Medical Spa MD: Physician community of skin clinics, laser centers, plastic surgeons, dermatologists and aesthetic doctors practicing nonsurgical cosmetic medicine.
The Fractional CO2 Laser chat transcript: The various Fractional Technologies. Lumenis UltraPulse, Reliant Fraxel, Juvia, Sciton ProFractional, Lutronics, Cutera Pearl Fractional, and others. Depth of Penetration, Energy Levels, Length and Width of Ablation and Coagulation, % Surface Area Covered etc.
Ok, I'm more than just a little tired of some of the bull shit that certain laser clinic and plastic surgery directories spamming the site and posting positive anonymous reviews of their services and laser hair removal listings.
So, there are about to be some very public spankings.
Medical Spa MD has attained some popularity, and some clout with physicians running laser clinics. I receive regular iquiries from docs looking for advice on cosmetic lasers and I personally know of a number of doctors who have printed out reviews from Med Spa MD and asked cosmetic laser sales reps about them. There are laser companies who are now Medspa MD members and (to my current understanding) are welcome members to the community.
However, there are some cheap laser clinc and plastic surgery directories that think that you're an idiot and post comments like those below. (There've also been some physicians offering their 'expertise' as trainers who have tried this to promote their training.) Don't. You've been warned.
1800laserhair.com: I don't know if 1800laserhair.com is posting these comments as part of their corporate policiy or if it's just a rogue individual salesman who's doing it for them. I also don't care. My guess is that they're some small little hack job outfit. It pisses me off personal that whoever this is thinks that this won't be found out.
Here's an example of laser clinc directory, 1800laserhair.com who posted this rave review to Med Spa MD under the name Dr. Don:
I have the two Candelas yag alexandrite and a light sheer diode. I use a service tech that is awesome and reasonable. I can't remember his name right off but I got his name from this great referral network I belong to. Call 1-800 Laser hair ask for Nancy or go to their website WWW.1800laserhair.com There may be a link but I think I got the guys name directly from Nancy. His name is Robert something... BTW anyone slow or having advertising or marketing issues, I am getting tons of referrals from the 1-800-laser hair network. You have to meet their criteria, they are very picky and exclusive but if they will accept you join!!! Two colleagues of mine were denied I am not sure why. The leads are great worth every dime. I resisted their advice at first, them I put my wife in charge of all of it, she followed their program to the letter now we are so overwhelmed with calls for laser (Not really what I want to be doing but I better not complain because laser hair removal is supporting my practice through this crappy economy. Nice plug for them...tell them Dr. Don sent you...I may get some referral bonus!! LOL
Back to Laser Hair removal service. I don't have a service contract. Don't get them. I regularly get laser check-ups. Robert (the service guy) calls my office when he is in my area. By getting him in when he is already in my area he gives me a break on service costs. I get the check-ups and do preventative laser maintenance. Also Nancy (the 1-800 laser hair removal lady) gave me a monthly weekly and daily check list that tells us how to properly maintain our lasers in between service visits. I have not had a significant laser repair cost in 7 years and I haven't had to replace a laser yet going on 10 years. After we got our staff to follow the checklist diligently we saw a significant drop in repair costs. My staff was going through thousands of dollars worth of parts yearly and I was watching our profits go to Candela, I too despise them. They have terrible service and they have been so shady. I think they would sell their grandmothers if they could make a buck!!! Their service contracts are totally over priced. bad plug!!
I really don't use the light sheer much but I keep it for a back up, just in case. Robert can usually fly in for emergency repairs next day. So I have never really needed it.
Posted As: DrDon
Posted Email: wtawtawdba@yahoo.com
Posted Link: www.1800laserhair.com
Comment Posted From This IP Address: user-24-96-114-40.knology.net (24.96.114.40)
I have to laugh at these claims of exclusivity. "You have to meet their criteria, they are very picky and exclusive but if they will accept you join!!!" Sure.
If I were Candela I'd be contacting my legal department about now. This is a perfect case of liable; posting damaging comments as fact under an assumed name. Candella can't be happy that these laser hair removal guys are bad-mouthing them and servicing their lasers at the same time.
Does anyone fall for these laser hair removal guys? I'd be interested in hearing what any identified physician using 1800laserhair.com thinks about their "tons of referrals from the 1-800-laser hair network."
If anyone has an email from 1800laserhair.com that they have archived in their inbox, I'd be interested in seeing it since the IP address is included. We could compare the two. I'd expect that they change their IP address shortly if they happen to match.
PS: This IP address has been banned.
Fractional CO2 Laser Disccusion:
Participate in the conversation as Fraxel, Lumenis, MiXto, Juvia, Dot, Lutronic and others (even a PreOwned Laser Dealer) try to convince MAPA Man to purchase their Fractional CO2 Laser. Fractional Erbium and Cutera Pearl Fractional will also be invited.
Discussions include treatment perameters, effectivness, cost, the technolgies and anything else of interest. All interested parties are invited. Reps who identify themselves and are willing to engage in open discusion are also welcome.
To participate: Click the launch window button above at the scheduled time.
Looking forward to seeing you.
I'm not sure how long Sciton's been in the forums or if they just found the Sciton Anyone forum thread but it's nice to see that at least one of the IPL & Laser companies is willing to respond to a forum discusson.
Palomar, Cutera, Lumenis and everyone else would be welcome.
I have a Q regared the 515 filter and lentigines. With the 10ms pulse widths I have seen moderate rxns at 11-12J with 25 cooling in type 2s ( moderate erythema with accentuation and darkening of lentigines). When I moved to 20ms 9-10J with 18 cooling in type 3 and 4s I saw no immediate response (eythema or darkening). I spoke with a patient today who stated minimal darkening 24hr out. These are the recommended settings but they do not appear to have the punch. Has anyone tried lowering pulse widths to 15ms or even 10ms with cooling let's say 15 to protect surrounding skin?? I have lot's of type 3-4s with lentigines. Your suggestions appreciated...
Live Physician Chat: Sciton BBL (Cosmetic IPLs & Lasers)
Tuesday February 24, 2009 9 - 10 PM EST
Syneron is launching Ematrix fractional resurfacing and promoting it with webinars.
