Company

Ticker Symbol

Product (s)

Cynosure

CYNO

Smartlipo™

Mentor Corp

mnt

UltraSculpt™

Sound Surgical Technologies

VASER® system; VAser liposelection® procedure

Name

Hospital affiliation

State

Panelist 1

Barnes West County Hospital

MO

Panelist 2

Private Practice

dc

Panelist 3

Swedish Medical Center

CO

Panelist 4

Plastic Surgery Specialists

IL

Panelist 5

Beth Israel Deaconess Medical Center

MA

Panelist 7

Manhattan Eye, Ear and Throat Hospital, St. Vincent

NY

Panelist 8

Stone Creek Plastic Surgery, Inc.

CA

Panelist 9

Del Mar Cosmetic Medical Center

CA

Panelist 10

Johns Hopkins Hospital

MD

Panelist 11

Ponte Vedra Plastic Surgery

FL

Panelist 12

DePasquale the Spa

NJ

Question

Page number(s)

Q1: Current marketplace dynamics

Please discuss the dynamics of the liposuction/body sculpting marketplace as you see it, including the following trends: • Patient candidates • Treatments provided • Products marketed to treat • Clinician type treating these patients

4

Click here for information on VASER and Mesosculpting --Please see Appendix A

4; 25

Q2: Current practices

How do you currently manage patients interested in liposuction/body sculpting? In your answer, please discuss what options you provide your patients, and if this differs by patient type. If you do not currently manage patients interested in liposuction/body sculpting, why not? What has prevented you from offering this service, and how interested are you in offering body sculpting to your patients and why?

6-9

Q3: Awareness of products on the market or in development

What liposuction/body sculpting manufacturers, if any, are you aware of and what is your perception of these companies? Who would you rank at the top of this market?

9-11

Q4: Strengths and weaknesses of current tools

What do you consider the greatest strengths and weaknesses of current products used in liposuction/body sculpting procedures today?

11-13

Click here to review product profile – Please see Appendix B

13; 27

Q5: Awareness of Smartlipo and perception

Prior to this discussion, had you heard of the Smartlipo system? If so, how did you become aware, and what was your perception of the system? Has that perception changed after reviewing the profile above? If so,how? If you were not aware of the Smartlipo system, what is your perception based on the profile above?

13-15

Click here to review several abstracts --Please see Appendix C

15; 29

Q6: Relative strengths and weaknesses

Compared to other systems designed for the liposuction/body sculpting marketplace, how does the Smartlipo system compare? Does this system offer any advantages over other systems you know? Is this system inferior in any way to other systems you are familiar with? Please explain.

16-20

Q7: : Ideal candidates

Who do you believe are good candidates for body sculpting treatment using the Smartlipo system? Does the Smartlipo system better serve any particular patient type?

20

Q8: : Likely end users

This is a panel of plastic surgeons. There is some discussion of body sculpting being performed in “alternative” markets, including primary care physicians, dermatologists, obstetrician/gynecologists, and med spas. Do you expect systems like the Smartlipo will penetrate these alternative markets or stay primarily in the plastic surgery field? Please explain.

20-21

Q9: Facilitators and barriers to adoption and use

What are the major facilitators and barriers to the uptake and use of the Smartlipo system?

21-22

Q10: Perception and/or experience with CYNO sales team

If you have any experiences with the Cynosure sales team, please discuss if the experience was positive or negative and why. What could a Cynosure sales representative do for you to increase the likelihood of use of the Smartlipo system?

22-23

Q11:  Other issues

Other than what has been discussed, what other issues, if any, are important in understanding the liposuction/body sculpting marketplace?

23-24

Introduction

Welcome to this discussion among plastic surgeons. Our primary goal in this discussion is to get your feedback on laser body sculpting, in particular the Smartlipo system. MedPanel discussions are enhanced when you, as a panelist, not only respond to the posted questions, but also reply to comments made by our moderator and your fellow panelists. We look forward to a lively and interactive discussion. Please note: In your participation on this panel, MedPanel expects and requires that you comply with the terms of the Consultant Confidentiality Agreement to which you previously agreed. If you have any questions about the terms of that agreement, please review them through the link provided on your MedPanel home page after you've logged in.

