SPSSCS Central Office • 11262 Monarch Street, Garden Grove, CA 92841 • www.spsscs.org562-799-0466 or 800-486-0611 • Fax 562-799-1098 • email: info@spsscs.org

Official Publication of the Susan Eldridge, Editor Winter2017

S O C I E T Y O F P L A S T I C S U R G I C A L S K I N C A R E S P E C I A L I S T S

SPSSCS Mission

The Society of Plastic Surgical Skin Care

Specialists is a voluntary, non-profit organization

dedicated to the promotion of education,

enhancement of clinical skills and the delivery

of safe, quality skin care provided to patients.

Susan M. EldridgeSecretary/Treasurer

Charlott Chotsie AdneyMember-At-Large

Alicia Barrera, RST, RMA, NCEAMember-At-Large

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SPSSCS Board of Directors 2016–2017

From theEditor’sDeskSusanEldridge

all is atime for me to review the year’s eventsand experiences, reorganize and begina plan for the following year. Wediscuss and tentatively schedule ourspecials and events for the upcomingyear. I look back on what we did, howwe did it and if we will do it again.How can we make it better?

This issue of the Specialty SkinCare newsletter provides importantinformation and tools that can be used by all to have a rewarding andsuccessful 2017. Dr. Dan Mills,President of the ASAPS, has shared his thoughts on the future direction of plastic surgery and stresses theimportance and value of the role ofskin care within a practice. Dr. Millsshares a great tool to follow, theBeauty for Life Pyramid, which creates a plan to continue professionalrelationships with patients throughoutthe years.

Specialty SkinCare

Continued on page 11

Shay Moinuddin, MHA, RN, CANSMember-At-Large

Belinda Hammergren, RN, BSN, CMMParliamentarian

Nina SpadaccinoImmediate Past President

Craig W. Colville, MDASAPS Advisor

Renato Saltz, MDASAPS Advisor

am deeply honored tohave been selected by my peers asPresident of The Aesthetic Society.ASAPS is the organization that Irecognized almost 30 years ago as the gold standard in my field. Ihad the benefit of the best plasticsurgeons in the nation as mymentors within ASAPS. Theydemanded that I maintain a high level of patient satisfaction and patient safety,and pushed me to improve my surgicalskills each and every time I performed an operation.

Today, along with other colleagues at the Society, I have the privilege ofmentoring many young surgeons as fellows.The practices they visit are much morecomprehensive than the ones I saw on myfellowship rotations. And much of that isdue to the emergence of medical skin care.Because of skin care professionals, we areable to offer our patients a continuum ofcare, helping them look and feel their bestthrough non-invasive, minimally invasiveand surgical procedures: In my practice Irefer to this philosophy as the “Beauty forLife Pyramid”.

My goal for every patient isto develop a plan that will helpthem look their best at everystage of life. This begins at the base of the pyramid with the fundamentals of health and wellness: Good nutrition,adequate sleep, plenty ofexercise and good hydration.

This also includes avoiding things that weknow are detrimental to our health andappearance such as smoking, sun exposure,alcohol in excess, too much stress, etc.

The next levels of the Beauty for LifePyramid are where good skin care, a high-quality skin care product regime andmedi-spa procedures come in.

The first thing to combat aging is topreserve and rebuild the collagen in theskin to combat wrinkles. The best plan isearly treatment to maintain skin and tissueelasticity and protection from wrinkles.Botox can be used prophylactically toreduce the repetitive muscle contractionsthat create wrinkles. There have also beenrecent articles that discuss what are referredto as “sleep wrinkles.1” This helps patientsbe more aware of everyday habits that

Surgical Skin Care and Aesthetic Surgery: A Logical Combination for Our Patients

Daniel C. Mills II, MDPresident, The American Society for Aesthetic Plastic Surgery

IF

Lizabeth Clouse, RN, CPSNPresident

Cindy Steele, LA, NCEAPresident-Elect

Donna ErbVice President

Continued on page 10

would like to take thisopportunity to thank all the members of SPSSCS for allowing me to serve as your President.

As we approach the coming months,there will be many changes. Change in the weather means change in how we not

only take care of our skin—but how we advise our patients to takecare of theirs. It is important to consider the individual and what is best for them.

Another possible change is a change in our lives and what maybe the next step in our career. After working in one place for thepast 12 ½ years, the opportunity to move on was given to me and I took it with optimistic anticipation. I believe it will be the best ofmy career. I want to thank Dr. Gene Sloan and his wife, Dr. MimiLee, for giving me this wonderful opportunity.

I I have also experienced changes in my personal life: the loss of a dear friend, Dr. Frank “Buddy” McCutcheon. Dr. McCutcheonwas a talented plastic surgeon who I had the opportunity to workwith in Little Rock, prior to his relocation to Asheville, N.C. Hetaught me a lot about the importance of skin care in the overall care of the plastic surgery patient. His death is a great loss to theaesthetic community.

