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Welcome Emma Registered nurse Certified IPL laser therapy trainer Certified lumislim and laser lipolysis trainer Practising Nurse for more than 13 years.

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Presentation on theme: "Welcome Emma Registered nurse Certified IPL laser therapy trainer Certified lumislim and laser lipolysis trainer Practising Nurse for more than 13 years."— Presentation transcript:

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2 Welcome Emma Registered nurse Certified IPL laser therapy trainer Certified lumislim and laser lipolysis trainer Practising Nurse for more than 13 years Providing Corporate Services for 6 years Qualified Nurse Educator Qualified Occupational Trainer Member of BMLA & WALT & BACN (British Medical Laser assoc. & World assoc. for Laser Therapy, British Assoc Cosmetic Nurses) Harley Street London

3 Teaching timetable An introduction to Laser, Intense Pulsed Light (IPL), Radio Frequency (RF) & E-Light therapies Anatomy and physiology IPL applications Hazard reduction "Core of Knowledge" & legislation issues Getting to know your machine Treatment regimes and practical teaching and scenarios Assessment and feedback Harley Street London

4 Course Objectives Gain a clear understanding of the science behind Light therapy; Learn how to provide treatments using IPL and RF machines; Gain the confidence to provide effective treatments to clients; Increase practical skills base and give you the tools to develop your own documentation; Gain understanding into the responsibilities of the technician; Give you the "core of knowledge" you require to be a safe practitioner & in order to comply with MHRA guidelines. Harley Street London

5 What you take away Your IPL machine unless you already have it.
Your own copy of the training materials. Copies of template forms and client guidance materials to get you started. A certificate to prove that you are a “Certified IPL machine technician” “Certificate of core of knowledge” model specific Harley Street London

6 Teaching timetable An introduction to Laser, Intense Pulsed Light (IPL), Radio Frequency (RF) & E-Light therapies Anatomy and physiology IPL applications Hazard reduction "Core of Knowledge" & legislation issues Getting to know your machine Treatment regimes and practical teaching and scenarios Assessment and feedback Harley Street London

7 Light is electromagnetic wave
Ultraviolet (UV) and infrared (IR) lights are invisible to human eyes. Harley Street London

8 Applications of ultra-violet light
Forensics: Crime scene investigations, hand washing monitoring; Industrial uses: Ensuring pipes sealed, metallic coating testing; Security: Think of bank note checking; CD/DVD players use UV light in order to read data from the discs; Disinfection: Certain concentrations can destroy bacteria; Laser eye surgery; Large doses of UV can damage the retina in your eyes; Large doses of UV cause sunburn and even skin cancer. Harley Street London

9 Applications of infra-red light
Generally thought of as heat as usually given off by hot objects Applications Thermal imaging Wireless remote controls Night vision Harley Street London

10 Medical applications of IR light
Soft tissue lasers in surgery (designed to vaporize tissues, λ=2940 nm) Cauterising/haemostasis (stopping bleeding in surgery, λ=810 nm) Hard tissue lasers (used on bones and teeth in dentistry, λ=2780 nm) Harley Street London

11 What is laser ? Laser = Light Amplification by Stimulated Emission of Radiation laser [ˈleɪzə] n 1. (Physics / General Physics) a source of high-intensity optical, infrared, or ultraviolet radiation produced as a result of stimulated emission maintained within a solid, liquid, or gaseous medium. The photons involved in the emission process all have the same energy and phase so that the laser beam is monochromatic and coherent, allowing it to be brought to a fine focus A laser is an optical oscillator, which is made out of a solid, liquid or gas with mirrors at both ends. At each end of the cavity, there is a mirror. One mirror is totally reflective, allowing none of the energy to pass through; the other mirror is partially reflective, allowing approximately 5 percent of the energy to pass through. Energy is introduced into the cavity from an external source ( light or electricity); this is called pumping. The pumping excites the electrons in the atoms, causing them to jump to higher orbits, creating a "population inversion." A few of the electrons drop back to lower energy levels spontaneously, releasing a photon (quantum of light/light cell). The photons stimulate other excited electrons to emit more photons with the same energy and thus the same wavelength as the original. The light waves build in strength as they pass through the laser medium, and the mirrors at both ends keep reflecting the light back and forth creating a chain reaction and causing the laser to "lase.“ The source of the laser light can be: Gas: Carbon Dioxide ( far infra-red region) Wavelength of 10,640nm The CO2 laser has been used to perform soft tissue surgery for almost 30 years Erbium 2940nm Penetration in skin is minimal as it is highly absorbed by water. This vaporizes tissue as soon as it impacts skin. The CO2 laser has been used to perform soft tissue surgery for almost 30 years Liquid: Rhodamine (as in pulsed dye) Solid state : Crystal as in ND:YAG ( Neodymium Yttrium Aluminium Garnet) laser or Ruby Laser Laser medium can be gas (e.g., CO2, wavelength of μm), liquid (e.g., Rhodamine) or solid (e.g., diode lasers). Harley Street London

12 Ordinary light vs. laser
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13 Ordinary light vs. laser
Laser: narrow beams Laser light is very much different from the natural light around us. It is the compressed light that comes from the cold, red part of the spectrum of radiation ( Near infra red) . It is just one colour, the colour of red. Its light travels in a straight coherent line. All waves in harmony, not spread like natural light) need a diagram It is monochromatic. This means that it is a single wavelength. It is polarized. The light focus its beam in a certain spot or area. A laser is a device for producing and emitting light of a very specific wavelength and power (wattage). A laser is a device that creates a uniform and coherent light that is very different from an ordinary light bulb. Laser light can be focused down to a tiny spot as small as a single wavelength. Many wavelengths Multidirectional Incoherent Single wavelength Directional Coherent Harley Street London

14 Light coherence Increasing Bulb LED Cheap laser High quality laser
Difference between a white light source,a LED light and a coherent laser beam. Cheap laser High quality laser Increasing

15 Interaction of light with matter
reflection absorption refraction and transmission scattering If the surface is not smooth, light is scatted. Harley Street London

16 Interaction of light with tissue
Photo-thermal: Light is converted to heat, i.e., Lasers & IPL. Photo-mechanical: break down particles within the skin, i.e., in the use of Q-switched lasers for tattoo removal. Photo-chemical: light is used to stimulate a chemical change within cells, i.e., Acne therapy, laser tooth whitening in dentistry. Lasers have been in use for medical purposes for many years and the physics, chemistry and biology of laser light interaction with human tissue are well documented. Medical uses range from surgery using high-powered lasers to stimulation of tissue repair Harley Street London

17 Photo-thermal If tissue is heated above boiling point, vaporization occurs (ablation). If tissue is heated above 60 degrees Celsius, coagulation occurs. This tissue is necrotic (dead) & will either slough away or be removed by the body's immune system. Heating less than 60 degrees Celsius: tissue denatured (injured but capable of recovering). Harley Street London

18 Skin components absorption
The diverse tissue and cell types in the body all have their own unique light absorption characteristics; that is, they will only absorb light at specific wavelengths and not at others. The diverse tissue and cell types in the body all have their own unique light absorption characteristics; that is, they will only absorb light at specific wavelengths and not at others. Harley Street London

19 Different lasers Harley Street London Near Infra-red: Nd:YAG 1064 nm
Penetrates the deepest of all lasers in the skin It is only slightly absorbed by Haemoglobin & Melanin Water absorption is also minimal. Penetration of up to 7 mm. Harley Street London

20 Near infra-red laser Nd:YAG 1064 nm Diode laser at 810 nm
Penetrates the deepest of all lasers in the skin; Slightly absorbed by Haemoglobin & Melanin; Water absorption is also minimal; Penetration of up to 7 mm. Diode laser at 810 nm Poorly absorbed by water; Slightly absorbed by Haemoglobin & Melanin; Penetration to 5mm. Ruby nm (merge of red & infra-red) Highly absorbed by Haemoglobin & Melanin; Penetration in skin is less: 3-4 mm. Harley Street London

21 If frequency increases then wavelength decreases and vice versa
Yellow & green laser Pulsed dye nm Yellow laser: highest absorption by Haemoglobin & melanin, penetration in skin is less: 2-3 mm. Frequency doubled Nd:YAG 532 nm It is possible to frequency double the Nd:YAG laser. Nd:YAG normally has a wavelength of 1064 nm, by frequency doubling it, this creates a wavelength of 532 nm. Remember what we said previously: If frequency increases then wavelength decreases and vice versa Harley Street London

