In January this year, the Therapeutic Goods Administration of Australia, aka the TGA, surprised the non surgical cosmetic industry with the news that we are no longer allowed to use common terms to describe some of the services we provide, using the drugs used in those services. Medical aesthetics can no longer use certain terms and those terms will be going away? What Kind of Terms are Changing in Medical Aesthetics? Terms that you commonly associate with the services you receive from a medical aesthetics practitioner are no longer able to be used in advertising, information on websites, and other key places. Anti wrinkle treatment Dermal filler Biostimulatory filler Fat dissolving injections You get the idea. What Do the New TGA Guidelines Say? It sent the industry into a panic and the TGA took its guidance offline to await confirmation. As of 7th March 2024 it had finalised its guidelines, and the new changes will go through, effective immediately. What do they say in essence? Historically, the TGA has allowed indirect references to prescription medicines to be referenced in advertisements related to cosmetic health services. This was allowed only in the context of promoting the service and only by using generic non-product specific terms such as ‘wrinkle reducing injections.’ Express references to products or ingredients themselves, such as ‘Botox’ or ‘botulinum toxin’, were not permitted. The TGA considered this a pragmatic approach which would allow cosmetic clinics who offered these services to differentiate themselves from those that did not. It goes into further details, the gist of which is essentially: we are no longer allowed to refer to those terms as they allude to the use of prescription drugs we are no longer allowed to use before/ after photos that suggest the use of prescription drugs eg before photo with someone frowning, and after photo without the frown; or a before photo of someone with thin lips and after photo with plumper lips etc Why is the TGA doing this? Recently, the TGA has observed that clinics and health services in other industry areas are advertising the availability of prescription medicines, usually by referring to a class of goods (for example ‘weight loss injections’, ‘medicinal cannabis’ or ‘nicotine vaping products’). The TGA has interpreted that promoting a health service in this way is also an advertisement for a therapeutic good that refers to prescription medicines, which is unlawful. The update aligns with the focus of other regulators on health professionals performing non-surgical cosmetic procedures and acknowledges the increasing vulnerability of Australians influenced by advertising in the cosmetic space. Prescription only medications carry higher risks than goods available for self-selection. Decisions about treatments that involve the use of prescription medicines should only be made by a health professional in consultation with each individual patient. In brief, as with all other means of prescription medications, a face to face consultation is the first step to addressing a concern in collaboration with your medical professional/ doctor to then determine next steps, treatment and whatever drugs that might involve. As you can imagine, this has the industry in a tizzy all over again. Do the TGA Guidelines Change the Medical Aesthetics Approach at Skin Essentials? At Skin Essentials, we’ve never advertised drugs by prices, nor by before/ after pictures such as above. We take a holistic full face approach to the face in front of us at a paid-for, non redeemable consultation designed with one thing in mind : understanding and addressing your aesthetic concerns determining if they can be helped or if you need another expert eg a plastic surgeon determining if we are likely to work well together ie a good fit determining if you have any vulnerabilities that make you unsuitable for cosmetic work or have unrealistic expectations determining the timeframe to get you results determining the cost of those results, which is significant determining if you are in a position, psychologically as well as financially to commit to the process as outlined If we tick all those boxes above, then we start. If you or I cannot tick any of the list above, then we don’t start, but you’ve had some idea as to what the cause of your concerns is, what is needed to correct them if/ when you are ready to begin. So from our point of view, not much will change to our processes at Skin Essentials. What *will* change is the ban on educating the general public on social media and the stern limitation of terms I can use to do this. Media from the USA and UK and other parts of the world continue to flood our feeds, with drug names and explicit videos of procedures. I used to use this for educational purposes but I will no longer be able to do this as this would be a violation of the TGA rules. While the goal and aim of the TGA is to stop unscrupulous operators from enticing and luring vulnerable people into medical aesthetics, often from a very young age, the reality is that since these changes were announced, the rogue operators, who continued to operate during Covid lockdowns, continue to post and use the terms “anti wrinkle”, “dermal filler” “nose filler” “biostimulatory filler” and more. As I’ve said before, I suspect they see pesky fines and disciplinary action as the price of doing business. As a small business, I can’t afford to do this nor do I want to. One of my strongest stances at Skin Essentials is our ethics and our values based approach to patient care. That won’t change in coming weeks and months as we pivot to find a new way to educate people without using terminology illegally. In the meantime, we ask our current patients to help others find us by leaving us honest feedback of their experiences with us in clinic given social media is being heavily censored going forward to help us stay in business. Thank you for your ongoing support and we hope to see you

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

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.