I would encourage all of our members to plan to attend ourAnnual Meeting from April 25–28, 2017 in San Diego, CA. In addition to an exceptional program, there will also be plenty oftime to network with your colleagues. Please spread the word aboutthe SPSSCS to your colleagues in the plastic surgical skin carecommunity. We invite them all to attend!

Enjoy the holiday season and make time for the people you care about! ▲

THE PRESIDENT’S MESSAGE

Liz Clouse, RN, CPSN

Are You Interested inAdvertising in

Specialty Skin Care?

PLEASE CONTACT THE

SPSSCS CENTRAL OFFICE

FOR COMPLETE INFORMATION

562-799-0466

OR VIA E-MAIL

MISSY@SURGERY.ORG.

MEMBER PROFILE:

Meghan Rundell BIRMINGHAM, MI

t has been 16 years since I startedworking in this industry and I still have

this same thought at least five times a day. I started off as acosmetologist and found my passion for skin care and it hasflourished since that day.

About 10 years ago, I started noticing a void between myemployer’s passion, and lack of skills to effectively run a businessand succeed. It was then that I took my business education andstarted working with small companies to help the owners grow their businesses and become successful! That is where I truly foundmy passion and excitement! I have been so fortunate to work withsalons, day spas, Forbes 4 and 5 star resorts, and recently withmedical practices.

I enjoy learning new techniques and technologies and I amconstantly amazed not only with what is trending but also theevolving technologic approaches to skin care! I love taking thatinformation which we glean from our annual meetings andnewsletters to help not only my current employer, but individuals as well, so that they may reach their fullest potential and success.

I love meeting new people and faces with the same passion anddedication so please, if you see me in San Diego, say hello! I cannotwait to meet you! ▲

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t all starts with our eyes. Our eyes are light meters,registering the amount of UV to which weare exposed. The light is registered by thepituitary gland which then releases POMC(proopiomelanocortin) which is cleavedenzymatically into signaling peptides, oneof which is α-MSH. The primary roll of α-MSH is that it binds to melanocortin 1receptor (MC1R). This attachmentstimulates the production and release ofmelanin.

The melanocyte is located at the basallayer of the skin, firmly attached to thedermal-epidermal junction. It is a long-lived, slow cycling skin cell. The implicationof this is if damage occurs to the cell, it willtake a long time to resolve. It is a dendriticcell, with long “arms” supplying up to 36surrounding keratinocytes with pigment.They work in synergy with the keratinocyte,forming part of the skin’s natural barrierfunction. It creates 2 types of pigmentation;brown pigment (eumelanin) and redpigment (pheomelanin). The production of pigmentation requires a lot of energyand therefore releases free radicals.

After α-MSH settles on themelanocortin 1 receptor (MC1R), themelanocyte is stimulated to producemelanin. The enzyme Tyrosinase oxidizesTyrosine, a non-essential amino acid(meaning it can be produced within thebody) used by cells to synthesize proteins.In this case, to create the melanosomecarrying the pigmentation. Then L-Dopaand Dopa Quinone create the melanin clearcolored granule. The melanin containingmelanosome then moves along themelanocyte dendrite and transfers to thekeratinocyte, when IPD (immediatepigment darkening) occurs. It is only upontransfer to the keratinocyte that themelanin granules take on a darkenedappearance. The pigment then settles overthe keratinocytes DNA to protect it fromUV exposure and radiation.

As the predominant cell of theepidermis, the keratinocyte makes up 70 to 80% of the cellular population. Workingin synergy with the melanocyte, it isresponsible for generating and maintainingthe skin barrier defense systems. It has an 8to 10 day life cycle from mitosis to arrivingin the stratum corneum, then 5 to 10 daysto desquamate (age dependent). Beinghydrophobic it repels water. It is the cellthat creates the epidermis, hair and nailsand has an unlimited stem cell source. Itcommunicates with all other cells withinthe epidermis and dermis controlling suchfunctions as activating the innate immunesystem.

The keratinocyte migrates from thebasal layer, through the spiny and granular,eventually metabolizing into a cornfield cell at the stratum corneum, eventuallysloughing off.

The residual pigmentation marks andblemishes left on the skin after years ofchronic and acute sun exposure is due toone or more of the processes going wrong.If the melanocyte suffers DNA damage, onemay have uncontrolled pigment production.If the cells are unhealthy, the melanocytedendrites may shorten, “dumping”pigmentation into the cells immediatelysurrounding it vs. evenly spreadingdistribution. If the keratinocyte DNA is damaged there may be a lack ofcommunication between the cells somelanogenesis is never “switched off.” The keratinocytes may also get saturatedwith pigment, causing excess pigment to accumulate at the dermal epidermaljunction, only oxidizing and appearing as pigmentation spots years later.

With an understanding of what cellsand systems are involved with pigmentationcreation, and what can subsequently gowrong, we now turn our attention to whatskin care ingredients we have at ourdisposal to correct the damage.

