Cosmetic Dermatology from the Point of View of a Full-Time, Non-Core Cosmetic Physician

I receive the occasional email from a derm or plastic asking me to post an article that they're not willing to post under their real name. Here's an email I got from a non-core doc practicing cosmetic medicine. It came with this introduction:

"I wrote this and would like you to post this. I don't want it posted under my name because I don't want to take the heat and wrath of the Plastics and Derms. I need to choose my battles. Please post this as if you got this forwarded from me and I received it from an unknown writer. The post should be from "A Full-Time, Non-Core Cosmetic Physician". Can you do this?"

In general I dislike ananymous posts or comments. While there can be genuine concerns and I protect the identities of all Members, the anonymous nature detracts from the legitimacy of the content and just isnt' as credible as identified authors. With that said, here's the post:

Cosmetic Dermatology from the Point of View of a Full-Time, Non-Core Cosmetic Physician

A physician’s clinical results are directly related to their clinical skills. These skills come from their ability, their training, their dedication to learning and their clinical experience. Gifted mentors along with a high volume clinical practice are also important ingredients.

Many of the best non-invasive cosmetic physicians are non-core physicians who have dedicated 100% of their professional activity to cosmetic dermatology.

-----

1. What is Cosmetic Dermatology?
2. Can Non-Core Physicians Practice Cosmetic Dermatology?
3. What is a Cosmetic Dermatologist? What is a Non-Core Cosmetic Physician?
4. Is a Cosmetic Dermatologist better than a Non-Core Cosmetic Physician?
5. How many Dermatologists are Fellowship Trained in Cosmetic Dermatology?
6. How many Cosmetic Dermatology Fellowship Training Programs are there in the United States? How many Fellows graduate every year from these programs?
7. Why do we need Experienced, Expert, Full-Time Non-Core Cosmetic Physicians Practicing and Teaching Cosmetic Dermatology?

-----

1. What is Cosmetic Dermatology?

Dermatology that concerns cosmetic issues. Anything that is not Medical Dermatology, like skin cancer and other serious medical conditions. Wrinkles, Age Spots and Skin Tightening are cosmetic concerns.Cosmetic Dermatology also includes some medical conditions like Acne, Rosacea and Melasma. It also includes Acne Scars, other types of Scars, Unwanted Hair and Unwanted Veins.

2. Can Non-Core Physicians Practice Cosmetic Dermatology?

YES. Cosmetic Dermatology involves treating cosmetic conditions. Non-Core Physicians practice Cosmetic Dermatology when they treat cosmetic conditions of the skin. Non-Core Cosmetic Physicians are NOT Cosmetic Dermatologists. They are Non-Core Cosmetic Physicians.

3. What is a Cosmetic Dermatologist? What is a Cosmetic Physician?

A Cosmetic Dermatologist is a Board Certified Dermatologist who does Cosmetic Dermatology. A Cosmetic Physician is a Board Certified Physician who practices Cosmetic Dermatology. Cosmetic Dermatologists and Cosmetic Physicians can be full-time or part-time. Most Cosmetic Dermatologists are NOT Fellowship Trained in Cosmetic Dermatology.

4. Is a Cosmetic Dermatologist better than a Non-Core Cosmetic Physician?

Not necessarily. It depends on each doctor’s training and the experience. A full-time Non-Core Cosmetic Physician can be better than a Cosmetic Dermatologist who only practices Cosmetic Dermatology as a small adjunct to their Medical Dermatology Practice and has not been Fellowship Trained. A Non-Core Cosmetic Physician in a state like New Jersey is probably a better Laser Physician than a Dermatologist or a Plastic Surgeon who does not do the actual treatments but instead supervises Physician Extenders in their practice.

5. How many Dermatologists are Fellowship Trained in Cosmetic Dermatology?

Not very many. I am not sure of the exact number, but not very many. There is a big difference between a Cosmetic Dermatologist who has been Fellowship Trained and a Cosmetic Dermatologist who has NOT been Fellowship Trained.

6. How many Cosmetic Dermatology Fellowship Training Programs are there in the United States? How many Fellows graduate every year from these programs?

Not very many. I don’t know the exact numbers, but it is not very many.

7. Why do we need Experienced, Expert, Full-Time Non-Core Cosmetic Physicians Practicing and Teaching Cosmetic Dermatology?

Full-Time, Expert Non-Core Cosmetic Physicians are needed because there is an inadequate number of Fellowship Trained Cosmetic Dermatologists and an inadequate number of Cosmetic Dermatology Fellowship Training Programs. A physician’s clinical results are directly related to their clinical skills.These skills come from their ability, their training, their dedication to learning and their clinical experience. Gifted mentors along with a high volume clinical practice are also important ingredients.Plastic Surgeons, Dermatologists and Non-Core Cosmetic Physicians all start from the same point.Dermatologists are expert in skin physiology and pathology. The Plastic Surgeons and the Non-Core Cosmetic Physicians must become experts in skin physiology. The Fellowship Trained Dermatologists are the future of Cosmetic Dermatology, but until there are more training programs and more Fellowship Trained Dermatologists, they will not be the primary providers of Cosmetic Services to the general population. Many of the best non-invasive cosmetic physicians are non-core physicians who have dedicated 100% of their professional activity to cosmetic dermatology.

Signed, A Full-Time, Non-Core Cosmetic Physician

Sciton BBL IPL Live Chat Scheduled

Next live physician chat has been scheduled for Tuesday, February 24th at 9PM EST. IPLs including the Sciton BBL will be discussed. All interested parties are welcome.

Transcripts of past medical spa physician chats: medical spa marketing & advertising, Thermage, Fraxel, Fractional C02Laser, & Fraxel Technology & Protocols.

Next live physician chat:

Sciton BBL (Cosmetic IPLs & Lasers)
Tuesday February 24, 2009   9 - 10 PM EST

All IPL users are welcome. Intense Pulse Light (IPL)Chat Tuesday February 24, 2009 9:00 pm - 10:00 pm Eastern Sciton BBL and others. All Welcome.

Medical Spa MD: Why email doesn't work.

Email is the second worst form of communicating and disseminating complex information. (The telepone is probably worse.)

As part of an email group I received a response to a question that was posed about how members of the list would like to receive information:

I am OK with a quick e-mail. I just don't have time to go to the web page frquently. It takes a few seconds to look at the e-mail subject line and delete if not interested.   M....

This reply got me thinking about why email does not work for sharing information among groups and what the remedies are. (see below)

Below is an exchange between a number of members. I've actually made it much more readable than the original by deleting all of the extra replies and leaving only the new message.

