From Jeffrey E. Epstein, MD

We would like to organize a group of “Volunteer Conference Reporters” who are going to various conferences and can report on what they have seen, heard and learned.

For example, I am going to the Harvard Conference in October (Laser & Aesthetic Skin Therapy:  What’s the Truth? 2008).  I will write about one or more of the topics covered at that conference.   After my summary is published, others can read it and learn from it.  We can also discuss it via the blog (the same way we are discussing the DeepFx Webinar Summary).   I am hoping that other readers who are going to this conference will become Volunteers and write about other topics covered at this conference.  This conference is organized by R. Rox Anderson and promises to be excellent (What is the Truth?).

We have a few other notable conferences coming up in the next few months.  In addition to the Harvard Conference in October, we have the Controversies and Conversations in Laser and Cosmetic Surgery:  An Advanced Symposium August 8-10, 2008 in British Columbia , Canada and the Cutera Clinical Forum in Chicago August 15-17, 2008.  There is also an Obagi Conference, November 13-14, 2008 (Ultimate Skin Symposium) in Los Angeles .  Finally, every April the ASLMS has its annual conference which is excellent.  I am hoping we can cover these conferences at a minimum and add others that we feel are top notch!

I have volunteered to be the Conference Reporter Coordinator and Organizer.

If you will be going to any of these conferences and would be willing to write a summary of one or more of the topics covered, please contact me so that we can coordinate our efforts.

Thanks,

Jeffrey E. Epstein, MD

email: Jeff4459@aol.com

It's a good article in which Medical Spa MD is introduced in the first sentence. It seems that the community here is making some waves among members of more 'mainstream' press. Here's the email that I first received from Healthy Aging about the story.

Here's an example via WPS:

NY Times Article: As Doctors Cater to Looks, Skin Patients Wait

“Cosmetic patients have a much more private environment than general medical patients because they expect that,” said Dr. Richey, who estimated that he spent about 40 percent of his time treating cosmetic patients. “We are a little bit more sensitive to their needs.”

Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists’ offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees.

In other offices, cosmetic patients spend more time with a doctor. And in still others, doctors employ a special receptionist, called a cosmetic concierge, for their beauty patients.

...According to a presentation for doctors from Allergan, the makers of Botox, a medical dermatology practice might have a net income of $387,198 annually, but a dermatologist who decreased focus on skin diseases while adding cosmetic medical procedures to a practice could net $695,850 annually. The same material advises doctors to “identify and segment high priority customers.”

Phoenix Business Journal Story - by Angela Gonzales

A Maricopa County Superior Court judge has appointed a receiver to handle the financial future of Dermacare Laser & Skin Care Clinics Inc., which at one time planned to sign on more than 120 franchisees nationwide.

The Scottsdale-based franchisor is embroiled in several arbitration cases and lawsuits. Its corporate offices have closed, and several franchisees have abandoned the Dermacare name.

At one point, Dermacare had six facilities throughout the Valley.

The company's founder, Carl Mudd, could not be reached for comment.

Four Valley franchisees no longer are affiliated with Dermacare. A facility in Litch­field Park is keeping the brand name, but operating independently.

A records search at Maricopa County Superior Court shows 10 lawsuits have been filed within the past several years against Dermacare Laser & Skin Care Clinics Inc.; its parent, DLC Dermacare LLC; and Mudd. The lawsuits were filed by vendors, franchisees and former Derma­care employees, claiming the company didn't pay its bills.

For example, WS Inc., formerly WGS Packaging Inc., was awarded a judgment of $384,000 against Dermacare Laser & Skin Care Clinics. According to the lawsuit, WS Inc. sued Dermacare in 2006 for not making payments on the clinic Mudd operated in Paradise Valley.

Richard Thomas, attorney for WS, said his client also has a pending claim through the American Arbitration Association for nonpayment of that note.

WS has received default judgments against Mudd, DLC Dermacare and Dermacare Laser Clinics, Thomas said.

"As to both of the entities, Dermacare has obtained the appointment of a formal receiver," he said.

Also named in the WS lawsuit was a Dermacare doctor, Abraham J. Sayegh, who was one of the first doctors to join Dermacare and later became its medical director.

Sayegh also is facing censure by the Ari­zona Medical Board. In March, the board cited him for drug and/or alcohol use after an anonymous complaint was filed in February. According to those filings, Sayegh said he would cease practicing medicine. It was Sayegh's second relapse, according to the medical board.

Meanwhile, Mudd filed a lawsuit in January against a blog on MedicalSpaMD.com, which features communications by former franchisees. Many of the blog entries criticized Mudd and Dermacare. In his lawsuit, filed in Maricopa County Superior Court, Mudd asked the site to reveal the bloggers' Internet service provider addresses so he could sue former Dermacare franchisees for defamation of character.

Mudd's attorney listed in that suit was John Skiba, but he filed a motion with the court Feb. 4 to withdraw as Dermacare's counsel.

Jeff Barson, founder of MedicalSpaMD.com, said the most active Dermacare discussion includes nearly 1,000 comments from existing and former franchisees.

"MedicalSpaMD.com has received numerous 'cease and desist' letters, threats and demands, including copies of a lawsuit and threats of suit against the site and myself personally if I didn't close down the discussion forums and identify all of the individuals who may have commented," Barson said.

