Nabota: New Botox alternative to enter the US Market?

If the FDA clears Nabota, a neuromodulator making its way to the US Market, it could become yet another Botox alternative fighting for market share?

The South Korean pharmaceutical company Daewoong is gearing up to become the newest manufacturer of a Botox alternative in the US market. Nabota, a botulinum toxin type A injectable neurotoxin, is cleared by several Asian and South American countries to use. For its market entry to the US, clinical trials are in process which could lead to an FDA approval.

Clinical trials

Currently there are two trials for NABOTA. One is for blepharospasm, and another for Crow’s feet. Literature comparing the efficacy of Botox, Dysport, and Xeomin are limited for Crow’s feet. Despite such, there have been studies about how effective these three neuromodulators are and were found effective by several researchers.

Implications

More botulinum toxin products mean more competition. Plastic surgery is common in South Korea, and beauty standards are high. Nabota could give Botox, Dysport, and Xeomin a run for their money if Nabota can deliver longer and better outcomes.

There are limited literature on the efficacy of Nabota. In one study comparing Botox, Daewoong's drug proved more effective. Other studies focused on NABOTA were for post-stroke upper limb spasticity (Nam et al., 2015), masseter reduction (Wanitphakdeedecha, 2016), and masseter muscle hypertrophy (No, 2015).

Its possible implication, once it is FDA approved, is the idea of using Nabota’s efficacy, which Botox and the others are unable to treat in the long term.

Differences with the Current Three

According to Dressler (2016), Nabota has a special purification process. No other information about the process has been disclosed. In a book by Seo (2017), the author tabulated a comparison of all the current botulinum toxin products. There are little to no significant differences with the current US neuromodulators.

So this raises the question of, would practices carry Nabota or would they stick with Botox and the others?

Treating Possible Dermal Filler Complications

As the demand for dermal fillers rise, so are the issues that come with it. There are some that go unnoticed or untreated, which could lead to later complications.

Your medspa staff should be aware of any adverse effects that may arise during administering dermal fillers. Side effects such as redness, pain, and swelling are easily treatable and would disappear over time. What about complications? How could they be treated?

It is possible, though rare, for patients to suffer from delayed complications from dermal fillers, and staff should know how they could detect these problems early on if a patient raises concerns. Of course you're very unlikely to need to use any of these, but still, it pays to be in the know.

Possible Complications of Dermal Fillers

Most literature and American Medical Associations categorize the complications or adverse side effects of fillers depending on the on-set or delay.

Pain and infection are the most common short-term complications with dermal fillers. Many patients experience pain despite lidocaine or topic anesthetic. Bruising and swelling are also common. Nodules could appear and are a sign of an infection. A Tyndall effect also happens. Necrosis and asymmetry are also reported complications.

Vision loss is a rare complication of dermal fillers, if administered incorrectly. There have been cases of vision loss among few patients (Loh et al., 2016).

In a study by Tal and Maresky (2016), an MRI was able to detect complications in patients whom have undergone treatments.

Findings

• Fourteen subjects underwent the MRI (13 females, 1 male)
• Filler substances used:
o Polyacrylamide gel (7 patients)
o Hyaluronic acid (3 patients)
o Silicone (2)
o Collagen (2)

• Complications that arose after filler injection:
o 4 cases of abscess
o 4 of granulomata
o 3 of allergic cases

The researchers suggest that through MRI, physicians can pinpoint a procedure that could correct the previously wrong injected filler.

Treatment of Common Complications

In the event of an infection, antibiotics and steroids should be taken by the patient (if the abscess is fluctuating) or antibiotics and drainage (if the abscess is non-fluctuating) (Kim, 2014).

In the case of telangiectasia and erythema, light-based procedures can help treat this complication (Kim, 2014; Kirkpatrick and Foroglou, 2016).

Nodules can be treated with antibiotics (Liao et al., 2013); however, most researchers also characterize them as granulomas, which has different treatments depending on the onset (Kirkpatrick and Foroglou, 2016).

Steroid injection may counter the effects of certain fillers such as Radiesse, Bellafill, and Sculptra (ABCS, 2016).

Other Modes of filler removal

Experts find that not all injected dermal fillers will be removed completely. However, these dermal fillers can be removed through different means depending on the injected substance.

