New Research Areas Around Minimizing Scars For Cosmetic Surgeries?

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New technologies are promising to be able to reduce the most visible after-effects of surgical cosmetic procedures, scarring.

The ability to truly reduce or eliminate scarring after surgery would be a godsend for surgical procedures where scars are visible. The scars are always a negative for the patient and they can become a focus that lessens the results that the surgery actually delivered. The current crop of lotions and potions have some effect, but some form of aggressive wound healing that minimized or eliminated scars would be an optimal outcome for any procedure.

In the article by published last year in the Science magazine, a research team found that they were able to reprogram fat from myofibroblasts by signaling it with the Bone Morphogenic Protein (BMP), which promote growth. In their study, they were able to find a way in regenerating fat from myofibroblasts in adults. The researchers observed that growth of hair follicles was indicative of adipocyte regeneration, which is what most of their findings resulted.  They noticed that adipocytes grew around the area where hair follicles appeared. 

If it were easy to execute, it could definitely change how aesthetic surgeons can treat scarring in patients.

There is an abundance of research on wound healing in the plastic surgery field. Possibly getting some insight from Plikus et al.’s research, aesthetic physicians and surgeons can be guided into finding a way to signal the BMP receptor, they can benefit greatly in using the approach so they could minimize the risk of acquiring a scar after the surgery and turn it into fat instead. In this manner, the adipocytes might be easier to treat as compared to the scars.

Plastic surgeons employ different techniques to minimize the scarring on the areas in which the incision was made. Silicone sheeting is one of the most popular techniques in minimizing scarring in the area. Another technique is to use corticosteroids (Janis and Harrison, 2014).

There have been many cases that examined treating wounds through methods such as laser resurfacing and injections. These two alternatives do help in accelerating wound healing, with botulinum toxins even enhancing the appearance of scars. Dermal fillers also have been seen to have regenerative properties, which could help in the process of healing.

As of the moment, the research team responsible for converting myofibroblasts to fat cells have yet to test their findings out on humans, but they were able to relate it to what they saw on the mice. It would definitely be groundbreaking especially in the field of aesthetic medicine. For now, it is up to the aesthetic physician to educate the patient how to treat their scars.

References:

  • https://insights.ovid.com/pubmed?pmid=24469191
  • http://science.sciencemag.org/content/355/6326/748.long

Would patches really replace injectables and laser or light based devices?

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Microneedle patches seem to have beneficial implications based on the current studies presented by researchers. It could then give another alternative for patients, for those who would need short term solutions or quick fixes maybe. Since the patches were made for the studies, it may be too early to say if it would be produced for the public. 

A few months ago, a microneedling patch to reduce fat was tested on mice, having good effects after the application of patches. In another study, a patch was also developed to brighten the skin, additionally there was another study which examined the use of hyaluronic acid on the microneedle patch. In this new study, a microneedle patch was used to reduce the appearance of wrinkles.

The question then is, would patches be the future of cosmetic medicine?

The latest study in microneedle patches was conducted by Hong and colleagues. The researchers divided the 84 participants into groups of 3, group 1 had the patch applied solely, group 2 had the wrinkle cream and patch, while group 3 had the wrinkle cream only.

Findings:

  • The researchers examined skin conditions before patch application, and 4, 8, and 12 weeks after application, with group 2 having improvement by 8 weeks, whereas groups 1 and 3 had eventual improve by the 12th week.
  • There were no adverse effects reported in the study.
  • Microneedle patch coupled with wrinkled cream was more effective as standalone patch or cream.

Would these patches have better efficacy than the current treatment options?

Based on the studies presented by the researchers, it would be good to examine the long term effects of using the patch. In the current studies about microneedling patches, there are no signs of adverse effects or symptoms on the subjects. It may be difficult to say regarding the use of patches as the literature is scant regarding it as these are nascent in the field. It does have its benefits, but a long term solution and efficacy are of utmost importance regarding treatments. So far, patches do offer short term solutions according to the studies.

