Wednesday 29 January 2014

The frozen face

“Doctor, please don’t make me look as though I’ve been through a wind tunnel”

“My husband has no idea I’m here, and we’ll keep things that way please”

“My friends cannot ever know I have been to a (cough cough) cosmetic clinic”

How many versions of “I don’t want to walk out of here looking plastic” have we heard? Is it because of the Silvio Berlusconis and Joan Rivers of the world? If everybody looked like them, believe me I wouldn’t be so fearless either! ... And, I’d probably be on job-seekers allowance!

So, we are approaching an era when it will be soon considered socially unacceptable to join the in-laws at table with vertical frown line between the eyes. Linear facial souvenirs of times, aka wrinkles will be about as yesterday as greying hair. While it is common knowledge that hair pigment is not retained well into our fifties and sixties, and therefore chemically enhanced, modern society as a whole somehow decrees that age-defiant facial beauty should solely be the result of a naturally fabulous stress free life and a providential gene pool.

Like the hues of our tresses becoming more drab, short of wearing a bland expression for the rest of our days, lest the wrath of the wrinkle later wreaks its havoc upon us, facial ageing is largely unpreventable. Of course the rate of acceleration can be reduced and somewhat controlled. As gravity pitilessly and unceremoniously takes its toll allowing creases to mar previously supple skin and jowls to make their debut appearance on what used to be smooth jawline, some form of intervention is inevitable should the plum be stopped from morphing into a prune.

Yet how do we reassure our patients that we wont turn them into eerie-looking waxworks? Facial rejuvenation or enhancement does not necessarily translate into faces totally devoid of movement and a frozen expression. We unanimously agree that expression is a requisite of normal social interaction and I know no practitioner worth his salt who would be proud to claim ownership of Wildenstein-esque feline visage. We are well aware that such results would tarnish our hard-earned reputations!

A quandary I have often come across is with those patients who wax lyrical about how they absolutely depend on natural looking results, yet return for top-up after top-up until every hint of movement is well and truly abolished. Sometimes the explanation that trying to get your money’s worth of toxin is NOT a good idea and a forehead so smooth that it resembles a polished marble egg does nobody any favours, just doesn’t seem to penetrate.

There also exists a cohort of patients who purposely desire the exaggerated look, and too often onlookers will immediately blame the treating practitioner. This is especially so with regard to lip enhancement and augmentation. I must have heard at least fifty times “I’d never have my lips done, as it’s always so obvious”. What the public fails to realize is that some of our patients specifically request the eversion of a pout and the increase on volume of their lips to such an extent that they feel the unnatural “done” look is in fact attractive. This tends to be predominant in some cultures more than others. I’ve had many requests from Iranian ladies (who are reputed to be among the world’s most beautiful women) to raise the lateral part of the eyebrow as much as possible (and this they further augment with eyebrow pencil) and to boost the lip considerably. Just take a walk in Knightsbridge and observe the ladies from the Gulf, piecing together their facial work together with their hair, make-up and exquisite attire.

Freezing and filling used alone or in combination have infamously hit the headlines countless times, thanks to the likes of Leslie Ash’s trout pout, and Madonna’s commendable effort to popularize the pillow face a few years ago. Lower face and mid face volumization procedures are often the easiest routes to crossing the bridge over to “too much work”. To our advantage (as opposed to permanent surgical implants), we can employ dermal fillers incrementally, using both our eyes and the patients’ as a judgment of the results, which are immediate.

Another area notorious for betraying the evidence of our intervention is the crow’s feet. Poor Nicole Kidman epitomized the unsmiling eyes. With the eyes being the window to the soul and all that carry on, this is probably the most delicate area when wielding our toxin. This is definitely a case of less is more and while softening deeply etched lines is highly desirable, erasing all traces of movement results in a flat expression. The upper face not moving in accordance to the expression of the lower face is a dead giveaway, and all in all a procedure badly done.

