Phakic IOLs: The Future of Refractive Surgery If you have been considering adding refractive surgery to your facility but are struggling with the cost of buying or leasing a laser, a whole new world may soon open for you. In the next few years, phakic IOLs will burst upon the refractive surgery scene and possibly change the way we treat ametropia forever. When they do, phakic IOL surgery will be a very attractive procedure to add to your suite of services, and a no-brainer addition if you already perform cataract surgery.

Phakic IOLs work exactly as normal IOLs do, but instead of replacing the natural crystalline lens, they enhance it. A number of companies have released phakic IOLs, but the one that appears closest to FDA approval is the Implantable Contact Lens (ICL), made by Staar Surgical.

The ICL is not a contact lens at all. It is a posterior chamber phakic IOL that rests in front of the lens, behind the iris without touching it. There are three versions of the lens being tested right now. The myopic lens should be available in the US in about 18 months (this lens is already available in Europe); soon after that, a toric lens to correct myopia and astigmatism should be released. A hyperopic lens won't be far behind.

I started participating in the clinical trials for the ICL back in 1993. Back then, laser surgery was all the rage, but then, as now, lasers had their share of problems-high cost, technically demanding and irreversible. Plus, laser surgery was never a viable option for patients with high degrees of ametropia-the very patients who could most benefit from refractive surgery.

I've implanted several phakic IOLs so far, and I'm impressed by how easy the procedure can be. As with any refractive procedure, the patient needs an initial exam, refraction, including a corneal topography evaluation, an A-scan measurement, a chamber depth measurement, and a white-to-white corneal measurement, to assure proper lens placement in planning for the procedure. The surgery itself, which usually takes about 10 minutes, involves applying a drop of topical anesthesia, making a clear corneal incision, and injecting the lens. The surgeon has to be careful not to damage the crystalline lens during this procedure. Most surgeons will quickly get comfortable implanting these lenses with the same instrumentation and maneuvers to which they are already accustomed with cataract surgery. Most patients can see immediately with superb visual quality (20/20 and even 20/15 in some cases), they retain accommodation, and there is no healing time (the incision heals naturally without a suture). Another benefit is that the procedure is completely reversible; if the patient isn't satisfied with his or her vision or needs a higher correction later on, we can remove the lens and insert another one. There are risks to the procedure. In addition to the risks associated with cataract surgery, including infection and inflammation, there's a chance that a surgeon may contact the crystalline lens during the procedure and induce a cataract in the natural lens. However, I believe these complications will be rare.

Staar initially plans to market the IOLs for patients with high ametropia (the company is currently testing powers from ????-???3 to ????-???20 and +3 to +20), but they could correct any degree of refractive error. Staar estimates that the ICL lens kit, which would include the lens and an injector device, would cost about $750; together with other supplies (like an eye drape and BSS), OR time, and staff time, the total case costs should be under $1,000. How that compares to the costs of LASIK depends almost entirely on volume. Because LASIK's costs are mostly fixed, higher volume means higher profitability. But there's no comparison in terms of cash flow; phakic IOLs do not require a large investment in equipment that is sure to become obsolete.

I anticipate that the fees for this procedure will exceed $2,000 per eye. If the case cost is $1,000, that leaves at least another $1,000 for the facility and the surgeon to share.

I believe phakic IOLs are the future of refractive surgery. The learning curve for doing the surgery is negligible, and the procedure could potentially benefit almost anyone with a refractive error, whereas LASIK is inappropriate for high myopia and impractical for more than moderate hyperopia.

In the very near future, it's quite feasible that we'll enhance implantable IOL surgery by creating IOLs that mimic the focusing ability of the natural lens, and even implanting IOLs with intraocular cameras and zoom lenses, allowing people to have better vision than they ever possible before. There's no doubt in my mind that laser surgery on the cornea will have a limited lifetime-in the future surgeons will not be cutting, burning or removing tissue from the cornea. Intraocular surgery will once again dominate the field of refractive surgery.

