Botox Therapy: Lips, Mid and Lower Face

Botox for the Lips, Mid, and Lower Face

Botox can help the lines that extend up and down from the upper and lower lips (lipstick lines), soften deep folds going from nose to mouth corner (nasolabial fold), and diminish the lines running from the mouth corner toward the chin (mesolabial fold). It can make the lip longer, and smooth out the chin. Botox will help mild-moderate wrinkles. More severe problems require fillers, laser therapy, or surgery.

Patient selection is the most important factor for successful cosmetic procedures. Wrinkles are smoothed by relaxing the facial muscles but not to the point of completely paralyzing the face and causing complications. Therefore, there may be a tendency to under treat initially and bring patients back for touch ups. People expecting huge changes immediately will be disappointed. People who require optimal control of the mouth like singers may risk compromising their careers. Because areas around the mouth are heavily worked (eating and talking), the Botox will wear off sooner there.

General Techniques
Good pictures should be taken before and after treatment to document results. Patients need to sign informed consent forms. Blood thinners are stopped 2 weeks before. Target muscles are identified with the patient contracting and relaxing the area several times. The area is cleaned and target muscles marked. Ice can be pressed on the skin immediately before injection for anesthesia and to help avoid bruising. Patients are treated setting up in a mechanical chair that can be flattened out of they become dizzy.

Wrinkles Around the Mouth
Lines around the mouth are from the orbicularis oris muscle that encircles the mouth. They worsen with age, smoking, and sun exposure. This muscle is necessary to close the mouth, to chew, to speak, and to show what mood your in. Botox is often used with fillers like collagen or Restylane to fill in deeper lines.

Botox may increase lip fullness. 1-2 units are injected at four evenly spaced spots along the upper lip margin. 1-2 units can be put along the lower lip border as well. Follow up can be done at 2 weeks and additional 1-2 unit injections can be given. Improvements do not last as long as on the fore head, and injections are needed every 2-3 months for best results. The side effects include an asymmetrical appearance and trouble kissing, sipping, and speaking. Complications can often be avoided by decreasing the dose by as little as 1 unit.

Injection sites for Botox treatment of vertical lip lines

Examples of vertical lip lines

Lip Lengthening
The gummy smile occurs when the levator labii superioris alaquae nasi (LLSAN) muscle pulls up the lip too high and exposes more gum than teeth. Injection of the LLSAN elongates the upper lip to show less gum during a smile. 1 unit is injected into the groove just outside of the nostril. A 2-3 week follow up is done with the option of more injections if necessary. Up to 5 units can be injected at each site. Risks include a disfigured smile with lip sagging, lip protrusion, and lopsided results. Overdone lip elongation can make you look like you have no teeth.


Before and after treatment for the “gummy smile”

Nasolabial Folds
The nasolabial fold is the groove that runs from outside the nostril to the corner of the mouth. In younger people in their 30-50’s, this is more from muscle activity and is better suited for Botox therapy. However, in older folks, cheek sagging contributes more to this fold and they may be better served with injectable fillers or face lifts.

Injecting the LLSAN helps smooth the upper and middle part of the fold. Injecting the cheek muscle may help but risks leading to sagging at the mouth corners. This may resolve in about 6 weeks. Marionette lines or drool lines are grooves that run from the mouth corners to the outer aspects of the chin. They are caused by activity of the depressor anguli oris muscle. It makes people look sad or angry. Treatment of this muscle can raise the corner of the mouth and give one a happier look.

Raising the mouth corners by injecting the depressor anguli oris muscle

When used with fillers, it can smooth out the drool grooves. Botox, 1-2 units is injected into each side. After 2-3 weeks more can be given with a maximum dose of 4-7.5 units per side. The injections must be placed just right. Too far inside and the lower lip sticks out making you look like Gomer Pyle. Injections too far outside hit the deeper chewing muscle and leads to biting and tearing up the inside of the mouth.

Chin Softening
An overactive mentalis muscle causes the apple dumpling or peach pit chin. It can cause a cleft in the chin as well. Peach pit chin is injected with 2.5-5 units of Botox at the end of the chin. The cleft chin is treated with 2 injections of 2.5-5 units each to get both bands of the double muscle. A total of 10-15 units can be given. Risks include trouble with speech and closing the mouth.


Injecting the mentalis Before and after treatment of the peach pit chin

Botox for the Neck

The skin on the neck can be damaged by the sun causing discoloration. It can loose its resiliency, and sag. The muscle can form cords that stick out. The fat can shift around creating hanging pockets. Lasers help the discoloration, while liposuction addresses the fat. But the necklace lines and cords or bands can be treated with Botox.

History
Patients should be asked what about the neck they want improved. They can bring in pictures of when they were younger to help illustrate this. Neck injection should be avoided in patients with neck weakness, swallowing problems, or chronic neck pains. Patients should be evaluated for neck bands, necklace lines, abnormal appearing skin, fat collections, and abnormal jaw shape with the patient at rest and neck contracted. The patient is instructed to clench their teeth and pull down the corners of the mouth to show the neck bands. The operator will pinch the band between the thumb and finger and inject the band. 3-10 units are placed into each site every 1-1.5 cm along the entire length of the band. Thin bands will need 15-20 units and thick bands may need 30 units. A total of 50-100 units can be used. More may risk neck weakness and swallowing problems.


Injecting neck bands Injection sites of neck bands

Before and after treatment of neck bands

Neck lines are treated with 1-2 units every 1 cm along the wrinkle. Injections are into the skin. Deeper injections may cause swallowing problems. Improvement may be noted at 5-14 days. 98.5% of patients in one study, from patient and physician input, reported good to excellent results. Side effects include swelling, redness, bruising, muscle soreness, neck weakness (can’t bend the neck forward while lying down), headaches, hoarseness, and swallowing problems. Patients should not rub the area for 24 hours and not lie flat for 4 hours. Complications usually resolve in a few weeks. Ice can help the bruising and pain.

Botox Therapy: Combination Treatments

Combination treatments

Botox can be used with other therapies to maximize results. Injectable fillers like collagen and Restylane can fill in deep grooves. Laser resurfacing therapies can rejuvenate the skin. Plastic surgery can remove excess tissue and lift sagging areas.

Botox with Fillers
Botox decreases muscle movement and can make filler implants last longer. Fine wrinkles and deeper folds can be treated at once with this combination. Areas include the glabella (area between the eyebrows), the forehead, nasolabial folds, the neck, and other areas around the mouth. Botox is injected about 1 week before filler implants. Freezing the muscle movement prevents trauma and movement of the implant.

