Issue Highlights

You’re So Veined
Mariel Chow speaks to Consultant Vascular Surgeons, Dr. Lee Soon Khai and Dr. Imran Nawaz about the differences between varicose and spider veins, the dangers related to untreated varicose veins and how these conditions are treated.
The main purpose of veins is to carry deoxygenated blood back to the heart. Superficial leg veins have the ability to collect blood and later distribute it to deeper veins. Because deoxygenated blood has to travel upwards against gravity, valves inside our veins help prevent blood from flowing down in the opposite direction. Should these valves become faulty, blood reflux will result, with blood pooling in the superficial veins. If left untreated, the veins will balloon and result in raised, bumpy and worm-like appearances. Spider veins, however, are much smaller and are often red or purplish and look like spiders’ legs or cobwebs. Although reasons behind spider vein treatment are purely cosmetic, it’s crucial that patients with varicose veins visit a doctor, as it is a progressive condition that can advance to painful and irreversible conditions including chronic dermatitis, non-healing venous ulcers, infection, blood clots and severe bleeding and contracture.
What are varicose veins and spider veins?
Varicose and spider veins are dilated veins, which are visible on the legs of affected patients. While swollen veins cause both versions, varicose veins are thicker and resemble worms under the skin while spider veins can be of various colours and look like spiders on the skin. Dr. Lee explains, “Varicose veins are tortuous, swollen and raised while spider veins are tiny and may appear red, purple-bluish or greenish and are visible on both the legs and face. Despite both conditions affecting both genders, studies have proven that women are more commonly affected. Dr. Imran believes that pregnancy, as well as female hormones, may cause varicose veins. Along with pregnancy, Dr. Lee adds that other common factors can include jobs that require standing for long periods of time, sitting cross-legged regularly for long periods, and obesity. While both are visible and can coexist among one another, spider veins cannot turn into varicose veins, as both conditions are unrelated. Dr. Imran clarifies, “Varicose veins and spider veins are dissimilar because one is bigger and deeper while the other is fine. What’s more, there are patients who have spider veins but will not exhibit signs of varicose veins.”
Causes of varicose veins begin with a weakness of the valves in some of the leg veins. This will then result in blood failing to naturally flow up towards the heart. In response, veins will stretch and engorge due to blood pooling. “While it’s very easy for blood to flow from the head and arms to the heart with the help of gravity, it’s more difficult for blood to flow from the feet to the heart because it’s a long way up,” says Dr. Imran. He adds, “Humans essentially need the presence of working and healthy valves to prevent blood from moving downwards because of gravity.”
Dr Imran1Dr. Imran Nawaz
What are the physical disabilities related to varicose veins?
Dr Lee Soon Khai photoDr Lee Soon Khai
Dr. Lee warns that untreated varicose veins may lead to multiple experiences of discomfort including, pain and heaviness which worsens after sitting or standing for extended periods of time; cramps, swelling, itching, bleeding, skin hardening and inflammation. According to Dr. Imran, symptoms of varicose veins are progressive and initial indications are normally unsightly veins. As time passes and if veins are untreated, patients can experience tiredness, pain and cramping. If left untreated for longer, physical changes take place where the skin in the lower extremities hardens, turns darker from pigmentation, breaks down into rashes and ultimately, becomes ulcerous. “If varicose veins aren’t treated for over 20 to 30 years, they can go from zero symptoms to non-healing wounds.” Despite such common occurrences however, Dr. Imran says that there are always chances of non-progressing symptoms among some patients, while others who have extreme valve faultiness and blood reflux can experience symptoms as early as their twenties.
Dr Imran Nawax and The Vein Centre
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When should patients consult their doctors?
Reasons behind varicose vein treatment are divided into two categories. First, there are patients who choose to undergo treatment simply because they don’t like the look of the condition. Conversely, the second patient group seeks treatment because physical symptoms are becoming a hindrance and affecting their work and lifestyle. Nevertheless, it’s quite clear that varicose veins are progressive and the earlier patients undergo treatment, the better the outcome. What’s more, when varicose veins reach a certain stage, symptoms are irreversible. “Untreated varicose veins that have reached late stages may affect in chronic dermatitis or lipodermatosclerosis. Such symptoms can be permanent,” Dr. Imran stresses. He further adds, “If doctors treat varicose veins at such stages, we may be only able to stop symptoms from worsening but are not able to reverse them.”
