This week in aesthetics, physicians discuss practice management concerns, including social media strategy and essential office policies; Dr. Jill Waibel explains innovations in scar treatment; Cheryl Whitman highlights the importance of staff training; Dr. Anna Chacon talks topical botulinum toxin; and Drs. Gary Linkov and Wendy E. Roberts detail how to start a hair practice.

While approaches to social media vary, defined brand, mission, and personality are musts for practice success.

Dr. Jill Waibel offers a multi-course menu of treatments, with the ablative fractional laser as the main course, designed to improve scar color, collagen, and discomfort.

Create A Winning Team, Improve Staff Performance

This week, Cheryl Whitman highlights the importance of creating a well-trained staff through continued training opportunities.

Dr. Anna Chacon examines the possibility and likelihood of a topical botulinum toxin to join the injectable anti-aging ranks.

Drs. Brook Jackson and Vivian Bucay share essential office policies they say keep their practices running smoothly and efficiently.

Hair loss is a hybrid disorder, requiring a medical foundation in how to diagnose hair loss and skill sets in procedural treatments.

Articles

This week in aesthetics, we highlight social media for the aesthetic physician, topical botulinum toxin and more. 

This Week in Aesthetics: October 19-23

Social media is one of the main avenues for catching a potential patient’s attention. Many are not only realizing the importance of having a social media presence in 2020, but also the need for authentic, educational, and entertaining content from the original skincare influencers, aesthetic physicians.

In a presentation at the recent virtual meeting of the American Society of Dermatologic Surgery (ASDS), Anna D. Guanche, MD, Elizabeth Bahar Houshmand, MD, Shereene Z. Idriss, MD, and Doris Day, MD, discussed how they have personally made social media work for their practices.

And success on the platforms can look different for everyone.

Instagram is the standout winner for the aesthetic specialty, according to the panelists, due to its highly visual nature and ability to reach audiences in multiple ways.

With posts, reels, stories, and highlights, Instagram lets you upload content in ways that are most relevant to viewers and then enables cross-promotion through other sites like Twitter, LinkedIn, YouTube, and newcomer, TikTok.

But just having the page itself is not enough. Effective accounts have a solid brand identity and mission.

Posting high-quality content and images and personalizing accounts to give followers a look into life outside of the practice can also prove effective.

However, finding success online takes many different forms.

For Dr. Guanche, success is multi-platform and focused on millennials and Gen Z. With her use of TikTok, she has connected to her audience through her personality, trends, challenges, and engagement. She then disseminates that content to her other social media accounts.

Compare that with Dr. Idriss who focuses on Instagram and the educational benefits of answering followers’ questions and explaining industry jargon.

While these approaches are different, both have seen massive success because they have stayed true to their brand identities and mission.

Social media is a process, and as the panelists explain, can be draining when maintaining it isn’t enjoyable.

By making the accounts a reflection of your personality and brand, posting multiple times a day becomes less of a task and instead something to look forward to.

While approaches to social media vary, defined brand, mission, and personality are musts for practice success.  

Making Social Media Work

Scars are multimodal problems and need customized solutions, Dr. Waibel emphasizes, which are determined by color, size, and location.

“Is it red, brown, or white? For red scars you need to pick a vascular laser first,” she says.

A pulsed dye laser is her device of choice for smaller treatment areas. For larger areas, it’s the IPL because it can cover a larger area in a shorter amount of time.

“Then I'll follow up with the ablative fractional CO2 or erbium in the same day of treatment, and then a topical application of Kenalog,” says Dr. Waibel.

Notably, she always performs the nonablative laser treatments first.

Dr. Waibel approaches brown scars, which are more frequently seen in skin of color patients, with the 1927 nm laser, calling it “magical” for hyperpigmentation. She follows that up with the ablative fractional laser followed by laser-assisted drug or molecule delivery.

“Hypopigmentation is the toughest,” she says. “I just published an article on this.1 Sometimes laser alone can repigment [the skin]. If you don't get laser repigmentation alone with laser, you can add laser-assisted delivery of bimatoprost. And you drip this in immediately postoperative laser and then the patient takes it home and does it twice a day, anywhere from 10 to 14 days.”

After color, the next big consideration for determining scar treatment is collagen: atrophic vs. hypertrophic scars.

“My favorite treatment for atrophic acne scars is doing the ablative fractional,” says Dr. Waibel.

To treat a specific acne scar patient, she describes using punch biopsies, fractional ablative laser, Z-plasty, and fractional ablative laser again to achieve around 80% improvement.

For surgical scars that are thick and hypertrophic, she says she uses the pulse dye and ablative fractional laser. However, for scars that are less than three months old, she’ll use the pulse dye and fractional non-ablative.

For keloids on the ears, Dr. Waibel says she performs a shave biopsy, leaving just 1 mm of the scar, which she then lasers and treats with Kenalog.

“If they haven't had surgery, this can be a permanent improvement. [However,] I always tell patients, keloids can recur,” she says.

