Body Language Issue 48

nov/dec

48

The UK Journal of Medical Aesthetics and Anti-Ageing www.bodylanguage.net

BOTULINUM TOXIN ADVANCES REVIEWED THE POWER OF PEPTIDES

Fillers and men INJECTION POINTS AND QUANTITY VITAL FOR TOP RESULTS

Your partner in injectable facial aesthetics

≤ 25°C

BOCOUTURE does not require a cold chain. ®

Transport and storage does not require refrigeration prior to reconstitution.

Unopened BOCOUTURE® vials can be stored at controlled room temperature ( 25°C) for up to 3 years.

Botulinum toxin type A free from complexing proteins

BOCOUTURE® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for BOCOUTURE are not interchangeable with those for other preparations of Botulinum toxin.

Reconstitution with 0.9% sodium chloride unpreserved for intramuscular injection (50 units/1.25 ml).

Standard dosing is 20 units; 0.1 ml (4 units) injected into each of the 5 injection sites: 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Use a thin sterile needle (e.g. 30 gauge). Intervals between treatments at least 3 months. Not recommended for use in patients over 65 years or under 18 years of age. Use immediately after reconstitution. Superior and medial alignment of the needle should be maintained during the injection. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided.

Injections into the corrugator muscle should be done in the medial portion of the muscle, and in the central portion of the muscle belly. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site.

Special warnings and precautions BOCOUTURE should only be used for one patient for one session.

Should not be injected into a blood vessel. Patients may experience exaggerated muscle weakness.

Not recommended for patients with a history of dysphagia and aspiration. Seek immediate medical care if swallowing, speech or respiratory disorders arise. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution if bleeding disorders of any type occur. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Caution in targeted muscles which display pronounced weakness or atrophy. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Use during lactation cannot be recommended.

Has a minor or moderate influence on the ability to drive and use machines. Interactions No interaction studies have been performed. Theoretically Botulinum neurotoxin may be potentiated by aminoglycoside antibiotics or other medicinal products that interfere with neuromuscular transmission e.g. tubocurarine-type muscle relaxants. Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Localised muscle weakness, blepharoptosis,

localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection.

Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain.

Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose Increased doses of Botulinum neurotoxin type A may result in pronounced neuromuscular paralysis distant from the injection site. Symptoms of overdose are not immediately apparent post-injection and may include general weakness, ptosis, diplopia, speech difficulties, paralysis of the respiratory muscles and swallowing difficulties which may result in an aspiration pneumonia. BOCOUTURE may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin.

Prescriber should consult the SmPC for full information regarding side effects. Legal Category: POM. Basic NHS Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany.

Date of revision of text: June 2010. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1047/BOC/JAN/2011/JH. Date of preparation: Jan 2011.

BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA.

contents

body language number 48 14

CONTOURING THE MALE FACE Dr Derek Jones passes on his experience of treating men with an array of fillers

18 TECHNIQUE TURN UP THE VOLUME Injecting a good amount of filler at the right points can fill in wrinkles and address volume in large facial areas, writes Dr Koenraad De Boulle

27

Designer Helen Unsworth 020 7514 5981 helen@face-ltd.com

21 CLINICAL NEEDLEPOINT Micro-needling skin rejuvenation doesn’t involve ablation or thermal injury and can be performed by all medical aesthetic practitioners and their trained personnel. Combination treatments are the way forward, writes Dr Robin Stones

25 RESEARCH PEER PRESS REVIEW Dr Rohit Kotnis surveys academic and association journals to report on advances in research in medical aesthetics and related fields

Classified Sales Simon Haroutunian 020 7514 5982 simon@face-ltd.com Publisher Head of Sales Raffi eghiayan 020 7514 5101 raffi@face-ltd.com Contributors Dr Derek Jones Dr Koenraad De Boulle Dr Robin Stones Dr Rohit Kotnis Dr Timothy Flynn Dr Raj Persaud Dr Beatriz Molina Mr Rajiv Grover Barbara A Green RPh Ronni Weinkauf PhD Kim Pearson Dr Nick lowe Dr Sangeeta Punjabi Dr Aamer Khan Martin Murray Dr Sheldon Pinnell

ANALYSES Reports and comments

14 COVER STORY

Editor David Williams 01273 606 799 david@face-ltd.com Assistant Editor Helen Twinam 01273 606 799 helent@face-ltd.com

6 OBSERVATIONS

27 INJECTABLES

33

HITTING NEW TARGETS The growth of aesthetic medicine can be traced to the rise of injectables, particularly botulinum toxin. Dr Timothy Flynn discusses papers that have investigated effects of the new formulations and how they have combined with fillers

30 PSYCHOLOGY THROUGH THE LOOKING GLASS We all know that cosmetic surgery can improve appearance, often with outstanding results. But does surgery improve self esteem? Dr Raj Persaud reviews the literature

33 FILLERS FILLER UP With an increasing variety of dermal fillers on the market, which one do you choose? Dr Beatriz Molina runs through their key characteristics

56 ISSN 1475-665X The Body Language® journal is published six times a year by FACE Ltd. All editorial content, unless otherwise stated or agreed to, is © FACE Ltd 2011 and cannot be used in any form without prior permission. The single issue price of Body Language is £10 in the UK; £15 rest of the world. A six-issue subscription costs £60 in the UK, £85 in the rest of the world. All single issues and subscriptions outside the UK are dispatched by air mail. Discounts are available for multiple copies.

Printed by Buxton Press Ltd. Enquiries, orders and all other mail should be addressed to Body Language, 2D Wimpole Street, London, England, W1G 0EB. To contact Body Language by telephone, please call us on +44(0)20 7514 5982.

Editorial e-mail: editorial@bodylanguage.net Advertising: advertising@bodylanguage.net.

Body Language can be ordered online at www.bodylanguage.net body language www.bodylanguage.net

37 INJECTABLES IN GOOD SHAPE Dr Derek Jones, Dr Tim Flynn and Mr Rajiv Grover discuss permanent versus resorbable dermal fillers for a range of indications

41 SKIN POWERFUL PEPTIDES Small, biologically active peptides can help slow facial ageing, reduce dark circles under the eyes and lighten unwanted spots, write Barbara A Green RPh, MS and Ronni Weinkauf PhD

3

editorial panel Dr Jean Carruthers MD, FRCSC, FRC is clinical professor in the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver, where she specialises in facial cosmetic surgery. With her husband, Dr Alastair Carruthers, she has received the Kligman award from ASCDAS .

Rohit Kotnis MRCS (lon), Dip SeM (ed) practises from clinics in Oxfordshire and Buckinghamshire and is a trainer in advanced botulinum toxin and dermal filler applications. He has published extensively in musculoskeletal and trauma research journals and specialises in sports and soft tissue injuries.

Professor Syed Haq trained at Harvard Medical School, Massachusetts General Hospital and Tufts University, New England Medical Center. Professor Haq is Director of The London Preventative Medicine Centre, Harley Street.

Syed is an honorary consultant at the Chelsea and Westminster Hospital NHS Foundation Trust.

Professor Andy Pickett has worked on botulinum toxins for over 23 years. Andy has lectured around the world on the products, translating the science into practical understanding for injectors. In 2011 Andy founded Toxin Science Ltd and is head of development at Q-Med.

Fiona Collins and Marie Duckett are registered nurses and members of the Royal College of Nursing forum for nurses in aesthetic medicine. Their clinic, Fiona and Marie Aesthetics Ltd, is based in Harley Street.

Anthony erian FRCS (erg) FRCS (ed) is an aesthetic plastic surgeon with more than 30 years’ experience.

He is a member of the American Academy of Aesthetic and Restorative Surgery and chairman of the European Academy of Aesthetic Surgery. Mr Erian practices in Cambridge and Harley St. Dr Stephen Bassett is medical director of the Aesthetic Training Academy and ShapeCYMRU Cosmetics. He is a Syneron luminary and member of the Merz academy, focusing on RF facial procedures. He is a barrister, fellow of the Society of Advanced Legal Studies and a legal consultant. elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies.

She is now director of education at LCS Academy Ltd in Milton Keynes.

Dr Séan Cummings MBBS T(GP), DRCoG, DFFP, MRCGP, llM is a cosmetic doctor practising in Harley Street. Dr Cummings has more than 20 years’ experience as a practitioner and has a masters degree in medical law.

Dr Cummings works as an expert witness and has sat on GP disciplinary hearings Renato Calabria MD is part of the voluntary faculty of the Department of Plastic Surgery at the University of Southern California, Los Angeles. He is a member of the American Society of Plastic Surgery, and the International Society of Plastic Surgery. Dr Calabria practises in Beverly Hills, Milan and Rome.

Dr Bessam Farjo MB ChB BAo lRCP&SI practises hair restoration at his clinics in Manchester and London.

Dr Farjo is a fellow International College of Surgeons, founder member British Association of Hair Restoration Surgeons and president of the International Society of Hair Restoration Surgery.

body language number 48

43 NUTRITION MICRONUTRITION AND IMMUNITY The best offence to bolster the immune system is a strong defence, writes Kim Pearson

45 PRODUCTS ON THE MARKET The latest products in aesthetic medicine, as reported by Helen Twinam

48 RESEARCH EVIDENCE-BASED PRACTICE Practitioners must combine clinical expertise with independent research. Dr Nick Lowe reviews the effectiveness of current study protocols and the importance of data-based evidence

50 DERMATOLOGY ATOPIC ECZEMA The prevalence of eczema is rising, caused by genetics and environmental factors. Dr Sangeeta Punjabi discusses treatment and patient management

53 PEER TO PEER UNDER THE SKIN In this issue, our panel of experts discuss dermatological issues and skin treatments, as well as the best hyaluronic acid techniques for facial rejuvenation

56 DERMATOLOGY FOLLOW THE LIGHT As well as being an effective skin cancer treatment, photodynamic therapy can be a useful addition to your armamentarium for conditions such as acne and rosacea. Dr Aamer Khan describes the procedure and aftercare

59 ACCOUNTANCY STRUCTURAL INTEGRITY With the onset of the 50% tax rate and potential loss of personal allowances, Martin Murray outlines the pros and cons of financial structures available to cosmetic practitioners

61 ANTIOXIDANTS UNDER THE SUN The sun may have set on the British summer but our skin is still under attack. Dr Sheldon Pinnell explains why topical antioxidants may provide skin protection that is not possible with sunscreens

66 COMMENT CONCLUSION Letter from the Editor, cartoon

Dr Masud Haq BSc, MRCP, MD is a consultant in diabetes and endocrinology who practises at Tunbridge Wells and 10 Harley Street. Dr Haq is a graduate of Guy’s and St Thomas’s Hospital, and he trained at Johns Hopkins in the US and in Melbourne. He has written for numerous publications and has a particular interest in the thyroid and menopause.

