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A PUBLICATION OF THE AMERICAN ACADEMY OF COSMETIC SURGERY 2015 ISSUE 1 18 08 22 Skin Tightening with Radiofrequency and Microfocused Ultrasound Energies Complications of Facial Cosmetic Surgery Greetings from the New AACS Executive Director Popular Sessions from the 31st Annual Scientific Meeting Contents FEATURES INSIDE Letter from the Editor 4 Presidents Word 6 Greetings from the New AACS Executive Director 8 2015 Live Surgery Workshop Series 26 A Perspective From Fellowship Where Has All The Vanity Gone 28 Practice Management Patient Loyalty. How to Earn it. How to Keep it. 30 News Notes 34 Editor-in-Chief Joseph Niamtu III DMD FAACS President Michael J. Will MD DDS FACS Director of Marketing and Communications Jean OBrien Published quarterly for members of the American Academy of Cosmetic Surgery the American Society of Liposuction Surgery American Society of Cosmetic Laser Surgery and the American Society of Hair Restoration Surgery non-profit organizations representing practitioners of medical disciplines including dermatology ophthalmology otolaryngology plastic and reconstructive surgery oral and maxillofacial surgery and general surgery. Views and opinions expressed are those of the authors and not those of AACS ASLS ASCLS or ASHRS. All contents 2015 American Academy of Cosmetic Surgery. For subscription information address changes AACS ASLS ASCLS and ASHRS membership inquiries contact Sentergroup Inc. 225 W. Wacker Drive Suite 650 Chicago IL 60606. Phone 312.981.6760 Fax 312.981.6787 Email website 2015 ISSUE 1 18 Complications of Facial Cosmetic Surgery 14 Body Contouring Master Session 10 Stem Cell Advances 20 Fractionated Lasers 24 Periocular Rejuvenation 22 Skin Tightening with Radiofrequency and Microfocused Ultrasound Energies Popular Sessions from the 31st Annual Scientific Meeting Cover photo Andrew Ordon MD Wednesday keynote speaker at the 31st Annual Scientific Meeting 44 Dear Members I am honored to serve yet another year as your editor of SURGE magazine. Like many of you I am still digesting all the pearls from our annual meeting. As usual I teach and learn there and every year come back with a litany of new things I want to try in my practice. My list included procedural and practice management changes and I can honestly say that going to that meeting has improved my surgery and management by implementing new ideas. Some of these pearls were from the live injection sessions some had to do with our featured speakers Drs. Braz and Ordon and some were simply from conversations I had with my many friends and colleagues at the meeting. There is something important that I would like to underline in this editorial and that is that the AACS like all organizations needs a continual inux of new members to prosper and grow. I think the AACS is one of the best-kept secrets in the entire eld of cosmetic surgery and urge all members to spread the word and sign up a friend to help us grow. Every year I have younger members ask me How can I lecture publish or teach within the AACS This answer is simple just ask us We are continually looking for committee members journal article contributors and speakers at our meetings. The AACS puts out a call for abstracts about six months before the annual meeting and this is the time to submit abstracts to speak at our annual meeting. Anyone who feels they would like to become a committee member can let me or any AACS staffer know. We need you and we want you and this is the way to move up through the membership and leadership of this organization. Joe Niamtu III DMD FAACS Joe Niamtu III DMD FAACS is board certified by the American Board of Oral and Maxillofacial Surgery and is a fellow of the American Academy of Cosmetic Surgery and the American Society for Laser Medicine and Surgery. 4 Letter from the Editor While in New Orleans I finally had the opportunity to reconnect with some of my old friends from Sentergroup and meet the new team members I have been conversing with over the past eight months. What a cool friendly and talented group of staff we have Special congratulations to Dan Garrett our new Executive Director. He is going to take us to great heights. I hope to see many of you at the summer workshop Dr. Cuzalina and I are hosting in Tulsa. Have a great spring. Joseph Niamtu DMD 5 6 Presidents Word It is a true honor to serve as the President of the AACS and to help facilitate the growth and advancement of our academy in conjunction with the support of a stellar board of trustees and an energetic and forward-thinking membership. Dr. Jane Petro our immediate Past-President along with our outstanding management company Sentergroup Inc. have allowed the academy to prosper and begin its rise to new heights. I thank both of them for their hard work and dedication to our academy. The AACS has hired a new Executive Director Daniel Garrett who came on board in late February and brings a great deal of experience in medical association leadership political action foundation development and association membership growth. Please reach out to Dan and welcome him and introduce yourself when possible. Dan has an incredibly infectious personality and an unwavering can do attitude. The academy is very fortunate to have him as our director and the new face of our organization. The academy is scheduled to have our strategic planning conference where the board of trustees and committee chairs will convene in May in Chicago to work with a strategic facilitator and Dan Garrett to develop our organizations short and long-term career path to position the AACS as the undisputed leader in cosmetic surgery and medicine education training and patient safety. I look forward to sharing the strategic plan with the membership upon completion of our conference in May. The academy has received full accreditation by ACCME as an educational organization in cosmetic surgery and medicine. The Sentergroup staff and the Education committee chairman Dr. Marco Barusco and his committee members have ensured complete ACCME compliance allowing the academy to earn full accreditation to grant CME through all of our courses conferences and workshops. Maintaining ACCME compliance within a large organization like ours that offers so many different educational opportunities is a tremendous challenge especially when the tolerance for compliance within the ACCME is very limited. Dr. Barusco and the Sentergroup staff are to be commended for a job very well done. The AACS has announced the dates location and faculty for our 2015 surgical workshops. We will offer surgical workshops focused on advanced facial cosmetic surgery body contouring breast augmentation non-invasive rejuvenation and fat transfer. These workshops provide outstanding educational opportunities to learn from some of the most experienced faculty in the country and to bring back clinically relevant techniques and advances to your individual practices. Michael J. Will MD DDS FACS Michael J. Will MD DDS FACS is a board-certified oral and maxillofacial surgeon and cosmetic surgeon in Maryland. He is a fellow member of AACS and currently serves as its President. 66 The AACS is actively recruiting fellowship directors in general and facial cosmetic surgery in order to expand our number of fellowship training opportunities. Every year applicants are unable to secure fellowship positions with one of our AACS cosmetic surgery fellowships because the number of qualified applicants exceeds the number of available training slots. This year the academy has decided to accredit facial cosmetic surgery fellowships for those surgeons who prefer to restrict their cosmetic practice to the anatomy above the clavicles. This is a great opportunity for oculofacial maxillofacial single- and double-degree dermatologic and head and neck surgeons. The American Board of Cosmetic Surgery ABCS has created the American Board of Facial Cosmetic Surgery ABFCS which is a separate and distinct board from the ABCS certifying exclusively in facial cosmetic surgery. This board will allow candidates to challenge the ABFCS exam following a facial cosmetic surgery fellowship or through the experience route. Please contact the ABCS for detailed information regarding the ABFCS qualifications and requirements. If you are interested in serving as a fellowship program director in either general or facial cosmetic surgery please contact the AACS headquarters. Finally I feel strongly that the AACS should be a member-driven organization that considers all relevant member input to be valuable and that we should harness the experience energy and forward-thinking minds of our membership to bring us to the next level. With that in mind I would like to encourage any of our members interested in serving on an AACS committee or assuming leadership positions in the organization to contact me or any of the executive committee or board members so that we can get you involved according to your focused interest. 