Vitamin A is one of the most important ingredients to be included in

a pigmentation regimen. As one of the keyregulators of DNA of the melanocyte andkeratinocyte, we can correct the damagedone through UV radiation or free radicalformation, and thereby see an improvementin the appearance of pigmentation.

Other important considerations areVitamin B3, niacinimide to stop the transferof pigment from the melanocyte to thekeratinocyte, Vitamin C to inhibit tyrosinaseactivity; Vitamin E, along with otherantioxidants, as free radical scavengers; andsunscreen to protect from further damage.Cosmetic Needling is a great tool to helpimprove the absorption of your topicallyapplied products and may result in a fasterresolution in the appearance of thepigmentation.

Some controversial ingredientconsiderations include the use ofHydroquinone, a powerful tyrosinaseinhibitor, but with complications of useincluding rebound pigmentation andtoxicity to all skin cells. Kojic acid isanother controversial ingredient that may cause fragmentation of DNA and skin sensitivity when used in the high percentages required to see animprovement. Alternatives would beSepiWhite MSH, where clinical studieshave shown its effectiveness at being amelanin stimulating hormone antagonist.

Candace is a Licensed Esthetician and MasterTrainer for DermaConcepts, exclusive distributor ofEnviron Skin Care in the USA, and hosts advancedtrainings on this pharmaceutical grade line. Sheholds certificates for internationally recognizedprograms including Advanced Skin Analysis,Dermal Needling and Oncology Esthetics, and is aproficient public speaker at medical and skin careconferences throughout the USA. Her belief is tonever stop learning, in hopes of sharing theknowledge gained by her continued studies. Born inSouth Africa, and having personal experiencebattling Melasma, she feels her passion for skin careis her biggest asset. She can be contacted atcandace@dermaconcepts.com ▲

MelanogenesisCandace Noonan, LE, COEI

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am aboard-certifiedgeneral surgeonand havespecialized in thetreatment of venousdisease of the lowerextremities for over

16 years. I have found that the key to goodresults starts with accurate examination anddiagnosis. The most common mistake Ihave seen from non-specialists is that theyoften treat the spider veins with topicallaser or sclerotherapy in presence of largeropy varicose veins.

DIFFERENTIATING VARICOSE VEINSFROM SPIDER VEINS

At consultation, ask about symptomssuch as leg pain, heaviness, cramping, andstasis discoloration. Most spider veins areasymptomatic. Symptoms may indicateunderlying venous disease. Then examinethe patient in a STANDING position.Many bulging veins will only be visiblewith gravity influence. I recommend feelingover the leg surface to palpate for ropyveins because smaller veins may not bebulging visibly but they can be palpable.Then complete the exam by palpating forpedal pulses to make sure the patient doesnot have arterial disease that may lead towound problem with any procedure. If thephysical exam finds varicose veins, thepatient may have venous reflux diseasewhich should be further evaluated by veinspecialist.

Healthy veins return blood from thelower legs to the heart and the direction ofvenous flow is going up against gravity.Our veins have one-way valves to assist thisflow direction. Patient with varicose veinsoften have incompetent valves. The mostcommon causes for incompetent valves are genetic, pregnancies, career withprolonged standing, and obesity. If thevalves are incompetent, the flow is pulleddown by gravity effect whenever thepatient stands and the downward venousflow is known as venous reflux disease.

The great saphenous vein (GSV) is themost common vein in the legs to have thisvalve issue. As the blood flow leaks downthe GSV, the flow will spread to itstributary branches causing them to enlargeon skin surface as ropy varicose veins.Without proper treatment, veins on theskin surface will continue to enlarge andspread; pressure will then transmit to the skin causing inflammation, itching,discoloration, and progressive ulcerationand blood clots. Because the surface veinsare caused by abnormal internal blood flow, treatments of the surface veins areineffective until the venous reflux is treated.Most GSV can now be ablated usingradiofrequency closure (also known asVenefit) or laser and it is commonlyperformed in the office/outpatient settingand is covered by most health insuranceproviders.

COSMETIC SPIDER VEIN TREATMENTIf the physical exam finds only spider

veins without any signs of varicose veins, most spider veins respond well tosclerotherapy injection. The advantage ofsclerotherapy over laser is that sclerotherapycan treat veins of different depth, size, and

color. If a vein is smaller than the needle,then sclerotherapy may not be effective. Iusually recommend those ultra-fine veins belasered. It is important to inform patientsthat results are NOT permanent becausetreatment cannot correct the underlyingcause of the spider veins related to geneticand hormone influence.

