Selecting New Treatments to Rejuvenate Your Medical Spa
By Cheryl Whitman
Skincare treatments are being developed almost daily. To remain competitive and satisfy patients, determine which offerings will enhance your practice by asking yourself these five questions about any new treatment you’re thinking of starting in your medical spa.
1. Is it effective? Ask the vendor or lab for peer-review studies and the names of dermatologists already offering the treatment. Ask these doctors for their feedback and search the Internet for anecdotal evidence.
2. Is there a market for the treatment? Find out if it is available locally, who offers it and how much it costs. Can you gain a competitive advantage by offering this treatment? Determine the number of local prospects aside from your current patients. Is the market large enough to make a profit? Or is the market niche so limited that you must charge a premium? Create a targeted marketing plan identifying the market and a communication strategy.
3. Does the treatment adhere to your practice objectives? Adding every new treatment under the sun will only complicate your operations and confuse patients. Let your passion, patient needs and revenue goals drive your choice. Don’t buy the latest acne treatment if you’re more interested in anti-aging and treating sun-damaged patients.
4. Will it be profitable? Be sure to consider the additional expenses in staff, overhead, training, marketing and equipment costs. Have your accountant prepare 2 years of profit/loss forecasts for the new treatment. Request a breakdown of equipment expenses from the manufacturer including training, warranties and service along with their associated costs.
If the equipment can be leased, perform a lease versus buy analysis. Financial and tax advantages are obtained by leasing equipment and some vendors will allow you to trade leased equipment for newer models.
5. Could this treatment increase your liability risk? Investigate the legal implications for the treatment by asking your attorney or calling your state’s health department. Does a physician have to perform the treatment or can you delegate it to a technician?
If you are still unclear, seek a medical spa consultant who can evaluate new treatments, inform you of eminent treatments and find cost effective alternatives that yield a higher profit margin.

Cheryl Whitman is the Founder and President of Beautiful Forever, which provides medical spa consulting, training, sales and account management. To contact her, visit www.medicalspaconsultant.com or call (877) SPA-MEDI.

“Facing” Bone Loss
It’s not only sagging skin and shifting fat that can cause rhytids. A new study has found that as people age, they also lose facial bone, which has an effect on hastening the visual aspects of aging.
Researchers, who presented the study results last month at the American Society of Plastic Surgeons (ASPS) annual conference in Chicago, also discovered that women had a more significant decrease in facial bone volume at a younger age than men.
In the study, researchers imaged the facial bones of 30 female and 30 male Caucasian patients using 3-D computed tomography (CT). Ten male and 10 female patients participated in each of three age categories (25-44, 45-64, and 65+).
Researchers used the 3-D CT scans to obtain the following measurements: glabellar angle (maximal prominence of glabella to nasofrontal suture), pyriform angle (nasal bone to lateral inferior pyriform aperture), and the maxillary angle (superior to inferior maxilla at the articulation of the inferior maxillary wing and alveolar arch). Each angle was taken in reference to the sella-nasion line.
Here were some of the specific findings:
• The glabellar angle in the female study participants had a statistically significant decrease from the young to middle age group, while the male population had a significant decrease from the middle to oldest age group. The maxillary angle showed significant decreases between all age groups for both genders, with the angle the greatest in the young age group.
• The pyriform angle did not show significant change between age groups for either gender.
• There was a significant increase in nasal area between all age groups.
• The decrease in glabellar angle found in this study suggests that the supra-orbital bar and nasion recede with age. This bony change may result in the appearance of brow ptosis and lateral orbital hooding noticed in the older population. The eyebrows appear to droop below the receded orbital rim and the upper eyelid skin appears deflated.
• The maxillary angle decrease may be responsible for the malar fat pad sliding down and forward, causing it to push up against the nasolabial crease, thus making it more prominent. The increase in the nasal area makes it evident that the bone recedes around the pyriform aperture, which may result in the appearance of nose elongation and drooping noticed with aging.
These results suggest that the bony elements of the mid face change dramatically with age. Researchers concluded that the most effective approach toward facial rejuvenation should be two-fold: restoring volume to compensate for the loss of bony volume, and lifting and reducing
the aged and less elastic soft tissue envelope.

