A White Paper by David J. Friedman, MD
I recently completed a clinical study of laser hair removal using the LightPod Neo, a 1064nm Nd:YAG laser from Aerolase. I was requested to conduct this study because I have a well established cosmetic dermatology practice in which I perform the laser treatments myself, and hair removal is a key area of my laser dermatology expertise.
I became intrigued by this laser’s unique 0.65msec pulse duration, which is below the skin’s thermal relaxation time; this unique feature negates the need for skin cooling during treatment that is common with other systems, and it allows for treatment that is virtually pain-free on any skin type. But the main question in my mind at the outset had to do with clinical efficacy: would this device have the capability of delivering long-term results?
The parameters of the study, conducted during the Winter of 2006/2007, were as follows:
Patients were treated without any form of cooling or application of gels or anesthetics, either before, during or after treatment, regardless of skin type. The laser delivered fluences that were appropriate for hair removal, causing hairs to singe and creating perifollicular edema as expected; transient erythema was observed in just a few instances and patients reported that the treatment pain ranged from painless to tolerable. Patients were treated monthly for a total # of treatment sessions ranging from 3 to 7, and they were followed to assess long-term results. The majority of patients reported >75% clearance; those treated 5 to 7 times reported 82% clearance on average and as high as 93%. These assessments were made, on average, 8.3 months after the patients’ final treatment sessions.
This study demonstrates that, from the standpoint of clinical efficacy, the Neo has the ability to perform hair removal in a similar fashion to Nd:YAG 1064nm lasers that employ substantially longer pulse durations. This is true not only in terms of % hair clearance for a given number of treatment sessions but, of particular importance, in terms of long-term results. When combined with the other advantages of the 0.65msec pulse duration mentioned above – no skin cooling with virtually no treatment pain and the ability to safely treat any skin type – this makes the Neo a unique addition to the field of Nd:YAG lasers from a clinical performance standpoint.
The physical characteristics of the LightPod Neo laser are also very unique.
Due to its air-cooled emitter design, it is a compact and portable device, in marked contrast to large conventional water-cooled laser systems. The Neo design has eliminated the water circulating system as well as fiber optic cables common in other systems, which results in a highly affordable device that is essentially maintenance-free.
In summary, the LightPod Neo offers a new and unique set of capabilities to laser hair removal, enabling it to be a foundation laser for a hair removal practice focusing on higher-profit facial, axilla and bikini treatment areas or an extension of an existing practice into treatment of darker skin types, pain-free performance and/or any practice where the laser’s compact size, portability or lack of required maintenance are deemed beneficial.
Cellulite – the dimpled, uneven skin that mars the backsides and thighs of women everywhere – is a scourge to bikini-wearers and a squelcher of lights-on romps in bed. No wonder the search for a solution has women shelling out millions. Some of the new light was shed recently in a New York Times article by a few cellulite experts.
Miracle cures advertised on billboards and all over internet are greatly exaggerated. “At this point, there is no outstanding treatment for cellulite,” said Dr. Molly Wanner, an instructor in dermatology at Harvard Medical School and an author of an evidence-based review of existing treatments in 2008. A lasting remedy would have to address the interplay between skin, fat, connective tissue and underlying muscle.
Still, treatments abound, from contour-refining lotions and liposuction to massage machines with lasers and light sources. And there’s no shortage of takers. The market for cellulite-reduction devices in the United States was more than $47 million in 2008, said Amy Krohn, a spokeswoman for the Millennium Research Group. It is projected to grow to $62 million by 2013.
But no treatment has emerged as the gold standard. “Most studies show a 25 to 50 percent improvement after multiple treatments,” Dr. Wanner said. “Some patients have even less improvement, and the effects may go away over time so patients may require additional treatments.”
Cellulite is a telltale sign that life is a crapshoot. Most women get cellulite after puberty. But men usually don’t. That’s because the connective tissue bands under men’s skin are crisscrossed like a net, keeping their fat more evenly restrained. By contrast, women’s tissue bands are organized in vertical columns, so fat may bulge irregularly.
“At a normal weight your fat cells fall nicely into valleys of connective tissue,” said Dr. Michael D. Jensen, a clinical professor of medicine at the Mayo Clinic, who has studied fat for 25 years. “When you get too many fat cells or too big of fat cells now they push up on the roof.” Or, your skin.
What’s more, women don’t have as thick a roof as men, all the better to show dimples. And thanks to estrogen, women have more fatty reserves.
