How to restore your BODY IMAGE age after Pregnancy

Pregnancy leads to many changes in a woman’s body, mainly through the interaction of steroid hormones, lactogen and cortisol on the underlying tissues and structures (1). The growing foetus itself causes mechanical change also by stretching skin, muscle and fascia and demanding an increased calorific supply (2). The amount of extra weight gained during pregnancy varies among women (3). The National Health Service recommends that the overall weight gain during the 9 month period for women who start pregnancy with normal weight should be in the region 10 to 12 kilograms (22–26 lbs.) but as many British females are already over weight these figures may be downsized. Physicians are aware, insufficient weight gain can compromise the health of the foetus during pregnancy and excessive weight gain can pose risks to the woman and the baby. For women who have gained weight between pregnancies, even a relatively small gain of 1-2 BMI units can increase the risk of high blood pressure or diabetes during their next pregnancy and may also increase the chance of giving birth to a large baby. New advice has just been published by the National Institute for Health and Clinical Excellence (NICE) as part of its public health programme (4)

It states that women who are obese (with a BMI over 30) when they become pregnant face an increased risk of complications such as diabetes, miscarriage, pre-eclampsia, blood clots and death. Obese women are also more likely to have an induced or longer labour, post-delivery bleeding and slower wound healing after delivery. They also tend to be less mobile, which can result in a need for more pain-relieving drugs during labour. These can be difficult to administer in obese women, resulting in a greater need for general anaesthesia with its associated risks (4).

So why do women have such a hard time dealing with this major body change, that often persists long after the post-partum period despite their best efforts regarding exercise and diet on their behalf. Why are humanoid females almost unique in turning into a different type of person during pregnancy? Why do females develop layers of subcutaneous fat around their midriff, their buttocks and inner thighs while males seem more prone to develop visceral fat around their organs? Why do pelvic bone widening changes occur in humans often causing major distress resulting in long term urinary and bladder dysfunction? Why does the skin stretch out of shape and lose the ability to spring back into shape?

One of the more interesting theories to explain why female fat deposits are located where they are was made by a Polish researcher called Boguslaw Pawlowski of the University of Wroclaw. To quote from an issue of Current Anthropology “the fat deposits may help to meet the balance requirements of two-legged walking during pregnancy and lactation” (5).

In this publication, Pawlowski notes that both during advanced pregnancy and when nursing, a human female has an additional anterior load that moves her centre of gravity forward and upward, making bipedal locomotion more difficult and energetically inefficient. This I feel explains a lot of the problems we see in the post-natal period. We have a quadruped means of reproduction been carried around in a biped body. Thus evolution may have promoted buttocks and thigh fat deposits to compensate for the biomechanical handicap imposed by carrying a baby. Interesting theory but it would probably explain some of the cultural effects of this new shape. We hence have two physiological types

1. 
   The ‘pre-baby’ or ‘mating’ body type with fat distribution seen in more normal areas of distribution. In this body type breasts are again used to ‘attract’ a partner rather than being a functional mammary organ. They tend to be ‘firmer’ due to fat distribution. Women prefer this body type as it symbolises health, vitality and beauty. Men prefer it as it shows a female who is ready to reproduce.
2. 
   The ‘post baby’ body type with fat now distributed subcutaneously especially in the buttocks and thigh area. There are breast volume changes with sagging, especially if the female has breast fed her infant. Breast volume may increase but usually we get shrinkage. In this physiological state the dermal tissue of the abdomen has been distended and sometimes left with long term ‘stretch marks’.

We shall now look at the problem encountered by the ‘post baby’ body type and what a patient can do to correct them. In some instances the tissues have been distended and sheared to such an extent that surgical repair is the best if not the only option. We will first look at excess fat. I do not put dieting and exercise as a primary option because most clients feel it is not effective

(1) Problem: Excess Fat Solution: Liposuction, VASER?,

Liposuction, also known as lipoplasty ("fat modeling"), liposculpture suction lipectomy ("suction-assisted fat removal") or simply lipo, is a cosmetic surgery operation that removes fat from many different sites on the human body. Areas affected can range from the abdomen, thighs and buttocks, to the neck, backs of the arms and elsewhere (6). There are many differing mechanism of liposuction including those below and the author will focus on VASER? Lipo as it is the one he is most familiar with.

