What 2016 Cosmetic Medicine Stats Mean For Your Clinic

Stats from 2016 are trailing indicators of the market but they should give you a clear view of where cosmetic medicine is headed.

When you're looking at where cosmetic medicine is headed, you'd do well to keep up with the latest stats showing that nonsurgical treatments are on a path to overtake cosmetic surgery in total dollars spent. 

If you look at some of these stats you'll sees some obvious trends, and that should make you think about what kinds of treatments you might look to ad or promote. Nonsurgical is where the growth is.

Nonsurgical cosmetic medicine's growth is accelerating according to the International Society for Aesthetic Plastic Surgery's (ISAPS) annual statistics.

Take a look at this chart of nonsurgical treatment's growth in the US, and compare that with the growth in surgical treatments. IPLs, cosmetic lasers, Botox and injectables.

Download and read the ASAPS report here.

The International Society of Aesthetic Plastic Surgery (ISAPS) 2016 Stats

Read the ISAPS report here

If you're not practicing cosmetic medicine in the US, you might want to think about starting a clinic in Brazil.

In the report, Brazil and the US trade top spots depending upon the proceedure. They're neck and neck, except when the treatment is further South. Brazil is almost double the total number of treatments in both Labiaplasty and Vaginal Rejuvenation than the US. (Interstingly, Labiaplasty worldwide had the greatest increase in treatments year over year at a massive 45% increase.)

The US has far more nonsugical treatments due to greater market penetration of cosmetic lasers and IPLs.

Here's a breakdown of nonsurgical treatments wich shows wider spread than if all cosmetic treatments (including surgical) are included.

Total Nonsurgical Procedures by Country

Here's another chart that gives a little insight into the macro trends around injectables worldwide.

Year-to-Year Comparison of Injectable Change

Winners? Juvederm, Restylane, Belotero Balance and Sculptra Aesthetic. Loser? Radiesse.

Implications and takeaways for your clinic

Non-surgical procedures continue to grow at a steady. No surprise there, but there are some areas of interest if you're looking at adding to your treatment menu. You really want to ride a wave that's growing and a careful reading of these types of reports can show you where that wave is headed.

The fastest growing cosmetic procedure of all? Labiaplasty, at 45% year over year growth. That's a pretty damn good indication that there's a lot of demand. 

The non-surgical options using RF and fillers for vaginal rejuvenation has just started to trend, but it's dramatic. You might want to take a hard look at adding vaginal rejuvenation to your treatment lineup.

More non-surgical procedures may continue to progress and develop, as dermal fillers and Botox are not limited to the use of the face. Lasers and IPL also contribute to the increase as they are considered non-surgical alternatives for fat reduction or skin rejuvenation. It is expected that in the coming years, there may be a spike of numbers coming in from the younger and middle age demographic.

Dr. Sarah Cenac Jackson - Audubon Dermatology, New Orleans

Part 1 of our interview with Audubon Dermatology in New Orleans: Dr. Jackson tackles the medical technologies used in their practice and her experiences as a Dermatologist.

Name: Dr. Sarah Cenac Jackson
Location: New Orleans, LA
Website: http://audubondermatology.com/

Of Interest: Dr. Jackson is a member of the Annenberg Circle of the Dermatology Foundation, the largest foundation of dermatologic research in the country. She lives in New Orleans, LA with her husband Konrad and their 3 children Adelaide, Henry, and Charles.

What sparked your interest in offering cosmetic medicine?

Botox and Restylane were FDA approved for cosmetic use when we were in training at a program that had an established cosmetic training clinic and education in place. It was a natural fit for us to continue using and perfecting our techniques with injections.

We have several leaders and mentors within the cosmetic field in New Orleans and we were inspired to stay at the cutting edge of this exciting time in dermatology. What keeps us in cosmetics is the high level of patient satisfaction with these procedures. People love looking better and it translates positively to other areas of their lives. The constant positive feedback stimulates a desire to continue training and offering our patients the best services possible.

What are the IPL and lasers you use? And how do you select the medical devices in your practice?

We use many lasers and energy devices. We started out by renting a hair removal, vascular, and resurfacing devices. As we became more booked up on the days we rented the lasers, we made business decisions to purchase devices. IPL and laser hair removal were our first purchases and remain very profitable.

We determine devices to purchase based on 1) demand 2) data on the device's success 3) profitability.

