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.
Laser based technology is regulated by the FDA based on ANSI standards. Cutera is committed to safe use of Lasers in Dermatology. Links have been provided to help educate our clients on the Rules and Regulations associated with the use of aesthetic systems. Some information may be directed toward Laser Surgery and may appear to not be related to advanced skin care, however, the principles of safety are the same.
USE OF LASERS/DELEGATION OF MEDICAL FUNCTIONS REGULATION BY STATE
Laws and Regulations
Current Legislation Pending by State
Directory of State Medical Boards
Laser Regulatory Agencies and Professional Organizations
Food and Drug Administration
American National Standards Institute (ANSI Z136.3)
Joint Commission on Accreditation of Health Organizations (JCAHO)
JCAHO
OSHA (Occupational Safety & Health Administration)
Association of Operating Room Nurses
American Society for Laser Medicine and Surgery (ASLMS)
Laser Hair Removal can present an uncommon side effect of
paradoxical hair growth along with the more common side effects found with permenant hair reduction.
Skin Rejuvenation and Laser resurfacing complications can be classified as mild, moderate or severe. It is important that the treatment provider be able to correctly identify and treat these possible complications. Do not ever perform a treatment that may produce a side effect that you are unable to recognize and treat. Accurate assessment and client education are key minimizing many of the potential complications.
Vascular lesions can be associated with other disease processes and require the correct diagnosis of the lesion before deciding on which laser based technology would be most appropriate for the vascular treatment.
Treating pigmented lesions or using an IPL device can prove to be challengeing to many treatment providers. Performing a test spot in the area of treatment and then evaluating epidermal response 48 hours later can be very valuable in preventing unwanted damage to the epidermis ("foot printing"). However, the test spot may take 1-2 months to demonstrate the signs of post inflammatory hyperpigmentation.
R. Lierly, RN
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
--- Renee Lierly, RN
Skin of Color is highly susceptible to Post-Inflammatory Hyperpigmentation and requires special care whether performing a chemical peel or using Laser based technology to treat pigmented lesions, performing Laser hair removal, Skin Rejuvenation or a Vascular Treatment.
The Fitzpatrick Skin Type Test is very important to help determine skin type. The FitzpatrickSkin Type Test takes into consideration an individual's genetic predisposition that may not be reflected in the color of the skin but can highly influence the individual's ability to form hyperpigmentation in response to trauma or the use of an Aesthetic Laser System.
--Renee Lierly, RN
Ask them.
You can put out surveys in your reception area and/or send an email to your patients. On your survey, ask if they would be interested in the new procedure and offer a small discount to anyone who responds.
If you are about to implement the new technology, then let your patients know it's coming. Set up countertop signs in your reception and treatment rooms. Send an email or a postcard annoucing your new aesthetic laser system and what it can do for your patients. Offer discounts or packages to encourage "early adopters", let them be your evangelists and drive referrals to your practice.
Get the word out!
It is important to educate the client that a treatment plan for Rosacea only helps to control the active signs and symptoms. Rosacea is a chronic condition.
Treating Your Skin with "Intense Pulsed Light"
By Kevin C. Smith MD FACP FRCPC
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
--Renee Lierly, RN
IPL & ANSI REGULATION UPDATE:
At the recent American Society for Laser Medicine & Surgery meeting, there was a small breakout for the ANSI 136.3 Laser Safety Committee to discuss some issues including eye safety issues with I.P.L.'s. The general consensus was to recommend that they NOT be included in ANSI laser safety standards, and instead have a position statement issued by the Safety Committee of the American Society for Laser Medicine & Surgery. This concerns primarily the common practice of users not wearing any protective eyewear during treatments because of the poor visibility through standard IPL glasses. It is recommended that all users and patients wear protective eyewear, and special "LightSpeed" glasses improve vision for the operator.
This information provided by: http://www.lasertraining.org/
Renee Lierly, RN
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.
