The Next Frontier: Stem Cell Enhanced Treatments

What was once considered and debated as a highly controversial topic, stem cells are being looked at in a completely different light.

We've always known that the use of stem cells were the cutting edge of medical science, but only now has the non-aesthetic arena begun to recognize and promote to the consumer the advantages stem cells have in the aesthetic industry.

In the Northeast Winter-Spring edition of New Beauty Magazine, the use of fat-derived stem cells is discussed in terms our patients and future patients can understand. The article states that plastic surgeons long discovered that fat harvested from liposuction procedures contain a vast amount of stem cells. And, while this was commonly known by many, exactly how to extract those stem cells and apply them is the one controversial factor faced by practitioners. The success of stem cell transfer is highly dependent on the techniques use for harvesting and processing, and other additives applied such as epithelial cells and growth factors. In the article Dr. Renato Calabria states "it's not as easy as just taking some fat and putting it where it's needed. This is a multistep procedure that is technique-dependent."

Regardless, physicians are embracing this fountain of youth and are researching and experimenting various techniques and applications to promote fuller breasts and buttocks, smoother skin by reducing pore size, improved skin tone and clarity, and stem-cell enriched fat transfer face lifts to name a few, and consumers are beginning to seek out those physicians who are pioneering the practice.

If this is not a band wagon you are contemplating jumping on, it definitely should be an area of aesthetics you will want to follow. As the word is now reaching consumers, ten-to-one they will be presenting you with questions.

Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

Submit a guest post and be heard.

Plastic Surgery Trends For 2010

The Consumer Guide to Plastic Surgery thinks they know what’s in store for cosmetic medicine in 2010, from how the newly proposed “Botax” could affect your self-improvement plans to which new products will come to market. Here's what you might see in 2010:

Even More Botox-Like Products Will Come to Market
First there was Botox Cosmetic; then 2009 brought the Botox alternative Dysport. In 2010, expect to see a few more Botox rivals, including a topical form of the popular wrinkle relaxer and at least one more injectable. A couple of injectable Botox cousins are in development, but PurTox will likely be the next to get a nod from the Food and Drug Administration (FDA). The main difference in these injectables seems to be how long the results last and how quickly the products start to work on your crow’s feet.

Fat Injections to the Breast Will Be Used Cosmetically
After being condemned by plastic surgery associations, fat injections to the breast were deemed OK for "touch-ups" after breast reconstruction in 2008. But these once controversial injections may soon play a role in cosmetic breast augmentation. Taking fat from a part of the body where there is too much (your thighs or butt, for example) and injecting it into your breasts where there is too little, may replace the need for breast implants when done in conjunction with a breast lift. Some kinks still need to be worked out, but fat injections to the breast are likely here to stay.

Surgeons Will Invent – and Perfect – Body Contouring Surgeries to Follow Massive Weight Loss
More and more people are undergoing bariatric surgery to lose weight, only to be left with hanging fat and flab in highly visible areas. As plastic surgeons put on their thinking caps to better address these issues, expect to hear about many new procedures, including the corset trunkplasty. This new surgery targets above-the-belly-button flab, to recreate an hourglass silhouette in formerly obese women and get rid of love handles in men who have lost massive amounts of weight. This area has been ignored by many traditional body contouring procedures that target the lower abs, buttocks and/or thighs. We will hear more about corset trunkplasty and other innovative body contouring procedures in 2010.

Fat Freezing Heats Up in 2010
Fat freezing (or cryolipolysis) may give liposuction a run for its money in the coming years. This technology works by freezing fat cells and breaking them down. Zeltiq is in clinical trials now, and results look promising. Stay tuned.

Cohesive Gel Breast Implants Receive FDA Approval
These so-called "gummy bear implants" have been making their way down the pike for some time, and they just may get the long-awaited FDA nod in 2010. Filled with cohesive silicone gel, these leak-resistant implants – used in Europe and Brazil – are being studied in the United States. Gummy bear implants have the positive attributes of silicone gel, but the gel doesn't migrate. This is a good thing, because if the shell should fail, the gel wouldn’t leak into surrounding tissue.

Lipodissolve Study Results Stun Skeptics
Lipodissolve, an experimental "fat-melting" technology, is being billed as a non-surgical alternative to liposuction. Also called mesotherapy, lipodissolve is performed via injection of a cocktail of chemicals into muffin tops, saddlebags, love handles and other trouble spots to dissolve fat cells. Critics were outspoken, which is why the American Society for Aesthetic Plastic Surgery started a rigorous scientific study of lipodissolve, using standardized ingredients. And while even the trialists were skeptical at first, and the final results have not been tallied, it works. The study results – to be released in 2010 – may encourage many doctors to offer lipodissolve. Still, lipodissolve is only for small areas of localized fat and will never replace liposuction.

“Botax” Will Raise Eyebrows
A health care reform bill will be passed in 2010, and it just may include a five percent tax on all cosmetic surgery procedures (except those deemed medically necessary). Let’s say that breast augmentation with implants costs $10,000 in 2008; add a five percent levy, and the total becomes $10,500 in 2010. With business already down, most plastic surgeons are up in arms about the Botax. There is also fear that taxing cosmetic surgery in the U.S. will encourage many to seek out services abroad or through unskilled providers who offer procedures at cut rates in America, compromising their safety.

Surgery-Free Tummy Tucks Trim Waistlines
Non-invasive body contouring procedures such as Thermage, VelaShape, UltraShape, LipoSonix and Zerona will continue to grow in popularity in 2010. Once reserved for the face,

Thermage also uses radio waves to lift and firm skin on your stomach, knees, arms, legs, hands or butt. VelaShape employs bipolar radiofrequency energy to reduce the size of the fat cells, along with infrared heat to tighten the skin. And Zerona uses a “cold” laser to painlessly zap the fat cells beneath your skin. These technologies (and more) may give tummy tucks and lower body lifts a run for their money in 2010.

Face Transplants Face Upsurge
Face transplant surgery was once nothing more than fodder for sci-fi thrillers like the movie Face/Off, but they are now becoming a reality. Eight have been performed so far in the United States and abroad, but there will likely be many more as reconstructive facial surgeons further hone their skills and work toward perfecting their highly complicated techniques.

Minimally Invasive Cosmetic Procedures Experience Rebirth
As our economy starts to show signs of life again, more people may opt for cosmetic surgery procedures, reversing the steep decline of the last two years. Don't expect the numbers to reach their record highs anytime soon, though. There will likely be a slight increase in plastic surgery procedures – especially minimally invasive ones such as injectables that allow people to put off more invasive (and expensive) procedures like face lifts until they really need them (and can better afford them).

Consumer Guide to Plastic Surgery is published by Ceatus Media Group LLC, an online provider of health information and physician directories. Consumer Guide to Plastic Surgery is a registered trademark of Ceatus Media Group LLC. http://www.yourplasticsurgeryguide.com

Cosmetic Surgeons enlist patients to fight the Botox Botax.

Cosmetic surgeons are asking for patient help to fight the Botox Botax. Here's what the ASDS (American Society for Dermatologic Surgery) is giving it's members to solicit the support of Botox consumers: Here's the form.

