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Aesthetics Practice Today

Power Plate for Health, Fitness and Beauty
February 3, 2015 8:32 AM by Mina Grasso
Power Plate works using vibration technology where energy is transferred from the vibrating platform to the body. This mechanical stimulus produces a stretch reflex which, depending on the selected frequency, results in muscles vigorously contracting 30 to 60 times per second. Each vibration set is performed no longer than 30, 45, or 60 seconds in length.

Power Plate exercises increase the production of regenerative and repair hormones, strengthen bone tissue, improve lymphatic drainage and increase metabolic rate. All this results in more strength, speed and stamina, increased flexibility and controlled fat reduction. These exercises are a good remedy for osteoporosis, pain reduction, improves collagen production, reduces lower back pain and rehabilitates injuries and ailments. Athletes all over the world have experienced the benefits of the power plate in their rehabilitation programs.

Power Plate Advanced Vibration Technology is very popular in Europe, but is slowly gaining interest here in the US. On August 21, 2012 the University of Southern California celebrated its grand opening of the John McKay Center--a $70 million, 110,000-square-foot athletic and academic facility. Among its state-of-the-art athletic training and fitness equipment are six custom Power Plate pro7's. 

Our clinic has been offering Power Plate for over 11 years. Ten to twenty minute sessions twice a week is recommended with a primary focus on muscle toning. A great percentage of our patients who regularly use the device claim they are addicted and are amazed with the benefit of cellulite reduction. Just recently we started to offer Yoga in the room the Power Plate is located, but did not dare remove it in fear of the negative response from regular users. There is no scientific evidence that I am aware of, but personally, I feel patients are benefiting in reduction of skin laxity as well - probably due to some collagen stimulation.  I now have personal power plates both at home and at my vacation home.

First time users of the power plate are initially startled by the amount of vibration. The amount and length of time of vibration is adjustable. The learning curve is very short. Within a few minutes, patients learn exercises that will isolate the muscle groups they want to target.

A Review of 10 Anti-Aging Secrets in the Last Decade
January 20, 2015 9:08 AM by Mina Grasso

Botox/Dysport: Neuro-modulaters Botox and Dysport have been around more than a decade and used prior to FDA approval for cosmetic purposes in some clinics. It became the WOW of the practice. By relaxing specific muscle groups, a person's muscle groups, they can appear happier and refreshed.

Tissue Fillers: Volume replacement has played a major role in helping one to look 10+ years younger. We have a better understanding of fat pad positioning in the bio-activators or a combination product and going beyond chasing lines such as the previous decade where collagen was introduced to a more global pan-facial approach keeping things looking more balanced and natural compared to years prior. Tissue fillers have made an amazing impact of non-surgical world of aesthetics.

Medical Skin Care: Advances in the delivery systems of skin care products has improved  therapeutic outcomes in acne, brown spots, redness and wrinkles etc. Patients can see and understand the transformation that occurs with compliance. More patients understand the importance of protecting their investment by using sun protection.

CO2 Fractional Laser Resurfacing: Fractional laser technology has allowed us to treat all skin types. With an appropriate skin prep and parameters for the skin type, patients can reduce wrinkles and result in overall more youthful skin. 

Photo Rejuvenation: One of the most popular non-ablative rejuvenation treatments involves photo rejuvenation - intense pulsed. Photo Rejuvenation treats redness, pigmentation, sun damage, acne, and pore size. Regular treatment have proven studies to show patients who have received a regular regimen of treatments show more youthful gene patterns when biopsies of skin treated non-treated skin was compared.

CoolSculpting - Freeze the Fat: CoolSculpting has changed the world of body contouring. For those seeking  non-surgical approach without downtime, CoolSculpting is a perfect alternative. Patients do best when near their ideal weight. With the right amount of cycles, patient can obtain near-liposuction results.

Radiofrequency Thermage, Thermitight RF: Thermage - monopolar radiofrequency was developed a little over a decade ago. Unlike much laser technology, we still provide this non-surgical skin tightening procedure for the face, neck and body. For those who want skin tightening without surgery and want to go beyond what Thermage can provide, ThermiTight RF is the in-between the "game changer" for the jowl   and neck area. It utilizes a thermal probe at the tip of the radiofrequency electrode while a FLIR camera is used to monitor the external temperature on the skin. With the accuracy of temperature guidance, consistency and safety aids in the popularity of this procedures with practitioners and patients.

