Inside Sona Medspas Part 6: Medical Directors & Physician Oversight

 Medical Spa MD - Inside Sona Medspas Part 6: Physician Oversight

These posts are written by former Sona Medspa owner Ron Berglund to provide an inside view of the way medical spa franchises recruit, train, and support their owners as well as detailing some of the problems with medspa franchises.

Read Part 1: Why I bought a Sona Franchise l Part 2: Sona Promises l Part 3: The Franchise Pitch l Part 4: Legal Structure & Revenue Sharing l Part 5: Opening a laser clinic

Sona Medspas: Physician Oversight

About medical oversight at Sona?

What did Sona tell us?  Sona gave us some rather generic information about the requirements for a medical director as they were aware of the pertinent statutes and regulations.

Sona's manuals included a generic "Medical Director's Manual" and "Nurse Manual" which covered some of the relevant concerns. Their franchise documents and verbal statements naturally put the burden on each individual franchisee to get legal counsel in their state to cover all the bases, etc. They provided us with a generic "standing orders and protocols" document for the nurse to provide to the treating nurses (or "laser technicians") which provided a good start for most.

I know that in California and a number of other states the standard Sona model did not work and these franchises had to have significantly more creative (and expensive) legal work done to structure the operation properly. In a number of other states the clinics had to be located literally "across the hall" from the medical director- or the clinic had to incur significantly higher expense to have a physician actually "on sight" to comply with that state's laws and medical board regulations. (Read: Can a non-physician employ a physician.)

In Minnesota we employed the standard off-site "medical director" model which required a licensed physicians to "oversee" clinic operations and protocols. (Read: Physician oversight in medical spas l Mid-level providers in medical spas)

Sona was strict about requiring our docs to review and either sign or initial each patient chart and each entry on every treatment log to double check that proper parameters were being used, etc. We also had a decent system set up requiring "adverse event" reports for every "incident" which was also sent to the corporate office each month. Fortunately, we had very few adverse events over the years--partly because the majority of our treating nurses were primarily interested in CYA and not having any of their patients experience "discomfort" or causing any minor burns or blisters. Due to the very conservative teaching and recommended parameters furnished by Sona our BIGGEST problem through the years was with EFFICACY.

The majority of our treated patients still had significant hair remaining after five treatments-- which caused most Sona operations to slowly crumble due to patient dissatisfaction and demands for additional free treatments, etc.

Did your system work for your medical directors?

The main problem encountered by both Minnesota clinics for the first few years of operation was keeping a medical director in place.

 

We went through a succession of medical directors for a variety of reasons-- retirement, relocating, not being comfortable with the procedures or the risk involved (vs the small fee we were willing to pay the medical director which ranged from $1500 to $2000 per month per center).

 

The most outrageous situation was our young dermatologist who was forced to give up her "moonlighting" job due to an edict issued by her boss-- who coincidentally was the head of her department at a major university and also owned a competitive laser center in the same city!.

 

Medical Oversight Problems?

The centers in Minneapolis and St. Paul actually operated without incident for six and four years respectively without incident until a female police officer treated in St. Paul (Woodbury) experienced a minor burn typical of treating skin with a "base tan" with high parameters required for Alexandrite laser hair removal treatments beyond the third or fourth treatment when high parameters are required for efficacy. 

 

Even though I told this woman that our nurse absolutely followed our established laser parameters, etc. she insisted that the nurse had done something wrong so she lodged a formal complaint with the Minnesota Nursing Board. The nursing board did a preliminary investigation and shipped the case to the Minnesota Attorney General's office where it is still under investigation. All this attention caused me to take a close look not just at the Minnesota statutes and regulations covering physicians but also the Nursing Board Act.

 

I was very surprised to see the level of detail required to legally employ nurses to operate lasers in Minnesota. I wrote a separate blog on this topic in another section of the web site where I asked if anyone out there was aware of a college or university that could provide a 30 hour course on the use and operation of lasers required by the nursing board.

 

They also require a very detailed delegation /prescription document from the physician to the nurse similar to what a nurse would need to legally dispense prescribed medications.

 

What questions did the staff have about this?

In order to try to avoid getting my staff riled up and worried about these "legal" issues (and the fact that they may have been guilty of "practicing medicine without a license"), where they were potentially  at risk of losing their nursing licenses, etc., my usual practice was to say as litle about this as possible.

 

My nurses were always well trained (especially after we started doing our own in-house training) and always treated patients cautiously. As we became more experienced we began doing more and more test spots-- even though these were not encouraged by Sona for the 80% of our patients who were Caucasian. 

