28 Aesthetic Laser Hair Removal for the Asian Face
Women of all races seek hair removal because visible hair on the face is aesthetically undesirable, darkens the skin, and interferes with makeup application. Men seek hair removal for a cleaner appearance, to avoid the inconvenience of daily shaving, and to avoid skin damage from shaving and folliculitis.
A narrow forehead is one of the major indications for laser facial hair removal in Korea. More traditionally minded Koreans and Chinese believe that a small forehead is aesthetically undesirable; this contributes to the popularity of facial hair removal.
Young women in Korea desire men with a hairless face; this has significantly increased their interest in laser facial hair removal.
Many factors are involved in the success of laser facial hair removal; among them, a doctor’s knowledge from experience performing the procedure is most important.
Consultation before the treatment is very important in setting reasonable goals for facial laser hair removal, especially if it involves widening the forehead.
An 800- to 810-nm diode laser (e.g., LightSheer XC, Lumenis) with pulse duration of 3 to 30 ms and an energy density of 23 to 40 J/cm2 can be used for facial hair removal. The chances of obtaining a positive outcome dwindle with a pulse duration exceeding 30 ms for Asian male facial hair removal.
Usually, slow treatment with higher fluence is more effective in facial hair removal. Lowering the skin temperature before treatment is very important to reduce the side effects of laser hair removal.
In addition to decreased facial hair, an aesthetic improvement of skin including brighter and soft skin tone, improvement of folliculitis/acne, and decreased hyperpigmentation associated with shaving can be achieved with facial laser hair removal.
A new forehead hairline needs to be designed considering the patient’s wishes, gender, and facial outline. Actively guiding the patient in regards to the optimal design and efficacy is important because patients tend to choose an excessively high or low hairline. The designing of the forehead hairline is not designing a beautiful hairline, but redesigning one-third of the natural facial outline.
Permanent laser hair removal became available in clinical practice in 1996 with the advent of the ruby laser, which had a pulse duration in the millisecond (ms) range and a skin cooling system.1,2 Alexandrite,3,4 800 to 810 nm diode,5,6 and Nd:YAG lasers7,8 entered the hair removal market soon after. The ruby laser was later withdrawn because of its instability and high risk in the Asian population; other lasers are still in use today. Most of the hair removal lasers currently available were developed in the late 1990s, with modifications in power density, fluence, or spot size; however, their basic specifications have not changed. Recently introduced diode lasers include the 755-nm,9 940-nm,10 980-nm (e.g., LEDA EPI 980 from Alma Lasers and LinScan 808/980 from GME), and 1060-nm (e.g., LightSheer INFINITY from Lumenis) models. Vacuum-assisted lasers11,12 and lasers with radiofrequency,13,14 with a low fluence, and with a high repetition rate15,16,17 have also become available.
Despite the development of lasers for hair removal, treatment guidelines have not been established, and controversy exists over the very possibility of permanent hair removal.18,19 Many physicians who perform hair removal procedures have not observed sufficient efficacy and believe that permanent hair removal is not possible.
My clinic, specializing in general laser hair removal procedures for 14 years, focuses on facial hair removal for men and women. Women seek hair removal because visible hair on the face is aesthetically undesirable, darkens the skin, and interferes with makeup application. Men seek hair removal for a cleaner appearance, to avoid the inconvenience of daily shaving, and to avoid skin damage from shaving and folliculitis. Recently, male celebrities with hairless faces have become popular in South Korea, leading the trend toward smooth and hairless faces in men. My survey of 100 Korean women revealed that only 16% regarded facial hair in men as an attraction. It also showed that women in their 40s (44.5%) showed more preference to facial hair in men than women in their 20s (10.2%) or 30s (16.7%). In addition, nearly 80% of respondents answered that they would be willing to recommend laser hair removal to their male romantic partners if the result was as good as shown in the photograph presented in the survey. For this reason, men are increasingly seeking facial hair removal in Korea. However, the facial hair of East Asian men is denser and has thicker shafts than in other areas of their bodies, or in relation to the hair of Caucasians20; therefore, permanent removal is very difficult, even with repeated treatments.
In Korea a small forehead is considered unattractive. Certain facial features are associated with fortune in Korea and China, and a small or narrow forehead is often associated with bad fortune. In addition, a narrow forehead disturbs the balance of the face, contributing to an unattractive first impression. Removing excess hair from the forehead to lift the hairline creates a rounded and attractive forehead in females. Unlike Caucasians, who tend to have a wide forehead, many Asians have a narrow forehead. Therefore, laser hair removal for hairline correction is a popular procedure in my clinic.21
In the skin, laser radiation is absorbed by the melanin present in the hair shaft, raising the temperature of the area and partially destroying follicular cells. However, it is still unclear whether the most effective target for hair removal is the hair stem cell or the papilla cell or both.22
In this chapter, I will discuss my clinical experience and knowledge in achieving permanent hair removal or aesthetic improvement by modifying the density of hair in the East Asian face.
