INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE

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May/June 2014

Volume 2 ❙ Issue 3

Colour Cosmetics ❚ HIPAA Compliance ❚ ISAPS-LEAP Foundation ❚ Facial Rejuvenation

May/Ju

ne 20

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e 2 ❙ Issue 3

ROBOTIC TECHNOLOGY

AND AESTHETIC MEDICINE

TELOMERESAGEING AND LONGEVITY

UPPER BLEPHAROPLASTY

AND BROWPEXYTREATMENT OPTIONS

HAIRRESTORATION

Surgical and non-surgical options

MULTI-SPECIALTY EDUCATION SEEMS TO BE A NEW BUZZWORD ASSOCIATED with many conferences around the world. As the original multi‑specialty symposium in the aesthetic market, those of us responsible for the Vegas Cosmetic Surgery Symposium are very proud to have had a role in changing the educational paradigm within our specialty. As evidence of this changing paradigm, this event has quickly grown to be the largest ‘independent’ aesthetic

conference in North America, annually attracting well over 1500 attendees and proving that there is a place for independent meetings that offer a high‑end educational product devoid of excessive industry influence.

Our goal from the very beginning has been to build educational bridges between what many consider the four core specialties associated with aesthetic surgery and medicine — aesthetic dermatology, facial plastic surgery, plastic surgery, and oculoplastic surgery. No other meeting has at its core a mission to gather the world’s leading experts from each of these fields and allow them to exchange ideas with one another.

The thing that I am most proud of when I reflect on the past 10 years is that we have encouraged other meetings to look at our model and many have even adopted some of the things we have tried to do over the past decade, including the recognition of the importance of the business aspects of our specialty. Vegas Cosmetic Surgery continues to feature a 4‑day track on the management and marketing aspects of aesthetic medicine and surgery. The word ‘trade show’ has never defined Vegas Cosmetic Surgery. This is an educational symposium in every sense of the word.

So what does all of this mean for our specialty and our patients? In my mind, our patients are the real beneficiaries of this level of cooperation among the core specialists. Our specialties also benefit from this cooperation as more and more barriers are broken down and cooperation among the societies continues to increase and strengthen. In fact, the Physicians Aesthetic Coalition was organised by Dr Renato Saltz and some of his courageous colleagues as a means of communication among the leaders of the four core specialties. This group has been meeting each year at the Las Vegas meeting in an attempt to enhance communication and cooperation on a myriad of issues that affect our specialties, our practices, and our patients.

A number of years ago I was asked to join the editorial board of PRIME as they launched the premier North American edition of this peer‑reviewed journal. I took a look at what they were already doing in Europe and commented on the quality of the publication in both content and style. It also did not escape my attention that the world’s leading publisher was behind this endeavour. So accepting this invitation was easy, as this journal was a reflection of all of the things that we were in fact doing in Las Vegas.

Clearly after 10 years some of our goals have been achieved and others are within reach, but there is still much left to accomplish. As we consider our next 10 years it is my hope that we can expand and become more of an advocate for our patients and the public in general. The confusion they now face when trying to decide on the legitimacy of a procedure and a provider for this procedure is well known, and we as the providers can no longer rely on the medical boards and the regulatory agencies to sort all of this out for them. We must develop close ties with our media partners, industry supporters and the lay media, and continue to find additional ways for our societies to work together to maintain our high ethical standards and help educate a very confused public.

prime-journal.com | May/June 2014 ❚ 5

| GUEST EDITORIAL

Dr S. Randolph WaldmanFacial Plastic Surgeon, Kentucky

International Journal of Aesthetic and Anti-Ageing MedicineInforma, Christchurch Court, 10–15 Newgate Street, London, EC1A 7AZ, UKwww.prime-journal.comISSN 2325-9817 (print)ISSN 2325-9825 (online)

Managing Editor Rosalind Hill rosalind.hill@informa.com

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Please send your manuscripts and press releases to: rosalind.hill@informa.com

All submitted manuscripts are evaluated on the basis of scientific quality, originality, appropriateness, contribution to the field and style. Suitable manuscripts are subject to peer-review. Manuscripts and accompanying files should be prepared in accordance with our Author Guidelines, which are available via www.prime-journal.com. All content © 2014 Informa UK Ltd

