Even low-level exposure to mixtures of chemicals commonly used in cosmetic and personal care products is associated with changes in women’s reproductive hormones, according to a new study in Environment International.

The study of reproductive-aged women, led by George Mason University researchers, suggests exposure to bisphenol A, chlorophenols, benzophenones and parabens often used in sunscreens and other cosmetic and personal care products could impact women’s lifetime risk of hormonally mediated diseases.

Researchers studied 509 urine samples from 143 healthy premenopausal women, who were not using birth control. They measured levels of these environmental chemicals, including antimicrobial preservative parabens and UV filtering benzophenones.

The novel component of this study the report on mixtures of chemicals widely used in personal care products, using multiple measures of exposure across the menstrual cycle. This improves upon research that relied on one or two measures of chemicals, author Anna Pollack, Ph.D., M.P.H., George Mason University assistant professor of Global and Community Health, said in a study-related press release.

Pollack and colleagues not only found that mixtures of chemicals might impact reproductive hormone levels, but also that the relationship between these chemicals and hormones is complicated. Certain chemicals and UV filters seem to decrease reproductive hormones in multi-chemical exposures, whereas exposure to others appear to increased reproductive hormones.

Taking a closer look at the findings: While paraben metabolites were associated with hormones in single chemical models, results from single chemical models did not consistently reach statistical significance.

In the multi-chemical approach, researchers uncovered statistically significant associations between the chemicals and hormone changes. For example, paraben factors, paraben metabolites and BPA factor were linked with increased estradiol. That’s consistent with previous study findings, the authors note.

Phenol and UV filter factors were associated with decreased estradiol when modeled together and separately. This association in the multi-chemical models is new, according to the authors.

Progesterone increased in association with all factors modeled together. The authors write that there have been no previously published associations between multi-chemical models of parabens, benzophenones and phenols related to increased progesterone levels.

Modeled together, phenol and UV filter factors were linked to decreased follicle stimulating hormone (FSH) and luteinizing hormone (LH).

Studying these mixtures of chemicals in widely used products might better mimic real-world exposure, but more work needs to be done to corroborate these results, according to the paper.

“Understanding the relationships of bisphenol, A, chlorophenols, benzophenones and parabens with hormone levels among healthy women is critical to disentangling potential effects on other reproductive and endocrine influenced health outcomes, such as endometriosis, fertility and hormonally influenced diseases,” the authors write.

Thread-lifting techniques have evolved to provide satisfactory short-term results, particularly in the midface, said an expert at summer Cosmetic Bootcamp held June 21-24 in Aspen, Colorado. However, he added, thread lifting often works best in conjunction with other procedures such as fat injections and fat contouring. And even at its best, thread lifting cannot approach the results or longevity of specialized surgical results.

Choosing between thread lifts and surgical lifts requires knowing what patients want, and how long they want results to last, said Providence, Rhode Island-based plastic surgeon Patrick Sullivan, M.D. For patients who want to be ready for a near-term event, with little postprocedural downtime, he explained, thread lifts may suffice. But if patients can tolerate a longer recovery in pursuit of more beneficial and durable results, the pendulum swings toward surgery.

After the original non-resorbable barbed sutures became available, said Dr. Sullivan, many patients who had undergone the procedure elsewhere presented at his practice with threads protruding through their skin. Newer resorbable barbed threads are little better, he said. "Those hooks don't seem to do the job as well as some of the other technologies."

The cone-and-suture structure of the Silhouette Instalift (Sinclair) is much more effective, said Dr. Sullivan. In the perioral area, he said, the bidirectional cones seem better able to lift and hold tissue in position. Over time, the polyglactin (glycolide/L-lactin or PGLA) material of which they are made resorbs into the body, forming a temporary filler, as polymethylmethacrylate does.

For perioral lifting, he marks three parallel entry points in the mid-cheek, which correspond to exit points in the upper cheek and perioral area. He then guides a long 18-gauge needle approximately 5 mm under the skin's surface to the upper-cheek exit point.

"You can see the different cones being brought through this one entrance site. This opening is not even made with a knife." Then he returns to the central entry point with the other end of the needle and anchors the other end of the suture in the perioral region. "It's very important to feed those cones in perfectly so they don't cause any tethering."

Next, gentle upward pushing across the length of the thread provides medial and lateral lifting as one locks the cones into place. "You can see this lifting, right on the table, which I find very satisfying."
Nobody knows how long Instalift results last, said Dr. Sullivan. He advised curbing patients' expectations regarding both duration and the procedure's effect. "The limited results I get are very different from what I get from surgery."