22 Two types of laser Continuous laser Pulsed laser Energy (Watts) Time
                        Energy (Watts) Time Energy (Joules) Continuous Lasers generate a light beam for as long as the user needs. Pulsed lasers generate a light beam of fixed pulse duration ranging from nanoseconds to seconds watt (W) - Unit of power or radiant flux (1 watt = 1 joule per second). Joule (J) - A unit of energy Energy (Qgener) The capacity for doing work. Energy content is commonly used to characterize the output from pulsed lasers and is ally expressed in Joules (J). Irradiance (E) - Power per unit area, expressed in watts per square centimeter. Time Harley Street London

23 Pulsing of light Pulsing of light reduces collateral tissue effects.
Pulsing reduces the "on" time of the light at the target tissue & reduces the conduction of heat. This reduces any collateral damage. We will revisit this picture later. Harley Street London

24 Summary Laser light is produced by stimulated emission.
Laser produces single wavelength of light. Certain wavelength of laser light are specifically absorbed by main tissue components. Absorbed laser light is converted to heat. Heat either vaporizes, coagulates or denatures tissue. Pulsing of laser reduces conduction of heat preserving nearby structures. Harley Street London

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26 The Skin The skin consists of three main layers Epidermis Dermis
Subcutaneous layer Harley Street London

27 The Epidermis The outer layer of skin, consisting of a layer of dead cells that perform a protective function and a second layer of dividing cells. It has no vascular structures within it. It contains no blood vessels and its thickness depends on the site of the body. Cell layers within the Epidermis. The Epidermis is split into 5 layers: from top to bottom. Stratum Corneum: The horny layer This layer sheds approximately every two weeks Stratum Lucidium:Clear layer Stratum Granulosum: granular cell layer Stratum Spinosum: Prickle cell layer Stratum Germinativum (basale): Basal cell layer. This is where Melanin is contained. Harley Street London

28 The Dermis The inner layer of the skin consisting of blood vessels, lymph vessels, hair follicles, sweat glands and sebum (the oily substance that stops skin from drying out) Harley Street London

29 The Subcutaneous Layer
Refers to the layer under (sub) the dermis. It is a layer of loose connective tissue and fat cells. Its main function is to regulate the body temperature. Harley Street London

30 Human Skin Anatomy

31 The main functions of skin
Protection: The skin is a barrier against mechanical impacts and pressure, temperature, radiation and chemicals. Melanocytes ( melanin producing cells in the epidermis) produce melanin to protect the dermis from harmful UV light. Regulation: The skin regulates the body temperature via sweat and hair, changes in peripheral circulation and fluid balance. It also acts as a reservoir for the synthesis of sweat. Sensation: the skin contains an extensive network of nerve cells that detect and relay changes in the environment. The skin is the largest body organ, Its three main functions are above. Harley Street London

32 Function cont.. There are separate receptors for heat, cold, touch, and pain. Damage to these nerve cells is known as neuropathy, which results in a loss of sensation in the affected areas. Patients with neuropathy may not feel pain when they suffer injury, increasing the risk of severe wounding or the worsening of an existing wound. This will be discussed further when we look at the assessment of clients. Harley Street London

33 The Fitzpatrick scale The Fitzpatrick Classification Scale was developed in by Harvard Medical School dermatologist, Thomas Fitzpatrick, MD, PhD. This scale classifies a person's complexion and their tolerance of sunlight. It is used by many practitioners to determine how someone will respond or react to facial treatments, and how likely they are to get skin cancer. Harley Street London

34 The Fitzpatrick Scale Harley Street London

35 The Fitzpatrick Scale Harley Street London

36 HAIR STRUCTURE Hairs are elongated keratinized structures. Keratin is a special protein, which is resistant to wear and tear. It is the protein that also makes up the nails. Like other proteins in the body, keratin is also a large molecule made up of smaller units called amino acids. The amino acids are joined together in a chain, like beads on a string. The diameter of a single hair fibre varies from person to person; but it is usually around 0.05 to 0.09 mm The epidermis is the outermost layer of the skin. Each hair arises from an indentation on the epidermis. The hair has two parts: the hair follicle and the hair shaft. Harley Street London

37 The Hair Shaft Composed mainly of keratin, it has three morphological regions—the cuticle, medulla, and cortex. A hair can be defined as a slender, thread-like outgrowth from a follicle in the skin of mammals. A hair grows from the papilla and is made up of dead, cornified cells. It consists of a shaft that projects above the skin, and a root that is imbedded in the skin. Its basic components are keratin (a protein), melanin (a pigment), and trace quantities of metallic elements. Harley Street London

38 Hair structure cont.. Cuticle The cuticle is a translucent outer layer of the hair shaft consisting of scales that cover the shaft. Medulla: The medulla is a central core of cells that may be present in the hair. If it is filled with air, it appears as a black or opaque structure under transmitted light, or as a white structure under reflected light. Cortex: The cortex is the main body of the hair composed of elongated and fusiform (spindle-shaped) cells. It may contain cortical fusi, pigment granules, and/or large oval-to-round- shaped structures called ovoid bodies. Harley Street London

39 Hair Structure Cont.. Harley Street London

40 THE HAIR FOLLICLE Harley Street London
The hair follicle is defined as the tubular epithelial sheath that surrounds the lower part of the hair shaft and encloses at the bottom a vascular papilla supplying the growing basal part of the hair with nourishment. At the base of the hair follicle is the dermal papilla and the bulb. These areas contain the growth hormones that promote hair shaft growth within the follicle. A little further up is the area called the "bulge" which has been found to contain growth cells. Melanocytes (the special cells found in the epidermis and the hair follicle) stimulate the production of Melanin and determine a person's skin and hair colour and level of protection from UV light. The more Melanin we have the darker our skin and hair is. In the hair follicle, melanocytes are located near the base (dermal papilla and bulb) of the follicle where a new hair is produced at the start of the anagen (growth) phase of the hair growth cycle. Harley Street London

41 Hair Follicle Sebaceous gland ( bulge behind) Dermal papilla
Sebaceous gland ( bulge behind) Dermal papilla Harley Street London

42 The hair growth cycle Each hair follicle lives in a cycle consisting of a long period of growth followed by a relatively short period of rest. During the rest period the hair is still attached to the hair follicle, but it is not growing. After the resting phase the hair is shed and a newer hair begins to grow, thus, starting a new hair growth cycle. There is a genetic predisposition of each hair follicle to follow a particular pattern of growth and rest. Hair follicles are programmed to stop producing hair and spend more time in the resting stage with the progression of age. Harley Street London

43 Hair growth cycle There are 3 distinct hair growth development stages:
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44 Anagen/Growth phase This is the active stage of hair growth which results in restructuring of the lower follicle. The dermal cord grows downwards into the dermis and outwards and there is multiplication of hair germ cells contained within the dermal cord. Approximately 85% of all androgenic ( body) hairs are in the growing phase at any one time. During the Anagen phase the follicle is nourished by the papilla. Harley Street London

45 Catagen/Transitional Phase
When the Anagen growth phase comes to an end, hair enters into a Catagen phase which lasts about one or two weeks. During this transitional phase, the hair follicle shrinks to about 1/6th of the normal diameter. The "root" is diminished and the dermal papilla breaks away and rests below the skin. The hair starts to rise in the follicle becoming drier as it loses water and essential fatty acids Harley Street London

46 Telogen/Resting phase
The resting phase follows the catagen phase and normally lasts about 5-6 weeks. During this time the hair does not grow but stays attached to the follicle while the dermal papilla stays in a resting phase below. Approximately percent of all hairs are in this phase at an one time. At the end of the Telogen phase the hair follicle re-enters the Anagen phase. The dermal papilla and the base of the follicle join together again and a new hair begins to form. If the old hair has not already been shed the new hair pushes the old one out and the growth cycle starts all over again. Harley Street London

47 Growth cycle Harley Street London

48 Growth cycle Harley Street London

49 IMPORTANT The only follicles to be affected by IPL are those in the Anagen phase as this is the only phase that has enough melanin in the follicle to create the heat required for cell destruction. Not all hairs are in the anagen phase at any one point. Harley Street London

50 Hair growth New or excessive hair growth can be affected by many external issues: Hormones (as in polycystic ovaries) Stress (Stress can stimulate the adrenal glands to initiate a hormonal reaction that can cause fine, soft hair to become more coarse and noticeable.) Diet Ethnicity Pregnancy Hereditary Medication Puberty Harley Street London

51 Types of hair There are three different types of hair, Terminal, Vellus and Lanugo. Lanugo hairs are present in utero but are shed in early childhood. Vellus hairs are the fine downy hairs that cover most of the body, particularly in women and children. Terminal hairs are generally much coarser and thicker and include those which cover the scalp, beard, chest hair and pubic areas. The quantity and texture of hair is determined largely by genetic make-up, but hormonal changes can also influence hair growth and hair loss. Terminal hair shape varies depending on the ethnic origin of an individual. Harley Street London

