The Science of the Zerona

Ryan Maloney Erchonia Medical

Zerona Basics

• The Zerona device employs 5 independent laser diodes

• The wavelength utilized falls within the visible spectrum at 635nm

• The intensity is 17.5 mW per diode, categorizing the laser as a class IIIb.

• The device emits a patented line-generated beam, which allows the Zerona to deliver a high concentration of photons across a large surface area.

Low-level laser therapy

• Low-level laser therapy (LLLT) continues to gain more and more acceptance as a viable application for myriad neurologic, dental, ophthalmic, dermatologic disorders, and injuries.

• LLLT operates under the scientific principle of photochemistry, and does not employ a photoacoustic or photothermal mechanism.

• For the physician and the patient, the beneficial clinical outcome is produced without any adverse event.

Photochemistry• Common logic is that laser’s must provoke a thermal event in order

to produce the clinical outcome. – Not the case with LLLT

• Photochemistry is the modulation of biochemical reactions via the absorption of photons.

• Similar to a drug-cell interaction, laser therapy targets photo-accepting receptors, which upon stimulation, induces an intra-cellular biological cascade.

• The wealth of studies have revealed LLLT’s ability to:– to preserve membrane and genetic material of cells that are

nutritionally starved

– regenerate erythrocytes enhancing their oxyphoric function – stimulate the differentiation of satellite stem cells– reduce extent of myocardial infarctions and ischemic strokes– accelerate wound healing – modulate chronic inflammation .

Photochemistry• The primary target of laser therapy is the photo-

acceptor molecule housed within the mitochondria. • The stimulation of this receptor upregulates the

production of Adenosine Triphosphate (ATP) and Reactive Oxygen Species (ROS).

• ATP serves as a catalyst for a wide-assortment of biochemical reactions

• ROS modulates the intra-cellular redox state which regulates transcription factor activation and gene expression.

• Laser therapy is a non-invasive approach to provoke a biological response many major pharmaceutical companies attempt alter.

The Scientific Foundation of Zerona

Dr. Rodrigo Neira utilizing scanning electron microscopy (SEM) and transmission electron microscopy (TEM) evaluated the morphological alterations of adipocytes subsequent to LLLT. Moreover, Dr. Neira used MRI to assess the depth penetration capabilities of low-level laser.

Dr. Susan Lim employed basic adipocyte staining techniques and SEM and TEM imagery in order to duplicate the work of Dr. Neira.

Dr. Arturo Ramirez analyzed optical transmission of adipocytes following LLLT to observe morphological changes within the fat cell.

Histology Dr. Neira revealed the formation of an aperture or transitory power in the

membrane of the fat storing cell (adipocytes) following laser irradiation at 635nm.

Figure 6 – TEM picture. Shows the cell membrane at 60000X magnification. After 6 minutes of laser exposure, the membrane is temporarily disrupted creating a transitory pore (see single arrow) that allows the liquefied fat to come out of the cell and be released into the interstitial space. Double arrow points out the fat particles released from inside the cell.

Alteration of the Bilipid Membrane

Copyright 2008 Erchonia Medical

SEM – Deep 2 Min.-

Transitory Pore

The formation of the transitory pore provides a means for the stored fatty material to seep out of the cell and into extracellular space.

Transformation of adipocytes

• SEM and TEM reveal the transformation from a voluminous state to a collapsed state.

Transformation of adipocytes (cont’d)

• More images reveal the collapse of adipocyte arrangements subsequent to laser irradiation.

Copyright 2008 Erchonia Medical

a c0 Minute 1 Minute 6 Minutes

12 Minutes 18 Minutes

CONVENTIONAL - SEM

Susan Lim

Dr. Arturo Ramirez

Control (top), Series results (right)

Two sets of

test/control images

MRI imaging (T1 and T2 sequences)

Does light penetrate that far?

• The physical penetration of photons cannot exceed 1 or 2 cm.

