Sunday, 31 March 2013

HAPPY EASTER..MY FAVOURITE KNOCK KNOCK JOKE:

HAPPY EASTER...MY FAVOURITE KNOCK KNOCK JOKE:

To get the full effect from this, one first needs to perfect a cute lisp, so remember to use your inner Ita Buttrose during the delivery:


Knock knock!

Who's there?

Ether.

Ether who?

Ether bunny!


Knock knock!

Who's there?

Another.

Another who?


Another Ether bunny!


Knock knock!

Who's there?

Cargo.

Cargo who?

Car go down the road and kill all the little Ether bunnies!


Knock knock!

Who's there?

Boo.

Boo (hoo) who?

Now now, don't cry!  Ether bunnies come back next year!




So, we hope you've all had a fabulous Easter, and that you eat all of that chocolate in moderation over the next few weeks...maybe even months if you're good at pacing yourself!  We wouldn't want to encourage increased internal glycation (which is thought to contribute to premature ageing) would we?

Thursday, 28 March 2013

WHEN FRAXEL RESURFACING GOES WRONG...HIGH RISK AREAS

WHEN FRAXEL RESURFACING GOES WRONG...

HIGH RISK AREAS

Sometimes a well marketed laser procedure creates a reputation for itself in the public domain that goes beyond what experienced clinicians think of it.
Fraxel can be a very useful laser procedure, but there is no doubt that some people who don't need it are being treated aggressively with it and aren't always happy with the outcomes.

For the lucky ones, it may have just been a waste of money without any permanent physical or psychological harm.
For some less fortunate, unnecessary (albeit well intentioned) laser procedures create issues that horrify those of us asked to correct them.
One such patient I met recently who appeared to attend for advice about a facial related issue, only to open up at the end of the consult with the real reason.

This isn't an unusual thing in the field of cosmetic medicine.  After all, it takes a while to establish rapport and trust when you've had a horrendous experience previously.

In this case, the patient had travelled interstate for Fraxel resurfacing to her face, neck and chest area about 9months previously.  It had appeared to go according to plan initially, in that she had woken from the general anaesthetic with some moderate discomfort on all areas, and then healed quickly on the face, but the chest was a different story.
Having returned to her home in Melbourne within 24 hrs, the patient reports very slow healing of the chest, with horrendous scarring initially appearing after 2 weeks, especially in the central/sternum area, which has steadily worsened over the next 6months.

I'm rarely lost for words, or ideas on how to fix a problem, but in this case I really did feel her pain and distress.
Her entire chest is covered in thick, contracted keloid scarring from one side to the other, from top to bottom.

I wish I could show you her photo, if only to warn you that some areas of the body are particularly prone to keloid scarring and the chest is probably the greatest example of that.

Here is an example, it is NOT of the patient described above.  This was apparently one that formed from a mole having been excised, and is not one of my patients, but is a good example of the keloid scarring that can result from even a minor surgical procedure on the chest.



I have a keloid scar on my own upper chest.  Fortunately it is only about 0.5cm diameter.  It developed 2 years ago after I was bitten by a mosquito there.
I'm highly allergic to mosquito saliva, as is my son, so I took antihistamines to suppress the inflammation and made sure not to touch the bite or scratch at it.  Despite these measures, the inflammatory response was so strong in this area that I have developed a hypertrophic scar that really does extend beyond the location of the original bite, hence is a genuine keloid scar.  I suppose if it really worried me I would have some cortisone injected it, but so far I've just left it alone, hoping that with time it will settle. 

If a mosquito bite can give me a keloid scar, it just goes to show how sensitive and keloid prone that part of our body really is.  Whenever someone asks me to perform an unnecessary (in my opinion) procedure on their chest area, I always show them my keloid scar, and explain how I got it.  Sometimes people just need to weigh up the risk/benefit ratio a little more carefully before diving in to a procedure that may have inherent risks no matter who is doing the procedure.  I guess that affects my income at times.  Big deal.  I would rather sleep well than lie awake stressing that some gorgeous previously confident woman has now had to undergo psychiatric assistance and adapt her entire wardrobe because I had given her a keloid scar that would be the envy of any Masai warrior in Africa.

Some laser procedures should never be done on areas off the face.  Others can be done, but very very carefully...especially in the central chest area.  

I NEVER encourage patients to have any laser or any injectable procedure done under a general anaesthetic or even "twilight sedation".  It is much safer to have a mentally alert (albeit somewhat anxious) patient able to give verbal feedback on what she is experiencing (ie feeling) as far as pain is concerned, than to have someone rendered incapable of providing this valuable feedback.  Very anxious patients can safely use an inhalation anaesthetic like Penthrox if necessary, without it impacting on their ability to liase during their treatment.  