Please read the exchange below. I am talking about Density Setting with DeepFx and percent of area covered. I was taught that density 3 was 15% and density 4 is 20%. I routinely treat with Density 3. This expert saysthat density 3is really 70% and density 4 is really 100%and then he goes on to talk about Gausian Distribution and "Top Hat" Pulses. Can anyone help me with this. Does anyone understand what he is talking about? He won't tell me. He just tells me to read his text books on Laser Physics. My comments are in black, his are in blue. Thanks: I usually use density 3 which I thought was 15% coverage. NO, IT IS MORE LIKE 70% Dr. Ross uses Density 4 which I think is 20% IT IS REALLY ALMOST 100% REMEMBER, IT IS A GUASIAN DISTRIBUTION coverage. You say that anything over density 2, is doing a full resurfacing.CORRECT I thought a full resurfacing was 100%.AGAIN, REMEMBER THAT THESE ARE NOT "TOP HAT" PULSES OF ENERGY BUY ENERGY DELIVERED IN A GAUSIAN DISTRIBUTION. PLEASE REFER TO MY LASER TEXTBOOK OR ANY LASER TEXTBOOK FOR FURTHER EXPLAINATION I am confused here. Could you clarify?

______________

Those are the same questions I have. I am not sure if by 100% coverage he is adding the ablative area to the coagulation area which then is equal to 100% coverage. We need to remember that as we increase the depth we are also increasing the Lateral area of coagulation.
The next question then needs to be, what is the ideal area of ablation and the ideal area of coagulation?

_______________

I sent an email to my Lutronic rep (I bought the machine already) and asked him your question. Below is his answer. I had a demo of the Smartxide and asked how it compared as I couldn't begin to figure out their system of treatment. Below is what he said.

Hi. Yes they are discussing % of total coverage. The density on your eCO2 equates to Lumenis’ density #’s (1, 2, 3 or 4 apparently). We use spots per square centimeter (50-400) which is really the correct way to measure density. (I have been doing well with 100-150 spots/cm- Sandra's comment) When you set your energy and density (in static mode) there will be a smaller number displayed as a percent below the density, this is your percent of area coverage treated which is calculated by energy, pulse-width and amount of spots per area (density) for a known treatment area. In dynamic mode (where I blend) you must calculate the area yourself and input this so the machine can calculate the % coverage correctly for you (this is where the grid masks help).

In a fractional system the idea is to treat only a “fraction” of the skins surface thereby leaving a large percent untreated to help the treated skin heal more quickly. 20%-30% coverage is generally considered to be enough for a decent fractional treatment (more or less depending upon the condition of skin, downtime and outcome required).

When he discusses “Gaussian” & flat top beam profile most all CO2 lasers have this “Gaussian” output beam mode. It simple means there’s a bullet shaped output beam where there’s more energy in the center than the edges and a flat top beam has even energy distribution across the whole beam. I can’t understand how they can confuse a #2 density with a full face resurfacing though (20%-100%)... I would think you could see the difference... It would take you many passes (with the 120u tip) to have almost 100% coverage. Maybe their confusing their spot sizes. I could see their “Active” Fx with a 1.25mm spot achieving this much coverage. This would be similar to you using the 1000u tip. (This ablates the skin superficially, like a micropeel)

The SmartXide is unlike any other laser out there. It uses “pitch” and “dwell” (which measures distance between spots and pulse-width).

______________

Greg

He is talking about beam divergence. Basically the area the energy distributes away from the focal point (called beam waist). This is measured with complex equations calculated by half-angles (paraxial approximation).

In physics he is correct because if you use enough energy, the outer areas spread and can touch each other though weak.

For practical application purposes Jeff, your percentages are truncated for easier understanding. Meaning the most energy at the beam waist and the tissue effect there.

I could not pass this to everyone, would you please.

______________

I really think that the answer to this questionvaries depending onthe underlying wavelength used (Erbium vs CO2 vs 1500, etc) and the depth of the beam. For example, it would take more % coverage using Erbium to exert the 100% effect than from a CO2 because of the more rapid water evaporization effect by Erbium energy. The deeper the hole is drilled the more collateral heat dissipation there is. I believe it should take more than 30% coverage to get to the 100% effect with CO2. Why did I think so?? I made this deductive reasoning from the fact that the Fraxel REPAIR does "full ablative" effect with 40% coverage with 1.4 mm depth in a dynamic mode (optical scanning mode)

Kevin

______________

Jeff,
Regarding top hat and gaussian... when lasers hit an object they normally have a Gaussian curve which looks like a bell curve from the side. Looking down on it -it would appear as a target with changes in energy going out from the center-being most 'Hot" in the center and less hot going out. A top hat is usually obtained using optics to correct the curve to have an equal energy through out. Now instead of a bell curve it is a square looking like a you guessed it a top hat.
The guy does not know what he is talking about and is parroting information or he would have been happy to tell you about this. I would..it really turns me on. I believe what he iseludingto is that your energy level may not be homogenous across the beam. many operators will overlap the beam to account for this, but you then run the risk of too much fluence and burning someone. I am looking at this percent thing and wondering if they are nottalkingabout what we call pitch. Energy is generally described as Fluence which takes into account the wattage, the area and the time of exposure to beam--Fluence = (Power x Time)/ Area. Where a Joule (I'm Joulish) is a watt-secode thereby describing energy and time. (shut me up)
With my fractionated laser- we have pitch which, desribes how far apart the holes are. a low pitch like 15% would be less coverage than 70%. It describes the percent coverage of the skin surface.
:  The mathematical function that describes the Gaussian beam Check out this link for a cool flash movie about this. Sciton- my people- use optics to correct laser G-curve to a Top hat. www.tanitlazerepilasyon.com/images/beamshape.swf
Hope this helps. Bruce

______________

He is talking about beam divergence. Basically the area the energy distributes away from the focal point (called beam waist). This is measured with complex equations calculated by half-angles (paraxial approximation).

In physics he is correct because if you use enough energy, the outer areas spread and can touch each other though weak.

For practical application purposes Jeff, your percentages are truncated for easier understanding. Meaning the most energy at the beam waist and the tissue effect there.

I could not pass this to everyone, would you please.

Greg

The problems with disseminating information via email.

1. It's a discusssion that really only takes place between a few people. In the example above there are four or so people involved in the conversation. However, there are about 40 people that the email is being sent to.
2. It's difficult to follow. The way that threaded emails work places all sorts of convoluted text in the replies that has to be filtered.
3. It's insecure. Every person on the email can see the email address of every other person. Believe me, there are already technology companies on that mailing list (I"ve already been contacted about it) and every member is now identified. Don't think that's a problem? See Dermacare sue everyone on Medical Spa MD.
4. It invites spam. (See reason 3 above.) Once that list is sent out, it's beyond anyones control.
5. It's useless for anone not on the list. If the goal is to learn, email is about the worst way possible since each individual now has to manage the list themselves, wasting time.
6. It's not archived. On of the nice things about sites is that you can find past or relevant content by searching Medical Spa MD. With email, it's just gone.
7. It's unmanagable. With the list above there are multiple threads. Each has to be managed by me. With one it's a pain but doable. With three or more it's just a mess.

If you look at the list above you'll realize why there's been a move away from email and to managing content on the internet where content can more easily be managed and accessed.

Dermatologists vs Plastic Surgeons vs Non-Core Physicians vs Non-Core Physician Extenders.

