Cosmetic Clinic Embezzlement: Bank Deposits

The following is a story from the Medical Spa Embezzlement & Employee Theft Scams Report which contains information for physicians and medspa owners to understand these scams and find out how to protect your cosmetic clinic.

The complete report is available for free to all Medical Spa MD members.

Beware anyone taking complete control of the books and the bank deposits.

Our embezzlement story has some classic elements: a break down in financial control procedures, an employee (bookkeeper) showing behavior changes and a drug problem, and a manager and a boss not paying close enough attention.

I have a solo private practice of plastic surgery with skin care services. At the time, we readily accepted cash payments, even for surgical procedures.

My practice manager was responsible to review the daily close, checking the work of the full-time bookkeeper. The manager was to make the bank deposit daily and attach the deposit receipt to the daily close. I would normally check our financial statements at my meeting with the manager every other week. It turns out that we missed one of our meetings, (because of schedule conflicts, being “too busy,” or the usual excuses/reasons that we end up skipping an administrative meeting) and I didn’t ask to see all the reports, anyway.

I became concerned when I noticed some behavioral changes in my bookkeeper, including erratic hours, late for work, leaving the office during the day.

When I discussed this with my manager, she noted that some of the daily reports were coming inconsistently.  I asked if the manager was getting the daily close and making the bank deposit;  my manager (now “buddies” with the bookkeeper) explained that the bookkeeper had taken this over “to help, since she saw I was so busy.”

The short story: the bookkeeper was pocketing all the cash and depositing/ recording only the credit card and check deposits, “cooking the books” to try to hide the missing cash. Fortunately, we discovered the ploy within a short time; our audit showed a loss of less than $11,000.

I brought in an HR attorney for the termination of the bookkeeper and the manager and filed a report with the Sheriff.

We subsequently learned the bookkeeper had developed a Vicodin/codeine habit from a fairly recent injury.

When the bookkeeper left the state, without forwarding address, and “could not be found,” we did not invest in prosecuting, on the advice of the attorney.

Lessons:

• Have secure financial/bookkeeping controls: Have a daily close. Make sure that the person who collects is different from the person who checks/records. Use a third person to make the deposit.
• Verify compliance with these procedures (“Trust, but verify!”).
•  No matter how “busy” you get, check the daily deposit.
• Hold yourself accountable,as well!

Erratic behavior is a warning sign of something worse. Trust your gut. If something “doesn’t seem right,” check it out, sooner rather than later.

Tea & Muffins on-demand graphic design for cosmetic medical clinics

Unlimited, beautiful graphic design for your business. 72 hour delivery (or less). 100% happiness guarantee.

Tea & Muffins is a design and advertising resource that you should take a look at for your clincs marketing and advertising.

Cosmetic clinics are in constant need of design and advertising, from small tweeks to before and after images to sophisticated advertising campaings. Tea & Muffins fills a critical space that gives your clinic the flexibility and capability you need at a fixed monthly price no matter how much you use them. It's essentially a subscription service that can fundimentally change the way that you think of how you think of your design needs.

A simple one time job can be had for a flat fee of $129, and for $399 you get work that is essentially unlimited as long as you only have 2 tasks outstanding at a time.

It's a perfect solution for clinics and medical spas who want to have a read resource that knows what they're doing at a fixed price.

Check them out at TeaandMuffins.com

Dr. Shuba Dharmana - Le Jeune MedSpa, India

Trained as a GP in the UK, Dr Shuba Dharmana runs three clinics in India and has become well-known among a celebrity clientele.

In this interview, Dr. Dharmana discusses her cosmetic clincis, staffing, marketing and working on darker skin types with IPL and lasers.

Name: Dr. Shuba Dharmana MBBS, DFFP, DPD (UK) Associate member of ISHRS (International society of Hair Restoration Surgeons)
Clinic: Le Jeune MedSpa
Location: Hyderabad, Bangalore, and Visag India
Website: www.lejeunemedspa.com

Brief Bio:

I trained and worked as a General Practitioner in the UK for several years for the NHS and in the private sector as an Aesthetic and a slimming specialist.

I worked for the National Slimming and Cosmetic Clinics in the UK in Northampton and Coventry and for several other aesthetic clinics as an injector for Botox and Fillers. I also ran my own clinic ‘Cosmesthetic’ in North London for 2 years before relocating to India. Whilst in the UK I trained under some eminent cosmetic surgeons and got certified to perform various basic and advanced procedures in cosmetology. In 2011, I undertook Hair Transplant training under one of Europe’s most eminent Hair Transplant Surgeons, Dr. Marwan Saifi, in Poland and also completed my post graduate diploma in Clinical dermatology from the university of Cardiff, UK.

I then relocated to India in June 2011 and after working briefly at a hospital heading a dermatology department, branched out on my own and set up my first clinic in Hyderabad. This clinic quickly became very popular with celebrities and socialites with operational break even from first month. Its been 2 years since that I further relocated to another city in India and quickly opened a second clinic in Bangalore and now the third in Vizag. I am an associate member of International Society of Hair Restoration Surgeons and also an ambassador for an NGO that aims to improve education levels in government schools called “Teach for Change’ in Bangalore.

Currently I am working on a unique style of liquid facelift that I call the V3 Lift with fillers that is popular with my celebrity clientele

What made you decide to pursue cosmetic medicine?

I suffered from eczema as a teenager and it prevented me from going into modelling which I had always wanted to do. I was selected as a finalist for Miss India competition but couldn’t compete because of medical exam commitments. I quickly saw how physical appearances matter a lot in this world. It gives you a world of confidence, grows your self esteem and opens up a lot of opportunities. My background in modelling and my skin problem made me realize the value of good skin and beauty.

Throughout my tenure as a GP also I gravitated and favoured to treat skin problems because I could relate to the psychological issues attached with them. When one of my GP colleagues told me about a Botox course I enrolled immediately and once there I realized just how quickly and amazingly medical technology had been advancing. For me there was no looking back since then. One after the other I did all the courses that were advertised in the UK in aesthetic medicine. All the money I kept earning through general practice went into funding my aesthetic training. I got my first job as an aesthetic doctor and slimming specialist at the NSCC and soon offers poured in from all around the country in UK.

Could you tell us more about your clinics?

I am running 3 clinics today in different parts of south India, in Bangalore, in Hyderabad and in Vizag. Since I live in Bangalore, its easier to manage here. The appointments are booked through a practice management software and I get to know about my appointments early in the morning. I have a digital marketing team that assist with Google adwords and social media marketing on twitter, instagram & facebook to get us leads, a PR team that help publish various news articles on latest trends, procedures, etc, a manager and counselor who follows up on the leads, makes appointments, mediates to negotiates payments and essentially helps to convert the lead. In my other centres I have employed doctors and dermatologists who are trained or are being trained by me. They consult all cases and do procedures such as Peels, Prp for hair loss and acne scars, lasers and other procedures they are competent at. Few skilled procedures such as botox, fillers and hair transplants are lined up for me once in 2 -3 weeks and they assist me with these procedures as well. 4-5 days before my arrival the clients are all informed about my dates and clients that particularly want to see me make their appointments with me during those dates.

The services we offer are : Peels, Dermaroller, Vampire facelifts, laser hair removal, Fractional CO2, Fractional RF, Skin brightening and toning with q switched ND Yag, Hydrafcial, O2 Intraceutical facial, RF refirme, Ultherapy, UltraLipo for body contouring, Cool Sculpting, Microdermabrasion, snake venom facial, sheep placenta facial, Scalp micropigmentation, PRP for Hair loss, eyebrow tattooing, Botox, Dermal Fillers, Lipodissolve PPC injections, weight loss programme with nutrition counseling and FUE hair Transplantation.

We see an affluent population as well as a middle class aspirational crowd for most procedures these days. Men want these procedures today as much as women do. Botox and Fillers are taken up quite a lot by the actresses followed by socialites and an expat crowd.

WE have grown into 3 clinics now, in Hyderabad, Bangalore and Vizag , all in the south of India

How do you manage your staff?

The manager who counsels and helps to convert a lead works on a salary and gets an incentive or a commission. If they demand a higher salary they do not get other incentives. We prefer they take a salary along with a commission on the sales so that they retain interest. If it’s a doctor we give them 3 different slabs of salaries with or without commissions. For eg: high salary with no more commissions and lower, basic salary slab with highest commission percentage and something in between with a lesser commission on treatments. I find this plan easiest to use as it gives the member the choice of how they want to work and when they choose to work for salary and commission they feel like this is their own business. The more work they put it the more they get out of it and it works best for everyone. They feel very involved in the business.

What available technologies do you use for your patients?

Most Indians have skin type IV so we invest in diodes. I have 2 of Syneron’s elase with elos technology that uses RF and diode energies. The diode is therefore kept low to avoid burns on dark skinned patients. Its is therefore very safe and very effective. The risk of burns is low but is mainly from the RF aspect when the handpiece is not kept in contact with the skin hence a little operator dependant. I am quite happy with the technology and results but cannot say anything positive about the service issues. You never get the support you are promised after purchasing the laser.

We have Soprano Accord from Alma Laser another diode system for laser hair removal. It is painless and quite effective like the elase but unlike elase’s RF component that can cause burns, this does not cause burns unless you are using grossly wrong settings. It is easier to train a technician on Alma Accord than Syneron’s elase. With regard to results I find Syneron’s superior because the RF component can be increased during the final sittings to target finer hair.