Consumables and warranties can become very expensive so we are sure to factor that in as we make purchase decisions. We calculate ROI per hour on devices including the time required for one of the doctors or aestheticians to operate it, including numbing and consents. More complicated and painful procedures have a cost to us in time!

Our Palomar IPL, Exilis radio frequency, and Cutera Hair Removal systems are fantastic because they require no numbing and have no consumable. Cool Sculpting is very popular as well. We do research to see how much competition we have locally with a particular technology, but we have found that our patients are very loyal and respect our expertise, so it has not been a big problem for us to compete with med spas or group-on type pricing.

Clear and Brilliant and Fraxel Dual are also very popular, but difficult to use in New Orleans in the summer as we have so many tanned and skin of color patients. We are starting to use Cutera's picosecond laser for pigment as it is more color-blind.

Our tattoo removal business has not been as busy as we had initially thought, but it is growing and we love having the picosecond technology as indications for that device grow.

Over the years we have become savvier about negotiating. We usually decide what technology we want (skin tightening, resurfacing, etc.) and then research which device by talking to other KOLs and peers. At meetings, we try to have meetings with laser companies and get to know their personality. We always, always demo the devices before purchasing. Prices are negotiable and we discuss extra warranty years, extra consumables, and what to do if the device is upgraded before ever signing.

What anecdotes can you share about your patients?

I think some of the worst patient situations that happened involved syncope secondary to patient anxiety about needles. As a physician injecting all day long, we need to be skilled in recognizing syncope and pre-syncope and be able to best treat our patients. We have had several episodes in the office of seizure-like activity as part of syncope. We have had patients jerk with these convulsions while a needle is near the globe and even fall off the exam table. One patient even had lateral nystagmus. After consulting with our Neurology colleagues, we learned these symptoms can be seen with syncope. We have found it very helpful to know the proper recovery for syncope. Most importantly to lay the patient flat and let the blood flow back to the brain. We keep juice and ice on hand and everyone in the office is ready and prepared in case it happens. People are not allowed to leave until fully recovered. We have had a young male patient try to leave to early and face plant the copy machine on his way out! So, we triage for this as part of the patient intake. “Have you ever passed out with needles?” We are always prepared with guarding the needle and stabilizing our hand in case the patient jerks. We have our staff prepared so the patient recovers fully and can have confidence in our care.

Bio: Dr. Jackson received her medical degree from Louisiana State University School of Medicine, where she was a member of AOA honor Medical Society. She also fulfilled her residency training at Louisiana State University Health Science Center where she served as Chief Resident in Dermatology. She received her undergraduate degree in Zoology from Louisiana State University, where she graduated cum laude. She is a board-certified Dermatologist with special interest and training in medical dermatology, dermatologic surgery, cosmetic dermatology and laser surgery. Dr. Jackson is a former President of the Louisiana Dermatological Society. Additionally, she served for several years as the Louisiana State Chair of the Dermatology Foundation. Dr. Jackson is a member of the American Academy of Dermatology, the American Society for Dermatologic Surgery and the Women’s Dermatologic Society.

Dr. Deirdre Hooper - Audubon Dermatology, New Orleans

Part 2 of our interview with Audubon Dermatology in New Orleans: Dr. Hooper of discusses marketing strategy and staffing.

Name: Deirdre O' Boyle Hooper MD
Location: New Orleans, LA
Website: http://audubondermatology.com/

Of Interest: Dr. Hooper is half of of Audobon Dermatology. She's an executive committee member of the Women’s Dermatologic Society, the nation’s 3rd largest dermatologic society. She also serves as Financial Vice Chair of the Women’s Dermatologic Society’s Legacy Council.  

Dr. Hooper lives in New Orleans with her husband and their 3 children.

Kindly give us a background of your clinic.

We have a condo in a medical office building across from a hospital. Being in a medical setting allowed us to become busy very quickly based on referrals from other doctors in the building. We offer a full range of medical, cosmetic, surgical, and laser dermatology. Treating medical patients over the years has fed our cosmetic business-for example, the mothers of our pediatric acne and wart patients become our injectable patients, and they often send their husbands to us as well!

We rented lasers until it became financially more sensible to purchase our own. We now each see about 35-50 patients each per day and have 2 full time aestheticians, 2 nurses who assist with cool sculpting and aesthetic procedures, and a skin care concierge. One of our early hires as an aesthetician has a business degree. As we have grown the practice, she has become more involved in the business and HR end and has now become our office manager.

