Aesthetic Tips Glynis R. Ablon, MD

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1 Aesthetic Tips Glynis R. Ablon, MD Dr. Ablon began by emphasizing the benefits of combination treatment in aesthetics and described her triple threat technique for treating the neck and periorbital region. For the neck, she recommends a combination of (1) submental skin snip along the mental crease to remove excess submental skin, (2) superficial microdroplets of hyaluronic acid fillers for horizonal bands, and (3) Erbium resurfacing for textural changes. Neuromodulator and radiofrequency can also be added to this combination treatment. Dr. Ablon emphasizes the importance of understanding the anatomy in all aesthetic procedures. For the periorbital area, Dr. Ablon recommends (1) neuromodulator, (2) a tightening device either invasive or non-invasive, and (3) lower lid filler either hyaluronic acid or fat transfer. It is important to address both the upper and lower lid, treating wrinkling, infraorbital hollowing, descent of fat pads, dynamic muscle wrinkling, and brow asymmetry. Fillers should be used to make the area smooth, but be careful not to overfill the area and create a shelf, making the lower lid look unnatural. Dr. Ablon advises being conservative at the first treatment and bring them back in a month for further treatment. It is also important to remember that filler will retain a lot of water, so be careful in choosing the correct product. Key Indicators of Practice Health David Wagener, MBA, CPA The most basic indicator of your practice health is whether or not you are making a living. It is important for a practice owner to identify what bench marks they want to monitor and how to go about it. Know your plans and goals and make sure to check in to see if you are on the right track. If your goal is to reduce a no-show rate make appropriate changes and make sure to monitor your progress. Some other possible key performance indicators include gross billings / collections, patient encounters, % new versus established patients, service mix, payer mix, days revenue in accounts receivable, accounts receivable aging, waiting time. Formula for days revenue in accounts receivable is accounts receivable/ DRA = days in accounts receivable. Other indicators of practice health include being up to date on MACRA, OSHA, CLIA, HIPPA, refund activity and turnover. If you are not doing a good number of patient refunds on a daily basis you are doing something wrong! Patients appreciate receiving refunds and it goes a long way. Take away message, choose the indicators that are pertinent to you and readily accessible, report on them and monitor trends. Non-CME: Marketing Doesn t Stop with the Sale Cheryl Whitman Beautiful Forever is the business owned by Cheryl and here we talk about how marketing doesn t end with a sale. It s important to focus on what the next step is after somebody has left the practice. It is important to have follow-up protocol. It is more cost effective to keep existing patient relationships then to acquire new patients. Nurture existing patients, and have your

2 practice have something that stands out from the rest. Have your unique sales point be 1 or 2 topics that you would consider yourself an expert on. When it comes to happy patients, seize the opportunity to get a testimonial. Have your patients be your advocate. Word of mouth marketing is very important, and is often times much higher when patients are not happy. Foster patient relationships by sending thank you cards, birthday cards, and really make the effort to make the patient feel appreciated. Know your target market, a millennial versus a man versus a female. Know how to market to each individually. Stay engaged with your patients through utilizing social media. If you can t do it, hire someone who can! The key is to build your patient loyalty. Ask the Experts: Complications Roundtable Discussion Session Director: David Goldberg MD, JD Filler Complications Joel Cohen, MD When injecting anywhere you have to think about anatomical area and where the vessels are. When injecting glabella use less volume. It has also been seen that when using filler, waiting to use it 1-2 weeks after neurotoxins leads to having to use less filler. When people want two things done on the same day, both filler and neurotoxin, then do filler first then neurotoxin. Occlusion of facial artery giving off to the angular artery looks like a mottled patter on the medial cheek. Chin augmentation complications include mental artery occlusion leading to a bruising on the lateral chin. Do not discontinue patients who are on therapeutic anticoagulants. It is encouraged that patients stop supplements with blood thinning properties. For patients with post procedure ecchymosis, pulse dye laser is recommended. When we see a patient with a nodule it is important to differentiate if it s inflammatory versus non-inflammatory. If it is inflammatory, culture it. If you do a delayed culture for micro-bacterium many times it will come back positive for inflammatory nodules. Laser Complications Michael H. Gold, MD Patient went to a med-spa for hair-removal on the back and received poorly done IPL. The patient had hypopigmentation until 1-year after which was treated with micro-needling. Dr. Goldberg recommends doing the excimer laser for this case. A patient with post ALA-PDT had red streaks on the face. Patient did not want to treat with steroid but wanted relief. Next patient had an IPL burn on the dorsal hand. The question is how to heal these patients. Dr. Gold recommends using a cosmeceutical with growth-factors. What caused these reactions? Both patients had gone for walks outdoors and therefore this is attributed to being in the sun. Ultherapy causing superficial ultra sound injury in the high dermis, it goes away in a few days. Peri-Oral Combination Rejuvenation: Integrating Resurfacing, BTX-A, and Fillers Dr. Joel Cohen, MD

