Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Galderma) and Xeomin (incobotulinumtoxinA, Merz) do not have equivalent strain reduction, according to a study of glabellar line treatments. The results, researchers conclude, confirm non-interchangeability of these neurotoxins.

Researchers treated 73 treatment-naive females randomized to 20 units of Botox, 60 units of Dysport or 20 units of Xeomin in the glabella. They imaged patients 4, 14 and 90 days post injection and noted change in average dynamic glabella strain.

The researchers found that at day 4 the Botox group had a 42.1% strain reduction, vs. a 39.4% reduction in the Dysport group and 19.8% reduction in the Xeomin group. By day 14, there was a 66.1% strain reduction in the Botox patients; a 51.4% strain reduction in the Dysport group; and a 42.8% strain reduction among those receiving Xeomin. At day 90, the Botox group had a 43.5% strain reduction, vs. a 38.4% strain reduction among those receiving Dysport and a 25.3% strain reduction in the Xeomin group.

NEXT: A Practical Opinion

A Practical Opinion

Dr. Niamtu"Evidence-based evaluation of cosmetic procedures is important but is difficult to quantify in many situations due to the myriad of variables including patients' individual muscle size, physiology, metabolism, drug resistance, depth of injection, etc.," Joe Niamtu, III, DMD, an oral and maxillofacial surgeon with a practice limited to cosmetic facial surgery in Richmond, Va., tells Cosmetic Surgery Times.

This study suggests that treatment dosage units of neuromodulator are not interchangeable. And all companies clearly state in their literature that units are not interchangeable, Dr. Niamtu says.

"Having said that, there is always an effort to estimate equipotent treatment doses amongst many drugs," Dr. Niamtu says. "We do this every day with anesthetic medications, analgesics, steroids and numerous substances. The average clinician is looking for an average consistency that can be approximated with a similar medication. This is not a bad thing, and helps doctors and patients make decisions that involve treatment and costs. We do the same thing with non-medical situations when we say that the effects of having a glass of wine are similar to drinking a single beer or a shot of whisky, or that taking one Alieve is the same as taking four Advil...."

From a purely scientific standpoint, these three neuromodulators may well not correlate in action to an algorithm of units, according to Dr. Niamtu.

"The fact that they do not correlate with dynamic strain is useful information, but clinically, in my experience, they correlate pretty closely. I feel that 20 Botox units, 25 Xeomin units and 60 Dysport units deliver a very similar clinical response and duration. I fully realize that this is anecdotal but it is also practical. Even with the utmost scientific study, different dosages of neuromodulators will have different effects on action and duration due to patient variability, and this is the hardest thing and may be impossible to quantify," he says.

The bottom line, according to Dr. Niamtu, who was not an author on the study, is that injectors should never dedicate an absolute number to interchangeability. This, he says, is a recognized tenant of experienced injectors. 

"Fortunately, there is a wide safety margin in the cosmetic dosages of neuromodulators and erroring moderately in either direction poses little danger," Dr. Niamtu says.

The 2016 Best & Worst Cities for Your Skin reports on how 150 major U.S. cities score and ultimately rank in 17 metrics, including environmental issues that affect skin quality, such as air pollution, smoking rates, temperature extremes and UV index; access to and cost of aesthetic skin procedures; skin cancer rates; and access to dermatologists.

The listing not only could help cosmetic surgeons better understand the skin health strengths and weaknesses in their communities, but also where access to skin care centers and retailers is limited or abundant.

Dr. Minkis "Just like skin health is vital to preventing skin cancer, the same environmental insults that lead to the development of skin cancer can also lead to photoaging-accelerated development of dyspigmentation, wrinkles, sagging and volume loss," Kira Minkis, M.D., Ph.D., a dermatologist at Weill Cornell Medicine and New York-Presbyterian tells Cosmetic Surgery Times. "Therefore, similar to skin cancer prevention, multiple personal and environmental factors should be taken into account to optimize skin health for the cosmetic minded patient: sun protection, avoidance of smoking, good diet and water consumption, accessibility to a dermatologist."