7 Dear AACS Members Greetings As some of you may know I am the newly appointed executive director of the AACS. Though Ive only had the opportunity to work with the rest of the AACS team since late February I already recognize a deep pool of talent and resources that I am confident will translate into myriad successes for our more than 30-year-old professional association. With a rich history of leadership and progress AACS is positioned to grow its membership enhance its relevance and set forth a new intentional path that leads us to higher levels of achievement and impact. Our future depends on strong volunteer leadership and member engagement within committees and task forces. It also depends on fostering and expanding our strategic alliances with our corporate and business partners. Setting both short- and long-term goals for membership recruitment and retention is a major priority for the AACS board of trustees. With ambitious plans to increase our membership AACS is concurrently committed to retaining our existing members. Both of these initiatives will realize success as we build our relevance and market position as the leading professional organization for cosmetic surgery. We must deliver enhanced member benefits and increase the value proposition for membership. Ultimately AACS will demonstrate how membership translates to success in regards to both our members careers and cosmetic surgery practices. Today successful professional associations thrive because of a steadfast commitment to maintaining and expanding their relevance. In the months and years ahead AACSs relevance will be strengthened through cutting-edge educational CME course offerings starting with our 2015 series of live surgery workshops and webinars. With topics ranging from scientific advancements in cosmetic surgery to stimulating your practices success AACS members will be equipped to be the best in the profession. Your success is our success In approaching the task at hand I like to think of Bill Gates quote My success part of it certainly is that I have focused in on a few things. Its a fitting statement for AACS as we usher in the creation and implementation of a new strategic plan later this spring. The Sentergroup team is laser-focused on making AACS a nimble fit and healthy organization with clearly defined goals objectives and strategies. By focusing on a few things and doing them well new levels of accomplishment are assured. Daniel Garrett Daniel Garrett is the new executive director of the American Academy of Cosmetic Surgery. Garrett joins the AACS with over 20 years of experience in philanthropy and association management having previously served as the executive director of the Iowa Chiropractic Society the president of the Young Womens Resource Center and the senior vice president of Prevent Blindness America. Garrett has a Bachelors in Business Administration from Iowa State University and is a member of the American Society of Association Executives and the Association Forum of Chicagoland. 8 Greetings from the New AACS Executive Director 9 In the book Road to Relevance written for associations it stresses the importance of focus and that trying to compete with other organizations across multiple fronts is futile. So AACS will concentrate on its core areas education and fellowships. The author states This will require a level of discipline heretofore unknown in the association community. It will require that boards understand the unfavorable consequences of dispersing resources across multiple association offerings. It will require the association to answer the concentration question. With condence in AACSs board of directors and my Sentergroup staff team we will continuously work on answering the concentration question. Both my professional and personal experiences have taught me that success is about the journey not the destination. I am excited to be on a new journey with all of you and look forward to seeing what we can accomplish together. 10 2015 ANNUAL SCIENTIFIC MEETING Stem Cell Advances While many physicians turn to the AACS and other various aesthetic societies to learn more about aesthetic medicine now surgeons from the AACS provide a teaching resource using their cosmetic skills in order to provide therapeutic stem cell deployments. How ironic that while medical doctors seek to secure a better economic status by virtue of adding cosmetic procedures to their practice cosmetic surgeons can now add therapeutic procedures to their repertoire. On January 15 during the Annual Scientic Meeting an all-day stem cell conference convened a multidisciplinary team of physicians that included cosmetic surgeons plastic surgeons orthopedic surgeons family practice specialists cosmeticgynecology surgeons stem cell scientists dermatologists urologists cardiologists immunologists and an attorney. This truly multidisciplinary group of physicians presented a variety of perspectives in the evolving area of regenerative medicine with foundations based in stem cell technology. In particular the event led off with Dr. Lewis Obi a renowned plastic surgeon from Jacksonville Florida. Dr. Obi discussed the use of adipose derived stromal vascular fraction added to adipose cells for a variety of clever breast reconstruction cases. Not only did he demonstrate improved volume replacement but also improved skin condition for difficult reconstructive cases suffering from tissue injury secondary to surgery andor radiation changes. He further demonstrated the use of adiposestem cell grafting in the area of facial rejuvenation. Dr. Steven Gitt a Phoenix based plastic surgeon went over statistics regarding safety and efficacy of a large network study. He described the basic safety in a study of over 1000 patients conducted in accordance by the Cell Surgical Network. There were minimal adverse eventsbasically related to mild liposuction site traumaand no significant adverse events related to the deployment of stromal vascular fraction SVF. Clinical outcomes showed good efficacy particularly in the orthopedic categories 80 positive outcomes and evidence of a majority of positive responses for all other categories of evaluation. Kristen Comella rated as one of the most influential stem cell scientists in America presented a variety of information about the efficacy of adipose derived stem cells. In addition she showed documentation of adipose cell superiority over bone marrow. She also showed enhanced cell production using medical grade collagenase versus lecithin. Lecithin has been recently used by doctors fearing the FDA has labeled collagenase as a substance causing more than minimal manipulation and therefore not approved for use. She also spoke about the recent FDA guidance draft suggesting Mark Berman MD FACS Mark Berman MD FACS is a cosmetic surgeon in Santa Monica California specializing in breast augmentation fat- grafting and Stem Cell Therapy. Dr. Berman is a Diplomat of the American Board of Cosmetic Surgery and the American Board of OtolaryngologyHead and Neck Surgery. He was 2010 President of the AACS. Dr. Berman was the course director for the 2015 Annual Meeting program on Stem Cell Advances. 11 that any disruption of the primary function of fat would be considered as more than minimal manipulation. Some of these guidance issues may or may not have relevance to the production of SVF. Jackie See MD a renowned cardiologist from UC Irvine shared a comprehensive history of SVF. Starting with the description by Zuk et. al. in 2001 he showed that over the next 10 years SVF had been shown to differentiate into a large variety of specialty cells beyond the typical mesenchymal variety typically attributed to adipose derived cells. His presentation in collaboration with his assistant Dennis Ling represented nearly 50 different articles chronicling the advancement of SVF to a multitude of cell lines. This important information suggests that stem cells from any source can be differentiated from nearly any cell line most likely because of the inuence of the particular growth factors and not because of the particular stem cell lineage. David Angelloni also a cell biologist looked at a variety of ways to harvest and quantify stem cells from adipose tissue. Todd Malan cosmeticgynecology furthered this discussion with a comprehensive view of adipose cell production by comparing a variety of cell production techniques and protocols. He showed good cell production for a variety of harvesting and processing techniques. Dr. Malan currently heads the