The MAPA blog has a new post up with a number of comments about dermatologists, non-core Physicians and non-core physician extenders competing for cosmetic medical dollars. Here's a blurb:

For years, dermatologists and plastic surgeons have been arguing about whether noncore physicians have a place in cosmetic medicine. Now, it seems more competition is likely, as nurse practitioners (NPs) and physician assistants (PAs) are pursuing careers in this lucrative field.

One way to thwart this trend is to deny them access to MD-directed training.

(Name Deleted) MD, also gave his viewpoint. Just because more NPs and PAs are assisting physicians doesn't mean doctors should give them even more control, said the clinical professor of dermatology.

"The more you promote them, the more problems we'll see," said (Name Deleted), alluding to NPs and PAs who act independently without physician supervision. Others set up their own practices with a name-only ­doctor on the payroll. The result, said Dr. (Name Deleted), is the potential for increased patient complications and a watering down of the expert skills dermatologists provide.

Core Physicians, Non-Core Physicians and Non-Core Physician Extenders

This is from a Guest Editorial in a National Magazine. It comes from the November 2008 American Society of Dermatologic Surgery meeting in Orlando.

Vol. 4 • Issue 5 • Page 6
Exerpt from Guest Editorial of Magazine

For years, dermatologists and plastic surgeons have been arguing about whether noncore physicians have a place in cosmetic medicine. Now, it seems more competition is likely, as nurse practitioners (NPs) and physician assistants (PAs) are pursuing careers in this lucrative field.

One way to thwart this trend is to deny them access to MD-directed training.

(Name Deleted) MD, also gave his viewpoint. Just because more NPs and PAs are assisting physicians doesn't mean doctors should give them even more control, said the clinical professor of dermatology.

"The more you promote them, the more problems we'll see," said (Name Deleted), alluding to NPs and PAs who act independently without physician supervision. Others set up their own practices with a name-only ­doctor on the payroll. The result, said Dr. (Name Deleted), is the potential for increased patient complications and a watering down of the expert skills dermatologists provide.

Your reaction?

Go to Advance for HealthyAging’s Website to view complete editorial. www.Advanceweb.com/HealthyAging

____________________________

Here's my opinion:

1. non-core physicians should not be performing cosmetic SURGERY, or any surgical procedure that they are not properly trained and credentialed in, regardless of the type of anesthesia used. "If you didn't complete an ACGME-approved residency in it, then don't do it".

2. Non-surgical, or medical procedures (injectables.) can often be safely performed by properly trained physicians of many specialties. But they need to know when they are over their head - and to refer to core-trained physicians in these circumstances.

3. Physician extenders, valuable though they are, require medical supervision by a physician supervisor with more cosmetic experience, training and/or credentialling than the extender they are supervising. This should ideally be on-site supervision.

4. Non-physicians, other than as listed above, have no business in cosmetic surgery or cosmetic medicine.

Tom

----

Tom: What is your definition of "cosmetic surgery"? I would assume that your comments would apply to derms as well? What is your opinion of derms vs.non-derms practicing "aesthetic medicine"? I have always been curious what would beleft if you subtracted the course work specifically related to skin diseases from all the standard dermatology curricula. Perhaps a new short track specialty could be created which would provide everythingthe standarddermatology specialtygenerallyminus the hours devoted to skin diseases.

---

I have only done Aesthetic medicine (a speciality in Canada) since 2003. Those in my area that have tried to do a little cosmetic medicine on the side have actually been good for my business. One primary care physician(now left the area) and the other plastic surgeon did not do effective treatments and people came to me on the rebound. The patients willing to travel to the larger city to the North of me for the cheap prices go to a "doc in the box" situation where the physician is hired to come in once/twice per week. These patients rebound to me as well. No one has been permanently injured by their treatments that I am aware. However, they are all mad about the money they wasted. When they come to my office, they are not yet turned away from trying another person out and I strive to do my best in giving them the treatment/outcome they want no different than any other patient, though.

I believe that no matter what, I do no harm, but I want to do the best treatment possible for my patients. The rapport with our patients is parliament.

Yes, I don't like competition because most of our patients,women, are shoppers. However, I price my services above average, because I give them the best treatment that I can. The difference is that my services are the best value for their money, period. I don't sell my self short. As a business, I am not Walmart, but I believe my services and all of us on this email list are above Macys or Nordstroms or any other high end business you can think of. All of us care enough to ask others how to do the best treatments for our patients. We are professionals and people need to know that our quality is thee best and they need to be aware of the quality involved with our services. How do we do this?

Can we stop non-physicians or NP's from starting up cosmetic businesses? It may have to come about through each state's regulation. In my state there is no law that states a non-physician can run any class of machines, there are only suggestions of care. I would love to be Aesthetic Medicine Board Certified if it meant anything, see 4M's new money maker.... Any others, suggestions?

Sandra

---

I don't worry excessively about the competition in the area, whether it be from other PS, derms, or non-core providers.

I just try to do the best I can for each patient....and word about who's good gets around by itself.

My prices are about market average, and we don't try to be the cheapest.

BTW: the word you are looking for is "paramount", not "parliament" :)

Tom

---

I think a differentiation needs to be made when talking about Providers. You have PA's and NP's which are lumped together because they are the only non physicians who can legally practice medicine, though their education is significantly different. Then you have a list of others which are allowed to perform specific duties depending on state.

Most people including physicians are not familiar (unless you work with or teach them)with PA education and training. This is an FYI not a confrontation, I know my limits and place as a PA.

PA's are educated in the medical model, the curriculum is the same as MD's but some non essential aspects are truncated in order to expedite the process to clinical practice. Three current program "specialties" exist; primary care, surgery and emergency medicine.The coreis essentially the same with much overlapbecause of national accreditation to sit for the board exam, all schools in all states follow the same criteria. A residency (16 specialties currently) is optional at this point but encouraged. Yes, even Dermatology and Surgery are available.

PA Residency Specialties

http://www.appap.org/prog_specialty.html

Curriculum From Albany Medical College (example is the one I attended). If you think they must be watered down, check the course description link at the bottom.

http://www.amc.edu/Academic/PhysicianAssistant/Curriculum.html

Sandra, I think its too late to stop this at a state level. This has been in motion with PA/NP for almost forth years at a state and federal level.

Tom, I have to respectfully disagree with you. Saying "If you didn't complete an ACGME-approved residency in it, then don't do it" is saying a physician or provider can not learn outside of this environment. We learn new and reinforce the already learned constantly as medicine advances. Example; I perform hair transplants, the donor area can get large 1.8 cm wide x 15 cm long. Ihad experience in lesion removal and suturing prior. I learned this procedure (and several others) from an experienced general surgeon 35+ years. I would 1st assist then he would 1st assist me, when we were both comfortable he would observe, coach and teach. Now I am on my own with indirect supervision. My skills do not compare to your surgical expertise, but I think its the providers responsibility to be in their scope of education and training on what they do.

NP's are educated in the nursing model. There is obvious cross over when they reach the clinical training. NP's help me out here.

