Animal tissue is widely used in various medical procedures with collagen proving to be a particularly valuable and accepted material for such purposes. Being one of the first biomedical materials used its properties of possessing high tensile strength and compatibility with human tissue, makes it a highly valued raw material utilised by medical practitioners and surgeons worldwide.

Being the most abundant protein in the human body and the main component of skin, tendons and ligaments, collagen has received global regulatory approvals for cosmetic, mobility and life saving procedures and products that contribute to an improved quality of life for those patients who have been the recipients of such procedures. However, increasing concern over the safe use of animal tissue in medical and other applications, where the end user is to be human, has resulted in the development of strict international compliance guidelines that necessitate medical products meet certain criteria.

As bovine collagen is one of the more popular animal tissue utilised in human applications, much has been written and formalised by many international governments on guidelines on its use. Safety guidelines include the following critical issues:

- All animal tissue in a product must have its source specifically identified as to what part of the animal has been used.

- Any bovine material should come from cattle that originate from countries which have a proven and recorded history of not containing or having a significant risk of introducing BSE.

- Traceable records should be maintained by the manufacturer for each lot of bovine material imported.

The source of the material is the most important parameter of the safety of the product. For bovine tissue, the best source is from a country or zone identified according to the International Animal Health Code (IAHC) as Bovine spongiform encephalopathy (BSE) free. The IAHC provides five categories for a countries BSE status, which are outlined below:

- BSE free country or zone

- BSE provisionally free country or zone

- Country or zone with minimal BSE risk

- Country or zone with moderate BSE risk

- Country or zone with high BSE risk

The assessment and ranking of countries and zones by this international organisation is determined based on the outcome of a risk assessment identifying all potential factors for the occurrence of BSE. These include the presence of an awareness program for all workers involved in the industry to encourage early identification and reporting, the implementation of an accredited BSE surveillance and monitoring system with approved and frequent laboratory tests, along with a ban on identified cattle feed sources known to contribute to the development of the disease.

It is becoming evident that any source of animal tissue that is to be used in any human medical procedure must be sourced from a country that not only remains BSE free, but has the regulations and programs in place to ensure that it remains this way. The quality of the products being produced, whether medical or not, can only be as good as the source of animal tissue being used in the production of such materials. Few countries are categorised as level one according to strict international standards. As a level one country, New Zealand has received high praise, not only in its ability to supply animal tissue that is contaminant and disease free, but in its stringent control programs that ensure the industry retains these high standards.

All too often the “bean counters” are telling us how we are falling short. They come up with some scheme to get us to see more patients than we can reasonably see or how to “create” more procedures than are called for. This is bottom-line or practice-centered medicine and in my opinion is unethical and immoral. It is also outside of what we are called to do and is unnecessary and counter to a healthy practice. What I believe builds a healthy practice and is simply at the heart of doing what is right for patients, is the patient-centered consult. This type of consult is designed to get to the root of the patient’s issues and do all one can do to help them achieve their health and aesthetic goals.

In this age of population-based medicine we have all been told to do the minimum, but that doesn’t change the fact that our patients are concerned with optimal health and results. Olympic athletes do not win their contests by training to the minimum nor will our patients be served by providing the minimum. Let’s look at an example of how population-based medicine is creeping into the exam room in a way that is not fully understood by physicians and yet has great impact on the individual (many similar examples can be seen in medicine today):

The drug companies tell us that Plavix is about 30% better than aspirin. What they do not tell us is that it is relatively 30% better. In absolute terms it is about 1% better. What does this mean? Well, in one study on CVA the relative risk reduction was quoted as 25% but the absolute reduction was 0.9 for ASA vs 1.2 for Plavix or about 0.3% (1). Now Plavix costs $5.00 per pill and ASA is about $0.05 so to the individual on a fixed income is the absolute difference of 0.3% worth $4.95 per day? Maybe, maybe not depending on many factors. Certainly it may be worth it to society but society is not paying the bill…the individual on a fixed income is. This is the confusion between population based and individual medicine. Some have even advocated taxing or eliminating Aesthetic procedures to reduce overall health costs in the US. This may help some number followed by economists but is it serving the individual who is interested in a specific goal?

So what is the patient-centered consult? Medicine is complex and in particular, Aesthetic Medicine is complex, yet it has been reduced to sound bites on TV. Commercials ask the question “Is it better than Botox?” or “Is it better than a Medical Peel?” yet they do not give the answer or any real helpful information. Patients have, in general, no realistic idea of what can and cannot be done for them. The patient-centered consult is an educational experience for the patient that helps them understand what is realistic and what is not.

It starts with gaining a detailed understanding of what the patient’s concerns are, not what treatments they are interested in. Most aesthetic patients come in thinking they know what they want. As an example many think they need an upper lid blepharoplasty but what they really need is a brow lift. Other come in asking about fillers but really need Botox or vice versa. The understanding of what they are concerned about is found not by asking what they are interested in but rather, what their concerns are. We start in a conversational manner. Most often a patient will start by saying something like “I think I need Botox right here.” My answer is generally something like, “Well, that is certainly something we can do, but what is it that makes you want Botox?” The next several questions are directed at helping the patient target the real issues behind the concerns such as texture, tone, tightness, wrinkles, poor size, volume etc.

