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Expert Insights: A review of laser-based technologies in aesthetic medicine

A review of laser-based technologies in aesthetic medicine

As demand for energy-based anti-aging procedures continues to rise, practitioners are faced with choosing from a wide array of aesthetic platforms and devices that are, at times, difficult to differentiate. Some are one trick ponies and offer a single procedure; others are full-blown multifunctional platforms that perform everything from energy-based hair removal to fat reduction, laser skin resurfacing and skin tightening.

According to statistics published by the American Society for Aesthetic Plastic Surgery (ASAPS), the above-named applications were among the top ten non-surgical procedures listed in 2017. Naturally, many of these procedures are performed using laser-based aesthetic devices.

“There are so many companies selling good products, it is a bit like a buffet,” said E. Victor Ross, M.D., director of the Laser and Cosmetic Dermatology Center at Scripps Clinic in San Diego, Calif., and past-president of the American Society for Laser Medicine and Surgery.

Additionally, an increasing number of non-core physicians – such as family practitioners, internists and OB/GYNs – are entering the aesthetic space as a means to supplement the decreasing income from their conventional, reimbursed medical services. For these medical professionals, easy-to-use non-surgical solutions are front of mind.

Nevertheless, both new and experienced practitioners are faced with real-world considerations when deciding on the right laser for their practice.

“Before making any purchase a physician should know what’s available, as well as the benefits and drawbacks of each,” said Edward Zimmerman, M.D., a cosmetic surgeon in Las Vegas, Nev. “They must know how to evaluate a technology or device. And, in addition to purchasing a laser-based system, physicians must then market themselves and the device.”

According to Anne Chapas, M.D., a dermatologist and dermatologic surgeon in New York City, N.Y., who specializes in laser surgery, physicians should start by looking at their existing practice needs. If you are a surgeon wanting to deal with surgical scars then you are going to want to buy a different laser than, say, a gynecologist whose patients are asking about vaginal atrophy and laxity,” she said.

A quick look at energy-based devices reveals a broad range of options, noted Lori Robertson, M.S.N., F.N.P.-C., owner and clinical director of Ajliss Medical Aesthetics in Brea, Calif.

“You have so many different types of technologies and devices to choose from. There are laser-based systems that can treat practically anything and everything that your patients can throw at you,” she expressed. “However, my number one concern is always whether or not the device and/or procedure is going to work. If it doesn’t work, then I don’t want it.”

Prior to making a buying decision, practitioners need to demonstrate a working familiarity with energy-based technologies, from solid-state KTP lasers to Ruby, pulsed dye, diode, Nd:YAG, Er:YAG, CO2, etc.; to intense pulsed light (IPL), radiofrequency (RF), ultrasound and light-emitting diodes (LEDs).

“Become familiar with the important features of each technology and their appropriate applications when selecting a device,” stated Ms. Robertson. “You can go from ultraviolet all the way up to infrared with lasers, so that you can work on any skin color. Additionally, various types of tissues can be targeted at many different depths.”

Diligent analysis should narrow down the list of possible purchases, stated Neil Sadick, M.D., F.A.A.D., F.A.A.C.S., F.A.C.P., a dermatologist and researcher in New York City.

“The best way for practitioners to learn about laser products is to read studies, as well as attend meetings where clinical research is presented,” he indicated. “Ask key opinion leaders who have experience with the studies and are not vested in the company as a consultant. Bring the machine into your practice on a trial basis to see if patients like it,” he said.

As reported by Ms. Robertson, “When new aesthetic systems hit the market, manufacturers will arm their sales people with white papers and technology background materials that purport to prove efficacy, best results, etc. While I’ll read them, I also take them with a grain of salt. Before I seriously review a product, I wait for peer-reviewed studies to be published. With white papers manufacturers can skew the test results any way they want, but peer-reviewed materials tend to be more objective and the statistics are more qualified.”

Understanding the history of energy-based devices, as well as their recent technology improvements is important, too. For instance, Nd:YAG and 810 nm diode lasers are well known for addressing hair removal. Recently, though, IPL devices have been shown to treat a wider range of skin types over larger areas.

Among IPL devices the Pulse™ Two from Mattioli Engineering Corp. (McLean, Va.), is a new system that supports skin rejuvenation and hair removal treatments via two applicators with distinct surfaces and characteristics. The unit features a multi-language interface with pre-programmed and user-selectable parameter settings, along with proprietary Q Fractional™ technology that uses a pulsed light emission source and patented filter for precise fractional emission of light energy.

