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Thursday
May112017

Dr. Michele Green - A Manhattan Dermatologist

New York Dermatologist Dr. Michele Green shares about her background in the cosmetic field, the way she runs her office, and the devices she uses in her practice.

Dr. Michele Green - Manhattan, NYName: Dr. Michele S. Green MD
Location: Manhattan, New York City
Website: http://www.michelegreenmd.com/
Brief Bio: Dr. Michele S. Green is a board-certified dermatologist based in NYC. She is a graduate from Yale University, with an MD from Mount Sinai Medical School in NYC, and has since opened her own private practice on the Upper East Side of Manhattan, and treats both medical and cosmetic dermatology patients with an emphasis on anti-aging and skin cancer prevention.

I use a range of laser treatments for skin rejuvenation and skin tightening. Popular laser treatment requests include Thermage for facial skin tightening, V-Beam, Fraxel dual laser and its “mini-fraxel” counterpart, the Clear+Brilliant, or eMatrix which helps produce new collagen and rejuvenate the skin’s appearance. I utilize the BBL laser which is my favorite IPL laser because of the ST skin tightening handpiece. While all new technologies and developments are of interest, we are very specific with picking the ones that we use for each condition and do not have...

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Tuesday
May092017

Dr. Ron Shelton - Cosmetic Lasers & Surgery In Manhattan, NY

With more than 27 years of practice under his belt, Dermatologist Dr. Ron Shelton gives us an insight about his experiences and running his practice in New York City.

Dr. Ron Shelton - Manhattan, NYName: Ron Shelton MD
Website: www.thenyac.com
Location: Manhattan, New York City
Brief Bio: An industrious, forward thinker, Dr. Ron Shelton, in 2001, brought together an accomplished group of surgeons to holistically address the needs of both cosmetically-minded patients and those needing Mohs surgery and reconstruction for skin cancer.

New York Aesthetic Consultants included Cosmetic Dermatologic and Plastic Surgeons. It was one of the first medical spas in New York City. In July 2014, Dr. Shelton was invited to join the prestigious NYC laser practice, Laser and Skin Surgery Center of New York. Both Dr. Shelton’s and LSSC’s practices have benefited by this merger as the Midtown NYC cosmetic dermatology practice has more than 60 lasers and devices and a dedicated research division for the development of new laser technology.

Our practice has 8 full time dermatologists and several part time dermatologists and a plastic surgeon. We practice in Midtown Manhattan and Southamptom Long Island, but my full time practice is limited to our NYC practice, in which I see patients from 8 AM to 5 PM, Monday through Friday. We have many administrators including the executive practice administrator, COO, office manager, nursing manager, laser research manager, many RNs and a few medical assistants. I perform all laser and cosmetic device treatments for my patients. We do not have ancillary providers perform lasers in our practice. Half of my practice is cosmetic dermatology including laser resurfacing, laser treatment of discoloration (facial erythema, lentigines, tattoo removal), body sculpting / skin tightening with liposuction and minimally invasive (ThermiTight) and non invasive treatments (Thermage, Ultherapy, ThermiSmooth, CoolSculpting, UltraShape, SculpSure), volume augmentation with fat injections as well as many of the hyaluronic acid treatments (Voluma, Vollure, Volbella, Juvederm, Restylane, Belotero) and other fillers and Sculptra. Botox is very commonly performed. The other half of my practice deals with skin cancer treatment with excisions, and Mohs Micrographic Surgery and Reconstruction.

The list of devices we have is quite long, approximately sixty and they encompass many types of lasers and devices. We have only one IPL. We have gentle laser toning with Cutera XEO Laser Genesis and PicoSure focus lens array and Clear & Brilliant and Permea. Lasers for resurfacing include Fraxel Restore/Dual, and Fraxel Repair.

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Wednesday
May032017

Injection Techniques for the Hand and Neck

In our previous post, we discussed filler injections for hand and neck rejuvenation. These procedures are on the rise, and many physicians are considering this procedure in their practice.

Injection Techniques for the Hands

There is a significant amount of literature for hand rejuvenation. Most have focused on injections and laser for the hands, as a non-surgical alternative. For this article, we shall go in detail on the injection techniques included in two studies.

