The Importance of Preventative Maintenance for
Your Aesthetic Laser System.

What can go wrong and more importantly,...
what you can do to prevent it.

as appeared in MEDICALSPAS^®, a leading medical magazine.
By © J. Peter Zimmer • President/CEO • Telsar Laboratories Inc.

Introduction

The laser, much like the computer, has found its way into our lives and business. Once a very costly and complex tool, we now find them in our homes, offices and cars. Dermatology is a field of medicine that is very familiar with lasers. We find them indispensable today for treatment of afflictions that were untreatable just a few decades ago. Today’s lasers are in some ways much less complicated to use than their predecessors, while at the same time much more complex instruments. The basic premise of Light Amplifications by Stimulated Emission of Radiation (LASER) has been augmented by microminiaturization and computer assisted controls.

History

Each day, we find ourselves introduced to another generation of lasers, treatments, techniques and skills necessary to take the practice of medicine into tomorrow.

In 1917 Albert Einstein theorized of stimulated emission. In 1958 C. H. Townes and A.L Schawlow investigated and developed the theory of LASER and suggested that mirrors could be used to develop the feedback necessary for the amplification through a lasing medium. It wasn’t until 1960 that Theodore Maiman of Hughes Aircraft built the first laser using a ruby crystal for the lasing medium. The rest, as we say, is history.

Medical specialties in Dermatology

The first lasers for dermatology were CO2 lasers to treat benign vascular birthmarks such as port wine stains over 40 years ago. Argon and CO2 lasers soon found wide acceptance in the field of Dermatology. They were and still are widely accepted modalities for treatment today. CO2 lasers became the norm for operating rooms around the world as a way of performing cutaneous surgery with a somewhat bloodless field. Studies abound of the different absorption characteristics of tissues over varying frequencies of laser light as well as the wavelengths, pulse widths and energy levels over the varying Fitzpatrick skin types.

Let us now fast forward to 2005. Lasers in medicine, while originally based in ophthalmology have widely spread to general surgery, Cardiology, Dermatology and Plastic surgery to name only a few. These lasers can vary widely in their cost of maintenance. Understanding the equipment and some of their basic requirements can be the key to keeping some of these costs in line.

The laser “on key” is not a random chance that you may practice today

When any laser is manufactured, before it is delivered to a facility, it must go through “final test” and pass all of the manufacturer’s specifications as well as all defined FDA requirements for that specific model and class of laser. There are safety and reliability concerns that must be satisfied before any laser is released for use. A laser is at its optimum performance when built and begins its ageing process immediately. A laser technician or engineer may be required to align and calibrate a laser on a periodic basis and this is necessary for its safe and effective operation. For cost containment reasons, many facilities will wait until a failure occurs before calling for service. This is a false economy. Rescheduling your patients and your time results in a much more costly delay than the cost required for a successful PM or check-out of the laser system. Most importantly, the risk of a major failure increases with time.

A misaligned beam can cause devastating results internal to the laser system by burning through coatings on optic components. At first, this is demonstrated when noticing an increase in power or time needed to produce the treatment. To compensate for this, manipulating the controls will allow the immediate treatment to be completed. However, if left alone, the minor damage to each optic will accumulate until a total failure of the device necessitates a very costly emergency service call.

What can go wrong and why?

Defective electronics, power supplies and computers all have the potential to cause failures in any equipment in which they are installed. Some failures are due to age, power surges and other reasonable factors. Others are not so easily determined.

A laser sits seemingly alone and untouched by any human in an office. Sometimes it is not used for days, weeks and maybe months at a time.

“It was just working. It worked fine the last time we used it. Why can’t I get the power up? Why does it shut down? Why is it burning the patient now? Why must the power be increased from when it was originally installed? The burn pattern is off. The mode has changed”

These are all observations and frustrations shared by all laser owners. There is no magic or secret involved here. There is no “Weird Science” that laser engineers perform to make a non-functioning system functional again. It is only science and basic technology that cause these problems, try your patience, and stress your staff.