Many things remain unclear regarding the use of patches, such as the long-term efficacy rate, number of treatments done to alleviate wrinkles or brighten skin, but the future of cosmetic medicine holds many possibilities, and patches could help advance the field for many providers and patients to come, considering it holds promise in the field to understand medical aesthetic in microneedling.

Botulinum Toxin is Effective in Treating Facial Synkinesis

Two new studies from the JAMA Plastic Surgery studied neuromodulators in treating facial synkinesis, With one of them comparing incobotulinumtoxinA (Xeomin), abobotulinumtoxinA (Dysport), and onabotulinumtoxinA (Botox) among one another (Thomas et al., 2017).

To determine its efficacy, the researchers depended on the Synkinesis Assessment Questionnaire (SAQ).

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The Newest In Dermal Fillers

Dermal fillers remain one of the most known methods of non-surgical rejuvenation, due to its popularity and effects, many patients have preferred dermal fillers. However, not everything ends well because of the possible adverse effects of dermal fillers. Thus there have been studies to ensure the safety of administering inejctables.

A couple of studies.

Double Injection Technique

Novel techniques are developed and presented to ensure the delivery and safety of the filler. Injecting requires skill and precision, thus it is crucial to learn safer techniques in injecting dermal fillers especially in the danger zones. One dermatologist mentioned that during a demo, the subject had become blind also.

Intravascular injection is something that all providers avoid due to disastrous side effects it causes on patients, and due to this delivery of injection, there have been cases of blindness and providers must always practice care and precision in administering the injection. 

The technique was double injection, as presented by the researchers, Huang and Lin, which could help prevent intravascular injection. Their method aims to thwart the possibility of intravascular injection, basically there would be an inner and outer needle in performing the procedure. In the event of drawn blood, the inner needle would move the blood out.

The researchers do admit limitations to their method and there could be more research that may be done in order to use this method.

Regeneration is the new Rejuvenation?

Dermal fillers could also demonstrate its efficacy in regeneration. Only two studies have examined dermal filler use for regeneration, it seems likely that in the near future, physicians could use dermal fillers for soft tissue regeneration. There are two studies regarding tissue regeneration and filler or fat injection, which have regenerative properties.

Fallacara et al. (2017) suggest that Urea could be cross-linked with HA considering its properties. According to the researchers, this could be the future of dermal fillers, and that could treat cosmetic issues other than its usual common dermatological concerns (e.g. psoriasis, calluses)

Additionally, there is another alternative to filler for tissue regeneration, which was discussed in detail by Dr. Cohen through Medscape that fat was also helpful in rejuvenating and regenerating  the reason he used fat was it made for a more natural look and that it lasted longer as compared to using fillers. Additionally, it adds more volume.

CaHA with Ascorbic Acid?

The study examined the efficacy of CaHA with Ascorbic acid to treat stretch marks. The researchers tested it on 35 patients, and on areas where stretch marks commonly appear such as: thighs, knees, buttocks, abdomen, and breasts. 

Findings:

  • 63% of patients in the study were satisfied with the treatment; while only 1 was unsatisfied.
  • Most patients were more satisfied in areas like abdomen, buttocks, and breasts.

Dermal fillers would have more potential uses in the future, and that it could have other uses in the future. For now, dermal fillers remain as one of the most popular treatment for cosmetic concerns, leaning towards rejuvenation.

A list of cosmetic dermal fillers here.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426873/
https://www.researchgate.net/publication/315818101_Hyaluronic_Acid_Fillers_in_Soft_Tissue_Regeneration
https://journals.lww.com/prsgo/Fulltext/2017/09000/Calcium_Hydroxylapatite_Combined_with.17.aspx

How are Nasal Function after Rhinoplasty and Mental Health Connected?

Recent studies link mental health and cosmetic surgery. The literature on both subjects have flourished, and that those undergoing cosmetic surgery could also have or are diagnosed with Body Dysmorphic Disorder (BDD).