LeFebvre-Vilardebo, Trevidic, and et al. (2015) go in depth with injection techniques, as different authors included in the study present their own injection methods on hands. The researchers also introduced their own injection technique: Scrape Skin Threading Technique. Below is the table detailing more on the injection techniques.

Data from Lefebvre-Vilardebo (2015)

LeFebrve-Vilardebo and Trevidic (2015) suggest using a blunt-tip cannula when injecting. The researchers use four injection techniques to administer the CaHA.

The first method only injected without massaging, and it is most effective on a less fat hand. On the 2nd method, massaged aided in distributing the filler evenly. However, the third method showed the filler only stayed under the tendons. In using their own technique, the SSTT, it was the only technique that showed where the product was targeted.

For Dr. Moradi (2015), he used Radiesse with lidocaine HCl. In performing the procedure, he tented the skin and utilized a bolus injected in the dorsum of the hand. Specifically, Moradi injects “…proximally by the wrist-hand junction, distally the metacarpal-phalangeal joint” (p. 265s).

In addition, the doctor added smaller units for added improvement on the hands. Its intended result is to lessen the appearance of veins and tendons and improve volume.

Alternatively, in Dr. Busso’s (2015), he used HA that would minimize the appearance of tendons. The patient should be in supine position. In order to see the veins better, Dr. Busso suggests placing the hand below the level of the heart. In addition, mark all injection sites. Then, finally, raise the hand slightly above the level of the heart.

The injection on the dorsal superficial lamina would yield easier injection administration. Injected fillers can easily spread and lessen any abnormal skin formation. Skin tenting is recommended to separate the veins from the injection area. There is a risk of nerve injury, so refrain from doing any intracompartmental injections “below the deep dorsal fascia” (p. 270S).

As for Drs. Sutton and Bucay (2015), their choice of filler is Radiesse. Like the previous cases above, cannula was used to administer the filler. The insertion of the cannula is between the 2nd and 3rd metacarpal.

The common observed side effects were edema and erythema in all cases.

Dr. Rivkin (2016) also conducted a study on hand rejuvenation and injection techniques. The author makes use of needles, instead of a cannula as mentioned in previous studies mentioned above. The technique the author adopted was injecting between the phalanges. Rivkin carefully fills in the spaces. The author expects that the appearance of vein and tendon reduce. After administering the procedure, it is recommend that the hand is massaged.

After the procedure, the author advises the patient to have hands elevated for the next couple of days and any tedious activity.

Here are the tips that Rivkin provides.

Injection Techniques for the Neck

The literature for injection techniques on the neck is limited; most studies have only studied on the use of lasers on the neck. There have been research on the neck using botulinum toxin, and there are doctors who use botox on their patients to perform a non-surgical neck lift.

Physicians should take note of the danger zones in the neck. Calisti and Elattar (2017). The researchers introduced a new injection technique on the neck, which is the “Three-Dimensional Circumferential Injection Technique” (p. 1). They applied this approach on the Posterior and Lateral Subcutaneous Areas of the Neck and Anterior Subcutaneous Area of the Neck and Horizontal Neck Rings.

Below is the table that further details the study.

Data from: Calisti and Elattar (2017)

Hand and neck rejuvenation are two procedures that result in patient satisfaction. The procedures are not nascent, and it is expected to rise in the coming years.

Monday
May012017

The Coming Shift to Telemedicine (Everywhere)

There is a rise of telemedicine startups everywhere, especially in cosmetic medicine. What might this mean for you?

The Shift to TelemedicineSilicon Valley, New York, London and Berlin all are investing big in telemedicine, A.I. and big data services. There are massive changes in the US that are opening doors for new services. what does it all mean for a little one-doc clinic in Des Moines, Charolette or San Antonio?

Why is there a need to utilize telemedicine?

Telemedicine makes it easier to keep patient records, track patient progress, saves time (and money) and offers the promise of integrated deep learning for clinical decision support.

There has been a report that patient preference leans towards employing telemedicine. It provides follow-up care for those who underwent surgery and many patients favor that. The convenience allowed for better communication with the physician through email.

Why are some physicians skeptical about telemedicine?

