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For Physicians In Cosmetic MedicineMedical Spa MD is the premier physician community for dermatologists, plastic surgeons and clinicians practicing in skin clinics, laser centers, and medspas with thousands of physician members around the world. Why should you join Medical Spa MD? Learn More > Join Now For Instant Access To Members Only Content & Downloads. It's free!

Stunted Emotional Growth From Botox In The UK?

Botox treatments on young patients (under 25) may retard their emotional growth and is "morally wrong" according to some UK clinicians.

At least that's a recent BBC headline that might be more link-baiting than actual research. 

According to the UK's Journal of Aesthetic Nursing, clinicians say there is a growing trend for under-25s to seek the wrinkle-smoothing injections but research suggests "frozen faces" could stop young people from learning how to express emotions fully. Additionally, a leading body of UK plastic surgeons says injecting teenagers for cosmetic reasons is "morally wrong".

What's going on here?

Nurse practitioner Helen Collier, who carried out the research, says reality TV shows and celebrity culture are driving young people to idealize the "inexpressive frozen face."

But she points to a well-known psychological theory, the facial feedback hypothesis, that suggests adolescents learn how best to relate to people by mimicking their facial expressions.

She says: "As a human being our ability to demonstrate a wide range of emotions is very dependent on facial expressions.

"Emotions such as empathy and sympathy help us to survive and grow into confident and communicative adults."

But she warns that a "growing generation of blank-faced" young people could be harming their ability to correctly convey their feelings.

"If you wipe those expressions out, this might stunt their emotional and social development," she says.


Dr Michael Lewis, a researcher in psychology at Cardiff University, says: "The expressions we make on our face affect the emotions we feel.

"We smile because we are happy, but smiling also makes us happy.

"Treatment with drugs like Botox prevents the patient from being able to make a particular expression and can therefore have an effect on our learning to feel emotions naturally."

Rajiv Grover, president of the British Association of Aesthetic Plastic Surgeons, says: "Injecting teenagers with Botox for cosmetic purposes is morally wrong and something that no ethical practitioner would do.

Of course this might have been morea bout Ms Collier's presentation at the Clinical Cosmetic and Reconstructive Expo and generating a little visibility for both the presenter and the venue.

I tend to agree with many of the premises here in that cosmetic treatments simply to cater to perceived imperfections for younger patients just shouldn't be performed, but it seems a stretch to say that the Botox is the cause rather that the effect. In the patients that I've seen that fall into this age group and are looking for cosmetic treatments there are already many factors that are contributing to this behavior in the first place rather that flowing from previous treatments.

Body dysmporphic disorder in the young is something that every cosmetic practioner runs into from time to time. It's up to each clinician to understand what the patient psychology is and how best to address it. Blaming the actual treatments is overly simplistic in my view.


Build Your Medical Spa Around Patient Experience & Your Patients Will Be Happier

Focusing on your patients experience in your medspa will result in happier patients, more positive word of mouth, and fewer headaches for you and your staff.

Physicians are often focused on outcomes, many times at the cost of a patients experience, but that's just bass-akwards in elective cosmetic medicine where the real outcome should be measured almost exclusively in long term patient satisfaction and not in visible results.

Unconvinced? Here are a couple of reasons that you'll want to focus on your patient's experience and how you might think about putting experience at the top of your patient interactions:

  1. There's new research that shows that purchases made on 'experiences' results in more happiness that spending money on tangible goods. Concert tickets, piano lessons, a fine dinner... all of these elicit more happiness than physical products and the effects last longer.

    "Purchasing things like televisions, clothes and coffee machines won't make you happier overall -- but buying experiences maximizes happiness," says Michael Norton in a CNN interview. (He's an associate professor of business administration at Harvard Business School and co-author of the book, "Happy Money: The Science of Smarter Spending.")
  2. We humans get additional pleasure from social interactions and bonding across the entire experience, starting with the anticipation and continuing on as positive memories. The difference is really one of degree with the social aspects having significant impact on how past experience are perceived. The result is that 'experiences' have additional reinforcement that happens over time adding to those positive feelings and acting as reminders.

 The focus on patient experience clearly explains how physicians or clinics who might not have nearly as significant outcomes are still able to compete, and in many cases dominate, clinics who focus entirely on the physical results their delivering. It's an important distinction and means real euros and dollars for your clinic.


2 New (And Free) Products For Medical Spas

Over the course of the next month we're going to release two new free products to address the needs of cosmetic physicians and medical spas.

You can see our current free deals for medical spas here.

