The progress of Laser medical device in the aspect of engineering studies

Takahiro FUJIMOTO, MD, PhD, MBA

Clinic F, Tokyo, Japan

Laser, EBMD, Energy-based-Medical-Device, DDS

Introduction:
“Laser” stands for “Light Amplification by Stimulated Emission of Radiation,” which is an artificially generated light that amplifies light (electromagnetic waves) using a resonator. Laser light has excellent directionality and convergence, and also has the property of maintaining a constant wavelength of the electromagnetic waves it emits.

The basic theory of lasers began in 1905, when Albert Einstein derived a new formula from Max Planck’s radiation formula based on the probability coefficients (Einstein coefficients) of the absorption, spontaneous emission, and stimulated emission of electromagnetic radiation in his paper “On the Quantum Theory of Radiation.” However, it took 50 years until the development of the first laser generator using ruby crystals by Theodore Maiman in 1960 for the completion of engineering technology. Maiman was awarded the Nobel Prize in Physics in 1964 for this achievement. Since then, various laser oscillation phenomena have been invented by researchers around the world, including the He-Ne laser in 1961, glass laser, semiconductor laser in 1962, Ar laser in 1963, CO2 laser in 1964, dye laser, picosecond laser in 1966, excimer laser in 1970, femtosecond laser in 1981, and attosecond laser since the beginning of this century. There have been 29 Nobel laureates in the field of lasers to date, but in other words, artificial light lasers have been in existence for just over 60 years since 1960.

The medical application of lasers can be broadly divided into two fields. One is the use of the unit periodicity of the wavelength of laser light as a sensor probe for information application to the diagnosis of cancer and cell analysis, i.e., the application of the “temporal” coherence of light. The other is the use of the focusing property of laser light as an energy source that can be used like a surgical knife, i.e., the application of the “spatial” coherence of light. The biological effects that occur as a result of the interaction between laser irradiation and living tissue include photothermal effects (as described below), photochemical effects (chemical changes that occur in substances, organisms, or living tissue due to light radiation), and biological stimulation effects (LLLT or low-level laser therapy, where laser photons act on the mitochondria of cells and help to generate ATP, which is the energy of cells).There are various effects such as the light pressure effect (control of the collective structure and optical properties of nanoparticles and polymers by the pressure of light) and photomechanical effects (gradually occurring effects such as photoacoustic effect, evaporation, and photothermal ablation as the power density increases) that can be utilized for diagnosis and treatment of diseases using lasers. Although the development of laser devices covers a wide range of fields, this article provides an overview of the basic engineering principles, impact on the human body, medical applications, and future progress of engineering laser devices.

“Engineering Principles of Laser Oscillation”
Atoms and molecules move with a specific energy, but when external energy is applied, they move with even higher energy (excited state). After a while, the atoms or molecules release the excess energy and return to their original energy state. At that time, the excess energy released becomes light and is emitted externally (spontaneous emission). Furthermore, when this light collides with other atoms or molecules with high energy, the same type of light is emitted (stimulated emission). If the number of atoms or molecules with high energy is increased by some means, the stimulated emission occurs in a cascade, and powerful light is emitted (light amplification). Furthermore, by using a resonator with mirrors facing each other under certain conditions, the emitted light is repeatedly reflected, and the light is amplified in a specific direction, becoming even more powerful. This is the basic principle of laser oscillation.

“Medical Applications and Biological Reactions of Lasers”
In the medical field, lasers are commonly used in five areas: plastic surgery, ophthalmology, dental and oral surgery, general surgery, and urology, and their use in the field of plastic surgery is particularly outstanding. Specifically, there are photodynamic therapy, excimer laser corneal refractive surgery, laser lithotripsy, low-power laser therapy, laser-based dental diagnosis and treatment, laser angioplasty, and endoscopic surgery using lasers. When arranged in the order of their application in the medical field, CO2 laser was the first to be announced.