Patient selection is critical. One patient he treated underwent surgical blepharoplasty, then decided three days later that her face needed lifting. But she had to return to work the following week. "When you have somebody who wants something extra to better match their upper face, the Instalift is a possibility to consider." For this patient, he said, the procedure provided modest lifting in the perioral area, and with threads along the jawline as well, but nothing in the neck.

"A better candidate might be someone who wants more at the same time." For example, one patient wanted an eyelid lift and fat injections to raise her cheeks and pre-jowl sulcus. "We also removed some fat from the jowl at the same time. When you combine treatments, that's a better approach." For this patient, he first inserted threads extending from the mid-cheek to exit points in the perioral area. "As we mark those out, we can really get a feel for what we want to lift. Then you can create the other exit points back up against the hairline."

The neck area is more challenging to treat with Instalift because patients find the postauricular exit openings less comfortable than preauricular ones, said Dr. Sullivan. Furthermore, Dr. Sullivan said he does not show patient results beyond six weeks for this procedure because after that, results are unimpressive.
For one female patient he treated, the Instalift facelift worked very well initially. "But when she returned 1.5 years later, we didn't see any improvement. Then you get into the value proposition, because each thread costs $150." However, he said that combining facial thread lifting with procedures such as blepharoplasty and fat injections gives patients more bang for their buck.

Regarding adverse events, Dr. Sullivan said that none of his patients have experienced tethering that lasted beyond five days. "But it has been reported. Some people say you have to make sure that the area of the central entrance point is very smooth, because tethering can last months." 
Poor candidates for neck thread lifts include those with subplatysmal fat, which one

can detect when patients swallow. "If you can feel that fat pull away from you, then it's probably deep to the platysma and more difficult to get with something like Kybella (deoxycholate, Allergan)."

Such patients are better candidates for procedures such as surgical neck lifting and contouring, he said.  "And if they are concerned about their face as well, the superficial muscular aponeurotic system (SMAS) lift can be very effective if done by the right surgeon. Surgical results vary greatly between surgeons.” A female patient for whom Dr. Sullivan performed an extended SMAS lift maintained very good results nearly eight years later, he said.

Other contraindications to thread lifts include heavy jowls, and deflation of the pre-jowl sulcus or posterior jawline. "A thread is not going to put enough volume in those locations. So fat injections, or one of the other synthetic materials, would be helpful there."

Men with thick, heavy skin and little subcutaneous fat also make poor neck thread-lifting candidates, said Dr. Sullivan. With such patients, he said, it's difficult to find anchoring points that will hold as long as he would like, and patients likely will have tethering or visible sutures. For a male bodybuilder with thick platysmal bands, Dr. Sullivan performed a full-width transection of the platysma, keeping incisions very low on the neck so the muscle incision would not be visible under the skin since the patient had no fat.

Nearly 2.5 years later, Dr. Sullivan said, the patient maintained an improved jawline and a far  better lift than threads would have provided. "Additionally, in his neck region, we were able to get control of the platysma, and you couldn't see any area where we did the full-width division inferiorly. Thus there are no scars visible at all from all of his face and neck surgery. His result is very natural, and that is just what he wanted."

Asian, African-American, Caucasian and Indian men share some similarities with signs of facial aging, but there are distinctions among male ethnicities that emerge as their faces age, according to a study published September 7 in the International Journal of Cosmetic Science.   

Researchers at L’Oréal Research and Innovation facilities in Shanghai, China, Chicago, Ill., Mumbai, India and Paris, France analyzed digital images of 1058 men, ages 18 to 80 years. Researchers illustrated potential progressive changes of male facial skin with age by looking for 15 to 20 different facial signs in each of the subjects and grading the signs with Skin Aging Atlases specific to the gender and ethnic groups studied.

They found Asian men tend to age faster in the upper face than in the lower half of the face. Their neck skin texture has an unpredictable profile but shows a sharp increase beginning in their 50s. Skin homogeneity changes appear fastest in localized pigmentary spots on the cheeks, which is a clear Asian trait, according to the authors. Their facial skin pores remain rather stable with age.

Compared to Asian men, Caucasian males have more pronounced glabellar wrinkle development. Pre-tarsal lower eyelid swelling, which seems a Caucasian trait, appears at a stable intensity, according to the authors. Neck skin texture seems stochastic but shows a sharp increase in aging from 40 years on. Vascular and pigmentary homogeneity in facial skin isn’t much affected by age, but skin pores increase in severity up to men’s 40s and decline after. Changes appear to occur faster in the upper part of the face than in the lower face.

