Welcome to Plastic Surgery Talk with Dr. Steven Mulholland brought to you by SpaMedica.
Hello and welcome. Dr. Steven Mulholland here in Toronto, Canada on Plastic Surgery Talk with the latest installment of our podcast series. If you’re finding these podcasts informative, educational, entertaining please sign up, comment and share. Our topic today’s on painless laser tattoo removal. So, why have a talk on painless? Well, clearly we have a whole topic, a whole podcast on painless because the act of laser tattoo removal can be quite uncomfortable. So what happens during laser tattoo removal? We have specialized lasers. Here at SpaMedica, we have a rev light, we have an accolade, we have an infinity, we have a PicoSure, we have a PicoWay, we have five different wavelengths of five different devices. And multiple different wavelengths. All in a very, very short pulsteration called a Pico which is a billion times shorter than a blink of an eye. A trillionth of a second. And having such a short pulsteration means that there’s very little thermal effect. When that laser beam hits the tattoo ink, impregnating your dermas, it shatters the ink into trillionths of little particles. Little grains of sand that your body can remove through it’s own immune system.
And so, even though there’s very little heat built up which is good. That’s one of the secrets of the Pico. Short pulsteration. A photo acoustic effect on the tattooing, shatter it into bite size morsels, so your immune cells come along like little pac-men and gobble up those tattoo particles and take them away to your liver and to the urinary tract where it’s eliminated. Because there’s very little thermal build up unlike earlier generation tattoo lasers, it doesn’t cause a hypopigmentation or as much ghosting as earlier tattoo lasers did. The earlier tattoo generations even I had those back 15 years ago. They cause a lot of hypopigmentation as well as tattoo removal.
The Pico. The PicoSure, PicoWay, the state-of-the-art Pico second pulsteration lasers. They avoid a lot of thermal trauma to the melanin pigment form of cells and shatter the ink particles through photo acoustic, not a heating effect. Now the pain in tattoo removal comes from that shattering effect. When the photon from the laser hits your skin, you hear a pew! An explosion. A photo-acoustic effect, and it shatters the ink part into millions and millions of particles. And for a Pico second, those particles are moving and breaking up and traveling through the skin in what’s called the dermas. And such high-velocity shatter effect or photo-acoustic effect is quite a potent stimulus in the sensory nerve ending. So the shattering of the pigment traumatizes or mechanically stimulates the nerve fibers and it hurts. It hurts because of the photo-acoustic shattering effect of the ink, not from the heat.
And so, it can hurt. In fact, it hurts far more to get the tattoo off than the pain of having a tattoo inserted. So, the challenge on the topic of the webinar. What do we do to give a laser tattoo removal patient a painless experience? So how do we render a painful laser tattoo removal experience painless? Well, multi-modal approach to controlling the pain fibers. So here at SpaMedica, a lot of the doctors out there that have been trained by me or come to my workshops or been on this podcast know that there’s no one thing that’s going to completely eliminate pain, but a multi-modal approach together with an inhalational agent can almost eliminate pain. So one of the ways we take down the pain and discomfort, like all clinics do, is topical anesthetic cream. So we might use some topical benzocaine, lidocaine, tetracaine, topical maxilene, topical five percent lidocaine. A topical anesthetic cream takes some of the sting away; however, it doesn’t penetrate deep enough to take the pain away from the shattered ink particles completely.
So topical anesthetic cream, we use for many years is one modality to reduce the pain, but we need something more than that and so another option is a chilling device. Like the Zimmer five or Zimmer six to force cold air on the skin definitely helps take down the pain when used in combination with a topical anesthetic cream. I would say 50 percent reduction discomfort, but that’s still not good enough. What else do we do? Well, for large tattoos, one’s that are bigger than the size of the palm of your hand. Let’s say a medium size of your hand or bigger, like part of a sleeve. We used something more than a topical and a chiller. And we use very dilute intra-lesional or injected into the skin, lidocaine. We actually inject the anesthetic agent like a dentist would if you’re getting a root canal or a wisdom tooth out. We freeze the skin which takes all the pain away.
So great all we need to do is injectable lidocaine and injectable local anesthesia. The problem is the injection of the lidocaine can hurt a lot. And so, what do we do ultimately to make the whole experience very, very comfortable? We give patients nitrous oxide. Good old fashion laughing gas. It’s been around in the dental offices for 40 years. Now, finally, we have both Health Canada and FDA- approval for a 50 percent medical outpatient clinic treatment. At 50 percent nitrous oxide, you’re legally able to drive in eight to 10 minutes after it’s used. So how do we make this a painless experience? We combine multi-modal options particularly intra-injection, intra tattoo injection of lidocaine. But under the influence of nitrous oxide. So how does nitrous oxide actually work? Well nitrous oxide is a gas. We have 90 percent nitrogen in the atmosphere, so 91 percent oxygen and carbon dioxide. But when we administer medical nitrous oxide, it’s at 50 percent, so 50 percent nitrous oxide, 50 percent oxygen. 50 percent nitrous oxide, and there’s several brands. The most commonly used brand in North America is called Pro-Nox from CAREStream.
