Medical Laser Blog - Fotona Straight Talk for the Physician

When is a Fractional Laser Treatment NOT Fractional?

As you probably know, fractional resurfacing is all the rage.  The idea behind a fractional laser treatment is that you make small, discreet and non-confluent injuries to the skin.  The uninjured skin around the sight of injury then accelerates the healing process, providing for a faster recovery time.  Typically, a fractional resurfacing will cover somewhere between 5 and 25% of the skin’s surface, per pass.  The original idea was that you would do one pass, allow things to heal, and then come back and do further treatments at a later time - generally at 4-6 wk intervals in order to give the initial treatment time to heal.

More and more we’re hearing about “multiple pass” fractional resurfacing.  As an easy example, if you’re covering 20% of the skin on a single pass, when you do three to five passes you are now covering 60-100% of the skin, making it no longer a fractional resurfacing.

So, many physicians are being fooled into believing that they’re giving a fractional resurfacing when they’re actually doing multiple, multiple passes.  Are they getting good results?  They are. But are they also getting the long down times?  They are indeed.

So be careful about the claims surrounding fractional and understand the concepts behind it.  One or two passes is probably still fractional, but three, four, five, six passes is no longer fractional – it’s just resurfacing.

Collagen - The Protein of Youth and FRAC3®

It is collagen that keeps our skin tight and looking young.  We have potions and lotions with collagen in them that purport to increase collagen in your skin.  We even inject collagen to plump up our lips or to fill wrinkles.  The best collagen is your collagen.  Collagen is one of the proteins we make in response to injury.  That is the basis for most peels (chemical or laser) and for most non-ablative therapies to improve the texture and appearance of the skin.

Most of these therapies are bulk heating.  This would include IPL, ultrasound and most lasers.  Fotona has once again revolutionized the industry and collagen stimulation laser treatments with FRAC3®.

FRAC3® is a completely different technique.  It is the technique of delivering the laser beam with very high energy but very short bursts.  It results in a sub-surface, auto-selective process that targets skin imperfections within the collagen-producing layer of the skin.  The advantage here is that you are not causing wide area injury.  You are not causing injury to the more normal skin, but rather you are targeting the imperfections in the skin.  These imperfections are heated, resulting in the stimulation of collagen growth.  Collagen growth right where you need it…at the imperfections.

We have been using FRAC3® in much the same way you should be using a fitness center.  You don’t expect to get in shape in just one visit to the gym, nor should you expect your collagen to be built up in just one treatment.  FRAC3® will build your collagen over time and with no sign of treatment.  So it is the ideal “no down-time treatment” and a great maintenance treatment after more invasive therapies.

This link shows a woman who was in for laser hair removal.  We also noted texture and pigment changes.  We treated her with hair reduction settings and FRAC3® with the same Nd:YAG laser.  Note how the pigment, texture and hair have improved.
http://www.fotonamedicallasers.com/hair-rem-b-a02/

Medical Lasers For Treating Infection. Targeted and Successful!

We have had several interesting experiences with infection.  Our early experience was in treating acne.  We had great results with acne.  In fact, our results with acne treatments are staggering.  Next, we had several patients that complained of recurrent boils.  We would scan them with the Nd:YAG laser and get complete resolution despite the failure of several I&D and antibiotics.  We then had a family friend who had CABG surgery and his Saphinous vein harvest site wound would not heal.  He was several months post op and several antibiotic and debridements into it when we first saw him.  After a few scans the wounds healed up just fine.  Later we started hearing about treating onychomycosis with the laser.  We started treating it and found great results.

How can this be?  Good question! The R&D department at Fotona looked into it and found that firing the laser at bacteria or fungus had no effect on them so it is not a direct toxic effect to the infection.  What we have found rather, is that areas of infection are inflamed.  Inflammation results in more blood supply and congestion.  This blood is a good local target for the laser.  The laser heats the blood and has several effects.  One is to kill the bacteria by heat alone, another is to release immune modulating chemicals from the injured blood vessels.  This results in a reduction in the infection by heat and an increase of the immune response locally.  

So if you are treating a patient with an infection and scan over an area you will get intermittent reactions from them.  They will be quiet and comfortable if you are over an area of no infection and no inflammation.  When you move over the active infection you will get a “felt that one” response.  Laser therapy for infection is self-selective and targeted.

Contact us to find out more!

Wave the Magic Wand - Or Use a Computer-Controlled Scanner For Laser Hair Removal?

Most laser hair removal systems require the work to be done by hand.  That is to say, the operator simply does his/her best to cover the whole area.  I have even had laser operators tell me they prefer the hand method because they can get it done faster!  But the speed at which you can do laser hair removal is a function of your spot size, the area to be covered, the repetition rate of your laser and the tolerance of your patient.  So, with modern high-powered lasers the speed is really limited by the tolerance of the patient. 