4

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observations

Tax would cause more harm than good, say critics HMRC says proposals simply clarify current legislation. Helen Twinam reports Government plans to introduce VAT on cosmetic surgical procedures have been blasted by the industry. The proposal, called the “boob tax”, would raise an estimated £500m per year, raising prices of procedures such as breast enlargements, facelifts, liposuction and abdominoplasties by around 20%, the current rate of VAT. Minor procedures, such as injectables and facial peels, are subject to VAT. But cosmetic doctors performing surgery will have to register for VAT and pass the charge on to their patients, unless they can prove the procedures are for medical reasons.

Guidelines issued by the HM Revenue and Customs (HMRC) state that services are VAT-exempt only if the purpose is to “protect, maintain or restore the health of the person concerned”. The guidance says that, while cosmetic treatment may make a person feel more confident about their appearance, this is not sufficient to make the treatment exempt.

Patients with psychological conditions, such as body dysmorphic disorder or those having corrective surgery, will not be affected by the proposal.

The British Association of Aesthetic Plastic Surgeons (BAAPS) claims the move will present an “ethical minefield” and drive patients abroad for cheaper surgery deals. “The subjective proposals being put forward by HMRC will potentially harm large numbers of patients. They imply that, by definition, any procedure that corrects appearance rather than

function is not a medical need.

There has been no meaningful discussion with the professional bodies involved,” says BAAPS president Mr Fazel Fatah.

“We can only hope that common ground can be found that protects the well-being of patients while balancing the obvious need to increase tax revenues. With surgery, we are dealing with human lives," Mr Fatah says.

A similar 5% levy on elective cosmetic procedures in the US, dubbed the “Bo-tax”, was proposed under President Obama’s healthcare reforms in 2009. But the move was dropped in favour of a 10% tax on tanning bed users.

The UK move has initiated debate on whether the government is acting to profit from the success of the industry, which has an estimated value of £2.3bn a year, and the difficulty in determining whether a surgical procedure can be classed as ‘therapeutic’.

Consultant plastic surgeon Douglas McGeorge says: “The amount of money HMRC will make out of this is astonishing. Should prominent ear correction in children be taxed?

What level of asymmetry or abnormality is required to justify breast surgery?

“Our role is to make sure patient needs justify treatment.

Any justification to HMRC of our decisions on VAT will be impossible unless patient confidentiality is breached,” Mr McGeorge says.

The potential invasion of patients’ privacy is also a contentious issue. Dr Samantha Gammell, president elect of the

“Justification to HMRC of decisions on VAT will be impossible unless patient confidentiality is breached” Douglas McGeorge, consultant plastic surgeon 6

British Association of Cosmetic Doctors, says that the aggressive stance taken by HMRC will discriminate against vulnerable women, some ethic groups and sufferers of disfiguring dermatological conditions. “When patients seek out care from doctors, they expect to be treated without judgement or prejudice, putting the maintenance of their health as our primary concern.

“We are appalled that HMRC inspectors in Wales are demanding to review confidential patient records for proof of their medical needs. It is an obscene invasion of privacy based on a ridiculous premise that a doctor, having taken on a duty of care, could do otherwise than protect the health of their patient,” Dr Gammell says.

“The public should not be put off seeking the help that they need. There is simply no legal basis for the HMRC’s approach and we will continue to fight for patients’ rights.”

However, HMRC maintains that the new tax is simply clarifying current guidance set out in a 2007 document. A statement issued by the HMRC says that, while it reviews its guidance in consultation with relevant trade bodies, there are no plans to change the VAT liability of cosmetic services.

“Medical care provided by registered health professionals in hospitals or clinics is, and will continue to be, VAT-free along with cosmetic services performed for therapeutic purposes. Medical treatment for purely aesthetic reasons has been, and continues to be, liable to VAT at the standard rate.”

HMRC adds: “We will generally accept that cosmetic services are exempt where they are undertaken as an element of a health care treatment programme. Where services are undertaken purely for cosmetic reasons, they will be standard rated.”

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observations

South-east Asia is a medical tourist hot spot Lower prices, well-trained staff and beaches and warm weather lure Western consumers The UK aesthetic medicine’s fears that more consumers will be lured to other countries because of the imposition of VAT on procedures is a distinct possibility. South-East Asia and India in particular has shown large growth in patients travelling from abroad to have aesthetic surgery.

Hospitals from India to Singapore and South Korea treat more than one million foreign patients a year, lured by cutprice surgery, no waiting lists, cutting-edge technology, and highly trained doctors.

Industry experts predict medical tourism in Asia will grow at a rate of 15–20% a year. American patients swell the numbers most, saving 40– 50% on domestic costs. The fastest growing visitor numbers are from China.

Kim Byung-gun, a plastic surgeon at the BK DongYang Plastic Surgery Clinic in Seoul, says medical tourism is going to be “one of the growth engines of the South Korean economy”.

He attributes the growth from China to the “Korean Wave”, which is popular Korean culture that is popular in China.

CLSA Asia-Pacific Markets estimated that China will account for 60% of the rise in high net-worth individuals' wealth in Asia over the next five years.

In 2007, fewer than 8,000 medical tourists travelled to South Korea. By 2020, the South Korean government envisages one million medical tourists a year.

India's government says its medical services are cheaper than those in southeast Asia,

Letters to the editor Problems with awards

I just read your “Conclusion” at the back of Sept/Oct Body Language, and I just wanted to write to commend you on this. I entirely share your views that giving “awards” and trophies to clinics is an impossible, not to mention thankless task—apart, that is, from the person receiving it!

I know that other cosmetic publications offer these routinely, however, I have always frowned upon these (as much as Botox will allow me of course—LOL) for the reasons that you have succinctly pointed out. Although I know that the commercial pressures may be great upon you but I do hope you will be able to uphold your thoughts and withstand having such awards in the future.

Mr Alex Karidis Plastic surgeon London

Body Language on iPad please!

In addition to the paper version, could we have Body Language available on the iPad please.

Dr David Varghese Hampshire Does BL on iPad suit your reading preferences? Email david@ face-ltd.com if this is something you would like to see. Or do you prefer good, old-fashioned paper. You can send your letters to the editor by email: david@face-ltd.com body language www.bodylanguage.net

and identifies its Englishspeaking doctors as providing a "major comfort factor". It has even introduced a special visa category to cater for the growing number of medical tourists.

Thailand sells itself as dual purpose destination where medical treatment can be combined with a cheap recuperative holiday.

The Singapore healthcare industry positions itself as a "premium" centre. Among its patrons have been many of Malaysia's sultans, as well as other high profile political figures and celebrities from Asia and the Middle East.

By next year, Singapore aims to treat one million foreign patients a year, generating about $3 billion for the economy, the Singapore Straits Times has reported.

Its area of expertise includes cancer treatments, cardiology and other specialised care. Like South Korea, it sees China, as well as India, as being the catalysts for growth, Neighbouring Malaysia, attracted nearly 400,000 medical tourists last year, and aims to increase that number to 1.9 million by 2020, mainly by way of undercutting Singapore.

A health official said costs in Malaysia are 30 percent cheaper than the city-state to the south.

The Philippines also sees itself as a cut-price destination, and is projecting the number of medical tourists to hit one million by 2015, generating at least $1 billion in revenue.

It targets patients from the United States, Canada, Taiwan and Japan.

Nanotechnology in breast implants reviewed Material could help cancer treatment A review published in Wiley Interdisciplinary Reviews: Nanomedicine and Nanobiotechnology is investigating whether nanotechnology may improve the safety of breast implants.

While groups have campaigned for their abolition on safety grounds, results from six ongoing post-approval studies on silicone implant safety and performance have shown no increased risk of breast cancer or connective tissue disease.

The US Food and Drug Administration ended its 14-year ban on silicone-filled breast implants in 2006 but the actual silicone rubber shells were never called into question and silicone rubber implants filled with saline were never withdrawn from the market.

Lead review author Judit E Puskas, PhD ME of the University of Akron and researchers

surveyed the literature on breast implants from the perspective of material science to determine how nanotechnology may enable the future development of safer breast implants.

By reducing the size of the components in nanostructured materials, “unprecedented properties can be achieved”, they say. The authors are developing an alternative nanostructured material to silicone rubber that they say will minimise complications. They say the new material will be able to deliver cancer drugs locally to improve the efficacy of treatment and minimise side-effects associated with chemotherapy.

There is potential for countless materials and devices to be developed for a range of applications but issues have been raised concerning toxicity, particularly when used in medicine.

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Signals from stem cells may spur hair growth Finding could lead to baldness treatments Researchers at Yale University have found that molecular signals from stem cells within the skin’s fatty layer are necessary to generate hair growth in mice. The finding could lead to new treatments for baldness, according to a study published in the September issue of Cell.

When hair dies, the scalp’s fatty layer shrinks, then expands as hair growth begins— a process known as adipogenesis. The Yale researchers found that the stem cells involved in the creation of new fat cells— adipose precursor cells—were

needed for hair regeneration, and that these cells produce platelet-derived growth factors.

Lead author of the study, Valerie Horsley, says: “If we can get these fat cells in the skin to ‘talk’ to the dormant stem cells at the base of hair follicles, we might be able to get hair to grow again.”

