From theory to practice

Dr Smita Sunil Ghate, Prof & HOD, HBTMC & RNCGH, and Consultant Dermatologist, Ghate’s skin and Laser Centre

As aesthetic dermatology continues to evolve in India, there is a growing need to bridge the gap between theoretical knowledge and hands-on training for residents. Do Indian postgraduate dermatology programmes, like their global counterparts, offer the required exposure to aesthetic procedures, or do they leave aspiring dermatologists to seek additional private training? In the quest to find answers, Aesthetic Medicine India takes the initiative to spotlight education in this rapidly expanding field.

In this exclusive interview, Shriyal Sethumadhavan connects with Dr Smita Sunil Ghate, Professor &HOD at HBTMC &RNCGH and Consultant Dermatologist at Ghate’s Skin and Laser Centre, to explore the current state of aesthetic dermatology training in India.

How has the aesthetic dermatology department evolved over the years in terms of training, research, and clinical exposure?

Aesthetic dermatology has changed a lot over time. In terms of training, a few procedures such as botulinum toxin, chemical peels, and lasers are now part of the postgraduate syllabus. When I was a resident, I was taught that the primary indication for chemical peels was melasma and pigmentation. However, the indications have now extended to facial glow and rejuvenation. It is commonly performed before important events to enhance appearance.

The number of patients seeking aesthetic procedures was negligible in the past. But now, due to social media, more patients inquire about these treatments. In our OPD, patients are evaluated and then selected for an aesthetic procedure based on indication. The selection of the best procedure, expected outcomes, and possible risks are discussed. Students are encouraged to present case series on aesthetic procedures at conferences or take up thesis topics related to aesthetic treatments. With the availability of lasers, botulinum toxin, and threads, residents are gaining a better understanding of the science and techniques involved. Additionally, many dermatologists conduct workshops to share their techniques and experiences.

Research in the technology of various equipment and pharmacological agents has evolved significantly, aiming to provide better outcomes with fewer side-effects. For example, during my residency, diode lasers for hair removal operated on a single wavelength. Now, multiple wavelengths are used to achieve better results. In municipal hospitals, the number of patients seeking aesthetic treatments is increasing. With greater awareness, the demand has risen. Aesthetic enhancement is now sought for job opportunities, marriage, or simply to boost self confidence. It is important for hospitals to make these facilities accessible to such patients.

How do you balance theoretical knowledge and practical exposure for students/residents?

Theory must be perfect before practical application. The application of theory should be well understood. I am particular about ensuring students know the theory before touching patients. Theory is taught through seminars, lectures, and journal clubs. For example, before a botulinum toxin injection procedure, a seminar is conducted where students must learn the origin and insertion of the muscle, its action, and the surface anatomy for the injection points. Practical aspects, such as how to dissolve the powder into the botulinum toxin solution, are also explained.

Patient selection is an important step. When a patient is selected for a particular procedure, the need for the procedure and the best available options are evaluated. Photographic documentation is crucial for assessing results. The importance of consent for medicolegal purposes is also emphasised. I prefer that students observe procedures before performing them and learn the technique thoroughly. I emphasise that students must understand the complications of each procedure and how to avoid them at every step. Techniques are taught by faculty, and students attend workshops on botulinum toxin, fillers, and threads.

“In the future, I would like to initiate an MUHS-certified one-year aesthetic dermatology course, where students conduct scientific studies in municipal medical colleges. ”

“Rural areas lack trained professionals and the latest technology, so the next generation has significant scope in developing such areas, though they may have to start from zero. ”

I thank Mr Prabhakaran from the company Spectra for sending his CO2 Laser twice a month. Hands-on training with this laser gives students experience in handling the equipment and understanding treatment outcomes. It provides them with opportunities to treat a variety of skin conditions. The machine has been available for six months, and students have gained confidence in handling it and selecting parameters. They also learn that post-procedure care is equally important for achieving the best outcomes and minimising side-effects.

Has technology influenced the way aesthetic dermatology is taught and practiced in your institution, and how?