Join Dr. George Hruza in a 1-hour webinar as he presents his early and ongoing findings as one of the initial investigators for Matrix RF - the worlds' first RF-only fractional skin resurfacing technology. Learn why eMatrix with Matrix RF is revolutionizing fractional skin resurfacing.
I've never had any interaction with Syneron so I don't really have an opinion. I'd like to hear from anyone pro or con as a user. Anyone ever attended one of these webinars?
Via a comment via Andrew D. Swain, Esq.
In New Jersey, laser or IPL hair removal can only be performed by a physician, and the term physician is defined as a person holding a plenary license issued by the New Jersey State Board of Medical Examiners.
New Jersey has consistently recognized that the use of a laser or light based device on a patient’s skin can only be used by a licensed physician. The use of a laser or light based device in a physician’s office is regulated by the State Board of Medical Examiners.
The State Board of Medical Examiners reviewed prior inquiries to determine whether non-physicians can use laser or IPL devices for hair removal. According to published Minutes, the Board has determined that only licensed physicians can use such devices for hair removal. On June 20, 2003, the Physician Assistant Advisory Committee of the New Jersey Board of Medical Examiners expressly stated that laser hair removal can only be performed by a physician.
The June 20, 2003 minutes stated:
b. The Committee reviewed a fax from Wanda Cooper, Sona International Corporation inquiring (1) as to whether a physician assistant is considered a nurse and therefore subject to the ruling of the Board of Medical Examiners regarding Thermolase laser; (2) as to whether the Board of Medical Examiners governs the Physician Assistant Committee and (3) whether a physician assistant can perform laser hair removal under the direct supervision of a physician.
As to the first question, it was the consensus of the Committee that physician assistants are not nurses.As to the second question, the Board of Medical Examiners governs the Physician Assistant Advisory Committee.
As to the third question,consistent with the determination made by the Board of Medical Examiners, physician assistants may not perform Thermolase laser hair removal as these procedures are deemed the practice of medicine and may not be delegated to a nurse or any other licensed health care professional other than a "physician".
A letter will be sent to Ms. Cooper so advising along with a copy of the statutes and regulations which govern the practice of physician assistants in the State of New Jersey.
On September 19, 2003, the Physician Assistant Advisory Committee of the New Jersey Board of Medical Examiners expressly stated that laser hair removal can only be performed by a physician, and that IPL photofacial or IPL procedures would be referred to the Medical Board to determine their position.
The Board stated:
c. The Committee reviewed a fax from Bryan A. Manhardt, PA-C, Allergy Asthma & Sinus Center, Somerville, NJ 08876, inquiring as to whether procedures for Microderm abrasion, Laser hair removal, IPL photofacial, Botox injections and Collagen injections can be performed under the supervision of a physician. The Committee determined, as to Laser hair removal and Botox Injections, consistent with the determination made by the Board of Medical Examiners, physician assistants may not perform these treatments as these are deemed the practice of medicine and may not be delegated to a nurse or any other licensed health care professional other than a "physician".
As to procedures Microderm abrasion, IPL photofacial and Collagen injections there is no policy statement from the Board of Medical Examiners at this time. A letter will be sent to Mr. Manhardt so advising, along with a copy of the draft proposal as it relates to these procedures which is not yet law.
d. The Committee reviewed a letter from Dr. Edwin P. Schulhafer, Allergy, Asthma & Sinus Center, inquiring as to whether nurses, physician assistants or nurse practitioners in the State of New Jersey can perform the following procedures: Laser hair removal; Laser skin rejuvenation; Endomology; Intense Pulse Light (not a laser but a visible light); Botox injections; Collagen injections and Microdermabrasion.
It was the consensus of the Committee that, as to Laser hair removal and Botox Injections consistent with the determination made by the Board of Medical Examiners, physician assistants may not perform these treatments as these are deemed the practice of medicine and may not be delegated to a nurse health care professional other that a "physician". The Committee has no jurisdiction over nurses and nurse practitioners. This inquiry will be referred to the Board of Nursing.
As to laser skin rejuvenation, Endomology, Intense pulse light (not a lser but a visible light), Collagen injections and Microdermabrasion, there is no policy statement from the Board of Medical Examiners at this time. A letter will be sent to Dr. Schulhafer so advising along with a copy of the draft proposal as it relates to these procedures which is not yet law.
On April 16, 2004, the Physician Assistant Advisory Committee of the New Jersey Board of Medical Examiners expressly stated that IPL devices used for hair removal can only be performed by a physician.
The published minutes from April 16, 2004 stated:
b. The Committee reviewed a letter from Jason Staback, PA-C, inquiring as to whether it is legal for physician assistants in the State of New Jersey to use IPL (Intense pulse light) device for the purpose of hair removal, made by Palomar. He stated that it is categorized as a category 2 device. It was the consensus of the Committee that a letter be sent to Mr. Staback advising based on the limited facts presented, consistent with the determination made by the Board of Medical Examiners, physician assistants may not perform laser treatments as these procedures are deemed the practice of medicine and may not be delegated to a nurse, or any other licensed healthcare professional other than a "physician". To the current time, the performance of microdermabrasion and glycolic acid peels have also been considered the practice of medicine but unlicensed personnel have been permitted to perform theses procedures under the supervision and direction of a physician . However, please be advised that the Board is further investigating this latter issue and obtaining opinions from appropriate expert professionals. If the Board promulgates a regulation in this regard in the future it will be noticed in the New Jersey Register. Mr. Staback will be so advised.
On September 17, 2004, the committee stated:
The Committee reviewed a letter from Thomas Geary, PA-C, inquiring as to whether a physician assistant in the State of New Jersey can perform hair removal, tatoo removal and resurfacing if the supervising physician is a D.O. The Committee determined that based on the limited facts presented, consistent with the determination made by the Board of Medical Examiners, physician assistants may not perform laser treatments as these procedures are deemed the practice of medicine and may not be delegated to a nurse, or any other licensed healthcare professional other than a "physician".In New Jersey, a physician cannot delegate laser hair removal procedures, laser skin resurfacing, or laser skin rejuvenation, to a physician’s assistant, a nurse, or any other licensed healthcare professional other than a "physician", which is defined as a licensed medical doctor. This position was stated on October 21, 2005, May 18, 2007, and reaffirmed again in September 2007. See Minutes, Physician Assistant Advisory Committee, September 21, 2007.
