In the last decade or more, fillers have become increasingly popular for noninvasive rejuvenation of the face, with a subsequent increasing number of adverse effects reported with rise in their use in the scientific literature.  The most serious complications of fillers include vascular complications (VO) and blindness. But how common is the most catastrophic side effect of all, blindness in one or both eyes, and who is most at risk?  With increased education and posts on social media of the side effects of medical aesthetics, especially fillers, comes necessary and healthy apprehension among patients, who should rightly be apprehensive. Medical aesthetics, often presented by marketing as “just beauty” is anything but, and carries rare but serious risk as well as significant limitations, so it is absolutely important patients are aware of these.  To better educate patients, it is imperative that your clinician keeps up to date with the latest data and protocols, so in this blog post, I went over 3 main articles looking to answer 3 main questions:  How common is blindness from fillers?  Are there areas of the face most at risk and if so, what are they?  If someone chooses to have filler, what are some green flags when choosing a provider?  The 3 articles I used are listed below. A summary of their findings follows:  between 1905 and 2015 98 cases of blindness were reported globally the bulk of these were within 2010 - 2015 in 2014 alone, more than 5.5 million filler treatments were reported globally between 2015 and 2019, a further 48 cases of blindness/ vision loss were reported due to fillers  virtually every anatomic location where filler is Injected on the face is at risk for blindness     the commonest sites are: glabella nose nasolabial fold forehead         note all these structures are midline ie located in the middle of the face, almost in a straight line, where circulation is most vulnerable to blockage.  of the fillers that caused vision loss: fat transfer was most common culprit at 47.9% (and not dissolvable)  HA fillers accounted for 23.5% collagen, for 8.2% PLLA, a biostimulatory filler, for 3.1% Cahydroxyapatite, another biostimulatory filler, for 2.0% the last article referenced here is a case study of filler into the glabella(frown area), the highest risk area of all to inject due to its close location to two major arteries, the supratrochlear and supraorbital arteries.  The conclusions reached by the articles:  rising demand for fillers won’t be going anywhere anytime soon moving to full face rejuvenation also means that larger volumes of filler (or fat) are needed to achieve desired results (even if you are open to face/neck lift, the only solution to volume replacement is with fat or filler) concern that non expert injectors are injecting fillers without adequate understanding of facial anatomy, increasing risk of complications while the outcome can be devastating, in experienced hands the risk is still very very low. conversely, when vision loss does occur, outcomes are almost unequivocally poor with no clear protocol or evidence base for their management.  the highest risk areas for vision loss again: glabella (frown lines)  nose nasolabial folds (smile lines)  forehead So what are some mitigating factors you can use to stay safe if you decide to undergo full face rejuvenation with fillers?  check your clinician’s qualifications check their protocols in the event of any complications - anaphylaxis, vascular occlusion, followup and vision loss check they have backup plans in place in the event of a disaster  If the idea scares you too much, it is perfectly reasonable not to have any fillers at all as long as you understand  that volume replacement is not possible without fat or fillers. After all, none of these treatments is medically necessary and you should never feel pressured to proceed if you are undecided, nor should you ever pressure your clinician into a treatment they do not feel is best for you.  At Skin Essentials, Dr Joshi does not inject the glabella at all, and will only undertake highest risk areas such as forehead, nose and nasolabial folds in patients she has known for some time, and when it will make a significant difference to their outcome AND they understand the risks. These are not areas to undertake at a first consultation nor without a standing relationship. We take your safety, and our own, very very seriously.  Did you know of these high risk areas?      Sources:  1. Dermatol Surg 2015 Oct;41(10):1097-117. doi: 10.1097/DSS.0000000000000486. Avoiding and Treating Blindness From Fillers: A Review of the World . Literature 2. Aesthet Surg J 2019 May 16;39(6):662-674. doi: 10.1093/asj/sjz053. (Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature) 3. https://doi.org/10.1016/j.ajoc.2022.101407 Ophthalmic artery occlusion after glabellar hyaluronic acid filler injection

I post a lot about safety with medical aesthetics, adequate experience and qualifications as well as aftercare protocols with the clinic you choose.  Why does this matter? I was in a surgical training program between 2002-2011 and did it full time for most of those years. Practice and training absolutely matters and cannot be disregarded.  At the same time, there are some common myths I hear all the time, and because I post about vascular occlusions to help raise awareness, it often puts people off, including some of my own patients. As always, it remains absolutely optional, but it is hard, if not impossible, to rejuvenate volume loss in a face without volume via either fillers or fat. So if a patient is adamant they would not consider fillers for volume replacement,  realigning expectations may be needed.  In saying that, when I hear people say they’d only consider fillers to certain parts of the face due to risk in other parts, I feel it is my job to correct medical misinformation, same as when medical aesthetics is passed off as “just beauty” with no risk.  So what do statistics and the evidence tell us?  For an indication, I looked at a recent article published in the dermatological journal JAMA Dermatology 2021; 157(2):174-180 The authors conducted a study looking at outcomes among a chosen cohort:  370 dermatologists followed for a year between August 2018 and August 2019. average experience between them was 22 years in practice Between them, 1.7 million syringes of filler were injected.  Their findings in summary:  1. The risk of vascular occlusion (VO) using a needle or cannula was 1: 5000 syringes used.  Overall risk using a needle was 1: 5410/syringe  Overall risk using a cannula 1:40882/syringe The authors emphasised that the choice of use of needle or cannula is nonetheless clinician dependent, and based on their experience, the area being injected as well as the anatomy of the patient.  2. VO can occur at any part of the face. Some areas are considered higher risk but no part of the face is no-risk eg lips, as many commonly believe  In this study, lips and the nasolabial folds (nose to mouth smile lines) were the most likely areas to be occluded. Highest risk areas include filler around the mouth, the nose, the frown lines.  3. Participants with > 5 years of experience had a 70.7% lower risk of VO than those with less experience.  By ten years of experience, this risk had evened out.  Risk of VO twice as high in someone with < 5 years experience.  As we know with surgical training, repetitive practice leads to fewer complications over time.  4. 85% of VO had no longterm consequences  Most VOs, if caught and treated in time, did not lead to any longterm problems such as scarring or deformity.  5. Highest rates of VO at lips and nasolabial folds  A common misconception is the notion that lips are low/ no risk and that risks of fillers, including of blindness, which is rarer still, is only with filler to the rest of the face. In practice, the literature indicates that lips are among the most common areas to have VOs.  6. Highest level of severity at the forehead  The riskiest areas to inject remain the areas around the lips, the nose and the forehead, and so it makes sense that if this happens, the highest likelihood of complications from a procedure is injecting these areas, especially the frown.  Take Home Message?  Experience trumps almost everything else, and the overall risk is still very low of a VO, and of blindness even lower but more catastrophic. Experience does not simply mean someone who has been doing this for 5 or more years, but also, in my opinion, someone who is safe, and has protocols in place, with followup and aftercare for more risky procedures so that nothing major is missed, and someone who can open the clinic up at 2am for you on a Sunday if needed.  So please, choose wisely. Price should not be your main determinant, and it’s better to have no treatment than to risk it with an inexperienced clinician. As I always say, medical aesthetics should be reassuringly expensive because it’s your face and side effects, while rare, can be catastrophic.  Source : JAMA Dermatology 2021; 157(2):174-180 doi:10.1001/jamadermatol.2020.5102

This question is a regular via email and DMs on social media. Sometimes people also send us selfies to help with the quotes. Prospective patients may be asking about specific treatment options such as injectables - anti wrinkle treatments and dermal fillers - or skincare or fat dissolving treatments. The short answer is, it depends. As an AHPRA registered professional, I cannot conduct consultations via DMs and even emails until we have established a therapeutic relationship with you that must be documented. Even after we have met in person, much as you’d expect with other doctors, it is not possible to provide ongoing regular advice via emails or text messages. AHPRA specifically requires us to maintain an appropriate doctor-patient boundary that is meant to safeguard you, and us. This is why unless it is a quick yes or no answer or we have planned a followup, most replies will result in brief advice and “please book another appointment if you wish to discuss this further”. As to the rest - how much is it likely to cost and how much should I budget? The answer to this, truly, is “it depends”. What factors might play a role? 1. Your age   The younger you are, the less ageing related changes and the less outlay needed to begin to address the concern at hand. Whether that is acne, or pigmentation or volume loss in the face or even lines and wrinkles. 2. Your basic genetics Not all of us will age the same. Our ethnicity as well as lifestyle factors and other medical history (or lack thereof) will play a significant role in how we age, as will our basic bone structure. 3. LIfestyle factors By now we all know, I hope, that chronic sun exposure, even if unintended, can have a lasting impact on how your skin will age, including lines and wrinkles, pigmentation, faster collagen depletion and volume loss. The WHO estimates that as much as 90% of skin ageing is due to UV exposure. Add in factors such as smoking and these will add up quickly to more work needed just to begin to undo some of the damage. The Initial Consultation The initial consultation is where we meet and begin to address some of these and other factors, in conjunction with your concerns. We take a medical history of not only your health, but any illness, medications as well as prior aesthetic work which may have an impact on future work.  We take baseline pictures of your face at different angles and then we assess your concerns together - what they represent, and how and IF we can address them. We discuss what can be improved non surgically, what needs surgery if you can budget for it and what cannot. At this stage, I can give you a pretty good idea of what your concerns mean, and how I can help, the timeframe needed and degree of investment required, both of time, frequency and money so you can decide whether you want to proceed or not. Due to my training I tend to approach everything as a continuum - what can we do now, in the medium term and then longterm and how they can all build on each other to give you the best possible result if you stay the course. My goal, always, is a longterm therapeutic relationship with my patients because we know that gives best results.  At our initial consultation, I can also more acccurately guide you as to “how much” in terms of quantities as well as costs and timeframe. As a guide:  anti wrinkle treatments, if begun in your late 20s to early 30s when you begin to see faint lines present at rest, may need slightly lower doses compared to starting at a later age, when lines are very visible even at rest and will take continuous treatment with higher doses to begin to fade. If you stop, lines and wrinkles will gradually reappear over time.  with dermal fillers to replace volume loss, every face is different but as a guide, a minimum of 2 mls in your 20s, 3 mls in your 30s and so on. If you have a slim build, you are likely to need much more. If you look gaunt already, you will need more than this. with biostimulator fillers, and most skin therapies, there is an initial series of treatments in close succession for best results eg a session every month for 3 months, then maintenance every 6-12 months. skincare is ongoing and lifelong, beginning with the best and cheapest option of all, daily sunscreen. If you stop, your skin will gradually revert to your pre treatment state.  When we meet, I am assessing your face not only in still photos but also in animation because this is where many people go wrong - they may look great in selfies but “wrong” when animating if overfilled or overtreated. All this planning and execution takes time, attention to detail and education. It also needs a realistic discussion about your willingness to commit and to budget because you will not get best results if you are likely to struggle to remain consistent. For this reason and many more as well as the medicolegal concerns, my opinion is that it is always a good idea to invest in an initial consultation with an open mind to understand what your concerns mean, and how they can be helped, and then to decide if you want to invest in the treatment options so as to avoid shortchanging yourself. Our price guide is regularly updated, but should give you some idea of how much you can expect to spend - the more concerns you have, the more significant the cost initially. I always say to patients it is like buying a car - there is a big upfront cost, then servicing is more manageable to keep it all running smoothly.  No two faces are the same or have the same

