Dr. Ahmad Rabb, Cosmetic Medicine At Medical & Cosmetology Centre In Toronto

Connecting with a Canadian physician practicing cosmetic medicine in Toronto, Dr. Ahmad Rabb.

Name: Ahmad Rabb, MD
Clinic: Medical and Cosmetology Centre
Location: Toronto, Canada

That's interesting: Dr. Rabb leads Bio Ethics Seminars for medical Undergraduates at the University of Toronto School of Medicine. He speaks English, Urdu, Punjabi, Sindhi.

You started out in family medicine but then switched to cosmetic medicine. Why did you switch?

It took me couple of years to transition from family medicine into cosmetic medicine. Over the years I realized that non-invasive and non-ablative skin care techniques were becoming increasingly popular and effective in reasonably reversing the adverse affects of different aging types ex. Photo-aging, Intrinsic aging (age related aging) and environmental aging.

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Botulinum Toxin as a Scar Treatment

A recent study shows that immediate post-surgery Botox injection could create a better scar appearance as opposed to delaying the Botox injection days after (Hu et al., 2018). The participating authors used saline to treat the other side of the scar side of the scar. Nineteen scars were evaluated in the study, and the authors used the Vancouver scar scale and the visual analogue scale.

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Botulinum Toxin is Effective in Treating Facial Synkinesis

Two new studies from the JAMA Plastic Surgery studied neuromodulators in treating facial synkinesis, With one of them comparing incobotulinumtoxinA (Xeomin), abobotulinumtoxinA (Dysport), and onabotulinumtoxinA (Botox) among one another (Thomas et al., 2017).

To determine its efficacy, the researchers depended on the Synkinesis Assessment Questionnaire (SAQ).

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Neuromodulators Introduced in 2017

Neuromodulators or botulinum toxins continue to gain popularity considering its effects on patients. Botox remains one of the most trusted brands in the market, and it does not seem to slow down along with the other two brands, Xeomin and Dysport. Of course, not everyone approves of having the botulinum toxins injected on them because of the effects that it has brought.

Revance Aesthetics is currently testing its RT002, and has had studies published regarding the efficacy of their neuromodulator, meanwhile EB-001 is fairly new but according to the company, their botulinum toxin seems to take effect much quicker than the current ones in the market. In that light, will the big neuromodulators brands be replaced by those still in testing phase?

In a previous article we published, we also wrote about Nabota, which has already been in use by some countries. Revance’s RT002 and Bonti’s EB-001 are currently undergoing trials, but both show potential.

According to Bonti, around 32% of patients show interest in having EB-001 injected on them. In a press release, the company mentioned they have conducted a clinical study, and it supports their claims about the product’s safety and efficacy. The product aims to be an introductory neuromodulator for those who have not tried and for time sensitive events.

As of December 2017, RT002 has reached Phase 3, which is showing better results than Botox. According to press releases, RT002 will have a six month duration period. If approved by the FDA, it’s the only neuromodulator that could ever receive that approval. Like the other neuromodulators, it has adverse effects like ptosis and headaches. Phase 3 will end its testing by February 2018.

These new brands will definitely shake the aesthetic market, since providers will have different options to choose. However, would these brands be able to replace the current ones?

These products will continue to compete regarding which one botulinum toxin would be enough to treat glabellar lines and crow’s feet, it is still unknown which among these treat these concern areas better. It is highly unlikely that the current three neuromodulators will be replaced, but possibly their market might change as there are other patients. Currently, patients can enjoy the present neuromodulators provided in your medical spa or practice.

Pricing Dysport, Xeomin, & Botox in the Aesthetics Market

Can you make money on Botox? Should you switch to Xeomin? The newest information shows that facial fillers and injectables will continue to be the primary physician-based cosmetic treatment (and a primary source of revenue and patient flow).

With Botox, Dysport and now Xeomin targeting wrinkles, and Juvederm, Radiesse, Kybella, Scupltra, and Belotero for volume/fullness, injection based treatments are the initial treatment point of contact for most cosmetic clinics, even those run by surgeons.

With the prevalence of these treatments we thought we'd take a look at the current state of care in the US (the largest single market) since there are a number of new players that are making inroads and taking some market share from the biggest players.

First up; Botox, Dysport and Xeomin.

Botox, Dysport, and Xeomin primarily treat glabellar Lines and lateral orbital rhytids (crow's feet) but they've seen increasing usage around the mouth in some practices. (We do not recommend this unless you're extremely skilled since this can cause some serious problems if you paralyze someone's mouth.)

These treatments are restricted by licence although there have been a number of unlicensed individuals (like this horror story) where individuals were treating patients.

Let's take a look at each.


The big boy in the market, Botox or onabotiliniumtoxinA was approved for cosmetic use in 2002. Approved treatment areas are as follows: hyperhidrosis, migraines, and the neck and chin. It is not limited to those areas as there are other FDA Approved uses in the body (Blepharophasm, Strabismus, and Overactive Bladder). It is used off-label by some physicians to treat other areas.

In 5 major US Cities, the average price of a Botox treatment for a patient is around $400. Botox (10mu) is selling around $400-$525 according to some US physicians and based on pharmacy price but it's much cheaper outside the US. Units used differ depending on the treated area, with a recommended 20 Units for the Glabellar Area, 6 to 20 Units for the Forehead, 4 to 12 for the Crow's Feet.