In the Fractional devices I have Fractional Co2 and Fractional RF. Fractional RF allows me to treat skin type IV and above with no risks but with fractional Co2 on skin type IV and above, esp if I want to use higher settings, I prep the skin with a demelanising cream for few weeks before treatment.

For Skin tightening I can try and compare my Ultherapy with RF Refirme. RF refirme does show results but several sittings are needed and then maintanence and results are nowhere as drastic as ultherapy. Ultherapy uses focused Ultrasound technology to lift and induce collagen and I have seen some amazing results. It requires only one sitting and hence Ultherapy treatment can be expensive. RF refirme on the other hand is not expensive and clients can easily afford several sessions. I have had the opportunity to work with Alma’s Clearlift also and I am quite impressed with the results. It falls somewhere in between RF Refirme and Ultherapy.

Alma promises to entice me with some upcoming great powerful lasers and user support but that is something I will have to wait and see. I like Ultherapy, the technology, the results and since they have been very supportive with marketing and training I would like to be associated with them forever. I am not happy with the support Syneron has given me despite buying several of their lasers including 2 elase and 1 e2 system and for this very reason I refuse to buy any more from them.

What are your marketing strategies?

We have a digital marketing team who are working on Google adwords, SEO and social media posts on facebook, twitter and instagram. In this digital age we live in digital marketing is extremely important, much more than traditional newspaper, radio or TV marketing. Everyone I know is hanging out on Instagram or facebook!

Our PR team helps with brand building activities, speaker opportunities, magazine and newspaper publications. I realize PR is very important but it helps in building your brand not in getting you immediate business. Do not expect leads or increase in business immediately from PR activities , it takes time and you should start this later if you cannot afford to do it right away.

Traditional marketing is not working for us anymore. There was a time newspaper advertising worked but not anymore. Radio marketing is also for brand building which did not get us any leads. TV marketing can get very expensive and depending on the area you live in, it may or may not work. If there is too much competition in your area and there are too many clinics advertising on a channel, it gets very expensive. If you are the only one of your kind and from a small town, then you have better chances of getting your audience’s attention.

I support causes that I am passionate about like education for kids in government schools through the NGO ‘Teach for Change’, and sporting and fitness events. Being a fitness enthusiast I get my clinic involved in fitness events like 8K, 10 run events, zumba or Yoga sessions with healthy breakfast, and also conduct beauty, nutrition and skin care workshops to educate groups of interested people. Involving yourself in such activities like charities, social events make people look upto you and notice you. It helps to pick an interest and develop it parallely. It helps to avoid a burn out and boredom. In the process you get to meet many potential clients.

Cconducting workshops, educating people, writing articles, writing books and speaking at events and on TV, radio etc helps people to recognize you as an expert in the field

What are the most sought after treatments or procedures in your clinics?

Hair Transplantation: The investment isn’t much and returns are good even thought t maybe labour extensive. Its also something that needs a lot of skill and hence the justification of profits. Its also highly satisfying to see their face transform. Its something that gives me a lot of joy.

Laser Hair Removal: Here in India dark hair on a darker skin tone makes one look even darker which isn’t liked by anyone. There is a big market for treatments for unwanted hair and this earns us our bread and butter. Ofcourse the investment in a laser is huge but because majority of the population seek this this can me something that is paying your rent and salaries.

PRP: PRP for hair loss is really picking pace. Hair loss issues are many in both women and men and PRP is showing excellent results. Investment is minimal and earns a good revenue

Peels: India has a big market for skin brightening and Peels really sell. Peels are for acne, for lifting Tan, spots, pigmentation, melasma, rejuvenation and they are used by one and all. Minimal investment and good returns

Botox and Fillers: can be good if you have a good celebrity /socialite clientele. In Bangalore I have an expat and socialite crowd that ask for it and in Hyderabad I have actresses, celebrities and socialites

Fractional Treatments: Investment is big in the machine and returns aren’t great. Most people do not want any downtime and they find the treatments expensive. If given a choice they choose dermaroller treatment

Hydrafacial: Good revenue can be generated by acne clientele. Has good scope for marketing with all existing clientele

O2 intraceutical : not really worth the investment but when it is clubbed with other treatments such as microdermabrasion or fractional it can be a luxury experience. So good to give some in a package

Ultherapy: cosumable cost is too high but there is a decent profit to be made if marketed well

Ultralipo: we haven’t done any marketing for it so its not really earning its money. I regret the purchase

E2 system: ematrix sublative fractional RF is good technology with good results but consumable cost is too high hence people find it expensive. We are not using the RF refirme as much as we’d have liked to. I regret the purchase

I am looking to add a Q switched ND yag . we are already working with Alma’s Clearlift and I like it. Investment is huge again but I am positive it will work for us because at large the population here suffers from pigmentation and colour issues and this should be a good source of revenue

Have you had any interesting episodes that you can share with us?

I have not had horrible situations in my clinic thankfully. The time I did have one not so horrible situation was because of a miscommunication as is usually what happens in these scenarios. What I clearly told her would happen and marked and showed was not understood and she expected something else. Although her tear trough area looked great after injecting she wanted it dissolved after few days because she felt it made her eyes look smaller. She was counseled for hyaluronidase injections and the hyaluronidase used that is known to cause allergic reactions caused a reaction. Throughout her treatment and post whilst she suffered the allergic reaction, I kept in touch with her to reassure and support. The reaction took 5 days to subside and she panicked initially but I was there for her. She told me after that how grateful she felt for everything and she even came back twice after that for further filler injections. She is still a good client of mine. When something goes wrong in cosmetic medicine , which maybe your fault or not but its important to not let communication be affected. If I have to put in extra work because of their misunderstanding I do it mostly even if its costing me additional money because for me its not about money. Its about giving them satisfaction and a good experience.

As an experienced physician, what can you share to your fellow physicians?

Good communication skills are key to set treatment goals and keep expectations in check. Showing them some of the before and after pics of treatments you have done allows them to see what they can expect. All concerns should be addressed before they sign a consent form. Get into the habit of taking before and after pictures for their own medical records. Document the procedure well and look for a history of mental health issues and depression. Document post care, hand them some post care instructions with clinic numbers to call in case of any concerns and do not ever neglect someone calling about a concern. The sooner the problem is dealt with the better their options to find a solution. An unhappy client is something you never want and an unhappy client landing in your competitor’s clinic is far worse. Writing bad reviews online and filing law suits are some others you don’t want to face.

About Dr. Dharmana

Dr. Shuba Dharmana is a renowned and experienced Cosmetic Dermatologist & Hair Transplant Surgeon with tremendous international exposure. In March 2012, she established her presence in India with Dr.Shuba Skin & Laser Clinic in Madhapur, Hyderabad.

'Dr. Shuba then founded LEJEUNE Medspa which in a short period of time' has gained tremendous popularity with locals and celebrities alike. Her celebrity clientele consists of several top socialites and famous personalities from the Tollywood and fashion industry.

She trained at several internationally famous cosmetic clinics in London and Ascot under the guidance of world renowned pioneers of Aesthetic medicine. She regularly and religiously attended various seminars, workshops and conferences conducted in UK like 'Faces' and in Monte Carlo 'Anti-Ageing Medicine World Congress'. She became a laser specialist after undergoing several laser training courses in London.

Whilst in United Kingdom, she established and successfully ran 2 clinics - 'The Ultimate Beauty' in Luton and 'Cosmesthetic' in West London. She worked for several private cosmetic clinics including NSCC (National Slimming and Cosmetic Clinics) in Northampton and Coventry for 4 years as a Cosmetic and weight Loss specialist and for 'Novo London' for over a year in Berkhamstead.

Dr. Shuba writes columns and articles regularly for leading magazines and newspapers such as - 'Aesthetic Life'- Pakistan's no.1 aesthetic magazine, 'You & I' magazine, 'Times of India', 'Postnoon', 'AndhraJyothi', 'Deccan Chronicle', 'Deccan Herald', 'Diabetic Living', 'Health India Portal' etc.

Dr. Ebtisam Elghblawi - Aesthetic Dermatologist in Tripoli, Libya

Libyan Dermatologist, Dr. Elghblawi, expresses her passion towards aesthetic medicine and continues to develop her skills in cosmetic medicine further.

Name: Dr Ebtisam Elghblawi. MD, MBBCh, MScRes, ADD, DRH and PGC skin cancer
Clinic: Tripoli, Libya
Specialties: Clinical, medical and aesthetic dermatology
Website: l2106.wordpress.com

Brief Bio:

I am based in the capital. (Tripoli)

I am not that big and I am not with the idea of having a busy crowded clinic as many do. I believe on quality rather than quantity and patient satisfaction would generate eventually loyal patients.

I am very keen passionate to master facial aesthetics. I always want to improve my current skills, scale them up and increase my knowledge in Aesthetic as it’s a dynamic medicine. It’s about the concept of “less is more" with minimally invasive procedures. So it’s about how to not guess the patient age and not to know if the patients had any work done already, just being looked refreshed and contented.

I developed passion about aesthetic dermatology and want to learn the art and the skills of it to tailor it accordingly. It’s delivering harmonious beautification and not overly done procedures with pleasing aesthetic results which will positively impact your patients’ lives. I personally want to create a pleasing reflection when my patients look into a mirror. Which would give them inner empowerment and which make a difference in peoples’ lives and create a self secure state. I am always eager to learn more and more.