 

After our business had collapsed financially in early 2006 we actually operated for several months without a medical director because my partner refused to dig deep enough to pay for one and we were primarily treating existing patients by this time.

 

During the late spring of 2006 my experienced nurses started to ask directly who the medical director was and they noticed that nobody was reviewing the charts on a weekly basis as had been done the previous three years. At this point I told them that my personal friend (a dermatologist who had been traveling regularly between Florida and Minnesota the past five years and had served as our director for several months previously) had agreed to act as our medical director for the time being. This was a stretch, of course. It is tough to do things right when you are stone cold broke!

 

Whart were your concerns with the medical aspect of the business? 

Once again-- hind sight is 20/20. But in the aftermath of my Sona experience I am more convinced than ever that MEDSPAs are not the place for entrepreneurs and non-medical businessmen. Most of the "doc in the box" business models have collapsed-- and I believe more will soon follow.

 

I believe the survivors will be the physicians who are actually owning and operating the clinics. This makes sense marketing wise-- as docs can market extensively and much more economically to their existing patient population-- as well as legally. I would venture a guess that a prospect is five times more likely to respond to a direct mail piece or a newsletter that comes from her physician than a mailer from an unknown operation that-- for all she knows --could be operated by any flake out there (maybe even a telephone call center headquartered in Michigan!).

 

Ron Berglund

If internists ran medspas.

Kevin MD thinks this is the 'best scrubs ever'.

Silhoutte Sutures: Threadlifts with bells and whistles.

More competition for the Threadlift, Aptos Threads, and the rest of the tricky non-surgical suture suspension lifts.

 
From the KMI Silhouette site: "SILHOUETTE MID FACE SUTURES ARE FDA 510(k) cleared for market" , not an extravagant claim for a suture made from 3-0 polypropylene.

Compared to the conventional barbed suture, the unique patent pending design of Silhouette MID-FACE Suture allows for tissue growth inside and around flexible, absorbable hollow cones, therefore creating a much stronger anchoring mechanism.

The Silhouette MID-FACE Suture is different than barbed sutures. Barbed suture is created when cuts are made in the shaft of conventional sutures, weakening the inherent strength of the thread. Silhouette MID-FACE Sutures utilize clear, flexible, absorbable cones. Once the cones are completely absorbed, tissue growth around the small knots will allow for tissue suspension.

This groundbreaking Silhouette MID-FACE Suture, designed by KMI, is manufactured using a 3-0 polypropylene substrate. This allows for smaller knot tying in the temporal area. Furthermore, these sutures can safely be removed after the cones are completely absorbed.

Via plasticized:

The thread lift, suture lift, feather lift, contour threads- they're all based on the same concept. Small incisions are made, barbed sutures are passed through the area area to be lifted, and tension is placed to move the tissue in desired direction. The reviews and anecdotal reports from surgeons are less than stellar in most cases. Its been adopted mainly by "non-surgeons" to offer facial rejuvination to pre-existing laser and botox patients. The newest technology in the chain of threads is called the Silhouette suture. It uses a "cup and ball" design rather than a barb. Will it be an improvement over previous designs? Judge for yourself, here.

First, this has got to be one of the worst web sites I've ever seen. The execution of this site alone is enough to make me question if this is a real company or two 14 year old myspace kids who want to break into the medical field. Not to mention that there are entire sections with the dreaded 'coming soon' banner. It does not breed confidence.

Surface performed Aptos and Threadlifts years ago when they first came out. We stopped for three reasons: One; threadlifts don't work well enough. The effects are so minor, even in cases with good results, that it wasn't a great alternative in our opinion. Second; There were enough complications that our docs became un-enchanted. Third: We developed Point Lift .

In my own humble opinion, threadlifts by themselves are just not effective enough given the hit-and-miss problems with patient satisfaction and complications. 

Any comments from physicians with differing points of view are welcomed. 

Medspa Q&A: Legal: Can a non-physician employ a physician?

 This question pops up regularly so I'll bring it over here and answer it.

Question: Is it illegal for a non-physician owned medspa franchisee to employ a medical director? Can a non-physician owned medspa franchisee (physician owned franchisor) legally employ its own medical director? - ELH

ELH, Thanks for the question. Here's the answer. 

Answer: A non-physician can not employ a physician OR own a medical practice that employs a physician OR partner in a medical practice with a physician. Only physicians can employ or partner directly with other physicians.

Most of the generally accepted principals of business do not apply for one simple reason; You, as a non-physician, man not be involved in the practice of medicine in any way. 

