Medical Laser Blog - Fotona Straight Talk for the Physician

Fotona Laser Hair Removal Is For All Skin Types

There is a long-held myth out there that Nd:Yag is only for darker skin types. This is simply not true! Nd:YAG is effective on all skin types and has very high efficacy when used properly. The issue with laser hair removal is more complicated than simply wavelength. It is also a matter of the way the energy is delivered.

There are several parameters that can be controlled with the laser, and only some laser companies have full authority over the way the energy is delivered.  A normal, unregulated laser simply has a very long energy delivery process. A laser with full authority, as you have with Fotona, has the ability to vary the way the energy is delivered. In other words, you could choose to deliver the laser energy in a very short period of time or a very long period of time. This is a little bit of a strange concept, but think about a cup of coffee. The cup contains the energy (the coffee itself) and you can either very slowly pour that coffee out or you could simply splash it out. Those are two very different ways of delivering the exact same amount of energy – very quickly or very slowly – and it makes a big difference in how it affects the structures you’re trying to target.

It turns out that Nd:YAG, with relatively short pulse durations, has great efficacy with laser hair removal and is very safe on skin. Other lasers, such as an Alexandrite, have a higher affinity in melanin and in darker skin individuals, the Alexandrite laser is actually absorbed into the skin rather than the hair follicle, resulting in burns (if you’re not very careful). The same can be said of diodes and IPL.

Because these are cosmetic procedures, safety is of paramount importance. You certainly don’t want to go to have an aesthetic treatment such as laser hair removal and end up with all kinds of burns that can either result in hypo (low) pigment or hyper (high) pigmentation in the skin.

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.”

Extra-Extra! Athletes Foot Bugs Killed by Fotona Nd:YAG Laser

As you know, athlete’s foot is a fungal infection of the superficial skin.  It can sometimes be quite difficult to treat.  The inflammatory response to the infection results in a thickening of the cutaneous layer of the skin, making it very difficult for the medication to penetrate deep enough to kill the infection in the deepest layers of the skin.

We have a solution to that problem.  With the laser I use – the Fotona XP Max (or any Fotona Nd:YAG laser) -  we use hair removal settings (or even a bit hotter) and use the computer controlled scanner to cover the area three times, being sure to get in all the nooks and crannies between the toes.  We get good, deep penetration with the laser and that heats the tissues that are inflamed, resulting in sterilization.

We’ve had very good results treating foot fungus that have been multi-drug resistant.  Especially the really thick heal calluses that are sometimes fungally infected and look cracked and broken and maybe have been filed off many times with a pumice stone  yet always return only to be as bad or worse.  We’re able to treat those very nicely and see good resolution of the thick callous and resolution of the fungal infection without ablation and without side effects.

Treating athlete’s foot with the Fotona Nd:YAG laser in our practice is a very nice ancillary treatment.  When we first started our laser practice we didn’t do much of this sort of thing.  But with our growing reputation for being able to resolve difficult-to-treat problems, people are coming into our office with toenail fungus,  athlete’s foot, folliculitis, etc.  As I’ve said in other blog posts, we’ve been able to close surgical wounds that had been left open secondary to infection and just never secondarily closed (they never granulated in).  I’ve talked about a pilonidal cyst case and we’ve also had a case of a coronary bypass graft where the harvest sight for the saphenous vein just would not close and would not close.  We started scanning it with the Nd:YAG laser and slowly over time it closed after being open for about a year.  After about 3 months of Nd:YAG therapy it closed completely and the scar had healed very well.  

The Nd:YAG laser, interacting with the inflamed tissue of the body, heats the tissue and results in sterilization of the tissue.  The nice thing is that it doesn’t interact with the non-inflamed tissue so you can scan widely because when you're scanning an area that is non-inflamed there is little or no pain associated with it.  When you’re over the inflamed tissue, it can get a bit hot, but you explain to your patient that when you feel that heat, it means you’re killing “bugs” and we’re moving forward.  

If you’re interested in learning more, let us know.  We’d be happy to walk you through the process!

