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

Official Publication of the Debra Yates, Editor • Jeannine L. Dabb and Karen Davis, Assistant Editors Winter 2010

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

Specialty SkinCare

SPSSCS MissionThe Society of Plastic Surgical Skin Care

Specialists is a voluntary, non-profit organization dedicated to the promotion of education,enhancement of clinical skills and the delivery ofsafe, quality skin care provided to patients withinthe office of a Plastic Surgeon certified by theAmerican Board of Plastic Surgery or the RoyalCollege of Physicians and Surgeons of Canada.

Sandra M. DayPresident

Susan M. Wells, RN, MSPresident-Elect

Tracy L. ThadenVice President

Stephanie Holden,RN, BSNTreasurer

Susan TognazziniSecretary

Karen DavisMember-At-Large

Abbey Helton, BSN, RN, CPSNMember-At-Large

Donna Sollima, RNMember-At-Large

Elena Reyes, CMA, RSTParliamentarian

Kathy Jones, BSN, RN, CPSNImmediate Past President

Richard A. D’Amico, MDASAPS Advisor

Renato Saltz, MDASAPS Advisor

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SPSSCS Board of Directors 2009–2010

oes anyone rememberthe episode of “Sex and theCity” where Samantha is talkedinto a chemical peel by herdermatologist and ends uplooking like a boiled lobster?While some chemical peels inreal life can do this, I worry theaverage TV viewer got theimpression all chemical peelswork this way and that’s just nottrue. So to answer the title questionscientifically, let’s first take a look atcommonly used chemical peeling agentsand categorize them by activity. There areactually three main types:

1. CORROSIVE AGENTS: Primarily acids used at a concentration

sufficient to dissolve skin cells. Low pH(<2) Trichloroacetic acid and Salicylic acidat concentrations greater than 10% andalpha hydroxyacids (e.g. Glycolic andLactic) greater than about 30%, are goodexamples of corrosive peeling agents.

2. TOXIC AGENTS: Used for deep peels, toxic agents kill

living cells. Phenol, Croton oil, (thecombination of which are in the Baker-Gordon peel) and 5-FU are cytotoxicpoisons that cause sheets of dermal cells to

die, separate and slough off.Note that Phenol is onlyweakly acidic...a 10% aqueousdispersion has a pH of around5. Croton oil, because it’s notwater soluble, isn’t acidic at all.If that’s not enough, 5-FUsolutions are actually basic,with a pH of around 9! So whosays you need a low pH to peelthe skin?

3. CELL ADHESION MODIFIERS: These are compounds that peel the skin

primarily by ‘unsticking’ skin cells fromeach other. Specifically, they chemicallyinteract with cellular adhesion molecules,which include molecular complexes calleddesmosomes, along with special proteinsand lipids that form chemical bonds on thesurfaces of cells. They usually have lowtoxicity and corrosive properties, and thusdon’t really ‘burn’ or injure the skin.

The most widely used of these agentsare low-concentration acids, such as TCAand Salicylic acid below around 10% andalpha hydroxyacids below approximately30%. Here the acids don’t dissolve cells;rather they just affect the adhesionmolecules so that skin cells disengage andslough off.

D

Rethinking Chemical Peels: Must we ‘Burn’ our Patients?

John E. Kulesza

From the Editor’s DeskDebra Yates

o exfoliate or not to exfoliate:that is the question. No, I am not quotingShakespeare, but it is a question thatcomes up in this issue of our newsletter.As someone that has been in the skincare business for over 25 years, I feel Ihave some expertise on the subject. Ido love the retinols and we are a bigproponent of tretinoin our practice. Wehave used Dr. Albert Kligman’s, “Thefather of Retin A™,” compounded formulafor over 25 years. We have seenremarkable results in our patients’ skin.

Please read John Kulesza’sinformative article on the latest inchemical peels and the science to backit up. I also like his analogy to one ofmy favorite TV shows. He brings up aninteresting question: how far do we goto injure the skin to get the best results?

Another viewpoint is from Dr. BenJohnson, who makes some very strongclaims and stirs up some controversy in

Continued on page 12Continued on page 15

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year, and we decided direct mail marketingwould be more effective. Inspired by aprinted brown bag from a local officesupply store, hidden within the advertisingpages of our Sunday paper, I had anepiphany. Instead of simply sending apostcard offering specials or a discount onproducts, we produced a mailing thatcaptured the recipients’ attention. For manyyears, we’ve placed purchased products inour 9” x 12” white signature plastic bagswith our name, phone number, and websiteimprinted in silver foil (keep your namebefore the buyer!). It was simple enough tohave our printer produce small goldadhesive labels to place on our bags withthe message, “17th Anniversary Special—20% OFF Everything You Can Fit in ThisBag!” IT WORKED! Clients who live in thepenthouses of the Ritz-Carlton, as well asthose who live in the suburbs, came in tofill their bag and purchase products. Itreminded many to schedule an overdueappointment for skin care or other services.Although it was certainly time consumingto print the address labels, stuff the plasticbags into our letterhead envelopes, seal andmail, it was definitely time well spent! Itmay sound gimmicky, but the results havebeen phenomenal.

Never before has the need to becreative been more important. Be the bestthat we all can be. Sharing ideas and

contributions are vital to our growth andmutual prosperity. Please contact medirectly at sandraday@neoderm.com withyour comments or questions.

The Society of Plastic Surgical SkinCare Specialists is devoted to providing youwith the latest educational information inour field to elevate your skill andknowledge levels. Our Program Committee,chaired with dedication by Susan WellsRN, MS, has been inspired by ourchallenging economy to design a dynamiclearning experience for the upcoming 16thAnnual Meeting in Washington, DC. You’llhave your choice of optimizing yourexperience from a variety of pre-meetingcourses, a well known and inspiringKeynote Speaker, Geno Stampora,outstanding scientific sessions presented byrenowned faculty presenters, roundtablediscussions…and much more. Make yourplans now to join us for Skin Care 2010—“Capitalize on Your Skills,” April 20-23, tonetwork with fellow professionals whoshare your passion in exceedingexpectations and thriving in our chosenfield.

A healthy, prosperous New Year to all!

