Background of Noninvasive Technology: Evolving Patient Selection

3 Background of Noninvasive Technology: Evolving Patient Selection

Julius W. Few Jr.

Summary

This chapter discusses the ability to incorporate nonsurgical technology into a clinical practice and how powerful that enhancement can be. However, there are risks, and patient selection and an expanding patient base are at the forefront. As technology continues to evolve and grow, we are seeing more and more near-surgical outcomes without the surgery. As a result, we are seeing exponentially more patients seeking non-surgical treatment options. Although surgical intervention remains the gold standard for cosmetic enhancement, we are now realizing that there are a variety of ways to achieve our patients’ goals without surgery.

Keywords: invasive, noninvasive, risk, microfocused ultrasound, fillers, toxins, photorejuvenation, intense pulsed light (IPL) treatments

Key Points

• Patients can be happy with their results without necessarily achieving surgical perfection.

• Some patient groups who have traditionally not been candidates for surgery, such as patients of color, may be good candidates for minimally invasive procedures.

• As technology continues to evolve and grow, we are seeing more and more near surgical outcomes without surgery and hence an increase in our patient base.

• In addition, patients who get an improvement with nonsurgical cosmetic care may pursue surgical cosmetic care in the future.

3.1 Introduction

If you had asked me what I wanted to do in medical school, the answer was “ophthalmic surgeon” in my second year and “heart surgeon” in my third year. This is particularly important to the evolution I will highlight below.

The birth of The Few Institute came 8 years after I was at a major metropolitan academic medical center, Northwestern Memorial Hospital in Chicago. I was the fourth plastic surgeon to join the practice after spending time learning about oculoplastic surgery. I was fortunate to be given a lot of freedom in the beginning, and I focused on a traditional academic plastic surgery practice. I taught the residents from Northwestern University and did active clinical research, while growing a very busy reconstructive and cosmetic practice. As I continued to treat a very sophisticated group of patients while doing research with the dermatology department next door, it became very apparent that less invasive cosmetic modalities were desirable. In addition, major concerns about injectable treatments in patients with pigmented skin led me to do the first clinical study focused on hyaluronic fillers in skin of a color, such as Restylane.1 This study not only proved that injectable fillers could be used safely in skin of color, but also it highlighted the important fact that people of color are just as interested in cosmetic enhancement as people with nonethnic skin. This realization helped me to really ask the question, “What are the barriers to cosmetic surgery?” A principle barrier is the perception of risk, risk of complication, risk of loss in identity, permanent changes, “looking fake,” etc. As I looked closer, it became apparent that the ability to offer a nonsurgical option in a patient with a history of keloids or a patient who is averse to surgery in general, was widely embraced, and I could witness the birth of cosmetic ethnic medicine on a larger scale.²

In the late 1990s, the advent of filler and botulinum toxin created a quiet revolution.³ I remember sitting in a national American Society of Plastic Surgeons (ASPS) meeting and having various surgeons state that this was a fad that will pass, just like skin-only facelifts, because the general belief at the time was that “lesser invasiveness means lesser results.” According to statistics from the major dermatologic and plastic surgery organizations,⁴ there is more than a tenfold dominance, which is increasing, for injectable treatments compared to aesthetic surgery.

As an early adopter of the use of fillers and neurotoxins, I learned many things about the larger population of patients wanting minimally invasive cosmetic enhancement. An important misconception for us as plastic surgeons is the one definition for successful rejuvenation of the face and neck: “surgical perfection.” Although surgical intervention remains the gold standard for cosmetic enhancement, I am now realizing that there are a variety of ways to achieve our patients’ goals without surgery. I began to learn that making a heavy frown line, or “parenthesis,” softer around the mouth through a nonsurgical technique could make a woman feel instantly better, sometimes several magnitudes greater than the happy surgical patient. The difference was that it was much easier to get the desired result, and the recuperation time was shorter and easier by comparison. I learned that the experience for the cosmetic patient was often as important as (in some cases more important than) the result, assuming there was visual improvement. This was the “Eyes Wide Shut” moment for me as a plastic surgeon. As my experience grew, especially in certain groups of patients, such as certain ethnic patients, who were traditionally not candidates for surgery, I learned that these patients were candidates for minimally invasive treatment. This rapid increase in the patient base opened the door to developing strategies in minimally invasive procedures, such as light- and energy-based treatments, and injectable treatments.