As recently as January 15, 2008, the New Jersey Board of Nursing did not approve of a licensed practicing nurse to administer IPL therapy. The Nursing Board Minutes stated:
Re: Inquiry from Doug Doyle, Esq., questioning whether Licensed Practical Nurses may administer “intense light pulse” therapy.
The Committee reviewed the e-mail and an article regarding Intense Pulse Light Therapy (IPL). The article stated that “IPL systems work on the same principles as lasers in that light energy is absorbed into particular target cells with color (chromophores) in the skin. The light energy is converted to heat energy, which causes damage to the specific target area.”
The Board of Nursing does not have regulations regarding administration of intense pulse light. On November 16, 2004, the Board of Nursing discussed this issue and made a motion to refer the issue to the New Jersey Board of Medical Examiners concerning the use of medical light–emitting devices (Lasers).
Consistent with the Board’s decisions of November 16, 2004, the Committee recommends that Mr. Doug Doyle’s question be forwarded to the New Jersey Board of Medical Examiners for review and comments.
As of 2008, the New Jersey Board of Medical Examiners consistently has taken the position that the use of laser or IPL device is the practice of medicine.
You can search the website of the New Jersey Board of Medical Examiners to review meeting minutes to update the above research. http://www.state.nj.us/lps/ca/bme/minutes/bmemin.htm. And, you and your employer should consider consulting an attorney or the medical board in your state for further clarification.
Lumenis seem to be some bad feelings towards some physicians who have posted comments on IPL and laser reviews and Medical Spa MD physician clinical exchange forums.
Herer is the content of an email I received from Lumenis about comments in the forums of Medspa MD:
Message: Dear Sirs,
It has come to my attention that a physician has created a blog and has used foul language and misinformation as a campaign against the company Lumenis, Inc. This can be found at http://www.medicalspamd.com/clinical-user-groups-physician/post/588128#post591701. We are aware of this physician who has sent us profanity laden emails containing threats and libalous and malicious content. We are purusing this matter with our attorneys.
It appears that this same physician has created this blog, and is using several aliases to respond to his own questions and provide comments. Given the derisive nature of his comments, we are asking that you remove these unfortunate comments, as well as monitor future comments placed on this site.
I thank you in advance for your serious attention to this matter.
Regards,
Rob Ellis
VP Global Marketing
Lumenis
There was at least one other email I recieved immediately after this one from someone stating that they had been asked by Lumenis to look at who was posting these comments. This person represented themselves as being tech-savvy and stated as above that most of the comments were left by someone posing as multiple individuals and responding negatively to questions that they themselves had asked.
With thousands of physicians reading this site each month the forums are very valuable and recieve a tremendous amount of traffic. It can certainly hurt a companies reputaton to have their IPL's, lasers, and management trashed. This is a good place to note that while information valuable, it should not be taken as more than what it is. It's entirely possilble that Lumenis is correct and this doctor is attempting to use tactics that are less than truthful.
Be somewhat suspicious of unidentified comments and please only use one screen name. If you're found to be doing something like this you may have your IP address blocked and all of your comments removed. It's happened before.
On my side it's about all I can do to try to keep the spammers out. On some days this site can get more than 25 new spam comments. With the 20-40 legit comments and 6-10 emails that's a lot and it's why I'm moving to distribute content to Medspa MD members via Senside.
The IPL Dog and Lemon Guide: Review and Analysis
Download the IPL Guide here
The Dog and Lemon is an IPL Guide which helps us decide which IPL System is best for our practices. You can get this guide from the internet or from Sciton. I suggest you get it and read it. This guide strongly suggests that Sciton is the best IPL System. Is this because Sciton is really the best or is this guide is biased towards Sciton. Those who would try to discredit this guide claim that it was done by Sciton and is biased. In this review and analysis, we will examine the points made by this report, understand why they are important and then try to assess whether it is biased or whether it correctly identifies the best IPL system.
I have no financial interest or other interest in the companies in this report. I am considering buying an IPL for my practice and this is why I started to look into IPLs. I own Reliant, Lumenis, Cutera and ConBio. I have been a full-time cosmetic physician with a busy cosmetic practice. This review and analysis is my opinion and is based from extensive reading and research. - CHMD
The Dog and Lemon Report suggests that the Sciton is the best IPL for many reasons. Let’s examine these reasons. I am hoping that other cosmetic physicians and company representatives will comment on the report and comment on my review and analysis. This review and analysis is meant to stimulate a lively debate and discussion of IPLs.
The report was done “to provide you, the cosmetic clinician practical, unbiased, objective information that empowers you to purchase equipment that best serves the interests of your patients and business alike”. There is a huge void in this type of information in the cosmetic dermatology field. There is so much hype and misinformation when it comes to lasers and light devices that it is difficult to find the best technology and the best companies when we want to purchase a piece of capital equipment for our clinics. We need a “Consumer’s Report for Cosmetic Medicine” - hopefully Paul Kadar and The Cosmetic Dog & Lemon Guides are it. Making the wrong decision when buying a laser or light device can be devastating. This is outlined on page 4 of the guide. The name of the game is excellent clinical outcomes and happy patients. In order to achieve this you have to have an IPL that will enable you to get excellent clinical results in all skin types. This type of guide - “The IPL Dog & Lemon Guide”, if unbiased and objective can help us all. Hopefully the laser companies are paying attention to this guide because it makes a lot of great points and it make intuitive sense.
Pages 7-9: These pages discuss how light intensity decays with increased distance from the light source. This means that the intensity of the light at the perimeter of the head is less than the intensity of the light at the center of the head. This loss is proportional to the square of the distance from the source, “if light that has traveled 10 mm produces a fluence of 20 m/cm2, that same light will produce a fluence of 5 j/cm2 if it has to travel another 10 mm (i.e. a doubling of the distance produces a quarter of the fluence).
