Reversing Hyaluronic Acid Filler Injections With Hyaluronidase

It's possible that at some point in your cosmetic clinical career - for whatever reason - you might need to try and minimize or reverse the results of a HA filler injection.

Patient's have been know to 'freak out' when the big lips that they thought they wanted are actually the ones they see in the mirror. It can be something of a challenging conversation.

Fortunately, there's Hyaluronidase, and some researchers have found that even small amounts were effective in dissolving hyaluronic acid fillers.

In a study by Juhász et al. (2017), the researchers found that small amounts of hyaluronidase were effective in treating complications from hyaluronic acid (HA). The study focused on the degradation of HA, and different periods to see its efficacy. Randomized study participants were injected with a HA injectable; Juvederm Ultra XC, Juvederm Ultra Plus, Juvederm Voluma XC, Restylane Silk, Belotero Balance, Restalyne Lyft (Perlane), and Restylane-L. Then patients were injected with saline or 20 or 40 unites of hyaluronidase and monitored over 14 days. 

The results showed that haluronidase was effecive in degrading the filler and that there was no decernable difference between the 20 and 40 unit injections. (So you don't have to use much.)

Here are the findings:

• Day 1 Post-Injection: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE, RESTALYNE LYFT (PERLANE)
• Day 2 Post-Injection: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE, RESTALYNE LYFT (PERLANE), RESTYLANE-L
• Day 3: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE, RESTYLANE-L
• Day 4: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE, RESTALYNE LYFT (PERLANE)
• Week 1 Post-Injection: JUVEDERM ULTRA PLUS, JUVEDERM VOLUMA XC, RESTYLANE SILK, BELOTERO BALANCE
• Week 2 Post-Injection: Everything except JUVEDERM ULTRA XC

The researchers also found that dermal fillers like Juvederm Ultra Plus and Restylane-L had a higher concentration, which took longer to dissolve with hyaluronidase, while Belotero Balance was the quickest to degrade.

Previous studies have only given their recommendations on the number units of hyaluronidase, based on experience or training. However the 2017 study presented their recommended dosage in degrading the HA. The authors suggest that a 20 unit injection of hyaluronidase is an effective way to degrade the HA.

One possible complication from using hyaluronidase is an allergic reaction. For patients who incur any allergies from hyaluronidase, there are other treatments for HA complications.

It's highly advisable to conduct allergy testing for patients before administering the dermal filler, which could reduce the incidence of complications. Ablon (2016) reminds medical providers in cosmetic medicine to observe the tissue as the dermal filler is injected.

Physician Depression, Suicide, & Burnout

Last year more than 62,000 medical professionals and their families signed a petition asking medical associations to track physician suicides and address factors common in healthcare environments that cause psychological distress.

There's an epidemic of depression and suicide among physicians. It's no joke.

The grim tally of suicides among physicians and medical students - 300 to 400 - in the US is probably low (since many suicides aren't listed as such on death certificates). It's about the size of the average medical school class. Male doctors are 1.4 times more likely to kill themselves than men in the general population; female physicians, 2.3 times more likely.

In one study, nearly 1/4 of med students reported significant symptoms of depression, and 7% had suicidal thoughts in the last two weeks.

Pam Wible MD on Why Physicians Kill Themselves TED talk.

Know this: You're not alone.

• Silence is the Enemy for Doctors Who Have Depression
• Why depression has made me a better doctor

High End Concierge Medicine For $80K A Year

Concierge clinics in the US have been around for more than a decade, but there's a subset of concierge docs who aren't the ones you might be thinking of, these docs are at the highest of "high-end".

The move in the US to population health and value based care may have thrown into question where much of healthcare may exactly end up, but there's much more clarity on where the highest-end concierge medicine already is; It's booming for those who have identified the market correctly.

Boutique concierge docs, clinics and even high-end hospital wards are caching in on Americans willingness to pay for high quality care and immediate access, and the stress reduction when there is an event. (I would argue that this reduction in stress knowing that you're going to have someone holding your hand is a primary motivator.)

