"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.

Mind the Gap!

A recent article in a health,wealth & lifestyle magazine sent out to medicos (available online) has highlighted the "very large gap" between actual cosmetic surgery in a hospital and treatments in a beauty salon. The article proposes that the gap is being filled by "specialist" clinics staffed by an overseeing doctor, nurse injectors and laser technicians. The article suggests that this is the business model for the 'gap" created by an expanding market. It seems that this type of business model will also be available in franchise form.
http://issuu.com/medicallife/docs/physicianlife_final/search

The alternative to this model can be appreciated by noting the numerous private clinician owned and operated clinics that have successfully functioned and have indeed been very popular for over a decade now.
These established clinics generally have one fundamental and very important principle and that is the reassurance that the person actually administering the treatment is the trusted medico (or a practitioner very closely supervised by the medico). Discerning patients may care to ponder whether a franchise business model can morph from concepts such as a fashion house or Gloria Jean's or McDonald's into cosmetic medical clinics. Perhaps! http://www.franchisebusiness.com.au/t/Health-Beauty-Franchises/Medical-Treatments
But it should be borne in mind we are not talking about selling garments, coffees or hamburgers here.
Mind the gap!

Platelet Rich Plasma-The Future? Maybe!

I am often asked by patients what I think of Platelet Rich Plasma (PRP) treatment for cosmetic improvement of the face. As an early adopter of this treatment I must confess that as a stand alone treatment I was not convinced that I was achieving all that much benefit for my patients and no longer offer it in that way. Nevertheless other practitioners have success with this treatment so in their hands it seems to work for their patients. My excellent colleague Dr. Naomi has a recent blog on this subject and I link to it here. http://drnaomi.blogspot.com/2011/07/platelet-rich-plasma-facts-interview.html

However I'm pleased to report my observation that admixed with autologous fat harvested for grafting, PRP does appear to significantly improve the graft success and I do believe there is supporting evidence in the medical literature for this benefit. Accordingly I use this combination in most of my fat graft cases.

 

A recent commentary has been published online by US Plastic Surgeon Dr. Barry Eppley and provides another point of view and is reproduced as follows:

 

March 4, 2011

The Vampire Facelift - Cosmetic Application of Platelet-Rich Plasma Concentrates

Author: barryeppley

One new interesting, but unusually named, cosmetic procedure is that of the “Vampire Facelift.” In truth, it is not really a facelift nor is it used by vampires or will make you look like one. The  Vampire Facelift is far less scary and has much more science to it than most science fiction tales. It is based on the more well known and highly popular injectable filler concept.

It works by injecting its magical potion underneath the skin, much like its man made counterparts such as Juvederm or Radiesse. But instead of using a prepackaged synthetic material, the Vampire Facelift (trademarked name by the company Selphyl) uses the patient’s own blood to make the injectable filler. A small amount of blood is first extracted from the patient. Then a device separates the platelet portion from the red blood cells. The concentrated platelets are then combined with the company’s  proprietary synthetic mixture and the composite is now ready for injection. The entire preparation process takes less than ten minutes to complete and can be done in an office setting.

The principle of this approach is that platelets are heavily endowed with growth factors. These potent little growth stimulants can induce the growth of new collagen. Collagen, of course, is what gives skin its fullness and suppleness. The implantation of a concentrated platelet mixture could help rejuvenate thin and aging tissues and overlying skin…in theory. It is also appealing to patients in that it is an organic approach to rejuvenation using one’s own tissues to help repair itself.

While this cosmetic application of a platelet concentrate is new, the concept is not. PRP (platelet-rich plasma) concentrates have enjoyed widespread use in healthcare in the past decade, particular in orthopedic and musculoskeletal medicine. Numerous companies have PRP technology and application devices. What makes Selphy unique is that they have made a more simple in-office device at a low cost, which are the requirements needed if cosmetic use will gain any popularity.