Dr. Kershner is director of the Orange Grove Center for Corrective Eye Surgery. Dr. Kershner has no proprietary or financial interest in the device or in STAAR Surgical.

Endoscopic Suturing: A New Option for GERD Patients

Until now, patients who suffer from chronic gastroesophageal reflux disease (GERD) have had two basic treatment options: acid-suppressing medical therapy or surgical (Nissen) fundoplication (plication of the fundus of the stomach around the esophagus). These options are not always ideal, as medical therapy is often chronic and fundoplication surgery has certain inherent risks and can cause serious complications. Now, a less invasive outpatient procedure is available that can help some GERD patients eliminate their drug dependence without undergoing surgical fundoplication.

In March of this year, the FDA approved endoscopic suturing for GERD, and since then, doctors have treated approximately 100 patients using the new technique. I have performed six of these procedures and will continue to do so, because I believe endoscopic suturing will come to play an important role in meeting the needs of many GERD patients.

Clinical Niche
Candidates for endoscopic suturing include GERD patients who respond well to acid-suppressing medications but whose symptoms consistently recur after discontinuation of the drugs. Ideally, these candidates are also young and healthy. Although the acid-suppressing medications work very well, I resist the idea of prescribing a lifetime of pharmaceutical therapy for any young patient.

Although a procedure is often warranted for patients on chronic medical therapy, surgical fundoplication may not be the best choice, since it requires an incision, general anesthesia, and a hospital stay as long as three days. It is also associated with a risk of serious complications (such as gastric/esophageal perforation and great vessel injury) and common postoperative symptoms such as dysphagia, inability to vomit, and the gas-belch-bloat syndrome. Surgical fundoplication is best reserved for patients who do not qualify for endoscopic suturing due to complicating conditions such as a large hiatal hernia or high body mass index.

The Technique
Endoscopic suturing involves using the Bard EndoCinch Suturing System, which is attached to the tip of a standard video endoscope. The physician suctions two sections of esophageal-gastric tissue into the suturing system, deploys a needle with a suture, and tightens a running suture through these two portions of captured tissue to form a pleat or internal plication-thereby creating a functional antireflex barrier. Company data on 64 patients show that the procedure reduced symptoms by an average of 73 percent, and that the proportion of patients on daily proton-pump inhibitors or multiple medications fell by 75 percent.

The biggest risk of endoscopic suturing is ineffectiveness; as much as one-quarter of patients do not respond. Although this could be related to patient selection, it is too early to tell just why this occurs. However, endoscopic suturing does not appear to rule out subsequent surgical fundoplication. Endoscopic suturing is also an option for qualified patients with failed surgical fundoplication. We are also unsure how long the procedure will last in patients who do respond. For me, the most significant complication to date is transient sore throat, although other reported problems include intraoperative hypoxia due to sedation, mucosal tears secondary to an overtube, dysphagia, and suture pull-out.

The Reimbursement Picture
As with any new technology, obtaining sufficient reimbursement can be a challenge. It is not an insurmountable one, however, and the procedure is slowly gaining credence among insurers. For every case, we request pre-approval and provide the insurer with a substantial amount of background information. We often use a cost-benefit analysis performed by the Peer Review Network (PRN) that compares the cost of this procedure with that of chronic medication use and fundoplication. PRN is a consulting firm that assesses new medical technologies for medical firms. Its analysis recommends a total reimbursement of $3,600 (national average), which includes a $1,914.22 facility fee that must cover an $850 single-use suturing kit. (The suturing system also consists of a $1,500 reusable handle.)

Right now, the reimbursement picture varies greatly across the country, although most facilities are at least able to cover the cost of the suturing kit. Here in New York, we have received a physician fee of approximately $1,500 from two insurers, and one practice in Michigan has received a facility fee higher than that received for endoscopic retrograde cholangiopancreatography. Other users have reported similar successes, and several users have reported higher reimbursements in their locales. To help make our case, we take great care to avoid the mistake of classifying this procedure as a routine endoscopy.

