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.

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.

Fotona Lasers: Like a Carpenter’s Hammer

If you go to Fotona’s website the tag line will be: “Highest Performance, Best Made Lasers in the World.”   Seems like a big statement – but I’m here to tell you that I believe it is absolutely true.  The president of Fotona is a man by the name of Matjaz Lukac, PhD.   He earned his PhD at Berkeley.  As I’m sure many of you know, Berkeley is one of the top schools in the country for almost anything.  Getting a PhD in physics from Berkeley is the equivalent of a medical degree from Harvard or being accepted to the NASA astronaut program.  But it doesn’t stop there.  Fotona has more PhD’s, engineers and technicians in their research and development program than any other laser company –period.  

In addition, they have a very large prototype shop.  Their abilities to manufacture “in- house” range from grinding their own optics, doing their own optical coating, building the laser boxes from sheets of metal, to building all of the electronic assemblies….remember again, this is all in-house.  This means they have total quality control!  For this reason, they are able to build prototypes, tweak the design, optimize the manufacture and then put it into production.

The Fotona optics are such that they easily have the most even beam profile of any manufacturer.  In order to achieve this, they had to reinvent the way certain kinds of laser wavelengths were delivered, and then of course patent those ways of delivery.  In order to optimize the amount of energy delivered, they not only designed lasers that self-calibrate, but that this self calibrating takes place within EACH laser pulse - so that the energy delivered is always the energy you have selected on the energy panel.  

If you’ve ever tried to change the light bulb on your car, you find that when you unscrew and take off the bolt that is holding the lens on, a little folded piece of sheet metal falls off.  Now you’ll likely never find that piece again and you’ll be left with a loose screw holding the light lens on your car.  If you look around on your car, you’ll see all sorts of these flimsy pieces.  You NEVER see anything like that on a Fotona.  You’ll always see a proper screw and a proper bolt.  If the bolt does screw into some sort of chassis assembly, it will be a properly tapped piece.  

The reason why Fotona has this tag line is because they build things the way things should be built.  They don’t take cost-cutting measures on quality.  They build the best product that can be built - with the finest engineering in them.  And when that happens, what you get is a medical laser that is highly efficient in terms of its delivery of energy, ranging from the power supply to the laser cavity itself, to the optics that discharge it.  In addition, you get a product that is robust in terms of its ability to simply do its job AND last a long time.

Fotona lasers are like a carpenter’s hammer…they just plain last.  When you’re looking at other lasers or possibly their websites, you look around and find that they don’t tell you much. They don’t give you the important details about their equipment.  Sometimes it’s even hard to figure out exactly which wavelength their laser is.  If you want to learn about our lasers, go to the Fotona website.  Everything is out there for you to read and understand: all of their technology, all of their wavelengths, why they’ve chosen these wavelengths, etc.  The white papers are there for you to read.  It is simply done right.

Laser Hair Removal Truth: Depth of Penetration Has Nothing To Do With Spot Size!

Let’s get back to basics for a minute.  If you’re doing a full-service medical spa, you'll do laser treatments such as those I do in my clinic: hair removal, all the vascular treatments, all the ancillary Nd:YAG treatments such as onychomycosis and warts and various infected skin lesions, etc.  We do the full compliment of Nd:YAG therapies and in addition we do ablative therapies, we do lipolysis, liposuction, tummy tucks, fat transfer and so-on.  

We do a vast array of therapies in our clinic.  Having said that, 50% of our business is hair removal.  50%!!  Personally I don’t have to spend much time thinking about hair removal because my nurse does all the hair removal treatments, yet it IS 50% of what we do in our clinic because men and women both are coming in every day just to get hair removal.  

It would be wise to think about that and optimize that part of your business.  If your hair removal patients experience pain or are uncomfortable, they’re not going to want to come back, they’re certainly not going to tell their friends about it...and your business will fall off.  

Now, a lot of the word on the street says that if your laser has a scanner, it’s because it’s not a powerful enough laser and it can’t achieve the spot sizes you need.  The companies that are generating this word on the street are the companies that are using 18mm spot sizes with contact cooling to do their hair removal.  