To test whether the signalling applies to humans, research is needed to identify other signals produced by the scalp’s stem cells and how these may help regulate hair growth, and whether they are required for human hair growth

BACN offers bursaries for prescribing course Nurses must apply now for 2012 The British Association of Cosmetic Nurses (BACN) is offering members bursaries for its V300 nurse prescribing course.

Completion allows cosmetic nurses to prescribe within their area of competence drugs such as botulinum toxin following a face-to-face consultation.

The V300 course can cost more than £1500. The BACN is offering £800 per member towards the full prescribing course, and £200 towards a pre-assessment course. Applicants can choose either, but not both, and payment will be made directly to the chosen university.

Nurses can apply for bursaries now, in preparation for the January 2012 intake. The first awards will be made on 5 December 2011. Further awarding dates will take place in 2012, or until all money has been allocated.

To be eligible, applicants must be a BACN member, have been practising in aesthetics for at least a year, hold current

registration as an adult nurse on the NMC register, obtain written support from a line manager or referee, submit an end of year final report to the BACN management board, and have been a UK, Channel Islands or Isle of Man resident for four years.

Applicants must write a 500-word supporting statement on how the course would benefit them and their patients, as well as a two-page CV and references. More information can be found on the BACN website at www.cosmeticnurses.org.

body language www.bodylanguage.net

60

second brief

SELLING POINTS How does online marketing of UK and US aesthetic clinics compare? A study presented at the British Assocation of Aesthetic Plastic Surgeons annual meeting evaluated the marketing practices of 100 top clinic websites offering cosmetic surgery—50 in London and 50 in New York. Results showed that more US-based practitioners take advantage of social media networking and interactive website features than UK surgeons

Accreditation 94% vs 64%: Nearly all US websites list surgeons’ accreditation, such as board certification, compared with only two-thirds of British websites The remaining 36% don’t include qualifications, are not on the specialist register or even listed with the GMC. Prices 24% vs 10%: One-quarter of British clinics provide price lists and indicative prices, compared with only 10% of US clinics Photography 100% vs 46%: US websites are much more likely to contain pre- and post-operative photographs of patients who have undergone specific procedures, compared with less than half of their British equivalent Media 66% vs 26%: American websites are more likely to feature video clips (and 72% animated graphics) online than UK clinics (56% graphics) 72% vs 30%: US-based practitioners are more likely to feature press and media coverage of their work compared with UK doctors Social media 58% vs 16%: More than half of American websites feature a blog, compared with only 16% of UK clinics 36% vs 6%: Over a third of US clinics have a link to a Facebook page (and 28% Twitter), compared with only 6% of UK websites (10% Twitter) Competitions 26% vs 12%: British clinics are more than twice as likely than US clinics to offer financial incentives such as prize draws, BOGOF offers and multi-procedure discounts Source: Aesthetic Surgery Journal/BAAPS

11

observations

training & events NOVEMBER

JANUARY

9th November Stem Cells and Growth Factor Technology in Cosmetics, Melia White House Hotel, London W: skingeeks.co.uk; 01865 338 046

12th January 5th Annual Oculoplastic Symposium, Atlanta W: sesprs.org

10th - 12th November 8th British Academy of Cosmetic Dentistry Annual Conference, Hilton London Metropole Hotel, London W: bacd.com 12th - 13th November Advanced Toxins & Fillers and Advanced Dermal Fillers Training Courses, Wigmore Medical, London W: wigmoremedical.com; 0207 514 5979

13th January Healthxchange Obagi Training Workshop, Manchester W: obagi.uk.com; 01481 748063 18th January Dental Block Training, Heather Irvine Aesthetics Academy, Bradford, W. Yorks W: heatherirvineaestheticsacademy.co.uk; 0844 324 9199

15th - 16th November SkinBrands Medik8 Training Courses, Cheshire W: skinbrands.co.uk; 05603 141 956

18th January Lynton Lasers Core of Knowledge Course, Lynton Clinic Training Centre, Cheadle W: lynton.co.uk; 0845 612 1545

22nd November The Future for UK Cosmetic Surgery: Creating a Safe, Successful Industry Seminar, Guoman Charing Cross Hotel, London W: inside-health.co.uk; 0845 666 0662

19th-21st January 15th Meeting of the European Dermatology Forum, Interlaken, Switzerland W: euroderm.org

23rd November Eden Aesthetics Agera, DermaFrac and Microdermabrasion Training Course, Manchester W: edenaesthetics.com; 01245 227752

19th - 21st January International Congress in Aesthetic Dermatology 2012, Bangkok W: euromedicom.com

24th November DNC Skin Microneedling Training Course, London Docklands W: wellnesstrading.co.uk; 01746 718123

24th January BACN Managing Complications for Nurse Prescribers, London W: cosmeticnurses.org

28th November Advanced Botulinum Toxin Training, Heather Irvine Aesthetics Academy, Bradford, West Yorkshire W: heatherirvineaestheticsacademy.co.uk; 0844 324 9199

26th January BAD Medical Dermatology Meeting, Royal College of Physicians, London W: bad.org.uk

30th November British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) Winter Scientific Meeting, Royal College of Surgeons, London W: bapras.org.uk

26th - 29th January International Master Course on Aging Skin (IMCAS) 2012 Annual Meeting, Paris, France W: imcas.com

DECEMBER

27th - 28th January British Academy of Aesthetic Dentistry Annual Scientific Conference, Stoke Park, Bucks W: baad.org.uk

1st - 3rd December 6th International Congress of Psoriasis: from Gene to Clinic, QEII Conference Centre, London W: psoriasisg2c.com

28th - 29th January Innomed Basic Botulinum Toxin and Dermal Fillers Courses, Greater Manchester W: innomedtraining.co.uk; 02380 676733

2nd - 3rd December Hyperhidrosis and Intermediate Botulinum Toxin and Advanced Dermal Fillers Training Courses with Dr Brian Franks, North London W: drbrianfranks.com; 07973 558595

31st January - 4th February 8th IACD World Congress of Cosmetic Dermatology, Cancun, Mexico W: wcocd2012.com

6th - 7th December SkinBrands Medik8 Training Courses, London W: skinbrands.co.uk; 05603 141 956 3rd December Dermis Deep Foundation Botox and Dermal Fillers Courses, Birmingham W: ddassist.com; 01675 625007 7th December Mapperley Park Core of Knowledge Course, Nottingham W: mapperleypark.co.uk/training; 0115 969 0111 7th December Lip Master Class Training, Heather Irvine Aesthetics Academy, Bradford, W. Yorks W: heatherirvineaestheticsacademy.co.uk; 0844 324 9199 8th - 10th December 19th Annual World Congress on Anti-Aging Medicine and Biomedical Technologies, Las Vegas, Nevada W: a4m.com 12th December Healthxchange Obagi Training Workshop, London W: obagi.uk.com; 01481 748063

FEBRUARY 1st - 4th February International College for Maxillofacial Surgery Congress, Gran Canaria W: icmfs.com 8th February Mapperley Park Core of Knowledge Course, London W: mapperleypark.co.uk/training; 0115 969 0111 9th-11th February 46th Annual Baker Gordon Educational Symposium, Coconut Grove, Florida W: bakergordonsymposium.com 27th February Healthxchange Obagi Blue Peel Training Workshop, London W: obagi.uk.com; 01481 748063 28th February Interventional Cosmetics: New Treatments & Management of Complications, Royal Society of Medicine, London W: rsm.ac.uk

13th - 14th December If you have an item you would like included SkinBrands SkinCeuticals Training Courses, London in Training & Events, send it for consideration W: skinbrands.co.uk; 05603 141 956 to editorial@bodylanguage.net

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Synthetic collagen shows promise for regeneration Too early to predict whether it is viable alternative Researchers at Rice Universi- similar way to native collagen, ty, Houston have developed a but we start with shorter pepmethod for creating synthetic tides,” says Hartgerink. collagen, which may aid tisThe researchers say that it is sue and organ regeneration too early even to predict whethfrom stem cells. er the synthetic collagen will be Lead author Jeffrey Hart- a viable substitute. gerink says: “Our final product Tests have shown, however, more closely resembles native that the enzyme that is responcollagen than anything that’s sible for breaking down napreviously been made, and tive collagen breaks down the we make that material using synthetic material at a similar a self-assembly process that is speed. remarkably similar to processes Future tests will determine found in nature.” whether cells can survive in the It has so far been difficult new material. to recreate collagen because of its complexity. Collagen fibres are constructed from millions of peptides, and the fibres can form hydrogels to trap water.

“Our supramolecules, fibres and hydrogels form in a CAD can aid the creation of a mould

Architect technology used for breast reconstruction Potential boon for tissue engineering Scaffolds for personal breast tissue reconstruction have been produced using computer-aided design (CAD) to create an accurate mould of the breast as a visual aid during tissue reconstruction.

Three female breast cancer patients in a study published in a physics institute journal were scanned by a 3D laser and the images fed into CAD software to create a single image representing the patient’s breast and thorax. The image was printed to form a 3D mould used as an operative aid for surgeons carrying out autologous tissue reconstructions. Patients reported higher satisfaction of surgical outcome compared with a control group.

CAD particularly shows

promise for tissue engineering in the creation of a mould for scanned tissue with the ability to tailor the porosity and pore size. This is essential to the seeding and diffusion of cells within the structure and is limited by modern technologies.

Professor Dietmar Hutmacher, co-author of the study, says: “The development of a clinically translatable method of engineering adipose tissue for soft tissue reconstruction requires investigation of several components. There must be coordination between all key aspects of tissue engineering, including the selection of cell source, scaffold material, cellular environment, and means of device delivery for the engineering of tissue to be successful.”

body language www.bodylanguage.net

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15th – 17th June 2012 3 DAY CONFERENCE PROGRAMME Hear the world’s leading facial aesthetic experts speak on the latest developments in Facial Aesthetics. As with 2011 FACE will include many parallel lectures to allow all topics within facial aesthetics to be covered with even more Exhibitor Workshops and Specialist Meetings.

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FACE OF THE CLINIC A concurrent business meeting providing an invaluable opportunity for you to invest in quality education for key personnel within your business. 2012 will see also much more focus on the marketing of your clinic as well as day to day managment.