“If we had not winter, the spring would not be sopleasant; if we did not sometimes taste of adversity,prosperity would not be so welcome.”—Anne Bradstreet �

he first signsof temperateweather arrived inmy hometown ofSarasota, Floridaby mid-October.Oh, yes, ourbeloved“snowbirds,”having escapedthe record-

breaking heat wave, returned earlier thanusual this year. I rejoiced in hearing frommany who had been away, that calling toschedule their skin care appointments wastoward the top of their lists. Welcome back!The reality of winter’s arrival set in when I talked with my daughter’s family inConnecticut during mid-October where ithad been snowing for the past five hours—the earliest storms recorded in history.Weather aside, changes in every arena ofour lives are affecting each of us, whereverwe reside and provide our services.

Following the slowest months ourpractice has ever experienced—August andSeptember—I want to share with you amarketing success story that boosted ourbusiness. I had been tossing around anumber of ways to thank our clients fortheir patronage and support over the pastyears. The expense of advertising in ourlocal magazines was not in our budget this

astyear was not theeasiest year formost of ourpractices; the

economy has been particularly tough onthis industry. I like to believe that thingswill get better, and here are some of myfavorite neat, new peels that may help adda little nudge to your practice’s winterdoldrums:

Therapon has introduced a new peel

called the “Frost Peel,” a TCA peel that hasdecreased patient downtime without theneed for Retin A preparations or dye tocontrol acid penetration.

SkinMedica introduced the new“Rejuvenize Peel” with a built in anti-irritant and penetration enhancer thatprovides controlled exfoliation of theuppermost damaged layers of skin, to revealfresher and healthier skin, with predictableresults and less down time.

And two of my favorite oldie but

L

T

THE PRESIDENT’S MESSAGE

Sandra M. Day

goodie peels, that smell just wonderful, arethe “Rejuvenating Masque” and“Resurfacing Masque,” from InnovativeSkincare. They make a nice refresher justright for the new year!

These are just a couple of newer peelson the market that may help give yourpractice an affordable kick this holidayseason.

All products mentioned are for informationalpurposes only. �

Worth-a-LookJeannine L. Dabb

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Member Profile:

Krissy King

graduated with an M.F.A. in Artfrom the University of Idaho in 1994. During my course of study asan art student, printmaking, specifically lithography, was always apassion of mine. I loved the entire process: physically graining downold images from the lithography stone, chemically etching myimages onto the prepared stone, and finally pulling a finished print.My work today as an aesthetician is just as rewarding to me as someof my cherished prints.

Never did I imagine back then that someday I would end upworking for plastic surgeons doing skincare. My art background hastaken me on a variety of journeys throughout my life as an educator,muralist, decorative painter, makeup artist, and aesthetician. I beganmy career in the skincare field as one of the front desk professionalsat Bella Via Skin and Body Therapies, a medical spa owned byplastic surgeons Drs. Colville and Zavell of Reconstructive andAesthetic Surgeons, Inc. in Toledo, Ohio. Some of myresponsibilities while working at the front desk included greetingclients, being knowledgeable about the product lines and services,and maintaining the makeup studio. I soon decided that a career inaesthetics was my calling. With the encouragement of my familyand co-workers I went back to school to become an aesthetician.My front desk experience, combined with my art background, hasdefinitely come in handy throughout my career as an aesthetician.

I enjoy many aspects about this business, such as the closerelationships with my clients and the continued education that I doin order to keep up on the latest skincare technology. I work withmany talented and wonderful people that are a constant resource forme and who are very willing to educate and share their vastexperience with me. I’ve been able to observe both Drs. Colville andZavell during routine office visits and different types of surgeries. Ican’t begin to tell you how many times I have drawn upon these pastlearning experiences to better serve my own clients. I feel that thephysicians and estheticians of Bella Via work as a team, and thiscombined effort provides our patients with the knowledge and besttreatments necessary for a successful outcome.

The knowledge gathered through interaction with ourphysicians and my co-workers and from attending meetings like theSPSSCS allows me to stay at the top of my game. I learned so muchfrom the last SPSSCS Annual Meeting in Las Vegas and as always,look forward to the next. I feel a responsibility to my clients to bethe best that I can be and to stay informed on the latest and mosteffective products and treatments. I definitely get a sense ofsatisfaction from helping my clients to achieve their skincare goals,whether it is taking someone through a course of pulse peels orapplying makeup for a wedding. It is all very rewarding. �

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44

n reviewingall of the treatmentsthat have beenprescribed overthe last 25 years

and their related claims, you would thinkthat we would have solved the problem ofaging skin by now. After all, research clearlyshowed that collagen formation wasactivated by Retin A™, multiple differentlaser wavelengths, the application of heat,infrared and LED, growth factors, amongstother things. Many of these treatmentsshowed promise in research but have failedto show progressive or permanent changesin the skin. Potentially aggravating theproblem is the additional damage we inflict(often daily) by forcing the skin to exfoliatefaster than it could manage on its own.

I’m in the skincare business so I am notdoing myself any favors by questioning theactivities of a vast majority of skin careprofessionals in practice today but I think itis important that we take what we alreadyknow about skin physiology and apply it tocurrent anti-aging efforts. We know that thereason the skin ages is due to its inability torepair 100% of the inflammation-baseddamage that occurs on a daily and/or annualbasis. Every year we lose 1% of our dermisand the processes of the skin continue toslow down. The question remains, if agingis the result of too much inflammation forthe skin to handle, then why do most of the“anti-aging” treatments add inflammation tothe skin? My belief is that we have identifiedswelling and scarring as successes becausethey temporarily improve pigmentation orgenerate a temporary tightening effect thatlooks like an anti-aging event for the oneday to one year that such an effect lasts.The other misconception (in my opinion) is that people think the results “lasted 6months” because the body continued to age and caught up with the improvementscreated by the procedure. Never mind thatthe loss of “results” seems to coincideperfectly with how long it takes the body to heal the damage.

All that being said, where we may reallybe failing our clients and patients is ournever-ending desire to assist the skin in theexfoliation process. We know the benefits…lightening of pigmentation, firming effects

that reduce fine lines and acne clearance inmany cases. We also know the downside;increased free radical damage which agesand likely increases skin cancer risk in theskin along with increased environmentaltoxin absorption, scarring (puttingirritants/acids on wounds) and dehydration(leading to oily/combination skin).