By 2015 all NP programs will be doctorate level, DNP's.

PA's have also breached the doctorate level. The first was about two years ago US Army/Baylor university put out it's first doctorate level PA's. Course included a rigorous 18 month EM residency. Interesting note; the PA's forego the title "Doctor" in order not to confuse the public of the gold standard of medicine.

Some articles of interest.

Greg

---

Greg:

No disrespect to you. I enjoy our conversations and respect your skillsas a PA. I took a look at a few of the surgical PA programs you listed - and they look like a good 12 month experience.

However, if we really compare things to a medical model, that's like completing a 12 month surgical internship after finishing med school.

It would certainly allow you to be proficient at relatively straightforward procedures, but even a good intern is not on the same level as the chief resident, or the attending.

My comment about ACGME-residency doesn't deny the possibility of postgraduate learning. It's just to state my opinion that taking a small number of weekend courses doesn't somehow "convert" a non-surgeon into a cosmetic surgeon or plastic surgeon-equivalent, as the AACS seems to think.

Tom

----

Hey Tom,

No disrespect taken. This is good dialogue! As always your comments are intelligent, well thought out and accurate. My disclaimers purpose was to be clear that I was not trying to offend or challenge anyone in our discussion group, only to educate and pass on information about the PA profession. There are still a good number of physicians (and others)that think a PA has no business with a stethoscope, rx pad, scalpel, laser, etc.... I think this opinion is largely based on a lack of information on PA education and training, or a misconception that PA's push for practice independent of physicians. My goal was to have those of this opinion take a second well informed look. NP's push and push hard for total independent practice very openly and looks like they will soon get it. The PA professions motto is "partners in medicine", and do not seek independence. The issue is, most allied health professions (nurse, pharmacist, physical therapist...)have a doctorate level of education available. PA's must follow suit to be competitive education and training wise, trying not to step on the toes of our greatest allies being physicians (MD, DO).

Your analogy of a surgical residency trained PA is excellent. I agree with you on the superior level of chief resident and attending. This is why PA's are dependent practicioners. I would describe my personal PA experience as a perpetual residency, I just get paid more.

I also agree with your opinion on the difference between CS and PS. "Weekend courses" do not give one expertise on anything. The AACS stance does not take into account the years of training in reconstructive surgery. I'm going to sit this one out, its an issue the physicians can argue out.

Greg

Wow -- an interesting discussion. I am Board Certified in both Family Practice, (and was even eligible in ER) and at no time in my training did I learn squat about cosmetic medicine. I was an FP practicing amongst the Amish in the late 70's with enough training to deliver babies, do C-Sections and if called on in a third world country could easily do old fashioned gall bladder surgery and appendectomies. But, my FP residency was tilted toward the surgical (my choosing).

As an FP I knew nothing about the organ called skin.
I would maintain (no offense) Plastic Surgeons know little about skin either (as an organ) beyond some basic and some even skilled surgical manipulation.

My derm training taught me everything I know about the skin, and CME keeps me abreast. I learned flaps from the renowned dermatologist Len Dzubow in Phila. (Several books on the subject of surgery of the head and neck.) I do them to this day.

Here's my big point -- those of us with experience (read = age) learned all of our cosmetic medicine at various courses -- some nonsense in quality -- others outstanding. I made a point of going directly to masters for mine so I could perform my art well. Sometime this meant going internationally.

I have a PA who does injectables under my supervision and as a technician she rivals many barely trained doctors. Reason? I trained her.

My staff of Medical Assistants, LPN's and RN's do laser work -- all taught by me -- with ongoing training as well. The repetition they do daily makes them expert -- and I supervise them. None of us in my office take a "cookie cutter" approach to laser settings -- varying them with subsequent setting changes based on client goals and response.
All of my staff know laser physics -- because with that knowledge they are less likely to do something stupid. It's my ass in the sling.

I daresay there are a lot of "non-traditionals" out there who have done as much due diligence as I -- and deserve their place amongst us -- but unfortunately I know a bunch who ought to stop -- now! I take care of their screw-ups -- so I know they exist.

We can't take the position of assuming formal credentials makes a perfect cosmetic surgeon -- we all know those with credentials who couldn't sew their way out of a paper bag without leaving dog ears or infection.

This is a tough issue. Responsibility lies with each of us to perform our art for the ultimate benefit of our clients. Turf wars based on degrees and memberships have little place here -- for those are indicators of interest -- not of skill or good judgement.

Respectfully submitted,
Jim

---

Tom,
You asked I take a stab at the categories:
Here're yours -- in blue -- with my thoughts in black following  (special note -- for convenience I have reverted to the male, "he" rather than attempts to be politically correct -- no offense to the amazing women out there who should simply replace "he" with "she", etc.)

1. non-core physicians should not be performing cosmetic SURGERY, or any surgical procedure that they are not properly trained and credentialed in, regardless of the type of anesthesia used. "If you didn't complete an ACGME-approved residency in it, then don't do it".

Cosmetic surgery was a term defined by providers first -- then an academy formed to attempt quality control. There's a wide spectrum in this category ranging from the mundane (a tech could do it if adequately trained and supervised) to the extremely complex -- such as breast augmentation -- best left in the hands of but a few plastic surgeons (for many don't seem to have the 'art' of body symmetry in their heads.) Note I said, just a few -- for even their board certification hasn't saved many from 'bad jobs'.

Last time I looked, my license says "Medical Physician and Surgeon". Since much of what we do is learned over time as the onslaught of change and technology develops we need personal boundaries governing what it is we do to people -- our clients. I never just take a course, for instance. I like to find someone renowned for "doing it best" and get hands on (not look over the shoulder) training.

Understand -- even in the best of hands, "shit happens" -- but I'm not talking of this. One plastic surgeon I know went on regional TV showing his placement of contour threads in the dermis proved Contour threads didn't work, when , in reality he put them in the wrong place. His client had blue lines throughout her face -- on ABC TV. Must have used the original brand to boot. How embarrassing for him. But he wasn't -- being ignorant of the procedure's technique. Board certification doesn't help ignorance.

My point is a good "cosmetic surgeon" is one who has a personal interest and honest curiosity with firm knowledge about human facial and body anatomy, coupled with graceful and artistic surgical skills with an appreciation for pre-existing naturally occurring body/facial asymmetry. He then plys his craft effortlessly, constantly altering his approach as the tissue before him "talks to him" for the best alignment. There are lines he simply will not cross because of respect for the client and his own integrity. He bails before the fact -- referring before putting his client in trouble.

I would say the plastic surgeon's turf includes breast augmentation/reduction, and myocutaneous flaps -- plus anything else he has done repetitively in his training requiring his special expertise. For instance, brain surgeons have no problem with their turf.

Other surgical procedures safely done in office surgery set-ups can be done by those adequately knowledgeable of anatomy plus the necessary skills to deliver results well within the comfort zone of confidence garnered from adequate training. I do a modification of the S-Lift because I figured out a way to do it better via different flap closures. No biggy -- just illustrating the fact that what I call "listening to and observing living tissue" is what makes the difference between a good surgeon and one who consistently produces outstanding results.

