Refurbishing Youth: Trends in Cosmetic Equipment

Medical Dealer Magazine | Cover Story July | Refurbishing Youth

Refurbishing Youth: Trends in Cosmetic Equipment

For someone with an expert knowledge of light-based medical technologies, Mitchel P. Goldman, MD, takes a dim view of the field of aesthetics.

Currently a volunteer Clinical Professor of Dermatology at the University of California in San Diego, Goldman knows the technical business of cosmetic technology first-hand: He has more than 40 different devices in his office and has participated in the development of more than a dozen of them, the most profitable of which is the intense pulse light (IPL).

“I built the first one in my garage 20 years ago,” Goldman says.

The problem he had been trying to solve was the painful bruising of patients who underwent pulse-dye treatments for leg vein discoloration. With the help of an engineer who worked through some of the technological hurdles, Goldman and his team discovered the techniques that evolved into contemporary photorejuvenation, he says.

“We got it to work on blood vessels; then as we’re treating all these blood vessels, it was also getting rid of pigmented lesions, making the skin smoother, and getting rid of the hair,” Goldman says. He says the technology also works on other vascular lesions, such as port wine stains and facial telangiectasia, without bruising the skin.

The company that Goldman helped launch eventually became Lumenis, one of the foremost manufacturers of IPL technology today.

But it’s not the pace of technology that frustrates Goldman; rather, it’s the tempo at which healthcare professionals looking to build a nest egg or avoid reimbursement headaches are entering the field of cosmetics.

“In the old days, 20 years ago, it was physicians who wanted to help people and advance technology,” Goldman says. “Now what’s happening is physicians hate doing insurance reimbursement any more. So more and more physicians are looking to get out of the insurance field and into the cash-pay.”

Medical Dealer magazine | Cover Story - July | Refurbishing Youth“You’ve got gynecologists doing Botox and proctologists running day spas,” he says. “You’ve got hair removal clinics and tattoo removal clinics. Next thing we’ll have Groupons for heart transplants. Doctors are trying anything they can to get patients in their office to spend money. Laser companies just want to sell their lasers.”

The whole enterprise is of course correlated with “the rise in the baby boomers who have a fear of dying and want to keep looking young forever,” Goldman says.

And although Goldman jokes that “the good news is that most of what we’re doing is not going to kill people,” the converse of that is a marketplace that “is not a heavily regulated field.” While that doesn’t necessarily lead to ethical lapses, he says there is a frustrating lack of consistency in technique, professional experience, and oversight in the rush to enter what has become a cash bonanza for some.

“What I see, unfortunately, almost on a daily basis, is patients that have gone to some strip mall and had some nurse or retired proctologist do something to them and have a scar,” Goldman says. “And the scar is going to be there permanently, but it’s not going to harm them or change their life, but the patient lost $500.”

That comes to bear on equipment purchases, he says, because in a field where the latest technology promises to deliver results, the physicians who endorse it can heavily influence the signal-to-noise ratio of the discussion.

“So often when I’m in the audience and I’m listening to those gurus on the podium, they show the one picture of one patient [for whom a procedure delivered results,” Goldman says. “There’s so much B.S. out there it’s appalling at the lack of ethical standards.”

Be that as it may, he says, “Most physicians want to be ethical [and] there are products that do good things. [But] for the average Joe out there...there’s so much B.S. that it’s very difficult.”

“There’s no machine that replaces surgical expertise, and at this point there’s no machine that can melt fat and no machine that can treat cellulite,” Goldman says.

A HUGE, UNTAPPED MARKET

The global marketplace for aesthetic capital equipment is $2.9 billion with a compound annual growth rate in the low double-digits, says Frank D’Amelio, CEO of aesthetics device maker Ellman International.

Of that, he says, some $1.1 billion is accounted for by surgical radiofrequency (RF) equipment used in facelifts, rhinoplasty and breast augmentation. The other $1.8 billion includes aesthetic lasers, intense pulsed light (IPL) and RF skin tightening devices used in various aesthetic procedures.

D’Amelio describes the marketplace for cosmetic lasers as a pyramid, atop which are the 5 percent of purchasers who spend in the $100,000-200,000 range for a device. The next tier, about 22 percent of the marketplace, spends anywhere from $55,000-100,000, with an average price around $87,500, he says.

“Below that is a huge, untapped market of physicians” that D’Amelio says Ellman has targeted with lower-priced, entry-level lasers.

“Since the market consists primarily of single physician practices, purchasing a laser can be a prohibitively expensive endeavor, he says “Buying a laser for $87,500 is a significant expense, and for that price, can only purchase a single type of laser: typically, physicians like to offer more than one type of laser procedure to their patients.”

“Here’s the dilemma: a physician wants to keep the patients they’ve treated for years, but there comes a time that both physician and patient realize that there is only so much they can do with just a syringe of Botox or filler. If they cannot allocate the funds to the purchase of a laser, they are at risk of losing the patient to another practice,” he says.

“We constantly hear from dermatology and plastic surgery physicians that they are looking for a clinically efficacious device at an affordable price to offer treatments to their patients who ask about lasers or RF skin tightening. They do not want to lose their patients.”

LASER CATEGORIES

D’Amelio described the four main cosmetic applications for which lasers are typically used. The first is skin resurfacing, which is used to counteract the effects of “years of sun damage, lines and wrinkles from smoking or scars from acne on their face,” he says.