Many patients find Botox as the most effective in making wrinkles disappear, most are satisfied with their treatments over time, with a 95% Satisfaction Rate among patients. Not all however are mostly satisfied with their procedure, because some have complained making their appearance worse, probably do to the fact that every patient with a new treatment becomes hyper-focused on the mirror. Still, don't be to quick to discount patient reported effects of unevenness, ptosis, and sagging.

According to Mukherjee (2015), Botox is expected to grow to $2.9 Billion by 2018 with the facial aesthetic market to balloon to more than $4 Billion, with the US contributing half of it. (Nice!)


The teenager Dysport (abobotiliniumtoxinA) entered the market in 2009 and has actually been giving Botox (Allergan) a respectable competitor. In its early release, many were skeptical about its efficacy, strengthening Botox' popularity among patients (possibly do to it's lower cost). However, many studies have shown that Dysport is a fast acting injectable as compared to Botox.

Why choose Dysport over Botox?

In a double-blind study conducted in 2011, Botox and Dysport were used to test ninety patients. Dysport was the better choice to treat crow's feet in the study. The dosage used in the study had 30 Units for Dysport, while 10 only for Botox.

On average, Dysport treatment costs $360 for some major US cities we looked at for Botox. As for the selling price of Dysport to physicians, it is at around $475-$800. According to some physicians, for treatment of crow's feet at least 30 units is used to treat one side, 20-80 for the forehead, and 40-80 units for the glabellar.

Dysport can be an alternative to those who do not find Botox effective. Some prefer Dysport as their neuromodulator of choice due to its longer efficacy. It has been said that due to lesser proteins, Dysport can easily be accepted by the body.

It has proven itself to be a worthy competitor against Botox with a 93% satisfaction rate by Dysport users. On the other hand, it is not all met with praise since it can cause the same side effects to patients that Botox can.


The new kind on the block. Among the three neuromodulators, Xeomin contains only incobotulinumtoxin A, resulting in some calling Xeomin the 'Naked Botox'. It has no proteins which both the two prior injectables contain, and it requires no refrigeration. Many observe that Xeomin has the slowest onset among the toxins, with results appearing 3-4 days after treatment.

In administering Xeomin, the needle is smaller and the injections are a few centimeters away from each other (less pain?). It also uses only around 10-25 units for one side for crow's feet treatment, 10-15 for the forehead, and 20 for the glabellar. Merz retails a bottle of Xeomin at $466, with some pharmacies selling it at a lower cost around $260 - $300. On average, the treatment of Xeomin to patients is around $355.

Xeomin showed great results for frown lines for most patients, but it's often rated slightly lower by patients in terms of satisfaction. This may be due to actual results, but it's also likely that differing injection techniques by new clinicians who have previous experience with Botox and Dysport, as well as less patient name recognition could be the cause.

As part of this series we're going to do some internal surveys and research into pricing and satisfaction across physicians. If you'd like to be involved and/or have access when we release these results, please make sure that you sign up as a member.

Read the sister post to this on filler injections pricing and satisfaction for clinicians.

Dr. Michael Law - Michael Law MD and Blue Water Spa, NC

Dr. Michael Law shares about his experience in aesthetic medicine, and how he runs his clinics with wife Kile in our interview with the Plastic Surgeon.

Dr. Michael Law - Michael Law MD and Blue Water Spa, NC

Name: Michael Law MD
Clinics: Michael Law MD/Aesthetic Plastic Surgery and Blue Water Spa
Location: Raleigh, North Carolina
Website: www.bluewaterspa.com, www.michaellawmd.com

Brief Bio:

Michael Law MD is a plastic surgeon certified by the American Board of Plastic Surgery. He received his M.D. degree at Emory University, where he graduated magna cum laude, second in his class of over 100 graduating physicians, and was inducted into Alpha Omega Alpha. He elected to pursue a rigorous ten-year training program that includes general surgery residency at the University of California Los Angeles (UCLA), plastic surgery residency at the University of Southern California (USC), and a plastic surgery fellowship at USC. His ten years of formal training following medical school amount to twice that of some plastic surgeons.

How did you get started with plastic surgery?

I knew I wanted to be a surgeon since childhood. I elected to become a plastic surgeon for several reasons: for the creativity required for practice of reconstructive surgery, for the procedural and anatomic variety of surgeries performed, and perhaps most of all for the opportunity to be artistic in my life’s work.

I practiced plastic surgery in Beverly Hills for several years after completing my surgical residency and fellowship. While there, I started working with aestheticians. I realized early in my practice that good skin care was a great compliment to aesthetic plastic surgery. When I made the decision to move to...

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New Botulinum Toxin Undergoing Clinic Trials: Daxibotulinumtoxina

More competition might be coming for Botox, Dysport and Xeomin.

Three cosmetic injectables are currently available in the market (Botox, Dysport, and Xeomin). A fourth one is shaping up as the next competitor against the botulinum toxins. Revance Therapeutics Inc. is gearing up to produce the newest in the botulinum toxin market. The daxibotulinumtoxina is the newest to gain interest.

