Medical Laser Blog - Fotona Straight Talk for the Physician

Back To School Aesthetic Laser Treatments

Here we are…it’s back to school. Our patients are super busy. Probably your aesthetic procedures are down a little bit because everyone is trying to get their kids ready to go back to school. But remember this….as soon as the kids are settled in school, parents will have a little more free time. Now is the time to remind people that they hated their spider veins all summer and they wanted to get them treated. It’s time to remind them that hair removal is easy to accomplish over the winter so that next spring they can wear their shorts with confidence and it’s time to remind your patients that all of the procedures they’ve been putting off because of summer – well, it’s now time to get them!

Whether it is a medium depth peel of their face or hair removal and spider vein treatments, or simply non-invasive skin tightening, now is the time to start thinking about incentive programs to get your patients re-thinking about their winter time treatments…because unfortunately, out of sight out of mind. All summer, people are wishing they didn’t have those spider veins or the hair on that certain part of their body and now they’re not thinking about it as they go back to wearing long pants, etc. So YOU need to remind them that now is the time to get these treatments. Or maybe you need to look even further ahead into the future and encourage your patients to consider gift certificates, as Christmas gifts for loved ones.

The key to sustaining your aesthetic clinic through the quieter times? Stay focused on thinking ahead.  Human nature has people wanting things, but they only remember them when they need them….and sometimes when they need them they don’t want to get them because it causes an interruption in their routine for summer, etc.

Fotona’s New XS Dynamis

Soon to be released, the Fotona XS Dynamis is the most comprehensive skin resurfacing workstation available on the planet  - period.  The XS Dynamis takes everything that the previous XS Dualis had and puts it on steroids!

This laser can do cold ablation, warm ablation, hot ablation and heat only treatments in both full-resurfacing mode and fractional mode.  In addition, it has something called Turbo Mode.  Turbo Mode allows for stacking pulses, both in the standard and fractional modes.  It will also be available with two scanners.  One will be a full resurfacing scanner and the other a fractional scanner.  

One of the interesting things about the fractional scanner is a mode called “random mode.”   The combination of using turbo mode in cold ablation plus random mode on the scanner allows you to do very interesting things.  If you happen to be a hair transplant surgeon, you can drill holes in the scalp for placing the harvested hair follicles.  Now the nice thing is that because it’s not a perfect pattern, but random, it looks much more natural.  The other noteworthy item is that while a hair follicle is round, a typical hair transplantation will use a needle to make these holes, which actually becomes a slit in the skin.  With the laser drilling a hole, the hair follicle fits better.  And because you use cold ablation you actually get bleeding, which is important for the graft to “take.”  Add this to the list as another unique, interesting advantage of the Fotona technology.  

In addition, you will be able to do variable smooth mode.  In other words, you can choose the depth of penetration of heat by the number of stacked pulses.  So – you can use long pulses, which are hot pulses, at sub-ablative settings and stack them in order to cause deep penetrating heat – resulting in phenomenal skin tightening.

Now, according to the FDA, there is no such thing as skin tightening, but our Fotona photographs are unbelievable.  People who you would swear had a tummy tuck, but instead just had a non-invasive laser treatment, have great before/after photos of the abdomen.  People have as much as a centimeter lift in their breast by doing full upper-chest skin tightening procedures.  

There are so many things that this machine can do.  And the great thing is that it uses the Fotona interface, which is intuitive, user-friendly and easy.  You don’t have to become a computer programmer to figure out how to use this thing…you just have to know what you want to do and then tell the machine to do it.  

Easy to learn.  Easy to set up.  Unbelievable results.  That’s Fotona.

Collagen Stimulation Decreases Snoring!

Snoring is generally caused by vibration of the posterior soft pallet – resulting in a whole bunch of noise!  I can tell you that I know something about snoring because my mother snored like a freight train when I was growing up and it could literally wake you up on another floor of the house!  

Snoring can be a gigantic deal for couples because the snoring issue will actually lead to them sleeping in separate rooms.  Snoring is also associated with sleep apnea and sleep apnea is associated with other significant health problems, including an excess risk for heart disease, etc.  

