"Couponic Plague"-A New and Potentially Devastating Medical Condition

We have recently entered the era of "couponised" goods and services. I have never been a fan of these sorts of incentivations. However it is easy to understand the entrepreneurial "pull" of these schemes. It is basically a case of get the punter through the door with the promise of a value added experience (albeit generally a one-time-only incentive).

However one would have imagined that the coupon-marketed discount delivery of medical services would be considered professionally inappropriate.
http://www.medicalboard.gov.au/documents/default.aspx?record=WD10%2f2669&dbid=AP&chksum=3W%2fN5vWpGoe0K892YW9sFw%3d%3d 
From the above link the medical board would consider this apparently so. Will the appropriate authorities police the statutes? Don't hold your breath! 

The intention to avail oneself of a medical service (cosmetic or otherwise) should be made with a gravitas that is commensurate with the health and well-being implications of a medical procedure, rather than on the dubious rationale of a discount online coupon.

While value for service is naturally an issue and consideration for patients, the success of a boutique style practice (such as ours) depends almost entirely on a reputation for a high standard of work and a welcoming practice atmosphere. 

One can only ponder the motivation for a medical practice (cosmetic or otherwise) to couponise its services. Arguably medical practice has never been more trivialised.

Perhaps we are destined to see a new medical malardy-"Couponic Plague"-scores of disaffected, disappointed and emotionally wrecked patients arriving like boat people refugees at our doors for cosmetic salvation. Julia and/or Tony may become obliged to conjure up a "solution". If only Nicola would have selected her own medical board's link (again): http://www.medicalboard.gov.au/documents/default.aspx?record=WD10%2f2669&dbid=AP&chksum=3W%2fN5vWpGoe0K892YW9sFw%3d%3d 

New Treatments --"Endopeel"

It is always interesting to hear of new treatments and to ponder the future possibilities for these treatments. One treatment that has caught my attention recently is called the "Endopeel" technique.
 http://www.endopeel.com/en/abstract-endopeel/abstracts-endopeel?start=4
From what I can ascertain it seems to be some sort of muscle "peel" by injection into the muscles of a carbolic acid (phenolic) like substance. For some background appreciation I hvae linked to the following site.
http://chrisbarnes.blogharbor.com/_attachments/1720613/PhenolBenzylAlcohol.pdf
One can note from the above link that injections of Phenol into muscles affected by spacticity can relax these spasaming muscles by damaging some of the nerves that supply the muscles. So the effect is somewhat like Botulinum toxin but via a different and perhaps more chemically destructive pathway as phenols cause non-selective denaturing of proteins, that ultimately results in the destruction of nerves.
Botulinum toxin is more selective in its action. To make a muscle contract, a nerve sends a signal to the muscle. The point where the nerve and the muscle meet is called the neuromuscular junction. When the signal gets to the neuromuscular junction a chemical called acetylcholine is released from the nerve side of the junction and binds to the muscle side of the junction causing more chemical reactions that make the muscle contract. Botulinum toxin works by blocking the acetylcholine receptors on the muscle side of the junction. There are some interesting links below to some of these actions.
http://www.youtube.com/watch?v=gO8VJ_VcMhA
http://www.comawakening.com/spasticity.html
http://ptjournal.apta.org/content/84/1/76.full
http://www.ncbi.nlm.nih.gov/pubmed/20332721  
http://www.ncbi.nlm.nih.gov/pubmed/15024330
So is "Endopeel" an alternative to Botulinum toxin and does the claimed lifting relate to the sort of indirect lifting that Botulinum toxin achieves by weakening some muscles so others work unopposed (and thereby more powerfully)? The inventor claims that lifting is achieved by "myoplasty, myopexy and myotension as main mechanisms of action". By this I am given to understand that the injected muscle is functionally enhanced.
I must confess that (considering the weakening actions of Phenol on overactive muscles in spasticity) I'm unable to grasp how a muscle injected with a Phenolic can directly induce or enhance lifting in that injected muscle.
Nevertheless perhaps we will gain a better functional appreciation if "Endopeel" technique ultimately gains popularity in Australia.

