M.D. Update June 2011 - Plastic Surgery

The Business Magazine of Kentucky Physicians and HealthCare Administrators JUne 2011

Issue Spotlight:

Plastic Surgery

The Gilded Era of

Aesthetic Medicine

With so many unqualified hands reaching in the pot, the hottest question in aesthetic medicine is whose hands are on the patient?

Volume 2, Number 6

Also inside

More perspectives on the aesthetic medicine and cosmetic and plastic surgery from Dermatologists, Hand Surgeons, and an Oculofacial Plastic Surgeon New contributors in IQ: Marketing, Estate Planning

Discover the Experience that New Moms are Buzzing About.

The Women’s Hospital at Saint Joseph East celebrated its first anniversary March 29, 2011. In our first year alone, we helped deliver more than 2500 bundles of joy to new moms across central and eastern Kentucky. The Women’s Hospital at Saint Joseph East offers moms-to-be a comfortable, family centered environment and spacious rooms. To learn more about what new moms are buzzing about, call 859.967.2229 or for a virtual tour, visit us online at www.SaintJosephEastKY.org.

Unique Care for Women Also Available at The Women’s Hospital at Saint Joseph East Michelle Morton, M.d.

Saint Joseph cardiology Associates 170 n. eagle creek, Suite 104 859.629.7100 credentiAlS American Board of cardiology SPeciAltY echocardiography, nuclear cardiology & diagnostic cardiac catheterization PrActice FocUS AreA Women’s cardiac disease, hyperlipidemia, cAd, chF & Preventive cardiac disease

kriSti h. Mckenzie, M.d.

Saint Joseph obstetrics and Gynecology Associates 170 n. eagle creek, Suite 104 859.967.5848 credentiAlS American Board of obstetrics & Gynecology and Fellow of AcoG SPeciAltY laparoscopic Surgery and Minimally invasive Procedures PrActice FocUS AreA Abnormal Periods, Fibroids, hormone replacement and obstetrics

2011 EDITORIAL CALENDAR 2011 EDITORIAL CALENDAR APRIL

Or thopedics & Spor ts Medicin e

MAY

Women’s Health

JUNE

Derm atology, Plastic Surger y & Allergies

JULY *

Intern al Medicin e & Prim ar y Care

AUGUST *

Pediatrics & ENT

SEPTEMBER

Urology & Nephrology

OCTOBER

Oncology

NOVEMBER

Neuroscience

DECEMBER

Psychiatr y & Ment al Health

Submission Deadline: Second Friday of the month before issue

JOIN TH E CLUB! Cont act us tod a y.

Gil Dunn, Publisher (859) 309-0720 phone gdunn@md-update.com Megan Campbell Smith, Editor-in-Chief (859) 309-9939 phone mcsmith@md-update.com mcsmith@md-updat

Letters

FROM THE DESK OF

Gil Dunn, publisher of M.D. Update

Kentucky Issue Volume 2, Number 6 June 2011 Publisher

Gil Dunn gdunn@md-update.com Editor in Chief

At the Intersection of Medicine, Marketing and Money

It seems to me that if we purchased all our health care like we purchased our homes, cars, food, and the other essentials for living in the USA in 2011, we would: 1) Buy more than we could afford to pay cash for and buy it on credit; or 2) Buy what we needed when we needed it, wanted it, and could afford it.

Which brings me to elective aesthetic medicine and some - not all - of the surgeries performed by plastic surgeons. Aesthetic or cosmetic surgery is the current best example of the consumer, aka patient, buying what he wants or needs, in the open marketplace, and paying a price for it.

Marketing, media and advertising have more impact in the decision making process for aesthetic surgery than anywhere else in healthcare because the patient, aka consumer, elects to engage the physician’s services. Advertising and marketing, in their many media forms, strongly influences that decision.

I’m certain that none of this is a revelation to our readers, but it brings me to the point, so well put by the physicians in this month’s M.D. Update, that patients choose their plastic and aesthetic surgeon based on the physician’s reputation and skill set. As Dr. Marc Salzman told me, no one chooses the second

BY Gil Dunn best plastic surgeon.

Reputation is critical, maybe the most important element of marketing and advertising. In this month’s edition, guest columnist Larry Trimmer, president of Strategic Media, addresses some of the differences between advertising and marketing and the need for both in a healthy business.

Aesthetic medicine and aesthetic surgery providers tend to lead the pack in leveraging marketing and advertising to the benefit of their practices’ financial success.

We’re happy to share many physician stories this month while we focus on plastic surgery, oculofacial plastics, and dermatology.

Next month, look for a Special Section on Sleep Medicine in advance of the annual fall meeting of the Kentucky Sleep Society. Please contact us if your specialty is coming up on the editorial calendar.

Until then, All the Best, Gil Dunn

Submit your Letter to the Editor to Megan Campbell Smith at mcsmith@md-update.com 2 M.D. Update

Megan Campbell Smith mcsmith@md-update.com Associate Editor

Greg Backus gbackus@md-update.com Photographer

Kirk Schlea kirk@ md-update.com Writers

Jennifer S. Newton Graphic Designer

James Shambhu art@md-update.com

Contributors:

Scott Neal Patricia Cordy Henricksen Calvin Rasey Larry Trimmer

Send your Letters to the Editor to: mcsmith@md-update.com

Mentelle Media, LLC

921 Beasley Street, Suite 210 Lexington, KY 40509 (859) 309-9939 phone and fax Mentelle Media, LLC is locally owned and operated. Mentelle Media strives to produce top quality referral and marketing resources for Kentucky’s professionals by welcoming the participation of our readers. For more information about how your business or medical practice can get involved, contact Gil Dunn at (859) 309-0720.

Standard class mail paid in Denver Co. Postmaster: Please send notices on Form 3579 to 921 Beasley Street, Suite 210 Lexington, KY 40509 M.D. Update is peer reviewed for accuracy.

However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials.

Copyright 2010 Mentelle Media, LLC. Contact Mentelle Media for information on obtaining reprints. Individual copies of M.D. Update are available for $7.95.

Contents

June 2011 Volume 2, Number 6

2 FROM THE DESK OF

cover story

5 FINANCE 6 MARKETING 8 Coding and Compliance 13 ESTATE PLANNING 14 COVER STORY 21 SPECIAL SECTION

AESTHETIC MEDICINE & Aesthetic Surgery 22 DERMATOLOGY 24 PLASTIC SURGERY

The Gilded Era of Aesthetic Medicine With so many unqualified hands reaching in the pot, the hottest question in aesthetic medicine is whose hands are on the patient?

Page 14

28 HAND SURGERY 29 OCULOFACIAL PLASTICS 32 PLASTIC SURGERY 34 DERMATOLOGY 36 GRAND ROUNDS 44 INDICES

On the Cover:

Globally renown surgeons Stephen A. Schantz, MD, and S. Randolph Waldman, MD, of Waldman Schantz Plastic Surgery Center of Lexington.

special section Investigating Aesthetic Medicine & Aesthetic Surgery from the multi-specialty perspective.

22 Dermatology

24Cosmetic 29 Oculofacial Plastic Surgery Plastics

32 Plastic Surgery 34 Dermatology JUne 2011 3

4 M.D. Update

Finacial

Investment Headwinds 2011 Much has been said about the ending of QE2, the Fed’s policy of injecting liquidity into the economy, which is set for the end of June. Recall that the intent of quantitative easing is to increase spending and therefore provide a boost to the economy. That simply has not happened. Instead of finding its way into the bank accounts of consumers, via increased borrowing, the new funds have found their way into the stock market, driving it up. Now that the flow of funds is ending, many people fear that the stock market has begun a serious decline since price-to-earnings ratios are significantly higher than their long term averages.

Analysts and traders have been looking for hints from Ben Bernanke that QE3 is on the horizon, but as of this writing at the beginning of June, he has offered nothing but disappointment.

It was surprising then, to hear more than one CEO of large institutional investment companies say that they expected the S&P 500 to grow by 10-20% this year.

Makes one wonder if they are simply engaging in wishful thinking or exactly what elixir they have been drinking.

I think that you will agree that the

Europe’s debt problem has not been resolved.

Investors haven’t bought into Europe’s bail-out strategy which

BY Scott Neal relies heavily on the belief that countries receiving funds can fix their problems AND pay back their debt. Mandated budget cuts and other austerity measures will only serve to weaken economies that are already on the brink and lack the tools to help themselves. In addition, the higher borrowing costs create a vicious cycle of rising debt levels undermining future growth. Debt still remains the big story of the decade.

Prices and costs are rising.

The CPI energy index has risen 19.0% over the past 12 months, with the gasoline component increasing 33.1% over the same period.

At some point, these increases have to make their way into the core inflation numbers and

Over the past few weeks, the list of potential negatives has grown to the point that I believe we could be witnessing a major shift in the markets.

financial markets are inextricably linked to the economy. Furthermore, economies around the world are now so inter-linked that one can attest to the old adage that when a butterfly flaps her wings in Asia (or anywhere else for that matter) the wind changes direction in New York. I have written extensively on how this is so in previous articles in this space. Over the past few weeks, the list of potential negatives has grown to the point that I believe we could be witnessing a major shift in the markets.

Here are some of my current concerns:

the prices we all pay for goods and services.

The CPI-All items index is up 3.2% over the past twelve months to its highest figure since 2008. I still do not place a higher probability on very high inflation. Demand is slowing, not increasing, but we may see more volatility in prices resulting in knee-jerk reactions which will cause the prices of stocks and bonds to gyrate more than usual.

Credit availability remains tight.

Loan demand has started to decline and

credit standards remain more restrictive than earlier in the decade. Demand for both consumer and business loans continues to show weakness, underscoring the fact that the economic growth is far from robust.

It remains very difficult for many to get a home equity loan and nearly impossible to get a construction loan.

Volatility in the commodity markets has increased.

The decline in commodities such as silver, gold and oil over the past few weeks is a combination of overleveraged speculators bailing out, and an overreaction to recent moves in the dollar. As is frequently the case with speculative bubbles, this sell-off may get overdone.

The U.S. government is pretending to be fiscally responsible.

There has been much media talk about reining in government spending; however, no real cuts have been made. If Washington does not solve this problem, the bond vigilantes will. And they will drive up interest rates in the process.

What to do?

In the face of these headwinds, we remain focused on building portfolios that succeed in a global context. We believe that for most investors there are still three objectives that must be satisfied to keep your long term goals reasonably attainable:  Preserve your capital. Do not let small losses turn into large ones.  Seek reasonably consistent returns.

Make friends with volatility.  Take advantage of opportunities where and when they arise.

Risk control has been our mantra since 2007. It is as important today as ever before.

As always, if you have questions about anything contained here let me know.

Scott Neal is President of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm. Questions and comments can be emailed to scott@dsneal.com or you may call 1-800-344-9098. ◆ JUne 2011 5

Marketing

“Advertising” or “Marketing” As I watched a few hours of television recently, I reflected on just how much the advertising world has changed in recent years. Sure, there were any number of car dealers celebrating the “biggest sale in their history”, the world’s “healthiest” cereal, the credit card that promised to make me wealthy with “points”, and a lovely bikiniclad woman directing me to the “tastiest burger” in the world. No surprises here.

In the same viewing period, I was presented with a long list of revolutionary drugs that I am supposed to make note of and ask my doctor about. There was a Board Certified eye surgeon offering to fix my eyes with his laser. There was another Board Certified surgeon offering to take years off my appearance with yet another laser. There was a major hospital touting its cardiac repair robot, and an imaging center reassuring me of complete comfort in an “open MRI”. The list, of course, goes on, as does the changing business climate in the medical field.

The drug companies view your patients – current and potential – as their customer. These pharmaceutical firms are driving their customer to the door of the physicians and/or the pharmacies. Meanwhile, they are closing the marketing loop of physician to customer by providing you with the latest samples, educating you on the pros and cons of the drugs and creating the perfect environment for selling their product. They are working from a marketing plan.

When I begin a consultation with a medical practice I often hear the words, “We are considering doing some marketing.” What they mean is that they “are considering doing some advertising” but are having a hard time saying the word.

Marketing is a sophisticated term void of scrutiny, while many view advertising as a synonym for tawdry. It is not a battle of semantics. It is a battle of mindset. At this point in my consultation, I might inject that I consider missed cash flow projections and the subsequent onset of poverty as being truly tawdry.

Advertising is just one part of a marketing plan. If your doors are open, you are 6 M.D. Update

engaged in marketing whether you think of it or not. Your décor is designed to make your patients comfortable. Your selection of waiting room reading matter hopefully

BY Larry A. Trimmer doesn’t happen by accident. The way your staff interacts on the telephone and face-to-face with patients and the way the staff dresses is planned to be reassuring and professional. Marketing is patient interaction, patient retention, public relations, graphic design, and so on. Advertising is just one element of an overall marketing plan.