For catastrophic scars that result from trauma, Dr. Waibel recommends performing scar treatment in the operating room to avoid the possibility of having the smell make a patient’s posttraumatic stress worse.

Beyond appearance, scar treatments can offer improved range of motion and reduce scar- related discomfort.

“We see lots of patients [for] range of motion, especially in the digital webs, the feet, and neck. But not only can we help range of motion, we can help our patients walk again after treatment,” she says.

Some scar patients have a significant amount of itching, especially in the first year posttrauma. Sometimes it’s the itching, not the scars, that cause the problems.

“And then one of the greatest honors of my career was treating Kim Phuc, the napalm girl…,” says Dr. Waibel, who performed a series of eight treatments with the pulse dye, IPL, thulium, nonablative fractional, laser hair removal, and Botox.

According to Dr. Waibel, this combination treatment brought her pain down from a 10/10 to a 3/10.

“Dermatologists have entered the trauma center,” says Dr. Waibel. “Treating scars really changes lives and if you're in front of someone who is suffering and you have the tools at your disposal to alleviate suffering, you act.”

Seago M, Shumaker PR, Spring LK, et al. Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations. 

The most effective approach to scar rehabilitation requires strategic device selection, technique, and order of treatment.  

Scar Treatment Combinations

From surgical techniques to silicone adhesives, scar management techniques have been around for years. It’s the addition of the ablative fractional laser that has changed the game, according to Jill Waibel, MD, a dermatologist in Miami, Fla., who discussed her strategic approach to scar management at the virtual meeting of the ASDS 2020.

“The real innovation in scars have been ablative fractional lasers,” says Dr. Waibel. “I tell patients it's like boiling water on the stove with steam coming out. We're literally steaming away scars.”

Add to that the benefit of using the ablative comes from the CO2 or erbium laser for drug delivery, and physicians can achieve an enhanced therapeutic response, she says.

The formation of any scar is affected by multiple factors, including level of trauma, location, and genetics. As a result, the best treatment approaches include a combination of therapies that address color, collagen, and discomfort. Dr. Waibel says she likes to use a specific analogy to explain it to patients.

“I tell patients it's like going out to dinner,” she says. There’s an appetizer, main course, and dessert that together create the ideal scar treatment menu.

The appetizer is determined by scar color. If it’s red, she uses pulse dye laser, intense pulsed light (IPL), or broad band light (BBL).

“If it's atrophic I use a nonablative fractional. If it's hyperpigmented I tend to use a thulium,” she says.

The main course is usually the fractional ablative CO2 or fractional ablative erbium lasers.

For dessert, she chooses from an extensive list of laser-assisted delivery techniques and molecules, from 5-Fluorouracil (5-FU) and poly-l-lactic acid (PLLA) to z-plasties and punch biopsies.

Before choosing the treatment menu, however, physicians need to understand the scar they’re treating.

“The first thing you have to do when treating scars is figure out the etiology. Is it acne, surgical striae, burn, or trauma? And then the physical classification can be atrophic, keloid, hypertrophic, or hypertrophic contracture,” says Dr. Waibel.

Innovations in Scar Treatment

Create A Winning Team – Improving Staff Performance

A Staff With Average Training Means A Practice With Below Average Performance.

One of the most important parts of an Aesthetic Medical Practice is your staff. Without a strong, well-trained staff, your day and your practice’s performance can be a nightmare. An inadequately trained staff results in lost patients, lost profits, and an endangered reputation. Engage in continuous training. Make customer service a priority and train your staff in what makes a satisfied patient. In addition, make sure your staff is exceptionally well trained in the procedures your practice offers, the products your practice sells, and the credentials your team holds. They should be able to answer patient questions in a friendly, informed, and professional manner in terms the patient can understand. Remember, an outstanding staff leads to a strong bottom line.

This tip is adapted from “Beautifully Profitable, Forever Profitable,” by Cheryl Whitman.

For more practice management tips, click 

Have a practice management question or topic you’d like us to cover? Let us know!

Create A Winning Team, Improving Staff Performance

Approximately five years ago, there was much buzz about the possibility of a topical neurotoxin. The advantages were obvious: Needle-phobic patients would have an option, and, perhaps, it could have the same lasting effects as injectable neurotoxin without pain or discomfort.

So where are we now in the development of this new neurotoxin modality?

I recently ran into a pharmaceutical company representative who offered this simple answer: “Topical Botox—they tried, but it never worked.”

The disadvantages of an injectable neurotoxin include more than just pain, which affects a significant patient population, including children who receive the injectables for cerebral palsy and neuromuscular disorders. The possibility of switching to a topical from an injectable may also save on costs, as injectables require additional preparation of mixing the product with saline, using ultra-fine insulin syringes, topical lidocaine, gauze, cotton-tipped applicators, sharps containers, and other devices needed close by when administering an injection.

In initial phases, newer methods of a topical botulinum toxin formulation showed evidence of bioactivity in small clinical studies.

