Episode 7: CoolPeel and DekaDeep Fractional CO2 Laser (Tetra CO2 Laser)

Fractional CO2 laser was first brought to market in 1964 but really did not gain notoriety for cutaneous or skin conditions until the 90's.  
It was "fractionated" in 2006 and from that time, it became popularized in that now skin conditions could be treated without having the excessive downtime  of the older, full field lasers.  
As patients lives invariably have become busier and busier, the desire for a laser that can give visible results but without the extreme downtimes became more desirable.

Now it is is still important to note that there is a downtime, but with the Coolpeel function of the Tetra CO2 laser, this becomes very manageable.

This episode will go through fractional co2 laser and specifically the Tetra CO2 laser (made by Deka and distributed in the US by Cartessa Laser).  It will also walk you through the differences between Coolpeel and DekaDeep settings to see which one may be right for you.

Enjoy!

Thank you for your listenership!

Transcript

Hi everyone. I hope you're well. Thank you so much for joining us in on another episode of Just Laser It and all things Cosmetic Jo Kane. We're in the middle of a holiday season here and it's been very, very cold here.

It has been so cold. This is the first day we actually feel like we're kind of thawing out with the cold, so hopefully everyone else is as well.

But what we're going to do today is we're going to talk about a laser that a lot of people come in asking about, and this is, you all know it as Coolpeel and DekaDeep.  It's actually a Tetra CO2 laser and this is made by DEKA, which is an Italian company that just builds Tonka trucks for lasers and is distributed by a company called Cartessa.

And we are going to basically go through today's episode and we're going to talk about the differences between Cool Peel, which is one of the functionalities of it, and Deka Deep, which is another functionality of the same laser.

But before we go into that, we have discussed in the past Lasemd and IPL, and so very briefly:

What's the difference? 

Okay, so Lasemd remember is a fractional non-ablative laser, which means that it keeps the epidermis, the top layer of the skin intact and creates these fractional zones into the skin. Whereas when we talk about ablative lasers such as the Tetra co2 we're vaporizing that top layer of the skin to get down to the dermis.

Okay. So I understand that part, but are, are you trying to achieve similar results in terms of stimulating elastin and collagen?

We are, we're always trying to stimulate a certain cell called the fibroblast to have this wound repairing process that creates collagen, elastic tissue, and also some mucin in the skin to give the skin it's vitality back, but one is more aggressive than the other. So CoolPeel is more aggressive than a fractional non-ablative, and then DekaDeep is more aggressive than a CoolPeel.

If you look at the LaseMd, that's kind of the gateway laser. That's a, a good starter laser, so to speak. And then you could graduate to a CoolPeel, and then from there you could even graduate to, to the DekaDeep.

You're exactly right. You know, sometimes patients come in and can, you've heard this often where they come in, they say give me the hardest laser that you've got. I want to do a one and done. Well, I'll tell you, with fractional technology, it really isn't ever a one and done. You usually must do a series of lasers, but sometimes the skin may not be appropriate. Maybe the skin coloration's too dark or the skin health is not there, or even the emotional downtime is not there.

So, a lot of times what I'll do is I'll start with fractional non-ablative lasers or a CoolPeel if I want to do ablative and watch how the skin heals and see how the patient does, and then we can graduate them to a deeper laser if needed.

Okay. So, you start with LaseMd, then you go to CoolPeel, which is more aggressive and that's taking some of that top layer of the skin off.

So let's talk about the CoolPeel:

Okay, well let's talk about fractional CO2 in general. Sometimes patients will also ask, can you do multiple non-ablative lasers and get to level of ablative? No, it's not quite apples to apples. I mean, I think that you are going to get more rejuvenation with ablative than you will get with non-ablative, but you'll still condition the skin with non-ablative. 

In regard to ablative lasers, remember a lot of what we're doing with an ablative laser is we're, yes, we're vaporizing off the top layer and we're creating a lot of heat in the skin target, and our target is the water that's in the cells, it's intracellular water, and we get to temperatures at about 80 degrees Celsius.  

