Medical Spa Key No. 7: Create the Optimal Menu of Services

In many ways, aesthetic practices and med spas are like restaurants. The core of the business is customer service, and oftentimes offering the right menu can make the difference between the success or failure of the enterprise.

Just as a first class restaurant strives to create a unique menu that will distinguish it from all its competitors, you should make it your mission to offer a service menu that offers not only all the most popular med spa treatments but also the most cutting edge, innovative procedures available.  Many of the prospects you will encounter are surprisingly well informed and will be looking for a med spa that can exceed their expectations. Some of these prospects already know the results they are looking for. They will look to you and your staff to guide them to the optimal combination of services, procedures and products to help them achieve their goals. On the other hand, many of your prospects will not have a clue about the specific technologies or procedures involved -- they will simply want to know they are in good hands and will look to you to recommend the best treatments and products for them.  

You will need to decide how broad a range of services you will offer. You may decide to offer all the popular services so your med spa will appeal to a diverse, market-driven client base. Or you may decide to carve out a more specialized niche. You will need to decide your basic positioning before you formalize your menu. One of the key factors will be to find the best service mix that matches your professional expertise. If you are a dermatologist, for example, you may wish to offer a range of specialized services for treating acne. If your background is OB/GYN, you may want to develop a specialty for the treatment of leg veins. Another key factor which you may determine from your research is your best estimate of the profitability of offering a wide variety of the most popular services compared with a more specialized approach. Heavy competition in some areas has driven fees for basic services such as laser hair removal to such low levels that such services must be evaluated merely as  "loss leaders" to help build traffic for your more profitable services.

In any event, you will need to keep current with rapidly growing technology and clinical applications by attending trade shows and workshops, subscribing to industry publications, joining various associations, and opening channels of communication between your medical and spa resources. Many practitioners pondering the question of what aesthetic services to offer have come to the realization that emphasizing treatments that require a high level of skill and/or experience is perhaps the best way to differentiate your clinic from the garden variety “medical spa” offering only “basic” treatments like laser hair removal that are available on every street corner. An excerpt from the 2007 national average fee schedule published by ASAPS clearly illustrates this point: 

Cosmetic Procedures        National Average Fee

 
Abdominoplasty     $ 5,350.00

Blepharoplasty                  2,840.00

Breast aug. (silicone)                 4,087.00

Breast aug. (saline)        3,690.00    

Facelift                   6,792.00

Hair transplantation                  5,874.00

Lipoplasty (suction)        2,920.00

Rhinoplasty                   4,357.00 

Non-Surgical Procedures      National Average Fee

Botox injection     $    380.00

Chemical peel           718.00

Fraxel          1,130.00

IPL Treatment           411.00

Noninvasive tightening       1,194.00

Injection lipolysis           905.00

Laser hair removal           387.00

Laser skin resurfacing- ablative      2,418.00

Laser skin resurfacing- non-ablative        580.00

Laser treatment leg veins          462.00

Microdermabrasion           130.00

Sclerotherapy           377.00

Collagen (Bovine)           397.00

Collagen (Human)           542.00

Hyaluronic acid (i.e., Restylane)         576.00

Sculptra         1,027.00

Srtecoll, Artefill        1,180.00 

Food for thought.

Clinical Exchange for Medspa Doctors: A Call to Action

We are looking for Clinical Providers and MedSpa Owners to help us with our Continuing Education Efforts. 

We want to provide quality content on Medical Spa MD to act as a stimulus for meaningful clinical exchange activities.

One type of Clinical Exchange is the discussions and the conversations that occur on blogs and websites.  Medical Spa MD is currently one of the only internet based clinical exchange platforms for Cosmetic Medicine.  We want to take advantage of Medical Spa MD’s leading position and large readership base to enhance its already strong presence in the Clinical Exchange field.

Our plan is to have people do summary notes of Webinars, Articles and Clinical Meetings.  These notes will be posted on Medical Spa MD and then a discussion can take place.  The conversations and debates will instruct us all!  Hopefully by sharing experiences and opinions, we will move the whole field forward in a positive and more rapid manner.

The first such Clinical Exchange Post was the summary of The IPL Dog and Lemon Guide.  This post has stimulated a lively discussion of the various IPL Systems.  Sciton and Palomar seem to be the favorite systems.  The clinical settings for treating Hair, Pigment and Vascular are being discussed.  We are all learning a great deal and a few knowledgeable and experienced thought leaders are emerging – Charry, Med Spa Guy, pmdoc, LH and SpaDocinCR.

Our second post will be a Summary of the DeepFx Round Table Webinar (May 2008) produced by Lumenis.  The Webinar was a Round Table Discussion between four of the most experienced and well known cosmetic physicians in the country – Jeffrey Dover, MD, Robert Weiss, MD, E. Victor Ross, MD and James Heinrich, MD.  Our post will summarize the Webinar.  The original Webinar is available to everyone on Lumenis’ Website.  We are hoping that our summary will prompt people to view the actual Webinar and then participate in the resulting discussion.  In the future, we hope that Lumenis will make their Webinars available in a form that can be downloaded onto iPods so we can listen in our cars.

Finally, it is our goal to get summaries done of the various meetings that are happening in the near future.  A few upcoming clinical meetings are The Cutera Clinical Forum in Chicago (August 2008), Controversies & Conversations in Laser and Cosmetic Surgery:  An Advanced Symposium in Whistler, BC Canada (August 2008) and the Harvard Conference in Boston hosted by R. Rox Anderson, MD entitled  “Laser & Aesthetic Skin Therapy:  What’s the Truth?” (October 2008).  We are hoping that conference attendees will write notes about the lectures and the sessions and then will submit those notes to Medical Spa MD to be posted.  We will be able to read these notes, learn from them and then discuss the content.  This will bring the information to countless more clinical providers.  In the future, we hope that the organizers of these conferences will record their sessions and sell the audio so we can benefit without having to travel and take time off from work.  At this years ASLMS Meeting, the lectures were recorded and you can purchase them for a nominal fee ($11 per Tape).

This Clinical Exchange Project is a grass roots activity that is meant to take the place of formal activities that Allergan and the big Laser Companies are not doing.  We are not sure why they have left this “information gap” and do not support meaningful continuing clinical education and meaningful clinical exchange, but we hope they will join our efforts once they see the value in these types of activities.  Better clinical outcomes and fewer adverse events will benefit the whole field.  By sharing information and communicating and making more information available to more providers, we can advance the field much more rapidly then our current method of each provider trying to figure things out by trial and error.