Botox and Laser Resurfacing
Botox just before laser resurfacing of the skin holds the area of laser treated skin still, so it can heal and remodel without the folding effects of muscle that created the wrinkle in the first place. The improvements after combination therapy last longer, and Botox can be given every 6-12 months instead of 3-6 months to sustain wrinkle free status. Combination therapy can be good for lipstick lines, drool grooves, forehead lines, and Crow’s feet.

Intense pulsed light (IPL) is a new nonlaser, less damaging light source, that can treat discolored skin lesions, and improve skin texture, pore size, and wrinkles. It burns through the deeper layer of the skin to stimulate new healing. Blood vessel and discolored skin lesions are taken care of along with the wrinkles. Improvement is maintained months longer if done after Botox treatments. There are other devices that heat deeper into the skin to tighten the skin to accomplish a nonsurgical facelift. Botox has bee combined with this treatment as well.

Botox can be combined with surgical procedures too. Surgery can be done cutting some of the brow muscles that make it sag. Botox freezes the area so the brow muscles heal evenly in the right places to give a good symmetrical result. Botox can correct the asymmetry after the surgery too. Botox can be used with blepharoplasty where surgery removes excess skin from around the eye. Keeping the area still helps wound healing. After a face or neck lift, muscles continue to pull the skin down and negate the effects of surgery over time. Botox injections may prolong surgical results.

Botox Therapy: Complications

Complications of Cosmetic Botox Therapy

In a poll, 77% of patients treated with Botox for cosmetic reasons felt more comfortable with their body. Greater than 80% thought the treatment was beneficial, and 100% would recommend it for others. Botox should not be given to people allergic to any part of the Botox preparation. It should not be given to people with unrealistic expectations or who are unsure about it. It should be avoided in patients with some nerve and muscle disorders, who are pregnant, or have skin inflammation over the injection site. Because there is a human protein in the mixture, there is a possible risk of viral disease transmission, although never reported. Some medicines interact with Botox and should be avoided including aminoglycoside antibiotics, cholinesterase inhibitors, succinyscholine, magnesium sulfate, quinidine, calcium channel blockers, lincoamides, and polymixins.

Complications include injection site pain, swelling, redness, and bruising. Allergic reactions from rashes to shock can occur. There was one death reported for someone treated for neck and back pain. Nausea and upper respiratory infections occur but the connection to Botox is unclear. Other side effects include swallowing problems, dry eye, and eyelid droop. There are rare reports of heart attacks and abnormal heart rhythms with noncosmetic use but a direct relationship is not proven. Botulism like in food poisoning is extremely rare. There are other reports of dry mouth, vision changes, and decreased sweating.

Patient Interview
Patients can go through a questionnaire beforehand to give them more time to think about the issues. People with psychiatric conditions must be handled carefully. There is a syndrome called botulinophilia, describing patients who continually seek Botox treatments. There patients should not be treated.

Physical Exam
The patient should be checked for skin infection, rashes, facial asymmetry, scarring, and previous signs of surgery. Patients with thick sagging skin with deep folds that do not improve much when the skin is stretched are not good Botox candidates. Patients with previous eyelid surgery are at higher risk of excessive lower lid sagging. Snap tests on the lower lid should be done to test the tone of the lid. People with already drooping eyebrows or lids are not good for injections to treat forehead wrinkles and risking further sagging. Nonreversible side effects have never been reported. In tests 43.7% of Botox treated patients complained of side effects compared to 41.5% who got a placebo (a fake drug). The most common complaints are headache, cold symptoms, lid drooping, nausea, and pain. Using more concentrated drug injected in lower volumes causes less Botox spread and fewer side effects. This is why patients are also told to remain upright for 4 hours and not rub the area. There is a case report of someone getting Botox into the forehead leading to immediate muscle paralysis. To avoid bleeding patients should avoid taking blood thinners like aspirin and nonsteroidal anti-inflammatory agents for a week. Other products also may thin the blood like vitamin E, ginseng, ginko, garlic, and ginger and should be avoided for 2 weeks.

Forehead
When forehead wrinkles are treated, there is a risk of the brow drooping. Therefore Botox injections must be dept above the mid brow. Muscles that depress the brow can also be injected to raise the brow. Some providers routinely inject the frontalis (forehead) muscle and brow depressor muscles to treat forehead wrinkles and avoid brow sagging at the same time. However, here you risk leaving one with inability to move the eyebrow at all. Eyelid drooping can happen if Botox leaks into the upper eyelid. Apraclonidine (Iopidine) or phenylephrine (Neosynephrine, 2.5%) can reverse the problem. If the outside portion of the forehead muscle is not given enough Botox, it may pull the outside end of the eyebrow up, giving a Jack Nicholson look. Drooping of the eye lid occurs 2-14 days after injection and lasts for 2-4 weeks.

Eyelid drooping Hematoma (bleeding) around the eye

Periocular
When Crow’s feet are treated, bruising can occur. Therefore injections are kept superficial. Using ice helps. Other complications include double vision, inability to close the eye, and upper lip sagging. Eye problems can be avoided by keeping injections 1 cm outside the lateral corner of the eye. If the eye won’t close, it should be taped shut at night and eye drops used until the Botox wears off. Injections below the eye can cause dry eye. When the muscle under the eye is weakened by treatment, the lower eyelid may droop, and too much of the white of the eye will show. Patients at risk for this happening have sagging skin under the eye, already show too much white of the eye pretreatment, or have had lower eyelid surgery.

Lip and Midface
Treatment of smile lines can cause one or both corners of the lip to droop. Other complications include drooling, an asymmetric smile, and problems eating and speaking. Treatment of the neck may be complicated by swallowing problems, hoarseness, and neck weakness.

Lip assymmetry

Laser Therapy for Cosmetic Purposes: Laser Basics

Laser Treatment of Skin
Laser Therapy for Cosmetic Purposes

Laser basics for Skin Treatments

Light is made of bundles of energy called photons. Electrons within atoms will absorb photons and store the energy associated with them. The electrons can release the energy by emitting the photons as a form of radiation. Photons from like atoms have the same energy.


Emitted photons move in waves. A wavelength is measured from the top of one wave to the next. These lengths are reported in nanometers (nm) or in billionths of a meter. Atoms of each material emit photons in specific wavelengths that identify them like fingerprints. Some emitted wavelengths are visible and some are invisible. Humans can see a certain set or band of wavelengths called the visable spectrum. Ultraviolet and infrared energy wavelengths are not visible to the human eye. But they are all part of the Electromagnetic spectrum.

There are basically two ways of making light for clinical uses. They are lasers and pulsed light devices.

The laser emits light energy of one single wavelength and the beam can be focused. Broad band light is emitted as light energy containing multiple wavelengths and cannot be focused.

Pulsed light devices utilize a light source such as a flashlamp that emits energy in a band or multitude of wavelengths from the base of the visible spectrum (400nm) to the border between the near and mid infrared wavelengths (1300nm). The light is directed often through a crystal to the tissue. Some pulsed light devices use filters to limit energy transmission to protect the tissue.

