Nose better

So what is non-surgical rhinoplasty?

I am increasingly asked about nasal treatments, particularly by patients who don't like their nose form the side (profile view). The nose may have always been like this, may be as a result of trauma, or there may be a bit of irregularity following nasal surgery or surgical rhinoplasty. 

Patients understandably want to avoid surgery due to the cost, the need for a general anaesthetic, and the prolonged healing and recovery time.

While there are limitations to the procedure, it is simple, safe (in the right hands), and lasts approximately a year.

While a variety of dermal fillers can be used, Dr Cormac uses Hyaluronic Acid (HA fillers) as they have excellent properties for use in this area. They volumise, integrate well and are well tolerated. Additionally they are very safe and, on the rare occasions that it may be required, are completely reversible..

Advantages:-

It is a short, clinic-based procedure.

Using lidocaine and adrenaline, we reduce the risk of bruising and damage to the delicate blood-supply. The dermal filler also has local anaesthetic for a more comfortable procedure.

Immediately noticable results.

Well tolerated. If minor bruising and redness occurs, it is short-lived and easily covered.

Cost= £300

 

 

A new year and a new you

Planning ahead, we need to think about positive changes.

And that often entails not only adding, but also taking away.

So here are a few options we can help with. 

Obviously this all comes on the background of a holistic, health centred approach. 

Read More

Digging for beauty

Digging for beauty- in the name of health

 

A recent visit to my Irish home brought back some old memories.

 

It coincided with the recent opening of “Home Place”, a facility dedicated to celebrating the life and works of Seamus Heaney.

Although he was born a generation ahead of me, we nonetheless share some common ground.

 

He was born less than 10 miles from me and he had similar farming origins.

He attended the primary school where my sister teaches and attended St Columb’s boarding school, at the same time as my father.

I studied his poetry at school.

 

In one of my favourite poems “digging” he reflects on the differences and similarities of his career path compared to his predecessors.

While I acknowledge that parallels are limited, I felt such a connection with Home and the similar beginnings that led to a different path.

 

I now combine health and beauty, using an evolving craft.

And a different kind of pen.

 

 

 

“Between my finger and my thumb

The squat pen rests.

I'll dig with it.”

 

Microsclerotherapy and laser treatment

What options are available to treat Thread veins?

 

Thread veins are essentially an aesthetic problem. They are not dangerous and do not cause symptoms. They may however be a sign of deeper issues that can be managed to prevent worsening.

 

The first question to consider is whether they are of significant size. Small areas of thread-veins can be covered using camouflage creams. If the affected area(s) are larger or more troublesome, there are other options. If there are varicose veins associated then the results of treatment are better if these are dealt with first (see varicose veins). Once any associated varicose veins are dealt with they can be treated with microsclerotherapy or lasers.

 

Microsclerotherapy requires injections using a very fine needle into the thread veins themselves. The aim is to damage the small vessels so that no blood can flow through them.

 

Support stocking should normally be worn after the procedure as this helps the veins to seal off and also supports the circulation. Sometimes, a small area of brownish pigmentation can occur at the site of the injection, and very rarely patients can experience a little ulcer. Precautions are taken to avoid these outcomes, and a combination of wearing support and attending follow-up will minimise the potential for such problems.

 

Laser treatment is an alternative treatment but is considered by many to be less effective than microsclerotherapy. In a recent medical review in the Drugs and Therapeutics Bulletin (the Medical equivalent of Which), it was concluded that microsclerotherapy was more effective than lasers and that it should be used in preference for most people with thread veins on the leg although laser is better for thread veins on the face.

 

Lasers also have the disadvantage that people have to avoid sun exposure before and after treatment and occasionally produce permanent areas of whiteness in the skin.

 

Whatever method is used, treatment takes some time to achieve the maximum effect and for everything to settle down. It is not realistic to decide to get your thread veins treated a week before your summer holiday.

 

A recent article of mine published in the Teoxane Times (page 1)

TEOSYAL® RHA 4: THE IMPORTANCE OF DYNAMICS Our patients tell us that they want natural-looking rejuvenation. They want volume replacement but, critically, they still want to look like themselves.