"I refused to comply and posted the letters and suit, as well as the case law around anonymous comments on the Web," he said.

Superior Court records show Mudd's lawsuit might be dismissed. Under Arizona law, a plaintiff has 120 days after filing a complaint to serve the defendants. If that does not happen, the court can dismiss the case.

Court records do not show affidavits have been served, said Andre Merrett, an attorney with Quarles & Brady LLP who is representing six Dermacare franchisees in an arbitration dispute through the American Arbitration Association.

When franchisees signed on with the company, their contracts included a stipulation that they would settle disputes through arbitration in lieu of lawsuits, Merrett said.

Trish Gulbranson owned the Dermacare franchises in Mesa and Chandler until February. She recently started getting calls from customers of the nearby Ahwatukee facility, saying it had closed and they were left holding prepaid packages or gift certificates.

Gulbranson decided to honor any unfinished laser services or valid gift certificates that had been purchased from the Dermacare of Ahwatukee office if customers could show their receipts.

"In light of the complete deterioration of the franchise system, (franchisees) simply want to be free from Dermacare and be allowed to go out and operate their businesses on their own in an effort to try and save their investments," Merrett said.

He said he hopes to connect with the receiver to see if the disputes his clients have with the company can be resolved without further litigation.

Other local franchise owners were not willing to discuss the matter.

You'll notice that Angela is asking to be commented by the physicians on the site who may have personal experience with Dermacare and Carl Mudd. Her contact information is below. Comments welcome.

Via the contact form on Medical Spa MD:

Subject: Dermacare and Carl Mudd
Message: I'm writing a story about Carl Mudd and Dermacare. Do you have a phone number or email I can use to reach him? Do you have an update on the DLC Dermacare LLC v. John and Jane Does (CV2008-090071) lawsuit. It looks like there was an intent to dismiss in April Any updates?

Angela Gonzales
Senior Reporter
Phoenix Business Journal
agonzales@bizjournals.com
602 308 6521

 _________________

My Response:
Hi Angela,
I'm afraid I don't have any information about where Carl Mudd is. However, I do know that there is a tremendous amount of discussion about where he is on my site at Medical Spa MD. There are plenty of people asking that exact question. If you'd like, I can get you in touch with some of those people. The only interaction I've had with Carl Mudd or Dermacare is a couple of cease and desist letters he's sent me and a threat to sopenia and sue me if I didn't hand over all of the names and IP addresses of people discussing Dermacare on my site.

Let me know if you'd like some of these physicians to contact you.
Yours,
Jeff Barson

 _________________

On Fri, Jul 11, 2008 at 2:37 PM, Angela Gonzales writes back:
Thanks for getting back to me so quickly, Jeff. Yes, I would really like to talk to these doctors.
It looks like that lawsuit is in limbo since Dermacare’s attorney withdrew as general counsel and because it doesn’t look like Dermacare has served anyone.
Thanks for your help!
Would you like to give me an official comment for my story regarding the immense dialogue on your site?

Angela Gonzales
Senior Reporter
602.308.6521

 _________________

I responded:
Hi again Angela,
I'll see if I can't get you some feedback from the physicians on the site. I'd also be happy to provide a comment.

MedicalSpaMD.com is an active community of thousands of plastic surgeons, dermatologists, and aesthetic physicians looking to enhance the free exchange of information about the treatments and business of cosmetic medicine. (With more than 50,000 unique visitors each month and thousands of members it's by far the leading site on the web in this area.)

Among the more active  discussion threads have to do with the practices, treatments, and leadership of medical spa franchises like Dermacare, American Laser Clinics, Sona, Solana, and others. The most active Dermacare discussion has almost 1000 comments from existing and former franchisees.

The site has become the focal point for these physicians to communicate to each other and hadn't gone over well with the medspa franchises looking to isolate these physicians. MedicalSpaMD.com has received numerous cease and desist letters, threats and demands, including copies of a lawsuit and threats against the site and myself personally if I didn't close down the discussion forums and identify all of the individuals who may have commented. (The lawsuit named all of these individuals by their 'screen name'.) I refused to comply and posted the letters and suit as well as the case law around anonymous comments on the web.
Happy to provide more if needed.
Yours,
Jeff Barson
Medical Spa MD

"We are offering 100IU vials of botulinum type A. Equal to Allergan brand of Botox.  Excellent product, long lasting results. $100 per vial. We also have the best generic Restylane on the market. Crosslinked for excellent long lasting results.
We sell to many spas, nurses and doctors in the USA. We have helped them to grow their business and see more profits. You are guaranteed to receive your order, we offer fast service.
Contact us
[Name]
[phone number]"

Anyone using this type of product on a patient is headed for big trouble.

"Well it looks like Buckingham and company can't hurt anyone else. The website is down and they are nowhere to be found. Hey, Over It...the truth hurts. Are you sure you aren't a Solana Owner in denial or just covering your rear end? Between the University of Arizona charges, Brooks College 60 Minutes expose and firing, Health West fiasco and connections, continuing client failures, deadbeat dad website stating a failure to pay tens of thousands in child support to his ex-wife (which was the final straw on why we didn't contract with Solana), etc... Wake up everyone associated or affiliated with Buckingham. it is time you recognize him for who he is before he hurts more people."