I use a consult tool I call the $10,000 mirror. We have a simple hand mirror that has no magnification on one side and 3 to 5 times magnification on the other. I hand it to the patient with the magnified side facing them. The interesting thing is that most people when given the mirror will start looking very intently at themselves and even start picking and brushing at things on their face. I then have a checklist of items I ask them about. We go through the checklist item by item and discuss its impact on the overall appearance of the face. Once this is completed, I formulate a plan of all that can be done for them, that will include things I can do but also things others may be able to do. As an example, I do not do face lifts, but if the result they are after is best served by a face-lift, I put that on the plan. It is rare that we don’t do most of what they will benefit from.

Remember this is patient-centered not practice-centered. This will also build trust in your patient, as it is proof to them that you have their best interests at heart. Something the bean counters seem to never think about.

Once the plan is composed it will generally be a list of several procedures. I then go through the list, from most comprehensive to least. So it might be a list that includes a referral for a face-lift, a laser peel, a non-ablative laser treatment (also discussed as a part of maintenance), Botox and fillers. The list is prepared so that the patient will go home with it. It is positioned as a “wish list.”

As an example, one of my “I need Botox” patients left with her list. Upon leaving she said “Well I am ruling out a face-lift as that seems like to much, but I am going to do the laser peel along with the Botox and after my tax refund, start the maintenance program you have outlined.” As you know, with the ever-increasing cost of Botox it is essentially a lost leader, and at best, a breakeven event. The easy thing to do would simply have been to give the patient Botox, but with the consult, we went from a lost leader to a multi-thousand-dollar procedure with the probability of many thousands more in future procedures and maintenance programs. This was done in a patient-centered way. The patent chooses the procedures - you do not sell them. This is not an attempt to avoid the discussion about money…in fact money is at the center of these consults. Patients want an honest and upfront discussion of cost and we give it. Remember, without a margin you have no sustainable mission, so do not be afraid to discuss money.

The face consult is just one example - we go through the same checklist with body contouring consults. A patient may come in interested in abdominal liposuction. After they understand how one area of the body is related to the next, they may find that for optimal results what they really need is upper and lower abdomen and flanks for a better definition of the waist and three dimensional profile. But again they are not told that what they want is wrong; rather they are educated about how what they think they want actually fits into a broader plan for optimal results.

Over the years this approach has been responsible for the most of the growth I have seen within aesthetic medicine practices. Not only will it almost always result in bigger or a greater number of procedures, it will also be responsible for many referrals. When you take the time to do a meaningful consult, your patients will tell their friends. We even get referrals from the friends of friends whom we have never met.

1) Steinhubl SR, Berger PB, Mann JT, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002; 288: 2411-20

About 3 months ago my biggest concern was my stained teeth. Every time i look at the mirror, i could not stand what i am seeing because of the color. Whenever i meet new people, they would stare at my smile, though nobody said anything bad about it but i know deep within me that something needs to be done. First impression is very important in our community, wherein people are judged with their physical appearance the first time they met. Having stained or discoloured teeth can make a bad impression especially in dates or job interview. Yellow or stained teeth is not very attractive to look at we all know that. A lot of people i know told me that my stained or discoloured teeth is due to the cigarettes and alcohol i took for the past years. Maybe it is true, and for this reason is am willing to quit smoking and drinking just to have a perfect white teeth and get rid of this stained ones.

Here are a few points to remember if you want to get rid of yellow teeth. There are a lof of professional teeth whitening treatment that are available now in the market. Though some are very expensive and can cost you around $500 or more, but they are proven to be very effective. If you’re on a tight budget but still want to whiten your teeth, there are still available methods for you out there. Maybe about a few months ago, i saw this television show that features about some particular professional teeth whitening product. The product can be used like a pen or gel and believe me the cost is way too much cheaper than going to a professional dentist. In the said product review, the lady demonstrated how you can make your teeth white fast and very easy by just using the whitening peroxide agent. And this agent is not harmful to your health, especially to your teeth.

The one i liked the best in the product review is the whitening pen, wherein all you have to do is apply the product anytime and anywhere. It is very easy and convenient to use, and the best part is that you can see the result after 10 t 15 minutes of applying the product. The said whitening pen also is said to restore the natural white color or your teeth, by removing the stain and the dirt, as well as the debris and chemicals which caused the teeth discoloration.

For those people who refuse to go to a professional dentist or other expensive cosmetic treatment, you can only see from moderate to substantial improvement in the brightness of your teeth as well as the whiteness. Though there is no permanent solution for a white teeth, but this whitening pen is best for occasions and other activities wherein you need to boost your ego because of its fast result. You can get this whitening pen for as low as $5 and you will be enjoying white perfect teeth.