Laser specialist Dr Elizabeth Raymond Brown gives an overview of the latest technological advancements in the field of aesthetic lasers
The concept of the laser traces back to the theory of stimulated emission proposed by Albert Einstein in 1917.1 The first experimental laser, using a synthetic ruby crystal, was demonstrated in 1960 by Theodore Maiman.1 According to Hecht,2 the development of the laser was ‘neither simple nor easy’, but in the intervening 55 years, lasers impacted every aspect of life, including surgical and non-surgical cosmetic interventions. The UK market for cosmetic interventions (consumer value) was worth £2.3bn in 2013, and it is estimated to rise to £3.6bn by 2015.
Non-surgical procedures (injectables, laser/light therapies) are estimated to account for 90% of procedures and 75% of the market value.3 Rarely can medical aesthetic clinics afford to invest in laser technology unless it offers a wide range of treatment modalities or unique features, with superior performance and benefits over other modalities and devices. What could be considered good examples of customisable laser and intense light devices for multi-applications include: the Alma Harmony XL, the Lumenis M22, Lynton Lumina and the Cutera Xeo (Figure 1). These systems offer versatile and expandable ‘platforms’ with
as many as 24 different treatment modalities from a single platform, helping to grow practice treatments and revenue. Devices offering fewer, but more specific applications, such as body contouring or treatment of hyperhidrosis include; the 10600 nm output of the Syneron-Candela CO2RE for ablative rejuvenation or the 1565 nm fibre laser of the Lumenis ResurFX (Figure 2), offering fractional non- ablative skin rejuvenation.
An established marketplace
The economic downturn and subtle changes in customer demands resulted in some key mergers and acquisitions, which has brought benefits to companies, investors and consumers alike. With companies extending their product portfolios, research and development (R&D) bases, and customer support services, practitioners expect suppliers to offer reliable, high performance devices, limited or zero consumable costs, on-going clinical education and ‘on-call’ service support. Lasers are designated as ‘Medical Devices’, and thus must be CE marked and comply with applicable European Medical Device Directives (within the EU).4 Unlike the United States, the UK is not required to register laser products, but it is a legal requirement to meet the ‘Essential Safety Requirements’ of the applicable European Directives, ie. BS EN 60601-2- 22:2013.5 Laser products are classified according to the accessible laser emission, and if this exceeds limits defined in BS EN 60825-1,6 the product must be accurately labelled and must incorporate engineering features such as key switches and interlocks. Manufacturers must also provide adequate instructions for safe and appropriate use. Laser eye protection has to be CE marked and comply with BS EN 207:2009,7 the ‘European Directive on Personal Protective Equipment’. As a certified laser protection advisor (LPA), I would strongly advise those purchasing equipment directly from non-European websites, or pre-used devices to seek independent advice on product safety compliance, output calibration and suitability of treatment protocols and protective eyewear.
All aesthetic laser and light-based therapies exploit the concept of selective absorption of incident radiation by a given chromophore or target, as described by the theory of Selective Photothermolysis.8 To achieve an efficacious and safe clinical outcome, specific device variables must be selected and controlled according to the presenting condition to be treated and patient factors such as skin type, hair colour etc.
These variables include:
Wavelength (nm / ?m) – determining absorption by a given chromophore, and depth of penetration into tissues.
Pulse duration (ms / ?s / ns / ps) – determining rate of heating of target tissues and thus interaction mechanism, eg. photochemical, photothermal, photomechanical.
Energy, power, fluence (J, W, J cm-2 according to output) – determining amount of energy/power delivered to the tissues.
Treatment area (mm, cm-2) – affecting depth of penetration into tissues, thermal diffusion of heat and treatment time.
It is the subtle but significant refinement of these variables that offer further opportunities to improve clinical efficacy, reduce treatment times and enhance patient comfort. For example, the introduction of ‘fractional’ technology – delivering energy in micro- spots rather than over a full beam area – had a significant impact on extending both ablative and non-ablative treatments.9 Other innovative advances are outlined below:
Rarely can medical aesthetic clinics afford to invest in laser technology unless it offers a wide range of treatment modalities
Some of the most recent product advances have come from the ability to produce reliable and repeatable ultra-short picosecond (ps, 10-12 s) pulses of energy, previously the reserve of the research laboratories. Picosecond pulses induce photodisruption – a physical effect associated with optical breakdown that results in plasma formation and shock wave generation.10 Photodisruption is a well-known tool of minimally invasive surgery such as posterior capsulotomy and laser- induced lithotripsy of urinary calculi.
The nanosecond pulses (ns, 10-9 s) of Q-switched lasers are successfully used for tattoo removal and treatment of pigmented lesions. However, picosecond pulses can produce incredibly high peak powers from lower pulse energies – still causing optical breakdown but with less disruptive effects to surrounding tissue.10 Devices exploiting this technology include:
To achieve an efficacious and safe clinical outcome, specific device variables must be selected and controlled according to the presenting condition to be treated and patient factors such as skin type, hair colour etc.
Patients not only expect great results, but also want fast and comfortable treatments, especially with hair reduction. Increasing treated area, scanned beams and comfort cooling are the industry’s response to these demands. For example:
Aside from the technological advances and refinements, it is notable that manufacturers now strive to enhance the customer experience of buying and using a laser. It is no longer acceptable to take delivery with a half day training session and being left to ‘get on with it’. With such a range of devices available from an increasing number of suppliers, it can be hard to differentiate between them, and the decision on system purchase often comes down to the rapport developed with an individual sales person. Whilst perhaps understandable, this can be risky and it is wiser to focus on company pedigree, product portfolio and customer support. Reputable and trust-worthy companies offer information on compliance with safety and licensing requirements, advice on premises and room layouts, dedicated clinical trainers, workshops and educational events, webinars and learning resources, ‘user’ groups, training and business development support and rapid response to equipment service or break-down. Companies can also support their customers with contacts for finance companies, laser protection advisers (LPA) and expert medical practitioners (EMP).
From the first medical treatment of a retinal tumour with a ruby laser in 1961,12 to the surgical and non-surgical interventions available today, lasers have proven themselves as precision tools for an incredibly extensive range of treatments. Pushing the boundaries with mid and far infrared wavelengths, beam delivery methods, faster treatments over bigger areas and enhanced comfort, will continue to raise expectations of both patients and users. A word of caution however, advancing the technology without advancing practitioner education is dangerous. Just because a laser can remove our wrinkles, reduce our hair growth and banish our brown spots, it should not mean that the technology becomes so readily accessible that anyone can perform such treatments. In my opinion, this is where manufacturers and distributors have a wider role to play than just selling the latest technology. But thanks to significant R&D and investment, it is now possible to deliver medical grade treatments from the most reliable, efficient and technically-advanced devices than ever before.