Cosmetic Surgery Times` key leaders
Transcription
Cosmetic Surgery Times` key leaders
® COSMETICSURGERYTIMES.com | NOVEMBER/DECEMBER 2012 | Vol. 15 | No. 10 �� ��t� �� ���meti� �ur�er How did the aesthetic industry fare in 2012? Where is it headed in 2013? Cosmetic Surgery Times' key leaders sound OFF The VECTRA® 3D imaging system helps you turn her dream into reality. your patient’s dream takes shape right before her eyes. She sees that you understand and gains confidence that you will meet her expectations. Invest with confidence. vectra 3D owners report a 23% increase in consults and a 27% increase in procedures.* the top reason patients quickly arrive at a shared understanding of treatment objectives when they explore possible outcomes using their own 3D image. Face, neck, breast or body—VECTRA does it all. *Data from a recent survey of practices using vectra 3D. Call today for a live, on-line demonstration, and see for yourself how VECTRA can sculpt the dream. 800.815.4330 www.canfieldsci.com / [email protected] / phone +1.973.276.0336 / (USA) 800.815.4330 3 D s o l u t i o n s • fa c i a l i m a g i n g & a n a ly s i s • i m a g i n g s o f t w a r e • p h o t o g r a p h y • r e s e a r c h s y s t e m s & s e r v i c e s • t r a i n i n g 3 NOVEMBER/DECEMBER 2012 Cosmetic Surgery Times is where the exchange on aesthetic perspective begins. It is your multimedia forum for accessing and discussing the leading technology, surgical & noninvasive techniques and practice management associated with cosmetic surgery. Perspectives, innovations and strategies are shared, debated & augmented by expert contributors & the larger community. The results are quality procedures & strong practices. MISSION STATEMENT: CONTENT RICHARD R. KERR | Group Content Director AMY STANKIEWICZ | Content Channel Director | [email protected] SUSAN R. 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COSMETIC SURGERY TIMES welcomes unsolicited articles, manuscripts, photographs, illustrations and other materials, but cannot be held responsible for their safekeeping or return. Library Access Libraries offer online access to current and back issues of Publication name through the EBSCO host databases. To subscribe, call toll-free 888-527-7008. Outside the U.S. call 218-740-6477. PRINTED IN U.S.A. COVER IMAGES FROM GETTY IMAGES/PHOTOALTO AGENCY RF COLLECTIONS/MICHEL LEYNAUD ® Editorial Advisory Board Tina Alster, M.D., is the founding director of the Washington Institute of Dermatologic Laser Surgery and clinical professor of dermatology at Georgetown University. She is a world-renowned lecturer and author on the subject of cosmetic laser surgery. James Carraway, M.D., specializes in plastic and reconstructive surgery and is professor, division of plastic surgery, and chairman, division of plastic surgery, at Eastern Virginia Medical School. Steven Fagien, M.D., F.A.C.S., is an internationally renowned cosmetic eyelid plastic surgeon with private practice in Boca Raton, Fla. He specializes in cosmetic blepharoplasty and injectable agents for facial aesthetic enhancement. David H. McDaniel, M.D., practices cosmetic dermatology and directs the Institute of Anti-Aging Research in Virginia Beach, Va. He is certified by the American Board of Dermatology and serves as assistant professor of clinical dermatology at Eastern Virginia Medical School, as well as co-director of the Hampton University Skin of Color Research Institute and adjunct professor in the School of Science at Hampton University. Patrick G. McMenamin, M.D., is a diplomate of the American Board of Cosmetic Surgery. He was the 2009 president of the American Academy of Cosmetic Surgery and is in private practice in Sacramento, Calif. He completed his surgical training at Johns Hopkins Medical Institutions and has served in faculty positions at Johns Hopkins and the University of California, Davis. Joe Niamtu III, D.M.D., F.A.A.C.S., is a board-certified oral and maxillofacial surgeon with a practice limited to facial cosmetic surgery in Richmond, Va. Jeffrey C. Popp, M.D., F.A.C.S., is a fully certified cosmetic and reconstructive surgeon and has been in practice since 1983. He is in private practice in Omaha, Neb. Use your smartphone to link to Cosmetic Surgery TimesÕ website Ñ scan this QR code! CosmetiC surgery times 4 Achieving attractiveness in any aesthetic patient requires much more than knowledge of available techniques and tools Ilya Petrou, M.D. S enior S taff CorreSpondent A esthetic physicians benefit from a large armamentarium of techniques and tools, all of which are used to improve the appearance of their patients. Though these state-ofthe-art procedures can rejuvenate a patient’s face, neck or body, understanding how resulting changes impact overall beauty is paramount, says Steven H. Dayan, M.D., facial plastic surgeon, Chicago. “Cosmetic surgery has gravitated towards making larger and noticeable changes in a patient’s appearance, whether performing volume augmentation with fillers, facelift surgery or other beautifying techniques. However, it is the small, subtle changes which are barely perceptible to the human eye that significantly alter the first impression that someone projects, a notion supported in evolutionary biology and neuropsychology,” Dr. Dayan says. 6 How can sound lift skin? Ultherapy uses micro-focused ultrasound to heat deep below the skin’s surface. It is the ONLY noninvasive procedure FDA approved to lift and tighten the neck, submental region and brow. Harness the Power of Sound. The Ulthera® System harnesses ultrasound to visualize and treat the deep support structures of the skin (SMAS / Platysma). Ultherapy® goes deeper than lasers and radio-frequency, focusing heat BELOW the skin without affecting its surface. The result is noninvasive lifting and tightening — in a single treatment with no patient downtime. Visit Ultherapy.com/Physicians to learn more. For full product and safety information, including possible, mild side effects, go to Ultherapy.com/IFU. ©2012 Ultherapy® is a registered trademark of Ulthera Inc. 1001685A CosmetiC surgery times 6 A 31-year-old female patient before (far left image, third from left image) and 10 weeks after receiving Botox on upper one-third of face; Botox in masseters to mildly narrow the jawline; Juvéderm in cheeks, nasolabial folds, vermilion border and oral commissural grooves bilaterally. (Photos credit: Steven Dayan, M.D.) Beauty continued According to Dr. Dayan, subtle cosmetic changes at the corner of the mouth, side of the nose, or corner of the eye or eyebrow have a significant impact on overall appearance. These small changes have a positive impact on a patient’s psyche as well. Dr. Dayan’s recent studies have shown that cosmetic facial treatments with botulinum toxin not only improve the first impressions that patients make; they can also improve their quality Dr. Dayan of life and self-esteem (Dayan SH, Lieberman ED, Thakkar NN, et al. Dermatol Surg. 2008;34(Suppl 1):S40-S47; Dayan SH, Arkins JP, Patel AB, Gal TJ. Dermatol Surg. 2010;36(Suppl 4):2088-2097). In a similar psychosocial impact study, Dr. Dayan found that cosmetic facial treatments with hyaluronic acid fillers can significantly influence the first impressions that patients project (Dayan SH, Arkins JP, Gal TJ. Dermatol Surg. 2010;36(Suppl 3):1866-1873). person in question has good genes, Dr. Dayan says. From an evolutionary and biological standpoint, beauty is largely based on symmetry and is an indicator of health, vitality and the potential for producing viable offspring. “The goal of a cosmetic procedure with an ideal outcome would be to make the patient look more beautiful, but no one can tell that he or she had something done. That’s the key to truly successful cosmetic surgery,” he says. “Patients who have an overtly noticeable cosmetic change in their appearance such as those seen after larger volume augmentation procedures and facelifts may look fake, which may inadvertently suggest suboptimal health or a genetic weakness, and that is the exact opposite message you want to send,” Dr. Dayan says. Many cosmetic physicians do not listen closely to their patients in terms of their cosmetic needs; according to Dr. Dayan, physicians often focus only on their own perception of beauty. All too often, a physician’s perception of beauty involves larger, more noticeable cosmetic changes, he says. This is reflected in the stunning before and after images often shown to patients and at meetings. While botulinum toxin will remove a patient’s ability to frown as well as smooth out visible wrinkles, treatments also make the patient more attractive by opening the eye and making it look younger. According to Dr. Dayan, there is a feedback mechanism between expressions and emotions, and if a patient can’t frown, theoretically he or she should be happier. It often only takes one small detectable change in a person’s face, expression or posture to completely alter the impression projected, he says. “These small but significant changes will not only positively influence the first impression an individual projects but also positively impact the patient’s self-esteem, which though difficult to quantify, are of immeasurable value in terms of making the patient genuinely happy from within,” Dr. Dayan says. “The ultimate goal for beauty is that you feel good about yourself because you are not beautiful unless you feel good. One of the central goals of cosmetic procedures is to make a patient more attractive, but it is more important that patients feel better about themselves. Once patients feel better, they will start to project themselves better,” he says. IMPACTING EMOTIONS Beauty is expressed through subconscious communication, portraying to a prospective partner that the SUBTLETY IS KEY According to Dr. Dayan, patients today typically ask for cosmetic changes that are unobtrusive and appear natural. “We have to learn to listen more to our patients and their cosmetic needs. It’s not just small, subtle changes that patients are looking for, but those changes must be made in the right places,” Dr. Dayan says. When approaching a cosmetic patient, Dr. Dayan says he will use both his expertise and artistic eye as well as knowledge of what makes someone attractive to recommend cosmetic treatments. Cosmetic outcomes should be subliminal, but the difference in the way a patient looks and feels should be palpable. “Cosmetic physicians are often painted as purveyors of beauty for the vanity challenged, and this couldn’t be further from the truth. Our task is not to make patients look better, but to make them feel better. I think this is a very important theme that needs to be studied and pushed in aesthetic medicine to advance our specialties and ultimately, to better serve our patients,” Dr. Dayan says. Disclosures: Dr. Dayan reports no relevant financial interests. the no pain no surgery no downtime no dieting body shaping solution Your patients want immediate results. Offer them the latest advancement in non-surgical body contouring technology, now available in the US: i-Lipo from Chromogenex. The award-winning, FDA-cleared i-Lipo uses low level laser energy to painlessly stimulate the body into naturally releasing targeted fat deposits. i-Lipo shrinks fat cells and reduces inches in only 20 minutes, and is safe for all skin types. Discover how quickly i-Lipo can deliver exceptional results for your patients and your practice. Be among the first in the US to offer this advanced technology. For physician references, patient success stories, or to schedule an in-office demonstration, call 1-855-GET-ILIPO. www.ilipo.com/fastresults COSMETIC SURGERY TIMES 8 Understand state law before assigning laser treatment responsibility to physician extenders Ilya Petrou, M.D. S ENIOR S TAFF CORRESPONDENT T hough cosmetic laser treatments and associated responsibilities are often delegated to physician extenders and office staff, the liability is not. By and large, the legal responsibility associated with commonly performed aesthetic laser treatments remains squarely on the shoulders of the office employer, and as such, careful supervision, extensive training of staff in laser treatments and knowledge of state law are three ways to help ensure that potential lawsuits are kept to a minimum, two experts say. Although cosmetic laser treatments performed in the office are intended to help patients achieve their desired aesthetic goals, the disgruntled patient may bring a lawsuit against the practitioner. “In regards to malpractice and laser treatments, one of the most important things is to know the laws Dr. Avram