We hope you will join our effort as a summarizer of Webinars and Conferences or as an active participant in the resulting discussions and debates.

Medical Spa Interviews & Answers: Your help needed.

I've had a couple of phone conversations with some of the physicians who regularly post on this site and have come away with some thoughts for a series of interviews with doctors and professionals running successful medical spas. It seems that there's an insatiable desire for more information on treatments, marketing, operations, and almost everything else that goes into organizing and running a successful cosmetic practice.

I'm going to be contacting a number of clinics and physicians around the country (or outside) that run what I deem to be successful practices and interview them. I have a tentative list of questions but I'd like to enlist you, my dear readers, to help me make sure I'm not missing anything that's relevant.

So, I'm asking for some help in formulating the questions, the more detailed the better.

Please post your list of questions as comments. If the repeat, great. We'll know that lots of people are interested in that information.

I plan on generating a report that will be organized around the questions rather than inline, so you can see what all the answers are to the question rather than collating that information from separate interviews.

Radiance Medical Spas: website trouble

If the Radiance Medical Spa here is an example of exactly how you don't want your medspa to be perceived as.

Via Plasticized:

"Radiance Medspa is a national franchise that has run into trouble with disgruntled owners and office closures.  In the cosmetic world, it can be a challenge to maintain quality over large distances with a range of practitioners with varying quality.  Some of the spas have broken away from the corporation. Others have closed in the last year.

Take a look at this Radiance website. The "highly skilled, licensed professionals " were unable to spell "specialization" and they left some latin text from the website template they ripped under "about us". Here is an example of how quality control can fail in a large entity"

I don't know if the Dermacare doctors have it any worse than these poor Radiance franchises.

DeepFx Forum (Exclusively for Encore UltraPulse Users)

Reliant UltraPulse Fractional CO2 Laser

 

DeepFx Webinar:  Notes and Analysis - Tuesday May 19, 2008
Reliant UltraPulse Fractional CO2 Laser

Introduction

Many Laser Companies offer regular Webinars for marketing and education (mostly marketing). These companies include, but are not limited to: Cutera, Lumenis, Reliant and Cynosure. These Webinars are available live or on the companies’ websites in their Webinar Archive Area. 

We have produced these notes for several reasons. We want to generate a clinical discussion of these Webinars so we can all learn more from the Webinars and learn even more from the discussion. We want to clarify certain points that were not clear during the Webinar. We want to ask and answer questions that were not asked and answered during the live Webinar (there is never enough time to ask and answer all questions). It takes 2 hours to sit through a Webinar, most are for marketing purposes and not worth our time, these notes will help us decide which Webinars we want to watch. Hopefully many times we will not have to watch the Marketing Webinar once we have read the summary and participated in the resulting discussion. This will enable us to get the information without sitting at our computer watching a Webinar for 2 hours. 

The bottom line is that we all need to become better providers of services and get better results which generate happy patients who refer friends and family to our practices. By having easier, more convenient access to the information in the Webinars and sharing our thoughts and experiences, we all learn more quickly and we avoid making the same mistakes made by others.  In this manner, we gain access to “best practices” more quickly and the whole field evolves more rapidly. We want to use these Webinars as “Seminal Events” to stimulate meaningful “Clinical Exchange” of important information.

We hope to get the industry “Luminaries” to participate in these discussions. We also hope the Laser Companies will start to host these type of “On-Line” discussions after their Webinars and we hope the Laser Companies will start to host more “Continuing Education” Webinars rather than just “Marketing Webinars”.

The first set of notes is from a Lumenis Webinar about the DeepFx treatment with The UltraPulse Fractionated CO2 Laser. This was a Round Table Discussion with some of the top Cosmetic Physicians in the field. It was very good, but had its flaws and requires further discussion and clarification on points made. The participants (Luminaries) were James Heinrich, MD, Robert Weiss, MD, E. Victor Ross, MD and Jeffrey Dover, MD.

If you are considering using the information in this summary, please view the Webinar to make sure you are comfortable with the parameters! If you view the Webinar and find any inaccuracies in my notes, please correct them in our discussion on MedicalSpaMD. I am hoping Lumenis and “The Luminaries” will review these notes and comment.

 

TotalFX Notes

Basic Facts & Theory:

1. ActiveFx plus DeepFx gives you a TotalFx Treatment
2. ActiveFx ablates 1.3 mm columns and can go 300 microns or 0.3 mm deep
3. DeepFx ablates 0.12 mm columns and can go 2000 microns or 2.0 mm deep
1. 1000 microns = 1.0 mm
4. 125 mj of energy with ActiveFx penetrates 300 microns deep
5. 30 mj of energy with DeepFx penetrates 1.9 mm deep (1900 microns)
6. Most photoaging occurs in the papillary dermis (the worse “solar elastosis” in elderly farmers is at a depth of 800 microns), so there is no need to go deeper.  Therefore our panel recommended a max DeepFx strength of 20 mj (1 mm deep?).  Going deeper gets you more tightening because of more tissue ablation and volume loss.   
7. Using 30 mj of energy and going to 2.0 mm deep has caused scarring around the eyes in one provider’s experience.  They do not recommend going this deep.
8. How long does the tightening last?  No one knows for sure.
9. ActiveFx:  Density 1:  75%; Density 2:  80%;  Density 3:  85%;  Density 4:  95%;  Density 5:  100%
10. MaxFx is ActiveFx at Density 5:  100%.
11. The MaxFx now is somewhat different than CO2 treatments done in the 1990s because only one pass is done.  In the 1990’s 3 passes were done wiping off the epidermis in between passes.
12. DeepFx:  Density 1:  5%;  Density 2:  10%;  Density 3:  15%;  Density 4: 20%;  Density 5: 25%.
13. Stronger treatments are done with the TotalFx on the West Coast.  Why?  In California the people have greater solar damage so you need higher settings OR the people in California are more demanding and want more dramatic results.  Interesting question!  What do you think?
14. Healing is slower off the face.  Dr. Weiss says 2-3 times longer, did he mean 2-3 days longer?
15. Doing Upper Lip Treatments with TotalFx can cause more vermillion lip border to “show”.  This is good