 While there are risks associated with both treatments, risks of topical delivery appeared to be less than those with injectable therapies. Refining the delivery of a topical botulinum toxin using nanotechnology is widely anticipated and standardizing techniques and delivery systems is a goal for the near future.

Initial evaluation showed that topical botulinum toxin is highly resistant to absorption transdermally. In the treatment of axillary hyperhidrosis, a topical botulinum toxin cream was evaluated as a new, noninvasive modality to enhance skin penetration.

 A clinical study of axillary hyperhidrosis found that a topical liposomal botulinum toxin A cream enhances drug delivery and is cost-effective, painless, and innovative. Results showed decreased sweating and improved patient satisfaction after several weeks of treatment of axillary skin without adverse effects.

Hyperhidrosis of the palms, axillae, and plantar feet is a common, burdensome, occupationally bothersome, and possibly even a hazardous condition to deal with. Treatment modalities are cumbersome and difficult to get a hold of, ranging from topical antiperspirants to systemic therapies such as anticholinergics, as well as more invasive interventions such as botulinum toxin injections and thoracic sympathectomies. While intradermal injections of botulinum toxin are effective, they are difficult to gain insurance approval for, and painful, as many injections are required over the surface area being targeted. Iontophoretic administration of Botox has been described as the toxin would enter eccrine sweat glands via sweat ducts and sweat pores.

 While the rationale seems promising, the feasibility of the topical treatment of botulinum toxin assisted through the application of an electrical gradient and low-frequency ultrasound needs further exploration.

A study published by the American Society of Dermatologic Surgery evaluated the use of a topical botulinum toxin type A gel for the treatment of lateral canthal lines.

 It appears to avoid a host of complications that accompany injections, including bruising, potential infection, redness/erythema, and pain. At the study’s conclusion, it was found to demonstrate improvement of lateral canthal lines and was found to be well-tolerated in patients, with no treatment-related adverse effects reported.

There are also alternatives investigated compared to Botox, including acetyl hexapeptide-8, which can be applied topically as a cream or serve as an injectable therapy.

 Argireline has less toxic potential than Botox. It has been studied in mice as an oil-and-water emulsion twice daily and was found to stimulate genesis of collagen type III when applied twice daily for six weeks. A total of 10% Argireline applied twice daily to 24 women 30 to 60 years of age for 60 days showed a decrease in trans-epidermal water loss compared to placebo, which caused a significant increase in the moisturization of the stratum corneum.

 Acetyl hexapeptide-8 may serve as a possible alternative for Botox because it can be used as a topical agent and has been found to have anti-aging properties. It also appears to have improved safety compared to Botox.

Several studies have examined other topical products that claim to achieve similar or better outcomes than botulinum toxin type A in the treatment of wrinkles. However, no clinical data or objective measures have been found to support these claims.

Despite the current economic struggles as a result of the pandemic, there continues to be an increasing demand for minimally invasive cosmetic treatments to slow the aging process. Injections of botulinum toxin continue to be the most common nonsurgical aesthetic procedure performed. Offering a different benefit, Revance Therapeutics has been working steadily on developing a neurotoxin product, Daxibotulinumtoxin A, with a six-month vs. three to four months lasting effect.

Although research and clinical studies have probed into a possible topical botulinum toxin, there has not been FDA approval of such a product at this time, and a longer-lasting neurotoxin appears to be more feasible and nearer in the pipeline compared to a topical product.

Collins A, Nasir A. Topical botulinum toxin. 

Saffarian P, Fooladi AAI. Topical Botulinum Toxin: A Non-invasive Way for Treatment of Muscle Disorders. 

Lueangarun S, Sermsilp C, Tempark T. Topical Botulinum Toxin Type A Liposomal Cream for Primary Axillary Hyperhidrosis: A Double-Blind, Randomized, Split-Site, Vehicle-Controlled Study. 

Lim EC, Seet RC, Chow A, Oh VM, Ong BK, Wilder-Smith EP. Topical botulinum toxin to treat hyperhidrosis? No sweat! 

Brandt F, O'Connell C, Cazzaniga A, Waugh JM. Efficacy and safety evaluation of a novel botulinum toxin topical gel for the treatment of moderate to severe lateral canthal lines. 

Satriyasa BK. Botulinum toxin (Botox) A for reducing the appearance of facial wrinkles: a literature review of clinical use and pharmacological aspect. 

Beer KR. Comparative evaluation of the safety and efficacy of botulinum toxin type A and topical creams for treating moderate-to-severe glabellar rhytids. 

Carruthers J, Solish N, Humphrey S, Rosen N, Muhn C, Bertucci V, Swift A, Metelitsa A, Rubio RG, Waugh J, Quiring J, Shears G, Carruthers A. Injectable DaxibotulinumtoxinA for the Treatment of Glabellar Lines: A Phase 2, Randomized, Dose-Ranging, Double-Blind, Multicenter Comparison With OnabotulinumtoxinA and Placebo. 

Dr. Anna Chacon examines the possibility and likelihood of a topical botulinum toxin to join the injectable anti-aging ranks. 