3.2 More Than Skin Deep

According to Dr. Dayan,5 it turns out that looking happy and healthy is more than just a superficial enhancement. It can lead to better pay at work, improved subjective mood, and more.

The use of botulinum toxin type A (Botox) to treat glabellar frown lines has been shown to improve major depressive symptoms in susceptible patients, according to a blinded, placebo-controlled study.⁵ This is particularly important as we look at the growth of cosmetic medicine and the barriers that patients have in seeking treatment.

Motivation for a given appearance can be a powerful tool to overcome fear of a procedure. If the rewards are high enough, as science is showing us, then those relative risks become less of a concern to our consumer. As technology continues to evolve and grow, we are seeing more and more near-surgical outcomes without the surgery. As a result, we are seeing exponentially more patients seeking nonsurgical treatment options.

Why would someone accept a less-than-ideal enhancement to their appearance? If we look at the science, some improvement is better than none, because it does affect one’s persona, and the way the outside world relates to these changes can be dramatic in terms of both one’s personal and professional life. I have had many patients come back to me after cosmetic intervention and indicate that they got a major promotion at work and/or found that special someone they never thought they would find. This type of event leads the cosmetic patient to say, “This was the best investment I have ever made.” This feeling for the patient is enhanced when the patient did not have to miss a day of work and suffered very little discomfort. The power of such an experience has dramatically built a cosmetic following that exceeds any other component of my practice.

3.3 History Does Repeat Itself

As previously mentioned, I had a strong interest in cardiothoracic surgery. I did research in this area, and one of my most trusted advisors specialized in this area. If we look at the history of cardiac surgery, there are many parallels to current plastic surgery. Cardiac surgery is a dramatic surgery with dramatic effects. Cardiology was largely diagnostic 25 years ago, when it was a distant second to the definitive nature of cardiac surgery treatments, and relegated largely to supporting patients after their surgery. This paradigm has dramatically changed. Cardiac surgery can largely be avoided by minimally invasive approaches performed by the interventional cardiologist. Long ago, there was only a handful of cardiac surgeons who embraced minimally invasive approaches and innovated in the area of circulatory medicine. I believe the same holds true for plastic surgery. As technology continues to evolve and we see more applications that allow for results without an incision or just a minimal one, we will see the base of patients grow and the demand for invasive procedures drop, as we did with cardiac surgery. Will we look at the facelift 10 years from now like we do the open patent foramen ovale surgical repair now? With the current technology, one can only imagine what the future will hold ( Table 3.1).

Table 3.1 Surgical and Nonsurgical Pros and Cons

PRO	CON
More defined but more involved	Longevity is less without maintenance
Predictable but very technical	Degree of improvement can be less if the patient is not a good candidate
More permanent, whether a good or bad result	Progressively improving result with time, which can be a positive for the patient fearing drastic alterations
May be more cost-effective in severe cases	Less risk
More control of bone and soft tissue combined	Less recovery
Historic gold standard	Duration

3.4 Practical Considerations

In 2008, I considered the acquisition of the new Ulthera (Ulthera, Inc.) platform (microfocused ultrasound), for nonsurgical browlift and facelift, primarily due to the concern of the declining U.S. economy and an assumption that patients would want a nonsurgical, less expensive alternative to facelifting (see Product Index (p. 176)). In 2009, I made the purchase. I quickly realized that the patient appreciated a less-than-facelift result and returned wanting to do other nonsurgical applications, such as those with lasers and fillers, because they liked the Ulthera model. This lead to the “stackable treatment,”⁶ an approach that purely looked at potential synergies in blending and combining noninvasive and minimally invasive approaches (see Video 1.1). A more detailed review of blending strategies will be reviewed in later chapters.