in the state in which you practice. The law regarding who can use lasers in different states varies, and differences can be significant from one state to another,” says Matthew M. Avram, M.D., J.D., director of the Massachusetts General Hospital Dermatology Laser Cosmetic Center, Boston. When hiring a physician extender, the office physician (employer) is responsible for any services that the extenders provide under their employment or within the scope of their employment in the office, Dr. Avram says. As such, a physician supervising that physician extender will be held liable for any malpractice or any legal consequences of the action being performed for that practice. “If complications arise from a laser treatment performed by a physician extender, even if the physician did not see or treat the patient personally, there can be liability attached to the physician for the performance or poor performance by the physician extender of that procedure,” he explains. According to Dr. Avram, it is absolutely crucial that the physician (employer) is aware of the potential accountability associated with laser treatments delegated to extenders, and their liability needs to have the appropriate malpractice coverage. practices have moved away from this traditional model and now delegate laser procedures to nonphysician extenders such as PAs and RNs. CONSIDERING CONFLICTS “In addition to TRAINING TIPS According to Dr. Avram, the training of physician extenders requires very close supervision to ensure that laser practices are performed well, and above all, safely. the variability of laws and liability in different states, there may be conflicts between the state medical board which licenses physicians and the state board licensing extenders, and therefore, lawsuits may be brought irrespective of who the provider is,” says David J. Goldberg, M.D., J.D., director of Skin Laser & Surgery Specialists of New York and New Jersey and adjunct professor of law at Fordham Law School, New York. “In general, extenders are employees of the physician. Thus if something goes wrong it is not uncommon that both the extender and employing physician will be sued.” The laws governing who can operate a laser are decreed by state law. Accordingly, the scope of practice for the use of lasers depends on which state one practices. According to Dr. Avram, some states require all laser and light procedures to be performed exclusively by physicians, and other states only require some degree of supervision by the physician of a physician extender. Other states do not have any regulation at all. “In the employer (M.D.)-employee (extender) relationship, the M.D. almost always has a legal responsibility. In accordance with state law, we have PAs doing laser treatments in our Florida office. In our NYC office, both PAs and RNs can do laser treatment. However, in our New Jersey offices Dr. Goldberg where the state rules are very strict, only physicians perform laser treatments,” Dr. Goldberg says. Practice models can differ in regard to which physician extenders are allowed by the employer to perform laser treatments as well. While some practices only allow employed physicians undergoing training in laser to perform laser treatments, other “The office employer will assess and judge when a physician extender in training is ready to perform laser treatments on their own, safely and effectively. They will decide when they feel comfortable trusting the extender to perform procedures with the requisite degree of supervision and oversight that they feel is necessary, which can vary from practice to practice,” Dr. Avram says. If physician extenders who perform laser treatments are well trained, they will often spend more time with patients than the physicians, Dr. Goldberg says. In addition, physician extenders usually charge less, and according to Dr. Goldberg, some patients may prefer to pay less and see the extender. On the flip side, many patients are willing to pay more to be treated by the M.D. In order to better train physician extenders, Dr. Goldberg co-directs an annual meeting that teaches all aspects of laser treatment to PAs and nurses who are employed by dermatologists and plastic surgeons. The Aesthetic Extender Symposium (www. aestheticextendersymposium.com) is one certain way to have such extenders well trained, he says. According to Dr. Avram, physicians who seek to employ extenders in the office can obtain information regarding liability from their respective state licensing boards, or they can contact an attorney who is well versed in the laws, regulations and requirements of a given state. Disclosures: Drs. Goldberg and Avram report no relevant financial interests. COSMETIC SURGERY TIMES 10 INVESTIGATING GPOs Cosmetic surgeons are embracing the power of group purchasing organizations — but the debate about patient discounts continues John Jesitus S ENIOR S TAFF CORRESPONDENT F acing a sluggish economy and cutthroat competition, cosmetic surgeons are embracing group purchasing organizations (GPOs) and some patient loyalty programs. In the latter area, however, discounts and social media remain somewhat touchy topics. Scot B. Glasberg, M.D., says that GPOs’ importance has grown because the U.S. economic downturn that began in 2008 was more dramatic than that of 2001. Additionally, “The bounce-back which we’ve seen Dr. Glasberg in the past has simply not been there.” He is vice president of finance for the American Society of Plastic Surgeons and a New York cosmetic and reconstructive plastic surgeon. Initially, he says, practices responded with the typical staff and overhead cuts made in prior downturns. “But at some point, you can’t cut anymore. You have to look for other ways to find savings,” he explains. Indeed, says Kaveh Alizadeh, M.D., president of Long Island Plastic Surgical Group (LIPSG), Garden City, N.Y., “We need to consider how we can lower the supply-side costs of running a practice.” Dr. Alizadeh says that LIPSG deals directly with vendors, adding that acting as its own GPO saves the 17-surgeon practice around 20 percent overall. Conversely, Dr. Glasberg joined Access Medical Purchasing (AMP), a GPO offered through the ASPS. Besides saving him 15 to 25 percent on everything from furniture to cell phones, he says, AMP streamlines purchasing. Therefore, “I’ve probably eliminated half an FTE (full-time equivalent).” He says that GPOs carry “very little risk and a lot of reward. There’s almost no reason not to join.” Similarly, Carey Nease, M.D., says that the Broadlane Group GPO gives his practice approximately 20 percent off most items. He is a Chattanooga, Tenn., cosmetic and facial plastic surgeon in private practice. Because an outside representative handles most of the practice’s purchases through the GPO, he says, “It’s very easy — you don’t even know it’s there.” POTENTIAL PITFALLS Potential disadvantages of GPOs include the fact that “As in any group decision, you give up some control to gain some efficiency,” Dr. Alizadeh says. Adam Summers, M.D., adds that some GPOs proffer low-ball prices up front. Then, months after a physician has joined, “They won’t be paying attention when prices slowly start to go up.” He is a Glen Burnie, Md., plastic surgeon and founder of MediGroup Physician Services, a 13-year-old GPO that serves 98,000 physicians, including 5,000 plastic and cosmetic surgeons. MediGroup eliminates such worries with yearlong contracts that require manufacturers and distributors to maintain prices, he says. The organization also offers software development, reputation management, patient surveys and, starting in early 2013, a patient loyalty program. According to Sara Ritacca, one-and-a-half-yearold Renew Advantage was the first company to offer aesthetic physicians a loyalty program that goes beyond a single practice or brand. She is vice president of marketing, Renew Advantage, and chief operating officer, Riverchase Dermatology and Cosmetic Surgery, Naples, Fla. Renew Advantage charges patients a $199 yearly membership fee then provides immediate savings of 10 to 25 percent on products and services at participating cosmetic surgeons’ offices, she says. During a yearlong study, “Enrolled patients spent 50 percent more annually than non-members and returned almost three times as often.” Renew Advantage also offers ancillary services such as a GPO, reputation management and a network of practice management consultants, Ms. Ritacca says. THE PRICE OF LOYALTY With patients no longer at the mercy of any particular physician or practice, “The onus is on practices to find ways to keep their patients loyal, whether it’s through service, the array of products they offer or the loyalty the practice returns to the patient,” Dr. Alizadeh says. For instance, he gives gift packages to patients who have frequent services. In the elective-procedures market, adds Jamie Castle, practice manager for Cherry Hill, N.J., facial cosmetic surgeon Susan M. Hughes, M.D., “We need our clients to know how important they are to us, and we have to think outside the box. “For our Botox (onabotulinumtoxinA, Allergan) clients, we have a ‘frequent frowner’ card,” she adds. For every neuromodulator session patients have in a year, the program gives a half-price vial of filler. Similarly, the practice allows patients who undergo eight aesthetician services to choose one free service. And for every referral, the practice gives the referrer and the referred friend $30 off their next treatment. These programs cost little, Ms. Castle says. They also make staff accountable for retention and introducing patients to new services. Together, they have helped the practice add 100 new aesthetic clients monthly for the past two years. Dr. Nease says that before he started a loyalty program, patients commonly had surgery at his office. “Then (they) went down the street to have their Botox because it’s less expensive.” NOVEMBER/DECEMBER 2012 11 In August 2012, Dr. Nease launched a Spa Access card that provides 10 percent off neuromodulators, fillers and skincare products, and 15 percent off chemical peels and laser hair removal. For a $99 annual membership fee, “Patients also get a free chemical Dr. Nease peel, laser treatment or whatever spa treatment they want,” he explains. With 200 members in its first two months, “It took off pretty fast. Within a year, we could probably have nearly 1,000 people,” Dr. Nease says. DEBATE ON DISCOUNTS Some “ You have to stay with the market and offer something doable for everybody. ” Jamie Castle Cherry Hill, N.J. Others Promise. Obagi Delivers. ® physicians aren’t sold on loyalty programs. Dr. Glasberg says he’s considered offering one, but his patients say that volume-based bargains counteract the VIP vibe they seek. “I’d be overstating if I said that discounting cheapens the perception of the practice. But perception is everything in our field. There’s nothing like good work and good results to bring those loyal patients back.” Provided discounts don’t go overboard, loyalty programs can’t hurt the bottom line, Dr. Nease says, adding that discounting skincare products and spa services 10 percent yields volume increases that more than compensate. However, he says, problems can arise when social media services nudge thousands of nonpatients toward medical procedures they weren’t necessarily seeking. Due to potential risks and complications, he says, “We don’t want to make these procedures look cheap, too simple, or create the impression that surgery is a spa service when it’s not.” Adds Dr. Alizadeh, “On principle, we do not engage with programs like Groupon or Living Social. Because they’re driven by the lowest cost as opposed to any other factor that would create value for a practice, patients are loyal to the price, not the doctor.” Although she wouldn’t advocate discounting physician services such as facelifts, “You have to stay with the market and offer something doable for everybody,” Ms. Castle says. She uses Groupon and Living Social, but “I would try an internal program first. If you don’t have a good retention program in place to handle that kind of influx, you’ll probably lose money.” Disclosures: Dr. Nease has been a speaker for Cynosure but reports no financial interests relevant to this article. Drs. Glasberg, Alizadeh and Ms. Castle report no relevant financial interests. Dr. Summers is founder of MediGroup. ® Those who know, use Obagi — the #1 physician-dispensed skin care company tThe brand most trusted by dermatologists and plastic surgeons1 tTransformational systems and specialty products for all skin types tProven efficacy supported by 26 clinical studies1 For more information call 1.800.636.7546 today. www.obagi.com Reference: 1. OMP, Inc. Data on file. Obagi, the Obagi logo, and Others Promise. Obagi Delivers. are registered trademarks of OMP, Inc. Distributed by OMP, Inc. ©2012 Obagi Medical Products, Inc. All rights reserved. 