Ok, so we’ve been getting a lot of enquiries about biostimulatory fillers, and we wrote a post on one of them here. Here is the other one on offer here at Skin Essentials, also known as calcium hydroxyapatite. What do you need to know about it to help you decide if you might be a candidate for it? Here is some initial information :  FDA approved since 2006 versatile biostimulatory filler to restore volume loss and improve lines and wrinkles also the only FDA approved injectable to date for use for rejuvenation in hands like other biostimulatory fillers, NOT reversible (so choose your clinician wisely)    How can it be used?  1. As a straight out filler, for cheeks, jawlines and more, where it has among the best ability to volumise sunken faces.  2. Diluted, in a ratio of 1:2 or higher, as a “wash” under the skin, to improve fine lines and wrinkles, crepiness, acne scars and even cellulite. Used this way, it can be used for overall subtle rejuvenation of the face, neck, hands, arms, abdomen and buttocks to improve skin quality by inducing collagen without adding volume.    So how does this filler work?  unlike hyaluronic acid fillers, the base material is calcium hydroxyapatite which stimulates collagen induction offer time. like HA fillers, CaHa works immediately to provide subtle volume and improvement to the treated area and over time, as the gel carrier is absorbed by the body, it stimulates your own collagen which lasts 18-24 months. used as a hyperdilute wash, this improves texture of skin where it is injected including in areas affected by chronic sun damage such as the face, neck, chest and hands.  Are there any side effects?  As with any injected medical procedure, commonest side effects include bruising and swelling and temporary lumps and bumps.  There is minimal aftercare unlike with the other brand of biostimulatory filler and I’d suggest 2-3 sessions in total a month apart for the initial course and then annually to maintain.  How much are you likely to need?  This filler comes in syringes of 1.5ml usually. Depending on the part of the body being treated and whether it is used diluted or undiluted will make a difference how much is needed.  Here is a guideline as to number of syringes needed, though the consultation is designed to address this with an accurate quote as well as detailed informed consent prior to proceeding with treatment (usually on another day unless time permits).  face and neck - usually a single 1.5ml syringe each per session hands - usually a single 1.5ml syringe for both hands, diluted to 3mls total buttocks - 1 syringe per cheeks for cellulitis and sagging skin (not for non surgical BBL which is much more) thighs - 1 syringe per thigh area (inner or outer) abdomen - minimum 2 syringes arms - usually 1 syringe per arm  2 sessions are initially needed for any given treatment area, spaced a month apart then repeated 6-12 months for maintenance and results last upto 2 years. 

Biostimulator fillers seem to be on the rise and gaining popularity rapidly. We are seeing many more enquiries for these fillers compared to years gone by, including from patients prepared to travel some distance who want to have the initial consultation and treatment on the same day, especially with poly-L-lactic acid. Due to Australian AHPRA regulations, we are not permitted to use drug names here. Invariably, the answer to consultation for a new patient and treatment on the same day is a no. Why is that, especially if they are coming from some distance? Read on to find out! There are two main brands of biostimulator fillers on offer at Skin Essentials, brand S and brand R. The one we are discussing here, is brand S  The aging process catches up with us all eventually, as seen in the loss of skin elasticity, sagging as well as (deep) lines, wrinkles and seemingly enlarged pores. The bulk of these skin changes are due to progressive collagen loss over the years:  we begin to lose around 1% of collagen production from our mid 20s for women, the menopausal process accelerates this through loss of oestrogen, with an estimated 30% collagen loss over 5 years thereafter, collagen loss continues at an accelated rate in women at 2% per year by age 70, it is estimated we’ve lost 80% of our collagen producing capabilities  So in addition to bony changes with ageing, most prominent around our eyes, our jawlines and around our mouths, thinning and sagging skin due to collagen loss over time contributes in large part to the loss of youthful glow in most of us.  This is why, beyond volume replacement, rejuvenation and maintenance should rightly shift to collagen induction and maintenance of healthy, supple skin in a variety of ways.  So what is this brand of biostimulatory filler and how does it work?  1. Full Face Rejuvenation  it is an injectable powder that is made up to form a solution that is injected into the skin where it stimulates collagen production it is usually an initial series of 3-4  treatments a month apart results are gradual, from around 6 weeks, look natural and last longer than most other injectables, as it is your own collagen. In studies, results lasted at least 25 months by inducing collagen production, this product works to restore some of the underlying structure of the face/ body that has become gaunt due to significant volume loss and improves skin radiance by thickening skin quality the added fullness, over time, improves the appearance of fine lines, wrinkles and folds. Bony areas can be softened and gaunt areas of the face, such as under the cheeks, and temples, can be rejuvenated also.  2. No PillowFace  the initial course recommended is 3-4 treatments a month apart over areas of the face that need the volume and skin improvement thereafter, maintenance is recommended with a single session annually unlike hyaluronic acid based dermal fillers, which can look overfilled, this is not possible with biostimulatory fillers, which can only stimulate your own collagen production, done well  3. Long Lasting Results  in studies, treatment with biostimulatory filler lasted at least 25 months, and likely longer. because it stimulates your own collagen production, with care to protect and maintain this collagen, the results are much longer lasting than many other treatments.  4. Low Maintenance Treatment Option  initial treatment is a series of 3-4 monthly sessions with a significant cost depending on how many vials are used thereafter, maintenance is a single annual session this is a great option for the face, crepey skin in the neck as well as décolleté and hands    Sold? Great, so why can’t you have it on the same day as the consultation, especially if you’re already familiar with it via Google?  1. Adequate informed consent is key  Results depend on the injector and their skill but no outcome can be guaranteed as the medication relies on your collagen induction powers AND your compliance with instructions  training for biostimulator fillers is not as common as with hyaluronic acid fillers. they’re also more expensive than hyaluronic acid fillers, especially for the initial course of treatments in terms of time commitment, consistency and budget this is not a treatment to be having with a new injector (or a new patient whom I do not know well)  2. Biostimulator Fillers are not reversible  unlike hyaluronic acid fillers, which can be reversed in the event of an adverse outcome, all biostimulatory fillers are not reversible in the event of an unexpected side effect or if you do not like the result  3. There is some aftercare needed and some side effects are reliant on aftercare  with this biostimulatory filler, I advise people to massage the treated area 5 times a day for 5 minutes, for 5 days, firmly. I show them how to do this to distribute the filler evenly among the tissue where it was injected, unlike with hyaluronic acid fillers lack of attention to this, rarely, may lead to nodules that need to be surgically  4. Results are gradual, over months  patients need to understand this they need to commit to the initial 3-4 sessions monthly and budget for it as delays will lead to a suboptimal result they need to understand aftercare and commit to it to minimise risk of adverse outcomes  5. It needs preparation prior to injection because it is prepared as a powder, it needs to be diluted and prepared with adequate mixing at least 24 hours prior to injection, preferably slightly longer. at Skin Essentials, this usually means that we spend our time in consultation addressing your concerns, assessing your suitability for it, and then talking you through what is involved including aftercare and then giving you some time to think about it and decide without any pressure. should you decide to go ahead, you’ll be required to pay an upfront non refundable deposit of 50% of the cost of each session before we start preparing

Injectables! Despite the booming popularity of these office procedures, there are many people who are still new to the choices available, and who may enter their 30s, 40s and even their 50s, having never had a needle near their face. On these occasions, I like to allow for enough time to address concerns, answer questions and sometimes, manage unexpected anxiety that may rear its head as they get on the treatment bed. Some say to me “I was all psyched up, ready to go, when I booked and signed the consent form, but now I’m having second thoughts…” Why these second thoughts? At Skin Essentials, we mail out as many of the relevant forms to you prior to your appointment to fill out as possible, to maximise your allocated appointment time in clinic with your treating doctor. So common side effects we warn you about: bruising swelling temporary headache (with anti wrinkle injections) lumps and bumps (with fillers) asymmetry (fillers and anti wrinkle)   Additionally, we talk to you about rarer side effects and some medical emergencies, so it is no wonder some patients, on reading consent forms, begin to worry.  Informed consent is an important part of any consultation and not something to be simply rushed into. Equally, it helps you prepare to minimise the chances of adverse effects on the day. Having said that, how can you present to your appointment and have the best possible outcome? 1. No makeup means no makeup. Patients will often present with a full face of makeup, or “on my eyes since you’ll be treating my cheeks” etc. For anti wrinkle, it is less important than fillers, which are semi permanent implants, but an absolutely clean surface is vital to reduce risk of contamination of equipment and minimise risk of not only infection but also nodules down the track. This is non negotiable for me, not to mention makeup affects the quality of the pictures we take for our records and makeup removal especially of layers, can take up precious time in clinic. 2. Hair tied back or off the face Another big thing. Taking pictures before and after procedures is part of the process and hairstyles and hair in the face can affect results so it is imperative that hair is held off the face, and that you come with suitable hair bands and ties to do this, and during the procedure also. 3. Please avoid any supplements and medications as well as social drugs that may increase risk of bleeding Common culprits include Vit E, ginseng, fish oil, ginkgo biloba and some medications such as aspirin and ibuprofen. Also, alcohol. All of these will increase risk of bleeding and bruising. 4. Please plan to go home after the procedure and ice the area treated Patients often plan their treatments just prior to a lunch meeting, or a shopping date, and while with many minor procedures this is fine, if we are doing a fair bit in one go, it is safer to simply go home and to keep icing the area for best results and to minimise bruising risk. 5. Please don’t plan to exercise or get a facial or a massage immediately before or after your appointment Lying face down for a massage or having a facial may move freshly injected medication to an unwanted area, so these procedures are off limits at least for a day or two. 6. Please plan your injectables at least 2 weeks before any big events such as birthdays, weddings and more. Some of this is logistics - it takes anti wrinkle injections anywhere from 3-5 days to begin to kick in and to peak at 2 weeks. Fillers can take 2-4 weeks to settle and lumps, bumps and some asymmetry are common. Likewise, bruising is a common and well known side effect of all injectable treatments, so please plan these at least 2 weeks prior to any big events. 7. Please plan your appointment at least a week prior to any planned trips and flights away I like to have patients around for at least 2-3 days post treatments in the event that there is an unexpected and serious side effect. There are limited options to help if you are interstate, or worse, overseas. 8. Keep your mind open and your expectations realistic This is a big one. Please be guided by your clinician as to what is possible with your unique anatomy rather than insist on what you have seen on social media, complete with filters and photoshop. The face is a highly mobile area of the body, and subtle changes can make for big impact, but only if done well. Have an idea of what you’d like, but be willing to listen to your provider and take their advice on board if it is not possible (or out of your budget). What else would you add? What else would you wish to know if you were to consider injectables? 