• The observable emulsification extending 5 cm into the subcutaneous fat is attributed to the systemic effect associated with LLLT.

• Multiple studies have identified that non-irradiated adjacent cells undergo the same photo-induced changes based on the upregulation of intercellular communicators.

• Laser therapy has been shown to promote a paracrine effect, similar to histamine in the sense that intercellular communicators are released (i.e. nitric oxide and chemokines), influencing non-irradiated cells.

• A study has shown that when adipose tissue located on the right side of the body is treated by ZERONA LLLT, the adipose tissue of the left side of the body endures fat emulsification

•Jackson, R., Roche, G., Butterwick, K.J., Dedo, D.D. and Slattery, K., Low-level Laser-assisted liposuction: A 2004 clinical trial of its effectiveness for enhancing ease of l

iposuction procedures and facilitating the recovery process for patients undergoing thigh, hip, and stomach contouring. AM. J. Cosmet. Surg. 2004:21(4);191-8.

•Schindl, A., Heinze, G., Schindl, M., Pernerstorfer-Schon, H. and Schindl, L. Systemic effects of low-intensity laser irradiation on skin microcirculation in patients with diabetic microangiopathy. Microvascular Research. 2002;64:240-46.

• Dr. Barnes will discuss a slimming effect in areas that are not directly treated by laser therapy, this is a direct result of the paracrine effect promoted by laser therapy.

ZERONA LLLT Systemic effect

Proposed Mechanisms• 1.) Lipid Peroxidation

– Because of electron excitation within the ETC a greater amount of ATP and ROS are produced.

– ROS are highly reactive, and in some instances begin reacting with membrane-bound cholesterol molecules.

– The breakdown of cholesterol within the membrane weakens its structural integrity and may induce the formation of a pore.

Building upon the foundation

• The histological evidence warranted a placebo-conrtolled, double-blind, randomized, multi site clinical study.

• Sixty-seven subjects were enrolled– 35 test participants – 32 control participants

• Patient’s waist, hip, and thighs were treated simultaneously. • Patients were treated consecutively for two weeks, every-

other-day (MWF), for a total of 6 treatments. • No other modalities were embrace, patients were unable to

make any positive changes to their diet and exercise habits.

Success Criteria

• Individual subject success criteria was defined as at least 3.0 inch reduction in combined circumference measurements for the waist, hip and bilateral thighs from baseline to after completion of the two-week study procedure administration protocol phase.

• The overall study success criterion, established by the Food and Drug Administration (FDA), was defined as at least a 35% difference between treatment groups, comparing the proportion of individual successes in each group.

Results: Total Reduction

Test Group (n=35)

Placebo Group (n=32)

Mean reduction in total circumference (in.)

-3.521 -0.684

Mean change in total combined circumference measurements from baseline to endpoint for treatment groups (n=67)

Comparison of the two independent group means for the continuous variable of mean change in total combined circumference (total number of inches) from study baseline to endpoint demonstrated a mean difference of -2.837 . The difference was found to be statistically significant (t = -7.30; df = 65; p<0.0001).

Results: Meeting Success Criteria

Test Subjects (n=35)

Placebo Subjects (n=32)

Number of participants meeting success criteria

22 2

% meeting success criteria

62.86% 6.25%

The total number and percentage of treatment group participants meeting the individual success criteria (n=67)

This outcome exceeded the pre-established target of 35% difference between treatment groups by 22%.

Once liberated, where does the fat go?

• The fat leaves the cell and enters into the extracellular space.

• The fatty material is absorbed by the lymphatic system, transported via afferent lymph vessels to lymph nodes, where triglycerides are broken down via lipases (Lysosomal Acid Lipase), and finally transported to the circulatory system where the debris can be processed by the liver (fatty acid oxidation).

• Overall, the body has a natural system in place to transport and degrade triglycerides without inducing an adverse outcome.