07/12 COSMETIC SURGERY TIMES 12 �at� Th� �� ���meti� �ur�e�� How did the aesthetic industry fare in 2012? Where is it headed in 2013? Surviving, but not thriving sound OFF JAMES CARRAWAY, M.D. Virginia Beach, Va. here are many factors to consider when looking at the current activity and potential growth of plastic surgery and the commercial activities that support this specialty. When you look at the industry, you see that in 2006 there were 1,923,000 surgical cosmetic procedures and 9,534,000 nonsurgical cosmetic procedures. When you compare this to 2011, the figures are 1,639,000 surgical cosmetic procedures and 7,556,000 nonsurgical cosmetic 14 procedures (data from American Society for Aesthetic Plastic Surgery). T See the difference Your skill – Artiste’s technology. The perfect partnership delivering a new level of performance.1,2 Precision in practice www.experienceartiste.com [email protected] Micromedics, Inc.: 1 651 452 1977 European Distributor: +44 (0) 1582 691905 References: 1. Micromedics Inc. Clinical study data on file 2. Micromedics Inc. Survey results on file MICROMEDICS COSMETIC SURGERY TIMES 14 2006 KEY LEADERS CONTINUED In an economy that is clearly depressed — and has been for several years — these figures are consistent with the economic downturn that has occurred. However, it is staying at a consistent figure, and although most plastic surgery providers as well as skincare centers are down about 15 to 25 percent, most are surviving from a business standpoint. PATIENT P.O.V. From the patient’s point of view, it appears that there are many more options for them today, and they have to research online and select carefully before pursuing a particular treatment option. There are promises being made by providers for the benefits of what one or another treatment will provide, and some of these treatment outcomes don’t live up to the promises made or expectations from the patients. 1,923,000 9,534,000 SURGICAL COSMETIC PROCEDURES NONSURGICAL COSMETIC PROCEDURES 2012 INDUSTRY STANDPOINT From the industry point of view, instrument and product representatives note that since about 1998 there has been an increased awareness on the part of patients because of the choices available to them. According to multiple instrument and machine reps to whom I have spoken, they are hearing across the board that cosmetic practice with surgery is down, but that noninvasive procedures are up. Because of this, the market from this group is focusing very strongly on these noninvasive ancillary procedures. OFF 1,639,000 7,556,000 In addition, more patients are getting procedures done in the older age group. I am seeing women in their 70s and early 80s still coming in for fillers and skincare, mainly because they have taken good care of themselves and feel no different than they did 20 years ago. Older patients are trying new things such as laser or nonsurgical body contouring procedures. They have learned to be smarter shoppers, and they are sometimes getting two or more opinions for the best possible outcome. They are also shopping for better prices. This group has less to spend because of the economy, but they are susceptible to marketing and will try new things. They are using more financing and at the same time demanding better results for the money spent. The bottom line from the patient perspective is that we are going to have a constant stream of patients coming to plastic surgery, and the numbers will be less or more, depending on the general economy and on disposable income. However, the good and reliable providers who market well and who are able to offer selective choices to their patients should continue to thrive, but not as much as in the days when the economy was so much better. sound SURGICAL COSMETIC PROCEDURES NONSURGICAL COSMETIC PROCEDURES There is some move toward leasing machines versus owning, and there is also the possibility of renting from some of the reps simply according to time use without obligating to a contract until its continued use is assured. Sales are flat for laser and associated technology machines, financing is definitely being needed for these, and some practitioners are sharing lasers. There are more refinements in some of the newer lasers, but these are less in demand because of practitioners not being able to afford them. The future of technology from the point of view of instrument and product providers is that CO2 laser prices are down and the machines are more versatile. Stem cell technology is seen to be the “wave of the future,” along with the associated use of PRP (platelet-rich plasma) and growth factors. Interestingly, this is a type of growth in plastic surgery that is reimbursable from the point of view of insurance companies as well as government grants. Commercial equipment sales in this area have gone up, and more companies are trying to get into this market. A recent ruling in a court case notes that the FDA (Food and Drug Administration) has classified stem cells as drugs, which means it will cost more for clearance studies. However, this rule does not apply to individual practitioners who are able to harvest stem cells and use them at the same time without storing them. PLASTIC SURGEON PERSPECTIVE From the plastic surgery point of view, some practitioners to whom I have spoken note that while cosmetic surgery procedures have dropped off in number, there has been a return of plastic surgeons to reconstructivetype surgery because of the need to maintain their case workload. This is being promoted by hospitals that would like their outpatient operating facilities and hospital beds to be occupied. Because of this, there is an increased push to hire plastic surgeons through the hospital to maintain this type of reconstructive workload. In speaking to plastic surgeons and residents at a recent regional meeting, it was noted that the new things on the horizon — such as the resurgence of fat grafting and the use of cellular dermis — are generating more cases. This is both from the reconstructive and cosmetic point of view. The residents interviewed think that these are “hot” areas for young plastic surgeons. Sales growth in machines dealing with fat grafts and stem cells has encouraged the specialty overall and given it a push in the direction of performing more of these procedures. Implant companies note that their sales have gone down for cosmetic surgery but are staying flat or slightly improving for reconstructive instruments. A LOCAL LOOK There is considerable variation now in plastic surgery practices and product and instrument sales, depending on what is happening with local economies. Military spending shifts in different areas from time to time or the real estate market in one city may be good and another terrible, and all of these things affect the local activity of plastic surgeons. What is generally being seen is that if the economy is good in a local area, then there are more cosmetic surgery procedures being done, but that growth is mostly in the noninvasive area. The reliable practitioners who market well are maintaining a steady source of patients for surgical procedures. Quite a few skincare centers have gone out of business because of a lack of revenue source, and some practitioners seem to be working less, but they are still maintaining their office spaces in the hopes of an upturn in the economy. Advice for young surgeons is to get more than one specialty area, continue doing some reconstructive surgery, add ancillary skincare procedures and product sales to your practice early and market these, and stay vigilant with what is happening in your surrounding area so that you can keep up with your peers in a competitive manner. � 16 GET A FREE $10 GIFT CARD TO STARBUCKS WHEN YOU TAKE OUR LIVE DEMO SOLUTIONREACH IS MY PATIENT ENGAGEMENT SOLUTION “We saw the results immediately. Our no-shows decreased dramatically, and we had much fewer phone calls to make to confirm appointments. We chose Solutionreach to save our staff time, but we had no idea how much our patients would love it.” -Beth, Office Manager Reduce No-Shows Increase Revenue Solutionreach has revolutionalized cosmetology marketing. We offer a custom and comprehensive marketing platform to help your practice acquire, retain, educate and reactivate patients. Solutionreach equips your practice with a Reactivate Lost Patients Unlimited Live Revolutionary Support high-tech solution that does not sacrifice high-touch personalization. And it’s all backed by our unlimited live Revolutionary Support. Remember to mention Starbucks when contacting our sales department $10 starbucks [email protected] 866.605.6867 COSMETIC SURGERY TIMES 16 �at� Th� �� ���meti� �ur�e�y culty, such substances may also offer great gains in efficacy for consumers. Looking ahead, as the economic pundits like to say, 2013 has the potential for some strong "headwinds" to slow recovery and growth, but I do believe there is a brighter future for minimally invasive cosmetic procedures. Some FDA approvals in late 2012 and new introductions for 2013 should liven up the menu of nonsurgical procedures, all with improved safety and efficacy as well as reduced pain and downtime. RESEARCH & DEVELOPMENT DAVID MCDANIEL, M.D. A minimalist mindset he year 2012 was a year of challenges for the cosmetic industry. Some sectors saw growth while Virginia Beach, Va. others have struggled to survive. Mergers and acquisitions continued as the industry experienced ongoing consolidation in many areas. There were also areas of growth, however, and some areas showed renewed innovation and investment in research. T Globally, there were wide variations in economic strength and weakness. Some areas such as Brazil and parts of Asia showed strong growth in certain cosmetic products and procedures, while other countries struggled with serious economic problems weighing down the cosmetic market. In America, large procedures (particularly those with recovery time and general anesthesia) remained weak, while noninvasive or minimally invasive procedures were stable or grew in popularity. Injectables generally showed an improvement, and cosmeceuticals — especially those in the anti-aging category — also continued to show significant growth. I believe there is substantial room for growth for injectables of all types without cannibalizing market share from existing products and companies. Antioxidants will continue to become more important, as will anti-aging cosmeceuticals in general. Some of these cosmeceutical products increasingly have drug-like effects, which potentially pose significant challenges regarding marketing and regulatory issues. Despite this potential for diffi- JEFFREY POPP, M.D., F.A.C.S. Riding the economic roller coaster 012 was a flat year for cosmetic surgery. The economy has affected us all Omaha, Neb. with a certain roller coaster ride of highs and lows, maybe more lows this time around. This is normal to some extent but more so in this uncertain economic world. As for next year, we may see an improvement if the economy becomes healthier. DEVICE DILEMMAS 2 Money is tight not only for the patient but for the surgeon as well. Sadly for us, most new innovations in cosmetic surgery in recent years has been driven by technology that is expensive to buy and maintain and is oversold by the companies that sell it. If a cosmetic surgeon were to buy a new laser or nonsurgical device, for example, they would need to fork out between $100,000 and $250,000 just to purchase the machine. Add to that the cost of disposables and an annual maintenance contract, and the price starts to look insurmountable. OUTLOOK Probably one of the most encouraging things from my perspective is the improved clinical results, and especially improved consistency of results, from the next generation of therapies. I remain very concerned about the lack of investment in research and development; many recent new introductions are coming from investment in research that is several years old or which even predates the economic crisis. The "innovation pipeline" is still far from robust, but it does appear to be improving. HOME-USE UPDATE Homeuse devices have thus far not been particularly commercially successful. There are now a few devices that possess good science and that have FDA approvals for the actual claims being made (something