We're getting some new parnters involved that are looking to address pain points that every clinic needs to address around increased clinic visibiliy, new patient leads, and clinic operations. Over the next few weeks we're going to realeas a couple of new (and free) services:

  1. A new and improved medical spa directory that incorporates the newest technologies to drive increased patient traffic. This new directory will tap in to existing networks and get you in front of potential clients where you can tell your story.
  2. A medical spa operations manuals that independent medical spas can use to train and manage their staff. This manual is excatly what you know that you need, but is usually unattainable. We've done a deal that will make the operations manual from one of the most successful multi-location medical spas to Members.

Both of these offerings will be free to Medical Spa MD Members so if you're not already a member make sure that you join to get the latest stuff.


New California Law Protects Patients From "Disparagement Clauses" That Some Medical Spas Are Using

A new California state law just signed by Gov. Jerry Brown makes reviews a lot safer for patients, and prevents medical spas or cosmetic practices from pursuing any legal action against patients who post negative reviews online.

This legislation is the first of it's kind and addresses so-called "disparagement clauses" that are sometimes used in a clinics patient forms that prohibit patients from posting negative comments about the services, staff, clinic or physician.

This new law effectively bans such clauses and any clinic that tries to enforce one could pay $2,500 for the first offense and $5,000 each additional time, with an extra $10k tacked on if the action is considered "willful, intentional, or reckless".

The First Amendment is only in the US of course, France is a different story. In July a French blogger was fined because her negative review of a restaurant was appearing too high in Google's search.

If you're in California, not only is any non-disparagement clause uninforcable, it's now illegal.

Here's the copy from the bill:

Click to read more ...


Unintended Consequences Of Policies Inside Your Medical Spa

How do we keep track of new patient inquires? How do I get my staff to sell more products and services? How can I get my front desk to mention our newest IPL treatment or Botox pricing?

New policies and procedures are usually implemented to try and address a perceived (or real) problem, ut even the most carefully crafted procedures are very seldom realized when you throw human nature into the mix. Take a look at these famous examples from a Quora thread on unintended consequences:

A particularly famous example named the Cobra Effect:

The term cobra effect stems from an anecdote set at the time of British rule of colonial India. The British government was concerned about the number of venomous cobra snakes in Delhi. The government therefore offered a bounty for every dead cobra. Initially this was a successful strategy as large numbers of snakes were killed for the reward. Eventually, however, enterprising persons began to breed cobras for the income. When the government became aware of this, the reward program was scrapped, causing the cobra breeders to set the now-worthless snakes free. As a result, the wild cobra population further increased. The apparent solution for the problem made the situation even worse.

Here's a particularly relevant one around trying to improve service times that results in exactly the opposite:

My first job was as a crew member at a Burger King. To ensure speedy service in the drive thru, a timer was installed and hooked up to a pair of sensors so that it started when the car drove up to the speaker, and stopped when the car left the drive through window. The times were aggregated throughout the day and the times for each restaurant were reported back to the district supervisor.

As a result of this system, on days when we weren't meeting our goal time (generally 3 minutes), the managers would instruct us to have each car pull around to the front of the restaurant immediately after receiving payment if their order wasn't ready yet, causing the timer to stop counting. Then, rather than handing the food out the window, we would have to step out from behind the counter, walk up to the front, deliver the order and then walk back. So the customers ended up waiting longer for their food because we had to travel farther to deliver it, and also reduced the amount of time that we could spend productively handling other customers.

If you're looking to implement a system or procedure to try and deal with a problem or need, make sure that you're not creating more work or building something that will cause unwanted behaviors in your staff. Your perception of what you need might actually be causing you more grief. Here are a couple of thoughts to remember:

  • Nothing you implement exists in a vacuum: If you're asking your staff to spend time talking to patients about your newest Botox or Restylane pricing, there's going to be less time to talk about your IPL or Thermage. If your focused on making sure that patients aren't taking advantage of your time by giving them only 10 minute consultations, your customer service will suffer.
  • Everyone acts in thier own 'perceived' best interest: If you're going to offer a discount for Botox treatments before noon and your nurse injector or front desk staff is bonused on total Botox revenue, don't expect them to be pushing this new program.
  • There's someting at work called Braess's Paradox: It states that "Adding extra capacity to a network when the moving entities selfishly choose their route, can in some cases reduce overall performance. This is because the Nash equilibrium of such a system is not necessarily optimal."

If you have any stories of something that you implemented that had unintended consequences in your clinic or medspa, leave them in the comments below.

Click to read more ...


