Fluorouracil for Wrinkles

If you pick up most women's magazines in the waiting room of many offices, usually what you see are endless fashion ads and fragrance samples. One magazine, Allure, seems to delve into the beauty industry far deeper than cosmetics and moisturizers with their investigative reports on scientific research. Kudos to you, Allure.

As a dermatology nurse, I came across a brief interesting article in the December issue of Allure entitled "Fast Anti-ager". For those of you who do not read Allure, let me post the entire article:

Doctors have long noticed that patients who use the prescription cream fluorouracil, a treatment for precancerous skin lesions, "tend to look really good afterward," says Dana L. Sachs, an associate professor of dermatology at the University of Michigan, Ann Arbor. Now a study led by Sachs has documented the cream's anti-aging effects. Patients who used it on their faces twice daily for two weeks had decreases in wrinkles, uneven skin tone, and brown spots, as well as in precancers. The drug injures the skin, triggering a beneficial repair response; redness can last for a few weeks. Sachs says studies are needed to assess fluorouracil's cosmetic use in people with relatively mild sun damage.

Perhaps a study worth following.

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

Submit a guest post and be heard.

Are the best medical spas making the most money?

Is you're medical spa providing the best medical care or just making the most money? Are they mutually exclusive?

There's a New Yorker article detailing the commencement address Atul Gawande Atul Gawande delivered this commencement address, titled “Money,” to the graduates of the University of Chicago Pritzker School of Medicine. It expands on the themes he touched on in his recent article about health-care costs in McAllen, Texas, which figured in President Obama’s speech on health care.

The text of this speech is available in this article in the New Yorker:

No one talks to you about money in medical school, or how decisions are really made. That may be because we’ve not thought carefully about what we really believe about money and how decisions should be made. But as you look across the spectrum of health care in the United States—across the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. And as you become doctors today, I want you to know that you are our hope for how this battle will play out.

Kevin MD has this on: Can doctors resist the lure of money?

That’s a tall order for many American physicians.

In his speech, which is an extension of his celebrated New Yorker piece, he looks at so-called “positive deviants,” or doctors who practice higher value, higher quality care, than everyone else.

What makes these doctors so special? In essence, they have to “resist the tendency built into every financial incentive in our system to see patients as a revenue stream.”

Indeed, “These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.”

Unfortunately, most American doctors fail to resist the allure of money. In some cases, it’s greed. But in many others, patients and business have to be intertwined simply to keep the doors open. Doctors cannot practice quality medicine while bankrupt.

Changing physician behavior needs to be accompanied by fundamentally modifying the incentives that influence doctors. Without radical physician payment reform, Dr. Gawande can implore future doctors to fight the financial incentives all he wants, but most will realize that resistance alone will be futile.

So where does that leave us? Are plastic surgeons and medical spas practicing medicine first, or business? How, if ever, does cosmetic medicine differ from 'real' medicine? Is there any ethical guideline that applies or is cosmetic medicine fundimentally different?

Share Medical Spa MD on Twitter or Facebook.

Medical Spa MD is foremost a community of more than 4,000 physicians around the world practicing cosmetic medicine. If you find something you like on Medical Spa MD, please share it.

To share a post on Twitter, Facebook or another social site, just click the 'Share' link at the bottom of every post.

You can find Medical Spa MD on Twitter here.

Do it yourself Botox, Restylane, & Juvederm Disasters.

So while there are still a number of people posting on how much the love Laurie D'Alleva and her videos touting the benefits of do it yourself Botox, there are a growing number of people who still have a non-paralyzed thought or two that are coming forward to talk about the problems you might have pumping fillers into your face. Perhaps the do it yourself Botox crew are also attracted to Trepanation.

Here's a story from ABC News: Watch the video on "20/20"here.

Some consumers are ordering prescription-only cosmetic products online and injecting themselves at home. One woman who self-injected her face with filler said it caused bags and lumps under her eyes, and a hard, infected pustule on her cheek.

For millions of Americans, the solution to crow's feet, thin lips, and frown lines is at the end of a syringe, or in a bottle. A quick trip to a medical spa, dermatologist or plastic surgeon for a Botox injection, lip augmentation or chemical peel offers the promise of a youthful look.

But these cosmetic procedures -- and the medical expertise that comes with them -- don't come cheap. For a single treatment of Botox, doctors charge about $380; for lip-plumping injections, over $500; and for a chemical peel, a whopping $700.

These high prices are enough for some consumers to take their business away from medical professionals, and go instead to the Web. They are "doing it themselves," ordering prescription-only products online, and injecting themselves at home.

Laurie D'Alleva, of Mansfield, Texas, is a big fan of "DIY" beauty injections and treatments. She is the face of a DiscountMedSpa.com, a website stocked with what she claims are pharmaceutical-grade cosmetics, similar to Botox, Restylane, and Retin-A. 

