Working with gel

Using gel during a treatment is in itself neither good nor bad. Using gel under a misguidance of what it actually does, inevitably leads to a negative effect in your results. The greatest benefit in the use of gel during a laser or light treatment is that it enables the applicator to glide more smoothly over the skin.

Using a gel as coolant for epidermal protection is not the most efficient epidermal protection you can offer your client. Skin cooling during a photothermal treatment is required to remove the heat from the epidermis. This is best accomplished by active cooling. It can be in the form of a water or air-based skin cooler, or even an ice pack. Using this type of skin cooling allows for the heat to be extracted and removed from the epidermis. An alternative is also cryogenic cooling. With this method of cooling, the skin is cooled right before and after it is heated.

Using gel as skin cooler does not allow for the heat to be removed. It creates a layer on top of the skin where the heat can conduct to. But then it is locked into the gel layer. As the treatment continues more and more heat is locked into the gel layer, causing an overall increase of epidermal temperature. This process can be reversed if you combine gel with a form of active skin cooling.

Another reason why therapist believe in the necessity of gel, is for conductance. This is an idea derive from technologies like ultrasound and micro-current, where conduction is of the utmost importance. With light therapy, absorption of the light is of the utmost importance. Any barrier between the applicator and the skin (or target) can have a negative influence on absorption.
The gel layer reflects and refracts the light. Depending on the wavelength and gel used, it can also absorb some energy.

To conclude, if you are using gel it is best to use the thinnest possible layer of gel to ensure minimal interference with your treatment results. If you use active skin cooling in combination with gel, it is important to remember that you still need to allow time for the cooling to be effective. If you have an applicator with build-in skin cooling that you glide over the skin on gel, you need to allow more time for a given area to be cooled sufficiently.

COVID-19: Round two

Looking around me, I see an everyday street scene. Pretty much similar to every other year before. It seems that most people around started to believe that the whole COVID-19 pandemic is something from the past. People are relieved to be out again, to be able to interact with others again.

Two weeks later, and we suddenly have a return of the pandemic with a vengeance. From one day on the other politicians don’t want to do television interviews any more and the blame-game for unpreparedness is starting all over. So, what is the biggest thing that we’ve lost during this small grace period we had? Our naïvety.

We no longer have a lag of experience on what it takes to keep the statistics reasonable. We no longer have a blind believe that it’s only going to be for a short period that we have to stick it through and it will become OK again. My question is what does it mean to me as an aesthetic clinic owner.

The whole collective thinking that kept us going through the first wave was, that in the not too distant future it will return to normal. Now, it becomes clear that it is not going to return to normal. It’s going to stabilize at something that is still unknown. So, how do I prepare myself and my business for this ride ahead?

I want to start with a little lesson that I’ve learned in my life so far. What ever happens, it’s not nearly as bad as the media wants you to believe. We all look up to the media to keep us informed, but it has one big fault. The media is also busy selling something, mostly advertising, and good news does not sell nearly as well as bad news. Therefore, stay informed, but don’t dwell on public opinions. Find a way for yourself to be able to make an objective judgement on how things are going. It doesn’t matter how simple it is, it just has to anchor you in times of uncertainty.

At present my biggest challenge is how do I redefine value? If we’re facing a two-year period where physical contact and close distance to other people are discourage at all cost, what is the real service that I will be delivering to my clients? Does this service consist of one or more components?

The depth and richness of the service we provide to our clients will become more meaning full. If you have focused on treatments only and have not introduced some retailing in your clinic, how will you accommodate the reduced treatments? But, it is not just about selling products. Do you provide your client with something unique? Does the client really has a reason to come to you, or can the supermarket provide the same or even superior value?

What the supermarkets are wonderful with, are options and choice. Unfortunately, a lot of therapists think that it is what they also have to offer. If options and choice are the only things you have to offer your clients, you do not have anything more to offer than the nearest supermarket.

