The Skinny on Medispas from the Wall Street Journal

This is a very important issue. We have seen patients significantly injured in spas. Many spas, including those run by physicians who have no experience in skin care, abandon patients who have problems. They are told "You better find someone to help you." This is a very sad situation.

Gerald N Bock MD

California Skin and Laser Center

Stockton & Lodi CA

Medical Spas Get a Checkup

States Weigh Tighter Rules on Cosmetic-Procedure Centers After Patient Injuries


States are tightening regulations on medical spas—and wading into some ugly disputes over where beauty treatments stop and the practice of medicine begins.

Medical spas are fast-growing hybrids between day spas and doctors' offices. They typically offer Botox injections, facial peels, laser skin treatments and other minimally invasive cosmetic procedures. Some add breast implants, tummy tucks and chin, face, brow and eyelid lifts as well.

Philip Montgomery for The Wall Street Journal

Nurse Paula Young, right, removes a tattoo with a laser Tuesday at her Bethlehem, Pa., clinic, which could be forced to close under new state rules.

The International Spa Association counts 1,750 across the U.S., up from 471 in 2003. Some of the growth comes from dermatologists and plastic surgeons adding services and amenities to their practices. But doctors trained in unrelated specialties, such as obstetricians or oral surgeons, also are supplementing their incomes with the lucrative procedures that are rarely covered by insurance, and many of the services are performed by a range of nonphysician personnel.

State regulations vary widely. Only a few require medical spas to be licensed. In some states, procedures from laser hair removal to liposuction can be performed by nonphysicians. Most require a medical doctor to oversee the services—though not necessarily to be on site or even in the same state.

Some serious injuries have prompted crackdowns. A month ago, Maryland Gov. Martin O'Malley signed a new law directing the state health department to oversee cosmetic-surgery facilities after one woman died and two others became seriously ill with Group A streptococcus infections traced to liposuction at a Baltimore clinic.

Florida now requires that liposuctions removing more than two pounds of fat be performed in a state-licensed surgical center with emergency equipment on hand, after two women died from overdoses of lidocaine, a local anesthetic. In California, it is now a felony, punishable by up to five years in prison and a $50,000 fine, for a corporate entity to own a medical spa; the majority owners must be M.D.s.

Pennsylvania is weighing tighter rules on who can provide laser treatments. Fourteen states are considering "truth in advertising" laws, many of which would require medical spas to list personnel's training and credentials in all marketing. Some proposals, like New York's, would require anyone who wears a white coat and treats patients to list credentials on a nametag.

The push for more regulation is being driven in part by dermatologists who say allowing nonphysicians to perform cosmetic procedures puts patients at risk.

"It's the difference between four years of medical school and four to five years of residency versus beauty school," says Timothy Flynn, president of the American Society for Dermatologic Surgery Association, which has lobbied for stricter rules in several states. The ASDSA considers any use of lasers, lights, electrical impulses, chemical peels, injections, insertions or tissue augmentation to be the practice of medicine, which it says should be performed by a physician or midlevel health professional, such as a physician assistant, under a doctor's supervision.


In a 2007 survey by the society, 56% of the 271 responding dermatologists said they had seen an increase in patients with complications—including blisters, burns, nerve damage and scarring—caused by nonphysicians doing cosmetic procedures. "Next week, I'm scheduled to see a patient who was injected with something by somebody in a garage," Dr. Flynn says.

Supporters of medical spas say they get a bad rap when it comes to injuries. "In 2009, there were over 9,000 deaths in hospitals related to errors, but one death occurs in a medical spa and it's on the national news," says Francis Acunzo, whose company, Acara Partners LLC, provides management advice for medical spas.

"I've treated patients who were burned at the hands of a doctor," says Paula Young, a nurse who owns three medical spas with her physician husband in Pennsylvania. She says she would have to lay off seven experienced laser technicians and close her tattoo- and hair-removal clinic under the state's proposal allowing only physicians or physician-supervised nurses and PAs to perform laser treatments.

Only a few states require medical spas to report injuries, so it is difficult to compare safety records. Spa supporters say it can be difficult for patients to learn complication rates for doctors' offices too.

Laws requiring that physicians perform procedures don't guarantee competence either, some critics say. "In New Jersey, only a doctor can do laser treatments—but it could be a psychiatrist," says David Goldberg, a dermatologist who owns medical spas in three states and teaches health law at Fordham University School of Law.

Several groups have sprung up to teach cosmetic procedures to doctors from other fields. The National Society of Cosmetic Physicians, for example, advertises two-day workshops in laser liposuction, breast augmentation and tummy tucks.

The proposed medical-spa law in New York would require doctors advertising themselves as "board certified" to specify which board. The American Board of Medical Specialties recognizes dermatology and plastic surgery but not cosmetic, aesthetic or anti-aging medicine.