The ranking, by WalletHub, found the Texas cities of El Paso, San Antonio and Austin were ranked first, second and third, respectively, as the overall best cities for skin health. Minneapolis, Santa Rosa, Calif., and Plano, Texas rounded out the top six winners. Port St. Lucie, Fla., came in last place, or 150 overall, as the worst U.S. city for skin. Akron, Ohio, Shreveport, La., and St. Petersburg, Fla., came in at 149, 148 and 147, respectively.

NEXT: Best & Worst Findings

Best & Worst Findings

With 87.52 cosmetics and beauty supply stores for each 100,000 residents, Orlando, Fla., earned the top spot among states for access to beauty and supply retailers. That was 12 times more than the number of stores per 100,000 residents in Brownsville, Texas, the city with the fewest, at 7.23.

In addition to looking at how many dermatologists were in each city per 100,000 population (Baton Rouge, La., scored highest in that category with 31.83), researchers analyzed the number of skin care centers in each city, per 100,000 residents. They found Scottsdale, Ariz., had the most with 134.22. Detroit had the least with 1.44 per 100,000 residents.

The median air-quality index is best in Honolulu. It's worst in the California cities of Riverside, San Bernardino, Fontana, Moreno Valley, Rancho Cucamonga and Ontario.

Smoking, associated with skin aging and more, is most popular among people in Fort Wayne, Ind., where 26.2% of adults smoke. San Jose, Calif., boasted the lowest smoking rate among adults, at 9.6%.

Baton Rouge, La., has the most dermatologists per capita, versus North Las Vegas, the city with the fewest derms.

And while a microdermabrasion procedure provided at a dermatology practice tends to cost the least in Little Rock, Ark., Jackson, Miss., and Omaha, Neb., it's likely to cost the most in Anchorage, Alaska, (that's right, Anchorage was the city where dermatologists charged the most for microdermabrasion), Yonkers, N.Y., and San Francisco.

In the climate category, which includes UV index, the best city was Anchorage. The worst: Honolulu.

Learn more about where your city ranks.

Disclosure: Dr. Minkis reports no relevant conflicts.

It’s called Lipo 202 and offers potential benefits, including revision liposuction. NOTE: Neoethics reported in December 2015 that Lipo 202 trials did not meet primary or secondary endpoints and have thus been cancelled. Video panel recording courtesy X-Medica.

Dr. KaplanDISCLAIMER: This blog is the author's opinon only. The views expressed herein do not necessarily reflect the views of Editorial Staff.

Your office provides excellent customer service. You offer every arriving patient a cup of coffee, tea or water. They never wait more than five minutes to see the doctor. You offer full price transparency online prior to the visit. The doctor encourages patients to email questions before a surgical procedure. The evening after the surgical procedure, the doctor calls to check on the patient, making sure the patient has the after-hours cell phone number to reach the doctor instantly via phone, text or email. No operator, no intermediary, straight to the doctor. That’s all you can do. It’s more than what most doctors do, but it’s also the right thing to do. And even still, you get a negative review. Why?

Gaming the System

By and large, these negative reviews are from patients who were unreasonable from the very beginning. Either you didn’t give them enough postop pain medication because their demands weren’t commensurate with normal postop pain control but rather, more related to drug-seeking behavior; or you didn’t provide them with a free Botox touchup (even though you told them during the initial appointment they needed more, but they weren’t willing to pay for the appropriate amount, so you warn them that touchups won’t be “on the house.”) Typically negative reviews, after you’ve provided all of the niceties mentioned above, are from folks gaming the system, and in a way, extorting you to give them more of what they want for free…or else! Of course some negative reviews are legitimate and will be discussed below but I would argue they are the exception, not the rule.

Should You Respond to Negative Yelp Reviews?

It’s time for doctors to recognize that sometimes the best option after receiving a negative review on Yelp is to do nothing. The customer isn’t always right and they don’t always deserve a response since their review often reflects deeper issues motivating their anger, issues that have nothing to do with your service. Most importantly, it’s very difficult to win an online verbal dispute. You can come off sounding defensive, unsympathetic, mean and accidentally reveal protected health information in the process.

One interesting aspect, specific to Yelp, is their algorithm. If the person writing the review, positive or negative, has only one to two prior reviews, all of their reviews are “filtered.” This means the reviews are moved to another page on the Yelp site where they’re deemed “not currently recommended.” Most consumers don’t visit this page. This is great if it’s a negative review but also frustrating if legitimate good reviews are filtered. The filtration algorithm is meant to ensure, in an automated fashion, that only the most credible reviews are left unfiltered for all to see. Because this is an automated process, many legitimate positive reviews are often filtered which is probably the single greatest source of small business owner’s animosity towards Yelp. 