According to Kirkpatrick and Foroglou (2016) on the Aesthetics Journal, an invasive method is possible, with the help of an ultrasound, needles, and stab incision. Surgical options are also a possible option for migration or for untreated granuloma and biofilm (Kim, 2014). Hyaluronidase is another method of dissolving dermal fillers for certain cases and substances such as: hyaluronic acid fillers.

In the event, a patient experiences vision loss, you may check the guide provided by (Loh, 2016) in their article.

As with any other treatment, a pre-screening of the patient must be done prior to treatment to avoid complications. Prepare your worst-case scenarios if anything like this happens to any of your patients.

So would there be a need to regulate who administers these injections? As of now, several states have imposed laws that only medical staff can perform injections, while some states have enacted that only physicians are permitted to do so.

It would be best that physicians should be present during the administration of dermal fillers, if possible. So that the supervising physician can oversee how the medical staff is handling the treatment.

Current Known Use of Imaging in Medical Aesthetics

Medical aesthetics continue to welcome technology in practices, allowing physicians and patients to connect further or envision outcomes prior to treatment, giving patients an opportunity a chance to see the possible outcome .

Despite the rising number of using imaging in practices, studies on imaging technology are limited in the field of plastic and cosmetic surgery although that is expected to change. As such, there are no reported studies about the efficacy of usage of these technologies prior to treatment. Bummer. It would be interesting to know the future of technology in the aesthetics field, and its effectiveness in bringing expected outcomes. Still, you can imagine what is coming down the pipe in the fairly near future.

Virtual Reality (VR Headsets)

Virtual Reality was first introduced to the gaming scene. Its use has branched out for other fields, which include medicine. VR is usually used via a headgear, introducing one to the “virtual world”. In the field of medical aesthetics, its function might be to help a physician figure out where to inject the fillers or perform the incision. Another possible function is to give the patient an idea about how a certain surgery would work on them or how a celebrity’s eyes, nose, or lips, or even body would fit well with them. Its other function is to lessen the pain during surgery, which has been employed for other fields of medicine. The idea is to have the patient where the headset post-surgery where a simulation will play as the patient recovers.

Augmented Reality

Its most famous use is in Pokémon Go, the game that swept the whole world by catching Pokémon anywhere with the use of one’s smartphone. In the aesthetics field, Illusio is one company that provides Augmented Reality for plastic surgeons. The application acts as a mirror, where it flashes the patient’s body. A physician can adjust the settings via toggles on the app, helping them visualize how an augmentation or reduction would look. Pretty rudimentary right now but continually improving.

Google Glass

Google Glass was used for one study in the operating room. It had the ability to transmit images real time for other observers to see. The device has the potential to become an educational or training tool.

3D Scanning and Printing

In a recent interview by Dr. Yakup Avsar with the International Master Course in Aging Science (IMCAS), he mentions that he uses 3D Scanning and Printing in his practice to visualize his patient’s face when it has aged. He has long used this method, as he emphasizes the need for this in the medical aesthetic field. While this is not a novel idea, more cases have yet to be reported or publicized.

The idea of technology in the field of aesthetic is promising. It will give physicians an opportunity to recognize any areas of concerns, which could be prevented as the patient ages. Its use could help medical aesthetics move forward in adopting more technology as the rest advances.

Krachap Lips: Lip "reduction" in Thailand

For most patients it would be unthinkable to want to have smaller lips. Not so in Thailand.

Plastic surgery in Thailand is cheap (which makes it popular). It's also pretty dangerous, with little to no regulation or oversight of services.

A fashion trend in Thailand is for women to 

Lip reduction is an uncommon procedure in the US, but its counterpart, lip augmentation, is a common procedure, with two options in doing so. One is surgical lip augmentation, while thither is through dermal fillers. So far, the only available option in reducing lips is to treat it surgically.

A lip reduction would need to remove skin or excess tissue along the dry-wet line of the lip. The stitches remain to form a "new" lip line (where they either disolve or are removed manually).