Indian men exhibit greater changes in the nasolabial fold and forehead wrinkles than Asian or Caucasian men. They also seem to have more prominent neck sagging and lower facial region ptosis. Their skin pores change with age and pigmentary macules spread, but those are the limited skin homogeneity signs that consistently, albeit slowly, increase in Indian masculine skin between 18 and 80 years of age.

In African American men most signs of facial skin aging have low scores compared to the other ethnicities. The most noted age-related sign among African American men appears to be chin withering. Facial skin rarely reveals pigmentary disorders, but pores increase in severity with age.

Overall, the research suggests there is a need to develop anti-aging cosmetic products aimed at specific ethnic groups, according to the study.

Should men and women be treated with the same facial products in the same way? A literature review by an international group of physicians shows that the physiological skin parameters of hydration, transepidermal water loss, sebum, microcirculation, pigmentation and thickness differ among men and women suggesting that treatment choices should differ as well.

“Understanding the physiological, chemical, and biophysical characteristics of the skin helps us develop a proper approach for the management of skin diseases,” wrote the authors of a review that focuses on sex differences of skin. The review appears in the September issue of the International Journal of Women's Dermatology.

The review, which included 57 studies, was led by Alireza Firooz, M.D. of the Center for Research and Training in Skin Disease and Leprosy at Tehran University of Medical Sciences in Iran.

“The studies show that the skin parameters of hydration, transepidermal water loss, sebum, microcirculation, pigmentation, and thickness are generally higher in men but skin pH is higher in women,” she and her colleagues wrote.

Developing a deeper understanding of the skin in this way could be used in developing facial products and cosmetic treatments that are truly sex-specific.

“The knowledge of sex-linked cutaneous differences might help in study planning and the development of female- versus male-specific products for more appropriate dermatological treatments or cosmetic interventions,” the authors wrote.

There are established sex differences in anatomy, physiology, epidemiology and in many diseases. “With regard to skin disorders, infectious diseases are presented more in men, but psychosomatic problems, pigmentary disorders, certain hair diseases, and autoimmune and allergic diseases are more common in women,” the authors wrote. In men, “skin pigmentation and thickness are significantly higher, facial wrinkles are deeper, and facial sagging is more prominent in the lower eyelids, but there is no significant difference in skin elasticity between the sexes.”

The molecular mechanism that drives these differences remain to be defined, but knowing they exist and treating patients accordingly may improve treatment outcomes.  In this article, we summarize key takeaways from the review.

HYDRATION
A healthy skin barrier protects against UV damage and other assaults, plus, it holds in moisture. Without adequate hydration the skin’s physical and mechanical properties are impaired.

The review cites a 2013 German study by Luebberding et al. that shows young men tend to have "high levels of stratum corneum hydration," but as the men aged beyond 40 years, the hydration decreased. Hydration on the forehead in both men and women beyond 70 years significantly fell below that of younger men.

TRANSEPIDERMAL WATER LOSS
While some studies reported comparable water barrier functions in both sexes, the 2013 study by  Luebberding et al. showed that in men younger than 50 years old, transepidermal water loss was significantly lower in men, but on the forehead, cheeks and neck, it was higher than that of women.

SEBUM PRODUCTION
Up until a 2012 study by Bailey et al., it was believed that sebum production between men and women was equal, but Bailey et al. described higher sebum levels in men on the face, except forehead. However, Luebberding et al. reported sebum content increased slightly on the forehead with age, but progressively decreased in women. In 2006, Roh et al. described a correlation between excessive sebum production and larger pores.

SKIN THICKNESS
In 1975, Shuster et al. first documented the loss of skin collagen (which is associated with skin thinning) with age, particularly in women after 50 years. In men, however, it decreases equally over time.

But the most recent study on skin thickness Dr. Firooz and colleagues cited was in 2008 in which Mogensen et al. confirmed the results of a 2006 study by Gambichler et al. who found no differences in epidermal thickness among men and women. Their study was based on optical coherence tomography imaging.

SKIN pH
Men tend to have lower acidic levels according to a 2012 study by Bailey et al.  which differs from a 1987 finding Zlotogorski and a 1991 study by Wilhelm et al. that showed no sex differences.

SKIN ELASTICITY
A 2012 study by Firooz et al. reported that females had slightly higher skin elasticity than men, but the findings were not statistically significant, which is in agreement with a 2012 report by Bailey et al. who found that women had higher skin elasticity, but only in the abdominal region. The 2014 Luebberding et al. study found that: “The mechanical properties changed differently in men and woman over their lifetime and that female skin is less distensible but has a higher ability to recover after stretching in comparison with male skin.”