• Suction-assisted liposuction (SAL)
• Ultrasound-assisted liposuction (UAL)
• Power-assisted liposuction (PAL)
• Twin-cannula (assisted) liposuction (TCAL or TCL)
• External ultrasound-assisted liposuction (XUAL or EUAL)
• Water-assisted liposuction (WAL)
• Laser Assisted

Liposuction can be combined with other procedures (i.e. radiofrequency) that involve a level of skin retraction. The level of skin retraction following liposuction is affected by the age of the patient, quality of skin, presence of underlying disease or smoking and the presence of previous skin damage such as caused by childbirth and surgery. Surgical lifts are also used post-pregnancy to address massive weight loss when the combination of large amounts of skin and shrunken fat cause significant skin drooping. Large volume Liposuction (SAL) in combination with other surgery is common, but may have higher complication rates.

Non-liposuction alternatives

• Cryolipolysis is the non-invasive cooling of adipose tissue to induce lipolysis - the breaking down of fat cells - to reduce body fat without damage to other tissues.
• Diet and exercise. Healthy eating habits combined with regular exercise also help people lose weight. This natural process, possibly as a result of Pawlowski's theories above, however, takes more time and determination after pregancy. Weight loss via exercise and healthy eating carries little risk compared to liposuction.

Without question, the development of SAL/ultrasound-assisted liposuction (UAL) has changed the face of excisional body contouring surgery. Almost all plastic surgeons use SAL/UAL as an adjunct to excisional abdominoplasty. VASER? Lipo is a minimally invasive procedure that ultrasonic technology to reshape the body after the changes of pregnancy. The makers claims what distinguishes the VASER procedure from conventional liposuction is its ability to differentiate targeted fat from other important tissues – such as nerves, blood vessels and connective tissue. Most physicians use this system to remove fat from common areas such as the abdomen, waist, hips, back, buttocks and thighs, as well as more delicate areas such as the arms, calves, ankles, knees, face and neck (7). Some physicians also use the device to sculpt female breasts. A majority of doctors questioned in a recent survey found that the system offered the following benefits over traditional liposuction: ? fast patient recovery ? less pain medication required ? minimal bruising ? reduced need for re-treatments ? smooth, predictable results ? skin tightening ? increased precision ? reduced physician fatigue Other advantages are skin tightening and reduction of blood loss. If we look at the skin tightening first, preliminary findings from a multi-centre clinical study measuring skin retraction in VASER Lipo patients shows 40% to 60% skin tightening. Most doctors agree that the key to good skin retraction is related to treating the layer of fat directly under the skin. This allows the physician to effectively sculpt an area and stimulate the dermal collagen, resulting in skin tightening (8). Another study in the July/August issue of the Aesthetic Surgery Journal, found that this device significantly limited blood loss during liposuction when compared to traditional liposuction alone. The authors concluded that VASER-assisted lipoplasty should be recommended over traditional suction-assisted lipoplasty for patients undergoing large-volume liposuction procedures or treatments in very fibrous areas of the body where increased blood loss is expected (9).

(2) Problem: Stretch marks Solution: Rioblush Carboxytherapy, Polaris RF, Tripolar RF, Aluma, Accent, PDT, Dermarolling, TCA peeling

Stretch marks occur during pregnancy and are caused by rapid stretching of the dermal tissue of the abdomen during the distension and weight gain of pregnancy (10). It is thought that nearly 85% of women will develop some degree of stretch marks during their pregnancy and these usually appear after prolonged weakening of the dermal tissues about the beginning of the third trimester. This is also a period of sustained distension (11). It is felt that dermal weakening occurs during pregnancy as a result of increased glucocortoid hormones, which actually effect the epidermis formation of fibroblasts (12). The reduced numbers of fibroblasts consequently result in less collagen and elastin being formed and this leaves the dermal tissue supporting structure susceptible to tearing. These skin changes eventually result in reddish or purple lines along the lines of stretching that tend to gradually fade to a lighter skin colour as a tendency towards re-epithelialisation occurs. Over time they can diminish but they do not disappear completely and can cause distress in the post natal female. There is little doubt that stretch marks are also influenced by hormonal changes in pregnancy as is also seen during associated with the rapid growth of puberty or weight gain during muscle building etc. (13).

