Skin-lightening Challenges

By: Zoe Diana Draelos, MD

This kind of aesthetic laser system purchase involves asking thorough questions to ensure the decision is good for your practice.  

Questions to Ask Before Buying an Aesthetic System from a Third Party

Does the seller have a clean title on the system?
Most aesthetic systems are leased.  For any system that is less than 3 years old, there may be a sizable payment remaining on the lease.  Until the lease is paid in full, the lien holder (usually the lease company) has rights to the system.  At a minimum, you should call the manufacturer to check the serial number on the system to verify the title is clear.

It is important for treatment providers to be familiar with legal issues of operating an Aesthetic medical practice. The regulations for the use of Laser based technology vary from state to state on who can perform the treatments. In some states Laser hair removal may be delegated to "an employee under the physician's supervision" while in other states the person performing the treatment must be a licensed healthcare professional. 

New Report Outlines Key Legal Issues for Medical Spas and Aesthetic Medical Practices

Source: The International Association for Physicians in Aesthetic Medicine
www.IAPAM.com

Laser Safety



Source: Betty Minor, BS, RN is President of Laser Resource, Inc., Aurora, Colorado since 1986 actively consults and teaches laser safety programs, facility safety audits and overall laser safety development across the country. She was the Operating Room Director of Surgical Services; Director of Education east coast based Laser Company. She is a Sitting Member of the ANSI Z136.3 Safety Committee. She was instrumental in the development of the Medical Laser Safety seminar, which is recognized throughout the country as the most informative and practical for any health care laser facility. For more information, please contact her via e-mail at bettyminor@ds-int.com.






 

Laser based technology requires that the treatment provider accurately assess client skin type. Successful skin rejuvenation may require treatment of pigmented lesions, skin tightening and Laser vein treatment. In order to minimize and manage unexpected outcomes and possible complications the treatment provider must choose correct parameters on the aesthetic laser system based on a comprehensive skin type evaluation. The Roberts Skin Type Classification System is a 4-part serial system that comprehensively identifies a patient's skin type characteristics, and provides data to predict the skin's likely response to insult, injury, and inflammation (i/i/i) for individuals of global skin types. The clinician evaluates 4 elements (phototype, hyperpigmentation, photoaging, and scarring) and assigns a numeric "feature" to each, according to established and original scales. This classification system can uniquely help determine the course of treatment, clarify postprocedure expectations, and optimize outcomes. This individualized approach to identifying features and elements in various skin types will positively impact on physician communication, patient awareness and compliance, and preventive measures.

Most laser based technology used in Dermatology creates a laser induced thermal injury by the absorption of electromagnetic energy by chromophores in the skin (melanin, hemaglobin and water). Thermal damage to structures of the skin is a combination of time and temperature, the temperature to which the cell is heated as well at the time period for which the temperature is sustained. The goal of controlling a thermal injury requires careful selection of wavelength, fluence, pulse duration and spot size. Skin color in addition to Cooling the epidermis before, during and after a laser pulse must be taken into consideration to prevent unwanted thermal injury to adjacent tissues. The failure to properly assess the client, select appropriate parameters and ineffective or improper cooling may all contribute to an unwanted adverse effect of a burn injury.

Laser hair removal, Laser vein treatment and the treatment of pigmented lesions can all result in a unwanted burn injury. The first objective in burn wound care is to dissipate the heat. Clinical evidence indicates a beneficial effect from immediate active cooling of a burn injury to dissipate the heat.
Cool tap water or saline compresses is an effective method of cooling. Colder substances such as ice can be detrimental by extending the zone of injury by constricting the blood vessels. The period of time that is required for active cooling is brief. Cooling stabilizes skin mast cells, decreasing histamine release, thereby, decreasing edema of the wound. Cooling is an effective way of controlling the pain of a partial-thickness burn. Cooling for pain control may be achieved by using moist cool compresses, not ice packs.

Treatment providers should not perform any procedure that produces a side effect that they are unable to recognize and treat. Treatment of a side effect must comply with the standard of care ordinarily used by other healthcare professionals practicing their profession in the same or similar locality and under the same or similar circumstances. The failure of a healthcare professional to observe the standard of care is negligence.
It does not matter if the burn injury was caused by an Aesthetic Laser system of some other heat source, the standard of care remains the same.
I have included several links for burn injury first aid to reference as the standard of care.
Mayo Clinic
Health Sciences Center, University of Utah
Burn Injury Lawyers
Massachusetts General Hospital

Laser based technology is both safe and effective for permanent hair reduction, skin rejuvenation, skin tightening, laser vein treatment and treatment of pigmented lesions. The use of an aesthetic laser system for advanced skin care requires the operator to be familiar standards of care and laser safety in order to be in compliance with Laser regulatory agencies such as JCAHO, OSHA, ASNI standards and state regulations.

The Laser Training Institute offers Aesthetic Laser Training and National Laser Certification. The laser course offers a foundation in aesthetic office procedures and safety.

Renee Lierly, RN

About the author:
Dr. Kevin Smith is a dermatologist in Niagara Falls, Ontario with a particular interest in protecting the skin and in correcting skin problems resulting from aging, rosacea and sun damage. He is an expert in the use of Botox®, fillers, lasers and intense pulsed light to maintain and enhance the appearance of the skin, and have lectured on those subjects across North America, and in Europe, Asia and Mexico. Read more at www.smithlaser.com

Pulse duration is one of the most significant laser parameters to understand. Proper pulse duration is key to a safe, consistent and effective laser hair removal or vascular treatment. For this reason, it is typically the first parameter set by practitioners. Vein treatments include facial veins, leg veins and an occasional varicose vein treatment--although varicose veins are part of a larger medical condition not treated by a non-invasive aesthetic laser system.