Clinical Tips:

16. Do the DeepFx first and then do the ActiveFx
17. If the DeepFx causes bleeding, wait until the bleeding stops before doing the ActiveFx (blood will absorb the energy from the ActiveFx pulses)
18. The experts said that they did a second treatment one month after first treatment.  I was told to wait 3 months.  This one month interval is new information to me. My big question to Lumenis is “when were you going to tell me and your other users about this change?  How do you keep us up to date about changes like this?”  I am pissed off, I am angry.  I want an answer and I want it NOW!
19. Dr. Ross sometimes uses thrombin spray (from Baxter) to stop the bleeding.
20. With DeepFx, you treat lower face first and move upwards so blood won’t drip down into your treatment field.  “South to North”
21. Do DeepFx before you do fillers.  The DeepFx may go deep enough to disrupt the fillers.
22. You can do fillers and then ActiveFx because ActiveFx only goes 100 - 300 microns deep.  Fillers are placed deeper than this.
23. Anesthesia:  Atavan or Valium (5 mg), IM Torodol 60 mg, Zimmer Cooler, Pliaglis Topical or Topical Lidocaine.  Is po Torodol ok? What about Percocet or Vicodan?
24. You may need to use a nerve block for upper lip treatment.  Dr. Weiss, “Do you do the Infraorbital Nerve Block or 5 short injections near the upper lip gingiva?”
25. Use intraocular eyeshields for upper eyelids.  You might be able to use tongue blade wrapped in moist gauze for lower lids
26. Segmental Resurfacing:  Do IPL on cheeks for pigment and do ActiveFx in peri-occular areas for fine lines and tightening.  Get the most out of your hour with the patient.  This sounds like a great idea-Segmental Resurfacing!
27. Dr. Heinrich does DeepFx only and then Deep plus Active one month later.  He says the patient’s skin gets used to treatment the first time, so downtime is less the second time.  This is my question:  what is the downtime with the first treatment and what is the downtime with the second treatment?  Do patients have to have two 4 day periods of downtime within 30 days?  I am not sure this makes much sense.
28. Some older patients (your mother-in-law) really need traditional CO2 or a facelift.  Give them that option.
29. Class 4 Wrinkles:  The best option is traditional CO2 with two weeks or downtime OR do TotalFx  2-3 times at one month intervals (Dr. Heinrich)

Treating Specific Conditions:

30. DeepFx is best for vertical lip lines, deep wrinkles, acne scars.  It goes deep and stimulates more collagen and ablates more tissue for more tightening.
31. ActiveFx is better for pigment and more superficial textural problems
32. Stretch Marks (Stria):  Use ActiveFx:  80-100 mj, density 1-2 (use Density 2 for thicker Stria).  Do NOT use DeepFx for Stria.
33. Melasma:  Experts are not sure it will work.  They do not recommend at this time.  They are doing test spots and experimenting with it.  Melasma is a whole topic unto itself.  Look for a specific blog about this in the future.
34. Tattoos:  DeepFx might be good for resistant Tattoos

ActiveFx, DeepFx & Total Fx Settings:

35. The experts usually treat with DeepFx in the range of 15 mj – 20 mj
36. Most experts would not go higher than density 3 with DeepFx (15%).
37. Recommended Settings: 
1. DeepFx:  15 mj, density 3, one pass. 
2. ActiveFx:  100 mj, density 3, one pass. 
3. You can go to 20 mj with DeepFx
4. You can to to 125 mj with ActiveFx. 
5. Density 3 seems to be highest density used with DeepFx (Dr. Ross goes higher, but he is very experience, an expert and he has experience with the full CO2).  Don’t go higher than Density 3 with DeepFx. 
6. For ActiveFx:  Higher density with one pass is better than lower density with two passes (Dr. Weiss).
38. To stay out of trouble with ActiveFx off the face, use Density 1 and 70-80 mj

Treating Specific Areas:

39. Eyes:  Use ActiveFx. Don’t do DeepFx around eyes (skin too thin?)
40. Eyes:  ActiveFx:  90-100 mj, density 2-3.  Downtime:  7-8 days of downtime (what TYPE of downtime?)
41. Eyes:  Upper Lid:  ActiveFx:  60-70 mj, density 1
42. Eyes:  Might consider using DeepFx for low lids:  5-10 mj with density 2?  This was the experts thinking outloud.  They are not recommending this!
43. Eyes:  Treat to the lid margins with ActiveFx:  Density 4-5, one pass (for greater tightening and because this is where much of the problem lines reside?)  This seems strong.  Listen to Webinar for yourself before doing this!
44. Neck:  Necklass lines are done with DeepFx, the rest of the neck is done with ActiveFx. 
1. DeepFx on the Neck:  15 mg, density 2 or 3. 
2. ActiveFx on Neck:  90 mj, Density 1 or 2. 
3. Neck with the above settings:  10-14 Days of downtime (what TYPE of downtime?)
45. Neck:  ActiveFx:  100 mj and density 3 was too strong.  Produced prolonged erythema.
46. Chest: 
1. ActiveFx:  100 mj, Density 1. 
2. DeepFx for sagging and wrinkling on Chest?  I think the experts recommending doing DeepFx.  Perhaps 15 mg, density 2?  Check the Webinar.
47. DeepFx can be done on neck, chest and hands

