04(12): Aesthetic medicine – does it deserve such a bad rap?

Background

Yesterday, I went to get a haircut and while I was en-route to the barber, I encountered a sign which advertised the list of aesthetic services offered by a GP clinic, which itself was a member of a chain of GP clinics. Interestingly, aesthetic medicine isn’t recognised as a specialty or subspecialty in Singapore. Doctors who attempt to market themselves as an ‘aesthetic surgeon’, ‘aesthetic physician’, or a similar title will have to face various penalties as this would be deemed unethical by the Singapore Medical Council.

Anyway, on the topic of specialties, as a mere medical student, it’s still rather premature to hone in specifically on a single specialty. After all, this isn’t the US where medical students are required to pick their specialty early on. In Singapore, doctors have the flexibility to slowly discover where their interests and aptitude lie. In tandem with the advice given by senior medical students and doctors, I have decided to keep an open mind regarding what I might find myself doing in the future. Besides, as someone who is about to advance to Year 4 of medical school, there are still so many specialties that I have yet to gain exposure to in the form of clinical rotations.

As such, besides ophthalmology, I possess a broad interest in many other areas including, but not limited to: family medicine (including aesthetic medicine), internal medicine (cardiology, dermatology, endocrinology, infectious diseases, medical oncology, neurology, nuclear medicine), pathology, radiology, radiation oncology, and otorhinolaryngology.

In this blog post, I would like to talk specifically about aesthetic medicine. The perception of aesthetic medicine by the general public doesn’t seem to be a positive one. Most people seem to view aesthetic medicine as an exploitative field where practitioners are so fiscally oriented to the extent that it is borderline sickening.

A late doctor’s thoughts on life, wealth, success, and happiness

The thoughts of the late Dr Richard Teo Keng Siang (1972-2012) have amplified such a perception. You can read his thoughts on life, wealth, success, and happiness here, a webpage which offers a transcript of a speech he delivered a few months before his passing. The webpage also offers an embedded YouTube video of his speech, which was recorded eight months after he had been diagnosed with terminal lung cancer.

For those among us who have chosen not to read the entire transcript or watch the video, the essence of Dr Teo’s speech is as follows:

As a person from a below-average family background, he was told by the media and his peers that happiness is about success, and that success is about being wealthy. So, Dr Teo made it his goal to become wealthy. Dr Teo was a brilliant student who excelled academically, even in medical school. After graduating from medical school, he obtained a traineeship in ophthalmology, and was also awarded a research scholarship to develop lasers to treat the eye. In the process, he was able to obtain two patents: one for developing the relevant medical devices, and one for developing the lasers. Despite attaining various impressive academic accolades, he realised that these per se did not bring him any wealth. Once his MOHH bond was completed, he left for the private sector (specifically, to practise aesthetic medicine) because he decided that ophthalmology training was taking too long, and that there was much more money to be made in the private sector. He became very rich from practising aesthetic medicine. However, one day, he presented with back pain and approached his colleague at SGH for an MRI just to rule out spondylolisthesis and other ominous conditions. Unfortunately, the results of the MRI scan and subsequent investigations were not reassuring as Dr Teo had hoped. Dr Teo was eventually diagnosed with terminal lung cancer, and given a prognosis that many patients would deem highly unfavourable. He finally opines that true happiness doesn’t come from serving yourself, and that we ought not to let society tell us how to live. We ought not to let the media tell us what we’re supposed to do. We have to decide whether we are working solely for our own benefit, and/or whether you are going to make a difference in the lives of others.

This speech by Dr Richard Teo is so well-known that I have encountered his story on three separate occasions. I remember hearing about Dr Richard Teo for the first time when I was preparing for my GCE O Level exam in my final year at Maris Stella. That was in 2013. As for the second time, I encountered it via a link that a fellow friend who was a medical student shared on her Facebook profile (this was before I deleted my Facebook account for good). Lastly, I also remember hearing it for the third time during my church’s Watchnight service on 31 Dec 2019, where the pastor shared Dr Teo’s story in an attempt to emphasise the point that much of the material possessions that we can indulge in are truly ephemeral in the light of eternity.

With such a story to top it off, it is therefore no surprise that some people feel that aesthetic medicine is the epitome of unbridled capitalism, where people who are insecure about their physical appearance (particularly those of the fairer sex) are mere cash cows to be milked till their udders are sore. Some people even go to the extent to say that providing aesthetic services is not really medical practice. However, in my opinion, even after all that Dr Teo had said in his speech, such perceptions of aesthetic medicine are too harsh. They are too one-sided and fail to offer a balanced perspective of what aesthetic medicine has to offer.

A careful reading of the transcript of Dr Teo’s speech would allow one to realise that aesthetic medicine is neither evil nor exploitative per se. What’s more critical is your intention that undergirds your practice of aesthetic medicine, which will manifest in your attitude towards patients, and consequently, how you treat them.

