Injection Techniques for the Hand and Neck

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

Injection Techniques for the Hands

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

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

Data from Lefebvre-Vilardebo (2015)

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

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

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

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

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

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

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

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

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

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

Injection Techniques for the Neck

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

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

Below is the table that further details the study.

Data from: Calisti and Elattar (2017)

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

Pricing Dysport, Xeomin, & Botox in the Aesthetics Market

Can you make money on Botox? Should you switch to Xeomin? The newest information shows that facial fillers and injectables will continue to be the primary physician-based cosmetic treatment (and a primary source of revenue and patient flow).

With Botox, Dysport and now Xeomin targeting wrinkles, and Juvederm, Radiesse, Kybella, Scupltra, and Belotero for volume/fullness, injection based treatments are the initial treatment point of contact for most cosmetic clinics, even those run by surgeons.

With the prevalence of these treatments we thought we'd take a look at the current state of care in the US (the largest single market) since there are a number of new players that are making inroads and taking some market share from the biggest players.

First up; Botox, Dysport and Xeomin.

Botox, Dysport, and Xeomin primarily treat glabellar Lines and lateral orbital rhytids (crow's feet) but they've seen increasing usage around the mouth in some practices. (We do not recommend this unless you're extremely skilled since this can cause some serious problems if you paralyze someone's mouth.)

These treatments are restricted by licence although there have been a number of unlicensed individuals (like this horror story) where individuals were treating patients.

Let's take a look at each.

BOTOX

The big boy in the market, Botox or onabotiliniumtoxinA was approved for cosmetic use in 2002. Approved treatment areas are as follows: hyperhidrosis, migraines, and the neck and chin. It is not limited to those areas as there are other FDA Approved uses in the body (Blepharophasm, Strabismus, and Overactive Bladder). It is used off-label by some physicians to treat other areas.

In 5 major US Cities, the average price of a Botox treatment for a patient is around $400. Botox (10mu) is selling around $400-$525 according to some US physicians and based on pharmacy price but it's much cheaper outside the US. Units used differ depending on the treated area, with a recommended 20 Units for the Glabellar Area, 6 to 20 Units for the Forehead, 4 to 12 for the Crow's Feet.

Many patients find Botox as the most effective in making wrinkles disappear, most are satisfied with their treatments over time, with a 95% Satisfaction Rate among patients. Not all however are mostly satisfied with their procedure, because some have complained making their appearance worse, probably do to the fact that every patient with a new treatment becomes hyper-focused on the mirror. Still, don't be to quick to discount patient reported effects of unevenness, ptosis, and sagging.

According to Mukherjee (2015), Botox is expected to grow to $2.9 Billion by 2018 with the facial aesthetic market to balloon to more than $4 Billion, with the US contributing half of it. (Nice!)

DYSPORT

The teenager Dysport (abobotiliniumtoxinA) entered the market in 2009 and has actually been giving Botox (Allergan) a respectable competitor. In its early release, many were skeptical about its efficacy, strengthening Botox' popularity among patients (possibly do to it's lower cost). However, many studies have shown that Dysport is a fast acting injectable as compared to Botox.

Why choose Dysport over Botox?

In a double-blind study conducted in 2011, Botox and Dysport were used to test ninety patients. Dysport was the better choice to treat crow's feet in the study. The dosage used in the study had 30 Units for Dysport, while 10 only for Botox.

On average, Dysport treatment costs $360 for some major US cities we looked at for Botox. As for the selling price of Dysport to physicians, it is at around $475-$800. According to some physicians, for treatment of crow's feet at least 30 units is used to treat one side, 20-80 for the forehead, and 40-80 units for the glabellar.

Dysport can be an alternative to those who do not find Botox effective. Some prefer Dysport as their neuromodulator of choice due to its longer efficacy. It has been said that due to lesser proteins, Dysport can easily be accepted by the body.

It has proven itself to be a worthy competitor against Botox with a 93% satisfaction rate by Dysport users. On the other hand, it is not all met with praise since it can cause the same side effects to patients that Botox can.

XEOMIN

The new kind on the block. Among the three neuromodulators, Xeomin contains only incobotulinumtoxin A, resulting in some calling Xeomin the 'Naked Botox'. It has no proteins which both the two prior injectables contain, and it requires no refrigeration. Many observe that Xeomin has the slowest onset among the toxins, with results appearing 3-4 days after treatment.

In administering Xeomin, the needle is smaller and the injections are a few centimeters away from each other (less pain?). It also uses only around 10-25 units for one side for crow's feet treatment, 10-15 for the forehead, and 20 for the glabellar. Merz retails a bottle of Xeomin at $466, with some pharmacies selling it at a lower cost around $260 - $300. On average, the treatment of Xeomin to patients is around $355.

