Painless Neurotoxin Injection Method? Join the Discussion!

What injection methods are most useful and reliable for neurotoxin injections: Botox & Dysport.

I have been in clinical private practice going on 14 years now and enjoy a busy and healthy cosmetic surgery practice.  Injectables, both fillers and neurotoxins, remain an integral part of my practice and I suppose that the loyalty my patients show by continuing to return to me as their injection provider is testament that my skills must be competitive with the many other local physicians who offer the same procedures.  I definitely do not price cut to keep the volume or attract new patients, and I believe I price fairly taking into consideration both my training and experience with typical pricing in my area by "mainstream" cosmetic providers.

I continue to strive to offer the least painful experience for my patients and have tried multiple different methods to decrease the degree of injection discomfort for my patients.  From topical anesthetics, icing, slow injection delivery, and currently vibration-distraction techniques, I have yet to find the WOW approach. I do use lidocaine-treated fillers and believe that these have advanced our patients' injection experience to an appreciable degree.

My intent for this entry is to stimulate a healthy community discussion on what methods the readers have found useful and reliable for neurotoxin injections (to keep this discussion focused I am not encouraging discourse on filler injections but perhaps this can be a future topic of discussion), in addition to disregarding any approach that they have found particularly not beneficial.  We all want to make our injections as easy as possible for our patients, so I am hopeful that this topic can generate healthy dialogue!

SIMON Says: “Run Forrest Run!”

Saying ‘No’ to Prospective Cosmetic Medical Patients

Certainly, everyone is entitled and should have access to cosmetic medical and surgical services. However, depending on your particular risk tolerance, there are certain times when you might want to just 'pass' on treating a patient.  Knowing which patients to sidestep is a gray art and is frequently based on hunches and ‘gut’ feelings.  This subtle impression, as described in Malcolm Gladwell’s book 'Blink: The Power of Thinking Without Thinking', is correct more often than not.  However, there are more objective guidelines available to help decide whether or not to dance with a particular patient. Several of these tips have been developed and expounded upon in numerous papers by Dr. Mark Gorney and in the book 'The Patient and the Plastic Surgeon' by Dr. Robert Goldwyn.  Consider running for the hills if:

• The patient is a SIMON – single,immature, male, overly expectant, and narcissistic.  Even worse if they answer to SIMON-SLAP (SIMON + still lives at parents). 
• You don’t click with the patient – or just plain dislike them
• The patient is critical of previous physicians but thinks you hung the moon.
• The patient is rude to your staff.
• The patient demands a guarantee.
• You are asked to do something you can’t deliver.
• Anyone in a hurry to have surgery – gotta do it now!
• The surgiholic patient.
• Patients wanting procedures because they are prodded by friends or family members.
• The out-of-town patient who has to bolt before you are comfortable with them leaving.
• The patient who is vague, indecisive and leaves the driving to you.

Unfortunately, patients don’t walk into your office with a label on their shirt saying ‘I’m going to be a real problem’.  Listen to the voices in your head and apply the above principles.  Cosmetic medicine is supposed to be fun – don’t let a rogue patient slip through the cracks and haunt you.  It just isn’t worth it!

Patients with High Expectations (Dreams versus Reality)

It is true that we all have dreams and we all, in some way, want to believe in magic.  But when it comes to cosmetic work and people's appearance, it's best to be realistic. I know we all have patients with unrealistic expectations. These patients are the ones we should be more careful with and we should spend more time educating them.  Patients with high expectations are usually well informed and they know about all the new technologies but they also, many times, are expecting unrealistic results. I have developed a good eye for these patients and what I have learned is that it is best to create low expectations, show them before and after photos that don't show fabulous results and always offer the possibility to go and get a second opinion. If they decide to stay and pursue their treatments, they know what to expect.  Taking before and after photos with these patients is very important or if you have a computerized image system (Visia), it is also helpful. At the end, the patient will be satisfied and feel that they got good results but realistic ones and you will save yourself from a potential headache.   

Botox & The "Spock" Look

Botox + fillers that make your patients look like Vulcans?

The clinical and cosmetic uses of neurotoxins continue to grow. Botox, perhaps after aesthetician visits, are often the first procedure consumers consider. It is very common for patients to tell me that they have been considering Botox treatments for 3 to 5 years. We frequently see these patients pleased with there Botox treatments and then very interested in fillers, non-invasive body contouring, and often surgical procedures. However, what quickly interrupts this transition to other services is a result from neurotoxins that looks unnatural.

In our practice, we have increased patient retention and satisfaction after their initial Botox treatment by reviewing with them possible outcomes. Patients will often complain about a quizzical or "Spock" look after glabellar and sometimes forehead injections. I am still surprised that patients are not told of this and that there is a simple remedy. As most practioners know, 2-4 units additional neurotoxin at or just above the over arched area will soften the arch of the eyebrow.  A follow-up call/visit or just good instructions to the patient can turn a dissatisfied patient into a lifelong member and proponent of your practice.

