Cosmetic Bootcamp Primer
SERIES IN COSMETIC AND LASER THERAPY Series Editors David J. Goldberg, Nicholas J. Lowe, and Gary P. Lask Published in association with the Journal of Cosmetic and Laser Therapy
David J. Goldberg, Fillers in Cosmetic Dermatology, ISBN 9781841845098 Philippe Deprez, Textbook of Chemical Peels, ISBN 9781841842954 C. William Hanke, Gerhard Sattler, Boris Sommer, Textbook of Liposuction, ISBN 9781841845326 Paul J. Carniol, Neil S. Sadick, Clinical Procedures in Laser Skin Rejuvenation, ISBN 9780415414135 David J. Goldberg, Laser Hair Removal, Second Edition, ISBN 9780415414128 Benjamin Ascher, Marina Landau, Bernard Rossi, Injection Treatments in Cosmetic Surgery, ISBN 9780415386517 Avi Shai, Robert Baran, Howard I. Maibach, Handbook of Cosmetic Skin Care, Second Edition, ISBN 9780415467186 Jenny Kim, Gary Lask, Comprehensive Aesthetic Rejuvenation: A Regional Approach, ISBN 9780415458948 Neil Sadick, Paul Carniol, Deborshi Roy, Luitgard Wiest, Illustrated Manual of Injectable Fillers, ISBN 9780415476447 Paul Carniol, Gary Monheit, Aesthetic Rejuvenation Challenges and Solutions: A Global Perspective, ISBN 9780415475600 Neil Sadick, Diane Berson, Mary P. Lupo, Zoe Diana Draelos, Cosmeceutical Science in Clinical Practice, ISBN 9780415471145 Anthony Benedetto, Botulinum Toxins in Clinical Aesthetic Practice, Second Edition, ISBN 9780415476362 Robert Baran, Howard I. Maibach, Textbook of Cosmetic Dermatology, Fourth Edition, ISBN 9781841847009 David J. Goldberg, Alexander L. Berlin, Disorders of Fat and Cellulite, ISBN 9780415477000 Kenneth Beer, Mary P. Lupo, Vic A. Narurkar, Cosmetic Bootcamp Primer : Comprehensive Aesthetic Management, ISBN 9781841846989
Cosmetic Bootcamp Primer Comprehensive Aesthetic Management With DVD Edited by Kenneth Beer MD PA Founding Director Cosmetic Bootcamp West Palm Beach, Florida, USA
Mary P. Lupo MD FAAD Founding Director Lupo Center and Cosmetic Bootcamp and Clinical Professor of Dermatology Tulane Medical School New Orleans, Louisiana, USA
Vic A. Narurkar MD FAAD Founding Director Bay Area Laser Institute and Founding Director Cosmetic Bootcamp San Francisco, California, USA
Disclaimer: This eBook does not include ancillary media that was packaged with the printed version of the book. First published in 2011 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK. Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue, 7th Floor, New York, NY 10017, USA. Informa Healthcare is a trading division of Informa UK Ltd. Registered Office: 37–41 Mortimer Street, London W1T 3JH, UK. Registered in England and Wales number 1072954. © 2011 Informa Healthcare, except as otherwise indicated No claim to original U.S. Government works Reprinted material is quoted with permission. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, unless with the prior written permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP, UK, or the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA (http://www.copyright.com/ or telephone 978-750-8400). Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. This book contains information from reputable sources and although reasonable efforts have been made to publish accurate information, the publisher makes no warranties (either express or implied) as to the accuracy or fitness for a particular purpose of the information or advice contained herein. The publisher wishes to make it clear that any views or opinions expressed in this book by individual authors or contributors are their personal views and opinions and do not necessarily reflect the views/opinions of the publisher. Any information or guidance contained in this book is intended for use solely by medical professionals strictly as a supplement to the medical professional’s own judgement, knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures, or diagnoses should be independently verified. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as appropriately to advise and treat patients. Save for death or personal injury caused by the publisher’s negligence and to the fullest extent otherwise permitted by law, neither the publisher nor any person engaged or employed by the publisher shall be responsible or liable for any loss, injury or damage caused to any person or property arising in any way from the use of this book. A CIP record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data available on application ISBN-13: 9781841846989 Orders may be sent to: Informa Healthcare, Sheepen Place, Colchester, Essex CO3 3LP, UK Telephone: +44 (0)20 7017 5540 Email:
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Contents
Contributors
vii
Preface
ix
Part I
Marketing and Management
1 The role of the aesthetic specialist
1
Kenneth Beer
2 The size and scope of the aesthetic marketplace
2
Neil S. Sadick
3 Aesthetic marketplace economics: Trends and performance of the top performing aesthetic medical procedures
9
Page S. Piland
4 Photography for the aesthetic patient
18
Holly P. Smith
5 Ergonomics for an aesthetic office
36
Steven K. Cordonnier
6 Interviewing the cosmetic patient
39
Susan H. Weinkle and Harriet Lin Hall
7 Red flag patients
43
Timothy Corcoran Flynn
8 Internal marketing
46
Amy Derick
9 Financial benchmarking for the aesthetic medical practice
50
Page S. Piland
10 Form, forms, forms
60
Kenneth Beer
Part II Clinical Cosmetic Patient Care 11 Skin type classification systems: Cosmetic consideration and planning for procedures
79
Wendy E. Roberts
12 When non-invasive is not enough: Limits to individual treatments
85
Roxanne J. Guy
13 Complications A to Z
98
Vince Bertucci
14 Botulinum toxins type A: Advanced techniques
106
Andreas Boker and Fredric S. Brandt
15 Botulinum toxin in the management of focal hyperhidrosis
115
Dee Anna Glaser
Fillers Advanced Techniques 16 One syringe wonder
130
Mary P. Lupo
v
vi
CONTENTS
17 Hyaluronic acid fillers
135
Mary P. Lupo
18 Calcium hydroxylapatite dermal filler for aesthetic correction of face and hands
141
Roberta D. Sengelmann
19 PLLA (Sculptra)
151
Cheryl M. Burgess
20 Permanent fillers
161
Derek Jones
21 Liposuction my way
165
Patricia Wexler
22 Chemical peeling
172
Sue Ellen Cox
Surgical Procedures 23 Aesthetic considerations in facial enhancement: A plastic surgery perspective
184
Julius Few
24 Periorbital rejuvenation utilizing blepharoplasty and adjunctive surgical techniques
189
Craig N. Czyz, Brian S. Biesman, and Jill A. Foster
25 Breast augmentation
209
Clark F. Schierle and Laurie A. Casas
26 Surgical rejuvenation of the neck
215
Anthony P. Sclafani, E. Ashlie Darr, and Ameet Kamat
Lasers and Lights 27 Intense pulsed light
225
Andreas Boker, David H. Ciocon, and David J. Goldberg
28 Fat melting devices
232
Kimberly Finder
29 Ablative fractional laser resurfacing
238
Vic A. Narurkar
30 Non-ablative devices
241
Vic A. Narurkar
31 Cosmeceuticals
245
Jeanine Downie
32 Diverse populations in aesthetics: Young patients
251
Ava Shamban
33 Diverse populations in aesthetics: Male patients
259
Toral Patel and Murad Alam
34 Diverse populations in aesthetics: Ethnic patients
265
Ava Shamban
Index
275
Contributors
Murad Alam Northwestern Medical Faculty Foundation, Chicago, Illinois, USA Kenneth Beer Cosmetic Bootcamp, West Palm Beach, Florida, USA Vince Bertucci Bertucci MedSpa, Woodbridge, Ontario, and University of Toronto, Toronto, Ontario, Canada Brian S. Biesman Vanderbilt University Medical Center, Nashville, Tennessee, USA Andreas Boker University of California San Francisco, San Francisco, California, USA Fredric S. Brandt PA and Dermatology Research Institute, Coral Gables, Florida, USA Cheryl M. Burgess Georgetown University, and Center for Dermatology and Dermatologic Surgery, Washington, DC, USA Laurie A. Casas University of Chicago Medical Center, Chicago, Illinois, USA David H. Ciocon Skin Laser and Surgery Specialists of New York and New Jersey, New York, New York, USA Steven K. Cordonnier Midmark Corporation, Versailles, Ohio, USA Sue Ellen Cox Aesthetic Solutions and University of North Carolina, Chapel Hill, and Duke University, Durham, North Carolina, USA Craig N. Czyz Ohio University College of Osteopathic Medicine, and OhioHealth Doctors Hospital, Columbus, Ohio, USA
Timothy Corcoran Flynn University of North Carolina, Chapel Hill, and Cary Skin Center, Cary, North Carolina, USA Jill A. Foster The Ohio State University, and Eye Center of Columbus, Columbus, Ohio, USA Dee Anna Glaser Saint Louis University School of Medicine, St. Louis, Missouri, USA David J. Goldberg Skin Laser and Surgery Specialists of New York and New Jersey, New York, New York; Sanctuary Medical Aesthetic Center, Boca Raton, Florida; and Mount Sinai School of Medicine, New York, New York, USA Roxanne J. Guy Brevard Plastic Surgery & Skin Treatment Center, Melbourne, Florida, USA Harriet Lin Hall Private Practice of Susan H. Weinkle, Bradenton, Florida, USA Derek Jones Skin Care and Laser Physicians of Beverly Hills, Beverly Hills, and David Geffen School of Medicine, University of California, Los Angeles, California, USA Ameet Kamat The New York Eye and Ear Infirmary, New York, New York, USA Mary P. Lupo Lupo Center, Cosmetic Bootcamp, and Tulane Medical School, New Orleans, Louisiana, USA Vic A. Narurkar California Pacific Medical Center, San Francisco; Bay Area Laser Institute, San Francisco; and University of California Davis School of Medicine, Sacramento, California, USA
E. Ashlie Darr The New York Eye and Ear Infirmary, New York, New York, USA
Toral Patel Chicago Lake Shore Medical Associates, Chicago, Illinois, USA
Amy Derick Derick Dermatology, LLC, Barrington, Illinois, USA
Page S. Piland Core Healthcare Consulting, Windermere, Florida, USA
Jeanine Downie Image Dermatology, P.C., Montclair, New Jersey, USA
Wendy E. Roberts Rancho Mirage, California, USA
Julius Few The Few Institute for Aesthetic Plastic Surgery, and Clinical Associate, University of Chicago, Division of Plastic Surgery, Chicago, Illinois, USA
Neil S. Sadick Weill Cornell Medical College, Cornell University, New York, New York, USA
Kimberly Finder The LipoSurgery Clinic, San Antonio, Texas, USA
Clark F. Schierle Northwestern Plastic Surgery Associates, Chicago, Illinois, USA
vii
viii
CONTRIBUTORS
Anthony P. Sclafani The New York Eye and Ear Infirmary, New York, New York, USA Roberta D. Sengelmann Mohs & Cosmetic Dermatologic Surgery, Santa Barbara, California, USA Ava Shamban Laser Institute for Dermatology and European Skin Care, Santa Monica; Ava MD, Beverly Hills; and UCLA School of Medicine, Los Angeles, California, USA
Holly P. Smith MedPhoto Group, Dallas, Texas, USA
Susan H. Weinkle University of South Florida, Tampa, Florida, USA
Patricia Wexler Wexler Dermatology, P.C., New York, New York, USA
Preface
The Cosmetic Bootcamp Meetings began as a way for colleagues in dermatology, plastic surgery, ophthalmology, and otorhinolaryngology to teach each other in a collegial environment. Cosmetic Bootcamp meetings are designed to provide core physicians (those in the specialties listed above) a forum to exchange ideas, explore new technologies and techniques, and discuss ways to improve patient care. In short, the focus is on advancing the science and outcomes using a multidisciplinary approach. We include each of the core aesthetic specialties at our meetings in addition to this book since we believe that one specialty does not hold all the answers. Moreover, the most interesting courses at each of our meetings are those that include physicians from different specialties to provide their perspective on a single patient issue or aesthetic technique. This book attempts to capture the flavor of these interactions Each chapter has what the editors consider essential information as well as a few “pearls”. The goal of this is to provide the framework to
understand the topic being discussed as well as the most salient, practical aspects of the chapter. While the book cannot provide the interaction that we see in our meetings, it does have an instructional DVD that helps bridge this gap. Following each meeting, the audience gathers to interact and ask questions about each lecture. Unfortunately, this is not possible with a textbook but most of the authors are participants at many meetings throughout the year and the reader is encouraged to ask him or her questions. Future versions of this text will include internet-based interactions that will foster these discussions. For those interested in a more direct interaction, please visit www. cosmeticbootcamp.com to see dates for upcoming meetings.
Kenneth Beer MD PA Mary P. Lupo MD FAAD Vic A. Narurkar MD FAAD
ix
1
The role of the aesthetic specialist Kenneth Beer
The Cosmetic Bootcamp arose from a simple concept asked at a lecture that I was delivering to a group of people attending a cosmetic meeting. An audience member responded to a statement that I made to the effect that the techniques I was discussing were best reserved for those individuals trained during a residency or fellowship to understand the anatomy and technical considerations involved. On the podium, I was asked, “If people can not learn these techniques at a meeting like this, where then should they learn them and what mechanism exists to train esthetic physicians?” Taken slightly aback, I responded that the mechanism, as I understood it, for training cosmetic physicians exists and is known as the residency or fellowship in an appropriate specialty. However, the question made me think about the role of specialists in aesthetic medicine and surgery. Ultimately it was the impetus to create a meeting where we could have an audience comprised of people that had a common level of education and skills and whom we could expose to new ideas that would enable them to advance. Specialists in medicine have traditionally been individuals who have advanced skills and/or training in a particular discipline. As medicine evolved and broader fields became more refined, some of the practitioners were “grandfathered” in as specialists. In dermatology, there are several examples of this, including those dermatologists who became certified as specialists in dermatopathology without taking the certification exam. Plastic surgery, head and neck surgery, and ophthalmology have each branched into several subspecialties whose practitioners have additional training and skills beyond the scope of the daily activities of most of the generalists in the field. In each of these areas, the specialists drive a great deal of the research and advancements in the field. There are now several physicians as well as several more nonphysicians performing cosmetic procedures far different from anything they trained in during their residency. Many of these physicians can perform basic cosmetic procedures such as injecting the glabella with botulinum toxins or spackling the nasolabial creases with soft tissue augmentation products. Some will perform enough procedures and attain the education to excel in these procedures. However, some of these physicians are also delivering babies or taking care of hypertension. While they may perform fundoscopic and otologic examinations, they typically lack the advanced skills of someone trained specifically to deal with these areas. So it is with the specialists in aesthetic medicine. What are the effects of non-specialists treating patients in this field? Usually, the consequences of the treatments are negligible and there should be no implication that specialists are all particularly gifted and free from cosmetic fiascos. One advantage that specialists have is that they typically understand advanced techniques, anatomy, and methods of combining treatments to optimize patient outcomes. Another is that they have frequently worked with other related specialties during the course of their training as well as in practice so that they are able to recognize the limitations of their own specialty and refer to a colleague when appropriate. The role of the dermatologist, ophthalmologist, otorhinolaryngologist, and plastic surgeon should be to assess the various components of aging and provide a roadmap of options for the patient and to
advance the specialties through research and educational activities. In the office, these specialists can help patients discuss the range of treatments available from lasers to intense pulsed lights, chemical peels, botulinum toxins, fillers, volumizers, cosmeceuticals, and surgery. Specialists should be able to discuss these alone and in combinations that are beyond the scope of those not trained during a formal residency or fellowship. Some of these specialists have broad areas of overlap but others do not—for instance, not all of these specialists will perform a facelift or consider themselves experts at injecting. These specialists have a responsibility to help the patient find the right person for their particular need. Specialists also have the responsibility to tell patients what they should not do. For some this means that no amount of botulinum toxins are going to make them look like they did when they were 20; for others, it is the reality that using a cream may be enough to accomplish some of their goals in a gradual, cost-efficient manner. Patients with unrealistic expectations or body dysmorphic disease should be assessed and should not be treated. There are times when they will mask their symptoms and get treated with unfortunate results for all concerned. For physicians who have participated as faculty or authors, the role of specialists in advancing the fields they are in as well as training the next generation of physicians and physician extenders is also a vital facet of their specialty. The leaders in the fields spend countless hours writing and preparing lectures to facilitate the education of their colleagues. One question that arises during any discussion of the role of aesthetic specialists is a salient one: Why bother with aesthetic specialists at all? This is asked by other physicians, medical economists, and patients concerned by the lack of “seriousness” of aesthetic medicine. My own belief is that there are three primary reasons. The first is that, since the beginning of time, man has always sought to improve his or her appearance and aesthetic medicine and surgery is a natural evolution of this process and one that will continue irrespective of what some may think. A second reason is the unintended consequences of the aesthetic technologies that evolve. Lasers once used to treat wrinkles on the face are now routinely used to treat debilitating and disfiguring burns. Fillers may be used to reconstruct areas damaged by trauma, and botulinum toxins are used to treat headaches, myofascial pain, prostate hypertrophy, spasticity associated with cerebral palsy and a host of other medical conditions. The third reason is that many patients that have an aesthetic procedure not only look better but feel better about themselves and have higher self-esteem and job performance. From botulinum toxins to lasers to fillers to breast augmentation, the properly performed procedure in the properly selected patient may significantly improve the quality of that person’s life. Specialists have the obligation to provide treatments better than poseurs. They need to contour the face instead of spackling lines. Perhaps as important is their role in education and advancing the various specialties. This includes training other specialists and students interested in the fields. The goal of any physician is to help patients and advance the field. I would hope that this book encourages readers to take the best care of their patients and educates those who need to be trained.
1
2
The size and scope of the aesthetic marketplace Neil S. Sadick
THE AESTHETIC MARKETPLACE
Aesthetics is a broad field, with physicians and trained clinical professionals of many different interests and areas of expertise. The spectrum ranges from plastic surgeons that perform reconstructive surgery and invasive procedures with lengthy recovery to dermatologists, skilled in non-invasive body contouring, laser/light rejuvenation, and injectables, to aestheticians addressing topical skin concerns and facilitating maintenance. The shared goal of aesthetics professionals is to create beauty and repair damage. However, their diverse education backgrounds and range of expertise create a vast assortment of procedures that are offered for aesthetic purposes. There is a growing demand on the part of the cosmetic consumer for holistic, aesthetic care—that is the integration of surgical and nonsurgical procedures at a medical aesthetic center. At such facilities, often termed medical spas, physicians and aestheticians can align their services into a synergistic platform to satisfy their patients’ desire for a continuum of care.
supervised by a physician, the organization and operation of an aesthetic medical center differs significantly from a typical doctor’s office. Figure 2.1 illustrates the primary difference between a traditional medical practice and an aesthetic practice—the flow and retention of patients. In a traditional model, patients flow into the office via insurance accepted by the physician. In the aesthetic model, patients are selfreferred or referred by friends and family. As such, patients/clients can come through various channels and the practice should promote itself to expand its footprint. The variety of services offered at an aesthetic medical center provides an opportunity for current patients to move up the cosmetic pyramid to more advanced procedures. The goal of any marketing program is to engage patients into the aesthetic practice at the basic level of care (facials, chemical peels, and low risk treatments) when topical and maintenance services are the patients’ primary need (due to age or financial restrictions) and migrate them into other physician administered services including surgery as they require them.
BACKGROUND
The medical spa is a term applied to aesthetic centers that offer services intended to be administered by a medical professional. The designation of “medical spa” attempts to differentiate the facility as more efficacious and therapeutic than commonplace “day spas.” There are several types of medical spas that include those that are run and owned by a physician (typically a specialist in plastic surgery or dermatology) and those that are owned by an entrepreneur with physician as medical director (either on- or off-site). Typical core services offered at most medical spas include microdermabrasion, chemical peels, medical facials, botulinum toxin, injectable fillers, hair removal, and photorejuvenation with laser and light sources. In addition, many medical spas commonly provide body contouring treatments such as cellulite reduction and skin tightening, injection lipolysis, acne treatment, tattoo removal, laser resurfacing, sclerotherapy, and leg vein removal. A few medical spas are also able to offer on-site cosmetic surgery (e.g., rhinoplasty, blephroplasty, brow, and facelifts), liposuction, and laser-assisted lipoplasty (Table 2.1). The Cosmetic Medicine Task Force (1) developed a classification system to educate the public on the outcomes and relative risks of various cosmetic procedures (Table 2.2). For example, “non-invasive” procedures do not penetrate the dermis and pose virtually no risk to health, while “minimally invasive” procedures do penetrate the skin and are associated with a slight health risk. In general, the closer the on-site involvement with a physician, the more likely “aggressive,” or “invasive” procedures are offered. The services offered by medical spas continue to evolve as novel technologies for aesthetic indications continue to be developed. The trend in demand has been toward nonsurgical procedures, and the top 10 patient-requested procedures in 2008 are shown in Table 2.3. It is interesting to note that many of the most popular procedures performed today did not exist 15 years ago or existed in a very early developmental state. For those contemplating expanding their aesthetic menu of services, it is important to stay within the top 10 most requested procedures to stay profitable as well as foresee the emergence of more powerful and efficacious approaches and invest accordingly. The aesthetic industry is projected to increase by 9% a year (2,3) and offers a lucrative and stable opportunity for expansion. Although the aesthetic services in a medical spa are often administered or closely
2
CORE SERVICES
Microdermabrasion Microdermabrasion is an exceedingly popular procedure for superficial skin resurfacing. It achieves improvement in scars, roughness, mottled pigmentation, and overall appearance, but not rhytids. The procedure involves the deposition of microcrystals, usually aluminum oxide (sodium chloride, magnesium oxide, and sodium bicarbonate are other options), on the surface of the skin with rapid strokes of the handpiece (4). Meanwhile, an aspiration tube attached to the handpiece vacuums the crystals and skin debris. The skin depth of the procedure is established by the strength of crystal flow, speed of handpiece movement, and the number of passes of the target region (4). Histology studies of microdermabrasion revealed the following changes: thickening of the epidermis and dermis, flattening of the rete pegs, vascular ectasia and perivascular inflammation, and hyalinization of the papillary dermis with newly deposited collagen and elastic fibers (5). It has been suggested that microdermabrasion produces clinical improvement by inducing molecular changes within the dermis that trigger dermal collagen remodeling and repair. Recent studies have reported that treatment activates the expression of cytokines AP-1, NF-κB, TNF-α, and IL-1β, which collectively serve to upregulate the expression of various connective tissue degrading enzymes (6). There are hundreds of different microdermabrasion machines on the market. In general, a comprehensive listing of available technology can be found in the Aesthetic Buyers Guide, a bi-monthly trade publication. The Food and Drug Administration (FDA) classifies microdermabrasion units as class 1 medical devices. As such, the machines can be sold without demonstration of clinical efficacy and operated without any medical supervision, as long as the procedure only removes the stratum corneum (7). There is a wide variation in the training of providers for this procedure and it is important to be aware that aggressive treatment can cause excesses in exfoliation, increased redness and rosacea, and dermatitis flares. Microdermabrasion is projected to remain a mainstay of “aesthetician-based” adjunctive care. The demand and increasing popularity of the procedure has resulted in the development of at-home microdermabrasion kits, although not as powerful as the technology available in professional aesthetic settings.
THE SIZE AND SCOPE OF THE AESTHETIC MARKETPLACE
Table 2.1 Procedures Offered in Medical Spas Core services
Common procedures
Microdermabrasion Chemical peels Medical facials Botulinum toxin Injectable fillers Hair removal Photorejuvenation
Cellulite reduction Tissue tightening Laser resurfacing Injection lipolysis
Less common medical procedures Sclerotherapy Laser leg vein removal Photodynamic therapy Tattoo removal Cosmetic surgery Liposuction Laser-assisted lipoplasy
Table 2.2 Classification System for Cosmetic Procedures Non-invasive
Minimally invasive
Body wraps Facials Deep-tissue massage
IPL Microdermabrasion Laser hair removal Laser leg vein removal Non-invasive fat reduction (e.g., High-intensity focused ultrasound or low level light therapy) Cellulite reduction
Moderately invasive
Invasive (surgical)
Botulinum toxin Injectable fillers Laser skin resurfacing Chemical peels
Face lifts Rhinoplasty Liposuction Abdominoplasty
Skin tightening (radiofrequency and infrared)
Breast lifts, augmentation, reduction, and reconstruction
Injection lipolysis
Arm and thigh lifts
3
A variety of mild chemical peels are available including glycolic acid, trichloroacetic (TCA) acid, salicylic acid, pyruvic acid, resorcinol, and Jessner’s solution (14% lactic acid, 14% resorcinol, and 14% salicylic acid) (8). Several proprietary peels are available including systems from Obagi and Theraplex (Melbourne, Australia). The indications for chemical peels are similar to microdermabrasion, but with considerable variation in efficacy and improvement based on depth of peel. Mild chemical peels are effective options for treating melasma in type IV-VI skin (9) and are considerably safer for this group than laser chromophore targeting. Moderate-to-deep peels are possible treatment options for patients wishing to target rhytids and achieve some degree of tightening. Medical Facials A facial is the most basic aesthetic service, typically comprising a deep cleaning, skin analysis (via a magnifying loupe), exfoliation (often with steam), extractions, massage, a mask to tighten pores, and moisturizer application. Medical facials could be defined as facials whose primary goal is to effect an improvement on the condition of the skin rather than deep cleaning and relaxation. Medical facials often focus on specific problems such as aging skin, large pores or acne, maintenance for rosacea, reduction of lines or wrinkles, reduction in hyperpigmentation, hydration, or combination of these conditions. The use of physiciandispensed products and a method of penetration that allows ingredients to penetrate more deeply in the dermis are commonly employed. Various methods to improve penetration are stratum corenum removal with chemical agents or microdermabrasion, ultrasonic devices, and heat or suction. Medical facials are mild treatments that do not claim lasting results but are appropriate adjuncts to other procedures and maintain and improve daily skin care regimens.