The two main ways to overcome Perimeter Loss are Photon Recycling and Twin Flash Lamps. We won’t discuss “small surface area of treatment head” here because this is technique is counterproductive for many other reasons (speed of treatments, depth of light penetration, life of flash lamps) and we won’t discuss “long light guide” (“a crystal that is too long will loose some of the light through the walls and hence the fluence delivered at the treatment area may be sub-therapeutic” -I will assume that crystals are not used for this reason and this assertion is correct).
“Photon Recycling is nothing but a marketing gimmick deceitfully used to entrap unwitting clinicians . . . It doesn’t take a rocket scientist to figure out that by the time this light is reflected from the skin into the treatment head and then back again, its fluence will have all but petered out.” This is a very strong statement but the physics make sense to me. It seems to me that the recycled light will have very little energy left once it is “recycled”. I am not convinced that “photon recycling” has any beneficial clinical effect.
Palomar uses photon recycling and tries to convince you that it works by showing you a slide to demonstrate that it works. This is the slide: there is an area of skin treated by IPL #1 without photon recycling and an area of skin treated by IPL#2 with photon recycling. The area of the skin that does not look treated was treated with an IPL that does not have photon recycling. The area of the skin that looks great was treated with a different IPL with photon recycling. We are expected to believe that the difference in the results is due to the photon recycling and not due to the difference in the IPL devices.
Based on my knowledge of physics and the fact that the intensity of light decreases by the square of the distance traveled, I think that photon recycling probably does not have a clinically significant effect on treatments. Palomar’s attempt to prove it works was critically flawed. I look forward to someone from Palomar explaining and proving that photon recycling can and will work in a clinically significant manner.
“Currently, an effective way of producing a uniform fluence across the entire face of the treatment head while maintaining a relatively large treatment area is through the use of two flash lamps in an over-under or figure “8” configuration”. The first flash lamp transmits light with the usual perimeter loss. “However, the second flash lamp fires in “the shadow” of the first and consequently transmits light in a polar opposite manner to the first”.
This gets a little fuzzy here, I am not sure I fully understand the duel flash lamp reasoning. If the second flash lamp is further away from the head than the first flash lamp, it has to transmit light at a higher initial intensity in order for the intensity of the light to be the same at the perimeter of the head. Does it do this? Is the intensity of the light really more uniform than a single flash lamp? I look forward to someone from Sciton helping me here. This will require diagrams and drawings, so please provide them on a website we can link to. If you send them to me, I will post them on my geocities website.
“Of the 8 top selling IPLs reviewed, 6 employ a single flash lamp. The only two models utilizing twin flash lamps are Sciton BBL and CyDen iPulse i300. However, only the Sciton BBL has the essential over-under (figure “8”) twin flash lamp configuration”.
“Not all IPLs deliver the full spectrum of therapeutic wavelengths. Naturally, you’ll enjoy greater returns on your investment the more treatments you can deliver.”
This is how I see the wavelengths and the condition they treat (by looking at the Absorption Curves of Melanin, Hemoglobin and ALA (Levulan) and by reading the manufacture’s literature:
420 nm: acne
500 nm: pigment
510 nm: pigment
515 nm: pigment
520 nm: vascular and pigment
525 nm: light, fine hair (Palomar)
560 nm: vascular and pigment
590 nm: pigment in skin types 4 and 5
615 nm: larger facial veins (Lumenis)
640 nm: superficial leg veins (Lumenis)
650 nm: Hair Removal (Palomar)
695 nm: thicker vascular lesions (angiomas, hemangiomas), superficial leg veins, Hair removal light skin
755 nm: thicker vascular lesions (angiomas, hemangiomas), superficial leg veins, hair removal darker skin
Please go to www.geocities.com/DogLemonIPL to see the Absorption Curves. Note where the absorption is high for melanin and high for hemoglobin. On the ALA Absorption Curve, note where absorption is high.
Palomar does not have a head for the 590 nm wavelength area. This is a very big deficiency in my opinion. You need this wavelength to treat skin types IV and V for pigmentation, hyperpigmentation and PIH (postinflammatory hyperpigmentation). Without this wavelength you cannot treat East Asians (Japan, China, Korea), South Asians (India, Middle East), Mediterranean (Italian, Greek) and Latin (South & Central America). In my practice, a large portion of my patients are “patients of color”.
The IPL Dog and Lemon Guide also talks about Fundamental Requirements of an IPL, Critical Factors for Producing Predictably Excellent Clinical Results, Head Size, Variable Temperature Control, Pulse Widths, Fluences, Clinical Training, Clinical Exchange Programs, Square Wave Deliver (this is very interesting and sounds very important. It makes intuitive sense to me), Sapphire vs. Quartz Crystals, Ongoing Education and Support, Adverse Reaction Plan, Optimizing Return of Investment, Portability, Marketing Support, Technical Support, Consumables, Profitability Analysis, Multi-Platform Options and System Summaries.
These issues are all summarized very well and will prompt you to think about these issues and ask these questions of your sales representative. I would encourage you to get and read The IPL Dog & Lemon Guide to review these issues.
Working with many Laser Companies, one of my big problems with most of these companies is their Continuing Education. their Clinical Exchange Programs, their On-Call Clinical Support and their Formal Ongoing Education.
The correlation between clinical competence and clinical outcomes should be obvious . . . Just as comprehensive initial training gives rise to predictably excellent clinical outcomes, the ability to exchange ideas and experiences with other IPL operators dramatically magnifies your clinical competence . . . a worthwhile clinical exchange program should utilize one or more of the following media: online forums, Teleseminars, Webinars and live phone support . . . any IPL that’s purchased with access to an established clinical exchange program can only benefit you and your patients . . . as the field of IPL therapy advances, all new clinically relevant finding and advanced techniques should be made readily available to you via a continuing education program. This may take the form of newsletter, website, DVD/Video and/or live workshops.
All companies have to do a much better job helping us learn the latest advancements and facilitating communication between providers so best practices can be communicated and propagated. Continuing education efforts must be made easily available, inexpensive, and convenient. For example, providers learn by different methods and they prefer to access information differently. Information should be made available in multiple formats so the greatest number of providers can access this information. Material should be presented in written format, by audio cassettes & DVDs, via the internet (Webinars) and live presentations. Once the material is presented in these varied formats, interaction and discussion should be encouraged and facilitated via conference calls, internet bulletin boards and blogs. Clinical experts and industry luminaries should be available to participate on these bulletin boards and blogs.