52 Hair type by ethnicity Harley Street London
In terms of hair type, three ethnic groups can be considered: black(Afro-Caribbean), Caucasian and Indo-Chinese. Afro-Caribbean: when cut in cross-section ,the hair is thin and a flattish oval in shape. The hair is twisted and curly causing it to be come easily tangled and broken. The pigments within black hair are a combination of black and red, with around 40% of black women having near black hair, 50% black/brown hair and around 10% having auburn shades. Caucasian: a cross-section shows a slightly fatter oval shape than for black hair, generally being fine textured and varying from wavy to straight. It is the only ethnic group with a wide variety of pigment varying from white blonde to reds to black. Indo-Chinese: the cross-section shows an almost perfectly round shape and the hair is generally straight or very slightly wavy. It is a very strong type of hair with a great capacity for growth. The Anagen phase can be twice as long as that of other hair types and the shedding rates less. This means that head hair can grow to the waist or below (Kingsley, 2003). Harley Street London

53 The need for multiple treatments
Once a hair in the Anagen hair phase has completed its period of growth, it moves into the Catagen phase which is the transitional period prior to dormancy. Then the Telogen phase follows and hair is shed from the follicle. This phase can take anything from a few days to a few weeks depending on the area treated and is always followed by the return to the Anagen phase. No-one can predict how many hairs in the treatment phase are in the Anagen phase at any given time. Remember IPL will ONLY work on hairs in the Anagen phase. Harley Street London

54 Multiple treatments The hair growth cycle and triggered new growth is the primary reason for multiple treatments. It is impossible to predict how many treatments are required for any one individual. As a rule of thumb the average is generally maximum. Each individual has a different drive to produce hair and this is impossible to predict. Never give exact figures - No-one can predict or quantify such a statement. The average number of treatments to the facial region is higher than for the body. Harley Street London

55 Now time to put it all together!
Hair Summary Hair is a keratinised structure that grows from a hair follicle. The follicle reaches through the epidermis terminating at the dermal papilla and Bulb. The dermal papilla and the bulb contain the growth hormones that promote hair shaft growth within the follicle. The Dermal Papilla contains the Melanocytes which are the special cells found in the epidermis and the hair follicle that stimulate the production of Melanin and determine a person's skin and hair colour and level of protection from UV light. The hair follicle goes through 3 stage of growth: Anagen - Active Catagen - Transitional Telogen - Resting The follicle structure consists of an inner and outer sheath. Now time to put it all together! Harley Street London

56 Laser & Hair Laser hair removal: a brief history
Laser treatment for hair removal has been a process that has been developed and studied since the 1960's. Machines were often cumbersome and hard to use. They could be difficult to calibrate and unpredictable sometimes resulting in pain, cell damage, skin damage or just poor quality results. Research continued until the mid 1990's when the emergence of the first effective hair removal system the Ruby Laser Light appeared to show a standardised method of laser use that worked. Harley Street London

57 Laser & Hair History The process used to remove the hair was one of Melanin absorption. Ruby lasers emitted in the well absorbed 694 nm (red) wavelength and were seen as the ideal tool for the job. One of the downfalls of the Ruby Laser method is that its high energy and, short pulse duration made the process too random, with the partial vaporisation of the hair. The after treatment effect was not always consistent as sometimes the photo-thermolysis was complete often the follicle was simply disabled and not damaged as is needed to prevent hair growth. Harley Street London

58 Laser Hair Removal/Reduction
Laser hair removal was the first to replace electrolysis for many hair removal patients, offering a less painful, faster and more effective solution. Laser procedures require multiple sessions to achieve complete hair removal, but in many cases the results are considered permanent. There are a variety of lasers used for this purpose, to help patients and doctors customize a treatment to a patient's hair colour and skin tone for best results. Harley Street London

59 Benefits of Laser Hair Reduction
The benefits of laser hair removal are numerous, and include: Permanent hair reduction is seen in most patients, after the recommended number of treatment sessions The procedure is not as painful as treatments like electrolysis or waxing Treatment can be done on larger areas, like the legs and back Hair that comes in after treatment is often finer and lighter in colour A variety of lasers allow doctors to customize a treatment to a patients specific skin tone and hair colour Harley Street London

60 Disadvantages of Laser Hair Reduction
Pain (during and after the procedure); Swelling; Redness (erythema); Blistering; Hyperpigmentation (temporary skin darkening). Multiple treatments will be needed to achieve desired results. Laser hair removal may not be a good choice for those with darker skin tones, since the risk of burning or skin damage is higher. Laser hair removal doesn't usually work on hair without pigmentation, such as white or red hair shades. Extreme and rare side effects could include Scarring, burns or permanent skin discolouration. These generally occur when the equipment is used by less skilled/qualified practitioners. Harley Street London

61 Hair Removal using light
Selective photo-absorption or the transfer of energy from a photon to an atom, molecule, or nucleus. In our case this is the transfer of light energy to the Melanin cells (melanocytes). The technical term for the action that occurs during light treatment is selective photo-thermolysis. Harley Street London

62 Photo-thermolysis The absorption of light ( photons) in Melanin in the hair. The transformation of absorbed light into heat ( thermo) above 70 degrees Celsius. The destruction (lysis) of the proteins/target cells surrounding the follicle responsible for the growth of new hairs. Harley Street London

63 Selective photothermolysis
Selective photothermolysis therefore refers to the precise targeting of a structure or tissue using a specific wavelength of light with the intention of absorbing light into that target area alone. The energy directed into the target area produces sufficient heat to damage the target while allowing the surrounding area to remain relatively untouched. Photothermolysis uses the colour of the hair, (the melanin) to act as an absorber of the applied light which causes it to heat up. Harley Street London

64 Selective Thermolysis
By conduction this heat is transferred to the adjacent cells (including those of the dermal papilla and bulge). If we ensure that enough light is applied to the area, the temperature rise will be sufficient to cause the surrounding cells to die. This ends the follicles capability to produce new hairs and the growing potential of the follicle. Energy must penetrate skin & be absorbed by target tissue. Pulsing of energy must be just long enough to stay within target - no conduction to surrounding structures. Harley Street London

65 Selective Thermolysis
There must be sufficient energy to have desired effect on target tissue. Photothermolysis is different to electrolysis. They are both permanent hair removal techniques. Electrolysis removes the hair one at a time and takes a long, long time if you're doing a large area. Laser and IPL cover a larger area at the same time. Electrolysis does have a tendency to be painful, slow and costly with the added risk of possible scarring. Harley Street London

66 Additional cooling During Laser/IPL treatment there should be minimal absorption and heat production in surrounding structures. It is usual during IPL treatments to use additional cooling to protect surrounding structures. This can take the form of chilled water flowing through the hand piece. Some lasers uses a cryogenic spray which is delivered to the skin as the laser fires. Harley Street London

67 Intense Pulsed Light (IPL)
As we saw earlier light sources such as the sun, lamps, torches & candles emit colours from every part of the spectrum. This light is said to be non-coherent, non Collimated and poly chromatic. This differs from the earlier description of lasers. The Intense Pulse Light (IPL) hair removal system uses non- coherent light. Normal light is : Non-coherent: Does NOT travel in a straight line Non-collimated: spreading Polychromatic: not single wavelength Harley Street London

68 IPL Harley Street London
IPL is generated using flash lamps typically Xenon or Krypton lamps which are lamps that produce a very short, but very intense, flash of white light. Unlike lasers, flash lamps do not emit a single wavelength but instead a broad band of visible light from UV to infrared IPL systems work on the same principles as lasers in that light energy is absorbed into particular target cells with colour (chromophores) in the skin. IPL is more versatile than laser due to the multi-wavelengths that can be isolated. The light energy is converted to heat energy, which causes damage to the specific target area. IPL systems are different to lasers in that they deliver many wavelengths (or colours) in each pulse of light instead of just one wavelength. Most IPL systems use filters to refine the energy output for the treatment of certain areas. This enhances penetration without using excessive energy levels and enables targeting of specific chromophores. (These are the chemical components in skin that absorb light). Harley Street London

69 IPL using a filter Harley Street London

70 IPL applications IPL systems are not lasers but because of the differing visible wavelengths available through filters they can be used for a variety of skin treatments. Treatments such as tattoo removal, telangiectasia (spider veins/naevi), leg veins, pigmented lesions, solar lentigines (freckles), birth marks, skin rejuvenation, hair removal and reduction of scars in certain cases. Harley Street London

