Members of the Agnesian HealthCare Podiatry team present on the new Cutera Genesis Plus Laser, which is for treatment of nail fungus, warts and scars

1. Know & Go!
Cutera Genesis Plus Laser
For Treatment of
Nail Fungus, Warts and Scars
Thomas Sheridan, DPM
Agnesian Foot Clinic

2. 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

3. GenesisPlus

4. 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).

5. 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

6. Treatment of Nails
 Baseline
 Infected area = 42%
 Nine months post final treatment
 Infected area = 5%

7. 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

8. 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

9. Treatment Technique
Recommend to debride nail if thicker than
2mm (normal thickness)
Do not use gel
Pre-treatment photographs recommended

10. Treatment Technique, cont’d.
Treat the entire nail bed, matrix and lateral
folds, extending approximately 2mm past the
nail

11. Treatment of Nails
With 5mm Spot Size

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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

18. 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

33. Treatment of Warts

34. Treatment of Warts
Before treatment
One month after
one treatment

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. Treating Individual Warts
 If wart is smaller than laser beam:
 Assess the surrounding tissue before
placing additional pulses to avoid overtreatment 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

44. 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

45. 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)

46. Warts Treatment Example
 Before
 Four weeks s/p treatment

47. Treatment of Scars

48. Scar Treatment
 Before Treatment
 Post Treatment

49. References
 Cutera - GenesisPlus. (n.d.). Retrieved January 22, 2014,
from Cutera: cutera.com/technology/ndyag laser/genesisplus/
 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

50. Thank You!

51. Know & Go!
Total Ankle Replacement
Alyssa Stephenson, DPM
Agnesian Foot Clinic

52. Ankle Anatomy
 The ankle is formed by the union of three
bones
 Talus
 Tibia
 Fibula

53. 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.

54. 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.

55. 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

56. Arthritis
 Arthritis - wearing away of the joint
surfaces.
 Three categories:
 Osteoarthritis
 Traumatic arthritis
 Inflammatory

57. Osteoarthritis
 Primary arthritis, degenerative arthritis
 Most common
 May be due to activity or family history,
wear and tear, age

58. Traumatic Arthritis
 Arthritis that develops after an injury to a
joint.
 Can cause pain, swelling, weakness,
trouble walking.
 Can affect activity level and lifestyle.

59. 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.

60. 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

61. Tests
X-ray
MRI
CT
Blood work
Diagnostic injections

62. Non-Surgical Treatment
 Orthotics
 Ankle braces
 AFO
 Shoe modifications
 Medication
 NSAIDS, steroids, corticosteroid injections

63. Surgical Treatment
 Debridment
 Allograft arthroplasty
 Distraction arthroplasty
 Arthrodesis (fusion)
 Total ankle replacement

64. Ankle Debridment
 “Cleaning up” the joint
 Arthroscopically
 Open
 Removal of the inflamed synovial
tissue, removal of loose cartilage and
removal of bone spurs

65. Allograft Arthroplasty
 Uses cadaver donated bone and
cartilage
 Tissue is transplanted in the ankle to
replace the damaged tissue

66. Talar Dome Lesion

67. Corrected Talar Dome Lesion

68. Talar Dome Lesion

69. Graft Arthroplasty

70. 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

71. 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

72. Case Study

73. Case Study

74. Case Study

75. Case Study

76. Case Study

77. Case Study

78. Surgical Options
Motion
No Motion
Debridment
Allograft arthroplasty
Distraction
arthroplasty
Total ankle
replacement
Arthrodesis
(fusion)

79. 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

80. Post-Op
 A cast or boot is worn for a few weeks to
keep the ankle from moving while the
incision heals.

81. Risks
Bleeding
Temporary or permanent nerve damage
Allergic reaction
Infection
Device loosening
Increased pain
Device noise
Bone breakage
Blood clots

82. Post-Op Total Ankle
Replacement

83. Thank You!