There are several popular sclerosant.Hypertonic saline is used for burnresuscitation and has high risk for skinnecrosis/ulceration when solution extravasatesoutside the vein. It is also painful so itshould be avoided. Glycerin is very thickand viscous and I have found it difficult touse due to higher injection pressure. I foundPolidocanol and sodium tetradecyl sulfatethe safest and both of them are approvedby FDA for sclerotherapy use. I preferAsclera (Polidocanol) because it does notcontain sulfur and does not bear the namesodium which patients associate withpainful hypertonic saline injection. Asclerainjection is almost painless. Polidocanol athigh concentration of 3–4% actuallycontains anesthetic effect. However, it isused at 0.5 to 1 % most of the time forspider vein injection.

Proper Evaluation and Treatment of

Spider and Varicose Leg VeinsMimi Lee, MD, FACS, RVT

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THE SCLEROTHERAPY PATIENTEXPERIENCE AND OUTCOME

If the solution is injected intravascularly,the patient should not have any pain.Another sign of intravascular placement isthat the solution should push the blood outof the vein, thus clearing it while injecting.When the needle is withdrawn, the veinwill refill and may become pink due toinflammation. I like using 32 and 33 gaugesneedles on a 3 cc luer lock syringe. I canaspirate a larger vein for blood return witha 32 g needle (but not 33 g) to confirmintravascular placement prior to injection of a larger vein. Patient should be restingcomfortably to avoid any movement. Ittypically takes 2–4 treatments to the samearea and treatment sessions are scheduledabout 1 month apart for best results.Patients are also advised to wear compressionof 20–30 mmHg for 3 days. Patients shouldexpect bruising which can make thetreatment areas look worse initially.

Other possible complications mayinclude hyperpigmentation, coagula,telangiectatic matting (formation of fine red veins), vasovagal reflex, and rarenecrosis. Hyperpigmentation can resultfrom combination of post-inflammatoryhyperpigmentation and hemosiderindeposit. Although studies have shownhemosiderin is a bigger factor forhyperpigmentation, I have found thatpatients of Fitzpatrick skin types IV andhigher also have higher risk of prolongedhyperpigmentation. Therefore, I recommendoffering a small test treatment to thesepatients to make sure they are comfortablewith the amount of staining before

performing full treatment sessions formaximal satisfaction. Patients should alsowithhold any minocycline and iron therapy.Larger darker patches of veins are usuallymore vascular and often will form thrombipostsclerotherapy and subsequent pigmentationrisk may be higher. Postsclerotherapythrombi/coagula can be drained by smallpunctures with needles once the clots areliquefied which is minimally 2–4 weekslater. Treatment of pigmentation, once itoccurs, is often unsuccessful and it takes along time to fade and, in rare cases, can bepermanent. Therefore, it is important toprepare patients with realistic expectations,especially the ones with higher risks forpigmentation.

Cutaneous necrosis is more commonwith hypertonic saline injections but should be rare with Polidocanol if injectedproperly. Necrosis may not be apparent for

several days. Less experienced injectorsshould avoid treatment to thinner skin areassuch as ankles and feet and be very awareof the location of the arteries to avoid those areas. I have also found patients onimmunosuppressants have higher risk ofskin blistering/necrosis with sclerotherapy.Patient should only have minimaldiscomfort from the needle puncture andno pain during injection. Any pain beyondthe puncture may indicate extravasations ofthe sclerosant and adjustment should bemade immediately by re-entering the veinor resite to another branch.

In conclusion, successful outcomes canbe achieved by selecting the rightcandidate for sclerotherapy and settingrealistic expectations for the patients alongwith accurate injection technique.

Dr. M. Mimi Lee received her general surgerytraining at University of Miami and has beenboard-certified since 1999. She is also certified invascular sonography (RVT & RPVI). Dr Leeestablished her practice in Little Rock after shemarried Dr. Gene Sloan, a board-certified plasticsurgeon from Arkansas. In 2002, she was theFIRST physician in Arkansas to perform the“CLOSURE” endovenous ablation treatment forvaricose veins. In addition to being an AmericanCollege of Surgeon Fellow, Dr. Lee is also a memberof American College of Phlebology which is amedical society with a mission to improve thestandards of practice and patient care related tovenous disorders. ▲

www.youngpharm.com

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n thefifty plus yearssince stem cellswere first identifiedand their potentialfor healingobserved,researchers have

worked diligently to understand them andharness their power. There have been manysuccesses along the journey so far, such asthe transplantation of healthy bone marrowcontaining adult stem cells into patientssuffering from leukemia and bone or blood cancers. There have also beendisappointments along the way, such asmany early generation topical antiagingcreams and treatments.

Many of the very early (1st generation)products used apple and plant stem cells.Theoretically, this held promise. In realitythere were barriers to success; but at thetime, there was little known about thespecific type of stem cells in human skinand what was required to turn them on.Plant based stem cells cannot penetrate thehuman skin due to their large size, and theyare not viable after being incorporated intoa topically applied cream that languishes inthe jar for months before use. The resultsprovided by these 1st generation productswere less than stunning. At best, theseproducts encouraged old, existing skin cellsto work a little harder, exhausting themeven more.