Okyanos Heart program in the Bahamas. Orthopedic surgeon Thomas Grogan MD provided perspective on his involvement with adipose SVF for orthopedic deployments. Approached by Mark Berman MD Dr. Grogan reported that he started out highly skeptical about the use of these adipose derived cells and their potential capability. After reviewing a number of journal articles suggesting positive outcomes for orthopedic conditions using SVF he reluctantly agreed to see patients sent by Dr. Berman for evaluation and possible cell deployment. After witnessing several positive responses he started sending his own patients to Dr. Berman and continued obtaining more positive responses. Most of the orthopedic cases represented a variety of joint arthritis and unless the patient completely lacked joint cartilage there was a positive response witnessed by decrease or absence of pain improved mobility and often accompanied by radiographic evidence of cartilage regeneration. Now Dr. Grogan and his associates are leading advocates of SVF therapy for degenerative orthopedic conditions and employ SVF as an integral part of their practice. Elliot Lander MD provided a urological perspective based on his experience with nearly one hundred urological cases. In particular he demonstrated positive outcomes for Interstitial Cystitis Peyronies Erectile Dysfunction and a variety of other renalurological conditions. More than 90 of the Interstitial Cystitis patients experienced a significant degree of symptom improvementsomething that has not been readily accomplished with this horrible condition. He showed positive responses with Peyronies and by using a combination of ultrasound disruption and SVF he demonstrated significant improvement in a majority of ED cases. 2015 ANNUAL SCIENTIFIC MEETING12 Stem Cell Advances continued Dr. Sharon McQuillan of the Ageless Aesthetic Institute presented her experiences with her new laboratory partners. She suggested that she can vastly improve stem cell concentrations obtained from bone marrow and voiced concern about the latest FDA guidance on minimal manipulation. She suggested that this new guidance might dampen the use of adipose derived cells and suggested that bone marrow derived cells may have greater potential than previously realized. Ahmed Al Qatani MD PhD a professor at both UC Irvine and Emirates University presented his work with growth factors. Dr. Al Qatani provided a unique discussion on exosomes and growth factors helping the conference to understand the importance of these significant transcriptional factors. These messenger cells are the mainstay of communication between cells and responsible for cell differentiation. One of our honored special guests was plastic surgeon and inventor Dr. Hee Young Lee from Seoul South Korea. Dr. Berman originally met Dr. Lee in April 2008 and so began their relationship that has evolved over the years. Dr. Lee presented his novel idea of home cryopreservation and cell incubation with a system he invented enabling the production of mesenchymal stem cell expansion in an enzyme-free environment. Dr. Lee suggests that this environment allows for continual safe duplication of cells without the typical loss of potency usually found after five replication cycles. If true this would represent a phenomenal breakthrough in cell expansion. Allan Wu MD a leading stem cell scientist and physician provided an overview of the use of SVF and PRP for a variety of regenerative and cosmetic uses. Dr. Wu neatly packaged the experience of the PhDs and the potential translational work being done in the field by the MDs. The need clearly exists for more symbiotic relations and cross sectional studies. Mark Berman MD FACS Mark Berman MD FACS is a cosmetic surgeon in Santa Monica California specializing in breast augmentation fat- grafting and Stem Cell Therapy. Dr. Berman is a Diplomat of the American Board of Cosmetic Surgery and the American Board of OtolaryngologyHead and Neck Surgery. He was 2010 President of the AACS. Dr. Berman was the course director for the 2015 Annual Meeting program on Stem Cell Advances. Stem Cell Advances continued 131313 Wrapping up the day were discussions about the regulatory issues of concern in the production of SVF. Noted attorney and FDA specialist Andrew Ittleman presented a fairly ominous perspective of the recent FDA guidance suggesting that it is unknown how the FDA will ultimately police their new policies with doctors practicing SVF or stem cell deployments. As the FDA has expanded their denition of minimal manipulation to include any process that changes the characteristics of the original tissue from its current functione.g. in the case of fat removing its ability to cushion or support tissuesit is uncertain as to whether the FDA will exert its authority over individual practitioners providing point of care service. After a long discussion however Dr. Berman rebutted these comments by pointing out that everyone seems to have ignored the first page of the FDA mandate 21 CFR part 1271namely that the purpose of the regulation is to prevent the transmission of communicable disease. This is essential to the understanding of the regulation as the FDA maintains responsibility of drugs and devices and NOT surgical procedures. As such if no risk of disease transmission exists then the FDA would not exert authority over the processing of SVF during a surgical procedure or point of care delivery. As pointed out the only clinics or laboratories that have been shut down by the FDA have been those that failed to maintain GMP standards for production in a laboratory environment not within the clinic. Indeed the FDA has evaluated a variety of clinics using laminar flow laboratory production of cells within their clinic as point of care deployment and found no cause to shut down these clinics. Dr. Berman further argued that since his group CSN uses a closed sterile surgical procedure to produce adipose SVF this makes the procedure FDA compliant even though the FDA could not approve or disapprove of the procedure. We want to thank all of the speakers who supported the AACS by making the Stem Cell Session such a successful program. 2015 ANNUAL SCIENTIFIC MEETING14 Body Contouring Master Session The AACS offered a multitude of great sessions at its January meeting in New Orleans. One of the most popular was its Saturday general session on body implants various lifts and general body contouring which was packed with attendees all day long. The rise of post massive weight loss patients who desire body contouring procedures likely increased the popularity of this session. The lectures included a nice mix of comparing fat grafting versus implants as well as standard skin resection techniques versus techniques using liposuction and minimal undermining during skin resection. As always safety was stressed and specific peri-operative measures to prevent problems when taking on these major surgical procedures. A key point as stressed by faculty was a thorough pre-operative workup especially for the post-bariatric patient. Making sure the post-bariatric patient has adequate Protein Iron and B12 levels among other nutritional factors is critical to ensure proper healing. Also an honest assessment of your own surgical skills and facility is required to determine which body contouring procedures can be performed safely and proficiently. For example Lateral Thigh Bicep Tricep and Calf implants are not the most common procedures yet Dr. Nicholas Chugay and Dr. Paul Chugay have had a very nice career within this surgical niche. Patients come to them from all over the world for body implants. In the Chugays case the majority of these implants are in subfascial position however they also place them in submuscular position when extremely thin tissues exist. They do note that submuscular placement for extremity augmentation carries a slightly higher risk than subfascial augmentation. In general they report a relatively low overall complication rate for these particular body implants. The novice surgeon should realize that the complication rate may be higher for those surgeons who do not regularly perform these extremity implants in their practice. Certain extremity implants such as calf implants are more common than lateral thigh augmentation and are relatively simple to place in a subfascial position Figure 1. Managing potential post- operative issues for an extremity is more demanding than the procedure itself. Angelo Cuzalina MD DDS Angelo Cuzalina MD DDS is board certified by the American Board of Cosmetic Surgery and the American Board of Oral Maxillofacial Surgery. He is a past president of the AACS and ABCS as well as the section editor for post massive weight loss in the American Journal of Cosmetic Surgery. Dr. Cuzalina currently practices in Tulsa Okla. Figure 1. This is a young man shown before and three months following Calf Augmentation using solid silicone implants placed in a sub-fascial position. The horizontal incision behind each knee remains slightly erytheinmatous. 