most of these devices do not have). The market has suffered from a flood of ineffective or bogus homeuse devices, but despite these early difficulties, I feel that this remains an area for huge future growth. The The real kicker is that the physician may purchase said device, but no one in their community will know they have it unless the surgeon advertises. More money spent, and they haven’t even done their first case! These surgeons might even need to hire another employee. Thus the cost rises even higher. Now the big question: Does the device do what it says it does? The true answer is, “Maybe.” Remember, these devices are all oversold as to their treatment success. You can probably make a case for 25 percent of the patients not having any acceptable improvement at all, and the remaining 75 percent will have minimal changes at best. These numbers are even more accurate the less invasive the device. This may be fine in the short science/marketing/distribution issues have simply not yet been mastered by any company, but when that occurs home-use device growth will soar as these devices gain more widespread acceptance in the market and become more integrated into daily life. ECONOMIC UNCERTAINTY One of the great questions for 2013 and beyond in America involves wondering what the net impact of the new economic realities and the significant increase in ‘non-core’ physicians and non-physicians into cosmetic medicine and surgery will be. Major shifts will continue to occur in research and development, business models and marketing, and the impact of social media on the daily practice of medicine will only accelerate further. All of these factors will lead to a profoundly different environment for cosmetic practices in the very near future. The world of 2013 and beyond is not the same as we have experienced in recent decades, and it will never return to those times. Many of the fundamental business and marketing tenets we based our careers on is a baseline for the past — but not a road map to the future. Profound change is upon us, and we must embrace the good parts and adapt to the negative parts if we are to thrive while continuing to offer our patients the best possible care with the ethical standards we wish to uphold. The core of how we do things is changing, and the rate of change is accelerating at an increasingly rapid pace (albeit an uncomfortable and unfamiliar one) for many. One thing is for certain: An exciting and challenging 2013 lies ahead! � run, but it will fade away with time or until the next best thing comes along. With this scenario, it would be better to focus on what we know works, doing fewer cases but minimizing personal debt and saving ourselves from an unused broken-down machine that is collecting dust in our garage along with all our other technology that “sort of works.” What we really need is a new surgical procedure disconnected to technology. The last great one was liposuction, and specifically tumescent liposuction. I still have and use many of my original $100 cannulas. Stem cell treatment may be the next tumescent liposuction, but it’s not there yet. 18 We can only hope. � Make plans to attend the 2013 meeting on a special spring date—the Spring Break Symposium for Knowledge ster * Regi eceive or NOW t iscount $200 d The 2013 South Beach Symposium Faculty to include: (Partial List) Symposium Chair: Mark S. Nestor, MD, PhD 11 th Annual 2013 South Beach Symposium Clinical Dermatology Symposium | Aesthetic Dermatology Symposium Practice Management Symposium | Masters of Pediatric Dermatology Symposium April 11–15, 2013 Loews Miami Beach Hotel | Miami, Florida Session Directors Glynis R. Ablon, MD Benjamin Ascher, MD Brian Berman, MD, PhD David E. Cohen, MD, MPH Joel L. Cohen, MD Doris J. Day, MD James Q. Del Rosso, DO Zoe D. Draelos, MD Michael H. Gold, MD David J. Goldberg, MD, JD Clinical Dermatology Symposium April 11, 12 and 14 The Clinical Dermatology Symposium will host the world’s top medical and surgical dermatology faculty to cover topics ranging from advances in clinical and therapeutic dermatology, photodynamic therapy, immune response modifiers, biologic therapies for psoriasis, wound care management, acne, rosacea, psoriasis and much more. Aesthetic Dermatology Symposium April 11, 13 and 14 The Aesthetic Dermatology Symposium will present new innovations in aesthetic procedures and technologies through multiple live patient demonstration and certification workshops given by world leaders in cosmetic and aesthetic dermatology. Practice Management Symposium Mark G. Lebwohl, MD April 11 and 15 Stephen H. Mandy, MD Gary D. Monheit, MD The Practice Management Symposium will include an interactive session on elements to improve both clinical and cosmetic practice, EMR and imaging solutions and risk management strategies. Darrell S. Rigel, MD, MS Theodore Rosen, MD Neil Sadick, MD Lawrence A. Schachner, MD BACK BY POPULAR DEMAND...Pre-Conference Symposium: Masters of Pediatric Dermatology Symposium April 11 This popular one–day program aims to educate physicians about advances in pediatric dermatology and supporting children with dermatological diseases. Daniel M. Siegel, MD, MS David L. Wagener, MBA, CPA Susan H. Weinkle, MD Registration includes clinical, aesthetic, practice management and pediatric dermatology symposium Robert A. Weiss, MD Earn CME/CE - AMA PRA Category 1 and ANCC credit offered. New Faculty being added every day!! www.southbeachsymposium.org/COSM Check www.southbeachsymposium.org for updates. *Register online at www.southbeachsymposium.org/COSM and use discount code COSM to receive $200 discount. Jointly sponsored by/co-provided by AKH Inc. Endorsed by the Foundation for Skin Disease Research and Education, Inc. The South Beach Symposium (Program #20113) is recognized by the American Academy of Dermatology for 45 AAD Recognized CME Credit(s) and may be used toward the American Academy of Dermatology’s Continuing Medical Education Award. South Beach Symposium • 6816 Southpoint Pkwy., Suite 1000 • Jacksonville, FL 32216 • Phone: 904-309-6262 • Fax: 904-998-0855 COSMETIC SURGERY TIMES 18 �at� Th� �� ���meti� �ur�e�� JOE NIAMTU III, D.M.D., F.A.A.C.S. A little luck, & lots of love am oftentimes asked how I think the profession and business Richmond, Va. of cosmetic surgery is faring in my area, our country and during this sour economy. It is not a simple question to answer, as there are so many variables. � Personally, my practice has prospered, and I have increased my bottom line every year since I limited my practice to cosmetic facial surgery a decade ago. I don’t say this to sound arrogant because it is my life’s work and in every stitch of the fabric of my being. I work all day, and I work when I go home by updating Web pages and blogs, doing before and after pictures, and keeping things tight. I probably work harder than I should, but I love what I do. It is a labor of love. RIGHT PLACE, RIGHT TIME I also may be an example of right time and right place, as my professional situation has matured after years of trying to be the best and working harder than others. It may just be my time in the sun. Some of my friends think I Minding males & more TINA ALSTER, M.D. think the biggest thing that took place in 2012 in terms of cosmetic surgery and Washington, D.C. aesthetic dermatology was the expansion of all of the noninvasive body contouring technologies. From CoolSculpting to Liposonix to VelaShape to others, this growing armamentarium increases the options we can offer our patients, whether they be used alone or in combination with liposuction. � Although dermatology-centric, I think it’s important to mention the exciting ground we gained in terms of being able to identify and analyze suspect moles with the launch of MELA Sciences’ MelaFind this year. This device uses multiple wavelengths to noninvasively analyze the histologic characteristics of a mole sound key leaders am lucky, but I remember my dad saying that when someone looks at a successful person and calls them lucky, that person could say, “Yes, I am lucky; the harder I work, the luckier I get.” Most of my friends who have successful practices have a common denominator, and that is love for what they do. They all also work harder than their competition. Having said that, I have several friends who are in large metropolitan areas that are not doing so well. They are hard workers and good surgeons. The intense competition in these large cities may have something to do with it. I often ask myself, “Why do some docs prosper while others of equal skill flounder?” One thing that has truly changed the landscape is the Internet and social media. I have seen seasoned practitioners who have been really successful become overshadowed by younger media-savvy newbies who understand the importance of the Internet, YouTube, Facebook, Twitter, etc. There has definitely been a paradigm shift, and those who don’t stay on top of it all may lose market share, regardless of their skill level. ECONOMIC STRUGGLES The economy definitely has played a huge part in the big picture. At a time when some people forego frivolous splurging on recreation or dining only minimally, cosmetic enhancement may be out of the question. I have patients who are Realtors and builders who were literally rolling eight years ago and now can’t afford and determine with great specificity and sensitivity whether or not it is a malignancy or at high risk of malignancy. The launch of MelaFind proves that the industry is focusing not only on new options for cosmetic procedures; it’s also maintaining focus on technologies that can be used to address potentially life-threatening diseases. A LOOK AHEAD As far as the future of cosmetic surgery is concerned, I’m particularly excited about the ongoing expansion I’m seeing in the number of male patients who are taking an interest in aesthetic procedures. Until now, the male market has remained largely untapped, and OFF Botox (onabotulinumtoxinA, Allergan), let alone a facelift. When the economy is astray, people hunker down and sit on their money. No doubt that when we do pull out of this economic tail spin, there will be a bump in the Bell curve from people catching up on things they could not afford. In the worst economies — even in the Great Depression — there is always a segment of the population with money. Today, someone will buy a Ferrari and someone will have a facelift. It is this class of patient that we need to stay in touch with during this economy. What’s more, people will pay for what they feel is important. I have had school teachers come in and plop down $10,000 in crumpled “cookie jar” money because they don’t like their aging changes. They may not go to Starbucks or the movies for three years, but darn if they are going to walk around with a turkey wattle and eye bags! In short, I feel that for the most part, cosmetic surgery has been growing exponentially, and it will continue to grow rapidly as the baby boomers push into their 60s and 70s. The mores of our society are supportive for health and longevity, and the taboo of “having some work done” has greatly diminished. The future is bright and the best we can do is work hard, provide the best patient care available, and try our best to reach the segment of our population who is interested and has the means to pay for our skills.