Dr. Sanjay Gheyi - Coltishall Cosmetic Clinic Norfolk, England

Trained as a general surgeon in India, the UK, and the US, Dr. Sanjay Gheyi's Coltishall Clinic in Norfolk runs the gamut of cosmetic offerings from Botox and IPL to cosmetic surgery.

Name: Dr Sanjay Gheyi
Clinic: Coltishall Cosmetic Clinic, Norfolk, England
Website: www.coltishallclinic.co.uk

Brief Bio: MBBS and MS general surgery India. FRCS, UK. WOSAAM board certification in Anti-ageing Medicine. Paris France

Medical Director Coltishall Cosmetic Clinic, Norwich UK.

Coltishall Clinic offers a full range of dermatologic laser treatments, non-surgical treatments such as botulinum toxins, fillers, face and body contouring treatments. Laser, skin and vein treatments such as IPL photofacials, non-ablative skin rejuvenation and toning, CO2 laser resurfacing, sclerotherapy, EVLT and ambulatory phlebectomy. We also provide minimally invasive options and cosmetic surgery under pure local anesthesia. This includes microcanula tumescent liposuction, fat transfer, laser assisted liposuction, blepharoplasty and face and neck lifts.

What made you decide to get into Cosmetic Medicine?

I had my board certification in General Surgery and worked in various surgical specialties including plastic surgery. I was always interested in cosmetic surgery but after spending 10+ years in Surgery in India, UK and a brief period as a surgical resident in the USA, I felt that there was more to life then perpetual residency so I decided to opt out of the rat race. I worked part time in general practice and also surgery. Then I discovered lasers and after much trepidation and sleepless nights brought my first device in 2006 and have never looked back. That was the best thing I ever did. I started slow and gradually added more services. I did not market very much but emphasized on training and education. I was working in the NHS at the time and gradually reduced my commitment as my private practice expanded. In 2010 I reduced my NHS commitment to just one session in Dermatologic surgery which I enjoyed immensely. After 5 years I resigned from the NHS completely to focus on my aesthetic practice full time.

What could you tell us about your clinic?

We are located in a beautiful suburban area north of Norwich. I decided to stay away from busy city centre because last thing you want to do after having a CO2 laser resurfacing for example is to be walking through town centre with a red face.

We have 3 treatment rooms, a reception room and separate comfortable waiting room. My wife is the general manager and we have two receptionists and one aesthetician. We have a small team so most patients know us well and we all know them very well. We offer only evidence based, results oriented services and where patients ask for treatments or services where there is not a lot of evidence base I tell them this very clearly.

We offer a full range of cosmetic dermatology services, minimally invasive surgeries such as skin lesion removals, tumescent liposuction, blepharoplasty and SMAS facelifts. We also have a vein practice and offer services for thread and spider veins anywhere on the face and body and also varicose veins treatments of EVLT and ambulatory phlebectomy under tumescent anesthesia.

How have you decided staffing in your practice?

Hiring the right people is very important. I was very lucky that my wife agreed to deal with the phone calls in the early days. She is a nurse so she had considerable health care experience which helped a lot. At first we used our NHS premises and staff on a part time basis but quickly learnt that was not a great idea. It is very hard to mix NHS services [I guess similar to your insurance patients in the USA] with self-funding private patients. So we moved out to private rented premises. We also appointed and trained dedicated staff members who had no NHS experience. We moved again to our new premises in 2010 as we were running out of space very quickly as the practice was expanding. Our new premises are future proof to allow for more expansion. We do not have a formal incentive scheme for staff but they are well looked after and we pay them well. We offer generous discounts on treatments and products and some free treatments. We have formal policies and procedures in place which are updated from time to time. When we hire new staff we allow them an opportunity to come and spend a day with us to see if they feel we are right for them and vice versa. Then we would have them on a trial period before appointment. We allow flexible working and our aesthetician manages her schedule herself. The feedback we get from staff is that this is a happy place to work and what is not to like!

Tell us about the technologies you use.