The U.S. Senate health care reform bill  (Patient Protection and Affordable Care Act) contains a proposed 5 percent tax on "elective cosmetic medical procedures."  While this may look like an attractive option to Senators looking for ways to pay for health care reform, we know that:

• Cosmetic medical procedures taxes are an unreliable and risky revenue source, which has proved to be a failure at the state level;
• A tax on cosmetic surgery discriminates against working women;
• The definition of cosmetic procedures is arbitrary and almost impossible to administer; and
• enforcement would necessitate review of patient medical records by tax collectors, a clear invasion of privacy.

Please enter your zip code below to be connected to an automatic email system which allows you to send a quick message to your Senator asking him/her to vote against this tax.

I've received an number of emails about this over the last 48 hours. Is anyone worried that this 'Botax' will hurt your medical spa, skin clinic or cosmetic practice?

Medical Spa MD: Burned out & depressed plastic surgeons more likely to commit medical errors?

Surgeons who are burned out or depressed are more likely to say they had recently committed a major error on the job, according to the largest study to date on physician burnout.

The new findings suggest that the mental well-being of the plastic surgeon is associated with a higher rate of self-reported medical errors, something that may undermine patient safety more than the fatigue that is often blamed for many of the medical mistakes.

Although surgeons do not appear more likely to make mistakes than physicians in other disciplines, surgery errors may have more severe consequences for patients due to the interventional nature of the work. Some estimate that as many as 10 percent of hospitalized patients are impacted by medical errors.

"People have talked about fatigue and long working hours, but our results indicate that the dominant contributors to self-reported medical errors are burnout and depression," said Charles M. Balch, M.D., a professor of surgery at the Johns Hopkins University School of Medicine and one of the study's leaders. "All of us need to take this into account to a greater degree than in the past. Frankly, burnout and depression hadn't been on everybody's radar screen."

Nine percent of the 7,905 surgeons who responded to a June 2008 survey commissioned by the American College of Surgeons for a study led by researchers from Johns Hopkins University School of Medicine and the Mayo Clinic reported having made a major medical mistake in the previous three months. Overall, 40 percent of the surgeons who responded to the survey said they were burned out.

Researchers asked a variety of questions, including queries that rated three elements of burnout -- emotional exhaustion, depersonalization and personal accomplishment -- and others that screened for depression.

Each one-point increase on a scale that measured depersonalization -- a feeling of withdrawal or of treating patients as objects rather than as human beings -- was associated with an 11 percent increase in the likelihood of reporting an error. Each one-point increase on a scale measuring emotional exhaustion was associated with a 5 percent increase.

Mistakes also varied by specialty.  

Surgeons practicing obstetrics/gynecology and plastic surgery were much less likely to report errors than general surgeons.

Researchers acknowledged the limitations of self-reporting surveys, saying they couldn't tell from their research whether burnout and depression led to more medical errors or whether medical errors triggered burnout and depression among the surgeons who made the mistakes.

The results are being published online on November 23 in the Annals of Surgery and will be published in the printed journal in an upcoming issue.

Notably, the research shows that the number of nights on call per week and the number of hours worked were not associated with reported errors after controlling for other factors.

"The most important thing for those of us who work with other surgeons who do not appear well is to address it with them so that they can get the help they need," says Julie A. Freischlag, M.D., chair of the Department of Surgery at the Johns Hopkins University School of Medicine and another of the study's authors.

via sciencedaily.com

Perhaps the most relevant items here are the decreased reporting of problems by plastic surgeons and the fact that 'depersonalization' has entered the discussion.

I'm really curious about what plastic surgeons think of this study.

Do it yourself Botox? ABC News wants to talk to you.

Have you tried do-it yourself plastic surgery or home Botox injections?

In tough economic times, many try to cut costs, including in their beauty regimen. Despite the risks, some people have decided to skip the doctor -- and obtain and self-administer cosmetic treatments.

If you have self-injected products like Botox, Restylane, Juvederm, silicone, and other substances, 20/20 would like to hear your story.

Please fill out the form below, including information about your experience, and a producer may be in contact with you.

You can tell ABC all about it here.

The Hidden Dangers of Beauty

Normally, I barely listen to the radio when driving in my car, but today on the John Tesh Radio Show (Sunday) my ears perked up when he started to discuss the hidden "dangers" of young girls using makeup too early. Dangers in makeup? Really?

The broadcast was entitled "The Ugly Truth About Young Girls Wearing Makeup". The line that grabbed my attention was "the sooner your daughter starts wearing makeup, the sooner it might kill her!" This was a quote coming from Stacy Malkan, a cosmetic expert who wrote the book Not Just A Pretty Face: The Ugly Side of the Beauty Industry. According to the John Tesh website, Malkan states "by the time most North American girls become teenagers, many have a daily make-up ritual that includes lipstick, mascara, eyeliner, nail polish and perfume, not to mention skin lotion, shampoo, conditioner, and hair color treatments." She goes on to say "in fact, experts estimate that a typical young girl now walks around with at least a dozen layers of beauty products on her body! As the makeup layers add up, so does her exposure to dangerous chemicals, and that’s very bad news for a young girl’s health."

Apparently the culprits are chronic exposure to parabens and phthalates which have been found to disrupt hormone levels during adolescent years which may result in early puberty. Malkin continues to state "one study found that HALF [sic] of all North American girls now begin to show signs of breast development by the age of 10 – which is more than two years sooner than females from our grandmother’s generation. Other studies link those unusual hormone levels to a higher depression rate among young girls, and a higher risk for breast cancer! That’s why experts recommend women of all ages find out exactly what chemicals go into their makeup."

There is a website suggested for reference to verify the ingredients in certain beauty products and cosmetics and it is called the Skin Deep Cosmetic Safety Database. I was instantly intrigued and raced to my Mac when I got home to give it a try! Here's how my products scored:

(Scale: 0-2=Low hazard; 3-6 Moderate Hazard; 7-10 High Hazard).

• Cleanser: 3 (moderate hazard) 
• Toner: 7 (high hazard) 
• Moisturizer: 5 (moderate hazard) 
• Eye Cream: 6 (moderate hazard) 
• Lip Cream: 7 (high hazard) 
• SPF 30: 7 (high hazard) 
• Concealer: 4 (moderate hazard) 
• Foundation Primer: 5 (moderate hazard) 
• Foundation: 9 (high hazard) 
• Loose Powder: 5 (moderate hazard) 
• Blush: 7 (high hazard) 
• Bronzing Powder: 8 (high hazard) 
• Eyeshadow: 7 (high hazard) 
• Mascara: 8 (high hazard) 
• Lipstick 6: (moderate hazard) 

My gosh, I'm a walking carcinogen!!! Like most women, I use an array of products, from medical grade like Obagi, spa grade like SkinCeuticals, high end department stores like Merle Norman, Estee' Lauder and Laura Mercier, right down to drug store brands like Maybelline. It seems no company's products were completely safe. And, makeup is just the beginning for young girls!

More and more young girls are taking their skin care regimens to the next level by having microdermabrasion treatments and chemical peels, with some escalating to laser and injectable therapies. Putting aside the various protocols for acneic adolescents, there has actually been a rise in the U.S. of young girls undergoing laser hair removal, photo facials, dermal filler procedures, even laser lipolysis. Where do we draw the line as clinicians? 21? 18? 16 with parental consent? I know in our medical spa we have been approached by parents inquiring as to what our policy is for treating adolescents for non-medical related conditions. The number one request is laser hair removal for ethic skin types predominately for excess facial hair. Many clinicians feel it is a low-risk procedure which can lift a child's self-esteem. Some clinicians disagree and feel a child is much too young to be exposed to laser therapies.