It doesn’t stop there. As we age, the connective tissue strands between our skin and muscle, which used to stretch to accommodate weight fluctuations, become inflexible. “Some of the bands tighten down and you get pockmarks with bulges next to them,” said Dr. Brian M. Kinney, an assistant professor of plastic surgery at the Keck School of Medicine at University of Southern California. Voilà, cottage cheese.
Traditional liposuction removes the fat, but it does not do anything to the inflexible connective tissue or too-thin skin. Laser assisted liposuction does a better job by heating and damaging collagen, which in turn causes connective tissue re-growth. New connective tissue is likely to have a much better flexibility and may result in tighter skin.
Cellulite is an uphill battle and no single treatment or laser modality can offer a complete cure. Cellulite reduction calls for a complex approach involving multiple laser and non-laser treatments and laser modalities. Few doctors can confidently claim that they have completed the puzzle.
Hidradenitis is a chronic disease of the apocrine glands (a form of sweat gland found on certain parts of the body). For unknown reasons, people with hidradenitis suppurativa develop plugging or clogging of their apocrine glands. It causes chronic scarring and pus formation of the underarms (axilla) and groin/inner thigh areas. In women it can also occur under the breasts. It is similar to acne, which is also a disease of the sebaceous glands. Hidradenitis is more common in people who have had acne. It may be an unusual type of adult acne.
Hidradenitis suppurativa is slightly more common in women and African-Americans. Hidradenitis usually starts as one or more red, tender, swellings in the groin or armpits. Over a period of hours to days the lesions enlarge and often open to the skin surface draining clear to yellow fluid. The involved area then heals with scarring. The condition usually continues for years with periods of flare and remission.
Available medical treatments for hidradenitis suppurativa, including systemic antibiotics, retinoids and biologics, have limited efficacy and significant side effects. Although surgery can be effective, it is associated with significant morbidity, including risks of infection and permanent scarring.
The long-pulsed 1,064 nm Nd:YAG laser provides safe and effective treatment for hidradenitis suppurativa, according to a study conducted by dermatologists Bassel H. Mahmoud, M.D., Ph.D.; Emily Tierney, M.D.; Camile Hexsel, M.D.; David Ozog, M.D.; and Iltefat Hamzavi, M.D., of the Henry Ford Medical Center, Detroit. The study group enrolled 22 patients (skin types II-VI) with Hurley stage II / III hidradenitis suppurativa that was bilateral and symmetric in distribution. Treatment sites included the axilla, inframammary region and/or groin. Areas of involvement on one side of the body were treated with topical antibiotics only, and the contralateral side was treated with topical antibiotics and the Nd:YAG laser. A total of four laser treatments were performed at monthly intervals and patients were followed for an additional two months thereafter.
The investigators speculate that the mechanism of action for the treatment benefit involves laser-induced hair removal and a photothermolysis effect leading to ablation and destruction of inflammatory lesions in the reticular dermis. These hypotheses are supported by findings from clinical evaluations and histopathologic studies.
Patients reported an early reduction in pain accompanied by an increase in discharge, which suggests the laser treatment worked similarly to surgical incision and drainage, ablating the hair follicle and allowing the discharge to escape through the follicular unit. “Our histopathology studies showed an early inflammatory reaction around the hair follicle, and evidence of follicular destruction at one month post-treatment,” Dr. Mahmoud says.
The differential responses of the three anatomic sites treated — the axillae, inframammary region and groin — are also consistent with the concept that hair removal is a primary mechanism of action.
Although improvement occurred at all three sites, when comparing the percentage changes from baseline LASI score, there was a statistically significant benefit for the combination treatment with the laser compared to the control only for the axillae and groin.
“Hairs in the groin and axillae are darker, terminal coarse hairs that respond better to photoepilation treatment than do the finer, vellus type hairs located in the inframammary region,” Dr. Mahmoud says.
This study is another example of the expanding diversity of treatments that can be performed with the 1064 nm wavelength.
This is a brief review of a study recently published by a group of Chinese researchers (see references here).
The study evaluated the efficacy and side effects of the Lumenis One™ IPL device for epilation (hair removal) in Chinese patients. Eighteen Chinese women with Fitzpatrick skin types III-V and black hair were treated four times at 4 to 6-week intervals on the axillae (arm pits) and the upper lip.
The energy density for treatment (fluence) ranged from 14 to 22 J/cm2 with filters for 640-755-nm wavelength and 3.5-7 ms pulse duration.