Folliculitis Nd:YAG Treatment = No Toxic Medications

Many of our patients suffer from resistant folliculitis.  The problem is, folliculitis can have many ideologies.  It’s obviously most commonly bacterial, but can also be fungal, viral and even parasitic.  The problem becomes getting medicine to the level of the infection.  Topical treatments often cannot penetrate to the depth of the infection, so are ineffective and usually just partially control symptoms.  Unfortunately, oral medication can often be toxic – especially if you’re dealing with a fungal folliculitis.  

This is where laser comes in.  You don’t get resistance to pathogens from heat.  The laser (in our case, the Nd:YAG Fotona XP Max laser) has a primary chromophore of hemoglobin.  In areas where there is little inflammation, there will be little erythema and little erythema means little hemoglobin.  In areas of more inflammation you will have more hemoglobin and more heat deposition from the laser irradiation.  That will result in heat and sterilization of the tissue.

We see this time and time again, whether it is treating active acne, whether it is treating folliculitis or as in a recent case, treating a severe, recalcitrant pilonidal cyst that had been surgically excised multiple times and was left open to heal by the last surgeon and it just never did.  We, however, were able to heal and close it with multiple passes with the Nd:YAG laser.

The side effect of treating folliculitis with Nd:YAG laser is hair removal.  So, if you’re treating a man’s beard area and he wants to keep his beard, you probably shouldn’t be using the Nd:YAG laser.  But, if he doesn’t care about his beard and wants his folliculitis gone, then it’s an excellent treatment because you’re not going to get folliculitis where there’s no hair left – so likely a permanent cure for this problem.

Treating folliculitis with the Fotona Nd:YAG laser is just one more treatment we do in our clinic regularly and with excellent results.

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. 

Microsoft Word and the Fotona Nd:YAG laser

At ALSMS this year there was a newly FDA cleared ultrasound device for brow lifts.  What they basically do is what ultrasound sonographers have desperately been trying to avoid for years, which is causing thermal injury to the deep tissues with ultrasound.

So, they have now created an ultrasound device that is able to create micro-thermal injuries to the dermal and sub-dermal tissue (but sub-epidermal) creating injury that requires a healing response that results in more collagen production and greater elasticity of the skin – resulting in a brow lift.

Now unfortunately, not only I but also a prominent dermatologist (a friend of mine that I was speaking with at the conference) looked at their before and after pictures and his comment was “…if you dropped them on the floor and picked them up, you would be very hard pressed to find the before vs. the after photograph.”  The company's statistical analysis claimed that they get about 1.9 millimeter lift of the brow.  And as this prominent dermatologist stated (and I certainly agree), you could easily achieve that same result with botox if you know the facial muscular anatomy and you know how to place the botox.

This ultrasound device is really just another case of radio frequency  - and in this case it’s ultrasound energy – but it’s the same idea as radio frequency causing these micro-thermal injuries.   And unfortunately, it looks like this ultrasound device has very similar results as radio frequency energy has.  Multiple studies have already shown that Nd:YAG skin tightening does as good or better a job than radio frequency.  

So in your hands right now, if you are a Fotona owner of an Nd:YAG, you have a device that works better than this recently FDA approved device (in my opinion).    And the nice thing is that you have a couple of options of how to do therapies – and I’m going to recommend that you combine them.  

There’s a Fotona procedure called T3 – meaning Tightening, Toning & Texture.  T3 is a bulk heating modality.  Basically it’s using around 50 joules per centimeter squared and around 50 milliseconds or so of pulse duration and scanning (using our computerized scanner) with a 6 mm spot and scanning the entire face.  

We also have FRAC3®.  Now FRAC3® is a 3 dimensional, self-fractionating therapy.  It is a very special zone of energy; high energy and very short pulse durations usually done with our 3mm spot size. Basically it selects imperfections at about the level of the papillary dermis, resulting in micro-thermal injuries, healing response and new collagen laydown.  By combining the T3 and FRAC3®,  we find we get even better results.  So rather than spending $60,000-100,000 dollars for a new gizmo in your office, remember that you can do a lot of things with the laser that you already own. 