� "�’m excited �articularl� about the on�oin� expansio� J’m seein� in the num�er of mal� �atients who are takin � an interest in aest�etic �rocedures." "The cos�etic the world saw a �ramatic shi � tra�itional �ur�ica� a�roach to from �acial rejuvenation minimall� inva�ive �roce�ures. �hese tren�s have wit� time, but most efforts of rejuvenation that provide safe, beautiful and longlasting results require much more. continue� Every year, some new technique to improve the appearance of the aging eye region surfaces that throu�� to today, yet experience has exposed the truth… heralds promise to obviate the need for surgery, yet with more experience, the truth about the results of such techniques are quite limited. Examples of this range from laser skin resurfacing to injectable filling to the to the “hollows” that required filling. agents around the eye. Although each Nothing had changed in lower periorbital of these has the potential for benefits -andaging or anatomy, just the perception and aesthetic improvement, they STEVEN n association with the downturn of and definitions that became dictated, are limited due to the small focus FAGIEN M.D., the economy in 2008, the cosmetic in part, by new treatment options. on a single component, whereas the F.A.C.S. world saw a dramatic shift from aging process is far more complex. Boca Raton, Fla. the traditional surgical approach to facial rejuBLEPHAROPLASTY UPDATE venation with minimally invasive procedures. These trends have continued The most common presentation for the In the end, a small group of patients through to today, yet experience has exposed the truth, and the shift may middle-aged female is still unhappiness might be satisfied with these abbrevibe heading back to more invasive options for all of the right reasons. with the appearance around the eyes, ated approaches, yet most require and the most common facial plastic much more to give a youthful and The reason for the shift to minimally invasive techniques is multifactorial, yet surgical procedure to date remains long-lasting result. Advanced surgical the emphasis on in-office procedures for facial aesthetic enhancement with blepharoplasty, or cosmetic eyelid procedures for eyelid rejuvenation minimal recovery was primarily due to a blossoming industry. New products and plastic surgery. take into account the many compodevices combined with customers who had reduced disposable income and less nents of aging in this region, and via time for convalescence yet still desired to maintain their youthful appearance. We’ve come a long way in surgical a single operative procedure, they techniques to improve the appearance can address the gravitational descent While a huge advantage to the masses of individuals interested in self-presof the region around the eye. From (lift); volume loss and shifts (the ervation or enhancement, many of the products and devices that overloaded the early days of making incisions to hollows); loss of structural support; the industry promised age reversal but ended up being more hype than hope. obtain access for skin, muscle and and skin appearance that no single Nonetheless, the explosion of interest and uptake was similar to the Starbucks fat removal to more comprehensive injectable agent or device can come phenomenon, in that more individuals could participate in this experience approaches that consider the real aging close to. Yes, there may be some and facial rejuvenation could be enjoyed by those other than the “rich.” changes in this region (with attempts recovery time required, but what to reverse this with resuspension and patients want more than anything A particular area of frustration has involved methods to improve the appearsoft tissue preservation), techniques else is to have a beautiful, longance of the soft-tissue region around the eye. The “tear trough” became a have advanced over the years. lasting result that defies detection. household name, and patients who would historically present to their aesthetic surgeon complaining of “bags” now presented to treat their “hollows.” This Of course, we (surgeons and patients There will always be a place for shift in perception was in part fueled by a newly discovered “filling” solution to alike) would prefer methods with minimally invasive procedures the aging lower eyelid. This solution converted the “bags” that required surgery substantial benefits and minimal down- selected for the appropriate patient. We must understand, however, the limitations of these procedures and how to best apply these techniques and realize that there is still a place for precise surgical solutions to these more complex issues. efforts to penetrate this particular patient population have, In addition to the clinical research I expect we’ll glean For more information: to date, been unsuccessful. from conducting more studies involving male patients, I also believe more exploration of male patients’ expectaFagien S. Discussion: Traditional lower blepharoplasty: Is additional support necesThis is a whole new area for physicians and for tions and the societal implications of aesthetic surgery sary? A 30-year review. Plast Reconstr Surg. industry, and one that I expect will spur a new era in males will take place. This January, I’m opening a 2011;128(1):274-277. of clinical research. The vast majority of studies men’s center at the Washington Institute of DermatoFagien S, Cassuto D. Reconstituted Injectable have been conducted with women until now, and logic Laser Surgery in Washington, D.C. This will be Hyaluronic Acid: Expanded Applications in as physicians, we are going to learn a lot more the first male-only center for medical and cosmetic Facial Aesthetics and Additional Thoughts on the Mechanism of Action in Cosmetic Mediabout what is appropriate for men aesthetically. dermatology in the nation, and I’m anticipating its quick cine. Plast Recontr Surg. 2012;130(1):208growth and high patient interest in our services. 217. It’s also important to note industry’s growing efforts to Fagien S. Lower Blepharoplasty: Blending the reach men in the aesthetic arena. More and more cosmetic There’s no doubt that the coming year will bring Lid/Cheek Junction. In: Cosmetic Oculoplastic Surgery; 4th edition; ed: S. Fagien. Elsevier companies are focusing on males. Case in point: Merz’s many exciting opportunities for expansion in both Publishers, London UK; 2007. 161-180. upcoming launch of a Radiesse to be re-packaged specifithe male patient population as well as noninvacally for men. I believe this new launch will be the first of sive technologies for aesthetic purposes. Here’s Fagien S. Algorithm for Canthoplasty. The Lateral Retinacular Suspension: A Simplimany that place a renewed focus on the male patient. to an invigorating, successful 2013! � " Returning tried true � fied Suture Canthopexy. Plast Reconst Surg. 1999;103(7):2042-2053. � NOVEMBER/DECEMBER 2012 19 coSmeTIc SUrGerY TImeS 20 B O D Y B R E A S T F A C E PLLA pearls Semi-permanent filler smooths chest skin wrinkles with no downtime A patient before (left) and four months after a third treatment with 16 cc dilution and total PLLA volume of 48 cc. A two-point improvement to Fabi-bolton Scale grade 2 (shallow, but visible lines) was noted in the after photograph. The patient did not have any other adjuvant treatment. (Photos credit: Sabrina G. Fabi, M.D., F.A.A.D.) Cheryl Guttman Krader S ENIOR S TAFF CORRESPONDENT S AN D IEGO — Off-label injection of diluted poly-L-lactic acid (PLLA; Sculptra Aesthetic, Sanofi-Aventis) is a safe and effective minimally invasive option for rejuvenating the aging chest, according to Sabrina Fabi, M.D., and colleagues. A retrospective review of outcomes in a series of 28 patients who presented with moderate-to-severe chest rhytids showed significant improvement in skin wrinkles, contour and laxity after an average of 2.3 treatments with the semipermanent synthetic soft tissue filler. No adverse events were noted, and there were no cases of nodule development. “Chest rhytids and other skin signs of photoaging are a common concern among patients seeking cosmetic enhancement. Fractionated CO 2 laser resurfacing has been used to address this problem, but requires downtime and has the potential for scarring. There have also been reports of injecting diluted hyaluronic acid, but 2 to 3 cc of filler is often needed to cover the entire chest, and the benefit may not be that long-lasting,” says Dr. Fabi, who is in private practice in San Diego. “Based on safety, efficacy and cost, we currently consider PLLA the best injectable for treating chest rhytids,” Dr. Fabi says. “However, we have also seen substantial improvement in deep chest rhytids with an added benefit of a simultaneous breastlift after a single treatment with microfocused ultrasound technology (Ultherapy, Ulthera), and this may become a useful treatment option to consider, even in combination with PLLA.” AssessinG ResuLTs Patients in the PLLA series were treated between March 2008 and February 2011. In order to evaluate the treatment benefit, Dr. Fabi and colleagues developed a novel fivepoint scale for rhytid severity rating. November/December 2012 21 “ Chest rhytids ... are a common concern among patients seeking cosmetic enhancement. ” Sabrina Fabi, M.D. San Diego Patients with a minimum score of 3, indicating the presence of moderately deep lines, were considered candidates for PLLA injection. In addition, they had to be non-immunocompromised since the benefit of PLLA depends on induction of neocollagenesis. The patients in the series were all women and ranged in age from 39 to 69 years. “In general, younger patients are better candidates for this treatment than more aged individuals because the younger ones tend to have a better fibroblast response,” Dr. Fabi says. Only 11 patients had before and after photographs available for rating the treatment effect, and they achieved a 1- to 2-grade improvement. “Three patients in the series also received IPL (intense pulsed light) between PLLA treatment sessions, and it was beneficial for improving vascular and pigmentary signs of photodamage. However, adjuvant IPL did not add to the effect of the PLLA injections for reducing wrinkle severity,” Dr. Fabi says. Technique Tips Using a higher dilution is important when injecting PLLA into the chest area where the skin is thinner than on the face, Dr. Fabi says. For the patients included in the series, the volume of diluent used to reconstitute each 150 mg vial of PLLA ranged from 10 cc to 16 cc. However, Dr. Fabi and colleagues concluded that use of 16 cc was associated with the best efficacy and safety results. Their protocol for using PLLA in the chest involves adding 14 cc of bacteriostatic water and 2 cc of lidocaine 1 percent with epinephrine 1:100,000 to each vial of PLLA. The mixture is allowed to sit at least two hours, and usually overnight, as that technique appears to reduce the risk of nodule formation. The injections are done with either a 1 cc or 3 cc syringe equipped with a 25 gauge, 1.5 inch needle, using a fanning technique to cover the entire area and injecting 1 cc per linear strand, Dr. Fabi says. Patients are instructed to massage the treated area five minutes, five times daily, for five days. Additional sessions are performed at least four weeks apart, and patients are counseled to return for retreatment every year to maintain the effect. “Massaging the treated area, adequate spacing between treatments, and appropriate dilution amounts are important for reducing the risk of nodules,” Dr. Fabi says. � For more information: Bolton J, Fabi S, Peterson JD, Goldman MP. Cosmetic Dermatology. 2011;24(6):278-284. Disclosures: Dr. Fabi reports no financial interest in Sculptra Aesthetic or its manufacturer. She is a consultant for Ulthera. It’s your turn for a lift. Physicians at the new Lifestyle Lift are Increase your surgical volume true experts. And, because Lifestyle Lift and income. on your craft invests heavily Focus in national marketing, without the and headaches generating morehassles than 600,000 calls from potentialofpatients annually, they are able managing a practice. to concentrate on what they do best— You’ll get allrange of these benefits and performing a full of facial rejuvenation many more When when you you join Lift. procedures. join Lifestyle Lifestyle Lift, Our join rapid offers you you a expansion fast-growing group ofseveral highly opportunities will enhance your skilled physicians that dedicated to advancing quality their field.of life. Full-time, part-time and certified-location opportunities are all available. If you’re a board-certified plastic or facial-plastic surgeon and would like to learn more, please call 888.257.9148. Opportunities available at these locations: Albany, NY Albuquerque, NM Buffalo, NY Cherry Hill, NJ Chicago, IL Cincinnati, OH Corpus Christi, TX Dallas, TX Denver, CO Des Moines, IA Harrisburg/York, PA Hartford, CT Kansas City, KS Memphis, TN Milwaukee, WI Nashville, TN New Orleans, LA Oklahoma City, OK Omaha, NE Orlando, FL Phoenix, AZ Portland, OR Raleigh, NC Rochester, NY San Antonio, TX San Jose, CA Scranton/WilkesBarre, PA Spokane, WA Troy, MI West Palm Beach, FL ® lifestylelift.com/physicians coSmeTIc SUrGerY TImeS 22 B O D Y B R E A S T F A C E Weighty issue Success of body contouring in massive weight loss patients faces challenges on many levels Cheryl Guttman Krader S ENIOR S TAFF CORRESPONDENT BOSTON — The growth of bariatric surgery is leading to a rise in the number of patients seeking body contouring procedures after massive weight loss. Optimizing efficacy and safety outcomes for these individuals requires understanding their complex medical, surgical and psychosocial issues and applying that information to develop a surgical plan that includes appropriate screening, preoperative intervention, proper surgical techniques and close postoperative