Standard guidelines of care: Laser and IPL hair reduction

Member, IADVL Dermatosurgery Task Force* and President and Director, NU Skin World & Nisarg Skin Lasers, Surat, Gujarat, India

Correspondence Address:
Rajesh M Buddhadev
President and Director, NU Skin World & Nisarg Skin Lasers & President, IDCALM � , B-wing, 307 Tirupati Plaza, Complexes, Athwa Gate, Nanpura, Surat, Pin: 395001, Gujarat
India

Copyright: (C)2008 Indian Journal of Dermatology, Venereology, and Leprology

Abstract

Laser-assisted hair removal, Laser hair removal, Laser and light-assisted hair removal, Laser and light-assisted, long-term hair reduction, IPL photodepilation, LHE photodepilation; all these are acceptable synonyms. Laser (Ruby, Nd Yag, Alexandrite, Diode), intense pulse light, light and heat energy system are the different light-/Laser-based systems used for hair removal; each have its advantages and disadvantages. The word "LONG-TERM HAIR REDUCTION" should be used rather than permanent hair removal. Patient counseling is essential about the need for multiple sessions. Physicians' qualifications: Laser hair removal may be practiced by any dermatologist, who has received adequate background training during postgraduation or later at a centre that provides education and training in Lasers or in focused workshops providing such training. The dermatologist should have adequate knowledge of the machines, the parameters and aftercare. The physician may allow the actual procedure to be performed under his/her direct supervision by a trained nurse assistant/junior doctor. However, the final responsibility for the procedure would lie with the physician. Facility: The procedure may be performed in the physician's minor procedure room. Investigations to rule out any underlying cause for hair growth are important; concurrent drug therapy may be needed. Laser parameters vary with area, type of hair, and the machine used. Full knowledge about the machine and cooling system is important. Future maintenance treatments may be needed.

Keywords: Photothermolysis, Hair removal, Permanent Hair Removal, Laser Hair Removal, LHE, IPL, Hirsutism, Hypertrichosis

Introduction

Hair reduction and hair removal are two of the most common cosmetology procedures performed by dermatologists all over the world. It is a safe and effective procedure.

Definition of Procedure

Any Laser/IPL/LHE-based equipment used for removal of unwanted hair should be labeled as "Laser and light based techniques for long-term hair reduction".

1. The word Laser is an acronym for Light Amplification by Stimulated Emission of Radiation
2. IPL is an acronym for Intense Pulsed Light system
3. LHE is an acronym for Light, Heat and Energy device
4. Any device that uses light and heat, either singly or both, and uses the basic principle of selective photothermolysis is included.
5. The phrase "long term hair reduction" should be used rather than permanent hair removal as the global experience of Laser and light-based technology is hardly two decades old.

Evidence: Level A

Barlow RJ, Hruza GJ. Lasers and Light tissue Interactions: Lasers and Light Vol 1. Saunders (Elsevier India Pvt Limited); 2005. p. 978-81

O′Shea DC, Callen WR, Rhodes WT. Introduction to Lasers and their applications. Menlo Park (CA): Addison-Wesley Publishing Co; 1978.

Anderson RR, Parrish JA. Selective photothermolysis: Precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524.

Arndt KA, Noe JM, Northam DB. Laser therapy: basic concepts and nomenclature. J Am Acad Dermatol 1981;5:649-54.

Tanzi EL, Jason R, Lupton M, Alster TS. Lasers in dermatology: Four decades of progress. J Am Acad Dermatol 2003;49:1-31.

Rodney D. Facial and Body Hair-Text book of Cosmetic Dermatology 2005 29: 275.

Rationale and Scope

Lasers are rapidly evolving with new machines being introduced each year. There are various claims made by the manufacturers, which are often not substantiated in clinical practice. Hence, variations exist in results and uniform recommendations are not possible in all cases. These guidelines outline the indications and treatment for removal of unwanted hair for cosmetic or medical reasons, various procedures and equipment that can be utilized, methodology, associated complications and expected results.

Indications

1. Removal of unwanted hair on the body for COSMETIC REASONS in a patient aged 15 years or older. ⁽⁶⁾ Evidence level B
2. Hirsutism
3. Removal of hair for medical treatment purpose, e.g ., sycosis barbae/pseudofolliculitis where hairs are not unwanted, but can be removed for therapeutic reasons.