Safety Parameters • It is absolutely imperative that any non-invasive device claiming to

remove fat or slim the body provide serum cholesterol and triglyceride data.

• To ensure that patients were not going to experience an elevation in triglyceride and total cholesterol levels subsequent Zerona, a 19 patient pilot trial was performed assessing pre-procedure and post procedure lipid panels.

• No patients experienced an unsafe elevation in both total cholesterol and triglyceride levels; in fact, 85% of patients demonstrated a decrease in cholesterol levels in just two weeks.

• This data has inspired Erchonia to pursue a clinical trial assessing laser therapy’s ability to serve as an alternative modality to lower cholesterol.

• For Zerona, these results place the device in its own category. A slimming device that is more than just a cosmetic tool.

Positive effects on Body• Eighty-four percent of study participants demonstrated an overall reduction in

cholesterol serum levels. The reduction ranged from -1.0 to -32.0 mg/dL with an average reduction of -17.6 points. Seventy-four percent of participants revealed a reduction in low-density-lipoprotein (LDL) levels while 58.0% of participants either maintained or demonstrated an increase in high-density-lipoprotein levels. Of the 19 participants, 58.0% showed a reduction in serum triglyceride levels with an average reduction of 27.45 mg/dL.

• 22 of 22 patients participating in a separate pilot trial demonstrated a reduction in the adipose-derived hormone Leptin.

• Further, of the 22 participants, the average change in LDL from baseline to study end point was -16.28 points or -15.65%. Based on the FDA Guidance Document which states a change in LDL from baseline to study end point evaluation is considered both statistically significant and clinically meaningful if it is a 15% or greater decrease, our results were clinically meaningful

Patient experiences: The certain vs. the uncertain

ZERONA emulsifies the fat 100% of the time on 100% of the patients; unfortunately, not all patients can successfully mobilize and degrade the fatty debris. – There are contraindications that will prevent the body

from absorbing and processing the emulsified fat• It is yet to be determined, but it is believed that certain

individuals based upon their lymphatic vessel structure are unable to deliver the fat away from the interstitial space in a timely manner.

• For the patient this means minimal results.

Patient Experiences Contraindications for ZERONA® Treatment

Patients with the following conditions should not be treated:– Pregnant or breast-feeding– Liver disease– Kidney disease– Disease of the lymphatic system– Cancer (active or within 1 year of remission) – Use a pacemaker– Currently/Regularly taking anti-inflammatory medication (ex. Corticoid steroids) Conditions that must be monitored; yet, are treatable:

— Cardiovascular disease (i.e. hypertension) — Suffering from metabolic disorders (i.e. hypothyroidism and diabetes)— Use of prescription grade NSAIDS

Other Criteria to Ensure Positive Results:

Female patients should wait at least one week post menstrual cycle to begin ZERONA treatments. ZERONA is less effective during menstruation.

Patients who have undergone liposuction will have varied results due to the presence of potential scar tissue formation and potential damage to lymphatic vessels.

Modalities to assist• It is essential that patients are properly hydrated. The lymphatic

system is an open ended system that requires a proper level of interstitial fluid in order to flush out the fatty debris.

• Moreover, the lymphatic system requires skeletal muscle movement; therefore, patients should embrace a lymphatic stimulation protocol, i.e. basic exercise and compression garments.

• Curva, a supplement formulated specifically for Zerona helps enhance the body’s natural pathways used to transport and breakdown the fat. – 200mg Niacin– 200mg Green Tea Extract– 100 mg L-carnitine– 60 mg Ginkgo Biloba – 880 mg of Omega 3 and Omega 6 fatty acids

The Zerona

• It is becoming clear that more and more patients are seeking cosmetic procedures that are non-invasive, safe, quick, and effective.

• The Zerona is the only clinical proven non-invasive device that can promise the reduction of inches in just two weeks!

• The question regarding Zerona is not what side-effects are there; but, what more can this device do for me besides promoting a slimming effect?

Thank you!

• Question?