The Value Of Board Certification In Cosmetic Medicine?

Is it better and safer to get Botox injected by a family physician who has been injecting patients for 15 years or a newly graduated plastic surgeon who just finished his residency last week?

In Cosmetic Surgery, the term "Board Certified" is the most highly used term for marketing purposes today. Thirty years ago, many doctors were "Board Eligible" or non boarded and their value came from their training and their experience and their expertise, not just a label. Today, doctors are expected to be board certified in something. That something is the topic of heated battles and debates and many of our colleagues are just as confused about it as are our patients and the public and the media. Insurance companies and third party payor and even hospitals require board certification and may use it for determining reimbursement. 

The American Board of Plastic Surgery (ABPS) and The American Board of Facial Plastic Surgery (ABFPRS) have had many decades of heated nasty all out warfare. For the most part, on the surface at least, the war is over but small battles and skirmishes are still waged amongst these two specialties here and there around the country. But cosmetic surgery is no longer being offered purely by Plastic Surgeons or Facial Plastic Surgeons, Oculoplastic surgeons, Oral surgeons, otolaryngologists, & dermatologists are a significant part of the cosmetic surgery providers. More over, family physicians, ER doctors, Radiologists, OBGYNs, and other doctors whose specialty is not traditionally associated with cosmetic surgery are now the fastest growing population of cosmetic surgery providers with Botox and fillers and lasers as their entry to the more involved mini facelifts and blepharoplasties and liposuction. The American Board of Cosmetic Surgery and the American Board of Laser Surgery has given this large heterogonous group of non-cosmetic surgeons an umbrella to gather under and a label to use for marketing and validation.  

The American Board of Plastic Surgery and The American Board of Facial Plastic Surgery have now joined forces in order to "protect the public" and inform the media and public about the lack of proper residency or fellowship training by many of these new non traditional providers.  Protecting the public is a noble endeavour and a great cause but I ask who is going to protect the public from less inept members of the American Board of Plastic Surgery and the American Board of Facial Plastic Surgery?  There is no doubt that the vast majority of poor cosmetic surgery with bad outcomes are being performed by Board Certified doctors, most of which are actually certified by these two esteemed Boards (ABPS and ABFPRS). 

Then what is the true value of "board certification" and how will the public be protected? We must police and control our own profession as a whole before we are controlled by outside forces. In Ontario Canada, a deal between the society of Plastic Surgeons and the Department of health posed a new regulation where no one other than a plastic surgeon could use the term "plastic surgery" in their advertising! So, is it better and safer to get Botox injected by a family physician who has been injecting patients for 15 years or a newly graduated plastic surgeon who just finished his residency last week or even from a nurse who works at a plastic surgeons office? This is a tough question that needs to be answered by us doctors before it gets settled for us by external forces. 

Medical Spa Embezzlement & Employee Theft Scams Report

Download the new, free report for Members: Medical Spa Embezzlement & Employee Theft Scams... Reading it could save your clinic.

It's the guide to beating embezzlement and employee theft schemes in your cosmetic practice or medical spa.

Taking cash payments in the treatment room, stealing Botox and fillers to inject their own patients, ordering fraud, trading extra services for large tips, or stealing your client database to sell or use... In a recent study, more than 82% of medical clinics reported experience with employee theft or embezzlement... that they were aware of. This new 40 page guide to beating embezzlement and employee theft schemes uncovers the hidden tactics behind how these scams work, and how you can find them before they capsize your business.

Embezzlement and employee theft are an unfortunate fact in almost every business, and especially in cosmetic medical practices. If you haven’t ever had to deal with this you’re extremely lucky since it has taken place in every clinic I’ve been personally involved with and the stories that are told by physicians and business owners are legion. If you think it can’t happen in your clinic you’re just whistling past the graveyard. It can. Don’t prepare yourself and it will.

Download this free members-only report >

Medical Spa Embezzlement & Employee Theft Scams

This report is designed to give you a fighting chance to identify how your business is at risk, to understand how these schemes work, and what you can do to minimize your risk and take action when you find a problem.

Here's some of what those who have already read this report are saying:

Great report! It should be required reading for all doctors — even for those of us who've been around!

Marguerite Barnett MD FACS PA, Mandala Medspa

A very eye-opening and sobering report. This is a must read for everyone!

Windie Hayano, The Skin Inc. Dermatology and Laser Center

Opened my eyes! The information in this report is invaluable! I hadn't even thought of some of the scams mentioned in these testimonials!