That is hot. In fact, 54 degrees Celsius will cause a secondary degree burn. So why aren't we burning the tissue? And the reason is, remember, lasers are specific to certain targets.

We're creating that heat in the target and there is some dermal spread of the heat. That's why we get a lot of redness and swelling afterwards. But the skin is maintained. We're basically creating a controlled wound which turns on the wound repair process to create this collagen and elastin in the skin.

Okay, so why would I want to do this?

If you have fine lines and wrinkles, a little bit of pigmentary changes to the skin and you're just trying to get a better grasp of creating more collagen, a CoolPeel might be absolutely appropriate for you. Now, tell you one more thing. So before I would never do ablative lasers on a kind of a olive Mediterranean skin, and certainly not on Asian skin but with CoolPeel which is lower energy but high peak power you can do it on slightly darker skin types. Now, I don't recommend it on very dark. I still think that there's other modalities that would be better, such as RF, microneedling, or non-ablative lasers, or PicoSure as well.

But you can expand your repertoire a little bit more with CoolPeel function. 

What do you mean when you say low energy? But high peak power?

High peak power, ablates the tissue without creating a lot of the heat effect. Now remember that heat effect is important to stimulate even more elastin and collagen, but it also allows for a quicker downtime and a quicker healing time with CoolPeel, and it doesn't go quite as deep as DekaPulse.

Okay, so before we dive into the DekaDeep, I do want to just backtrack a little bit. So, a LaseMD is, I don't know what the right word is. An entry level.

Why would I want to do something more aggressive than that?

Like the CoolPeel if we're just trying to, at the end of the day, stimulate elastin and collagen?

Because you can get more with a fractional CO2 as far as benefits than you can with a Lase md, but you have to be the appropriate patient.

You can't have dark skin type you have to have that little bit more of a downtime. This is kind of your weekend laser. A CoolPeel. You can get it done on a Friday and be back to work on Monday.  You can put makeup on top and you can relatively hide any, any of the residual healing that occurs with the CoolPeel.

Now remember with Cool Peel we basically oscillate between four watts and six watts settings. So a six watt CoolPeel will have a slightly longer downtime than my 4 watts.

And typically you can expect about a two, possibly a three day downtime. Again, everybody's different with how they heal, but that's kind of the average of it.

So is it safe to say that just the more aggressive, the laser that you're using, the more elastin and collagen can be stimulated but you also have a little more downtime? 

Yes, correct. You have a little more downtime. And also, it's not just the wattage or, or the energy levels that we're selecting. It's also something called the density, how much of the tissue we are treating. So if I put these little spots, these little fractional zones very close together, I'm treating more tissue and there's going to be more downtime, there's going to be more redness, there's going to be more swelling.

Put these little dots a little further apart. There is a quicker healing period, but this is definitely a very popular laser in the sense that you can titrate it and give patients some really nice results.

Now, well, I know most of our patients will do this in a series. They'll have a package of cool peel.

Is that, is, is that something that would be more beneficial or why would we want to do a series?

I think that optimally you want to do about three to four CoolPeels to really get yourself to goal. We sell them in packages of three, but yes, I do think that patients will want about three to four CoolPeels to really stimulate their collagen.

Are you going to see something with one? Absolutely. Are you going to get to that optimal goal? No. I think you're going to need more than one to get there. 

How frequently would you do those three or four? What was the spacing of that?

About four to six weeks apart for the CoolPeels, you can, you know, there's no harm done. If someone says, well, I can't get in until eight or nine weeks, that's fine too.

But I think about every kind of six weeks is, is the average of when we do it. And again, you build collagen all the way up to six months’ time period. Where I would say the majority of result is going to be seen at three months post your last CoolPeel, and then you'll continue for about six months, and then you'll sustain there for a while before the degradation occurs.

