Aesthetic Dermatology

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.

Dr. Robert Weiss, an expert and researcher for laser and energy devices, highly encourages dermatologists to consider at least one laser machine for their office. In this video, Dr. Weiss discusses various machines, and how you can take into account the size of your practice and patient population to choose the right device.

Dr. Robert Weiss, an expert and researcher for laser and energy devices, highly encourages dermatologists to consider at least one laser machine for their office. In this video, Dr. Weiss discusses various machines, and how you can take into account the size of your practice and patient population to choose the right device.

Dr. Robert Weiss, an expert and researcher for laser and energy devices, highly encourages dermatologists to consider at least one laser machine for their office. In this video, Dr. Weiss discusses various machines, and how you can take into account the size of your practice and patient population to choose the right device.

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.

ATLANTA – Noninvasive body contouring is the "new frontier" in dermatologic surgery, according to Dr. Michael S. Kaminer.

Last year in the United States, noninvasive contouring was performed more often than liposuction, and while the competition between devices is getting fierce, not all are created equal, said Dr. Kaminer, a dermatologist in private practice in Chestnut Hill, Mass.

In fact, only four devices are approved by the Food and Drug Administration for noninvasive fat removal. Of those, Dr. Kaminer discussed three for which the data – and his own experience – are most compelling: CoolSculpting, which destroys fat through cryolipolysis; Liposonix, which destroys fat using high-intensity focused ultrasound; and the Zerona laser, which destroys fat using LED light.

The CoolSculpting device from Zeltiq made its debut about 7 years ago and was approved in 2012 for fat reduction. Cryolipolysis induces apoptosis in the adipocyte, and then the body clears the dead fat cells.

Case reports suggest that CoolSculpting reduces fat by about 21%, on average, with a single procedure, Dr. Kaminer said at the annual meeting of the American Society for Dermatologic Surgery.

In some cases, 50% fat reduction can be achieved within 90 days. The effects, which include skin tightening, seem to be durable based on 4-year follow-up studies, he said.

In a small pilot study in his practice, Dr. Kaminer found that 80% of patients were happy (rating their improvement as at least a 7 on a scale of 1-10) after a single procedure. The remaining 20% reached that level of satisfaction after a second treatment.

CoolSculpting is particularly useful for treating fat at the bra line and at the waist, with these areas typically requiring two or three treatments in his office, he said.

The CoolCurve+, a new applicator developed by Zeltiq to expand the capabilities of the CoolSculpting device, allows for treatment in more areas.

Liposonix from Solta Medical destroys unwanted subcutaneous adipose tissue and fat using high-intensity focused ultrasound. This device "made a big splash" when it was approved specifically for noninvasive waist circumference reduction in 2011, Dr. Kaminer said.

Most of the end effects are based on heat, although there is some mechanical or acoustical component that disrupts and "basically kills" the fat cells. Some evidence also suggests that this device promotes contraction and thickening of collagen, thereby tightening the skin.

"I think the jury may still be out on that one ... I don’t know if it is a skin-tightening device, but I haven’t seen any proof that would say that it definitely is," he said.

One particular benefit of this device is its customizability. The transducer can be used more heavily in areas where there is more fat and lighter in areas where there is less fat, and it can be worked around the umbilicus in those with an umbilical hernia, so it can be used more as a sculpting device than a "bulk fat remover," he said.

Patient comfort can be an issue with this device. "This hurts, so what we’ve started to do is use a low fluence, multiple-pass protocol," he said. When low fluencies are used, no pain medicine is needed. The exception is treatment of the sensitive inner thighs.

The Zerona laser from Erchonia Medical is approved for general body contouring and basically uses low-level laser therapy to deliver light to the skin. "The key effect of Zerona – and this is sort of the concept that I think we are all going to have to start to think about and decide if we buy it – is the concept of a transitory pore, which is basically a hole that’s poked into a fat cell by exposing it to 635-nm red light," he said. The fat leaks out of the adipocytes, causing long-lasting and perhaps permanent change.

Dr. Kaminer said that he uses CoolSculpting as his "go-to device" for love handles, bra line, and abdomen treatments. The workflow is easy: A nurse can put the applicator on and the patient can read a book for an hour or watch television. This treatment – like any treatment that uses suction – can be problematic in patients with an umbilical hernia, however, he added.