Xeomin showed great results for frown lines for most patients, but it's often rated slightly lower by patients in terms of satisfaction. This may be due to actual results, but it's also likely that differing injection techniques by new clinicians who have previous experience with Botox and Dysport, as well as less patient name recognition could be the cause.

As part of this series we're going to do some internal surveys and research into pricing and satisfaction across physicians. If you'd like to be involved and/or have access when we release these results, please make sure that you sign up as a member.

Read the sister post to this on filler injections pricing and satisfaction for clinicians.

Fillers in Men; Reshaping the Face of Masculinity

Guest Post by Dr. Ebtisam Elghblawi, an aesthetic dermatologist in Libya.

Dr. Elghblawi's interview.

Nowadays it is vital to feel confident, self assured and self content about the general look. Face and beauty is always appealing and pursuing beauty is one of the most deeply ingrained human drives as always and as ever.

It has been found that beauty is innate preference as they have noticed a three- months babies were staring for long on beautiful faces.

Over the recent years, demands for medical cosmetic procedures have growing by leaps and bounds, with an immense potential. It has been noticed that the number of patients who is receiving cosmetic has risen. Cosmetic procedures have dramatically increased in popularity over the past two decades in the USA and men newly represent a growing percentage of all consumers, beside women who still make up the main bulk of the filler market.

More than ever, males nowadays are seeking cosmetic procedures for various reasoning. They become more self-concerned and self-conscious to look their best in the impossible quest with the possible available non invasive ways.

This surge could be attributed to the pressure of the media, glamorous lifestyle magazines, and tempting television adverts and offers with movies promoting men’s trendy styles, baby “boomer” male, grooming appealing utilities, and fitness merchandise. This new trend is contributing to the rise of male aesthetic procedures in dermatology.

Men nowadays are much more open and proactive about their appearance and it’s not considered a taboo as it used to. And this can be explained to the reason of quick fix at lunch time with no downtime.

Some men will recognize particular areas of concern to combat, while others point out only the overall aging appearance.

Men generally are less price sensitive comparing to their counterpart women, and are difficult in making follow up appointment and more pain sensitive comparing to women. They want a less bruise work and pain free fix with easier administration.

Men differ from women when it comes to inject their faces, as different methods can be adopted due to the biological, anatomical and behavioural variation aspects.

Men have a squarer face, strong horizontal brow, a more angled and larger jaw, strong chin, and equally balanced upper and lower facial proportions. Thus feminizing men facial features will lead to patient’s dissatisfaction.

Any person per se is considered a piece of art, a sculpture, and herein we are creating an appealing exquisiteness. The face has divine measures. We have to look for an artist for each client faces to achieve what is desired. Also addressing patients’ main expectations and checking out realistic outcomes are the main goal in any successful aesthetic practice.

We have to hand men a large hand held mirror to appreciate and compare the treated and untreated areas.

In many instances some patients do have body ‘dysmorphia’ whereby they never appreciate nor see any positive outcomes even if it was merely subtle. It’s after all, patients own perception of their body and they could just make unnecessary troubles which we should ensure before any procedure to save the hurdles incurred after then.

The general joking says ‘the more fit men are, the worse they look, they look close to death’. As in fact heavy exercise causes fat to exhaust from a destitute area and build up in parts of the face where it conveys an ugly look for men. Many men want that quick subtle make over for their face to be probably ready for action.

In defining unique male characteristics we need to consider certain aspects in order not to feminize men. We have to emphasis on the masculine athletic look. For instance, the projected chin, chiseled jaw, and sculptured men jaw line, and the ‘alpha men’ are the preferable one. After all, men with wide angle, strong face and chin is the picture domain for most men.

There are different ways to approach men face with injectable fillers. In fact injectables are meant to shape the face subtly and not grossly without going under the knife.

Strong chin give the confidence look and adding 1-2 cm projection to the chin would imply as adding few inches to the actual height. In fact it gives the alpha men appearance. Also under eye darkness, bags, puffiness and hollowness would imply a tired look and adding little filler will give the rested and the super refreshed look and more youthful outlook.

Full face filler - subtle augmenting facial features treatment can be the right choice to approach after full face assessment. In fact small changes will give big impact and boost the self confidence and body image. Even nose hump correction, with the under eye, cheek, and chin augmentation would all reflect in one way or another with a positive attitude.

The ultimate aim is not to overuse and just aim to have a subtle favorable improved look. It’s in fact a combination between aesthetic and cosmetic reasoning to stay proactive and trendy.

It’s not favorable to augment men lips though some demand that in the western society in copying some celebrities. After all it’s everyone choice and should consider it from all aspects. However, pouty lips are considered to be sexually attractive by both men and women and certainly a feminine attribute. When augmenting lips in the male patient, under-correction is the rule to be undertaken.