When a vaporization-type laser is focused on the skin or organs, the laser light is absorbed by the moisture in the cells and extracellular substances and converted into thermal energy. From an engineering standpoint, when the laser energy density per unit volume exceeds the material’s vaporization threshold, a reaction force is generated by the vaporization scatter. Furthermore, when the laser light intensity becomes high and exceeds approximately 10¹² W/cm², optical breakdown occurs. The high-temperature and high-pressure plasma that is generated initially expands at hypersonic speed, and when the expansion wave decelerates, a shock wave is generated. As a secondary interaction between the laser and the medium, cavitation occurs, and acoustic waves are also generated by the pressure collapse. Histologically, the tissue temperature rises instantly, and the proteins that make up the tissue coagulate at 60-70°C, and when the temperature reaches 90°C, the moisture vaporizes and expands, breaking through the coagulated cell membrane. Furthermore, as the temperature increases, the coagulated protein contracts and carbonizes, and at this point, the cell disappears as if it had been vaporized by the laser light. When laser light is applied to a living body, it diffuses concentrically in the surrounding and deeper areas from the irradiation point. The outermost area is “activation,” the second is “fusion” (below 55°C), the third is “protein breakdown” (68°C~), the fourth is “protein coagulation” (above 100°C), followed by “vaporization” (110°C~) and finally “carbonization” (200~2000°C).

Figure 1: Temperature rise and irradiation effect on biological tissues by laser.

“Surgical applications and limitations of lasers”
In the early days of laser application in the medical field, carbon dioxide lasers were used as surgical scalpels, which vaporized the surface around the incision and created a thin coagulation layer by heat transfer. This coagulation layer causes the edges of the cut capillaries to contract and seal, providing the advantage of hemostasis at the same time as incision, unlike conventional scalpels. However, since medical lasers simply vaporize and coagulate the irradiated area and there was no clinical need for large and expensive laser devices, clinicians did not choose laser scalpels as their first tool for incision and coagulation, and instead, they used the electric scalpel, which is simple to handle and low-cost. Table 1 compares the surgical scalpels of each laser. The use of a semiconductor laser for incisions and wound closures in the surgical field leaves a shallow muscle layer and has less impact on deep tissues, which accelerates healing and reduces postoperative pain. Although medical equipment using CO2 lasers as a light source, which began in the 1970s, did not become widespread as surgical tools, they are easy to use for small surgeries and hemostasis in outpatient settings, as we can see from recent examples in dentistry. In the field of skin formation, CO2 lasers of around 10W are used for the removal of warts, moles, and vaporization.

Table 1: Comparison of surgical scalpels.

“Four types of YAG lasers”
The YAG laser is the most commonly used laser for research and medical purposes. “YAG” is a crystal used as a medium for solid-state laser oscillation, and each alphabet of YAG stands for a complex oxide of yttrium with an atomic number of 39 and aluminum with an atomic number of 13, which is a garnet (pomegranate stone) structure crystal that is an artificial substance that does not exist in nature. In the process of producing YAG crystals, there are many YAG lasers that replace yttrium with other rare earth elements. Nd:YAG (neodymium YAG) laser is produced by doping yttrium with a small amount of neodymium with an atomic number of 60, and is used for the removal of pigment spots in the field of dermatology. Ho:YAG (holmium YAG) laser is produced by doping yttrium with a small amount of holmium with an atomic number of 67, and is used as a vaporization laser in urology, such as for lithotripsy. The success rate per treatment for endoscopic holmium laser lithotripsy is over 95%, and the cure rate for bladder stones is 100%. This type of surgery requires no perforation or bleeding risks, making it safe and effective.This type of surgery can simultaneously treat conditions such as ureteral tumors, ureteral polyps, and stenosis, as well as avoid the need for perforation or the risk of bleeding. The particles produced by Holmium laser fragmentation are in a fine powdered state, which significantly shortens the time required for their discharge after fragmentation. Er:YAG (Erbium YAG) laser is a laser that has been doped (added) with a small amount of erbium with atomic number 68. It is used in dermatology to peel off skin and for vaginal tightening purposes by utilizing its highly water-absorbent properties. Tm:YAG (Thulium YAG) laser is a laser that has been doped (added) with a small amount of thulium with atomic number 69, and is also used in skin reconstruction surgery for resurfacing (smoothing out the skin).