Mechanisms of Laser Hair Removal
The first hair removal laser was based on the concept of “selective photothermolysis.”1,23 Years later, this concept was expanded as the “extended theory of selective photothermolysis.”24 According to these theories, the main chromophore is eumelanin in the hair shaft and hair bulb. Heat from laser absorption in the melanin pigments of the hair follicle diffuses out to damage the hair follicle, interfering with regeneration of the visible terminal hair. Recently, low-fluence, high-frequency lasers have been found to produce results similar to those of high-power, low-frequency lasers.15,16,17
To remove hair permanently, the targets should be cells that are biologically necessary for regeneration of the hair follicles. Based on this hypothesis, the biological targets should be either the hair stem cell (Fig. 28.1) or papilla cell, or both.22 However, although this hypothesis is plausible, no data supporting this have been published. Damage to other targets, including vessels and melanocytes, or nonspecific damage to the hair follicle are also considered as possible mechanisms. However, the exact mechanism of laser hair removal is still unclear, even though the procedure was developed 20 years ago.
Factors That Improve the Efficacy of Permanent Hair Removal
Many factors, including fluence, pulse duration, wavelength, spot size, and treatment interval, affect the success of laser hair removal.25 In addition, the knowledge and experience of the physician influence the results. Optimal factors that improve the success rate are as follows:
Proper pulse duration: 20 to 80 ms (from personal experience)
Proper treatment interval: 4 to 8 weeks, depending on the treated area43
Proper care of adverse effects: postinflammatory hyper- or hypopigmentation, scabbing, persistent erythema, urticarial reaction, the Koebner phenomenon, laser-induced cataract, and iris atrophy44,45,46,47,48,49,50,51,52,53
Proper physician: one with optimal knowledge and scrupulousness42
Consultation is an important phase in the laser facial hair removal process, especially for males seeking widening of the forehead. In male facial hair removal by laser, detailed explanations about the possibility of temporary side effects, including crust, erythema, and hyperpigmentation, before the first treatment session are mandatory, because usually higher fluences are used compared with general laser hair removal of other areas or in female facial hair removal.
In designing to widen a forehead, I consider the jaw line, shape of the head, and gender of the patient to determine the extent of forehead expansion. Among these considerations, determining the forehead height that is most appropriate for the patient’s face is especially important. The usual height of the forehead is one-third of the facial height; however, the final ratio should be decided according to the doctor’s or patient’s aesthetic sense. In designing the hairline, guiding the patient in regards to the optimal design and efficacy is important because patients tend to choose an excessively high or low hairline. I always inform the patients that designing the forehead hairline is redesigning one-third of the facial outline, not just redesigning the hairline.
In facial hair removal by laser, checking the facial skin color, recent history of sun exposure, daily hair removal method, thickness of hair, color of hair, and presence of coexisting facial skin disease is crucial for deciding the exact treatment parameters and planning the schedule. Taking the patient’s photographs before and after each treatment to assess the outcome is important, and the need must be explained to the patient.
Careful and frank evaluation of the final result is required for both the patient and doctors, but it is not always easy in laser hair removal. The final outcome should be assessed at least 6 months after the final treatment.
Facial Hair Removal in Female East Asians
East Asian women receive hair removal treatments to create a more feminine appearance, to brighten the skin tone, and to enable them to apply makeup more easily. For reasons that are unclear, the facial hair of East Asian women responds more poorly to laser removal than does axillary or leg hair, even with optimally adjusted fluence and wavelength. Therefore, more than nine treatments are necessary in many cases. I recommend setting the fluence based on the patient’s current skin color rather than the Fitzpatrick skin type. Skin color can change with ultraviolet (UV) light exposure, and two people with the same Fitzpatrick skin type can present different skin colors depending on the degree of sun exposure. I have divided the skin color by gross examination into nine types, and I refer to the melanin index when gross examination is not definitive (Fig. 28.2). Because of overseas travel, many people are exposed to strong UV light during the winter as well as in the summer. Therefore, skin color should be closely examined regardless of the season.
As facial hairs are thin in East Asian women, long-pulseduration laser does not sufficiently remove the hairs unless the fluence is very high. Therefore, an optimal outcome depends on a balance between fluence and pulse duration. I prefer to use a high fluence despite the possibility of causing pain, except in patients very sensitive to pain. When the fluence is set low to avoid pain, the chance of permanent hair removal declines and the therapeutic goal cannot be achieved. It is helpful to clearly communicate to the patient that the treatment may be painful and that topical anesthetic is available.
From my experience, pulse duration of 3 to 30 ms and an energy density of 23 to 40 J/cm2 using an 800-nm diode laser are effective. But the chance of obtaining a positive outcome dwindles with a pulse duration exceeding 30 to 40 ms.
Based on the skin color, I use a higher fluence in lighter skin. I start the treatment at 30 ms and 22 to 28 J/cm2 when using an 800-nm LightSheer XC laser. When a patient has dark skin due to sun exposure, I use a lower fluence or postpone the next treatment to 2 to 3 months.
After the first treatment, I increase the parameters by 5 to 10% if no adverse effects have been observed and the skin has not darkened.
I wait for 4 weeks between the treatments for the first four sessions and increase the interval after the fifth treatment depending on the outcome. When the skin is darkened, the risk of adverse effects increases with higher fluence, and the next treatment should be postponed or the fluence should be lowered.
I apply laser irradiations thoroughly so that no target area is missed.
I prolong contact cooling time or increase coolant spray time in areas with thicker and denser hairs.
Lowering the ambient room temperature helps to lower the skin temperature. A topical anesthetic is applied in patients particularly averse to pain.