Self-injecting botulinum toxin might sound dangerous, but D'Alleva, 39, tries to put her customers at ease with informational videos, complete with tips and pointers on how, and where, to inject. "It doesn't hurt... It's easy," D'Alleva claims in one video, as she stands in front of a mirror and injects her face repeatedly.

Disaster isn't what "Alex," a paramedic, had in mind when she visited DiscountMedSpa.com a few months ago. In her 40s and dating, she just wanted to improve her look, and save some money. She asked ABC News not to disclose her identity.

After viewing "every one" of the instructional self-injection videos on D'Alleva's site, Alex was convinced she could do it herself, since using needles was part of her job.

"Why should I pay somebody else that got a few hours of training to do something I think I can do pretty easily?" she said she thought at the time.

Alex paid $450 for a DiscountMedSpa.com products including an injectable facial filler. She says she injected the products under her eyes and alongside her mouth.

But "the next morning, I woke up horrified by what I saw," she said. "Literally, my heart started pounding, and I thought, 'What have I done, what am I going to do?'"

Career Advancement for Medical Estheticians

Awhile back I posted an aesthetician position on a local job search website. In my requirements, I had stated that only those aestheticians who have been trained in the proper use of laser technology should apply. I must have received over 100 resumes with barely a few who have ever laid their hands on a laser or even observed any procedures.

I selected a few resumes who I felt had years of experience and; therefore, would know the basic concepts of how skin reacts to laser light, Fitzpatick Skin Typing Scale, etc. I was surprised at how many of them had no idea how to answer what I was asking them.

It's obvious there are many skilled aestheticians out there seeking employment, or desiring to advance their career. I would highly suggest the Advanced IPL & Laser Training Course for Estheticians & Medical Spa Laser Technicians.

Advanced IPL & Laser Training Course is much more than knowing what the difference is between 532nm and 2940nm of light; or how different wavelengths affect blood, pigment and water; or even how laser light affects the stem cells of a hair shaft during the anagen growth phase. It's about broadening your knowledge of the aesthetic field, becoming a more valuable member to a medical aesthetic team, increasing your revenue by commission and upselling with your knowledge, and benefiting your patient by being able to explain various treatment options for them (some performed by you and other treatments by the physician). Even though you may not perform every treatment in a medical spa, such as injectable procedures or laser skin resurfacing, your knowledge of those procedures is very important in the patient advocate and educational process.

Even if you have no hands on training at this point, the Advanced IPL & Laser Training Course for Estheticians & Medical Spa Laser Technicians will lay down the foundation you need to secure a position in a medical spa. If one of the candidates had any understanding of some of the principles of laser technology, I would have brought them in for a personal interview with the physician. Hands on training is the easy part, the hard part is the theory behind laser technology.

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

Submit a guest post and be heard.

Cosmetic Surgeons enlist patients to fight the Botox Botax.

Cosmetic surgeons are asking for patient help to fight the Botox Botax. Here's what the ASDS (American Society for Dermatologic Surgery) is giving it's members to solicit the support of Botox consumers: Here's the form.

The U.S. Senate health care reform bill  (Patient Protection and Affordable Care Act) contains a proposed 5 percent tax on "elective cosmetic medical procedures."  While this may look like an attractive option to Senators looking for ways to pay for health care reform, we know that:

• Cosmetic medical procedures taxes are an unreliable and risky revenue source, which has proved to be a failure at the state level;
• A tax on cosmetic surgery discriminates against working women;
• The definition of cosmetic procedures is arbitrary and almost impossible to administer; and
• enforcement would necessitate review of patient medical records by tax collectors, a clear invasion of privacy.

Please enter your zip code below to be connected to an automatic email system which allows you to send a quick message to your Senator asking him/her to vote against this tax.

I've received an number of emails about this over the last 48 hours. Is anyone worried that this 'Botax' will hurt your medical spa, skin clinic or cosmetic practice?

Do it yourself Botox: Are these people for real?

Wow. For whatever reason there's a lot of traffic on the do it yourself Botox thread: Fake Botox or not, Discount Medspa is going to jail.

Evidently there are a lot of Botox self injectors flocking to this site to comment on the story of the woman who was selling some form of Botox replacement online, and then publishing videos about how to inject yourself.

Certainly illegal, the site, Discount Medspa has been shut down. My guess is that there are a host of legal troubles ahead for the owner.