Images © Shutterstock.com, unless otherwise stated

PRIME® (ISSN 2325-9817) is published bi-monthly by Informa, 52 Vanderbilt Avenue, New York, NY 10017. Application to mail Periodicals postage rate is pending at New York, NY, and additional mailing offices. POSTMASTER: Send address changes to PRIME, PO Box 1170, Skokie, IL 60076

BOARD MEMBER SPECIALISM STATEDr Ashraf Badawi Dermatologist OntarioDr William H. Beeson Plastic Surgeon IndianaDr Anthony Benedetto Cosmetic Dermatologist PennsylvaniaDr Valerie Callender Dermatologist MarylandDr Andrew Campbell Facial Plastic Surgeon WisconsinProf Wayne Carey Dermatologist QuebecDr Anoop Chaturvedi Anti-ageing Practitioner TexasDr Joel Cohen Dermatologic Surgeon ColoradoDr Lisa M. Donofrio Cosmetic Dermatologist New YorkDr Joseph Eviatar Oculofacial Plastic Surgeon New YorkDr Michael H. Gold Dermatologist TennesseeDr Steven B. Hopping Plastic Surgeon Washington, DC

BOARD MEMBER SPECIALISM STATEDr Gustavo H. Leibaschoff Cosmetic Surgeon TexasWendy Lewis Industry Expert New YorkDr Z. Paul Lorenc Aesthetic Plastic Surgeon New YorkDr Ronald Mancini Oculoplastic and Orbital Surgeon TexasDr Neil Sadick Dermatologist New YorkDr Joel Schlessinger Cosmetic Dermatologic Surgeon NebraskaDr Nazanin Saedi Dermatologist PennsylvaniaDr Hema Sundaram Dermatologist Maryland/VirginiaDr Amy Taub Dermatologist IllinoisDr S. Randolph Waldman Facial Plastic Surgeon KentuckyDr Heidi A. Waldorf Dermatologist New YorkDr Susan Weinkle Dermatologist Florida

PRIME JOURNAL NORTH AMERICA EDITORIAL BOARD

For the full list of our international board members, visit www.prime-journal.com/editorial-board

®

Wendy Lewis previews the 10th Vegas Cosmetic Surgery and Aesthetics Dermatology Symposium, held in Las Vegas from 18–22 June 2014

VEGAS COSMETIC SURGERY AND AESTHETIC

DERMATOLOGY IS TURNING 10

VEGAS COSMETIC Surgery and Aesthetic Dermatology is celebrating a big milestone. 2014 marks its 10th anniversary in

Las Vegas under the leadership and coordination of its founder, Kentucky facial plastic surgeon S. Randolph Waldman, MD.

According to Dr Waldman, 'We are extremely proud to host the leading educators and teachers in the fields of facial plastic surgery, plastic surgery, dermatology, and oculoplastic surgery. Vegas Cosmetic Surgery and Aesthetic Dermatology was not only the first truly multispecialty forum in the aesthetic field, but by listening to our faculty and attendees, it has grown to be the largest event of its kind in North America.'

The goal of Vegas Cosmetic Surgery (VCS) was to foster a spirit of cooperation and understanding among the medical specialties that are primarily involved in the science, practice, and teaching of aesthetic surgery and medicine. 'We try to have at least 25 members of each specialty represented so it is a true multi-specialty meeting. We go out of our way to make sure any interspecialty conflicts are left out of this meeting. It’s not about politics; it’s about education. We believe we are inviting the best people in their respective fields to join our faculty, and we try to find the leaders on each subject within their fields as well,' said Dr Waldman.

According to Kentucky facial plastic surgeon Donn Chatham, 'VCS is an

equal-opportunity symposium; regardless of specialty, we all have much to share and much to learn. And there is really no political agenda but to listen and improve one's game.'

'VCS 2014 is an opportunity to network and learn alongside your peers as well as mingle with many of the leading experts in the industry,' said plastic surgeon Renato Saltz, MD, FACS. 'This multi-specialty conference provides plastic surgeons, facial plastic surgeons, dermatologists, oculoplastic surgeons, physician extenders, and practice managers with a great educational experience. It is also the only meeting where one can bring the entire office staff and everyone will take new information home!'