The second point of evolution was the use of energy-based technology, such as radiofrequency and magnetic field generation, to aid in the resolution of swelling and skin tightening in the postliposuction patient, and patients undergoing traditional, ultrasonic, and laser liposuction. Patients appreciated the proactive approach. There was no disposable cost, and it fit nicely into our value-added model, justifying a differential cost model. Patients are much more accepting of a treatment that costs more if there is little pain and minimal downtime involved, as long as there is enough of an improvement.

The advantages are numerous when looking at nonsurgical cosmetic procedures. Fillers and toxins represent the perfect example. They are readily available, and the results are relatively predictable but can be largely reversible and are not permanent in nature. Fillers and toxins can be combined in all kinds of creative ways and are largely amenable to customization. For patients who are uncertain as to what approach they wish to consider, the nonsurgical approach is often more palatable and allows the potential surgical patient to gain confidence in advancing to a surgical application, if it is in his or her best interest. The so called “7/47” effect has been referenced by the injectable industry through internal surveys and holds great reality for the plastic surgeon and nonsurgeon alike.⁷ The survey finds that 7% of the general population will go to a nonsurgeon for plastic surgery. This number increases to 47% if a patient has a good outcome from a nonsurgical treatment provided by the nonsurgeon. The clear message is that patients who get an improvement with nonsurgical cosmetic care will pursue surgical cosmetic care. This is the definition of a continuum of beauty, in which a rainbow of options exists for the patient who wants wrinkled, tired-appearing skin to look better, from injectables to facelifting with or without skin resurfacing.

3.5 Pretreatment Planning

When looking at minimally invasive and noninvasive cosmetic medical treatments, I note that there a number of variables to consider and present to the patient. Timing is crucial, especially as it relates to treatment options. When looking at neurotoxin therapy, such a Botox injection, I typically advise patients to have their treatment at least 2 weeks in advance of an important event. This can be accompanied by filler to deficient fat pockets of the face, such as the cheeks. While botulinum toxin treatment will typically be effective for 3 to 6 months, fillers are affective for 1 year or more, making the timing of treatments important to plan for the patient in terms of scheduling and financial considerations.

It is therefore easy to carry over this concept to the use of the energy-based applications. For example, the use of microfocused ultrasound platform (Ulthera) typically gives a roughly 2-year enhancement for face and neck treatments. Patients will typically do their second treatment at 18 months, and we time this with their filler and toxin treatment so that only one trip is needed, maximizing efficiency for the patient. In addition, similar to taking care of an automobile, patients are given a general budget of the expenses for their given care plan so that they are able to break down the cost on a monthly basis instead of thinking about the expenses of the cosmetic treatments in large lump sums. This also allows the patient to look at surgical alternatives.

When comparing treatment alternatives, a patient can put a facelift, blepharoplasty, and ablative laser resurfacing next to filler, botulinum toxin injection, microfocused ultrasound, and a series of intense pulsed light (IPL) photorejuvenation treatments. One can look at the time off work and the financial impact of lost productivity versus the time taken to visit a given medical office. One must also look at longevity as well. If a series of noninvasive treatments ends up delivering a result that ultimately costs the same and has more maintenance involved, the patient may opt for the surgery because of its ease and predictability. Patients can also take a hybrid approach, in which they do a submental necklift in the office under local anesthesia and combine it with fillers and laser or microfocused ultrasound to the upper face or radiofrequency-based skin tightening therapy. In this hybrid approach, the patient weighs in a very strategic way the tolerance for recovery, the affordability, and the greatest result or degree of improvement that can be achieved through each treatment option. If one does not look at the minimally invasive approach in this way, the patient will be confused and it will be unlikely that the patient will end up with the most ideal outcome (see Video 2.11). In reality, I have seen patients who have a truly amazing result from their filler, but they were terribly upset because they were bruised for 10 days and felt that surgery would have been easier. When reviewing the options, these examples are very helpful to allow the cosmetic patient to make the most informed decision, minimizing the likelihood for an unhappy patient.