Sclerotherapy
Table 2.3 Top 10 Requested Procedures in 2008 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Botulinum toxin Laser hair removal Injectable fillers Chemical peels Laser resurfacing Microdermabrasion IPL Sclerotherapy Breast augmentation Liposuction
Chemical Peels Chemical peels are typically used for treatment of acne and enlarged pores, melasma, anti-aging, and to enhance the results of other aesthetic interventions, most commonly laser treatments. Three types of peels are readily available and classified based on the depth of the peel: superficial/mild, medium, and deep. Chemical peels performed in the medical spa are usually of the superficial or “lunchtime” variety without excessive post-procedure downtime. Most medical spas use aestheticians or nurses for the administration of mild chemical peels. The more moderate-to-deep chemical peels should be administered by a physician or under the direct supervision of a physician due to higher potential for adverse events and skin sensitivity.
Botulinum Toxin Botulinum toxin type A or BTX-A (BOTOX, Allergan, Irvine, California, USA; Dysport, Medicis, Scottsdale, Arizona, USA) is a purified complex of the neurotoxin, produced from the bacterium Clostridium botulinum. Originally approved for the treatment of blepharospasm and strabismus, off-label use began to produce reports of cosmetic improvement. Injections of botulinum toxins are frequently the entry point for patients into procedural aesthetic medicine. In 1992, the first published cosmetic study reported that 16 out of 17 subjects had market improvement in glabellar wrinkles after BTX-A injections into the corrugators with results lasting for 3 to 11 months (10). Since then there have been multiple studies validating these effects and establishing optimum dosing guidelines and injection points, as well as demonstrating the prophylactic and anti-aging effects of this treatment (11–14). In April 2002, BOTOX Cosmetic received FDA approval for the treatment of moderate-to-severe frown lines of the glabella. In 2009, Dysport followed receiving the safe FDA approval. Both formulations are used off-label in other areas of the face/neck for aesthetic benefit and have become the most commonly performed cosmetic procedure. With several other formulations of BTX-A currently in development and undergoing FDA approval (e.g., Purogen, Xeotox) including a topical formulation (Reloxin), the market for BTX-A injections is only projected to grow (15). Performing BTX-A injections requires a strong knowledge of anatomy, muscle function, and toxin diffusion patterns in the treatment area. Only dynamic wrinkles that are caused or worsened by muscle movement can be expected to improve with treatment. The most common treatment area is the upper third of the face including periorbital lines, frown lines in the glabella, and transverse lines across the forehead. With experience, providers can also treat vertical lines of the upper lip, jowl contour and platysmal bands, chin dimpling caused by
4
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
Insurance
Appointment scheduled
Office visit
Billing
Retained patients
(A) Advertising
Appt. scheduled
Office visit
Consultation
Promotions No Website
Yes Word of mouth Billing PR
Retained patients
Insurance (B) Figure 2.1 Business models of traditional medicine and aesthetics. (A) Traditional model; (B) Aesthetic medical spa model—yellow diamond indicates the decision to purchase by the patient and the opportunity to convert to billing.
mentalis, muscles exacerbating marionette lines, and other areas of the lower face and neck. Unwanted local effects of BTX-A injection are generally transient. As with any injection, pain, bruising, and infection can occur. The most adverse events—aside from bruising—include asymmetry, headache, and pronounced lateral elevation of the brow. Brow and eyelid ptosis are more severe side effects, which occur in less than 1% of injections and are usually related to technique (16). Injectable Fillers Injectable dermal fillers have experienced a vast surge in popularity since the debut of injectable bovine collagen (Zyderm, Zyplast, Allergan, Irvine, California, USA) in the 1980s. Since then the demand and variety of products offered have only continued to grow with no signs of abatement. The advent of safer, longer lasting agents, as well as the increasing acceptance of and recognition of the significant enhancements that are able to be realized with these procedures strongly contribute to their popularity with both practitioners and consumers. Fillers are frequently the second procedure that cosmetic patients undergo after they have been treated with botulinum toxins and the two procedures are frequently utilized concurrently. Initially intended for the correction of localized and fine facial lines, the current arsenal of products is able to address numerous aesthetic concerns both on and off the face. FDA-approved fillers fall into several classes: hyaluronic acids, collagen-based materials, calcium hydroxylapatite (CaHA), poly-l-lactic acid (PLLA), and polymethylmethacrylate
(PMMA). All fillers are approved for nasolabial fold enhancement; however, many are widely used off-label for other procedures such as lip augmentation, brow elevation, marionette line correction, cheek and tear trough enhancement, and overall volume correction. Developed at the outset as a passive and resorbable correction, fillers have augmented their offerings to provide a biostimulatory and even in some cases permanent response. Biostimulatory fillers include Radiesse (BioForm Medical, San Mateo, California, USA) composed of CaHA microspheres in an aqueous carboxymethylcellulose gel carrier, and Sculptra (Dermik Laboratories, Berwyn, Pennsylvania, USA) composed of PLLA microparticles in a sodium carboxymethylcellulose gel. Both CaHA and PLLA particles are phagocytosed and become surrounded in a capsule of connective tissue cells, macrophages, lymphocytes, mast cells, and foreign body cells (17). As time passes, there is a fibrous-tissue response with collagen deposition providing sustained correction (18). The injection of fillers requires an artistic aesthetic sensibility, excellent eye-hand coordination, and an intimate knowledge of facial anatomy, as necrosis due to vessel occlusion is possible. The necessary skills are difficult to obtain and require much experience. Injectable fillers are recommended for use by experienced dermasurgeons or by physician assistants or nurse practitioners who are under close supervision of a derma-surgeon. Combination treatments with several fillers classes as well as lasers have brought about the nonsurgical or “liquid” facelift—a treatment algorithm focused on global volume enhancement and age-prophylaxis. This sector of aesthetics is projected to experience heavy growth as new products and indications are continuously being developed.
THE SIZE AND SCOPE OF THE AESTHETIC MARKETPLACE Hair Removal Lasers are a popular option in aesthetics for permanent hair reduction. The FDA defines this as “long-term stable reduction in the number of hairs regrowing after a treatment regime” (19). Laser hair removal first became available in the mid-1990s. As with almost all laser technologies, laser hair removal is based on the principle of selective photothermolysis (20). In the case of hair removal, the goal is to heat and destroy the follicular unit without damaging the surrounding tissue. The target chromophore is melanin in the hair follicle. The amount of melanin in hair and skin varies widely between individuals. Therefore, it is crucial to select the appropriate wavelength, spot size, and pulse duration based on the patient’s skin type and hair color for safety and efficacy. The first lasers were only effective in light-skinned and dark-haired patients. Advances in technology have allowed for safe treatments in darker-skinned patients and those with lighter colored hair. There are several different wavelengths and types of devices available, some of the most common offering are:
• •
•
•
• •
Ruby—The ruby laser (694 nm) was the first laser widely used for hair removal (21,22). Although it was effective in lighter skinned patients, it is not used frequently today. Alexandrite—The alexandrite laser (755 nm) was introduced shortly after the ruby and is still used frequently today. Its longer wavelength allowed for deeper penetration and it could cautiously treat some darker skinned patients (23). Studies have reported a reduction up to 50% after only single treatment; and up to 95% hair reduction after multiple treatments, depending upon the number of treatments and body location (24,25). Diode—Treatment of unwanted hair with the diode laser (810 nm) has been demonstrated as comparable to those of the ruby or alexandrite lasers. After a single treatment, hair reduction of about 30% have been reported; and up to 84% reduction with multiple treatments (26). The diode should also be used with caution on darker phenotypes. Nd:YAG—The Nd:YAG laser (1064 nm) is the safest type to treat unwanted hair on patients with dark skin, but the laser does not provide an optimal wavelength for hair removal. Results can be achieved, but higher energies are necessary to achieve results due to lesser affinity with melanin. Reports have shown an improvement of about 50%, depending on the number of treatments administered and body location (27). Intense pulsed light (IPL)—IPL systems have a wavelength range from 550 to 1200 nm. Filters are used to cut off certain wavelengths depending on treatment indications. Bedewi reported a mean hair reduction of 80% after five IPL treatments (28). Intense pulsed light and radiofrequency—The combination of IPL/diode laser with bipolar radiofrequency (RF) is a recently developed dual energy treatment. The hair follicle is pre-heated by light or laser and then RF causes further injury. Because RF does not require a target chromophore, this was the first technology to effectively treat light-colored hair, including white (29,30), albeit at a lower efficacy.
The number of treatments necessary and the interval between treatments are important considerations of laser hair removal and depend on the body area being treated. Only hair in the anagen or growth phase can be effectively treated. Hair in the telogen or catagen phases of rest does not have a mature enough follicle to be treated. The length of time spent in each phase depends on the location of the hair. On the scalp, hair follicles spend up to 10 years in anagen, but on the trunk, brow, and limbs, anagen lasts no longer than 6 months. This variability in hair cycling explains the need for multiple treatments, the correct timing of treatments, and the inability to remove hair 100%.
5
Recently consumer demand has contributed to emergence of at-home hair removal technologies. These technologies are in their infancy and deliver significantly lower energy levels than their professional counterparts. Nonetheless, they present an important evolution of this aesthetic concern and can provide an “entry-level” service for clients who may not be ready for a professional treatment. Photorejuvenation Photorejuvenation refers to the use of lasers and light sources to remove unwanted epidermal pigmentation and reduce upper dermal telangiectasia to improve the texture and tone of the skin. These modalities utilize the principle of photothermolysis with the target chromophores of melanin for pigmentation and hemoglobin for telangiectasia. Several devices in this category have also been reported to improve superficial wrinkles and cause some skin smoothing. IPL is the modality utilized most often for photorejuvenation and nonablative treatment of superficial damage. IPL uses non-coherent polychromatic light (500–1200 nm) to effectively target both melanin and hemoglobin. The minimal risk and virtually no downtime associated with this procedure have contributed to its success. A key IPL study by Bitter (31) showed that serial treatment with IPL visibly improved wrinkling, irregular pigmentation, skin coarseness, pore size, and telangictasias in more than 90% of patients. A newer technology that combines IPL with bipolar RF (electro-optical synergy or el s) was evaluated by Sadick et al. (32) and found to be as efficacious for pigmentation and vascularity but potentially more advantageous for pore size, superficial rhytids, and texture. This difference was caused by the addition of RF, which can penetrate more deeply into the dermis and stimulate collagen remodeling. Other modalities used for photorejuvenation are the pulsed dye laser (PDT 585 nm) and the potassium titanyl phosphate (KTP 532 nm) laser. Both wavelengths effectively target oxyhemoglobin and melanin making them effective at treating red and brown discoloraiton. In a controlled, split face study, Hsu et al. (33) investigated PDT for the treatment of rhytids and reported improvements of surface topography of 9.8% (one treatment) and 15% (two treatments) supported by histologic evidence of collagen remodeling. COMMON SERVICES
Cellulite Reduction Treatment of cellulite can be divided into four main categories: attenuation of aggravating factors, physical and mechanical methods, pharmacologic agents, and laser treatments. Many technologies employed today attempt to improve lymphatic circulation and drainage via negative pressure massage, increase connective tissue to remodel the epidermal–dermal interface, and reduce the size of adipose cells that herniate into the dermal layers. Popular approaches include the use of multi-modality devices to achieve the above aims. The use of bipolar RF, infrared light, and vacuum massage is combined by the VelaShape system (Syneron, Yokneam, Israel). Studies with device have demonstrated the improvement of surface texture, skin tightening as well reduction of circumference of thighs or abdomen (34,35). Other devices that claim to reduce the appearance of cellulite are TriActive (Cynosure, Westford, Massachusetts, USA), a combination of diode laser and massage and SmoothShapes (Eleme Medical, Merrimack, New Hampshire, USA.), a dual wavelength laser with vacuum massage. Recent studies have introduced extracorporeal pulse activation therapy (EPAT) to improve skin elasticity in cellulite. EPAT aims to induce tissue damage through the delivery of high-pressure acoustic energy; this process is followed by dermal remodeling involving recruitment of chemical mediators and neocollagenesis (36).
6
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
Overall the devices for cellulite reduction require multiple treatments (8–16) and ongoing maintenance treatments to maintain effect. The results can be modest with some improvement in contour, reduction of rippling, and slight circumferential reduction. Patients need to be properly informed about procedure timing and maintenance as well as realistic expectations to successfully incorporate this procedure into an aesthetic practice. Tissue Tightening Tissue tightening has been a major force in the aesthetic marketplace since the FDA approval of the first non-invasive treatment for rhytids in 2002. The promise to lift and firm the tissues of the face and body without surgery is an important component of nonsurgical aesthetic rejuvenation. With increasing desire on behalf of the cosmetic consumer for earlier and effective nonsurgical intervention, this sector of aesthetics will see prolific growth and development to become a core aesthetic offering in the near future. Monopolar RF devices designed to uniformly heat the dermis utilizing the tissue’s inherent resistance to current flow initiated the field of tissue tightening. This technology facilitated the creation of thermal zones within the dermis while leaving the epidermis undamaged. Results were associated with a wound-healing response by way of recruitment of heat-shock proteins and inflammatory mediators such as TNF-α, IL-β, and TGF-β (37). Histologic analysis revealed new collagen deposition at 10 weeks post-treatment characterized by increased cellularity and hyaluronic deposits (37–39). Early results with RF were promising but inconsistent and shortcomings led to the development of combination therapy using electrical and optical energies. Today the device offerings have extended to monopolar and bipolar RF, broadband infrared light, bipolar RF with broadband light, and ultrasound. Monopolar RF continues to maintain dominance in this aesthetic indication with the ThermaCool (Thermage, Inc., Hayward, California, USA) being the pacesetter. Thermage has expanded its arsenal of heating tips and products to treat the delicate thinner skin areas of the eyelids and hands, as well originate tips with deeper penetration for targeting the subcutaneous layer and treating the abdomen, flanks, thighs, buttock, and arms. Off-face applications of tissue tightening technologies are commonly employed for post-partum abdomen and laxity after sudden weight loss as well as an adjunct to liposuction. Ultrasound is an emerging modality for tissue tightening. Ultrasound delivers heat to the dermis through the absorption of acoustic energy and the cellular response is thermal damage and subsequent recruitment of specific cytokines and inflammatory mediators similar to RF (40). The Ulthera system (Ulthera, Mesa, Arizona, USA) received FDA clearance for non-invasive tissue tightening in 2009. A study by Alam et al. (41) of patients treated with a single pass at 4.5 mm focal depth and energies of 0.4 to 1.2 J demonstrated at least 0.5 cm improvement in brow elevation in 89% of evaluated subjects. Laser Resurfacing Laser technology is a rapidly growing area of skin rejuvenation and aesthetic improvement. Through different mechanisms, all laser therapies utilize thermal energy to reform and homogenize connective tissue. Initially there is a localized coagulation of collagen fibers for 14 days post-treatment, and this process is followed by new connective tissue synthesis from the thermally altered matrix (42). Histologically fibroblasts may be observed migrating to the affected regions and initiating new collagen formation (43). The entire process is mediated various inflammatory cytokines and culminates in increased elasticity and improved aesthetic appearance of the skin (44). Laser resurfacing began with the ablative devices (CO2 and erbium:YAG) that completely eliminate the epidermis and the upper
layers of the dermis, inducing the formation of a wound. This lesion subsequently reconstitutes an epithelium in approximately 7 to 14 days (45). Although ablative treatment demonstrated unparalleled effectiveness in ability treat sun-induced skin damage, it was associated with significant side effects including delayed erythema and edema, pigmentation abnormalities, significant scarring, and increased risk of infection (46,47). Furthermore, the reepithelization period constituted significant downtime. These challenges lead to the emergence of fractional lasers. Fractional photothermolysis (FP) produces distinct lesions of thermal damage surrounded by larger zones of undisturbed normal skin (48). The combination of lesions and adjacent viable tissue allows for complete reepithelization within 24 to 48 hours and creates an annular configuration of thermal coagulation which enhances tissue tightening because collagen shortening is a three-dimensional mechanism (49,50). The stratum corneum remains undamaged, which greatly reduces the risk of developing an infection and serves to function in exfoliating underlying coagulated tissue, referred to as microepidermal necrotic debris (MEND) (48). Complete regeneration and full clinical benefits of using FP takes approximately three months. The emergence of fractional resurfacing or FP has significantly advanced laser therapy. The potential therapeutic benefits of this revolutionary technology device are only beginning to unravel and many more devices and applications are expected in the near future. Injection Lipolysis Injection lipolysis, also sometimes referred to as mesotherapy, denotes the intradermal injection of multiple chemical substances and lipolytic agents for the purposes of circumferential reduction. The active ingredient appears to be deoxycholate, a detergent that saponifies fat and leads to fat’s absorption by the body. Most of the time the injection cocktail is formulated as a phosphotidylcholine/deoxycholate mixture in various proportions. The mixture is then injected—during multiple sessions—in the target area for fat reduction. While very popular, especially in Europe and South America, this technique is not standardized with most practitioners employing a proprietary mixture to which vitamins and other agents are added. A heavy criticism of this procedure has been a paucity of controlled, double-blind clinical trials supporting the results. This technique is not FDA approved and is performed by practitioners with great variability in experience and education making it a risky course of action without researching the provider. CONCLUSION
In recent years, much progress has been made in technological approaches for aesthetic indications. At the same time, the desire for holistic aesthetic care on behalf of the consumer has driven the emergence of medical spas and aesthetic medical centers offering primary services administered or closely supervised by a physician. Core services such as microdermabrasion, medical facials, photorejuvenation, laser hair removal, and injectables are fixtures at most medical spas, with cellulite reduction, tissue tightening and laser resurfacing becoming increasingly common. The growing demand for safer devices with less downtime as well as less invasive and nonsurgical approaches has led to the development of some innovative therapies. In particular novel devices able to induce thermal damage while sparring the epidermis, either for laser resurfacing or tissue tightening indications, as well as advanced injectables are posed to lead the way in nonsurgical and age-prophylactic aesthetic indications. The trend toward non-invasive approaches assures that further advances in science and technology will serve to create superior services for the aesthetic marketplace.
THE SIZE AND SCOPE OF THE AESTHETIC MARKETPLACE
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23. Garcia C, Alamoudi H, Nakib M, et al. Alexandrite laser hair removal is safe for Fitzpatrick skin types IV-VI. Dermatol Surg 2000; 26: 130. 24. McDaniel DH, Lord J, Ash K, et al. Laser hair removal: a review and report on the use of the long-pulsed alexandrite laser for hair reduction of the upper lip, leg, back, and bikini region. Dermatol Surg 1999; 25: 425. 25. Bouzari N, Nouri K, Tabatabai H, et al. The role of the number of treatments in laser-assisted hair removal using a 755 nm alexandrite laser. J Drugs Dermatol 2005; 4: 573. 26. Lou WW, Quintana AT, Geronemus RG, et al. Prospective study of hair reduction by diode laser (800 nm) with long-term follow up. Dermatol Surg 2000; 26: 428. 27. Tanzi EL, Alster TS. Long-pulsed 1065 nm Nd:YAG laser-assisted hair removal in all skin types. Dermatol Surg 2004; 30: 13. 28. Bedewi AF. Hair removal with intense pulsed light. Lasers Med Sci. 2004; 19: 48. 29. Goldberg DS, Marmur ES, Hussain M. Treatment of terminal and vellus non-pigmented hairs with an optical/bipolar radiofrequency energy source with and without pre-treatment using topical aminolevulinic acid. J Cosmet Laser Ther 2005; 7: 25. 30. Sadick NS, Laughlin SA. Effective epilation of white and blond hair using combined radiofrequency and optical energy. J Cosmet Laser Ther 2004; 6: 27. 31. Bitter P. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg 2000; 2: 59. 32. Sadick NS, Alexiades-Armenakas M, Bitter P, et al. Enhanced fullface skin rejuvenation using synchronous intense pulsed optical and conducted bipolar radiofrequency energy (ELOS): introducing selective photothermolysis. J Drugs Dermatol 2005; 4: 181. 33. Hsu T, Zelickson B, Dover J, et al. Multicenter study of the safety and efficacy of a 585 nm pulsed-dye laser for the nonablative treatment of facial rhytids. Dermatol Surg 2005; 31: 1. 34. Waniphakdeedecha R, Manuskiatti W. Treatment of cellulite with bipoal radiofrequency, infrared heat, and pulsatile suction device: a pilot study. J Cosmet Dermatol 2006; 5: 284. 35. Sadick N, Magro C. A study evaluating the safety and efficacy of the velasmooth system for the treatment of cellulite. J Cosmet Laser Ther 2007; 9: 15. 36. Christ C, Brenke R, Sattler G, et al. Improvement in the skin elasticity in the treatment of cellulite and connective tissue weakness by means of extracorporeal pulse activation therapy. Aesthet Surg J 2008; 28: 538. 37. Zelickson B, Kist D, Bernstein E, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency based nonablative dermal remodeling device. Arch Dermatol 2004; 140: 204. 38. Hantash B, Ubeid A, Chang H, et al. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis. Laser Surg Med 2009; 41: 1. 39. Hodgkinson D. Clinical application of radiofrequency: nonsurgical skin tightening. Clin Plast Surg 2009; 36: 261. 40. Laubach HJ, Makin AR, Barthe PR, et al. Intense focused ultrasound: evaluation of a new treatment modality for precise microcirculation within the skin. Dermatol Surg 2008; 34: 727. 41. Alam M, White L, Martin N, et al. Ultrasound tightening of facial skin: a rater-blinded prospective cohort study. J Am Acad Dermatol 2010; 62: 262. 42. Alster TS. Cutaneous resurfacing with CO2 and erbium:YAG lasers: preoperative, intraoperative, and postoperative considerations. Plast Reconst Surg 1999; 103: 619.
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43. Alster TS. Increased smooth muscle actin, factor XIIIa, and vimentin-positive cells in the papillary dermis of carbon dioxide laser-debrided porcine skin. Dermatol Surg 1998; 24: 155. 44. Sarradet M, Hussain M, Goldberg D. Electosurgical resurfacing: a clinical, histologic, and electron microscope evaluation. Laser Surg Med 2003; 32: 46. 45. Bodendorf M, Grunewald S, Wetzig T, et al. Fractional laser therapy. J Dtsch Dermatol Ges 2009; 7: 301. 46. Teikemeier G, Goldberg DJ. Skin resurfacing with the erbium: YAG laser. Dermatol Surg 1997; 23: 685.
47. Sriprachya_anunt S, Fitzpatrick RE, Goldman MP, et al. Infections complicating pulsed carbon dioxide laser resurfacing for photoaged facial skin. Dermal Surg 1997; 23: 587. 48. Hantash BM, Mahmood MB. Fractional photothermolysis: a novel aesthetic laser surgery modality. Dermatol Surg 2007; 33: 525. 49. Hantash BM, Bedi VP, Chan KF, et al. Ex vivo histological characterization of a novel ablative fractional resurfacing device. Lasers Surg Med 2007; 39: 87. 50. Goerge T, Peukert N, Bayer H, et al. Ablative fractional photothermolysis—a novel step in skin resurfacing. Med Laser Appl 2008; 23: 93.