15 Dr. Jane Petro gave a superb talk specifically addressing safety concerns for major body contouring. She presented salient recommendations and reviewed pertinent literature related to body contouring like the major risk factors cited from a past PRS article listing these factors that remain applicable today. Dr. Clayton Frenzel also presented excellent pre- and post-care recommendations for the post-bariatric patient who desires a body lift. His dual training in bariatric and cosmetic surgery benefited the audiences understanding of post-bariatric patient needs. He stressed the nutritional deficiencies that may adversely affect the surgical outcome and should be evaluated before these major procedures. Major and Lethal Complications Risk Factors Pulmonary Embolism Massive Hemorrhage Surgical Times 4 hours Combination of Tumescent and General Anesthesia Greater than 4 liters of volume liposuction Necrotizing Fasciitis apparent within 24 hours Skin necrosis a consequence of poor surgical technique Visceral perforation nonexistent in Dermatologic care but was found in both tumescent local and localgeneral anesthesia Lack of surgical experience accompanied the failure to recognize complication in a timely fashion had a significant influence on morbidity. Plast. Reconstr. Surg. 121 396e 2008 Most cosmetic surgeons use more tumescent or super wet anesthesia in practice than is often reported in some plastic surgery literature. No doubt the use of this type of localized anesthetic fluid has had major positive influences on cosmetic surgery results. However it does create a potential for lidocaine toxicity that should not be overlooked. Dr. Tony Mangubat and Dr. Carey Nease stressed safety and each made nice use of subcutaneous fluid to improve their techniques during body lifts and Brachioplasty respectively. Both discussed details of these body contouring procedures with minimal undermining following liposuction and lipo-dissection prior to major skin resection Figures 2 and 3. Figure 3. This is a 50-year-old Hispanic female with severe circumferential trunk laxity following massive weight loss. She is shown before and six months following a full body-lift lipo-abdominoplasty and gluteoplasty. Figure 2. This is a 32-year-old post-bariatric female before and six months following Brachioplasty with liposuction immediately prior to limited undermining skin excision. She also had a mastopexyaugmentation. 2015 ANNUAL SCIENTIFIC MEETING16 Body Contouring Master Session continued Many of the great lectures from New Orleans can be viewed or purchased via AACS resources. Body Contouring Session Lectures at the AACS Annual Scientific Meeting 1. Augmentation of Calves and Hips Dr. Nicholas Chugay 2. Augmentation of Biceps and Triceps Dr. Paul Chugay 3. Buttock Augmentation via Fat Dr. Chad Deal 4. Buttock Augmentation via Implants Dr. Fil Rodriguez Dr. Marvin Borsand 5. Thigh Knee and Back Lifts Dr. Angelo Cuzalina 6. Arm Reduction Brachioplasty Dr. Carey Nease 7. Comparing 100 Consecutive Rhytidectomies Dr. Erik Nuveen 8. Body Lift Planning and Risk Prevention Dr. Clayton Frenzel 9. Lipo-Assisted Body Lifts AdvantagesDisadvantages Dr. Tony Mangubat 10. Body Sculpting Safety Concerns Dr. Jane Petro 11. Buttock and Pectoral Implants When Fat is Not an Option Dr. Angelo Cuzalina The variety of surgeons and body contouring techniques did allow great discussions and room for disagreement. Arguments are typically present when determining whether fat or implants may be the best choice for gluteal enhancement. Dr. Chad Deal obtains outstanding results with fat during Brazilian Butt Lifts but confesses that some patients simply have inadequate fat to get the buttock they are looking for thereby requiring Gluteal implants. Gluteal Buttock implants as discussed by Dr. Borsand and Dr. Rodriguez was a popular lecture since buttock augmentation in general has seen a rise in numbers thanks to shows like The Kardashians. Gluteal enhancement requests in the last two years have increased significantly making knowledge of surgical options and limitations mandatory Figure 4. Other talks covered most of the remaining procedures encountered following massive weight loss such as thigh lifting buttock lifts and back lifting. Thigh lifting tends to be one of the most intimidating body contouring procedures particularly if the laxity is extreme in nature. Massive thighs may even be staged with liposuction to debulk the thighs and perform a thigh lift with skin excision 36 months later Figure 5. It is prudent for a surgeon to begin with an easier and less risky body contouring procedure for a new patientto see how the patient healsbefore putting the patient through a more rigorous procedure and healing process. Major face and neck laxity can also be daunting. Dr. Erik Nuveen compared 100 consecutive facelifts and shared his comprehensive conclusions. It is interesting how many post massive weight loss patients can suffer extreme skin laxity of their mid-section yet often show minimal facial laxity. Facial laxity appears to have a stronger genetic component than environmental one. Regardless the theme of this all-day session involved addressing either skin laxity or body deficiencies to sculpt the human body. Angelo Cuzalina MD DDS Angelo Cuzalina MD DDS is board certified by the American Board of Cosmetic Surgery and the American Board of Oral Maxillofacial Surgery. He is a past president of the AACS and ABCS as well as the section editor for post massive weight loss in the American Journal of Cosmetic Surgery. Dr. Cuzalina currently practices in Tulsa Okla. 17 As far as advantages and disadvantages for staging a body lift Butt Lift Abdominoplasty it comes down to patient and surgeon preference. One distinct advantage for performing the butt lift portion at second stage is the ability to tighten or lift more aggressively one at a time and possibly a lower more hidden incision. There are however several advantages to the simultaneous body lift as well. Advantages of a Body Lift Butt Lift and Tummy Tuck performed in a single stage 1 Efficiency One single procedure for mid-section issues 2 Easier to avoid lateral dog ears 3 Simplicity in matching incision lengths 4 Convenience Especially if it is the patients top two complaints single recovery recovery period Advantages of Staging a Body Lift Tummy Tuck 1st Stage and Butt Lift 2nd Stage 1 Theoretically safer Lower DVT prevention better mobility after one major procedure vs. two Less blood loss Less O.R. time Less hypothermia 2 Easier post op course for patient less soreness 3 Potentially more skin excision on each side if separately performed Pearls for any Post Massive Weight Loss Patient Planning Cosmetic Surgery Correct anemia as much as possible prior to surgery Assure protein levels are adequate and get patient to 100 grams of protein per day for healing Be sure patient is getting adequate B12 and Iron prior to surgery Be prepared for a longer operation than that of a non-massive weight loss patient of the same size The AACS session on body contouring hopefully helped many cosmetic surgeons improve their practice with safe and reliable results. Superb facilities surgical help and a great ancillary team are all critical in effectively caring for these patients. Thankfully the Academy routinely offers continuing education and has surgeons willing to honestly report ndings and welcome questions from others seeking to improve. Figure 4. Before and after Brazilian Butt Lift or fat grafting to the buttock is shown in patients A and B. In C results from Gluteal Implants are shown along with pre operative markings demonstrating implant location just above the ischial tuberosity. Fat can also be added simultaneously as required to any lateral depressions. Figure 5. The before and after shown is following a major Thigh Lift using a vertical and horizontal excisional technique. Of note this was a 2nd staged procedure following initial liposuction debulking removing several liters of thigh fat during a abdominoplasty four months prior to this 2nd stage thigh lift. 2015 ANNUAL SCIENTIFIC MEETING Complications of Facial Cosmetic Surgery Elie M. Ferneini MD DMD MHS MBA FACS Dr. Ferneini is a practicing Oral and Maxillofacial Surgeon in Connecticut. Hes the Medical Director of Beau Visage Med Spa and an Assistant Clinical Professor at the University of Connecticut. He is on the editorial board of multiple medical journals. 