Blocking portions of the spectrum can protect the nontarget tissue to avoid complications. Most filters are high pass devices which block light at and below a specific wavelength. Only light generated above the specified wavelength is emitted to tissue. An example would be a filter to block wavelengths that are absorbed by red blood vessels and allowing through only wavelengths treating specifically brown melanin based lesions like age spots. In this way the age spots can be removed without damage to the surrounding blood vessels.

LASER stands for Light Amplification by Stimulated Emission of Radiation. A laser harnesses an excitation source, often a flashlamp, to drive photons from the laser medium. The light generated has very distinct properties and a single wavelength.

The types of lasers are classified by the type of medium used and the wavelengths of light energy they emit.

Lasers will emit light energy in different ways. It can transmit energy as one continuous beam or break up the transmissions into numerous short pulses.

Light from either device is often delivered to tissue through a hand piece. It may be attached to a fiber optic cord or a hollow arm with directional mirrors within the joints. They commonly use optics to focus the beam to a small diameter or spot size, at a specific distance before tissue contact. When the light comes in contact with tissue there are predictable and controlled reactions.

When light energy is directed at the skin it can be reflected, transmitted, or scattered, none of which cause any clinical effects. However, when light energy is absorbed then significant laser light interaction can take place.

The most common reaction that occurs when laser light energy is absorbed is heating of the tissue. The depth of tissue heated is determined partly by the absorption wavelength.

To be clinically beneficial, enough of the laser energy must be absorbed by tissue to cause thermal damage. This results in ridding tissue of certain unwanted elements.

In tissue there are several elements or structures called chromophores. Each chromophore will selectively absorb light of only certain wavelengths.

Chromophores that are targets for laser light therapies include hemoglobin in red blood vessels (to destroy vascular lesions), melanin in skin pigment (to remove pigmented lesions or unwanted hair), water (to ablate certain levels of skin), and exogenous substances (as ink in tattoo removal).

This slide illustrates the different lasers and their emitted wavelengths and which targets they will treat.

Different types of lasers emitting their different wavelengths will also penetrate skin tissue to different depths.

Erbium and CO2 lasers provide light wave lengths that are strongly absorbed in the epidermis (the outside layer of skin). Therefore, they are heavily utilized for destroying this layer where the wrinkles are as a part of resurfacing procedures.

Visible light or intense pulsed light (IPL), or broadband therapies can penetrate to the deeper dermis for more aggressive resurfacing or treatments that get rid of undesirable skin pigment like age spots.

Basic Laser Priniciples

Basic laser settings, depending on the device, include fluence, power, pulse width, and spot size. The amount of energy delivered to the tissue is measured in joules. The amount of energy delivered per unit surface area is called the fluence, or joules per centimeter squared. Some laser settings are displayed in watts. One watt is one joule of energy delivered over one second. For lasers that deliver energy in pulses rather than continuously, the amount of time the laser is on during a pulse is called the pulse width, measured in seconds, milliseconds, even nanoseconds. The spot size is the size of the target area hit by the laser.

The interaction of laser energy with tissue
The amount of energy that is within a laser beam is related to the wavelength. There is more energy in the photons of a laser beam of shorter wavelength than of longer wavelengths. In fact a beam with a wavelength of 532nm delivers twice as much energy per unit than a wavelength of 1064nm. Laser photons can be relected or absorbed. When absorbed by a target molecule called a chromophore, the molecule will undergo a change which could be damaging. Each chromophore will tend to absorb light energy of only certain wavelengths. When treating skin, there are three main chromophores that are being targeted; water, hemoglobin (blood), and melanin (skin pigment). Water will absorb wavelengths at primarily 980nm, 1480nm, and 1060nm, with a maximum at 2940nm. Hemoglobin will absorb at 415, 540, 577, and 940nm. Melanin absorbs wavelengths <800nm.>

Exposing wide areas of tissue to laser energy but damaging only selected targets like blood vessels or hair relies on a principle called selective photothermolysis. In this way laser energy is delivered with a wavelength that is absorbed only by the target chromophore say melanin. If enough energy is delivered, the target lesion containing melanin (say hair follicles) will be destroyed without harming surrounding skin that do not absorb that particular wavelength. This would be like launching smart missiles that hit only the desired targets.

Preventing damage to tissue around the target chromophore relies on the principle of the thermal relaxation time. The thermal relaxation time is the amount of time it takes for the target to cool a certain amount from the peak temperature achieved. For a lasered target it is the amount of time it takes for the target to cool off after the laser pulse is given. So, if the pulse is too long, the target can cool off during the pulse. Just like trying to slowly fill a bucket with a big leak. The bucket will never fill. In the same way if cooling is taking place during laser heating, the target may never reach the temperature high enough to destroy it. Therefore, the pulse width or duration of a laser pulse is set at less than the thermal relaxation time to assure all of the destructive energy is delivered to damage the target before it has a chance to cool off. If the pulse width is too short, the pulses can vaporize the target, a more explosive result that yields more damage to target blood vessels with more bleeding and unsightly bruising. Longer pulses can more gradually heat damage targets without blowing up the vessels.

Lasers can treat skin lesions in other ways other than with heat damage. Lasers can be used to stimulate chemical reactions to destroy tissue. One example is with treatment of acne. A chemical called aminolevulinic acid is spread on the skin where cells in sebaceous glands convert it to PPIX. When PPIX is hit with photons, it is converted to an oxygen radical that destroys acne causing gland cells. Light therapy can also cause biostimulation. LED light can supposedly increase collagen tissue formation in the skin to tighten and firm up aging facial skin.

The skin has two basic layers, the epidermis or outer layer and the dermis or underlying layer. The epidermis absorbs most of the light exposure because most of the melanin giving skin its pigment is located there. The dermis contains several of the target chromophores including blood vessels and hair follicles. It also contains collagen tissue that supports the skin and gives it its tone. There are several different kinds of lasers with various applications. The violet intense pulsed light and LED lamps can treat acne. The 940nm and 1064nm Nd:YAG lasers are used for resurfacing to treat wrinkles. Wrinkles and scars are also addressed with CO2 or Er:YAG lasers. Spider veins and telangiectasias can be treated with 1064nm lasers or intense pulsed light (IPL). 1064nm lasers can be used for unwanted hair removal from the face and back as well.

Cooling
When deeper targets in the dermis are approached with a laser, especially hair or blood vessels, the outer layer of skin, the epidermis, may be damaged because melanin in this layer absorbs laser light as well. This can result in burning, crusting and scarring of the epidermis. To avoid this, the epidermis is cooled to protect it from heat injury while laser energy passes on through to targets in the dermis. Surface cooling can be achieved with ice, cooled gels, and cold glass or sapphire plates the laser can pass through. Devices like the Zimmer chiller blows cold air on the site to keep it cool. Cooling can also result in pain reduction as well with laser treatments.