Well, here’s the truth:  depth of penetration has nothing to do with spot size!  It has to do with power.  Fluence is what I’m talking about.  Now, there is some relationship between spot size and depth…there’s always a kernel of truth in almost everything you read…but here’s how it’s actually related:

The moment a laser hits the skin it starts to interact with the tissue and scatter and so the effective fluence becomes less and less the deeper you go.  So if you have a larger spot size, the scatter is such that at the center of the spot, the fluence remains constant at a greater depth.  With that kernel of truth being known, all you have to do with a smaller spot size is to turn your power up a little bit.  

Now, if your machine doesn’t have clean optics and you don’t have a top-hat beam profile, if you already have a hot-center to your beam and you turn the heat up in order to get more depth in a smaller spot size, you’re going to burn people.  And in fact,  we’ve had people call us and ask us for our settings (telling us they had a Fotona Laser, when in fact they didn’t) and then they call us back telling us they’re burning their patients – which is, of course, the point in which they admit they don’t actually own a Fotona laser.  

This is the beauty of the Fotona platform:  What we have ultimately done is to optimize the spot size we use for hair removal.  We typically use a 6mm spot size because it’s an excellent compromise between a large spot size (which actually causes more pain) and too small of a spot size which doesn’t give as efficient depth of penetration.  In order to make the spot size work well and work fast & efficiently, we use a computer controlled scanner.  We’re able to scan the 6mm spot size onto a 42x42mm spot – or any size from one dot all the way up to a full scan pattern – very rapidly.  In fact, faster than any patient can tolerate, so the speed with which we do hair removal is related to tolerance of the patient.  

The beauty of this is once you’ve done a treatment or two and you have already eliminated several of the large targets (ie. more tender targets), you can turn up the speed and go faster and faster.  If you’re willing to spend a little bit more time on the front end and not hurt your patient, you will make up for it with speed on the back end and you will more than make up for it with patients being very happy, very comfortable and very excited to refer their friends.

So back to the basics – that is, Hair Removal.  It’s likely 50% of your business and you might not even know it.

The Magic is in Real Medical Lasers With Real Results

Have you noticed how much magical thinking there is in the world today?  In the vendor area of both AAD and ASLMS this year, we saw gizmos and contraptions that are presumably painless, leave no sign of treatment, and just make you look fabulous!  Whether it’s the red laser gizmo that just melts away your fat while you just lay there, or some other similar technology – it seems we’re surrounded by magic.  

Well, I don’t believe in magic.  I looked very carefully at these devices and you know what?  If you shine these devices on somebody’s belly AND then you do laser lipolysis, they DO look great afterwards.  And these are exactly the pictures they’re showing you.  

You’ve got to be careful when you’re looking at the latest fad gizmo.  The truth is:  physics is real.  Physics is how the world works.  Physics is the study of nature and nature is where we live.  Now…are there new discoveries to be made?  Yes, there absolutely are.  

But remember this:  your patients don’t care about fancy computer-generated graphics.  Nor do they care about the fancy third-order statistics required to show there was improvement.  They want their friends to notice from across the room and exclaim “Oh my gosh, what did you do?  You look fabulous!”  THAT’S THE MAGIC!  The magic is in real aesthetic/medical lasers with real results.  

The real lasers that provide real results unfortunately have downtimes.  I’ve talked a lot in the past about non-ablative, non-invasive procedures and they’re great.  I typically position them as a procedure that is for maintenance.  Now, a lot of people will lead with them, and in fact many of our owners that have only a Fotona Nd:YAG and don’t have the opportunity to do ablative procedures, will lead with FRAC3® and they have great results, but those results come over time.  You do FRAC3® every 8 weeks for a year, you’re going to have a really nice result.  You’re going to improve dyschromia, texture and tone.  But for the “wow” result in 10 days,  you need to do an er:YAG ablative procedure – whether it’s fractional or standard.

In the bottom line is the old adage:  “If you see something that’s too good to be true, the overwhelming probability is, it is.”

MAGIC…And the Art of Aesthetic Laser Medicine

I am still reeling from the ASTOUNDING things you see in the vendor area at ASLMS and even at AAD this year.  Some of these things are apparently FDA cleared to “melt away fat.”  One of the aesthetic treatment devices is a red laser beam – it looks like a heni beam, like the aiming beam to the laser you may already own, and it just shines on the belly and it supposedly is going to just melt away the fat.  They show some impressive photographs and then you read the fine print and it turns out that they use this machine before they did laser liposuction!  They claim that this machine liquefies the fat under the skin so that laser liposuction is easier.  