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This will be the 4th incarnation of an evening with and once again we will have one of the industry greats explain the methods used to have a thriving clinic and a healthy business model.

ALTERNATIVE AGNEDA FOR 2012 As in the last four years FACE has always created the need for delegates to see and hear more and 2012 will be no different. With the prospect of more than 4 parallel conferences on each day FACE 2012 will undoubtedly be the biggest conference yet.

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THE UK’S PREMIER MEDICAL AESTHETIC CONFERENCE AND EXHIBITION Celebrating 10 Years of FACE In 2012 FACE will be celebrating 10 years of being the UK’s premier medical aesthetic conference. From the first 5 hour evening meeting in 2002, FACE has grown into a congress with over 70 hours of lectures held by some of the worlds best practitoners and pioneers in facial aeshtetics. The growth has been consistent and over the next few years we expect to see even more developments for the FACE Conference.

Wendy Lewis, Beauty Consultant “FACE is the most important aesthetics congress in the UK and an absolute must for any vendor doing business in the region.”

Dr Daniel Goldberg, Clinical Dermatologist “One of the most dynamic and exciting cosmetic meetings I have ever lectured at.”

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cover story Dr Derek Jones

Contouring the male face Dr Derek Jones passes on his experience of treating men with an array of fillers

I

start every filler lecture with anatomical slides of high-risk structures, and that is vascular anatomy. Anyone picking up a filler syringe must know it inside and out, like the back of your hand. The facial artery supplies the blood to the face, breaking off on the lower lip, into the inferior labial artery, into the superior labial artery, travelling up along the course of the nasolabial fold. All of these present high-risk for vascular occlusion.

This network connects the dorsal nasal artery to the supratrochlear artery. If you inject your filler into any point along this and occlude the vessel, you can get a watershed vascular occlusion that affects a portion of or the entire network, manifested an an immediate white blanching of tissue followed by a retiuculated purple-blue erythema. There are increasing case reports secondary to intravascular occlusion with fillers; that’s why we have to know where these vessels are, where they run, and we have to be respectful of them so that we don’t create any mischief.

We have much data on Restylane, Juvederm and Belatero.

Studies show that when you reach optimal correction with hyaluronic acid and retreat in 6–12 months, you need less volume for optimal correction, and the corrections start to persist for

14

longer periods—often 18–36 months. HAs are long-lasting with repeat treatments.

HAs are “erasable”. I use many fillers—they all have a role— but I particularly like hyaluronic acid because I sleep well at night. If I have a problem I know I can erase it with hyaluronidase. If I have an unfortunate intravascular accident, which can happen to even the best of us, I have hyaluronidase in my cabinet that I can use to flood the area and resolve it.

We use Vitrase in the USA; the one common here is Hylase.

When using hyaluronidase, you need to have some awareness of the difference between fillers. It takes more Vitrase to dissolve Juvederm than it does Restylane. That doesn’t mean one product persists longer than the other. But if you’re using Juvederm and you’re trying to erase it, it’s going to take twice as much hyaluronidase than Restylane.

From my clinical experience, each tenth of a cc of Juvederm that I estimate I want to dissolve, I use 10 units of Vitrase; and for each tenth of a cc of Restylane that I estimate that I want to dissolve, I use five units. The hyaluronidase works well and breaks the cross links immediately. You often see the hyaluronic acid fading away before your eyes.

HAs are great for male lips. You must be careful not to overbody language www.bodylanguage.net

cover story Dr Derek Jones

volumise them. I ing as you pull back, you have much less chance of injecting never use calcium straight into an artery. hydroxylapatite or Cannulas are becoming much more popular these days. I’m polylactic acid. Lips still mostly a needle injector, but I would certainly seek experiare for hyaluronic ence with cannulas when injecting Radiesse because it may be acid only; it’s a less risky. Never inject it into the lips; never inject it into the much softer, more glabella, which is a high risk area for necrosis; and never inject it supple product and into the tear trough. you can erase it.

Sculptra is a subtle volumiser.

HAs work nicely You have to do multiple treatments and I would say do not for tear troughs. inject this product superficially. It is not an intra-dermal injecMany practitioners tion, it’s a SubQ injection. You want to make sure that you rewant to treat tear constitute with 5cc or more using a linear threading technique. troughs, but they I’ve done a significant amount of work with the HIV lipoatroare the most techni- phy community. I was among a group of authors who published cally complex area data on 77 patients treated with liquid injectible silicone using to treat. I get many micro-droplet technique, 2cc per treatment at monthly intervals, referrals because until we got optimal correction. (Derek H Jones MD, Alastair Carruthers MD, David Orentreich MD, Harold J Brody MD, Know your anatomical danger zones. Avoid of my experience facial artery branches, infraorbital nerve and with hyaluronidase.

Mei-Ying Lai MS, Stanley Azen PhD, Gregory S Van Dyke MD, parotid gland Most people come PhD. “Highly Purified 1000-cSt Silicone Oil for Treatment of to my clinic with an over-volumised tear trough.

Human Immunodeficiency Virus-Associated Facial LipoatroI inject on a deep plane through this area, going in at a 90-de- phy: An Open Pilot Trial,” Dermatologic Surgery, Vol 30, Iss gree angle with, generally, a 32-gauge half-inch needle. You don’t 10, pp 1279–1286, Oct 2004.) The treatment worked beautifulwant to put it too superficially. You need to go just a little infe- ly. You have to go slowly with the micro-droplet technique using riorly to the trough into the sub-orbicularis oculi fat and place it highly purified 1000-cSt silicone. I do find this to be absolutely properly, usually in an epiperiosteal location. the best treatment for HIV facial lipoatrophy.

If there’s any mid-facial atrophy in the cheek, you have to adWe have recently followed up with about 135 of these padress this before you treat the tear trough; otherwise you’ll create tients. Extremely good results were evident at five years or more. a sausage effect that is basically buttressing out over a hollow We have had four patients who have developed some subcutacheek, and that’s a no-no. Often by just restoring cheek atrophy, neous induration, which is expected with any permanent filler. you can make eyes look better.

Luckily we’ve been able to treat it quite nicely with intralesional HAs can treat the ear lobes. One patient had a little line in cortisone with 5-flourauracil. the ear that bothered him. I put .4 ccs of HA in each ear lobe and he was thrilled.

Dr Derek Jones is an associate professor of dermatology at UCLA I always pay attention to what bothers patients. I give them and director of the Skin Care and Laser Physicians clinic of Beverly the mirror and ask them. I may have all sorts of ideas about what Hills. W: skincareandlaser.com I want to do, but I really try to incorporate their primary complaint foremost, without doing any harm.

Radiesse is a one-year filler, and we have histologic studies showing that. Calcium hydroxylapatite is visible in CT and X-ray and does not obscure underlying structures or pathology. It is FDA-approved for the nasal labial fold in HIV facial lipoatrophy.

HIV facial lipoatrophy patients can take much volume.

For more advanced stage two lipoatrophy, the average optimal correction using Radiesse is about 13cc; our silicone stud- A 42-year old male injected with filler into lips before (left); at two weeks, 12 weeks, 24 weeks, ies suggest about the same. You’re not go- 36 weeks and 48 weeks ing to make patients happy with a smaller amount. Part of what we need to do as good cosmetic injectors is to be able to estimate how much volume someone will need.

Radiesse is a robust product. There are probably a disproportionate number of vascular accidents with Radiesse because novice injectors are using it and injecting it too rapidly, getting into vascular structures. I use a lot of it in my own practice. Inject it very slowly. I use a linear retrograde technique, using a long needle. If you’re inject- An HIV patient before Silikon-1000 injections and after 11 at monthly intervals body language www.bodylanguage.net

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technique Dr Koenraad De Boulle

Turn up the volume Injecting a good amount of filler at the right points can fill in wrinkles and address volume in large facial areas, writes Dr Koenraad De Boulle

R

evolumising the face can make patients look so much younger.

Those who have seen me inject know I use the bolus technique.

I check that I'm not in a vessel, that I'm not scraping the periostium and that I am on the bone.

My old adage is always “stab quickly, inject slowly”. On average, for a cheekbone enhancement, I need anywhere from 0.25–0.75cc. I follow up with a little massaging of the area.

I get my patients to smile so that I can assess volume, then I inject one side, and ask to smile again as to assess the other side. I inject the requisite volume for an even look. Then I feel whether everything 18

is in the right position, For the mid-face I make a single injection into the deepest point. If I can have the tip of my needle around that area, then I know the maximum amount of product will be delivered there for maximum lift. As I pile up the filler like a pyramid, I can squeeze it so that it goes perfectly into place.

Vessel I check that I'm not in a vessel—if I am in a nerve the patient will definitely tell me.

If I am in a vessel, the aspiration test will tell me that. I put my finger where I feel the orbital rim and inject very softly.

I will have close to 0.75cc in this area

if it is not mixed with lidocaine. Then I will look at both sides. Typically, I may inject 0.75 to 1cc in the cheekbone and around 1cc per side in the mid-face.

I do not use icepacks on a regular basis, especially when fillers containing lidocaine are used. Once during a demonstration, the injectors were using a filler containing lidocaine and afterwards they put icepacks on the patient.

Later I saw the patient, who was due for another treatment. She had frostbite, because the doctor didn’t see any signs of too much cooling and the patient did not complain because she could not feel anything.

For the temple area, if you see a vessel, body language www.bodylanguage.net

technique Dr Koenraad De Boulle

don't stab into it. I often use a 27-gauge so that the filler really flows easily.

Again, I check whether there is not the odd vessel that runs in this area and then I put in the product, building a little pyramid. After the injection, sometimes you can see that vessels around that area become a little inflated, become more voluminous. It's a trauma, and so the body reacts by getting all the fluids and the blood there to control it. Also a little oedema might develop immediately after the injection due to the trauma.

I will do this in one bolus technique.

I put in something like 0.5 to 1 cc maximum. You will see a little lump of product. I smooth it out and ask the patient to look up. If I still see little lines, I will add a little bit more product.