Looking good is important to most people and everyone wish. Facial beauty can be defined by an amalgamation of factors that involve symmetry, visually pleasing and aesthetically pleasing geometrical proportion. After all, men are still only a small portion of most clinician’s total patient population.

The good about cosmetic injections that it offers immediate results with no downtime and thus a quick return to work after the procedure

Cosmetic dermatology continues to offer refined, improved, and new patient aesthetic treatments and desired therapies. Dermatology is a continuous, open-ended practice, and I always strive to perform the greatest procedures to my patients with the wish to enhance and improve the appearance of their skin. In many occasions, a new product and procedure doesn’t always live up to manufacturer’s promotion, expectations or advance reviews. My patient’s consulate me for advice about safety, effectiveness, and the painless performance of desired procedure, to keep them in the look they yearn for.

My greatest reward is when my patients are happy, and exceeded their expectations and improved their self esteem.

My patients in general, want to look younger, natural, refreshed, and vibrant, simply a better version of them and without any downtime.

My current driving passion is detection of skin cancer by the dermatoscope and applying my own skillful knowledge on cosmetic dermatology.

To come to an end, men who desire fillers have their own needs and anticipations. It’s important to optimize men satisfaction with the yielded outcomes. After all cosmetics are utilised to beautify, enhance attractiveness, and sometimes altering one’s look without affecting the underneath structure or functionality. And in order to optimize outcomes - cosmetic approach must be tailored for each patient individually and it’s important to have a proper understanding and a mutual communication to achieve the desired results.

Hyaluronic acids will keep on growing in both male and female patients, and the sole principles of the male face must be well-known as treatment goals in order not to feminize men. Furthermore, symmetry, steadiness, and an harmonious mix are the crucial objectives for delivering perfect treatment.

About the Author

Dr. Ebtisam Elghblawi is a Libyan-based Aesthetic Dermatologist. She is very much passionate in learning more about aesthetic medicine as she progresses in her career.

Submitting a guest post.

Dr. Mohiba Tareen - Tareen Dermatology, Minnesota

In our interview with Dr. Mohiba Tareen, she shares her views about staffing and running a successful dermatology and cosmetic practice.

Name: Dr. Mohiba Tareen
Clinic: Tareen Dermatology
Location: Minneapolis, Minnesota
Website: www.tareendermatology.com

Dr. Mohiba K. Tareen is a board certified dermatologist and dermatologic surgeon. She serves as medical director for Tareen Dermatology, a full service medical, surgical, and cosmetic dermatology practice located in Roseville, Minnesota. Dr. Tareen is proud to be the mother of 4 young and active sons.

About Tareen Dermatology:

Since its inception in 2011, Tareen Dermatology has provided high quality dermatologic care to thousands of patients in the Twin Cities and suburbs of Minneapolis and St. Paul. Dr Tareen trained at University of Michigan in Ann Arbor and Columbia University and also worked at a number of high profile New York City Dermatology practices prior to relocating to Minnesota. The Tareen Dermatology aesthetic practice began as a natural extension of the dermatology practice. It has now grown to employing 5 aestheticians in 2 different locations as well as a total of 4 physician assistants and 40 support staff members (clinic administrator, receptionists, clinical assistants, pharmacy staff, etc).

As a dermatologist, what sparked your interest in cosmetic medicine?

Dermatology and aesthetic medicine are complementary. I trained and worked in New York City for several years before moving to Minnesota. Patients in the midwest were surprised by the minimal and natural approach that I brought to toxins, fillers, lasers and skin care. The practice has grown tremendously as patients know that I will recommend simple and cost effective interventions that will enhance their youthfulness and beauty, while keeping them natural.

Tareen Dermatology prides itself as a comprehensive practice that cares for all aspects and ages of skin and health. I am proud to care for 3 and 4 generations of patients. From a cosmetic perspective, this may translate to chemical peels for a teenager with acne, filler/botox for a middle aged parent, and full face laser resurfacing for the grandmother to rejuvenate the skin. I also care for all of their medical needs.

As the physician, I form the center of the wheel. My four physician assistants work with me to provide excellent medical care. Our aestheticans perform procedures and consults. Our medical assistants make sure patients are comfortable and all their needs are taken care of. I surround myself with the best- a patient recently remarked that Tareen Dermatology is like "Dermatology Disneyland" as we really have such a happy office!

Can you tell us more about you think of and use your staff?

My rule is to always over-staff. My job is much less stressful if we have enough staff. When I enjoy my job, everything always runs more smoothly! Also, I have learned that, these days, most staff only work at any given place for a few years. I used to take it personally when staff left, but now I have changed my perspective and try to feel fortunate that I was able to have a skilled individual for a few years. Most of my staff keep in great touch and it is exciting to see the great things that they go on to do.