Laser Therapy: Varicose Veins and Spider Veins

Laser Treatment of Varicose Veins and Spider Telangiectasias

Laser treatment of spider veins on the face laser treatment of leg veins

Varicose veins and spider veins occur in over 40% of women and 15% of men in America. Abnormal veins can appear as superficial spider veins, fine linear vessels called telangiectasias, deeper small veins that feed the spiders (reticular veins), or larger varicose veins that stick out of the skin. The causes may be hereditary, from jobs requiring prolonged standing, being obese, or from pregnancy. They may cause leg fatigue, aching, cramping, throbbing, swelling, skin discoloration and leg ulcers. The most effective therapy has been sclerotherapy. This involves injection of a detergent into the veins that causes them to clot off or scar shut. It is more effective for reticular veins and large spiders. Lasers can be used for very small superficial spiders or telangiectasias <0.5>75% improvement.

The laser can treat vessels <3mm>

Treatment
For patients with a low pain threshold or when treating larger veins, an anesthetic cream can be applied 30-60 minutes before hand. The area then must be cleaned off with alcohol before treatments begin. Patients may note swelling, redness, or a raised rash around the lasered vessels. The use of ice or steroid creams can help speed recovery and decrease the skin darkening side effect. Side effects of laser treatment include skin damage, blood clots, inflammation (superficial phlebitis), hyperpigmentation (skin darkening), and lack of clearing. Incomplete treatment can be taken care of with further laser or sclerotherapy. Painful blood vessel clotting can be addressed by suctioning out the old blood with a larger needle. Abnormal skin darkening can be avoided using longer wavelength lasers and better skin cooling devices.

Treatment summary

Patient examination
Veins and telangiectasias should be classified prior to treatment according vessel diameter and depth, which can be assessed by micrometer, dermatoscope, venoscope, or a Duplex ultrasound. A pre-treatment photo should be taken to assist in evalulating the effectiveness of the treatment.

Site prep
Shave the area to be treated. Cleanse the area with mild soap and water followed by an alcohol swab to thoroughly remove any residue from lotions, makeup, or shaving. Remove the alcohol with a gauze and plain water leaving the surface of the skin slightly moist. Patients generally lie flat for the procedure. The head may be raised to allow the leg veins to fill so that they are more visible.

Anesthesia
There is a cooling plate that is used with the Sciton laser that helps relieve discomfort. Injectable anesthesia is usually not used. Topical anesthesia is usually not effective but can be tried. Patients will usually feel a sensation like being snapped with a rubber band or mild burning that lets them know the laser is working.

Clinical Endpoints
Vessels may disappear, darken, lighten, or appear unchanged but fade with time. Variations depend on the depth, diameter, and oxygenation of the vessel.
There may be blurring of the vessel margins.
If prolonged blanching of the skin is seen, the fluence or power of the laser should be decreased or the cooling parameters increased. Blanching may lead to blistering.
If a second pass is needed, fluence may be increased by 10 J/cm2.
Contraction, disappearance, lightening or darkening of the vessel will become apparent within 15 seconds after the laser treatment.
Slight amount of hyperemia (redness) in the treated area will occur.
Urticaria (red wheals) may be visible after 1-2 minutes.

When purging (gently rubbing the vessel to push out the blood) after treatment and the vessel neither disappears nor back fills, then the vessel is static and does not have blood flowing through it. This a definite endpoint and further treatments are not necessary.

Some vessels will disappear after purging post treatment. Pruge blood that is trapped. If treatment is successful it will not backfill. This is another common endpoint where no further treatments are necessary.

Post-treatment considerations
Topical treatments to reduce erythema may be applied at the discretion of the physician. Cool compresses can be applied for patient comfort. Any skin breakdown or blistering should be treated with a topical antibiotic ointment to prevent infection. Immediate clinical response to be noted include percentage of vein closure, loss of venin margins, clotting, blanching, erythema, edema, or prupura (bruising).

Compression stockings may be used at the clinician’s discretion. The treated area should be evaluated and documented in the patient’s chart. Urticaria, patient’s tolerance of the procedure or other reactions.

Rexamination and or retreatment can be scheduled at 4 weeks.

Laser Therapy: Hair Removal

Laser axillary hair removal before and 5 years after the fourth treatment




























Laser Hair Removal

There are several hair removal methods including shaving, waxing, tweezing, creams, electrolysis, and laser therapy. There are two types of hair. Terminal hairs are long and thick and colored by a dark material called melanin. They are found on underarms, genital areas, eyebrows, scalp, face, arms, chest, and back. Vellus hairs are small nonpigmented short and found on areas like the forehead.

There are three phases of hair growth, the Anagen, Catagen, and Telogen phases. The Anagen phase is where hair is growing actively. This is the only stage that hair is susceptible to treatment with a laser. In the Catagen phase, growth stops and in the Telogen phase, hair falls out in preparation for development of new hair. This is a dormant stage where there is no growth.
Hair should be treated in the Anagen phase.
Hair growth is variable. It is affected by gender, hormonal changes, as with pregnancy or menopause, endocrine disorders like PCOS (polycystic ovarian syndrome)and Cushings disease, medications like BCPs (birth control pills), HRT (hormone replacement therapy), and age, diet, and exercise habits.

Laser hair removal has been done since 1996. The laser light penetrates the skin and destroys hair follicles by heat, shockwaves, or by laser stimulated chemical reactions. Melanin is the substance contained in hair follicles that gives it its color. It is therefore the target for laser destruction. A laser with the proper wavelength is chosen. This wavelength will be selectively absorbed by melanin (600-1100nm) deep within the skin where the hair follicles lie and not so much by the other structures. With enough energy (fluence), this results in selective damage to the hair follicles. The laser energy is delivered for such a short amount of time (short pulse width), that the damage is done quickly without any excess heat diffusing from the target to damage surrounding structures. The problem is that melanin exists in the outer layer of skin to give skin its color, more in some than others. In order to avoid heat damage to superficial skin while destroying hair follicles deeper below, cooling of the outer layer is done using ice, cooled gel, cooled glass, a cooled sapphire window, cold spray, or piped in cold air.

Sometimes stem cells in the hair follicles are not pigmented (do not contain melanin) or are farther from the melanin containing parts of the hair. These cells yet may need to be damaged to achieve more hair loss. Therefore laser pulses with longer durations may be given to achieve permanent hair loss. Hair destruction with shockwave like destruction has been used with very short pulses (in the nanosecond range) but result in only temporary hair loss. Hair removal by laser stimulated chemical reaction has been done as well. Aminolevulinic acid is a substance that is converted to protoporphyrin IX (PPIX) by some cells in the skin. When PPIX is exposed to laser photons it is changed to an oxygen radical that damages target cells. In one study about 40% hair loss was noted in 12 patients with a single laser treatment 3 hours after an ALA skin application.

