April 1, 2007
Recognizing the increased usage of laser surgery and to provide professional guidance to state and federal regulatory bodies addressing laser and other surgery issues, the American College of Surgeons wishes to make the following revised statement regarding these operative techniques. The original statement was published in the March 1991 issue of the Bulletin, and this revised statement was approved by the Board of Regents at its February 2007 meeting.
Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is a part of the practice of medicine. Surgery is also the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue, which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reduction for major dislocations and fractures, or otherwise altered by any mechanical, thermal, light-based, electromagnetic, or chemical means. Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system is also considered to be surgery (this does not include administration by nursing personnel of some injections, such as subcutaneous, intramuscular, and intravenous when ordered by a physician). All of these surgical procedures are invasive, including those that are performed with lasers, and the risks of any surgical intervention are not eliminated by using a light knife or laser in place of a metal knife or scalpel.
In recent years, technological advances have made it possible to perform cosmetic surgical procedures of the skin using a variety of devices and techniques. Lasers, pulsed light, and radiofrequency devices are often used for ablative and nonablative treatments. An ablative treatment is expected to excise, burn, or vaporize the skin below the dermo-epidermal junction. Nonablative treatments are those that are not expected or intended to excise, burn, or vaporize the epidermal surface of the skin. Any procedures that can damage the eye (cornea to retina) are ablative and should only be performed by a licensed physician.
The American College of Surgeons believes that surgery using lasers, pulsed light, radiofrequency devices, or other means is part of the practice of medicine and constitutes standard forms of surgical intervention. It is subject to the same regulations that govern the performance of all surgical procedures, including those that are ablative or nonablative, regardless of site of service (that is, hospital, ambulatory surgery center, physician’s office, or other locations). Patient safety and quality of care are paramount, and the College therefore believes that patients should be assured that individuals who perform these types of surgery are licensed physicians (defined as doctors of medicine or osteopathy) who meet appropriate professional standards. This is evidenced by comprehensive surgical training and experience, including the management of complications, and the acquisition and maintenance of credentials in the appropriate surgical specialties (that is, board certification) and in the use of lasers, pulsed light, radiofrequency devices, or other similar techniques.
However, the College also recognizes that the use of ablative lasers may be delegated to non-physician advanced health care practitioners (defined as nurse practitioners or physician assistants) who are appropriately trained and licensed by the state in which they practice. Ablative treatments or procedures performed by nonphysician advanced health care practitioners should fall within the statutory and/or regulatory scope of the practitioner’s profession. The physician may delegate the performance of ablative treatments through the use of written protocols to an advanced health care practitioner. Direct supervision should be provided by the physician whenever performance of ablative treatments has been delegated to an advanced health practitioner, unless specific state regulations allow for lesser amounts of supervision. The physician is responsible for doing the initial review of the patient and for authorizing the treatment plan. This should be appropriately noted in the patient’s chart prior to any initial ablative treatment.
Physicians may also delegate the performance of nonablative treatments to nonphysician health practitioners (defined as registered nurses, cosmetologists, aestheticians, and medical assistants or other qualified personnel), provided the treatments are performed under direct supervision by the physician consistent with state laws and regulations in the state where they practice. The physician must also assure that these practitioners are appropriately trained, licensed by the state in which they practice, practicing within the scope of their licensure, and provided with written protocols. Similar to ablative treatments, the physician is responsible for doing the initial review of the patient and for authorizing the treatment plan, and this should be appropriately noted in the patient’s chart prior to any initial nonablative treatment.
In those cases where the surgeon may utilize the services of a nonphysician advanced health practitioner or nonphysician health practitioner as an assistant during the performance of laser surgery (including ablative or nonablative procedures), the assistant must meet the following requirements:
Individuals who perform laser surgery utilizing lasers, pulsed light, radiofrequency devices, or other techniques should meet the principles of the College in all respects, to include the avoidance of any misrepresentations to the public regarding unfounded advantages of the laser compared with traditional operative techniques.
Reprinted from Bulletin of the American College of Surgeons
Vol.92, No. 4, April 2007