 I don't know why the Solana Medspas site is down but it can't be a good sign. (The first time you load the page you may see a little 'Solana Medspas Logo' flicker for just a second before you're redirected to the under construction page. This is usually a sign that the ISP has suspended the account.

Just as a first class restaurant strives to create a unique menu that will distinguish it from all its competitors, you should make it your mission to offer a service menu that offers not only all the most popular med spa treatments but also the most cutting edge, innovative procedures available.  Many of the prospects you will encounter are surprisingly well informed and will be looking for a med spa that can exceed their expectations. Some of these prospects already know the results they are looking for. They will look to you and your staff to guide them to the optimal combination of services, procedures and products to help them achieve their goals. On the other hand, many of your prospects will not have a clue about the specific technologies or procedures involved -- they will simply want to know they are in good hands and will look to you to recommend the best treatments and products for them.  

You will need to decide how broad a range of services you will offer. You may decide to offer all the popular services so your med spa will appeal to a diverse, market-driven client base. Or you may decide to carve out a more specialized niche. You will need to decide your basic positioning before you formalize your menu. One of the key factors will be to find the best service mix that matches your professional expertise. If you are a dermatologist, for example, you may wish to offer a range of specialized services for treating acne. If your background is OB/GYN, you may want to develop a specialty for the treatment of leg veins. Another key factor which you may determine from your research is your best estimate of the profitability of offering a wide variety of the most popular services compared with a more specialized approach. Heavy competition in some areas has driven fees for basic services such as laser hair removal to such low levels that such services must be evaluated merely as  "loss leaders" to help build traffic for your more profitable services.

In any event, you will need to keep current with rapidly growing technology and clinical applications by attending trade shows and workshops, subscribing to industry publications, joining various associations, and opening channels of communication between your medical and spa resources. Many practitioners pondering the question of what aesthetic services to offer have come to the realization that emphasizing treatments that require a high level of skill and/or experience is perhaps the best way to differentiate your clinic from the garden variety “medical spa” offering only “basic” treatments like laser hair removal that are available on every street corner. An excerpt from the 2007 national average fee schedule published by ASAPS clearly illustrates this point: 

Cosmetic Procedures        National Average Fee

 
Abdominoplasty     $ 5,350.00

Blepharoplasty                  2,840.00

Breast aug. (silicone)                 4,087.00

Breast aug. (saline)        3,690.00    

Facelift                   6,792.00

Hair transplantation                  5,874.00

Lipoplasty (suction)        2,920.00

Rhinoplasty                   4,357.00 

Non-Surgical Procedures      National Average Fee

Botox injection     $    380.00

Chemical peel           718.00

Fraxel          1,130.00

IPL Treatment           411.00

Noninvasive tightening       1,194.00

Injection lipolysis           905.00

Laser hair removal           387.00

Laser skin resurfacing- ablative      2,418.00

Laser skin resurfacing- non-ablative        580.00

Laser treatment leg veins          462.00

Microdermabrasion           130.00

Sclerotherapy           377.00

Collagen (Bovine)           397.00

Collagen (Human)           542.00

Hyaluronic acid (i.e., Restylane)         576.00

Sculptra         1,027.00

Srtecoll, Artefill        1,180.00 

We are looking for Clinical Providers and MedSpa Owners to help us with our Continuing Education Efforts. 

We want to provide quality content on Medical Spa MD to act as a stimulus for meaningful clinical exchange activities.

One type of Clinical Exchange is the discussions and the conversations that occur on blogs and websites.  Medical Spa MD is currently one of the only internet based clinical exchange platforms for Cosmetic Medicine.  We want to take advantage of Medical Spa MD’s leading position and large readership base to enhance its already strong presence in the Clinical Exchange field.

Our plan is to have people do summary notes of Webinars, Articles and Clinical Meetings.  These notes will be posted on Medical Spa MD and then a discussion can take place.  The conversations and debates will instruct us all!  Hopefully by sharing experiences and opinions, we will move the whole field forward in a positive and more rapid manner.

The first such Clinical Exchange Post was the summary of The IPL Dog and Lemon Guide.  This post has stimulated a lively discussion of the various IPL Systems.  Sciton and Palomar seem to be the favorite systems.  The clinical settings for treating Hair, Pigment and Vascular are being discussed.  We are all learning a great deal and a few knowledgeable and experienced thought leaders are emerging – Charry, Med Spa Guy, pmdoc, LH and SpaDocinCR.

Our second post will be a Summary of the DeepFx Round Table Webinar (May 2008) produced by Lumenis.  The Webinar was a Round Table Discussion between four of the most experienced and well known cosmetic physicians in the country – Jeffrey Dover, MD, Robert Weiss, MD, E. Victor Ross, MD and James Heinrich, MD.  Our post will summarize the Webinar.  The original Webinar is available to everyone on Lumenis’ Website.  We are hoping that our summary will prompt people to view the actual Webinar and then participate in the resulting discussion.  In the future, we hope that Lumenis will make their Webinars available in a form that can be downloaded onto iPods so we can listen in our cars.