follow-up, according to Jane A. Petro, M.D. Dr. Petro One of the most important aspects of the screening protocol considers the physiologic impact of the bariatric surgery procedure. Although there are no solid data from a rigorous scientific study detailing complications associated with cosmetic surgery in the postbariatric surgery weight loss patient, many of the complications seen after the body contouring procedures are clearly associated with nutritional deficiencies, says Dr. Petro, a plastic surgeon in Boston and previously acting executive director of the Cosmetic Surgery Foundation, Chicago. “Therefore, the careful surgeon will pay close attention to the preoperative evaluation and optimizing the patient’s condition before surgery in order to maximize the probability of success after cosmetic surgery,” she says. but there are also additional significant mineral and vitamin deficiencies associated with malabsorptive procedures that are specific to the type of surgery and that should be corrected to minimize the risk of complications and maximize the outcomes of body contouring surgery,” she says. Comprehensive laboratory testing should be ordered by the body contouring surgeon, Dr. Petro says, because by the time patients present for the cosmetic surgery, there is a good chance they are no longer being followed by the bariatric surgery team. “According to some data, more than 60 percent of patients are no longer under the care of the bariatric surgery group two years after their procedure and so they are often unaware that they may have significant medical problems,” she says. Laboratory testing should check for prealbumin and albumin levels to detect protein malnutrition. Patients who have undergone a malabsorptive procedure may have deficiencies of a variety of fat-soluble vitamins, including vitamins A, D, E and K. In addition, bariatric surgery patients often have deficiencies in folic acid, iron, vitamin B1, vitamin B12, copper and potassium. should elicit a complete history of the weight loss. Knowing the type of bariatric surgery procedure performed provides insight into what nutritional deficiencies may be present, Dr. Petro says. Among other problems, these various nutritional deficiencies can lead to metabolic issues, hematologic abnormalities and peripheral neuropathies that can compromise healing and raise the risk for other complications during and after body contouring surgery, Dr. Petro says. “Almost all patients who have significantly reduced caloric intake are likely to have some degree of protein deficiency, In addition to knowing what type of bariatric surgery was performed, the history should determine how long PreoP eValuatioN The preoperative evaluation November/December 2012 23 “ Be sure the patient’s expectations are appropriate and can be matched by the surgery, but also remember that patients lie. ” Jane A. Petro, M.D. Boston ago it was performed, if weight loss is completed, and if the patient is maintaining adherence to a good diet and exercise program, Dr. Petro explains. “Ideally, body contouring procedures should be performed in patients with a low BMI whose weight remains stable for at least three months after being at least one year out after the bariatric surgery. For optimal long-term results, body contouring procedures for massive weight loss patients should not be undertaken while they are still on a steep downward slope of weight loss or if they appear to be on a path to rebound weight gain,” she says. As for any surgery, the history should also identify whether the patient is a smoker and any previous surgeries that can complicate the body contouring procedure. In particular, these patients may have an increased likelihood of having had gall bladder surgery or hernia repair, she says. Psychological status Consideration of psychological issues and proper patient expectations are also important in the preoperative evaluation of the postbariatric surgery patient, as they are for any individual presenting for cosmetic surgery. However, problems may be more prominent in the massive weight loss population, Dr. Petro says. Although massive weight loss has been shown to significantly improve quality of life for the previously morbidly obese person, the experience may also be accompanied by significant life stressors. For example, there is a high divorce rate in the massive weight loss population that can result in social isolation, and these patients may also have long-standing body image issues, she says. “Be careful when operating on someone who has recently experienced major life changes, and be aware that massive weight loss patients may have a form of body dysmorphic disorder. Be sure the patient’s expectations are appropriate and can be matched by the surgery, but also remember that patients lie,” Dr. Petro says, adding they are unlikely malicious in their deception; rather, they are trying to present the best possible scenario of their situation as they may feel it will help them get what they are seeking. surgical stePs In planning the surgery, all of the standard precautions are taken for preventing serious complications, such as instituting prophylaxis for thromboembolic events for any procedure done under general anesthesia and exceeding two hours. Early ambulation, incentive spirometry, appropriate pain management and judicious use of antibiotics are essential following major surgery, Dr. Petro says. Risks of postoperative complications, including wound infection, dehiscence or seroma formation, should all be discussed in advance, as should the location of the scars and their prominence. Dr. Petro notes that some surgeons are using in-office ultrasound to identify, drain or monitor seroma formation. Close follow-up in the first weeks after surgery may include use of garments, if liposuction has been performed. Nutritional issues should also be addressed, making sure that the patient is following a healthy diet, especially if exercise is reduced during postoperative healing, and patients may need to be seen frequently in the days following surgery until secure wound healing is documented. “With more patients traveling for surgery, plans for deep vein thrombosis prophylaxis during long car rides or flights should also be included in planning,” Dr. Petro says. � Lalonde Skin Hook Forceps easily win the “Rose Petal Test.” TM SEE FOR YOURSELF. Even on this delicate rose petal, LalondeTM Extra Fine Skin Hook Forceps (shown at top) leave only tiny dots that are barely visible, vs. the larger track marks caused by the teeth and shaft of an Adson forceps. 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As a simple software upgrade to Lumenis’ UltraPulse fractional CO2 laser system, the SCAAR FX mode allows CO2 laser energy to penetrate up to 4 mm deep, two times deeper than any other currently available CO2 laser on the market, Dr. Waibel says. “Today’s standard fractional CO2 lasers work well for the treatment of more superficial surgical and acne scars. However, a sufficient penetration depth of the laser energy has been one of the central limiting factors in the effective treatment of deeper scar lesions. While other CO2 devices will only reach a maximum of 2,000 micron depth, the SCAAR FX now allows us to go down to 4,000 microns, the depth needed to better impact thicker scar tissue,” she says. 4,000 microns MeCHANisMs OF ACTiON One of the most important factors regarding fractional ablative devices used for wrinkle and scar improvement is the ablation, which results in a microscopic zone in which the tissue has been vaporized, Dr. Waibel explains. Ideally, this ablation zone treats a portion of the depth of the scar, some of which can be several millimeters thick. Another important factor of fractional ablative devices is the thin layer of coagulation around the column of fractionally ablated tissue. According to Dr. Waibel, this layer can range from 10 percent to about 40 percent of the ablation column, depending on the device used. “One of the powerful mantras of fractional resurfacing is the creation of tiny ablated wounds in the skin in between, which are islands of normal healthy skin and a sufficient amount of residual coagulation,” she says. According to Dr. Waibel, the treatment of conspicuous, complex and deep skin lesions such as more severe surgical and acne scars requires a balance of ablation and coagulation to be effective. The SCAAR FX (Synergistic Coagulation and Ablation for Advanced Resurfacing) modality employs a unique combination of short pulse durations and high-energy pulses (up to 150 mJ per pulse per spot), resulting in deeper and more precise treatments, she explains. “This ablation and coagulation combination turns on a healing response. On the opposite side, too much coagulation may result in too much lateral spread of the CO2 heat energy, which would be more reminiscent of a nonfractional treatment. If there is excessive lateral spread of the coagulation and no November/December 2012 25 “ A sufficient penetration depth of the laser energy has been one of the central limiting factors in the effective treatment of deeper scar lesions. ” Jill S. Waibel, M.D. Miami zones are left untreated, the healing is no longer fractional and the risk of complications increases,” she says. Using an ideal ablation/coagulation ratio, the SCAAR FX mode is designed to significantly improve the structure of deep contracted skin lesions such as contracted hypertrophic scars. This leads to an increased range of motion in these areas as well as improvement of the skin’s appearance, Dr. Waibel says, adding that the SCAAR FX’s therapeutic benefit can also be appreciated in the treatment of deeper unsightly acne scars. Tissue Types Scar tissue types can vary and can include ice pick scars, box car scars, rolling scars or keloid scars. According to Dr. Waibel, acne scar treatment requires a multimodality approach, and here, it is paramount that the disease process is stopped before further scar therapies are considered. For the acne scar lesions left behind — particularly for the deeper and more difficult to treat box car type scars — Dr. Waibel says she often performs a series of small punch biopsies, closing with a single suture, and then she conducts follow-up with fractional CO2 treatment using the SCAAR FX. For minor acne scars that require more superficial resurfacing (a depth of approximately 400 to 500 microns), Dr. Waibel often uses Lumenis’ DeepFX. However, for deeper acne scars and in severe burn trauma patients who will typically have 2- to 3-inch thickened scars on the body, she uses the SCAAR FX. “In my opinion, the SCAAR FX mode is ideal for advanced resurfacing applications, including deeper and more severe acne and surgical scarring. The modality is not FDA (Food and Drug Administration) approved for burn scar treatment; however, used off-label, I have been able to achieve excellent results,” Dr. Waibel says. � Disclosures: Dr. Waibel has received honoraria as a speaker for Lumenis. A Two-Day, CME-CERTIFIED MEETING Practical Aspects of Running a Successful Practice FEBRUARY 23–24, 2013 | PHILADELPHIA, PA Thomas Jefferson University Campus Sponsored by In Partnership with News and Analysis for Today’s Skincare Specialists And in Consultation with UP TO 15 CME CREDITS AVAILABLE! For more information or to register, visit www.BIZMEDICINE.org coSmeTIc SUrGerY TImeS 26 B O D Y B R E A S T F A C E Pump up the volume Addition of fat grafting for volumetric enhancement to surgical contouring procedures has become mainstream in cosmetic surgery Rochelle Nataloni S ENIOR S TAFF CORRESPONDENT N EW YORK — When it comes to breast augmentation/ mastopexy and even facial rejuvenation, surgical shaping alone is not enough, say surgeons who combine such procedures with volumetric enhancement to attain results that they say are not possible with either modality alone. “ Fat gave us a tool to shape the face and body in three dimensions that we simply never had before. Sydney Coleman, M.D. New York “Fat gave us a tool to shape the face and body in three dimensions that we simply never had before,” says Sydney Coleman, M.D., a New York surgeon. “And now that there are so many other fillers available and in demand, the practice of adding volume is here to stay.” The combination of volume enhancement with surgical shaping should be a standard part of every aesthetic surgeon’s armamentarium, says Nashville, Tenn., surgeon Patrick Maxwell, M.D. ” vector of aging Historically, people identified the vector of aging as being a downward phenomenon, Dr. Coleman says. “For quite a long time, the focus of plastic