October 27, 2024 • 30 mins
Part 1: all things surgical and non surgical within plastic surgery an amazing chat with Dr Somia.
Dr Naveen SOMIA is a Sydney based specialist Plastic Surgeon.
Dr Naveen SOMIA is a strong advocate for patient safety, evidence based,
Patient centric collaborative care and is passionate about good patient outcomes.
Naveen’s leadership roles include past president of ASAPS, the Australasian society of aesthetic plastic surgery.
Dr Somia is the scientific convenor of the non surgical symposium that is Australia’s premier non surgical meeting and is a Council member of the Australian Society of plastic surgeons.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Appogia production.
Speaker 2 (00:11):
Hi, my name's beck Woodbine and welcome to Tenderness for Nurses.
Speaker 3 (00:15):
I'm grateful for the person that I have the opportunity
to be.
Speaker 1 (00:20):
So I hit it and parked it for Nelly four years.
Speaker 2 (00:24):
We always have free will, We always get to choose.
We are autonomous. Hi everyone, thank you for tuning back
into Tenness for Nurses. Today, I have the esteemed plastic surgeon,
doctor Levine Samayah from Sydney having a chat with me
and I'm very honored that he's taken the time to
come into the studio to do a podcast with me.
Doctor Levine is a Sydney based specialist plastic surgeon. He
(00:46):
is a strong advocate for patient safety. He is evidence based,
patient centric, collaborative care and good patient outcomes. That is
what he works by. He has leadership roles with as
the past president of ASAPS, which is the Australasian Society
of Aesthetic Plastic Surgery is ON or is this scientific
(01:07):
convenor of the Non Surgical Symposium that is Australia's premier
nonsurgical meeting of which I attended this year and actually
spoke with doctor VerTech. It was wonderful and he is
also a council member of the Australian Society of Plastic Surgeons.
Speaker 1 (01:21):
So welcome, Thank you Beck.
Speaker 2 (01:23):
We've got you on to chat about a couple of things.
Actually we posed some questions and have been asked some
questions about lipedema, but we'll do that as second part
of our conversation. The first part of our conversation is
I just want to hear a little bit about your
background and how you've got to where you are and
why patience safety is so paramount for you with your practices.
Speaker 1 (01:47):
We'll start off with my plastic surgical training which I
did in Melbourne and in Sydney. And once you complete
your specialist plastic surgery training in Australia, you've set an
exam called the FRASCS and become registered as a specialist
in plastic surgery by our property as a medical Regulator.
And I pursued additional advanced cosmetic surgery training in Atlanta, USA,
(02:09):
both in facial cosmetic surgery and I LID cosmetic surgery,
and somewhere along the way I decided to do a
PhD which was focusing on I LID reanimation in patients
who have had facial paralysis. So there's a whole heap
of concentrated content expertise in and around that area. Yeah,
then you start off being a specialist plastic surgeon offering
(02:32):
clinical services. And I was lucky enough to be appointed
at both the public hospital systems in Sydney and as
well as have a private practice that has evolved over
many years. And just as a natural fit, all of
us tend to gravitate towards certain procedures that would be
your area of expertise, and in my case, I focus
a lot on I lid, upper ilid, lower island and
(02:55):
pre orbital surgery, face facial surgery and obviously surgical and
non surgical. And then laipedema has as a passion of
mine and has become an interest of mine over the
last eleven years since I started treating patients with lepedema
and in the Kids Hospital in Sydney, I do treat
(03:15):
children who have vascular birthmarks. These are complex venus malformations
ateriovenous malformations that majority of them occur in the face
and the neck area, which tends to be quite an
issue for everyone. So we kind of have a plastic
surgical skills as a collaborative care approach in the multitisipary
(03:36):
is setting so that the patients who have vascular birth
marks can benefit from the treatment offered by a dermatologist
and interventional ideologists followed by a plastic surgeon who can
come and quote unquote rest or some degree of normalcy
to these areas.
Speaker 2 (03:50):
At what age do you start treating them?
Speaker 1 (03:53):
So the vascular legions have been oversimplified to give an
impression that one size fits all and somehow the laser
is the only treatment of help. Now this is further
from the truth because they are multiple types of vascular allegiance.
Because as we know that, you know, blood vessels are
not just arteries, their veins as well, and lymphatics come
(04:15):
somewhere close by as well, and sometimes you have a
combination of arteries and veins and pains and lymphatics. So
it just complicates the picture. Sometimes you have one, sometimes
you're multiple, Sometimes you're small, sometimes you're big. So all
of a sudden, the complexities just keep compounding. And the
presentation that we see in the kid's clinic is mainly
(04:36):
when usually the GPO of the pedutrition knows that this
is a concern and they start referring the child to
the clinic. And when they come, it is not a
single practitioner who sees the patient. The multitude of practitioners
see starting from dermatologists, individual idiologies, surgeons, plastic surgeons, and
if necessary, other additional specialties like yenos and throat as
(04:58):
well as orthopedic surgeons may need to see the patient
as well. And once we see the patient, basically most
of the time is spent trying to get to the diagnosis,
and the diagnosis is primarily basing is it an artery
or utter venus or venus of venosymthatic And once you
define the diagnosis of that, then you can then treat
(05:21):
the patient based on what the cause is and how
big the lesion is. And most of the time these
treatments are staged. These treatments may be timed. Sometimes we
don't wait till the kid is five or six or
seven or eight. Sometimes we wait till that so it
is very individualized. It is very individualized, so it's not
like one size fits all. And one of the things
(05:43):
that we have in the last few years started to
do is to start mapping the genetic profile of these
vascular birthmarks to see if there is a mutation of
one of the genes, with the hope of trying to
find a targeted therapy as an oral tablets which can
help prevent a recurrence. So sometimes some of these are inoperable,
(06:08):
or if they do get operate, on the risk of
references quite high. So fortunately we have access to collaborative
care through other disciplines, mainly hematology on college departments who
have expertise in this area, and through the genetic profiling services,
we can access this and provide a very good service
to these patients.
Speaker 2 (06:28):
I had no idea it was that complex. I'm like
what you said. I just assumed it was managed through
lasers and dermatology. You know that maybe one might be excised.
But I had no idea it was so complex.
Speaker 1 (06:44):
That's great. The etiology could be multifactorial. And I think
what we have learned is the more time you spend
trying to get the diagnosis right makes a whole heap
of difference to the eventual outcome of the the lesion.