Cosmetic injectables are on the rise, we see them everywhere we go. In a recent blog post I summarised the FDA meeting from March 2021, noting that adverse effects from cosmetic injectables are on the rise, in part due to their rising availability, often by less experienced injectors and related to this, failure to recognise adverse events when they do occur.  Nonetheless cosmetic injectables are a billion dollar industry, and the marketing is slick and everywhere.  They're in every mall, on every corner, advertising with big signs "injector in clinic today, complimentary consult!" So you go in, and your venture into the world with your first ml of dermal filler, most commonly, lip or cheek filler for most people. You are sent home, and told bruising, swelling and some discomfort are normal and it'll all settle in a few days. So when should you worry if it is just bruising or something more? Some basics first: bruising is almost certainly guaranteed anytime skin is penetrated by a sharp object, usually needles  swelling as a side effect of the bruising is also likely, with some asymmetry that is usually temporary (unless it is pre-existing)  some parts of the face are more prone to bruising. Common areas include the delicate area around the eyes, and the lips, among the most common areas to treat with injectables, both anti-wrinkle treatments as well as dermal fillers.  So how do you know what is normal and when to worry?  Vascular Occlusion ie VO due to cosmetic injectables occurs when filler is inadvertantly injected into a blood vessel instead of in the surrounding tissue. This can lead to complete or partial blockage of the vessel. this is usually immediate if complete blockage, but may be delayed due to some other factors  So what signs should you be looking for to indicate a VO bruising? Pain  Severe pain is sometimes experienced at the time of injection, but it is not always a given. The use of numbing cream or injected local anaesthetic may mask this symptom if used, so may be less reliable until it wears off some hours later. Worsening severe pain during treatment or in the hours following treatment, especially if one sided eg one cheek or one side of a lip, is a possible sign of a VO versus just a bruise, requiring an urgent review.  Blanching With compromised blood supply to areas downstream of the injected area, a change in colour of surrounding skin is common, and may vary from white, to pale, or dusky depending on what is happening. This colour will persist and not respond to massage or heat or warmth and with progression may look more like a lacey doiley.  Discolouration  Discolouration of the skin is usually several hours following treatment if it is not picked up earlier as skin begins to accumulate blood that cannot flow and which does not have enough oxygen, leading to a dusky, purplish hue and eventually, blue-grey appearance of the skin. It may resemble bruising, but bruises do not discolour on pressure, while this will if your clinician has shown you how to look for this (I routinely do, especially if injecting high risk areas or new patients).  Coolness  With compromised blood supply to an area of the skin, the skin begins to cool down over time, and this may be appreciated by comparing warmth in nearby skin versus compromised skin (hard to do if you are not trained).  Skin Death  This occurs if the VO is not picked up, usually around 2-3 days post injury. The compromised skin has begun to die due to lack of nutrients and oxygen downstream from the blocked vessel. At this stage, it is still not too late, though some skin may not survive and repair may take weeks to months compared to if picked up sooner.  So should you simply avoid all injectables?  The aim of this educational blog is to illustrate the following points:  medical aesthetics is not just beauty, which works on the surface of unbroken skin. Once skin surface is broken, it is medical territory with attendant risks.  all medical procedures are a risk : benefit analysis and you should rely on your treating doctor or clinician to educate you on your options and risks, which must necessarily include doing nothing at all, and not proceeding if you are too worried/ afraid or want no risk.  your choice of clinician is your insurance in the event something does go wrong despite all due diligence, so choose based on qualifications and experience not on price.  your aim, as with any consultation you book with a doctor, should be to go in to be informed and to be educated, not to be sold to, and not to be treated irrespective of whether the treatment is right for you. Pay for the expertise and service of your clinician, so you can make the best and safest decision for you, not just on the day, but also longterm.           

Following the publication of my post on cheap cosmetic injectables for Mamamia last weekend, I’ve been inundated by questions from people I’ve never met on social media, asking about the safety of injectables and specifically, of dermal fillers. One person said she’d been considering fillers to her lips and cheeks, but is now worried and scared and “How can you avoid getting a vascular occlusion? Is getting fillers in lips and cheeks ok?” As I do always, I encouraged her to seek a qualified and experienced cosmetic injector and to ask about their setup for recognising and handling a complication should it occur. It did get me thinking though, about how weekly now, we are seeing “botched” injectables on social media, not just dermal fillers, but also antiwrinkle treatments, and awareness is rising, but many people still seem unaware of what can go wrong, and equally, what that might look like because with rising awareness, is also rising anxiety which is good to some extent, and beyond a point, unhelpful.  Here is an image of the face, with a simplified drawing of the facial artery, which supplies the face, and its branches with focus on the area around the mouth, among the commonest areas that dermal filler is requested for and competed on.    When I did filler training (it was a weekend course over 2 days) years ago, we each injected 1/2 a side on a model eg 1/2 a lip or 1/2 a cheek under supervision. I was horrified at what could go wrong, and how, after this 2 day course for doctors, we were essentially given permission to go out and do dermal fillers, limited only by (in my case given my surgical background) common sense and a healthy fear of what could possibly go wrong. So how does a vascular occlusion occur? A vascular occlusion (VO) occurs when blood is no longer able to pass through a vessel. It may be a complete blockage or a partial one, causing a reduced blood flow to the parts of the body downstream from it.  A VO may be caused by many things, but in the case of aesthetics, it is most commonly caused by the accidental injection of dermal filler into a blood vessel. If left untreated, a VO of a blood vessel supplying the skin can ultimately lead to skin death due to loss of blood flow to it.                How common is vascular occlusion?  The reported rate of VO for all dermal fillers is thought to be around 1:100,000 cases, however it is widely understood among practitioners that this is likely widely underreported for the following reasons:  the rate of complications is rising rapidly and we do not have more recent numbers  increased popularity and the procedures being performed by less experienced injectors  many are underreported and if only partially blocked, may not show up with typical symptoms, or may be missed and therefore underreported, skewing data A summary by the FDA following a panel meeting on dermal fillers on March 23rd 2021 had this to say:  we all worry, and rightly so, about the highest risk areas for blindness from dermal fillers : the nose (41%) the cheeks (15%) smile lines (11%)and frown lines (10%)  what was new information to many of us was that the areas for highest risk of non-blindness related VO were as follows:  lips (38%) filler injections around the mouth ie smile lines (18%)  What does this all mean?  The report from the FDA, which is likely reflective of the state of most countries, shows that serious injury reports from the use of medical devices ie dermal filler have steadily risen, from 94 cases in 1996 to 1146 in the USA in 2020, a total of 10,325 cases between 1996-2020.  Keep in mind, these reports are in one country, and are assumed to be underreported because of the number of cases that go unnoticed or missed unless they cause serious and severe adverse outcomes.  So what is the take-home message?  safety first what are your injector's qualifications? how many years of general medical experience do they have before they ventured into medical aesthetics? do they know how to recognise an adverse outcome? are they contactable for the first 24 hours or so after a treatment which is when most VOs will present? can they seek help in a timely manner especially if unable to prescribe the antidote themselves, and reliant on a prescriber to do so?  You would, I hope, never consider getting surgery, even minor surgery, from someone who was not adequately qualified and experienced and did not operate from clean and medical premises. The premises themselves, is your assurance of the kind of care you should be expecting, so why would you compromise that with medical aesthetics and injectables, or anything that punctures the skin barrier such as many skin therapies?  Safety should always be first for you, and your treating clinician and if they cannot adequately reassure you, then you should not be going ahead.  As someone who has seen poor outcomes, they can often be harder to undo when I don't always know what was done, what was used, and how much of it was used. These are all medical procedures, and as a doctor, I have a duty of care to each and every one of my patients to educate them, consent them to the best of my ability and their understanding and to say no if I do not feel their expectations are realistic. After the procedure, I have a duty of care to manage any emergencies that arise in a timely manner and to see them through until resolved even if that means referring them on to someone else.  These are the basics every medic learns around patient safety and should be your assurance even if something goes wrong, since medical procedures can never be guaranteed. So please, choose wisely, choose someone qualified and experienced who can

There is a saying, "young bodies are slim, but young faces are full of fat."  This begins to change as early as our teens and our twenties.    When we're young, fat in the face is evenly distributed in the forehead, temples, cheeks, and areas around the eyes and mouth. With age, that fat shifts downward, so features that were formerly round may sink, and skin that was smooth and tight gets loose and sags. Meanwhile other parts of the face gain fat, particularly the lower half, so we tend to get baggy around the chin and jowly in the neck. It is this very look that brings many distressed patients into clinics such as mine and all over the world because we see this in the mirror before we reach for concealer, makeup and more.  While there are some who are happy to be proud of the ageing process and all that it brings, I obviously see a slightly skewed population that is wanting to slow the process down as much as is feasible, for a variety of reasons.  Most patients, while we acknowledge we must all age, do not like, nor embrace necessarily, some of the changes that are inevitable with the ageing process. Most of us, are not looking to fool anyone; we are not aiming to look like mutton dressed as lamb, nor to fool anyone about our real age. What we are attempting to do, is to age well. To do so gracefully and in a way that still has us mostly liking what we see in the mirror, well into our 50s and 60s if not longer.  It is like the difference between ageing without caring for our bodies - by not exercising our bodies and minds, by remaining active, by being mindful that in our 30s and 40s and beyond, we are merely halfway through a long life, (most of us will live to our 80s) and that the hallmark of a good life, is one that is filled with quality over quantity. What this quality means, varies by person. For many of us, who will work till well into our 60s and 70s, it means presenting the best looking version of ourselves to prospective clients and patients; looking vital, fresh, and capable. So what happens when predictable changes to our faces give lie to the way we feel within, which, thanks to science and modern medicine may be a decade or more younger?  I get patients occasionally, well into their 60s and 70s, who continue to work, and who want to invest in their faces and skin to some degree because they recognise that when they look tired and haggard, it affects the way clients see them, as being less than capable. So what are some early signs that our faces are ageing, that we can focus on if we want to proactively work on this to be our most productive selves for as long as we desire? Some caveats first:  the longer you leave it, the more time, energy and money you will need to begin to rectify some of it.  at around 50, with few exceptions I will explore someone's willingness to consider a face/ neck lift because if they are willing to tolerate the downtime and have the budget, this may be best especially if they do not have significant volume loss but largely sag.  in the absence of willingness re budget/ downtime, we explore other options but my general advice then tends to be: the longer you leave it, the older you are when you begin regular, consistent care, the more time, energy and money it will take, and it will almost certainly be more invasive treatments.  1. The area around our eyes. Among the first signs of ageing may be ageing around the eyes, which may lead to a deep or sunken look giving us a chronically tired appearance as early as our teens. If we also have skin of colour, this can exacerbate the appearance of dark circles, giving a suggestion of someone who never seems to get enough sleep, which, together with unsolicited comments, can be distressing for many people as early as their 20s.    In youth, this may be an easy enough issue to fix, with some dermal filler, but it gets trickier with age. With age, the bony eye socket begins to get wider and loses its height, leading in some people, to deeper eye sockets, more sunken-in appearance of the eyes and even bulging of some of the fat around this area. At this point it may be hard to fix with just some dermal filler, which may make matters worse and a more multi-faceted approach is needed over some sessions in discussion with your clinician.    2. The area around our nose and mouth.  While the nasolabial folds, ie the smile lines from our nose to our mouth are normal most of us do not begin to notice them or to be bothered by them until they begin to look like deep grooves on either side of our lips. When this occurs, there are usually several causes for why this might be occuring, best assessed with a face to face initial consultation, but among them, may be the recession of the maxilla, the bone that forms the support for the upper lip and teeth and surrounding area of our faces. With age again, this begins to recede, leading the skin around the upper lip to lengthen, the lip itself to fold into the mouth a bit more, lengthening this area in a way that can be ageing, and more prominent nasolabial folds due to diminishing bony support.          Loss of bony support here can also cause sagging and pooling of skin around the lower face, causing a more boxy appearance to the lower face.                3. The broken jawline.      Lastly, let's talk about the jowls. It seems almost

