The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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II Business Basics
8 The Spa and the Law
Michael S. Byrd
Abstract
:hile medical spas (MedSpas) are gaining increasing popular-
ity, they also introduce increasingly complex regulatory and
legal issues, requiring a new way of thinking and a compliant
structural foundation. This chapter will not only highlight many
of the common compliance issues facing MedSpas and their
owners but also shed light on how to become compliant. The
compliance risks for a MedSpa tend to reside with the physician.
The consequences of running an ´illegalµ medical spa range from
fines all the way to losing a medical license. :hen the stakes
are this high, no room exists for educated guesses. Opening and
operating safe and compliant MedSpas requires guidance and
careful navigation of this regulatory minefield. State laws and
licensing board rules governing the practitioners in a MedSpa
often offer confusing (sometimes contradicting) information.
This chapter will expand on these risks and offer solutions to the
most common issues facing MedSpas today.
Keywords
MedSpas, medical spas, ownership, delegation, supervision, plas-
tic surgeon, nurse practitioner, aesthetician, physician assistant
8.1 Introduction
The explosion of the noninvasive medical aesthetic market
directly impacts the business of plastic surgery. This market,
where a practice is commonly branded as a medical spa or
´MedSpa,µ challenges both the noninvasive services offered
by an aesthetic practice and the market for surgical services.
Technological advances increasingly make a MedSpa treatment
an attractive alternative to surgery. Health care reform and
decreasing reimbursements increasingly draws noncore physi-
cians and others to the cash-based MedSpa model. The influx of
private money by investment bankers and angel investors into
the MedSpa market fuels this explosion.
The data behind this MedSpa market growth is compelling. The
number of MedSpas has increased by more than 20 annually. In
2016 alone, 11,674,754 nonsurgical procedures were performed,
and of that, 4,597,886 botulinum toxin type A treatments were
conducted, according to the American Society for Aesthetic Plastic
Surgery. This number represents a 75.5 increase from 2011.
1ot only has the number of botulinum toxin injections risen;
hyaluronic acid injections have increased by 106.9, chemical
peels have increased by 60.4, and nonsurgical skin tightening
treatments have increased by 76.9.
As in so many other industries, the state and federal lawmakers
are far behind the advances in the MedSpa market. It will take
years to know how the various professional boards and state
statutes will govern MedSpas. In the meantime, existing law
causes an overwhelming percentage of MedSpas to be noncompli-
ant. Because of the training and typical staffing of a plastic surgery
practice, plastic surgeons sit on a unique compliance advantage to
not only survive the influx of MedSpa competition but also thrive.
8.2 The Big Three: Compliance
Issues to Owning and
Operating a MedSpa
Because a MedSpa is a fusion of health care and retail, patients,
providers, and investors have a fundamental disconnect from
the need for compliance. Beneath the fast, noninvasive, relatively
painless experience found often in a retail setting lies an import-
ant truth: most MedSpa treatments are the practice of medicine.
In diagnosing the source of noncompliance of MedSpas, three big
traps exist. The traps can be found in the ownership structure of
the MedSpa and the staffing for treatment of MedSpa patients.
8.2.1 Who Can Own a MedSpa?
In most states, only physicians (and sometimes other health care
professionals) are legally allowed to own MedSpas. The legal
doctrine, called the ´corporate practice of medicine,µ is enacted
to prevent nonphysicians from employing physicians to offer
medical services. States that have strong corporate practice of
medicine rules include 1ew This raises the obvious question as to how nonphysicians can
own a MedSpa. The answer is an old model found in health care
and in the business of plastic surgery (historically for different
purposes): the management services organization (MSO) model.
The Management Services Organization Model
The MSO model allows physicians and nonphysicians alike to
effectively own a MedSpa. The MSO model splits the business
and clinical aspects of a MedSpa into two different entities. The
MSO is the business entity that provides management services to
the clinical entity. Ownership of the clinical entity must follow
the applicable state law governing ownership of a professional
entity that provides medical services. The MSO, however, may be
owned by anyone. The cord that tethers the two entities together
is a management services agreement (MSA). The MSA outsources
the business aspects of the MedSpa to the MSO and typically
drives the economics of the MedSpa to the MSO entity. Examples
of the services provided by an MSO include leasing of space and
equipment, licensing of intellectual property, marketing, human
resources, accounting, billing, and payroll (Fig. 8.1).

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Why Do the Ownership Rules Matter to
Aesthetic Surgeons?
The impact of the ownership requirements of a MedSpa to an
aesthetic surgeon depends on the nature of the relationship
between the surgeon and the MedSpa. The three most common
scenarios for a surgeon to be involved with a MedSpa are as fol-
lows: (1) the surgeon owns a MedSpa ancillary to the physician’s
surgical practice, (2) the surgeon owns a MedSpa with a mid-
level provider or a business partner, or (3) the surgeon serves as
a medical director for a MedSpa.
The situation posing the most potential risk to an aesthetic
surgeon is serving as a medical director for a MedSpa. The
surgeon, in this arrangement, is asked to serve in a limited role
to supervise and delegate treatments to the actual providers of
MedSpa services, while typically receiving not much more than
a monthly stipend. Surgeons often find value in this by hoping
their name awareness will generate new surgical patients from
the MedSpa. Many surgeons sign on as medical directors with
little inquiry into the structure of the MedSpa. If the MedSpa is
not compliant with the ownership rules of the applicable state,
the surgeon may unwittingly be supervising a medical practice
that is not authorized to practice medicine.
The second common scenario for aesthetic surgeon involve-
ment within a MedSpa is co-ownership with a nonphysician.
Depending on state law, this arrangement may not comply with
the ownership rules governing medical practices. The MSO model
then becomes the compliant model for the surgeon to continue
the MedSpa in this co-ownership arrangement.
Finally, many aesthetic surgeons have a MedSpa as a part of
their surgical practice. This is the ideal position for aesthetic
surgeons, as the MedSpa will comply with the ownership rules
of any state in this scenario. Increasingly, aesthetic surgeons are
nevertheless choosing to adopt the MSO model. By adjusting
the legal model, the aesthetic surgeon has now positioned the
MedSpa to be acquired in the future by either a successor surgeon
or a nonphysician-owned MSO. The market for potential buyers
then expands exponentially.
Fig. 8.1 The MSO model. This figure depicts the structure of a MedSpa medical entity partnered with a management services organization (MSO)
business entity through a management services agreement (MSA). The various arrows and boxes give a thorough explanation not only of how the
model is structured, but also of how to handle the flow of money from patients to physicians to billing legally.
Patient
MedSpa
Doctors
Doctors
MSO
MedSpa
Services
Ownership
Ownership
Non-Doctors
Ownership
MSA
$$$
$$$
$$$
$$$
$$$

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II Business Basics
8.2.2 Who Can Diagnose for Nonsurgical
Cosmetic Treatments?
-ust like any traditional medical treatment, any MedSpa proce-
dures that constitute the practice of medicine require an initial
diagnosis. The definition for the practice of medicine is typically
broad in most states and encompasses many of the common
MedSpa treatments. For example, injectables, lasers, micronee-
dling, dermablading, body contouring (e.g., CoolSculpting),
medical-grade chemical peels, and microdermabrasion most
often fall within the definition of the practice of medicine. In any
medical practice, including an aesthetic practice, the physician
may provide the initial exam and diagnosis.
Typically, physician assistants (PAs) may also perform the initial
exam and diagnosis. However, the requirements vary by state,
so it remains important to understand the nuances. Most states
allow a PA to diagnose but require the supervising physician and
the PA to have the appropriate training in aesthetics. The key then
becomes planning for appropriate training when bringing in a PA
from another specialty.
Similarly, a nurse practitioner (1P) and advanced practice
registered nurse (APR1) will usually be able to provide the initial
exam and diagnosis. The scope of practice and other boundaries
for 1Ps and APR1s vary widely from state to state. In some states
an 1P or APR1 will have more autonomy than a PA. On the other
hand, some states have requirements that 1Ps or APR1s may
diagnose only in the specialty for which they are certified. This
creates a risk, because currently no aesthetics certification exists.
Those states typically relegate the 1P’s or APR1’s scope of practice
in a MedSpa to that of a registered nurse (R1).
In most states, it would be beyond the scope of practice for an
R1 or a licensed practical nurse (LP1) to engage in the diagnosis
phase of treatment. This becomes a problem for MedSpas, because
it is common for an R1 to see and treat patients in the facility
without the patient ever coming into contact with a physician or
mid-level practitioner (Table 8.1).
In a recent survey by the American Med Spa Association, 37 of
responders admitted that either they do not perform a good faith
examination prior to a patient’s first treatment or the exam is not
performed by a physician, PA, or 1P. ´Good faith examinationµ is a
term used in California, but it simply refers to performance of an
appropriate medical exam before prescribing, dispensing, or fur-
nishing a dangerous medication, which would include botulinum
toxin A or fillers prescribed for a patient. Other terms used for
this exam and diagnosis include ´initial examµ or ´initial consult.µ
This response rate indicates a broader issue of noncompliance,
because physicians, or the mid-level practitioners to whom they
can properly delegate the task, often do not perform an initial
patient examination or prescribe treatment plans for MedSpa
patients. And while the semantics may differ, all states have some
requirement that a physician must prescribe a course of treatment
before rendering services.
8.2.3 Who Can Provide Treatment?
:hile an initial exam must be provided by either a physician or
a mid-level practitioner to be compliant, many types of licensed
professionals can provide a variety of treatments in a MedSpa.
The exact scope of practice for any type of practitioner is going
to depend on state-specific laws and regulations, and it typically
varies based on education and experience. Aside from physi-
cians, PAs, 1Ps, R1s, and aestheticians (usually spelled this way
to distinguish them from medical aestheticians, who usually
work in hospitals and concentrate on reconstructive care) are
the main practitioners in a MedSpa setting. The providers who
have authority to diagnose (MDs, PAs, 1Ps, and APR1s) may also
provide treatment. Additional providers, depending on the state,
include master aestheticians, laser techs, medical assistants, and
even patient coordinators.
Registered Nurses
Like many practitioners, the scope of practice for an R1 will
depend on the state where he or she holds a license. The board of
nursing for each state regulates specific action for R1s. However,
in a medical practice setting, the scope of practice will rely heav-
ily on delegation. Generally speaking an R1 will have little inde-
pendent authority but can receive various delegations for those
procedures. Some states, such as 1ew -ersey, currently limit an
R1’s ability to inject and fire a laser. Most states, however, will
allow the traditional MedSpa services to be delegated to an R1.
Aestheticians
Unlike other licensed professionals, aestheticians in most states
are unable to perform any tasks that are categorized as the prac-
tice of medicine. While unable to perform medical treatments,
Table 8.1 Common treatments offered by MedSpas and which ones constitute medical treatments
0ediFDO 0' 51 13 3A
1RnmediFDO DeVWKeWiFiDn
Microdermabrasion penetrating the epidermis
Microdermabrasion for cosmetic treatment (only outermost layer of skin or
stratum corneum)
Physician-grade chemical peels (e.g., glycolic)
Aesthetician-grade chemical peels/exfoliation (superficial/epidermis; not
medium-depth/grade)
Laser treatment (intense pulsed light >IPL@ devices, etc.)
Hair removal by tweezing, depilatories, waxing (electrolysis limited to
licensed electrologists)
Treatments to remove scars, blemishes, wrinkles, pigmentation
Deep-cleaning facials and skin care (cleaning pores, sloughing off dead
surface cells via commercially available products)
Injectables (e.g., botulinum toxin)
Laser hair removal (when applicable)
Adapted from =ide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg 1998;101(3):840–851; =ide BM, Swift R. Addendum to “How to block and tackle
the face.” Plast Reconstr Surg 1998;101(7):2018.

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77
aestheticians are able to administer a variety of cosmetic treat-
ments. Aestheticians are usually licensed and regulated by the
state board of cosmetology and must undergo a state-specified
training program. Some national programs exist, but by and
large this is a state regulation. :hile not yet commonplace,
some states have implemented a new ´Master Aestheticianµ
license. The master aesthetician completes training beyond that
of the aesthetician license and expands their scope of practice.
:hile expanding aestheticians’ training and knowledge into
areas such as pharmacology, medical terminology, and pre- and
postoperative care, these programs still do not give aestheticians
carte blanche to operate outside their state-mandated scope.
Some states, such as Utah and Virginia, along with the District
of Columbia, have expanded the aesthetician practice to include
more education and, in some instances, more treatment oppor-
tunities. Employing aestheticians or master aestheticians is legal
so long as they are not operating outside their scope of practice.
Ensuring that they are administering only limited treatments
not constituting the practice of medicine will help maintain
compliance and avoid enforcement actions. As a word of caution,
aestheticians are commonly operating outside their scope of
practice in MedSpa settings. Typical noninvasive cosmetic treat-
ments seem like a natural extension of traditional aesthetician
services, leading physicians and aestheticians to provide medical
services unwittingly.
Medical Assistants and “Unlicensed Persons”
Last, some states have laws and regulations for medical assis-
tants, while others are completely silent on the matter. Medical
assistants are unlicensed, although sometimes certified, indi-
viduals who may work in a medical setting. Medical assistants
typically assist with administrative duties or perform some
clinical duties such as taking medical history and assisting a
physician. Typically medical assistants are not qualified under
state law to receive delegations, but there are some instances
when that might not be the case. Some state laws allow dele-
gation to ´unlicensed persons.µ In these instances, a physician
(or an autonomous NP) can delegate to an unlicensed person as
long as that person is ´qualified.µ However, there is substantial
risk associated with this type of practice. Ultimately, as with any
delegation or practice, the physician will hold the liability on
behalf of those who receive the delegation orders. :ith that in
mind, best practices are to delegate medical treatments to those
who are licensed professionals and trained to perform the task
at hand.
Enforcement
A common question that arises with compliance issues is how
the medical board, or any regulatory body, would become aware
of a compliance issue. Stated more bluntly, the question is typi-
cally some variation of ´How is everyone else doing it and getting
away with it"µ :hile random audit of a practice is typically a
low risk, tangible ways to come under the enforcement spotlight
exist. The most frequent sources of enforcement initiatives are
(1) patients, (2) competitors, and (3) disgruntled ex-employees.
Once the enforcement spotlight is turned on a practice, exposure
becomes real.
8.3 Remaining Compliance Issues
8.3.1 Commissions
:hile the law varies significantly, payment of commissions to
staff can create significant risk in many states. In a survey of
MedSpas by the American Med Spa Association, 31 of those
who responded pay commissions for the performance of certain
medical treatments. For example, the providers commonly
receive an hourly wage plus a certain percentage of revenues
for treatments provided, products sold, and even treatments
provided by other providers. The amount paid ranges from 5
of sales net of product cost to 25 of gross sales. Many MedSpas
create a business problem by essentially paying all the profits to
the providers. More important, commissions in some cases are
illegal.
Commissions fall within a veritable minefield of regulations
that intersect to make what otherwise would be a benign form
of compensation (when properly structured) into a payment that
can range from unprofessional conduct to illegal. Common law
legal doctrines that prevent fee splitting of medical revenues vary
from state to state. States such as 1ew fee splitting. Other states create regulatory risk for commissions
through their corporate practice of medicine doctrine, antikick-
back laws, and antireferral laws.
The simplest answer in navigating this regulatory minefield is
to avoid commissions. The best practices of MedSpas are to pay
a bonus for specified performance metrics or pay discretionary
bonuses. A discretionary bonus is the simplest approach, as
it avoids the pitfalls with creating complicated metrics. This
approach requires trust between the provider and the MedSpa
that the MedSpa will fairly compensate for performance. The
performance metric approach sounds great in theory but is
challenging to create. The idea behind this approach is to create
performance goals that tie into the overall goals of the MedSpa.
Common performance metrics include team revenue targets,
individual revenue targets, efficiency targets, and patient satisfac-
tion benchmarks.
8.3.2 The Health Insurance Portability
and Accountability Act
:hile the Health Insurance Portability and Accountability Act
(HIPAA) is familiar to physicians, the breadth of issues that must
be considered with patient privacy and security is elusive. A
common question posed by MedSpa owners is ´I have heard that
HIPAA does not apply to a MedSpa because it does not take insur-
ance; is that true"µ :hile the law, of course, is more complicated
than this, there is a good rule of thumb that the federal HIPAA
law may not apply for a cash-only business. However, three big
caveats to this rule of thumb exist: (1) most states have a state-
level HIPAA law covering patient privacy that apply to MedSpas,
(2) many MedSpas are actually a part of a surgical practice that
does bill insurance and is therefore subject to HIPAA, and (3)
most states recognize some civil level of patient protection for
violations of patient privacy, which may result in a direct lawsuit
from a patient to the MedSpa.

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II Business Basics
:hen HIPAA does apply to a MedSpa, the real consideration
is the evolution of patient privacy and security laws. The Health
Information Technology for Economic and Clinical Health Act
(HITECH) was signed into law in 2009 by President Obama as
part of the health care reform. This act established privacy and
security measures and expanded HIPAA in five ways: (1) business
associates are now directly governed by HIPAA rules, (2) there
is a new notification of breaches requirement, (3) there are new
restrictions on certain disclosures, (4) there is an alteration of the
disclosure standard, and (5) new accounting rights of patients
have been provided.
Because of the importance on protecting patient privacy and
information, HITECH requires that organizations implement com-
pliance plans to describe and outline privacy policies. All covered
entities are required to have privacy policies and security policies
to protect sensitive patient information. Compliance plans have
seven elements: (1) written privacy and security policies and
standards of conduct, (2) designation of a compliance officer and
compliance committee, (3) workforce training and education,
(4) effective lines of communication, (5) issuing disciplinary
guidelines, (6) internal monitoring and auditing, and (7) timely
responses to detected breaches and corrective mechanisms.
A MedSpa must first determine whether HIPAA applies to the
MedSpa and understand the scope of patient privacy regulation in
the applicable state. From there, a MedSpa may design and build
an appropriate plan to protect patient privacy.
8.4 Emerging Trends in the
MedSpa Industry
8.4.1 Private Equity
Investment from private equity funds, hedge funds, and oppor-
tunistic businesses has been an accelerant to the explosion
of the MedSpa market. Private equity brings great economic
opportunity for MedSpas and aesthetic providers. The drawback
to this influx of private equity capital is a lack of sophistication
regarding the principles for compliance. Consequently, the lack
of compliance in the MedSpa space is high and will ultimately
draw increased enforcement and scrutiny from the medical
boards, nursing boards, and other governmental bodies. Like it or
not, private equity is a new reality for MedSpas and for those in
the aesthetic sector. A look into the dental sector will shed light
on the impact (good and bad) of private equity in health care.
The common thread between MedSpas and dental practices in
the private equity world is that they tend to operate like a retail
store from a business perspective and like a health care practice
from a regulatory compliance perspective. In the dental market,
this looks like a branded chain of dental offices typically found
in retail real estate space. Similarly, MedSpas tend to be branded
as retail elective health care services. The regulatory hurdles are
similar for the management of dental and medical practices, and
the legal solutions to these regulatory hurdles are structurally the
same.
From a compliance perspective, private equity accesses the
dental provider market in a similar manner to the MedSpa market.
Dental service organizations (DSOs) and MSOs share similar busi-
ness and legal compliance characteristics. DSOs are management
organizations in the business of providing all back-office business
management services to dental practices. MSOs, by contrast,
provide similar business services to medical practices, including
MedSpas. Because the DSOs have been around longer, they serve
as a great example for the infusion of private equity into MedSpas.
:hile the private equity world is just starting to enter into
the MedSpa field, the development of the dental private equity
market is instructive for those physicians who want to use private
equity as a MedSpa exit strategy. Because private equity investors
are typically growth-oriented rather than value-oriented, it is
important to be clear that the business strategy is in alignment
with private equity strategy. Moreover, the founding physicians
must be able to articulate clearly a vision for the next 3 to 5
years. They must also be able to communicate the competitive
advantage over the competition clearly, and the MedSpa must be
compliant from a regulatory standpoint. Compliance includes the
legal structure from a corporate practice perspective as well as
patient privacy and staff delegation. Last, the service organization
must be able to articulate a strategy for attracting and keeping
clinicians.
Businesses in the younger and emerging MedSpa market would
be wise to pay attention to the trends and developments in the
DSO market. Private equity is coming into the MedSpa market,
presenting unique opportunities to surgeons to expand the
potential audience of buyers of a MedSpa. If the MedSpa house
is not in order from either a regulatory or business perspective,
private equity will flee.
8.4.2 Autonomy of Nurse Practitioners
A current trend across several states has been to expand the
authority and autonomy of an 1P. Because 1Ps have earned
either a master’s degree or a doctoral degree in nursing, they are
able to work in a variety of specialties. This impacts MedSpas
in a few ways. First, in some states this allows 1P ownership,
which expands competition and potentially eliminates the need
for physician involvement. Second, in some states, the aesthetic
surgeon may staff the MedSpa with an autonomous 1P and sub-
stantially reduce the need for clinical oversight, thus allowing
the surgeon to spend clinical time operating and focus on the
business side of the MedSpa. Although 1Ps may be autonomous in
a particular state, states differ as to whether an 1P can then own
a MedSpa. For example, an 1P with 3,600 hours of experience
in 1ew a MedSpa. On the other hand, an 1P in :ashington may own a
MedSpa outright. :hether a physician is staffing a MedSpa or
agreeing to partner with an 1P, understanding an 1P’s autonomy
and ability to own are imperative from a compliance perspective.
The wave of 1P independence in some states may also create
opportunity for the physician in staffing a MedSpa. However,
while many states have opened up legislation to allow for 1P
independence, sometimes this independence is tied to the NP’s
particular specialty. For example, an 1P who specializes in neona-
tal care might not be completely autonomous in adult care. More
important, some state licensing boards are hesitant to pronounce
1Ps autonomous in aesthetic medicine. Aesthetic medicine is not
currently a recognized specialty for advanced education; conse-
quently, some states take the position that an 1P is limited to the
scope of practice of an R1 in aesthetic medicine.

