Board certified in general and cosmetic surgery, Jerry M. Guanciale DO is operating in Myrtle Beach, South Carolina.
Name: Jerry M. Guanciale, DO, FACOS
Location: Myrtle Beach, SC
That's interesting: Dr. Guanciale was accepted to the American Academy of Cosmetic Surgery fellowship program with the Beverly Hills Cosmetic Surgical Group in Beverly Hills, California. He's been awarded medical licenses in Ohio, Kentucky, South Carolina, Arizona, and California with current active licenses in South Carolina, Arizona, and California.
What attracted you to cosmetic surgery and how did you get started?
While practicing in Myrtle Beach South Carolina, I had the good fortune to be asked by Dr. Steven K. White, a Board Certified Plastic and Reconstructive Surgeon to assist him in his larger plastic surgery procedures. I had, over the years, become somewhat disenchanted with certain trends in General Surgery in which procedures were being introduced that were clearly not changing patient outcomes but were narrowing the scope of my practice by creating multiple subspecialties of General Surgery. I needed something to infuse some vitality into an aging practice and frankly, into the monotony of the diseases and patients I had been treating for nearly two decades.
I applied for and was accepted into an approved AACS cosmetic surgery fellowship with the Beverly Hills Cosmetic Surgery Group in Beverly Hills, CA. The cool thing was, I had no other pressures than to spend all of my time learning aesthetic surgery for an entire year. My program directors, Dr. Fardad Forouzanpour and Dr. David Rahimi made sure of the scope and variety of my training by allowing me to work with anyone in Beverly Hills or the surrounding area that they felt had something more to offer in certain procedures. This included a good deal of time with Dr. Mark Berman and his techniques for facial fat grafting. I spent my last month with Dr. White in Myrtle Beach coming full circle with my training.
Were there changes you had to make when you decided to shift from general surgery into cosmetic surgery? Can you tell us how your clinic is organized? And what treatments are available to your patients?
I fashioned my cosmetic surgery practice in a somewhat different way than I had my general surgery practice. I attempted to narrow my scope of practice to procedures that I felt most comfortable and the ones that I had the opportunity to receive the most experience during my training. Unlike, for instance trauma surgery where you had to be competent in all facets of surgery to obtain a favorable outcome, elective cosmetic surgery allows me to choose patients and procedures that interests me most. I know that I couldn’t learn every facet of aesthetic surgery in one year despite the scope of my training. I remain a solo practitioner with a capable support staff in an office manager and a seasoned esthetician. Our office is about 1600sq. ft. with a dedicated minor procedure room, two exam rooms, and a dedicated aesthetic laser treatment area. The waiting area is more of an educational center with the focus on the procedures we provide as well as skin health, age management, and nutritional support. The primary office is located just outside of Myrtle Beach, SC in Carolina Forest with a second satellite office in Murrells Inlet, SC.
As a resort area, our patients have broad demographics. My cosmetic surgery interests are Laser-assisted Lipolysis, Body and Breast contouring procedures including Fat Grafting, and the full gamut of fillers and neuromuscular agents. I personally perform all of the injections myself, something that I feel gives the patients the knowledge that I “own” my procedures while giving them the opportunity to discuss any other procedure we may offer as a captive audience.
The economy continues to dictate my acceptance of some general surgery procedures like skin cancer treatment, diagnostic and therapeutic upper and lower endoscopy. We routinely see 8-10 new cosmetic patients per week.
Staffing is always something that physicians are interested in. Can you give us some insight into how you hire and manage your staff and the mistakes that you won't allow to happen anymore?
I learned some hard lessons over the course of my career with respect to staff responsibility and oversight. Physicians, especially solo practitioners that came out of their residencies and fellowships without any real-world business experience or the luxury of joining a large established group, are playing an individual game of Survivor. I remember relying on a hospital that had recruited me right out of my residency, to hire my office staff. They were in my office the day I started and I was told had extensive experience in office management. I couldn’t figure why after months of a rapidly growing practice and an ever expanding accounts receivable, I was bringing in very little money. The hospital, despite paying me a guarantee for the initial year of practice could not offer an explanation. I took it upon myself to hire an office manager from another general surgery practice as a consultant. She found a drawer full of EOB’s that had been declined by insurance companies. My office manager admitted that she thought those declined EOB’s were the final determination. She never asked for any assistance in recoding or resubmitting the forms. Lesson learned…right? Wrong.
