Featured Doctor: Deborah L. Manjoney, M.D.

Deborah L. Manjoney, M.D., medical director at the Wisconsin Vein Center and MediSpa, has her finger on the pulse of the latest trends and technology for medispa treatments. For nearly eight years, she has been on a mission to build a medispa practice that utilizes her medical background as well as her special interest in beauty/image restoration. A graduate of the University of Vermont College of Medicine and a recipient of the Senior Surgical Research Award, Manjoney has created a vein, laser and skin-care center that provides on-premises varicose vein treatments, photofacial rejuvenation, permanent hair reductions, Botox injections, wrinkle treatments and a variety of aesthetic procedures. Dr. Manjoney recently discussed the medispa profession with VEIN’s Claudia Schou.

It’s summertime, and people are going to the beach. Is your medispa typically busy this time of year?

Our medispa is definitely busy now, with a steeper increase in appointments than we usually see. People want to get rid of their spider veins or want their varicose veins eliminated before short and bathing-suit season, so spring is always busy. This year, since winter has held on longer in the Midwest and Northeast, we didn’t see the upswing as early. Now we are seeing a surge in appointments.

At what age do varicose veins become visible on women, and are most of the cases you see cosmetic or serious medical concerns?

Smaller varicose reticular veins may become evident in women as early as their teen years. Larger varicose veins, associated with superficial truncal vein insufficiency, often become evident initially during pregnancy in the 20- to 30-year-old age group. Some of these varicosities will regress after the completion of the first or second pregnancy but tend to persist by the third. As women age, they are more likely to develop varicose veins, regardless of their obstetric history. Most of the cases that we see are definitely associated with symptoms of venous insufficiency; frequently these symptoms went unheeded by the primary-care physician, who did not realize that varicose veins, even in the absence of ulceration, were more than a cosmetic issue.

What are some of the challenges of incorporating a medispa into a vein practice? (e.g., insurance reimbursements, administration, etc.)

Incorporating a medispa into a vein practice can make a lot of sense if the vein practice is independent of a hospital. Medispa services are all considered cosmetic, so none of these are billable to health insurance companies. Similarly, spider vein services are cosmetic. All of these treatments are paid for at the time of service. In contrast, most varicose vein treatments are submitted to insurance for reimbursement. The front staff must be trained, therefore, to accept payments; this is usually not a big change since they have had to collect copayments. However, the entire staff will need training in the whole concept of providing purely elective service.

Anyone answering the phones must be pleasant and informed, much more of a customer service rep than a scheduler, in order to get the inquiring caller to come in the door.

The receptionists must treat the customers like VIPs. These services are typically quite expensive, and the sophisticated patron understands that similar services can be found elsewhere.

Clinicians should be educators about the offerings of the medispa, so they must be well-versed in the features and benefits of the services and feel comfortable to discuss cosmetic services. It is actually an unfamiliar role for a nurse or physician to be a salesperson, so they receive training in sales techniques. By stressing the educator aspect of this position, introducing other services becomes much more palatable. We provide a gift certificate to be used toward a cosmetic treatment to each of our medical vein patients so that anyone interested is encouraged to experience the medispa.

Advertising is essential for a vein practice but even more so for the medispa side. Competition is fierce, so finding the branding strategy that sets you apart is very important.
Tracking referral sources and estimating the cost of obtaining an inquiry require perhaps more extensive monitoring than is usual in a medical practice.

What are some of the tough recommendations you have made for certain venous disease?

Some of the toughest treatment recommendations are the non-intervention ones. If a person has deep-venous disease that is causing significant symptoms, there may not be any alternative to prescribing graduated compression hose to be worn for the rest of the patient’s life. The other tough challenges involve patients who have had previous vein treatment, usually stripping, and have recurrent symptoms and varicosities. The truncal vein may no longer be the problem, just isolated branches and tributaries. My goal is to reduce the congestion caused by the remaining insufficient veins, determining which ones will reduce that critical venous pressure causing the symptoms.

Is there a particular case that stands out in your mind?

I recently saw a young man of 30, who had had bilateral deep-venous thrombosis when he was 17. He had no postphlebotic signs in the lower extremities. On venous duplex, he definitely had deep-venous insufficiency, and partial deep-venous obstruction in one lower extremity. His saphenous systems were competent. He presented with bilateral varicosities of the lateral abdominal wall from superficial epigastric vein incompetence. He was a weight lifter and body builder. He did not like to hear my recommendation to change his exercise routine and to wear graduated compression hose when he would be standing or sitting for prolonged periods.

Because your medical practice is so accessible to the public, do you feel that there are certain obligations you must uphold as a service to the community, such as vein education?

I feel that I must continue to educate the public about their medical problems and the options available to them. As a woman cardiothoracic surgeon, I had been very involved in educating women about their risks of heart disease. It was natural for me to continue educational endeavors for both physicians and patients who are under-informed about venous disease. For the public, we provide complimentary vein-screening exams to each patient on initial visit. We evaluate and then educate the patient about venous function and explain what we think might be wrong. To each patient, we provide understandable written materials that explain how veins work, why they fail and detail each treatment that we perform. Whether the problem is spider veins or venous insufficiency, our patients learn what we consider the safest and most effective treatments. I also feel that as a member of the community, our business has an obligation to “give back” in gratitude for our success. During certain times of the year, we donate a percentage or our profits toward research and education projects for women’s heart disease and lung-cancer awareness.

In what ways are you working to educate the public on vein disease and treatment?

I give seminars frequently to local organizations and speak at hospital-sponsored and health organization–sponsored educational events. The ads that I run in the newspaper explain some facts about vein disease and emphasize the free screening on first appointment. I also appear on a local television show once a month to talk about vein problems and the new therapies that are available. I have written columns for a local health newspaper, and I have had three-hour-long radio call-in shows to “Ask the Vein Doctor.”

What are some of the new trends that you think will be popular in the treatment of varicose veins in the future?

I think that endovenous thermal ablation methods are here to stay, at least for the next several years. Outcomes are excellent, and, in my opinion, they are currently the safest, most efficient and best tolerated procedures for varicose veins. The caveat to that, of course, is that these procedures need to be performed only after proper training of the physician and with complete respect for the potential complications that can occur if the operator is not diligent.

Have you read any recent medical studies that intrigued you? If so, what were they?

I was actually quite interested in a flow perfusion study reported in an issue of Phlebology last year that examined the physiology of the venous valve agger function in response to noradrenaline in a canine model. It was intriguing to see the research with the detailed examination of valve function moving us closer to understanding venous architecture. I also like reading the recent outcome studies for endovenous laser therapies, my preferred treatment. It is nice to see that others are finally reporting up to 99 percent closure of the great saphenous vein at one year follow-up because our results have also been that good.

Deborah L. Manjoney, M.D., specializes in cardiovascular and thoracic surgery. She opened the Wisconsin Vein Center and MediSpa in Pewaukee, Wis., in 2001.