Other uncommon indications include hair from donor site and men undergoing sex change operations.

Evidence: Level A

Olsen EA. Methods of hair removal. J Am Acad Dermatol 1999;40:143-55.

Savant SS. Laser hair removal-Chapter 55: Text book of Dermatosurgery and Cosmetology 2005;55:454-5.

Dover JS, Arndt KA, Dinehart SM, Fitzpatrick RE, Gonzalez E. Task force-Guidelines of care for Laser surgery J Am Acad Dermatol 1999;41:484-95.

Liew SH. Laser hair removal: Guidelines for management. Am J Clin Dermatol 2002;3:107-15

Jackson BA. Lasers in ethnic skin: A review. J Am Acad Dermatol 2003;48:S134-8.

Kelly AP. Pseudofolliculitis barbae. In: Arndt KA, LeBiot PR, Robinson JK, Wintroub BU, editors. Cutaneous medicine and surgery: An integrated program in dermatology. Philadelphia (PA): WB Saunders; 1996. p. 499-502.

Contraindications

Absolute:

1. Less than 15 years of age.FNx01
2. An uncooperative patient
3. Associated photo-aggravated skin diseases and medical illness, e.g ., systemic lupus erythematosus (SLE) (evidence level A)
4. Treatment area with active cutaneous infections, e.g ., herpes labialis, staphylococcal infections etc. (evidence level A)

Explanation: Age: No specific data exists on the precise age for Laser hair removal. There is no consensus on an age limit for Laser hair removal in adolescents. After taking all factors into consideration, the Task Force recommends that Laser hair removal may be performed above 15 years of age. However, proper counseling of the parent and the adolescent is important and the procedure should be performed only after proper considerations.

Relative

The Laser has to be used cautiously in the following indications only after proper counseling of the patient. Use of the Laser in these situations depends on the individual situation and on the treating dermatologist′s judgment.

1. Patient having keloid and keloidal tendencies: Caution should be exercised in patients with keloids and keloidal tendencies. Such patients should be treated less aggressively, and only after proper counseling of the patients. A test patch may be performed to judge the keloidal tendency. Laser hair removal should not be performed if the treatment area has keloid.
2. Superficial cuts and injury in the treatment area.
3. Patient on long-term drugs that cause the skin to be more sensitive towards light, e.g ., minocycline, isotretinoin etc. Patients who have been taking the above drugs in the past can be taken for Laser treatment only after proper counseling.
4. Patient with unrealistic expectations.
5. Psoriasis and vitiligo patients should be treated cautiously (for risk of Koebnerization of treated area).
6. Previous history of herpes simplex is a relative contraindication for Laser hair removal because of the risk of precipitation of active lesions. Laser hair removal being a cosmetic procedure, its risks should be seriously considered prior to performing the procedure. If the treating physician decides to perform the procedure, the risks and benefits should be explained to the patient. Also, the procedure should be performed only after getting proper informed consent and only after a course of acyclovir.

Evidence Level D

Dierickx CC, Grossman MC. Chapter 4 -Laser hair removal, Lasers and lights. Vol 2. In: Goldberg DJ, editor. (ISBN 1 4160 2360 7) 2005. p. 61-6.

Savant SS. Laser hair removal: Text book of dermatosurgery and cosmetology 2005;55:457.

Hair Reduction Systems

Different Laser systems are available:

1. Ruby laser-- 694 nm
2. Alexandrite laser-- 755 nm
3. Diode laser-- 800 nm
4. Neodymium - yttrium-aluminium-garnet (Nd:YAG) laser-- 1064 nm
5. Intense pulsed light system (IPL) without heat-- 550-1200 nm
6. Light and heat energy LHE-- 400-1200 nm
   • There is also no consensus on the most preferred and beneficial Laser or IPL broadband Light devices. Newer systems such as ELOS (electro optical surgical system) have also been introduced.
   • Efficacy and safety of each system varies
   • Each system has its own advantages and disadvantages
   • Each system has different power output/spot size and requires different lengths of exposure, which is also important in the selection of hair removal procedure according to the Fitzpatrick skin type classification of patient/client.
   • The treating dermatologist should always refer to the manufacturer′s / marketing company′s specifications.
   • Proper patient selection and tailoring of the fluence used to the patient′s skin type, remain the most important factors in efficacious and well tolerated Laser treatment.

