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12. The Medi Spa and Other Practice Considerations
Sammy Sinno, Jeremie Oliver Piña
See Essentials of Aesthetic Surgery, pp. 143–159
PRACTICE BASICS
1. The Code of Federal Regulations requires that ambulatory surgical centers participate in Medicare through
the Center for Medicare and Medicaid (CMS). This entails limiting Medicare-covered surgical procedures to
those with duration of <90 minutes or <4 hours of postsurgical recovery and type of surgery in which
scenario?
A. Procedures that can generally result in extensive bleeding.
B. Procedures that generally require major or prolonged invasion into body cavities.
C. Procedures that directly involve major blood vessels.
D. Procedures that do not involve major blood vessels.
E. Procedures that are not generally an emergency or life-threatening in nature.
PRACTICE BASICS
2. An aesthetic surgeon has accepted a position in a new city. What is a useful strategy to market and establish
his or her practice early on?
A. Create a website only after you have started the new position.
B. Avoid speaking engagements, local radio, or television shows until you have become established in the
community.
C. The surgeon should establish a niche and identify the community's needs or what is lacking in other aesthetic
surgeons in order to stand out.
D. Patient referral patterns should be studied once every 1 to 2 years.
E. Minimize complementary services, like peels for facelift patients, or offering packages that combine surgical
and nonsurgical treatments, as this is a nonfavorable internal branding strategy.
PRACTICE BASICS
3. What is a good timeline to renew the practice website?
A. Never.
B. Once a month.
C. Every 6 months.
D. Every 2 to 3 years.
E. Rarely change, as consistency is important to patients.
PRACTICE BASICS
4. Which of the following is the best strategy to capitalize on growth and expansion of the practice?
A. Hire outside services.
B. Add a partner or nonphysician provider to the practice.
C. Carefully project goals and finances often.
D. Invest in new equipment and products.
E. Spend more on marketing than other aesthetic providers in your area.
AMBULATORY SURGERY FACILITY CERTIFICATION AND STANDARDS
5. Which type of practice setting would require American Association for Accreditation of Ambulatory Surgery
Facilities, Inc. (AAAASF) accreditation?
A. Any practice offering aesthetic services.
B. Only practices in the state of California.
C. Only practices in the state of Texas.
D. Any practice offering procedures under sedation or general anesthesia.
E. Any practice offering invasive procedures of any kind.
70 Part IV&Skin Care
AMBULATORY SURGERY FACILITY CERTIFICATION AND STANDARDS
6. An ambulatory surgery facility has a class A accreditation; which of the following is allowed at this facility?
A. IV and parenteral sedation only.
B. Oral medications producing minimal or moderate sedation.
C. Regional blocks.
D. Spinal or epidural anesthesia.
E. LMA or endotracheal intubation.
LEGAL CONSIDERATIONS
7. As per mandate by the American Society of Plastic Surgeons (ASPS), American Society of Plastic Surgeons
(ASAPS) (The Aesthetic Society), American Medical Association (AMA), and Center for Medicare Services (CMS),
all practices offering procedures requiring more than just local anesthesia or oral sedation must comply with
which of the following accreditation councils?
A. Medicaid certification.
B. Federal licensure.
C. American Association of Plastic Surgeons (AAPS).
D. American College of Surgeons (ACS).
E. Accreditation Association for Ambulatory Health Care (AAAHC).
LEGAL CONSIDERATIONS
8. Which of the following statements is true regarding nonphysician aesthetic providers?
A. Very few states allow for nonphysicians to administer aesthetic services.
B. A board-certified physician must be in the room observing nonphysician providers.
C. It is difficult to train nonphysician providers to perform aesthetic office services.
D. They are able to offer nonsurgical aesthetic services when competent, trained, and licensed.
E. Nonphysician providers are fully responsible for complications of treatment they provide.
PATIENT SELECTION AND PATIENT SAFETY
9. Which of the following aesthetic procedures, when combined with an additional procedure, puts patients at
greatest risk of postoperative complication?