This is where I ask you to make a gigan-

marketing plan will obviously involve the media, raising the questions of which combination of media, which specific media outlets, how many ads, how often, and of course how much will it cost? Then there is also the question of the ad itself. A perfectly planned and funded ad campaign can be torpedoed by a bad ad, regardless of the media selected. Working with the right advertising professional(s) can make this process both easier and more cost effective.

Beware of anyone ready to “diagnose” your particular need without a thorough “examination”. Don’t become a victim of advertising malpractice.

A professional will want to talk with you about your current patient/customer profile and determine if you want more of the same or a change in that profile. S/he will want to discuss the things that make your

When I begin a consultation with a medical practice I often hear the words, “We are considering doing some marketing.” What they mean is that they “are considering doing some advertising” but are having a hard time saying the word. tic leap in mindset by simply re-reading the above paragraph and substituting the word “customer” for “patient”. If you do so (without your head exploding) you are going to start to envision new business opportunities and new ways to refine your marketing; and advertising might just be the next step in that plan.

Advertising is how you reach out to prospective new (patient) customers. When I am in your exam room under your care, I am a patient. When I am on-hold for twenty minutes to make an appointment, I am an angry customer. If I have never heard of you, I am a business prospect for you (or for your competitor). If you want me to be your patient, perhaps you should invite me to be your customer before the guy down the street does. Advertising is how you “invite” growth for your business.

The advertising part of your expanding

practice unique and how you view your competitive environment, what advertising (if any) you have done in the past, and what did or didn’t perform as expected. S/he will ask what growth you expect for the practice in the next year and the next five years and how success will be measured. There will, and should be, many questions.

The next steps will be the development of a preliminary media plan and setting the budget required to fund it. Once the plan is approved the creative process begins, and the ads begin to take shape. For many of my clients this is where the real fun begins.

Just as your practice came into being with an executed business plan, your growth depends on your marketing plan. Taking control over that aspect of your business is critical for long-term success.

Continues on page 9 >

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JUne 2011 7

Coding & Compliance

A Primer on the Transition to EHR There is a massive effort by the Centers for Medicare and Medicaid Services (CMS), to modernize America’s health care delivery information system. The intent for accomplishing this task lies in a transition from the age-old paper charting system to Electronic Health Records (EHR), an electronic software information system that will promote ease of patient documentation. This transition has been long anticipated and makes perfect sense in the present environment to bring Health Information Management into the electronic information age. In order to encourage provider participation, CMS is providing incentives to eligible providers who “can demonstrate meaningful use of certified EHR technology to CMS by attesting to their compliance with program requirements”.

Clearly one of the main purposes of EHR is to provide a consistent method for communication among physicians, nurses, labs, and other healthcare professionals without having to rely on hand-written or transcribed notes stored in a particular location that must be transferred by a method other than rapid response. EHR allows access to patient information from multiple locations with password-protected security, offering instant access for doctors’ orders that will complement services provided for patient care. EHR provides for streamlining of communications and improvement for the consistency of patient care, thus enabling health care providers and facilities to function more efficiently and costeffectively, according to CMS. EHR falls naturally into the area of health care compliance in that its use must comply with all aspects of patient care, including documentation of every service provided, proper coding of each diagnosis and treatment procedure, and implementation of evidence-based protocols with protection of patient information, not only from those outside the health care system but from anyone who may have unauthorized access within the facility or physician’s office. Thorough and correct documentation of patient care also provides the foundation for legal defense when a provider 8 M.D. Update

BY

Patricia Cordy Henricksen

or facility faces a potential challenge. The adoption of EHR provides a response to the need for compliance with legal requirements, as they are vital tools for the protection of patient privacy

and security.

The transition to EHR will require astute management and constant finetuning for adaptation to the physician’s specialty since many of the EHR software programs incorporate tools with defaults, including functions for Chief Complaint, PFSH, ROS, and Medical Necessity, all designed to help providers document more effectively. Audit findings, however, reveal that these functions are not always indicat-

lead to audits, which lead to unintended consequences like fraud and abuse charges and penalties. According to HIPAA, fraud occurs when an individual “knows or should have known” about improper practices being performed. That language shifts responsibility for thoroughly understanding coding and documentation conventions to anyone submitting claims and focuses the responsibility directly on the providers, who have a due diligence obligation to identify and proactively prevent fraud. When using EHR, it is essential to be mindful of these potential pitfalls:  Take special care when using templates, as they are not always pertinent for the specific treatment  Document each encounter specifically and in your own words. Copy and paste functions are often perceived as cloning.  Review each note for accuracy before closing the program. Once closed the only option for change is an addendum.

The transition to EHR will require astute management and constant fine-tuning since many of the programs incorporate tools with defaults... all designed to help providers document more effectively. Audit findings, however, reveal that these functions are not always indicated - or even performed - at each visit.

ed, or even performed, at each visit. If the provider does not review each record thoroughly and make corrections to the default information on an individual patient basis, the EHR will not reflect the true nature of the patient’s condition or information gathered at that visit.

Inaccurate documentation poses serious health dangers for the patient. Most problems with the use of EHR arise not because a provider diagnoses or prescribes incorrectly, but because inaccurate documentation leads to coding or compliance errors, which

 Addenda should only be provided in order to clarify or report clinical information, never for revenue-based information.  Discuss EHR issues with coders and compliance professionals within your practice and allow them to share their concerns.  Review audits and documentation deficiencies in order to maintain compliance.

Like all new technologies, EHR has its issues with implementation as well as use, but when finessed and mastered by users, EHR implementation should result in pro-

“Advertising” or “Marketing” Continued from page 6

viding greater efficiencies in patient care, as well as in practice management.

In order to assist providers in the transition, CMS is encouraging doctors, hospitals, and other health care providers to adopt EHR by providing incentive payments for the meaningful use of certified EHR technology. The EHR Incentive Programs were established by the American Recovery and Reinvestment Act of 2009, designed to assist financially in the implementation and meaningful use of certified EHR technology. This year since January, $83.3 million has been disbursed by state Medicaid EHR incentive programs to eligible professionals and hospitals that have met federal and state program requirements, with Kentucky included along with six other states in this first round of incentives.

Medicare has issued $75 million for incentive payments thus far.

Under the Medicare EHR Incentive Program, eligible professionals can receive as much as $44,000 over a five-year period and under the Medicaid EHR Incentive Program, eligible professionals can receive as much as $63,750 over six years. Providers eligible for both Medicare and Medicaid EHR Incentive Programs must select which incentive program will be most beneficial, as it is not possible to participate in both programs, although it is permissible, before 2015, to switch programs one time after the first payment to the provider from one program is processed.

These incentives are in place in order for providers and facilities to speed up the process of conversion to EHR without interrupting excellent patient care and providing a means for lowering costs. For more information visit: http://www.cms. gov/ehrincentiveprograms.

Patricia Cordy Henricksen, MS, CHCA, CPC-I, CPC, CCP-P, PCS, is senior vice president of Soterion Medical Services and is a certified instructor of the Professional Medical Coding Curriculum for the American Academy of Professional Coders. More information is available at www.soterionmedical.com and by calling (859) 233-3900. ◆

If growing your practice sounds appealing, the first move is simple. Sit down soon with your partners and trusted advisors and have a serious conversation about marketing and advertising. Set the agenda for the meeting by insisting that everyone refer to and think of the

practice as “the business” and the patients as “the customers”. I think you will see a lot of very lucrative light bulbs turn on.

Your marketing success depends directly on the professional advice you are given. Moreover, just as my health depends on my physician’s profes-

859-519-3346

Larry Trimmer is President of Strategic Media, Inc., a Lexington-based advertising agency he founded in 1998. He can be reached at ltrimmer@gmail.com or (859) 533-3964. ◆

JENIFER DUNCAN

TAMARA McCAIN

Vice President, Treasury Management Officer

sional ability, your business health depends on the marketing and advertising professional(s) you choose.

Consider that it may be time for a check up on your business health.

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JUne 2011 9

XIAFLEX® For adults with Dupuytren’s contracture with a palpable cord

THE ONLY FDA-APPROVED

NONSURGICAL

CHOICE WITH PROVEN EFFICACY XIAFLEX is a combination of 2 types of collagenase that appear to work synergistically to provide hydrolyzing activity on collagen Percentage of patients achieving a reduction in contracture to 0°-5° of normal 30 days after up to 3 injections*: All primary joints (MP† or PIP‡)1 CORD§ I

306 patients evaluated at 16 sites throughout the US; published in The New England Journal of Medicine 2 MEAN: 50° contracture before treatment

CORD Il

66 patients evaluated at 5 sites in Australia MEAN: 52° contracture before treatment

% 64 achieved 0°-5°

7% (7/103) Placebo

% 44 achieved 0°-5°

5% (1/21) Placebo

(130/203)

(CI||: 47%, 67%)

(20/45)

(CI||: 14%, 62%)

At study entry, in both pivotal studies, patients must have had: (1) finger flexion contracture with a palpable cord of at least 1 finger (other than the thumb) with MP joint contracture of 20°-100° or PIP joint contracture of 20°-80° and (2) positive “tabletop” test.

XIAFLEX is indicated for the treatment of adult patients with Dupuytren’s contracture with a palpable cord.

Important Safety Information In the controlled and uncontrolled portions of clinical trials, flexor tendon ruptures occurred after XIAFLEX injection. Injection of XIAFLEX into collagen-containing structures such as tendons or ligaments of the hand may result in damage to those structures and possible permanent injury such as tendon rupture or ligament damage. Therefore, XIAFLEX should be injected only into the collagen cord with a MP or PIP joint contracture, and care should be taken to avoid injecting into tendons, nerves, blood vessels, or other collagen-containing structures of the hand. When injecting a cord affecting a PIP joint of the fifth finger, insert the needle no more than 2 to 3 mm in depth, and avoid injecting more than 4 mm distal to the palmar digital crease.

Other serious local adverse reactions in clinical trials include: pulley rupture, ligament injury, complex regional pain syndrome (CRPS), and sensory abnormality of the hand.

In the controlled portions of the clinical trials (Studies 1 and 2), a greater proportion of XIAFLEX-treated patients (15%) compared to placebo-treated patients (1%) had mild allergic reactions (pruritus) after up to 3 injections.

The incidence of XIAFLEX-associated pruritus increased after more XIAFLEX injections.

Although there were no severe allergic reactions observed in the XIAFLEX studies (e.g., those associated with respiratory compromise, hypotension, or end-organ dysfunction), severe reactions including anaphylaxis could occur following XIAFLEX injections. Healthcare providers should be prepared to address severe allergic reactions following XIAFLEX injections.

In the XIAFLEX trials (Studies 1 and 2), 70% and 38% of XIAFLEX-treated patients developed an ecchymosis/ contusion or an injection site hemorrhage, respectively.

The efficacy and safety of XIAFLEX in patients receiving anticoagulant medications (other than low-dose aspirin) within 7 days prior to XIAFLEX administration is not known.

Therefore, use with caution in patients with coagulation disorders including patients receiving concomitant anticoagulants (except for low-dose aspirin).

The most frequently reported adverse drug reactions ( 5%) in the XIAFLEX clinical trials and at an incidence greater than placebo included: edema peripheral, contusion, injection site hemorrhage, injection site reaction, pain in extremity, tenderness, injection site swelling, pruritus, lymphadenopathy, skin laceration, lymph node pain, erythema, and axillary pain.

Please see Brief Summary of the Full Prescribing Information on adjacent page.

10 M.D. Update

y: da to ll 9) ing r ca - 353 o ain

tr m 42 ure .co 7- 9 7 ed oc LEX (1- 8 pr or AF EX I ll f ro t X FL A En si Vi - XI 7 - 87 1

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* Patients may have received up to 3 injections of study medication into the cords associated with contracture of the primary joints on Days 0, 30, and 60. Assessments were made 30 days after the last injection (on Days 30, 60, or 90). † Metacarpophalangeal. ‡ Proximal interphalangeal. § Collagenase Option for Reduction of Dupuytren’s. || 95% confidence interval for difference between XIAFLEX and placebo.

References: 1. Data on file. 2. Hurst LC, Badalamente MA, Hentz VR, et al; for the CORD I Study Group. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361:968-979.

© 2010 Auxilium Pharmaceuticals, Inc.

1009-023.c

JUne 2011 11

Brief Summary—Before prescribing XIAFLEX®, please see Full Prescribing Information and Patient Medication Guide (1) INDICATIONS AND USAGE: XIAFLEX is indicated for the treatment of adult patients with Dupuytren’s contracture with a palpable cord. (2) DOSAGE AND ADMINISTRATION: (2.1) Dosing Overview XIAFLEX should be administered by a healthcare provider experienced in injection procedures of the hand and in the treatment of patients with Dupuytren’s contracture. XIAFLEX, supplied as a lyophilized powder, must be reconstituted with the provided diluent prior to use [see Dosage and Administration (2.2)]. The dose of XIAFLEX is 0.58 mg per injection into a palpable cord with a contracture of a metacarpophalangeal (MP) joint or a proximal interphalangeal (PIP) joint [see Dosage and Administration (2.4)]. The following is an overview of the volumes of sterile diluent for reconstitution and the reconstituted XIAFLEX solution to be used in the intralesional injection [see Dosage and Administration (2.2, 2.4)]. Approximately 24 hours after injection, perform a finger extension procedure if a contracture persists to facilitate cord disruption [see Dosage and Administration (2.5)].

