Medical Laser Blog - Fotona Straight Talk for the Physician

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.

Skin Rejuvenation After Sun Damage

Golfing season is upon us in Minnesota.  For those of you who live in the more southern latitudes, you’re already deep into summer, but for us, we’re just now starting to see some consistently warm temperatures!  

One of the best ways to manage sun-damaged skin is with an erbium laser.  Studies have shown that an erbium laser results in fewer re-occurrences than other therapies and one of the places to find people with a lot of sun damage is at the golf course.

Men with receding hairlines often have a lot of AK’s on the top of their head.  What you might think about doing is going out to the golf course and talking to the manager there about giving away some gift certificates as prizes in their golfing events.  Don’t just make them for the women…make them for the men too.  The men have got lots of sun damage from being outside.  A lot of people take care to wear a long sleeved shirt to protect their arms from burning, yet the backs of their hands are often very aged looking, from age spots, AK’s and the like.  The Fotona erbium laser does a fantastic job of resurfacing the back of the hand.

Don’t forget that it’s very easy to use some Restalyn or some other filler substance, or even harvested fat, and injecting it into the back of the hand to take away that really aged look of skin on skeleton that comes with age.

You can do a really wonderful job of skin rejuvenation of the hands and the skin on the face and the top of the head with a full or fractional treatment with the erbium laser.  So go where the people are – tennis clubs, golf clubs, boating marinas (sailors & boaters are in the sun all the time).  These are people who are interested in being fit and healthy and active and they also want to look as good as they feel.

You can target these groups pretty easily just by offering some gift certificates as prizes.  These kinds of promotions will increase traffic to your clinic, produce happy patients and in turn, give word-of-mouth advertising.  All in all, a good deal for everyone.

Mole Removal – Laser Vs. Excision

Obviously, if you have any concern at all that a mole might be malignant it needs to be excised and sent for pathology.  But, if you’re quite confident that it is a benign mole, it is so much faster to excise it with the laser than it is to excise it with scalpel and then suture it. 

 

Take a look at this video link and see what I mean.  http://www.fotonamedicallasers.com/fibroma-removal-ablation/

Not only do you get faster removal of the mole or fibroma, but also the healing process is much faster AND the scarring is generally much less. 

 

I’d really encourage you to check out this video showing the laser removal of a fibroma – essentially the same technique as with a mole.  Then contact us if you want more information about this technique.

 

http://www.fotonamedicallasers.com/fibroma-removal-ablation/

Non-Invasive, Breast Enhancement Therapy

Another interesting “trick” that we’re able to pull off with our Erbium:YAG laser is breast firming.   It turns out that using a pixilated smooth-mode (in other words, fractional smooth-mode) with our erbium laser, we can treat the chest wall from the clavicle to the costal margin with emphasis on circumferentially treating the breast.  This skin tightening gives a lift to the breast and a firming to the breast that is quite noticeable to patients. 

This laser treatment is typically done at the highest tolerated setting with the smallest pixel size reasonable for the size of area (we usually use the PS02 – our fractional handpiece) and it’s usually done in a series of treatments.  After the first treatment, we have a certain amount of result.  But if we wait 12 weeks and repeat the treatment (we usually do 4 in a year) we find very satisfying results for women who might have that post-baby sag where the upper pole of the breast is a little deflated and the supportive structures of the skin have lost their elastic strength and they have, perhaps, mild ptosis (meaning that the breast is drooping).  We have documented several millimeters of improvement of ptosis – so clearly it’s not going to be a one or two centimeter improvement, like you might experience with a breast pexi or a surgical breast lift, but nonetheless, it’s a significant improvement and women say they now fill out their bra cup better and now have better aesthetic lines in their clothes.

This is a procedure that we do commonly and we find the results to be very pleasing.  It’s also another thing you can add to your laser treatment listing for procedures getting outcomes just shy of surgical results.  So how do we position this?