Question: Can you tell us a little bit about you and how you got started in cosmetic medicine?

I started in 2012 embarking and learning about the aesthetic dermatology in great details to learn the basic knowledge, essence and the foundation. Plus learning the science behind emerging aesthetic medicine based products and devices. It’s a wide field and every time it keeps changing as I said up about medicine development. Even now I can speculate that the future in aesthetic for face lifts by facial threading as its emerging strongly in the market. It’s a huge market though and any one should be familiar and well oriented about its pros and cons in order to avoid fatal mistakes and patients disappointment. It is very vital to meet patient’s expectations at the first place, in order to gain their trust and develop a mutual rapport and understanding which I consider the backbone to any booming procedures. I started developing my own skills from reading extensively and attended some training workshops abroad plus subscribing to attending online webinars and sharing views, procedures and results.

I am inborn artistic as I do drawing as a hobby since I was young and I believe tasting beauty and performing it would help to achieve the desired subtle changes to enhance beauty in an acceptable and a comforting manner. I dislike extreme changes which would imply and reflect negatively.

A person per se is a piece of art, a sculpture, and herein we are creating a beauty. We have to look at each person face objectively. Moreover the market currently is looking at attraction and beauty the most and aesthetic work should improve the quality of people lives. Aged skin involves a lot of physical process, starting off with the photo-aging and the process of aging itself, where skin become thin, loss its elasticity, elastin and collage, fat, and with imminent bone resorption and become loose, redundant and sagging with gravity which would impact our wellbeing and self confidence.

The face should have divine measures. We have to look for artist for each client faces. Patients are exceptionally critique due to many brands across the market.

Moreover as I said, medicine is evolving speedily and constantly and a new lesson to gain and learn is essential. We learn over time and nowadays practicing medicine is uniform across the world as its all connected by the well developed technology, the ‘internet’, and is only culturally differs. Medicine after all is Nobel and risky profession. “The day we graduate medical school we say, “Doctor do no harm.” Thus taking care of the patients by listening to them wisely and addressing their worries, show empathy and compassion and meeting their expectation is a triumph to any doctor.

Any medical practitioner has to have the appropriate training; in-depth knowledge based learning, expertise and experience to perform the procedure and to deal with all routine aspects of care and any likely complications. It is very essential to be reacquainted with facial anatomy and should pay a careful attention to the dangerous zones of the face, where detrimental complications can happen, namely vascular obstruction, tissue necrosis and permanent blindness.

Nonetheless, in reality nowadays, many registered medical doctor has started performing non-cosmetic surgical operations without proper qualifications from an accredited training body at all. There should be some guidelines and appropriate regulations with licensing that would have had more force, and offer more protection to the public and for doctors towards having appropriate qualifications and proper training. Nonetheless, it stops short of mandating a minimum qualification. The decision as to the level of expertise or experience is left to the doctor.

In the least practicing doctors should have the required knowledge, expertise and experience. However, no one is immune as in fact many qualified surgeons also harm patients and generate complaints.

The public trust the level of training and supervision involved is some reassurance a minimum level of skill has been obtained. The problem is always, ‘oversimplified the procedures and overstated the results’, which would have a strong impact on patients’ attraction as many medical practitioners do. It is after all the integrity of the treatment which should be the main concern for any medical practitioners.

Moreover, additional local anaesthetic may be administered, and this could lead to an overdose, which is potentially fatal if was not used wisely.

Some cosmetic surgeons have a significant conflict of interest – putting patient interest ahead of profits. Also it’s mandatory that ethical obligations to patients supersede profits. This is an important first step, but it cannot be the last. Also subtle changes would help rather than looking like aliens.
Moreover, patient assessment and informed consent is mandatory for the medical practitioners to provide and convey clear information about risks and possible complications.

I myself offered some patients who wanted to have cosmetic for a change and cannot afford the high prices, and to feel confident by injecting them for free and paying only the price for medicine from the dealer. I am trying to help my patients to have the face that they want to feel better in and out, and I offer empathy that many doctors lack, and I know what I am doing. I constantly stop while performing the procedure and let the patient to look into the mirror to show and explain what I am doing. One patient I recall told me that these changes changed her life and made her feel good and even men complimented her at work. It is always good to not putting profit above the wellbeing of our customers.

Nowadays, there are procedures done by the girl who runs the tanning bed shop or a local hairdresser and it is atrocious.

I give myself top-ups with fillers and Botox. I know the human face better than many expensive surgeons, and I can even do procedures on myself proudly speaking. Many of my cosmetic colleagues just inject patients and did not try on themselves at all and wondering why not to have the feel of.

I take the say of “I wouldn’t perform a procedure I had not had done on myself, to experience the procedure myself. We need to protect anyone who has cosmetic procedures and I should know – I have been under the needle and behind it.

Conversely, women have long been held path to a higher aging standard than men, but it appears as though that gap may be closing, as now men are joining in women, and “They realize that they also want to look and feel their best, and to maintain a healthy and youthful appearance especially when older work in a younger men workforce environment. Botox for instance, helps turn the frown line upside down and sometimes as the say of ‘The person looking back in the mirror is not the person you feel like’. It’s called ‘Brotox’ for men.
Men nowadays are much more open and proactive about their appearance. And this can be explained to the reason of quick fix with no downtime for starters.

It has been found that youthful appearance can generate more revenue than their older looking peers, and the widespread accord that men require higher doses of Botox than their female counterparts.

Many men do secretly Botox ‘little and often’, where nothing is severe really. Vain middle aged men like to call it a ‘Brotox’ and like to give it a go. Botox is shameless vanity, an expensive, self indulgent secret.

The ‘English look’ is where a skillful needlework given to freshens up a face rather than creating a creepily smooth forehead. It is always better to address the face as a whole to look better and not necessarily different.
The general joking say is ‘the more fit men are, the worse they look, they look close to death’. As in fact heavy exercise causes fat to drain from a needy area and build up in parts of the face where it conveys an ugly look for men. Brotox is meant to just accentuate masculinity which means improving the jaw line rather frown freeze thing.

Men who have tried Botox look better, feel better, and believe it gives them a competitive frame. Furthermore there's also less of a stigma associated with cosmetic procedures nowadays and they don’t see it a taboo treatment as used to be and they believe on the importance of maintaining a youthful look. After all, skin treatments can improve their looks and self-confidence.

Lastly, it is always the ubiquitous search for eternal beauty and youth which won’t stop at all and always will be developing and evolving.

Question: Can you tell us more about your clinic?

I don’t have my own clinic. However I always suggest some changes and offer some ideas to make the clinical practice more appealing, charming and attracting. The aesthetic in Libya is still kind of primitive and I expect to grow more across the coming years. The clients can vary unexpectedly and both genders nowadays want to look their best, refreshed and alluring.

The services I do are mostly clinical and aesthetic dermatology, namely, Botox, filler, PRP, chemical peeling and laser technology.

Question: Staffing is always something that physicians are interested in. Can you give us some insight into how you hire and manage your staff and what you’ve learned?

Not applicable.

Question: What IPL or laser technologies are you using? What are your thoughts about the technologies you’re using now?

I have worked with Candela laser gentlelase for hair removal and was a good pleasing experience. I know IPL is not that effective as the laser itself and I have written a paper about it and hereby the link to it;

• Alex Laser Hair Removal with Candela GentleLASE®; http://blog.healthjobsnationwide.com/alex-laser-hair-removal-with-candela-gentlelase/

Question: How do you market your clinic?

Not applicable.

However, from what I am seeing recently that most uses the social media, face book to generate, advertise and promote about their works and I think it conveys the message strongly, however we have to be very careful about spreading and disseminating our work and it should be the truth and not just selling sparkling and dazzling words. We have to reflect precisely what we do to gain and keep patients trust.

Question: What treatments or services are most profitable for you?

I can’t comment precisely about this as I am not that kind of a doctor who likes to have a lot of patients to work on one go. I like to work in peaceful, calming and quite environment to create, innovate and deliver a quality appealing results that patients will like, and not a quantity results.

My patients come to me and most often, the first thing they say is, I don’t want to look done. In fact, some of my patients don’t tell anyone they have had work, not even their partners. They simply want to look refresher and good.

Question: What have you learned about practicing cosmetic medicine? What stories can you tell?

What I can add is that we have to listen to our patients sensibly and address their main concern and worries and don’t give unrealistic expectation to avoid misfortune and disappointment which would incur a lot of problems, plus will affect our reputation.

Addressing patients’ main expectations and checking out realistic outcomes are the main goal in any successful aesthetic practice. In many instances some patients do have body dysmorphia whereby they never appreciate nor see any positive outcomes even if it was subtle. It’s after all, patients own perception of their body and they could just make unnecessary troubles.

I happen to see lately a lady that I feel sorry for her. She did filler since few years that she is not aware of the kind injected and I think it was calcium hydroxylapatite (CaHA) and the issue caused her four big hard stony nodules in her smile lines and cheeks. I sought medical advice from abroad to try sorting her out and called her twice. However she responded but declined attendance, and I kept thinking of her I must say as its really a tragic misfortune that could happen to any injectors.

