Medical Laser Blog - Fotona Straight Talk for the Physician

The Laser Lipolysis Debate

The debate about laser lipo continues to rage.  In a recent article from AmericanHealthandBeauty.com there is a point/counter-point about laser lipo.  The pro-guy is saying it’s the greatest thing since sliced bread, while the con-guy is saying it hasn’t been shown to be as effective as standard lipo and that it may, in fact, be dangerous. 

 I think one piece of the puzzle surrounding laser lipo is that there is a lot of confusion around what our goals are.  The goal of laser lipo is to heat a volume of tissue (fat) to a relatively specific temperature.   Companies using the sort of over-simplified idea of selective photothermolysis have at some points chosen inappropriate wavelengths. 

In our paper on laser lipolysis, we show how there is an optimal place between affinity or absorption and scattering.  There are also other safety considerations because we’re looking at a volume of different kinds of tissues.  We certainly want to achieve a specific temperature within the target tissue, but we don’t want to super-heat surrounding tissues to an unwanted amount.  Certain wavelengths have a higher affinity or higher absorption in the skin than they do in the fat.  As an example: Nd:YAG actually has no significant change in absorption in the fat vs. the skin so you don’t see a spike in this undersurface of the skin temperature the way you do with other wavelengths such as 1440nm, 1320nm,  980nm or 920nm.

Laser Lipolysis, like any procedure, if done incorrectly certainly can be very dangerous so should only be done by:

1) people who understand what they’re trying to achieve and have been trained in the ways to achieve it. 

2) selecting the proper equipment. 

Everyone is trying to get an edge, and as I’ve said many times before in this blog, most companies, rather than trying to figure out what needs to be done and perfecting it, focus instead on marketing and aim for a patented, custom wavelength that’s a few nanometers here or there from a standard wavelength.  A good example of that is Nd:YAG, which has several harmonics (the primary of which is the 1064nm wavelength) but there are other harmonics as well.   Some companies have used these other wavelengths, and even patented them, telling us that there is some new, bigger, better, faster idea or way to manage aesthetic laser procedures.  The truth is….that’s hype.

If you look at an absorption curve, there aren’t tiny regions – there are broad regions – where wavelengths are efficacious.  The idea that 3 or 4 nm this way or that way or even 1, 20, 100 or 200nm are dramatically different is really just wishful thinking on the part of the marketing department. 

What’s really important is having precise control of the delivery of your energy so you can have precise control over the tissue interactions, and that of course, as I’ve said many, many times, is the strong suit of Fotona.   

Fotona has taken the time, effort, energy and engineering know-how to create the kinds of controls on their lasers that really matter.

When you’re contemplating laser lipolysis, take care not to be fooled by the hype and all these goofy machines that measure temperature, etc.  If you have to measure temperature so closely, you’re not doing it right!  When you’re doing laser lipolysis, you should have one hand right over where the tip is so that you can feel it moving through the tissue and guess what?  If you’re hand is getting hot, the skin is getting hot!   These goofy gizmos that turn the thing on and off automatically or presume to give you dosimetry – these are rough estimates on a good day.  What really needs to be done is to put your human hands on your patient just like you always have and you need to feel what’s going on.   When you feel it, you will a) get consistent results, because you will feel how the tissue is reacting to the laser and b) you won’t over-heat the tissue because you will be feeling it the heat!

So, laser lipolysis… friend or foe?  I think it’s a friend.  I think it has specific applications.  I think it’s a great addition to a liposuction practice.  We use it and we find it useful, especially for double-sided skin tightening.  Consider the "laser sandwich." We put the skin between laser on the underside of the skin and laser on the upper side of the skin and get really dramatic skin tightening along with the fat removal.

 

Laser Lipolysis for Fat Reduction With a Wow Result

Zeltiq is one of the fat reduction tools.  I’ve been looking at it for years.  I’ve been watching their publications come out and finally had an opportunity at a recent trade show to talk to their rep in detail.