18 This educational session reviewed the most common complications associated with facial cosmetic surgery. It was divided into four lectures Complications of blepharoplasty presented by Dr. Mo Banki Complications of rhytidectomy presented by Dr. Charles Castiglione Complications of minimally invasive facial surgery presented by Dr. Elie Ferneini Frequently encountered facial cosmetic surgery complications presented by Dr. Cortland Caldemeyer Complications following facial cosmetic surgery can be devastating particularly because of the elective nature of these procedures. As with any surgical procedure complication prevention is paramount. Additionally early recognition and management are important. The most important factor in cosmetic procedures including facial surgery is managing your patient expectations. Patient selection is a key factor in maintaining a successful and prosperous practice. Effective communication between the surgeon and patient allows the surgeon to understand the patients motivations expectations and goals. This is extremely important in the post-operative period when the patient might feel unsure or insecure about the surgical outcomes and results. Additionally early recognition is an important factor in proper and accurate management of any complication. Informed consent is also an important aspect of the pre-operative surgical planning. Ideally an informed consent must be detailed and should address any possible surgical complication. Complications from blepharoplasty can be divided into early within a week after surgery intermediate 16 weeks post-operatively and late after 6 weeks. Although rare visual loss after a blepharoplasty is an early and dreaded complication. This is usually due to a retrobulbar hemorrhagehematoma. A retrobulbar hematoma usually presents as severe unilateral pain with a tense proptotic globe. This is a true medical emergency. Immediate decompression is recommended. This is usually performed by a lateral canthotomy and cantholysis. Additionally opening all the incision sites can help decrease the intraocular pressure. Other medical management to prevent permanent vision loss includes Mannitol Diamox and corticosteroids. An ophthalmologic consultation is also recommended. This rare complication can be avoided by a detailed preoperative evaluation as well as intra- and post-operative hemostasis. Other complications include corneal abrasion chemosis upper eyelid ptosis lagophthalmos lower eyelid malposition and strabismus. 19 Rhytidectomy is a predictable procedure with a high patient satisfaction rate. Some of the complications from rhytidectomy include 1 hematoma 2 nerve injuries 3 infection 4 skin flap necrosis 5 hypertrophic scarring 6 alopecia and hairlineearlobe deformities and 7 parotid gland pseudocyst. A post-operative hematoma must be recognized and promptly treated. It usually occurs within 24 hours post-operatively. Facial nerve injury is another rare complication. The deeper your plane of dissection the greater the risk of nerve injury. Minimally invasive cosmetic procedures are safe for the most part. However these procedures have been recently associated with rare and potentially irreversible adverse events. Some of these complications include embolization andor arteriole occlusion injectable-related vascular compromise and skin necrosis cellulitis hypersensitivity reactions and nodules and granulomas. Irreversible blindness is a rare but worrisome complication following facial soft tissue filler augmentation. This is usually due to an inadvertent injection of a filler material into a small facial artery and retrograde arterial flow. Some of the filler facial danger zones include Glabella area Supratrochlear artery Lip Labial artery Nasolabial folds Angular artery Some of the ways to avoid an intravascular injection include Injecting slowly Using extreme caution in areas of large vessels Angular artery Supratrochlear artery Supraorbital notchforamen Infraorbital foramen Aspirating before injection Knowing your landmarksanatomy Finally proper patient selection mastery of pertinent anatomy attention to meticulous surgical technique and conscientious post-operative care are all important factors in preventing and managing facial cosmetic surgery complications. 2020 2015 ANNUAL SCIENTIFIC MEETING Fractionated Lasers 20 Suzan Obagi MD Suzan Obagi MD is the Associate Professor of Dermatology and Associate Professor of Plastic Surgery at the University of Pittsburgh Schools of the Health Sciences. She is also Director of the University of Pittsburgh Medical Center UPMC Cosmetic Surgery and Skin Health Center and the UPMC Cosmetic Surgery and Skin Health Center MediSpa. Dr. Obagi is board certified by the American Board of Dermatology and American Board of Cosmetic Surgery. Advances in fractionated lasers have spurred an increase in skin-resurfacing procedures. At one point in time chemical peels were the mainstay of skin resurfacing. The introduction of carbon dioxide CO2 10600 nm and erbium yttrium aluminum garnet ErYAG 2940 nm lasers made skin resurfacing a procedure that could be taught to many physicians especially those that were either afraid of chemical peels or had not learned chemical peel resurfacing during their training. It became apparent that one had to be selective when choosing on whom this laser resurfacing was performed due to the incidence of hypertrophic scarring and permanent hypopigmentation. Quickly the pendulum swung from ablative laser resurfacing to nonablative resurfacing. However even with multiple treatments the results were minimal at best. At this point nonablative fractionated lasers came out claiming to be more aggressive than nonablative lasers but less so than traditional CO2 and ErYAG lasers. Once the safety of these devices was confirmed companies introduced ablative fractionated lasers. A variety of ablative fractionated lasers are available on the market. While it is beyond the scope of a short article to cover the nuances of each device in detail there are several considerations to take into account when deciding which device to purchase. Wavelength is probably the most important consideration. The most common wavelengths available are CO2 ErYAG erbium yttrium scandium gallium garnet ErYSGG 2790nm and fractionated radiofrequency RF. Each wavelength has unique properties that can be an asset or a detriment depending on the goals of treatment. ErYAG lasers have a 25 fold higher affinity for water compared to CO2 lasers. This means that ErYAG lasers are ideally suited for ablation especially of fibrotic tissue. Since there is little coagulation left behind these lasers make ideal channels for opening up portals for drug delivery into the skin. The downside is that this wavelength does not leave a big zone of heat coagulation around each microthermal injury zone MTZ so there is only a small amount of tissue shrinkage or tightening. The best indication for this may be in patients with darker skin types patients with fibrotic or thickened scars possibly followed by topical steroid or 5-fluorouracil application and skin that has heavy solar elastosis. CO2 laser has less affinity for water therefore the treated skin has small zones of ablation and a fair amount of coagulation around each MTZ. This means that patients with stretchable improve in appearance if the skin is stretched scars stretchable wrinkles and lax skin are the ideal candidates for this procedure. The downside although I personally have not experienced any is the concern about treating darker skin type patients due to the concern with hypopigmentation. This issue needs to be studied further as it seems that even in darker skin patients there is very little real risk of hypopigmentation. ErYSGG lasers claim to have a bit of the vaporization profile of ErYAG and some of the coagulation tightening of CO2. This wavelength seems to help with fibrotic scars and deeper rhytids. The downside to this laser is the pixel marks left on the skin of the face but more so when this laser is used off the face. Other factors to take into consideration with the purchase of a new laser is the ease of use any disposable costs whether or not this modality ts the patient demographic and ethnic makeup in your practice and the amount of sun and hot weather versus cooler temperatures in your region. However with proper patient selection skin preparation and the proper laser results can be extremely rewarding. 