You'd think that people would be a little smarter than to inject themselves with Botox or anlything else they just bought online, but I can't tell what's going on with comments like this:

Excuse me Mr.RealMD you are getting the same stuff we are in a bottle that is sealed in a pure form un constituted. Could you PLEASE tell me how do you really honestly know what you’re injecting into your patient besides reading the Botox label across the bottle? You didn't package the bottles you received! and I am more than sure you didn’t have anything to do with the making of the batches of Botox either. All you did was received your order, took it out the boxes and stored it in your freezer upon delivery of your shipment and used it when it was time to inject your patients.

The injection part of receiving Botox IS very important and for you to have the nerve to say I quote “You guys don't really understand the issues involved with the actual preparation of the toxin before it is placed in the bottle. You are focusing on injection technique and the fact that you want to save some money and you think doctors make money off of you. You don't really understand that if this preparation is not authentic Botox or authentic Dysport you are risking your lives. “

Matter of fact Mr. RealMD we are!!! Focusing on the injection technique do you think were crazy do you know if you don’t focus on the injection technique that we could really damage ourselves and probably end up looking like some paralyzed freaks walking around, and you ARE risking your life if you dont know how to properly inject the Botox also so please dont play down that aspect of the procedure.. And I don’t understands you when you say authentic how do YOU know your trusting source is authentic I get the same effect as when you give it to me, so how do you know if the effects are the same the wrinkles are gone and the face muscle are numb for a 3-4 month period.

So I ask you again if the effects and the outcome of the Botox injections are the same how can YOU know that your (BOTOX) is the real thing and I am taking a chance with my Botox. To be honest we all including yourself is taking a chance we really do not know what this is doing in the long run, but our quest for the fountain of youth is keeping us on this same road ,the road of trying to keep our youth as long as we can and as safe as we can accomplish it, and that is including myself.

Dee Medspa is number one

Laurie the psycho just emailed me saying she is opening back up fr business and just taking time off for the Holidays. LOL,like we don't know why. She must be nuts thinking we don't know what happened. She must want to go to prison that bad. I'm sticking with mybasicsonline.net. It's cheaper and better from what I can tell.

here is what her email says.....

In a message dated 12/2/2009 3:33:32 P.M. Central Standard Time, discountmedspa@charter.net writes:

We at Discount Medspa have been working to make sure we are here for you for years to come! Please be patient and we will contact you with our new details soon!

There has been lots of media attention to our site and we will be taking some time off to ejoy the Holidays and Relocate. I appreciate all of you and your support during this difficult time, and promise to be available in the near future!

Dana

I’ve been a “self-injector “ for almost 3 years. I inject small amounts of filler frequently and thus have gained practical experience regarding my own face. I studied injection techniques for almost a year before I self-injected – I did not just jump into this, and I hope nobody else does too. My study resources came mostly from physician to physician professional videos, books and even my own injection doctor (past tense) from whom I asked questions and requested a mirror.

I stopped going to my supposedly “expert” filler doc because; 1) the outrageous fees he charged , 2) he didn’t seem to care about his patients at all – it really was about the money – he always charged me extra supposedly for time spent addressing my concerns -- so please don’t tell us docs actually care about us, 3) even though his credentials were impeccable, he is a “doc to doc injection teacher”, he left me very bruised and swollen almost every visit – something I have never done to myself. Thus I started ordering injectables off the Net and Laurie’s site was one of them.

I enjoyed the convenience, great prices, fabulous customer service, and knowing she and others had tried and tested her products (it would have been all over the news/net had someone been seriously harmed /disfigured from her products). Yes, I was very cautious and did a good deal of research regarding her company, her client results/feedback, products and her background before entering my first order.

While I was pleased with the products purchased from Laurie, I was troubled by her aggressive marketing of such and considered her business practice to be very deceptive (and I believe one of her charges are related to just that). This is where my concern with her company lied.

It irked me to see her market generic Chinese HAs as Sculptra (not even close), Restylane, and Juvederm. It also disturbed me to no end to see her market the permanent Chinese filler Amazingel as Artefill -- to even offer a permanent filler to potential first- timers is beyond belief crazy and extremely disturbing.

Yes, I will continue to self-inject, as most others will, as long as doctors remain money hungry and uncaring. But I close this with: buyer beware, do your homework/research (intensely), study anatomy/injection technique, buy pro videos, don’t let anyone tell you “anybody can do it, even a child”, research your product and don’t assume it’s what the seller is telling you it is.

It’s not as hard as the docs make it out to be, but don’t assume anything.

salome

Is this actually possible?

Liposuction Technique: Thin Cannulas

Liposuction Training Video: Why thin liposuction cannulas give the best result.

Dr. Ricardo Rodriguez is a Yale trained, board certified plastic surgeon specializing in multiple procedure makeovers. He performs unique procedures such as the body lift, brazilian butt lift, stem cell facelift, endoscopic brow lift, and lip lift. He is Medical Director of his own AAAASF accredited surgery center in Baltimore, Maryland.