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8.4.3 New Tax Reform
In December 2017, Congress passed the Tax Cuts and -obs Act
(TC-A), which is causing big changes for the business community.
At the heart of the bill is a new scheme that will reduce the
personal income tax rate for owners of pass-through entities.
These entities, typically partnerships, sole proprietorships and
subchapter S corporations, will receive a 20 deduction on their
taxable income. However, for specified service trades (which
includes health care professionals), the deduction applies only
for those who fall below a threshold. The threshold for a single
filer is 207,500, and the threshold for married joint filers is
415,000. :hile a taxpayer loses the full deduction at 207,500,
the deduction begins to be phased out at 157,500. In a profitable
MedSpa, this could be an issue.
Because regulations indicating how the new tax law will be
enforced have not been issued, Certified Public Accountants
(CPAs) and tax attorneys are left to speculate on strategies that
may work to fit within this deduction. Some speculate that MSO
owners may be able to work around the service trade limitation.
Additionally, there is a thought that separating product sales into a
separate entity may create a benefit as a nonservice entity for this
new deduction. This new law and the pending regulations merit
monitoring, as new strategies may surface to refine the business
structure of MedSpas in a tax-advantageous manner.
8.5 Concluding Thoughts
MedSpas directly and indirectly impact the business of aesthetic
surgery. Aesthetic surgeons face important business decisions as
to how and when to incorporate a nonaesthetic cosmetic service
strategy into their business. The heart of the risk for the MedSpa
market lies in health care compliance. :hile some smaller
MedSpas may continue to operate in a noncompliant structure,
the dual benefit of operating a compliant MedSpa is that (1) the
risk for the MedSpa is substantially reduced and (2) the opportu-
nity for a successful sale of the MedSpa is increased.
Suggested Reading
>1@ Adatto BE, Byrd MS. Legal and regulatory issues in the medical spa industry. Mod
Aesthet 2017;(Suppl 2: May–-une):8–9
>2@ Thiersch AR. The medical spa boom. Mod Aesthet 2017;(Suppl 2: May–-une):5–6

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9 Social Media
Anthony Youn
Abstract
How does a plastic surgeon effectively navigate the world of
social media" 1etworks such as Facebook and become a go-to source of information for cosmetic surgery
patients. A majority of our patients use social media every day,
and recent studies are documenting its rising impact on the plas-
tic surgeon–patient relationship. Facebook, Instagram, Snapchat,
Twitter, and influential social media networks for plastic surgeons. But how
does a doctor choose which outlet to use and how to benefit
maximally from the time and effort that he or she invests" The
first step is to determine which social media network matches
your ideal patient, or avatar. Then, match the network to the
surgeon’s interests: live video" text articles" This chapter shares
practical tips and advice to pick the best social media networks
for a practice and use each network effectively and efficiently.
Keywords
social media, Facebook, Instagram, Snapchat, Twitter, 9.1 Introduction
The methods plastic surgeons use to interact with prospective
patients are constantly changing. In the 1990s, print still ruled.
Plastic surgeons bought ads in the Yellow Pages, newspapers,
and magazines. In the 2000s, we discovered the power of the
Internet and began creating websites with extensive before-
and-after photo galleries. Today, social media have emerged as
the quickest growing factor in the interactions between plastic
surgeons and patients.
In fact, recent studies reveal that more and more patients are
being influenced by social media to undergo cosmetic procedures,
and they’re utilizing social media to interact with their doctors
in ways never before imagined. It’s also become a way for plastic
surgeons to educate and court prospective patients. So, in this
chapter I’ll describe the most prominent social media networks,
break down which ones you want to consider participating with,
and recommend how to maximize your time with them.
If you’re a novice in the world of social media, the dozens of
options of networks can be daunting. :hich social media channel
should you spend your efforts on" Facebook" Instagram" Twitter" This is the first major question you need to answer.
The best way to determine which social media network to pick
is to first decide who is your avatar. would consider as your ideal patient. :ould your avatar be male
or female" :hat age would your avatar be" :hat socioeconomic
group would he or she belong to" :hat are your avatar’s primary
concerns and interests"
Choosing your avatar can help you choose which social media
channel is ideal for you. For example, if your favorite surgery to
perform is breast augmentation, then your avatar is likely to be
a woman in her 20s or 30s. If your preferred procedure is facelift,
then your avatar may be a woman in her 50s. Or maybe gyneco-
mastia surgery is your primary focus" Then your avatar may be a
man in his 30s.
Once you determine your avatar, then pick the social media
channel that your avatar gravitates to. Go where your patients are.
9.2 The Main Social Channels
9.2.1 Facebook
Currently, Facebook is by far the most popular social media
network in the world, with over 2 billion users worldwide. Its
massive reach extends across all age groups, with over 70 of
Internet users between the ages of 18 and 65 using this network.
Its users are both male and female, with women making up 52.
Of all the social media channels, Facebook has the most varied
content. create live video (Facebook Live). So if your avatar matches
Facebook’s demographic and you like to share a wide variety of
content, then Facebook may be the optimal network for you.
9.2.2 YouTube
over 1 billion users. It’s basically a repository for videos, allowing
users to create their own ´channels.µ Videos can range in length
from just a few minutes to a half hour or longer. ´socialµ as the other networks, as it doesn’t allow for you to share
thoughts or photos, limiting the interaction and community feel
to it. Its demographic is extremely wide, however, and some
people are even using place of Google.
9.2.3 Instagram
Instagram is the most rapidly growing social media channel,
with approximately 800 million users and counting. It’s a very
visual medium where users can post photos and videos (up to
60 seconds long) in their main feed. Followers can ´likeµ and
comment on these posts. Instagram users can also post ´stories,µ
short videos of 15 seconds or less that disappear after 24 hours.
It’s believed the stories feature was added in order to compete
with Snapchat. Instagram users trend younger than Facebook,
with 59 of Internet users between the ages of 18 and 29 active
on the network but only 33 of 30- to 49-year-olds using it. Its
users skew female, with 58 women.

9 Social Media
81
9.2.4 Snapchat
Snapchat began as an app that allowed users to send rapidly
disappearing photos to each other. This was initially very pop-
ular with teenagers, who used it to send hidden messages and
photos to their friends. Then Snapchat added the stories feature,
and the network exploded in popularity. Plastic surgeons who
were early adopters, such as ´Dr. Miamiµ (Michael Salzhauer) and
Dr. Matthew Schulman, quickly accumulated audiences in the
millions as they ´snappedµ their day’s surgeries, often in explicit
detail. Snapchat remains very popular among the younger crowd,
with 400 million users, the majority of them under the age of 24.
Although millions of men are active on Snapchat, its users skew
female, making up 70 of its user base. Snapchat’s growth has
become fairly stagnant over the past couple years, eclipsed by
Instagram.
9.2.5 Twitter
Twitter allows its users to post short messages, or ´tweets,µ of
280 characters or fewer. These can include text, photos, links,
and short videos. Unlike the other channels, Twitter users some-
times tweet dozens of times per day. Its demographic is wide and
has a 53:47 male-to-female audience. Although Twitter has 317
million users worldwide, its growth has also stagnated in recent
years.
9.3 Some Smaller Networks
9.3.1 Pinterest
Pinterest has 150 million users, most of whom are female, with
an average age of 40. It allows users to create small graphics
called ´pins,µ which are then placed onto a virtual bulletin board.
These graphics can include recipes, quotes, and images. Although
some plastic surgeons have Pinterest accounts, as of this writing
no plastic surgeons have fully taken advantage of this network.
9.3.2 Reddit
Reddit users skew young and male, with an average age in
their twenties. It’s basically a huge bulletin board of interesting
stories, videos, and images, which users can up-rate or down-
rate, depending on how interesting they think the posts are. The
posts can be grouped into separate channels depending on the
subject matter³for example, Plastic Surgery, Announcements,
TodayILearned. Although the least known among the major
social channels, it boasts 125 million users.
9.3.3 LinkedIn
LinkedIn is a professional networking site with 106 million users.
It’s a social channel that enables users to network with friends,
coworkers, and others in industry to make connections, obtain
jobs, and promote what’s happening with your work. It’s not a
place for doctors to court patients, and it should be used in a
professional fashion only.
Google Plus, Vine, tumblr, Periscope,
and MySpace
Google Plus, Vine, tumblr, Periscope, and MySpace are dead.
Social media channels notoriously come and go. One day a
medium is hot with millions of users, and a mere year later no
one uses it anymore. This is the nature of online marketing and
communication in today’s world. So don’t put all your eggs into
one social media basket. Today’s hot channel may be in tomor-
row’s digital dustbin.
9.4 Tips for Using Each
Social Channel
9.4.1 Facebook Tips
Every plastic surgeon or practice should have a Facebook business
page separate from the owner’s personal page. Business pages
enable you to access analytics to see how your page is perform-
ing, purchase ads, and promote posts. The business page can be
centered on your actual business or on yourself. For example, I
have a Facebook page for my practice, a separate Facebook page for me as a public figure. If you haven’t
yet used Facebook for your business, then I recommend creating
a page for your plastic surgery practice first.
Facebook allows a very wide range of posts, so if you like to share
a wide variety of items, from before-and-after photos to short
videos of you performing surgery or injections to links to online
articles, and even images with famous inspirational quotes, then
this is the best network for you. It skews a bit older, so if your prac-
tice is more mature³consisting of facelifts, blepharoplasty, and
laser treatments³then it will match your avatar well. If, however,
your practice skews younger³with more breast augmentation,
liposuction, and Brazilian butt lift (BBL) surgeries³then Facebook
probably shouldn’t be where you spend your resources. Look to
Instagram and Snapchat instead.
If you don’t like taking photos or videos of yourself or your
patients and would rather write articles and share links to other
content, then Facebook is a better fit for you than Instagram or
Snapchat, which require considerable amounts of video to be
successful. However, over the past several years Facebook has
pivoted toward live video and even added Facebook stories to its
feed. So now it’s basically become a one-stop shop for all sorts of
sharable items.
Currently, the most effective way to use Facebook is by going
live. By creating live video, you can take advantage of more organic
reach than any other type of post. :hat types of live videos should
you create" I recommend starting simple. For my first Facebook
Live video, I pointed my iPhone camera at myself and discussed
the popular facial fillers in my office. I had a box of each of them
and pointed the camera at each box while I discussed which ones
I used and why.
If you haven’t done a Facebook Live, then I strongly recommend
you try it. It’s a real rush. who are watching you during your broadcast, and you can even
read and reply to their questions live

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comments and questions which you can read on a separate device
during the live broadcast. For example, you can go live from your
phone and read the comments and questions on your iPad. This
is a great way to interact with prospective patients, show your
personality, and even promote specials in your office.
If you want to take it to the next step, then try broadcasting a
live treatment. This can really enable your followers to virtually
step into your office and see a procedure they are interested in.
:e’ve had great success with broadcasting live procedures on
Facebook, as it demystifies the treatment for the viewers and can
make them more apt to call for an appointment. I recommend
starting with a noninvasive treatment first, such as a chemical
peel or laser treatment, prior to proceeding to more invasive
procedures such as filler and surgery.
So what do you do after you make a Facebook Live video" Post
it to your feed to get hundreds or thousands more viewers and
organic reach. Facebook to show it to more people. little as 1 to as much as you want to spend. If you boost a post, I
recommend that you boost only posts that have some popularity
already. The posts with more engagement get better results when
boosted, so your paid reach can actually increase your organic
reach. I also recommend boosting posts that can make you money.
For example, it doesn’t make sense for you to pay 20 to boost a
post about a fun movie you watched over the weekend, since there
is no direct monetary benefit. But a post about your new toxin and
filler office special" That makes more sense
So how would you do this" It’s actually quite easy. Once you
click that you’d like to boost a post, Facebook will prompt you to
target an audience. Audiences can be targeted in terms of gender,
geographic area, and interests. This allows you to very specifically
choose the type of users you want to see your post. For example,
let’s say I have a toxin and filler special I’d like to advertise. Since
we perform these injectable treatments on both men and women,
I’d choose both genders. I’d select Metro Detroit as the geographic
area to target. In regards to interest, I may choose people who have
indicated that they are interested in -uvederm (Allergan, Dublin,
Ireland), Botox (Allergan, Dublin, Ireland), and cosmetic surgery.
This allows me to target very specifically the types of people I’d
like to see my ad and pay only for those people.
9.4.2 YouTube Tips
Every plastic surgery practice should have a It’s a perfect place to post promotional videos, such as an intro-
duction to your practice and videos showing minimally invasive
treatments, surgical procedures, and even consultations. Unlike
Facebook videos, to years after they are posted, and successful videos can garner
hundreds of thousands of views.
Also, unlike Facebook videos, with ads. -ust click the button ´monetizationµ when editing the
video and choose which type of ad you are ok with and will pay you when people view these ads. Some experts believe
that your organic reach is higher for videos that are monetized
with ads, since there is a financial incentive for show your video with ads more than a non-monetized video.
Unfortunately, ads featuring graphic content such as live surgery
are usually exempt from ad placement.
If you create a that you separate your individual videos into appropriate play-
lists. These playlists can have separate names, such as ´Surgery
Videosµ and ´Online Consultation Videos,µ allowing viewers easier
navigation when they get to your site. If they open your channel
and the videos are all haphazardly arranged, they’re more likely to
click and exit away without watching anything.
I also recommend creating a professional-looking video that
introduces you and your practice. This video should be pinned to
the front of your channel so any new visitor sees this video first.
website as well.
I also recommend that you embed relevant videos in your
website procedure pages. For example, under my website page for
breast augmentation, I have embedded a video of me explaining
the differences between various types of breast implants. Surveys
show that most people would rather watch a video than read an
article, so having both available on your website is ideal. also embed a video of you performing the actual surgery so that
the process is demystified for potential patients.
Any videos you post in Facebook page. -ust click ´shareµ on your video’s page, then click
the Facebook icon to place the video in a post on your Facebook
page. 9.4.3 Instagram Tips
Instagram is all about the image, making it the obvious top choice
for many plastic surgeons. Those users who are most successful
on this network consistently post attractive images and videos.
Although you don’t need to hire a professional photographer or
videographer, make sure any images you post are visually appeal-
ing and in harmony with your brand. Use a similar color palette
when posting static images about you and your plastic surgery
practice. This brings a sense of familiarity to your page. want the colors to be haphazard or inconsistent from day to day.
Currently, you can post on Instagram in two ways: as a regular
post and as a ´story.µ Regular posts consist of a photo or video up
to 60 seconds long. in one post if you’d like to share several images or videos on one
post. These show up in the main, scrolling feed of the user who
follows you.
Attractive before-and-after photos typically get good engage-
ment on Instagram. Many plastic surgeons (including myself)
have had great response from intraoperative videos as well. Static
images that are obviously advertisements don’t typically do as
well, nor do selfie photos or selfie videos unless you’re a celebrity
or extremely attractive.
In very short time, Instagram stories have outgrown Snapchat
stories. These reside at the top of the app as a bar with a row of cir-
cles, each one representing a different person’s stories. Instagram
stories last up to 15 seconds long and are a great place for you to
share video clips from inside the office and operating room. These
stories stay for 24 hours, after which they are erased. However,
you can choose to ´highlightµ certain stories keep them on display

9 Social Media
83
when anyone visits your profile page. These highlighted stories
can be separated into categories that you create, such as ´breast
augmentation,µ ´facelift,µ or ´Botox.µ
.eep in mind that nudity is not allowed on either Instagram or
Facebook, so make sure to cover nipples and private parts; other-
wise you risk getting banned by the networks. Instagram stories
allow you to ´pinµ items over these sensitive areas digitally, or you
can just cover them at the time of filming. Adherent nipple covers
can be purchased online.
As with Facebook, you can pay Instagram to boost your posts
and show it to more people than your organic reach allows. This
may be worth it for really important posts, especially those which
you can monetize. These Instagram ads are actually created using
the Facebook ads manager program.
9.4.4 Snapchat Tips
If you’re not a millennial, Snapchat can be very difficult and
counterintuitive to use. It was probably engineered that way to
keep older people from being active on the app and making it less
´coolµ to the younger crowd. Upon opening the app, you see the
video camera portion of the app. Swiping in the different direc-
tions (up, down, left, and right) brings you to different screens,
such as your friend list, your previous snaps, the discover page,
and more. As on Facebook, you can ´friendµ other users, but
unlike Facebook and Instagram, Snapchat doesn’t have an easy-
to-use, general search page. This makes it more difficult to find
people you might know or want to follow. For this reason, many
users find that their followers on Snapchat are more engaged
with their posts than, say, Facebook followers.
One main benefit to Snapchat for plastic surgeons is that it is
the only major social media network that allows you to post nude
photos and videos. This can be especially helpful for surgeons
who do a lot of breast and genital surgery. Unlike Facebook and
Instagram, Snapchat doesn’t allow longer-form videos, however.
Its stories only allow ten-second clips (unlike Instagram, which
allows 15 seconds), but it’s very easy for users to post dozens of
these short clips together, which is what most plastic surgeons
who are active on this network do. A recent update from 2017
increased the allowable length of recordings. Snapchat allows
you to record continuously for a full 60 seconds. Then Snapchat
automatically clips it into 10-second clips for upload. This is
all done automatically and when viewing the snap videos, it’s
virtually seamless. This was a huge change that makes recording
surgical procedures much simpler than on Instagram. Also, you
can upload video clips of up to 60 seconds from your camera roll
as well. Snapchat allows you to edit these videos (add captions,
add filters, etc.) within its platform.
Snapchat’s younger audience is interested in procedures rel-
evant to their demographic, such as breast augmentation, BBL,
and liposuction. Practices with older patients might not find
this network as valuable. Snapchat’s younger interests, trying to be a bit creative with your
posts without being unprofessional.
Prior to investing a lot of time and money in Snapchat, make sure
to gauge the current climate for this outlet. Ever since Facebook
bought Instagram, forecasters have been predicting the demise of
Snapchat. It hasn’t happened yet, but some people believe that the
future isn’t so bright.
9.4.5 Twitter Tips
My good friend, and the person whom I consider the ´4ueen of
Twitter,µ Dr. Heather Furnas (Santa Rosa, California), has stated
in our many talks together that ´Twitter is not for getting new
patients.µ Although she has amassed over 120,000 followers, she
doesn’t find that it’s effective in obtaining new patient leads.
Instead, Twitter has become a very valuable outlet for network-
ing with other plastic surgeons.
A few years ago, Dr. Olivier Branford (London, United .ingdom)
started a movement to use #plasticsurgery as a way for plastic
surgeons to network by sharing the latest news, tips, and research.
Now there are hundreds of plastic surgeons throughout the
United States and the rest of the world who use this hashtag to
communicate with each other, building an online community of
collegial plastic surgeons. New research is shared on Twitter from
The Aesthetic Surgery Journal, Plastic and Reconstructive Surgery,
and others, with plastic surgeons commenting on the findings and
learning and supporting each other.
Do you want to get involved" One way to join the conversation
is to retweet and comment on posts by other plastic surgeons and
the journals while using #plasticsurgery. Although you’re unlikely
to get new patients from doing this, you can make new friends with
your colleagues and peers. engagement from your peers by tagging them on posts and images,
essentially giving them a ´heads-upµ that your tweet is something
for them to pay attention to. this can be a quick and effective way to spread the word.
9.5 Code of Conduct
The ethical use of social media by plastic surgeons is currently a
hot topic. Stories of cosmetic and plastic surgeons acting inappro-
priately in the operating room abound, including dancing while
performing surgery, poking fun at patients and/or their body
parts, and making crude jokes. The two main plastic surgery
societies, The American Society for Aesthetic Plastic Surgery
(ASAPS) and the American Society of Plastic Surgeons (ASPS),
have both made changes to their ethics and bylaws to address
the growing concern about unethical behavior on social media.
Although often it is the most controversial and provocative posts
that draw the most attention and views, surgeons must always
remember that we serve our patients first, not our social media
followers.
Please see Fig. 9.1 for the ASAPS Suggested Social Media
Guidelines. This is a great resource to gauge the ethical standards
of your social media activities.
9.6 Patient Privacy Issues
One final, but extremely important note: Make sure always to
obtain consent from your patients prior to featuring them on
social media. Be very cognizant of patient identifiers that might

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not be as obvious, such as tattoos (cover them up), patient names
on charts and photos, and bystanders in your videos. HIPAA rules
apply with social media, and training your staff to be aware of
this is defi nitely recommended.
policy. Check with your insurance carrier if your insurance covers
you for breaches of confi dentiality or other liability associated
with your social media. If not, then you might want to look into a
separate cyber policy that covers you for it.
9.7 The Future of Social Media
Social media represent a constantly changing and evolving
avenue for interacting with and educating our patients. They
may soon surpass traditional advertising as the preferred way
to promote our practices to new patients. By keeping up to date
with the current and future trends in social media, you can be
sure to maximize this incredibly powerful tool.
Glossary of Terms
• Avatar: tion, interests
• Engagement: Followers interacting with your social media
network via liking, commenting, or sharing
• Organic reach: The number of people who view your post
organically, without having to pay for it. Organic reach for
most networks, especially Facebook, has dwindled over the
years, causing some to proclaim “organic reach is dead.”
• Stories: Short videos measuring 10 to 15 seconds long, which
disappear after 24 hours
• Tag: To attach a user’s name to a post
• Tweet: A post on Twitter, up to 280 characters; can also
contain photos and short video
Suggested Reading
>1@ American Academy of Facial Plastic and Reconstructive Surgery. Social Media
Continues to Infl uence Facial Plastic Surgery Requests. 2017.
org/media/press-release/20170616.html. Accessed September 23, 2019
>2@ Gould D-, 1azarian S. Social media return on investment: how much is it worth
to my practice" Aesthet Surg J 2018;38(5):565–574
>3@ Gould D-, Grant Stevens :, 1azarian S. A primer on social media for plastic
surgeons: what do I need to know about social media and how can it help my
practice" Aesthet Surg J 2017;37(5):614–619
>4@ Lewis :. Aesthetic Clinic Marketing in the Digital Age. Boca Raton, FL: CRC Press;
2018
>5@ Pho ., Gay S. Establishing, Managing, and Protecting Your Online Reputation: A So-
cial Media Guide for Physicians and Medical Practices. Phoenix, MD: Greenbranch
Publishing; 2013
>6@ Sorice SC, Li A<, Gilstrap -, Canales FL, Furnas H-. Social media and the plastic
surgery patient. Plast Reconstr Surg 2017;140(5):1047–1056
>7@ Spredfast 2018 Social Audience Guide.
social-media-tips/social-media-demographics-current. Published 2018. Ac-
cessed May 13, 2018
Fig. 9.1 ASAPS Suggested Social Media Guidelines. (© American
Society for Aesthetic Plastic Surgery, all rights reserved. Used with
permission.)