Another telltale sign on an otherwise smooth forehead are those annoying lines which would have previously never bothered the patient prior to treatment, yet persist after the effects of the injected toxin are evident. I’m referring to the solo appearance of bunny lines and mephisto lines. It is often difficult to predict the exact dose of toxin and the exact reaction. Hence it is often a case of titration with necessary modification at the two-week follow-up. While most ladies laud the raised eyebrow, the Berlusconi-style permanently surprised look is to be avoided at all costs. It doesn’t suit anyone, not even him!

When it comes to treating our male patients, I found that it is only a very small group of them who are comfortable with being open about their attendance to our practices. Hence while the gentleman usually consumes more toxin for the same desired effect than his lady counterpart, aggressively reviving his youthful appearance will probably do him no favours in the long run. I find that with men I am especially cautious with the use of dermal fillers.

I am probably one of the most conservative aesthetic professionals around. However, this I believe goes a long way in preventing the “done” look. It is no advert if a patient walks out of my clinic, looking like she has just been there. Rather, the ideal look is a refreshed one, as though she has just spent a week at a spa! My advice to patients is to avoid the temptation to restore their faces to their original ravishing youthful looks in one session. Doing it in a stepwise fashion, that is every treatment separated by at least two weeks (to allow for any bruising or swelling to subside) often lets the patient to realize that all the treatments originally signed up for would have perhaps been a little much. It also generally isn’t a good idea to launch a major rejuvenation overhaul immediately before an upcoming cosmetically sensitive event, such as a wedding. It is wise to embark on such a mission at least 6 weeks beforehand.

A great result from any cosmetic intervention is largely dependent on the initial discussion. An aesthetic procedure is one that is taken to make the patient feel better about his or her outwardly appearance. So I guess it is pretty clear that we need to know what it is the patient is seeking to achieve, and in turn we need to be absolutely clear on what is realistically achievable! Any fears and concerns, the associated downtime, possible complications and possible contra-indications need to be addressed without ambiguity. As there is no such thing as a cosmetic emergency per se, if things are done unhurriedly and in a timely step-wise fashion, overstepping the mark is easier to avoid. The follow-up session is then the time to top up and perfect results, or add on procedures. The demand for noninvasive treatments that skip the scalpel and focus on replenishing youth to the face is skyrocketing internationally. The goal is to minimize wrinkles and restore facial volume without the patient needing to re-mortgage the house and with minimal recovery time.

It is not to our advantage that only the horror stories grace the tabloids. These over-the-top celebrities who as a result of cosmetic treatments could easily be passed off as Tupperware adverts, are the occasional result of one procedure too many, thwarted ideas of beauty, lack of insight and ill judgment on both sides (patient and doctor!) The best cosmetic interventions never make it to the headlines. This is because they result in natural looking fabulousness, through a thorough consultation and meticulous technical expertise.

Friday 29 November 2013

The beauty of aesthetic medicine

Why do some of us choose a career in Aesthetic Medicine? What tempts us away from the conventional challenges pertaining to the world of medicine and surgery,  treating sick and injured people, to a world of facial enhancement, beautification and rejuvenation?

This aspect of medicine appeals to those medical professionals with an eye for the aesthete. This is the only specialty which introduces art into a works of science. The appreciation of this marriage between art and science is is what allows us to safely deliver superior results to our patients.

While we would immediately assume that aesthetic medicine does not involve illness per se, the cohort of patients we see, differs extensively from our usual patients presenting to our surgeries. Psychological morbidity may feature quite heavily in aesthetic clinics.

Aesthetic medicine is a unique specialty because it allows us to safely enhance and improve our patients' sense of well being and self esteem.

Tuesday 15 October 2013

The Academy of Aesthetic Excellence at the Clinical Cosmetic & Reconstructive Expo 2013

We have had a very busy weekend at the CCR EXPO at Kensington Olympia but it has been totally worth it.

The Academy of Aesthetic Excellence Masterclasses at the CCR Expo at Kensington Olympia last weekend were overflowing with delegates keen to learn from our Medical Director Dr Raina Zarb Adami.  

Lectures and live demonstrations included rejuvenation of the upper face using Botulinum toxin A, rejuvenation of the lower face and the mid face using Botulinum toxin A and dermal fillers, advanced methods of lip enhancement and the use of Botulinum toxin A for hyperhidrosis.

