In December each year, historically, my children and I plan some time off during the summer school holidays during which we reconnect. For me, as someone who is (mostly) super organised, it is an annual tradition to plan my upcoming goals and aims for the year ahead in 4 domains: - personal - familial- professional - business Personal is obviously a huge category, emcompassing my personal and spiritual goals; health and fitness goals; skin and aesthetic goals, relational goals and more. So while I am behind on this goal setting for 2023, I find it soothing to have a plan, and a way to track my progress and to keep me accountable. With this in mind, I thought I'd share my top tips for helping you with your skin and aesthetic goals if you're not usually a planner and what I've seen work, time and time again, for my most successful patients over the years.  After all, as a Specialist GP with niche training and interests across several areas, including mental health, I find great joy and satisfaction in helping people who want to do better, simplify so they can see the results they say they want to see while holding them accountable; after all, as the saying goes, what is not measured, cannot be improved.  One of my longstanding patients said to me today, when times have been lean for her, she's prioritised the things that have given her the biggest bang for her limited buck so she could save for the more expensive things when things weren't as lean. 1. That is why at Skin Essentials, we focus so much on the initial consultation to understand your goals and aims, but also to give you a realistic picture of what we need from you to help you attain those goals, and over what timeframe. 2. It is why we hold you accountable to booked appointments, and will ask you if you are truly in the right frame of mind to invest in yourself if you regularly reschedule or cancel. In our experience we know this will not yield best results and the token late fee really does not pay our overheads.  3. Without trust there can be nothing - so the initial and subsequent consultations are designed to help determine fit - it has to be a two-way street, without which we cannot proceed. My patients I know, can see that I would never suggest anything that is not in their best interest, no matter how much money they have to spend on it. Equally, I don't work to your budget. I tell you what you need to budget, and you decide if you will find the money and how.  4. Lastly, realistic expectations are everything. So what are some realistic expectations I discuss with you and which we must align on if we are to work together?  I cannot help with significant lift - that is the job of a plastic surgeon. I can help with everything else - tone, texture, volume loss, even some tightening, but not lifting.  I cannot be oncall for you between appointments. This does not apply to emergencies obviously, in the first 24-48 hours when we touch base with you regularly if a treatment is new to you or you are new to us. Thereafter we do expect that if you have pressing concerns you will make an appointment online via video call or face to face to have your concerns addressed or make a note of it to discuss it at your next appointment - this especially applies to concerns to do with skin, skincare and changes which take months, not weeks to begin to show.  there is a mandatory wait period post injectables such as anti wrinkle and fillers, before which we will reassess you to address unevenness, lumps and bumps and more. There is a sound reason for this, and as I always say, medical aesthetics is for the patient patient.  Most medical aesthetics is entirely discretionary spending so it is important to me that you understand what your initial upfront cost will be, and also that you are prepared to budget and to commit so as not to waste your money and our time together. Equally, while we all have things come up occasionally, we also know that frequent cancellations and rescheduling of appointments will mean that you will end up with subpar results. As someone who prides herself on ethical care based in accountability, this is frustrating for me especially when significant sums of money and time are involved.  So as we round out 2022, the patients who've made the most progress and had the most gains have managed to:  stay on track communicate their changed goals if this applies, especially in view of current inflation and rising costs  remain compliant with at-home care, no matter how simple it is remain on schedule with all booked appointments remained patient with outcomes, understanding and accepting that it will take a minimum of 3 months, and often as long as 6 to 9 months to really begin to see progress communicated disappointment if I've said something to upset them, and likewise taken feedback on board when they've likewise because we have understood that boundaries help us stay in the therapeutic relationship.  So my advice with respect to goals, for my patients in 2023, if we are to continue working together to improve your skin, are:  Simplify your skincare, with expert help if needed and then stick to it. you don't need much, but the basics will make a massive difference OVER TIME and with diligence. once you know what that looks like for you, stick to it especially if you have sensitive or problem skin.       2. Less is more the media is constantly trying to sell you lots of STUFF everyone has an opinion on what will make your skin woes go away, yesterday. stop, ignore and press pause. if you have skin problems, you need