Seven years later while transitioning between my second and third practice location I hired an office manager to continue to work my accounts receivable from the practice I had just left. Despite a very busy practice, I just didn’t seem to be making much of an impact on my bottom line. She found patient after patient who’s insurance profile showed payment had been satisfied, the EOB’s and daily balance sheet had matched the patient encounters, payments and deposits, and yet there was only sporadic documentation of a patients responsibility for payment. What was eventually found was over $135k (that we could find) in insurance checks that had been cashed by the bank at “my bequest” by my office manager that only had “check depositing” capabilities. This had been going on for two years despite my best efforts to put a system of checks and balance into the front office. Six months earlier I had hired a professional service to audit my books and give me recommendations of best practice changes that would increase my collections. He blamed my stagnant bottom line on the ever declining reimbursements. He pocketed $5k for his efforts and my office manager spent 18 months in a Federal penitentiary. My embarrassment was short-lived as multiple calls came in over the next 6 months asking for assistance from my contacts that prosecuted my employee. This scenario is rampant in medical practices especially practices that have cash as a source of many payments. I guess my point is, you have to take an active position with respect to the front office take on a lot more responsibility with the day to day operations. Just doing surgery doesn’t cut it anymore, nor can it be used as an excuse when you find out your cosmetic practice is being embezzled.
Because my esthetician wears more hats than someone that turns on the laser key, I have attempted to incentivize her with a salary and a generous commission package involving office procedures she performs, sales of skinceuticals, and a percentage of cosmetic procedures I perform in the office. I realize this is not the norm in my area, or across the country for that matter, but I think it makes her feel as if it is her practice as well. Without that package, other practices in the area are continually in a state of chaos with respect to a flux of employees. The area is just too small to have a constant source of safe, capable technicians.
What IPL or laser technologies are you using? What are your thoughts about the technologies you’re using now?
I guess you would call me a Palomar snob. I spent a tremendous amount of time during my fellowship asking a lot of questions about what technologies to contemplate purchasing to augment my newly obtained surgical skills. I was worried about the steep learning curve of some of the modalities especially non-fractional CO2 laser for ablative resurfacing. In one office I was shown a room with about 12 lasers that were no longer in use. I listened to all the hype but took his suggestion to purchase a good IPL platform as an office workhorse and a fractional Erbium laser. I purchased the Palomar Starlux 500 with the MaxG and LuxY handpieces for vascular and pigmented lesions and the LuxR for hair removal.
I had used another platform prior to purchasing the Palomar and had less than satisfactory results. My patients see results with this platform. I have also used the non-ablative Lux1540 for striae and scar treatment as well as facial resurfacing for fine lines and wrinkles. It takes a few treatments to get results that the patients expect but they like the little or no down-time. To round-out the office lasers I purchased a Palomar Q- Yag 5 Laser for tattoo removal.
Choosing a platform for laser-assisted lipolysis was a little more difficult. After using one of the big three during my fellowship I was less than excited with the results. A second platform I actually purchased with another plastic surgeon produced reliable results with good skin-tightening and reliable lipolysis but pushed the safety curve a little too far to the right to achieve my goals. Then I had the opportunity to use the Palomar SlimLipo. It had 2 completely different wavelengths (924/975) then the other lasers, had a continuous pulse, and when placed on a blend mode was so much faster because you didn’t have to retreat after you performed the conventional liposuction to get the type of skin tightening I wanted. My results improved without changing my technique and I felt the safety profile was much better with respect to potential burns fairly common with the 1319 and 1320 wavelengths. I purchased this platform through Palomar’s Energy Program. This gives the practice a significantly lower price for the unit but you have to pay for energy which is delivered as a transferred file that you download into their memory USB drive then transfer the drive to the unit and it downloads the energy. About $1/joule. This really helped me get the technology without a large outlay of money and it’s sort of a use as you go expenditure. The only other disposables are the laser umbilical fiber that if maintained should last about 25 cases and disposable laser tips that come in 3 lengths at about $150 a piece.
So as I had alluded to previously, I love to fat graft. During my fellowship fat preparation consisted of harvest, a gravity decant, pouring of the decanted tumescent fluid and blood, transferring the fat to smaller syringes and injecting it. I suppose I had about a 35-40% take. Most of the patients needed at least 2-3 more treatments to get the results I desired. Toward the end of my training, Dr. Berman began using Lipo-Kit (Medikhan, South Korea). A closed-system tumescent infusion, aspirator, and centrifuge all in one. It made the procedure much more streamlined and with the proprietary filtered plunger system in the syringe that, through centrifugation, compressed the fat allowing more effective separation of the blood and tumescent fluid as well as the damaged, liquefied fat, survival after injection increased approaching 85-90%. Prior to using this technology we would overcorrect about 20% in an attempt to make up for cell death and reabsorption. About a year ago, guess who, (Palomar) bought the rights to distribute the device. The 60cc syringes are expensive, about $100 a piece. So with the ability to prepare and centrifuge up to 4 at a time can make this a little pricey. For physicians that need large volumes of fat rapidly for breast or buttock augmentation this procedure is relatively slow. But the quality of the treated fat is so much better than that obtained without the device.