Dr Imran 2Dr. Imran Nawaz
Varicose veins can progress into certain conditions. What are these conditions and how dangerous or painful can they be?
Although initial stages can be heaviness, tiredness and pain, untreated varicose veins can also lead to painful and irreversible problems. Dr. Lee explains, “Patients experiencing further stages of the condition can suffer eczema, lipodermatosclerosis, venous ulcers, thrombophlebitis (infection), severe pain, bleeding from burst veins, ulceration and contracture that incapacitates walking.” Dr. Imran adds that both lipodermatosclerosis and chronic dermatitis remain in the same spectrum. Lipodermatosclerosis will result in the skin becoming thicker, harder and darker due to pigmentation. Chronic dermatitis, however, is basically rashes. At the end of this spectrum comes venous ulcers, which is caused by veins which have been left untreated over long periods of time. “Venous ulcers are very painful because they are long-term, non-healing breaks in the skin that can physically grow up to great lengths,” Dr. Imran says. He adds, “I once had a patient who had venous ulcers from her ankle all the way up to the knee!” Chronic dermatitis on the other hand is itchy and may ooze liquid, but like venous ulcers, can become infected and lead to secondary health issues as well.
Superficial thrombophlebitis is blood clotting caused by stagnated blood in the veins. This condition not only affects in severe pain and redness but possible migration of the clots. Dr. Imran states, “While superficial thrombophlebitis may not be as problematic as deep thrombophlebitis, it’s not completely innocuous and can spread to the deep veins.” Likewise, because the veins tend to stretch and become bigger, they can ultimately burst like a balloon and result in severe bleeding.”
How are spider and varicose veins treated?
Because faulty valves cause varicose veins, the logical treatment would obviously be to treat the valves. Unfortunately, there are no satisfactory means to faulty valve treatment. Because vascular surgeons cannot repair these valves, the only option would be to remove them. Dr. Imran expounds, “The great thing about vein removal is that the leg has more than enough unaffected veins which are healthy enough to carry out their primary purpose. Treatment will not affect blood flow in any way and in fact, improve it as faulty vein removal enhances circulation efficiency.” There are multiple techniques to vein removal. First, there is the traditional or tried and true method, which is surgery. Now, there are newer techniques, which according to Dr. Imran, involve removing the veins without physically removing them. “Such techniques are divided into sclerotherapy and lasers or radiofrequency. The former is an injected chemical, while the latter utilises heat ablation. They work by shrinking the veins, with the body eventually and naturally disposing its remnants.”
Dr. Lee Soon Khai and the SK Lee Vascular and Vein Centre
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How are spider veins treated?
Surgeons will not surgically remove spider veins because they are too small. As such the treatment for spider veins remain mainly a cosmetic procedure, with surgeons normally opting for either sclerotherapy or transcutaneous lasers. Dr. Lee says, “Sclerotherapy treatments work by the injection of a sclerocent into the spider vein using a very fine needle. The sclerosing agent (sodium tetradecyl sulphate) will cause the spider veins to thrombose. The body will later absorb the thrombosed veins.” In terms of transcutaneous lasers however, the treatment is non-invasive, where energy is introduced over the skin’s surface. “After the laser is absorbed through the skin, light will be consumed by the veins and affect in shrinking. While there are other forms of treatment such as electric probes and radiofrequency, I don’t believe they are very effective and do not utilise them in my practice,” says Dr. Imran.
How are varicose veins treated?
Varicose veins are much bigger and deeper and hence, medically significant. While surgery is a possibility, there are of course downsides related to invasive procedures including hospitalisation, anaesthesia, increased downtime, risk of scarring and infection and so on. In lieu of surgery, Dr. Imran now turns to ultrasound-aided sclerotherapy for the removal of varicose veins. Sclerotherapy has been around since the time of the ancient Egyptians and now with the help of modern medicine and technology, surgeons no longer have to utilise sclerotherapy blindly as ultrasound allows them to pinpoint the exact locations of the veins. Furthermore, sclerotherapy chemicals have drastically improved, taking on a foam form as opposed to the previous and ineffective, liquid form. With so many advances in sclerotherapy injection, many doctors are choosing to solely use this form of varicose vein treatment. Moreover, the other advantage of only using sclerotherapy without lasers is that treatments are very affordable. However, sclerotherapy will requisite multiple sessions and it is imperative that surgeons understand how to deliver the treatment correctly as side effects are a possibility.