Alma Lasers’ Soprano Ice Platinum platform addresses hair removal, as well as lesions, offering three combined wavelengths covering the optimal spectrum, with new three-dimensional, trio-clustered diode technology for 755 nm, 810 nm and 1064 nm treatments. The platform offers virtually painless hair removal on all skin types, including tanned skin.

Lasers are also useful in addressing other skin-related problems, such as facial wrinkles, pigmented and/or vascular lesions, acne scars and other skin blemishes that can be treated using a wide assortment of wavelengths.

For instance, in addition to hair reduction, the DiolazeXL from InMode Aesthetic Solutions (Richmond Hill, Ontario, Canada) also addresses vascular and pigmented lesions. This advanced 810 nm diode laser features one of the largest treatment spot sizes, as well as a large, built-in skin cooling surface that renders treatments virtually painless. Another of the company’s laser-based devices, Vasculaze, runs on a 1064 nm diode laser to address vascular lesions, such as angiomas, telangiectasias, port-wine stains and leg veins.

Aerolase (Tarrytown, N.Y.) offers the Neo 650 ms laser, which asserts a new approach to treating acne, including problematic conditions like nodulocystic acne and acne conglobata. This new treatment option, called NeoClear, offers an efficacious solution for patients that have not responded to traditional therapies.

In recent years, lasers have played a big part in non-surgical feminine rejuvenation procedures and other forms of aesthetic gynecology.

For the physician looking to establish a feminine rejuvenation business, the multiplatform CO2 MiXto Pro V-Lase® from Lasering USA (San Ramon, Calif.) performs non-invasive vaginal rejuvenation treatments, in addition to ablative skin resurfacing, hair removal and facial rejuvenation. Indications include acne scars, facial wrinkles, stretch marks, facial and leg vascular lesions, and benign pigmented lesions.

Aesthetic laser technology continues to improve within the body shaping arena as well.

One example of this is exemplified in SLIMUS by Hironic Co., Ltd. (Seoul, Korea), a non-invasive lipolysis device for use on various body areas, such as the abdomen, back, arms and thighs. The system features Laser Vibration Alliance Technology (LVAT), which provides high penetration depth while achieving minimal absorption in the dermis. The LVAT also synchronizes with the unit’s 1060 nm diode laser for effective fat reduction.

“These are well-regarded companies with really good track records that have been improving on established workhorse technologies, and developing novel technologies, as well,” stated Dr. Chapas. “I think we’re going to see a lot of great devices for vascular issues – in addition to skin resurfacing and tattoo removal systems – more in the picosecond
laser realm.”

Of late, tattoo removal, once the sole province of Q-switched and Nd:YAG lasers, has been addressed by modern picosecond devices. The PICOCARE picosecond Nd:YAG laser from WonTech, LLC (Philadelphia, Penn.), offers wavelengths of 532 nm, 595 nm, 660 nm and 1064 nm for tattoo removal, along with treatment of dermal, epidermal and pigmented
lesions.

Another example of Picosecond technology is presented in the Discovery PICO Series 1064 nm, 532 nm and 694 nm (ns only) system from Quanta Aesthetic Lasers (Samarate, Varese, Italy). Discovery PICO Series delivers both picosecond and nanosecond pulses with an industry leading 1.8 Gw of peak power. In addition, PICOBOOST technology offers four separate emission modes. Options include a chilled tip Twain IPL and a Twain Er:YAG handpiece.

In recent years, we’ve observed manufacturers and physicians embracing multifunctional platforms, Dr. Zimmerman noted. “It’s a smart move to bundle treatment modalities using a single energy-based platform. For instance, we have a photofractional device that is a combination of a non-ablative technology and IPL,” he said.

“One company may put together a fractional laser that’s in the infrared spectrum, while another does RF utilizing a needle and a tiny disposable. When both vendors claim to be the best of breed, analyzing that claim can be challenging,” he added.

One of the latest multifunction systems mixes CO2 laser treatments with RF-based microneedling. The Fraxis DUO from Rohrer Aesthetics (Homewood, Ala.) incorporates both modalities to treat scars, photoaged skin, poor skin tone, facial resurfacing and stretch marks.

Versatile multifunctional technology can also be found in the StarWalker MaQX from Fotona, LLC (Dallas, Texas), which combines four complementary wavelengths and 14 laser modalities. This highly versatile, multipurpose system performs a variety of aesthetic applications, including tattoo removal via the system’s proprietary FracTAT™ procedure.