While there are many benefits to telemedicine, it is still faced with criticism. Many physicians are hesitant to adopt telemedicine because of costs. One of the many concerns about adopting telemedicine is the HIPAA. Patient privacy can be breached, especially with aesthetic medicine where photographs and video can be saved or used as before and after media output. Tools and software can be costly, because of this doctors would prefer to stick with traditional practice instead.

When will aesthetic medicine adopt telemedicine practices?

Several dermatology and plastic surgery practices have made progress in using telemedicine. The most common telemedicine method for aesthetic practices are Skype consults. Virtual consults cost less and patient retention is slightly higher.

Another example of telemedicine applicable for aesthetic practices are Virtual (VR) and Augmented Reality (AR). Primarily known for its use in gaming, it has branched out to other science and technology fields. Several plastic surgery practices have installed some devices such as VR or AR for patients to visualize the expected outcome of their procedure. Back in 2015, plastic surgery performed through Google Glass resulted successfully. In other uses, scribes send data to physicians via Glass. Expectations to use Google Glass in the practice is huge.

Telemedicine is also not limited to patient care, as it focuses also on the devices you use for your practice. While Luan et al., (2015) study focuses on access to plastic surgery literature, a physician can utilize their devices to use to communicate with patients. In addition, since the rise of smartphones, it is easier to enforce telemedicine. Video messaging apps like FaceTime and Skype can be used for telemedicine.

How to prepare yourself in integrating telemedicine in your practice?

Telemedicine, while mostly beneficial, may be difficult to integrate to a practice especially if it is not telemedicine-ready. You may need to consider these factors.

According to Krupinski (2014), set-up a room dedicated for all telemedicine needs. You will need to examine factors such as lighting and audio and video so you can examine them better. Let your patients feel comfortable inside the room as well.

2015 Telemedicine Report from Freelance MD

Choose the telemedicine tools, methods, and technologies you will adopt. As we have mentioned there are various tools and devices for the physician’s use, but you do not need to employ everything. Some examples of the telemedicine methods you can use are Real Time (RT), which you can do on your own devices or through store-forward (SF). A physician can find a telemedicine tool or software online, which one can subscribe to.

Training is important, as studies have shown that those who are mishandling telemedicine tools or software can make patients feel uncomfortable. Train along with your staff so everyone in the practice has an idea how your telemedicine devices and software work.

Most physicians overlook the hindrances and barriers to using telemedicine for easier accessibility. Telemedicine is not just implementation just to keep up with trends, but its convenience and eventual cost-cutting advantages can help save practices.

Download the Medical Spa MD Telemedicine Report here.

Thursday
Apr272017

New Advancements In Cosmetic Lasers (2017)

Cosmetic laser technology has continuously advanced over the years, and many physicians have noted the progress in the past few years.

The American Association of Dermatology (AAD) Annual Meeting was held in March. One common topic according to the AAD articles is the advancement and improvement of aesthetic laser devices. Aesthetic laser devices can target skin and facial conditions, even allowing multiple treatments on one device.

Dr. Michael Gold, a renowned dermatologist, spoke in a symposium, noting the significant changes of the current aesthetic devices.

Aesthetic companies like Syneron, is gearing up to release new devices and make improvements with their current devices. In addition, Cutera introduced PICO Genesis last December that treats skin pigmentation, which also enhances the patient’s skin complexion.

Two doctors from the AAD conference has noted that laser will improve further in the future. Dr. Chapas said that there are studies being conducted over the use of a picolaser for other cosmetic purposes other than laser hair removal. Additionally, Dr. Waibel mentioned that research is also done to examine other laser uses.

The dermatologist added she is aware that new technology are being developed such as the free electron laser, which has promising uses for the medical sector.

It is expected that lasers will continue to develop in aesthetic medicine. What are your expectations for aesthetic or cosmetic lasers in the future?

