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WHY SHOULD YOU ADD NON-INVASIVE COSMETIC PROCEDURES TO YOUR PRACTICE?
ALTRUISM?INDEPENDENCE?FINANCIAL SURVIVAL?
David M. Duffy, M.D.33nd Annual Superficial Anatomy & Cutaneous Surgery Course, July 11-15, 2016
I have no relevant commercial affiliations
This lecture incorporates PowerPoint slides and information abstracted from lectures and publications by both Dr. Duffy and Dr. Zimmett
Disclosures
Important Questions
Why aren’t many qualified physicians carrying out non-invasive cosmetic procedures?
Why aren’t non-invasive cosmetic procedures taught in most derm programs?
What does the future hold for “traditional” dermatologists? Missed opportunities for improvements in patient care
and financial independence
Many Answers
Adequate training?
Academic and colleague biases?
Lack of interest?
Costs?
Patient Benefits
No one is better qualified to carry out certain types of cosmetic procedures than trained physicians
Patients are being treated by poorly trained individuals in less than optimal circumstances, e.g., “Mall medicine” (sometimes with disastrous results)
The FDA has recently published warnings (regarding blindness with fillers, recommending that patients should be treated by well trained practitioners)
Benefits of Cosmetic Procedures for Your Practice
Protection from declining revenues and reimbursement cuts from managed care
Develop an income stream independent of insurance reimbursement
Taps into a growth segment
Allows you to capture a large percentage of total derm expenditures from your existing patient base
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Bad News From the Untrained “Wrong Filler in the Wrong Hands”
Courtesy Joe Niamtu, M.D.
The Future of American Physicians
More paperwork, less income, more oversight Declining revenues/reimbursement cuts MOHs
surgery compensation and indications are increasingly scrutinized; expect new limits.
Elective procedures will become an increasingly vital component of common dermatologic practices.
Training
Residency Realities
One dermatologist notes that when people came out of school who wanted to do “cosmetics” they were looked down on. At Harvard, they called it “Throwing pearls to the swine. Now in terms of survival it’s what you do.” Steinhauer J. N.Y. Times 1/18/2000
Applicants for Derm Residencies Know Better Than to Show Any Interest in Cosmetic Procedures
Over 95% felt that they would have been rejected for residency programs if they expressed any interest in cosmetic procedures.
50% of dermatologic residents were unprepared for the type of practice they intended to have.
85% feel they should have had more training in cosmetic procedures.
Duffy DM, Torok H, Keeling J. Surveying Cosmetic Procedural Residency Training: Are We Short-Changing Tomorrow’s Dermatologists? A Preliminary Report. Cosmetic Dermatology. Sept. 2008. Vol 21, No 9.
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What’s not being taught in many Residencies
No formal credentialed courses in cosmetic procedures in most derm residencies
No plans to put them in place The relevance of what you are learning as it relates to
the socioeconomic realities of private practice
What Isn’t Being Mentioned
In fact, 90% of many dermatologic practices deal with issues of purely cosmetic importance: Warts, Acne, Hair Loss, Pruritus, Hyperhydrosis and other less than life threatening conditions -Glogau
Lack of training and meaningful credentialing will inevitably lead to inadequate patient care and an increase in preventable complications
Quotes from Academia
Medical dermatology is threatened by “Cosmeticisization”
This trend runs the risk of “marginalizing dermatology in the eyes of both the public and other physicians” Wirth et al. Derm Clinics Vol. 19 Number 4 Oct. 2001
Patient’s choose between health and satisfaction?
Academia Hello Dr. Freud “Cosmetic surgery is not really a requisite for good
health”, “How does it justify its existence as part of a medical profession whose purpose is to promote health?”, “Should patient satisfaction rather than health be the proper goal of medical care”, a “contractual model is not necessarily appropriate for medicine.” Ringel EW Arch. Derm Vol. 134, April 1998.
“Life As A Dermatologic Beautician”
“Fifty years ago dermatologists were considered to be ‘external doctors’ with little knowledge with pathophysiology and whose therapeutic armamentarium consisted of slapping ointments on the skin. Lifestyle will again give us the image of being external.” “From here on it’s only a few steps to the beautician. The end result will be loss of reputation, loss of resources, trivialization, and marginalization of our specialty.
Klaus Wolff, MD, Vienna, Austria 2003
Blindness After Glabellar Artecoll“Simple Filling”
“It takes weeks or even days to learn simple filling” Klaus Wolff, MD, Vienna, Austria 2003
Obviously this physician took Dr. Wolff’s advice to heart.
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Negative peer PerceptionsPublished Opinions
Academic Puritans. Satisfaction is incompatible with health?