Clinical Technique
Before treatment it is important to note the patient’s skin type, hair color, and coarseness of the hair. The patients who respond best have realistic expectations, no severe endocrine problems, thick dark hair and light skin. Therapies are not good at getting rid of white or fine hairs.

Laser therapy works best when the pigmented hair is in the hair follicle. Therefore patients should not pluck out hairs or get waxed for 6 weeks before a treatment. Shaving, bleaching, or using chemical depilatory agents are OK. Shorter wavelengths are alright to use in light skinned patients but not in darker skinned patients. Longer wavelengths are needed here to avoid problems with skin discoloration. If a patient has a sun tan, it is safer to wait until it fades before starting treatment. There have been reports of increased hair growth after laser therapy, usually in young females with darker skin and fine hairs on the face.

An example of a laser for hair removal is the 1064nm wavelength laser which is safer for treating darker skin than shorter wavelengths. Intense pulsed light or noncoherent broadband light sources have been used also. Filters can be placed to allow only longer wavelengths to be delivered, to penetrate more deeply to the hair follicles and maintain safety for darker skin. Aminolevulinic acid can be spread on the skin. The chemical can then be activiated by laser light to a form compound toxic to hair follicle tissue. It prevents 30% of hair regrowth after one treatment. It is possible this could be the way to treat white hair as well.

Patient interview
The interview must include an assessment of patient expectations, a medication history, a history of scarring, previous hair treatments, an endocrine history, and an account of sun exposure. Patients should be checked for things causing hypertrichosis (excessive hair growth) like hormone disorders seen in adrenal gland diseases, polycystic ovary disease, or drugs like Minoxidil or Dilantin. Hair removal treatment may be limited in these conditions. Patients with active skin infections should not be treated. If they have a history of staph or herpes infections in the past they should get pretreatment antibiotics to prevent new infection. Patients with a history of excessive scar formation should be treated more conservatively. Moles should be avoided. It is controversial whether to treat patients on isotretinoin (Accutane). In the very least they will need to wait 6 months after stopping the drug before laser treatment can be done. Patients on gold therapy can get blue grey skin from laser treatments. Patients with psoriasis or vitiligo can get Koebnerization (where injury to the skin can lead to the appearance of psoriatic lesions at that site) after laser therapy.

Treatment 6 weeks before laser therapy
Patient s should avoid plucking, waxing or electrolysis. Shaving or depilatory creams are allright. Avoiding the sun or using heavy sunscreen is important. Bleaching creams as 3% hydroquinone, retinoic acid 0.025%, and hydrocortisone 2% can be given to patients with darker skin or with recent sun tans.

The day before therapy, the patient should shave the area or use a depilatory cream. Pretreatment antibiotics or viral agents as valacyclovir, famcyclovir or acyclovir are given.

On the day of the procedure, make up and skin cream must be removed. Anesthetic skin cream is used on sensitive areas. Either a cooling gel or cooling device on the laser is used to protect the outside layer of skin. During laser hair removal, the laser wavelength is absorbed by the hair pigment (melanin). The hair becomes hot, and the heat damages the hair bulb, disabling the hair forming structure. A treatment response is seen immediately. A few minutes later some swelling and redness occur. Visible hairs should be burned, and there is an odor of burnt hair. Hairs may fall out. There is perifollicular edema or punctate swelling and redness. If signs of acute skin injury are seen, as whitening, blistering, or sloughing, the fluence setting on the laser should be reduced.

Postprocedure ice packs can decrease pain and swelling. Steroid creams can also be used. Pain pills are not usually needed. Courses of antibiotics and antiviral medications should be finished. Antibiotic ointment can be used two times a day if epithelial injury i.e. blistering or ulceration has occurred. For the first week, patients should stay out of the sun or use sun block. Make up can be used the day after treatment unless there has been epithelial damage. Damaged hair falls off within a few weeks.

So ideally, the best laser hair removal patient has dark hair and light skin. Black and brown hair contain a large amount of melanin where blond, white, and grey hair contain less and respond only partially to treatments. Laser hair removal is not permanent but is approved by the FDA for permanent reduction. When hair does eventually grow back, it is finer, lighter in color and more sparse. The number of treatments needed is predicted by the Richards-Merhag chart. For example 20% of leg hair is in the Anagen phase. Therefore it will take 5 treatments 6-8 weeks apart to get maximal hair reduction. An average hair series might include for the lip 2-3 treatments, face 3-4, bikini lines 3-4, arms 5-6, underarms 3-4, and legs 5-6 treatments.

Most hair removal lasers are safe for light skinned patients but longer wavelengths with longer pulse widths and skin cooling is needed for dark skinned patients.

Side effects
Patients may complain of pain during and after therapy. Anesthetic creams preoperatively can be used to prevent this. Swelling, redness, and epithelial damage can occur with high fluency settings especially in darker skin patients with a tan. Herpes and skin infection are rare. Folliculitis (inflammation around the hair follicles) can occur in areas lasered after excessive sweating. Swimming or hot tubing should probably be avoided around therapy. Most common side effects are hypopigmentation (excessive skin lightening) or hyperpigmentation (excessive skin darkening) mostly in darker skinned or tanned individuals. Scarring is rare except when treatments are too aggressive or with skin infection. Disappearance of pigmented skin lesions or fading of tattoos can happen. Leukotrichia, lichen planus, and a Koebner phenomenon has been reported. Swelling, redness, itching, allergic rashes, and mottled skin appearance can be seen. Steroid cream and antihistamines may help. Stimulation of hair growth has been seen in young females with dark skin. Retinal injury can occur from the laser so eye protection should be worn during laser exposure.

Treatment Summary Using the Sciton Laser System

The removal of hair with light based technologies has been steadily improving over the last decade. Several different laser wavelengths and methods have been used. The history of hair removal includes complications and limiting factors that put at least some portion of the patient population at risk for blistering, scarring, hyper and hypopigmentation. Darker skin type individuals have experienced the core of the complications seen to date. In order to avoid epidermal melanin while targeting hair follicles with high levels of safety, many physicians are using infrared lasers such as the Nd:YAG laser at a wavelength of 1064 nm. The combination of a safe clinical wavelength with a tissue colling system protecting the patient’s skin, during, and after the laser pulse makes the Sciton Profile the laser of choice for the long term reduction of unwanted hair in all akin types.