“Introduction of Selective Photothermolysis theory (Selective Photo-thermolysis)
In the field of dermatological surgery, the theory of Selective Photothermolysis, which was announced by Anderson and Parrish in 1983, changed the laser technology significantly. This theory involves the selection of specific targets, such as melanin pigments, hemoglobin pigments, and water molecules, and intracellular structures by adjusting three parameters: the wavelength (nm) of the laser light, the pulse duration (µs) of the irradiation, and the power per unit area (W) (or the energy amount (Fluence: J/cm2)) used for the irradiation. Anderson and his colleagues examined the chromophores that absorb light well and the absorption characteristics in a specific wavelength range when they irradiated the skin with light in the ultraviolet to infrared region and created a detailed absorption spectrum. This technique has been applied to treatments such as laser depilation and pigment spots or tattoo removal. The biological tissues targeted by laser treatment have a property of strong absorption of light due to the fundamental vibration or group vibration of specific amino acids, proteins, nucleic acids, lipids, and biological pigments in the biomolecules, especially in the near-infrared wavelength range, despite weak absorption in the visible wavelength range. By irradiating various near-infrared wavelengths of laser that have unique absorption characteristics for cells and biological tissues, it is possible to selectively excite specific sites and cause interactions, leading to laser therapy becoming a low-invasive diagnostic and treatment method with high disease selectivity.

Figure 2 Absorption characteristics curve of tissue by wavelength

“Introduction of Fractional Laser Technology”
In 2000, a device was developed that used a laser (1.32μm) to cause inflammation in the dermis layer while protecting the epidermis with a cooling device and eliminate small wrinkles through wound healing reaction. Although the mechanism was correct, the amount of collagen produced was very small, resulting in limited treatment efficacy. The fractional laser, which gained recognition from the academic society as a rejuvenation treatment laser, was introduced in 2004 at the American Society for Laser Medicine and Surgery conference held in Dallas. An Er:Glass (1.54μm), which has a moderate absorption to water, was used as the laser. This device separates the laser beam and creates approximately 2,000 coagulation columns with a diameter of around 70 μm per 1 cm2 on the skin surface, ensuring the formation of wounds in the dermis, resulting in a high amount of collagen production and coagulated epidermis regeneration. The regenerated skin has a unique lattice structure, resulting in a smooth skin surface. The fractional laser has a high safety profile and can be applied to various parts of the body, and has become a popular laser therapy device.”(figure 3) By removing (punching out) old keratin at the same time, the corneal barrier function can be restored early because the wound is very small, and the inflammation is reduced, which has the effect of accelerating wound healing efficiency by normal epidermal basal cells immediately surrounding the pore. With fractional laser technology, irradiation density (spots/cm2) has emerged as a new fourth parameter in laser therapy.

Figure 3: Fractional laser irradiation area and wound healing process in the living body after irradiation.

The fractional laser beam is capable of treating a surface area instead of individual points by integrating the tissue vaporization, coagulation, and activation phases of the tissue in the living body, as shown in Figure 4. By applying the three physiological activity volume ratios (white = vaporization, red = coagulation, orange = activation) that change depending on the laser wavelength used, as shown in Figure 5, the treatment enables texture improvement therapy such as acne scar treatment.

Figure 4: Vaporization, coagulation, and activation phases of living tissue by the fractional laser beam.
Figure 5: Conceptual diagram of texture improvement therapy by the fractional laser.

“Laser treatment for adipocytes (fat cells)”
In the future of the field of plastic and reconstructive surgery, the most in-demand laser treatment will undoubtedly be those targeting sebaceous glands and subcutaneous fat, due to market demand. This will enable the achievement of acne-free skin and body contouring. While dieting can lead to weight loss throughout the entire body, it is impossible to specifically target and slim down particular areas to achieve an ideal proportion. However, by selectively destroying targeted fat cells with a laser, it becomes possible to achieve this goal. The absorption characteristics of sebaceous glands and fat cells for various wavelengths have already been elucidated by a team at Harvard University, with the strongest point being at 1680nm. (5)