“Cosmetic surgery is not really a requisite for good health”, “How does it justify its existence as part of a medical profession whose purpose is to promote health?”, “Should patient satisfaction rather than health be the proper goal of medical care”, a “contractual model is not necessarily appropriate for medicine.” Ringel EW. Arch Derm, Vol. 134, April 1998.
Negative Peer Perceptions
Fifty years ago dermatologists were considered to be ‘external doctors’ with little knowledge with pathophysiology and whose therapeutic armamentarium consisted of slapping ointments on the skin. Lifestyle will not again give us the image of being external.” “From here on it’s only a few steps to the beautician. The end result will be loss of reputation, loss of resources, trivialization, and marginalization of our specialty”. Klaus Wolff, MD, Vienna, Austria 2003
Reality Check
“There is nothing wrong with the pursuit of happiness as a goal of professional medicine”
“The cosmetic dermatologist reaches a therapeutic alliance with the patient” Glogau RG. Arch Derm Vol. 134 Oct. 1998
“There is nothing wrong with the pursuit of happiness as a goal of professional medicine”
“The Cosmetic dermatologist reaches a therapeutic alliance with the patient” Glogau RG. Arch DermVol 134, Oct. 1998
Is Cosmetic Dermatology Inherently Inferior?
Appearance is an essential component of health; a powerful determinant of success in interpersonal relationships.
No one ever died of acne, I’ve rarely found a dermatologist who is not willing to treat it.
Acne is not inherently abhorrent and vitiligo is not a deformity. Glogau 2005
Is Cosmetic Dermatology Inherently Inferior?
Appearance is an essential component of health; a powerful determinant of success in interpersonal relationships.
No one ever died of acne, I’ve rarely found a dermatologist who is not willing to treat it
Acne is not inherently abhorrent and vitiligo is not a deformity.
Real Problems with Cosmetic Dermatology
Peer reviewed literature often presents unrealistic assessments of new technology which cannot be verified by impartial practitioners
There are no established criteria for training or incorporation of new technology/procedures
Fundamentally dishonest and intentionally misleading advertisements are commonplace
Plenty of “hired guns” who promote questionable cosmetic devices and procedures
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The Cosmetic Patient
You will be dealing with a different kind of patient
BDD can be as high as 15% in cosmetic patients
Training for yourself and your staff
Many procedures are demand-driven
There may be an impact on general derm patients
Risk Management of the Cosmetic Patient
Beware of overly demanding patients who were dissatisfied with previous results in other offices. Endless questions
Under promise!
Discuss risks, show before and after photos
Consent forms
Be artful in handling complications
Patient Selection
Expect some reluctance, but not conflict
Are they exaggerating their problem?
Do they have endless questions?
Don’t be afraid to “flunk” a patient and send them out to think it over
Wide Spectrum of Non-Invasive Aesthetic Treatment Options
Spectrum of Aesthetic Treatment OptionsSome require less commitments of time and
resources
Every Dermatologist or qualified physician should carry out at least a few of them
Spectrum of Treatment Options for the Aging Face
Pre surgery Post Surgery
Injectables, fillers, neurotoxins
Lasers RF Ulthera Fillers,Neurotoxins
Laser RF Ulthera
Wrinkles,Volume
Texture, pigment
Laxity, tone
Neck, brow
Maintanence
Three D’s of Aging Skin
Deterioration Fine lines
Brown spots
Telangiectasias
Loss collagen
Deflation Volume loss
Descent Laxity/sagging
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American’s are Getting GrayerAnd More of Them Are Seeking Help for It
Cosmetic Procedures are a Growth Industry
Neurotoxin procedures up 5,407% since 1997
Skin Rejuvenation 1997 – 2014 up 2,900,838%
Percent of Total Nonsurgical Procedures by Age as of 2014
Future patients -
Healthy retireesMen of all agesPeople of color
Cosmetic Procedures A Growth Segment
Growing Demand for Cosmetic Services
From 1997 to 2010 there has been a 700% increase in the number of non-invasive procedures according to ASDS and ASAPS
The Challenges of Volitional Medicine
New role of physicians
Patient satisfaction is important but must be balanced with ethical practice
Success comes from a sound business model as much as from sound medical judgement
Youthful Face
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Multiple Changes in Facial Structure With Time
Changes Over Time
Occur in skin, fat, muscle and bone
Signs of Facial Aging
Lines of expression Frown, forehead, crows
Loss volume Cheeks, Temples Hollowing, sagging
Nasolabial folds Around the mouth & jaw
Vertical lip lines Lips Marionette lines Bone resorbtion Enlargement of eye sockets Solar and chronological
cutaneous effects
Early 20s Late 70s
Facial Aging
Expect Increases in Masculine Concern About Appearance
Cosmetic Procedures now Females / Males 8:1
Considerations – Degree of Involvement
Training/Education
Practice management
Supervising Extenders
Marketing
Incorporating an Aesthetic Product Line?