Under Dr Waldman’s experienced tutelage, the VCS team devotes their concerted efforts all year round to keep the programme relevant to their registrants. 'I’m always looking towards what I want to hear, who would I be interested in listening to, and what are the trends and hot topics,' said Dr Waldman. 'The courses and

workshops are where registrants really learn pearls they can take away and use in clinical practice.'

Executive Director Delphine Hepp has her work cut out for her. She and her team of three go to task on the next year’s event as soon as the annual meeting concludes. It’s a full time job and then some. Along with Executive Assistant, Sheridan Likoy, and Meeting Coordinators, Laura Beth Harris and Matthew Waldman, the VCS staff has a full plate. 'We believe that Vegas Cosmetic Surgery and Aesthetic Dermatology brings together the best of the best in the cosmetics and aesthetics world, and it has been very exciting to see it grow over the years,' said Hepp.

And their hard work has certainly paid off, with a loyal following of faculty and attendees. 'The Vegas Meeting has such great appeal because it brings together thought leaders in the core subspecialties so that ideas are exchanged and developments within each subspecialty are shared. Dr Waldman and the steering committee develop the programme by inviting speakers who are innovators, so the meeting is different each year and the attendee can acquire new ideas and techniques that can help the practitioner better serve their patients. It has become a must attend for top physicians across the country,' said New York facial plastic surgeon Andrew Jacono.

2014 multispecialty programmeWith such a diverse 5-day programme, there is a wealth of topics to choose from.

L–R: Donn Chatham, Renato Saltz, Foad Nahai, and S. Randolph Waldman

MEETING PREVIEW |

12

❚ May/June 2014 | prime-journal.com

This is a meeting with a high yield of

knowledge acquisition and opportunity.

There is a roster of 15-minute clinical presentations that focus on industry trends and hot topics across all core specialties, including blepharoplasty, rhinoplasty, facelifting, dermal fillers, neurotoxins, fat grafting, skin resurfacing, and topical agents. If you want to take a deeper dive into the art of aesthetics, you can check out the 45 minute Masters Seminars that explore innovative techniques. Expert roundtables that feature leaders in their field also showcase the latest tools and technologies available.

The meeting’s rhinoplasty programme is a labour of love for New York facial plastic surgeon Steven Pearlman. 'Bringing an illustrious faculty of leaders together in one location every year seems like a monumental task, but the Vegas Cosmetic Surgery meeting is considered one of the top meetings in the field internationally. This year we are exploring some innovative techniques and complex cases to stimulate an open debate and evidence-based discussion.'

Brian Biesman, an oculoplastic surgeon from Nashville, TN, said, 'The faculty is world-class, the meeting is long enough so that there is sufficient time to cover topics in detail. There are some very frank and open discussions about complications, alternative approaches to certain clinical problems are discussed, and the fact that it is a multispecialty forum ensures that some of the same issues will be examined from multiple viewpoints. It is so helpful to hear how surgical and non-surgical options are integrated into an overall approach to facial aesthetics, and I always come away feeling as if I have learned more than I taught.'

New York dermatologist Heidi Waldorf agrees. 'The strength of VCS is twofold: a strong multidisciplinary faculty and the array of topics presented. Each core cosmetic specialty has its own unique approach; however, over recent years we've realised that by exchanging ideas and learning from each other, our fields improve exponentially. The mix of lectures, panels, and live demonstrations makes the meeting a busy one and very worth attending,' she said.

Emphasis on practice managementWant to learn how to use Facebook? Confused about the new EHR regulations? Interested in starting a medispa or skin

care range? The VCS practice management track features a roster of specialists who will be speaking on a wide range of critical issues in online marketing, social media, staff training, managing difficult patients,

SEO, SEM, coding, medical liability, public relations, reputation management, and much more.

The marketing and management workshops present the tools you need to help your aesthetic practice thrive and grow. 'We were the first people who put the

emphasis on the idea of practice management and marketing. Because of that, we have recognised the importance of the office staff in aesthetic practices. We encourage physicians to participate in meetings with their staff because they are as important, if not more so, than the physicians. We were the first meeting to put the practice marketing track on the same level with the clinical sessions,' said Dr Waldman.

According to Jeffrey Spiegel, MD, FACS, a facial plastic surgeon in Boston, 'I find this conference to be very focused on areas of interest for those who run busy aesthetic practices. The different concurrent programmes (e.g. surgery, non-invasive, practice management) allows for an intensive learning experience.'

