Uncategorized Archives | The Aesthetic Clinique

Why are Blunt Microcannulas the Obvious Choice for Dermal Fillers?

Dermal fillers are becoming increasingly popular worldwide. Contouring of the face, restoring volume loss, enhancing features such as lip plumping can all be obtained with very little downtime. Just 15 years ago, surgery was the only way these enhancements could be performed. There are some minor complications associated with fillers such as pain, bruising, swelling which are fairly common (>70%) and some major risks such as vascular occlusion, blindness, and stroke which are much less common.

The most common method to administer fillers is using the needle which is packaged with the product. While needles are very easy to use, in the author’s opinion, they are more risky and lead to more downtime versus the blunt microcannula technique. Microcannulas were introduced to the United States about 8 years ago from Europe. These were a smaller version of the already widely cannulas which were used for fat transfer. When compared with a needle, cannulas are more flexible, longer, and their tip is more rounded. The following advantages are found with cannulas:

Fewer dermal penetrations – cannulas are introduced through only a small number of pilot holes.
Less discomfort – the dermis contains more pain fibers than the deeper tissues. The injections with cannulas are below the dermis, so discomfort is less.
Less trauma to tissues/less bruising – because of the rounded tip, the cannula is less likely to nick blood vessels leading to less bruising and swelling.
Faster procedure times – With an experienced cannula user, placement of filler is done very quickly and efficiently. (Cheek/tear troughs <5 minutes per side, lips <5 minutes)
Less vascular occlusion risks – While cannulas aren’t 100% safe, the risks of injecting into a blood vessel are less because entering a vessel is more difficult with the rounded tip and flexible shaft. This is true for the larger gauge cannulas such as 22, 23, and 25. Recent studies by Dr. Pavicic and Cotofana have shown the 27g cannulas have the same force needed to enter a vessel as a 27g needle and therefore should not be used.

Galderma recognized the advantages of microcannulas and became the first company to get FDA approval for their use with Restylane Silk in lips in 2017, and for Restylane Lyft for the cheeks in 2018. While less than 10% of providers use cannulas in the US, there is a push by the top injectors to encourage their widespread use.

Dr. Weiner has been using microcannulas since 2012 and is one of the most experienced cannulas injectors in the US. He is one of the leading trainers for Galderma, particularly for their cannula trainings. He is available for private trainings in off label use of fillers – face/body. There are shadowing opportunities as well as week long internships opportunties. For inquires, please email: info@theclinique.net or steve@stevenfweiner.com

Why Dysport is Dr. Weiner’s Favorite Neuromodulator/Neurotoxin

The most popular cosmetic procedure in the world is wrinkle reducing injections with neurotoxins or the friendlier term, neuromodulators. The injections work by reducing the activity of the muscles they are injected to, there by resulting in less movement and less dynamic wrinkles. Static wrinkles, ones that appear at rest, are less affected by these injections, but over serial treatments, improve as well.

The history of neuromodulators dates to the isolation of the botulinum toxin, the cause of botulism, in the 1928. It was later refined and made commercially available for injections in the 1989 and initially FDA approved for strabismus, lazy eye. Soon thereafter, blepharospasm, spasm of the muscles around the eye, treatments were approved. The team of Carruthers and Carruthers observed that during blepharospasm treatments, the wrinkles around the eye, crows feet, were also improved. Studies were later performed on the frown lines, and FDA approval for cosmetic use was achieved in 2002.

There are currently 3 FDA approved neuromodulators of botulinum toxin A for cosmetic use: Botox, Dysport, and Xeomin. They all work similarly by blocking the acetylcholine release at the neuromuscular junction. Each brand has their own definition of what a unit dose is, so this can be confusing to both the practitioner and the patients. The differences between the 3 is the associated inactive protein, or absence of this protein in the case of Xeomin. Studies have shown that once the drug powder is mixed with water or saline in the provider’s office, the inactive protein disassociates almost immediately. Why then, are there differences in clinical outcomes between the 3 neuromodulators?

There is a recent comparison of the active protein molecule in the 3 products dosing in the glabella. The study looked at the FDA approved doses for frown lines – glabella. A very interesting finding was that there was 0.27ng in Dysport using the 50u dose vs 0.18ng in Botox’s. Xeomin was a distant 3^rd coming in at 0.08ng with their 20u dose. In essence, patients are receiving a stronger dose when using Dysport when compared to Botox or Xeomin.