So here are my impressions.  It’s an interesting concept.  Basically, the machine works like this:  there is a vacuum pump that pulls a fold of the subcutaneous layer up into a chamber and then that fold of skin is cooled from both sides with an electro-coupled cooling device.  The device is applied and a technician stays with the patient for the first five minutes or so (because that is the most painful period) and then after that, the patient becomes somewhat numb to the procedure. The technician then takes a built-in paging device so he/she can go and do other things.  The patient can push a button and call the technician at any moment or the pager goes off at pre-selected intervals to remind the technician to check in on the patient during the hour-long treatment.

Now, studies have been done and this treatment does show fat reduction.  But frankly, these fat reductions are very modest. When you look at clinically relevant pictures it appears that only relatively fit people with very small love handles or saddlebags are going to be happy with the results.  Remember that my major philosophy is to get the “wow” result (I’m a liposuction surgeon) – so getting a tiny improvement on a person who’s already quite fit (non-invasively) might be something of interest only to that particular demographic.  I don’t think this is going to be very useful for most individuals because most have a greater amount of fat to lose and I don’t think this technology is going to do it.

So for the very refined, niche market, where they talk about a 25% reduction in the fat layer – what they’re really talking about is a reduction from 7.2 millimeters to 5.4 millimeters and if you think about that reduction, while it is 25%, how clinically relevant is that?  Zeltiq has a few before and after pictures that show love handles on a man and they definitely show a decrease in the after picture – however, these photos are very difficult to take to accurately show results.  For example: in the before picture are the hands horizontal and in the after picture the hands are vertical?  This can make a big difference in the profile.  I don’t know the answer to this because they don’t show the positions of the hands, so I’m not suggesting they’re trying to cheat – but in my experience, getting excellent before and after photographs is very, very difficult.  Lighting and difference in body positions can create a dramatic difference.  

Overall, my impression of Zeltiq is that it’s an interesting technology, but probably not an adequate therapy for somebody who really needs fat reduction.  It’s more of a subtle body-contouring technique for somebody who’s already pretty ripped but can’t get rid of that small love handle or saddlebag.  

If you really want fat reduction in a significant way, you ought to consider  laser lipolysis (with the Fotona XP Focus) or just plain liposuction as a minimally invasive and very safe procedure for fat reduction and body contouring.

Fotona Lipolysis Laser at ASLMS: Lower Cost, More Power

So here we are at the ASLMS (American Society for Laser Medicine & Surgery) Annual Meeting and Exhibit.  I’m sitting in our Fotona booth and looking around and I see SmartLipo, Smooth Lipo, Slim Lipo and Cool Lipo…and they all are one-trick-pony boxes.   In contrast, Fotona’s Lipo and Endo-Vascular unit is about $40,000 cheaper than our closest competitor and it’s more powerful.

I’m looking around at these machines and take Slim Lipo, for example. They display a graph with all the different laser wavelengths and it’s claiming that the best wavelength is 924nm.  I had talked about that wavelength in a previous post, talking about how 924nm has a very high absorption into fat.  At first blush, that might seem like a good idea doesn’t it?  But when you’re very highly absorbed, you get a very hot core and in lipolysis, we’re not trying to ablate – we’re trying to heat.  So at 924 you get a small volume of fat heated.  At 1064, because it has a much lower affinity for fat, you get a very large area that is heated and thus more efficient melting which means fewer passes and a more efficient treatment.

So when looking at lasers, remember that if you’re trying to ablate something, clearly you want a high affinity.  If you want to heat something – you don’t.  And it turns out that 1064 nm has kind of an intermediate absorption in fat.  It’s got a higher absorption than 1320nm, but far lower than 924 nm.  

Take a look at the Fotona lipolysis machine called the Focus XP-2.

Laser Lipolysis Equipment. No Snapping. Just Efficient.

I may have related this story on the blog before, but it’s such a silly story that I have to tell it again.  I was attending a workshop where a company that has  two-wavelength laser lipolysis equipment was demonstrating, and the doctor was alternating between the two wavelengths.  One of the two wavelengths makes a snapping sound when you’re doing the lipo and you can hear it right through the skin.  So…this snapping sound is going on and the doctor who is demonstrating the system, who is sort of the representative for this company, is grinning and saying “aaah, I love that snapping sound – isn’t that great?  You can just tell there’s something going on in there!”    Well, the interesting thing is that the snapping sound is caused by an undesireable effect...a very high absorption in the fat.  That very high absorption into the fat causes a super-heating and an ablative reaction that causes the snap sound.  That ablation absorbs the energy and does not allow for a lot of transfer of the energy to the surrounding tissue, so you get a very small volume of tissue heated.  