Because if you say, example, if you're treating an arteriovenous
malformation with an agent to block the circulation, that is
(07:07):
not meant to be for avy malformations it will not
work right, or as if you use a arteri venous
malformation blocking agent for a venous malformation, it will not work.
So it has to be so this time you spend
trying to get the diagnosis right. See which blood vessel
feeds into this malformation is actually an essential part of
the diagnostic workup.
Speaker 2 (07:29):
That is fascinating.
Speaker 1 (07:31):
Coming back to cosmetic nursis and in a you're whare
that there's an anatomy for injectors. Of course we do
a day before the actual non surgical symposium and it's
all about facial anatomy of way to inject, where not inject,
inject are not inject and most of your complications or
poor patient outcomes in facial cosmetic injecting is primarily due
(07:53):
to knowing where the vessels are or where the vessels
are not. Are the normal or the abnormal? Is it
a variation of normal? So coming back to the vascular
anatomy of the face. So when you're a plastic surgeon,
that's what you do all the time. You know what
the anatomy is, how much you can push, how much
you can't go beyond when you start doing children who've
got vascular birthmarks, your knowledge of vascular anatomy of the
(08:14):
face just gets taken to the next level because you
see not just the abnormal thing, but you not only
see the abnormal ones, but you also see the normal ones.
And you're able to distinguish between what is a normal
vessel or this is where it's meant to be, this
is where it's been amplified, this is where it's malformed.
So there's a whole heap of vascular biology and the
(08:35):
vascular floor patterns that you understand very well.
Speaker 2 (08:38):
It's interesting. I use an ultrasound in my clinic and
it has absolutely taken my practice to the next level.
But oh my lord, has it been a huge learning
curve for me trying to differentiate the different shades of
the cut like white literally, but it has helped me
(09:00):
dramatically and like a good example is I had a
patient come in yesterday, a lovely young lady who had
had way, way, way too much filler over the years.
Beautiful looking woman, but the tear troughs and where the
filla had been placed it had just I would suggest
(09:21):
it had been placed inappropriately initially, and it was sagging
all down through here and here, and so she really
didn't like what was happening with the Naser labial folds
even though she hadn't had filler through here and her
tear troughs well, she cried after we did a treatment
to dissolve because she could not believe the difference and
(09:44):
how much younger she looked. And it just took it
to you know, knowing anatomy, you know, knowing how to
use the ultrasound, it just takes your skill set to
the next level. And it's it's I mean, obviously no
idea about vascularity like you do, but you know it
(10:05):
makes a big difference and it helps your patients dramatically
once you know at that level.
Speaker 1 (10:10):
Absolutely look the last. Needless to say that the Vescula
Clinic we do have ultrasounds for every single patient. We
check in, measure and map out the flow and so
on and so forth. But last year at the Anatomy
for Injector's workshop, we had an ultrason workshop on the
side introducing the concept of facial ultrasound for cosmetic nurses
for injecting understanding anatomy. And I personally feel that having
(10:33):
an ultrasound probe is like having a third eye right,
and it gives you not only the understanding of the anatomy,
but also gives you an understanding of the variability of
the anatomy, which is not really appreciated. So all of
us rely on anatomy based on the textbook diagram, and
I think that one size fits all. The answer is
you can have a very thick artery in one plane
(10:55):
on the right side, and the other side other half
of the face you'll have an exactly opposite In other words,
a classic one is the labial artery for the lip.
See most of the time, eighty percent of the time
the arter is in the bulk of the muscle, So
if you're injecting a normal filler to any of the
lip area, you're pretty safe. But there's two percent of
(11:16):
the time it'll be right at the place where you
should normally goes right, and on one side it'll be
in the depth of within the muscle, and on the
other half of the lip it will be where it
should not be. So if you had an alder sound
to kind of make sure that there is a hazard there,
you'll be very safe. Or sayerw injectors so to speak,
so I personally feel that if you're injecting, I think
(11:37):
that's a skill that I should not be your blind spot.
Speaker 2 (11:41):
One of the things I admire about you is your
willingness to embrace nurses. And you were one of the
first to encourage nurses to speak at the conference. And
what is it that you feel is so important about
incorporating nurses on the stage and as part of that
(12:02):
scientific group. Why is it so important to you that
nurses are included in this.
Speaker 1 (12:07):
First of all, thank you for the kind comments, and
you're right, we wanted to include every professional group that
was involved in cosmetic injecting. I think this space has
evolved over the last thirteen years that we have known. First,
initially it was independent injecting was not allowed. The subsequently
things progressed and evolved, and along with that you had
(12:29):
expertise increased by nurses who were injecting little by little
and then going on to run very successfulmitical practices, become
key opinion leaders in this space. And all of a
sudden you suddenly find that there were people who had
not just passion, who were very professional, had enormous amount
of expertise. And I think we have an open mind
(12:52):
towards learning from anybody right, very flexible in that because
no one has a monopoly of anyone's thought process, you
should be an independent thinker and you could do very well, right.
And that's what you see in the modern day world
of startup and unicons. And if you ever serve with
a number of unicons that are companies that are valued
at a billion dollars plus. If you look at the
(13:12):
founders of those unicons, they come from extreme diverse backgrounds,
extreme disruptive backgrounds, extreme disruptive thought process. So if the
tech companies have led the space by twenty one, yours
becoming billionaires, right because they had some incredible ideas. So
it's all about ideas. And this is a knowledge economy
that we're dealing with. And your knowledge is how you
(13:33):
apply your basic learning, your imaginative creative process, and your
understanding of patient safety and stay within the boundaries. So
it was very important for us to understand a perspective
of a wide variety of nurses who are kind of
the dominant injectives in the space. If you look at numbers,
nurses by far are the largest number of cosmetic injectives
(13:55):
in the country and medicine is quite hierarchical in how
it is being dealt with as a framework and a system,
so in some ways, trying to get an alternative viewpoint,
maybe a different perspective, helps to enrich everyone's practice. And
that was kind of the empetters. And subsequently, a few
years later, when the Dental Board of Australia decided to
(14:19):
include cosmetic injecting within the scope of the dental practitioner,
the Non Surgical Symposium was then open to dental practitioners
to attend the NSS right now, that was the logical
step because if a statutory body has made it to
the scope of practice, there's no reason why an educational
provider cannot make it open to you. Yes, and I'm
(14:41):
very privileged to have the support of my NSS Scientific
Adversory Committee, where we have one representative or at least
the minimum one representative from every single craft group that
represents the spectam of the industry. And to me, that
has been an incredible learning platform.