Permanent Make Up: Permanent makeup has been performed many decades ago, but at the start of the decade, it was just starting to gain acceptance. When I first performed permanent makeup in 1997, people still felt somewhat reluctant to have it done due to seeing bad outcomes, taboo about a tattoo, and other various     reasons. Those who had the procedure enjoy waking up with makeup and love the convenience of saving time applying makeup. Colors, styles and techniques of application continue to improve over the years. Some patients report that it's the best investment that they have made.

Sclerotherapy: Sclerotherapy for unsightly leg and hand veins is the process of injecting solution to irritate and destroy veins and takes one to four weeks on average patients can dress in confidence again.

Bio-Identical Hormonal Replacement: Patients can now feel as good as they look with safer hormonal options. They can regain their motivation, energy, stamina and vitality and lead a more productive and happier quality of life. Vitality helps patients feel younger.

Advances in Clinical Photography
January 6, 2015 8:23 AM by Mina Grasso

Patients frequently forget what they look like after aesthetic procedures. It is critical to have photos of patients before and after procedures for documentation to protect you and the patient. It is difficult to prove clinical improvement without proper imaging.

Over the years as more practitioners perform aesthetic procedures they appreciate the value of high quality professional photographs with user-friendly systems that are used for consultation, documentation and presentation. As a result, clinical photography has advanced tremendously. Aside from medical-legal issues photographs can be used for educating patients.

Standardization is the most important part of clinical photography. This includes the use of the same camera settings, background, lighting, positioning and expression of patient.  Attempts to have the same garment and avoiding jewelry such as earrings can assist in ease of evaluation. It is becoming well understood that just changing the lighting alone can create an amazing before and after photo.

Over the years, we have had various types of photography set-ups going from face to body. Many requests of patients to see before and afters left us a bit embarrassed to the following reasons: lack of photos, different positions and animation, different lighting, different clothing or objects obscure visibility including hair, jewelry makeup or eyeglasses.

After purchasing new equipment and having to incorporate body photography, we decided to abandon other systems after learning the benefits of guided user-friendly photography. Clinical photography for what we desired and what images were actually captured was always a challenge with staff. FotoFinder has developed onscreen templates that make it easy for staff to remember what photos and positions we are looking for with a specific procedure so that images are repeatable. If a new position is required, the image position can be input by the company. Retrieval of photos is easy and labeled by color "before treatment" vs. an "after treatment" with same positions placed side by side for comparison. In addition, the zoom lock feature can be used to compare the same exact spot to aid in comparison.

Using photos as a teaching tool was much more time consuming in the past and would obstruct the flow of traffic in the clinic when a patient had to be taken to the photo suite to review photos. Now, the FotoFinder iPad app provides image access in any of our consultation rooms immediately. Additional photos can be taken in the consultation room that can be stored and tagged for each particular procedure and goes directly into the patients file folder.

We find that the FotoFinder provides us with the cutting edge imaging solution for consistent before and after photo documentation of virtually any aesthetic procedure from head to toe consistently and has provided an excellent educational and selling tool. We are finally able to accurately reproduce and document the effectiveness of treatment which leads to patient satisfaction.

12 Holiday Tips in Customer Service
December 18, 2014 9:56 AM by Mina Grasso
  1. Greet patients warmly with a smile as they enter your place of practice. Acknowledge them as soon as possible even if you are on the phone or helping another patient. First impressions are created within seconds.
  2. Greet patients on the phone as if they see you smiling.
  3. Acknowledge the patient by his/her name while you are on the phone or in person.
  4. Make eye contact with those you come in contact with even in passing whether or not you are involved in the patient care.
  5. Listen to the patient and make an attempt to understand their goals and expectations.
  6. Be sensitive to privacy during treatment and ensure confidentiality.
  7. Earn trust by showing confidence in your interaction with the patient in all aspects of interaction such as greeting, treating a patient, just in passing discussing treatment or when teaching patients about products or services.
  8. Remember that it's more about the experience for the patient than it is the technical skill.
  9. Allow patients time for questions whether it is their first visit or a returning patient. There are many products and procedures for patients to choose from.
  10. If a patient is looking for the restroom or another treatment room, escort them to the place they are looking for instead of just giving the directions. Because of all potential information given to them, patients can feel overwhelmed.
  11. Temperature control -- provide a comfortable environment by checking if the patient is either too warm or cold.
  12. Make a follow-up call or send a note showing appreciation for their visit.
How Do I Get Rid of My Scar?
December 9, 2014 7:52 PM by Kimberly Cray

A common aesthetic concern among patients is scarring. Surgical scars, acne scars and scarring from burns are among the most frequently treated scars.     