Do you have specialized knowledge that you can apply to reach a decision? Knowledge is worth nothing, applied knowledge is priceless. The one thing that the world needs at this point in time is courageous people who are willing to apply their knowledge to arrive at decisions. As we are more and more flooded by a sea of options and choice the more we have need of firm decisions. When, you have the capability to guide your client in the decision-making process you have more value to offer than most others. The question now is how do you apply this in everyday life?

You start by getting to know your clients and understand their needs and preferences. Only then can you help your client to make a decision that benefit her most. The easier way to introduce this into your clinic is to start with your 20% top clients. The clients responsible for the most net profit in your business. Learn to provide these clients with an true client experience and you may find that this group may be sufficient to carry you through turbulent times.

Triple wavelength diode laser hand-piece: marketing gimmick or advanced technology?

All of a sudden triple wavelength diode laser hand-pieces seems to be the greatest advancement in hair removal laser for the decade. But is it truth or trickery? The arguments are logical and not easy to disproof. Thus, for most it seems to be the latest advancement in hair removal lasers.

Since it takes years to make an accurate evaluation of a new technology, it is still too early to talk from experience. But what we can do is to look at science and model the latest and greatest on our existing body of collective knowledge. And based on the outcome of these models we can make some predictions.

The first thing we will look at is the actual mechanical working of combining three different diodes in one hand-piece. This is possible as we all know, but does it come with a price we prefer not to know? One of the greatest challenges when building a diode laser is controlling residual heat. This is the heat that a diode generates and that remains in the hand-piece from the process of turning energy from electricity into light energy. This heat is one of the main threads to the life of a diode and a manufacturer has to optimize the machine’s internal cooling system to get rid of this heat.

The residual heat created, differ between different wavelength diodes. Building a three wavelength hand-piece, a manufacturer can optimize for one of the wavelengths and not all three. Thus, two of the diodes will not be optimized. Some manufacturers will go for a 50%, 25%, 25% distribution between the wavelengths, indicating that the system has been optimized for the 50% wavelength. Other manufacturers will go for a 33,3%, 33,3%, 33,3% distribution, indicating that either one or none of the wavelengths has been optimized for.

The prediction we can make from this knowledge is that a system that has been optimized for a specific diode, like a single wavelength hand-piece will be more stable and outperform a system that has been partly optimized. Thus, the chance of a single wavelength hand-piece breaking is much lower than that of a triple wavelength, the productive lifetime of this single wavelength system will also be significantly longer. But this is purely technical and only relates to the machine.

The flip side of the coin for having the benefits of three wavelengths, is that you also have the drawbacks of three wavelengths. What I mean with this is that you as therapist can no longer optimize your treatment protocol to improve results to the extent that you can when working with a single wavelength. Do you have a dark skin type? Although you have 50% Nd:YAG in your hand-piece, you are actually governed by the 25% Alexandrite Thus, you have to reduce the energy to a level where you protect the epidermis against the shortest wavelength of your system.

The melanin absorption coefficient differ almost with a factor ten between 755 nm and 1064 nm. It means that if you reduce the melanin absorption at 755 nm by 1, you reduce the melanin absorption at 1064 nm by 10. If you have a 755 nm (25%), 810 nm (25%) and 1064 nm (50%) hand-piece and reduce the fluence from 10 J/cm2 to 9 J/cm2 (10% reduction), you will greatly reduce the melanin absorption for the greatest part of your machine’s output. The effect of 755 nm will reduce to 97% of what it was, the effect of 1064 nm will reduce to 50% of what it was.

Working with a single wavelength hand-piece, you can optimize your treatment protocol for that wavelength. Working with a triple wavelength hand-piece means that you have to optimize your treatment protocol for the wavelength that forms the highest risk to your client, even if it is the smallest percentage of your output.

The prediction here is that when you work with a multi-wavelength hand-piece you will not be able to optimize for hair removal, but you will be forced to optimize for skin protection. This means that you will get better hair removal results with a single wavelength hand-piece.