Evaluating the Effectiveness of an Anesthetic Peel for Laser Hair Removal
Because laser hair removal is a painful procedure, some form of anesthesia is required. A prospectively randomized, double-blind, placebo-controlled study was performed to evaluate the safety and effectiveness of a lidocaine 7% and tetracaine 7% (LT) peel. The peel, a self-occlusive topical local anesthetic, is a eutectic mixture that applies as a cream and when exposed to air dries and forms a flexible membrane that can be easily peeled away from the skin.
For this study, 50 adults undergoing laser-assisted hair removal received concurrent 30-minute applications of the LT peel and the placebo peel randomized to the top/right or bottom/left side of the treatment surface. After study drug removal, laser–assisted hair removal procedures were performed on the designated treatment areas. The primary measure of efficacy was the subject’s evaluation of pain using the 100 mm (0 mm = no pain, 100 mm = worst pain) Visual Analog Scale. Secondary measures of efficacy included patient’s impression of the anesthesia, investigator and independent observer’s separate evaluations of patient pain and investigator’s overall impression.
Results
The LT peel was shown to produce clinically effective anesthesia during laser hair removal procedures by both patient and investigator assessment. Patients, investigator and independent observer evaluations consistently rated the anesthetic efficacy of the LT peel significantly superior to the placebo peel. The LT peel was shown to be safe and well tolerated.

Poster Authors: Tina Alster, M.D., Marta Rendon, M.D., and Jeffrey Adelglass, M.D.

Treating Photodamaged Skin
A multi-center, double-blind, randomized, parallel-group study was performed to compare the efficacy and tolerability of tazarotene 0.1% cream plus hydroquinone 4% cream to that of tazarotene 0.1% cream alone in patients with facial photodamage.
To be included in the study patients had to be between the ages of 30 and 60 years with at least moderate mottle hyperpigmentation, at least moderate overall integrated assessment (OIA) score and Fitzpatrick skin types II, III or IV. Subjects were randomly assigned to receive one of the following, once daily for 24 weeks:
• Tazarotene 0.1% cream (p.m.) and placebo cream (a.m.)
• Tazarotene 0.1% cream (p.m.) and hydroquinone 4% cream (a.m.).
As of publication of the poster, 131 patients had been evaluated with 92% with available data completed. No subjects discontinued treatment due to lack of efficacy, though three discontinued treatment because of adverse events (1 with tazarotene and 2 with tazarotene plus hydroquinone).

Results
Both regimens were found to be highly effective in reducing photodamage. The incidence of patients achieving at least 50% global improvement was significantly greater in patients treated with tazarotene plus hydroquinone than tazarotene alone at weeks 8 through 16. The results were comparable for both groups at week 24 (88% for the tazarotene plus hydroquinone versus 76% for the tazarotene alone group).
The tazarotene plus hydroquinone group had a significantly greater chance of achieving at least a 1-grade improvement in lentigines at weeks 12 through 24 (P<0.01) and mottled hyperpigmentation at week 16 (P<0.05).
Both regimens were equally well tolerated with no significant differences between the groups in the incidence of adverse events.
Researchers concluded that the efficacy of tazarotene 0.1% cream in improving facial dyspigmentation due to photodamage can be enhanced with the adjunctive use of hydroquinone 4% cream.

Poster Authors: Nicholas Lowe, M.D., Stephen Horowitz, M.D., Emil Tanghetti, M.D., Zoe Draelos, M.D., and Alan Menter, M.D.

Laser Treatment House Calls
The American Medical Aesthetics Corp. (AMA Corp.) is making cosmetic skincare house calls with its mobile laser clinic in Southern California. The mobile clinics provide celebrities and high-profile patients with exclusive, hands-on treatments by experienced specialists in the privacy of their own homes. The clinic has treated more than 2,000 patients, including at high-profile events such as the Oscar Suites and the Miss USA pageant (CA division), according to Asher Milgrom, CEO of AMA Corp.
The mobile clinic, which can treat almost everything that can be treated at the AMA Corp’s Centers, is staffed by a medical aesthetician and by the corporation’s Medical Director Alice S. Pien, M.D., who has performed more than 40,000 laser procedures during the past 6 years. The mobile clinic is equipped with half a million dollars of state-of-the-art medical equipment and FDA certified medical lasers, according to the company.
Mobile treatments include permanent hair removal, epidermal laser facial peels, collagen regeneration for wrinkle reduction and vein removal. Age spots, sun damage, spider veins, broken capillaries and rosacea can also be treated. Botox and Restylane treatments are also available. Some services can only be performed at the company’s centers because some lasers are not easily transported.

