PicoWay: FDA Approved Laser for Removal of Tattos and Benign Pigmented Lesions

Here's some good news for patients who want to remove their tattoos and cosmetic surgeons alike: the Food and Drug Administration's has approved of Syneron Candela's PicoWay, a dual-wavelength picosecond laser.

It is estimated that about 25% of the population in the United States have tattoos and about 50% of them want to have their tattoos removed.

The newly FDA approved PicoWay enables the removal of recalcitrant and multi-colored tattoos, as well as benign pigmented lesions on any skin.

According to the Syneron Candela's site, the PicoWay works by delivering ultra-short picosecond pulses of energy to the tissues. The burst of energy create a photo-chemical impact which breaks up the tattoo ink or pigmentation into smaller and more easily eliminated particles. 

Some of the advantages of using PicoWay include its use of dual wavelengths and its ability to treat wide range of tattoos. It claims also to have the shortest picosecond pulses, that is 40% shorter, making it more effective while lowering risks or other side effects.

As early as 1965, Q-switched lasers were already used. These types of lasers produce a very short laser pulse in nanosecond range. This is the most commonly used laser in clinical practice. As Q-switched lasers come in three types, there is a tendency that there will be a need to use another type of laser, rather than owning just one of them to completely remove a patient's tattoo.

To remedy this, physicians shrink the spot size and increase energy deposits which significantly lead to the probability of producing a scar.

Compared to Q-switched lasers, Dr.Shimon Eckhouse of PicoWay says that:

Scientists acknowledge that shorter pulse duration lead to higher efficiency for converting laser energy needed to fracture particles into fragments. Smaller fragments mean that it is easier for the body to effectively remove it. Q-switch technology requires numerous treatment sessions, causes significant discomfort during treatment and incompletely removes tattoos and pigmented lesions.

Picosecond technology has ultra-short pulse durations that are 100 times shorter than Q-switch lasers, and in trillionths of a second. 

Read more on:

http://syneron-candela.com/na/product/picoway

Getting Naked on the Internet: What does the law say?

Telemedicine and Cyber Security

The Health Information Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of your personal health information (PHI). HIPAA includes several rules and provisions that set guidelines and requirements for the administration and enforcement of HIPAA. The relevant ones for the exchange of PHI in the digital cyberspace are the Privacy Rule1, the Security Rule2, and the aptly named Health Information Technology for Economic and Clinical Health (HITECH) Act3.

Telemedicine is a burgeoning field of medicine that incorporates digital technology such as electronic health records (EHR), information sharing, and videoconferencing to enhance the interaction between physicians and their patients, and ultimately, improve the delivery of healthcare. Having been a plastic surgeon for several years now, I’m all too familiar with meeting people at social events, and immediately getting bombarded with intrusive and unusual questions and requests as soon as my chosen profession is ousted. Sure, it’s unlikely that a woman will disrobe and expose herself in front of me and my wife at a friend’s dinner party, but get us into an online “private” videoconference call, and who knows what body parts will make an abrupt entrance into the conversation. Physicians must approach with caution, says American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) President Stephen S. Park, M.D. in a recent article4. But, for me and most physicians I know, I feel like the cat is already out of the bag. Considering the amount of texts, emails, online chats, phone conversations over internet and satellite lines, and selfies of both pre- and post-op patients I’ve been privy to, I’m sure I’ve already broken too many laws, and completely disregarded the good doctor’s advice. The truth is, though, that we’ve only begun to scratch the surface.

Telemedicine may involve the electronic exchange of PHI which is protected under HIPAA law. Security considerations with telemedicine involve making sure unauthorized third parties cannot eavesdrop on or record a videoconferencing session where sensitive PHI is transmitted seamlessly, and unfortunately, innocently. Recently, a monumental data breach at one of the nation’s largest insurance providers has spurred a bipartisan political effort to reexamine HIPAA as it relates to telemedicine, possibly adding costly and cumbersome requirements to encrypt EHR data5. Additionally, a recent report done by BitSight Technologies, a cyber security risk analysis and management firm, found that healthcare and pharmaceutical companies ranked the lowest among the four industry categories studied6. Suffice it to say, people are taking heed of this emerging new threat.

The aforementioned laws, rules, and regulations guide the generation, maintenance, and implementation of telemedicine HIPAA compliance. We must be cautioned, though, that HIPAA compliance does not necessarily equate to actual cyber security, and that simply meeting standards set forth in these regulations may not be enough. As more public attention and scrutiny rise to the forefront of media exposure, look for the healthcare industry to take the cyber security threat much more seriously.