Various treatments are available for the purpose of improving the appearance of existing stretch marks, including laser treatments, dermabrasion, and prescription retinoids. In terms of lasers I have used 585-nm pulsed dye lasers with some effect but I prefer a combination of dermarolling with radiofrequency. There are many publications citing this means of therapy (14). I find bipolar and tripolar devices to be of the most benefit. I have used this combination with a Syneron Polaris RF for many years. More recently, I have treated abdominal stretch marks with fractionalised CO2 laser resurfacing with some effect. This method is limited by little published data but I have now treated about 15 cases with lower density settings over multiple treatments in order to wound the dermis and try and recreate the collagen and elastin underlying structure, which the skin was deprived off. One can expect about 70% benefit over five sessions spaced one month apart (15). Many patients ask me if there are any topical creams to help with stretch marks, either during their formation or after they have occurred. There are no proper control studies but some research suggests a daily application of a cream containing Gotu Kola extract, vitamin E, and collagen hydrolysates was associated with fewer stretch marks during pregnancy. Other favourites include combinations of cocoa butter, vitamin E, panthenol, hyaluronic acid, elastin and menthol. It was associated with fewer stretch marks during pregnancy versus no treatment (16). In some cases we have almost complete resolution with Carboxytherapy and this is preferred treatment here.

Carboxytherapy is a simple and proven technique that can dramatically improve the appearance of stretch marks by improving local tissue metabolism and perfusion. Treatments are rapid, comfortable and effective for a high percentage of patients. Carbon dioxide (CO2) is infiltrated into the subcutaneous tissue through a tiny 30G needle (0.3mm in diameter) (17). From the injection point, the carbon dioxide diffuses easily into adjacent tissues. Unfortunately, nothing much has been published in the literature about this technique, excepting its relationship to breaking down adipose tissue (18). Various treatments have been proposed for the treatment of post-pregnancy stretch marks but in my opinion most of them are as good as carboxytherapy.

.

(3) Problem: Sagging Skin Solution: Abdominoplasty

Abdominoplasty or "tummy tuck" is a popular cosmetic surgery procedure used to make the abdomen firmer after pregnancy. The surgery (which can be radical) involves the removal of excess skin and fat from the middle and lower abdomen in order to tighten the muscle and fascia of the abdominal wall. Abdominoplasty operations vary in scope and are frequently subdivided into categories, depending on the extent of the surgery. There are different variations on the technique dependent on which tissues are sagging and if there is associated weight loss or residual fat to be removed. The first variant is whether a partial or a complete abdominoplasty is required (19)

1. Complete abdominoplasty, which can take from 1 to 5 hours. During this procedure, an incision is made from hip to hip just above the pubic area and another is made to free the navel from the surrounding skin. The skin is then detached from the abdominal wall to reveal the muscles and fascia to be tightened.
2. Partial abdominoplasty(mini-tuck abdominoplasty) can be completed between 1 to 2 hours. During this technique a smaller incision is made and the skin and fat of the lower abdomen are detached in a more limited fashion from the muscle fascia. The skin is stretched down and excess skin removed.
3. Extended abdominoplasty includes a lateral thigh lift. The operation allows for complete abdominal contouring as well as smoothing the contour of the upper lateral thigh.
4. High Lateral Tension Abdominoplasty (HTLA) tightens abdominal muscles in a vertical line. This method in addition to vertical-line tightening, muscles are also tightened horizontally. The final result with this technique is a dramatically flat abdomen with significantly better-defined waistline (20).
5. Floating Abdominoplasty or FAB technique (also known as an extended mini abdominoplasty) allows for tightening and shaping through a smaller incision that isn't placed around the belly button. Through this smaller incision, excess skin is removed and the belly button is temporarily detached, floating above the muscles during this process. The muscles are tightened and reshaped from sternum to pubic area.
6. Combination abdominoplasty includes a lower body lift is done in conjunction with another procedure such as breast reduction, breast lift, hysterectomy or liposuction contouring.

Abdominoplasty carries certain risks that may be serious or life-threatening. When making the decision to undergo such a procedure it is recommended to compare the benefits with the potential risks and complications. Hence, all patients must be informed on all the risks they are exposing themselves to (21). These combination techniques mean the patient is under anaesthesia for a longer period of time, increasing the mortality risk. Contraindications to abdominoplasty include right, left, or bilateral upper quadrant scars (relative); severe comorbid conditions (eg, heart disease, diabetes, morbid obesity, cigarette smoking); future plans for pregnancy (relative); a history of thromboembolic disease (relative); morbid obesity (BMI >40); and unrealistic patient expectations. Combined aesthetic and gynecologic surgery is an attractive option for both patients and surgeons. A popular name for breast enhancement procedures performed in conjunction with an abdominoplasty after pregnancy is called a "Mommy Makeover".

(4) Problem: Breast Atrophy Solution: Breast Implants, Macrolane?