3.6 Acquisition of Novel Technology

When considering the acquisition of new technology, one must first look at the pool of patients available. It is a common mistake to buy a technology, like the latest edition laser, thinking it will bring in all sorts of new laser patients. While this is possible, it is incredibly risky as an investment. It is far wiser to develop a more formal business plan in which there is an inventory of potential candidates that currently reside in your practice, and to assess what this could mean in terms of actual patient treatment days, which is the number of patients per day plus the net financial outcome. For fillers and neurotoxins, the risk is lowest, given the relative predictability of overhead, the assessment of actual consumers, the ease of acquiring, and the long shelf life with the ability to grow other parts of the aesthetic business. As one moves into energy-based technology, the assessment becomes much more complicated:

• Is the device a laser, lifter, smoothing, or tightening device?

• What is the current base of patients in your practice?

• Have you taken a poll for the potential interest if the new offering were available?

• Have you taken a poll for the cost tolerance by your clients?

• Are you able to bundle your new offering with something else?

• What is your backup if patients are not accepting of the treatment result?

• Are there disposables?

• If so, how does the disposable affect the treatment cost?

• Is there room to make the treatment financially effective for your practice compared to other offerings?

These are some of the vital questions one must ask before acquiring a new technology. It is very easy to get overwhelmed by the hype and marketing of a new technology. Making such an important capital decision on emotion alone is a major mistake, and one that can be devastating to a clinical practice.

Basic Considerations for Acquiring New Technology

1. Can the practice afford it? It is critical to review the financial implications of making a corporate loan or using vital business reserves to acquire a new technology. This basic question must be answered, because purchasing a new technology that the practice cannot afford leads to desperate behavior that clouds good clinical judgment, and both the patient and practice will suffer the consequences.

2. Have you created a business plan? Again, a good accountant can help with this effort. Some of the more sophisticated companies have already done some of this work for you, based on your demographics. You must look at the amount of internal interest you have for new applications, the financial return of the new technology versus the cost of overhead, the potential to draw new clients (this is usually where the exaggerations occur, because you never get as many new clients as you think), the time to payoff, the service plan cost, the annualized cost to operate the device, and the cost to drop the technology if needed. The annualized cost is one of the most elusive points. One must look at the cost of the hardware, the cost of staffing (and pulling staff away from other moneygenerating activities), the annual service contract cost, and the interest cost to finance the new technology. Does the novel technology have the ability to increase the utilization of an existing technology? This finding has been very powerful in our practice. For example, when we offered inoffice laser liposuction, our utilization of nonsurgical skin tightening increased by more than 50%. There are some technologies that have hidden value, ones that pique the interest of our clients. Cryolipolysis is an example. This is a technology that is well known across our population, and the offering of such a service can have a major appeal to new clients.

3. Market saturation. Are you literally going to be the last person in your community to acquire a given technology? If so, you must rely completely on internal appeal, which means that your existing clients will see the new acquisition as value-added for them, because you brought the technology in so that they do not have to leave your practice. This can be very powerful and defy the typical logic of purchase planning. In general, if the market is saturated, one must move cautiously and put the burden of proof on the manufacturer.

4. Trial period. It is often beneficial to trial a new technology, “test drive it” to get staff feedback and envision it in your practice. This is typically something you have to ask for, and the period of time varies, depending on availability and how in demand the technology is. Even if you have to pay for the disposable cost, this opportunity is invaluable.

5. Do you have physical room for the technology? If you are in a big city like I am, raw space comes at a premium. If you are looking to acquire a new technology that is physically large, you must look at the available space. What will you have to displace to make room for the new item? Are you putting a new technology in place at the expense of a more profitable offering in your practice? Will the new item generate enough to make it appropriate for the clinic, looking at the cost for a given space?

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