Volumes Needed for Reconstitution and Administration - For cords affecting MP joints - Volume of Sterile Diluent for Reconstitution: 0.39 mL; Reconstituted XIAFLEX Solution to be Injected: 0.25 mL. For cords affecting PIP joints - Volume of Sterile Diluent for Reconstitution: 0.31 mL; Reconstituted XIAFLEX Solution to be Injected: 0.20 mL. (Notes: The reconstituted XIAFLEX solution to be used in the intralesional injection contains 0.58 mg of XIAFLEX. The entire reconstituted XIAFLEX solution contains 0.9 mg of XIAFLEX. Reconstituted XIAFLEX solution remaining in the vial after the injection should be discarded.) Four weeks after the XIAFLEX injection and finger extension procedure, if a MP or PIP contracture remains, the cord may be re-injected with a single dose of 0.58 mg of XIAFLEX and the finger extension procedure may be repeated (approximately 24 hours after injection).

Injections and finger extension procedures may be administered up to 3 times per cord at approximately 4-week intervals. Inject only one cord at a time. If a patient has other palpable cords with contractures of MP or PIP joints, these cords may be injected with XIAFLEX in a sequential order. (2.2) Reconstitution of the Lyophilized Powder a) Before use, remove the vial containing the lyophilized powder of XIAFLEX and the vial containing the diluent for reconstitution from the refrigerator and allow the two vials to stand at room temperature for at least 15 minutes and no longer than 60 minutes. b) After removal of the flip-off cap from each vial, using aseptic technique swab the rubber stopper and surrounding surface of the vial containing XIAFLEX and the vial containing the diluent for reconstitution with sterile alcohol (no other antiseptics should be used). c) Use only the supplied diluent for reconstitution. The diluent contains calcium which is required for the activity of XIAFLEX. d) Using a 1 mL syringe that contains 0.01 mL graduations with a 27-gauge ½-inch needle (not supplied), withdraw a volume of the diluent supplied, as follows: 0.39 mL for cords affecting a MP joint or 0.31 mL for cords affecting a PIP joint. e) Inject the diluent slowly into the sides of the vial containing the lyophilized powder of XIAFLEX. Do not invert the vial or shake the solution. Slowly swirl the solution to ensure that all of the lyophilized powder has gone into solution. f) The reconstituted XIAFLEX solution can be kept at room temperature (20° to 25°C/68° to 77°F) for up to one hour or refrigerated at 2° to 8°C (36° to 46°F) for up to 4 hours prior to administration. If the reconstituted XIAFLEX solution is refrigerated, allow this solution to return to room temperature for approximately 15 minutes before use. g) Discard the syringe and needle used for reconstitution and the diluent vial. (2.3) Preparation Prior to Injection a) The reconstituted XIAFLEX solution should be clear. Inspect the solution visually for particulate matter and discoloration prior to administration. If the solution contains particulates, is cloudy, or is discolored, do not inject the reconstituted solution. b) Administration of a local anesthetic agent prior to injection is not recommended, as it may interfere with proper placement of the XIAFLEX injection. c) If injecting into a cord affecting the PIP joint of the fifth finger, care should be taken to inject as close to the palmar digital crease as possible (as far proximal to the digital PIP joint crease), and the needle insertion should not be more than 2 to 3 mm in depth. Tendon ruptures occurred after XIAFLEX injections near the digital PIP joint crease [see Warnings and Precautions (5.1)]. d) Reconfirm the cord to be injected. The site chosen for injection should be the area where the contracting cord is maximally separated from the underlying flexor tendons and where the skin is not intimately adhered to the cord. e) Apply an antiseptic at the site of the injection and allow the skin to dry.

(2.4) Injection Procedure a) Using a new 1 mL hubless syringe that contains 0.01 mL graduations with a permanently fixed, 27-gauge ½-inch needle (not supplied), withdraw a volume of reconstituted solution (containing 0.58 mg of XIAFLEX) as follows: 0.25 mL for cords affecting a MP joint or 0.20 mL for cords affecting a PIP joint. b) With your non-dominant hand, secure the patient’s hand to be treated while simultaneously applying tension to the cord. With your dominant hand, place the needle into the cord, using caution to keep the needle within the cord. Avoid having the needle tip pass completely through the cord to help minimize the potential for injection of XIAFLEX into tissues other than the cord [see Warnings and Precautions (5.1)]. After needle placement, if there is any concern that the needle is in the flexor tendon, apply a small amount of passive motion at the distal interphalangeal (DIP) joint. If insertion of the needle into a tendon is suspected or paresthesia is noted by the patient, withdraw the needle and reposition it into the cord. c) If the needle is in the proper location, there will be some resistance noted during the injection procedure. After confirming that the needle is correctly placed in the cord, inject approximately one-third of the dose. d) Next, withdraw the needle tip from the cord and reposition it in a slightly more distal location (approximately 2 to 3 mm) to the initial injection in the cord and inject another one-third of the dose. e) Again withdraw the needle tip from the cord and reposition it a third time proximal to the initial injection (approximately 2 to 3 mm) and inject the final portion of the dose into the cord. f) Wrap the patient’s treated hand with a soft, bulky, gauze dressing. g) Instruct the patient to limit motion of the treated finger and to keep the injected hand elevated until bedtime. h) Instruct the patient not to attempt to disrupt the injected cord by self-manipulation and to return to the provider’s office the next day for follow-up and a finger extension procedure, if needed. i) Discard the unused portion of the reconstituted solution and diluent after injection. Do not store, pool, or use any vials containing unused reconstituted solution or diluent. (2.5) Finger Extension Procedure a) At the follow-up visit the day after the injection, if a contracture remains, perform a passive finger extension procedure (as described below) to facilitate cord disruption. b) Local anesthesia may be used. Avoid direct pressure on the injection site as it will likely be tender. c) While the patient’s wrist is in the flexed position, apply moderate stretching pressure to the injected cord by extending the finger for approximately 10 to 20 seconds. For cords affecting the PIP joint, perform the finger extension procedure when the MP joint is in the flexed position. d) If the first finger extension procedure does not result in disruption of the cord, a second and third attempt can be performed at 5- to 10-minute intervals. However, no more than 3 attempts are recommended to disrupt a cord. e) if the cord has not been disrupted after 3 attempts, a follow-up visit may be scheduled in approximately 4 weeks. If, at that subsequent visit, the contracted cord persists, an additional XIAFLEX injection with finger extension procedures may be performed [see Dosage and Administration (2.1)]. f) Following the finger extension procedure(s), fit patient with a splint and provide instructions for use at bedtime for up to 4 months to maintain finger extension. Also, instruct the patient to perform finger extension and flexion exercises several times a day for several months. (4) CONTRAINDICATIONS: None. (5) WARNINGS AND PRECAUTIONS: (5.1) Tendon Rupture or Other Serious Injury to the Injected Extremity In the controlled and uncontrolled portions of the clinical trials, flexor tendon ruptures occurred after XIAFLEX injection [see Adverse Reactions (6.1)]. Injection of XIAFLEX into collagen-containing structures such as tendons or ligaments of the hand may result in damage to those structures and possible permanent injury such as tendon rupture or ligament damage. Therefore, XIAFLEX should be injected only into the collagen cord with a MP or PIP joint contracture, and care should be taken to avoid injecting into tendons, nerves, blood vessels, or other collagen-containing structures of the hand. When injecting a cord affecting a PIP joint of the fifth finger, the needle insertion should not be more than 2 to 3 mm in depth and avoid injecting more than 4 mm distal to the palmar digital crease [see Dosage and Administration (2.3, 2.4)]. Other XIAFLEX-associated serious local adverse reactions in the controlled and uncontrolled portions of the studies included pulley rupture, ligament injury, complex regional pain syndrome (CRPS), and sensory abnormality of the hand. (5.2) Allergic Reactions In the controlled portions of the clinical trials (Studies 1 and 2), a greater proportion of XIAFLEX-treated patients (15%) compared to placebo-treated patients (1%) had mild allergic reactions (pruritus) after up to 3 injections. The incidence of XIAFLEX-associated pruritus increased after more XIAFLEX injections. Although there were no severe

allergic reactions observed in the XIAFLEX studies (e.g., those associated with respiratory compromise, hypotension, or end-organ dysfunction), severe reactions including anaphylaxis could occur following XIAFLEX injections. XIAFLEX contains foreign proteins and patients developed IgE-anti-drug antibodies in greater proportions and higher titers with successive XIAFLEX injections. Healthcare providers should be prepared to address severe allergic reactions following XIAFLEX injections. (5.3) Patients with Abnormal Coagulation In the XIAFLEX trials (Studies 1 and 2), 70% and 38% of XIAFLEX-treated patients developed an ecchymosis/contusion or an injection site hemorrhage, respectively. The efficacy and safety of XIAFLEX in patients receiving anticoagulant medications (other than low-dose aspirin, e.g., up to 150 mg per day) within 7 days prior to XIAFLEX administration is not known. Therefore, XIAFLEX should be used with caution in patients with coagulation disorders including patients receiving concomitant anticoagulants (except for low-dose aspirin). (6).

ADVERSE REACTIONS The following serious adverse reactions are discussed in greater detail elsewhere in the labeling: Tendon ruptures or other serious injury to the injected extremity [see Warnings and Precautions (5.1)].

The most frequently reported adverse drug reactions (≥ 25%) in the XIAFLEX clinical trials included edema peripheral (mostly swelling of the injected hand), contusion, injection site reaction, injection site hemorrhage, and pain in the treated extremity. (6.1) Clinical Studies Experience Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Out of 1082 patients who received 0.58 mg of XIAFLEX in the controlled and uncontrolled portions of the XIAFLEX studies (2630 XIAFLEX injections), 3 (0.3%) patients had a flexor tendon rupture of the treated finger within 7 days of the injection. The data described below are based on two pooled randomized, double-blind, placebo-controlled trials through Day 90 in patients with Dupuytren’s contracture (Studies 1 and 2). In these trials, patients were treated with up to 3 injections of 0.58 mg of XIAFLEX or placebo with approximately 4-week intervals between injections and the patients had finger extension procedures the day after injection, if needed, to facilitate disruption of the cord [see Clinical Studies (14)]. These trials were comprised of 374 patients of whom 249 and 125 received 0.58 mg of XIAFLEX and placebo, respectively. The mean age was 63 years, 80% were male and 20% were female, and 100% were white. In the placebo-controlled portions of Studies 1 and 2 through Day 90, 98% and 51% of XIAFLEX-treated and placebo-treated patients had an adverse reaction after up to 3 injections, respectively. Over 95% of XIAFLEX-treated patients had an adverse reaction of the injected extremity after up to 3 injections. Approximately 81% of these local reactions resolved without intervention within 4 weeks of XIAFLEX injections. The adverse reaction profile was similar for each injection, regardless of the number of injections administered. However, the incidence of pruritus increased with more injections [see Warnings and Precautions (5.2)]. The incidence of adverse reactions that were reported in greater than or equal to 5% of XIAFLEX-treated patients (N=249) and at a frequency greater than placebo-treated patients (N=125) after up to 3 injections in the pooled placebo-controlled trials through Day 90 (Studies 1 and 2) were: (XIAFLEX vs placebo): All Adverse Reactions (98% vs 51%), Edema Peripheral—most of these events were swelling of the injected hand (73% vs 5%), Contusion—includes the terms: contusion (any body system) and ecchymosis (70% vs 3%), Injection Site Hemorrhage (38% vs 3%), Injection Site Reaction—includes the terms: injection site reaction, injection site erythema, injection site inflammation, injection site irritation, injection site pain, injection site warmth (35% vs 6%), Pain in Extremity (35% vs 4%), Tenderness (24% vs 0%), Injection Site Swelling—includes the terms: injection site swelling and injection site edema (24% vs 6%), Pruritus—includes the terms pruritus and injection site pruritus (15% vs 1%), Lymphadenopathy—includes the terms: lymphadenopathy and axillary mass (13% vs 0%), Skin Laceration (9% vs 0%), Lymph Node Pain (8% vs 0%), Erythema (6% vs 0%), Axillary Pain (6% vs 0%).