Speaker 2 (14:58):
That's so wonderful to hear. I know, I go to
the States a lot to see my daughter who's over there,
and I have been to quite a few conferences over
there and those nurses that are key opinion leaders, or
they're not even KOLs, they just are amazing injectors that
(15:19):
are getting up and talking and the information that is
shared blows me away. And I loved that. I was
sitting there and here were plastic surgeons deferring to some
of these nurse injectors about different techniques or skills because
they had an idea, but they knew that these nurses
or nurse practitioners were highly skilled in that particular space,
(15:43):
and it was really lovely to see. They've worked really
hard to be recognized in the States, particularly nurse practitioners,
and I have to say it's been quite refreshing. So
when I came and because I hadn't been to it
for a couple of years here in Australia and then
I went to NSS this year and I loved it.
(16:05):
It was great. There was this wonderful cross section of
people speaking. I learned a lot from this NSS because
I think there was such diversity, absolutely, because not everyone's
going to resonate with me, and it was funny the
ones that did resonate were a little bit quirky and
bit out there. I loved it so I'm cutos to
(16:25):
Scientific Committee because they really did a great job.
Speaker 1 (16:28):
Absolutely, thank you for the comments. And this year's NSS,
which is in SS twenty twenty four, in my opinion,
was one of the best nesss. It had a buzz
that we never experienced before. There's a whole deal of
positive energy as well as both from the industry as
well as participants and the regulators who came and spoke
as well. They were kind of quite very impressed to
know that this was a meeting that was actually talking
(16:49):
about ethical clinical practice, about ethical advertising, about evidence based
and these are all good standard recipes from good medical practice,
good clinical practice and good pasient outcomes. There's nothing more
about it.
Speaker 2 (17:03):
So I have I suppose it's a bit of a
controversial question. Why do you think that the Nursing Midwife
Board aren't recognizing cosmetic nursing as a specialty when it's
cosmetic medicine is a specialty.
Speaker 1 (17:19):
Now, cosmetic medicine is not an official specialty in Australia.
So if you look at the number of recognized specialties
in Australia, Opera has a list of all of it, right,
and cosmetic medicine is not one of them.
Speaker 2 (17:31):
Because this is so, can you explain that?
Speaker 1 (17:35):
So it's The National Law, also called the National Health
Practice Law, has listed list of medical specialties and subspecialities
and also listed the appropriate titles that people can use
if you're registered in that speciality. Say, for example, if
(17:57):
you're registered in their recognized medical speciality of plastic surgery,
you can call yourself a plastic surgeon. If you're an ottolarengologist,
you cannot call youself a plastic surgeon. That is against
the National law. Okay, So each registration category is linked
to a specific title, and trying to get a speciality
(18:20):
recognized by our as a new speciality is quite a
long and cumbersome process, which I'm not aware of how
combersime it is, but I know it is a long process.
So cosmetic medicine has not been recognized as a independent
speciality yet. Whether it's going to be done in the future,
I don't know. However, as it stands in the current
current statutory arrangements, if you're a registered medical practitioner, you
(18:42):
can practice cosmetic medicine. So registered medical practitioners anyone finishes
a basic medical degree who goes on to become a
general practitioner goes on to become a specially surgeon, goes
on to become a medical specialist, medical practitioner. Ong, you
can do cosmetic medicine right now. If you're a registered
dental practitioner, you can perform a cosmetic medicine. So it
(19:05):
is now within the scope of the nursing in the
midimitary board that you can you're allowed to practice cosmetic
medicine as a registered nurse or an endroid nurse or
a nurse practitioner. Whether it's going to be a separate discipline,
I don't know, And I think when you start looking
at the diverse group groups of people practicing cosmetic medicine,
the chance of it becoming a recognized medical specialty becomes
(19:26):
difficult because it is not homogenous likes a gastrientologist. They're
not homogenosts like say a habitably or resurgeon. It is
not homogenous like North Big surgeon. So there's too many
patterns within that group. So I'm not sure if that
will level be recognized as a medical specialty. But the
(19:46):
scope of practice is not going to be restricted as
far as we know.
Speaker 2 (19:50):
Okay, so they're what we're classes protected titles. So our
nurse practitioner is a protected title that is correct. Okay, Okay,
So a plastic surgeon is a protected title that is correct. Okay,
that makes sense. So for nurses, it means that we
will be registered as registered nurse and we choose to
(20:12):
work within the dermatology space or clinical dermatology, or within
cosmetic or it just seems such a dirty word in
nursing to say you're a cosmetic practitioner, which is why
I actually say I do cosmetic dermatology because I do lasers,
and I do other things and I do skin and
so it's one of those funny terms within nursing. Even
(20:36):
nurse practitioners are funny. With cosmetic nurse practitioners. It's this
wild West at the moment in nursing around this area.
Speaker 1 (20:47):
Look, that's that's interesting to say that because even if
you looked at cosmetic surgery, which is the practice of
cosmetic surgery, it was seen as an undesirable element by
the mainstream medicine folks thirty forty years ago, but the
market did not go according to that plan. The market
(21:10):
demanded that the cosmetic surgery was being provided and the
mainstream trained surgeons were reluctant the same for the same
reasons as you just mentioned, and that vacuum was filled
in by people who are willing to offer the service
and trying to pretend there were surgeons and the patient
outcomes were not perfect, right, And this is what hit
(21:34):
the headline news probably heard about the cosmetic cowboys and
all the four corners scenes that came after that, And
that is how it culminated. And you start off doing
small things and then next thing you know, as you
scale it a little bit, and next thing you know,
no one does anything about it, and sooner or later
you get confident and you think, OK, I can get
over this. Let me do this a bit more, and
(21:54):
sooner or later things became quite quite bad. So the
antidote to that, so we as ethical, evidence based practitioners
have an obligation to provide good patient care. And the
way we do this is we need to put a
hand up and say, look, I'm happy and capable of
providing good cosmetic surgery, and so should you, because you
(22:15):
know that if you shirk that responsibility and take a
step back, the person who provides a cave will not
be as well trained as you, not as well, meaning
as you, which does not translate to good passion outcomes. No,
it doesn't, Okay, so the good people have to put
the hand up and say, yep, this is what we provide.