Finally, it is our goal to get summaries done of the various meetings that are happening in the near future.  A few upcoming clinical meetings are The Cutera Clinical Forum in Chicago (August 2008), Controversies & Conversations in Laser and Cosmetic Surgery:  An Advanced Symposium in Whistler, BC Canada (August 2008) and the Harvard Conference in Boston hosted by R. Rox Anderson, MD entitled  “Laser & Aesthetic Skin Therapy:  What’s the Truth?” (October 2008).  We are hoping that conference attendees will write notes about the lectures and the sessions and then will submit those notes to Medical Spa MD to be posted.  We will be able to read these notes, learn from them and then discuss the content.  This will bring the information to countless more clinical providers.  In the future, we hope that the organizers of these conferences will record their sessions and sell the audio so we can benefit without having to travel and take time off from work.  At this years ASLMS Meeting, the lectures were recorded and you can purchase them for a nominal fee ($11 per Tape).

This Clinical Exchange Project is a grass roots activity that is meant to take the place of formal activities that Allergan and the big Laser Companies are not doing.  We are not sure why they have left this “information gap” and do not support meaningful continuing clinical education and meaningful clinical exchange, but we hope they will join our efforts once they see the value in these types of activities.  Better clinical outcomes and fewer adverse events will benefit the whole field.  By sharing information and communicating and making more information available to more providers, we can advance the field much more rapidly then our current method of each provider trying to figure things out by trial and error.

We hope you will join our effort as a summarizer of Webinars and Conferences or as an active participant in the resulting discussions and debates.

I'm going to be contacting a number of clinics and physicians around the country (or outside) that run what I deem to be successful practices and interview them. I have a tentative list of questions but I'd like to enlist you, my dear readers, to help me make sure I'm not missing anything that's relevant.

So, I'm asking for some help in formulating the questions, the more detailed the better.

Please post your list of questions as comments. If the repeat, great. We'll know that lots of people are interested in that information.

I plan on generating a report that will be organized around the questions rather than inline, so you can see what all the answers are to the question rather than collating that information from separate interviews.

Via Plasticized:

"Radiance Medspa is a national franchise that has run into trouble with disgruntled owners and office closures.  In the cosmetic world, it can be a challenge to maintain quality over large distances with a range of practitioners with varying quality.  Some of the spas have broken away from the corporation. Others have closed in the last year.

Take a look at this Radiance website. The "highly skilled, licensed professionals " were unable to spell "specialization" and they left some latin text from the website template they ripped under "about us". Here is an example of how quality control can fail in a large entity"

I don't know if the Dermacare doctors have it any worse than these poor Radiance franchises.

DeepFx Webinar:  Notes and Analysis - Tuesday May 19, 2008
Reliant UltraPulse Fractional CO2 Laser

Introduction

Many Laser Companies offer regular Webinars for marketing and education (mostly marketing). These companies include, but are not limited to: Cutera, Lumenis, Reliant and Cynosure. These Webinars are available live or on the companies’ websites in their Webinar Archive Area. 

We have produced these notes for several reasons. We want to generate a clinical discussion of these Webinars so we can all learn more from the Webinars and learn even more from the discussion. We want to clarify certain points that were not clear during the Webinar. We want to ask and answer questions that were not asked and answered during the live Webinar (there is never enough time to ask and answer all questions). It takes 2 hours to sit through a Webinar, most are for marketing purposes and not worth our time, these notes will help us decide which Webinars we want to watch. Hopefully many times we will not have to watch the Marketing Webinar once we have read the summary and participated in the resulting discussion. This will enable us to get the information without sitting at our computer watching a Webinar for 2 hours. 

The bottom line is that we all need to become better providers of services and get better results which generate happy patients who refer friends and family to our practices. By having easier, more convenient access to the information in the Webinars and sharing our thoughts and experiences, we all learn more quickly and we avoid making the same mistakes made by others.  In this manner, we gain access to “best practices” more quickly and the whole field evolves more rapidly. We want to use these Webinars as “Seminal Events” to stimulate meaningful “Clinical Exchange” of important information.

We hope to get the industry “Luminaries” to participate in these discussions. We also hope the Laser Companies will start to host these type of “On-Line” discussions after their Webinars and we hope the Laser Companies will start to host more “Continuing Education” Webinars rather than just “Marketing Webinars”.

The first set of notes is from a Lumenis Webinar about the DeepFx treatment with The UltraPulse Fractionated CO2 Laser. This was a Round Table Discussion with some of the top Cosmetic Physicians in the field. It was very good, but had its flaws and requires further discussion and clarification on points made. The participants (Luminaries) were James Heinrich, MD, Robert Weiss, MD, E. Victor Ross, MD and Jeffrey Dover, MD.

If you are considering using the information in this summary, please view the Webinar to make sure you are comfortable with the parameters! If you view the Webinar and find any inaccuracies in my notes, please correct them in our discussion on MedicalSpaMD. I am hoping Lumenis and “The Luminaries” will review these notes and comment.

