2011 Wrap Up & Synopsis of the Highlights

With the advent of EMR utilization, one new term in many dermatologists’ lexicons is ‘meaningful use’. The list of meaningful use criteria for earning Medicare electronic health records (EHR) implementation incentives can be daunting, Sharon Andrews, RN, CCS-P, owner of DermResources, LLC, said. However, she said that exceptions are available for measures that make no sense in a dermatology practice.

Practice owners who meet Medicare's criteria can earn up to $44,000 per physician over 5 years if they implement HER systems. Conversely, Ms. Andrews said, "If you work for Dr. X, and he counts you as part of his practice's 'meaningful use,' Dr. X gets the money."

On a broader scale, she noted that logos and branding are particularly important to aesthetic practices. Accordingly, "Don't be afraid to hire a marketing firm. And make sure they understand where you're trying to go before they start the work."

Somewhat similarly, Barry Lycka, M.D., associate clinical professor of dermatology, University of Alberta, said that becoming a great cosmetic physician requires positioning yourself as an authority -- by writing books, doing TV and radio interviews, and hobnobbing with celebrities, who influence patients more than scholarly articles do.

Dr. Lycka suggested many tips for budding practitioners, but the most important tip was to not be afraid to ask for reviews and compliments from patients. While it is not in our nature as physicians to ask others to reassure us of how good we are, in this day and age others are fearful that they may have a bad experience and demand ‘proof’ that you are what you say you are. That’s where Dr. Lycka inserts plaudits from his many satisfied patients.

Additionally, Dr. Lycka reminded residents to WRITE, WRITE, WRITE. Whether it is a blog, article or newsletter, getting your ideas down on paper or computer is extremely important. The power of the media is huge and anything you communicate in today’s world gains traction over time, increasing your visibility and ‘Google-ability’ in the future, gaining dividends for you!

And unfortunately, said Arthur C. Huntley, M.D., a Seattle-based dermatologist in private practice, "A lot of it has nothing to do with the ability of the doctor, but the friendliness of the staff," or the amount of the bill.

To combat negative reviews, he said, "Own your own reputation -- create your own online content that will essentially overwhelm any negative comments." Tools to that end can include the following:

• your websifte -- best for static information such as your location and credentials
• YouTube videos -- to outline a particular procedure or disease state, for example
• Twitter -- best for frequent updates and news
• press releases -- to announce novel treatments or charitable efforts
• your practice's Facebook page
• blogs
• patient testimonials -- tell your happiest patients exactly which sites to post to, and give them sample verbiage to make it easy for them, said Dr. Lycka.

The Exilis (BTL) RF device essentially heats fibroblasts to produce new collagen fibers, thereby achieving skin tightening. As such, she said it's helpful for areas ranging from the face to the bra-area fat rolls and the abdomen. In the latter area, its maker claims a single treatment can achieve an average 1.2 cm reduction. "I haven't seen that. After about 4 treatment sessions, I've seen an average of 2 inches lost," stated Dr. Downie.

"And that's in my patients who are not gaining weight, and exercising lightly and drinking lots of water. I weigh-in patients at every treatment. I had one patient this summer who gained 4.5 pounds while she was undergoing Exelis treatment, and lost an inch." Such patients may try to hit you up for extra, unpaid treatments, Dr. Downie said.

Other RF devices use up to 8 poles, noted Michael H. Gold, MD, Nashville based dermatologist. However, he said, "If you're using more than 2 or 3, you're doing that to reduce the power" from each pole. "Therefore, you probably need to add some other treatment to it to increase efficacy."

Additionally, Dr. Gold said that no manufacturers have addressed the issue of when to schedule maintenance treatments. "We just say, come back when you need it. Long-term studies with these noninvasive devices are not that plentiful in the literature. The companies are not going to spend the money doing that. So we must do the studies ourselves."

As for the Zerona (Erchonia), Suzanne Bruce, M.D., a Houston-based dermatologist in private practice, said keys to success include picking the right patient, who has appropriate expectations. "I definitely believe Zerona has an effect. But people can eat that effect away pretty quickly." Therefore, she says she uses Zerona to boost results for highly motivated patients who are dieting -- and using the supplement regimen recommended by Erchonia.