While the Vampire facelift (perhaps better understood as a PRP filler) treatment sounds intriguing, it is not known if it will last any longer than that of off-the-shelf injectable fillers. The theory is biologically appealing but whether it actually works has not been conclusively shown. I commonly mix PRP concentrates with fat injections with the theory that the platelets may stimulate better fat preservation or stem cell conversion into adipocytes and/or fibroblasts. This is employing the identical approach but with a different substrate. Time will tell if these biologic injectable mixtures will live up to their theoretical benefits.  

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The Naso-Labial Fold..Is It Normal??

Many of the most recognisably beautiful women have definite Naso-Labial folds.

It does not detract from their beauty.

However not a week passes at our clinic without requests for treatment of a patients naso-labial fold. Sadly this focus remains an unfortunate obsession amongst many cosmetic patients and often a poorly understood phenomenon in our profession. The genesis of the fold is complex and multi-factorial. Fundamentally the naso-labial fold (and the labio-mental {marionette} grooves below) deepen due to contraction (or atrophy/involution) of the teeth and bones surrounding the mouth.
Filling these depressions with injectable fillers and even relaxing them a little with muscle relaxant injections can improve them a little, but not for long. If you place a finger on the naso labial fold you will feel the root of the tooth only millimeters under the skin. So there is very little distensible tissue for a filler to go. So what is the answer? There is a growing appreciation that treatment of the cheeks above and the lips below focuses the eye's attention to the aesthetic improvement in these far more important regions of beauty (and as a bonus can also indirectly improve the folds).
Furthermore some minimally invasive per-cutaneous tissue lifting through tiny skin punctures can improve the aesthetics a little further. The most famous plastic surgeon in history, Professor Ivo Pitanguy recognised this issue in 1999. The conclusion from his published paper on "Round Lifting" is reproduced below as well as a little history of this illustrious colleague.

Treatment of the Aging Face Using the “Round-lifting” Technique
Ivo Pitanguy et al
Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro, Brazil
Aesthetic Surgery Journal, Volume 19, Issue 3, May-June 1999,

"There is as yet no ideal solution for the surgical correction of the naso-labial fold component of the aging face. However, all of the techniques described are considered safe and have precise indications. It should be stressed to the patient that the nasolabial fold is part of the anatomy of the face and that the goal of treatment is to soften the appearance of the fold, not to eliminate it completely."


"Ivo Pitanguy is famous throughout the world, but in his native Brazil he’s a legend, eclipsed in public recognition only by Pelé, the soccer god. That a plastic surgeon could reach this level of renown says something about the Brazilian worship of physical beauty and, of course, Pitanguy’s knack with the knife, for which he’s been dubbed “the Michelangelo of the scalpel.” But the doctor clearly possesses other, more subtle qualities as well. “Pitanguiser,” a word coined in the local Portuguese dialect, translates as “human charisma, intelligence and compassion.” In our harshly clinical Nip/Tuck culture, Pitanguy has said he sees his business as “the search for harmony between body and soul.”
Read More http://www.wmagazine.com/beauty/2008/07/ivo_pitanguy#ixzz1R36OHbG6

The Eyes Have It-Windows To The Soul

Donald has just received a pair of hypnotism goggles and plans to use them on Pluto.
The incomparable Donald Duck knows the hypnotic power of the eyes in the cartoon "The Eyes Have It" http://www.youtube.com/results?search_query=the+eyes+have+it&aq=f

"The eyes are the window to the the soul."
 http://the-windows-to-your-soul.webs.com/inalltheirglory.htm

The following are links to excellence in upper eyelid rejuvenation surgery, in many ways similar to what we endeavour to achieve in approach, technique and outcome at our clinic.
http://www.youtube.com/watch?v=kH0Cl1U8h74&feature=related
 http://www.youtube.com/watch?v=VCszUm0Pu_c&feature=related
http://www.youtube.com/watch?v=Stjxzc5J5TE&NR=1

Engaging eyes, fulsome cheeks, generous mouth and a sleek jawline and neck are the fundamentals of a beautiful feminine face

Sophia Loren