Yes, technology has had a profound effect on the way it is taught and practiced. In terms of training, online training and simulator training are used. However, in our institute, handson training is provided. Technology in laser has influenced the treatment process. It has also evolved in other energy-based devices, and many new devices have entered the market. Additionally, new peeling agents and new types of threads offer better results and fewer side effects.

How does your department incorporate real-world patient concerns, like urban skin issues, into the academic and clinical curriculum?

Urban skin faces issues like pollution, stress, and a sedentary lifestyle. However, due to internet access, these concerns have extended to suburban areas. More patients come with complaints of dull skin or an ageing appearance. In our department, the effects of the environment, stress, and a sedentary lifestyle on the skin are discussed in journal clubs through article reviews or seminars. During OPD, case-based discussions on these topics are conducted. Postgraduate students are made aware of new modifications in creams compatible with urban lifestyles, e.g., sunscreens with added protection against IR (infrared radiation) for those working on computers for long hours. They are also taught a holistic approach to treatment, enabling them to counsel patients on the need for exercise and meditation.

“Postgraduate students are made aware of new modifications in creams compatible with urban lifestyles, e.g., sunscreens with added protection against IR (infrared radiation) for those working on computers for long hours. ”

What do you think is the current gap between academic training and real-world aesthetic dermatology?

The gap is in the form of a lack of the latest technologies. Postgraduate students are not experienced or have not seen all technologies and innovations. The kind of patients who come to municipal hospitals are low profile, so the exposure to dealing with real-world aesthetic patients is lacking. Aesthetic dermatology should be learned as a science, not as a money-making branch. Initiatives should be taken to study it scientifically so that techniques can be improved.

How do you emphasise ethics and patient safety in aesthetic dermatology, especially concerning advanced procedures?

Patient safety is the primary focus and should not be overlooked due to patients’ unrealistic demands or postgraduate students’ over-enthusiasm. I tell my students that even if they cannot achieve the desired result completely, it is okay. They can provide a touch-up or a second sitting but should not overdo the procedure and worsen the outcome due to enthusiasm. In aesthetics, patients are sensitive about their appearance and seek better outcomes; they become disheartened if results are worse.

Selecting realistic patients, explaining the procedure, discussing expected outcomes and possible complications are important. Talking to patients, addressing their queries, and ensuring they fully understand the procedure without rushing is crucial. Consent and photographic documentation are essential. Each step of the procedure must be meticulously followed to avoid complications. The entire procedure must be performed under aseptic conditions.

Do you collaborate with aesthetic medicine brands or clinics for workshops and training? How do these partnerships benefit students/residents?

Yes. Being in municipal colleges, the resources are limited. Collaborations open new horizons for learning, not only for students but also for faculty. Through collaboration, we get hands-on experience with many devices and access to experts to learn from their experiences and the latest innovations. In the future, they can offer job opportunities to students.

Any key challenges you foresee for the next generation of aesthetic dermatologists?

The main challenge is competing with non-dermatologists and non-medical professionals who practice aesthetic dermatology. There is a lack of standardised protocols, so dermatologists follow their own protocols. Rural areas lack trained professionals and the latest technology, so the next generation has significant scope in developing such areas, though they may have to start from zero. An important challenge is patient education about realistic expectations, which are often heightened due to media exposure.

How does the Indian aesthetic dermatology education and practice compare with global standards?

In India, aesthetic dermatology is evolving due to increasing awareness and demand. During postgraduation, the main emphasis is on clinical dermatology, with some training in aesthetic dermatology, which is not sufficient. In Maharashtra, there are no university-certified courses in aesthetic dermatology. Students need to take private courses, often requiring multiple courses for different indications.

In the future, I would like to initiate an MUHS-certified one-year aesthetic dermatology course, where students conduct scientific studies in municipal medical colleges. Globally, university-certified aesthetic dermatology courses are available. There is a vast difference in practicing aesthetic dermatology in India compared to global standards. Indian skin types differ from European and American skin, so treatment parameters are adjusted accordingly. Since technology is imported, treatment costs are higher.

In India, aesthetic procedures are performed by nondermatologists and non-medical professionals, which is not the case in global standards.