Many practitioners today continue to look into new ways of expanding patient services while generating additional cash income for their practice. One way is by offering services such as laser hair removal, treatment of vascular lesions or the ever popular non-ablative laser therapy, also known as photorejuvenation. If you are considering purchasing a laser, you have probably noticed the vast array of products on the market today. In an effort to assist you with a better understanding of laser technology as well as the differences between them, the following is provided as a review. After shining a brief light on this technology, you will be a more educated consumer with a laser that truly fits your needs.
The word LASER is an acronym for the words “Light Amplification by Stimulated Emission of Radiation.” Laser light is a concentrated beam of coherent, monochromatic light unlike ordinary light which encompasses a collection of all colors traveling in all directions at once. Monochromatic light is important because different targets will absorb certain wavelengths of light better than others. Lasers utilize some type of an excitation source such as a flashlamp or high voltage charge to excite atoms which in turn produce energy in the form of a photon, or light particle. These particles are typically passed through a synthetic crystal medium while being bounced back and forth between mirrors, concentrated in a parallel line fashion. This action stimulates even more excited atoms that are eventually emitted from one of the mirrors through a delivery device or handpiece.
Depending on the laser medium used, laser light will be concentrated at a very specific wavelength on the electromagnetic spectrum. The laser energy will be absorbed, scattered or reflected by tissue depending on wavelength (color), power (fluence), time applied to target (pulse dura- tion), and spot size used. Different types of targets have specific absorption characteristics depending on certain components in the targeted tissue. These targets or “chromophores” may include but may not be limited to hemoglobin, oxyhemoglobin, melanin, or water. Laser wavelengths are measured in nanometers(nm) and for cosmetic laser purposes, typically in the visible, near or at the infrared part of the spectrum. Lasers produce energy that is either long pulse (typically in milliseconds), continuous wave (CW) or Q-Switched (nano-seconds). A continuous wave laser produces a constant stream of light (like steady pouring of water from a bucket). A pulsed laser produces light in short bursts typically in the millisecond range (like the bucket of water being dumped and refilled in milliseconds). This produces less heat buildup by allowing for thermal relaxation of tissue (the amount of time it takes for 50% of the energy to dissipate). Q-Switching a laser pulses the light in nanoseconds. Pulsing the light at this speed results in an additional photo-thermal effect producing a shock wave which is very effective in treating tattoos and certain types of pigment.
Spot Size, Repetition Rate & Cooling
Spot size is critical to the clinical performance of most lasers. In the field of aesthetic lasers, a larger spot is preferable for laser hair removal and photorejuventation; however, a smaller spot may be preferable when treating spider veins and facial telangiectasia. According to the laws of laser physics, a larger spot penetrates deeper than a smaller spot. This is primarily due to less scatter. Some lasers with smaller spot sizes come with scanners which automatically moves the laser beam over a larger area in a very precise, controlled fashion. Scanners are used quite frequently in ablative resurfacing treatments involving CO2 lasers where smooth coverage of the face is critical. Smaller spots with increased scatter will have less than adequate efficacy when compared to a 10 or 12 mm spot. It is advantageous to have 3, 5 or even 7 mm spot sizes available when treating finer vessels. Typically the target is not as deep, and the smaller spot confines the laser light to the target and not the surrounding tissue.
When it comes to repetition rates (the speed at which the treatment beam is delivered, i.e., 1 Hz equals one pulse per second), it is advisable to have a system that will deliver the required treatment parameters at a 1.5 – 2 Hz repetition rate for laser hair removal. Large areas such as a man’s back can take a long time if you can only treat at a 1 Hz rate. Conversely, a system that offers a repetition rate of 5 Hz (5 shots per second) is probably more horsepower than you will ever need and could lead to trouble if the user is inexperienced. With vascular lesions, single shot is the best way to go because this provides the user with increased control for proper placement of each spot.
Cooling of the skin for patient comfort and safety during treatment with lasers is becoming more popular. The most common ways to cool the skin are with cryogen spray, contact cooling, and super chilled air. This is certainly more than adequate but may increase the cost per procedure, thus slightly reducing your profit (unless you decide to build the disposable cost into your fees). Claims are being made that parallel cooling is better than pre-cooling, which in turn is better than post cooling. However, there are several systems out there utilizing each method, so choose the one that you are most comfortable with.
Lastly, a term you will hear repeatedly when discussing lasers is “selective photothermolysis.” Simply put, selective photothermolysis occurs when laser light is absorbed by the targeted tissue only, leaving the surrounding tissue untreated.
LASERS & WAVELENGTHS
KTP Laser: This laser produces a green light of 532 nm. Its energy is highly absorbed by hemoglobin and therefore is very effective when treating facial telangiectasia. In addition to its high hemoglobin absorption, KTP is also highly absorbed by melanin. Because of its high melanin absorption, the KTP laser is less than ideal when treating patients with darker skin types.
Pulsed-Dye Laser: The PDL has been a popular laser over the years for treating vascular lesions. It has a high peak of absorption in hemoglobin and is excellent for treating port wine stains and thick red scars. However, because of its short pulse width and high absorption by blood, it can be painful and may also rupture vessels causing unsightly purpura (bruising) which can last for weeks.
Ruby Laser: This laser produces a red light at 694 nm. Although this laser was one of the first used for hair removal (long pulse ruby), its application remained limited, mainly because of its relatively high melanin absorption in the skin. This laser is now being used for treating some tattoos and pigmented lesions in a Q-Switched mode.