The neurotoxin is currently undergoing trials since early 2016. It claims that it will have a longer effect on the face against those available in the market. A 2011 study have found the effects of daxibotulinumtoxina for injection (RT002), which shows its efficacy and longevity.

How would this affect the three existing neurotoxins?

So far, Botox is the popular choice of neurotoxin, it being the first and proven effective for treatment of glabellar and lateral canthal lines. Xeomin and Dysport treats Cervical Dystonia and the glabellar lines. Many have expressed their concerns with the existing neurotoxins, most specifically with the possible side effects (e.g. ptosis).

Why does it matter?

Revance will include a peptide technology called: TRANSMTS in their (what they claim) a highly purified botulinum toxin to produce a longer-lasting effect. Aside from treating any aesthetic concern, daxibotulinumtoxina will also treat plantar fasciitis--- which is also undergoing study— and cervical dystonia. The neurotoxin will also come in a topical form.

Peptides have been used also for some cosmetics, with some calling it as an alternative to Botox having anti-aging effects for the face. Most studies regarding peptides are focused mostly on cosmetic products (i.e. make-up).

Botox, Dysport, and Xeomin have been met with their own criticisms from patients and physicians. The daxibotulinumtoxina could be a game changer in the market. Trials are underway for the daxibotulinumtoxina. Not much can be said about the trials but so far, the sample has not experienced any serious or adverse effects. According to clinicaltrials.gov, the study for the efficacy of daxibotulinumtoxina will be released on 2018 at the latest.



Dr. Steven Ang - Steven Aesthetic and Laser Clinic, Orchard Road

From injecting earlobes for good luck to training other physicians, Singaporean Physician, Dr. Ang has a number of interesting stories to share.

Dr Steven Aesthetic and Laser Clinic, Orchard RoadName: Dr Steven Ang
Clinic: Dr. Steven Aesthetics and Laser Clinic
Location: Orchard Road, Singapore
Website: stevenaesthetics.com


Dr Steven Ang started his private cosmetic medicine practice in Singapore in 1998. The same year, he became a member of the International Union of Esthetic Medicine, and in the process, introduced the term and concept of esthetic medicine (cosmetic medicine) locally. He was one of the pioneer cosmetic doctors in laser medicine and surgery, intense pulsed light, botulinum toxin and dermal filler injections in Singapore. In the past, he had been a trainer in botulinum toxin injections. He had developed the course syllabus at a local beauty school. He was a member of the Beauty Task Force, a committee set up by the Consumers Association of Singapore to look into objectionable practices by beauty salons and consumer complaints in Singapore in 2002.

Which factors played in your journey to cosmetic medicine?

I was exposed to using lasers for skin treatment in 1991 while working at a clinic. In the process, I saw a big market potential for cosmetic medicine.

As a teenager, I suffered from severe acne. One of the nasty remarks made by a former classmate that stuck in my mind was: “Your face looked like excreta.” Later, I managed to treat myself and regain confidence. This motivated me to want to help others. My favorite tagline is “Sculpting Beauty, Creating Happiness”.

I graduated with Bachelor of Medicine and Surgery degrees from the National University of Singapore in 1987. I sought further training at the renowned St John’s Institute of Dermatology in London and obtained my Master of Science degree in Clinical Dermatology from the University of London in 1994.

In the early days, there was no formal training for cosmetic medicine. I enrolled at a local beauty college that offered diplomas from the United Kingdom and Switzerland. I learnt the practices of an esthetician. In 1998, I became a member of the International Union of Esthetic Medicine (IUEM), which was based in Europe.

I started my private cosmetic medicine practice in Singapore in 1998, and through my membership with IUEM, introduced the term and concept of esthetic medicine locally.

Slimming and body contouring are another aspect to cosmetic medicine. To learn more, I undertook the clinical and oral examinations conducted by the American Board of Barriatric Medicine (now renamed as the American Board of Obesity Medicine) in 2002.

I now practiced at two locations, in Orchard Road and Redhill. We offer a full range of esthetic services. Our staff strength is 13 personnel. We serve thousands of patients each year.

Every cosmetic physicians has stories. What stories can you share with us?

One thing I learnt about practicing cosmetic medicine is unpredictable situations can arise and you must learn to respond. Once, I have a Chinese patient who consulted about getting dermal filler in his earlobes. According to him, a bigger earlobe will attract fortune and ensure a long life. Being Chinese myself, I know that these ethnic physiognomy beliefs are real. Therefore I proceeded to treat him.

As an experienced physician, what can you advise your fellow doctors in cosmetic medicine?

Over the years, I have learned that there are several critical factors that can contribute to the success of a practice...

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Dr. Ebtisam Elghblawi - Aesthetic Dermatologist in Tripoli, Libya

Libyan Dermatologist, Dr. Elghblawi, expresses her passion towards aesthetic medicine and continues to develop her skills in cosmetic medicine further.

Dr. Ebtisam Elghblawi - Aestethic Physician in Libya

Name: Dr Ebtisam Elghblawi. MD, MBBCh, MScRes, ADD, DRH and PGC skin cancer
Clinic: Tripoli, Libya
Specialties: Clinical, medical and aesthetic dermatology
Website: l2106.wordpress.com

Brief Bio:

I am based in the capital. (Tripoli)

I am not that big and I am not with the idea of having a busy crowded clinic as many do. I believe on quality rather than quantity and patient satisfaction would generate eventually loyal patients.