“Carbon dioxide or CO2 lasers are used for deep resurfacing of the face,” D’Amelio says. “Another laser wavelength used for resurfacing is Erbium, which provides very light resurfacing of the face that people liken it to microdermabrasion.”

Then there is hair removal, which D’Amelio says is “the highest volume of cosmetic lasers sold and the number one volume cosmetic laser procedure.”

Tattoo removal is similar in many ways, D’Amelio added, “but this time it’s an explosion, with more and more patients requesting removal of their unwanted tattoos or revision of existing tattoos.” Sometimes, tattoo artists will even buy lasers for touch-up work.

The fourth technology, IPL, is technically not a laser, though it is often lumped into the same category. IPL is intense light that is filtered to mimic the effects of lasers, D’Amelio says, and is frequently used for treating dark spots, or dyschromia, and for general facial rejuvenation. IPL treatment, which can be delivered by an aesthetician, has become popular in the medi-spa market.

The third technology area is RF. Surgical RF devices are used every day by aesthetic physicians. Not all devices are the same and the most advanced use a very high frequency, 4 MHz. The gold standards by which surgical RF devices are judged, D’Amelio says, are how cleanly they cut, how quickly the patient heals and how minimal a scar is left behind.

Medical Dealer magazine | Cover Story - July | Refurbishing Youth

OUTCOMES AND PATIENT EXPERIENCE

Mark Epstein, MD, FACS, is a plastic surgeon in Long Island, N.Y. When it comes time to making decisions on equipment purchasing in a small practice such as his, doctors frequently are conflicted by competing impulses, he says.

Medical Dealer magazine | Cover Story - July | Refurbishing Youth“People vary on what their motivation and what their ethics are,” Epstein says. “Not all technology gives the same degree of efficacy. If there’s no efficacy in it, I don’t care how much money it’s going to make me. Outcomes and patient experience are everything.”
The story Epstein likes to tell to sum up the crux of such decisions dates back to when he and his dermatologist wife, Elyse Rafal, MD, with whom he practices, first started discussing the purchase of a dermatological laser.

“My wife and I have been together 15 years, and we’ve been talking about buying a laser since we were dating,” Epstein says. “But I didn’t find one I liked. We bought two lasers at the end of 2012 and we’re thrilled with them.”

“You have to be careful, and with technology, you have to be patient,” Epstein says. “You can’t be trigger-happy. The stuff is very expensive, it eats up a lot of capital, and if you’re a small practice, you can’t afford to make mistakes.”

One of the safeguards against such pitfalls, he says, is not only having the patience to wait for a technology— and sometimes a manufacturer—to mature, but also to get recommendations from fellow practitioners.

“Call your friends,” Epstein says. “Call your colleagues in other geographic areas who are not afraid to tell you the truth.”

Rafal says that waiting to make the purchase helped ensure that the technology they ultimately purchased was “very quick” and “a lot safer” than what had been initially available. Practitioners should seek a device that’s “state-of-the-art, that’s going to grow with you,” she says, and that means picking a vendor that’s financially sound, and that offers good patient education and accessible management.

“The most important thing is efficacy,” Rafal says. “If you’re not producing results, you’re not going to get patients referring other patients. It’s not like other things; it’s a lot more risk. And next year there could be a better machine.”

Medical Dealer magazine | Cover Story - July | Refurbishing Youth

DEVICE LIFE CYCLES

Another consideration for equipment purchasing in this tech sector is how long the devices last—and whether the procedures for which they’re approved will remain viable (or preferable) long enough for a small-practice physician to pay off the loan required to purchase them.

“Most of the companies have plans that if the new technology comes out you’re not going to have to spend another $50,000 to get the new technology,” he says.

D’Amelio says that although Ellman hasis positioned its products to fit in the lower rung of aesthetic pricing, the market was saturated with pre-owned equipment before he entered it,to provide physicians efficacious lasers and pre-owned “will always be out there in every field.

“When I was in endoscopy, we competed against our own products and our competitors’ products in the same marketplace,” he says. “We focus our salespeople on discussing our clinical performance, return on investment for our customers and value with physicians. I really don’t spend any time discussing the competition. We serve a larger market segment at a lower price point. It’s a different level of service; it’s a different infrastructure.”

Ellman services its customers directly and also operates authorized, third-party repair centers all over the world. “Our customers have invested with us and we in turn invest is supporting them,” D’Amelio says.

In a business where technologies come and go, he says, manufacturer longevity makes a difference, and Ellman leans on its 53-year operational history.

“When someone buys a laser from us, what do they get? A high quality product, clinical and safety training by a nurse and practice management support from our marketing staff,” he says.

Epstein says that refurbished equipment wouldn’t make it to his radar “unless someone had the laser I wanted and it was a demo unit of something I wanted.”

“There are certain pieces of equipment that never go out of style,” he says. “OR tables are still in demand 30 years later. They cost a fraction of new, they work perfectly well, and they do the job. Lasers are something that’s always getting better.”

And, according to Goldman, there are some very real challenges that even bleeding-edge cosmetic technology is still working to solve. There have not been home runs hit yet, as he puts it, for non-invasive technology in the fields of skin tightening and fat and cellulite treatments. “We’re still trying to finesse things,” he says.

“The problem is it’s very difficult to not cause pain with all of these technologies,” Goldman says. “When you sit down there and have one of these devices put on you, it is painful. Everyone has a different way of dealing with pain. But that’s another thing we still have to overcome.”

“There’s only so much fooling of the body that you can do.”