As practitioners, our aim is to restore contours, shape and balance, and achieve a youthful, aesthetically pleasing result. What is often neglected is the requirement to consider not only the resting face but the face in animation. While age-related changes occur in all layers of the face, a focus on volumetric restoration leads us to consider the fat compartments as a priority. Facial fat is composed of deep and superficial layers, neatly divided by the superficial musculoaponeurotic system (SMAS) or mimetic muscles. These layers are further divided into compartments which follow a predictable pattern of depletion. In the deep layer most volume loss occurs in the lateral and medial sub-orbicularis oculi fat (SOOF), the deep medial cheek and chin fat compartment. In the superficial layer, most volume loss occurs laterally in the temporal and preauricular regions and, to a lesser degree, in the middle and medial superficial cheek fat compartments. The superficial nasolabial compartment and the superior and inferior jowl compartments are relatively unaffected by volume loss and may develop some hypertrophy. They tend to move medially because of a lack of fibrous fixation and lateral support. Further to the redistribution of fat and general volume depletion, the individual fat compartments become more discernible as separate entities.

Hyaluronic acid (HA) dermal fillers are well established as the most popular products for treatment of volume depletion and static lines. They are increasingly used in multiple planes, targeting the volume deficient compartments for a more natural and balanced effect. In recent years we have considered rheology important when selecting an HA filler. A higher viscoelastic modulus (measured as G*) relates to a harder product which is resistant to deformation and effects a better volumisation. Cohesivity of a product relates to its ability to stick together despite application of an external force compression.

TEOXANE LABORATORIES’ TEOSYAL® RHA 4 IS THE MOST VOLUMISING PRODUCT IN THE NOVEL RESILIENT HYALURONIC ACID (RHA) RANGE. Utilising longer HA chains, their 3D structure affords a dynamic stability due to the presence of natural, labile and mobile low-energy bonds, supplemented by a low ‘BDDE’ crosslinker rate of 4% to create anchor points. Possessing a high level of strength to resist pressure forces, while maintaining an impressive ability to stretch and accompany the dynamism of surrounding tissues, RHA 4 elicits, as demonstrated by clinical trials, an impressive clinical improvement both immediately and in the long run, and very high patient satisfaction.

RHA4 strikes an excellent balance between tolerability, product integration, volumisation, dynamism and longevity.

Peyronie's Disease

The P-Shot is increasingly used to treat Peyronie's Disease. I hope the following information about the condition is helpful..

 

Peyronie's Disease is a condition that is due to development of scar tissue inside the penis that causes curved, painful erections.

Having a curved erection is common and isn't in itself a cause for concern. Unfortunately, in some men, Peyronie's disease causes a significant bend or pain resulting in difficulty having sex or getting/maintaining an erection (erectile dysfunction). Obviously, in many men, this causes stress and anxiety.

There are characteristically two phases of the disease; An acute phase lasts 3-6 months followed by a chronic phase lasting around a year during which the disease usually stabilises.

While it is possible for Peyronie's Disease to go away on its own, it usually remains stable or worsens. Treatment is advisable if the curvature is severe enough that it prevents successful sexual intercourse.

 

What are the symptoms (and signs)?

  • Symptoms may develop gradually or appear suddenly.
  • Scar tissue - Felt under the skin of the penis as flat lumps or a band of hard tissue.
  • A significant bend to the penis - The erect penis might also have narrowing or indentations.
  • Erection problems.
  • Shortening of the penis.
  • Pain - With or without an erection

 

What are the causes?

While we don’t know for sure, we believe that Peyronie's disease results from repeated injury to the penis. For example, during sex  or sport. Most often, men don’t recall episodes of trauma. During  healing, scar tissue forms which can result in a lump or change in penis shape. This is particularly obvious when the penis becomes erect as the scarred part is unable to stretch.

A number of factors can contribute to poor wound healing and excess scar tissue:

  •  Heredity - If your father or brother has Peyronie's disease, you have an increased risk
  • Connective tissue disorders - Some  men who have Peyronie's Disease also have a condition known as Dupuytren's contracture where a cord-like thickening across the palm causes the fingers to pull inward
  •  Age - The prevalence of Peyronie's Disease increases with age
  • Diabetes
  • Cigarette smoking may be linked to Peyronie's disease

 

How might Peyronie's Disease affect me?