Overseas Cosmetic Surgery Holidays (OCSH) -A Good Thing or Bad?

We increasingly live in a global economy in all aspects of our lives and this seems set to increasingly include medical and dental services that prove comparatively expensive here in Australia. http://indianmta.blogspot.com/

"Economic globalization" refers to increasing economic interdependence of national economies across the world through a rapid increase in cross-border movement of goods, service, technology and capital (Joshi, Rakesh Mohan, (2009) International Business, Oxford University Press, New Delhi and New York)

For invasive cosmetic procedures (eg: Face lifts, Tummy Tucks, Breast Enhancement) the local service/product can be very expensive indeed compared to some Asian countries. Increasing numbers of patients are now opting to travel for these services in Asia.

I recently saw a patient who had travelled to Thailand for facelift surgery. The outcome was of a high standard and the patient was very pleased with the experience. The cost of the whole exercise was less than a third of the $26,000 quote she had initially received from a local plastic surgeon!

So is the concept of OCSH a good idea? If the surgeon and the anaesthetist are highly competent and if the hospital facility and care is of a high standard, then the patient is entitled to ask "why not"?  However these are big "ifs" to consider, so prospective patients had better research these matters diligently.  Although there appears to be plenty of well trained and very affordable  surgeons in Asia, what readily comes to mind is the risk of complications occurring after returning home. Understandably very few local Australian surgeons are well disposed to the idea of managing the complications of an overseas surgeon's work. By way of example some time ago a patient of mine had breast implant surgery in South America that became badly infected shortly after returning in Australia.
The costs associated with management of this complication included further surgery back here that was far more expensive than the original surgery.
Nevertheless the OCSH trend will be interesting to observe over the next few years.
Interestingly the cost differential for minimally invasive procedures performed here and overseas is low.
There is very little incentive for patients to travel for an OCSH experience for minimally invasive in-clinic cosmetic work.Yet another reason that this will be the trend for cosmetic practice here in Australia.  Patients remain delighted by the opportunity to have the procedures that we perform "in-house" under local anaesthesia generally associated with minimal risk, minimal downtime and very natural outcomes (and home is only  drive away).

Body Liposculpture and Self-Esteem

A recent consultation reminded me of the important issue of self-esteem in patients seeking body liposculpture. A relatively slender young female patient was consulted in the company of her male partner for consideration of abdomen and flanks (hips) liposculpture. She had been seen by another practitioner who was happy to proceed. However the patient could not afford the fee quoted. Mine was the second opinion. I felt the contour defects were only modest and actually could be considered quite feminine. Furthermore the areas of concern could certainly be improved by some exercise as her tissues were a little lax and she had not been undertaking any significant physical activity recently. In discussion she mentioned that her partner had remarked on her being overweight and she was spooked by his comment (although I'm sure he had meant well). I declined to treat her but recommended some directed exercise.
At the risk of sounding sexist I venture to state that in my experience women can often be very sensitive to comments about weight-even if well intended. It may be prudent to desist from commenting on a woman's weight even if invited to do so by the woman-eg. "Do you think my bottoms too big?"-Better to say NO than anything that may taken to imply that it actually might be!
On a more serious note there are studies in the academic literature to support concerns about the stigmatisation both females and males regarding weight issues. The following quote is from an article in the journal "Obesity" (and linked below to the full article).  
"Weight Stigmatization and Ideological Beliefs: Relation to Psychological Functioning in Obese Adults" Kelli E. Friedman and Associates-
"Weight-based stigmatization is a common experience for obese individuals seeking weight loss treatment and appears to contribute to poor mental health adjustment. The negative effects of these experiences are particularly damaging for those who hold strong anti fat-beliefs."