SKIN FRICTION
A 2011 study by Zhu et al. showed a “significant positive correlation between skin friction coefficient and stratum corneum hydration on the canthus and dorsal hand skin for women and on the forehead and dorsal hand skin for men.”

WRINKLES
In 2013, Tsukahara et al. reported that among men and women between 65-75 years, women disproportionately had more wrinkles than men.

Picosecond lasers are not only effective for pigmentation and tattoos, but also for scars and skin rejuvenation, creating innovative trends in dermatology. And while there are a number of picosecond lasers available, I have chosen PICOCARE from Wontech (Daejeon, Korea) because of its superior engineering and clinical performance. Its 450 ps pulse duration and 1.33 GW peak power provide excellent performance and great results. In my experience with PICOCARE, I have found that it is very versatile, effectively treats a variety of skin lesions and is safe even for darker skin types.

Compared to nanosecond lasers (one billionth of a second), picosecond lasers (one trillionth of a second) offer greater photoacoustic effect versus photothermal effect and, consequently, are associated with fast, efficacious and safe treatments. The picosecond pulse duration can shatter endogenous and exogenous macro-pigment particles into much finer micro-pigment particles, allowing more efficient macrophage clearance. It also produces less procedural discomfort and adverse effects such as vesiculation, purpura and post-inflammatory hypopigmentation.

PICOCARE’s dual wavelength (532 nm and 1064 nm) targets epidermal pigmented lesions (e.g. solar lentigines, freckles/ ephelides), epidermal pigmented birthmarks (CALM), dermal pigmented birthmarks (e.g. nevus of Ota, Hori’s nevus, epidermal nevus), and exogenous pigment (e.g. tattoo, iron-infusion staining). See Figures 1 and 2.

                                               

With a novel fractional handpiece, the ultra-short pulses and high-intensity energy generate laser-induced optical breakdown (LIOB). LIOB produces multiple plasma-induced micro-vacuoles within the skin layer (epidermis and/or dermis) without damaging the stratum corneum and dermo-epidermal junctions, resulting in fast and effective tissue repair and remodeling. PICOCARE’s HEXA Micro Lens Array (MLA) handpiece has various spot sizes from 3 – 10 mm, allowing physicians to perform more delicate treatments; 3 – 4 mm for acne scar treatment; and 8 – 10 mm for skin rejuvenation (improvements of enlarged pores, fine lines, wrinkles and uneven skin texture). See Figures 3 and 4.

             

After only one to three sessions, HEXA MLA rejuvenation is especially effective for enlarged pores, fine lines, wrinkles and uneven skin texture, as well as pigmentation. Since PICOCARE offers minimal procedural discomfort and downtime, with visible results, this treatment is popular among patients with busy lives who desire improved skin quality. See Figures 5 and 6.

                    

PICOCARE is a valuable laser in my practice because it can effectively treat a range of skin conditions, and it is suitable for all skin types. My patients and I have been extremely satisfied with the great results achieved in the treatment of pigmentation, scars and skin rejuvenation. In addition, PICOCARE has recently been advocated for new indications, such as nail fungus and benign melanochia, further extending its versatility.

---

Adrian Lim, M.B.B.S., F.A.C.P., F.A.C.D.

Dr. Lim is one of Australia’s leading dermatological experts. He is a visiting dermatologist in the department of dermatology at the Royal North Shore Hospital, St. Leonards (Sydney, New South Wales, Australia) and the founder of uRepublic Cosmetic Dermatology and Veins in Sydney.

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The subtly profound outcomes achieved with Clear + Brilliant (C+B) from Solta Medical, a division of Bausch Health Companies, Inc. (Bothell, Wash.), are a testament to the versatility and wide appeal of this multi-wavelength laser system. Among its many benefits and uses as a preventative therapy, it can usher in a younger patient base, exposing them to the offerings and capabilities of your practice, and allowing the natural allure of successful outcomes to drive new business.

Founder and director of Van Dyke Aesthetics in Scottsdale, Ariz., veteran dermatologist Susan Van Dyke, M.D., is a true believer in Clear + Brilliant. As the first physician in the Southwestern U.S. to offer the technology to patients, she has enjoyed much success with it in her practice.

“Clear + Brilliant utilizes the 1440 nm fractional diode laser to provide lighter treatment, or as maintenance after more aggressive therapies, in either case staving off the need for additional intervention and keeping skin looking youthful and healthy,” she said. About four to six sessions will refresh skin and stimulate neocollagenesis.