References:

Thinking of a Picosecond Laser? Do I need one and which one to buy.

http://www.prnewswire.com/news-releases/syneron-candela-announces-new-technology-and-indications-at-the-2017-american-academy-of-dermatology-aad-annual-meeting-300416266.html

http://www.prnewswire.com/news-releases/cutera-launches-new-pico-genesis-treatment-with-enlighten-300373489.html

http://dermatologytimes.modernmedicine.com/dermatology-times/news/advances-lasers-light-sources-0

http://www.healio.com/aesthetics/laser-procedures/news/online/%7B8048864e-2466-4db7-a033-17ea4f3df1a9%7D/recently-approved-aesthetic-devices-improve-on-previous-generations

http://www.mdedge.com/edermatologynews/article/134277/aesthetic-dermatology/video-picowave-laser-uses-are-expanding-beyond

Wednesday
Apr262017

Overlooked Anti-Aging Procedures

Many fillers and injectables are marketed for the face and skin. According to the 2016 ASPS statistics, there were 2,600,000 procedures for dermal or soft tissue fillers alone. However, dermal fillers are also used for other purposes, like on the hand and neck.

Overlooked Anti-Aging ProceduresNumbers are scarce regarding treatments for those areas, however some patients seek hand or neck rejuvenation, which are overlooked procedures.

There have been studies about using neck and hand rejuvenation, mostly showing promising results to the patients. Few studies have only shown complications about rejuvenation and resurfacing. Frequent modalities used in treating these areas are dermal fillers (used for off label use) and lasers or IPL.

In the official statistics provided by the ASPS, only hand surgery is listed as a surgical procedure and so far, hand and neck rejuvenation is not listed as a non-surgical procedure. It is probable that it is part of the filler statistics.

HAND REJUVENATION

Common injectables used for hand rejuvenation are Collagen, Hyaluronic Acid (HA), Calcium Hydroxlypatite (CaHA), and Poly-L-Lactic Acid (PLLA) (Kühne and Imhof, 2012). According to the authors, side effects of the fillers on the hands are swelling and bruising. In addition, they suggested that dermal fillers for better effectiveness is CaHA due to collagen stimulation. Furthermore, according to Butterwick and Sadick (2016), hand rejuvenation procedures are more effective when treated with multiple modalities such as IPL, RF, and CaHA and PLLA.

In Maruyama’s (2016) study, it focused on the hand rejuvenation for 128 Japanese patients. The researcher took into consideration some skin differences and side effects. The researcher used IPL by using two wavebands, one using 560nm and another 515nm.

Immediate downtime results for wrinkles showed that most of the patients were mostly unpleased, effects improved after two or more treatments. Meanwhile, many patients were satisfied by the results with the dorsal lentigines. One of the prominent side effects presented in the author’s study was erythema, followed by hyperpigmentation and itching.

Despite such, most patient satisfaction for hand rejuvenation is usually high and there is an expected patient return or retention for a treatment of hand rejuvenation (Rivkin, 2016).

After administering an injection related hand rejuvenation procedure, massaging is recommended as it helps in the longevity of the treatment on the hands.

NECK REJUVENATION

With surgery, come the complication and risks. Batniji (2014) enumerates the possible risks of surgical neck lifts, such as induration, neck injury, and skin contour irregularities. Despite such complications, neck lifts is slowly on the rise.

As an alternative, some cosmetic physicians offer non-surgical neck rejuvenation.

However, recent literature is still little for non-surgical neck rejuvenation.

de Oliviera et al.’s (2017) study presented a 100% improvement rate upon treatment. A combined RF and PEMF treatment shows significant positive results when used to treat the neck. Additionally, the researchers note that RF alone may not be as effective. It is suggested these combined treatment be used in observing shorter downtime and lesser complications.

Their main limitation was no follow-up was done after their initial study. Any observed complication was quickly resolved.

In another study, di Bernardo (2016) used two modalities for the neck: a laser and RF for different purposes. Their study focused on the procedure of using the modalities for the neck. The researchers marked the areas to laser and used tumescent anesthesia for this treatment. As for the RF treatment, they plotted the areas to treat the neck to avoid neuropraxia.

Finally, Oram and Akkaya (2014) uses CO2 as another option in treating the neck as it showed improvement with Skin Laxity, Jowling, Fat Disposition, and Horizontal Neck Lines. Their study, however, presented complications, however it was only short lived. Despite such results, most of the patients returned for further treatments in the long-term. Their main takeaway in the study was the skin tightening due to the bettering of the skin laxity and in turn causing good effects with the jowling and fat disposition.

These two procedures, while, not popular, are also sought by patients. These elective procedures are befitting

In another post, we discuss injection techniques for hand and neck rejuvenation.