TotalFX Notes

Basic Facts & Theory:

1. ActiveFx plus DeepFx gives you a TotalFx Treatment
2. ActiveFx ablates 1.3 mm columns and can go 300 microns or 0.3 mm deep
3. DeepFx ablates 0.12 mm columns and can go 2000 microns or 2.0 mm deep
1. 1000 microns = 1.0 mm
4. 125 mj of energy with ActiveFx penetrates 300 microns deep
5. 30 mj of energy with DeepFx penetrates 1.9 mm deep (1900 microns)
6. Most photoaging occurs in the papillary dermis (the worse “solar elastosis” in elderly farmers is at a depth of 800 microns), so there is no need to go deeper.  Therefore our panel recommended a max DeepFx strength of 20 mj (1 mm deep?).  Going deeper gets you more tightening because of more tissue ablation and volume loss.   
7. Using 30 mj of energy and going to 2.0 mm deep has caused scarring around the eyes in one provider’s experience.  They do not recommend going this deep.
8. How long does the tightening last?  No one knows for sure.
9. ActiveFx:  Density 1:  75%; Density 2:  80%;  Density 3:  85%;  Density 4:  95%;  Density 5:  100%
10. MaxFx is ActiveFx at Density 5:  100%.
11. The MaxFx now is somewhat different than CO2 treatments done in the 1990s because only one pass is done.  In the 1990’s 3 passes were done wiping off the epidermis in between passes.
12. DeepFx:  Density 1:  5%;  Density 2:  10%;  Density 3:  15%;  Density 4: 20%;  Density 5: 25%.
13. Stronger treatments are done with the TotalFx on the West Coast.  Why?  In California the people have greater solar damage so you need higher settings OR the people in California are more demanding and want more dramatic results.  Interesting question!  What do you think?
14. Healing is slower off the face.  Dr. Weiss says 2-3 times longer, did he mean 2-3 days longer?
15. Doing Upper Lip Treatments with TotalFx can cause more vermillion lip border to “show”.  This is good

Clinical Tips:

16. Do the DeepFx first and then do the ActiveFx
17. If the DeepFx causes bleeding, wait until the bleeding stops before doing the ActiveFx (blood will absorb the energy from the ActiveFx pulses)
18. The experts said that they did a second treatment one month after first treatment.  I was told to wait 3 months.  This one month interval is new information to me. My big question to Lumenis is “when were you going to tell me and your other users about this change?  How do you keep us up to date about changes like this?”  I am pissed off, I am angry.  I want an answer and I want it NOW!
19. Dr. Ross sometimes uses thrombin spray (from Baxter) to stop the bleeding.
20. With DeepFx, you treat lower face first and move upwards so blood won’t drip down into your treatment field.  “South to North”
21. Do DeepFx before you do fillers.  The DeepFx may go deep enough to disrupt the fillers.
22. You can do fillers and then ActiveFx because ActiveFx only goes 100 - 300 microns deep.  Fillers are placed deeper than this.
23. Anesthesia:  Atavan or Valium (5 mg), IM Torodol 60 mg, Zimmer Cooler, Pliaglis Topical or Topical Lidocaine.  Is po Torodol ok? What about Percocet or Vicodan?
24. You may need to use a nerve block for upper lip treatment.  Dr. Weiss, “Do you do the Infraorbital Nerve Block or 5 short injections near the upper lip gingiva?”
25. Use intraocular eyeshields for upper eyelids.  You might be able to use tongue blade wrapped in moist gauze for lower lids
26. Segmental Resurfacing:  Do IPL on cheeks for pigment and do ActiveFx in peri-occular areas for fine lines and tightening.  Get the most out of your hour with the patient.  This sounds like a great idea-Segmental Resurfacing!
27. Dr. Heinrich does DeepFx only and then Deep plus Active one month later.  He says the patient’s skin gets used to treatment the first time, so downtime is less the second time.  This is my question:  what is the downtime with the first treatment and what is the downtime with the second treatment?  Do patients have to have two 4 day periods of downtime within 30 days?  I am not sure this makes much sense.
28. Some older patients (your mother-in-law) really need traditional CO2 or a facelift.  Give them that option.
29. Class 4 Wrinkles:  The best option is traditional CO2 with two weeks or downtime OR do TotalFx  2-3 times at one month intervals (Dr. Heinrich)

Treating Specific Conditions:

30. DeepFx is best for vertical lip lines, deep wrinkles, acne scars.  It goes deep and stimulates more collagen and ablates more tissue for more tightening.
31. ActiveFx is better for pigment and more superficial textural problems
32. Stretch Marks (Stria):  Use ActiveFx:  80-100 mj, density 1-2 (use Density 2 for thicker Stria).  Do NOT use DeepFx for Stria.
33. Melasma:  Experts are not sure it will work.  They do not recommend at this time.  They are doing test spots and experimenting with it.  Melasma is a whole topic unto itself.  Look for a specific blog about this in the future.
34. Tattoos:  DeepFx might be good for resistant Tattoos

ActiveFx, DeepFx & Total Fx Settings:

35. The experts usually treat with DeepFx in the range of 15 mj – 20 mj
36. Most experts would not go higher than density 3 with DeepFx (15%).
37. Recommended Settings: 
1. DeepFx:  15 mj, density 3, one pass. 
2. ActiveFx:  100 mj, density 3, one pass. 
3. You can go to 20 mj with DeepFx
4. You can to to 125 mj with ActiveFx. 
5. Density 3 seems to be highest density used with DeepFx (Dr. Ross goes higher, but he is very experience, an expert and he has experience with the full CO2).  Don’t go higher than Density 3 with DeepFx. 
6. For ActiveFx:  Higher density with one pass is better than lower density with two passes (Dr. Weiss).
38. To stay out of trouble with ActiveFx off the face, use Density 1 and 70-80 mj