In Thailand, they call it “krachap lips” wherein they reshape the lips as if they were buffalo horns with very pronounced curvers. (Removing distal portions of the lip along the vermilion border to achieve an exagerated 'bowed' look.) Lip reduction has been linked to Thai’s superstition of having smaller lips to good fortune explaining why many opt to undergo the procedureThe lips are modeled after actor Patcharapa “Aum” Chaichua. The procedure’s common and immediate side effects are redness, pain, bruising, and swelling. According to some websites, a lip reduction surgery costs anywhere from $800 to $2000 (US).

Despite botched consequences for other patients, it doesn’t stop some other potential patients undergoing the knife for the procedure. Presently, there are no significant studies about lip reduction.

Photos: Dr Apple Surgery/Facebook

Injection Techniques for the Hand and Neck

In our previous post, we discussed filler injections for hand and neck rejuvenation. These procedures are on the rise, and many physicians are considering this procedure in their practice.

Injection Techniques for the Hands

There is a significant amount of literature for hand rejuvenation. Most have focused on injections and laser for the hands, as a non-surgical alternative. For this article, we shall go in detail on the injection techniques included in two studies.

LeFebvre-Vilardebo, Trevidic, and et al. (2015) go in depth with injection techniques, as different authors included in the study present their own injection methods on hands. The researchers also introduced their own injection technique: Scrape Skin Threading Technique (SSTT). Below is the table detailing more on the injection techniques.

Data from Lefebvre-Vilardebo (2015)

LeFebrve-Vilardebo and Trevidic (2015) suggest using a blunt-tip cannula when injecting. The researchers use four injection techniques to administer the CaHA.

The first method only injected without massaging, and it is most effective on a less fat hand. On the 2nd method, massaged aided in distributing the filler evenly. However, the third method showed the filler only stayed under the tendons. In using their own technique, the SSTT, it was the only technique that showed where the product was targeted.

For Dr. Moradi (2015), he used Radiesse with lidocaine HCl. In performing the procedure, he tented the skin and utilized a bolus injected in the dorsum of the hand. Specifically, Moradi injects “…proximally by the wrist-hand junction, distally the metacarpal-phalangeal joint” (p. 265s).

In addition, the doctor added smaller units for added improvement on the hands. Its intended result is to lessen the appearance of veins and tendons and improve volume.

Alternatively, in Dr. Busso’s work (2015), he used HA that would minimize the appearance of tendons. The patient should be in supine position. In order to see the veins better, Dr. Busso suggests placing the hand below the level of the heart. In addition, mark all injection sites. Then, finally, raise the hand slightly above the level of the heart.

The injection on the dorsal superficial lamina would yield easier injection administration. Injected fillers can easily spread and lessen any abnormal skin formation. Skin tenting is recommended to separate the veins from the injection area. There is a risk of nerve injury, so refrain from doing any intracompartmental injections “below the deep dorsal fascia” (p. 270S).

As for Drs. Sutton and Bucay (2015), their choice of filler is Radiesse. Like the previous cases above, cannula was used to administer the filler. The insertion of the cannula is between the 2nd and 3rd metacarpal.

The common observed side effects were edema and erythema in all cases.

Dr. Rivkin (2016) also conducted a study on hand rejuvenation and injection techniques. The author makes use of needles, instead of a cannula as mentioned in previous studies mentioned above. The technique the author adopted was injecting between the phalanges. Rivkin carefully fills in the spaces. The author expects that the appearance of vein and tendon reduce. After administering the procedure, it is recommend that the hand is massaged.

After the procedure, the author advises the patient to have hands elevated for the next couple of days and any tedious activity.

Injection Techniques for the Neck

The literature for injection techniques on the neck is limited; most studies have only studied on the use of lasers on the neck. There have been research on the neck using botulinum toxin, and there are doctors who use botox on their patients to perform a non-surgical neck lift.

Physicians should take note of the danger zones in the neck. The researchers introduced a new injection technique on the neck, which is the “Three-Dimensional Circumferential Injection Technique” (p. 1). They applied this approach on the Posterior and Lateral Subcutaneous Areas of the Neck and Anterior Subcutaneous Area of the Neck and Horizontal Neck Rings.

Below is the table that further details the study.

Data from: Calisti and Elattar (2017)

Hand and neck rejuvenation are two procedures that result in patient satisfaction. The procedures are not nascent, and it is expected to rise in the coming years.

The Coming Shift to Telemedicine (Everywhere)

There is a rise of telemedicine startups everywhere, especially in cosmetic medicine. What might this mean for you?