We started with a Lumenis quantum IPL and I still use it. We are lucky to have a full range of dermatologic lasers. For vascular work on the face we use IPL, PDL and long pulsed Nd-Yag. IPL is very useful for rosacea treatments. For leg veins it is usually sclerotherapy or Nd-Yag.
We also have a full range of pigment and tattoo removal lasers including the q- switched KTP,Nd-Yag and Ruby lasers. For ablative treatments we use CO2 laser and endovenous laser treatment are carried out with a 1470 nm diode laser. For laser assisted liposuction I use 980 nm diodes and also a 1470 nm diode laser.

For skin tightening we use radio-frequency and for skin toning we use q-switched Nd-Yag lasers and also in quasi-synchronous mode.

I like IPL because it is gentle and can address a number of concerns simultaneously. I love the lasers and there is no laser that I dislike. If you know you lasers well, you know their indications and basic science- each has its place in our armamentarium. I do dislike some doctors giving presentations and insisting that it has to be a particular brand of laser to do the job best. Look beyond the hype. If you know the wavelength, pulse duration and fluence you can make your own conclusions. One note of caution though-please don’t transfer recommended settings of one device to another-unless you are practicing on yourself first! Please stick to recommended settings and you can improvise as your experience grows.

Although I like new technology I do not rush in to buy the newest device as it hits the market. I once heard a physician say that he does not try any new drugs on his patients till they have been on the market for three years. Well, in cosmetic medicine we can't be that long but I like to wait at least six months and make sure and the machine that I'm investing my money in works well.

What marketing strategies do you use?

Our practice has been growing slowly and organically over last many years. We deliberately stayed away from aggressive marketing. I see two types of practices opening up. The first is cut- price businesses which turn these procedures into commodities. The second type is the practices that focus on premium services. We belong in the second camp.

Internet marketing has worked well for us and we use SEO and also PPC advertising. I created my own website, however, now due to lack of time I am getting an external website designer to revamp our website and make it mobile friendly. We advertise in local magazines. We don’t do national media or radio advertising.

Increasingly we see patients through word of mouth which is the best form of marketing. We also get referrals from local family doctors and hospital consultant colleagues.

Which procedures or treatments do you perform the most?

Surgical procedures are more profitable but lower volume. Next on the list is Botox and fillers followed by IPL and laser skin rejuvenation treatments. Laser hair removal and tattoo removal has become a commodity as a number of cheap places have opened up. We have however seen patients that are either dissatisfied from these services or had complications and we are seeing an uptick in laser hair and tattoo removal. Our unique selling point is that we have a number of devices so we can optimize the treatment using the best device based on patient’s unique characteristics.

We are moving away from non-invasive fat reduction as they fall short and again a number of cheap places are opening up. I can provide such good results with tumescent liposuction that non-invasive technologies will have to improve a lot before I can be convinced to offer them on a bigger scale.

What are your thoughts about cosmetic medicine, would you perhaps have any stories to tell?

Medical knowledge is obviously important but cosmetic medicine is both science and art, especially if you're going to do facial or body contouring or both.

Choose your patients carefully and learn to say no. Patient expectations are very high and in some cases are completely distorted.

There is inherent variability in response which means that some patients may respond very nicely and others may not respond at all. So don't provide any guarantees. They don't work in medicine!

I saw this clinic opened up locally who started doing laser hair removal and advertised 100% guaranteed laser hair removal. Six months later the guarantee had gone down to 1 year period following your last session and I believe now the guarantee has disappeared. Obviously they must have learnt the hard way!

Complications are a part of life and you will get complications. Be honest and take good care of your patient if you get complications and they will usually be very understanding and forgiving.

What advice could you tell to your fellow physicians?

Education is key. Patient’s come to us for results and a good experience. If you can provide this you will succeed. Fortunately we have many resources available to us. I found the discussions on medical spa MD very useful and they also helped me stay clear of hyped up devices which over promise but fall short on delivering results.

Don't buy the latest cool device. Instead go to devices which have had a proven track record. Talk to your colleagues, visit clinics, attend conferences and keep up-to-date and good luck.

About Dr. Gheyi

Dr Gheyi has triple board certifications in General Surgery, Family Medicine and Anti-ageing Medicine. He devotes full time to his Aesthetic and Anti-ageing practice. He personally administers thousands of laser, injectable and surgical procedures each year. He worked in NHS hospitals for 21 years in surgical specialties and last 5 years in dermatologic surgery.

He is an invited speaker at laser seminars and mentors other doctors training in lasers and cosmetic dermatology and surgery.