It is important that patients understand that genetics, as well as skin type and ethnicity, play a large role in wound healing and scar formation. Also, certain areas of the body tend to heal much better, and faster, than other areas. An injury on the face is likely to heal quickly, with the resulting scar favorable, whereas injuries to the lower extremities typically take much longer with often less desirable scar outcomes. 

I find in medicine, the old mentality is that a scar is a scar. Patients are often told that there is nothing that can be done. While no treatment or cream ever removes a scar, they can certainly help minimize their appearance. Fortunately, the newer mentality is that there are in fact treatments to reduce scars and make them less noticeable. Here are a few key treatment options:

Topical Therapy

One of the most important aspects in scar treatment is early intervention. The sooner you begin treating the better. Among my favorite topical for the use of scars is medical grade silicone. Products such as Biocorneum and Silagen are silicone gels that can help to flatten, soften and smooth scars and reduce redness and discoloration. Silicone creates a protective barrier, which increases hydration and provides the optimal environment to normalize collagen production. For best results with topical scar products use twice daily with sun protection. For dark scars, bleaching agents like hydroquinone or skin brightening cosmecueticals may be used.

Intralesional Kenalog

For thick scars (such as hypertrophic scars or keloid scars) Intralesional Kenalog injections are first-line therapy. For years, scars have been injected with this anti-inflammatory medication to shrink the scar down and provide relief from associated symptoms such as pain or itching. Injections also commonly improve redness in scars. Injections are typically performed monthly until the scar subsides. 


There are many lasers that can also improve the appearance of scars. For textural changes, fractionated energy can be used to induce a controlled thermal injury in the skin to stimulate collagen. This can significantly reduce how noticeable a scar is, especially for scars that are indented such as cystic acne scars. For red or dark scars, vascular lasers that target vessels and pigment can be used.

While these treatment options will not remove scar tissue, dramatic improvement can be achieved. When asked "How Do I Get Rid of My Scar?" patient education is key and making sure patients have realistic expectations goes a long way.

Respect for Social Downtime with Facial Injectables
December 2, 2014 3:46 PM by Mina Grasso
As we get into the holiday spirit, we find this time of year to be a bit busy in the clinic and challenging with the patient that we see. Media and advertising many times underplay social downtime. Although some patients don't mind letting others know what they had done, others prefer not to have to answer questions or make excuses for redness, bruising or swelling.

During the holidays some patients take advantage of the extra time off and use that time for healing post procedure. Others prefer less downtime due to holiday events and parties.

We do not like to underplay and respect each patient's time during the holiday season. Social downtime with facial injectables can be described as mild redness, swelling and bruising. This can affect feeling self-conscious at work or during social gatherings. I usually inquire about events in the upcoming few days.

Patients fear having to explain or cover up bruising, redness or swelling. I prefer to wait one to two weeks prior to an event to perform a procedure. In addition, patients are given a list of medication and herbal supplements to avoid in order to reduce the risk. When using facial injectables bruising is always a risk when using traditional needles due to the vascularity of the face. It's almost a wonder how one doesn't bruise after injectables due to the extent of vascularity. I will usually have the patient or an assistant hold pressure over the treatment site to minimize bruising post injection.

IPL or V-Beam has been an effective way to reduce bruising. Protocols for these procedures must be followed, because they are not without risk. Treating a "bruise" with a large target of blood can create more energy absorbed than desired, potentially leading to blistering and necrosis.

