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Part one of our series on starting a laser practice went into the business nuts and bolts of launching a laser business - the how and why. Once dermatologists have determined there is a need for laser services at their practices and why, they’ll have to decide which lasers to purchase or lease.
National report - Part one of our series on starting a laser practice went into the business nuts and bolts of launching a laser business - the how and why. Once dermatologists have determined there is a need for laser services at their practices and why, they’ll have to decide which lasers to purchase or lease.
That, too, requires homework. Without it, you might be stuck trying to resell boxes that lose value as soon as they’re delivered to your office, experts say.
Tina S. Alster, M.D., who started her laser practice in Washington, D.C. - the Washington Institute of Dermatologic Laser Surgery - with only one laser and has since added about one laser a year, says laser technology applications in cosmetic and medical dermatology have flourished. It’s a much more complicated process for dermatologists wanting to incorporate lasers today compared to when she opened her laser practice in 1990.
“For people today, it would be very difficult to start with one laser and go about it the way I did,” she says. “These days, you really need at least a couple of systems, along with a clear working knowledge of how to incorporate good skincare. (This includes) dispensing of cosmeceuticals, along with fillers and toxins, so you can give a whole package to somebody - one-stop shopping.”
The first step in this process, according to Dr. Alster: Have at least a basic understanding of how different lasers work and what categories of technology exist. These include vascular lasers, pigment and tattoo removal lasers, hair removal lasers, resurfacing lasers and body contouring devices.
“There are certainly many textbooks out there that I and others have written that clearly outline the basics of lasers in dermatology. The courses at the American Society for Dermatologic Surgery and even more basic at the American Academy of Dermatology, will introduce you to the basic tenets of laser surgery. For our residents in training, there are these scholarships for rotations with various people at the mentorship awards through the Women’s Dermatologic Society or through the American Society for Dermatologic Surgery,” Dr. Alster says.
The categories of lasers dermatologists ultimately choose have to reflect the patients they’re targeting, according to Terrence Keaney, M.D., who practices with Dr. Alster and started a men’s cosmetic center within the Washington Institute of Dermatologic Laser Surgery.
“If you have an existing medical practice and you’re trying to add more procedural components, and you have a lot of acne and rosacea patients, maybe starting with a pulsed dye laser might be worthwhile,” Dr. Keaney says.
The idea is to start with workhorse lasers that can treat different conditions; then, add lasers with specific functions to meet patient demand, according to Dr. Keaney.
“You don’t want to buy every laser on the market because you don’t know if the patients are going to be there for you, and there’s a big upfront cost,” he says.
The dermatologists who spoke to Dermatology Times agree there are a few good bets, or workhorse lasers (We’ll go more into the workhorse lasers at practices around the county in a future article in this series).
Vic Narurkar, M.D., chairman of dermatology at California Pacific Medical Center, San Francisco, does only cosmetic dermatology and has 16 onsite energy based devices to address a variety of issues.
But of those, there are three he uses daily.
“The most used lasers in the practice are my Fraxel laser and my Excel V KTP laser (Cutera) and my Palomar Max G IPL. Those are the ones I use daily, multiple times a day,” he says.
Dr. Narurkar’s advice for dermatologists deciding which lasers to bring into their new laser practices is to first consider a vascular laser.
“A vascular laser is the workhorse of a dermatology practice because we see red things all day long, like angiomas, telangiectasias, poikiloderma, rosacea, red scars,” Dr. Narurkar says. “The second thing that comes across is photodamage. That’s why the second laser that I recommend is to get some sort of resurfacing device like a Fraxel laser, because that too becomes the workhorse to treat photodamage of the face, neck and body, as well as scars.”
By the same token, there are lasers dermatologists might want to hold off on, at least in the beginning, he says.
“In terms of laser hair removal, even though it’s a very effective treatment, if you’re just starting it’s going to be very competitive because a lot of spas and non-derm practices are offering it at reduced rates,” Dr. Narurkar says. “So, it makes sense to have it as part of a comprehensive center, but it isn’t the first thing that I would get.”
Dermatologists should seek out unbiased recommendations from colleagues using lasers, experts say.
Bruce Katz, M.D., a dermatologist who opened the Juva Skin and Laser Center in downtown Manhattan, New York, in 1998 and today has more than 50 lasers, recommends dermatologists attend meetings by such professional organizations as the American Society for Laser Medicine and Surgery (ASLMS), where they not only learn through lectures, but also see various technologies and talk informally with doctors who use specific technologies at their practices. Asking doctors who use the devices to recommend lasers and manufacturers offers insight dermatologists might not get from people who represent laser companies.
“If you go to a company, they’re going to try to sell you their laser,” Dr. Katz says. “(While at a meeting, for example, go to) the pulsed dye section and ask someone their preferences, why and the benefits of one laser to another. Then, you can go to the company, and you’re an informed consumer. You know what questions to ask and whether their devices meet the criteria of the expert doctors.”
