Coming To Bare

New devices are making laser hair removal faster, more efficient and less painful.
Laser Hair Removal

"Laser hair removal was first reported 15 years ago by scientists at Massachusetts General Hospital and Harvard Medical School,” says Omar A. Ibrahimi, MD, PhD, assistant professor of dermatology and director of cutaneous laser and cosmetic surgery at the University of Connecticut Health Center in Farmington, Connecticut, and visiting scientist at Massachusetts General Hospital. “Since then, many advances have been made which make laser hair removal highly effective, long-lasting and safe when performed by a properly trained professional.”
The most commonly reported side effects of laser hair removal are “blistering and scarring or changes in skin pigmentation—hyperpigmentation or hypopigmentation,” says Bruce Katz, MD, clinical professor of dermatology, The Mount Sinai School of Medicine, and director of Juva Skin & Laser Center, New York. “Occasionally, reticulate erythema—the inflammation and reddening of the skin in a net-like pattern—has been reported in patients who have a history of chilblains. These events are certainly decreasing with improved devices and better protocols.” While previous technologies removed hair effectively, they also damaged the surrounding skin, notes Dr. Katz. “Newer lasers penetrate the deep dermis instead, decreasing the damage to surrounding
skin,” he says.

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Finding the Gold Standard

Legs

As practitioners and engineers continue to refine both techniques and technologies, opinions vary regarding the most effective wavelengths for permanent hair reduction. “We have sorted out over the years that the alexandrite, ruby and YAG lasers can do a good job, but we can argue that the diode 810nm wavelength is the best,” says Corey S. Maas, MD, FACS, Maas Clinic, San Francisco. “One of the newest laser hair removal devices is the LightSheer Duet from Lumenis. Combining vacuum with lower power settings has added considerably to advancing this technology by reducing pain and increasing the speed of treatment. In practiced hands, many devices can produce comparable results, but in my opinion the Duet system is the best.”
The LightSheer Duet (aesthetic.lumenis.com) was introduced in March 2009 and features two hair removal systems on one platform. In addition to the LightSheer ET system—which is ideal for smaller or bony areas such as the chin and ankles—the new high speed (HS) handpiece features a 22mm by 35mm diode array designed for large areas, such as the legs and back. The HS handpiece also employs vacuum assist technology, which lifts the skin into the treatment aperture before applying laser energy. This has been shown to decrease pain and improve energy delivery, allowing clinicians to treat large areas quickly with minimal discomfort to patients.
“The pain factor is big for patients,” continues Dr. Maas. “With the Duet you don’t need a topical painkiller in most cases, although I do often suggest one for patients having hair removal done in sensitive areas such as the bikini line.”
Dr. Katz also likes the 810nm wavelength but prefers a newer system. “Since its introduction in 2010, the SopranoXLi from Alma Lasers (almalasers.com) has been the gold standard in laser hair removal,” he says. This system combines up to 20 J/cm2 power with the company’s IN-Motion sweeping technology, and it includes pre-programmed settings for all male and female face and body parts.
“Unlike earlier systems, the SopranoXLi uses high power and a rapid, 10 pulse-per-second repetition rate to penetrate deep into the dermis where hair follicles are located. This diode laser is FDA-cleared for Fitzpatrick skin types I-VI—even patients with tanned skin—and has consistently positive results. In addition, patients have indicated that SopranoXLi offers a comfortable treatment, especially compared to other hair removal procedures they have experienced in the past,” adds Dr. Katz.
“I think it’s a common misconception that the gold standard in laser hair removal is the diode laser,” says Shino Bay Aguilera, MD, Cosmetic Dermatology & Laser Institute, Fort Lauderdale, Florida. “What you are trying to do with the laser is deliver enough energy to the hair bulb to destroy the root of the hair, and the 755nm alexandrite does this the most efficiently. To me, physics proves that the 755nm alexandrite laser—which has more affinity for melanin—is the ideal wavelength for hair removal and should be considered the gold standard for hair removal on lighter skin types.”
Dr. Aguilera prefers the Elite MPX from Cynosure (cynosure.com), which includes both the 755nm alexandrite wavelength and the 1064nm Nd:YAG wavelength. Introduced in March 2009, the Elite MPX incorporates Cynosure’s proprietary MultiPlex technology, which sequentially fires two wavelengths, a built-in Zimmer SmartCool skin cooling system and eight different spot sizes. “The 755nm alexandrite is ideal for skin types I-III; the 1064nm is safest for skin types IV and above,” says Dr. Aguilera.
“In my opinion, the two most popular devices for hair removal today are the Lumenis LightSheer Duet and the Candela GentleLase device (candelalaser.com). However, there are many devices on the market that can be used to achieve hair removal with high patient satisfaction,” says Dr. Ibrahimi.