How many new technologies can you afford and manage?
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Deciding Where to Start
Well established indications, outcomes / risk / benefit ratios
Low initial investment / maintenance costs
Will not require new staff
Will not require extensive advertising, equipment or supplies
FDA approved
Should not require substantially higher malpractice insurance costs
Training should be accessible
Should not rely upon expensive technology / rapid obsolescence
Pro Tip
Best to start with “temporary” agents
Collagen / Hyaluronic acid have clear indications. FDA approved
Well established benefit / risk ratio
Training / Sumposia / hands on training readily accessible
With increasing experience “longer lasting” fillers can be employed
Worth Considering
Fillers Neurotoxins Chemical Peels Micro needling with or without radiofrequency PRP (Platelet Rich Plasma) Deoxycholic acid (Kybella™ - submental fat reduction) Dermasanding (poor man’s dermabrasion) Cosmetic Sclerotherapy
Duffy DM. Cosmetic applications of sclerotherapy. G Ital Dermatol Venereol2011;146:45-63.
Injectables(neuromodulators, volumizers)
Poly-L-lactic acid (Sculptra™) Hyaluronic acid (Voluma™, Bellatero™) Calcium hydroxylapatite (Radiesse™) Silicone (Silikon 1000™) Polymethylmethacrylate (Bellafill™) Botulinum toxin A (Botox™) IncobotulinumtoxinA (Xeomin™) AbobotulinumtoxinA (Dysport™) Deoxycholic acid (in the pipeline - Kybella™)
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Superficial Peels
Alpha-Hydroxy acids
TCA 15-20%
Vitalize® Prepackaged peels
ViPeel® Prepackaged peels
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Peels In A Package
Vitalize Peel® Very Superficial chemical peel
Ingredients-% proprietaryRetinoic Acid 0.3% solution (not included with the peel kit)
Lactic Acid: Alpha-hydroxy acid (AHA) , creates a mild exfoliation, that helps to reduce the appearance of wrinkles and improve skin texture. More suitable for darker pigmented skin typesdue to the lack of irritation
Resorcinol: A synthetic acid. Promote keratolytic effect and anti-inflammatory activity by inhibiting enzymes, responsible for inflammation (Cox -1 and Cox-2)
Salicylic Acid: A beta-hydroxy acid (BHA) lipid soluble agent with keratolytic activity has the ability to penetrate into sebaceous follicles and exfoliate inside the pore as well on the surface of the skin. Salicylic acid is closely related to aspirin (acetylsalicylic acid), and it retains its aspirin-like anti-inflammatory properties.
Panthenol: Pro-vitamin B-5, stimulates cellular growth and aids in tissue repair, has soothing and anti-inflammatory activity
Saponins: Enhances the performance of the active ingredients through it’s penetrating properties
Courtesy SkinMedica Carlsbad, CA
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Peels In A Package
Vitalize Peel®
Cost $35 to provider
SkinMedica Carlsbad, CA
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ViPeel®
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Vi Peel™
TCA
Phenol
Retin-A
Salicylic Acid
Vitamin C
10% each
Cost $50 – $60
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25% Glycolic Peel Combined with Hyaluronic Tissue Augmentation
Photo damage
AHA slow
Multiple treatmentsSlow results
VI Peel™
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Vitalize Peel
10
Vitalize Peel™
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Phenol Peel Lower Lid
Pre peel 30 days post peel
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Dermasanding
Grit coarseness determines depth of abrasion
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Dermasanding
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Dermasanding
25% TCA applied before dermasanding
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Dermasanding
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DermasandingNon Invasive skin Tighteners and Texture and Pigmentary Improvers
Ablative and non ablative CO2, Q-switch lasers
Radiofrequency (Pelleve and others)
Ultrasound (Ulthera)
Fat reduction devices (Ultrasound, and cryotherapy)
Aesthetic Skin Care Line
Dizzying array of options
New products all the time
Claims outpace science
Sunscreens
AHAsRetinoids
PeptidesGrowth Factors
Others
Topical Antioxidants
Solar simulated UVR to back skinSkin biopsies one day later (sunburn cells/mm of epidermis)
Making the Jump
Begin with simple procedures that don’t require a huge cash outlay or extensive training
Expanding Your Cosmetic PracticeStaffing Challenges
Use of physician extenders makes sense for profitability and time savings
They can devote more time to the patients and procedures
You must hire wisely, train constantly and monitor efficiency.