It’s long been established that Dysport seems to be effective (in 1-2 days) sooner than Botox (3-4 days) but the reason was never clearly elucidated. It’s also well known that higher dosing of any of the neuromodulators will lead to longer durations of action. This higher level of active protein with Dysport can explain the clinical phenomenon of quicker onset and longer duration.

One other topic needing addressing is the myth of higher diffusion with Dysport vs Botox. Diffusion or spread, is a result of dosing, volume, speed of injection and not a function of the neuromodulator. As stated before, when reconstituted, all the products are free of their associated proteins and only consist of free, active protein. We now know that Dysport has more active protein in their approved dosing, so to compensate, lower volumes must be used for reconstitution. The author’s recommended reconstitution for Botox is 2cc and for Dysport is 1.5cc for the glabellar injections. When diffusion or spread is desired, larger volumes can be used.

With the recent comparison study of active protein in the dosing schemes of the 3 commercially available neuromodulators, it is easy to see why Dysport should be the standout choice. Dysport gives more effective treatments because of the higher active protein, leading to quicker onset and longer duration (up to 5 months) than Botox and Xeomin. Pricing is usually less with Dysport, so it becomes a “no brainer” 1st choice for Dr. Weiner’s practice.

Laser Hair Removal Just Got A Long Awaited Upgrade – Splendor X

Removing hair using a laser dates back to 1995, when the first laser was FDA approved for this purpose. The LightSheer laser (Diode) was approved in 1997 and has been the most popular laser for hair removal since then. About 6-7 years ago, the LightSheer Duet was developed for faster and safer treatments and was the laser used by the author for the past 6 years. The Alexandrite (855nm) wavelength has been consider possibly a more effective laser for hair removal, but it’s limitations have been pain and speed. In addition, both the Diode and Alexandrite laser aren’t considered safe for the dark skin tones where a 1064 (Nd:YAG) laser is needed. The Splendor X has solved all these problems and is now the most innovative laser for hair removal on the market.

The concept of laser hair removal was invented by Dr. Rox Anderson from the Wellman Institute at Harvard’s Mass General. To permanently remove hair, the hair germinal cells must be killed. This is done by using a laser whose wavelength matches the pigment of the hair. The heat absorbed by the pigment travels to the germinal cells and permanently injures them. In the growth phase of a hair cycle (one of 3 phases of the life of a hair), the hair is attached to the germ cells so the heat is effectively transferred to them. In the other 2 phases of the hair cycle, the heat will not lead to killing the germ cell. This is why several treatments are needed, so as to eventually hit most of the hairs in the growth phase. One should expect about 75-85% hair reduction after 6 treatments, and the need for touch ups, 1-2 times per year.

What makes Splendor X different?

Dual (Blended) Wavelengths: Spendor X has both the Alexandrite 855nm and the Nd:YAG 1064 wavelengths. It can safely treat all skin types. For the lighter skin, mostly the 855nm is used. For darker skin, the laser uses a blend of the 2 wavelengths while in type 6’s, only the 1064 is used. While some companies had 2 wavelengths on their device, it is either one or the other, and not a synchronized output. The benefit of the 1064 laser for lighter skin types is that it penetrates deeper than the 755 laser and can attack deeper hair follicles as well as the vasculature feeding these follicles.

Square Footprint: The pulse from the laser is uniquely square. This overcomes the uneven treatments which are inherent in the typical circularly outputs. With the circular footprints there will be potential for skipped areas and/or over-treated areas from overlapping pulses. The Splendor X has a glow-in-the-dark marking system to guide the operator to place pulses abutting each other with minimal overlap.

Double Cooling System: The Splendor X uses both integrated Zimmer Air Chilling as well as a chilled tip to doubly ensure a safe treatment. By chilling the skin surface, the laser will preferentially heat into the deeper dermis where the hair follicles are and is less likely to be attracted to skin pigment (less burn or PIH risk).

Highest Speed: Improvements in speed was one of the major attributes to the LightSheer Duet. It could do a man’s back in about 15 minutes, down from the 45-60 minutes it took previously. With the Splendor X, we can now do the back in about 6 minutes with the same or more safety.