71 IPL for hair removal Technology of hair removal
People frequently refer to IPL hair removal as laser hair removal or IPL laser hair removal and although IPL and laser are both light-based technologies, there are distinct differences between the two. Though IPL is not a laser, it can be compared to one.  The main technological difference between the two is that laser uses one specific wavelength of light, while IPL uses a full spectrum. This means that unlike lasers, which can only deliver a wavelength, IPL can release light over a wide wavelength range. In short, IPL uses intense light pulses instead of laser rays. IPL and lasers work in similar ways by sending light into the Hair Follicles. The light absorbs in the hair follicle, turns into heat and destroys it. Harley Street London

72 IPL for hair removal IPL hair removal: IPL operates on broad light spectrum, sending out of only one particular wavelength, which achieves a highly selective effect on the relevant biological tissue in the hair follicle. Laser hair removal: Hair removal lasers use a single wave length of light that target individual hairs whereas IPL devices utilize a flash lamp that emits multiple wavelengths of light that covers a larger area of the skin but is not as targeted. For optimal results, both systems are best suited for persons with light skin and dark hair (Fitzpatrick 1-4). Unfortunately the physics that make the light energy work so well are those that make it more risky for darker skin complexion people. Harley Street London

73 IPL and Laser Risks For Dark Skin
When the laser light or the IPL (Intense Pulse Light) is projected at the skin, the light meets the melanin cells. In the regular cases if the skin has light tone and the hair is dark tone – all the laser light energy will be absorbed by the hair and it will heat up until it is destroyed.  For people with darker skin (African American) this is more complicated because the laser or IPL light will be absorbed at the skin surface which is rich in Melanin – and this may cause soreness, blisters and in extreme cases burns and scars. Hair removal with IPL is the same process as discussed within the laser hair removal in that it uses the melanin absorption method. Most lasers used for hair removal target melanin and are therefore designed to burn structures that contain melanin. The more melanin, the more damage. Harley Street London

74 IPL advantages over laser method
The light targeted onto the melanin is a broad band and contains a range of wavelengths. The pulse duration can be set much larger than the lasers (remember the pulse graph earlier?) Energy levels can be set easily A choice of wavelengths with individual filters can be chosen Treatment is efficient due to relaxation times of skin and hair melanin IPL treatment heads are much larger than the small spot produced by lasers and therefore treatments are much faster, saving the client both time and money. IPL machines typically do not require the same high levels of power as hair removal lasers and feedback from persons who have had IPL treatments have indicated that IPL hair removal is not painful or uncomfortable. For optimal results, both systems are best suited for persons with light skin and dark hair. Harley Street London

75 IPL advantages over laser method
The light beam may be safe for a wider spectrum of skin tones and hair colours than some other types of lasers. The FDA has approved IPL for permanent hair reduction. IPL hair removal may be more cost effective than laser treatments, because there is less time involved. There is less risk of skin damage from an IPL treatment than laser hair removal. IPL lends itself well to larger areas of hair removal. IPL is reported as less painful than laser hair removal by many patients. Harley Street London

76 Disadvantages and side effects
Unlike laser hair removal, IPL hair reduction can cause skin damage, burning and scarring because of overexposure and ineffective radiation if not handled by an experienced professional who knows what they are doing. 1. A slight risk of scarring. 2. Short-term effects may include reddening, mild burning, temporary bruising or blistering. Hyper-pigmentation (browning) and Hypo pigmentation (lightening) have also been noted after treatment. These conditions usually resolve within 3-6 months, but permanent colour change is a rare risk. Avoiding sun exposure before and after the treatment reduces the risk of colour change. 3. Infection: Although infection following IPL is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. Should any type of skin infection occur ensure your client informs their GP as very occasionally antibiotics may be necessary. 4. Bleeding: Pinpoint bleeding is rare but can occur following IPL treatments. 5. Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations have been reported. 6. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation. Harley Street London

77 Side effects and risks of IPL
There may be some degree of discomfort, i.e., stinging, pin pricking sensation, hotness and or tightness, along with tenderness, mild "sunburn" like effects that may last a few hours to 3-4 days or longer. Pigment changes hypo-pigmentation or hyper-pigmentation on the skin lasting 1-6 months or longer may occur. Freckles may lighten and/or temporarily or permanently disappear in treated areas. IPL / laser hair removal treatments can cause eye injury and protective eye- wear must be worn during treatment. Serious complications are rare, but possible. Harley Street London

78 Radiofrequency for Skin Rejuvenation
Radiofrequency (RF) energy treatment is a new and promising technology for non-surgical tightening of the early signs of loose or sagging skin; ideal for those people who either don’t want, or don’t believe they are old enough to have a surgical procedure. Pure RF energy alone is primarily used to treat skin laxity by facial tightening, and is best suited to patients with mild to moderate sagging of facial tissues, usually those in their mid thirties to fifties, with any skin colour. It is commonly used to treat the forehead, under the eyes, cheeks, mid-face, jaw line, and the neck. Based on current RF technologies, most people should see at least a mild improvement in their skin tightness, with minimal risks and downtime compared to surgery. Prices for radiofrequency facial tightening treatment depend on the area(s) treated and the device used. Harley Street London

79 RF for facial rejuvenation
The use of electric currents in medicine has been documented almost since electricity itself was discovered. Radiofrequency (RF) surgery has a lengthy history of use in oral, ophthalmic, plastic, and gynaecological surgery of over 70 years. Gradually, its use in the practice of dermatology, cosmetology, cardiology, neurosurgery, hepatology, and ENT procedures gained momentum and popularity. Low frequency alternating currents are also used in physiotherapy for their ability to cause contractions in muscles. RF surgery traditionally utilizes a wave of electrons to cause frictional heating of tissues to incise, excise, ablate or coagulate the targeted tissue. Harley Street London

80 RF Harley Street London
Radiofrequency rejuvenation uses heat (the radiofrequency energy) Pure RF energy alone is primarily used to treat skin laxity by facial tightening, and is best suited to patients with mild to moderate sagging of facial tissues, usually those in their mid thirties to fifties, with any skin colour. It is commonly used to treat the forehead, under the eyes, cheeks, mid-face, jaw line, and the neck. Based on current RF technologies, most people will see at least a mild improvement in their skin tightness, with minimal risks and downtime compared to surgery. The main goal of radiofrequency skin rejuvenation is to stimulate collagen production deep within the skin (the dermis and cutaneous layers) while leaving the skin's surface (the epidermis) relatively untouched. Collagen fibres are essential for firm, youthful-looking skin, but they tend to degenerate as we age, mainly because of overexposure to the sun. In addition to stimulating new collagen, radiofrequency treatment also causes some contraction of the skin, thus tightening it. Although clients notice the treatment's tightening effects immediately, the more significant improvements will occur gradually over a period of several weeks or months as the new collagen forms.  Harley Street London

81 How does Radio-frequency Work?
It works in a number of ways: Tissue Retraction: The generated heat causes local contraction of the collagen fibres, thereby immediately tightening the skin to remodel and rejuvenate the previous effects of ageing. New Collagen Formation by local fibroblasts is stimulated the next few months by heating the dermis and it then acts as a new deep foundation for the skin. This produces further delayed tightening which only becomes evident slowly over. Improved Circulation: Radio-frequency also improves blood flow and lymphatic drainage, thereby providing a better oxygen supply and greater toxin clearance to reduce the further effects of ageing. Harley Street London

82 How does Radio-frequency Work?
Photo Credit: Syneron Medical A representation of the flow of electrical current through the skin using a bipolar RF system. Harley Street London

83 How does Radio-frequency Work?
This unique combination of processes thus provides both an immediate uplifting effect but also further longer term skin tightening, restructuring and rejuvenating benefits. Bipolar RF is mainly used to skin rejuvenation and Collagen production. Unipolar RF is mainly used for fat reduction and Cellulite treatments. Monopolar RF heats tissue in the treated area rather deeply (usually up to 20 mm) and thus affects both the skin and subcutaneous fat. Bipolar RF heats tissue in the treated area less deeply (usually up to 2-4 mm) and thus primarily affects the skin. There are very few contraindications with RF. However, people with electrical devices e.g., pacemakers, or metal implants e.g., artificial metal hip joints, heart valves or dental plates, cannot be treated because RF current flowing through the body may interfere with these devices or heat up metal implants, which could be dangerous. Harley Street London

84 E-Light treatment Harley Street London
E-light treatments are basically IPL & RF combined to provide effective skin rejuvenation and the tightening effect that RF can provide. In effect providing a safe, light and electrical based non-invasive facelift. The two targeted energies (IPL and RF) penetrate deeper below the skin dermis than laser and IPL, more effectively targeting the hair follicle in hair removal. RF energy can be applied to any type of skin. As hair removal equipment, this E-light (IPL+RF) equipment can be used in deep colour skin or light colour hair. This is because the IPL setting can afford to be lower as the RF thermal effect is not damaging. E-light equipment will not generate any burning risk and uncomfortable feeling caused by traditional IPL laser treatment instrument. This E-light (IPL+RF) Equipment is especially effective for blond hair and light colour pigmentation removal. Harley Street London