Clearly, the use of foreign stem cellswas not working, but activating the humanbody’s own dormant stem cells might.Research into stem cells continued with the focus on identifying what was neededto grow these cells (Growth Factors) andwhat was required to prod the dormanthuman stem cells to provide healing andrejuvenation. Research into growth factorsfocused on conditioned medium growthduring the 2nd generation. ConditionedMedia is a liquid media in which cells havebeen grown for a period of time. As theygrow, the cells condition the media bysecreting proteins, cytokines, and chemicals

into it. By studying the conditionedmedium, researchers could determine how different substances affected thegrowing stem cells. This highly potentmixture of secreted elements offered strongregenerative potential.

But, 2nd generation products still useda fire-hose approach to activation. Sincethe specific stem cell type and the specificproteins required to “turn on” the healingfunction of those stem cells had not yetbeen identified, 2nd generation productsused a soup of proteins which activatedeverything. Unfortunately, everythingincluded the potential to activate TGF-b, a potent cancer trigger.

By the 3rd generation of stem cell skincare products, the composition of thegrowth factors had been defined. Scientistswere narrowing down the types of stemcells that are linked to skin repair. By 2010,the master dermal stem cell had beenidentified. Snippert, et.al, concluded the“LGR6 Marks the Stem Cells in the HairFollicle That Generate All Cell Lineages ofthe Skin.1”

This was a significant step forward, butthere was still substantial effort neededbefore these products would live up to their potential promise. Third generationproducts still relied on the “activateeverything soup” to prod the stem cells intoaction. Patients saw minimal benefit fromthese products despite the marketing hypeprimarily due to the absence of an activatorwhich would “turn on” the master dermalstem cell to begin the healing process.Without the ability to switch on theLGR6+ stem cells, the best that could bedone was to encourage old, tired anddamaged skin cells to work harder.

What was still missing was the key toturning on production of new skin cells. Bynow, researchers knew that peptides werethe key that was needed. Peptides areproteins which are found naturally in thehuman body. They stimulate collagenformation and help prevent collagendestruction. The discovery of Defensins2—

the peptides that function as the skindefense mechanism—represented thequantum leap forward into the 4thgeneration of stem cell skin care. Defensinspeptides switch-on the body’s own specificmaster dermal stem cells (the LGR6+ stemcells), causing them to activate the healingand rejuvenation process and create freshnew skin cells.

For the first time ever, it is possible to topically apply a stem cell skin careregiment and see amazing results in a verybrief period of time. In as little as six weeks,test subjects of a double blind study saw avisible skin aging reduction of an average of 18 years.3 Deep wrinkles were relaxed,crepey texture disappeared, and textureimproved. The great promise of healing andrejuvenation first hypothesized over 50years ago by Drs. McCullough and Till isfinally being realized.

Internationally recognized aesthetic businessdevelopment expert, Cheryl Whitman is founder andCEO of Beautiful Forever. She is a sought-afterspeaker and industry marketing specialist. With herseasoned team of professionals at Beautiful Forever,Cheryl assists physicians and med spas inidentifying and executing new business strategiesaimed at improving their bottom line. A celebratedauthor, Cheryl’s “Aesthetic Medical Success System,”and her second book, “Beautifully Profitable, ForeverProfitable” provides solid, practical information onhow to create, launch and grow successful aestheticMedical Practices and related businesses. For moreinformation: beautifulforever.com or emailCheryl@beautifulforever.com ▲

References1. Snippert Hugo J., et. al., Lgr6 Marks StemCells in the Hair Follicle That Generate All CellLineages of the Skin. Science 2010.327:13885-9

2. Lough D., et al., Plast Reconstr Sugr.2016 Nov; 132(5):1159-71

3. Keller, Gregory S., Use of Defensins in aNew Cosmeceutical for Skin Rejuvenation.Defenage White Paper. Pilot Studies.GSK

Significant Advances in Stem Cell Skin CareCheryl Whitman

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the fittest. However, as physicians acrossthe spectrum seek to replace lost income,and as Baby Boomers and Gen Xers age,demand again continues to grow forminimally or non-invasive cosmeticprocedures made possible by newtechnologies with a focus on lasers.

Susanne Warfield, president and CEOof Paramedical Consultants, Inc., andexecutive director of the National Coalitionof Estheticians, Manufacturers/Distributors& Associations (NCEA) and the Society ofDermatology SkinCare Specialists (SDSS),feels the number of physicians entering themedical spa arena continues to grow in partbecause many doctors have been hurt bythe Patient Protection and Affordable CareAct (PPACA), or Affordable Care Act(ACA), but better known as ObamaCare.“We’re talking anesthesiologists, emergencyroom physicians, allergists, gynecologists,obstetricians,” says Warfield. “The legal andliability issues that were being faced back inthe early 2000s have not changed. Whathas changed is that in the last decade, thephysicians have sought after legislation tolimit the use of the scientific modalities. Soan esthetician who goes to work with aphysician may or may not still be working

under their esthetician license. But they aredoing these procedures, in the medicalpractice, and unfortunately, despite massiveefforts, we have not been able to raiseenough awareness to get estheticians reallyconcerned about where they are going toend up if they don’t start protecting theirfuture.”