There is a recent trend of famous actresses and models embracing ageing and encouraging other women to do likewise. It is refreshing, certainly far more so than the famous women of similar vintage claiming all they use is olive oil. We now have some famous and beautiful faces that are showing us firsthand what ageing in our 40s and 50s can look like, if we simply allow nature to take its course: Paulina PorizkovaSarah Jessica Parker to name a few. It is certainly brave of these women and others like them to do so, especially in an industry where looks are seemingly everything. At Skin Essentials we don’t believe in defying ageing, or helping patients look like mutton dressed as lamb, rather we recognise that ageing is a disease, a decline in our bodies and our skin, that over time, for many of us, can also affect our self esteem, our morale and especially if we are working, how others see us. For us, the aim and goal is always a holistic approach to ageing well, whatever that may look like for each individual, man and woman, though our society disproportionately places a heavier emphasis on women than on men to look ageless forever. With that in mind, I though I’d do a case study on some famous faces and their aging process in their 50s, which is the decade of peak decline for most women, if nothing is presumably done. Caveat - as actresses and models, each of these women had stunning bone structure in her youth to begin with, which offsets a lot of the signs of ageing in our 40s and 50s - high cheekbones, strong chin and jawline, when most of us begin to notice sagging and jowling as early as our late 30s if our lower face is not strong and well defined. Sarah Jessica Parker 56       At 56 the actress is openly and freely embracing the ageing process and good on her!  Note - she has a strong side profile to begin with and being always slim, she never really developed any significant jowling, except where the skin has sagged due to 3 factors:  - bony loss - around mouth, including chin and angle of jaw; around orbits of the eyes - fat pad loss and movement downwards  - ligament laxity due to loss of support  - hooding of her eyes in part due to bony loss around the eye sockets but I also suspect, due to drooping eyelid skin  Many of these are amenable to tweaks not to hide the fact she is 56 but to help her appear less tired and grumpy, what I refer to as “negative signs”. The signs in an ageing face that elicits unwanted comments about looking tired, sad, angry and may lead others to see us as being untrustworthy.  Paulina Porizkova 54  A supermodel with impeccable bone structure as evident in her youth, the perfect heart shaped face, she continues to wear it well into her 50s, with only noticeable changes due to her bone structure. Paulina is another one ageing naturally and she does it well!  In fact, barring anti wrinkle treatment, and skin therapies (which she takes up consistently to improve skin structure and quality) her bone structure will likely continue to carry her for years to come with minimal drooping even around the eyes and lower face.  My main issue when women in their 40s and 50s urge others to embrace ageing is this:  - it is admirable that they do so and encourage us mere mortals to accept ourselves as we are - it is equally telling that these are often individuals who, by virtue of their career choices, are usually in the top 1% in terms of looks and have at their disposal, immeasurable amounts of money and staff as well as genetic advantage that the rest of us simply do not have.  - just as telling, many of these supermodels and actresses have made more money in their youth than most of us will see in our lifetime, such that they can afford to retire far earlier than we would. For those of us who continue to work till 65 or later, especially if in customer facing roles, we still have to look well enough that we don’t solicit unwanted comments or pity because we look “like you should be retired”, a comment made to one of my patients in her 60s.  Ultimately what anyone does or does not choose to do, we ought to be supportive and if we cannot, simply go past. As a doctor, like all doctors, I see and hear firsthand the impact careless comments have on someone’s self esteem and psyche, and the very real fears some have around their careers in their 40s and 50s when competing against younger fresher faces.  I advocate for looking your best at every age and stage, rather than looking like the latest face or trend of the day.  Just as we advocate for exercising regularly to keep your heart strong, and keeping your brain young through exercising it with mental activities, learning a new language and more, so it is with our skin and faces if we want to invest for years to come - we must make the time, effort and budget to enable us to indulge in our faces and our skin that will allow us to like what we see in the mirror for years to come.     

If you've followed the series from your 20s through to now, you know the basics:  sun protection is the holy grail to ageing well  good longterm lifestyle habits are key - eating mostly well, limiting alcohol, not smoking (or quitting) and exercising regularly are all good habits to implement sooner than later  obtaining personalised medical guidance for your skin is just as important as obtaining advice on other aspects of your health as is prioritising preventive care such as regular skin checks. Prevention is not sexy, or heroic, but it is the best bang for your buck longterm and far easier than undoing damage.  In saying all that, it is never too late to begin exactly where you are, as long as you are mindful that the longer you leave it, the harder it is to reverse some of the changes, the more expensive and healing may be impeded from minimally invasive surgery due to thinner more fragile skin.  Our life expectancy is now well into our 80s in countries like Australia, and many if not most of us, will work till 70 or beyond if we hope to maintain a similar standard of living post retirement.  Focusing on judicious medical aesthetics is then not only about vanity but about continuing to look our best at every age and stage, to look functional and competent to our colleagues and if we are in a service role, to our clients and patients, as well as informing our sense of self and healthy self esteem.  The desire to continue to like what we see and to feel good about ourself goes far beyond mere vanity for most of us, and at Skin Essentials we take a holistic view of this, with a roadmap drawn up especially for you, over time - weeks, months and years to come to help you age well. In return we ask for your commitment, consistency and your budgeting to allow you to follow recommended treatment plans. Without this investment, we cannot attain success.  The fact remains, however that in our 60s, no matter how diligent we were in the earlier decades, there will be inevitable changes in our skin over our entire body but treatment and care in the earlier decades can influence how much the ageing process shows up on your face and body.  Volume loss continues to be the biggest issue as we age in this decade:  there is loss of fat pads and their migration south in the face as well as bony loss around the mouth such that skin can seem to hang off a frame there is loss of skin elasticity, giving rise to fine lines and wrinkles and crepeyness in skin - around the eyes, around the mouth, and on limbs.  continued collagen loss also means that skin lacks the usual plumpness and glow of youth. In the 5 years immediately post menopause, there is as much as 30% collagen loss, and thereafter 2% per year instead of the previous 1% per year from our 20s.  So what can we do in our 60s, if we are still active and our outside seems a mismatch to our inside?  1. Surgery  As always, beyond an age, I usually raise the idea of a face and neck lift with patients in this age group and their willingness to consider it. Will their budget and lifestyle allow for it? If so, it may be a feasible option and I can help refer to a plastic surgeon.  2. Minimally Invasive Fat Loss and Skin Tightening  For many people, surgery may not be an option or a path they wish to go down. Minimally invasive fat loss and skin tightening procedures may then be a suitable alternative as discussed also in the 50s age group.  3. Volume Replacement  It is important for patients to recognise that surgery along will not replace volume loss in the face - specifically, in the temples, around the forehead, in the cheeks and more. Even if they opt for surgery, to reposition ligaments and muscles and to remove excess skin, they will also need volume replacement for best results, otherwise they risk looking windblown, as the old face and necklift cases of the past often show. Some may opt to have the surgery first and then return to us for volume replacement via dermal fillers, skin therapies that replenish collagen, or both.  4. Ablative Laser Resurfacing  With deeply etched lines and wrinkles due to sun damage, this may be a sound choice and option for patients. There is usually downtime of 7-10 days and is a treatment undertaken in clinic if you are a suitable candidate.  5. Medium Depth Chemical Peels  Medium depth peels are another way to resurface superficial skin layers and reveal fresher less lined skin underneath. They can be used on the face, neck and decollete as well as hands, depending on the concern and like lasers, have an associated downtime of several days.  6. Focus on other areas - hands, neck, decollete  For many patients who start at a younger age, the 50s and 60s can often be a time to shift focus from the face to the other exposed areas of our body that can age us - our hands, our neck and decollete.  They are all subject to sun exposure and ageing. Hardworking areas such as our hands may look thin, heavily veined and far older than our chronological age depending on how much work we do with our hands, while the neck has thinner skin and not a lot of fat, which is progressively lost with age, such that from our 40s onward, it can begin to age quite rapidly without a commitment to improvement.  As always, at Skin Essentials our aim and goal is a longterm holistic relationship with you, personalised for you and your specific concerns with a focus on honest, ethical beauty. Ready to start a conversation?   

The 50s are often the decade where it may feel like it all goes downhill, especially if you are female.  Perimenopause may have begun to make its mark known from your mid 40s, but it is often not until menopause that many women begin to struggle - the plummeting in oestrogen levels can cause an impact on most of our systems, from mood, to brain fog to dry skin, hair loss and more.  This is the time, if it is appropriate to do so, to talk to your primary care provider about your options including and especially for MHT or HRT, aka hormone replacement therapy. Menopause is nature's way of allowing us a reprieve from the draining and exahusting role of childbearing and caring for young children but with improved quality of life and function, many of us will live to our 80s and it makes no sense to be chronically miserable in our skin (literally!) and body and deprived due to outdated ideas of what we ought to accept as being normal; additionally a holistic approach will ensure that any in-clinic procedures we formulate with and for you will strengthen each other to help you live life to the best of your ability.  That said, your 50s are the time when if you've maintained some degree of care of your skin in the preceding decades, you will begin to see them pay off dividends now, as you continue to build on it.  Many women tell me they look in the mirror and no longer recognise themselves. Others regularly get unsolicited comments from colleagues and friends and family about how tired/ cranky they look as well as questions asking if they are ok. If these women are still working outside the home, this can be challenging and sometimes demoralising since we place such an emphasis on the way we present to the world and how we are seen based on it.  Even if you've thus far done the bare minimum or even neglected your skin, it's never too late to begin, as long as you have realistic expectations of what is and is not possible.  For many women who have done nothing to date and who find themselves disliking what they see in the mirror now which is usually a myriad of things- age spots (brown discolourations), deepening wrinkles even at rest and sagging skin due to volume loss. Sagging is by far, the biggest issue for this age group.  Many non invasive techniques may be insufficient and this may be the perfect time to consider minimally invasive surgical options or,  if budget and downtime allows, we can refer to plastic surgeons who can address this concern with you if needed via a face and neck lift.  If surgical options are not feasible for you, read on to see what else you may wish to consider to help improve your skin quality over the years and decade to come.  1. Eyelid Correction Surgery Often recommended for people in their 40s, this continues to be a staple for many people in their 50s also, not just for vanity but also because in many people the drooping eyelids which began in their 40s begin to affect functional ability, especially at the end of the day or when tired, when they might droop a bit more, or with the use of anti wrinkle when even a judicious dose of treatment to the forehead lines causes discomfort. Some patients also report chronic headaches that resolve post eyelid correction surgery.  This surgery is undertaken in clinic under local anaesthetic and most patients tolerate this very well. There is some downtime as with most procedures involving the eye area, and we would suggest a week or two of time off work, not due to any disability but due to expected swelling and bruising as the wound heals. Results are permanent and last years until further skin sags over the eyes again.  2. Dermal Fillers  If you first explore medical aesthetics in your 50s, it may be sagging and volume loss that brings you in for an opinion. Hollowing under the eyes, eyebags (which may only be amenable to surgery), excess skin around the eyes as well as jowling around the lower face and deep smile lines may be causes for concern as well as the seemingly overnight appearance of a double chin due to volume loss and sagging of skin from above.  Used judiciously dermal fillers may be used to replace some of the volume loss while we work on the deeper underlying issues, which will take longer and require planning, time and budgeting. The risk of too much dermal filler of course, is that they risk overfilling and leading to a caricature so it is best to stick to a practitioner who understands medical aesthetics and whose work you like.  3. Skin Therapies  By far and away, the mainstay of skincare in your 40s and up is effective skincare that is personalised to you and your concerns. In our 20s and sometimes even our 30s, we may get away with dabbling and trying every new trend that erupts on the scene, but by our 30s, we begin to see signs of a childhood with too much sun, or active facial muscles or chronic sun damage that never quite turned into an actual sunburn.  Fine lines and wrinles on animation as well as the appearance of dark discolouration on the skin begin to accelerate with age and over time if we do nothing in addition to progressive collagen loss that leads to a loss of plumpness and glow in our skin.  For most patients who are adequately volume replaced, my go-to in clinic is a combination of collagen induction therapies using biostimulator fillers 6-12 monthly as well as a series of skin therapies personalised to your skin concerns, with our skin therapist.  Most skin therapies take time, and a series of regular treatments to begin to see effects - usually 3-6 months minimum, in conjunction