You've got a number of lasers, and in some cases more than one of the same kind. Can you give us a run-down of the technology you're using?

We have three Excimer lasers for Psoriasis, three vascular specific lasers, 2 Candela Gentlemax units for hair removal and deep vascular lesions, a fractional and non fractional CO2, 2 coolsculpting machines, and we just purchased an Enlighten laser for tattoo removal!

In general, I prefer specific lasers, not IPL modaliies, as I feel they deliver safer and more predictable results

Most of your marketing is word-of-mouth and based on your exisiting dermatology patients. Is that so?

Our marketing is almost completely internal. We are fortunate to have an audience of 150- 200 dermatology patients who trust us who come into our office every day as well as patients who spread the great work that we do.

My time is money- so the services that I do not have to perform directly- coolsculpting, vascular laser, laser skin tightening, and laser resurfacing- are the most profitable. I still do filler and toxin personally so I always struggle as I likely could make more money seeing medical patients during the time it takes me to do these procedures. However, I do enjoy the artistry and patients love my natural approach!

As a dermatologist whose practice is not entirely cosmetic, what have you learned about practicing cosmetic medicine?

In a medical and cosmetic dermatology office, often the lines can be blurred. Several years ago, we did a full face CO2 on a wonderful patient who had many medical and cosmetic procedures in the past. As she was checking out my assistant presented her with the $2,500 charge. She was confused and said, "Oh, I thought this was medical and we were doing it for my pre-cancer spots!" This taught me that I need to always draw a line between medical and cosmetic. Now, PRIOR to procedures, patients sign a form delineating their charges.

What advice can you impart to your fellow dermatologists or physicians?

Ironically, I was against the significant growth of my aesthetic practice. I thought that it would take away from the legitimacy of my very successful medical and surgical dermatology practice. I resisted the growth and purchase of expensive lasers. My husband, a urologist and my business manager, encouraged me. He said "Mohiba, people know you do good work. They are going to other places now and not getting the results they desire." My husband was correct, and our practice has grown exponentially. I think that if people know you do great work medically, aesthetics is a natural extension. I wish I would have grown my aesthetic practice sooner!

About Dr. Tareen

Dr. Tareen completed her dermatology residency at Columbia Presbyterian Medical Center in New York, New York. During this time, she also lectured extensively and had her work published in a number of prestigious medical journals, including The New England Journal of Medicine. In addition, she was awarded the Conrad Stritzler Award of the New York Dermatological Society while a second year resident.

Dr. Shuba Dharmana - Le Jeune MedSpa, India

Trained as a GP in the UK, Dr Shuba Dharmana runs three clinics in India and has become well-known among a celebrity clientele.

In this interview, Dr. Dharmana discusses her cosmetic clincis, staffing, marketing and working on darker skin types with IPL and lasers.

Name: Dr. Shuba Dharmana MBBS, DFFP, DPD (UK) Associate member of ISHRS (International society of Hair Restoration Surgeons)
Clinic: Le Jeune MedSpa
Location: Hyderabad, Bangalore, and Visag India
Website: www.lejeunemedspa.com

Brief Bio:

I trained and worked as a General Practitioner in the UK for several years for the NHS and in the private sector as an Aesthetic and a slimming specialist.

I worked for the National Slimming and Cosmetic Clinics in the UK in Northampton and Coventry and for several other aesthetic clinics as an injector for Botox and Fillers. I also ran my own clinic ‘Cosmesthetic’ in North London for 2 years before relocating to India. Whilst in the UK I trained under some eminent cosmetic surgeons and got certified to perform various basic and advanced procedures in cosmetology. In 2011, I undertook Hair Transplant training under one of Europe’s most eminent Hair Transplant Surgeons, Dr. Marwan Saifi, in Poland and also completed my post graduate diploma in Clinical dermatology from the university of Cardiff, UK.

I then relocated to India in June 2011 and after working briefly at a hospital heading a dermatology department, branched out on my own and set up my first clinic in Hyderabad. This clinic quickly became very popular with celebrities and socialites with operational break even from first month. Its been 2 years since that I further relocated to another city in India and quickly opened a second clinic in Bangalore and now the third in Vizag. I am an associate member of International Society of Hair Restoration Surgeons and also an ambassador for an NGO that aims to improve education levels in government schools called “Teach for Change’ in Bangalore.

Currently I am working on a unique style of liquid facelift that I call the V3 Lift with fillers that is popular with my celebrity clientele

What made you decide to pursue cosmetic medicine?

I suffered from eczema as a teenager and it prevented me from going into modelling which I had always wanted to do. I was selected as a finalist for Miss India competition but couldn’t compete because of medical exam commitments. I quickly saw how physical appearances matter a lot in this world. It gives you a world of confidence, grows your self esteem and opens up a lot of opportunities. My background in modelling and my skin problem made me realize the value of good skin and beauty.