21 Photos are before and after Fracitonal ErYSGG resurfacing of the forehead and perioral areas along with chemical peeling of the rest of the facial skin. 2015 ANNUAL SCIENTIFIC MEETING22 Melanie D. Palm MD MBA FAAD FAACS Melanie D. Palm MD MBA FAAD FAACS is Director of Art of Skin MD and Assistant Volunteer Clinical Professor at University of California San Diego. Radiofrequency for Skin Tightening Radiofrequency RF is a type of electromagnetic wave with wide applications in the medical and technology fields. Industrial applications include the use of RF frequencies ranging from 3 kHz to 24 GHz. Interestingly RF has been used in medicine for over a century and radiofrequency has wide ranging applications from radio and TV broadcasting to wireless technology and satellite communications. RF has become an increasing popular modality for skin tightening. It relies on bulk heating of tissues to create neocollagenesis and resultant improvements in skin texture and tone. Higher RF frequencies result in more supercial skin treatment whereas lower frequencies allow deeper tissue penetration. RF technology for skin tightening is typically divided into monopolar and bipolar technologies describing the placement of the electrodes on the device. Monopolar technologies are composed of a negative electrode active treatment site with a remotely located positive grounding electrode grounding pad located elsewhere on the body. Bipolar RF technologies consist of positive and negative electrodes located together at a fixed distance on the active treatment tip. Multipolar technology describes the use of various monopolar and bipolar configurations such as tripolar or octopolar platforms. Other categories include unipolar RF in which one electrode emits a large field of RF from a signal broadcasting node and field RF which creates a large surface area of RF treatment. The potential advantages of RF technologies include a minimally invasive to noninvasive treatment modality for skin tightening to the color-blind effect on tissue. Due to its purely thermal effect on target tissue all skin types may be treated with RF. Disadvantages of RF include modest treatment outcomes adverse events associated with monopolar current grounding or inappropriate energy delivery and consumable parts on some devices. Radiofrequency technologies is an area of intense industry growth and patient interest and it is likely that technological gains in coming years will yield beneficial results for patients. Microfocused Ultrasound for Skin Tightening Microfocused ultrasound MFUS is a more recent development in the skin tightening arena becoming FDA-cleared for its first application in brow lifting in 2009 with separate indications for the neck submental area and dcolletage in the last three years. MFUS uses sound frequencies beyond the audible range. Ultrasonic waves of energy in the MHz range are used to both image tissue during treatment as well as focus them to deliver precise points of thermal injury to stimulate new collagen growth eventuating in tissue lifting and skin textural improvements. Skin Tightening with Radiofrequency and Microfocused Ultrasound Energies 23 A MFUS treatment consists of using several transducers that deliver the focused ultrasound energy at different frequencies. Lower frequencies such as the 4MHz deliver energy at a greater depth approximately 4.5 mm below the skin surface while the highest frequency 10 MHz transducer delivers ultrasound at a shallow 1.5 mm depth. MFUS is completed as a single session with results appreciable at 36 months after treatment. Although results from MFUS are FDA-cleared for 12 months of duration clinical experience indicates that the skin tightening effects may last for 1824 months. Potential advantages of MFUS include a single no downtime treatment session and safety in all skin types. Similar to RF disadvantages of MFUS include clinical results that may not approximate a surgical intervention and the use of a consumable component during treatment which increases the price of the procedure for the patient. The applications of MFUS are likely to diversify in the future. Although FDA-cleared for the brow lower face neck and dcolletage treatment off-label use has included treatment of the buttocks arms knees axillary hyperhidrosis scar remodeling and softening of implanted silicone. 1 MHz 2 MHz 3 MHz 4 MHz 5 MHz 6 MHz 7 MHz 8 MHz 9 MHz 10 MHz 2015 ANNUAL SCIENTIFIC MEETING24 Julie Woodward MD Julie Woodward MD is the Associate Professor of Ophthalmology and Dermatology and Chief of Oculofacial Surgery at Duke University Medical Center. The diverse and multidisciplinary panel was directed by Julie Woodward MD with invited speakers Suzanne Freitag MD Tanuj Nakra MD Joe Niamtu DMD Adam Scheiner MD and Betsy Coln-Acevedo MD. Periocular rejuvenation can be a daunting experience for the cosmetic surgeon to master. The skills utilized to perform successful procedures on this area can be perfected throughout a surgeons career. This course attracted professionals of all levels of experience from the very novice to the well-seasoned blepharoplasty surgeon. Dr. Freitag from Harvard began the course by describing the upper eyelid anatomy and upper blepharoplasty evaluation. Periocular aging is characterized by volume loss skin and muscle laxity and bone reabsorption. She reviewed pearls of upper blepharoplasty evaluation and techniques. Due to the complex eyelid and orbital anatomy and its direct relation with the eye care must be taken to avoid damage to the ocular surface while performing such procedures. Therefore a full ophthalmic evaluation including visual acuity intraocular pressures and corneal status should be included in the pre-operative evaluation. She wrapped up with management of complications such as dry eyes corneal abrasion and orbital hemorrhage. Dr. Nakra from Austin took on the challenge of describing many techniques to improve the appearance of the lower eyelids. He discussed evaluation of the lower lid including dermatochalasis tear trough pronunciation lower eyelid position and laxity and midface volume loss. He provided detailed descriptions of techniques to transpose fat over the infraorbital rim and into the midface in conjunction with lower eyelid tightening pearls. Dr. Niamtu from Richmond described advanced blepharoplasty techniques using technologies such as the CO2 laser incisional surgery and radiofrequency unit to create a nearly bloodless surgical field. He also described the importance of addressing photo-aging at the same time as blepharoplasty with either laser resurfacing or chemical peel. Dr. Niamtu routinely performs blepharoplasty with facelifts and browlifts but characterizes blepharoplasty as one of his favorite and most rewarding procedures to perform. Periocular Rejuvenation 25 Dr. Scheiner from Tampa discussed his techniques of using lasers to minimize lower lid festoons. He also reviewed management of laser resurfacing complications. He reviewed laser settings for both Erbium and the CO2 laser. For those surgeons interested in performing minimally invasive rejuvenation with fillers Dr. Coln-Acevedo Duke University Oculofacial fellow provided a complete review of facial fillers. The use of dermal fillers with cross-linked hyaluronic acid HA for periocular rejuvenation is a safe and effective procedure for restoring volume loss and improving the appearance of the infraorbital and malar hollows. Selecting a good HA filler will depend on a patients evaluation and on knowing their filler rheologic properties G due to the fact that this characteristic is essential to make a good product selection. Restylane and Belotero were recommended to be the preferred fillers in this area because they do not swell as much as other fillers and are reversible with hyaluronidase. Anatomy of the supra-trochlear dorso-nasal and angular and transverse brow arteries were reviewed to avoid emboli and blindness. Dr. Woodward Chief of Oculofacial Surgery at Duke wrapped up the talks by reviewing key points for the blepharoplasty evaluation. She showed various photos of cadaver dissections to highlight key anatomic structures. She mentioned the rotation of the lower midface inwards as well as the floor of the orbit downwards. Different brow lifting techniques including endoscopic and trichophytic were described and a suggestion to not over-perform the brow lift was mentioned. Again the importance of being able to manage complications was stressed. The surgeon should have fluorescein and a cobalt blue penlight available to be able to diagnose a corneal abrasion. Proper pressure patching of an abrasion with ointment was shown. The differences between a venous and an arterial orbital hemorrhage were shown. Techniques to prevent these are of course the best medicine but proper immediate treatment with lateral cantholysis drops to lower the pressure and oral Diamox 150mg to 500mg were also discussed. Periocular aging remains one of the most popular patient requests for facial rejuvenation. Patients want this to avoid looking tired or mad and instead provide a youthful