Two days a week, I spend long days conducting primarily skin checks on patients and its related sibling, skin cancer surgery under local anaesthetic that does not need sedation. These days end up being long as the patient load is high, and despite better sun protection awareness, there remain many gaps in our understanding as Australians on what effective sun protection measures mean, and look like, posted elsewhere. While we are doing better with the Slip, Slop, Slap campaigns, we have some ways to go due to common misunderstandings around what “being in the sun” means and when sun protection is needed (hint: every single day for most of us). Skin cancer is primarily excessive exposure to UV radiation and is one of the leading causes of morbidity (ie illness) in Australia. Australia has the highest melanoma rates in the world, with the cancer most commonly affecting the young- depending on source,, ages 15-44 or 20-39. In older Australians, cumulative damage to skin cells from sun exposure as early as our childhood, onto incidental sun exposure in our adult years leads to errors in replication in skin cells, eventually leading to pre cancer cells and if not caught and treated, skin cancers- the commonest being basal cell carcinomas (BCC), squamous cell carcinomas (SCC) and melanomas.  While we educate people on what to look out for themselves to monitory for suspicious changes using the ABCDE method, the truth is there are many skin concerns that simply do not follow the rules and having a regular care provider who is familiar with what to look for, who does a comprehensive top to toe look on you using magnification as needed, is best.  Source: DermNet Our predisposition to increased skin cancer (and sun damage) rates is due to a few facts: our climate - primarily sunny all year around where the UV index rarely falls below 3, even in winter. our primarily Caucasian population, with fair skin that is not suited to this climate our closeness to the equator - QLD has much higher skin cancer rates than Vic or TAS, for example. our location. The planet is 1.7% closer to the equator in January (southern summer) and 1.7% further in July (northern summer) so when the sun is strongest in southern summer is 3.4% closer to the sun than in northern summer, increasing UV exposure by around 7%.  lower pollution and clearer air (due to lower population of the Southern Hemisphere) also results in UV levels about 7% higher than in the Northern hemisphere. All these factors combined mean that Southern Hemisphere locations receive around 15% more UV radiation than the equivalent Northern Hemisphere latitude in any given year. (Source cancerwa.asn.au) While pigment protects us from photoageing as well as provides some degree of sun protection, darker skin is not exempt from sun damage, especially if someone is out a lot, works outdoors or does not use sun protection.  Most of the sun damage occurs before the age of 20, but chronic incidental sun exposure on a day to day basis adds up to many years of cumulative sun damage that begins to show in our 40s and up, whereas melanoma is usually linked to a history of sunburns.  So the best way to protect yourself?  daily sun protection irrespective of the weather forecast, all year around self monitor any moles and seek advice if you notice any changing make a date with your doctor for annual skin checks at minimum from your 20s; if you are someone who works outdoors or is outdoors a lot, or has a history of skin cancers already, you may need more frequent appointments.  Caught early, skin cancers are easily managed, so don’t delay this important preventive care option! 

There is no doubt about it. Even in people with good skin, the gradual process of ageing, questionable lifestyle choices and transitions that make up part of life all begin to take their toll, sooner or later.  For some of us, this may begin as early as our 20s, which is when collagen production generally begins to slow down, and the plumpness and glow of youth is gradually lost. For others, if genetics are on our side and we observe some basics such as rigorous sun protections habits, we may get longer, into our 30s, and if we are fortunate, our early 40s.  Alas, for all of us, it is inevitable that over time, collagen will begin to decline, along with other changes - volume loss in the face, loss of plumpness in the skin and overall glow and the gradual etching of fine lines and wrinkles that may eventually make way for deeply etched lines present even at rest.  When I first see patients in clinic, especially if they've let nature take its course for some years, or even a decade or more, it is important to replace volume loss quickly with dermal fillers and to restore some youthfulness to the face. However, it is equally important to recognise that this is not a panacea, and that more and more filler will inevitably risk the dreaded pillowface, or overfilled face, which is a caricature.  Instead once we have optimally replaced lost volume, I encourage patients to shift focus with me to longterm goals, which relay on improving skin quality, inducing collagen and establishing and maintaining lifelong habits that will enable them to age well, for a decade or longer to come. The aim is not to be a one-and-done thing but rather an ongoing investment in oneself and commitment to ageing well, whatever that looks like for the individual.  To that end, skin therapies are the bedrock of any ageing-well regimen because they rely on building habits and maintaining those, no matter how big or small, such that over time, imperceptibly, they pay dividends. They are not the stuff of "wow" or "magic" or instant gratification, but rather a gradual and sustained improvement visible only after some weeks or months, which in the process, teach us the value of prioritising ourselves, investing in ourselves and committing to our stated goals with our time, energy and budget.  Skin Therapies consist of a personalised treatment plan with our team, in conjunction with you and your stated goals. They consist of:  a bespoke skincare regimen addressing your specific concerns, whether based on our cosmeceuticals range or prescription range if there is existing skin disease such as acne, rosacea or pigmentation  support around beginning active ingredients that may cause irritation by our staff until you are comfortably and safely using the regimen nightly  recommendations from monthly in-clinic skin therapies that would complement your skincare regimen, designed with you and your goals in mind, which also hold you accountable to your treatment and skin goals.  as with all skin therapies, skin takes time. Skin diseases take longer to resolve and begin to show improvment, typically 6-10 weeks depending on the concern. During this time, in-clinic treatments may accelerate some of the results  most skin therapies needs a series of initial treatment sessions to jumpstart the process, after which we would recommend a repeat session once or twice a year to maintain results Results are cumulative and worthwhile, the hardest part is finding a clinic and treatment partners who are qualified and who can work with you to help you achieve your goals, and then getting started. 

Australia has the highest melanoma rates in the world. Melanoma is the most common cancer affecting 20 to 39-year-old Australians and one Aussie is diagnosed with the disease every 30 minutes. It is estimated 1300 Australians will die from melanoma this year. Melanoma of the skin was the fourth most commonly diagnosed cancer in Australia in 2017. It is estimated that it was the third most commonly diagnosed cancer in 2021.In 2017, there were 14,846 new cases of melanoma of the skin diagnosed in Australia (8,747 males and 6,099 females). In 2021, it is estimated that 16,878 new cases of melanoma of the skin will be diagnosed in Australia (9,869 males and 7,009 females). In 2021, it is estimated that a person has a 1 in 18 (or 5.7%) risk of being diagnosed with melanoma of the skin by the age of 85 (1 in 15 or 6.7% for males and 1 in 22 or 4.6% for females). Ultra-violet radiation (UVR) is a Group 1 carcinogen which causes melanoma and other types of skin cancer, including basal cell and squamous cell carcinoma. Exposure to UVR via sun exposure is estimated to cause around 95% of melanoma cases in Australia, and excessive childhood sun exposure may impart a particularly high risk for developing melanoma. Skin types that have a greater tendency to sunburn are also associated with a greater risk of melanoma. So what can you do? daily sun protection - follow the 5S- do you know what they are? get at least annual skin checks keep an eye on your own skin & any new or unusual changes keeping in mind: A- asymmetry B- irregular border C - colour darkening/changes D- diameter > 5mm or different to other moles E - evolving changes Prevention is always better than cure & sun protection is a habit as important as brushing your teeth! Overdue for a skin check? Book in for one sooner than later! Your skin is the largest organ you have and most exposed to the elements so it’s imperative you look after it!

So you are now in your 40s. It is a great time to be alive, especially if you are a woman. Your career may be on track, or you may be gaining momentum there. Your kids may be of school age, and life might be feeling a bit easier now. You may feel like the frantic rushing of the earlier decades may be settling, and you are ready to focus on you again after feeling second best (or last!) for the best part of many years. Many women find their 40s to also be the decade they start caring less about the unsolicited opinions of others and start being more vocal about what they will and will not accept in their lives and from others. What's not to love? The good news is, if you've maintained some of the skincare basics in the earlier decades, you may hit your 40s in good stride, with not as much to do as someone who has kept putting it off. What is irrefutable? volume loss in the face due to ageing - none of us can avoid this progressive collagen loss in skin, leading to deeper wrinkles and lines and loss of that plump, glowing texture young people have pigmentation due to cumulative sun damage, pregnancy and more! early sagging of skin which pools around the lower face - showing up as jowls, a double chin and neck folds drooping upper eyelids and sometimes, onset of eyebags that are not amenable to dermal fillers due to the presence of fluid within them aka malar bags or festoons which need different treatment modalities. in our mid 40s onwards, as oestrogen levels begin to decline, many women experience thinner skin, hair loss and more brittle nails. Even if they've been careful with sun protection of the face, neglect to the hands, neck and decollete may begin to show up here. So here are some suggested options that may help.  As may be apparent by the non-exhaustive list above, a personalised holistic full face approach to rejuvenation is needed here, not just some ad hoc anti wrinkle treatment here and there when time and budget allows for best results. This is often the decade where sitting down with a doctor who does this day in and day out and takes a holistic, multi-modal approach and will guide you as to your options, timeframe and budget, so you can decide if you will commit, or age as nature intended, is key. So what are some common procedures I recommend to my patients in their 40s, who've not had much, if anything, to date, and have another 20+ years of ageing as well as a career ahead of them, with young blood appearing daily? Dermal fillers  By the time we hit our 40s, if we have not had any injectables prior, most of us who are at a healthy weight will begin to see the signs of significant volume loss in our faces by way of hollowing temples; undereye shadows and hollows; loss of volume in the cheeks, leading to prominent folds around the nose and mouth, and if we are naturally very slim, a gaunt appearance. Additionally, most of us have underdeveloped chins, easily visible in our side profiles, but do not really realise it until we hit our 30s and up, when we begin to see early pooling of skin around the lower face. In this case, judicious use of chin and sometimes, jawline filler can help camouflage the appearance slightly and give a better looking profile. Dermal fillers can be a great way to gradually add volume to these areas of deficit over time (3-9 months depending on the amount of volume needed - it may be as much as 15 mls over 2-3 sessions as your budget allows) and mask some of the signs of ageing. It used to be thought that dermal fillers need to be replenished every 6-12 months but we know now that likely leads to the pillowface syndrome we see all around us now. In most of us, fillers will last around 12-18 months once we hit maintenance, and often for much longer such that after the initial upfront cost and volume, we may only need an extra 2-3 mls (if that) annually. At this point, less is definitely more and I begin to steer patients away from more filler to other treatments that will work on improving skin quality that will last them over the years to come. 2. Anti wrinkle treatments If we have not begun anti wrinkle treatments in the earlier decades, this is often the decade where we may wish to consider adding them to our skincare staple. Due to a combination of thinning skin, repetitive facial movements over decades, most of us will reach our 40s with deep lines with movement and many of us will see these lines between our eyes, on our foreheads and around our eyes even at rest. Anti wrinkle treatments, done well do not simply freeze the muscles, but rather soften the relevant muscles without freezing them so much that other nearby muscles begin to work overtime to allow some movement. Unless one has the budget to freeze almost all the face, I generally advise that freezing an area is unlikely to be of benefit to most of us, and may lead to discordance in the way we appear to others - stiff and emotionless. 3. Personalised, prescription skincare  If you have not already, a personalised skincare routine, which may involve prescription products, is a great idea in this decade, when childbearing may be behind us and we worry less about side effects and effects of certain medications on pregnancy. I regularly see patients who have damaged their skin barrier by mixing and matching whatever happens to be the latest skincare trend, and who present with skin problems as a result of overuse. Equally, hormonal changes related to pregnancy and adult female acne are common culprits we may meet

