Texan Magazine
Anti-Aging Treatments And More
Important Information To Keep You Safe
By Laura Bennack, M.D.
Aesthetic medical procedures (often obtained at “Medical Spas,”) are increasingly popular. Ads promoting such services are everywhere and it’s understandable if the average consumer has questions and concerns about the efficacy and safety of such procedures.
What I would like to do in this article is try and give you as much information as possible on the offerings of the modern medical spa, and some educated suggestions on what questions a patient should ask before obtaining such a treatment.
First a little bit of introduction to the term “medical spa.” These entities seemed to appear about the 1990s, NOT coincidentally, the same year that cosmetic lasers were approved by the FDA. The idea was to make the medical offerings of a cosmetic doctor, such as Botox, fillers, laser hair removal, etc., more inviting to the general public since very often the clientele for these types of procedures are educated, affluent, and very much looking for the “Nordstrom experience.”
In case you’re not familiar with Nordstrom’s strategy, it is to provide a compelling customer experience with outstanding services. As a practicing physician, I tell my staff often, “Be the Nordstrom,” with one caveat:
Nordstrom’s motto is “the customer is always right.”
In a medical setting this is not always a correct assumption. Patient’s should rely on staff’s medical schooling, training, and experience to decide what is best in any particular instance.
The Medical Spa was envisioned to treat patients or “clients” in a “spa” type manner, thus merging the spa atmosphere with medical expertise hoping to make the patients more comfortable with their purely elective medical treatment.
The original idea envisioned medical doctors opening these locations or adding this type of service onto their current practice. However, as the range of aesthetic medical offerings expanded and the demand for such procedures rapidly grew, many other types of entities and persons OTHER than doctors began to offer these services. Among them were corporations, beauty salons, and various other MEDICALLY-UNTRAINED personnel.
Realizing the inherent risks in these procedures, many states have enacted legislation, ensuring that most of these medical procedures stay in the medical realm. The specific laws vary widely from state to state; however, I can speak with respect to Texas, where a medical spa MUST be owned by a physician, an M.D. or a D.O.
That brings me to a serious point I’d like to make . You will find numerous “medical spas” that have NO in-person or virtual physician involvement.
That leads me to the first question you should ask when you enter one of these establishments, and that is to ask who is in charge of the location.
Is there a physician overseeing the practice, and will you see them in person, or perhaps have a virtual meeting with them?
In Texas, all new patients that will receive any kind of medical cosmetic treatment must FIRST have a physical exam by either a physician, a nurse practitioner (NP)or a physician’s assistant (PA). Additionally, the doctor, and ONLY the doctor, must approve the treatment for each patient . The doctor must, at a minimum, outline in writing “standing orders,” that tell the PA or NP exactly how the procedure will be administered, what the complications might be, and how to handle any complications.
All of this documentation MUST be present at the location where you are treated.
Now as a patient, you won’t necessarily see all of this; however, it should be a RED FLAG if they cannot answer your questions about a physician available for questions or complications.
To be clear, once you see the physician, either virtually via cell phone, or in person , you can THEN be treated by an RN, NP, or a PA thereafter for many if not all, aesthetic procedures. An NP or a PA can also substitute for the VISUAL assessment of the patient but CANNOT write the standing orders for the procedure; this must be done by a doctor who is required to co-sign and approve all treatment records.
You will see numerous NPs and PAs in this position and most are well-qualified. Rest assured, at least in Texas, there MUST be a physician, backing them, training them, and overseeing them. But it’s important for you to be sure that the injector /provider has clear, standing orders from the physician, as well as having the physician available even on short notice in case of any complications.
So now that we’ve gone past the boring stuff of verifying that you’re in a place that’s actually following the laws enacted for your protection, let’s talk a little bit about what procedures medical spas offer and more questions you might want to ask.
The bread-and-butter of most medical spas is their injectable practice. This involves neurotoxins like Botox, Dysport, Xeomin and fillers, such as Juvéderm, Restylane, and more. You may hear the names of other newer “toxins” like Jeuveau and soon you will hear Daxxify. These are all FDA approved and just because Allergan (Botox and Juvederm ) advertises widely, it doesn’t mean it’s better or safer.
Inquire About Experience
You should rely on the recommendation of your injector as to which injectable best fits your needs; which is why their experience is key, and why inquiring about the injector’s experience is the next question you should raise. One note of explanation:
Even though neurotoxins are FDA approved for many areas, they are often used “off label” for other parts of the body, such as in the neck, and the scalp.
This is absolutely legal and appropriate if the doctor has approved their use and written a standing order for that use.
I would like to offer a bit of additional information on neurotoxins. The name “neurotoxin” is just a generic name and part of the “lingo” for what people better know as Botox or Dysport and several similar neurotoxins that have come on the market, which all go by different names.
Don’t be confused if the medical spa offers one, two, three or even four different brands of a neurotoxin. Botox has become such a big medical spa offering that so many of the drug companies other than Allergan have jumped on the bandwagon to produce their own proprietary neurotoxins many which strongly resemble Botox in many ways.
Your provider may have a preference as to what they use based on their skills and based on what you actually need. For example, Dysport has been known to kick in faster than Botox, which usually takes about seven days, so if you’re in a hurry for these results your provider might recommend Dysport instead of Botox. And, although allergies to these neurotoxins are very rare, a person may be allergic to one versus the other, so having options is always a good thing.