Treating Specific Areas:

39. Eyes:  Use ActiveFx. Don’t do DeepFx around eyes (skin too thin?)
40. Eyes:  ActiveFx:  90-100 mj, density 2-3.  Downtime:  7-8 days of downtime (what TYPE of downtime?)
41. Eyes:  Upper Lid:  ActiveFx:  60-70 mj, density 1
42. Eyes:  Might consider using DeepFx for low lids:  5-10 mj with density 2?  This was the experts thinking outloud.  They are not recommending this!
43. Eyes:  Treat to the lid margins with ActiveFx:  Density 4-5, one pass (for greater tightening and because this is where much of the problem lines reside?)  This seems strong.  Listen to Webinar for yourself before doing this!
44. Neck:  Necklass lines are done with DeepFx, the rest of the neck is done with ActiveFx. 
1. DeepFx on the Neck:  15 mg, density 2 or 3. 
2. ActiveFx on Neck:  90 mj, Density 1 or 2. 
3. Neck with the above settings:  10-14 Days of downtime (what TYPE of downtime?)
45. Neck:  ActiveFx:  100 mj and density 3 was too strong.  Produced prolonged erythema.
46. Chest: 
1. ActiveFx:  100 mj, Density 1. 
2. DeepFx for sagging and wrinkling on Chest?  I think the experts recommending doing DeepFx.  Perhaps 15 mg, density 2?  Check the Webinar.
47. DeepFx can be done on neck, chest and hands

Pigment Changes, Post Inflammatory Hyperpigmentation, Melasma

48. Don’t treat Melasma (Dr. Ross)
49. Dr. Weiss has never seen PIH with ActiveFx.  The company has told a friend of mine that they don’t get PIH with ActiveFx.  This is complete and utter bull!  I have gotten PIH with skin types 4 (Italian, Greek). We need an open and honest discussion of this.  Dr. Weiss may only be treating skin types 1-3.  If this is the case, he and the company need to be much more transparent, open and honest when they talk about PIH.  What they say (you don’t get PIH with ActiveFx) is misleading, false and dangerous.  To just dismiss the PIH problem with ActiveFx is irresponsible and dishonest!  This type of cavalier attitude pisses me off!  This view (no PIH with ActiveFx is parroted by others (company reps and clinical advisors) and this type of dishonesty will get YOU & ME into trouble!  If PIH is not a problem, why isn’t ActiveFx used in darker skin types?  A friend of mine has posted his PIH pictures at www.geocities.com/pih_pih/.  Go to this site to see PIH after ActiveFx.  Dr. Weiss, I am looking forward to your comments about these pictures.  Please don’t talk about PIH if you only treat skin types 1-3!  I would also like to hear from the other Luminaries and Lumenis who claim that PIH is not a problem.  Let’s move on . . . I am calming down now.
50. None of the presenters use Hydroquinone to prevent or treat PIH.  This is because they say they don’t get PIH with ActiveFx, DeepFx or TotalFx.  Either I am an idiot or they are not being honest or they are not treating the patients that I am treating.  I am not treating any skin types 5 or 6 and I am being very careful with skin type 4.  I use Hydroquinone, RetinA and Hydrocortisone pre and post treatment on my skin type 4 patients.  Maybe I should not treat skin type 4?  Not treating skin type 4-6 eliminates about 40% of my patient population (so why should anyone buy the machine unless they live in Sweden or Finland?).  Let’s discuss this PIH issue!  Is “bronzing” PIH?  You can go to www.geocities.com/pih_pih/ to see my photos of PIH after ActiveFx.  I am interested in your comments (and I hope Drs. Weiss, Ross, Dover and Henrich will comment as well).  I think this is another case of “The Emperor Has No Clothes” (Everyone thinks that they will be called “stupid” if they don’t see what everyone says they are supposed to see. This is the question, “Do you get PIH with ActiveFx?”  If so, how do you prevent it, how do you treat it, who do you have to be careful with?  This is THE “cop out” answer that I do not want to hear, “I only have skin type 1-3 in my practice”.  This is bull (almost 50% of our population is now “patients of color” and if this is true, then YOU are not an expert using this technology!  (Just my opinion) (Sorry about the emotion, but I am fed up with the dishonest bull that comes from the companies and their luminaries.  I am on the front lines and it is me and my patients who get screwed by this type of pandering and dishonesty - hopefully one of the benefits of this type of blog will be to get the “experts” to be more thorough and honest in their presentations, you can’t be dishonest when everyone is watching and talking about your presentation!).
51. Dr. Ross uses Hydroquinone once he sees PIH.  You generally start to see PIH 15-28 days after procedure.  Wouldn’t it be better to prevent the PIH, Dr. Ross?  Can you prevent it?  Do you know who is at greatest risk for PIH?
52. Patients are generally not allergic to Hydroquinone (HQ), they can be sensitive to it.  15% of patients get irritated with HQ – contact irritation.  This is not a true allergy.  You can change the HQ to 2% OTC Hydroquinone.  Other options are to use it less frequently (every other day), use if for less time (3 hours per day rather than overnight), or use it with Hydrocortisone 1%.   (These other options are from me, not the experts).  There are also other bleaching agents like Azelaic Acid and Kojic Acid (see The Supplement to the September 2005 Skin & Aging Magazine on www.geocities.com/foxydog1064 for a Hyperpigmentation Round Table Discussion). 
53. In skin types 4 and higher (Persians and Hispanics) go a little lighter (less density, less energy).  Density is % coverage; Energy is depth of treatment.  I think both matter.  Perhaps % coverage matters more (it matters more when you do a Fraxel Treatment).
54. No one is treating skin types 5 and 6 with ActiveFx or DeepFx.  This includes Aftrican-Americans, East Asians (Japan, China) and Southern Asians (India, Middle East).  You can use Fraxel Re:store 1550 for these patients.  Be very careful to avoid PIH when you treat these darker skin types with the Fraxel. 
55. Experts:  “PIH clears very quickly”.  Me:  I have read that it can last 6 months to 2 years.  In my opinion, you should not minimize PIH by saying it clears so quickly.  Just read www.realself.com to see patients with long standing PIH.
56. Experts:  “Koreans are skin type 4”. Me:  I would treat them as skin type 5!  I wonder what Dr. Eliot Battle would say?

