Advice from four physicians on attracting the patients you want by offering energy-based therapies

If you took a test drive in the latest Porsche and fell in love with it, would you wait until you had the $80,000 in the bank before you bought this luxury vehicle? Not likely. You would probably find a way to justify the expense by evaluating the potential impact on your life, and start planning a way to finance the purchase.

Americans are no different when it comes to anti-aging procedures. In a study released in 2005, the American Society of Plastic Surgeons (ASPS) polled 644 patients and determined that their household incomes had little bearing on their decision to have a procedure.1 According to the poll, 30% earned $30,000 or less; 41% earned $31,000 to $60,000; 16% earned $61,000 to $90,000; and only 13% earned $90,000 or more. In fact, 70% of the participants felt they obtained emotional and psychological benefits. Further­more, the number of minimally invasive procedures performed from 2002 to 2004 increased by 53%.

Another study conducted by the ASPS found that 34% of US patients who underwent plastic surgery in 2004 had more than one procedure.2 It appears that many Americans choose to invest in anti-aging solutions, figuring that the cons of the financial picture do not outweigh the procedure’s benefits.

Yet, with so many options to choose from, it is all but impossible for many surgeons to offer every solution available. In fact, when it comes to photorejuvenation, perhaps one of the biggest factors in this decision is the ever-changing technology. Because energy-based devices are ex­tremely specific, identifying the right wavelength for the right condition can be difficult. Yet, many plastic surgeons have focused on this area and have three or four energy-based devices in their offices.

When we look at total patient care, some energy-based devices serve to fill the gap for flaws that cannot be otherwise treated. The use of these devices offers a broad range of medical and aesthetic treatments for patients in many age-group categories. What can energy-based devices accomplish? How can they best be used?

To answer these questions and more, we requested feedback from four physicians (see page 60) who use these devices in their practices.

What conditions do you use energy-based devices for?

The use of energy-based devices holds promise for many applications. (See sidebar on page 62.) However, training and expertise are important considerations in the decision to incorporate these devices into a practice. Under­standing the capabilities of radio frequency and selecting the right wavelength to treat individual conditions may appear to be an enormous task. In fact, when it comes to energy-based de­vices, it is better to “undersell” and “overdeliver.”

Even though energy-based devices are not necessarily a substitute for surgery or other minimally invasive procedures, they can be an alternative for some patients or a complementary procedure for others to achieve a fully satisfactory outcome.

The patient’s lifestyle also plays a role in the decision to use an energy-based device. Many patients must receive multiple treatments. However, they still find these devices appealing because of their lack of downtime and comparative minimal side effects. In the end, energy-based devices have much potential, the advances in light therapy have been groundbreaking, and the opportunity to treat a wider range of patients is possible.

Why did you find it important to bring photorejuvenation into your practice?

There are many reasons why medical practices would want to incorporate photorejuvenation. First and foremost is pa­tient demand. Ever since suntanning baby boomers used baby oil in their youth, the incidence of sun damage and skin cancer has risen. Second, patients like procedures with little risk and downtime. In fact, besides the physician’s expertise, two major factors that contribute to the decision to have a procedure are risk and downtime.

The goal of photorejuvenation in plastic surgery is to offer a noninvasive tool for treating aging or damaged skin. It is not a substitute for surgery or chemical peels. Yet, the benefit of being able to provide total patient care is attractive.

Photorejuvenation is also associated with comparatively few side effects—there­by providing an opportunity for higher patient-satisfaction levels, which strengthens the doctor–patient bond and leads to more follow-up procedures and referrals. With the many aesthetic and medical applications for photorejuvenation available, the list of reasons to purchase energy-based devices is long.

How do you choose a vendor?

Vendor choice appears to be a multipronged approach. Attending annual meetings held by organizations so that you can receive a demonstration of various energy-based devices and use each device to rate user-friendliness can go a long way toward making the right energy-based device choice. With all of the primary vendors at your disposal, you can compare the costs and weigh the benefits of each option.

Do not underestimate the importance of references. They can be provided by the vendors themselves or may be obtained by posting an inquiry on organizations’ message boards. In this inquiry, it might be helpful to cite specifics about the practice, such as its size and whether its focus is reimbursed medicine or cash pay. Because various staff members may be using the technology, it is important to receive feedback from everyone in the practice who will be using the device.