85 Bipolar Radio Frequency + IPL +Skin Contact Cooling
When the three are united in one treatment, a wonderful treatment experience and result can be expected. The energy of Radio Frequency can reach the middle and deep layer of the skin and heat up tissue, thus, lower energy is applied during the IPL treatment. The uncomfortable feeling during the IPL treatment will be decreased significantly and a better result can be expected. In addition, cooling system involved in E-light hair removal equipment can also ease the uncomfortable feeling. The absorbing of the energy of radio frequency is not concerned with melanin. So, the E-Light treatment can get good result on the soft or thin hair so as to decrease the risk caused by traditional IPL treatment. Harley Street London

86 Functions of E-light (IPL+RF) Equipment:
Skin tightening, skin lifting, improves flexibility and tone of skin; - Skin rejuvenation: fine wrinkles, pigments, freckles, vascular lesions (telangiectasis) removal; skin whitening, changes the size of large hair pores; - Permanent Hair removal; - Acne removal: improve the situation of oily skin; kill acne bacilli. So in effect all the treatments that you can get with IPL with much reduced risk of burning or discomfort. Harley Street London

87 Contraindications Pt 1. Harley Street London
Clients with the following conditions MUST NOT be treated. Contagious or infectious diseases Liver disease Kidney Disease Epilepsy Hypertension (high blood pressure) Must not be used on individuals who appear to be under the influence of drugs or alcohol or who give a history of frequent drug use and/or alcohol binge drinking Heart problems Pacemaker Individuals undergoing radiation therapy. This includes radiological procedures, radiotherapy and sunlight therapy for skin conditions or seasonal affective disorder Cancer especially breast cancer with lymph node removal/involvement or malignant skin cancers Immune suppressed disorders Pregnancy ( in particular Melasma/cholasma or "pregnancy mask") Diabetes (Type 1 – Insulin dependent) Clotting disorders ( such as warfarin therapy, aspirin use long term, Haemophilia, hepatitis) Vascular disorders-Aortic aneurysm, peripheral vascular disease, intermittent claudication Varicose Veins The presence of keloid scarring Previous severe reaction to IPL or laser treatment especially if it left a scar. Any inflammatory skin condition e.g. eczema or active Herpes Simplex. Care must be taken before treatment commences as some skin disorders can be exacerbated if treated with light. Harley Street London

88 Contraindications Pt 2. Harley Street London
Client with the following conditions CAN be treated with a signed disclaimer, but it is recommended that they consult their GP before commencing treatment. Photosensitive skin disorders Diabetes ( providing it is well controlled) Tattoos ( due to risk of fading) Dermatitis Skin lesions Psoriasis Porphyria- A very rare disorder.( Definitely not to use) Clients using drugs that can cause photosensitivity. It should say on the bottle but if the client is unsure ring your local Pharmacy for clarity. Metal implants Undiagnosed lesions Recent surgery or minor operation within the last 6 weeks Any illness or disorder that affects hair growth Recent chemical peel in preceding 2 weeks Clients with skin type 4 & 5 on Fitzpatrick Scale Dark mole or pigmentation St. John’s Wort Harley Street London

89 Hazards of IPL All Lasers & IPL have high power components.
Only manufacturer's technician should open casing, this usually has tamper proof casing. Ensure dry hands prior to using. Avoid spills. Harley Street London

90 Teaching timetable An introduction to Laser, Intense Pulsed Light (IPL), Radio Frequency (RF) & E-Light therapies Anatomy and physiology IPL applications Hazard reduction "Core of Knowledge" & legislation issues Getting to know your machine Treatment regimes and practical teaching and scenarios Assessment and feedback Harley Street London

91 Core of knowledge syllabus
The syllabus for the "Core of Knowledge" is described in the UK government's Medicines and Healthcare products Regulatory Authority (MHRA) "Guidelines for the safe use of lasers, intense pulsed light sources and LED's in medical and dental practice". The topics that must be covered include: 1. Laser / light characteristics 2. Radiation generation 3. Hazards due to device malfunctions 4. Quality assurance 5. Equipment management 6. Light / tissue interaction 7. Eye and skin exposure 8. Laser Safety Management         a. Local Rules         b. Laser Controlled Areas         c. Laser Protection Adviser         d. Laser Protection Supervisor         e. Procedures in event of accidental exposure         f. Hazards due to reflection and absorption         g. Keeping exposure of unprotected eye and skin below Maximum Permitted Exposure  9. Hazards to the client         a. Incidental hazards         b. Electrical         c. Fire         d. Explosion         e. Cryogenic liquids         f. Atmospheric contamination         g. Tissue debris 10. Standards and Guidelines 11. Risk Assessment Harley Street London

92 Laser safety Safe design, use and implementation of lasers.
Minimise the risk of laser accidents, (especially those involving eye injuries). Relatively small amounts of laser light can lead to permanent eye injuries. The sale and usage of lasers is typically subject to government regulations. Moderate and high-power lasers are potentially hazardous because they can burn the retina of the eye, or even the skin. Most regulations also prescribe required safety measures, such as labelling lasers with specific warnings, and wearing laser safety goggles when operating lasers. Harley Street London

93 Laser safety Continued
European Community eye protection requirements are specified in European norm EN 207. European norm EN specifies optical densities in extreme situations. The higher the Class number, the greater the laser radiation hazard posed by the laser. Harley Street London

94 Classification of lasers

95 LASER RADIATION AVOID EXPOSURE TO BEAM CLASS 3B LASER PRODUCT
Class 3B & 4 lasers Class 3B ( Lumislim & Diode laser) LASER RADIATION AVOID EXPOSURE TO BEAM CLASS 3B LASER PRODUCT A Class 3B laser is hazardous if the eye is exposed directly, but diffuse reflections such as from paper or other matte surfaces are not harmful. Continuous lasers in the wavelength range from 315 nm to far infrared are limited to 0.5 W. For pulsed lasers between 400 and 700 nm, the limit is 30 mW. Other limits apply to other wavelengths and to ultra short pulsed lasers. Protective eyewear is typically required where direct viewing of a class 3B laser beam may occur. Class-3B lasers must be equipped with a key switch and/or a safety interlock. Harley Street London

96 Class 4 ( IPL & Laser) Harley Street London
LASER RADIATION AVOID EYE OR SKIN EXPOSURE TO DIRECT OR SCATTERED RADIATION CLASS 4 LASER PRODUCT Class 4 lasers include all lasers with beam power greater than class 3B. By definition, a class-4 laser can burn the skin, in addition to potentially devastating and permanent eye damage as a result of direct or diffuse beam viewing. These lasers may ignite combustible materials, and thus may represent a fire risk. Class 4 lasers must be equipped with a key switch and a safety interlock. Most industrial, scientific, military, and medical lasers are in this category. There are further links & tools at the end of the presentation to assist you in your risk assessment and to help you investigate local authority guidelines. Harley Street London

97 HSE guidelines for Laser & IPL
Risk assessment should be carried out & specialist advice may be needed. Provide face shields, goggle & other protect eyewear. Provide gloves where appropriate. Designated treatment rooms with restricted access. Curtains around equipment. Workers are at a distance from patients who are exposed. Provide information & training to staff. Display appropriate warning signs. Monitor & enforce use of control measure (local rules). If any workers are over exposed, employers to provide medical examination & consider whether follow-up health surveillance is appropriate. Registration with Local Authority an requirement. Harley Street London

98 Local Enforcement in England
Beauty spas, tattoo studios and salons where lasers and IPL are used, need to contact their local Environmental Health Officers (EHO) to check that they meet the required standards. Requirements vary from council to council but it is usual for your EHO to expect you to show some evidence of: A risk assessment of your treatment room; "Local Rules" which set out the precautions to be taken every time the laser/IPL is used and which overcomes any hazards identified in the risk assessment. Core of knowledge training. Operational/Manufacturer training on the equipment which should also include knowledge of any contra-indication of the treatment. Full training on the Core of Knowledge for IPL and laser users is advised. Harley Street London