http://www.nature.com/oby/journal/v13/n5/full/oby2005105a.html

"First Impressions" and Minimally Invasive Cosmetic Treatments

I was reminded in the last 2 weeks as to how some patients still endure significant angst when embarking on their first experience of cosmetic treatment. This is despite the reality that many treatments such as muscle relaxant injections are really less traumatic than a visit to the hairdresser! Today most treatments are minimally invasive with very little trauma and are performed in the clinic, walk in-walk out.
Usually this anxiety relates to how a partner, family member or close friend may judge them for acceding to such an indulgence! I recently treated a patient with neck liposculpture who did not tell her husband about it until he arrived home that evening. Happily he was very supportive and the outcome was very pleasing! Minimally-Invasive does generally equal Minimal-Risk.
So once people appreciate that what we do does not carry the risk burden of invasive surgery (like face lifting), the angst dissipates like the wrinkles do! 
I was drawn to a recent online article about how aesthetic enhancement by muscle relaxant injections impacted on other’s first impressions of them. As you will read the effect is positive!
"The popular cosmetic enhancement, botulinum toxin A (Botox) positively effects first impression judgments in relation to attractiveness, dating success, and athleticism, says new research presented at the 2008 American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Annual Meeting & OTO EXPO in Chicago, IL.*
According to researchers, first impressions of a person are influenced by facial appearance and improved by cosmetic surgery. They wanted to determine whether or not the use of botulinum toxin A would contribute to a person receiving higher scores on a variety of first impression scales. Photos were taken of the study participants before and after the treatment with the botulinum toxin A, then the photos were randomly divided into books with each subject represented only once per book. Blinded evaluators completed a survey rating their first impression on various measures of success for each photo in the book.
Subjects who received the injections improved first impression scores for scales of dating success, attractiveness, and athletic success The authors did not find any positive correlation between botulinum toxin A injection and increased scores regarding social skills, financial, or relationship success."
*Title: Botulinum Toxin A Can Positively Impact First Impression. Presenters: Amy S. Anstead, MD; Steven H. Dayan, MD. Date: Sunday, September 21.
ScienceDaily (Sep. 22, 2008)

"Muscle Relaxant" Injections-The WOW factor

With judicious application really pleasing aesthetic outcomes are possible with "muscle relaxant" injections and are these injections are always very popular at our clinic. Although muscle relaxant injections do not achieve anything like a face lift, the wrinkles around the eye can be improved, the frown lines relaxed with the eyes rendered more open and engaging in appearance. Actually there are many nice tricks with muscle relaxants to make the face more appealing but it does take a lot of time and experience to get the technique right and correctly tailored to suite the individual patient. As my talented colleague Dr.Naomi McCullum http://www.drnaomi.com.au/HOME.html  writes on her great website, treatments must be "bespoke".
There are of course limitations as to what can be achieved with this agent alone. They should be part of an aesthetic treatment plan that may include fillers, lifts, laser treatments and of course good home based skin care management. 

Outside cosmetic treatments "muscle relaxant" injections have been perhaps  a little hastily lauded as the new "cure-all" therapy in medicine. For example a well constructed recent study of these agents in the treatment of neck induced headaches was not supportive of a true benefit. 
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD008626/frame.html

In cosmetic facial treatment there is no doubt about treatment efficacy if injected well and in the appropriate patient.

Veins, Veins and more Veins

Injection sclerotherapy of legs veins runs hot here in the winter months. While I love doing veins I don't know how some injectors do this all day every day. 
The vast majority of the veins we see respond well to these injections. The veins take several months to fully respond to sclerotherapy, so to look good for the summer months it is necessary to have treatment before the end of September. Nevertheless I seem to treat veins all year long. 
The treatments are tolerated very well by patients and although strong compression stockings http://www.venosan.com/index_en.php?TPL=25000&x25000_ID=108 need to be worn for up to 1 week during the day, patients can return to normal life (but no gym work for 1 week).
http://www.phlebology.com.au/varicose-veins-spider-veins
In selected cases I have been using "foamed" sclerotherapy solution for some years now. This upgrades the potency of the sclerosant solution and allows us to achieve improved outcomes for more extensive cases.
http://www.youtube.com/watch?v=ySb9Wxd3A1A&feature=related
While surgery still has a place in treatment cosmetically unsightly veins rarely require surgery these days.