3
Aesthetic marketplace economics: Trends and performance of the top performing aesthetic medical procedures Page S. Piland
The year 2008 marked the beginning of a challenging economic time for many aesthetic medical practices in respect of productivity and income. These economic challenges continued through 2009 and are still persistent at the time of this publication. During this challenging economic time, many practices were forced to reevaluate their strategies and make modifications to existing business plans. A major part of this process involved identifying underperforming areas and refocusing marketing activities. Frequently, this led to a shift from large surgical procedures to smaller nonsurgical procedures. This was not a welcome shift for surgeons, but many recognized the need to make a change for the short term. Many physicians initially believed that patients were deferring higher priced surgical procedures until the economy improved. Many patients opted to have nonsurgical procedures performed in the interim. These lower priced nonsurgical alternatives were viewed as a way to meet present patient demand. It also represents a way for the practice to remain engaged with its patient base and generate revenue. Cosmeceutical sales are also viewed in a similar manner and can help retain a patient’s bonds with a practice. OBJECTIVE ECONOMIC DATA: PARSING THE ASAPS COSMETIC SURGERY NATIONAL DATA BANK STATISTICS
All the data in this section have been gathered by the American Society for Aesthetic Plastic Surgery (ASAPS). ASAPS has conducted a multispecialty survey for 12 years in order to collect this information. These data are useful in analyzing the aesthetic market and measuring individual practice performance. Methodology A paper-based questionnaire was mailed to 16,000 board-certified physicians (6000 dermatologists, 6000 otolaryngologists, and 4000 plastic surgeons). A total of 894 completed and valid responses (461 plastic surgeons, 277 dermatologists, and 156 otolaryngologists) were received. Final figures have been projected to reflect nationwide statistics and are based exclusively on the board-certified plastic surgeons, otolaryngologists, and dermatologists. The findings have been aggregated and extrapolated to the known population of 23,600 physicians who are board certified in these specialties. Though the confidence intervals change by procedure, depending on the grouping’s sample size and the response variance, the overall survey portion of this research has a standard error of ±3.21% at a 95% level of confidence. The Survey on Cosmetic Procedures Performed in 2008 was compiled, tabulated, and analyzed by Industry Insights, Inc. (www.industry insights.com), an independent research firm based in Columbus, Ohio. Market Overview and Assessment There were 10,258,556 surgical and nonsurgical procedures performed in 2008. The 2008 market performance was down by 12.33% or 1,442,478 procedures compared to the number of procedures in 2007 which was 11,701,031. This reduction in the number of procedures resulted in a revenue loss of $1.37 billion. To help put this number into perspective and demonstrate the growth of the market over the last 10 years, it is important to recognize that the 2008 market loss represents half of the entire market just
10 years previously. In the 1998 market, 2,772,924 procedures were performed. In the years since that time, there have been only two other market declines. The first was in 2002 with a loss of 18.66% and the second in 2005 with a loss of 3.6% of the total market volume over the previous year. With the exceptions of 2002 and 2005, the years between1998 and 2004 were years of exceptional growth ranging from a low of 19.78% in 2003 to the peak performing year 1999 which experienced 66.14% growth. Since 1997 there has been over a 162% increase in the total number of cosmetic procedures performed. Nonsurgical procedures have led in the percentage growth category, coming in at over 233%, while surgical procedures have grown by almost 80% since 1997. In 2008, women accounted for almost 92% of the procedures. The age of patients with the highest number of cosmetic procedures in 2008 ranged between 35 and 50 years, representing 44.6% of the total market volume. Breaking Down the Economics of Surgical and Nonsurgical Proceduresa In order to organize the data for increased comprehension and ease of use, the top five surgical and the top five nonsurgical procedures will be reviewed and analyzed (Fig. 3.1A and B). The complete data set is available at the ASAPS website: http://www.surgery.org/. Surgical Procedures: The Top Five Surgical Procedures The top five surgical procedures are ranked by total expenditure or revenue generated (Fig. 3.2A and B). Figures are for physician/surgeon fees only and do not include fees for the surgical facility, anesthesia, medical tests, prescriptions, surgical garments, or other miscellaneous costs related to surgery. Figures for procedures often performed on more than one site in the same session reflect typical fees for one site. Breast Augmentationb Breast augmentation held the first position among the cosmetic surgery procedures in the years 2006, 2007, and 2008. This procedure accounted for 11.3% of the total revenue generated in 2008 within the aesthetic market (Fig. 3.3). It generated $1,327,566,071 in revenue, which was down from 2007 by 13.6% or $208,925,578. The national average physician/surgeon fee per surgery in 2008 was $3744, which was a decrease by $144 per surgery (Fig. 3.4). This procedure was performed 355,671 times in 2008, which was a decrease of 10.96% resulting in 43,769 fewer surgeries. The average number of breast augmentations in 2008 per ASAPS member was 62.6, resulting in 15.5 fewer procedures. Silicone Gel Vs. Saline Implants. Saline implants were the first choice of implant 52% of the time in 2008. The use of silicone gel implants continued to increase obtaining a 48% market share. For the last 3 years, saline implant usage has decreased significantly while silicone gel implants demonstrated a consistent growth.
a b
The American Society for Aesthetic Plastic Surgery. The American Society for Aesthetic Plastic Surgery.
9
10
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 0 2006
2007
2008
Surgical procedures
1,922,788
2,079,032
1,766,695
Nonsurgical procedures
9,533,980
9,621,999
8,491,861
2006
2007
2008
Surgical procedures
$7,632,270,642
$8,395,851,754
$7,222,233,062
Nonsurgical procedures
$4,542,014,327
$4,752,340,323
$4,559,075,462
(A) $9,000,000,000 $8,000,000,000 $7,000,000,000 $6,000,000,000 $5,000,000,000 $4,000,000,000 $3,000,000,000 $2,000,000,000 $1,000,000,000 $0
(B) Figure 3.1 Market volume for surgical vs. nonsurgical procedures: (A) total number of procedures; (B) total expenditure. Source : The American Society for Aesthetic Plastic Surgery.
The national average physician/surgeon fee per procedure for silicone gel implants in 2008 was $3885 and $3603 for saline implants. Silicone gel implants generated $637,177,252 and saline implants generated $690,338,819 in revenue. Lipoplastyc Lipoplasty was the second among the top five cosmetic surgery procedures in 2008. This procedure accounted for 8.43% of the total revenue generated in 2008 within the aesthetic market (Fig. 3.5). It generated $984,028,900 in revenue, which was down from 2007 by 26.45% or $353,867,291. The national average physician/surgeon fee per surgery in 2008 was $2903, which was a decrease of $38 per surgery (Fig. 3.6). This procedure was performed 341,144 times in 2008, which was a decrease of 25.32%, resulting in the largest procedure decline in 2008 of 115,684 fewer surgeries. The average number of procedures in 2008 per ASAPS member was 55.1, resulting in 17 fewer procedures.
c
The American Society for Aesthetic Plastic Surgery.
Suction-assisted Vs. Ultrasound-assisted Lipoplasty. Suction-assisted lipoplasty was still the first choice 81.7% of the time in 2008. Ultrasoundassisted lipoplasty lost market share from 20.4% in 2007 to 18.3% in 2008. For the last 3 years, suction-assisted lipoplasty has been the first choice by a significant margin. The national average physician/surgeon fee per procedure for suctionassisted lipoplasty in 2008 was $2874 and $2933 for ultrasound-assisted lipoplasty. Suction-assisted lipoplasty generated $804,268,214 and ultrasound-assisted lipoplasty generated $179,760,686 in revenue. Faceliftd Facelift was the third among the top five cosmetic surgery procedures in 2008. This procedure accounted for 7.6% of the total revenue generated in 2008 within the aesthetic market. It generated $891,524,394 in revenue, which was down from 2007 by 4.99% or $46,807,663. The national average physician/surgeon fee per surgery in 2008 was the highest fee for a surgery or procedure at $6728. This was a decrease of $64 per surgery.
d
The American Society for Aesthetic Plastic Surgery.
11
AESTHETIC MARKETPLACE ECONOMICS $1,800,000,000 $1,600,000,000 $1,400,000,000 $1,200,000,000 $1,000,000,000 $800,000,000 $600,000,000 $400,000,000 $200,000,000 $0 2006
2007
2008
$907,651,429
$991,544,589
$806,185,765
$1,379,731,684
$1,536,491,649
$1,327,566,071
$791,678,946
$829,274,709
$787,844,501
$903,002,712
$938,332,057
$891,524,394
$1,162,407,264
$1,337,896,191
$984,028,900
Abdominoplasty Breast augmentation Breast reduction Facelift Lipoplasty (A) $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0
2006
2007
2008
Abdominoplasty
$5,263
$5,350
$5,470
Breast augmentation
$3,678
$3,888
$3,744
Breast reduction
$5,429
$5,417
$5,630
Facelift
$6,532
$6,792
$6,728
Lipoplasty
$2,902
$2,941
$2,903
(B) Figure 3.2 (A) Total expenditure or revenue generated per procedure and (B) national average for physician/surgeon fees per procedure for the top five surgical procedures. Source : The American Society for Aesthetic Plastic Surgery.
$1,200,000,000
This procedure was performed 132,504 times in 2008, which was a decrease of 4.09%, resulting in the smallest procedure decline in 2008 of 5649 fewer surgeries. The average number of procedures in 2008 per ASAPS member was 16.1, resulting in 3.4 fewer procedures.
80.3%
58.1%
$1,000,000,000
$800,000,000
52%
$600,000,000 48% $400,000,000 41.9% $200,000,000 19.7% $0 2006
2007
Silicone gel implants
2008 Saline implants
Figure 3.3 Total expenditures with percentage of market share for breast augmentation using silicone gel implants vs. saline implants. Source : The American Society for Aesthetic Plastic Surgery.
Abdominoplastye Abdominoplasty was the fourth among the top five cosmetic surgery procedures in 2008. This procedure accounted for 6.8% of the total revenue generated in 2008 within the aesthetic market. It generated $806,185,765 in revenue, which was down from 2007 by 18.69% or $185,358,824. The national average physician/surgeon fee per surgery in 2008 was $5470, which was one of only two surgery fee increases in 2008. This was an increase of $120 per surgery. This procedure was performed 147,392 times in 2008, which was a decrease of 20.47%, resulting in the second highest surgical procedure percentage decrease in 2008. There were 37,943 fewer surgeries in 2008. The average number of procedures in 2008 per ASAPS member was 22, resulting in 8.3 fewer procedures per ASAPS member.
e
The American Society for Aesthetic Plastic Surgery.
12
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT $4,200 $4,100 $4,000 $3,900 $3,800 $3,700 $3,600 $3,500 $3,400 $3,300 $3,200 2006
2007
2008
Silicone gel implants
$3,813
$4,087
$3,885
Saline implants
$3,544
$3,690
$3,603
Figure 3.4 National average for physician/surgeon fees per procedure for breast augmentation using silicone gel implants vs. saline implants. Source : The American Society for Aesthetic Plastic Surgery.
This procedure was performed 139,926 times in 2008, which was a decrease of 8.60%. There were 13,161 fewer surgeries in 2008. The average number of procedures in 2008 per ASAPS member was 16.6, resulting in 3.8 fewer procedures per ASAPS member.
$1,200,000,000
$1,000,000,000
Nonsurgical Procedures: The Top Five Nonsurgical Procedures The top five nonsurgical procedures are ranked by total expenditure or revenue generated (Fig. 3.7A and B).
$800,000,000
$600,000,000 79.6% 82.3% 81.7%
$400,000,000
$200,000,000 17.7%
20.4% 18.3%
$0 2006 Suction-assisted
2007
2008
Ultrasound-assisted
Figure 3.5 Total expenditures for suction-assisted vs. ultrasound-assisted lipoplasty. Source : The American Society for Aesthetic Plastic Surgery.
Breast Reduction (Women) Breast reduction for women was the fifth among the top five cosmetic surgery procedures in 2008. This procedure accounted for 6.7% of the total revenue generated in 2008 within the aesthetic market. It generated $787,844,501 in revenue, which was down from 2007 by 5% or $41,430,208. The national average physician/surgeon fee per surgery in 2008 was $5630, which was the highest increase in surgery fees in 2008. This was an increase of $213 per surgery.
Botoxf Botox held the first position among nonsurgical cosmetic surgery procedures in the years 2006, 2007, and 2008. This procedure accounted for 9.3% of the total revenue generated in 2008 within the aesthetic market. It generated $1,090,374,483 in revenue, which was up from 2007 by 3.4% or $35,807,747. The national average physician/surgeon fee per procedure for Botox in 2008 was $443, which was an increase of $63 per procedure. This procedure was performed 2,464,123 times in 2008, which was a decrease of 11.21%, resulting in 311,053 fewer procedures. The average number of procedures in 2008 per ASAPS member was the highest at 222.5, accounting for 24% of the market. The procedure decrease resulted in 129.9 fewer procedures performed per ASAPS member. Laser Skin Resurfacing Laser skin resurfacing was the second among the top five nonsurgical cosmetic procedures in 2008. This procedure accounted for 6.4% of the total revenue generated in 2008 within the aesthetic market (Fig. 3.8). It generated $751,926,177 in revenue, which was up from 2007 by 70.94% and was the highest growth percentage of all surgeries and procedures on this list. Laser skin resurfacing grew by $312,039,521 over 2007. The national average physician/surgeon fee per surgery in 2008 was $1619, which was an increase of $120 per procedure (Fig. 3.9). This procedure was performed 570,880 times in 2008. This was the largest procedure percentage increase at 11.96% in 2008, resulting in 60,979 more procedures. The average number of procedures in 2008 per ASAPS member was 20.1, resulting in 2.1 more procedures.
f
The American Society for Aesthetic Plastic Surgery.
13
AESTHETIC MARKETPLACE ECONOMICS $2,980 $2,960 $2,940 $2,920 $2,900 $2,880 $2,860 $2,840 $2,820 2006
2007
2008
Suction-assisted
$2,868
$2,920
$2,874
Ultrasound-assisted
$2,936
$2,963
$2,933
Figure 3.6 National average for physician/surgeon fees per procedure for suction-assisted vs. ultrasound-assisted lipoplasty. Source : The American Society for Aesthetic Plastic Surgery.
$1,400,000,000 $1,200,000,000 $1,000,000,000 $800,000,000 $600,000,000 $400,000,000 $200,000,000 $0 2006
2007
2008
$1,326,367,287
$1,054,566,736
$1,090,374,483
Laser skin resurfacing
$546,256,262
$439,886,656
$751,926,177
Hyaluronic acid
$848,191,987
$834,460,585
$714,165,690
Laser hair removal
$550,344,982
$546,698,426
$417,299,496
Chemical peel
$485,958,315
$412,907,539
$416,573,762
2006
2007
2008
$417
$380
$443
$1,593
$1,499
$1,619
Hyaluronic acid
$532
$576
$566
Laser hair removal
$373
$387
$326
Chemical peel
$870
$718
$704
Botox
(A) $1,800 $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $0 Botox Laser skin resurfacing
(B) Figure 3.7 (A) Total expenditure or revenue generated per procedure and (B) national average for physician/surgeon fees per procedure for the top five nonsurgical procedures. Source : The American Society for Aesthetic Plastic Surgery.
14
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
Ablative Vs. Nonablative Resurfacing. Nonablative resurfacing was still the first choice 71.2% of the time in 2008. Ablative resurfacing lost market share from 43.1% in 2007 to 28.8% in 2008. The national average physician/surgeon fee per procedure for nonablative resurfacing in 2008 increased by $565 to $1145. Ablative resurfacing decreased by $324 to $2094 in 2008. Nonablative resurfacing generated $535,467,810 and ablative resurfacing generated $216,458,367 in revenue. Hyaluronic Acid (Injectible)g Injectible hyaluronic acid was the third among the top five nonsurgical cosmetic surgery procedures in 2008. This procedure accounted for 6.1% of the total revenue generated in 2008 within the aesthetic market. It generated $714,165,690 in revenue, which was down from 2007 by14.42% or $120,294,895. The national average physician/surgeon fee per procedure in 2008 was $566, which was a decrease of $10 per procedure. This procedure was performed 1,262,848 times in 2008, which was a decrease of 12.83%, resulting in 185,868 fewer procedures. The average $600,000,000 $500,000,000
71.2% 83.1%
$400,000,000 $300,000,000
56.9%
$200,000,000
number of procedures in 2008 per ASAPS member was 81.5, resulting in 26.5 fewer procedures performed per ASAPS member. Laser Hair Removalh Laser hair removal was the fourth among the top five nonsurgical cosmetic surgery procedures in 2008. This procedure accounted for 3.5% of the total revenue generated in 2008 within the aesthetic market. It generated $417,299,496 in revenue, which was down from 2007 by23.67% or $129,398,930. The national average physician/surgeon fee per procedure in 2008 was $326, which was a decrease of $61 per procedure. This procedure was performed 1,280,964 times in 2008, which was a decrease of 9.32%, resulting in 131,693 fewer procedures. The average number of procedures in 2008 per ASAPS member was 90.4, resulting in 38.7 fewer procedures performed per ASAPS member. Chemical Peel Chemical peels were the fifth among the top five nonsurgical cosmetic surgery procedures in 2008. This procedure accounted for 3.5% of the total revenue generated in 2008 within the aesthetic market. It generated $416,573,762 in revenue, which was up from 2007 by 0.89% or $3,666,223. The national average physician/surgeon fee per procedure in 2008 was $704, which was a decrease of $14 per procedure. This procedure was performed 591,808 times in 2008, which was an increase of 2.91%, resulting in 16,728 more procedures. The average number of procedures in 2008 per ASAPS member was 39.7, resulting in 3.5 more procedures performed per ASAPS member. CONCLUSION
$100,000,000
28.8%
43.1% 16.9%
$0 2006
2007 Ablative
2008
Nonablative
Figure 3.8 Total expenditures with percentage of market share for ablative vs. nonablative laser skin resurfacing.
The economics of the aesthetic marketplace have grown and contracted dramatically over the past few years. Some of this growth is due to the fact that the procedures have gotten so much better than the ones that preceded them. Contractions in the aesthetic marketplace have typically been due to economic downturns or from news-related blips. During contractions, practices that have coherent marketing plans can alter their strategies and try to convert to less invasive, less expensive procedures. During periods of expansion, practices that can scale with the growth have an opportunity to grow. During either, it is essential to have an understanding of economics as it pertains to an aesthetic practice.
$3,000 $2,500 $2,000 $1,500 $1,000 $500 $0
Ablative Nonablative
2006
2007
2008
$2,341
$2,418
$2,094
$845
$580
$1,145
Figure 3.9 National average for physician/surgeon fees per procedure for ablative vs. nonablative laser skin resurfacing. g h
The American Society for Aesthetic Plastic Surgery. The American Society for Aesthetic Plastic Surgery.
15
AESTHETIC MARKETPLACE ECONOMICS
APPENDIX
500,000 450,000 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 2006
2007
2008
Abdominoplasty
172,457
185,335
147,392
Breast augmentation
383,886
399,440
355,671
Breast reduction
145,822
153,087
139,926
Facelift
138,245
138,153
132,504
Lipoplasty
403,684
456,828
341,144
2006
2007
2008
Abdominoplasty
1.5%
1.6%
1.4%
Breast augmentation
3.4%
3.4%
3.5%
Breast reduction
1.3%
1.3%
1.4%
Facelift
1.2%
1.2%
1.3%
Lipoplasty
3.5%
3.9%
3.3%
(A) 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0%
(B) Figure 3.A1 (A) Number of procedures, (B) percentage of total procedures. (Continued)
16
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT 90 80 70 60 50 40 30 20 10 0 2006
2007
2008
Abdominoplasty
31
30.3
22
Breast augmentation
73
78.1
62.6
Breast reduction
23
20.4
16.6
Facelift
20.7
19.5
16.1
Lipoplasty
72.7
72.1
55.1
(C) Figure 3.A1 (Continued) (C) Average number of procedure per ASAPS member for the top five surgical procedures. Source : The American Society for Aesthetic Plastic Surgery.
3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2006
2007
2008
3,181,592
2,775,176
2,464,123
576,509
509,901
570,880
Hyaluronic acid
1,593,554
1,448,716
1,262,848
Laser hair removal
1,475,296
1,412,657
1,280,964
558,432
575,080
591,808
2006
2007
2008
Botox
27.8%
23.7%
24.0%
Laser skin resurfacing
5.0%
4.4%
5.6%
Hyaluronic acid
13.9%
12.4%
12.3%
Laser hair removal
12.9%
12.1%
12.5%
Chemical peel
4.9%
4.9%
5.8%
Botox Laser skin resurfacing
Chemical peel (A) 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%
(B) Figure 3.A2 (A) Number of procedures, (B) percentage of total procedures. (Continued)
17
AESTHETIC MARKETPLACE ECONOMICS 400 350 300 250 200 150 100 50 0 2006
2007
2008
183.1
352.4
222.5
Laser skin resurfacing
17.4
18
20.1
Hyaluronic acid
78.3
108
81.5
Laser hair removal
62.8
129.1
90.4
Chemical peel
25.5
36.2
39.7
Botox
(C) Figure 3.A2 (Continued) (C) Average number of procedure per ASAPS member for the top five nonsurgical procedures. Source : The American Society for Aesthetic Plastic Surgery.
4
Photography for the aesthetic patient Holly P. Smith
Photography serves a multitude of purposes in medicine; research, medical–legal reasons, comparative studies, and publication as well as for marketing purposes. All of these reasons depend on accurate photographic documentation. The majority of physicians and office staff are not properly trained in existing photographic standards for good patient photography. It is important to implement these standards into your practice because aesthetics is all about aesthetics. It is about being able to visually show an aesthetic improvement and if your photography is not good, it can often depict inaccurate results or more often, no results at all. In a cosmetic or aesthetic practice, the practice of photography can be extremely beneficial especially for communicating what your goals are to your patient. This can be performed through simulated imaging and pre-operative/treatment analysis of your patients’ photographs. Providing photography in your practice is providing a service to your patients. It is one of the most valuable tools that can assist your practice in many ways. For example, photographing your patient’s result throughout different time intervals can reinforce your patient’s perception of treatment success, which leads them to experience a greater level of satisfaction with your products and services. Another example is by providing samples of your work rather than using stock imagery. This helps gain trust with your patients by showing them that you get results. You can explain a procedure or treatment process to a patient but nothing is going to compare to showing a patient the “before and after” photographic result of an outcome you performed. Photography sets the foundation for how your work will be evaluated and presented. Setting high standards in photography and using existing protocols will ensure that your talent is properly represented. PRINCIPLES OF PHOTOGRAPHY
Staff and physicians who may not have a background in photography perform most patients’ photography. Knowing photographic basics will help improve patient photography when photographing in the operating room or clinical setting. The following are the fundamental principles of photography. Aperture Aperture refers to the size of the adjustable opening in the iris in a lens that determines the amount of light falling onto the film or sensor. The size of the opening is measured using an f-number or “f-stop” (f8, f11, etc.). Because f-numbers are fractions of the focal length, “higher” f-numbers represent smaller apertures (1). The smaller the aperture, the greater the depth of field. This means that if you use a smaller aperture, you will have the forefront, middle, and background in sharp focus. For patient photography, it is important to use a small aperture, as you want all areas to be in focus. An aperture between f11 and f22 is suitable for patient photography. Shutter Speed The shutter speed determines how long the iris of the camera is open exposing the film or sensor to light. For instance, a shutter speed of 1/125 s will expose the sensor for 1/125th of a second. Electronic shutters act in a similar way by switching on the light sensitive photodiodes of the sensor as long as requested by the shutter speed (2). For patient photography, it is important to use a shutter speed faster than 1/60.
18
Anything under a 60th of a second can produce blurring if the patient or photography moves even slightly. Depth of Field Depth of field refers to the distance between the closest and farthest in-focus area of a photograph (also called the focal range). Depth of field is affected by the aperture, subject distance, focal length, and film or sensor format. The smaller the aperture, the greater the depth of field meaning that objects within a certain range behind or in front of the main focus point will appear sharp (3). Focal Length The focal length of a lens is defined as the distance in mm from the optical center of the lens to the focal point, which is located on the sensor or film. The focal length establishes the field of view. The longer the focal length the narrower and compressed the field of view becomes. The shorter the focal length, the larger the field of view becomes (4). Camera lenses are categorized by normal, telephoto, and wide angle, according to the focal length and film size.
•
• •
Normal—When the focal length of a lens is in a range close to the diagonal measurement of the film/sensor’s format, the lens is said to be “normal.” For example, 43.27 mm is the exact distance of the diagonal of a 35 mm (35 × 24) film plane; therefore, the closest equivalent lens would be 50 mm. The 50 mm lens has a field of view of 46°. Wide—When the focal length is shorter than the film/sensor’s diagonal; it’s a “short” or wide-angle lens. For example, a 20 mm lens on a 35 mm (35 × 24) film plane would be considered a wide angle. The 20 mm lens has a field of view of 94°. Telephoto—When the focal length of a lens is longer than the film/sensor’s diagonal; it’s a “long” or telephoto lens. For example, a 105 mm lens on a 35 mm (35 × 24) film plane would be considered telephoto. The 105 mm lens has a field of view of 23°.
Single Lens Reflex (SLR) It is a camera in which a system of mirrors shows the user the image precisely as the lens renders it. This is the recommended camera type to use for patient photography. Through the Lens (TTL) Refers to a metering system in which a light sensitive mechanism within the camera body measures exposure from the image light passing through the lens. ISO How sensitive the camera’s sensor is to the amount of light falling on it. Raising the ISO of a camera makes the sensor more sensitive to light. This can be useful when photographing in low light situations where you don’t want to use a flash. The disadvantage to raising your ISO is that you increase camera noise. DIGITAL CAMERA MODES AND WHAT THEY REPRESENT
Digital cameras offer many shooting modes for photographing in various settings. Professional digital single lens reflex (DSLR) cameras primarily have the basic modes while prosumer or consumer digital cameras may
PHOTOGRAPHY FOR THE AESTHETIC PATIENT offer some of the basics but also include some predetermined settings that are represented by icons. Some of these modes may and may not be useful for patient photography. Below is a list of some of the basic modes and icons found on digital cameras and what they represent. Aperture Priority Aperture priority mode if generally represented by an AV or A depending on your camera. This is the preferred mode for photographing patients. This allows the user to choose the aperture and the camera selects the shutter speed to accommodate correct exposure. It is important to have a small aperture when photographing patients because you want all areas to be in focus-greater depth of field. Shutter Priority Mode Shutter priority mode is represented by TV or S. This mode allows users to choose the shutter speed. This mode would be important if you were trying to capture a fast moving object without blur, but it is typically not used in patient photography. Manual Mode Manual mode is represented by an M. Manual mode allows the user to choose both the shutter and aperture. This is the preferred method when photographing with studio lights in a clinical setting as it gives you complete control over the exposure of the scene. Program Mode Program mode is represented by a P. The program mode allows the user partial control over both the aperture and shutter. This mode is not necessary for patient photography. Symbol of Person Running This mode is typically used for fast moving subjects. It sets your shutter speed to a fast setting and raises your ISO. This mode is not necessary for patient photography. Symbol of Mountains Depending on your camera, this mode typically sets your aperture to the smallest setting possible given the available light, and can raise your ISO. Although it may seem unlikely, this mode can be used for capturing subjects in greater depth of field than in other modes. Symbol of a Person’s Profile This mode represents portrait mode. Although it may seem like a good mode for capturing the face of a subject, it is not recommended to use this mode as it widens the aperture putting the background out of focus. For patient photography, it is best to use a small aperture so that all features are in focus. Symbol of Flower (Macro Mode) This mode represents macro mode. It is important to know about macro mode because it can be useful to use in some situations but it does have its disadvantages. With digital photography, the term largely refers to the camera’s closest focusing distance. The macro mode generally has a flower icon. When this icon is chosen, it tells your camera that you want to focus on a subject closer to your lens (5). Typically the macro mode in patient photography is used when the camera needs to be 6 inches or less in distance to the subject being photographed. The disadvantage when photographing in macro mode for patient photography is that it typically tells your camera to use a large aperture, which decreases your depth of field. WHAT TO LOOK FOR IN A DIGITAL CAMERA
There are many objectives to look for when shopping for a digital camera.