Aesthetic medicine can offer individuals the opportunity to put their best foot forward in this society which places such an undue emphasis on one’s external appearance (like it or not). This can give patients greater self-confidence, allowing them to fulfill their potential even as they wend their way through society.

Thus, in this blog post on aesthetic medicine, I would like to take the opportunity to briefly introduce some examples of aesthetic services that may be offered in a GP clinic. This is in no way an attempt to promote any specific clinic. Rather, undergoing the process of writing this blog post would mean that I would need to acquire a basic understanding of each of the procedures that is advertised. Ultimately, I hope to have a better understanding of those aesthetic services as aesthetic medicine is a future area of practice that I’m considering. Additionally, as an inquisitive person, it brings me great joy to learn more about things that pique my curiosity. It brings me great joy to engage in writing, and sharing what I’ve learnt with you, dear reader.

The following image is a photograph I took of the sign:

I shall attempt to briefly describe how each procedure within Section 6 (highlighted in pink) works, based on the readings I have done for this blog post. Note that there’s going to be some overlap between the sections as the listed bullet points are not mutually exclusive.

Laser Hair Removal

Laser hair removal is a procedure which involves shining a laser on the region with the unwanted hair. The light is absorbed by the melanin (a dark pigment) in the hair. Within the melanin, the light energy is converted into heat, which damages the follicles that produce the hair. This in turn impairs future hair growth. The effect isn’t permanent, though such laser hair removal effectively delays hair growth for a long time. Any hair that grows out subsequently may be shorter and thinner than before.

Whitening & Pigmentation Treatment

Skin whitening can be achieved via chemical peels, or IPL (intense pulsed light therapy). Chemical skin peels will be discussed in a later section.

As for IPL therapy, which is also known as a photofacial, it is a non-surgical modality for one to improve the colour and the texture of the skin. IPL uses the energy from photons to target a certain coloured pigment on your skin. When the particular region of skin is heated, the body gets rid of the unwanted cells in that region, and that gets rid of the thing you’re being treated for. Unlike lasers, an IPL device sends out more than one wavelength of pulsating light. As such, IPL can treat a range of skin conditions at the same time.

Nevertheless, you can’t have your cake and eat it too. Due to the use of several wavelengths at a relatively gentle intensity on your skin, multiple sessions are normally required for the desired results to be achieved. After IPL, you may look younger because your skin tone is more even. And since the light doesn’t hurt other tissue, you can get better quickly.

As for pigmentation, the skin can either be hypopigmented or hyperpigmented. Hypopigmentation refers to having skin that is lighter than your overall skin tone. Conversely, hyperpigmentation refers to having skin that is darker than your overall skin tone.

There are many modalities that can be employed to treat hypo- or hyper-pigmentation. These include dermabrasion, chemical skin peels, laser skin peels, and IPL.

Laser Surgery for Moles/Warts/Lumps

Moles, warts, and lumps are typically harmless, and patients often want them removed or at least reduced in size for cosmetic reasons. One way of achieving this is via laser surgery. However, at least for moles, lasers (which are typically CO2 lasers) are only used for small moles. This is because for larger moles, the laser would not be able to penetrate deep enough to eliminate the pigmented cells that give rise to the moles.

Microdermabrasion

Remember how I mentioned ‘dermabrasion’ earlier? Well, that is different from microdermabrasion. Dermabrasion is an exfoliating technique that uses a rotating instrument to remove the outer layers of skin, and as you can imagine, this is most often requested for the facial region. Immediately following dermabrasion, treated skin will display some of the cardinal signs of inflammation such as rubor (reddening) and tumor (swelling). Note that I’m not actually suggesting that a neoplasm would form as a result from dermabrasion! It’s just that the Latin word ‘tumor’ is used to refer to ‘swelling; oedema’! The skin that grows back after dermabrasion is usually smoother.

As you may have guessed from the terms, microdermabrasion is a less aggressive form of dermabrasion. Microdermabrasion is a noninvasive cosmetic procedure which involves the doctor spraying or rubbing fine crystals onto the skin with a wand that gently exfoliates the surface, removing the top layer. The complications aren’t severe as that of dermabrasion (e.g. there’s no bleeding in microdermabrasion); however, the results of microdermabrasion unfortunately aren’t as spectacular as that of dermabrasion.

Chemical Skin Peel

Chemical peels work by having a chemical solution is applied to the skin to remove layers of the skin, revealing the underlying skin. There are three types of chemical skin peels: light, medium, and deep. As we go from light to deep, the thickness of the skin that is ‘peeled’ off increases. For the light skin peel, only the epidermal layer is peeled off. However, for the deep chemical skin peel, both the entirety of the epidermis and the dermis are peeled off. After the skin peel is done, the new skin underneath is often smoother, appears less wrinkled, and may have less damage.

