How Does A Plastic Surgeon Incorporate Lasers Into A Primarily Surgical Practice?

One of the most common questions that other physicians ask me is “how do I incorporate lasers into my surgical practice?”

I am often called by a plastic surgeon, specializing in cosmetic surgery, who wants to know how he or she can begin to use lasers in their practice. It can seem exciting yet daunting to bring in a new procedure because of the level of knowledge and training required to properly treat patients and produce excellent results. And 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, the laser procedures can help surgeons 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. One 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 maintenance laser procedures and good medical skincare. Finally, a laser procedure can often help a plastic surgeon treat a patient who does not really need surgery yet, so that the patient does not have to be referred elsewhere.

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 of each different laser device is the key to fully utilizing the device in treating patients, not just in safety measures but in achieving great results (remembering that you can undertreat just as much as you can over treat). Although I unfortunately see burns and other complications from other practices, it is much more common for me to see a patient who has had a treatment somewhere else who is unhappy because they were “undertreated” or treated with the wrong device. This commonly occurs when a physician delegates a “lesser laser” procedure to someone who is not properly trained. Laser hair removal and IPL (intense pulsed light) are probably the two most common procedures that patients have had somewhere else before coming to see me and are unhappy with lack of desired result. A thorough consultation, informed consent, expectation discussion, and proper patient selection are also necessary for success.

There are basically two ways for a surgeon to begin to incorporate lasers. I call it “top down” or “bottom up.” “Top down” simply means that the surgeons first laser is one that provides the highest grade result for skin tightening that a laser can provide. The “top” is actually a surgical result, but the top laser is, in my opinion, a CO2 resurfacing laser. As the laser practice grows, the surgeon can begin to incorporate other lasers “down” from the CO2 laser including fractional lasers (both ablative and non-ablative), IPL, vascular lasers, and laser hair removal lasers. That way, the surgeon first adds what compliments surgery the most (my favorite is fractional ablative and fully ablative CO2) and then adds other as the need arises. This is the best way to develop a laser practice, but it necessitates a lot of involvement by the surgeon (which is the way it should be!).

The “bottom up” approach allows the surgeon to start with a more common and simpler procedure like laser hair removal. Delegating this procedure to a non-physician can be done carefully with proper training of the practitioner and proper continued involvement of the physician (after he or she is well-trained and individually comfortable with all aspects of the laser procedure). Then, as the “laser side” develops, other devices can comfortably be purchased as the practice wants to incorporate 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.

So how do you get trained?

Ideally the physician received proper training as a resident and was exposed to a wide range and number of procedures. Residency programs such as dermatology and plastic surgery are increasing requirements for cosmetic laser and procedures, but the majority of physicians reading this may not have had much experience with lasers as a resident. Regardless, the physician 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 only cover 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 good for the beginner without much experience. Once the basics of theory and physics are learned and specific laser training is obtained, the physician usually can begin to conservatively treat staff members, family, friends, and trusted patients. This is a common way to start treating because a lot can be learned from conservative treatments that become more aggressive with comfort. Proper disclosure to those treated about the complication risk but especially the chance of under treatment will allow the physician to carefully treat and learn how he or she can begin to treat more aggressively. Once the physician has performed a number of basic treatments, then further training can be obtained at a practice like mine in which someone can come and spend a few days getting advanced training. Practice makes perfect, and that’s why they call it practice! Remember that the enemy of good is better!

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. A procedure like laser hair removal, IPL, or fractional CO2 may be offered by five to ten companies or more. I am a practitioner, not a “techy”, but I know my laser physics and theory, so when I consider a new device, I want to be shown the science.

Any new sales rep that calls on me will be met with an initial question from me of “show me the science.” Don’t let them show you a bunch of procedures and pictures and say “it really works,” find out why! This is the most common mistake practitioners make in buying the wrong device. One 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.” I will typically 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 or leave a comment below.

Knowing what each laser can and cannot treat is also very important. “If all you have is a hammer, then everything looks like a nail.” This is true for any device, especially those that have 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 have 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 and use this when you consider buying a device. If it’s hard to believe that it can really do that, it probably doesn’t do it as successfully as the 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 the state medical board’s policy regarding delegation, and this information can be found on the state board’s website or by simply calling the board itself. My best advice in this situation is to first 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. This is the most important thing to remember for success: that practitioner must be able to perform the procedure just as well as you! This can be achieved by the well-qualified practitioner acting under you if you stay involved. You should always see the patient for the initial consult and consent. I believe that it works best if the physician does the initial consult with the practitioner along with you. If this is not possible (in some practices this may be difficult), then this can be done time efficiently by having the practitioner who will be performing the procedure do the bulk of the consult and the physician can give a “final blessing” and consent. However, it works best if the physician 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. This will give the patient the utmost confidence that they are not receiving a lesser treatment than they would if the physician was performing the treatment. I actually had a patient recently come to see me for solar damage treatment.  I recommended IPL (which I perform myself).  She was hesitant to agree and informed me that she had had it done somewhere else and "it didn't work."  She was also told by the person who performed it that, since it didn't work, she could get it done with the "other IPL" which the physician supposedly performed and "that might work better!"  I don't think I need to comment further!

One last word of advice concerns medical skin care. I have trained many physicians and am always concerned if a practice is beginning to use lasers without including a good medical skin care line. Pre- and post-procedure skin care is extremely important. Aestheticians or a skin care consultant staff member can be a key part of this 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 everything there is to know about the skin care lines we carry, I believe that having another specialist to separately help the patient is ideal. It will also save you a lot of time if, although you will direct the product selection, the specialist can set a full skin care plan for the patient. I see all too often that a very well-trained surgeon will begin performing laser procedures without also focusing on skin care. You never want to perform a great laser procedure and put the patient on non-medical over the counter junk! Finally, I always recommend further training in skin care and the organ of skin itself!

In summary, I believe that incorporating laser procedures into a cosmetic surgery practice can be very beneficial to both the practice and the patients. My best advice is to start slow! Don’t take on too many lasers and not properly learn what needs to be known about each one. Start with one or two devices and master them. Then you will have started to build the “laser side” of the practice with good devices and good results. The biggest mistake that I see physicians all too make is to buy one or a number of lasers and hand them off to another practitioner without the physician or the practitioner obtaining the proper training and comfort with the procedure. Every day, I see a patient who came in from another office where they were burned or more often just undertreated with little to no result. And, that patient just as frequently comes from one of the big practices in town as from one of the corner “medspas.” A patient wouldn’t want a surgical procedure from you if you don’t have experience any more than they would want a laser procedure from an undertrained physician or practitioner!

1. Learn the theory and physics of lasers in general and of each device.
2. Take your time in choosing a laser after a lot of research, asking questions, and demonstrations.
3. Ask someone you trust who has experience with the device you are considering.

Take your time and get trained! Patients will love you for it when they love the result. Remember that you will be lucky if one happy patient gains you one more patient, and luckier if one unhappy patient doesn’t lose you more than 20 potential patients!