Link to this video on Vimeo.

Medical Spa MD: Filler Injection Tips (Restylane, Juvederm)

Restylane, Juvederm and filler injections tips for physicians running medical spas and laser clinics.

The following is from a string of emails that were circulating among some of Medical Spa MDs Members. I've edited this somewhat to make it readable and get rid of all the extraneous copies. I'm also not displaying the identity or email addresses of the physicians in this thread.

Please leave your thoughts below as a comment.

Note: Some of the comments below might be out of order from the original thread. Emails' somewhat difficult to follow as a thread but you'll get the gist.

Filler Injection Discussion & Tips: Restylane | Juevederm | Evolence

1.  When I use the "push ahead" technique, I feel that I get better "plumping" per cc of filler.  I learned this from Kevin (thanks Kevin).

 

2.  When I use the "push ahead" technique, the filler fills a few millimeters in front of the needle tip.  You need to realize this to be able to put the material exactly where you want it.  Sometimes you have to "feel" the injection because you can't "see" the plumping.

 

3.  I mix 0.1 cc of lidocaine with epinephrine with my Juvederm.  This helps with bruising (epinephrine) and when the lidocaine goes away and the Juvederm attracts water, the two effects cancel each other and there is not as much enhancement after the injection due to the hydrophilic nature of the Juvederm.

 

4.  I use Juvederm Ultra under the eye and above the lip.  I use Juvederm UltraPlus everywhere else.

 

5.  I constantly complain to my Juvederm Rep about the 0.8 cc syringes.  I use lots of Radiesse because you get almost twice as much material for the same price.  Volume, volume, volume.  Please complain to your rep, maybe we can get them to change. 

 

6.  I hear the Evolence is very good.  We will be getting trained and start using it next month.

Thanks for the filler tips.Can you explain how you get the Lido with epi mixed into the Juvederm syringe? --PD

Fluid Dispensing Connector from Braun Medical Inc (you can get from PSS)

BD 1 ml Luer-Lok Syringe

 

This syringe allows you to get very precise amount of lidocaine (swish back and forth 20 times).

 

I use this syringe to put exaclty 1 cc of saline in my Botox Bottle. When I reconstitute the Botox (this gives it full strength per unit). The chances of intravascular injection might be lower with push ahead because the material will push the vessels out of the way as you advance --  Jeff

Hi Jeff,--I agree w/ #6.  I seem to get good augmentation, less redness, swelling and bruising with Evolence.  I use it for deeper fills in cheeks, NLF, etc.  Don't use it for lips or under eyes.  I do same with Lido w/ epi.  I tend to use Juvederm in lips.  Perlane / Restylane for other areas.  I agree w/ why Allergan uses 0.8 cc syringes. I've moved away from Radiesse.  I feel that the duration is not that much longer than a good correction with the HA's.  Besides, I believe a fair amount of the volume of Radiesse is a gel carrier, thus needing touch-ups at 2-3 months.  Perhaps that's why the went to the larger syringes? -- Don

The push ahead technique also moves small blood vessels out of the way, so you may notice less ecchymosis is overall pts. -- Greg

Jeff: --"Push ahead" has a higher risk of vessel cannulation & potential for vascular effects - skin necrosis in glabella, even potential for retro-grade flow to eye (causing visual loss).  I wouldn't recommend that technique for the periorbital area.

Restylane is recommended for the tear troughs;  it's less hydrophilic than juvederm - which means less post-treatment swelling.--Tom  --  [note from Jeff:  Tom is a plastic surgeon]

I would not use push ahead around the eye, I agree with Tom's comments. It works great for NLF. I was actually taught this by a PS -- Greg

Thanks Jeff for your kind comments. However I must make a few points in regards to fillers:

1) There are some areas that one has to still do the retrograde injection either b/c the purpose was to make a straight line (eyebrow lift and vermillion border and the bow-tie (the vertical lines connecting the base of nose and the upper lip border) AND when injecting the most inner 1/3 of the tear-trough to avoid risk of filler getting into the orbital space due to its close proximity to the orbital rim.