A. Rhinoplasty.
B. Blepharoplasty.
C. Facelift.
D. Breast augmentation.
E. Abdominoplasty.
Chapter 12&The Medi Spa and Other Practice Considerations 71
Answers
PRACTICE BASICS
1. The Code of Federal Regulations requires that ambulatory surgical centers participate in Medicare through the
Center for Medicare and Medicaid (CMS). This entails limiting Medicare-covered surgical procedures to those with
duration of <90 minutes or <4 hours of postsurgical recovery and type of surgery in which scenario?
D. Procedures that do not involve major blood vessels.
The Code of Federal Regulations requires that ambulatory surgical centers participate in Medicare
through the Center for Medicare and Medicaid (CMS). This entails limiting Medicare-covered surgical
procedures to those with duration of <90 minutes or <4 hours of postsurgical recovery, and to those type
of surgeries that: Do not generally result in extensive bleeding, do not require any major or prolonged
invasion into body cavities, do not involve major blood vessels, and are generally an emergency or lifethreatening in nature.
REFERENCE
1. U.S. Government Publishing Office. Electronic Code of Federal Regulations, Title 42, Part 416. Available at www.
ecfr.gov
PRACTICE BASICS
2. An aesthetic surgeon has accepted a position in a new city. What is a useful strategy to market and establish
his or her practice early on?
C. The surgeon should establish a niche and identify the community's needs or what is lacking in other
aesthetic surgeons in order to stand out.
Depending on the landscape of the community of practice, an aesthetic surgeon will be most successful if
he or she can establish a special niche area, which may be lacking in other aesthetic practices in that
geographic region. Although it is always wise to maintain a broad, comprehensive skillset in all that
aesthetic services have to offer, a niche area can identify why your practice and medi spa are unique or
novel. Having an attractive and informative website should start early, even months before the doors
open and would be best created by a web designer. External marketing strategies such as community
outreach and engagement of referral sources should also be a priority early on. Additionally, noninvasive
cosmetic procedures or suggestion of complementary services are powerful tools to garnish direct
patient referrals.
1
1
REFERENCE
1. Nahai F, Colon GA, Lewis W, et al. The practice: models, management, and marketing. In: Nahai F, ed. The Art of
Aesthetic Surgery: Techniques and Principles. 2nd ed. New York: Thieme Publishers; 2010
PRACTICE BASICS
3. What is a good timeline to renew the practice website?
D. Every 2 to 3 years.
With advances in technology, internet sources, referral bases, and patient preferences, it is advisable to plan
to update the practice website every 2 to 3 years at a minimum. Hire a full-time social media/website manager to thoroughly study the trends in marketing and advertisement of the practice.
PRACTICE BASICS
4. Which of the following is the best strategy to capitalize on growth and expansion of the practice?
C. Carefully project goals and finances often.
Aesthetic surgeons should set goals for themselves and their practice for financial growth, practice expansion, patient management, and experience. Although projections and goal calculations can certainly be time
consuming, goals may go unfulfilled if this is not done. Careful planning and research will allow surgeons to
balance their income and assets with expenses and future goals.
1
72 Part IV&Skin Care
REFERENCE
1. Kuechel MC. The prac tice: staffing, services, and financial planning. In: Nahai F, ed. The Art of Aesthetic Surgery:
Techniques and Principles. 2nd ed. New York: Thieme Publishers; 2010
AMBULATORY SURGERY FACILITY CERTIFICATION AND STANDARDS
5. Which type of practice setting would require American Association for Accreditation of Ambulatory Surgery
Facilities, Inc. (AAAASF) accreditation?
D. Any practice offering procedures under sedation or general anesthesia.
Initially established by plastic surgeons, the American Association for Accreditation of Ambulatory
Surgery Facilities, Inc. (AAAASF, formerly the American Association for Accreditation of Plastic Surgery
Facilities) helps promote quality control and patient safety in ambulatory surgery centers all around the
country. Today, most state departments of health accept accreditation through the AAAASF instead of
state licensure, as well as offer Medicare certification.
