From Hair to Bare

Laser hair removal has come a long way, but challenges persist.

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Itsy bitsy teeny-weeny bikinis are the standard uniform among the svelte set in Newport Beach. So it’s no wonder that laser hair removal is one of the more popular offerings at Bonakdar Institute, a concierge cosmetic dermatology practice in the affluent Southern California coastal community.

“People in my geographic area are concerned with body hair hygiene year-round,” says the Institute’s medical director Monica Bonakdar, MD. Hair removal represents 6% of her laser revenues, though she does no marketing, other than letting existing clients know that the service is available.

A smooth bikini line and fur-free back and chest are increasingly becoming de rigueur across the country—not just on Miami and Malibu sands. According to the American Society of Plastic Surgeons, laser hair removal is the nation’s fourth most-popular minimally invasive procedure (only Botox, fillers, and chemical peels rank higher), with more than a million procedures performed in 2012—a 52% increase over the past 12 years.
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New and Improved Features

There’s a good reason for the surge in laser hair removal popularity: With larger spot sizes, built-in cooling systems, better safety mechanisms and speedier treatment times, today’s lasers are faster, more comfortable and have fewer potential complications than their predecessors, practitioners say.

“The original technology was slow and hurt more. A back would take one and a half hours to treat,” says Dr. Bonakdar, who calls the latest devices “a world of improvement.” Today, she can treat a client’s back in 20 minutes, with more comfort for the client, even without anesthetic cream.

“Newer lasers treat very large areas of unwanted hair in a short amount of time,” says Eric Bernstein, MD, owner of Main Line Center for Laser Surgery in Ardmore, Philadelphia. He has been offering laser hair removal procedures for 15 years, and it currently makes up about 20% of his practice.

“My sore back can attest to the days when I used a slower laser with a small spot size and spent hours [bent over] during a single session,” he says. The most popular and effective devices for hair removal are intense pulsed light systems, 755nm, 810nm and 1064nm wavelengths. Two of the latest devices to come to the market are the Sciton Forever Bare BBL (sciton.com) and Alma Lasers’ Soprano ICE (almalasers.com). They offer “continuous movement” or “In-Motion” technologies that allow for lower fluence pulses and a higher repetition rate.

“With the older single pulse devices, you have to deliver more energy than you necessarily need to heat the hair to the appropriate temperature to damage the growth center—somewhere between 50 to 55 degrees C,” says Stephen Martin, MD, of The Martin Center in Mobile, Alabama, who works with the Soprano ICE in his plastic surgery and laser center. “When you use In-motion, you’re pulsing about10 times/second and you’re creating a cumulative heating effect that still gets you to the temperature target you want but in a gentler way, so when you have pigmentation in the skin, you’re not blasting those melanocytes with such high levels of energy.”

The cumulative heating makes the treatment more comfortable for the patients and also allows practitioners to treat a wider range of skin types, says Dr. Martin.

Laser platforms that include multiple handpieces in one unit—each with a specific wavelength or range of wavelengths—are available. For some practices, the ability to offer multiple treatment modalities with one device is attractive. Others prefer wavelength-specific devices. “For laser hair removal, very rarely do you need to use both units for a single client. We have separate units in individual rooms, so—staff permitting—we can book [more] appointments,” says Chris Dryden, a certified laser operator/aesthetics, who owns Indy Laser, a cosmetic laser center in Indiana.

Choosing Your Device

Practitioners looking to purchase a professional laser hair removal device have several choices. Dryden, whose clients include the Indianapolis Colts, the Colts cheerleaders, and Miss Indiana contestants, says his “go-to machines” are the Syneron-Candela GentleLase and GentleYAG (syneron-candela.com). “[These devices] use the most effective wavelengths—755 nm for lighter skin and 1064 nm for darker skin,” he says. “They also have larger spot sizes and faster repetition rates for faster treatments times. Their built-in cooling system makes for a more comfortable treatment, without the need to cover the area with gel.”

Dryden also appreciates the device’s adjustable settings, allowing for a customized treatment. Dr. Bonakdar, on the other hand, is a long-time fan of Lumenis devices (aesthetic.lumenis.com). She is also a speaker and physician trainer for Lumenis Aesthetic Lasers.