Some medical laser equipment companies address the speed issue with a bigger spot size.  They then make claims about small spots not being effective.  The problem is that big spots hurt, and this limits speed.  So you need to find a balance between clinical efficacy, discomfort and speed.  That is where the Fotona Laser S-11 scanner comes into play.  The scanner will reproducibly lay down a pattern of spots that have been shown to be big enough to do the job yet small enough to be comfortable.  In fact, many of our patients will fall asleep while doing larger hair removal areas… I’ll bet you won’t see that with an IPL, or a big spot size!

Many hair removal centers will tell patients they should be treated every 2 weeks.  This is not because they get better results - it is because they are missing hair follicles when treating by hand.  With the Fotona S-11 scanner we can treat the entire area with no gaps or missed spots.  We treat every 6 to 8 week and get great results.

Onychomychosis - Not Exactly Sexy, But Another Good Reason to Have a Medical Laser

But… it is a common problem that people are interested in treating.  The options for the most part are not so great:  take a med for about 3 to 6 months that has a significant toxicity.  In addition, the cure rate at 3 to 6 mo. is about 29%.  If you continue treatment for about a year, the cure rate is about 68%.

In comparison, with several hundred fungal nail treatments documented, our cure rate to date is greater than 90%.  This is without drugs and without serious toxicity.  We use laser.  With our computer-controlled scanner, we scan the nail and the surrounding tissue.  For about a 30% cure rate you could treat just one time.  We choose the 90+% cure rate (to date it is 100% in published papers) so we treat 4 times over 2 weeks.  The treatment is fast, less than 2 min. per nail, and well worth our time. Onychomychosis - just one more reason to include aesthetic laser equipment / laser medicine in your practice.

How is it done?  We scan the nail with a Nd:YAG laser (1064 nm), 3 passes at moderate fluence.  This is repeated 2 times a week for 2 weeks. Done.  Now just wait for the nail to grow out.  We tell all of our patients that if the nail is not clear when it grows out we will re-treat for free.  We have not needed to do that.  We are in a relatively small town so we only charge about $900.00 for one extremity.  If they have more involvement we may charge more.  Not bad for 10 min work.

How To Prepare For Opening A Medical Laser Aesthetics Practice

I was on the phone this evening with a doc who is interested in opening a medical laser Aesthetics practice.  He is really afraid of the investment and was wondering what to do to hit the floor running.  I recommend what has work for us and for others….

1.  Start talking to your patients today about your plans.  Let them know what you are planning and when you plan to start.  Whether it is laser hair removal, laser vein removal, skin resurfacing, acne or onychomychosis or more, many of your patients will be quite excited.  The really interesting thing is that you will be surprised which patients are the excited ones.  So don’t assume - tell everyone.  At one time, I thought I knew who would buy treatments and who would not.  Boy have I been wrong.  One of our best patients is a 50 year old, never married, never been kissed, farmer.  Go figure.

2.  Next, put a nicely framed (remember this is Aesthetics) poster in your waiting area about what you are doing. You might even find or take a photo of an over 50 friend who is looking good.  Have her dress up nicely - black dress and pearls sort of thing. At the top it should say: “I’m 50 (or 60 or what ever) and loving it.  Austin Laser Skin Clinic.” At the bottom it should say something like “Coming Soon: Austin Laser Skin Clinic.  Featuring Laser Hair Removal, Spider Vein Treatments, Skin Tightening, Collagen Rejuvenation and so much more!”

3.  Get your staff involved.  Keeping this secret will kill you.  Your staff should be able to answer basic questions and if not making an appointment with the interested party, at least starting a list of those interested patients.  If you make a list, select a few for your training day.  Charge them half price and make some money while being trained on your new laser.

If you are willing to follow these few steps you can make money from day one.  From a standing start, in a stand-alone office, with no established patient base, this is how we had over $36,000 in the bank at the end of our 3rd month in business.  That was over 8 years ago and we are still going strong.

Aesthetic Laser Equipment. The $10,000 Consult Tool That Costs Ten Bucks

I use a consult tool for my aesthetic laser patients that I call the $10,000 mirror.  We have a simple hand mirror that has no magnification on one side and 3 to 5 times magnification on the other.  I hand it to the patient with the magnified side facing them.  The interesting thing is that most people, when given the mirror, will start looking very intently at themselves and even start picking and brushing at things on their face. I then have a checklist of items I ask them about.  We go through the checklist, item by item, and discuss its impact on the overall appearance of the face.  Once this is completed, I formulate a plan of all that can be done for them that includes things I can do, but also things others may be able to do. As an example, I do not do face lifts, but if the result they are after is best served by a face-lift I put that on the plan. 