19
One of them is the capability of the camera’s zoom. There are typically two types: digital and optical zoom. The digital zoom takes a part of the scene and interpolates data to fit on the CCD sensor plane. It mimics a greater zoom without actually gaining any additional image detail. It often results in a blurry and pixilated image. The optical zoom changes the amount of the scene falling on to the CCD sensor. It is preferable to have an optical zoom because the information is not interpolated and can be enlarged and cropped with higher quality results (6). A 3× optical zoom will give you a focal length of 35 to 105 mm, which is the minimum necessary for photographing the face and body. There are different types of viewfinders available on digital cameras. The viewfinder is the window you look through to compose the scene (7). The following are examples of the different types of viewfinders. Optical Viewfinder on a Digital Compact Camera The optical viewfinder on the digital compact camera is positioned above the camera lens so what you see through the optical viewfinder is different from what the lens projects onto the sensor. This type of sensor has parallax error, which can make framing inaccurate when photographing close-up. Optical Viewfinder on a Digital SLR Camera (TTL) The optical viewfinder of a digital SLR shows what the lens will project on the sensor via a mirror and a prism. It does not have parallax errors and shows information at the bottom of the LCD viewfinder that has a camera and exposure settings. LCD on a Digital Compact Camera (TTL) The LCD on a digital compact camera shows in real time what is projected onto the sensor by the lens. This is also called “through-the-lens” (TTL) viewing. The LCD does not have parallax errors but does shorten battery life and can be difficult to see LCD screen in bright sunlight conditions. Electronic Viewfinder (EVF) on a Digital Compact Camera (TTL) The electronic viewfinder shows in real time what is projected onto the sensor by the lens. It simulates in an electronic way the effect of the (superior) optical TTL viewfinders found on digital SLRs and doesn’t suffer from parallax errors. EVF allows more accurate framing but can shorten the battery life. Video Capability Another important feature to look for when purchasing a digital camera is whether or not it has video capability. Many consumer cameras come with digital video capability but some do not. Having the capability to shoot digital video on your camera is useful for relaying important information between physicians, patients, and for media presentations. Flash Options There are many options for flash capability on digital cameras. If you are using studio lights with your digital camera, it is important that you purchase a digital SLR that has either a hot shoe or an external flash input connection on the camera. These types of connections allow the user more flash and remote flash synchronization options. CONSIDER THE PATIENT
Your patient photography should be performed in a private location, even if it only consists of photographs of the face. Public areas such as open rooms or hallways should be avoided when photographing your patient. Many patients may feel intimidated and embarrassed about being photographed so ensuring privacy will make the experience
20
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
Figure 4.1 Watermark of doctor’s name shown on top of an image.
more comfortable. Being aware of how your patient feels about the experience and discussing the reasons for taking the photographs with your patient will help make them more at ease, especially when documenting more sensitive areas of the body. Allow them to express any concerns they may have and discuss them with your patient prior to photographing them. The person responsible for photographing should always inform the subject what areas are being recorded in the camera’s field of view. To provide anonymity, the head should never be recorded in the same field of view with the breasts or body. Although a chaperone is not typically used when photographing, patients should be offered the opportunity for a chaperone if they would like one. If the patient is under 18, a parent or legal guardian must be present during the photography session. PATIENT PREPARATION
Photographic Consent The practice of photography should be included in the Health Insurance Portability and Accountability Act (HIPAA) mandated notice of information signed on admission (8). This should cover photographing and ownership of photographs for treatment purposes only. Below is an example of what is typically incorporated into the informed consent. Sample Paragraph for HIPAA Mandated Notice of Information Signed on Admission that Covers Photography for Treatment Purposes I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that [organization name] will retain the ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law or outlined in [organization name]’s policy. Images that identify me will be released and/or used outside the institution only upon written authorization from my legal representative or me. If you want to use your patient’s photographs for non-treatment purposes; education, publication, marketing, Internet, discuss this with your patient and request that they sign a consent for non-treatment purposes, which lists the possible uses of the images. This should be a separate consent form and should be made as a request only.
Sample Photography for Non-treatment Purposes Consent I hereby authorize ______________ to make audio recordings or to take photographs, videotape, or digital images of me (“Images”). I understand that ______________ may use and release my images to the general public for the following purposes: (1) educational lectures and presentations for health care professionals; (2) scientific publications such as journals or books; (3) patient education materials; (4) broadcast, print or Internet media for educational or public interest purposes. I understand that after release of my images to the general public, they may be subject to redisclosure. I understand this authorization is voluntary and I may refuse to sign. There are different state laws that govern the use of photographs so always review your consent form with an attorney prior to using. If the patient is under 18, a parent or legal guardian should be requested to sign the photographic consent form for non-treatment purposes and use. Make a point to discuss the release for the Internet. Because of the nature of the web, any image can be downloaded and repurposed so make sure your patient understands this possibility. To deter others from taking your work, embed a watermark with your name/practice name on top of the image (Fig. 4.1). In the past, masking the eyes was used to de-identify a subject. Today the stance that the International Committee for Medical Journal Editors takes is that “Identifying details should be omitted if they are not essential, but patient data should never be altered or falsified in an attempt to attain anonymity. Complete anonymity is difficult to achieve, and informed consent should be obtained if there is any doubt. For example, masking of the eye region in photographs of patients is inadequate protection of anonymity” (Fig. 4.2) (8). Attention to Detail After the proper consents have been obtained, the patient can be photographed. Attention to detail is an important aspect of medical photography. You want your photographs to be generic and neutral to best depict the anatomy. This can be achieved by having the subject remove any jewelry (including navel rings) from the camera’s field of view as this can often distract the viewer from seeing what is intended. Personal undergarments can be another distraction and disposable undergarments should be supplied for patients to wear to achieve consistency throughout a series of photographs taken at different time intervals and to keep the patients generic looking.
PHOTOGRAPHY FOR THE AESTHETIC PATIENT
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(B) Figure 4.2 (A, B) Techniques used in the past to de-identify a subject.
Make-up should be removed prior to photographing as it can camouflage the skin’s condition and texture. Having cleaners readily available for your patients to use can speed up the process of make-up removal. After your subject has washed their face, wait until the skin has returned to its normal moisture level before photographing. This will ensure that it is in its most natural state. Requesting the patient to come in without make-up prior to their consultation is the best way to ensure accurate documentation. Hair should be pulled back with hair-colored headbands. If the bangs are too short to be pulled back, have hair-colored bobby pins available for use. Long hair should be pushed off the shoulders. People have been trained to smile when being photographed but this should be avoided for patient photography as it can distort facial features. Unless a particular series calls for animation, careful attention should be paid to not animating the face. Having someone completely relax his or her face is not typically a natural feeling. Request your patient to relax their brow, eyes, and jaw rather than requesting them to just relax their face. This approach can be more successful as often patients don’t realize these areas are animated until they are specifically pointed out. If a series calls for repose and animated views, ensure that the repose views are photographed prior to the animated ones as it is often difficult for the subject to completely relax the facial muscles after animation. These small nuances can often make extreme differences in comparative photographs, especially in non- and minimally invasive procedures such as botulinum toxin injections. If a patient is having difficulty with keeping their eyes open during the flash, have the subject close their eyes and then take the photograph right as they open them. The goal of clinical cosmetic photography is to provide accurate photographic representations from clinical results. This documentation relies on standardizing photographic variables. These variables can be categorized in five components: Standardized views, positioning and alignment, lighting, focal length and camera-to-subject distance, and simplifying the background. Standardized Views Different staff members often perform photography in a clinical practice so it is helpful to use a standardized series. A standardized series is a
predetermined set of photographs per procedure that ensures that the patient will have the same views photographed each time they come in. The series is built for each specific treatment and the patient is generally photographed either 180° or 360° in 45° increments, depending on the procedure and treatment. It is recommended to have the series readily available for whoever is performing the photography. The following are standardized series for some of the cosmetic and aesthetic procedures (Figs. 4.3–4.11). These series not only ensure that the same views are photographed, but they also help define reference points for accurate positioning. There are variables that exist in each face series depending on the surgical procedure or treatment being performed. These variables are noted in each section.a POSITIONING AND ALIGNMENT
Proper anatomical positioning and alignment are important. Identifying reference points and using positioning devices can be helpful in achieving this. For example, placing a target on the wall for the patient to view in the lateral position can help with standardizing the head alignment. Head Positioning: The Frankfort Plane vs. the Natural Horizontal Facial Line The Frankfort plane is used as a reference line for correct head positioning in an X-ray film and has also been used by physicians as a standard for head alignment when photographing the face. Some physicians choose to use the natural horizontal facial plane for alignment (9,10).
a
Author’s note : The focal length information supplied is assuming a 35 mm format of film and/or equivalent CCD/CMOS size of 24 × 36 mm. On some digital cameras, an equivalent lens will have a much smaller focal length because image sensors are much smaller than 35 mm film. For example, while 35 mm has an area of 36 × 24 mm, a 2/3-inch image sensor is only 8.8 by 6.6 mm (11 mm diagonal). For cameras with smaller sensors, a focal length modifier is necessary for achieving the same focal length as with the 35 mm lens.
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Figure 4.3 (A–F) Standardized face/neck series. Camera orientation: Focal length lens/distance: Landmarks: Reference points:
Key points:
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(F) Optional views showing subject with teeth gritting on the left and head down on the right. These views help to depict platysmal banding and submental fat.
Vertical 80 mm at 1 m full face 80 mm at 0.6 close up views Hairline to clavicle Anterior—Align naturally as if subject were looking into a mirror Obliques—Medial part of the eye to the dorsum Laterals—Align brow to chin Make sure that the head is in the standard anatomical position and that the patient is sitting straight and not slumping. Any degree of neck flexion or head retraction can greatly enhance the effect of submental fat/jowl line or conversely neck extension can improve the jowl line.
The Frankfort Plane (Fig. 4.12A) Horizontal plane that transverses the top of the tragus (external auditory canal) across the infraorbital rim (11). Can cause noticeable changes in jaw definition and submental soft tissue (12).
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The Natural Horizontal Facial Plane (Fig. 4.12B) Achieved when the patient looks straight ahead as if looking into a mirror at eye level (10). Preferred for use in plastic surgery photography. Used in patients that have low-set ears (10).
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Lateral Face Alignment Having the subject open their mouth and checking commissure alignment can perform proper alignment of the lateral side of the face. This
helps to prevent over or under side-to-side rotation of the head. To help correct the up and down orientation of the head, vertically align the brow with the chin. Consistency in head alignment from photographs taken during different time intervals is important. Placing a sticker on each wall at eye level height and asking the subject to point their nose at it can achieve this (Fig. 4.13). LIGHTING
Lighting is one of the most important variables to standardize in cosmetic photography because it can dramatically change the appearance of the patient with even slight changes. All light has color depending on its wavelength. Our eyes have the ability to correct for color differences in light; the camera however, does not. This can be easily demonstrated by taking a photograph in ambient light without the use of a flash. Your photograph will have an orange colorcast.
PHOTOGRAPHY FOR THE AESTHETIC PATIENT
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(E) Figure 4.4 (A–E) Standardized eye/brow series. (Photographs below are to be taken in addition to the face series.) Focal length lens/distance: 80 mm at 1 m full face 80 mm at 0.6 close up views Camera orientation: Horizontal Landmarks: Eyes—Slightly above eyebrows to slightly below lower orbital rim. Brow—Just above hairline to just below eyebrows Eyes looking into camera with pupils aligned horizontally Eyes looking up (shows submental lower eyelid fat and any upper eyelid hooding) Eyes looking down (shows submental lower eyelid fat and excess upper eyelid skin) Brow (shows detail of horizontal lines and close up of glabellar muscle) Key points: Make sure that the brow is not raised in the photograph with the eyes looking up. Have the subject relax their brow while simultaneously looking up with their eyes.
Using a daylight balanced flash in your photography will help prevent this so you can depict more accurate color for your patient’s skin (Fig. 4.14). Not only do you want to use a flash, you want to use multiple flashes. Using a single on camera flash can produce harsh contrasting of the shadows and highlights.
There is not one lighting technique that can produce the proper lighting for all procedures, so decisions need to be made before setting up your lights. The size of the area, the clinic workflow, and the staff experience are all factors that should be addressed prior to choosing lighting techniques for your photography.
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Generalized Lighting The typical studio lighting setup has two flashes (strobes) positioned at 45° angles and 3 to 6 feet away from the subject (Fig. 4.15). This studio lighting produces an overall even distribution of light, is easily reproducible, and works well for most face and body procedures.
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It also provides an efficient clinic workflow. This lighting setup is best used in a clinical setting where multiple staff members are assigned to photograph. This ensures that lighting variables are controlled because the lights are stationary not repositioned per different procedures.
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(G) Figure 4.5 (A–I) Standardized laser/skin series. (Photographs below are to be taken in addition to the face series.) (Continued ).
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PHOTOGRAPHY FOR THE AESTHETIC PATIENT
(H) Figure 4.5 (Continued) Camera orientation: Focal length lens/distance: Landmarks:
Key points:
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(I) Vertical and horizontal 80 mm at 1 m full face 80 mm at 0.6 close up views Main thirds of the face Top—Just above hairline to just below eyebrows Middle—Just above the eyebrows to just below the nose Bottom—Just above nostrils to just below chin Cheeks—Just above the eyebrow to just below the jawline Lateral to neck—Ensure consistent rotation by aligning corners of subject’s mouth when mouth is opened. This view is intended to show tonal changes of the skin, if any, from the cheek to the jaw to the neck. Position slightly above eyebrow to collarbone. Make sure that all make-up has been removed prior to photographing.
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(F) Figure 4.6 (A–K) Standardized botulinum toxin series. (Continued ).
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(K) Figure 4.6 (Continued) Camera orientation: Focal length lens/distance: Landmarks:
Key points:
Vertical and horizontal 80 mm at 1 m full face 80 mm at 0.6 close up views Glabellar (top third of face)—Just above hairline to just below eyebrows. Horizontal brow lines (top third of face)—Just above hairline to just below eyebrows Crow’s feet (middle third of face)—Just above the eyebrows to just below the nose Vermillion border (bottom third of face)—Just above nostrils to just below chin. Ensure that repose views are photographed prior to animated views. It can be difficult to fully relax facial muscles after having animated them. Photograph a full face view animated and repose in addition to the close up views. The close-up view alone can sometimes be difficult to determine if post injection if the patient is animated or not.
Facial Lighting The preferred lighting technique especially for rhinoplasty, facial fillers, and other cosmetic procedures, produces more three-dimentional effect of the facial structure (Fig. 4.16). This lighting technique is performed similar to the generalized lighting technique except the lights
are positioned above and closer to the subject. This causes shadows to be created by the dorsum, nasolabial folds, and jawline. The disadvantage of this technique is that it is more prone to produce inconsistencies between comparative photographs because the slightest change in flash positioning can produce a dramatically different result rendered
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PHOTOGRAPHY FOR THE AESTHETIC PATIENT
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Figure 4.7 (A–J) Standardized filler series. Camera orientation: Vertical Focal length lens/distance: 80 mm at 1 m full face 80 mm at 0.6 close up views Landmarks: Just above the hairline to just below the chin. Align like face series. Key points: Make sure that repose views are photographed prior to animated views. It can be difficult to fully relax the face after having animated it.
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Figure 4.8 (A–H) Standardized lip augmentation series. Camera orientation: Landmarks: Key points:
Vertical and horizontal Just above the hairline to just below the chin. Make sure that repose views are photographed prior to animated views. It can be difficult to fully relax the face after having animated it. Photograph lips slightly parted so the full volume of the lips can be shown in the photographs. Remove lip liners and lipstick prior to photographing.
PHOTOGRAPHY FOR THE AESTHETIC PATIENT
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(E) Figure 4.9 (A–D) Standardized rhinoplasty series. (Photographs below are to be taken in addition to the face series.) Camera orientation: Horizontal Focal length lens/distance: 80 mm at 1 m full face 80 mm at 0.6 close up views Landmarks: Basal view (Worm’s eye) Head tilted all the way back with top of nose between eyebrows. Shows contour and asymmetries of the nostrils and alar, tip defining points, width of alar and any deviation. (May require adjustment if subject has extremely low tip projection or large lips that block the alar area) Half basal view—Head tilted back with tip of nose just below eyes. Shows dorsal hump and/or deviation of nose. Cephalic view (Bird’s eye)—Head tilted down and photographed from front of subject. Shows cephalic shape, tip defining points, subtle depressions in the dorsum and deviation and/or existing facial fractures. Oblique variables—The oblique can be photographed different ways depending on personal choice. The first way aligns the tip of the nose to the cheek and the second way aligns the dorsum to the inner eye. Key points: The subject should look straight ahead in all views. Place a dot on both sidewalls and ask the patient to point their nose at the dot. This often helps with being consistent with alignment. Supplemental views: (E) If a depressor-septi release s to be performed, additional views of the patient smiling are often taken to show the muscle pulling the nose downward.
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Figure 4.10 Standardized breast augmentation series. Camera orientation: Horizontal Focal length lens/distance: 50 mm at 3 m Breast alignment: The breasts are photographed with the head and feet in alignment. Again, a positioning mat and tripod will help to keep the height consistent and lens parallel with the subject. Care should be taken to ensure that a proper lateral is taken. This can be identified by two ways. First, if the subject has their shoulders relaxed and arms positioned to the side, a reference point can be established by seeing how much of the back is shown. If no back is seen then the patient is turned too far towards the camera. If both sides of the back are seen then subject is over rotated. Using the back rather than the breasts to identify correct lateral views is more dependable. If the breasts were used instead, for example, both breasts were shown in the lateral view, can be often undependable because of the natural asymmetry of the breasts. Landmarks: Just above the inframammary fold to just below the naval. This shows the proportion of the breasts to the rest of the body. Key points: A foot placement mat is helpful for correct alignment. Have subject relax shoulders prior to photographing. For the obliques, when arms are relaxed to the sides of the body, the upper arm should touch the top of the breast.
PHOTOGRAPHY FOR THE AESTHETIC PATIENT by the shadows. This technique would be recommended for clinics that have a person trained in medical photographic techniques, a clinic that provides more space for different photographic setups, and one that is limited to photographing just a few different types of procedures. Cellulite Lighting However, there are some procedures that are better depicted with different studio lighting set-ups. These setups can become more time
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consuming and more apt to inconsistency and reproducibility because the lights are being repositioned for specific procedures. The advantage is more definition of the skin, contour, and facial features. One lighting technique is for cellulite. This lighting emphasizes the skin’s tone and texture and is accomplished by placing the flash above and about 1 to 2 feet in front of the subject. This produces harsher shadows but gives the skin more definition. An additional light placed behind the subject and pointed at the backdrop can reduce the background shadows (Fig. 4.17).
(A) Figure 4.11 (A–D) Standardized body contouring series. (Continued ).
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(B) Photograph on the left shows the patient with the legs too close together. Middle figure shows correct stance for a patient. Knees should not extend passed the hips. Photograph on the right shows patient with legs to far extended.
(C) Figure depicts distorted view of patient when camera is not kept parallel to subject. These photographs were taken seconds apart and are of the same subject. The left figure shows camera at a downward angle, the right an upward angle. Distortion can greatly affect comparative photographs as shown by the comparison of the waist in these two photographs.
(D) Figure shows optional body contouring view called the divers view and is used to depict skin laxity. Figure 4.11 (Continued) Camera orientation: Focal length lens/distance: Body alignment:
Landmarks: Key points: Supplemental view:
Vertical 50 mm at 3 m The body should be aligned from head to toe. The legs should be separated at hip width as shown in the middle photograph in (B). Feet should remain parallel to each other. Twists of the torso should be avoided as they can greatly distort the body and make consistency between photographs taken during different times difficult to compare. To achieve consistent results, a foot-positioning mat should be used to ensure that correct positioning is maintained. Using a tripod is necessary to ensure the camera lens is parallel to the subject and positioned at the midpoint of the body. Distortion can occur if the lens is tilted up or down towards the subject as shown in (C). Just above the inframammary fold to just below the knees. A foot placement mat is helpful for correct alignment. Arms should be bent and held out of the field of view at breast height only. Weight should be distributed evenly and feet should be parallel to each other. The distance between the feet should not extend the knees past the hips. (D) A “diver’s” view is often taken for patients to demonstrate skin laxity and fat.
PHOTOGRAPHY FOR THE AESTHETIC PATIENT
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(B) Figure 4.12 (A) Frankfort plane vs. (B) natural horizontal facial plane.
Figure 4.13 Lateral face alignment. Left depicts over rotation, middle photograph is correct lateral rotation and the photograph on the right is under rotated.
Figure 4.14 Example of with and without flash.
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FOCAL LENGTH AND CAMERA TO SUBJECT DISTANCE
Figure 4.15 Studio example of two 45° flashes.
Figure 4.16 Preferred lighting technique.
Photography has changed dramatically in the past 10 years and the use of digital over 35 mm is commonplace in healthcare. These changes have called for changes in standardizing photography for patient photography. This is most evident in the control of focal length and distance. Proper focal length and subject to camera distance need to be controlled for patient photography to avoid unwanted distortion. Before digital cameras, using a fixed focal length lens in manual focus mode performed proper focal length. The photographer would move back and forth to the patient in order to achieve focus rather than using auto focus. This technique ensured that the correct distance and focal length were used for the area being photographed (9). With the advent of digital cameras, this technique can be reproduced but often consumer zoom lenses are used making it more difficult. The photographer should be aware of the focal length being used and place identifying markers on the floor so that he or she stands the same distance from the subject each time. It is important to control the focal length and distance to prevent unwanted distortion as shown in Figure 4.18. The Cardiff/Westminster scales of reproduction, that was the magnification of the 35 mm film plane for patient photography, decided the focal length. For example, the breasts were photographed with a normal 50 mm lens at a distance of 1/10 while the face was photographed using a long 100 mm at a distance of 1 m (13). All depended on the film plane to be a set size 24 × 36. Then came digital cameras with variable sized sensors making the focal length more difficult to determine per camera. The focal lengths and distances of lenses built for the 35 mm would need to take into account the smaller sensor sizes. For example, the 50 mm lens would now be the equivalent to a 30 mm lens on a digital camera with a 2/3 sensor size. This was determined by using the following formula now known as the FLM—focal length modifier. By taking the diagonal of the sensor and multiplying it by 1.5. Simplify Background with Backdrop Using a backdrop will help simplify your photographs, eliminates distracting objects, helps to produce a contour of the patient and maintains consistency between photographs taken during different timed intervals. The choice of a background color is important. Medium blue is often used and was carried over for the same reasons that laps and
Figure 4.17 Studio example showing difference in lighting techniques used to photograph cellulite.
PHOTOGRAPHY FOR THE AESTHETIC PATIENT
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Figure 4.18 Proper focal length of the face is shown on the left and distorted facial features from improper focal length on the right.
drapes are blue and green in the operating room, to counter the amount of red seen to prevent eyestrain as well as offering contrast to the red seen in medical subjects (9). Naturally it carried over into the clinical setting to make the backdrop colors in operative and clinical photographs consistent. Medium blue also contrasts well with a variety of skin tones. A white background should be avoided because it reflects light and can make subjects appear washed out. It is also not as aesthetically pleasing and does not work well to provide enough contrast to provide contour definition. Black is often used but can absorb a lot of light. It may not work well with dark-skinned people but has been used successfully with additional background or rim lights to highlight the subject’s contour from behind (11). If a room has been dedicated for photography, the wall can be painted blue. A flat-based paint should be used instead of a gloss to prevent reflections from the flashes. If material is used, make sure it is a wrinkle-free material that does not have a lot of sheen to it. Polyester works well for most cases. Rolled paper backdrops can be used with stands and are available at professional photography stores. CONCLUSION
The value of photography in a clinical practice is often underestimated. Staff members are regularly used to perform the practice of patient photography and are often not properly trained in photographic standards. Using these guidelines you can improve the quality of your photography, which in turn improves the documentation of your talent and can create better communication and trust with your clients and patients. REFERENCES
1. Bockaert V. Aperture. [Available from: www.dpreview.com/learn/?/ Glossary/Exposure/Aperture_01.htm] (accessed May 6, 2010).