Over 100 exhibitorsThe aesthetic industry is also an important component of the decade-long VCS success story. There are over 100 exhibitors registered this year. New

products from skin care to injectables and devices are featured in the exhibition hall so attendees are able to gain an overview of what is new and exciting.

'The meeting attracts a wealth of key opinion leaders under one roof that draws industry to participate year after year,' said Dr Waldman. 'Along with a packed programme of workshops and special events, many sponsors will have receptions going on to meet and greet your colleagues and peers from all over the country and the world.'

Las VegasVegas Cosmetic Surgery and Aesthetic Dermatology will be held on 18–22 June 2014 at The Bellagio in the heart of the Las Vegas strip. Las Vegas is known as a playground for adults and world-class restaurants, shows and concerts, and designer shops abound. The immensely popular O from Cirque du Soleil® features an international cast of acrobats, synchronised swimmers, divers, and characters who perform in, on, and above the water for a truly memorable evening. Enjoy some unique dining experiences at Petrossian, Le Cirque, Michael Mina, Picasso, and Prime Steakhouse, or shop-'til-you-drop on the strip in between courses.

Further information Physicians can earn as many as 46+ hours of CME credit. To register, call Vegas Cosmetic Surgery at +877-673-3273 or visit vegascosmeticsurgery.info/

Andrew Jacono, MD, FACS

New products from skin

care to injectables

and devices are featured

in the exhibition

hall so attendees are

able to gain an overview

of what is new and exciting

| MEETING PREVIEW

prime-journal.com | May/June 2014

❚ 13

celebrating 10 yearsMulti-Specialty Education seems to be

a new buzzword associated with many conferences around the world. As the original multi-specialty symposium in the

aesthetic market, those of us responsible for the Vegas Cosmetic Surgery (VCS) Symposium are very proud to have had a role in changing the educational paradigm within our specialty. As evidence of this changing paradigm, this event has quickly grown to be the largest ‘independent’ aesthetic conference in North America, annually attracting well over 1500 attendees and proving that there is a place for independent meetings that offer a high-end educational product devoid of excessive industry influence.

Our goal from the very beginning has been to build educational bridges between what many consider the four core specialties associated with aesthetic surgery and medicine — aesthetic dermatology, facial plastic surgery, plastic surgery, and oculoplastic surgery. No other meeting has at its core a mission to gather the world’s leading experts from each of these fields and allow them to exchange ideas with one another.

The thing that I am most proud of when I reflect on the past 10 years is that we have encouraged other meetings to look at our model and many have even adopted some of the things we have tried to do over the past decade, including the recognition of the importance of the business aspects of our specialty. VCS continues to feature a 4-day track on the management and marketing aspects of aesthetic medicine and surgery. The words ‘trade show’ have never defined VCS. This is an educational symposium in every sense.

So what does all of this mean for our specialty and our patients? In my mind, our patients are the real beneficiaries of this level of cooperation among the

core specialists. Our specialties also benefit from this cooperation as more and more barriers are broken down and cooperation among the societies continues to increase and strengthen. In fact, the Physicians Aesthetic Coalition was organised by Dr Renato Saltz and some of his courageous colleagues as a means of communication among the leaders of the four core specialties. This group has been meeting each year at the Las Vegas meeting in an attempt to enhance communication and cooperation on a myriad of issues that affect our specialties, our practices, and our patients.

Clearly after 10 years some of our goals have been achieved and others are within reach, but there is still much left to accomplish. As we consider our next 10 years, it is my hope that we can expand and become more of an advocate for our patients and the public in general. The confusion they now face when trying to decide on the legitimacy of a procedure and a provider for a procedure is well known, and we as the providers can no longer rely on medical boards and regulatory agencies to sort all of this out for them. We must develop close ties with our media partners, industry supporters and the lay media, and continue to find additional ways for our societies to work together to maintain our high ethical standards and help educate a very confused public.