I guess I continued to purchase the Palomar products because they seem to be (knock on wood) bulletproof. In the two years I have had them, there has been no issues…seriously NONE. They do offer overnight loaners if something does happen and their service contracts are let’s just say a lot less than other companies.
What are essential promotional tips that you have found effective?
Marketing in my practice area has been very challenging. Once again I tried to garnish as much information from my preceptors in Beverly Hills prior to returning back to South Carolina. How soon I found out how very different the marketing strategies had to be. Thank God for my wife who readily accepted this task! First, as a resort/retirement community, with 180 of the Atlantic Ocean limiting our attentive public, the scope of our advertising has to be much more focused. We began with the conventional paper advertising but added the Beverly Hills twist of focusing on a different theme each month and not just publishing the location of the office and the entire list of what we offered, with a picture of the doctor, but tried being briefly informational and witty and offering something eye-catching associated with either the with the witty statement or photo. It worked great. I had people constantly coming up to me stating they saw the ads and how great they were. Here apparently, plagiarism was the best source of flattery because all the mundane ads we had seen for years were now being changed to look like ours. The funny thing was that despite the notoriety, it really didn’t bring people into the office for consults or services. And realized very quickly how much of a marketing budget was devoured by paper ads. We spent $1500/month for a year to advertize in “the” local magazine. We always asked patients where they had heard about us and not one person mentioned that magazine in an entire year! At the same time we buffed the website, and three generations later seem to have a site that is the major source of our non “word-of-mouth” clients.
Our most consistent source of patients have come from word-of-mouth referrals…we are in the south you know! We offer monthly specials, usually IPL, Botox and fillers. We will occasionally offer a significant discount off of surgeon’s fees in larger procedures with, honestly, limited success. We have loyalty programs that work really well with, for instance, 12.5u of Botox free after the 5th treatment. But we still constantly see our patients going to other practices to take advantage of their bargains. People here will drive 30 miles out of their way to get a dollar off a unit of Botox.
As with my general surgery practice, if you take a genuine interest in the people you see, treat them well, offer services that do what you say they do, and give excellent follow-up, they don’t stray very far and usually come back.
What treatments or services are most profitable for you?
There are very few specialties in conventional medicine that can truly be called a business. Let’s face it, if the physician isn’t physically involved in a consult, procedure, or treatment, the practice isn’t making money. Most of us aren’t radiologists being paid to sit in a dark room interpreting a final product with a facility, radiology technicians, support staff, and millions of dollars of diagnostic equipment at their disposal and it costs them nothing. That has changed, albeit a small change by adding IPL, tattoo removal, and skinceuticals to the practice. I can still be performing the surgical procedures and my esthetician as augmenting the practice with her expertise. We have stopped offering hair transplants. To offer the patient that procedure with all of its technical aspects and the time it takes to do the procedure, we were spinning our wheels. I now send those patients to someone that does two and three patients a day.
I am hoping that in the very near future we can add the ablative, fractional handpiece to the Starlux to capture the facial resurfacing patients.
What have you learned in the cosmetic industry? Can you share interesting stories?
During my fellowship, because it was a private practice, my preceptor and I would always do the consults together. I always had the opportunity to ask the patients questions and interject my thoughts during the interview. I had noticed this quite stunning woman and her boyfriend at the desk, a 34 year old patient requesting a breast augmentation. During the course of the consult she had denied any previous surgeries or medical problems. Late in the consult my preceptor realized that he had forgot to inquire about any medications she was taking. When asked she responded, estrogen. I waited a few minutes and inquired about the obviously omitted hysterectomy from her past surgical history. She and her boyfriend looked at me like I had suddenly developed a third eye. My director didn’t even raise an eyebrow. Despite that I persisted. Silence from all parties. She was handed a gown and we left the room to have her change for the exam. In an indignant way I asked my director why he didn’t press her about the total hysterectomy if she was on estrogen with the increased risk of DVT and PE postoperatively. He chuckled and said…”it’s a guy.” I had practiced in the south too long.
I had a 70 year old woman who last year presented to my office for a breast lift with augmentation because of severely asymmetric and ptotic breasts. She was extremely active, lived by herself, traveled, just an all around beautiful woman. She didn’t smoke, and exercised at a gym on a daily basis and never had any children. One thing she requested was not to have that “funny shape” of the breasts when she did her chest exercises that she had seen in women that had had breast augmentation.