From a simple CO2 laser for wart removal to a complex Excimer for psoriasis treatment, the operation and life expectancy of the laser itself is based on many factors. The complexity of the laser, with its many electrical, electronic, mechanical and optical components requires them all to operate with no less than perfect timing and consistency. Additionally the utilities coming into the facility such as incoming power, the water supply, and the ventilation, are all variables that contribute to the successful operation of a system and can each be cited as a cause of laser failure.

The “unknown cause”

Heating and cooling of different materials may cause them to expand and contract at different rates. While this factor is known for many materials and can be compensated to some extent, the cause of most laser alignment and other problems can fall into the “unknown cause” category. The last visit by a laser engineer to repair or maintain the laser required the exact and proper orientation of each of the optical components relative to each other. This time consuming procedure ensures that each mirror, reflective surface and optical component all allow the laser to operate as a system to produce its optimum energy.

While the office environment with a laser may be consistent during the workday, setback thermostats and other seemingly unrelated cost saving devices all contribute to the next laser service call.

Switching from spring-time forced air ventilation, to summer-time cooling, to the furnace for winter heating, all contribute to a very unstable environment for a laser system which relies on the accuracy of the accurate alignment of each optical component for safe and effective operation. Even with locking each optical component in place, slight movements due to thermal expansion and contraction will lead these once perfectly aligned components to shift out of alignment over time.

The known effect

The alignment changes will cause a shift in the mode structure of the laser beam and may greatly effect the treatment performed. If not corrected through proper maintenance, a laser that originally had a fundamental mode of TEM (0,0), can quickly become multi-mode at something other than its specified TEM (0,0). If we are talking about a Q-Switched Yag laser, the effect could be minor complications such as small burns or small areas of bleeding during skin resurfacing to name a few. Small changes in these alignments in a Q-Switched Yag laser can be compensated by turning up the energy to get the desired effect but this also increases the risk and complications to the patient and staff. This is but one demonstrated effect, there are many more which underscores the need for routine and proper maintenance of the system.

Routine Recommended Maintenance

Mean Time Between Failure (MTBF) is a term equipment manufacturers are familiar with and should be asked about when purchasing any equipment, not only lasers. By doing all that is recommended to increase this number, you can be assured of high laser reliability while providing safe and effective treatment for the patient. Most of these recommendations are found in the operations manual of each laser system.

All laser manufacturers have a recommended schedule of preventative maintenance to be performed. With rare exceptions, these visits should be either once or twice a year. The technician/engineer will check the equipment for alignment, calibrations, and power/energy output. All optics as well as electronic should be inspected and any defects noted to the Laser Safety Officer (LSO).

For example, a typical routine maintenance visit could cost upwards of $2000 when travel expenses and time are added in to the equation. While this may seem costly as a routine expense, when compared to the cost of canceling and rescheduling 10-20 patients, it is quite inexpensive and that in addition, the office overhead will still need to be paid every day.

A pretreatment checklist should be adhered to before each patient along with a daily operational checklist for each laser in your practice. Just as you would not expect a high performance automobile to run for years without an oil change, the maintenance for a laser system should be just as diligent.

Laser Safety and the LSO (Laser Safety Officer)

The safe operation of any laser should be first and foremost in the mind of the physician operating it, as well as the facilities manager, up to the very top of the management chain. Basic laser safety is taught on many levels when a laser is purchased. Knowledge and documentation of the safe operation and handling of any laser is important for successful defense of a lawsuit. A facility offering any laser services should have a specified Laser Safety Officer who is in charge of this program no matter how small the facility may be. More about this very important subject will be discussed in future articles.

Conclusion

Consider that we strive to keep laser energy away from tissue, especially the eyes. Now consider that, as physicians you are called upon to use this energy to benefit your patient in the practice of your medicine. We conclude that laser safety and optimal operation, achieved through routine maintenance, are of utmost importance to the physician, the staff, the patient and anyone else within the operational environment of the laser.

Points to be taken:

The Importance of Preventative Maintenance for Your Aesthetic Laser System.

What can go wrong and more importantly,... what you can do to prevent it.