For remaining lines in the lateral frontal area, don't use botulinum toxin because you may end up with a lateral brow drop. Fill them—not the lines as such because this will make them look like a ridge. Fill the whole area. For people who are skinny and a little older, it’s a nice procedure to do.

I may use a cannula. I will add a drop of lidocaine and then drill a little hole with a needle—not that much smaller than the cannula, otherwise you have to stab again.

Then I put in the cannula, such as a 27-gauge, 1-inch cannula. You can fan out the product, first putting it in one place, as I do with the bolus technique.

I feel if everything is okay and then massage the area for a while Closing words Over time, with repetitive treatments following a treatment plan, your patients’

overall facial features will hardly age and may even improve. We are not injecting fillers only for the filling aspect of their properties. The stretching of the fibroblast induces neocollagenesis.

Complications can arise. The stimulation of fibroblast is ongoing—the fibroblasts do not have a little switch that stops it at the critical point.

One patient had polylactic acid and presented with what appeared to be a granuloma, but was an ongoing fibrosis.

The gentleman was not happy with his continuing neoformation of collagen. A steroid injection was the solution.

Complication issue number two is bacterial infection. You need to cleanse the patient carefully.

Always wear gloves. I’ve seen practitioners demo without gloves, putting a cannula against the chin or cheek to show where they were going to inject and then inject with the same cannula. That is asking for trouble, because you can easily introduce your bacteria into those areas.

In the so-called homogenous gels, there is a constant exchange of water with surrounding tissues. These are, by definition, excellent growth media for bacterial infection. HAs are slightly acidic, which helps to prevent infection.

If you’re dealing with an infection, use antibiotics to start with. If the area is a bluish or violet colour, it is most probably a granuloma. If it is red and swollen, tender, sometimes with a fever, it is most likely an infection.

Dr Koenraad De Boulle is a dermatologist and director of Aalst Dermatology Clinic, a private dermatology clinic in Aalst, Belgium

In one session the mid-face and cheeks were filled using the bolus technique. Juvéderm Voluma was used—1cc per side, mid-face; 1cc per side, cheek —overall 4cc.

Fanning was with a 25G cannula after local anaesthesia was used for the stab entry. The after photo was taken 3.5 weeks later body language www.bodylanguage.net

Follow-up questions Q: What proportion of your practice has changed more towards contouring and volume compared with filling lines and wrinkles?

A: I'm not injecting the nasolabial area with filler anymore. Filling changed so dramatically with the filling of the midface—I don't think it’s necessary. If there is a remaining part that I can’t treat midface, then I will fill.

Q: If you have a patient with frown and forehead lines who doesn’t want a toxin, would you inject fillers in the glabellar area and indeed the frontalis, and if so at what level would you inject?

A: First, if they don't want any botulinum, you can definitely use fillers in the central frontal area, as toxin is not that important there. Glabellar is another issue. Products in superficial layers are fine.

In deeper layers, you need to be aware that if you put in a large quantity you can block an artery. This can result in an occlusion or a vascular compromise.

Q: How can you differentiate between a granuloma and infection?

A: If it has a bluish/violet colour, this is most probably a granuloma. If it is red and swollen, tender, sometimes accompanied with a fever, this will be an infection.

For granuloma, with people who have been injected with multiple products, you need to ascertain which is the culprit.

Even if you're precise, cleansed and the procedure goes wrong you may think you are to blame. But it may have been the stabbing that led to a reactivation in the deeper layers. So you may need to do a biopsy to determine the culprit.

If you are dealing with an infection, don't start steroids, but antibiotics, high-dose, long-term.

Q: One of my patients was injected with a toxin in the crow's feet and the result was not that good. How do you fill this area?

A: Crow's feet can be way too deep for a toxin. Think of a deflated balloon with a wrinkled surface. If you inflate it, it becomes stretched, and so we don't have to inject anymore toxin there. Just enhance the area with a little volume.

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clinical Dr Robert Stones

Micro-needling skin rejuvenation doesn’t involve ablation or thermal injury and can be performed by all medical aesthetic practitioners and their trained personnel.

Combination treatments are the way forward, writes Dr Robin Stones

Needlepoint M

icro-needling is not a new concept. The Carruthers were using needles subcutaneously to divide adhesions under full thickness in grafts on the nose before micro-injections of fat as a levelling procedure. In 1995 the Orentreichs in New York described their use of a tri-bevelled needle under the skin, again to cut the deep attachments from fibrotic scarring. This is a process that became known as subcutaneous incisionless surgery, which we now call subcision. Many of us use this technique routinely when we’re treating depressed fibrotic scars.

What I want to focus on is microneedling in a perpendicular plane to the skin—rather than underneath it—to stimulate collagen formation. Dr Des Fernandes in South Africa in 1996 devised a needle stamp to treat upper lip lines. It was a crude device that he had body language www.bodylanguage.net

some success with, but the design and mechanism would limit its widespread use due to pain and peripheral damage.

In 2005, the advent of a medical device, the Dermaroller from Dermaroller GmBH, enabled the use of micro-needles in an easy to use, patient comfortable device. A landmark study, by Dr Martin Schwarz in 2006, looked at the histology of what happened following microneedling. Dr Schwarz demonstrated that a micro-needling procedure would lead to the formation of new collagen in the middermis. A much larger series of patients in a study published by Dr Aust in 2008 with data taken six months after a single micro-needling procedure showed a 60– 80% improvement in treated conditions.

The mechanism of action similar to other technologies: fractional lasers, fractional RF. As the needles cause a multiplicity of tiny micro-wounds and we

wound the skin, we get a wound-healing response.

Initially, we’ll get an inflammatory response and release of inflammatory mediators from monocytes and platelets.

Fibroblast growth factor and transforming growth factor, which will initiate the proliferative phase, lead to the production of collagen and elastin, enhancing the extracellular matrix and angiogenesis.

This will be followed by maturation and remodelling of collagen, with resulting contraction and tightening, collectively leading to a significant enhancement in the appearance of the skin.

One of the key differences of medical micro-needling leads to wound-healing without scar tissue formation, as there is no ablation and the mechanically induced needle columns naturally close, which is clearly important for some of the indications of this technique. TGF Beta 1 and 21

clinical Dr Robert Stones

Beta 2 induce collagen synthesis, but the wound-healing occurs with a fibrotic scarring response. Micro-needling has been shown to up-regulate TGF Beta 3, which facilitates wound-healing without scarring, and the new collagen that’s been laid down will be in a normal lattice-like pattern, which will rebuild normal skin architecture.

Every procedure has contra-indications. In micro-needling it is any form of active infection, active inflammatory dermatosis, skin cancer, keloid scars, systemic retinoids and anti-coagulants.

As usual, patients must have a consultation and give proper informed consent.

The procedure is simple to perform. It’s done under topical anaesthesia—the one of your choice—30-40 minutes with or without occlusion is normally adequate for this procedure, followed by the rolling, done in a vertical/horizontal plane and the two diagonals.

If I don’t get much pin-point bleeding, I don’t feel as though I’ve caused enough stimulation, and wounding down to the mid-dermal plexus with pin-point bleeding will give a good wound-healing response. You can wipe blood away immediately with antiseptic, or leave and clean at the end of the procedure.

Bleeding does not continue post treatment, and one is left with erythema, which will normally resolve in 24–48 hours. The skin will return to normal within 24 hours, and most patients find that they can return to work. They will notice some increase in exfoliation in the first week, and from a week onwards, improvement in the texture and tone. From three weeks, pigmentation can start to improve.

The main collagen effect will be evident six weeks and onwards. Six weeks is the chosen interval between treatments.

There are a number of devices avail-

able. A 1.5mm needle length is best for most facial work. For sun-damaged skin or pigmentation, a course of three or four micro-needling treatments at six-weekly intervals should be adequate. For scarring of any type, I usually start with four treatments, but this can be extended. If there is clear improvement on an ongoing basis, there’s no limit to how many treatments you can carry out.

Where the dermis is much thicker— the back, the buttocks, or where there isn’t anything firm beneath to roll against, such as the abdomen for stretch marks—a longer needle length of 2–2.5mm is probably better. Very short needle versions are designed for patients to use at home two or three times a week between the medical micro-needling sessions.

Micro-needling generates a woundhealing response and new collagen, but there’s no ablation, no removal of epidermis, no thermal damage… it creates

DR ROBIN STONES DR DAVID ECCLESTON

DR MATTEO TRETTI CLEMENTONI

Stretch marks before and after a course of five 1.5mm microneedlng treatments. After photo taken seven months after final treatment

A 54-year-old woman before and after two Dermaroller treatments five months apart.

Nerve blocks were used for surgery and treatment with Tretinoin 0.05% for two months before and two months after the surgical sessions.

Immediately after a micro-medical skin-needling procedure with 1.5mm needles 22

DR IGOR SAFONOV

DR ROBIN STONES

Before and after three 1.5mm needling sessions

Before and after 1.5mm treatments body language www.bodylanguage.net

clinical Dr Robert Stones

purely a physical injury. The downtime is minimal and it has an excellent safety profile for all skin types. The most widely published data records treatment of acne scars and I find that I can get as good a result with a single Dermaroller microneedling session for acne scarring as with a single fractional erbium laser treatment.

A study of 350 patients and satisfaction in the micro-needling treatment of wrinkles used a visual analogue scale of 0–10. Ten was completely satisfied and zero was completely dissatisfied. The average pre-operative score, following a single micro-needling procedure, was 8.5.

In addition, a survey by the Consulting Room showed that 91% of practitioners used this technique for skin rejuvenation.

Half reported very good results, and a third reported excellent results.

Combination therapies Combination therapies using micro-needling are becoming more popular. I favour an LED device. We know, from use of the Omnilux device, that there’s much evidence over years for the effects of its light wavelengths on the skin. The blue is obviously a photodynamic effect for acute inflammatory acne from the bacterial porphyrins.

The red light at 633 has been shown to have a specific healing effect. It’s been used for years to treat leg ulcers and nonhealing surgical wounds. The infrared 830 wavelength also stimulates fibroblastic activity.