The Fotona Laser has been used, in several studies around the world, to reduce snoring.  Accomplished with a fractional hand piece, this erbium treatment is designed to tighten the tissue of the posterior soft pallet resulting in better airflow across the soft pallet, less vibration and less snoring.  It’s simple, non-invasive and almost painless.  It’s an easy treatment to provide and dramatically improves the quality of life, if not for the snorer, then certainly for the snorer’s spouse.  

Fotona continues to research and find ways to improve the lives of its patients…and this time the snorer is helped through the application of collagen stimulation/production, which results in a tightening of the soft pallet and an improvement in snoring.

Are You Qualified to Run or Supervise a Medical Laser?

I’m gonna bet that you did pretty well in high school.  Then you went to college – learned the material set in front of you and got good grades.  Then you went to Medical school.  Only people with really good grades get into medical school and you were there, learning and competing with a bunch of really smart people – and you survived.  Now you’re a medical doctor and you went to some kind of specialty training (probably) and in that training, you learned more material.  

I don’t think anyone could question your ability to learn, but what about your general reasoning capacity?  Well, you’re a doctor.  You have to collect data, synthesize it, formulate a problem list, a differential diagnosis and proceed to a firm diagnosis.  This is your daily routine.   Your daily routine is problem solving and sleuthing.  There is no reason to question your ability to problem solve and critically reason.  

So what about other specialties?  Is anyone really getting laser training? Well recently – yes.  But as little as just a few years ago there was no-one learning about lasers in their primary training.  And now, most of the training people get on lasers is in its use as a cutting tool (using a CO2 as a scalpel during laparoscopic surgery for example).    It’s not as if some other specialty has a giant let up on you.   They don’t.

So what would be required for you to be competent to run or supervise the running of a medical laser?  The proper training.   You need to understand the machine.  You need to understand how it could be dangerous. The scalpel is a very dangerous tool.  The difference is that you have to be in direct contact with someone with the scalpel.  With the laser, if you haphazardly point it, you could injure someone from a distance.  And believe it or not, the more dangerous lasers are the ones that aren’t ablative (in general).    So – there are some tricks you need to know, but they’re easily learned.  Basic safety can also be easily learned and then you need to learn the applications -also easily learned and far less complex than most other areas of medicine and those areas that you already work in now.  

To become a competent laser operator or supervisor requires mastery of a fairly small domain of topics.  Once you’re a competent laser operator, you need to simply follow the protocols.  If you follow the protocols, it is possible to get expert outcomes simply by being a competent laser operator or supervisor.  

To become a true laser expert, you need experience.  And experience comes from time operating and supervising the treatments.  

If you want to get expert outcomes right away, simply select your patients properly (which is easily trained and learned), and apply the protocols properly - over and over and over…. until it’s second nature and until you can begin to refine and hone and customize.  

It’s not hard.  The skill-set is relatively simple.  The parameters are finite.  The rewards are great!

Aesthetic Laser Medicine: Is it the shot in the arm your practice needs?

I was looking at this month's issue of Medical Economics and the entire issue was dedicated to bringing more joy to your practice. Well, I must tell you that aesthetic laser medicine has brought a lot of joy to MY practice. Not just for me – but for my patients. It has freed up my time, it’s freed up intellectual curiosity (I’m able to learn new things and apply them) and frankly, it’s nice to see a patient come in and do something because they want to do it and are excited to do it and not just there because they have to do it and they don’t want to do it!

The biggest challenge I have in sorting out my practice comes from my diabetic patients who are more interested in getting their aesthetic procedures done than they are in refilling their diabetic supplies. I have a few heart-to-hearts with my diabetics and tell them we’re not going to treat their aesthetic issues if their diabetes is not under good control.

That’s the difference between “want to do it” and “have to do it.” There might be a complaint about a co-pay to see me for diabetes, yet the same patient will gladly drop multiple $100 dollar bills on the table to have their aesthetic work done.