surgery was to lift anything that sagged. It’s taken us the last 15 years of readjusting the way we think to realize that the removal of the signs of aging like wrinkling and jowls by cutting them out really doesn’t restore a youthful look; it deforms a person’s face into something that has no wrinkles or jowls but does not look the way it looked when the person was young. Dr. coleman “These should not be viewed as different operations but rather required additive techniques within a given procedure to achieve improved outcomes,” he says. “One plus one is more than two. Volumetric enhancement plus surgical shaping advances the predictability and desirability of outcomes beyond what either of these techniques could do alone.” “We’ve gradually figured out that if you don’t address the loss of fullness, it doesn’t result in rejuvenation,” he adds. “It just results in deformities that remove the signs the aging.” Says Dr. Maxwell, “Over the years, surgeons have become able to add predictable fat transfer to November/December 2012 27 “ Volumetric enhancement plus surgical shaping advances the predictability and desirability of outcomes beyond what either of these techniques could do alone. ” Patrick Maxwell, M.D. Nashville, Tenn. surgical tissue tightening or enhancement. Beginning with the addition of small-volume fat transfer combined with facelifts, mostly enhancing the malar area, surgeons have become accustomed to techniques of fat removal, cell washing and simple yet refined injection of fat layering into the tissues. “Additionally, in breast reconstruction, this has long been a frequently used technique where smaller volumes of fat help blend implant contours into the chest or fill chest deformities in combination with implants,” Dr. Maxwell adds. “These applications have enabled surgeons to become predictable in fat transfer techniques, which has led to adaptation, with more sophistication in other areas.” Up for the challenge Fat transfer for volumetric enhancement and acellular dermal matrices (a form of biologic scaffolding) have enabled surgeons to increase volume over and around breast implants effectively, Dr. Maxwell says. “These combinations of regenerative techniques plus implants have made even the most challenging breast revision cases involving multiple capsular contractures, repeated bottoming out, stretched deformities and ptosis to be predictably revised with consistently improved outcomes,” he says, adding that this has led to the frequent use of fat grafting in primary aesthetic breast surgery. For example, one could use enhanced fat grafting after placing breast implants to augment the smaller breast or to simply enhance cleavage, he explains. “Shaped, form-stable implants enhance predictability in breast form, and adding fat grafting or biological scaffolds may further enhance the volume in addition to surgical reshaping and contouring,” Dr. Maxwell says. Minimally invasive facial suspension and tightening procedures also benefit from volumetric enhancement with fat grafting, Dr. Maxwell says. “As both of these techniques are minimally invasive and give desired improvement with long-lasting results, increasing numbers of patients opt for these facial procedures. “Likewise, in either primary breast aesthetic procedures of mastopexy or perhaps augmentation, the enhancement with predictable fat grafting is significant,” he says. “Especially in challenging aesthetic breast revisions, the addition of ‘regenerative’ volume is helpful.” Breast techniques that are complemented by the addition of volume include capsulectomy, site change from over the muscle to subpectoral position, creation of neopectoral pockets and mastopexy, according to Dr. Maxwell. “Acellular dermal matrix scaffolds can support tissue or minimize the possibility of recurrent capsular contracture by adding a regenerative surface layer between the implant and the tissue, and fat grafting further refines the shape with precisely desired aesthetic outcomes,” he says. rejUvenation benefits Sculpting with fat injections offers a more youthful look just by virtue of the additional volume, but fat injections offer an added rejuvenation bonus, Dr. Coleman explains. “Fat has the added benefit of rejuvenating the skin. It actually improves the quality of the skin, the wrinkles, the color, the size of the pores. All of these are improved dramatically by the placement of fat right next to the skin,” he says. “Although volume is an important element, I think the restoration of the quality of the skin that takes place is equally, if not more, important.” While the mechanism of action regarding fat’s reparative capabilities is up for debate, Dr. Coleman says there is consensus in the aesthetic surgical community that skin quality improves in response to fat injections or grafts. “It probably has something to do with the fat’s stem cells, and it also has something to do with the stem cells releasing growth factors,” he says. “There are a lot of unknowns. We are just beginning to scratch the surface.” � coSmeTIc SUrGerY TImeS 28 B O D Y B R E A S T F A C E Update on injectables New York surgeon Z. Paul Lorenc, M.D., describes his experience with the newest neurotoxins and fillers Ilya Petrou, M.D. S ENIOR S TAFF CORRESPONDENT N EW YORK — As more fillers and neurotoxins enter the aesthetic market, physicians must take care when choosing products. Specifically, they must make sure that the results of the products they use are based on solid science, says Z. Paul Lorenc, M.D., F.A.C.S. “Nonsurgical rejuvenation has become such a prominent part of our practices, and more than ever, patients demand noninvasive rejuvenation procedures that are not only safe but result in good cosmetic outcomes with little to no downtime. Newer agents come onto the market very frequently, and therefore, it is crucial to have updated information on the newcomers,” says Dr. Lorenc, an aesthetic plastic surgeon in New York. KnoWinG tHe neuRotoXins Currently available in Europe and Canada, Xeomin (incobotulinumtoxinA, Merz) has been cleared by the Food and Drug Administration, but the company is waiting for an injunction to be lifted in January 2013 to launch in the United States. According to Dr. Lorenc, the big difference between Xeomin and the other two players in the U.S. market (Botox/onabotulinumtoxinA, Allergan, and Dysport/ abobotulinumtoxinA, Medicis) is that Xeomin does not have complexing proteins around it. “ Belotero’s technology and characteristics are unique and represent the latest permutation of HAs, which we can use to our advantage. Z. Paul Lorenc, M.D. New York ” Xeomin is a 150 kDa active molecule that does not have to be refrigerated because it doesn’t have proteins that can denature. It is being touted as a “purified” toxin, meaning that the product may have less antigenicity once injected, Dr. Lorenc says. In theory, Xeomin could address the issue of nonresponders, differentiating itself from the other neurotoxins based on its manufacturing process, he says. “If a patient is exposed to complexing proteins just once or on a recurring basis (as is the case with cosmetic neurotoxin injections), they could potentially form antibodies to the proteins and become nonresponders, meaning they will have no effect from the neurotoxin. In theory, this is less likely with Xeomin as there are no complexing proteins,” he explains. November/December 2012 29 “ One should be acutely familiar with the physiochemical properties of the products you inject and know which ones are optimal for each particular anatomical part of the face or the body. ” Z. Paul Lorenc, M.D. New York According to Dr. Lorenc, the rate of nonresponders used to be about 9 percent before Botox changed its formulation in the 1990s. Currently, the rate of nonresponders is very low (less than 1 percent), but for those patients who are nonresponders, Xeomin could prove to be very useful, he says. HA updAte Belotero Balance (Merz) is one of the newest hyaluronic acid (HA) fillers to have received FDA clearance for the correction of moderate-to-severe facial wrinkles and folds. The filler will likely be a big player among the other long-established fillers, including Restylane (Medicis) and Juvéderm (Allergan), Dr. Lorenc says. At a concentration of 22.5 mg/cc, Belotero differs from other HAs in its unique cohesive polydensified matrix (CPM) structure and in the fact that it is a nonparticular monophasic filler. Treatments result in very even augmentation effect, which integrates homogeneously into the surrounding tissue, Dr. Lorenc says. The high content of free HA in Belotero changes the characteristics of the filler and allows one to inject more superficially in the dermis without causing the Tyndall effect or nodularity, which can sometimes occur with other HA fillers, he explains. “I will often use HA fillers because I think they are the most versatile fillers available. Belotero’s technology and characteristics are unique and represent the latest permutation of HAs, which we can use to our advantage. I am in favor of such advances; however, they must be based on good, sound science, as is the case here,” he says. CustomizAtion Counts Fillers are classified as volumizing agents — such as Belotero, Juvéderm and Restylane — or biostimulatory agents — such as Radiesse (Merz) and Sculptra Aesthetic (Valeant). When used at different dilutions, however, fillers can be customized to achieve other off-label effects in the skin, Dr. Lorenc says. “Years ago, we used to take the fillers off the shelf and inject them at the standard manufactured dilutions. Now, I am almost exclusively customizing the fillers I use by altering the dilutions and matching that to the specific anatomic area and indication I am treating,” he says. Though the on-label indication using Sculptra is a 5 cc dilution for volumization of the face, Dr. Lorenc says he often injects the filler at a 9 cc dilution in order to achieve a greater and safer volume enhancement. When rejuvenating the décolletage, however, he will dilute Sculptra to 24 ccs. “I use Sculptra because at a higher dilution, it is not a volumizing agent anymore, but instead it does more to stimulate collagen, plump up the skin and improve the quality of the skin,” he says. “You can much more appreciate the changes in the character of the skin.” Customization with Radiesse • C heeklifting/volumization:0.3ccof1percentlidocaine plus 1.5 cc of Radiesse (total 1.8 cc) • V olumizationofthedorsumofthehand:1ccof1percent lidocaine plus 1.5 cc of Radiesse (total 2.5 cc) Dr. Lorenc says he also customizes his Radiesse injections and dilutes with 1 percent lidocaine, depending on the area of the face being addressed. When volumizing and lifting the cheek, for instance, he injects the deep medial fat pad using a dilution of 0.3 cc of 1 percent lidocaine plus 1.5 cc of Radiesse (total of 1.8 cc). When volumizing the dorsum of the hand, Dr. Lorenc adds 1 cc of 1 percent lidocaine to 1.5 cc of Radiesse (total of 2.5 cc). “Diluting the filler not only changes the viscosity but reduces the G prime, or lifting capacity, as well. The filler is much more easily dispersed throughout the tissues and it is more appropriate for volumizing the dorsum of the hands,” Dr. Lorenc says. Customizations are off-label, and as such, patients must be informed and the treatments well documented, Dr. Lorenc says. “As more and more products become available on the market, you should base your decisions more on science. One should be acutely familiar with the physiochemical properties of the products you inject and know which ones are optimal for each particular anatomical part of the face or the body,” he says. � Disclosures: Dr. Lorenc is a consultant for Medicis, Mentor, Johnson & Johnson and Merz. COSMETIC SURGERY TIMES | 30 PRODUCTS & SERVICES SHOWCASE Go to: products.modernmedicine.com SERVICES Wonder what these are? COMPANY NAME Go to products.modernmedicine.com and enter names of companies with products and services you need. marketers, find out more at: advanstar.info/searchbar SURGICAL EQUIPMENT SHIPPERT Search for the company name you see in each of the ads in this section for FREE INFORMATION! Search 31 | NOVEMBER/DECEMBER 2012 PRODUCTS & SERVICES laser for sale COMING THIS MARCH IN PARK CITY, UT! Syneron Core CO2 The Art Of Sedation and Tumescent Anesthesia in Face and Breast Cosmetic Surgery This 3 day live surgical workshop will provide cosmetic surgeons the education to provide safe cosmetic face and breast surgeries under tumescent anesthesia and sedation. Bring the family and come enjoy the greatest snow on earth! Fractional & Full Laser For practice for sale Sale nevada Excellent Laser, in perfect condition, equipped for Full CO2 or Fractional CO2 Rejuvenation.Approx1yearoldandused only 15 times, being sold due to clinical changes of practice. 