  • Inability to have sexual intercourse
  • Difficulty achieving or maintaining an erection (erectile dysfunction)
  • Anxiety or stress about sexual abilities or the appearance of your penis
  • Stresses on the relationship with your sexual partner
  • Difficulty fathering a child, because intercourse is difficult or impossible

 

When should I see a Doctor?

If you have pain or a curvature of your penis that prevents you from having sex, you should see your general practitioner (GP) who will probably suggest a referral to a specialist in male sexual disorders (urologist).

 

What might the doctor ask?

  • When did you first notice a curve in your penis or scar tissue under the skin of your penis?
  • Has the curvature worsened over time?
  • Are  erections painful, and if so, is it worsening or improving over time?
  • Do you recall having an injury to your penis?
  • Do you have difficulty having sex?

Your doctor may ask you to complete a survey, such as the International Index of Erectile Function, to gauge the effect of the condition on your sexual function. You may also be asked to take photographs of your penis when erect to detect the degree of curvature and location of scar tissue.

 

What might the doctor do?

Diagnosis of Peyronie's disease  is usually based on a physical examination to identify scar tissue in the penis. Measurements may be taken to monitor progress.

You may also be referred for an ultrasound scan. This test uses sound waves to produce images of soft tissues, allowing assessment of blood flow and checking for presence of scarring.

 

And treatment options?

If symptoms are mild, you may be advised to “wait-and-see” (watchful waiting).

If your symptoms are severe or are worsening over time, your doctor might recommend treatment to address the pain or curvature.

Some treatments used with variable success include Vitamin E, Potaba, Colchicine and Verapamil.

Surgery is not used frequently but will be considered when penetration is impossible, particularly when the bend is 45 degrees or greater. Surgery usually isn't recommended until the curvature of the penis stops increasing.

Surgery, particularly the simplest 'plication' procedure, unfortunately can be associated with further shortening of the penis and increasing the risk of erectile dysfunction. Newer procedures include insertion of semi-rigid or inflatable implants which can be particularly helpful if there is also erectile dysfunction.

Drugs called 'collagenases' (including Xiapex) can be injected to help dissolve collagen in the scar tissue and are available when there is a curvature greater than 30 degrees.

Platelet Rich Plasma (PRP) is used in a treatment called the P-Shot which holds potential as a natural approach, using the patients own blood to treat the scarring and deformity while improving size and erectile dysfunction. 

Lip sync..

Usually refers to a technical term for “matching lip movements with pre-recorded sung or spoken vocals..”

 

We think it should also refer to the procedure of rejuvenation of the ageing lip.

 

A previous blog called “ lips, camera, action! ” included lots of information about the ageing lip as well as technical information about relevant measurements.

 

Basically, as we age our lips become thin and they lose their curves. The upper lip flattens hiding the upper teeth, the lips turn downwards and the mouth descends, exposing the lower teeth. The result is a change in the smile.

 

As the mouth is the focus of the lower face, it is critical in the ageing process. Any treatment to rejuvenate or wind the clock back must consider the mouth.

We need to synchronise the mouth with the rest of the face, aiming for a more youthful harmonious result where nothing stands out.

 

Many patients worry about having a “trout pout” and basically a result that’s not in keeping with the rest of the face.

 

We encourage our patients to bring a photograph of themselves from 10-20yrs ago and use that as a benchmark for that individual. It is often surprising how adding a little volume and definition can improve the smile and make our patients feel like they want to use it!

 

So remember…  lip sync

Cosmeceuticals for photodamage

 

 

We (the royal we) are guilty of thinking that in winter we just need to apply a little more moisturiser. Harsh weather is after all quite drying.

But consider this.

95% of ultraviolet radiation (UVR) is UVA. This is the non-burning variety and as it has a longer wavelength than UVB, it penetrates deeper into the skin. It also travels through clouds (and glass) so we are fooled into thinking we don’t need protection when it’s overcast.

And as UVA doesn’t result in sun-burn, there are no immediate signs of damage.