The Liposonix device also can do a nice job on the abdomen and love handles, and perhaps the bra line, and it is really the only device that can be used on the arms and the outer and inner thighs, which "respond really nicely to Liposonix," he said. Treatment can be painful, however, and this can be limiting in some practices.

Dr. Kaminer has been a consultant to Thermage, Sciton, and Zeltiq and has stock ownership or options in Cabochon, Miramar Labs, and Thermage.

ATLANTA – Noninvasive body contouring is the "new frontier" in dermatologic surgery, according to Dr. Michael S. Kaminer.

Last year in the United States, noninvasive contouring was performed more often than liposuction, and while the competition between devices is getting fierce, not all are created equal, said Dr. Kaminer, a dermatologist in private practice in Chestnut Hill, Mass.

In fact, only four devices are approved by the Food and Drug Administration for noninvasive fat removal. Of those, Dr. Kaminer discussed three for which the data – and his own experience – are most compelling: CoolSculpting, which destroys fat through cryolipolysis; Liposonix, which destroys fat using high-intensity focused ultrasound; and the Zerona laser, which destroys fat using LED light.

The CoolSculpting device from Zeltiq made its debut about 7 years ago and was approved in 2012 for fat reduction. Cryolipolysis induces apoptosis in the adipocyte, and then the body clears the dead fat cells.

Case reports suggest that CoolSculpting reduces fat by about 21%, on average, with a single procedure, Dr. Kaminer said at the annual meeting of the American Society for Dermatologic Surgery.

In some cases, 50% fat reduction can be achieved within 90 days. The effects, which include skin tightening, seem to be durable based on 4-year follow-up studies, he said.

In a small pilot study in his practice, Dr. Kaminer found that 80% of patients were happy (rating their improvement as at least a 7 on a scale of 1-10) after a single procedure. The remaining 20% reached that level of satisfaction after a second treatment.

CoolSculpting is particularly useful for treating fat at the bra line and at the waist, with these areas typically requiring two or three treatments in his office, he said.

The CoolCurve+, a new applicator developed by Zeltiq to expand the capabilities of the CoolSculpting device, allows for treatment in more areas.

Liposonix from Solta Medical destroys unwanted subcutaneous adipose tissue and fat using high-intensity focused ultrasound. This device "made a big splash" when it was approved specifically for noninvasive waist circumference reduction in 2011, Dr. Kaminer said.

Most of the end effects are based on heat, although there is some mechanical or acoustical component that disrupts and "basically kills" the fat cells. Some evidence also suggests that this device promotes contraction and thickening of collagen, thereby tightening the skin.

"I think the jury may still be out on that one ... I don’t know if it is a skin-tightening device, but I haven’t seen any proof that would say that it definitely is," he said.

One particular benefit of this device is its customizability. The transducer can be used more heavily in areas where there is more fat and lighter in areas where there is less fat, and it can be worked around the umbilicus in those with an umbilical hernia, so it can be used more as a sculpting device than a "bulk fat remover," he said.

Patient comfort can be an issue with this device. "This hurts, so what we’ve started to do is use a low fluence, multiple-pass protocol," he said. When low fluencies are used, no pain medicine is needed. The exception is treatment of the sensitive inner thighs.

The Zerona laser from Erchonia Medical is approved for general body contouring and basically uses low-level laser therapy to deliver light to the skin. "The key effect of Zerona – and this is sort of the concept that I think we are all going to have to start to think about and decide if we buy it – is the concept of a transitory pore, which is basically a hole that’s poked into a fat cell by exposing it to 635-nm red light," he said. The fat leaks out of the adipocytes, causing long-lasting and perhaps permanent change.

Dr. Kaminer said that he uses CoolSculpting as his "go-to device" for love handles, bra line, and abdomen treatments. The workflow is easy: A nurse can put the applicator on and the patient can read a book for an hour or watch television. This treatment – like any treatment that uses suction – can be problematic in patients with an umbilical hernia, however, he added.

The Liposonix device also can do a nice job on the abdomen and love handles, and perhaps the bra line, and it is really the only device that can be used on the arms and the outer and inner thighs, which "respond really nicely to Liposonix," he said. Treatment can be painful, however, and this can be limiting in some practices.