Sure, hospitals and HMO's employ physicians but they have lobbyists in Washington, you do not. This is an absolute so I'll state it again, non-physicians can not employ physicians as employees. There are no exceptions (no matter what a medspa franchise might say.) Read the WSJ article on unhappy medspa owners here.

Clarification: That non-physicians can not employ physicians is an absolute rule. However, there are ways in which non-physicians can do business with physicians but they require a careful legal setup that doesn't violate the law.

• Example 1: You have a spa with a visiting physician who comes in and performs Botox and Restylane. You 1099 them at the end of the year as an independent contractor. WRONG: You can not do this as you would be employing a physician.
  
• Example 2: You have a spa and a physician solicits you to allow them to come in and treat your clients. The physician and you plan to split the revenue. WRONG: This would put you in a partnership with the physician as well as potential trouble for splitting fees. Big, big, trouble.

 Additional: In situations where a medical spa is set up incorrectly, the physician will be at risk. Every malpractice policy will be voided if a physician is practicing outside of the law, which this is. A physician who gets in trouble in a situation like this will be completely on her own and my best guess is that the prosecuting party will be happily pointing this out in court... not a good place to be.

The non-physician will be at risk as well. A physician can shut down your business at any time by refusing to extend their oversight to any medical treatments. The state could also be a problem since if it's found that you own a 'medical' business, you'll be shut down by the state tute suite.

You should be very wary about how you state what you own. While I've used examples of what you may not do, I've stayed away purposefully from exactly how you can legally set this up since I don't want to give advice that someone might follow and get themselves in trouble. Consult a lawyer who specializes in this area of medicine.

Angry penis removal; zip, zap.

 Sometimes you just can't make this stuff up.

The unpleasant business of the angry, penis removing surgeon.

...Surgeon Naum Ciomu, who had been suffering from stress at the time, had been operating on patient Nelu Radonescu, 36, to correct a testicular malformation when he suddenly lost his temper.

Grabbing a scalpel, he sliced off the penis in front of shocked nursing staff, and then placed it on the operating table where he chopped it into small pieces before storming out of the operating theatre at Bucharest hospital.

They said he had been under stress and had lost his temper after he accidentally cut the man's urinary channel and 'overreacted' to the situation.

...Vice-president of the Romanian Doctors Union, Vasile Astarastoae, said: 'Ciomu's case is a dangerous precedent for all Romanian doctors. In future doctors may have to think very carefully about what work they undertake.'

...The director of the ophthalmology hospital in Bucharest, Dr Monica Pop (yes, actually her name), agreed saying that doctors would in future avoid any cases where they could end up in court having to pay damages.

She added: 'Doctors in Romanian earn too little to be able to pay amounts like this. As a result it will be entirely fair if they only accept cases where they cannot make mistakes. The only way this can be avoided is if the insurance companies cover all the risk.'

I guess the guy should count his lucky stars it wasn't brain surgery. 

Medspa Q&A: Planning ahead for your medical spa.

This post is part of Medspa Q&A, questions that I receive from physicians. If you have a question you'd like me to answer, you can email it to me here.

Hello Jeff,
Thank you for your reply.

I graduated medical school in the summer of 2003, in Denmark, Copenhagen, and have since completed my internship (11/2 years) and worked temporarily in a general practice in Norway. I am currently on maternity leave and will be starting a PhD program in the summer of 2007.

I’ve always wanted to be a plastic surgeon. Plastic surgery seemed like the natural choice for me as I’ve always been very creative and love the combination of aesthetics and surgery. I love the challenge of correcting disfigurements and doing cosmetic enhancements.

I’ve had several opportunities to shadow other plastic surgeons and found their work exciting, but also somewhat crude and that’s why I really like the idea of non-surgical cosmetic medicine.

I have had plans for a long time of running my own clinic someday. My sister is a cosmetologist/spa manager and she introduced me to your website. We have often talked about working together and incorporating our different, but very complementary skills into a health enhancing, cosmetic business.

Until I read your website, I had no idea that medical spas existed. It seems like the perfect model for us. We have already committed to opening a medical spa.

I was hoping that I could get some information from you on how to start up such a practice, what I’d need and where I could be taught how to use fillers (e.g. Restylane, Botox, Liposolve, laser, point lift and other anti-aging techniques. I plan to learn as many techniques as possible at the same time as I’m doing my PhD. A bit of a mouthful, I know. I hope to start up the medical spa shortly after the end of my PhD program, which is roughly going to last 3 years. It will probably take longer than I anticipate and I’m also ready for that.

