IPL Systems: Review and Analysis

The IPL Dog and Lemon Guide: Review and Analysis

 
Download the IPL Guide here

The Dog and Lemon is an IPL Guide which helps us decide which IPL System is best for our practices. You can get this guide from the internet or from Sciton. I suggest you get it and read it. This guide strongly suggests that Sciton is the best IPL System. Is this because Sciton is really the best or is this guide is biased towards Sciton. Those who would try to discredit this guide claim that it was done by Sciton and is biased. In this review and analysis, we will examine the points made by this report, understand why they are important and then try to assess whether it is biased or whether it correctly identifies the best IPL system.

I have no financial interest or other interest in the companies in this report. I am considering buying an IPL for my practice and this is why I started to look into IPLs. I own Reliant, Lumenis, Cutera and ConBio. I have been a full-time cosmetic physician with a busy cosmetic practice. This review and analysis is my opinion and is based from extensive reading and research. - CHMD

The Dog and Lemon Report suggests that the Sciton is the best IPL for many reasons. Let’s examine these reasons. I am hoping that other cosmetic physicians and company representatives will comment on the report and comment on my review and analysis. This review and analysis is meant to stimulate a lively debate and discussion of IPLs.

The report was done “to provide you, the cosmetic clinician practical, unbiased, objective information that empowers you to purchase equipment that best serves the interests of your patients and business alike”. There is a huge void in this type of information in the cosmetic dermatology field. There is so much hype and misinformation when it comes to lasers and light devices that it is difficult to find the best technology and the best companies when we want to purchase a piece of capital equipment for our clinics. We need a “Consumer’s Report for Cosmetic Medicine” - hopefully Paul Kadar and The Cosmetic Dog & Lemon Guides are it. Making the wrong decision when buying a laser or light device can be devastating. This is outlined on page 4 of the guide. The name of the game is excellent clinical outcomes and happy patients. In order to achieve this you have to have an IPL that will enable you to get excellent clinical results in all skin types. This type of guide - “The IPL Dog & Lemon Guide”, if unbiased and objective can help us all. Hopefully the laser companies are paying attention to this guide because it makes a lot of great points and it make intuitive sense.

Uniform Delivery of light energy to the target tissue: Perimeter Loss, Photon Recycling and Twin Flash Lamps.

Pages 7-9: These pages discuss how light intensity decays with increased distance from the light source. This means that the intensity of the light at the perimeter of the head is less than the intensity of the light at the center of the head. This loss is proportional to the square of the distance from the source, “if light that has traveled 10 mm produces a fluence of 20 m/cm2, that same light will produce a fluence of 5 j/cm2 if it has to travel another 10 mm (i.e. a doubling of the distance produces a quarter of the fluence).

The two main ways to overcome Perimeter Loss are Photon Recycling and Twin Flash Lamps. We won’t discuss “small surface area of treatment head” here because this is technique is counterproductive for many other reasons (speed of treatments, depth of light penetration, life of flash lamps) and we won’t discuss “long light guide” (“a crystal that is too long will loose some of the light through the walls and hence the fluence delivered at the treatment area may be sub-therapeutic” -I will assume that crystals are not used for this reason and this assertion is correct).

Photon Recycling:

“Photon Recycling is nothing but a marketing gimmick deceitfully used to entrap unwitting clinicians . . . It doesn’t take a rocket scientist to figure out that by the time this light is reflected from the skin into the treatment head and then back again, its fluence will have all but petered out.” This is a very strong statement but the physics make sense to me. It seems to me that the recycled light will have very little energy left once it is “recycled”. I am not convinced that “photon recycling” has any beneficial clinical effect.

Palomar uses photon recycling and tries to convince you that it works by showing you a slide to demonstrate that it works. This is the slide: there is an area of skin treated by IPL #1 without photon recycling and an area of skin treated by IPL#2 with photon recycling. The area of the skin that does not look treated was treated with an IPL that does not have photon recycling. The area of the skin that looks great was treated with a different IPL with photon recycling. We are expected to believe that the difference in the results is due to the photon recycling and not due to the difference in the IPL devices.