Also sometimes you keep explaining to the patients and it seems they are mute and cant digest it well. For example a lady with a facial and neck sagging skin came to me and I advised according to her budget to have her face done in stages to appreciate the subtle changes. So basically I told her we can do the forehead with Botox to relax it and improve a bit the two long deep vertical lines around the glabella and I explained that we might even need filler to smooth it out after filling it and for the neck I can start with short mono lift threads and I even didn’t charge my hands work. She only paid for the goods, and after that she came complaining that she just wasted her money and didn’t see nor appreciate that changes though it was obvious and clear. She kept saying that the forehead is only a skin over the bone and doesn’t have any muscle really and that I didn’t do anything really for that. And as far as for her sagging neck, I explained it needs time to see the subtle changes and might need more needles the cog ones or the silhouette soft lift. However she is not prepared to pay for them as they are costly. Moreover she declined me taking photos after where I can compare and show her the changes that she cant see really. Some patient can be so stubborn that won’t see nor appreciate and just give you a hard time and put blame whatsoever on you and accuse you with all sorts of reasoning. You explain and even tell them to read on the internet to have the basic feel, and the knowledge; however it is as you throwing words in the air. Nothing really would work and such patients should be declined at the first instance as they will only waste your time, create troubles and give you a hard time.

Another story a lady who has pigmentation on her face and came and demanded a clearing up for her face skin. I explained about the chemical peeling and what is expected and all can her brain process is having a baby pink skin and other drawbacks her brain couldn’t digest. So she kept coming and blaming me for that as its my own fault. They think all just can happen in a glimpse of time.

Another story that a lady who had a deep simle line and a big fatty face demanded filling up those lines and declared she wont pay for more than one syringe of one cc. I had managed to make her dream come true through that and was an amazing sublte correction that my colleague appreciated it well by that small amount. However she kept coming and complaining and said it wasn’t as she wished.

Another story a lady who had filler for her smile line and a tiny bit on the sides of her lip, kept complaining of angioedema and thought its due to the injected filler. Though her examination didn’t show any lumps and after a through investigations, found that she fancy taking red chili plus she had bad teeth hygiene and gums troubles.

Another story from a greedy colleague who wants to make profit on you. A patient I did since sometime and she was content and all went well. This colleague obviously has no morality. He didn’t pay my money and despite of that called the patient and told her if she has any problem that she can complain about me and took all that as an excuse to not pay my money for the lady I did. Anyhow after 8 months she shown up in another clinic that I work in and she knew me and was happy about my aesthetic services and told me that the greedy colleague wanted to use her for his own sickness and asked her to complain if she didn’t like my work which obviously she declined as in fact she is happy with the results she achieved by me. It seems sometimes that colleague can act badly and secretly and the sky is the limit.

Question: What advice would you give to other physicians based upon your experiences?

I always emphasize the foremost on is listening to our patients carefully and addressing their main concerns and needs in order to reach a good settlement that would give a pleasant experience which would mean keeping the work on even in the future once patients gained the physicians trust. It’s also vital to weigh things between patient needs versus patient wants.

Cosmetic involves and covers all phases from patient assessment through to aftercare. And a small wrong thing in patients is unforgettable. Plus it’s highly recommended to document every small thing because patients keep forgetting especially when it comes to cosmetic.

I always like to provide quality aesthetic procedures to my patients. It’s important always to learn how to develop and sharpen our aesthetic eyes, and keep up to date with the latest studies, researches and technology in the field of Aesthetic Medicine.

We all know that aging process is inevitable. Thus, it’s vital to understand the concept of the aging process and the proper aesthetic analysis in order to create and correct. I recently joined a course which addressed the 4 ‘R’, which stands for; rejuvenation modalities- (Resurface (skin care), Relaxation (Neurotoxins), Refill and replenishment (Dermal Fillers) and Re-suspend and boost (Face-lifting).

It is not the injectable but rather the injector who makes the difference after all once mastered the art. It’s also important to hear to the patient feedbacks in order to improve, master and innovate.

Lastly, it’s about safely enhancing the patients’ current beauty without altering their natural facial features. After all, People are now more conscious about their outlook and they scare the aging process and wish to defeat it.

Dr. Alan Matarasso - Park Avenue, Manhattan

Dr. Matarasso He has published more than 200 articles, letters and abstracts in prestigious peer-reviewed medical journals; delivered over 500 lectures, invited lectures, exhibits, panel presentations and instructional courses.

Name: Dr. Alan Matarasso, MD, FACS, P.C.
Clinic/Office: Park Avenue, Manhattan NYC
Website: alanmatarassomd.com

What factor made you decide to venture into cosmetic medicine?

I was influenced by a professor D. Ralph Millard while a medical student at The University of Miami School of Medicine. I completed a residency in Plastic Surgery followed by a specialized fellowship in Aesthetic Surgery at Manhattan Eye, Ear and Throat Hospital in NYC. Cosmetic surgery became the sole focus of my practice. With the introduction of non-surgical procedures, like Botox we evolved into the ability to offer the full range of surgical and non-surgical treatments, fillers and energy based treatments (lasers, ultrasound and radiofrequency devices). I then became the first cosmetic medicine section editor of the Aesthetic Surgery Journal.

What can you tell about your office?

Our office is located on 85th and Park Avenue. I have a wonderful team of nurses, physician assistants and assistants who specialize in cosmetic medicine. The staff is overseen by our coordinator. We provide a full range of cosmetic surgery services (face and eye lift, rhinoplasty, liposuction, abdominoplasty and breast surgery) and all of the non- surgical procedures (neurotoxins, fillers, lasers etc.) We have an accredited operating room on premises, I perform many procedures at Manhattan Eye, Ear and Throat Hospital/Lenox Hill Hospital which is a world known ambulatory surgery center specializing in aesthetic surgery. 

Tell us more about your staff and your hiring process.

There’s a saying “slow to hire fast to fire.” Your staff represents the doctor, their thought process and can be the patient’s first interaction with the office. We constantly look for intelligent people who are consumer orientated, always keeping in mind that we are a service business and that the patient’s satisfaction comes above everything. Members of the team receive a guaranteed salary and generous benefits package that includes health insurance and a retirement plan.

Which non-surgical cosmetic technologies do you use?

Surgery addresses the quantity of tissue, skin, fat etc., but not the quality. Non-surgical treatment often addresses other issues and can complement or enhance surgery or address areas that surgery will not improve. It’s ideal to be able to offer the patients a full range of surgical and non-surgical procedures based on their needs, rather than a practice that can only offer what they have available.

Our Nurse Practitioner, Tiffany M. Rice, N.P., manages the nonsurgical side of the practice. The InMode Platform is the nonsurgical technology that Tiffany is currently using along with fillers (Juvederm, Voluma, Restylane, Kybella etc) and neurotoxins.

In regards to IPL specifically, Lummeca is our preferred treatment. Patients are satisfied with the results of Lummeca as clearance of pigmentation is typically achieved in 1-3 sessions as compared to 3-6 sessions with other IPL technologies that we have used in the past.

We are approached on a regular basis with new technologies which we appreciate and evaluate according to the needs of our patients.

How do you market to patients?

Our referrals come from word of mouth and doctors. Periodically will do blogs about our professional activities such as lecturing to medical groups and writing medical journal articles. I do an extensive amount of plastic surgery education, lectures and journal and textbook writing. I have always been involved in plastic surgery and I’m currently American Society of Plastic Surgery Vice President of Aesthetic Plastic Surgery and Private Practice Committee.

What do you find as profitable for your practice?

What is most profitable is a happy patient. Happy patients refer friends and family and usually remain patients for life. We are always looking into adding new proven techniques that benefit the patients. We also consider adding trained personnel that preform services we do not currently provide such as hair removal or tattoo removal.

Can you tell us any stories in your current career in cosmetic medicine?

Everybody looks into their own mirror, in other words different things bother different people. I recall a young male with a large mole on his nose and when I introduced myself in my typical fashion of asking what was bothering him, he mentioned something completely different then what I would have thought and never mentioned the very apparent mole on his nose. Or, when a girl comes in and says she wants a B-cup but shows me a picture of an exotic dancer size breast. What most people want is a better more natural version of themselves, not to look different. Another part of the patient encounter is predicting satisfaction, who will be happy and less so. I’ve learned that for any surgical or non-surgical procedure to the extent possible to have an in depth conversation and understanding of all your patients goals. I find we spend more time explaining what the procedures won’t do rather then what it will do. “Under promise over deliver”. Remember pre-treatment it is an explanation, post it is an excuse.

What can you tell your fellow physicians?

It’s all about delivering a good product and being forthright with the patients. In order to showcase your ability it requires communicating with patients in a language they understand. It’s also about the complete “experience”, from the moment they call to their final follow up appointment.

With regards to insights into cosmetic medicine it is a rapidly evolving exciting speciality and staying abreast of all the surgical and non-surgical advantages is essential. Always work hard and put the patient first.

About Dr. Matarasso  

Dr. Matarasso is a native of Westchester County in New York. He attended public schools where he was a 3 letter varsity athlete. He is a magna cum laude graduate of Boston University and a graduate of the University of Miami School of Medicine. Dr. Matarasso trained in general surgery at the Albert Einstein College of Medicine-Montefiore Hospital where he continued as resident and then chief resident in plastic surgery. He completed a fellowship in cosmetic surgery under the direction of Dr. Thomas D. Rees at Manhattan Eye, Ear and Throat Hospital/Institute of Reconstructive Plastic Surgery-New York University Medical Center. He was certified by the American Board of Plastic Surgery in November 1986. Dr. Matarasso achieved the rank of Clinical Professor of Plastic Surgery at Albert Einstein College of Medicine. His clinical practice is located in Manhattan, New York. He maintains an AAAASF-accredited operating room and has hospital privileges at numerous New York City medical centers. Dr. Matarasso has devoted his entire career to the specialty of aesthetic plastic surgery.