Then 6 to 12 months later, you might come in for another series. Is that right? 

You might come in for one Cool Peel, or you might want to top it off with a Lase MD somewhere in between where maybe you don't have the large downtime, but you do a series and then six months later you, you do a Lase MD to maintain it.

So it really is looking at this holistically that this is a process and it's a plan that people have to have in place to where they can space this out. You can interchange a Lase MD in a CoolPeel, but at the end of the day you're, you're trying to stimulate that elastin collagen to get the most benefit.

But it's not just a one and done, it's really just an ongoing maintenance at that point.

It is. And then finally, I'm going to give you a little blurb about the DekaDeep. So we call it DekaDeep because that is the deeper laser. Again, these are the same laser. Tetra CO2 is a laser, this is a different type of treatment, different parameters that we select from that same laser.

So the DekaDeep I do in the practice, the CoolPeel, both myself and Lauren primarily does in the practice. Lauren's very good at the CoolPeel.  With the DekaDeep, I'm selecting much higher energies, I should say. But I'm also creating a little more heat in the skin.

So with the DekaDeep, you can expect pinpoint bleeding right after the procedure. You can have this yellow serous drainage in the first 24 hours, and then you'll certainly be swollen for the first four to five days and you really cannot wear makeup until five days. So that differs from CoolPeel. 

With any fractional CO2 laser, if we're going over the eyelids, of course we need corneal ocular shields, to protect the eyes. Now sometimes we don't go over the eyelids, in which case we can do external shields but typically the patients who are doing DekaDeep want their eyelids treated.

So the DekaDeep is ultra aggressive.

It is ultra aggressive now. It's still not a one and done. Some patients at six months might need a second DekaDeep as well, but I typically like to separate those out by three to six months.

Can you do those any time of the year?

You can, you can do it because it's not based on melanin.

However, I do want patients to really sun protect after they have had it done. So I do want them for at least a week to, to be out of the sun altogether. And so that's why I typically probably do them more October through May, but absolutely I do teachers in the summertime all the time when they know they can send protect.

And is that the same skin types and skin tone apply?

No. I do this only on, on something called Fitzpatrick's skin types one through three, which means about. Someone with dark hair, but lighter skin or lighter than that, I do not do these on Asian skin. The DekaDeep there's a higher risk of post-inflammatory hyperpigmentation.

And now that we have multiple modalities that can give benefits, again, RF microneedling and also different fractional non-ablative laser, we can, we can oscillate to that.

So if I'm a patient and I'm discussing these options with you and I'm trying to weigh okay, does a series of CoolPeel benefit me versus a DekaDeep, how would I go about making the decision? What am I trying to achieve to where one versus the other would apply?

Well, one, I would want to see, have you had any lasers before in the past? Which is important because I think that I would probably start off with at least one CoolPeel and then go to a DekaDeep.

If you have had lasers before, and let's say you've had CO2 and your skin, I know about the healing aspects of your skin, then very well go into a DekaDeep. I do have patients text me on a daily basis with DekaDeep for the first four days because they, I might tell them that You're going to look crazy tomorrow.

You're going to look like chopped meat tomorrow. But until they go through it, there's an emotional component to it as well that, am I supposed to look like this? And the answer is, yes, you are, and it will heal. 

So even though you can set that expectation, it's still shocking the next day when you see yourself in the mirror and you're like, boy, is this what it's supposed to look like?

Correct. I did this laser once on you.

Yeah. I remember. I was like, is this, are you sure this is what it's supposed to look like? And yes, it is.

Eaxactly. Now, when I do DekaDeep I do use exosomes on top to help with the healing process post procedure. And I also want to say that DekaDeep, I only do on the face, I do not do this on the neck, and I certainly do not do this on the chest.

There's not enough healing structures on those zones to heal appropriately. . And again, there are other modalities that we can select from for those regions. And you always have to be careful under the eyes. That's an area that doesn't have a lot of hair follicles. So that's an area too, that you've got to be careful with your settings.