So in some ways there's an existing preconcy bias in society,
(22:38):
both at all levels. And I think I can only
speak from experience of cosmetic surgery, where everyone, starting from
government and regulators and your surgical colleagues, think that our
cosmetic surgery is so trivia that can be trivialized. The
answer is not, because people do get hurt, and we've
seen the evidence points the other way around. And then
with a whole heap of cosmetic surgery reforms that came in. Now,
(23:01):
finally the title surgeon is finally protected. For you to
use a title surgeon, you have to be registered as
a specialist surgeon. You cannot call you self a cosmetic
surgeon anymore. If you're not a registered surgeon. You cannot
call youself a plastic surgeon anymore, if you're not registered
in the recognized medical specialty of plastic surgery.
Speaker 2 (23:20):
And I think that that's wonderful because that stops people
getting harmed and maimed.
Speaker 1 (23:27):
It prevents people from looking for a loophole to advertise
and misrepresent their skills and a qualification, because when you
say that you're a surgeon, it implies certain skills, qualifications,
and expertise when actual fact, you've just done a basic
medical degree and the day you finish your internship you
call your self a cosmetic surgeon.
Speaker 2 (23:48):
Yeah, no, that's not great.
Speaker 1 (23:49):
Yeah, and you can pretty much predict the outcomes.
Speaker 2 (23:52):
It's interesting. I was literally I came from work to
chat with you, and I was talking to another colleague
that had come in to see me today and she
works in a different specialty to me, and we were
chatting about how when this industry started to boom, so
(24:13):
many people just thought it was part of the beauty industry,
like it is in the UK. It's a nightmare over there.
And it's interesting for those of us that have always
tried to keep it medicalized and safe, but there's so
many out there that or the education to the general
public has been that a little bit of you know,
GGI whatever is just a bit of the beauty routine,
(24:36):
and it's not. It is really serious business, yes, And
I think the education needs to be for the general
public around that that this just isn't you know, pop
in and have a couple of meals with this and whatever,
that it's really important that you go to a really
(24:56):
good ethical practitioner.
Speaker 1 (24:58):
That's right. Look, that's very important for people to realize
that message. And I think popular media, Instagram, instant influencers,
they somehow trivialize the effort to find a good practitioner
as well as to understand the seriousness of what can
really go wrong. And all of us know when things
go wrong, they really go wrong. Yeah, And I think
(25:21):
for practitioners to understand that because practitioners, although they may
have been trained to do certain procedures, not realizing the
full implications of how the whole pendulum could swing will
also become a lot more causes. And if the public
are aware that, Okay, you find it is important for
(25:41):
me to look for a good, sensible, credible trained practitioner,
then I think you have a good system going forward.
And I think that the NESS are you may be
aware of that. We are starting what is called the
NESS Academy to facilitate this learning and also have a
public facing messaging system to start maybe next teen the
(26:03):
year after to say that look, This is kind of
the one of the benchmarks that you can use to
look for expertise and endorsed expertise.
Speaker 2 (26:10):
We're going to do a little shift now and I
want you and you mentioned a little earlier that you
have a big interest in lipidema.
Speaker 1 (26:25):
That's great.
Speaker 2 (26:26):
Can you explain what it is?
Speaker 1 (26:29):
Lipadema is a disease of abnormal fat storage that is
a genetic disease that you inherit through your genetic patterns,
which is influenced by hormonal searches of your body during
its natural cycle men namely puberty, pregnancy, and menopause. The
(26:49):
fat alipus tissue, which is a consequence of diet or
exercise or lack of ditallex exercise, is not the primary trigger.
It is a secondary trigger, and that's what confuses people.
So it'll come like a clockwork. It is like having
a tendency to have diabetes and you can aim to control,
but you can't cure it. It's like having tell my
patients it's a bit like having curly hair and the
(27:11):
only way to have straight hair is you and I
know how to do it, and haircut is not one
of them. So it is a condition that you inherit.
It is you same as the color of your hair,
color of your eyes, or your curly hair astraight hair,
and you have to be in a mode of lifelong control.
So this is kind of what confuses people. And because
it does not fit into the stereotyped assumptions of what
fat is, it behaves exactly opposite to that. That's what
(27:34):
confuses people. It looks like normal fat but behaves exactly opposite.
So the pattern of distribution of fat in lipidema is
the three common areas is thighs, legs between n between
n mee and ankle, and the arms elbowed to shoulder right.
(27:54):
There are rare forms of LIPIDOMTD position that could be
occurring only in your hips and your upper bottock areas,
and sometimes in the forearms. But these three patterns of
the commonest ones, and you will see people who have
absolutely small waists yes, and big legs. And the classic
question to ask patients is if you buy genes off
the rack, if the gene fits your thigh, is your
(28:17):
waist to lose? And if they say yes, that is lipidema.
Because genes are cut to a global average pattern of
waste to hip ratio and lipid patients fall outside that region.
If you have thighs, sorry legs, which is need to
ankle bigger, which is colloquially corald as cankles, patients will
(28:37):
not be able to put on a pair of boots.
They cannot wear ski boots or normal boots right, And
that has always been the classic questions you can ask patients.
And the other thing you ask patients is if you
put on weight, does your legs get worse? The answer
is yes, But if you lose that weight to the
legs get better, the answer is no.
Speaker 2 (28:56):
I have a dear friend of mine that is struggling
with this at the moment, and it's interesting since I've
become really aware of it and have had the conversations
with her. It's not that uncommon.
Speaker 1 (29:11):
It is very common. Conservative estimates predict the problems to
be around ten percent, that is, one in every ten
women have it in some studies have shown as high
as forteen or fifty percent.
Speaker 2 (29:25):
Does it tend to run in Caucasian lines in different ethnic.
Speaker 1 (29:29):
Lines, No, it's not unique to any single genetic group
or ethnic group. I've seen it in every single ethnic group.
The one group I haven't seen. It is in East Asians.
In other words, Asian Chinese people haven't seen them, but
the rest of the groups I've seen everyone, Northern European,
Southern European, Middle East, and African South Asian. Everyone.
Speaker 2 (29:52):
Thank you so much for taking time out of the
conference to coming and chat with me.