Delegates included doctors, dentists and nurse prescribers eager expand their  aesthetic practices.  These masterclasses covered the off label indications for these products - areas which are often not covered in many training courses.

In addition, Dr Raina Zarb Adami also delivered a presentation regarding the use of Botulinum toxin A in the beautification of the lower face as well chairing various sessions and participating as a panelist in many of the live debate sessions.  The topics included: Who should be injecting? Are surgical and non-surgical rejuvenation methods complementary or in opposition to each other?  How fine is the line between business and medicine?

For those of you interested in practice aesthetic medicine please check our courses at

We really look forward to next year's CCR expo!

Tuesday 13 August 2013

The psychology behind cosmetic intervention decisions

The great Aristotle said "Personal beauty is a greater recommendation than a letter of reference." This adage today is held so close to the heart! Is it the yearn for everlasting youth? Or the undying wanton of perfection? Is our purpose on this earth as aesthetic practitioners to restore what once was and maintain it? Or rather, is it to remove all traces of facial and bodily imperfections, perceived or actual? Is the needle or the knife always the solution?

Life today, alas is no longer about embracing our imperfections and frailties, rather, about soldiering on in battle to defeat them and proving to the world that we are perfect………… and quite naturally and effortlessly so, needless to say! For every problem known to man, there are self-help books and counselors in plentitude……….. and for those not so confident in their outwardly appearance, we are there! But really, we are all aware that there is a line to be drawn, and it’s not that fine. However, where do we draw it? Is the onus on us, as practitioners equipped with the adequate training, and expertise? When do we say no? And when does it dawn on us that perhaps that very line has already been crossed? Are there any remedial solutions then?

We are all too familiar with the patient who insists on natural looks, yet returns again and again for toxin top-ups until every hint of muscle movement and god forbid wrinkle is well and truly abolished, her forehead thus resembling a polished marble egg. And who of us hasn’t been hailed the new savior by the patient who just walked into the surgery? Five minutes into the consultation, Mrs. Jones is heaping exultation on you, and just knows – she has that innate hunch - that you are astonishingly gifted, and that you will be the restorer and provider of her ravishing youthful looks. This is of course in sharp contrast to the six other aestheticians she’s seen before you, who just happen to be plain stupid, don’t understand her needs, one is an utter butcher, the other couldn’t even hold a conversation, the other left her looking like a chip munk and the last one turned her into the joker from Batman! Any bells of familiarity ringing yet? Well, if the bells aren’t ringing, the red light should be flashing!

Recent studies have shown that a larger proportion of individuals seeking cosmetic interventions suffer from psychological and psychiatric co-morbidities than the general population. One study, Malick et al (Journal of Plastic and Reconstructive Surgery May 1998) states that up to 47.7% of cosmetic patients demonstrate traits of psychiatric co-morbidity. While we have all come across a patient here and there who is blatantly suffering from body dysmorphic disorder and know to tread carefully, many of our patients present more subtly. Many people might come across as ‘doctor shoppers’ and will be extremely savvy with technical terms and might also have a knack for intimidating the practitioner and persuading him into performing a procedure he might deem unnecessary or inappropriate.

Out there, plenty of literature exists exhorting us to learn to love our flaws, as they are not such but marks of individualism, making each of us unique and distinctive! In sharp contrast however, when it comes to the fa├žade we present to the world, things are not quite so. Modern society and celebrity culture repeatedly epitomize the yearn to covet unchanging youth and age-defiant beauty. The contemporary consumerist civilization that defines the noughties and the noughtiers dictates that wants tend to override needs. Whereas most forms of medical and surgical interventions are largely unwelcome necessities, cosmetic treatments are purely elective procedures that a (usually) otherwise healthy individual seeks to undergo as a means to improve appearance and to restore that ‘feel-good’ factor.
Fifteen years ago, facials, Botox and regular trips to the hairdresser’s were emblematic of those with enough disposable income and ample time on their hands. Today the desire to be one of the "beautiful people" has developed into an obligatory tool for success in the professional world too. This in itself is part of the psychology that fuels the industry. Looks matter more than ever before.

