Medical Laser Blog - Fotona Straight Talk for the Physician

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. 

Is Laser Hair Removal Right For You?

 There seems to be a lot of interest on the internet about laser hair removal. I guess I think of it as a fairly mature and reasonably understood technology, however, that doesn’t appear to be the case. Constantly educating our patients is so important. There is so much mis-information out there. I recently saw a blog post that talked about laser hair removal being “absolutely” safe. Well nothing is absolutely safe. Everything has some element of risk and it’s imperative that you consult your patients carefully, thoroughly and honestly.

The risks of hair removal are mostly trivial, in terms of medicine, but they can be dramatically devastating to an individual patient. A patient coming to you for hair removal is sometimes looking for convenience – simply not wanting to shave their underarms. Sometimes the patient comes to you because of a deep stigma that they feel. We have women come in that have five o’clock shadows every bit as dense as mine. They come to our clinic to get laser hair removal because they are devastated by this hair growth. They have been teased throughout their life or maybe it’s just something in their own mind that makes them feel not feminine. If that person were to get maybe even a perfect hair removal result, but because of the way the therapy was delivered, they get a side effect of a hypo-pigmentation, the person could be left with a stigmata that is every bit as devastating to them psychologically as the hair growth was.

The consult needs to help the patients understand the things that could possibly happen. Now – I try to give them some sort of reference point for how likely it is for these things to happen. A few weeks back, I talked in a blog post about you get in your car every day and drive around, not really considering that this is likely the most dangerous thing you could be doing! And putting it over the course of your lifetime, the danger from driving your car is quite significant. Now – the problems that can crop up with hair removal are 1) it might not work to your satisfaction, 2) you might get burned, and the burns can result in hypo-pigmentation or hyper-pigmentation, 3) it’s possible that you don’t kill the hair follicle but instead only burn it below the surface of the skin, and if that happens, you could end up with a lot of ingrown hairs in that area which can become infected and quite unpleasant – even leading to disfigurement.

Some laser operators use lidocaine or similar numbing gel. Virtually all of the deaths associated with laser hair removal can be attributed to an inappropriate application of lidocaine to the skin. Fortunately, with Fotona Lasers we do not use any kinds of topical lidocaine preparations because we simply don’t need them. We have other ways to very adequately control any discomfort. All things need to be adequately explained to the patient and in the end the question that really needs to be asked is: “listen – which is worse in your mind, the hair you have growing or the potential side effects?” And if the answer is “the side effects,” then you should simply advise the patient not to have hair removal. Side effects are unlikely, but they could happen. On the other hand, if the patient says “well gosh, if I get a color change in my skin I could always camouflage it with make-up, but you can’t camouflage a five o’clock shadow." Well that’s someone who understands what we’re talking about and I would do the hair removal on her without hesitation.

You must think through these consults. You must be honest and thorough with your patients because what you don’t want is someone to have what is a known complication of hair removal, and for them to be surprised and profoundly unhappy, feeling like they weren’t properly consulted.

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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.

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.

Growing Your Laser Hair Removal Practice

Hair removal is about 50% of most laser offices practice.  And it’s much easier to see a big increase in revenue by getting a small bump in your hair removal than it is to develop a whole new therapy, because there you’re starting from scratch and there’s a wind up time.  So here’s one thing that we do.  We identify our patients who have really been excited.  Though all of our patients are happy with their hair removal, some are really excited.  Some are evangelists and you need to find those evangelists. When you identify an evangelist, you partner with them to market, and here’s how you do it.  It’s quite simple.

You tell them that you want to have a party for them.  They’re going to invite a minimum of 10 friends to your office and you’re going to have hors’devours or whatever is appropriate for your practice in your area.  If you don’t sell make up, you have the Mary Kay rep come out, or whoever has been trained in make-up application. Or if you sell make-up in your office, you have your make-up specialist there to give make-up tips.  You have a discussion about botox. You have a prize drawing to give a free botox treatment to the lucky winner and you have a discount on the sale of laser hair removal packages.  

Now the word “package” here is important.  You never sell a single hair removal treatment because a single treatment will give them a single “shed” but then hair will continue to grow.  You need a series of treatments to get effective hair removal because remember, there are 400 (more or less) hair follicles per square centimeter on your entire body and we can only kill a hair follicle when it is actively growing.  So if you have 5 follicles growing in that square centimeter when you do a laser procedure, you kill those 5 follicles.  But the other 300+ follicles in that square centimeter are not injured so we have to wait for the next growth cycle to kill them.  So you never sell in a single – you always sell a package.  You sell a package of 3 or you sell a package of 6 at a bit of a bigger discount and so on.  

We tell the party organizer (your evangelistic patient) that for every person that signs up for a treatment package, whether it’s for hair removal or some other therapy you provide, we’ll give the party organizer a gift certificate.  The gift certificate can be in any denomination.  We give out pretty big certificates.  For every party attendee that signs up for a treatment, we give the party organizer a $200 gift certificate.  Now, the sign up has to occur on the night of the party.  So we provide the party with the packages, and a 10% sign-up discount.  When the person buys the package at the end of the night, and if all ten people bought a package, the party organizer gets 10 $200 gift certificates.