This is one of the most obvious places to see the difference between a ‘pre’ and ‘post’ pregnancy body type. During pregnancy, the ovaries and the placenta produce estrogen and progesterone. These hormones stimulate the 15 to 20 lobes of the milk-secreting glands in the breasts to develop. It is widely accepted that most breasts seem to undergo a "deflationary" change in the weeks and months after weaning. The reason that this occurs is due to the fact the ratio of fat tissue to gland tissue in a women’s breast actually changes with the new requirements of the body. Most women tend to regain their normal cup size post natally but many do not, especially if they have breast fed. The body has underwent a physiological redistribution of fat and when the breast gland tissue regresses there is less fat and the breast may shrink, especially in the upper poles. Ptosis of the breast is the medical term for drooping or sagging female breasts. Many women and medical professionals mistakenly believe that the breast itself offers insufficient support and that wearing a bra prevents sagging. Many also believe that nursing increases sagging. Society is hard on mothers and very few magazine pictures display this new physiotype as anything to be proud of.

One of the most popular treatments for breast atrophy remains breast implants. There are three general types of these devices, defined by their filler material: saline solution, silicone gel, and composite filler. The saline implant has an elastomer silicone shell filled with sterile saline solution; the silicone implant has an elastomer silicone shell filled with viscous silicone gel; and the alternative composition implants featured miscellaneous fillers, such as hyaluronic acid, soy oil and even polypropylene string (22). When compared to the results achieved with a silicone-gel breast implant, the saline implant can yield acceptable results, of increased breast-size, smoother hemisphere-contour, and realistic texture; yet, it is likelier to cause cosmetic problems, such as the rippling and the wrinkling of the breast-envelope skin, accelerated lower breast pole stretch, and technical problems, such as the presence of the implant being noticeable to the eye and to the touch (23).

Women with breast implants may have functional breast-feeding difficulties; mammoplasty procedures that feature periareolar incisions are especially likely to cause breast-feeding difficulties. Surgery may also damage the lactiferous ducts and the nerves in the nipple-areola area

The presence of radiologically opaque breast implants (either saline or silicone) might interfere with the radiographic sensitivity of the mammograph, that is, the image might not show any tumor(s) present. In which case, an Eklund view mammogram is required to ascertain either the presence or the absence of a cancerous tumor, wherein the breast implant is manually displaced against the chest wall and the breast is pulled forward, so that the mammograph can visualize a greater volume of the internal tissues; Nonetheless, approximately one-third of the breast tissue remains inadequately visualized, resulting in an increased incidence of mammograms with false-negative results (24).

Macrolane? treatment has now largely been discontinued in the UK and Ireland as a breast enhancer due to the lack of consensus amongst radiologists regarding how to examine breasts that have been injected with filler. The technique involved injecting stabilised hyaluronic acid into the deflated breast and then moulding to the desired shape. The benefits are that it requires only a local anaesthetic and will leave no scarring, although bruising, swelling and discomfort for a few days are expected. The effect however only lasts for 12 months, after which further injections are required. The procedure has also drawn criticism as its long term effects are relatively unknown. The only medical trial was supported by the manufacturers, involving 1000 patients in Japan, and anybody taking the procedure will be entered into a European-wide research trial. Problems with Macrolane? included capsular formation and product migration. I saw some patients with small lumps of product that required aspiration. I think it was a wonderful product but each new lump had to be treated with respect.

The breast augmentation patient usually is a young woman whose personality profile indicates psychological distress about her personal appearance and her bodily self-image, and a history of having endured criticism (teasing) about the aesthetics of her person. In 2008, the longitudinal study Excess Mortality from Suicide and other External Causes of Death Among Women with Cosmetic Breast Implants (2007), reported that women who sought breast implants are almost 3.0 times as likely to commit suicide as are women who have not sought breast implants.

(5) Problem: Breast Sagging Solution: Breast Lift

Breast Lift (Mastopexy) refers to cosmetic surgery designed to lift or change the shape of a person's breasts. The surgery may involve repositioning the areola and nipple, as well as lifting the breast tissue and removing skin (25). A breast lift may be performed alone, or in combination with placement of breast implants; when implants are used, the procedure is typically called breast augmentation. The effects of a breast lift often get less with time as the shape and distribution of existing breast tissue tends to be temporary, as the effects of gravity and aging continue, causing ptosis to recur over time (26). A classification system has been suggested by Regnault and modified by numerous authors (27). The most commonly used system is as follows:

Grade 1: Mild ptosis - Nipple just below inframammary fold but still above lower pole of breast