Another popular form of varicose vein removal is endovenous laser treatment. Dr. Lee reveals that the treatment begins with a needle puncture at the lower end of the vein below the knee. The laser fibre will then pass through the needle until the groin where back flow begins. He says, “Once the diseased vein is coated with local anaesthetic, it can be closed using laser energy.” Likewise, because the wire is precisely inserted, skin and surrounding structures will not be damaged. Although there are two varying forms of heat ablation – laser and radiofrequency – that are as effective, Dr. Imran only offers lasers in his practice. He was the first doctor in this part of the world to specialise in endovenous laser treatment. Moreover, he also believes lasers have more control and variability and have higher safety and stricter licensing protocols.
Dr. Lee treats varicose veins with laser and combine with sclerotherapy depending on the cases. Dr. Imran states that he’ll either primarily utilise heat ablation or a combination of both lasers and sclerotherapy if there is a need for touch-ups. He explains, “The reason I mainly prefer to deliver heat energy over sclerotherapy is because lasers have reduced side effects with 99 percent success rates. Sclerotherapy treatment however drastically reduces those rates to 88 percent.”
What can patients expect during and after varicose and spider vein treatment?
In Dr. Lee’s practice, the endovenous laser treatment will take about an hour and patients will be slightly sedated. Patients will also be placed in day care for about three to four hours and will not experience any pain during the procedure. Once patients awake, they can immediately walk and drive home. In Dr. Imran’s practice, patients will undergo local anaesthetic, feel comfortable throughout the forty-minute procedure and of course, will be able to drive and walk home immediately after. While endovenous ablation is a one-time process, Dr. Imran says that sclerotherapy may necessitate anywhere between one to three sessions depending on severity. “In my practice, sclerotherapy treatments can take anywhere between half and hour to two hours and patients will be put under light sedation for improved comfort,” Dr. Lee divulges. He adds, “Once patients wake, they can drive and walk home normally.”
Dr. Imran notes that post-procedural varicose vein care is important and it is vital that patients wear pressure stockings everyday over the next one to three weeks. Possible side effects related to laser treatment could be temporary downtime of one to five days, pain, bruising and nerve damage that leads to numbness. With sclerotherapy however, Dr. Lee suggests, “There may be a minimal amount of bruising, raised red areas, skin sores over the injection sites and darkened lines that may last up to a year.” Dr. Imran maintains that although no one knows why pigmentation occurs, it can affect 20 to 25 percent of patients where bruising can turn temporarily pigmented.
Like varicose vein treatment, spider vein treatment (sclerotherapy and transcutaneous laser) is relatively painless and the number of treatment sessions will depend on severity. For example, if a patient has spider veins all over her leg, it’s unlikely that surgeons will be able to treat all those veins in one sitting. However, because doctors try to treat as much as possible within single sessions, patients will probably have to undergo nothing more than two to three treatments. Possible side effects related to transcutaneous lasers are skin burns. But like sunburns, skin will peel and heal in time.
What are varicose and spider veins’ recurrence rates and how can patients reduce chances of recurrences?
Dr. Lee says that recurrence after endovenous laser treatments are very low, and only affect three to five percent of patients in five years. Spider veins however, are notorious, and regularly recur at rates of 50 to 60 percent. Although the rates may seem alarming, Dr. Imran notes that reappearances will take years and patients can always return for follow-up treatments. He points out, “Patients should be aware that sclerotherapy and transcutaneous lasers are not cures and procedures offered actually treat the effects as opposed to eradicating the condition.”
Despite reappearance being a very real possibility; everyone can avoid such potentials by modifying certain lifestyle choices. “Patients can reduce vein recurrences by exercising regularly, maintaining an ideal body weight, keeping the feet elevated above the heart, wearing compression garments and trying to avoid standing or sitting and sitting cross legged for extended periods of time,” Dr. Lee recommends. However, and despite heeding the doctor’s commendations, it’s almost impossible to keep feet elevated all day.