UVA affects the immune protective function of the skin, especially ‘Langerhans cells’. It is also linked to formation of ‘free radicals’ which are linked to DNA mutations and cancer promotion.

We do actually have some natural defences for protection including the ‘cutaneous’ barrier, vitamins and radical scavenging enzymes. And the enzymes, including catalase and superoxide dismutase, do fare better in winter as they’re heat sensitive. But sadly we have less enzymes in the skin as we get older.

UVB is less an issue in winter, especially our winters with almost constant cloud cover. Do bear in mind that the winter sun will contribute to our long term UVB exposure which is linked with Squamous Cell Carcinoma and Actinic Keratoses. 

Sadly it doesn’t get easier as we do actually need some sun exposure due to our requirement for Vitamin D to prevent a variety of illnesses. 

I present a common scenario relevant to many of us. Some reference is made to trial evidence with references available on request.

 

A Caucasian (Fitzpatrick Type 2) woman in her 40-50s presenting with moderate pigmentation and sun-damaged skin who seeks improvement of her skin's appearance alongside her regular Botox and fillers treatment.

This lady, already receiving aesthetic treatments, is recognising the aesthetic (if not health) benefits to addressing sun-damage(photodamage). 

Most soft-tissue damage results from free radicals produced by Ultra-violet (UV) radiation exposure. Another contributory factor is Infrared A (770-1400nm), also responsible for generation of reactive oxygen species(ROS), induction of matrix metalloproteinase-1 (MMP-1) and hence photodamage.

This condition manifests as accelerated skin ageing with clinical signs including pigment change, lines and wrinkles, thread-veins, yellow complexion and leathery skin. Microscopically it is characterised by variable thickening in the stratum corneum, epidermal thinning, reduced glycosaminoglycan levels(resulting in dehydration of the dermis), reduction and fragmentation of elastin and collagen, and reduced basal cell division. 

While the skin has integral antioxidants to suppress free radicals, this function declines with age, often overwhelmed by levels of free radicals produced during UV assault.

In the skin, lipid biomolecules are most vulnerable to free radical attack and cell membranes, being rich in polyunsaturated fatty acids (PUFAs), are readily exposed to this process called “lipid peroxidation”. A biochemical process particularly responsible for photoageing involved glycation (attachment of glucose and ascorbic acid) of proteins including collagen and elastin with formation of Advanced Glycation End Products (AGEs). These AGEs are highly reactive in cross-linking proteins, an irreversible process responsible for deep wrinkling. Surely treatments reducing UV or Infrared exposure, and their effects, will benefit treatment and prevention of photoageing?

Retinoids

Having wide-ranging biological effects, been vigorously investigated for the treatment of photodamage, utility at therapeutic doses unfortunately is limited by associated skin irritation. 

Attempts to reduce irritation by esterifying vitamin A with fatty acids or other organic acids, such as palmitic acid to produce retinyl esters (e.g., retinyl palmitate) result in less effective products.

Alpha hydroxy acids(AHAs)

AHAs are used for many dermatologic indications. Their mechanism of action primarily involves reduced corneocyte cohesion (exfoliation) with effects including brightening through melanin loss, Glycosaminoglycan and collagen stimulation, therefore overall positive benefit on photodamaged skin. 

Chemically, AHAs are both acids and alcohols, but reactions where AHAs are reacted as “alcohols” are uncommon.

A group of women with grade 3 photo-damage or higher (Glogau Scale) were treated using a novel bioengineered retinoid ester, a conjugate of AHA(as the alcohol) with a lipophilic retinoid. Canfield VISIA digital imaging and investigator evaluation found significant improvements in photo damage.

Treatment of pigmentation is no longer commonly treated using hydroquinone due to the possibility of carcinogenesis in in-vitro studies. Arbutin, although safe, has quite a mild effect. Kojic acid, though mild and fairly safe, has fallen out of favour in Japan having demonstrated to have mutagenic potential. A new tyrosinase inhibitor deoxyArbutin(dA) was shown to have slight but significant lightening properties and improvement in solar lentiges resulted. 