Daniel Kaufman, MD
Discreet Plastic Surgery

Bibliography
1. http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/
2. http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/
3. http://www.healthit.gov/policy-researchers-implementers/health-it-legislation-and-regulations
4. http://cosmeticsurgerytimes.modernmedicine.com/cosmetic-surgery-times/news/cosmetic-virtual-consult
5. http://medicaleconomics.modernmedicine.com/medical-economics/news/senate-review-hipaa-security-medical-records-light-anthem-breach
6. http://info.bitsighttech.com/bitsight-insights-industry-security-ratings-vol-4-rc

Mommy Makeovers for Mom's Day

Mother's day is just right around the corner. Husbands and children are thinking about ways to make this day special for moms. A makeover and pampering may just be the right gift for her.

Mommy makeover is a marketing strategy and a marketing term which has gained popularity over the years. In a study conducted by the American Society of Plastic Surgeons, 62% of mothers who want to regain their youthful look before giving birth.

Mothers who want to restore or improve their post-pregnancy bodies undergo multiple plastic surgery procedures which include tummy tucks, liposuction, breast implantations and breast lifts.

Medspas may capitalize on this by providing discounts for bundle procedures, especially with the celebration of Mother's Day.

Plastic Surgeries for Men... Again

Recent trends in cosmetic surgery reveal that more and more men are requesting for aesthetic surgery. This may be attributed to men wanting to feel good and not wanting their female counterparts to look better than they do after the latter has gone to some rejuvenation procedures.

Nowadays, more men are looking forward to having a more balanced nose, a rejuvenated face and a trimmer waistline. There are those working dads in their late 40s who thinks to themselves that he used to look so goon in college. In a Business Insider, it was mentioned that these "athletic dads" tend to avail of jawline recontouring, liposuction, and a small eyelift.

According to American Society of Plastic Surgeons member Dr. Jay Lucas, MD, some of the most common procedures are eyelid rejuvenation, neck lifts, rhinoplasty, chin augmentation, and male breast reduction.

Eyelid Rejuvenation

Signs of aging are often shown in the eyes. Fortunately, surgery to restore the upper eyelids to a fresh and vibrant appearance with correction of any eyelid droop can be a good remedy. The lower lids can be rejuvenated by removing excess fat and repositioning this tissue over the cheek to eliminate the tear trough. This can be important not only in social situations, but also in how a person is viewed in the workplace.

Neck Lifts

Neck lifts help men get rid of the hanging skin and excess fat around his neck which obscures his jaw line and shows his signs of aging. This procedure helps men restore their youthful look to create a strong jaw line and a crisp chin-neck junction. Neck lifts are done as an out-patient procedure with minimal pain and a recovery of around two weeks.

Rhinoplasty and Chin Augmentation

These procedures suggest proportionality in the face of the patient and requires a great understanding of the patient's facial appearance. If the nose seems big, maybe the lower face is out of place, such as a small lower jaw or chin. To create a harmonious facial appearance, rhinoplasty along with chin augmentation is performed.

Liposuction

This is not a weight loss technique, rather it is a contouring tool which reshapes the abdominal area to create a sleeker frame. Male patients are however encouraged to go on a healthy diet and exercise before availing of this procedure as an adjunct to improve appearance.

In our culture, looking good and youthful is prized, men included. The advent of the advent of latest technology and availability of several plastic surgery procedures drive men to look and feel good themselves. Med Spa owners may capitalize on this trend to open their clinics not only to the women, but the men clientèle as well.

Read more on: http://www.plasticsurgery.org/news/plastic-surgery-blog/most-commonly-requested-plastic-surgery-for-men.html

Dealing With Pain As A Physician

I admit it! I was channel surfing between CSPAN and the Lehrer News Hour...

...and not so accidentally, stumbled upon one of the Kardashian sisters getting some sort of "minimally-invasive" facial rejuvenation procedure in a posh Miami medical office. The procedure was fairly routine, but what really caught my eye was the incredible amount of pain this young lady was willing to endure. I reflected back to my training in Plastic Surgery and General Surgery, and realized how little attention we paid, as a community, to pain.

I often find myself bringing up to my patients a "Postop Pain Plan", only to find them caught in a moment of bewilderment. "I thought I'm not gonna feel anything", I hear sometimes. In recent years, the increasing dumbing down of medicine and plastic surgery in pop culture media, has some people denying the existence of pain after surgery. Furthermore, of the ones that do expect some postop pain, few expect to define a specific plan for managing that pain. Albeit, they come to me with much greater concerns about their appearances, but nonetheless, the change in appearance comes at a price.