Therefore, Dr. Imran suggests regular motion as opposed to standing or sitting still as movement will encourage blood circulation as opposed to stagnation.
Secondly, because pregnancy seems to be the number one aggravating factor, Dr. Imran advises expectant mums to wear properly fitted pressure stockings throughout their pregnancy and practice leg elevation as frequently as possible.
Beauty Repair In Fractions
The role of lasers in aesthetic medicine.
Not all of us are blessed with skin that is flawless and able to stand the test of time. As we age, we need a little bit of help to maintain our youth and for those who are not born genetic lottery winners, getting the flawless skin that they have always dreamed of requires a lot of effort. Thanks to the latest developments in the aesthetic industry, ‘help’ can come in many different forms. One of them is the fractional laser.
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Fractional laser treatment is a non-invasive procedure using a device that delivers a laser beam. The laser beam is divided into thousands of microscopic treatment zones that target a fraction of the skin at a time. The easiest way to explain the process is by seeing it as an alteration of a photograph, pixel by pixel.
The increasingly popular treatment has managed to bridge the gap between the ablative and non-ablative laser techniques used to treat aging and sun-damaged skin. Whilst ablative laser treatments work mainly on the skin cells surface (epidermis) and non-ablative treatments work solely on the mid-layer of skin (dermal collagen) only, fractional laser treatment works on both the epidermal and dermal layers of the skin.
Dr. Cindy Yang (Dr Cindy’s Medical Aesthetics Clinic)
Cindy YangCindy Yang
Fractional lasers are one of the mainstays of aesthetic treatments in my clinic. It has been a very versatile tool that can be recommended to most patients with varying skin conditions. A fractional laser is very effective in a wide range of conditions ranging from improving old scars, rhytides and bringing back glow to the skin. It is also effective in the treatment of skin pigmentation and textural changes from sun damage. It can be used safely even in patients with darker skin types.
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YouLaser has a duo-wavelength capacity which increases the efficacy of the treatment with lesser downtime. With two wavelengths emitted together in one session, the outcomes are maximised as compared to the use of either wavelength alone. As these two wavelengths are individually adjustable, treatment protocols for patients can be highly individualised, tailoring each setting to the specific problems of each patient.
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Before and After Skin Resurfacing
3 YouLaser B&A picture Acne Scars Paolo Sbano MD
Before and After Acne Scars
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Wrinkles and Skin Laxity (5 days - 60 days)
The treatment is very much for everyone regardless of age and skin type. Furthermore, as the treatment settings can be highly individualised, YouLaser can be recommended to treat specific textural skin problems or just to achieve an overall improvement in the skin condition.
In general, patients can see an improved glow in a week. Real textural improvement in scars and rhytides can be seen between one to three months. Repeat treatment might be necessary depending on the extent of sun damage, scarring and wrinkles of the patient.
Dr William Hoo (Anna Hoo Clinic)
William Hoo 2Dr William Hoo
IntraCel Fractional Radiofrequency treatment plays an important role in treating acne scarring and facial rejuvenation for the patients at our clinic. Fractional micro needling radio frequency targets the deeper level of the skin. As IntraCel treats active acne and acne scars, one’s skin laxity will also improve due to production of new collagen and elastin. This will help to reduce wrinkles, tighten skin and reduce pore size.
There are two groups of patients that can benefit from fractional micro needling radio frequency treatment. The first group is patients with scarring, for instance, acne scars, surgical scars and accident scars. The second group of patients are those who ask for facial skin rejuvenation, tightening and lifting.
Intracel before afterIntracel Before and After
Not all patients are suited to this treatment, for instance those with bleeding disorders or who are currently taking anticoagulants. People who are prone to keloids should be cautioned before going for any procedures, which includes Intracel. Generally, most doctors try not to perform any procedures on people with skin cancer or those who are pregnant.
Immediately after the treatment there may be some pinpoint bleeding and swelling. Both can be quickly resolved with cooling packs. Redness maybe variable from person to person, but it usually settles within 24 to 48 hours.