Pigment Changes, Post Inflammatory Hyperpigmentation, Melasma

48. Don’t treat Melasma (Dr. Ross)
49. Dr. Weiss has never seen PIH with ActiveFx.  The company has told a friend of mine that they don’t get PIH with ActiveFx.  This is complete and utter bull!  I have gotten PIH with skin types 4 (Italian, Greek). We need an open and honest discussion of this.  Dr. Weiss may only be treating skin types 1-3.  If this is the case, he and the company need to be much more transparent, open and honest when they talk about PIH.  What they say (you don’t get PIH with ActiveFx) is misleading, false and dangerous.  To just dismiss the PIH problem with ActiveFx is irresponsible and dishonest!  This type of cavalier attitude pisses me off!  This view (no PIH with ActiveFx is parroted by others (company reps and clinical advisors) and this type of dishonesty will get YOU & ME into trouble!  If PIH is not a problem, why isn’t ActiveFx used in darker skin types?  A friend of mine has posted his PIH pictures at www.geocities.com/pih_pih/.  Go to this site to see PIH after ActiveFx.  Dr. Weiss, I am looking forward to your comments about these pictures.  Please don’t talk about PIH if you only treat skin types 1-3!  I would also like to hear from the other Luminaries and Lumenis who claim that PIH is not a problem.  Let’s move on . . . I am calming down now.
50. None of the presenters use Hydroquinone to prevent or treat PIH.  This is because they say they don’t get PIH with ActiveFx, DeepFx or TotalFx.  Either I am an idiot or they are not being honest or they are not treating the patients that I am treating.  I am not treating any skin types 5 or 6 and I am being very careful with skin type 4.  I use Hydroquinone, RetinA and Hydrocortisone pre and post treatment on my skin type 4 patients.  Maybe I should not treat skin type 4?  Not treating skin type 4-6 eliminates about 40% of my patient population (so why should anyone buy the machine unless they live in Sweden or Finland?).  Let’s discuss this PIH issue!  Is “bronzing” PIH?  You can go to www.geocities.com/pih_pih/ to see my photos of PIH after ActiveFx.  I am interested in your comments (and I hope Drs. Weiss, Ross, Dover and Henrich will comment as well).  I think this is another case of “The Emperor Has No Clothes” (Everyone thinks that they will be called “stupid” if they don’t see what everyone says they are supposed to see. This is the question, “Do you get PIH with ActiveFx?”  If so, how do you prevent it, how do you treat it, who do you have to be careful with?  This is THE “cop out” answer that I do not want to hear, “I only have skin type 1-3 in my practice”.  This is bull (almost 50% of our population is now “patients of color” and if this is true, then YOU are not an expert using this technology!  (Just my opinion) (Sorry about the emotion, but I am fed up with the dishonest bull that comes from the companies and their luminaries.  I am on the front lines and it is me and my patients who get screwed by this type of pandering and dishonesty - hopefully one of the benefits of this type of blog will be to get the “experts” to be more thorough and honest in their presentations, you can’t be dishonest when everyone is watching and talking about your presentation!).
51. Dr. Ross uses Hydroquinone once he sees PIH.  You generally start to see PIH 15-28 days after procedure.  Wouldn’t it be better to prevent the PIH, Dr. Ross?  Can you prevent it?  Do you know who is at greatest risk for PIH?
52. Patients are generally not allergic to Hydroquinone (HQ), they can be sensitive to it.  15% of patients get irritated with HQ – contact irritation.  This is not a true allergy.  You can change the HQ to 2% OTC Hydroquinone.  Other options are to use it less frequently (every other day), use if for less time (3 hours per day rather than overnight), or use it with Hydrocortisone 1%.   (These other options are from me, not the experts).  There are also other bleaching agents like Azelaic Acid and Kojic Acid (see The Supplement to the September 2005 Skin & Aging Magazine on www.geocities.com/foxydog1064 for a Hyperpigmentation Round Table Discussion). 
53. In skin types 4 and higher (Persians and Hispanics) go a little lighter (less density, less energy).  Density is % coverage; Energy is depth of treatment.  I think both matter.  Perhaps % coverage matters more (it matters more when you do a Fraxel Treatment).
54. No one is treating skin types 5 and 6 with ActiveFx or DeepFx.  This includes Aftrican-Americans, East Asians (Japan, China) and Southern Asians (India, Middle East).  You can use Fraxel Re:store 1550 for these patients.  Be very careful to avoid PIH when you treat these darker skin types with the Fraxel. 
55. Experts:  “PIH clears very quickly”.  Me:  I have read that it can last 6 months to 2 years.  In my opinion, you should not minimize PIH by saying it clears so quickly.  Just read www.realself.com to see patients with long standing PIH.
56. Experts:  “Koreans are skin type 4”. Me:  I would treat them as skin type 5!  I wonder what Dr. Eliot Battle would say?

Downtime:

57. The experts discussed “Downtime” and “Quality of Downtime”.  Absolute Downtime, Relative Downtime & Social Downtime.  Absolute Downtime would be when you can’t go out (the day after an ActiveFx).  Social downtime would be when you don’t want to go out but can go to work (after the peeling, ActiveFx:  days 5-7). Days 2-4 are Relative Downtime, when you feel fine but don’t look to good.  You don’t want to go to work, but you can work at home and pick the kids up from school (stay in the car).     
58. We should come up with some words and definitions for the different types of downtimes so we can communicate this to our patients.  What are your thoughts on how to categorize downtime?
59. There is a big difference between 3-4 days of downtime and 5-7 days of downtime.  With 3-4 days, you can have procedure on Thursday and be back to work by Monday.  With 5-7 days of downtime, you have to take the week off.
60. The experts prefer to do TotalFx over Fraxel Re:store (1550).  They do the Fraxel when the patient prefers to give one day of downtime x 5 rather than 4 days of downtime once.

ActiveFx, DeepFx, TotalFx vs other Lasers:

61.  DeepFx and Fraxel Re:pair CO2 are the only lasers that go deep and ablate.  The others ablate shallow and then coagulate deep.  They also have spot sizes which are macro (1.3mm)  rather than micro (0.12mm)
62. The best results for deep wrinkles, vertical lip lines and acne scars can only be obtained with deep ablation
63. Experts:  It is nice to have a CO2 Laser because it has an ablative handpiece that can treat syringomas, sebaceous hyperplasia, warts and moles.  We need to start a blog which discusses how to treat these conditions and avoid scarring.  Feel free to blog on sryingomas, sebaceous hyperplasia, warts and moles!  How do you treat them with the ablative handpiece of the Encore?
64. Why Deepfx?  People were disappointed in Perioral wrinkles and lines.  DeepFx does a better job.  You may have to do 2-3 treatments, one month apart!  How much downtime would this be?  What type of downtime (absolute, relative, social)?  How do we explain this to our patients? 