In most cases, patients start to notice the appearance of lines on their face when they move the underlying muscles. As these lines morph into a static rhytids, some people dislike the way their skin now looks and opt to restore it to its former appearance. Most of these individuals seek a natural look and are content with the results. A similar theory applies to ‘mummy make-overs’. As the age of motherhood increases (and we largely have our high-flying careers to blame for this), abdominal skin doesn’t quite spring back to its original contours and elasticity so easily. The key point is to seek out the patient’s motivations and expectations. Hence, the invaluable worth of the consultation, especially the initial one.

It is worthy to note though, that many patients embark on their cosmetic journey with what we would objectively call a reasonable outlook. This is to look good and more importantly to feel good. It has been proved that these treatments, especially the less expensive, minimal discomfort non-invasive procedures can fuel an addiction. We the practitioners do little to ameliorate this situation. Easy access is granted to our services with most of us offering free consultations. “Is the start of a wrinkle? Oh no!! Nip out to lunch, grab a shot of Botox on the way?” “Ooh it’s Friday, no big plans this weekend. Hmmmm, lips or Dermaroller?” This could evolve into a vicious circle of brow lift here, cheek enhancement there, neck lines next week etc… at an alarming rate.

What do we look out for? How do you detect the metamorphosis of a seemingly sound individual into a dysmorphophobe? When do we start to entertain the thought that the beauty conscious lady (or gentleman) is now leaning towards ‘cosmo-junkie’ status? Are there any other sinister traits we should be on the look-out for? And more importantly, when do we bite the bullet and refuse to treat a patient or delicately refer her for psychological help? While our professional training has left the large part of us immaculately skilled with the knife, needle or drill, our training in such issues is limited to that brief interlude during our under-graduate years, when we merely flirted with the notion of psychiatry for a couple of months. Hence, most of us are rather ill-equipped to diagnose such afflictions and deal with them in a timely and appropriate fashion. It is hardly easy to turn to your loyal patient who has been on the receiving end of your needle for so many years that she’s part of the furniture, and say “Well, I think you might need psychological help”

What happens when one scratches the surface of a simple thought like, "I'd like to look more attractive." yields a whole myriad of different and surprising results. When one begins to deliberate on this idea, subconsciously acknowledging the trouble-free access to a plethora of solutions to the quandary at hand, it is easy to comprehend the nascence of a fixation and it’s development into something more sinister. Underneath that initial thought, all kinds of intuitive messages are rallying for attention.

For people with realistic expectations, cosmetic interventions can positively enhance body satisfaction. It is key to actively seek what the patient is trying to achieve with this treatment, and whether she is happy with her overall appearance. If she is accepting of her face and body but dislikes one particular feature and wants it restored, enhanced or corrected, the chances are that she will benefit from the treatment both physically and emotionally. Setting realistic achievable goals is an imperative part of the consultation. In repeat patients, these questions need to be re-addressed and the patient’s outlook explored to ascertain that no unhealthy trends are developing.

Body image dissatisfaction is inextricably linked with self-esteem issues. While most of the time, cosmetic interventions might go a long way to help to fortify and replenish such self-image wellbeing; it has been shown that extensive procedures may in fact be detrimental to the psyche. Patients suffering from body dysmorphic disorder obsess over inexistent physical flaws or exaggerate barely noticeable defects. In 2006 a study carried out in Germany noted that this affects 2% of the population. The benefit gained from cosmetic interventions tends to be fleeting and effects last only until the patient develops a new focus of obsession. Promise of improvement and change of physical appearance is extremely alluring and expectations rise beyond the attainable. These are the patients who are rarely satisfied with the results of their treatments.

A content patient will very often return with “Doctor, what else do I need?” While this is testament to the quality of the treatment provided and is evidence of a doctor-patient rapport built on trust, it may well be the open-ended beginning of a very slippery slope. Cosmetic treatments per se, are never indicated for health reasons and are largely a matter of opinion. Beauty is in the eye of the beholder, and when in our surgery, the patient herself should be the said beholder, not the holder of the needle!