The IPL Dog & Lemon Guide must be updated. The information about Palomar is not current. They have a StarLux 500 which is very different than the reviewed Medilux. Hopefully Palomar can update some of the missing information and tell us how the StarLux 500 overcomes some of the objections raised by this report. Hopefully the other companies can provide updated information.
These are the questions that I have after reading The IPL Dog & Lemon Guide. Who is Paul Kadar? What are his qualifications? Does he have any conflicts? When was the report written? Is “Photon Recycling” clinically important or is it a marketing ploy? Do “Twin Flash Lamps” in a figure “8” configuration overcome “Perimeter Loss” and how does this work (in detail)? How big are the light sources (lamps) in the heads and how far are they from the edges of the heads? How important is “Variable Temperature Control” & “Integrated Cooling”? Can you truly use less fluence with equal or better clinical results with twin flash lamps and “square wave delivery”? What are the best wavelengths and algorisms for treating Rosacea and Pigmentation in “patients of color”? Is IPL Hair Removal as good as Hair Removal with the 810 nm Diode or the 770 nm Alexandrite? Is IPL treatment of Rosacea and Veins as good as vascular treatments with the 532 nm KTP Laser, the 595 Pulsed Dye Laser and/or the 1064 Nd:YAG Laser? Is the Sapphire Crystal really better than the Quartz Crystal?
I hope this summary and analysis of The IPL Dog and Lemon Guide is helpful. I hope it helps you find the best IPL for your practice and I hope it helps generate questions which we all can answer by participating on the resulting blog. I also hope that this summary, analysis and report will stimulate the IPL companies to provide better IPL devices and provide better continuing education and support.
My opinion of The Dog and Lemon Guide is that it is a great start and a great tool to start to understand IPLs. For those companies that did not fair well, you should tell us why the Guide is wrong or you should make your devices and your support better. I would not assume that Paul Kadar is biased. I am going to assume that he wrote a genuine guide to help us all. Read his introduction on page 4. He hits many issues right on the head! I hope he writes more guides. His guide is well written and thorough and makes sense. What he says “rings true” to me.
So let’s start the discussion!!! We should have a very lively debate. Please convince me to buy the device you have or you sell. If you have the device or sell the device, please identify yourself as a user or seller EACH time you comment.
A “practical, unbiased, objective” response to the published materials authored by Paul Kadar of cosmedicreviews.com.
The choice of the words “practical, unbiased, objective” in the title are borrowed directly from the opening pages of the review by Mr. Kadar. His 41 page review is neither practical, unbiased nor objective and it contains so many inaccuracies that one would question whether it is of any value what-so-ever. Admittedly, I do not know Mr. Kadar, nor his qualifications to analyze competing technologies. I will address, page-by-page all of the inaccurate factual pronouncements in his paper, so I will refer to this comments by making references to his original comments. To be fair, he does make some valuable contributions for understanding how to optimize IPL technology, however, his clear bias toward the Sciton BBL system completely cloud his judgment and produce some very “fuzzy physics”.
Page 6 – Obviously, the MediLux has been a popular IPL in many parts of the world, however, not in New Zealand or Australia. We sold none in these two countries. I can only assume that he is referring to the StarLux and I will go forward using all references to the StarLux, not MediLux. However, he therefore gets many of the specifications confused between the two units.
Page 7 – Uniform Delivery - Many of the points made in the first few paragraphs are correct. Many poorly designed and constructed IPL heads have a very poor distribution of light throughout the optical waveguide to the tissue. He is correct in the assessment of the temperature rise within the hair follicle and that if the temperature is insufficient to completely damage the hair, the result will be a thinner, finer hair, which is in fact a recurring problem for most hair removal devices. He is also correct in saying that poor spatial distribution across the sapphire or quartz waveguide will necessitate larger more overlapping from pulse to pulse, and this again has its’ own set of problems, including adverse side effects from too much energy absorption by the epidermis. Using the term “perimeter loss” as Mr. Kadar employs it, necessitates a better explanation of what cause it. His reference to the “inverse square law” is interesting and would be useful if we were discussing the amount of sunlight hitting the various planets in the solar system, but it is not relevant at all when dealing with a few centimeters close to the skin. His reference assumes that no manufacturers do anything to the pulse of light in terms of controlling the direction and focus of the output. If the 20 J/cm2 were a point source of light and you doubles the distance to the observer , it would indeed decrease by the distance squared. However, all IPL manufactures use some type of reflector system to directionally deliver as much light as possible through the waveguide to the tissue. It is not the difference in the distance from the lamp to the edge of the waveguide versus the center of the waveguide that matters, (even if it did, this is a simple geometry problem, not an Inverse Square Law problem) it is a problem of the optical reflector design.
So, let’s look at Mr. Kadar’s solutions to minimizing “perimeter loss”.
1. Small Surface Area of the Head – He is correct that if you make the tip small, you usually get a better homogenized beam, but the real reason that the tip (size of the surface area of the waveguide) is small is due to the lack of energy produced by the flashlamp in the first place. The Syneron ELOS – Aurora or E-Light are perfect examples of this. The only way they can show a high output fluence to match other systems is to design a small spot size hand piece. You may also notice that physically small hand pieces, although they appear small and therefore are easier to manipulate on the skin also have physically small flashlamps. There is “no free lunch” in this area. The length and cross-sectional area of a flashlamp will dictate the energy output in all practical areas. If I choose to use a small lamp and electrically “pump” it very hard, I can produce high output energies, but I will kill the lamp very quickly.