Some patients developed vasovagal syncope after finger extension procedures. Immunogenicity During clinical studies, patients with Dupuytren’s contracture were tested at multiple time points for antibodies to the protein components of XIAFLEX (AUX-I and AUX-II). At 30 days post the first injection of XIAFLEX 0.58 mg, 92% of patients had antibodies detected against AUX-I and 86% of patients had antibodies detected against AUX-II. After the fourth injection of XIAFLEX, every XIAFLEX-treated patient developed high titers of antibodies to both AUX-I and AUX-II. Neutralizing antibodies to AUX-I or AUX-II, were detected in 10% and 21%, respectively, of patients treated with XIAFLEX. However, there was no apparent correlation of antibody frequency, antibody titers, or neutralizing status to clinical response or adverse reactions. Since the protein components in XIAFLEX (AUX-I and AUX-II) have some sequence homology with human matrix metalloproteinases (MMPs), anti-product antibodies could theoretically interfere with human MMPs. Immunogenicity assay results are highly dependent on the sensitivity and specificity of the assay used in detection and may be influenced by several factors, including sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of incidence of antibodies to collagenase clostridium histolyticum with the incidence of antibodies to other products may be misleading. (7) DRUG INTERACTIONS Anticoagulant drugs: XIAFLEX should be used with caution in patients receiving concomitant anticoagulants (except for low-dose aspirin) [see Warnings and Precautions (5.3)].

(8) USE IN SPECIFIC POPULATIONS (8.1) Pregnancy Pregnancy Category B There are no adequate and well-controlled studies of XIAFLEX in pregnant women. Human pharmacokinetic studies showed that XIAFLEX levels were not quantifiable in the systemic circulation following injection into a Dupuytren’s cord [see Clinical Pharmacology (12.3)]. Reproduction studies have been performed in rats with intravenous doses up to 0.13 mg (approximately 45 times the human dose of XIAFLEX on a mg/kg basis, if administered intravenously) and have revealed no evidence of impaired fertility or harm to the fetus due to collagenase clostridium histolyticum. Almost all patients develop anti-product antibodies (anti-AUX-I and anti-AUX-II) after treatment with XIAFLEX, and the clinical significance of anti-product antibody formation on a developing fetus is not known [see Adverse Reactions (6.1)]. Because animal reproduction studies are not always predictive of human response, XIAFLEX should be used during pregnancy only if clearly needed. (8.3) Nursing Mothers It is not known whether collagenase clostridium histolyticum is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when XIAFLEX is administered to a nursing woman. (8.4) Pediatric Use The safety and effectiveness of XIAFLEX in pediatric patients less than 18 years old have not been established. (8.5) Geriatric Use Of the 249 XIAFLEX-treated patients in the double-blind, placebo-controlled, clinical trials (Studies 1 and 2), 104 (42%) were 65 years of age or older and 9% were 75 years of age or older. No overall differences in safety or effectiveness of XIAFLEX were observed between these patients and younger patients. (10) OVERDOSAGE The effects of overdose of XIAFLEX are unknown. It is possible that multiple simultaneous or excessive doses of XIAFLEX may cause more severe local effects including serious adverse reactions (e.g., tendon ruptures) than the recommended doses. Supportive care and symptomatic treatment are recommended in these circumstances.

(16) HOW SUPPLIED/ STORAGE AND HANDLING Each single-use vial of XIAFLEX is packaged with a single-use vial of sterile diluent in an outer carton. The National Drug Code is: NDC 66887-003-01. XIAFLEX is available in single-use, glass vials containing 0.9 mg of collagenase clostridium histolyticum as a sterile, lyophilized powder. Sterile diluent for reconstitution is available in single-use, glass vials containing 3 mL of 0.3 mg/mL calcium chloride dihydrate in 0.9% sodium chloride. Storage and Stability Prior to reconstitution, the vials of XIAFLEX and diluent should be stored in a refrigerator at 2° to 8°C (36° to 46°F) [see Dosage and Administration (2.2)]. Do not freeze. The reconstituted XIAFLEX solution can be kept at room temperature (20° to 25°C/68° to 77°F) for up to one hour or refrigerated at 2° to 8°C (36° to 46°F) for up to 4 hours prior to administration [see Dosage and Administration (2.2)].

Auxilium Pharmaceuticals, Inc. 40 Valley Stream Parkway Malvern, PA 19355 www.auxilium.com www.XIAFLEX.com

041410

Estate planning

Short Term Tax Relief In the final weeks of 2010, the estate tax laws were modified by the Tax Relief, Unemployment Insurance Re-authorization and the Job Creation Act (the Act). President Obama signed this multi-billion dollar tax cut into law on December 17 2010. The new law only gives taxpayers some certainty in tax planning until December 31, 2012.

So what does this all mean regarding you and your estate plan? Some of the most significant changes to the estate and gift tax laws are: The Act establishes a $5 million estate tax exemption per individual and a maximum estate tax rate of 35%. Before 2010, an individual could protect an increasing amount of assets from the estate tax, in 2009 $3.5 million could be past by an individual or $7 million per married couple.

Next, in the following year the estate tax was suspended, meaning the estate of the person who died in 2010 would not be subject to any estate tax. The new law in-acted the estate tax, but increased the amount to $5 million per individual or $10 million per married couple.

The Act established the reunification of the estate and gift tax. Until now, each person could only gift $1 million during their lifetime without any gift tax occurring, most individuals using their annual exclusion of $13,000 to any individual

per year. With the new law, this gift tax exemption has been increased to $5 million allowing an individual to transfer up to $5 million during their life or at death without the gift or estate tax.

BY Calvin R. Rasey The Act established a $5 million Generation-Skipping Transfer (GST) tax exemption for gifts made and decedents dying after January 1, 2010. Transfers made in 2010 will be subject to a zero GST tax rate and gifts made in 2010 to grandchildren outright or in trust will incur no current GST tax. Furthermore, future distributions to a grandchild in a trust created in 2010 can also be made free of GST tax. However, distributions in 2010 from a non-exempt GST Trust can still be made without incurring a GST tax.

The Act established the elimination of carry-over basis. Between the years of 2001 through 2009, assets that were transferred at death received a full step up in basis. This gave the beneficiary of property a tax basis in the property, which was equal to their fair market value at death. An example of

The Tax Relief, Unemployment Insurance Re-Authorization and Job Creation Act of 2010 is temporary and will expire at the end of 2012.

this could be the family farm which if the beneficiary sold the farm, the amount of capital gains tax owed would be based on the difference between the sale price and the step-up in base price at the date of death.

This automatic step-up in basis was eliminated in 2010 this allowed the government to seek considerable capital gains tax following the sale of inherited assets. The new Act eliminated this problem and restored the step-up in basis to its pre-2010 form.

The Tax Relief, Unemployment Insurance Re-Authorization and Job Creation Act of 2010 is temporary and will expire at the end of 2012.

If the new legislation does not pass the exemption in 2013, it will once again decrease back to $1 million. While it is unlikely that Congress would allow the estate tax to revert, they are always looking at ways to increase revenue. Now is the time to review your current estate plan or to create an estate plan for you and your loved ones. Here are few questions to ask yourself, while we have these estate planning opportunities:  Are you using tax savings trusts?  Could you benefit from allocating property to a trust?  Would making larger gifts benefit your overall estate plan?  Should you consider planning techniques using insurance funded with larger gifts?

Remember an estate plan utilizes the tools provided to us to minimize taxes that may be owed at death, but more importantly, it involves taking care of your family. Making sure that the appropriate advisors will be in control over your affairs, if you cannot be.

Taking care of a minor child in the event of death and determining who will receive inheritance in the appropriate manner. In the words of Winston Churchill, “Failing to plan is planning to fail.”

Calvin R. Rasey is president of Physicians Financial Services II, LLC of Louisville. You can reach him by calling 1-800-928-8834 or by email at calvinrasey@insightbb.com. ◆ JUne 2011 13

Cover Story

The Gilded Era of Aesthetic Medicine With so many unqualified hands reaching in the pot, the hottest question in aesthetic medicine is whose hands are on the patient?

By Megan C. Smith, Photography by Kirk Schlea

A moment of beauty during a facelift at Waldman Schantz Plastic Surgery Center of Lexington captured by Kirk Schlea.

June 2011 15

Cover Story

LEXINGTON Kentucky laws and their uncoordinated and separate medical and nursing boards make this a buyer beware state for patients seeking medical aesthetic treatments.

S. Randolph Waldman, MD, founder and partner of of Waldman Schantz Plastic Surgery Center of Lexington, laments that in Kentucky, “doctors have more limits legislated than do nurse practitioners.”

Waldman, like many other physicians practicing in aesthetic medicine and aesthetic surgery, believes that the Kentucky legislature needs to examine how well the public is being protected at salon-based, injectable cosmetic practices “where there is often little to no physician oversight beyond the name on the door.”

Protecting the patient is essential, says colleague Stephen A. Schantz, MD, because “much of the public does not really know the difference between getting injected by a nurse in a salon and having it done in a plastic surgeon’s office.”

So what is the difference? The answer lies in the doctor administering the service.

Internationally Renown Surgeons

Stephen A. Schantz, MD, body contouring and breast aesthetics specialist

16 M.D. Update

Schantz’s near stellar career took off because he was able to “come out and do my passion, cosmetic surgery, right from the start.” He joined Waldman’ Schantz Plastic Surgery Center in 2002 following completion of his plastic surgery residency at UK and fellowship in cosmetic plastic surgery under Dr. Grant Stevens of the Marina Plastic Surgery Center in Los Angeles.

Waldman by this time had an established base in facial plastics. Going forward, Schantz recalls, they soon realized that Schantz would sub-specialize in cosmetic surgeries of the body. “With Randy’s foresight we were one of the first practices to do this, while it has become a lot more common since,” he says. “This merger has worked in concert very nicely. I can do what I love, which is body contouring, breast aesthetics, and reconstruction.”

Early on, Schantz was recognized as a national leader in breast aesthetics through

his utilization of the Laser Bra, a breast reduction technique that was invented by Stevens.

Schantz was one of a handful of surgeons nationwide utilizing the technique. Today more centers are doing it, but “for a while we were the first practice to go to east of the Mississippi,” says Schantz.

S. Randolph Waldman, Taking the tried and true MD, facial plastics and technique of breast reduction reconstructive surgeon surgery and adding the CO2 laser, the Laser Bra technique allows Schantz to utilize the skin on the early interest in the anatomy of the head inferior aspect of the breast, treat it with a and neck – “the most complex anatomy CO2 laser to rid the skin of appendages and of the body.” During his residency in head follicles, and then tuck and affix the skin to and neck surgery at the Cleveland Clinic, the chest wall. “There it acts like a sling or Waldman began to gravitate towards rhian internal bra, which supports the breast noplasty, a procedure for which he draws tissue,” he says. patients from across the US. “That was Recently, Schantz was selected as one always my favorite operation,” he says. “It is of four worldwide participants to train a surgery of micro millimeters. With many in Sweden for a new breast augmenta- of the procedures we do - and rhinoplasty tion technique and implant by the Mentor in particular - we make a huge difference in Corporation. people’s lives. We change people’s lives each In partnerships, everybody has to find and every week and that is a very gratifying their niche. “We quickly found ours because thing.” we have different interests that complement Over the past ten years, Waldman has each other,” says Waldman, who began his been instrumental in bringing together the surgical career in head and neck surgery country’s top minds in multi-specialty aesand has been performing aesthetic surgery thetic surgery through the annual symposia exclusively since 1989. founded by the Foundation for Aesthetic Waldman’s trajectory took off from an Surgical Excellence (FASE). What started as

a small annual meeting in Newport Beach, California designed to fulfill Waldman’s academic urges has grown into the nation’s largest independent, multi-specialty aesthetic surgery symposium, Vegas Cosmetic Surgery, now in its seventh year.

“The purpose of the meeting is to build bridges, like Steve and I have done in our own practice,” says Waldman. “FASE pulled together groups that had previously never really educated each other - dermatologists, oculoplastic surgeons, facial plastic and plastic surgeons - and created enough détente that everyone could learn from one another.

It has worked out over the past seven years and now it is the largest of its type.”

By extension, Waldman also helped to initiate a new umbrella group called the Physicians Aesthetic Coalition. The Coalition is composed of the presidents of dermatology, eye plastics, facial plastics and general plastics societies, and they gather several times each year to talk about patient safety issues that are common to the four specialties.

The best interest of the patient

Schantz agrees that Waldman has helped to mend the “unnecessary animosity” among the nation’s educators in the field of aesthetic medicine. “We are all very well educated surgeons and physicians, and to think that just because someone does things a little bit differently or brings something different to it means that they are not doing it right is incorrect,” says Schantz. “Randy June 2011 17

Cover Story

has brought these different groups together who all perform cosmetic surgeries because he is trying to make sure that there are not patients out there that are getting services provided by people who are not qualified to do so. That is only going to harm everyone’s reputation.”

There are two quotes that are often heard resonating through Waldman Schantz Plastic Surgery. Schantz learned from his mentor Dr. Stevens that the goal of every practice should be to make every patient a “patient for life. That implies that just because a patient might have a procedure at age 50 does not mean that we should stop treating them. We want them to be our patients for life.”

Waldman, who did his aesthetic surgery fellowship at Tulane under the tutelage of the late Dr. Jack Anderson, reminds the surgical staff of this on a daily basis that “there is no short cut to quality.”

Waldman also recalls from the first few days of the partnership how apparent it was that Schantz was completely devoted to pleasing people both inside the practice and out. “In our field this is a tremendous attribute. Our field is all about making people happy and doing it within their budget.”