I’d be happy for any advice or information you could provide.
Sincerely,
Dr. E B...

Ask a question, get an answer. Here goes...

It’s certain that I know a lot about my own company Surface. I’ve opened a few clinics myself and consulted more than a few doctors opening medical spas. You’ll have to decide if what I’m about to write makes any sense for your situation.

Decide how much money you’ll need to make: Since you’re at the beginning of your career, you’re in a much different situation than the many physicians I deal with who are looking to change their practice or add to an existing clinic. One of the benefits is that your overhead is probably as low as it’s going to be for a while. (Existing practices offer different challenges.) So ask yourself; How much money do you need to make.

Many doctors make the mistake of opening a new medical spa and only after they’re in business do they figure out that they’re not able to make the money they need to take home and keep the business afloat. When you’re thinking about your startup and recurring costs, keep in mind that you’re going to have to eat. Can you live on the cheap for a while? There’s a distinct possibility with any business. Don’t think that you’re going to be taking home 20k the first month, or any month during the first year.

Decide what kind of medical spa you want to start: Perhaps the most common problem that doctors get into is the leaping before you look strategy of business. Here’s a tip: Day spas do not make any money. As a rule, the average margins for day spas in the US is 6%. Medical practices generally lie in the 50-60% margins. Physicians hear day spa and start thinking this is great. The day spa will bring in all these patients and my hard working staff will kick them upstairs for face lifts and boob jobs. Sorry. It doesn’t work that way.

So, decide very carefully about the medical spa you’re starting. The answer to this question will largely depend on what your own background is and where you have connections. What is your current situation? How is it structured? What’s the legal and liability issues? Who owns what? What’s the offering and pricing? Who’s responsible for the advertising? Who’s running the operations? Get the picture? Not easy to know in advance but there it is. This is Retail Medicine and it’s significantly different from the mainstream.

Find someone who knows more than you: This is not a recommendation buy a medspa franchise or hire a spa consultant. The truth is; The only people I recommend that you really talk to are already running successful medical spas of the type you’d like to emulate. Salesmen, professional trainers and spa consultants are in the business of retailing their services to you. (Read: Inside a Sona medspa franchise series.)

You’re probably going to research training, seminars, and conventions on the net. You’ll find lots of people telling you that they know the secret. I once actually sat in a training session at the NY Medspa Expo with the title: Make $200,000 per treatment room. Right Now! The expert advice to turn each room into a gold mine? Never let a patient leave without rescheduling a future appointment and buying at least $100 in retail. Utter tripe and a good way to kill your own reputation. I could go on ad nauseam but you get the idea. Find someone who’s in the business of running medical spas. Not a doctor who already does Botox, they can’t teach you what you need to know.

OK, so that said, what does it take to start a medical spa? Well, here are a few principal ways I’ve seen physicians start cosmetic practices.

Start with a lot of money: Get $500,000, hire the best people you can find, and then count on not making much money for the first 6-12 months until you’re able to build a client base and some sort of reputation. Of course you might make any number of mistakes in hiring, advertising, or choosing the wrong technology.

Medical Spa as a sideline: Build your aesthetic practice alongside your existing one. This is probably the most common route. It seems the easiest and probably has the least risk. But it still has challenges. When you hire full time employees your burn rate can skyrocket quickly.

(There’s often the esthetician who has ‘hundreds of clients’ that they’re willing to bring in exchange for a regular paycheck. Sorry. Any aesthetician who has hundreds of clients is not looking for a job. I can’t tell you the number of time I’ve heard variations on the ‘the aesthetician was supposed to bring the clients in’ theme.)

The advice here would be to start slowly and learn fast. If you’re going it alone, spend as little as possible until you have to. Never buy redundant technologies. Get professional help from a reputable advertising agency with medial spa experience.

Get lucky: I know a few good luck stories when it comes to starting a medical spa but not many and It’s not the kind of odds you’d like to bet on.

Hope this helps.

Protecting your medical spa from embezzlement.

Employee (and accountant) embezzlement is rampant in medical clinics. Medical spas, laser clinics, and plastic surgeon offices are no different. We've even had the unpleasant experience of a physician embezzling from one of our clinics. 

Download the free, members-only report: Medical Spa Embezzlement & Employee Theft Scams

Submit your own story about medical clinic embezzlement or theft here

Entrepreneur.com: Protecting your medical spa from embezzlement.

So what should you do to ensure that you have controls in place to minimize the opportunity for embezzlement at your company? Here are some tips:

1. Don’t leave cash lying around in an unprotected spot. It can easily disappear, and you don’t want to tempt people by being careless.