He is a trained and qualified surgeon. He has extensive clinical experience both in the UK and USA and has attended numerous perceptorships in cosmetic medicine & surgery. He has built a premier laser practice with sixteen different state-of-the-art laser and light systems and he continues to invest in training and new technology.

Kybella: FDA Approves Non-surgical Drug for Double Chin

In a 2014 survey, about 68% of those asked by the American Society for Dermatologic Surgery said they are bothered by submental fullness... welcome Kybella

Submental fullness (double chin: subcutaneous fat that makes a person look older and heavier) has a new FDA approved treatment that gives medical spas who are not performing tumescent liposuction another newly approved treatment. (Liposuction is the current standard to remove submental fullness.) Good news for cosmetic physicians in the US who need FDA approval.

Kybella, (ATX-101 accordig to the Kythera website) is a patented formulation of deoxycholic acid. It is a less-invasive, non-surgical option treatment for submental fullness. It's manufactured by Kythera Biopharmaceuticals in California.

Kybella contours the area under the chin by destroying fat cells when it is injected into the adipose tissue or subcutaneous fat. Injections into the fat are done through a series of treatments, no less than one month apart. A natural healing and elimination process should follow.

The drug has been developed for more than 9 years. More than 2,600 patients were involved and 20 clinical studies were conducted. Noted side effects may include nerve injuries that may lead to a lopsided smile or facial weakness, bruising, redness, swelling, and pain.

The approval by the FDA of Kybella does not carry with it the approval of its use for fats located in other parts of the body.

In a statement made by the deputy director of the Office of Drug Evaluation III in the FDA's Center for Drug Evaluation and Research, Dr. Amy Egan mentioned that the drug is only approved for treatment of fat below the chin and it is not known if Kybella is safe or effective for treatment outside this area.

Download: Product Info & Final Labeling PDF - Indications, Dosage, and Injection Technique Information.

Radiofrequency Assisted Liposuction (RFAL) - A new technique for adipose tissue treatment & 3D-skin tightening

The new technique using radiofrequency assisted liposucion (RFAL) from Invasix is based on bipolar radiofrequency energy which is applied to the subcutaneous adipose tissue and subdermal skin surface.

Preliminary clinical trials, histologic biopsies of the treated tissue and thermal monitoring demonstrate a rapid liquefaction of the adipose cells, coagulation of surcutaneous blood vessels and uniform sustained heating of tissue.

The dramatic rise in liposuction procedures, the aging “baby boomer” population, with decreasing skin tone and advanced laxity are seeking new body contour procedures.

The traditional tumescent, suction-assisted liposuction (SAL) is a mechanical disruption of adipose tissue through the openings in the cannula with induced negative pressure and can be quite traumatic to the patient.

 In seeking to improve the postoperative patient recovery of swelling, bruising, pain and to enhance skin contraction as well as to diminish physician effort, newer generations of energy-assisted liposuction technologies have been developed.

Preliminary studies with the RFAL technique reported faster treatment, improved safety, reduced tissue trauma, liquefaction of adipose tissue, blood vessel coagulation and uniform heating of the skin and subcutaneous tissue as well potential 3D-skin tightening. Due to histologic observation of connective tissue in the treatment area there is a significant change in its structure with coagulation of the deep, dermal collagen. After treating the subcutaneous fibrous and dermal matrix with RFAL the results are impressive in 3D-soft tissue contraction and contours.

Dr. Bratani has no disclosures and interests with Invasix Ltd.

2 Day Awake Tumescent Laser Liposuction Course: Dr. Thomas Young

Dr. Thomas E. Young's available training dates for 2012 for his CME Awake Tumescent Laser Liposuction Course Beginner with hands On "6 Steps to Good Results"

Includes laser, ultrasound and water jet liposuction devices and techniques.

 This 2 day course provides 17.0 AMA PRA Category 1 Credit(s)™ to course attendees from AKH, Inc. - Advanced Knowledge in Healthcare. This 2-Day course is beginning level training that includes didactic discussion, observation and hands-on cases.

Course dates for 2012:

• March 32-24
• June 15-16
• August 17-18
• October 19-20
• December 14-15

Visit the registration page here

Many physicians across the U.S. have spent time with Dr. Thomas E. Young learning the various techniques and aspects of awake tumescent liposuction.