Coming back to our initial question: marketing gimmick or advanced technology? I believe that triple wavelength diode hand-pieces for laser hair removal is a marketing gimmick. I do not say that you will have no results with a triple wavelength hand-piece. What I do say is that you will have inferior results with a triple wavelength system if directly compared to an equivalent single wavelength system, and even then operator competence will be the determining factor.

Skin resurfacing with Er:Glass vs Er:YAG

In a 2015 study: “A Prospective, Randomized, Double-Blind Comparison of an Ablative Fractional 2940-nm Erbium-Doped Yttrium Aluminum Garnet Laser With a Nonablative Fractional 1550-nm Erbium-Doped Glass Laser for the Treatment of Photoaged Asian Skin”. Found the researchers that:

Reductions in pigmentation and uneven tone/erythema scores were significantly greater after Er:YAG, while wrinkle score reduction was significantly greater after Er:glass. Physician and patient assessments for the overall features showed greater improvement in the Er:glass. Treatment-related pain or adverse events were less in the Er:YAG.

Let’s start by looking at the difference between the two wavelengths. Er:Glass at 1550 nm and Er:YAG at 2940 nm.

At 1550 nm the water absorption coefficient is 1/2000 of that of 2940 nm. We also find some melanin absorption at 1550 nm which is no longer present at 2940 nm and there is still some haemoglobin absorption at 1550 nm what also is not present at 2940 nm.

What does this mean in practice? At 1550 nm you still have a photothermal reaction, where you have a photoablative reaction at 2940 nm.

What happens with Er:Glass fractional, is that you create small ‘wells’/’tunnels’ in the skin where you coagulate and evaporate the tissue. These ‘wells’ can range from 400 μm (micrometer) to 1,4 mm (depending on various factors). The average thickness of the epidermis is 0.1 mm or 100 μm.

Er:YAG has very little penetration depth compared to Er:Glass, about 50 µm (depending on various factors) per pulse. But unlike with Er:Glass where you are more limited in the amount of passes you can go over an area during a treatment, with Er:YAG you can increase the passes. This makes Er:YAG more suitable for problems in the epidermis, like pigmentation. Whereas Er:Glass is more suitable for deeper laying problems, like rhytids.

Keep in mind that you can ablate with an Er:YAG as deep as you can treat with an Er:Glass. But with a fractionated machine this is not very practical to do. With a full ablative Er:YAG machine you will have no limitation on ablation depth, since you just keep doing passes until you reach the required depth.

A combination fractional treatment of Er:Glass and Er:YAG is actually the ideal for impressive anti-ageing and skin rejuvenation results without extended recovery time. Although, each of the wavelengths on its own will also not disappoint.

Building your client list with referrals

The cost of acquiring clients has sky-rocketed the past few years and the COVID-19 lockdown has not brought any change in that. The contrary happened. With online growing so fast due to the lockdown the online cost to acquire new clients has even spiked during the lockdown and following.

Where does it leave us, laser therapists, as specialized small business owners? In quite a difficult place. We need clients to stay in business, but we also need to make a profit to justify staying in business and a lot of all the marketing advice we’ve got (sometimes very expensively) lately have proven to be worth nothing.

In this article we will look at the good old way of growing a client list; referrals. This method remains the goose laying the golden eggs. But as with everything else, this goose also updated to stay with the times and getting referrals nowadays is not exactly what it used to be. However, keeping to a couple of simple rules, this goose is still willing to lay her golden eggs.

The first rule is: Do not ask all your clients for referrals. This may sound counter-intuitive, but think about it for a moment. Only ask the clients who are willing to sell you to their friends and family. This usually means your top 20 to 30% of clients.

Timing is also very important when you ask for a referral. The best time to ask for a referral is when your client is the happiest with your service. This is usually when she has just bought or booked a specific treatment. You should also ask for a referral related to that specific product or treatment and not in general.

It is also easier to get a client to refer if you make the experience shareable. Make it possible for the client to gain ‘brownie points’ with an acquaintance by bringing her (or him) with for a treatment to share. Again, don’t extend this offer to all your clients, only the top 20% of your clients. This way you get all the referral’s information without asking for a referral, since the person will complete a client information form before the treatment starts. You also get the opportunity to book another treatment with this new client at the end of the treatment and will certainly benefit from the support of your existing client.