What kind of analysis did you perform to identify the best device to choose?

A priority-features list and budget are equally important. In fact, a long-term plan may be the most appropriate because the technology is continually expanding and you may need to incorporate a variety of energy-based devices to fully satisfy a patient. When determining your priorities, consider the following:

• Know your market and what you want to accomplish.

• Identify how expansive you wish energy-based devices to be in your practice.

• Identify the integration process and time commitment for training.

• Focus on key device features including simplicity and smooth operation.

• Know how long the technology has been in the marketplace and why it is considered “tried and true.”

• Understand what typical stumbling blocks may be encountered during product integration or use.

• Identify the type of support and turnaround time that is available for assistance, including maintenance and repair.

• Identify the costs associated with in­stallation, maintenance, and training.

• Consider whether the complementary benefits of energy-based devices will provide a greater value to your patients.

• Consider sharing the cost with other physicians to decrease your expenses or forming a relationship with a laser-rental company so that you can benefit from the wealth of rentals that they might have available.

• If you purchase, investigate backup energy-based device rentals should your device break down and cause your staff to reschedule patients.

• Inquire about trade-in options that might be available.

How has photorejuvenation produced a return on investment for your practice?

For practices that are just getting started, it may be best to first identify how well you wish to market and integrate energy-based devices. With the large number of different devices that may need to be purchased to fulfill all your patients’ desires, it may be difficult to evaluate the initial return your on investment. Likewise, because each device costs $10,000 or more, it may appear that these devices are cost-prohibitive.

Because technology is always changing, it may appear questionable to purchase energy-based devices, but “tried-and-true” versions are available. Still, an initial return on investment can be made using a leasing strategy. The advantages of leasing may include not only the avoidance of the no-trade-in option associated with some energy-based device purchases, but also the reduced initial cost to jump-start a return on investment.

For practices already on the photorejuvenation bandwagon, many ad-vantages are sure to come. From the patient perspective, it can be appealing for many reasons. After all, it is great for baby boomers to have soft, supple skin, but it may not be as appealing if they have untreated visible red blood vessels on the tips of their noses. PSP

Lesley Ranft is a contributing writer for Plastic Surgery Products.


1. American Society of Plastic Surgeons. Study reveals who is really considering plastic surgery. Available at: http: // news_room/press_releases/PRS-Sept-study.cfm. Accessed December 12, 2005.

2. American Society of Plastic Surgeons. 2004 cosmetic demographics. Available at: http://www. /commonspot/security/getfile.cfm&PageID=16152. Accessed December 12, 2005.

3. Adult acne. Available at: http://www. Accessed December 12, 2005.

4. Rosacea guide: Skin care and treatment information provided by North American dermatologists. Available at: http:// Accessed December 12, 2005.

5. American Society for Aesthetic Plastic Surgery. Top nonsurgical cosmetic procedures. Available at: http: // Accessed December 12, 2005.

Our Panel

Bahman Guyuron, MD, FACS, a board-certified plastic surgeon, is chief of the Division of Plastic Surgery at Case West­ern Reserve University in Cleve­land. He pre­viously was director of the section of Craniofacial Surgery at the Cleve­land Clinic Foundation and chief of the Division of Plastic Surgery at the former Mt Sinai Medical Center. He can be reached at (440) 461-7999.

Scott Miller, MD, FACS,
 a board-certified plastic surgeon, is the director of the Miller Cosmetic Surgery Cen­ter at Scripps Hospital in La Jolla, Calif, and a clinical assistant professor of plastic surgery at the University of Calif­ornia, San Diego. He is on the instructional course committee of the Plastic Educational Foundation, and he authored a textbook on facial-rejuvenation surgery. He can be reached at (858) 453-3133.

Alastair Carruthers, MD, FRCPC,
 president-elect of the American Society for Dermatologic Surgery for 2006–2007, is a cosmetic dermasurgeon in private practice in Van-couver, BC, Canada. He is also a clinical professor of dermatology on the faculty of medicine at the University of British Columbia. He is best known for his pioneering work on the cosmetic use of botulinum toxin. He can be reached at (604)  714-0222 or via his Web site,

Richard H. Tholen, MD, FACS,
is pre­sident, senior partner, and owner of Min­neapolis Plastic Sur­gery, Ltd, and he has been in private practice for 18 years. As a faculty member of Laser Centers of America, he has taught numerous courses nationally, and has been an invited lecturer and vi­siting professor in Seoul, Korea. He can be reached at (763) 545-0443 or [email protected].