Key Considerations
For outpatient facilities contemplating this procedure, there are at least three important considerations. First, physician involvement with insurers is very important. As with any new therapy, the physician can often most effectively convey its significance to patients and insurance carriers. If your surgeons are unwilling to do their homework, you may face many reimbursement roadblocks. Second, physician training is mandatory. Endoscopists must be able to perform other advanced endoscopic procedures and enroll in a formalized proctoring session. Third, good conscious sedation is paramount. We use a variety of regimens, including Demerol 150 to 200 mg plus Versed 5 mg. We have also administered deep sedation with propofol.

Outlook
From 7 to 10 percent of the general U.S. population have daily heartburn symptoms, and an estimated 19 million people take medication for heartburn at least twice weekly. The implications of GERD go well beyond heartburn and regurgitation, however. A substantial percentage of people with asthma have GERD, and 50 percent of patients with unexplained chest pain also suffer from the condition. Epidemiologic evidence also suggests that long-standing GERD increases the risk of esophageal adenocarcinoma, regardless of the type of GERD therapy. I believe endoscopic suturing can help physicians better meet the needs of this population and, as with any new technology, it can also help attract new patients.

Dr. Starpoli is Director of the GERD Unit at St. Vincent's Hospital and Medical Center. He has no financial or proprietary interest in the Bard EndoCinch device or in C.R. Bard.

Discography: A High-Level Diagnostic for Chronic Pain Patients

One of the most frustrating things about chronic back or neck pain for patients with degenerated vertebral discs is that it's often difficult to pinpoint the exact location and cause of the pain. Consequently, after months of trying different treatments, patients often simply give up and decide to live with the pain. However, if you already offer pain management or orthopedic procedures, you may be able to offer a service that may help them and create a new profit center for your facility. The procedure is discography.

Discography is a diagnostic procedure that helps the pain management specialist determine if and where a patient's spinal discs have torn or degenerated, causing the soft core of the disc to herniate and put pressure on the spinal nerves. It involves inserting needles into the discs and then pressurizing the needles by injecting dye into them to simulate what happens to the spinal column when the patient stands up. Using fluoroscopy, the practitioner can then track the progress of the dye as it spreads through the disc. In a normal disc, the dye will pool in the middle of the structure. However, in a torn or degenerated disc, the dye will spread throughout the cartilage, highlighting exactly where it has herniated and is putting pressure on the nerve.

I started offering discography in my facility three years ago because I saw that there was a real need for it. In my facility, I improve on "traditional" discography by using a video system to monitor the entire procedure and make sure I am getting accurate data. I also put patients to sleep before I insert the spinal needles and wake them up when the needles are in place. I've found that this makes the procedure much more comfortable than just using local anesthesia.

I perform discography procedures in an OR. First, I do a full prep of the back to ensure sterility. I also monitor the patient exactly as I would in a standard procedure. I then sedate the patient using a quick-acting anesthetic, usually propofol, which takes about five to 10 minutes to take effect. Once the patient is asleep, I insert the needles into the discs that I think are causing the patient's pain. I then wake up the patient to begin the process of injecting the dye.

As I inject the dye through each needle, I use a video system to make three separate video recordings and one audio recording: I record the fluoroscopy image as the dye is flowing into the disk, the pounds per square inch (psi) manometer reading, and the patient's facial reactions as he responds to the pressurizing of each needle. I also make an audio recording of what is said during the procedure. The diagnostic portion of the test takes about 40 minutes.

After the test, my staff monitors the patients for about a half an hour in the recovery room. They then go directly to a nearby hospital for a CT-scan, which gives me a three-dimensional image of where the dye has ended up and provides even more data to make an accurate diagnosis. In total, the procedure takes about two hours.