Dr. Alison Brooks - The Mirabel Clinic in Swindon, England

Located in Swindon, England, Dr. Alison Brooks made the switch from general practice dealing with Britan's NHS to focus entirely on cosmetic medicine.

Name: Dr Alison Brooks
Cosmetic Clinic: The Mirabel Clinic, Swindon, Wiltshire, England
Website: www.mirabelclinic.co.uk

Brief Bio:

I qualified as a doctor in London in 1989 and spent the next few years working as a junior hospital doctor and then became a General Practitioner (GP) in 1996. I worked as a GP in various locations in the South of England and then became a salaried partner in Swindon in the early 2000s. I established The Mirabel Clinic in 2006 and left General Practice in 2014 in order to concentrate entirely on cosmetic medicine

Let us know more about your journey to cosmetic medicine.

I have a lot to thank my sister for as it was her who got me started! She got divorced in 2005 and was back out on the dating game so decided to get some botox and fillers to help boost her confidence. When she told me about the experience saying that the person who administered her treatment was a General Practitioner this got me thinking and stimulated me into considering training to do this work. Almost immediately I looked up on the internet how to get trained in toxin and filler administration and I booked on a course with Adrian Richards – a plastic surgeon in Buckinghamshire. I spent a day training. I then came home and contacted two local beauty salons to ask if I could use their premises on a fee per patient basis. I started advertising in a local magazine and set up a website. For the next two years I gradually built up a small practice in the two salons, which was in addition to my usual work as a General Practitioner. In 2008 I bought a second hand laser/IPL machine from a local colleague, which precipitated a change in premises as I had to register my clinic with the Health Care Commission and I would never have been able to do that whilst working out of the two salons. So I approached The Shalbourne Suite, which is the private wing of the local NHS Hospital and asked if I could hire a room for a few hours a week. They agreed to this and I then spent the next 8 years working there, gradually building up to two really busy days a week. I gave up General Practice finally at the end of 2014 and haven’t looked back since. I have just moved into high street premises in Swindon, having taken a 10 year lease on a old property above a shop and completed a complete refurbishment on it. It has 3 clinic rooms, an office, reception room and a waiting room and is just about perfect!

What could you tell about your clinic?

Currently the clinic consists of me and my clinic manager, Debbie. She has worked for me for 6 years and now does all her back office work whilst sitting in the reception room greeting patients and answering the phone. We are in the process of taking on two other new aesthetic doctors to do half a day per week, as well as a receptionist and a laser trained beauty therapist. We open 4 days per week with two late evening till 8pm every week. We are located on a lovely street In Wood Street, Old Town, Swindon with a number of cafes, delis, restaurants etc. Wood Street is the most prestigious street in Swindon and is definitely the best location for a high end Medical Cosmetic Clinic such as Mirabel. We offer the usual toxin and filler injections, Laser and IPL for skin and hair as well as tattoo removal. I also do chemical peels, diathermy for minor skin lesions, Dermapen for scarring as well as Sculptra and Silhouette Soft thread lifting. We have a new Lipomed cryolipolysis machine that is waiting for a therapist to operate it! We have a database of about 2000 and I usually see about 40 to 50 patients per week but these numbers are expanding rapidly. Our patient demographic is mainly female with an age range of about 35-65.

Tell us about your staff also.

I have been very fortunate in finding a very good friend who has now become my irreplaceable Clinic Manager. I remember asking Debbie about seven years ago if she could spread the word about my need to find someone to do my back office work of filing and accounts. She suggested herself and I laughed saying that I thought she was overqualified for the role. She persuaded me to take her on and it has been the most amazing journey for her and me. She is one of the most organised and reliable people I know and is an incredible manager. I genuinely could not have developed the clinic into what it is now without her. We are now taking the next step of hiring staff and I am very aware (from other doctors in this business) of the pitfalls. Watch this space…..!

Which technologies do you use in your practice?

I have a Lumenis Quantum IPL and Laser multiplatform machine which I bought second hand in 2008 which I am very fond of and use a lot. I do IPL for hair removal and skin rejuvenation and it has an ND Yag head which I used for deeper thread veins and a Q-switched ND Yag head which I used for blue/black tattoo fading. I bought a second hand Alma Soprano Hair Removal diode laser for hair removal in sensitive areas and on darker skin types. I love this machine but use it less at the moment and will hand this one on to a laser therapist to administer treatments shortly. I also bought a new Lipomed machine last year but have yet to get going properly with this as it will be a therapist administered treatment. I am constantly on the look out for new machines and have considered getting a radiofrequency machine for skin tightening and more recently have looked at the new plasma soft surgery devices for non-surgical blepharoplasty and removal of benign skin lesions such as seborrheic warts. That said, buying new machines is a bit of a minefield. The reps will tell you that you will recoup your money in six months and that never happens! I find getting truthful advice about expensive machines is very difficult. I mainly take advice from other medical colleagues in the cosmetic medicine world.

Any marketing strategies that work for you?

I think marketing is a very difficult thing to get right. I and all my friends in this business have, at some point in our careers, been sold advertising in magazine and locals papers (at great expense) which have made absolutely no difference to our turnover! At The Mirabel Clinic do a little advertising in a free local paper and have a good website with some online selling. We don’t do much in the way of social media marketing and know that we should focus more on that area. The one single thing that made the biggest difference was investing in a radio ad on a local radio station. We have used this for the last 4 years and it constantly brings more custom into the clinic and has paid for itself several times over in terms of new customers and repeat business.

Which procedures do most of your patients undertake?

Without a doubt toxin treatment is the most profitable treatment I do, followed by dermal fillers and then IPL treatments. My least profitable treatment is in fact laser tattoo fading which is almost a non-profit making enterprise. I had to replace my Q-switched laser head last year and had a good long think about whether it was worthwhile, from a commercial perspective, to carry on doing tattoo fading. In the end I felt that I could not let my patients down and bought another head! It is a pro bono treatment but it makes me feel better about myself. I have just started Silhouette Soft Thread Lifting and am really enjoying the new technique. It definitely helps with the lower half of the face and I sell it as the only treatment I have in my armoury of non-surgical treatments that will do much for the jowls. The next step is really plastic surgery, and that is not for everyone.

Any stories you would like to share as a physician in cosmetic medicine?

I definitely have some stories of strange characters who have turned up in my clinic asking for unusual hair removal treatments and I remember one particular time early on when my children were very small and I was still taking calls for appointments on my personal mobile. I was in the changing room of a local swimming pool getting the children dressed when I took a call from a rather breathless man asking if I performed certain unmentionable services. I was so flustered that I almost dropped the phone and a baby too! I said “No!” and put the phone down feeling very shaken but I did have a good laugh about it later.

What is your advice to your fellow physicians?

Be brave. It is quite terrifying stepping out into the big commercial world – especially in the UK where most doctors are NHS employees. The rewards from growing a successful business can be huge, both financially, and in terms of your own personal self-esteem. Take a big breath and do it. Dig deep and you will surprise yourself.

About Dr. Brooks

Dr Brooks set up Mirabel Clinic in 2006 after completing advanced training in cosmetic injection and filler therapies at an expert training course run by a team of Consultant Plastic Surgeons. She completed her laser training in 2009.

Dr Brooks is a member of the British College of Aesthetic Medicine, regularly attending conferences and training updates to learn about the latest advances in cosmetic medicine and laser treatments.

Dr Brooks always offers free initial consultations as she feels that it is very important to advise you on the most suitable treatments, tailored to your individual requirements, before any committment is made by you.

Dr. Sanjay Gheyi - Coltishall Cosmetic Clinic Norfolk, England

Trained as a general surgeon in India, the UK, and the US, Dr. Sanjay Gheyi's Coltishall Clinic in Norfolk runs the gamut of cosmetic offerings from Botox and IPL to cosmetic surgery.

Name: Dr Sanjay Gheyi
Clinic: Coltishall Cosmetic Clinic, Norfolk, England
Website: www.coltishallclinic.co.uk

Brief Bio: MBBS and MS general surgery India. FRCS, UK. WOSAAM board certification in Anti-ageing Medicine. Paris France

Medical Director Coltishall Cosmetic Clinic, Norwich UK.

Coltishall Clinic offers a full range of dermatologic laser treatments, non-surgical treatments such as botulinum toxins, fillers, face and body contouring treatments. Laser, skin and vein treatments such as IPL photofacials, non-ablative skin rejuvenation and toning, CO2 laser resurfacing, sclerotherapy, EVLT and ambulatory phlebectomy. We also provide minimally invasive options and cosmetic surgery under pure local anesthesia. This includes microcanula tumescent liposuction, fat transfer, laser assisted liposuction, blepharoplasty and face and neck lifts.

What made you decide to get into Cosmetic Medicine?

I had my board certification in General Surgery and worked in various surgical specialties including plastic surgery. I was always interested in cosmetic surgery but after spending 10+ years in Surgery in India, UK and a brief period as a surgical resident in the USA, I felt that there was more to life then perpetual residency so I decided to opt out of the rat race. I worked part time in general practice and also surgery. Then I discovered lasers and after much trepidation and sleepless nights brought my first device in 2006 and have never looked back. That was the best thing I ever did. I started slow and gradually added more services. I did not market very much but emphasized on training and education. I was working in the NHS at the time and gradually reduced my commitment as my private practice expanded. In 2010 I reduced my NHS commitment to just one session in Dermatologic surgery which I enjoyed immensely. After 5 years I resigned from the NHS completely to focus on my aesthetic practice full time.