NEXT: Why Responding Too Quickly Is Never a Good Idea

Why Responding Too Quickly Is Never a Good Idea

Because reviewers that only have one to two reviews are typically filtered, you should wait at least four to five days before responding to any negative review — if you respond at all. For example, if a patient’s review of your practice is the only review they have ever written, it will most likely be filtered and no one will see it. However, if you jump the gun and respond to the review immediately, that will make that negative review appear credible in the eyes of the Yelp algorithm and you will have unwittingly made that review “stick” rather than allowing it to be filtered in due course.

As a general rule of thumb, my opinion is that you shouldn’t respond to any negative reviews. I understand this may fly in the face of other recommendations mentioned in this recent Cosmetic Surgery Times article, but if you provide excellent customer service, there’s not much more you can accomplish in responding to unreasonable negative reviews.

That said, some reviews may reference being accidentally overcharged or some other legitimate issue. While it’s frustrating that the patient would resort to Yelp initially to voice their complaint rather than working directly with your office, your staff can contact the patient and right the wrong. Once you correct the situation, those patients will typically remove the review entirely and in some cases, give you that 5-star review you’re desperately seeking! Unfortunately, these legitimate gripes are the exception. As detailed below with reference to the opioid crisis, some negative reviews can be related to underlying pathology that you’ll never be able to resolve with good customer service alone.

NEXT: Don't Fear a Negative Yelp Review

Don't Fear a Negative Yelp Review 

Has Yelp Contributed to the Current Opioid Crisis?

You can read more about this topic here, but there is pressure on doctors to accommodate almost any request by a patient for fear of getting a negative Yelp review.

For example, pain. If a patient doesn’t feel their pain has been adequately addressed, they can make it very clear in the form of a negative Yelp review. Regardless of the legitimacy of their pain complaints (maybe they’re in real pain, maybe they’re drug seeking), the doctor pays for it in the form of a negative Yelp review which can affect their business. 

After a long day of seeing 20 to 40 patients, doctors are human and start to find the path of least resistance. While they may have tried to reason with the 2nd patient that was asking for more pain medicine, by the 12th patient, they’re tired of convincing the patient they need to wean off their pain meds. Mix that with a patient that is vaguely threatening and you have a perfect storm where the doctor will pacify the patient one more time to avoid a bad Yelp review. This natural yearning to avoid confrontation is an understandable motivation to reduce your chances of a negative Yelp review, but you have to fight that natural instinct. If a patient is drug seeking, you can’t enable them, even if it means a negative review.

I’m not suggesting the opioid crisis is Yelp’s fault. But they are a cog in the system that has led to the current opioid crisis. When online reviews become so powerful, even doctors can be stuck between refusing to refill a narcotics prescription and in turn, receive a negative review versus possibly over-treating a patient’s pain. The threat of a negative review can’t be our guiding force — making appropriate medical decisions must be.

Dr. Jonathan Kaplan is a board-certified plastic surgeon based in San Francisco, CA and founder/CEO of BuildMyBod, an online marketplace for healthcare services. 

If you go to a plastic surgeon’s website and it says online ratings give her an aggregate average of 4.9 points out of 5, you might assume she does a great job and her patients love her.

In fact, reality may be something else entirely: She may actually have a 3.5 overall rating, perhaps, or even lower. What happened? Most likely, the surgeon hired a tech company who fudged the truth — a decision that could have major consequences.

“We’re seeing companies bragging that they’re providing a competitive advantage by using technology to manipulate results,” explains Ryan Miller, president of Etna Interactive, a tech consulting firm based in San Luis Obispo, Calif. “If the doctor is unethical and uses this technology to an unethical end, they’ll eventually be called out for it.”

Benefits of Aggregate Ratings

Aggregate ratings themselves aren’t the villain. They’re becoming common on physician websites, says Miller, who spoke earlier this year at The Aesthetic Meeting, the annual meeting of the American Society for Aesthetic Plastic Surgery. “They’re a way that a practice can take an active role in leveling the review playing field and share a more representative picture of their reviews,” Miller says.