I'm not a laser expert and am uncertain as to if many aesthetic equipment manufacturers have performed clinical trials on adolescents for laser procedures (other than port wine stains). I'm more apt to believe the answer to this questions will become clearer as the years go on and by remembering the first rule is to "do no harm".

That, and to throw away your teenager's makeup!

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

Submit a guest post and be heard.

Plastic Surgery & Cosmetic Surgery Trends For 2008

The ASAPS (American Society for Aesthetic Plastic Surgery) reports 10.2 Million Cosmetic Procedures in 2008. The Aesthetic Society, after collecting multi-specialty procedural statistics since 1997, says the overall number of cosmetic procedures has increased 162 percent since the collection of the statistics first began. The most frequently performed nonsurgical procedure was Botox injections and the most popular cosmetic surgical procedure was breast augmentation.

Top nonsurgical cosmetic procedures among men and women in 2008:
Botox - 2,464,123
Laser Hair Removal - 1,280,964
Hyaluronic Acid (including Hylaform, Juvederm, Perlane/Restylane) - 1,262,848
Chemical Peel - 591,808
Laser Skin Resurfacing - 570,880

Top surgical cosmetic procedures among men and women in 2008:
Breast Augmentation: - 355,671
Lipoplasty (liposuction) - 341,144
Eyelid Surgery - 195,104
Rhinoplasty - 152,434
Abdominoplasty - 147,392

source: ASAPS press release

“For the first time in the twelve years these statistics have been collected liposuction is a runner up in popularity to breast augmentation. There is no doubt that this turnabout will generate discussions in the medical community and the public at large,” Alan Gold, MD, Aesthetic Society president, reflects that “changes in fashion, i.e. décolletage baring styles, might be a factor behind this change.”

TRENDS AND DEMOGRAPHIC DATA

Top surgical and nonsurgical cosmetic procedures among men and women in 2008:
Surgical	# procedures	Nonsurgical	# procedures
Breast Augmentation:	355,671	Botox	2,464,123
Lipoplasty (liposuction)	341,144	Laser Hair Removal	1,280,964
Eyelid Surgery	195,104	Hyaluronic Acid (including Hylaform, Juvederm, Perlane/Restylane)	1,262,848
Rhinoplasty	152,434	Chemical Peel	591,808
Abdominoplasty	147,392	Laser Skin Resurfacing	570,880

Top cosmetic procedures for WOMEN:
Surgical	# procedures	Nonsurgical	# procedures
Breast augmentation	355,671	Botox	2,239,024
Lipoplasty	309,692	Hyaluronic Acid (including Hylaform, Juvederm, Perlane/Restylane)	1,200,420
Eyelid surgery	166,426	Laser Hair Removal	1,101,255
Abdominoplasty	143,005	Chemical Peel	554,492
Breast Reduction	139,926	Laser Skin Resurfacing	532,008
____________________________________________________________________________________________________
Women had almost 92 percent of cosmetic procedures. The number of procedures (surgical and nonsurgical) performed on women was over 9.3 million, a decrease of over 11 percent from the previous year. Surgical procedures decreased 15 percent; nonsurgical procedures decreased by 11 percent. Since 1997, surgical procedures increased 104 percent, while nonsurgical procedures have increased 233 percent.

Top cosmetic procedures for MEN:
Surgical	# procedures	Nonsurgical	# procedures
Liposuction	31,453	Botox injection	225,099
Rhinoplasty	30,174	Laser hair removal	179,708
Eyelid Surgery	28,678	Hyaluronic Acid (including Hylaform, Juvederm, Perlane/Restylane)	62,428
Gynecomastia	19,124	IPL laser treatment	46,887
Hair transplantation	18,062	Microdermabrasion	39,824
____________________________________________________________________________________________________
Men had over 8 percent of cosmetic procedures. The number of procedures (surgical and nonsurgical) performed on men was over 800,000 a decrease of over 21 percent from the previous year. Surgical procedures decreased 18 percent; nonsurgical procedures decreased 22 percent. Since 1997, surgical procedures have decreased over 15 percent while nonsurgical procedures have increased 239 percent.

Frequency of cosmetic procedures by AGE GROUP:
% of total	Age	# procedures	Top surgical procedure	Top nonsurgical procedure
45%	35-50	4.6 million	Liposuction	Botox
26%	51-64	2.7 million	Eyelid Surgery	Botox
22%	19-34	2.2 million	Breast augmentation	Laser Hair Removal
6%	65 and over	634,667	Eyelid Surgery	Botox
2%	18 and under	160,283	Rhinoplasty	Laser Hair Removal

Racial and Ethnic Distribution

Racial and ethnic minorities accounted for 20 percent of all cosmetic procedures in 2008. Hispanics again led minority racial and ethnic groups in the number of procedures: Hispanics, 8 percent; African-Americans, 6 percent; Asians, 4 percent; and other non-Caucasians, 2 percent.

Location and Fees
Over fifty-three percent (53 percent) of cosmetic procedures in 2008 were performed in office-based facilities; 26 percent in freestanding surgicenters; and 19 percent in hospitals. Americans spent just under $12 billion on cosmetic procedures; $7.2 billion was for surgical procedures, and $4.6 billion was for nonsurgical procedures.

RealSelf.com Doesn't Want You Doctor

It seems that if you're not a boarded plastic surgeon or cosmetic derm, you're no longer wanted to participate on RealSelf.com.

I guess that eveyone who didn't identify themselves as a boarded Derm or Plastic found their account uncerimoneously deleted without warning. Nice. All the docs who worked to answer questions evidently weren't answering them 'correctly' or to Real Selfs satisfaction and they're out.

There's some lively discussion on the physician forums: RealSelf.com has kicked out all non-core physicians!

Thermage changes its name to Solta Medical

Thermage Inc., has changed its name to Solta Medical Inc. and unveiled a new logo, along with a new logo and website for the Thermage product.

Theremage the company bought Reliant Technologies, maker of the laser resurfacing device Fraxel, for $87.5 million in a cash and stock deal last year. The new ticker symbol will be "SLTM" and is listed on the Nasdaq.

The design of the new Thermage site a fine change from the stagnant templates that most of the IPL and laser companies use. We'll have to see how it works for them.

From the Solta press release:

Thermage, Inc. (NASDAQ: THRM) announced that effective today it has changed its corporate name to Solta Medical, Inc. At the open of the NASDAQ exchange this morning, Solta Medical, Inc. will begin trading under the symbol “SLTM.”

"The name and ticker symbol changes are a great start to the New Year and a key milestone in the integration of the acquisition of Reliant Technologies, Inc. The new company combines the industry’s two leading brands, Thermage® and Fraxel®, under a new corporate name that will now form a global leader in aesthetic energy devices,” said Stephen J. Fanning, chairman of the board, president and CEO. “Solta Medical will focus on providing superior anti-aging solutions for patients and physicians by offering the gold standard of care for tightening, contouring and resurfacing of the skin with Thermage and Fraxel treatments.”

Solta Medical also announced the expansion of its industry-exclusive customer loyalty program which allows physicians to lock-in preferred pricing for Thermage and Fraxel treatment tips along with other preferred customer benefits to help physicians grow their practices and increase practice profitability.