2. Don’t use signature stamps for checks. They're too easy to misuse. Sign the checks yourself with a pen.

3. Minimize the number of employees who have signature authority on your bank account. Too many hands in the pot can lead to disaster.

4. Make deposits nightly so that excess funds aren't left onsite...

Update on 2012-08-28 21:56 by Medical Spa MD

The Medical Spa Embezzlement & Scams Report

Download the new Medical Spa Embezzlement & Employee Theft Scams Report 

Medspa Advertising: White space & upscale.

Advertising is a common concern for cosmetic physicians and medispas. (Medspa Advertising & Marketing Discussions l Advertising & PR Category)

One of my businesses is an advertising agency and I understate the situation to the extreme when I say that the discussion of what constitutes good design and what clients think is effective is something of a joke in the industry. Clients see white space and instantly want to put something in it which aggravates designers to no end. First, because it really does look ugly, and second, because it makes it look cheap (and more than anything else, creatives hate cheap).

You can see that the Surface print ads we run have a fair amount of white space. Some of them are almost completely free of copy. We do this because it's effective and it speaks to our target audience.

I acknowledge of course that this site is not a blazing example of the use of white space or fantastic design skills. Why? Information is a tricky thing on line. I've opted to use the 'find it now' strategy of keeping the most used links readily available.

A list Aparts post on white space is spot on. The excerpt below is discussing a direct mail piece.

Take the following example.

Figure 3. Examples of direct mail vs. luxury brand design

The content is the same on both designs, as are the other elements, such as photography. Yet the two designs stand at opposite ends of the brand spectrum. Less whitespace = cheap; more whitespace = luxury.

A lot more goes into brand positioning than just whitespace, but as a brief lands on your desk for a luxury brand, it’s very likely that the client—and their target audience—expects whitespace and plenty of it to align the product with its competitors.

If your ads look like the first example, you're shooting yourself in the foot. There has never been a woman (and our patients are 93% female) that has ever wanted to have any medical treatment on her face performed by a medspa because it was the cheapest.

If you're in need of better advertising, you can contact Wild Blue Creative here. 

Medspa Patient Categories: Glogau Scale

Glogau Classification Scale – Photoaging groups

Skin type	Age (years)	Findings
1, Mild	Early 20s or 30s	Early photoaging: early pigmentary changes, no keratoses, fine wrinkles
2, Mod.	30s to 40s	Early to moderate photoaging: early senile lentigines, no visible keratoses.
3, Adv.	50 plus	Advanced photoaging: dyschromia and telangiectasia, visible keratoses, wrinkles at rest
4, Sev.	60s or 70s	Severe photoaging: dynamic and gravitational wrinkling, multiple actinic keratoses.

Recommended therapies based on the Glogau wrinkle scale

Type 1 skin

Education, sunscreen, and topical antioxidants
Tretinoin
Alpha hydroxyl acid (AHA) lotions and superficial (glycolic acid) peels
Microdermabrasion (monthly)
Botulinum toxin neuromodulation
Photorejuvenation treatments (intense pulsed light)

Type 2 skin

Education, sunscreen, and topical antioxidants
Tretinoin
AHA lotions, superficial peels (glycolic acid)
Medium depth peels (trichloroacetic acid [TCA])
Botulinum toxin neuromodulation
Soft tissue augmentation
Photorejuvenation treatments (intense pulsed light)
Combination procedures (Botox plus fillers, Thermage)
Nonsurgical (radiofrequency-mediated Thermage); face, neck, and eye- brow lifts

Type 3 skin

Education, sunscreen, topical antioxidants
Medium depth peels (TCA)
Photodynamic skin rejuvenation (intense pulsed light plus Levulan)
Soft tissue augmentation
Botulinum toxin neuromodulation
Combination procedures (Botox plus fillers, Thermage)
Nonsurgical radiofrequency-mediated (Thermage); face, neck, and eye- brow lifts
Minimally invasive face lifts (Pointe lifts)

Type 4 skin

Education, sunscreen, and topical antioxidants
Botulinum toxin neuromodulation
Photodynamic skin rejuvenation (intense pulsed light plus Levulan)
Soft tissue augmentation
Combination treatments (Thermage, Pointe lifts, Botox, and Fillers)
Surgical face-lift, brow-lift, blepharoplasty

Plastic Surgery: Patient Lotteries

Plastic surgons are, 'appalled at this new scheme but unfortunately not surprised'.

Plastic surgeons have criticised a company for running the world's first cosmetic surgery "superdraw".