For many of us, our 30s can be a time of much change. Many of us may have children, with pregnancy and associated changes, breastfeeding, chronic sleep deprivation and wrangling little children. Additionally many of us may be dealing with work outside the home at the same time, and making progression on the career ladder, with the requisite sacrifices of time and some quality of life in the process. These combinations of sleep deprivation, late nights and long hours, plus physiologic changes such as pregnancy, birth and raising babies, can all wreak havoc on our wellbeing, and our skin. 1. Hormone related changes may result in pigmentation that becomes very hard to get rid of and is mostly an ongoing lifelong management issue. 2. Fine lines and wrinkles may begin to make themselves known on our faces from decades of frowning, squinting and even smiling. 3. Skin begins to thin, and superficial blood vessels may become more apparent, with easier bruising. With the decreasing collagen that began in our 20s, skin begins to lose its plumpness and glow and for some, adult acne may make itself known. Chronic sleep deprivation and stress may contribute to overall slight decline in skin health and our general sense of feeling blah. It is never too late to begin however your 30s heralds a shift in focus from prevention to more correction and if you've done the minimum to date, you may find initially there will be significant upfront costs before maintenance. So here are some tips to halting the ravages of time and beginning to reverse some before the process worsens. As always, the foundation of great skin in your 30s remains the same: - daily sun protection - getting as much sleep as is feasible - limiting poor food choices - processed foods, alcohol- avoid or quit smoking as it's among the worst choices you can make for your overall health and shows on your skin, teeth and nails. - get regular exercise. - consistency with all of the above. 1. Personalised skincare including prescription skincare If you are noticing problems on your skin that you dislike, over the counter skincare may no longer cut it, and may even make matters worse.  Consider a trusted doctor who can help assess and treat your skin concerns including with bespoke prescription ingredients. Common skin concerns in our 30s and older include pigmentation, rosacea as well as acne. These are all skin diseases, and once present, may be tricky if not impossible to cure, so do yourself a favour and spend on a personalised assessment, diagnosis and treatment plan to manage these conditions instead of experimenting and risking making matters worse.   Skincare favourites in this decade of life, provided there are no pregnancy related concerns, are Vit A derivatives and Vit C alongside any others your doctor may prescribe. 2. Anti wrinkle treatments Unlike anti wrinkle treatments in our 20s, when some use them in baby doses for prophylaxis, by now, you may noticed the faint beginning of lines even at rest aka static lines- a combination of declining skin quality and receptive muscle movements. These are much harder to soften and take time, and regular anti wrinkle treatments are a great way to do this. The drug works by softening/ paralysing the muscles used in forming the lines such that over time, the lines are softened. Using smaller doses as preventatives in other areas of the face remains a viable option to prevent deep etched in lines a few years later. Additionally, anti wrinkle treatments help smooth out skin and pores, giving skin an added luminosity that is hard to beat when done well. 3. Dermal Fillers This is often the decade when we begin to notice a definite loss of volume in the face as the combination of chronological ageing, cumulative sun damage and lifestyle choices begin to take effect. Depending on our genetics we may notice the changes under our eyes, or our cheeks, with dark circles, or deepening lines around the mouth. In some of us, we may even begin to notice hollowing of the temples.  We may get unsolicited comments about how tired or sad we look. Dermal fillers work to replace some of the lost volume in our faces that give a hollow, gaunt and tired appearance. While they don't lift, they do replace some of the lost volume, creating the illusion of lifting and refreshing the face, in small amounts. Too much filler, however is a bad thing and risks venturing into the territory of the faces we see all around us - duck lips, Simpson lips, chipmunk cheeks and more so stick to the one injector who knows what they are doing and who takes a holistic approach to the ageing process. Importantly, ensure they know when to say no. 4. Laser neocollagenesis Laser toning or neocollagenesis is a great way to gently induce collagen production with little to no downtime. On the surface, it's simply a laser session that seems quite relaxing, and doesn't seem to do much immediately.  A series of sessions are needed for best results, as with all skin therapies, but the laser heats skin layers under the surface, stimulating your own collagen in the process. In the process and depending on the type of laser, it may also help with pigmentation and mild redness.  5. Collagen Induction Treatments Treatments such as skin needling, Radiofrequency micro needling as well as Aquagold, PDO threads and PRP treatments are among some of the options available to help induce your own collagen over multiple sessions to induce your own collagen that will last you upto 2 years at a time.  While the exact method may differ, and different options may be recommended to you based on your skin, your concerns and your budget, they all work by inducing your own collagen production where applied leading over 3-6 months to smoother, firmer skin that has that glow we all seek.  6. Radiofrequency treatments Radiofrequency treatments

To those of us in our 30s and beyond, it can often feel like the aging process begins literally, overnight. One day, you're young and carefree and waking up with flawless skin (ifyou're lucky) despite late nights, poor dietary and lifestyle choices. It feels like no matter how poor the choices, our body and skin will keep up. Then suddenly, one day, whether that is in our late 20s, or our 30s, the signs of ageing seem to magically appear: pigmentation in patches on our faces early lines and wrinkles when we smile, frown and laugh if stress is a constant, skin issues including acne signs of sun damage, including less commonly, skin cancer dark circles under the eyes due to a combination genetics and choices leading to volume loss under the eyes and pigmentation that gives us a chronically tired look We could go on and on and on but let's not dwell... As a primary care doctor ie a GP, my passion is preventive care. I feel SO HAPPY when people see me for preventive care BEFORE (any) disease begins to take hold, when it often becomes a case trying to minimise ongoing damage, often incompletely. The solution, as always, is to begin before you think you need it, to maintain what you have and to capitalise on building what you do not have to see you through your 20s, 30s and well beyond with judicious tweakments. The benefit of this of course, is also some other key factors: by starting young you need less so can afford to budget for it. you learn how to budget effectively for self care and for the things that make you happy you learn to get comfortable with being held accountable to someone who will hold you to your goals and nudge you along through accountability you build consistency, a lifelong habit that often means the difference between those who see success and those who don't After all, any treatment you begin with that is tailored for and personalised to you, is going to stimulate your own collagen that will last you for years to come. So what are the best treatments that you should be focusing on in your 20s? So first the basics that you must get right or work on while planning your in-clinic treatments: daily SPF, regardless of the weather, especially in sunny cities like Sydney and really, most of Australia barring Tasmania. Even on cloudy days, the UV index is usually well above 3, leading to inadvertant sun exposure and damage. If you smoke, let's start working on quitting. Smoking depletes your own collagen and stains teeth and gives skin a sallow appearance. eat well, most of the time watch the alcohol consumption exercise is not only good for your heart, it's also great for your skin That being said, what are the best 5 in-clinic treatments in your 20s? 1. Small doses of anti wrinkle treatments - if you're open to it No two faces are the same nor are two skin types. If you have a very mobile face, you may find that you form deep wrinkles when animating that begin to set grooves in your skin over time. This is the perfect time to consider small doses of anti wrinkle treatments to limit the degree of animation without freezing movement completely. By the time most people present for anti wrinkle treatment, it's due to lines that are deep, etched into the face even at rest, and which bother them; at this stage, it usually takes a year of regular treatments to soften these etched-in lines. Starting younger keeps the worst of these at bay. 2. Laser genesis/ toning Also known as a laser peel, this is a gentle laser treatment that will help improve pore size by inducing collagen, improve fine lines and skin texture. There is no downtime unlike more intense lasers, so this is perfect for maintaining and improving skin quality and inducing your own collagen over the years. If wanted, you can also combine it with an LED treatment to add to the benefits and make it the ultimate relaxing treatment that will continue to reap benefits long after the appointment itself. 3. Chemical peels Not just for acne prone skin, light chemical peels are great when beginning to work on acne prone skin for adolescents and for adults alike. While a bespoke skincare plan, which may include prescription medication is important, a series of chemical peels will begin to work on the acne already present and lighten existing hyperpigmentation on the surface of the skin, reducing ongoing damage to the skin surface while the skincare and medication takes its time to work from below (typically 6-12 weeks to begin to show effects). Equally, depending on the formulation used, there are other chemical peels that work well for other skincare concerns in tandem with personalised skincare including pigmentation as well as early signs of ageing such as lines and wrinkles and smoothing overall skin appearance. 4. Bespoke skincare tailored to your skin concerns Given that our skin makes up 90% of our faces it is entirely appropriate that we feel self conscious when our skin doesn't feel at its best. Contact dermatitis due to excessive use of cosmeceuticals, or mixing the wrong products is common and something I see more often than I'd like to and most of this is because the skin is a living breathing organism, that is not just an inert blank canvas for the products we slather on it. The best way to invest in your skin now and well into the decades to come is through a personalised skincare regimen, especially if you have skin issues already, be it sensitivity, acne, or other concerns. Let a professional assess your skin and suggest a bespoke treatment plan. Once you find what works, it becomes a simple enough matter to stick to it for best results, until circumstances change eg pregnancy, ageing or any new concern.

Injectables are tricky to master, and anyone who tells you it’s easy, is often not telling the truth. With more experience, I’ve found that I see more and more variation in faces as to what can go wrong, go awry and even lead to unexpected results. Just like with Medicine, there is usually a Dunning-Kruger effect initially- when we are very new and know a little, we think we know a lot and it sometimes veers on arrogance. With actual experience and knowledge, we realise just how limited we are in our understanding, and how much can truly go wrong - not necessarily catastrophically wrong, but inconveniently, sometimes embarrassingly wrong, with areas such as the human face, which we use to emote and express and which is so important for non verbal communication.  This week I’ve had several patients new to some injectable treatments for them, with some glitches reaching out, concerned something has gone wrong, when it is all part and parcel of first time treatment. At Skin Essentials we reach out regularly after someone’s first treatment when things may go wrong, and as our patients feel more confident, we take a far more laidback, hands off approach as is appropriate, reserving advice and discussion for in person reviews. Nonetheless the enquiries this week have me thinking about the things that can potentially occur with anti wrinkle treatments, which are normal, no matter how much we prepare patients for them. So what are the commonest side effects that, while not life threatening or a medical emergency, nonetheless may cause someone to reach out for advice until it all settles?  1. Asymmetry. Among the commonest, asymmetry. Few of us are completely symmetrical, and sometimes the symmetry may be so mild as to not be apparent to us until we begin to undertake injectables. Then, perhaps as we begin to pay more attention to our own faces and the smallest of changes, or sometimes because anti wrinkle treatment may affect one side more than the other initially, even if the same dose was used; or surrounding muscles may pull on one side more than the other, asymmetry may be more obvious to us and to others also till it equalises.                                                      This is fairly common for first time treatment to a given part of the face - I often warn patients of this, and to leave well enough alone till 14 days because we cannot not do anything till then. 9 times out of 10 the asymmetry will settle in a few days, leading to evenness by the 14th day. Problem fixed!  Asymmetry is commonest in areas such as: Eyebrows when treating for frown lines Forehead lines when brows are raised, such as when treating forehead lines The degree of gum on show when treating for gummy smile In paired areas, especially when multiple muscles are involved such as with frowns and smiles, it is impossible to achieve complete symmetry (it is a rare person who's symmetrical anyway), but eyebrow asymmetry is usually easily fixed as are uneven forehead lines. We offer all new patients a complimentary review at 14 days to assess their first treatment in clinic and to address any concerns. This is much easier than emails to and fro, and allows me to standardise for photos taken in clinic if there are symmetry concerns for next time.  2. Heavy forehead/ brows In some patients, this may be an issue when the toxin is first kicking in. The forehead, which is the main elevator of the forehead, may feel heavy. When overdone, eyebrows may flatten and be hard to raise at all, giving women a mannish appearance. In severe cases, patients report not being able to raise their brows at all, and feeling like someone is pressing down on their forehead the whole time. This is different to patients who prefer a more arched appearance to their brows, and who have severe, visible forehead lines because of the regular unconscious raising of their eyebrows. With toxin to the forehead, they may still be able to raise the brows, and the forehead lines may smooth out due to treatment, but they may feel uncomfortable or dislike the effect treatment to this area has for them, unlike overtreatment of the forehead, which causes a flattening of the brows, inability to raise them and drooping of the eyebrow, causing eyelid skin to be pushed down as in the photo above (courtesy of Dr Joe Niamtu) If there is suitable movement retained, the dose is likely not excessive, but all toxin to the forehead will slightly flatten the brows such that if the effect is one that is distressing for the patient, they may prefer forehead lines over the unpleasant feeling/ loss of arch in their brows or prefer a smaller than ideal dose that softens lines without compromising the ability to raise brows (more). Ultimately that is a personal matter that only each patient can decide for themselves. Life is too short to be frustrated about non essential treatments.  Unlike dermal filler, toxin cannot be removed or dissolved and we must wait it out, a process which can begin as early as 6 weeks post treatment. Also unlike dermal filler, the beauty of anti wrinkle treatment is that if unhappy, it’ll resolve itself in time (indeed, nothing CAN be done), whereas when done well, patients want results to last forever, which leads to our next point. 3. Return of lines/ movement sooner than 3 months It is a misconception that faces treated with toxin will remain looking treated until the 3+ month mark when more treatment is needed. Toxin, once injected, depending on the brand used, begins to kick in as early as 3-5 days and peaks (ie has maximum efficacy) at 14 days post treatment which is the best time to assess for effect.  As early