So as you’re thinking about our patients and realizing that they’re all complaining about their co-pays (because yes, that’s something they have to do – not want to do) – know that what your patients want is to feel good and look younger. In my case, I can do that by treating their diabetes so they have good control and help them to look younger by having an aesthetic practice.

They shot in the arm I asked about? This comes in the greater sense of pleasure within the practice of medicine.  It comes in a better bottom line which means you don’t have to fight quite as often or quite as hard with the insurance companies over trivial rules they have about whether or not you can use this drug or that drug, etc.

In other words – an aesthetic medicine practice gives you some freedom. Freedom = choices. Choices often lead to happiness.

Safe Laser Hair Removal for Dark Skin Types

We have a large collection of laser hair removal photographs.   I have them on light skin, on dark skin types, on many skin types.  I have recently seen pictures showing skin injury, posted by people warning of the dangers of laser hair removal on darker skin types.  Unfortunately, it’s gotten to the point where laser hair removal is almost thought of as a commodity, so poor treatment outcomes arise from people going to the cheapest place rather than the best place for their treatments.  

Laser hair removal, when done wrong – just like plumbing, when done wrong – can be extremely expensive.  When done right, it can be a tremendous value.  Choosing the right people and the right equipment sounds like a great plan…but how does the average person really figure that out?

There are some concrete ideas, one of which is that generally you don’t want to use a laser whose primary chromophore is melanin.  The reason is that while there is indeed melanin in the hair follicle, there is melanin in the skin as well.  In the picture I saw, the person with Fitzpatrick Type 5 skin clearly had a lot of melanin in his skin and the laser used was almost certainly a shorter wavelength laser such as a diode or alexandrite.   These are primarily melanin-driven lasers.  If the operator would have used a longer wavelength laser, such as Nd:YAG,  with appropriate pulse duration and power settings, it is almost assured that a very good result could have been achieved with little or no side-effect.

The concrete advise is also a bit complicated.  I just finished saying that if you have darker skin you should use a longer wavelength laser such as Nd:YAG, but not all Nd:YAG’s are created equal, just as all pepperoni pizza’s are created equal. One pepperoni pizza you might love and find to be your favorite and the next you hate because of the other ingredients and so on.  It’s the same with lasers.  

So what is a person to do?  A common problem will be this:  You go to a website for a laser clinic and let’s say, for example, that you find out that the laser operator is using brand “x” laser.  Then you go to the brand “x” website and you often will find that it’s very difficult to find out what wavelength they’re using because they sell more sizzle than they do science.   If you go to a real, science-based company what you find is that they will very frequently have all of the scientific data on their website and that will result in a deeper understanding of the wavelengths they’re using and the capabilities they have.  

A website such as www.fotona.com will have a deep amount of scientific information so that you can make good decisions.  If patients started to demand that kind of information I think we could change the industry from this sort of over-sold and under-delivered, hyper-marketing driven entity to a more appropriate medicine and science-based industry.  

I would encourage everyone interested in laser treatments to be very discerning and demand science from their laser operators and the companies that provide them their equipment.  As an example, here is a link to a whitepaper on laser hair removal.  It’s a bit scientific, but it gives you a deep understanding of what you’re trying to achieve. 

Fotona Lasers are the Bentley of Lasers

The other day I was talking to a physician who was thinking about starting an aesthetic practice.  He was really concerned because he hadn’t seen a lot of glossy ads for Fotona Lasers in the medical media.  I asked him, “How many Ford commercials have you seen on television?”  He responded, “Oh – well they’re on all the time!”  He’s right.  "And how many Chevrolet commercials do you see on TV?"  Again, he said, “Oh wow, all the time.”  Finally I asked him about luxury brands like Mercedes Benz and he acknowledged that he doesn’t see them as often as Ford or Chevrolet. Then we talked about a Bentley.  When was the last time someone saw an ad for Bentley on television?  After considering this he said “Well, come to think of it, I’ve never seen a Bentley commercial on TV – same with Ferrari.”