After studying the audio and video data and the CT-scan, I'm able to get a clear picture of which particular discs, and what areas of the discs, are causing the pain. I can then suggest therapeutic measures, such as surgery to fuse the vertebrae around the disc or a newer procedure called Intradiscal Electrothermal Therapy (IDET), which uses a heated wire to destroy the pain-sensitive nerves.

The most important aspect of offering discography is making sure the practitioner is skilled. This is one of the most complex pain management procedures performed today; doctors must master less complex procedures, such as lumbar facet injections, lumbar epidural injections, and cervical injections, before they even attempt discography. In untrained hands, serious nerve damage can result. In rare cases (the incidence is about 1 in 600) the needles can introduce infection, causing discitis and necessitating disc removal. In even rarer cases, improperly placed needles can damage the spinal cord itself.

If you're already offering pain management or orthopedic procedures, you probably have the two main pieces of equipment-the OR table and the C-arm-that you need to perform discography. Other supplies include the spinal needles, a pressurized needle system (which consists of a reusable manometer, a disposable syringe, and a length of 72-inch tubing), and the anesthetics (propofol and a local anesthetic). I also use a video system to record data; however, such a system is optional. I rely on the assistance of one nurse to recover the patient from the propofol and document the manometer pressure values. Total supply costs are typically about $170. With anesthesia and staff time (but not including other overhead) our cost is about $275 to $300.

Medicare does not reimburse for discography in an ASC setting. However, we've had no problems getting reimbursed from private insurers (including major HMOs such as Blue Cross/Blue Shield and Met Life). The average facility reimbursement for discography is typically around $1,500; the facility profit is around $1,100 to $1,200 and the average physician reimbursement ranges from $150 to $500. We typically do about three to four cases a month; since we offer a full suite of pain management services, patients usually filter down to this service after they've tried other options.

Provided you have the proper equipment and a skilled, experienced practitioner, discography could be a profitable, much-needed service to add to your facility. In the right hands, it's an effective, yet surprisingly simple procedure that could be the last hope for chronic pain patients.

Dr. Lipov is the Medical Director at the Poplar Creek Center for Pain Management.

Thermal Balloon Ablation: A Simple Alternative to Hysterectomy

At one time, the only certain cure for women with abnormal uterine bleeding or fibroids was hysterectomy. Even today, the Centers for Disease Control and Prevention estimates that surgeons perform approximately 600,000 hysterectomies every year in the US alone, at a cost of more than $5 billion, making it the second most common procedure performed on reproductive-aged women (the first is Cesarean section). Many women, however, are understandably reluctant to undergo such an invasive, inpatient procedure, even if they no longer wish to have children. At our facility, we have just started offering a new alternative for some of these women-thermal balloon ablation-and have high hopes for its success. If you're already offering GYN procedures, perhaps this procedure could work for your facility, as well.

Endometrial ablation itself isn't a new procedure; typically a surgeon uses a hysteroscope to visualize the uterus and then ablates the uterine lining with roller ball cautery, a laser, or a similar instrument. This procedure is difficult and time-consuming to perform; treating the uterine lining uniformly takes a significant amount of skill, and most surgeons simply recommend hysterectomy. With thermal balloon ablation, however, the surgeon can achieve a controlled, uniform ablation with or without hysteroscopy in less time.

We started offering thermal balloon ablation just this past May because we felt it was a relatively inexpensive, simple procedure that our gynecologists could offer patients. Our GYN surgeons were extremely eager to take advantage of the service for their patients; we actually had a waiting list when we first started because patients themselves had begun asking their physicians about it. So far, we've done approximately 20 cases; now we're typically performing about four to five cases a month.

When a patient arrives for the procedure (approximately one hour prior to surgery), she is greeted by an RN who performs a simple screening of her health status and medical history and provides her with a gown, robe and slippers. An anesthesiologist then reviews her medical history and does a brief examination.

