Dr. Lena Fan: Seeing unsatisfactory results from Skinboosters? Here’s why

Dr. Lena Fan

Collagen and hyaluronic acid (HA) are key components of healthy and youthful skin. Collagen is integral to keeping skin firm and tight, while HA hydrates the skin by retaining water molecules up to 1000 times its weight. As we age, our collagen and hyaluronic acid levels decrease, resulting in dry and lax skin that lacks the radiance and firmness of our younger selves.

Skinboosters are a fuss-free and convenient way to combat this by restoring lost HA and collagen levels in our skin. Traditionally associated with injections that contain HA to provide hydration to the skin, Skinboosters today run the gamut, from non-HA containing ones to those that correct textural imperfections and signs of ageing, such as skin laxity, fine lines and wrinkles. 

While there are many popular options out there, it is important to choose the skinbooster that is most suitable for your skin’s needs. In this article, I will explain the differences between 4 popular types of skinboosters (Profhilo, Rejuran, Nucleofill and Gouri) to help you decide which is the best for your skin. 

What are the different types of Skinboosters in Singapore? 

The table below details different types of skinbooster treatments and their characteristics

Profhilo is an improvement on traditional HA skinboosters by virtue of its high concentration of pure HA molecules that is well-tested in its bio-remodelling abilities to provide deep dermal hydration and gentle tightening in the long-term.

Rejuran Healer and the newer Nucleofill both contain polynucleotides (PN) derived from fragments of salmon DNA that kickstart the production of collagen and elastin in our skin. Nucleofill has a higher concentration of PN compared to Rejuran Healer, but both contain powerful skin healing properties which are suitable for persons with damaged skin, such as sensitivity, pigmentation, or scarring.

Gouri is the newest kid on the block, made up of liquid-type polycaprolactone (PCL) that stimulates collagen production. It subtly restores volume to sunken areas with collagen loss, at the same time improving the look of fine lines and wrinkles. 

Which skinbooster is suitable for me?

There are many factors to consider when it comes to deciding which skinbooster best serves my patients’ needs. I’ve personally found these guidelines to work: 

One thing to note is that our skin does not experience ageing evenly, some parts of the face may age more quickly or are more dehydrated than other parts due to factors such as genetics, sun exposure, etc. A combination of different skinboosters helps to maximise the results for patients who suffer from multiple concerns. Having a wide range of skinbooster choices allows the doctor to customise each patient’s treatment plan and target their individual concerns precisely. 

Getting the most out of your skinbooster

Unlike dermal fillers, skinboosters have no risks of blindness or skin necrosis. That is not to say that injection of skinboosters doesn’t require expertise and experience. 

Clean does not always mean effective 

For example, Profhilo contains HA and needs to be injected superficially in order to achieve its intended results of deep and long-lasting dermal hydration. If you have ever done a Profhilo session without seeing any large wheals or bumps at the injection points that gradually subside in 2-3 days, it means that the Profhilo was not injected at the correct dermal layer, resulting in minimal to no result while causing more propensity for bruising. 

On the other hand, Gouri needs to be injected in the deep dermis to stimulate collagen production. This is also a primary reason why your personal experience of skinboosters may be different from your friend’s. 

Always ensure your Skinbooster treatment is customised to YOUR comfort and needs 

Another common misconception that patients often have is regarding the injection techniques for each skinbooster. Profhilo injections are known to be less painful than Rejuran as it is commonly touted to require only 5 injection points each side of the face compared to the bee-hive style of Rejuran which can take more than 100 detailed injection points. 

Detailed injection style of Rejuran

Large wheals formed with 5-BAP injection style of Profhilo

However, as all skinboosters are fully soluble, it is possible to use the 5-point injection technique for Rejuran as well. An experienced doctor will be able to treat particular areas of concern with varied injection points no matter the choice of skinbooster—the best injection technique is one customised for each patient’s individual needs. 

Method of delivery matters 

The use of an injector gun to easily and quickly achieve over 100 injection points is a common method when it comes to Rejuran. However, the use of an injector gun is less precise at delivering the skinbooster to the right layer of skin, and a substantial amount of skinbooster is gone to waste due to the inevitable leakage. The lack of precision of the injector gun can also damage blood vessels, causing unnecessary bruising. Therefore, I always choose freehand manual injection over injector guns for my patients as it optimises the results of their skinboosters. Every drop counts!

How long does it take for Skinboosters to work?

From the very first treatments, patients can begin to observe the varying results of different skinboosters. Here is the part where I remind them that consistency is key—it is important to complete the initial sessions before moving onto the maintenance phase. 

Depending on your skin condition, 2 to 3 sessions are required initially at 1 month apart in order to achieve a baseline of the active ingredients in your skin to kick-start the intended bio-stimulation effects for long-lasting results. 

After the initial sessions, you only need a session every 6 to 12 months in order to maintain the optimal state your skin is in to reverse any signs of ageing.

Conclusion..

Skinboosters are one of my favourite aesthetic treatments given their safety, convenience, and well-tested results. I hope this article has been helpful to you at deciding which skinbooster is best for you, and to troubleshoot why a certain skinbooster that you have tried may not have met your expectations and needs. 

If you have further questions, feel free to drop me an email at ask@veritas.com.sg.

Dr. Lena Fan: CoolSculpting in Singapore 2022 – Obsolete or still an essential treatment?

I’ve consulted patients over the past months who were looking for help getting rid of stubborn fat that did not respond well to exercise or dieting. In recent times, there has been some growing resistance with Coolsculpt as a body contouring treatment option:

• Doc, I heard CoolSculpting is really expensive nowadays! Isn’t there a cheaper option?
• I read in an article that lasers are much more effective now, why are you offering me an outdated treatment?
• Doesn’t CoolSculpt have a LOT of bad side effects? I heard of patients who even got fatter post-treatment!

With a myriad of options for non-invasive body contouring available on the market today, many of my patients’ concerns are valid, and it can be tempting to chase the newest trend and latest technology. However, they should never compromise the safety of any treatment you undergo. The safety of body sculpting procedures has been in and out of the spotlight for some time, most recently with a botched liposuction procedure resulting in the unfortunate demise of a young lady in Kuala Lumpur in Oct 2020. I’d like to give an overall picture of where CoolSculpt stands in today’s aesthetic landscape, and why I strongly recommend that CoolSculpt be the front line treatment for stubborn fat. Before this, let’s talk about some of the popular non-invasive fat lipolysis treatment brands on the market – the list isn’t meant to be exhaustive, but here is the low-down on some of the more popular treatments available.

SculpSure

A non-invasive 1060nm diode laser lipolysis treatment that induces programmed fat cell death through heating instead of cooling, with additional skin tightening effects on top of the ability to eliminate stubborn fat pockets. It is FDA approved for treatment over the abdomen, flanks, back, inner thighs, outer thighs and submental area.

Vanquish

A non-invasive radiofrequency lipolysis treatment that removes unwanted fat cells similarly via programmed cell death, that also has skin tightening effects. Vanquish treatments are contactless as panels are used to surround treatment areas, instead of placing applicators onto skin. It is currently FDA approved for circumferential reduction of the abdomen.

Ultraformer III HIFU

A treatment that uses high intensity focused ultrasound waves, where energy is focused at specific depths, and in the case of body contouring, in the subcutaneous layer where fat cells are found. Elevated temperatures above 58 degrees are created in these localised areas which absorb ultrasound energy, leading to fat cell death via a process called coagulative necrosis.

With various modalities of body contouring treatments to choose from, fat freeze treatments have come under attack for being outdated and expensive, and many complain about the long wait time for results to become apparent (up to 3 months). However, in 2022, I still believe CoolSculpt is the premier first line fat lipolysis technology available today. I favour it over other forms of body contouring treatments, and it is my choice treatment to get rid of stubborn fat bulges in areas that do not respond well to a regime of diet and exercise. Here’s why.

First of all, what is CoolSculpting?