Q1: Current marketplace dynamics

Please discuss the dynamics of the liposuction/body sculpting marketplace as you see it, including the following trends: • Patient candidates • Treatments provided • Products marketed to treat • Clinician type treating these patients

Panelist 1: Typically our liposuction patients are in their 20's to 50's and are usually on the larger size (BMI >25). We are in St. Louis and have seen our liposuction patient volume decrease significantly due to Lipodissolve in the past 18 months (down by 70% prior to lipodissolve). The only patients left are the large patients. Lipodissolve is mostly administered by nurses/aestheticians under MD supervision (very loose supervision). Of those patients who get liposuction, some get SAL, some UAL, and some using PALs.

Panelist 11: Patients are interested in little or no downtime as evidenced by the interest in mesotherapy. Many patients believe that liposuction doesn't work ie "the fat goes elsewhere" On the other hand, many patients would prefer liposuction on the abdomen when abdominoplasty may be the procedure recommended by the plastic surgeon so a device that produces more predictable skin retraction is needed.

Panelist 12: My patients are generally in their late 20's to mid 50's. Mesotherapy has caught on in the NYC area to any great extent that I can tell. Most of my patients tend to be pretty athletic and frustrated that they can't exercise away their saddlebags, lovehandles or such. Another group is the double-chin population (late 30's to mid 50's) that isn't ready for a face or neck lift. With the external ultrasound or powerlipo techniques I offer, other than wearing a compression garment, I only ask that they avoid strenuous activity for 2 days. That's generally well accepted. Most procedures are done by plastic surgeons or dermatologists although there have been a few itinerants from south america that pass through periodically and leave carnage in their wake.

Panelist 3: Body sculpting is becoming a rapidly changing field from the perspective of technique. While the technology has changed very little (except for devices such as the VASER), our ability to achieve better results has. Liposuction has become an effective modality both on its own as well as an adjunct to other surgical procedures. In addition, the demand for other less invasive techniques has continued to rise.

Panelist 9: Liposuction still is consistently a popular request in my practice. I have used vaser for 5 years and with superficial techniques, obtain significant skin tightening.

Panelist 5: My practice is in the northeast and we have noticed a general decrease in cosmetic surgery with liposuction down a proportional amount. Our patient demographics have also changed with fewer younger patients. I don't see this as relating to the introduction of lipostabile but rather as a reflection of the economy in general and specific conditions in our area.

Panelist 7: there is a steady flow of patients for liposuction. cuurently using sal and powe assisted liposuction

Panelist 10: The patient demographic is quite broad. I get patients from early 20's all the way to the 60's. Of course, as they age, they are more often candidates for excisional procedures such as abdominoplasty, but they come for "liposuction". About 10% ask indepth questions like "do you use liposelection" "do you use tumescent technique". Almost all in the Balto-DC area are treated by plastic surgeons, but about 15% are treated by dermatologists and facial plastic surgeons/ENT. Some have friends that have had painful recovery or lumps, but many know someone with good results

Panelist 2: our practice dynamic is as most panelists, patients in the 20's to 50's and is pretty stable. we are in the dc metro area and have found that vaser is pretty popular but not widespread; any new technique that will enhance skin tightening would be welcome

Follow-up ALL: Increase in Mesosculpting and Vaser (UAL)

A few panelists note a decreasing interest in more traditional liposuction procedures, and an uptick in patient interest in mesotherapy and Vaser (UAL). Another panelist believes general economic conditions are more to blame for the decrease in liposuction demand. What do other panelists believe? Are others seeing a decrease in demand, and if so, to what do you attribute this trend? What trends are you seeing in liposuction versus less invasive sculpting techniques?

Panelist 12: I haven't seen any significant change in "demand" for liposuction. Patients inquire about mesotherapy since they see it in the media. At least in my patient population, most aren't ready for an unproven therapy.