“Development of Attosecond Lasers”
The pulse duration, which refers to the irradiation oscillation time of a laser, has evolved through engineering to include millisecond, microsecond, nanosecond, picosecond, femtosecond, and now attosecond oscillation, with laser equipment capable of oscillation as short as 10^-18 seconds (one quintillionth of a second) having been developed. While molecular structural changes were the subject of measurement in the femtosecond time domain, with attosecond technology it is now possible to image how the electronic wave function changes on a time scale faster than molecular structural changes, making it possible to examine the ultimate short-time response of material systems. Research using this technology has led to new research fields including the study of properties of light functional materials such as photocatalysts and solar cells, as well as the development of biological observation techniques including new materials and medical diagnostic technologies. For example, with imaging and chemical reactions, the mechanisms of “interactions between electrons” in molecular electronic wave function development and multi-electron systems are being elucidated through attosecond time-resolved measurements of tracking and controlling molecules. As an applied field for biology, drug discovery, and medicine, high-resolution biological imaging has become possible by using attosecond pulse light in the soft X-ray region as a light source for microscopy and diffraction methods.

“Application of lasers to subcutaneous drug delivery”

In the field of transdermal drug delivery, both chemical methods utilizing bases such as liposomes, polymer micelles, and nanoemulsions, as well as absorption enhancers, and physical methods utilizing electric fields such as iontophoresis, electroporation, ultrasound, tape stripping, and microneedles have been verified. However, if the perforations created by fractional lasers are considered as “physical” transdermal absorption pores, they could serve as a powerful tool for enhancing drug delivery systems (DDS). There are reports of the introduction of local anesthetics, NSAIDs, opioids, cancer chemotherapy drugs, corticosteroids, vaccines, vitamin C, and botulinum toxin by using fractional lasers. It can be expected to be useful for improving injection drugs for internal pressure tissues such as insulin or vaccine administration for internal medical conditions and keloids. Furthermore, it is thought that stem cell-based cell transdermal delivery, such as iPS cells, will also be possible in the future. The improvement of transdermal drug delivery through fractional laser assistance is becoming a trend in the third medical application of lasers, following the acquisition of biological information and their use in biological resection and modification. (6)

“Conclusion:
In the 21st century, laser medicine is expected to accelerate its development in both technology and clinical applications. Based on research into the biological effects of lasers, new diagnostic and treatment methods will be invented by exploring the optimal parameters for their effects on living organisms. In the future, continuous improvements and progress in laser equipment will lead to the development of smaller and higher-performance laser devices, as well as fiber-optic technology. Various lasers of different wavelengths and outputs will be inserted into the body or blood vessels for surgery and irradiation therapy. High-power, ultra-short pulse free-electron lasers will be widely used in digestive tract and urinary tract incisions, stone fragmentation, and other surgeries. Biological cascades under the effect of laser light are also becoming increasingly clear, and applications of photodynamic therapy and other laser-based photodynamic therapies for cancer treatment are expected to progress.
The American Society for Laser Medicine and Surgery (ASLMS), mentioned earlier, has changed its name to the Energy-based Medicine and Science Society, or the Energy Based Medical Device (EBMD) Society, since a few years ago. While lasers were the only energy source used for activating subcutaneous tissue since the 1970s, many other technologies have been invented, including electromagnetic waves beyond the width of light (Figure 6). From the late 1990s, phototherapy with intense pulsed light (IPL) has been used, and in the 2000s, energy devices using principles other than lasers, such as radio waves (RF), cryotherapy, atmospheric pressure plasma, high-intensity focused ultrasound (HIFU), shock waves, and high-intensity focused electromagnetic fields (HIFEM), have been developed. Although the application of these newly developed energy-based devices to other medical fields is a field without textbooks, I believe that it can be one of the cutting-edge medical fields that will continue to evolve based on research presentations at world conferences.”

reference

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藤本幸弘: 泌尿器科15（3) 221‐228, 2022 特集レーザー泌尿器科手術の現在　巻頭論文「工学からみた医療レーザーの進歩」の翻訳

