesthesia.
Tuberous Angioma
PW
4-7
50-80
Verruca 1
(Verruca Vulgaris)
PW
4-15
10-100
Topical anaesthesia.
Verruca 2
PW
0.5-2
10-20
Infiltrative anaesthesia.
Verruca Pedis**
CW
8-10
Watt
Xanthelasma
PW
0.5-3
10-20
Infiltrative anaesthesia.
Zoon Balanitis**
PW
1-2
10-20
(Verruca Plana)
Infiltrative anaesthesia.
*: In the LEVEL column the suggested ranges for the level setting are shown.
Consider that usually, the procedure starts setting higher level value (which
corresponds to a deeper skin ablation effect) for the rough-shape phase. At
the end of the procedure the level value is reduced to perform more precise
final touches.
**: Treatment not included in the Treatment Menu of SmartXide DOT system.
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6 Clinical Cases
6.1 Fine wrinkles, Textures and Spots
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Before and 21 days after 1 session. Courtesy of Dr C. William Hanke Indianapolis, IN USA.
Before and 17 days after 1 session. Courtesy of Dr C. William Hanke Indianapolis, IN USA.
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6.2 Wrinkles
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Before and 6 days after 1 session. Courtesy of Dr Hee-Jin Han Seoul - Korea.
Before and 14 days after 1 session. Courtesy of Dr C. William Hanke Indianapolis, IN - USA.
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Before and after 2 sessions. Courtesy of Dr Jahanara Ferdous Khan - Dhaka Bangladesh.
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6.4 Keloid
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Before and after 2 sessions. Courtesy of Dr Jahanara Ferdous Khan - Dhaka Bangladesh.
Before and after 2 sessions. Courtesy of Dr Jahanara Ferdous Khan - Dhaka Bangladesh.
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6.9 Melasma
Before and after 2 sessions. Courtesy of Dr Jahanara Ferdous Khan - Dhaka Bangladesh.
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