Post-procedure arnica, vitamin K and other herbal preparations may help prevent or shorten the duration of bruising or swelling. When using injectable fillers, the trend for safety and reduction of bruising using blunt cannulas is on the rise. If someone is attempting to avoid bruising as much as possible, I prefer to use the cannula. Precision to some degree especially in the lips, is somewhat sacrificed, but with much practice in using cannulas for lip injections beautiful full or hydrated lips can result. Again, I sometimes find that the tradeoff is potentially more swelling, especially if the skin is very thin. When injecting under the eyes using a blunt cannula, I like to make the patient aware of the probable swelling the following 2 mornings, especially after awakening.

Although patients may seem okay while they are in your clinic, bruising can certainly be a reason why a patient doesn't return to you. Although the patient may already have had photos and topical anesthetic ready to go, it's almost better to reschedule their procedure if their downtime seems unrealistic. Management of expectations and potential post-procedure social downtime can be addressed by communicating with the patient. Better communication and respect goes a long ways in customer service and patient satisfaction.

The GRASS Regimen
November 26, 2014 3:51 PM by Kimberly Cray

I couldn't help but notice that a PA colleague of mine had a beautiful display on her medical suite counter.  No frilly flowers or fancy vases.  This was a simple, yet chic, display of a vibrantly modern grass.  Yes, you read correctly. Grass. Not only did this look pretty, it was pure genius.

I soon learned from her that SkinMedica concocted a brilliant skincare educational tool, "The GRASS Regimen." This tool was developed by SkinMedica to help patients in choosing skincare products. If you know anything about me, it's that I love patient education. You see, "GRASS" stands for "Growth Factors, Retinol, Antioxidants, Specialty Products, and Sun Protection." The categories are an easy to remember, and recognize (think cute grass and product display), pneumonic to aid in formulating a complete anti-aging skin care system.

Growth Factors

This category has me jumping up in down in excitement. If I could bring one thing to a deserted island, it would be my growth factor product. Growth factors help minimize fine lines and wrinkles and improve texture and tone. Can you feel the earth shaking? I'm still jumping. This is a great add-on to your current skin care regimen if you are looking to rejuvenate the skin. Let's face it, who isn't?


Another important category is Retinol. Retinol does so many great things, such as stimulates collagen, turns over dull surface skin, and improves texture and tone of skin, to name a few. Mild redness, peeling and irritation is common when first beginning to use Retinol. As you begin, limit use to every second to third evening and increase use as tolerated. Let a medical professional help you to know which product is right for you. 


Since our skin is exposed to damaging free radicals on a daily basis, it is essential to protect our skin around the clock. Antioxidants serve to provide a defense against free radicals. Vitamins C, E, and Green Tea, are just a few examples. These products improve skin texture and also give skin a healthy glowing quality.  

Specialty Products

This category is where your medical professional can really shine as skin care is tailored to your specific needs and overall goals. For example, if you have melasma, or brown pigmentation on the face, a bleaching or brightening cream can be incorporated, as well as supped up antioxidants to get maximum glow. Other common concerns, such as scars or redness, could benefit from products special products, specifically designed for those needs. Every regimen should be unique to the individual.

Sun Protection

This category is always on every list, and that's for a reason. It's not typically what people want to hear, but it has proven itself as an anti-aging staple. Since damage from the sun is cumulative, it is never too late to start and it is imperative to overall skin health. Protect with Broad Spectrum UVA/UVB sun block.  Look for components such as Zinc Oxide or Titanium Dioxide, which will block the sun's rays from penetrating and harming the skin.

Can you see how with the "GRASS" Regimen patients can quickly, and memorably, get a good idea of what their day to day skin care routine should consist of. I say kudos to those smart folks at SkinMedica who came up with this simple (yet ingenius) idea. I believe it serves to help patients and providers alike in understanding skin care and learning about what products can be incorporated into an effective and comprehensive daily regimen.

What's New in Hair Rejuvenation?
November 18, 2014 5:16 PM by Mina Grasso

The current treatment of choice for androgenic alopecia (AGA) involves surgical hair transplant, use of Minoxidil and/or Finasteride. For those patients who do not want to undergo the expense and process of hair transplantation, they opt to have more conservative, less invasive treatments.

We have been performing LLLT for over a decade to treat hair loss for men and women. LLLT has been proven to promote hair growth in males. We actually treated more women then men with good results. A recent study published in the Lasers in Surgery and Medicine using LLLT of the scalp using 655nm, the same parameters as the study in males, reports the results to show significantly improved hair counts in women with androgenic alopecia (AGA). We have found that patients do well with regular treatments from 3-6 months, but usually drop off due to time constraints.