In 2012, approximately 2,100 medicalspas were operating in the United States,according to a Marketdata Enterprisesmarket study titled “Medical Spas: AMarket Analysis.” This segment continuesto become more mainstream. Marketdataestimates that revenues of the 2,100 U.S.medical spas reached $1.94 billion in 2012,and will hit $3.6 billion this year. Averagerevenues per facility are $924,000—withabout 80% coming from procedures and20% from retail product sales. The marketis forecast to grow 18% per year. Expertsagree that a large majority of this growth isdriven by laser technology advances thatare less invasive. According to Marketdata,Americans spent $10 billion on cosmeticnon-invasive procedures in 2011. That year,12 million cosmetic non-invasive procedureswere performed, including Botox injections,

The Evolution of Medical EstheticsMelinda Taschetta-Millane

As the industrycontinues to grow,continued educationand increasedinvolvement is key to its success.

he medical spa industry is one ofthe fastest growing segments of the spaindustry. Although it has been around fordecades, a new respect is beginning toform, and boundaries are slowly being setas to what the esthetician in the medicalenvironment can and cannot do. We haveseen medical spas grow in the spa industry,especially over the past two decades. Thewords that define the medical spa industrycover a vast spectrum, as healthcare andoverall wellness have become mainstays intoday’s world.

The International Spa Association (ISPA)defines a medical spa as a facility overseenby a licensed health care professional thathas the primary purpose of providingcomprehensive medical and wellness carethrough the integration of traditional spaservices and complementary therapies andtreatments. The National Coalition ofEstheticians, Manufacturers/Distributorsand Associations (NCEA) further defines itas a facility that during all hours of businessshall operate under the on-site supervisionof a licensed health care professionaloperating within their scope of practice,with a staff that operates within their scopeof practice as defined by their individuallicensing board if licensure is required.

MEDICAL ESTHETICS THROUGHTHE DECADES

Medical spas began to emerge in themarket in the early 1990s, and thenexploded in number between 2007 and2009. The spa industry overall took a majortumble when the recession hit, exposing insome what was overoptimistic revenueassumptions and poor management. Amajor shakeout took place as franchisesfailed. It became an era of the survival of Continued on page 9

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dermal fillers, laser hair removal, chemicalpeels, microdermabrasion and skinrejuvenation.

MODERN DAY ESTHETICSToday’s esthetician working in a

medical environment is essentially workingas a medical assistant, according to TerriWojack, education director, businessdevelopment at True U Education inChicago. “In most states, the doctor mustdo the initial patient consultation and thenthe esthetician can follow-up,” she says.“The role of the skin care specialist isimportant for retention and to help thepatient with skin health, which is whyeducation is so important. Even if you arejust doing facials, you still need to knowabout the medical industry, and this is whymy mission is to help educate.”

In the late 1990s, doctors were havingbad experiences with estheticians due to lack of proper training, level ofprofessionalism and knowledge of issuessuch as HIPAA. “There was a time periodwhere doctors were kind of looking downon the estheticians and skin care, andskeptical about having retail in a medicaloffice. However, now I feel like it hascompletely turned back,” continues Wojack.“I think with more training programs,estheticians are now better at working withdoctors instead of trying to take the placeof doctors. I feel like that has come a verylong way.”

Treatments. Pre- and post-op carecontinue to be the mainstay treatments forestheticians to perform in a medical setting,along with chemical exfoliation, non-ablative laser treatments, dermaplaning andmicrodermabrasion. “I always recommendthat if an esthetician is going to work in amedical office, whether they’ve beentrained or not, is to take that first monthand shadow the physician and see whatpatients are coming through and how theyreact to different things,” suggests Wojack.“Here, three weeks after every surgicalprocedure or appointment, patients get afree treatment with an esthetician usingultrasound to help induce lymphaticdrainage, reduce swelling and promotehealing. The estheticians are always around,and the patients know that. They don’t justknow the doctor, they come in and theyknow the estheticians because they arethere to take care of their skin, maintain itand keep it healthy. Estheticians areretention tools for doctors.”

Scope of Practice. Education is a major

differentiating factor when defining thescope of practice. “Doctors have to go toschool for at least 10 years, and estheticiansusually go for a year at the most. Theyshouldn’t be in the same category. But therole of the physician is to perform medicaltreatments that are going to make a changein the skin—the more invasive procedures,”says Wojack. “The esthetician should be thesupport to the doctor. Sometimes we havethe estheticians go in with the patients andjust hold their hand while they are gettinginjected. Essentially the esthetician in themedical setting is there to help maintainthe skin, maintain its health and prolongand enhance the effects of what a doctorcan do with their treatments. It’s importantfor the doctor to understand that theesthetician is definitely helping grow theirbusiness; they are growing it with retail,they are keeping them in the office andthey are retaining them. The estheticiancan start the appointment by cleansing theskin and talking with the patient, and thenthe doctor can go in for 5 minutes, and tothe patient it may seem like 30 minutes. Ifdone correctly, the benefits of having anesthetician in a medical setting areamazing. I think it’s about having the righttrained person.”