2. Photon Recycling – I would absolutely agree that Mr. Kadar is clearly no “rocket scientist”, but his analysis of photon recycling is so incorrect, that I would have to doubt that he has any understanding of science. First of all, just to straighten out the misinformation, light travels at 300,000 m/sec (186,000 miles/sec). If the distance between the flashlamp and the skin is 3 cm (light travel 30,000,000 cm/sec) and the pulse of light is 30 milliseconds long, a photon of light could travel approximately 1,000,000 cm in that time. So, if the distance to the skin and back to the flashlamp is 3 cm each way, you could at least get 150,000 oscillations or cycles at a minimum. Therefore the statement that the “fluence will have all but petered” is purely ridiculous. Photon recycling (developed and patented by Dr. Rox Anderson at MGH/Wellman Labs of Photomedicine and licensed and implemented by Palomar) is designed to recapture as much scattered light from the various surfaces and structures in the skin whenever those photons scatter back into the hand piece. Much light is still lost due to scattering which is not perpendicular to the skin (this is the flash that you see with you eyes). There are some basic principles that are necessary for photon recycling to work. First, the waveguide must be in direct contact with the skin. Floating a hand piece tip in a thick ultrasound gel does not work. Secondly, the reflectors in the hand piece must be specifically designed to focus the IPL light toward the skin and maximize the amount of deliverable photons of light to the skin and thirdly, the tip of the waveguide must be designed to minimize any light leakage laterally from the tip. The Palomar StarLux meets all three criteria better than any other system.
3. Long Light Guide – Mr. Kadar is correct that a long waveguide does homogenize the light passing through the waveguide and consequently, the output pulse of light is very uniform across the entire surface of the waveguide. And in fact he is also correct that some light is lost in the homogenization process, but if the reflective surfaces are properly designed and all surfaces are coated properly with the correct reflective coatings, these losses are minimized. However, where Mr. Kadar’s objective review falls short is in recognizing that the Palomar StarLux produces the highest output fluences available in the industry even with these long waveguides.
4. Twin Flashlamps – Twin flashlamps can be of value in an IPL system, but not for the reasons Mr. Kadar states. If you assume that there are no reflectors at all in an IPL head, then indeed, one lamp might be in the shadow of the other lamp, but his assumption makes no sense at all if the hand piece is built with parabolic reflectors surrounding the foci of the lamp’s location. Simply put, when you turn on the head lights of your car, why does the light travel so far in a relatively collimated beam? It is because the mirror surrounding the bulb in the head lamp is a parabola. He is also incorrect when discussing the side-by-side configuration of a dual lamp system. This design also works well and helps produce a more uniform beam. However, as stated above, properly designing an IPL head solves all of these problems. Mr. Kadar’s clear bias rings through on this one when he refers to the “essential, over-under twin flashlamp design of the Sciton BBL. The only thing that twin flashlamps buys you is that a somewhat lower flashlamp pumping energy is needed for each flashlamp so you can get long lamp lifetimes, but we will discuss this later.
Head Size – Again, Mr. Kadar begins correctly and his first few paragraphs are correct in reference to scattering deeper into the tissue. Larger spot sizes permit deeper scattering into the tissue and better results, particularly for hair removal. However his statements in the lower half of page 10 are incorrect. If you have the same fluence (Joules per square centimeter), the larger spot size will give you better and deeper scattering, you don’t need three times the energy if the spot is three times larger if you start with the same fluences. The larger spot size hand piece will necessarily put out more total energy to achieve the same fluence, but fluence is fluence, period. Clearly, the last statement on the page has absolutely no scientific support and is just another commercial comment for the Sciton BBL system.
Variable Temperature Control – At least in this section, I do have some degree of agreement with Mr. Kadar. Cooling the skin is very important for all IPL applications, some more so than others. I also do agree that IPl’s with no cooling can be safe and effective, but the procedures are riskier, so if some one says that cooling is unnecessary, they are mistaken. His chart is incorrect again, because the Palomar MediLux does not have integrated cooling, but the StarLux does. In fact, Palomar holds some of the dominant patents in cooling technology. Variability in the temperature control is nice, but he avoids the more important considerations of cooling. Temperature control or the absolute low temperature setting are of no use what-so-ever if you can’t effectively get the heat out of the skin. In other words, many IPL’s that have integrated cooling built into the system have inadequate overall cooling to constantly extract the heat from the skin. It is a basic Law of Thermodynamics that the extraction of heat from is a rate equation. You must have a thermal mass large enough (large piece of sapphire, not quartz) that has proper contact cooling with it and has direct contact with the skin as well as an adequate chiller inside the basic unit. All too often, as a procedure starts, the tip of an IPL is cold and then as each light pulse is emitted, the tip heats up until the skin gets burned because there is no longer any effective cooling. Only the Palomar StarLux has this degree of efficient, effective long lasting contact cooling. So it is not the temperature to which the hand piece cools that really counts, it is “how well does it stay cold during a lengthy procedure that counts”.
Long Pulse Widths – for the sake of brevity, I will not try to correct some small inaccuracies in this section, it is basically correct. His chart is incorrect because again he refers to the Palomar MediLux, instead of the StarLux and he refers to the pulse durations for the Palomar system as 400 msec. It is true that the StarLux can extend the pulse duration to 500 msec, but for all practical purposes, we very rarely use any pulses longer than 100 msec.
High Fluence – I find it very interesting that in this section, Mr. Kadar retreats from the issue of directly comparing fluences of various systems. There is plenty of truth to the statement that no two systems are designed the same or produce the same outputs, so the fluence of one system may not actually be directly comparable to the fluence of another system from a clinical evaluation point of view, but in this area where the BBL produces only a modest output fluence, Mr. Kadar simple says it is not really important. I doubt that many others will agree with this.
Pages 13 and 14 – These pages deal with Clinical Training issues, which although these are very important, they are not unique to a machine or device, so I will skip these.
Integrated Contact Cooling – His synopsis is basically correct although he does not explain how a system maintains a constant temperature.
Filtering – Almost all IPL systems use water to cool the flashlamp to prevent it from exploding (which would be an undesirable operating characteristic). Therefore, all IPL wavelengths above 950 nm are at a minimum. The normal operating output of a xenon arc lamp is about 380 nm to 1,400 nm. Even without the water cooling and consequential absorption of the long wavelengths by water, there is very little energy available from the lamp at the very long wavelengths.
Therapeutic Dose – Again, Mr. Kadar begins correctly but his logic and assumptions digress rapidly. His Non-Square Wave and Square Wave descriptions are basically correct and the consequences and potential side effects of the Non-Square Wave pulse are also correct. However, at Palomar, we maintain that neither of his pulse profiles is very good and the only really “Square Wave Output” is one that does not that the series of 10 or so short pulses (which can also be very dangerous). Our Smooth Pulse design (also patented) is truly a square wave profile and produces the safest, most predictable results. Mr. Kadar’s chart on page 17 is completely incorrect. All Palomar systems produce a ‘smooth pulse profile” and always have since the EsteLux was introduced in 2001. Our advanced power supply technology permits considerable variation in the pulse format if we so desire to change it.