Lori Robertson FNP, Skin Perfect Medical Rancho

Great! ...after reading others experiences I realize that you just cannot be too careful when it comes to the financial security of your business.

Anne Talbot, Owner, Victorias Cosmetic Medical Clinic

This report will help other centers avoid going through what we had to endure and overcome.

Brian Sidella, Founder, Forever Young Medspa

You’re about to read the many stories that have been collected from clinics and physicians; from how a physician-employee put an extra account on a credit card terminal to deposit payments into his own checking account to how a NP would inject patients with straight saline and steal the Botox to use in her own side business... and a host of others... ordering fraud, trading extra services for large tips, or stealing your client database to sell or use, setting up false bank accounts, switching acocunts on the credit card reader... all of these scams are covered through real life accounts from the physicians and clinic owners who experienced them.

Some of the stories are almost beyond belief in their brazenness and the damage that was caused. In almost every case, the employee was a trusted team member. Do yourself, your family, and your business a favor and read this report. No matter what your experience has been, you're going to learn something important.

Have your own story? Submit it here for the next edition

Radiofrequency Assisted Liposuction (RFAL) - A new technique for adipose tissue treatment & 3D-skin tightening

The new technique using radiofrequency assisted liposucion (RFAL) from Invasix is based on bipolar radiofrequency energy which is applied to the subcutaneous adipose tissue and subdermal skin surface.

Preliminary clinical trials, histologic biopsies of the treated tissue and thermal monitoring demonstrate a rapid liquefaction of the adipose cells, coagulation of surcutaneous blood vessels and uniform sustained heating of tissue.

The dramatic rise in liposuction procedures, the aging “baby boomer” population, with decreasing skin tone and advanced laxity are seeking new body contour procedures.

The traditional tumescent, suction-assisted liposuction (SAL) is a mechanical disruption of adipose tissue through the openings in the cannula with induced negative pressure and can be quite traumatic to the patient.

 In seeking to improve the postoperative patient recovery of swelling, bruising, pain and to enhance skin contraction as well as to diminish physician effort, newer generations of energy-assisted liposuction technologies have been developed.

Preliminary studies with the RFAL technique reported faster treatment, improved safety, reduced tissue trauma, liquefaction of adipose tissue, blood vessel coagulation and uniform heating of the skin and subcutaneous tissue as well potential 3D-skin tightening. Due to histologic observation of connective tissue in the treatment area there is a significant change in its structure with coagulation of the deep, dermal collagen. After treating the subcutaneous fibrous and dermal matrix with RFAL the results are impressive in 3D-soft tissue contraction and contours.

Dr. Bratani has no disclosures and interests with Invasix Ltd.

Add Allergan's Brilliant Distinctions Program To Your Website's Social Media Buttons

What is the Allergan Brilliant Distinctions Program?

Brilliant Distinctions (BD) is a frequent user program by Allergan for their products of Botox, Juvederm, Latisse and their skin care line. This program gives the patients coupons and rebates. Many practices in the US who inject Botox have the opportunity to join this program. Your Botox/Allergan representative would have more information. In my location, Brilliant Distinctions is well utilized.

New Patients look for Brilliant Distinctions

I have also found that when experienced Botox and Juvederm patients move to my area, they sometimes come armed with Brilliant Distinction discounts which they would like to use. They have called my office asking whether we take Brilliant Distinctions  These patients usually come from different states, and the transition process is painless. We just need their name, zip code, and birthdate. With that information, the patients can use their points and earn new ones at our practice. With any patients who have somehow created multiple accounts, a quick call to the toll free hotline provided by Brilliant Distinctions usually solves the problem.

Creation of the Brilliant Distinctions Button 

I thought it would be useful to create a button that goes along with some of our social media buttons. I presented the idea to Allergan, and they actually helped me create some of their logos that matched the size of frequently used social media "buttons." By buttons, I mean those icon or logos that represent Facebook, Twitter, YouTube, etc. I have had links from my website before to Brilliant Distinctions, but they were big clunky pictures, and I've never matched it up on the page with the Facebook or Twitter logos. I asked Allergan about the idea and they sent me basic BD logos to work with. I spent some time trying to make these logos match, and I've shown them to Allergan.  Allergan has a section on their website for physicians which has logos to use on their websites, but when I contacted them, they didn't have ones of this design. I thought I'd share these logos with you so you can put them on your websites yourself or have your trusty webmaster do it if you like the idea.

Please feel free to copy the Brilliant Distinctions Buttons (ie. Right click/save-as). 

I've seen many beautiful websites out there with beautiful social media buttons. Now you can also add a matching BD logo to the collection.

I made a website displaying the logos that Allergan and I tweaked to match most common social media buttons which are already used on many plastic surgery, dermatology, and aesthetic websites.