Accreditation & Governance of Aesthetic Practices

The operating facility at Waldman Schantz is nationally accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).

18 M.D. Update

Kentucky legislation does not require private ORs to be accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), though many states do. “We take a lot of time and effort from our practice to make sure that our operating facility is nationally accredited by AAAASF,” says Schantz. “When I was coming into practice, the American Society of Plastic Surgeons recognized this as an issue and put forth a mandate that demanded compliance with their OR accreditation standards in order to continue to practice as a member.”

Schantz, whose lab coat is embroidered with the iconic circular logo of the ASPS, asserts that “our OR meets the same requirements as a hospital OR from a safety and

preparedness standpoint.” He also points out that all procedures are performed under IV sedation, eliminating PONV and reducing bleeding risk caused by increased blood pressure. He and Waldman employ four nurse anesthetists who have a combined experience in IV sedation of over 80 years, one of whom has been with Waldman for 29 years.

Experience, Judgment, and Realistic Expectations

“You as a patient do not want to be a part of someone’s learning curve,” says Waldman, who believes that an experienced aesthetic surgeon will impart realistic expectations and even correct unrealistic ones. “Sometimes, you really have to dig inside their brain to figure out what it is they really want, what they are really expecting from the treatment,” he says.

“With experience comes judgment, and a good surgeon exercises judgment on when to operate on someone and also on what that patient needs.”

When working with prospective patients, Schantz makes sure to show

photographs of prior work because “I want patients to have a realistic picture of what they can expect from treatment.” Treatment following weight loss or bariatric surgery, he points out, is a current example of the need to demonstrate expected outcomes because surgical results for patients who have lost a lot of weight are going to differ from the 120 pound woman seeking a mommy makeover. “We do not use any company pictures,” he says. “We only use images of people we have treated. That way we can show the results of specific treatments applied to treat specific conditions.

“We learn over time the different kinds of results you can expect from different skin types, different body and facial shapes, and you can really begin to predict the results,” Schantz concludes. By focusing on the techniques and applications of their chosen subspecialization, Schantz and Waldman are very confident in their expertise and ability to provide to patients what they really want to receive. ◆

You as a patient do not want to be a part of someone’s learning curve.

– Dr. Randolph Waldman

June 2011 19

20 M.D. Update

Aesthetic Medicine & Aesthetic Surgery Perspectives from Dermatology, Hand Surgery, Plastic Surgery, and Oculofacial Plastic Surgery

June 2011 21

Dermatology

Cassis Dermatology & Aesthetics Center

Going Solo to Provide a Pair of Specialties and a Full Spectrum of Services By Jennifer S. Newton LOUISVILLE For board certified dermatologist Tami Cassis, MD, entrepreneurship and medicine are symbiotic concepts. A solo practitioner in Louisville’s east end, Cassis has built her practice, Cassis Dermatology & Aesthetics Center, on the foundations of good patient care, a full continuum of services, well-established techniques, and advanced specialized training. The practice has two focal points: clinical and cosmetic dermatology. “We offer medical, surgical, and aesthetic options here, anywhere from massage to facial, from removing skin cancer to lasers, so it is a pretty broad spectrum,” says Cassis.

Cassis completed her residency in dermatology at the University of Louisville in 2005, but because there were no cosmetic fellowships at the time, she felt her training was incomplete.

“When I was in residency, we only had the ability to go and mentor other physicians, so that is when I took it upon myself to take every extra training course that I could on injectable fillers, injectable neurotoxins, and lasers,” she explains. Cassis used her elective and vacation time to study with physicians in markets with higher volumes of cosmetic procedures, including training in Miami with Marta Rendon, MD, in New Orleans with Mary Lupo, MD, and in Beverly Hills with Ronald Moy, MD. Cassis also credits the Chairman of the UofL School of Medicine Division of Dermatology, Jeffrey P. Callen, MD, as being a motivating guide in her medical career. From a business perspective, she recognizes her father, Duane Buss, for mentoring her early in life and her husband, Chuck Cassis, an attorney, for providing the “you can do it” motivation and attitude.

Clinical and Cosmetic Dermatology

The fusion of independent business owner and physician specialist is mirrored in the duality of the center’s foci. As the name implies, Cassis Dermatology & Aesthetics Center has two aspects: clinical dermatology and cosmetic dermatology. The office has 15 staff members including an aesthetician, 22 M.D. Update

Tami Cassis, MD, board certified dermatologist and solo practitioner at Cassis Dermatology & Aesthetics Center of Louisville.

massage therapists, nurses who perform laser procedures, and office staff. Cassis sees a volume of about 50 patients a day, four to five days a week. “It is a fast, motivated, keep moving kind of practice here,” she explains. Cassis sees patients as young as two years old and estimates that her patient mix is 75 percent adult and 25 percent teenagers and children. While women probably make up the largest percentage of her patients, she also sees a significant number of men.

On the clinical side of the practice, Cassis laments the fact that skin cancer is still the one of the most prevalent diagnosis they see. “Skin cancer is definitely on the rise, we have not gotten our hands

completely around it yet,” says Cassis. “We see way too many melanoma and nonmelanoma skin cancers every day.” Other common conditions include acne, psoriasis and common irritating rashes. Advances in dermatology have led to a variety of options in the treatment of pre-cancerous lesions.

Traditional freezing of atypical lesions is still utilized. However, topical chemotherapies and immunomodulators are also available, as well as newer therapies including laser treatment, photodynamic therapy. These options allow me to help the patient choose what is best option for their situation. “We are not just treating one lesion anymore, we are treating the entire fields,” says Cassis.

“So with one pre-cancerous lesion on the

cheek, we are looking at the whole face and getting more aggressive because if you have one now, you probably have many more coming down the road.”

The best treatment for regular skin cancers is still surgical removal.

Cassis does minor surgeries in her office, including removing small skin cancers, cysts and lipomas. Anything outside this scope is referred to a surgeon. For acne, Cassis believes in the tried-and-true routines of topical medications up to oral antibiotics and medications such as isotretinoin.

There is much crossover between the clinical and cosmetic practices, and Cassis admits that she is a huge referral source to herself. Often, a clinical patient will also become a cosmetic patient over time.

The Aesthetics Center offers a full spectrum of cosmetic services. Treatments include injectable neurotoxins such as BOTOX and Dysport; dermal fillers, including a range of semi-permanent versus hyaluronic acid-based products; chemical peels; and laser treatments, including CO2 resurfacing lasers, laser hair removal, intense pulse light, and blue light therapy. The aesthetician performs epidermal leveling for facial hair removal, facials, and customized peels.

Multiple skin care lines can be tailored to fit each patient. Spa services such as massages and facials were not a part of Cassis’ original plan but were a patient-driven addition to her services.

When it comes to trends, Cassis says what is old has become new again. Chemical peels, which have been around for decades, are experiencing a resurgence with new variations, which she attributes to their relative cost efficiency. Another existing treatment

cal and aesthetic aspects of the field. “So straight out of the gate, first year residents are performing injections and operating lasers.

They are doing everything,” says Cassis. As a UofL faculty member, Cassis also staffs the Veterans Administrations clinic and has spearheaded an effort at the VA to teach residents specific injection therapy techniques for lipoatrophy patients, a first at the VA in Louisville. “We are serving patients that really have no other choices, and the residents are getting great exposure,” says Cassis.

Cassis also serves on the Kentucky Board of Medical Licensure, a position she was nominated for by the Kentucky Medical Association and appointed to

by Governor Steve Beshear.

She feels honored and challenged by her duties on the board, which awards and monitors state medical licenses to physicians in the Commonwealth.

As for her private practice, Cassis expects to add another physician in the future to help keep pace with the patient volume. An indicator of her exponential growth and her entrepreneurial spirit is that she is thinking in terms of a 12-month plan and a 24-month plan, rather than five or 10 years down the road. Since the practice opened in 2008, Cassis has physically added another 1,500 square feet, but that still has not been enough. Fortunately, Cassis’ landlord is her husband, and there is more room for expansion in the building.

She attributes her rapid growth to her location in the northeast corridor, an area that was lacking dermatologists. “Perfect timing, perfect place, and I have got a great staff.

We bend over backwards for our patients,” says Cassis. ◆

I think I very much have the entrepreneurial spirit. When somebody tells me I can’t, I’m definitely going prove them wrong. So I did, and I haven’t looked back. It has been a great, great experience for me. – Dr. Tami Cassis

that has become popular among the center’s patients is the filler Sculptra, which is a poly-L-lactic acid. It is touted as the liquid face lift but is also used in HIV lipoatrophy patients for facial muscle wasting.

Giving Back and Looking Forward

Cassis’ enthusiasm for her field is evident not only in her fast-growing practice but also in her commitment to give back to the medical community and the community at large. While cosmetic fellowships do exist now, they are not accredited or recognized yet. However, Cassis feels dermatology training has “come full circle.” She is on the faculty at UofL and now dermatology residents can spend part of their three-year residency training in her office studying both the clini-

June 2011 23

Plastic Surgery

Self + Market = Success

Dr. Marc Salzman reveals the formula for a successful cosmetic plastic surgery practice

By Megan C. Smith

LOUISVILLE Every business leader has a formula for success, and some business leaders are the formula for success. Nowhere in medicine is this more apparent than in the business of cosmetic plastic surgery. Take this maxim from Marc J. Salzman, MD, FACS, of Louisville’s Salzman Institute of Cosmetic Surgery: “I have come to the conclusion that people who have plastic surgery identify the procedure they will have done with the doctor who administers it, and everyone wants to believe that their doctor is the best plastic surgeon that can be found.”

This is no braggadocio. For Salzman, clear insight into market desires forms the foundation of his business acumen, and it is the reason for the continued success of the Salzman Institute when, nationally, cosmetic plastic surgery practices face diminishing profits.

“Friends of mine around the country were down 30% the last few years,” he says, acknowledging that Louisville did not experience as much boom and bust as the rest of the country. From his perspective, Salzman saw patient volumes hold steady from 2007 to 2010 with a lot of growth in 2011.

Importantly, Salzman observes, the way that plastic surgeons earn their living is changing. “It used to be that most of the patient volume came from surgical procedures, but now the growth is in the non-surgical and minimally invasive part of the business.”

In aesthetic medicine, the key to being perceived as the best is to deliver what people want. According to Salzman, people want to go into a practice that “encompasses all of the different aspects of plastic surgery, not just an office where only plastic surgery operative procedures are done.” In other words, what people want is the whole spectrum of aesthetic options and outstanding results.

Products and services like Botox, Juvederm, Restylane or many of the other fillers, lasers, hair removal and body contouring modalities represent the noninvasive or minimally invasive modalities in plastic surgery today. It is in this arena that the new mall medispas try to compete.

24 M.D. Update

For Dr. Marc Salzman, clear insight into market desires forms the foundation of his business acumen, and it is the reason for the continued success of the Salzman Institute when, nationally, cosmetic plastic surgery practices face diminishing profits.

The Salzman Institute Story

An important factor in being the best, says Salzman, is practicing solo. As part of his plastic surgery residency at Duke, Salzman studied hand surgery under Louisville’s Harold Kleinert in 1990. “It was a six month rotation in Louisville that convinced me to return and practice here,” Salzman says.

“While I was here doing the hand surgery residency, I met Dr. Norman Cole.

At that time, he was the president of the American Society of Plastic Surgeons, and I spent some time with him in the plastic and aesthetic surgery center that he had set up at Jewish Hospital.” Cole invited Salzman to join his practice in 1992, and with his wife’s blessing, they moved to Louisville.

“One of my first assignments for Dr. Cole was to find us a new office, and I presented him with five or six different options,” Salzman recalls, “none of which he liked. Finally, he decided he was going to move his set up out of Jewish Hospital, and he suggested that I should stay at Jewish because I was the heir apparent to the program.”

Salzman agreed. “Everybody wants the best possible person as their surgeon. If you are the junior guy in the office to a nationally recognized plastic surgeon, there is no way people are going to think that you are the best in that office!” When Salzman moved to his own building in 1995, “the practice increased dramatically because I was no longer a junior

Dr. Marc Salzman performs a Lower 2/3 Facelift that addresses saggy skin in the neck and chin area. Here he uses a tumescent technique for liposuction of the neck area incorporating power assisted liposuction (PAL).

associate.” In solo practice, he observes, you do not get pigeon holed into doing just one or two procedures.

Innovation Philosophy

In aesthetic medicine, the key to being perceived as the best is to deliver what people want, and what they want is the whole spectrum of aesthetic options and outstanding results.

Remaining involved in academia, teaching medical students and residents, keeps Salzman on top of his game. He has also been involved in the development and physician education on the laser assisted liposuction procedure called LiteShape. A less invasive technique for body contouring and tightening of the overlaying skin, the LiteShape method utilizes a laser that liquefies fat that is then removed with a liposculpture canula before the laser is again used, at another wavelength, to tighten the skin.