Based on my knowledge of physics and the fact that the intensity of light decreases by the square of the distance traveled, I think that photon recycling probably does not have a clinically significant effect on treatments. Palomar’s attempt to prove it works was critically flawed. I look forward to someone from Palomar explaining and proving that photon recycling can and will work in a clinically significant manner.

Twin Flash Lamps:

“Currently, an effective way of producing a uniform fluence across the entire face of the treatment head while maintaining a relatively large treatment area is through the use of two flash lamps in an over-under or figure “8” configuration”. The first flash lamp transmits light with the usual perimeter loss. “However, the second flash lamp fires in “the shadow” of the first and consequently transmits light in a polar opposite manner to the first”.

This gets a little fuzzy here, I am not sure I fully understand the duel flash lamp reasoning. If the second flash lamp is further away from the head than the first flash lamp, it has to transmit light at a higher initial intensity in order for the intensity of the light to be the same at the perimeter of the head. Does it do this? Is the intensity of the light really more uniform than a single flash lamp? I look forward to someone from Sciton helping me here. This will require diagrams and drawings, so please provide them on a website we can link to. If you send them to me, I will post them on my geocities website.

“Of the 8 top selling IPLs reviewed, 6 employ a single flash lamp. The only two models utilizing twin flash lamps are Sciton BBL and CyDen iPulse i300. However, only the Sciton BBL has the essential over-under (figure “8”) twin flash lamp configuration”.

Range of Wavelengths:

“Not all IPLs deliver the full spectrum of therapeutic wavelengths. Naturally, you’ll enjoy greater returns on your investment the more treatments you can deliver.”

This is how I see the wavelengths and the condition they treat (by looking at the Absorption Curves of Melanin, Hemoglobin and ALA (Levulan) and by reading the manufacture’s literature:

  420 nm: acne
  500 nm: pigment
  510 nm: pigment
  515 nm: pigment
  520 nm: vascular and pigment
  525 nm: light, fine hair (Palomar)
  560 nm: vascular and pigment
  590 nm: pigment in skin types 4 and 5
  615 nm: larger facial veins (Lumenis)
  640 nm: superficial leg veins (Lumenis)
  650 nm: Hair Removal (Palomar)
  695 nm: thicker vascular lesions (angiomas, hemangiomas), superficial leg veins, Hair removal light skin
  755 nm: thicker vascular lesions (angiomas, hemangiomas), superficial leg veins, hair removal darker skin

Please go to www.geocities.com/DogLemonIPL to see the Absorption Curves. Note where the absorption is high for melanin and high for hemoglobin. On the ALA Absorption Curve, note where absorption is high.

Palomar does not have a head for the 590 nm wavelength area. This is a very big deficiency in my opinion. You need this wavelength to treat skin types IV and V for pigmentation, hyperpigmentation and PIH (postinflammatory hyperpigmentation). Without this wavelength you cannot treat East Asians (Japan, China, Korea), South Asians (India, Middle East), Mediterranean (Italian, Greek) and Latin (South & Central America). In my practice, a large portion of my patients are “patients of color”.

The IPL Dog and Lemon Guide also talks about Fundamental Requirements of an IPL, Critical Factors for Producing Predictably Excellent Clinical Results, Head Size, Variable Temperature Control, Pulse Widths, Fluences, Clinical Training, Clinical Exchange Programs, Square Wave Deliver (this is very interesting and sounds very important. It makes intuitive sense to me), Sapphire vs. Quartz Crystals, Ongoing Education and Support, Adverse Reaction Plan, Optimizing Return of Investment, Portability, Marketing Support, Technical Support, Consumables, Profitability Analysis, Multi-Platform Options and System Summaries.