You have to think of the laser you already own kind of like Microsoft Word.  Most people buy Microsoft Word and they just type on it.  And if they want to make business cards or banners they buy special programs just for that.    The truth is, Microsoft Word will do it all.  Your Nd:YAG laser is very much like that.  It is Microsoft Word – and if you know how to use it, you can get a lot out of it – including skin tightening (with your Fotona Nd:YAG laser)!

Vascular Laser Equipment for Endovascular Therapy

I think I blogged a little bit about this while at AAD, looking around from the Fotona booth and seeing Smart Lipo, and Smart this and Smart that….

I mentioned briefly that the laser lipo machine that we have at Fotona, called the XP 2 Focus, also does endovascular work.    And for almost exactly the same reasons that it’s really the best  “box” for laser lipolysis, this is really an excellent box for the treatment of varicose veins – from an endovascular point of view.

For those of you who aren’t familiar with it, let me just take a minute to review the procedure -  it’s really very simple.  

• First, you do an incompetency study, which is an ultrasound test of the veins.  The ideal treatment candidate, for example, would have an incompetent great saphenous vein.  This means that the valves aren’t working properly (the valves not supporting one-way directional flow in the saphenous vein AND that person has varicose veins that are map-able back to the great saphenous vein).  

• At this point you put a needle into the great saphenous vein, slide a cannula into the vein, position the cannula under ultrasound guidance, then put peri-vascular anesthesia (meaning lidocaine tumescent anesthesia) around the vein.  

• The tumescent has epinephrine in it which makes the vein squeeze down against the catheter so you get a nice, close proximity to the laser fiber, and then you fire the laser while slowly pulling the laser fiber back to shoot laser energy into the vein along it’s length – causing it to die.

• This process results in redistribution of flow to the deep system and it blocks off the incompetent orifices from the great saphenous vein into the varicose veins and causes dramatic relief of the pressure, pain, discomfort and of course, the size of the varicose veins.  

So that’s how the procedure is done.  We do it in our office.  The issue would be “why would Nd:YAG be the best wavelength?”  Well, it’s back to a theme I’ve talked about many times before.  In endovascular therapy, you’re trying to heat volume.  You’re not trying to ablate tissue.  If you want to ablate tissue,  you should look for something that has a very high affinity for that tissue.  So, a lot of companies are using diode lasers  -maybe in the 800 nm spectrums -  and they have a very high affinity for hemoglobin.  Unfortunately, what happens with those lasers, is they super heat the blood, causing  a steam explosion and causing rupture of the blood vessel and in this example, rupture of the wall of the great saphenous vein.  What that does is to cause significant ecchymosis and a lot of pain.  In direct comparisons,  a side-by-side, leg-for-leg comparison of the Fotona XP2 Focus, using their Nd:YAG Quasi-Continuous wave mode, (which is the mode you would use for this therapy) vs. a diode laser, there was dramatically less ecchymosis and pain. And why is that???

The Nd:YAG wavelength has a lower affinity for hemoglobin so it’s able to heat a larger volume to a more reasonable temperature.  Instead of the diode laser heating the end of the catheter  to maybe 1700 degrees, we’re able to raise the temperature of the volume of blood with the Nd:YAG laser to just maybe a few hundred degrees and that causes coagulation of the tissues and that results in the death of the vein.

Remember, when you’re thinking about laser, if you’re trying to ablate something you definitely want to have a very high affinity for the tissue.  On the other hand, if you’re trying to heat (and to have controlled heat), you want to have a lower affinity to the tissue and you want to have some serious control over how that energy is delivered.  The mastery of Fotona is in how the energy is delivered.  We’ve developed this very specific quasi-continuous mode with variable power.  We can   range the power from very little all the way up to 50watts.   It’s the most powerful endovascular laser on the market.  

So that’s the Fotona endovascular story.  The XP2 Focus is a great product, and it’s great for endovascular work if you’re even marginally surgically inclined.  It’s an easy procedure to learn – no more difficult than learning to put in a central line – and in fact, it’s easier.  Endovascular laser therapy for varicose veins originating from an incompetent, superficial system….a very good procedure. 