Some advantages of the Pofile laser includes:
Ability to treat skin types I-VI with minimal epidermal damage
Suitable for dark skin types including tan skin
It is noninvasive
Shorter course of treatment than electrolysis
Consistent reproducible results
Non-sequential high speed scanning

Introduction
Avoiding epidermal melanin
A problem in using laser energy that is absorbed in melanin for hair reduction is heating the melanin of the epidermis in Fitzpatrick skin types IV-VI and in tanned Fitzpatrick skin types II-III. The Profile laser resolves the problem with two methods. The first is the ability to select pulse widths that target hair follicles while avoiding damage to melanocytes and melanin in the epidermis. The second is the Profiles ability to cool and protect the epidermis and dermis with a controlled, adjustable surface cooling system. Theses two methods, a large range fluence range and a computer-guided scanner, allow treatment of all skin types at high speed and full treatment coverage without the need for the time and mess of a topical anesthetic for the majority of patients.

Surface Cooling
The Profile cooling plate cools the skin before, during and after treatment for maximum protection.

Patient Selection
Profile laser therapy is not indicated for those patients who:
• Are hypersensitive to light.
• Take medication, which is known to increase sensitivity to sunlight, such as accutane and gold treatment therapy.
• Have suspicious pigmented lesions.
• Have very recent sun exposure or tanning

Profile BBL therapy is contraindicated for those patients who:
• are hypersensitive to light;
• take medication that is known to increase sensitivity to sunlight, such as accutane and
gold treatment therapy;
• have seizure disorders triggered by light;
• have suspicious pigmented lesions;
• have very recent sun exposure or tanning.

Classification of Skin Types
Fitzpatrick Scale
The following table offers a broad guidance to identifying skin types based on hair, skin and eye color as well as sun reaction.

Type Hair Color Skin Color Eye Color Sun Reaction
I Red Light Blue-green Burn, never tan
II Blonde Light Blue Burn, may tan
III Brown Medium Brown Burn, then tan
IV Brown-black Moderate brown Brown-black Tan
V Black Dark brown Dark Tan
VI Black Black (African) Dark Tan

Consultation / Treatment
The consultation or initial visit allows an exchange of views between case provider and patient in an attempt to reach a decision regarding treatment. The patient must understand the procedure, pre and post care instructions, and expectations before the procedure is performed.

Patient Education (Expectations)
The Profile laser is used to reduce or eliminate unwanted hair. Patients must understand that results vary with each individual.
Duration of hair growth cycles varies as to the body location being treated. The laser can only eliminate the hair that is currently in an anagen growth cycle. Multiple treatments are necessary over a time span (6-8 week intervals) to remove hair from most areas. Final results may not be apparent for several months post treatment. Suggested treatments and treatment intervals are:

Body Part /Number of Treatments /Treatment Interval
Lip /3 - 4 /6 – 8 weeks
Face /3 - 4 /6 – 8 weeks
Bikini Line /4 - 5 /6 – 8 weeks
Arms /6 -7 /6 – 8 weeks
Under arm /4 - 5 /6 – 8 weeks
Back /4 - 5 /6 – 8 weeks
Legs /5 - 6 /6 – 8 weeks



The laser pulse is often described as a wave of heat with the sensation of a pinprick. A topical anesthetic may be applied if necessary. Sciton’s cooling device is found to be effective in pain reduction during the laser treatment.
Erythema/follicular edema may be seen for 4 – 6 hours following the laser treatment. The treated hairs can take 7 – 14 days to exfoliate and may appear to be "growing" during this time.

Patient History
A thorough history of previous treatment methods, current medications, allergies and pigmentary problems should be discussed. Exclusion criteria may include but not be confined to: photosensitivity, keloid formation, immunosuppression, and/or history of poor wound healing.

Patient Documentation Forms
Consent: the process of accepting and confirming treatment must be reviewed,
understood and signed by the patient prior to treatment. This document must review
the topics discussed during consultation and acknowledges that the patient
understands the procedure and that all questions have been answered.
Review post care instructions and confirm that the patient will adhere to such
instructions throughout the course of their laser treatment. (Sample post care
instruction sheets are included.)
Upon patient's assessment, the case provider must determine the need of medications
or creams. These can be given before the procedure and used throughout the
treatment.
Post-treatment appointments are scheduled for: treatment assessment, patient
evaluation and routine therapy.

Photographs
Before and after photographs should be taken throughout the course of the treatment to
monitor patient response to therapy. Photographs should be taken prior to treatment,
immediate post operatively and during follow-up visits. Results must be similar in quality and camera parameters (settings) should be the same to maintain photographs of similar quality. Obtaining a photo release form the patient will enable you to develop of catalog of results for education of your patients.

Pre Treatment Procedure
For better results, patients are to avoid sun exposure, tanning beds and tanning creams for 2-3 weeks prior to treatment and throughout the course of their laser treatment. Sunless tanning lotions must also be avoided for 2-3 weeks prior to treatment. However, if sun exposure is not avoidable a reduced fluence may be used. In this case treatment sessions need to be increased. Instruct the patient that recent sun exposure may result in
cancellation of the treatment.
Instruct the patient to shave the treatment areas 24 hours prior to treatment. This is to
remove the overlying hair from the treatment site. Thick overlying hair (if not shaved)
will absorb the laser energy and superficial thermal injury can occur as well as
reducing the amount of energy absorbed by the hair follicle.

Post Testing Evaluation
Treatment energies for each patient will vary according to patient skin type, location and color of hair. Test spots using a variety of energies are recommended. These will ensure that the energy delivered to the patient is within a safe parameter range.
Evaluation of the tested area(s) usually occurs 1-2 weeks post treatment.
Verify that any hypo/hyperpigmentation has been transient (to date). If the patient is
concerned about the pigmentary changes, further treatments may be delayed. Once
the area returns to normal skin tone, treatments may be resumed.
If the treated area appears hypopigmented (blanched or white) this is an indication that
the energy density was too high and should be decreased accordingly.
Further testing may be indicated depending on the results seen from the first tested
area(s).

Determination of Clinical Endpoint
Warning: Treating with excess energy levels can result in adverse effects
such as abnormal pigmentation and scarring.
Sparking – the visible hair shaft should flash when instantly heated by the laser pulse.
Smell of success – hair has a unique and very noticeable odor when it burns.
Mild discomfort – thermal damage to hair follicles will be noticed by the patient during
the laser pulse.
A slight erythema should be noted in the skin around the hair follicles. Increased
erythema during the treatment can indicate the energy is too high or the patient has
had recent sun exposure.
Peri-follicular edema – in some cases edema will show up around the treated hair
follicles.
If the treatment area has even the slightest tan, the erythema response is greater and
can lead to a purpuric response (blue-gray discoloration). If blistering occurs, treatment should be stopped immediately. Treatment can resume when the tan has
faded.