Alexandrite Laser: This laser produces light at 755 nm, has a slightly longer wavelength than the Ruby, and also less absorption in melanin. This wavelength allows for deep- er penetration of the energy and is a very popular laser for hair removal because of its absorption characteristics and speed. Some practitioners report that they can treat tanned patients and darker skin types with this technology; however, they may sacrifice efficacy for safety thus requiring patients to have additional treatments.
Diode Laser: This is a solid state laser similar to an LED. It is considered the “mini” laser because of its small size and portability. Medical diode lasers produce energy at various wavelengths but are typically used most often at 532 nm for superficial vascular lesions and at 800 nm for hair removal. Diodes are believed to be very reliable but can be expensive to replace.
Nd:YAG Laser: This laser, when using it with a longer pulse width and spot size that is slightly larger than the vessel being treated, has become very popular for treating leg veins because of it’s deep penetration and small uptake in melanin. Since its introduction to the mar- ket, it has also been found to provide excellent results when performing hair removal (especially in dark-skinned and tanned patients). When in a Q-Switched mode, this laser is very good for treat- ing tattoos.
Intense Pulsed Light: This device produces broad spectrum non-coherent light (technically not a laser). These systems use highly charged capacitors that excite a powerful hand-held flashlamp and use “cutoff” filters to eliminate unwanted light. The advantage of an IPL is its versatility and its production of energy over a broad band of the electromagnetic spectrum which is absorbed by a number of targets. It has become extremely popular for photo-rejuvenation.
Wrinkle Reduction Lasers: The lasers that are FDA cleared for this specific application are currently at 1064 nm, 1320 nm and 1450 nm; however, other lasers can produce some of the same effects. While it is not entirely clear as to the exact mechanism, it is believed that these lasers target and heat a specific depth in the dermis or microvascular structure which in turn can stimulate collagen production. The downside of these lasers is that it can take months for a patient to see results when compared to traditional CO2 resurfacing.
A new model laser of high quality and power could cost anywhere from $50,000 to $150,000. The majority of physicians tend to go with a lease purchase when buying systems of this amount. Monthly lease payments for lasers in this price range are typically around $1,000 to $3,500 per month. Most tend to choose a 3 – 5 year lease with a 10% buyout at the end to keep the monthly payment lower. Also, if the lease is structured correctly, each monthly payment can be deducted as an operational expense (check with your accountant). If money is tight at start up, many lease companies offer deferred payment programs which allow you to save capital for marketing or other expenses. This may seem like a lot to add onto your monthly overhead but consider that some physicians are generating an additional $10,000 – $100,000 per month from their laser services. Be sure to read the fine print in the lease documents. Whenever there is a dispute or problem, many physicians claim they do not fully understand the complete terms of the lease agreement. Most lease companies that specialize in funding lasers understand the cosmetic market and can often be a good resource for information. Do not let the lease company tell you which system is best for you. Their expertise is
financing, not clinical application. Rates are fairly comparable among lease companies so look for the ones you like working with and those who have the most flexible terms.
Used lasers are another alternative for the physician who perhaps requires as little up-front cost as possible when adding a new device to their practice. They are becoming more popular as new ones tend to depreciate rather quickly. You can often save 30 – 50% off the price of a new one, even if the laser is only one or two years old. If you decide to purchase a used laser, be sure you can get a warranty and training if needed. There are independent laser repair services available but make sure they use authorized parts and have been trained on your product.
Take time to clearly analyze your specific needs before buying. Understand what features are best for your individual office, patients, and budget. When you have done your homework and feel ready to purchase, find the best deal you can and fire away.
WHAT TO BUY?
When considering which laser to purchase, decide as specifically as you can what the needs of you and your patients are and make sure you pick a laser that fits those needs. Some of the features you will need to consider are: wavelength, spot sizes, peak power, fluence, pulse-widths, hertz rates, epidermal cooling, absorption characteristics, versatility, overall costs, power requirements, portability, handpieces, scanners, and so on.
Some questions you will want to ask the company representative are:
How many versions of the laser do you have? Is this your most / least expensive system? What are the differences? How new is this model? Are there parts I will have to replace on a regular basis? How stable is the company, and are there any lawsuits pending?
What procedure(s) is this system cleared for? Do you offer turn-key marketing assistance?
What are the realistic capabilities and limitations of your system? What clinical data do you offer as a proof source?Do you have references I can contact or visit? Do you offer preceptorships or additional training after the sale? How many treatments will it take on average to get results? How will results vary on different skin types?
How will I be trained and by whom? What are their qualifications? Where will the training take place?
What is the cost of consumables per procedure? Do I need a cooling system and what will it cost to operate? Is there an upgrade path or trade-in program toward an upgrade?
How will I be taken care of if there is a problem? Where will the service technician and parts come from? How long will the will it take either to arrive? Will you guarantee it and put it in writing?
How much will my extended warranty cost? (You can usually expect to pay 7-10% of the purchase price for the warranty per year after the first year.) Can I pay for it quarterly or semi-annually? If I decide to sell my system at a later date, will you provide a warranty at the same price to the purchaser? Can you guarantee that parts and service will be available for the length of my lease?
Can I get a better price if I agree to be a reference, train other physicians, or provide clinical data and photos?
What are other physicians in my area charging for these procedures? Who else in the area is using this system?
Don Berryhill has worked directly with physicians in the medical industry for over 20 years. Specializing in medical lasers, he developed his consulting business to assist physicians in the selection and successful implementation of equipment best suited for their individual practice needs.
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