Management Strengthening Measures for Beauty-Related Medical Clinics

Takahiro Fujimoto, MD, PhD, MBA　ClinicF Tokyo Japan

Introduction
This paper is a revised version of the content presented at the 34th Annual Meeting of the Japanese Society of Aesthetic Surgery, under the lecture category of “Risk Management.” The original presentation was titled “Management Strengthening Measures for Hospitals, Including Corporate Conversion of Medical Institutions and Anti-aging Treatment.”
Currently, the healthcare system in Japan faces various problems such as the national health insurance system and increased healthcare costs, mixed insurance and medical care, shortage of doctors and uneven distribution of medical specialties, medical fee system, medical quality and malpractice, and more. However, these problems are not unique to Japan; they exist in various countries worldwide, even with different systems. When considering national healthcare policies, the essential elements of cost, quality, and access are emphasized. However, since these three elements compete with each other, it is difficult to achieve them all simultaneously. In Japan, healthcare costs are among the lowest of advanced countries, and access to healthcare is guaranteed by the national health insurance. As for medical quality, it can be said that it is maintained at a certain level primarily through the efforts of physicians.
Modern Western medicine has developed by investigating the cause of newly arising diseases and developing treatment methods, including drugs and medical devices, to overcome them, with the focus on treating patients with diseases to bring them closer to a healthy state. Consequently, while the importance of preventive medicine, which protects healthy individuals from chronic diseases, such as lifestyle diseases, has been emphasized recently, it has received less attention in the past.
Based on the above, this paper discusses peripheral topics related to independent beauty-related medical clinics and their management strengthening measures. For convenience, this paper uses the term “beauty clinic” to refer to beauty-related medical clinics, “beauty doctor” to refer to physicians involved in beauty-related fields, and “beauty treatment” to refer to the treatment provided by beauty clinics.

1. Features of Beauty Treatment
(1) Preventive Medicine, Maintenance and Promotion of Beauty and Health
The “Health Japan 21” campaign, which is being promoted by the Ministry of Health, Labour and Welfare, aims to “realize a reduction in mid-life mortality, an extension of healthy life expectancy, and an improvement in quality of life.” It emphasizes “further promotion of primary prevention, which focuses not only on early detection or treatment by medical checkups, which has been the center of conventional disease measures but also on the promotion of health and the prevention of disease.” Thus, national policies related to health aim to reduce physical illnesses, improve mental health, and promote health and beauty. Beauty treatment is expected to contribute to preventive medicine, which is essential for maintaining health, and to promote the maintenance and promotion of beauty and health.

(2) Specificity of Aesthetic Medical Treatment
As of the end of 2010, the number of doctors in Japan was 280,431 (180,966 in hospitals and 99,465 in clinics), showing an increase of about 15.3% over the past 10 years. Although the number of cosmetic surgeons is relatively small compared to the total number of doctors, there were 427 at the end of 2010 (21 in hospitals and 406 in clinics), which is about twice the number 10 years ago. However, since cosmetic surgery is included in the field of plastic surgery, which deals with the surface and shape of the body, the actual number of aesthetic doctors is expected to be much higher, and it is expected to increase in the future, including those who switch from other specialties.

However, since medical education at university medical schools still focuses on the treatment of diseases, there are few opportunities to learn medical techniques for those who aspire to become aesthetic doctors. Due to their lack of experience, there is a risk of medical malpractice, among other things. Furthermore, since most aesthetic medical treatments are based on elective procedures, hospitals tend to handle them less frequently, and small clinics are the main providers. In addition, medical devices used for medical purposes in aesthetic treatments, such as photo-laser treatment equipment, have advanced rapidly in technology, and the investment required to upgrade to more expensive models that provide higher treatment effects is significant. If the trend of an increase in doctors and a decrease in patients continues, there is a risk of financial difficulties in clinic management.

Thus, it can be said that aesthetic medical treatment is a unique field among medical specialties.

On the other hand, while there are no accurate statistics on the attributes of patients undergoing aesthetic medical treatment, since most of these procedures are elective and non-urgent, the number of patients is believed to be influenced by their income level. In other words, if the current economic downturn continues, there is a tendency to reduce spending on aesthetic medical treatment, and latent demand is expected to decrease.

