[My Best Laser Series] GreenXel, New MIDAS, MIXEL

As a plastic surgeon, I used to think that laser devices are useful only in dermatology. However, my patients would often ask me to recommend a dermatologist after receiving plastic surgeries for their body contour. Now I endeavor to provide beautiful skin as well as body line to my patients, with more attention to skin lasers. Since my focus is on surgery, I seem to have slightly different criteria for selecting a laser device. I tend to prefer devices that provide immediate effect and strong output, in addition to safety. Of course, the unit price and other charges for consumables are important factors as well. The lasers described below were selected according to these criteria, and I’m still quite satisfied with them.

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GreenXel: treating pigmented or vascular lesion without the need for consumables

GreenXel Laser (HIRONIC) provides long-pulse 532nm wavelength, with focus and fractional handpieces, to treat pigmented or vascular lesion. A rejuvenation effect may also be expected from the long-pulse. The principle of this laser is that 808nm wavelength from the diode source becomes 1064nm by crystal pumping and then 532nm by frequency doubler. The charges for consumables, as well as the effect of a laser, are an important factor among practitioners. As mentioned above, GreenXel uses diode as a medium, which means that it does not require consumables since electrical energy is converted to light energy.

GreenXel

A number of lasers lack 2 things: one is that pigmentation is not treatable by IPL and Q-switched Nd:YAG and that it requires repeated therapies. The other is in regard to the treatment of a vascular lesion. It is my understanding that vascular laser is a low priority among devices to be purchased even by dermatologists. High unit price of the device itself and the cost for dye replacement (about 10 million won a year) make purchasing it too burdensome. GreenXel thankfully satisfies both of these aspects.

GreenXel has many other advantages. For pigmented lesions, it provides potent therapeutic effect with just single procedure for dark epidermal lesions. Chloasmata had been treated with Q-switched Nd:YAG alone, but since combining it with GreenXel, patients have been expressing better satisfaction then for monotherapy. Recurrent chloasmata had been difficult to treat without vascular treatment, but when vascular treatment was followed by the procedure for chloasmata, the recurrence rate was markedly decreased, although complete recovery is still hard to achieve. High unit price of GreenXel also gives slightly more financial burden to patients.

For vascular lesions, both types of handpieces are used, mainly for redness from acnes and telangiectasia. Among the two types of handpieces, fractional one is mostly used when applying even energy across a broad area. The area of beam irradiation can be controlled, but I use it by safely controlling the fluence and the number of beams not the area, such as increasing the fluence while reducing the number of beams or increasing the number of beams while reducing the fluence. I also prefer to use slightly higher fluence than the parameter offered by the manufacture, which tend to be weak considering safety issue.

Focus handpiece is used when applying more elaborate treatment in parts. There are 3 modes including pulsed mode, but pulsed mode is used in most cases. The number of irradiated beams, pulse duration and delay time can be modified, depending on the darkness and depth of a lesion, for safe and effective treatment.

Since most lesions of redness from acnes are widely distributed, fractional handpiece is used first, followed by focus handpiece for more intensive treatment. During the latter, the duration of treatment can be shortened by irradiating multiple beams and by reducing off time. Unlike other existing therapies, long pulse protects from bruise and allows the control of erythema or edema that may develop after the procedure, giving less interruption to the patient’s daily life.

GreenXel is satisfactory to patients with telangiectasia since it can provide an immediate effect by instantaneous coagulation upon irradiation. The effect can be enhanced when the fluence is slightly increased at the start and end of the procedure. As anyone knows, overlap should be avoided and post-procedural cooling is most important.

New MIDAS: face lifting and body shaping simultaneously without pain

Radio frequency (RF) energy has been used for medical purposes for about 70 years now. One of representative is Vovie, which is used for various procedures. RF energy has developed to protect the epidermis while delivering energy selectively to deep dermis or subdermal layer. Despite deep energy penetration using high frequency, previous RF devices were limited by strong pain and high prices of consumables.