Vascular Laser Treatment for Rosacea Gets Results with Fotona

Rosacea is something we very commonly treat...while most other laser companies will tell you that rosacea is very difficult to treat. Let me tell you a story about just one of our patients and again, I’m going to remind you that we commonly do this type of vascular laser treatment and tell you why we’re able to do it.

So, we have a patient that we’ve been seeing for several years now and in fact, his pictures have been published in our photographic album of results that we make available to Fotona owners. He had previously been seen at an internationally famous aesthetic center here in Minnesota for 7 years. He had been on multiple prescription antibiotics and other therapies for rosacea and he’d had marginal results. And by that I mean he’d had good control of his rosacea, yet it’s still really obvious he has rosacea (sort of between the eyes and the glabella region, a flair over the bridge of his nose, down the edges of his nose and onto his cheek bones – at least he did when we first met him). He came into our office on the recommendation of a friend, just wondering if there was something we could do. And we said, “well yes, indeed we can.” So we treated him with our Nd:YAG laser (the XP Max) with the 6mm spot size, computer controlled scanner over the entire area where he was flared. The result? He had near complete resolution of his rosacea. He was thrilled to death. We saw him about 6 months later when he came in with a small flair in an area where we hadn’t scanned him before, so we scanned that area and again had full resolution within about 48 hours.

Currently we see him about every 9 months for some small flair, but between flairs, he’s essentially asymptomatic…almost completely clear skin. In his words, it’s “100% better than the treatment he was getting, prior to seeing us." He’s been off all medications for a couple of years now. This is what we experience routinely with our rosacea patients. We have many roasacea patients who have been on multiple drugs and using the Nd:YAG laser at moderate power settings, we’re able to get these fantastic results. Typically, we’ll use a 6mm spot size on the computer-controlled scanner, and we’ll use approximately 50 joules per centimeter squared.

WHY is it that other companies will tell you that they just can’t get a good result with rosacea and we can? Well, it’s like asking why one pepperoni pizza is better than the other. It has to do with the quality of the ingredients. Our laser has something called VSP – Variable Square Pulsing. VSP falls out of another Fotona technology called EFC or Energy Feedback Control. What that means is that we can control our beam profile extremely precisely. As an example, if you were to let a laser fire on its own, what you would find is that the energy in that beam would very rapidly rise, it would come to a peak and then it would very rapidly decay. The second half of the decay would be very slow, with a very long tail. It would look something like an EKG spike, only with a very rapid QRS and then a very long t-wave. The Fotona beam can simply turn on, stay on and then turn off – and that is a square pulse. That's what allows us to control the energy. In other words, if you have a very rapid, high spike and then a long tail – where’s the energy? You can’t tell how much of the energy is really affecting the tissues and what is the real dose. But with the true square pulse, like Fotona gives us, we know exactly how much energy is put onto the tissue. That’s the first thing.

The second thing that allows us great rosacea results is calibration. Fotona’s lasers calibrate multiple times during each and every pulse of the laser beam. So we know how much energy the laser is delivering at all times, not like other machines that you have to hand calibrate maybe once or even a couple of times per day. Our machines calibrate with every single pulse –automatically.

Lastly is our optics. The optics are such that the amount of energy hitting the skin at the edge of the spot is virtually the same as the energy delivered at the center of the spot. Most laser optics will have a Gaussian distribution – meaning that they’re very hot in the center and very cool on the edges.

Fotona Laser Treatments Effective for Warts

This is an aesthetic/cosmetic laser blog and here we are talking about warts…not commonly thought of as a mainstream cosmetic procedure.  But warts are unsightly and people want them gone!  

Now you might be thinking “Gee, I could go to my primary care doctor and get it treated and it’ll be paid for by insurance, so why would anyone want a wart treated by an aesthetic laser?”  

Well, the answer to that is, quite simply, that the standard treatments for warts aren’t very good!  You can put some kind of plaster, potion or lotion on it – and you put it on repeatedly and repeatedly – and often times it takes weeks and weeks, if not months and months to go away.  You can have it frozen.  The freezing process is associated with a tremendous amount of pain, swelling and discomfort.  You can have it burned off, hyfrecated, etc., but the Fotona laser provides another unique opportunity that has a completely different side effect profile.  