(3) Types of Aesthetic Medical Treatments
Although there are many types of aesthetic medical treatments, they can be classified by the type of procedure, as shown in Table 1. In addition to cosmetic surgery, which was previously the mainstream, there has been an increase in internal medicine treatments such as doping therapy, hormone replacement therapy, immune enhancement, antioxidant drips, injections, which do not require as much expertise. Relatively new fields include health-promoting therapies that use supplements, foods, herbal medicine, enzymes, etc., to supplement nutrition, exercise, and rest. Furthermore, there has been an increase in aesthetic dermatology treatment centered on treatment with photo-laser devices, which have made rapid technological progress over the past decade. The reason why the table uses the term “maintenance therapy” is that while other therapies are transient, meaning that when the treatment is completed, the patient’s visits usually end, maintenance therapy is a continuous therapy that aims to maintain the achieved aesthetic results.

2. Business Strategy of a Cosmetic Clinic
As a medical corporation, a cosmetic clinic is subject to non-profit constraints. In other words, legally, it is required not to engage in “activity aimed at profit.” However, even if it is non-profit, to maintain and improve the quality and safety of medical care through sufficient investment in facilities and human resources and to stabilize management, it is necessary to secure an appropriate financial foundation. Furthermore, in the future, as mentioned above, it is expected that there will be an excess supply of doctors and clinics compared to demand (number of patients), so there is an increasing trend to introduce the concept of for-profit business management while prioritizing mission fulfillment at cosmetic clinics.
While business administration is primarily a field of study that aims to construct theories with a long-term perspective for efficient and effective operations in for-profit enterprises, when applied to cosmetic clinics, it leads to researching methods (strategies) to gain appropriate profits to maintain and stabilize management and to invest in the latest knowledge and expensive medical equipment. Until now, many cosmetic clinics and their physicians in charge have felt that management is important in the back of their minds, but they have often been too busy with treatment to consciously incorporate strategies, and it cannot be said that many clinics have consciously incorporated strategies. For example, when opening a new cosmetic clinic, it is important to conduct market analysis, set up a proper concept, consider specific strategies to achieve that concept, decide on resource allocation methods, and execute tactics distinguishing long, medium, and short-term goals. However, if the marketing strategy is left to others, staff education and financial management are also done in a rough way, it is unlikely to be successful. The following presents some of the management strategies that should be introduced in cosmetic clinics based on the author’s experience.

(1) Concept Development
Even if a cosmetic clinic boasts of treating cosmetic issues, it is difficult to address all patients and all symptoms, and there is no uniqueness or creativity in terms of external image, and the treatment results may not be satisfactory in cases where it is not their forte. In cosmetic clinics with many individual practitioners, it is believed that disclosing the most proficient treatment and dedicating oneself to that specialty can lead to credit assurance, an increase in repeat patients, and a decrease in errors. If the treatment results are good, patients will be evaluated and become repeat customers, and as a result, new patients will increase through word of mouth. For example, there is a medical form called “Medical Focused Factory” that has been attracting attention in the United States recently. This is a form in which physicians who are specialists in treating diseases such as cancer, heart disease, foot diseases, hernias, etc., concentrate on treating only one type of disease, and the number of cases treated increases, making it possible to achieve high treatment results. Therefore, in order to increase the effectiveness and efficiency of cosmetic clinics, it is necessary to establish a clear concept and specialize in specific treatments.

Opening a beauty clinic requires a clear concept regarding the type of patients to target, the field of treatment, and the specific treatments or procedures to offer. In the service industry, market segmentation involves classifying customers based on various criteria and promoting or selling services tailored to their specific characteristics. Similarly, when opening a beauty clinic, it is essential to analyze and determine the attributes of the target patients, such as age, location, and income level, while considering Table 1 as a reference to clearly define the clinic’s strengths in terms of treatment fields, diseases, and treatment methods.

Moreover, if the clinic targets beginners who have never visited a beauty clinic like a, the concept should prioritize educating and providing thorough guidance to beginners, including insurance-covered treatments. On the other hand, if the clinic targets patients who have already experienced beauty clinics, such as b, they need to consider strategies and tactics such as b-1 attracting patients from competing clinics to win over competition or b-2 offering additional treatments that the patients cannot receive at other clinics.