Grade 2: Moderate ptosis - Nipple further below inframammary fold but still with some lower pole tissue below nipple

Grade 3: Severe ptosis - Nipple well below inframammary fold and no lower pole tissue below nipple; "Snoopy nose" appearance

Pseudoptosis - Inferior pole ptosis with nipple at or above inframammary fold; usually observed in postpartum breast atrophy

Women who experience multiple pregnancies repeatedly stretch the skin envelope during engorgement while lactating. As a woman's breasts change in size during repeated pregnancies, the size of her breasts change as her mammary glands are engorged with milk and as she gains and loses weight with each pregnancy. In addition, when milk production stops (usually as a child is weaned), the voluminous mammary glands diminish in volume, but they still add bulk and firmness to the breast. These changes in the mammary glands contribute further to sagging.

(6) Problem: Melasma Solution Triluma, Azelaic acid (20%), Hydroquinone, Isotrex (Tretinoin). IPL, ActiveFx, SmartXide DOT, Fraxel, Fraxel Repair, Fractionalised Erbium

Melasma is the formation of irregular pigmented patches and are commonly found on the sun exposed face in the period surrounding pregnancy. It is thought they are caused by increasing levels of both oestrogen and progesterone and may be seen outside pregnancy during administration of the oral contraceptive pill (28). The hormones are thought to stimulate melanocytes resulting in increased production of the normal tanning protective chemical but why this pigment occurs in patches or even gets caught in the dermis is less well known. There appears to be a racial predisposition to the problem, especially in East Europeans and Jews (29). It is also known to occur in patients with thyroid disease and stress may result in increased levels of melanocyte stimulating hormone (30). The pigmentation usually disappears itself four months after the circulating hormone levels return to normal. However, we can help to accelerate the depigmentation process if required.

I feel it is important that someone with clinical experience of pigmented lesions should be involved in their removal. There are many reasons for this, melanomas can regress and depigment and lesions such as lentigo malignas can appears in the same locations on the face as melasma. That said, melasma is comparatively easy to diagnose as it tends to occurs in large patches rather than isolated lesions. When there is doubt, I sometimes use a Wood's UV light to determine the depth of melanin pigmentation in the skin: contrast in epidermal pigmentation is increased while contrast in dermal pigmentation is decreased under Wood's lamp illumination compared to ambient visible light. Under Wood's lamp, excess melanin in the epidermis can be distinguished from that of the dermis. Dermal melanin is more difficult to remove by methods that do not reach this level. Of particular benefit is the Beau Visage dermal melanin analysis system but I am aware all clinics have not this technology at their disposal. I find this is of particular benefit, especially if it is decided to use a series of IPL laser treatments to help depigmentation. If the pigmentation is dermal then we will require some other method of removal as it will only serve to darken the lesions. Whenever dermal melanin is involved I tend to use either the Fraxel or ActiveFx fractionalised CO2 laser. Mandelic Acid (Triluma cream) has also been shown to be of benefit in these cases. If the melasma is epidermal then topical depigmenting agents, such as hydroquinone (HQ) are a good starting point. These creams come in either in OTC (over-the-counter) (2%) or POM prescription (4%) strength. As physicians, we tend to use 4% as standard. Hydroquinone is a chemical, which inhibits tyrosinase, one of the enzymes involved in the production of melanin. I also use Azelaic acid (20%) as it also decreases the activity of melanocytes. Hydroquinone topical has been assigned to pregnancy category C by the FDA. Animal studies have not been reported. There are no controlled data in human pregnancy. Hydroquinone topical is only recommended for use during pregnancy when benefit outweighs risk. It is unknown if Hydroquinone Cream is excreted in breast milk. After pregnancy I use many topical creams for depigmentation. Isotrex (Tretinoin) as 0.025% OTC or 0.05% POM is a retinoic acid that increases skin cell (keratinocyte) turnover. This treatment is the topical form of Roaccutane and cannot be used during pregnancy. After pregnancy, we can also use facial peels with alpha or beta hydroxyacids or chemical peels with glycolic acid. The biggest problem with removal of melasma is the possibility that the condition will return. The patient should also be told the lightening effects are gradual because the pigmented cells have to grow out to the stratum corneum and a strict avoidance of sunlight post procedure is mandatory. We should also be aware that ordinary sunscreen in my opinion does not prevent melasma recurring and topical agents with physical blockers, such as titanium dioxide or zinc dioxide should be used. Ordinary light will make melasma recur. Some products such as MD Skincare Sunscreen Pads with Vitamin C SPF 30 provide some protection and nourishment to skin. Olay Regenerist Targeted Tone Enhancer contains an amino peptide complex combined with Pro-Retinol, (a less irritating form of vitamin A), to boost cell turnover within the skin's surface to reduce the appearance of dark spots. Other less wounding treatments such as glucosamine, mulberry root, and yeast extracts can work to accelerate the skin's natural exfoliation process, in effect buffing away the dark spots. Of course the patient may not want a procedure and may be told that cosmetic cover-ups can also be used to reduce the appearance of melasma.