I am very keen passionate to master facial aesthetics. I always want to improve my current skills, scale them up and increase my knowledge in Aesthetic as it’s a dynamic medicine. It’s about the concept of “less is more" with minimally invasive procedures. So it’s about how to not guess the patient age and not to know if the patients had any work done already, just being looked refreshed and contented.

I developed passion about aesthetic dermatology and want to learn the art and the skills of it to tailor it accordingly. It’s delivering harmonious beautification and not overly done procedures with pleasing aesthetic results which will positively impact your patients’ lives. I personally want to create a pleasing reflection when my patients look into a mirror. Which would give them inner empowerment and which make a difference in peoples’ lives and create a self secure state. I am always eager to learn more and more.

Question: Can you tell us a little bit about you and how you got started in cosmetic medicine?

I started in 2012 embarking and learning about the aesthetic dermatology in great details to learn the basic knowledge, essence and the foundation. Plus learning the science behind emerging aesthetic medicine based products and devices. It’s a wide field and every time it keeps changing as I said up about medicine development. Even now I can speculate that the future in aesthetic for face lifts by facial threading as its emerging strongly in the market. It’s a huge market though and any one should be familiar and well oriented about its pros and cons in order to avoid fatal mistakes and patients disappointment. It is very vital to meet patient’s expectations at the first place, in order to gain their trust and develop a mutual rapport and understanding which I consider the backbone to any booming procedures. I started developing my own skills from reading extensively and attended some training workshops abroad plus subscribing to attending online webinars and sharing views, procedures and results.

I am inborn artistic as I do drawing as a hobby since I was young and I believe tasting beauty and performing it would help to achieve the desired subtle changes to enhance beauty in an acceptable and a comforting manner. I dislike extreme changes which would imply and reflect negatively.

A person per se is a piece of art, a sculpture, and herein we are creating a beauty. We have to look at each person face objectively. Moreover the market currently is looking at attraction and beauty the most and aesthetic work should improve the quality of people lives. Aged skin involves a lot of physical process, starting off with the photo-aging and the process of aging itself, where skin become thin, loss its elasticity, elastin and collage, fat, and with imminent bone resorption and become loose, redundant and sagging with gravity which would impact our wellbeing and self confidence.

The face should have divine measures. We have to look for artist for each client faces. Patients are exceptionally critique due to many brands across the market.

Moreover as I said, medicine is evolving speedily and constantly and a new lesson to gain and learn is essential. We learn over time and nowadays practicing medicine is uniform across the world as its all connected by the well developed technology, the ‘internet’, and is only culturally differs. Medicine after all is Nobel and risky profession. “The day we graduate medical school we say, “Doctor do no harm.” Thus taking care of the patients by listening to them wisely and addressing their worries, show empathy and compassion and meeting their expectation is a triumph to any doctor.

Any medical practitioner has to have the appropriate training; in-depth knowledge based learning, expertise and experience to perform the procedure and to deal with all routine aspects of care and any likely complications. It is very essential to be reacquainted with facial anatomy and should pay a careful attention to the dangerous zones of the face, where detrimental complications can happen, namely vascular obstruction, tissue necrosis and permanent blindness.

Nonetheless, in reality nowadays, many registered medical doctor has started performing non-cosmetic surgical operations without proper qualifications from an accredited training body at all. There should be some guidelines and appropriate regulations with licensing that would have had more force, and offer more protection to the public and for doctors towards having appropriate qualifications and proper training. Nonetheless, it stops short of mandating a minimum qualification. The decision as to the level of expertise or experience is left to the doctor.

In the least practicing doctors should have the required knowledge, expertise and experience. However, no one is immune as in fact many qualified surgeons also harm patients and generate complaints.

The public trust the level of training and supervision involved is some reassurance a minimum level of skill has been obtained. The problem is always, ‘oversimplified the procedures and overstated the results’, which would have a strong impact on patients’ attraction as many medical practitioners do. It is after all the integrity of the treatment which should be the main concern for any medical practitioners.

Moreover, additional local anaesthetic may be administered, and this could lead to an overdose, which is potentially fatal if was not used wisely.

Some cosmetic surgeons have a significant conflict of interest – putting patient interest ahead of profits. Also it’s mandatory that ethical obligations to patients supersede profits. This is an important first step, but it cannot be the last. Also subtle changes would help rather than looking like aliens.
Moreover, patient assessment and informed consent is mandatory for the medical practitioners to provide and convey clear information about risks and possible complications.

I myself offered some patients who wanted to have cosmetic for a change and cannot afford the high prices, and to feel confident by injecting them for free and paying only the price for medicine from the dealer. I am trying to help my patients to have the face that they want to feel better in and out, and I offer empathy that many doctors lack, and I know what I am doing. I constantly stop while performing the procedure and let the patient to look into the mirror to show and explain what I am doing. One patient I recall told me that these changes changed her life and made her feel good and even men complimented her at work. It is always good to not putting profit above the wellbeing of our customers.

Nowadays, there are procedures done by the girl who runs the tanning bed shop or a local hairdresser and it is atrocious.

