Keren B. Horn, MD Meyer A. Horn, MD Neha D. Robinson, MD Peter A. Lio, MD Emily Arch, MD 1455 N. Milwaukee Avenue-Second Floor Chicago, Illinois 60622 T 773.276.1100 F 773.276.1102 SMARTXIDE DOT FRACTIONAL CO2 LASER SMARTXIDE DOT INFORMATION DOT Therapy with the SmartXide DOT Fractionated CO2 Laser offers skin rejuvenation in just under an hour for most treatments. DOT Therapy is ideal for the treatment of sun damage, brown spots, fine lines, wrinkles, skin laxity/texture and acne scars. DOT Therapy provides noticeable improvement safely and quickly. PROCEDURE DESCRIPTION Each treatment will range from 15-60 minutes. Prior to the treatment, a topical anesthetic will be applied about an hour before treatment. During the treatment your eyes will be covered with protective eyewear. The treatment can range from barely noticeable to mildly painful. Any discomfort is best described as a warm stinging. RISKS/COMPLICATIONS After each treatment, patients should expect significant redness, swelling, and scabbing for 5-10 days; however, downtime will vary depending on the aggressiveness of the treatment, which will be determined after discussion with your doctor. Skin will be dry, red, coarse and flaky and gradually slough away in 1-2 weeks. During this time it is very important to follow post treatment instructions. Skin discoloration, scabbing, blisters and crusting can occur, although unlikely. In rare instances infection and/or scarring can occur. Sun exposure after a treatment can cause blotchy pigmentation, which is usually temporary but can take a few months to resolve. Cold sores can be triggered by any facial procedure. If you have a history of cold sores, be sure to notify your doctor prior to your procedure, so that you can be given a medication to reduce the chance of a breakout. There is no guarantee of results, and though it is unlikely, there may be minimal or no improvement of the condition. CONTRAINDICATIONS  Use of isotretinoin (Accutane) in the previous 12 months  Recent sun exposure and suntan —avoid the sun one month before and after treatment  Pregnancy  Keloid tendency BEFORE YOUR SMARTXIDE DOT TREATMENT • Avoid sun exposure six weeks before and after treatment (VERY IMPORTANT!). Be sure to use a sunscreen that has an SPF of at least 30 and zinc oxide as an active ingredient. Apply generously and reapply every 1-2 hours. • Self Tanners/ Spray Tans should be avoided for at least two weeks prior to your treatment. • Avoid harsh scrubs or exfoliants 1 week before and after the procedure. • Stop retinoids (like Retin-A, Differin, Tazorac, Renova, Afirm, Tri-Luma), alpha hydroxy acids/glycolic acids at least 1 week before procedure. • If you have a history of cold sores, please let us know before the day of the procedure so that a medication can be given for you to take. In rare instances, a herpetic outbreak may still occur. • Patients who are taking sun-sensitive oral antibiotics (such as Oracea, minocycline, doxycycline, Monodox, etc.) should discontinue these medications 3 days prior to their appointment to prevent adverse side effects. If you are not sure if your medications fall under these categories, ask your physician or provider. These may be restarted as soon as the procedure is complete. Pleas be aware that patients with rosacea may experience a sight flare with any temporary discontinuation of oral antibiotics. • To minimize discomfort, you may take 600mg of ibuprofen 1 hour before your treatment. • It is a good idea to bring a hat, scarf, or other protective clothing to help protect the area on your way home after the treatment. Rev 12/14/12 ed AFTER YOUR SMARTXIDE DOT TREATMENT  After each treatment, patients should expect significant redness, swelling, and scabbing for 5-10 days; however, downtime will vary depending on the aggressiveness of the treatment, which will be determined after discussion with your doctor. Skin will be dry, red, coarse and flaky and gradually slough away in 1-2 weeks. During this time it is very important to follow post treatment instructions. Immediately post treatment:  Apply cooling mask (provided by physician) immediately after treatment once you return home for 30-60 minutes  Apply Vaniply ointment (provided by physician) to prevent direct contact between the treated tissue and the air during the healing process. The ointment should be applied liberally to the treated area several times a day to ensure the area remains moist. The use of an occlusive ointment optimizes skin healing, improves patient comfort, and reduces the sensation of pain and burning by preventing air from contacting the treated region. After healing is completed an intense moisturizer may be used.  Apply ice packs (without direct skin contact every 1-2 hours as needed over the next 24 hours.  Some patients report a “hot” feeling, which lasts a few hours to a few days.  