These issues are all summarized very well and will prompt you to think about these issues and ask these questions of your sales representative. I would encourage you to get and read The IPL Dog & Lemon Guide to review these issues.

Working with many Laser Companies, one of my big problems with most of these companies is their Continuing Education. their Clinical Exchange Programs, their On-Call Clinical Support and their Formal Ongoing Education.

The correlation between clinical competence and clinical outcomes should be obvious . . . Just as comprehensive initial training gives rise to predictably excellent clinical outcomes, the ability to exchange ideas and experiences with other IPL operators dramatically magnifies your clinical competence . . . a worthwhile clinical exchange program should utilize one or more of the following media: online forums, Teleseminars, Webinars and live phone support . . . any IPL that’s purchased with access to an established clinical exchange program can only benefit you and your patients . . . as the field of IPL therapy advances, all new clinically relevant finding and advanced techniques should be made readily available to you via a continuing education program. This may take the form of newsletter, website, DVD/Video and/or live workshops.

All companies have to do a much better job helping us learn the latest advancements and facilitating communication between providers so best practices can be communicated and propagated. Continuing education efforts must be made easily available, inexpensive, and convenient. For example, providers learn by different methods and they prefer to access information differently. Information should be made available in multiple formats so the greatest number of providers can access this information. Material should be presented in written format, by audio cassettes & DVDs, via the internet (Webinars) and live presentations. Once the material is presented in these varied formats, interaction and discussion should be encouraged and facilitated via conference calls, internet bulletin boards and blogs. Clinical experts and industry luminaries should be available to participate on these bulletin boards and blogs.

The IPL Dog & Lemon Guide must be updated. The information about Palomar is not current. They have a StarLux 500 which is very different than the reviewed Medilux. Hopefully Palomar can update some of the missing information and tell us how the StarLux 500 overcomes some of the objections raised by this report. Hopefully the other companies can provide updated information.

These are the questions that I have after reading The IPL Dog & Lemon Guide. Who is Paul Kadar? What are his qualifications? Does he have any conflicts? When was the report written? Is “Photon Recycling” clinically important or is it a marketing ploy? Do “Twin Flash Lamps” in a figure “8” configuration overcome “Perimeter Loss” and how does this work (in detail)? How big are the light sources (lamps) in the heads and how far are they from the edges of the heads? How important is “Variable Temperature Control” & “Integrated Cooling”? Can you truly use less fluence with equal or better clinical results with twin flash lamps and “square wave delivery”? What are the best wavelengths and algorisms for treating Rosacea and Pigmentation in “patients of color”? Is IPL Hair Removal as good as Hair Removal with the 810 nm Diode or the 770 nm Alexandrite? Is IPL treatment of Rosacea and Veins as good as vascular treatments with the 532 nm KTP Laser, the 595 Pulsed Dye Laser and/or the 1064 Nd:YAG Laser? Is the Sapphire Crystal really better than the Quartz Crystal?

I hope this summary and analysis of The IPL Dog and Lemon Guide is helpful. I hope it helps you find the best IPL for your practice and I hope it helps generate questions which we all can answer by participating on the resulting blog. I also hope that this summary, analysis and report will stimulate the IPL companies to provide better IPL devices and provide better continuing education and support.

My opinion of The Dog and Lemon Guide is that it is a great start and a great tool to start to understand IPLs. For those companies that did not fair well, you should tell us why the Guide is wrong or you should make your devices and your support better. I would not assume that Paul Kadar is biased. I am going to assume that he wrote a genuine guide to help us all. Read his introduction on page 4. He hits many issues right on the head! I hope he writes more guides. His guide is well written and thorough and makes sense. What he says “rings true” to me.

So let’s start the discussion!!! We should have a very lively debate. Please convince me to buy the device you have or you sell. If you have the device or sell the device, please identify yourself as a user or seller EACH time you comment.

Medical Spa Classified Ads: IPLs, lasers & spa stuff.

New classified section for cosmetic medical & spa equipment.

