A patient from Santa Barbara that I saw in my Ventura office last week asked me about the best way to make the LASIK flap. There are basically two approaches: using the femtosecond laser to make the flap (sometimes called “bladeless LASIK”) or using the mechanical microkeratome to make the flap (often negatively referred to as using “the blade”) to make the flap. The goal of creating a flap is to separate and lift a thin surface layer of the cornea itself and then fold it back as a flap. The excimer laser is applied to the underlying cornea and the flap is re-positioned. The laser and the mechanical microkeratome method differ in how they make the flap. The femtosecond laser delivers tiny, ultra-short pulses of laser energy in the targeted corneal layer. Each burst of energy creates an expanding plamsa bubble mini-explosion which separates the flap. The mechanical approach uses a device that directly separates the layer of the cornea much like a mini spatula separating layers of lasagna. In reality, each approach as its own pros and cons. More importantly, each is very dependent on which generation of flap making device is used. Clearly older generation laser flap devices are not as good or as safe as newer generation technology. Similarly, there have been dramatic advances in the accuracy and performance of mechanical microkeratomes. I published a study that I carried out which showed the accuracy of flap depth control was equivalent with modern “bladeless” laser flap creation and modern mechanical “blade” flap creation. Adding to this study, another study was just recently published showing similar safety and visual outcomes after LASIK with femtosecond laser flaps as with mechanical flaps. Both approaches have their place and in their latest, most advanced forms, both do excellent jobs of creating the LASIK flap. Of course LASIK laser eye surgery also can be performed with no flap at all! This version of the surgery is called “flapless LASIK” or PRK. Interestingly, not only are the visual results equivalent with laser flaps or flaps made with the “blade”, the laser vision correction results are also equivalent if no flap at all is made. This suggests that the most important variable is the laser treatment itself. My experience has been that regardless of how the flap is made or if no flap is made at all, the most important variable is the use of the latest generation of customized wavefront technology.