2. Bockaert V. Shutterspeed. [Available from: www.dpreview.com/ learn/?/Glossary/Exposure/Shutterspeed_01.htm] (accessed May 6, 2010). 3. Bockaert V. Depth of field. [Available from: www.dpreview.com/ learn/?/key=depth+of+field] (accessed May 6, 2010). 4. Bockaert V. Focal length. [Available from: www.dpreview.com/ learn/?/Glossary/Optical/Focal_Length_01.htm] (accessed May 6, 2010). 5. Rowse D. Macro photography tips for point and shoot cameras. [Available from: www. digital-photography-school.com/macrophotography-tips-for-compact-digital-camera-users] (accessed May 6, 2010). 6. Bockaert V. Digital zoom. [Available from: www.dpreview.com/ learn/?/Glossary/Digital_Imaging/Digital_zoom_01.htm] (accessed May 6, 2010). 7. Bockaert V. Viewfinder. [Available from: www.dpreview.com/ learn/?/Glossary/Camera_System/viewfinder_01.htm] (accessed May 6, 2010). 8. International Committee of Medical Journal Editors. Protection of patients’ rights to privacy. Br Med J 1995; 311: 1272. 9. Williams AR, Nieuwenhuis G. Clinical and operating room photography. In: Vetter JP, ed. Biomedical Photography. Boston: Focal Press, 1992:: 251–301. 10. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg 2002; 109: 1421–34. 11. Williams AR. Positioning and lighting for patient photography. J Biol Phot 1985; 53: 131–43. 12. Sommer D. Pitfalls of nonstandardized photography in facial plastic surgery patients. Plast Reconstr Surg 2004; 114: 10–14. 13. Young S. Maintaining standard scales of reproduction in patient photography using digital cameras. J Audiov Media Med 2001; 24(4): 162–5.
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Ergonomics for an aesthetic office Steven K. Cordonnier
INTRODUCTION
Ergonomics plays an extremely vital role in an aesthetic office. It can often mean the difference between a very successful and growing practice and one that is barely surviving. This is why it should be an important component during the design and layout of any examination or procedure room and aesthetic office. It should also be a consideration during any equipment purchases and staff training. Unfortunately, ergonomics is often an overlooked area that many times is not given serious attention. When it comes to healthcare facilities, ergonomic principles are just as important for patients as it is for physicians and staff. For patients, the issue is also one of accessibility, which can often be tied to ergonomic principles. When implemented correctly, ergonomic principles can help the healthcare facility owner achieve the highest levels of comfort and safety for patients, physicians, and staff. The foundation for any efficient and successful practice is the level of comfort and safety provided by the facility, especially its exam and procedure rooms. BENEFITS OF ERGONOMIC PRINCIPLES
The benefits of implementing good ergonomic principles in the aesthetic office are many. And these benefits are felt by patients, physicians, and staff. As we mentioned earlier, the two most significant benefits of ergonomic principles are that the office and exam rooms will be more comfortable and safe for everyone. These two factors alone can directly influence the quality level of the physician/patient relationship during a visit. Following are the benefits, including comfort and safety, that can be realized when ergonomic principles are implemented in an aesthetic office. Comfort Comfort is one of those basic human needs, that when met, can help put someone at ease, foster efficient performance, and help facilitate a pleasant experience. These results are especially important in a healthcare environment. For patients, the level of comfort can directly influence their level of anxiety and help ease “white-coat syndrome.” Meanwhile, physicians need to be comfortable in their environment in order to provide efficient and effective patient care. For instance, the inability to easily maneuver in the examination or procedure room can often cause physicians to alter their work style over time, which can result in repetitive motion injuries. Simple comfort considerations in design and equipment can play a significant role in helping physicians conduct a more thorough and accurate exam or procedure and increase the overall satisfaction level of the patient.
procedure table. In many facilities, the burden falls on staff to lift or assist the patient. This sort of patient/staff interaction has a high potential for serious injury to one or both of the parties involved. At the very least, it could result in back injuries for staff, which is a serious issue in the healthcare industry. The National Institute for Occupational Safety and Health (NIOSH) estimates that direct and indirect costs associated with back injuries in the healthcare industry are about $20 billion annually. Accessibility As the healthcare industry evolves, equal access healthcare is an increasingly important issue affecting our healthcare system across the country. It basically pertains to a practice’s ability and willingness to ensure that healthcare is accessible and inviting for elderly patients, as well as those with other mobility concerns, such as patients with disabilities or obesity issues. Quality of Care/Efficiency of Procedures Implementing ergonomic and accessibility principles in a healthcare facility, and in particular the exam/procedure room, will raise the level of the quality of care being provided and increase the efficiency of the procedures being conducted. The basic fact is that the less physicians and staff are forced to strain to move patients or endure uncomfortable positions, the more they will be able to focus on the patient and provide the best quality care possible. Reputation and Perception From a business standpoint, the perception of the patient and the reputation of the healthcare practice are very important. The more pleasant the patient experience, the more likely it is that they will not only return for other procedures; they may even recommend these services to a friend or family member. In any medical practice, especially a cosmetic one, the appearance of your exam tables, lighting, etc. immediately tells a patient whether you are using the best and staying current or whether you are a poseur. GROWING IMPORTANCE OF ACCESSIBILITY
Too many facilities and clinics still lack total architectural and programmatic accessibility. By providing an accessible healthcare environment that works for everyone, providers improve the quality of patient care as well as the quality of their patients’ lives. Full accessibility is closely tied to many ergonomic principles. As a result, it can greatly improve patient safety and patient outcomes, as well as productivity and profitability for the practice. CONSIDERATIONS FOR THE AESTHETIC OFFICE
Safety It is important that patients and staff feel safe when they are in the office and exam/procedure room. A safe environment is conducive to a pleasant experience for everyone. If a patient does not feel safe, they may become agitated and decide not to visit this office in the future. Staff who do not feel safe may become dissatisfied and decide to look for different employment. And if an accident does occur, a safety concern can quickly lead to a liability issue. For example, with the average age of patients on the rise, it is more likely that patients may need assistance in accessing an exam or
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To fully understand the significant role ergonomic and accessibility principles can play in an aesthetic office, it is important to look individually at specific areas and equipment found inside the facility. Entrance and Lobby For patients, ergonomic and accessibility principles can have an effect on them before they ever step foot inside the exam or procedure room. Simple considerations such as accessible parking, wheelchair accessibility, and power door operators can make the office more inviting and create a more safe and comfortable environment. Additionally, it
ERGONOMICS FOR AN AESTHETIC OFFICE is important to have adequate and comfortable seating for patients and any staff. Another ergonomic issue often found in entrance and lobby areas is the potential for trips and falls caused from environmental hazards such as slippery or wet floors, uneven surfaces, cluttered or obstructed passageways, inadequate lighting, or poorly maintained walkways. Exam and Procedure Rooms Since physicians spend most of their time with patients in exam and procedure rooms, it makes sense that these areas are where ergonomic and accessibility principles can have the greatest impact on the quality level of the healthcare environment and care provided. The design and layout of the exam/procedure room can have a significant effect on the quality of patient care and comfort and safety of the facility. The size of the room is very important. It needs to be large enough to comfortably accommodate the patient, physician, and staff and allow procedures to be properly performed. The industry standard for an exam room is approximately 8 ft × 8 ft; however, increasing the room to 10 ft × 10 ft—or larger, if possible—provides a 60-inch diameter area to accommodate wheelchair turnaround for disabled patients, as recommended in guidelines of the Americans with Disabilities Act (ADA). Procedure rooms can be 12 ft × 12 ft, depending on procedure equipment, and patient positioning required. The slightly larger room allows the door to be reverse-hinged to increase patient privacy. If a staff member enters the room to assist the physician, the patient is not exposed to other patients in the corridor. Larger rooms will also accommodate newer equipment, such as lasers, and will allow for versatility down the road if one needs to add new in-office procedures. For most aesthetic procedures, the work of the physician and staff is concentrated around the head section of the table. However, there are other procedures that occur at the foot and midsection of the table, so access around the entire table is critical. To facilitate this access, the procedure table should be positioned either in the middle of the room or at an angle, allowing the physician and staff to work at the head end of the table, and as much as possible in a neutral position, without too much overreaching or bending and twisting of the back and head. And adequate room space will mean that the physician can easily move about while seated on a stool, minimizing any aches that might be caused by continually sitting and standing during an exam or procedure. Procedure tables must be able to afford the physician an opportunity to inject, laser or otherwise treat without having too much neck flexion. It is also a good idea to include side chairs in the room. These chairs can have multiple uses. Two chairs are commonly used for the patient and potentially an accompanying family member to sit together during any sort of consultation. Typically, the patient would sit on the procedure table and a family member would be seated across the room. This is less desirable because the physician must consult the patient and answer questions from all people, wherever they are located. The two chairs, positioned side by side, allow the physician to consult with both individuals simultaneously and maintain eye contact without constantly moving the head or torso, thereby decreasing the stress on the neck and back. As with the lobby and entrance, the exam and procedure room is another area where trips, slips, and falls often occur. Along with slippery and uneven surfaces, other hazards include cords from all the equipment in the room that stretch across the floor. By using floor outlets, the power cord of the procedures table can be shortened and kept from stretching across the floor. Additionally, outlets located on the procedures table enable the physician to plug equipment into the table and keep the associated cords from stretching
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across the floor. Lastly, using wireless controls can completely eliminate the control cords going to the equipment and allow staff to position the controls where they make the best ergonomic sense. An emerging trend that certainly helps the ergonomics of the office is to incorporate a consultation area in the procedure room. This has the benefit of reducing room changes for both the physician and the patient. The doctor can then stay seated and simply turn around when they want to go from the consultation to the procedure. This setup certainly requires a very aesthetically pleasing and friendly, warm environment. The placement of surfaces, instruments, equipment, and access to equipment all require a well thought out plan to make this setup a success but when it is done correctly it can be a very ergonomic solution Lighting It is important to have medical lighting in the exam/procedure room that provides a large pattern size with an even distribution of light throughout that eliminates shadows. It should also remain safe and cool to the touch. The lighting should be counterbalanced to provide precise positioning without drifting and without any undue spring or frictional force that would cause the user to overly push or pull in order to position the light. Thus, it should be easy to maneuver, eliminating any strain on physicians. Physician Stool For a physician, the ergonomic properties of the stool are very important. The ideal stool should feature a contoured seat that molds to the shape of the body and provides maximum comfort and support for the buttocks, feet, and torso. It should also feature a strong base structure that offers stability and minimizes the chances of tipping. Padding is essential in order to avoid compression during consultations. The stool should be easily adjustable and maneuverable, to allow physicians to find the most comfortable working height and effortlessly interface with the patient. The adjustable height will allow physicians to maintain neutral postures and keep shoulders relaxed and the head balanced and looking essentially straight ahead, while minimizing overreaching and sustained bending, and twisting. Stools with armrests should be avoided, as these often limit access to the patient and interfere with other items in the room. Procedure Table or Chair The procedure table or chair is the one piece of equipment in a practice that touches nearly every patient. It can be the most valuable asset of a successful practice. The right procedure table can increase the level of efficiency, comfort, and safety, and enhance the delivery of care. For example, being able to easily get onto a procedure table can increase a patient’s comfort during the visit. In addition to patient and physician comfort, the right procedure table can mitigate risk by preventing injuries and falls. The most important feature of the table is that it should be barrierfree and be able to lower to a height of 19 inches or less so patients are able to get on it with little or no assistance. Being able to easily get onto a procedure table can increase a patient’s comfort, help the physician conduct a more thorough and accurate exam or procedure, decrease potential for staff ’s back injuries and increase the satisfaction level of the overall patient experience. Barrier-free tables also reduce the likelihood of distress and injury to patients who are elderly, disabled, obese, or even pregnant who may have difficulty in accessing a standard procedure table. The tables and chairs should be fully adjustable and feature power height, back, foot, and tilt. This will enable the patient to remain relatively still during the entire procedure. This will also enable easy access and flexibility during examinations and procedures, saving the
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physician from overreaching, twisting or bending the back or torso too much resulting in awkward postures. According to Occupational Safety and Healthy Administration (OSHA), “‘awkward postures’ means working with various parts of the body in bent, extended or flexed positions rather than in a straight or neutral position. Working in awkward postures increases the exertion and muscle force that employees must apply to complete a task and compresses tendons, nerves and blood vessels.” In addition, the federal agency points out that “twisting the torso creates an asymmetry which stretches some sets of muscles while compressing others forcing smaller, isolated groups of muscles to provide the needed force for the task. Twisting the spine creates nonsymmetrical forces on the fibers of the disc which weakens the structure making it more susceptible to bulging and rupture … .” It is clear from OSHA that to minimize the risk of injury, the physician and staff should minimize awkward postures as much as possible. Of special importance to the aesthetic medicine physician is the ability to have close access to the patient. Having close access enables the physician and staff to stand upright without unnecessary bending or twisting while still performing the procedure. Since much of the aesthetic medicine work is performed on the face, neck, and upper body, having a procedure table with a small headrest and a very narrow back section is vital in providing this close access. And because many physicians or staff work from a seated position, it is important to have a thin headrest and back section without obstructions. This gives physician the ability to roll in close to the procedure table’s back section or headrest without bumping their legs or knees on the table components. All of this facilitates proper posture and will reduce strains and injury to the physician. Powered height, from 19 inches up to 40 inches, is crucial to keep the physician and staff from bending over the patient. This large height range adjustment allows both shorter and taller physicians and staff to work at the most appropriate height and limits the amount of neck and back flexion. OSHA studies have found that the work site should be such that the forearm and upper arm should be at 90° angles because it helps keep the strain off of the shoulder muscles. Rotation of the table should also be considered because it allows the physician to move the patient to the other equipment in the room instead of requiring the physician to move around or require movement of the equipment. In addition, by rotating the patient, the physician can position the work site close to a counter or supply storage area so that twisting movements and overreaching can be minimized. A final consideration for the procedure table or chair should be its controls. The controls for moving the table or chair should ideally either be wireless or in the form of accessible, easy-to-use foot controls. And the size of the controls should not be overly large and obtrusive that they cause a trip hazard or force the doctor or staff away from the work site. The latter would result in the user leaning over the patient and put undue strain on the lower back and neck. Casework/Cabinetry Casework designed specifically for medical environments is often more durable and will not break down under medical use, unlike common wood casework. While casework does have an aesthetic effect on the image of the practice to patients and staff, it also can be tied closely to ergonomic principles.
For example, a pull-out writing surface at an approximate height of 30 inches would allow any paperwork needed during an examination to be readily and conveniently accessed. And locating the sink in the corner maintains a countertop surface closer to the working environment and isolates any splashing to eliminate potential slippery spots on the floor. Another important area on the cabinetry is the kick area of the base cabinet. This should be high enough to allow the legs of the stool to slide under the edge of the base cabinet while the user’s foot is positioned on the base in a very common use scenario. This allows the user to get in closer to the cabinets and countertop and eliminates frequent and unnecessary bending or stretching. And consideration should be given to how items are placed in the cabinetry. For example, keeping the most frequently accessed supplies on the lowest shelves keeps physicians and staff from constantly overreaching. Monitors Monitors have become a critical part of the exam/procedure room. Physicians need to be able to easily view the monitor during any procedure. For this reason, it is important to have a fully adjustable monitor on a monitor arm that allows it to be easily positioned for both sitting and standing postures and for a variety of procedures. Making sure that the monitor is of high resolution and free of smudges will eliminate any eye strain, blurred vision, dry eyes, or headaches that may result from prolonged concentration to view images that are unclear or washed out. An emerging trend is to use mobile carts that can be brought to the side of the procedure table so the physician can maintain the provider/ patient eye connection while still entering data into a practice management system or electronic health records (EHR) system. This arrangement eliminates staff twisting to access any electronic systems or eliminates any awkward balancing that happens with portable tablet computers. Ideally these mobile carts should be height adjustable so a physician can work either sitting or standing. Staff Awareness and Training OSHA recommends that practices establish a training program designed and implemented by qualified persons to provide continual ergonomics education and training. It should also be a part of any new employee orientation. The training should cover not only ergonomic hazards and principles, but appropriate procedures, such as patient lifting guidelines, as well as the proper use of the equipment. The training should also provide an overview of the potential risks, causes and symptoms of back injuries, and work-related musculoskeletal disorders. CONCLUSIONS
The well-designed esthetic office needs to not only look good but also function well. It does the physician little good if he or she is able to build a practice only to become disabled due to a herniated disk in the neck or back. By following guidelines and using well-designed equipment, the physician can enjoy a long and comfortable career. In addition, his or her patients will have the knowledge that the office has invested the time and money to make each visit comfortable and safe as possible.
6
Interviewing the cosmetic patient Susan H. Weinkle and Harriet Lin Hall
INTRODUCTION
The initial visit of a dermatology cosmetic patient has specific nuances that the medical dermatology patient visit does not have. Many of the treatments given and issues addressed are for conditions that are not pathologic, but rather for normal physiologic phenomena (1). Some patients may come to the office not necessarily knowing what they need but are unhappy with their present appearance. Other patients may come to the office with a specific concern but may not be a good candidate for cosmetic rejuvenation because of an underlying systemic disease. In order to fully meet the cosmetic dermatology patient’s expectations, a complete pre-operative assessment including a thorough medical and psychosocial history and focused physician examination is imperative. Key information is obtained through the medical interview. Mastering the skills of interviewing the cosmetic patient will assist in building trust and contribute to the successful treatment of the dermatology patient desiring cosmetic enhancement. THE MEDICAL INTERVIEW
Engel (2) stated “the interview is the most powerful, encompassing, and versatile instrument available to the physician.” The medical interview is highly personal and confidential, so much so that access to the content and records of the physician–patient conversation is protected by law (3). The Accreditation Council for Graduate Medical Education (ACGME), the American Association of Medical Colleges (AAMC), and the American Board of Medical Specialties all have adopted requirements that specify core clinical competencies and performancebased evaluations addressing clinician–patient interaction (4). Importance is placed on domains involving medical professionalism and communication with emphasis on interviewing skills. Talking with patients is not a skill reserved for such specialists as psychiatrists, psychologists, and social workers (4). Cosmetic dermatologists need to develop strong skills in medical interviewing to separate a good cosmetic candidate from a poor cosmetic candidate that may have an underlying personality disorder, such as body image dissatisfaction. In addition to solid interviewing skills, dermatologist/psychologist Richard Fried has written extensively on when patients may not be a good candidate for cosmetic rejuvenation. Dr. Fried developed a screening profile called the CPS-D (Cosmetic Procedure Screen-Derm) (5), which will be discussed in more detail later in this chapter. Sarwer has also written extensively on the psychological assessment of patients who present for cosmetic surgery plastic (6). Other organizations that help clinicians enhance their communication skills include the American Academy of Physician and Patient (AAPP) and the Bayer Institute for Health Care Communication (BIHCC) (7). CONSULTATION SUCCESS STARTS WITH EDUCATION
Historically, patient education occurs throughout the entire encounter with the medical dermatology patient with emphasis that functions toward the end of an interaction or subsequent visits. The cosmetic patient should be educated throughout the complete cosmetic consult. Educating patients means giving them information and, if necessary, motivating them to act on it (8). According to Werschler, education starts from the time before the cosmetic patient even comes to the office (9). Education can start via your website or from the receptionist who answers the phone (Fig. 6.1). Your website should in fact be an
educational tool, describing your services, credentialing you for your expertise and your experience, in addition to everything else, such as directions to the office (9). Many dermatologists who have incorporated cosmetics into their practice have spent time educating their staff and have specially trained practice coordinators. Because of the sensitive nature of the initial interaction, it is critical to have practice coordinators who are receptive, understanding, and aware that patients may display a limited understanding of cosmetic dermatology (10). The majority of cosmetic patients’ knowledge base comes from the media and fashion magazines. They may lack the knowledge and understanding of the procedures themselves, however, are often quite clear on how they want to look after the procedure (10). If the cosmetic patient elects to utilize your practice, the patient will like to have questions concerning costs and payment plans. Consultation charges are frequently questioned by cosmetic patients. The practice coordinator can address this with the patient prior to arriving at the office. Whether there is a charge or not needs to be clearly communicated. Many cosmetic dermatologists elect to waive the consultation fee if the patient decides to have a procedure performed the same day or soon after the consult. INTERVIEWING AS PART OF THE COSMETIC CONSULT
The initial cosmetic consult between the dermatologist, the staff, and patient should include some major themes of medical interviewing. During the interviewing process, the dermatologist should be objective, precise, sensitive, specific, and reliable when making observations about the patients’ cosmetic desires (8). Active listening skills connect the dermatologist with the patient. Below is a partial list of listening skills that help build a therapeutic relationship with the cosmetic patient (8). 1. Choose a mutually comfortable setting. 2. Remain attentive. 3. Observe the patient respectfully as a whole person, not just as a person needing facial rejuvenation. 4. Allow the patient to tell a story with as few interruptions as possible. 5. Note discrepancies in meaning between what the patients say and how they say it. Additionally, the need to demonstrate respect for the cosmetic patient is important in order to connect with the patient and provide optimal treatment. MEDICAL HISTORY AS PART OF THE COSMETIC CONSULT
Once a sound medical history is completed, the cosmetic component of the consult can commence. The consult should take place in a comfortable setting where the patient and physician can exchange valuable information. During this time, the patient may be assessing the environment, asking about credentials, and voicing concerns about their expectations. It is also a good practice standard to inform the patient who will be performing the procedures whether it is the dermatologist, the advanced practice nurse, the physician’s assistant, or aesthetician. Patients are increasingly knowledgeable and sophisticated about cosmetic procedures and expect the most up-to-date treatments. According to Schlessinger (10), it is advantageous to give a tour of your practice to help put your patients at ease. Someone who is knowledgeable about your practice and a firm advocate
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Figure 6.2 Having patient identify their specific concerns. Figure 6.1 Education starts with the receptionist during the first phone call.
Table 6.1 Patient Framework should give this tour. If your practice has several facets such as general dermatology, surgical dermatology, i.e., Mohs micrographic surgery, or clinical cosmetic research, these options should be highlighted. All staff encountered should be introduced, and the staff should be urged to respond pleasantly to the patient and tour guide (10). If the appropriate measures discussed have been taken, the consultation process in the exam room should progress smoothly. The patient should be much more likely to follow your lead as a physician, allowing you to take the time to explain the procedure chosen, review pictures of previous patients, interact openly and honestly with the patient and establish priorities that would offer optimal treatment (10). THE FIRST TIME COSMETIC PATIENTS VS. THE EXPERIENCED COSMETIC PATIENT CONSULT
Many first time cosmetic patients will not only have one specific concern but many. A good starting point with these patients is to provide a mirror and have them point out their specific concerns (Fig. 6.2). Patients often identify multiple areas of concern, but also tend to prioritize what bothers them the most (1). What may seem like a cosmetic flaw to the physician may not be a concern to the patient and if the physician suggests an area for treatment that the patient has not mentioned, the patient may feel offended. Werschler (9) developed a framework that divides the cosmetic patient into one of three distinct buying groups: (i) enhancement patients, (ii) rejuvenation patients, and (iii) restoration patients ( Table 6.1). According to Werschler (9), the restoration patient has traditionally been the bread and butter of dermatologists because they frequently deal with skin cancer, agerelated concerns of the skin such as rosacea, lentigos, and pre skin cancers. These patients typically have had interaction and good experience with dermatology. The enhancement patients have been patients of plastic surgery because the majority of dermatologists usually do not offer extensive facial reconstructive services for that group of patients. The rejuvenation group may opt to visit both dermatologists and plastic surgeons, depending on demographics and availability of cosmetic dermatologists. When consulting with the cosmetic patient, keep in mind their psychodynamic drivers. Give careful consideration to why they are in your office. For example, if you offer to make enhancement patients’ lips look like a famous celebrity’s lips they will probably indicate “That’s exactly what I want.” If you were to offer the same service to a rejuvenation patient, they might respond “ No, that’s a little too much,
Enhancement patient
Rejuvenation patient
Restoration patient
Very young; range 18–29 years of age; may have acne; desires better skin care, bigger lips, correct “bump” in nose; wants to look better than genetically made
Usually 30–50 years of age; complaints of looking older than they feel; want to look younger not change entire appearance; usually take good care of themselves
Generally 55+; desires to be the best looking for age group; interested in repairing sun damage, prevention of skin cancer; slowing aging process
I just want a little bit of filling and just have a bit more of a pouty look.” The notion of interacting with patients to identify their concerns and decide upon the best course of therapy should always define how cosmetic dermatologists structure their practices and evaluate the various cosmetic procedures available (10). Once the patient’s concerns are identified, the physician can proceed with a pretreatment assessment. Physician concerns should include and address the type and extent of wrinkles, folds, furrows, and other signs of aging including any disease state such as skin cancer or actinic keratosis. It is at this point that photographic documentation is crucial. The physician should set goals with the patient about cost, timeline of treatments, follow-up visits, and agreeing to the extent of correction possible. PATIENTS WHO SHOULD NOT HAVE COSMETIC FACIAL REJUVENATION
Patients that do not make good candidates for cosmetic procedures include patients displaying, underlying personality disorders including depression. Also, any patient with active systemic disease should not have cosmetic treatment. For example, a female patient in her late 60s with unstable angina is probably not a good candidate for laser surgery. According to Fried and Werschler (5), the late Eugene Farber wrote in the 1990s about the other dimension in the management of psoriasis; that intrapsychic factors and stress can affect treatment outcomes. Dermatologists frequently have patients present to their office with complaints of feeling stressed and unhappiness with their appearance. Many patients have been misinformed about cosmetic procedures and products via the internet and media. This sensory overload makes it difficult for patients to make well-chosen cosmetic interventions that maximize the likelihood of achieving their desired result (5). Fried and Werschler developed a screening tool for dermatologists to identify patients that will be most likely dissatisfied with a cosmetic
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INTERVIEWING THE COSMETIC PATIENT
CPS-D (COSMETIC PROCEDURE SCREEN-DERM) Please specify the cosmetic/skin problem(s) that bother you.