1,2,3
REFERENCES
1. American Association for Accreditation of Ambulatory Surgery Facilities. Regular Standards and Checklist for
Accreditation of Ambulatory Surgery Facilities. Available at www.aaaasf.org
2. American Society of Plastic Surgeons and American Society for Aesthetic Plastic Surgery, Inc. Policy Statement on
Accreditation of Office Facilities. Available at www.plasticsurgery.org
3. American Medical Association. Office-based Surgery Core Principles. Available at www.ama-assn.org
AMBULATORY SURGERY FACILITY CERTIFICATION AND STANDARDS
6. An ambulatory surgery facility has a class A accreditation; which of the following is allowed at this facility?
B. Oral medications producing minimal or moderate sedation.
Accreditation of ambulatory surgery facilities can vary based on safety precautions and resources
available at each surgery center. Class A accreditation allows for oral medications producing minimal or
moderate sedation as well as topical or local anesthesia. The classification system allows for the most to
be administered at Class C facilities, and the least to be offered at Class A facilities. Both Class C and Class
C-M accredited surgery facilities are permit ted to administer propofol and spinal/epidural anesthetic
agents. The differentiator bet ween Class C-M and Class C is that Class C certification allows for
inhalational agents to be administered to patients, as well as use of laryngeal mask airway (LMA) or
endotracheal intubation. In general, there are more mandates as the anesthesia becomes more invasive.
1
REFERENCE
1. American Association for Accreditation of Ambulatory Surgery Facilities. Regular Standards and Checklist for
Accreditation of Ambulatory Surgery Facilities. Available at www.aaaasf.org
LEGAL CONSIDERATIONS
7. As per mandate by the American Society of Plastic Surgeons (ASPS), American Society of Plastic Surgeons
(ASAPS) (The Aesthetic Society), American Medical Association (AMA), and Center for Medicare Services (CMS),
all practices offering procedures requiring more than just local anesthesia or oral sedation must comply with
which of the following accreditation councils?
E. Accreditation Association for Ambulatory Health Care (AAAHC).
ASPS and ASAPS mandated in 1999 that members performing plastic surgery using more than local
anesthesia or oral sedation should be in a facility with either:
*
State licensure,
*
Medicare certification, or
*
Accreditation by an organization like the AAAASF, Accreditation Association for Ambulatory Health Care
(AAAHC), or Joint Commission on the Accreditation of Health Care Organizations (JCAHO).
The mandate does not require practices to obtain accreditation or licensure through all of these agencies.
Rather, any one of them would offer sufficient accreditation on its own to verify the safety of the practice
facility based on the ASPS, ASAPS, AMA, and CMS standards.
1
Chapter 12&The Medi Spa and Other Practice Considerations 73
REFERENCE
1. American Society of Plastic Surgeons and American Society for Aesthetic Plastic Surgery, Inc. Policy Statement on
Accreditation of Office Facilities. Available at www.plasticsurgery.org
LEGAL CONSIDERATIONS
8. Which of the following statements is true regarding nonphysician aesthetic providers?
D. They are able to offer nonsurgical aesthetic services when competent, trained, and licensed.
Nonphysician aesthetic providers can be a vital part of any practice's success. From 2012 data as cited in
the text, office injectable procedure numbers in the U.S. increase by 20% when those by nonphysician
injectors are included. As demand continues to rise faster than the number of board-certified physicians
can accommodate, practice productivity and revenue can multiply with surgeries, while qualified
nonphysician providers perform nonsurgical cosmetic procedures.
1
REFERENCE
1. American Society for Aesthetic Plastic Surgery. News releases: cosmetic procedures increase in 2012. Available at
www.surgery.org
PATIENT SELECTION AND PATIENT SAFETY
9. Which of the following aesthetic procedures, when combined with an additional procedure, puts patients at
greatest risk of postoperative complication?