Throughout my tenure as a GP also I gravitated and favoured to treat skin problems because I could relate to the psychological issues attached with them. When one of my GP colleagues told me about a Botox course I enrolled immediately and once there I realized just how quickly and amazingly medical technology had been advancing. For me there was no looking back since then. One after the other I did all the courses that were advertised in the UK in aesthetic medicine. All the money I kept earning through general practice went into funding my aesthetic training. I got my first job as an aesthetic doctor and slimming specialist at the NSCC and soon offers poured in from all around the country in UK.

Could you tell us more about your clinics?

I am running 3 clinics today in different parts of south India, in Bangalore, in Hyderabad and in Vizag. Since I live in Bangalore, its easier to manage here. The appointments are booked through a practice management software and I get to know about my appointments early in the morning. I have a digital marketing team that assist with Google adwords and social media marketing on twitter, instagram & facebook to get us leads, a PR team that help publish various news articles on latest trends, procedures, etc, a manager and counselor who follows up on the leads, makes appointments, mediates to negotiates payments and essentially helps to convert the lead. In my other centres I have employed doctors and dermatologists who are trained or are being trained by me. They consult all cases and do procedures such as Peels, Prp for hair loss and acne scars, lasers and other procedures they are competent at. Few skilled procedures such as botox, fillers and hair transplants are lined up for me once in 2 -3 weeks and they assist me with these procedures as well. 4-5 days before my arrival the clients are all informed about my dates and clients that particularly want to see me make their appointments with me during those dates.

The services we offer are : Peels, Dermaroller, Vampire facelifts, laser hair removal, Fractional CO2, Fractional RF, Skin brightening and toning with q switched ND Yag, Hydrafcial, O2 Intraceutical facial, RF refirme, Ultherapy, UltraLipo for body contouring, Cool Sculpting, Microdermabrasion, snake venom facial, sheep placenta facial, Scalp micropigmentation, PRP for Hair loss, eyebrow tattooing, Botox, Dermal Fillers, Lipodissolve PPC injections, weight loss programme with nutrition counseling and FUE hair Transplantation.

We see an affluent population as well as a middle class aspirational crowd for most procedures these days. Men want these procedures today as much as women do. Botox and Fillers are taken up quite a lot by the actresses followed by socialites and an expat crowd.

WE have grown into 3 clinics now, in Hyderabad, Bangalore and Vizag , all in the south of India

How do you manage your staff?

The manager who counsels and helps to convert a lead works on a salary and gets an incentive or a commission. If they demand a higher salary they do not get other incentives. We prefer they take a salary along with a commission on the sales so that they retain interest. If it’s a doctor we give them 3 different slabs of salaries with or without commissions. For eg: high salary with no more commissions and lower, basic salary slab with highest commission percentage and something in between with a lesser commission on treatments. I find this plan easiest to use as it gives the member the choice of how they want to work and when they choose to work for salary and commission they feel like this is their own business. The more work they put it the more they get out of it and it works best for everyone. They feel very involved in the business.

What available technologies do you use for your patients?

Most Indians have skin type IV so we invest in diodes. I have 2 of Syneron’s elase with elos technology that uses RF and diode energies. The diode is therefore kept low to avoid burns on dark skinned patients. Its is therefore very safe and very effective. The risk of burns is low but is mainly from the RF aspect when the handpiece is not kept in contact with the skin hence a little operator dependant. I am quite happy with the technology and results but cannot say anything positive about the service issues. You never get the support you are promised after purchasing the laser.

We have Soprano Accord from Alma Laser another diode system for laser hair removal. It is painless and quite effective like the elase but unlike elase’s RF component that can cause burns, this does not cause burns unless you are using grossly wrong settings. It is easier to train a technician on Alma Accord than Syneron’s elase. With regard to results I find Syneron’s superior because the RF component can be increased during the final sittings to target finer hair.

In the Fractional devices I have Fractional Co2 and Fractional RF. Fractional RF allows me to treat skin type IV and above with no risks but with fractional Co2 on skin type IV and above, esp if I want to use higher settings, I prep the skin with a demelanising cream for few weeks before treatment.

For Skin tightening I can try and compare my Ultherapy with RF Refirme. RF refirme does show results but several sittings are needed and then maintanence and results are nowhere as drastic as ultherapy. Ultherapy uses focused Ultrasound technology to lift and induce collagen and I have seen some amazing results. It requires only one sitting and hence Ultherapy treatment can be expensive. RF refirme on the other hand is not expensive and clients can easily afford several sessions. I have had the opportunity to work with Alma’s Clearlift also and I am quite impressed with the results. It falls somewhere in between RF Refirme and Ultherapy.