From a NY Times article

There are rewards for the physicians themselves, of course. A successful internist in New York or San Francisco might earn $200,000 to $300,000 per year, according to Dr. Shlain, but Private Medical pays $500,000 to $700,000 annually for the right practitioner.

For patients, a limit of no more than 50 families per doctor eliminates the rushed questions and assembly-line pace of even the best primary care practices. House calls are an option for busy patients, and doctors will meet clients at their workplace or the airport if they are pressed for time...

... In most of these practices the annual fee covers the cost of visits, all tests and procedures in the office, house calls and just about anything else other than hospitalization, as well as personalized annual health plans and detailed quarterly goals for each patient.

Interestingly, the 'marketing' that is used to pitch these concierge services to clients is that of being an 'asset manager', with the asset being your familys health and peace of mind. (Expect to see this messaging in Medical Spa MD Mebers who are offering concierge services.)

While the money is good (for those who are successful) there are often some feelings that are in conflict with why many physicains entered medicine. After all, you're essentially limiting the 'total' amount of value you provide in order to make more money. Many concierge docs defend their decisions fervently, but for some it can cause an internal conflict.

It's a fair question: Where is the ethical line?

For some concierge docs it's a boundry they deal with by limiting prices.

Again fromt the Times article:

...the new approach does not sit so well with veteran practitioners like Dr. Henry Jones III, one of Silicon Valley’s original concierge doctors at the Palo Alto Medical Foundation’s Encina Practice. He charges $370 a month, a fraction of what newer entrants in the area like MD Squared and Private Medical do. “It’s priced so the average person in this ZIP code can afford it,” he said.

Dr. Steven Knope who was a pioneer in concierge medicine is not conflicted and says it's time to overthrow the "mandates of the bureaucrats of Medicare and the pack predators of teh HMO's, big insurance, and big government". 

Concierge medicine is here to stay. It's proven to be both popular and profitable, but there are some areas where physicians tend to tread carefully. After all, success in this area is actually a business problem, one of branding, and if patients view you as being inauthentic or insencere, there are plenty of other docs down the road happy to take them.

Additional Reading:

• Posts on concierge medicine
• The Ethics of Concierge Medicine (Freelance MD)
• The Need For Concierge Medicine (Freelance MD)

Botox For Depression? Yep.

Depression symptoms were reduced 47% in subjects given a one-time Botox injection. Huh?

Guess what? That Botox that you're injecting may be having an effect on more than just crows-feet.

File this under "cool things you can bring up during a Botox consultation".

In a study (Finzi et al., 2014), researchers found that it can also help treat symptoms of depression.

According to the P.I., Professor Norman Rosenthal the research offers a new approach that shouldn't conflict with other treatments the patient might be on.

The reserarchers injected 74 subjects, half with Botox and half with a placebo.

From the abstract:

To determine the antidepressant effect of onabotulinumtoxinA (OBA) treatment of corrugator and procerus muscles in people with major depressive disorder, we conducted a double blind, randomized, placebo-controlled trial. In an outpatient clinical research center, eighty-five subjects with DSM-IV major depression were randomized to receive either OBA (29 units for females and 40 units for males) or saline injections into corrugator and procerus frown muscles (74 subjects were entered into the analysis). Subjects were rated at screening, and 3 and 6 weeks after OBA treatment. The primary outcome measure was the response rate, as defined by ≥ 50% decrease in score on the Montgomery–Asberg Depression Rating Scale (MADRS). 

The result showed that in the group that got the Botox injections there was a 47% reduction in depression symptoms. The p;acebo group showed a reduction of just 21%.

The thinking is that there's a feedback loop where facial espressions aren't just an expression, but can actually influence mood. So people who can't frown (for whatever reason) aren't getting that reinforcement and feel less depressed. It's a theory from a new area of psychology called embodied cognition - the idea that we actually think with our bodies. So the Botox makes it harder to frown = people feel less depressed.

