Medical Laser Blog - Fotona Straight Talk for the Physician

Laser Skin Resurfacing or Chemical Peel. Precision vs Guess.

It would be reasonable to ask “why do laser peels when you can do chemical peels for so cheap?” A big part of this is the tried and true answer of “you get what you pay for.” I tell patients a chemical peel is a little like using prunes as a laxitive. There’s an old commercial for kids and it goes something like this: “Is two enough? Is three too many? We just don’t know.” Well, it’s a bit like that with chemical peels. When you put the chemicals on the face there’s a timing element and the correct timing depends on the degree of hydration and the overall health of your skin.

With a laser, you take things down layer by layer, in a controlled fashion, to landmarks that you have pre-determined. If you want to stay within the curatenous layer, you simply ablate to a white color on the skin. If you want to get down into the living tissue (the upper papillary layer), you ablate until there’s a yellow color. And if you want to take it down to the papillary dermis, you ablate until you can see a fine, reticular mesh of capillaries and start to see some very fine punctate bleeding. If you want to go deeper than that, you start to see more and more bleeding. For every level, there are very definitive endpoints.

With a chemical peel, you place the chemical on the face and you wait. But how long do you wait? Do you wait 2 minutes, 5 minutes, 30 minutes? It depends on the preparation, it depends on the operator and so many other variables. There are fewer variables with a laser skin resurfacing. In my mind, a laser skin resurfacing is safer, and because you are getting to your pre-determined endpoint in terms of depth of the skin layers, it is more efficacious as well.

So the difference between a chemical peel and a laser skin resurfacing is a guess versus precision. It’s as simple as that.

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.

Erase Years With Full or Fractional Laser Skin Resurfacing

“Doc – how long is this skin resurfacing going to last??”  I’m certain it’s a question you’ve heard. I know it’s a question I get a lot and the answer lies in how well you treat your skin.

With the full or fractional laser resurfacing of your skin, we have literally taken age off of your skin and the moment we’re done and you start to heal, you start to age all over again.  Yet – there are certainly many things that you can do to slow down the aging process or at least the appearance of aging on the skin. 

Probably the most important is sun protection.  Not only do you want to provide your patients with excellent cosmeceutical grade, high SPF sun blocks, you also want to provide good sun protection clothing.  One of things we do in our medical laser spa/clinic is to provide a line of sun protection clothing for sale:  wide brimmed hats, sun-protective shirts and so on.  

Another item of great importance is moisturizer, which is critical to reducing the signs of aging.  Often, the sun blocks can be combined with the moisturizing component.  If you want to know what we use in our office, get a hold of us and we’ll connect you with the company we recommend.

The other really important thing is nutrition.  You want your body to have all of the building blocks necessary for repairing and building.  If your patients are eating the standard American diet (which is abbreviated SAD) this is not a good thing.  They need to be eating a minimum of 5 servings of vegetables and 3 servings of fruit per day and healthy choices of proteins – proteins that are low in fat, or in other words, lean meats, poultry and fish and not the typical high fat foods.  

Next they ought to consider some sort of multi-vitamin with extra anti-oxidants in it.  And there are yet more nutritional things we do for our patients with the full line of nutritional elements in our clinic.  

On top of all this there are laser maintenance therapies.   Now, the very therapies that other companies position as their primary therapies such as “non-invasive or fractional skin tightening” and stuff like that, we position as maintenance therapies.  It’s true that if you get a Fotona FRAC 3® or T3 therapies with an Nd:YAG over the course of a year you’ll really get some good results.  The problem is that very few people are patient enough for that, so we like to position the “wow therapies” in front - but we fall back to the less invasive treatments for those who don’t want to have the downtime.  Non-invasive therapies will help to keep their skin looking younger, longer.  It will help prevent the pigments from coming back and so on.  

There’s a whole list of things we do, ranging from moisturizers, sun blocks, protective clothing and nutritional supplements and additional laser therapies for keeping skin looking younger.  How long will your skin stay looking good?  It depends on how you treat it –but what I tell patients is that we set the clock back 10 years and then you’re going to start aging again.  Take note that when you’re older, you don’t repair as well.  So if you don’t treat your skin better, it’s only going to take 5 years to gain that 10 years we just took off your skin. 

What's Fractional Laser Skin Resurfacing Got to Do With Driveway Cracks?

Father’s Day is right around the corner and while many of us may not think about it, men want aesthetic services just as women do.  We see a lot of men in our medical laser practice, particularly men in the sales professions, wanting to look young, healthy and vital.  They do this with Botox, by getting a Fotona full or fractional laser skin resurfacing, re-volumizing injections…basically all the same procedures that women are interested in (just applied slightly differently).  

With Father’s Day coming up you might think about coming up with a promotion that reminds men that they fix the cracks in their driveways, kill the weeds in their lawns, repair the paint chips on their car and why aren’t they fixing the imperfections in their face?

When you present an issue to your audience, you need to use their own language.  Men understand maintenance and men understand health.  To promote your medical laser spa services to men, you really need to present from the perspective of a man’s point of view.  While he’s thinking about the chips on his car and the cracks in his driveway, etc., he may not be thinking about beauty and aesthetics and could use a friendly reminder!   You should also promote wellness.  Men work hard and workout hard, but wanting to look good includes healthy looking skin.  In addition to toning muscles, you can help him look healthy by taking the furrows out of his face.  