Pre and Post Treatment Tips:

65. Mild moisturizers avoid acne flare-ups
66. You don’t have to use aquaphor or vasoline.  Mild moisturizers are good enough (personal communication from company reps).
67. Be careful of the lanolin in the aquaphor.
68. Using Aveeno Water Gel gets you one less day of Downtime!  (From Dr. Weiss).  What is Aveeno Water Gel?  How do we get it?
69. Post TotalFx Care:  Use “Soaks” every 3-4 hours.  (What type of soaks?  Saline Soaks (saline and gauze)?  How long do you soak every 3-4 hours?) 
70. Post Care:  Cold packs or Zimmer Cooler for 30-45 min after treatment
71. Valtrex for everyone.  One case of disseminated herpes on the face is not good.  Can we use Acyclovir?  It costs less, much less (Four Dollars at Walmart!).
72. Check all patients the next day, this makes you and them feel better.
73. Don’t give pain meds after treatment.  If they have pain, you want to know about it and see them.  They should not have pain for more than a few hours after treatment.  Prolonged pain suggests infection:  bacterial, viral, fungal.  Can we discuss post procedure infections and how to treat them? 
74. Pliaglis can be mixed with cetaphil cleanser or cetaphil moisturizer.  90% Pliaglis and 10% cleanser or moisturizer.
75. Experts worry about Lidocaine toxicity.  Compounded Lidocaine works as well or better than Pliaglis.  Pliaglis costs $60 per treatment.  Compounded Lidocaine costs about $6 per treatment.  Do the experts have a financial interest in Pliaglas?  Are the experts afraid that they will be sued if they talk about compounded lidocaine?  The discussion on this topic did not seem to be open, honest and complete!
76. Experts do not routinely use oral antibiotics unless indicated for acne outbreak prevention:   Keflex 500 mg TID, Doxycycline 100 mg BID, Erythromycin can be used to prevent acne outbreak.
77. Sunscreens:  Use everyday after skin is healed up.  Wear hat and stay out of sun until healed.
78. Use a good UVA blockers:  Neutrogena, Helioplex or Loreal Products.

The Opinions of the Transcriber (CHMD) & Other Misc Issues:

79. These experts have only been using the DeepFx and TotalFx for 6 months, so their use is evolving.  It will be very important for Lumenis to keep us informed about changes in these expert’s opinions as they get more experience.  We must all advocate very loudly and strongly for a Newsletter from the company which keeps us up to date (not just Webinars which take 2 hours to watch and are mostly for marketing and selling lasers).  Go to www.geocities.com/FoxyDog1064  for more information about Advocacy for Better Clinical Education and Clinical Exchange Programs. 
80. We must also make sure the company picks experts that have significant experience using their laser in skin type 4!!!  To say, “I don’t have the problem because I don’t have patients with skin type 4” is bull.  It is a big cop out and is counterproductive.  Plus, I don’t believe it or accept it.  Skin type 4 is Italians, Greeks and others who don’t burn but tan easily and get dark easily when exposed to the sun.  If you are not treating skin type 4, patients I am not sure you are practicing in the USA!
81. If you want to contact Lumenis directly, address all questions and comments to Amy Easterly, Product Manager.  Her email is: amy.easterly@lumenis.com.  Perhaps she can ask the Drs. Heinrich, Weiss, Ross and Dover to participate in this discussion, read this blog and comment and clarify.  I believe that they get paid a lot of money to do the Webinar.  I believe their job has been done incompletely when they leave us with unanswered questions and incomplete thoughts.  Remember, we are treating patients.  Real patients with real faces that can be scarred and hyperpigmented!!!  We want excellent outcomes with very few complications.  Lumenis owes it to us!
82. This Webinar will be available soon in Aesthetics Buyers Guide.  When?  Let’s see how good the Aesthetics Buyer Guide Version is.  I bet it will be edited to sell lasers!  Lumenis, it’s ok to do a version to sell your laser, but you should also do a version for your Encore UltraPulse Users as Continuing Education.  Let’s see if you step up to the plate for your Users!

Now let’s blog.  Let’s get it on!!!  Let’s get what we need (more self support and more company support).

Is Cutera violating FDA guidelines?

Certainly I'm not a lawyer. So when I received this inquiry about Cutera selling in violation of FDA guidelines, I decided to post it here on the main page and see what the thoughts around it are.

Are Cutera, Palomar, Cynosure, Alma, and the rest of the IPL and laser technology companies violating the FDA's guidelines for selling medical devices to non-physicians? Does anyone care? Should non-physicians be able to own an IPL, cosmetic laser, or Thermage unit? Is this more about protecting a market or patient safety?

Happy to have Cutera respond. 

via email from T:

I have read this blog for over a year and a half and have been interested in the business and legal aspect of this industry.

There are many issues which intrigue me but a couple areas that stand out are: 1.) The legality of sale of prescription medical devices to "business people" and 2.) How laser companies such as Cutera are double dipping and hurting doctors business through their unethical sales practice… as well as violating FDA regulations with regards to selling prescription medical devices to business people under the guise of the use of a "medical director".

First, I know first hand that Cutera is selling prescription medical devices to business people directly.  As you know the FDA clearly states with regards to medical devices:

Medical Devices: Purchasers of medical device items hereby certify and assure that such items will be used or resold only under the conditions specified below:
Medical device items are subject to the laws and regulations administered by the Food and Drug Administration (FDA). Provisions of the governing statute, the Federal Food, Drug and Cosmetic Act appear in 21 U.S.C. 331, et. seq . In summary, the Act prohibits the movement in interstate commerce of medical devices that are misbranded or adulterated. The Act authorizes FDA to initiate criminal enforcement proceedings against companies and/or individuals responsible for violations of its provisions. Moreover, the Act authorizes FDA to initiate civil proceedings to seize, or enjoin the distribution of such items. Prescription devices are subject to additional Federal, state and other applicable laws. Federal law requires that prescription devices be in the possession of either persons lawfully engaged in the manufacture, transportation, storage, or wholesale or retail distribution of such device, or practitioners licensed by their state. Federal law also requires that prescription devices be sold only to or on the prescription or order of a licensed practitioner for use in the course of his or her professional practice, and that the devices are labeled in a specific manner. Refer to 21 CFR 801.109.

The area underlined above states the obvious and is in direct contrast to this “medical director” concept used by companies such as Cutera.  I have a copy of Cutera “medical director” form and no where does a doctor neither signs the form nor put their license on the form for the purchase of these devices.

These “medical directors” don’t own the business, the lasers are not used in the course of their professional practice” and yet Cutera and other laser companies continue to sell these devices in this manner.

This leads into my second point. As this is happening, it increases competition to “legal” laser clinic and medical offices that have the authority to own and operate these prescription devices.  These laser companies are selling their prescription devices to their “core customer base”, physicians and then turning around…even in the same town and selling to “non-physicians and increasing competition. As well, the AAD and other medical organizations allow these companies to display and exhibit at medical meetings. This is sickening.