Vitamin C

L-ascorbic acid (AsA, vitamin C) affects collagen synthesis, has antioxidant actions and inhibits melanin production by reducing o-quinones, with melanin not being formed by tyrosinase until all AsA is oxidized. Unfortunately, AsA is quickly oxidized and is unstable in water. A solution was found through the synthesis of the more stable magnesium-L-ascorbyl-2-phosphate (VCPMG)[7]. VC-PMG is hydrolysed in skin to AsA. 

VC-PMG was effective in lightening ephelides and normal skin.

Some photoprotection may result without penetration into the epidermis or the dermis, however to prevention photodamage of collagen and elastin and to effect collagen synthesis, vitamin C must penetrate the dermis. 

Coenzyme Q10(CoQ10)

As we age, there is increased induction of reactive oxygen species(ROS) due to altered mitochondrial physiology. CoQ10 is integral to the mitochondrial respiratory chain, its level declines with age and is also depleted by UV exposure. Supplementation for 7 days was shown to  result in a significant improvement in mitochondrial function. 

Genistein

This isoflavone from soybeans has oestrogenic, antioxidant and anticancer properties. A study using topical treatment on patients with fitzpatrick skin type II to IV 60 minutes before UVB exposure showed a protective effect from the treatment.  

Standard sunscreen plus antioxidant cocktail

A cocktail of grape seed extract, vitamin E, CoQ10 and vitamin C mixed with sunscreen(SPF30) were compared against sunscreen alone in a double-blind randomised study. Biopsy analyses showed the antioxidant cocktail offers significant protection against MMP-1 up regulation and therefore provides additional Infrared photoprotection.

Conclusions

It is generally accepted that gold-standard treatment and prevention of photo-damage includes daily sunscreen and night-time retinoids. Addition of cosmeceuticals including those detailed above may speed visible results. I believe the addition of antioxidants to sunscreen to be the most interesting finding particularly as it addresses the previously unknown Infrared A mediated photodamage. 

And as ever, it's better and easier to prevent rather than to treat.

 

Regulation in Aesthetic Medicine- past and future

 

Introduction

Aesthetic medicine is a term used by medical professionals to describe surgical procedures and medical treatments that aim to improve a person’s appearance or subjective well-being.[1]

Public appetite, celebrity endorsement and media fascination have helped cosmetic procedures, worth approximately £2.3 billion in 2010 in the UK, grow towards an estimated £3.6 billion by 2015. Social media and the internet take credit for the changing attitudes and resultant market growth. 

In the UK 6.5% of women had had cosmetic surgery and 45% wanted it.[2]

The Girls Attitudes Survey discovered that 25% were unhappy with their looks and 90% would change some aspect of their appearance.[3]

In 2013, 75% of all cosmetic procedures performed were non-surgical[4]. Subsequent estimates predicted this figure would rise to 90% by 2015.[1]

Health tourism has been an issue for some years, with 75000 UK citizens traveling abroad for cosmetic surgery in 2008.[5] Recently concerns have been raised that different regulatory standards within the UK may result in cross-border tourism for non-surgical cosmetic interventions (NSCI’s).[6]

 

Background

The PIP scandal has been credited with the change in public awareness to the risks of cosmetic treatments, this awareness accentuated by the lack of government regulation and inadequate self-regulation. In the immediate aftermath, UK patients were affected by a lack of insurance for removal/replacement, a lack of fully qualified surgeons to provide further surgery, and a lack of implant registry to inform or reassure women whether they had PIP implants.

More generally there were concerns regarding advertising, selling techniques, operative facilities and consenting procedures.

The non-surgical procedures were also highlighted as being in need of regulation, being subject to fewer restrictions than cosmetic surgery. Some of these treatments are delivered by nonregulated practitioners including beauty therapists.

The Medical Devices Agency, part of the Medicines and Healthcare Products Regulatory Agency (MHRA), is the Competent Authority in the UK for overseeing conformity of medical devices to European safety standards. It puts the onus mainly on manufacturers to ensure devices safety. Medical devices are awarded a CE mark of conformity by one of 80 independent european ‘notified bodies’ so they can be marketed and sold across the EU.