Treatment Procedures
The highest energy density determined through test spots should be utilized. An
increase in fluence should be tolerated after 2-3 consecutive treatments.
A white or yellow washable marker can be used to outline the area to be treated.
Caution! The use of blue, black or brown markers may absorb the laser energy and
result in epidermal injury.
The system allows the continuous cooling on the treatment area to ease the pain
sensation from the laser pulse. A coating of gel, KY, surgilube or water may be used
in conjunction with the system as a conduit for the laser energy.
A decrease in fluence may be necessary in sensitive areas and high hair density areas
such as the upper lip, shin, ankle area and bikini areas.
Topical anesthetics such as EMLA may be applied to the treatment area 90 minutes
prior to treatment. Cover the area with a liberal amount of EMLA and provide an
occlusive covering (e.g. saran wrap with edges taped). Eutectic LA ointment may be
applied only 20 - 30 minutes prior to treatment.
Double pulsing at the same spot is not recommended and can increase the chances of
post treatment complications.
Following the treatment, the cooling system or an ice pack can be applied to the
treated area to ease the sensation from the laser pulses. Post treatment cooling is
highly recommended for darker skin types.
Treatments can be scheduled at 6 to 8 week intervals for most body areas or when
hair is actively regrowing. It is not recommended to re-treat any sooner than 6 weeks.

Sun Protection
A broad spectrum (UVA/UVB) sun block with an SPF of 30 must be applied 15
minutes prior to casual sun exposure.
Prolonged sun exposure requires repeated applications of sun block every 2 hours
(e.g. yard work, beach activities, etc.).
Sun block must be reapplied after swimming.

Adverse Effects
Complications, though rare, can occur and should be discussed and understood. The patient must understand the importance of the post-care instructions and that failure to comply may increase the probability of complications.
Scarring, though rare can occur following any laser procedure.
Blistering during treatment may be an indication of sun exposure or too high of a
fluence setting for the skin type. Blistering can occur during the first three days
following the laser procedure. Blistered areas should be treated with care, keeping the
area moist with an ointment until area has healed.
Pustules or pimples may develop in the first few days following treatment. The areas
should be kept clean and treated with care.
Histamine/Hives: some patients develop raised papules similar to hives. This irritation
usually subsides in a few hours.
Pigmentary changes: hyperpigmentation or hypopigmentation are rare when treating
with a 1064nm wavelength.

Post Treatment Skin Care
Patients should receive post skin care instruction following each laser treatment. Sample post care instruction sheets are included.

Application of an ointment or aloe vera:
Ointment is applied to the area to prevent drying and crusting. If crusting develops it
should be allowed to fall off naturally (no picking). Ointment applied following the
laser treatment can have a soothing effect and should be utilized if there is any
blistering or break in the skin.
The patient should be instructed to contact the office if there is an
indication of infection (redness, tenderness or pus).

Shaving:
No shaving of treated area for 1 to 3 days post treatment.

Bathing:
If treated area is irritated the area should not be rubbed with a face cloth
or towel. The area should be patted dry.

Makeup:
If the area blisters, extreme caution should be used when applying or removing
makeup. The treated area is very delicate and should be treated with care.
ClearScan Hair Reduction Protocol –12/26/05 v5.5 Page 8 of 18
Rough removal of makeup can increase the incidence of post treatment
complications.

PROFILE™ CLEARSCAN™ 1.064-μM LASER MODULE:
HAIR REDUCTION SAFE START PROTOCOL
The following protocol is a safe start guide based upon the clinical observations of experienced physicians.