Panelist 2: i havent seen a downturn in demand; dont recommend mesotherapy and most people dont ask about it, except the international clients;

Panelist 10: i agree with the other panelists -- I have not seen a decrease in demand--most of my practice is word of mouth and so people want what their friend had --which is liposuction. No one seriously inquires about mesotherapy--and if they do, I dismiss it in one sentence and the patients never return to that topic. They do ask about VASER or ultrasound in general. I think cosmetic surgery is refractory to most mild economic swings. Certain geographic regions are evergreen -- NY, DC, where as more suburban markets may be sensitive to macro-economic conditions. The housing market (>$500,000 is very elastic, but small purchases $5000-$7,000 do not show such sensitivity in my practice.

Panelist 1: The decrease in demand for us is directly related to lipodissolve.

Panelist 11: Patients have heard of mesotherapy and lipodissolve but it is difficult to determine if that has had a material effect on our liposuction practice which is stable. We have looked at and continue to be interested in the VASER system.

Panelist 7: i think there may be a decrease in demand for plastic surgeons who perform large liposuctions as patients seek supposedly less invasive and quick fixes. I think this is a trend in cosmetic surgery in general

Panelist 3: While there is definitely an increased interest in less invasive body contouring modalities, I don't feel that this has drmatically influenced the number of traditional body contouring procedures. In other words, I feel that the pie has grown and will continue to grow. Also, even though treatments such as mesotherapy are becoming more popular, I predict a backlash against this technology when the lackluster results become available.

Panelist 9: I have not had anyone ask about Lipodissolve. Vaser or liposelection still is requested by 25% of my patients. I have had 2 patients inquire about Smartlipo in the past 4 months. Liposuction body contouring still remains a high percentage of my surgical practice.

Panelist 5: as I said earlier, I attribute this primarily to economic conditions

Panelist 8: I haven't seen any decrease in demand for liposuction. A few patients do ask about mesotherapy or UAL after hearing about it in the media.

Click here for information on VASER and Mesosculpting --Please see Appendix A

Panelist 4: Panelist 4: Lipo is one of those procedures that is very prone to the latest “fad” Many of these “latest techniques” have been found to show little advantage and some occasional undesirable complications. I feel many plastic surgeons tend to latch onto these new techniques to attract more patients by being “cutting edge."

Panelist 2: i havent seen a downturn in demand just occasional market fluctuations; as for mesotherapy i dont recommend it and people dont tend to ask for it; everyone is treated individually so some need more sculpting and some need more generalized fat removal

Panelist 8: Our patients are mainly in their 30's to 50's. Patients generally are requesting more non-invasive techniques, incl mesotherapy, VASER, but tumescent liposuction and UAL are still recommended to many patients. A device or procedure that would help with skin tightening would be much welcomed, as considerable numbers of patients have skin laxity issues, requiring some type of abdominoplasty procedure. Loose thigh skin is another area that is often difficult to address. Plastic surgeons and dermatologists, and some ENT, are providing most of these procedures in our area.

Q2: Current practices

How do you currently manage patients interested in liposuction/body sculpting? In your answer, please discuss what options you provide your patients, and if this differs by patient type. If you do not currently manage patients interested in liposuction/body sculpting, why not? What has prevented you from offering this service, and how interested are you in offering body sculpting to your patients and why?

Panelist 1: Paitents with significant skin laxity usually start with a skin excision procedure (abdominoplasty or circumferential body lift). We frequently combine liposuction with these procedures. For those patients without skin laxity, we will perform liposuction. Mostly SAL, but for fibrous areas or redo's we will use the VASER (UAL). We have a microaire, but rarely use it. We've tried lipodissolve in our practice and Idon't think it works that well. For a significant number of large patient's (BMI >30), we will perform a debulking liposuction followed by a skin tightening procedure 4-6 months later.

Panelist 11: We see a significant number of patients interested in lip/body sculpting. Some of them are better candidates for abdominoplasty alone or in combinatation with liposuction. Others are poor candidates due to the relative degree of deformity i.e. a small amount of loose skin and minimal fat who don't want a mini-abdominoplasty scar.