When I examine a woman who comes in for breast issues, I will give her the entire spectrum of treatment options.  I will tell her what I see as the issue. If it is ptosis and the need for some kind of lift, I try to explain how much lift can be expected from each type of therapy.  Many women will respond that they understand that they likely need a surgical procedure to lift things fully, but that they’re not quite ready for that yet.  They’ll often opt to try laser therapy first to see what kind of result they can get.  And I always remind them that having good elastic, strong tissue for the surgeon to work with is always a benefit.  It’s like giving the artist a good canvas to paint on.  So even if, in the end, the woman decides that “gee, this procedure did help, but it just wasn’t enough” – we have only helped the surgeon’s cause by improving the strength of the tissues he/she will have to work with.  

There you have it: Erbium YAG, Smooth-Mode, Fractional Treatment for Breast Lift.

Laser Scar Revision

Laser scar revision is dramatically helpful to patients with scars that are sometimes a lingering reminder of an unpleasant episode in their life or sometimes just cosmetically unpleasant. Scars come in many shapes and sizes, such as acne scars which sometimes resemble ice-pick wounds or a surgical or cosmetic surgery scar from a wound that didn’t heal ideally, or just a traumatic wound.  Scars can be hyper-pigmented, meaning that they’re dark, or they can be hypo-pigmented. 

Scar revision with laser therapy is really quite satisfying to both the operator and the patient.  There are obviously some scars that are going to be very difficult to treat with any modality – keloid scars as an example.  While I’m occasionally talked into treating a keloid scar, there really isn’t a great therapy for this type of scar in anyone’s hands (I don’t believe).    I’ve done everything from steroid injections into keloid scars, to excision and reapproximation and also ablative laser therapies and the best you can hope for is a “ya win some, ya lose some” approach.  I am therefore very aware to consult the patient carefully and let them know that keloids really aren’t the best candidates for revision.  

Your basic hypertrophic or rough/textured scar however, can be very well treated.  A dark scar we’ll often treat with Nd:YAG to get any hyper-vascular structures coagulated and calmed down (while helping to calm down any inflammatory response), and then we will “plane down” any scars to the surface, using our erbium YAG laser.  Especially with jagged scars, or scars that have irregular contours, planing them down works very nicely with erbium YAG laser, resulting in a very smooth texture.  

A friend of our family had a melanoma on her neck and it was excised and fortunately, found to be a superficial spreading and felt to be completely cured.  She’s been disease free for many years, but she had this rather jagged scar on her neck, which was somewhat unsightly, and after we treated it, first with Nd:YAG to take down any hyper-vascular portion of it and then with Er:YAG to smooth it, it is all but invisible!  It went from a ¼” wide, roughly textured scar to nearly an invisible line on her neck.  These are the types of results we see routinely with our laser scar revision.

And the list keeps on building for the things that you can do with your Fotona Laser. 

Better Laser Skin Resurfacing with the Fotona Erbium YAG

I saw a woman in the clinic the other day who had been treated with an IPL in another clinic for spots on the back of her hands.  Now, an IPL is a broadband light device that has a large spot size.  With the large spot size you’re not targeting specific spots on the hand, but rather you’re targeting all of the tissue and you’re hoping there’s a differential absorption of the IPL energy into the spot, causing the spot to super-heat and then slough off.  Unfortunately, because an IPL is broadband, it has very broad absorption in the skin.  And in the case of this lady, I think they treated her a little hot as well. When I saw her, she had certainly very inflamed-looking, swollen dorsum of the hand.  The pigments had sloughed, but they were showing a lot of erythematous change and eventually she developed post-inflammatory hyper-pigmentation of most of the back of her hand.  

We do laser skin resurfacing and thus treat spots on the hand a little bit differently.  We are able to use our Fotona Erbium YAG laser, which is an ablative laser.  We can use it in a very short pulse mode with moderately high energy so that we’re in a zone of ablation that we call cold ablation.  Basically that means that all of the heat from the ablation is contained within the tissue that is ablated away!  There is then very little heat left in the tissue.  We literally go over the spots like you’d use a pencil eraser and we erase the spots, taking them down layer by layer until they’re gone – not having to go any deeper than necessary.  We’ll typically then do a light skin resurfacing over the rest of the hand to even out the texture of the skin on the back of the hand, and from there, we let it heal.  We rarely, if ever, see post inflammatory hyper-pigmentation.  We don’t see burns or swelling or other side effects, except on the most rare of occasions.  We get great results with hand spots.

Laser Technology For Tissue Absorbtion: High or Low, Good or Bad?

