Peer to Peer
Diversity of procedures
Put to our panel are questions on hair removal, lidocaine, vitamin K and patient trust.
Our panel this session comprises: Dr Jean Carruthers, a clinical professor at the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver; Mr Rajiv Grover, an NHS consultant plastic surgeon who runs a private practice in Harley Street and London's King Edward VII Hospital; and Dr Ash Dutta, a former Sunderland GP who founded the Aesthetic Beauty Centre more than eight years ago and now has centres in both Newcastle and Sunderland
Q - I’ve got a patient on whom I do ancillary hyperhidrosis. She is interested in having laser hair removal under her arms. What time delay should there be?
Dr Ash Dutta: There is no fixed rule. Sensible and commonsense should apply. When you do hair removal, you have to bring the patient back every six to eight weeks if Caucasian. For a hyperhidrosis patient, you don’t need to see him or her for six to 12 months. You can always ask the patient to come back three to four weeks after the hyperhidrosis treatment and do laser hair removal.
Q - What is this safe sort of percentage of hydroquinone in people of skin of colour, type 5 and 6?
Dr Ash Dutta: I would always start with 2% for Asian patients, as it gives me huge confidence knowing it is a safe dose. For Caucasian patients, you can go up to 4%.
Q - Do you find that vitamin K helps treat patients’ circles around their eyes?
Dr Ash Dutta: The skin around the eyes is only about 400 to 600 microns. The rest of the skin is relatively thick, and so the colour of the basement membrane, which is about five or six layers down, is showing a lot more. Oriental and South East Asian patients tend to have a higher dark circle. Reactivity of the melana sites is important. There are over-the-counter preparations with vitamin K, but I haven’t found them helpful.
Q - What is your opinion of lidocaine in injectables?
Dr Jean Carruthers: I love it and I have to say I hate bruising my patients. Lidocaine makes it possible to inject almost anything just using topical anaesthetic on the skin. I add 0.1cc of 2% lidocaine with 1:100 Epinephrine to the already lidocained product.
If the most potent source of referral I have is the friends and family of my current patients and they say, “Oh no, it didn’t hurt” then more people come in.
But the other thing it translates to is more syringes per patient because you’re not hurting them and so, if they actually needed six syringes, they’re getting them, where they may not have been able to tolerate them before. Am I worried about lidocaine toxicity in any of those patients? I’m putting in only 0.1cc to 0.2cc of lidocaine—well away from any toxic level.
Q - Is skin rejuvenation a subtle way of patients coming to you, or are you so famous for Botox that they come to you straight for that?
Dr Jean Carruthers: My best hook is Botox, but obviously we sell skin-care products and there is “Hope In a Jar”. It’s really important that patients use good sunscreens, good vitamin creams, good cleansers and good moisturisers so that they feel good about their skin. The “feel-good” side of things is really important.
I’ve gone round into people’s practices who do mesotherapy and asked them what they do and it’s like chicken soup. I’m not going to inject chicken soup into somebody’s skin because I don’t want to slough their lower lid. If there is a large company thinking of putting together something that’s more scientific and less recipe-based, I’d be interested.
Q - Have you seen the average volume of filler used in patients increasing in the past five years?
Dr Jean Carruthers: The average injector does one syringe in their patients. I use five or six and I use different fillers in different areas of the face. In the less mobile areas of the face you can get away with just about anything. If you go about the education of patients by showing them examples, that is a powerful motivator for people to do just that bit more filler, because it makes such a huge difference.
I build trust by saying to them: “Well that is lovely and you’re on the way but I don’t think you’re going to get a result that you’ll be happy with from only one syringe. I don’t want to take your money and give you a sub-standard result. Save up for three syringes.”
Mr Rajiv Grover: Something I learned a few years ago was that patients don’t like to be sold to; patients like to buy. Some of my procedures are surgical, and so the consultation is lengthy, but one thing I find invaluable—and every patient who gets the letter to come to see me has this written in it for their appointment—is please bring photographs of yourself from 10, 20, 30, 40 years ago.
Looking at photographs of themselves is a useful exercise because they probably haven’t done that before. It emphasises to them how they have aged. I say, “Well, look at these pictures. How do you think you’ve aged?” They’re going to tell you that they’ve lost volume. You’re not selling to them. They’re buying.