I give myself top-ups with fillers and Botox. I know the human face better than many expensive surgeons, and I can even do procedures on myself proudly speaking. Many of my cosmetic colleagues just inject patients and did not try on themselves at all and wondering why not to have the feel of.

I take the say of “I wouldn’t perform a procedure I had not had done on myself, to experience the procedure myself. We need to protect anyone who has cosmetic procedures and I should know – I have been under the needle and behind it.

Conversely, women have long been held path to a higher aging standard than men, but it appears as though that gap may be closing, as now men are joining in women, and “They realize that they also want to look and feel their best, and to maintain a healthy and youthful appearance especially when older work in a younger men workforce environment. Botox for instance, helps turn the frown line upside down and sometimes as the say of ‘The person looking back in the mirror is not the person you feel like’. It’s called ‘Brotox’ for men.
Men nowadays are much more open and proactive about their appearance. And this can be explained to the reason of quick fix with no downtime for starters.

It has been found that youthful appearance can generate more revenue than their older looking peers, and the widespread accord that men require higher doses of Botox than their female counterparts.

Many men do secretly Botox ‘little and often’, where nothing is severe really. Vain middle aged men like to call it a ‘Brotox’ and like to give it a go. Botox is shameless vanity, an expensive, self indulgent secret.

The ‘English look’ is where a skillful needlework given to freshens up a face rather than creating a creepily smooth forehead. It is always better to address the face as a whole to look better and not necessarily different.
The general joking say is ‘the more fit men are, the worse they look, they look close to death’. As in fact heavy exercise causes fat to drain from a needy area and build up in parts of the face where it conveys an ugly look for men. Brotox is meant to just accentuate masculinity which means improving the jaw line rather frown freeze thing.

Men who have tried Botox look better, feel better, and believe it gives them a competitive frame. Furthermore there's also less of a stigma associated with cosmetic procedures nowadays and they don’t see it a taboo treatment as used to be and they believe on the importance of maintaining a youthful look. After all, skin treatments can improve their looks and self-confidence.

Lastly, it is always the ubiquitous search for eternal beauty and youth which won’t stop at all and always will be developing and evolving.

Question: Can you tell us more about your clinic?

I don’t have my own clinic. However I always suggest some changes and offer some ideas to make the clinical practice more appealing, charming and attracting. The aesthetic in Libya is still kind of primitive and I expect to grow more across the coming years. The clients can vary unexpectedly and both genders nowadays want to look their best, refreshed and alluring.

The services I do are mostly clinical and aesthetic dermatology, namely, Botox, filler, PRP, chemical peeling and laser technology.

Question: Staffing is always something that physicians are interested in. Can you give us some insight into how you hire and manage your staff and what you’ve learned?

Not applicable.

Question: What IPL or laser technologies are you using? What are your thoughts about the technologies you’re using now?

I have worked with Candela laser gentlelase for hair removal and was a good pleasing experience. I know IPL is not that effective as the laser itself and I have written a paper about it and hereby the link to it;

• Alex Laser Hair Removal with Candela GentleLASE®; http://blog.healthjobsnationwide.com/alex-laser-hair-removal-with-candela-gentlelase/

Question: How do you market your clinic?

Not applicable.

However, from what I am seeing recently that most uses the social media, face book to generate, advertise and promote about their works and I think it conveys the message strongly, however we have to be very careful about spreading and disseminating our work and it should be the truth and not just selling sparkling and dazzling words. We have to reflect precisely what we do to gain and keep patients trust.

Question: What treatments or services are most profitable for you?

I can’t comment precisely about this as I am not that kind of a doctor who likes to have a lot of patients to work on one go. I like to work in peaceful, calming and quite environment to create, innovate and deliver a quality appealing results that patients will like, and not a quantity results.

My patients come to me and most often, the first thing they say is, I don’t want to look done. In fact, some of my patients don’t tell anyone they have had work, not even their partners. They simply want to look refresher and good.

Question: What have you learned about practicing cosmetic medicine? What stories can you tell?

What I can add is that we have to listen to our patients sensibly and address their main concern and worries and don’t give unrealistic expectation to avoid misfortune and disappointment which would incur a lot of problems, plus will affect our reputation.

Addressing patients’ main expectations and checking out realistic outcomes are the main goal in any successful aesthetic practice. In many instances some patients do have body dysmorphia whereby they never appreciate nor see any positive outcomes even if it was subtle. It’s after all, patients own perception of their body and they could just make unnecessary troubles.

I happen to see lately a lady that I feel sorry for her. She did filler since few years that she is not aware of the kind injected and I think it was calcium hydroxylapatite (CaHA) and the issue caused her four big hard stony nodules in her smile lines and cheeks. I sought medical advice from abroad to try sorting her out and called her twice. However she responded but declined attendance, and I kept thinking of her I must say as its really a tragic misfortune that could happen to any injectors.