Although used off-label, PRP - Platelet Rich Plasma is becoming more popular. Patients like the idea that it is their own blood, centrifuged to concentrate the platelets rich in growth factors, transforming factor beta, vascular endothelial growth factor epidermal growth factors, insulin-like growth factor and fibroblast growth factor 2.

After the concentration of the PRP, practioners must prepare and activate the PRP and choose to either apply the PRP directly to scalp after miconeedling or inject small amounts at multiple locations... The PRP then stimulates the proliferation and differentiation of stem cells in the hair follicle. Treatment protocols using PRP have not been standardized.

With the advances in micro-needling, the scalp can be treated at various depths in the scalp, creating micro-channels for the PRP to penetrate. As with other injections there is a risk for bruising, swelling, pain and infection post treatment. Some practitioners perform this procedure weekly on patients up to 6 months.

PRP has been used alone or in conjunction with LLLT or alone. LLLT therapy usually requires 20-minute sessions 2-3 times per week. Patient selection is crucial. Someone with advanced hair loss who is "shiny bald" and those with autoimmune disorders are not good candidates. With either PRP or LLLT along and even greater with the combined therapy, a lot of patience and proper patient selection, a high patient satisfaction rate can be achieved.

Neck and Body Contouring with the Velashape III
November 11, 2014 11:15 PM by Kimberly Cray

The VelaShape III is an FDA cleared, non-surgical device proven to effectively reduce cellulite. What makes Velashape III unique is its combination of Bi-Polar Radiofrequency, Infrared Light Energy, and Vacuum and Mechanical Massage, all in one treatment. 

VelaShape III safely contours, shapes and slims the body, allowing patients to achieve a more toned, contoured and well-shaped figure in as few as four treatments. In fact, with the increased energy capacity of this third generation system, noticeable results have even been seen in as few as 1-2 treatments. What's even better is that the process is virtual painless with no downtime.  

This is a new option for patients looking to reduce cellulite and body circumference, as well as to reshape problem areas such as the abdomen and legs. In a clinical multi-center study, 85% of the treated areas reported Circumferential Reduction of thighs of at least 1 cm, ranging up to 7.2 cm in reduction in many patients.

Velashape III incorporates precise heating to ensure safe, effective, and fast treatments. The system utilizes vacuum and specially designed rollers, which mechanically massage the area of cellulite to smooth out the skin and facilitate safe and efficient heat energy delivery. After reaching a specifically targeted temperature, fibroblasts in the dermis promote new collagen production and there is an increase in the metabolism of fat. This treatment increases the metabolism of stored energy, increases lymphatic drainage and reduces the size of the actual fat cells and fat chambers. Velashape III is also safe on all skin types and causes no additional risk to the epidermis. 

Velashape III is also being used to improve a common complaint among patients known as the "double chin." It can improve skin sagging along the neck and chin to create a more toned and natural neckline. Along with body contouring, the neck region is of major concern to patients and a popular treatment to pair with other aesthetic procedures.        

Is your practice utilizing body contouring devices? If so, which devices? I'd love to hear your feedback and clinical experience.

Changing Beauty Routines During Pregnancy
November 4, 2014 4:34 PM by Mina Grasso

Patients become accustomed to their beauty routines, however, during pregnancy, they must be cautioned to avoid certain procedures and products. Some have been proven to be harmful during pregnancy and others lack adequate evidence of safety during pregnancy.

Laser treatments such as laser hair removal, photorejuvenation, laser collagen rejuvenation, radiofrequency, treatment for brown spots or broken capillaries and acne laser treatments should be avoided during pregnancy. Since there are inadequate studies showing safety of laser treatments during pregnancy, many practices just make it a policy not to perform these procedures to avoid medical legal issues. Alternative treatments for skin rejuvenation could include pampering facials, microdermabrasion or micro-needling with or without PRP (platelet rich plasma). Platelet rich plasma utilizes the patient's own plasma (rich in growth factors) to stimulate stem cells in the skin into a repair reponse - rejuvenating the skin.