The British Association of Aesthetic Plastic Surgeons (BAAPS) accused Europa International of "plumbing new depths".

It said the company was using marketing gimmicks to attract customers to surgery abroad.

But John Babbage, co-founder of the Prague-based company, said there was no difference between somebody winning surgery, and paying for it.

People are encouraged to enter the company's draw via text or phone through a section on their website entitled "win your surgery for just £1.50".

The monthly draw gives people in the UK the chance of winning £6,000 towards cosmetic surgery.

Hat tip to Kevin MD 

Inside Sona Medspas Part 5: Opening a laser clinc.

Medical Spa MD - Inside Sona Medspa series Part 5: Opening a Sona Clinic

These posts are written by former Sona Medspa owner Ron Berglund to provide an inside view of the way medical spa franchises recruit, train, and support their owners as well as detailing some of the problems with medspa franchises.

Read Part 1: Why I bought a Sona Franchise l Part 2: Sona Promises l Part 3: The Franchise Pitch l Part 4: Legal Structure & Revenue Sharing

Opening a Sona Laser Clinic

 

How did you hire? 

My partner and I hired our first employee several months before our build out was completed, so she had to be very patient. She was a "friend of a friend" and after a couple interviews we decided she would be an excellent choice for the key position of lead sales consultant. She had an extensive operational background based on her experience running a vererinary clinic for her former husband. She had also recently completed cosmetology/estheiology school, and she had an oputstanding personality. The only thing she lacked was actual sales experience, which concerned me a great deal. I hoped that her other qualities would make up for lack of actual sales background.

 

Shortly after hiring her we hired another "friend of a friend" for the extremely important "front desk" position. Once I had a good idea about our projected opening date based on the progress of our 2850 sq. ft.build out I was able to schedule our staff training visit to corporate headquarters in Virginia Beach which took place over a 10 day period in February, 2003. I ran several newspaper "help wanted" ads but was unable to hire a nurse to operate the laser in time for the nurse to accompany the rest of us to Virginia Beach. We had to hire a full time and part time nurse as soom as we got back and arrange for Sona to send a training nurse to Minnesota in late February to train them. We ran several ads in the St. Paul Pioneer Press and were successful in filling the positions but did not give ourselves adequate time to screen a sufficient number of candidates to allow us to find stellar employes for these extremely critical positions. 

 

What support did Sona provide? 

Sona provided support for our opening by providing fairly decent operations manuals and clinical manuals, providing OK staff training during our visit to Virginia Beach, and sending an experienced laser nurse to Minnesota to train our full time and part time nurses. Sona also sent several people to St. Paul to assist us with set up and installation of our equipment, furnishings and decor, as well as to participate in and "assist" with our "grand opening" which was held in early March, 2003. 

 

What was Sona good at?  

Once again, hind sight is 20/20. Therefore, as I reflect back on the content and delivery of the training and support Sona provided I am able to evaluate whether or not Sona actually delivered what they promised they would, as well as whether or not the guidance and training provided was beneficial or detrimental to the success of the operation. Perhaps more significant than any misleading claim or breached promise Sona made was the fact that it touted having a "proven business model" and a "formula for success" when this in fact proved NOT to be the case. Aesthetic lasers and the services available today have been cleared in the U.S. for these popular indications for less than a decade.  The medical spa pioneers of the early 2000s have barely had time to truly figure out how to properly market, sell, and deliver these services properly. Many entrepreneurs had the idea that opening a medspa would be similar to opening a Kinkos-- and as many of us have discovered nothing could be further from the truth.

 

Sona actually did a fairly decent job of helping to train my original staff on the critical components of laser hair removal sales and delivery in accordance with the Sona business model in effect in early 2003. That model has changed significantly since that time as the Sona management team has tried to react to a host of franchisee failures, complaints and litigation. Their help with set up-- even including hanging pictures on the walls and showing our nurses how to properly arrange storage cabinets-- was excellent. Their assistance with our "grand opening" was, however, worthless. And based on four years of experience trying to profitably operate a med spa I can certainly say that their promised guidance and support along the way was pathetic.

 

What did they say they would do that they did not do? 

Sona's extensive list of breached promises was previously detailed in an earlier section. 

 

Did I have a business plan? 