Many companies will tout their laser technology regarding the high absorption of their laser into their target tissues, and depending on the application, this can be a very good thing or a very bad thing.  In the case of ablative procedures, extremely high coefficient of absorption into water is clearly a very good thing.  This is fully explained in Fotona’s white paper on ablative procedures.

The short answer here is that a very high coefficient of absorption into water allows for more versatility in your ablative procedures.  You can use a very short pulse duration with this highly absorbed wavelength and get nearly cold or completely cold ablation.  You could also manipulate the pulse duration using a longer pulse duration to get more coagulation - leaving more heat in the tissue, if that is the desired outcome.  On the other hand, laser lipolysis is an area where you really don’t want a highly absorbed wavelength while doing that procedure.  Some companies tout that their wavelength is highly absorbed in the fat layer.  Well, if that’s the case, if they really have a high absorption coefficient, they’re going to have a small volume of tissue that is highly heated.  Now at first glance, this seems like a good idea, but what this really means is that your footprint with each pass is small, so you’re going to require more and more passes through the fat layer in order to get the desired temperature and “fat melting.”

With an optimal mixture of absorption and diffusion into the tissue, you can get a larger volume of tissue to your target temperature.  And it is the target temperature that you desire.  Not too cold, not too hot.  As Goldilocks would say…  “just right.”  It turns out that for laser lipolysis, a lower coefficient of absorption allows for a larger volume of tissue to be heated through diffusion of heat which results in more efficient melting of the fat for fewer passes and more efficient and a faster laser lipolysis procedure.  

So you need to be cautious when listening to sales pitches from sales guys.  It is not simply a matter of  “does this laser have high absorption or low absorption?” The  question is, “what is the application and what are we trying to accomplish?”  If we’re trying to accomplish the warming or heating of a bulk area, you don’t want high absorption.  On the other hand, if you want ablation, very specifically, and you want to have the latitude to manipulate the amount of heat you’re placing in tissue, then you do want very high absorption.  

The other thing you want is a laser that can be fully manipulated.  Having the opportunity to vary the wavelength is difficult.  There are lasers out there that call themselves “tunable lasers.”  The lasers in the aesthetic market that call themselves tunable are actually a fixed wavelength that are varying their pulse-width… something that Fotona has been doing, not by trying to trick you into thinking it’s a variable wavelength, but my simply telling you that we can vary the pulse duration.

So, rather than going for gimmicks, look for the laser that you have the most authority over and look for the company that has perfected the square pulsing, the flat top optics, the variance of it’s pulse durations and the power that will give you spot sizes and speed.  That’s what you’re looking for…not some magical marketing terms like “tunable!”

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.

Erbium Laser Treatment for Stretch Marks

Stretch marks are actually deep wounds in the skin.  People have tried to treat them with creams and lotions - with little success.  They have been treated with superficial treatments like microdermabration - also with minimal results.  Some have tried more aggressive therapies, like CO2 lasers, but that will often scar in areas other than the face. So what is one to do?

We use a VSP Er:YAG laser.  With it we are able to address all of the issues inherent in stretch marks.  First, we can do a light-to-moderate resurfacing that will help with the pigment and contour issues.  Next, we use fractional SmoothMode - a heat only mode that simulates collagen growth and repair deep in the skin.  Rather than be aggressive, we consult the patient about the physiology and how the stretch marks did not appear overnight and they will not go away overnight.  We do a series of treatments.  We will typically do 3 to 8 treatments spaced at 4 to 8 weeks.  We have seen good results with this (better than we have seen elsewhere).  When at conferences I always walk around looking at the many before and after pictures displayed.  Have you noticed, like I have, that it is not always easy to tell the before from the after?  Our Fotona pictures are clear and remarkable. However, it is important to be very clear when consulting a person with stretch marks.

Stretch marks are a lot like acne scars in that they carry a lot of emotional energy.  If you make the stretch marks 75% better they are still 25% there.  This may not be what the patient was after.  They may have been dreaming of their former bikini days.  So, as with all of Aesthetic medicine, a great consult is imperative.  I often tell women that we can get their stretch marks to a place they can wear a short, untucked shirt for a little skin to show - but not to their prior flawless state.