CoolSculpt is a fat freezing technology that employs cryolipolysis, a method to freeze and destroy fat cells using controlled cooling. These cells are then naturally excreted and removed from the body over the next 3 months. It has been FDA cleared for treatment of fat bulges in 9 target areas, namely:

• Submental (under the chin)
• Submandibular (under the jawline)
• Thigh
• Abdomen & flanks
• Bra fat
• Décolletage
• Back
• Below the buttocks
• Upper arms

This isn’t just a throwaway point: There isn’t any other fat freezing, much less fat lipolysis machine on the market, that has FDA approval for these many target areas, especially for larger ones like the back or flanks. CoolSculpt’s unique versatility makes it easy for me to prescribe holistic treatment programmes for my patients. With a newly released emotional attributes consultation guide, patients are better able to consolidate which areas of their body would most benefit from CoolSculpt too.

Above: Allergan’s emotional attributes guide

Above: Allergan’s recommended areas to target for CoolSculpt based on your individual goals

Compared to Coolsculpt, the number of FDA-cleared treatment areas for other brands of fat lipolysis trail behind, which means that for certain individuals with multiple target areas, other brands simply aren’t even an option.

So how does Coolsculpting match up with the rest of the competition in Singapore?

Much of the criticisms levied against CoolSculpt include its intra-procedural pain, side effect profile, as well as its safety and efficacy. We can address these in turn, while contrasting them with other technologies on the market.

Treatment comfort level

While some patients report some mild discomfort experienced during CoolSculpting treatments, fat freezing at low temperatures is generally more tolerable compared to fat reduction involving heat. Using HIFU as an example, this treatment usually involves a significant amount of heat and discomfort, depending on how intense the settings are. A milder treatment will reduce the level of discomfort, but may, in turn, compromise the end result.

Side effect profile and consistency in effects

When radiofrequency treatments are used for body contouring, there may be a variation in effectiveness from person to person. This is because each individual’s skin impedance is different, which in turn affects treatment depth and intensity, therefore, side effects such as burns may also occur as a result of this. In the same vein, when non-invasive laser treatments are used to sculpt the body, results may not be consistent across individuals, as varying amounts of laser energy is first absorbed by the skin depending if you are fair or dark toned, before reaching the subcutaneous layer of targeted fat cells.  As cryolipolysis is not dependent on skin tone or skin impedance, Coolsculpt delivers more consistent results with fewer complications when it comes to body contouring. After a CoolSculpt treatment, there may be localised temporary swelling, numbness and bruising, which usually resolves within 14 days. Often, patients are able to return to work post-procedure, deserving its label as a “lunchtime procedure”

Total number of coolsculpting treatments needed

After a CoolSculpting session, a distinct reduction of up to 27% of total fat can be seen 3 months after treatment, and further improvements seen when a second treatment is done. With radiofrequency treatments such as Vanquish, 4 to 6 treatments are usually recommended for optimal results depending on the amount of subcutaneous fat present, while it takes 2 to 3 sessions of Sculpsure to get a more contoured appearance. 

Safety & Patient Satisfaction

CoolSculpt enforces the highest standard of safety on both its equipment and operators, with one-of-a-kind built-in safety technology such as Cool Control and Freeze Detect in its machines, as well as training and regular upgrading provided to clinic staff. Well regarded as a safe modality for fat lipolysis, CoolSculpt’s clinical efficacy have been documented in both human and animal trials, with an impressive patient satisfaction track record – out of 528 patients surveyed from 2010 to 2012, only 6 had a negative experience with CoolSculpting. Upon a second treatment, this number was reduced to 2! (2)

Here’s a table that shows where CoolSculpt stands when compared to other popular body contouring technologies on the market.

As you can tell, by almost any metric, CoolSculpt matches up quite favourably to other treatments currently available. While low level laser therapy and acoustic wave therapy might look favourable in terms of pain and side effect profile, they are relatively new and unresearched technologies for fat lipolysis. Strong and conclusive studies on their consistent efficacy as fat reduction treatments are much harder to come by and I’d be hesitant to recommend them as of yet.

Are other fat lipolysis treatments ineffective?

Absolutely not, and I believe there are body sculpting and fat lipolysis treatments available which have a ton of merit. SculpSure, perhaps CoolSculpt’s biggest rival, is also FDA-approved and boasts an impressive resume that is comparable to CoolSculpt in many aspects. It has skin tightening advantages due to its neocollagenesis effect, and there are flat applicators which can be used in areas with a smaller bulge and lesser pinchable fat. However, when it comes to my patients, I tend to favour patient satisfaction and safety as the biggest priorities as an aesthetic doctor. 

Simply put, CoolSculpt has the best safety track record and consistency of any body sculpting technology currently on the market. I think that such statistics should not be viewed in isolation; CoolSculpting treatments have gone through rigorous testing and been involved in multiple peer-reviewed studies over more than a decade. As of last month, more than 8 million treatments have already been successfully done worldwide!

It could be that other body sculpting technologies seem equally or more effective than CoolSculpt, but I wouldn’t buy into the hype just yet. Until more studies and patient experience surveys are published, I will still prescribe CoolSculpt in 2022 as my choice option for targeting stubborn pockets of fat.

Do you have a question for me?

I am more than happy to answer them at ask@veritas.com.sg and +65 6283 3885

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079633/
   Nils Krueger, Sophia V Mai, Stefanie Luebberding, and Neil S Sadick. Cryolipolysis for noninvasive body contouring: clinical efficacy and patient satisfaction. Clin Cosmet Investig Dermatol. 2014; 7: 201–205.  
2. https://pubmed.ncbi.nlm.nih.gov/23858510/
   W Grant Stevens, Laura K Pietrzak, Michelle A Spring. Broad overview of a clinical and commercial experience with CoolSculpting. Aesthet Surg J. 2013 Aug 1;33(6):835-46.
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140909/
   Jason C. McBean, MD, Bruce E. Katz, MD. Laser Lipolysis: An Update. J Clin Aesthet Dermatol. 2011 Jul; 4(7): 25–34.

Dr. Lena Fan: Demystifying Hair Loss Treatments in 2022 – A Doctor’s Approach

Hair loss, or alopecia, remains a controversial topic in 2022. Despite progress made with emerging evidence in recent years, there has yet to be an unequivocal consensus as to what a safe and efficacious hair loss treatment protocol is. 

Fun fact –  do you know that it is illegal to advertise on Google by stating that a particular treatment for hair loss “guarantees results” or is “proven to be effective”? Individuals who previously fell prey to less than reputable hair loss treatments online would understandably harbour lingering fear, uncertainty and doubt after hard earned dollars were once spent on ineffective or sham treatments. 

Many patients, both male and female, suffering from alopecia, would love a solution to their conditions. However, if you are searching for a single treatment that works for all patients, the harsh truth is that it does not exist.

Why? The growth of hair is a complex process which is affected by a multitude of factors, which includes our age, diet, lifestyle, genetic predisposition, ongoing medication, other pre-existing medical conditions, etc. The list goes on. This is not to say that modern hair loss treatments are ineffective, rather, only through an in-depth understanding of the patient’s condition can we then prescribe a suitable treatment programme that is able to effectively correct or reverse one’s alopecia.

What hair loss and scalp treatments are currently offered by Veritas?

Here are a list of available treatments that we currently provide at Veritas Medical Aesthetics:

Topical

• Minoxidil scalp lotion
• CG210 hair spray

Scalp Treatment

• Clearz scalp treatment
• Fotona Hair Restart Laser
• Collagen Induction with PDRN scalp infusion
• Aquapure electroporation
• Low Level Laser Therapy (LLLT)

Surgical

• FUE Hair transplant

If you noticed, the treatments are grouped based on their level of invasiveness.

Why is this important?

There are different stages of alopecia. At Veritas Medical Aesthetics, we generally try to manage alopecia with non-invasive treatments before opting for minimally invasive ones. Hence, we urge that you come for a proper consultation so that a treatment protocol can be planned.

Let’s take a 40 year old gentleman I recently saw. He was experiencing early onset androgenetic alopecia, with thinning hair over his frontal area. He was concerned about the progression of his condition and tried over-the-counter hair serums and shampoos, only to notice that it continued to worsen. Clinics which he previously visited offered a FUE hair transplant but he had balked at the high costs involved.

After a consultation, examination and investigations, I started him on a regime of topical Minoxidil (1) CG210 spray, and oral Finasteride, and he started to notice fuller and thicker hair over a period of 3 to 6 months. This is a relatively straightforward example of early onset male pattern baldness which improved simply with topical and oral medications.