Why does the skin slow down over time?Why does it progressively lose its ability torepair itself? In order to believe in chronic(daily) exfoliation strategies you have tobelieve that the skin slows its epidermalturnover rate unintentionally. Personally, Ithink the skin knows what it is doing! I amconvinced that the skin slows down becauseit has lost its food/immune cell supply dueto lost circulation and overwhelming repairefforts that occur as a part of aging. Just likeevery other process in the body, when facedwith declining nutrition, skin metabolism(turnover) slows. If a lack of nutrients is theproblem then how does daily exfoliationimprove turnover? Simple, the skin recognizesthat a damaged epidermal barrier is lifethreatening so it naturally rushes to fix the

problem by placing the epidermal “holes” asa priority over maintaining the rest of thedermis. It diverts scarce lipids, proteins,enzymes, collagen and antioxidants fromthe daily maintenance activity of the dermisto the “emergency repair” of the epidermis.Leaving aside the extra work created by thedamage of most “anti-aging” procedures,doesn’t it seem counter-intuitive to continueto stress the healing process after they visityour office by increasing free radicals andthe workload of the skin with a post-procedure exfoliation approach? Collagen isbeing generated as much as three weeksafter many of these treatments. Do wereally want to be adding inflammation anddepleting resources during this criticaltime…or at any time? Have we not alreadylearned that adding inflammation to atraumatic procedure is a recipe for post-inflammatory issues and declining results?The results from our “20 year experiment”on the benefits of AHA’s, high dose retinoland Vitamin C, Retin A™ and othertreatments has proven that we are notreversing (or preventing) aging with thesestrategies. It has shown us that the skin,when repeatedly abused, does not getprogressively better. Skin cancer, rosacea,melasma/hyperpigmentation and aging areall growing in incidence and severity.

Is there hope? You bet. There is a growingmigration within professional skincare (andthe general public) towards alternativestrategies that are more gentle. LED andInfrared appear to have mild– moderateeffects on the skin by improving it’s healingefforts. You are also starting to see a shift offocus in skincare towards delivery systemsas we all recognize that to fight aging weneed to target dermal (not epidermal) activity.These include things like the dermaroller,blading, liposomes and other deliveryenhancers. The first two add inflammationto the skin so I prefer liposomal delivery,especially since it improves penetration by10-fold over traditional creams. We havealso seen an increase in popularity of niacinand niacinamide usage although mostpeople do not look at their activity in theskin as being a nutrient provider…that ismy assessment. Retin A is toxic andimmunosuppressing to the body. It is notmeant to be floating around in our skin and

IIs Skin Damage Reversible?

Ben Johnson, MD

55

so its positive attributes are ultimatelytrumped by its toxic effects. Long termRetin A has not worked, just look at theskin of those on it for years. There areseveral non-toxic alternatives, the mostpotent being retinaldehyde which wasproven to be as effective as Retin A onfibroblasts but is stored by the skin afterutilization (unlike Retin A). Retinol andVitamin C are good for the dermis, but notso good for the epidermis. Only withappropriate delivery systems will their useincrease remodeling without addinginflammation. Without better delivery, bothadd too much epidermal inflammation andwill have a net negative response for agingoverall. There are several other researchproven collagen stimulators like Chlorella,Beta Glucan, Lipoic Acid and EGF that donot add inflammation to the process.

In-office treatments are more difficult.Occasional exfoliation is something theskin can handle so that process does notneed to be discarded. My advice is tochoose more conservative options thatcreate quick results for pigmentation, etcbut do not put the patient at risk for

Welcome NewMembersKaylin Renee Byers—Hagerstown, MDLaura Lee Evans, RN, BSN—Cincinnati, OHDeborah Freund—Independence, MOSandra Lutz, RN—Cincinnati, OHAnn M. Stratton, RN, BSN—Peoria, ILStacey Tuomey, RN, BSN—Hagerstown, MDSyndee S. Zisumbo—York, ME

Abbey Helton, BSN, RN, CPSN Chair, Membership/Mentor Committee

“ Attendance at theSPSSCS Annual

Meeting has beenessential for my aesthetician’s

professional growth.Because she functions

at the master aesthetician level and works solo

with my practice, the professional peer-to-peer opportunities

at SPSSCS are unparalleled and

available in almost no other place.”

Richard A. D’Amico,MD, FACS

Capitalize on Your SkillsApril 20–23, 2010 • Washington, DCGaylord National Hotel & Convention Center

Growing Your Skin Care Practice?

• Innovations in Skin Care by Knowledgeable Speakers• Networking • Exhibits • Mentoring Program• Marketing • Social Media • Product Formulation• Intro to Building a Plastic Surgical Skin Care Practice

(a must for the novice as well as the Skin Care Specialist that needs a motivating business plan!)

• Aesthetic Meeting Course (ASAPS) focusing on “Cosmetic Medicine” including “live” patient demos of lasers & fillers

SOCIETY OF PLASTIC SURGICALSKIN CARE SPECIALISTS

16th Annual Meeting

VISIT OUR WEBSITE BEGINNING JANUARY 2010 FOR COMPLETE MEETING AND REGISTRATION INFORMATION

SPSSCS.ORG800/486-0611 OR 562/799-0466

permanent damage. I still prefer thestrategy of liposomal delivery of high dosedermal stimulants which is something thatcan also be added to exfoliating proceduresto enhance results. Exciting possibilities arealso coming with the improvement in stemcell related growth factor serums andcollagen precursor technology, both ofwhich will soon be available from severalcompanies. If we recognize the delicatestate of the dermis and stimulate it withoutadding inflammation or depleting resourcesthen we give the skin a chance to recoverwhat it has lost in our adult years. Isn’t thatthe goal after all?

Ben Johnson, MD started in aesthetics with oneof the first medi-spa chains in the country. Soon afterhe founded/formulated his first skincare line,Cosmedix. Currently he is the founder/formulator ofOsmosis Skincare. Dr. Johnson has also recentlydeveloped a technology for the treatment of eczemaand psoriasis (amongst many other conditions) thatis just being launched. In addition, he is a renownedinternational speaker/educator.

DrBen@OsmosisSkincare.comwww.osmosisskincare.com (303)674-7660 �

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JOELLEN COZEN

Merion Station, PATo say this is a life altering event wouldn’t even

START to explain the emotions I experienced at theWorld Burn Conference in New York this August.I’ve been a member of the Image Enhancement Teamfor the past four years and listened to the heartwrenching stories of my patients while applying theirmakeup. This year I encountered several women whohad been severely burned at very early stages of theirlives and had never really taken the time to pamperthemselves in any way. For some, it was their first(but not last, they vowed!) convention. They allfound the camaraderie, classes, lectures, and therapysessions “amazing.”