Early recognition of a laser burn is essential if gross complications such as keloid scarring are to be prevented.  The best way to recognise a laser burn early is to have the patients awake at the time of the procedure, and to have them attend for follow up within 2 weeks of the procedure.  It's hard to do that if you're going interstate or overseas for your treatment, so think again before deciding that the only factor worth considering in the choice of your treatment is the price.

After all, any burnt patient will tell you that it hurts like hell being truly burnt by a laser..and it's a very different sensation compared to the normal fleeting mild-mod pain experienced during most routine laser treatments. 

Our pain fibres provide very valuable information to the doctors treating us.  But only to those who actually want to know about it.

Tuesday, 26 March 2013

NEW AND UNUSUAL USES FOR DERMAL FILLERS-IMCAS review

NEW AND UNUSUAL USES FOR DERMAL FILLERS- IMCAS review


Treatment of Flat Inverted Nipples



I viewed a presentation by a visiting dermatologist at IMCAS, Paris earlier this year, who was discussing the use of dermal fillers for the treatment of flat inverted nipples.
He suggested the careful placement of filler around the edge of the nipple itself, and felt that it worked very well in those clients treated, as the surgical correction of this problem is fraught with difficulty and often doesn't have satisfactory outcomes.

It all sounded quite interesting so I thought I'd ask him some questions about the procedure afterwards, thinking that there are no doubt a number of female patients in Australia who may be interested in this.
My first question was whether the filler procedure had caused any breastfeeding or mammography problems.  You know, my number one concern with any new treatment is ALWAYS: IS IT SAFE?
He responded that he had only done the procedure in younger women, under the age of needing screening mammography, so couldn't comment on whether it caused any radio-opacity.
As for the breast-feeding/mastitis concern, his response surprised me:
"the milk only comes out of the duct in the centre of the nipple, so it shouldn't effect breast-feeding, though I'm not sure how many of the women I've treated like this have needed to breast feed.."

I'm afraid that's when he lost all credibility in my eyes.
As a woman who has breast fed my child, I can assure anyone reading this post who perhaps hasn't yet found themselves in that situation, or witnessed their wife expressing breast milk, that breast milk doesn't come out of a central duct in the nipple.  It comes out of multiple ducts throughout the nipple.

Given that the dermatologist has only treated "about 20" women with this procedure, and has no followup safety data to present to the captivated audience (judging by the number of eager male doctors asking for detailed 'how to' instructions at the end of his presentation) I had some real concerns about whether this procedure should be promoted in any way at this time.

Don't get me wrong..I'm all for treatments that help women to overcome problems that affect their self-confidence.  But experimenting on women's breasts without any regard for functional side effects or mammogram safety is really not on.  Ductal carcinoma in-situ is a relatively common cause of (sometimes bilateral) mastectomy, and it would be an absolute tragedy to have either unnecessary surgery or missed diagnosis because of a cosmetic procedure that hadn't been investigated enough before being marketed to the world.  Having said that, I think this procedure would have a place helping those who have already undergone major breast reconstruction, and need their new nipples to look a bit more 3 dimensional.  Might have to suggest it to a couple of clients who fit this category.  Will let you know how they go!

Minimising Earlobe Creases



This is something that I already perform on patients who make the request, and it really is very easy, straightforward and effective.
Interestingly, the results appear to be quite long lasting without any particular side effects of note, other than the usual possibility of bruising and temporary excessive swelling.

Earlobe creases appear in older patients, and when I was a medical student were thought to be related to heart disease, so it is interesting that some patients notice them and complain of their cosmetic appearance.  However, if you want to have your earlobe creases injected, it might also be a good idea to make sure that your GP is monitoring you for other much more reliable signs of coronary artery disease.  We wouldn't want to overlook the onset of angina would we?   

Saturday, 23 March 2013

FACIAL REJUVENATION FOR MEN..REVERSING SUNDAMAGE!



FACIAL REJUVENATION FOR MEN..REVERSING SUNDAMAGE!

Are men finally catching up with women when it comes to looking after their skin? Apparently yes!
Data from multiple sources show a clear upwards trend in the numbers of men seeking medical advice for a variety of cosmetic skin problems, and given the extremely high rates of severe sun damage amongst Australian men, it's little wonder.
In my opinion this isn't because Australian men have fallen prey to the dreams of Dorian Grey immortality.  Rather, Australian men are increasingly sophisticated enough to realise just how far behind the game they have fallen.