10 Hiring and Training a Superstar Patient-Care Coordinator
85
10 Hiring and Training a Superstar Patient-Care Coordinator
Karen A. Zupko
Abstract
More than just about any role in an aesthetic practice, the
patient care coordinator (PCC) can be a strong marketing asset
or a big marketing liability. This chapter discusses the success
characteristics and skills, best practices for hiring and training,
and ideas for rewarding the PCC without alienating the rest of
the staff. Included are insights from practice leaders who have
successfully recruited and retained high-performing PCCs.
Keywords
hiring, training, recruitment, incentive, motivating, patient care
coordinator, practice building, sales, customer service
10.1 Introduction
More than just about any role in an aesthetic practice, the patient
care coordinator (PCC) is a strong marketing asset or a big mar-
keting liability. An effective PCC can build the surgeon’s value
and credibility with enthusiasm, cultivate long-term patient
relationships, and improve the patient acceptance rate (PAR).
Because the person you hire can enhance or fracture the patient
consultation experience, as well as be a significant influence in the
patient’s decision to schedule surgery or not, I strongly advise aes-
thetic surgeons not to fill this role too quickly. Instead you must fill
it with the right individual. Doing so may take a little more time,
but if the process is completed thoroughly and correctly, the result
will be worth the wait.
This chapter discusses the characteristics and skills of suc-
cessful PCCs, best practices for hiring and training, and ideas for
incentivizing. Included are insights from practice leaders who
have successfully recruited and retained high-performing PCCs.
10.2 Superstar Characteristics
and Skills
Before you even begin your recruitment effort, do you know
what kind of person you are looking for" Do you know which
characteristics make for a PCC superstar" Hiring someone with
the right talent and aptitude at the outset increases the likeli-
hood that the employee will be successful, stay motivated, and
stick with you for many years,
:e asked multiple practice leaders what they feel are the char-
acteristics of their superstar PCCs. Excellent communication skills
and the ability to relate to others are at the top of the list. They
know how to build relationships and are engaging in a way that
makes patients feel they are important and well cared for.
Rapport building is an essential part of the PCC’s job. Her or
his role is to become the patient’s ´best friend foreverµ (BFF), the
nonclinical confidant to whom the patient can ask questions that
might be too embarrassing to ask the surgeon. An effective PCC
becomes a bridge between the surgeon and the patient’s support
team. She or he can be the one who will listen when a patient
says she has no encouragement from her adult children or spouse.
She or he helps patients find solutions to childcare during early
postop. To achieve this successfully, the PCC must be able to facil-
itate conversation.
The PCC also must be intuitive, sensing when someone is
hesitating and able to probe to find out the real reasons why.
Despite what many surgeons believe, most of the time a patient
does not schedule, it’s not about the fee. Maybe a patient hasn’t
discussed surgery with a spouse or feels pushed. Great PCCs know
how to read people and tailor the consultation conversation in a
way that the patient can understand, handing these nonfinancial
roadblocks with aplomb. They must be good listeners, which I
would add is an essential skill not only for understanding patient
concerns but also for handling objections.
Great PCCs are genuine. Patients can see right through a cha-
rade intended only to sell them something. Finding a PCC who is
genuine ensures she or he doesn’t come off as pushy or phony.
Genuine people know how to convey confidently to patients that
they truly believe in the practice, the surgeon, and the results
patients will get if they choose to schedule their procedure with
the practice. It builds patient trust. Don’t underestimate the deep
sense of connection that can occur when a patient feels genuinely
heard and understood.
Practice leaders also describe their long-term superstars as
compassionate, empathetic, and nonjudgmental. They recognize
the worth of others and can sense when a patient is fearful or
insecure. They know how to provide assurance that things are
going to be okay. Their empathy may be enhanced if they, too,
have had that procedure and had some of the same concerns.
Finally, a medical background is a nice to have but not a
requirement. Few aesthetic practices these days require the PCC
to have a licensed practical nurse (LP1) or registered nurse (R1)
certification. Certainly, a clinically trained person can capably
answer medical questions, but after working with thousands of
PCCs over the past several decades, I can say with certainty that
service skills are more important to this role than answering
questions about drains and dressings. Moreover, Box 10.1 explains
why I believe surgeons must use caution when hiring from other
aesthetic offices.
Additional essential skills for this role include the following:
1. Ability to ask for the sale: The PCC role is a sales and service po-
sition. Assessing patient needs, providing estimates, scheduling
consultations and surgeries, and following up with patients
who have not scheduled are sales responsibilities. Glossing over
this fact will lead you to hire someone who may be personable,
bright, and organized but who will not fill the surgery sched-
ule. If you are serious about hiring a superstar, you must look
for someone who either has sales or service experience or has a
propensity for sales and can learn. That means hiring someone

86
II Business Basics
who is comfortable handling objections, ´closing,µ and asking
patients for large sums of money.
2. +LJKSURfiFLHQF\ NH\ERDUGLQJ VNLOOV This is a fast-paced, intense
job. If your PCC can’t speedily enter data, she will never get her
quotes, emails, follow-up letters, and practice management sys-
tem tasks completed. Hire a hunter and pecker at your own peril.
3. Comfort using Internet applications and social media: A signifi-
cant amount of aesthetic marketing and communications hap-
pens online. PCCs must understand the importance and use of
social media, online ratings, email, and web inquiry forms.
4. Ability to write in complete sentences: The last thing you want
is a poor first impression when a potential patient receives a
response to emails and web forms. Ask for a writing sample to
evaluate each person’s skills in this area.
5. Top-notch organizational and project management abilities: Each
surgical case is its own little project with many steps, forms, and
customer touch points³not to mention the project of your next
Facebook posts, website relaunch, or spring VIP event. A PCC
must be able to stay organized and on top of every one. .eeping
all these plates spinning takes organization and tenacity.
Box 10.1
Think Outside the Botox
Our firm has recruited many hundreds of patient care coordina-
tors. I can tell you with confidence that “She worked for another
plastic surgeon” or “She looks the part” should not be at the
top of your list of reasons to hire someone for this role. We’ve
seen plenty of PCCs who “look right” but lack the sales ability,
customer service, technology proficiency, and strategic thinking
required to be successful in this role.
Handling the service experience and patient needs in an aes-
thetic practice requires skill and sophistication. The PCC must be
adept at assessing patient needs and buying style, convey your
value proposition, quote fees with grace, overcome objections,
and offer personalized service. These abilities do not come
naturally to everyone, and the baggage and lack of training that
comes from working in a previous plastic surgeon’s office can be
a challenge to correct.
Some staff can be retrained, but others may be congenitally
unable to change their behavior or style to meet your expec-
tations. This is particularly important to understand when an
applicant arrives with a competing aesthetic surgeon’s name
on her résumé. Don’t assume the person was trained or has the
right skill set for your practice just because of having worked in
another practice. Other practices’ standards don’t necessarily
equal yours.
10.3 Hiring Process Part 1:
Organize, Search, and Curate
:e break the hiring process into two primary parts. Part 1,
shown in Fig. 10.1, includes all the steps in the process up to
narrowing the candidate pool to two or three finalists. Part 2
includes assessment of those final candidates before deciding to
make an offer to one of them.
10.3.1 Step 1: Develop a Position
Description
To describe the job or write an ad, it’s essential that you put the
role’s responsibilities in writing. The description should clarify
the title, and reporting relationship and give a summary, as well
as list the qualifications and experience you require and the tasks.
:e find that categorizing tasks by key areas of the job makes
organization easier. Box 10.2 contains an excerpt of a PCC role
description. Early-stage aesthetic practices can combine this role
with an office manager role until the practice builds its patient
volume, at which time the PCC must become a full-time role.
Box 10.2
Excerpt of a Patient Care Coordinator Role Description
Position: Patient Care Coordinator
Responsible to: Surgeon or Practice Administrator
Job summary: Speaks with potential patients by phone, counsels
all aesthetic patients about costs of surgery and other treatments,
and coordinates scheduling and follow-up. Reviews marketing
and productivity data and conducts meaningful report review
and analysis. Initiates and/or implements marketing programs to
increase aesthetic surgery revenues and patient base.
Education: Associate’s or bachelor’s degree preferred
4uDOiÀFDWiRnV Dnd e[SerienFe
• Three to five years of work experience, with increased
responsibility, in high-end retail, hospitality, or other service
industry, or an elective surgery practice
• Sales experience required: preparing estimates, discussing
details, and closing the sale
• Proficiency with Internet applications and Microsoft Office
applications
• Proven ability to handle upscale clientele
• Excellent writing and communication skills; ability to build
long-term relationships
• Experience discussing financial arrangements and asking for
money
• Neat, professional appearance
Responsibilities include, but are not limited to, those in the
following lists.
Relationships with Potential Patients
• Appropriately discusses aesthetic consultations, procedures,
and skin care services with prospective patients over the
phone; encourages them to schedule and executes a follow-up
system for those who don’t schedule immediately
• Schedules aesthetic patients into the computer system; asks
them how they heard about the practice and enters required
demographics
• Schedules all appointments into the computer; keeps a ´can-
cellation listµ and calls patients if their appointment can be
rescheduled to an earlier time
• Sends information to prospective patients and tracks activity
in the database

10 Hiring and Training a Superstar Patient-Care Coordinator
87
Surgery Counseling, Scheduling, and Follow-Up
• Greets aesthetic patients, when possible, at the front desk
• Discusses fees and financial policies with aesthetic patients
after their consultation³provides written information and
answers patient questions
• Tracks information about patients who scheduled surgery and
those who didn’t schedule surgery
• Schedules all surgeries³coordinates patient preoperative
paperwork, history and physicals (H P), examinations, and
lab work and confirms written consent for procedures
• Collects surgical scheduling deposits and posts transactions
into the computer system
• Takes and/or ensures patient photos placed in the record after
consultation and surgery
• Screens patient phone calls postoperatively, advising the
patient or deciding whether a telephone conversation or
appointment with the surgeon is necessary
Practice Enhancement and Marketing
• Ensures that all information about aesthetic patients is entered
into computer system
• Generates monthly reports for surgeon and team
• Calculates the practice’s Patient Acceptance Rate (PAR) of
consultations to surgeries
• Ensures that marketing information capture tools are under-
stood and used by all staff and that staff are trained properly
in using marketing collateral
• Maintains the database of patients who have had surgery and
who haven’t, and targets specific mailings about other services
and the skin care program
• Maintains and updates the patient brochure, outlining infor-
mation about the surgeon, skin care, and the entire practice
• Initiates and/or implements practice enhancement programs³
tracks revenue and discusses progress with the surgeon
• Coordinates seminars³arranges room, food, information to be
distributed³then follows up with attendees on the phone or
in writing
• Participates in handling requests from the practice website;
checks and responds to email messages that come from the
site within guidelines
Other Essentials
• Meets with the surgeon monthly to review reports and mar-
keting program results
• Maintains proficiency with imaging software and Internet
applications
• Maintains patient confidentiality by following the Health
Insurance
Portability
and
Accountability
Act
(HIPAA)
Compliance Plan
• Attends American Society for Aesthetic and Plastic Surgery
(ASAPS) and American Society of Plastic Surgeons (ASPS)
training, or other educational courses as requested
10.3.2 Step 2: Put the Word Out
There are two ways to announce that you’re looking: (1) word
of mouth, through your personal professional network, and (2)
placing an ad. :e find that the most efficient option for finding
the right person is the former, but invariably you’ll need to do
both. Savvy managers and surgeons begin their search by telling
colleagues, employees, and their personal network, as well as
posting the opportunity on LinkedIn, since that is an extended
network that links with your network’s networks³highly
efficient.
Placing an ad in the local classifieds and on job websites invites
a flood of rpsumps for you to wade through, many of which won’t
Fig. 10.1 Hiring process part 1: Organize, search, and curate.
1. Develop a
position
description
2. Put the
word out
3. Review
résumés
4. Conduct a
phone
screen
5. Interview
3–5
candidates
in person or
via video call
6. Conduct
second
interviews
with 2–3
candidates
Hiring process part 1: organize, search, and curate

88
II Business Basics
be a fit. -ust as I advise clients that it is much better to have fewer
consults with the right surgical candidates than to blast through
a torrent of appointments only to find that only half of them are
actually potential patients, a similar principle applies in hiring.
So before you write an ad and post it for the masses, start with a
word-of-mouth, inner-circle approach.
Practice leaders we interviewed shared these tips for ways
they’ve procured their superstars:
• Post the job internally and ask employees whether they know
anyone who is looking.
• Reach out to skin care product, implant, injectibles, and
patient financing company representatives who know you and
your market and may be looking or know someone who is.
• Consider people in upscale salons, high-end spas and hotels,
and gourmet restaurants.
• Talk to your personal shopper, personal chef, or that amazing
associate at Tiffany or 1eiman Marcus who knows you by
name.
• Tell your friends you have an open position, and describe the
characteristics you are looking for.
• Ask the folks at the hospital and ambulatory surgery center
whether they know anyone looking.
1ext, post an ad on your practice website and social media sites,
as well as the online job sites Monster, Indeed, CareerBuilder,
GlassDoor, and Craigslist. Include in the ad a summary of the
role, key requirements, and benefits, as well as who would make
a good candidate. Box 10.3 is a sample you can customize to your
needs.
Box 10.3
Sample Job Ad for a Patient Care Coordinator
Patient Care Coordinator for Prestigious Aesthetic Surgeon
Our high-profile practice is looking for a sales-oriented and
style-conscious professional who moves at a fast pace, can
manage multiple projects simultaneously, and delivers superb
customer service to patients. If you have experience in luxury
retail, five-star hospitality, or an aesthetic surgery, dermatology,
or spa environment, we’d love to hear from you.
As part of our team, you will counsel patients who are con-
sidering aesthetic surgery procedures. Experience handling an
upscale clientele, providing service quotes, asking for payment,
and building long-term customer relationships are all required.
Use of our state-of-the-art practice management system and
social media will be central to your success. Professionalism,
poise under pressure, and penchant for detail are essential.
Experience in aesthetic surgery, dermatology, or another
elective surgical specialty, along with strong customer service
and effective writing and communication skills, are all pluses.
Preferred candidates who have been in managerial positions
at a surgical or aesthetic dental practice that cater to clients
accustomed to luxury will be strongly considered. A bachelor’s
degree is required.
For this full-time position, we offer a competitive salary with
bonus potential, health benefits, retirement, and a variety of
other perks. We conduct background, credit, and reference
checks, and assess skills. With your rpsump, please include a
cover letter detailing why your experience qualifies you for this
role. Email to: hiring#highprofileaesthetics.com
10.3.3 Step 3: Review Résumés
Think of cover letters and rpsumps as a method to rule out
unqualified candidates so that you’ll have fewer to screen by
phone. The following rpsump missteps should immediately rule
out an applicant:
• =ero sales or service experience
• 1othing that indicates the person has ever worked with an
upscale clientele
• 1o degree, if you specified that one is required
• Typos, misspellings, poor grammar
• An email address or phone number that is clearly through the
person’s current employer
• A personal e-mail address that has unseemly connotations
A candidate’s failure to provide a salary range/need in response
to an ad that specifically requested it may not rule the candidate
out immediately, but salary needs/ranges should be discussed to
determine whether you are both in the same ballpark.
Be aware, however, of your state and city employment laws
about salary history. To fight the issue of wage discrimination
and the gender pay gap, cities, states, and territories around
the United States are banning employers from asking for a job
candidate’s pay history. As of May 2018, Oregon, Massachusetts,
Delaware, and California, as well as Philadelphia and 1ew City, have disallowed questions about salary history for private
and public companies. 1ew Orleans and Pittsburgh have similar
ordinances for city agencies. Do your homework about what you
can and cannot ask.
10.3.4 Step 4: Conduct a Phone Screen
:hen our firm recruits in other specialties, we often make
the first conversation with a potential candidate a video call.
Aesthetics is different. The PCC is going to spend a great deal
of time on the phone, engaging patients in conversation and
encouraging them to schedule an appointment or surgery. As
.endra Cook, Operations Director at Columbus Aesthetic
Plastic Surgery in Upper Arlington, Ohio, put it, it’s like being a
judge on the television show The Voice. This seems to run counter
to the idea of a video call; clarifying text might be needed. allows
you to focus on energy and tone as well as whether or not they
have the right phone skills.
As Cook rightly explains, the person may have relevant sales
experience on paper, but is the person engaging on the phone"
Can she or he keep the phone conversation going" ´That’s what
I’m looking for and what will warrant an in-person interview,µ she
explains. ´This person is going to be asking people to pay 20,000.

10 Hiring and Training a Superstar Patient-Care Coordinator
89
If they can’t do that on the phone, they won’t be able to do it in
person.µ
-anit Pike, Practice Administrator of Charlotte Plastic Surgery in
Charlotte, 1orth Carolina, adds, ´If the person doesn’t give ¶good
phone,’ they don’t get an interview. Effective phone screening
can really save you from scheduling in-person interviews with
people you are never going to hire.µ Ask a few basic questions on
the phone, and you’ll quickly know whether the person has the
answer or experience or not. ´If they don’t, you politely thank
them for their time and tell them you’ll be back in touch if you
decide to schedule an interview,µ Pike advises.
The following are a few options for phone screening questions:
• I’m curious why you are interested in this job. Tell me what
attracted you.
• Give some detail about your sales experience at >company
on the rpsump@. Describe the customer base. :hat were you
selling" How were you successful"
• How do you handle pricing objections"
• :hen customers didn’t buy on the first round, what was your
follow-up plan"
• Tell me two or three things you learned from our website" (If
they didn’t visit in anticipation of the call, that’s an indicator
of poor initiative.)
10.3.5 Step 5: Interview Three to Five Can-
didates In Person or by Video Call
If your phone screening has been effective, you’ll only need to
interview three to five candidates individually, in person or by
video call. The surgeon, practice manager, and at least one other
staff person should interview each candidate. Don’t conduct
interviews with all three in the first interview. Some practices
arrange for one or two of these interviews to be completed on
the same day, while others conduct first interviews to screen
candidates for the surgeon to interview only the final two.
Prior to the start of each interview, ask each candidate to com-
plete and sign an application. This important step confirms that
candidates understand their own employment history, secures
a handwriting sample for neatness and readability, and provides
a signature attesting to the accuracy and truth of everything
candidates have listed on their applications. If you don’t have an
application with an accuracy attestation statement, contact an
attorney to obtain one that complies with the laws in your state.
Many application forms ask candidates to provide the names of
several references. If yours does not, ask candidates to provide
them.
The goal of the first interview is to determine whether the
person is a cultural fit, can demonstrate she or he has the key
characteristics discussed at the beginning of this chapter, and
provide assurance that he or she does have the skills and expe-
rience for the role. Let the candidate do most of the talking during
the interview. To do this, ask open-ended questions, as opposed to
questions that can be answered yes or no. Open-ended questions
encourage the responder to speak at length. They begin with
words such as ´Describe . . .µ; ´Tell me about . . .µ; or ´How . . .µ
4uestions that begin with ´are,µ ´is,µ and ´willµ typically represent
closed-ended questions, which to do not facilitate the goal of
getting the applicant to talk. Box 10.4 offers seven questions that
we find work very well to understand the candidate beyond just
skills and experience.
Box 10.4
Interview Questions That Work
1.
What do you know about us? “They’ve got to arrive knowing
something about your practice,” says Pike. “If they don’t,
they haven’t done their homework,” which indicates a lack
of curiosity and initiative.
2.
What do you do when you need to accomplish something (for
a project, a patient, a boss), but no one has told you how?
This question provides insight into problem-solving skills,
initiative, and tenacity.
3.
If your last manager or supervisor were sitting here, how would
he or she describe you? What words would he or she use? How
about a coworker? Getting the candidate to move out of first
person and into the mind of others provides an interesting
perspective.
4.
Tell me about a hard time you had at work (you and your
boss; you and a customer; an experience that went badly) and
how you handled it. Listen for introspective responses and
an ability for the candidate to be honest. If the candidate
has “never” had a hard time, it indicates a lack of ability to
self-assess.
5.
What do you read to keep up with the aesthetic practice (or
high-end service) profession? Ask for specific publications. If
a candidate isn’t reading, his or her knowledge is probably
stale.
6.
What have you tried, in any sphere of life, that didn’t work out?
What did you learn? You’ll get a sense of how comfortable
the candidate is with dealing with failure by asking this ques-
tion. A candidate who has never failed either hasn’t tried to
grow or is not being honest.
7.
In order to be successful here, what do you need from me? No
one you hire will be perfect. Pike says she ends the interview
with this question because “I like to know what I can do to
support their success. The PCC’s success is our practice’s
success.”
It’s important to ascertain how well the person will be with
patients, and in service and sales. Cook uses patient scenarios to
find out how the candidate would handle them. She also suggests
asking about time management and prioritization, providing
candidates with a sample to-do list and asking what they would
address first, second, and so on. Following are scenarios that our
firm uses during recruitment:
1. The fee quote to achieve the facial rejuvenation recommended
by the surgeon is 19,500. The patient says, ´:ow, that’s a lot.µ
:hat is your response, and how might that conversation go"
2. The surgeon is running 30 minutes late in the operating room
(OR), and afternoon consult patients have started to arrive. One
has already been waiting for 10 minutes. How would you com-
municate the delay to patients already in the reception room as
well as those on their way"

90
II Business Basics
3. :hen you open the office in the morning, one of your regular
patients is waiting. ´I know it’s my fault for not calling to sched-
ule,µ she says. ´But could Dr. :onderful fit me in for a quick
injection" Please"µ The schedule is already overbooked.
Ask questions that get at the candidate’s ´service sense.µ :hat
has the candidate done to successfully resolve a customer com-
plaint" :hat specific things has the candidate done to build rela-
tionships with upscale clientele" Asking the candidate to handle
scenarios can give you a sense of the person’s service orientation,
confidence, and ability to think on his or her feet. Expect those
who have worked in high-end retail or with upscale brands to
have reasonable responses, based on their customer service and
sales experience.
As part of the interview, pay attention to the following:
• Do the candidate’s handshake, posture, and facial expression
exhibit confidence and a positive, can-do attitude"
• Is the candidate capable of keeping the conversation flowing in
a way that is engaging"
• Can the person maintain eye contact"
• Is the candidate able to explain her or his work history in a way
that aligns with the rpsump"
Do not discount the importance of decorum. In an age where so
many are fascinated with their mobile devices, etiquette is often
overlooked in practice hiring. But it is not lost on your high-end
patients, who expect a certain level of personalized attention and
´correctµ behavior.
people say in interviews. Do your best not to appear wide-eyed
with disbelief and simply take the odd things people say and do
as an opportunity to pare down the candidate pool closer to a
final decision. And keep in mind that certain questions and topics
of discussion are illegal during the selection process. Do not ask
candidates anything regarding marital status or plans, parental
status or plans, race, ancestry, age, religion, political affiliation,
sexual orientation, veteran status, or disability.
10.3.6 Step 6: Conduct Second Interviews
with Two or Three Candidates
At the end of the first round of interviews, you should expect to
have two or three excellent candidates to bring back for a second
interview. Some practices ask that these candidates shadow the
front desk for a few hours as part of that second meeting. Others
set up peer-to-peer interviews with more members of the staff.
Still others do both. All of these are efforts to have the maximum
number of staff spend time with candidates and opportunities for
candidates to learn more about you as you learn more about them.
10.4 Hiring Process Part 2:
Assess Final Candidates
Dnd 0DNe Dn 2̵er
After a second interview, you may well have been able to pare
your choices. :hether your final pool is one, two, or three at this
point you’ve ascertained a cultural fit, and candidates will have
met with nearly all staff. experience. In the final steps, you’ll assess their workstyle and
skills and conduct reference checks. See Fig. 10.2 for a list of all
steps in this second part of the hiring process.
1ote: Depending on scheduling and everyone’s availability,
sometimes the workstyle analysis and skills assessment may
happen during the second interview or between the first and the
second. The point is not that each step must occur sequentially³
only that all the steps are completed before an offer is made.
10.4.1 Step 7: Administer a Workstyle
Analysis
The abilities of a PCC to ´readµ people, communicate well, and
build relationships are important characteristics discussed earlier.
A workstyle analysis, such as Proception2 (Maximum Potential, St.
Paul, M1), is a low-cost and strikingly accurate way to determine
whether the candidate has those abilities innately, as well as which
other effective team building, communications, and workplace
strengths and weaknesses they would bring to your practice.
Fig. 10.2 Hiring process part 2: Assess final candidates and make an offer.
7. Administer
a workstyle
analysis
8. Assess
essential
skills
9. Check
references
and social
sites
10. Send offer
letter
11. Conduct a
background
check