But with the DekaDeep, you are going to have a significant downtime and healing process. So why would I choose that option versus a series of CoolPeel?

I'm trying to understand that

Once again, a series of cool peel may not be equivalent to a DekaDeep. A DekaDeep is going to go deeper into the tissue.

It's going to go into that reticular dermis a little deeper. That's why we see that pinpoint bleeding. Whereas the cool peel will just be in the upper layer of the dermis, the papillary dermis, which a lot of our, a lot of our healing, a lot of our rejuvenation does occur there. But let's say patients have some acne scarring or some deeper wrinkles, then I would select the DekaDeep.

So with the deeper wrinkles. And, and, and I'm assuming that it would just, it's, if it's more aggressive, it's also going to be more aggressive in terms of stimulating elastin.

Correct. It will be, you'll get more bang for your buck with your DekaDeep. But again, it has to be the right patient and it has to have the appropriate healing times because even after the five days, you'll still be read in little zones of the skin for two weeks more.

There is a certainly some healing time and that that redness is part of the healing process. You'll be stimulating more and more collagen with that.

And is that something, after you've had that done, would you, would you scale back to a Lase MD or a CoolPeel for a maintenance perspective as well?

You can, or six months later you can do another DekaDeep, and then once you're there, yes, I do think you can scale back and then again, we'll look at, at volume loss, et cetera, whether Sculptra something, et cetera.

You know, there's different ways that we segue off to, to maintain results, but the healing afterwards, both of them require an emollient such as Aquaphor post-treatment. CoolPeel, typically in the first two days with DekaDeep, we say for the first four days, and then at nighttime, around the eyes for an additional couple of weeks because it dehydrates the top layer of the skin and that that damaged top layer of the skin will then slough off and new, new skin, so to speak, is then formed rejuvenated skin is formed.

Okay, so as I'm visualizing this, it's really a tiered system. When I look at it, where the Lase MD is the least aggressive and then you can graduate to a more aggressive, CoolPeel and then you can graduate to an even more aggressive DekaDeep. And as you get more aggressive, you're lasting in collagen stimulation will also get more aggressive. 

Correct. But I would think that 80% of the patients, a series of CoolPeel will do them. It's that 20% that might need the DekaDeep. So that's kind of how we think.

And it's important that those folks understand that this is a longer healing time. 

Longer downtime. And yes, your face is supposed to look like that, correct?

Correct. It basically renews the skin. So that is going to be, let me make it a little bit louder. “Renew with co2.”

That's what we're going to do as our phrase that saves. And what I would say is I'm not going to just limit it to a number. I'm going to say patients that call in in the month of January to schedule their series of CoolPeels, we're going to take off an additional 10% off of the already discounted package of three, but they have to schedule their first one in the month of January.

Okay, so what is it? 

Renew with co2, and you'll get an additional 10% discount on top of the package discount that we 

offering. Correct? 

Correct. For the month of January where the 1st one of the series has to be scheduled for January.

Correct. And this is Cool Peel face. This is for the face. That is Tetra CO2 in a nutshell.

The CoolPeel functionality and also the DekaDeep. It's still one of our favorite lasers to do. And in fact, Kane, it's one of the oldest lasers out there. It's been around since the 1960s actually, and it's really come into existence. From the nineties onward, and then of course it got fractionated in about 2006.

And that's where we can do some things with CO2 without having that huge, huge downtime. But still, again, the difference between Cool Peel and DekaDeep has to do with the parameters that we select, which correlates to the downtime, which correlates to the final result.

And we have a lot of patients that do this.

It is very popular. And so, and the, and the results are, are very well received. So,

so that is it. So otherwise, I hope everyone has a wonderful, wonderful start to 2023. Happy New Year to everyone and goodbye from me.

Happy New Year, and thank you so much for listening.