Let’s discuss another gentleman who had Stage 5 Hamilton-Norwood hair loss at the point of consultation. He had a receding hairline with a bald patch at the vertex. Having been started on topical and oral hair loss medications for a year or so, they had minimal effects in improving his hair loss. After a consult, scalp examination, and some investigations, he was assessed to be a suitable candidate for an FUE hair transplant.

Before embarking on a FUE hair transplant, we had to first optimise the health of his scalp and existing hair follicles, to strengthen the foundation on which hair grows and to boost the thickness and quality of transplanted hair for a best possible outcome. To achieve this, we started him on several treatments of Polydeoxyribonucleotide (PDRN) scalp infusion (2) as well as a programme of Fotona Hair Restart Laser prior to the FUE hair transplant to improve hair density and scalp health, priming for a successful FUE hair transplant.

Are combination hair loss treatments the answer then?

Once again, how treatment combination is selected varies between individuals, depending on the root cause of their hair loss. There are a variety of factors that can lead to hair loss and each of them needs to be examined in isolation as well as in their entirety before treatments can be prescribed.

For example, an individual with an oily scalp who is also experiencing thinning hair is more likely to benefit from a treatment approach including hair lotions, scalp care sessions and PDRN infusions. An individual who has a healthy scalp while experiencing hair loss would benefit more from hair stimulation treatments like Fotona hair restart laser(3).

What is a reasonable expectation of how much time and money I would need to invest to improve moderate hair loss?

With consistency and patience, many patients with hair loss successfully improve or recover. I would say that 3 months of regular treatment is the minimum duration when it comes to treating something as complex as alopecia. Generally, one can expect to see improvements after 3-6 months of appropriate hair care and compliance to doctor prescribed treatments.

Here are some rough numbers of what to expect when it comes to the various treatment options, per treatment course:

• Scalp treatments (topical creams, orals) – starts at S$1,600
• PDRN infusion – Starts at S$2,500
• Fotona Hair Restart Laser – Starts at S$3,000 
• FUE Hair Transplant – S$5-7 per strand

There are numerous options available to treat hair loss on the market and it can be tough for patients to truly discern what’s best for them. At the end of the day, I’d advise my patients not to assume the worst before getting a consultation with an experienced doctor who can assess and examine their hair loss or thinning. Once a diagnosis is made, an appropriate treatment plan can then be tailored to effectively address the individual’s condition.

Do you have a question for me?

I am more than happy to answer them at ask@veritas.com.sg and +65 6283 3885

References

1. Suchonwanit, P., Thammarucha, S., & Leerunyakul, K. (2019). Minoxidil and its use in hair disorders: a review. Drug design, development and therapy, 13, 2777–2786. https://doi.org/10.2147/DDDT.S214907
2. Lee, S. H., Zheng, Z., Kang, J. S., Kim, D. Y., Oh, S. H., & Cho, S. B. (2015). Therapeutic efficacy of autologous platelet-rich plasma and polydeoxyribonucleotide on female pattern hair loss. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society, 23(1), 30–36. https://doi.org/10.1111/wrr.12250
3. Ke, J., Guan, H., Li, S., Xu, L., Zhang, L., & Yan, Y. (2015). Erbium: YAG laser (2,940 nm) treatment stimulates hair growth through upregulating Wnt 10b and β-catenin expression in C57BL/6 mice. International journal of clinical and experimental medicine, 8(11), 20883–20889.

Dr. Chua Cheng Yu: It’s 2022 and hair transplants are in more demand than ever during the pandemic. Are you still wasting money on inefficient hair loss treatments?

Restore your hair with nourishing herbs and scalp massages — does this messaging sound familiar in your search for a cure to your thinning hair? Perhaps, you even tried one of these typical hair loss treatments you saw on TV or in beauty salons, and its poor results left you wondering in despair if your hair would ever return to its former glory.   

While there’s nothing wrong with getting some TLC for your crown, most hair loss treatment solutions are not scientifically proven; they merely nourish your hair without investigating the root cause of your hair loss, with a slim to none chance of actually stimulating hair growth. Some treatments such as Regenera Activa can even make matters worse by triggering an autoimmune response that causes more rapid hair loss. In a world of false advertising and upselling, it’s easy to fall prey to promises of “value-for-money” and “guaranteed results”.

Previously, my colleague Dr. Lena Fan wrote an article covering the types of medical hair loss treatments available in Singapore and Veritas Medical Aesthetics. In the article, she shared some non-invasive and relatively affordable treatments patients tend to consider first, such as oral medications and laser treatments. 

While I don’t disagree with the use of medication, remember that they are just temporary solutions. As someone who has personally struggled with a receding hairline for years since my late 20s, I have experienced firsthand the emotional toll it can take on a person. My advice is this — If you seriously want to combat hair loss without being put on medications for life, or just want to enjoy life without worrying about the potential of being bald, opting for a hair transplant is the only permanent solution to hair loss. 

To find out more about my personal journey with FUE hair transplant for my male-pattern baldness, I shared how pleased I am with my results here.

How do I know if I need help for my hair loss? What can I do at home?

Hair loss is known as androgenic alopecia, a medical condition that affects your scalp and/or entire body. It is not the same as the occasional few strands of hair you drop in the shower (50-100 strands per day is normal); patients with androgenic alopecia usually experience more severe hair loss resulting in: 

• Gradual thinning of hair at your crown, resulting in a receding hairline 
• Circular/patchy bald spots
• Hair that drops easily even with gentle tugging 
• Full body hair loss

Alopecia can occur in anyone, but it is more common in men and onsets earlier and more intensely. We usually refer to alopecia in males and females as: 

Male pattern baldness 

Male-pattern baldness is characterised by a well-defined M-shape, where hair loss starts from the temples and slowly recedes down as the patient gets older. Up to 50% of men experience significant hair loss from male-pattern baldness.  

Female pattern baldness 

Unlike male-pattern baldness where hair loss occurs all over the head, female-pattern baldness affects only a certain area. The hairline also does not recede as much. Up to 40% of women suffer from female-pattern baldness which usually occurs post-menopause or when a woman is in her 40s to 60s. 

Other factors that contribute to hair loss include: 

Side effects from medication 

These include medication used for chemotherapy, depression, high blood pressure and heart problems. 

Poor diet 

A diet low in calories and protein can lead to hair loss. 

Stress 

Stress (physically or emotionally) can lead to hair loss that lasts for several months, but this is only temporary. 

To effectively treat your hair loss, it is necessary to identify the cause of your hair loss — is it something that can easily be fixed, such as stress or diet? Or is it something that requires medical intervention like genetics (which, by the way, accounts for more than 95% of hair loss in Singaporean males)? 

Knowing the cause of your hair loss can also help determine the severity and rate of progression of your hair loss — which will go a long way in choosing the appropriate treatment method. 

What are the scientifically proven methods to treat hair loss in Singapore?

Minoxidil 

Minoxidil is an FDA-approved topical treatment that works by increasing the size of the blood vessels in the scalp, thereby improving blood flow to the area. For long term hair regrowth, Minoxidil should be used continuously. 

Finasteride 

Taken for male-pattern hair loss, Finasteride is an oral medication that blocks the enzyme 5 alpha-reductase, lowering DHT levels. However, once stopped, hair loss restarts after 6 months. 

Low Level Laser Therapy (LLLT)

Light-emitting diodes (LEDs) are used to transmit red light to the scalp, which increases collagen synthesis, cell metabolism and blood flow to the scalp. This activates resting hair follicles to enter anagen phase, resulting in increased hair coverage. 

CG210 Hair Spray

CG210 is a topical botanical lotion that reduces hair shedding and promotes hair growth. It is usually used in combination with minoxidil lotion and finasteride. 

Fotona HairRestart

Super-long pulsed laser beams are delivered to the scalp, resulting in more scalp blood vessels. The scalp’s cellular response is increased, and dormant hair follicles are stimulated to transition from telogen phase to anagen phase. I like to start patients on a programme of Fotona HairRestart prior to their hair transplant to prime their scalp for a successful transplant. 