HIgHLIgHTS Of THe DAyThe consult to the treatment and everything in betweenTime 08:45E. Gaylon McCollough, MD

Combining upper blepharoplasty with brow lifting using a single incision Time 12.00Julius Few, MD

Is it ethical to name or trademark a surgical procedure? Time 15.00Harold Kaplan, MD

Integrating bioidentical hormone replacement therapy into an aesthetic practiceTime 17.00Sharon Giese, MD, Greg Buford, MD, Brian Kinney, MD

Panel: Dealing with the challenging patientTime 17.30Moderator: Donn Chatham, MD. Panel: MK Maloney, RN, Laurie Mercier, Brent Kock, MD, Todd Schlesinger, MD, Theresa Schultz, PhD

yOUr Daily gUiDe tO tHe Vegas cOsMetic sUrgery anD aestHetic DerMatOlOgy syMpOsiUM z

thursday june 19, 2014

S. Randolph Waldman Founder and Chair, Vegas Cosmetic Surgery

Register to PRIME online for FREE at prime-journal.com

Online first Article Archive Video Interact Available on-the-go

DOes FacebOOK generate FaceliFts?

The International Confederation for Plastic Reconstructive and Aesthetic Surgery (IPRAS) is a huge organisation, with over 37 000 aesthetic and plastic surgeon members and 35 000 residents in training across 99 nations. With their size and resources they recognize they have the capabilities to do great humanitarian work and are continuously developing new initiatives to make use of their skills for the benefit of others. One such initiative is the Women for Women program. I spoke to one its founders and now Managing Director, Dr Constance Neuhann-Lorenz, to find out more.

Women for Women aims to provide reconstructive plastic surgery and medical care to women in developing countries who have suffered the effects of an injury. These women would have little to no access to health care, and the program works to help alleviate their suffering through reconstructive surgery.

Itwas developed in 2006 by the current President of IPRAS, Dr Marita eisenmann-Klein, and Dr Neuhann-Lorenz. The two were good friends and shared the belief that there was a need for a program that dedicated its efforts to helping women in developing countries, who they felt were under-represented in humanitarian medical missions. They took their vision to the 2007 IPRAS delegate meeting and convinced the board of directors and executive committee to green-light the program.

Since it was founded, the program has travelled to many countries helping women who had been the

victims of domestic violence, accidents, war or natural disasters. Their work has not only restored physical function and external appearance to many women, but also increased the educational or employment options for these women who were often marginalised in society because of their injuries.

Women for WomenA key difference between the Women for Women program and other volunteer schemes is that all the plastic surgeons who volunteer for the program are women. To understand why they made such a decision, Dr Neuhann-Lorenz tells me you have to understand the society in which these women live.

‘Many women from certain socio-cultural backgrounds in the Third World would have more confidence to be treated by a woman or would only be allowed to be treated by a woman,’ she explains.

‘In the past, if these humanitarian efforts arrived in these countries the women would normally send their husbands or their children before they came for treatment. They would send their husbands because they would be the ones who go out to work and the children are the future, so the women tended to put themselves in the background. When we come as women they understood it is for them,’ she continued.

Social media is changing the way your patients see themselves, and it also provides another way for you to reach them and brand your practice. With 1.31 billion monthly users, facebook remains the biggest social platform out there, but it’s not the only game in town. Other social platforms of importance to all service businesses include Twitter, LinkedIn, Pinterest, Instagram, google+, and youTube.

When it comes to your practice’s facebook page, post once or twice daily about any specials at your practice, upcoming speaking engagements or publications, as well as any trending plastic surgery stories. Remember the goal is not quantity; rather it should be quality and engagement. These elements are more important than merely the number of facebook fans you have. To gauge engagement, look at whether your facebook posts are being liked, commented on and shared. At its core, social media is all about building relationships with your audience.

Sharing photos and video content is key. Research suggests that people are 44% more likely to engage with content that has images. Make your business page look like a magazine — with attractive and appealing images, customized content, and a beautifully designed cover photo. your page is like real estate so don’t waste that space.

Social media is not free or something you can just dabble in. It involves an investment of your staff’s

time and/or the possibility of outsourcing your social media accounts to an experienced vendor. facebook ads are also needed to grow your fan base. Without ads, it will take a long time to build a respectable sized community. It also helps if you boost facebook posts for as little as $15 using targeting features. Don’t forget to use ‘Like us on facebook, follow us on Twitter’ signage in your practice and on all materials to help build your online community.

your practice’s social media presence is a big factor in the search engine-ranking algorithm, and enhances branding and word-of-mouth exposure. Take it seriously and have fun! Social media is here to stay.