So Pro-Nox the most commonly used product. Very simple to use, on wheels, you can take it from room to room, little tank of oxygen, little tank of nitrous oxide mixed together in a simple inhalational obturator in tubing. So the patient inhales six, seven, eight deep breaths. Within a minute, the start to have that nitrous oxide effect. So what does nitrous oxide do? The inhalational agent held for a couple of seconds, six to eight breaths, releases a tremendous amount of intracortical, or intercranial neurotransmitters of well-being. The endorphins called dopamine and serotonin. These neurotransmitters give you an overwhelming since of euphoria or happiness. And so you can feel the injection of the tattoo or the soft tissue fillers, like Juvederm, Restylane, or Botox or laser hair removal. We use it for many different things. You can feel the laser tattoo removal freezing going on, or the tattoo removal itself. But your brain appears so full of euphoria you separate your brain from the painful experience going on in your hypothalamus. Your hypothalamus which registers the pain goes, “That hurts, that hurts.” And your brain goes, “Ah, I don’t care. I’m feeling great. I’m euphoric.”
And so, nitrous oxide or laughing gas doesn’t leave you stoned in the sense of let’s say, medical marijuana would; an altered consciousness. It leaves you very acute and aware but distanced. Almost separated. An out of pain experience what I call fun pain. You know what’s going on, but you don’t care. Very, very fun feeling. In fact, many patients start giggling hence the term laughing gas. So it’s patient administered. Patient’s hanging on to the obturator in tube and it’s spiraling out of the 50/50 mixture of nitrous and oxygen while the technician or the doctor’s injecting, lasing, and treating. And patients find this a tremendously fun and pain diminishing, almost eliminating type of experience. And it’s been such an important object to my aesthetic practice. I would say it’s the single most important technology I brought into my practice in the last three years. It has made so much more money through retention and referral than you can imagine. And as we’ll see later in this podcast, I think it’s one of the most important decisions you might make in 2019 is to bring, if you’re a doctor listening to this podcast, bring nitrous oxide or Pro-Nox in your practice.
If you’re a patient, go to those practices that’s going to give you a great experience. Fun pain with the use of laughing gas. So what’s the big deal? How painful is laser tattoo removal? I mean, it’s got to hurt more to get the tattoo on, right? Wrong. It’s actually far more painful to get the tattoo off. So most patients say they had their tattoo removal and it was tolerable, maybe a four our of 10. But they describe tattoo removal, even with the Pico second pulsteration, PicoSure, PicoWay, that tattoo removal, using a laser can be upwards of eight or nine out of 10 on pain. So it’s one of the more painful laser treatments we inflict on patients. Laser hair removal, laser CO2 resurfacing, laser fractional or resurfacing, laser hair removal, or mirror dry, sweating. These are some of the more painful treatments and anytime we can reduce that pain, and it makes the patient experience more rewarding, less distressful, certainly less painful. We’re going to get a patient who’s going to say good things about us, tell their friends, and come back for more treatments.
Okay, so if laser tattoo removal is going to give you an eight out of 10 pain, which is significant. How effective is Pro-Nox? How effective is nitrous oxide? How effective is laughing gas reducing that? Well, if you ask patients to give you a score out of 10 after they’ve used laughing gas after laser tattoo removal or Botox or soft tissue fillers or laser hair removal. Any of the painful things we do, laser CO2 resurfacing. They will tell you after laser tattoo removal, that pain went from and eight out of 10 down to about a one or a two. So significant reduction. Massive reduction. The perception, the experience, and the processing of that painful stimuli, the patient know it’s there, but the euphoria that washes over their brain by the release of dopamine and serotonin.
With the laughing gas. The Pro-Nox. The nitrous oxide. Eliminates virtually all the pain down to a minimal amount of discomfort that patients basically corticate and evaluate as being insignificant compared to treatments they might have had without laughing gas and nitrous oxide. So a massive reduction of pain making the whole process a desirable and a fun kind of pain that patients are not going to be afraid of coming back for their second, third, fourth, fifth, and sixth treatment. So if it really hurts the first time, the chance of getting them back excited about the second time is diminished. They may not show up because you didn’t take care of the pain. Laughing gas, nitrous oxide helps your attention rate because it eliminates virtually all the pain.
So what are the timelines like? The timeline to starting the inhalational, when you have the pain reduction and relief, and then how long does that pain relief last? In general, when you’ve had a full inspirational eight or nine breaths, you’re going to get a good three, four, five minutes of pain relief. So a lot of patients will take a minute or two of inhalational deep breaths while we’re doing a treatment like laser tattoo removal, and then they might remove the obturator from their mouth and breathe normal room air. When it starts to get painful again, they might again takes some inspired nitrous oxide or laughing gas to again enhance and build up the levels of serotonin and dopamine again.