Alma promises to entice me with some upcoming great powerful lasers and user support but that is something I will have to wait and see. I like Ultherapy, the technology, the results and since they have been very supportive with marketing and training I would like to be associated with them forever. I am not happy with the support Syneron has given me despite buying several of their lasers including 2 elase and 1 e2 system and for this very reason I refuse to buy any more from them.

What are your marketing strategies?

We have a digital marketing team who are working on Google adwords, SEO and social media posts on facebook, twitter and instagram. In this digital age we live in digital marketing is extremely important, much more than traditional newspaper, radio or TV marketing. Everyone I know is hanging out on Instagram or facebook!

Our PR team helps with brand building activities, speaker opportunities, magazine and newspaper publications. I realize PR is very important but it helps in building your brand not in getting you immediate business. Do not expect leads or increase in business immediately from PR activities , it takes time and you should start this later if you cannot afford to do it right away.

Traditional marketing is not working for us anymore. There was a time newspaper advertising worked but not anymore. Radio marketing is also for brand building which did not get us any leads. TV marketing can get very expensive and depending on the area you live in, it may or may not work. If there is too much competition in your area and there are too many clinics advertising on a channel, it gets very expensive. If you are the only one of your kind and from a small town, then you have better chances of getting your audience’s attention.

I support causes that I am passionate about like education for kids in government schools through the NGO ‘Teach for Change’, and sporting and fitness events. Being a fitness enthusiast I get my clinic involved in fitness events like 8K, 10 run events, zumba or Yoga sessions with healthy breakfast, and also conduct beauty, nutrition and skin care workshops to educate groups of interested people. Involving yourself in such activities like charities, social events make people look upto you and notice you. It helps to pick an interest and develop it parallely. It helps to avoid a burn out and boredom. In the process you get to meet many potential clients.

Cconducting workshops, educating people, writing articles, writing books and speaking at events and on TV, radio etc helps people to recognize you as an expert in the field

What are the most sought after treatments or procedures in your clinics?

Hair Transplantation: The investment isn’t much and returns are good even thought t maybe labour extensive. Its also something that needs a lot of skill and hence the justification of profits. Its also highly satisfying to see their face transform. Its something that gives me a lot of joy.

Laser Hair Removal: Here in India dark hair on a darker skin tone makes one look even darker which isn’t liked by anyone. There is a big market for treatments for unwanted hair and this earns us our bread and butter. Ofcourse the investment in a laser is huge but because majority of the population seek this this can me something that is paying your rent and salaries.

PRP: PRP for hair loss is really picking pace. Hair loss issues are many in both women and men and PRP is showing excellent results. Investment is minimal and earns a good revenue

Peels: India has a big market for skin brightening and Peels really sell. Peels are for acne, for lifting Tan, spots, pigmentation, melasma, rejuvenation and they are used by one and all. Minimal investment and good returns

Botox and Fillers: can be good if you have a good celebrity /socialite clientele. In Bangalore I have an expat and socialite crowd that ask for it and in Hyderabad I have actresses, celebrities and socialites

Fractional Treatments: Investment is big in the machine and returns aren’t great. Most people do not want any downtime and they find the treatments expensive. If given a choice they choose dermaroller treatment

Hydrafacial: Good revenue can be generated by acne clientele. Has good scope for marketing with all existing clientele

O2 intraceutical : not really worth the investment but when it is clubbed with other treatments such as microdermabrasion or fractional it can be a luxury experience. So good to give some in a package

Ultherapy: cosumable cost is too high but there is a decent profit to be made if marketed well

Ultralipo: we haven’t done any marketing for it so its not really earning its money. I regret the purchase

E2 system: ematrix sublative fractional RF is good technology with good results but consumable cost is too high hence people find it expensive. We are not using the RF refirme as much as we’d have liked to. I regret the purchase

I am looking to add a Q switched ND yag . we are already working with Alma’s Clearlift and I like it. Investment is huge again but I am positive it will work for us because at large the population here suffers from pigmentation and colour issues and this should be a good source of revenue

Have you had any interesting episodes that you can share with us?

I have not had horrible situations in my clinic thankfully. The time I did have one not so horrible situation was because of a miscommunication as is usually what happens in these scenarios. What I clearly told her would happen and marked and showed was not understood and she expected something else. Although her tear trough area looked great after injecting she wanted it dissolved after few days because she felt it made her eyes look smaller. She was counseled for hyaluronidase injections and the hyaluronidase used that is known to cause allergic reactions caused a reaction. Throughout her treatment and post whilst she suffered the allergic reaction, I kept in touch with her to reassure and support. The reaction took 5 days to subside and she panicked initially but I was there for her. She told me after that how grateful she felt for everything and she even came back twice after that for further filler injections. She is still a good client of mine. When something goes wrong in cosmetic medicine , which maybe your fault or not but its important to not let communication be affected. If I have to put in extra work because of their misunderstanding I do it mostly even if its costing me additional money because for me its not about money. Its about giving them satisfaction and a good experience.