The MHRA first noted concerns about the PIP implant in 2008, 2 years after publicly reported concerns by surgeons. The Howe report exonerated the MHRA, saying they adequately dealt with concerns, reporting them to the inspection agency who eventually unearthed the scandal.[7]

What is noteworthy however is that the MHRA didn’t warn providers or the public until December 2011.

This compares poorly with French women who were immediately informed and advised to consult their surgeon, then later to have stringent surveillance, with implant removal if there was any suspicion of rupture.

In 2012, the french health minister planned an inquiry into failings of the EU licensing and inspection systems. Some would argue that while the French considered it a ‘scandale’, in the UK it was treated more like a scare.[8]

During the review process leading up to the Keogh report, stakeholders from all groups held the view that a new legislative framework was required to effect quality regulation.

Those having cosmetic procedures are often vulnerable and yet assume their provider has had specialist training, has appropriate insurance and provides aftercare.

The Keogh review [4] had key recommendations:-

High quality care

• New legislation should classify fillers as a prescription-only medical device

• The Royal College of Surgeons should establish a Cosmetic Surgery Interspecialty Committee (CSIC), its purpose to set standards for surgical practice and arrange formal certification of cosmetic surgeons

• Registration for all those performing cosmetic interventions

• HEE should develop accredited qualifications which should be tiered depending on the professional group and treatments concerned

• Re-establishment of a breast implant registry

An informed and empowered public

• The operating surgeon should take fully informed consent before the operation.

• The importance of development of evidence-based standardized patient information.

• Providers of NSCI’s should hold a record of consent.

• Prohibition of time-limited offers or financial inducements.

Accessible resolution and redress

1. The remit of the Parliamentary and Health Service Ombudsman (PSHO) should extend to cover the private healthcare sector.

2. Individuals performing cosmetic interventions must have appropriate professional indemnity insurance

 

Regulation

Regulation has become an instrument to solve a problem of a community seen to be, or which perceives itself to be at risk.

Effective regulation needs to manage actuarial, sociocultural and political risk. Actuarial risk management by regulation is evidence-led and quantitative, being more likely to avert future risk by ensuring appropriate, proportionate ongoing reform and compliance. Sociocultural risk management reassures a public that feels vulnerable, while political risk management prioritizes political legitimacy for future government success.[8]

The cosmetic surgery sector has already seen regulation take place as part of wider reforms, particularly the Care Standards Act 2000 which was enacted to better regulate private practitioners of aesthetic medicine[8]. Under the act, practitioners were required to either be on the specialist register or have undertaken relevant specialist training if they were practicing before 1 April 2002.

The act also stipulated that patients should be interviewed pre-operatively by the consultant and be given a pre-treatment cooling off period of 2 weeks before treatment.

The Health and Social Care Act 2008 emphasized the importance of consent, aftercare, sanitation and training. Individuals and employers providing surgical treatments, being already regulated by the Care Quality Commission (CQC), led to suggestions that this organization playing an inadequate role. Of note, the CQC doesn’t regulate non-surgical procedures.

France has already enacted legislative change, having reacted to healthcare scandals in the 1990s involving contaminated products. The Kouchner law (2002) devoted a chapter of the law to cosmetic surgery.

It has been argued [8], that the older Kouchner law was a much more thorough piece of legislation than the Keogh report and had already dealt with surgeon insurance, qualification and audit.

The french had also already addressed advertising, sales, consent, sanitation and to some extent, cosmetic medicine.

Before the PIP scandal, successive UK governments chose to ignore requests for stricter regulation of cosmetic surgery.[9] Private establishments were left to monitor surgical standards.

Before the introduction of medical revalidation (2012), doctors deemed themselves competent in a procedure. Although not perfect, medical revalidation provides an opportunity to strengthen cosmetic practice. A ‘Responsible Officer’ assesses a doctor’s competence and fitness to perform their current role, thereafter making revalidation recommendations to the General Medical Council(GMC)[4]. Nurses and dentists are introducing similar systems.

There are no current standards or accredited training for NSCI’s. Anyone may legally perform these procedures without qualifications.

Regulation should ideally begin by identify general training requirements. These then used to identify, for each professional group, which needs haven’t been addressed by prior training.

The following are considered essential points:-

• Training must ensure that practitioners can identify and manage complications of treatment.