Her right breast was severely ptotic, without much volume, the left was much less ptotic but also without volume. Because of her age, but especially the right breast ptosis, I discussed the delayed procedure with her, performing the bilateral mastopexy followed by a subglandular silicone augmentation in 6 months. She refused stating that she was in great health and wanted it all done at one time. Despite my better judgment, and after explaining all the possible risks of performing that procedure to the patient and her continued desire to “give me one shot,” I agreed.
The case went beautifully. The breasts were very symmetrical, with modest volume (the implants were purposely kept small, 220cc range), giving the patient an aesthetically pleasing full C cup size. I personally checked the nipples and areola about a half hour after the case prior to her discharge. Both were pink, with a less than 3 second capillary filling. I saw her back the next day. She thought it would be best to remove her bloody sports bra and place a sports bra she had purchased when she got home that night. When I removed the bra, she had a significant amount of edema on the right breast, less on the left but still significant. Her nipple and areola on the right was very dusky, and a large portion on the left looked the same. I used needles to puncture the areolas and there was some dark venous blood oozing from the sites. I removed the sutures from around the areola on the right but really didn’t see much improvement. I had a sinking feeling…the same feeling I use to get when I saw some bubbles in a pelvis filled of saline while putting air up the rectum after performing a low anterior anastamosis.
Two days later I was removing a completely necrotic nipple, areolar complex on one side and half an areola on the other. I saw her every third day for the next two months. Used a newly developed wound vac that had the wound completely reeipthelized in a little over 1 month. And with the help of my Plastic and Reconstructive friend placed a full thickness skin graft to reconstruct the areola, and learned how to construct a nipple with a Skate flap. Through all of this, I made sure that patient knew I was going to make this right and from our initial conversation about what we were going to do, she had the best comment… ”Shit happens.”
What advice would you give to other physicians based upon your experiences?
Cosmetic surgery patients are so different than the patients I have been use to seeing in my general surgery practice for the last 20 years. For the most part, especially on trauma call, you have no idea what just came through the door, you probably have had no previous interaction with the patient or their family, and the patient is very sick or dying. I have worked in facilities that made the front-line MASH units in Afghanistan look like Baltimore Shock Trauma compared to the OR, the equipment or your support staff. Hell, I did a nephrectomy, partial colectomy, small bowel resection, repaired a hole in a stomach, spleen and a diaphragm on a gunshot victim during a Class 3 Hurricane that had knocked out the electricity and very early in the case, the emergency generators. There were 3 nurses in the pitch black OR holding flashlights for 3 hours. My point is I was forced to treat those patients.
Cosmetic surgery gives you the opportunity to get to know the patient. You need to spend a lot of time trying to figure out their expectations and, more importantly, if you can deliver them. It doesn’t take a wise surgeon very long in his or her career to recognize those short hairs standing up in the back of your neck when you’re in the presence of someone you dislike. Avoid, at all cost, the temptation to do surgery on them. It’s not worth it. Also, if you have a “misadventure” with a patient’s treatment or surgery, even though it may be an accepted complication of the procedure, tell them immediately. Be honest about it and make sure the patient and the family know that you will do everything you can to make sure they continue to get the best care you can provide.
About: Dr. Jerry Guanciale graduated from the Pennsylvania State University in 1979 with a B.S. degree in Biology. Graduating in the top ten percent of his class from the Philadelphia College of Osteopathic Medicine in 1986, Dr. Guanciale completed his rotating internship and General Surgery residency at the Grandview Hospital and Medical Center in Dayton, Ohio. He completed his residency program as Chief Resident in 1991. Dr. Guanciale was extensively trained in trauma and minimally invasive surgery during his residency with subsequent rotations in Colorectal Surgery at the Cleveland Clinic, Cleveland, Ohio, Pediatric Surgery at the Children’s Hospital in Dayton, Ohio and Trauma Surgery at Grant Hospital in Columbus, Ohio. Board certified in General Surgery by the American Board of Osteopathic Surgeons. Dr. Guanciale has been an oral board examiner for the American College of Osteopathic Surgeons since 1993. Prior to completing a fellowship in General Cosmetic Surgery through the American Academy of Cosmetic Surgery, Dr. Guanciale has been a practicing general surgeon since 1991 with special interest in laparoscopic and advanced endoscopic procedures. His interest in surgically underserved areas and his desire to be able to practice all facets of general, vascular, and gynecologic surgery moved him initially to rural Kentucky and, then to South Carolina.
This interview is part of a series of interviews of physicians running medical spas, laser clinics and cosmetic surgery centers. If you'd like to be interviewed, just contact us.