and rested appearance. This course provided experts who taught from many years of personal experience and provided a multitude of pearls including evaluation techniques safety and management of complications. SURGERY WORKSHOPS26 The Academys 2015 Live Surgery Workshops are designed to bring you to the front lines of the most popular and sought-after treatments in cosmetic surgery today. From fat grafting to breast augmentation you have an opportunity to observe first-hand the leading techniques and best practices employed by top surgeons. Earn valuable CME in cosmetic surgery. Each two-day course offers between 1619 CME credits. Observe and ask questions of a diverse roster of experts renowned for their groundbreaking techniques and technologies. Build relationships with course faculty and fellow participants expanding your cosmetic surgery network. Enhance your skills in the techniques and treatments your patients want resulting in better patient outcomes and more business for your practice. Space is limited so reserve your spot early at AACS workshops are intended for the intermediate surgeon but can serve as a refresher for those more experienced. They are held over weekends and offer CME credit. Space is limited based on location size. Registration Rates AACS Member 2400 Nonmember 2700 Resident 1000 For more information and to register visit 2015 Live Surgery Workshop Series 27 The Art of Fat Grafting for Facial Rejuvenation and Body Contouring May 1517 Directors Carey Nease MD and Chad Deal MD Chattanooga Tennessee Offering up to 16 CME Credits Enhanced Facial Rejuvenation June 1213 Directors Angelo Cuzalina MD DDS and Joe Niamtu III DMD Tulsa Oklahoma Offering up to 17 CME Credits Breast Augmentation Improving Patient Outcomes September 1112 Director Mark Mandell-Brown MD Cincinnati Ohio Offering up to 16 CME Credits Liposuction Fat Grafting and New Lipoabdominoplasty Techniques October 1617 Directors Marco Pelosi II MD and Marco Pelosi III MD Bayonne New Jersey Offering up to 19 CME Credits Body Contouring following Bariatric Surgery Massive Weight Loss November 67 Directors Angelo Cuzalina MD and Jacob Haiavy MD Tulsa Oklahoma Offering up to 17 CME Credits FELLOWSHIP28 Dayne R. Jensen MD DMD Dayne R. Jensen MD DMD is a 2014-2015 Cosmetic Surgery Fellow at Cosmetic Surgery Affiliates in Oklahoma City Oklahoma. A Perspective From Fellowship Where Has All The Vanity Gone I was a second-year resident when I knew that I wanted to pursue cosmetic surgery. I was mesmerized by the combination of surgical techniques and anatomical artistry. At least for me it seemed that no other arena could have possibly been a better fit. As I began to vocalize my career ambitions most agreed that the surgical procedures were second to none however an equally strong sentiment followed concerning the cosmetic patient population. I was told how these patients were difficult vain and impossible to please. Others voiced the unimaginable torment it would be to deal with these patients on a daily basis. I have to admit this feedback was to say the least alarming. If this was going to be a miserable career choice then maybe I should re-evaluate my desires. I began to explore other avenues with the hopes that my passion for cosmetic surgery would be overtaken and superseded by another more acceptable field. My disappointment availed and I could find nothing that excited or inspired me like cosmetic surgery. I vividly remember the night I sat down with my wife to share my unfortunate decision to pursue cosmetic surgery. When I informed others of my decision I was given their condolences and the proverbial Im glad its you and not me pat on the shoulder. It was with this frame of reference that I packed my little family into a U-Haul with all of our tattered belongings and headed to fellowship. What happened next turned everything I thought I knew about cosmetic surgery upside down. Every year during the first week of July my fellowship director returns to his home town for a family reunion. The surgical schedule is appropriately cleared and all patients are advised. Our practice manager takes advantage of this time and this past year scheduled a studio to film patient testimonials for our new website. As no surgeries were scheduled I was invited to the studio to learn the marketing side of the business. A total of thirteen patients were invited to the studio with instructions to wear what made them feel confident. No script or coaching was provided. I imagined what the patients were going to look and be likeskimpy clothing and shallow perspectives. I watched and listened as our first patient was brought on set. She was an older woman and very modestly dressed. She spoke about finally looking the way she had always felt she should and being a better grandmother since her surgery because she had regained her self-confidence. She spoke of taking control of her life and for the first time feeling as if she were living it to its fullest. She proudly reported that she had always met and attended to the needs of those around her and this was the first time she had truly done something for herself. She beamed with confidence. Her testimonial was inspiring and emotional. I thought to myself after she left Certainly this will be the only patient of substance soon those vain and shallow patients will arrive. I was amazed when patient after patient arrived and all had a story more inspiring 29 than the next. Where is the vanity I thought. When will I meet those patients The truth is that this was a precursor for most of my future patient interactions. My fellowship director quickly taught me that the most important aspect of a consultation is to listen to the patient. They all have a story and in order to truly provide a service you must understand who they are and where they are coming from. I took this advice to heart. I have tried to truly understand where the patient is coming from and I have been fortunate to meet some inspiring people. Most of whom were dealt situations in life at no fault of their own that appeared near impossible to overcome. However overcome they did and each would tell you that they are better because of it. I have come to learn that this career choice isnt great in spite of these patients but because of them. The surgical component of what we do is second to none but participating in renewing ones self-worth is priceless. Before every surgery my director says to each and every patient I wish I could guarantee you that everything in this surgery is going to turn out perfect. If I could I would. There may be challenges ahead and I am honored that you have chosen me and my practice to accompany you as we move forward together on this journey. I promise you I will do my very best and that during this time you will have my undivided attention. While you are under my care in this surgery you are the most important thing to me in the world. We will make it through this together. Again thank you for trusting us. These patients have chosen us because they believe we can help them. The short time I have spent in this wonderful eld has taught me that it is simply our privilege to join them in their journey towards bettering themselves. PRACTICE MANAGEMENT30 Practice Management Patient Loyalty. How to Earn it. How to Keep it. Tami Vileta-Wells Tami Vileta-Wells is the Director of Creative Strategy for Strategic Edge. She presented this information at the AACS 31st Annual Scientific Meeting in January during her session Patient Loyalty. How to Earn it. How to Keep it. Starbucks. Apple. Harley-Davidson. Some of the most admired brands in the world have the most fiercely loyal customers. They spend time and resources focusing on customer loyalty because there are so many rewards that go along with it. At the 31st Annual Scientific Meeting we presented Patient Loyalty. How to earn it. How to keep it. We made the case for practices to turn their attention from mere satisfaction goals to loftier loyalty goals in order to stay competitive in todays market. Making Patient Loyalty an integral part of corporate culture can truly transform a practice. One of the ways we have seen practices elevate their patient loyalty is by launching a well-executed patient loyalty program. But before you launch we have five important keys to success 5 IMPORTANT STEPS TO LAUNCHING A SUCCESSFUL PATIENT LOYALTY PROGRAM 1. Give your program a name and graphic treatment. You should follow a few rules when you and your staff are brainstorming program names. Make sure your final pick is short and sweet highly memorable can withstand the test of time and flows well with your overall brand. After you have a name secured bring it to life with a stylized graphic treatment and use this treatment consistently wherever you promote your program. Examples 2. Put your new program name on a commemorative item that your patient will be proud to carry with them and must display to redeem benefits. Most practices choose some form of metal or plastic rewards card that can fit in a wallet but your item could take many forms. You can get really creative here. Think about your patient base and what they might embrace. A lapel pin A key tag Maybe a tote Whatever you select make sure that your commemorative item can be printed to beautifully represent your new name and graphic treatment and that you package the item in a unique way to elevate its perceived value. Your commemorative item and its packaging should be worthy of sparking a conversation if its seen by a non-member. 