Welcome to Plastic Surgery Talk with Dr Steven Mulholland, brought to you by SpaMedica. Hello and welcome Dr Steven Mulholland in Toronto, Canada. And we’re at our weekly podcast on Plastic Surgery Talk. This week is on laser hair removal and it’s one of the most common requested laser procedures. In fact, after doing this now for 20 years, laser hair removal still remains in one of the top four or five treatments we do in the medical spa and it still is associated with significant discomfort. Huge benefits, smoothless, shimmery, silken hair-free skin, but there are some discomfort in getting that laser energy into the skin. So this week’s podcast, like similar podcasts in the past, is how to achieve painless laser hair removal. If find these podcasts entertaining, engaging, educational, informative, please subscribe, share and comment.
First and foremost, how does laser hair removal work and why is there a discomfort or pain associated with it? Laser hair removal involves the use of a laser, a medical device, an energy emitting device that pumps out little bundles of the energy, electromagnetic energy called laser or photons. These photons are bundles of light that travel like a sound wave in a wave pattern. And when they hit the skin, they’re looking for a target. And so the target that laser hair removal is looking for is melanin or pigment forming cells, not the melanin and pigment forming cells we see on the surface of the skin, although we’re going to be cautious in treating that, but the melanin down the hair shaft.
So it heats up the hair shaft, creates heat that radiates out to the growth centers and kills the growth centers. Now in exchanging the heat with the hair shaft, it photo-coagulates the hair shaft. So if you’ve had laser hair removal, you smell that smell, that faint smell of singed hair. That’s the photo-coagulation of the shaft that then sends the heat out to the growth centers, and the heat acts as a suicide bomb, a suicide bomb of thermal energy for the growth center. So it kills the growth centers dead. But in creating that heat, the heat can create some collateral discomfort or pain.
And so we do several things to reduce the pain or perception of pain during laser hair removal. Number one, we have dynamic cooling systems. The best laser hair removal lasers are super fast. They often slide on the skin. They cool the skin as they go, which reduces the discomfort. Often they pre cool, cool during the pulse and post-cool. We also can use topical numbing cream to numb the sensory nerve fibers that are getting heated during the interaction of that photon in the skin. There’s cold air systems. We can hold cold air that blows on the skin and numbs the nerve endings, sort of like on a cold winter day, your face can feel numb. We use that same principle to minimize the discomfort during laser hair removal.
We can use the cryogen spray that hits a skin and numbs the skin just before the laser pulse. But what I found the most effective in addition to any one of those number of topical techniques is the use of nitrous oxide or laughing gas. The use of laughing gas or nitrous oxide can take a discomforting feeling like laser hair removal and make it fun pain, converting the pain that you actually dissociate from and find the whole experience euphoric and full of happiness. Not only for the outcome, but that sensation of discomfort is modulated.
So what is the severity of discomfort or pain during Laser hair removal? What’s the pain score? If 10 is the most painful thing you ever do an aesthetic medicine or treatment sort of waxing or having sort of a tummy tuck or something that works on your muscle, those are an eight, nine or 10 out of pain. No pain would be something like a microdermabrasion or a gentle bulky radio-frequency treatment like the form or the Venus. Laser hair removal, depending on your pain tolerance is somewhere in between this. It’s about a five or a six. Some sensitive areas like a guy’s back may be seven or eight out of 10 in pain.
So it’s moderate in discomfort to moderate to strong. And so anything we can do to decrease or modulate that sense of discomfort during laser hair removal makes it way more tolerable for the patient. And for the physician practice it’s going to facilitate more referrals, more patients that are compliant with returning for their multiple treatments because it’s often five to six treatments once every six or more weeks to get 75 to 80% reduction. So you’ve got your patients coming back up to five or six times. You want to make sure it’s a comfortable experience.
So how does nitrous oxide or laughing gas work to reduce or eliminate the pain and discomfort of laser hair removal? Well, first what is nitrous oxide? It is laughing gas. The atmosphere, what we breathe in every day has about 9% nitrogen. This is 50% nitrous oxide, NO2. And it’s 50% pure oxygen. So when you have that concentration of inspire laughing gas or nitrous oxide, there’s a sudden release of serotonin and dopamine, the two neurotransmitters of euphoria. They are the neurotransmitters released when you exercise and you work out. They’re like our endorphins and they swamp our brain with great feelings of wellness and wellbeing and euphoria. So even though the treatments being done, the lasers being fired, we’re singeing the hair, we’re killing the growth centers, your pain is processed in the center in your brain called the hypothalamus and your hypothalamus is going this hurts, this hurts. But your brain, which is above the hypothalamus, it’s euphoric and it looks at that pain center and it says I don’t care.