PDRN Scalp Infusion

PDRN is a powerful scalp healing treatment that contains anti-inflammatory and wound healing properties to treat hair loss from the inside. It regenerates cells and repairs scalp skin, thus activating growth factor and stem cells. Like Fotona HairRestart, I put patients on PDRN scalp infusion before their hair transplant to strengthen the foundation for healthy thick hair to grow. 

Hair Transplant

A hair transplant is the only permanent solution for male and female pattern hair loss and delivers dramatically better results out of all the options above. It involves harvesting healthy hair follicles from donor sites and implanting the follicles on areas of hair loss. 

What are the differences between FUE vs. FUT hair transplant?

There are two types of hair transplant in Singapore: Follicular Unit Extraction (FUE) and Follicular Unit Transplantation (FUT). 

Follicular Unit Extraction (FUE)

FUE takes individual hair follicles from the back of the head and moves them to another part of the head where hair is thinner or absent. This is done through small incisions. The FUE process is more delicate and time consuming, but there is no linear scar and wound care; hence post-surgery discomfort and downtime is significantly reduced. 

Follicular Unit Transplantation (FUT)

FUT takes a strip of skin with hair follicles from the head and separates them into smaller tissues called hair grafts. These hair grafts are then individually placed into small holes made on balding areas. Unlike FUE, FUT leaves a long horizontal scar across the back of the head and requires more intensive aftercare. 

FUE or FUT: Which is better?

Although FUT has the potential to yield more grafts for extensive transplants as compared to FUE, it also leaves a large, nasty scar that may be permanent. Especially for Asian skin that is thicker and more prone to poor wound healing, such a wound may cause complications that can otherwise be avoided with FUE.

What can I expect during the procedure?

Briefly, there are 4 main steps during a FUE hair transplant: 

1. Extraction 

To prepare for the extraction of hair follicles, your donor site is first cleansed with an antiseptic solution and numbed with anaesthesia. Depending on what is appropriate, your donor site can range from the back of your head to your body and underarm. Each hair follicle is extracted individually using a micropunch tool and then preserved in a special solution to prepare for implantation. 

2. Hair graft inspection 

Every single hair graft goes through an intensive selection process where they are inspected under a microscope. We do this to ensure only the best and highest quality hair grafts are used. 

3. Planning and implantation 

After choosing the hair grafts, I then personally plan the angle, direction and distribution of the grafts to make the transplant look as natural as possible. Once that is done, we go ahead and implant the extracted hair grafts on the selected areas. 

4. Recovery 

You may experience some swelling at the donor side and across your forehead for a few days post-surgery; it is important you take the greatest care during this period to increase the survivability of your transplant. 

What happens after the procedure?

Hair transplant by FUE is an extremely safe procedure in Singapore that is in high demand. When performed well, it should look totally natural. You emerge from the surgery with tiny incisions that quickly heal. The implanted hairs typically fall out first before they regrow, and it may take up to a year for the full, permanent results to take place.t While adverse effects are extremely few and far apart, there are instances where patients experience hair transplant failure in first failing to choose the right clinic, and/or neglecting post-procedure care. 

I strongly advise avoiding these activities within the 1st month after the procedure: 

• Swimming 
• Excessive sun exposure 
• Washing your scalp with strong water pressure — use a cup to gently rinse instead 
• Scratching your scalp 
• Dyeing your hair 
• Drinking alcohol and smoking 
• Being in unsanitary environments

For my patients at Veritas, I also invite them back to the clinic regularly after the procedure in order to review the progress of their hair transplants and ensure the success of each graft.

How much does a hair transplant cost in Singapore?

In Singapore, a typical FUE hair transplant can cost from $6,000 to $15,000, depending on: 

• The condition of your hair loss 
• Number of hair grafts needed 
• Procedure chosen (manual/ARTAS) 
• Area of transplant (Head/Eyebrow/Beard)

At Veritas, FUE hair transplant starts at S$5 per graft.

What is the best age for hair transplant?

Often, patients would delay their hair transplant. Despite being bothered by their thinning hair, they turn to their busy schedules or convince themselves that they are too young to consider such a procedure. “It may all grow back one day”, they look into the mirror and think to themselves with false optimism mingled with paralysing dread, while their hair continues to retreat. I do not encourage that at all. 

Remember — the amount and survival rate of your hair grafts play a huge part in the overall success and cost of the treatment.  To qualify as a suitable candidate for FUE hair transplant, you need to have enough hair grafts to begin with. 

As such, the best age for a hair transplant is before alopecia hits — that’s typically before age 40 or as early as 30 for males and females. 

Should I go for a FUE hair transplant?

To me, a hair transplant is a long term investment that carries more rewards than risks. For both myself and my patients, it has made a world of difference to our self-confidence.  I urge you to seriously consider it before it’s too late. 

Do you have a question for me?

I am more than happy to answer them at ask@veritas.com.sg and +65 6283 3885

References 

1. Phillips, T. G., Slomiany, W. P., & Allison, R. (2017). Hair Loss: Common Causes and Treatment. American family physician, 96(6), 371–378.
2. Wolff, H., Fischer, T. W., & Blume-Peytavi, U. (2016). The Diagnosis and Treatment of Hair and Scalp Diseases. Deutsches Arzteblatt international, 113(21), 377–386. https://doi.org/10.3238/arztebl.2016.0377
3. Rashid R. M. (2014). Follicular unit extraction with the Artas robotic hair transplant system system: an evaluation of FUE yield. Dermatology online journal, 20(4), 22341.

Dr. Chua Cheng Yu: Will Ellansé (少女针) render hyaluronic acid fillers obsolete?

It is no longer a secret that celebrities turn to aesthetic medicine to keep their faces supple and youthful looking. Dermal fillers, specifically hyaluronic acid (HA) fillers, have been the go-to anti-ageing treatment for many A-list superstars for years due to their fast and immediate results. For the average person, they can leave the clinic with a younger, fresher overall look in less than an hour – that’s how fast dermal fillers can deliver results. 

However, as consumers become more savvy and are more in tune with the sustainability zeitgeist, their preference for treatments that produce instant, dramatic results have shifted towards treatments that are also more natural looking, longer lasting and cost-efficient in the long run. 

The same goes for fillers.  

Ellansé, a new generation collagen stimulator injectable, fulfills this need. 

What is a collagen stimulator and how does Ellansé work?

Collagen is a natural protein created by the body responsible for our skin’s structure, elasticity, and strength. Our body’s ability to abundantly produce this protein begins to decline once we hit the age of 25¹. Following this, you will start to notice changes in your skin – fine lines and wrinkles start to show on your forehead or the sides of your lips, and your cheeks may look saggy as they lose volume. 

Collagen stimulators combat these ageing symptoms by restoring the skin’s volume and improving its elasticity; collagen production is triggered as the stimulators are injected into the dermal tissue. 

Ellansé, also known as the Needle of Youth (少女针), is a collagen-stimulating filler. Its efficacy in producing excellent anti-ageing results can be credited to its main ingredients: 30% biodegradable polycaprolactone (PCL) microspheres and 70% carboxymethylcellulose (CMC) gel carrier. 

When injected into the skin, Ellansé works in two stages.

1. First, the CMC gel fills hollow areas of the face caused by volume loss. This process improves the skin’s suppleness, resulting in the diminishing of fine lines and wrinkles while providing a subtle and natural-looking face lift. 
2. Next, the PCL is activated and stimulates the production of Type 1 collagen² in the skin, which allows the skin to preserve the effects of the collagen stimulator for a long time. Results of an Ellansé treatment can last anywhere from 18 months to 3 years, depending on the type of Ellansé used. After which, the PCL molecules are degraded and reabsorbed by the body. 

What can an Ellansé collagen stimulator do for me?

The reason why a lot of my patients have diverted their anti-ageing preference to Ellansé is because of the benefits that this product has in store for them.

1. Continuous collagen production, which makes results last longer;
2. Cost-effective, as the effects of one treatment can last from 6 to 18 months depending on the type of the Ellansé used;
3. Immediate results;
4. Improved skin volume on sunken areas on the face;
5. Reduction of fine lines and wrinkles

Ellansé can be used to treat and enhance the skin over your chin, cheeks, eyebrows, forehead, nose, temples, and jaw.

How is Ellansé different from hyaluronic acid fillers? 