If you are a licensed physician and are interested in beginner to intermediate level training in Laser, Ultrasound, Water Jet liposuction, or tumescent anesthesia, Dr. Young is offering a two-day program with hands-on experience.

If you are interested in training with Dr. Young, please complete the form below for submission and specify the type of training you are looking to achieve and what dates you are interested in.

One of our staff members will contact you to discuss with you any questions you may have, available dates, and the needs of your visit.

The fee for this two-day course is $4995.00.

Learning Objectives: Upon completion of the educational activity, participants should be able to:

1. Describe the process involved during the patient's first and second Awake Tumescent Liposuction consultations;
2. Discuss the risks associated with Laser, Ultrasound and Water Jet Liposuction & Tumescent Anesthesia;
3. Demonstrate proper marking and positioning of the patient for Awake Tumescent Liposuction;
4. Compare average tumescent infiltration volumes for abdomen, waist, arms, and thighs;
5. Describe symptoms of lidocaine toxicity;
6. Describe the functions of various lipolysis devices, power outlets, wavelengths, and areas to be treated during the liposuction procedure;
7. Demonstrate basic techniques relating to grid marking, hand piece manipulation, fanning, speed and clinical endpoints;
8. Demonstrate fat harvesting through appropriate suction techniques;
9. Discuss patient post-operative experiences and instructions;
10. Delineate the necessary equipment needed for liposuction and emergency situations;
11. Demonstrate the proper technique for mixing tumescent anesthesia.

Liposuction Patient Selection

Selecting Liposuction Patients

Cosmetic practices spend large amounts of time planning their clinic, what services they are going to offer, and advertising to get patients interested enough to come in and purchase services. Unfortunately, practices do not spend enough time identifying good liposuction candidates after they walk in the door. As a consequence, patient safety, outcomes, and patient satisfaction can greatly be affected. To be a successful surgery center or medical spa, and eliminate possible liability, you must be able to identify which type of patients you want signing up for surgical procedures.  

Cosmetic patients are for the most part kind, caring and wonderful people. When you are conducting services and they feel comfortable with you, they will tell you all about their marriage, divorce, kids, job, etc. There are simply a plethora of good patients. Unfortunately, there are a few cosmetic patients who may be at the wrong point in their lives for undergoing cosmetic surgery. When patients come in for services such as Liposuction, you are entering a relationship with these patients that will extend through the surgery and through follow ups and aftercare. The ideal relationship you want to create is one of harmony, happiness, peace, instead of dysfunction and high-stress.  So how do you identify what patents might be best for liposuction?  

It all starts even before the consult. If a patient comes in to your office and is rude to the receptionist or other staff, be cautious and understand that this is a person your office will have to interact with many times over the course of their treatment(s).  If they are not happy with minor everyday events, they probably will be very unhappy recovering from surgery and in a binder for one month. During the consult, a patient can sometimes be harboring some unrealistic expectations due to media, false advertising, and their own ideas. This is where the patient care coordinator or Surgeon needs to educate the patient on what he/she can expect as an outcome.  Sometimes it’s a joke when a patient says, “I want to look like J. Lo in the butt and Dolly Parton in the breasts.”  Other times a patient is serious and you need to explain what is and is not possible with their body type.  Showing your before and after pictures during this time of previous cosmetic patients who have the same body shape is important so patients can form their own picture of what they can expect with their results.  

Another red flag is if the patient has had multiple plastic surgeries and is still not happy with their body or the patient believes their abdominal fat is sticking out over their jeans t and you cannot visually see that for yourself. Such a patient may be suffering from body dismorphic disorder (BDD).  BDD is observed in as many as 10% of all cosmetic patients. Signs and symptoms of BDD include a strong belief that a patient has an abnormality or defect in their appearance that makes them ugly, feeling extremely self-conscious, avoiding social situations, refusing to appear in pictures. Patients with body dismorphic disorder may focus on a body feature they want to change and then focus on another part in the future (picture Heidi Pratt). Please realize you can never make possible BDD types of patients happy and refer suspected BDD patients to a mental health provider for treatment. If you are in doubt, it might be a good idea to refer your patient to a mental health professional for clearance before moving forward with cosmetic surgery.