New MIDAS

New MIDAS (HIRONIC) was designed to overcome various limitations of light and RF devices and enables simultaneous irradiation of strong contact cooling, large output of infrared (IR) and RF energy, heating the dermis and stimulating collagen regeneration. One of the most remarkable aspects of New MIDAS is the strong cooling effect. Larger energy output for superior therapeutic effect accompanies more pain and side effects, such as burns. To overcome such issues, New MIDAS is equipped with strong contact cooling to as low as -5℃ for painless treatment.

New MIDAS uses two handpieces, bipolar and monopolar. The bipolar handpiece irradiates both RF energy and infrared simultaneously and is used primarily for wrinkles, elasticity, pores and lifting. The strong cooling enables painless, comfortable treatment, 2Hz shot speed shortens overall procedure time on face by 15-20 minutes, and the procedure is very simple. Monopolar handpiece provides continuous irradiation of energy with a 45-㎜ spherical probe and is used for lipolysis around the body. This body shaping function does not cause pain, bruising or hemorrhage, and the tip size and further enhanced power as well as the variability of frequency (0.5-10Mhz) is useful when delivering proper energy depending on the area of procedure; such a focused energy delivery to the target area allows superior effect. The monopolar handpiece actually provides relatively satisfactory results immediately after liposuction by lipolysis of remaining fats and by inducing collagen activity inside the dermis to enhance elasticity of sagging skin. Such a painless heating of the dermis lifts the skin immediately after the procedure by collagen contraction, a previous step of collagen regeneration, occasionally making patients amazed. From what I’ve seen from prognoses of quite many patients after the procedure (although very subjective, of course), the effect seems quite positive. Some patients even snored during the procedure, showing how comfortable the procedure is. Furthermore, patients with nasolabial folds due to saggy cheeks, double chin and neck wrinkles may benefit from bipolar procedure followed by as short as 5-10 minutes of monopolar face mode, even more supporting its positivity.

Moreover, New MIDAS does not require additional consumables and can be applied for body shaping as well as face lifting. The possibility of utilizing it for obesity treatment is also helpful in terms of business management. Above all, considering the advantages such as no interruption of daily life and painless procedure, New MIDAS is a very effective device highly recommendable for office workers or women who are particularly sensitive to pain.

MIXEL: ease of use and high beam quality

MIXEL (HIRONIC) is a CO₂ fractional laser. Fraxel repair is being used in one of the two clinics that I run. When opening another branch, I invested so much effort when selecting a fractional laser. In conclusion, it was an excellent choice. Despite my initial thoughts that domestic devices would still have lower quality than world renowned devices, the recent purchase totally changed my prejudice on Korean devices. One of the reasons is in the quality of the beam. MIXEL produces a very small beam despite using CO₂ as a medium. By using a metal tube and lens, post-procedural crust is also very different from that of Korean devices in the past. Tube itself is made in the USA.

Second reason is in overlap function, which enables 10 repeated irradiations on one spot. I haven’t used up to 10 but only up to 3 for patients with severe acne scars. This overlap function seems to overcome the limitation of not very deep penetration due to the nature of CO₂, compared to Er:Glass. CO₂ fractional laser with overlap function would be particularly appropriate for acne scars or burn scars.

MIXEL

The third reason is in the ease of use. As a frequent user of laser, the ease of use is not something to be ignored. MIXEL is well designed in this aspect as well. Easy configuration of frequently used menus and memory function are often overlooked in many devices, but MIXEL automatically calculates the number of dots and treatment area once the power, density, repetition rate, area and pattern are set up in one screen. Several lasers make operators excited even before starting a procedure. What makes such a mood for operators is patient outcome after the procedure and comfort during the procedure. In this sense, MIXEL is a laser which makes procedures a pleasant experience.

[My Best Laser Series] Vbeam, Profile, GentleLase

Vbeam: gold standard of vascular therapies.

Vbeam is a pulsed dye laser, manufactured by Candela, the company which produced the first dye laser system, and is considered as the gold standard for the treatment of vascular lesions. It was initially recognized only for the treatment of vascular diseases, such as nevus flammeus, but it has been distributed worldwide with an excellent effect for aesthetic treatments, including telangiectasis, facial flushing, acne and red marks. I also have used Vbeam for various diseases from vascular to aesthetic diseases since introducing the device. It is particularly useful for the removing redness from acne.