1. PRE-TREATMENT CONSIDERATIONS
1.1. CLEAN SKIN
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment area.
Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use special
care around the eyes.
1.2. ANESTHESIA
Use a topical preparation, as needed, to alleviate discomfort for sensitive patients or
sensitive areas prior to treatment. Remove before treatment with mild soap and water or
an alcohol swab, then plain water. Dry the area thoroughly before treatment.
1.3. SHAVING OR THE REMOVAL OF SURFACE HAIR
Removal of surface hair prior to laser treatment assures a safe treatment without the risk
of epidermal irritation or burn from the presence of dark surface hair. The site should
present at treatment with only short stubble, no longer than 0.5 mm long, in order to
clearly identify the treatment area. Shaving immediately before treatment is safe as long
as the nicking of skin is avoided and short stubble remains.
1.4. SCANNER CLEANING
Prior to each treatment, clean the cooling plate with an alcohol swab. Check the lenses
and cooling plate during long procedures and clean as necessary.
1.5. EYE PROTECTION
Always use eye protection for the patient, the operator, and anyone in the laser treatment
room during the treatment.
1.6. TREATING AREAS WHERE ARTIFICAL MAKE-UP, TATTOOS, or DARKENED
MOLES ARE PRESENT:
TATTOO or MAKE-UP
Areas with tattoos or artificial make-up must be avoided. Tattoos with red or frosty white
appearance commonly have iron or titanium in their composition. The red or white
pigment will often oxidize and turn black from laser exposure. If one must treat those
areas, a test spot with close monitoring for one to four days is recommended.
DARKENED MOLES
Darkened moles often have unwanted dark hair present in their core. It is important to
remember that the removal of that hair and the subsequent potential bleaching of the
mole prevent monitoring of the mole. Cancerous lesion assessment is based on the
ABCD method (Asymmetry, Borders, Color, and Diameter).
CAUTION: Tattooed areas should not be treated. Tattoo ink may absorb laser
energy resulting in a color change in tattoo ink or a risk of epidermal
damage.
CAUTION: Darkened moles should not be treated. Moles may absorb laser
energy resulting in a color change creating a risk of epidermal damage and
the inability to monitor the lesion under ABCD guidelines.
2. SETTING TREATMENT PARAMETERS
2.1. COOLING TEMPERATURE
5°C is recommended for maximum patient comfort. Treating with higher COOLING
temperatures will require treating with lower FLUENCE settings. The inverse also applies.
The cooling temperature is set on the separate chilling device and not on the laser panel.
Most treatment can be performed at the 5°C setting. A coating of colorless gel or
surgilube should be used in conjunction with the system for better heat removal, improved
optical coupling, filling void and irregularities in the skin, and lubrication for sliding the
plate over skin. The gel simulates contact with the skin while reducing the risk of damage
to the plate.
2.1 FLUENCE
The FLUENCE required depends on the starting surface temperature of the area being
treated. Reduce fluence by as much as 20% over bony areas such as shin and the face.
Patient response can vary, so fluences should begin low, 50 to 70 J/cm2. After assessing
the individual patient response the fluence may need to be increased in 5 to 10 J/cm2
increments to get the desired immediate clinical result. In some cases you may need to
treat in excess of 100 J/cm2 for effective results.
At the correct fluence there should be noticeable sparking of the hair during treatment,
and the patient may report immediate discomfort in the area being treated. The desired
response is spontaneous erythema converting within a few minutes of laser application to
perifollicular edema (similar in appearance to razor burn or rash). Fluence and pulse width
settings will need to change for a patient during the series of treatments. Perifollicular
edema may last approximately 4-6 hours after treatment. Be sure to properly evaluate the
treatment parameters before each treatment based on previous successes, or complications, and the response of the patient to questions about the first 24 hours after the previous treatment. Those who respond with no irritation, blistering, or complication for the first 24 hours after treatment are within a safe, and possibly low, fluence range.
2.2. PULSE WIDTH
Set the starting pulse width according to the onscreen guidelines, previous fluences, or
personal experience. Understand that pulse width is partially determined by the size of
the hair shaft and follicle. As hair reduces in size during the treatment series it will be
necessary to reduce the appropriate pulse width. ClearScan uses a train of pulses to
achieve the desired fluence.
3.1. PATIENT POSITION
Position is based on the area to be treated. Patient should be in a comfortable position.
The treatment area should be presented to the laser user at a convenient height and
position.
In areas where hair bearing skin is adjacent to mucous membrane (mouth or genital
areas) care should be taken to avoid non-hair-bearing skin.
3.2. TEST AREA
Treating a test area before a patient’s first treatment can establish their response
threshold and help establish safe starting parameters. The test area should be monitored
for response for a period of five to ten minutes. Blistering or the immediate grey or white
presentation of the skin is the immediate concern.
Set the scanner to single spot or a small 2 by 2 array. TEST AREA should reach the
desired response of erythema and perifollicular edema within a few minutes.
Increase fluence in small increments until the desired response is achieved.
CAUTION: Use only enough fluence to achieve the desired endpoint of erythema. At
the correct fluence there should be noticeable sparking of the hair during
treatment, and the patient may report immediate discomfort in the area being
treated. Excessive fluence, immediate retreatment, pulse stacking, or poor contact
with skin can lead to dermal injury or blisters. Use gel to create good cooling
contact without having to apply pressure to the skin.
IMPORTANT: Keep fluence conservative for the first treatment session, and monitor
the patient for any evidence of prolonged erythema, swelling, urticaria or blistering.
3.3. SCANNER POSITION
Position the SCANNER so the cooling plate is in full contact with the skin. For highly
curved regions, a smaller scan pattern or using OFFSET to place the scan pattern near
the edge of the cooling plate while pushing the skin upward with your other hand will
insure proper cooling. Use the OFFSET function to place the scan pattern near the edge
of the cooling plate near the boundary of cosmetic regions.
The SCANNER must remain in contact with the gel on skin long enough before and after
the laser scan to cool the surface of the skin and reduce the heat sensation. It will take
several seconds for the deeper heat to propagate to the surface after the scan. A coating
of colorless gel, KY, surgilube or water must be used in conjunction with the system for
better heat removal, improved optical coupling, filling voids and irregularities in skin, and
lubrication for sliding the plate over skin.
3.4. TREATMENT METHOD
Match the “trailing edge” of the next scan to the “leading edge” of the previous scan. The
computer-guided scanner will give a uniform treatment with selected beam placement
within the scan.
Make certain to maintain complete skin contact below the scanned area before, during
and after the scan. Adjust the scan size or shape to fit only the area where chill plate is in
good skin contact. A coating of colorless gel or surgilube must be used in conjunction with
the system for better heat removal, improved optical coupling, filling voids and
irregularities in skin, and lubrication for sliding the plate over skin.
Use the 6 mm single-spot handpiece with small chiller window accessory if unable to get
complete contact with the scanner. Do not overlap or immediately repeat laser pulses.
CAUTION: Do not stack pulses or overlap consecutive scans. Repeated pulses in
the same location, improper cooling plate placement, repeated scans, improper
cooling temperatures, or excessive fluence may lead to a build up of subsurface
heat and a subsequent blister or burn.
Presentation of a blister or immediate graying or whitening of tissue indicates
immediate complication. Treatment methods and parameters should immediately
be reevaluated. The blisters or skin discoloration will commonly resolve without
complication.
A thin layer of gel between the cooling plate and the skin surface will avoid needing
pressure on skin and will protect the cooling plate from damage due to burning
hairs.
4. TREATMENT GOALS
The ideal fluence will often present as small light flashes on tissue (sparks) as the
scan occurs.
The light smell of denatured proteins (rotten egg or sulphuric smell), and the voluntary
shed of a few hairs at the treatment site when wiped immediately after the scan.
Patients should feel mild discomfort from the laser during treatment.
Patients will typically report feeling tighter skin or the sensation of mild sunburn
following treatment.
The immediate goal is light, uniform erythema converting to perifollicular edema
(similar to razor burn or rash in appearance) a few minutes after treatment.
5. POST-TREATMENT CONSIDERATIONS
5.1. OBSERVATIONS
Erythema, perifollicular edema, and a mild sunburn sensation should be noticed in the
treatment area for up to two hours after treatment.
Patients should not feel any significant discomfort after treatment.
Hair should appear to grow for several days post treatment as the hair is extruded.
Hair should spontaneously fall out about day 4 -14.
Shaving of the area is allowed between laser treatments as necessary.
5.2. INTERVENTION
Cold compress can provide some comfort after treatment. If blistering occurs, aggressive
wound treatment should be administered, i.e. Vigilon, Second Skin, silastic sheeting or
other intervention.
Caution: When treating the bikini area, panty elastic at the leg should be avoided
for several days after treatment. The irritation of the elastic over the treatment area
can lead to rash or blistering.
5.3. INTERVAL
Recommended time interval between treatments is 6 - 8 weeks. Physicians report that a
fixed retreatment time may shorten the series period and increase efficacies. The number
of treatments necessary may be roughly estimated from the Richards-Merhag chart by
dividing the percentage of Anagen hair present in an area into 100% and adding one
additional treatment. (example: Legs, 20% anagen divided into 100% equal five cycles
plus one additional treatment to equal six total)
6. CONCURRENT PROCEDURES
COMBINATIONS –Hair reduction treatments may be given in combination with other
minimally invasive therapies. If a patient is to receive another treatment (light chemical
peel, microdermabrasion, Botox, collagen injection), it is advisable to perform the hair
removal treatment first. There may be increased sensitivity in the treated areas for an
hour or two.
7. PSEUDO-FOLLICULITIS BARBAE
PFB can be successfully treated with the parameters shown above. Treatment may
produce permanent change preventing hair regrowth in the treatment area. This can have
long term effect in areas where beard growth is desired.
8. CONCLUSIONS
Do not be overly aggressive. Begin conservatively and be patient. Results are determined
by the physiology of the patient’s skin. This is not a surgical process; hair reduction takes
time. You should help your patient understand that the results are long term.