Disorders Treated by Photorejuvenation

Skin disorders

Skin disorders continue to be an area of growing concern. Here are some statistics concerning specific skin disorders:

• According to, adult acne affects 50% of all adult women and 25% of all adult men.3 

• According to Rosacea Guide, more than 13 million people in the United States have rosacea. With the multitude of interested parties, the established anti-aging “repeat-procedure” buying trends, the lack of downtime, and the decreased side effects, there may be a substantial number of reasons to investigate energy-based devices for total patient care.4 

As we know, many effective treatment options are available for acne. However, a comprehensive treatment plan also includes options for acne scars. Many physicians feel that photorejuvenation holds more promise in the treatment of acne scars than any other treatment option.

In fact, a host of accessible devices to treat the wealth of skin disorders is available. An intense pulsed-light (IPL) energy device has proven useful for patients with rosacea. A flash-lamp pumped dye laser has produced favorable results for the treatment of matted telangiectasias, cherry angiomas, and spider angiomas.

The pulsed-dye laser has served well for areas with small telangiectasias. The frequency-doubled Q-switched Nd:YAG laser has been beneficial for patients suffering from solar lentigines and localized telangiectasias.

There are combinations that might work best to treat a patient’s total facial concern. For example, the combination of Er: YAG and CO2 lasers has been used to treat acne scars and wrinkles. Other practices use the CO2 laser alone not only for acne, but for surgical scars as well.

Veins and lesions therapy

When it comes to vascular lesions, phototherapy is considered state of the art among many physicians. Many of them have turned to the flash-lamp pumped dye laser to treat vascular lesions. The same laser may be used to treat blue, red, or purple port wine stains. Red or blue facial and leg veins have responded well to an intense pulsed-light or laser approach, although schlerotherpy has remained a mainstay of nonlaser IPL treatment.

Birthmarks and tattoos

The Q-switched laser is generally used to remove tattoos. Vascular birthmarks have been served well with pulsed-dye laser treatments.

Excessive or unwanted hair  

Statistics from the American Society for Aesthetic Plastic Surgery showed that more than 900,000 patients received laser hair-removal treatments in 2003,5 and this number continues to increase. The YAG laser has been a favorable treatment option among physicians.

Sun-damaged and aging skin

Depending on the patient’s lifestyle, goals, and tolerance for downtime and multiple treatments, energy-based devices have been useful for photoaging, pigmentation irregularities, and possibly the improvement of skin-pore size. The treatment does not replace chemical peels or skin-care programs; rather, it is complementary. The IPL laser is an approach favored by some practitioners for cases involving photoaging, hyperpigmentation, and nonideal pore size.

At the same time, pulsed-dye lasers and IPL devices have been beneficial for treating sun damage. Some practitioners contend that pigmented lesions may be best served by combining frequency-doubled Q-switched Nd:YAG laser treatment with topical therapy, although, in some cases, topical therapy may not be required at all. The treatment plan for a melasma patient may commence with Kligman’s formula, followed by a frequency-doubled Q-switched Nd:YAG laser.

The frequency-doubled laser may also be used to treat post-traumatic hyperpigmentation. Improvements in sun-damaged and aging skin may be considered incremental for patients in warmer climates who are repeatedly exposed to the sun.

On the other hand, wrinkles and sagging skin are a separate problem. One energy-based device may lift a brow 2 mm and “save” a patient from a potential brow lift. However, restoring elasticity may be difficult to accomplish, require extensive expertise, and produce outcomes that are not yet understood.

Some practices use the Er:YAG– CO2 laser combination for wrinkle treatment. Others use the CO2 laser alone to treat skin irregularities, fine lines, and darkish skin discoloration.

Finally, energy-based devices have been known to help produce collagen. Because fibroblasts are better supported, the effects of sagging are decreased in future years. Wrinkles may be best served with the combination of standard treatment options and light therapies. Many patients have remarked that they love the “glow” on their face that appears after light therapy. —LR