Dr. Kaminer has been a consultant to Thermage, Sciton, and Zeltiq and has stock ownership or options in Cabochon, Miramar Labs, and Thermage.

ATLANTA – Noninvasive body contouring is the "new frontier" in dermatologic surgery, according to Dr. Michael S. Kaminer.

Last year in the United States, noninvasive contouring was performed more often than liposuction, and while the competition between devices is getting fierce, not all are created equal, said Dr. Kaminer, a dermatologist in private practice in Chestnut Hill, Mass.

In fact, only four devices are approved by the Food and Drug Administration for noninvasive fat removal. Of those, Dr. Kaminer discussed three for which the data – and his own experience – are most compelling: CoolSculpting, which destroys fat through cryolipolysis; Liposonix, which destroys fat using high-intensity focused ultrasound; and the Zerona laser, which destroys fat using LED light.

The CoolSculpting device from Zeltiq made its debut about 7 years ago and was approved in 2012 for fat reduction. Cryolipolysis induces apoptosis in the adipocyte, and then the body clears the dead fat cells.

Case reports suggest that CoolSculpting reduces fat by about 21%, on average, with a single procedure, Dr. Kaminer said at the annual meeting of the American Society for Dermatologic Surgery.

In some cases, 50% fat reduction can be achieved within 90 days. The effects, which include skin tightening, seem to be durable based on 4-year follow-up studies, he said.

In a small pilot study in his practice, Dr. Kaminer found that 80% of patients were happy (rating their improvement as at least a 7 on a scale of 1-10) after a single procedure. The remaining 20% reached that level of satisfaction after a second treatment.

CoolSculpting is particularly useful for treating fat at the bra line and at the waist, with these areas typically requiring two or three treatments in his office, he said.

The CoolCurve+, a new applicator developed by Zeltiq to expand the capabilities of the CoolSculpting device, allows for treatment in more areas.

Liposonix from Solta Medical destroys unwanted subcutaneous adipose tissue and fat using high-intensity focused ultrasound. This device "made a big splash" when it was approved specifically for noninvasive waist circumference reduction in 2011, Dr. Kaminer said.

Most of the end effects are based on heat, although there is some mechanical or acoustical component that disrupts and "basically kills" the fat cells. Some evidence also suggests that this device promotes contraction and thickening of collagen, thereby tightening the skin.

"I think the jury may still be out on that one ... I don’t know if it is a skin-tightening device, but I haven’t seen any proof that would say that it definitely is," he said.

One particular benefit of this device is its customizability. The transducer can be used more heavily in areas where there is more fat and lighter in areas where there is less fat, and it can be worked around the umbilicus in those with an umbilical hernia, so it can be used more as a sculpting device than a "bulk fat remover," he said.

Patient comfort can be an issue with this device. "This hurts, so what we’ve started to do is use a low fluence, multiple-pass protocol," he said. When low fluencies are used, no pain medicine is needed. The exception is treatment of the sensitive inner thighs.

The Zerona laser from Erchonia Medical is approved for general body contouring and basically uses low-level laser therapy to deliver light to the skin. "The key effect of Zerona – and this is sort of the concept that I think we are all going to have to start to think about and decide if we buy it – is the concept of a transitory pore, which is basically a hole that’s poked into a fat cell by exposing it to 635-nm red light," he said. The fat leaks out of the adipocytes, causing long-lasting and perhaps permanent change.

Dr. Kaminer said that he uses CoolSculpting as his "go-to device" for love handles, bra line, and abdomen treatments. The workflow is easy: A nurse can put the applicator on and the patient can read a book for an hour or watch television. This treatment – like any treatment that uses suction – can be problematic in patients with an umbilical hernia, however, he added.

The Liposonix device also can do a nice job on the abdomen and love handles, and perhaps the bra line, and it is really the only device that can be used on the arms and the outer and inner thighs, which "respond really nicely to Liposonix," he said. Treatment can be painful, however, and this can be limiting in some practices.

Dr. Kaminer has been a consultant to Thermage, Sciton, and Zeltiq and has stock ownership or options in Cabochon, Miramar Labs, and Thermage.