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Recent Literature

Making Your Choice

Underarm

As technologies continue to advance, the trend is toward more versatile devices. “No one laser wavelength works best for all patients,” says Dr. Aguilera. “The ruby laser can be better for fine hair but will burn even the lightest skin. The alexandrite is better for skin types I-III, but skin types IV and above are safest with the 1064nm wavelength. Safety is highest when the operator is experienced in choosing the right wavelength and fluence for the right skin type. I train other doctors to use lasers for hair removal and I know there is a learning curve with these devices.”
What do you need to consider when deciding which device to buy?
Safety. Most experts agree that adverse events are usually not attributable to the device but result from operator error—using the wrong fluence, overlapping too many pulses or failing to recognize tanned skin.
“There are still two major variables in laser hair removal: the Fitzpatrick skin phototype of the patient and the laser operator’s understanding of the laser-tissue interaction and his knowledge of the patient’s medical history, allowing him to identify contraindications for treatment,” says Dr. Ibrahimi.
“Laser hair removal is not in the same category as salon cosmetic procedures. Operators need thorough training and physician oversight. Laser treatments are not without risk,” adds Dr. Maas. “When an unskilled operator burns a patient, everyone offering laser hair removal is hurt. Clinics and medical spas offering laser hair removal need to establish excellent clinical care standards and careful, thorough protocols. Doctors monitoring these procedures need to insure that all adverse events are reported promptly.”
That said, when evaluating a purchase, it is important to consider ease of operation, built-in safety options and availability of training for you and any additional operators.
Range of skin types. Platforms that include both the 1064nm wavelength and either a diode or alexandrite laser can be safely used with most patients, but there may be trade-offs in efficacy with different skin types. If you can afford only one machine or the time to become expert in the use of only one device, it might be best to purchase the most efficient device for the majority of your patients and refer other skin types to colleagues.
Patient comfort. “Unfortunately, pain control remains a major issue in hair removal treatments,” says Dr. Katz. “Patients still report hesitation because of past procedures that burned or damaged their skin. There is no reason for an extremely painful hair removal experience when there are devices built for efficacy and patient comfort. I always recommend hair removal lasers that have built-in cooling.”
“Pain has been greatly reduced with newer devices,” says Dr. Aguilera. “Some use vacuum, some use cold plates or cryogen cooling, but I think the best cooling devices use air cooling that’s integrated into the handpiece. They work best because they cool at all times—before, during and after the energy pulses. There is still some discomfort, but it’s a lot less. Remember, too, that pain can aid safety. If a patient is experiencing more pain than usual, check your settings.”
Ease and cost of operation. Long-term hair removal has become a very competitive business. Before choosing a device, you need to consider not only patient outcomes but the cost of delivering each treatment, including the initial purchase price of the equipment, consumables per treatment, space requirements and operator time. “Because of competition, hair removal is a lot cheaper for patients than it was five years ago,” says Dr. Aguilera. “Prices are dependent on where the clinic is located and the patient’s hair and skin type. We offer package prices from $250 to $1500.”
Can we expect major improvements in laser hair removal devices in the near future? “We can only destroy hair in the anagen growth stage, when the hair shaft is directly attached to the area where the cells that create the hair reside,” explains Dr. Aguilera. “This means laser hair removal will always require multiple treatments and be dependent on skin type. We may be able to make additional refinements but I don’t see any major breakthroughs in the pipeline.”

Linda W. Lewis is a MedEsthetics contributing editor.

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Resources

The following companies offer laser hair removal devices for aesthetic practices.
Alma Lasers, 866.414.2562, www.almalasers.com
Candela/Syneron, 800.733.8550, www.candelalaser.com
ConBio, 800.532.1064, www.conbio.com
Cutera, 888.428.8372, www.cutera.com
Cynosure, 800.866.2966, www.cynosure.com
DEKA, 877.303.5273, www.dekalaser.com
Focus Medical, 866.633.5273, www.focusmedical.com
Lasering USA, 866.471.0469, www.laseringusa.com
Lumenis, 877.586.3647. www.aesthetic.lumenis.com
Lutronic, 888.588.7644, www.lutronic.com
Palomar Medical, 800.725.6627,
www.palomarmedical.com
Sandstone Medical Technologies, 205.290.8251, www.sandstonemedicaltechnologies.com
Sciton, 888.646.6999, www.sciton.com