It is alarming to note that there could be undiagnosed cases of BDD and physicians may need to take necessary measures. As such, it appears many researchers have taken notice of the mental health perspective for those undergoing cosmetic procedures.

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Microneedle Patch May Replace Lasers & Injections for Fat Removal

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Researchers created a skin patch to deliver a drug that can convert white fat to calorie-burning brown fat.

Liposuction is still one of the top procedures performed by surgeons worldwide. It is consistently in the top five in the ISAPS Global Statistics, and it may continue to rise.

On the other hand, fat freezing, lasers, radio-frequency, and ultrasound technology are the common treatment modes of treatment for fat removal. These devices have different effects on each individual, some may work, some may not.

What if patients do not need to go to a clinic and could eventually stick a patch on themselves to remove the fat?

A patch is currently being developed to burn the fat in your “love handles”, and it is being tested in mice. A study by Zhang et al. (2017) They use brown fat by using nanoparticles and Rosiglitazone on the patch. The researchers used brown fat because of its properties. They used the in vivo method in their study. Their patch seemed effective on the mice and it could serve as therapeutic use for patients with obesity. In their study, the researchers found an increase in the following factors: energy, oxidation, and body weight control (Zhang et al., 2017, p. E).

 Zhang et al., ACS Nano

Zhang et al., ACS Nano

The research team designed a skin patch with 121 cone-shaped polymer needles that can be filled with a drug encapsulated by nanoparticles. The tiny needles penetrate the skin and the ends collapse. The nanoparticles then slowly release the browning drug into the fat cells. By delivering the drug directly to fat cells, the drug’s side effects in other parts of the body might be prevented or minimized.

The researchers tested the skin patch, which was a little larger than a pencil eraser, on the abdominal fat pads of three groups of normal mice. The first group received a skin patch without any drug; the second group received a patch containing rosiglitazone (a diabetes drug that’s also known as Rosi or by its trade name Avandia); and the third group received a patch containing a compound called CL 316243. In mice treated with either drug, the white fat cells shrunk and beige fat cells appeared. A genetic analysis and other tests confirmed that both drugs induced fat browning and improved metabolism in the mice.

The research team then treated obese mice with skin patches for 4 weeks. The drugs increased browning, as evidenced by smaller fat cells and increased expression of brown fat cell genes. They also reduced the size of the fat pad and improved metabolic signs.

It's possible, even likely, that patches may eventually replace surgical and non-surgical means of losing fat in the love handles? For now, patients would still need to undergo either a surgical or non-surgical procedure.

What 2016 Cosmetic Medicine Stats Mean For Your Clinic

Stats from 2016 are trailing indicators of the market but they should give you a clear view of where cosmetic medicine is headed.

When you're looking at where cosmetic medicine is headed, you'd do well to keep up with the latest stats showing that nonsurgical treatments are on a path to overtake cosmetic surgery in total dollars spent. 

If you look at some of these stats you'll sees some obvious trends, and that should make you think about what kinds of treatments you might look to ad or promote. Nonsurgical is where the growth is.

Nonsurgical cosmetic medicine's growth is accelerating according to the International Society for Aesthetic Plastic Surgery's (ISAPS) annual statistics.

Take a look at this chart of nonsurgical treatment's growth in the US, and compare that with the growth in surgical treatments. IPLs, cosmetic lasers, Botox and injectables.

Download and read the ASAPS report here.

 Nonsurgical cosmetic medicine growth

The International Society of Aesthetic Plastic Surgery (ISAPS) 2016 Stats

Read the ISAPS report here

If you're not practicing cosmetic medicine in the US, you might want to think about starting a clinic in Brazil.

In the report, Brazil and the US trade top spots depending upon the proceedure. They're neck and neck, except when the treatment is further South. Brazil is almost double the total number of treatments in both Labiaplasty and Vaginal Rejuvenation than the US. (Interstingly, Labiaplasty worldwide had the greatest increase in treatments year over year at a massive 45% increase.)

The US has far more nonsugical treatments due to greater market penetration of cosmetic lasers and IPLs.