Downtime:

57. The experts discussed “Downtime” and “Quality of Downtime”.  Absolute Downtime, Relative Downtime & Social Downtime.  Absolute Downtime would be when you can’t go out (the day after an ActiveFx).  Social downtime would be when you don’t want to go out but can go to work (after the peeling, ActiveFx:  days 5-7). Days 2-4 are Relative Downtime, when you feel fine but don’t look to good.  You don’t want to go to work, but you can work at home and pick the kids up from school (stay in the car).     
58. We should come up with some words and definitions for the different types of downtimes so we can communicate this to our patients.  What are your thoughts on how to categorize downtime?
59. There is a big difference between 3-4 days of downtime and 5-7 days of downtime.  With 3-4 days, you can have procedure on Thursday and be back to work by Monday.  With 5-7 days of downtime, you have to take the week off.
60. The experts prefer to do TotalFx over Fraxel Re:store (1550).  They do the Fraxel when the patient prefers to give one day of downtime x 5 rather than 4 days of downtime once.

ActiveFx, DeepFx, TotalFx vs other Lasers:

61.  DeepFx and Fraxel Re:pair CO2 are the only lasers that go deep and ablate.  The others ablate shallow and then coagulate deep.  They also have spot sizes which are macro (1.3mm)  rather than micro (0.12mm)
62. The best results for deep wrinkles, vertical lip lines and acne scars can only be obtained with deep ablation
63. Experts:  It is nice to have a CO2 Laser because it has an ablative handpiece that can treat syringomas, sebaceous hyperplasia, warts and moles.  We need to start a blog which discusses how to treat these conditions and avoid scarring.  Feel free to blog on sryingomas, sebaceous hyperplasia, warts and moles!  How do you treat them with the ablative handpiece of the Encore?
64. Why Deepfx?  People were disappointed in Perioral wrinkles and lines.  DeepFx does a better job.  You may have to do 2-3 treatments, one month apart!  How much downtime would this be?  What type of downtime (absolute, relative, social)?  How do we explain this to our patients? 

Pre and Post Treatment Tips:

65. Mild moisturizers avoid acne flare-ups
66. You don’t have to use aquaphor or vasoline.  Mild moisturizers are good enough (personal communication from company reps).
67. Be careful of the lanolin in the aquaphor.
68. Using Aveeno Water Gel gets you one less day of Downtime!  (From Dr. Weiss).  What is Aveeno Water Gel?  How do we get it?
69. Post TotalFx Care:  Use “Soaks” every 3-4 hours.  (What type of soaks?  Saline Soaks (saline and gauze)?  How long do you soak every 3-4 hours?) 
70. Post Care:  Cold packs or Zimmer Cooler for 30-45 min after treatment
71. Valtrex for everyone.  One case of disseminated herpes on the face is not good.  Can we use Acyclovir?  It costs less, much less (Four Dollars at Walmart!).
72. Check all patients the next day, this makes you and them feel better.
73. Don’t give pain meds after treatment.  If they have pain, you want to know about it and see them.  They should not have pain for more than a few hours after treatment.  Prolonged pain suggests infection:  bacterial, viral, fungal.  Can we discuss post procedure infections and how to treat them? 
74. Pliaglis can be mixed with cetaphil cleanser or cetaphil moisturizer.  90% Pliaglis and 10% cleanser or moisturizer.
75. Experts worry about Lidocaine toxicity.  Compounded Lidocaine works as well or better than Pliaglis.  Pliaglis costs $60 per treatment.  Compounded Lidocaine costs about $6 per treatment.  Do the experts have a financial interest in Pliaglas?  Are the experts afraid that they will be sued if they talk about compounded lidocaine?  The discussion on this topic did not seem to be open, honest and complete!
76. Experts do not routinely use oral antibiotics unless indicated for acne outbreak prevention:   Keflex 500 mg TID, Doxycycline 100 mg BID, Erythromycin can be used to prevent acne outbreak.
77. Sunscreens:  Use everyday after skin is healed up.  Wear hat and stay out of sun until healed.
78. Use a good UVA blockers:  Neutrogena, Helioplex or Loreal Products.

