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How did the aesthetic industry fare in 2012?
Where is it headed in 2013?
Cosmetic Surgery Times' key leaders
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NOVEMBER/DECEMBER 2012
Cosmetic Surgery Times is where the exchange on aesthetic
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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
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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.
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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.
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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.
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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�
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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
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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
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16
�at�
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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. �
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to improve both clinical and cosmetic practice, EMR and imaging solutions and risk
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COSMETIC SURGERY TIMES
18
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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.
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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. �
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coSmeTIc SUrGerY TImeS
24
B O D Y
B R E A S T
F A C E
Going
deep
New fractional CO2 treatment modality enables laser energy
to penetrate up to 4 mm for treating thick scar tissue
Ilya Petrou, M.D.
S ENIOR S TAFF CORRESPONDENT
MIAMI — Lumenis’ SCAAR FX treatment
modality allows effective treatment of
thicker scars by allowing CO2 laser energy
to penetrate deeper into the tissue than any
other CO2 laser to date, according to Jill S.
Waibel, M.D., founder and owner of the Miami
Dermatology and Laser Institute, Miami.
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.
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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
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| 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.
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