99 Occular hazard Harley Street London
All cells contain water, lasers that are absorbed by Water such as the Carbon Dioxide & Erbium( gas state lasers) can burn the cornea. More seriously a retinal burn, leading to permanent blindness may result from light transmitted through the cornea from a near infra red laser such as the Nd:YAG or other visible light lasers. Clients must have adequate eye protection usually in the form of fully opaque "tanning booth" goggles or metal eye shields. The operator and persons viewing the treatment must have eye protection to prevent them receiving more than the Maximum Permitted Exposure (MPE) to the beam. MPE is a calculated value & takes into account wavelength and collimation of the laser beam and assumes a 10% dose of the light that would cause eye or skin injury. Another term used on laser & IPL safety is Nominal Ocular Hazard Distance (NOHD). This is the radius from the emitted laser beam where a risk of eye injury exists. The distance will depend on the type of laser or IPL in use. however most aesthetic lasers and IPL's have a handset which delivers the energy as a focused beam-beyond the focal point the beam diverges (i.e., the further you pull the light away from the skin the more it fans out & becomes a broad band.). Most aesthetic equipment therefore has a NOHD of approximately 4 m. It is usual practice to designate the whole treatment room as the hazard zone and restrict access to this room. Harley Street London

100 Safety eyewear Wavelength specific glasses must be worn for the laser type being used. These should be marked on the frame. Special IPL glasses for IPL exist. In Europe, laser & IPL glasses must be CE marked & conform to standard EN 207. Harley Street London

101 Eye injury precautions
Access to laser or IPL should be restricted Designated laser treatment room Warning signs Staff communication Laser or IPL should be in standby mode when treatment paused Key should be removed and securely stored when device not in use Harley Street London

102 Fire/Thermal injury ( hazard to staff and clients)
Fire extinguishers must be available In the case of vaporizing laser use of wet swabs around sites to protect adjacent structures ( for surgical CO2 based) Non-alcoholic skin preparation to be used Bowl of water handy to dowse any ignition Laser/IPL should be in standby when not in use Laser/IPL should only be aimed at target tissue Harley Street London

103 Smoke Hazard: (relates to surgical laser )
Tissue smoke from vaporising lasers may contain carcinogens and/or viral particles (HIV, Hep B HPV). Certain lasers that eject hair during hair removal may also pose a biohazard. Ablative skin resurfacing laser causes plume. Particles to be released from the epidermis into the atmosphere. Smoke evacuators with secondary filters are needed to remove the smoke particles at source. Harley Street London

104 Other considerations The Treatment room should not have any highly reflective surfaces which may reflect the laser or IPL beam. Reflectors in spotlight fittings may pose a hazard & the fitting should be changed r a diffuser fitted to prevent laser/IPL reflections. Windows should be covered during treatment to prevent the laser or IPL beam being viewed from outside. Permanent structures such as stainless steel sinks should have a suitable drape applied for the duration of the treatment. Coverings should be non flammable. Harley Street London

105 The Treatment room The layout should reflect local rules applied within your organisation. The room should be laid out in a sensible fashion ensuring no trip hazards are present, walkways are clear, No water near electrical equipment. Warning signs should be placed outside the door to indicate the presence of a laser. These can be bought commercially. A lock on the inside of the door ensures no-one can enter during a procedure & restricts access to the treatment room. A risk assessment of the premises must be carried out. That takes into account all the hazards mentioned previously. A set of local ( organisational) rules should be produced. This needs to set out step by step safety precautions that must be adhered to each time the laser/IPL is used. Harley Street London

106 Regulatory issues: Control of lasers & IPL devices in the UK.
Classes of laser & IPL that are regulated in the UK. Lasers are classified as to the degree of risk they pose. The lowest risk, class 1 lasers can be viewed safely, indirectly, without eye protection ( laser pointers). As the risks become greater, so does the classification. Aesthetic lasers are designed to "damage" target tissues and so dependent on the laser type they will fall into either class 3b or more usually class 4. Harley Street London

107 ALL IPL DEVICES ARE INCLUDED IN CLASS 4
In the UK, class 3b & class 4 lasers plus all IPL devices are controlled by a variety of regulatory bodies. Changes since Oct 2010 In England, users performing simple cosmetic, non- medical/non-surgical treatments no longer have to register under the Health & Social Care Act 2008. Instead local government Environmental Health Officers are now responsible for establishments offering such treatments. Harley Street London

108 Local Enforcement in England
Beauty spas, tattoo studios and salons where lasers and IPL are used, need to contact their local Environmental Health Officers (EHO) to check that they meet the required standards. Requirements vary from council to council but it is usual for your EHO to expect you to show some evidence of: A risk assessment of your treatment room "Local Rules" which set out the precautions to be taken every time the laser/IPL is used and which overcomes any hazards identified in the risk assessment. Core of knowledge training Operational/Manufacturer training on the equipment which should also include knowledge of any contra-indication of the treatment. Often Local Councils issue a "special treatment" licence to establishments that meet their requirement. Some councils require laser/IPL users to employ a Laser protection Advisor to carry out the risk assessment & write the "local rules" Other councils allow the owner ( often in conjunction with the equipment manufacturer) to provide these documents themselves. As by definition the laser/IPL treatments that come under local council regulation are "non- medical" it is not usually a requirement to have a medical expert practitioner involved. Harley Street London

109 Registration under the health & social care Act 2008
Laser/IPL users living in Wales or Northern Ireland or those users who carry out medical or surgical treatment must register with their respective regulatory authority: England: Care Quality Commission Wales: Health inspectorate Wales NI: Regulation Quality Improvement Authority Harley Street London

110 Rationale for changes in regulation
Ensure that treatment carried out by an "appropriate person”. Beauticians and Tattooist are only allowed to carry out simple cosmetic treatment. ( Hair & tattoo removal) Healthcare professional for regulated treatments. Registration therefore ensures that an "expert medical practitioner" who is experienced in laser techniques will; over see "clinical" treatments. Harley Street London

111 Artificial optical Radiation (AOR) safety
In addition to the specific UK laser & IPL regulations already discussed, from April 2010 owners/employers of establishments where lasers/IPLs are used must comply with new H&S legislation The safety regulations apply to all forms of light that may affect workers or clients ( arc welding, sun tanning booths etc) This legislation has a section specifically referring to establishments using laser & IPL. Harley Street London

112 Summary of regulatory issues
Local councils register beauticians and tattooists in England who carry out simple cosmetic procedures. In Wales & NI or any clinic in England offering med/surgical lasers must register under the HSC Act. Must hire a Laser Protect Advisor & Medical Expert Practitioner. These establishments are inspected by the CQC or equivalent regional body. Laser/IPL owners must ensure they comply with HSE guidelines on AOR safety. Harley Street London

113 Teaching timetable An introduction to Laser, Intense Pulsed Light (IPL), Radio Frequency (RF) & E-Light therapies Anatomy and physiology IPL applications Hazard reduction "Core of Knowledge" & legislation issues Getting to know your machine Treatment regimes and practical teaching and scenarios Assessment and feedback Harley Street London

114 Equipment management Equipment checks, Maintenance & Quality assurance. The manufacturer or supplier of your equip should have installed your laser/IPL & checked initial performance. If you have installed the system yourself you must make sure that: Power supply is correct phase & voltage. The fuse rating is adequate- some systems draw more amps than the usual domestic 13 amp circuit. That any water cooling tank has been correctly fitted with no air locks. All hoses connected properly, no water leaks. These checks should be carried out before each use. Harley Street London

115 Output specifications
Your supplier should give you a copy of the system specifications. This should show the actual measured output of the laser compared to the manufacturers specification. If your system has a calibration mechanism then you should check this each time the system is used. If the device fails to deliver the energy within the specifications an error message is displayed indicating a need for servicing. The Flash lamps in IPL systems will deteriorate with each shot fired and are usually limited to a certain number ( e.g., 100,000). Regulatory bodies will wish to review maintenance logs at their inspection. Harley Street London

116 Equipment checks The safety equipment should be regularly checked.
Safety spectacles should be checked for scratches and cracks that may allow light to penetrate and damage wearers eyes. Cables carrying light should be checked. Hand pieces should be checked for cleanliness and cleaning schedules documented using manufacturers guidelines. This will reduce the build up of hair and dirt. The handpiece cooling temperature should be regularly checked. This is not an exhaustive list and any checking should reflect the organisation’s local rules. Harley Street London

117 Caution when using a Laser/IPL machine
Do not use the device if any leads appear to be damaged or broken. Do not use the device in the presence of flammable or explosive substances. Ensure all settings are configured correctly prior to commencing any treatment. Heat may be generated whilst using the device, ensure that there is adequate cooling and ventilation for comfort. The device must only be operated by trained and certified technicians. Switch off and unplug the device from the mains power when not in use. Harley Street London

118 Equiment Summary Equipment should be regularly calibrated by the user.
Calibration, maintenance and safety logs should be kept. Safety equipment needs to be checked and stored close to machine. Treatment heads to be kept clean. Light carrying cables should be checked to ensure no light “leaks”. Cooling system temperature to be monitored. Harley Street London