The Opinions of the Transcriber (CHMD) & Other Misc Issues:

79. These experts have only been using the DeepFx and TotalFx for 6 months, so their use is evolving.  It will be very important for Lumenis to keep us informed about changes in these expert’s opinions as they get more experience.  We must all advocate very loudly and strongly for a Newsletter from the company which keeps us up to date (not just Webinars which take 2 hours to watch and are mostly for marketing and selling lasers).  Go to www.geocities.com/FoxyDog1064  for more information about Advocacy for Better Clinical Education and Clinical Exchange Programs. 
80. We must also make sure the company picks experts that have significant experience using their laser in skin type 4!!!  To say, “I don’t have the problem because I don’t have patients with skin type 4” is bull.  It is a big cop out and is counterproductive.  Plus, I don’t believe it or accept it.  Skin type 4 is Italians, Greeks and others who don’t burn but tan easily and get dark easily when exposed to the sun.  If you are not treating skin type 4, patients I am not sure you are practicing in the USA!
81. If you want to contact Lumenis directly, address all questions and comments to Amy Easterly, Product Manager.  Her email is: amy.easterly@lumenis.com.  Perhaps she can ask the Drs. Heinrich, Weiss, Ross and Dover to participate in this discussion, read this blog and comment and clarify.  I believe that they get paid a lot of money to do the Webinar.  I believe their job has been done incompletely when they leave us with unanswered questions and incomplete thoughts.  Remember, we are treating patients.  Real patients with real faces that can be scarred and hyperpigmented!!!  We want excellent outcomes with very few complications.  Lumenis owes it to us!
82. This Webinar will be available soon in Aesthetics Buyers Guide.  When?  Let’s see how good the Aesthetics Buyer Guide Version is.  I bet it will be edited to sell lasers!  Lumenis, it’s ok to do a version to sell your laser, but you should also do a version for your Encore UltraPulse Users as Continuing Education.  Let’s see if you step up to the plate for your Users!

Now let’s blog.  Let’s get it on!!!  Let’s get what we need (more self support and more company support).

Certainly I'm not a lawyer. So when I received this inquiry about Cutera selling in violation of FDA guidelines, I decided to post it here on the main page and see what the thoughts around it are.

Are Cutera, Palomar, Cynosure, Alma, and the rest of the IPL and laser technology companies violating the FDA's guidelines for selling medical devices to non-physicians? Does anyone care? Should non-physicians be able to own an IPL, cosmetic laser, or Thermage unit? Is this more about protecting a market or patient safety?

Happy to have Cutera respond. 

via email from T:

I have read this blog for over a year and a half and have been interested in the business and legal aspect of this industry.

There are many issues which intrigue me but a couple areas that stand out are: 1.) The legality of sale of prescription medical devices to "business people" and 2.) How laser companies such as Cutera are double dipping and hurting doctors business through their unethical sales practice… as well as violating FDA regulations with regards to selling prescription medical devices to business people under the guise of the use of a "medical director".

First, I know first hand that Cutera is selling prescription medical devices to business people directly.  As you know the FDA clearly states with regards to medical devices:

Medical Devices: Purchasers of medical device items hereby certify and assure that such items will be used or resold only under the conditions specified below:
Medical device items are subject to the laws and regulations administered by the Food and Drug Administration (FDA). Provisions of the governing statute, the Federal Food, Drug and Cosmetic Act appear in 21 U.S.C. 331, et. seq . In summary, the Act prohibits the movement in interstate commerce of medical devices that are misbranded or adulterated. The Act authorizes FDA to initiate criminal enforcement proceedings against companies and/or individuals responsible for violations of its provisions. Moreover, the Act authorizes FDA to initiate civil proceedings to seize, or enjoin the distribution of such items. Prescription devices are subject to additional Federal, state and other applicable laws. Federal law requires that prescription devices be in the possession of either persons lawfully engaged in the manufacture, transportation, storage, or wholesale or retail distribution of such device, or practitioners licensed by their state. Federal law also requires that prescription devices be sold only to or on the prescription or order of a licensed practitioner for use in the course of his or her professional practice, and that the devices are labeled in a specific manner. Refer to 21 CFR 801.109.

The area underlined above states the obvious and is in direct contrast to this “medical director” concept used by companies such as Cutera.  I have a copy of Cutera “medical director” form and no where does a doctor neither signs the form nor put their license on the form for the purchase of these devices.

These “medical directors” don’t own the business, the lasers are not used in the course of their professional practice” and yet Cutera and other laser companies continue to sell these devices in this manner.

This leads into my second point. As this is happening, it increases competition to “legal” laser clinic and medical offices that have the authority to own and operate these prescription devices.  These laser companies are selling their prescription devices to their “core customer base”, physicians and then turning around…even in the same town and selling to “non-physicians and increasing competition. As well, the AAD and other medical organizations allow these companies to display and exhibit at medical meetings. This is sickening.

It would seem to me that a site that is committed to the success and professionalism of the spa industry, such as medicalSpaMD could shed some light on the sale practices by the laser companies. You do a great job telling people how to run and market their clinics but if you really want to make a difference and help your fellow physicians succeed, it would helpful to eliminate the “illegal” practice and competition being perpetrated by laser companies.