We are committed to making sure that each and every patient is confident in our care. This means that we will take care of you every step of the way, whether your journey includes skin cancer surgery, skin diseases, lasers, injectables, or anything in between for a high-tech natural rejuvenation. At Audubon Dermatology, we specialize in comprehensive dermatologic care for all ages, skin types, and skin conditions. We utilize a wide array of the most innovative products and procedures to give you the best care possible. We are located in New Orleans but often have patients coming in from around the country to receive our services.

How do you approach staffing in your practice?

We offer quarterly bonuses that incentivize the office goals and behavior we want to achieve. We feel like it’s a great way to positively reward great employees and check in more frequently with employees who may still be learning. We have a policy that employees may not request a merit increase until they have improved on their evaluation scores for 3 consecutive quarters.

It’s important for employees to experience and try the products and procedures in your office so that they can recommend them to patients. However, we have found that not all employees utilize procedures, or they may not understand the value of a procedure or product when given absolutely freely. We offer "Audubon Bucks" quarterly based on very simple and specific measures we expect every employee to complete. If employees call in sick multiple times or are not completing items on their detailed job descriptions, they lose their Audubon bucks, we have found this to be an effective way to avoid giving free services to less effective employees, and to be a great way to allow employees to see the costs and value of services we offer.

Hiring and Firing seem to be the most common struggle we and our colleagues face. We have learned 3 important points: 1) Hire experience for the back, personality for the front. 2) Hire people that you personally like and would enjoy spending time with outside the office. 3) Incentives are not only monetary-appreciation and acknowledgement are just as important.

What are your marketing strategies?

We find that word of mouth is our biggest referral system. We rarely pay for advertising but do focus on our social media. The marketing world is changing, we are constantly trying to grow our online presence.

When we started our practice 10 years ago we had a yellow pages ad. That is long gone as we implemented a tracking module in our EMR and started tracking-how did you hear about us? 95% from my friend or another physician! In recent years, the number of patients who find us by google is growing, so we are sure to keep our website updated and search-friendly and we are utilizing social media, mainly Facebook (including Facebook live), Instagram, and twitter.

We use Constant Contact to email patients about specials and new services. In our office, we have discreet signs on the back of every door mentioning current specials and customized cards that give an overview of products and services we offer for varying cosmetic complaints such as red face, fine lines, or pigment problems. These often generate questions as patients read over them as they wait for us.

We have tried newspaper ads, ads in local magazines, even billboards. None of these have approached the success of internal marketing and social media.

What procedures are most performed in your clinic?

We try and focus on treatments that make a clinical difference. We are always bringing in new devices or products. Staying on top of all scientific and technological advances in skin care and device modalities has been a priority of ours from the beginning. We do track our ROI and if something is not selling we phase it out, but typically that goes hand in hand with new advances that we are upgrading to anyway.

What pearls and tips can you give fellow physicians?

One important lesson is not to let the patient tell you what to do. As we begin in cosmetic medicine, we may want to please the patient, and go against what we judge to be the best cosmetic outcome. We have learned that the patients are there for our expert injections, and also our expert eye. We know what looks best, and they benefit from our knowledge of beauty. Many patients come in and say “whatever you think, Doctor”, but unfortunately not all of them. For those patients we try to educate them, and offer them our best plan for a great outcome. If they cannot see our way, we do not inject them. You want as an injector to be proud of every patient that you work with. Be selective and always stick with what you know is best!

Bio: Dr. Hooper is an honors graduate of Louisiana State University School of Medicine. She received her undergraduate degree in biology from Louisiana Tech University, where she graduated cum laude. Her postdoctoral training included Louisiana State University Department of Dermatology as well as a Women’s Dermatologic Society Mentorship with Dr. Pearl Grimes in Los Angeles, CA. Dr. Hooper is a Board-Certified Dermatologist with special interest and training in medical dermatology, dermatologic surgery, moles and melanoma, cosmetic dermatology and laser surgery. She is an executive committee member of the Women’s Dermatologic Society, the nation’s 3rd largest dermatologic society. She also serves as Financial Vice Chair of the Women’s Dermatologic Society’s Legacy Council. She is a member of the American Academy of Dermatology and has served on that organization’s Youth Education Committee. Dr. Hooper is also a member of the American Society of Dermatologic Surgery and Louisiana Dermatology Society. Dr. Hooper lives in New Orleans, LA with her husband and their 3 children.

