Lasers have been widely used for cosmetic surgery since the 1960s, but their period of greatest technological advance and popularity has come within the last decade and a half. The booming American economy of the 1990s and the aging of the Baby Boomer generation have coupled to make cosmetic surgery more popular than ever before.

The road to making the investment in cosmetic lasers pay off is fraught with peril, however. Says Charles Halasz, MD, who works with several types of lasers in his office-based dermatology practice in Norwalk, Conn., "Facilities get into offering laser services to patients for two reasons. Physicians may have heard a buzz about a certain type of laser at a physician's conference or a trade show, or they may have read about it in a journal. They think that investing in a laser may be profitable. Or, physicians may be legitimately interested in exploring the medical possibilities of the laser. The two goals don't have to be mutually exclusive, but at the end of the day, it should be treating patients that comes first. Many who have gone into laser surgery hoping to make a lot of money end up disappointed."

Facilities wishing to offer cosmetic laser surgery must consider several crucial factors before they invest in any type of laser. This article will outline the issues involved in assessing whether adding cosmetic laser services is worth the cost. We will also take an up-close look at five different types of lasers to assess their potential benefits and drawbacks, both from an outcomes standpoint and in terms of their versatility and cost.

Important factors to consider
Says Robert Adrian, MD, medical director of the Center for Laser Surgery in Washington, DC, "before you buy your first laser, you have to look at your practice, your location, and the demographics of your potential clientele. This takes some effort, but it's critical if you're going to spend $300,000 to outfit a laser practice."

Obtain surgeon buy-in.
Experts strongly advise that you ensure that the cosmetic surgeons who are already associated with your center are interested in doing these procedures, because attracting outside interest is often quite difficult. Realize that your toughest competitors for cases will likely be doctors who have lasers in their own office-based surgery suites or ASCs. So, unless you have physicians on staff who have experience with laser surgery or are absolutely confident that they can attract new patients, investing in a laser may not be worth the risk.

Dr. Adrian, who owns his own ASC specializing in laser surgery, knows the challenges of attracting physicians to a facility just to use a laser, even though his facility is extremely well equipped. "We've tried for years without great success to actively encourage utilization of our laser facilities by other physicians," he says. "We have our own ORs equipped with monitoring equipment and a well-trained support team that has expertise in both restorative and cosmetic laser surgical procedures, including nurses and board-certified pediatric and adult anesthesiologists."

The level of outside interest, however, has been disappointing, he says. "For the procedure to be worthwhile for both the facility and the physician, you would have to block out a schedule for each physician, and he or she would have to bring in a large volume of patients on the designated day of surgery. A reasonable facility fee, given the interruption of your own practice and the expense of the equipment, might be about $150 for the first 15 minutes of usage and $100 for each additional 15 minutes. So, for instance, if a doctor did a half-hour procedure for which he charged the patient about $600, he'd wind up giving almost half of that fee to the laser center."

Thus, to make lasers viable at your facility, it is absolutely crucial that the doctors at your facility have a strong case-referral base from which to work. Says David Bank, MD, of the Center for Dermatology, Cosmetic, and Laser Surgery, Mount Kisco, NY, "If you have doctors who have used these lasers a lot, especially over a period of years where they have a track record of patients who have been very happy with their results, the doctors will continue to get a steady stream of new patients-often building a network of friends and relatives of past patients who have witnessed the positive results and are likely to be satisfied customers themselves. They go in knowing what it is involved and they are more likely to be willing to undergo the intensity of the procedure."

Examine Your Patient Population.
Even the most motivated, talented surgeons won't be able to make a laser service work if your patient population simply isn't there. Experts advise examining the income levels and the ethnicity of your prospective patients to determine if a laser service will be viable at all, and, if so, what kind of laser might be most appropriate.

Reports Dr. Adrian, "It's an established fact that high-income areas contain the most frequent seekers of certain cosmetic services, such as treatments of facial blood vessels, brown spots, wrinkles, and hair removal."

He continues, "A lot of places don't examine whether a particular laser would be appropriate for that population. For example, if the community you serve is predominantly African-American, the incidence of facial veins will be low, so the demand for the service would be low."

You may want to consider the fact that certain laser types may, for the same procedures, produce better outcomes with different ethnic populations (and, consequently, be more likely to cultivate satisfied customers who will bring future business to you). This is certainly the case with hair removal. Explains Dr. Bank, "At our facility, we've found the Diode laser to be a versatile, effective laser for many types of hair removal. However, our patient population is predominantly Caucasian. It's my understanding that some of the longer pulse-duration lasers, like the Altus laser, often work better for hair removal with darker-complected patients."

In addition to researching prospective patient demographics, don't forget to ask your current patients what they want. Recommends Dr. Adrian, "Distribute questionnaires about what types of cosmetic laser services your patients would like you to offer. Solicit their feedback as to whether, say, spider vein treatments or tattoo removal would be something that would interest them. You can then act accordingly with greater confidence."

Consider the competition.
One of the reasons laser procedures are so competitive is that you don't need an OR, or, in some cases, a physician to offer them. The marketplace is dotted with many non-medical facilities that offer laser procedures, especially relatively simple ones such as hair removal. To compete with these facilities, you have to play up your strengths as a health care facility.

Says Dr. Adrian. "We have to do a good deal of patient education to convince them that there are very real benefits to coming to an accredited medical facility with board-certified doctors instead of going to a ?doc-in-the-box' at a spa or their local salon. The rates of success are better when you have experienced personnel who are knowledgeable about the latest equipment. The number of treatments required are often fewer. And there are much greater assurances in an accredited facility that the equipment is properly maintained and that there are people on hand who know what to do if something goes wrong, such as if the patient experiences unexpected discomfort."

Dr. Balin, who has nine types of lasers at his facility, agrees. " Surgery centers offer distinct quality-control and safety assurances to patients that competitors can't offer. When it comes to these issues, you can't quantify their value in financial terms."

Dr. Adrian acknowledges, however, that the non-medical competitors aren't about to go away. He says that other strategies are necessary, too. "We'll never get everyone to drop the spa approach. But we can also speak to the bottom line sometimes and convince patients that they aren't necessarily saving money by going to a spa. Actually, spas frequently charge them more than we do for some of the exact same cosmetic procedures. For example, in the Washington, DC, area botox treatments at a spa often run about $500 to $600. We charge $250 for the same exact procedure."

If you're not able to charge less than competitors, you may be able to cut your costs by employing your own non-physician personnel to perform certain simple laser procedures. Different states have different regulations. Some states require the physician to do all the work and some will allow a nurse and/or a technologist to do the procedure with physician supervision. Some will allow a nurse and/or a tech to do laser work without physician supervision; a physician need only serve as a consultant and help the patient decide which laser therapy would be most appropriate.

No matter what your strengths are, however, it is probably not a good idea to enter an already-saturated market. Says Dr. Adrian, "Look around to see what laser services are especially prevalent in your area. If you find that there are a glut of hair removal places and some are advertising laser hair removal for $99, it's safe to assume that it may not be a good time to start doing laser hair removal at your facility."