INTRODUCTION
Low Level laser Light Therapy (LLLT) is an internationally accepted name for biostimulation with low energy lasers in order to achieve therapeutic desired effects. Traditionally, LLLT falls under the realm of Physical Medicine, which uses stimulation therapy to activate the body's natural defense mechanisms. When LLLT is the stimulus, the treatment modality is known as PHOTOBIOSTIMULATION.
LLLT has been indicated in sports medicine, physical/manual medicine, dermatology and neuroendocrine disorders in human and animal patients. The anti-inflammatory and analgesic properties of LLLT, as well as its effect on collagen formation, are good indications for LLLT in traumatology, surgery and dentistry, especially after major operations.
LASER
The word Laser is actually an acronym which stands for Light Amplification by Stimulated Emission of Radiation. Laser generates extremely pure light, i.e. light of one wavelength, not of an entire spectrum like a light bulb. The light emitted is highly organized in flow (It may help to think of laser as a single malt scotch and not a "blend" of different wavelengths of light). Laser can be any wavelength of light, visible or invisible, high energy or low energy.
In 1917, Albert Einstein introduced his basic theory for stimulated emission of electromagnetic radiation. This theory was verified by Landberg in 1928, but at the time there were no practical possibilities for producing a functional laser. In 1951, Fabrikant, a Russian physicist submitted a patent application and subsequently published a paper on laser in 1959.
Mester, a Hungarian scientist, was the first to publish a series of articles in 1960 on the biostimulatory effect of LLLT on cell cultures. In 1963, he published the results of animal experimentation which showed that re-growth of epithelium over skin lesions was faster if the lesion was irradiated with1 Joule per square centimeter. Higher doses did not give any better effect. In fact, if the dose was increased many-fold the result was the opposite. Wound healing was inhibited.
In 1965, Laor and his team found that laser irradiation (LLLT) stimulated the rate of healing burns and mechanically induced wounds.
PHYSICS 101
A Laser is a device which produces electromagnetic radiation in the light band. Electromagnetic radiation is a form of energy flux which has properties of both a wave and a particle. These Wave-Particles are called PHOTONS.
Photons have a certain amount of energy (E) which unifies these two properties of waves and particles. Energy (E) is proportional to the mass of the photon (m) according to Einstein's famous equation:
E=mc2
Energy (E) is also proportional to the frequency (f) of the photon according to the equation:
E=hf
Since f x wavelength equals c (speed of light), it follows that f=c/wavelength. Substituting above, E is proportional to 1/wavelength, or the Energy of a photon is INVERSLEY PROPRTIONAL to its wavelength.
Thus, the BIGGER THE WAVELENGTH OF A PHOTON, THE SMALLER IS ITS ENERGY.
When a PHOTON hits an object, what happens to its energy? If the photon (light) reflects from the surface of the object, the photon retains its energy. If the photon is transmitted further (beyond the object), it likewise retains its energy. If the photon gets absorbed by the object however, its energy is delivered to the atoms and molecules of the object.
Depending upon the wavelength (and hence the energy) of the absorbed photon, several scenarios may occur. This absorbed energy may result in heat oscillations, i.e. the atoms/molecules become hot, if the energy is low. If the absorbed energy is higher, the atoms and molecules of the object can become excited and/or ionized. If the energy absorbed is high, it can cause the break up of chemical bonds in the atoms/molecules of the object and result in the formation of new compounds.
Laser light then, consists of photons of a specific wavelength, i.e. PURE LIGHT, and hence, a specific energy level, which can interact with a given object. The results of that interaction are dependent upon this specific wavelength (energy level).
MEDICAL LASERS
There are many different types of medical lasers available, but they can be classified into two main groups:
HIGH POWER LASERS cut coagulate and evaporate tissue. These are also known as Surgical Lasers because they replace the scalpel of the surgeon. These lasers produce photons (light) of high energy.
LOW LEVEL LASERS stimulate cell function. The effect is not thermal as in the case of surgical lasers. These non-surgical therapeutic lasers are certified Class 3A by the FDA. The energy produced by the photons of these lasers is low and does not have a thermal component that can cause injuries to users and/or operators. This low level energy does not alter molecular structures, but STIMULATES the body's mechanisms to REPAIR AND HEAL itself.
Low level (energy) laser light photons are absorbed by the chromophores within the cells. This induces increased production of cellular energy in the form of ATP, which leads to normalization of cell function, pain relief and healing. These effects are especially striking in areas of the body where cells are under stress.
The photo-energy from these low level lasers is low and remains a long way below the levels needed for ionization of the atoms and molecules of the cells. Thus no induction of cancer growth has been linked to these lasers. The risk of eye injury is almost non-existent, but goggles are recommended.
LLLT FOT HAIR LOSS (ANDROGENETIC ALOPECIA)
What type of laser device would benefit patients with androgenetic alopecia? The devices being promoted must be safe for use. They must be effective to meet the manufacturer's claims. The consumer must know what he/she is buying, and the device must not expose the consumer to undo risks.
The therapeutic factors in choosing a laser are as follows:
(a) The wavelength of the light is important as it determines penetration depth in the target tissue. For example, red light at 670 nanometers penetrates greater than other lasers close to the red spectrum. Since wavelengths of 670-690 nanometers support the oxidation processes, it is believed that the 670 nanometer wavelengths show better efficacy in therapeutics than lower wavelength lasers.
(b) For hair applications, the first and most significant condition in choosing laser wavelength is depth penetration, which should be sufficient to target hair bulbs typically resting at 5-6 mm depth.
(c) Visible red light at a wavelength of 660 nanometers penetrates tissue to a depth of 8-10 mm so that the entire hair organ will be covered to a depth just beyond the hair bulb. Visible red light could theoretically be effective in the entire scalp and might include wounds, cuts, scars, folliculitis, etc.