It would seem to me that a site that is committed to the success and professionalism of the spa industry, such as medicalSpaMD could shed some light on the sale practices by the laser companies. You do a great job telling people how to run and market their clinics but if you really want to make a difference and help your fellow physicians succeed, it would helpful to eliminate the “illegal” practice and competition being perpetrated by laser companies.

Needed: Clinical Education Programs for Dermatology

Advocating for Better Continuing Clinical Education Programs and Clinical Exchange Programs

In the field of Cosmetic Dermatology, Continuing Clinical Education Programs are terrible and Clinical Exchange Programs are nonexistent. Who is to blame?

The big laser companies are to blame! Cutera, Lumenis, Cynosure, Palomar, Sciton and other big laser companies have not developed meaningful Clinical Education Programs and they have not encouraged or facilitated Clinical Exchange Programs. This includes Cutera’s bi-yearly Clinical Forums.

Why should they do this? Why should they put a great deal of time and resources into continuing clinical education programs and clinical exchange programs? Because clinical outcomes would be better, demand for laser treatments would increase, their customers (the providers) would do better financially (and professionally) and finally, patients would get better and safer treatments with better clinical outcomes. When the tide is higher, all boats float at a higher level. The tide (clinical outcomes) is not where it should be and this is mainly due to the laser company’s apathy and disdain towards continuing clinical education and clinical exchange programs.

We spend hundreds of thousands of dollars to purchase our lasers and then they charge us tens of thousands of dollars per year in support. They abandon us. They don’t know how to use the lasers themselves and they expect each of us to figure it out through trial and error. Trail and error on our paying patients. Yes, I am fighting mad about this and you should be too.

The correlation between clinical competence and clinical outcomes should be obvious . . . Just as comprehensive initial training gives rise to predictably excellent clinical outcomes, the ability to exchange ideas and experiences with other [laser] operators dramatically magnifies your clinical competence . . . a worthwhile clinical exchange program should utilize one or more of the following media: Online Forums, Teleseminars, Webinars and live phone support . . . as the field of [laser] therapy advances, all new clinically relevant findings and advance techniques should be made readily available to you via a continuing education program. This may take the form of a newsletter, website, DVD, Video and/or live workshop. ---The IPL Dog & Lemon Guide

How do I know there is a problem? Because I see it everyday in my practice, I talk to other providers and I read the blogs. I read how physicians don’t know how to use the Fraxel, I read how physicians don’t know how to minimize pain, I read how physicians don’t know how to prevent and treat postinflammatory hyperpigmentation. I read the blogs and I see lots of patients are not very happy with the outcomes of their laser treatments. I read the content of their complaints and these patients are not complainers, they didn’t get the results they wanted or they got a complication they didn’t want. In addition, their provider didn’t have good answers when this happened. Their providers were like “deers caught in the headlight”. These patients did not get the best treatments because their provider were not properly informed and educated about the cosmetic procedure they were performing. My prospective patients read these blogs and they don’t want to have the laser treatments because they think the treatments hurt, they won’t work or they will produce unwanted side effects.

I look around and I see very few meaningful continuing clinical education programs. I look around and I see zero clinical exchange programs other than the type we are trying to have on MedicalSpaMD.com. Zero clinical exchange programs from the big laser companies. Zero!!!

How do I know there is a problem? I have to find out about new techniques by luck and happenstance! For example, the only reason that I know that you can do ActiveFx with intervals of one month rather than 3 months is because I listened to a Webinar where this was mentioned as an afterthought. Lumenis has no mechanism or plan to keep providers informed about new techniques or thoughts. The only reason that I know you should not do Fraxel more than 3 times in a patient with Melasma is because I happened to complain about something else and the clinical educator mentioned that Reliant was receiving reports that the fourth and fifth treatments make Melasma worse. Reliant had no system and has no plan to keep its providers informed about new techniques or new thoughts. This makes me mad. When I speak to the companies about this, they pat me on the head and tell me to go away like a good boy. They just don’t get it! They tell me that I am the only provider asking to be kept informed. They try to make me feel stupid for asking questions and expecting to be kept informed. I don’t feel stupid, I think they don’t care and I think this is not smart.

They are not going to get it unless we force it down their throats. I say, “Let’s force it down their throats!” We can do this if we all politely and forcefully ask and demand these type of programs. Numbers will get their attention. When some companies do it, the others will do it because they will be able to use it as a marketing tool.

If you agree with me, please contact your laser company (your local sales representative, the person who runs the Webinars and the Corporate Vice President in charge of Marketing and Education) and ask for meaningful programs in the next 6 months at the lastest. Tell them how disappointed you are in their performance so far. Tell them that you would not recommend their lasers to another physician because they don’t have clinical exchange programs and continuing clinical educational programs.

All they have to do is put out a monthly Newsletter and put up a Discussion Bulletin Board on the Internet for their clients. They should also publicize and promote the use of the Newsletter and the Bulletin Board. They should provide expert moderators who contribute to the discussion. They also should summarize or transcribe all of their Webinars and Clinical Forums so more physicians have access to this information (without having to sit at a computer for 2 hours each time to view a marketing Webinar). Each Webinar and Clinical Forum should serve as a “discussion springboard” off of which a Discussion Bulletin Board with Expert Moderator is launched.

If you would like these things, contact your laser company today. If they pat you on the head and give you excuses about why they can’t do this or won’t do this or why they don’t think it is important, send them a copy of this website and let them read this entry. Tell them they can do it now or do it later. Tell them they can do it the hard way or do it the easy way. Tell them the view never changes unless you are the lead dog. They want to be the lead dog on this issue.

Stock prices tumbling for laser and IPL companies.

 LASkinDoc comments on the down trend in IPL and laser providers stock prices in the Physician to Physician forum:

I have been following the stock prices for the following companies: Cutera, Thermage, Syneron, and Medicis and have noticed that these companies' stock has dropped anywhere from 20 -60% in the last 12 months.

Cutera INC: $9.95 down from $25.60 per share 12 months ago
Syneron: $17 down from $26.04 per share 12 months ago
Thermage: $3.17 down from $7.50 per share 12 months ago
Medicis: $23.92 down from $32.32 per share 12 months ago

Anyone here worried about the future of cosmetic medicine? The laser companies are not selling as many machines because...
Read the entire thread and comment here > 

Medspa Specialist

If the world is really bigger, if you can find the best in the world to do what you want, no matter what it is you want, does that change things?