“We recommend it because it is the kind of thing patients don’t always know they need until they’ve had it and seen the result,” Dr. Van Dyke shared. “It is an ideal avenue into aesthetic medicine, even before turning to injectables, or it may be used in conjunction with them.

“I got my first device in 2011 when microdermabrasion was all the rage,” she continued. “Within a few months we got rid of our microdermabrasion machines and converted patients to Clear + Brilliant. It’s a great first-line light treatment for texture, color or pigmentation, pore size and more, and it has proven itself as a great introductory treatment for anyone.

“Over the years we found out that it can be useful for any age of patient, especially as a ‘starter’ laser,” Dr. Van Dyke pointed out. “Currently our patient base for Clear + Brilliant ranges from ages 18 to 80 years.

“Half of my practice is laser-based so this provides a nice experience with lasers that allows patients to become comfortable with them, and often leads to more aggressive therapies in time, as appropriate,” she added.

The addition of the Perméa handpiece to the Clear + Brilliant armamentarium takes the technology to the next level, providing another dimension to C+B therapy, Dr. Van Dyke highlighted.

Using the 1927 nm wavelength (which has a higher absorption coefficient) at a fixed depth of 170 μm, Perméa does not penetrate the stratum corneum, thus preserving barrier function. This wavelength has an affinity for water rather than melanin, making it safe for darker skin types, and the fractional delivery pattern of holes may be suitable for facilitating topical delivery of therapeutic compounds.

Furthermore, because it is gentle, superficial, and the wavelength is not pigment-specific, Clear + Brilliant Perméa may be ideal for melasma, especially when used in a multi-vector protocol.

“When treating melasma with a laser you run the risk of exacerbating the condition, but much less so with Perméa because of the nature of the wavelength and depth of delivery,” explained Dr. Van Dyke. “This is now my go-to treatment for melasma, precisely because we don’t see that rebound pigmentation. I often use this with hydroquinone therapy.”

In fact, Clear + Brilliant is great for combatting pigmentation in general. “I practice in Arizona so everybody has some level of sun-induced pigmentation, and Clear + Brilliant is a great option for this indication in patients of any age,” she said.

As a preventative treatment, Clear + Brilliant appeals strongly to the younger patient base. “Aesthetic medicine is much more accessible than it once was, due to changes in cultural attitude, information availability, and the rise of effective but low-hassle and more affordable options, so our potential patient population is getting younger and younger,” Dr. Van Dyke stated.

“Clear + Brilliant is an excellent option for the younger patient,” she expressed. “Sessions take maybe 20 minutes. It is not very aggressive so treatment is comfortable without anesthesia, and downtime is non-existent. This group of patients doesn’t usually need much, but their skin is ripe for refreshing because they’re still young. With regular treatment and good self-care, regular sunscreen use, etc., such a patient may maintain a healthy, youthful glow for quite a long time.

“If younger patients come in with textural issues and pigment, I go with the Clear + Brilliant Perméa – the 1927 nm wavelength,” Dr. Van Dyke advised. “If there is some acne scarring or superficial dermal issues, I’ll go with the 1440 nm because I can go deeper.”

For darker skin types, Perméa may be better. “It treats superficially and doesn’t target melanin, so it is safer for that patient group,” she noted. “However, if their issues require a more aggressive approach, I will do six sessions over six months using the 1440 nm wavelength. For post-pregnancy or for melasma in darker-skinned patients I will often do Perméa plus topical lightening or brightening agents, same number of sessions and interval.”

Although the outcomes are more subtle than what is seen with more aggressive treatments, patient satisfaction is still excellent – high enough to turn otherwise skeptical or hesitant patients into believers in aesthetic medicine, Dr. Van Dyke stated. “This technology has been a true gateway treatment, opening doors for patients since we brought it into our practice. Once people have experienced Clear + Brilliant, they’re often eager to try something else.”

That said, the gateway potential for Clear + Brilliant is crystal clear. According to Dr. Van Dyke, “A typical scenario is this: A 30-something-year-old patient comes in wanting a more aggressive treatment, but that may not be appropriate, or they may still be a little uncomfortable with the idea. We give them a Clear + Brilliant treatment and they get comfortable with the experience, then later we move them to something like Fraxel Laser (Solta Medical), then back to Clear + Brilliant every three or four months as a maintenance treatment.

“Or, if downtime is an issue and they want to go a bit more aggressive but aren’t entirely comfortable, we may do one session of Fraxel and then a few months of Clear + Brilliant, and see where we go with minimal lifestyle impact. Fraxel and Clear + Brilliant work extraordinarily well together.”