Speaker 1 (29:57):
Thank you, Beck, thanks for having me.
Speaker 3 (29:59):
Thank you for listening to Tenderness for Nurses. That concludes
part one of Beck's chat with doctor Levin. In part two,
she puts your questions submitted online to doctor Levine. Make
sure you follow the podcast and we'll see you next week.
Appogia production.
Speaker 2 (00:11):
Hi, my name's beck Woodbine and welcome to Tenderness for Nurses.
Speaker 3 (00:15):
I'm grateful for the person that I have the opportunity
to be.
Speaker 1 (00:20):
So I hit it and parked it for Nelly four years.
Speaker 2 (00:24):
We always have free will, We always get to choose.
We are autonomous. Hi everyone, thank you for tuning back
into Tenness for Nurses. Today, I have the esteemed plastic surgeon,
doctor Levine Samayah from Sydney having a chat with me
and I'm very honored that he's taken the time to
come into the studio to do a podcast with me.
Doctor Levine is a Sydney based specialist plastic surgeon. He
(00:46):
is a strong advocate for patient safety. He is evidence based,
patient centric, collaborative care and good patient outcomes. That is
what he works by. He has leadership roles with as
the past president of ASAPS, which is the Australasian Society
of Aesthetic Plastic Surgery is ON or is this scientific
(01:07):
convenor of the Non Surgical Symposium that is Australia's premier
nonsurgical meeting of which I attended this year and actually
spoke with doctor VerTech. It was wonderful and he is
also a council member of the Australian Society of Plastic Surgeons.
Speaker 1 (01:21):
So welcome, Thank you Beck.
Speaker 2 (01:23):
We've got you on to chat about a couple of things.
Actually we posed some questions and have been asked some
questions about lipedema, but we'll do that as second part
of our conversation. The first part of our conversation is
I just want to hear a little bit about your
background and how you've got to where you are and
why patience safety is so paramount for you with your practices.
Speaker 1 (01:47):
We'll start off with my plastic surgical training which I
did in Melbourne and in Sydney. And once you complete
your specialist plastic surgery training in Australia, you've set an
exam called the FRASCS and become registered as a specialist
in plastic surgery by our property as a medical Regulator.
And I pursued additional advanced cosmetic surgery training in Atlanta, USA,
(02:09):
both in facial cosmetic surgery and I LID cosmetic surgery,
and somewhere along the way I decided to do a
PhD which was focusing on I LID reanimation in patients
who have had facial paralysis. So there's a whole heap
of concentrated content expertise in and around that area. Yeah,
then you start off being a specialist plastic surgeon offering
(02:32):
clinical services. And I was lucky enough to be appointed
at both the public hospital systems in Sydney and as
well as have a private practice that has evolved over
many years. And just as a natural fit, all of
us tend to gravitate towards certain procedures that would be
your area of expertise, and in my case, I focus
a lot on I lid, upper ilid, lower island and
(02:55):
pre orbital surgery, face facial surgery and obviously surgical and
non surgical. And then laipedema has as a passion of
mine and has become an interest of mine over the
last eleven years since I started treating patients with lepedema
and in the Kids Hospital in Sydney, I do treat
(03:15):
children who have vascular birthmarks. These are complex venus malformations
ateriovenous malformations that majority of them occur in the face
and the neck area, which tends to be quite an
issue for everyone. So we kind of have a plastic
surgical skills as a collaborative care approach in the multitisipary
(03:36):
is setting so that the patients who have vascular birth
marks can benefit from the treatment offered by a dermatologist
and interventional ideologists followed by a plastic surgeon who can
come and quote unquote rest or some degree of normalcy
to these areas.
Speaker 2 (03:50):
At what age do you start treating them?
Speaker 1 (03:53):
So the vascular legions have been oversimplified to give an
impression that one size fits all and somehow the laser
is the only treatment of help. Now this is further
from the truth because they are multiple types of vascular allegiance.
Because as we know that, you know, blood vessels are
not just arteries, their veins as well, and lymphatics come
(04:15):
somewhere close by as well, and sometimes you have a
combination of arteries and veins and pains and lymphatics. So
it just complicates the picture. Sometimes you have one, sometimes
you're multiple, Sometimes you're small, sometimes you're big. So all
of a sudden, the complexities just keep compounding. And the
presentation that we see in the kid's clinic is mainly
(04:36):
when usually the GPO of the pedutrition knows that this
is a concern and they start referring the child to
the clinic. And when they come, it is not a
single practitioner who sees the patient. The multitude of practitioners
see starting from dermatologists, individual idiologies, surgeons, plastic surgeons, and
if necessary, other additional specialties like yenos and throat as
(04:58):
well as orthopedic surgeons may need to see the patient
as well. And once we see the patient, basically most
of the time is spent trying to get to the diagnosis,
and the diagnosis is primarily basing is it an artery
or utter venus or venus of venosymthatic And once you
define the diagnosis of that, then you can then treat
(05:21):
the patient based on what the cause is and how
big the lesion is. And most of the time these
treatments are staged. These treatments may be timed. Sometimes we
don't wait till the kid is five or six or
seven or eight. Sometimes we wait till that so it
is very individualized. It is very individualized, so it's not
like one size fits all. And one of the things
(05:43):
that we have in the last few years started to
do is to start mapping the genetic profile of these
vascular birthmarks to see if there is a mutation of
one of the genes, with the hope of trying to
find a targeted therapy as an oral tablets which can
help prevent a recurrence. So sometimes some of these are inoperable,
(06:08):
or if they do get operate, on the risk of
references quite high. So fortunately we have access to collaborative
care through other disciplines, mainly hematology on college departments who
have expertise in this area, and through the genetic profiling services,
we can access this and provide a very good service
to these patients.
Speaker 2 (06:28):
I had no idea it was that complex. I'm like
what you said. I just assumed it was managed through
lasers and dermatology. You know that maybe one might be excised.
But I had no idea it was so complex.
Speaker 1 (06:44):
That's great. The etiology could be multifactorial. And I think
what we have learned is the more time you spend
trying to get the diagnosis right makes a whole heap
of difference to the eventual outcome of the the lesion.
Because if you say, example, if you're treating an arteriovenous
malformation with an agent to block the circulation, that is
(07:07):
not meant to be for avy malformations it will not
work right, or as if you use a arteri venous
malformation blocking agent for a venous malformation, it will not work.