Download Medical Spa Embezzlement & Employee Theft Scams - It's Free

In a recent study, more than 82% of medical clinics reported at least one issue with employee theft or embezzlement... that they were aware of. This free guide to beating embezzlement and employee theft schemes uncovers the hidden tactics behind how these scams work, and how you can find them before they capsize your clinic.


Download Medical Spa Embezzlement & Employee Thef Scams


Embezzlement and employee theft are an unfortunate fact in almost every business, and especially in cosmetic medical practices. If you haven't ever had to deal with this you're extremely lucky since it has taken place in every clinic I've been personally involved with and the stories that are told by physicians and business owners are legion.

If you think it can't happen in your business you';re just whistling past the graveyard. It can. It will.This report is designed to give you a fighting chance to identify how your business is at risk, to understand how these schemes work, and what you can do to minimize your risk and take action when you find a problem.

You're about to read the many stories that have been collected from clinics and physicians; from how a physician-employee put an extra account on a credit card terminal to deposit payments into his own checking account to how a NP would inject patients with straight saline and steal the Botox to use in her own side business. Some of the stories are almost beyond belief in their brazenness and the damage that was caused. In almost every case, the employee was a trusted team member.

Employees that are embezzling or stealing from you are enabled by ignorance and naivety. On the following pages you'll begin to remedy those issues.

I wish a report like this wasn't necessary, but it is.

If you don't read it you're a fool.


Download Medical Spa Embezzlement & Employee Thef Scams


Here's what physicins are saying:

Great report! It should be required reading for 
all doctors — even for those of us who've 
been around!
Marguerite Barnett MD FACS PA, Mandala Medspa
A very eye-opening and sobering report.
This is a must read for everyone!
Windie Hayano, The Skin Inc. Dermatology and Laser Center
Opened my eyes! The information in this report is invaluable! I hadn't even thought of some of the scams mentioned in these testimonials!
Lori Robertson FNP, Skin Perfect Medical Rancho
Great! ...after reading others experiences I realize that you just cannot be too careful when it comes to the financial security of your business.
This report will help other centers avoid going through what we had to endure and overcome.
Brian Sidella, Founder, Forever Young Medspa

Louisiana Cosmetic Laser & IPL Law Questions & Answers

Legal issues around who can own or use a cosmetic laser or IPL are among the most common questions asked by both physicians and non-physicians who are investigating the medical spa market.

Here's a question posted inside the Medical Spa MD LinkedIn Group

What is the best way to find out what the Louisiana Laws are for operating lasers at your spa? From what I have read, it seems as though you have to have a physician present, however, most of the medi spas around run lasers but do not have physicians present so I am very confused. Does anyone know a way to find out more information?


Concierge Medicine: The First Insurance Company Moves To Reimburse Physicians For Online Care

Physicians just got a little bit of a boost towards the ability to use the power of the web to deliver services online, and be reimbursed for it.

Arches Health Plan has activated 30 new CPT codes specifically for telemedicine sessions conducted by physicians, PAs and nurses marking the first health insurance co-op and the first non-affilliated insurance company to provide reimbursment for both primary online care and primary specialty online care.

Here's the press release.

Click to read more ...


Expression As An Filler Injection? FDA Warning & Company Recall.

Enhancement Medical recieved a warning letter from the FDA that takes them to task for allowing their product to be used as a "filler injection" which, according to the FDA, it was never approved for. In response, Enhancement Medical has recalled all lots of Expression.

Expression Filler Injections FDA RecallPhoto: Wikipedia“The FDA has become aware of adverse events associated with the unapproved use of the Expression product as a dermal filler,” reads the warning. “The FDA has not approved this product for use as a dermal filler and recommends that health care providers stop using Expression by Enhancement Medical LLC as a subcutaneously administered substance.”

Manufactured by Enhancement Medical, Expression was approved by the FDA in 2012 as an intra-nasal splint to be used after nasal surgery. According to Enhancement Medical, it’s a "third-generation hyaluronic acid gel" that’s sulfite- and pathogen-free.

Unlike Juvederm, Restylane, Perlane, and other commonly used hyaluronic acid products, which are FDA-approved for cosmetic use, Expression is being used off-label. (Off-label use is common and not illegal. Botox was used for years off-label to treat wrinkles, migranes and sweating for which it had not yet been approved.) Nevertheless, in the past couple of years Expression has come into wider use by doctors and cosmetic clinics. The number of growing treatments has resulted in a correstponding increase in complaints.