Please specify the cosmetic/skin problem(s) you would like improved or corrected.
How do you envision your life will change after your cosmetic procedure?
Will having a cosmetic procedure “fix” any of your problems?
Yes
No
Have you seen any other physicians for cosmetic concerns?
Yes :
No
If yes, how many?
What were your concerns? Were you satisfied with the results? Have you had any previous cosmetic procedures? If yes, which ones? Were you happy/satisfied with the results? Do you drink alcohol? : Yes
No
How often? How much?
Are you taking prescription medications for pain? Do you feel overwhelmed or confused?
Yes
Yes
No
If yes, which ones?/How often?
No
Are you being strongly encouraged or discouraged from having a cosmetic procedure? Yes : Are you generally satisfied with your life?
Yes
No
Are you worried about the way you look and wish you could think about it less? How many minutes or hours in an average day do you think about how you look? Do you cut or otherwise purposely harm your skin?
No
Yes
Yes
No Minutes
Hours
No
Are so distressed by your cosmetic concern to the point where it interferes with you ability to be happy or carry out your necessary daily chores? Yes No Have your cosmetic concerns gotten in the way of doing things with your friends and family?
Yes
No
Figure 6.3 Fried & Werchler Screening Tool.
intervention (Fig. 6.3). Dissatisfied cosmetic patients can drain the physician and staff and potentially damage the reputation of your practice (11). Choosing the appropriate patients is the key to selecting cosmetic treatments that will satisfy and exceed patient expectations (Fig. 6.3). Besides the self-administered CPS-D questionnaire, Fried developed the STEP (Society of Trust and Estate Practitioners) program for helping the dermatologists identify patients you should avoid treating. The STEP program encompasses medical, surgical, and psychodermatology. A PLETHORA OF OPTIONS
The availability and novel applications of dermal fillers has made the reversal of the aging face accessible to a wide range of patients. The trend is likely to continue as the public becomes more familiar with existing nonsurgical treatment options and the Food and Drug Administration (FDA) continues to approve newer treatments. The challenge for physicians is to screen cosmetic candidates to identify high risk patients that would not be appropriate for cosmetic procedures. In the moments prior to and at the initial cosmetic consultation, there are many facets of the consultation that bear scrutiny and reinforcement with staff (10). Cosmetic consultations can be a rewarding experience for both physicians and patients when appropriate key interaction is
displayed for selecting cosmetic procedure that satisfies and exceeds patient expectations. REFERENCES
1. Beynet D, Greco J, Soriano T. Approach to the cosmetic patient. In: Murad A, Gladstone H, Tung R, eds. Cosmetic Dermatology. London: Saunders Elsevier, 2009: 3–6. 2. Frankel R. Forward. In: Smith, R, ed. Patient Centered Interviewing, 2nd edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2002: ix. 3. Frankel, R. The interview in history. In: Smith R, ed. Patient Centered Interviewing. 2nd edn. Philadelphia, PA: Lippincott, Williams & Wilkins, 2003: xi. 4. Coulehan JL, Block MR. Introduction. In: The Medical Interview. Mastering Skills for the Clinical Practice. 5th edn. Philadelphia, PA: F.A. Davis Company, 2006: xvii–xviii. 5. Fried R , Werschler W. The key to mastering cosmetic dermatology patient selection. Skin & Aging 2006; 14(10): 42–5. 6. Sarwer DB, Grossbart TA, Baker AW. Understanding the cosmetic surgery patient. In: Kaminer MS, Arndt KA, Dover JS, Rohrer TE, Zachary CB, eds. Atlas of Cosmetic Surgery, 2nd edn. Philadelphia, PA: Saunders Elsevier, 2009: 3–9. 7. Coulehan JL, Block MR. Interviewing as a clinical skill. In: The Medical Interview. Mastering Skills for the Clinical
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Practice. 5th edn. Philadelphia, PA: F.A. Davis Company, 2006: xvii–xviii. 8. Smith RC. Patient centered interviewing, 2 edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2003: 235–52. 9. Werschler WP. Integrating dermatology and cosmetic dermatology practice: an expert interview with William Phillip Werschler, MD.
Medscape Dermatology, Nov 7, 2008. [Available from http:// cmemedscape.com/viewarticle/582738] 10. Schlessinger J. First contact: improving consultation techniques and procedure selection. Practical Dermatology, August 2009: 43–6. 11. Fried R. Visions of beauty. Skin & Aging 2007; 15(10): 45.
7
Red flag patients Timothy Corcoran Flynn
One of the joys of practicing cosmetic dermatology is the relationship that exists between physician and patient. Cosmetic patients are by and large intelligent, interesting, active individuals who seek to improve their appearance as an augmentation to their robust lives. Many of these patients are dynamic people who comment that their outward appearance does not match how they feel inside. They are frequently seeking to restore their face or body to a more youthful appearance. They usually wish to appear a bit younger and fresher than many in their peer group. Cosmetic patients can be delightful to work with. They are upbeat and positive individuals who enjoy coming to the dermatologist. Most cosmetic dermatologists with busy practices enjoy the interaction. Inevitably, however, one encounters individuals that are unpleasant or difficult. These patients are termed “red flag patients.” They can trigger a mental warning signal when initially encountered. These “red flag patients” should be approached with caution and if the warning signal turns into an alarm, they should be avoided. Studies have shown that up to 47% of patients seeking consultation for a cosmetic procedure meet criteria for a mental disorder (1). Ritvo et al. (2) have noted that common conditions seen in the cosmetic population include body dysmorphic disorder, narcissistic personality disorder, and histrionic personality disorder. A thorough medical and social history can be used to gain a complete understanding of the cosmetic patient and discover these traits. Usually people with personality disorders produce strong feelings in the physician. Body dysmorphic disorder patients can demonstrate a preoccupation with an imagined problem with their body or excessive concern over one body area. This concern causes them significant distress and can occupy great amounts of time and energy on their part. Listening carefully will help identify these patients with more serious psychiatric conditions. Judgment on which patients to treat and which to reject takes time to acquire. Eugene Tardy Jr.’s excellent chapter in the book Facial Aesthetic Surgery (3) wrote “surgical residents in training quickly and accurately learn the physical characteristics favorable for aesthetic surgical correction, but the experience in judgment to assess emotional motivations are less readily acquired.” He further goes on to state “every effort must be made to develop a sixth sense about patient expectations and motivation.” While some red flag patients are easy to recognize by their brashness and atypical behavior, other difficult patients require a bit more care to recognize. Oftentimes your office staff gets the first clue that a person is a drapeau rouge. They may have an unusual interaction on the telephone or during the consultation with your cosmetic coordinator. Some red flag patients, particularly those who are arrogant or feel that they are a “VIP,” may seem extremely pleasant to you, the treating physician. However, they have treated your nursing staff with contempt and disgust. It is wise for the cosmetic dermatologist to pay attention to the opinions of your office staff from the front to the back office. Staff are often correct in their assessment. Identifying difficult patients can be helped by carefully listening to the wishes and desires of the patients, fine-tuning one’s listening skills (with the emphasis on listening) will help ferret out the red flag patients. Oftentimes they give clues within their comments or expression, which helps the experienced cosmetic dermatologist know what patients to avoid. For example, there can be a warning sign if differing inflections are used in the sentence “the other doctor used a filler.” If
you detect sarcasm when the patient states “the other physician,” it is an important clue that this may be a patient who is very difficult to be pleased. The paragraphs below describe the types of “red flag patients” which one can encounter in the office.
“WHERE CAN I GET IT DONE THE CHEAPEST?”—THE BARGAIN HUNTER
Bargain hunters are people who are continually moving from doctor to doctor or calling practices trying to find the absolute best price. They are incorrectly paying attention to the cost of the procedure and not focusing on the outcome. These patients can be like a ping pong ball, going from place to place or spending hours on the phone or internet. They are frequently unhappy because they are seeking treatment from non-experts in the field, oftentimes encountering physicians outside of the non-core specialties. These physicians, in turn, are trying to lure patients to their practice using price as a motivator. They frequently do so by, for example, using less botulinum toxin units than that may be required, thus reducing their cost. Obviously the patient is not going to get as desirable a result when they are undertreated. Bargain hunters can be avoided by establishing a reasonable price for the correct therapeutic regimen. Many times they are treated by non-physicians.
“I WANT TO LOOK EXACTLY LIKE …”—THE PATIENT WITH UNREALISTIC EXPECTATIONS
The patient with unrealistic expectations come to see the cosmetic dermatologist wishing to have a wrinkle “completely removed” or to have the doctor produce “perfection.” Sometimes patients will bring in a photograph from a magazine, stating that they wish to have their complexion exactly match the one in the picture. Alternatively, they may desire something that is physically impossible to achieve, such as a person with very thin lips wishing to have 12 mm of red show on the upper lip only. These patients with unrealistic expectations fail to understand the anatomic limitations. Several of these patients may have seen other physicians or undergone scalpel surgery to try and achieve their idealized appearance. One warning sign for these patients is the feeling that they are inflexible in their goals and the cosmetic dermatologist may have a sense that the patient is not listening to or understanding the cosmetic dermatologist.
“HOW ABOUT 10% OFF DOCTOR?”—THE CHEAP PATIENT Many patients are concerned about expense, particularly in the times of a down economy. However, there are some red flag patients who continuously attempt, at each visit, to get a discount on their services. These patients can be annoying, but more so their focus is often not on the outcome, but rather on the cost. They take extra time during the treatment session, arguing over a few bucks. A statement such as “We do not discount for our services” will usually stop this constant price haggling. Some of these types of patients may be made happy by giving them a little something extra. However, you must be careful in providing a value-added service, because they usually will want it at every visit.
“DOCTOR, CAN’T WE GET MY INSURANCE TO PAY FOR IT?”—THE MANIPULATOR
While there are certain dermatological treatments that can be billed to insurance (e.g., the use of a vascular laser to treat a port wine stain),
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there are very few procedures in cosmetic dermatology which are appropriate to charge to an insurance company. It is important to clearly state to the patient that you can only do this when appropriate and in their case it is not. You can comment to them that you practice medicine with the highest ethical standard and that the patient’s medical records must reflect that. Sometimes a simple joke such as, “I don’t think the insurance company or the government would appreciate it,” can simply sum up the situation quickly and diffuse their wish for you to be dishonest.
“IT HAS TO BE PERFECT!”—THE PERFECTIONIST Perfectionistic people are frequently be encountered by the cosmetic dermatologist. These patients are often immaculately dressed and their grooming is exquisite. They may literally have “not a hair out of place.” Perfectionistic patients may come in with long, detailed lists of their problems or may write detailed letters discussing their problems. Other warning signs that you may be working with a perfectionistic patient may be that they refuse to take off their makeup when asked to do so by your staff. While they seem to understand that a dermatologist must examine the skin unencumbered with cosmetics, they cannot bring themselves to remove their camouflage. Many perfectionists will not be satisfied until every detail is corrected and their appearance becomes “flawless.” A simple phrase which the author has used not to treat perfectionists is “I don’t think I will be able to provide you what you want.” Giving perfectionists the name of other reputable cosmetic dermatologists who may be interested in treating the patient is a courteous service to the patient, but a burden for your colleagues. Perfectionistic patients can also include people with an untreated obsessive–compulsive disorder and are obsessed with their appearance. Some of these people can fall into the category of body dysmorphic disorder. These patients can seem to be greatly disturbed by their perceived cosmetic deformity when, in fact, on examination there is no disorder to be seen. These patients with normal outward appearance who focus in detail on their perceived deficiency are among the most dangerous to treat, because they are usually not satisfied and, in fact, can turn angry about the money and time that they have spent.
“DOCTOR, I CAN’T MAKE UP MY MIND”—THE INDECISIVE Indecisive patients are people who have come in for multiple inquiries, but never can quite decide to receive a treatment. They may have seen several other doctors only for consultation, never having a treatment. These patients may have trouble with decision making. This behavior can be a sign of abnormal passivity, in which their lives are full of other people making their decisions. These patients may state “it’s up to you” or “do whatever you want.” This is not a good idea because the patient should always have a clear understanding as to what will be done and have appropriate “buy in” to the situation. Their informed consent must reflect complete knowledge of what is done and then their desire to have the procedure.
“DOCTOR, YOU ARE SO GREAT!”—THE SEDUCTIVE PATIENT Occasionally, when encountering people, one gets an uncomfortable feeling of inappropriateness. It seems that the patient does not seem to understand normal social boundaries and the doctor is getting the feeling that they are being seduced. These patients range from being overly familiar to being sexually inappropriate. These patients may have a pattern in their life of getting attention and manipulating situations. They may have learned that these skills can, at times, afford them certain advantage. However, any flirtation is not appropriate between a doctor and a patient. These people are often trying to gain the favor of the physician for preferential treatment and can be difficult.
“YOU ARE THE ABSOLUTE BEST IN YOUR FIELD”—THE EXCESSIVELY COMPLIMENTARY PATIENT
We would all like to feel that we are the best in our specialty, but a good cosmetic dermatologist can usually recognize another physician whose skills in certain areas are superior to their own. Thus, the cosmetic dermatologist will understand that the patient who comes in and states repeatedly “I know you are the best” is a patient to be worried about. These people can be over-flattering and frequently commenting on the reputation and an almost magical power that the treating physician may possess. At times you may hear demeaning comments about other dermatologists or other cosmetic practitioners. One has to be careful of these patients because if the result is not what they expect, then their excessive compliments may turn into overt criticism. They may be angry and outraged following their treatment.
“DO I HAVE TO SHOWER BEFORE THE PROCEDURE?”—THE PATIENT WITH POOR HYGIENE
All patients are entitled to an occasional bad hair day, but these difficult patients are unkempt, dirty and show a lack of care for themselves. They may be at risk for skin infections due to their slovenly existence, and may not practice simple wound care. These people can be at risk to treat because they may not always follow the cosmetic dermatologist’s advice. They do not seem to care much for themselves. If they will not follow the simple rules of hygiene, brushing ones teeth or bathing, how can you know that they will follow your instructions following the procedure?
“I CAN ONLY COME IN AT NOON FOR JUST 20 MINUTES, TOPS!”— THE VIP PATIENT
People, who are involved in the media, appear before the public, or hold positions of importance frequently seeking improvement by the cosmetic dermatologist. However, some of these people can be extraordinarily demanding. Clues for this include only a limited range of times that they can be seen by the dermatologist and inflexibility surrounding their schedule. They frequently seek “special appointments,” exceptions from standardized treatments, and other forms of special care that can be of disaster to a busy practice. We have had patients who have asked us to open the office on Sunday morning and who have requested that the doctor “cancel his vacation because I need to be treated.” These people are oftentimes not worth treating, as they are unable or unwilling to follow the usual care guidelines, as they spend their life cutting corners or doing only what they want. In their minds, they are such important persons that the usual rules do not apply to them.
“LET ME TELL YOU ABOUT ME”—THE LOQUACIOUS PATIENT Many cosmetic dermatology patients are fascinating and have many stories to tell. Many of them seem to be packing more fun or activities into their lives than many folks. It is often fun to listen to them and to learn. However, there are some patients who are excessively talkative. They often interrupt the doctor, refuse to listen, and verbally dominate every encounter with the dermatologist. When obtaining an informed consent many of these individuals will not let the doctor or the nurse finish the consenting process. Occasionally this can be seen in manicdepressive individual (perhaps in a manic phase) but more often than not it simply reflects a self-obsessed individual who fails to ever listen to others.
“I KNOW I AM GOOD LOOKING”—THE NARCISSIST Caution must be exercised in people with narcissistic personality disorders. Outwardly these people seem to be extremely conceited and vain. They have an inflated sense of self-importance and are preoccupied with one’s self. They exaggerate talents and achievements and react to criticism with rage. This requires constant attention and admiration.
RED FLAG PATIENTS Inwardly they are often unhappy, frequently dissatisfied, believe they are fundamentally unacceptable to others and will often be displeased with their cosmetic outcomes. One clue for narcissism is the negative comments that they often make about others while describing how wonderful they are. They frequently take advantage of others to achieve their own ends. Narcissists are rarely satisfied and have been known to return to the office, demanding their money back due to the “terrible results,” which they may proclaim loudly at your front desk.
“YOU’RE THE EIGHTH DOCTOR I HAVE SEEN”—THE DOCTOR SHOPPER
The clue for a dissatisfied and unappeasable patient is a patient who has seen multiple physicians, often for the same cosmetic treatments. This is a clue that, as they were not satisfied with their initial treatment, they are unlikely to be satisfied even with your good outcome. It is best to decline them get treated unless you feel that you have something specifically different to offer, and that your treatment will truly improve them.
“I THINK I NEED ANOTHER PROCEDURE”—THE SURGIHOLIC Often one glimpse of this individual is enough to identify that they are a person who has had repeated cosmetic procedures, sometimes to a degree of either inappropriateness or disfigurement. Their medical history may reveal that they have had several breast augmentations, each time seeking additional improvement. These patients will continue their unending quest, moving beyond treatment to disfigurement and excess. They no longer fit into the normal range of human appearance.
“I AM GOING TO SUE THAT QUACK”—THE LITIGIOUS PATIENT There is not a doctor who enjoys hearing that their patient is involved with or considering litigation. A pause in the interaction will often cause the patient to describe their unhappiness with their previous physician and their decision to sue. It is extremely essential that the cosmetic dermatologist not make disparaging remarks about the previous physician. If one detects excessive focus on the negative
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results, or perceived negative results, avoid treating the patient. They are already angry. It is worth noting that currently in the practice of medicine, it is common to see patients who may be on psychoactive medications. We commonly see patients on an antidepressant medication such as an SSRI (selective serotonin reuptake inhibitor) or perhaps an anxiolytic. Many of these patients are fine to treat. Many of these patients have been put on the medication for minor issues or the drugs may be used off-label for treatment of other symptom collections such as menopause. Spending a few minutes discussing those medications and trying to get a sense of the patient’s psychiatric stability usually reveals that the patient is not significantly impaired. One also encounters patients with a more serious psychiatric diagnosis, which is being treated with additional or higher doses of medications. We always openly discuss the psychiatric drugs with these patients and if under regular care of a psychiatrist, usually ask to place a phone call to their treating doctor. It is important to remember that in the current practice milieu you must ask the patient’s permission to contact their psychiatrist. When the patient gives permission you should state that you have obtained permission from the patient when you call their psychiatrist. The practice of cosmetic dermatology can be rewarding and fun. Most cosmetic dermatologists state that they really enjoy their cosmetic patients and have a great deal of joy making people look and feel better. Learning to avoid red flag patients can make your practice delightful and satisfying. REFERENCES
1. Ishigooka J., Iwas M., Suzuki M, et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998; 52: 283–7. 2. Ritvo EC, Melnick I., Marcus GR., Glick JD. Psychiatric condition in cosmetic surgery patients. Facial Plast Surg 2006; 22: 194–7. 3. Tardy ME, Thomas JR, Brown RJ. Initial encounter: a personal approach (Chapter 3). In: Facial Aesthetic Surgery. St. Louis, MO: Mosby, 1995: 66–83.
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Internal marketing Amy Derick
OVERVIEW
Definition In this chapter, internal marketing is defined as the process of persuading existing patients of a dermatological practice to purchase cosmetic services or products. Advantages of Internal Marketing Internal marketing is a highly effective way to increase cosmetic revenue. Whether you are serving a medical patient considering cosmetic services or products for the first time, or an experienced cosmetic patient contemplating an additional purchase of cosmetic services or products, internal marketing has the following advantages over external marketing: 1. An ongoing medical practice already has a stream of potential cosmetic patients walking through its doors without having to spend additional advertising dollars to reach them. 2. Existing patients are a captive audience during their visits to the practice. 3. Existing patients are typically receptive to the advice of their trusted provider. Leveraging these inherent advantages in a professional manner will help a practice grow its cosmetic revenue—probably to the elevated satisfaction of both patient and provider. Methods Discussed The methods of internal marketing can be assembled into the following major categories: 1. 2. 3. 4.
Building a cosmetic brand Capturing patients who are predisposed to cosmetic treatments Stimulating new cosmetic interest in existing patients Maintaining strong overall relationships with patients
Each of these categories will be discussed in this chapter. At the conclusion, the reader should feel confident about implementing these methods in his or her practice. BUILDING A COSMETIC BRAND
Defining the Cosmetic Brand A brand, in the context of this chapter, is the collection of images or ideas a patient perceives when considering to patronize a given medical practice. A good cosmetic brand will clearly convey that the medical practice in question is a “provider of choice” for cosmetic services and products. Delivering a Cosmetic Brand to Patients There are two main processes through which a cosmetic brand can be clearly conveyed to patients: explicit internal marketing and implicit internal marketing. Explicit Brand Building In explicit brand building a practice overtly states the message it wants to deliver. One advantage of explicit brand building is that the practice has complete control of the message. For example, a practice might adopt the slogan “ABC Dermatology: A Leader in Cosmetic Skin Care.”
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This message directly presents a cosmetic brand to patients. Explicit brand building can be used through vehicles such as print advertisements, radio or television advertisements, practice materials such as brochures or business cards, and the website of the practice. The first step toward developing an explicit brand building campaign is defining the value proposition of the practice. The value proposition is the unique combination of service, quality, and price that each practice offers its patients. Each organization must focus on no more than two of these elements. For example, a practice that offers the highest quality care and service will not probably be able to offer the lowest possible price. Each practice must analyze its position within its chosen marketplace and demographics to determine the best competitive approach. Once the value proposition has been determined, it needs to be communicated clearly to targeted patients. As an example, XYZ Dermatology is a practice in a small market. In the area in which it practices, the doctors have built a reputation for providing excellent medical care, but they have little cosmetic business. The primary cosmetic competition in the area is a medispa that operates without on-site physicians. XYZ Dermatology believes its practice provides higher quality care than the competition but feels it cannot compete on price with the medispa. The practice determines that it will focus on high service and quality as its value proposition. Accordingly, the practice adopts the slogan, “XYZ Dermatology: Medical and Cosmetic Skin Care Advice from the Doctors You Trust.” This slogan highlights the chosen value proposition, and it gives patients a clear reason to consider the practice for their cosmetic needs. Implicit Brand Building The second channel for communicating a cosmetic brand to patients is implicit brand building. Implicit brand building does not directly state a brand message. Instead, it conveys a brand impression indirectly through the patient experience. Some examples of implicit internal brand building covered in this chapter include the physical office environment and customer service. The physical office environment is a critical influencer of overall patient experience. The environment can either enhance or detract from the internal marketing campaign. A practice that wants its patients to feel comfortable spending money on discretionary cosmetic procedures must pay attention to details. Cosmetic services are luxuries for most patients, and the goal of the environment is to put the patient in a state of mind that is receptive to luxury spending. The office should, above all, be clean and free of clutter. Flat surfaces should be clear of papers or debris. The décor should be updated and coordinated. Furniture should be comfortable and in good condition. Ideally, the patient should “experience” the ambiance of the practice. Patients should “feel” the brand. The interaction between staff and patients presents additional opportunities for implicit brand building. Each employee of the practice, from providers to reception staff, should be cognizant of his or her individual contribution to patient experience. The common saying is that patients might not remember what a doctor said or did, but they will always remember how the practice made them feel. In the context of internal marketing, the goal should be to make each patient feel important all the time. It is common, in a busy medical practice, for staff and providers to lose focus on the patient as the constant and highest priority. Reception
INTERNAL MARKETING staff may be distracted with phone calls or chart-work. Clinical staff may be focused on documentation or assisting. Providers may be caught up in the stress of running behind schedule. All members of a practice have many important jobs and worries, and no one person can solely be responsible for providing customer service. It takes a team focus on service to make a positive impression on patients for each and every step of the patient process, and it is entirely worth the extra effort. A patient who feels truly appreciated is much more likely to trust a practice with his or her cosmetic business—and may become a source of valuable referrals as well. CAPTURING PATIENTS WHO ARE PREDISPOSED TO COSMETIC TREATMENTS
Identify Patients Who Want Cosmetic Services The simplest and most effective way to increase cosmetic business from existing medical patients is to identify patients who are predisposed to cosmetic services. After predisposed patients have been identified, the staff and providers can address these patients’ cosmetic needs. One straightforward way to determine which medical patients have an interest in cosmetic services is simply to ask them. Use a Cosmetic Interest Form at Check-in Each time a patient arrives for a medical appointment, the practice has an opportunity to gather valuable information. A cosmetic interest form is one way that a practice can easily (and with no guessing) determine what cosmetic products or services might be of interest to a particular patient. This form typically looks like a menu of services and products offered by the practice. The form allows the patient to indicate topics for which the patient might welcome additional discussion from the clinical or aesthetic staff. The key is to use the form effectively. Discuss the Cosmetic Form with Patients At the conclusion of the patient’s medical visit, a member of the staff or a provider, depending on the preferred flow of the practice in question, can discuss the patient’s cosmetic form. Here is a typical discussion:
• • • • •
Provider: “Mrs. Johnson, we have now concluded your medical visit. Do you have any further questions about your diagnosis or treatment?” Patient: “No, I think I understand everything. Thanks for your help.” Provider: “You’re welcome Mrs. Johnson. I notice on your intake forms you mentioned that you have an interest in learning more about laser hair removal. This is a service our practice provides. Would you like to hear more about laser hair removal?” Patient: “Sure. I’ve always been bothered by the hair on my upper lip, but I didn’t know your office could help with that.” Provider: “We certainly can. If you are interested, I can go over the basics with you. Then our aesthetician can come in for a few minutes and explain your options in detail. Would you like that?”