Related: Bad Patient Reviews?

For example, a practice may choose to display an aggregate of online ratings from a variety of sources — Yelp, Google, RealSelf, Healthgrades and more — instead of just displaying ratings from one source. There’s an added bonus: Google detects aggregate ratings and displays them when users find practices during online searches.

But Beware Legal and Ethical Issues

The problem: It’s easy for a tech firm to tweak the aggregate rating so negative numbers don’t count. A keystroke here, a keystroke there and voila — A doctor with a 3.2 average overall rating from several sources suddenly has a 4.8 with no one the wiser.

As an example, Miller points to a Texas plastic surgeon whose aggregate rating is quite impressive, partly because a 1-star rating got thrown out.

Not surprisingly, this kind of manipulation could pose a legal problem. “In every state, you may not engage in fraudulent, misleading or false advertising,” Miller says. “If you are offering an ‘unbiased’ aggregation of all review content but tossing out any criticism, then it’s our belief that you’re misleading patients.” And, of course, misleading patients is an ethical no-no.

What should you do? Miller says it’s fine to tout aggregate ratings on your website, but you need to do so in a honest and ethical manner.

Being up front is actually a time-saver, he says, because “it does take more effort to willfully cut out stuff that’s critical.” And besides, he says, “for the most part, practices are liked and respected by their patients. You don’t need to lie.”

...Or is it a case of apples vs. oranges? Six surgeons answer, but not all agree. Watch and find out.

Does 3-D printing have a role in plastic surgery? The answer may be as plain as the nose on your (patient’s) face.

At the University of Pennsylvania, researchers have testing the ability of 3-D printing to produce models of how patients’ noses will look after rhinoplasty. 

The work is still in the early stages: The researchers haven’t produced 3-D models for any actual patients. But the technology is already wowing those who’ve been able to hold models of their own noses in their hands. 

“For the patients who had the imaging done and their models created, they love them!” says Michael Tecce, BS, a clinical research fellow with the Division of Plastic Surgery at the University of Pennsylvania. “Some say, ‘Wow, so that’s what my nose looks like?’ It’s interesting to see people’s reactions to what they perceive in the mirror versus holding the model and seeing what other people see.”

Three-dimensional printing — the production of 3-D objects — has been around since the 1980s, but the technology has advanced far enough to allow users to create objects made of materials like rubber, plastics and metals. On the medical front, scientists are dreaming of creating prosthetic body parts, although they haven’t been able to actually produce tissue that could be transplanted into the body. 

At the University of Pennsylvania, Tecce and colleagues Dr. Anthony Wilson and Dr. Scott Bartlett came up with the idea of models for rhinoplasty while developing a way to use 3-D printing in craniofacial surgery. “We thought, ‘Hey, what if we printed a pre-operative and simulated a post-operative result for a nose?’” Tecce tells Cosmetic Surgery Times. “That way the patient could hold a model of what their nose would potentially look like after surgery. At that point, you could make any adjustments and speak with the patient in order to optimize their experience.”

Related: Practice changer: 3D printing for consults

But there were big hurdles, says Tecce, who made a presentation about his research in April at The Aesthetic Meeting, the annual gathering of the American Society for Aesthetic Plastic Surgery. “Perhaps the most significant was figuring out the best way to print the models.”

As he explains, “The 3-D camera takes a surface image of the entire face. Then, we isolate the nose by manipulating the image.” 

However, “The image is only a surface area scan. So it has no depth to it and is unable to be printed unless we give it more of a spacial mass. Figuring out how to do that was challenging.”

With the help of the Vectra imaging system, Materialise 3-matic software and a Stratasys 3-D printer, Tecce and colleagues were able to create models of real-life noses that people could hold in their hands. They also created models of mock “post-surgery” noses. 

Why not try out the technology on actual patients to see if the models accurately reflect “before” and “after”? “This is a proof of concept study,” Tecce says. “So we have yet to test it on subjects who actually undergo surgery.”

In case you’re thinking about trying this at your own office, Tecce notes that 3-D printing software and printers are expensive. And, he says, it’s important to remember that 3-D models of post-surgery noses aren’t real-life post-surgery noses. “You might not get the result that matches the model perfectly,” he says. “It’s just the way it is.”