“Thermage and Fraxel are the strongest aesthetic device brands available to physicians today,” said Suzanne Bruce, MD, dermatologist and president of Suzanne Bruce and Associates in Houston, Texas. “By combining these two brands into one company and expanding the customer loyalty program, Solta Medical is opening a number of new opportunities for doctors to conveniently and cost-effectively access a full suite of safe and effective anti-aging solutions.”

Should I open a medical spa?

Below is an example of the many emails I receive from doctors in residency. Many of these types of questions are from doctors in Family Practice but there are also quite a few from Plastic Surgery and Dermatology residents who don't want to be a lacky forever.

I've removed the name from the email but the questions are common so I thought I'd post this and see what sort of collective wisdom you more experienced doctors have for an about-to-be-graduate.

I am currently in my first year of Residency in Family Medicine. I am very interested in Aesthetic Medicine and in opening up a Cosmetic Spa when I am finished with my residency training. What are your suggestions in terms of how feasible this will be for me? Do I need to work for a few years as a general practioner before being able to proceed in this direction, or do I have the opportunity to dive straight into a cosmetic spa when I finish my training. I am hoping to use my elective time to learn cosmetic procedures. Any advice would be greatly appreciated.

Thank you,
VJ, MD
University of Oklahoma

Dermacare sues everyone on Medical Spa MD?

It appears that Dermacare has thrown in the towell regarding it reputation.

I received this email from Dermacare and it's CEO Carl Mudd regarding a suit that Dermacare has filed. Since this is the first contact I've ever had with Dermacare, I'm a little surprised. It makes me wonder what's been going on on that Dermacare thread that has 700 comments. 

Rather than engage in a back and forth or aim for clarity, which is what I would have recommended, or complaining to me that some of the remarks have crossed a line, (I have actually taken down many comments if they contain profanity directed at any specific individual.), Dermacare and it's CEO Carl Mudd have actually gone and filed suit. (I also received a PDF of the suit naming multiple John and Jane Does.)

Here's the email: 

VIA E-MAIL AND U.S. MAIL

Jeff Barson
(I've removed my address here)

                Re:         DLC Dermacare, LLC v. John and Jane Does – CV2008-090071

Dear Mr. Barson:

My office represents DLC Dermacare, LLC (“Dermacare”) and its CEO Carl Mudd.  I am writing in regards to the blog that you host located at www.medicalspamd.com .  As you know, you have allowed numerous persons to post information related Dermacare and about Mr. Mudd personally on your site.  The information posted is overwhelming incorrect and has served as a discussion board for Dermacare franchisees to not only discourage potential franchisees from partnering with Dermacare but to also promote the breaching of current franchisee agreements held by many of the bloggers on your site.

The comments that you have allowed to be posted on your site have evolved from mere discussions/complaints into actionable claims against the bloggers and possibly even you personally.  Pursuant to our filing the above referenced complaint we are now seeking the Internet Protocol (IP) address and the Internet Service Provider (ISP) for each of the following bloggers on your site:

• Dermadoc
• Mr. Bob
• Just Another Ex
• Passive Conduit
• Pm
• Jennifer D
• Pengy
• Mr. Freeze
• Bastard Son of Dermadoc
• GH
• Maxwell Smart
• The Clinician
• The Real M. Smart
• John Galt
• George
• Max
• XYZAL
• Christmas
• Maxwell’s Silver Hammer
• The Passive Conduit
• The Riddler & The Joker
• DoubleDermadare You
• Mad Max
• Manic Max
• Mad as Hell in Dermacare Hell
• A current Franchisee
• FreeTheDerm@ yahoo.com
• WPS
• Insider
• Thomas Jefferson, Jr
• TF
• T. Jefferson, Jr.
• The Joker
• Curious
• Mr. X

Please provide the IP address and ISP for each of the above names no later than Friday, January 18^th, 2008.  Should you not provide the requested IP addresses and ISP by this date I will be forced to have you served with a subpoena to obtain this information.  I have included a copy of the lawsuit that was filed in this matter for your files.  If you have comments or questions please direct them to my office.

                  Sincerely,

John N. Skiba

One North Macdonald Road, Suite 201
Mesa, Arizona 85201
Tel. 480.361.5643
Fax 480.704.3071
www.skibalaw.com

You can download the actual PDF of the Suit here.

I wasn't asked to keep any of this confidential so here it is. 

 

So what's Dermacare and Carl Mudd doing?

This is what is know as a CyberSLAPP suite. Basically it's a way of intimidating critics by threatening to find out their identity and hit them with some kind of suit. (read below)

You'll notice that Dermacare and Carl Mudd are demanding that I turn over everyones ISP. For those of you who are not that technically savvy, ISP = Internet Service Provider, which I have absolutely no way of knowing anyway as far as I can tell. The IP address is different. That's a unique identifier and could be used to find out who someone is.

These kinds of suits have become increasingly common as a way of combating free speech on the internet. It used to be that if someone said something unkind, it didn't matter that much since only a few people would hear about it. The net changed all of that and now someone who's unhappy with you or your business can be found by everyone so those whe illicit a lot of negative comments tend to have a rougher go of it.

My guess is that this is intended to intimidate those who may comment in a negative way about Dermacare or Mr. Mudd, and to find out who everyone is. While anonymous speech is protected by the constitution, its still unnerving to have someone you've been talking about know exactly who you are, especially if you're in some kind of business relationship. By filing a real suit against 'everyone' in the form of John and Jane Does, it allows him to issue a legal subpoena to get information. (It's basically a cynical way of using the courts which is why some states like California have laws specifically against this.)

Here are some links about these kinds of CyberSlapp suits and where the law comes down on free speech and other issues around this:

Chilling Effects Clearinghouse: A joint project of the Electronic Frontier Foundation and Harvard, Stanford, Berkeley, University of San Francisco, University of Maine, George Washington School of Law, and Santa Clara University School of Law clinics.

Do you know your online rights? Have you received a letter asking you to remove information from a Web site or to stop engaging in an activity? Are you concerned about liability for information that someone else posted to your online forum? If so, this site is for you.

Defamation
The law of defamation balances two important, and sometimes competing, rights: the right to engage in free speech and the right to be free from untrue attacks on reputation. In practice, the filing or even the threat to file a lawsuit for defamation has sometimes been used as a tool to shut down legitimate comments on the Internet.

John Doe Anonymity
Do you post to a public message boards or discussion areas on websites such as Yahoo, AOL or Raging Bull? Do you use a pseudonym, fake name or a "handle"? Has someone asked the host of the discussion or your ISP to turn over information about you or your identity? If so, then the John Doe/Anonymity section may answer some of your questions.
Topic maintained by Stanford Center for Internet & Society

Protest, Parody and Criticism Sites
The Internet, which offers inexpensive access to a worldwide audience, provides an unparalleled opportunity for individuals to criticize, protest and parody.

The following is long but you'll come away with a much better understanding of what this all means: 

About Defamation:

Question: What are the elements of a defamation claim?

Answer: The party making a defamation claim (plaintiff) must ordinarily prove four elements:

1. a publication to one other than the person defamed;
2. a false statement of fact;
3. that is understood as

a. being of and concerning the plaintiff; and
b. tending to harm the reputation of plaintiff.

4. If the plaintiff is a public figure, he or she must also prove actual malice.

Question: What defenses may be available to someone who is sued for defamation?