Also sometimes you keep explaining to the patients and it seems they are mute and cant digest it well. For example a lady with a facial and neck sagging skin came to me and I advised according to her budget to have her face done in stages to appreciate the subtle changes. So basically I told her we can do the forehead with Botox to relax it and improve a bit the two long deep vertical lines around the glabella and I explained that we might even need filler to smooth it out after filling it and for the neck I can start with short mono lift threads and I even didn’t charge my hands work. She only paid for the goods, and after that she came complaining that she just wasted her money and didn’t see nor appreciate that changes though it was obvious and clear. She kept saying that the forehead is only a skin over the bone and doesn’t have any muscle really and that I didn’t do anything really for that. And as far as for her sagging neck, I explained it needs time to see the subtle changes and might need more needles the cog ones or the silhouette soft lift. However she is not prepared to pay for them as they are costly. Moreover she declined me taking photos after where I can compare and show her the changes that she cant see really. Some patient can be so stubborn that won’t see nor appreciate and just give you a hard time and put blame whatsoever on you and accuse you with all sorts of reasoning. You explain and even tell them to read on the internet to have the basic feel, and the knowledge; however it is as you throwing words in the air. Nothing really would work and such patients should be declined at the first instance as they will only waste your time, create troubles and give you a hard time.

Another story a lady who has pigmentation on her face and came and demanded a clearing up for her face skin. I explained about the chemical peeling and what is expected and all can her brain process is having a baby pink skin and other drawbacks her brain couldn’t digest. So she kept coming and blaming me for that as its my own fault. They think all just can happen in a glimpse of time.

Another story that a lady who had a deep simle line and a big fatty face demanded filling up those lines and declared she wont pay for more than one syringe of one cc. I had managed to make her dream come true through that and was an amazing sublte correction that my colleague appreciated it well by that small amount. However she kept coming and complaining and said it wasn’t as she wished.

Another story a lady who had filler for her smile line and a tiny bit on the sides of her lip, kept complaining of angioedema and thought its due to the injected filler. Though her examination didn’t show any lumps and after a through investigations, found that she fancy taking red chili plus she had bad teeth hygiene and gums troubles.

Another story from a greedy colleague who wants to make profit on you. A patient I did since sometime and she was content and all went well. This colleague obviously has no morality. He didn’t pay my money and despite of that called the patient and told her if she has any problem that she can complain about me and took all that as an excuse to not pay my money for the lady I did. Anyhow after 8 months she shown up in another clinic that I work in and she knew me and was happy about my aesthetic services and told me that the greedy colleague wanted to use her for his own sickness and asked her to complain if she didn’t like my work which obviously she declined as in fact she is happy with the results she achieved by me. It seems sometimes that colleague can act badly and secretly and the sky is the limit.

Question: What advice would you give to other physicians based upon your experiences?

I always emphasize the foremost on is listening to our patients carefully and addressing their main concerns and needs in order to reach a good settlement that would give a pleasant experience which would mean keeping the work on even in the future once patients gained the physicians trust. It’s also vital to weigh things between patient needs versus patient wants.

Cosmetic involves and covers all phases from patient assessment through to aftercare. And a small wrong thing in patients is unforgettable. Plus it’s highly recommended to document every small thing because patients keep forgetting especially when it comes to cosmetic.

I always like to provide quality aesthetic procedures to my patients. It’s important always to learn how to develop and sharpen our aesthetic eyes, and keep up to date with the latest studies, researches and technology in the field of Aesthetic Medicine.

We all know that aging process is inevitable. Thus, it’s vital to understand the concept of the aging process and the proper aesthetic analysis in order to create and correct. I recently joined a course which addressed the 4 ‘R’, which stands for; rejuvenation modalities- (Resurface (skin care), Relaxation (Neurotoxins), Refill and replenishment (Dermal Fillers) and Re-suspend and boost (Face-lifting).

It is not the injectable but rather the injector who makes the difference after all once mastered the art. It’s also important to hear to the patient feedbacks in order to improve, master and innovate.

Lastly, it’s about safely enhancing the patients’ current beauty without altering their natural facial features. After all, People are now more conscious about their outlook and they scare the aging process and wish to defeat it.

Facial Injections: Does the size of the needle matter?

For Botox injections, is there any benefit with using smaller needles?

The current standard seems to be 30-gauge needles for Botox, buta recent study shows that 33-gauge needles caused less pain.

(Investigations related to clinical needle derived pain also demonstrate that needle size is not the only factor affecting patient comfort level. In addition, the mechanics of needle insertion has been found to significantly affect pain. Both the force and the mechanical workload (i.e., area under the force-displacement curve) of hypodermic needle insertion have been found to positively correlate with the frequency of pain. Thus, needle tip sharpness and other factors, such as lubrication, which can reduce the force of insertion and mechanical workload, and pre-treatment with a topical anesthetic are important parameters that can be optimized to reduce pain from needle insertions.)

From the study:

The highest level of pain was in the malar region, and the lowest level was in the glabella. Although all pain scores were lower for the 33-G microneedle, the difference was significant only for the forehead. Because most minimally invasive procedures require multiple injections during the same sitting, the overall procedure was evaluated as well. Assessment of the multiple-injection process demonstrated a significant difference in pain level, favoring the 33-G needle. Although the difference in bruising was not statistically significant between the two needles, the degree of bruising was lower with the 33-G needle.

Conclusions: For procedures that involve multiple injections to the face (such as mesotherapy and injection of botulinum toxin A), thinner needles result in less pain, making the overall experience more comfortable for the patient and the physician.

There are a few other studies that show similar results and there are some contradictory findings from a study in 2010.