Make referring as easy as possible. The lower the barrier for the client to refer someone to you, the higher the chance that she will do it. Don’t ask the client to complete a page of questions just to refer someone.

Deliver results. A satisfied client will keep on referring to you long after she completed her treatment course.

These are just some ideas on how to get your client list growing with the help of referrals. Let us know if you tried some of these ideas and if they worked for you.

The lies people tell

We often get people asking our option about equipment they want to buy. They will forward an ad or quotation and usually ask if it is possible to do X, using this machine. The information that came cross our mailboxes have over the years changed from informative to imaginative to a point now that 95% of what we see can be classified as either Sci-Fi or Pie-in-the-sky.
Given the effort we sometimes need to put in to establish what is true or possible in some circumstances is mind-boggling. It is understandable that the buyer today is simply overwhelmed.

One of the first things we usually recommend is that if they promise it, you should experience it in person. With this we do not mean a once-off quick demo, but a complete course of treatments or at least 4 treatment. If a representative shows you a video of how this wonderful machine can do hair removal on two complete legs in 9 minutes do at least 4 full leg sessions on this machine using that exact technique on yourself and then wait 3 months before you make a buying decision. If it is true, this machine will be worth paying full price for. And if you are pushed to make a buying decision without proper first-hand experience, the best decision is always to decline.

So what are the main themes we encounter nowadays in the marketing materials that get send to us?
The first one is treatment speed. It has been for a while now that manufactures have an ‘arms race’ on who provides the quickest treatment. The claims used to be a time saving of 10 to 30 % on the competition. Now it is not unusual to hear a claim that the longest part of the client interaction is to swipe the client’s credit card.

The truth is that there is no machine on the market that is too slow to run a commercially successful laser clinic. Even with the super fast machines you have to decrease the speed in reality if you wish to gain lasting results without severe side effects. Taking hair removal as example, the thermal damage time needed for hair removal is between 200 ms and 400 ms. Since very few people can perceive milliseconds, this means no more than two pulses per second. On top of that you have to heat the dermal papilla to 65 °C or more. Thus, you need enough energy focused on one follicle to heat the hair and allow time for the heat to spread to the surrounding tissue and then make sure the surrounding tissue stays above a minimum temperature for a certain length of time.
As we’ve discussed in previous articles you get away with less energy and a gliding motion given that you have thick dark hair on a light enough skin for the first session or two.

Apart from the time that is needed for the reaction in the skin, you also need to factor time in for skin cooling and client comfort or else you will end up with no returning clients. Keep in mind that laser treatments are luxury treatments and the most important factor for running a successful laser clinic is the client experience. Even if your results are superior to all others, without a good client experience you will not be able to make a clinic work. This means that your client needs to value your service more than the money she has to spend with you and spending a reasonable amount of time with the client contribute greatly to the perceived value.

Another theme becoming popular is multi-wavelength diode lasers. This is when the machine has a handpiece with 3 different types of diodes providing you with various wavelengths. The common argument is that it provides you with the best of all three wavelengths. The problem is that it is only a portion of the truth. It also provides you with the worst of all three wavelengths and it divides the power provided by the power-supply of the machine over three diodes with different efficiency factors. The three wavelengths do not increase the fluence or ‘strength’ of the machine. It remains the same, but is now divided over 3 wavelengths.

We have encounter no evidence that a multi-wavelength handpiece provides any more value or benefit than a single wavelength handpiece for hair removal. Given the fact that the wavelength determines the target molecules in the skin you end-up with a situation where you spread your energy over more molecules that absorb the energy. For something like skin rejuvenation this may be a good thing and that is why IPL’s give good rejuvenation results.