As an experienced physician, what can you share to your fellow physicians?

Good communication skills are key to set treatment goals and keep expectations in check. Showing them some of the before and after pics of treatments you have done allows them to see what they can expect. All concerns should be addressed before they sign a consent form. Get into the habit of taking before and after pictures for their own medical records. Document the procedure well and look for a history of mental health issues and depression. Document post care, hand them some post care instructions with clinic numbers to call in case of any concerns and do not ever neglect someone calling about a concern. The sooner the problem is dealt with the better their options to find a solution. An unhappy client is something you never want and an unhappy client landing in your competitor’s clinic is far worse. Writing bad reviews online and filing law suits are some others you don’t want to face.

About Dr. Dharmana

Dr. Shuba Dharmana is a renowned and experienced Cosmetic Dermatologist & Hair Transplant Surgeon with tremendous international exposure. In March 2012, she established her presence in India with Dr.Shuba Skin & Laser Clinic in Madhapur, Hyderabad.

'Dr. Shuba then founded LEJEUNE Medspa which in a short period of time' has gained tremendous popularity with locals and celebrities alike. Her celebrity clientele consists of several top socialites and famous personalities from the Tollywood and fashion industry.

She trained at several internationally famous cosmetic clinics in London and Ascot under the guidance of world renowned pioneers of Aesthetic medicine. She regularly and religiously attended various seminars, workshops and conferences conducted in UK like 'Faces' and in Monte Carlo 'Anti-Ageing Medicine World Congress'. She became a laser specialist after undergoing several laser training courses in London.

Whilst in United Kingdom, she established and successfully ran 2 clinics - 'The Ultimate Beauty' in Luton and 'Cosmesthetic' in West London. She worked for several private cosmetic clinics including NSCC (National Slimming and Cosmetic Clinics) in Northampton and Coventry for 4 years as a Cosmetic and weight Loss specialist and for 'Novo London' for over a year in Berkhamstead.

Dr. Shuba writes columns and articles regularly for leading magazines and newspapers such as - 'Aesthetic Life'- Pakistan's no.1 aesthetic magazine, 'You & I' magazine, 'Times of India', 'Postnoon', 'AndhraJyothi', 'Deccan Chronicle', 'Deccan Herald', 'Diabetic Living', 'Health India Portal' etc.

2016 Trends: Classic and Elegant Beauty

The year 2016 is predicted to be a time for putting forward a classy, elegant, and modern yet effortless look.

Beauty experts reveal that  the trend is leaning more on the "natural" look as complexions are expected to be taking a softer turn with a subtle quality.

Glowing and luminous skin will be a trend. According to Vogue, the recent call to natural beauty was given a windswept polish this season, with healthy washes of sun-kissed blush at Gucci and Michael Kors Collection meeting the breeze-tousled waves of Versace, Alexander McQueen.

Its all about bright and pouty lips this 2016, with classic reds and browns as "in" lip colors as they balance against a backdrop of a bare skin.

Hairstyles are expected to be going back to basics as natural and effortless look will be in style and buns and ponytails will be given a fresh twist. As they say, less is more.

With these trends, minimally invasive aesthetic procedures are expected to be popular among medspa patients to achieve a more enhanced yet effortless and youthful look.

Non-surgical facelifts, use of autologous fat grafting, botox injections, and fillers are among the procedures that are expected to be a trend in 2016.

Non-invasive procedures which offer less pain and quick recovery are also seen to be popular among patients. 

For more beauty trends in 2016, you may browse: http://www.vogue.com/13359453/top-beauty-trends-spring-2016-fashion-week/.

Radiesse: FDA Approved For Hand Rejuvenation

Radiesse is now FDA approved for "hand rejuvenation".

Radiesse is an FDA approved dermal filler for smoothening out facial wrinkles and facial contouring. Recently, Radiesse got its FDA approval, making it the only FDA-approved filler for the hands although hyaluronic acid has been used by physicans for years.

The product, according to its website, can hide visible bones and tendons, making the hands look more youthful and smooth. Radiesse utilizes a safe gel formula that contains calcium microspheres (CaHA). These can immediately create added volume and then stimulate the body to produce collagen which results in volume augmentation that can last for around a year.

According to board-certified plastic surgeon Dr. Brent Moelleken, MD FACS:

Radiesse is a great option as a filler for hands. It’s safe for all skin types, and leaves no obvious line between the hand and wrist. The hands are the last frontier, so-to-speak, and often give away the true age of a woman.