Remember, this is patient-centered not practice-centered.  This will also build trust in your patient, as it is proof to them that you have their best interests at heart (something the bean counters seem to never think about).  In addition, it is rare that we don’t do most of what they will benefit from.  Don’t just accept what the patient thinks they want in aesthetic medicine, but rather help them achieve optimal results by explaining what is achievable.  Send them home with a wish list.  Over time they will work through the list, resulting in a more optimal result for them and a better practice for you.

Measure the Cost of Cosmetic Laser Ownership the Right Way

What is the cost of ownership of a laser system?  Is it the purchase cost? I don’t think so.  Is it the per-patient cost?  That is part of the answer.  What about maintenance costs?  Well you know what, you get what you pay for.  Recently I had an interesting discussion with the owner of a competitive aesthetic clinic in our town.  He said, I am so glad you are in town.  I literally took a step back and said, “Why is that?”  He had at one point said that his intent was to put us out of business.  In addition, at the beginning we had counseled him that the equipment he was looking at was not likely to get the results they claimed.  So these many years later he is glad we are in town why?  “Because,” he said, “we can’t get the results you get, our cost of operation has been much higher than anticipated and I am going to focus on my core business and send the other stuff to you.”  I replied, “let's have lunch because I am sure we have business for you as well.”

The acquisition cost of our lasers is a bit above the average of the high-end machines.  But our per-patient cost is measured in gauze 4X4’s and alcohol preps, not in per-patient treatments heads or disposable hand pieces.  Fotona quality is legendary.  Our team of laser maintenance engineers is self-employed and work on many brands.  Without exception they tell us we have the fewest problems in the field.  Lasers are machines and so naturally will have issues, but Fotona lasers are built to a higher standard.

Aesthetic Laser Medicine Turf, Turf, Turf

In a recent New York Times article, the displeasure of “core cosmetic” specialties with other specialists being involved with Cosmetic and Aesthetic Medicine was voiced (1).  My feelings are summed up by this quote from the same article:

“For their part, some doctors from other fields contend that the latest cosmetic procedures, like facial injections and vein removal, are far less complicated and risky than Caesarean sections or appendectomies and that the fundamentals can be learned in continuing-education classes.”

And they go on to quote Dr Kilanko…

"We are all doctors with the same primary training whose education continues after medical school by learning new techniques," said Kilanko. "I know core physicians don't want non-core physicians like me in it, but dermatologists and plastic surgeons can't own aesthetic medicine by themselves."

You know, I am a residency trained and board certified family doctor.  I did well in med school and was actually courted by the chief of surgery.  But I had a “Marcus Welby” complex.  In the days of my residency, one could still be trained to do surgical procedures.  In my day I have done C-sec, hernias and appy’s.  I now do many Aesthetic procedures.  Throughout my career, my complication rate has been quite low.  Why?  Because I seek out and get the best training I can.  I then carefully select cases that, as far as can be seen, will be straight-forward.  The problem with most new surgeons is that they think they can do it all.  I know I cannot.  As a family doc, I know that I can do many things and yet I need to refer others.  As my experience increases and my exposure to the unforeseen expands, I can do more.  That is how you create an Aesthetic laser practice -one step at a time, get good training, gain experience and as a consequence, increase the complexity of cases you choose to take on.  We offer unparalleled training with the purchase of our lasers.  In addition we offer unlimited, ongoing support.

1) New York Times Article

Why Nd:YAG for Laser Lipolysis?

The 1064 nm Nd:YAG lasers are the most widely used lasers for lipolysis, with the longest clinical record of safety and efficacy. The clinically observed minimal discomfort, exceptional long-term success and short recovery are attributed to this lasers ability to optimally target laser energy into fatty tissue, thereby limiting undesirable side effects.

In addition, the Nd:YAG 1064 nm laser systems have developed significantly since their introduction for laser lipolysis. For example, the latest Fotona XP-2 Focus has a 30W QCW mode power generating capacity, reaching higher procedure speeds and efficiency while operating at a fraction of its maximum capacity. This ensures system durability, essentially lowering running costs. In conjunction with the VSP (Variable Square Pulse) technology, a wide range of selectable pulse durations are now available in Nd:YAG lasers. This provides better procedure control and extreme versatility. The latest Nd:YAG laser devices can be used not only for laser lipolysis but also for endo and exo vascular procedures, FRAC3 skin rejuvenation, acne treatments, hair removal, and other procedures. The high performance and versatility of the latest technology solid crystal Nd:YAG 1064 nm laser systems, combined with their optimal efficacy and safety, make these lasers the medical devices of choice when compared with other wavelength devices for laser lipolysis.  Take a look at our white paper on laser lipolysis for more information.