My partner had financials and an operating budget from his Minneapolis operation which we used as the basis for a "rough" business plan for the new St. Paul center. I was able to easily peg our monthly expenses for the critical elements of the operation including rent, Sona's "laser placement (revenue share) fee", insurance, postage, printing, utilities, credit card fees, etc.  Payroll expenses would be based on the number of employees needed to run the operation (which would-- of course-- increase as the number of clients needing treatments increased), and the amount spent each month for advertising was based on Sona's recommendation of a minimum of $15,000 per month up to $100,000 gross revenues and 15% of revenues thereafter. No matter how "scientific" you try to be with a business plan, however, you really have no idea how many of your advertising dollars are going to result in lead calls, for example. Estimated costs are pretty easy to come up with, but you need a crystal ball to determine what your anticipated income might be.  Three very significant things that impacted my operation long-term were the extremely SEASONAL nature of aesthetic services (in Minnesota, June through December can be hell), the low-margins actually experienced when all expenses are accounted for, and the tendency of advertising sources to diminish after a period of time.  For example, for our first year of operation the St. Paul Pioneer Press was a very effective and consistent advertising medium for us. However, after about 18 months the costs of leads and sales generated in our primary newspaper vs. the costs of the ads made it a questionable source to continue with. After a period of time, it seems that every resident of the St. Paul metro area  who actually reads the paper (and the younger market in increasingly NOT reading newspapers) had seen our ads multiple times. After a while, the ads seem to wear out their effectiveness. Radio ads-- on the other hand-- almost NEVER cost justified. Direct mail and quarterly newsletters would have probably been our best place to spend money. Unfortunately, Sona never emphasized these avenues so by the time we thought about it it was already to late!

 

LipoSonix: High Intensity Focused Ultrasound (HIFU) for your medspas body scuplting.

Tested on pigs with slow metabolism, LipoSonix wants to be the first to have a technology solution to liposuction. No word yet on if the test pits show impoved body image.

From the LipoSonix site: 

LipoSonix is taking a rigorous, science-based approach to technology development. All new clinical studies begin with the demonstration of patient safety and then progress to detailed efficacy studies that provide evidence for the aesthetic benefits of our device.

LipoSonix achieves targeted reduction of tissue volume by precisely focusing high intensity ultrasound energy to cause thermocoagulation of adipose tissue. A custom designed ultrasound transducer delivers energy across the skin surface at a relatively low intensity, but brings this energy to a sharp focus in the subcutaneous fat. At the skin surface, the intensity of the ultrasound energy is low enough so that no damage occurs. The focusing of the ultrasound beam at specific depths beneath the epidermis, combined with proprietary application techniques, results in adipose tissue thermocoagulation. This result is achieved through several mechanisms of action, including temperature rise secondary to direct absorption of ultrasonic energy and mechanical processes such as cavitation, streaming, and shear forces with their inherent thermal effects.

Once adipocytes have been disrupted, chemotactic signals activate the body's inflammatory response mechanisms. Macrophage cells are attracted to the area to engulf and transport the lipids and cell debris. This results in an overall reduction in local adipose tissue volume. The goal is to achieve precision that will result in effective non-invasive body sculpting.

LipoSonix' initial efforts involved extensive pre-clinical in vitro and in vivo testing to demonstrate proof of principle and refine specific treatment protocols. Initial human feasibility studies were performed on patients undergoing abdominoplasty surgery, allowing for detailed evaluation of the patho-physiological process. The safety of these trials was assessed through evaluation of extensive blood panels, gross pathology, histological analysis, and non-invasive imaging (including computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound.

Abstracts from Plastic Surgery 2005 (.pdf), 2006 (.pdf); the American Academy of Dermatology 2006 (.pdf); and the American Society for Aesthetic Plastic Surgery 2006 (.pdf)

(hat tip: Engadget , Medgadget, & Gizmag)

Anti-Aging: Skin, sundamage, & twins.

From Elle Magazine & Darrick E. Antell, MD

Though she has a sense of humor about it now—Block calls herself "the bad twin"—at the time, she was disturbed by the proof that years of excessive sun exposure had made her look so much older than her (formerly) identical sister.

Gay Block at 59 (left) with deep wrinkles and sagging skin. Her twin, Gwyn Sirota, spent less time in the sun, and it shows.

Eye of Science: Life in the microcosmic world.

Eye of Science

01. Medical science: skin, lateral cut
Electron microscopy

A section through human skin. The skin layers, from top to bottom, are the stratum corneum (flaky, brown), composed of flattened, dead skin cells that form the surface of the skin.

The dead cells from this layer are continuously being shed and replaced by cells from the living epidermal layer below (red) The lowest layer seen here is the dermis (grey-brown, lower centre), a thick layer of fibrous connective tissue that supports and nourishes the epidermis. In the middle, a sweat gland can be seen. Coloured scanning electron micrograph, Magnification: x50.

