Steer clear of the Botox cowboys

On Friday, the Department of Health will be issuing new guidelines on the use of Botox and fillers. But what they are going to propose has left many of the more conscientious within the industry feeling that the DoH has bottled out of imposing any regulations at all. The guidelines will ask the industry to take the lead on improving safety and regulate itself. It is understood they will be proposing a voluntary system whereby clinics join a register run by the Independent Healthcare Advisory Services. No legislation, and no penalties for bad practice.
The British Association of Aesthetic and Plastic Surgeons (BAAPS) is not at all happy with this, saying it will not protect the public from cowboy clinics. They want a system of fines or the register to be compulsory. Currently Botox can be carried out anywhere by anyone with training in giving injections. Podiatrists, physiotherapists and veterinary surgeons have all enquired about injecting the toxin for cosmetic reasons and in fact anyone could set up shop offering Botox jabs. The temptation to do so must be huge, with the anti-wrinkle treatment becoming increasingly popular, especially in London. Over 100,000 Britons a year use Botox and take up has gone up 2,500% in three years, making it the fastest-growing treatment in the cosmetics industry. It’s big business.
The medical profession is usually pretty strict about what can and cant be done by people with various levels of qualification, but Botox and fillers seem to have been overlooked. They are invasive procedures and Botox is a prescription-only medicine. Patient safety should be paramount. When things go wrong, and they do, (think Leslie Ash) patients can be left physically or psychologically scarred for life.
Botox blocks the nerve signals to muscle in the area it is injected, so that the muscles relax, smoothing and softening wrinkled areas. Its effect wears off after four to six months. It is generally safe and well tolerated but it isn’t always harmless. Cliff Richard and Lynne Franks both suffered drooping brows after treatment, and other users have had headaches, double vision or sagging facial muscles. In rare cases, it can cause an allergic reaction that can kill.
It is also sold to patients in some very unethical and irresponsible ways. Alcohol fuelled Botox parties. Two for One, time limited offers and non-refundable deposits all put pressure on patients to undergo procedures they may well later regret. This is immoral in any branch of medicine. The GMC states that the patient must have a two-week cooling off period to think it over before deciding to have work done.
In France and Denmark there are laws that limit who can do what, to whom and where, and the same is likely to happen in Mexico and Spain, yet still the British government is avoiding improving regulation to safeguard patients. I’m not at all sure why.
If you are considering any sort of cosmetic procedures I would urge you to check your surgeon's qualifications first. They should be on the Specialist Register of the GMC, and preferably registered with BAAPS, but remember that the UK government insanely refuses to recognize cosmetic surgery as a specialty. If a surgeon is not listed on the Specialist Register, they have not received a full surgical training in the UK.
The cosmetic surgery industry was born in the 80s but the law has failed to keep pace with regulation and training. But as many will argue self-regulation is better than no regulation at all, as is currently the case.

The perils of heels

The years of ignored warnings have finally become a reality for Victoria Beckham as she caves in to pain, discomfort and deformity and elects to have surgery to correct her impressively large bunions. Wearing six-inch heels constantly, even to do daily activities, has predictably taken its toll. At only 34 one would think that Posh is really rather young to be having this sort of surgery, but the allure of heels now means that orthopaedic surgeons are busier than ever correcting the damage that tottering around on spikes causes.
I have seen some truly horrific injuries to the ankles of teenage or twenty-something year old girls that occurred due to a combination of alcohol and unsuitable footwear. Ankle fractures sustained by ‘going over’ on a heel can be extremely messy, with no single clean break, and often require complex pinning operations that never fully restore normal use of the ankle, and inevitably cause osteoarthritis of the joint in later life.
The body comes with a wide array of early warning and damage protection mechanisms, pain being the most obvious one. If something hurts, then it is probably causing damage and should be stopped. This is common sense. Yet surveys have shown that 42% of women will happily endure pain in order to wear a pair of killer heels.
What I found more worrying were the images of 3-year-old Suri Cruise being proudly showed off by her mother whilst wearing high heels. If you want to cripple a child before she reaches her teens then stick her in heels.
Heels cause many stresses on the foot: in addition to restricting, they also massively increasing the weight pressing down on the restricted areas, pushing the toes with enormous force into a small wedge shape. The best-known foot problem is probably the bunion, known medically as hallux valgus. It occurs because the big toe becomes excessively angled towards the second toe – and a bunion is a symptom of this deformity. Once the big toe starts leaning like this then the problem tends to get progressively worse. The jury is still out on whether high heels actually cause bunions; we know there is a genetic component involved, but heels certainly exacerbate them. Bunions do occur in societies that don’t wear heels at all however.
Whilst I fully appreciate that telling women not to wear heels will be about as effective as telling kids not to eat sweets I thought I would give you my top tips on how to minimise the damage as much as possible.