• NSCI’s must be performed under the responsibility of an accredited professional.

• Anyone prescribing fillers or performing potentially harmful non-surgical cosmetic procedure should be professionally accountable.

• Practitioners must be centrally registered, with registration being subject to accredited qualifications, premises requirements, adherence to a code of practice and regular, annual appraisal.

Previous attempts to encourage cosmetic injectable providers to self-regulate were made following the Department of Health’s 2005 Cayton Review. “Treatments You Can Trust” held little interest for the providers.

Ultimately the UK government are seeking:-

• Safety

• A system that pays for itself / takes care of itself

• Reduced burden on the NHS (An increasing cost)

• Formal mechanisms for reporting complications

Regulation ensures political legitimacy and as such the regulatory endpoint must be robust against future scandal.

 

The Current Situation

Currently the Care Quality Commission (CQC) regulate independent clinics offering cosmetic surgery and laser lipolysis in England. NSCI’s are otherwise unregulated.

There is no formal regulation of independent clinics in Scotland. Health Improvement Scotland (HIS) has legal powers that relate to independent health care services through amendments to the National Health Services (Scotland) Act 1978 by the Public Services Reform (Scotland) Act 2010. These powers have not been commenced, and notably if they were, they would exclude independent nurse led clinics due to a requirement for the presence of a medical or dental practitioner[6].

The Scottish Cosmetic Interventions Expert Group (SCIEG) was set up in January 2014 to consider the requirement for regulation of cosmetic procedures following the publication of the Keogh Review. Their deliberations led to a desire for a ‘risk-based’ approach introduced in three phases. This will start with registration and inspection of health-care professionals.

Health Education England (HEE) exists to improve quality of care delivered. Mandated by the Department of Health (DH) to conduct a review of qualifications required for delivery of NSCI’s [10], attention was focused on the five main areas identified in the Keogh Report:-

• botulinum toxin injections

• dermal filler injections

• chemical peels and skin rejuvenation treatments

• laser, intended pulsed light (IPL) and light emitting diode (LED) treatments

• hair restoration surgery

They have presented draft education and training frameworks, providing indicative content, the consistent aim being to provide opportunity for all practitioners to attain necessary skills. HEE’s remit covers delivery of non-surgical, level 2 interventions.

Cosmetic surgeons don’t require specialist qualifications in plastic surgery, rather training in ear nose and throat surgery, eye surgery and plastic surgery includes aspects of cosmetic training.

The CSIC was created, it’s remit to cover invasive surgical procedures. This includes level 1a procedures potentially involving general anesthesia as well as level 1b, lower risk procedures.

 

The Future

Changes are imminent. The government has the appetite and, given the market growth, the public needs protection.

Surprisingly the DH doesn’t agree to statutory regulation of all cosmetic practitioners, rather “will look to strengthen standards through training and qualifications and how far supervision from regulated professionals can support self-regulation of the sector”.[11]

Meanwhile we await the Phase 2 report from HEE regarding recommendations for accredited qualifications and course delivery.

In Scotland, changes to regulation begin soon:-

Phase one- Beginning in 2016 involving the commencement of existing powers to allow inspection of independent clinics provided by regulated health-care professionals. Statutory arrangements for independent clinics and the capacity for Healthcare Improvement Scotland to receive complaints from the public will foster improvement in the delivery of high quality care.

This will also help align regulation in Scotland with that already in existence in England.

Phase two- Will focus on cosmetic practitioners without membership of a statutory register. While details have not been finalised, SCIEG are hopeful that a combination of UK-wide policy and compulsory local authority licensing will provide the best option.

Phase three- to consider options for additional health professional. e.g. Clinical scientists supervising or performing aesthetic laser procedures.

As already noted, a major concern is the lack of regulation of dermal fillers. Only some cosmetic surgery implants fall under medical device regulations. e.g. Breast implants do, while buttock implants and dermal fillers do not.

