Bad economy is making patients more cost-conscious, and plastic surgeons, the elite corps of lavishly compensated surgeons are going to unheard-of lengths to drum up business.

Some are sending out discount coupons and offering payment plans. Others are turning to less expensive and less invasive procedures. And all of them have to actually market their aesthetic practices.

After many years of steadily growing demand, spurred by increasingly higher standards of beauty, a  30% to 50% drop in the number of cosmetic procedures performed comes as a big surprise to many plastic and cosmetic surgeons. Many of them have boasted annual incomes in the seven-figure range. Dr. Mark Sultan, plastics chief at Beth Israel Medical Center, earned $4.1 million in 2006. That made him the second-highest-paid doctor on the payroll of any New York City hospital, according to a 2008 Crain’s Health Pulse survey of hospital salaries.

After seeing his cosmetic business shrivel by 20%, Dr. Steven Pearlman, who operates at Lenox Hill Hospital in New York says, “For the first time ever, I sent out “To my loyal patients’ discount cards”.

In a city that has long been driven by Wall Street money, Park Avenue facial specialist Dr. Yael Halaas has come up with a spiel that fits with that ethos. “We’re telling people it’s a great time to invest money in yourself [with cosmetic surgery],”she says.

Key Points

Photodynamic therapy (PDT) results in a five-fold increase in levels of Ki67
Baseline immunostaining for the tumor suppressor gene p53 may be a predictor of response to treatment
Utility of PDT for the treatment of dermatoheliosis and the changes of skin aging

National report — Photodynamic therapy (PDT) results in a fivefold increase in levels of Ki67, a protein important to the growth and development of new skin cells.

Information such as this, which quantifies our understanding of how PDT works, is crucial to optimizing treatment and advancing the field, says Jeffrey S. Orringer, M.D., director of the Cosmetic Dermatology & Laser Center, University of Michigan, Ann Arbor, Mich.

“Our study represents an attempt to quantify, on a molecular level, epidermal and dermal matrix changes following PDT,” Dr. Orringer says.

Dr. Hirsch believes the information can help clinicians better use the skin sensitizers and lasers that are currently available, and guide future developments in the field.

Trial parameters

The trial enrolled 25 patients who were generally healthy, had clinical evidence of significant photodamage, and had no history of significant cosmetic interventions at the site examined.

The study involved the use of the photosensitizer 5-aminolevulinic acid (5-ALA, Levulan) and a single-pass treatment with a pulsed dye laser.

While the majority of PDT procedures occur on the face, the forearm was used in the study, because baseline and multiple follow-up skin punch biopsies held a potential for scarring.

Study findings

In addition to the increase in Ki67, researchers found a 1.4-fold increase in epidermal thickness; a 70-fold increase from baseline in cytokeratin 16 levels; and significant upregulation of procollagen I messenger RNA (2.65-fold increase) and procollagen III messenger RNA (3.32-fold).

There also was a correlation between baseline p53 levels and subsequent production of cytokeratin 16 in response to therapy.

“Using the topical photosensitizer clearly gave us more consistent and quantitatively greater changes in the skin compared to historical studies using nonablative laser therapy alone.

“This tracks very nicely with the bulk of the clinical evidence in this field, including clinical split-face studies,” Dr. Orringer tells Dermatology Times.

Baseline immunostaining

Another interesting finding was that baseline immunostaining for the tumor suppressor gene p53 — an excellent indicator of the extent of photodamage — may be a predictor of response to treatment.

Baseline staining for p53 correlated with levels of cytokeratin 16 at acute time points after treatment, and this, in turn, was linked to collagen production.

“Patients with greater sun damage at baseline were more susceptible to a controlled injury from the treatment and, therefore, were able to produce more collagen in response to it.

“This implies that we may be able to get greater changes from this kind of a treatment among patients who have significant sun damage,” Dr. Orringer says.

Dose response curve

“In general, our working hypothesis is that the stronger the treatment applied to the skin, the more dermal remodeling one is likely to get out of it.

“While the concepts of less downtime and exceptionally safe treatments are terrific, we have to find that happy medium between keeping things convenient for patients and providing an intervention that is effective,” Dr. Orringer says.

Collagen production

Dr. Orringer believes that enhanced collagen production is a key response for durable improvement in photodamaged skin. He has found that the variability of response often depends on the degree of insult the procedure delivers to the skin.

“When we use ablative carbon dioxide laser resurfacing, the wound-healing responses are very highly organized, very consistent from patient to patient.

“At the opposite end of the spectrum, with very mild interventions like microdermabrasion or non-ablative laser treatments, some patients did very well and produced lots of collagen, and others had very little change at all,” he says.

Contact time

In the current study, Dr. Orringer says that the photosensitizer was left on for three hours “to ensure there was adequate absorption to allow for true photodynamic therapy effects, to be sure that we weren’t looking at changes that were the result of the laser therapy alone.”

He says the clinical trend toward significantly shorter contact time for photosensitizer application prior to use of the laser, for the convenience of the patients and flow of the office, “may not be optimal and is not necessarily based on molecular and cellular biology.

“It probably takes somewhat longer for the Levulan to be taken up by cells than most practitioners allow the material to remain on the skin prior to treatment. I’m not sure that clinicians are always taking full advantages of the PDT effect.”