In this example, the patient had a predisposed interest in laser hair removal. Without the use of the cosmetic interest form, the provider would not have been aware of this interest. In addition, because the patient had indicated on her form that she wanted more information about this particular procedure, the provider should not feel awkward bringing it up at the conclusion of the medical visit. The form can act as an effective ice breaker between patients who may be nervous about discussing cosmetic procedures and providers who do not want to appear pushy about cosmetics.
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Reputation Is Everything The reputation of a practice is its most valuable asset. All care must be taken to protect and build a practice’s good name. Without daily vigilance, a practice can develop a negative reputation for being pushy with cosmetics. Aggressive sales behavior in the practice will almost certainly be reported by word of mouth to the detriment of the practice, that is, as referrals evaporate. No one wants the following comments to be floating around in the community: “I went to XYZ Dermatology for a wart, and the doctor spent the whole time trying to sell me Botox.” The simplest way to avoid a pushy reputation is to use the cosmetic interest form. A provider or cosmetic coordinator should discuss only the issues for which a patient has explicitly expressed interest. This policy will ensure that no patient is offended by the suggestion that he or she consider a cosmetic procedure. If the provider feels it is important to bring up cosmetics with a patient who has not expressed interest on the cosmetic interest form, this must be handled delicately. One viable approach is to ask simply, “How are you taking care of your skin?” This question usually leads to a discussion of products, routines, and cosmetic concerns. If diplomatically handled, this conversation may result in either a cosmetic service or a scheduled consultation. Focus on the Relationship To achieve long-term success as a cosmetic practice, each provider must focus on the patient relationship. Whenever a patient is considering a cosmetic purchase, there are two factors in play: the transaction and the relationship. The transaction is the short-term consummation of a purchase. The relationship is the long-term association between provider and patient that is based on trust and mutual benefit. Whenever a provider is considering a cosmetic procedure for a given patient, he or she must ensure that the transaction does not interfere with the relationship. This can be accomplished by doing only what is best for the patient. Often this means a provider will have to discourage a patient from choosing a procedure that is not a good fit for him or her. Although giving such counsel means forgoing a profitable transaction, it will build trust and benefit the patient relationship in the long run. STIMULATING NEW COSMETIC INTEREST IN EXISTING PATIENTS
Educate Patients About the Offerings of the Practice Medical patients may come to a practice having never previously considered cosmetic procedures. This does not mean that these patients would not be interested in cosmetic procedures or products if they were educated about their options. It is a primary goal of internal marketing to ensure that no potential cosmetic patient leaves a practice without at least being aware of what services the practice offers. To educate existing medical patients effectively, a practice should do the following:
• • • •
Take polite advantage of a captive audience Show off good results Offer cosmetic consultations Host group seminars
Take Polite Advantage of a Captive Audience When patients are sitting in the waiting room, or waiting in an exam room for a provider, they are effectively a captive audience. They typically have few distractions other than what the practice provides. To leverage this opportunity, a practice can offer educational materials that inform patients about cosmetic services and products provided. Brochures describing specific procedures or products allow patients to read about areas of interest in a low-pressure environment. Educational videos, such as those sponsored by the American Society for Dermatologic Surgery, can provide ambient information for patients’
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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
education. Each practice will have a different comfort level with the amount of promotional material it wants to make available in the waiting room, and it is important to find a balance. Show Off Good Results Good photography is critical for any practice offering cosmetic services. One of the most effective internal marketing tools is a wellconstructed before-and-after portfolio of patient photographs. Copies of this portfolio can be displayed in the waiting room and in exam rooms. Patients will browse through the portfolio out of curiosity, and this will often stimulate interest in the displayed procedures. For many medical patients, words such as Botox, Restylane, laser, or IPL are terms they have previously heard but do not fully understand. This is what makes a before-and-after portfolio such a terrific entry point for marketing cosmetics to medical patients. A picture requires no preexisting knowledge to interpret. A patient can identify with the appearance of the person in the before picture, and admire the cosmetic improvements in the after picture. Such enlightenment will often lead to this typical discussion:
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•
Patient: “Doctor, I was looking at the before-and-after book while I was waiting today, and I noticed a picture of a lady with red veins on her nose like mine.” Provider: “Yes, those are called telangiectasias, and they are a common cosmetic complaint in fair-skinned patients your age.” Patient: “In the after picture, the veins looked much better. In the binder, I read that she had three treatments with a laser, but I don’t remember the name of the laser.” Provider: “She had three treatments with our pulsed-dye laser. If you are interested in the procedure, I can evaluate you formally to determine if you are a good candidate for this laser. If, after the evaluation, you have additional questions, or would like to discuss the price of treatment, I can have our cosmetic coordinator go over the details with you.” Patient: “That would be great. I didn’t even know those veins could be fixed.”
In this example, the patient did not know that a laser remedy is available for her telangiectasia. She did, however, know that she did not like the look of the red veins on her nose, and when she saw the before-andafter pictures, she asked questions that were important to her. This common scenario highlights the importance of showing off your good cosmetic results. Offer Cosmetic Consultations Perhaps the best way to educate existing medical patients about cosmetic services and products is to conduct a cosmetic consultation. First, though, a patient needs to be aware that cosmetic consultations are available in the practice. For example, a sign in the waiting room can alert patients that the practice offers cosmetic consultations. Cosmetic consultations can also be mentioned on the cosmetic interest form completed at check-in. During the cosmetic consultation, the patient learns (from a provider or from a cosmetic coordinator) about all available options for treating his or her cosmetic concerns. If handled properly, cosmetic consultations can expand existing medical patients into cosmetic patients. The individual practice should determine whether or not to charge for cosmetic consultations. If such consultations are complimentary, expect many more patients to schedule appointments. However, to minimize numbers of the curious only, some practices charge a fee that can be applied toward any procedure purchased. The best price structure may ultimately depend on who within the practice is actually conducting the consultation, that is, an aesthetician may not command a premium price for a consultation, but a physician may.
Host Group Seminars Another way to reach existing medical patients who are predisposed to cosmetics is to hold educational seminars. Some patients are more comfortable in a group setting, and they may prefer to attend seminars over scheduling individual consultations. Each seminar can be as general or specific as the practice chooses. Often patients are offered an incentive to attend, such as a discount on procedures scheduled at the event. These seminars can conveniently be hosted at the practice, if physical space allows. To solicit reservations for these seminars, the practice can send flyers or emails to targeted patient groups, as well as display announcements in public areas of the office. In addition, a practice can seek out patients who are social connectors and have many friends or ties to the community. These patients can be given an incentive to help organize the events. An example of an incentive could be a discount on cosmetic procedures for each attendee the patient recruits. MAINTAINING STRONG OVERALL RELATIONSHIPS WITH PATIENTS
A practice that maintains strong overall relationships with its existing medical patients will have a much easier time converting patients into cosmetic customers. Patients like to feel that they are more than a medical record number. Above all, patients want to feel important. There are many effective ways to maintain lasting and positive relationships:
• • •
Newsletters Digital marketing Patient appreciation
Newsletters A newsletter can keep patients routinely engaged with the practice. The content of a newsletter can be a mix of educational and promotional material. For example, depending on the frequency of publication it might make sense to offer seasonal skin care tips. A summer newsletter might offer sun-safety advice—thus leading to a promotional announcement about a new line of sunscreen products available at the practice, as well as a discussion of laser options for treating sun damage. Newsletters also offer the opportunity to discuss changes and developments at the practice that will be of interest to patients. For example, if the practice purchases a new laser or adds a new provider, a newsletter is a perfect vehicle to reach patients with this important information. Digital Marketing As communication has become increasingly electronic, the options available to practices wishing to stay in touch with existing patients have expanded. A website for the practice can be a valuable way to stay connected with patients. If elements such as posted lab results or online consultations are incorporated into a website, medical patients will have a reason to log in regularly. This web traffic will provide a platform that is useful for delivering marketing information. A practice might incorporate a blog to supplement the promotional information in a newsletter. Blogs have an advantage over print media in that they can be updated quickly with current information. A blog also has a low cost of publication, and its audience is more easily traceable. It is easy for a practice to know how many newsletters it mails, but it is impossible to know how many are read by patients. Web-based marketing can give accurate and up-to-date metrics on the number of people who view a practice’s marketing materials, as well as the time spent viewing. The one caveat about blogs is that a practice must be cautious about communicating content (into the public domain) that has not been approved by appropriate authorities or for which the providers are not entirely confident. If in doubt, leave it out. In addition to website-based communications, email is an important component of a complete internal marketing campaign. Email has
INTERNAL MARKETING many of the same advantages that a blog enjoys over print media with a particular added benefit. Because each email is targeted to a specific patient, the tracking data can be more specific. Email-based marketing firms can give patient-specific information on response rates to various promotions. The more information a practice can learn about what truly works, the more effective its marketing will become. Patient Appreciation A sure way to build relationships with patients is to let them know they are appreciated. A simple gesture, such as a birthday or holiday card, can keep a practice at the top of its patients’ minds. A practice can also extend special privileges to the patients it wants to recognize as VIPs. VIPs can be designated based on cosmetic dollars spent in a given year or on any metric the practice feels will adequately describe the demographic it is aiming to recognize. VIP patients can be offered perks such as increased access to providers after hours or during special time slots. VIP patients could also qualify to participate in special promotions the practice occasionally offers. These benefits can create an additional incentive for medical patients to seek and accept cosmetic services and products at the practice.
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CONCLUSION
Key Lessons from This Chapter All practices that want to maximize cosmetic volume should first direct their attention toward internal marketing. The cost of delivering a message to existing patients is relatively low compared with the cost of creating new patients. In addition, the likelihood that a marketing message will be well received is much higher in a base of patients who already know and trust a given practice. Apply These Lessons in Practice There are many channels through which a practice can pursue internal marketing. Ultimately it will be up to the individual practice to determine which methods will work best with its specific patient population. Ideally, all four major categories discussed in this chapter can play a role in a coordinated internal marketing campaign. A practice that successfully builds a cosmetic brand, captures patients who are predisposed to cosmetic treatments, stimulates new cosmetic interest in existing patients, and maintains strong overall relationships with patients will dramatically improve patient satisfaction and the sale of cosmetic services and products.
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Financial benchmarking for the aesthetic medical practice Page S. Piland
FINANCIAL HEALTH OF THE PRACTICE
The financial performance of a cosmetic practice is, next to patient care, the most important component of your practice. Yet, in most instances, it receives little attention until a problem arises that calls attention to it. Frequently, this problem is of a magnitude that it affects the viability of the practice and its ability to meet its financial obligations. Many physicians have become complacent with respect to the financial health of their practices. They rely heavily upon the skills of others, some of whom have little more than a high school degree and a paucity of experience. In many practices, the financials are left to the office manager and the physician defers to his staff. In my experience, this is a mistake because no one has more of a vested interest in the financial health of the practice than the physician. In order to make good decisions, it is imperative to have the right information and to act upon it in a timely manner. Over the past decade, I have had the opportunity to work with many of the leading cosmetic practices and in this chapter, I would like to share some of what I have gleaned. Knowing the necessity of measuring the financial health of your practice is the first critical step. Carving out the time to actually do this is the second. Many of the practices that I work with have a mandatory meeting with me and their financial team (which can include an accountant, bookkeeper, office manager, etc.) on a quarterly basis. The demand for this type of meeting has dramatically increased during 2009 when many such practices were impacted by the global economic downturn. One cautionary note to remember while analyzing your financial data is to avoid the pitfall of analysis paralysis. This occurs when the data cause the physician to freeze like a deer in the headlights—this is bad and should be avoided. The goal of any analysis is to gather pertinent information and use it to take action. Physicians that spend too much time diving deep into the data without confronting their problems will become victims of data overload. This chapter will help one to identify significant numbers and understand the metrics that will define the success or failure of your practice. INSPECT
There are several ways to inspect the financial health of a medical practice. I highly recommend comparing your practice’s performance to both internal and external metrics. Internal metrics include a profit and loss statement prepared by an accountant, productivity reports, payroll summary reports, and an accounts receivable aging analysis. Areas that deserve special attention include collections, new and existing patient encounters, fixed and variable overhead ratios, net collected revenue by provider, and revenue per patient encounter. Comparing this with prior year’s data will help one to identify trends that define the success or failure of your practice. INTERNAL ASSESSMENT
Evaluate Once you have completed the internal assessment, it is essential to understand how it compares with other practices. External practice data are available from many sources. Among the ones that I use are the AAD, ASAPS, and ASPS, The Health Care Group, Kline and Company, the Healthcare Group and the BSM Consulting Group/Allergan Practice Consulting.
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Most physicians have a familiarity with a profit and loss statement. Unfortunately, the amount of time spent reviewing this statement is usually minimal and is focused only upon the top and bottom line numbers. The numbers in between frequently tell the real story of the practice and physicians need to spend more time looking at them and understanding these. Spending hours evaluating and re-calculating the numbers is not productive. Your accountant and bookkeeper should already have a mastery of these and be able to distill them for you. I recommend increasing your understanding of the larger, individual line-item expenses. Typical large areas include payroll, rent, medical supplies, and marketing. These line items are all areas that represent an opportunity to increase efficiency and eliminate wastage. Once the larger items have been scrutinized, attention can be turned to the items lower on the list. Table 9.1 provides a quick reference that can be used to compare your practice’s financial performance to the key benchmarks of the Allergan/ BSM Consulting Financial Database. The table includes the mean and median values for the key benchmarks from the years 2006, 2007, and 2008. Each category will be discussed in detail throughout this chapter. COSMETIC MEDICAL PRACTICE BENCHMARKS: INCOME
One of the biggest challenges faced by practices when trying to measure the practice financial performance is obtaining reliable data. There are many sources for data but most physicians do not know where to access it or how reliable the data are. Most practices rely on the data from the Allergan/BSM Consulting Group Financial Benchmarking database. These data have been collected from the actual financial documents, tax returns, payroll summary reports, and practice summary reports. The data come from dermatology, plastic surgery, facial plastics, and oculoplastic practices. These data are verified, published every year, and shared freely with the industry. I will reference many of the Allergan/BSM Consulting 2008 benchmarks in this chapter. There are many terms and formulas used when discussing the financial performance of the medical practice that can very often be confusing to non-accountants. I will attempt to simplify the terminology and focus upon the areas that provide the most pertinent data for measuring your practice performance. Let’s start with the top line number also known as net collected revenue. The net collected revenue is classified as all monies received by the practice during the fiscal year by way of professional services, facility fees income, and spa services. Basically it is the money the practice has brought in before expenses. The usefulness of the top line number is not as pertinent when making comparisons because of the large variety and types of practices. The different practices include solo, group, and multi-specialty. Many practices also have mid-level providers and aestheticians that contribute to the practice revenue. Therefore, a direct practice comparison is not the most accurate method to measure your practice performance. For this reason, we will look at all of the key contributors on an individual basis in order to compare “apples to apples.” NET COLLECTED REVENUE PER FULL TIME EQUIVALENT PHYSICIAN
The net collected revenue per full time equivalent (FTE) physician is the first category we will examine (Fig. 9.1). An FTE physician is classified as a physician who works 1600 hours per year or 4 days per week. The total net collected revenue of the practice is divided by the
51
FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE
Table 9.1 Key Benchmarks 2006 Benchmark Net collected revenue per FTE physiciana ($) Revenue rate per hour per FTE physicianb ($) Net Collected revenue per FTE non-physician providerc ($) Collected revenue by cosmetic providersd ($) Net collected revenue per FTE aestheticiane ($) Revenue rate per hour per FTE aestheticianf ($) Net collected revenue per FTE support staffg ($) Operating expense ratioh (%) Non-provider payroll ratioi (%) Rent expense ratioj (%) Marketing and advertising ratiok (%) Number of FTE support staff per FTE providerl
2007
2008
Mean
Median
Mean
Median
Mean
Median
1,395,469
1,244,391
1,467,812
1,306,776
1,478,829
1,385,389
872
778
917
817
924
866
399,385
349,450
453,016
391,667
485,360
426,768
283,482
209,281
308,870
199,840
300,421
207,636
145,675
122,026
141,701
125,799
152,412
132,281
70
59
68
61
73
64
345,545
313,716
365,020
322,991
337,748
304,497
62.8 15.3 5.1 4.4
62.8 14.9 4.5 3.2
63.0 15.0 5.2 4.5
62.2 14.3 4.7 3.4
65.3 15.7 5.7 4.7
66.0 15.6 5.0 3.7
4.82
4.33
4.95
4.46
5.40
4.99
a
Net collected revenue per FTE physician—The total physician-collected revenue divided by total full-time equivalent physicians. A full-time physician is assumed to work 1600 hours or more per year. b Revenue rate per hour per FTE physician—The total physician collected revenue divided by the total hours worked by the physician. This measure provides an evaluation of physician productivity in relation to hours worked during the measured period. c Net collected revenue per FTE non-physician provider—The total non-physician provider collected revenue divided by total full-time equivalent non-physician providers. Non-physician providers include physician assistants and nurse practitioners and full time is calculated at 2080 hours per year. d Net collected revenue by cosmetic providers—The total revenue collected for services performed by cosmetic providers. A cosmetic provider includes registered nurses, licensed practical nurses, medical assistants, and others who are performing injections, laser procedures, and other cosmetic services. This excludes licensed aestheticians, physician assistants, nurse practitioners, and other service providers performing non-medical procedures, i.e., massage therapists. e Net collected revenue per aesthetician—Total aesthetician-collected revenue divided by total full-time equivalent aestheticians (FTEs calculated at 2080 hours per year). f Revenue rate per hour per FTE aesthetician—The total aesthetician-collected revenue divided by the total hours worked by the aestheticians employed by the practice. g Net collections per FTE support staff—The practice’s total collected revenue divided by the sum of full-time equivalent support staff employees. A support staff employee includes cosmetic providers, licensed aestheticians, and non-physician providers working in a support capacity, i.e. those not producing revenues independently. A full-time support staff employee is assumed to work 2,080 hours per annum. h Operating expense ratio—Total expenses (cost of goods sold and operating expenses) divided by the total net collected revenue as reported on the practice’s financial statements or tax return. Operating expenses exclude provider compensation, bonuses, retirement contributions, automobile expenses, as well as depreciation. i Non-provider payroll ratio—Gross non-provider payroll divided by the total net collected revenue as reported on the practice’s financial statements or tax return. j Rent expense ratio—Total rent expense or occupancy costs divided by the total net collected revenue as reported on the practice’s financial statements or tax return. k Marketing and advertising ratio—Total marketing and advertising costs divided by the total net collected revenue as reported on the practice’s financial statements or tax return. l Support staff per FTE provider—Total full-time equivalent support staff divided by the sum of full-time equivalent physicians and non-physician providers.
$1,400,000 $1,350,000 $1,300,000 $1,250,000 $1,200,000 $1,150,000
2006
2007
Figure 9.1 Net collected revenue per full time equivalent physician.
2008
52
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
actual number of FTE physicians working in the practice. The 2008 median range was $1,100,000 to $1,600,000. The median is $1,385,389.a The percentage growth rate over 2007 ($1,306,776) was 6.02%. The percentage growth rate of 2007 versus 2006 ($1,244,391) was 5.01%. Many economic factors contributed to the slower growth rate in 2008. There aren’t any data available for 2009 yet, but it should prove to be an interesting year. Some early anecdotal information suggests that the 2009 growth will be flat. It appears that practices that were primarily focused upon high dollar surgical procedures saw a decline in revenue in 2009. Practices that had a balanced portfolio of cosmetic services were able to weather the storm a little better and in some cases actually grew their revenue over 2008. REVENUE RATE PER HOUR PER FTE PHYSICIAN
The revenue rate per hour per FTE physician is another important number to monitor (Fig. 9.2). The pertinence of this metric is that helps physicians understand the value of their time. This measurement also helps achieve perspective pertaining to the physician’s daily activities. Example I have worked with many physicians who insist upon performing non-patient’s care-related projects in order to avoid the expense of paying someone else to do these projects. Some physicians undertake projects such as creating marketing materials or working on their website because it is a “hobby.” When this information was discovered, most of these physicians found a new hobby, hired additional personnel, or outsourced specific projects. By comparing the value of their time versus the much lower cost of finding the right person for the right job, most physicians opted to bring in additional personnel. The revenue rate per hour per FTE physician is calculated by dividing the actual net collected revenue of all of the physicians in the practice by the total number of physician hours worked. The hours worked assumes 1600 hours for an FTE physician and is adjusted for part-time physicians working less than 1600 hours. The median revenue rate per hour per FTE physician for 2008 was $866 per hour and the healthy benchmark range was from $625 to $1000 per hour.b The percentage
growth over previous years is similar to the growth seen in the net collected revenue per FTE provider. The percentage growth over 2007 ($817 per hour) was 6% and the percentage growth of 2007 over 2006 ($778 per hour) was 5.01%. NET COLLECTED REVENUE PER FTE NON-PHYSICIAN PROVIDER (MID-LEVEL PROVIDER)
Physician assistants and nurse practitioners continue to make a significant contribution to the profitability and quality of patient care in the aesthetic medical practice. The median net collected revenue value for 2008 was $426,468, which was an 8.89% growth over 2007. The 2008 growth percentage was lower than the 2007 versus 2006 growth percentage of 12.08%. The median value for 2007 was $391,667 and for 2006 it was $349,450.c The number of Physician Assistants and Nurse Practitioners continues to increase as more physicians understand the positive impact achieved by incorporating them into the practice. This is reflected by the positive growth seen in the number of practices that have a nonphysician provider (Fig. 9.3). In 2006, 22.5% of the practices in the Allergan database had an MLP/NPP. In 2007, the number was 24.5% and that grew to 28% in 2008.d The increase in the popularity of mid-level providers has been caused by several factors. The fact that the demand for specialized care has outpaced the supply of physicians for several years is one primary reason. Physician assistants and nurse practitioners have done a more than adequate job in helping practices meet this demand. Another reason contributing to their success is that they have been accepted by the patients. This acceptance continues to grow as the patients are educated and gain understanding of the qualifications and capabilities of physician assistants and nurse practitioners. This is supported by the consistently high scores they have earned on patient quality of care surveys conducted over the last few years (Fig. 9.4). NET COLLECTED REVENUE PER FTE AESTHETICIAN
The median value for aesthetician’s net collected revenue for 2008 was $132,281e (Fig. 9.5). This number reflects aesthetician services only. The median net collected revenue value for 2008 was $132,281, which was a 5.15% growth over 2007. The 2008 growth percentage
$880 $860 $840 $820 $800 $780 $760 $740 $720
2006
2007
2008
Figure 9.2 Revenue rate per hour per full time equivalent physician.
c a b
Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database.
d e
Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database.
FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%
2006
2007
2008
Figure 9.3 Practices with non-physician providers.
$500,000
$400,000
$300,000
$200,000
$100,000
$0
2006
2007
2008
Figure 9.4 Net collected revenue per FTE non-physician provider.
$64 $63 $62 $61 $60 $59 $58 $57 $56
2006
2007 Figure 9.5 Revenue rate per hour per FTE aesthetician.
2008
53
54
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
outperformed the 2007 versus 2006 growth percentage of 3.09%. The median value for 2007 was $125,799 and for 2006 it was $122,026. Product sales are not included in this number and will be reviewed separately. The aesthetician median revenue rate per hour for 2008 was $64 per hour, which was an increase of 4.92% over 2007 at $61 per hour. The aesthetician net collected revenue rate per hour for 2006 was $59 per hour. I have often debated with physicians regarding the value of offering aesthetician services in the cosmetic medical practice. The argument I hear from physicians and managers is that the aestheticians are barely breaking even when they look at the profit and loss statement. The first point I like to emphasize is that it is important to include the aesthetician’s revenue generated from product sales (Fig. 9.6). This is often approximately equal to the revenue generated from aesthetician services. The second point I like to make is that there is a value that is difficult to measure because of intangible factors. Aestheticians often offer gateway procedures that bring in new patients. If the practice has a conversion strategy in place, these new patients often convert to the higher valued services provided by the practice. Depending upon the job description and office infrastructure, many aestheticians contribute to the front and back office serving as back-up or patient educators.
RETAIL PRODUCT SALES
Retail product sales continue to be one of the biggest areas of opportunity for the cosmetic medical practice in regard to revenue earning opportunities. According to the 2009 market overview published by Kline & Company, the total cosmeceutical market volume for 2008 was $1,055,700,000. The market grew by 7.54% in 2008 over 2007. Medical care providers generated 26.4% or $279,200,000 of this volume, which represents an 11.5% growth change from 2007. Spas and salons continue to hold the lead position in the market share at 50.7% or $535,700,000 but experienced the slowest growth over 2007 at 5.4%. Retail stores have the lowest volume at $240,800,000 and were in second place with a growth of 8% over 2007f (Fig. 9.7). The fact that medical care providers hold only ¼ of the market share should be enough information to motivate most practices to take action. This is the low hanging fruit in my opinion because nobody knows more about skin health and maintenance than a qualified medical practice. To further emphasize this point, consider the following facts. The median retail sales volume per office in 2008 was $118,300 according to the 2008 Allergan Practice Consulting Financial Benchmarking database. This was one of the largest growth areas in the database at 28.3% over 2007, which was $92,204. The 2007 growth over 2006
$134,000 $132,000 $130,000 $128,000 $126,000 $124,000 $122,000 $120,000 $118,000 $116,000
2006
2007
2008
Figure 9.6 Net collected revenue per FTE aesthetician.