There are several differences between Ellansé and HA fillers, aside from their ingredients. The table below shows a summary of these dissimilarities.

The differences presented does not mean that HA fillers have completely no purpose. Personally, HA fillers may be a better choice if you need last minute touch ups and want to achieve immediate results for, say, an event. However, all of these can also be achieved by Ellansé, and the results are much longer-lasting. 

Ellansé vs Radiesse vs Sculptra – Why I personally prefer Ellansé 

Ellansé is not the only collagen stimulating dermal filler available in Singapore. You may have heard of Radiesse and Sculptra, two very worthy competitors.

But among the 3, my personal preference is still Ellansé because it is safer and more cost-effective as compared to Radiesse and Sculptra. 

Why the doctor matters when doing Ellansé collagen stimulator in Singapore

One very crucial thing to remember before getting an Ellansé treatment is to confirm that your chosen doctor has sufficient experience and knowledge on Ellansé. g. 

Why is this important? 

As an official Ellansé trainer in Singapore, I have encountered many doctors who are intimidated by or are reluctant to use Ellansé despite its many virtues over HA fillers. This fear stems from its semi-permanent nature that’s not easily reversible compared to traditional HA-fillers. 

Semi-permanent simply means that the results of the product cannot be easily reversed once the fillers have been injected.  This sets Ellansé apart from HA fillers which can be dissolved with the use of hyaluronidase.

When using Ellansé, doctors must take extra caution not to overfill the treatment area due to its semi-permanent nature. To ensure that my patients get the safest and highest quality results, I usually schedule a complimentary review session that involves some touch-ups when necessary.

Similar to other procedures, side effects may be experienced following an Ellansé treatment. The most common side effects include slight bruising, infection, minor swelling, and minimal pain, especially during the administration of the collagen stimulator. These side effects are only temporary.

What can I do at home to ensure the safest results? 

Your doctor should be able to give you more detailed aftercare instructions following your Ellansé treatment. In general, these are what you should do and not do after your procedure to help your skin heal and avoid side effects.

DO:

• Remember to wash your hands prior to touching the treatment area
• Treat the bruised or swollen area by gently applying an ice pack

DO NOT:

• Apply intense pressure on or massage the treatment area
• Consume alcohol or take aspirin for the next 12 to 48 hours following your treatment
• Engage in strenuous activities, such as tough exercise routines in the next 3 days
• Expose yourself to heat and the sun without proper protection in the next 3 days
• Use makeup in the next 24 hours

On that note, some individuals may not be a perfect fit for an Ellansé treatment. It is best to let your doctor know if:

• You are under cortisone treatment
• You are hypersensitive to any of the ingredients that make up Ellansé
• You are prone to developing keloid or hypertrophic scarring
• You currently have (or history of) autoimmune disorders
• You currently have active sepsis or infection
• You have skin diseases that are acute or chronic 

How much do Ellansé fillers cost in Singapore? 

Ellansé fillers have 3 variations (Ellansé S, M, and L). Their main difference lies in the number of PCL molecules they each contain, which affects the longevity of results.  

Do you have a question for me?

I am more than happy to answer them at ask@veritas.com.sg and +65 6283 3885

References 

1. Reilly DM,  Lozano J. Skin collagen through the lifestages: importance for skin health and beauty. Plast Aesthet Res 2021;8:2 . http://dx.doi.org/10.20517/2347-9264.2020.153
2. Sharif, S., Ai, J., Azami, M., Verdi, J., Atlasi, M. A., Shirian, S., & Samadikuchaksaraei, A. (2018). Collagen-coated nano-electrospun PCL seeded with human endometrial stem cells for skin tissue engineering applications. Journal of biomedical materials research. Part B, Applied biomaterials, 106(4), 1578–1586. https://doi.org/10.1002/jbm.b.33966

Dr. Lena Fan: Feminine rejuvenation in 2022 is a complete life changer. Here’s why.

Many of my female friends who are in their early thirties all share the same worry: how will my body change after giving birth naturally?

Even in 2022, I find that many ladies aren’t very familiar with what rejuvenation of our feminine parts actually is. Feminine rejuvenation refers to a few corrective procedures suited for women who have given birth or are approaching menopause. These women suffer from conditions including:

• Laxity of the canal
• Urinary incontinence
• Inability to lubricate

As a female doctor, I understand that there are many psychological drawbacks when it comes to going for a procedure like feminine rejuvenation. The same can be said for aerolar or privates whitening procedures. Women who have given birth multiple times would often rather accept the reduction of quality in their sex life rather than consider that they might need a procedure like this.

Given the social stigma associated with a women’s sexuality, laxity in our feminine parts is an incredibly underreported problem. It is historically not recognized as a “treatable condition” and clinical papers and research on the topic are far and few between. However, recent studies ₍₂₎ have shown that up to 48% of surveyed women suffer from a degree of laxity in our feminine parts that negatively affects their overall quality of life.

As ladies, the nagging feeling that our appeal has faded can be a huge burden to bear. Some of my friends who are young mothers can definitely relate; many of them harbour the feeling that their sex lives have slowed down and they are no longer as confident with their bodies as once before.

Ladies, this doesn’t need to be the case.

Introducing Fotona IntimaLase, a modern photodermal feminine rejuvenation technology

With the new technology of Fotona IntimaLase, aesthetic doctors now have access to a non-invasive, incision-free laser feminine rejuvenation treatment that is safe, effective and uncomplicated.

• A modern solution for feminine parts relaxation syndrome
• Non-invasive and incisionless
• Only topical anaesthesia required
• No long downtime
• Visible results after only one treatment
  

Above: A visual representation of a successful Fotona Intimalase treatment

How does it work?

The Fotona IntimaLase treatment makes use of a specialized and 2940nm Er:YAG laser technology called Fotona SMOOTH_® which is engineered to deliver a set of specially composed laser energy pulses specifically to the mucosa tissue.

These pulses of non-ablative laser energy are tuned in order to induce a thermal effect within the tissue, which stimulates both collagen remodelling as well as triggering the growth of new collagen fibers. This triggers collagen neogenesis and the end result is a tightening of the feminine canal.

What sort of results can I expect?

One would imagine that in order to effect a significant change in physiology, this would require months and months of expensive treatments. However, clinical studies on women who only underwent a single treatment of Fotona IntimaLase came back with the following statistic ₍₁₎:

95% reported an increase in friction and sensation during sex

57% reported an improvement in the quality of orgasm

14% reported an increased frequency of orgasm

5% reported no discernible improvement

In the 3 month controlled study, women who had underwent 2-3 Fotona IntimaLase treatments and answered a controlled questionnaire reported these improvements in their overall sexual gratification by the 3 month mark:

Above: Charted improvement in overall sexual gratification 3 months after Fotona IntimaLase therapy

Immediate results are great – but what about the long term effects then?

It’s easy to fawn over positive statistics for 1 to 3 month long treatments – but that’s not exactly our end goal for ladies undergoing this procedure. What we want is a safe, sustainable and wholistic improvement to the physical and mental well-being of ladies who have had their confidence in their sexuality shaken due to pregnancy or menopause.

In 2016, a study was conducted where interviews were conducted with patients at the 6, 12, 18, 24 and 36-month follow ups post-treatment. ₍₃₎ Most patients who had undergone the treatment reported that the positive effects lasted upwards of 16 months, with none reporting any major adverse effects. More than 83% of the patients reported that they would be willing to repeat the therapy – it was concluded that only two treatments (with a maintenance session 8 months after) were needed in order to obtain a substantial improvement in tightness.

That’s amazing! – why only now?

Previously, some gynaecologists and aesthetic doctors would use radiofrequency technology (e.g. ThermiVa, Viveve) for women suffering from feminine parts relaxation syndrome. ₍₄₎ However, due to the issues with social stigma I previously mentioned, there have been relatively few extensive studies have been conducted on the safety and efficacy of such methods.

Currently, there isn’t any radiofrequency device on the market that’s cleared by the US FDA for feminine rejuvenation. Over the last decade, many brands were accused of deceptive marketing and the US FDA raised concerns about the medical integrity of such devices. Hence, I was hesitant to offer these treatments to my patients.

