Cutera

I heard from a colleague who recently attended a customer event at an aesthetic practice.  The event was sponsored by Allergan and primarily promoted Latisse to their event attendees. 

The physician was offering a discount on Latisse to any attendee who purchased that evening or within a few days. 

I thought it was interesting that the physician did not promote her other services or products.  She sold ~10 units of Latisse at the event and of course, there will be a great opportunity to market additional services to those buyers going forward but I think it would have been a more profitable event had the physician enlisted additional vendors for support and opened up her event to more promotion.  She could have promoted laser hair removal (which can be safely performed year-round with CoolGlide Nd:YAG, even on tanned patients), non-invasive skin rejuvation (Laser Genesis, again, safe on all skin types, year-round), Titan, fillers and BOTOX. 

Open houses and customer events are a great way to have current customers (patients) bring friends and family, enjoy some wine and hors d'oeuvres while learning about new products and services and enjoying special attention (receiving goodie bags, being offered special discounts for packages paid for that evening or within 48 hours, referral $ or points if their friends/family buy product or sign up for packages). 


Customer events are great marketing tools - just be sure to leverage the event for all it is worth!

The reason for selecting YSGG over CO₂ is only strengthened when comparing YSGG to low power CO₂ lasers. Low Power CO₂ lasers (typically 30 watts and below) exaggerate the problems of CO₂ and have several independent problems as well. Histology obtained from data sheets for Deka’s SmartXide DOT and Alma’s Pixel CO₂ are included to illustrate the problems with devices that do not have sufficient power and energy density in each spot. 

Many people believe wavelength determines depth. For ablative lasers, this is not true. Wavelength determines the thermal characteristics of the laser, but depth of ablation is determined by power and energy density. With the right amount of power, all ablative wavelengths can ablate equally deep. Their thermal damage zones, however, vary significantly across devices.

A first typical problem of lower power CO₂ lasers is ablation depth. To ablate deep, lasers must have high energy densities delivered in short time periods. This requires high power. Depth of ablation is directly proportional to treatment results up to about 400-800 µm deep. Beyond this depth, there are two schools of thought. One thought is that greater depth is better, the other is that greater density is better. There is likely some truth to both. Either way, however, device should be able to treat at least 400-800 microns deep. 

In the histology image below, the image on the left shows a lesion from a single laser pulse. The ablation depth in this image is ~200µm (based on epidermal thickness of ~70µm). The histology image on the right shows a deeper treatment, but as can be seen, this required stacking 3 pulses (i.e. firing three pulses in the same location). Stacking pulses is challenging as even minor movements by the patient or practitioner can misalign the treatment holes as each spot is only several hundred microns in diameter. Further, it takes 3X longer to perform a treatment if stacked pulses are required. This means the patient experiences 3X as many shots per pass, which can reduce the tolerability of the treatment.

The second problem with low powered CO₂ devices is pulse duration. The primary problem with any CO₂ laser is excessive thermal damage. This thermal damage leads to increased potential for pigmentary complications and slows wound healing time. This is the reason all low power CO2 units were long ago abandoned for full resurfacing. This thermal damage is also a limiting factor or fractional CO₂ devices and can lead to the same complications as observed with full resurfacing CO₂ lasers if greater depth or density treatments are attempted. To properly perform a resurfacing procedure with a CO₂ laser total exposure time should be less than ~600µs to confine thermal damage. 

·        This is documented in the text “Cutaneous Laser Surgery” Chapter 6, Carbon Dioxide Laser Surgery.  In this text, it states that the thermal relaxation time for the volume of ablated tissue during CO₂ resurfacing is about 695 us and pulse durations of less than 950 us (0.95 ms) are sufficient to prevent clinically significant thermal damage

Because the laser is low powered, long pulse durations must be used to deliver sufficient energy to ablate tissue. In fact, many pulse durations as much as 100X longer than was experimentally and clinically proven optimal for CO₂ lasers.