There are various protocols. I keep mine simple. Immediately after microneedling, I put the patient under the Omnilux Red infrared lamp for 20 minutes.

Other practitioners use micro-needling in combination with the red light before and after.

In non-fractionated RF, there are ways of ways of focusing the energy into different layers of the skin and the subcutis, and this could present good combinations with micro-needling. A collagen stimulation from hyaluronic acid products, possibly from a stretching effect of the dermis, does seem to generate activity of fibroblasts and production of collagen.

Potentially we could combine the deeper layer filling procedures with the microneedling surface procedure.

Low molecular wight and less crosslinked HA products are also candidates for combination therapy. I know of one practitioner who uses four Dermaroller treatments interspersed with Restylane Vital, showing good and rapid responses.

So the HA hydrates and gives a fast result body language www.bodylanguage.net

while waiting for the collagen maturation to take effect. A logical extension to that thought process is: HAs are by injection, so if we’re doing micro-needling, which is going to breach our normally protective stratum corneum and epidermis, why do we need to inject the HA under the skin?

Why don’t we just apply it topically? Will it work if we do that and then carry out a micro-needling procedure? Well, the answer is, yes, it does.

Study A study by Dr Martin Schwarz, a plastic surgeon, and the dermato-pathologist Dr Laaff, both from Germany, applied HA topically to the skin, which was rolled in using a Dermaroller medical device. They showed that not only was the HA present in the needle channels, but also in the dermis around it. They postulated that it may be travelling within the lymphatic channels This leads us to consider all the mesotherapy techniques, because there are many topical agents that mesotherapy practitioners apply to the skin. Work is being conducted on combining microneedling and topical agents, but it is in its early stages.

Finally, I want to mention the home needling device that is available and has been shown to be beneficial. It doesn’t cause any bleeding. It’s designed for two or three times a week use, and it’s really designed for use with the longer needles used in the medical micro-needling procedure.

If you’re using a roller device, get one that is approved as a CE-marked sterile single-use medical device. There are many cheap alternatives available on the internet. Avoid them. I use the genuine Dermaroller device manufactured by Dermaroller GmBH. I now apply a topical HA serum before rolling. Afterwards, I apply a calming cream, put them under the Omnilux Red light, and get them to use a topical HA product between the six-weekly Dermaroller sessions.

Micro-medical skin needling is established now. We do have evidence for various applications. There are some interesting areas that can be looked at in the future for which we don’t yet have the proper evidence, but may well come with time.

Dr Stones is co-medical director of Court House Clinics and has worked in private cosmetic practise for the past 13 years and in NHS dermatology practice for 25 years

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peer press review

Peer press review Dr Rohit Kotnis surveys academic and association journals to report on advances in research in medical aesthetics and related fields

Botulinum Toxin A Treatment of Raynaud’s Phenomenon: A Review Iorio ML, Masden DL, Higgins JP. Semin Arthritis Rheum. 2011 Aug 23.

Botulinum toxin A has conventionally been used in the upper extremity to treat spasticity resulting from stroke, paraplegia and dystonia.

In this study, an Ovid MEDLINE search from 1950 to September 2010 was performed to identify reports on the use of botulinum toxin in the treatment of Raynaud’s disease or associated vasoconstrictive disorders.

Since 2004, there have been five studies that have evaluated the use of botulinum toxin A for the treatment of Raynaud’s.

In each study, patients received a range of botulinum toxin injections (10-100 units) in their fingers and hands. The studies have many limitations, such as lack of controls, variable severity of disease and variability of dosing, but all report favourable clinical results. All showed improvement in patient pain and a reduction in soft tissue ulceration.

Initial reports on the use of botulinum toxin A for Raynaud’s phenomenon are promising. Larger controlled trials with improved study design are warranted.

Botulinum toxin treatment in upper limb spasticity: Treatment consistency Papavasiliou AS, Nikaina I, Bouros P, Rizou I, Filiopoulos C. Eur J Paediatr Neurol. 2011 Aug 19.

The study assessed treatment consistency of botulinum toxin administration in spastic upper limbs through stability of dosages

and between injections intervals.

Over eight years, 153 children (81 with bilateral spastic cerebral palsy, 72 with unilateral) were treated according to accepted, experience-based guidelines with Botox and Dysport.

Treatment response was based on assessment of spasticity and attainment of pre-determined goals at three, six and 12 months post treatment.

Mean age at treatment onset was six years four months and median follow-up was 2.5 years.

The number of injection sessions ranged between 1–10 and few had more than six sessions.

In 106 children, more than one anatomic region of the limb was injected. Most (56.2%), had at least two injection sessions with a median time interval between the sessions of nine months.

Children over four years old at the first treatment had longer intervals between sessions (25.8%) compared to younger ones.

The mixed effects models demonstrated that botulinum toxin dosage was stable over subsequent visits and that intermediate intervals for subsequent visits were similar to the first one.

This is a useful article illustrating a common application for botulinum toxin in conventional medical circles. Patients enquire about the safety of the treatments cosmetically—this study can give the practitioner information on the use of the product in children which can be explained to a new client.

Extensive necrosis after injection of hyaluronic acid filler: case report and review of the literature.

Kassir R, Kolluru A, Kassir M. J Cosmet Dermatol. 2011 Sep;10(3):22431.

The use of dermal fillers for soft tissue augmentation has become an integral part of aes-

body language www.bodylanguage.net

thetic practices. Dermal fillers temporarily remove the appearance of rhytids and reduce the depth of skin folds. But even with the most experienced of injectors, adverse effects can occur, ranging from mild bruising to severe injection necrosis.

Physicians should be able to treat the severe complication of vascular necrosis and detect impending necrosis after injection of a dermal filler, especially with hyaluronic acid fillers.

This case report followed a patient for six months from time of hyaluronic acid injection to complete healing of the wound.

Complete wound healing was achieved with early recognition and institution of treatment. The study concludes that early recognition of vascular necrosis with specific protocol for treatment after injection necrosis with hyaluronic acid fillers improves the outcome of wound healing.

Cosmetic procedures in children Curr Opin Pediatr.

Aug;23(4):395-8

2011

Many cosmetic procedures are being performed on children for aesthetic reasons and for the management of dermatological conditions such as psoriasis and vitiligo.

Recent developments in laser technology have improved our ability to treat paediatric cutaneous disorders. Most of these technologies were first developed for aesthetic dermatology in adults. Collagen-stimulatory agents such as poly-L-lactic acid were first approved for lipoatrophy associated with human immunodeficiency virus.

Poly-L-lactic acid and dermal fillers have potential therapeutic applications in children with atrophic disorders such as lipoatrophy and morphea. Injection of botulinum toxin is

very successful in the treatment of hyperhidrosis in adults and can improve quality of life in children with the condition.

The field of cosmetic dermatology is evolving quickly, with limited safety and efficacy studies in the paediatric age group.

Children may benefit from thoughtful application of these technologies.

Tissue engineering, regenerative medicine, and rejuvenation in 2010: the role of adipose-derived stem cells Beeson W, Woods E, Agha R. Facial Plast Surg. 2011 Aug;27(4):378-87.

Epub 2011 Jul 26.

There is a wide variety of dermal fillers for facial rejuvenation and many more are in development. Over the past few years, the study of adult-derived stem cells has become an active area of research. Adult stem cells are an attractive option for volume restoration and facial rejuvenation.

Adult stem cells are isolated from adipose tissue-adipose derived stem cells and have mesodermal, ectodermal, and endodermal potentials. Adipose-derived stem cells could conceivably be an alternative to pluripotent embryonic stem cells and could play a critical role in the rapidly expanding fields of tissue engineering and regenerative medicine.

This article reviews the history of soft tissue augmentation using adipose tissue grafting and the advent of adipose-derived stem cells. State-of-the-art stem cell isolation techniques as well as anticipated future therapeutic indications are also addressed.

Reviewing the peer press is Rohit Kotnis (Lon), Dip SEM (ED).

Rohit is an advanced tutor at Dermis Deep, Birmingham and a member of the Body Language editorial panel

25

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injectables Dr Timothy Flynn

g n i t t i H w e n targe ts The growth of aesthetic medicine can be traced to the rise of injectables, particularly botulinum toxin. Dr Timothy Flynn discusses papers that have investigated effects of the new formulations and how they have combined with fillers

N

eurotoxins have revolutionised our practices. Patients have a Botox or neurotoxin treatment, can’t believe the results, and say they wish they had done it earlier.

Times have moved on since Botox was the only toxin available. We now also have Azzalure, (Dysport) and Bocouture (Xeomin). We also have a type B toxin (Neorobloc).

Five units of these products can change how people feel about themselves. For example, I had a patient who I treated for a gummy smile. She said she hated having her picture taken because her smile was all teeth. Five units of Bocouture later and her smile looks normal.

The toxin structures are all composed

body language www.bodylanguage.net

of heavy chains and a light chain, which is the active toxin. But some of the toxins have complexing proteins. The questions that have arisen over the past few years are: what is their role and do we really need them?

We now understand that they are less important than originally thought. At a physiologic pH, the active compound— the 150 kDa portion —actually dissociates. At a pH of 6.6, which is what the Vistabel is placed in the vial at, the complex is associated. As the pH increases, the active complex separates from the other surrounding proteins.

Once it is in the patient, you have only the 150 kDa complex at work, and this dissociates quickly. The half-light of the complex at a pH of 7.27.4 is virtually

none, in other words, it instantly dissociates so that the effective release of the active compound from the complexing proteins occurs in less than a minute.

Bocouture has much less toxin protein—it does have a little more human serum albumin, but this is a stable compound. All the toxins are stable, but Bocouture can be stored at room temperature for 36 months. You can virtually heat this up to 60°C for a long period and you do not lose any effectiveness. It has a very stable molecule. Also, at cool temperatures, reconstituted Botox has been proven to be stable for six weeks when refrigerated.

In the US we have many FDA-approved indications for Botox. Using it for prophylaxis of headaches in a patient with chronic migraine won’t work for everyone, but a decrease in intensity and frequency is usually evident. Beware patients asking to try if for non-cosmetic indications.