Women for WomenWhat Twitter said…“Great day at the meeting serving as a moderator with Dr. Steve Yoelin at

the Master’s Session!” @DrRyanGreene

“How to create a youthful upper eyelid? Dr. Nancy Swartz revealed

her “youthful triad” strategy today at #VCS2014! Written details tomorrow!” @DermTimesNow

“Best multi-specialty conference hands down. Great space to share

and exchange ideas on #cosmeticsurgery #VCS2014” @PhoenixSkin

“Does the aging nose droop or is it all an illusion, asked Dr. Val Lambros in

his presentation today at #VCS2014? Stay tuned for details!” @CSTNow

“Learn more about our “Game Changing” Subscription Program for

Aesthetic Technology at Booth #113. #VCS2014 #Bellagio” @VenusConcept

“Get your tweet on @VCS2014 using the hashtag #VCS2014 and see

whether you’re featured in our daily news on Thursday, Friday and Saturday!” @PrimeJournal

“Team Davis goes to Vegas! Follow along with the Aesthetics meeting

on Instagram using #vcs2014” @DrDavisPlastic

“Attending #VCS2014? Contact your Realself Advisor to schedule a

complimentary video session in the Realself TV studio” @DrCommunity

Share your thoughts on the 10th Annual Vegas Cosmetic Surgery Congress using Twitter and the hashtag #VCS2014 and have your Tweets featured in this column!

Wendy Lewis is President of Wendy Lewis & Co Ltd

Balraj Juttla is Subeditor of PRIMe. Read the full article online at www.prime-journal.com

Social media is not free or something you can just dabble

in. It involves an investment of your staff’s time and/or the

possibility of outsourcing your social media accounts to an

experienced vendor. IN fRIDAy’S eDITION... Trending: EU vs US

The power of PR and earned media for physicians

Fillers in the United States: what’s coming?

HIPAA: what you need to know

Fillers in tHe UniteD states: WHere We stanD

Drs Heidi Waldorf and Doris Day discuss the dermal filler market in the US. In part 1 of 3, they discuss what

is currently available, in part 2 what we are likely to see in the next 5 years, and in part 3, the properties of a hypothetically ‘ideal’ filler.

HW: In the US, obviously we’ve been a lot slower to get to market on a lot of the fillers. However, it’s not as though we need hundreds of options. The biggest change for our market was when Voluma was brought in, because that was the first larger HA that could give us the kind of lift that previously we needed to use a significant amount of HA to increase volume, or we had to use CaHA. Now we have a longer-lasting filler that gives lift, but can also be erased.

DD: I totally agree, Voluma is one of the most natural, softest-looking products I’ve seen.

HW: In my practice we still use a lot of the other fillers. I still use PLLA, I use CaHA, and I use some of the smaller HAs, but for certain patients I do find that Voluma is more helpful.

DD: Part of it is getting comfortable with the new fillers as they come on the market, knowing the best places to use them, and also the risks. With Voluma I’m finding that it’s my go-to product more and more, as I learn all that it can do, and as I’m seeing patients back looking beautiful, natural and so happy with their results. But I have my favorites for different places, so I still prefer Restylane or Belotero under the eyes, and Juvéderm for the lips. The only product I use in the hands is Radiesse. If I need a volumizer for someone who’s a fitness trainer or someone who has a lot of lipoatrophy, sometimes I’ll use Sculptra for a few sessions just to build them up a little bit locally or pan-facially, and then I’ll start building with an HA. So, Voluma is starting to eat a little bit into my Perlane and Juvéderm Ultra Plus types of volume, and starting to cannibalize that just a little bit, but otherwise we have a very nice mix.

HW: I think we have similar approaches. We both have some patients who go to SoulCycle twice per day, who are very tiny and will

often require pan-volume. If their skin is not too terribly sun damaged, and if it’s less of an age thing and more to do with the health of their skin, then I like pan-volumizing with Sculptra. I also find that it’s great for the temple area because we can reflux from the plunger, we can feel safer in certain areas, but it also does take a certain kind of patient who is willing to do the homework of massaging, but is also willing to wait to see the results.

DD: Some people like the initial subtlety and that gradual result, and that’s another area where Sculptra really excels.