Dr. Van Dyke added that Clear + Brilliant also works well with injectables and/or skincare regimens. “That’s how Clear + Brilliant is so versatile, you can do much with it as a stand-alone, but use it with other things as well.”

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Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

I recently read Gloria Kim, MD’s excellent essay “How Yelp made me a better doctor,” a runner-up in the Medical Economics 2018 Physician Writing Contest. Kim, an OB/GYN, was devastated when a patient wrote a scathing review of her on Yelp. Kim had provided thorough, caring service for a patient and had certainly done nothing to warrant the fury that emanated from the review, “skewering everything about me and my office with vehement gusto.”

Kim spent a great deal of time thinking about this negative review. She pored over the patient’s chart. She perseverated on the review for months. The review devastated Kim. A consciousness and caring physician, she writes in her essay that “I really wanted [my patients] to like me.”

As I read this essay, my heart ached for Kim, and for every physician who faces the dilemma of “asymmetrical rewards.” In other words, all the hard work and effort put into 99 percent of your day can completely fade away in response to one single negative response or complaint.  

In the case of Kim, the good work that she did “spending sometimes over an hour with a distressed patient…telling me of her disintegrating marriage” or “another patient [telling me] of her teenage son’s horrific and tragic death” was meaningless compared to one patient who was dissatisfied with her, for no obvious reason.

While Kim was able to make the best of her situation, using the negative review as an opportunity to make improvements in her work flow, other physicians may find themselves feeling burned out when they face angry patient reviews.

But what if I told you that the occasional negative patient complaint online could actually turn out to be a good thing for your reputation?

Guess what? It can!  

Pratfall effect

When I say a negative online complaint can help a physician’s reputation, I’m not talking about a doctor with a page full of one-star reviews but rather a Gloria Kim-type of physician with many four- and five-star reviews. Think a high-quality, caring physician who just has an off day, or runs across a difficult patient that even TV’s Marcus Welby couldn’t make happy and ends up with a less-than-stellar review.  

You see, there’s this interesting little concept in psychology called “pratfall effect.” It turns out that we like people who have a few flaws much better than we like people who seem “perfect” or invincible. So, if a physician has nothing but five-star reviews, they may seem intimidating and be perceived as less likeable than the doctor that has mostly five stars and one or two one-star reviews. So, believe it or not, having a bad review from time-to-time can actually gain you patients!

Bad reviews bring out your champions

The other positive thing that can happen when we get a negative review is that the occasional detractor can bring out our champions. Most of the time people who really like us don’t take the time to write us reviews. But when patients who like their doctor see a vicious review of a doctor that they care about, then look out! Patients will often rush to that doctor’s defense, and you will then see a string of positive reviews that quickly neutralize a negative review.

 Although this may happen organically, we can always improve our online reviews by asking our patients to write reviews of our practice. There is nothing wrong with this – “the solution to pollution,” after all, “is dilution." The more positive reviews that you have online, the less likely that a negative review will be noticed.

Take control

Another way to negate unwanted comments on review sites is to take control of your social media and web presence. Marjorie Stiegler, MD, an expert on social media for physicians and the author of The Social Prescription: How Savvy Doctors can Leverage Digital Platforms for Professional Success points out that the more web presence you have, the more likely it is that when someone searches for your name or practice, your own sites thatyou control show up ahead of doctor rating review sites.  

It’s much easier to do this than you might think. Start by making a Google page for yourself and for your business, as well as a Facebook page. You can add a Twitter account or Instagram if you feel ambitious. Create a website using an online service that makes it easy to do yourself (which can be remarkably affordable) or hire a professional website developer to help you. Many online websites even offer free SEO (search-engine optimization) services that allow search engines like Google to find your website when people are searching for keywords that you have linked to your site (“family physician” or “general surgeon” for example).  

Acknowledge your feelings

Finally, remember that although negative reviews are inevitable and are unlikely to actually hurt your practice, they do cause physicians emotional distress. When we get a negative review or an angry letter from a patient, we need to acknowledge our feelings – it can hurt. We all want to be liked, and we work hard for our patients. 

Usually patient complaints are related to some type of misunderstanding or confusion, but they are rarely something that the patients are willing to work on if they are at the point of firing off angry letters or reviews. As physicians, we mustreconcile ourselves to this – it is impossible to please everyone, no matter how hard we try. Perfectionism is an impossible ideal, and if we expect perfection from ourselves, we will inevitably fail. Seeing ourselves as failures, or inadequate as physicians, is one of the major hallmarks of burnout.