Here's a breakdown of nonsurgical treatments wich shows wider spread than if all cosmetic treatments (including surgical) are included.

Total Nonsurgical Procedures by Country

 Total number of nonsurgical treatments by country

Here's another chart that gives a little insight into the macro trends around injectables worldwide.

Year-to-Year Comparison of Injectable Change

 Injectable filler injection treatments

Winners? Juvederm, Restylane, Belotero Balance and Sculptra Aesthetic. Loser? Radiesse.

Implications and takeaways for your clinic

Non-surgical procedures continue to grow at a steady. No surprise there, but there are some areas of interest if you're looking at adding to your treatment menu. You really want to ride a wave that's growing and a careful reading of these types of reports can show you where that wave is headed.

The fastest growing cosmetic procedure of all? Labiaplasty, at 45% year over year growth. That's a pretty damn good indication that there's a lot of demand. 

The non-surgical options using RF and fillers for vaginal rejuvenation has just started to trend, but it's dramatic. You might want to take a hard look at adding vaginal rejuvenation to your treatment lineup.

More non-surgical procedures may continue to progress and develop, as dermal fillers and Botox are not limited to the use of the face. Lasers and IPL also contribute to the increase as they are considered non-surgical alternatives for fat reduction or skin rejuvenation. It is expected that in the coming years, there may be a spike of numbers coming in from the younger and middle age demographic.

Reversing Hyaluronic Acid Filler Injections With Hyaluronidase

It's possible that at some point in your cosmetic clinical career - for whatever reason - you might need to try and minimize or reverse the results of a HA filler injection.

Patient's have been know to 'freak out' when the big lips that they thought they wanted are actually the ones they see in the mirror. It can be something of a challenging conversation.

Fortunately, there's Hyaluronidase, and some researchers have found that even small amounts were effective in dissolving hyaluronic acid fillers.

In a study by Juhász et al. (2017), the researchers found that small amounts of hyaluronidase were effective in treating complications from hyaluronic acid (HA). The study focused on the degradation of HA, and different periods to see its efficacy. Randomized study participants were injected with a HA injectable; Juvederm Ultra XC, Juvederm Ultra Plus, Juvederm Voluma XC, Restylane Silk, Belotero Balance, Restalyne Lyft (Perlane), and Restylane-L. Then patients were injected with saline or 20 or 40 unites of hyaluronidase and monitored over 14 days. 

The results showed that haluronidase was effecive in degrading the filler and that there was no decernable difference between the 20 and 40 unit injections. (So you don't have to use much.)

Here are the findings:

  • Day 1 Post-Injection: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE, RESTALYNE LYFT (PERLANE)
  • Day 2 Post-Injection: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE, RESTALYNE LYFT (PERLANE), RESTYLANE-L
  • Day 3: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE, RESTYLANE-L
  • Day 4: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE, RESTALYNE LYFT (PERLANE)
  • Week 1 Post-Injection: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE
  • Week 2 Post-Injection: Everything except JUVEDERM ULTRA XC

The researchers also found that dermal fillers like Juvederm Ultra Plus and Restylane-L had a higher concentration, which took longer to dissolve with hyaluronidase, while Belotero Balance was the quickest to degrade.

Previous studies have only given their recommendations on the number units of hyaluronidase, based on experience or training. However the 2017 study presented their recommended dosage in degrading the HA. The authors suggest that a 20 unit injection of hyaluronidase is an effective way to degrade the HA.

One possible complication from using hyaluronidase is an allergic reaction. For patients who incur any allergies from hyaluronidase, there are other treatments for HA complications.

It's highly advisable to conduct allergy testing for patients before administering the dermal filler, which could reduce the incidence of complications. Ablon (2016) reminds medical providers in cosmetic medicine to observe the tissue as the dermal filler is injected.

What Your Medical Spa Staff Should Understand About Body Dysmorphic Disorder

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

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

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

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

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

What have studies found out so far?

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

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

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

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

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

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

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

What can your clinic staff do?