“It was important to find out how to achieve safe, satisfying, and consistent results from using lasers under the skin since protocols did not exist other than anecdotal cases,” says Salzman. “I started exploring the science behind it with the help of the manufacturer Sciton. One of the devices we developed was an internal temperature sensing canula called TempASSURE. We did a lot of research through 2008 and 2009 to make this laser very safe and efficacious in fat removal. I trademarked the name LiteShape because patients do not really like the sound and connotations of the word liposuction.”

Salzman is also the developer of the Ouchless needle, and founder and CEO of its manufacturer, BellaNovus. Expected to cost $18 per device, and having sufficient spray for 18 shots, the Ouchless needle is disposable and has the efficacy of “about 40 minutes of numbing cremes. Your throughput as a provider is better and your spontaneity of sale is better,” notes Salzman. “Sales projections just keep going up.”

The most common procedures at the Salzman Institute are breast augmentation and body contouring with liposuction or tummy tucks, which dominate the spring, and facial rejuvenation filling in the fall schedule.

June 2011 25

Plastic Surgery

“With the face there are a lot of things that we do, such as facelift alone or with fat grafting to restore the youthful shape of the face,” he says. “Now we are combining facelift with a restoration of the elasticity to the skin using full face laser resurfacing. So, we can do all three things with one operation - volume, tightening of skin, and skin quality.”

Popular among younger women, the Fusion lift is another procedure Salzman developed. “The procedure is an amalgam of several different principles. One is to move the soft tissues of the face through small incisions near the ears, which is performed under local anesthesia in the office,” Salzman explains. “Next we use a laser to tighten the substance of the skin and to remove fat from the neck and jowls.

We use another laser to treat the skin quality.”

26 M.D. Update

Observing that patients no longer wait until their need for a facelift is dramatic, Salzman says the practice is very involved in preventive and preemptive procedures with toxins, fillers, plumpers, facial lasers, and intense pulse light.

“Our philosophy has evolved to emphasize trying to offer our patients the complete repertoire of cosmetic enhancements, be it surgical or minimally invasive, obviating the need for the patient to visit a multitude of other cosmetic providers or strip mall medispas,” says Salzman. “We can address their whole aging phenomenon from start to finish, both face and body. With these smaller procedures done earlier in age, the question then becomes what can be done for upkeep every year to keep this look up and avoid drastic procedures. That is our institute’s philosophy.” ◆

Salzman is the innovator of several plastic surgery devices and surgical techniques.

Remaining involved in academia helps keep him on top of his game.

June 2011 27

Hand Surgery

New Plotline for Storied Condition

subhead subhead subhead subhead subhead subhead By Gil Dunn

Kirk Schlea Luis R. Scheker, MD employs surgical treatments and injection therapy for Dupuytren’s Contracture (DC).

28 M.D. Update

Dupuytren’s Contracture: image by Bruce Barton, MD.

There are notable individuals who have suffered with Dupuytren’s Contracture, namely President Ronald Reagan, Senator Bob Dole, British Prime Minister Margaret Thatcher, playwright Samuel Becket, and British author Sir James Barrie who authored Peter Pan. It is theorized that Barrie’s own contracted hand inspired the infamous Captain Hook.

The disease is named for Baron Guillaume Dupuytren, the French anatomist and general surgeon (1777-1835) who described the condition in 1831. Part of Dupuytren’s renown comes from his treatment of Napoleon Bonaparte for hemorrhoids.

Kentucky physicians specializing in hand and plastic surgery see a steady stream of patients with Dupuytren’s Contracture (DC). Patients presenting with the disease tend to be male, older than 50, with a strong disposition to genetic factors, including Northern European or Mediterranean heritage. Lifestyle and occupations are not considered significant factors.

Hand surgeon Luis Scheker, MD, with Kleinert Kutz Hand Care Center in Louisville (KKHCC) estimates that in his 30+ year

Kentucky physicians have adopted new injectable therapy for Dupuytren's Contracture, a disease with historical significance. practice he encounters one or two patients a week with DC, either new patients or those returning for follow up. Michelle Palazzo, MD, also with KKHCC has a smaller DC patient volume, 20-30 per year.

Hand surgeon with KKHCC of Lexington, Margaret Napolitano, MD, estimates that she sees 75 cases per year. And Bruce Barton, MD, a plastic surgeon and solo practitioner at Body Spectrum Plastic Surgery Center in Lexington gauges his DC patient load at 20 cases per year.

DC is sometimes misdiagnosed, says Scheker, “as a nodule, a ganglion cyst or inclusion cyst in the palm.” According to Napolitano, observations made during the physical exam will determine the treatment course. “If significant contractures are present which impact hand function, we recommend surgery for multiple cords and Xiaflex injections for isolated pretendinous cord.”

Xiaflex (collagenase clostridium histolyticum) by Auxilium is the first, non-surgical treatment approved by the FDA for adult patients with DC. According to information provided by the manufacturer, the collagenase compound is injected directly into the Dupuytren’s contracted cord resulting in an “enzymatic reaction that helps disrupt the collagen cord and improve hand function.”

Splinting, Xiaflex injections and exci-

sion are Palazzo’s preferred treatment regimen with splinting for early diagnosis.

Xiaflex injections have proven 100% effective so far, states Palazzo, however she notes that “time will tell about recurrence.”

Patients with advanced contracture receive more aggressive treatment, says Scheker. “Most patients with contracture of the PIP (proximal interphalangeal) joint of the ring finger, we treat faster than those with contracture of the MP (metacarpal phalangeal) joint as the PIP joint undergoes irreversible changes if left for a long period of time in the flexed position.” Scheker has performed needle aponeurotomy, dividing the cord with a needle, in the office for over 20 years for those individuals that have a finger band mainly affecting the ring finger.

“For patients with severe contracture, the treatment is surgically opening the palm of the hand, removing diseased tissue and changing the direction of the fibers by performing z-plasties. We then place the hand in an extension splint to be worn at night and patient is started on range of motion two days after surgery,” states Scheker.

Barton also agrees with the approach of needle subcision, injection and excision for his patients. With regards to recurrence of the condition after injection therapy, he believes that the “jury is still out.” Barton mentions a senior in his practice with complicated disease who has had bilateral treatments with injection. As with many new pharmaceuticals, costs must be factored into the equation and are not insignificant.

Chronic recurrence of DC is commonly seen among Kentucky’s physicians treating the disease. “It is a chronic condition that can recur no matter what treatment modality is implemented,” states Napolitano.

“Patients must know that the surgeon can only treat the consequences of the disease, releasing the contracture but not preventing contractures,” says Scheker. “The contracture is a result of the genetic information the patient carries in the cells of the myofibroblasts that are present in the individual with Dupuytren’s disease. Therefore recurrence of the contracture does not mean the surgeon has not performed a proper release at that time.” ◆

Oculofacial plastics

The Triumph of Vision

Dr. William R. Nunery is the seminal figure in ophthalmic Graves’ disease, and that’s just the beginning of the story. By Megan C. Smith William R. Nunery, MD, is the soft-spoken giant in the field of oculofacial plastic and orbital surgery.

In his prestigious career, Nunery has held two long-term academic appointments – one in ophthalmology at Indiana University where he has taught for over 30 years, and another as director of UofL’s Oculofacial Plastic and Orbital Surgery Service where he has been employed since 2005.

Nunery is one of those foundational kind of providers.

Over the past 25 years, he has served in every position of executive leadership for the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) including president in 2002. Today, he is a member of the ASOPRS Advisory Board and earned the ASOPRS Research Award in 2008 for his paper “Medial Canthal Open Nasal Fracture Repair” in which he describes a new incision technique – since coined the Nunery Incision.

After receiving his medical degree from Case Western Reserve University, Nunery studied Oculoplastic, Orbital and Reconstructive Surgery under Emory University fellowship director Clinton McCord, Jr., MD. The work that transpired between June 1979 and June 1980 affixed Nunery’s career to the path of ardent researcher and devoted provider of oculoplastic surgical therapies, especially in the treatment of ophthalmic Graves disease.

LOUISVILLE

The First Spark

“No matter how well you do something, there is always a better way,” says Nunery. “Our goal is to find that better way.”

Nunery first developed an interest in Graves’ disease while writing his thesis on the pathogenesis of Graves’ disease as it was understood at that time. “As I was going over the literature on the disease,” says Nunery, “it struck me that there were two different and equally valid - but separate - lines of

thought.” Nunery discovered that there was one proliferative process involving orbital fat (Type I) and a second inflammatory process affecting extraocular muscles (Type II) of ophthalmic Graves’ disease.

That discovery led Nunery to conduct research with his own patients over the first few years of practice. He learned that Graves’ patients who had eye muscle prob-

lems were a completely different demographic than those who did not.

Those differences, says Nunery, “different ages, different genders, and different smoking habits,” had implications that sparked a lifelong interest in Graves’ disease.

What happened next, one must assume, came to bear on that passion as well.

“I first reported that smoking was a part of Graves’ disease back in the 80s at a national meeting,” recalls Nunery. “I submitted my findings at that time, but it was such a radical concept that I had trouble convincing the reviewers that it was valid.”

It was not until 1993 that Nunery’s article, The Association of Cigarette Smoking with Clinical Subtypes of Ophthalmic Graves’ Disease, was at last published. Just one month prior to his paper being published, Nunery says, a group from Amsterdam became the first to publish on the topic.

“It was a bittersweet moment, but nevertheless it was good to have made that discovery and get it printed,” states Nunery.

Debunking the Double Vision Myth

In the years that followed, Nunery has published numerous other discoveries on Graves’ disease such as the differences between subtypes, surgical techniques, and the predictive value of increased smoking rates.

While the correlation is indirect, Nunery says, “Our Type II patients have a different response to surgery, and they have a significantly higher smoking rate than our Type I patients. So... I judge the probable outcomes of surgery based on whether the patient is Type I or Type II.” The standard surgical treatment for ophthalmic Graves’ disease is orbital decompression. Double vision, before Nunery’s research, June 2011 29

Oculofacial plastics

had been inaccurately attributed to all cases of decompression surgery since the 1960s.

“In the 1960s, decompressions became more popular, but the first people reporting on that cited a high rate of double vision. It became a cardinal issue around decompression that the likelihood of double vision was high,” reports Nunery. “My data in the 1980s discredited that notion and said that we could in fact predict how patients would respond based on motility before decompression surgery.”

If ocular motility is normal before surgery, he affirms, it is very rare to encounter double vision after surgery. “I reported an incidence of four percent, but the feeling that all Graves’ patients would develop double vision after decompression surgery prevented many doctors from offering decompression to those who did not have double vision before surgery. Our data indicated that those who had normal eye movement

Dr. William R. Nunery, director of UofL’s Oculofacial Plastic and Orbital Surgery Service, has made numerous discoveries in the treatment of ophthalmic Graves’ disease and is noted for his improvements to orbital surgery techniques.

before surgery would only develop double vision after surgery in very rare circumstances. So we demonstrated the efficacy and safety of decompression surgery in a population of Type I patients.”

Further Discoveries

Nunery is engaged in ongoing research on the development of the congenital anoph-

thalmic socket , which is a condition in which a child is born with no eyes. “I have been interested in researching how to best rebuild those children,” he says. “When I started practice, the prevailing notion was to simply let those kids grow up and if necessary, in extreme cases, one could do cranial reconstructive surgery as an adult.

I and some of our fellows demonstrated with laboratory data that putting volume in congenital orbits was extremely important to the growth of those orbits.

“We followed that up with studies that showed how important it was to place those volumes early, that the slope of the expansion Thanks to Nunery’s research, orbital decompression is now the standard surgical treatment for ophthalmic Graves’ disease.

30 M.D. Update

curve and achievable results tend to diminish with time. That affected how I treated children under those circumstances, and has at this point affected how all of us collectively treat those conditions as the importance of early volume placement has spread.”

Nunery was one of the first three principle investigators in the use of porous hydroxyapatite implants in adult anophthalmic sockets. “I came to the conclusion early on through that research that non-porous implants were performing as well as porous hydroxyapatite implants and chose to write about that issue, the difference in complication rates between the two, and also recommendations on how to make non-porous implants as effective as porous implants for achieving good prosthetic motility. These things all affected the way I practice and also how others have practiced as well,” says Nunery, who has also published on the use of dermis fat graft in the anophthalmic socket as a reconstructive tool. Nunery’s conclusion is that the use of a patient’s own tissue allows it to be more readily adapted to the socket.

Another significant area of interest for Nunery is the field of facial trauma . He states that he has been “very happy to make some contributions to that field.”

The aforementioned Nunery Incision, that he pioneered, is a useful approach to orbit fracture repair. It utilizes small incision techniques that cuts down surgical time and gives improved results.

Reaching Forward

by Looking Back

Confessing an interest in history, especially medical history, Nunery observes that some trends from earlier generations have a tendency to come around again. “I read articles and realize that the point has been made before,” he reflects, “and perhaps also abandoned before.”

His research on Graves’ disease is a good example. When Nunery began researching, he was fairly convinced that the information current to that day would lead only in the direction of an immunologic answer based on inflammation in the orbit, for the current belief was that Graves’ disease was only an inflammatory process.