10 Hiring and Training a Superstar Patient-Care Coordinator
91
Proception2 is based on the Dominance, Influence, Steadiness,
Conscientiousness (DISC) theory, a neutral and observable
´languageµ first developed by psychologist :illiam Marston.
The instrument is used worldwide, and has been validated. It
measures behavior and emotion; it does not measure intelligence,
values, skills or education, and it is not a personality test. The
profile provides practical insight into a person’s interpersonal,
decision-making, data management, and other skills.
Our firm has used Proception2 in consultation and recruitment
projects for more than 30 years. For less than 100, you’ll be
amazed at what you can learn about a candidate. The assessment
is striking in its ability to accurately predict the workstyle and
communication preferences of candidates.
:e recommend that the final candidates take the online,
26-question assessment. The result is a comprehensive profile
report that can be used not only for insight, but to conduct
additional conversations with candidates, as well as determine
training needs.
10.4.2 Step 8: Assess Essential Skills
It’s one thing to ask a candidate whether he or she can write fol-
low-up letters and effective email thank-you notes. It’s another
to actually read what the candidate has written and determine
this for yourself.
Ask final candidates to perform a few skills tests:
• Writing: Ask for several samples, for example:
1. A follow-up email to a patient who was quoted a Mommy
Makeover but decided not to schedule
2. An email response to an inquiry on your website about breast
augmentation and laser services
Assess for the ability to construct sentences using correct gram-
mar and punctuation.
• Keyboarding: As discussed previously, an important skill is to
operate quickly on the keyboard. Test how fast the candidates
type.
• 2̶FH VRfWZDUH Test candidates’ proficiency on your word pro-
cessing (e.g., Microsoft :ord), email (e.g., Microsoft Outlook),
and spreadsheet (e.g., Microsoft Excel) software.
Total Testing () offers more than 800
online tests. Our firm has found particular utility with the Microsoft
Office assessments, which distinguish the Excel and :ord whizzes
from candidates who would need additional training.
10.4.3 Step 9: Check References and
Social Sites
time to check the references. :e are often asked whether, in these
litigious times, a former employer or boss will provide much
other than the person’s name, position held, and employment
dates. In most cases, you will find that this is not the case. Most
former employers will be open to answering your questions. For
PCCs who will have managerial responsibilities in their role, we
ask for two references of people they have supervised.
In addition to reference checks, it’s quite beneficial to review
candidates’ public online presence. As long as the information you
review is posted publicly, it is legal and acceptable to ´ask Googleµ
about the candidates, as well as search for them on Facebook,
Twitter, Instagram, and other social sites to review their public
posts. Do not send them a ´friendµ request, however. And regard-
less of what you see in their public profile, interviewing and hiring
decisions cannot be based on race, color, religion, sex, or national
origin. Consult with an attorney for additional details.
10.4.4 SWeS  Send Dn 2̵er /eWWer
:ith everything complete, it’s time to summarize and make the
offer. :e highly advise that this be done in writing; however, in
those states that are ´at-will,µ be clear in the letter that it is not
a contract. Box 10.5 is an example of the information to cover
in your letter. The sample may be customized and used in your
hiring efforts.
Box 10.5
SDmSOe 2̵er /eWWer
[Put on Practice Letterhead or Insert Graphic of Logo]
Date
Name
Address / Email
Dear BBBBBBBBBBBBB,
I am pleased to offer you the position of Patient Care
Coordinator. The job description for this role is attached, and
the offer described below is contingent on the results of a back-
ground check. Details about our medical insurance and employee
policies will be provided to you in our employee handbook.
This letter summarizes the benefits that are offered and is not
a contract, as >your state@ is an employment-at-will state.
The Patient Care Coordinator role is a full-time, non-exempt
position, with an annual salary of BBBBBBBBBB. Benefits include
medical insurance, 14 days of PTO, a 40% discount on skin care
products, a surgery benefit (available after two years of service),
and a first-year training stipend of 1,500. After 120 days, you will
have an opportunity to participate in a compensation bonus for
the entire team. You will also receive on-the-job training over the
next several months.
All staff are hired on a 90-day probationary basis. During this
period both you and the practice can assess whether it is a good
fit.
As we discussed, your start date will be BBBBBBBBB. Please
arrive by 9:00 am.
Going forward, your performance is reviewed annually on
or around your hire anniversary date. Raises are merit-based,
contingent on performance.
I’m very enthusiastic about the skills you bring to my practice.
I look forward to having you on board!
Sincerely,
Shannon
Shannon Surgeon, MD, FACS

92
II Business Basics
10.4.5 Step 11: Conduct a Background
Check
Background checks enable physicians to avoid potentially disas-
trous hires of people who seemed great or ´looked the partµ but
clearly weren’t. A background check provides relevant, detailed
facts that typically aren’t uncovered during a standard reference
check, and it is an important risk mitigation step when it comes
to HIPAA requirements around privacy and data security. Theft
of a patient’s identification can result in hefty fines and attorney
fees. Our insistence that practices perform background checks
has uncovered information such as the following:
1. Felony charges
2. Universities listed on rpsumps that the candidate never attended
3. Degrees and certifications the candidate never earned
4. Six-figure credit card debt for a candidate who was to manage
an aesthetic practice
TrustedEmployees (trustedemployees.com) is a cost-effective
background screening company that provides a report of a per-
son’s criminal and credit history, work, education, and identity
verification, and more. number and signed authorization to execute the search.
10.5 Orientation and Training
:ith the hiring process behind you, it’s time to make sure your
new superstar is a success. Orientation and training are vital to
making that happen.
Rushing the new employee orientation process can be a costly
mistake. If your practice provides a week of training that focuses
primarily on completing paperwork, obtaining office keys, and
observing coworkers as they do their jobs and use the computer
system, the PCC is being set up to fail.
Training must be comprehensive and intense. The new PCC must
learn everything from the surgeon’s style and computer software
to the nuances of scheduling surgery and preparing quotes, and an
overview of your practice culture too.
Plan on 3 to 4 weeks of training before you put the PCC in front
of a patient on her or his own.
Savvy practice leaders agree that a focus on culture is an
important first step. Interviewing is like dating. :hile you can be
blissfully happy while dating, the decision to live together might
make you miserable. At Charlotte Plastic Surgery, a new PCC shad-
ows the surgeon, a scrub tech, the front desk staff, and the clinical
staff in the first week, all of whom are asked for feedback about
whether they feel the new hire is a good fit. ´The person could be
Box 10.6
7ZeOYe IWemV WR InFOude in IWem
7DrgeW dDWe IRr
FRmSOeWiRn
'DWe FRmSOeWed
1.
Establish performance goals and initial projects that need attention. Setting expectations is
vital to the new person’s success. Establish some short-term and long-term goals for the
person and the position and put them in writing.
2.
Review the practice website in detail. The entire team must know it like the back of their
hand so they can direct patients to use it and explain what’s there.
3.
Review the surgeon’s curriculum vitae CV. All staff must be able to explain the scope of your
training, the medical school you attended, and where you completed your fellowship.
4.
Review all the practice’s social media and online rating site listings. Schedule time with the
surgeon and the manager to discuss findings within the first 2 weeks.
5.
Review the websites of the surgeon’s top Àve competitors. It’s essential that the PCC have
intelligence about the other options in the market.
6.
Review social media and physician rating site listings for the surgeon’s top Àve competitors.
Look at RealSelf, 7.
Read ASAPS and ASPS printed and online materials. Schedule time to discuss which proce-
dures you perform most often and point out any differences in your patient care.
8.
Schedule a welcome lunch with the manager and physician. This is a good opportunity to get
to know your new employee personally and to review topics such as expected behaviors,
practice culture, and the characteristics of your patient mix.
9.
Attend technology training. Ideally, schedule training directly with vendor to optimize the
new employee’s knowledge of the system.
10. Shadow 5 to 10 aesthetic consultations. Make sure staff thoroughly understand the consul-
tation process so they can accurately explain it to patients.
11. Observe surgery and postop care. Seeing patients in the OR and in the exam room postop-
eratively will give your team the “big picture” of the patient experience.
12. Read Seth Godin’s Purple Cow, a book about differentiating yourself based on your uniqueness,
or another book on customer service or marketing. Discuss learnings in an upcoming staff
meeting.

10 Hiring and Training a Superstar Patient-Care Coordinator
93
the best coordinator in the world, but if they don’t fit into your
culture, it’s a dead end,µ says Pike.
Observing the roles and tasks of every member of the practice
or MedSpa team is essential. ´Our surgical patients receive an
allowance in the spa, so the PCC has to know all those services
and products cold,µ shares Roxanne Housley, Executive Director
at Maxwell Aesthetics in Tucson, Arizona. ´They must also spend
time listening to the front desk staff on the phone, observing
consults, and observing follow-up visits with the surgeon.µ
Housley also advises allotting significant time for the new PCC
to spend with the surgeon during the first few weeks and months.
´The PCC needs to hear things directly from the doctor in order
to learn the doctor’s medical philosophy and style.µ Housley says
that frequent, 10-minute meetings after consult days and surger-
ies help ´cement the relationship between the surgeon and PCC
early on.µ
Pike and Housley avoid a common mistake we observe in aes-
thetic offices: skipping orientation and sufficient shadowing and
moving right to training. Think of orientation as ´pretraining;µ
the foundational elements that will make your new PCC’s training
even more effective.
Box 10.6 contains 12 items to include in the PCC’s orientation
plan. :e recommend that every new employee you hire³not only
the PCC³complete many, if not all, of the items. The more deeply
the new PCC understands the practice culture and services, the
surgeon’s style, and the patient mix, the better the PCC will serve
as a marketing ambassador. The orientation items need not all be
completed before training begins; in most practices, the two are
done concurrently.
It’s worth emphasizing that technology training provided
directly by the vendor³not from a coworker³is much more
effective. back ideas about features and reports that are currently unused.
´1o matter how dire your need, you cannot cut the orientation
or training process short,µ warns Cook. Columbus Aesthetic
Plastic Surgery learned this the hard way, through experience. So
Cook used the lessons to develop a 4-week, comprehensive train-
ing plan, summarized in Box 10.7. It’s divided into three chunks:
culture, software training, and business operations. At the end
of the training Cook conducts an evaluation. If the new PCC isn’t
100 ready, training continues for another week. ´Everyone learns
differently,µ Cook says. ´:e make sure they are confident before
they are on their own.µ
Box 10.7
New PCC Training at Columbus Aesthetic & Plastic Surgery
Week 1: Culture immersion: The new PCC gets oriented to
everything about the culture of the practice. She or he reviews
the website thoroughly, shadows front desk and call center staff,
observes clinic workflow, and receives an overview the consul-
tation process, from first phone call to scheduling surgery. This
week is mostly about understanding the brand and the patient
experience at every touch point in the process.
Week 2: Software training: The PCC continues with shadow-
ing and learning processes, but this week is focused primarily on
learning the software from an internal trainer, who provides an
attestation that the new employee has successfully passed the
training. “If your PCC can’t maneuver in the software before they
ever see a patient, you are going to sacrifice the patient experi-
ence,” Cook insists. “There is no way they will be confident and
sure. You are setting them up to fail at scheduling the patient.”
Week 3: Business operations: The primary focus of the week
is surgeon shadowing. The new PCC sits in on consultations and
follow-up visits with the surgeons. She or he also sits in with the
other PCCs to learn how to have patient conversations about
the quote and how to schedule surgery. She or he continues to
practice what was learned in software training and work with
other team members to learn the procedures of the PCC role.
Week 4: Evaluation: Before the new PCC can see her or his
first patient, Cook administers an assessment and conducts
role-playing scenarios. Cook, the surgeons, and staff must feel
confident that the PCC can answer questions correctly and is
ready to see patients. If the new employee does not feel 100%
ready, Cook addresses the hesitations and challenges and will
extend training another week.
10.6 Measuring and Rewarding
Success
“Employees respect what managers inspect.”
My associates and I have been saying this for more than 30
years, and it is still true. A PCC who knows that she or he is being
measured based on a standard goal, task, or metric is much more
apt to focus on being on top of his or her game.
Although it is important to track and monitor your PAR, it’s
unfair to use this metric as the sole measuring stick for PCC
performance. The reason is that there are many other influencers
on whether or not a patient schedules surgery. Among them are
patient interaction with the surgeon, whether the appointment
schedule was on time, and the mood of the nurse that day. 1one
of these are within the PCC’s control.
The issue here is fairness. For a reward system to be effective,
it must reward not only the PCC but also the other team mem-
bers who contribute to converting callers to patients, building
the spa business, check-in consults with a smile, or removing
stitches oh, so gently. All of this is part of the patient’s experi-
ence (Box 10.8).
Box 10.8
Should I Pay the PCC a Sales Commission?
No. Not only can commissions balkanize other staff against a PCC
who gets a bonus when they do not; commissions for this role
are a violation of the state medical practice act in some states.
Don’t do it.
For instance, Cook has developed protocols and tasks on which
she measures the practice’s PCCs. ´All patient leads are entered
into the customer relationship management (CRM) system so we
can track,µ she explains. Among the performance items monitored
by the practice are the following:

94
II Business Basics
• :as the patient contacted within 2 hours of the call or email
inquiry"
• :as the correct, practice-approved verbiage emailed"
• How many phone/Internet leads converted to a consultation"
´Our benchmark is that 60 of our inquiries come in for a
consultation,µ Cook explains. If a PCC falls below, we provide
coaching.µ
Effective measurement includes a variety of qualitative and
quantitative data. Synthesizing it provides a broad picture of PCC
performance. For example:
• How many hours of OR block time are scheduled"
• Is the PCC hitting key task metrics such as sending follow-up
emails within protocol time frames"
• Is their performance free of patient complaints"
• How well does the surgeon feel the PCC is performing"
Pike believes that a key to retaining sales people is offering a
bonus. But because everyone in the practice contributes to the
surgery schedule being filled, as well as the bottom line, it’s not
only the PCCs who benefit. ´:e give a quarterly bonus if the
practice makes money. It’s not based on individual performance;
it’s based on the practice as a whole.µ This system has gone over
well for the practice, Pike says.
Maxwell Aesthetics implemented something similar. Everyone
who is involved in the first call all the way through to the PCC and
the medical assistants receives a quarterly bonus. ´It’s based solely
on net income,µ Housley explains. ´:e have a preset percentage
for the bonus and multiply that by each quarter’s net income.
Then we allocate the amount to everyone based on the hours they
worked during that quarter. Everybody gets something, even those
who work part-time. It’s easy to administer and staff are thrilled.µ
Cook’s group provides a combination of financial and nonfinan-
cial bonuses³for example, a monetary bonus for the PCC team and
gift cards, certificates, and team competitions where the reward is
free lunch for the team. The practice gives accolades for the ´best
month everµ and works hard to make sure everyone knows that
his or her contributions count.
The knowledge that you value an employee’s opinion can be its
own reward. At the end of the day, saying thank you means a lot to
a team that is loyal and that has your best interests in mind. It can
be energizing and motivating for the PCC and others on your team
if you simply stop by their desk and tell them you’ve noticed that
surgeries are up and that you appreciate their hard work. Try it.
You’ll see.
Suggested Reading
>1@ Cain A, Pelisson A, Gal S. 9 places in the US where job candidates may never
have to answer the dreaded salary question again. Business Insider, April 10,
2018.
us-2017-10. Accessed May 30, 2018
>2@ =upko .. 10 non-financial reasons patients don’t schedule. Aesthet Soc News
2016(Spring):65–66

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11 Evidence-Based Pricing Strategies That Work
Karen A. Zupko
Abstract
In aesthetic plastic surgery practices, price is the least under-
stood of the four marketing Ps. Instead of setting fees and cre-
ating offers using proven business methods that align with the
practice brand, most aesthetic practices ´do what everyone else
is doing.µ Then they acquiesce to patient pleas for discounts when
they fear the surgery schedule won’t fill. Using evidence-based
pricing strategies is a more effective way to establish fees that
reflect the value of the service and experience you deliver and
proactively build loyalty and revenue. This chapter discusses
how to use evidence-based pricing to increase revenue while
enhancing and maintaining the credibility of the practice brand.
Keywords
price, pricing, fee schedule, packaged price, discounts, special
offers, luxury brand, premium, value, differentiate, unique, mar-
keting strategy, patient experience
11.1 Introduction
Every day, plastic surgeons make evidence-based decisions while
treating and caring for patients. driven management principles when it comes handling one of
their most important business decisions: pricing procedures and
services. Instead, many surgeons set their fees on hunches or let
emotions fuel their decisions.
This chapter explains the essentials of evidence-based pricing
strategies and how they can be used to establish, offer, and dis-
count aesthetic surgery and nonsurgical services fees. It addresses
various uses of these strategies by luxury and retail brands and
why aesthetic practices should adopt one or more of these strate-
gies instead of charging based on competition, or worse: charging
less than competitors in hopes that will garner more surgical or
nonsurgical patients.
The primary concepts covered are
• Premium pricing
• Strategic discounting
• Special offers
• Bundled pricing
• The power of nine
11.2 Premium Pricing
The Cosmopolitan and Planet Hollywood hotels are located
across the street from each other on the Las Vegas Strip. In May
2018, the rate for a double-occupancy room for a mid--uly 2018
visit to ´The Cosmo,µ as it’s known, started at 330 per night.
Planet Hollywood’s started at 143.
One could argue that both hotels are offering the same product
because they have similar features. Both have identical placement
on The Strip. Both have casinos, restaurants, workout facilities,
meeting room space, and sleeping rooms, of course. Both are high-
rise hotels with views.
So what’s the difference" The difference is that the Cosmo has
differentiated itself as a ´unique luxury resort hotel and casino like
no other in the heart of Las Vegas,µ and it can command a higher
price because of it. Comparing the two hotels’ websites conveys
this. The Cosmo’s website is chic and sexy, with high-quality pho-
tography that positions the hotel’s interior design, restaurants,
rooms, and clubs as hot and modern. People in the photos are styl-
ishly dressed and are shown doing exciting things. The marketing
copy tells you to ´Plan on 1o Regrets.µ Anyone who ever hoped to
hang out with ´the beautiful peopleµ would want to stay in a place
that looks like The Cosmo.
Conversely, Planet Hollywood’s home page looks like a dis-
count travel aggregator site, boasting ´dealsµ and wasting prime
home page real estate to promote ´Hotel Highlightsµ instead of
indicating anything about the experience you’ll have as a guest.
On the highlights list: in-room :i-Fi, self-check-in, pool access,
and fitness center. Really" These are ´highlightsµ" the same for La 4uinta. That’s because these ´highlightsµ are in
fact, commodities, which BusinessDictionary.com defines as
´reasonably interchangeable goods or materials that are sold
freely as an article of commerce.µ Planet Hollywood is a decent
commodity hotel offered on the Las Vegas Strip, and it has priced
itself accordingly.
I doubt that, after all their years spent in training and fellow-
ship, many aesthetic surgeons consider themselves ´reasonably
interchangeable.µ price themselves ´like everybody else.µ Our firm advises surgeons
to rethink this mindset and instead differentiate their practice
and the patient experience as a premium brand. Doing so requires
that, before you even think about your fees, you step back and ask
yourself: :hat is my Unique Service Proposition (USP)" :hat
makes my practice unique" :hat would I like to be known for"
:hat kind of experience do we deliver to patients and potential
patients" Differentiating your brand is essential when considering
what to charge.
In his book Purple Cow, marketing guru Seth Godin talks about
teasing out what makes you product or service remarkable. To
paraphrase Godin, most cows (your competitors) are brown.
A purple cow would really stand out in a sea of brown cows. It
would be remarkable. And according to Godin, ´Something
remarkable is worth talking about. :orth noticing. Exceptional.
1ew. Interesting. It’s a Purple Cow. Boring stuff is invisible. It’s a
brown cow.”
:hen .ay -ewelers offers diamond rings for 489, does Tiffany
rush to match the price" 1ope. :hen Dunkin’ Donuts and
McDonald’s duke it out to see who can sell the most espresso-based
beverages and fancy coffee drinks, does Starbucks jump in the ring

