Medical Laser Blog - Fotona Straight Talk for the Physician

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.

THE TOP 15 AESTHETIC PROCEDURES

Recent surveys have shown the following to be the 15 most popular aesthetic procedures:

 

1. Botox
2. Soft Tissue Fillers
3. Laser Hair Removal
4. Microdermabrasion
5. Facial Rejuvenation - IPL
6. Chemical Peel
7. Laser Facial Peels
8. Sclerotherapy
9. Facial Rejuvenation – Non-Invasive Tightening
10. Laser Leg Veins
11. Facial Rejuvenation - Fractional
12. Soft Tissue Filler - Radiance/Radiesse
13. Soft Tissue Filler - Collagen
14. Soft Tissue Filler - Autologous Fat
15. Soft Tissue Filler - Sculptra

 

Now, several of these are really the same thing.  Numbers 2, 12,13,14,15 are all really just fillers of one sort or another.  Fillers are great for the pharmaceutical company that makes them, but there is not much margin in them. The same is true for number 1, Botox.   Now, I am not saying don’t do them.  I am just saying they are more of a “lost leader.”  You need to provide them to fill out your services menu, but they are not going to be your bread and butter.

 

That leaves 3, 4, 5, 6, 7, 8, 9, 10 and 11. The Fotona platforms can accomplish these procedures with excellent results.  Take a look at number 8 - sclerotherapy.  I know you have heard that lasers are not as good as sclerotherapy, but I am here to tell you differently. 

 

I have been doing sclerotherapy since 1989, and I can tell you I am good at it.  But in a head to head competition between my wife (RN and Laser operator) and me (MD and sclerotherapist extraordinaire)… She won!  The Fotona XP Max can do spider veins from the smallest to 4 or even 8 mm, on any body part with less pain, less bruising, faster healing. That’s my experience.  So now I rarely do sclerotherapy, as the Fotona laser is just that good.

 

As for the other procedures on the list, let me just say… Fotona hands down!