But Nunery was also aware of an earlier generation’s animal models for Graves’ disease that indicated many of the features which he later called the Type I disease

Nunery’s leadership in the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) helped to establish the discipline’s standard twoyear fellowship.

category. “Those patients had many of the features of Graves’ disease but notably had no inflammation. That observation from historical data is what first made me think that there might be two separate but parallel phenomena that occurred in the orbit. Indeed, as we researched it, this turned out to be the case.”

“I learned a slogan as a fellow and have taken it to heart over the years. No matter how well you do something, there is always a better way,” says Nunery. “Our goal is to find that better way. I am a person with academic curiosity who has not simply taken precepts from the previous generation at face value, but rather had an inquisitive mind to look a little bit beyond that.” ◆

June 2011 31

Plastic surgery

Dr. Bruce Barton

Once a pilot and surgeon on active duty, this Lexington-based plastic surgeon reflects upon his early influencers and the future of aesthetic medicine.

By Megan C. Smith, Photography by Kirk Schlea

For the young Bruce Barton, today a plastic surgeon at Body Spectrum Plastic Surgery in Lexington, flying was the means to a bright future.

His father, an employee of Pan American World Airlines in the glory days of airline travel, allowed young Barton to fly around the world with a view from the cockpit of a Boeing 707. These jump seat adventures, impossible in the era of global terrorism, inspired Barton to obtain his pilot’s license at 17 and prompted an opportunity rarely afforded to others.

Barton recalls how his career in medicine began “with a hand shake and a smile” when a former World War Two USAF bomb group offered Barton a scholarship to Johns Hopkins University School of Medicine. He would later join the US Air Force, but while in medical school, Barton rubbed elbows with some of the brightest minds in medicine.

Barton recalls the unique talent he encountered at Johns Hopkins; how he scrubbed with surgery giants Drs. George Zuidema, Georgeanna Seegar Jones, and Vivien Thomas; that his molecular genetics professors, Drs. Hamilton Smith and Dan Nathans, won the Nobel Prize in medicine while he was there. It is the mentoring he received from the department of plastic surgery at Hopkins that encouraged Barton to pursue plastic surgery, he says, “before it was cool.”

LEXINGTON

The Active Duty Surgeon

Following surgical residency at the University of Colorado, Barton successfully completed his general surgery board examinations. He joined the United States Air Force, and, while in uniform, he trained in plastic and reconstructive surgery at Wilford Hall USAF Medical Center in San Antonio, TX, including time spent at the Brooke Army Hospital Burn Unit, one of the nation’s finest centers.

Barton obtained his plastic surgery board certification while on active duty.

32 M.D. Update

Dr. Bruce Barton, plastic surgeon at Body Spectrum Plastic Surgery of Lexington.

At the time, the military demonstrated its desire for board certification of its physicians by offering substantial bonuses for diplomates. Meanwhile, the American Board of Plastic Surgery required minimum case volumes prior to sitting for exams.

According to Barton, obtaining theses cases while on active duty was actually easier then in a civilian practice because the military tightly controlled the provider work force.

In 1991, Barton moved to Louisville for a six-month rotation at Kleinert Kutz. This was his first visit to Kentucky, and it was the first time the Air Force sent their residents to train with the renowned hand surgeons.

During the fellowship, Barton was called to the Medical Center at Scott Air Force Base, Illinois. There Barton along with the hospital commander established Hospital Without Walls, a program that sent specialty care physicians to remote installations. Hospital Without Walls allowed doctors to fly to the troops and treat them on site at their home

bases. This was also the time Operation Desert Storm, during which Barton ran the department of surgery at Scott AFB; fortunately, the wounded were few.

Civilian Life

As a civilian, Barton returned to Louisville to complete his fellowship training at the Christine Kleinert Institute and passed the Examination of Added Qualification in hand surgery. According to Barton, “the international collegiality of the hand surgeons studying at Jewish Hospital at the time was absolutely unique. It was a privilege to have that opportunity.”

Barton then entered private practice and established Body Spectrum Plastic Surgery (BSPS) in Lexington, where he provides reconstructive and cosmetic surgery cases, including hand surgery. He also works in a rural clinic in Knox County, Kentucky, and has a weekly clinic in Madison County.

Barton’s wife, Dr. Melissa Knuckles, is a Kentucky native and dermatologist in pri-

vate practice in Richmond and Corbin. She has specific interest in psoriasis treatment and cosmaceutical development.

“The field of plastic surgery continues to expand” says Barton, “recently with the introduction of fat grafting for facial volume restoration, and most recently for primary and secondary breast volume enhancements.” This science ties in with the spectrum of stem cell research and reparative medicine, and it may be, according to Barton, “that grafted fat cells mediate local fountain-of-youth events.”

BSPS also sees much patient interest in the availability of hyaluronic acid (HA) fillers, such as Juvederm and Restylane, for facial volume restoration. While they have no capacity for stem cell stimulation, they are readily available without harvesting concerns. “While complications are few,” Barton says, “skill set development for these injectables is to be taken seriously for best outcomes.”

Barton also observes that many patients prefer that a physician accomplish these injections, “not health extenders with, perhaps, limited training.”

Recently, Dupuytren’s disease management has seen the introduction of another injectable - collagenase clostridium histolyticum (Xiaflex, Auxilium). This material has the capacity to lyse the problematic palmar cord of patients so afflicted. Barton’s experience in Lexington has, to date, been favorable. Markets are driven by price, he remarks, and the material is not inexpensive particularly in the era of medical cost containment. Separate skill sets are required here, as well.

Credentialing and Caveat Emptor

Barton acknowledges there is value in advertising and marketing through various media - particularly the internet - but with certain cautions. He believes that rising interest in procedures not covered by insurance companies has led to unbridled marketing efforts by credentialed and uncredentialed health care providers. He sees alarming aspects to this trend.

“It is too easy for non-trained indi-

Barton, who prefers to accomplish injectable fillers himself, is alarmed how unbridled marketing of procedures not covered by insurance has led to many uncredentialed providers in the marketplace.

Plastic surgery has a long history of innovation and I am confident that will continue into the future.

– Dr. Bruce Barton viduals to offer many of these services. It is diluting the market and creating potential dangers for patients. At the very least, it creates confusion, not unlike the wild wild west of yesteryear.

“The public needs to be able to differentiate between certified, trained providers and those who are not. The professional societies are falling far short when it comes to educating the public about their doctors, despite large budgets spent on this matter.

At the end of the day, patients must do their homework about their healthcare.

“We as physicians are tasked to help them,” Barton concludes, “and I enjoy that.” ◆ June 2011 33

dermatology

Fundamentals of Healing

For Dr. Leigh Ann Scalf with Advanced Dermatology, medical practice begins with a mission. By Megan C. Smith In her youth, Leigh Ann Scalf, MD, had no intention to enter the medical profession. She wanted to be a high school Spanish teacher, but her life took its fundamental turn during a mission trip to Honduras. There, in 1993, she was pulled into a medical clinic to help with communication.

While she assisted in the clinic with translations, Scalf recalls, she encountered an elderly man from the mountains who came to the clinic for treatment. “He told me that he had come that day to get medicine for his body,” she relates, “but that he also received medicine for his soul. He told me that I needed to be a doctor so that I could tell others about Jesus.”

That was her transformative moment.

“I have always felt that my beginnings in medicine go back to that moment in Honduras,” she says.

Scalf, whose Christian faith is a fundamental aspect of her life and her practice, sought to fulfill the elderly man’s advice upon returning to the US, so she began working as a medical assistant to test whether indeed medicine was the path for her.

Scalf recalls how another pivotal figure, Dr. Joseph F. Fowler of Louisville who mentored her in contact dermatitis and patch testing, inspired her to pursue medical practice passionately. Patch testing, she explains, pinpoints the allergens causing the contact dermatitis without the use of needles. “The year I spent with Dr. Fowler really gave me a love for patch testing,” she says. “He is a contact dermatitis guru and a fabulous mentor.”

Scalf completed her residency at the University of South Florida, benefiting from the strong medical and surgical program there, and stayed on to complete a dermatopathology fellowship. Then, when her husband Dr. Richard Scalf went to the Mayo Clinic for a fellowship in radiology, Scalf embarked on a second fellowship in Advanced Clinical Dermatology, with an emphasis on patch testing and contact dermatitis, under Dr. 34 M.D. Update

I have always felt that my beginnings in medicine go back to that moment in Honduras.

Mark Davis of the Mayo Clinic.

“The love I had already acquired for patch testing made the situation perfect,” she remarks, adding that Dr. Davis’s mentorship and expertise has a strong impact on her work today. Scalf remains an active member of the Mayo Clinic Contact Dermatitis Group (MCCDG), so she is able to provide patients with the most current resources on the condition.

Dermatology Practice and Dermatopathology Lab

A sole practitioner since 2007, Scalf feels that it is important to be a part of the medical community. Dermatology lends

itself to solo practice, she says, because the procedures are generally small and manageable enough to be performed in an office setting. Patient volume, she reports, has grown exponentially since her practice began and she has cultivated relationships with other dermatologists in town.

In addition to dermatology consults, Scalf serves as medical director of Advanced Dermatology’s dermatopathology reference laboratory, where she processes skin biopsy specimens from outside physicians for readings or second opinions. “I like it because they can just pick up the phone and we can discuss a case, the clinical aspect as well as what I am seeing under the microscope,” she says. “I have found that they really appreciate that personal touch.”

The staff at Advanced Dermatology (AD) includes two full time NPs and one part time PA, and they treat people of all ages. The practice is part medical and part surgical, but first and foremost it is a general dermatology clinic. Patch testing is a large component of the practice because, as Scalf observes, it is quite an undertaking to stock and maintain all of the allergens needed for extensive patch testing. After the cause of the contact dermatitis has been found, patients are typically returned to their referring physician for management.

AD also provides light therapy treatment options for psoriasis and a variety of other medical treatments utilizing narrow band UVB and hand/foot PUVA. In addition to psoriasis, light therapy is also beneficial in the treatment of eczema, dermatitis, pruritus, vitiligo, mycosis fungoides, and generalized itching.

Scalf believes that taking excellent care of her patients is the prime goal for the future of her practice. “Interesting patients are our specialty,” she says, concluding, “It is important to see the patient as a person.”

Leigh Ann Scalf, MD, is a solo dermatologist and dermatopathologist at Advanced Dermatology. ◆

Toast to a Cure

F U N

•

M U S I C

•

W I N E

•

F O O D

July 9, 2011 from 6 p.m. to 9 p.m. at Talon Winery Proceeds to benefit:

Music by Panic Show Food by Billy’s BBQ $15oo general admission $25oo admission including food Cash bar (beer & wine) from Talon Winery To purchase tickets: (859) 268-9129 or www.diabetes.org/toasttoacure Bring your blankets or chairs and enjoy an evening of great music, food and wine while supporting a good cause!

You may bring your own picnic food. Please no outside beverages.

For tickets: (859) 268-9129 or www.diabetes.org/toasttoacure

grand rounds NEWS ◆ ARTS ◆ EVENTS news@md-update.com

Statewide Health Care System Takes Step Forward

The Boards of Saint Joseph Health System, UofL Hospital/James Graham Brown Cancer Center and Jewish Hospital & St Mary’s Healthcare recently approved merger plans that will form a statewide health care delivery system. The new health system is yet unnamed.

At a joint press conference in Frankfort

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36 M.D. Update

Robert Hewett, chair of the Community Board of Trustees for the new health system.

on June 14, leaders from each organization described the benefits to Kentuckians of the combined systems and hospitals.

“This will lead to improving the health of not only individuals, but entire communities,” said Bob Hewett, who will be the first chair of the new system’s Community Board of Trustees. “At the same time, we will work to lower costs as we advocate for the poor and underserved,” said Hewett.

The combination of academic research at UofL with JHSMH and Saint Joseph hospitals “means increased access to the latest developments in diagnostic, therapeutic and preventive care by some of the nation’s leading physician scientists at UofL,” stated James Taylor, CEO, University of Louisville Hospital/James Graham Brown Cancer Center.

Dr. Kerri Remmel, UofL chief of Vascular Neurology, director of the Stroke Center at University Hospital, and associate dean for Clinical Development and Regionalization, demonstrates robotic telemedicine capabilities during the June 14 press conference.

The new system will bring together academic and community physicians, creating a medical staff of more than 3,000 physicians across Kentucky with over 3,316 licensed hospital beds and nearly 80 health care facilities.

Daniel Varga, MD, chief medical officer, Saint Joseph Health System said , “The new organization will train Kentucky’s next generation of rural physicians.”

The use of robotic telemedicine will enable system physicians to expand access of specialty care providing stroke, neurol-

news

ogy consultations to network facilities. Catholic Health Initiatives will incrementally invest $320 million in the new system. The new system will invest $200 million to expand the academic medical center in Louisville and $100 million in statewide health care services.

Biggest Research Grant ever for UK aids goes to translational science

LEXINGTON The National Institutes of Health (NIH) has awarded $20 million to the UK’s Center for Clinical and Translational Science (CCTS) to move research discoveries to health care solutions more quickly.