What touched one woman, severely burned at22 months old, the most emotionally, was herpersonal image enhancement session with me. As wewere talking, I noticed her eyes swelling up withtears. When I asked if she was ok, she said “no onehas ever fussed over me, cared for me or touched me inthe kind way you’re doing right now, and I promiseI’ll try not to cry.” Being the softy I am, I too welledup. Upon completion of her makeup session, I handedher the mirror to see the results (she looked fantastic!)and the flood gates opened! Sobbing, she hugged meand said “you (collectively) are all angels, I can’tthank you enough.” At that point, I too, was crying.When she left the room, I noticed the difference in herbody language. She was standing tall, and holdingher head high. She had a wonderful smile of prideand contentment on her face.

I can’t help but think back to what amazed meon my first trip to the convention some four yearsago. The SPIRIT of the burn survivors just blew meaway. Young, old, men, women, all were amazing! Ican only hope that I helped in some small way, notonly with their personal enhancement, but also byallowing them to cry and encouraging them to laughduring our brief encounter together.

I would like tosay thank you tothe companieswho donated greatproducts to the

Phoenix Society’s Image EnhancementProgram at this year’s World BurnCongress. SkinMedica, Société Clinical,Dermesse, iS CLINICAL, Sesha, andOxygenetix. We deeply appreciate all youhave done to help this cause. Even though Iwas unable to attend this year’s event, itmakes me so happy to know that the legacyof the SPSSCS will always be there to assistin this wonderful program. Our group ofdedicated volunteers makes me very proudof our Society. On the behalf of theSPSSCS and the World Burn Congress,thank you everyone for giving of yourselvesand of your own souls! I only hope andpray to continue the success of theseendeavors. As Mother Teresa once said, “Befaithful in small things because it is in themthat your strength lies.”

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SUSAN ELDRIDGE

Portland, OregonThis is my third World Burn Congress. It never

ceases to amaze me the courage the burn survivorsdisplay. It humbles me every time. I was sitting witha gentleman, his wife and daughter at the closingbanquet. From our conversation, I learned this wastheir first World Burn Congress. They came fromWisconsin. His wife was saying how much theywere enjoying themselves and that before thisexperience they felt isolated and were in a terriblesituation. After hearing some of the other survivors’stories they now feel blessed. Blessed! This gentlemanwas in a wheel chair, had no legs, one arm and onlyone digit on his remaining hand. They were awonderful family and felt blessed. I was moved andhumbled!! As I have said before it puts things inperspective every time.

I taught a lovely lady how to cover her burnscars on her face and neck. She was thrilled with theresults and proceeded to ask if she can go out inpublic like this. She wanted to know if she couldleave the room. After assuring her she looked greatshe then stated she hadn’t left the house without hermask in two and a half years. She didn’t believe itwas fair for the public to see her scars. She began tocry and shake. We encouraged her to go ahead leaveher mask off. She left the room and within 2 minutesshe was back, scared and needing reassurance. Thiswas amazing to me, as she looked beautiful.Eventually after lots of assurance she put away hermask and gave me a big hug and a kiss. It feels goodto make a difference in one person’s life!

World Burn CongressJeannine Dabb, Co-Chair, Philanthropic Committee

Thank You For Your Generous Support!

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n Saturday,October 3rd,2009, SPSSCSmembers JoannaPinkerton, ShariWeniger and

Mary Shaver traveled to Washington, DCto volunteer for the annual Spa Day at theWashington Cancer Institute, WashingtonHospital Center. Their time, dedication,hard work and expertise were utilized andgreatly appreciated, doing specializedfacials for cancer patients and survivorsduring this event.

Over 100 women were treated to a dayof pampering featuring facials, massages,exercise and nutritional education, paraffinhand treatments and catered lunches.Keynote speakers included physiciansspeaking about the unique challenges ofcancer treatments.

Joanna, Shari and Mary were a key partof the team of aesthetician volunteers whohelped make this day and their facials avery special experience for all theattendees. Instructions regarding the specialskin care needs of the cancer patients were

PICTURED LEFT TO RIGHT: ALEC CALL, EXECUTIVE VICE-PRESIDENT, IS CLINICAL; SANDRA ADAMS, CLINICALEDUCATOR, IS CLINICAL; SPSSCS MEMBER VOLUNTEERS – MARY SHAVER, JOANNA PINKERTON, SHARI WENIGER;BRYAN JOHNS, CEO, IS CLINICAL

DEBRA YATES

SELECTED TOP

TEN WOMEN IN

BUSINESS FOR

ABWAThe American

Business Women’sAssociation,Camelot Chapter,is proud toannounce that our

past president, Debra Yates, has beenselected as one of the 2010 TopTen Womenin Business.

ABWA Top Ten Women in Business is a national program that honors 10outstanding members of ABWA forachieving excellence in career, educationand community involvement. Debra washonored at the National LeadershipConference held in Kansas City, Missouri

on September 24 thru 26th. ABWA alsocelebrated their 60th Diamond Jubileeanniversary.

The mission of the American BusinessWomen’s Association is to bring togetherbusiness women of diverse backgrounds andprovide opportunities for them to helpthemselves and other grow professionallythrough leadership, education, networksupport and local/national recognition.www.abwa.org

BETSY

RUBENSTONE:BEST OF PHILLY

2009Another of our

past presidents,Betsy Rubenstoneof Philadelphia, isfeatured inPhiladelphia

Magazine’s “Best of Philly” …for the secondtime! Read more about Betsy and DEMECosmetic-Dental Center at: Best of Philly2009: Cosmetic-Dental Center—Philadelphia Magazine—phillymag.com.

Congratulations, Betsy!“Having won Best of Philly when I first started

my career 17 years ago, and receiving it again,makes working in this profession so worthwhile. Somuch has changed since we started and if you arewilling to keep changing with the times, everyone canbe the “Best.” I feel so fortunate to have joined apractice that has allowed me to continue to grow andshare my expertise with dentists, plastic surgeons, anutritionalist, a massage therapist and a psychiatristall under the same roof. I now have 6 aestheticansthat have joined my practice and with theacknowledgement of magazines like PhiladelphiaMagazine, we hope to continue to grow for years tocome.”

—Betsy Rubenstone �

Members in the News

SPSSCS Members “Giving Back”Sandra Adams, Clinical Educator, iS Clinical/Innovative Skincare®

O

provided, as well as how to perform thesespecialized facials for cancer patients priorto beginning the day.