High Power: There is higher power than most lasers with the Splendor X – 75% more – 7 Kw vs 4 Kw. Higher power equates to more efficient treatments, more results, less sessions needed.

Plume evacuation: There is a built in suction to remove the plume of the the vaporized hair. Besides removal the smell, this is important as we learn there are possible negative side effects from the plume.

There has been a lack of innovation in the laser hair removal arena for years. Now the Splendor X leaps to the front of the line with its innovative blended wavelengths, square footprint, and lightening speed. Patients can be confident they are receiving a highly effective, comfortable, and quick hair removal treatment.

Subcision of Acne Scars – Revisiting an Old Technique

Acne scarring is a significant psychologically debilitating disease affecting millions in the US, approximately 1% of the adult population in one study. Treatments for acne scars include:

Lasers
RF Microneedling
Fillers
TCA Cross
Subcision
Microneedling
PRP (Platelet Rich Plasma)
PDO Threads (?)

Most of these techniques are based on trying to make the disorganized collagen in the scar to be more organized and natural. Using carefully induced tissue trauma with heat or microneedles (mechanical), the body initiates a healing process to smooth the scars.

Acne scars will often affect tissues deeper than the dermis. Fibrosis/scarring can affect the subcutaneous tissues and fat and lead to tethering of scar to the deeper structures. Lipoatrophy (fat loss) can occur as the result of the inflammatory mediators released from the acneic process. When heating from lasers and RF is applied, it is preferentially conducted through the collagen because the water content of collagen is high. Heating collagen will lead to collagen remodeling but also collagen contraction. If the collagenous attachments to the deeper tissue are not cut (subcised), there is actually potential for worsening the appearance of the scars with these heating devices.

A recent paper suggested that using a cannula to subcise acne scars is better tolerated, with less adverse events, and judged to have better results by the patients. This is Dr. Weiner’s (and acne scar expert Dr. Davin Lim’s per personal communication) preferred method of subcision vs using a Nokor needle. By subcising, the energy flow to the deeper structures is severed and harm to fat is less as is the risk of pulling some scars deeper. Placement of filler (Restylane Defyne, Bellafill) is often done simultaneously with the subcision to help elevate the scars and prevent reattachment of the scars.

Subcision has been around for decades for acne scar treatment. It is now even more important when energy devices are used to maximize the benefits of these treatments. The use of cannulas for this procedure leads to more comfort, less risks, and better satisfaction.

The Aesthetic Clinique has been designated an Acne Scar Center of Excellence by Suneva (Bellafill) and is considered an acne scar expert.

**(Subcision is also useful for treating cellulite as there are fibrous attachments from the skin which cause the dimpling.)

Emsculpt: A New Treatment Category – Muscle Strengthening with Fat Destruction

It’s been the dream of generations. Hundreds of machines have failed. Now there is Emsculpt. It is now possible to strengthen your abdominal muscle muscles effortlessly and pain free. How about lifting and shaping the buttocks without squats? In fact, you can drink wine, eat a donut, or watch a movie while this is happening – NO JOKE!

The science behind the device is fairly simple to understand. The Emsculpt uses electromagnetic waves to stimulate the underlying muscle. Think of the TENS unit that is used to improve aches and pains, ON STEROIDS. The contractions are “supramaximal”, meaning more intense than a person can do on their own. During a 30 minute session, the abs/buttocks contract equivalent to a workout of 20,000 crunches/squats. The usual protocol is to have a total of 4 sessions in 2 weeks. Expect some muscle soreness the next day or 2 but there is essentially no downtime. Better yet, there is really no risks either. There are 2 handpieces for each machine. This means that 2 patients can be treated simultaneously on the abdominal area or one patient on the buttocks area.

There were 7 different sites that studied the Emsculpt. Before and after CT scans, MRIs, and Ultrasounds were taken in the study group. Results showed muscle mass increased 16% consistently. What is even more interesting is that the average fat loss was 19% and waist measurements decreased by 4 cm.

Another treatment area is the gluteal area. Using 2 handpieces simultaneously, the buttocks is treated. The settings are adjusted so as to not cause any fat destruction but just muscle hypertrophy. Other areas being treated experimentally by some physicians are the thighs and calves. The pectoralis muscles definitely can’t be treated because they are too close to the heart and the strong electromagnetic waves might stimulate the heart.