As plastic surgeons, we need to address the issue of pain in a more sincere and serious manner. We need to stop painting rosy pictures and admit to our patients that surgery is painful, that what they are asking us to do is, unfortunately and necessarily, inflict pain. We need to implement a Pain Plan. A simple, lay-term, and effective protocol addressing individual patients' postop pain control needs. We also need to document the plan and incorporate it into our informed consent plan.

As patients, we need to inquire within. Ask our surgeons about the nature of the pain, the duration, the severity. We need to request a specific plan, and decide preoperatively how to manage the pain. But most importantly, we need to stop believing everything we see and read in the lay media. We need to realize that elective surgery is surgery nonetheless. It hurts, and we ask for it. So let's treat it like the serious business it is.

Surgery for Free???

"I want my surgery for free" my friend tells me... Just how many times have we (plastic surgeons) heard that before?

Obvious to me, that meant that my surgical fee will be waived. Oddly enough, for my friend, an intelligent person in her own right, this meant something completely different. She thought the entire surgery was actually for free. After a slightly awkward moment, I asked her if she knew anything about surgical fees and healthcare costs. To my astonishment, she had absolutely no idea. Being the consummate educator that I am, I decided to use this conversation as a teachable moment to instruct my friend about the economics of plastic surgery. Delving further into the topic, I found that one of the most popular Google searches regarding plastic surgery is plastic surgery costs. Frankly speaking, plastic surgery cost is so paramount, that if you listen to some of my friends and colleagues at our trade meetings, it seems that cost is so often the only determinant factor indicating performance of the surgery or not. In light of these glaring facts, here's a brief primer on the topic.

In performing cosmetic and plastic surgery there are three basic fees that must be considered:

1) the surgical fee,

2) anesthesia fee, and

3) facility fee and materials costs.

The surgical fee is the simplest to understand, and frankly the easiest to negotiate. Basically, it is what the surgeon takes home. From this fee the surgeon pays for all the costs incurred in becoming and being a surgeon. This may included school loans, malpractice insurance fees, office rent or mortgage, staff salaries, and other costs, to name just a few. The surgical fee is determined by the judgement of one person alone, the surgeon. Depending on his/her practice expenses, he/she determines the fee, and is ultimately the one able to negotiate it. More often than not, when plastic surgery fees are negotiated and consequently lowered, the change in price comes from this portion of the overall cost of the surgery.

The anesthesia fee, one often overlooked by many, is the hardest one to negotiate. Basically, it is what the anesthesiologist takes home. This fee may depend on several factors, including the nature of the surgery, the nature of the anesthesia administered (local, regional, or general), the time of surgery, and other technical issues as well. The anesthesia fee is usually determined ahead of time between the surgeon, anesthesiologist, and/or the surgical facility, and thus, it is usually not subject to much negotiation.

The facility fee, also one that is difficult to understand, generate, and consequently, negotiate, is composed of many elements that may not be readily seen. These include the costs of nursing care, medical materials and drugs used during surgery, and other costs of running an ambulatory surgery facility. Again, this is usually a fixed price that most commonly is not subject to negotiation, especially with the operating surgeon. Additional material costs may be added, for example, when using breast or facial implants or other materials related to specific cosmetic surgery.

During your plastic surgery consultation, when the time comes to talking about the costs of surgery, it is always worthwhile to ask about each one of these fees, as some may be negotiable. The fact that cosmetic surgery is not covered by medical insurance, and is thus a luxury item paid for by discretionary income, has actually contributed to it becoming so affordable and within reach to larger segments of the population. Plastic surgery is one of the last vestiges of the healthcare industry where free market forces act to shape the economic transactions between producer (doctor) and consumer (patient). The more knowledgeable and informed you are, the better the chances you'll get a better product and bigger bang for your buck. A cautionary note, however, is that in plastic surgery, as in most industries, you get what you pay for. Your quality assurance is the doctor's credentials and bedside manner, their specialty-specific board certification, and surgical center accreditation. If all of those factors are satisfactory, then feel free to shop around. And remember, an educated consumer gets the best deal.

The Value Of Board Certification In Cosmetic Medicine?

Is it better and safer to get Botox injected by a family physician who has been injecting patients for 15 years or a newly graduated plastic surgeon who just finished his residency last week?

In Cosmetic Surgery, the term "Board Certified" is the most highly used term for marketing purposes today. Thirty years ago, many doctors were "Board Eligible" or non boarded and their value came from their training and their experience and their expertise, not just a label. Today, doctors are expected to be board certified in something. That something is the topic of heated battles and debates and many of our colleagues are just as confused about it as are our patients and the public and the media. Insurance companies and third party payor and even hospitals require board certification and may use it for determining reimbursement. 