Evidence: Level A

Liew SH. Laser hair removal (guidelines for management). Am J Clin Dermatol 2002;3:107-15.

Jackson BA. Lasers in ethnic skin: A review. J Am Acad Dermatol 2003;48:S134-8.

Nanni CA, Alster TS. A practical review of Laser-assisted hair removal using the Q-switched Nd:YAG, long pulsed ruby, and long-pulsed alexandrite Lasers. Dermatol Surg 1998;24:1-7.

Smith SR, Tse Y, Adsit SK, Goldman MP, Fitzpatrick RE. Long-term results of hair photo-epilation. Lasers Surg Med Suppl 1998;10:43.

Gold MH, Bell MW, Foster TD, Street S. Long-term epilation using the EpiLight broad band, intense pulsed light hair removal system. Dermatol Surg 1997;23:909-13.

Battle E, Suthamjariya K, Alora B, Palli K, Anderson RR. Very long-pulsed diode Laser for hair removal on all skin types. Lasers Surg Med 2000;12:85.

Rogachefsky AS, Silapunt S, Goldberg DJ. Evaluation of a new super-long-pulsed 810 nm diode Laser for the removal of unwanted hair: The concept of thermal damage time. Dermatol Surg 2002;28:410-4.

Weiss RA, Weiss MA, Marwaha S, Harrington AC. Hair removal with a non-coherent filtered flashlamp intense pulsed light source. Lasers Surg Med 1999;24:128-32.

Physicians′ Qualifications

General

1. Any qualified dermatologist (DVD or MD) may perform the procedure.
2. The physician should have knowledge of skin, hair and subcutaneous tissue including structural and functional differences and variations in skin anatomy in general.

Specific

1. The Physician should have basic knowledge and training about skin and Laser physics. Basic knowledge of how the Laser works, is important for successful outcome and ultimate cosmetic results.
2. Proper hands-on training of any system is mandatory before a dermatologist actually start doing it. It can be obtained from the equipment supplier′s medical experts or from dermatologists/plastic surgeons experienced in performing the procedure.
3. The physician should have appropriate hands-on training and experience in working with the particular Laser, IPL or LHE systems.
4. Knowledge of basic anatomy of hair and the endocrine system is essential.
5. The physician should be familiar with early recognition, prevention and treatment of Post-Laser (Postprocedure) contraindication such as hyperpigmentation or hypopigmentation, scarring, burns etc.

Evidence: Level A

Liew SH. Laser hair removal (guidelines for management). Am J Clin Dermatol 2002;3:107-15.

Alster TS. Getting started: Setting up a Laser practice. In: Alster TS, editor. Manual of cutaneous Laser techniques. 2nd ed. Philadelphia: Lippincott, Williams and Wilkins; 2000. p. 2-4.

Dover JS, Arndt KA, Dinehart SM, Fitzpatrick RE, Gonzalez E. Task force-Guidelines of care for Laser surgery. J Am Acad Dermatol 1999;41:484-95.

Dierickx CC, Grossman MC. Chapter 4-Laser hair removal, Lasers and lights. Vol 2, In: Goldberg DJ, editor. (ISBN 1 4160 2360 7). 2005. p. 61-6.

Savant SS. Laser hair removal: Text book of dermatosurgery and cosmetology. Publisher ASCAD; 2005. p. 457.

Taskforce Recommendation

The actual procedure of Laser hair removal is a simple procedure once the parameters have been determined. While it is preferable for the physician himself/herself to perform the entire procedure, this may not be possible in all situations, particularly in large body areas. It is therefore, acceptable for the nurse assistant/junior doctor to perform the procedure after proper training. However, the nurse assistant should perform the procedure only after the patient has been informed about this and only under the direct supervision of the senior physician, as per the directions of the physician and after the parameters have been determined. Further, it should be understood that the final responsibility for the procedure rests solely with the physician.

Facility

Laser hair removal is a simple procedure needing only minor facilities. It may be performed in the dermatologist′s clinic/minor procedure room/day care theatre. The presence of a female nurse assistant is desirable for female patient /client. Proper lighting, operating table/cosmetic chair and comfortable seating for the treating physician are essential. Proper cooling systems need to be available for each individual machine, as per the manufacturer′s recommendation. A cosmetic chair without a metallic surface (which may reflect Laser/light beams accidentally) and of washable material is preferred. An emergency hazard switch should be in place (for shutting off of all systems in case of any accidents).