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

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

A Brief Overview on Cannulation Techniques For Fillers

Physicians have used cannulas to inject fillers as an alternative to needles.

Blunt-tip cannulas prevent the pricking on the veins. In addition, it is found that cannulas are more effective and safer for some patients. In one study, it is found that microcannulas lessened the incidence of tissue injury (Salti and Rauso, 2015). Dr. Sabine Zenker presents her techniques in using cannulas on the sagged lateral cheek areas and lips.

Many physicians have used the same method as cannulas have been seen as more effective and safer compared to needles. The author’s techniques are limited to the upper lateral and the lips.

Their technique for the lateral cheek is gentle molding, which would give an optimal result. The author recommends a linear threading method proceeding with a fan-shape that would help with cannulating from the entry point, the Zygomatic Arch.

As for the lips, the Zenker addresses it with “multiple boli” starting from the center eventually going laterally. In enhancing the lips, a lateral technique is also utilized. Thread volume is little, which allows correcting of the lips. The author reminds that there is a risk of overcorrection in this area.

So how else have authors used cannulas in their studies?

The authors have presented some cannulation techniques and recommendations on how to administer these injections. With cannulas, downtime has lessened significantly (Luthra, 2015). In addition, the author noted that patients returned for augmentation or enhancing procedures.

According to Arsiwala, when injecting with large-volume fillers, a cannula is more effective as opposed to the traditional needle. In Hedén’s (2016) study, which focuses on the nose, cannulas that are 25-G or wider lessens any risk to the vessel, in addition using thin cannulas reduces risk with intra-arterial injection. Montes, Wilson, Chang, and Percec (2016) recommend using a cannula for the upper eyelid to achieve ideal results.

Loghem, Yutskovskaya, and Werschler (2015) focuses on the danger zones and injection areas for cannulas. The authors suggest a multi-level approach (linear threading) when doing a brow lift and to avoid overcorrection to look masculine. In line with Zenker’s work, the researchers suggest to utilize a two-point cannula method when approaching the Zygomatic area.

To read more about the author’s techniques find out more about it here: https://www.prime-journal.com/indication-specific-cannula-treatment/

For the injection techniques by Loghem, Yutskovskaya, and Werschler, check it out here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295857/

Effective Medical Spa Platelet Rich Plasma Treatments?

PRP (Platlet Rich Plasma) treatments have become a staple for some clinics, so what's the deal?

Combining aesthetic techniques is probably the most popular 'cross-selling' technique and platlet rich plasma treatments are an easy add if you're set up for them. PRP serves mainly as regenerative, but it has branched out to anti-aging medicine. A number of clinics and physicians are using PRM an alternative to dermal fillers or adding them to filler treatments.

In a Medscape interview with Dr. Matarasso (plastic surgeon) last 2012 , he emphasizes that fillers and injectables break down over time, while using PRP would last longer—because it is natural and has no risk of rejection and allergy. Additionally, Puri (2015) suggests that given the natural treatment of PRP, it is considered an alternative to any synthetic filler—for patients who are unwilling to have them injected.

Most of the studies we've read have seen better results when adding PRP treatments into the mix, but there are any number of physicians who still have their doubts (perhaps they cynical group).

Using PRP with fat or Adipose tissue?

Sommeling et al. 2012 suggests that using a PRP and fat grafting technique for a treatment would enhance fat improvement. On the other hand, In Malekpour et al. (2014)’s study of the usage of PRP and fat grafting, patient satisfaction was reported despite lesser significant outcomes on the third and sixth month follow-up on the treatment.

Kumaran (2014) suggests that using PRP, mixed with fat grafts in treating scars, followed-up by a fractional laser treatment may yield good results. In the topic of lasers, PRP has also been treated alongside lasers and derma rollers or microneedling; studies focused on those modalities have resulted to patient satisfaction.

The usage of PRP and laser is deemed effective for some patients, reported better texture, elasticity, and lesser erythema (Shin et al. 2012).