Cutera Reviews: Buying Used Lasers & IPLs

Cutera is a major player in the cosmetic space with a number of platforms and systems:Cutera Coolglide, Cutera XEO, Solera Opus, the LimeLight IPL, ProWave Nd:YAG and Solera Titan. So what's Cutera's reputation with physians?

If you read the discussion threads on Cutera there are some positive opinions about the technology but there's a a lot of negative reactions to the company policies around sales and support practices. Much of it mimics these opinions in the comments on this Cutera discussion thread from way back in 2007: Is any Cutera technology work buying?

Many of the comments or reviews fall in to a couple of buckets that are recognizable and are often repeated; problems with the effacacy, pricing and costs too high, buyer felt lied to or misled by the sales rep (oversold and under-delivered), and the companies desire to lock in the buyer and extract every possible dollar. (We're working on series of posts and a guide to address all of these areas.)

Cutera's not the only laser manufacturer facing some negativity of course. All of the cosmetic laser companies have some issues that they deal with all of the time. In some cases it's unrealistic expectations from buyers but there's a lot of sales reps that aren't doing these companies any favors in overselling and promising revenue outcomes that are much more dependent on the buyers business sense and marketing that the IPL or laser they're buying.

Don't Buy New comments:

I'm new to this site and so happy to see that I'm not alone. Recently wooed into purchasing the Cutera Excel V (at a conference) BIG mistake. Free drinks, good salespeople, and me-new to industry, naive and inexperienced with lasers and zero business savvy. I was told by the speaker at the event, who was also a friend of a friend who I thought had my best interest in mind, that I was getting "the best deal the salespeople are allowed to give" for the demo unit at that conference. Paid $125,000, it broke on day of training and then 2 more times over next few months, and I did not see the results I expected. Long story short...after 6 months of minimal use, I am trying to get rid of the laser, have been offered $30,000 by 2 different laser re-sale companies! Called financing company Cutera had me sign with-Heartland (no options given and no discussion of terms) who informed me that my payoff is actually $170,000 with no ability to pay less early! Can't resell on my own because warranty doesn't transfer unless I pay Cutera another $30,000 to transfer ownership.

and from LH

... The only Cutera piece I still use is the 1064. I will never buy new from Cutera again. I may buy a used 1064 for 20 cents on the dollar or less. The secondary market is very crowded with Cutera products which continues to devalue them.

but one anonymous poster (sarah) said this:

As a Cutera owner I am shocked to stumble across this site. I have been working with this system 2 years. I have very satisfied patients, many of them are thrilled with the how much better the 1064 works for hairs than other treatments they have had elsewhere.  There the no equal to the 1064 for safely treating facial veins.
Also, anyone who is not getting great results with the Titan is just not doing right. I have people coming over from Thermage all the time. Just prepare your patients, doing this treatment to get great results comes with a lot of discomfort. 
Anyone complaining about a warranty... should have bought it at the beginning. My sales rep is amazing, we can always count on him to support our events and set up extra training whenever we feel under prepared.

In short, We love our Cutera system! It just took learning how to use it correctly.

My impression in reading Sarah's comment is that she is not the owner of the clinic or buyer of the system. (Just a hunch.) Most buyers are always talking about the business costs vs return rather than the personality of the sales rep.  : |

Notes: We allow anonymous comments on this site for obvious reasons but you might want to judge the voracity of those comments vs commenters who are identifying themselves (which you do when you login and comment.) All comments are individual opinions and don't necessarily reflect the views or opinions of others on the site. Make your own decisions.

Anyone have thoughts on the current state of Cutera's technology or sales practices?

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Medical Spa MD Classified Ads

We're re-launching the classified ads for cosmetic clinic owners to let you buy and sell your used devices. IPL's, cosmetic lasers, RF devices, services and even entire clinics have a place to find a new home.

The 'classified ad' section of the site was a great start when it was first launched years ago and we're happy to say that hundreds of lasers and IPL's and even cliincs transited the site, but truth be told, it's suffered from some neglect. Since it was free to post it attracted a fair amount of spam and junk. We decided that it was worth fixing, so we started fresh and revamped the site.