27

injectables Dr Timothy Flynn

Another issue that has arisen is an apparent immunity to toxins at cosmetic doses. Typically, this is when a patient has repeat treatments and the toxin stops working. When the person honestly says that it didn’t work this time, what’s the most common reason? Most likely not enough units were used, but there have been six case reports in the literature of true secondary non-responders.

There have been no cosmetic secondary non-responders reported to date for Bocouture, but Bocouture simply has not been available for long. We have to be prudent and say that in another 10 years we might have some Bocouture secondary non-responders.

You can treat someone with type A resistance with type B, however, many of these people later develop this resistance, but this is in therapeutic cases.

What about dosage? In an article by Sattler, which A Carruthers and I participated in, we tested 360 females aged 18– 50 years with moderate glabellar lines. All were injected with 24 units of Xeomin or Botox, using a standard injection pattern, and were monitored for 12 weeks.

Instead of doing equal numbers, we injected more subjects with Xeomin than Botox, because we have more Botox data.

We looked for differences in results and complications.

Patients had to have one point improvement on the four-point facial wrinkle scale. They were rated by the investigators and also by a blinded independent panel of three experts who looked at glabellar lines.

The blinded independent panel—people who were sitting in rooms looking at slides all day—judged results as equivalent after 12 weeks and one month. The investigators’ and the patients’ global assessments of their own lines were the same. The toxins has equal effectiveness.

When we looked at adverse events,

both toxins produced the same low degree—this includes headaches, injection pains, and the like. For related adverse events, such as eyelid ptosis, Xeomin has none and Botox one, but this is statistically insignificant. How many people see ptotic eyelids anymore? Hardly any.

A smaller study of 21 patients by Prager in Germany looked at the two toxins.

He injected 12 units of either Botox or Xeomin in crow’s feet and had exactly the same results.

When we look at interchangeability of Vistabel versus Azzalure—these toxins are dosed at different rates, there’s no clear dosage pattern. Some people use these in different ways, but the average is about 2.5 Azzalure to one Botox unit.

Anecdotal evidence There are some anecdotal reports of a more rapid onset action with Dysport.

Many studies ask patients to write down in their journal when they first noticed a result. I may be biased towards my own research, but reports and the literature have the onset of both Vistabel and Azzalure within 24 hours.

In an old study of Botox versus Myobloc, the type B toxin, a comparison was made by injecting patients with Botox on one side, and Myobloc on the other. The subjects were photographed every day.

The type B toxin was seen to act faster than the type A toxin. Most likely all toxins can show an onset as early as 24 hours noticeable by controlled photography.

Is there a difference in diffusion between toxins? A study by Lee in 2009 showed no difference in the diffusion when injected into mouse legs. The objective was to investigate the transfer of toxin from one muscle group to another, and he found no significant diffusion.

Recent papers examining new uses for the toxins include a study on topical botulinum toxin. This incorporates an agent

that can transfer large proteins across the stratum corneum and down through the epithelial cells that affect the underlying muscular trim. Toxin was rubbed on subjects’ crow’s feet. The study showed a decrease in lateral canthal lines—around a two-point improvement. But the study observed only lines at rest and did not comment on lines in motion.

Does toxin around the mouth plus a filler work better in combination? Carruthers et al studied three groups of 30 subjects: one group had Botox plus Juvederm around the mouth, another group just Botox around the mouth, another group just Juvederm around the mouth. The Botox doses were six units administered periorally—in the little lines around the lips. The Juvederm was injected for optimal correction.

When we’re working on the perioral area, we can get improvement with Botox—we can get better improvement in terms of how it looks with the Juvederm—but when you use them together we get an even better response. Basically the conclusion was that they are safe and effective, and when combined are superior than used alone.

Doctor Schim et al in Korea used three-dimensional laser scans to see how much volume is lost in the lower face.

They injected 15 patients in the lower and lateral masseter with 25 units of Chinese toxin called Lanzhou. The reduction in the masseter occurred maximally at 12 weeks. So when we’re reducing the size of large muscles, we don’t look at them at two weeks, we have to wait out for three months to treat the so-called “Korean square face”.

Dr Timothy Flynn is a consultant dermatologist and medical director of the Cary Skin Center. He is also clinical professor at the department of dermatology, University of North Carolina at Chapel Hill

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psychology Dr Raj Persaud

Through the

looking glass We all know that cosmetic surgery can improve appearance, often with outstanding results.

But does surgery improve self esteem?

Dr Raj Persaud reviews the literature

I

suspect I am not alone in being impressed by the slides my aesthetic colleagues show at conferences, demonstrating impressive before and after results. But I wonder, if those smiling faces could talk, what would they say about how they feel after treatment? They might look, in our opinion, better than before—but has it actually made a difference to their lives?

This is more difficult to assess than simply observing physical change. In polite society, it’s not customary to make detailed comment, however accurate, on another’s appearance. So how do we confirm how we look?

The issue isn’t just how we look to ourselves, but how we appear to the outside world. The issue of appearance is such a taboo—everyone knows everyone else is busy giving compliments but maybe thinking something else entirely.

Anyone who has treated sufferers of body image disorders such as imagined ugliness syndrome, or body dysmorphic disorder, will be aware of how much these patients have chosen to infer from subtle, or entirely imagined, feedback. This group, although at an extreme end of the spectrum, shares with cosmetic surgery patients the tendency to regard appearance as important.

They also have a clear evaluation of how they compare to others on this front. This crucial combination of scoring high on ‘body image orientation’ (how important it is in life) combined with low evaluation (low satisfaction with personal appearance) delivers the motivation to seek an alteration. Scientific research has been performed to fill the gap in this area and provides useful feedback to cosmetic professionals about the psychological impact of their work.

The study, conducted by a team led by Dr Skilleborg based in Norway, used a questionnaire to study 155 female cosmetic surgery patients. The investigation was published in the Journal of Plastic, Reconstructive and Aesthetic Surgery, and compared responses before surgery to six months after. A representative sample of over 800 Norwegian women with no cosmetic surgery experience also completed the questionnaire.

Procedures undertaken included breast enlargements, breast lifts, liposuctions, abdominoplasties and eyelid operations. Results revealed high scores on satisfaction with the actual procedures, with 91% reporting post-operatively, that they would still choose to have surgery if they had to make the choice again.

There were no differences between the comparison non-surgery group and those having surgery in prevalence of psychological problems. This is interesting given the stubborn public perception, in some quarters, that to opt for a procedure is a sign of something problematic psychologically.

30

Intriguingly however, those who had surgery but scored high on psychological problems before the procedure, ended up being much less satisfied than average with surgical results. Those without psychological problems before surgery ended up with a more positive change in body image evaluation and raised selfesteem post-surgery.

Overall, self-esteem went up following surgery, but psychological problems remained. This result confirms that surgery is not a solution for deeper psychological problems. The issue here is that the simple low self-esteem that those who go for cosmetic surgery appear to suffer could be confused with deeper problems, which really aren’t there.

Normal The key take home message from this study is that the increase in body image evaluation in the operative group was such that patients after surgery no longer differed from the ‘normative’ sample—in other words, the surgery made them feel ‘normal’ again.

Many people undertaking cosmetic surgery are not so much vain or seeking some kind of unfair advantage in appearance, they simply want to feel normal or like the rest of us.

If, as a surgeon, you want your patients to end up scoring high on satisfaction post-surgery, you need to keep your eye on those who score high on psychological problems beforehand.

This group are much less likely to end up feeling positive about the results. It was also notable that the study showed no statistically significant differences between different kinds of surgery in terms of positive body image and satisfaction with outcome.

But there was a trend for breast augmentation to be associated with more positive body image evaluation post-surgery. It is important to note that rhinoplasty did not feature in this study.

Cosmetic surgery did improve the patients’ self-esteem, but it was a relatively small change. But, on average, there was a definite improvement in satisfaction with appearance.

Post-operative measures of appearance satisfaction, self-esteem and psychological problems did not differ from the comparison sample. Surgery appears to make people feel normal again rather than making them feel better than normal.

Perhaps this indicates that this desire for more superior results than average for cosmetic surgery may be an ominous predictor of a less than satisfactory outcome in the longer-term.

Dr Raj Persaud FRCPsych is a consultant psychiatrist working in private practice at 10 Harley St, London W1 body language www.bodylanguage.net

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fillers Dr Beatriz Molina

Filler up With an increasing variety of dermal fillers on the market, which one do you choose?

Dr Beatriz Molina runs through their key characteristics

T

here are over 100 fillers on the market, providing us with a great deal of choice. So what is the difference between them, and which one do we choose? All are different when you look at their physical properties.

This allows us, as physicians, to choose different products for age, skin type and desired outcome.

One of the key differences is the concentration of HA and degree of cross-linking in the product. This will provide different characteristics, producing a softer or harder gel. But we need to work out how this extrusion force will affect injecting the filler in the dermis.

Characteristics Molecular weight ranges from 500–6,000kDa. In terms of concentration, 10mg/ml is usually the best—any less and the product will disappear quickly from the skin.

Even if the filler is nice to inject, it won’t last more than two to three months. Restylane and Juvéderm are 20mg/ml and 24mg/ml, which have done well clinically.

Optimal concentration is between 18–24mg/ml, but some companies choose to go slightly below to get different characteristics. In terms of skin tolerability, an uncrossed-linked product is unlikely to cause any reaction but it will give no lifting capacity. So there needs to be a balance to give the filler the physical properties we need.

The more cross-linking there is in the product, the more the G-prime will increase, therefore causing more inflammation. A product with a low G-prime will cause minimal inflammation.

But the higher the G-prime goes, the more severe the reaction body language www.bodylanguage.net

is. Manufacturers have to balance the concentration and crosslinking for the optimal effect.

All HAs will cause some swelling. They are hydrated by water, so a fully-hydrated filler has reached its equilibrium and there will be less swelling in the dermis. Non-equilibrium gels will have more swelling post-injection.