How long will that last? Generally, about 10 minutes of pain relief when you stopped inspiring. And so, patients can actually do a whole 15, 20, 30 minute procedure simply by taking several deep breaths in a row, waiting, breathing room air, then taking some more when it starts to get more painful. So they can titrate the laughing gas to the needs of their discomfort and have perpetual pain reduction for half an hour, 45 minutes or and hour depending on the length of the laser tattoo removal procedure.
What are the side effects of nitrous oxide? There are very, very few risks. I mean, it’s present in the atmosphere that you breathe in at 90 percent. At 50 percent, very few risks. If you had full minute advanced liver failure, insufficiencies to your kidney failure or significant or unstable heart disease or angina. Clearly, you’re not going to be using nitrous oxide and most commonly you’re not going to be presenting to a cosmetic plastic surgeon, dermatologist, or SpaMedica getting this treatment, so it’s for well medical patients. If you’ve got a well medical body, then nitrous oxide completely tolerable. There are some side-effects in about five percent of patients after some deep inspirations and a great laughing gas effect, they might feel a little light headed. You might feel sometimes a little bit sweaty or even a vague sense of nausea and sometimes even a headache can occur from the nitrous oxide, but 95 percent of the time there are no symptoms like that.
The symptoms of light-headedness, vague sense of nausea, maybe a headache goes away in about five to 10 minutes if you do get those symptoms. So 95 percent of the time, no side effects, no medical contraindications making it one of the best pain relief reduction options I’ve got in my practice.
So who’s a candidate for nitrous oxide, laughing gas, or Pro-Nox? The best candidates for laughing gas are those patients undergoing an outpatient medical treatment that is painful, so medically well. And they’re undergoing a painful laser treatment, like laser tattoo removal, laser hair removal, injectables. Nitrous oxide, laughing gas is great for Botox and soft tissue fillers. Particularly the soft tissue fillers that feel quite uncomfortable. It’s a great treatment for those patients undergoing, let’s say, local anesthetic infiltration. You’re doing some liposuction under local and you want to put the freezing into the fat. It’s great to take the pain away from the freezing, once you’re frozen, you don’t feel the pain of the treatment. So it’s great to provide pain relief while you’re making an area very numb or frozen.
It is great to use during, let’s say, after surgical treatments like removal of staples and sutures in sensitive areas like blepharoplasty eyelid or sensitive areas in the breast or the labial region or abdominal area. Removal of staples and sutures, it’s great for that. There’s so many little applications for nitrous oxide in your practice that you’ll find that if you’re like me, patients seek me out because they know they’re coming to get a great treatment from a great physician who has great nurses, as well. And they’re going to be treated well, and they’re going to get laughing gas or nitrous oxide to make their clinical experience no matter if it’s injectable, laser, post-op care, or intraoperative infiltration of local anesthesia. The laughing gas is going to take 80 percent of the discomfort plus away.
So what should you be looking for in a clinic when getting a treatment you know after your online review you know to be painful? Once you’ve done your Google searches, you look for the top treatment centers in you city. Google and my problem or the type of laser, the type of clinical treatment you want. Botox, my city. Or soft tissue fillers, my city. Or laser tattoo removal, or PicoSure tattoo removal, my city. Come up with the top practices. And if Google has ranked them relevantly in the top one, two, three, or four, they’re going to be the best in that city.
Now what else should you look for? You should be looking for the practice itself. What kind of lasers they use? How long have they been doing it? What’s the experience of the lead physician and his delegees? What kind of experience in terms of pain reduction they’re going to offer you? If you want the painless, current state-of-the-art 2019 going for painless reduction of laser treatment such as laser tattoo removal, you want to see practices that offers you not just topical anesthetic cream, not just an air chiller, not just a local anesthesia, but nitrous oxide, laughing gas.
Laughing gas with the integrated aforementioned techniques and the painful laser treatment like tattoo removal will take you from an eight out of 10 down to a one. Making the pain fun pain. The kind of pain you don’t mind coming back for. The kind of discomfort aesthetically acceptable discomfort that leaves you thinking, “Okay. I can do a series of treatments and I actually enjoyed this. I’m looking forward to coming back.” And that’s the kind of practice you’re looking for. The practices committed to pain reduction of it’s customers, clients, and patients. And nitrous oxide is going to be an extremely important part of that decision and you go forth in 2019 and 20. The best practices are going to have laughing gas.
So thank you for joining me here. Dr. Steven Mulholland in Toronto, Canada on Plastic Surgery Talk. Where our podcast today was on painless laser tattoo removal using laughing gas or nitrous oxide. If you found this podcast entertaining, informative, and educational please share it, sign up and comment.