Sophisticated!  I hear you scoff!  It isn't a word one usually hears uttered in the same sentence as "Australian male".  And perhaps by some markers of sophistication there's still room for much progress!  However I like to consider basic sophistication as an awareness of others' cultural norms brought about by repeated global travel..and that's something that Australians are very very fond of.  Thanks to a relatively high Australian dollar, falling air travel costs over the last 40 years and a penchant for extended overseas work postings, Australians are increasingly globally aware citizens.

My oldest patient is almost ninety years old and happens to be a delightful farmer from a warmer part of the state.  He first came to see me 9 years ago following the removal of several small skin cancers on his face, and looking to do something about the remaining severe sun damage visible from the opposite side of the street.  His children (all in their 60s themselves) initially thought it was hysterically funny that their salt of the earth father would care so much about his weathered face to see a cosmetic medical skincare specialist.  However, they've now come to love the way he looks vibrant and spritely, with very few other skin cancers requiring excision over the last decade.  If they realised how many operations and chunks of skin excisions/grafting their father would have faced if he hadn't taken action 9 years ago, they'd probably be coming in themselves!  The reality is that for many Australian men, recurrent facial skin cancer ultimately causes extreme disfigurement.  Even the most stoic and ocker of us would rather not have to watch ourselves slowly morph into an image that is unrecognisable from our former selves.     

Farmers and other outdoor workers aside, there is another much more urban source of male skincare customer.  Visit any golf, tennis, cricket, surf life saving or sailing club in Australia and you'll see them there by the dozens amongst the senior members.  They're the men whose lifelong sporting obsessions have brought much enjoyment (&sometimes elite success) but along the way the stubborn refusal of many men to wear sunscreen on a regular (read daily) basis, has left their delicate pale complexion blotchy, reddened, scaly and persistently "dry".  Here are a few typical examples of the sort of sundamage that many of you may recognise amongst your own friends and relatives:



The top of the head is a classic area of sundamage for those who are bald!


I love looking after unhealthy skin.  There are few things that appeal to my medical/motherly need to fix someone's evidence of chronic self-neglect than a mature man in need of some very practical and very inexpensive skincare quickfix solutions!   

These men are often remarkably well educated in their field of expertise, have travelled widely and have seen with their two eyes how much more youthful looking their fellow fair-skinned Caucasians are in their native countries.

In Paris recently I found myself sitting next to a well known New York dermatologist who gasped in wonder when I confessed to being Australian.  "But you don't have enough sun damage to be an Australian!" he replied.
"Especially for a 44year old"  I thought to myself.  "I've been looking after my skin for a very long time" I replied.
Another patient, an Australian born male who recently returned after working in London for the last decade, reported how he'd noticed on moving there that his colleagues all looked very youthful for their age, but on returning to Melbourne he is horrified to see how much his school friends have aged.

Rejuvenating men's skin isn't necessarily about using injectable treatments such as anti-wrinkle injections or dermal fillers.

Most men can be remarkably rejuvenated with medicated prescription skincare alone. 
Pre treatment-actual Skin Temple client

Post treatment-actual Skin Temple client, medicated prescription skincare only!

Some may require laser treatment if significant pigmentation or broken capillaries exist.
Significant facial redness due to extensive broken capillaries is a Medicare rebatable laser treatment, when performed by a medical practitioner.
The downtime post laser treatment is really quite minimal, though significant healing is required with some of the medicated prescribed skincare.

So, if you're reading this and identifying strongly with some of these descriptions, perhaps its time you did yourself a favour and consulted a cosmetic medical specialist today.  There's no time like the present to make up for yesterday's sun damage!


Friday, 15 March 2013

WRINKLE TREATMENT UPDATE- THE PERFECT CHEMICAL BROW LIFT



WRINKLE TREATMENT UPDATE- THE PERFECT CHEMICAL BROW LIFT, IMCAS 2013

Few things get me more excited than the tips on perfecting the chemical brow lift I came back from Paris with. 

This is because anti wrinkle injections are the most popular of all the cosmetic medicine treatments done at Skin Temple, and around the world in 2012.

The global economic downturn since 2008 has left many cosmetic and plastic surgeons bemoaning their reduced revenue, but in the world of non surgical skin treatments business is doing ok, with many people opting for non surgical options such as anti-wrinkle injections, dermal fillers and laser skin treatments.
Anti-wrinkle injecting might look easy enough to most people, and on face-value (pardon the pun) it's certainly not a technically difficult procedure, but there are some real pitfalls for both novice and experienced injectors. 