The new site (http://ad.medicalspamd.com) will now charge $10 for a 30 day listing and $97 for a full year. That should be enough to keep the spammers at bay but be negligable for members who are really looking to sell a device or service. After all, if you're selling a $90k IPL, a $10 classified ad listing is probably the best deal you're ever going to see. 

You can always access this through the "Classifieds" link in the main menu above. Additionally, we reserve the right to delete listings that we don't like for any reason or for no reason, especially if we think it's spam.

To create a classified ad and sell your laser or IPL.

To create a classified ad you'll have to create a new account since it's on a separate platform and manages a different system. (Sorry about that.) You'll be able to sort and filter depending upon what you're looking for since there are a number of categories; Cosmetic Lasers, Fractional Lasers, IPL, RF devices, equipment, business services, miscellaneous and even medspas and clinics for sale. 

Don't worry if there's not a massive selection right now. It will grow.

1. Create a new account on the classifieds site: http://ad.medicalspamd.com
2. Post your ad. (Make sure it's good if you want it to sell.)
3. Go through the pament process.

That's pretty much it. You can log in to that account to change/edit your ad any time you want, and all payment and communications will take place outside of the system. (You'll be responsible for that after the initial contact.) Simple, simple, simple.

Notes:

• Once we have a few ads up we'll be sending a selection from the classifieds out during our weekly emails to all members so we'll take care of that too.
• We have members worldwide. Take that into account when you're browsing or selling.

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Survey: The Cosmetic Clinic Consultation Blueprint

The money is a cosmetic clinic is made in the consultation room. We want you to make more of it.

Take this quick survey and help us build a blueprint of best practices for cosmetic patient consultations.

What do you say? What do you do? What tools, software, or photos do you use to educate your patients during a consultation? What's your teams process and training? What results or metrics do you track?

Patient consutations are where your clinic makes money. That's the truth. The services you then deliver are just a fulfillment of the promises and commitments you made in the consult room. So improving your patient conslultatons is something that you should be focused on as a clinician, and working to get everyone on your team behind. 

Help us build the roadmap to the perfect cosmetic patient consultation by taking this quick survey and telling us how you perform consults, what works, and what you've tried that doesn't. We'll compile all of the answers along with input from consult guru's and top performers to build a "cosmetic clinc consultation blueprint" that will be available to members to learn from and help train their team to up-level one of the most critical parts of your cosmetic business. 

Take this survey and share your thoughts. 

This survey has 10 questions and should take you just a few minutes. (We might even contact you for more info for the guide.)

Sex Sells: Vaginal Rejuvenation For Your Clinic Or Medspa

Vaginal rejuvenation is one area of cosmetic medicine where OBGYN's are actually leading the way. Surgery, lasers, filler injections, and RF tightneing are all being used. Should you take a look at adding labiaplasty, vaginoplasty, vaginal tightening or rejuvenation to your services?

OBGYN's have been making inroads into cosmetic medicine for more than a decade with some of the nonsurgical treatments (Botox, fillers, lasers) but the actually have a big head start on vaginal rejuvenation front and the laser and RF companies are increasingly marketing to them as a 'first choice'.

It's clear that female genital rejuvenation is in demand across the board and many clinics are adding it in some form to their services.

One study showed that women are being influenced by increased media attention to the appearance of their genitals. In the study, most participants (95%) frequently examined their own labia minora (LM). Almost half of the participants (43%) found the appearance of their LM important, and 7% had considered LM reduction.

If you extend those number just to your own patient base, you can see that there's plenty of demand if you're positioning and marketing these services correctly.

So what treatment options are available for most cosmetic clinics? Generally they fall into three areas; lasers (ablative and non-ablative), Radio Frequency (RF), and some different modalities around filler injections. Below is some information to get you started, but we'll be following up by providing in depth looks at individual devices, service histories, patient satisfaction and efficacy.

Lasers

Lasers are probably the the most common current treatment modality and we've included a list of some of the players here.

Laser-based devices

FemiLift  |  Alma Lasers  |  Fractional CO2 Laser  |  3 Tx at 4–6 wk intervals

MonaLisa Touch  |  Cynosure  |  Fractional CO2 Laser  |  3 Tx at 6 wk intervals

IntimaLase   |  Fotona  |  2,940-nm non-ablative Er.YAG  |  2 Tx at 8 wk intervals

Petite Lady  |  Lutronic  |  2,940-nm Er:YAG  |  3 Tx at 2 wk intervals

Studies show a pretty good satisfaction by patients with these laser treatments. Ablative lasers (e.g. CO2 and Er:YAG) have lesser side effects based on different research (Vanaman et al., 2016; Karcher and Sadick, 2016). Many patients reveal their sexual activity has improved after the treatment and they are satisfied by the procedure. In one study that explored CO2 to treat-vulvo-vaginal atrophy, there was a 91.7% satisfaction rate among the participants in the study. In the studies we reviewed there are no significant reported complications with ablative lasers but lasers are highly dependent upon the skill level of the clinician so it's hard to say what those rates are in real-world environments.