A Cleveland plastic surgeon who’s performed more than 850 double mastectomies for transgender men says respect and openness are among the keys to success. Surgeons must be willing to undergo public scrutiny, he says, and they must treat patients with the proper gravitas as they undergo what may be the most important procedure of their lives.

The mastectomy procedures themselves are typically quick and well-tolerated operations, says Daniel Medalie, M.D., a plastic surgeon with Metrohealth Medical Center of Cleveland and assistant professor at Case Western Reserve University. “It’s not any harder than a breast reduction or other procedures that plastic surgeons do,” he says.

But does Dr. Medalie’s own extraordinary workload — he performed double mastectomies on some 850 patients from 2006 to 2015 — suggest that many of his colleagues may not be as willing to work with transgender patients who want to transition from female to male? “People shouldn’t be coming from all over the country and world to see Daniel Medalie in Cleveland, Ohio,” he says.

Dr. Medalie reports on his experiences in a report that was released in poster form at The Aesthetic Meeting in April. He spoke with Cosmetic Surgery Times about his continuing commitment to transgender patients, and he provided advice for surgeons who wish to follow in his footsteps.

He first encountered transgender surgeries, mostly male to female, while training at the University of Pittsburgh. After graduating in 1999, he worked at the University of Kentucky.

Like his colleagues who perform breast augmentation surgeries, he began to be approached by transgender patients seeking breast surgery. “The difference between me and them was that I’d say, ‘Sure, no problem.’ Any plastic surgeon can do this kind of surgery, but there has to be a willingness to do it.”

He performed more double mastectomy procedures after moving to Cleveland in 2002, and his presence on the Internet sparked intense interest from transgender patients. His YouTube videos of two types of procedures have attracted more than 500,000 hits, he says.

“A vast majority of patients come from out of town and other countries,” he says. “Many people come from England because it’s more expensive to have it done there than to come to Cleveland and stay for a week.”

In This Article

Surgical Stats

Unique Challenges

NEXT: Surgical Stats

Surgical Stats

According to his report, Dr. Medalie has provided successful double mastectomies for 850 patients with high satisfaction and an aesthetic revision rate of less than 10%.

He groups patients into three groups based on pre-operative photos:

1. A double mastectomy with free nipple graft
2. A subcutaneous mastectomy with partial areolar incision
3. A subcutaneous mastectomy with a circumareolar incision and “purse-string” closure.

The procedures take 1.5 to 2 hours, he says. Hematoma accounted for almost all early complications, leading to re-operation rates of 1% within the first five days after surgery. Two patients had late hematoma infections that required IV antibiotics. No patients reported complete loss of nipple graft.

Future research, he says, will use questionnaires to focus on issues after surgery like satisfaction with results and quality of scars.

NEXT: Unique Challenges

Unique Challenges

These procedures do pose unique challenges for plastic surgeons, but not in the realm of the operations themselves.

For one, “you have to play a little bit of psychiatrist,” Dr. Medalie says, and make sure patients are confident in their decisions to undergo double mastectomies. “Sometimes I’ll meet the patient in holding area and they seem nervous, they don’t seem masculine, and they’re young.” Not only does he require a therapist’s letter, he also uses his own powers of judgment to decide who should go under the knife.

It’s also crucial to understand that these patients aren’t like others, he says. “You’re changing this person’s life in a dramatic way. This is the most important day of their life. For me, it’s one of four procedures I do that day. I have to keep reminding myself about how important this is for the patient.”

Openness to the outside world is also vital. “You can’t hide bad results. In the age of the Internet, you’re wide open,” he says. “If you’re treating it like another liposuction surgery, if you don’t get the pronouns right or find out the name they like to be called, they’ll post about you on the Internet right away.”

So why perform these procedures at all? Dr. Medalie says they’ve “really been a positive experience” for him, and his other patients haven’t reacted negatively. Insurers cover about 20% of the procedures, which cost about $6,700 in his clinic, and laws in some states make insurance coverage mandatory.

“It’s possible to do this in a safe fashion, and there’s good patient satisfaction,” he says. “We’re plastic surgeons, and we should be doing this.”

Disclosures

Dr. Medalie reports no relevant disclosures.