In Feburary 2014 the FDA first contacted Enhancement Medical regarding complaints of adverse reactions and in June sent them a warning letter criticizing them for what the FDA perceived as inadiquate follow-up and investigation as well as using the term "filler injection" in the copy on their web site. 

The FDA says that there are adverse events associated with the unapproved use of the Expression product, hyaluronic acid that is packaged in a syringe, as a dermal filler. Events have included swelling, tenderness, firmness, lumps, bumps, bruising, pain, redness, discoloration, itching, and the development of hard nodules.

Expression is listed with the FDA as an intranasal splint, and is intended to minimize bleeding and swelling and to prevent adhesions (sticking together) between the septum and the nasal cavity. Intranasal splints are placed in the nasal cavity after surgery or trauma and are usually constructed from plastic, silicone, or absorbent material.

The FDA issued a warning letter to Enhancement Medical LLC on June 4, 2014, advising the company of multiple quality system, correction/removal, and medical device reporting violations that were revealed during an inspection.From the FDA letter:

FDA also reviewed your firm’s medical device registration and listing, which lists the Expression as a Class I exempt intranasal splint. Generic devices classified under 21 CFR 874.4780 (Intranasal Splint, Class I) are intended to minimize bleeding and edema and to prevent adhesions between the septum and the nasal cavity. Intranasal splints are placed in the nasal cavity after surgery or trauma.

We note, however, that FDA is aware of and has reviewed multiple documents for Expression that contain claims, phrases and/or statements that refer to your firm’s device as an “injectable filler.”

For example, during FDA’s recent inspection, your firm provided the Investigator with a document entitled “The Science Behind Expression” which contained the following statements:

  • “Enhancement Medical is using the new pathogen-free, raw HA material to develop and manufacture Expression™ injectable filler in Wauwatosa, Wisconsin.”
  • “Enhancement Medical uses the raw HA product from Novozymes as a non-toxic and non-pathogen delivery medium for its Expression™ injectable filler.”
  • “In formulating Expression™, the HA molecules are cross-linked with divinyl sulfone (DVS) and the gel is swelled to equilibrium. This provides the Expression injectable filler product with an 80/20 gel to fluid ration with up to 26 mg/mL of HA. Thus the formulation combined with the highly robust HA molecules result[s] in a very rich and potent filler compared to others.”
  • “Clinicians find Expression™ does not have the hydrophilic effect when placed into tissue, eliminating guesswork from corrections and providing greater utility for multi-purpose use.”

As stated above, under 21 CFR 874.4780, intranasal splints are placed into the nasal cavity after surgery or trauma. Intranasal splints are not intended for injection through intact skin or mucosa and placement into tissue. Injection through intact skin or mucosa and placement into tissue may raise new questions of safety and effectiveness that could require either premarket approval and/or clearance before the device may be marketed in the United States. Please provide us with the basis for your identifying Expression as an “injectable filler” and whether you intend to continue making such claims. See 21 CFR 874.9(a) (limitations on exemption – promoting your device as an injectable filler may indicate a different use which could cause it to no longer be 510(k) exempt).

Additionally, FDA has noted that your firm’s website ( contains the following statement for the Expression injectable filler: “Expression has FDA indication for use as intranasal splint.” Please be advised that this statement may be confusing to users and could create an impression of official approval of your device. As such, we request that your firm please remove any reference that FDA has indicated your device, Expression, for a specific use.

The response from Enhancement has been to recall all lots of Expression.

According to the recall letter the company received 99 complaints from 14,835 syringes shipped with compaints that included "swelling, redness, pain, bumps, firmness, bruising, itching, inflammatory reactions, infections and abscesses". 

The letter continues, "We do not recommend that Expression be injected subcu-taneously for any reason because Expression’s safety and effectiveness as a subcutaneously administered substance has not been established in controlled clinical studies."

What's interesting here is that the list of complaints are pretty much exactly what you'd expect with any filler like Juvederm or Restylane. I'm wasn't able to find anything online that would call out Expression as having reactions that are abnormally high (althought they might be). If anyone has relevant stats please leave a comment below.

In any event, you'll want to send back your recalled Expression if you've been using it.



Dubai (UAE) Has The World's Highest Concentration Of Plastic Surgeons

Interesting story on CNN detailing how Dubai has more plastic surgeons than the US or Brazil.


