Titan Mobile Advanced Technique

Training

Indications
The Cutera Titan handpiece is US FDA-cleared for topical heating for the purpose of elevating tissue temperature for temporary increase in local circulation where applied The Cutera Titan Handpiece is EU CE marked for the treatment of wrinkles Histologic evidence following Titan exposure shows collagen contraction
Zelickson B, Ross V, Kist D, Counters J, Davenport S, Spooner G. Ultrastructural Effects of an Infrared Handpiece on Forehead and Abdominal Skin. Dermatologic Surgery 2006;32:897-901

The wavelength is 1100-1800nm Appropriate for all skin types

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Spot Size
Spot Size: size of treatment window
Titan S and Titan V: 1.5 cm x 1 cm Titan XL: 3 cm x 1 cm Treatment window maintained at 20 C for epidermal cooling

Titan S

Titan V

Titan XL

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General Considerations
The decision to treat with light therapy should be based upon appropriate diagnostic evaluation and consideration of all patient factors. The Titan Handpiece should only be operated by qualified practitioners who have received appropriate training and have thoroughly read the operator manual. Please consult the Titan Treatment Guidelines and the Operator Manual for additional information including indications for use, contraindications, possible adverse effects, safety warnings and features, and system operation. Appropriate parameters will vary. Always observe tissue reaction during treatment.
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General Considerations
Proper patient screening, parameter selection, treatment technique, epidermal cooling, and tissue observation are important to achieve the desired outcome without unwanted side effects. It is important to observe tissue reaction during treatment. Excessive heating of the skin can increase the risk of blistering, burns, erosion, hyperpigmentation, and hypopigmentation; some of which may result in scarring.
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Contraindications
Pregnant Patients Treatment of Skin Cancer

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Pre-Op Medical History Pre-Op

The following conditions are not contraindications but should be considered before treating:
Current medications (both routine and occasional use)
Accutane do not treat if taken in the last 6 months Aspirin, ibuprofen, herbs (such as St. Johns Wort), vitamins, and anticoagulants The above examples may increase risk of purpura or bruising. Gold Therapy May cause blue-gray discoloration Photosensitizing drugs (Tetracyclines, etc.) Be aware that you may have to adjust the treatment parameters according to clinical response from test area(s).

History of vitiligo
Heat from the treatment could induce a flare-up in patients with preexisting vitiligo.

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Pre-Op Medical History Pre-Op Continued

History of Herpes Pre-treatment with an antiviral may be indicated. History of Coagulopathies Diabetes May impede wound healing Autoimmune diseases Wound Infections History of Keloids or Hypertrophic Scarring Tattoos, including permanent make-up, in treatment area Do not treat over tattoos. Pacemaker or defibrillator (consult cardiologist) Implants or surgeries in treatment area

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Pre-Op Patient Consent Pre-Op

Patient Consent
Provides treatment information Informs of expected and unexpected side effects

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Patient Prep Clean

Remove all make-up, sunscreen, topical anesthetics, etc.
Any creams or products left on the skin can interact with the light and increase the risk of unwanted side effects. Skin products and/or chemicals (i.e., depilatories, sunless tanners, etc.) normally tolerated by a patient may cause an adverse skin reaction with pulsed light treatment. Avoid using these products at least 24 hours before and after treatment.

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Pre-Op Photos Pre-Op

Pre-op photos are your MOST valuable tool and protection. You only have one chance to obtain good pre-op photos.
Document baseline condition Use for comparison purposes later on in treatment Consistent technique is important for useful, comparable photos. Matched patient positioning Camera settings Room lighting Side views often show the best results

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Patient Prep Shave

Shave the treatment site.
Remove all hair from the surface of the skin to allow for complete contact with the cooling device. Hair in the treatment area may not allow full contact of the handpiece with the skin.

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Eye Safety
Safety eyewear must be worn by ALL people in the treatment room.
Example Operator Eyewear Patient Eyewear

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Patient Prep Patient Comfort

These treatments, if performed properly can be tolerated without anesthesia. Anesthetics may be used, but are not recommended.
The use of anesthetics is not recommended as patient feedback is important in determining treatment settings. If used, topical anesthetic must be completely removed prior to treatment.
CAUTION: Toxicity may result with overuse of topical anesthesia. Consult the manufacturer's labeling.