Daily Huddle Up! Self-Organizing Your Medical Spa Every Morning

I hate meetings. They're one of the most expensive things you do since every attendee is essentially unproductive for that amount of time, they tend to be too long, and they ramble. Painful. Here's how to do better.

Note: This is the first in a series of posts... or maybe a guide, on how to organize and manage your clinic for max productivity.

Meetings are inherently expensive. Depending upon your team size, an hour long meeting might cost you anywhere from a hundred to more than a thousand dollars in overhead costs and lost productivity. If you look at every 'meeting' as having that kind of cost, you'll probably look at your meetings differently, but we can take some lessons from the folks who focus the most on productivity: Silicon Valley startups. Those are the teams who developed productivity systems like scrums, sprints, and others techniques that are designed to maximize throughput across teams. These some practices that you can adopt to increase both your teams productivity and engagement, and minimize cost and downtime.

One of the most effective uses of 'meeting' time is to hold a daily standup huddle every morning with the entire team (or multiple teams if you're big). It's effectively a coming together to ensure that everyone is focused on the targets for that day and a chance to have everyone state what their daily goals are (making everyone accountable).

Setting it up

Here are the rules. I've used the typical 'tech' standup as a guide but have adapted it to the clinic environment:

1. A pre-set time every day. Which time and place is up to the team to decide. It is a meeting in which the team plans their day.
2. Keep a time-box of 5 to ten minutes. The purpose of the standup is NOT to have a rambling discussion or airing of grievances or planning.
3. Standing up. It keeps the meeting short since no one likes standing in a meeting. You'll see that it takes up much less time but everyone (yes you doc) has to stand. (This is not required but is often useful, especially to start and set the tone and expecatations.)
4. Every member of the team “answers” three questions:

• What did I accomplish since the last meeting?
• What am I working on or until the next meeting?
• What getting in your way or keeping you from meeting my goals?

Note: If detailed discussions come up it is a good practice to take them offline immediately after the meeting.

How to do it:

The process I suggest is this:

1. One set daily meeting at the beginning of the day. 
2. Forced timeboxed duration. 10 minutes be fore you unlock the front door is a good time and forces compliance to the time limit. (15 minutes is usually too long unless you're a bigger team. See below.)
3. Everyone stands up (Some teams don't but I've found it useful when introducing new teams. You'll see that people speak faster and it moves right along.)
4. Speak in turns. (You can use an object to pass. Only the person with the object can speak.)
5. Keep updates in the form of: What I did, what I plan to do, what is blocking me.
6. Any follow-up conversations take place after the meeting.

Things to remember.

It's a collaborative effort.

One of the most common standup meeting mistakes is making it a turn-based 1:1 chat with the physician or clinic manager. This completely defeats the purpose of the stand-up and should be avoided at all costs. This is valuable time that should be treated as collaborative effort for the whole team.

 A good way to keep scrum meetings efficient is to establish a simple rule:

• Everything you say should be valuable to everyone in the room. Individual talks can happen at any time of the day aside from the stand up meeting.

Stick to a schedule and a routine

It would be easier if your huddles were done on a specific day and time. Always start your meeting at the set time. Those who miss it or who are late will feel guilty and try harder to make it to the next one.

Hiding work details

It's important that every team member is transparent in his or her work and gives accurate updates. Members need to disclose any issues so they can be resolved on time, without impacting the entire team's commitment to goals. The daily stand-up isn't just about answering the same three questions every day; it's a perfect forum for discussing any gaps in the team's commitment and understanding of requirements.

Additional Reading/Resources

• https://www.laserfiche.com/ecmblog/10-ways-to-make-stand-up-meetings-better-office-hack/
• http://www.pinnacleprojects.com/index.php/daily-stand-up-meeting/144-the-daily-stand-up-meeting-a-core-practice-for-self-organizingteams

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