Evidence Level A

Alster TS. Getting started: Setting up a Laser practice. In: Alster TS, editor. Manual of cutaneous Laser techniques. 2nd ed. Philadelphia: Lippincott, Williams and Wilkins; 2000. p. 2-4.

Smalley PJ. Laser safety management: Hazards, risks, and control measures. In: Alster TS, Apfelberg DB, editors. Cosmetic Laser surgery. 2nd ed. New York: Wiley-Liss; 1999. p. 305-19.

ANSI Z 136.3 For the safe use of Lasers in health care facilities. New York: American National Standards Institute; 1996.

Wausau WI. Standards of practice for the safe use of Lasers in medicine and surgery. American Society for Laser Medicine and Surgery; April 3, 1998.

Beck WC. Lighting the surgical suite. Contemp Surg 1978;12:9-13.

Drake LA, Ceilley RI, Cornelison RL, Dinehart SM, Dorner W, Goltz RW, et al . Guidelines of care for office surgical facilities: Part I. J Am Acad Dermatol 1992;26:763-5.

Drake LA, Ceilley RI, Cornelison RL, Dinehart SM, Dorner W, Goltz RW, et al . Guidelines of care for office surgical facilities: Part II, Self-Assessment checklist. J Am Acad Dermatol 1995;33:265-70.

Elliott RA. The design and management of an aesthetic surgeon′s office and surgery suite. In: Regnault P, Daniel R, editors. Aesthetic plastic surgery: Principles and techniques. Boston: Little Brown; 1984. p. 46

Recommended practices for Laser safety in practice settings. AORN J 1998;67:263-4,267-9.

Informed Consent

A detailed consent form (see appendix 1) should specifically state that multiple sessions may be needed for significant hair reduction and that performing Laser hair removal will not prevent future hair growth due to any underlying cause. Patients should be provided with adequate information through brochures, photographs and personal consultation.

Counseling should include information on hair anatomy, medical reasons why hair grows, importance of drugs to be avoided, actual procedure (if possible with actual video or power point slides), likely side effects, numbers of approximate sittings required, interval between two sittings, per sitting cost etc. As with any cosmetic procedure, realistic expectations are important for patients, particularly because of the exaggerated claims that are mentioned in media advertisements.

Evidence: Level B

Savant SS. Laser hair removal -chapter 55: Text book of Dermatosurgery and Cosmetology. Mumbai: ASCAD; 2005. p. 457.

Dover JS, Arndt KA, Dinehart SM, Fitzpatrick RE, Gonzalez E. Task force-Guidelines of care for Laser surgery. J Am Acad Dermatol 1999;41:484-95.

Dierickx CC, Grossman MC. Chapter 4 -Laser hair removal, Lasers and lights. Vol 2. In: Goldberg DJ, editor. (ISBN 1 4160 2360 7) 2005. p. 61-6.

History and Examination

A complete and detailed history should be obtained to rule out associated illness. This should include history of any photosensitizing drugs, keloid and hypertrophic scars, history of recent sun exposure and tanning and occupations involving prolonged exposure to sun. Female patients must be evaluated properly to rule out the underlying cause for hirsutism. If necessary, a gynecologist′s / endocrinologist′s opinion should be sought. While no investigations may be necessary in most patients, specific tests such as complete blood counts, fasting blood sugars, urine analysis, serum LH, FSH, prolactin, DHEAS, free testosterone and USG-whole abdomen (PCOD) etc may be evaluated in consultation with the gynecologist or endocrinologist in selected patients.

Preprocedure Work-Up

1. The patient should be instructed not to use bleaching, plucking, thermolysis or electrolysis or waxing in treatment areas once he/she decides to start with the Laser hair reduction treatment.
2. The patient should be instructed to avoid sunbathing, swimming in sea water and other activities which might produce tanning of treatment areas.
3. Patient should avoid any over the counter (OTC) products / herbal remedies / homeopathic medicines etc.
4. Photography: Preprocedure photographs of treatment areas are recommended but not mandatory and should mention the name of the patient, date of the photograph. This practice will make the work of the practicing doctor easier at a later date in case of patient dissatisfaction.