It isn’t that unusual to come across other difficult personality traits that might be a challenge to manage. Histrionic personalities tend to over-dramatize issues, are confrontational, melodramatic and rather emotionally volatile, especially when met with criticism or disparity of opinion. These are the patients most likely to doctor-hop and heap insult on the poor preceding practitioners. Delicate handling is a must, if not, such patients may well be injurious to an otherwise hard-earned fine professional reputation. This trait is usually commoner among (but by no means exclusive to) the fairer sex. A note of caution to male practitioners: ladies exhibiting these features tend to be rather over-the top and unrestrained in making sexual advances on those they consider to be in a position of superiority to themselves.

Whereas women are more apt to displaying signs and symptoms of emotional or psychological instability, men are by no means exempt from either of the above-mentioned conditions. More common to the male sex is the narcissistic personality disorder. This seldom manifests as a full-blown personality disorder, but as a characteristic that one might come across while speaking to the individual. This group of people comes across as egotistical and self conceited with little regard or empathy, if any at all, for those around them. An air of grandiosity and self-importance is an accompanying factor.

Increasing attention has been drawn to the psychological implications of cosmetic interventions. This is perhaps in part due to the rising toll of medico-legal litigation. Various guidelines are in place, facilitating a more straightforward method of comprehensively integrating psychoanalysis in the initial consultation. Questions pertaining to social behavior, past psychiatric issues (especially depression, anxiety or eating disorders), patient self-assessment on perceived physical flaws should be asked as open-ended questions, and where deemed necessary, probed further. The patient’s motivational factors bringing her to seek treatment should be explored and elucidated, together with obtaining an idea as to whether the patient can afford the treatment, or is she taking out a loan. Is this a last means of desperation for her? Does the patient fully grasp the ensuing consequences of the procedure in question, and its risks? Does she have the necessary education and maturity to rigorously follow post-procedure protocol? Are the patient’s emotional reactions appropriate to the circumstances? This list is by no means exhaustive, but such questions provide insight to a patient’s psyche, and might be useful in staving off potential disasters.

The mere suggestion of cognitive behavioral therapy is rarely met with pleasure and gratitude, rather with hostility and “who do you think you are?” Numerous diverse methods of approaching this situation and conveying your professional concern exist. Perhaps the thorniest challenge is refusing to perform the treatment in question. When placed in a situation where our misgivings cause us to be ill at ease performing any procedure, the astute practitioner would deem it prudent to wait it out, make clear to the patient (in plain words) his concerns, and ask the patient to reconsider her choices. At the end of the day, a cosmetic treatment is never an emergency.

While it is important to recognize our role as clinicians with a duty to our patients, it is important to ensure the patient acknowledges her responsibility in taking this decision to be treated on a voluntary and elective basis, with no causal factor other than as aspiration for the improvement of appearance.

Although many cosmetic clinics are under pressure to keep the business afloat, and most of us do thoroughly enjoy applying our manual skills, at the end of the day it is our responsibility to respect the Hippocratic Oath, “first do no harm”. The wellbeing of the patient, cosmetic or otherwise is imperative to the integrity of our practices. The relevance of psychological issues in the undertaking of aesthetic treatments is well recognized. In repeat treatments, the patient can be in and out within ten minutes. This begs the question “Is this good medical practice?” It’s not as simple as hello this is the explanation, these are the risks, sign the consent form, treatment – there you go - and see you in a fortnight! The key take-home point is ensuring that the patient’s expectations are realistic and that a thorough consultation identifies actual or potential problems. When signing the consent form, the patient should be well versed in the potential risks and anticipated outcomes. Expectation management is an integral part of our communication skills. An element of the aesthetic practitioner’s expertise is his aptitude as a discerning psychoanalyst. A patient is never a blank canvas, but an exclusive inimitable sculpture, which has already weathered some storms and displays the signs of the times. While this fleshy envelope, which we present to the world, succumbs to genetic and environmental factors and insults, the will to maintain the illusion of youth and beauty persevere.

Most of us are certainly extremely talented in our field. Alas, this does not translate into “we are omni- and totipotent”. Knowing when to say no and when a referral to our psychiatric colleagues is warranted is part and parcel of what makes a good doctor a brilliant one. At the end of the day, it is better to turn away a patient, than to disappoint her. A happy patient tells five people. An unhappy patient tells a staggering twenty!!