The European Commission Proposal 14493/12 of 2015 recommends that products with aesthetic or other non-medical purposes such as body implants and fillers should be regulated within medical devices legislation. Time will tell how the proposals and those of the review committee will be implemented in the UK.[12]

Interesting too the growing trend for “request for treatment” using Patient-centred Consent Forms. Demonstrating capacity and consent, requesting treatment while acknowledging risks and complications, all by the patient’s hand certainly puts the patient at the centre of their care.[13]

Melanie Latham, from a middle-of-the-road feminist perspective regarding regulation, opined-

“the type of autonomy I want to promote as a principle of regulation then is one that entails fully informed consent; constructive dialogue and counselling that builds self-trust and recognise structural oppression; professional self-awareness and ideally an institutional commitment to work against damaging social and cultural pressures”[9].

I believe this applies to both sexes.

Ultimately, while a plethora of guidance is available, guidance is not regulation.

 

Bibliography

1. Tan KBH. Aesthetic medicine: a health regulator's perspective. Clinical Governance: An International Journal. 2007;12(1):13-25. Available from: http://dx.doi.org/10.1108/14777270710725364 [Accessed 15/11/15].

2. Molina AR, Baker RH, Nduka C. ‘What women want’—the UK's largest cosmetic surgery survey. European Journal of Plastic Surgery. 2012;35(8):607-612. Available form: http://link.springer.com/article/10.1007/s00238-011-0635-5#/page-1 [Accessed 16/11/15].

3. Girlguiding UK. Girls Attitudes Explored- Role Models. Available from: https://www.girlguiding.org.uk/pdf/GirlsAttitudesExploredRoleModels_FINAL.pdf [Accessed 16/11/15].

4. Department of Health. Review of the Regulation of Cosmetic Interventions. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_of_Cosmetic_Interventions.pdf [Accessed 12/12/15].

5. Treatment Abroad. A world of medical opportunity:special report on health tourism. Available from: http://www.treatmentabroad.com/medical-tourism/a-world-of-medical-opportunity [Accessed 14/12/15].

6. Scottish Cosmetic Interventions Expert Group Report July 2015. Options for regulation. Available from: http://www.gov.scot/Publications/2015/07/2616/8 [accessed 3/12/15].

7. Howe FRPC. Review of the actions of the Medicines and Healthcare products Regulatory Agency (MHRA) and Department of Health. Department of Health. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216537/dh_134043.pdf [Accessed 18/12/15].

8. Latham M. ’If it ain’t broke, don’t fix it?’: Scandals, ‘Risk’, and cosmetic surgery regulation in the UK and France. Med Law Rev. 2014;22(3):384-408. Available from: doi:10.1093/medlaw/fwt033. Epub 2014 Jan 9. [Accessed 16/11/15].

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Cosmeceuticals- why should you consider them?

"My skin is fine! Right? I mean I drink my water, use high SPF when it's hot, and already use expensive cosmetics. And It's not like I'm exposed to pollution.."

 

It is true that generally taking care of your health and drinking plenty of water is the first step. 

But we should all ideally use light-protection daily, not just when the sun is bright (those rare occasions). 

And cosmetics, expensive or otherwise, only have an effect on the outer, dead skin layers.

And we are all, to varying extents, exposed to environmental pollution.

 

When you consult a doctor, he/she will advise on the best treatment based on their assessment.

Your skin type must be assessed, including how fair or dark you are (Fitzpatrick skin type), whether you have dry/oily/mixed skin, whether you have acne, scars, the extent of sun (photo)-damage and pigment. 

 

Everyone is affected by 'chronological ageing' as this is genetically programmed and unfortunately there's nothing you can do about it.

We should focus our attention on 'extrinsic ageing', which includes photo-aging, environmental pollution and cigarette smoking. Clearly we can protect ourselves at least partly from these factors. So avoiding intense sun exposure and cigarette smoking will help prevent (further damage)

Unfortunately everyone is exposed to pollution

Your lifestyle will also be considered in relation to how committed you can be to a particular prescribed regimen (sadly us men are notoriously poor at following directions!)

 

Ultimately cosmeceuticals are different from cosmetics in that they reach the living layers of skin and actually affect the behaviour and development of the skin.

Your doctor may also discuss (should discuss!) skin peels as a related topic as a way of adding to the benefits of cosmeceutical. 

And with an assessment and advice, you can make an informed choice.

#be_better