Vinegar soaks should be performed daily for the next 3 days to reduce burning sensation and reduce the possibility of infection. o Mix 1 tablespoon white vinegar with 1 pint of cool water. Wet a soft cloth or gauze, soak treatment site for 15 minutes with dilute vinegar solution.  There may be areas of pinpoint bleeding. This is normal and can be cleaned with a gentle cleanser and tepid water.  Sleeping with the head elevated on pillows (head above the heart) the first few nights post treatment can help minimize swelling 1-2 days after treatment:  2-3 times a day, gently wash area with tepid water and a gentle skin cleanser starting the morning after your treatment. Then immediately re-apply post op ointment for a least _____ days. It is very important that you keep your skin moist with the Vaniply ointment during this healing time.  You can continue cold compresses as needed.  You can take antihistamines, such as Claritin/Allegra in AM and Benadryl/Zyrtec in PM or an anti-inflammatory such as Advil/Motrin/Ibuprofen (400 mg 2-3 times/day) if desired to help decrease any swelling, pain and itch.  Avoid any sun exposure. If you need to go outdoors, wear a protective hat or visor. 3-7 days after treatment:  Once the skin surface has completely healed (4-6 days), you may use over-the-counter hydrocortisone cream 2-3 times a day as needed for itching  Avoid any direct sun exposure for at least 6 weeks. Apply an SPF 30+ sunscreen with zinc oxide when skin has healed. Sunscreen with zinc oxide provides broader protection.  May use a mineral make-up once skin is healed in _____ days.  Your skin should feel like it is somewhat returning to normal, but you should expect the following: o Redness _____ days o Swelling _____ days o Scabbing/Crusting/Oozing _____ days  If you do still have some peeling, continue to do the vinegar soaks as this will help resolve the peeling.  Continue to use the gentle cleanser. At this time, you can switch from using the Vaniply ointment to using a gentle non-comedogenic moisturizer, such as Cetaphil cream, Cerave cream, Trixera balm or Vanicream Things to avoid:  Avoid mechanical exfoliation (microdermabrasion, etc.) for 4 weeks.  Avoid dirty, dusty environments, painting, hairspray, and perfumes while skin is healing.  Avoid hot water/steam on treated area when showering  Do not pick at or aggressively scrub the treated skin, and allow it to gently exfoliate during the washing process.  Smoking and/or excessive drinking can delay your healing time.  Avoid strenuous exercise and excessive sweating for 3 days. Please make a follow-up appointment for __________ days and __________ weeks. Rev 12/14/12 ed COST OF YOUR SMARTXIDE DOT TREATMENT Full Face $1800 Eyes $500/individual treatment $1300 package of 3 Cheeks and Perioral $1000 Perioral $400 * This financial quote for treatment is valid for 90 days from the date of receipt. Prices are subject to change and an updated quote will be provided if necessary after 90 days. CONSENT TO SMARTXIDE DOT TREATMENT Patient Name:___________________________________________________________ DOB:___________________________ 2 1. I consent to the performance of SmartXide DOT Fractional CO Laser within one year of date of this consent; to be performed by or under the supervision of Dr.______________________________________________. 2. The procedure has been explained to me including the benefits of the treatment, risks involved, and possible alternative methods of treatment. I have had the opportunity to discuss this procedure and received answers to all questions I asked. __________ (initial) 3. I understand that there is no guarantee that any particular results will be obtained. 4. Dermatology & Aesthetics of Wicker Park is affiliated with Northwestern Memorial Hospital, which is a teaching hospital. Medical education and research are part of the Hospital’s role. For the purpose of advancing medical education, I consent to observation of this procedure by qualified observers (including medical and nursing students). I authorize Dermatology & Aesthetics of Wicker Park employees to take pictures and publish the pictures in scientific journals and exhibit them for educational purposes, providing that the identity of the patient is not revealed. (If the patient’s identity would be revealed by publication of the pictures of accompanying text, they will not publish unless I specifically agree to this in writing. 5. I authorize the taking of clinical photographs to asses the effect of treatment and for the possible use for marketing, patient education and scientific purposes. I understand my identity will be protected. I have read the above and understand it. My questions have been answered satisfactorily by the doctor and doctor’s associates. I accept the instructions, risks and complications of the procedure. Patient Signature Rev 12/14/12 ed Date