So sort of dissociate you from the discomfort. And it’s not that you alter your consciousness, it’s not like you are feeling stoned as if you had a narcotic substance or if you’re in Canada, a non-narcotic substance like marijuana. It doesn’t alter your perception of reality. It distances your brain in its reality from the pain. And so it’s like pain that you don’t care about. Kind of fun pain. And so this rush of endorphins or euphoria happens in about seven or eight breaths. And then once you’ve stopped having your laser hair removal, you stopped using the nitrous oxide that washes out, you’re back to normal in about eight minutes. So 10 minutes later, you can legally drive. How much does it reduce the pain? It can take a six or seven, eight out of 10 laser hair removal pain and make it a one, virtually eliminating it.
So what is the temporal sequence? What’s the flow when you come into Spa Medica or another laser hair removal center that uses laughing gas or nitrous oxide, Pro-Nox or nitrox? So you’ll come in, you check in, you’re having your treatment that day. We disrobe, we make sure you shave your hair area down to a stubble. We might put a little topical anesthetic cream on, but generally we don’t need help from anesthetic cream when using Pro-Nox or nitrous oxide. And then the treatment begins. We start with six to eight deep breaths of nitrous oxide. Hold it for about three seconds, allowing it to fill your lungs, get into the capillary membranes and the bloodstream of your lung. That takes it right to your brain and boom releases all that good stuff. The dopamine and the serotonin, the sense of euphoria washes over you and then we begin the treatment.
Laser hair removal treatments now are super fast, whether they’re using high-speed diode like the Triton or the Dilaz or the Vectus or the Soprano or an Alexandrite YAG laser like the Gentle Max Pro. We can often do large zones like a full leg, half leg in 10 minutes or so. A whole back, a chest again in 10 to 15 minutes. We do have the topical sliding glide water cooled tips of the diodes, the eight 10 nanometer diodes, and often the cryogen spray of the Alexandra [inaudible 00:08:25] or the air chiller. In addition to our nitrogen oxides, we have a quick treatment. Patients can self administer the laughing gas during the treatment. They can take a minute or two break if they want or they can continue to breathe throughout the treatment.
In general, there’ll be the separation of euphoria and pain. Patients often are quite separated from the discomfort. They comment that they didn’t even feel it. They were aware of it, but they were distanced from it and it was a one out of 10 experienced for discomfort. Some say I don’t even call it discomfort. They actually had fun or it was pleasurable to have that euphoric sense for the period of time during the treatment. Then after the laser treatment, we clean off the ultrasound gel or whatever topical you may have on, we go through the laser hair removal post treatment instructions and you must wait about eight minutes before you can legally drive. And you come back again in your prescribed time, six, eight, 10 weeks later and do your next treatment again under the benefit of nitrous oxide.
The risks or side effects of using a nitrous oxide for laser hair removal or any other aesthetic treatment? Well, they’re divided into absolute contraindications. For example, a pregnant woman, someone who has respiratory disease or liver failure or primary organ decompensation, kidney failure. And then the relative contraindications, some unrealistic expectations for the treatment. Patients who are prone to nausea and vomiting or have had nausea or vomiting while getting nexus oxide during a dental procedure. Individuals that have contraindications for treatment of that technology in the treatment zone. So there’s relatively few contraindications. The number one contraindication is patient’s expectations for the treatment are unrealistic and therefore doing the treatment with or without nitrous oxide does not make any sense. Individuals who are prone to nausea and vomiting after anesthesia should be cautious when using nitrous oxide, but in general, super well tolerated, virtually no contraindications other than the rare circumstances we just listed.
And it becomes one of the most important elements of your aesthetic practice whether it’s injectables, whether it’s a laser like laser hair removal or radio frequency treatment, ablative treatments, pre freezing for surgery. You’ll find nitrous oxide insinuates and situates itself in your practice and very elemental important junctures, the interface of the pain and to patient, patient and pain. When you put nitrous oxide in between those two, the experience of the patient, the return visit frequency, the referral of other patients blossoms. So you really need to look at nitrous oxide as a method to grow your practice and have your patient experiences far superior.