Silicon Valley, New York, London and Berlin all are investing big in telemedicine, A.I. and big data services. There are massive changes in the US that are opening doors for new services. what does it all mean for a little one-doc clinic in Des Moines, Charolette or San Antonio?

Why is there a need to utilize telemedicine?

Telemedicine makes it easier to keep patient records, track patient progress, saves time (and money) and offers the promise of integrated deep learning for clinical decision support.

There has been a report that patient preference leans towards employing telemedicine. It provides follow-up care for those who underwent surgery and many patients favor that. The convenience allowed for better communication with the physician through email.

Why are some physicians skeptical about telemedicine?

While there are many benefits to telemedicine, it is still faced with criticism. Many physicians are hesitant to adopt telemedicine because of costs. One of the many concerns about adopting telemedicine is the HIPAA. Patient privacy can be breached, especially with aesthetic medicine where photographs and video can be saved or used as before and after media output. Tools and software can be costly, because of this doctors would prefer to stick with traditional practice instead.

When will aesthetic medicine adopt telemedicine practices?

Several dermatology and plastic surgery practices have made progress in using telemedicine. The most common telemedicine method for aesthetic practices are Skype consults. Virtual consults cost less and patient retention is slightly higher.

Another example of telemedicine applicable for aesthetic practices are Virtual (VR) and Augmented Reality (AR). Primarily known for its use in gaming, it has branched out to other science and technology fields. Several plastic surgery practices have installed some devices such as VR or AR for patients to visualize the expected outcome of their procedure. Back in 2015, plastic surgery performed through Google Glass resulted successfully. In other uses, scribes send data to physicians via Glass. Expectations to use Google Glass in the practice is huge.

Telemedicine is also not limited to patient care, as it focuses also on the devices you use for your practice. While Luan et al., (2015) study focuses on access to plastic surgery literature, a physician can utilize their devices to use to communicate with patients. In addition, since the rise of smartphones, it is easier to enforce telemedicine. Video messaging apps like FaceTime and Skype can be used for telemedicine.

How to prepare yourself in integrating telemedicine in your practice?

Telemedicine, while mostly beneficial, may be difficult to integrate to a practice especially if it is not telemedicine-ready. You may need to consider these factors.

According to Krupinski (2014), set-up a room dedicated for all telemedicine needs. You will need to examine factors such as lighting and audio and video so you can examine them better. Let your patients feel comfortable inside the room as well.

Choose the telemedicine tools, methods, and technologies you will adopt. As we have mentioned there are various tools and devices for the physician’s use, but you do not need to employ everything. Some examples of the telemedicine methods you can use are Real Time (RT), which you can do on your own devices or through store-forward (SF). A physician can find a telemedicine tool or software online, which one can subscribe to.

Training is important, as studies have shown that those who are mishandling telemedicine tools or software can make patients feel uncomfortable. Train along with your staff so everyone in the practice has an idea how your telemedicine devices and software work.

Most physicians overlook the hindrances and barriers to using telemedicine for easier accessibility. Telemedicine is not just implementation just to keep up with trends, but its convenience and eventual cost-cutting advantages can help save practices.

Download the Medical Spa MD Telemedicine Report here.

Face Lifts For Smokers.

A new study suggests that cosmetic surgery could help a patient quit smoking long term. Most surgeons in North America suggest a cessation period of 2 weeks before surgery. However, it was found in previous studies that those who ceased smoking 4 weeks prior showed lesser rate of complications. Nineteen (19) percent of patients in their research attained complications. A follow-up was made by the researchers stating that only 10 of their patients have not smoked since their surgery.

Previous studies also delved in cosmetic or plastic surgery and smoking cessation.

In a study conducted earlier in the year found that there were postoperative complications as expected. The study was on a larger scale examining more than 40000 patients. However, among the 40425 patients in their study, 15.7% were smokers. Additionally the researchers of the study found that smoking had an effect as to where the procedure had been done.

Findings:

• 3376 (8.4%) patients incurred postoperative complications
• 732 (1.8%) patients had medical related complications
• 1611 (4.0%) patients had wound related complications

There were surgical complications for patients who underwent breast reconstruction, craniofacial/head and neck, and upper and lower extremities. Wound-related complications were found for craniofacial/head and neck and upper lower extremities patients.