119 Teaching timetable An introduction to Laser, Intense Pulsed Light (IPL), Radio Frequency (RF) & E-Light therapies Anatomy and physiology IPL applications Hazard reduction "Core of Knowledge" & legislation issues Getting to know your machine Treatment regimes and practical teaching and scenarios Assessment and feedback Harley Street London

120 Treatment with IPL Consultation Prescription client preparation
machine set-up Application of laser/light therapy Documentation Safety Harley Street London

121 Consultation Practicalities: suggested protocols Pre-consultation
The consultation Expectations Consent  Room preparation Machine preparation Client Preparation Harley Street London

122 Pre-consultation/consultation
Client completes skin typing form Clients attending for repeat treatment should be given a new skin typing form & new consent prior to each treatment.( They may have been sunbathing and temp increased their skin type) The consultation Review health questionnaire and discuss any contraindications Complete and sign client consent form Ascertain client goal / target area(s) Assess objective / target Ask client to highlight areas of concern and determine where treatment should be focused to achieve client objectives Take preliminary treatment pictures if agreed. Recommend treatment regime required Explain treatment schedule and costs Post-treatment instructions Known clients should have any changes from previous visits clearly marked on their file and the treatment plan adjusted accordingly. Harley Street London

123 Expectations Harley Street London
Clients should have their expectations managed honestly. They need to understand their commitment to the course. They should understand the nature of the expected results and that it is a gradual improvement. It is better to undersell & have a pleased client than promise the earth and have a disappointed client. The consent form should be signed by the client after any questions have been answered. It is important to obtain consent for every treatment visit ensuring the forms are correctly dated. The client should have adequate time to review your practice consent form. This needs to be a standard form prepared with your solicitor to minimise risks. It should cover the treatments you offer and state any risks involved. It should only be signed in advance of the treatment in the presence of the operator. Harley Street London

124 Room & machine preparation
Room preparation: This should be prepared in advanced based on local rules Machine preparation:   The machine should be started up and warmed up in line with the manufacturer's manual and all recommended checks carried out ( and documented if necessary) Particular care should be taken to ensure that any chilled hand pieces have chilled sufficiently before treatment begins Any ice crust or condensation should be wiped away before use. NB: For mobile IPL/Laser operatives Mobile operators should carry materials with them such a warning signs, fire resistant drapes, adhesive tapes etc to cover reflective surfaces and make clients home safe for treatment. Ensure you carry a supply of distilled water, tubing and a funnel to maintain the machine's cooling system. Harley Street London

125 Settings for the Machine
If using IPL ensure the correct filter is in place: 420 nm or 530 nm is suitable for active acne. 530 nm, 585 nm, or 595 nm are optimal for facial redness/facial veins/rejuvenation plus pigmented lesion. 695 nm is usually used for collagen stimulation or hair removal. Your IPL may have slightly different filter values but will still be in the same range. Set the IPL or laser to the correct patch test settings for the treatment concerned but do not press "ready"-keep the system in "stand-by" ( your manual should come with recommended settings) Harley Street London

126 Variables on the machine
The main variables that can be set on a machine by the user include: Spot size: The treatment beam diameter in mm. In lasers this may be user variable but with IPL the treatment head is usually an fixed rectangular window. Different sized IPL heads can be fitted dependent on your manufacturer. Fluence: In joules/cm2, the treatment energy delivered to a given area of skin. Pulse Number: The number of pulses that will be delivered to the skin. Pulse duration/pulse width: the "ON" time or gap between the pulses. Usually measured in milliseconds. Delay or interval the "OFF" time or gap between the pulses. Usually measured in milliseconds. Frequency or repetition rate: the number of pulses per second displayed in hertz ( Hz) 1Hz= 1 pulse per second. Harley Street London

127 Fluence Power is measured in Watts : Think light bulb!
Energy takes time into account and is measured in Joules. 1 Joule = 1 Watt per second In order to give clients consistent treatment the size of the area must be take into account. It is usual to record the energy in Joules per Square Centimetre delivered by the laser or IPL. As an example, this could be documented as: 40 J per cm2. This is known as fluence. Harley Street London

128 Client preparation: Harley Street London
All make-up should be removed thoroughly using simple soap & water/ foaming cleanser Oily skin may need a more thorough cleanse Non-alcoholic skin cleanser may be used but this should be removed & the skin dried A client pre-treatment photo should be taken paying attention to the lighting and distance Copies of before and after pictures should be kept in case of any client dispute relating to outcomes in the future. Ensure clients eyes are covered with the opaque safety goggles and that all other occupants in the room are fitted with appropriate safety glasses/goggles. If the treatment is for hair removal ( or if there is excessive hair covering an area to be treated for another condition), then the area to be treated should be shaved. ( this prevents burning of the skin surface when melanin absorbs heat) this is best done with an electric trimmer or disposable razor No Plucking/waxing or depilation creams should be used After shaving it is best to cleanse the area to ensure no residual hairs are left on the skin surface Harley Street London

129 Patch testing method Harley Street London
The manufacturer's documentation should have suggested settings in the manual. Usually carried out at 3 increasing energy levels The site chosen should be inconspicuous, but always in the near regions to the proposed treatment zone The client notes must record the positions and settings Contact gel should be used to cover the skin to a depth of around 2mm over the are to be tested. The laser/IPL should be set to "ready“ Apply hand piece firmly to the skin surface and using the lowest of the 3 patch test settings & fire. The client reaction should be assessed taking into account physical as well as personal effects. ( pain/ toleration/sensation) IPL/Laser should be reverted to standby mode and setting increased for second test patch, this process continues until 3rd setting complete. Based on the feedback received this will determine the energy level to be used/tolerated for actual therapy Harley Street London

130 Patch results It is usual to ask your client to remain in your clinic for approximately 15 minutes in order for you to review the immediate skin response. Your client needs to return for a review of the test patch and initial treatment at a later date. The interval before review and subsequent treatment will depend on the treatments and skin type of the client. Darker skin clients will most likely have delayed response and their test patch review schedule should reflect this. Do not attempt treatment on type V or VI unless you have suitable equipment. If there are any pigment changes especially "greying" of the skin, then the setting is too high. Greying indicates a burn and should be treated accordingly. Greatest care should be exercised in dark skin test patches as skin burns can cause long term (occasionally) irreversible pigment changes. Harley Street London

131

132 Setting selection When at the correct setting it is normal to see erythma (redness) which should subside within hours. No redness generally means too low a setting (especially if the client indicates that they felt no heat sensation at the time of treatment). Oedema (slight swelling) is normal and again tends to calm within hours. The test treatments should be tolerable if a little uncomfortable. If redness or oedema are prolonged the settings are too high and must be reduced. Ensure this is all documented clearly. Harley Street London

133 Treatment Harley Street London
Now you have decided on the correct settings after the patch test you can start to organise your full treatment. Continue to check the client's response throughout the session as you fire each shot. Work methodically over the treatment area. Remember to reduce settings over bony prominences or where skin is thinner. There is a chance of the light being reflected back into the tissue in effect doubling the treatment dose. After each main pulse, move the treatment head to the new treatment position overlapping the previous one by a third to ensure coverage. Ensure good contact before firing. The tracks in the contact gel will help you to see where you've just been. Do not use dark marker pen to mark the treatment area as the dark ink will absorb the heat and could leave burns. Use white marker if you really want to mark. Harley Street London

134 Treatment Mask any problem areas from the beam ( such as moles) these will also absorb the heat & cause pain. Moles/pigmented lesions should never be treated with IPL to Laser and should be referred to a dermatologist and/or GP. After firing about 6 times in a row wipe the treatment area to remove the build up of gel/debris. Ensure enough gel on the skin before recommencing. If the client feels uncomfortable during treatment or severe redness or swelling occurs-stop immediately and investigate. Lower settings if necessary (document all of this) Harley Street London

135 Post-treatment Harley Street London
Continue the treatment until the whole area has been covered Remove gel with tissues A cool/cold compress will help with initial redness and swelling Take time to document all setting, times reactions etc. An immediate post-treatment record photo should be taken for your records Clean treatment heads and stow safely Switch machine off if necessary (if there is a delay between clients) Creams or lotions can be applied. Aloe Vera is most suitable. Clients need to be reminded to stay out of the sun for several weeks and to use at least SPF 30 Harley Street London

136 Incidents & complaints
It is your responsibility to ensure that your documentation is concise and up-to-date at all times. See further reading for a link to the MHRA poster with contact numbers for incident reporting. The HSE has links to support you in managing adverse outcomes. If you have any adverse reactions to treatments then these should be fully investigated in terms of settings used, compliance with post-treatment recommendations etc. Adverse incidents MUST be recorded. Similarly any complaints should be dealt with promptly, logged and recorded. Harley Street London