 
Here's the new classified section for Medical Spa MD: Medical Spa Equipment

Here's where you can add a new listing.

If you've got something you're trying to move, now you've got the place to do it. There are currently four listing areas: IPLs, Lasers, Medical Equipment, and Spa Equipment. I'll add others if needed.

If  you've got something listed elsewhere or on consignment, I'd encourage you to list it here as well. Medical Spa MD has more than 18,000 unique monthly visitors and a large contingent of physicians. Better yet, the listings are free and there's no 'percentage of sale' so you've got no complaints there. The site is up and fully functional although there will be improvements as we go along.

I'm anxious to find out if this is a need that many have. Another middle-man gone.

Note: The classifieds will also be monitored and spam or solicitations will be removed. Equipment only for now. 

IPL Reviews & Comparisons: Download the Dog & Lemon Guide PDF.

There's always mucho demand for reviews and comparisons between IPL and laser technologies and companies.

Download the IPL Dog & Lemon Guide PDF

Ican't vouch myself for any of the info or reviews. Midwest sent me the link to his report so she's responsible for cudos or blame.

The link at the end points to a spam farm of text ad links which is somewhat unpromising but I'll leave that for you to judge. Certainly the report is well written and at 41 pages is much longer than the usual reviews.

I'd welcome comments on the report, or the voracity of the author if anyone knows. 

Portrait Plasma Skin Regeneration: The power of high powered wrinkle gas.

Rhytec's Portrait plasma skin regeneration: A cool little jet engine for wrinkles.
 

Is anyone using Rhytec's Portrait Plasma? I've heard a few docs comment on it but haven't seen it in action yet. Watch an animation of plasma in action or some patient and physician testimonials.

From somewhere on a Rhytec press release:

Plasma may be the next weapon of choice in the anti-aging arsenal. Rather than relying on chemicals, lasers, light, or injections, the Portrait Plasma Skin Regeneration system employs plasma, a highly energized gas. The gas penetrates below the skin's surface, extending into the dermis without any direct contact, charring, or vaporization.

Unlike other treatments that ablate the skin, the controlled heating of tissue below the skin's surface from Portrait, which is FDA-cleared for treatment of wrinkles, superficial skin lesions, and actinic keratosis, leaves the skin surface intact during the healing process.

"By allowing the preserved outer layers of skin to act as a protective dressing until new skin regenerates, it produces much faster healing and minimizes the risk of complications," says Richard E. Fitzpatrick, M.D., an associate clinical professor of dermatology at the University of California–San Diego School of Medicine and one of the clinical investigators of Portrait.

In taking a look at the Portrait site I find myself somewhat unimpressed. The site itself is cumbersome to use and poorly architected. I'd have chosen a different beauty shot to build my imaging around as well. The model seems to have skin stretched so tight that her ears are almost meeting behind her head and such an odd expression that I couldn't exactly call it aspirational. 

However, I'm open to hearing if anyone's had experience, good or bad, with plasma. If the comments are resoundingly positive, maybe I'll buy one to toast marshmellows.

Some of the abstracts from the Rhytec site:

Evaluation of Plasma Skin Regeneration Technology in Low-Energy Full-Face Rejuvenation Bogle M, Arnt K, Dover J, Archives of Dermatology; February 2007

Portait PSR3 Technology Provides True Skin Regeneration Kronemyer B. European Aesthetic Buyers Guide; Spring 2006

Plasma Energy Harnessed for Damaged, Aging Skin Skin & Allergy News Supplement; Spring 2006

Plasma Skin Resurfacing for Rejuvenation of the Neck, Chest and Hands: Investigation of a Novel Device Alster T, Tanzi E. Presented at ASLMS Meeting, Boston, April 2006

Effectiveness of Multiple Treatment, Low Fluence Technique with Plasma Skin Resurfacing for Facial Rejuvenation Bogle M, Arndt K, Dover J. Presented at ASLMS Meeting, Boston, April 2006

Dermatologist Study: IPL anti-aging, the patients perception.