Answer: There are ordinarily 6 possible defenses available to a defendant who is sued for libel (published defamatory communication.)
1. Truth. This is a complete defense, but may be difficult to prove.
2. Fair comment on a matter of public interest. This defense applies to "opinion" only, as compared to a statement of fact. The defendant usually needs to prove that the opinion is honestly held and the comments were not motivated by actual "malice." ( Malice means knowledge of falsity or reckless disregard for the truth of falsity of the defamatory statement.)
3. Privilege. The privilege may be absolute or qualified. Privilege generally exists where the speaker or writer has a duty to communicate to a specific person or persons on a given occasion. In some cases the privilege is qualified and may be lost if the publication is unnecessarily wide or made with malice.
4. Consent. This is rarely available, as plaintiffs will not ordinarily agree to the publication of statements that they find offensive.
5. Innocent dissemination. In some cases a party who has no knowledge of the content of a defamatory statement may use this defense. For example, a mailman who delivers a sealed envelope containing a defamatory statement, is not legally liable for any damages that come about from the statement.
6. Plaintiff's poor reputation. Defendant can mitigate (lessen) damages for a defamatory statement by proving that the plaintiff did not have a good reputation to begin with. Defendant ordinarily can prove plaintiff's poor reputation by calling witnesses with knowledge of the plaintiff's prior reputation relating to the defamatory content.

Question: Can an opinion be defamatory?

Answer: No — but merely labeling a statement as your "opinion" does not make it so. Courts look at whether a reasonable reader or listener could understand the statement as asserting a statement of verifiable fact. (A verifiable fact is one capable of being proven true or false.) This is determined in light of the context of the statement. A few courts have said that statements made in the context of an Internet bulletin board or chat room are highly likely to be opinions or hyperbole, but they do look at the remark in context to see if it's likely to be seen as a true, even if controversial, opinion ("I really hate George Lucas' new movie") rather than an assertion of fact dressed up as an opinion ("It's my opinion that Trinity is the hacker who broke into the IRS database").

Question: Is there a difference between reporting on public and private figures?

Answer: Yes. A private figure claiming defamation — your neighbor, your roommate, the guy who walks his dog by your favorite coffee shop — only has to prove you acted negligently, which is to say that a "reasonable person" would not have published the defamatory statement.

A public figure must show "actual malice" — that you published with either knowledge of falsity or in reckless disregard for the truth. This is a difficult standard for a plaintiff to meet.

Question: Who is a public figure?

Answer: A public figure is someone who has actively sought, in a given matter of public interest, to influence the resolution of the matter. In addition to the obvious public figures — a government employee, a senator, a presidential candidate — someone may be a limited-purpose public figure. A limited-purpose public figure is one who (a) voluntarily participates in a discussion about a public controversy, and (b) has access to the media to get his or her own view across. One can also be an involuntary limited-purpose public figure — for example, an air traffic controller on duty at time of fatal crash was held to be an involuntary, limited-purpose public figure, due to his role in a major public occurrence.

Examples of public figures:

• A former city attorney and an attorney for a corporation organized to recall members of city counsel
• A psychologist who conducted "nude marathon" group therapy
• A land developer seeking public approval for housing near a toxic chemical plant
• Members of an activist group who spoke with reporters at public events

Corporations are not always public figures. They are judged by the same standards as individuals.

Question: May someone other than the person who originally made the defamatory statement be legally liable in defamation?

Answer: One who "publishes" a defamatory statement may be liable. However, 47 U.S.C. sec. 230 says that online service providers are not publishers of content posted by their users. Section 230 gives most ISPs and message board hosts the discretion to keep postings or delete them, whichever they prefer, in response to claims by others that a posting is defamatory or libelous. Most ISPs and message board hosts also post terms of service that give them the right to delete or not delete messages as they see fit and such terms have generally been held to be enforceable under law.

Question: Can an ISP or the host of the message board or chat room be held liable for
defamatory of libelous statements made by others on the message board?

Answer: Not in the United States. Under 47 U.S.C. sec. 230(c)(1) (CDA Sec. 230): "No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider." This provision has been uniformly interpreted by the Courts to provide complete protection against defamation or libel claims made against an ISP, message board or chat room where the statements are made by third parties. Note that this immunity does not extend to claims made under intellectual property laws.

Question: Must an ISP or message board host delete postings that someone tells him/her are defamatory? Can the ISP or message board delete postings in response to a request from a third party?

Answer: 47 U.S.C. sec. 230 gives most ISPs and message board hosts the discretion to keep postings or delete them, whichever they prefer, in response to claims by others that a posting is defamatory or libelous. Most ISPs and message board hosts also post terms of service that give them the right to delete or not delete messages as they see fit and such terms have generally been held to be enforceable under law.

About John Doe Anonymity

Question: How is Internet anonymity affected by John Doe lawsuits?

Answer: Often called "CyberSLAPP" suits, these lawsuits typically involve a person who has posted anonymous criticisms of a corporation or public figure on the Internet. The target of the criticism then files a lawsuit so they can issue a subpoena to the Web site or Internet Service Provider (ISP) involved and thereby discover the identity of their anonymous critic. The concern is that this discovery of their identity will intimidate or silence online speakers even though they were engaging in protected expression under the First Amendment.

Question: Why is anonymous speech important?

Answer: There are a wide variety of reasons why people choose to speak anonymously. Many use anonymity to make criticisms that are difficult to state openly - to their boss, for example, or the principal of their children's school. The Internet has become a place where persons who might otherwise be stigmatized or embarrassed can gather and share information and support - victims of violence, cancer patients, AIDS sufferers, child abuse and spousal abuse survivors, for example. They use newsgroups, Web sites, chat rooms, message boards, and other services to share sensitive and personal information anonymously without fear of embarrassment or harm. Some police departments run phone services that allow anonymous reporting of crimes; it is only a matter of time before such services are available on the Internet. Anonymity also allows "whistleblowers" reporting on government or company abuses to bring important safety issues to light without fear of stigma or retaliation. And human rights workers and citizens of repressive regimes around the world who want to share information or just tell their stories frequently depend on staying anonymous – sometimes for their very lives.

Question: Is anonymous speech a right?

Answer: Yes. Anonymous speech is presumptively protected by the First Amendment to the Constitution. Anonymous pamphleteering played an important role for the Founding Fathers, including James Madison, Alexander Hamilton, and John Jay, whose Federalist Papers were first published anonymously.

And the Supreme Court has consistently backed up that tradition. The key U.S. Supreme Court case is McIntyre v. Ohio Elections Commission. http://www.eff.org/Legal/Cases/mcintyre_v_ohio.decision

Question: How do CyberSLAPP plaintiffs discover the identity of anonymous Internet critics?

Answer: CyberSLAPP plaintiffs usually get the personal information you gave an ISP or online message board when you signed up (name, address, telephone number, etc.). Some web sites that host discussion boards might only have your e-mail address, in which case a second subpoeana to the ISP that hosts that address will reveal your identity. In many cases, even more detailed information about your use of the Internet can be obtained; it's important to realize that when you go online, you leave electronic footprints almost everywhere you go. (With advanced knowledge of the Internet, however, there are ways to cover your tracks.)

Question: Don't judges review subpoenas before they are sent to ISPs?