The plastic surgeon who trained me in SmartLipo warned me not to do what his highly regarded Board Certified colleague did -- rammed the probe right through an abdominal hernia into the gut. Hmmm -- anatomy and a respect for the unusual (always a possibility) anyone?

Seems our dilemma is what kind of doctor do you want to be? And trust me -- Board certification won't save you or your client when things go south.

Tom -- here's my rule. I do what I know beyond a doubt I can do at least as well as anyone else -- or better. And I'm always looking for creative ways to do it better.
If I want to do something more, I go find a teacher who has done thousands of cases and can tell me the "insider secrets" for best results and keeping out of trouble. I never go just to the doc (no matter his certification) who's pimping for a laser company. One more step always is to find someone else who knows what he's doing cold.

2. Non-surgical, or medical procedures (injectables.) can often be safely performed by properly trained physicians of many specialties. But they need to know when they are over their head - and to refer to core-trained physicians in these circumstances.

Totally agree. Oddly enough, I've had frustrated clients from plastics come to me. There's this elusive thing called "the art of medicine". It a blend of Sherlockian curiosity coupled with hard science -- because just like flying a plane you must abide by the laws of physics or you'll auger in.

3. Physician extenders, valuable though they are, require medical supervision by a physician supervisor with more cosmetic experience, training and/or credentialling than the extender they are supervising. This should ideally be on-site supervision.

Total agreement -- and in most states -- the law.

4. Non-physicians, other than as listed above, have no business in cosmetic surgery or cosmetic medicine.

Cosmetic medicine includes many entry level "stuff': products (medical grade), facials, microdermabrasion, peels (both acid and laser) and many non-ablative laser procedures. I believe a properly trained staff person (RN, MA) operating under my supervision will provide higher quality results by the sheer fact of repetition (under supervision) with results matching or exceeding that of a physician doing it occasionally.
This is safe for the client -- often better (women dealing with women) with results from someone who does it daily being enhanced.

Quite frankly -- I'd rather fall on a sword than do bikini line laser hair removal. My esthetician and medical assistants have become expert in this -- and my time is leveraged to do what I want -- facial surgery, earlobe repair, laser lipo, etc.

Cosmetic surgery is a wide concept -- anything done to the skin or body to alter (for benefit or correction) by invasion of tissue. From what I've seen, results are all over the map on this -- regardless of credentials. There's "good guys", "bad guys" and total experts out there. Certified or self-taught doesn't seem to matter much here except for general quality (or standards) of care guidelines.

One of the best known, (internationally) published, and sought after eyelash transplantation surgeon lives in Mexico -- is self taught and very inventive. Nobody can match what he does.

What makes him so different? His love of what he does ... and his love for his clients.

That's what makes a great cosmetic surgeon.

Best to all as we add our two cents to this most stimulating and important conversation.

Jim

---
Jim:

Thank you for your thoughtful reply.

The problem is: for every person like yourself, who cares about their quality, and their patient outcomes, there are 10 who say, "don't restrict me - my licence says I'm a surgeon, so I'm gonna do cosmetic surgery, whether I'm trained / good / etc. or not, because I'm legally allowed to."

This doesn't help the patient in the end. Personal boundaries, unfortunately, are subject to abuse to egotists.

So, with this in mind, why don't you try writing a concise set of rules like I did. I think you'll find it's harder than you expected.

Best regards,
Tom
---

Tom,
Writing rules is a difficult exercise indeed and I give you credit for doing so. If rules such as yours were implemented I think a grandfathering clause for those who've proven merit would be necessary after which they too would be credentialed in some way.

I agree about the pollution of charlatanism within what is termed "Cosmetic Medicine" and "if we don't police ourselves ... etc." someone else may do it for us.

I can't write the rules -- you're correct -- too difficult.
Perhaps the answer lies with the public -- letting them know what's in store for them if they choose the wrong doctor/facility.

May I say to the MAPA/Epstein group -- to all who are PA's, estheticians and the like that you are not being targeted in this discussion -- for your interest in this forum indicates the dedication both you and your doctors share to the proper delivery of quality care to your clients. It's the poison without that is our common enemy and we must in some way differentiate ourselves from them.

Tom has shown leadership in this and his words have merit.
Lots to think about,
Jim

---
Thank you for your discussion. It appears you are quite experienced. Which courses and journals do you recommend? Who are the masters that you can go to for training? What do you think of the American Academy of Aesthetic Medicine, because they give out board certification? Their teachers are from all over the world. Which courses are good for Asian skin? I would also appreciate any reply for the group.

Sincerely,
Carolyn

---
I believe the best way to learn is one-on-one from very experienced physicians. GOing to courses can only take you so far. In regards to treating Asian skin, you must get the experience directly from treating the patients and sharing info with others of same practice profile. I have been treating Asian and Hispanic skin for the past 5 years and I still get surprised by certain skin reaction from patients

Kevin
---
ASLMS had a full half day on treating patients of color. It is GREAT! and a must for anyone serious about treating patients with lasers. If you can't go, you can order the CD from www.ASLMS.org and listen to it.

I have probably learned the most from reading the blog threads on MedicalSpaMD and talking to the experts there, like Kevin, Lornell, Greg, Tom, etc. I copy the thread and print it. I read it and underline and study what people are saying. Give this a try and your will learn more then you can learn at any conference!

I think the discussions we are having right now with our email list is a great way to learn. We will be taking these discussions to MedicalSpaMD for archiving and further discussion.

Jeff E

New additions and sponsors of Medical Spa MD.

There's been a tremendous amount of activity around the site lately and I want to make sure that Medical Spa MDs new sponsors, advertisers and partners are noticed.

The Medical Spa Classifieds Ads have really taken off with with a number of sales in it's first month of existence. If you're an individual (not a business) you're invited to list your your equipment for free there.

New Sponsor:

Medical Chat Live has joined the site as a sponsor and they're offering a substantial discount to their service for those physicians and clinics who would like to add live chat to their website and join throught the link on Medspa MD. While their regular pricing is a $100 setup fee and $50 a month, you can try it out through Medical Spa MD for just $9.95 for the first month and then $30 a month if you're satisfied with the service.

A new addition to the Medica Spa Directory

Cherry Hill Laser & Skin Care Center - NewJersey Dr. Jeffrey Epstein and Cherry Hill Laser are the most experienced providers of Cosmetic Skin Care Services in South Jersey. We have performed over 40,000 procedures and we have 14 Cosmetic Lasers. Dr. Epstein is also a prime mover behind the addition of the new Medical Aesthetic Practice Association area to the site.