Ongoing research

Ongoing research includes looking at evolving fractionated laser technologies and minimally ablative technologies, “to see what type of dermal changes, if any, we can create by simply disturbing the epidermis,” Dr. Orringer says.

“We think that we are developing a working molecular model that may one day be used to predict the clinical value of new technologies as they arise,” Dr. Orringer says.

Confirmation

“It certainly is exciting to get molecular data that confirms anecdotal and clinical study evidence of the utility of PDT for the treatment of dermatoheliosis and the changes of skin aging,” says Ranella J. Hirsch, M.D., president of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

“A significant next step for this line of research would be experimentation with alternative incubations to see what the molecular findings are with each,” she says.

For more information: Orringer JS, Hammerberg C, Hamilton T, Johnson TM, Kang S, Sachs DL, Fisher G, Voorhees JJ. Molecular effects of photodynamic therapy for photoaging. Arch Dermatol. 2008 Oct;144(10):1296-302. PMID: 18936392

weathering-the-storm

Cosmetic facial surgeon Joseph Niamtu, III, D.M.D., F.A.A.C.S. says there are several things that cosmetic surgeons can do to ride out this economic storm.

An evaluation of the efficacy of a 1064-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser using lower than traditional fluences (22-40 J/cm2) for treatment of pseudofolliculitis barbae (PFB) was completed by the Dermatology Department of the Naval Medical Center San Diego, San Diego, California.

Twenty-two (22) patients with PFB refractory to conservative therapy received five weekly treatments over the anterior neck using a 1064-nm Nd:YAG laser at 12 J/cm2. Pulse duration was 20 ms with 10 mm spot size. Topical anesthesia was not used. Treatments were completed 15 minutes after patient arrival. Patients presented for 2- and 4-week follow-up. Ten evaluators used a Global Assessment Scale (GAS) to assess dyspigmentation, papule counts, and cobblestoning by comparing baseline to 4-week follow-up visit photographs. Hair and papule counts were performed on five patients and compared with the GAS. Investigators recorded adverse effects using a visual analog and side effects scale.

RESULTS

Eleven (11) patients demonstrated 83% improvement on the GAS (p<.01). There was a mean reduction of 59.5% in dyspigmentation (p<.03), 91.2% in papule count (p<.01), and 75.6% in cobblestoning (p<.02). Patients reported 1 out of 10 on both adverse effects scales.

CONCLUSION

Low-fluence 1064-nm laser treatment achieved significant temporary reduction in PFB. Subjects noted minimal pain without topical anesthesia.

Source: Dermatologic Surgery, Volume 35, Number 1, January 2009 , pp. 98-107(10)

People are cutting back on cosmetic surgery and other elective surgeries in response to the dismal economy, reversing the booming popularity of tummy tucks, eye lifts, and breast implants, which have soared in popularity in recent years, particularly among the middle class.

When polled in October, 62 percent of members of the American Society of Plastic Surgeons said their business was down 20 percent or more from the year before. “I expect it’s more than that in some areas, a 40 or 50 percent decrease,” says Michael McGuire, president-elect of the ASPS. That’s particularly true in areas like New York, California, and Florida, which led the surge in popularity. A small survey by the society in October found that 60 percent of respondents said the economy had had an impact on their plans for cosmetic surgery. That’s not surprising, given that cosmetic procedures aren’t covered by insurance.

People may be shunning surgery not only because of the cost but because of the downtime for recovery. “Now, you just even don’t want to take the time off [from work],” says Alan Gold, president of the American Society of Aesthetic and Plastic Surgeons, a group of doctors who specialize in cosmetic surgery.

The demand may be deferred, not denied. Alan Gold, who says he saw a similar downturn after 9/11, predicts that business will revive with the economy. Those who desire cosmetic procedures “are people who are concerned about their appearance or are concerned about age-related changes,” he says. “They may defer that desire, but the desire isn’t lost.”

As a contrast to the surgery statistics, it appears that non-invasive treatments, like injectables and laser rejuvenation, are still on the rise. Hair removal and photorejuvenation are value offers for consumers. In most cases these procedures are cheaper than Botox but may provide a much longer lasting result with no downtime.

Mongolian spots are congenital hyperpigmented areas of varying size and shape and are usually confluent grayish-blue in color. They are found most frequently in the sacral region and typically disappear during childhood. Occasionally, they persist to adulthood.

The use of Q-switched alexandrite laser treatments for Mongolian spots and examinaton of the therapeutic outcomes of 26 Japanese patients with Mongolian spots was reported in the Dermatologic Surgery, Volume 34, Number 12, December 2008 , pp. 1689-1694(6).

RESULTS

A good therapeutic outcome was achieved overall, but some adult female patients subsequently developed severe postinflammatory hyperpigmentation. Sacral Mongolian spots were more laser-resistant than extrasacral Mongolian spots.

CONCLUSION

The outcome correlated with the age of patients at the initiation of treatment; therefore, sacral and extrasacral Mongolian spots should be treated before 20 years of age. To avoid severe postinflammatory hyperpigmentation, the optimal interval between laser treatments and the use of other treatment modalities including Q-switched ruby laser, Q-switched neodymium-doped yttrium aluminium garnet (Nd:YAG) laser, or bleaching creams should be considered.