Vibration Anesthesia + Insulin Syringes: Does it make a difference?

Having some yahoo stick needles in your lips hurts. We try to mitigate that using everything from topical anesthetics (the most common), ice, and even nerve blocks, but should we be using vibration anesthesia and/or insulin syringes?

Vibration Anesthesia has been explored since 2004, but it hasn't reached mainstream adoption.

The study also applied topical anesthetic cream to lessen the incidence of pain as well.

Findings:

• 25 patients underwent the procedure
• 92% of patients were comfortable with vibration anesthesia
• The 8% of unsatisfied patients felt more pain and anxiety from the vibrations

Previous studies are also on the positive side of vibration anesthesia.

In conclusion, vibration anesthesia is deemed effective from some other studies. Smith et al. (2004) conducted one of the earlier studies of vibration anesthesia with regard to dermal fillers. The researchers recommended the use of vibration anesthesia for several procedures to help alleviate pain, but it is also suggested to use other methods in producing less pain to the patient.

Another study also explored vibration anesthesia, Mally et al. (2014) showed the efficacy of vibration anesthesia, with around 95% of their participants preferring vibration anesthesia.

What anesthesia works in your practice and for your patients?

In another article, an insulin syringe was used to inject dermal filler on the lips. More and more studies emerge in terms of injection techniques. What about what the needles used for injecting dermal fillers, do they matter as well? 

It is best to consider the consistency of the filler (Urdiales-Gálvez et al., 2017) before going through what needle or cannula to use. Many physicians made the switch from needles to cannulas, simply because of its ability to reduce pain and cause less discomfort to the patient. There is collagen stimulation when a cannula is administered (Brackenbury, 2015). On the other hand, needles are more precise, and a few injection sites would suffice. Bruising is the most common complaint when using needles.
 
Both modes have their pros and cons, but eventually the physician will need to discern, which is much better for dermal fillers.

In one journal article, the researchers found that an insulin syringe is also an effective way to deliver dermal filler injections. Kechichian et al. (2017) used an insulin syringe for lip augmentation. It is a novel method, but the idea is to give the patient more comfort as the injection is administered. Their findings leaned towards the preference of using insulin syringe due to its fine needle.

In the end, it all boils down to the administering of the injection and the comfort of the patient, and the experience of the provider.

Non-Surgical Nipple Reconstruction or Correction Using Dermal Fillers

Using filler injections to treat the areola nipple complex (NAC) after surgery.

Most hyaluronic acid filler studies focused on dermal fillers are about injection techniques and areas of injection in the face, and sometimes the hands, but hyaluronic acid fillers’ other function can also be used in reconstruction. There are only a few cases in using dermal fillers to correct or reconstruct any physical surgical complications.

One case of using dermal fillers was to reconstruct the nipple areola complex, which for some patients, they lose the Nipple Areola Complex (NAC) projection after surgery (Belman et al., 2017).  The article’s case focused on a 49-year-old woman who has undergone a mastectomy, and the researchers observe that sometimes after surgery the NAC suffers from atrophy. As such, the physicians of the study sought to correct the surgery using dermal fillers. A bilateral injection was made on each nipple, and the procedure was a success adding projection after injection.

Key Findings:

• Increase of 1.5-1.6mm on both breasts
• Nipple projection for both breasts are 3.3mm after injection

A similar study was conducted back in 2010 where the researchers used Artecoll to augment the nipple (McCarthy, 2010). It also focused on creating better nipple projection. Twenty-three patients underwent the procedure in the study, and with the use of Artecoll, the mean post-injection was higher than pre-injection.

There was a case wherein a patient had multiple cleft lip and palate surgeries (Stolic et al., 2015). The injection was carried out after biphasic therapy. The researchers mentioned the importance of injection technique when correcting the surgical complications.

Another case involved injectables to reconstruct soft tissue on the ear. In that case, the study’s investigators used Macrolane. The study’s investigators conducted multiple injection sessions to expand the ear needing reconstruction and expansion. There were no reported complications after the treatment sessions.

Despite the studies’ outcomes, adverse effects may arise with the patient, and it could be necessary to follow-up with the patient after a few weeks or months. Bottomline is, dermal fillers help patients give a natural look, if the physician knows what they’re doing. It is important to know injection techniques as well to avoid any complications.

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.

Soft Tissue Fillers May Be Causing Blindness in Patients?

The rising popularity of soft tissue fillers has led to a rise in reports of side effects such as blindess.

The FDA approved the use of soft tissue fillers for the correction of moderate to severe facial wrinkles and skin folds (like the nasolabial folds). Some soft tissue fillers are approved for the restoration or correction of facial fat loss in people with HIV.

But according to the Food and Drug Administration, there are risks associated with the use of these fillers.

 Any soft tissue filler can cause long-term side effects, permanent side effects, or both. However, most side effects associated with soft tissue fillers happen shortly after injection and most go away in less than two weeks.

Swelling and pain after hand treatment may last a month or more. In some cases, side effects may appear weeks, months, or years after injection.