1.5 year warranty remainingonlaser.FabulousforaPlastic Surgeon. Motivatedtosell,bestreasonableoffer. Inquire: [email protected] otc products PLASTIC SURGERY OFFICE WITH AAAASF OR IN RENO / Tahoe Relocating? starting? semi-retiring? like to ski more? Perfect location with Lake Tahoe 30 min away and no state tax. Plastic Surgeon had to move for family reasons. His loss is your gain. Take over the office, phone numbers, grandfathered ad contracts, and office. Last several years over 2M practice. 2 connected medical condominimums in garden setting, 1/4 mile to hospital in most affluent area of town. About 2800 sf each. Buy or lease one or both, with or without equipment. 1031 welcome. No Blue sky. The only AAAASF approved facility in Northern Nevada and the only free standing HBOT center in the area. Over 2M invested. Taking reasonable offers. 775-742-9174 or email at [email protected]. washington www.vincentsurgicalarts.com COSMETIC SURGERY PRACTICE FOR SALE IN BEAUTIFUL PACIFIC NORTHWEST equipment for sale Located 15 minutes from downtown Portland, only 2 hours from coastal beaches or mountain skiing. Approximately 2000 sq ft office includes: BodyJet Liposuction Machine For Sale • Operating room & Recover Area • Two exam rooms, 1 that doubles for small procedures • Physician office with attached exam room & private bathroom • Storeroom on main floor • Basement storage with built in shelving Excellent for Liposuction & Fat collection Approximately 3 years old, like new Retail $80k, no reasonable offer refused Will train if needed AAAASF class “C” accreditation, ideal for single Practitioner. Physician is retiring, Patient Files included Contact: Dr. Robert Golden 678-848-0384 or [email protected] Are you introducing a new product or service to the cosmetic surgery industry? Terry Phillips (360) 694-1031 • [email protected] practice for sale georgia space available Facial plastic surgeon looking for physician experienced in cosmetic surgery to take over practice as current surgeon transitions into retirement. Practice is located within the Atlanta metro area with an in-office surgery center and beautifully designed and decorated large office space. california CONTACT Anna Paulk at 404-252-9991 or [email protected] indiana For marketplace advertising, contact Karen Gerome, Solo board certified cosmetic surgeon, selling thriving Medical & Aesthetic Practice in Midwestern metro area. Practice established in 1996, and generated over $2,000,000 in 2011. Sale includes beautiful 11,000 square foot surgery center with 2 operating rooms & 4 recovery 800-225-4569, Ext. 2670 or [email protected] Huntington Beach Cosmetic Plastic Surgery Office Excellent Turn-key space available for one or more doctors, multispecialty cosmetic in warm, upscale environment 3400 usable sq feet of space including 300 sq ft waiting room, Reception area with marble counter tops & copy room, Telephone/IT closet, Kitchenette, Chart storage with sliding metal cabinets, Two 10 x 12 physician offices , 5 exam/treatment rooms, 2 consultation rooms, 2 administrative offices (office manager, nursing), Storage/substerile room, Operating room (not certified), Bathroom, Nursing station, Aesthetician room Enhancements include: • a lldesignerchairswithnewfinishesandfabric. • couches,loveseat,coffeetables,endtables • Artwork.Completeinventoryavailable • O fficefurniture,customdesks,cabinets,hutches. • ORtable,light,cabinets • Designerlights&sconces • Electricexamchairs&spachair • NewCiscoVOIPphonesystem. Inquiries to: [email protected] rooms, which was built in 2005. Physician leaving to move closer to family in CA., and is available to assist in transition. Website and Search Engine Optimization staff on site to enhance start up of successful buyer Please send inquires to [email protected] PLACE YOUR MARKETPLACE AD TODAY! FOR RECRUITMENT ADVERTISING, contact Jacqueline Moran, 800-225-4569, Ext. 2762 or [email protected] FOR MARKETPLACE ADVERTISING, contact Karen Gerome, 800-225-4569, Ext. 2670 or [email protected] MARKET pl ace education COSMETIC SURGERY TIMES | 32 RECRUITMENT florida oklahoma MARKET p l a c e Busy Cosmetic Surgery Practice seeks BC/BE Plastic Surgeon w/Florida License Miami/Tampa/Orlando, Florida PHYSICIAN RECRUITMENT Great Income potential in a well-established, accredited plastic surgery center. Full service cosmetic / plastic surgery opportunity in the thriving metropolis of Oklahoma City. Inexpensive cost of living, great lifestyle, and excellent schools. Choose from living in a stellar community Contact: [email protected] or call 813-579-1659 utah Cosmetic / Plastic Surgeon on acres of land with a short commute. Vincent Surgical Arts is looking for a Board Certified Plastic or Cosmetic Surgeon to join our busy, thriving private practice in Salt Lake City, UT. We operate in our own Accredited Outpatient Surgery Center performing 100% cosmetic plastic surgery. Competitive pay on combined salarycommission basis. A Utah medical license will need to be obtained. We look forward to hearing from you. Fellowship training is preferred, but not required. Technologically advanced, 10,000-square-foot facility with upscale Contact Call: 801-942-1111 E-mail: [email protected] www.vincentsurgicalarts.com worlds: a busy, metropolitan practice with a professional environment. Work in our on-site ambulatory surgery suite, which is AAAHC accredited. The new surgeon can develop a practice mix that meets their own professional desires. There are healthy opportunities for cosmetic/plastic surgery within the community. Options include: Associateship, partnership or buyout. For further details, please email CV to Juan Stanley at [email protected] To Advertise in Cosmetic Surgery Times Contact: Karen Gerome at 800-225-4569 ext. 2670 [email protected] Jacqueline Moran RECRUITMENT ADVERTISING at 800-225-4569 ext. 2762 [email protected] WORKS! let us prove it to you. Call 800.225.4569 Jacqueline Moran, ext. 2762 FOR RECRUITMENT ADVERTISING, contact Jacqueline Moran, 800-225-4569, Ext. 2762 or [email protected] FOR MARKETPLACE ADVERTISING, contact Karen Gerome, 800-225-4569, Ext. 2670 or [email protected] | NOVEMBER/DECEMBER 2012 33 with qualified leads and career professionals Post a job today Jacqueline Moran RECRUITMENT MARKETING ADVISOR (800) 225-4569, ext. 2762 [email protected] FOR RECRUITMENT ADVERTISING, contact Jacqueline Moran, 800-225-4569, Ext. 2762 or [email protected] FOR MARKETPLACE ADVERTISING, contact Karen Gerome, 800-225-4569, Ext. 2670 or [email protected] MARKET pl ace CONNECT COSMETIC SURGERY TIMES 34 B O D Y B R E A S T F A C E Power play Be aware of laser settings, ability to cool skin when treating patients with skin of color Louise Gagnon S TAFF CORRESPONDENT NATIONAL REPORT — When treating patients with skin of color, it is best to err on the side of caution to avoid complications such as pigmentary changes or scarring, say two leading dermatologists who have expertise in treating this patient population. “There has been a slow but steady evolution of technology, and our expertise in better understanding skin of color is evolving as well,” says Eliot Battle, M.D., CEO and president, Cultura Dermatology and Laser Center, Washington, and clinical professor, department of dermatolDr. Battle ogy, Howard University School of Medicine. “We need to be much more conservative and careful when treating skin of color.” KEEPING IT COOL One of the keys to success when treating patients with skin of color is to aggressively cool the skin. Pigmented skin has a higher incidence of thermal injury, and keeping the skin cool during treatment dramatically minimizes the risk of heat-related side effects, Dr. Battle says. “By keeping the skin cool, we are able to treat it more safely,” he says. “Pigment competes for light, and our skin converts light to heat. Blisters resulting in postinflammatory hyperpigmentation occur when the skin heats past 45 degrees Celsius.” Khalil Khatri, M.D., a dermatologist in private practice and medical director, Skin & Laser Surgery Center of New England, Chelmsford, Mass., and Nashua, N.H., notes that there are several options available to clinicians to cool the skin. These include using cryogen spray, cold airflow or parallel cooling and/or applying ice. “If the epidermis is cold, we can get more energy to the deeper tissues,” says Dr. Khatri, adding that all the complications that occur in lighter skin are even more pronounced in darker skin if the technology is not used correctly. WAVELENGTH MATTERS To minimize the development of complications, clinicians need to choose devices with longer wavelengths. The Nd:YAG laser’s 1,064 nm wavelength is better tolerated than the ruby laser, which has a wavelength of 694 nm, with the latter causing pigmentary challenges and scarring in darker-skinned patients, according to Dr. Khatri. Generally, pulsed lasers provide more selective absorption by the target chromophore than do continuous wave lasers, leading to a decreased risk of pigmentary change and scarring, he explains. Patients who undergo laser or light therapy administration must be counselled about avoiding sun exposure and indoor tanning pre- and posttreatment, Dr. Khatri says. lasers, by using spot sizes that are smaller than the lesion you are treating,” he says. SKINCARE “Skin tightening is an exciting arena for skin of color,” Dr. Battle says. “The most common lasers for noninvasive skin tightening are infrared lasers and radiofrequency lasers, and both inherently bypass the top layer of the skin, making them appropriate for providing anti-aging effects on patients with skin of color.” Tattoo removal is also a greater challenge in patients with skin of color, with there being an increased incidence of scarring and discoloration with tattoo removal, he adds. TECHNOLOGY TIPS “In addition to cooling the “I don’t recommend using intense pulsed light (IPL) in most patients of color,” Dr. Battle says. “It is a very effective device on patients with lighter skin but is probably the most dangerous device to use on people with skin of color.” skin and using safer wavelengths, we can also treat skin of color by using parameters that bypass the top layer,” says Dr. Battle, citing the microsecond Nd:YAG laser as an example of a technology that is capable of bypassing the top layer. The redness and crusting that normally appears with IPL treatment can lead to postinflammatory hyperpigmentation on patients with skin of color who have Fitzpatrick skin types V and VI, Dr. Battle says. The microsecond Nd:YAG can be safely used on patients of color to improve texture and reduce unwanted pigmentation from melasma or postinflammatory hyperpigmentation, he says. “We are very effective on hair removal on all skin types,” Dr. Battle says. “Hair removal, for example, on a Fitzpatrick skin type VI, would call for Nd:YAG laser coupled with aggressive skin cooling or using a diode laser that minimizes epidermal heating by using suction or fast movement.” “The take-home message in treating skin of color with lasers is to try and reduce any damage or irritation which includes redness, edema or any form of ablation to the skin,” he says. “There is no guarantee that we, of color, will recover back to the same texture and tone if our skin gets irritated.” Industry has made significant strides in developing new technologies and refining old technologies to enable the new-generation devices to be safely used on patients with skin of color, Dr. Battle says. Complexion blending or getting rid of dark spots from acne or scars is relatively effective in patients with skin of color when using technologies like microsecond Nd:YAG lasers or fractional devices, Dr. Battle says. “I applaud industry for focusing their research and creating new devices that are safe on skin of color,” he says. “There is now not one manufacturer (of lasers and light devices) who does not understand the need to focus on skin of color.” “We can also treat individual small lesions in skin of color, like moles or tattoos with KTP or Q-switched Disclosures: Drs. Khatri and Battle report no relevant financial interests. Dr. Obagi has no affiliation with Obagi Medical Products. He resigned to pursue the expansion of skin health restoration. is Zein Obagi, MD ZO Medical. The New Alternative to Obagi Nu-Derm ® ® Dr. Zein Obagi no longer recommends the Obagi Nu-Derm® system. 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