Only in recent years did the practice of using a non-ablative laser technology like Fotona IntimaLase really gain in traction and popularity. Studies specific to the Fotona SMOOTH_® technology were also published, allowing me and many other doctors to gain confidence in its efficacy and safety when offering this treatment to my patients ₍₅₎.

Personally, I prefer to use a non-ablative laser technology over radiofrequency due to:

• Better side effect profile
• More studies supporting its safety and efficacy
• RF technology requires a manual repetitive “in-out” motion, which can be embarrassing to some ladies, compared to the 360° nature of the Fotona IntimaLase
• Fewer treatments required for the same results

I know this can help me – but it’s a really tough decision to make.

For all ladies who have given birth or are in or approaching menopause, I know it isn’t easy to overcome the mental barrier of going for an intimate laser treatment for your feminine parts. In fact, many of my friends still have reservations even after I educate them about the efficacy of such treatments.

We understand that it’s not easy. A women’s intimate parts are very much linked to their sense of femininity and self-esteem and making the decision to treat them is definitely an extremely challenging one.

As a female doctor practicing at Veritas Medical Aesthetics, I personally perform all Fotona IntimaLase treatments as many patients are more comfortable with a female doctor for this particular procedure. If you’re someone going through the struggles that I’ve outlined above, I would implore you to give this little known but highly effective treatment a try.

Do you have a question for me?

I am more than happy to answer them at ask@veritas.com.sg and +65 6283 3885

Dr. Chua Cheng Yu: Fungal Acne in Singapore — This Grossly Underdiagnosed Condition May be the Reason Why Your Acne Treatments Are Not Working

Do you have stubborn zits that just won’t go away despite trying every acne treatment under the sun? Chances are, you might just be suffering from fungal acne instead, which is NOT the same as bacterial acne despite its similar appearance, and will not respond to regular acne treatments. 

But don’t worry, fungal acne is not difficult to treat once you know what you’re dealing with in the first place and seek appropriate treatment from a medical professional. Many patients who suffer from fungal acne have shared with me different remedies and tips they saw online, from skincare youtubers to an entire sub-Reddit dedicated to fungal acne. While a number of these hold some truths, many are pseudoscience packed with misinformation that may lead to a worsening of your condition. 

Instead of being misguided by social media, let me break down fungal acne for you — including how to tell if you have this condition, the dangers of a misdiagnosis and treatment options in Singapore. 

What is fungal acne?

Contrary to its name, fungal acne is a total misnomer — not only is it not really acne, it has nothing to do with fungus too. Rather, fungal acne is an infection of hair follicles on the face or body caused by excess yeast called Malassezia folliculitis. 

While fungal acne can be hard to diagnose due to its similarity in appearance to regular acne, there are a few tell-tale signs: 

Size of infection 

Look out for blackheads and whiteheads that are about a millimetre big. There might also be pus-filled bumps that are all the same size, unlike bacterial acne that come in different sizes. 

Location 

Fungal acne often appears on the chest, back, or upper arms, though it can also show up on the face like typical acne. 

Itching 

An obvious characteristic of fungal acne is itching around the infection site.

Clusters 

Fungal acne often appears in clusters; usually as uniform papules or whiteheads. 

Now, one thing to know is that the yeast that causes fungal acne, Malassezia, actually lives on everyone’s skin. However, because yeast levels tend to spike in the presence of sweat or hot and humid weather, this condition is extremely common in Singapore given our climate. 

On top of hot weather, other triggers to fungal acne include;

• Greasy skin 
• Tight fitting clothing 
• Sweating a lot especially during and after exercising 
• Using too much makeup, sunblock or moisturisers that can block hair follicles 
• Overuse of antibiotics for acne 
• Bodily contact with someone with the infection (yes, fungal acne is contagious) 

How do I know if I have fungal acne? 

Due to the similarities between Malassezia folliculitis and acne, trying to determine yourself whether you suffer from fungal acne is extremely difficult. Even many doctors who either lack the experience or do not know how to test for Malassezia folliculitis are prone to making a  wrong diagnosis. To further complicate things, fungal acne often coexists with bacterial acne on the face, misleading many to arrive at the wrong diagnosis and treatment plan. 

If you would like to find out for sure whether you have fungal acne in order to embark on the right treatment plan for your spots, consult a doctor who is experienced and well-equipped in testing for fungal acne. 

An easy and inexpensive way that I do to test if my patients are suffering from fungal acne or regular acne is to shine a black light on the infection site—as fungal acne appears differently from regular, bacterial acne. Illuminated by black light, bacterial acne appears orange-red while fungal acne has a blue-white hue.

photo from Root Remedies

The dangers of a misdiagnosis and the harm conventional acne treatments can cause 

In Singapore, acne is treated with a myriad of procedures, from microneedling to lasers depending on your condition. While they are known to not just treat acne but also bring on a slew of additional benefits (e.g. collagen production, skin rejuvenation), they DO NOT work the same for fungal acne. In fact, it’s been shown that treating fungal acne with conventional acne treatments can worsen the condition and exacerbate symptoms ¹. What’s a cure to bacterial acne can be sustenance for fungal acne to flourish. 

Since we’re on this topic, I’d like to again emphasise the importance of choosing the right doctor and treatment for your acne — especially if lasers are involved. I’ve spoken about how the wrong lasers can worsen acne, but did you know that wrong lasers  can cause fungal acne too? 

In this particular study ², more than 50% of patients experienced significant fungal growth after full-face laser resurfacing. The lasers used in question were Fractional CO2 and Erbium:YAG lasers — both fractional ablative lasers that involve removing the top layer of skin, hence increasing the chance of micro-organism population. 

This is why I only use non-ablative fractional lasers in my practice that can treat acne and acne scars at the same time for patients that exhibit symptoms of fungal acne. 

Read more to find out how I treat acne scars. 

How can I treat fungal acne in Singapore?

First, correct diagnosis is most important — so make sure you get that out of the way before doing anything else. 

At home, I recommend the following: 

• Use Nizoral, an anti-dandruff shampoo that gently and effectively cleanses your face and body. Allow the shampoo to sit for a few minutes before rinsing off for best results 
• Avoid any oil-based products that contain ingredients such as oleic acid, shea butter, cocoa seed butter, avocado oil and linoleic acid 
• Avoid engaging in activities that cause your skin temperature to rise, such as hot yoga, sauna
• Shower and change out of your dirty clothes right after sweating
• Opt for loose, breathable fabrics so your skin gets adequate air circulation and balanced fungal growth 

For those impatient with the results of home treatments, or find it difficult to adjust their lifestyle habits in Singapore to avoid fungal acne, I highly recommend them to consider aesthetic treatments to eradicate their spots. In a clinical setting, I usually treat fungal acne with: 

• Agnes RF, a minimally invasive radiofrequency microneedling device that permanently removes bacterial acne and fungal acne by targeting the common root cause, hyperactive sebaceous glands. This is especially suitable for those with stubborn spots that always reoccur at the same areas as AGNES RF can precisely target and treat these compromised facial follicles without damaging the skin’s epidermis. 
• Oral medication such as Fluconazole 
• Skincare containing BHA (salicylic acids) and retinoids. Although these ingredients can be found in OTC products, prescription strength retinoids are more effective. 

Conclusion

So there you have it! I hope this guide helped you understand fungal acne better and the treatment options available. Remember both acne bacterial and fungal acne can look and feel similar, but they are not the same and require different treatments. When in doubt, always speak to a professional to avoid worsening your condition. 

References 

1. Ayers K, Sweeney SM, Wiss K. Pityrosporum Folliculitis: Diagnosis and Management in 6 Female Adolescents With Acne Vulgaris. Arch Pediatr Adolesc Med. 2005;159(1):64–67. doi:10.1001/archpedi.159.1.64
2. Alam, M., Pantanowitz, L., Harton, A. M., Arndt, K. A., & Dover, J. S. (2003). A prospective trial of fungal colonization after laser resurfacing of the face: correlation between culture positivity and symptoms of pruritus. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 29(3), 255–260. https://doi.org/10.1046/j.1524-4725.2003.29060.x

In this feature, they share why you should add Veritas Medical Aesthetics to your beauty black book

Read the article to find out more!