Answer: No. The issuing of civil subpoenas is not monitored by the court handling the case. Under the normal rules of discovery in civil lawsuits, parties to a suit can simply send a subpoena to anyone they believe has information that could be useful. That information doesn't even have to be relevant to the lawsuit, as long as it could possibly lead to the discovery of relevant information. The only way that a court will evaluate an identity-seeking subpena is if either the ISP or the target of the subpoena files a motion asking the judge to block the subpoena. Unfortunately, in practice that rarely happens. That is because these subpoenas usually have a short, roughly 7-day deadline, and because many people never even find out that their Internet data has been subpoenaed.

Question: Isn't my ISP required by law to tell me if someone asks for my Internet-usage records and identity?

Answer: Unfortunately, in practice CyberSLAPP subpenas are rarely challenged becaue ISPs often fail to notify the individual who's personal information is sought. Even when they do, the short deadline (often as little as 7 days) does not provide enough time for the speaker to find and hire an attorney and the attorney to prepare the Constitutional arguments necessary to defend against the subpena.

Question: What is a "motion to quash" a subpoena?

Answer: This is a formal request for a court to rule that your information should not be given to the requesting party. This normally includes the request, plus a legal brief (sometimes called a memorandum of points and authorities) explaining why, by law, your information should not be turned over. Samples of briefs filed in John Doe cases are available at:

EFF Archive, Cullens v. Doe, http://www.eff.org/Privacy/Anonymity/Cullens_v_Doe/
http://www.citizen.org/litigation/briefs/IntFreeSpch/articles.cfm?ID=5801

Question: What should I do if I receive notice that my ISP has received a subpoena for my data?

Answer: First you should decide whether you wish to fight to protect your identity, Internet usage records, or whatever else is being sought. You might want to ask your ISP for a copy of the subpoena if they haven't already provided one. If you decide to fight it, you should inform the ISP immediately, and you may want to request that they delay compliance to give you time to find a lawyer. Then find a lawyer, who will file a motion to have the subpoena thrown out. (If your lawyer can later prove that the lawsuit was frivolous, you may be able to recover legal fees if your state has passed an anti-SLAPP statute.)

Question: What are the typical claims behind a CyberSLAPP suit?

Answer: The most common complaints by CyberSLAPP plaintiffs are defamation, trademark or copyright infringement, and breach of contract. Speech that involves a public figure - such as a corporation - is only defamatory if it is false and said with "actual malice." It also must be factual rather than an expression of opinion. In the US, because of our strong free speech protections, it is almost impossible to prove defamation against a public figure. Trademark and copyright complaints typically claim that defendants have violated intellectual property rights by using the name of a corporation or its products, or by quoting from some of their copyrighted materials such as an annual report. In reality, the First Amendment includes a clear right to criticize and discuss corporations and their products, and the law includes clear exceptions for the "fair use" of protected material for those purposes. Breach of contract suits often involve a claim that anonymous speakers might be employees who have violated a contract by releasing confidential information. Of course, the right to anonymous speech is meaningless if a corporation can unmask your identity at will because you might be an employee breaking a promise of confidentiality.

Question: How do judges decide whether to let a subpoena go forward?

Answer: This is a very new area of the law, and there are few well-established principles. The courts do have a duty to balance the right of anonymity against the need to prevent true defamation. So far there have been both good and bad rulings from judges; fortunately several have ruled that the plaintiff must prove that his case has at least a theoretical chance of prevailing before anonymity can be stripped away. Other cases have established a set of key factors to be used in judging anonymity-stripping subpoenas. In most of these the key factors are 1) that the party seeking the subpoena provide evidence that the identity is needed; 2) that the identity is directly needed for a key element in the case; 3) and that the identity information is not otherwise available to the party seeking it. While not yet firmly entranched in the law, these common-sense principles are clearly the right way to ensure that First Amendment rights are protected while still allowing identity to be revealed when there is a genuine need to do so.

Question: What are some of the important cases in this area of law?

Answer: Important CyberSLAPP cases include Dendrite v. Does, http://www.citizen.org/documents/dendriteappeal.pdf,
Melvin v. Doe, http://legal.web.aol.com/decisions/dlpriv/melvinop.html,
Doe v 2TheMart.com, http://www.eff.org/Cases/2TheMart_case/20010427_2themart_order.html,
Global Telemedia International v. Doe, http://www.casp.net/busted.html. Additional information about these and other cases can be found by searching the Internet or looking on the Web sites listed below.

Question: Can I do anything to help change this situation?

Answer: You can do several things. Be educated about your rights. Find out your ISP's policy on the handling of subpoenas, and encourage them - and any Web sites you frequent - to adopt good policies, especially a pledge to notify you of any subpoena before any private information is disclosed. Encourage your state legislators to pass legislation requiring such notice, and press them to amend state anti-SLAPP statutes to explicitly include Internet anonymity cases.

Question: What other resources are available?

Answer: Web sites dealing with this issue include:

www.aclu.org,
www.citizen.org,
www.eff.org,
www.epic.org,
www.johndoes.org,
www.casp.net,
www.cybersecuritieslaw.com,
cyber.findlaw.com/expression/censorship.html

Question: Can someone ask for my identity even if I am not the Defendant in the case?

Answer: Yes. The rules of civil discovery allow a party to a lawsuit (the plaintiff or defendant) to ask anyone for any information that may lead to the discovery of relevant evidence to their case. However, your ability to quash such a request if you are not named as a party to the lawsuit is the same as if you are named. You can still file a motion to quash. Below is a link to the case files for such a case:

http://www.eff.org/Cases/2TheMart_case/

Question: I am in California. Do I have a right to both resist such a subpena and to ask a court to throw out the case, right away, and award me attorneys fees?

Answer: Yes. California has a specific statute, called the anti-SLAPP statute, that allows an early motion to be brought to have a case dismissed if it is aimed at silencing protected expression and participation in matters of public concern.

Code of Civil Procedure § 425.16(b)(1) provides:

A cause of action against a person arising from any act of that person in furtherance of the person’s right of petition or free speech under the United States or California Constitution in connection with a public issue shall be subject to a special motion to strike, unless the court determines that the plaintiff has established that there is a probability that the plaintiff will prevail on the claim.

A legal brief explaining the California statute further in a case involving claims of online defamation is available at:

http://www.eff.org/Legal/Cases/Kesler_v_Doe/

Question: What are the key federal decisions involving anonymous speech?

Answer: 1. Buckley v. American Constitutional Law Foundation (1999) 525 U.S. 182, 197-200;

2. McIntyre v. Ohio Elections Commission (1995) 514 U.S. 334. In that case, on page 357, the Supreme Court said:

"[A]n author is generally free to decide whether or not to disclose his or her true identity. The decision in favor of anonymity may be motivated by fear of economic or official retaliation, by concern about social ostracism, or merely by a desire to preserve as much of one’s privacy as possible. Whatever the motivation may be, . . . the interest in having anonymous works enter the marketplace of ideas unquestionably outweighs any public interest in requiring disclosure as a condition of entry. Accordingly, an author’s decision to remain anonymous, like other decisions concerning omissions or additions to the content Amendment.
* * *
Under our Constitution, anonymous pamphleteering is not a pernicious, fraudulent practice, but an honorable tradition of advocacy and dissent.