Physicians love a long tite: Intense pulsed light technology and its improvement on skin aging from the patients perspective using photorejuvenation parameters.
Daniel Laury, MD - Read the entire study here.

From the study:Importantly, all patients showed improvement based on their calculation of perceived age. That indicates that there was no perceived worsening of aging signs and no perceived regression of improvements over the study period. Though using subjective data, bias in computing the improvements noted in this population is part of the endpoint.

Other studies have evaluated the outcomes after IPL treatments. Negishi et al. found a combined (physician and patient subjective improvement evaluation) 60% improvement in their evaluation parameters in more than 80% of Asian patients undergoing a similar five or more IPL treatments. In another study also involving an Asian population and also using a combined score, his team found a rating of "good" to "excellent" in 90% for pigmentation, 83% for telangiectasia and 65% for skin texture. Similarly, Kawada et al. found that 48% of patients had more than 50% of improvement and 20% had more than 75% improvement. Goldberg and Samady used a patient satisfaction score as well as including an evaluator assessment component in their study comparing intense pulsed light and Nd:YAG laser on facial rhytids. Several other authors have also demonstrated improvements. Histology studies with and without a monitoring of clinical impression have demonstrated changes in another fashion. However, histological information is difficult for patients to understand and often does not translate into clinically visible changes. Therefore, the specific answer to the question, "How much younger will this make me look?" is hard to answer from these other studies.

This preliminary study has a number of limitations some of which have been previously noted, e.g. small population size, subjective bias. Though the study was prospective, no placebo or blinds were in place. In addition, a larger study might take into consideration the operator differences in performing the procedures and the possible effect of the anesthetic gel. The Negishi studies bring into question the differences between results and ethic origin. The population in this study was exclusively Caucasian. Additional consideration may be given as to whether three weeks is the optimal interval for treatments and whether strict adherence is important. Another time interval may give different results. It would be interesting to identify if there is any regression over time as well. A repeat questionnaire at a later date would be instructive.

Generally the intense pulsed light technology is safe as evidenced by the literature and the author's personal experience, though it still has potential for malfeasance.

On average, patients considering IPL photorejuvenation therapy may be told that there is a 2 year perceived facial age improvement per visit. The informed consent process requires a discussion about the anticipated benefit to treatment. Incorporating the above information may be useful in counselling patients regarding this esthetic procedure.

Read the entire study here.

IPL & Lasers Absorption rates: Melanin, hemoglobin, & water

IPL & Lasers: Absorption rates: Target wavelengths for melanin, hemoglobin, & water

Cutera Xeo ND Yag For Leg Veins

I have to say I've been unimpressed with Cutera Xeo and its ND Yag laser for vein treatments.

Previous post: Cutera Xeo. Does it work?

We took possession of one of these Xeos about two months ago and have since treated a couple of patients, including some of our physicians and staff so that we could keep close tabs on both how well we thought it works as a treatment, the efficacy, time, etc. I have to say that we're somewhat unimpressed. My staff of physicians are really down on it, having used is on their own leg veins and seeing either such light results as to be nothing, or actually an increase in the visibility of the veins, which is exactly what we didn't want.

Another problem was found where, after a Yag treatment, one of my staff was injected with Sclerotherapy and had a previously unseen  and unwanted reaction in which the vein blanched black, something none of my physicians had ever seen before. One of our physicians was a big proponent of this Cutera, but as I said, we've so far been less than impressed. I would like to hear if anybody else has better results.

Laser treatment for veins, of course, are becoming increasingly popular and, to be honest, they're more profitable since they seem to be worth more to the patient and hence, you can charge more. At one of the seminars or symposiums I came away with the feeling that great reactions from a treatment with  lasers hovers around 5%, which I find abysmal.