A cosmetologist in her late 50s in the USA posted recently about her skin transformation over 7 years and the true cost of it and it got me thinking. Much of the beauty and aesthetic industry is on an race to the bottom: they hire junior doctors and nurses to perform injectables purchased wholesale at bargain basement prices, with minimal training and minimal followup. consultations are cursory and complimentary and designed to convert on the day to people walking in expecting to pay hundreds to order a treatment off a menu irrespective of whether they’d be suited to that treatment.  In many cases, this is fine, there is definitely a market for this, and for those who don’t need much done, and want a quick pick-me-up, this is an absolutely ok model with lower risk treatments and no real problems to address.  This, however, is not the case for many as early as our late 20s and more typically our 30s and beyond.   By the time we get to our late 40s and early 50s, many, if not most women, if they’ve not had anything done till then, will begin to be reasonably bothered by what they see in the mirror, prompting online searches, a foray into online groups for advice, following influencers to see what their skincare routine is and even seeking a complimentary opinion from one of the clinics mentioned above, for guidance on how to fix what bothers them.   Many may decide not to pursue anything, and we have women who talk about this such as Mia Freedman on her notox stance .  On the opposite end we have beauty influencers such as Caroline Hirons known for speaking out against clean beauty and who is also a lot more open about spending on skincare as well as toxin and fillers. And who has drawn the line at plastic surgery for herself.      In your 20s, as a general rule, much of skincare, including injectables and skin therapies, tends to be relaxation and enhancement if there are no skin disorders such as acne. You may have lips that are thinner than you’d like, and 1-2 mls of filler is a quick and simple fix to address this.     In your 30s, these changes begin to become more pronounced: sun damage adds up lines and wrinkles become more apparent, especially if skincare has been minimal to date volume loss in the face leads to hollows, shadows and even sagging which can be distressing and invite unsolicited comments from others.     These changes, once present, will only worsen in our 40s, 50s and beyond as the perimenopausal and menopausal years set in alongside the relentless ageing process which is inevitable irrespective of what we undergo by way of skincare, in-clinic procedures and even surgery.            Depending on when you choose to begin your journey to ageing well, IF you choose to do so, the costs will begin to add up quite quickly at least initially, especially if there is a significant degree of effort needed to first halt or even reverse some processes eg acne with scarring; pigmentation including sungamage; etched in lines and wrinkles at rest; volume loss; loss of skin plumpness.  These concerns all require an approach that I call a Full Face Rejuvenation or an FFR and can be initially costly in terms of both your time commitment and money. There is quite simply, no easy or cheap way around this if you want to do it well. Would you expect to straighten your teeth for less than $7000-10000 and expect a good job for less than 12 months’ commitment?  Would you expect to pay less than say, $15000 for breast implants or a rhinoplasty and expect it all to settle within weeks rather than months? Would you expect to pay less than $30000 for a tummy tuck or a facelift and be driving the next week? The more work there is to be done, the more time, effort, consistency and money it will take and anyone who tells you otherwise is, quite simply, lying to you and selling you marketing Koolaid. It’s dishonest and it is taking advantage of vulnerable people. Sometimes I hear of people being told “You need 6-8mls of filler but if you can only budget for 1ml, let’s start with that and add to it over time.” My concern that I take issue with this is: 1 ml will almost always do nothing to show you any significant progress that will motivate you to save for more and to come back if you need 6-8 times that amount someone who has a budget for only 1ml is unlikely to be able to find the money for 6-8 times that amount in quick supply and may experience distress or financial angst as a result  there is a high chance of dissatisfaction and loss to followup and in the process, they’ve spent hundreds of dollars to achieve nothing, which could have been spent elsewhere on something else that might have brought joy FFR takes a degree of accountability - it is you that needs to decide if you will show up and commit and be consistent. The work in clinic is 20% of the entire process, if that. The remaining 80% is dependent on you and if you cannot or will not commit, then it is often easier and kinder for me to say no.  The woman who posted her own progress over 7 years in the USA, spent USD44,000 over the 7 years to achieve her results and for her, it has been totally worth it. This is what my own patients who have similarly spent significant sums of money, often in their 30s and 40s and hit maintenance which is far more manageable, tell me. As with all discretionary spending, it is entirely up to each individual what they wish to prioritise that makes them happy. No judgement here either way.  For some