It has been recommended by many dermatologists that it is preferable to start with broad-spectrum sunscreens prior to Laser hair removal. As tanned skin is more likely to absorb Lasers (as it contains more melanin), it is thought to be more likely to develop Laser burns after the use of Lasers. However, there is no convincing data to support a mandatory pretreatment with sunscreen in all patients nor is there any data on the likely duration of use of sunscreen. Hence, no recommendations can be made for the routine use of sunscreens. However, if in a physician′s opinion, the patient has had increased sun exposure, which may increase the chances of Laser erythema, the use of broadband sunscreens may be recommended. Likewise, if a patient has tanned skin, mild depigmenting creams like plain hydroquinone 2-4% may be used at night for 10-15 days before treatment. The taskforce recommends this preprocedure preparation only as an optional requirement to be chosen by the physician, and not as mandatory requirement. Level D Test patch : An initial "test patch" has been practiced by many dermatologists. A test patch has the advantages of defining the precise treatment parameters and determining the pain threshold of the patient. It may also help determine the attitude and expectations of the patient. However, a test patch is not feasible in all cases and hence, is not to be recommended as a mandatory requirement. It may be considered in selected cases such as a nervous and unreliable patient with unrealistic expectations.

Evidence: Level C

Dierickx CC, Grossman MC. Chapter 4 -Laser hair removal, Lasers and lights. Vol 2. In: Goldberg DJ. (ISBN 1 4160 2360 7) 2005. p. 65.

Savant SS. Laser hair removal-chapter 55: Textbook of dermatosurgery and cosmetology. Mumbai: ASCAD; 2005. p. 457.

Dover JS, Arndt KA, Dinehart SM, Fitzpatrick RE, Gonzalez E. Task force-guidelines of care for Laser surgery. J Am Acad Dermatol 1999;41:484-95.

Laser Hair Removal Procedure

1. Hair should be trimmed with a electrical trimmer or the patient can shave the area a day earlier (at the time of treatment, hair length should not be more than 1-5 mm)
2. The area to be treated should be properly cleaned with soap/detergent and it should be free from make-up.
3. Local anesthesia is rarely required; however, in a nervous patient and in patients with poor pain tolerance (low pain threshold),, a topical anesthetic such as EMLA/Prilox ^® is recommended 30-90 minutes before the actual procedure
4. Adequate lighting on treatment area is essential.
5. Cooling is essential after the treatment; however, this depends on the system used. Some systems have inbuilt cooling devices, others do not. If inbuilt cooling is not available, ice cubes or cryogen spray may be used.
6. Depending on the area to be treated, the patient can be in a supine or sitting position (use of hydraulic chairs or operation tables is to be encouraged).
7. Standard precautionary measures should be observed for all devices:
   1. Eyes of the patient should be wrapped with white gauze pieces or covered with eye protective devices such as goggles (as specified in the Laser manufacturer′s manual).
   2. The treating doctor and assistant should use the goggles provided by the manufacturer.
   3. The treatment area should not be covered by metallic objects such as chains etc
   4. Cosmetic chairs made of washable material and without any visible metallic surface, which may reflect light-Laser beams accidentally, should be used.
   5. An emergency hazard switch should be used-provided in all systems for immediate shut-off of systems in case of accidents.
8. If a "test patch" has been performed, the parameters of that patch may serve as the guide for treatment.
9. Each patient needs individualized parameters; hence, maintenance of individual records is vital.
10. Surgical jelly should be used as specified in manual except in the case of LHE systems, where it is contraindicated.
11. It is always helpful to inform the patient just before starting the treatment that actual delivery of Laser light is about to begin.
12. The hand piece of the system should be placed perpendicularly to the skin surface (gently but to press sufficiently to displace blood from capillaries and to bring the hair follicle nearer to the aiming source).
13. All areas may be treated in one sitting.
14. Overlapping of hand pieces in treating adjacent areas (10%) is generally accepted.
15. The larger the spot size, the better is the penetration.
16. The presence of any severe erythema/blisters in the previously treated areas should alert the physician to reduce fluence or halt the procedure (rarely needed if proper selection of the patient and test patch has been performed).
17. After the entire procedure is complete, cryogen spray or chilled Eau Thermal water or ice packs may be used.
18. Proper sunscreen block or Lotion is applied.