Lynne McNees, president of the International Spa Association, suggests potential customers do as much research as they can on the procedures, the facility and the practitioners—starting with the local Better Business Bureau. "Intuition plays a big part," she adds. "If it doesn't feel right, don't do it."

Write to Melinda Beck at

April 06, 2013

Big Pores and Oily Skin

There are certain complaints and requests that are frequently mentioned by patients, but are problems for which we don't have good treatments. High on this list is the complaint about large pores. A cosmetic specialists we want to please our patients and give them outstanding results. It is frustrating to both physician and patient when we're forced to say that we don't have a decent treatment for a problem.

That's not to say that there have not been claims advanced by many device makers that their machine will reduce pore size, and there are a many providers out there offering these treatments. However, there is a long tradition of treatments that have been marketed and then fallen into disuse when it became clear that they produced no significant results. The placebo effect is significant, and it is not difficult to persuade patients that they have improvement, when little is visible.

We try to avoid such situations since we build long term relationships with our patients, and failing to deliver on our promises destroys the trust that is necessary for these relationships to develop.

In the March 2013 issue of the Dermatologic Surgery Journal there was a report of using intradermal injections of botulinum toxin to reduce the oiliness of the skin (sebum production) producing a high degree of patient satisfaction. Similar studies have suggested that pore size is also reduced by these treatments. If these observations hold up we will have the first effective and practical method for reducing pore size.

It should be noted that in this technique the depth of product placement is critical. Too superficial placement can fail to produce results and too deep placement can result in undesireable weakening of some muscles of facial expression. This procedure should be performed by an experienced and highly trained injector, not a family practitioner, gynecologist or nurse practitioner. Dermatologists developed and perform the largest number of these noninvasive procedures and, in general, have the greatest expertise in dealing with problems that may arise. 

Too often we see patients who have been treated by ancillary providers who are told, when a problem develops "You need to find someone who can help you". When you choose someone to provide cosmetic services, one of the things you should evaluate is how well they will be able to deal with a problem, if one develops.

Gerald N. Bock MD

California Skin & Laser Center

Stockon & Lodi, CA

Serving Galt, Valley Springs, Manteca, Modesto, Sacramento, Davis, Rio Vista, San Francisco, Fairfield, Concord and other Northern California communities

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March 25, 2013

Yes...Your Face is NOT Symmetrical

It is through continuing education that we get better and better. This past weekend I attended a workshop on the fine points of filler injection. Although we have been doing this for many years, our understanding continues to improve and our technique continues to advance.

No one has a completely symmetrical face, but symmetry is associated with beauty. As the face develops the two halves develop somewhat independently, and they are more like siblings than identical twins. It takes practice to appreciate the small differences between facial halves, but they are there if you look carefully enough. Having the ability to recognize this is the first step toward being able to correct this, resulting in a subtle but very noticeable improvement, producing a fresher and more youthful appearance.

When you look at yourself in the mirror you get primarily a two dimensional view of yourself. However, others see you from multiple angles and see you in three dimensions. With recent advances in understanding the anatomy of the face, and the locations of tissue loss with aging, new injection techniques have been developed that not only fill in the defects but recreate the curvatures and projections of youth. The results are often dramatic, while still looking very natural and subtle. Furthermore these new injection techniques greatly reduce the risk of bruising and are more comfortable than the older techniques.

To learn how this might apply to you, call us for a consultation at 800-500-5842 or 209-956-4260, or request an appointment through our web site

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA



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January 29, 2013

Brown Spot Treatment


Almost all of us are born with clear, youthful looking skin. As we age we tend to get brown discolorations which make our skin look muddy and loose it’s youthful shine. These discolorations make us look older and less healthy. We now have good treatments for almost all of these discolorations and we can make you look significantly more youthful.

Sun exposure over the years is the most common cause of discolorations and muddy looking skin. Good sun protection, with clothing, shade and sunscreens is essential to keeping your skin looking young.

Actinic keratosis are rough tan to brown pre-cancers resulting from sun exposure. We can now treat these well with the Blu-U light plus Levulan, which may sometimes be covered by insurance. At times topical medications such as Retin A, Retinol or 5 Flurouracil can also be used. These growths will also respond to the microlaserpeel or Sciton laser resurfacing. A series of microdermabrasions will also help.

Freckling and larger irregular brown spots called lentigines are also signs of sun damage and aging. These respond to treatment with the Broad Band Light, the microlaserpeel and Sciton laser resurfacing. Sometimes the Broad Band Light and the microlaserpeel are performed on the same day, frequently producing very impressive results.

Seborrheic keratoses, dark rough brown growths, more common in darker skinned individuals, respond well to treatment with the KTP laser. These spots are also the result of sun exposure, but they are not pre-cancers.

