Small incision lenticule extraction (SMILE) has earned its place in modern refractive surgery. Its safety profile is well established. Outcomes are predictable. Patient satisfaction is high. Demand for flapless refractive solutions continues to grow. And yet—in many mid-volume practices—SMILE utilization plateaus shortly after acquisition. The question we must answer is “why?”
After three decades in refractive surgery—from helping lead the excimer laser launch in the US, to operating high-volume centers with VISUMAX at Laser Eye Center of Silicon Valley, to advising practices through my book Beyond Bedside Manner and the PX90 training framework—I’ve seen a consistent pattern: technology creates opportunity; systems determine whether that opportunity scales.
We’ve seen this mindset before
When excimer lasers entered the market, hesitation wasn’t primarily clinical. The data were strong. The outcomes were compelling.
Adoption stalled because practices were not operationally prepared. Message confusion and price erosion weakened the LASIK category. Very few physicians understood that the rules change when you move from traditional medical care to what is essentially “medical retail”—a purely elective procedure requiring patient-driven decision-making.
The surgeons who scaled quickly recognized that refractive surgery is not just a procedure. It is a coordinated experience delivered by a system. Staff messaging, workflow alignment, patient education, and surgical-day execution mattered as much as the laser.
The parallels with SMILE today are unmistakable.
The most common operational barriers
In practices where SMILE volume remains low, the obstacles are rarely technical. They are operational and include:
- Inconsistent staff messaging
- Workflow friction
- Optional positioning
Inconsistent staff messaging
If technicians, counselors, and surgeons describe SMILE differently—or position it as one option among many rather than a core solution—patients sense hesitation. Research in healthcare communication consistently shows that clarity and confidence influence elective decision-making.
Workflow friction
Screening protocols misaligned with candidacy criteria create inefficiency. Surgical-day scheduling that treats SMILE as an exception disrupts consistency.
Optional positioning
When SMILE is framed as a niche alternative instead of an integrated part of the refractive mix, utilization becomes sporadic.
The limiting factor is rarely the procedure. It is implementation.
To combat inconsistent messaging, download our supplemental SMILE guide, which includes a front desk training script, a pre-surgical email template, and patient information handouts
Our experience with VISUMAX
At Laser Eye Center of Silicon Valley, we acquired our first VISUMAX 500 in 2016. We developed a clear clinical protocol defining parameters for SMILE, LASIK, and PRK recommendations.
Equally important, we built a structured communication framework to address patient preferences when individuals arrived already informed—or already biased—toward a specific procedure.
In 2021, we added a VISUMAX 500 in our second location. This eliminated disparity between offices, enhanced convenience, and allowed us to retire our Intralase platform, improving operational efficiency.
Integrating VISUMAX in both locations required redesigning key workflow elements:
- Technician pretesting protocols
- Candidacy screening alignment
- Counselor scripting
- Surgeon recommendation language
What surprised us most was not the technology—it was how small inconsistencies in team communication directly affected volume.
Once the team gained clarity and repetition, confidence rose. As confidence rose, case mix shifted. SMILE moved from occasional to routine. Performing SMILE in both locations further normalized utilization and strengthened overall refractive volume.
Repetition builds belief—for surgeons and staff alike.
Offering SMILE vs. operationalizing SMILE
There is a critical distinction between “We offer SMILE” and “SMILE is integrated into our refractive system.” Offering is passive. Operationalizing is intentional.
Operationalizing requires three foundational elements:
- Clear Education Frameworks: Patients must understand why SMILE is recommended—not simply that it exists. Counselors need structured language. Surgeons must confidently recommend when appropriate.
- Aligned Screening and Workflow: Technicians must understand candidacy parameters. Pretesting must flow efficiently. Surgical days must be predictable—not improvised.
- Team Training and Repetition: Confidence is contagious. If staff hesitate, patients hesitate. Structured, repeatable training tools transform variability into consistency.
In Beyond Bedside Manner, I wrote that patient experience is not a personality trait—it is a system. The same is true for procedural adoption.
Why implementation determines confidence
Mid-volume surgeons often assume volume will follow acquisition. But confidence does not come from technology alone. It comes from preparation, alignment, repetition, and measurement.
Practices that monitor refractive mix percentage, conversion rates, and surgical-day efficiency identify gaps early and adjust accordingly.
Leadership is decisive. When the surgeon consistently reinforces SMILE as a core solution—and ensures the team is trained to support that positioning—volume stabilizes and grows.
The bigger picture
SMILE is not simply another procedure in the refractive toolbox. It represents an evolution in corneal refractive surgery. The ZEISS VISUMAX platform enables that evolution. But scalable growth requires more than capital investment. It requires operational discipline.
We learned this during the excimer era. The practices that treated refractive surgery as a system—not an event—became market leaders. The same principle applies today. SMILE success depends on preparation, training, and repetition.
When supported by strong systems, it becomes routine—not occasional. And when it becomes routine, confidence grows. With confidence comes volume. With volume comes leadership in refractive care.
Ultimately: Technology enables -> systems scale.