2) On the glabellar injection, it is best to first push and pull the needle thru the space underneath to break up the tissue before actually injecting the filler both in an anterograde and retrograde pattern

3) I ONLY use the 1/2 inch needles in all my injections

4) One can inject even Radiesse and/or Perlane via an 1/2 inch 30 gage needle. Why is this noteworthy to mention?? When I work on the lips and Marrionette's lines, I ususally first build the Vermillion border with Radiesse or Perlane (I get the best "lifting outcome" with heavier filler). I push the 1/2inch needle all the way forward then slowly and steadily inject while withdrawing (retrograde method). Then I re-evaluate how much of a correction I already get of the Marrionette' line and lifting up of the lip body. My next step is to inject into the most lateral lip section (about 1 cm distance) starting at the corner (using Perlane or Restylane or Juverderm). This time I inject slowly as I push forward (anterograde). Often I ended up correcting about 50% of the marrionette's line by going after the lip's border and most lateral body. Besides, the patient loveto see that they now could see their lip body all the way to the corner and more "smiley shape". The last step is the trickiest one, I use either Radiesse or Perlane on an 1/2 inch 27 gage needle. First placing my left thumb at the patient's lower half NLF's I retract the skin upward (about 2-3cm upward) then I approach my needle in an upward (vertical) position at about one centimeter lateral and one cm below the mouth corner of that same side. Then I aim diagonally toward the corner and start injecting anterograde just 1-2 mm below the imaginary horizontal line of the mouth corner (about 0.2 cc), then I withdraw the needle and reaim straight up and inject just below the horizonal line (0.2cc) then I do it one more time aiming diagonally outward (0.2cc). What was I attempting to do?? I was laying down a new flooring along the imaginary horizontal line. After the injection, release the left thumb. You will be surprised to see the retracted portion just rest right along this new floor, thus the Marrionette'line has been corrected. This is different from the common fanning technique of using the filler to "blow up" around the Marrionette's line. If you look carefully at those company's issued photos, the area around the Marrionette's line now appeared very swollen and puffed up. It is aesthetically unpleasant. It looked like the patient was beat up below the mouth. It reduced the profile of the chin.

5) For those of you that use fillers on the highly vascularized and shallow areas such as the temporal, crow's feet, undereye area lateral to the submalar area and along the lateral border of the cheek prominence (especially in those older skinny Caucasian ladies with much excessive very thin skin) I now emulate the same technique used in the hand. I would pinch to levitate the skin itself above the bony structure, then I bolus Restylane into the empty space. Then I massage it down. This elimates the risks of injecting into the vessels and nodules.

Interesting discussion.  So Kevin, how do you account for the difference in that anterograde injection you need less filler than in retrograde injections, assuming all else being equal?

Second, I am understanding one group claims anterograde injection carries a higher risk of vessel cannulation and possible intravascular injection, while another group claims that anterograde injection "pushes away" blood vessels, thus decreasing the risk. Not sure how anterograde increases risk of intravascular injection any more than retrograde.  If you push the needle ahead, transfixing a vessel, then begin injection, you can still conceivably deposit some material intravascularly, can you not?  Am I missing something here?

I also found an interesting idea of sub q bolus technique in areas of thin skin, ie crowsfeet, etc.  Anyone else try this method? ~ Don

Tom:

I do agree with you about those risks with anterograde injection. The key is always the skills in doing it, be it retrograde or anterograde. One always has to be very carefully doing anything around the eyes. However, the anterograde techinique has been advocated some of the best known experts such as Arnold Klein, MD and Kent Remington, MD. I also believed that the filler amount used was critical. It takes much more amount to get the same result with the often taught retrograde technique compared with the anterograde one. For example, I almost never required more than one full syringe in correcting bilateral NLF's vs what was typically used ( 2 syringes) by most others. I attached the before and after of a case wherein I used Readiesse to correct her NLF's and Marrionette's lines with anterograde technique. The after photo was taken right after. You can still see some of needle marks. I used one full 1.3 cc syringe, 1/2inch 30g for the Vermillion border and 1/2inch for NLF's and Marrionette's line. Notice also there was no "puffy/swollen look" medial to the Marrionette's line often seen with retrograde and fanning technique used by most others. ~ Kevin

All interesting comments.  The only place, I use “push ahead” is in the cheeks when doing them via the intra-oral route. (Apparently Radiesse is no longer teaching this method because may practitioners couldn’t get the hang of it but it works for me.)  I might try it in the “safe” areas such as NL folds.  We use only Radiesse and Juvederm and  I find that neither filler lasts as long as advertised in “first-timers”.  I’ve also had disappointing longevity in my older patients (>65) with both types fillers despite using numerous syringes.  I’m sure this has to do with their inability to generate collagen around the filler once the carrier gel is gone.  Does anyone know the age range of patients done in the filler studies? ~ SD

I came across this old thread way down in my inbox and read it again.  I’m not sure who wrote #4 below.  It sounds interesting but I’m having a hard time visualizing it.  Do you steadily move the needle forward  toward the lip edge as you are injecting or do you hold it in place while the area fills?  I’d love to see a drawing on where you start.  ~ SD