The last thing we will look at in this article is the technical specifications provided. It has become almost impossible to get accurate specifications for a machine nowadays. A manufacture will have a range of options for each machine and will only provide the client with specifications that looks good on paper and may be available on the most expensive version. Most buyers don’t bother with this because they don’t understand it anyway. The technical specifications tell you what exactly you buy and what you can do with it.
When you want to purchase a machine insist on the full technical specifications for the model and version of machine that you want to purchase and then find someone that can help you to understand it.

It is understandable why people buy equipment without understanding what it is that they are buying because the misinformation is just so overwhelming. But keep this in mind; once you’ve bought a machine you will not get your money back when you’ve realized that it was the wrong machine for your needs or the person selling it to you misled you. There is a general misperception that people think that when they buy equipment for professional exploitation they are also covered by consumer protection laws. This is not the case, the law assumes that if you want to sell services or products professionally you possess the necessary knowledge to make the right buying decisions.

The difference between laser hair removal for men and women

When we look at the difference between hair removal for men and women, there are two main areas that we need to keep in mind. The first is the hormonal differences between the two and secondly, the psychology.

Hormones is the number one factor that determine hair growth and hair distribution patterns. Therefore, it is not surprising that there are some significant differences. When we have a testosterone dominant system such as that of a man the hair distribution pattern is wider spread, meaning that more of the body is covered in hair. Next to that we also find that we deal with thicker hair as the scales tip more towards testosterone.
Given that the hormonal homeostasis is influenced by so many factors ranging from genes to lifestyle it is no surprise that there are a lot of variations from the average.

In general a male treatment will be for a larger area than a female treatment. This means that you will pulse more times during the treatment session and the treatment will be more taxing on men than on women. It also means that if a treatment is done correctly the average treatment time will be longer for men than for women. When you use a topical anesthetic like Emla, you will have to factor in that the anesthetic must remain active for a longer time. On a small treatment this does not differ between men and women, but if you do a larger area like legs you need to plan for this.

Because hair are thicker and darker on men, men will also experience more sensation during the treatment than women. The thicker, darker hair has more melanin available to convert the light energy to heat. Therefore, you create more heat in the skin of an average male client than a female client. Especially when you deal with facial hair, and have to decrease the energy to prevent possible side effects.
Because of the thicker hair, men usually see more results after the first or second treatment than women. But thereafter it tends to equal out.

The last point we will touch on is the difference in psychology between male and female clients. Men are more outcome driven, where women are more process orientated. In general, men will endure an unpleasant process if they know it will deliver the desired results. Whereas, women need to derive benefit from the process and will then be more willing to accept an outcome that differ from the original expectation.

Therefore, the therapist needs to be aware that a certain type of interaction that is welcomed by female client may cause a level of irritation with male clients. It can also be said that female clients may experience a certain type of interaction that works with male clients, as cold and distant.

How effective are home-use lasers and IPL’s for hair removal?

The amount of home use devices have increased exponentially the last couple of years, but how effective are they really?
There is no manufacturer or seller who doesn’t have a list as long as my arm of happy clients according to their seller reviews.

Just why is it that a little device costing less than €400 seems to be able to do permanent hair removal just as well as a €40000 machine? The short answer is that it doesn’t. The secret is that it causes shedding and it is a common misperception that shedding is equal to permanent hair removal.

Protein denaturation starts at about 41 °C. This is not that much higher than normal body temperature of 37 °C and that is also why it is possible to have hair loss because of high or extended fever (telogen effluvium).

Sufficient protein denaturation in the follicle causes shedding. Although not every device will give enough energy to cause shedding, it has become quite common for these devices to do so. The hairs that shed will return during the next growth cycle. The trick here is that if a user does regular treatments (s)he will cause the hair to shed earlier in the growth cycle and therefore the visible hairs will become less and finer.

The damage caused to the follicle by temperatures under 48 °C is reversible and of temporary effect. To cause permanent hair removal / reduction you need to create irreversible damage and you will have to heat the dermal papilla up to over 65 °C for a minimum length of time. The thermal damage time (TDT) for hair range between 200 ms and 400 ms.