1. The Effect of Microneedle Thickness on Pain During Minimally Invasive Facial Procedures: A Clinical Study. . Aesthetic Surgery Journal. 1 July 2014 Billur Sezgin MD, Bora Ozel MD, Hakan Bulam MD, Kirdar Guney MD, Serhan Tuncer MD, Seyhan Cenetoglu MD

2. Effect of Needle Size on Pain Perception in Patients Treated With Botulinum Toxin Type A Injections: A Randomized Clinical Trial. JAMA Dermatol. 2015 Nov;151(11):1194-9

3. Dermatol Surg. 2010;36(1):109-12. Needle preference in patients receiving cosmetic botulinum toxin type A. Price KM1, Williams ZYWoodward JA.

4. Egekvist H, Bjerring P, Arendt-Nielsen L. Pain and mechanical injury of human skin following needle insertions. Eur J Pain. 1999 Mar;3(1):41-49.

5. Egekvist H, Bjerring P, Arendt-Nielsen L. Regional variations in pain to controlled mechanical skin traumas from automatic needle insertions and relations to ultrasonography. Skin Res Technol. 1999;247-54.

6. Schneider LW, Peck LS, Melvin JW. Penetration characteristics of hypodermic needles in skin and muscle tissue. Phase I (Appendices B-E). Final report. Highway Safety Research Institute, Ann Arbor, MI; 1978

7. Dermatol Surg. 2005 Dec;31(12):1655-9. Single-center, double-blind, randomized study to evaluate the efficacy of 4% lidocaine cream versus vehicle cream during botulinum toxin type A treatments. Carruthers A1, Carruthers J.

Originally published on LinkedIn by Michael Greenspan. Link

Pfizer's Inversion Of $160 Billion Allergan Deal Called Off

Pfizer terminated it's $160 billion agreement to aquire Botox marker Allergan.

It's something of a victory for lawmakers looking to stop corporate mergers designed to reduce taxes in the US. It would have cut Pfizer's tax bill by 'relocating' the company to Ireland where Allergan is registered.

In backing out of the deal Phiser will have to pay Allergan up to $400 million for it's expenses according to the merger aggrement. (Who negotiated that?)

The Treasury Dept. also implement a new rule that does not allow stock accumulated through a foreign company's U.S. deals in the last 3 years to count towards the "book value" needed to meet this new inversion threshold.

2016 Trends: Classic and Elegant Beauty

The year 2016 is predicted to be a time for putting forward a classy, elegant, and modern yet effortless look.

Beauty experts reveal that  the trend is leaning more on the "natural" look as complexions are expected to be taking a softer turn with a subtle quality.

Glowing and luminous skin will be a trend. According to Vogue, the recent call to natural beauty was given a windswept polish this season, with healthy washes of sun-kissed blush at Gucci and Michael Kors Collection meeting the breeze-tousled waves of Versace, Alexander McQueen.

Its all about bright and pouty lips this 2016, with classic reds and browns as "in" lip colors as they balance against a backdrop of a bare skin.

Hairstyles are expected to be going back to basics as natural and effortless look will be in style and buns and ponytails will be given a fresh twist. As they say, less is more.

With these trends, minimally invasive aesthetic procedures are expected to be popular among medspa patients to achieve a more enhanced yet effortless and youthful look.

Non-surgical facelifts, use of autologous fat grafting, botox injections, and fillers are among the procedures that are expected to be a trend in 2016.

Non-invasive procedures which offer less pain and quick recovery are also seen to be popular among patients. 

For more beauty trends in 2016, you may browse: http://www.vogue.com/13359453/top-beauty-trends-spring-2016-fashion-week/.

Stunted Emotional Growth From Botox In The UK?

Botox treatments on young patients (under 25) may retard their emotional growth and is "morally wrong" according to some UK clinicians.

At least that's a recent BBC headline that might be more link-baiting than actual research. 

According to the UK's Journal of Aesthetic Nursing, clinicians say there is a growing trend for under-25s to seek the wrinkle-smoothing injections but research suggests "frozen faces" could stop young people from learning how to express emotions fully. Additionally, a leading body of UK plastic surgeons says injecting teenagers for cosmetic reasons is "morally wrong".

What's going on here?

Nurse practitioner Helen Collier, who carried out the research, says reality TV shows and celebrity culture are driving young people to idealize the "inexpressive frozen face."

But she points to a well-known psychological theory, the facial feedback hypothesis, that suggests adolescents learn how best to relate to people by mimicking their facial expressions.

She says: "As a human being our ability to demonstrate a wide range of emotions is very dependent on facial expressions.

"Emotions such as empathy and sympathy help us to survive and grow into confident and communicative adults."

But she warns that a "growing generation of blank-faced" young people could be harming their ability to correctly convey their feelings.

"If you wipe those expressions out, this might stunt their emotional and social development," she says.


Dr Michael Lewis, a researcher in psychology at Cardiff University, says: "The expressions we make on our face affect the emotions we feel.

"We smile because we are happy, but smiling also makes us happy.

"Treatment with drugs like Botox prevents the patient from being able to make a particular expression and can therefore have an effect on our learning to feel emotions naturally."

Rajiv Grover, president of the British Association of Aesthetic Plastic Surgeons, says: "Injecting teenagers with Botox for cosmetic purposes is morally wrong and something that no ethical practitioner would do.