There have been anecdotal reports of enhanced athletic performance after Emsculpt treatments. Is this a new legal way to get an edge on the competition?

Contraindications are people who have pacemakers, metal IUDs, metal implants or surgical clips (close to the treated area).

Bottomline, six pack abs and brazilian butt lifts can now be obtained using the noninvasive, risk free, no downtime, Emsculpt.

Call The Aesthetic Clinique for more details, the Emsculpt headquarters of the US.

850.622.1214

How to Minimize Risks of Vascular Occlusion and Blindness During Filler Injections

Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.

There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.

A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.

The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.

In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.

There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.

The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)

Techniques for optimizing safety during dermal filler administration:

Know the major vascular structures and their landmarks
Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
Use cannulas whenever feasible, preferably 25/23g or larger
Avoid boluses, small linear threads are safer
Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
Injection onto periosteum is safest but does not guarantee a vascular free injection
Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
Retrograde injections are safer than anterograde injections
Dermal injections should be relatively safe
Avoid deep injections in the lips. Stay superficial to the muscles
An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
Have on hand 6-8 vials of Hylenex
Any unusual bruising, pain or visual change needs immediate evaluation

The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.

Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.

Deceptive Practices Used in Before and After Photos

“A picture is worth a thousand words”. It’s true, seeing a great before and after speaks volumes for a certain physician’s or practitioner’s abilities. Unfortunately, there are some deceptive practices that can trick the eyes into believing results are better than they are really are. Instagram is a showcase for the aesthetic industry, but there is no oversight as to the claims made on the photos displayed. The bullet points below will help one to develop a critical eye to discern the truth from the “fictional results”.

Lightening must be the same in both pictures. A common misleading practice is to have a dark before picture and a light after picture. In the lighter picture, wrinkles and shadows are going to be less, and fool the observing into thinking these were related to the procedure.
Angle of the neck/head must be the same in both pictures. Take a look at the nose and jaw to see if the head is in the exact same position. If the head is tilted more upward in the after picture, the neck will appear to have less fullness, less wrinkles, and be firmer. This is particularly popular in the Kybella before and after photos.
The expression must be the same in both pictures. If a patients is partially smiling in the before and not in the after, the wrinkles around the mouth and cheek will appear falsely improved.
Sculptra pictures should have at least a 3-6 month interval. Sculptra is always mixed with water or saline for reconstitution. The immediate results after injection reflect merely the effects of the water/saline and not that of Sculptra. The collagen stimulation from Sculptra will take at least 3 months to appreciate, with 6-9 months being even a better gauge of results.
Using company photos or other physician’s photos without noting this or giving the appropriate credit on their websites or posts is also a common practice.
If make-up is used, it must be similar in both photos. Too often the before has none and the after has make-up.

Perfect before and after photos are very challenging. Even when results are extraordinaire, there are often difficulties trying to capture these changes with the camera. However, purposely trying to “enhance” photos with the practices above must be pointed out to the practitioners.

Restylane Refyne and Defyne, New Fillers with Unique Benefits

(Dr. Weiner is one of the most experienced users of Restylane Refyne and Restylane Defyne in the US and has trained multiple physicians on his injection techniques of these new products.)

Restylane Defyne Treatment Radial Cheek Lines – Dr. Steven F Weiner

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Late 2016, two new dermal fillers, Restylane Refyne and Restylane Defyne were FDA approved. Although new to the US, these fillers had approval in Europe in 2010 and in Canada in 2015 under the name Emervel. The announcement flew mostly under the radar and it wasn’t until early 2017 that Galderma officially launched the new fillers. Although these fillers are similar in composition, hyaluronic acid (HA), to many of the other fillers on the market, it is the technology behind them that set them apart from the rest.

Restylane Refyne and Defyne are made with XpresHAn technology which adds flexibility to the fillers – “think honey” – and makes them perfect for treating areas of expression. (Other Restylane fillers are based on NASHA technology, and are particulate in nature – “think sugar”.) Additionally, Refyne/Defyne have high crosslinking that lends to their ability to stretch and recoil. Refyne has less links, so it can stretch more, while Defyne is more tightly bound.