Warfield cautions that the scope of theesthetician working in a medicalenvironment is changing. “It’s not that ourscope is being limited, it’s that thetechnologies that are now out there areoutside of our scope,” she explains. “Ifyou’ve got a 600-hour trained esthetician,her scope hasn’t changed. What haschanged are all the advancements and thescientific technologies, and the fact that ourlicensing and training of estheticians isfalling way behind.”

STANDARDIZATION OF THE INDUSTRYThere are no national standards for

defining or regulating medical spas or theestheticians working in this environment,and the lines are blurry between themedical spas and the physicians’ practices.Mishandled procedures by poorly trainedtechnicians have been an issue, since not all medical spas have a physician on-site.“Obstacles that have limited med spa successin the past have included widely varyingstate regulations, botched proceduresresulting from improper use of laser machines,poor expense controls and a spate of failedfranchises. However, most of these issueshave been resolved and the business lessons

have been learned,” says MarketdataResearch Director, John LaRosa.

Wojack agrees that regulation is a hugeissue. “It’s been a long, slow process, and it is really needed. It’s important for anesthetician to have medical knowledge,” she says.

“We still have states that are notrecognizing the esthetician once they go to work in the medical practice. Theesthetician still needs to work in a licensedfacility, and a lot of the estheticians whoare working in these medical estheticenvironments have no clue that they are in violation of the law,” stresses Warfield.“And then we have some states that sayonce the esthetician leaves the typical salonand spa environment and moves into themedical environment, then they no longeroversee them. The esthetician has to have afacility license so that the state can send aninspector in. if the facility doesn’t have afacility license, then what we’ve been told bystate boards is that they can then go intothe facility. So the big loser in all of this isgoing to be the esthetician, especially if shethinks she has liability coverage. She mayhave it, but may be in violation of the statelaw, and doesn’t even know it. But ofcourse, ignorance is no defense.”

FUTURE OF MEDICAL ESTHETICS“The key point here is to get involved.

Stay active in your industry,” stressesWojack. “I fear that the regulatory boardsare going to stop a lot of what estheticianscan do, but if the estheticians get togetherand fight, then we can develop astandardized medical esthetics program.”

It is important for estheticians workingin a medical environment to protect theirfuture in this industry, and to get involvedand play an active role. “I think ourindustry needs a wakeup call,” stressesWarfield. “I would challenge all estheticiansworking in medical practices to get theirnational certification and then lobby forhigher education hours and standards attheir state level to expand their scope ofpractice. There is a lot of change that stillneeds to happen.”

Melinda Taschetta-Millane is a Chicago-basedwriter and editor who has specialized in theprofessional skincare industry for more than twodecades. She is the former editor-in-chief of Skin Inc.magazine and former program director for the Face &Body Conference and Expo. ▲

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SURGICAL SKIN CARE AND AESTHETIC SURGERY: A LOGICAL COMBINATION FOR OUR PATIENTSContinued from Cover

restrictive to our patients’ lifestyle followingtreatment. You can also do this treatmentwithout having to stay completely out ofthe sun. With a good sun screen, patientscan return to their normal activity within aday or two.

While there have been someadvertisements you might see for at-homemicroneedling, the process we use in theoffice is very different from the at-homeoption. Medical Microneedling penetratesmuch deeper into the dermis for aneffective result, and we add a step that can’t be done at home. We use PRP (plasmarich protein) during the treatment whichimproves healing and encourages healthycell growth. This technique has been usedin other types of surgeries in the past andwe’re finding it very effective in helpingbuild collagen.

As skin care professionals and plasticsurgeons continue to work more closelytogether, I believe we will significantlyimprove the choices and aesthetic plans thatpatients can take advantage of. I believethat ASAPS and SPSSCS have the samecore values: quality patient care, the best inpatient safety and the pursuit of ever-improving products and aesthetic techniques.It’s exciting to have new treatments forproblems such as rosacea, melasma andcellulite that we haven’t in the past.

Here at The Aesthetic Plastic SurgeryInstitute, we develop a Beauty for Life“prescription” with the participation of thepatient, myself as the Plastic Surgeon, our

Paramedical Aesthetician and our MediSpaprovider. We create an immediate, 1-year,5-year and 10-year plan based on the goalsof the patient and an examination of thepatient and their lifestyle, personal andfamily history. This prescription is reviewedand adjusted periodically to accommodatefor differences in goal or patient physiology.Patients are looking for simple, effectivetreatment plans. They love to be able toutilize a thoughtful system that takes theguesswork out of what to do when. Thekey long term compliance with a beautyplan is to have something that is simple but effective.