Promote your services to men…especially now around Father’s Day.  Speak the right language using the concepts of “maintenance” and “wellness.”

How to Properly Consult the Aesthetic Laser Patient

People are funny.  The other day I was in the office, just having completed an aesthetic laser procedure consultation.  My consultations are fairly detailed.  I go into all the possible side effects and complications.  I want people to go into any kind of cosmetic procedure with their eyes wide open, so that they understand the risks.  I want them to accept the risk and I try to place the risk into some kind of context.  Statistics are sometimes very difficult to grasp, so I typically try to place it in terms of ordinary activities.  

There might be a risk the equivalent of driving your car in the city for a year.  I tell them, “look, you jump in your car and drive off, not really thinking about the fact that there are bridge abutments and semi-trucks out there that could run you over.  Now, that could result in nothing more than damage to your property but it could also result in serious bodily injury or even death. 

I went through this entire consultation and the patient’s response to me was “so…there’s nothing that could really go wrong here, right?”  What do you do with that patient?  I’ll tell you what I do with that patient:  I look them in the eye and say, “everything I just said to you is a potentially real complication."  If it’s true, I might say, “I haven’t experienced that complication with any of my patients,” or “out of the x number of treatments I’ve done I’ve seen that complication x number of times.”  But, in one instance, the patient said this same “yeah, but nothing bad is going to happen, right?”  three times in a row.  After the third time I said, “’y’know what?  I can’t guarantee that and we’re done.”  Then I cancelled the procedure.

Now interestingly enough, this patient came back to our Fotona Laser clinic about a month later, bringing her husband.  She wanted to do the consult again and I was a little beside myself.  I thought, “I’m a busy guy and I’m not terribly interested in re-telling this story.”  But I did – this time with the husband present.  The husband was an interesting guy.  He said maybe 4 or 5 times throughout the consult: “sweetheart, I love you and you don’t need to do this for me.  I love you just the way you are and I’m here to support you if you want to do this.”  At the end of the consult, the patient turned to her husband and said, “What do you think?”  He said, “I don’t think you need to do this, but if you want it, I think what he’s telling you is that it’s perfectly safe but he can’t predict the future.”  She then agreed to do the procedure.  

What happened in that instance is that I made it perfectly, abundantly and absolutely clear that I don’t have control over every single possible side effect and she was forced to take responsibility for her own body’s healing, etc. (at least in our presence).  Whether she would hold to that in a court of law is a different issue.  But I think these consults are very important.  I think you need to stand your ground and to protect yourself from people who are just plain goofy.  

A properly consulted patient understands the normal things that are going to happen in a procedure.  They understand that their face is going to be beet red (as I like to tell them, it looks like “they’ve washed their face in a french fryer,”) - when they understand that that’s what they’re going to look like the next morning when they look in the mirror, they’re not freaked out or mad at you. In fact, most of my patients when I call to check on them chuckle and say “yep – it’s exactly like you said…I look terrible!”  That’s really the way you want your post-op situation to be.  You want to have your patients so clear on what’s going to happen that when it does indeed happen, you get a chuckle that says, “That guy was right.”

Your consults are the way you make your life less stressful.  If your patient is calling you in a panic, there was something wrong with the consult.  

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.

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.

Skin Resurfacing Laser System - Look 10 Yrs Younger in 10 Days

That is what patients are asking for and you can provide it.  Fotona Er:YAG resurfacing is in a class by itself.  I have talked extensively in the past about how the Er:YAG is the most versatile resurfacing wavelength.  This is due to its ability to give cold ablative, warm or hot ablative treatments and heat only treatments for resurfacing and skin tightening.  With warm to hot settings and a papillary dermis peel, we are told by our patients and by their friends that they look 10 years younger.  The recovery time for this is generally less than 10 days.  For most of our patients, they are back to work in 3 to 4 days with cover up makeup. 

The process is quite simple.  After a consult to be sure they are a good candidate (no skin problems, healing issues, no bleeding issues, no psychological issues, etc), have them start a good skin hydration protocol with pigment control about 2 to 4 weeks prior to the treatment.  On treatment day we do a light peel to open the dermis and then apply BTL (lidocaine) cream for 20 min.  At 20 min we are ready to start the procedure.  The patients will be quite comfortable, but for those who are worry-warts or 'nervous Nellies', we suggest Valium and/or Vicodin prior to treatment.

The treatment is given with the Er:YAG laser. I generally use a 5 mm spot, 15 hz and about 3 - 5 Flu.  At these settings, you will see the capillary flush or punctate bleeding in about 2 or 3 passes.  I use orthogonal passes to be sure a more even ablation is given.

After the treatment is complete we place aquaphor or a similar topical on the skin and we are done.  We keep in touch by phone and follow up at 3 to 7 days.

Total time for MD about 20 min. Total time of procedure including prep about 1 hour.  The charge is going to be between $1,700 and $ 3,500 or so… You do the math.  Is it worth your time?