So who’s a candidate for nitrous oxide or a Pro-Nox or Nitrox? Any patient undergoing a medical aesthetic treatment, whether it’s discomfort or pain involved that doesn’t have a contraindication and is willing to wait the eight to 10 minutes before driving a motor vehicle is absolutely a great candidate for nitrous oxide. I started out using nitrous oxide mainly to use during my local anesthetic face lifts and liposuction when I’m [inaudible 00:11:43] or freezing an area. And then I expanded to injectables like soft tissue fillers, Botox, painful laser treatments, virtually anywhere where there’s discomfort. Pro-Nox or nitrous oxide has become a big part of the practice. And so what’s an indication? A patient having a treatment that’s uncomfortable.
So what would the costs be to you, the patient or you the physician if your physicians watching this podcast? Well, first to the patient, most practices adopt one of two models. The first model is that the nitrous oxide is rolled into the price and there’s no additional costs. Then there’s the cost to the doctor. Cost to the doctor is the cost of the tubing, it’s often 15 to $17 US and the cost of the nitrous oxide, which is about I estimate about 10 to $15 every 10 minutes. And so $25 for the average cost of goods and services to the doctor. And if you have a high average selling price procedure like a face lift or liposuction or multiple fillers, mirror dry treatment, you might consider just rolling that into the price of the service.
If however you have a lower priced procedure, a small amount of botox or a one or two syringes of filler, you might pass that $25 to $70 US cost onto the patient as an additional benefit for bringing that euphoria, that disassociation in the discomfort from the treatment through the use of laughing gas onto the procedure price. And so you can layer it on the price. So you can charge per use. You can roll it into the price and and keep the costs hidden. Either way, it’s essentially you offer this to the patient. It’s affordable, and most patients when asked would you spend 25 or more dollars to have a painless aesthetic treatment like that? Most would say absolutely.
So what to look for in a laser hair removal practice if you’re a patient? Well, first of all, look for a clinic with experience. Many, many years doing laser hair removal. Now, if they’ve had a lot of experience like the Spa Medica, we’ve been doing laser hair removal for over 20 years. An experienced center like mine that’s successful is not going to have just one wavelength. You’re going to have multiple wavelengths. We have an eight 10 diode, two or three of them that we can use on light skin with dark hair and even brown skin and dark skin with dark hair. They’re going to often have an Alexandrite, a 755 nanometer Alexandrite laser, which is great for white skin and dark hair. You’re also going to need to have a long pulse YAG for the most part at 10 64 nanometer. A long pulse device that’s very safe on dark skin with dark hair. And so you’re gonna have options.
And if you’re a center like Spa Medica, you’ll even have a Triton, which is like the god of [inaudible 00:14:22] where you get all three wavelengths in one box. In fact, you get fusion of wavelengths. You can treat a light skin, dark haired patient with a 755 8-10 combo or Fusion wavelength where both the Alexandrite and the diode are hitting the skin simultaneously, optimizing permanent reduction of some hair follicles that might be sensitive to one wavelength, not the other, or these follicles sensitive to the diode and not the Alex. You get broader coverage, you get more terminal, thermal exchange with growth centers and you get after three treatments, upwards of 85% perimeter reduction. The best permanent hair reduction ever reported.
On the other side of the spectrum for darker skin, we can combine the 10-64 YAG along false YAG and the diode, and again after three treatments get 81% perimeter reduction of women of color, which is amazing because we often have to turn down the energy on skin types of color to minimize interacting the laser hair removal with the skin brown tones. And so look for multiple wavelengths. Look for a center with lots of experience, look for a beneficial pricing, look for great testimonial patients on rating and review sites like Google+, Facebook, Twitter, Instagram, Real Self and Radium DS, Yelp. Make sure that people are saying good things about this practice, particularly with their laser hair removal.
Check the colleges of physicians, of surgeons in Canada or the medical boards to make sure that there’s a licensed physician that looks after/owns the clinic and that has no medical legal actions successful against them, particularly in a hair removal. And then just go in for a consultation and make sure, hence the topic of today, they have adequate discomfort management, particularly the use of nitrous oxide, Pro-Nox or Nitro knocks to make your laser hair removal experience not only efficacious but comfortable.
So thank you for joining me, Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk. Our podcast today was on laser hair removal. Specifically, how is it done? What’s involved? What are the indications? Contraindications? What kind of outcome? We’ve never been this good at it. Three treatments, 85% perimeter reduction for patients with light skin, dark hair, and three treatments, 81% perimeter reduction if you have dark skin, dark hair. How do we make it comfortable? Nitrous oxide or laughing gas. Yet another indication for nitrous oxide in the experience, the optimized experience of an aesthetic patient, laser hair removal. So if this podcast was entertaining, was engaging, mostly and importantly informative, and you want to see more, please sign up, comment and share.