The long pulse durations used with low power CO₂ lasers can be seen histologically in the two images above. In both cases, the coagulation / thermally damaged tissue zone is ~250-300 microns wide and deep. This means the treatment diameter of the laser is not just the spot size, but the spot size plus ~250 µm on each side of thermally damaged tissue, meaning the spot size is ~500µm wider than stated – leading to greater downtimes if treatments are performed to equivalent depths for equivalent treatment results.

The end result of minimized ablation depth, excessive thermal damage, and large effective spot sizes is that treatments are predominately thermal (not ablative), and are not very deep. Fractional non-ablative devices were completely thermal, and deeper, but required 4-6 treatments. Low powered CO₂ lasers do have maximized ablation (the only difference between ablative and non-ablative fractional lasers) meaning these treatments and results are closer to fractional non-ablative devices. Further, it is often necessary to perform multiple treatments to provide equivalent end results as highly ablative fractional devices (like Pearl Fractional). Many before and after pictures actually show results pre and post 3 treatments each spaced roughly 1 month apart.

Pearl Fractional was designed to reproducibly deliver deep fractional ablation with variable density to provide single-treatment results with maximum results and consistency. Accomplishing this and limiting downtime and complication risks required a wavelength capable of providing controlled thermal coagulation in a pulse-duration that is thermally confined. Pearl fractional was designed with sufficient power to ablate to necessary depths (typically 600-800 microns, which is ½ of maximum power). See comparison histology images below – image sizes are scaled to maintain approximately equal magnification. Histology images for the SmartXide DOT and the Alma Pixel CO₂ were obtained from product brochures from each company.

In a simple answer, Cutera selected YSGG (Pearl and Pearl Fractional) for thermal control with the desire to maximize ablation and control, but not eliminate coagulation (thermal damage). A little thermal damage during ablative procedures is a benefit, but too much can be a liability. Laser wavelength is the primary determinant of thermal damage. Power determines how deep an ablative laser vaporizes – and necessary power is determined by water absorption. At the edges of the ablation column though (sides and bottom) there is not sufficient power to continue ablating tissue. From this point outward, the zone of thermal damage is determined by how far sub-ablative intensity light penetrates through tissue – creating a coagulation zone. Cutera selected YSGG because this zone is 40-60 microns thick. Conversely, Er:YAG is about 10-20 microns and CO₂ is about 75-150 microns.

The coagulation zone (thermally denatured tissue) with YSGG is thick enough to coagulate normal microvasculature in dermal tissue, thus preventing significant operative bleeding. It is small enough though to be able to maximize ablation area without unduly increasing the size of the lesion. Note: thermally denatured tissue is dead / necrotic tissue that the body must also clear for the wound to heal. Additionally, excess thermal damage is associated with increased risks of pigmentary complications. With the thermal control of YSGG, Pearl fractional can maximize treated area and tissue vaporization beyond that of CO₂, yet still provide coagulation and thermal stimulation that is lacking with Er:YAG.

1. Don't drop prices (much) - instead concentrate on package deals, being very mindful of consumer price sensitivity
2. Leverage existing patients - reward them well for referrals
3. Market internally - use brochures, email newsletters, posters, dvds, photo frames, before and after books, countertop signage
4. Work social media - encourage patients to post positive reviews on as many review sites as possible such as Yelp, RealSelf.com, CitySearch.com...

A frequent question regarding Pearl and Pearl Fractional for resurfacing is which product is more aggressive? The common misconception is that Pearl Fractional is less aggressive than Pearl. This misconception comes from old technologies like CO₂ traditional resurfacing vs. fractional – where the fractional therapy is less aggressive. 