Among the rare side effects reported to the FDA are severe allergic reactions which require immediate emergency medical assistance, migration or movement of filler material from the site of injection, leakage, or rupture of the filler material at the injection site or through the skin (which may result from tissue reaction or infection).

There were also rare reports of formation of permanent hard nodules in the face or hand, vision abnormalities, including blindness, stroke, injury to the blood supply, and damage to the skin or the lips.

Recent reports by the American Society for Dermatologic Surgery, Inc. and published by Wolters Kluwer Health, Inc. showed that with the rising popularity of soft tissue fillers has led to a rise in reports of adverse events.

The study conducted a literature review of the reported cases of blindness after the filler injection. The study also examined some prevention and management strategies that may be done.

The results were as follows:

• 98 cases of vision changes from filler were identified.
• The sites that were high risk for complications were the glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and forehead (12.2%).
• Autologous fat (47.9%) was the most common filler type to cause this complication, followed by hyaluronic acid (23.5%).
• The most common symptoms were immediate vision loss and pain and most of the cases of vision loss did not recover.
• Central nervous system complications were seen in 23.5% of the cases. No treatments were found to be consistently successful in treating blindness. 

Even though the risk of blindness from fillers is rare, researchers concluded that it is critical for injecting physicians to have a firm knowledge of the vascular anatomy and to understand key prevention and management strategies.

For more information: http://journals.lww.com/dermatologicsurgery/Abstract/2015/10000/Avoiding_and_Treating_Blindness_From_Fillers___A.1.aspx

Improved Method for Treatment of Burns

The use of meshed split skin autographs (SSGs) combined with autologous cultured proliferating epidermal cells provided better wound healing and less scarring compared to using SSGs alone.

In a 40-patient clinical trial, researchers from The Netherlands found that such technique provided better results for patients who suffered serious and deep burns. The usual method of treating burns was the use of split skin autographs.

The new technique developed by the researchers used autologous (self-donated), cultured proliferating epidermal cells that were “harvested” from a small donor site, and “seeded” in a collagen carrier that could, in theory, enhance the wound healing rate and improve scar quality.

Dr. Shinn-Zong Lin, Vice-Superintendent for the Center of Neuropsychiatry, professor of Neurosurgery at China Medical University Hospital, and coeditor-in-chief for Cell Transplantationwas quoted saying that this study offers a promising, improved therapeutic method for treating severe burns.

According to Dr. Esther Middelkoop of the VU University Medical Center in Amsterdam, a co-author of the study,

The rate of epithelialization in the experimental treatment was statistically significantly better when compared to the standard treatment. We also established improved pigmentation for the wounds treated with cultured ECs. Scar quality impacts patients’ lives in many ways due to cosmetic and functional concerns.

Additionally, there is a high economic burden on patients due to extended hospital stays and the cost of rehabilitation and reconstructive therapies. Because of this, additional research in burn wound treatment and the improvement of scar quality will always be of the highest priority.

It was revealed that epithelial cells applied to a carrier system could, in fact, reduce wound healing time and improve both short-term and long-term functional as well as cosmetic scar quality.

It was observed that the primary outcome was wound closure after five to seven days, said the researchers. Secondary outcomes were safety and scar quality, which were measured at three and 12 months.

Read more on: http://ingentaconnect.com/content/cog/ct/pre-prints/content-CT-1380_Gardien_et_al

Why Blackberry Failed, And Why Traditional Medicine (And Your Medical Spa) Will Too

The Globe and Mail has an article on the fall of BlackBerry which actually has three authors and takes a deep-dive into the Canadian phone makers woes.... but there's information in there for physicians.

The overarching explanation of what happened is something that we already know: RIM (Blackberry's maker) failed to iterate/change/evleove at anywhere near the speed that the market demanded in the post-iPhone era, but the article, which includes quotes from an interview with RIM founder Mike Lazaridis really puts touches the main point with the tip of a pin. Here's the quote:

“The problem wasn’t that we stopped listening to customers,” said one former RIM insider. “We believed we knew better what customers needed long term than they did. Consumers would say, ‘I want a faster browser.’ We might say, ‘You might think you want a faster browser, but you don’t want to pay overage on your bill.’ ‘Well, I want a super big very responsive touchscreen.’ ‘Well, you might think you want that, but you don’t want your phone to die at 2 p.m.’ “We would say, ‘We know better, and they’ll eventually figure it out.’ ”

Hubris is the fall of many frontrunners and works on every business scale, including individual small business.

You may know better than your patients, but if you don't listen to them and execute what they want, they'll go somewhere else eventually; just ask the droves of plastic surgeons how have lost patients to the familiy practice guys who aren't constantly pushing their patients into surgical proceedures.

Top 5 Male vs Female Non-invasive Cosmetic Treatments

Are men getting more nonsurgical treatments?

With all the talk of men making up a growing percentage of cosmetic treatments, it's just not the case as the infographic above shows.

SIMON Says: “Run Forrest Run!”