Handling A Bad Online Review Of Your Medical Practice

Dr. Lawerence Broder of Beleza Med Spa in Austin, TXGuest Post by Dr. Lawerence Broder of Beleza Med Spa in Austin, TX

Online review sites have done a lot for promoting practices for many doctors who have worked hard to establish a good reputation among themselves and their staff. Unfortunately they can also do a lot of damage when vindictive or disappointed patients go out of their way to leave negative reviews on these sites; some true statements of less than stellar service and other negative reviews that aren’t quite accurate. It seems that those who have a complaint are twice as likely to make the effort to make their grievances known so learning to handle these bad reviews and perform the proper damage control is essential to keeping your practice in good standing.

As mentioned, there are generally two types of negative review circumstances, one in which the patient or consumer has a valid, accurate complaint for a service that was less than what it should have been and they were let down in receiving care that was less that you hope for from your staff. Then there are those whose expectations are probably not in alignment with what you provide as a practice and may have unreasonable demands or are easily aggravated.

When a client has been let down by an off day at your practice, the best move is to take responsibility for the situation sincerely and offer both an apology as well as a remedy for the disappointing service. Recognize that replying to a negative review is often an opportunity to prove your genuine interest in your patients by responding to their complaints. Those who have a legitimate complaint should be handled professionally and an offer for a redo might be suggested. Some irrational complaints are bound to occur, but this still provides an opportunity to respond with a level head and a rational comment so that others who might come across the review can judge for themselves between the two comments. Regardless of the nature of the complaint, even if it’s completely absurd, be sure to respond to show that your practice hears the complaints and feedback of their clients regardless.

It’s important to maintain brand consistency when responding to reviews online by responding with a name that coincides with the practice instead of your own personal account or name. The name you respond with should show the name of your practice as well as your title as the owner or main practitioner. If you have someone else who manages your social media accounts on your behalf, make sure they login with the appropriate account before posting.

Work towards transparency in all your online messages and responses. Instead of working to hide any negative feedback (which can make it seem as though you’re brushing negativity under the rug), respond professionally and resolve matters as they come up. This will help in building a reputation as a trustworthy practice that provides top notch service and fixes their mistakes when necessary.

Dr. Lawrence Broder is a cosmetic surgeon and founder of Beleza Med Spa in Austin, TX. Dr. Beleza now has 5 locations in the area and is one of the most successful medical spas in Austin.

Submit a guest post and be heard.   


Texas Law & Medical Spas

The first of July (2014), a Texas judge in the 126th State District Court in Austin ruled that the Texas Medical Board Rule 193.17 which sought to impose restrictions on who could practice cosmetic medicine was without "reasoned justification" and should be remanded for further consideration.

Mark one up for the Texas Association of Aesthetic Nurses.

The association had sued asking for the rule to be invalidated and it seems that the judge agreed.

Under Rule 193.17, among a laundry list of requirements, medical spas could not perform nonsurgical medical procedures without having a physician, a nurse practitioner or physician assistant on staff to complete a 10-step process before beginning the procedure. The rule did not, however, require a physician actually be on the premises during the procedure, but rather necessitated only that a doctor be available for an emergency consultation. Judge Yelenosky’s order noted that: The rule allows qualified unlicensed personnel to perform a procedure without a physician or midlevel practitioner onsite during the procedure and without requiring the physician to go onsite in the event of an adverse outcome. Yet the reason given for the rule is that the presence of a physician or midlevel provider during procedures to personally treat or supervise treatment of any complications arising from the procedure insures patient safety. The rule and the justification contradict one another.

According to the ruling it seems that if the Rule were to require a physician or midlevel practitioner to be present during a procedure, it would probably pass muster with the judge.

Although I don't think that Texas has passed specific legislation or adopted particular rules governing medical spa operations (check with your lawer if you're in TX), there has been a number of administrative actions taken related to unauthorized services being performed or the failure of such licensed professionals to adequately supervise the performance of such services. Additionally, the Texas Medical Board has established a rule that requires physicians who perform procedures for which anesthesia services, including the use of analgesics and anxiolytics, are provided in an outpatient setting to register with the TMB. While this TMB registration requirement primarily affects outpatient surgeries performed at licensed Ambulatory Surgery Centers in Texas, the language of the rule would also cover any outpatient surgeries performed in a medical spa that require anesthesia services. A new TMB rule related to nonsurgical medical cosmetic procedures (22 Tex. Admin. Code § 193.17) became effective on November 7, 2013.

Texas often likes to chart it's own course so we'll watch and see where this goes.

My opinion is that a physician should be on site if a NP or PA is not the one administering the treatments. It seems somewhat rediculous to allow the term "medical spa" to be used as it is in Canada and parts of SA and the EU when there's no medical personnel involved. It seems that the medical board in Texas stretched just a little too far in trying to restrict cosmeitic medicine to physicians but not making them be on site.

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