One of the most common questions that other physicians ask me is how to begin to use lasers in their practice. It can seem exciting, yet daunting, to bring in a new procedure that centers on a device.
The exciting part? Acquiring new devices means expanding your aesthetic services. The daunting part is the level of knowledge and training required to properly treat patients and produce excellent results. Many times, physicians have limited time for further training once a busy practice has been established.
In addition, lasers are expensive, and most surgeons are not used to having to purchase expensive equipment beyond the initial investment in supplies to start a surgical practice. That being said, laser procedures can help you offer a much wider range of treatments that will benefit both the patient who has had surgery and the one who is not yet ready for surgery.
I tell physicians and patients that laser procedures can be “insurance for your surgical procedure” in many ways. Laser procedures can help add to the result of surgical tightening by treating dyschromia, discoloration, texture, pore size, vascular lesions, and providing overall better skin health and appearance.
You can pull the skin tighter with surgery, but the skin often needs surface treatment with laser procedures. Don’t just focus on achieving tighter skin; focus on overall better-looking skin, also.
This may sound like a sales pitch, but you will hear me often say, “Don’t put cheap tires on a Rolls-Royce.” Surgical results will greatly benefit from follow-up, “maintenance” laser procedures, and good medical skin care.
Finally, a laser procedure can often help you treat a patient who does not really need surgery yet, so that you don’t have to refer the patient elsewhere.
TRAINING IS PARAMOUNT
My advice always starts with telling fellow surgeons that they need to obtain proper training in the type of laser they are going to incorporate into their practice.
Understanding the theory and physics, and differences, of each laser device is the key to fully utilizing the device in treating patients, not just in safety measures but also in achieving great results (remembering that you can undertreat just as much as you can overtreat).
Although I unfortunately see burns and other complications in patients who come to me from other practices, it is much more common for me to see a patient who has a treatment somewhere else who is unhappy because they were “undertreated” or treated with the wrong device. Commonly, this occurs when a physician delegates a “lesser laser” procedure to someone who is not properly trained.
Commonly, I’ve seen many patients who have had laser hair removal and treatments with intense pulsed light (IPL)-based devices and were unhappy about the result. A thorough consultation, informed consent, expectation discussion, and proper patient selection are always necessary for success.
PATHS TO FOLLOW
There are basically two ways for you to begin to incorporate lasers: “top down” or “bottom up.”
Top down—your first laser is one that provides the highest-grade result for skin tightening that a laser can provide. The “top” is actually a reference to the quality of the surgical result that can be achieved by a laser. In my opinion, the top laser is a CO2 resurfacing laser.
As your laser practice grows, you can begin to incorporate other lasers “down” from the CO2 laser, including fractional lasers (both ablative and nonablative), IPL, vascular lasers, and laser hair-removal lasers.
There are also alternatives that rely on new technologies to tighten skin. For example, Solta Medical Inc’s Thermage is a noninvasive radiofrequency (RF) procedure for tightening and contouring skin. Another more recent noninvasive skin-tightening device is Ulthera, from the firm of the same name—a procedure that uses micro-focused ultrasound instead of traditional light or RF energy-based approaches. There are many more examples of products that make up the energy-based device universe, the enumeration of which is beyond the scope of this article (see “Laser- and Energy-Based Devices Snapshot” in the sidebar below).
In practice, you first add what complements your surgery the most—you already know that my favorite is fractional CO2—and then adds other as the needs arise. This is the best way to develop a laser practice, but it necessitates a lot of hands-on involvement.
Bottom up—you start with a more common and simpler procedure, such as laser hair removal. Delegating this procedure to a non-physician can be done carefully with proper training of the practitioner, as well as your proper continued involvement (after you are well-trained and individually comfortable with all aspects of the laser procedure).
As your laser business develops, you can comfortably purchase other devices as the patient population begins asking for procedures that demand a wider variety. If you’ve ever read my material or heard me train or lecture, then you have heard me warn you against becoming the “jack of all trades, master of none.” So, be careful to master each procedure before spreading you or your staff too thin.
THAT LITTLE THING CALLED TRAINING
How do you get trained in lasers? Ideally, you received proper training as a resident and were exposed to a wide range and number of procedures.
Residency programs like dermatology and plastic surgery are increasing requirements for cosmetic laser procedures, but the majority of physicians reading this may not have had much experience with lasers as a resident.