If I need heart surgery, I can find the world's best heart surgon. If I need an actinic keratosis looked at, I can find the best dermatologist. If I need SEO help, get me the world's best SEO person. If I need breast implants, I can find the best breast implanter in my area. Not the second-best or someone who will try really hard or someone who is pretty good at that and also good at other things. Sure, there are times when a diagnostician with wide-ranging experience is important (but I'd argue that that's a specialty in and of itself).

When choice is limited, you want a generalist. When selection is difficult, a jack of all trades is just fine.

But whenever possible, you will choose a brilliant specialist.

If you're shaking your head in agreement with this obvious point, then the question is: tell me again why you're a generalist?

Dermacare post is back up.

The most commented on post about Dermacare Laser and Skin Care Clinics is now appearing. I put this down to a technical glitch of some sort since I did nothing and it seems to be working fine now.

Sorry for the hold up. Dermadoc is now back in the house. 

IPL Systems: Review and Analysis

The IPL Dog and Lemon Guide: Review and Analysis

 
Download the IPL Guide here

The Dog and Lemon is an IPL Guide which helps us decide which IPL System is best for our practices. You can get this guide from the internet or from Sciton. I suggest you get it and read it. This guide strongly suggests that Sciton is the best IPL System. Is this because Sciton is really the best or is this guide is biased towards Sciton. Those who would try to discredit this guide claim that it was done by Sciton and is biased. In this review and analysis, we will examine the points made by this report, understand why they are important and then try to assess whether it is biased or whether it correctly identifies the best IPL system.

I have no financial interest or other interest in the companies in this report. I am considering buying an IPL for my practice and this is why I started to look into IPLs. I own Reliant, Lumenis, Cutera and ConBio. I have been a full-time cosmetic physician with a busy cosmetic practice. This review and analysis is my opinion and is based from extensive reading and research. - CHMD

The Dog and Lemon Report suggests that the Sciton is the best IPL for many reasons. Let’s examine these reasons. I am hoping that other cosmetic physicians and company representatives will comment on the report and comment on my review and analysis. This review and analysis is meant to stimulate a lively debate and discussion of IPLs.

The report was done “to provide you, the cosmetic clinician practical, unbiased, objective information that empowers you to purchase equipment that best serves the interests of your patients and business alike”. There is a huge void in this type of information in the cosmetic dermatology field. There is so much hype and misinformation when it comes to lasers and light devices that it is difficult to find the best technology and the best companies when we want to purchase a piece of capital equipment for our clinics. We need a “Consumer’s Report for Cosmetic Medicine” - hopefully Paul Kadar and The Cosmetic Dog & Lemon Guides are it. Making the wrong decision when buying a laser or light device can be devastating. This is outlined on page 4 of the guide. The name of the game is excellent clinical outcomes and happy patients. In order to achieve this you have to have an IPL that will enable you to get excellent clinical results in all skin types. This type of guide - “The IPL Dog & Lemon Guide”, if unbiased and objective can help us all. Hopefully the laser companies are paying attention to this guide because it makes a lot of great points and it make intuitive sense.

Uniform Delivery of light energy to the target tissue: Perimeter Loss, Photon Recycling and Twin Flash Lamps.

Pages 7-9: These pages discuss how light intensity decays with increased distance from the light source. This means that the intensity of the light at the perimeter of the head is less than the intensity of the light at the center of the head. This loss is proportional to the square of the distance from the source, “if light that has traveled 10 mm produces a fluence of 20 m/cm2, that same light will produce a fluence of 5 j/cm2 if it has to travel another 10 mm (i.e. a doubling of the distance produces a quarter of the fluence).

The two main ways to overcome Perimeter Loss are Photon Recycling and Twin Flash Lamps. We won’t discuss “small surface area of treatment head” here because this is technique is counterproductive for many other reasons (speed of treatments, depth of light penetration, life of flash lamps) and we won’t discuss “long light guide” (“a crystal that is too long will loose some of the light through the walls and hence the fluence delivered at the treatment area may be sub-therapeutic” -I will assume that crystals are not used for this reason and this assertion is correct).

Photon Recycling:

“Photon Recycling is nothing but a marketing gimmick deceitfully used to entrap unwitting clinicians . . . It doesn’t take a rocket scientist to figure out that by the time this light is reflected from the skin into the treatment head and then back again, its fluence will have all but petered out.” This is a very strong statement but the physics make sense to me. It seems to me that the recycled light will have very little energy left once it is “recycled”. I am not convinced that “photon recycling” has any beneficial clinical effect.

Palomar uses photon recycling and tries to convince you that it works by showing you a slide to demonstrate that it works. This is the slide: there is an area of skin treated by IPL #1 without photon recycling and an area of skin treated by IPL#2 with photon recycling. The area of the skin that does not look treated was treated with an IPL that does not have photon recycling. The area of the skin that looks great was treated with a different IPL with photon recycling. We are expected to believe that the difference in the results is due to the photon recycling and not due to the difference in the IPL devices.

Based on my knowledge of physics and the fact that the intensity of light decreases by the square of the distance traveled, I think that photon recycling probably does not have a clinically significant effect on treatments. Palomar’s attempt to prove it works was critically flawed. I look forward to someone from Palomar explaining and proving that photon recycling can and will work in a clinically significant manner.

Twin Flash Lamps:

“Currently, an effective way of producing a uniform fluence across the entire face of the treatment head while maintaining a relatively large treatment area is through the use of two flash lamps in an over-under or figure “8” configuration”. The first flash lamp transmits light with the usual perimeter loss. “However, the second flash lamp fires in “the shadow” of the first and consequently transmits light in a polar opposite manner to the first”.

This gets a little fuzzy here, I am not sure I fully understand the duel flash lamp reasoning. If the second flash lamp is further away from the head than the first flash lamp, it has to transmit light at a higher initial intensity in order for the intensity of the light to be the same at the perimeter of the head. Does it do this? Is the intensity of the light really more uniform than a single flash lamp? I look forward to someone from Sciton helping me here. This will require diagrams and drawings, so please provide them on a website we can link to. If you send them to me, I will post them on my geocities website.