The iS Clinical/Innovative Skincare®Cancer Care Program, established in 2003,includes sponsoring the annual Spa DayEvents as well as quarterly skin care

education classes for cancer patients andsurvivors at Washington Cancer Institute,Washington Hospital Center and UCLARevlon Breast Center. For more informationregarding the unique skin care challenges ofpatients undergoing cancer treatments goto www.isclinical.com/iscancerprog �

8

hen you decide to take the solemnvows of marriage, you not only marry thatperson, but also for better or worse the restof the family. When choosing a product youshould also look at the company thatrepresents it. The relationship between youand the vendor will support a successfulventure, resulting in increased retail sales.

In this two part series we will discussthe important part that is often overlookedin product selection, the relationship withthe vendor. Part I reviews sales support,while Part II examines marketing support.By partnering with suppliers, professionalinsight and growth can be gained. In thecurrent economic state, it is financially wiseto research all options of saving orincreasing the return on your money.

SALES CONSULTANTS

There are numerous benefits to having alocal consultant. Your business is theirbusiness. Sales consultants see the industryfrom a different perspective and can offerimmense knowledge. They see otherbusiness on a daily basis and can identifysuccessful traits and support your businessneeds.

There are differences between a salesconsultant and a sales representative. A salesconsultant is a business partner, is genuine,only recommends what is best for thebusiness, and will proffer their sustenance.On the other hand, a sales rep will sell youproducts just to meet their sales quota andonce you place your opening order, you willnever hear from them again.

Talk to the sales consultant to find outwhat services they will offer and how theywill be of support. Your sales consultant willeducate the staff, explain new productlaunches, and offer assistance at your openhouses and events. An involved salesconsultant is similar to having a freelanceexpert helping you. A consultant can equateto the same pay as hiring an expert, savingyou $500 per month.

RETAIL SPECIALIST

If you are the company’s top account orpurchase a large sum, they may support youwith a retail specialist. This person willcreate interest in the product line throughsales and education. A retail specialist willmerchandise the products throughout yourbusiness, provide product consultations,maintain inventory levels, unpack orders,etc. Potentially the salary of a salesspecialist can be split with the vendor orthey will pay the entire salary. This is alarge expense to the vendor but if you arean elite account you can use this as anegotiating tool.

OPENING PACKAGES

Having the option of an openingpackage allows for the decision to be yoursas to the dollar amount you would like tospend. Opening packages will typicallyoffer a savings or free marketing and/orproducts. Opening packages may be thebest option to receive free merchandise,saving you the cost on purchasing thosesame items. On average treatment productcost can range from $4 to $15. Subtractingthat cost from your overhead will increaseyour profits. If 10 clients are seen per daythat is a $40–$150 per day savings, weeklysavings of $240–$900 or monthly savings of$1040–$3900!

TRADE-OUT PROGRAMS

Trade-outs, also referred to as “buybacks,” are a program that is a win/winsituation for both parties. Trade-outs allowthe account to take the current product ininventory and give it to the vendor for acredit towards the opening order. So if youhave $500 of “xyz brand” and you want towork with “abc brand,” “abc brand” will buyback the $500 in inventory of “xyz brand”and put it towards the opening order of “abcbrand.”

This scenario is beneficial when youhave a high amount of inventory in aproduct line that you no longer want toretail. It solves the problem instantlywithout losing time, discounting, or

deceiving the client to purchase a productthat is no longer going to be available.Overstocked shelves hold retail dollarshostage. The burden will be lifted fromyour shoulders, freeing hundreds tothousands of dollars.

PREMIER STATUS

Many companies will offer specialprograms for their top accounts. Theseprograms will be beneficial for businessgrowth and offer valuable incentives. Whenyou reach a certain level of sales, whichmay be based on monthly, quarterly oryearly sales, you receive additional perks.Typically, the more you order from thecompany the grander the award dollars.The awards range from gratis, testers, co-opadvertising, marketing collateral and/ordeluxe samples. An average of 5-15% ofyour qualifying sales amount will gotowards the rewards. Ask your consultant ifthis program is available and to provide youwith your sales numbers and where youstand with qualifying. It would be anoversight to miss these rewards because youwere $50 short of qualifying.

Sarah Burns-Eggenberger has authored a booknamed “Guide to Product Selection.” by PCIPublishing and authored a chapter “Make-upApplication” for “Tic, Tock Stop the Clock.” She isthe founding member of Advanced AestheticEducation Association and is currently the actingpresident of the organization. She is an editor for thePCI Journal, reviewing studies and writing abstracts.Sarah has also written articles for a variety of tradepublications, including Skin Inc magazine. Sarah isreviewer evaluating publications for Milady’s,Delmar Learning. She is a supporting member ofseveral industry organizations.

Sarah has been with gloProfessional, a skincareand cosmetics distributor and manufacturer, for thelast ten years. In her current position as BrandManager, Sarah is responsible for the research anddevelopment of a highly efficacious skincare line. Alsoresponsible for coordinating activities of production,sales, advertising, promotions, marketing research,purchasing and sales forecasts. �

How to Maximize Profitswith Vendor SupportSarah Burns EggenbergerPART I

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oth chemotherapy and radiation therapycommonly have side effects that involve theskin. Some of these are broad effects fromthe treatments in general and some arespecific to certain chemotherapeutic drugsused. The discussion here will be restrictedto those reactions unique to chemotherapyand radiation therapy.

Cancers are composed of abnormal cellsthat divide rapidly. The faster the tumor’sgrowth rate the more rapidly its cells aremultiplying. Although a more rapid rate ofcellular division is associated with greatermalignant potential, this rapid growth ratealso makes the tumor susceptible tochemotherapeutic drugs. Chemotherapytargets cells that are rapidly dividing. Thegoal of chemotherapy is to kill as manycancer cells as possible so the tumor caneither be completely eradicated, i.e. “cured,”or placed in remission, a state where therestill may be some cancer cells present in thebody but the patient is without symptomsand feels well for an extended period of time.

In addition to tumor cells, there arecertain normal cells in the body which arealso rapidly dividing. Chemotherapeuticdrugs target all rapidly-dividing cells andtherefore effect not only tumor cells but alsoany other cells in the body which are under-going rapid cell division. Other normal rapidlydividing cells include skin and the skin’sappendages hair and nails, gastrointestinalcells, bone marrow and its product bloodcells, and reproductive cells including spermand ova. It makes sense that skin effects arecommonly seen with chemotherapy sinceboth skin cells and tumor cells are undergoingrapid cell division. Similarly, it makes sensethat other common side effects of chemo-therapy involve these other organ systemsand include ulcers and infections in themouth, stomach and intestine, anemia,decreases in white blood cells and plateletsand temporary loss of reproductive ability.As long as a few of the body’s normal cellsin skin, GI tract, reproductive tract andbone marrow remain the body can

regenerate and recover these functions oncethe chemotherapy is stopped.