I recently did a  live on Instagram with Clinical Psychologist Dr Toni Pikoos, in which we discussed the intersection of medical aesthetics and psychology as I have been reflecting on the type of patients who are less likely to have success with aesthetic treatments. As a doctor, I cannot overestimate the importance of the initial consultation in assessing patient concerns, their understanding of what is possible as well as their expectations of how aesthetic treatments will help them, whether they are willing to stick to the suggested timeframe and budget for the best possible outcomes. As such we simply will not engage with anyone who refuses to begin with an initial consultation or believes they can simply order a treatment as there is a chance they may be wrong, and feel they’ve wasted their time in attending the appointment. Perhaps especially because non-surgical treatments are largely elective from a medical point of view, I believe that practitioners have an ethical responsibility to select patients carefully, including screening for certain red flags and having protocols in place before treatment even begins. Related to this, it is imperative to look out for signs of body dysmorphic disorder (BDD) during the initial consultation and early stages of treatment as this is a contraindication to aesthetic treatment. The mental health of patients and the responsibility to protect the vulnerable ultimately lies with us so we have a duty of care to assess this before we inject or to press pause if we recognise it after starting if we can’t educate our patients.  Social media contributes to the disconnect between what is physically possible and what is best left to photoshop and filters, and marketing by big companies further encourages this by disguising medical treatments as just beauty - “lunchtime procedures” etc only serves to perpetuate this myth, so at Skin Essentials we go to some lengths to screen all new patients for potential red flags, but read on to see why this is harder than it seems. 3 key examples we encounter regularly enough: 1. Unrealistic expectations Often as early as during the consultation, but more commonly during the early treatment stages, it may begin to become apparent that the patient has expectations of aesthetic treatments that are unrealistic - for example, they may expect to be frozen with anti wrinkle treatments and to stay that way for the whole 3 months. or they may expect that 1ml of filler will replace typical volume loss in a 40 year old face, which might need on average, 4-6mls. others may come in with stories of having had treatment elsewhere with impossibly low doses which lasted unreasonably long periods of time.  At this stage, if it becomes apparent, I try and explore this expectation with them, how likely it is, and whether I can reasonably help them, including suggesting I may not be the right person for them if I am unlikely to be able to meet their expectations with respect to price, dose (and related to this, cost) or timeframe.  2. Budget vs true cost mismatch By the time we see people at Skin Essentials, most people have been dissatisfied with the ageing process for some time, usually months to years, and are keen to begin to do something about it. Unfortunately due to social media, as well as well meaning friends and a general sense of secrecy around the true cost of aesthetic treatments  they may severely underestimate the cost in terms of timeframe, frequency of treatments initially and the budget realistically needed to effect significant change in the areas that trouble them, which are usually also multi-factorial: skin lines, wrinkles and sundamage volume loss with hollowing of the face and sagging around the lower face  sun damage  pigmentation  redness/sensitivity etc  There is no one treatment that will treat all these various concerns; treatment options are usually best combined, and undertaken over multiple sessions over months to begin to see changes. For this reason, I commonly tell patients it is like orthodontic treatment - if it’s going to cost $10,000 and they only have a budget of $2500, they may be better off not beginning as they won’t achieve desired results. Equally, it is better to start and keep going than to wait because the ageing process will not.  3. Requesting to look like celebrities Rarely, patients will present with pictures of celebrities they wish to look like eg JLo, one of the Kardashians or specific attributes - big juicy lips, a non surgical butt lift for example - and it is then up to the practitioner to explain why it may not be a reasonable goal even if they have the money for it, due to limitations of anatomy.  So when this occurs, how do we deal with it at Skin Essentials?  1. Consultation  The fact is, there is never such a thing as “just some anti wrinkle treatment for X or Y” or “just some lip filler”. It does not matter how simple the prospective patient thinks the issue is, as a medical practitioner it is my responsibility and duty of care to assess each person, including a detailed medical history, assessment if appropriate and their expectations before we proceed to treatment, if it is appropriate to do so. We don’t do treatments made to order.  At Skin Essentials, you are emailed an intake form as soon as you have booked an appointment and it is in your best interests to fill this out as soon as feasible so we have a clear idea of your concerns as well as what is likely to be the problem. In truth, the consultation begins well before you walk through the door and we have a fairly good idea of what we will see and suggest when we finally meet you.  2. Education  We aim to maximise our time in clinic addressing your concerns, educating you on what they mean, and what, if any, the options to help improve them are; additionally, we discuss