Non-ablative lasers have shown efficacy as well, but there was one adverse effect: mucosal burn in one study, which eventually healed. We did look at another study that reported that lasers were effective, but a few of the study’s patients that opted out of treatment after a 24-week follow-up due to complications (Gambacciani et al., 2015).

Radiofrequency (RF)

RF is an alternative for lasers and show similar efficacy and patient satisfaction. There are a number of players who are offering this RF tech. (There are others that may not be included here for a variety of reasons.)

None of these treatments require anesthesia, and on average, the treatment duration spans 15 to 30 minutes. Patients report tolerable warmth but usually not pain. There's no down-time and patients can resume their normal activities the same day

Radiofrequency-based devices

ThermiVa  |  ThermiAesthetics  |  Temperature-controlled radiofrequency  |  3 Tx at 4–6 wk intervals

ReVive   |  Viora   |  Bipolar radiofrequency  |  4-6 Tx at 2–3 wk intervals

Venus Fiore   |  VenusConcept   |  Multipolar-radiofrequency with pulsed electromagnetic field  |  3 Tx at 1 wk intervals

Viveve System  |  Viveve Medical  |  Patented radiofrequency  |  1 Tx

Ultra Femme 360  |  BTL Aesthetics  |  Monopolar radiofrequency  |  3-4 Tx at 1 wk intervals

Pelleve   |  Ellman International  |  Monopolar radiofrequency  |  3 Tx at 2–3 wk intervals

Studies here that show that it's a viable treatment modality. Patients responded well to the treatments - there were also some reported complications in these studies - but overall the results are similar that of with lasers.

Study: Radiofrequency treatment of vaginal laxity after baginal delivery: nonsurgical vaginal tightening.Vanaman et al. 2016

Results: No adverse events were reported; no topical anesthetics were required. Self-reported vaginal tightness improved in 67% of subjects at one month post-treatment; in 87% at 6 months (P<0.001). Mean sexual function scores improved: mv-FSFI total score before treatment was 27.6 ± 3.6, increasing to 32.0 ± 3.0 at 6 months (P < 0.001); FSDS-R score before treatment was 13.6 ± 8.7, declining to 4.3 ± 5.0 at month 6 post-treatment (P < 0.001). Twelve of 24 women who expressed diminished sexual satisfaction following their delivery; all reported sustained improvements on SSQ at 6 months after treatment (P = 0.002).

Conclusion: The RF treatment was well tolerated and showed an excellent 6-month safety profile in this pilot study. Responses to the questionnaires suggest subjective improvement in self-reported vaginal tightness, sexual function and decreased sexual distress. These findings warrant further study.

Study: Vaginal rejuvenation using energy-based devices - Karcher and Sadick (2016)

Results: ...Results from the study showed that after 1month, post-treatment self-reported vaginal tightness significantly improved in 67% of subjects and in 87% at 6months. Mean sexual function scores also improved, and no adverse events were reported.

Lastly, in Fistonić et al.’s (2016) work, RF is effective also in non-invasive labial laxity. Similar to vaginal rejuvenation, it improved their participants’ sexual function and satisfaction.

Study: Monopolar Radiofrequency Device for Labial Laxity Improvement - Noninvasive Labia Tissue Tightening - Fistonić et al.’s (2016)

Results: An average 2.9 (of maximum 4) points improvement rate in vulvar appearance was observed (P < 0.01). Mean of the total FSFI score enhanced from initial 75–87% (P < 0.001). Resultant 4.7 (18%) points increase was achieved. Ninety four percent of subjects reported mild to none discomfort during the treatment. No adverse events during the study course were reported.

Conclusion The present study demonstrates the positive effect of focused monopolar RF device for non-invasive labia tissue tightening. The treatment is effective and safe with high patient satisfaction.

In a study conducted by Hamori (2014), the author suggests that three to four sessions per month shall be done to achieve best results and satisfaction.