（2）Patient retention is essential to a beauty clinic as patients can easily choose to visit other clinics if they are dissatisfied. To increase patient satisfaction and retention, the clinic should implement measures such as clearly explaining the expected effects of treatments and how to maintain beautiful skin, allowing patients to choose treatment methods, using equipment that can explicitly demonstrate the effects, and providing post-treatment care guidance.
In addition, since the service industry accounts for about 70% of Japan’s current industrial structure, it is essential to thoroughly examine the nature of services provided. Researchers from various fields are combining efforts to study services from a multidisciplinary perspective, given that the majority of IT industry operations are now service-oriented.

（3）Furthermore, it can be said that all services provided by a cosmetic clinic are applicable to providing comfort, but the most important service is the patient’s self-realization menu. Patients have expectations beforehand, and satisfaction increases when their treatment results meet those expectations, leading them to want to return. Conversely, if their expectations are high but their results are evaluated poorly, they will be disappointed and the clinic will lose the patient. Additionally, a patient’s expectations naturally increase over time, so it is necessary to carefully communicate honestly, confirm treatment details and expected results in order to guide their expectations to their proper level. To increase patient satisfaction and provide them with an experience that impresses them with the results of the treatment, it is important to bring their inflated expectations back to a reasonable level and allow them to enjoy self-realization.

In this way, it is desirable for a cosmetic clinic to satisfy all the service elements of goods, information, and comfort, so efforts should be made to make up for any missing elements. However, providing goods requires funding, and providing information requires time to obtain the latest information through domestic and international academic activities. Therefore, the quickest service to provide is the comfort service, and within that, it is desirable to have a variety of self-satisfaction menus.

(4) Comfort Service and Staff Education
There are many factors that make patients feel favorable towards a cosmetic clinic, or in other words, increase their satisfaction. Of course, the most important factors are the patient’s trust in the physician’s knowledge and skills and the treatment results, but it is not an exaggeration to say that all services provided from the moment they enter the clinic until they leave are also related. However, the service referred to here does not mean manners (behavioral rules to avoid making patients feel uncomfortable), but hospitality (consideration for patients and heartfelt hospitality). Manners that show well-behaved behavior without offending the patient can usually be manualized, but hospitality, which means showing consideration that brings patients closer and creates a sense of intimacy, or the service that goes beyond what the patient is looking for, is difficult to manualize because it requires discerning each patient’s type and timing. Even if it could be manualized and carried out exactly as written, it would not impress the patient.

As for the elements that make patients feel comfortable, there are hardware aspects such as the location of the clinic, the building, the interior, and medical equipment, as well as human attractions such as the clinic director’s knowledge, skills, personality, and familiarity. However, in order to make patients feel hospitality, it is important for the staff’s actions and attitudes to be considered. To instill the spirit of hospitality that cannot be manualized in the staff, it is important to establish and disseminate the philosophy and service concept of the clinic, to make the staff proud and have pride, to create a mechanism for collecting patient needs, and to accumulate ingenuity in the field. In particular, it is most important to make the staff proud and have pride, and the physician as the manager should always talk and act with the attitude of “providing the best service to patients” in staff meetings, enlightening the staff’s consciousness and inspiring pride and ambition.

(5) Understanding patient needs
In a beauty clinic where customers are somewhat selected, it is considered more suitable to recognize and understand the differences in each customer’s values, needs, and treatment history, and to approach each one individually according to their individual needs (One-to-One Marketing). For example, in order to respond to a customer’s order at a beauty salon or bar such as “as usual,” it is necessary to grasp each customer’s preferences and habits. In a beauty clinic, in addition to questionnaires, medical records, and invoices, staff should create a character note for each patient, record what was talked about during treatment, such as preferences for food, fashion, and shopping, things to be careful about, preferences, and disliked words, etc., and read it before the patient comes in, in order to provide hospitality that matches the patient’s needs.
3.The Future of Aesthetic Clinics Management
Under the system of elective medical treatments, patients have the freedom to choose their medical institution and treatment method, and pay for it themselves. Except for medical underserved areas where no other clinics exist, it is clear that patients will not go to clinics that do not provide any benefits in fiercely competitive metropolitan areas, as mentioned above. Therefore, let’s consider what we can do for the future management of aesthetic clinics.