Panelist 12: I don't treat the "big" ones with lipo, they get excisional surgery or perhaps go elsewhere. I've been very happy with the microaire device and generally find that the amount of swelling and bruising I see is comprable to that with external ultrasound but with less OR time. There does seem to be more skin contraction with XU so I use that in the face and on the bellies that are a tad loose. Otherwise, I go with the power lipo, particularly for smaller areas under local. Patients seem to tolerate it better. The only time I still use traditional lipo is if I'm planning to re-inject the fat, then I use the Tulip system.

Panelist 3: For my body contouring patients, I either use VASER LipoSelection alone or in combination with an excision procedure (e.g.: tummy tuck). I find that the VASER is extremely effective at creating a smooth contour and is definitely associated with a shorter healing time as compared to traditional liposuction. Given the fact that I am practicing in Denver, I find that my patients are extremely motivated and tend to be very athletic as well as versed on proper nutrition. This combination makes for a much smoother postoperative course overall.

Panelist 9: We use the vaser on every patient. With a large fat pad and abdominal skin laxity, the vaser liposuction for debulking, combined with the Avelar abdominoplasty technique has provided excellent results. I have avoided lipodisolve due to reports of irregular and unstifactory results.

Panelist 5: patients are seen in consultation, evaluated and treatment options given. If appropriate for lipo they may be done in our JCAHO certified Office OR or in the hospital depending on health criteria number of regions to be done and the total amounts of fat expected to be removed. I use ual, pal and old fashioned hand suction

Panelist 7: patient is either a candidate for liposuction or a candidate for excisional body contouring. Some are candidates for both. The patient needs to be educated to this and informed. Treat patients with sal/pal/excision. I do not use laser, smart lipo or lipodissolve

Panelist 10: Liposuction is a big draw--its the most popular easy-fix that patients seek. Once they come in, they may be more appropriate for alternate procedures, or will start to inquire about other procedures. Often, it is the "Gateway" procedure. They are usually pleased, and return to the practice over the future years. Most often, it is plain old liposuction. More male gynecomastia or repeat liposuction, I offer liposelection (my platform of choice for UAL). Almost all get PAL (easier on my arms/back). I have to dissuade patients who think this is an alternative to weight loss (about 5% of patients). Some just have to diet and hit the gym.

Panelist 2: my practice includes PAL (microaire), SAL and VASER and skin excision. i usually lipo contour with all tummy tucks and will often do other areas as well. i use the vaser on more challenging patients but not often.

Follow-up ALL: Experience with Lipodissolve

Panelists 1 and 9 indicate they are not satisfied or have heard reports of unsatisfactory results with Lipodissolve. What are others’ experiences with lipodissolve? Panelist 7, you mention you do not use laser, Smartlipo, or Lipodissolve. Why have you chosen not to use these approaches?

Panelist 12: I haven't heard of any satisfactory responses

Panelist 2: no experience with lipodissolve; have heard some promising anecdotes;

Panelist 10: I have no experience with lipodissolve and have not heard any significant anecdotes about it either. Now I'll have to go and google it.

Panelist 1: see my 1st response

Panelist 11: I have no experience with lipodissolve. I have had several patients mention that they were going to try it and have asked them to let me know whta they think Our society has been very specific in it's admonition against using lipodissolve so we are awaiting the results of the current studies.

Panelist 7: have used vaser which is more time consuming than sal or pal and there is no better result; smart lipo is too expensive and I have never been offered to try the machine; our literture states that the jury is not yet out on mesotherapy and the technology has not been perfected

Panelist 3: I think that the general consensus among most plastic surgeons is that results from mesotherapy are unproven and very disappointing. While it may have a role for very localized removal of fat, it will definitely not replace contouring of much larger areas.

Panelist 5: I have seen a couple of patients after lipodissole with unevenness and unhappiness.

Panelist 8: Have no experience with, nor have I heard any reports regarding lipodissolve.