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II Business Basics
and cut the cost of a grande latte" 1o. Starbucks doesn’t have to,
because it has redefined coffee consumption and is in a class all by
itself. The company is now selling ´reserveµ whiskey-barrel-aged
coffee for 10 a cup, with great success.
It’s remarkable products like this, coupled with the memora-
ble Starbucks store experience (music, smells, ambience), that
McDonald’s or Dunkin’ Donuts will never be able to deliver.
Dunkin’ Donuts and McDonald’s don’t have that kind of pricing
ability, because selling lattes and cappuccinos cannot change
how consumers perceive their brands. 1either chain will ever be
considered upscale, no matter how many trendy items they add.
Premium brands target different customers than their lower
price–driven counterparts do, and there are plenty of consumers
who are willing to pay a premium price for these brands. Research
conducted by Michael Silverstein and 1eil Fiske, formerly of
Boston Consulting Group, shows that, in dozens of categories,
luxury brands sell at huge premiums over conventional goods.
Their findings show that people are willing to pay a little more
if they feel they are getting a unique value. The aesthetic surgeon
who understands how to differentiate him- or herself from the
pack will win with these consumers.
Premium brands know they are remarkable. They can articulate
their value proposition because they know what differentiates
them from the herd. And, most important, premium brands
recognize that they are not everyone’s gourmet grocer, coffee
purveyor, or clothing store. 1ot everyone will appreciate and pay
for the value and experience they offer; and that’s okay. Aesthetic
surgeons must adopt a similar philosophy.
As you think about what makes you remarkable, realize that
you don’t have to spend tens of thousands of dollars on marketing
or build a Taj Mahal. 1. Don’t be like everybody else. For example, don’t send canned
thank-you notes post consultation. Use scenting throughout the
reception and exam room areas. Be on time.
2. Deliver memorable experiences, which create a higher price toler-
ance. One practice we visited uses dimmer switches in the exam
room to make patients feel more confident, and decorates the
rooms using beautiful furniture and framed mirrors that you
would expect to find in a lovely home. A movable ´swing armµ
was used to enable patients to self-register into the imaging sys-
tem, using a tablet computer.
3. Articulate why you are remarkable, and train your team to
demonstrate and deliver it.
Pricing power comes with differentiation. luxury, such as a luxurious spa or facility experience, or cloth
robes instead of paper. as healthy, organic meals delivered for a week after surgery,
a black car service that transports patients to/from their first
postop visit, or special events only for men. convenience that no one else does, such as office hours outside
of the typical 9 a.m. to 5 p.m., which are appreciated by working
women, or upscale overnight stay suites in your facility, or a
hotel partnership, both of which are staffed with your own
overnight nurses.
:hatever you choose, make it memorable and make it remark-
able. Box 11.1 provides guidance on how to identify your differen-
tiators. Being remarkable is powerful. If you are not ´like everyone
else,µ you won’t have to charge ´like everybody else.µ
Box 11.1
3remium 3riFing 5eTuireV 'i̵erenWiDWiRn
What’s Your Unique Service Proposition (USP)?
Define what makes your practice different. Hint: It’s not that you
are board certified. price yourself at a premium.
1.
Sit down with your team and create a list of everything that
makes you unique and different from your competitors. Once
it’s all down on paper, pare it back to a Top 5 list.
2.
Ask three to Àve happy patients what they believe makes you
fabulous. What do they believe makes you valuable and
worth it? Modify the Top 5 to include words and phrases
you heard from patients. Add any of the differentiators that
patients valued, if they were not on the Top 5 list.
3.
Synthesize what you’ve learned into a written “talk sheet.” Use
it to create short, scripted responses that staff can use on
the phone with potential patients and that the patient care
coordinator can use to handle the objection “that’s expen-
sive” when discussing surgery options.
4.
Be OK with patients choosing someone other than you. If you
price yourself at a premium, not everyone will be able to
afford your services. That’s OK. In a world of plenty, there
are many who appreciate your unique value and have the
means to pay for it. You must accept that you are not every-
one’s plastic surgeon. more revenue overall.
11.3 Strategic Discounting
Strategic discounting can build loyalty and repeat visits. However,
it requires practices to think strategically about offering the right
type of discount, at the right time, for the right reason.
Reactionary discounting³caving in to patients when they ask
for a lower fee during the quote review³delivers no long-term
benefit to the practice, and in fact, it can tarnish your brand.
:hen practices rush to offer discounts and compete on price,
they often look desperate. Haphazard or ´let’s make a dealµ
discounting can backfire and make it difficult to recoup your rep-
utation. When word gets out that Dr. Wonderful drops the price
15 if you just ask, transaction buyers will start to fill the schedule.
Dr. Paul :ang of 1orthwestern University’s .ellogg School of
Business is widely known for identifying buyer types. Two of these
classifications are particularly relevant for aesthetic surgeons:
transaction buyers and relationship buyers. :e’ve summarized
some of the relevant descriptors of these buyer types in Table 11.1.
Transaction buyers are primarily motivated by price. These are
the patients who come into your office with three quotes in hand
from other surgeons, demanding that you match the lowest one.
Transaction buyers are not loyal. They came for the price, and
they’ll leave for a price. Their psychology is ´I want to get the
best deal.µ It doesn’t matter how differentiated your value or how
fantastic the patient experience. This is lost on them. A good piece
of advice is never to price match their ´best offerµ from another
office. :ord of mouth and mouse will spread that you can be

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97
coerced, and the floodgates will open with the transaction buyer’s
friends.
Offering free consultations is a good way to attract transaction
buyers. :hen the consult is free, there’s no risk for patients to
see you for a second opinion after they’ve already scheduled
surgery elsewhere. And who can blame them" :hy not verify
the recommendation of another surgeon when the consult is free,
free, free These patients don’t, and won’t, appreciate the value
associated with the overall patient experience you and your team
have worked so hard to create. To them it’s a free opportunity to
ask a ´reasonably interchangeableµ surgeon a bunch of questions
and perhaps get an additional set of images. And if the consult is
free, many patients reason, ´:hy not ask for a discount on the
surgery"µ
Relationship buyers, on the other hand, are patients who genu-
inely like you and your services. They refer to you as ´theirµ plastic
surgeon. about their vacation plans, which child just graduated, and the
patient’s most recent work promotion. These patients value
good service and reliability. They believe that shopping around
is a waste of time, so relationship buyers will not be swayed by
bargains. They may likely become long-time patients, who will
continue to invest in and trust you to keep them looking terrific.
Even better, they’ll recommend you to their relationship buyer
friends.
Strategic discounts that effectively build your practice and
attract relationship buyers have a few important characteristics:
1. 3URDFWLYHO\ R̵HUHG, which keeps you and the staff in the driver’s
seat instead of reacting to a patient’s discount request
2. 7DUJHWHG WR D VSHFLfiF GHPRJUDSKLF RU D VSHFLfiF SURFHGXUH³as
opposed to offering a discount to everyone, for any procedure
3. 8VHG WR VROYH D VSHFLfiF EXVLQHVV SUREOHP, such as to introduce a
new aesthetician or pay for a technology that hasn’t had quite
the uptick you had hoped
4. Used with discretion, because ´exclusivesµ work better than
giving discounts to everyone; be selective and don’t blast out
special offers to everyone in the email database or post them to
Facebook
Box 11.2
How to Track and Evaluate Strategic Discounts
1.
In the practice management system, create an “adjustment”
category for each type of discount you offer—for instance,
consultation, multiple procedure, skin care services,
promotion.
2.
Make specific “consultation” and “promotion” categories.
For instance, an adjustment for Consultation—Breast,
Consultation—Face, or Promo—Spring Laser.
3.
Charge the full fee, then use the adjustment category to
apply the discount.
4.
Generate and review an “Adjustments Report” each quarter
to review the totals.
In addition to reviewing the amount of the discounts, evalu-
ate the composition of the group who took advantage of the
discounts. :ere they new patients or established patients" Did
they schedule something else, after their discounted service" Take
a look at the Lifetime Value report, available in most aesthetic
practice management systems. Is the discounting strategy effec-
tive in building a valuable, loyal patient relationship, or were most
recipients of the discount transaction buyers"
Following are a few examples of strategic discounts that work.
Remember also to track and evaluate the discounts you offer. Box
11.2 explains how.
• Occupational discounts: Offer teachers a special discount if
they schedule in -uly or August, when their seasonal break
makes recovery time a nonissue, or offer a flight attendant dis-
count if you live in the hub city for a major airline. In Atlanta,
Dallas, and Chicago, it’s easy to see why a surgeon would offer
a strategic discount for Delta, American, and United flight
attendants, respectively. It makes them feel special. Several
clients also offer discounts to active military personnel or their
family.
• 0XOWLSOH SURFHGXUH GLVFRXQWV IRU VXUJHU\ LQ WKH VDPH ÀHOG
Consider the offer of a discounted fee when a patient schedules
an abdominoplasty and two or three areas of liposuction. It
makes sense because you generate an additional hour or two
of surgical fees with only slightly more time pre- and postop-
erative. :e commonly see practices offer anywhere between
5 and 25 off the second and third procedure, with 10 being
the median. 1ever reduce the price on the primary or most
expensive procedure.
• Splurge cards: These discount cards are given after the patient
has had a procedure or spends a certain amount on services in
the spa. It gives them an incentive to splurge on themselves
again, this time at a 10 or 20 discount. For example, send a
splurge card to patients who have had a series of neurotoxin
services, encouraging them to consider scheduling a peel or
other facial service at a discount.
• Birthday discounts: People appreciate being remembered on
their birthday, which is why this discount can be more effec-
tive than the offered-to-everyone discounts. Mail or email a
certificate for a 75 credit toward fillers or laser services, for
example, and make the offer valid for up to 60 days after the
patient’s birthday.
• Introductory discounts for a new laser: Promote the bene-
fits of a new piece of equipment you purchased by offering a
limited time discount on a package. It can boost appointments
and help you recover the costs more quickly.
Table 11.1 Transaction buyers vs. relationship buyers
7rDnVDFWiRn EuyerV
5eODWiRnVKiS EuyerV
• Price-driven
• No loyalty
• Pride themselves on getting the
“best deal”
• Less profitable/fewer repeat
customers
• Seek “trust” in you
• Want friendly, reliable services
and products
• Feel shopping and comparing
are a waste of time
• Appreciate those who
recognize and value them

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II Business Basics
11.4 SSeFiDO 2̵erV
A special offer is a strategy is whereby you make special,
limited-time offers designed to reach specific business goals. In
luxury brands, targeting a special offer to a specific group makes
it even more exclusive. For example, 1ordstrom offers sales
only a few times each year, whereas at Macy’s nearly every item
seems to be perpetually on sale. :hen used correctly, special
offers can increase the profitability of your practice and amplify
your brand.
Special offers come in a variety of forms. For example, similar
to the birthday discount mentioned previously, consider the
offer of exclusive vouchers to a targeted patient group. Perhaps
target your best referring patients or those who attend a special
VIP event, or have a Mommy Makeover in September after the
kids are back at school. Science shows that vouchers can increase
happiness. A study by Dr. Paul -. =ak, professor of neuroeconomics
at Claremont Graduate University, showed that coupon recipients
who received a 10 voucher experienced a 14 rise in oxytocin
levels, an 8 decrease in the stress hormone adrenocorticotropin,
and a 27 reduction in respiration compared with those who did
not receive one and self-reported that they were happier than
those who did not.
In some cases you may be able to leverage special incentives
from skin care or injectible companies or patient financing
companies. Combining efforts can create a significant success. For
instance, CareCredit, the healthcare credit card company, offered
a special offer to new cardholders in the spring of 2018. :hen a
new customer applied for a CareCredit card and spent 1,000 with
a practice, the patient received a 100 credit on his or her next
statement, which could be used toward a future service at the
practice. Having 100 to spend in your practice or spa is almost
guaranteed to garner additional revenue to the bottom line. So
practices that aligned their spring promotions with CareCredit’s
special offer were able to, in effect, benefit from the offer of a 100
credit without actually paying for it.
Always make sure that the special offers you create are advanta-
geous to the practice and not just a ´loss leaderµ³a pricing strategy
in which a product is sold at a price below its market cost to stim-
ulate other sales of more profitable goods or services. In a luxury
brand like aesthetic surgery, this isn’t necessary for driving revenue.
A client in the :est designs brilliant VIP events, inviting select
patient groups. Breasts and Bras was held at a local lingerie
boutique and featured the surgeon discussing all breast surgery
options, after which guests enjoyed drinks and light snacks and
had the opportunity to shop for beautiful bras. An event at the
practice featured Pilates and Plastic Surgery, and the surgeon as
well as the president of the neighboring upscale Pilates studio
talked about healthy weight and healthy bodies. At these events
as well as others, attendees always leave with a special offer that
no one but them receives. It’s different each time but is typically
something like a 75 credit in the MedSpa or a dollar figure credit
toward a procedure.
Every practice, in every geography, has a ´doldrumsµ season, a
time when everything seems to slow to a near halt. For most, it’s
August and September. A special offer can help reach the goal of
increasing the number of scheduled surgeries over the previous
year during the doldrums season. :hen patients in spring and
early summer ask for a discount or express their wish to pay less,
offer a ´limited-time special priceµ if they schedule their proce-
dure no later than -une 30 for a date of surgery that is between
August 15 and September 15. The patient care coordinator can
explain that as ´when Dr. :onderful’s otherwise busy schedule
has more openings.µ
Finally, consider developing special offers for procedures that
have a high margin. As an example, an upper lid blepharoplasty,
performed in the special procedure room, paired with the right
aesthetician services, for a bundled price may be very profitable.
It’s an easy ´age-reducing treatmentµ with a short recovery time
that can be promoted as a limited offer during a specific time
period.
11.5 Bundled Pricing
Bundled pricing occurs when several items or services are sold
as one item, at one combined price. It goes by name names,
including package price, collection, or gift set. promotions at department makeup store counters: ´Buy our new
perfume and get a free Plum Power lipstick, concealer, and blush
in a convenient travel bag.µ
The travel industry often uses bundled pricing. A 7-day trip
marketed on an airline vacation site includes business airfare,
hotel, car rental, and spa gift certificate for one amount, including
taxes and fees. It makes the vacation easy to budget for, which
speeds a person’s decision making. 1o additional charges or
surprises are lurking behind the price tag. The beauty of this
approach is that the consumer cannot see which business partner
or partners lowered their usual fees³nothing is itemized³so all
discounting is opaque.
The reason bundled pricing is so effective is because it addresses
an interesting ´problemµ that many people suffer from: consumer
innumeracy. Research reveals that ´percentage offµ discounts
are less enticing to people than getting something extra or free,
because most people are lousy at fractions. Deals such as 10, 13,
or 17 off confuse them because they can’t do the ´complicatedµ
math in their heads that is required to determine the real value of
the discount. So, when you offer ´13 off a syringe of Restylane,µ
you’ve put the patient into hyperperplex. And, since most people
don’t have an ´anchorµ price for a syringe of any injectable in
mind, even if they could do the math, they don’t have anything
to compare the discount with in order to determine whether it’s
good or bad. According to the research, a complimentary bag of
goodies, a gift set, or a bonus³something extra³entices a sale
more effectively than getting it at a discount. So, swap your ´per-
cent offµ deals with giving patients something extra or free. It’s
easier for the staff to explain, too.
Another psychological reason for the effectiveness of packaged
pricing is the human preference for getting a ´dealµ and the fact
that it’s easier for people to justify a single price for a bucket of
products or services than purchase multiple things individually.
Advantages of this strategy for aesthetic practices include the
following:
1. ,W VLPSOLfiHV WKH SULFH Fewer prices and fewer questions make it
easier to decide.

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99
2. The psychological cost of purchasing all the items is lowered. Buy-
ers feel as if they are getting a deal.
3. It makes for easier accounting, in many cases. There is no need to
track or report individual product sales tax. The patient sees one
simple fee. Of course, on the ´back endµ of your practice man-
agement system is where each individual line item is properly
posted and sales tax for products and/or garments is calculated.
So while the patient sees one opaque fee, the practice’s revenue
reports retain their accuracy, and the products sold as part of
the package are properly removed from the system’s inventory
count.
4. It builds the overall value of what the patient is buying. For exam-
ple, staff may explain to patients, ´Our fee includes incision line
reduction gel and a garment because Dr. :onderful believes
these are important to your recovery and outcome.µ
A simple way to incorporate the strategy of bundled pricing into
your practice is to offer a single fee for certain surgical procedures.
Antiaging packages for injectibles and laser services lend them-
selves well to bundled pricing too. In terms of procedures, bundled
pricing is very effective for breast augmentation, which is typically
bought by a price-sensitive, younger patient demographic. Fig. 11.1
shows how one client provides the quote for augmentation. 1otice
how it delineates everything that is included, providing potential
patients with an all-inclusive fee for 7,200. (Pain medications are
excluded from the bundled price because they vary due to patient
safety and preference.) Mommy Makeover and abdominoplasty
also lend themselves well to packaged pricing, as well as packages
provided in the MedSpa³laser, injectibles, or bundling skin care
products with treatment packages.
Another aesthetic surgeon uses the bundled price concept to
add a ´bonusµ to all surgical procedures. Patients receive a spa
allowance that varies in value with the cost of the surgery. Patients
choose to purchase the services they desire.
The way you bundle your services is up to you, based on your
creativity and your market needs. The point is to bundle items or
services that increase the overall perceived value of the purchase
and make it simpler for the patient to say ´yes.µ :e recommend
that if you do decide to try bundled pricing, you start with breast
augmentation.
11.6 The Power of Nine
:hy is it that so many retail items are priced at 99, 8.99,
79.99" Because this psychological pricing strategy has been
proven to increase sales, according to multiple studies.
A classic example is an experiment conducted by MIT and
the University of Chicago. A women’s clothing item was tested
at three price levels: 35, 39, and 44. Interestingly, the price
at which the item sold best was 39. The same study also found
that prices ending in 9 sold better than even their lower-priced
counterparts by an average of more than 24. This is one of eight
studies dissected in the book Priceless, all of which concluded that
the ´power of 9µ does work to increase sales.
To implement this strategy, simply change the last number in
your procedure fees to a 9: 4,999, 3,599, etc. For instance, you
could modify the previously discussed 7,200 bundled price for
breast augmentation to 7,199. The power of 9 also works beauti-
fully in the MedSpa with products and nonsurgical services.
11.7 Concluding Thoughts
:hen pricing your services, focus less on what competitors are
charging and more on creating perceived value for patients.
Differentiate your practice and make the experience memo-
rable. Implement retail-tested strategies such as premium and
packaged pricing, and be thoughtful and selective about special
pricing and discounts. The goal of effective pricing is to build
patient loyalty over time, not to get a one-time patient onto the
schedule.
Author’s Note
The American Society for Aesthetic Plastic Surgery (ASAPS; http://
) and the American Society of Plastic Surgeons
(ASPS; ) both conduct annual fee
surveys of their members’ surgical and nonsurgical fees. These
data can be particularly useful if you are just starting practice.
The survey results are available on each society’s website.
Suggested Reading
>1@ Godin S. Purple Cow. 1ew >2@ .line D. Coffee wars: McDonald’s, Dunkin’ Donuts fight on price. USA Today, -une
28, 2017. USAToday.com/story/money/personalfinance/2017/06/27/when-it-
comes-to-coffee-price-isn’t-everything/103224458/. Accessed September 24,
2019
>3@ Silverstein M, Fiske 1, Butman -. Trading Up. 1ew House; 2008
>4@ =upko .. Going from free to fee consultations. Soc News 2017(October 4):56–57
>5@ Alexander V, Tripp S, =ak P-. Preliminary evidence for the neurophysiologic
effects of online coupons: changes in oxytocin, stress, and mood. Psychol Market
2015;32(9):977–986
>6@ =upko .. Evidence based pricing strategies for plastic surgeons³winning the
price wars. Aesthet Soc News 2018(March 26):99–100
>7@ The psychology of discounting. Something doesn’t add up. The Economist, -une
30, 2012. Accessed September
24, 2019
>8@ Anderson ET, Simester DI. Effects of 9 price endings on retail sales: evidence
from field experience. Quant Mark Econ 2003;1(1):93–110
com/article/10.10232FA3A1023581927405. Accessed May 24, 2018
Fig. 11.1 Example of packaged pricing as a way to simplify surgery
quotes. (Please note: Fees are for illustrative purposes only.)
The one fee—breast augmentation
Estimate of surgical fees
Sam Wonderful, MD
Description
Item price
One simple fee.
Breast augmentation silicone
$7,200.00
Our fee is all-inclusive and includes Dr.
Wonderful’s fee, implants, operating room,
anesthesia, garments, incision line reduction gel,
and all pre- and post-operative visits.
In some states, using a bundled approach means you don’t charge sales tax
Subtotal: $7,200.00
Tax: $0.00
Quote $7,200.00

(Trang không có chữ)

Part III
Nonsurgical
Cosmetic
Treatments
III

(Trang không có chữ)

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12 Clinical Decision Making for Nonsurgical Cosmetic
Treatments
Mikaela Kislevitz, Foad Nahai, and Jeffrey M. Kenkel
Abstract
1onsurgical office-based cosmetic treatments are becoming
more mainstream. These treatments can provide patients
alternative options to surgery. It is important to understand that
nonsurgical cosmetic treatments do not provide the same out-
come as surgery. All options of treatment and realistic outcomes
should be reviewed with the patient.
Keywords
nonsurgical cosmetic treatment, facials, fillers, chemical peels,
toxins, injectables, laser, rhytids
12.1 Introduction
Today, nonsurgical and less invasive, office-based procedures
and treatments are the mainstay of therapy for our patients.
According to the American Society for Aesthetic Plastic Surgery
(ASAPS), nonsurgical procedures increased by a total of 4.2 in
2017. The most significant increases in nonsurgical procedures
in 2017 included microablative skin resurfacing (up 99.5), full-
field ablative skin resurfacing (up 29.2), nonsurgical fat reduc-
tion (up 24.7), chemical peel (up 15.9), and nonsurgical skin
tightening (up 15.1). :hile they have not replaced surgery, their
consistency and lack of significant recovery time requirements
have appeal for many of our patients. :ith the emphasis on a
youthful facial appearance and an appealing, slim figure, much
younger patients are consulting us about facial rejuvenation and
body contouring.
Cosmetic treatments are nonsurgical treatments that require
minimal or almost no downtime, returning our patients to the
acts of daily living without delay. Many of these treatments can
be delegated to an aesthetic technologist, nurse, and/or physician
assistant (PA). :e feel that most treatments should be performed in
a clinical environment under the supervision of a physician. :hile
facials, lighter peels, and microdermabrasion may be performed by
an appropriately trained aesthetician in a nonclinical setting, we
believe that their training, experience, and the identity of a physician
to contact in case of a problem should be transparent to the patient.
More invasive procedures, such as injections of toxins and fillers,
and invasive laser treatments should be performed in a clinical
setting, such as a physician’s office or outpatient center, rather than
at a spa or beauty salon. These are procedures and require a medical
environment to ensure the patient’s safety. Although injectables
and other technology-based procedures are safe in the hands of
trained technologists, nurses, and PAs, a physician should evaluate
the patient, make decisions concerning treatment, and be available
while these procedures are being performed.
These office-based and less invasive procedures keep patients
cycling in a practice. It is not uncommon to see some patients con-
vert from these procedures into surgical ones. Research has shown
that patients who are satisfied with their cosmetic treatments are
likely to return to the same surgeon for surgical procedures as the
aging process continues. It is a rare aesthetic practice that does
not offer the full range of cosmetic treatments.
12.2 Cosmetic Treatments
Options for office-based cosmetic treatments (such as those
listed in Table 12.1) are constantly increasing. Our patients are
tuned in to these treatments, heightened by direct-to-consumer
marketing. In many cases, claims are being made without
well-controlled studies or any objective data. It is imperative for
us as physicians to stay abreast of the dissemination of this type
of information to our patients so that we are adequately prepared
to discuss them and answer questions regarding these products
and devices. :hile great advancements have been made in the
nonsurgical arena, they are still not a replacement for surgery,
nor do they approach the type of results and longevity achieved
with surgery. That being said, patients understand this and are
willing to accept a ´lesserµ result and even the need for multiple
treatments. Most important, we need to choose treatments that
can achieve a certain result in a predictable fashion. This is a
constantly evolving field that requires treating physicians to stay
informed. Outcomes and safety help differentiate us from many
other providers and it behooves us to familiarize ourselves with
mode of action, safety limits, risks, and limitations.
Table 12.1 Nonsurgical treatments in order of increasing invasiveness
1RninYDViYe
0inimDOOy inYDViYe
0RderDWeOy inYDViYe
Spa treatments
Facials
External ultrasonography
Light-based treatments
Microdermabrasion
Fruit acid peels
Nonablative lasers
Sclerotherapy
Transcutaneous skin tightening
Injectables
Ablative lasers
Peels: TCA, croton oil
Dermabrasion
Abbreviation: TCA, trichloroacetic acid.