Thursday
Apr202017

What Your Medical Spa Staff Should Understand About Body Dysmorphic Disorder

Are you at risk of treating patients with Body Dysmorphic Disorder (BDD)? What should your staff be doing to screen and communicate with risky patients.

Understanding Body Dysmorphic DisorderEveryone who's in the industry has delt with peatients who have unrealistic expecations and who make you think that there's not something quite right with their perception of themselves.

Most physicians avoid these patients after dealing with one or two of them that go from big cheerleaders before the treatment, to keying cars in the parking lot after the results don't live up to their unrealistic expectations.

It's something that everyone experiences and the more ethical providers aim to steer clear of these patients, but the result is that they'll go elsewhere.

Whill BDD seems to be underdiagnosed, there are some things we've learned that you might want to pass along to your clinic staff.

What have studies found out so far?

Many patients are faced with this concern that going under the knife would appease them, however symptoms of BDD can still linger. Many studies have shown that patients who have undergone cosmetic surgery still exhibit symptoms of BDD.

In a study conducted by Bouman, Mulkens, van der Lei (2017), a sizeable number of physicians are still unaware about body dysmorphic diagnostic disorder and what it entails both for the patient and the provider. In their study, they found when plastic surgeons refused patients to cosmetic treatment and had them referred to a psychologist, some of these patients attempted to sue the physicians. Additionally, their plastic surgeon sample considered surgery as a contraindication of BDD. Their sample also mentioned that they will not pursue with a procedure, provided the patient exhibited symptoms of BDD.

In the end, the researchers stressed the importance for cosmetic physicians to educate themselves further about recognizing the disorder, diagnosing the patient, and treating it.

Despite such events, there was research about the positive effects of cosmetic procedures with BDD also (Bowyer, Krebs, Mataix-Cols, Veale, and Monzani, 2016). One study was conducted that some patients manifested some BDD symptoms pre-surgery and the patient group reported satisfaction one year after the surgery (Felix et al., 2014).

What should you tell your staff to look for? (Note: This is not medical or legal advice, just an opinion.)

Patients may exhibit a number of symptoms and attitudes that staff can identify as potential problems including:

  • If a patient thinks that a treatment is going to change their life in some kind of unrealistic way.
  • Odd confidence that a physician is going to 'fix' them. These patients often are your most ardent supporters before the treatment.
  • Wanting to 'stack' treatments together and build a pipeline of problems that they want fixed.

What can your clinic staff do?

  • Understand that this is not really a vanity issue, even though it appears to be. BDD patients feel bad about this and their perceived as vain and shallow, but they're not able to stop obsessing. This is as real as depression, anxiety or other mental disorders.
  • Understand that they have poor insight regarding their treatment and their body perception. You won't be able to 'talk them out of it'.
  • Don't encourage BDD if you see symptoms. (I've seen a number of unethical clinics do just this.)

This isn't something that you want your staff to be in the dark about since there can be serious consequences if you don't take it seriously.

Thursday
Apr132017

Dr. Gregory Buford - Beauty by Buford, Englewood, CO

Dr. Gregory Buford of Beauty by Buford gave us insight of how he started practicing medicine and how he runs his clinic in our interview with the author and plastic surgeon.

Name: Dr. Gregory Buford
Clinic:Beauty by Buford
Location: Englewood, CO
Website: http://www.beautybybuford.com/

Brief Bio:

Dr. Gregory A. Buford is Board Certified in Plastic Surgery with additional Fellowship training in Anti-Aging/Restorative Medicine. He is a nationally recognized expert on minimally invasive facial rejuvenation and author of “Beauty and the Business” and has performed over 6000 procedures with liquid facelift products including BOTOX® and advanced dermal fillers, such as Juvederm®, Voluma®, Sculptra®, Radiesse®, Vollure®, and Volbella®. Dr. Buford is recognized by Allergan as a Diamond BOTOX® /Juvederm® Provider, signifying that he is ranked among the TOP 1% of BOTOX® injectors in the nation. In addition, he is a nationally recognized trainer for the Allergan Facial Portfolio and trains other medical practitioners in advanced injection techniques. Dr. Buford has been consistently recognized in the media for his Plastic Surgery expertise and has participated with resources including Vogue, E Online, ABC News, FOX News, EMedicine, and many others. In addition, he was selected twice as a finalist...

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