3 There is not one simple answer to rejuvenating the perioral region. Combination therapy utilizing neuromodulators (NM), fillers, and resurfacing is needed to best address this area. It is critical to carefully evaluate each patient. Patients with etched lines to the upper cutaneous lip apparent at rest are good candidates for fillers and resurfacing, while those with etched lines that are created by mechanical animations will benefit from a NM. Pretreatment should be done with NM 1-2 weeks before additional therapy with fillers and resurfacing. Caution should be taken to not use too high of a NM dose to soften the perioral region. Duration of result should be about 3 months. For etched lines at rest, filler such as Restylane Silk or Belotero can be directly injected into the lines if bigger than the tip of the needle itself. Many patients take a host of over-thecounter supplements such as fish oil and glucosamine that can thin the blood and cause bruising to occur for 7-10 days. Patients need to be aware of the downtime involved with the procedure. When augmenting the body of the lip, small aliquot injections of filler should be placed into the tubercle/projection points. Injections that are too superficial or in excess can distort the lip and cause fibroplasia that will change the appearance of the lip. Often patients are uncertain of the lip fullness they desire. The Merz Lip Fullness Grading Scale can be a good guide to help objectively identify the degree of fullness patients are seeking. Fractional ablative and full field ablative erbium laser to the face is instrumental in targeting deep perioral etched lines. Utilizing ablative erbium laser can significantly improve the peau d orange appearance of the perioral region. Pretreatment with NM 1-2 weeks prior to resurfacing therapy can be beneficial to the healing stage post-therapy via preventing mechanical actions that result in dynamic etched lines. Female Rejuvenation Dr. Jason Pozner, MD Vaginal health concerns is prevalent among many parous and post-menopausal women. Weakening of the pelvic diaphragm and associated muscles with childbirth, especially seen in twin birth, can lead to alteration of the vaginal appearance, laxity, stress urinary incontinence, overactive bladder syndrome, pelvic organ prolapse and fecal incontinence. In the same regard, lower production of estrogen due to menopause leads to vaginal epithelium dryness, irritation, and often dyspareunia due to less lubrication. Treatment options that exist for urinary incontinence and pelvic organ prolapse include surgical procedures such as slings/mesh and vaginal pessaries, respectively. However, women often do not want surgical therapy. In the same regard, topical estrogen creams as well as estrogen hormone pills to address post-menopausal dryness and irritation exist but may not be an appealing/safe option (women with a history of breast cancer) to patients.

4 This is where devices can be instrumental to vaginal rejuvenation to improve both functional and sexual health. The devices can be divided as lasers (fractional CO2, Erbium, and Hybrid 1470/erbium) or radiofrequency (RF). There is much clinical data and short-term studies that exist to support these devices being effective to address vaginal rejuvenation. Combination therapies of both laser and RF devices probably yield the best results. Other devices that exist include magnetic field therapy which works by providing continual contractions or Kegels to address strengthening the pelvic diaphragm, as well as low level light/heat devices, which can be used in the comfort of the patient s home to remodel vaginal tissue. Combination in Aesthetics Susan H. Weinkle, MD Dr. Susan Weinkle provided patient before and after photos along with each case s specific multiple modality approach to emphasize the importance of combination aesthetics. Dr. Weinkle s approach is to take care of the outer envelope and then work inward. She gave examples of her patient s problematic areas, and showed all of the modalities she utilized in order to provide a natural, youthful face for that individual. Dr. Weinkle has learned the incredible benefits of starting with a Jessner chemical peel. Once you improve one aspect of the face, both the patient and practitioner become suddenly aware of other problematic regions previously overlooked. With the explosion of social media and the epidemics of selfies - there has been an increase in cosmetic procedures on the nose- both non-surgical and surgical. If performing a non-surgical rhinoplasty, Dr. Weinkle advises to always take before and after photos. Often, patients forget their old face as they become accustomed to their new look. The non-surgical rhinoplasty or the liquid nose job has little to no down time, there is minimal pain, and cost is lower than rhinoplasty. She cautions to not overfill and has found she can obtain a more desired outcome over two appointments. Dr. Weinkle also has obtained incredible outcomes for her patients through the use of Kybella to correct jowls. By pulling the jowl away from the mandible, and using 1cc of Kybella, major vessels can be avoided but great results can still be achieved. After the fat pad has been reduced, Dr. Weinkle uses fillers to create a defined mandibular sweep. In conclusion, she recommends a more natural look in producing the best results. If you make them look weird, you will be feared. What Men Want in Corrective Aesthetics Doris J. Day, MD Despite extensive marketing, men comprise only 10% of the corrective aesthetic market. As men age, they experience the 5 Ds: Deterioration, Deflation, Descent, Disproportion, and Dynamic Discord, where overpowered muscles give men an expression at rest, such as frowning

5 or puckering of the lips. When addressing male patients, it is essential to avoid feminizing the male face, as it can have major social ramifications. The male face should have a flatter brow, with the lateral portion lower and not arched, a wider chin and jaw, and a broader malar base with the apex of the cheek being more modest and infero-antero-medial in contrast to the female face. The main issues of the male face tends to be sinking, sagging, and wrinkling, particularly in the submalar cheek. Fillers can also be especially helpful in the prejowl sulcus, and for reinflation and contouring of the chin. Additionally, a bolus of filler can be placed above the periosteum at the gonial angle of the mandible to nicely lift the entire jawline. When addressing the area around the mouth the marionette zone and lateral oral commissure it is important to avoid stiff fillers that can affect the smile or natural movement. Combination technique with neuromodulators can slowly and softly improve the aging male face.