A new addition to our practice as anon-surgical option is Cellfina. This is thefirst cellulite treatment that I have beenconfidently able to provide for my patients.I think this is an example of how scienceand medicine continue to develop new andeffective ways to provide our patients whatthey need.

1: Hilton L. Rested or wrinkled. Oh, the irony.Cosmetic Surgery Times. August 2, 2016.http://cosmeticsurgerytimes.modernmedicine.com/cosmetic-surgery-times/news/rested-and-wrinkled-oh-irony

Daniel C. Mills, II, MD, is an aesthetic plasticsurgeon in Laguna Beach, CA, and serves asPresident of The Aesthetic Society. ▲

create aging of the face. I find that ourpatients are looking for more natural,organic and holistic choices in treatmentsand products. We have incorporated avitamin, mineral and supplement line intomy practice that can help with stress, sleepand hormone imbalance. High qualitysupplements can naturally help restore thebalance that we lose due to our busy livesand the natural aging process.

We are more aware in general of notonly the aesthetic results of sun damageand lifestyle stressors to our skin, but alsohealth concerns such as skin cancer. We are fortunate today to have more tools toprevent and treat skin cancers.

When good lifestyle choices and goodskin care and maintenance treatments are inplace, it helps makes a plastic surgeons’ jobmuch easier! Our aestheticians have animportant role to play in preparing the skinfor both MediSpa procedures and surgicalprocedures. Treating the skin with Retinol(combined with paramedical facials and a good skin product routine) for a month or two prior to treatment will make thetreatment more successful. When it is timefor a surgical intervention it’s also best todo smaller procedures sooner, rather thanwaiting until a more aggressive surgery isrequired. It’s the difference between ElizabethTaylor, who used small improvements tolook her best at every age, and Joan Rivers,who waited until later in her life and didthe “Blue Plate Special” and chose a veryextensive and noticeable facial plasticsurgery plan. Our patients are choosing less invasive treatments more often andavoiding recovery time. They want resultswithout having to change their normaldaily plans due to excessive peeling,swelling and discoloration.

Microneedling is a newer addition toour tool box that builds collagen and takesoff the top layer of the stratum corneum.This allows for a better delivery system sothat our products work better, more deeplypenetrating the dermis. It’s a great preparationto make other MediSpa treatments moreeffective. There is little to no down time. I suggest having this procedure once amonth for the first three months and thenquarterly thereafter for maintenance. It has a similar effect of what some of ourolder peel options had, but is much less

Three very intelligent women, Dr. Mimi Lee, Candace Noonan andCheryl Whitman, share their expertisein their respective fields helping us growand become more knowledgeable,which allows us to provide the bestchoices for patients. Being educatedis, of course, very important in ourfield in order to stay abreast of all thenew changes and most importantlyprovide safe options.

While products and technologygrow by leaps and bounds, it isimportant to also stay educated on thelegalities of our position within amedical practice. Melinda Taschetta-Millane brings up some very goodpoints in her article. Working withinour scope has always been ofimportance to me. We need to becognoscente of the legal ramificationsenforced by individual states. It is ourresponsibility to stay informed andeducated on the changes being madeand ensuring we are staying within thelegal boundaries.

Looking forward to 2017, let usmake a plan to have a successful,healthy and rewarding year, continueto educate ourselves, believe in whatwe do, share the knowledge and knowthat if we stick to our passions theywill be realized. ▲

FROM THE EDITOR’S DESKContinued from Cover

11

SOCIETY OF PLASTIC SURGICAL SKIN CARE SPECIALISTS

WWW.SPSSCS.ORG/MEETING2017

23rd Annual Meeting

April 25–28Hilton San Diego

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SpecialtySkinCareSOCIETY OF PLASTIC SURGICAL SKIN CARE SPECIALISTS11262 Monarch Street, Garden Grove, CA 92841-1441 • www.spsscs.org

Lisa Adams, RN, BSN—Raliegh, NCAlicia Alvarado—Bellevue, WALisa Berlasi, RN, BSN—Farmington, MIRonald K. Downs, MD—Mishawaka, INTatjana Dzamov—Columbus, OHSabel Fleshman—Eugene, ORKathleen Joan Gorman—Roanoke, VAHeather Happy—Franklin, TNStacie Liang, RN—Atlanta, GAKatie Z. Link—Louisville, KYAbigail L. Meyer—Chesterfield, MOPatti Owens, RN, MHA, CMLSO—Rancho Mirage, CARobin Prusse, RN—Portland, ORDennis K. Schimpf, MD—Summerville, SCDeanna T. Sirkoch, RN—Sewickley, PALauren Tynan—Wilmington, DELori Ward, RN—Washington, DCAdrienne Yanich, LPN—Columbus, OH

WelcomeNewMembersKaren Menard, RNChair, Membership/Mentor Committee