MAPA - The Medical Aesthetic Practice Association

The MAPA area of Medical Spa MD has been fleshed out a little and now includes some fantastic information and the addition of live hosted chats to the site. Inside the MAPA area you'll find:

• Regularly scheduled chats and archived transcripts on a variety of medical spa topics including; Marketing, Fraxel Treatments & Protocols, and Thermage, Fraxel, and CO2 Laser Ablation.
• Medical Spa Technlology Reports and Wrapups that include a DeepFX Webinar Summary of Reliant Ultrapulse Fraxel CO2 Lasers, Pain control when performing Fraxel treatments, Fraxel side effects and treatment protocols.
• A forum to discuss MAPA as an organization.
• A blog where MAPA articles, news and event summaries will reside.
• Contact or inquire about joining MAPA as a member.

You'll also be able to see new posts to the MAPA area with the RECENT POSTS section of the navigation that will include new posts from throughtout the site.

MAPA member are some long-time supporters and are well know to regular members. We'll do our best to get this fledgling entity off the gound and provide pleanty of opportunity and exposure.

Thera are some other deals in the works with big players. If you'd like to have exposure on the site or offer benefits to our 200+ Members you can contact us via email, or apply to become a Select Partner.

I've also had a number of excellent phone conversations with a well know Laser and IPL supplier as well as trade show organizers, large web site networks, and technology companies. I'm hopeful that at least a few of these contacts and discussions will bear fruit and provide additional benefits for members.

Also, I wanted to make sure that Members who have recieved their first free downloads recognize the name Sendside since I'm using that to distribute that information. If you receive and invitation to join Sendside make sure you sign up and get a free account. It's currently the only way we're using to send that info.

Also of note: We're in the early stages of building out a consumer facing sister site to Medical Spa MD that will allow physicians to answer patient questions and provide a number of interesting features around capturing local patients. We'll be disclosing details of this to a number of docs and gathering feedback.

Pigment & Redness: Sciton BBL Treatment Parameters

Sciton BBL Treatment Parameters: Pigment & Redness

Hi everyone, Just started with BBL.I have a Q regared the 515 filter and lentigines. With the 10ms pulse widths I have seen moderate rxns at 11-12J with 25 cooling in type 2s ( moderate erythema with accentuation and darkening of lentigines). When I moved to 20ms 9-10J with 18 cooling in type 3 and 4s I saw no immediate response (eythema or darkening). I spoke with a patient today who stated minimal darkening 24hr out. These are the recommended settings but they do not appear to have the punch. Has anyone tried lowering pulse widths to 15ms or even 10ms with cooling let's say 15 to protect surrounding skin?? I have lot's of type 3-4s with lentigines. Your suggestions appreciated

-------

Hey Sal, these are notes that I made.

They are settings that I used on a few difficult patients.

I am trying to figure out how to best use the BBL.

Not really sure why some worked but I am beginning to play with all parameters of the BBL

Interested in your thoughts as well as the thought of the others.

Jeff E

Pt #1:

I just did a BBL on an age spot that was difficult to get to darken.

It had faded about 60% with two previous treatments but would not fade further.

I increased the wavelength to get deeper.

I increased the energy to 22 j/cm2.

I increased the temperature to 25 degrees.

The pulse duration was 20 ms.

I need to check these settings. Not sure about the exact pulse duration or temp.

Perhaps 515 ms would have worked if energy and temp were high enough?

JEE

Dark Circles Under Eyes with BBL

Patient #2:

Finally got darkening with 515-20ms-20d-15j

increased energy, lengthened pulse duration and increased temperature.

He had PIGMENT as the cause of his dark circles

prior settings were:

The first 4 treatments did not produce any lightening.

515-13j-15ms-20: Rx #1

515-16j-15ms-18: Rx #2

560-16j-15ms-18

560-18j-10ms-18

515-15j-20ms-20: Rx #5: worked

515-15j-20ms-20: Rx #6: worked

Patient #3

Rx # 2: 590-11ms-21j-20d

She had Vascular Etiology of her dark circles

Rx #1 showed no improvement with 560-10ms-16j-20d

I used a longerwavelength and increasedthe energy to get the response.

Did this work because longer wavelengths go deeper?

JEE

Pt #4:

Just did a BBL for pigment. Skin type 4 (looked like Asian but from Russia).

Test spots at 590 nm, 20 ms, 12-18 j, 20 degreesdid not react. (smallest round spot size)

I turned MS down to 15 ms and did test spots at 15, 16 and 17 and the 17 j reacted. (used the square mask)

Gota nice darkening with the square mask, 17 j , 590 nm, 15 ms.

Not sure whether using larger spot size made the difference or turning to lower pulse duration.

Probably lower pulse duration!

JEE

-------------------------

Ithink it depends. I will use higher settings if I am spot treating and a little lower when doing full face chest etc. I agree that the "safe" numbers given by Sciton are a little under treating. I think on a Fitz 3 you can drop to 15msec and increase your joules. I tend to do a test spot and watch the reaction for a few minutes. If I do see a response then I will increase the Joules. I also tend to always use 20 to 25 degrees cooling.

Lornell

Redness after Laser Treatments

I am getting lots of redness which is lasting 6 weeks and longer.
Checkerboard where I did Deepfx. Any suggestions about how to avoid or help
it fade faster. It fades to the point where it can be covered up within 2 weeks,
but still would like to know any tricks you have come up with.

Also for men, they don't use coverup makeup! - so this is more of a problem.

Finally, any tips for better visualization of where you have treated with
DeepFx?  Hard to see pulse patterns and with blood and serum oozing, hard to tell exactly where you have been. Any tips???  Are you all having the same problems?

I do Deepfx at 17.5 j with Density 3
I do ActiveFx over deepfx at density 1 energy 70 (to blend color).
I try to place pulse patterns right next to each other without leaving
spaces. I do Activefx around the eyes (not deep)

JEE

----
I think your settings are pretty reasonable for what you are doing. The
question for me then would be what product or treatment can you do to
accelerate the healing? Or is it simply the patient profile that would be
more likely to stay red. I have had a few stay red up to 3 months, and
several go about 4-6 weeks, but fading gradually over that time. The
patients that do this tend to have more fair skin to start with, but I also had an
FST4 that stayed red for 6 weeks, so go figure. Sun exposure is obvious but it
seems like people don't want to follow that one and it can keep them red much
longer if they dont comply. If it comes down to product, we have done well
with SkinMedica Ceramide Treatment Cream. Not a definitive answer but hope it starts some conversation.

Brian

----

This is an indication that you’ve done a deep treatment. Think back to your experience with totally ablative co2 – deeper treatments are pinker for longer. You may want to adjust your parameters to decrease your fluence.

Tom

----

Agree with all, but we also use a series of high intensity red and yellow led treatments afterwards which definetly helps. Some redness post Co2 is expected though and this happens even with the lowest treatment settings.

Mtich

------------

Thats a great point - who is using LED and what is your opinion? I have heard
both sides but only a small survey. Any downside to LED?

Brian

-----------------

Any long term pigment issues (hypo/hyper) with ST 4? Have you done darker ST
with the fractional CO2?

You are right on with the sun issue. People will use every crappy cream in the
book or stand on their head for the first 24hrs, but sun avoidance is the
uncompliant patients specialty.