Take a look at any celebrity filled magazine and you'll be sure to find an example of someone who looks good, but slightly odd, and chances are they are having a cosmetic treatment that could be done better by a very experienced injector.
For example, take a look at Kylie Minogue's right eyebrow, Nicole Kidman's frown and forehead areas, and Kim Kardashian's cheeks.  All of these features look slightly odd to me..not particularly unattractive, but distinctly in the odd basket.  
Nicole Kidman's eyebrows are nicely lifted in the outer parts (the standard chemical brow lift) but significantly lowered in the inner parts by the standard frown treatment technique she appears to be a fan of.   

 This can sometimes make her look a little odd, and will cause sagging of the inner upper eyelid skin as she ages.  Her forehead is remarkably immobile for a woman of 45years old, and again, such complete lack of expression reduces her ability to communicate with her audience and exacerbates the low position of her eyebrows.

A better aesthetic treatment would specifically address the problem of medial brow ptosis and lift both ends of brows equally.  This is the technique that was discussed at IMCAS Paris 2013, and since my return I've been trying it out on a number of patients prone to this problem, with excellent results!
Not everyone needs or suits this technique, but for those that do, or have put off having anti-wrinkle treatments for fear of looking slightly odd, it's fantastic news. 

HAND REJUVENATION- IMCAS review




HAND REJUVENATION

Long regarded as the area that gives a woman's true age away, hands are now in the spotlight as the area to pay particular attention to, now that safe and effective treatment options have become available.

Hands show the ageing process in numerous ways, from thinning of the skin, loss of subcutaneous fat volume, to loss of elasticity, precancerous changes and surface pigmentation.  The nails are another area of much neglect, and complete hand rejuvenation must also address this area.
In Paris there was much discussion on the best way to rejuvenate the hands, with some famous examples of celebrities who have forgotten this area:

Sarah Jessica Parker

Madonna


Home based hand care remains the cornerstone of patient satisfaction, and is essential to address before longterm success can be achieved with clinic treatments.  All consultations at Skin Temple address the use of home care on the skin, and we also offer preventative care for avoiding skin cancers on high risk areas such as the backs of the hands and face.
As far as clinic based procedures are concerned, the options include:

  • Laser or Light based treatments for surface pigmentation  and collagen stimulation
  • Topical cryotherapy or immune modulator creams for precancerous actinic keratoses
  • Fillers and Collagen stimulators for volume loss

At Skin Temple we commonly use our alexandrite based Gentlelase to remove isolated areas of pigmentation on the backs of the hands, or our IPL for more widespread pigmentation problems.  These treatments work incredibly well, but take about two weeks to recover from, and the patient must be very careful to wear sunscreen (and preferably also gloves when driving!) in order to prevent a reaccumulation of pigmentation.

I'm not a big fan of cryotherapy though, having seen many cases of permanent hypopigmentation from this procedure used in general practices and dermatologist offices over the years.  In my opinion, it is much safer and more cosmetically appealing to use an immune modulator such as Aldara or a topical chemotherapy product such as Efudix to treat sunspots (actinic keratoses) or early squamous cell or basal cell carcinomas.  Sometimes these will need to be excised and surgically repaired, which we also do in the clinic.
 
The two most popular options are gel based dermal fillers or collagen stimulators.
Gel based fillers must be soft enough to disperse evenly under the skin, so those with strong lifting capacity (known as G' prime rating *see below for further explanation) are inappropriate in this area.  Even dispersion prevents lumpiness and allows for fewer insertion points and smaller cannulas.  Low G' prime gel based fillers will last up to 12 months, but may only last 6 months in some patients.

Collagen stimulators are currently my favourite method of hand rejuvenation, as some work quickly but with reliable medium term longevity.  Again, some products, when diluted 50:50, have a lower G prime allowing for easy distribution in the upper dermis.  

So please, if you're looking after your facial appearance, don't forget your hands too!