Facial injectables such as botulinum toxins, BotoxTM and DysportTM, and tissue fillers such as RestylaneTM, JuvedermTM, RadiesseTM, SculptraTM and Artefill should be avoided during pregnancy. The safety of use during pregnancy, again, has not been adequately studied. It is usually recommend patients wait until after breast-feeding to resume treatments with facial injectables.

Certain topical ingredients are suggested to be avoided, especially during the first trimester of pregnancy. However, some routinely avoid during the entire course of pregnancy: retinoids, salicylic acid, benzoyl peroxide, hydroquinone and kojic acid.  These ingredients can usually be found in creams for acne, hyperpigmentation or wrinkle creams. Pregnant patients can safely use the following ingredients topically: Lactic acid, topical vitamin C or E and topical hyaluronic acid.

Although patients during pregnancy are somewhat limited in their options for skin treatment, their naturally enhanced skin and hair provide the noticeable glow of childbearing.

7 Habits of Highly Effective Skin Care
October 30, 2014 11:15 PM by Kimberly Cray

1.  Less is more.  A common misconception in skin care is that more is better.  In fact, over washing and over doing it with products usually only serves to irritate skin.  Consistency is more important than frequency, in many cases, and when we say pea-sized amount we mean it.   

2.  Know when to skimp vs. splurge.  Sure you could spend a pretty penny on washes and night creams, but if you buy the right product for you, your skin will thank you in the long run.  An added bonus is that your wallet likely will too.  Think of all the Over the Counter products cluttering your vanity.   Medical professionals often recommend great OTCs (we love for patients to save money) and we can also steer you away from products you simply don't need.  Avoid clutter and wasting money on skin care.  Key here- ask a professional.    

3.  There is such a thing as healthy oil.  For years, our culture has been obsessed with all things Oil Free.  Recently there's been a trend towards using oils on the skin for multiple purposes and I love this trend.  Remember, a healthy balance of oil is key.   Let's break the Oil Free stigma.

4.  A healthy lifestyle is key.  Avoid smoking, excessive sun, and make a healthy diet and exercise a priority.  Don't forget to get your beauty sleep.  Yes, there is such a thing.  It is scientifically proven that if we do not get adequate sleep it takes a toll on our skin.  And drink lots of water.  Even the best moisturizers can't touch our skin if we are constantly dehydrated.   

5.  Be open to change.  Like most things, skin changes as we age.  We, therefore, must account for this by making adjustments in our routine.  Maybe it isn't that your "cream stopped working."  It may be that it was no longer right for you.  Change can be hard, but oh so good for you.         

6.  Exfoliating doesn't have to be abrasive.  Many patients only feel like they are exfoliating if they are red and irritated when they are finished.  Using harsh products or using agents too frequently could be detrimental to your skin.  This all ties back to consistency over frequency.  Exfoliating scrubs and masks make patients feel great- that they are doing something extra which will results in something good for their skin.  Unfortunately, this often leads over drying and irritating the skin.  Remember that some of the best exfoliation is done at the microscopic level with proper product application.  

7. Protect your skin, as well as time and investment.  All your hard work will go down the drain if you skip this one simple step.  Some of my favorites include mineral physical sunblocks (say good bye to those harsh and irritating chemicals) and easy to throw in your purse (or man bag) brush versions.  Remember any tanning of the skin is a sign of damage.  Do yourself a favorite and protect yourself.  Unfortunately, we don't see most sun damage until years down the road.  Be proactive and start now, if you haven't already. 

I'll Have What My Friend Had
October 14, 2014 9:32 PM by Kimberly Cray
Just like one pair of jeans may fit someone perfectly, the chances of that same pair being right for the next person that walks through the door are, well, pretty much zero

One of the most important factors in considering an aesthetic treatment is what it will do for your skin. The same treatment that helped a friend may or may not be the best treatment for you. I can't tell you how often people ask for something familiar to them or something they know about through a friend's positive experience.

On the contrary, treatments should be tailored around what is best for a patient- not necessarily what "their friend had" or what is trending at the moment. Now of course, there are important exceptions. I emphasize that while a treatment someone's friend did (and loved) may actually be a great choice for them, it is our job to determine that and go over the best options for each individual patient.