So it has to be so this time you spend
trying to get the diagnosis right. See which blood vessel
feeds into this malformation is actually an essential part of
the diagnostic workup.
Speaker 2 (07:29):
That is fascinating.
Speaker 1 (07:31):
Coming back to cosmetic nursis and in a you're whare
that there's an anatomy for injectors. Of course we do
a day before the actual non surgical symposium and it's
all about facial anatomy of way to inject, where not inject,
inject are not inject and most of your complications or
poor patient outcomes in facial cosmetic injecting is primarily due
(07:53):
to knowing where the vessels are or where the vessels
are not. Are the normal or the abnormal? Is it
a variation of normal? So coming back to the vascular
anatomy of the face. So when you're a plastic surgeon,
that's what you do all the time. You know what
the anatomy is, how much you can push, how much
you can't go beyond when you start doing children who've
got vascular birthmarks, your knowledge of vascular anatomy of the
(08:14):
face just gets taken to the next level because you
see not just the abnormal thing, but you not only
see the abnormal ones, but you also see the normal ones.
And you're able to distinguish between what is a normal
vessel or this is where it's meant to be, this
is where it's been amplified, this is where it's malformed.
So there's a whole heap of vascular biology and the
(08:35):
vascular floor patterns that you understand very well.
Speaker 2 (08:38):
It's interesting. I use an ultrasound in my clinic and
it has absolutely taken my practice to the next level.
But oh my lord, has it been a huge learning
curve for me trying to differentiate the different shades of
the cut like white literally, but it has helped me
(09:00):
dramatically and like a good example is I had a
patient come in yesterday, a lovely young lady who had
had way, way, way too much filler over the years.
Beautiful looking woman, but the tear troughs and where the
filla had been placed it had just I would suggest
(09:21):
it had been placed inappropriately initially, and it was sagging
all down through here and here, and so she really
didn't like what was happening with the Naser labial folds
even though she hadn't had filler through here and her
tear troughs well, she cried after we did a treatment
to dissolve because she could not believe the difference and
(09:44):
how much younger she looked. And it just took it
to you know, knowing anatomy, you know, knowing how to
use the ultrasound, it just takes your skill set to
the next level. And it's it's I mean, obviously no
idea about vascularity like you do, but you know it
(10:05):
makes a big difference and it helps your patients dramatically
once you know at that level.
Speaker 1 (10:10):
Absolutely look the last. Needless to say that the Vescula
Clinic we do have ultrasounds for every single patient. We
check in, measure and map out the flow and so
on and so forth. But last year at the Anatomy
for Injector's workshop, we had an ultrason workshop on the
side introducing the concept of facial ultrasound for cosmetic nurses
for injecting understanding anatomy. And I personally feel that having
(10:33):
an ultrasound probe is like having a third eye right,
and it gives you not only the understanding of the anatomy,
but also gives you an understanding of the variability of
the anatomy, which is not really appreciated. So all of
us rely on anatomy based on the textbook diagram, and
I think that one size fits all. The answer is
you can have a very thick artery in one plane
(10:55):
on the right side, and the other side other half
of the face you'll have an exactly opposite In other words,
a classic one is the labial artery for the lip.
See most of the time, eighty percent of the time
the arter is in the bulk of the muscle, So
if you're injecting a normal filler to any of the
lip area, you're pretty safe. But there's two percent of
(11:16):
the time it'll be right at the place where you
should normally goes right, and on one side it'll be
in the depth of within the muscle, and on the
other half of the lip it will be where it
should not be. So if you had an alder sound
to kind of make sure that there is a hazard there,
you'll be very safe. Or sayerw injectors so to speak,
so I personally feel that if you're injecting, I think
(11:37):
that's a skill that I should not be your blind spot.
Speaker 2 (11:41):
One of the things I admire about you is your
willingness to embrace nurses. And you were one of the
first to encourage nurses to speak at the conference. And
what is it that you feel is so important about
incorporating nurses on the stage and as part of that
(12:02):
scientific group. Why is it so important to you that
nurses are included in this.
Speaker 1 (12:07):
First of all, thank you for the kind comments, and
you're right, we wanted to include every professional group that
was involved in cosmetic injecting. I think this space has
evolved over the last thirteen years that we have known. First,
initially it was independent injecting was not allowed. The subsequently
things progressed and evolved, and along with that you had
(12:29):
expertise increased by nurses who were injecting little by little
and then going on to run very successfulmitical practices, become
key opinion leaders in this space. And all of a
sudden you suddenly find that there were people who had
not just passion, who were very professional, had enormous amount
of expertise. And I think we have an open mind
(12:52):
towards learning from anybody right, very flexible in that because
no one has a monopoly of anyone's thought process, you
should be an independent thinker and you could do very well, right.
And that's what you see in the modern day world
of startup and unicons. And if you ever serve with
a number of unicons that are companies that are valued
at a billion dollars plus. If you look at the
(13:12):
founders of those unicons, they come from extreme diverse backgrounds,
extreme disruptive backgrounds, extreme disruptive thought process. So if the
tech companies have led the space by twenty one, yours
becoming billionaires, right because they had some incredible ideas. So
it's all about ideas. And this is a knowledge economy
that we're dealing with. And your knowledge is how you
(13:33):
apply your basic learning, your imaginative creative process, and your
understanding of patient safety and stay within the boundaries. So
it was very important for us to understand a perspective
of a wide variety of nurses who are kind of
the dominant injectives in the space. If you look at numbers,
nurses by far are the largest number of cosmetic injectives
(13:55):
in the country and medicine is quite hierarchical in how
it is being dealt with as a framework and a system,
so in some ways, trying to get an alternative viewpoint,
maybe a different perspective, helps to enrich everyone's practice. And
that was kind of the empetters. And subsequently, a few
years later, when the Dental Board of Australia decided to
(14:19):
include cosmetic injecting within the scope of the dental practitioner,
the Non Surgical Symposium was then open to dental practitioners
to attend the NSS right now, that was the logical
step because if a statutory body has made it to
the scope of practice, there's no reason why an educational
provider cannot make it open to you. Yes, and I'm
(14:41):
very privileged to have the support of my NSS Scientific
Adversory Committee, where we have one representative or at least
the minimum one representative from every single craft group that
represents the spectam of the industry. And to me, that
has been an incredible learning platform.