All the more reason that psychology can help! Kim suggests in her essay that residency training should include a psychology and indeed, psychology is something that can truly benefit all physicians. We can learn how to cope with the powerful emotions that patients can elicit in us and learn how to process them in a healthy way. We can also use psychology to help our patients more effectively, and hopefully mitigate their urge to write those negative reviews that we hate so much.

In the next article in this series, we will discuss using psychology to try to prevent bad reviews – by using deep listening and emotional mirroring to show empathy and create a more efficient yet satisfying patient visit. 

Rebekah Bernard is a family physician and the author of Physician Wellness: The Rock Star Doctor’s Guide. Change Your Thinking, Improve Your Life. She can be reached at her self-titled site, Rebekah Bernard, MD.

Sponsored

The Discovery Pico Plus laser by Quanta System (Milan, Italy) packs so much speed and power, some say it is the ‘Dirty Harry’ of tattoo removal lasers. The laser creates a bloodless fracturing effect that crushes pigment into microparticles by applying up to 0.8 GW at 532 nm and 1.8 GW at 1064 nm.

“This allows us to fire more energy, and disrupt some of the deeper pigments,” said James Chao, M.D., a plastic surgeon in San Diego, Calif. “Think of it like a gun, you’re using a 44 Magnum, so the bullet that you discharge is more powerful.”

Having had a very good experience with Quanta’s Q-switched Q-Plus C, Dr. Chao’s practice moved up to the Discovery Pico Plus because of the exceptionally quick pulse durations available – 400 ps at 532 nm and 450 ps at 1064 nm.

The Discovery Pico Plus laser allows stacked treatments, cutting the number of sessions required in half. “While removing a tattoo with a Q-switched nanosecond laser takes up to 12 treatments for difficult cases, the picosecond laser usually requires six to eight applications,” said Dr. Chao.

RELATED: Discovery Pico advances scar treatment and skin rejuvenation

According to Dr. Chao, “The concept behind stacking is that if you apply energy into the skin, the skin will resorb some of that energy.” With many lasers, this dynamic creates collateral damage – a burn. “But now, hitting the ink with a faster picosecond pulse allows for two treatments at one sitting,” he said.

“You can let the patient recover for 20 minutes, then treat the tattoo again without creating collateral damage. You want to selectively shatter those cells that have ink in them while preserving those that do not,” Dr. Chao further explained.

The 1064 nm wavelength targets dark green and black pigment. The 532 nm wavelength targets red, orange and yellow ink, and the 694 nm Q-switched ruby wavelength targets green and blue ink. “You need three active wavelengths to cover almost all colors,” Dr. Chao stated. “Many lasers only have two, with the other wavelength deriving from inefficient dye conversion.”

Dr. Chao likes Discovery Pico Plus’s large spot sizes because many of his clients have full tattoo sleeves.

“Another unique aspect of this laser is that the spots are not only round, but also square and fractional,” Dr. Chao continued. “It is very easy to line up squares and overlap very precisely, so you get a much more consistent treatment.” He also likes the fact that the system needs no expensive dye packs or other consumables.

On average, Dr. Chao’s practice performs around 100 Discovery Pico Plus treatments per week. “With the Quanta technology, we’ve been able to offer what we call ‘we’ll treat you for free.’ If we tell a patient it will take a certain number of sessions to remove a tattoo and it actually takes more, I offer the patient free treatments for the next year. That’s how much confidence we have in the laser. To date, no one has had to collect on this offer.”

Sponsored

The future of aesthetics is regenerative medicine – the harnessing of the body’s often dormant natural mechanisms to stimulate healing and maintain youthful function. Adipose tissue, rich in progenitor cells and stem cells, is the business of Carlsbad, Calif.-based Millennium Medical Technologies (MMT), whose efforts in this arena are designed to not only shape the leading edge of regenerative aesthetics and medicine, but help others who may be developing their own technologies and ideas.

MMT is dedicated to the successful harvest of fat for body shaping, processing and transfer. According to David Angeloni, chief technology officer and president at MMT, the company began in aesthetic medicine with liposuction and autologous fat transfer products, before evolving into a driver of regenerative medicine.

“As we grew and learned from the physicians we worked with, we saw a need for better, safer, more efficient and cost-effective methods of harvesting and handling the current building blocks of regenerative medicine, adipose tissue and the powerful components within,” he explained. “This is changing how medicine is practiced within the aesthetic industry, but also medical fields outside of cosmetic, plastic and reconstructive surgery, such as dermatology and orthopedics.”

MMT’s flagship device, AcquiCell™, features a vibrating cannula for gentler and less invasive harvesting and transferring of fat without the use of expensive consumables or time-consuming processing. This saves time and money without sacrificing safety or quality.