104
III Nonsurgical Cosmetic Treatments
12.3 Choosing the Right Option:
2ffiFe-%DVed YV SurgiFDO
Procedures
In the first edition of this book, this section was titled ´Choosing
the Right Option: The 1eedle or the .nife.µ It is no longer a
question of needle or knife; these are not competing but rather
complementary treatment methods. :e also have to recognize
that many patients have made up their mind that surgery is not
on the ´optionsµ list. Despite this, we routinely review what a
surgical procedure can accomplish. This often serves as a frame
of reference as they begin to consider nonsurgical options.
Choosing a nonsurgical option in a patient who clearly needs
surgery to achieve the desired goal leads to a dissatisfied patient
who often can be difficult to manage. On occasion, saying ´noµ
is the best for the patient. :e have seen some of these patients
come back later on and move forward with surgery.
It’s not unusual for young people who are nowhere near ready
for a facelift to come in to discuss a facelift, while individuals
with advanced facial aging who are no longer candidates for
cosmetic treatments frequently ask for nonsurgical treatments.
and injectables, if needed, while strongly advising patients to
wait for the appropriate time to undergo a surgical procedure. To
an older patient who is a candidate for surgical rejuvenation but
comes in to discuss cosmetic treatments, I recommend surgical
treatment as the first choice and discuss cosmetic treatments as a
less effective alternative and perhaps a better adjunct to a surgical
procedure rather than the primary treatment.
The choice between cosmetic treatments and open surgical
procedures should be an informed decision, and all options,
including expectations of them, should be discussed during initial
consultation. The patient must clearly understand what outcomes
are anticipated with both surgical and nonsurgical treatments
and should also understand how many treatments would be
required and what the longevity of the procedures are (Fig. 12.1;
Fig. 12.2; Fig. 12.3; Fig. 12.4).
12.4 Face
Most women undergoing noninvasive facial cosmetic treatments
are seeking improvement of their facial skin. It is important
to note the degree of skin pigmentation and redness and the
nature of each. Is it superficial or deep, and what does it consist
of" The texture, thickness, and quality of the skin are deter-
mined. Finally, static and dynamic lines are assessed. Having a
systematic approach to the analysis of the skin ensures that all
aspects of the evaluation are reviewed, allowing a more detailed,
patient-specific recommendation. These evaluations are usually
performed by the physician and aesthetician together.
Classification systems such as the one for rhytids given in Table
12.2 may be useful to describe the patient and objectively assess
their progress following intervention.
Pigmentation, a darkening of the skin, results from an increased
production of melanin. Increased pigmentation in the epidermal
layer appears light brown, whereas hyperpigmentation in the
dermal layer can appear blue–gray. Increased vascularity can
contribute to a bluish pigmentation.
The texture of one’s skin can be smooth or rough. Extremely
coarse textures characterize individuals with rough skin surfaces
including deep creases, wrinkles, and loss of skin laxity. Visually
smoother skin would be consistent with an improvement in
texture.
12.4.1 Rhytids
Grade I: No Rhytids at Rest or on Animation
Grade I patients (Fig. 12.5) require only preventive and main-
tenance skin care. The importance of sunblock is stressed, the
cornerstone of prevention. In most cases, it is too early for any
Fig. 12.2 Patient pre (left) and post (right) filler and botulinum toxin.
Restylane was injected to the lower eyelid/tear trough bilaterally. The
crow’s feet and glabella were injected with botulinum toxin.
Fig. 12.1 (a) Anterior, (b) right and left oblique views pre (left) and
post (right) intense pulsed-light (IPL) treatment (five total treatments).
a
b

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105
surgical or invasive procedures, and the patient’s best interests
would be served by preventive measures, including tretinoins
and glycolic acid peels, if needed, but most of all we discuss skin
health: avoiding environmental toxins, such as smoking and
secondhand smoke, and taking precautions about sun exposure.
Patients are also advised on general antiaging measures, includ-
ing diet, exercise, and the use of antioxidants. It is important
for patients to understand that these preventive measures will
not eliminate the aging of their skin but may delay or help avoid
some of the sequelae of the aging process.
GrDde ,, SuSerÀFiDO 5KyWidV 2nOy Rn AnimDWiRn
For each successive grade, most if not all of the treatments of the
preceding grade are applicable, along with specific treatments
for the current grade. Superficial animation lines are best treated
by directly targeting the underlying muscle function. By elim-
inating muscle function, especially in the glabella, forehead,
and crows’ feet, the lines are minimized. Additionally, the brow
shape and position can be altered and improved (Fig. 12.6).
Table 12.2 Classification system for rhytids
Grade I
No rhytids at rest or on animation
Grade II
Superficial rhytids on animation only
Grade III
Deep rhytids on animation only
Grade IV
Superficial rhytids at rest, deep on animation
Grade V
Deep rhytids at rest, deeper on animation
Fig. 12.4 (a) Anterior and (b) lateral views pre (left) and 9 months post
(right) erbium:yttrium aluminum garnet (Er:YAG) laser treatment.
a
b
Fig. 12.3 (a) Anterior, (b) lateral, and (c) oblique patient views pre
(left) and 4 months post (right) Ulthera skin tightening to the lower
face and submental area.
a
b
c

106
III Nonsurgical Cosmetic Treatments
Grade III: Deep Rhytids on Animation
In grade III patients (Fig. 12.7), for the glabella, forehead, and
crow’s feet, toxins are the best agents to soften their appearance.
Adjunct treatments may be required to have a greater impact on
these areas.
Options may include some of the following:
• Intradermal fillers
• Dermal ablation with peeling agents, ablative lasers, or
dermabrasion
Perioral lines and wrinkles deserve further discussion. Dynamic
lines in this area are responsive to botulinum toxin. It is import-
ant for patients to realize that the results may last only 2 to 2.5
months. Additionally, it may be more difficult for these patients to
drink out of a straw or to whistle. Spot treatment of the lines with
dermal fillers is also an option for patients not wanting a longer
downtime period. Many of these patients are concerned about
´filling and plumpingµ of their lips, so this should be approached
cautiously. That being said, most women would rather accept
more limited improvement and the need for repeat treatments
than the excess downtime associated with more aggressive abla-
tive treatments.
GrDde ,9 SuSerÀFiDO 5KyWidV DW 5eVW Dnd 'eeS
on Animation
The recommendations for grade IV patients (Fig. 12.8) are essen-
tially the same as those for grade III patients. :hen considering
ablative treatments, it is often helpful to diminish the dynamic
nature of the area with a toxin in appropriately designated areas.
This may allow better healing and dermal line fill. Additional sur-
gical procedures of the face and periorbita are often considered.
Grade V: Deep Rhytids at Rest and Deeper on
Animation
Grade V patients are the best candidates for perioral adminis-
tration of toxins, but, as in grades III and IV, toxins alone are not
sufficient. These patients clearly need a multimodal approach,
as any single treatment alone will have limited improvement.
Fig. 12.5 Grade I rhytid condition.
Fig. 12.7 Grade III rhytids.
Fig. 12.6 Grade II rhytids.
Fig. 12.8 Grade IV rhytids.

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107
Surgical facial rejuvenation procedures help address these lines
by shifting the underlying superficial musculoaponeurotic
system (SMAS)/fascia and skin, helping soften the appearance
of the lines. Most of these patients benefit from ablative resur-
facing, which may be performed in combination with surgical
intervention or in a staged procedure (Fig. 12.9).
12.4.2 Nasolabial Folds and Marionette
Grooves
:hile surgery is a very good option for treating deep nasolabial
fold and marionette lines, injectable fillers have become the
mainstay of treatment for many patients due to the ease of
treatment and quick recovery. These areas are often one of the
earlier signs of aging noticed by patients, with glabella frown
lines pushing them to seek treatment. Complaints of looking old,
tired, and even angry are common. :e have learned that even
when surgery is chosen, these areas often need either fat or filler
to complement the surgical procedure. It is hard to compete with
the predictability and ease of office-based filler injections.
Unlike facial rhytids, which reflect the insertion of the muscles of
facial expression into the skin, nasolabial folds and marionette grooves
reflect not only muscle insertion and muscle pull but also adhesions
of the dermis to the fascial layers of the face. Established nasolabial
folds and marionette grooves are resistant to superficial and even
deep ablative skin procedures. However, muscular manipulation
with toxins and superficial and deep injections of filler materials can
be very effective in ameliorating these folds. The deeper the fold, the
deeper the level of injection and the more viscous the material. In
addition to dermal and subdermal injections, filler materials may also
be placed within the subcutaneous tissues. Many surgical options are
also available, including various rhytidectomy procedures as well as
local excisions. Recommendations are made based on the grading of
the folds according to the system shown in Table 12.3.
Grade I: Visible Folds on Animation
The majority of patients with this presentation need nothing
more than reassurance. Nasolabial folds with animation are
normal and are part of human expression. Fillers injected der-
mally to obliterate dynamic lines may be noticeable and promi-
nent in repose. :e discourage the use of injectable products for
this type of fold (Fig. 12.10).
Grade II: Visible Folds at Rest
For grade II patients (Fig. 12.11), dermally injected fillers may
be the best option to soften their appearance. Typically, a small
amount of product is needed superficially. It is important to inject
evenly. :hen lower-viscosity products are used, care should be
given to how aggressively one massages the area treated, as it
may dissipate the product, losing its effect.
Grade III: Visible Folds at Rest and Deepening
of Folds on Animation
Grade III patients (Fig. 12.12) require the injection of a filler
product at different levels. Deeper injections help fill its depth,
but often a dermal injection is required to soften the fold better.
Fat may be used as an alternative to injectable fillers. :hile fat
is less predictable than off-the-shelf filler products, it nicely
complements a surgical procedure and may be preferred by
some patients.
Toxin injections of the depressor anguli oris for the marionette
grooves are helpful in some patients. Toxins in the lip elevators
(the levator labii superioris and the levator labii superioris
Table 12.3 Classification of nasolabial folds and marionette grooves
Grade I
Visible folds on animation
Grade II
Visible folds at rest
Grade III
Visible folds at rest and deepening of folds on animation
Grade IV
Deep folds at rest and deeper on animation
Grade V
Overhanging folds
Fig. 12.9 Grade V rhytids.
Fig. 12.10 Grade I nasolabial fold.

108
III Nonsurgical Cosmetic Treatments
alaeque nasi) should be approached with caution, as animation
can be affected.
Grade IV: Deep Folds at Rest and Deeper on
Animation
The recommendations are similar to those described for grade
III. Surgical intervention, specifically midface lift with fat trans-
fer, should be considered (Fig. 12.13).
Grade V: Overhanging Folds
The recommendations of filler injections and toxin remain the
same for this grade (Fig. 12.14). As far as surgical interventions,
I add the option of direct excision as an alternative to a midface
lift. Should the patient choose to undergo a midface lift, the
direct placement of autologous dermis fat graft or SMAS fat graft
is an alternative to autologous fat injections. Most individuals in
grades IV and V are more suitable candidates for rhytidectomy
procedures, with injectable fillers as an adjunct.
12.4.3 Periorbital Region
The periorbital region improves predictably with nonsurgical
options. Proper analysis enables one to manipulate the area, also
correcting asymmetries and elevating the brow. The mainstay
of treatment includes the use of botulinum toxin along with
both superficial and deep filler injections to diminish volume
loss along the orbital rim and tear trough, as well as their use
to help correct upper lid and brow volume deficiencies and to
help improve static lines. These products are very predictable
and, in the case of the fillers, often last over a year. These
products cannot address skin laxity, crepelike skin, or fat her-
niation. Other adjuncts, including surgical excision and ablative
resurfacing, may be required in order to address these specific
issues. Administration of injectable products in this area should
be performed with a thorough understanding of the underlying
anatomy, including the vasculature. Significant complications,
including tissue loss and even blindness, have been reported.
12.4.4 Neck
The neck is a more challenging area to treat with nonsurgi-
cal devices and products. The following areas may require
intervention:
• Skin
• Medial platysmal bands
• Fat
• Salivary glands
• Anterior belly of the digastric
Fig. 12.11 Grade II nasolabial folds.
Fig. 12.12 Grade III nasolabial folds and marionette grooves.
Fig. 12.13 Grade IV nasolabial folds and marionette grooves.
Fig. 12.14 Grade V nasolabial folds and marionette grooves.

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109
The skin of the neck may be thin and lax. It is important to
understand that neck skin has about 10 of the glandular struc-
tures of facial skin, significantly decreasing its healing capacity
following injury. For that reason, caution and conservatism should
be used when treating the neck with ablative devices. There are a
number of skin tightening procedures available using laser, light,
radiofrequency, and microneedling. In some cases, a combination
of several modalities can be used. Appropriate expectations must
be established with these devices (Fig. 12.15; Fig. 12.16).
Fat in the neck can be addressed in many ways. The gold stan-
dard remains liposuction, which can be performed in the office
under a local anesthetic. It requires one treatment and produces
predictable results. Alternatives do exist, including cryoadipolysis,
deoxycholic acid, and heat-based technologies,
Fig. 12.15 (a) Anterior, (b) lateral, (c) oblique views pre (left) and 3
months post (right) Ulthera after one treatment.
a
b
c
Fig. 12.16 (a) Anterior, (b) lateral, (c) oblique views (left) pre and (right)
1 year status post office-based neck liposuction.
a
b
c

110
III Nonsurgical Cosmetic Treatments
It is beyond the scope of this chapter to elaborate on nonsurgi-
cal means to address platysmal banding and prominent salivary
glands (see Chapter 21).
12.5 Concluding Thoughts
Facial rejuvenation with office-based products and devices
is now commonly performed on a wide range of ages. Early
changes and late changes from the aging process can be delayed
or reversed. Toxins and fillers lead the way. There are more and
more treatment options for our patients, allowing the physician
to tailor treatment plans to the patient’s specific needs. Most
of these treatments have little downtime and produce predict-
able results. These procedures not only keep patients with our
practices but nicely complement the surgical procedures we
perform.
Clinical Caveats
• Patients have an increasing number of options for office-based
cosmetic treatments. These treatments can provide great
benefit for appropriate candidates but are not a replacement
for surgery.
• Utilize a systematic approach to determine which nonsurgical
office-based cosmetic treatments should be administered.
• Referring to the classification of rhytids can help in objectively
assessing outcomes of interventions.
• Injectables are usually the first-line treatment for deep naso-
labial folds and marionette lines.
• The neck region is a challenging area to target with office-
based cosmetic treatments.
Suggested Reading
>1@ Achauer BM. Lasers in plastic surgery: current practice. Plast Reconstr Surg
1997;99(5):1442–1450
>2@ Alam M. :ho is qualified to perform laser surgery and in what setting" Semin
Plast Surg 2007;21(3):193–200
>3@ Alster TS, Lupton -R. Lasers in dermatology. An overview of types and indica-
tions. Am J Clin Dermatol 2001;2(5):291–303
>4@ Atiyeh BS, Dibo SA. 1onsurgical nonablative treatment of aging skin: radiofre-
quency technologies between aggressive marketing and evidence-based efficacy.
Aesthetic Plast Surg 2009;33(3):283–294
>5@ Bass LS. Injectable filler techniques for facial rejuvenation, volumization, and
augmentation. Facial Plast Surg Clin North Am 2015;23(4):479–488
>6@ Carruthers -, Fagien S, Matarasso SL; Botox Consensus Group. Consensus
recommendations on the use of botulinum toxin type A in facial aesthetics. Plast
Reconstr Surg 2004; 114(6, Suppl)1S–22S
>7@ Cosmetic Surgery 1ational Data Bank statistics. Aesthet Surg J
2017;37(Suppl 2):1–29
>8@ D’Amico RA, Saltz R, Rohrich R-, et al. Risks and opportunities for plastic surgeons
in a widening cosmetic medicine market: future demand, consumer preferences,
and trends in practitioners’ services. Plast Reconstr Surg 2008;121(5):1787–1792
>9@ Day D-, Littler CM, Swift R:, Gottlieb S. The wrinkle severity rating scale: a
validation study. Am J Clin Dermatol 2004;5(1):49–52
>10@ Fitzpatrick RE, Rostan EF, Marchell 1. Collagen tightening induced by carbon
dioxide laser versus erbium:>11@ Honigman R, Castle D-. Aging and cosmetic enhancement. Clin Interv Aging
2006;1(2):115–119
>12@ .arimipour D-, .arimipour G, Orringer -S. Microdermabrasion: an
evidence-based review. Plast Reconstr Surg 2010;125(1):372–377
>13@ .im EH, .im Dermatol Sci 2007;46(2):111–116
>14@ Matarasso A, Glassman M. Effective use of Botox for lateral canthal rhytids.
Aesthet Surg J 2001;21(1):61–63
>15@ McCullough -L, .elly .M. Prevention and treatment of skin aging. Ann N Y Acad
Sci 2006;1067:323–331
>16@ Rohrich R-, Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Restylane)
in facial cosmetic surgery: review and technical considerations. Plast Reconstr
Surg 2007; 120(6, Suppl)41S–54S
>17@ =ielke H, :|lber L, :iest L, Rzany B. Risk profiles of different injectable fillers:
results from the Injectable Filler Safety Study (IFS Study). Dermatol Surg
2008;34(3):326–335

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111
13 Over-the-Counter Skin Care and Nutraceutical Basics for
the Aesthetic Surgeon
Mary P. Lupo and Katharine Saussy
Abstract
Skin care is a basic step in the improvement and maintenance
of healthy, beautiful skin. There is a plethora of choices on the
market, which can be overwhelming for the patient. Many
physicians retail cosmeceuticals from their offices. It is optimal,
however, to have at least some knowledge about less expensive,
mass-marketed, over-the-counter products, their ingredients,
and their best uses. Skin care protocols are needed to target the
treatment of different symptoms of skin aging and maintain
improvement postprocedure. This chapter discusses key compo-
nents of skin care protocols from the perspective of the cosmetic
physician.
Keywords
over the counter (OTC), recommended daily allowance (RDA),
antiaging, skin care regimen, sunscreen, cleansing, moisturizing,
cosmeceuticals, nutraceuticals, dyspigmentation
13.1 Introduction
Proper skin care is an essential component of both health and
beauty. The skin plays a vital role as the first line of our body’s
defenses. It is constantly exposed to internal and external
influences, which ultimately lead to visual and physical changes,
hastening skin aging. For the aesthetic surgeon, patients often
present with specific concerns. These concerns of irregular pig-
mentation, coarse texture, fine lines, deeper folds, and laxity can
be the result of both intrinsic (chronological) aging and extrinsic
aging. External influences, including but not limited to lack of
adequate cleansing, ultraviolet radiation, tobacco and chemical
exposures, lack of exercise, stress, hormonal dysfunction, and
insufficient nutrition are a few of the most common factors
leading to damaged skin. Internally, increased production of free
radicals, oxidative stress, and inflammation lead to quickened
collagen and elastic fiber reduction, cell damage, and cell death.
These intrinsic factors also result in the signs and symptoms of
aging skin.
Over-the-counter (OTC) skin care can be overwhelming for the
patient, as the products available for purchase are vast. In turn, the
extensive OTC options to choose from can be challenging for the
aesthetic surgeon to have a comprehensive understanding of all
available products. In this chapter, we review common OTC skin
cosmeceuticals and oral nutraceuticals, recommended practices,
and suggested ingredients for pigment, inflammation, redness,
and scar reduction.
13.2 OTC Skin Cosmeceuticals and
Oral Nutraceuticals
OTC skin cosmeceuticals and oral nutraceuticals are thought to
play key roles in antiaging, maintaining youthful and healthy
skin, and treating damaged skin. Cosmeceuticals consist of
products that have more than a superficial benefit to the skin
but do not quite reach to the level of pharmaceutical changes.
If the manufacturer claims physiologic changes, more rigorous
testing is required. 1utraceuticals are naturally derived dietary
components thought to have benefits medically as well as nutri-
tionally. It is critical to mention that few OTC cosmeceuticals
and oral nutraceuticals have been extensively investigated or
validated by significant clinical trials. Most are not regulated by
the U.S. Food and Drug Administration (FDA), and not all have
recommended dietary allowances (RDA) set by the Food and
1utrition Board of the Institute of Medicine. This discordance
places the responsibility on the aesthetic physician to research
and recommend products appropriately based on the physician’s
clinical expertise.
In this section, we discuss what we believe to be the most
important components of a comprehensive skin care regimen for
the aesthetic surgeon to recommend to patients. To understand
which type of product to recommend in order to slow the appear-
ance of aging, maintain improvement from aesthetic procedures,
and treat aging skin, we review the mechanisms in which skin is
damaged and best aesthetic practices. As you will find, many of
the cosmeceuticals and nutraceuticals mentioned in this chapter
have many functions in the skin and human body. Some of these
agents fall under multiple categories and will not be repeatedly
discussed. :hether addressing a specific concern, tailoring for a
procedure, or creating a daily routine, these components all play
a role in a comprehensive skin care regimen and can be applied to
any aesthetic patient.
13.2.1 Skin Cleansing
:hen creating a comprehensive skin care regimen for the
aesthetic patient, it is essential to start with skin cleansing. The
number of available OTC facial cleansing products is vast, making
skin cleansing the first step to tackle when recommending
products.
There are multiple types of cleansers, each with a different com-
position and pH. Surfactants are the main active component in a
cleanser, with the ability to reduce surface tension, allowing the
cleanser to remove substances that do not readily mix with water
such as makeup, dirt, and sebum and offer a fresh facial canvas
and better absorption of active ingredients. The skin’s natural pH
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skin’s natural pH, the more tolerated. In regard to facial cleansers,
one of the most popular types of cleansers is a synthetic detergent
(syndet), non-soap-based, that creates a neutral to mildly acidic
pH environment (pH 5.5–7). This composition is optimal, as it
decreases the amount of protein denaturation, which can then
cause a reduction of intercellular lipids. Loss of epidermal lipids
compromises the skin barrier. This compromise from cleansers
with a higher pH can result in irritation, pruritus, tightness, ery-
thema, and dryness as the skin loses its ability to retain moisture.
Various ingredients can be added into cleansers such as natural
oils, exfoliating materials, topical vitamins, antibacterial agents,
fragrances, and moisturizers (hydrators/occlusive/emollients).
Micellar cleansers are one of the most popular cleansers rec-
ommended by aesthetic physicians, as they delicately cleanse the
skin and they are suitable for all skin types. Micellar cleansers
are considered mild surfactants, containing molecules with a
hydrophilic head and hydrophobic tail. These surfactant mole-
cules arrange to form clusters, referred to as micelles. These more
or less spherical micelles arrange themselves in such a way that
when applied to the skin, the hydrophobic tail gently removes
makeup, dirt, sebum, leaving the face cleansed without disrupting
the epidermal lipid layer.
For sensitive skin patients and those more susceptible to contact
allergens, it is imperative to review the ingredients in these prod-
ucts carefully. Patients with dry and/or sensitive skin should focus
on facial cleansers that contain micellar properties, or ones with
added oils and moisturizers to help support the stratum corneum’s
epidermal barrier. Patients with oily and/or less sensitive skin
can usually tolerate foaming cleansers. Patients with acne-prone
and oily skin can use benzoyl peroxide washes. It is important to
inform patients that benzoyl peroxide can be drying and irritating
to delicate facial skin. Benzoyl peroxide is generally well tolerated
on the chest and back, even if not also tolerated on the face. Benzoyl
peroxide is also notorious for bleaching towels, so recommend use
of white towels when using benzoyl peroxide–containing products.
All aesthetic patients should be advised to cleanse the skin
every morning and evening, as this allows the skin to be properly
cleansed of external factors residing on the surface, and washing
the skin serves as a vehicle for better penetration of later steps in
the regimen.
13.2.2 Skin Moisturizing and Barrier
Repair: Hydrators, Occlusives, and
Emollients
As the skin serves as a barrier to what it defends inside, it is
essential to provide additional protection by adequately mois-
turizing the skin. Adequate moisturization supports the stratum
corneum’s ability to hold on to water within the dermis and
epidermis. When the epidermal barrier is disrupted, signs and
symptoms of skin dehydration become a common concern for
the aesthetic patient. Patients often want to discuss moisturizers
when the skin shows signs of dryness, roughness, scaling, or irri-
tation. Regardless of skin type or aesthetic concern, all patients
should be advised to moisturize the skin appropriately as a part
of their daily skin care regimen.
Moisturizers come in multiple vehicles, such as lotions,
creams, ointments, gels, and serums. The components needed
in a moisturizer can be tailored to a specific skin type (oily, dry,
combination, sensitive, etc.). In general, it is best to recommend
moisturizers with the properties of being noncomedogenic, hypo-
allergenic, and fragrance free. Moisturizers are most commonly
either a lotion or cream. Lotions are compounded as oil-in-water
emulsions, while creams are compounded as water-in-oil emul-
sions, the main differences being the amount of lipid composition
and thickness of product.
Moisturizers, regardless of vehicle used, are intended to assist
in hydrating the skin, serve as an additional barrier to extrinsic
factors, and support the intrinsic properties of the skin. During
patient counseling, it is recommended to apply twice daily after
properly cleansing the face for best results. In patients with dry
and sensitive skin, it is imperative to implement at least twice
daily moisturization to the entire body. More frequent applica-
tion of moisturizers reduces epidermal lipid loss, which helps
prevent inflammation resulting from skin dehydration. :hen
showering, advise patients to pat dry and apply moisturizer to
damp skin within minutes of bathing since lipids and water are
lost during bathing, leaving the skin feeling tight and even drier.
The benefits of shorter showers, utilizing more tepid to cool water
temperatures, should be mentioned. There are various types of
moisturizers to consider.
Hydrators/Humectants
Hydrators/humectants are products that increase water reten-
tion by drawing water into the skin through water-soluble,
absorptive properties. This allows the stratum corneum to
appropriately swell and retain water from viable epidermal
and dermal layers, as well as external exposures when in high
humidity. Examples of humectants are hyaluronic acid, glycerin,
alpha-hydroxyl acids, and sorbitol.
Hyaluronic acid (HA) is currently the most common humec-
tant. It has gained in popularity lately for its innate humectant
and hypoallergenic properties. HA is a glycosaminoglycan found
in the skin’s extracellular matrix (ECM). HA’s ability to enhance
tissue hydration is seen in its capacity to bind and retain water.
HA has been reported to bind water nearly one thousand times
its volume. As we age, the concentration of HA is significantly
reduced, leading to signs of aged skin such as loss of elasticity,
dehydration, and atrophy. HA has been claimed to improve fine
lines and wrinkles. This ability is the result of HA’s absorptive
properties by drawing water into the stratum corneum, allowing
viable layers to swell, giving the appearance of a reduction in fine
lines and a more even skin texture. Humectants work best in more
humid environments, where water can be captured extrinsically.
Occlusives
Occlusives are products that serve to decrease transepidermal
water loss by creating a hydrophobic layer on the skin surface.
These oily products have strong hydrophobic properties that
repel water from being lost to the outside environment; as
such, these are ideal in low-humidity climates. Petrolatum is a
commonly used ingredient in occlusive products. Petrolatum
consists of a synthetic substance that mimics the work of the
skin’s intercellular lipids, thereby decreasing transepidermal