LAS VEGAS – The 595-nm pulsed dye laser, which allows for the application of 8 micropulses instead of a single pulse is one go-to device for treating vascular lesions, according to Dr. Melanie Palm.

"This allows me to use higher fluences without some of that eggplant purple discoloration or purpura that I would get if I used higher fluences in earlier generations of this laser," Dr. Palm said at the annual meeting of the American Academy of Cosmetic Surgery.

For example, when treating nasal telangiectasias, Dr. Palm said she sets the parameters to a fluence of 13-15 J/cm², a pulse width of 40 milliseconds, and a spot size of 7 mm. "Using this new platform, I don’t get any of the purpura that you would expect with the more traditional 585-nm pulsed dye laser," said Dr. Palm, a dermatologist in Solana Beach, Calif.

Dr. Palm said she also has used the 595-nm pulsed dye laser (PDL) to treat rosacea, cherry angiomas, venous lakes, vascular malformations, postinflammatory erythema, striae distensae, scars, and purpura. "I will often combine treatments," she continued. For scars, she may combine 5-fluorouracil and intralesional Kenalog (triamcinolone), and immediately treat with the 595-nm PDL set to a fluence of 8 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. For recalcitrant warts, she will often try intralesional bleomycin combined with the 595-nm PDL set to a fluence of 1-15 J/cm², a pulse width of 1.5 milliseconds, and a spot size of 7 mm. "If the 595-nm PDL is the only laser in your office, you can use it to treat solar lentigines and other pigmentary disorders with some success," Dr. Palm said. "I also use it a lot for posttreatment bruising."

Intense pulsed light (IPL) is another technology Dr. Palm said she uses to treat vascular lesions. When discussing this technology with her patients, "I set the expectation that this is going to involve multiple treatments," Dr. Palm said. "I’ll often show them right after treatment that the vessels have gone into vasospasm. They have disappeared, but they will come back, and it will be several weeks before they see improvement."

Dr. Palm said she typically uses lidocaine cream as a numbing agent to improve patient comfort prior to IPL procedures. "But if patients want a stronger numbing agent, I mix lidocaine with tetracaine, which has a tendency to cause flushing," she said. "You can also use a hair dryer to aggravate erythema on the face prior to treatment."

Dr. Palm said she often uses the 515-nm filter with IPL energy applied in triple pulses to treat facial erythema. For facial telangiectasias, she typically uses the 560-nm filter with IPL energy applied in double pulses. "For stubborn spots, I switch to a smaller treatment hand piece, which creates higher fluence," she said.

Dr. Palm said she advises clinicians to be aggressive in treating postoperative scars. "If I see some redness, I’ll often treat as early as 1 month after treatment, using either a PDL or an IPL," she said. If she uses a PDL, she sets it to a fluence of 7-10 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. If she uses an IPL, she employs a 560-nm filter, and sets the device to a fluence of 16-18 J/cm² and a pulse width of 4 milliseconds.

To treat postprocedural bruising, Dr. Palm said she may use a PDL set to a fluence of 6 J/cm², a pulse width of 6 milliseconds, and a spot size of 10 mm. If she opts to treat the bruising with an IPL, she employs a 560-nm filter and sets the device to a fluence of 13-15 J/cm² and a pulse width of 4 milliseconds, and applies it in a double-pulse fashion. "You want to titrate the fluence inversely to the degree of bruising," Dr. Palm advised. "If you have an intense bruise, you want to decrease the fluence. If it’s a light bruise, you want to use higher fluences," she said. "I typically use a single pulse. You want to avoid pulse stacking because you can make the bruising worse. I don’t just treat where the bruise is. I treat within a centimeter around the bruised area as well."

Dr. Palm also discussed her experience using the Q-switched Nd:YAG double-frequency 532-nm laser as "a peel" to treat facial redness. "It’s usually a single-pass treatment that uses a double-frequency 1,064 Nd:YAG platform," she said. "I typically use an 8-mm hand piece set to a fluence of 3.5-5 J/cm². Results are usually apparent within one to two treatments," she noted.

Dr. Palm disclosed that she is a speaker for Valeant, Medicis, and Lumenis. She is also a consultant for Lutronic.

d.brunk@elsevier.com

LAS VEGAS – The 595-nm pulsed dye laser, which allows for the application of 8 micropulses instead of a single pulse is one go-to device for treating vascular lesions, according to Dr. Melanie Palm.