(7) Problem: Varicose Veins, Spider Veins Solution: Lasers, IPL, Sclerotherapy, Surgery

Pregnancy tends to worsen spider veins and smaller varicose veins because circulating hormones associated with pregnancy soften the vein walls and valves. During pregnancy veins have to carry a greater circulating blood volume. Sometimes the enlarged uterus compresses abdominal veins, causing further back pressure the leg veins. Changes in body chemistry due to birth control pills and constrictive on clothing, such as tight hosiery can also contribute to spider vein development. Other related factors are heredity, obesity, menopause, aging, prolonged standing, leg injury, and abdominal straining (31). Treatment can be either conservative or active. Active medical intervention can be divided into surgical and non-surgical treatments. Newer methods including endovenous laser treatment, radiofrequency ablation and foam sclerotherapy appear to work as well as surgery for varices of the greater saphenous vein (32).

The medical term for spider veins is telangectasias. These fine red and purple veins are approximately 1 millimeter or less in size and can occur anywhere on the body. Patients most commonly seek treatment for spider veins on the legs and chest. Spider veins are often found in combination with varicose veins. Laser and Intense Pulsed Light treatment of spider veins is accomplished using the 595 nm pulsed-dye laser, the 1064 YAG Laser or Intense Pulsed Light (IPL). These systems produce vein specific wavelengths which seal the spider veins. (33) (34)

Sclerotherapy has been used in the treatment of varicose veins for over 150 years. The procedure is used to treat smaller varicose veins with a chemical sclerosing agent or type of foam in order to make these vessels necrose or shrink in size. In this rather simple procedure, veins collapse and fade from view. The procedure may also remedy the bothersome symptoms associated with spider veins, including aching, burning, swelling and night cramps. The medicines that are commonly used as sclerosants are polidocanol (POL), sodium tetradecyl sulphate (STS), Glycerin and Chromated Glycerin and hypertonic saline (35). The liquids can be mixed at varying concentrations of sclerosants and varying sclerosants/gas proportions, with air or CO2 or O2 to create foams.

Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlebectomy and CHIVA. Stripping consists of removal of all or part the saphenous vein (great/long or lesser/short) main trunk. The complications include deep vein thrombosis, pulmonary embolism and wound complications including infection (36). There is evidence for the great saphenous vein growing back again after stripping.

Note * this paper covers most of the aesthetic problems associated with pregnancy and their current management. Treatments will change with time and the authors preferences are based on his personal experience and skill level. Some of these problems also occur outside of pregnancy but become exacerbated due to the physiological changes that occur during gestation.

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Dr. Patrick Treacy is Chairman of the Irish Association of Cosmetic Doctors and Irish Regional Representative of the British Association of Cosmetic Doctors. Honorary Board Member of the World Medical Trichologist Association. Fellow of the Royal Society of Medicine and the Royal Society of Arts. (London). Honorary Ambassador to the Michael Jackson Legacy Foundation and the Haiti Leadership Foundation, which opened orphanages in both Haiti and Liberia the past year. He holds Honours Degrees in Molecular Biology and Medicine. He is the recipient of the Norman Rae Gold medal from the Royal College of Surgeons in Dublin. He has also received many national and international academic awards including the prestigious AMEC Award in Paris and runner up Aesthetic Doctor of the Year UK & Ireland 2016.  

He has authored or co-authored more than 200 articles in medical and scientific journals and published many peer-reviewed papers within these disciplines, including a sentinel study on the rising incidence of cutaneous malignant melanoma for the Mayo Clinic, Rochester in 1990. He pioneered facial implant techniques for HIV related facial lipodystrophy and early radiosurgery venous thermocoagulation. He is an advanced aesthetic trainer and has trained over 800 doctors and nurses from around the world. 

He is a renowned international guest speaker and features regularly on national television and radio programmes. He has featured on the Today Show, Ireland AM, CNN, Dr. Drew, RTE, TV3, Sky News, BBC and Newsweek.