Extravasation injury is a type of skin injurythat occurs when a chemotherapy druggiven IV leaks out of the vein and into theskin. Depending on the drug in question,this effect can be mild swelling, localirritation and inflammation or even actualtissue necrosis.

Alopecia is hair loss associated withtoxicity to rapidly dividing hair cells. Thisincludes all body hair and is not limited toscalp hair only. Recovery occurs and hairgrowth resumes after chemotherapy stopsalthough there may be a permanentalteration in hair color, texture or curl.

Certain drugs can cause specific typesof allergic or hypersensitivity responses.The platinum derivatives (cisplatin,carboplatin) can cause an IgE-mediatedhypersensitivity with itching, redness andswelling occurring within an hour after theinfusion is begun. If life-threatening, thisreaction is termed “anaphylaxis”and the drugwill not be given again in these severe cases.Formation of antigen-antibody complexesoccurs with methotrexate which causes avasculitis (inflammation surrounding bloodvessels) or rituximab can cause serumsickness (an illness with flu-like symptoms).A specific type of rash called “erythemamultiforme” of which the hallmark is the“target lesion” is caused by antigen-antibodycomplexes and can occur with a number ofmedicines including chemotherapeuticagents. Activated T cells cause contactallergy and may be seen with nitrogenmustard (mechlorethamine).

Pigmentary changes can involve the skin,mucous membranes or nails. These may betemporary or permanent. After alopecia, itis not unusual for hair to regrow with acolor or texture change. Pigmentary changesare particularly common with the cytotoxicdrugs such as alkylating agents or tumor-directed antibiotics. Hyperpigmentation of thegums can be found with cyclophosphamidetreatment and is permanent. 5-fluorouracil

(5-FU) treatment is often seen withhyperpigmentation reactions in all areas ofskin or in only sun-exposed areas. Pigmentchanges with 5-FU can also follow thepattern of an underlying vein and appeartwisting or serpentine. 5-FU can darken themucosa of the tongue, conjunctiva of theeyes or nails. Tegafur, a 5-FU analog, cancause circular areas of pigmentation of thepalms, soles and nails. Although 5-FUcauses discrete areas of hyperpigmentation,other drugs may result in generalizedhyperpigmentation. These include busulfan(and has been referred to as the “busulfantan”), pegylated liposomal doxorubicin,hydroxyurea and methotrexate. Daunorubicincan cause hyperpigmentation in solar-exposedareas. Increased pigmentation in areas ofinjury or pressure may be seen with cisplatin,hydroxyurea and bleomycin. Some drugsare secreted in sweat and can causehyperpigmentation under adhesive tape;these include docetaxel, thiotepa andifosfamide. Circular areas of scalphyperpigmentation can be associated withdaunorubicin.

Part II will include insights intoacneiform rashing, the effects of radiationon the skin and more include charting onaddressing key side effects with skincaretherapies.

Dr. DeHaven is board certified in InternalMedicine and Emergency Medicine, with specificemphasis in the age management field. Dr. DeHavenacted as Physician in Charge and Director ofPractice Management for the Kronos Anti-AgingClinics. She was the founder and Chief Physician ofthe Longevity Institute, specializing in Anti-AgingMedicine. She has written extensively on agingrelated issues. Dr. DeHaven has developed andimplemented anti-aging medical protocols for both theLongevity Institute and the Kronos Clinics,pioneering research in hormone replacement therapy,and oxidative stress management. �

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Chemotherapy and Radiotherapy

Effects on the SkinPART ONE

Charlene DeHaven, MD

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Genetics of Skin AgingJoseph Banis, MD

s withall of our organsystems, our skin

quality, function and rate of physiologicaging is determined not only by extrinsicfactors such as diet, stress, and exposure totoxic agents, but also, and even moresignificantly, by intrinsic genetic factors.We know that the genetic backgrounds ofcertain ethnic populations (NorthernEuropean) strongly differentiate themselvesfrom other ethnic populations (African andAsian) by the quality and durability of theirskin. We all (in the skin care profession)know intuitively and by experience thatfair/red haired, blue eyed individuals willhave more “problematic,” damage proneskin compared to darker complected, browneyed people. We know that these “at risk”populations will show significant evidence ofaging in a more rapid, severe, and aggressivemanner compared to genetically “favored”populations.

The basic mechanism by which intrinsicaging of skin occurs is complex and not wellunderstood. However, in both types ofaging (intrinsic and extrinsic) the rate ofaging is said to be a fine balance betweendeoxyribonucleic acid (DNA) damage andrepair. Recent advances in molecular biologyhave helped us to better understand thisprocess. Currently, several mechanisms havebeen proposed as contributors to the agingprocess, such as disruption of genes in cellcycle regulation, alteration of cellularconstituents (proteins, lipids, nucleic acids),production of reactive oxygen species (freeoxygen radicals), and telomere shortening.

In all of the above, the central mechanisminvolved is the cell’s inability to repair DNAdamage that has occurred. Mutations inDNA repair genes have been linked tovarious diseases such as cancer, acceleratedaging, and neurological diseases. It is alsowell known that inherited defective genescan lead to premature aging syndromes such as progeria. These syndromes arecharacterized by genetic mutations, andthese mutated genes can be identified. Sincecurrent scientific evidence indicates thatskin quality and premature aging are mainlyregulated at a genetic level, specific geneticmarkers such as these will enable us to

identify the gene(s) involved in the skinaging process.

Unfortunately, to date we are unable totailor our skin care and treatment protocolsto the most important determinant of skinquality—the genetic component. Ourscientific understanding of skin physiologyand function has helped us make greatstrides in optimizing skin quality, but cancarry us only a limited distance whenconfronting the genetic limitations of anindividual’s skin composition. For instance,we are all aware of the need for thestimulative effects of retinoids, and theantiaging and damage preventing effects ofantioxidants in improving skin quality. Notto mention now the increasing emphasis onthe restorative and anabolic effects ofgrowth factors on the skin. But as effectiveas these components are, the next level ofintervention will logically be when we cannot only optimize skin function at whateverbaseline one has, but can actually interveneat a genetic level to reconfigure the geneticmakeup to enable the body to producebetter quality genetically superior proteincomponents for the skin.