I actually took a course where one of the instructors was absolutely convinced that this thing made a gigantic difference.  He claimed that the fat was even a different color when it was coming out.  Well, there is no thermal effect here.  This is a cold laser.  I’d be very cautious about getting fooled by things that currently cannot be explained by science – and this device clearly cannot.  

Now it may well be that at some point in the future we’ll figure out some photo biologic mechanism for why this might work, but as it stands now, the power densities are extremely small that likelihood that that light is really penetrating very deep into the tissue is pretty small and even if it does, I think the biologic effects are very small.  It’s highly unlikely that you’re going to go from obese to skinny just by shining this red light on your skin.  

So all things laser are not necessarily good.  I’d be very cautious about these things that are just far too good to be true.  When you combine a treatment with something like laser liposuction, there are so many variables it’s hard to be able to have really good controls.  For instance, is the difference going to be in 4 more strokes of the liposuction wand or is the difference coming from the laser you used?  It’s just so hard to tell.  

There’s so much magic in aesthetic procedures.  Be cautious and remember that your patients don’t want therapies that require a computer algorithm to decide if it helped or not. They want their friend to look at them from across the room and know that it helped.

Laser Hair Removal Spot Size Wars and More

Spot size criteria:  Depth of penetration is governed by the absorption coefficient of the laser wavelength and by internal reflection. The internal reflection is the reason that a larger spot size gives a greater depth. For shorter wavelength lasers, larger spots have a greater effect on depth than with longer wavelengths. But there is another reason for the spot size wars. In a effort to improve treatment speed they have increased spot size. Unfortunately a larger spot size will give greater heat at the center of the spot and greater patient discomfort.

We have been using a 6 mm spot size in conjunction with a Fotona computer-controlled scanner for 8 years. Due to the smaller spot size we see significant improvement in patient comfort. In addition we have excellent results with regard to permanent hair reduction. One of the reasons for improved results is that the scanner takes out operator error and variability.

Laser Parameters: Being in Minnesota, we frequently treat type 1 and 2 skin, but have a large population of type 3, 4 and 5 skin types as well. We treat all of them with excellent results. A reason we are able to treat darker skin types with minimal side effects is due to several laser specific parameters. One is Variable Square Pulsing (VSP). This is a technique that results in the peak power and the average power of a pulse being nearly the same. Next is Flat Top Optics. These two techniques result in more uniform heat distribution, and so fewer hot spots to burn, hyper or hypo-pigment the skin.

Non Contact Cooling: We are able to do large area hair removal because we do not need topical creams for anesthesia. We use a Zimmer chiller for non-contact cooling of the skin as the only analgesia. Treatments are comfortable; in fact several men getting back hair removal have been known to fall asleep!

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!”

Fotona Laser Treatment VS. As Seen On TV

Many times in our laser spa we’ll get calls after some television program or talk show host will highlight a therapy of some sort.  And of course, it will be a specific company with a big media budget and they will have been able to position their product onto some television show.  The brand name will be spoken..the wonderful accolades will be given to this new “miracle” procedure.  And yet, the procedure is almost always, frankly, not unique.  

We get calls all the time as a result of shows highlighting a laser treatment.  One caller might ask “do you do fraxel?”  And we say, “we do fractional laser treatments, absolutely.  Come on in and let us explain it to you.”    We might be asked if we do some other specific, brand-name treatment.    Well, the truth is, Fotona has the most powerful lasers, the largest range of spot sizes, the largest range of pulse widths and the largest range of procedures of any company on our platforms.  Period.

So when people call us and ask, can you do “that?”, our answer is always, “Yes, we can do that.”  The scenario is often like this:  people call….and might be asking for ‘kleenex’ and we can tell them that we have high-end, top quality tissue – every bit as good as Kleenex and in many cases (I would go so far as to say MOST cases), better than Kleenex.

So, our competitors ads are always good for us. And the other interesting thing is, our competitors down the street are always good for us, because it’s extremely rare that we can’t get better results, with less discomfort and less downtime.  That’s our experience in our medical spa.  And I think it’ll be your experience as well.