Conversely, she said that she believes CoolSculpting (Zeltiq) provides longer-lasting results. "Many people aren't willing to change their diet, or exercise. Those are the patients in whom CoolSculpting does a better job."

During my talk I explained that ATX-101 (sodium deoxycholate, Kythera/Intendis) will begin FDA Phase 3 testing soon. It will address the submental area, which other noninvasive treatments such as CoolSculpting and Liposonix (Solta) don't. I believe it will provide a new tool to bring patients into our offices.

In clinical trials that I have conducted, some patients have maintained results for up to 24 months. However, perhaps the biggest surprise was that I expected MRI to be the most reliable way to measure fat reductions achieved with ATX 101. However, calipers have proven shockingly accurate in this regard.

• "The best steroid occlusion mix I know of is Clobex (clobetasol, Galderma) spray covered with Theraseal (Healthpoint). It's just as good as and intralesional injection."
• Using liquid nitrogen to lightly freeze lentigines on an elderly patient's hand can be your best advertisement. "For the next six months, every woman in her bridge club is asking her why her hand looks so good. You'll get 10 patients" for every patient for whom you provide the treatment on one hand at a time.
• Topical timolol has changed the game for childhood hemangiomas, even severe ones (Khunger N, Pahwa M. Br J Dermatol. 2011 Apr;164(4):886-8.). "The immediate effect is vasoconstriction. The intermediate effect is to blockade the vascular pro-angiogenic factors such as endothelial growth factor. The long-term effect is due to reduction and apoptosis of epithelial cells," said Dr. Ely. Topical timolol may have effects on keloids as well.

Pamela Basuk, M.D., a Bay shore, New York-based dermatologist in private practice, said that for lentigo maligna melanoma (LMM), surgery is the treatment of choice. "But not all patients are surgical candidates." Alternatives include imiquimod, 5-fluorouracil, radiation, cryotherapy, azelaic acid, topical retinoids, laser, and ED&C.

Regarding imiquimod, a very recent study involving 43 patients has shown a 53% histological clearance rate of LMM at 3 months (Ly L, Kelly JW, O'Keefe R et al. Arch Dermatol. 2011 Oct;147(10):1191-5.). Accordingly, said Dr. Basuk, "Clinical clearance does not mean pathological clearance." Taken together, she said, all the research in this area suggests using imiquimod monotherapy for LMM with caution in appropriately selected cases. "More study is needed."

As for the role of sentinel lymph node biopsy (SLNB) in melanoma, research findings are somewhat contradictory. "It is used as one criteria for melanoma staging and treatment planning. And it may be useful for melanomas of intermediate thickness," Dr. Basuk said.

However, "SLNB is not useful for assessing prognosis in thick or thin tumors. Current data now show that there is no increased overall survival, regardless of SLNB results. Additionally, 10 percent to 15% of patients who have negative SLNB will go on to develop metastatic disease. And 1/3 of patients who do have a positive lymph node will not develop metastatic disease."

Moreover, she added, "Only 20% of patients who have a positive lymph node will have other (positive) nodes. This means that 80% of patients are having elective lymph node dissection, and there's no benefit. It's not known whether microscopic disease on biopsy equals macroscopic disease." In fact, she stated, the latest research suggests ultrasonography may prove more useful in assessing melanoma prognosis.

The treatment requires drawing a patient' is blood, then spinning it in a centrifuge down to only platelets and plasma. "And rather than just injecting it, as the company tried in the past, you catalyze it with a little calcium chloride, which causes the plasma to create a clot," which keeps the injected platelets in place for 7 days. After about 6 weeks, the patient develops new collagen and capillaries, she added.

"But on the flipside, I do not appreciate that this treatment was being pushed by a sales representative as FDA-approved instead of correctly describing it as an off-label use." Overall, Dr. Woodward said that this technology merits more research and likely will play a role with autologous fat transfers.

We will be providing other pearls over the next several weeks, but these are just a few teasers. We will be holding Cosmetic Surgery Forum next year from November 29th to December 1st at the Palazzo/Venetian in Las Vegas, so register now for the early bird rates and a great hotel rate of only $159 a night! Register Here