Inside Sona Medspas Part 4: Legal Structure & Revenue Sharing

Medical Spa MD - Inside Sona Medspa series Part 4: Legal Structure & Revenue Sharing

These posts are written by former Sona Medspa owner Ron Berglund to provide an inside view of the way medical spa franchises recruit, train, and support their owners as well as detailing some of the problems with medspa franchises.

Read Part 1: Why I bought a Sona Franchise l Part 2: Sona Promises  l Part 3: The Franchise Pitch

The Medical Spa Legal Structure & Revenue Sharing

Who owned what? 

My partner and I set up an LLC to own and operate our laser center. Since our intention was to "dominate the market" in the Twin Cities, he and his daughter executed both Sona franchise agreements and "area development agreements" for the greater Minneapolis metropolitan area and he and I did the same for the St. Paul area. The agreements were rather vague as to the number of centers required to maintain "exclusivity" for the Twin Cities, but these concerns soon became semantics due to the inability of the business model to generate real profits.

How was the money divided?

My partner and I were 50/50 owners of our LLC. Sona had no ownership interest in the LLC, but shared in revenues generated each month by virtue of the "revenue sharing" provisions contained in the franchise agreement.

The standard franchise agreements contained a sliding scale ranging from a 27% share of gross revenues at the $60,000 monthly revenue level which percentage dropped to under 20%  when monthly revenue exceeded $100,000.

My partner and I received a slightly reduced revenue share percentage which started at 22% of gross revenues due to the fact that my partner was one of the original Sona affiliates. The revenue share payment encompassed the franchise royalty, laser lease and laser maintenance and service.

What did we have to do? 

In accordance with the franchise agreement, we had to follow all the Sona dictates and limitations on our operations-- right or wrong-- or be faced with an action for violation of the agreement. 

During the first year of operations we were limited to performing strictly laser hair removal services utilizing the Sona/Cynosure Alexandrite and Nd:YAG lasers. We could not do anything else-- or use any other equipment-- during the first year of operations. We were not even allowed to sell any product. I got in trouble for trying to sell SkinCeuticals sun block as Sona didn't even offer a sun block!  We wererequired to spend a minimum of 15% of gross revenues on advertising and marketing but were encouraged to spend more. At this point we were being told that the "successful" operations such as St. Louis were spending over 20% and were doing gangbuster business. Sona was of course happy to see its franchisees spending enormous amounts on advertising since Sona's revenue share was based entirely on gross revenues. Whether a franchisee actualy made any real PROFIT or not was not their concern.   

During the second year of our tenure Sona introduced a very "half baked" program for skin rejuvenation services including the DiamondTome microdermabrasion system, the VISIA skin analysis system, the Cynosure "Mini V" pulsed dye laser, and several other pieces of equipment.

How much control did Sona have? 

Due to Sona's extremely one-sided franchise agreement, they had pretty much 100% control over our operations. We were free to hire our own employees and medical director and determine how much to spend -- and where-- for advertising, but that was pretty much the deal. Sona furnished many sample print ads but allowed us to create our own so long as we gave them an opportunity to "approve" them before publication.

Endotine Ribbon: Thread Lift / Featherlift replacement?

Coapt has released a new 'thread lift' suture, the 'Endotine ribbon'.

It is a device with two rows of small spikes that can be used with tiny incisions to lift areas on the face, similar to the thread lift. The device is absorbed by the body in about 6 months.
The long term results from products like this remain to be proven.

From the Coapt site:

The ENDOTINE Ribbon is a bioabsorbable implant designed for lower face suspension of the jowl and neck. It is made of 82/18 L-lactide/glycolide, similar to LactoSorb™, and consists of a long slender leash with 34 tines that can be customized to the patient’s anatomy and procedure by cutting either the tine bearing area or the smooth leash area. When implanted, the Ribbon engages the deep anatomy (SMAS or platysma) of the newly created surgical plane, and is sutured to the temporal or mastoid fascia to maintain the vector of lift until biological healing takes place. The Ribbon replaces conventional suspension suture used in lower face and neck suspension surgery, and is an effective alternative to ‘thread lifting’.

Via Plasticized

Many patients say they can feel the devices, and have discomfort in the area of implantation, even after 6 months. Additionally, the cost of these devices can be as much as more traditional rejuvination procedures such as facelifts, which probably last much longer and have what many would say are more reliable effects.

We gave up on thread lifts / featherlifts long ago after seeing poor results, dissatisfied patients, and other problems. Point Lift was develope to deal with these shortcomings and is gaining very quick acceptance by those trained in the procedure. We'll see what happens.