Whether one chooses a single procedure or multifunction approach, the question to buy comes down to what is most relevant for your practice.

“There are many sides to the equation,” Dr. Ross expressed. “Have a look at the competition in your area. This will be different for everybody. If you think you want to incorporate CoolSculpting into your practice, for instance, in an area where 30 clinics already use CoolSculpting and are also advertising on Groupon, then you might want to reconsider.”

The choice of device relies on how well you want to differentiate your practice, Dr. Chapas agreed. “A device is not going to build your practice. A device is a scalpel. It is only as good as the person holding it. It really is up to the physician and staff to learn how to use a device, how to deal with complications and how to obtain the best results,” she said.

While big box, multi-use, energy-based platforms reflect a recent trend in aesthetic treatments, a secondary trend shows that many small handheld microneedling devices intended for skin rejuvenation have become popular with physicians, as well, said Dr. Chapas. “These devices are up to fourth generation now, where they have become more stable with better results and less downtime,” she said.

An example of energy-based microneedling is the recently released Vivace RF from Aesthetics Biomedical (Phoenix, Ariz.), which contours and tightens skin on the face, neck, hands and body by stimulating the natural production of collagen to reduce the appearance of facial wrinkles and lines after a single procedure.

“With so many available options, you have to look at manufacturer reputation, warranty, reliability, price, footprint and ergonomics,” Dr. Ross indicated.

“All of those aspects are important, because if you delegate treatments to staff then you have to consider what they require, as well as make sure they know or learn how to use the device. A lot of nuances go into getting the right equipment. Really talk with the sales representative. Find out if he or she knows about the equipment. Something to evaluate carefully is the user interface. Like navigation in your car, is it easy-to-use? Are the menus well placed and intuitive?”

There are also many important considerations when a practitioner is deciding whether to lease or purchase a device. “Fortunately, right now there is a lot of cash available for financing capital purchases in medical practices,” Dr. Chapas noted. “The banks and even the manufacturers are happy to finance you. If you have a cash flow issue, a lot of times  it can be better to just purchase the machine because you don’t have to deal with a lease that can be difficult to get out of once you’re in a better cash flow state.”

One problem with leasing is the interest rate, Dr. Chapas added. “Those rates can fluctuate over the term of the lease, so it’s challenging sometimes and even when the seller breaks it down for you the details are still hard to sort out,” she said.

Ultimately, buying an aesthetic system is like buying a car, Dr. Chapas pointed out. “You wouldn’t buy a car made by a company you’ve never heard of, right? What if you need a part or need service? These devices cost as much as a car, so you want to go with a firm that offers a good service contract, as well.”

Naturally, devices that have been blessed by the FDA are preferred. Nonetheless, “physicians should be aware of FDA terminology,” Dr. Sadick advised. “Some physicians don’t know the difference between FDA-approved and FDA-cleared. FDA-cleared means that the product has been cleared for safety. Approved means it has been approved only for a specific indication, clinically.”

No matter what system one chooses, always keep track of return on investment (ROI), Ms. Robertson advised. “When you first purchase a device you kind of ballpark your ROI. Is there a consumable? How much is it going to cost per treatment? While ROI is always better when you don’t have a consumable, a lot of devices have consumables so you may need to take that into account. For instance, how much can you mark up the treatment to make it profitable and cover the consumable?

“We use computer software to track all of our bookings and sales,” she continued. Every quarter we sit down and look at the number of bookings that used a device. Other considerations include the cost of staff to operate the device, the cost of service and insurance, as well as liability issues.”

New practitioners will want devices that offer a fast ROI, noted Dr. Ross. “But you have to weigh the pros and cons of the whole package. Even if your new device doesn’t use consumables, the ultimate consumable is the warranty,” he said. “There may be wiggle room on the warranty so don’t be afraid to negotiate.”

After that first device starts paying for itself, most physicians will start eyeing other systems that address commonly requested aesthetic concerns, Dr. Sadick remarked.

“The good news is that devices are getting better all the time,” he stated. “We are seeing better cooling mechanisms for safety. Higher energy delivery systems lead to more effective treatments, especially in hair removal. Expect to see shorter pulse durations, even shorter than what you find in picosecond laser systems. The trend in multiple platform technologies housed in a single unit will continue. Improved economic models, preferably based on usage, will emerge, along with next-generation technologies for whole body rejuvenation and new approaches to neuromuscular stimulation.”