*To quote Dr Leslie Baumann, cosmetic dermatologist in the USA:

"The stiffness or G′ (pronounced G prime) of a product is one of the most important considerations. G′ is a measurement of gel hardness. It is obtained when a gel is placed on a plate. A second plate is placed over the gel and a lateral force is applied. The measurement of resistance to deformation is known as the elastic modulus or the G′. Together with the cohesivity of the product, G′ values could be used to determine the appropriate placement of an XX dermal filler. For example more robust products (higher G′ values and higher cohesivities) such as XXXXXXXX XXXXX XXXX and XXXXXXX®, should be used in deeper lines, such as nasolabial folds and marionette lines, as well as to lift the lateral brow, to correct the nasal bridge, to give the ear lobe youthful volume, to evert the nipples, and to raise the nasal tip. More fluid products such as XXXXXXX XXXXX and XXXXXXXXX® are more suited to be used over large areas such as the cheekbones and cheeks. Low G′ products such as XXXXXXXX® and XXXXXXXX XXXX® are necessary in areas that require a softer agent, such as the body of the lip or the tear trough. As new products reach the market, knowing the G′ will help practitioners match fillers with indications."

Please note that several of the products mentioned by Dr Baumann are not available in Australia (XXXXXXXX XXXX, XXXXXXXX)  whilst other products with much higher G' available in Australia (XXXX**) are not yet available in the USA, nor are some of the lighter G' products commonly used in Australia (XXXXXXXX XXXX**, XXXXXXXX XXXXX**, XXXXXXXX**, XXXXXXXX XXXXXX**, XXXXXXXX XXX XXXXXXX**).

**Apologies to those confused by the products referred to above.  For legal reasons, under Australian law, the TGA has directed all medical practitioners to refrain from using the names of S4 products "unless authorised or required to be made under the Act." Therefore all S4 product names have been censored in this post and replaced with generic Xs.  If a member of the public were to write this blog, it would not be a problem though! Government censorship of educational material on the internet and harassment of cosmetic practitioners is a very real occurrence in Australia today.

Tuesday, 12 March 2013

Anti-wrinkle injections: American XXXXX VERSUS French XXXXXXX...which is better?



XXXXX** VERSUS XXXXXXX**....THE JURY GIVES THEIR VERDICT


IMCAS 2013, Paris
Numerous studies from both the USA and Europe were completed and posted in a number of peer-reviewed scientific journals in 2012, looking at data comparing the use and effects of American Xxxxx and French Xxxxxxx.  Some studies also included the German toxin, Xxxxxx, soon to hit Australian shores in early 2014.

The remarkable and most notable outcomes of these papers was the consistency of the findings.
As a result, we can now reliably state that:


  • Xxxxxxx has a faster rate of onset than Xxxxx
  • Xxxxxxx and Xxxxx have near identical maximal effects.
  • The conversion for Xxxxxxx and Xxxxx units is generally 2.5:1, but in some areas of the face may be closer to 2:1.
  • Xxxxxxx has a longer duration of effect compared to Xxxxx, by several weeks in most published studies
  • Xxxxxx is identical to Xxxxx in terms of dosage units, onset, peak effect and duration.


Diffusion continues to be discussed, with most published articles commenting on the importance of toxin concentration when measuring and especially comparing diffusion.

Overall, I'm predicting that Allergan, makers of Xxxxx, will be under significant pressure to lower the cost of Xxxxx vials in Australia by the end of the year.
Otherwise, they risk losing very significant market share as the scare campaign against Xxxxxxx backfires when people realise what advantage it has over Xxxxx in terms of value for money.
The main caveat for consumers in the toxin turf war, is to find an injector experienced in BOTH Xxxxx and Xxxxxxx.  Only unbiased injectors are capable of giving unbiased opinions, in my opinion!

Sadly, there was also data presented that looked at the prevalence of counterfeit product being sold online.  Truly horrifying to see what is actually in some of this stuff!
It's difficult for consumers to know if they are being injected with legitimate product. 
One tip worth remembering though is that these products can ONLY be sold to REGISTERED MEDICAL PRACTITIONERS. So that nurse who's offering half-price "Xxxxx" injections from her own home, or the local hair salon, is definitely not operating a legitimate business.  The product may well have been purchased online, and she/he most certainly won't be covered by any insurance (medical negligence or public liability) in the event of any adverse complication if the product is later found to be contaminated.

You know what they say, don't you?  If it sounds too good to be true, it probably IS too good to be true!  

**Apologies to those confused by the changes made to the brand names in this post.  For legal reasons, I am unable to use the exact names of the anti-wrinkle injections used in Australia.  That is because I am a medical practitioner.  If I was a beauty therapist, or any other unregistered health practitioner of any kind, or in fact just a regular member of the public, I would be able to mention all of those by name.  No wonder it is increasingly difficult for the public to get accurate and unbiased information on cosmetic treatments in Australia!  Censorship of public health information is rampant in Australia when it comes to cosmetic medicine.