In another study, conducted by Oyunsaikhan, Amarsaikhan, Batbyar, and Erdenetsogt (2017), dermarollers are another effective method as there have been improvements on the facial wrinkle grade and after six months, collagen and epidermal thickness had significantly improved.

Most study limitations focused on the ethical use of two materials for one treatment. Research on the treatment for aesthetic purposes is limited. In addition, most physicians noted that with PRP, one is "over-correcting" the treatment on the patient—which some claim that is how you get results. A select few also think that other treatments would be best suited for facial or skin rejuvenation or tightening.

 Most physicians already using PRP seem hopeful about the benefits and look to patient satisfaction as more of an indicator of efficacy .

Anyone having first hand experience is welcome to comment.

Why You Should Review Injecting Techniques

Injectables are one of the many popular non-cosmetic procedures. Around 45% of the aesthetic/cosmetic procedures done in 2015 in the US was injectable procedures. It ranks high as an alternative to cosmetic surgery, and it is expected to rise in the coming years. These procedures have received praise by many patients. However, there is a constant need for reminder on injecting dermal fillers and botulinum toxin on patients. It is all in the [method of] injection, declares all practitioners. Additionally, some studies and researchers have emphasized the importance of administering procedures.

Some patients have reported that they have issues with fillers, which have caused adverse side effects like disfiguration of the face and vision loss. These side effects should serve as reminders to practitioners.

In the latest study by Scheuer, Sieber, Pezeshk, Campbell, Gassman, and Rohrich (2017) the authors present how to minimize problems in administering soft tissue filler injections. The authors suggest to inject slowly with small doses. In addition, a serial puncture technique is best in high risk areas. They cover six regions, which are considered danger zones.

Even with experience, physicians and certified injectors could still make mistakes in administering these injections. Thus, physicians must remember these safety concerns and administering of injections.

 Brow and Glabellar Region

  • Digital injection must be applied.
  • The authors recommend that intradermal injections must be done for this area.
  • Blindness and tissue loss are common serious side effects in this region.

Temporal

  • The measures of the danger zones in this area are 2.5 mm lateral and 3.0 mm superior to the peak of the brow (Scheuer, Sieber, Pezeshk, et al., 2017).
  • Deep and superficial injections can be done in this area,
  • The adverse side effect when injecting in this area is blindness.

Infraorbital

  • Practitioners should refrain from injecting deeply
  • Authors suggest to inject laterally and pushed medially
  • Tissue necrosis is an adverse side effect in this region

Lips/Commissure

  • On the commissure, the linear crosshatching method in injecting is safe.
  • Injections done in either lips must be done superficially with around 3mm deep.
  • Tissue necrosis is a serious side effect in these regions.

Nasolabial Fold

  • Intradermal injections can be administered as well injected in the preperiosteal plane.
  • Injections on the deep and superficial subcutaneous and dermal areas in the nasolabial fold are safe
  • On the alar base, only intradermal injections should be administered.

Nose

  • Fillers should be injected deeply and greater than 3mm.
  • As suggested by the authors, any injections done on the tip and dorsum should be in the preperichondrial and preperiosteal planes.
  • Tissue necrosis and visual loss are some of the adverse side effects.

To learn more about the injection techniques, you can watch the video provided by the authors here: http://journals.lww.com/plasreconsurg/Pages/videogallery.aspx?videoId=972&autoPlay=true

Physician Burnout in the Cosmetic Medicine Community

Physicians are under immense pressure, which could lead to exhaustion that may cost their time in the practice but also their patients. In this article, we tackle the causes of burnout in the field of cosmetic medicine.

Physician Burnout in the Cosmetic Medicine Community

It is not uncommon for any working adult to say, “I’m tired, I want to quit”.

Physicians may feel this burden heavier others considering the amount of pressure over a career.