The clinical outcomes of using Refyne and Defyne are unique and directly related to their manufacturing process. With placement in the dermis using small aliquots (a different technique than other fillers) in areas of high muscle movement (expression), the filler will support the skin and soft tissue in unparalleled ways. In fact, muscle strain around the mouth was tested before and after Refyne/Defyne placement and was shown to revert a 55 year old’s profile to one similar to a 30 year old on average. The hyperactivity of the muscles was “constrained” by the filler, just as Botox or Dysport does in the glabella and crows feet. The previously difficult to treat radial cheeks lines (smile lines) can now be improved significantly with the new Restylane Refyne/Defyne fillers. Other fillers used to treat this area are more apparent and obvious due to their lacking the XpresHAn technology, and don’t look as natural with movements. Adding bulk/volume to the lower face is usually not desired because beautiful and youthful faces are V or heart shaped. The unique placement of Refyne/Defyne in the dermis does not add fullness in the lower face during corrections of the marionette lines, prejowl sulcus, and smile lines in Dr. Weiner’s experience.

Cohesiveness is the ability of a filler to “stick to itself” and integrate with the surrounding tissues. Both Refyne and Defyne have a high cohesivity. This equates to more blending of the filler with the tissues, and a more natural appearance. In clinical use, these new fillers can be injected into the mid/deep dermis (a dermal filler actually being injected in the dermis!) and still go unnoticed, without nodules or lumps.

One final highlight of Refyne/Defyne is their low degree of swelling associated with injections. This is beneficial for areas such as lips and tear troughs, where swelling can lead to social downtime, precluding some clients from doing these procedures. When comparing all the HA fillers available in the US, it’s been Dr. Weiner’s experience that Refyne/Defyne have the least amount of swelling.

Restylane Refyne and Defyne open up a new treatment paradigm for the perioral smile lines (radial cheek lines) where previous corrections were usually suboptimal. This area is often overlooked or discouraged, but is a frequent concern for a majority of dermal filler clients. The satisfaction rate with these corrections have been extremely high in Dr. Weiner’s experience. With the additional benefits of high conhesiveness and low swelling, Restylane Refyne and Defyne are a great addition to the filler armamentarium of the advanced injector.

Dr. Steven F. Weiner’s 6 year Experience with Blunt Cannulas for Dermal Fillers

The value of volume replacement in the aging face is now universally recognized as one of the most beneficial procedures to restore youthfulness. The combination of sun exposure, aging, and genetics leads to collagen, fat, muscle, and bone loss. Reinflating the cheeks, lips, and tear troughs are routinely done by physicians across the world on a daily basis. Most of these patients will have a week or more of downtime – swelling, bruising, discomfort – but that doesn’t have to be. Blunt cannulas can minimize most of these side effects associated with filler injections and has become standard practice for Dr. Weiner for the past 6 years.

The benefits of blunt cannlas are:

There is only one insertion point to treat multiple areas. This equates to less intrusions through the skin and therefore a more comfortable procedure.
The tip is rounded and blunted. This very fact accounts for less bruising/swelling. When a blood vessel is encountered with the end of the cannula, the vessel is more likely to be gently displaced rather than punctured.
There is increased safety. A phenomenon termed “vascular occlusion” occurs when a filler is injected into a blood vessel. The filler then blocks the blood flow and can lead to necrosis (death of skin) or even blindness. It is much less likely to occur with blunt cannulas, particularly larger cannulas (23 or 25 guage), because they don’t enter blood vessels as easy as needles do.
Allows treatment in areas otherwise not easily accessible. Due to the safety of the cannulas, there are now areas of the face which are more easily treated. The superficial temporal area, supraorbital, forehead, piriform, periocular and lower eyelid are now routinely treated with cannulas whereas with needles, these areas were very precarious to inject.
Downtime is minimize. As a result of all the benefits listed above, most patients have significantly less healing time and are much happier after receiving their filler treatments with blunt “safety” cannulas.

If blunt cannulas have so much benefits, why are only 5% of the providers using them for dermal fillers? The art of using cannulas is not an easy one. Patience is required because directing the tip to the exact spot it is needed is not always easy. Remember, when the tip encounters an obstruction (vessel, ligament, collagen), it will need to traverse around it and not pierce it (as needles would do). This can be frustrating and lead to longer and less satisfactory results for the inexperienced cannula injector.