3. Structure your program for commitment. Certainly youre going to build in a commitment to the patient when you structure your loyalty program. Youre going to offer them products and services at an attractive rate in order to increase their immunity to the pull of competition and keep them coming back to you again and again. But also remember to structure in a commitment from the patient to your practice. The best programs weve seen have some form of financial skin in the game from the patient as well. Free programs are not perceived as high in value as those that require some form of financial obligation. There are a number of ways you can structure a financial commitment from your patient. The final method you choose should take into consideration your patient base and demographics the competitive landscape your suite of procedural offerings your practice lifecycle and your long-range program goals. Typically we see practices offering 23 buy-in or pre-paid options and patients can select the level that best ts their budget and aesthetic goals. As they increase their financial commitment they receive incremental value i.e. increased benefits complimentary services priority scheduling etc. Another form of commitment structure amortizes the financial commitment via a monthly membership structure. Patients can sign up for a 6- or 12-month commitment and are billed monthly. Still other methods can structure around a suite of services aimed at solving an aesthetic challenge ie anti-aging and sun damage and follow a flat fee structure with a deep discount rate. 31 32 There are literally dozens of methods you can use to build in reciprocal commitment between your practice and your loyal patients. Whichever one you select be sure to include rewards and incentives for the following loyalty behaviors 1 Reward for referrals 2 Reward purchases across product and service lines 3 Reward for winning total share of customer 4 Recognize key dates for members such as birthdays and anniversaries Also make sure your structure is SIMPLE so your staff can easily explain it and patients can quickly understand it. Benchmark a few of your commitment structure ideas with some of your most loyal patient champions and get their feedback. In addition solicit ideas from your staff. If you need further assistance with program structure seek the advice and consultation of a professional medical marketing firm who specializes in developing patient loyalty programs. 4. Make your program HIGHLY visible. Many loyalty programs are launched and then simply left. Subsequently they may have a great name and structure but are just never noticed. Youve got to make your program visible in your office on your website and in your patient take-home materials so patients NOTICE it. Give it a dedicated web page and make sure you point links to this page throughout your site. Promote it on your electronic kiosks and with professionally designed posters or pop-ups in your waiting areas. Make sure every consult room and your check-out desk has a mini-kiosk with program Tami Vileta-Wells Tami Vileta-Wells is the Director of Creative Strategy for Strategic Edge. She presented this information at the AACS 31st Annual Scientific Meeting in January during her session Patient Loyalty. How to Earn it. How to Keep it. Practice Management Patient Loyalty. How to Earn it. How to Keep it. PRACTICE MANAGEMENT 33 information. Produce a brochure with the details of your program and include it in every patient folder. Give your staff and patients a few promotional items that carry your program name and graphic treatment. Hype your program in your eblasts newsletters on social media and in direct mail. Finally if youre launching a new loyalty program to your patient base do it with a spectacular launch event and then continue to have mini events for members throughout the year. The most successful programs are promoted professionally and promoted WELL. 5. Ensure success from the ground up. This is by far the most important step to ensure success for your loyalty program. Your staff has got to LOVE it. More importantly they have to BELIEVE its in your patients best interest. The best way to ensure your staffs love and belief in the program is to solicit their early engagement and ideasand build them into your overall structure. Developing a patient loyalty program should not be a top-down directive but more a dynamic and organic team effort. Once youve developed your program train your staff to suggest it sell it AND gather feedback from patients about it after launch. Loyalty programs should not be static. Once launched you should have a continuous improvement process in place to enhance the program over time. As you make positive changes it gives new opportunities to communicate with your patient base. Remember keeping your program mechanics simple and easy to understand will go a long way in helping your staff embrace it. After all they are the ones who have to explain it to your patients. Finally incentivizing your staffeither financially or with a trial of some of the program benefitsis a great way to ensure they suggest and sell the program. Keep the program top-of-mind in your weekly meetings and set clear milestones that are celebrated when met. NNews Notes 34 NEWS NOTES SUBMIT YOUR ARTICLES Surge is dedicated to bringing you the latest news and information about AACS members and cosmetic surgery. Each issue of Surge features articles on procedures technology current news member activities and updates. We encourage you to submit your news items for review. Submissions may be sent to Jean OBrien Director of Marketing at Questions Call 312.981.6760. UPDATE YOUR PROFILE TO APPEAR IN FIND A SURGEON TOOL The Find a Surgeon tool is one of the most popular areas of the new AACS website Can potential patients find you Log in to the website today and update your profile to ensure your correct address appears in search results. Only physician records with validated professional addresses will appear. And make sure to select your specialty and also list the procedures you performanother way patients can find you. If you need assistance please email or call 312.981.6760. MESSAGE FROM THE COSMETIC SURGERY FOUNDATION We hope you had a fantastic meeting in New Orleans. The Cosmetic Surgery Foundation would like to thank our volunteer board members and our donors for their auction items and donations. If you missed out dont worry there will be a second chance auction posted soon for a few newly donated observational courses. Because of your generosity we were able to raise 50000 through the event. 2015 is off to a great start We are looking forward to updating you on our exciting monthly progress toward our three key goals research and education grant awards our pro bono program and funding for fellowships. NEW MEMBERS The AACS would like to welcome the following who have been recently approved for membership. Congratulations and welcome to the AACS community AACS FELLOW Anthony Bared MD Mark Karolak DO James Steven Widner DDS AACS PHYSICIAN Emily Bullock MD Zoe Deol MD FACS Lisa Espinoza MD Clinton Wilkinson Evans MD Charles F. Fatseas MD Wissam Fayad MD PC Ricardo Becker Ferla MD Bonnie Fraser MD Daniel Harris MD Robert B. Hunsaker MD DDS Shereene Idriss MD Ray Pourang Kamali MD John T. Katzen MD Brian Calder Kerr MD John Paul Laura DO Jeffrey T. Liegner MD Emilio Lopez MD Shahzad Musavi MD Mohsen Naraghi MD William Onwuka MD Michelle Owens MD Ellen Ozolins MD Herman Pang MD Jose Emiliano Rivas MD Omeed Sani MD Randy Sanovich DDS Anamika Sharma MD Adel Soliman MD Ismet Tamer MD Jamshid Tamiry MD Zaw Tun DDS Wei-Tai Yu MD RESIDENTS Demetri Arnaoutakis MD Christopher Fries DDS Mark A. Halsey MD Max Kernizan DMD Honey Mahmoudi MD Jeremy May DDS Heather Vande Ven DO Ruslan Zhuravsky DO ALLIED HEALTH MEMBER Mandy Newman Trang Bui Paige Cuzalina Meagan Taylor Larson Holly Rainer Laura Kelly Richter Tuckwiller 225 W. Wacker Drive Suite 650 Chicago IL 60606