SD: I wrote those threads. The techniques that I described were similar to what you could see watching the video instruction on www.thederm.org by Kent Remington and his colleagues (lower face injection portion) THe only thing new from my thread was when fixing the Marrionette's line, his doctor (Nowell Solish) injection upward and anterograde from the lower part toward the lip corner only one time vs what I now do is I do the same thing but with a fanning pattern where (with the skin lifted about 1-2cm upward with the other thumb) I laid down "three such "anchoring points" along an imaginary horizontal floor starting from the lip corner going laterally for about 3-5cm long. Here I used something firmer such as Radiesse or Perlane. Having done this, you would release the thumb letting the skin go back down. Often you will see the Marrionetter's line is much improved because "part of that Marrionette's line" now is positioned along the horizontal flooring that you just created. ~ Kevin

PS: It is hard for me to send over some graphic illustration but I will attempt to do this in the future

Medical Spa MD: Burned out & depressed plastic surgeons more likely to commit medical errors?

Surgeons who are burned out or depressed are more likely to say they had recently committed a major error on the job, according to the largest study to date on physician burnout.

The new findings suggest that the mental well-being of the plastic surgeon is associated with a higher rate of self-reported medical errors, something that may undermine patient safety more than the fatigue that is often blamed for many of the medical mistakes.

Although surgeons do not appear more likely to make mistakes than physicians in other disciplines, surgery errors may have more severe consequences for patients due to the interventional nature of the work. Some estimate that as many as 10 percent of hospitalized patients are impacted by medical errors.

"People have talked about fatigue and long working hours, but our results indicate that the dominant contributors to self-reported medical errors are burnout and depression," said Charles M. Balch, M.D., a professor of surgery at the Johns Hopkins University School of Medicine and one of the study's leaders. "All of us need to take this into account to a greater degree than in the past. Frankly, burnout and depression hadn't been on everybody's radar screen."

Nine percent of the 7,905 surgeons who responded to a June 2008 survey commissioned by the American College of Surgeons for a study led by researchers from Johns Hopkins University School of Medicine and the Mayo Clinic reported having made a major medical mistake in the previous three months. Overall, 40 percent of the surgeons who responded to the survey said they were burned out.

Researchers asked a variety of questions, including queries that rated three elements of burnout -- emotional exhaustion, depersonalization and personal accomplishment -- and others that screened for depression.

Each one-point increase on a scale that measured depersonalization -- a feeling of withdrawal or of treating patients as objects rather than as human beings -- was associated with an 11 percent increase in the likelihood of reporting an error. Each one-point increase on a scale measuring emotional exhaustion was associated with a 5 percent increase.

Mistakes also varied by specialty.  

Surgeons practicing obstetrics/gynecology and plastic surgery were much less likely to report errors than general surgeons.

Researchers acknowledged the limitations of self-reporting surveys, saying they couldn't tell from their research whether burnout and depression led to more medical errors or whether medical errors triggered burnout and depression among the surgeons who made the mistakes.

The results are being published online on November 23 in the Annals of Surgery and will be published in the printed journal in an upcoming issue.

Notably, the research shows that the number of nights on call per week and the number of hours worked were not associated with reported errors after controlling for other factors.

"The most important thing for those of us who work with other surgeons who do not appear well is to address it with them so that they can get the help they need," says Julie A. Freischlag, M.D., chair of the Department of Surgery at the Johns Hopkins University School of Medicine and another of the study's authors.

via sciencedaily.com

Perhaps the most relevant items here are the decreased reporting of problems by plastic surgeons and the fact that 'depersonalization' has entered the discussion.

I'm really curious about what plastic surgeons think of this study.

Medical Spa MD: How to operate effectively in turbulent times.

If you’re involved with or own a medical spa, this question is no doubt on your mind.

In this article, I will give you several tips and tools to evaluate your laser centers culture and operations, so you can successfully navigate any economic downturn… And live to sell another day when the inevitable upturn comes around.

What is the Passion and Purpose of Your Medical Spa?

You reap what you sew. When you engage proactively and passionately in your business you will undoubtedly be successful and see your practice expand. It helps to articulate your passion for your medical spa.

At Assara Laser, our passion is to “help clients look and feel great, not fake.”

Why the Recession Drastically Affects Your Laser Clinics Bottom Line

You’ve probably noticed that generating revenue is not as easy as it once was. There are myriad reasons for this; from the decline in disposable income, to unemployment hitting record highs and tanking real estate valuations. As if these facts were not bleak enough, credit markets are virtually frozen so business owners are finding it nearly impossible to obtain small business loans and lines of credit. Refinancing current loans has become difficult for small businesses.

In short, we're operating in the perfect storm.

Accepting Reality and Responsibility Today

The easy way out is to close up shop and blame the recession. This will not help you going forward, it will not pay your devoted employees their wages, and most of all, it will not help your clients “look and feel great, not fake.”