HW: I agree, and I think that that is one of the decisions that as physicians we make. We have to find out, we look at the patient, we evaluate the patient, we decide what our recommendations are, and our recommendations may come down to a choice of two different products for one area, another product for a different area, and then we present it to the patient and see what fits with the patient’s lifestyle and needs — do they have an event they have to look good for, or are they looking at just looking better gradually for life? And like Doris, I will also layer these fillers, so I may use Sculptra for pan-volumizing or use Radiesse as scaffolding for the jaw line. for the lower lids and tear trough I like a combination of Restylane and Belotero.

DD: Me too.HW: And I do a lot in the lateral

forehead now, as well as the mid-forehead and the temple.

DD: Me too. What do you do there?

HW: If I’m not using Sculptra, with a cannula I will use Radiesse or dilute Voluma in the temples, otherwise I use Restylane. As with Doris, as we’ve been using Voluma more and more, and seeing our patients back, I’m now extending it and using it as some of my Canadian colleagues have recommended, in a more dilute manner to spread it like a layer in the temple area, and even into the lateral forehead. In the forehead generally though, I’m layering Restylane and then for some fine lines above, Belotero. I think for those of us who do a lot of fillers, we have this armamentarium of tools, and we’re figuring out and

constantly changing our ideas, adjusting and tailoring them to our patients.

DD: And we’re using devices as well. We’re using Ulthera, Thermage, fraxel and fractional CO

2 to

complement and enhance treatments. These are all very effective on every layer of the skin, using more than just one tool. fillers, lasers, and other devices — it’s really a global combination approach.

HW: It’s very different to when we started in practice. If you think of 20 years ago, we had collagen and you could fill a line for about 4 months and you were always starting from scratch. Now we are looking at growing old while staying youthful-looking and natural because our patients are coming in earlier. Someone might visit in their late 20s or early 30s because they’re starting to notice the brow and frown lines, or are concerned about dark circles under the eyes that make them look tired. So we might start tweaking, put a little bit of an HA for example, a little toxin.

DD: I’ve started asking patients to bring in pictures from when they were in their late 20s or 30s, sometimes mothers and daughters come together, and I’m even going one step further. Instead of looking at someone and saying ‘here’s where you’re deflated, here’s where you’ve lost’, I can look at someone now who is 30 who is just in the very early stages of deflation, I can just see the signs of it coming and I think the commonality of the ageing experience is intrinsic. you can actually start adding in volume very gently, just a little bit in part of their face, in their early 30s and perhaps before they really notice that they’re ageing, and you can actually not have to catch up later. It lasts longer, it looks better instantly, but they also stay looking better for years to come.

HW: I agree. I would say that even if I look back at some of my patients over the last 15 years or so, we may have started doing a little Restylane here, a little there, and tweaking. Then as the patient has aged and as our tools have increased, we adjusted as we need and you can pretty much keep them at a very good baseline.

DD: And then we need less product, less often. So people we’ve been treating for over 15 years, they’re 15 years older but they look better and they don’t need as much as often to maintain that look. Just as we have preventive neuromodulators, now we’re starting to have a preventive filler. And it’s not to change how you look, but to keep you at a great place and to keep that balance. It also links to education — you don’t want someone coming in asking for ‘more more more’; it’s a matter of putting in just enough and in the right way to keep them in a good place.

HW: I do think that as we get some of the newer products like Voluma, even with the products that we’ve had, there’s always been this risk of practitioners who are not looking at the patient as a whole, not looking at the face from all angles. I think for Drs like Doris and I, we’re spending our time telling patients what not to do; we’re saying no and we’re spending the time to educate. We would move a lot quicker if all we did, for example, in the US was treat what’s on-label, because unlike other countries, in the US when something has an on label indication, that’s all that the direct-to-consumer advertising can cover. So in the past, with the nasolabial folds, we had to spend a lot of time discussing with patients that if you just fill the nasolabial folds you’re going to look very strange. Now for our patients and staff, the concept of doing the cheek is very natural, but now that Voluma has that indication we’re talking more about that and that’s very helpful for us and again, it doesn’t mean that it’s taken away our use of Radiesse, Sculptra, Belotero or Restylane. I think that, as Doris said, there are some of the mid-level fillers that it’s going to change.

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