Possible complications with RF? The reported complications of using RF however include leukorrhea and abdominal discomfort. According to studies, the efficacy of the RF treatment lasts up to 12 months.

Injectables: Filler injections, autologous fat injections

While less commonly used than RF and lasers, injectables treatments (hyalurnonic acid, autologous fat) are being used for genital rejuvenation. These are generally used to increase size of a specific area to decrease laxity rather than 'shrinking' tissue as with lasers and RF. There have been a number of studies on this and these treatments do offer some benefits; reversible, cheaper for patient, no technology costs for clinician.

Study exploring the use of HA for the labia majora: Labia Majora Augmentation with Hyaluronic Acid Filler - Fasola and Gazzola (2016)

Results: A total of 31 patients affected by mild to moderate labia majora hypotrophy were treated with 19 mg/mL HA filler; 23 patients affected by severe labia majora hypotrophy were treated with 21 mg/mL HA filler. Among the first group of patients, one underwent a second infiltration 6 months later with 19 mg/mL HA filler (maximum 1 mL).  A significant improvement (P < .0001) in GAIS score was observed, both in the scores provided by the patients and by the doctor. A greater relative improvement was observed in patients affected by severe hypotrophy. No complications were recorded.

Hexsel et al. (2016) also conducted a similar study using Macrolane VRF 20 (originally used to augment the breasts, which is discontinued by Q-Med due to the side effects). In their study, the researchers injected around 14 to 120mL of soft-tissue fillers on the labia. No adverse complications arose from the treatment.

There are some other treatments that also deserve mentioning here.

G-Spot Amplification: Supposedly a way of increasing sexual gratification, G-spot shots involve injecting HA fillers into that area to increase friction during intercourse. Other fillers (collagen, autologous fat, silicone) have been used but it seems that HA is the most common.

O-Shot: Something different here. O-shots use injections of platelet-rich plasma (PRP) injected into the clitoris and upper vaginal wall, intended to stimulate stem cells to grow new tissue. While there are some patients who express satisfaction, there's not been much study of this.

Most results lead to women feeling more satisfied about how their sexual activity became better, and sexual function has significantly improved. There is still a lack of reported outcomes regarding vaginal rejuvenation using fillers, but if you're in a situation where you're just investigating where these types of treatments might fit in your services offering, fillers may be a place to start.

Thoughts, ideas or comments welcome.

Survey Results: What Are Cosmetic Clinics Interested In?

What are cosmetic clinics looking for? Here's what they said.

A little while ago we emailed a survey to a few hundred physicians to try and understand what topics they were most interested in. (If you were one of the clinicians who responded; thank you.)  While some of the findings seem pretty straightforward. There were a few things that were suprising.

Below are the questions, response percentages, and some thoughts. Note: Not all responeses were from the same physician base.

What information are you most interested in?

No big suprise here. Most clinics think that they do a great job on clinical care and services, a passable job on business operations, but want to know how to get more patients. 

Would you pay for access to new staff (nonclinical) training programs?

Example: An online beginning training course for new staff members; sales, consultations, marketing, customer service, etc.

New staff onboarding is always problematic. Most clinics are small and just throw new staff into the mix to learn on the job, but that inroduces lots of slop in the system. We're going to look at how we might provide some services that help small (and big) clinics implement real operational systems.

Would you consider paying for an operations manual that you could customize to your clinic?

An editable operations manual that allows you to have written procedures for every appointment, job, and task in your clinic.

This question goes hand in hand with the question above. Clinic operations is often a week point and many physicians want an 'office manager' to just handle everything. (Read the free embezzlement and employee theft scams report to see how this can work out.)

Would you consider paying a flat fee of $399/month to have access to ongoing (and unlimited) marketing and advertising resources for your clinic?

For anyone answering yes to this question, check out Tea & Muffins or Frontdesk Marketing who provide advertising, marketing and design services for cosmetic clinics and advertise on this site.

Thoughts

The survey we sent out was in direct response to a number of inboud inquiries requesting some of these services. Knowing if there's real demand allows us to focus on providing information that's actually of use to our members (you). 

So, it looks like there's a fair amount of interest in all of the info/services above, and it's probably worth the effort to souce or find reputable businesses that can provide them. 

Note: If you're business that feels that you can address these areas, please contact us on our parnters page and let us know what you're offering.

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