Follow-up ALL: Microaire

Panelist 1 has but rarely uses Microaire (PAL); Panelist 12 has been very happy with Microaire because the amount of swelling is comparable to external ultrasound with less OR time, however external ultrasound is better for the face or skins that are loose because of the amount of skin contraction. Do others use Microaire? Please discuss why you use or do not use Microaire and your experiences.

Panelist 12: As another panelist noted, PAL is easier on the surgeon which is another plus given that the results are as good, or better, as with other methods I've tried.

Panelist 2: i use microaire more than any other modality; have been happy with sweling and/or skin retraction;

Panelist 10: I've been pleased w/ microaire. No untoward effects related specifically to that. will continue to use.

Panelist 1: see my 1st response

Panelist 11: We do not use microaire and currently are not interested due to mixed reviews. It is my impression that in Florida most plastic surgeons limit their liposuction to 4 L or less so fatigue is not that much of an issue.

Follow-up Panelist 11: Mixed reviews

You mention you are not interested in using Microaire because of mixed reviews it has received. What have been the negative reviews holding you back from using Microaire?

Panelist 11: Most practitioners with whom I have spoken have given it mixed reviews.

Panelist 12: I've had only positive experiences with PAL and with Microaire

Panelist 5: I too have had a great deal of success with micraire and PAL. It is in fact my instrument of choice for liposuction. My only complaint is that the gas powered handpiece in my hospital is very loud.

Panelist 1: None that I know of.

Panelist 1: None that I know of.

Panelist 11: Little or no increased efficacy over standard SAL.

Panelist 11: Little or no increased efficacy over standard SAL.

Panelist 3: I have actually used the PAL system and wasn't impressed. In addition to the fact that it really was hard on my wrist, I also didn't think that it offered any advantage over conventional liposuction. When compared to the VASER system, which is extremely easy to use, I definitely wouldn't recommend Microaire PAL...

Panelist 10: No problems with Microaire. I actually like it

Panelist 2: i like it

Panelist 9: I have tried it several times and felt the equipment was heavy, warm, and vibrated too much.

Panelist 8: None that I know of.

Panelist 7: I use microaire PAL almost exclusively as it is available at the hospital and make the surgery go quicker with less effort. i am able to acheive the same reult with sal

Panelist 3: I do not use Microaire and have been extremely pleased with the results of VASER for skin contraction.

Panelist 5: see below

Panelist 8: I do not use Microaire mainly due to mixed reviews.

Panelist 4: We use standard tumescent lipo with excellent results. We have a busy lipo practice with no significant complications. We rarely use VASER or microaire, though both are available.

Panelist 1: see my 1st response

Panelist 8: I try to screen out those who just need to lose weight first (5-10%) and suggest that they diet and hit the gym. I always determine whether they require skin excision, fat removal and/or both. I have been offering traditional tumescent liposuction and have now begun using VASER. I do not use lipodissolve.

Panelist 9: Vaser with a lower power superficial utilization, coupled with post op endermologie message, has given us safe and dramatic skin tightening results. While I have not used PAL, there should be no contraindication to it's use with vaser.

Q3: Awareness of products on the market or in development

What liposuction/body sculpting manufacturers, if any, are you aware of and what is your perception of these companies? Who would you rank at the top of this market?

Panelist 1: Well's Johnson: Standard SAL: Good, trustworthy company. Sound Surgical: VASER: Works well. Good Company. I don't like their "lease program." Microaire: PALs: Works well. Cost effective. Cyanosure: Smart lipo. No idea about this company.

Panelist 12: I've had only good experiences with Wells Johnson and with MicoAire. Can't speak to the others.

Panelist 3: The major players are Sound Surgical Technologies, Lysonix, and Mentor.

Panelist 9: Vaser (SST) good company although I do not like their lease program. Lysonix has caused major problems such as burns and seromas. Smartlipo from cynosure may have a role in superficial lipo and skin tightening, but the long term results are not available.

Panelist 5: Wells Johnson, Microaire, Byron, Tulip, Grams, all companies I have dealt with favorably. I really have no experience with Vaser nor Laser lipo

Panelist 7: use microaire PAL and coleman cannulas for AFG

Follow-up PANELIST 3 and 7