Dr. Weiner is one of the leading authorities on cannula injections of dermal fillers and has used them for over 6 years for nearly all of his injections. The cannulas provide a safe, comfortable, minimal downtime technique for volumizing the aging face, even with multiple syringes being used simultaneously.

How to Choose the Best Laser for Tattoo Removal

Tattoo removal is most effectively performed with lasers. The mechanism by which the laser works is by breaking up the larger ink granules into smaller particles. The body is unable to clear the larger particles but when smaller, the immune system is capable of clearing the ink. Successful clearance of a tattoo is dependent on several factors which will be highlighted in the remainder of the blog. While the experience of the physician performing the tattoo removal can’t be ignored, he/she is limited by the laser being used.

There are 3 aspects that need to be considered in a tattoo laser. They are power (and spot size), wavelengths, and pulse durations.

Power

Power is a measure of how much energy can be delivered to the skin. What’s more important is how much is getting to the level of tattoo. It remains obvious, the more power delivered to a tattoo, the better clearance there should be. This is limited by the damage to the skin and surrounding soft tissue. Excessive energy to the superficial skin can lead to blistering, prolonged healing, scarring, and pigmentation changes. High-power lasers are able to use large spot sizes (10-15mm) to deliver the energy to the tattoo. Larger spot sizes give deeper penetration of energy and a safer treatment. Under-powered lasers need smaller spot sizes to get enough energy into the skin to cause an effect on the tattoo. This leads to the superficial skin heating up and potential for blistering/scarring.

depth

When comparing energies between lasers, most companies measure the output from the laser. What is not discussed is how much the energy is diminished while going through the arms, mirrors, and handpiece. This can account for 20-30% less energy at the skin than what is the measured output of the laser in the lab. (The energy measured by the Piqo4 system is to the skin while all other systems is output from laser.)

1064-2

Wavelength

The wavelength of a tattoo laser determines what colors it can treat. The most common color in tattoos is black. The best wavelength for treating black inks is 1064nm. This wavelength also is the safest for darker skin type. Even if the tattoo doesn’t look like it has black ink, over 95% have some component of black ink. It is imperative that the laser chosen for tattoo removal has a 1064 wavelength. The next most common ink is red. This is best treated with a 532 wavelength. Almost always, the 532 and 1064 wavelengths are packaged together in the same laser. It requires a doubling of the frequency to go from 1064 to 532 (double frequency means halving wavelength). The remaining colors require a variety of wavelengths so it is essential to have multiple wavelengths to treat colored tattoos. The lighter the color – pink, yellow, white, light blue – the harder it is to treat.

Pulse Duration

The lasers for tattoo removal are much faster than lasers used for hair removal, photofacials, telangiectasias, and leg veins. Where as the typical pulse duration is measured in milliseconds for the dermal treatments, tattoo lasers are measured in either nanoseconds or picoseconds (1000x – 1,000,000x). These extremely short pulses lead to extremely high energies being placed into the tattoo. This energy leads to a shock wave hitting the ink and breaking it up. The faster the pulse, the higher the energy and the more directed the energy is to the ink and less to the surrounding tissues. The longer the pulse, the more time the energy has to spread to the tissues. In the author’s opinion, initial treatments for tattoos are best performed with nanosecond pulses (to break up the larger ink particles) while the later treatments need picosecond pulses to clear the remaining ink particles which are smaller in size. It is most effective to have a laser with both nano and picosecond capabilities for treating tattoos.

The Best Laser for Tattoo Removal

After understanding the important qualities required in a laser for optimal treatment of a tattoo, it becomes fairly easy to see the obvious best laser. The Piqo4 has the highest energy (to the skin) of all nano/picosecond lasers. As a corollary, it has the largest spot sizes on the market – meaning safer, deeper, and faster treatments. With it’s 4 wavelengths, it has the capabilities to treat the 9 most common colors. It has 4 different pulse durations – 2 and 8 nanosecond and 600 and 800 picosecond. In conclusion, the Piqo4 combines high power, 4 wavelengths, and multiple pulse durations to enable it’s lasers to be the most effective option available on the market.

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