Speaker 2 (14:58):
That's so wonderful to hear. I know, I go to
the States a lot to see my daughter who's over there,
and I have been to quite a few conferences over
there and those nurses that are key opinion leaders, or
they're not even KOLs, they just are amazing injectors that
(15:19):
are getting up and talking and the information that is
shared blows me away. And I loved that. I was
sitting there and here were plastic surgeons deferring to some
of these nurse injectors about different techniques or skills because
they had an idea, but they knew that these nurses
or nurse practitioners were highly skilled in that particular space,
(15:43):
and it was really lovely to see. They've worked really
hard to be recognized in the States, particularly nurse practitioners,
and I have to say it's been quite refreshing. So
when I came and because I hadn't been to it
for a couple of years here in Australia and then
I went to NSS this year and I loved it.
(16:05):
It was great. There was this wonderful cross section of
people speaking. I learned a lot from this NSS because
I think there was such diversity, absolutely, because not everyone's
going to resonate with me, and it was funny the
ones that did resonate were a little bit quirky and
bit out there. I loved it so I'm cutos to
(16:25):
Scientific Committee because they really did a great job.
Speaker 1 (16:28):
Absolutely, thank you for the comments. And this year's NSS,
which is in SS twenty twenty four, in my opinion,
was one of the best nesss. It had a buzz
that we never experienced before. There's a whole deal of
positive energy as well as both from the industry as
well as participants and the regulators who came and spoke
as well. They were kind of quite very impressed to
know that this was a meeting that was actually talking
(16:49):
about ethical clinical practice, about ethical advertising, about evidence based
and these are all good standard recipes from good medical practice,
good clinical practice and good pasient outcomes. There's nothing more
about it.
Speaker 2 (17:03):
So I have I suppose it's a bit of a
controversial question. Why do you think that the Nursing Midwife
Board aren't recognizing cosmetic nursing as a specialty when it's
cosmetic medicine is a specialty.
Speaker 1 (17:19):
Now, cosmetic medicine is not an official specialty in Australia.
So if you look at the number of recognized specialties
in Australia, Opera has a list of all of it, right,
and cosmetic medicine is not one of them.
Speaker 2 (17:31):
Because this is so, can you explain that?
Speaker 1 (17:35):
So it's The National Law, also called the National Health
Practice Law, has listed list of medical specialties and subspecialities
and also listed the appropriate titles that people can use
if you're registered in that speciality. Say, for example, if
(17:57):
you're registered in their recognized medical speciality of plastic surgery,
you can call yourself a plastic surgeon. If you're an ottolarengologist,
you cannot call youself a plastic surgeon. That is against
the National law. Okay, So each registration category is linked
to a specific title, and trying to get a speciality
(18:20):
recognized by our as a new speciality is quite a
long and cumbersome process, which I'm not aware of how
combersime it is, but I know it is a long process.
So cosmetic medicine has not been recognized as a independent
speciality yet. Whether it's going to be done in the future,
I don't know. However, as it stands in the current
current statutory arrangements, if you're a registered medical practitioner, you
(18:42):
can practice cosmetic medicine. So registered medical practitioners anyone finishes
a basic medical degree who goes on to become a
general practitioner goes on to become a specially surgeon, goes
on to become a medical specialist, medical practitioner. Ong, you
can do cosmetic medicine right now. If you're a registered
dental practitioner, you can perform a cosmetic medicine. So it
(19:05):
is now within the scope of the nursing in the
midimitary board that you can you're allowed to practice cosmetic
medicine as a registered nurse or an endroid nurse or
a nurse practitioner. Whether it's going to be a separate discipline,
I don't know, And I think when you start looking
at the diverse group groups of people practicing cosmetic medicine,
the chance of it becoming a recognized medical specialty becomes
(19:26):
difficult because it is not homogenous likes a gastrientologist. They're
not homogenosts like say a habitably or resurgeon. It is
not homogenous like North Big surgeon. So there's too many
patterns within that group. So I'm not sure if that
will level be recognized as a medical specialty. But the
(19:46):
scope of practice is not going to be restricted as
far as we know.
Speaker 2 (19:50):
Okay, so they're what we're classes protected titles. So our
nurse practitioner is a protected title that is correct. Okay, Okay,
So a plastic surgeon is a protected title that is correct. Okay,
that makes sense. So for nurses, it means that we
will be registered as registered nurse and we choose to
(20:12):
work within the dermatology space or clinical dermatology, or within
cosmetic or it just seems such a dirty word in
nursing to say you're a cosmetic practitioner, which is why
I actually say I do cosmetic dermatology because I do lasers,
and I do other things and I do skin and
so it's one of those funny terms within nursing. Even
(20:36):
nurse practitioners are funny. With cosmetic nurse practitioners. It's this
wild West at the moment in nursing around this area.
Speaker 1 (20:47):
Look, that's that's interesting to say that because even if
you looked at cosmetic surgery, which is the practice of
cosmetic surgery, it was seen as an undesirable element by
the mainstream medicine folks thirty forty years ago, but the
market did not go according to that plan. The market
(21:10):
demanded that the cosmetic surgery was being provided and the
mainstream trained surgeons were reluctant the same for the same
reasons as you just mentioned, and that vacuum was filled
in by people who are willing to offer the service
and trying to pretend there were surgeons and the patient
outcomes were not perfect, right, And this is what hit
(21:34):
the headline news probably heard about the cosmetic cowboys and
all the four corners scenes that came after that, And
that is how it culminated. And you start off doing
small things and then next thing you know, as you
scale it a little bit, and next thing you know,
no one does anything about it, and sooner or later
you get confident and you think, OK, I can get
over this. Let me do this a bit more, and
(21:54):
sooner or later things became quite quite bad. So the
antidote to that, so we as ethical, evidence based practitioners
have an obligation to provide good patient care. And the
way we do this is we need to put a
hand up and say, look, I'm happy and capable of
providing good cosmetic surgery, and so should you, because you
(22:15):
know that if you shirk that responsibility and take a
step back, the person who provides a cave will not
be as well trained as you, not as well, meaning
as you, which does not translate to good passion outcomes. No,
it doesn't, Okay, so the good people have to put
the hand up and say, yep, this is what we provide.