As physician assistants and nurse practitioners, I believe we have the unique job to go the extra mile to make sure we are really educating patients. I find that by taking the time beforehand you avoid miscommunication and provide the most realistic expectations for patients.     

I ask patients what they would like to improve and listen to their concerns. While it seems like such a simple concept, it is easy for a provider to make recommendations based on what our eyes see without also satisfying the patient's desires and not our own. Many patients come wanting to know what we would recommend.  While they want a professional opinion on what they could do to look better, I still think it is important to establish their desires to make sure at the end of the day they are fully satisfied. For example, if a patient is asking about fillers to improve their nasolabial folds (like their friend just had and loved) but they state that what really bothers them are the fine lines around their eyes. Be sure to then educate them on how Botox and great skin care could actually be a better option for them. Use a mirror and show the patient. Have them look on as you describe what the different products do and where they are used. Many people (even those who have had treatments done before) do not know how things like Botox or fillers work. All it takes is a few moments of your time and I guarantee it goes a long way with patients.      

Moral of the story, as a provider be open to treatments that bring patients in. However, always keep in mind that no two patients are exactly the same and it is our job to educate a patient if there is a better option for them to address their specific needs.

Anterior and Posterior Axillary Fat Pad (Armpit Fat)
October 7, 2014 3:23 PM by Mina Grasso
Wardrobe frustrations and an endless search for the perfect bra, spanx or other compression material to conceal fat bulges around the bra go on. A particularly challenging fat bulge is the anterior and posterior axillary fat pad area (armpit fat). This fashion-limiting issue is something that many patients often demand a solution for.

Injectable RF (radiofrequency) using a procedure called Thermi-Tight may be a promising solution for those frustrated with the unwanted bulges and skin laxity.

This injectable RF procedure is a minimally invasive procedure that requires local anesthetic into the area to be treated. A small probe the size of short thin spaghetti is inserted under the skin into the fat. The tip of the probe gradually heats the deeper fat to approximately 70° C. At this temperature, you can actually hear the popping of fat cells as apoptosis occurs. Some practitioners choose to do liposuction instead of or in addition to melting fat with the RF probe.

After the fat is treated, the probe is directed closer to the subdermal layer and slow radial movements are made under the skin, treating a small zone, while attempting to maintain temperatures around 60°-65° C for approximately 10 minutes which promotes skin tightening. As the probe moves through the skin, you are able to see temperature reading through a digital monitor. In addition, a thermal camera is used to monitor the external skin temperature while a light spectrum shows various temperature range (coolest to hottest zones) during the treatment. The hottest spot is highlighted and the monitor has a digital display of average temperature of the zone being treated externally. The goal is to maintain the external temperature to approximate 42°-45°C. The practitioner and the circulating assistant can safely monitor the temperature and minimize damage to the tissue.

A compression garment is usually recommended for 72 hours. Swelling is to be expected as well as some bruising for a few days. Most patients resume regular activities in a couple days. Skin tightening is expected to gradually progress 3, 6, 9 and even up to 12 months.

Practitioners are happy with being able to deliver higher energy levels for more efficacy, while having safety in the temperature control. Patients treated for armpit fat are highly satisfied and are freer to wear straps, strapless or sleeveless fashion.

"I Hate My Neck"
September 9, 2014 3:38 PM by Mina Grasso

Looking in the mirror at submental (under the chin) fat, loose, crepey, puckered skin and tight platysmal bands going down the neck can have a psychological impact. Loss of the definition of the jawline and neck can be from a genetic predisposition, weight gain or aging. It is generally considered aesthetically unappealing.

Most seem to be aware of the surgical (facelift) option with or without liposuction of the submental fat or a platysmaplasty. Surgical procedures are very effective, but some patients may not be candidates due to various medical, social or economic conditions. The rapidly advancing world of light and laser technology in aesthetics during the last 2 decades has introduced patients to a variety of exciting non-surgical options. Pigmentation, texture, broken capillaries, sun damage, fine lines and wrinkles have been treated with various light, laser, radiofrequency and ultrasound devices externally. Most procedures require multiple treatments. Some of these procedures resulted in minimal satisfaction for patients while others depending on severity of condition and patient expectations result in great satisfaction.