Finally melasma, also known as the mask of pregnancy, is an extremely common condition that has been very frustrating to  treat. It is made worse by hormones and is more common in women, particularly those with dark skin. In this condition the pigment is beneath the surface of the skin. For years we have treated it with topicals with mixed results, but we now have a rapid and effective treatment combining a microdermabrasion with the Medlite Q switched YAG laser. This usually produces very significant improvement in one to four treatments.

Gerald N Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

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January 12, 2013

Dramatically Improved Treatment for Melasma

Occasionally there becomes available a new treatment for a condition that we have had difficulty treating in the past. That has now happened with the treatment of melisma, the brownish discoloration on the face that occurs most commonly in women, but also occurs in some men. This is frequently seen with pregnancy and birth control pills and has also been called “the mask of pregnancy”.

The treatment involves performing a microdermabrasion followed immediately by treatment with a laser used for tattoo treatment. There is no downtime after the treatment, and the treatment is not painful. It requires between one and four treatments for significant improvement.

This is important because melasma is a common problem and has been a very frustrating condition to treat.

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

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January 05, 2013

The Sun Is Your Friend?

This is a photo of a 96 year old man. It compares his wrist to his shin. He never wore shorts.


Sun Damage

These changes take years to develop and progress for many years after sun exposure has been stopped. Sun protection from childhood is the answer. Clothing and /or shade is the best protection. Sunscreens can help, but they must be applied daily and re-applied regularly.

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

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December 02, 2012

Melanoma Detection

Melanoma is the deadliest skin cancer, killing about 12,000 americans each year. Melanoma detection should be relatively easy, since most of the melanomas are readily available to the naked eye. There is a new device called Melafind that is designed to be used by dermatoligists to help diagnose melanomas. I just attended a meeting where reviewers and users spoke unfaborably about the device. 

They feel it recommends too many biopsies and too frequently is unable to come to a conclusion about a lesion. What seems to be of much more value is the use of the dermatoscope. This is a device that presses a magnifying lens against the skin and enables the trained dermatologist to more accurately predict whether a pigmented lesion is suspicious. In Australia, where melanoma is epidemic, this device has enabled them to pick up much smaller melanomas than are typically picked up in the US. Early detection equals better cure rate.

While the dermatoscope is not a new device, we are becoming more skilled in using it. If you're concerned about melanoma and your dermatologist does not use a dermatoscope, find one who does.

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

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November 14, 2012

Choosing a Cosmetic "Provider"

I just returned from a weekend training course in fillers and botulinum toxin, given by the American Society for Dermatologic Surgery, and I thought I’d share some of the things I learned, particularly those relevant to choosing a provider for cosmetic procedures.

There are major shifts in the patterns of cosmetic procedures being performed. According to the American Academy of Plastic Surgeons, the number of invasive procedures performed by physicians of all specialties has decreased by 17% from 2000 to 2011, while the number of minimally invasive procedures performed has increased by 123% in the same time period.  This includes  628% increase in Botulinum toxin procedures and a 190% increase in the use of soft tissue fillers.

Dermatology is the specialty performing the largest number of these minimally invasive procedures.

In many offices or “salons”, you will be injected by “providers” who are “physician extenders”. You may be interested to know that to be trained to become a nurse, a nurse practitioner or a physician’s assistant requires between 500 and 2,800 hours of training. To become a dermatologist requires 18,720 hours of training.

The breadth and depth of the training, as well as the ongoing continuing education often makes a profound difference in the quality of care you receive. Today we saw a woman who had difficulty making an appointment for Botox, so she went to another office. She was back today because she was very dissatisfied with the results.

While we cannot promise perfection, we are committed to excellence, to ongoing education and to doing our best to give you outstanding results.

Gerald N. Bock MD

California Skin & Laser Center

Stockton & Lodi, CA

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October 21, 2012

Fat Removal by Injection

Several years ago there was a brief surge in publicity about a product called "Lipodissolve" or mesotherapy, claiming to reduce fat by local injections. While some people did see benefits, problems developed including scarring, skin deformation and painful lumps under the skin. The product, which was manufactured in Braxil, was never approved by the FDA which eventually forced the material off the market.

Lipodissolve contained a mix of phosphatidylcholine (PPC), which was thought to be the active ingredient, and deoxycholate, which was thought to be a carrier for PPC. However, subsequent studies showed that seoxycholate was, in fact, the compound that injured the fat cells. Studies on deoxycholate, now known as ATX-101, have continued and considerable new information has emerged. ATX-101 acts as a detergent, dissolving cell membranes. 

Continue reading "Fat Removal by Injection" »

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October 17, 2012

I recommend the following site:

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