Board Forum: The Four Cores: Status Update and Future Trends

Thinking of the four core specialties and their offerings, what do you see as the greatest strengths in Aesthetic Medicine? Are there any weaknesses?

Sachin Shridharani, MD, FAAD: The greatest strength of aesthetic medicine is the unceasing commitment of specialty physicians to ensure patient safety and continually improve outcomes. In aesthetic medicine, we as physicians have the opportunity to perform a diverse array of treatments and improve patient experiences more now than ever before. The expansion of available treatment options allows for a more tailored and individualized approach to patient care. Physicians have the ability to more closely align their treatment strategy to the patient’s inclination and expectation. Further, with more overlap and increased collaboration between the core specialties, patients are receiving multimodal and multispecialty treatment.

On the other hand, advancements in science and technology have generated such an abundance of treatments options that the market has become increasingly difficult for the average consumer to navigate. As such, consumers often have misconceptions regarding the outcome and safety of these procedures. If patient expectations are not addressed prior to treatment or are not properly managed by physicians, patients may be dissatisfied or doubtful of the efficacy of these treatments. Additionally, there is a paucity of Level I scientific evidence in medical studies. Considering the rapid growth and ubiquitous availability of aesthetic medical treatments, the need for evidence-based data on these treatments is critical.

Naomi Lawrence, MD, FAAD: The greatest strengths of the core specialties is expertise and innovation. As we are often the pioneers and developers of new aesthetic procedures we know how to optimize results and minimize complications.

Ryan Greene, MD, PhD, FACS: The strengths in aesthetic medicine lie in the collaborative efforts among the core specialties. Through these collaborations and symbiotic relationships, the result is continual development of new treatments, technologies, and approaches to offer to patients and deliver increasingly better outcomes. Any weaknesses result from divisions artificially created between the core specialties, which only serve to stifle growth and development within aesthetic medicine.

Sue Ellen Cox, MD, FAAD: The strength of a “core four” is the extensive training we receive. Dermatologists spend years becoming experts in health of the skin, hair, and nails. We are thoroughly educated in both normal and abnormal pathology of the skin. We understand the depth of injury required to initiate the wound healing process that brings desired outcomes, such as collagen remodeling and improvement of tone, texture, and color of the skin. More importantly, we know how to do that safely. We are also in the unique position to be able to recognize and treat unforeseen complications. As dermatologists we “own the skin”—the largest organ system of the body.

I don’t see any weaknesses unique to a core specialty. All physicians need to be advocates for the patient, treating each as a unique individual and customizing their treatment accordingly. This also requires that we know when to refer patients to other specialties so that the patient is always being cared for by the appropriate expert in the field.

What do you see as the greatest opportunities for the specialties in general in 2018? How about for you and your practice, specifically?

Dr. Lawrence: The explosion of noninvasive technology has transformed aesthetic medicine. In addition, we have the opportunity to use products earlier in the aging process to prevent aging or “pre-juvenate.”

Dr. Greene: In the past two years, we have seen an exponential expansion of the services and treatments we offer. Whereas in the past, the public viewed cosmetic treatments as being only for the wealthy, now they see that these services are attainable by a large sector of the population. Minimally invasive treatments are becoming more effective, and minor treatments can often yield profound results. These great opportunities can only be realized by educating the public and developing treatments that are attainable by a larger population of patients.

Dr. Cox: Physicians’ continued partnership with industry will bring new products, devices, and procedures to market. I have a busy research component to my practice allowing me to be on the cutting edge of the aesthetic field and market place. This gives me the opportunity to use new toxins and fillers before they come to market. I typically will have a one to three year lead on products before they come to mainstream core physicians. This allows me to delineate within my own mind how the product, procedure, or device will be positioned in my practice. I can refine my offerings and use the best product or device for a specific indication. I am better able to customize a treatment plan for my patients as soon as the product or device becomes available.

Dr. Shridharani: We will see broader, more extensive applications of tried and true cosmetic treatments as well as increased opportunities to reach growing markets. For my practice specifically, we are continuing to evolve and grow in regards to our patient base. In particular, we have seen an increase in the number of male patients seeking cosmetic procedures as well as an increase in younger patients interested in preventative treatments.

What about threats to the specialties, to patient care, or practice overall?

Dr. Greene: In my opinion, untrained and unethical practitioners pose the greatest threat to patient care and the core specialties. When practitioners deliver substandard or illegal treatments, it violates the public trust and alters the overall perception of aesthetic medicine. Maintaining excellence in aesthetic medicine is critical to the growth of our specialties and practices, and we should take an active role to ensure that the best practices are followed and delivered to our patients. We must uphold equally high standards for both ourselves and our colleagues.

Dr. Lawrence: The threats are from the lay practice of medicine performing procedures and experiencing complications and creating suboptimal results.

Dr. Cox: Improperly trained, unsupervised providers, and the explosion of medspas are both threats to the specialties. Aesthetic medicine as a whole is damaged when optimum results are not obtained or complications occur. Patients don’t distinguish based on providers’ skill level until a complication occurs, and it’s then left to the specialties to fix.

Patients that price shop can always find a lower cost, and may have a good experience a time or two. But eventually the turn over, substandard equipment or lack of training at the commodity oriented facilities results in bad outcome. As a dermatologist I have cared for many of these poor outcomes.

Dr. Shridharani: The emergence and escalation of untrained and unlicensed practitioners masquerading as core specialty providers represents a major threat to the specialties. It is far too often that the incompetence of untrained practitioners leads to devastating and fatal outcomes. The public is often unaware of the seriousness and safety of these procedures, and they are commonly uninformed regarding who is qualified to perform them. When consumers hear of a treatment resulting in a suboptimal or injurious outcome, they do not realize that the “cosmetic surgeon” providing the care was not trained or authorized to perform the procedure. The core specialties suffer the consequences of these untrained practitioners due to the negative outcry from the public.

What devices or services will you introduce in 2018 that you are most excited about? What are the most significant changes—if any—you are making in 2018?

Dr. Lawrence: We will be introducing threadlifts and microneedling.

We are working to improve patient understanding of our services and use multimedia approach to help with pre- and post-procedure instructions.

Dr. Greene: Every year, I continually try to achieve perfect balance between my personal and professional life.

Dr. Cox: There is continued expansion of the portfolio of hyaluronic acid fillers and new neuromodulators that have potential for longer durations. Also in the pipeline are HA threads and HA boosters to enhance skin quality. Some may come to market in 2018.

I will continue to use injected PRP to treat difficult conditions, such as androgenic alopecia, dark circles under the eyes, and scars. I expect to expand the use of topically applied PRP following Halo Pro, Fraxel, Clear+Brilliant, microneedling and BBL treatments. I recently began offering feminine rejuvenation with the radiofrequency device Geneveve, and will be adding thread lifts to my practice in the weeks ahead.

Dr. Shridharani: Rather than a change, we are continuing to implement the same strategic philosophy of our practice: treating to an outcome. By embracing and systematically integrating nonsurgical procedures into our procedural repertoire, we have eliminated the commoditization of nonsurgical care and, instead, made the priority achieving a specific outcome.