So, accept responsibility. 

The hardships of the recession create a fact-pattern, problem to be solved; not a reason for failure. To paraphrase Michael Jackson, start, first, with the man in the mirror. Think about the following questions. And pay attention - there will be homework at the end of this article!

Finding Your Medspas Winning Competitive Difference?

Let’s be honest. The quality of your laser clinc's treatments are probably not drastically better than that of your competitors. The proprietary equipment and IPL or laser systems (Thermage, Fraxel, Titan) that you use are, for the most part, available to the competitive skin clinic market at large.

You may believe (and tell clients) that your microdermabrasion treatments are better because you use a diamond-tipped wand or aluminum oxide crystals. You may think that your IPLs or laser hair removal treatments are better because you use cryo-cooling or because you use chilled air cooling, or because you use a diode laser or because you use alexandrite lasers . . .

BUT . . .

Step in to your clients' shoes. To them, the bells and whistles of your Thermage or Fraxel device don't matter. Your clients already expect expert advice and cutting edge cosmetic lasers, IPLs and skin tighening equipment, so merely meeting this fundamental requirement is not a winning competitive difference.

What does matter to your clients are presentation, client interaction, customer service, reliability and consistency. Consider this carefully.

What is each of your medspas clients worth? 

At Assara Laser, one of the most popular packages is our $449 per month Unlimited Laser Hair Removal Program. On average, a client that signs up for this program will remain a member of the Program for 7 months, depending on the results they wish to achieve. How much is a single unlimited client worth to us?  A client in the program for 7 months, making a monthly payment of $449 is worth $3,143. For many laser clinic owners, a single laser hair removal client is worth more than a home mortgage payment!

Do you treat every single potential laser treatment client that contacts your laser clinic as if they’re worth $3,000?

What is your time and effort worth?

Before my partners and I built Assara Laser, I was an attorney. I still practice corporate law as a labor of love, when a friend or business contact has an exciting deal. I normally discount my rate to about $400 per hour, as law isn’t my primary source of income. 

Assume an hour of your time is worth $400.  Assume further that, every time your customers complain, you are willing to give a discount, or a free treatment and that, collectively, free and discounted treatments account for a 20% loss in your revenue. To make up for this lost revenue, how much more work do you have to do? 

Well, let’s add 20% to your 10 hour day, which now makes it a 12 hour day. If your annual sales are say $1,000,000 per year, you’ve lost $200,000. This translates into 500 hours more of work you must do to bring your revenue back to status quo!

Is there a big difference between a day that starts at 9:00 a.m. and ends at 7:00 p.m. versus ending at 9:00 p.m.  You betcha there is!  Is there a big difference between a loss of $200,000 and a loss of zero. You betcha there is!  And these differences drastically affect your quality of life.

How Do You Avoid Mistakes?

Mistakes are costly. A happy client is worth more than $3,000, and will likely refer business, the best and cheapest form of marketing. A single angry client will result in you working 2 hours more per day for the following seven work days, and will possibly diminish your reputation by badmouthing your medspa. 

A lot of people think excellent customer service means free treatments. It doesn’t. Excellent customer service means delivering what you promise. You know the limitations and effectiveness of your treatments so promise only what you can deliver and do it consistently, with a smile on your face!

Your Homework

Write an email to one close friend or business partner (or to me, if you would like to engage in this project with me: wshuman@assaralaser.com), in which you answer the following questions.  Cut and paste the text below into your email, and fill in the blanks with no more than three sentences: 

I wanted to pick your brain for a moment. I’m working on a plan to really blast my medical spa practice off the ground, and I wanted you to use your intuition to judge the quality my sentences below.  What do you think? 

The best way to succeed in business while I make clients feel great is:

The recession has made it harder for my medical spa to operate because:

My medical spa’s winning competitive difference is:

Each of my laser center's potential clients is worth:

I will earn every cent paid to me from a client’s hard earned money by:

The biggest recurring (or systemic failure) affecting my customer service is:

Please let me know your thoughts.

Note: The above is a guest post from Will S. of Assara Laser Centers.  You can find Assara on the web at the following links: Assara Homepage and Assara Blog.

If you would like to write or guest post for Medical Spa MD please contact Medical Spa MD here.

Cynosure hair removal lasers + service

Buying used cosmetic lasers can be tricky.

For those of you that have had problems with Cynosure there is help, for those that do not or have not had problems you are lucky.  Not all of Cynosure service department is bad, there are a few good technicians and some that are just there for a job. 