"This allows me to use higher fluences without some of that eggplant purple discoloration or purpura that I would get if I used higher fluences in earlier generations of this laser," Dr. Palm said at the annual meeting of the American Academy of Cosmetic Surgery.

For example, when treating nasal telangiectasias, Dr. Palm said she sets the parameters to a fluence of 13-15 J/cm², a pulse width of 40 milliseconds, and a spot size of 7 mm. "Using this new platform, I don’t get any of the purpura that you would expect with the more traditional 585-nm pulsed dye laser," said Dr. Palm, a dermatologist in Solana Beach, Calif.

Dr. Palm said she also has used the 595-nm pulsed dye laser (PDL) to treat rosacea, cherry angiomas, venous lakes, vascular malformations, postinflammatory erythema, striae distensae, scars, and purpura. "I will often combine treatments," she continued. For scars, she may combine 5-fluorouracil and intralesional Kenalog (triamcinolone), and immediately treat with the 595-nm PDL set to a fluence of 8 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. For recalcitrant warts, she will often try intralesional bleomycin combined with the 595-nm PDL set to a fluence of 1-15 J/cm², a pulse width of 1.5 milliseconds, and a spot size of 7 mm. "If the 595-nm PDL is the only laser in your office, you can use it to treat solar lentigines and other pigmentary disorders with some success," Dr. Palm said. "I also use it a lot for posttreatment bruising."

Intense pulsed light (IPL) is another technology Dr. Palm said she uses to treat vascular lesions. When discussing this technology with her patients, "I set the expectation that this is going to involve multiple treatments," Dr. Palm said. "I’ll often show them right after treatment that the vessels have gone into vasospasm. They have disappeared, but they will come back, and it will be several weeks before they see improvement."

Dr. Palm said she typically uses lidocaine cream as a numbing agent to improve patient comfort prior to IPL procedures. "But if patients want a stronger numbing agent, I mix lidocaine with tetracaine, which has a tendency to cause flushing," she said. "You can also use a hair dryer to aggravate erythema on the face prior to treatment."

Dr. Palm said she often uses the 515-nm filter with IPL energy applied in triple pulses to treat facial erythema. For facial telangiectasias, she typically uses the 560-nm filter with IPL energy applied in double pulses. "For stubborn spots, I switch to a smaller treatment hand piece, which creates higher fluence," she said.

Dr. Palm said she advises clinicians to be aggressive in treating postoperative scars. "If I see some redness, I’ll often treat as early as 1 month after treatment, using either a PDL or an IPL," she said. If she uses a PDL, she sets it to a fluence of 7-10 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. If she uses an IPL, she employs a 560-nm filter, and sets the device to a fluence of 16-18 J/cm² and a pulse width of 4 milliseconds.

To treat postprocedural bruising, Dr. Palm said she may use a PDL set to a fluence of 6 J/cm², a pulse width of 6 milliseconds, and a spot size of 10 mm. If she opts to treat the bruising with an IPL, she employs a 560-nm filter and sets the device to a fluence of 13-15 J/cm² and a pulse width of 4 milliseconds, and applies it in a double-pulse fashion. "You want to titrate the fluence inversely to the degree of bruising," Dr. Palm advised. "If you have an intense bruise, you want to decrease the fluence. If it’s a light bruise, you want to use higher fluences," she said. "I typically use a single pulse. You want to avoid pulse stacking because you can make the bruising worse. I don’t just treat where the bruise is. I treat within a centimeter around the bruised area as well."

Dr. Palm also discussed her experience using the Q-switched Nd:YAG double-frequency 532-nm laser as "a peel" to treat facial redness. "It’s usually a single-pass treatment that uses a double-frequency 1,064 Nd:YAG platform," she said. "I typically use an 8-mm hand piece set to a fluence of 3.5-5 J/cm². Results are usually apparent within one to two treatments," she noted.

Dr. Palm disclosed that she is a speaker for Valeant, Medicis, and Lumenis. She is also a consultant for Lutronic.

d.brunk@elsevier.com

LAS VEGAS – The 595-nm pulsed dye laser, which allows for the application of 8 micropulses instead of a single pulse is one go-to device for treating vascular lesions, according to Dr. Melanie Palm.