Dr. Rachel Chew (Skin Art Clinic)
Fractional CO2 laser plays an important role as a non-ablative resurfacing laser treatment for acne scars, skin tightening and stretch marks. It is very effective and we can see about 20-30 percent improvement even after the first treatment. The result will further improve after a few sessions. The treatment is minimally invasive. There are no injections involved and the downtime is very minimal.
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I would recommend this treatment to patients who are looking for scar and fine line reduction, as well as smoother, firmer, brighter and radiant skin but who, at the same time, prefer minimal invasive treatment. The CICU offered at our clinic is a good treatment of choice.
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When combined with other treatment like PRP, medical grade skin care, oral supplement, radio frequency, meso therapy and PDO thread, laser treatment done with correct technique will be able to reduce the total sessions of laser and yield a faster and better result.
Dr Nimi Sutina Nordin (En-Hanze Clinic)
Dr Nimi SutinaDr Nimi Sutina Nordin
Frictional laser is very effective for the right type of condition. For example, Mosaic F1 is the machine of choice at our centre for those who want to reduce pore size, refine and smooth out their skin tone and reduce acne scars. It is also able to do other things like reduce dyschromia, tighten skin or general rejuvenation. For pore reduction, no other laser or procedure does it better than the Mosaic F1 as the effects can be seen in just a single session. The best part is, there is barely any downtime as it is not ablative, and recovery is quite fast.
nimi sutina 2Dr Nimi Sutina Nordin mosaicMosaic HP
I highly recommend MosaicF1 treatment for everyone, specifically those who want pore reduction or those with soft acne scars and those who want to refresh and refine their skin. Some patients even do it for maintenance of healthy skin on a monthly basis. In general, all fractional lasers treat an average of 20 percent of the treated surface area and therefore in order to get optimal results of at least 50-60 percent improvement, patients are recommended to undergo at least three sessions. Of course if the condition is bad, he or she may require more sessions.
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Acne Scar (Before and 6 weeks after 1 session)
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Skin Rejuvenation (Before and 1 month after Treatment)
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Skin Laxity & Erythema (Before Treatment and 1 month after Session)
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Fine Wrinkles (Before Treatment and 3 weeks after 1 Session)
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Striae Distensae (Before Treatment and 1 month after 4 Sessions)
Dr Shah Jumaat Mohd Yussof (UiTM Private Specialist Centre)
Untitled>Dr Shah Jumaat Mohd Yussof
Lumenis AcuPulse Fractional CO2 is one of the more popular treatment options that I offer at my clinic. In fact, it is the first energy-based device that we have ever used. The versatility of the machine is useful as it can also be used as a surgical tool aside from scar management and resurfacing treatment. The treatment with Lumenis Acupulse can be very effective if it is used as indicated. The surgical hand piece is able to treat small benign skin lesions.
AcuPulse imageAcuPulse Multimode Fractional CO2Laser
I have been using Lumenis Acupulse for quite some time and I find that the technology is very precise, which makes me feel more confident about using it on my patients. The results are quite consistent and we can predict outcome in most cases. I use the machine mostly for treatment of scars. It helps improve the appearance and can be combined with other treatment options like PRP for improved results.
However, I always believe that a consultation is essential to see the suitability of the treatment on individual patients. The most important thing is that they are aware of the fact that we cannot remove scars. We can only improve the appearance. Treatment with Lumenis Acupulse is definitely a good option, considering the fact that patients can see results even after a single session.
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Acne Scar Treatment with AcuPulse(Baseline and 6 months post)
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Soft Tissue (Mole) Removal with AcuPulse (Baseline and 3 months post)
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Soft Tissue (Mole) Removal with AcuPulse (Baseline and 3 months post)
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Upper Eyelid Blepharoplasty and Lower Eyelid Resurfacing with AcuPulse (Baseline and 4 months post)
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Upper Eyelid Blepharoplasty with AcuPulse (Baseline and 4 months post)
Clinical Training in Comfort
Skin M.D invests in a learning venue for doctors and nurses.