In the OR, the anesthesiologist places an IV and administers a small dose of Versed and/or Fentanyl. We also offer all patients monitored anesthesia, since when the fluid in the balloon is heated, it may cause significant cramping. To do the procedure, the surgeon dilates the cervix and inserts the device, which is a flexible silicone balloon that has a heating element incorporated into the tip. The end of the balloon has an adaptor attached to a syringe. A cable extends from the end of the balloon to the ablation unit that controls the heating element and measures the intra-uterine pressure, indicated on the front of the machine. The unit is also equipped with a safety feature, which emits an audible alarm if the prescribed parameters are exceeded.

The surgeon inflates the balloon with sterile solution, causing it to expand and fill the uterine cavity. The fluid is heated to 87 degrees Celsius and maintained for exactly eight minutes. The surgeon then turns the machine off and deflates and removes the balloon.

The patient is then transferred to the recovery room where she is observed for approximately 30 to 40 minutes before being discharged. We give her written instructions and may prescribe a mild sedative for discomfort. We tell her that her uterine lining will slough off like a period in the following seven to 10 days. In most cases, patients resume normal activities in a few days; all our patient responses have been very favorable.

Risks are minimal; although there is a chance that the balloon may break, we always double-check it before insertion, and we've never had a balloon rupture. The procedure isn't for everyone; patients with any evidence of endometrial cancer or abnormal anatomic pathology aren't candidates. Also, since the procedure treats only the external layers of the endometrial lining, some women may still experience breakthrough bleeding. Those patients may have to eventually undergo an additional procedure or have a hysterectomy.

Offering the procedure does involve a substantial initial equipment investment. The ablation unit costs from $10,000 to $12,000 and the balloon costs approximately $650 to $700. This, combined with the cost of medical supplies, pharmaceuticals, personnel, and OR time, establishes the global cost of the procedure.

So far, we've been able to get reimbursed for this procedure by commercial insurers. Our reimbursement is based on our contractual agreements with each insurance company.

One thing that was instrumental to our ability to offer the procedure was forming a strong relationship with the manufacturer of the balloon ablation unit (Gynecare, a division of Johnson & Johnson). As we continue to develop the service, we are communicating with them on a weekly basis. They've been supportive in supplying the equipment and disposables and providing technical support, as well as helping us run training seminars for our physicians and providing patient education materials.

Thermal balloon ablation is a high-demand procedure that almost any multispecialty center that does GYN procedures could easily add to its suite of services. Now that we've successfully passed through the initial stages of acquisition, training, and procedure performance, with little disruption to the efficiency of the center, we anticipate an increase in the number of physicians who will offer this procedure as an alternative to other, more invasive procedures.

Ms. McGucken is Director of Nursing at the Yale New Haven Ambulatory Services Corp. Neither Ms. McGucken or Yale New Haven have any proprietary or financial interest in the thermal balloon ablation device or Gynecare.

Sentinel Node Biopsy Improves Patient Care

When we decided to offer sentinel node biopsy (SNB) to breast cancer patients one year ago, we knew it wouldn't be our most profitable procedure. But we did know that it could greatly improve patient care, significantly enhance the satisfaction of our general surgeons, and help create a more positive image for our facility as a whole. Over the past year, SNB lived up to these expectations.

The Benefits of SNB
Before SNB, surgeons routinely performed axillary node dissection (AND) along with simple mastectomy in an effort to remove all cancerous cells from the breast and axillary tissues. AND involves removing all, or nearly all, axillary tissue-including fat, lymph nodes, lymph and blood vessels, and some nerves. The biggest consequence of AND is lymphedema, which affects 25 percent of patients and has a profound impact on quality of life. Treatment may also be uncomfortable and unsuccessful. Other complications include chronic pain, soreness, tingling, and numbness.

We now know that indiscriminate removal of axillary tissue does not prevent the spread of breast cancer, and that at least 80 percent of dissections are negative for malignancy. However, knowledge of axillary node status is still important because a positive node greatly increases the likelihood of occult systemic spread and alters the treatment plan. With SNB, we are now able to determine if the cancer has spread to the lymphatic system by removing and evaluating only one or more key nodes, including the sentinel lymph node.