Regardless, you must become familiar with what each laser can and cannot treat, the range of treatment parameters, the risks and complications, and what type of patient will benefit from a procedure.
Typical “weekend courses” are very expensive and usually cover only the basics of different procedures (and are often “company specific,” so that you would need further training if you bought another brand of the same type of laser). These courses are useful for the beginner without much experience.
After you learn the basics of theory and physics, and obtain specific laser training, you usually can begin to conservatively treat staff members, family, friends, and trusted patients. A lot can be learned from conservative treatments that become more aggressive with comfort.
You must properly disclose to those you treat about the complication risk. In particular, the chance of undertreatment will allow you to carefully treat. Via experience and additional education and training, you can learn how to treat more aggressively. Once you have performed a number of basic treatments, then you can obtain further training at a practice like mine, in which you can spend a few days getting advanced training. Practice makes perfect.
SHOW ME THE SCIENCE
Another great question is how to choose a laser in a certain category of procedures. It is overwhelming even for someone with experience to consider all of the different companies that make a laser that treats the same condition.
Several firms offer procedures like laser hair removal, IPL, or fractional CO2. I am a practitioner, not a “techie,” but I know my laser physics and theory. When I consider a new device, I want to be shown the science. Any sales rep that calls on me will be met with that first question: “Will you show me the science?”
Don’t let fast-talking salespeople present you with a list of procedures and pictures and just get away with saying, “But it really works.” You need to find out why it works and how well it works. Do your homework.
The most common mistake practitioners make is in buying the wrong device. You will rarely find a “cheaper laser” that does what its more expensive competitor does. You get what you pay for. You need to research a number of different options and companies, discuss with trusted colleagues, understand the device and conditions it treats, and try it before you buy it.
Typically, I will research a device for months, let others try it first and publish studies, demo it, and wait for results before even considering cost and purchase. I personally offer training services, so please feel free to contact me for more information.
Knowing what each laser can and cannot treat is also very important. There’s a saying: “If all you have is a hammer, then everything looks like a nail.” This is true for any energy-based device, as well, especially those with a wide range of conditions that are FDA-approved for the laser to treat.
Usually, each condition is only best treated with one or two devices. Practitioners will invite complications if they try it for something else—to see if it works. Although this philosophy can cause complications, it more often simply leads to an unhappy patient.
Stick to what you know the laser can do. You can feel free to borrow that line and use it like a mantra when you consider buying a device. If you find it hard to believe that it can really do what it says it can do, it probably cannot—no matter what you think the before-and-after pictures show.
Physicians will often delegate laser procedures to non-physician practitioners. If done correctly, this can be very financially beneficial to the practice and very cosmetically beneficial to the patient.
You must always know your state medical board’s policy regarding delegation, and you can find this information on the state board’s Web site or via a simple phone call.
Prior to delegating, become very comfortable with the procedure yourself and build a history of achieving great results. Then have the practitioner spend ample time observing you perform the procedure and, eventually, you observing them perform.
Here is the most important thing to remember for success: Practitioners must be able to perform the procedure just as well as you, which can be achieved by the well-qualified practitioner acting under you—if you stay involved.
In any case, you should always see the patient for the initial consult and consent. And I also believe that it works best if you do the initial consult with the practitioner along with you. If this is not possible (in some practices, this may be difficult), then it can be done efficiently by having the practitioner who will be performing the procedure do the bulk of the consult and you can give a “final blessing” and consent.
However, it works best if you can also see the patient each time a treatment is to be performed, so that past treatment and result and future settings can be discussed.
MEDICAL SKIN CARE
As I have trained many physicians, I am always concerned if a practice is beginning to use lasers without including a good medical skin care line.
Too often, I see a very well-trained surgeon begin performing laser procedures without also focusing on skin care. You never want to perform a laser procedure and then put the patient on non-medical-grade, over-the-counter junk.
Pre- and postprocedure skin care is extremely important. Aestheticians or a skin care consultant staff member can be key in that they will be able to help you train the patient in using the proper skin care.
Each of my laser procedures has a very detailed required skin care regimen for before and after the procedure. Although I know the skin care lines I carry, having another specialist to separately assist the patient is ideal. Although you will direct the product selection, you will save a lot of time if your skin care specialist sets up the patient’s full skin care plan.
Warren B. Seiler III, MD, is a cosmetic surgeon in private practice in Birmingham, Ala. He can be reached at (205) 870-0204.