Saying ‘No’ to Prospective Cosmetic Medical Patients

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

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

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

Stem Cells & The Vampire Facelift

If you attend medical conferences, or read the trade journals, you’ve no doubt heard about stem cells and their incredible potential in the healthcare industry. These cells have the ability to repair or replace damaged cells, reduce inflammation, and possibly even have a role in disease prevention and cure.

Lately, these cells have been the target of much interest in the cosmetic field. Platelet-rich plasma (PRP) is the portion of the blood that remains after centrifugation has separated out the red cells. This fraction is unusually rich in growth factors and stem cells, that have the ability to repair damaged skin, and act as a long-lasting filler to volumize the face. The PRP is activated using calcium, and then is immediately injected into the donor’s face.

At Canyon Lake MedSpa, we have been using the patented “Vampire Facelift” technique (Regen Labs) in conjunction with standard HA or CHA fillers. We inject the filler using standard technique and then layer the PRP on top. Although still very new to this technique, we believe we are seeing the early effects including improved skin tone and color. Research has documented significant prolongation of filler effect, but we have not been doing this procedure long enough to attest to that yet.

Since we are only minimally manipulating the blood (centrifuging and decanting off the PRP) in a completely closed system, and re-injecting it into the same patient, there is virtually no risk.

In our next article we will discuss, in greater detail, tips on collecting and injecting PRP, how to educate patients and the outcome of our patients’ results.

There has been tremendous interest in the very-well marketed “Vampire Face Lift” and we have experienced an increase in our Med Spa new-patient visits as a result of this interest.

Medical Spa MD: Average 2011 Physician Income By Specialty

Average physician incomes by specialties for 2011

Physician Entreprenurs & Cosmetic Medicine

The Medical Fusion Conference was held this last weekend in Las Vegas.

A number of the physicians that I've interviewed on the Medical Spa MD Podcast were there as speakers, and a number of physicians that I met at the conference are going to be on the podast.

The Medical Fusion Conference is still relatively small. I think there were less than 100 physicians attending.

(There were a few Medical Spa MD Members that I got to say hello to which was very nice. I didn't come close to going bankrupt with my offer to pay for a month of Frontdesk SEO oursource marketing services which I think of with somewhat mixed blessings.)

I'd attended the conference for a number of reasons; Medical Fusion is one of our Select Partners, I wanted to find out what value the conference held for physicians, and I wanted to guage the reaction of the physicians who attended.

Across the board it was all positive. Every physician I spoke to gave the conference two thumbs up and described it as an excellent overview of potential options in non-clinical medicine that had the wheels spinning. One of the take-aways was that every physician is looking for what the military world calls 'actionable intelligence', ways to put these strategies and information into action.

As a result, I'm launching a new site for physicians that want to gain more control of their career, income and lifestyle.

The New Medical Spa MD Podcast

Medical Spa MD now has its own podcast for physicians and medical spas and the first couple of episodes are now live.

I've been looking to start a podcast for Medical Spa MD for a while now, and we've finally launched.

With each new episode, we'll talk about cosmetic medicine, plastic surgery, cosmetic lasers, clinic operations, management, marketing, sales, treaments, cost controls and everything else you'll want to know. We'll be asking (and hopefully answering) the tough questions. How do different cosmetic lasers compare? Which IPL company provides the best service? How should you compensate and motivate your staff? How to market your clinic? Where to spend your advertising budget? How to get started. How to grow. How to compete. Finally, what does that mean for your business and lifestyle?

To start, we're interviewing physicians who discuss their own concept of personal brand and how they've managed their careers outside of clinical medicine. 

In the first episode we talk to Dr. Greg Bledsoe about the Medical Fusion Conference and his desire to help physicians control more of their career. Greg's speaking from experience here. He's a leader in expedition medicine and organizes his other businesses to facilitate the lifestyle and income that he wants.

In episode 2 we're talking with Dr. Elliot Justin of Swift MD about telemedicine and the efficient delivery of medical services remotely. Elliot talks candidly about Swift MD and how company got started and functions operationally. He's also got some views on the state of US healthcare that resonate with almost every other physician I know.

We've already got another few episodes being edited and a long list of physicians and others who are scheduled to appear. My goal is to get out at least one every other week for the foreseeable future.

This new podcast will focus on providing relevant information for physicians, with a special emphasis on cosmetic practices, techniques, marketing, operations and just about everything you'll want to be aware of the field of nonsurgical cosmetic medicine. While we'll have plenty of physician interviews, we'll also be talking to technology companies, marketing gurus, and others about what it takes to run a successful medical practice, and exactly how to use these tactics and operations inside your own clinic. We'll be providing broad overviews as well as delving down into specific treatments and 'how tos'.

The Medical Spa MD Podcast is a permenant addition. You can find it by clicking on the link in the main navigation at the top the page. You'll also be able to subscribe to the RSS feed directly or subscribe via iTunes as soon as they index the feed.

Please leave a comment and let me know what you think. What topics would you like us to cover in the future? What guests would you like us to interview?