The sentinel node is the first node to receive cancer cells. If it is negative, the nodes ????-??downstream' are almost always negative. To biopsy the sentinel node, we tag it by infiltrating the primary site with a radioactive dye (Sestamibi) and a pigmented dye (1% isosulfan blue), which migrate along lymphatic channels to the nodes that drain the tumor. We identify the incision location by detecting the radioactivity at the nodes with a hand-held gamma probe. Through the incision, we can readily see the blue pigment along the lymphatics and node(s), and we confirm the area of concentrated radioactivity with the probe before excising the node(s). After the excision, we verify that we have captured the right node(s) by passing the probe over the specimen before sending it to pathology. The ability to obtain the sentinel node depends heavily on surgeon training and skill. Accuracy declines when the lesion is close to the axilla or when the dye is injected into an excisional biopsy cavity.

We perform SNB for primary breast cancers of all sizes, whether palpable masses or microscopic, mammographically detected lesions. They are especially valuable for patients who have cancers with low expected rates of nodal metastases and elderly patients in whom full axillary dissection would cause unacceptable morbidity. Most surgeons, however, will still recommend a full axillary dissection for very large lesions.

Cost Analysis
The only extra equipment needed to perform SNB is the gamma probe and its unit, which cost us approximately $28,000. We opted for a reusable probe, which requires a new cover for each procedure but is clearly less expensive than a disposable probe.

Our average procedure, a simple mastectomy with SNB, lasts about 2 hours and costs our facility $549.68, itemized as follows: $108 for direct labor, $305.68 for supplies (including probe cover and $99 dye cost), and $136 for the probe unit depreciated over five years.

We have had to negotiate with insurers and repeatedly demonstrate that this a better and more economical experience for the patient. For the most part, we receive approximately $1,100 from private insurers who will reimburse for the procedure; not all do. The Medicare reimbursement is lower and depends strictly on the number of nodes removed. When we perform simple mastectomy with SNB and remove six or more nodes, we receive a group 7 reimbursement ($949); if we remove five or fewer nodes we receive just $486, a group 3 reimbursement. We're hoping to change this.

Important Considerations
There are at least two important considerations for outpatient facilities thinking of adding SNB. First, SNB is only for facilities that serve large populations, and we recommend performing a thorough market analysis. Second, physical proximity of both radiology and pathology services is essential. A radiologist must inject the radioactive dye three to four hours preoperatively, as the dye takes that long to migrate to the lymphatic system. It would not be possible to offer SNB if we had to send patients to the local hospital for this service. Fortunately, we have a nuclear medicine facility within very close walking distance. An on-call pathology service is also important. Intraoperatively, we send the nodal specimen out for an immediate frozen section evaluation. When the result is positive, we immediately perform a full axillary dissection before closing the incision. Approximately 20 percent of specimens deemed negative by frozen section turn out positive on final pathologic review; most of these patients return for a second surgical procedure to remove the surrounding nodes.

For us, SNB has been a great procedure. Thanks to the high skill level of our close-knit outpatient team, our rate of accuracy approaches 100 percent and we have had no complications to date. We are doing a great service to our patients and to our general surgeons, and SNB has been a terrific way to round out our breast service.

Ms. Henderson is the executive director and Dr. Schultz is a general surgeon at The SurgiCenter of Baltimore.

Alexandrite Laser Technology: A Better Solution for Hair Removal

If you perform cosmetic surgery procedures in your facility, chances are you may already have a referral base of patients who may be interested in improving their looks by getting rid of excess hair. Believe it or not, hair removal-shaving, waxing, electrolysis, and a variety of other methods-is a multi-billion dollar industry. Now, a relatively new technology may help you offer a quick hair removal option for patients of all skin types-with just one laser.