What could you tell us about your clinic?

We are located in a beautiful suburban area north of Norwich. I decided to stay away from busy city centre because last thing you want to do after having a CO2 laser resurfacing for example is to be walking through town centre with a red face.

We have 3 treatment rooms, a reception room and separate comfortable waiting room. My wife is the general manager and we have two receptionists and one aesthetician. We have a small team so most patients know us well and we all know them very well. We offer only evidence based, results oriented services and where patients ask for treatments or services where there is not a lot of evidence base I tell them this very clearly.

We offer a full range of cosmetic dermatology services, minimally invasive surgeries such as skin lesion removals, tumescent liposuction, blepharoplasty and SMAS facelifts. We also have a vein practice and offer services for thread and spider veins anywhere on the face and body and also varicose veins treatments of EVLT and ambulatory phlebectomy under tumescent anesthesia.

How have you decided staffing in your practice?

Hiring the right people is very important. I was very lucky that my wife agreed to deal with the phone calls in the early days. She is a nurse so she had considerable health care experience which helped a lot. At first we used our NHS premises and staff on a part time basis but quickly learnt that was not a great idea. It is very hard to mix NHS services [I guess similar to your insurance patients in the USA] with self-funding private patients. So we moved out to private rented premises. We also appointed and trained dedicated staff members who had no NHS experience. We moved again to our new premises in 2010 as we were running out of space very quickly as the practice was expanding. Our new premises are future proof to allow for more expansion. We do not have a formal incentive scheme for staff but they are well looked after and we pay them well. We offer generous discounts on treatments and products and some free treatments. We have formal policies and procedures in place which are updated from time to time. When we hire new staff we allow them an opportunity to come and spend a day with us to see if they feel we are right for them and vice versa. Then we would have them on a trial period before appointment. We allow flexible working and our aesthetician manages her schedule herself. The feedback we get from staff is that this is a happy place to work and what is not to like!

Tell us about the technologies you use.

We started with a Lumenis quantum IPL and I still use it. We are lucky to have a full range of dermatologic lasers. For vascular work on the face we use IPL, PDL and long pulsed Nd-Yag. IPL is very useful for rosacea treatments. For leg veins it is usually sclerotherapy or Nd-Yag.
We also have a full range of pigment and tattoo removal lasers including the q- switched KTP,Nd-Yag and Ruby lasers. For ablative treatments we use CO2 laser and endovenous laser treatment are carried out with a 1470 nm diode laser. For laser assisted liposuction I use 980 nm diodes and also a 1470 nm diode laser.

For skin tightening we use radio-frequency and for skin toning we use q-switched Nd-Yag lasers and also in quasi-synchronous mode.

I like IPL because it is gentle and can address a number of concerns simultaneously. I love the lasers and there is no laser that I dislike. If you know you lasers well, you know their indications and basic science- each has its place in our armamentarium. I do dislike some doctors giving presentations and insisting that it has to be a particular brand of laser to do the job best. Look beyond the hype. If you know the wavelength, pulse duration and fluence you can make your own conclusions. One note of caution though-please don’t transfer recommended settings of one device to another-unless you are practicing on yourself first! Please stick to recommended settings and you can improvise as your experience grows.

Although I like new technology I do not rush in to buy the newest device as it hits the market. I once heard a physician say that he does not try any new drugs on his patients till they have been on the market for three years. Well, in cosmetic medicine we can't be that long but I like to wait at least six months and make sure and the machine that I'm investing my money in works well.

What marketing strategies do you use?

Our practice has been growing slowly and organically over last many years. We deliberately stayed away from aggressive marketing. I see two types of practices opening up. The first is cut- price businesses which turn these procedures into commodities. The second type is the practices that focus on premium services. We belong in the second camp.

Internet marketing has worked well for us and we use SEO and also PPC advertising. I created my own website, however, now due to lack of time I am getting an external website designer to revamp our website and make it mobile friendly. We advertise in local magazines. We don’t do national media or radio advertising.

Increasingly we see patients through word of mouth which is the best form of marketing. We also get referrals from local family doctors and hospital consultant colleagues.

Which procedures or treatments do you perform the most?

Surgical procedures are more profitable but lower volume. Next on the list is Botox and fillers followed by IPL and laser skin rejuvenation treatments. Laser hair removal and tattoo removal has become a commodity as a number of cheap places have opened up. We have however seen patients that are either dissatisfied from these services or had complications and we are seeing an uptick in laser hair and tattoo removal. Our unique selling point is that we have a number of devices so we can optimize the treatment using the best device based on patient’s unique characteristics.

We are moving away from non-invasive fat reduction as they fall short and again a number of cheap places are opening up. I can provide such good results with tumescent liposuction that non-invasive technologies will have to improve a lot before I can be convinced to offer them on a bigger scale.

What are your thoughts about cosmetic medicine, would you perhaps have any stories to tell?

Medical knowledge is obviously important but cosmetic medicine is both science and art, especially if you're going to do facial or body contouring or both.

Choose your patients carefully and learn to say no. Patient expectations are very high and in some cases are completely distorted.

There is inherent variability in response which means that some patients may respond very nicely and others may not respond at all. So don't provide any guarantees. They don't work in medicine!

I saw this clinic opened up locally who started doing laser hair removal and advertised 100% guaranteed laser hair removal. Six months later the guarantee had gone down to 1 year period following your last session and I believe now the guarantee has disappeared. Obviously they must have learnt the hard way!

Complications are a part of life and you will get complications. Be honest and take good care of your patient if you get complications and they will usually be very understanding and forgiving.

What advice could you tell to your fellow physicians?

Education is key. Patient’s come to us for results and a good experience. If you can provide this you will succeed. Fortunately we have many resources available to us. I found the discussions on medical spa MD very useful and they also helped me stay clear of hyped up devices which over promise but fall short on delivering results.

Don't buy the latest cool device. Instead go to devices which have had a proven track record. Talk to your colleagues, visit clinics, attend conferences and keep up-to-date and good luck.

About Dr. Gheyi

Dr Gheyi has triple board certifications in General Surgery, Family Medicine and Anti-ageing Medicine. He devotes full time to his Aesthetic and Anti-ageing practice. He personally administers thousands of laser, injectable and surgical procedures each year. He worked in NHS hospitals for 21 years in surgical specialties and last 5 years in dermatologic surgery.

He is an invited speaker at laser seminars and mentors other doctors training in lasers and cosmetic dermatology and surgery.

He is a trained and qualified surgeon. He has extensive clinical experience both in the UK and USA and has attended numerous perceptorships in cosmetic medicine & surgery. He has built a premier laser practice with sixteen different state-of-the-art laser and light systems and he continues to invest in training and new technology.

Dr. Paul Cronin - Eternal Youth Clinic in Cheshire, England

Eternal Youth Clinic uses updated aesthetic technologies and sees returning and loyal patients in our interview with Dr. Paul Cronin.

Name: Dr Paul A C Cronin
Clinic: Eternal Youth, Cheshire
Website: www.eternalyouth.co.uk

Brief Bio:

A one time family doctor who branched out into aesthetic medicine over sixteen years ago. He has extensive experience in injectables, radio-frequency skin tightening, micro needling and laser resurfacing. He opened Eternal Youth clinic over ten years ago and offers Fraxel, Thermage, Ulthera, INTRAcel, ULTRAcel and VASER liposelection.

What made you pursue cosmetic medicine?

I blame it on my mum really. She rang me up very excited one day and said ‘you have to go and learn Botox.’ When I asked why she said that she had just had some treatment by a young doctor who used to be a GP and now does this. She thought it would be good for me and I might be good for it. It seems that she was right

Mind telling us a background about your clinic?

My clinic is a small and very personal run affair. We used to have a large clinic in Alderley Edge with several staff, but now we work from purpose built premises in our garden. My wife is in charge really and makes sure I know who is coming next and what for. we have a varied patient base from quite long distances in some cases. Our patients appreciate the discretion and the very personal services we offer.

What are your insights about your staff?

To be honest when we had more staff I didn’t think I was a very good picker. I think it is hard to find someone who will work as hard for your business as you will. That might say more about me than the staff I suppose…

Enlighten us with the technologies you're using for your practice.

We offer Fraxel Restore at EYC and have done for over ten years. I am always impressed that it is still doing a great job. So many pieces of kit cost so much money and become redundant when a newer/better one comes out. Fractal has definitely been my best investment. We have recently purchased ULTRAcel which is an excellent device offering three modalities of skin tightening and rejuvenation in a single platform.

What are your marketing strategies for your clinic?

I am not sure I am very good at this. I have spent a ton of money over the years on Cheshire Life magazine, radio ads and stacks of other stuff and I still think most of my new patients arrive through word of mouth. I really think you have to care about your patients and do the best you can and then over the years the list will grow. Probably slower than you would like but patients who come from personal referrals are usually patients for life. Adverts tend to produce more ‘tire kickers’ who come to suss you out. Personal referrals come with money in their pocket. They trust you already as much as they trust the friend who referred them.

Which treatments and procedures are popular in your clinic?