Vbeam may sometimes damage a blood vessel and leave a bruise when a strong energy was applied; however, if the target vascular lesion is treated, the bruise disappears within 2 weeks on average. One might consider increasing the energy fluence for a better effect. In this case, the pulse duration may be increased for a thick blood vessel and decreased for a thin blood vessel, considering TRT time of blood vessels, for a better therapeutic effect.

Vbeam

High mechanical stability and proven therapeutic effect are advantages of Vbeam. It has been in use for almost 10 years now since the introduction, but it has seldom caused a problem and becomes as good as new only by replacing the consumables called Dye PM kit. The high price of this kit can be considered as a disadvantage of Vbeam; however, I don’t consider it as a cause for dissatisfaction, because greater cost of consumables also means as much greater number of dye laser procedures.

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Profile(JOULE): safe and effective procedure for pore tightening and hair removal with contact cooling system

Profile, manufactured by SCITON, is a laser combined both Er:YAG and Nd:YAG in one device and was an innovative machine at the time of purchase. Now an upgrade version named ‘JOULE’ has been released combining Er:YAG, fractional, Nd:YAG, IPL and laser assisted lipolysis in one device.

Profile was first purchased because it can resolve both scar treatment with Er:YAG and pore and skin tightening with Nd:YAG from one device. SCITON is a company which takes a pride in being the world best producer of Er:YAG laser. The initial model, Profile, was equipped with an unique tunable resurfacing laser (TRL) and a computer scanner. The Nd:YAG scanner had contact cooling system for safe and effective pore tightening and hair removal; the cooling system is still utilized a lot. Margin cutting is essential for effective treatment of an already developed scar.

The Er:YAG laser of Profile is appropriate for reducing artifacts by allowing fine setting for effective removal of a scar margin. However, fractional laser is more effective for stimulating collagen remodeling and skin restoration of a depressed region and for reduced recovery period after the procedure, which is why ProFractional-XC has been released recently for effective scar treatment. ProFractional-XC irradiates Er:YAG laser of strong peak power by time reiteration and allows tissue ablation of up to 1500um. It is mainly used for serious scars, including icepick or boxcar scars. Coagulation can be added by 3 stages; I use stage 1 (50um) for contraction of a micro spot zone punctured by a fractional beam.

Profile(JOULE)

The advantage of this device is the possibility of individualized procedure. For a scar treatment, a combination of ProFractional-XC and TRL skin resurfacing, according to the patient’s time, financial status and severity of the scar, would result in a good outcome. The disadvantage of this device is the risk of pigmentation and erythema, which is a common problem of all fractional lasers. The duration and likelihood of such an event may be reduced by lowering the depth of penetration.

GentleLase: effective for pigmentation and pore treatments as well as for the original indication, hair removal

GentleLase, manufactured by Candela, is a long-pulsed Alexandrite laser and was introduced as a laser for hair removal. I introduced this device for the treatment of pigmented lesions, based on the expectation that pigmentation diseases, including freckles and chloasmata, would be treated by another theory other than Q-switched Nd:YAG technique. The result was as expected; the melanosomes in the epidermal layer was eliminated in the form of microcrust. In this case, the risk of pigmentation or depigmentosus nevus is low, and widely distributed pigmentation areas can be treated easily because the applied spot size is large. Irradiation site response may be delayed by 1-2 minutes than the existing Qs-Nd:YAG lasers; therefore, care should be taken so as not to stack in another laser.

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GentleLase

Another indication of GentleLase is pore tightening. Laser energy from GentleLase applied to the hair inside a pore gives general contraction effect, which is considerably effective for the treatment. Furthermore, the Alexandrite wavelength can penetrate into the upper dermis, which is quite helpful for stimulating collagen remodeling and general pore tightening. GentleLase is also known to be effective for relatively thicker blood vessels that are not appropriate for Vbeam.

Lastly, as for the original indication of GentleLase, hair removal can be performed without much burden on duration of the procedure, one of the reasons for avoiding hair removal in the past, when 18mm spot size is combined with DCD cooling and 2Hz.