The aesthetics industry is on the brink of unprecedented change. The wide-scale reform and increasing demand for information is accelerating the growth in aesthetics medicine, forcing medical professionals to expand their knowledge to keep up with this fast-paced industry. This is why Skin M.D., a leading distributor of aesthetic equipment, is making a significant and ongoing investment to provide medical professionals with a clinical lounge that has the facilities required to foster a quality learning experience. This educational hub, which will be located in Singapore, is specifically designed for doctors and nurses to acquire the necessary skills so that they are abreast with the advancements in the world of aesthetics. Gladys Cheng, founder of Skin M.D. predicts that the formal operations of the clinical lounge will begin in January 2017.
This one-of-a-kind clinical lounge allows doctors and nurses to keep pace and explore the advancements in medical aesthetics. It is going to feature a wide variety of aesthetic machines and lasers that are currently available in the industry. This is to ensure that doctors and nurses have access to the current technology and a great learning experience to facilitate their desire to grow. “This industry is growing by leaps and bounds, and there is always something new to learn every single day. We want to be able to provide the services needed for doctors and nurses to expand their knowledge of the current advancements in this industry,” says Gladys. She believes that the growing complexities in the industry of aesthetics medicine require doctors to master not only effective communication but also extensive knowledge and a variety of skillsets. In the aesthetics industry, repeated exposure with enhanced experience will help improve the skills and confidence of doctors. This unique clinical lounge will be the platform that doctors and nurses can use to systematically garner the extended knowledge that will be beneficial in aesthetics medicine.
To allow doctors to be able to learn and master the medical aesthetic devices in the clinical lounge effectively, training sessions will be carried out. These training sessions will also include specialised sessions for nurses to ensure that they are also trained to operate the machines and lasers provided by Skin M.D. Doctors and nurses will have an opportunity to develop and refine their skills, repeatedly if necessary, using these specialised training sessions provided by the clinical lounge. This will be essential, especially when using new machines and lasers because doctors and nurses are able to test out new aesthetic equipment without putting patients at risk. Medical professionals that own the equipment distributed by Skin M.D. will be informed about these training sessions once the lounge is up and running.
To run these specialised training sessions, there will be trainers or regional trainers available. These trainers will have a good grasp and a helicopter view of all the equipment available in the clinical lounge. They will be able to provide demonstrations, pointing out the correct techniques of using the medical equipment before doctors and nurses test it out for themselves. These demonstrations would be useful in that any questions regarding the innovative machines and lasers can be tackled early on. The equipment then can be used at ease. “The aim of these specialised training sessions are for medical professionals to have a platform to upgrade their skillset. Our desire is to bring medical aesthetics to a higher standard,” says Gladys.
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In addition to the wide practical knowledge that is available when using aesthetics equipment, this clinical lounge will also provide a place for medical professionals to soak up theoretical knowledge. Doctors and nurses can drop by the library in the lounge which will be filled with clinical resources. Gladys says that the library is designed to look cozy and relaxing so to allow doctors and nurses to be as snug as a bug while going through the resources available for their reading pleasure.
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A clinical lounge would be a long-term investment in medical education and if all goes well, Skin M.D. intends to open another clinical lounge in Malaysia sometime at the end of 2017. It can serve as a platform to test out new and innovative medical equipment available in the market while allowing doctors to master the techniques needed to use the equipment. The training conducted in this clinical lounge may also offer an added benefit to doctors and nurses, possibly enhancing their knowledge on the variety of machines and lasers available in this day and age.
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“I personally believe that this is the first concept of its kind that any distributor has come up with. It is obvious that the aesthetics medicine market is experiencing monumental development and Skin M.D. is in a good position to help medical professionals take full advantage of this growth. With the ability to provide a spot to explore innovative technology in aesthetics medicine, we wish to be ahead in the game. Skin M.D. is trying to promote a continuous and never-ending learning experience as an integral part of building a successful chain of clinics. We hope to constantly grow with our clinics, and this is just a small service we hope to offer to our customers,” says Gladys.
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February, 2017

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Leng Yein
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ARTICLES

  • ASK THE DOCTORS
  • MEDICAL, AESTHETIC & DENTISTRY
  • BEAUTY+
The Healing of Wounds
You’re So Veined
Clinical Training in Comfort
Light, Bright and Beautiful
The Price of Plastic Surgery Part One: Face
Age Regally
Refreshed At Any Age
Beauty Repair In Fractions
FATS Registry Study Initiation
Smiles For A Lifetime
All About Melasma
Law And Order
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