Now you might think, “oh my gosh, I’ll go bankrupt doing that.”  Well, hair removal with the Fotona system, remember, is quick and quite comfortable. Why?  Because we use the right spot size, with a computer controlled scanner to get excellent clinical results with minimum discomfort and at remarkable speed.  So when they come in to use their $200 gift certificate (they’ve previously done hair removal on their upper lip and chin and now they want to do their under arms) - it takes us about 5 minutes to do their under arms on each side and that 10 minute investment of time with that patient just earned us an entire new package which is worth about $1,000.  So the gift certificate is a wonderful way to highly incentivize your patients to bring new customers to you and it’s a wonderful way to make your evangelists even more evangelical!

Think about growing your hair removal practice by recruiting your evangelical patients. The want more procedures, they love the idea of getting them at a reduced cost and they are really happy with you and your clinic and want their friends to know about it…they just need a better vehicle for them to tell their friends and this is one of those vehicles.

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!

Use a Computer-Controlled Scanner For Laser Hair Removal?

Most laser hair removal systems require the work to be done by hand.  That is to say, the operator simply does his/her best to cover the whole area.  I have even had laser operators tell me they prefer the hand method because they can get it done faster!  But the speed at which you can do laser hair removal is a function of your spot size, the area to be covered, the repetition rate of your laser and the tolerance of your patient.  So, with modern high-powered lasers the speed is really limited by the tolerance of the patient. 

Some medical laser equipment companies address the speed issue with a bigger spot size.  They then make claims about small spots not being effective.  The problem is that big spots hurt, and this limits speed.  So you need to find a balance between clinical efficacy, discomfort and speed.  That is where the Fotona Laser S-11 scanner comes into play.  The scanner will reproducibly lay down a pattern of spots that have been shown to be big enough to do the job yet small enough to be comfortable.  In fact, many of our patients will fall asleep while doing larger hair removal areas… I’ll bet you won’t see that with an IPL, or a big spot size!

Many hair removal centers will tell patients they should be treated every 2 weeks.  This is not because they get better results - it is because they are missing hair follicles when treating by hand.  With the Fotona S-11 scanner we can treat the entire area with no gaps or missed spots.  We treat every 6 to 8 week and get great results.

Laser Hair Removal Seen On TV Talk Shows: Marketing Vs. Science

So what is it better to have? The best science or the best marketing? Depends. If you are selling a "thing", it’s marketing.  If you are selling a service, it’s science!  In marketing the theme is “don’t sell the stack, sell the sizzle”.  Well that is all well and good, but when you as a doctor are selling a service, it is results that matter.  Results are achieved by science.  Results make your patients happy.  Results bring in new patients.  

The laser hair removal market is filled with wild claims that, while marginally true, are deceiving and lead to disappointment from both doctors and their patients.  One company claims to be able to treat white and gray hair.  Even its own literature shows that it will reduce white and gray hair by about 10%.  This is a clinically insignificant number and can be achieved by most any system.  But they market white and gray hair.  Guess what… you buy such a claim and the result will be your patients (and then you) will be very unhappy.

If you take a look at most companies web sites, you will find they are marketing driven.  It is hard in many instances to find out what wavelength they are using and in some cases if it is a laser or something else.  They sell application specific devices.  They have one for this and one for that.  This is great for the company - they sell lots of boxes - but not so great for you.  You need a high quality, science-based, versatile device to accomplish your services.

That is why I have Fotona Lasers - they are science driven.  Look at the web site.  Look at the White Papers.  For instance “Scientific Evaluation of VSP Nd:YAG Lasers for Hair Removal” written by myself and others.  While “they” talk about gray hair, Fotona delivers the goods!  Under promise and over deliver - that is what you get from Fotona.

The Worst Possible Way To Choose a Laser Hair Removal System

There are a lot of laser hair removal systems out there… how do you choose?  The worst possible way is actually the most commonly used.  The typical person looking for a laser makes a list of the highest fluence, largest spot size, fastest reputation rate… etc.  What this creates is a list of clinically meaningless parameters.  Companies are great at this game and promote it to their advantage. As an example -  fluence = Joules per centimeter squared.  In order to create a big fluence number simply place the machine on the smallest spot size and the highest power, two things you would never do in the clinic.

So how should you choose a laser hair removal system? 

First look at wavelengths.  You would like to choose a wavelength that is safe on all skin types.  That means it will need to be above 1000 nm.  

Next is the quality of the laser discharge and the optics.  In other words, is the discharge on/off or is it like a dimmer switch…slow on/slow off?  The former is desired.  With the optics, is the beam flat or with hot spots?  Flat is desired.

Comfort is next.  Many companies solve the quest for speed with a large spot size, yet large spots hurt more.  Smaller spots are better - to a point (see below).

Speed is a tricky issue.  You can only go as fast as your patient can tolerate.  As noted above, larger spots hurt more, but too small a spot may not have adequate penetration.  The ideal spot has clinically relevant penetration.  A smaller spot is hard to successfully place by hand, side by side.  So a scanner is needed… a computer-controlled scanner is a must for fast, safe and comfortable hair removal.  Speed is also related to power.  So a more powerful machine can go faster.  Be careful about power - it is not fluence.  Even the sales guy often is not sure of the power.  So ask how fast it can go at a clinically useful setting.

By design, the Fotona XP MAX has a wavelength of 1064 nm, has on/off, VSP (variable square pulsing) power control, has Flat top optics, a computer controlled scanner and is the most powerful Nd:Yag laser on the market.  The Fotona XP MAX is the ideal laser hair removal system period.

I have been using Fotona lasers in my clinic for 8 years now.  I had the first XP MAX in the country and have used it on a daily basis since that time.  We get great results, safely, on all skin types.  We also see many refugees from competing clinics (due to poor outcomes or pain)… also with great results.