Botox and fillers always provide the ‘bread and butter’ but I love the results that the Fraxel and ULTRAcel can provide. They obviously cost more money but some of the before and afters are amazing. I would like to promote my cosmetics more as some of my colleagues seem to do better with products than I do. Maybe I’m just not ‘pushy’ enough?

Any stories about your career in cosmetic medicine?

My favourite bit is the fact that some of my patients have been coming to see me for 15 plus years. These patients see me three or four times a year and trust me implicitly. Knowing that if I recommend something new its not because I need the money and is because I think it will help them look better. It is this personal relationship which is the corner stone of my practice. Recently I had a consultation with one of my longer standing patients and just for fun we looked back at her original photos from over ten years before. We both agreed that the before photos today looked better than the after photos from ten years ago. That is priceless.

Share what you would like to tell fellow physicians.

Don’t worry so much about kit. You can waste a lot of money on devices which eventually sit lost and lonely in the corner of the room. There are however some technologies which do stand the test of time.

Care deeply about your result. Make sure the patient knows you care. The actual outcome of the treatment is really less important than whether the patient thinks you tried hard and really wanted to do your best. This may sound off but I do believe it is true.

Be particularly vigilant for patient expectations. It is always a whole load cheaper to ‘not take the money’ and ‘not do the treatment’ than pay for the litigation….

Get to know your patients. You don’t need thousands of patients to make a very good living in this business. A few loyal repeat customers will be a lot less work for the same money.

Don’t work too hard. Life is for fun too.

About Dr. Cronin

Dr Paul Cronin was once a local GP and has been in the medical profession since 1985. He has specialized in Cosmetic Medicine for many years and last year alone he performed over 1500 treatments to brighten up the lives and faces of the ladies and gentlemen of Cheshire including some very “well known” faces!

Now Dr Cronin has relocated Eternal Youth Clinic onto the outskirts of Congleton in Cheshire. Nestled into the hills overlooking the Derbyshire peaks, bringing the tried and trusted benefits of muscle relaxing treatments and fillers now combined with several new cutting edge treatments.

Dr Joshua Berkowitz - Wimpole Aesthetics in London

Wimpole Aesthetics is a small cosmetic clinic with a loyal staff on Harley Street in London. Here's our interview with Dr. Joshua Berkowitz.

Name: Dr. Joshua Berkowitz
Clinic: Wimpole Aesthetics, London
Websites: www.wimpoleaesthetics.co.uk / www.ivboost.co.uk

Brief Bio:

My school education was completed in Bulawayo (Rhodesia/Zimbabwe). In 1966 I started medical school obtaining a MB ChB degree from Birmingham University (UK). After several junior positions in Internal Medicine, General Surgery, Urology and General Practice I decided to specialize in Obstetrics and Gynecology. Thus, after further training in the Birmingham Teaching Hospitals, I obtained Membership of the Royal College of O & G followed later by the Fellowship in 1993. I was in private O & G practice in Johannesburg from 1982 till 1996 when I emigrated to the UK/London. During my years in private practice I was also a part time Consultant in the University Teaching Hospital in Johannesburg.

In 1997 I became the Medical Director to Ivax Pharmaceuticals. I was responsible for the Company’s medical activities in the UK, Europe and China. Ivax was sold to Teva in about 2005 and I took a redundancy package to start Wimpole Aesthetics in Wimpole Street, London W1.

Could you tell us your journey toward cosmetic medicine?

I started Wimpole Aesthetics after leaving the pharmaceutical industry in about 2005/6. I initially modelled the clinic upon a clinic I had visited in Israel several years previously. This clinic was using Botox & fillers and using IPL and Laser machines. I have always been interested in Women’s Health and Wellbeing/Functional Medicine and therefore expanded the clinic into these areas and into the treatment of several chronic diseases/conditions.

What could you divulge about your clinic?

I run the clinic together with several nurses and a non-medical assistant who is responsible for the internet sites and other aspects of management, the clinic is located in the medical district of London near Harley Street. Not a big clinic.

How are you as the Medical Director of Wimpole Aesthetics with regards to staff?

There are no stories to tell. I choose staff who are loyal and discrete and obviously capable and affable. I am also loyal to them. Bonuses are awarded when we have a good month.

What technologies are you using in your practice?

I have become disenchanted by the machinery in the aesthetics world since few instruments are able to meet the claims printed on the box. Also the machines are excessively expensive. Prices are based on perceived earning potential not on machine production and marketing costs. Furthermore, manufacturers now include a consumable to ensure that they remain a “partner”. Training is usually poor and inadequate.

I have Syneron IPL and Laser -- both very old and a very modern CO2 Deka.

I have a Vaser machine and several small machines plasma, etc.

What is your marketing strategy? 

 Marketing is by word of mouth by patient to potential patient referral and by internet.

We are a proper medical clinic, hence there are no incentives (buy one get another at half price type stuff) and no social media.

Any stories you would like to share? And what have you learned so far as a physician in cosmetic medicine?

No stories but I am concerned about the many doctors and their egos and many false representations of themselves (e.g.) calling themselves surgeons when they are not putting degrees on stationary they do not have and are not pushing treatments that are completely without merit; making up treatment combinations that are completely unproven; seeking publicity and making false claims about their expertise.

So what I have learned is that I respect and admire very few of my colleagues.

That there is very little evidence based med in the aesthetics field; and that morality and integrity are often absent; and that the aesthetics speciality is littered with doctors and others who are not properly trained or qualified to do the procedures they do or to manage the complications that may arise.

About Dr. Berkowitz:

Dr Josh graduated from Birmingham University Medical School in 1971. He became a Member and later a Fellow of the Royal College of Obstetricians and Gynaecologists (FRCOG). For nearly twenty years, Dr Josh was a Consultant Obstetrician/Gynaecologist in a private medical practice in South Africa. This has given him a helpful holistic perspective on women’s health and the ways that hormonal changes and child bearing can impact on a woman’s skin health, body shape and body image. 

Upon his return to the UK in 1997, and following additional specialist training, he diversified into non-surgical aesthetic and anti-ageing procedures for men and women.

Committed to providing patients with safe and reliable techniques, Dr Josh ensures that Wimpole Aesthetics uses the best quality materials and products. Dr Josh is an expert in all the treatments offered at Wimpole Aesthetics and and he frequently updates his own skills with continual professional development conferences and seminars.

Dr Josh is acknowledged as a preferred trainer of cosmetic medical doctors by the manufacturers of Vaser medical laser technology. Vaser Liposelection is a gentle and non-invasive alternative to liposuction surgery. Dr Josh was one of the first cosmetic doctors in the UK to introduce Vaser Liposelection treatment to his practice.

His warmth and approachability are frequently commented upon by patients, who appreciate the unhurried and thorough consultations offered by Wimpole Aesthetics. Dr Josh is registered with the General Medical Council (GMC). He is a member of the British Medical Association, The Royal Society of Medicine and the British Association of Cosmetic Doctors.

Syneron Candela's UltraShape Power

The Food and Drug Administration (FDA) has cleared Syneron Candela's UltraShape Power as a non-invasive fat reduction treatment in the US.

The technology is an upgrade from its predecessors and has gained more interest in the last few months. It has created buzz by doctors who have started offering UltraShape Power in their clinics, even being the first in their respective states to do so.

UltraShape has been in the market for  some time, but UltraShape Power is an upgrade to the product line around non-invasive fat reduction. In  secured the FDA approval, Syneron Candela says the system is the first to receive clearance but there will likely be others to choose from that are using the same method of action. Unlike other procedures, it does not melt nor freeze fat. Using a handheld ultrasound device, UltraShape claims to destroy fat with ultrasound energy and vacuum-assisted radio frequency. The company assures physicians that UltraShape Power will have a high ROI which is everyone's standard sales practice.

Syneron Candela also claims that the procedure is painless which would be nice if true. According to the website, of those who have undergone an UltraShape treatment, most have said they felt"satisfied" after the treatment (can we get a better reaction than 'satisfied' please.. not exactly a ringing endorsement). According to Syneron, the procedure takes about 45 minutes and has no swelling nor downtime. In addition, results can be seen soon and are also long-lasting.

How Has Your Medical Spas Revenue Changed?

In 2012 we published the Medical Spa MD Physician Report which surveyed medspa owners and physicians to determine what was happening in nonsurgical cosmetic medicine.

The graphics below are from our 2012 report.

What is the total income of your clinic or medspa per month?

What percentage of your clinic's revenue is spent on staff payroll?

What we found was telling and we've decided that we're going to expand and update these reports which are provide to our members for free.  To make sure that you receive these reports just join Medical Spa MD as a member. (It's free.)

Venus Freeze Plus

Venus Concept recently launched their new anti-aging technology in the market, which is the Venus Freeze Plus. The company claims that the system is easy-to-use for the operator and it has more progressive safety features. Not only that, it is safe to use for the patients and allows comfort at the end of the procedure. The patient will also have no downtime at the end of the treatment.

But the reviews aren't all stellar from patients, many of which are paying up to $1,500. A number of review sites show satisfaction scores from patients to be in the low to mid 40 percentile which isn't fantastic and probably has some affect on word of mouth... Here's some more info:

The new system uses multi-polar radiofrequency (RF), proven to be safe. Compared to previous treatments, topical application may not be necessary after using the Venus Freeze Plus. It also has two applicators, a DiamondPolar (small) and an OctiPolar (large) great for focus areas. These applicators have sensors for feedback and monitoring.