1. Make sure your heels are properly fitted. Most are not. If your feet slide to the front, leaving a gap behind your heel then they don’t fit. Look for narrow heels with a snug but not tight fit.

2. Try to avoid very thin, heels and opt for a thicker one, to increase stability. They should give you better balance and may help relieve some pressure by distributing the weight on your foot more evenly.

3. Invest in some silicone metatarsal pads, which act as excellent shock absorbers and help reduce pain and damage to the ball of your foot.

4. Avoid heels with a straight drop down from the heel to the toe. These can be very hard on your arches: go for a gentler slope.

5. Wear open-toe high heels to relieve pressure on corns and calluses. Closed-toe heels cramp and deform the toe joints more.

6. Try these exercises to strengthen the muscles and tendons around your big toe: put your feet side by side, and try to move your big toes towards each other. Do this three or four times a day, 10 reps each time.

Carbon Monoxide leaks are a hazard in the home

Towards the end of last year I saw a young girl in clinic with rather strange and non-specific symptoms. As well as dizziness, nausea and shortness of breath, which would have hinted at some sort of respiratory infection, she had one very worrying sign: she was pale, but had bright cherry red lips. She had been staying with her mother in a rather swish houseboat moored on the Thames at Chelsea.
Because of certain suspicions I sent her to the nearest hospital to have her blood gas composition analysed and it showed carbon monoxide levels in her blood of 22%. Normal levels are around 0.1 to 2%.
She was given oxygen therapy under pressure and thankfully made a full recovery. Investigation revealed a faulty exhaust system on the boat that had causes levels of gasses to build up at the end of the boat where the girl slept.
Carbon monoxide is a colourless and odourless gas that accumulates rapidly in the lungs and blood. It can bind to haemoglobin and does so about 240 times more tightly than oxygen, forming a compound called carboxyhaemoglobin. This means that if both carbon monoxide and oxygen are inhaled, carbon monoxide will preferentially bind to haemoglobin. This reduces the amount of haemoglobin available to bind to oxygen, so the body and tissues become starved of oxygen. Carboxyhaemoglobin also has direct effects on the blood vessels of the body - causing them to become 'leaky'. This is seen especially in the brain, causing the brain to swell, leading to unconsciousness and neurological damage.
Symptoms of toxicity are rather non-specific including headache, nausea, dizziness, confusion, vomiting, and lethargy and are often misdiagnosed. Long-term neurological complications of CO toxicity occur in 14% to 40% of patients and include cerebral oedema, cardiac ischemia, rhabdomyolysis, and thrombosis.

I hate to admit it but I suspect that in private practice CO poisoning is rarely ever considered as a possible diagnosis for a simple reason: we usually think of those at risk of CO poisoning as staying in crummy bed sits and run down hostels: not the type likely to be accessing private healthcare, and certainly not well-heeled Chelsea types. But doctors should never make assumptions about class and background in this way, for obvious reasons: if we misjudge, it could kill.
As if on cue a new national campaign called Carbon Monoxide – Be Alarmed! has just been launched to try to reduce the number of deaths and injuries caused by carbon monoxide poisoning. It’s also lobbying for legislative change to make putting alarms in new builds and rented properties law. According to their research this subject is particularly relevant to us Londoners. We are half as likely as the national average to have an audible carbon monoxide alarm in their home and significantly less likely to understand the risks and characteristics of carbon monoxide.
I had never really thought this much of an issue before. But this recent case of mine was an eye opener. 93% of homes have smoke alarms, but only 15% have carbon monoxide alarms. And as it is the most common cause of fatal poisoning in Britain today, again a fact that I did not know and would never have guessed, this is clearly something we all need to address.