3. Talley v. California (1960) 362 U.S. 60. (holding unconstitutional a state ordinance prohibiting the distribution of anonymous handbills)

4. Lamont v. Postmaster General (1965) 381 U.S. 301, 307 (finding unconstitutional a requirement that recipients of Communist literature notify the post office that they wish to receive it, thereby losing their anonymity);

5. ACLU of Georgia v. Miller (N.D. Ga. 1997) 977 F. Supp. 1228 (striking down a Georgia statute that would have made it a crime for Internet users to “falsely identify” themselves online).

Question: Aren’t people required to explain why they’re subpoenaing my identity and other information?

Answer: Not with the initial request. The reasons for the subpena are only provided if the subpena is challenged, through a motion to quash. In opposing the motion to quash, the person seeking the information must demonstrate, at a minimum, that it is likely to lead to the discovery of information that would be useful in a lawsuit.

Question: I signed a confidentiality/privacy agreement with my ISP that provides that they will not release my information. Doesn’t that protect me?

Answer: No. Most privacy agreements state that information will be turned over in response to legal requests, and a subpena is such a request. Even if the agreement does not say so, a legally issued subpoena overrides such agreements as a matter of public policy. Each ISP has a different policy about notifying users when their information has been subpoenaed, but they cannot simply ignore a subpoena under the law without risking legal santion themselves.

Question: What does "respond" to the subpena mean?

Answer: Usually, it means that the ISP will give the requested information to the requesting person. In some cases, ISPs have resisted requests for information on behalf of their customers, but this is not the norm. Unless specifically told differently by your ISP, you should assume that your ISP will turn over your information as part of its response.

Question: Can an ISP or the host of the message board or chat room be held liable for defamatory of libelous statements made by others on the message board?

Answer: No. Under 47 U.S.C. sec. 230(c)(1): "No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider." This provision has been uniformly interpreted by the Courts to provide complete protection
against defamation or libel claims made against an ISP, message board or chat room where the statements are made by third parties. Note that this immunity does not extend to claims made under intellectual property laws.

Question: Can my ISP or the host of a message board be held liable for defamatory statements I make on the grounds that they are a "publisher" or "republisher" of the information?

Answer: No. Federal law provides: "No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider." This has been interpreted to protect hosts of discussions between other people against defamation and libel claims as a "republisher" of the information. Note that this protection does not extend to claims under intellectual property laws.

Question: Must an ISP or message board host delete postings that someone tells him/her are defamatory? Can the ISP or message board delete postings in response to a request from a third party?

Answer: 47 U.S.C. sec. 230 gives most ISPs and message board hosts the discretion to keep postings or delete them, whichever they prefer, in response to claims by others that a posting is defamatory or libelous. Most ISPs and message board hosts also post terms of service that give them the right to delete or not delete messages as they see fit and such terms have generally been held to be enforceable under law.

Question: My ISP tells me it's been asked to turn over my name as part of a lawsuit against hundreds of "John Does" in a faraway state. What can I do?

Answer: You should probably contact a lawyer, and suggest that the lawyer take a look at arguments raised by the EFF, ACLU, and Public Citizen in one of these suits (e.g., http://www.eff.org/IP/P2P/RIAA_v_ThePeople/JohnDoe/20040202_UMG_Amicus_Memo.pdf)

More family practice doctors switching to aesthetic medicine.

Guess what? Family practice Doctors are moving to cosmetic medicine in increasing numbers.

 
This isn't any surprise to me but it's going to make the cosmetic medical market even more crowded and competitive. 

Why? because the normal market conditions don't apply quite as much in medicine as they do in the 'real world'.

In a normal market, if you fail, you go out of business.

In cosmetic medicine, physicians who fail (and there are some), just end up making less money since it's the family practice, OB/GYN, or internal medicine practice that's making the bread and butter. Doctors don't die, they just get older and complain more.

As a result, large numbers of physicians are running pell-mell into this market to make that extra $60k a year, flooding the market with me-too competitors who individually can't compete but as a group add up to a significant portion of the available dollars taken out of the marketplace.

This is why the plastic surgeons and cosmetic dermatologists are pulling their hair out. While they're still making good money, the unwashed hordes of unboarded doctors who are moving in are all pulling a percent or two away from the front end of the funnel. Not much as individuals but as an aggregate it really starts to make an impact.

So when a board certified plastic surgeon or dermatologist sees a burn, blister, or other complication, his predilection is to chalk it up to another one of those 'bargain basement cosmetic practices'  that have opened their doors down the street. (and he might be right since it really is kind of the wild west out there.) 

I do have two predictions here.

Since it's the state medical boards that make oversight and regulatory rules and since those boards are made up of physicians, I think that:

• Regulations will tighten up to try to keep anyone other than physicians out of the market.
• The in-fighting between plastic surgeons, dermatologists, and other physicians performing cosmetic medicine will escalate.

Both of these strategies will fail. While regulations probably should be tightened in most states, the current system is hugely inefficient and natural market forces will force the vast majority of physicians into a commodities market which will shrink physician incomes. Nor will plastic surgeons and dermatologists be able to keep non-boarded physicians out of cosmetic medicine (This recent Florida situation with off site medical spas notwithstanding.)

So if you're running a medical spa or laser clinic or you're a plastic surgeon or derm... it's only just begun.

LH: Comments on Medspa Franchises & Doctors in Business.

 LH thinks that most doctors suck at business. Is he right?

"I have been reading these as well. Thank God I am not involved with a franchise. I think what you are seeing is that there is more business involved in these franchises than medicine. The focus is completely upon making money for the franchise and they seem to care less about the franchisees.

The franchises think of it as a business and the docs/nurses think of it as medicine. They are not meeting in the middle and the franchises are trying to make it a 100% business model which may work short term but will not work long term. This will do nothing but piss off the medical personnel and they will continue to have high turnover rates and pissed off docs complaining about them on sites like this one.

The other side of the coin is that the docs/nurses want it to be 100% medicine. In medicine, they have the old addage that build it and they will come. We need to understand, that when they are elective procedures with expendable cash, patients have a choice. So business must play more of a role in this situation than in a normal medical practice.

What's LH talking about?

American Laser Clinics & Armed Guards
Dermacare Laser Clinics
Sona Medspas: The medical spa franchise pitch
Sona Medspas: Physician & Medical Oversight 

In a normal medical practice most visits are not based on "wanting" to be seen but upon "needing" to be seen. So in this situation the patients will come to you out of "need". The business side of aesthetic practices must focus on the "wanting" to be seen. You must create the "want" for patients to come to you. This is where the business side steps in.

All of these enterprises are going to fail, if the business people do not understand that this is still medicine and if the medical people do not understand that this is a business. These franchises that are failing is because of their lack of understanding the difference between medicine and business. They are trying to take medicine completely out of the equation.

I have watched some of what Jeff is doing and feel he is at least moving in the right direction with Surface (although I do not have inside knowledge of his contracts with physicians/nurses). Surface seems to understand that the physicians must play a key role in both the medical and business side of the MediSpa.

We as medical personnel must understand that most of us suck at business. This is why most physicians are no longer in private practices and work for some large health system like Keiser or others. So we as physicians must learn the business side or our aesthetic businesses will disappear."

I'll thank LH for his nice comment on Surface. We do build our clinics around physicians. there are a number of reasons for this but I'll list three here:

• One: It's a competitive advantage. Every potential patient want's to be seen and treated by a physician rather than a 'technician'. 
  