Anybody with views, I'm happy to hear them because that's about a $130,000 piece of equipment and I would like to be able to get some use out of it rather than getting rid of it. I have to get multiple physicians to agree on it however.

Palomars Medilux, Starlux, & Estelux

The Palomar Starlux is being sold in droves and has created a heavy secondary market for their Medilux and Estelux platforms.

 
The Starlux has a significant power increase over the Medilux and the ability to add any head they want. Supposedly, the Fractal heads from Palamar (or the Fractal rip off head) should be available soon.

For many treatments, however, the Medilux or the Estelux have enough power. In fact, you might now want to have all the power that the Starlux has because you have to be a little bit careful, depending upon the heads you're using.

An interesting note is that the Estelux head works perfectly well on the Medilux, except that the plastic part around the connection is a different configuration. I have seen Estelux heads configured so that they run on perfectly Medilux devices, making the cost per head dramatically lower. I wouldn't be surprised if somebody actually turns this into a business.

Does anyone know where Estelux heads can be configured to run on a Medilux?

Where To Buy Your Medical Spa Technology.

Medispa technologies aren't cheap.

I spoke today with a doctor that called to pimp me for my thoughts on whether she was getting a good deal on the platform she was interested in buying. She was looking at buying the Cutera Xeo platform from the company and had been quoted a price of around $157k. I put her on the track of a barely used Xeo that I knew she could get for at least $50k cheaper. (This should not be taken as an endorsement of Cutera. I just happen to have some info on that device.)

Click to read more ...

Is Cutera finally starting to roll?

Cutera, Inc., a leading provider of laser and other light-based aesthetic systems for practitioners worldwide, reported financial results for the fourth quarter and year ended December 31, 2005. Key financial highlights are as follows:

Fourth quarter 2005, compared with the same quarter in 2004:

-- Revenue increased by 49% from $16.1 million to $24.0 million

-- Operating margins improved from 17% to 29%

-- Earnings per diluted share climbed from $0.16 to $0.41

-- Cash generated by operations improved from $3.9 million to $7.6 million

Full year 2005, compared with full year 2004:

-- Revenue increased by 44% from $52.6 million to $75.6 million

-- Operating margins improved from 10% to 22%

-- Earnings per diluted share climbed from $0.31 to $1.00

-- Cash generated by operations more than doubled, from $9.2 million to $20.4 million

-- Cash and marketable investments increased by $25.7 million from $66.3 to $92.0 million.

"These impressive results are attributable to the positive reception that our products have been receiving in the marketplace and to the expansion of our sales force," said Kevin Connors, President and Chief Executive Officer. "In 2005, we experienced significant financial leverage in our business model. We increased gross margins and decreased each of our operating expenses, as a percent of revenue.

"We remain committed to aggressively investing in our business to exploit the growth opportunities in this robust market. Specifically, we are focused on the following key initiatives, which are yielding measurable returns as proven by our results in 2005: (i) worldwide sales force expansion -- we ended 2005 with 47 direct sales territories in North America, up from 32 territories at the end of 2004; (ii) new aesthetic solutions and product introductions; and, (iii) marketing to the broad and expanding market of physicians outside of the traditional dermatology and plastic surgery physician specialties, including the emerging medi-spa market. That market is comprised of physicians who offer aesthetic treatments in a spa environment."

Revenue highlights for the full year 2005, compared with the full year 2004, are as follows:

-- U.S. and international revenue increased by 57% and 19%, respectively.

-- Product revenue grew by 46%, primarily due to our premium multi-application Xeo product and the newly introduced Solera platform products.

-- Service revenue increased by 60%, primarily due to the sales of post-warranty service contracts to an increasing number of customers.

-- Revenue from Titan refills- an annuity business line introduced in late 2004 -- contributed $1.8 million in 2005.

Mr. Connors concluded, "We are very pleased with the results of our key initiatives. Our strong financial position, together with the fast-paced growth of our company, strategically position Cutera as a leading global provider of light-based aesthetic systems."