137 Summary Harley Street London
Standardised forms and protocols need to be devised for your practice. Clients must always have a skin typing questionnaire completed along with a consent form (each visit). Discuss any medical history that may be pertinent. Set realistic expectations. Become familiar with your machine: the settings, safety features, protocols etc. Remember that generally darker skin requires less energy (fluence in Joules), but longer pulse durations. Determine the client setting by using a patch test. The IPL/Laser must only be in the "ready" mode when you are actually firing. Maintain good skin contact using gel to enable effective skin cooling. Ensure clients understand the post-treatment skin care regime. Harley Street London

138 Protocols & Methods Treatment using Green/Yellow laser light.
Green & yellow light only penetrate to shallow depth. Melanin & Haemoglobin easily absorb this light. Laser: KTP laser or pulsed dye laser. IPL Green 520 nm or Yellow 585 nm filter Used for: Red facial Vein Superficial pigmented lesions (freckles/age spots) etc Superficial vascular lesions (handset moved along vessels). Usually only 1-2 treatments required Harley Street London

139 Treatment using Green/Yellow laser light cont.....
Red Facial Vein treatment technique: Gel applied to skin; Laser/IPL applied; Endpoint is vessel darkening (damage) or vessel disappearance. Pigmented lesion treatment technique: The lesions tend to get darker then flake away a few days later. Harley Street London

140 Pigmented lesions before & after

141 Pre & post facial vein treatment

142 Treatment is not a cure, simply a means of controlling it.
Active acne infection The only treatment that uses a photochemical effect as opposed to a photo thermal effect. ( using light to stimulate a chemical change) Bacteria that cause Acne contain naturally occurring porphyrins Porphyrin is a light sensitive molecule (sensitive to blue/green/yellow light) When activated the porphyrin releases super oxygen 03 (a very unstable version of Oxygen) This Free- radical Oxygen kills the bacteria cell. Laser :KTP or pulsed dye IPL with blue/green filter is used (420 nm or 530nm) Low energy is used as it is a chemical reaction not requiring heat. Secondary benefit of "drying out" of sebaceous glands where bacteria thrive. Also reduces redness-as in rosacea. Treatment is not a cure, simply a means of controlling it. Harley Street London

143 Hair reduction treatments
As light is delivered into the dermis which is absorbed well by the melanin in the hair shaft. Lasers: (Ruby & Alexandrite) IPL using 690 nm filter The bulge is now thought to be responsible for hair growth. The follicle & bulge can be selectively heated by applying the correct setting on the laser/IPL machine. Fairly long pulse is needed for the heat to conduct outwards towards the bulge. Growth phase affects outcome. Only hairs in growth phase will be destroyed. Series of treatments carried out, usually 6-8 weeks apart. Harley Street London

144 Technique: Area first shaved: Necessary to remove hairs at the surface which would absorb energy and waste laser/IPL energy. Heat absorbed at the surface would be very painful for the client as the heat would be transferred to the skins surface. Contact gel applied: Increases conductivity of energy. Laser or IPL energy delivered. Energy absorbed by Melanin which transfer heat to follicle and bulge which is then destroyed. Harley Street London

145 Hair removal before & after

146 Hair reduction Approx 40% of growing hairs destroyed with each treatment. Ruby, Alexandrite & IPL provide rapid coverage. However these systems are for lighter skin types only up to skin type IV (must not be used on types V & VI) Hazards of skin type High absorption of Ruby, Alexandrite & IPL by melanin not only in hair but in the basal layer of skin. Therefore only suitable for skin I-IV. Otherwise post-inflammation hyper (or hypo) pigmentation may occur. Important to understand skin types using Fitzpatrick scale. Harley Street London

147 Hair reduction in skin type V & VI
The Nd:YAG (1064nm) is absorbed by melanin but has a lower absorption than all other systems. It also has deep penetration in skin. It is the safest hair reduction laser -suitable for all skin types Certain diode lasers can also be used with care to treat type V skin. A combination of IPL & RF (known as E-light) can also be used on type IV but not type V. Long pulsed hair reduction in type V & VI skin reduces risk of burning &/or pain. In order to reduce the heat absorbed in the melanin in type V & VI very long pulses are used. These long pulses allow conduction of heat away from the critical melanocytes ( melanin producing cells in the basal layer) Remember the pulses graph? Harley Street London

148 Superficial leg vein treatment using Nd:YAG laser
Because of its deep penetration, leg vein treatment is also possible with the Nd:YAG laser. Nd:YAG penetrates deep into the dermis. It can treat vessels up to 4mm. Can treat blue as well as red veins. Superficial not Varicose Veins. Varicose Veins need surgery not laser. Harley Street London

149 Skin rejuvenation Skin rejuvenation :
A non-ablative technique for improving the appearance of skin using wavelength lasers or IPL. Not to be confused with skin resurfacing Resurfacing involves removal of layers of the epidermis. Skin rejuvenation : Treatment for fine lines & sun damage. Treats face, chest neck & hands. No down time. Can be performed in lunch hour! Typically several treatments needed. Harley Street London

150 Rejuvenation concept Laser/IPL heat superficial and deeper skin dermal structures. While simultaneously cooling the superficial skin. Stimulation of a reparative process resulting in new collagen & elastin fibres being reproduced with no injury to skin. Harley Street London

151 Step-by-step skin rejuvenation
Step 1: Visible Green/yellow light (from laser or IPL) Aim: target superficial blood vessels Injury caused which release inflammatory mediators which then stimulate fibroblast to increase collagen. Step 2: Use longer Nd:YAG or IPL source which will automatically have the longer wavelengths in the broadband of light delivered. (Remember the fanning effect of light scattering!) This will non-selectively heat the dermis - It gives a sub threshold injury to dermal structures ( it will denature the structures without destroying them). - Causes a repairing process and stimulate collagen reformation as before. Harley Street London

152 Synergistic effect 3 effects: Removal of vascular/pigmented blemishes.
Stimulation of mediators/fibroblasts leading to collagen remodelling. Direct stimulation of collagen with some immediate tightening plus longer term collagensis. Harley Street London

153 Ablative and fractional techniques
Skin resurfacing lasers: highly absorbed by water vaporize tissue as soon as they impact the skin. Lasers include the CO2 laser, Erbium YAG, Yttrium scandium gallium garnet (YSGG) Original resurfacing technique: Use pulsed CO2 laser to remove facial epidermis down to papillary dermis. Performed under GA in OT. Needed occlusive dressings (6/52 recovery). Harley Street London

154 Non-ablative treatment
Skin laxity/tightening using infra-red laser device. Use cooled hand piece delivering broad band infra-red directly to the collagen layer. Collagen fibres shrink by up to 1/3 in length when heated. As the collagen will be denatured, longer term new collagen production. Harley Street London

155 Ablative skin rejuvenation
before after before after

156 Skin rejuvenation with IPL

157 Laser tattoo removal: how it works?
Laser tattoo removal is achieved by using a special laser that has a Q switch. A Q switch is an electro-optical device that delivers the laser energy in an extremely short pulse (nanoseconds) and high intensity burst of energy. The energy is absorbed so quickly in the tattoo ink that if the energy setting is correct. The tattoo ink is mechanically broke down into small fragments which are removed by the body's immune system. Harley Street London

158 Usual wavelengths used
Nd:YAG (1064 nm) is suitable for blue/black inks. Frequency doubled Nd:YAG is suitable for red/brown inks. Note: These lasers are special Q-switched versions The normal Nd:YAG & frequency doubled YAG cannot be used for tattoo removal. Green & Yellow ink are the hardest to remove due to poor absorption of the various wavelengths. Harley Street London

159 Skin type considerations
The tattoo removal laser is capable of interfering with the naturally occurring melanin in dark skinned clients. It is important to limit treatment to clients of types I-IV only. Permanent light or darker pigment can occur on type V & VI. Usual many treatment to successfully remove. Harley Street London

160 Summary Aesthetic light based applications depend on the wavelengths of light chosen & the pulsing characteristic of the device. These must be chosen to match the relevant tissue target. Skin type of the client is an important factor to consider when deciding whether treatment can go ahead, and which wavelength/type of equipment is suitable. Harley Street London

161 Teaching timetable An introduction to Laser, Intense Pulsed Light (IPL), Radio Frequency (RF) & E-Light therapies Anatomy and physiology IPL applications Hazard reduction "Core of Knowledge" & legislation issues Getting to know your machine Treatment regimes and practical teaching and scenarios Assessment and feedback Harley Street London

162

163 Requesting service For service go to and click on the “Priority Service Call” button on the home page. Complete the job ticket and you will receive a response within 1 business day. Harley Street London

164 Further reading Useful links and tools: Harley Street London
Link to MHRA Device bulletin 75 MHRA top tips poster for your wall HSE Optical radiation safety guidelines Harley Street London


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