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Hiring Tips
Look for experience, character and communication skills List essential requirements Can’t teach personality Attention to detail Start with phone interview
Grammar, confidence, choice of words, enthusiasm
Interview multiple candidates Involve current staff
Working interview
The Marketing Challenge
Higher costs of equipment and staff means you must maintain volume to stay profitable.
That means active marketing : internal and external
External Marketing
Fliers, Brochures, Posters, Displays
E-Blasts – offers
Special events – Lunch/Learn, Happy Hour, Open House
External Marketing
Website/SEO have an expert
Social media –requires time and content
Traditional media – print, TV, radio, outdoor local
Keep your referral base informed
Tie in to the Buzz of National Media
OnlineMagazines
Television
Strategy
Roll out services one at a time
Budget for equipment over 5 years
Consider the aging face and what it requires
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Fillers and Collagen Stimulators
Immediate results, last 6 – 12 months Types – Hyaluronic Acid, polymethylmethacralate, (etc –
I’ll get them) Collagen stimulators done as a series may last up to 2
years High satisfaction Repeat business Low risk
Key – Select the right product, location, good technique and don’t over correct
What Fillers Can Do
Hyaluronic AcidNasolabial folds and lips
Note improvement in contours of the nasolabial folds and lip volume. In this case, improvement persisted a full year.
Note dimensions, configuration of these flexible broad based scars
Post surgical scar
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Post rhinoplasty defect
Post surgical defect
Dog bite age 4 Pre tx dog bite Silicone +5 years
Kythera (Kybella deoxycholic acid)
A derivative of mesotherapy
Injections of deoxycholic acid fibrose sub-mental fat (double chin)
FDA approved April 2015
Purchased by Allergan for 2.1 billion dollars
An ideal addition to low cost, low tech, suite of cosmetic procedures.
Kybella™
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Platelet Rich Plasma (PRP) Micro needling
Ultherapy™ (Ultrasound Skin Tightening)
Permanent Fillers Rock: But This is for Advanced Practitioners
Pre tx nasolabials, periorbital, oral commissure, lips.
+4 years post silicone
Botulinum Toxin
Expanding Your Practice
Pigment
Texture / resurfacing
Rosacea / telangiectasias
Scarring
Sun Damage
Ablative
Q Switch/Pico
IPL
Fraxel
Pulsed Dye (KTP, 532, Alexandrite, Diodes)
Problems Equipment
Expanding Your Practice
Skin Tightening
Ultrasound-based for face, chin, nek, brows, décolletage
Radiofrequency for face, neck and body
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Expanding Your Practice
Costly equipment that will require aggressive marketing
The cost of consumables
Safety vs. efficiency
Training and use of physician extenders for lengthy treatment - Dermis
- Fibro-muscularLayer
- FatTreatment
Line
Ultherapy
Only FDA-approved treatment to lift skin
Stimulates collagen production
Face, Neck, Décolletage
CONFIDENTIAL – Internal Use Only, Do Not Distribute
Pre-Treatment 120 Days Post Treatment
CONFIDENTIAL –Internal Use Only
UltherapyAge: Early Fifties Radiofrequency
Face Eyes
Mouth
Face
Neck
Combinations
Body Décolletage
Abdomen
Hips/Buttocks
Arms/Thighs
Hands
Radiofrequency
Small Vessel Sclerotherapy
Another Treatment Dear to My Heart
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SLOW PATTERN (FADING)(.2 - .4mm vessels)
Pre-Tx 1 Tx + 25 days + 30 days after 2nd Tx
2nd Tx + 3 mo.
Pigment rare, multiple treatments the rule, “Fading Pattern” common and intrinsic to vessels this size.
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Sclerotherapy isextremely versatile with experience. Benefits canbe derived following thetreatment of a variety ofanatomic sites
Training Options
Botox – Allergan Cosmetic (800) Botox-MDwww.Botoxcosmetic.com
Restylane – Medicis Aesthetics (866) 221-1470www.Medicis.com
Sculptra – (800) 666-6030www.Sculptra.com
Training Options
ASDS – American Society of Dermatologic Surgery (847) 956-0900 www.asds-net.org
AAD – American Academy of Dermatologywww.aad.org
ASCDAS – American Society of Cosmetic Dermatologic and Aesthetic Surgery
www.ascdas.org
ACP – American College of Phlebologywww.phlebology.org
www.DrDavidMDuffy.com