The energy needed to cause this temperature rise at the depth of the dermal papilla can cause permanent blindness. This is why lasers suitable for permanent hair removal are always class 4 lasers. However, it is possible to have shedding with class 1 or class 2 lasers.

Coming back to the question: How effective are home-use lasers and IPL’s for hair removal? It seems that the technology has matured to such extent that temporary hair removal can be done quite effectively with a home device. Permanent hair removal / reduction is still an exception to the norm for these devices and will remain so because of the safety restrictions on class 4 lasers.

How I can contribute to repairing the economy

It is only now with more countries reopening their economies that we start realizing just what a disastrous effect this pandemic has. This brings me to, what can I as an individual do to contribute to the quickest possible recovery.

A lot of times we see ourselves as too small a drop in the ocean to think that we can actually make a difference. This is not true at all. We will still buy things, even if we have to scale down for time being, and it is this that gives us power. We have to use our money to create a better life for everyone in our communities.

The only idea I want to convey with this article is: Buy local.

Buy from local businesses that sell locally produced products, equipment and services. This way we ensure that we all benefit.

When you buy local:

  • Local people (your clients) are employed and can therefore afford your services and products.
  • The profit goes to local business owners that will spend more of it locally, and will make more micro investments in their businesses that will lead to further employment opportunities for local people. Thus, more clients for you.
  • This creates a diverse local business environment. Maybe three or four smaller shops employing 3 people each, than one warehouse employing 9 people. When a downturn hits the economy this means that the other shops can absorb one or two of the employees when one shop closes. When a warehouse closes it means the community is out of suppliers and everybody is unemployed.
  • Local social stability and welfare is created.

Tips for a safe reopening

As more and more countries and territories allow for personal care services to reopen the question is; how do I keep my clients, my staff and myself safe?
Although this is the most important question, I will start this article with the question, how do I keep my equipment safe?

Most equipment used in a salon or clinic are manufactured to have the contact areas (applicators) disinfected regularly. However, this does not mean that the whole machine has been designed to be disinfected multiple times a day. Be especially careful over areas with lettering, logos and other printing, alcohol can remove these markings from the body of the machine. It is also possible that a machine has a protective filter or layer applied over the screen. This filter can be damaged by chemicals.
Make contact with your suppliers and ensure that you follow the manufacturer’s recommendations for disinfecting your equipment.

Remember that alcohol will damage or deteriorate leather surfaces. Better to use a product like bacoban, which offers longer lasting protection. Where possible replace leather furniture with furniture from other materials that can handle regular disinfecting and simply remove any unnecessary objects from the rooms where you will receive clients. The alternative is to cover all leather surfaces with high quality covers that will block all chemicals used for disinfection.

When we look at protection for your clients, staff and yourself; there are loads of resources available on-line from every government. Given that you adhere to all regulations placed on you by your local authority, there are a couple of points I also want to touch on in this article.

Firstly, make the time to take care of yourself. Maintain a health lifestyle that allows your body, mind and spirit to be in the strongest possible position to fight any potential infection. With this comes controlling your environment where possible to ensure you are physically in a safe space.

Pay extra attention to:
• Masks. When possible the first choice is N95 / FFP2, especially for the therapist.
• Wash and disinfect your hands regularly, also remember to use a good quality moisturiser to help your skin to cope.
• Use latex or nitrile gloves in mass. Replace it with a new pair before every client or when ever you suspect that you may have touched something that is contaminated. Provide each client with a pair of gloves when they enter your salon or clinic.
• Avoid public toilets and deter clients from using your toilet facilities. At least keep a separation between facilities for clients and for staff. Make sure the toilet lid is closed before you flash the toilet.
• Ensure good ventilation, taking other safety measures into account. Laser safety still requires an enclosed environment to prevent eye and skin damage to people passing by. Please do not perform laser treatments with open doors and windows.
• Ensure proper extraction of plume and laser generated air contaminants, as it may contain the virus. This is especially relevant for fractional and ablative laser treatments.

Above all remember that you cannot take care of anyone else if you do not first take care of yourself. By ensuring that you stay healthy, you cannot infect a love one.