The laser is able to provide treatment that has only minimal post-procedural discomfort.  As an example, many of you readers know that my wife and I live in rural Minnesota.  We live in basketball country.  Our high school is sort of an area basketball powerhouse - particularly the women’s teams, who have been to the state tournament multiple, multiple times.  The men’s teams have been many times as well – and in fact, they just won the state title in their division.  One of the star basketball athletes came to our office just before the last few games of the season, just before play-offs and state tournament time, with about 25% of the ball of her dominant foot covered with warts.  Now normally, treating that would have taken her out of the games for the rest of the season.  She would have been sitting on the bench – maybe even with her foot up because of discomfort due to all that raw tissue.

We were able to treat her warts with the Nd:YAG laser.  You hit them pretty hard…you use pretty high fluences.  It gets your undivided attention when you hit the wart, but post-procedurally, this young woman was able to put her sock and basketball shoe back on and run back out onto the court and straight into practice.  She didn’t miss a game and they went to the tournament finals.

So, unlike other treatments for warts, which are not only painful when they’re being done, but they’re painful post-procedurally, the Nd:YAG can offer an alternative with much less downtime for the patient in terms of being active – especially when dealing with plantar warts.  Another nice thing about treating warts with the laser is that many times these are they types of warts that are close to the nail bed (particularly on fingers).  Those can be dangerous areas to attempt treating because you can alter the nail matrix and cause permanent disfigurement to the nail.  And while I’m not going to tell you you’re never going to see disfigurement to the nail, it’s my experience that you have LESS likelihood of disfigurement to the nail when using laser over electrodessication or cryo.  

One more thing that we use our Fotona Lasers to treat commonly, and treat well, are warts.  And again, LOTS of people have warts.  They don’t like them.  We find that the laser treats them very effectively and our patients are extremely happy with the therapy.

Onychomycosis Treatment Success With The Fotona Nd:YAG Laser

Treatment options for onychomycosis are, right now, not very good. There are a couple of medications: a couple of them topical, but most of them oral. The oral medications carry with them some significant oral toxicity and you have to be on them for long periods of time. In fact, a 12-week course of oral anti-fungals carries with it about a 60+% cure rate for onychomycosis. In other words, 40% of the time the patient relapses.

We have done studies (we meaning the Fotona family of physicians) published in European journals that show a way better than 90% cure rate for onychomycosis. And I’m talking about culture proven cure rate of onychomycosis with no known toxicity. It’s quick and it’s easy. It’s done with Nd:YAG laser, fairly low power, and multiple passes – simply to heat the nail itself and the nail bed. The heat kills the fungus.

In our office we started doing this sort of as an out-reach of our treatment of other infections of other things such as acne and so on, and found it worked so well that basically, it’s the only way I treat onychomycosis anymore. We’re a bit different in our treatment. Consider that there’s a company that has a machine that ONLY treats onychomycosis and they advertise one treatment, one time – done. Well it turns out that that machine has a cure rate (with a single treatment) that’s approximately equal to the medications. I wasn’t exactly excited about being equal to the medications, considering 40% of the people who use the medications have relapse. So we do the treatment 2x/week for 2 weeks. Because of our computer-controlled scanner, we can do the treatments very, very rapidly, even if it’s all toes involved. Therefore, we don’t have to charge any more than the company that does the one-time treatment. So…same cost, a little bit of inconvenience to the patient because they have to come back a few times, but dramatically better results in terms of long-term curing.

It turns out that there are a lot of people with onychomycosis, and they hate it. They don’t want to wear sandals; they don’t want to go swimming in somebody’s pool because someone will see their nails. They don’t want their nails seen in public at all. They’ll file down their nails until they actually bleed just to make them look relatively flat and then they’ll paint them with several layers of polish in order to camouflage them.

Onychomycosis is in your practice right now and you may not know it. Less than 10% of people ask about being treated for onychomycosis. Of the 10% that do, only about half of those have insurance that will cover the medicine and the medicine is really expensive - far more expensive than a course of therapy with the laser. Consider the aesthetic laser treatment of onychomycosis. The treatment parameters are simple, it’s quick to do, and very effective. One more procedure that your patients are looking for and that you can provide.