In laser lipolysis, you’re not trying to ablate the fat – you’re trying to liquify the fat.   You’re trying to disrupt the cellular membranes and liquify the fat, so you want to heat volume.  The larger volume of tissue you can heat, the more efficient your lipolysis will be.  

Fotona's laser lipolysis systems, through it’s superior R&D and engineering, have been given a wavelength that has a relatively low absorption in fat.  That low absorption in fat allows the energy of the laser to diffuse into the fat layer, heating a large volume of fat resulting in a more efficient heating and disruption of the cell membranes and liquification of the fat in the subcutaneous layer.  That results in the requirement for fewer passes of your liposuction wand – for a faster treatment with less trauma.  

You have to be careful.  Snapping things and little noises – while they might sound intriguing, are they really what you’re looking for in a system?  What you’re looking for is an efficient treatment and in some treatments you want a very high absorption, there’s no doubt about that.  In other treatments, you want a relatively moderate absorption so that you get more diffusion.  

Now, it would be possible to have a wavelength that had such low absorption that it wouldn’t heat the tissue at all – it would just pass through it, like white light passes through clear glass.  That wouldn’t be helpful.  You have to have the right wavelength with the right parameters to create a large volume of heated tissue.  

The other quality that makes Fotona a unique laser lipolysis company is that our wavelength has a relatively low absorption at the underside of the skin interface…that subcutaneous dermis interface.  Some of the other wavelengths – the one in particular that I was just talking about that makes the snapping sound – have a very high absorption and that’s a bit of a concern.  You know, many companies are creating all sorts of do-symmetry sorts of devices or safety devices where if you stop wiggling the handpiece, the laser turns off and so on.  Those are all fine and good, but the reason why they need those is because you have a very high absorption in that subcutaneous skin interface and you could burn the skin from the underside very easily.

We (Fotona) have engineered the beam profile properly to avoid those issues.  Now, you still have to know what you’re doing because as you know, you can injure yourself with anything in life and you can certainly injure someone if you’re doing your procedure clumsily, but done properly, the Fotona Laser Lipolysis machine is among the safest on the market, has the largest volume of tissue heated and therefore is the most efficient system in terms of work required to liquify the fat.  So laser lipolysis is the cutting edge technology for fat reduction.  Forget about all these transcutaneous laser wands that you just wave over the skin.  Give me a break!  Use some common sense.  If it were that easy, we would all be doing it.  Use the real thing.  Use Fotona’s laser lipolysis system.

Why Nd:YAG for Laser Lipolysis?

The 1064 nm Nd:YAG lasers are the most widely used lasers for lipolysis, with the longest clinical record of safety and efficacy. The clinically observed minimal discomfort, exceptional long-term success and short recovery are attributed to this lasers ability to optimally target laser energy into fatty tissue, thereby limiting undesirable side effects.

In addition, the Nd:YAG 1064 nm laser systems have developed significantly since their introduction for laser lipolysis. For example, the latest Fotona XP-2 Focus has a 30W QCW mode power generating capacity, reaching higher procedure speeds and efficiency while operating at a fraction of its maximum capacity. This ensures system durability, essentially lowering running costs. In conjunction with the VSP (Variable Square Pulse) technology, a wide range of selectable pulse durations are now available in Nd:YAG lasers. This provides better procedure control and extreme versatility. The latest Nd:YAG laser devices can be used not only for laser lipolysis but also for endo and exo vascular procedures, FRAC3 skin rejuvenation, acne treatments, hair removal, and other procedures. The high performance and versatility of the latest technology solid crystal Nd:YAG 1064 nm laser systems, combined with their optimal efficacy and safety, make these lasers the medical devices of choice when compared with other wavelength devices for laser lipolysis.  Take a look at our white paper on laser lipolysis for more information.