Greg

----
I have done acne scar revision on a few FST4 and 5 with ONLY DeepFX and have
had no pigmentation issues past the 5-7 day healing time. If they are prone
to PIH based on history or my gut feeling, I will pre-treat with Tri-luma for
a few weeks prior to the procedure, but it seems like the trick is to heal
them as fast as posible to avoid the lingering inflammation that wakes up the
melanocytes. I should also add that I have done test spots on those FST 4 and
5 patients before treating also and all of them so far have passed the test.

We have gone so far as to make a 'contract' out of the bullet points on pre
and post care (like sun exposure) and they have to sign it that they fully
agree and understand before we treat. This is in addition to the actual
consent. Minimal liability protection to be sure, but it puts it in writing
in front of them one more time.

Brian

Fraxel: Rashes, Reactions & Treatment Protocols

I just had my third fraxel treatment. I gotten a rash after each but this is much worse then the others. I am afraid to go out of the house. I have been given an antibiotic and I do not feel I my rash is improving. It itches and when I scratch it feel soooo sore. Why does this happen? I am not going to do this again unless I can figure out why

Posted by Jeff E

My first assumption is they are using something topically for after care that is causing a contact dermatitis. This is why I hate to use the topical antibiotics. I only use vaseline for after care. It could be something in the topical from the compounding as well. Just my first impressions.

Lornell

I agree, it may be the topical. Even Aquaphor caused problems with some folks.
I have done hundreds of the fractional treatments, and have gone to a very "ingredient free" occlusive ointment from Elta. Have not had a problem since!

Deb

What is a good moisturizer which has minimal irritating "stuff" in it?

Jeff E

Maybe this can help...

I have seen rashes like this occuring after thedoctor (chiropractor) at my office performs a fraxel treatment. He is known to not wipe the numbing cream off thoroughly and then puts the gliding gel on directly after. After performing the treatment he does not thoroughly clean the skin and immediately puts aloe on the skin. Clients usually come in days later complaining of a rash and itchiness, especially on the cheeks and chin. Im guessing the rash is from a combination of the heat and multiple substances still being on the skin. It is very important to make sure that the skin is very clean before, during and after the treatment. The topical we use is a 7/7 lidocaine/tetracaine combo and most clients that I've treated come out pretty good without any complications after aside from the swelling.

After the treatment I let the client sit with cold aloe vera along with the simmer chiller blasting cold air onthe face for about 15 mins. Then I have them rinse the skin and I immediately apply the Neocutis BioRestorative Gel that is very light in texture and great for post op care. The Neocutis line is great for burns, scars, rashes, irritations and is best for after fraxel treatments for the first week. It helps the skin get back to a normal state. i usually sell these products along with the Fraxel package so that the client can use the products at home and continue caring for the skin properly. Using anything thick like a vaseline base, bacitracin, heavy creams immediately after the treatment and during the first week post op will irritate and clog the skin and cause more complications.

Jessica

For post laser sunblock, consider Elta MD 45 physical block-never seen acne break out or contact dermatitis with it. It is extremely cosmetically elegant, just not waterproof.

Mitch

We put a cream on similiar to Cetaphilday 1.We are experimenting with a post balm ointment....that we sell. I will let you know how this works out.

Sandra

My first choice is vaseline but I have some of the Elta and i am giving it a try.

Lornell

I agree, it may be the topical. Even Aquaphor caused problems with some folks.
I have done hundreds of the fractional treatments, and have gone to a very "ingredient free" occlusive ointment from Elta. Have not had a problem since!

Deb

Fraxel: Pain Control when doing Fractional Treatments

To the group: What is the strongest numbing cream that you can order from a compounding pharmacy? I currently get a combination of lidocaine/prilocaine that the pharmacy will not tell me how and what concentration it is. It is better than Emla, but is there anything else out there? Currently we are getting people through the CO2 first pass with my cream, a 10 mg of Vicodin and 2 mg of Ativan, all PO, but when it comes to the dynamic phase where I blend, they start squirming. I am at the point, I may start to do conscious sedation with Fentyl and Versed. If anyone is using the Lutronic CO2, my settings are 100-160 mJ and 100-150 spots/cm2(density is automatically calculated for you). Thank you.

Sandra

Sandra, have you considered IM Toradol or IM Versed? Conscious Sedation is an interesting idea. I was just speaking with an anesthesia doctor friend of mine about this. He said you would need a anesthesia nurse ($100 per hour) and you might need certain credentials in certain states (surgi-center?). I think Dentists do this all the time. It is an idea worthy of further discussion.

Jeff E

-------------------------

What about Nitrous Oxide (gas)? I have a patient who received cosmetic treatments in FL with this and always asks why we don’t do it. Any thoughts?

Susan DeGuide

-----------------------

I have been told that it will increase your malpractice insurance and it is expensive to get started.

Lornell
--------------------------

nitrous use requires a proper "scavenging system" - OSHA rules. It's not just about having a tank...

Tom

-------------

Toxic to officepersonnel-- especially women of child bearing age.

Jim

Our doctor did her initial training in FL. They used nitrous oxide for everything, including injectables. They positioned themselves as a place to go for pain freecosmetic procedures. We bought a nitrous oxide cart system when we were down there, but we did not realize the laws in PA were so different than FL and we have not used our nitrous yet (a couple of years now) because we can't find anywhere to go to get certified to use it. We have tried dental schools, dentists, etc and have had no luck. If anyone knows how we can do that, we would love to hear some feedback, otherwise we are now trying to sell it.

Dina

------------------

In most states your malpractice insurance will go up significantly if you start doing conscious sedation.

Lornell

Hi Sandra
Toradol does make a big difference for 'heat pain'. Also consider using Intramuscular demerol instead of vicodin. I use a blt in a specially prepared base, demerol, ativan and toradol and it goes well. Must time the dosing right though

Mitch

In PA surgicenters used to be ways of getting more money out of insurance companies (speaking very frankly). Medicare and Ins. Co.'s got wise to it and now these entities are falling off.

Gotta balance the risk/benefit of having someone under anesthesia -- even via 'conscious sedation' without the STANDARD OF CARE (legal sticking point) offered forresuscitationsay, as in a hospital setting.

This is why (at least in PA) the plastics docs and surgeons use Short Procedure Units. Saves on both liability and cost of equipment in the office setting.

This brings me back to setting your panel of procedures to optimal revenue generation -- for the requests of those most willing and able to pay -- at the lowest risk. Then do a lot of them. The best way to do a lot is (if you can) to leverage your time by getting staff to do as much as possible for you -- thus the popularity of IPL devices in Jersey -- docs have to do the real lasers.

Feedback?