Of course this might have been morea bout Ms Collier's presentation at the Clinical Cosmetic and Reconstructive Expo and generating a little visibility for both the presenter and the venue.

I tend to agree with many of the premises here in that cosmetic treatments simply to cater to perceived imperfections for younger patients just shouldn't be performed, but it seems a stretch to say that the Botox is the cause rather that the effect. In the patients that I've seen that fall into this age group and are looking for cosmetic treatments there are already many factors that are contributing to this behavior in the first place rather that flowing from previous treatments.

Body dysmporphic disorder in the young is something that every cosmetic practioner runs into from time to time. It's up to each clinician to understand what the patient psychology is and how best to address it. Blaming the actual treatments is overly simplistic in my view.

Fee-splitting Botox & Restylane In Medical Spas

Fee-splitting Botox & Restylane In Medical Spas

medical spa fee splitting for botox and restylaneHave you ever paid a commission for Botox and laser treatments? Although it’s very common ... it’s also very illegal.

During the past several years, a very troubling trend has developed in the medical spa industry. Nurses, nurse practitioners, physician assistants and laser technicians are being paid by commission in order to incentivize them to bring new business into the spa. This is very lucrative for both the spa and the individual, but unfortunately, in most states, it is illegal.

However, by accepting commissions for Botox treatments, she was engaging in illegal fee-splitting. Not only could she face significant monetary sanctions if she continued to do so, but both she and her supervising physician risked immediate suspension or revocation of their licenses if the state learned she was taking commissions.Fee-splitting refers to dividing or sharing fees from medical services between a physician and a nonphysician. In most states, all fees generated for medical treatments must be paid directly to a physician or physician-owned corporation. No one other than the physician—including nurses, physician assistants or any nonphysician medical practitioners—may receive any share of a medical fee.

Although the prohibition against fee-splitting has been on the books in most states for years, the practice of paying commissions has become quite prevalent in the medical spa community. This is probably because, in medical spas, most medical directors do not want to spend time firing lasers or injecting since other services can be more lucrative. As a result, injections and laser treatments are delegated to other medical professionals, who, in turn, develop a large client base. An easy way to compensate those professionals is to pay commission.But the consequences for fee-splitting are severe. In most states, the state licensing board has the power to revoke, suspend or refuse to renew licenses in response to fee-splitting allegations. Accordingly, regardless of the monetary incentives, it is always advised to avoid paying or receiving commissions. A safe alternative to fee-splitting is to use a pre-set bonus structure—the nonphysician can still be rewarded for performance, but the bonus is not related to the number of treatments performed.

Recently, a client called me with an urgent concern. This client, a registered nurse in Chicago, worked in a medical spa as an injector and laser technician. She was well-compensated: In addition to an hourly salary, she was also given a commission—a percentage of net revenue—for every Botox and laser treatment she performed. And boy did this nurse perform—during the past 12 months, she personally had generated more than $350,000 in revenue for the spa.

Her concern arose from a conference she had recently attended where she learned that most states have laws prohibiting fee-splitting. She was informed that taking commissions on Botox and laser treatments might land her in hot water with the state nursing board. She explained that this didn’t make sense, given that she had been receiving commissions for years, and that the physicians who paid her surely wouldn’t risk their licenses by doing something illegal.

It is imperative for any medical spa professional to seek legal counsel immediately if being paid a commission for medical treatments. The laws of each state vary and are often difficult to find, but as is often the case, ignorance of the law is never an excuse.

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Dr. Alicia Teska - Skin Temple Medi Clinic & Spa In Melbourne, Austrailia

Dr. Alicia Teska Australian Cosmetic Physician

Name: Dr. Alicia Teska                  
Clinic: Skin Temple Medi Clinic & Spa
Location: Melbourne, Australia
Website: skintemple.com.au
That's interesting: Dr. Alicia Teska is a founding fellow of the Australasian College of Aesthetic Medicine.

What is it like practicing cosmetic medicine in Australia?

Cosmetic medicine is much regulated for doctors in Australia, but completely unregulated for any other health provider. It can be very frustrating to find that your previously loyal client is now going to the home of a local plastic surgeon’s nurse to have their Botox injections.

Unsupervised (and uninsured) nurse injecting (of just about any substance at all) is quite rampant in Australia. I get a number of new clients coming in each week who have had treatments in salons or at the nurse’s home, with complaints about the outcome.

Australia regulates its own medical technologies independently of other countries. If the technology has been approved for a use in the USA, it definitely assists to get it through the Therapeutic Goods Administration in Australia a lot faster.

I have been reported for calling myself a "Cosmetic Physician". In Australia, there is a frightening holier-than-thou attitude towards medical practitioners who work outside of a “Royal College” setting. It is disturbing to see how ignorant many medical practitioners are of the work being done by Cosmetic Physicians. The regulatory body in Australia (AHPRA) would like to see the Cosmetic Physicians who are vocationally registered (Fellows of the RACGP, such as myself) call themselves Specialist GPs. This would be quite misleading to my patients, as I no longer practice the full spectrum of normal General Practice.

There is an opportunity to establish a subspecialty/special interest group of General Practice in Cosmetic Medicine/Dermatology. I think it’s likely that a group of us who work exclusively in that area will get together and put Cosmetic Medicine on the map in this country.. if the politics allow!

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