“Another key product, Lipo-Loop®, works perfectly with AcquiCell, but both stand alone as well,” Mr. Angeloni said. “Lipo-Loop creates a closed system that is simple and easy to use for fat grafting from tumescence to harvest to transplantation.”

The company also manufactures a wide variety of ancillary products such as tubing, pumps, cannulas and reusable canisters. MMT devices are FDA-cleared for fat collection and transfer.

Mr. Angeloni also noted that the company has some exciting new products in development planned for release in late 2018. “These products will help standardize autologous fat grafting procedures, which are currently fragmented due to differing products and opinions.”

In addition to manufacture and distribution of liposuction and autologous processing devices, MMT’s self-stated mission is to provide comprehensive solutions and support for harvesting, processing and deployment of FDA 361-compliant tissues and cells, as well as device development and support services.

“Our products are designed to meet FDA minimal-manipulation criteria”, said Mr. Angeloni. “There is a homologous-use component to 361 regulations, but that is not at the manufacturer level, it is between the physicians and their patients. We make no claims about the cells or what they do, or how they should be used.

“As medical researchers labor to discover additional approaches to harnessing and utilizing the remarkable regenerative properties of these tissues, we’re facilitating their work by offering safe, effective, efficient harvest and transfer modalities,” he continued. “We put science first and won’t sell or manufacture a product we wouldn’t use on ourselves or our families.”

While the science is still in its infancy and there are certainly regulatory minefields to navigate, Mr. Angeloni is excited about the future of MMT and regenerative medicine as a whole.

“There is tremendous potential, but scientists and physicians alike need viable material to work with,” he said. “We provide that for them, playing a part in the shape of things to come.”

Still a popular first-line therapy, microdermabrasion is performed daily in dermatologic and aesthetic practices, as well as medspas worldwide. Ultrapeel II® from Mattioli Engineering Corp. (Arlington, Va.) stands apart from diamond-tipped microdermabrasion systems by providing safe, effective and hygienic treatments via sterile disposable consumables rather than reusable components that require repeated sterilization. Additionally, physician intervention is largely unnecessary during sessions, making the device ideal for use by ancillary staff.

Ultrapeel II is one of the most reliable and versatile devices of its kind on the market. According to dermatologist Lawrence Green, M.D., medical director of the Aesthetic & Dermatology Center in Rockville, Md., and associate clinical professor of dermatology at George Washington University School of Medicine (Washington, D.C.), “We tried several different systems, but once we tried this one we stuck with it. It is a completely closed, sterile system. Everything that touches a patient has never been used on any other patient.”

Flow regulation with Ultrapeel II is designed to be as efficient and clean as possible; thus, the microdermabrasion crystals flow beneath the disposable treatment tip and are suctioned away. Vacuum power and crystal flow can be adjusted to accommodate a variety of needs and is completely safe for users and patients alike. Pressure of the tip on the skin is adjustable from levels one to ten as well.

“Modulation of crystal flow and tip pressure allows us to accommodate different treatments or individuality of skin type, whether rough or sensitive, oily or dry, making it very versatile,” Dr. Green said.

Ultrapeel II also features a built-in pedal-operated air compression, enabling deeper treatments. Among the variety of treatable conditions are aging skin, wrinkles and superficial rhytides, minor scarring and stretch marks, enlarged pores, localized pigmentation, acne and blemishes, as well as a pre-treatment before other therapies.

Chelsea Madill, a licensed clinical aesthetician at Dr. Green’s office, performs microdermabrasion with Ultrapeel II regularly. “I think this device sets us apart from other offices,” she stated. “I find the safety and sterility extremely appealing. Once I mastered the machine, I fell in love with it. It is so easy to provide even, consistent treatment because I can see where we’ve treated, which also shortens procedure time and saves powder because we’re not over-treating.” According to Ms. Madill, crystals left on the surface after treatment can be massaged into the skin for additional exfoliation.

Patients love Ultrapeel II microdermabrasion. “Feedback is always very positive,” Ms. Madill reported. “Patients I’ve spoken with who have had other microdermabrasion treatments say this is better and more efficient, and provides a smoother result. Those who have used this for years often try other things, but then come back because they just love the Ultrapeel II. The results are outstanding.”

“As a community we’ve been doing microdermabrasion for decades and some things have changed over that time,” Dr. Green pointed out. “Ultrapeel II definitely has new features that other machines don’t, but Mattioli has maintained some of the features other devices have moved away from, that in my opinion improve patient safety. It merges the best of the old and the new to deliver safety, sterility, consistency and versatility.”