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.

Uniform Delivery of light energy to the target tissue: Perimeter Loss, Photon Recycling and Twin Flash Lamps.

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:

“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.

Twin Flash Lamps:

“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”.

Range of Wavelengths:

“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.