Commodities are what we see on television.  Commodities are a Ford, a Chevrolet or even, in this day and age, a Mercedes Benz.  A value product is the top of the top of the line.  That’s a Ferrari or a Bentley.  

Fotona Lasers are the Bentley of lasers.  There is a qualitative difference.  If you pick up any other laser and put the hand piece in your hand, you’ll find that it’s made of plastic.  A Fotona hand piece is generally made out of titanium, unless it is one of our complex, computer-controlled scanners that require a different kind of shaping ability, in which case it’s going to made out of a polymer.

If you’re wondering why you don’t see ads for Fotona, it’s simply because it’s reputation proceeds itself.  Now, if you’re not deep into lasers, you may never have even heard of Fotona, just like if you’re not deep into luxury cars you may never have heard of a Ferrari or a Bentley.    Those people who are into lasers, while they may not even own one (yet), they certainly know about Fotona and they will say very good things about it.  

The reason someone may not own a Fotona is because they bought a commodity.  They bought a commodity because they didn’t know any better until they got into it.  Once they got into it, they will all agree…Fotona has far fewer technical issues, has a longer work life, has more applications, and has better outcomes.  

We’ve shown these better outcomes time and time again.  We take our before/after pictures on the road all the time – all over the world.  Whether they show the results of laser hair removal, laser vein removal, cystic acne or folliculitis treatments, skin rejuvenation or any other procedure, we’ve been accused of re-touching our photographs many, many times because we get results that nobody else gets.  Now this is NOT because we’re such stupendous laser operators! This is because we have the best made, highest performance laser in the world – period.  This is Fotona Lasers.

Can A Medical Laser 'Recession-Proof' Your Office?

Well, the truth is, nothing can recession-proof your office, but it can diversify and stratify your income stream.

You need to think about your income in the same way that a good financial advisor would teach you about your investments. In difficult economic times, most experts would agree that the best defense is diversification. So you have stocks and bonds and real estate and precious metals…but in your office you have third-party payers – and that is all. And the third-party payers are getting more aggressive. They are decreasing reimbursement and increasing the hassle-factor of getting that reimbursement. In fact, a portion of the strategy is simply to deny and a certain percentage of physicians won’t fight the claim and therefore that’s less that have to pay out. Increasing the hassle factor for getting reimbursement is actually part of their economic strategy.

The truth is, insurance companies often live on the float. What that means is that every day that they keep the money they owe you, they earn interest on it and that interest (to a large bank account) can add up to substantial sums of money. Insurance companies are really investment companies. They take the premiums and they invest them.

So we need to take on similar strategies. We need to diversify our income strategy just like we diversify our personal investment strategies and the way insurance companies diversify their strategy. A laser can help you with that because a laser creates a pure, cash income stream – totally separate from your third party payers!

Now, how does this become a recession hedge? If you look at the statistics on any aesthetic medicine downturn during the recent financial difficulties, you’ll see that it was large cosmetic procedures like face lifts, breast augmentation and major body contouring that really went to near zero. In our office, the laser hair removal, laser spider vein treatments stayed reasonably constant. Ok – it took a bit of a dip, but nothing like liposuction or breast augmentation and those kinds of procedures.

Why would this be? Well, these procedures are in the domain of reasonable discretionary spending. They cost a few hundred dollars, but not several thousands of dollars. So an individual who has active acne and wants it treated is significantly motivated. A person with a lot of spider veins on their legs or face also has a significant motivator to getting them treated. Somebody who is maybe even fearful for their job and continuously wanting to place their best foot forward wants to treat themselves so they can compete in today’s youth-oriented job market.

There are many reasons why people will continue to pay for the relatively lower cost laser treatments during an economic downtime. Throughout 2009 and into 2010, the laser portion of our aesthetic office has remained busy. And I want to remind you that our office is in a small, mid-Minnesota, agricultural community, so it’s not like we are somehow on Rodeo Drive or in Scottsdale, AZ or Manhattan. We are in a small community. I’ve always felt that if our laser practice can survive and thrive, we have to be the worst-case scenario.