In explaining neurotoxins, it often confuses people that most come in a type of “freeze dried” state. This means that the provider must dissolve, reconstitute or mix the substance with some type of fluid before injecting it. Sometimes people confuse this with diluting it. Usually this fluid added is sodium chloride, which is the same thing that you may have received in an IV if you were in the hospital, and it’s a substance that is plentiful in your body and very rarely allergenic. That also means that this reconstitution may vary from location to location based on the providers familiarity with the neurotoxin as well as their experience.
The amount of liquid used as well can vary between locations and injectors. These variances can make somewhat of a difference in your result, the timing of the result, as well as how much fluid the provider is injecting. I mostly see these neurotoxins diluted with 1/5 of a teaspoon or 1 ml of sodium chloride to prevent spread of the neurotoxin due to too much fluid, however; two and three ml’s is perfectly acceptable and a lot of it depends on the area that’s getting injected. That is something, if you’re interested in understanding in more details that you may inquire of the injector. It does NOT mean however, that the cost is less or more, based on dilution.
The cost should be the same per unit of Botox, whether that unit contains one ml of fluid or two mls. Any provider that’s experienced and legitimate will NOT mind you asking these questions.
I’ve even had patients ask me to reconstitute in front of them, as well as ask for a fresh bottle, which is fine with me. It’s no different than if I ask the chef how they prepare a meal, although, it might be a bit more difficult to get the chef to let you you watch them actually prepare the meal!
Another substance you may come across that is used for injecting for cosmetic reasons is PRP, which is short for platelet rich plasma. This is a legitimate and effective treatment, but it may come with its own set of questions you may want to ask. The provider is going to take blood from you, separate out the platelets, and then concentrate those platelets into a much greater amount than normally exists in your body. This is called a “super concentrate.” They will then inject this super concentrate into your skin for various reasons, such as collagen regeneration, to increase blood flow and more.
This procedure has been used by orthopedic doctors for years in worn out or injured elbows knees, etc. Again, caution is advised as to where you have this procedure done. You should be sure your provider uses specific sterile blood tubes designed for this procedure and that they have the expertise to concentrate the platelets correctly. You might find a place that will use regular test tubes that labs generally use to draw blood for preparing the concentration.
This is not appropriate and could cause problems, such as lack of results or complications such as infection.
As far as fillers go, they could actually comprise an entire article on their own. In the last 20 years we have accumulated more than two dozen different kinds of fillers by many different companies. Fillers vary by their content and their results, so you need to rely on your injector to help you make a decision about which filler to use. Many fillers, like Juvéderm, and Restylane, are made up of hyaluronic acid.
These types of fillers are widely used and gradually dissipate over a period of time (anywhere from three months to two years,) and they are also dissolvable or reversible with a substance called hylanex which breaks down the molecules.
These might be your filler of choice if you’re very concerned about the results or want the option to undo what’s been done. There are also some fillers that are NOT dissolvable such as Sculptra, Radiesse and Bellafill which are made up of varying substances which are not hyaluronic acids. These fillers also dissipate over time, but they cannot be reversed. Different fillers carry different risks. These should all be discussed with your injector. Some fillers require you to massage them, (or NOT to massage them,) to sleep in a certain way, or to stay out of the sun.
You need to be VERY CLEAR on the post-procedure instructions and you should be provided a written copy of them and and feel free to ask questions or call back for more information.
Most often the problems that I see in patients coming from different places are from either their failure to follow the instructions because they were not given them adequately, or they didn’t understand them, or from the failure to discuss the results fully with the injector so they understood what the results were going to be like.
Most medical spas have many more options for treatments other than their injectables. For instance, you commonly see laser hair removal, and facials that can be done with lasers for resurfacing on virtually any area of the body. You may see an aesthetician in these locations that will do facials that are more of a medical grade than you would find at your normal beauty salon. You might also see things such as laser tattoo removal, hormone treatments, noninvasive fat treatments, body sculpting and often liposuction, if the physician has been trained and is skilled in this area. This is all in keeping with the need of physician oversight and training.
This brings me to the last, but not least important, area of what aesthetic patients should know. Almost all of these procedures should be obtained from a medical provider, (a medical spa) and NOT at a beauty salon.
These treatments are medical procedures which require specialized training and carry real risks. Stronger facial peels in the wrong hands can actually cause bleeding and can pose substantial risks of infection and scarring. Some procedures cannot be done on all skin types. I can’t stress enough the need for skilled providers as well as detailed, standing orders by a physician and oversight by that physician for the procedures and training of personnel. Since you will be seeking these procedures at a legitimate medical practice you should be concerned if you are not required to fill out a complete history before you’re seen by the provider.
Many things can affect your treatment such as medications you are taking, if your skin is tanned and whether you plan to go into the sun. Whether you’re pregnant or plan to get pregnant and additionally, your history about whether you’ve had cancer and if so , and what type of cancer, plus of course any allergies are key information your provider should ask for and receive.
The field of aesthetic medicine offers wonderful options for clients who want to look their best. Approach any procedures you are considering armed with these questions, assure yourself that your provider is both legally and by virtue of their expertise, able to provide you with safe and effective treatments. You will be more comfortable, knowing that, having done your homework, you can relax and look forward to the results.
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Dr. Bennack is a graduate of Trinity University, St. Mary’s School Of Law and UTHSC of San Antonio. She holds a Bachelor of Science in Business Administration, a Doctorate Of Jurisprudence from St. Mary’s and an M.D. from UTHSC. She also obtained her CPA after a brief stint in accounting. Apparent is her desire to never, ever stop learning and she carries that desire into her aesthetic practice at Radiance Medspa of San Antonio which she started in 2006. Art is her full time hobby which she not only expresses in her medical practice, but also in her spare time building miniature doll houses and painting in oils and pastels.