In my day to day work which is largely procedural, bruising is a common and often expected occurrence so it’s important that I educate patients on what to expect and when to worry. Nonetheless, for someone who’s new to the world of either skin cancer surgery or injectables (or both) it can be initially fraught, knowing when to worry and when to relax and let nature take its course. Bruising is among the commonest and expected side effect of procedural work that breaks the skin, by far, and anyone who promises you won’t bruise is either lying or inexperienced. Equally, patients sometimes get impatient or have unrealistic expectations of how quickly a bruise ought to resolve. So here is some basic information to help you out.     What is a bruise? A bruise, by definition, is an injury appearing as an area of discoloured skin on the body, caused by either blunt trauma eg a fall/ blow or impact rupturing underlying blood vessels. In the case of injectables and other skin penetrating treatments, this can also be caused by sharp instruments working in a similar fashion. The blood leakage from ruptured blood vessels collects under intact skin, and pools there, and over the coming days to weeks, as the body breaks the haemoglobin in it down, changes colour, from reddish to purple/ black to green and yellow before eventually returning skin to its normal colour. Most facial bruises do not require medical attention and will resolve over coming days to weeks and change colour in the process as the blood is broken down and removed from the skin.        How do I treat my facial bruising post injectables? Most treatment is simple and consists of the following steps. Ice the affected area for 15 mins at a time for several hours initially to help reduce pain and swelling.  Take anti inflammatory medication to help reduce pain and swelling  keep the affected area elevated - in the case of facial bruises, try and avoid lying down for several hours after the immediate injury  after 36 hours, if you’re able to apply a warm compress to the bruised area to help increase circulation  to expedite bruise breakdown, you may massage the affected area gently, including with the use of creams that may help breakdown occur faster such as Hirudoid.  How quickly will my bruise be gone?    In most cases, your bruise will be gone — or almost invisible — in about two to three weeks. In response to initial injury, skin may typically look pink or red, changing colour to bluish-purple soon after or within a day or two as the blood that has collected at the injury site changes color. Around 5 to 10 days, the bruise turns a green or yellow color. At 10 or 14 days, the bruise’s colour will be more of a yellow-brown or light brown. This is the final stage of your body absorbing the collected blood. The color will gradually fade away, and your skin will be back to its normal color by 2-3 weeks.  If the bruise doesn’t seem to be changing, or appears to be getting bigger or still prominently present at around 2 weeks, touch based with your doctor to check all is on track. 

With the rise in injectables everywhere, I am seeing weekly, new cases of influencers and others posting about their own experiences with vascular occlusions, sometimes from new injectors and other times from their regular treating clinicians.  Each time I’ve posted on this topic on my Instagram feed to educate others, I invariably get patients in clinic pulling out of planned dermal filler treatments, to “think about it some more” or telling me in clinic that I need to stop frightening them.  My goal and aim, with all that I do, is not to scaremonger but to educate. The medical aesthetic industry in Australia, while safer than that in places like the UK, is nonetheless, largely unregulated and heavily marketed to a largely unsuspecting public who sees them as akin to getting your hair, nails and makeup done.  While there is no absolute guarantee against a poor outcome or a potentially serious complication, here are some ways to keep yourself safe when undergoing these treatments.  The commonest point of confusion among laypeople post dermal filler treatment is “is this a bruise or a blockage?”  Bruise vs Blockage ie Vascular Occlusion   A bruise is a traumatic injury, usually to unbroken skin, where underlying blood vessels are ruptured and blood leaks out into surrounding tissue. Over the next days to weeks, this blood is broken down by the body, and eventually cleared, returning skin to its normal colour and status. In injectable treatments, where a needle, is used to penetrate the skin barrier, bruising is almost a given, and among the commonest expected side effect, variable in size based on the degree of injury to skin and area injected.            A vascular occlusion (VO), by contrast, occurs when blood is no longer able to flow within a blood vessel ie a blockage. This blockage may be partial, or complete, resulting in tissue downstream of the blockage being deprived of oxygen and other nutrients, resulting, if left untreated, in skin death eventually. In the case of dermal filler injections, this VO is due to unintended, and often unrecognised injection of some filler directly into a vessel. While enough blockage may occur immediately so as to warn the injector and patient, this may occur an hour or some hours later, which is why education and aftercare and followup in the first 24 hours or so is important.        Given the serious nature of a VO, which is a life threatening emergency, how is a layperson to know the difference post injectable treament?  While no two faces are the same, and no two people will have the same concerns, or outcomes, there are some important red flags to watch out for which should prompt you to reach out to your treating clinician for help if this happens within hours of your treatment.  Two of the hallmarks of a VO that enable us to diagnose them are:  pain - often of sudden onset, severe and disproportionate pain, especially compared to the non VO side/ area, is a red flag.   skin discolouration - while it may initially resemble a bruise, with a VO, skin that is deprived of oxygen, rapidly begins to blanch (white spots or white areas within the bruise/ area), become bluish or mottled, and resemble a lacey pattern over skin.  Any of these should prompt an affected person, especially within hours of treatment, to reach out to their clinician for help and advice, with photos of the affected area.  Left alone, and we are reading of some injectors telling patients to sleep on it, or to watch and wait, or to even see them in the next day or two, these changes will progress to skin downstream of the blockage becoming starved of oxygen and discolouring further and eventually dying - the bluish discolouration may progress to blue-black; sterile pustules may form, as the skin begins to die, but we’d hope no one would ever get to that stage with proper aftercare and followup by their clinician.  So can you guarantee avoiding a VO?  The short answer, for anyone who chooses to have injectables, especially dermal filler, is no.  While choosing a clinician on the basis of years of experience and their qualifications is important insurance against poor and especially catastrophic outcomes, every person has variable anatomy and medical procedures, unlike hair, nails and makeup are complex and delicate work; despite appropriate knowledge and experience, things can still go wrong which is why all medical procedures should be undertaken, ideally, with adequate informed consent and with full awareness of limitations and risks.  How is a VO treated? A VO is a medical emergency and usually occurs within hours of treatment, so your clinician should have aftercare protocols in place already that safeguards you in the first 24 hours or so post treatment. This should be discussed with you at least briefly at the time of consent for the dermal filler your first time, and again as part of the aftercare. You should have a way to contact your clinician in the hours immediately following treatment if you have concerns or can’t differentiate between bruising and a possible VO and a way to send pictures across. They should be able to either reassure you on the basis of the pictures or be able to reopen clinic to assess you face to face if concerned at any hour of the day or night as time is of the essence here. If they confirm it is a VO, they should have the necessary drug on hand to dissolve the affected area once they determine where this is (likely to be). Post dissolution, you and your clinician should both see return of circulation to the affected skin before you’re allowed to go home. If this does not occur, more assessment may be needed, including from other clinicians they can access for help. Post dissolution, you’d normally be seen the next day for followup and then a week or two later

There was a recent excellent piece on Mamamia by Erin Docherty on the rise of cosmetic injectables and reversal of treatments, often for poorly done work, and reflection by two doctors on why this might be increasingly the case. A common reason cited, which is well known among those of us who’ve been around a while, is the explosion of aesthetics and injectables in the beauty space, which has led to the proliferation of chain clinics and corporates that pull in relatively junior and inexperienced nurses and doctors, with minimal medical training post graduation, into this industry. They can be trained in injecting after as little as a weekend or a week long boot camp and then set up in salons and chain clinics to inject with minimal oversight and supervision. With the large numbers recruited by these chains, prices drop and potential consumers, who know no different, and may choose based primarily or only on price, may go to these places. Most will be fine, even if they don’t always get the results they want, and some will be injured. When I see patients in my clinic who’ve had something go awry elsewhere, or because they are coming to me as new patients and I go over consent, some express anxiety and surprise at the potential issues and concerns I discuss with them to sign on the consent, including risk of bruising and bleeding, risk of injury to a blood vessel with dermal filler causing blockage which, if not caught in time, can cause skin death as well as the rarest complication of them all, blindness in one or both eyes.   Yet others I see who’ve been going elsewhere routinely cannot tell me if they’ve had anti wrinkle or filler to areas of concern, or what brand or how much was used. All this points, disturbingly to a lack of regulation and oversight of often very junior and inexperienced nurses and doctors, who may lack the necessary skills to educate and choose patients appropriately and manage unrealistic expectations, much less unexpected complications such as vascular occlusion and the rarest of them all, blindness.     In the absence of education, most people will assume that it is similar to shopping at ALDI vs shopping at Coles or Woolworths, rather than recognising that qualifications matter, experience matters, as does the ability to effectively consent a potential patient on risk, manage expectation and say no if there are problems within those. Medical procedures are not the same as non invasive hair and beauty procedures but they’re being heavily advertised and sold as such through marketing.  In an ideal world, we’d like our desired objects/ goals/ treatments to be fast, good and cheap. Alas, the truth is that at best, you may get 2 of the 3, leaving the third which you actually pay for. Most experienced clinicians will not be cheap. If they are, you really need to ask yourself why. Most experienced clinicians will usually be fast, but that is because we’ve done the years of work that goes into learning, and honing our skills, such that it may take us a fraction of time to do what a newer clinician will take twice as long on, and usually with fewer mistakes. Lastly, most experienced clinicians, outside of Covid times, tend to be booked out and can’t fit you in on the day barring emergencies post treatment and will hold you accountable to your treatment goals as it’s in your best interest to do so.  Most experienced clinicians are more interested in educating you, and helping you choose what’s best for you in the bewildering array of cosmetic procedures, including skin improvement, rather than simply selling you a preplanned, generic package or a deal that may or may not suit. The current marketing push from big chains and corporates may be one of the contributing reasons for why we see vending machine style aesthetics and so many weird faces walking around among us, who frequently use these services, in which the patient largely designs their own treatment and the person injecting simply says yes. Doing cosmetic enhancements on the face especially, where millimetres of change are apparent, is complex, delicate work, and it takes a combination of science and art to bring it all together and years of experience and practice. You cannot learn that in a 5-day boot camp or a weekend course and certainly not without some foundational years in the basics of medicine, during which you learn the art of medicine - consultation, assessment, correct diagnosis as well as recognising complications when they occur and how to manage them. Junior staff are heavily supervised in hospitals and other settings for this very reason and not left to their own devices for years, until deemed safe to the public and competent.  As with the cosmetic cowboys expose not that long ago, many people are being harmed by non invasive medical aesthetics, we just don’t see it as much of a problem because to some degree, we’ve become so desensitised to it since we all know (of) someone who’s walking around among us with frozen faces, overinflated lips, exaggerated cheeks and hollow temples and a face that does not match the neck/ décolleté and hands. It is not what aesthetic medicine, at its core, was even intended to be, and I hope we are taking back the reigns and as doctors and nurses, returning to the core of what we undertook in training for this in the first place - to first do no harm.