"This allows me to use higher fluences without some of that eggplant purple discoloration or purpura that I would get if I used higher fluences in earlier generations of this laser," Dr. Palm said at the annual meeting of the American Academy of Cosmetic Surgery.

For example, when treating nasal telangiectasias, Dr. Palm said she sets the parameters to a fluence of 13-15 J/cm², a pulse width of 40 milliseconds, and a spot size of 7 mm. "Using this new platform, I don’t get any of the purpura that you would expect with the more traditional 585-nm pulsed dye laser," said Dr. Palm, a dermatologist in Solana Beach, Calif.

Dr. Palm said she also has used the 595-nm pulsed dye laser (PDL) to treat rosacea, cherry angiomas, venous lakes, vascular malformations, postinflammatory erythema, striae distensae, scars, and purpura. "I will often combine treatments," she continued. For scars, she may combine 5-fluorouracil and intralesional Kenalog (triamcinolone), and immediately treat with the 595-nm PDL set to a fluence of 8 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. For recalcitrant warts, she will often try intralesional bleomycin combined with the 595-nm PDL set to a fluence of 1-15 J/cm², a pulse width of 1.5 milliseconds, and a spot size of 7 mm. "If the 595-nm PDL is the only laser in your office, you can use it to treat solar lentigines and other pigmentary disorders with some success," Dr. Palm said. "I also use it a lot for posttreatment bruising."

Intense pulsed light (IPL) is another technology Dr. Palm said she uses to treat vascular lesions. When discussing this technology with her patients, "I set the expectation that this is going to involve multiple treatments," Dr. Palm said. "I’ll often show them right after treatment that the vessels have gone into vasospasm. They have disappeared, but they will come back, and it will be several weeks before they see improvement."

Dr. Palm said she typically uses lidocaine cream as a numbing agent to improve patient comfort prior to IPL procedures. "But if patients want a stronger numbing agent, I mix lidocaine with tetracaine, which has a tendency to cause flushing," she said. "You can also use a hair dryer to aggravate erythema on the face prior to treatment."

Dr. Palm said she often uses the 515-nm filter with IPL energy applied in triple pulses to treat facial erythema. For facial telangiectasias, she typically uses the 560-nm filter with IPL energy applied in double pulses. "For stubborn spots, I switch to a smaller treatment hand piece, which creates higher fluence," she said.

Dr. Palm said she advises clinicians to be aggressive in treating postoperative scars. "If I see some redness, I’ll often treat as early as 1 month after treatment, using either a PDL or an IPL," she said. If she uses a PDL, she sets it to a fluence of 7-10 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. If she uses an IPL, she employs a 560-nm filter, and sets the device to a fluence of 16-18 J/cm² and a pulse width of 4 milliseconds.

To treat postprocedural bruising, Dr. Palm said she may use a PDL set to a fluence of 6 J/cm², a pulse width of 6 milliseconds, and a spot size of 10 mm. If she opts to treat the bruising with an IPL, she employs a 560-nm filter and sets the device to a fluence of 13-15 J/cm² and a pulse width of 4 milliseconds, and applies it in a double-pulse fashion. "You want to titrate the fluence inversely to the degree of bruising," Dr. Palm advised. "If you have an intense bruise, you want to decrease the fluence. If it’s a light bruise, you want to use higher fluences," she said. "I typically use a single pulse. You want to avoid pulse stacking because you can make the bruising worse. I don’t just treat where the bruise is. I treat within a centimeter around the bruised area as well."

Dr. Palm also discussed her experience using the Q-switched Nd:YAG double-frequency 532-nm laser as "a peel" to treat facial redness. "It’s usually a single-pass treatment that uses a double-frequency 1,064 Nd:YAG platform," she said. "I typically use an 8-mm hand piece set to a fluence of 3.5-5 J/cm². Results are usually apparent within one to two treatments," she noted.

Dr. Palm disclosed that she is a speaker for Valeant, Medicis, and Lumenis. She is also a consultant for Lutronic.

d.brunk@elsevier.com

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

d.brunk@elsevier.com

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

d.brunk@elsevier.com

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

d.brunk@elsevier.com