Pearl (confluent) is not designed to create deep full coverage resurfacing like old CO₂. This is not due to its ability, but rather due to the market desire. There are very few deep full coverage resurfacing procedures performed due to the prolonged downtime and high risk of complications. Pearl (with YSGG) is able to perform a treatment that no other wavelength can accomplish. That is to treat to the D/E junction with a thermally confined pulse to provide full surface improvement and collagen stimulation without weeping, oozing or long downtimes and risk. 

Pearl Fractional is designed to be the aggressive tool. Because it treats fractionally, it is possibly to create deep ablation without high risk and downtime. When performing Pearl Fractional procedures, the energy delivered from the laser is significantly more intense than a Pearl laser shot, resulting in ablation in excess of 1mm. Most treatments are performed at 600 to 800µm, which is 1/3 to ½ of the maximum settings on the device.  . Density is then selected by the user to determine the degree of coverage – and subsequent intensity desired. Pearl Fractional is actually one of the most powerful and potentially aggressive devices available on the market today. The aggressiveness of Pearl Fractional treatments (depth and coverage percentage) is limited by physician choice, not by the device.

So why use both? Pearl performs a treatment no fractional laser can accomplish. It treats the entire surface of the face to the D/E junction. This improves universal skin tone, texture, quality, pigment, etc. Pearl Fractional is aggressive to treat significant damage with minimal downtime, but does so by being fractional. This can be used to create greater dermal injuries in focal regions for greater stimulation – but it, like all fractional lasers, intentionally does not treat the majority of the skin’s surface.

• Press release
• Video footage (interview with Brian Biesman, MD and treatment footage)
• Set of before and after patient photos
• Image of the Pearl Fractional device
• Hyperlinks to Cutera.com and PearlSkin.com
• Press fact sheet
• Press Frequently Asked Questions
• Article on Pearl Fractional

• Do you have a diverse patient population with all or most skin types and many different ethnicities?
• Are you able to offer aesthetic treatments to all of these patients?
• Do they know you have aesthetic products and treatments for THEM?

• Mention it on your web site (with a link back to original site)
• Tweet about it on Twitter (with a shortened hyperlink)
• Bookmark a link to the original site on your practice's Facebook page
• Email a mention on your newsletter to clients

• Setting the Tone
• Providing a Polished Image
• Rewarding Employees
• Accountability
• Be Creative

Advance for Nurse Practioners has an interesting series of media tip articles.  Video marketing is getting big - both on websites and using social media sites like YouTube!

You can create promotional videos, infomercials, patient education, training or testimonial videos.  If you can think of it, you can make a video about it. 

Lights, Camera, Aaack! Advice by Patti Weaton, NP

     Watch Patti's video

On Air! Advice by KC Arnold, NP

     Watch KC's video

What are YOU waiting for? 





 

Hair Stimulation Following Laser and Intense Pulsed Light

The increased terminal hair growth occurred mostly in areas in which fine hair or both fine and coarse hair was present prior to initiation of treatment.

Laser based technology has provided a permanent hair reduction for many people. However, for a very small percentage there can be counterintuitive hair growth.

Increased terminal hair growth has been seen with near infrared and infrared technology.

It is important to be aware of this possibility when providing Laser Hair removal services.
 

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.

The American Society of Plastic Surgery (ASPS) released statistics today, indicating "ethnic cosmetic procedures increased 11 percent in 2008, with more than 3 million performed, while procedures among Caucasians dropped 2 percent. Cosmetic procedures among Hispanics, the largest and fastest growing ethnic group in the U.S., experienced the greatest growth; up 18 percent."

That is great news for any practice offering aesthetic procedures with a diverse patient population.

"We're seeing a rise in Hispanics opting for cosmetic procedures that coincides with the growth we're seeing in the nation's population," said ASPS President John Canady, MD. "Less social stigma, as well as, advances in procedures allow patients to maintain their ethnic look. While the majority of patients continue to be Caucasian, the profile of the typical patient is changing."

Tripti Burt, MD, is shown here treating her hispanic patient with fillers and Cutera's Laser Genesis to improve her skin's tone and texture.