Medscape has done a study on physician burnout and bias last January. Measures of burnout were based on low sense of personal accomplishment, feeling of cynicism, and loss of enthusiasm for work. In cosmetic medicine (i.e. dermatology and plastic surgery), the top reason for burnout is bureaucratic tasks. Other reasons cited were computerization of practice, outcome of the Affordable Care Act, and lower received income.

In an article by dermatologist, Dr. J. Michael Knight, he points out the causes of burnout for aesthetic medicine practitioners (i.e. dermatology and plastic surgery). He further elaborates on the causes also enumerated by Medscape, which contribute to the physical and mental exhaustion of a doctor in cosmetic medicine. Bureaucratic tasks and adoption of telemedicine seem overwhelming to cosmetic practitioners. Time is mostly dedicated to patients, and the growing use of technology in the clinic seems a never-ending race. 

Patients are also a key factor in physician burnout. In cosmetic medicine, old procedures evolve and new procedures are implemented. With the increase of insecurities brought upon by social media and peers, more individuals look to aesthetic practitioners for their source of self-esteem. That demand increases, making it difficult for some physicians to fulfil a patient’s request. That could have a butterfly effect as that one patient could network to more individuals seeking treatment, which could mean less inquiries and walk-ins for new and potential patients. 

As similarly pointed out by the surveyed doctors in Medscape, low income is a cause for physician burnout as well. Some physicians know that costs are piling up, yet are paid less than most. In an example by Knight, they overshadowed by the deals presented by online sites that would entice their patients to purchase cheaper procedures done by non-physicians. Knight adds that it does not help they are working more hours with lesser pay. 

One way to prevent this from happening again is to educate and inform the staff about this occurrence. Acknowledging that physician burnout is important. The fact that other physicians take notice, staff could be made aware of the pressures faced by physicians whether it is medical or practice related. 

Another way is to make time for other activities. It will be difficult considering the demanded number of hours, but it is always recommended to make time for yourself or the activities that you once did which could help take your mind off work. A recommended activity is exercise, as it is one of the best ways to relieve any stress.

Aside from this, Mayo Clinic presented nine strategies to avoid burnout and you could find the resource here: http://www.mayoclinicproceedings.org/article/S0025-6196(16)30508-0/pdf

Article Links:

http://modernaesthetics.com/2016/06/physician-burnout-careers-in-crisis-part-1
http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview
http://www.medscape.com/features/slideshow/lifestyle/2016/dermatology
http://www.medscape.com/features/slideshow/lifestyle/2016/plastic-surgery
https://wire.ama-assn.org/life-career/avoiding-burnout-strategies-senior-physicians
http://catalyst.nejm.org/physician-burnout-endemic-healthcare-respond/
http://medicaleconomics.modernmedicine.com/medical-economics/news/what-price-physician-stress-and-burnout?page=0,0

Patients Do Better With Female Physicians?

Female doctors patients may have lower death and readmission rates. Does that have any relevance to your clinic?

JAMA Internal Medicine published a study about patients favoring women as their doctors. The study is centered on readmission and mortality rate among the elderly. The authors selected random data, in which a third of the physician sample were female. 

For the study, researchers examined hospital readmissions and mortality data for a random sample of traditional Medicare beneficiaries 65 or older who ended up in acute-care hospitals from Jan. 1, 2011, through Dec. 31, 2014. Those data consisted of slightly more than 1.5 million hospitalizations, in which patients were seen by 58,344 physicians. About a third of those physicians were women.

The researchers adjusted the data to account for different characteristics of hospitals and patients, as well as physician characteristics that were not based on sex, such as experience level. These types of adjustments ensure that the study's findings do not simply reflect a situation where male physicians are seeing sicker patients, for instance.

The female physicians tended to be younger––their average age was 42.8 years, compared with 47.8 for men. They also were more likely to have training in osteopathic medicine and to have treated fewer patients.

Findings:

  • Patients treated by women had mortality rates of 11.07%, compared with 11.49% for those seen by men.
  • Readmission rates were 15.02% among those seen by women, compared with 15.57% for male physicians.