$120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0
2006
2007 Figure 9.7 Retail sales.
f
Source: 2009 Kline & Company.
2008
FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE of $86,597 was 11.47%.g This growth trend leads me to the conclusion that medical practices are beginning to recognize the opportunity this represents and are formulating strategies to better provide their patients with the highest quality of skincare products available. COSMETIC MEDICAL PRACTICE BENCHMARKS: EXPENSES
This section pertains to the less glamorous, but equally important area of cosmetic medical practice expenses. We will examine several areas which are traditionally the largest line item expense categories but are easily controlled with proper attention and focus. Similar to income categories, it is easier to measure your internal performance because you already have the data on hand and can compare it to data from previous years. Measuring against external data is more difficult because it is often harder to find. Inspecting the financial health of the medical practice requires vigilance on the part of the physician and management team. The physician needs to have a working knowledge of the components of a profit and loss statement, but as stated before, the physician should avoid being consumed with data analysis. There are several ratios and line items that can be evaluated to provide a snapshot of the financial health of the practice. When the financial numbers are running in the appropriate ranges, then scrutiny is sometimes relaxed because of a false sense of security. When they began to go outside of the desired ranges, then some practices increase their attention level to investigate more deeply into what is causing the fluctuations. Sometimes this can be too late to make quick course corrections. The goal should be to create a habit of reviewing the data on a monthly basis, which will enable the practice to make small course corrections as needed rather than trying to turn the ship away from the iceberg one minute before impact. OPERATING EXPENSE RATIO
The operating expense or overhead is the ongoing cost for running a business or all of the money you spend to run your practice. Fixed and variable expenses are the two main components of a practice’s total overhead expense. Fixed costs are those that do not fluctuate with changes in productivity or sales volume. Examples of fixed costs include rent, insurance, society dues, journal subscriptions, equipment leases, payments on loans, management salaries, and advertising. Variable costs are those that respond directly and proportionately to
changes in activity level or volume, such as surgical supplies, hourly wages and commissions, utilities, cosmeceutical inventory, office supplies, mailing, and shipping costs. The operating expense ratio is calculated by dividing the operating expenses by total practice net collected revenue. Operating expenses used in this ratio exclude physician and non-physician provider compensation, bonuses, retirement contributions, depreciation, and automobile expense. The cost of goods sold is included in the operating expenses. The benchmark healthy range of the operating expense ratio for the cosmetic medical practice in 2008 was 55% to 70%. The median was 66%, which is an increase of 3.8 percentage points. The median in 2007 was 62.2%, which was down from 62.8% in 2006h (Fig. 9.8). NON-PROVIDER PAYROLL RATIO
The non-provider payroll or the support staff payroll is traditionally the largest line item expense that a cosmetic medical practice has. This ratio is calculated by dividing the total non-provider gross payroll by the total net collected revenue. Payroll includes the gross wages but does not include employee benefits or payroll taxes. The median non-provider payroll ratio for 2008 was 15.6% with a benchmark healthy range of 12% to 18%. This was 1.3 percentage points higher than the 2007 median of 14.3%. The median for 2007 was slightly lower than 2006, which was 14.9%i (Fig. 9.9). Example If your net collected revenue is equal to the mean of the database at $1,385,389 and your non-provider payroll ratio is also at the mean value of 15.6%, then your yearly payroll should be around $216,121 to be considered within the healthy range. There are a couple of ways to verify whether your payroll ratio is right for your practice. The first is to calculate your number of FTE support staff per provider. FTE support staff includes all non-provider personnel working 2080 hours. The FTE number can be calculated by adding all support staff hours from your payroll summary report and dividing by 2080. In 2008, the FTE support staff ratio was 4.99 support staff to one provider. This is up from 2007, which was 4.46 and 2006, which was 4.33j (Fig. 9.10). The second method of verifying your payroll expenses is to compare your individual support staff positions to published data. The Health
66.00% 65.00% 64.00% 63.00% 62.00% 61.00% 60.00%
2006
2007
2008
Figure 9.8 Operating expense ratio.
g h
Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database.
55
i j
Source: Allergan/BSM Consulting Financial Database. Source: Allergan/BSM Consulting Financial Database.
56
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
Care Group conducts an annual Staff Salary Survey which provides nationwide salary statistics for 38 key office positions. It is organized by position, years of service, and locale and also provides data on benefits and turnover rates. One example of these data is for the position of medical assistant (MA). The data collected for this position came from 1248 surveys collected from multiple types of practices across the United States. An MA with less than 2 years of experience earned $12.41 per hour. An MA with 2 to 5 years of experience earned $13.52 per hour and one with more than 5 years of experience earned $15.32 per hour.k While these data are not specific to cosmetic medical practices, it is still very useful in gauging the range of salaries you will be competing with when recruiting. It is also a valuable measurement tool you can use to ensure that you are offering your current employees a competitive wage. It is also a useful management tool that can be used to improve employee performance by holding them to a higher standard if you are currently paying them at the top of the range. RENT EXPENSE RATIO
Many physicians I work with throw up their hands in surrender when the discussion turns to the rent. They basically say “it is what it is and it is something that I have no control over.” Whether you are paying a landlord or if you own the property and pay yourself, this ratio will at the least give you an idea of where you stand. You may not be in a
position to negotiate your rent now, but when the time comes you will know that there is a benchmark available regarding healthy ranges. The rent expense ratio is calculated by dividing the total practice rent by the total practice net collected revenue. Rent expense does not include additional occupancy expenses such as utilities and maintenance. The 2008 median rent expense ratio for cosmetic medical practices was 5% (Fig. 9.11). The rent expense ratio has increased slightly over the two previous years in which it was 4.7% in 2007 and 4.5% in 2006.l Example If your net collected revenue is equal to the mean of the database at $1,385,389 and your rent expense ratio is also at the mean value of 5% then your yearly rent should be around $69,269 to be considered within the healthy range. MARKETING EXPENSE
The discussion pertaining to marketing expense is usually very interesting. Some practices are lackadaisical in regard to advertising/ marketing their practice and consider the printing of business cards sufficient in meeting their needs. Other practices feel compelled to be on every billboard in town, on the back of the phone book, and on broadcast media once every hour. I will defer judgment on what is beneficial and what is not because each practice is different and what works for one may not work for another.
16.00%
15.50%
15.00%
14.50%
14.00%
13.50%
2006
2007
2008
Figure 9.9 Non-provider payroll ratio.
5.00 4.80 4.60 4.40 4.20 4.00
2006
2007
2008
Figure 9.10 Number of FTE support staff per FTE provider.
k
Source: The Healthcare Group – Year 2008.
l
Source: Allergan/BSM Consulting Financial Database.
FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE Two activities regarding marketing that have proven to be effective are as follows. The first is to maximize your internal marketing efforts before considering external marketing. It is more cost effective, easier to manage, and typically has a much higher return on investment. The other tip is to track your advertising. Whether it is internal or external marketing, it is very difficult to know what is working and what is most cost effective if you do not track and measure it. This can be easily accomplished by assigning each marketing program a unique identification code and adding a “How did you hear about us?” type of question to your intake form or on patient surveys. The mean value ratio of marketing expense for 2008 was 3.7% of the total net collected revenue. This ratio has continued to increase as demonstrated in 2007 when it was 3.4% and 2006 at 3.2%m (Fig . 9.12). Example If your net collected revenue is equal to the mean of the database at $1,385,389 and your marketing expense ratio is also at the mean value of 3.7% then your yearly marketing should be around $51,594 to be considered within the healthy range. TACTICAL OPPORTUNITIES
The financial benchmarks provide the healthy parameters for practice operations. If you are outside of the healthy range or if you want to
ensure that you stay there then the next question is usually “now what do I do?” If you have gone through the inspection and evaluation of your practice and you have identified areas of opportunity, the next step is to modify or take action. The financial health of your practice can be impacted by reviewing your internal controls and processes. A good place to begin is to review your cash-handling procedures. Ensure that you appropriately segregate duties. Investigate all areas in which cash and checks are handled. One good idea is to have different personnel receive the monies and another to post the payments. The goal is to minimize the risk of embezzlement by removing the temptation. A good offense is to create an oversight process that is known by all. It is important to educate the staff and to demonstrate that all cash handled is accounted for and scrutinized during all phases from landing in the mailbox to being deposited at the bank. This will effectively reduce the opportunity and temptation to embezzle by the fact that if the books do not add up at the end of the day then a full audit will be conducted and the loss will be identified. Example I worked with a practice many years ago that had just begun offering cosmetic services. Before then the practice was all medical and did not receive cash from the patients. The majority of the transactions were through third party payers. The checks came in the mail and went
5.00% 4.90% 4.80% 4.70% 4.60% 4.50% 4.40% 4.30% 4.20%
2006
2007
2008
Figure 9.11 Rent expense ratio.
3.70% 3.60% 3.50% 3.40% 3.30% 3.20% 3.10% 3.00% 2.90%
2006
2007 Figure 9.12 Marketing and advertising expense ratio.
m
Source: Allergan/BSM Consulting Financial Database.
57
2008
58
COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
straight to the bookkeeper. They did not have a process in place to receive cash payments directly from the patient. This all became evident during a financial benchmarking analysis. The chief concern from the physician was that they were performing more and more cosmetic procedures but the growth percentage was not in line with revenue. This was verified by comparing the productivity analysis report with income statement. The revenue growth was a flat and slightly smaller percentage than the aesthetic versus medical procedure growth. This was the first red flag. It was fairly simple to identify the problem and create a solution in this scenario. We simply discussed the cash flow process, identified the problem, and created a solution. The problem was that all cash received from patients was put into an unlocked drawer at the front desk. There was no cash tray, no lock box, no cash register, and no organization. Sometimes a handwritten receipt was given to the patient, but usually only if the patient asked for it. The cash was not regularly deposited, and sometimes weeks would pass between deposits. No one ever really knew how much cash was on hand or much less how much cash was supposed to be on hand. The cash was completely accessible to staff and patients. It was often treated as petty cash for staff lunches, office supplies, etc. It was also unattended which provided disgruntled employees and/or employees who thought they were underpaid or overworked the opportunity to supplement their income. The solution was to take away the opportunity by creating new cash-handling procedures with multiple waypoints for inspecting and auditing. A cash register was purchased and incorporated into the daily operations. The cash register provided organization and security. Each person performing check-out duties had an individual batch. These batches provided the link to the superbill and were reconciled at the end of each day. These minor changes effectively removed temptation and created the necessary oversight to ensure accurate accounting. EXTERNAL PROFESSIONALS
This is the right time to re-assess the relationships you have with external professionals. It amazes me that some businesses have not figured out that a down economy is one that you can’t take their business for granted in. The competition for the customer has increased dramatically, and these businesses don’t provide exemplary customer service and a high quality product, then the chances of being replaced increase exponentially.
finally established communications it took another week to receive the management report. To add insult to injury, the payroll company charged her a ridiculous fee for a document that they should have provided many months before. The result of this experience was that the medical practice now has a new payroll company that understands customer service and provides timely management reports as part of the service. The demand for better service applies to all professionals who support your practice. These are some questions that you need to ask yourself. Are you getting what you need from your current attorney, accountant, and consultants? Are they serving your practice to the best of their abilities, or have they taken your business for granted? Are they delivering timely, accurate, and useful information at a fair market price? Make sure you are getting your money’s worth and that you utilize them to the fullest. This is also a good time to review all of your insurance policies and evaluate the necessity. Are any of them redundant? You may want to consider having several brokers bid for your policies. EXPENSE CONTROL: NEW OPPORTUNITY
A new opportunity for aesthetic medical practices in the area of decreasing medical and surgical supply costs has recently emerged in the form of a group purchasing organization (GPO) offered by the Aesyntix Physician Network. This GPO can help practices achieve cost savings from 5% to 20% on their medical, surgical, and business supply purchases. It is endorsed by ADA/M and is a free service to ADA/M members. Additional information is available by following this link: http://www.corehc.com/articles.html. TACTIC: CREATE A BUDGET
The single biggest area of opportunity I have observed regarding fiscal responsibility in the medical practice lies in the area of budgeting. The days of falling backwards into the flowery fields of success have come to an end for most medical practices. Having a plan and a budget with operational and expenditure parameters is essential to successful daily operations. A budget is simply a financial planning tool that lists all planned expenses and revenues. It is a forecasting tool which enables the management team to apply appropriate intervention in a timely manner. A simple six-step process for creating a budget is outlined below. 1. Gather all historical income and expense financial data. 2. Separate into fixed and variable expenses. 3. Perform assessment of future trends and changes based upon past performance. 4. Establish expenditure limits. 5. Monitor and compare the actual results on a monthly basis (at a minimum) and compare it to the plan. 6. Make necessary changes and modifications.
Example I was recently conducting a financial analysis for one of my clients. They were having difficulty obtaining one document that we needed in order to complete the analysis. The document was a year-end payroll summary report. The practice administrator couldn’t get her payroll company representative to call her back for several weeks. When she
Table 9.2 Specialty Breakdown of Cosmetic Practices 2006 Specialty type Plastic surgery Facial plastics Oculoplastics Cosmetic dermatologya Total a
2007
2008
No. of practices
Percentage (%)
No. of practices
Percentage (%)
No. of practices
Percentage (%)
162 38 7 82 289
56.1 13.1 2.4 28.4 100.0
160 36 7 73 276
58.1 13.0 2.5 26.4 100.0
113 23 5 53 194
58.2 11.9 2.6 27.3 100.0
Dermatology practices where 50% or more of collections are attributable to cosmetic procedures.
FINANCIAL BENCHMARKING FOR THE AESTHETIC MEDICAL PRACTICE Make sure that you diligently work within the parameters of your budget. Celebrate success with your management team when this is accomplished. When you exceed the budget, strive to understand what happened. Have your management team provide the cause and then offer coaching and counseling to avoid going over budget in the future. Holding yourself and the management team accountable is essential to the success of budgetary compliance. The budget planning process will provide you with the information needed to implement changes. Appropriate oversight, accountability, and flexibility will help you achieve the goal of improved financial growth and stability for the practice. The first step to improve the financial strength of your practice is to take action. Find the time to work with your management team and
59
communicate what you are looking for and why it is important. Schedule monthly meetings to review the top line data and hold yourself and your team responsible for sustaining your financial diligence. SUPPLEMENTAL INFORMATION
Allergan/BSM Consulting Financial Database Parameters As of December 2009, the database includes information from 289 practices for 2006, 276 practices for 2007, and 194 practices for 2008. A breakdown of participating practices by specialty is illustrated on Table 9.2. Since participating offices typically provide data for the most recent complete year plus two previous years, the number of practices in the database for each year will continue to grow as additional practices submit their information.
10
Forms, forms, forms Kenneth Beer
Our lives as cosmetic specialists depend not only on our skills and education but on the various forms that define our daily practice. Whether these forms are on paper or in an electronic format, they are the means by which we document what we have done, define the risks and benefits to the patients and instruct them on what we expect them to do before and after each treatment. In broad terms, forms may be divided into pre-operative instructions, financial agreements, examination/ progress notes, procedure/ operative notes, consent forms, and postoperative care sheets. PRE-OPERATIVE
Pre-operative checklists for the operating room staff need to have all of the required lab and examination data checked off to ensure patient safety (Fig. 10.1). Equipment and instrumentation required for the procedure is also spelled out and this avoids the risk of delay that occurs when a procedure occurs without the correct equipment (Fig. 10.1). Good patient pre-operative forms articulate the dos and don’ts that will have an impact on the outcome of the procedure. The length and depth of this form depend on the level of invasion and impact of the procedure as well as the style of the physician and prevailing norms for the medical community in the area. For instance, some highly litigious areas will have several pages of pre-procedure instructions for a routine soft tissue augmentation procedure and this is the norm. In these locations, the form will be delivered to the patient and a signed, carbonless copy will be retained to document the transaction. For geographic areas that have more reasonable attitudes, the norm will be to either verbally discuss what is required or to provide a written form advising the patient on what they should and should not do. The length of the form should be long enough that it encompasses the various factors that will optimize outcomes but short enough that patients can read the form and integrate the information. For injectables such as soft tissue augmentation and botulinum toxins, many physicians do not routinely provide pre-operative forms but rather will advise the patient on ways to minimize bruising such as avoiding aspirin and other platelet inhibitors. Fractional lasers, intense pulsed lights, laser hair reduction, and vascular lasers require more pre-procedure instructions (such as sun avoidance and herpes prophylaxis) and thus the forms need to encompass the entire scope of pre-procedure requirements. Lack of proper information in the form for these procedures will result in postponement of procedures or increased rates of complications. As the level of invasiveness increases, the pre-operative form must also be more comprehensive. Thus, for breast augmentation, liposuction, blepharoplasty, and other procedures in this category the pre-operative forms need to be more encompassing and patients need to articulate and agree with the regimen prior to the procedure. Elements of a good pre-operative form include all elements of pre-operative preparedness. This may include preoperative antibiotics and antivirals (which need to be spelled out), avoidance of certain foods, supplements, and medications. In addition, if general anesthesia is involved, when the patient should refrain from eating needs to be carefully communicated. Laser and light procedures need to have sun avoidance discussed and treatments involving dark skin types should mention pre-treatment bleaching creams when appropriate.
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FINANCIAL AGREEMENTS
When and what type of financial agreements to use depend on the relationship with the patient (is it a first time consultation leading to a procedure or a patient you have known for decades?) and the amount of money involved. Bringing financial agreements into a consultation for botulinum toxins used in one area probably is not appropriate but not having one in place for a face lift is similarly inappropriate (Fig. 10.2). A good financial agreement needs to be clear about what is provided and how much it will cost. If a surgical procedure will involve a facility fee, anesthesia, and pathology charges, these need to be spelled out so that the patient has a complete understanding of the costs involved. In addition to these costs, what is not covered is also important to discuss. Some physicians routinely use antibiotics and pain medications and it makes sense to tell patients that the fee for this is or is not included (depending on whether the physician dispenses these drugs). When multiple procedures are contemplated (whether these are spaced out over time as in a fractional laser procedure or they are performed at the same time) each of these should be defined with a clear cost attached to it. If discounts are applied to these combinations, they should also be spelled out so that patients know that such discounts are only applicable when the entire program is performed. Despite the degree of preparation associated with each of these agreements, some patients will fail to honor them. Whether they believe that the results obtained were not “worth” the fee charged or they intentionally defraud the practice, there will be costs associated with recovering the fee if the physician chooses to pursue this route. If the physician intends to attempt to recover fees when this occurs, the costs associated with this need to be part of the financial forms. Financial forms are a necessary part of esthetic medicine and surgery but the degree of detail depends on the philosophy of the individual practitioner. EXAMINATION/PROGRESS NOTES
In order to capture the information about what was done to a patient, the data must be documented in a form devoted to this activity. In broad categories, injectables, lasers, intense pulsed lights, chemical peels, and sclerotherapy each require a separate progress note. Surgical procedures also require an operative note specific to each. No matter what the procedure, each form needs to have documentation of patient allergies, materials, devices and settings used, and areas treated. The fact that post-operative care is discussed and that a post-operative care sheet is given (if one does this routinely) is also documented. It is highly recommended that each form documents the fact that photographs were taken and by whom they were obtained. Notation of any adverse events should also be recorded. There are many different forms to choose from and in this section, I will detail some of the components that I find helpful but by no means find definitive (Figs. 10.3–10.8). Injectable forms typically have several sections (Fig. 10.3). The first ascertains whether or not the patient has any allergies. In addition, a section documenting the type of anesthetic and quantity used is included. A diagram of the face with the underlying muscle groups and folds typically targeted forms the middle of the form. This is used to sketch out what products have been used in each area so that a botulinum toxin dose can be documented in each of the muscles injected, fillers are diagrammed where injected and other notes are also made to
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FORMS, FORMS, FORMS
PREOPERATIVE CHECK LIST OPERATING SURGEON ________________________________ Patient Name_____________________________ Chart# _________________________________________ Date of Surgery: ______________________________________ Date of Pre-op: ____________________________
8:00 arrival
On-call for arrival time
Pre-op Nurse:_______________________________
PROCEDURE(S):_________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ TO BE COMPLETED PRIOR TO SURGERY: ()
Date pre-surgical packet sent___________________
()
Pre-op consent forms completed
()
Mentor gel consent *dated 7 days prior to sx
()
Labs:
( ) CBC, ( ) CMP, ( ) PT, PTT, ( ) EKG ( ) CXR ( ) STRESS TEST
Received
( ) CBC, ( ) CMP, ( ) PT,PTT, ( ) EKG ( ) CXR ( ) STRESS TEST
mail
email
Required
in person
N/A
Additional Orders:______________________________________________________________ Labs at S.P.S. ________________________________ ()
Medical Physician:______________________________
Medical Clearance Required Phone:______________________
Medical clearance received:__________
Faxed Request: _______________________ ()
Mammogram_________________________________
()
Prescriptions:___________________________________
()
Pre-op Pictures: Day of surgery
()
Implant (s): ___________________________________________________________________ Breast Implants:
Saline
Gel
Profile:
Required Called in
moderate
mod +
N/A
Under age 40
written script given
high
()
Implant (s) ordered: _____________________________________________________________
()
Operative garmet:
()
Weight:______________ Measurements:______________ Waist _________________Hips
Surgibra
Girdle _____________________________________________
copy of checklist to O.R.___/_____/____ _
Completed chart to O.R.____/_____/____
Account Balance Paid in Full________________________________ Reviewed by: ________________________________ Chart ready for Sx ( ) Yes ( ) No R.N. _________________________________ Chart ready for Sx ( ) Yes ( ) No Anesthesiologist _________________________________ Chart ready for Sx ( ) Yes ( ) No Surgeon Revised 05/22/08
Figure 10.1 A sample pre-operative checklist.
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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
MEDICAL HISTORY and PHYSICAL Patient Name: Patient No:
4241
Today’s Date:
11/6/2009
Surgery Date:
11/10/2009
Surgeon Name: Jason N.Pozner, M.D., F.A.C.S. AUGMENATION MAMMAPLASTY (Silicone): BILATERAL
Procedures: Chief Complaint:
Past History:
Family History:
Allergies: Medications: Operations – Minor: – Major:
Physical Findings:
BP: WNL
Temp:
Pulse:
Resp.
Abnormal Findings
Head Neck Chest Cardio–Vascular Abdominal Genito–Urinary Skin Bones and Joints Glandular Neuromuscular Working Diagnosis Physician’s Signature: Date: Figure 10.2 Pre-operative form for breast augmentation. (Continued)
Wt.
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FORMS, FORMS, FORMS
FINA NCIA L
P OLICIES As patients approach surgery, they frequently need information about the various payment options and have questions about their potential insurance benefits. We hope the following information will be helpful. Our financial coordinators are readily available to meet with you personally to provide the specific information you desire. They specialize in this area and will use their expertise to help you obtain the maximum benefits from your policy.
PAYMENT OPTIONS
Payment for cosmetic plastic surgery is due in full at the time of your preoperative visit. We provide a number of payment options which may be used individually or combined according to your wishes. CASH OR CHECK:–Personal check, cashier’s check, or cash. CREDIT CARDS:–Visa, Master Card, Discover or American Express.
OPTIONAL FINANCING PLANS: We will be happy to assist you with applying for financing should you so desire. INSURANCE COVERAGE
INSURANCE: Our practice does not accept insurance. If you are having a procedure that may be covered by insurance, we will be happy to provide you with insurance forms however payment is expected in full for all procedures. PATHOLOGY: On certain occations it will be necessary to send tissue samples to the pathologist for examination. The fee for this service will be billed directly to you the patient by the pathologist. We will inform you if this service is necessary and you can contact them regarding insurance coverage. Please discuss all arrangements regarding payment of your account with us.
CANCELLATION POLICY
We understand that a situation may arise that could force you to postpone your surgery. Please understand that such changes affect not only your surgeon but other patients as well. Dr. Pozner’s time, as well as that of the operating room staff, is a precious commodity, and we request your courtesy and concern. A non-retbndable deposit of 10% of your surgical fees are due at the time you book your surgery. The balance of your surgical fees are due 2 weeks before surgery. If you cancel your surgery within 48 hours, your fees will not be refunded. Surgery can only be rescheduled due to medical reasons. If you have any questions or need assistance with financial matters, please ask Valerie Pasqualini, R.N. to help you.
SIGNATURE
SIGNATURE: I understand and agree to the afore stated financial policies.
Signature of Patient Jason N. Pozne, MD., F.A.C.S. (561) 367-9101
Figure 10.2 (Continued).
Date
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COSMETIC BOOTCAMP PRIMER: COMPREHENSIVE AESTHETIC MANAGEMENT
BOTULINUM TOXIN TYPE A AND SOFT TISSUE AUGMENTATION/VOLUME REPLACEMENT OPERATIVE NOTE Patient Name Date of Birth
ALLERGIES
Date of Service
_________________ HX COLD SORES _________________ ANESTHESIA 1% lidocaine/septocaine/ citanest with 1:100k epi ml injected locally infraorbital mental