Diversification is the key to weathering any economic situation. If you are fully dependant upon the whims of insurance companies for your income, you ought to think about diversification. It can de-stress your practice, it can increase the “happy” quotient and it can make your financial world better.

Who Can Operate a Medical Laser?

We get calls all the time from doctors across the country wondering if  they are qualified to operate a laser.  Some of them have suggested that they might need to go back to residency to become a dermatologist or plastic surgeon or something like that.  

The truth is, that until very recently, nobody learned how to use lasers in residency and all of the current “guru’s” learned to use lasers after their training.  Some residencies now include some laser training, but by-and-large, most aesthetic laser training is still done outside of residencies.   

It’s like anything else in medicine:  we get this strange idea that after residency you’re just suddenly unable to learn anything, when the truth is that learning is a lifelong event.  In fact, your medical acumen and just plain clinical smarts are far greater today than they were when you were a resident.  You know already what an injury to the skin will look like, you know what the layers of the skin are, you know how to assess for injury…..you know a lot more than you think you know about the skin.  And by compiling it properly, you can quite rapidly become a competent laser operator and a very competent laser supervisor for your anxillary staff that may be doing some of the non-invasive laser therapies.  

So don’t be intimidated by laser medicine.  A laser is just a tool.  It is far safer than a scalpel and far safer than most of the drugs you already use.  The only mystery comes in that you don’t know about it yet.  BUT – we have highly focused, very comprehensive training programs to get people up to speed and competent very rapidly.  

Now, I’m using the word “competent” on purpose because competent means that you are safe, and that you can do the job.  It doesn’t mean you are a laser expert.  To cultivate being a laser expert requires time behind the machine.  Many studies are done on being an expert and really, being an expert requires doing – not just reading.  

So, once you have your laser, you start “doing” and as you gain experience, you become more and more expert.  But competency is something that can be learned very, very rapidly – depending, of course, on the type of procedure(s) that you plan to do.  It can be achieved in as little as an hour or in as much as a day or two of training or whatever you need.  

The answer to the question “What do you need to be a competent laser operator?” is "the proper training in safety and applications.  With time and experience you will become more and more expert."  Don’t be intimidated –it’s pretty straight forward.

Maximizing the Aesthetic Laser Patient's Outcome (part II)

Absolute honesty is always the best policy and consulting in such a way that helps your patient to completely understand the risks and benefits, to understand what can and can’t be done and also to understand how to optimally treat their specific concern.   These are the things that you want to include in a consult.  

A lot of doctors are afraid of scaring their patients.  Yet every single one of my consults includes this phrase:  “There is the possibility of complications that could lead to disability, disfigurement or even death.”  Now, I want my patient to hear that phrase because I want them to think about risk. Risk isn’t something that we spend much time thinking about, but it’s something we’re involved in every day, all day.  Waterskiing, jumping out of an airplane, or simply choosing to drive our car – those all hold varying degrees of risk.  Sometimes my patients will say, “Well, I don’t want to take any risk” and my response to that is, “well, it’s time to go home, lock your doors and for certain, don’t go into the bathroom, which is where most home accidents happen.”  You can’t have a risk free existence.  So making these fairly aggressive statements about disability, disfigurement and death allows the patient to think about risk in perhaps a way they never have before and that way, I also tell people that the risk of something bad happening is very small, but if it happens to you, it is 100%.  

Patients need to think about this.  If they get a white spot on my face due to laser hair removal,  it is the end of the world, or would the patient rather just camouflage it with make-up than have all this unwanted hair growth? 

You need to help your patients understand what they don’t know.  That’s why when we train physicians to do laser procedures, quite frankly, the physical part is pretty easy.  It’s the preparation that’s more difficult.  We spend ½ a training day on bookwork helping the laser owner to understand the in’s and out’s of the Fotona Laser physics, the fine points of consulting the patient, and significant time is spent helping them get facile with the hand/eye coordination of actually doing the laser procedure.  This combination has been very successful for the people who’ve worked with us and they’ve since had excellent clinical experience.