Cynosure hair removal lasers are very good if maintained properly.  There are few things that you must be aware of:

1. Flash lamp pulses on the Cynosure: Do not go over 1 million on the yag and 750,000 on the alex.
2. Keep track of your voltage: Do not run the laser over 820v, this could lead to pump chamber failures and blown power supplies.  These will be very expensive repairs.
3. Inspect your hand pieces every time you use them, making sure that there are not large pits and / or burn spots inside.  Keep your windows clean and change frequently.  If your hand piece is getting hot during use, then you have problems with it, and the hand piece needs to be checked.

If you are thinking of having your Cynosure laser service by a third party company, just remember not everyone can work on them, even some of the manufacture’s technician have problems working on them. There are many after market parts available as well but you get what you pay for. Would you take your Mercedes to Bob’s Auto for service?  I know of only a couple technician outside of Cynosure who can repair them.  We make sure that you get what you would expect from the manufacture.   

If you are thinking of purchasing a used Cynosure laser or other cosmetic laser, please have a technician that knows the laser look at it for you before you put any money down.  Would you buy a used car from a fly by night dealer without having your mechanic look at it? I have seen and heard every nightmare you could think of, I have also seen some very good deals.  I had a lady call me that purchased a laser that had blown the power supply on it 2 weeks after purchasing the laser.  That same laser was about to be sold to a customer of mine that wanted me to help him find a laser.  I told him that this laser in poor shape and that it would need very costly repairs.  I was not surprised when the lady called me and gave me the serial number of the laser.  It does not cost to get a second opinion on something that could save you in the long run. 

When it comes to Cynosure, Candela and Deka lasers if you are having problems or need support please feel free to contact us at Integrity Laser Inc.

Note: The above is a guest post from Integrity Laser. If you would like to write for Medical Spa MD please contact Medical Spa MD here.

Botax: Taxes on Botox and plastic surgery?

The medical spa and plastic surgery community is in an uproar over some proposed legislation that could make a trip to the plastic surgeon or a Botox injection at the medical spa more expensive.

People are calling it the Botax. It's a 5 percent tax on elective procedures such as Botox, Juvederm, Restylane, laser hair removal, facelifts, breast augmentation and other nips and tucks that lawmakers are hoping will help fund the nearly $1 trillion health care plan.

The bill says the tax would not apply to surgeries to fix a deformity either from birth, accident, or disease. It would apply to procedures like face lifts, liposuction, cosmetic implants and teeth whitening.

But as Dr. Paula Hicks points out sometimes cosmetic surgeries have very medical purposes.

"Certainly breast reduction surgery is a very good surgery for a lot of women and a lot of them will get denied by the insurance company as cosmetic surgery," said Dr. Hicks of the Ave Medical Laser Spa and Laser Clinic.

Under the proposal, Dr. Hicks says an eyelid tuck, which can help with vision, would cost an extra $100 in taxes on top of the $2,000 price tag for the procedure.

She says that could be a big hit to her business since most of her clients are not wealthy.

"Most of these procedures are not done on people that are rich and have endless amounts of money, it's middle class working women that would be targeted with this tax and it's really not fair."

According to the American Society of Plastic Surgeons 86 percent of cosmetic surgery patients are women. Sixty percent of them have annual incomes between $30,000 and $90,000.

The tax, if approved, would raise $6 billion over 10 years.

Allergan, which sells Botox, took a civil rights angle: The tax “discriminates against women,” the company said in a statement. Some 86% of cosmetic surgery patients are working women ages 35-50, with an average annual income of $55,000 per year, according to Allergan.

“What’s next? Are we going to tax people who color their hair?” the CEO of Medicis, a drug company that sells fillers, told Dow Jones Newswires.

The American Academy of Cosmetic Surgery, which is fighting the provision, says “a large portion of those being taxed would be the baby-boomer generation. And as this age group continues to age, the more interest will be generated in cosmetic procedures.”

A spokesman for the 2,500-member group said they were surprised to see the provision in the Senate bill this week, because it had already surfaced and sank in July. The tax is not in the House bill.

The tax is on elective procedures, and would not apply to any procedure to correct birth defects or issues arising from disease, accidents or trauma. The CBO says it would raise about $5 billion over the next decade.

Follow Medical Spa MD on Twitter.

Medical Spa MD + Others

It's been an interesting last few weeks for us at Medical Spa MD.

We've seen in increase in the number of inquires around partnering with Medical Spa MD. While I'd normally guess it had something to do with the successes that our current partners are having... but I don't think that information is public knowledge.

In the last three weeks we've been approached by or talked to a number of consumer facing websites, medical publications, potential authors, and even some technology providers and pharmacies.

We're also launching a number of internal iniatives. We've emailed a few of our Members to ask what would be of the greatest benefit. (If you've received an email please give us your thoughts.)

We'll see how this pans out for Medical Spa MD but I'm hopeful that we'll be able to work out some additional deals and benefits for Medspa MD Members.