Sometimes patients come in with an urgency to get surgery performed “right away.” The sense of hurry needs to be explored as this could be related to a divorce or other catastrophic event that may not be in the patient’s best interest nor lend the patient’s full dedication to a surgical procedure. It’s always a good idea to wait until a patient is in a “good place” in their lives.  Further, patients, who are excessively obese, have psychological or emotional problems, history of drug abuse and unrealistic treatment goals are also not good candidates. It is mandatory to perform a comprehensive preoperative consultation including a screening questionnaire to identify patients who are appropriate candidates. A liposuction consultation should cover the risks, goals, anticipated results, and expected postoperative care. All patients’ questions should be answered and an assessment should be made as to whether or not the patient is the right candidate for surgery.

The ideal patient for cosmetic procedures is content, with a pleasant disposition and not dealing with any life changing problems when they come into your office. They are realistic about their expectations and basically feel good about themselves but have an area or two that is troublesome. Patients need to be made aware that liposuction is strictly a body-contouring procedure and should never be viewed as a method of weight loss or an alternative to diet and exercise. Patients should be selected with localized adipose deposits that will not go away despite diet and exercise. As in all cosmetic procedures, proper patient selection is vitally important in ensuring satisfactory results after liposuction.

Wendy Hovorka B.S.  M.L.A.  Valley Laser Surgical Solutions Vein Center,  McAllen, Texas

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Zeltiq vs. Zerona

Zerona and Zeltliq booth promise to freeze fat and shed pounds well enough that it would be a slam dunk to add these treatments to your medical spa or laser clinic. But do they work?

Here's some commentary from the NY Times Story

Doctors and patients alike are excited by the prospect of having new technologies that can attack fat without surgery. It is too early, however, for consumers to know how effectively either device works. That hasn’t stopped men and women unhappy with back fat and muffin tops from paying thousands for treatment in recent months...

...Zeltiq Aesthetics, based in Pleasanton, Calif., is a cautious wallflower that aims to get the data behind its device approved by the F.D.A. before it makes too rowdy an entrance to the party. Its slogan is “More Science. Less Fat.”

Meanwhile, Erchonia Medical, based in McKinney, Tex., has aggressively marketed its Zerona laser as “the first non-invasive body contouring procedure to effectively remove excess fat” even though it has yet to receive F.D.A. clearance to promote this use. (In general, the F.D.A. must sanction a medical device for a specific use before a company can market that use. But doctors are free to use devices off label. )

Nonetheless, a brochure for Zerona states patients can collectively “lose up to 9 inches without the pain or down time of surgery.” Nationwide, medical spas, chiropractors, cosmetic surgeons, plastic surgeons and dermatologists now offer Zerona for $1,700 to $3,800 for six sessions. Part of the reason the device has made inroads during these strapped times is that doctors don’t buy it outright, but pay per use.

So how is Zerona supposed to work? The low-level laser causes “fat to seep out of a cell, almost like a balloon being struck by a needle,” said Ryan Maloney, medical director for Erchonia Medical. The fat enters the lymphatic system, and is eventually used as energy, Dr. Maloney said.

Zeltiq uses controlled cooling to target and eliminate fat cells, a process called selective cryolipolysis. Skin isn’t damaged, but subcutaneous fat, which is more sensitive to targeted cold, begins a two-month death march soon after exposure to Zeltiq.

Doctors on the advisory board for Zeltiq Aesthetics have put the word out about it on television news segments. But at this stage, the company itself has been careful not to promote its device directly to consumers since its F.D.A. clearances for, say, pain reduction during dermatologic treatments don’t encompass fat reduction. Gordie Nye, the chief executive, sent an e-mail message declining to be interviewed for this article.

The company has clinical data that has been submitted to the F.D.A. for approval, according to a few doctors who were principal investigators. Data relayed at a meeting of the American Society of Dermatologic Surgery showed a 22 percent reduction of the fat layer as measured by ultrasound.

Erchonia Medical has published the results of its clinical trial in Lasers in Surgery and Medicine. Thirty-five patients in the treatment group lost an average of 3.5 inches total in hips, thighs and their midsection according to the company’s clinical trial. The company has promoted Zerona as “a new body-sculpting procedure designed to remove fat and contour the body without invasive surgery.” But the F.D.A. has not sanctioned marketing this use. It has cleared the Zerona laser for pain reduction 24 hours after breast augmentation or as a way to decrease the pain associated with recovering from liposuction.