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water loss. Mineral oil is a thinner, less greasy occlusive used for
its same properties as petrolatum. It is also a commonly added
ingredient to moisturizers to ease the spread on the skin surface
during application. Other commonly used occlusives are olive
oil, coconut oil, silicone, paraffin, and ceramides. Occlusives
are considered the optimal family of products to use after skin
resurfacing to speed re-epithelialization and protect from sec-
ondary infection. It is important to note that acne-prone patients
undergoing resurfacing for acne scars will most likely get an
acne outbreak as a result of this occlusive therapy and be advised
as such preoperatively.
Emollients
Emollients serve as fillers between desquamating corneocytes
and keratinocytes in order to hydrate the skin and increase
cohesion between cells. Emollients adequately hydrate the skin
while also improving skin texture with increased appearance
and smoothness. Emollients are frequently found in thick topical
agents such as those used for atopic dermatitis patients, as the
epidermal barrier is more easily disrupted than normal skin.
Many topical products have emollient properties as well as
humectant and occlusive properties. Common emollients are
shea butter, collagen, and elastin. Common combination hydra-
tors are products such as petrolatum and mineral oil.
13.2.3 Exfoliation and Cell Renewal
Alpha-Hydroxy and Beta-Hydroxy Acids
Alpha hydroxy acids (AHAs) and beta-hydroxy acids (BHAs) are
in many OTC products used for acne, antiaging, and dyspigmen-
tation, as well as when preparing the skin for procedures. AHAs
and BHAs exfoliate the skin, creating an environment to allow
for deeper penetration and support a more homogeneous skin
surface by thinning the stratum corneum. AHAs are typically
water-soluble and work by decreasing intercellular adhesion,
allowing the bonds between dead skin cells to dissolve on the
skin surface. BHAs are commonly oil-soluble, so they penetrate
deeper beneath the skin’s surface, desquamating the stratum
corneum. In specific preparation for procedures, AHA- and
BHA-containing products are often used in combination with a
procedure such as a chemical peel for enhanced results. During
patient counseling, it is recommended that patients use moistur-
izers containing AHAs and BHAs for 2 to 3 weeks prior to certain
procedures in order to decrease the risk of postinflammatory
hyperpigmentation and promote a more even skin surface. This
pretreatment step may reduce acne flare in resurfacing patients.
Retinoids
Topical retinoids are one of the most commonly recommended
product for the aesthetic patient. Topical retinoids are acknowl-
edged for their highly efficacious abilities such as increasing
dermal thickness, healing, and re-epithelization, while also
decreasing the risk of hyperpigmentation and acne. Retinoids
are also celebrated for reducing appearance of fine lines and
wrinkles. Topical retinoids accelerate skin cell turnover, normal-
ize follicular hyperkeratosis, reduce inflammation, and inhibit
melanogenesis by a few proposed mechanisms, such as inhibit-
ing the transfer of melanin from melanosomes to keratinocytes.
These properties make topical retinoids highly effective for
patients when targeting aging, dyspigmentation, and acne and
in pre- and postprocedure patients.
For the pre- and postprocedure patient, a minimum of 2 weeks
prior to procedure has been found to be beneficial. In the ideal
setting, applying topical retinoids nightly for 3 months prior to
the procedure is desired. In the preprocedure setting, topical ret-
inoids are intended to accelerate re-epithelization and decrease
melanin production. Discontinue topical retinoids 1 week prior
to procedure. Patients using retinoids prior to a procedure such
as a chemical peel can discontinue use 5 to 7 days prior to and
after the procedure to decrease risk of irritation. Caution should
be used if the retinoid is not discontinued a week before the
procedure, as it will make the procedure more aggressive than
the clinician might have intended or might be prepared to handle.
For the acne and antiaging patient, it is recommended to apply a
pea-sized amount of the topical retinoid to the entire face nightly.
For patients with dry or sensitive skin, recommend the patient
to start every other night and increase to nightly as tolerated. For
sensitive skin patients using topical retinoids, it might be benefi-
cial to discuss the short-contact application technique, allowing
the topical retinoid to be applied to cleansed skin for 2 minutes
to 2 hours, then rinsed off the skin. Increase length of application
time as tolerated. Patients can also be advised to mix the topical
retinoid with a moisturizer in order to decrease initial irritation
when adding this step into a daily regimen.
It is noteworthy to counsel the patient on the side effects such
as dryness, flakiness, and possible irritation during the first few
weeks of using topical retinoids. It is key to discuss a quality mois-
turizer for patients. It is crucial to advise patients to discontinue
topical retinoids in patients who are pregnant, trying to become
pregnant, or breastfeeding, as topical retinoids have not been
validated as safe to use in these circumstances.
13.2.4 Photoprotection: Sun Protection
Factor, Antioxidants, Ultraviolet
Radiation Defenses
Chemical and Physical Sun Protection Factor
It is of the utmost importance to stress daily sunscreen use to all
patients. There is a common misperception that sunscreen is to
be used when there is direct, visible sunlight, when exposed for
an extended amount of time, or during distinct events such as
sunbathing on the beach. What patients might not understand
is the significant and cumulative exposure they receive when
near a window, walking to and from locations by foot, driving or
riding in the car, on cloudy/rainy days, and during nonpeak sun-
light hours as well as the importance of reapplication throughout
the day.
Patients often express dislike for sunscreens due to their
texture, smell, or appearance when applied. There are countless
sunscreen-containing products on the market. It is recommended
to review major differences in specific products such as differences
in vehicle (cream, lotion, stick, spray), in texture (thin or thick),
and in appearance (tinted or nontinted). Having specific products

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to recommend on a sheet of paper or having products available
for sale in the office are recommended ways to increase use of
daily sunscreen. The goal is to help your patients find sunscreen
products that they will consistently use for best results.
Ultraviolet (UV) light can be broken down into three different
categories (UVA, UVB, and UVC); however, only two are pertinent
to discuss in this chapter. UVA (320 to 400 nm) and UVB (280 to 320
nm) are important to discuss with patients, as these wavelengths
are harmful to the skin, while the shorter UVC wavelengths are
filtered out in the stratosphere. UVA wavelengths are commonly
described as the photo-damaging rays, while UVB wavelengths are
notorious for causing sunburns. To review, sun protection factor
(SPF) refers to protection from UVB radiation. The higher the SPF,
the greater the UVB radiation needed to develop the minimum
erythema dose (MED) after adequate sunscreen application. SPF
30 stops (1 ï 1/30) ð 100 approximately 97 of UVB rays, while
SPF 50 blocks (1 ï 1/50) ð 100 98 of UVB rays.
There are two broad categories of sunscreens³chemical and
physical³which differ in how they process UV light. Chemical
sunscreens work by absorbing the UV radiation and release it as
heat, while the majority of physical sunscreens instead reflect the
UV light. Chemical sunscreens commonly consist of compounds
such as octocrylene, octisalate, octinoxate, avobenzone, and
homosalate. Physical sunscreens most commonly consist of zinc
oxide or titanium dioxide. Chemical sunscreens vary in their
UV radiation coverage, specifically targeting UVA, UVB, or broad
spectrum (UVA/UVB) filters. Chemical sunscreens are more
common for causing contact and irritant dermatitis, particularly
in patients with rosacea and atopic dermatitis. For patients with
various contact allergies or sensitive skin, it might be beneficial to
recommend a physical blocker. Physical sunscreens are primarily
better tolerated by patients, with a decrease incidence of reported
sensations such as burning, stinging, erythema, or contact derma-
titis. However, physical sunscreens are often reported as thicker
by patients and noted to leave visible residue when used in excess,
so compliance can suffer as a result.
During patient counseling, review recommended practices with
your patient, including when to apply sunscreen, how often to
reapply, and key words when searching for a product. It is crucial
for your patient to understand the importance of daily sunscreen
use with SPF 30 or higher. Sunscreens should be applied at least
15 minutes prior to sun exposure, with reapplication every 2
hours at baseline, and every hour when in water or excessively
sweating. Sunscreens should generally be water resistant and
should be broad spectrum in coverage, meaning that they protect
against both UVA and UVB exposure. It is also relevant to mention
that although many makeup products have SPFs, it is important
to wear a sunscreen on its own, over other steps in the skin care
regimen but under makeup. To reiterate, the best sunscreen for
your patients is a sunscreen they are willing to consistently and
appropriately apply.
Vitamin C
Vitamin C, also known as ascorbic acid or ascorbate, is a
water-soluble compound with major antioxidant and free radi-
cal scavenging properties that play a vital role in defending the
skin, cell membranes, and D1A from oxidative and free radical
damage. Previous studies report that vitamin C can reduce the
skin’s malondialdehyde concentration, a marker of oxidative
stress. Vitamin C is an electron donor and a vital cofactor in col-
lagen hydroxylation, which supports the growth of intracellular
and extracellular collagen production. Most recently, studies
have reported that vitamin C is able to decrease UVB-induced
oxidative damage and UV radiation–induced skin neoplasms in
mice. Studies also note that vitamin C is capable of protecting
keratinocytes from UVA-induced lipid peroxidation. Topical
vitamin C agents, such as products containing 5 to 20 ascorbic
acid, have been reported to improve pigment and are commonly
a part of a daily regimen for their skin-brightening effects.
For ascorbic acid to be stable, it has to be kept at an acidic pH,
which encourages a greater potential for skin irritation, espe-
cially if other topical products are used in addition to vitamin C.
Derivatives of ascorbic acid, including tetrahexyldecyl ascorbate
(fat-soluble), magnesium ascorbyl phosphate (water-soluble), and
ascorbyl palmitate (fat-soluble), are stable at neutral pHs and are
better tolerated by patients.
Vitamin C must be ingested by humans or applied topically. In
vivo, vitamin C is oxidized to dehydroxyascorbic acid, which is
then transported into cells by glucose transporters. Once inside
the cell, dehydroxyascorbic acid is reduced to ascorbic acid and
so can be used by the cell. Oral vitamin C supplementation has
been proven to be effective in increasing skin and plasma content.
:ell-known dietary sources of vitamin C consist of fruits such as
strawberries, oranges, and grapefruits as well as vegetables such
as Brussels sprouts, broccoli, and peppers. RDA for oral vitamin C
is 90 mg/day for men and 75 mg/day for women.
Vitamin E
Vitamin E is a fat-soluble compound that is most commonly
found as alpha-tocopherol (dzT), which is its biologically active
form in human metabolism. dzT defends against UVB damage by
inhibiting the formation of reactive oxygen species and free rad-
icals, which in turn stabilizes the membranes of cells, decreasing
the amount of apoptotic cells. UV radiation counteracts vitamin
E by decreasing the dzT concentration in the skin when exposed.
Vitamin E, along with vitamin C, has been shown to increase
the MED when taken orally. Oral supplementation of vitamin
E is most popularly found in nuts and seeds such as peanuts,
almonds, walnuts, pistachios, and sunflower and sesame seeds.
The RDA is 15 mg/day orally for men and women.
Zinc
=inc is an essential mineral and cofactor that serves to defend
against lipid peroxidation, UV-induced cytotoxicity, and oxi-
dative stress. The highest concentrations of zinc in the skin are
found within the epidermis, as zinc supports keratinocyte differ-
entiation and epidermal proliferation. Of note, zinc is involved in
wound healing and has anti-inflammatory properties by decreas-
ing proinflammatory markers within keratinocytes as well as
nitric oxide. Topical zinc is noted to support re-epithelization
by activating matrix metallopeptidases (MMPs), which prompts
keratinocyte migration. Proteins such as red meat and seafood,
whole grains, and fortified foods are rich in zinc. The RDA for
oral zinc is 11 mg/day for men and 8 mg/day for women. For the

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purposes of wound healing specifically, suggested daily supple-
mentation is 15 to 30 mg/day.
Selenium
Selenium is an essential mineral that most commonly exists as
selenomethionine in humans. Selenium assists enzymes: gluta-
thione peroxidases and thioredoxin reductases. Through these
reactions, harmful by-products such as lipid hydroperoxides,
hydrogen peroxide, and peroxynitrite are removed, which pro-
tects against oxidative damage to D1A and enhances cell mem-
brane stabilization through D1A synthesis and repair. Foods rich
in selenium are meat and seafood. The RDA of oral selenium is 55
mcg/day for men and women.
N-Acetylcysteine
1-Acetylcysteine is a crucial amino acid that acts as a precursor
for glutathione. Glutathione serves as the major endogenous
intracellular antioxidant in the body. As we age, the synthesis of
glutathione production slows, which poses the risk of increased
oxidative stress, leading to oxidative stress and ultimately aging.
A previous study evaluated the significance of cysteine and
glycine oral supplementation. The study reported that prior to
supplementation, older individuals were found to have signifi-
cantly lower levels of intracellular glutathione than younger
individuals. The subjects were evaluated 2 weeks after taking
daily oral supplementation and found to have a significant
increase in concentrations of red blood cell glycine, cysteine, and
glutathione. They also reported a decrease in oxidative stress
and oxidative damage. Various studies have suggested ranges
from 1,000 mg to 3,000 mg orally a day.
N-Acetylglucosamine
1-acetylglucosamine (1AG) is another vital amino acid, serving
as the precursor to hyaluronic acid. It has multiple crucial roles
in the human body, one of which is its role in the skin. 1AG is
reported to have properties in the skin such as aiding in wound
healing, increasing hydration of the skin, improving fine lines and
wrinkles, reducing dyspigmentation, and stabilizing structural
integrity of the skin. Further studies are needed for oral supple-
mentation recommendations. Topical products containing 1AG
have been found to improve pigmentation as well as strengthen
the dermal–epidermal junction.
Carotenoids (Beta-Carotene, Lutein,
Zeaxanthin, Lycopene)
Carotenoids are fat-soluble plant pigments that mammals are
unable to synthesize, so that humans must consume them by a
well-balanced diet or through supplementation. Carotenoids are
known for scavenging reactive oxygen species, which defends
the skin against oxidative stress. Oxidative stress and UV
exposure cause a decrease in carotenoid concentrations in the
skin. Beta-carotene, lycopene, lutein, and zeaxanthin are four
common dietary carotenoids.
Beta-carotene increases the MED, protecting against sunburn and
photosuppression of the immune system. It also serves by halting
free radical and singlet oxygen–induced lipid peroxidation, thus
defending against cell damage. Green leafy vegetables and yellow
and orange fruits are packed with beta-carotene. Beta-carotene
gives rise to vitamin A. The RDA of dietary all-trans-beta-carotene
is 10,800 mcg/day for men and 8,400 mcg/day for women. The
RDA for oral supplemental all-trans-beta-carotene is 1,800 mcg/
day for men and 1,400 mcg/day for women.
Lutein and zeaxanthin are carotenoids found in the skin working
as antioxidants against free radical damage and protecting against
UV radiation damage. Studies report that both lutein and zeaxan-
thin increase the mean MED, inhibit MMPs (which slows ECM
degradation), decrease lipid peroxidation, defend keratinocytes
from UV photoaging, and improve skin tone, luminance, and color.
Both oral supplementation and topical application have been
studied to show these skin effects. Eggs, green leafy vegetables,
and oral supplements are required in adequate amounts, as the
body cannot endogenously produce lutein and zeaxanthin. Studies
suggest 2 mg/day of zeaxanthin and 6 to 10 mg/day of lutein.
Lycopene is the last major carotenoid we mention. It serves
a crucial role as a singlet oxygen quencher, which decreases
UV-induced erythema, and slows the breakdown of collagen by
inhibiting the activity of MMP-1. It has been shown to decrease
the severity of skin roughness when greater amounts are found
in the skin. There is no RDA for lycopene; however, foods with
higher levels of the carotenoid include tomatoes, watermelons,
and grapefruits.
13.2.5 Collagen and Dermal Repair
Collagen and dermal repair has been a huge focus as of late.
Various cosmeceuticals and oral nutraceuticals fall into this
category that have already been discussed elsewhere. Peptides,
growth factors, collagen supplements, retinoids, vitamins, and
minerals are promoted for their rejuvenation properties.
Peptides
Peptides, which are short-chain sequences of amino acids, are
capable of encouraging the production of collagen, increasing
skin hydration, and lessening skin wrinkling through various
mechanisms depending on the specific type of peptide contained
in the product. Signal peptides exhibit their effects by enhanc-
ing new collagen production and inhibiting the destruction of
existing collagen. 1europeptides work by specifically targeting
different aspects of the neuromuscular junction (1M-), which
clinically results in improvement in fine lines and wrinkles, as
they lessen the contractions of facial muscles. Finally, carrier
peptides play a role in collagen regeneration and wound healing
by stabilizing and delivering known essential elements, such as
copper, to the skin. Cosmeceutical peptides are recommended
in addition to topical retinoids. Topical peptides are especially
recommended after procedures to help further increase collagen
production with lasting results. These peptides are applied daily,
along with sunscreen if used in the morning, or with retinoids if
applied at night.
Copper
Copper is an essential trace mineral that has many roles in
the human body. Copper is vital in the proliferation of dermal