The five-year funding, awarded through the NIH’s institutional Clinical and Translational Science Awards (CTSA) pro-

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June 2011 37

news

UK’s Center for Clinical and Translational Science joins NIH consortium of leading translational science institutions.

gram, is the largest research funding award ever received by UK. CCTS is led by Dr. Philip Kern, associate provost for clinical and translational science, who will serve as

principal investigator of the program.

NIH launched the CTSA program in 2006 to encourage collaboration across scientific disciplines and spur innovative approaches in tackling research challenges. With the addition of the 2011 recipient institutions, the program is now fully implemented and includes 60 CTSAs across the nation.

CCTS is the only designated CTSA in Kentucky.

The 2011 CTSAs expand consortium representation to two additional states — Kansas and Kentucky — extending the network to 30 states and the District of Columbia. With these most recent awards,

the NIH is funding 60 CTSA institutions. Besides UK, the new institutions are: Pennsylvania State University, Milton S. Hershey Medical Center, Hershey; University of California, Los Angeles; University of Kansas Medical Center, Kansas City; and University of Minnesota, Twin Cities.

UK established its clinical and translational science center in 2006 with the goal of becoming a consortium member.

“Receiving this award not only provides significant funding but also the recognition of being among the top biomedical research Universities in the country,” said UK Provost Kumble Subbaswamy. “This award is the end-result of much hard work and diligence by many, many people at the university who have demonstrated their expertise in clinical research and their ability to build successful interdisciplinary collaborations.”

New 40 Bed Hospital for Mount Sterling Mt. Sterling The new $60 million Saint Joseph - Mount Sterling hospital opened June 16, The two-story, 114,000 sf structure will allow for the expansion of several service lines, such as cardiology, imaging, OB-GYN and same-day surgery.

Since its founding in 2008, St Joseph – Mount Sterling is the fourth major construction project for Saint Joseph Health System.

Attending the ribbon-cutting ceremony held June 1 were Mt. Sterling Mayor Gary Williamson, Bishop Ronald Gainer, and Saint Joseph Health System Interim CEO Bruce Klockars, along with numerous local officials.

38 M.D. Update

Leading the ribboncutting on Saint Joseph – Mount Sterling is SJHS interim CEO Bruce Klockars.

news

Dr. Frederick C. de Beer, an internal medicine specialist, has been appointed dean of the UK College of Medicine.

Internist named Dean of the UK College of Medicine

LEXINGTON Dr. Frederick C. de Beer, longtime University of Kentucky faculty member and current chair of the Department of Internal Medicine, has accepted the position of dean of the College of Medicine and vice president for Clinical Academic Affairs, effective July 1, 2011.

De Beer received his medical degree from the University of Pretoria, South Africa. His postgraduate education was at the Royal Postgraduate Medical School, London. Prior to coming to the United States in 1989, he served as professor of medicine at the University of Stellenbosch, South Africa.

In 1993, he was named chief of the Division of Endocrinology and Molecular Medicine at the UK College of Medicine.

He has also served as vice chair of the Department of Internal Medicine, director of the UK Graduate Center for Nutritional Sciences, and chief of medicine at the Veterans Affairs Medical Center in Lexington. In 2003, he was appointed as the Jack M. Gill Professor and chair of the Department of Internal Medicine. Dr. de Beer has authored or co-authored 129 peerreviewed publications as well as a number of book chapters and editorials. He maintains an active research laboratory and has been continually funded by the National Institutes of Health for more than 20 years.

Dr. de Beer succeeds Dr. Jay Perman who was named president of the University of Maryland, Baltimore, in 2010. Since

then the former dean, Dr. Emery Wilson, tory infusion. has served as interim dean of the college.

At the request of Dr. de Beer, Wilson has New VP, Chief Nursing Officer agreed to continue to work with alumni for Our Lady of Peace and friends of the College of Medicine in Louisville Jewish Hospital & St. Mary’s building support for the college’s initiatives. HealthCare has named Brad Lincks vice president and chief nursing officer at Our New VP for JHSMH Lady of Peace. Lincks has more than 15 Louisville Jewish Hospital & St. Mary’s years experience in nursing and manageHealthCare (JHSMH) has named Mark ment. He most recently served as the direcMilburn vice president of Owsley Brown tor of medical surgical and behavioral health Frazier Cancer Care, Pharmacy Plus and VNA Nazareth Home Care Pharmacy. In his new role, Milburn is responsible for JHSMH pharmacy related programs.

Milburn, a native of Louisville and a graduate of the University of Kentucky College of Pharmacy, previously served as Director of Pharmacy for VNA and has been with JHSMH network since 1998.

During his time with the organization, his responsibilities have included retail pharmacy services for JHSMH employees and discharge patients, chronic disease pharmacy programs including transplant and oncology, diabetes education and ambula-

Brad Lincks, vice president and chief nursing officer at Our Lady of Peace

services at Clark Memorial Hospital. From 1996 to 2002, he worked at Our Lady of Peace (then known as Caritas Peace Center) as a charge nurse, house manager and nurse manager.

Lincks has a Master of Arts degree in management and leadership from Webster University and a bachelor of science in nursing from Purdue University. He is also a Board Certified Nurse Executive.

Mark Milburn, JHSMH vice president of Owsley Brown Frazier Cancer Care, Pharmacy Plus and VNA Nazareth Home Care Pharmacy

Quality Award for BHE Wound Care Center

The Baptist East Wound Care Center has been honored with the Diversified June 2011 39

news

Clinical Services’ Center of Distinction Award for exceeding quality standards for patient healing plus patient satisfaction at 92 percent or above. The Center achieved a 97 percent healing rate, which bests national benchmarks.

UK Orthopaedic / Sports Medicine in Owenton

The University of Kentucky Department of Orthopaedic Surgery & Sports Medicine has opened an outreach clinic in Owenton. The clinic is run by Dr. Mary Lloyd Ireland, who is a fellowshiptrained orthopaedic surgeon who specializes in sports medicine. Located at New Horizons at 120 Progress Way in Owenton, the clinic will occur on the first Tuesday of each month. Appointments are made by phyLEXINGTON

40 M.D. Update

sician referral only.

Ephraim McDowell Health President/CEO earns top healthcare management credential

Vicki A. Darnell, president and CEO, Ephraim McDowell Health, recently became a Fellow of the American College of Healthcare Executives (FACHE). Darnell is one of only 7,500 healthcare executives hold this distinction.

To obtain fellow status, candidates must fulfill multiple requirements, including passing a comprehensive examination, meeting academic and experiential criteria, earning continuing education credits and demonstrating professional and community involvement. ACHE fellows

Danville

Vicki A. Darnell, FACHE

undergo recertification every three years.

Slayton named Malcolm Baldrige Examiner

LOUISVILLE Val Slayton, MD, MPP, MBA, CPE, vice president of Medical Affairs at JHSMH, has again been appointed

by Dr. Patrick Gallagher, Director of the

news

Commerce Department’s National Institute of Standards and Technology (NIST), to the 2011 Board of Examiners for the Malcolm Baldrige National Quality Award. The Award, created by public law in 1987, is the highest level of national recognition for performance excellence that a US organization can receive. The award may be given annually in each of six categories: Manufacturing, Service, Small Business, Education, Health Care, and Nonprofit.

As an Examiner, Dr. Slayton is responsible for reviewing and evaluating applications submitted for the Award. The board is composed of approximately 500 leading experts selected from industry, professional and trade organizations, education and health care organizations, and nonprofits (including government).

Next Step for UK / Norton Partnership

Val Slayton, MD, MPP, MBA, CPE

LOUISVILLE UK HealthCare and Norton Healthcare have announced the next step in their collaborative partnership: aggressively target Kentucky’s most pressing health problems. The health systems plan includes: A statewide stroke and advocacy collaboration; a cancer program to share resources, research agendas and clinical trials; an educational network to address obesity and weight management; expanded teaching programs designed to increase the number of medical professionals with an educational residency rotation for UK medical students in Norton Healthcare hospitals, and Norton Healthcare physicians to join UK’s faculty; and a transplant and spe-

June 2011 41

news UK’s Center for Excellence in Rural Health – Hazard

cialty clinic in Louisville.

New Director for Rural Health Center

LEXINGTON Frances J. Feltner, a longtime nurse and lay health worker administrator, has been selected as director of the University of Kentucky Center for Excellence in Rural Health – Hazard. Feltner is the center’s fifth full-time director. She served as interim director of the center since July 2010, succeeding Dr. Baretta Casey. In this role, Feltner will oversee all aspects of the center, including Kentucky Homeplace program, Kentucky Office of Rural Health and the center’s other rural health initiatives in education,

42 M.D. Update

research, service and community engagement.

Feltner has worked in various positions in rural health for 35 years. Feltner earned a licensed practical nursing degree from Hazard Area Technical College, a registered

nursing degree from Hazard Community College, a bachelor of science and master of science in nursing from Eastern Kentucky University, and is pursuing a doctorate in nursing practice from UK. ◆

arts

Ancient Bronzes

The International Museum of the Horse is poised to open the doors on June 24 to its new exhibit “Ancient Bronzes of the Asian Grasslands,” presented by the Arthur M. Sackler Foundation, New York, NY. Featuring a major sampling of steppe art from the collections of the late Arthur M. Sackler, M.D., the exhibition presents eighty-five works illustrating the personal decorations and equipment of the horse-riding steppe dwellers of the second and first century BCE. The dwellers of the Eurasian grasslands, also known as the steppes, lived and domesticated horses on the rollLexington

ing grassy plains, punctuated by snowtopped mountain ranges like the Tien Shan (Heavenly Mountains), and deserts like the Gobi and the Taklamakan.

Their culture is only now beginning to be understood by scholars. Exhibited in their art, richly decorated with animal motifs, the ancient grassland dwellers not only were the first to domesticate horses, but they began to supply horses to the empires of Eastern and Western Asia.

The ornate and richly patterned bronze belt buckles, plaques, and weapons of these ancient nomadic horsemen will be on display at the International Museum of the Horse at the Kentucky Horse Park from June 24 – October 9, 2011. ◆

June 2011 43

index

Featured Professionals Bruce Barton . ........................................ 28, 32-33

William R. Nunery.......................................... 29-31

Tami Cassis.................................................... 22-23

Michelle Palazzo..................................................28

Vicki A. Darnell.....................................................40

Calvin Rasey........................................................13

Frederick C. de Beer............................................39

Kerri Remmel................................................. 36-37

Frances J. Feltner................................................42

Marc J. Salzman............................................ 24-26

Patricia Cordy Henricksen.................................. 8-9

Leigh Ann Scalf....................................................34

Robert Hewett............................................... 36-37

Stephen A. Schantz..................................C1, 14-19

Philip Kern...........................................................38

Luis Scheker.........................................................28

Bruce Klockars.....................................................38

Val Slayton...........................................................41

Brad Lincks..........................................................39

Larry Trimmer................................................... 6, 9

Mark Milburn.......................................................39

Daniel Varga................................................... 36-37

Margaret Napolitano............................................28

S. Randolph Waldman.............................C1, 14-19

Scott Neal..............................................................5

advertisers index 2011 Louisville Brewfest..................................... C3

Kirk Schlea Photography......................................27

Physicians Financial Services...............................41

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www.schleavisualarts.com............. (859) 332-7562

physiciansfinancialservice.com...... (502) 893-7001

American Diabetes Association............................35

Lexington Clinic Orthopedics - Sports Medicine...7

Republic Bank......................................................10

www.diabetes.org/toasttoacure.... (859) 268-9129

LCSportsMed.com.......................... (859) 258-8575

www.republicbank.com..................1-888-584-3600

Cane Manor.........................................................43

Logan Financial....................................................40

Soterion Medical Services...................................42

www.kyvacationrental.com............ (859) 309-9939

phil-loganfn@triad.rr.com............. (336) 945-3966

www.soterionmedical.com............. (859) 233-3900

D. Scott Neal........................................................36

MAG Mutual...........................................................8

Unified Trust........................................................ C4

www.dsneal.com............................1-800-344-9098

www.magmutual.com....................1-888-642-3074

www.unifiedtrust.com...........(859) 296-4407 x 202

DCx: the Design Commission................................4

McBrayer, McGinnis, Leslie & Kirkland.................37

Xiaflex............................................................ 11-13

collaborate@thedesigncommission.com..... (859) 797-1261

www.mmlk.com.............................1-866-218-5040

www.wfoflou.com.......................... (502) 891-8700

Kentucky Audiology & Tinnitus Services....... 31, 36

Northwestern Mutual.................................... 20, C4

Women’s Hospital at Saint Joseph East............. C2

rhotenwhite@windstream.net...... (859) 554-5384

www.jeffrey-todd.com............(859) 252-8644 x 25

www.sjhlex.org.............................. (859) 967-2229

For advertising information contact Gil Dunn, Publisher (859) 309-0720 or gdunn@md-update.com 44 M.D. Update