Injections for localized fat reduction is performed in some clinics including ours years ago. Often a combination of phosphatidylcholine and deoxycholate is compounded in the formulation. The solution disrupts adipocyte membranes, which leads to adipocytolysis.  This creates an inflammatory response, reduces the fat but causes swelling in the area treated for several days. Other potential side effects include localized pain, bruising and erythema. It is common for patients to report transient numbness and induration post procedure. Multiple treatments are required. These localized fat injections have gone in and out of popularity probably due to lack of well-controlled clinical studies and standardization of formula. There is a proprietary formulation of synthetically derived deoxycholic acid that is currently being studied. In our experience, our patients felt that it was too much downtime per procedure and multiple treatments were required.

Injectable RF (radiofrequency energy) using ThermiTight is a new minimally invasive procedure. Local anesthetic is applied to the neck and jowl. A thin radio frequency probe is inserted under the skin and used to heat the submental fat and surrounding skin while the resulting temperature rise is closely monitored with a special heat-sensing camera. Fat reduction and skin tightening is the end result. Patients are noted to see improvement around 2-3 months but may continue to improve for up to 15 months.

Neurotoxins, such as Botox, have become one of the favorite treatments for the neck. It minimizes necklace lines, softens platysmal bands and helps define the jaw and neckline. Patient satisfaction is extremely high with one or more of the above treatments.

In addressing patient's concern of wanting to improve the appearance of their neck, realistic expectations with results must be carefully discussed. Practitioners have to be sensitive to social downtime and accurately describe the post-procedure time frame and possible complications. Satisfaction is highest using a combination of modalities while keeping in mind the patient's budget.

Thermi-Tight Injectable RF
August 13, 2014 3:46 PM by Mina Grasso

Before non-surgical skin tightening was available, the only option to address loose skin was to surgically remove it. Thermage, a non-surgical procedure utilizing mono-polar radiofrequency, provided an option for those wanting to avoid the surgery. This is accomplished by heating the skin externally to a temperature that would stimulate collagen fiber contraction. For those not expecting a "surgical result", repeated treatments over the years kept them happy. For many, the results were just not good enough.

Over the last two decades aesthetic laser industries introduced hundreds of non-ablative skin-tightening and skin rejuvenation devices. There was just no "in-between" until laser lipolysis and skin tightening using Cool-LipoTM and Smart-LipoTM Lasers were developed. These were considered minimally invasive skin-tightening surgical procedures that were performed in the office. After local anesthetic is administered in the area to be treated, a laser is then inserted under the skin delivering heat. Using the laser to heat the area would result in lipolysis and skin tightening.

Temperature control was the issue with these devices. External infra red thermometers were required to monitor the temperature. Temperature readings would vary on the distance and angle of the thermometer. Some lasers had thermistors on the laser but not at the tip where the energy was delivered. Due to inconsistencies of temperature monitoring, complications such as burns would occur with excess heat delivered with delayed temperature registering. For extra safety in monitoring, we would routinely utilize 2 staff members, each with an external infrared thermometer for temperature control. Temperature control was the issue. Over-heating or under-heating could potentially result in a burn or suboptimal results.

Comprehensive thermoregulation integrating continuous subsurface and epidermal temperature monitoring is now possible using the Thermi-Tight Injectable RF. This technology will be the game changer for minimally invasive skin tightening. Skin temperatures can now be monitored precisely using a platform that incorporates state of the art infrared imaging camera allowing for visual clinical end-points, which contributes to the overall safety. Injectable RF, radiofrequency energy can be applied using proprietary cannulas with a thermistor at the tip to measure the precise temperature of the target tissue. The proprietary cannula can be set to shut off when the desired temperature is achieved. Controlled heat can be delivered to targeted tissue using the precise level of external and subsurface tissue monitoring without risking epidermal damage. 

Patients that are attracted to Thermi-Tight Injectable RF are usually those that are "in-between". They have minimal downtime. They are not quite ready for a surgical procedure and feel that results of a non-surgical skin tightening procedure will not be enough for them.

Patient's who desire minimally invasive skin tightening with very little downtime can now benefit from Thermi-Tight Injectable RF with added safety due to the comprehensive thermoregulation. Practitioners can provide safer more consistent results and have more satisfied patients.



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    Occupation: Physician Assistant/Nurse Practitioner
    Setting: Miami & Upland, Calif.
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