With our increasing understanding ofthe human genome, it is conceivable andeven expectable that we will acquire theknowledge necessary to understand thecritical sites in our genetic code that affectskin function and physiology, and tomanipulate them in specific and tailoredfashion to effect improvement in eachindividual’s skin. This information is not yet

available, and to achieve this level of detailedinformation of our genetic code and itsrelationship and effect on the skin willrequire further extensive investigations onlarge populations. Our research team iscurrently involved in a project to identifygenes that determine skin quality anddevelop effective methods to counter theadverse effects of aging. We will examinethe genetic profile of an ideal populationwhich reflects both subtle and establishedage-related features. In some individualsthese changes begin in the third decade andare gradual, while in others, it becomespronounced within a short period of time.We believe that by identifying the specificgene(s) we will be able to get an insightinto the underlying mechanism of how skinages, thus paving the way for early diagnosisand development of targeted therapies.Until the scientific breakthroughs becomereality we will continue to incrementallyimprove our understanding and care of theskin with the phenotypically tailoredremedies and technologies.

Dr. Banis is a Certified Plastic Surgeon withover 20 years of experience in plastic surgery. He wasan early pioneer in the use of microsurgery, routinelyaddressing the most challenging cases of reconstruction.Over his years of practice he understood the importanceof healthy skin. His research has led him to developvitamin/herbal formulations for skin support anddisorders such as acne.

Please feel free to contact Dr.Banis or his nurse,Abbey Helton, at 502-589-8000 or visit his websiteat www.aesthetics.com �

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the world of skin care with his opinion. How do you feel about Dr. Johnson’s

article? I would love to post your responseson our newsletter and website.DYates7870@aol.com. �

—”This above all: to thine own self be true.”—

Continued from Cover

From the Editor’s DeskBecome a Fan

Search “Society of Plastic Surgical

Skin Care Specialists” to find us.

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ecently, EMR (ElectronicMedical Records) has become quite the“buzz” word in the skin care community. As

we move towards a more “green” world, the dawning of EMR is uponus and the days of documenting on paper are rapidly approachingtheir twilight. Simply put, EMR is a digital means of documentingpatient visits encompassing not only the history and exam, but alsoproviding a means to prescribe medications, provide educationalmaterials and treatment regimens, as well as the ordering andreceiving of testing including labs. As simple as this may sound, oneshould be wary as not all systems are created equal.

With many vendors on the market plying their wares, choosing asystem that can be used in a skin care setting can be quite intimidatingand confusing. So what should consumers be looking for when investingin an EMR? Because the needs and wants of every practice aredifferent, the answer may not be simple. Certain common factorsshould be considered when comparing systems: product flexibility,industry expertise, industry experience, training of the product,product support and cost.

Industry experience, expertise and number of users are importantconsiderations when making an educated decision about which EMRsystem to go with. Is the system designed with the skin care field inmind, or is it a one size fits all, mocked up copy that was designedfor some other area? Is this a new and untested product or is itsuccessfully being used by your peers and colleagues? Successfulvendors that have stood the test of time do so because they servicethe needs of your community. Attentiveness to client feedback andincorporating suggestions as new functionality is paramount to thesuccess of any vendor product. A product targeted to your specificcommunity will have the advantage of resources being allocated inthe development of function needed to make your practice run moreefficiently. A generic product that can be used throughout thespectrum of medical specialties may not be able to address thedetails and needs your practice.

Speaking to references from your community will help ingauging whether the product will be a good fit for your practice.When speaking to references one should inquire about ease of use,training and support. Adequate training should include aid inproduct customization as well as showing how to use the productsuccessfully on a daily basis. Good support guarantees that theproduct will remain usable not just from the start but into the future.

Cost is usually a big factor with many decisions in life and it isno different when it comes to selecting an EMR system. The triedand true sayings, “Buyer beware” and “You get what you pay for”unfortunately ring true more often than not. System cost runs thegamut from low to high and some may seem appealing on thesurface, but will they be able to provide the tools needed that a skincare setting demands? Will the system be around in a year or willthey be out of business? Do they have the resources to support anddevelop the product to meet the ever changing needs of the skincare community? Are they truly CCHIT (Certification Commissionfor Health Information Technology) certified or is it a particularcomponent that is certified? These are all very important questions

to ask especially when taking into consideration the passage of TheAmerican Recovery and Reinvestment Act of 2009. From informationavailable to date this piece of legislation will be offering monetaryrebates for those practices that have a “usable and certified EMRsystem.” Rebates will be disbursed over a five year period starting in2011 (with the largest disbursement occurring in the first year andgradually decreasing over the next four years). In addition there willbe a two percent increase in the amount of Medicare reimbursementto these practices. Practices that are not using a certified EMRsystem may be penalized via a two percent reduction in Medicarereimbursement and obviously will not qualify for a rebate towardsthe purchase of an EMR system.

Upon scratching the surface and delving a bit deeper one shouldbe able to see that although cost is a big issue; there are a multitudeof other factors that carry as much weight (if not more) than justlooking at the bottom line figure. The purchase and implementationof an EMR system into a skin care practice should be viewed as aninvestment that will mature and pay back dividends over time.

With just under 10 years experience working in the practice management andEMR fields under the banner of NexTech Systems, Dr. Butty brings a freshapproach to the design and implementation of EMR to your practice. Feel free tocontact him at h.butty@nextech.com or 813-425-9220. �

New Horizons—The Dawning of EMRHesham E. Butty, MD

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Interestingly, some of these adhesionmodifiers have additional biologicalproperties of their own, in which case wesometimes get ‘two things for the price ofone!’ Consider the polyhydric phenols,meaning phenol with an additionalhydroxyl group (OH) attached to it:

As you can see, Phenol, Resorcinol andHydroquinone are extremely similarmolecules, the latter two differing fromPhenol only via the addition of a singleoxygen atom. This small addition, and itsposition on the carbon ring, radicallyreduces the toxicity of Phenol whileconferring other biologicial properties suchas keratolytic and tyrosinase-inhibitingeffects. While many practioners alreadymake use of the keratolytic properties ofResorcinol (the Jessner’s Peel contains14%), few realize that at a similar levelHydroquinone will peel the skin andsimultaneously inhibit melanogenesis. Thisproperty makes Hydroquinone an agent toconsider for peeling high Fitzpatrick (dark)skin types, because it greatly reduces therisk of post-inflammatoryhyperpigmentation (PIH).