E. Abdominoplasty.
Although abdominoplasty procedures are not associated with a higher risk for overall postoperative
morbidity, the data do support that when combined with an additional procedure, abdominoplasty
carries a statistically significant higher risk for postoperative complications compared to all other
aesthetic procedures. In order to minimize potential complications, the aesthetic surgeon should remain
vigilant, avoid hypotensive surgery, and thoroughly evaluate such patients undergoing combined
procedures before their discharge from the PACU.
1,2,3
REFERENCES
1. Soltani AM, Keyes GR, Singer R, et al. Outpatient surgery and sequelae: an analysis of the AAAASF internet-based
quality assurance and peer review database. Clin Plast Surg 2013;40:465
2. Iverson RE, Gomez JL. Deep venous thrombosis: prevention and management. Clin Plast Surg 2013;40:389
3. Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast
Reconstr Surg 2002;110:1337
13. Anatomy, Physiology, and Disorders of the Skin
Sammy Sinno, Jeremie Oliver Piña
See Essentials of Aesthetic Surger y, pp. 181–190
ANATOMY
1. Which of the following cell types provides UV protection to the skin?
A. Keratinocytes.
B. Melanocytes.
C. Merkel cells.
D. Langerhans cells.
E. Squamous cells.
ANATOMY
2. Which epidermal cell layer is mitotically active, providing stem cells to repopulate the epidermis each month
(Fig. 13.1)?
A. Stratum corneum.
B. Stratum lucidum.
C. Stratum granulosum.
D. Stratum spinosum.
E. Stratum basale.
Stratum corneum
Stratum lucidum
Stratum granulosum
Stratum spinosum
Stratum basale
Papillary dermis
Epidermis
Fig. 13.1 Layers of the skin with adnexal structures.
(Source: Anatomy. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
SKIN PHYSIOLOGY
3. What is the approximate ratio of type I:III collagen in the dermis of a normal adult?
A. 1:1.
B. 2:1.
C. 4:1.
D. 3:1.
E. 5:1.
Reticular dermis
Dermis
Hypodermis
Chapter 13&Anatomy, Physiology, and Disorders of the Skin 75
SKIN PHYSIOLOGY
4. Which of the following characteristics of skin is most relevant to surgical planning of scar formation?
A. Pigmentation.
B. Comedones.
C. Pore size.
D. Gland density.
E. Fitzpatrick type.
SKIN PHYSIOLOGY
5. Which cell type is the most important in regulating promotion of growth factors and affecting wound
healing?
A. Neutrophils.
B. Basophils.
C. Macrophages.
D. Fibroblasts.
E. Melanocytes.
SKIN PHYSIOLOGY
6. A patient is told to stop smoking cigarettes 4 to 6 weeks prior to her upcoming breast augmentation surgery.
By having her stop cigarette use, what primary negative effect on wound healing are you trying to mitigate?
A. Epithelial injury.
B. Endothelial injury.
C. DNA strand breaks and helical cross-linking.
D. Increased inflammatory state.
E. Peripheral microvascular vasoconstriction.
SKIN PHYSIOLOGY
7. Final scar healing strength will reach a maximum of 80% original strength by approximately __ days.
A. 15.
B. 30.
C. 45.
D. 60.
E. 90.
FACTORS AFFECTING WOUND HEALING
8. In which of the following skin conditions can surgical correction be beneficial?
A. Ehlers-Danlos.
B. Elastoderma.
C. Cutis laxa.
D. Progeria.
E. Stevens-Johnson syndrome.
FACTORS AFFECTING WOUND HEALING
9. Which of the following medications is associated with decreasing collagen synthesis?
A. Antineoplastic agents.
B. Interferon.
C. Nicotine.
D. Systemic anticoagulants.
E. Anti-inflammatory agents.
76 Part IV&Skin Care
SKIN ANALYSIS
10. How does treatment approach differ for static versus dynamic rhytids of the face?
A. Static rhytids cannot be treated, dynamic rhytids can.
B. Static rhytids do not respond well to surgery.
C. Dynamic rhytids require excision of muscle.
D. Static rhytids can be treated with laser resurfacing, fillers, or surgery.
E. Dynamic rhytids do not respond well to botulinum toxin injection.
SKIN ANALYSIS
11. In determining aggressiveness of a melanoma, which of the following characteristics is most predictive of
staging and prognosis?