Dr. Chua Cheng Yu: It’s 2022. Have Melasma Treatments Finally Improved?

Melasma is notorious for being one of the most difficult pigmentations to treat. Why? Hi, my name is Dr Chua Cheng Yu. At my practice in Veritas Medical Aesthetics, a good portion of patients who consult for melasma express disheartenment when previous treatments at other places fail to yield improvements.

• May occur with other forms of pigmentation
• High chance of recurrence or relapse
• Affects multiple layers of the skin
• If treated incorrectly, it can worsen in severity

It is not uncommon for patients with melasma to bounce from doctor to doctor due to dissatisfaction with the results of their treatments, as melasma is a condition where there isn’t a one size fit all treatment protocol.

Current available treatments for Melasma include:

• Topical Creams –  4% Hydroquinone, tretinoin, azelaic acid, cysteamine, kojic acid
• Oral medication – Tranexamic acid
• Lasers – Low fluence Q switched Nd YAG or picosecond Q switch Nd YAG, Pulsed dye laser
• Chemical peels –  Glycolic acid and trichloroacetic acid (TCA) are among the peels commonly prescribed

The question is: are these treatments still effective?

The answer is: Yes, they are.

Will they always give you the best results?

No, definitely not.

Hence, the question remains: How can we separate the good treatments from the not?

I believe there are multiple important factors to take into account before we can conclude whether a treatment should be recommended or not. By identifying them, we will be able to determine the treatments best suited for the patient.

What are these factors?

Type of melasma – Is your melasma dermal? Epidermal? Mixed? It is important to identify the skin layer involved as it impacts my treatment decision. For example, epidermal melasma usually responds well to topical lightening creams, while dermal and mixed types might require other additional types of treatment.

Medical history & past treatments – Patients may experience a rebound in their condition, especially so for those with melasma. Rebound melasma can happen when melasma is treated too aggressively, partially treated, or when lifestyle factors are not properly managed. For example, if chemical peels are used to treat melasma without caution, there is a possibility of a rebound and also side effects of skin irritation and post-inflammatory hyperpigmentation (PIH), which can be especially severe in darker skinned patients.

Timing, onset and duration of symptoms also need to be properly documented in order to establish a baseline prior to commencing treatment and to monitor improvement.

Patient’s health & lifestyle – I cannot stress how important this is. Even with a well-tailored treatment plan, it can be difficult to improve melasma if there is continued sun exposure, usage of wrong skincare products, or hormonal imbalances. 

Other underlying conditions – Melasma can co-exisit with other forms of pigmentation. Are there lentigenes as well? Does the patient also suffer from PIH? In many cases, I treat pigmentations in a specific order so as to avoid complications or further damage being done.

With a thorough understanding of these factors, I will be better able to design a treatment plan customised to the patient’s skin condition and lifestyle.

In my opinion, treating melasma in 2022 is no longer about using 1 or 2 separate methods. Over the years, Veritas Medical Aesthetics has built up a reputation for preferring combination treatments and we have more than 10 machines in our arsenal, each equipped with multiple unique lasers.

Many of our patients find this strange and often ask – why the need to recommend so many different lasers?

Isn’t there a single do-it-all laser to solve my pigmentation problems?

The reason we invest so much into different lasers is because – different lasers attack different factors.

Because of the various factors I’ve named – no single tool, no matter how well-marketed, can effectively resolve every component contributing to the development of melasma.

Let me give you the best example of this: Picolasers

Picosecond lasers have been touted by some as the answer to almost all forms of pigmentation. Many of my patients and colleagues alike have the opinion that picolasers are the best choice to treat melasma.

I have to be honest – while I believe picosecond lasers are good, it is only a single tool out of the many that we use to treat pigmentation at Veritas Medical Aesthetics. There is nothing radically different about picosecond lasers that allows them to fully treat conditions like melasma. The photomechanical effect a picosecond laser generates serves a similar function to what a nanosecond Q switch laser does. It is important to consider all the strengths and weaknesses of a tool before deciding it is the right one to treat a condition.

From my own personal experience, I would say that patients who only undergo picolaser treatments will generally see a 10-40% improvement after 3 treatments. While these results are respectable, they are definitely not the best.

Picolasers are like a larger, sharper sword to enter a fight – when others are attacking with guns.

Let’s talk about a patient of mine who went through melasma treatment fairly recently.

Being close to her 40s, being of a darker skin tone and having given birth recently, she pretty much fit the quintessential profile of a melasma patient. After closer examination, I realized that her melasma was of a vascular variant. This would mean treating both the dermal components of melasma as well as the vascular components.

After the first consultation, my initial prescription to her included:

• Topical 4% Hydroquinone cream
• Physical sunscreen (SPF 50 and PA+++) to be applied daily on sun exposed skin before leaving the house, with reapplication every 2-4 hours.

She returned to the clinic after 3 weeks for her first laser session.

I used a combination laser treatment of Quadrostar Pro Yellow Laser, Fotona Starwalker PICO, and Fotona Versa 3 for this patient. Why these 3 lasers, you might ask?

Let’s talk about each of them in more detail.

Quadrostar Pro Yellow Laser: Targets superficial blood vessels and pigmentation.

Fotona Starwalker PICO: Targets epidermal keratinocytes and deeper melanosomes

Fotona Versa 3: Targets deeper blood vessels that the Pro Yellow Laser cannot reach.

From this, we see that each laser was chosen to tackle a specific aspect in which melasma acts on skin. With a thorough understanding of the properties and mechanisms of each laser, I am able to choose the best suited treatment combo for each patient’s condition. Should her pigmentation present differently, the lasers I picked might have been completely different!

A combination approach also allowed me to reduce the total number of sessions needed to tackle her condition. After 3 laser sessions with a treatment period spanning 2.5 months, she saw significant improvement in her condition and we switched her to a topical regime for post-treatment maintenance.

So what can we learn from this patient’s case study? Simply put:

Single lasers don’t allow you to target specific components of complicated conditions.

Combination lasers, however, do.

Many doctors can and also are providing combination lasers, which is a step in the right direction. At the end of the day, I believe it is about having a thorough understanding of the condition as well as the components of skin involved in disease pathways, before deciding on a suitable laser setup to use in order to deliver safe and reliable results.

For example, the trio of Pro Yellow Laser + Pico + Versa 3 that I listed above is a combination that can be recommended to a proportion of melasma patients I see. This combination is but 1 of the many combinations we use at Veritas, and is a no downtime treatment. There are other combinations that range from no downtime to bloody faced options immediately after treatment! 

For those visiting Veritas clinic or are looking for laser solutions to melasma around Singapore, don’t be surprised if you notice a shift in doctors’ recommendation towards that of combination lasers. I believe that as our knowledge increases in the years to come, more effective combination treatments will become commonplace for treating complicated pigmentation conditions such as melasma.

Do you have a question for me?

I am more than happy to answer them at ask@veritas.com.sg and +65 6283 3885

References

(1) Trivedi, M.K. & Yang, F.C. & Cho, B.K.. (2017). A review of laser and light therapy in melasma. International Journal of Women’s Dermatology. 3. 10.1016/j.ijwd.2017.01.004. https://pubmed.ncbi.nlm.nih.gov/28492049/

(2) Sarkar R, Aurangabadkar S, Salim T, et al. Lasers in Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group. Indian J Dermatol. 2017;62(6):585-590. doi:10.4103/ijd.IJD_488_17 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5724305/

(3) Park YW, Yeo UC. Current and New Strategies for Managing Non-Responders to Laser Toning in the Treatment of Melasma.  Medical Lasers 2016;5:7-16.

Dr. Lena Fan: Non-surgical vaginal rejuvenation — A key to female orgasms, or just a marketing gimmick? 

We know that a woman’s body changes with age, especially after childbirth and menopause. Some time last year, I wrote about vaginal rejuvenation, an umbrella term used to describe corrective procedures that can help women with laxity in their feminine parts, or vaginal relaxation syndrome. 

One of the talking points I mentioned was a reduction of quality in the bedroom—ladies who used to view sex as unpleasant or even painful are surprised to find that they start enjoying sex with their partners after starting vaginal rejuvenation treatments. Since then, I’ve received a number of enquiries on whether this treatment really can enhance sexual intimacy. It is important that I address this question for a few reasons:

• How does vaginal rejuvenation lead to ‘better sex’? 
• Is it an aesthetic doctor’s (or anyone’s, really) place to promise satisfaction in something that’s subjective and dependent on many factors, including performance and mood? 