In a recent study referenced below, it remarks that a previous research what it had reported regarding the effects of RF on the skin.

Drs. HK Kim, Min, Choi, and SH Kim noted in their study:

[It] is reported to be effected at reducing wrinkles and in the treatment of acne scars by increasing blood circulation and promoting collagen generation,[…]

The same study also goes in depth as to how RF affects pigmentation and skin tone. It was tested against low-level laser therapy and electroacupuncture. In the end, RF was successful in the study in producing a positive outcome on the skin, particularly in the left and right eye rims and the left cheeks.

This could mean that the RF on whichever procedure would not produce any detrimental dermatological effect on the patient’s face. Therefore, the Venus Freeze Plus would definitely benefit those who undergo treatment, and would see results better in the upper part of their face.

Study: Kim et al., 2016

Cynosure SculpSure

SculpSure is a laser-based non-surgical treatment that apparently melts abdominal fat. The treatment is recently gaining more interest as it claims to be the first system to do such a procedure. It was only in late 2015 that the Food and Drug Administration (FDA) that the department approved the use of this treatment for patients.

During the procedure, four flat non-suction applicators and contouring frames are placed in the area where the adipose tissue cells will be burned. According to Cynosure, the company for SculpSure, the wavelength (1060 nm) has an affinity towards the adipose tissue. They use a Proprietary Energy Modulation method elevating subdermal temperature from 45 up to 47 degrees Celsius. Despite the heat, cooling is available making the patient comfortable. They claim that up to 24% of fat is reduced in a span of 25 minutes.

The company has had patients try their procedure before after one to two treatments, showing significant changes in their abdominal area. A weight change may or may not occur; even gain after 6 weeks is possible. No data regarding diet or behavioral habits are revealed which could explain the gain or loss.

Considering the effects after six weeks, a study referenced below investigated a low-laser light treatment (LLLT) done weekly in a span of six weeks. The study’s results proved to have high very satisfactory ratings (54%) for participants. Thus, the study may imply that prospective patients of laser-based fat destruction treatments may consider the effects based on the research’s findings.

Dr. Thornfeldt, Dr. Thaxton, and Dr. Hornfeldt find that:

"subjects undergoing LLLT experience no treatment-related discomfort or other post-treatment adverse effects. In addition, the six week protocol will allow[s] for a more convenient treatment plan, further increasing the likelihood of overall patient satisfaction."

Eventually, it is the patient’s decision whether to try the breakthrough SculpSure or find another one that may suit their needs (and possibly their budget). SculpSure ensures that the procedure is done quickly and after one to two treatments, with results showing after 6 weeks' time.

Study:

Thornfeldt et al., 2016

Lynton Lasers & 3Juve

Lynton Lasers introduced 3Juve, using a three-step treatment to combat the signs of aging. It equips and combines three popular technologies: laser, intense pulse light (IPL), and radiofrequency (RF). Lynton proposes three steps in using all the methods, Resurface, Rebright, and Remodel.

The Resurface process tackles on skin renewal and the reduction of fine lines and wrinkles through collagen fibers. Rebright uses IPL in which it targets the pigmentation. Finally, Remodel makes use of the radiofrequency that will help tighten the skin.

Dr. Askari, a UK based doctor, is one of the first to use 3Juve on his patients says:

“The great thing about this means that my patients can get a truly customisable, individual program, created by myself and my staff that will last them several weeks giving them the best possible results.”

Combining technologies is not unheard of, and a study shows that with IPL and RF, patients are able to see positive results. This study, referenced below, used IPL, continuous RF, and ablative RF. In the research, the disappearance of fine lines and wrinkles were successful using those three technologies.

Findings:

• Lesion score: Pigmentation change after 6 weeks = 40%
• Found: mild erythema and edema for all and had been treated after one day
• 100% improvement in wrinkling

However, with this research they claim reduced pigmentation had least improvement. The authors of the research agree that all the technologies used to treat signs of aging are safe and effective.

In another study, it notes the importance of using light-based technologies for skin treatment.

The authors acknowledge IPL’s efficacy on pigmentation:

“IPL devices have also been used to treat benign pigmented lesions including ephelides and solar lentigines, with significant lesional improvement observed after a series of monthly treatments.”

In the same study, laser resurfacing have achieved best results with improvement and recovery.

Studies are somewhat light, but have shown potential as a new non-surgical treatment that would lessen any incidence of signs of aging in the long run.

Studies:

Gold et al., 2016   
Husain and Alster, 2016

The Outlook for Cosmetic Medicine In 2017 And Beyond

It seems the technology in cosmetic medicine is advancing in order to keep pace with new areas of research around stem cells, lasers, and nanotechnology. 2017 appears to have more growth in store and it shouldn't be ending any time soon.

It was predicted that by 2017 the market for cosmetic surgery would see an increase in procedures and treatments. Based on recent statistics published by the International Society of Aesthetic Plastic Surgery, patients have availed procedures and had a 26% increase from 2010.

In research presented by Arif and Adil (2016), the study’s authors suggest that nanotechnology is a valuable technology in the modern world, and its uses could branch out to dermatology. For Rohrich and Weinstein (2016), they discuss the future trends of cosmetic medicine in Journal of the American Society of Plastic Surgeons, and of the field (in extension). In their paper, they predict that more studies about non-surgical treatments may be in place by the time 2026 rolls in. In a 70 year projection (approximately by 2086), it hopes to see advanced developments in procedure particularly with nanotechnology and plastic or cosmetic surgery in space.

RoC Skincare conducted a study back in 2015 on states, which have the highest wrinkle rate. Citizens from Philadelphia, Denver-Aurora, Seattle-Bellevue-Everett, Chicago-Naperville-Arlington Heights, and Minneapolis-St. Paul-Bloomington are  more prone to getting wrinkles. (Who knew?)  Of course this is just marketing fluff for RoC to talk about their lotions and potions but many are still hopeful over the improvements that could potentially be seen over time as some of the bleeding edge tech moves out of the lab and on to main street.. An interview by the Oxford University Press to Dr. Foad Nahai, editor of Aesthetic Surgery Journal, he suggested that non-surgical procedures can still be improved and that injectables might as well replace surgical facial proceedures.

Therefore, it seems that non-invasive surgical procedures may dominate in the next few decades considering hopeful thoughts for improvement have been presented to the public.

Studies referenced:

Rohrich and Weinstein (2016)
Arif and Adil (2016)

References:

http://dermatologytimes.modernmedicine.com/dermatology-times/news/cosmetic-surgery-market-predicted-double-2017
http://blog.oup.com/2015/09/future-aesthetic-surgery/

The obesity epidemic trend continues to push new patients to cosmetic clinics

Obesity remains a growing trend across the US (and the world) and there should be a corresponding growth in cosmetic treatments that treat obese patients.

According to the Center for Disease Control and Prevention, in the US alone, around 36.5% people are obese. This is a cause for any number of health-related alarms, but will continune to drive new cosmetic medical technologies to address the effects. While any number of clinics are offering liposuction for to remove love handles or a lettle extra belly fat, more is being uncovered about the effects of plastic or cosmetic surgery especially to Massive Weight Loss (MWL) patients who have undergone bariatric surgery.

It is important to note the psychological effects and the experiences faced by patients after surgery. Studies show that most patients appear to have a positive reaction towards their newer self, but there are also negative effects that some patients report.

In the studies referenced below, researchers find that majority of their sample patients were better able to identify with their new selves (However, the sample size was only 20) and the researchers used physical health; self-esteem/appearance; social acceptance; mental health; intimacy/sexuality; social network; and self-efficacy towards eating as measures.

Findings

• Greatest change was found in physical health (Score = 21.06)
• The surgery seems a success for the patients considering their perception of self and their body image.
• A minority (n = 4) find it difficult to adjust with their new bodies and needed both recuperation and intervention be available after their bariatric and plastic surgery.
• With regard to identity transformation, the majority are satisfied with their results and embraced their new body conformation.
• Confidence played a major part with several participants as it helped them get through any issues they have encountered.

So how should providers at each end of the spectrum (bariatric surgery vs tumescent liposuction, Thermage, etc) set up patient expectations?

Clinicians, including support staff, should be prepped to answer questions and identify patients who might be at risk for acceptance of their new look including:

• Discuss with patients the possible outcomes that may occur against the patient’s expectations. 
• Staff should be educated on how best to deal with patients who might have unrealistic expectations.
• Any cosmetic 'fat removal' treatment should be accompanied by a diet and excercise plan. (You might want to consider getting local gyms to offer a discount for your patients as a form of co-marketing.)

References:
Gilmartin, SJ, Long, A and Soldin, M (2015) Identity transformation and a changed lifestyle following dramatic weight loss and body contouring surgery: An exploratory study. Journal of Health Psychology, 20 (10). 1318 - 1327. ISSN 1359-1053

Jumbe, S., Meyrick, J. and Harcourt, D. (2016) Patient’s experienceof life after weight loss surgery: Psychological adjustment. In: Appearance Matters 7, Royal College of Surgeons, London, 28-30 June 2016. Available from: http://eprints.uwe.ac.uk/29251
Avashia, Y., Nair, N., Berhane, C & Panthaki, Z. (2013). Preoperative evaluation of the postbariatric patient. In Thaller, S. & Cohen M. (Eds.), Cosmetic Surgery After Massive Weight Loss. London: JP Medical Ltd.