In general, Karen Riley, a spokeswoman for the F.D.A., said “it is considered off-label promotion if you are marketing to the public a use that has not been cleared.” Steven Shanks, the president of Erchonia Medical, said, “Since we use the exact same power for liposuction and breast augmentation, we self-certified the device.” He said that in January 2009, the company had applied for a 510K clearance — which is based on the notion that an older device is substantially equivalent to a new one — and had yet to receive it. (Such a delay is atypical, Ms. Riley said, adding, “most 510Ks are cleared within six months.”)

Last month, Dr. Robert B. Seltzer, a dermatologist in Pasadena, Calif., ran an advertisement in The Los Angeles Times for an informational seminar that called Zerona “the holy grail.” In a phone interview, however, he said, “I’m not 100 percent convinced” and planned to return his Zerona if he didn’t continue seeing results in his patients. (So far 5 out of 6 have been pleased.)

After reviewing Erchonia Medical’s clinical study, Dr. Brian M. Kinney, a plastic surgeon in Los Angeles, said, “I can’t prove that it works.” His concerns are that the tape measure method of gauging circumferential changes “isn’t consistently reliable.” What’s more, study participants and the placebo group were assessed only two weeks after their last treatment, not long enough to measure adequately whether results last.

Dr. Kinney doesn’t have a Zerona or a Zeltiq cooling device, though in the case of the latter, he said, “it is well documented that freezing fat tissue aggressively enough can lead to fat necrosis,” or, fat dying, over a few months.

Patient selection for any body contouring procedure is crucial, said Dr. Jeffrey M. Kenkel, vice chairman of plastic surgery at the University of Texas Southwestern Medical Center in Dallas. Dr. Kenkel, who recently replicated results of Zerona’s clinical trial in 12 of his patients, doesn’t offer Zerona to obese patients, or to ones who have had surgery in the area they want treated. “It’s critical to be evaluated by a doctor,” he said.

Success is also dependent on diet and exercise, he said. If you’re sedentary and not eating healthy food, he said, then once fat is leaked after Zerona treatments, “your body will just store it again.”

How the body rids itself of fat, and how quickly, after any noninvasive body slimming procedure is unclear, said Dr. Lawrence S. Bass, a plastic surgeon in Manhattan who started using a Zeltiq device last July. That includes, he said, forthcoming devices like UltraShape and LipoSonix, which employ ultrasound waves to single out fat. It’s a “sticking point with the F.D.A. with all these things,” he said. Dr. Bass was not a clinical investigator for Zeltiq, but he said, “I’m convinced both on the science and clinical experience, it’s able to eliminate fat noninvasively.”

Nadine Tosk, a publicist for Zeltiq, explained that the rollout of the device was “very limited right now.” Dr. Jeffrey Dover, a dermatologist in Chestnut Hill, Mass., who advises Zeltiq and participated in its clinical trial, said a few board-certified plastic surgeons and dermatologists were “handpicked” because “we know they do good work.” Restraint is key, he said, because a doctor could apply Zeltiq to “the same spot” in the same day, which isn’t how it’s meant to be used. Hourlong treatments are best spaced out by two months, said Dr. Dover, who charges $700 per spot.

That said, a doctor with a Zeltiq device isn’t hard for patients to find. More than five dozen “Zeltiq specialists” can be found by ZIP code at body-contouring.com, which is a patient guide not sponsored by manufacturers of body-slimming devices. Dr. Jason N. Pozner, a plastic surgeon in Boca Raton, Fla., appears topless in a YouTube.com video that shows his left flank being suctioned and cooled as he reads his Kindle. (His partner, Dr. David J. Goldberg, was an investigator for Zeltiq.)

Ms. Bonvouloir hasn’t given up on Zerona. Recently, she paid $2,100 for six treatments at Parker Day Spa in Parker, Colo. This time, each session is followed by a massage that supposedly speeds the release of fat. “I still have three more sessions,” Ms. Bonvouloir wrote in an e-mail message. “Again, they are convinced I will lose some inches. I’d like to know when!!!”

Not exactly a raging endorsement but that shouldn't come as a surprise. Is anyone we know having success with Zerona treatments? Is Zeltiq or Zerona going to cause trouble for Thermage?