Hence, in this article I will address the elephant in the room and try to provide an objective take on modern feminine rejuvenation technology based on scientific evidence and research.

First, what is a “loose vagina” or vaginal relaxation syndrome?

Vaginal relaxation syndrome is a condition generally associated with ageing and menopause in older women, but is also present in younger women with multiple childbirths or traumatic vaginal births. Patients with this condition typically experience laxity of the canal, the inability to lubricate and consequently a reduced quality in sex life. Surveys show that 95% of patients feel that vaginal laxity affects sexual function, and 57% have expressed their concerns on relationship happiness¹ as a result. This often negatively impacts both partners in the relationship.

Besides sexual intimacy issues, women who suffer from vaginal laxity also tend to have a weak pelvic floor or conditions like pelvic organ prolapse (POP) and urinary incontinence. Although this laxity tends to happen after vaginal childbirth, it can also occur due to ageing and menopause. Recently, we’re seeing younger women in their 20s and 30s who have not given birth experience this issue too, due to excessive weight gain and unhealthy lifestyle habits. 

Clearly, vaginal laxity is a serious and bothersome subject for many women. Yet, it is still underreported, partly due to a lack of objective data to measure vaginal laxity. Furthermore, vaginal laxity is not a disease or life-threatening illness, so there are little to no guidelines for its treatment apart from traditional non-invasive methods like physical therapy and Kegel exercises—which often have limited efficiency due to poor patient compliance. 

Of course, there’s the surgical option of a vaginoplasty too, but that is rarely done due to the invasive nature of such a surgery and risks of side effects, such as bleeding, infection and even a vaginal prolapse. 

Vaginal rejuvenation in Singapore—becoming mainstream, or just a dream? 

The topic of a woman’s sexuality has long been regarded as taboo in Singapore, but thankfully there’s been more acceptance in recent times due to education and awareness. Locally, we’re seeing a 30% increase in women below 50 years old seeking treatment for female sexual dysfunction². 

This encouraging statistic is partly due to the advent of new energy device-based therapies in the last decade, including radiofrequency, different laser technologies and high-focused ultrasound. Compared to traditional non-invasive methods, these minimally-invasive solutions are more efficient at treating genitourinary problems. 

Top of the list of minimally-invasive solutions are: 

• Microablative fractional CO2 lasers, which work by creating superficial micro ablation zones on the mucosal surface, thereby triggering a healing response and resulting in new collagen formation. 
• Er:YAG lasers, which work by creating rapid sequential heat pulses. These heat pulses are then compounded and transferred deeper into the mucosa, resulting in tightening of the mucosa and triggering new collagen growth without damaging the tissue surface. 

At Veritas Medical Aesthetics, we use Fotona IntimaLase, a Er:YAG laser that incorporates Fotona SMOOTH technology to safely and effectively restore tissue quality in a non-ablative manner. This leaves the tissue surface intact, reducing the risk of unwanted side effects especially after multiple repeated treatments. 

Additionally, because the water absorption of an Er:YAG laser is higher than a fractional CO2 laser, the chances of excess heat buildup are a lot less likely; hence unintended damage and discomfort to surrounding tissue are much lower.  

The IntimaLase laser is designed with a unique 360° nature that’s non-invasive, painless and involves minimal recovery time. The procedure lasts about 15 minutes and feels similar to having a pap smear test. 

But can such devices really be trusted? 

Let’s first talk about the results before we delve into safety. In a 2020 study, participants who underwent a Fotona IntimaLase treatment session reported greater satisfaction and overall significant improvement in their sex life. 

What does it mean to have ‘better sex’? Most can agree it means more pleasure (more orgasms) and connection. 

In the study, 95% experienced more sensation during sex, 57% experienced better orgasms and 14% experienced more orgasms³. 

80% described their vaginal canal as tight or very tight at their second follow-up 12 months post-treatment, when before treatment 36.4% reported their vagina to be very loose and 45.5% reported their vagina as loose. 

After a 3 year follow-up, patients on average enjoyed benefits that lasted up to 16 months and many still described their vaginal canal as no longer as loose as before. From this observation, we can suggest that for most people, one treatment is sufficient to obtain long-lasting improvement, though individual results may vary. 

Personally, I recommend 2 sessions with a maintenance session 6-8 months later for mild to moderate laxity. For more severe cases, 3 sessions may be recommended with subsequent maintenance sessions. 

Now let’s talk about safety. 

Historically, there has been some criticisms regarding vaginal rejuvenation, especially since the FDA sent a warning letter in July 2018 to 7 energy-based device manufacturers that market lasers for vaginal rejuvenation. This letter came after several reported cases of pain and burning sensation after fractional CO2 laser treatment, which resulted in skepticism for such treatments—even in countries where they have been approved for clinical use. 

While FDA’s warning is not entirely unwarranted, I have to humbly disagree due to its broad generalisation on all vaginal laser procedures. Different lasers come with different mechanisms of action and risk profiles. In contrast to the fractional CO2 laser, an ablative laser that prompted the FDA warning, the laser used in Fotona IntimaLase is a non-ablative one that does not physically harm the tissue surface or create overheating due to optimal spacing between SMOOTH micropulses. As such, there are little to no risks connected to tissue ablation, including scarring and infection. Out of the options available, Fotona IntimaLase has the highest safety profile.

What else can vaginal rejuvenation with Fotona IntimaLase do for me? 

Apart from increased sexual pleasure, vaginal rejuvenation also brings a slew of personal and health benefits, such as: 

• Vaginal tightening 
• Improve symptoms of urinary stress incontinence and pelvic organ prolapse 
• Increase vaginal lubrication 
• Repair scarring and trauma in vagina from childbirth 

I personally perform all Fotona IntimaLase treatments as most patients are more comfortable with a female doctor. 

Can vaginal rejuvenation really improve my sex life?

We have the statistics to prove that Fotona IntimaLase leads to more sensation and more and better orgasms during sex— but do these really apply to everyone across the board? Keep in mind that these are just physical advantages that may or may not happen due to a variety of reasons. 

Sexual performance and satisfaction is multidimensional; there are many factors like family problems, stress and a faltering relationship that can affect the quality of your sex life. In those instances, perhaps it is better to seek other forms of therapy to treat the root of the issue. 

I must also add that vaginal rejuvenation may not be suitable for those who want to treat painful sex as that is usually a sign of a more serious underlying condition. 

Patients with the following conditions are not suitable candidates for vaginal tightening treatment: 

• Vaginismus 
• Anorgasmia 
• Dyspareunia 
• Severe prolapse 
• Vaginal lesions 
• Libido dysfunctions 
• Genitourinary tract infections 
• Hematuria 
• Autoimmune diseases 
• Pregnancy 

Ultimately, there are many aspects to motivate sexual satisfaction. As a medical professional, it is my responsibility to educate and advise on the most appropriate treatment for you. 

However, if you feel that treating your vaginal laxity will improve your sex life with better and more orgasms, or if you simply wish to improve other symptoms associated with vaginal laxity, I highly encourage you to give this treatment a try with us at $1,000 onwards per session. 

Do you have a question for me? 

I am more than happy to answer them at ask@veritas.com.sg and +65 6283 3885. 

References 

1. Lee M. S. (2014). Treatment of Vaginal Relaxation Syndrome with an Erbium:YAG Laser Using 90° and 360° Scanning Scopes: A Pilot Study & Short-term Results. Laser therapy, 23(2), 129–138. https://doi.org/10.5978/islsm.14-OR-11
2. https://www.todayonline.com/singapore/more-women-opting-rejuvenate-their-vaginas-better-sex-lives
3. Mitsuyuki, M., Štok, U., Hreljac, I., Yoda, K., & Vižintin, Z. (2020). Treating Vaginal Laxity Using Nonablative Er:YAG Laser: A Retrospective Case Series of Patients From 2.5 Years of Clinical Practice. Sexual medicine, 8(2), 265–273. https://doi.org/10.1016/j.esxm.2020.01.001