A. Asymmetric shape/border.
B. Dark pigmentation.
C. Ulceration.
D. Depth >2 mm.
E. Evolution of morphology.
PHYSIOLOGY OF COMMON MEDICAL SKIN THERAPIES
12. A retired farmer presents with multiple, small, rough and scaly erythematous plaques on his face. Which of
the following is an appropriate initial course of action in treating this patient?
A. Watch and wait.
B. Topical 5-FU.
C. Steroid injection.
D. Standard surgical excision.
E. 2.5% Hydrocortisone cream.
PHYSIOLOGY OF COMMON MEDICAL SKIN THERAPIES
13. Which of the following potentially predisposing factors contributes most to a patient's increased likelihood
of developing malignant melanoma?
A. Frequent current sun exposure.
B. History of sun burns as a teenager.
C. Family history of melanoma.
D. Multiple actinic keratoses.
E. Fitzpatrick type I skin.
Chapter 13&Anatomy, Physiology, and Disorders of the Skin 77
Answers
ANATOMY
1. Which of the following cell types provides UV protection to the skin?
B. Melanocytes.
As the pigment-producing (melanin) skin cells, melanocytes provide the skin with UV protection.
Melanocytes are located mostly within the basal layer of the epidermis.
REFERENCE
1. Chu DH, Haake AR, Holbrook K, et al. The structure and development of skin. In: Freedberg IM, Eisen AZ, Wolff K,
et al, eds. Fitzpatrick's Dermatology in General Medicine. 6th ed. New York: McGraw-Hill; 2003
ANATOMY
2. Which epidermal cell layer is mitotically active, providing stem cells to repopulate the epidermis each month
(Fig. 13.1)?
E. Stratum basale.
The stratum basale is mitotically active, providing stem cells to the upper layers of the epidermis for
differentiation. In regenerative medicine, these epidermal stem cells can be modified in vitro (inducedpluripotent stem cells, iPSCs) and used for stem cell replacement of other tissue types in the body.
1
1
REFERENCE
1. Chu DH, Haake AR, Holbrook K, et al. The structure and development of skin. In: Freedberg IM, Eisen AZ, Wolff K,
et al, eds. Fitzpatrick's Dermatology in General Medicine. 6th ed. New York: McGraw-Hill; 2003
SKIN PHYSIOLOGY
3. What is the approximate ratio of type I:III collagen in the dermis of a normal adult?
C. 4:1.
The dermis is the component making up the majority of the skin tissue. It is divided into a papillary (superficial) and reticular (deep) layers and is composed primarily of elastic fibers and collagen (types I and III in a
4:1 ratio) maintained by fibroblasts.
1,2
REFERENCES
1. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconst Surg 2014;133:199e
2. Glat P, Longaker M. Wound healing. In: Aston SJ, Beasley RW, Thorne CH, et al, eds. Grabb and Smith's Plastic
Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1997
SKIN PHYSIOLOGY
4. Which of the following characteristics of skin is most relevant to surgical planning of scar formation?
D. Gland density.
Glands in the skin come in several varieties, including sebaceous, eccrine, and apocrine. Their primary
functions involve maintaining skin hydration, assisting with thermal regulation, and providing a
regenerative source for the epidermis to repopulate. Increased gland density (particularly in the face)
allows for resurfacing procedures to have positive effect; on the other hand, reduced gland density (i.e.,
below the jawline) delays epidermal regeneration, which can lead to more severe scarring.
1,2
REFERENCES
1. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconst Surg 2014;133:199e
2. Glat P, Longaker M. Wound healing. In: Aston SJ, Beasley RW, Thorne CH, et al., eds. Grabb and Smith's Plastic
Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1997