“Of the 8 top selling IPLs reviewed, 6 employ a single flash lamp. The only two models utilizing twin flash lamps are Sciton BBL and CyDen iPulse i300. However, only the Sciton BBL has the essential over-under (figure “8”) twin flash lamp configuration”.

Range of Wavelengths:

“Not all IPLs deliver the full spectrum of therapeutic wavelengths. Naturally, you’ll enjoy greater returns on your investment the more treatments you can deliver.”

This is how I see the wavelengths and the condition they treat (by looking at the Absorption Curves of Melanin, Hemoglobin and ALA (Levulan) and by reading the manufacture’s literature:

  420 nm: acne
  500 nm: pigment
  510 nm: pigment
  515 nm: pigment
  520 nm: vascular and pigment
  525 nm: light, fine hair (Palomar)
  560 nm: vascular and pigment
  590 nm: pigment in skin types 4 and 5
  615 nm: larger facial veins (Lumenis)
  640 nm: superficial leg veins (Lumenis)
  650 nm: Hair Removal (Palomar)
  695 nm: thicker vascular lesions (angiomas, hemangiomas), superficial leg veins, Hair removal light skin
  755 nm: thicker vascular lesions (angiomas, hemangiomas), superficial leg veins, hair removal darker skin

Please go to www.geocities.com/DogLemonIPL to see the Absorption Curves. Note where the absorption is high for melanin and high for hemoglobin. On the ALA Absorption Curve, note where absorption is high.

Palomar does not have a head for the 590 nm wavelength area. This is a very big deficiency in my opinion. You need this wavelength to treat skin types IV and V for pigmentation, hyperpigmentation and PIH (postinflammatory hyperpigmentation). Without this wavelength you cannot treat East Asians (Japan, China, Korea), South Asians (India, Middle East), Mediterranean (Italian, Greek) and Latin (South & Central America). In my practice, a large portion of my patients are “patients of color”.

The IPL Dog and Lemon Guide also talks about Fundamental Requirements of an IPL, Critical Factors for Producing Predictably Excellent Clinical Results, Head Size, Variable Temperature Control, Pulse Widths, Fluences, Clinical Training, Clinical Exchange Programs, Square Wave Deliver (this is very interesting and sounds very important. It makes intuitive sense to me), Sapphire vs. Quartz Crystals, Ongoing Education and Support, Adverse Reaction Plan, Optimizing Return of Investment, Portability, Marketing Support, Technical Support, Consumables, Profitability Analysis, Multi-Platform Options and System Summaries.

These issues are all summarized very well and will prompt you to think about these issues and ask these questions of your sales representative. I would encourage you to get and read The IPL Dog & Lemon Guide to review these issues.

Working with many Laser Companies, one of my big problems with most of these companies is their Continuing Education. their Clinical Exchange Programs, their On-Call Clinical Support and their Formal Ongoing Education.

The correlation between clinical competence and clinical outcomes should be obvious . . . Just as comprehensive initial training gives rise to predictably excellent clinical outcomes, the ability to exchange ideas and experiences with other IPL operators dramatically magnifies your clinical competence . . . a worthwhile clinical exchange program should utilize one or more of the following media: online forums, Teleseminars, Webinars and live phone support . . . any IPL that’s purchased with access to an established clinical exchange program can only benefit you and your patients . . . as the field of IPL therapy advances, all new clinically relevant finding and advanced techniques should be made readily available to you via a continuing education program. This may take the form of newsletter, website, DVD/Video and/or live workshops.

All companies have to do a much better job helping us learn the latest advancements and facilitating communication between providers so best practices can be communicated and propagated. Continuing education efforts must be made easily available, inexpensive, and convenient. For example, providers learn by different methods and they prefer to access information differently. Information should be made available in multiple formats so the greatest number of providers can access this information. Material should be presented in written format, by audio cassettes & DVDs, via the internet (Webinars) and live presentations. Once the material is presented in these varied formats, interaction and discussion should be encouraged and facilitated via conference calls, internet bulletin boards and blogs. Clinical experts and industry luminaries should be available to participate on these bulletin boards and blogs.

The IPL Dog & Lemon Guide must be updated. The information about Palomar is not current. They have a StarLux 500 which is very different than the reviewed Medilux. Hopefully Palomar can update some of the missing information and tell us how the StarLux 500 overcomes some of the objections raised by this report. Hopefully the other companies can provide updated information.

These are the questions that I have after reading The IPL Dog & Lemon Guide. Who is Paul Kadar? What are his qualifications? Does he have any conflicts? When was the report written? Is “Photon Recycling” clinically important or is it a marketing ploy? Do “Twin Flash Lamps” in a figure “8” configuration overcome “Perimeter Loss” and how does this work (in detail)? How big are the light sources (lamps) in the heads and how far are they from the edges of the heads? How important is “Variable Temperature Control” & “Integrated Cooling”? Can you truly use less fluence with equal or better clinical results with twin flash lamps and “square wave delivery”? What are the best wavelengths and algorisms for treating Rosacea and Pigmentation in “patients of color”? Is IPL Hair Removal as good as Hair Removal with the 810 nm Diode or the 770 nm Alexandrite? Is IPL treatment of Rosacea and Veins as good as vascular treatments with the 532 nm KTP Laser, the 595 Pulsed Dye Laser and/or the 1064 Nd:YAG Laser? Is the Sapphire Crystal really better than the Quartz Crystal?

I hope this summary and analysis of The IPL Dog and Lemon Guide is helpful. I hope it helps you find the best IPL for your practice and I hope it helps generate questions which we all can answer by participating on the resulting blog. I also hope that this summary, analysis and report will stimulate the IPL companies to provide better IPL devices and provide better continuing education and support.

My opinion of The Dog and Lemon Guide is that it is a great start and a great tool to start to understand IPLs. For those companies that did not fair well, you should tell us why the Guide is wrong or you should make your devices and your support better. I would not assume that Paul Kadar is biased. I am going to assume that he wrote a genuine guide to help us all. Read his introduction on page 4. He hits many issues right on the head! I hope he writes more guides. His guide is well written and thorough and makes sense. What he says “rings true” to me.

So let’s start the discussion!!! We should have a very lively debate. Please convince me to buy the device you have or you sell. If you have the device or sell the device, please identify yourself as a user or seller EACH time you comment.