Deciding which and how many lasers to get is a matter of economics, according to Dr. Narurkar. Dermatologists need to have an idea of how many patients they need to treat daily in order to make a laser viable.
“My other piece of advice is don’t always go with the latest and greatest, because oftentimes they’re disappointing and even though it might get a lot of hype, it might not be sustainable. Get what’s tried and true - something that works and is reliable and offers consistent results,” Dr. Narurkar says.
You have a few lasers in mind. Now, it’s time to find the right company with which to do business. The company you choose does much more than deliver a box to your practice. It becomes a long-term partner that can make or break your laser practice’s success.
“Sometimes the lasers can be relatively equivalent. So, then it comes down to the company, itself,” says Elizabeth L. Tanzi, M.D., clinical professor of dermatology at George Washington University Medical Center and co-director, Washington Institute of Dermatologic Laser Surgery. “You have to ask yourself: Is this is a long-standing, financially stable company? Are they going to be there for me in two or three years, if I have an issue with my laser or I need an upgrade to my laser?”
Dermatologists should look critically at whether the laser company has a good track record with clients. Ask dermatologist customers (not only the ones the laser company recommends). Talk with company representatives about the company’s laser maintenance program, any consumables required.
“You want to know about their support staff because if a laser breaks down in your office that is an immediate loss of revenue. You have to cancel patients. You need to be able to get them on the phone immediately for customer service,” Dr. Tanzi says. “That is going to be critical. You don’t want a laser company that sells you a box, then you never hear from them again. That is a recipe for disaster. Lasers need to be maintained. They need to be fixed. There are always upgrades that happen. There are questions. You want to be able to talk to your laser company about the latest techniques that are being used. All of these things will be important down the road for your practice.”
Dr. Alster says dermatologists should try to test devices or, at least, see them in use.
“Depending on the laser company, some of them will bring them in so they can kind of see how these things work or go to workshops where these laser devices are being used, so they can at least get a little bit of hands-on experience,” Dr. Alster says.
Dermatologists have a range of options when considering leasing versus buying. They can buy lasers, outright; lease or lease-to-own them; and, in some cases, rent them by the day.
Dr. Alster recommends dermatologists first figure out how many patients they would have to see or treat in any given month, in order to make a payment on a laser. Patient volume not only helps you determine which lasers are best for your practice but also how to pay for them.
“If you think you have a tattoo case once or twice a month, you’re not going to buy a really expensive laser for that. You can rent it and have patients come in one day a month for tattoo removal. But if you have people who you are doing wrinkles on the face every day (I use my fractional laser three, four, five times a day, just for patients who have wrinkles), there’s no point in my renting one. I’d rather have it there to use every day,” Dr. Katz says.
How you pay for laser technology also depends on your financial situation, according to Dr. Narurkar,
“Like automobiles, lasers and energy devices have very low value on the used market. At the same time, if you finance these things, there’s always a fee. So, it’s best to talk with your accountant and find out what makes the most sense to you. (That includes) whether to lease it, so you don’t have the initial capital outlay starting out, or to purchase it and depreciate it, if you have cash and it’s going to be profitable,” Dr. Narurkar says.
Buying, leasing or renting a laser or other device is only the beginning. After that, there’s the upkeep and maintenance, Dr. Alster says.
“These are all things - the nuts and bolts, so to speak - of having these systems in your office,” Dr. Alster says. “It’s not a standalone thing. It’s a whole process and must be thought out from A to Z. All of them require a service contract, which is expensive. This is a big ticket item and you want to make sure you can afford it.”
There might be added expenses. Some machines, for example, need a cooling device. Dermatologists need to understand whether the cooling device is an added expense or if it comes with the machine. Many of these systems require a different electrical outlet - specifically, two 20-voltage outlets, instead of one 10-voltage, according to Dr. Alster.
Consumables, including laser tips and cartridges, are another consideration, according to Dr. Narurkar. Some dermatologists see consumables as a negative, he says. But they aren’t, according to Dr. Narurkar.
“Don’t be afraid of consumables,” Dr. Narurkar says. “It is in the interests of manufacturers that sell you consumables to take care of you, even after you purchase the laser. So, while consumables may seem to be a pain initially, in the long term it’s a partnership between you and the manufacturer - just like it is with you and the injectable companies.”
Editor’s Note: Stay tuned for the next article in this series, which discusses types of lasers and their indications.
Disclosures: Dr. Tanzi is on the medical advisory board of Zeltiq, Miramar and Clarisonic. Dr. Narurkar has performed clinical trials for Palomar, Solta and Zeltiq. Dr. Alter has relevant disclosures with Cynosure, Home Skinovations, Palomar and Syneron. Dr. Keaney reports no relevant financial interests.