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Advanced Guidelines for Mobile Technique

Skin Type Fluence Face
I-VI Including tanned skin 40-46 J/cm2

Fluence Neck
38-44 J/cm2

Passes

3-6

Common approach for treating:

Fluence can be adjusted outside the given ranges as needed.
Patient should be able to tolerate the treatment with no more than a moderate level of discomfort.

3 to 5 treatments with an average of 4 week intervals. The number of exposures (pulses) required can vary significantly from patient to patient based on the size of the area to be treated.

*These parameters are based on physician feedback and provided as a guide only. Observe clinical response, patient discomfort and, area being treated to determine appropriate settings for each patient. See the Titan Treatment Guidelines for more information.
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Mobile Technique
Allows for a significant increase in fluence compared to stationary method
Example: Stationary technique 36 J/cm2 Mobile technique 46 J/cm2

Move the handpiece in a small circular motion (approximately 20% of the crystal dimension) in all directions
Do NOT move the entire width of the crystal The movement should be continuous throughout the entire pulse

Crystal should be placed adjacent to prior placement as performed with the original stationary method (crystal edge to edge without overlap)
Crystal motion will overlap adjacent treated areas during treatment exposure See following animated placement slides

Clinical endpoint
Reach patient pain tolerance limit by end of last pass (note: tolerance assumes no anesthetic)
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Mobile Technique
Move about 20% all directions

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Mobile Technique
Move about 20% all directions Pulse 1 Pulse 2

Crystal should be placed adjacent to prior placement as performed with the original stamp method (crystal edge to edge without overlap) Crystal motion will overlap adjacent treated areas during treatment exposure
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Treatment Technique Key Points

Apply a thick (1 - 3 mm) layer of clear, no-color ultrasound gel.
May use chilled gel

Always make sure to keep entire window in contact with the skin. Reduce fluence over sensitive or bony areas. Do not stack individual treatment pulses. Do not lift the handpiece until treatment pulse is complete.

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Treatment Technique A
Divide face into smaller sections Treat one area with 3-6 passes before moving to next area
Repeat for each area on the face Move to neck and treat in the same manner

5 8 7 6

Place pulses adjacent to each other Do not stack pulses on one spot

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Treatment Technique B
Treat small area with a minimum of 3-6 passes Average of 3-5 pulses per area Place pulses adjacent to each other Movement speed of crystal during treatment can vary according to patient tolerance Do not stack pulses on one spot
Titan XL Crystal Placement

4 3 2b 1b 1a 2a 2 1 5

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Titan
Results may be subtle and/or delayed
Collagen remodeling takes 3-6 months Do not promise immediate results

Pictures are necessary

Patients forget what they looked like

Length of results vary

Results are permanent (new collagen) but patients continue to age and lose collagen
Not like injectables that go away

Factors that may diminish outcome or length of efficacy

Health of patient including skin health Sun damage past and future Age Smoking
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Titan Mobile Treatment Quick Reference Sheet

This Quick Reference Sheet is not intended to be a complete set of guidelines. Refer to accompanying PowerPoint presentation for guidance on performing the Titan Mobile technique. Consult Titan Clinical CD for complete treatment information.

PARAMETER SELECTION
Skin Type I-VI Including tanned skin Fluence Face 40-46 J/cm2 Fluence Neck 38-44 J/cm2 Passes

3-6

Common approach for treating: Fluence can be adjusted outside the given ranges as needed. Patient should be able to tolerate the treatment with no more than a moderate level of discomfort 3 to 5 treatments with an average of 4 week intervals The number of exposures (pulses) required can vary significantly from patient to patient based on the size of the area to be treated. These parameters are based on physician feedback and provided as a guide only. Observe clinical response, patient discomfort and, area being treated to determine appropriate settings for each patient. See the Titan Treatment Guidelines for more information.

TREATMENT TECHNIQUE
Allows for a significant increase in fluence compared to stationary method. Example: o Stationary method 36J/cm2 o Mobile technique 46 J/cm2 Move the handpiece in a small circular motion (approximately 20% of the crystal dimension) in all directions o Do NOT move the entire width of the crystal Crystal should be placed adjacent to prior placement as performed with the original stationary method (crystal edge to edge without overlap) o Crystal motion will overlap adjacent treated areas during treatment exposure o See animated slides on Titan Mobile Technique presentation or Titan Mobile Technique video for example Clinical Endpoint is reached when patient reaches pain tolerance limit by the end of third pass (note: tolerance assumes no anesthetic)

December 2008 DO777_Rev. A Titan Mobile Technique Quick Reference