Jim

DeepFx Webinar: 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:

1. Do the DeepFx first and then do the ActiveFx
2. If the DeepFx causes bleeding, wait until the bleeding stops before doing the ActiveFx (blood will absorb the energy from the ActiveFx pulses)
3. 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!
4. Dr. Ross sometimes uses thrombin spray (from Baxter) to stop the bleeding.
5. With DeepFx, you treat lower face first and move upwards so blood won’t drip down into your treatment field. “South to North”
6. Do DeepFx before you do fillers. The DeepFx may go deep enough to disrupt the fillers.
7. You can do fillers and then ActiveFx because ActiveFx only goes 100 - 300 microns deep. Fillers are placed deeper than this.
8. 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?
9. 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?”
10. Use intraocular eyeshields for upper eyelids. You might be able to use tongue blade wrapped in moist gauze for lower lids
11. 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!
12. 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.
13. Some older patients (your mother-in-law) really need traditional CO2 or a facelift. Give them that option.
14. 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:

1. 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.
2. ActiveFx is better for pigment and more superficial textural problems
3. Stretch Marks (Stria): Use ActiveFx: 80-100 mj, density 1-2 (use Density 2 for thicker Stria). Do NOT use DeepFx for Stria.
4. 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.
5. Tattoos: DeepFx might be good for resistant Tattoos

ActiveFx, DeepFx & Total Fx Settings:

1. The experts usually treat with DeepFx in the range of 15 mj – 20 mj
2. Most experts would not go higher than density 3 with DeepFx (15%).
3. 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).
4. To stay out of trouble with ActiveFx off the face, use Density 1 and 70-80 mj

Treating Specific Areas:

1. Eyes: Use ActiveFx. Don’t do DeepFx around eyes (skin too thin?)
2. Eyes: ActiveFx: 90-100 mj, density 2-3. Downtime: 7-8 days of downtime (what TYPE of downtime?)
3. Eyes: Upper Lid: ActiveFx: 60-70 mj, density 1
4. 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!
5. 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!
6. 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?)
7. Neck: ActiveFx: 100 mj and density 3 was too strong. Produced prolonged erythema.
8. 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.
9. DeepFx can be done on neck, chest and hands

Pigment Changes, Post Inflammatory Hyperpigmentation, Melasma

1. Don’t treat Melasma (Dr. Ross)
2. 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.
3. 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!).
4. 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?
5. 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).
6. 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).
7. 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.
8. 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.
9. Experts: “Koreans are skin type 4”. Me: I would treat them as skin type 5! I wonder what Dr. Eliot Battle would say?

Downtime:

1. 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).
2. 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?
3. 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.
4. 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:

1. 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)
2. The best results for deep wrinkles, vertical lip lines and acne scars can only be obtained with deep ablation
3. 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?
4. 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:

1. Mild moisturizers avoid acne flare-ups
2. You don’t have to use aquaphor or vasoline. Mild moisturizers are good enough (personal communication from company reps).
3. Be careful of the lanolin in the aquaphor.
4. Using Aveeno Water Gel gets you one less day of Downtime! (From Dr. Weiss). What is Aveeno Water Gel? How do we get it?
5. 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?)
6. Post Care: Cold packs or Zimmer Cooler for 30-45 min after treatment
7. 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!).
8. Check all patients the next day, this makes you and them feel better.
9. 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?
10. Pliaglis can be mixed with cetaphil cleanser or cetaphil moisturizer. 90% Pliaglis and 10% cleanser or moisturizer.
11. 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!
12. 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.
13. Sunscreens: Use everyday after skin is healed up. Wear hat and stay out of sun until healed.
14. Use a good UVA blockers: Neutrogena, Helioplex or Loreal Products.

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

1. 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.
2. 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!
3. 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!
4. 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).

Fraxel, Thermage, and CO2 Laser Physician Chat

You'll want to make you take advantage of the newest feature on Medical Spa MD, MAPAs live discussions and chat archive.

Last Chat: Tuesday, Jan 27 at 8PM EST
Thermage, Fraxel, and CO2 Laser Ablation

The discussion will include treatment perameters, effectivness, cost, the technolgies and anything else of interest. Physicians with experience are invited but the chat is open to any interested parties. Fraxel, Thermage or other reps who identify themselves and are willing to engage in open discusion are also welcome.

The transcripts of previous chats on Marketing and Fraxel are already available on the new MAPA Chat Archive along with a new area for reviews of medical spa technologies.

The Medical Aesthetic Practice Association (MAPA) + Medical Spa MD.

Medical Spa MD is pleased to now be providing services to MAPA, The Medical Aesthetic Practice Association.

MAPA members have been using this site for some time to organize events and schedule chat sessions. We're happy to provide additional capabilites to MAPA by building out a portiion of the site that will allow MAPA members a single place to stay up to date.

Read the new MAPA Blog, participate in a live chat or read the transcripts, find reviews of medical spa technologies, or contact MAPA.

About MAPA from Jeffrey E. Epstein, MD:

The Medical Aesthetic Practice Association has been formed to advance the Clinical and Business practicies of Medical Aesthetics by facilitating "information exchange" among clinic owners and medical practitioners who work in large and small communities all around the world.

This organization is about taking the information we get from the laser companies, product companies, lumenaries and experts and putting it through the "real world" grinder of everyday experiences in busy clinical practices in order to perfect and polish the final informational product. We hope this will lead to safer treatments with better clinical outcomes.

The MAPA area will grow increasingly robust over the coming weeks with forums, a library and archive and additional features.

I'll note here that MAPA is an independant organization and not owned by Medical Spa MD.

New Thermage web site design.

Solta Medical, the parent company of Thermage and now Fraxel, has a new and somewhat suprising look for the new Thermage web site.

I like it if only for trying something new and getting away from the bordom that pervades the typical corporate technology site.

Botox training for physicians: SEO Garbage

SEO (search engine optimization) is becomming increasingly important for your clinic or medspa.

If you happen to search for Medical Spas on Google you'll be thrilled to know that Medical Spa MD ranks #1. Why? Because there are thousands of comments and nearly a thousand posts that are all original content and create for those searching for informaton that's found on this site.

Of course there are the scammers and hackers who play the system.

Search for Botox Training for Physicians and you'll see a hose of adword-cram sites that exist only to get you to click on a paid listing link and charge the company for the click. These pages are build in the hundreds and stuffed with backlinks and garbage content that's copied and pasted. It's not original, it's not worth anything, and it exists only to trick consumers into clicking on ads since they typically have no other navigation or content for anyone to click on.

Here's an example con job page that ranks high in Google for 'Botox Training for Physicians'. You'll notice that there's no links other adwords. This site is so bad they're actually named Link 1, Link 2, Link 3 at the bottom and evey other link is named; Is anything better than Botox, Physician Botox training and other such keyword stuffing. So this site is actually sitting on top of the content that you would actually be looking for if you were looking for Botox training. The best content on the page is actually 'in' the ppc ads but there's no relevance, just paid listings.

I should note here that if you try to do this a couple of things happen:

• You loose all credibility. It's really easy to spot when sites are doing this.
• Google could very well catch you and penalize you by dropping your ranking. If you're using some type of SEO service that does this you're equally vulnerable.

I'll be writing more about SEO and how the web can be used correctly to disseminate the content you want to send and put it in front of the potential patients who are looking for you.