Pulse duration determines the volume of tissue treated by the laser. Long pulse durations treat large volumes, short pulse durations treat small volumes. As an analogy, imagine a hot iron. A person can tap the surface of a hot iron that is several hundred degrees and not feel pain or get a blister. The reason is only the most superficial cells heated up during the time their finger contacted the iron. The heat did not have time to spread deeper into the finger. Conversely, it's extremely difficult to hold a hot cup of coffee even though it's far less hot than the iron. The difference is contact time. The cup is in contact for a long time so heat has time to conduct into the finger. Another analogy that compares to laser treatments is a pot full of hot soup. The soup stays hot in the pot for a long time, but if it's poured into 10 separate bowls, the bowls of soup cool down rapidly. This is because small objects give away heat to their surroundings more rapidly than large objects.

These same concepts are used when performing a laser vein treatment or laser hair removal treatment with an aesthetic laser system. The goal of every treatment is to heat the target you want to treat, but do as little collateral damage to surrounding tissue as possible. Large vessels (like leg veins) are like a pot of soup. They heat up slowly, and also don't give away their heat to their surroundings as well as small veins. This means long pulse durations will heat the vein, but still not heat surrounding tissue. In contrast, small veins, like facial veins, are very small and give away heat to their surrounding tissue quickly. This means energy must be applied in a short time--faster than they can give away their heat. If the pulse duration is too long, some of the energy (heat) ideally meant to treat the vein is lost into surrounding tissue heating the surrounding tissue, but not the vein. So, if the pulse duration is too long, more fluence (power) is required to achieve a clinical endpoint, but some power was wasted in surrounding tissue increasing the risk of complications. If the pulse duration is too long, it becomes impossible to treat the target regardless of the amount of fluence.

Using the correct pulse duration results in the most consistent outcomes with the lowest risk of complication. This allows the lowest amount of fluence to have the greatest impact on the target with the greatest degree of protection to the epidermis. In a nutshell, every treatment wants to use a pulse duration shorter than the time it takes for the target (hair or vein) to give away heat (thermal relaxation time) and longer than the time required for the epidermis to give away heat. Pulse durations longer than 5-10 ms provide epidermal safety by the same principal that prevents a long pulse duration from efficiently treating a small vein. The longer the pulse duration, the safer it is to the epidermis, but if it's too long, it will cease to be effective on the target.

So, in summary, how does someone select the correct pulse duration? Small targets require short pulse durations, large targets respond to long pulse durations. Longer pulse durations maximize epidermal safety. The following are approximate times to help select the correct pulse duration. If the duration is within about 5-10 ms of the ideal pulse duration, the treatment will achieve maximum efficacy and safety with minimum fluence. Remember, cooling is also a critical factor effecting epidermal protection and is also required for safe treatments.

Hair Treatment:

• Fine = 5-20 ms
• Medium = 15-30 ms
• Coarse = 25-50 ms
• Very coarse = 40-80 ms

Vein Treatment (size of vein is measured diameter):

• Typical pulse durations range from 10ms to 100ms for small high pressure telangiectasias to large low flow leg veins.

Let's say that you have an existing practice with an established patient base.  How do you let your patients know you are about to acquire an aesthetic laser system, such as the Cutera Xeo with Pearl, Titan and LimeLight?  You will have the ability to treat your patients for facial veins, leg veins, laser hair removal, pigmented lesions and overall skin rejuvenation including skin tightening and laser skin resurfacing.

Wow, that is very exciting!

Your patients will be excited.  So, let them know your news in a variety of ways (most of which are inexpensive and easy to do).

   1. Signage in your waiting and exam rooms
   2. Patient education brochures
   3. Add the news to your invoices and receipts
   4. Direct mail to your patient base
   5. Reception
   6. On-hold messaging
   7. Staff evangelism

1.  Put up posters and/or countertop displays.  If you are pre-announcing, indicate that the services will be offered soon and encourage making appointments right away (before we are fully booked....).  Offer free consulations to existing patients.

2.  Brochures that educate patients are available from your vendors.  Cutera has standard patient brochures for all of our procedures and we are unique in our industry - we also have a web site where customers may order customized patient brochures.  Visit CuteraPatientTools for details.

3.  If you have a custom field on your printed invoices and receipts - add a line about your new aesthetic offerings.

4.  Send a letter with a brochure to your patient base.  Let them know what you now offer.  While it is great to target specific demographics, aethetics are of interest to most of your patients.  They may pass your brochure on using lasers for permanent hair reduction, vascular treatment, Pearl laser resurfacing or Titan to their children, parents, spouse or friends.

5.  Train your front office on your new offerings.  Give them Frequently Asked Questions (FAQs) or a phone script to use to inform, promote and soft-sell.  Consider having a sign at the front desk or have your staff wear buttons that say "Ask me about Laser Genesis" or another application.

6.  Every time you put a caller on hold, you have an opportunity to market to them.  You can record an on-hold message for a few hundred dollars.  Be sure to pick a package that allows you to update the message regularly so you include package information, seasonal treatments and holiday specials.

7.  Your staff are your evangelists.  Give them free treatments.  They need to know what the treatment feels like, how long it takes, what is needed to prepare for the treatment and be alert to the no-no's (such as tanning before IPL or using self-tanning products).  They should be so thrilled with their own results that their enthusiasm and positive comments will help create additional excitement in your patients who are considering any laser based treatments.