Hair reduction was assessed at baseline, immediately before each treatment session, and at 4 weeks after the fourth treatment. Patient’s satisfaction on a 5-point scale was also evaluated.
The average hair reduction for all sites was 49.9% after one session, 58.6% after two sessions, 79.3% after three sessions, and 83.8% after four sessions. The hair reduction of 44.1%, 52.1%, 81.1%, and 86.0% were achieved after each treatment for axillae, with 65.1%, 75.7%, 74.6%, and 78.0% for upper lip.
Patients got more satisfaction after four sessions (score 3.1) than that after two sessions (2.0). In both the assessments, upper lip appeared to show a better response than axillae after two IPL treatments, which reversed after four treatments.
No significant complications or adverse events were reported, and the study concluded that the IPL device provides a safe and effective means of hair removal for Chinese patients.
There are very inspiring articles in Cosmetic Surgery Times about the use of current Internet technologies, which allow some physicians to stay on the edge, effectively market their practice and blog about it.
Marketing of any private medical practice, and in particular of a fee-for-service aesthetic clinic has become more important than ever given the current state of the economy.
Online marketing has proven to be the most effective, measurable and sustainable type of marketing offering the highest rate of return on the investment. It is also the most overlooked and underestimated type of marketing among doctors.
Last week, Solta Medical presented a study by Steve Weiner, MD at the annual American Academy for Dermatology meeting. The presentation sparked a few discussions among doctors who have had some experience with the “new Fraxel”.
Fraxel Re:pair is a “non-invasive” laser treatment used for the reduction of fine to moderate wrinkles on the face, neck and chest. “As a plastic surgeon I’ve found this to be the best treatment on the market to date and I don’t anticipate anything will replace it for many years,” said Weiner. Some may argue that Dr. Weiner’s opinion is biased since he did the study on the Solta’s buck and featured his patients at several nationwide webinars promoting Solta’s lasers. However, Weiner’s research clearly shows the advantages of his technique, which are very valuable for many physicians.
How does Fraxel Re:pair compare to a traditional face lift?
A face-lift is a surgical procedure under general anaesthesia performed by a plastic surgeon, often in a specialized outpatient center or a hospital. The Fraxel Re:pair is considered to be a non-invasive treatment with the use of CO2 laser technology, which can be done by physicians of different specialties and in a doctor’s office. Results are expected to last up to 10 years. For most patients only one treatment is required, for deeper wrinkles two may be necessary, according to Weiner.
The laser effectively removes portions the epidermis and heats the dermis to tighten the skin and help with collagen elasticity, referred to as resurfacing. As with other laser treatment the new skin is exposed and wound care is necessary. This is the part where one may question the definition of a non-invasive treatment. After the Fraxel treatment the patient goes home with dressings on the face. The dressings need to be changed every 3-4 hours and you have to stay indoors for 5-7 days. Most patients would arguably call this pretty invasive.
The Fraxel Re:pair seems to work very well on mildly deep wrinkles, acne scars and brown spots, caused by the sun exposure. With some extra skill and experiens a doctor can work with Asians and Hispanics. Smokers and individuals with heavily tanned, pigmented or very dark skin types are not good candidates for this treatment.
The cost for Fraxel Re:pair ranges from $1,300 to $6,300, approximately 1/3 the cost for a surgical face lift which can cost more than $10,000.
Our medical panel agrees that leaving the issue of cost differential aside, for the vast majority of patients the CO2 fractional treatment with Fraxel will work just as well, if not better than the surgical face-lift. The additional benefit is that the laser actually improves the skin texture, whereas the lift merely stretches the skin.
Actifirm Post Laser Gel combines skin-soothers like Aloe and Chamomile with a Mushroom-derived, exfoliating enzyme, Mucor Miehi Extract, to inhibit pain and inflammation, while helping renew your skin to its freshest form. You’ll be looking your best in no time.
Cutera will preview its Adjustable Depth Selectivity (ADS) Technology at the 67th Annual Meeting of the American Academy of Dermatology in San Francisco, March 6-10, 2009. ADS is the result of five years of clinical research conducted with in-vitro human fat cells at the Cell Culture Facility at the University of California Medical Center, San Francisco (UCSF).
The research determined fat cell survival rates following thermal exposures, which is necessary to establish treatment parameters and to make the next step in the development of new technologies for non-invasive body contouring. The two key features of this technology are the ability to selectively target and heat fat cells and to vary treatment depths within the fat.
The findings will help physicians develop new protocols for more efficacious treatment of a wide variety of patients and boost new device innovation.