(1) Introduction of Anti-Aging Medicine
The elderly population (age 65 and over) in Japan has rapidly increased from approximately 29.4 million in 2010 to 35.9 million in 2020, and is expected to continue increasing gradually or stay flat until around 2050. Among them, more than 80% are healthy elderly people who do not require care. However, although they are healthy, they have a higher incidence of illness and worries about health and illness compared to younger people. Anti-aging medicine, which aims to maintain and manage health and counter aging, is a topic of interest to elderly people who are conscious of their appearance and physical strength and want to delay the progression of aging.

According to the Japan Anti-Aging Medical Society, anti-aging medicine is defined as “the theoretical and practical science aimed at enjoying longevity in good health” and is considered a very broad concept, emphasizing that it is “the ultimate preventive medicine focused on aging.” Note that it is inevitable for human physical and mental functions to decline with aging. Therefore, as mentioned above, the author wants to view anti-aging medicine not as a medicine that prevents diseases but from the perspective of “maintaining health or beauty” or “delaying progression.” In other words, just as beauty medicine is a medical treatment that focuses on appearance and “maintaining beauty,” anti-aging medicine also focuses on appearance and “maintaining health and beauty.”

Many for-profit companies have already made various attempts to enter the huge anti-aging market of 80% of the elderly population, but fortunately, aesthetic clinics have experienced many treatments and methods related to anti-aging, including skin diseases such as spots, sagging, wrinkles, and dark circles, and have many overlaps with the concept of anti-aging medicine. Therefore, for aesthetic clinics that are forced to endure unstable management, entering the new market of anti-aging medicine can be expected to raise their management foundation.

(2) Hospital Corporatization
Under current legal systems, it is not possible to establish a new corporate hospital. However, there are cases where corporations indirectly participate in hospital management by leasing hospital land, facilities, and equipment to doctors, for example. As mentioned above, it is considered difficult for corporations to enter hospitals that are primarily focused on insurance medical care, but it can be said that there is a foundation for realizing the entry or conversion of corporations into beauty clinics, especially those with a business model that is primarily focused on private medical services and is similar to profit-oriented service industries.

Summary
Until a few decades ago, medical services in Japan were largely controlled by doctors, and patients had to rely on them and follow their orders. However, as education levels have increased and more women have entered the workforce, patients have become more demanding of medical services that are more rational and efficient in terms of time and money. As a result, patients have started to seek more information about their illnesses and suitable medical facilities. Medical books and know-how related to medical care are available in bookstores, and the internet is overflowing with information on the causes, symptoms, progress, treatment methods, side effects, and so on of various diseases. As a result, the asymmetry of information between doctors and patients is gradually disappearing, and patients are becoming able to choose medical facilities that are suitable for them. Therefore, it is said that competition is intensifying in beauty clinics, particularly because patients have a lot of freedom to choose medical facilities and treatment methods. As a result, there is a risk of bankruptcy for clinics that operate without proper management.
Here, we introduce some of the management know-how used in profit-oriented service industries in beauty clinics and attempt to explain it with several examples based on the author’s experience. Furthermore, since anti-aging medical care is promising in the future and overlaps with the treatment and care provided in beauty clinics, we have discussed the possibility of entering the field of anti-aging.

Finally, it should be emphasized that until now, the role of medical institutions has been primarily to discover and treat diseases, which has been considered legitimate. However, the field of health maintenance and promotion has tended to be considered beyond the scope of medical care. Moreover, the government is focusing more on preventive medicine rather than health maintenance in order to respond to the increasing burden of medical expenses. On the other hand, with the increasing number of women in the workforce and the aging of society, the demand for medical care focused on “maintaining health and beauty” has been increasing. Therefore, it is necessary for medical institutions to take on new roles and to provide high-quality medical services that meet the changing needs of patients.

藤本幸弘；美容関連診療所の経営強化策、日本美容外科学会会報、第35巻、第1号、平成25 (2013)3月p32−p39 翻訳版