The American Board of Plastic Surgery (ABPS) and The American Board of Facial Plastic Surgery (ABFPRS) have had many decades of heated nasty all out warfare. For the most part, on the surface at least, the war is over but small battles and skirmishes are still waged amongst these two specialties here and there around the country. But cosmetic surgery is no longer being offered purely by Plastic Surgeons or Facial Plastic Surgeons, Oculoplastic surgeons, Oral surgeons, otolaryngologists, & dermatologists are a significant part of the cosmetic surgery providers. More over, family physicians, ER doctors, Radiologists, OBGYNs, and other doctors whose specialty is not traditionally associated with cosmetic surgery are now the fastest growing population of cosmetic surgery providers with Botox and fillers and lasers as their entry to the more involved mini facelifts and blepharoplasties and liposuction. The American Board of Cosmetic Surgery and the American Board of Laser Surgery has given this large heterogonous group of non-cosmetic surgeons an umbrella to gather under and a label to use for marketing and validation.  

The American Board of Plastic Surgery and The American Board of Facial Plastic Surgery have now joined forces in order to "protect the public" and inform the media and public about the lack of proper residency or fellowship training by many of these new non traditional providers.  Protecting the public is a noble endeavour and a great cause but I ask who is going to protect the public from less inept members of the American Board of Plastic Surgery and the American Board of Facial Plastic Surgery?  There is no doubt that the vast majority of poor cosmetic surgery with bad outcomes are being performed by Board Certified doctors, most of which are actually certified by these two esteemed Boards (ABPS and ABFPRS). 

Then what is the true value of "board certification" and how will the public be protected? We must police and control our own profession as a whole before we are controlled by outside forces. In Ontario Canada, a deal between the society of Plastic Surgeons and the Department of health posed a new regulation where no one other than a plastic surgeon could use the term "plastic surgery" in their advertising! So, is it better and safer to get Botox injected by a family physician who has been injecting patients for 15 years or a newly graduated plastic surgeon who just finished his residency last week or even from a nurse who works at a plastic surgeons office? This is a tough question that needs to be answered by us doctors before it gets settled for us by external forces. 

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.

Adipose-Derived Stem Cells In Cosmetic Surgery: Ready For Prime Time?

Are adipose-derived stem cells in cosmetic surgery ready for prime time use in your cosmetic practice?

Google “aesthetic stem cell treatments” and you will be greeted with a panoply of therapeutic offerings ranging from mundane to fantastic. Injecting your own adipose derived stem cells can lift your face, tighten your skin, enlarged your breast, slow the ageing process and even put some zip in your libido if injected into anatomically correct nether regions. Cosmeceutical manufacturers are even putting non-viable stem cells into facial creams hoping to knock 10 years off your visage. These marketing claims have captivated the public with the promise of a minimally invasive fountain of youth.

Adipose-derived stem cells are multipotent and possess the ability to differentiate into fat, bone, cartilage, nerves and pancreatic tissue.  They also secrete cytokines that are angiogenic, antioxidative and immunosuppressive. They release a whole host of growth factors that facilitate wound healing and tissue regeneration. Stem cells hold great clinical potential and offer considerable commercial possibilities.

We are all very enthusiastic about the promise and potential offered by the emerging field of adipose- derived stem cell science. Encouraging data from hundreds of ongoing international trials support a bright future for aesthetic and regenerative applications and real progress has been made in developing methodologies and protocols for every day clinical use. Yet many are advising caution.

A recent review in Plastic and Reconstructive Surgery notes that there is considerable uncertainty about the true clinical potential of adipose-derived stem cells and too much remains unknown about their fundable biology to be used safely and reliably. There are several contradictory studies about whether these cells promote or repress cancer growth. There are no standard protocols yet developed for adipose-derived stem cell applications. We still are unsure of the number of cells required per treatment or how many treatments are needed to achieve a desired clinical outcome predictably. In short, we are not quite sure what we are doing yet with adipose-derived stem cells despite the encouraging science and our best intentions.

A lot remains unknown about how to effectively and safely use this new technology. To market aesthetic stem cell procedures outside of clinical trials to the public seems a bit deceptive considering the current state of the art. What do you think??

Top 5 Cosmetic Surgery Treatments In 2011

According to the American Society of Plastic Surgeons cosmetic surgical procedures increased 2 percent, with nearly 1.6 million procedures in 2011. The top five surgical procedures were:

• Breast augmentation (307,000 procedures, up 4 percent) 
• Nose reshaping (244,000 procedures, down 3 percent)
• Liposuction (205,000 procedures, up 1 percent)
• Eyelid surgery (196,000 procedures, down 6 percent)
• Facelift (119,000 procedures, up 5 percent)