Clinic Costs
Charges for the mobile clinic are not calculated by individual treatments — the mobile clinic bills by a 1/2 day, 4-hour clinic. For instance, from 9 a.m. to 1 p.m. the half-day clinic costs $6,000.
“This is why in many cases the hosting patient may invite some of her or his friends to take advantage of the presence of the clinic in her or his house. Presumably, the group shares in the cost and thus individual treatments remain quite reasonable,” explained Mr. Milgrom. “Thus the clinic becomes an enjoyable social event. Some of the more wealthy patients prefer total privacy and don’t flinch at footing the entire bill alone.
AMA Corp., which is now focusing on its two full-service Medical Skin Care Centers in California, is reserving the mobile clinic only for special V.I.P. patients, primarily those who want to avoid paparazzi, etc. According to the company, on average, the AMA Mobile Clinic will conduct one to two private V.I.P. clinics per week.

For more information about AMA Corp’s mobile clinic, its Southland locations, holistic laser protocols or educational programs, go to www. AMACorp.com.

New Cooling Device for Laser Hair Removal and Leg Vein Treatment
When treating leg veins and performing hair removal, a new study has found that a novel cooling device can provide a safe, effective alternative, especially for darker-skinned patients.
Authors concluded the proprietary cooling device optimized epidermal safety, side effect profile and fluence delivery associated with treatment of hair removal and vascular lesions, especially in patients with darker (Type IV-VI) skin.
“Our study illustrates that clinical efficacy of an Nd:YAG laser can be improved with efficient epidermal cooling,” said Dr. Narurkar. “The innovative design of the Mydon handpiece allowed us to deliver higher therapeutic energy to the target chromophore, whether a hair follicle or blood vessel, with a relatively high degree of comfort and lack of epidermal damage. This benefit was especially significant for darker-skinned patients (Type IV-VI) who require longer pulse durations.”
The retrospective clinical study was designed to assess the treatment of lower extremity telangiectasia, hypertrichosis and facial telangiectasia in 30 patients of skin types I to VI with a long pulsed 1064 nm laser utilizing a novel cooling tip. According to the authors, most patients reported feeling relatively little pain during the treatment; patients who had treatments with other similar devices reported the pain was much less severe in nature and the application of cold was soothing. None of the patients needed post-procedure analgesia and all were able to resume normal activity immediately after treatment.

Poster Authors: Akhil Wadhera, M.D., Daniel B. Eisen, M.D., Vic Narurkar, M.D., and Emanual Maverakis, M.D.

Study Parameters
Patients were asked to rate pain experienced during and after the treatment on a scale from 1 to 10, 1 being no pain and 10 being the worse pain ever experienced. The mean pain scores were 3.93 for hair removal and 4.38 for vascular lesions. There were no incidences of blistering, pigment alteration, crusting or scarring. The most common side effect reported was temporary erythema lasting a few hours.
For hair removal, 14 patients were treated, predominantly of darker skin type (III-VI). The fluences ranged from 30 J/cm2 to 50 J/cm2 with a pulse duration ranging from 15 ms to 90 ms, depending on skin type and diameter of hair being treated. The spot size used ranged between 7 mm and 10 mm, depending on the area being treated. A clear gel was applied to the area to help improve the cooling and mobility of the handpiece.
For vascular lesions, 16 patients were treated and represented a range of all skin types. The fluences ranged from 150 J/cm2 to 250 J/cm2 with pulse durations between 20 ms and 65 ms. The areas to be treated were covered by a clear gel and spot sizes of 1.5 mm, 3 mm and 5 mm were used, depending on the size and color of the vascular lesion. The maximum size of telangiectasia was limited to 3 mm. Frequency of pulses delivered in both arms of the study ranged from 1 Hz to 1.8 Hz.