Perhaps the biggest way to understand that medical aesthetics isn’t the same as hair, nails and beauty, is the fact that in order for us to carry out any procedures on you, it is a legal requirement to consent you for the procedure prior. While many, if not most people rush to sign the form at the very bottom and may not even properly read it, trusting their technician or doctor, it is in your best interest to not rush this, and to take your time and understand what you are signing up to and for. In my experience, a lack of attention and proper informed consent can lead to potential misunderstandings when something goes wrong. Think of consent forms as your opportunity to understand what you are saying yes to, and that you understand the risks and side effects - common and rare- as well as what is expected of you - eg a series of treatments in a given timeframe - as well as what you can expect from your doctor in terms of aftercare and followup routinely as well as in the event of a problem. Many clinics that offer complimentary consultations rely on the quick and cursory consultation that relies on a very brief process before waving a form under your nose to sign before treatment. They largely rely on a high conversion rate on the day (commonly boasting >95%) to generate revenue. This model does not work for me and feels inherently dishonest to me. Perhaps due to my background as a surgical trainee, I’m aware that consent is important and more than just cursory and often, a cooling off period is needed or a pause if a patient is uncertain, or more scared/ nervous than excited. So what should a consent form cover to give you peace of mind of an ethical provider? 1. You should understand the risks realistically before signing the form.  At Skin Essentials, we email all forms out at the time of booking so patients have plenty of time to read, process and look into any potential risks before signing if they are comfortable. On occasion, patients may hold off signing if they have further questions till they are back in for the treatment. Doing this ensures we allow patients enough time to read through the information without feeling rushed into signing. 2. The consent form should outline common and rare risks and side effects of the procedure and note that these are general, and your experience may nonetheless vary.  No two faces are the same, nor are two faces going to have the same anatomy and potential for complications. Equally, common side effects, while common, may be different for each person. So your consent form should give you some idea of what to expect from best case to worst case scenario so you can proceed with as much information as possible. 3. You should understand the costs, whether results can ever be guaranteed and the importance of the aftercare process or timeframe if appropriate and relevant.  Costs should be outlined for you, and you should understand what you will pay, your payment options as well as when payment is due as well as a reasonable estimate of any extra you may need to factor in for more, since aesthetics is an inexact science with no guarantees of outcomes. 4. You should be able to access the form to read over well before your planned procedure ideally.  Ideally, you should have access to the consent form well ahead of your planned procedure so you can read it in your own time, mull risks and side effects as well as downtime and sign with as much knowledge as you can reasonably be expected to have, without any pressure to go ahead. 5. The form may clarify what will happen if you need more treatment, and costs if applicable.  Due to medical aesthetics being an inexact science, many consent forms will often say things like “we cannot guarantee outcomes, only treatment” as well as costs if you were to end up needing more product than originally budgeted for/ estimated so you understand who’s liable for the cost. Equally, many will state cleary their policy with regards to refunds due to change of mind/ dissatisfaction with outcome etcetera. You should satisfy yourself that you understand all of these before proceeding. 6. You should have access to a copy of your signed consent.  Lastly, ideally, you should have a copy of your signed consent for your own records in the event of any dispute so you can see exactly what you signed consent to. Remember, medical aesthetics, unlike beauty, involves machines and procedures that frequently either break skin or go beneath the skin and carry rare but real risks so take your time, ensure you understand the risks and side effects including downtime and costs, to avoid misunderstandings. Anything else you’d add that you think should be included before signing a consent form?

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

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.