• Two: It means that we're always in complete compliance with any state or federal regs. It won't matter at all if the laws change or scope of practice varies. Surface is built around physicians.
• Three: It allows us to offer complete but focused services. "Low hanging fruit" is a favorite term I hear from franchisors. It's a code word that means 'no barriers to competition'. Anyone can get the low hanging fruit and abbreviating your offering puts you in a position of competing with everyone else. You become the 'K-mart' of medicine. Not a good place to be. Physicians allow us to get all the fruit.
  I like fruit.
  

The American Academy of Anti-Aging Medicine (A4M)

CNN.com has an article on the American Academy of Antiaging Medicine (The A4M). It's general journalism and, while not too flattering, isn't a complete hatchet job. Since there's been a number of comments on this site about forming a recognized body of some sort, I thought I'd link to the CNN article and see what everyone thinks.

The American Medical Association does not consider anti-aging an official specialty. Unlike Casas, who is board-certified in internal medicine and was an assistant professor at Dartmouth Medical School, many anti-aging practitioners are not certified in traditional fields. Robert Goldman and Ronald Klatz, the co-founders of A4M, are osteopathic physicians who were once ordered by the state of Illinois to stop identifying themselves as MDs.

Some observers say the whole field is an expensive hoax. "There is no such thing as anti-aging medicine," huffs Jay Olshansky, a sociologist at the University of Illinois who studies medicine and longevity. "As long as humans have existed, we have always desired to live longer. Every society, every religion, every culture. Of course, they all failed at dramatic life extension." Olshansky was slapped with a $120 million dollar defamation lawsuit by A4M after he accused the organization of promoting quackery. He counter sued and both sides eventually agreed to drop their cases.

Do all doctors need a medical spa?

I had a very interesting day speaking to visiting doctors at Surface.

It's quite common to receive requests for physicians to contact us for input. This generally comes in a number of forms. The 'send me your sales information' is one that I generally don't respond to. It connotes a lack of depth and understanding and I've found that most physicians who solicit this kind of info have not been investigating the market long enough to understand what they need. They're just shopping around and don't really understand what they're trying to do. (At least that's my impression.)

Then there are physicians who contact us in a way that shows that they've been investigating the market, possibly lurking for some time and reading in an attempt to make informed decisions. I always respond to these physicians since I've found them to be the type of doctors we're looking for.

I receive that type of question a lot; 'what type of doctor are you looking for?' My answer is always 'smart and motivated'.  Monday I met with two of these latter type of docs. (At least that's my current opinion.)

RB MD is a cardio thoracic surgeon who's been practicing for 20 years in a different state. His credential list is as long as my arm. He told me his average take home check for heart surgery and 60 days of post op care... is $1800. RB MD would like to have his life back. He'd like to spend some time with his wife. He'd like to have an income that wasn't dependant on others. In short, he thinks he'd like to have a cosmetic practice. I think he will and I think I'll help him.

KN MD is an associate professor in internal medicine and practices at a hospital. She's also taken a look at the medical landscape and decided that she doesn't like the lay of the land. She's wants to move into cosmetic medicine too.

Why don't these doctors buy a medical spa franchise? Possibly because they don't see what value they add. DermaDoc, a Dermacare owner, will be surprised to hear this but he's the happiest medical spa franchisee I've ever interacted with. He describes himself as merely frustrated. Most medical spa franchisees say something different.

So why are internists and surgeons so unhappy with regular medicine that they want to get out of it?

Doctors Without Dollars

"Removing hair from unmentionable parts of ladies in Westchester County is how my friend Jerry spends a good part of his week. Not that there's anything wrong with that, except Jerry (not his real name) is a cardiologist, trained at one of the finest medical programs in the country. Trained to save lives. His expertise is the complex and delicate management of congestive heart failure, but he gets paid a lot more to do a laser Brazilian."

Comments welcome.

Wall Stree Journal Article on Medical Spa Franchises: Medspa boom is a bust for some

Via Wall Stree Journal. Read the entire article here.

Read the Medical Spa MD series: Inside a medical spa franchise.

Medspa Boom Has Become a Bust for Some

By RHONDA L. RUNDLE
November 21, 2006

...Medspa ownership turnover generally reflects business stumbles rather than safety issues. Ms. Leavy says many of the troubled spas are affiliated with franchise chains with flawed business models, such as those requiring too much of a franchisee's revenue to go for marketing. (She estimates that about 10% of medspas are franchises, although other industry experts put the percentage at 30% or higher.)

Several Sona franchisees, though not Mr. Nebot, are in private arbitration over problems that include misrepresenting a complicated business as a turnkey operation and failing to provide needed support. Sona officials declined to comment.

Several franchisees of Radiance MedSpa Franchise Group PLLC, a franchiser in Scottsdale, Ariz., say the company's financial projections overestimated revenue and underestimated initial start-up costs, including working capital.

The president of Radiance, Charles L. Engelmann, recently said: "There are currently 32 open stores and we will have 47 or 49 open by the end of the year. None of the stores have closed." He also acknowledged that some franchisees are attempting to get their money back.

One common pitfall for medspa operators is the failure to properly account for prepaid services, such as discounted packages of laser or light-based facial treatments. At Mr. Nebot's shop, for instance, clients would routinely pay $1,000 in advance for a package of laser hair-removal treatments to be delivered over a year or more. The shop's rooms were then filled with nurses treating customers who had paid months earlier. Finding new customers with fresh cash was a constant struggle.

Mr. Nebot says he felt like a cartoon character, "running faster all the time but falling further behind." He used radio advertising to draw more clients, moved to a larger space and extended his operating hours. To avoid alienating customers, he gave away free treatments to those who complained that their hair kept growing back after they finished the five-treatment regimen they purchased.

In the wake of the recent legal changes in Florida, some medical-spa owners there must shell out an extra $60,000 a year or so to a dermatologist or plastic surgeon to oversee operations.

"I can't be my own medical director any more, which is an added expense I can't afford," says one Florida physician who is not a dermatologist. He says he is "facing personal bankruptcy and trying my best to get out while there is something left for my family" after miscalculating what it would take to market, advertise and build his business. Indeed, many medspa owners are doctors who hope to make easy cash at a time when income is shrinking from their traditional medical practices.

Some franchisers have run afoul of state regulators by violating laws against the corporate practice of medicine. In February 2005, California denied a franchise application from HealthWest Inc., a Los Angeles firm that had more than a score of Inaara MedSpas around the country. California ruled that HealthWest had "falsely represented" to owners that they could legally own a medspa without a medical background. HealthWest has gone out of business, but some Inaara shops broke away from the founders and still are operating as independent, stand-alone shops. (Note: The former owners of HeathWest are now 'licensing' medspas under the name Solana.)

Another bust was Skin Nuvo International LLC, which filed for bankruptcy and sold its 37 stores to a private equity firm that in turn sold them to Pure MedSpa, a Toronto company.

Sleek MedSpa, a closely held chain in Boca Raton, Fla., recently acquired SkinKlinic's Fifth Avenue flagship in Manhattan, but SkinKlinic's two other stores, one in Las Vegas and the other in Greenwich, Conn., have closed. SkinKlinic's founder, Kathy Dwyer, is a former senior executive of cosmetics giant Revlon Inc. Attempts to reach her for comment were unsuccessful...