E-cigarettes are no exception either since it contains nicotine. In 2016, a study focused on the use of e-cigarettes and if it has lesser detriments as compared to regular cigarettes. The effects weren’t as severe, but it did not eliminate the incidence of complications.

Additionally, according to many plastic surgeons, they have a smoking cessation session prior to surgery. Despite some efforts to do so, several patients had also reported smoking before their surgical procedure. It is unclear whether cessation intervention helped the patient quit smoking prior and after surgery.

New Advancements In Cosmetic Lasers (2017)

Cosmetic laser technology has continuously advanced over the years, and many physicians have noted the progress in the past few years.

The American Association of Dermatology (AAD) Annual Meeting was held in March. One common topic according to the AAD articles is the advancement and improvement of aesthetic laser devices. Aesthetic laser devices can target skin and facial conditions, even allowing multiple treatments on one device.

Dr. Michael Gold, a renowned dermatologist, spoke in a symposium, noting the significant changes of the current aesthetic devices.

Aesthetic companies like Syneron, is gearing up to release new devices and make improvements with their current devices. In addition, Cutera introduced PICO Genesis last December that treats skin pigmentation, which also enhances the patient’s skin complexion.

Two doctors from the AAD conference has noted that laser will improve further in the future. Dr. Chapas said that there are studies being conducted over the use of a picolaser for other cosmetic purposes other than laser hair removal. Additionally, Dr. Waibel mentioned that research is also done to examine other laser uses.

The dermatologist added she is aware that new technology are being developed such as the free electron laser, which has promising uses for the medical sector.

It is expected that lasers will continue to develop in aesthetic medicine. What are your expectations for aesthetic or cosmetic lasers in the future?

References:

Thinking of a Picosecond Laser? Do I need one and which one to buy.

http://www.prnewswire.com/news-releases/syneron-candela-announces-new-technology-and-indications-at-the-2017-american-academy-of-dermatology-aad-annual-meeting-300416266.html

http://www.prnewswire.com/news-releases/cutera-launches-new-pico-genesis-treatment-with-enlighten-300373489.html

http://dermatologytimes.modernmedicine.com/dermatology-times/news/advances-lasers-light-sources-0

http://www.healio.com/aesthetics/laser-procedures/news/online/%7B8048864e-2466-4db7-a033-17ea4f3df1a9%7D/recently-approved-aesthetic-devices-improve-on-previous-generations

http://www.mdedge.com/edermatologynews/article/134277/aesthetic-dermatology/video-picowave-laser-uses-are-expanding-beyond

6 Keys to Medical Spa Success

References:

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/the-blog/2008/2/23/key-number-4-to-med-spa-success-the-physical-embodiment.html
/the-blog/2008/3/16/key-no-5-to-medspa-success-know-thy-competition.html
/the-blog/2008/4/26/medspa-success-key-6-service.html

Overlooked Anti-Aging Procedures

Many fillers and injectables are marketed for the face and skin. According to the 2016 ASPS statistics, there were 2,600,000 procedures for dermal or soft tissue fillers alone. However, dermal fillers are also used for other purposes, like on the hand and neck.

Numbers are scarce regarding treatments for those areas, however some patients seek hand or neck rejuvenation, which are overlooked procedures.

There have been studies about using neck and hand rejuvenation, mostly showing promising results to the patients. Few studies have only shown complications about rejuvenation and resurfacing. Frequent modalities used in treating these areas are dermal fillers (used for off label use) and lasers or IPL.

In the official statistics provided by the ASPS, only hand surgery is listed as a surgical procedure and so far, hand and neck rejuvenation is not listed as a non-surgical procedure. It is probable that it is part of the filler statistics.

HAND REJUVENATION

Common injectables used for hand rejuvenation are Collagen, Hyaluronic Acid (HA), Calcium Hydroxlypatite (CaHA), and Poly-L-Lactic Acid (PLLA) (Kühne and Imhof, 2012). According to the authors, side effects of the fillers on the hands are swelling and bruising. In addition, they suggested that dermal fillers for better effectiveness is CaHA due to collagen stimulation. Furthermore, according to Butterwick and Sadick (2016), hand rejuvenation procedures are more effective when treated with multiple modalities such as IPL, RF, and CaHA and PLLA.