“I was an early adopter of laser hair removal technology in early 2000 with a Lumenis Light Sheer,” she says. In 2009, she upgraded to the Lumenis Light Sheer Duet. “It has two handpieces, allowing for fast, comfortable treatments of large body areas,” she says.

Dr. Bernstein, who uses several laser hair removal devices in his practice, likes both Syneron-Candela and Lumenis products. The Lumenis’ LightSheer has been a mainstay in his practice for more than a decade. “I was an early LightSheer adopter. It’s a wonderful device that we still use quite extensively,” he says. “I started with LightSheer because it was, in my opinion, the first laser that was safe and effective enough for my practice. The earlier ruby laser had a safety profile that wasn’t acceptable to me.”

He has also used Candela’s GentleMax Pro since it was first introduced in 2012. “Its safety, speed, and effectiveness are the reasons we use this device. This laser also delivers variable pulse-durations to treat thick or thin hair,” he says.

The Cynosure Elite MPX (cynosure.com) rounds out Dr. Bernstein’s arsenal of laser hair removal devices. The dual wavelength device, which combines a 755 nm Alexandrite and 1064 nm Nd:YAG lasers, boasts an integrated Zimmer chiller to treat all skin types, and it may also be used for facial and leg veins, benign pigmented lesions, and photo-aged skin.

Persistent Challenges

Despite impressive innovations, challenges remain. Santa Monica, California, dermatologist Tanya Kormeili, MD, notes, “Some people are not laser candidates.” 

Patients with light skin and dark, coarse hair get the best results. “Blonde, white and gray hair continues to be an issue due to a lack of melanin, which is the laser’s target,” Dryden says.
Some newer lasers promise to treat light hair, but Dryden feels evidence of their efficacy is lacking. “None had trials that ran long enough to properly evaluate the claims that they can get results on lighter-colored hair,” he says.

“For patients with light or blond hair, I recommend electrolysis,” Dr. Bernstein says. Patients with an active tan are at a higher risk for burning. “To get the best results in the fewest visits, the client’s skin needs to be as close to the natural skin tone as possible,” says Dryden. “Any additional color to the skin means we have to turn down the settings, regardless of the laser being used. More pigment in the skin equals lower power settings.”

To avoid this, Dryden educates the client. “The client has to make a decision: ‘Do I want to get the best results with the fewest treatments possible, or do I want a tan?’”

Dr. Martin notes that this is where new technologies that use lower fluence pulses with a high repetition rate offer a key advantage. “You can treat all skin types, including tanned skin,” he says.
Excessive hair growth, particularly on the face, can be caused by hormonal imbalances, including unregulated thyroid levels, Polycystic Ovary Syndrome (PCOS), menopause, puberty and pregnancy, that is resistant to laser hair removal.

“Doing treatments when hormone levels are not stable means hair growth cycles can be sporadic, and treatments may not be effective,” Dryden says.

All patients in Dr. Kormeili’s practice undergo a medical consultation that helps her identify potential nonresponders due to hormonal irregularities. “We evaluate their concerns for hair removal within the context of any medical conditions, medications, hormones, as well as hair density and skin types to set realistic expectations,” she says.
And while there’s been no evidence that lasers are harmful to a mother and her unborn baby, Dryden says his practice will not do treatments on pregnant women. “We do not want to take any chances,” he says.

Laser hair removal has typically been offered to remove excessive body hair. Over the years, it has become a popular option for removing facial hair. But the sensitive skin on the face and reports of paradoxical hypertrichosis requires special care. “If the hair is dark and coarse and there are no hormonal issues, it responds well to laser treatments,” Dryden says. “But if it is fine or light, we have to get more aggressive with the settings, and it will typically take more treatments.”

Setting Client Expectations

Though laser hair removal is one of the most popular procedures in medspas and cosmetic practices, the range of outcomes can lead to dissatisfaction. Patient education and realistic expectations are key to positive outcomes. “I spend time educating my patients that between three to five treatments are needed before permanency is reached,” Dr. Bonakdar says. “If the patient is hairier than the average person, I prepare them to expect to do more than five treatments. I explain that ‘permanent’ hair removal is defined as achieving six months hair free. This means that future touch-up treatments are needed from time to time.”

Dr. Bernstein agrees: An educated client is a happy client. “The best way to improve patient satisfaction is to set lower expectations than you really have, because patients often only hear the positives.”

Maryann Hammers is a freelance writer and specializing in the medical, beauty and spa industries.

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