Another important example of cellularadhesion modifiers are Vitamin A compoundssuch as Retinoic acid (Tretinoin) andRetinol. These are powerful keratolyticagents that also act on receptors in livingcells to produce a variety of beneficialeffects, such as upregulation of collagenproduction, dispersion of melanin granulesand elimination of atypia and dysplasia. Atrelatively low levels (0.1% and below forRetinoic acid), vitamin A compounds canbe applied at home for ongoing therapeuticpurposes (anti-acne, anti-aging). However,at higher levels (0.5-1%), they begin toreduce the cohesion of sheets of cellsdeeper in the epidermis and act as a peel.

Other therapeutic compounds that canact as cellular adhesion modifiers includeAscorbic acid at concentrations greaterthan around 30%, and Phytic and Azelaicacids when properly solubilized at levelsbeyond about 10%. All three can provideanti-inflammatory, anti-oxidant andmelanin-inhibiting effects while

superficially peeling the epidermis, and areespecially useful in treating high Fitz-typepatients or those prone to PIH.

To better understand how the variouspeeling agents fall into this classificationsystem, here is a graphical presentation thatcan be used as a quick reference:

So to answer my initial question, canwe peel our patients without ‘burning’ them,the answer in many instances is yes. As wehave discussed, some peel agents can evenreduce side effects, such as inflammationand PIH, inherent in the peel process. Thatsaid, peeling agents that are toxic and/orcorrosive also have their place in thetreatment of deep lines and wrinklesassociated with severe photodamage.

What remains unanswered is exactlyhow peels created using corrosive agentscompare with cellular adhesion modifier-based peels. In other words, can aTretinoin+Azelaic acid peel (which won’thurt and has low PIH potential) deliver thesame result as a TCA peel (which hurts andcan cause PIH)? More study is required onthat one.

And finally for dear Samantha, I havethe following advice: Sometimes we have toendure the style-cramping side effects ofchemical peels, but make sure your doctorknows about the full spectrum of agentsthat can keep you looking beautiful withmuch less drama!

John E. Kulesza is founder and president ofYoung Pharmaceuticals, Inc., a 32-year old firmbased in Hartford, Conn. that develops and marketsproprietary dermatology products to dispensingphysicians. Kulesza, an industrial chemist bytraining, holds several US patents on dermatologicaltechnologies including drug delivery systems andprescription drugs. A graduate of Yale University, heis the principal formulator of one of the best knownphysician-promoted consumer product lines on themarket today and scientific advisor to severalmultinational skincare product makers. �

Continued from Cover

Rethinking Chemical Peels

THE CASE OF THE SUDDEN

HYPERPIGMENTATION

49 year old Fitzpatrick IIIfemale presented for improvement of acne scars andfine rhytids. No hyperpigmentation was evidenton exam. She received four fractional lasertreatments for collagen stimulation between August– March, and had an excellent result. In Augustof that year she went on a scuba diving trip andexperienced a sudden onset of rather markedhyperpigmentation on her forehead, cheeks andneck. We treated her with Tretinoin 1%,comprehensive hydroquinone-tretinoin home care regimen, phloretin CF, a series ofmicrodermabrasions, and an IPL. The patient has had about a 65% improvement, but is still distressed about the cloud like pattern ofdyschromia on her lateral cheeks and neck. The fractional laser representative stated she has seen one other case like this.

WHAT WOULD YOU DO NOW? Have you successfully treated a case

like this? Submit your suggestions tomissy@surgery.org and please do not listany manufacturer names.

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Ask the Specialists

Expanding the Wealth ofExperience of Our Membership

Do you have a difficultskincare issue that you’ve hadtrouble solving? Would you like tolook to your fellow SPSSCSmembers for their help andexpertise? Each quarter we will getinput from members that havesuccessfully treated some of yourmost difficult skincare issues.

If you’d like to submit a case,please email your patient profile/history to: missy@surgery.org Be sure to include such things aspatient age, Fitzpatrick type,heritage, life style, etc. You mayalso include some of the treatmentsand products you’ve already tried.Please be as specific as possiblewithout listing any manufacturer’snames. We will present a new caseeach quarter. �

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

“THE BUZZ”Saunda (Sam) Wolfersberger, RN

Plastic Surgery Center, Ltd.

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their concerns of competing in the jobmarket, so they seem very concerned withvisual maintenance (what the potentialemployer sees). They are addressing facialsun damage, telangiectasia, facial rhytids withoptions they still consider affordable. Areaswe have noticed that have stayed stable evenin this economy are the dermal fillers,

neurotoxins, laser skin resurfacing, light based therapies, permanentmake-up applications, sclerotherapy, and aesthetician based skin care.

What to do for the patient that tells you—”I have tried the skincreams for my wrinkles and none of them work!” “I may as well havethrown my money away!” “How do I know which cream to use, youhave so many?” I agree with the patient that some creams do notwork for every patient, but many do, and that is why they needdirection—specifically, our aesthetician! They need a professional toguide them. Have they considered their biological age vs theirchronological age, it is not all about that date of birth. Today’s skincare market is confusing, expensive, and saturated with hype.Common mis-steps include incorrect application of products, andlack of patience on the consumer’s part. Most changes with productstake 2-3 months and may require alterations, additions or deletionsto the skin care protocol. Managing the patient’s expections is key.So, when patients tell me skin creams do not work—I tell them,“You need to see our aesthetician!

All products mentioned in the above article are for informational purposes only. �

trend we are beginningto see with our patients is the request for the“mini-botox” treatment. The focus seems tobe directed toward an abbreviated treatmentwith a more natural appearance. We do stillhave some patients who feel that they shouldhave no movement above their cheek bones,so patient preference for a tailored treatmenthas become the norm.

Dysport® is getting rave reviews in our practice and the patientsdo seem to like having a choice. We have noted the more rapidonset of effect with Dysport® but have not been using it longenough to see if our patients report if they notice a longer durationfrom the treatment. We are now seeing the national advertising forDysport® in magazines which will translate to more patientsrequesting the product.

A buzz word related to make-up that I noticed recently was,“high-def skin.” Some manufacturers are incorporating silicone intotheir foundations to create a flawless look. Primers prior to make-upachieve ease of application and produce a more even finish.

We have our topical tretinoin mixed in varying strengths withadded emoillient by a pharmacy to adjust to different skin types, butrecently a patient asked about Refissa™. Refissa™ is a 0.05% tretinoincream, fragrance free, emollient based option for patients who prefera commercial brand.

With unemployment near 10%, patients are commenting on

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