Evidence: Level B

Russell SH, Dinehart SM, Davis I, Flock ST. Efficacy of corneal eye shields in protecting patients eyes from Laser irradiation. Dermatol Surg 1996;22:613-6.

Koay J, Orengo I. Application of local anesthetics in dermatologic surgery. Dermatol Surg 2002;28:143-8.

Epstein RH, Halmi B, Lask GP. Anesthesia for cutaneous Laser therapy. Clin Dermatol 1995;13:21-4.

Drake LA, Dinehart SM, Goltz RW, Graham GF, Hordinsky MK, Lewis CW, et al . Guidelines of care for local and regional anesthesia in cutaneous surgery. J Am Acad Dermatol 1995;33:504-9.

Dierickx CC, Grossman MC. Chapter 4 -Laser hair removal, Lasers and lights. Vol 2. In: Goldberg DJ, editor. (ISBN 1 4160 2360 7) 2005. p. 63-6.

Postprocedure

A. Analgesics are not usually needed. but paracetamol and other pain-reducing agents may be prescribed for three days. B. Sunscreen lotion should be prescribed along with detailed instructions on how to use it. C. Immediate and continuous sun exposure as well as working under halogen lights is to be avoided. D. Depending on the area of treatment-proper schedule, with date and time should be given to the patient in their native language so that there is no lapse in treatment. E. The patient should be counseled about possible, immediate perifollicular erythema and edema and damaged hair (explain to them that is transient or temporary). F. In case of any persistent pain-blisters or vesicles in the treated areas, the patient should be asked to report for proper management.

Potential Side/Adverse Effects

1. Pain and discomfort may occur; mild oral analgesics may be prescribed.
2. Vesiculation and local crusting are treated with antibiotic/steroid creams and mild emollients.
3. Secondary infection is rare and can be treated with antibiotic cream and antibiotics
4. Hyperpigmentation may occur infrequently and is treated with sun block and/or a mild steroid cream such as hydrocortisone and/or hydroquinone cream. This is usually temporary and needs to be explained to the patient.
5. Localized hypertrichosis in other areas or compensatory hypertrichosis is rare, but may occur and cause anxiety to the patient. This also may need to be treated with Lasers.

Evidence: Level C

Nanni CA, Alster TS. Laser assisted hair removal: Side effects of Q-switched Nd:YAG, long pulsed ruby, and alexandrite Lasers. J Am Acad Dermatol 1999;41:165-71.

Top of Form

Lanigan SW. Incidence of side effects after Laser hair removal. J Am Acad Dermatol 2003;49:882-6.

Use of Eflornithine Cream Along with Lasers

Eflornithine can be used in a combination therapy along with Lasers. It may be started immediately after Laser treatment, and evidence seems to suggest some added advantage of this combination.

Evidence: Level C

Hamzavi I, Tan E, Shapiro J, Lui H. A randomized bilateral vehicle-controlled study of eflornithine cream combined with Laser treatment versus Laser treatment alone for facial hirsutism in women. J Am Acad Dermatol 2007;57: 54-9.

Tan E, Hamzavi I, Shapiro J, Lui H. Combined treatment with Laser and topical eflornithine is more effective than Laser treatment alone for removing unwanted facial hair: A placebo controlled trial. Presented at: The 4th Intercontinental Meeting of Hair Research Societies; June 17-19, 2004; Berlin, Germany. Abstract #P10.144.

Smith SR, Piacquadio D, Beger B. A randomized, double-blind, vehicle controlled, bilateral comparison study of the efficacy and safety of eflornithine HCl 13.9% cream in combination with Laser in the treatment of unwanted facial hair in women. Presented at: The 61st Annual Meeting of the American Academy of Dermatology; March 21-26, 2003; San Francisco, CA. Abstract #P649.

Conclusion

Laser-IPL-LHE (light-based devices) hair reduction technique is the most commonly performed cosmetic procedure all over the world. This gives excellent results in a patient if performed by a trained dermatologist in a proper manner. In India, IPL and different systems such as LHE. Alexandrite or Diode have been used for almost 7-10 years now. Experience has shown almost all systems to be effective. Careful patient selection, proper evaluation of individual cases, pre- and postoperative care-all are essential parts of this therapy to get satisfactory cosmetic results. It is also important to note maintenance therapy with further sessions of treatment may be needed. As in any cosmetic procedure, proper counselling of the patient plays a major role in good therapeutic outcomes.