Who does what when it comes to fat harvesting techniques? Drs. Andrew Campbell, Barry DiBernardo, Michael Persky, Jason Emer, Corey Maas and Jason Pozner share their approaches during Vegas Cosmetic Surgery 2015. Video panel recording courtesy X-Medica.

Plastic surgeons, patients and office employees are supposed to be a united front, all dedicated to promoting beauty and self-esteem. But sometimes, not everyone on the team is playing the same game.

California attorney Robert Aicher, Esq., knows this better than most. He has served as general counsel to the American Society for Aesthetic Plastic Surgery since 1998. As he explained at this year’s The Aesthetic Meeting in Las Vegas, plastic surgeons face unique legal threats from those they know most intimately on the job — patients and staff.

But a few preventive measures may lower the risk that you’ll end up in court. Here are 3 tips from Aicher:

In This Article:

Chargebacks and HIPAA

Patient Bullies

Aesthetician Patient Theft

NEXT: Chargebacks and HIPAA

Chargebacks and HIPAA

They say there’s no free lunch, but you may occasionally come across patients who believe there’s a free procedure. For them, a common weapon of choice is the credit card “chargeback.”

Chargebacks are a nuisance for just about anyone who provides a service.

For example, Aicher says, “we buy something at the hardware store, and we don’t get satisfaction. Then when the bill arrives, we dispute the bill.” At that point, the credit card company launches an investigation and considers whether to deny the payment to the merchant.

In aesthetic medicine, a chargeback request can come from a patient who’s dissatisfied with, say, a filler injection or Botox. “I’m not sure there’s a whole lot anyone can do to avoid a chargeback,” Aicher says, “other than try to deliver the best service you can.”

But there’s good news too. As a plastic surgeon, you aren’t defenseless when Visa or MasterCard (or Discover or American Express) gets in touch and wants information about the procedure you provided. Aicher urges his clients to provide details about procedures in these cases. HIPAA, he believes, doesn’t apply when the patient has already raised the issue of a medical procedure to the credit card company.

“In my view, it’s not a privacy violation,” he says. “Our members routinely provide the medical records to prove the service was received, and they routinely win the cases.”

NEXT: Patient Bullies

Patient Bullies

Physicians aren’t big on risk, and they aren’t big on confrontation. “They don’t train them in medical school to be fighters,” Aicher says. “They train them to be healers.”

That’s the way it should be. So what’s the problem for physicians? It’s simple, Aicher says: “This makes them great targets for bullies.”

And patients can most definitely be bullies. They might demand a free re-do of a procedure and threaten to tattle to Yelp if they don’t get their way. They may insult everyone in the surgeon’s office until the staff begs you to fire them as patients. And you, Dr. Nice Surgeon, end up in the middle.

What to do? Aicher suggests that plastic surgeons learn to say no. Not in an aggressive way, he advises, but firmly and unapologetically. “You’ve got to get them off their game,” he says. “Fold your hands and say no. Let the silence hang.” And don’t give in.

NEXT: Aesthetician Patient Theft

Aesthetician Patient Theft

Aestheticians come and go, and there lies the rub: They will sometimes head to another clinic and try to bring your patients along with them.

“You can’t completely prevent it,” Aicher says, but there are ways you can make patient-thieving by aestheticians less likely.

“It’s a good thing to have them sign a release, an acknowledgment that your customers are protected trade secrets,” Aicher says. Non-compete clauses are another option, he says, but some states have right-to-work laws that frown on contracts including these restrictions.

What if these measures don’t work or aren’t feasible? Don’t expect to turn to medical privacy laws. “Technically, patient theft is probably not going to be a medical privacy issue,” he says, “as long as they’re just stealing patient names and contact information, and there’s no medical information attached to the names.”

So what can you do after a theft? “I encourage our members to write directly to the new employer and remind them that these are protected patient lists, and the new employer is prohibited by law from marketing to them,” he said. (It’s OK, though, for aestheticians to provide basic information to patients about their job switches when they move to a new employer, he says.)

You may also be tempted to change passwords after an aesthetician leaves so the person can’t get into the system and swipe patient names. But Aicher is skeptical that this will work. “I’m afraid employees are smarter than that,” he says. “By the time you hear that they’re leaving, they’ve gotten what they wanted.”