So in some ways there's an existing preconcy bias in society,
(22:38):
both at all levels. And I think I can only
speak from experience of cosmetic surgery, where everyone, starting from
government and regulators and your surgical colleagues, think that our
cosmetic surgery is so trivia that can be trivialized. The
answer is not, because people do get hurt, and we've
seen the evidence points the other way around. And then
with a whole heap of cosmetic surgery reforms that came in. Now,
(23:01):
finally the title surgeon is finally protected. For you to
use a title surgeon, you have to be registered as
a specialist surgeon. You cannot call you self a cosmetic
surgeon anymore. If you're not a registered surgeon. You cannot
call youself a plastic surgeon anymore, if you're not registered
in the recognized medical specialty of plastic surgery.
Speaker 2 (23:20):
And I think that that's wonderful because that stops people
getting harmed and maimed.
Speaker 1 (23:27):
It prevents people from looking for a loophole to advertise
and misrepresent their skills and a qualification, because when you
say that you're a surgeon, it implies certain skills, qualifications,
and expertise when actual fact, you've just done a basic
medical degree and the day you finish your internship you
call your self a cosmetic surgeon.
Speaker 2 (23:48):
Yeah, no, that's not great.
Speaker 1 (23:49):
Yeah, and you can pretty much predict the outcomes.
Speaker 2 (23:52):
It's interesting. I was literally I came from work to
chat with you, and I was talking to another colleague
that had come in to see me today and she
works in a different specialty to me, and we were
chatting about how when this industry started to boom, so
(24:13):
many people just thought it was part of the beauty industry,
like it is in the UK. It's a nightmare over there.
And it's interesting for those of us that have always
tried to keep it medicalized and safe, but there's so
many out there that or the education to the general
public has been that a little bit of you know,
GGI whatever is just a bit of the beauty routine,
(24:36):
and it's not. It is really serious business, yes, And
I think the education needs to be for the general
public around that that this just isn't you know, pop
in and have a couple of meals with this and whatever,
that it's really important that you go to a really
(24:56):
good ethical practitioner.
Speaker 1 (24:58):
That's right. Look, that's very important for people to realize
that message. And I think popular media, Instagram, instant influencers,
they somehow trivialize the effort to find a good practitioner
as well as to understand the seriousness of what can
really go wrong. And all of us know when things
go wrong, they really go wrong. Yeah, And I think
(25:21):
for practitioners to understand that because practitioners, although they may
have been trained to do certain procedures, not realizing the
full implications of how the whole pendulum could swing will
also become a lot more causes. And if the public
are aware that, Okay, you find it is important for
(25:41):
me to look for a good, sensible, credible trained practitioner,
then I think you have a good system going forward.
And I think that the NESS are you may be
aware of that. We are starting what is called the
NESS Academy to facilitate this learning and also have a
public facing messaging system to start maybe next teen the
(26:03):
year after to say that look, This is kind of
the one of the benchmarks that you can use to
look for expertise and endorsed expertise.
Speaker 2 (26:10):
We're going to do a little shift now and I
want you and you mentioned a little earlier that you
have a big interest in lipidema.
Speaker 1 (26:25):
That's great.
Speaker 2 (26:26):
Can you explain what it is?
Speaker 1 (26:29):
Lipadema is a disease of abnormal fat storage that is
a genetic disease that you inherit through your genetic patterns,
which is influenced by hormonal searches of your body during
its natural cycle men namely puberty, pregnancy, and menopause. The
(26:49):
fat alipus tissue, which is a consequence of diet or
exercise or lack of ditallex exercise, is not the primary trigger.
It is a secondary trigger, and that's what confuses people.
So it'll come like a clockwork. It is like having
a tendency to have diabetes and you can aim to control,
but you can't cure it. It's like having tell my
patients it's a bit like having curly hair and the
(27:11):
only way to have straight hair is you and I
know how to do it, and haircut is not one
of them. So it is a condition that you inherit.
It is you same as the color of your hair,
color of your eyes, or your curly hair astraight hair,
and you have to be in a mode of lifelong control.
So this is kind of what confuses people. And because
it does not fit into the stereotyped assumptions of what
fat is, it behaves exactly opposite to that. That's what
(27:34):
confuses people. It looks like normal fat but behaves exactly opposite.
So the pattern of distribution of fat in lipidema is
the three common areas is thighs, legs between n between
n mee and ankle, and the arms elbowed to shoulder right.
(27:54):
There are rare forms of LIPIDOMTD position that could be
occurring only in your hips and your upper bottock areas,
and sometimes in the forearms. But these three patterns of
the commonest ones, and you will see people who have
absolutely small waists yes, and big legs. And the classic
question to ask patients is if you buy genes off
the rack, if the gene fits your thigh, is your
(28:17):
waist to lose? And if they say yes, that is lipidema.
Because genes are cut to a global average pattern of
waste to hip ratio and lipid patients fall outside that region.
If you have thighs, sorry legs, which is need to
ankle bigger, which is colloquially corald as cankles, patients will
(28:37):
not be able to put on a pair of boots.
They cannot wear ski boots or normal boots right, And
that has always been the classic questions you can ask patients.
And the other thing you ask patients is if you
put on weight, does your legs get worse? The answer
is yes, But if you lose that weight to the
legs get better, the answer is no.
Speaker 2 (28:56):
I have a dear friend of mine that is struggling
with this at the moment, and it's interesting since I've
become really aware of it and have had the conversations
with her. It's not that uncommon.
Speaker 1 (29:11):
It is very common. Conservative estimates predict the problems to
be around ten percent, that is, one in every ten
women have it in some studies have shown as high
as forteen or fifty percent.
Speaker 2 (29:25):
Does it tend to run in Caucasian lines in different ethnic.
Speaker 1 (29:29):
Lines, No, it's not unique to any single genetic group
or ethnic group. I've seen it in every single ethnic group.
The one group I haven't seen. It is in East Asians.
In other words, Asian Chinese people haven't seen them, but
the rest of the groups I've seen everyone, Northern European,
Southern European, Middle East, and African South Asian. Everyone.
Speaker 2 (29:52):
Thank you so much for taking time out of the
conference to coming and chat with me.
Speaker 1 (29:57):
Thank you, Beck, thanks for having me.
Speaker 3 (29:59):
Thank you for listening to Tenderness for Nurses. That concludes
part one of Beck's chat with doctor Levin. In part two,
she puts your questions submitted online to doctor Levine. Make
sure you follow the podcast and we'll see you next week.
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