Sapphire vs Quartz – This issues Mr. Kadar brings up regarding the difference between sapphire and quartz are small concerns. The major difference deals with Thermal Conductivity. Quartz (similar to window glass) is an insulator. It has always been used as an insulator. On the contrary, sapphire (and for that matter - diamond) is one of the few crystalline materials that have the same thermal conductivity properties of a metal. So the heat transfer needed for effective contact cooling can only be accomplished using sapphire as the tip of the hand piece. Again, Mr. Kadar invents his own statistics regarding which manufacturers use which materials. Palomar was the first to use Sapphire and has never used anything but Sapphire in all of our IPL hand pieces.
Again, his discussion of training and adverse reaction reporting, although important, are unique to different distributors, etc.
Repetition Rate – Most of what he has said here is OK, some minor problems, but his explanation of the capacitor circuits is satisfactory. One major addition is needed. The repetition rate is also a function of the fluence for each pulse. The more energy that needs to be discharged from the capacitors to the lamp means the more time that is required to recharge the capacitors. So operating at high fluences means inherently slower repetition rates. Therefore, the chart on page 21 should be amended because the Palomar StarLux operates at 2 Hz, not 1 Hz. The StarLux 500 System is now 70% faster than the original StarLux so even at higher fluences, the rep rates are higher.
Range of Wavelengths – (page 22). Again, Mr. Kadar assumes a very simplistic approach to wavelength selection. The reason manufacturers like Palomar design specific wavelength ranges for specific application hand pieces is to maximize the effects of the individual hand pieces for the specific treatment protocol. By using dual wavelength filtration, (both absorption and dichroic-relecting filters), we can make an IPL hand piece operate more like a specific laser wavelength. Therefore, the chart that Mr. Kadar shows is incorrect for the Palomar systems. In addition, what Mr. Kadar does not understand or make the effort to understand (from his unbiased point of view as an expert) is how the Cutera system works (I presume the CyDen iPulse works the same as the Cutera system, but we don’t see that system here in the US, so I can’t absolutely make that statement).
Control of the discharge temperature of the flash lamp determines the emission spectrum of the output. The discharge temperature is often called the “color temperature” of the lamp. Short pulses, with the same output energy, produce a higher color temperature because of the higher peak power needed to create an output pulse with the same energy as a pulse with a longer pulse duration. Lengthening the output pulse, with the same output energy, lowers the color temperature of the pulse and shifts the natural emission spectrum of the output to the “redder” part of the spectrum. Cutera claims approximately 70 – 100 nanometers of wavelength shift from the yellow/red area to the redder wavelengths. They also claim that this is enough to produce selectivity in their treatment protocols to treat darker skin types. All Palomar systems have had this power supply design feature from the first EsteLux units in 2001. This is a “patented” technology that is a standard Palomar feature. However, even though the wavelength shift is helpful, Palomar does not believe that this shift alone provides enough selectivity or safety for the each treatment protocol. In fact, Palomar now offers 7 different IPL hand pieces which all provide over 100,000 shot warranties. Then there are an additional 5 laser hand pieces and 2 Halogen lamp based hand pieces for deep heating. So the chart on page 23 is also incorrect, but the rest of the page is acceptable.
Pages 24 – 26, while obviously relevant to the user, is completely dependent on the distributor or the manufacturer. As in previous charts, Mr. Kadar does not accurately represent the amount of support information committed to the end user by Palomar.
Treatment Head Replacement - When a single treatment head is used for all treatments by the interchange of slide in filters, the consumption of that single head should be fairly fast. In addition, if there is a malfunction of that single head, the user is completely out of luck and must shut down their entire operations until a replacement is made. Palomar’s plan has always been to optimize the hand piece for the application. The availability of individual hand pieces to optimize the treatment protocols for each application is our most important goal, but this also has a very positive operating cost savings as well. Each IPL head is warranted for a minimum of 100,000 pulses (or two years – which ever comes first), so with a standard system consisting of a Lux G, Lux Y and Lux R hand pieces, you have over 300,000 pulses guaranteed and you optimize the output parameters as well.
Profitability Analysis – This section is based on so many inaccuracies previously mentioned that it is impossible to even comment on it. With over 5,000 IPL systems sold in the last 5 years, I can absolutely assure any prospective customer that our customers earn a very substantial return on their investments. Clearly, how a user operates their own business will ultimately determine the degree of success. A completely fabricated chart of ROI will not even remotely provide the answer.
Page 36 – just completely incorrect, not even the system we sell in N.Z and Australia. This page is just further evidence of the very poor quality of this analysis.
Further discussions at the end of the analysis are also incorrect for many of the above mentioned reasons. His beginning summation of platform technologies is incorrect again so I see no possibility that any further discussions by Mr. Kadar will have any merit as well.
Here's the new classified section for Medical Spa MD: Medical Spa Equipment
Here's where you can add a new listing.
If you've got something you're trying to move, now you've got the place to do it. There are currently four listing areas: IPLs, Lasers, Medical Equipment, and Spa Equipment. I'll add others if needed.
If you've got something listed elsewhere or on consignment, I'd encourage you to list it here as well. Medical Spa MD has more than 18,000 unique monthly visitors and a large contingent of physicians. Better yet, the listings are free and there's no 'percentage of sale' so you've got no complaints there. The site is up and fully functional although there will be improvements as we go along.
I'm anxious to find out if this is a need that many have. Another middle-man gone.
Note: The classifieds will also be monitored and spam or solicitations will be removed. Equipment only for now.
There's always mucho demand for reviews and comparisons between IPL and laser technologies and companies.
Download the IPL Dog & Lemon Guide PDF
Ican't vouch myself for any of the info or reviews. Midwest sent me the link to his report so she's responsible for cudos or blame.
The link at the end points to a spam farm of text ad links which is somewhat unpromising but I'll leave that for you to judge. Certainly the report is well written and at 41 pages is much longer than the usual reviews.