Depending on the severity of the volume loss, patients should expect to pay for about one to two syringes of Radiesse at an average cost of $800 - $1,200 per syringe for their hands.

Dr. Moelleken adds that because of the product's pliability and softness, it is a great filler which may also be used for deep filling in the face.

Patients are cautioned to seek out experienced and board-certified plastic surgeon in using the Radiesse hand filler because of the many veins, nerves, and arteries in the hand. During the clinical trials, patients showed swelling, redness, bruising and pain in injection sites.

Because of this recent development, cosmetic doctors may now offer enhancement and rejuvenation for both the hands and faces of their patients.

For more information, you may visit:

https://global.radiesse.com/treatment-options/hands#hands

Filler Injections: Achieving the Ideal Lip Shape

Our lips provide competence to the oral cavity when we chew our food. They may also affect sounds and facilitate facial expression which help us communicate what we feel. Lips also have their own aesthetic value.

Earlier this year, the Kylie Jenner Lip Challenge went viral on the internet. People who took the challenge sucked the air out of a glass to create fuller lips that is said to be more attractive. Of course, everything did not go well for others because many attempts ended in painful bruisings and trips to hospitals.

Sucking glass cyclinders did not make Kylie's lips look plump - it was cosmetic enhancement that did it. In an interview with Cosmopolitan magazine, she admitted using a filler and advised others who want a similar look to try a filler that lasts about two to four months, in case they change their mind and want to give it up.

For dermatologists and Medspa owners who work with patients desiring for plump lips, giving advice to patients during patient consultation may boost patient satisfaction rate.

A study in Germany was conducted "to clarify what it is that makes lips attractive - and whether there are gender-related differences of an attractive lip and lower third of the face".

After patients' lip and chin regions were photographed and evaluated by voluntary judges through a Likert scaling system, the results showed that there were certain parameters of the lips that add attractivity of both male and female individuals. Further, gender-related differences were manifested in the form and shape of an attractive lower third of the face.

• There is a significant higher ratio of upper vermillion height/mouth-nose distance in frontal-view images of attractive compared to unattractive female (p < 0.001) and male (p < 0.05) perioral regions.
• Furthermore, the ratio of upper vermillion height/chin-nose distance was significantly higher in attractive than in unattractive female (p < 0.005) and male (p < 0.05) lip and chin regions.
• The nasolabial angle was significantly sharper in attractive compared to unattractive female perioral regions (p < 0.001).
• Attractive female lip and chin regions showed a wider mentolabial angle compared to unattractive female lip and chin regions (p < 0.05).
•  Comparing men and women, we found that attractive female perioral regions showed a higher ratio of lower vermillion height/chin-mouth distance (p < 0.05) and lower vermillion height/chin-nose distance than attractive male perioral regions (p < 0.05).

Read more on: http://www.jprasurg.com/article/S1748-6815(15)00137-0/abstract

Keeping Your Aesthetic Patients Happy Is Good Business

Keeping patients happy makes sense, both to avoid problems and build your reputation and referral base.

Not all patients that state they had a poor experience from another provider are signaling the proverbial red flag. Most of these patients HAVE had an experience of poor treatment outcome.

And to add salt to their wound,the previous treating provider could care less!

We must keep in mind that for most of our patients, coming in for Medical Aesthetic treatments is an exciting and much anticipated experience.

The number one reason patients state they no longer go to their previous provider is, "He was a jerk!" Oddly enough, the number one complaint I hear regarding a female provider is "I had to wait too long." This is not to say there are no female jerks or that patients don’t have to wait too long to see a male provider. These statements are simply the most common that I hear from (from) my patients.

No one is perfect. I don’t care how good you are at fillers, Botox, lasers, and surgery. We’re human, and we have bad days too. Bottom line: If you did achieve a less than desirable outcome, fix it for heaven's sake! With a smile on your face. If you're running more than 15 minutes behind, be prepared to apologize profusely and don't let it happen again. At both our clinics over 50% of our new patients are by referral. The most common reason for these referrals: “They're so nice!” Patients in general have a sense of helplessness when it comes to being treated by a provider. Do not tell a patient what they have to do. This is not life or death nor a dictatorship. Our patients know that we truly love what we do and we care. You don’t have to be all hugs and kisses, but, you'd better have a smile and a few jokes up your sleeve. You must keep in mind that this is the grown up version of a trip to Disneyland. It’s an E ticket ride with a high price tag. This is not an area of medicine of need.

This is completely a "WANT" this treatment situation. We encourage our patients to tell us what they are looking to have done and then offer safe, sane treatment options for them. This gives the patient a greater sense of control, and a decreased sense of possibly being pressured. If they can't afford all of the treatments at one time, what ever you do, never pressure a patient! If they like the one treatment you do and you personally, they’ll be back. And that’s how you keep your patients.