Dr. Ashish Jha, co-author of the study, also can’t figure out the discrepancy, raising concern about how men could be thought of not being better practitioners. In addition, he suggests that issues like gender and pay gaps should be further discussed finding the latter unacceptable. 

In the case of cosmetic medicine, a study by Huis In ‘t Veld; Canales; and Furnas, with the latter two being plastic surgeons part of the research as well. The sample consisted of 200 patients, all of which were female. In addition, the study delved in which areas of concern that the patients want to undergo on.

Study findings:

  • Among the sample, 26% chose a female surgeon, and another 12.5% chose the female surgeon (Furnas) in the study
  • Area of concern for those who favored a female surgeon: breast, body, face, and genitalia
  • Generally speaking, gender did not matter so long as the surgeon had a reputation and experience

In another research, a study was published in 2015, modelled from an older study conducted to British patients. The sample consisted of 515 women, with only 500 accomplishing the provided questionnaire. Similar to the above research, gender also did not matter as knowledge and experience were the major factors for choosing surgeons as well. 

Study findings:

  • Among the sample, 190 patients preferred female surgeons.
  • More than half (59%) had no preference to which gender. 

This raises the question as to why patients choose female physicians, which could pose a gender gap issue in practicing physicians. For cosmetic medicine, a reason linked for female patients choosing female doctors is due to the intimate areas of the body. In addition, patients favored female doctors because of more comfort and lesser embarrassment. 

Studies cited:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5131538/
https://www.ncbi.nlm.nih.gov/pubmed/27913412
http://www.modernhealthcare.com/article/20161219/NEWS/161219912

Cosmetic Clinic Embezzlement: Bank Deposits

The following is a story from the Medical Spa Embezzlement & Employee Theft Scams Report which contains information for physicians and medspa owners to understand these scams and find out how to protect your cosmetic clinic.

The complete report is available for free to all Medical Spa MD members.

Beware anyone taking complete control of the books and the bank deposits.

Our embezzlement story has some classic elements: a break down in financial control procedures, an employee (bookkeeper) showing behavior changes and a drug problem, and a manager and a boss not paying close enough attention.

I have a solo private practice of plastic surgery with skin care services. At the time, we readily accepted cash payments, even for surgical procedures.

My practice manager was responsible to review the daily close, checking the work of the full-time bookkeeper. The manager was to make the bank deposit daily and attach the deposit receipt to the daily close. I would normally check our financial statements at my meeting with the manager every other week. It turns out that we missed one of our meetings, (because of schedule conflicts, being “too busy,” or the usual excuses/reasons that we end up skipping an administrative meeting) and I didn’t ask to see all the reports, anyway.

I became concerned when I noticed some behavioral changes in my bookkeeper, including erratic hours, late for work, leaving the office during the day.

When I discussed this with my manager, she noted that some of the daily reports were coming inconsistently.  I asked if the manager was getting the daily close and making the bank deposit;  my manager (now “buddies” with the bookkeeper) explained that the bookkeeper had taken this over “to help, since she saw I was so busy.”

The short story: the bookkeeper was pocketing all the cash and depositing/ recording only the credit card and check deposits, “cooking the books” to try to hide the missing cash. Fortunately, we discovered the ploy within a short time; our audit showed a loss of less than $11,000.

I brought in an HR attorney for the termination of the bookkeeper and the manager and filed a report with the Sheriff.

We subsequently learned the bookkeeper had developed a Vicodin/codeine habit from a fairly recent injury.

When the bookkeeper left the state, without forwarding address, and “could not be found,” we did not invest in prosecuting, on the advice of the attorney.

Lessons:

  • Have secure financial/bookkeeping controls: Have a daily close. Make sure that the person who collects is different from the person who checks/records. Use a third person to make the deposit.
  • Verify compliance with these procedures (“Trust, but verify!”).
  •  No matter how “busy” you get, check the daily deposit.
  • Hold yourself accountable,as well!

Erratic behavior is a warning sign of something worse. Trust your gut. If something “doesn’t seem right,” check it out, sooner rather than later.