I'd welcome comments on the report, or the voracity of the author if anyone knows.
Is anyone using Rhytec's Portrait Plasma? I've heard a few docs comment on it but haven't seen it in action yet. Watch an animation of plasma in action or some patient and physician testimonials.
From somewhere on a Rhytec press release:
Plasma may be the next weapon of choice in the anti-aging arsenal. Rather than relying on chemicals, lasers, light, or injections, the Portrait Plasma Skin Regeneration system employs plasma, a highly energized gas. The gas penetrates below the skin's surface, extending into the dermis without any direct contact, charring, or vaporization.
Unlike other treatments that ablate the skin, the controlled heating of tissue below the skin's surface from Portrait, which is FDA-cleared for treatment of wrinkles, superficial skin lesions, and actinic keratosis, leaves the skin surface intact during the healing process.
"By allowing the preserved outer layers of skin to act as a protective dressing until new skin regenerates, it produces much faster healing and minimizes the risk of complications," says Richard E. Fitzpatrick, M.D., an associate clinical professor of dermatology at the University of California–San Diego School of Medicine and one of the clinical investigators of Portrait.
In taking a look at the Portrait site I find myself somewhat unimpressed. The site itself is cumbersome to use and poorly architected. I'd have chosen a different beauty shot to build my imaging around as well. The model seems to have skin stretched so tight that her ears are almost meeting behind her head and such an odd expression that I couldn't exactly call it aspirational.
However, I'm open to hearing if anyone's had experience, good or bad, with plasma. If the comments are resoundingly positive, maybe I'll buy one to toast marshmellows.
Some of the abstracts from the Rhytec site:
Evaluation of Plasma Skin Regeneration Technology in Low-Energy Full-Face Rejuvenation Bogle M, Arnt K, Dover J, Archives of Dermatology; February 2007
Portait PSR3 Technology Provides True Skin Regeneration Kronemyer B. European Aesthetic Buyers Guide; Spring 2006
Plasma Energy Harnessed for Damaged, Aging Skin Skin & Allergy News Supplement; Spring 2006
Plasma Skin Resurfacing for Rejuvenation of the Neck, Chest and Hands: Investigation of a Novel Device Alster T, Tanzi E. Presented at ASLMS Meeting, Boston, April 2006
Effectiveness of Multiple Treatment, Low Fluence Technique with Plasma Skin Resurfacing for Facial Rejuvenation Bogle M, Arndt K, Dover J. Presented at ASLMS Meeting, Boston, April 2006
Physicians love a long tite: Intense pulsed light technology and its improvement on skin aging from the patients perspective using photorejuvenation parameters.
Daniel Laury, MD - Read the entire study here.
From the study:Importantly, all patients showed improvement based on their calculation of perceived age. That indicates that there was no perceived worsening of aging signs and no perceived regression of improvements over the study period. Though using subjective data, bias in computing the improvements noted in this population is part of the endpoint.
Other studies have evaluated the outcomes after IPL treatments. Negishi et al. found a combined (physician and patient subjective improvement evaluation) 60% improvement in their evaluation parameters in more than 80% of Asian patients undergoing a similar five or more IPL treatments. In another study also involving an Asian population and also using a combined score, his team found a rating of "good" to "excellent" in 90% for pigmentation, 83% for telangiectasia and 65% for skin texture. Similarly, Kawada et al. found that 48% of patients had more than 50% of improvement and 20% had more than 75% improvement. Goldberg and Samady used a patient satisfaction score as well as including an evaluator assessment component in their study comparing intense pulsed light and Nd:YAG laser on facial rhytids. Several other authors have also demonstrated improvements. Histology studies with and without a monitoring of clinical impression have demonstrated changes in another fashion. However, histological information is difficult for patients to understand and often does not translate into clinically visible changes. Therefore, the specific answer to the question, "How much younger will this make me look?" is hard to answer from these other studies.
This preliminary study has a number of limitations some of which have been previously noted, e.g. small population size, subjective bias. Though the study was prospective, no placebo or blinds were in place. In addition, a larger study might take into consideration the operator differences in performing the procedures and the possible effect of the anesthetic gel. The Negishi studies bring into question the differences between results and ethic origin. The population in this study was exclusively Caucasian. Additional consideration may be given as to whether three weeks is the optimal interval for treatments and whether strict adherence is important. Another time interval may give different results. It would be interesting to identify if there is any regression over time as well. A repeat questionnaire at a later date would be instructive.
Generally the intense pulsed light technology is safe as evidenced by the literature and the author's personal experience, though it still has potential for malfeasance.
On average, patients considering IPL photorejuvenation therapy may be told that there is a 2 year perceived facial age improvement per visit. The informed consent process requires a discussion about the anticipated benefit to treatment. Incorporating the above information may be useful in counselling patients regarding this esthetic procedure.
IPL & Lasers: Absorption rates: Target wavelengths for melanin, hemoglobin, & water
Previous post: Cutera Xeo. Does it work?
We took possession of one of these Xeos about two months ago and have since treated a couple of patients, including some of our physicians and staff so that we could keep close tabs on both how well we thought it works as a treatment, the efficacy, time, etc. I have to say that we're somewhat unimpressed. My staff of physicians are really down on it, having used is on their own leg veins and seeing either such light results as to be nothing, or actually an increase in the visibility of the veins, which is exactly what we didn't want.
Another problem was found where, after a Yag treatment, one of my staff was injected with Sclerotherapy and had a previously unseen and unwanted reaction in which the vein blanched black, something none of my physicians had ever seen before. One of our physicians was a big proponent of this Cutera, but as I said, we've so far been less than impressed. I would like to hear if anybody else has better results.
Laser treatment for veins, of course, are becoming increasingly popular and, to be honest, they're more profitable since they seem to be worth more to the patient and hence, you can charge more. At one of the seminars or symposiums I came away with the feeling that great reactions from a treatment with lasers hovers around 5%, which I find abysmal.
Anybody with views, I'm happy to hear them because that's about a $130,000 piece of equipment and I would like to be able to get some use out of it rather than getting rid of it. I have to get multiple physicians to agree on it however.
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