Social media is great, as is Google. However, they often convey myths around cosmetic treatments that are not always true.  While many doctors hate it when patients have googled their probably symptoms/ concerns (because more often than not, the presumed diagnosis is incorrect), I don't mind it because it gives me some idea as to what a patient's concerns are, and a starting point on where to begin educating them. In saying that, when I repeatedly get the same questions in consultations, or via DMs or when I invite questions, it's time for a PSA. Read on to find out some of the commonest questions I encounter around skincare and cosmetic treatments by patients considering one or both! Myth #1: Moisturiser makes oily skin worse. While this makes sense in theory, the reality is paradoxical. I regularly meet patients with persistent mild/ moderate acne who use multiple anti-acne agents including some really drying ones like benzoyl peroxide, AHAs and BHAs and more, but won't use moisturiser because their skin feels "always oily" Oily skin needs a light, non comedogenic moisturiser. When you strip moisture from your skin's surface, your skin reacts by producing more sebum and oil, some of which can clog up pores and cause more acne. It becomes a vicious cycle and the way to break that is by doing what seem counterintuitive - moisturising, and staying away from overly drying products or combining them without medical oversight. Myth #2 : You don't need sunscreen and sun protection if you have dark skin. This is a common one. Related to this, sun protection is mainly for people who burn, not those who tan because tanning indicates sun damage.  Darker skin has some inbuilt sun protection - it's estimated that a much darker skin type can confer a natural spf of around 10- 13, which effectively screens out some 90% of UV rays. This is why, we have sayings like "black don't crack" and "Asians don't raisin" because the more pigment you are naturally born with, the more inbuilt protection you have compared to someone with very fair skin, who's more likely to burn. In saying that, even with an inbuilt spf of 10-13, you're only screening out some 90% of UV rays, leaving the other 10% to regularly damage your skin and risk skin cancers over time. My general advice for anyone I see in clinic, for skin cancer checks as well as for advice on ageing well, is to begin with daily sun protection - SPF 30+, reapplied regularly if you'll be out and about + sunhat, sunglasses, shade and protective clothing. Myth #3 : If you begin using anti wrinkle treatments, you can't ever stop because the wrinkles will be worse when you do. This is a myth and fearmongering at its worst. Anti wrinkle treatments work by relaxing muscles that are active in facial movements that allow us to be animated. Over time, and with aging, as skin thins due to collagen loss, these muscles create furrows and grooves in our skin, much like track marks by a vehicle using the same route over and over on a dirt road. When these muscles are regularly and repetitively treated, they weaken and cannot make as much of a groove and over time, the lines, if present, become fainter. If, after 2,3 or 5 or more years, you were to decide to stop using anti wrinkle treatments, your muscles won't regain their prior strength immediately. Over time and with ongoing muscle use during animation, you'll regain strength and the lines will likely come back, but it won't be immediate and it may take months or longer for the wrinkles to return full force. Myth #4 : Anti Wrinkle treatment can treat all types of wrinkles There are lines, and then there are lines, which is why it takes an experienced and skilled injector to know what lines you mean when you raise it as a concern, and whether it is lines that anti wrinkle treatment can improve eg frown lines, forehead lines, crows feet, or lines that are due to volume loss in the face, that cannot be improved by anti wrinkle injections, and which may give rise to odd movements if attempted eg smile lines, which can be improved by volume replacement, such as with collagen induction therapies and (dermal) fillers. Equally, some lines are present due to lifestyle factors. If you sleep on your side, or on your abdomen, you will be smushing your face into your pillow and over time, these may show up as lines on your face, especially forehead, that are not amenable to treatment to improve them.     Myth #5: Lip Filler will give you duck lips Lip filler, in my experience, like filler around the eyes, are hard to do well due to the fact that these are among the most mobile parts of the face, and filler an move over time, and migrate in these areas.   Equally, if one has an underdeveloped lower face/ chin, getting lip filler without treating the lower face as a unit, can give the appearance of a Marge Simpson/ duck lip look that can be jarring and worse. Done well, lip filler can be subtle and natural so choose your clinician wisely! Dissolving badly done lip filler can be expensive!           Myth #6 : I should get the same results with the same dose as my sister/ friend/ cousin. No two faces are the same, even in identical twins, nor are their healing processes, and eventual outcome unless we treat them in a vacuum and expose them to the same aftercare conditions, which would have ethical problems. I commonly see patients referred by a friend or sibling who's been happy with their results, to us. The expectation is, because she had great results with x units of anti wrinkle or y mls of filler, so should I. I see sisters who routinely talk to each other about

Most Australians will only use sun protection on the hottest days of summer and forget it is not heat but UV rays that cause sunburn and photoageing as well as skin cancer. Australia has among the highest rates of skin cancer in the world and it is possible to burn in as little as 11 minutes on a summer's day. Ultraviolet (UV) radiation, unlike Infrared heat, is invisible and around us anytime there is daylight. It is radiation we can neither see nor feel and is present on even overcast and cool days in winter, as well as on cloudy days. Exposure to UV radiation is the major contributing cause of photo ageing, sun damage and skin cancer, so at Skin Essentials, at an initial consultation with any new patient, we cover sun protection in depth, because it is our firm belief that it forms the basis of all anti-aging practices, without which all other in-clinic treatments will give subpar results.  What types of UV are there? UVA - tends to penetrate deeper into the skin's layer, the dermis, where it can trigger the pigment producing cells, the melanocytes, causing tanning. Darkening of the skin is always a sign of sun damage. It is also associated with cell damage and skin cancers. UVB- tends to penetrate skin more superficially, the epidermis and is more likely to cause sunburn; Ozone stops most of the UVB from reaching us but 15% of it still gets through. UVC - the most dangerous type but the Ozone layer absorbs all of it and none of it reaches us. On any given day, year around, UV levels vary and are affected by location, altitude, time of day, time of year and clear vs cloudy skies. UV rays are present all year around anytime there is daylight. The UV Index The UV index is a tool to enable you to protect yourself from UV radiation. It tells us the times of the day when UV is expected to be highest so that we need extra protection. Sun protection measures are recommended anytime the UV index is at 3 or above above which it can cause skin damage.       What are some ways we can be exposed to UV rays and not even realise it? Incidental sun exposure is rife among Australians and it all adds up over a lifetime of sunburn, sun damage and over time, skin cancer risk. Examples of incidental sun damage: walking the dog walking to check the mailbox and chatting to a neighbour hanging up the washing and taking it in going out to get a quick bite to eat, or a coffee sitting in the car or on public transport daily not reapplying sunscreen regularly through the day not using other sun protective factors and relying only on the sunscreen   What is SPF? SPF stands for Sun Protection Factor. It is the amount of time the sunscreen will protect you from the UV rays. SPF on sunscreen tells you how much additional protection you will obtain by using it. For example, if you are someone who would normally burn after 30 mins of sun exposure, using a sunscreen with an SPF rating of 15 would multiply this protection THEORETICALLY by 15 ie 450 minutes before you burn. In reality, this is impossible because: sunscreen itself is gradually degraded by exposure to the elements most people do not use sunscreen correctly or reapply often enough sweat and other factors would render it less effective For these reasons, it is recommended we reapply sunscreen regularly: every 2 hours if we are out and about  every 30-40 minutes if we are in the water  combine sunscreen with other sun protective behaviours: wear a sunhat wear sunglasses wear protective cothing seek shade So how does your SPF protect you from UV rays? SPF in sunscreen refers mainly to UVB rays you are protected from. No sunscreen blocks 100% of UV rays which is why using ONLY sunscreen is not enough sun protection SPF 15 blocks 93% of UVB rays SPF 30 blocks 97% of UVB rays SPF 50 blocks 98% of UVB rays 80% of Australians do not apply enough sunscreen or correctly. Every bit of UV exposure adds up over the years to photoageing and contributes to your risk of skin cancer How much sunscreen should you use? 5ml for every area of your body to be protected 5 ml or 2 finger lengths of sunscreen for the face and neck including ears; each limb etc. reapply every 2 hours if out and about, more often if in the water Suncreen is very effective when applied correctly - however it is not a suit of armor so other protective measures are just as important: protective clothing a hat sunglasses shade        

It is the job of the beauty industry to sell us all the hype and the myth of the perfect ingredient that will address and fix our skin, hair and other beauty woes for a bargain or by selling us a package. As a doctor, I see the flip side of this regularly, in the form of reactions to common ingredients used within the cosmeceutical industry, that nonetheless causes problems for patients. So what exactly, is a cosmetic and how does it differ from a drug? A cosmetic is defined as a topically applied product that is used to beautify, cleanse or protect the hair, skin, teeth or complexion. A cosmetic should not contain any active drug ingredient that may affect the structure or function of the skin. The demaraction of cosmetics and drugs is not always clear as there are many products available that have two intended uses, for example, an antidandruff shampoo is a cosmetic because it is intended to cleanse the hair, but it also contains a drug to treat the scalp and dandruff. Such products must comply with the requirements for both cosmetics and drugs. In 2015 the EWG determined that the average American woman came into contact with 168 potential ingredients and the average man, 85 in the course of a single day. Closer to home, it is estimated that on average women are using at least seven types of cosmetic each day and reactions to these products are quite common. Studies suggest that up to 10% of the population will have some type of reaction to a cosmetic throughout a lifetime but this may be an underestimated as many mild reactions will not warrant seeking medical attention. So what kind of reactions can occur? contact urticaria burning sensation to the affected area, with hives or weals, usually settles within hours anaphylaxis Breathing issues, swelling. Rare but may be fatal. irritant contact dermatitis 80% of all contact dermatitis, with a reaction to exposure to active ingredients. Often common in people with sensitive skin. patches of itchy, scaly skin, red rash or occasionally, blisters. allergic contact dermatitis allergic contact dermatitis occurs when a person’s immune system is sensitised to an allergen (the person is allergic to a specific ingredient). A rash usually develops more than 12 hours after contact with the allergen and peaks about 48 hours after exposure. symptoms of allergic contact dermatitis include redness, swelling, intense itching and urticated erythema. the face, lips, eyes, ears and neck are the most common sites for cosmetic allergy. photo contact dermatitis caused by the interaction of sunlight with an ingredient in a cosmetic.  Some people may develop more than one type of reaction. For example, an individual with sensitive skin may be prone to reaction with some active ingredients which in turn increases their likelihood of becoming sensitised, as their skin barrier function is weakened. The range of cosmetics is vast, so the pool of allergens is infinitely huge. The commonest allergens that appear to most frequently cause cosmetic allergy are fragrances preservatives and paraphenylenediamine (PPD) found in hair dyes. Fragrances the most common reason for contact dermatitis from cosmetics. 70–80% of fragrance allergy can be picked up by patch testing Cosmetics labelled “unscented” does not mean fragrance-free; some unscented products may contain a fragrance to mask another chemical odour. Products should be labelled 'fragrance-free' or 'without perfume' to indicate no fragrances have been used. Preservatives Preservatives are the second most common cause of contact allergic dermatitis to cosmetics. Cosmetics that contain water have a preservative in them to prevent bacterial or fungal growth. Some of the preservatives most commonly found in cosmetics have been covered Paraphenylenediamine in hair dye Paraphenylenediamine (PPD) is the third most common ingredient after fragrances and preservatives to cause allergic contact dermatitis. It is used widely in permanent hair dyes because it results in a natural colour. Reactions to PPD may be mild and involve dermatitis to the upper eyelids or rims of the ears or may be more severe with swelling of the scalp, face and more widely. How is cosmetic allergy diagnosed? By patch testing at a clinic designed to test for allergies. What is the treatment for cosmetic allergy? cease using the product seek medical attention - using a mild steroid, antihistamines if advised occasionally if the reaction results in an infection, antibiotics may be needed Prevention of cosmetic allergy The best way to prevent contact allergic dermatitis to cosmetics is by avoiding all products that contain the allergen. Seek personalised skin advice especially if you have sensitive or sensitised skin to minimise the risk of adverse effects. Read the list of ingredients on all cosmetic products to identify if they contain a relevant allergen. Test new cosmetics placing a small sample of the product on the inner wrist or elbow and observe for 24–48 hours. Choose products with few ingredients to minimise potential allergens. Apply perfume to clothing rather than to the skin; allow the perfume to dry before putting on the clothes. Look for products that are hypoallergenic, fragrance-free and non-comedogenic. However, be aware that these may still cause reactions. Your skin is the largest organ in your body and despite all the marketing hype thrown at all of us daily by the multi-billion dollar beauty industry, it may be in your best interests and that of your skin, to seek personalised advice around it, and its needs so you avoid potential adverse effects.  When it comes to your skin, tried and true is far better than pursuing every new trend that is out there.