Laser Technology
The FDA cleared the first laser for hair removal in 1995, and since then, many lasers have flooded the market. Almost all of them attempt to target darker pigment, or melanin, in the roots of the hair follicles and destroy the hair while sparing the lighter colored skin and surrounding tissue.

One of the main problems of some lasers is that they target the melanin in the hair as well as the skin, causing blistering and scarring in darker-skinned patients. But the Alexandrite laser uses a longer wavelength and longer pulse width (the length of time the laser is exposed to the treatment area). The laser is able to bypass the melanin in the epidermis and target the concentrated melanin in the hair follicle with enough energy to destroy the hair, allowing us to treat patients with darker skin.

Five lasers on the market use Alexandrite technology. I happen to use the Apogee Cynosure Alexandrite laser a year ago; it offers numerous parameters that allow me to match hair location, hair type, and skin type to each patient. Other lasers that use Alexandrite technology may be just as appropriate.

Patient Base
Patients usually come to us via our cosmetic surgery practice. The most common areas we treat are the bikini area, the underarms, and the face. We instruct patients not to pluck, wax, or bleach the hair for at least a few weeks before treatment. Patients also fill out a questionnaire to make sure they are healthy and have no immunosuppressive disorders. The procedure itself is fairly simple and typically requires no anesthesia; the patient feels a stinging sensation. Our laser also has a cooling module to minimize heat transfer to the skin. The average session lasts 15 to 20 minutes; we can typically treat an entire inguinal area in one session. Patients leave immediately after the procedure; we simply instruct them to apply an antibacterial ointment for two days, keep the area uncovered, and use a sunscreen. They return every six to eight weeks for follow-up treatments; the typical course is six treatments over 12 months.

Keys to Success
There are two important keys to success if you're thinking of offering laser hair removal. First, ensure that your cosmetic surgeons have proper training and experience in laser operation before you invest in any laser. All lasers are different, and if used improperly, they damage the patient's skin, causing scarring, hyperpigmentation, and hypopigmentation. A physician should learn how to use a laser during at least one training course, and it also takes a lot of hands-on experience with different skin types to get optimal results. State regulations vary in terms of who can perform the procedure, but the supervision of a medical doctor is mandatory. Second, make sure your surgeons and staff handle patient expectations wisely. They should make sure that patients must understand the following:
- The technology is not 100 percent effective; individual results will depend on the amount of hair and the skin type. While it is possible to permanently remove up to 70 percent of the hair in some patients, the treatment may only remove 30 percent in others. In the vast majority of cases, if hair does grow back, it will be less thick, dark, and dense. Patients must understand that they'll need to commit to at least three to as many as eight treatments to get optimal results.
- Patients may experience complications, including scarring, pigmentary changes, and blistering. Fortunately, with Alexandrite technology, the complication rate has dropped to 1 to 2 percent.

Profit Picture
If you'd like to get into laser hair removal, the initial capital outlay for buying an Alexandrite laser ranges from $50,000 to $120,000. You'll also have to ensure that your facility is set up to host the laser with proper wiring, outlets, and a ventilation/filtration system. You will need to make sure that at least one staff person is certified as a laser safety officer. This person needs to be on site every time the physician uses the laser to make sure all safety standards are maintained.

Since these procedures are completely elective, there are no insurance caps on how much you can charge; prices will vary depending on your local market. We charge from $300 for six sessions of toe or finger treatments to $4,500 for a full leg treatment. We're starting to build interest by marketing the laser directly to consumers and patients in our practice. We're also building a web site to help attract and educate patients.

With all the hype that's occurred in laser hair removal technology, it's gratifying and exciting to use one laser for all types of patients. I believe that Alexandrite technology can allow us to give patients the results they've been looking for. I anticipate that it will become a highly profitable part of our cosmetic surgery practice.

Dr. Rohrich is the chair of the Department of Plastic and Reconstructive Surgery at the University of Texas Southwestern Medical Center at Dallas. He has no proprietary or financial interest in the Apogee Cynosure Alexandrite laser or in Alexandrite technology.