In Maruyama’s (2016) study, it focused on the hand rejuvenation for 128 Japanese patients. The researcher took into consideration some skin differences and side effects. The researcher used IPL by using two wavebands, one using 560nm and another 515nm.

Immediate downtime results for wrinkles showed that most of the patients were mostly unpleased, effects improved after two or more treatments. Meanwhile, many patients were satisfied by the results with the dorsal lentigines. One of the prominent side effects presented in the author’s study was erythema, followed by hyperpigmentation and itching.

Despite such, most patient satisfaction for hand rejuvenation is usually high and there is an expected patient return or retention for a treatment of hand rejuvenation (Rivkin, 2016).

After administering an injection related hand rejuvenation procedure, massaging is recommended as it helps in the longevity of the treatment on the hands.

NECK REJUVENATION

With surgery, come the complication and risks. Batniji (2014) enumerates the possible risks of surgical neck lifts, such as induration, neck injury, and skin contour irregularities. Despite such complications, neck lifts is slowly on the rise.

As an alternative, some cosmetic physicians offer non-surgical neck rejuvenation.

However, recent literature is still little for non-surgical neck rejuvenation.

de Oliviera et al.’s (2017) study presented a 100% improvement rate upon treatment. A combined RF and PEMF treatment shows significant positive results when used to treat the neck. Additionally, the researchers note that RF alone may not be as effective. It is suggested these combined treatment be used in observing shorter downtime and lesser complications.

Their main limitation was no follow-up was done after their initial study. Any observed complication was quickly resolved.

In another study, di Bernardo (2016) used two modalities for the neck: a laser and RF for different purposes. Their study focused on the procedure of using the modalities for the neck. The researchers marked the areas to laser and used tumescent anesthesia for this treatment. As for the RF treatment, they plotted the areas to treat the neck to avoid neuropraxia.

Finally, Oram and Akkaya (2014) uses CO2 as another option in treating the neck as it showed improvement with Skin Laxity, Jowling, Fat Disposition, and Horizontal Neck Lines. Their study, however, presented complications, however it was only short lived. Despite such results, most of the patients returned for further treatments in the long-term. Their main takeaway in the study was the skin tightening due to the bettering of the skin laxity and in turn causing good effects with the jowling and fat disposition.

These two procedures, while, not popular, are also sought by patients. These elective procedures are befitting

In another post, we discuss injection techniques for hand and neck rejuvenation.

Patient Retention through Better Customer Service

Even medical practices need to brush up on customer service. Some patients complain about the poor services provided by staff. Online reviews for some practices have patients talking about how poorly they were treated by the staff and may need to find a new doctor. This could hurt your practice, as your leads could decrease because of your staff members.

If you received poor reviews about the staff, then it might be time to reconsider getting friendlier staff or training them for better customer service.

Manage staff well

Customer service starts within the practice. How you deal with staff could translate to their behavior towards patients. Aside from better treatment towards staff, provide them with appropriate training such as customer service and procedures.

In a medical aesthetic practice, allow staff to have training and delegate tasks for them so they could also take part in your practice and learn more about how to deal with patients in different situations.

Survey Patients

One of the many ways you can connect with your patients is to give them a say in what you are offering. Many experts suggest this method as a way to put your patients first. While you cannot offer every treatment out there, at least consider the idea of having that non-surgical treatment or an alternative.

For your reference, the most common procedures in 2016 (according to the ISAPS) were Botox or dermal filler related procedures, chemical peels, microdermabrasion, and laser hair removals.

Hold Offers, Discounts, and Specials

All patients love to hear the words discount and special. If you have found footing Advertise it on social media or conduct an email blast. Either way, build a relationship with all your returning patients, and hook them up with your offers and specials so they could refer your practice to their other friends.

Invest in Social Media

A large number of practices are on social media, not to keep up with trends, but to connect with customers digitally. Social media is one of the most recommended marketing strategies, and this is how you can pick up potential patients for the practice.

Twitter and Facebook are among two social media outlets that have improved on the business side of customer service. Businesses on Twitter have been given a feature to accept or decline a Direct Message (DM) from an individual. Facebook has also that option on Messenger to set up chatbots for your business. Further discussion about this concept will come at a later time.