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fibroblasts, stimulating the production of collagen and elastin by
fibroblasts. It maintains collagen-crosslinking properties, serv-
ing a vital role in collagen building and wound repair by enhanc-
ing fibroblast and keratinocyte production. It also functions as
a cofactor with lysyl oxidase and tyrosinase during enzymatic
reactions. During the lysyl oxidase enzymatic reaction, collagen
is crosslinked, which is necessary for building and maintaining
the ECM. Copper also has antioxidant properties, serving as a
cofactor in antioxidant reactions protecting against free-radical
production, lipid peroxidation, and membrane damage. Among
these roles, copper’s wound-healing properties (by enhancing
angiogenesis and promoting and stabilizing the skin’s ECM)
prove to be most key when focusing on postprocedure scar
prevention/reduction. Topical copper is also reported to have
anti-inflammatory and antibacterial properties, which help in
wound healing in damaged skin. Meat, seafood, grains, nuts, and
seeds are popular dietary sources of copper. :hen consumed
orally, the RDA is 900 mcg/day for men and women.
13.2.6 Pigment Reduction
Heterogeneous skin pigmentation is undesired by the aesthetic
patient, as it is a primary sign of aging skin and skin damage.
Pigment reduction is a common request, whether the patient is
postprocedure, post-trauma, or has accumulations of unwanted
melanin from factors such as chronic UV radiation exposure or
hormonal/pharmacologic causes.
Pigment-modifying products are successful in reducing melanin
production by inhibiting the main enzyme, tyrosinase, respon-
sible for creating pigment. There are multiple mechanisms by
which pigment reduction can be accomplished, including simply
inhibiting tyrosinase from working, inhibiting the production of
the enzyme itself, reducing the transfer of melanin from mela-
nosomes to keratinocytes, or interrupting any part of the process
that assists in melanogenesis. Regardless of the pigment-reducing
product used, it is key to inform patients that multiple treatment
types may be needed and to inform patients of the consequences
of re-exposure to the underlying cause of pigment production.
Often patients who are continuously exposed to UV radiation will
exhibit repigmentation after treatment, as UV light is a known
stimulator of melanogenesis. Broad-spectrum UV protection is
crucial for many reasons, this being one of them. There are oral
and topical products available to modify pigment, including AHAs
and BHAs, kojic acid, vitamin C, vitamin E, niacinamide (vitamin
B3), hydroquinone (H4), oral tranexamic acid (TXA), azelaic acid,
polyphenols, and fatty acids. Here we will review a few of the
most common products that have not been mentioned previously.
Kojic Acid
.ojic acid is a hydrophilic product that is derivative of various
fungi. It limits melanin production by inhibiting the binding
of copper to tyrosinase. .ojic acid is commonly found in OTC
skin-lightening lotions, creams, serums, and pads.
Niacinamide
1iacinamide, vitamin B3, is a water-soluble vitamin that
inhibits the transfer of melanin to keratinocytes. Previous
studies reported that niacinamide also supports skin hydration,
decreases transepidermal water loss, increases skin elasticity,
softens fine lines and wrinkles, and improves the appearance of
hyperpigmented macules.
Hydroquinone
H4 inhibits the production of pigment, melanogenesis, by inhib-
iting tyrosinase and is reported to have melanocyte cytotoxic
effects. As mentioned previously, tyrosinase is the main enzyme
responsible for creating pigment. Hydroquinone remains the
topical gold standard for pigment reduction. The amount of the
active component in a product typically ranges from 2 to 4 but
can be as high as 8 in some agents. Recent studies have shown
no significant benefit in percentages greater than 2 to 4 H4. H4
can cause skin irritation and postinflammatory hyperpigmenta-
tion at higher doses, so it is commonly compounded with topical
steroids. Improvement in pigment is commonly seen between 4
and 6 weeks, with reports of stabilizing results in 3 to 4 months.
However, newer products on the market are promoting H4 skin
brighteners that can be used year-round. It is recommended that
patients use the skin-brightening product twice daily for best
results.
Oral Tranexamic Acid
TXA is an oral agent used for pigment reduction. In 1979, Sadako
reported the use of TXA for melasma. TXA works by inhibiting
tyrosinase activity through various mechanisms involving
the plasminogen/plasmin conversion and interaction between
keratinocytes and melanocytes. Suggested dosing for treating
melasma ranges from 250 mg twice daily to 1,500 mg daily for 8
to 12 weeks. Caution must be exercised in patients with a history
of blood clots.
13.2.7 ,nÁDmmDWiRn 5edneVV Dnd
Scar Reduction
:hether a patient is postprocedure or dealing with inflamma-
tion and redness from other etiologies, there are multiple oral
and topical products to recommend. These products commonly
have antioxidant and anti-inflammatory properties while also
hydrating the skin. Commonly recommended products that
assist in lowering the erythema and inflammation include oral
and topical vitamin C, oral and topical vitamin E, hyaluronic
acid (humectant), ceramides, niacinamide (vitamin B3), and oral
and topical polyphenols. Vitamin C, vitamin E, and hyaluronic
acid have been mentioned previously. Here we discuss some in
further detail.
Topical and Oral Polyphenols
Polyphenols, such as curcumin and epigallocatechin gallate
(EGCG), are secondary metabolites of plants with reported
anti-inflammatory, antioxidant, and anticarcinogenic proper-
ties. Curcumin is a chemical compound found in the turmeric
spice. Curcumin is well known for its anti-inflammatory proper-
ties by hindering proinflammatory cytokines (prostaglandin E2,
interleukins 6 and 12, MMPs, tumor necrosis factor–alpha, and

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117
cyclooxygenase >COX@-2). Curcumin is also capable of hindering
lipid peroxidation, reducing reactive oxygen species (ROS)
production, scavenging free oxygen radicals, and diminishing
c-reactive protein levels, which highlight curcumin’s antioxidant
abilities. Reported studies suggest 2 to 8 g/kg daily for oral sup-
plementation of curcumin.
EGCG is found in green tea and is reported to be the most
potent tea polyphenol. EGCG and other tea polyphenols have
anti-inflammatory and antioxidant properties. ECGC also has
the ability to hinder proinflammatory cytokines, similarly to
curcumin. ECGC is able to reduce the amount of UV radiation–
induced D1A damage, minimize the amount of ROS and free radi-
cals produced, and hinder lipid peroxidation in the skin. EGCG has
effect both topically and orally. Topically, ECGC has been shown
to decrease erythema and edema induced by UV radiation. It has
also been reported to decrease UV-induced skin tumors in mice.
Recent publications support 300 mg/day of oral EGCG is tolerated.
Licorice Extract
Licorice extract, also known as licochalcone A, exhibits
anti-inflammatory and antierythema properties by indirectly
inhibiting COX and lipoxygenase pathways, reducing UV-induced
erythema, and decreasing the production of proinflammatory
cytokines released by keratinocytes. Topical products containing
licorice extract can be applied daily.
Oatmeal
Colloidal oatmeal is one of the most common ingredients found
in OTC products targeted to help relieve inflammatory skin con-
ditions such as atopic and contact dermatitis. One of the main
components contributing it its anti-inflammatory properties is
the dietary component, beta-glucan. It is found in many OTC
cleansers and moisturizers thanks to its anti-inflammatory and
soothing properties. Beta-glucan has also been studied and found
to have wound-healing properties both topically and orally.
Previous studies note that beta-glucan supports wound repair
by encouraging wound growth factors released by macrophages,
which stimulate fibroblast and collagen activity. :hen focusing
on wound-healing properties, a previous study suggested that
topical beta-glucan be applied twice daily or 50 mg/kg/day when
supplemented orally. Topical oatmeal is suggested to be applied
at least twice daily to help relieve inflammation.
13.3 Concluding Thoughts
In this chapter, we reviewed many OTC cosmeceuticals and oral
nutraceuticals that play a role in a comprehensive skin care regi-
men for the aesthetic patient. As the skin is constantly challenged
by many internal and external influences, it is important to discuss
and recommend the vital components of daily proper skin care.
Many of the cosmeceuticals and oral nutraceuticals mentioned in
this chapter play multiple roles in skin care. :hether addressing
a specific concern, tailoring for a procedure, or creating a daily
routine, the OTC cosmeceuticals and oral nutraceuticals discussed
in this chapter all play a role in a comprehensive skin care regimen
and can be applied to any aesthetic patient. It ultimately is the
responsibility of the aesthetic surgeon to recommend a regimen
based on clinical judgment and expertise.
Clinical Caveats
• Every aesthetic patient should be educated on and recom-
mended a comprehensive daily skin care regimen.
• Every patient should be educated on the importance of daily
sun safety precautions and be knowledgeable about proper
SPF use.
• It is beneficial to have products available in the office for
purchase or a suggested product list with retailers so that
patients can purchase from verified sources.
• It is helpful to give written instructions for a daily regimen to
ensure proper compliance.
Suggested Reading
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14 A SFienWiÀF ASSrRDFK WR &RVmeFeuWiFDOV
Leslie Baumann
Abstract
A scientifically validated approach to diagnose skin phenotype
and customize a targeted skin care regimen to patients is critical
to enhancing skin health. Once an efficacious skin care regimen
has been developed, the physician must communicate the plan
to patients and encourage them to follow it. To match products
properly to patients, and to educate and encourage them to use
the products, it is critical to enlist the help of staff members to
improve efficiency and engagement with patients. A method-
ology to educate staff and patients in a systematic manner is
essential so that patients are given the correct products, told
how and encouraged to use them, and reminded periodically
to stay on the prescribed regimens. This chapter discusses the
science behind a skin typing system known as the Skin Type
Solutions (STS) system, which was developed to streamline the
cosmeceutical recommendation process in a brand-agnostic
manner, enabling physicians to choose what products or brands
they want to retail in their practice and prescribe them using
a scientific method designed to improve outcomes. The STS
system assesses skin based on four primary barriers to skin
health: dehydration, inflammation, dyspigmentation, and skin
aging. Evaluating the presence or absence of these barriers to
skin health in facial skin provides the physician with data to
diagnose the patient as having one of 16 Baumann Skin Types, for
which proper cosmeceutical ingredients can then be prescribed.
The patient’s Baumann Skin Type (BST) is diagnosed using a
customized, expert skin care diagnostic system that diagnoses
the skin type and automatically generates a skin care regimen
that contains ingredients beneficial to that skin type and does
not contain ingredients harmful to that skin type. The STS
system assists physicians in selecting skin care products in an
unbiased, ethical, and methodical way to improve personalized
care for patients. Appropriate use of the system can enhance staff
training and doctor–patient communications, as well as patient
education, compliance, and outcomes. This chapter will discuss
the science of the skin issues that need to be considered when
developing a skin care regimen: sebum production, skin barrier,
presence of inflammation, melanocyte activity, and the presence
of lifestyle habits that lead to skin aging.
Keywords
Skin Type Solutions System, barriers to skin health, Baumann
Skin Type, cosmeceutical, skin aging, skin lightening, skin reju-
venation, sensitive skin, compliance, outcomes, staff training,
antiaging, antioxidants, anti-inflammatory, tyrosinase inhibi-
tors, regimen, skin care
14.1 Introduction
To achieve and maintain skin health, consistent daily use of a
skin care regimen ideally suited to an individual’s skin is critical.
Pre- and postprocedure skin care regimens customized specifi-
cally for the patient’s skin type and procedure type will improve
outcomes if the patient is compliant with the directions. It is a
challenge for practitioners to stay up to date on cosmetic science
and to communicate current knowledge to their staff, who are a
vital part of the skin care recommendation process. Establishing
a standard approach or methodology for prescribing skin care
products yields consistency in patient recommendations and
provides a scientific methodology for the staff to follow while
promoting patient education, engagement, and compliance.
Diagnosing a patient’s skin type is the key first step in prescrib-
ing an ideally suited skin care regimen. The Skin Type Solutions
(STS) system, developed by the author to address the essential fea-
tures of the skin, employs a validated questionnaire for patients.
This allows practitioners to diagnose patients as having one of 16
Baumann Skin Types (BSTs).
The STS system evaluates skin according to four spectra or
barriers to skin health:
1. Dehydration (oily >O@ vs. dry >D@)
2. Inflammation (sensitive >S@ vs. resistant >R@)
3. Dyspigmentation (pigmented >P@ vs. nonpigmented >1@)
4. Skin aging (wrinkle-prone >:@ vs. unwrinkled or tight >T@)
A validated questionnaire identifies skin phenotype based on these
four parameters, allowing 16 different skin types, each represented
by a four-letter designation as well as color and number designations
to help patients remember their BST (Fig. 14.1; Fig. 14.2). For exam-
ple, an individual with dry skin, redness, even skin tone, and fine
lines would be assigned as a DS1: (Dry, Sensitive, 1onpigmented,
:rinkle-prone) type, or BST number 4 with a light pink color code.
Multiple forms of labeling are used because studies have demon-
strated that some patients primarily remember the number of their
skin type, while others primarily remember the color, and yet others
the four-letter designation. This skin-typing system facilitates com-
munication between physicians and patients as well as the process
of prescribing the optimal products for a patient’s skin type.
The BST should be diagnosed at least once a year because the skin
type can change based on numerous factors, such as climate, lifestyle
habits, hormone status, pregnancy, medication use, sun exposure,
smoking, and other factors. At each visit the patient’s skin type and
regimen should be evaluated and updated according to the presence
or absence of the four barriers to skin health. This chapter will proceed
with a discussion of diagnosing skin type based on the BST, matching
product ingredients to skin type, and designing a corresponding skin
care regimen. The focus will shift then to the science of skin aging and
pigmentation as well as the cosmeceutical ingredients best suited to
treat these conditions, along with the formulations appropriate for
treating the skin before, during, and after cosmetic procedures.

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III 1RnVurgiFDO &RVmeWiF 7reDWmenWV
14.2 Diagnosing Skin Types
The 16 BSTs are based on the presence or absence of these
primary barriers to skin health: dehydration, infl ammation,
dyspigmentation, and skin aging. The patient is assigned a
designation for each of the skin status parameters or barriers: O
(oily) or D (dry), S (sensitive) or R (resistant), P (pigmented) or 1
(nonpigmented), and : (wrinkled) or T (tight), with 16 diff erent
combinations possible. There are also four subtypes of sensitive
skin: acne, rosacea, burning and stinging, and susceptibility to
contact and irritant dermatitis.
14.3 Matching Ingredients to
Skin Type
Each of the following factors should be considered when choos-
ing ingredients by facial skin type.
14.3.1 Oily Skin
Individuals with oily skin (O) produce an adequate or elevated
level of skin sebum. Sebum functions as an occlusive that helps
the skin hold on to water, which can compensate for an under-
lying barrier impairment. For this reason, patients with an
adequate or excessive amount of sebum do not have decreased
amounts of water in the epidermis (i.e., dry skin). An ´oilyµ
skin type is desirable because of the protective eff ects that
sebum has on the skin, including hydrating and antioxidant
properties.
Products These Patients Should Use
Salicylic Acid
This lipophilic compound can penetrate into the pores to
facilitate desquamation of the stratum corneum (SC), thus
preventing the clogging of pores and the development of come-
dones (blackheads or whiteheads) and acne. This member in the
salicylate (aspirin) family also confers anti-infl ammatory activ-
ity. Cleansers containing salicylic acid are ideal for acne-prone
individuals with oily skin. Such cleansers should be formulated
at a pH of less than 2.97 to be eff ective.
Foaming Cleansers
Anionic surface-acting agents (surfactants or detergents) pro-
duce foam and display the greatest ability among cleansers to
remove oil, sunscreen, and debris. Only individuals with oily skin
types should use these products, which remove oil from the skin
and can be irritants to dry, sensitive skin types.
Retinoids
These vitamin A formulations can help keep pores clear by
regulating keratinization. Oral retinoids can reduce the size of
sebaceous glands, thus diminishing sebum production. Topical
retinoids are unlikely to aff ect the sebaceous glands directly but
are benefi cial in oily skin by preventing comedones.
Polymers
Skin appearance can be rendered less shiny through the use of
polymers, which surround or sequester oil. These are often called
´primers.µ Polymers should be rinsed off nightly to prevent the
development of comedones.
Products These Patients Should Avoid
Oils
Individuals with oily skin already have increased amounts of
lipids on the skin. They should avoid oils or heavy creams that
contain oils, which feel heavy and greasy on oily skin types. Oily
skin types can omit a moisturizer or choose a light moisturizer
with humectant ingredients instead of occlusive oils.
Comedogenic Ingredients
Oily skin types are more likely to develop comedones. Many
ingredients (Table 14.1) can contribute to comedoformation.
Major culprits include coconut oil, isopropyl myristate, and
isopropyl palmitate.
Silicone-Containing Moisturizers and Sunscreens
Silicones are often used to mask oil on the face but they can hold
sebum and debris in the pore, resulting in comedones. If silicones
are used on the face, they should be washed off at night.
Fig. 14.1 The 16 Baumann skin types. (This image is copyrighted by
Metabeauty Inc. and cannot be used without permission.)

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121
14.3.2 Dry Skin
Individuals with dry (xerotic) skin have an impaired skin barrier,
characterized by the absence of water in the epidermis. Cracks and
fissures appear in the skin when levels of water, the main plasticizer
for the skin, are low. The water content of the SC must surpass 10
for the skin to feel and appear normal. :hen a defect in the perme-
ability barrier of the skin permits excessive water to be lost to the
atmosphere, this rise in transepidermal water loss (TEWL) results
in dry skin. Genetic defects, harsh detergents, acetone, alcohol, and
frequent bathing in hot water are among the various factors that
can engender such barrier disturbance. As skin becomes too dry,
desquamating keratinocytes build up on the skin’s surface, making
it rough and unable to reflect light properly. It can become irritated,
inflamed, and itchy. The arms, legs, and torso, which contain rela-
tively few oil glands, are the most vulnerable to this condition.
Products These Patients Should Use
Nonfoaming Cleansers
1onfoaming cleansers, which were developed through attempts to
mitigate the irritancy of cleansers by adding secondary components,
are appropriate for patients with dry skin because these compounds
deposit lipids on the skin. Superfatted soaps, transparent soaps,
combination bars (combars), and syndet bars (bars composed of
synthetic surfactants) are the primary nonfoaming cleansers, which
have a neutral pH and include ingredients such as alkyl glyceryl ether
sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium
cocoyl monoglyceride sulfate, and sodium cocoyl isethionate.
Patients are increasingly concerned about the sourcing of products,
so it is important to assure them that organic nonfoaming agents
are also available, including saponins, a large family of plant-derived
structurally related substances, and sucrose laurate.
Hydroxyacid Cleansers
These versatile compounds exhibit humectant activities that help
hydrate the skin and are appropriate for individuals with dry
skin. Humectants are water-soluble materials with high water
absorption capacities. Hydroxyacids help to exfoliate dead skin
cells, which tend to amass on the surface of xerotic skin. Skin
appears more radiant when the skin surface is smooth. It is worth
noting that enzymes that help exfoliate do not work as well when
there is less water on the skin. However, the exfoliating activity
conferred by hydroxyacids allows better penetration into the SC
Fig. 14.2 (a) DRPW: This skin type is characterized by wrinkles, pigmentation and dry skin. (Photo credit El Nariz/Shutterstock.) (b) OSNT: This skin type
often occurs under the age of 30 and is characterized by increased sebum production and inflammation resulting in acne. (Photo credit Vladimir Gjorgiev/
Shutterstock.) (c) OSNW: This skin type has increased production of sebum and often cannot find a sunscreen that does not feel oily. Inflammation in this skin
type results in rosacea and an increased risk of aging. (Photo credit Lipowski Milan/Shutterstock.) (d) OSPW: This skin type is characterized by increased sebum
production. Inflammation and sun exposure has resulted in unwanted pigmentation and an increased risk for aging. (Photo credit Michael Jung/Shutterstock.)
b
d
a
c

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III Nonsurgical Cosmetic Treatments
by ingredients applied after the cleanser. These compounds are
also suitable for individuals with dry, acne-prone skin because
the low pH contributes to an inhospitable microbiome for
Propionibacterium acnes, rendering it difficult for the bacteria to
thrive.
Barrier Repair Ingredients
The topical application of ceramides, cholesterol, and fatty
acids³the main skin barrier lipid components³has long been
targeted as central to enhancing skin barrier function and
hydration. It is important to apply all three of these in a 1:1:1
ratio because an imbalanced ratio impairs the barrier. In 1993,
Man et al demonstrated that barrier recovery was delayed when
ceramide and fatty acid were applied without cholesterol. They
also showed that barrier repair was delayed with the application
of two other mixtures of cholesterol plus fatty acid or choles-
terol along with ceramide. Such incomplete mixtures generated
abnormal lamellar bodies, yielding abnormal SC intercellular
membrane bilayers. Conversely, complete blends of ceramide,
fatty acid, and cholesterol resulted in normal barrier recovery.
Additional studies have buttressed the importance of including
all three primary barrier repair ingredients in topical formula-
tions in a minimal ratio of 1:1:1. Investigations in young mice (
10 weeks) and humans (20–30 years of age) have revealed that
applying a mixture of cholesterol, ceramides, and essential/non-
essential free fatty acids (FFAs) in an equimolar ratio results in
normal barrier recovery, and application at a 3:1:1:1 ratio of these
four ingredients, with cholesterol dominant, accelerates barrier
recovery. Multilamellar emulsion (MLE) technology touting
the inclusion of type III synthetic ceramide or pseudoceramide
was established nearly 15 years ago as the foundation for such
innovative approaches to barrier repair. See Table 14.2 for a list
of fatty acid alcohols suitable for use by patients with dry skin.
Products These Patients Should Avoid
Foaming Cleansers
As noted previously, only individuals with oily skin types should
use these products.
Alcohols
These compounds dry skin out and injure the skin barrier (see
Table 14.3).
Table 14.1 Acne-causing ingredients to avoid for individuals with oily skin
Acetylated lanolin alcohol
Algin
Almond oil
Anhydrous lanolin
Arachidic acid
Ascorbyl palmitate
Azulene
Beeswax
Benzaldehyde
Benzoic acid
Beta-carotene
Beta-hydroxy acid
Bubussa oil
Butyl stearate
Butylated hydroxyanisole (BHA)
Cajeput oil
Calendula
Camphor
Capric acid
Carbomer 940
Carnauba wax
Carotene
Carrageenan
Castor oil
Ceteareth-20
Cetearyl alcohol
Cetyl acetate
Cetyl alcohol
Chaulomoogra oil
Cocoa butter
Coconut butter
Coconut oil
Colloidal sulfur
Corn oil
Cottonseed oil
D & C Red # 3
D & C Red # 4
D & C Red # 17
D & C Red # 19
D & C Red # 21
D & C Red # 27
D & C Red # 30
D & C Red # 36
D & C Red # 40
Decyl oleate
Dioctyl succinate
Disodium monooleamido
Emulsifying wax NF
Ethoxylated lanolin
Ethylhexyl palmitate
Evening primrose oil
Glyceryl-3-diisostearate
Hexadecyl alcohol
Hydrogenated castor oil
Hydrogenated vegetable oil
Hydroxypropylcellulose
Isocetyl alcohol
Isodecyl oleate
Isopropyl isostearate
Isopropyl lanolate
Isopropyl linoleate
Isopropyl myristate
Isopropyl palmitate
Isostearyl isostearate
Isostearyl neopentanoate
Laneth-10
Lanolin acid
Lanolin alcohol
Lanolin oil
Lanolin wax
Laureth-23
Laureth-4
Menthyl anthranilate
Mink oil
Myristic acid
Myristyl lactate
Octyl palmitate
Octyl stearate
Oleth-3
Oleth-10
Oleyl alcohol
Palmitic acid
Peach kernel oil
Peanut oil
PEG (polyethylene glycol) in:
• PEG 2 sulfosuccinate
• PEG 8 stearate
• PEG 16 lanolin
• PEG 100 distearate
• PEG 150 distearate
• PEG 200 dilaurate
• PEG 300
• PEG 400
Pentarythrital tetra isostearate
Propylene glycol (PG) in:
• PG caprylate/caprate
• PG dicaprylate/caprate
• PG dipelargonate
• PG monostearate
Polyglyceryl-3-diisostearate
Potassium chloride
PPG (polypropylene glycol) in:
• PPG 2 myristyl propionate
• PPG 5 ceteth-10 phosphate
Red algae
Sandalwood seed oil
Sesame oil
Shark liver oil
Solulan 1
Solulan 16
Sorbitan oleate
Soybean oil
Steareth-2
Steareth-10
Steareth-20
Stearyl heptanoate
Sulfated castor oil
Sulfated jojoba oil
Synthetic dyes (especially, D C Red 3,
4, 6, 7, 9, 17, 19, 21, 27, 30, 33, 36, 40),
Triethanolamine
Vitamin A palmitate
Wheat germ glyceride/oil
Xylene
Table 14.2 Fatty acid alcohols safe in dry skin
Cetearyl alcohol
Stearyl alcohol
Behenyl alcohol (docosanol)
Caprylic alcohol (1-octanol)
Cetearyl alcohol (very common)
Cetyl alcohol (very common)
Decyl alcohol (1-decanol)
Lauryl alcohol (dodecanol)
Myristyl alcohol (1-tetradecanol)
Isostearyl alcohol
Oleyl alcohol (octadecenol)
Table 14.3 Alcohols that individuals with dry skin should avoid
Isopropyl alcohol
Specially denatured (SD) alcohol
Denatured alcohol
Ethyl alcohol (ethanol)
Methyl alcohol (methanol)
Benzyl alcohol