(d) There is the question of continuous wave vs. pulsed operation of the laser. Pulsed operation has been shown to stimulate tissue repair and regeneration to a greater degree than continuous wave operation. Pulses have been shown to stimulate cellular activity. Pulses can regulate biologic rhythms or cycles. Finally, pulsed operation exhibits greater anti-inflammatory effects than the continuous mode.
The GOAL of LLLT is to increase the circulation of the blood to the follicle area and to stimulate the hair organs (nerves, muscles and growth centers of the follicle). The effects of LLLT to stimulate, enhance or speed up the normal life cycle and production cycle of the exposed hair follicles is presently being studied and will fast become the science by which this technology will be judged:
In 1996 Pontien published a Microcirculation study with the Laser Hair Care Device and showed an increase in blood flow.
In 2005 Weiss and McDaniel showed that photo modulation using visible light can alter the expression of genes associated with the stimulation of hair growth. They described it as more of a "minoxidil-like" effect.
EFFECTS OF LLLT
The physics of laser light, along with its known properties, led the way to a practical application for low energy lasers in medicine. Various studies have confirmed these properties on the living organism. Taken together, the data points to the following effects of low level laser light on the scalp:
(1) Increased scalp blood flow and microcirculation by 20-30%
(2) Increases nutrient supply to enhance hair growth
(3) Stimulates and accelerates hair growth
(4) Stops the progression of hair loss
(5) Repairs and improves hair shaft quality
(6) Reduces excess levels of skin 5 alpha reductase and DHT which contribute to genetic thinning
(7) Relieves scalp conditions such as psoriasis, seborrhoeic dermatitis, itchy/scaling scalp (anti-inflammatory properties)
(8) Normalizes sebum production (also increases production in under activity and dryness and decreases production in over activity or greasiness)
(9) Reduces tight, tender scalp
These effects also make LLLT excellent adjunct therapy for pre-operative and post-operative Hair Restoration procedures.
TREATMENT PROGRAMS
In developing treatment programs with LLLT one must first consider whether the treatment will be administered with a Class 3A laser machine, with a hand held laser device, or with both.
The larger Class 3A Laser Machine is a patented cool laser which creates a soft halo of light around the scalp. The light is delivered from multiple rotating laser positions designed to increase blood flow to the scalp. There are 30 diode lasers rotating in a half sphere around the head delivering pulsed low laser energy to the scalp. This requires twice weekly or more visits to the clinic. The use of adjunct products, including a vasodilator, is recommended. FDA approval for the use of this laser for hair loss is pending.
The hand held laser comb is a hand held wand-like instrument with laser light ports arranged across its surface like the teeth of a comb. It is used at home 3 to 4 times weekly for 10-15 minutes per use. It is easy to use and convenient for the patient, so compliance is high. FDA approval for its use for hair loss is pending. It is accepted as a medical device in Canada. This allows advertising to make therapeutic claims about the hand held laser device such as its ability to increase the strength of scalp hair in men and women, its ability to prevent scalp hair loss in men and women, and its ability to cause re-growth of scalp hair in men and women.
Studies with the hand held laser comb have reinforced these claims:
In 2003, Martin Unger showed that LLLT has been found to have biomodulating effects on human hair and hair follicles. 97% of the patients studied had some benefit in improvement of hair characteristics, stabilization of hair loss or hair re-growth (defined by Unger as an increase of hair count by 11% or more from baseline).
Santino and Markou, in 2003, studied 35 patients (28 males, 7 females) with androgenetic alopecia on the LaserMax Comb. The treatment regimen was an every other day application of the comb for 5-10 minutes for 6 months. The results showed that, all patients considered, 93.5% of patients had a hair count increase and 78.9% had an increase in hair tensile strength.
There are ongoing FDA trials for men and women with thinning hair. These individuals undergo two treatments per week with the hand held laser comb for 6 months. All of the details of the trials are not available but preliminary results show that in men, 10% had stabilization of both frontal and vertex hair loss, 84.6% had re-growth of some hair in the frontal area and 82.8% had re-growth of some hair in the vertex. In women, 100% had stabilization of hair loss in the vertex, 87.5% had stabilization of hair loss in the frontal area, 75% had re-growth of some hair in the frontal area and 96.4% had re-growth of some hair in the vertex. Thus far, no side effects or eye damage has been reported.
CANDIDATES FOR LLLT
Based upon the information thus far and the various clinical trials in progress, a potential list of candidates for LLLT for hair loss is as follows:
Men and women between the ages of 18 and 65
Thinning to moderate hair loss
Patients ineligible for hair Restoration Surgery due to early stages of hair loss
Women experiencing diffuse or general thinning including the sides and the back
Pre and Post operative hair restoration.
There are three general categories of user experience with LLLT as regards to hair loss. 45% of patients will see positive results after 8 weeks of treatment, 45% will see positive results after 10-16 weeks of treatment and 10% see improvement after 16 weeks.
Finally, to give an idea of the types of laser programs that exist, the Hair Restoration Group has three different programs. Patients choose a program based upon specific needs.
The IN-CLINIC PROGRAM consists of 46 sessions of LLLT over 12 months with three cappilliscope readings to measure hair density. The AT HOME AND IN CLINIC PROGRAM utilizes the hand held laser comb three times a week for ten minutes at home with 12 monthly LLLT sessions in the clinic. Finally, there is a POST-OPERATIVE LLLT PROGRAM consisting of 2 twenty minute sessions of LLLT per week for 8 weeks. The patients undergoing post-operative LLLT notice that healing is accelerated, scarring is minimized (especially in the donor area), graft growth is accelerated, graft appearance is improved and post-operative swelling does not occur.
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Richard P. Giannotto, MD, are owned or
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