Note that deep chemical skin peels are really rather invasive and nowadays, they are increasingly done less in favour of laser resurfacing, which we shall soon cover in the next section.

Laser Skin Peel & Resurfacing

Laser resurfacing treatment involves the emission of beams of light (this is basically what a laser is) to penetrate the skin and target either pigment, haemoglobin, or water in the skin. Depending on what is targeted, different skin abnormalities can be addressed. When pigment is targeted, age spots, sun spots, and dark spots can be reduced. When intradermal haemoglobin is targeted, erythema (reddening), scars, and stretch marks can be reduced. When intradermal water is targeted, wrinkles and fine lines can be reduced.

Radiofrequency

Radiofrequency skin tightening involves the doctor using a handheld device that is connected to a machine that creates radio waves. They will pass the device over your body to apply radio waves to your skin. The radio waves are exothermic, and this stimulates the production of more intradermal collagen and elastin. This treatment also speeds up cell turnover, and as such, the skin gets firmer and thicker over time. The process can take about an hour, depending on how much skin you are having treated. The treatment will leave you with minimal discomfort. You may see these treatments called by the brand names Thermi, Exilis, Profound RF, and Thermage, among others. The ‘Therm-‘ prefix that you see in some of these brand names should remind you that the radio waves are exothermic!

Botox & Skin Fillers

We have come to what is arguably one of the most famous aesthetic services: Botox.

Botox is the brand name for botulinum toxin, which is a substance that is produced by the bacterium Clostridium botulinum and a few other related organisms. As the name suggests, this toxin is toxic! Specifically, the toxin is toxic to the nerves. It prevents the release of the neurotransmitter acetylcholine (ACh) from axon endings at the NMJ (neuromuscular junction), thus causing flaccid paralysis. When people are infected by this organism, and experience flaccid paralysis, the disease they are said to have is botulism. It’s similar to how when people are infected by a related organism, Clostridum tetani, they are said to have tetanus.

Unlike the experience in botulism, where the infective bacterium is rampant in the body and affecting all sorts of nerves via the unbridled spread of the botulinum toxin, Botox treatment is administered meticulously by the doctor. In Botox treatment, small amounts of the toxin are carefully delivered to specific regions via fine-needle injections.

Based on the pathophysiology of botulism, it’s not hard to see how Botox treatment can reduce wrinkles. With the administration of Botox on the face, signals (the neurotransmitter ACh) that cause the facial muscles to contract are blocked. Temporarily, at least, this would reduce the wrinkles around the eyes and on the forehead.

Fractional CO2 & Resurfacing Laser

See the above point on Laser Skin Peel and Resurfacing.

Antioxidant Treatment

Antioxidant treatment can entail a process known as iontophoresis, which is a process of transdermal drug delivery by use of a voltage gradient on the skin. Molecules are transported across the stratum corneum (the most superficial layer within the epidermis) by electrophoresis and electro-osmosis and the electric field can also increase the permeability of the skin.

Think of iontophoresis as basically priming the skin for receiving the antioxidant (the increased skin permeability would mean increased absorption of the antioxidant). This is one solution to the perennial challenge that cosmeceutical companies face, which is to develop products that can penetrate well enough into the human skin.

Let’s talk specifically about Vitamin C (ascorbic acid), a well-known antioxidant. When iontophoresis is used in combination with vitamin C, absorption is effectively expedited (once again, due to the iontophoresis-induced increased skin permeability). Transdermal delivery of vitamin C via iontophoresis would improve superficial pigmentation issues such as freckles, spots, and acne.

Conclusion

There is a wide variety of aesthetic services that are available at many GP clinics. It is intellectual sloth to simply paint broad strokes of aesthetic medicine as an arena in which the udders of insecure cash cow patients are milked in the name of unfettered profit maximisation. Doctors who provide aesthetic services are often unfairly stereotyped as greedy and exploitative.

At least through the lens of a member of the general public who is also a medical student, I opine that aesthetic medicine appears to possess tremendous potential as a means by which people can heighten their self-confidence, and allow them to put their best foot forward in a world which can be rather critical of people’s external appearances.

Moreover, the practice of aesthetic medicine isn’t confined within the four walls of a physical clinic. Excellent patient management is anchored in good patient education, which in the context of aesthetic medicine would include educating the patient on the importance of having, as a baseline, a skincare routine. I challenge you to find me a single doctor who doesn’t think that consistent application of moisturiser and sunblock (even for patients without any known dermatological conditions) is good practice.

Let’s be more open-minded and remember that health, as defined by the World Health Organisation, is ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.

Nic
21 June 2022

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