A non-cross-linked HA has no lifting capacity, so we need to cross-link them. The two most common functional groups are carboxylic acid and hydroxyl with alcohol. These cross-links will try to improve the bio-chemical properties while ensuring it is still compatible with the body.

The total degree of modification will be a percentage of the cross-link, plus the non-cross-link, or pendant agents. An increased cross-link will result in increased hardness or stiffness of the gel. Swelling will make the product degrade quicker, and only cross-linked HAs will resist degradation in the body.

The gel texture will be modified by the cross-linking, which is hard to measure and it is therefore difficult to get these measurements from manufacturers. Indirect approaches involve measuring the mechanical characteristics of the product, or a rheological analysis.

So we have the G measurement, which is the elastic modulus, and the G-prime which is the viscous modulus. The ratio of these is the most reliable information we can get regarding crosslinking and how the material reacts in the skin.

We know that the more cross-linked the product, the closer it is to a solid and therefore is a much stronger gel. It will be harder to manipulate and more resistant to higher forces. So you will probably use it in deeper places or nasolabials when you 33

fillers Dr Beatriz Molina

want a lot of movement. If the product is less cross-linked, it is closer to a liquid and will dissolve more in the tissue and spread more easily. Most HA fillers will be visco-elastic. We need that combination of elasticity and viscosity to give us the total effect.

Gels with a higher G will be stiffer, with more ability to resist dynamic forces. Those with a low G will be used for more static and superficial wrinkles or the lips.

Particles Once a product is cross-linked, it needs to be particulated, or we end up with a lump of gel. Particle sizing is very important to how it will be injected into the skin. A gel needs to be calibrated in the tissue to prevent too much spread—perhaps you want the product to stay in the same place, or you want to calibrate it in a different way to make it more malleable.

Ultimately, when we inject the product, we want minimal pain for the patient, less swelling or reactions and a smaller extrusion force. Particles have to be small enough to go through very small needles. If you want to reduce the extrusion force by reducing the particles’ average, you need to make the sizes very even—if there are bigger particles mixed with smaller particles, the flow will not be continuous and you will have a blockage in the needle.

Firm gels will have a higher ability to resist deformation so they must have small particles. The distribution has to be narrow so that the flow is smooth. They also have an easy way to spread so we will be more superficial with them.

Particle size alone affects the extrusion force of the filler. But without knowing the rheological properties, such as the modulus, then we don’t know how the product is behaving.

The total degree of modification will be a combination of cross-linked and uncrossed-linked HA, the concentration and the degree of hydration—all of which will affect the rheological properties.

A firm gel with a high G will provide the best resistance to formation, but will be harder to push with a higher extrusion force— a needle with a larger diameter may be needed. A soft gel will feel more natural and can be injected more superficially on the skin.

All these ingredients provide an optimal balance for a product. But depending on the patient’s age, skin colour, nature or depth of wrinkles, we will use different products in different areas.. We need a bigger calibration and more cross-linking when we want to go deeper in the skin, or it won’t last and won’t lift.

But we need to avoid too much cross-linking or we get too much swelling and the product will dissolve too quickly.

We need to calibrate the gel depending on the needle we inject it through. Clinical results will not only depend on these characteristics but also on the response of the biological host, or patient. A product that gives you fantastic results may suddenly not achieve the result in a particular patient.

The same filler in different people will react differently— unfortunately, this is something you will learn through clinical experience and so you may choose a slightly different concentration or calibration on different patients. The depth of injection technique will afG1 G2 fect the hydration and inflammatory response we create.

The higher the G prime, the more inflammation there will be. (G1) Restylane G=350 whereas (G2) Puragen G=1000, with noticably more inflammation 34

Dr Beatriz Molina is a cosmetic physician and medical director at Medikas Medispa in Somerset

History of dermal fillers 1890s: Fat was extracted from a patients arm and injected into their faces. Early 1900s: Paraffin was used as a skin filler but a high incidence of foreign body granuloma formation was discovered 1940s: Highly refined injectable silicone was used as a dermal implant with excellent cosmetic results. But it had high abuse potential and problematic adverse effects from contaminated composites. It has since been banned 1970s: Injectable bovine collagen was approved by the FDA in 1981 as Zyderm I, Zyderm II, and Zyplast. As of the end of 2010, all collagen fillers are no longer available in the US, as they have been voluntarily withdrawn from the US market. 1980s: Reconstituted human serum product was introduced, which worked by forming clots. In the face of the AIDS epidemic and a concern for blood-borne diseases, it was taken off the market. Autologous collagen processed from harvested fat presented an alternative. Aquamid, an injectable water-based polyacrylamide gel (2.5% polyacrylamide, 97.5% water) was launched. 1996: Hylaform, an FDA approved hyaluronic acid (HA) obtained from rooster combs and then highly purified through a vigorous filtering process is launched. Despite being animal-derived, it does not require a skin test. Its effect lasts 4–5 months as the product is naturally reabsorbed by the body. 1998: Restylane comes to the market. The HA is a glycosaminoglycan disaccharide composed of alternately repeating units of D-glucuronic acid and N-acetyl-D-glucosamine. 1999: Sculptra, injectable poly-L-lactic acid, is launched. It is a dermal filler indicated for the restoration and/or correction of the signs of facial fat loss, or lipoatrophy. 2001: Aquamid gains approval in Europe 2002: Isolagen, or autologous cell therapy (ACT), the process of using the body’s own cells to help repair trauma and ageing, arrives in the UK in late 2002. 2003: Cosmoderm and Cosmoplast, or "injectable bioengineered human collagen implant”, are introduced. Both products contain 35mg/mL of human-derived collagen in phosphate-buffered physiological saline containing 0.3% lidocaine. Cosmoderm is not cross-linked and is used to treat superficial lines and wrinkles. Cosmoplast is cross-linked with glutaraldehyde and can be used for deeper wrinkles. Bio-Alcamid is launched. It is a gel polymer with several networks of alkyl-imide groups and 96% nonpyrogenic water. 2004: Radiesse, launched in the US in 2000 as Radiance FN, is introduced to Europe in June 2004. It consists of synthetic calcium hydroxylapatite (CaHA) microspheres suspended in a gel carrier—an aqueous gel that contains sodiumcarboxymethylcellulose, glycerin and high purity water.

Evolence luanched. This is a naturally occurring collagen filler derived from porcine tendons. It is voluntarily removed from the US market in 2009.

Reviderm Intra is an injectable implant with flexible dextran microbeads. Dextran is a carbohydrate complex of 40–60 microns in size. The microbeads are evenly suspended in a non-animal HA. 2009: Novabel is launched. It is a colourless dermal filler composed of cross-linked alginate, a natural and biocompatible polysaccharide extracted from marine algae. The extracted alginate undergoes an intensive purification and stabilisation process to become smooth, microscopic, three-dimensional gel spheres called Geleons. Merz Pharmaceuticals GmbH issues a field safety notice in 2010), advising practitioners to stop using the product.

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injectables Jones, Flynn & Grover

Dr Derek Jones, Dr Tim Flynn and Mr Rajiv Grover discuss permanent versus resorbable dermal fillers for a range of indications

In good shape Dr Derek Jones is a consultant dermatologist and founder of the Skin Care and Laser Physicians of Beverly Hills I have conducted a considerable amount of research with liquid injectable silicone, specifically for HIV-associated facial lipoatrophy. I use liquid silicone only for this one indication. In 2004, we published a study in the Journal of Dermatologic Surgery treating 77 patients with Silikon 1000—a highly purified silicone oil. It is FDA-approved for injection into the globe of the eye for tamponade in retinal detachment. We can use it legally on and off label.

With silicone, we use a microdroplet serial puncture technique. We inject 1/100th of a cc of Silikon 1000 into the subcutis at 2–4 mm intervals. Our protobody language www.bodylanguage.net

col calls for no more than 2cc in a given treatment visit. We wait one month then re-inject and continue injecting until we achieve optimal correction.

The initial 2004 report showed that it takes 12cc on average to achieve optimal correction. Studies by Carruthers et al. investigating the amount of Radiesse (calcium hydroxylapetite) it takes for optimal correction for HIV lipoatrophy showed around the same amount—12–13cc. I have treated over 700 patients with with liquid silicone for HIV fat loss in my Los Angeles clinic.

I presented an abstract in 2010 at the American Society of Dermatologic Surgery looking at the long-term follow-up of these individuals at five years. I’ve been impressed with the results and have seen nothing better than liquid injectable silicone for this specific indication.

In that long-term follow-up, we’ve had about five adverse events of note. Two were complaints of over-correction. One

gentleman had gained 30lb in weight so this may have been the cause of his overcorrection in the face. The other was slight and improved over time.

Three patients developed subcutaneous induration and firmness. We expect this in a certain subset of individuals who have permanent fillers, especially silicone.

But the consensus is that if you’re injecting a highly purified material with the microdroplet technique, you should not have too many cases.

In these three patients, I took the lead from the Carruthers’, who treated a number of Artecoll-induced granulomas in Canada. They used 40mg/cc of a high potency triamcinolone intralesionally. I used this in these individuals and it worked well. The cumulative doses were not very large over time; about 1cc of material. Two these patients had signs of adrenal insufficiency and fatigue, which prompted me to get an endocrine consult. Both had AM cortisol results that 37

injectables Jones, Flynn & Grover

were zero. The endocrinologist who has a lot of experience with this population told me adrenal insufficiency due to exogenous cortisone is very common in HIV patients. So I recommend not using high doses of intralesional cortisone in an HIV-infected host. Since then, I have injected 50mg/cc 5-fluorouracil (5-FU) mixed with 10–20% of 40mg/cc triamcinolone and results have been good with no adverse effects.

I will not use a permanent filler in non-HIV patients—while not serious, those who experience adverse events will probably have them for life. HIV facial atrophy is a unique condition that takes a lot of volume and large volumes of a durable material will work best.

In terms of resorbable fillers, I’m a huge fan of hyaluronic acids (HAs) because they are reversible. They can also last a lot longer than 12 months with repeat treatment. Literature shows this on Restylane, Juvederm and Belotero products. We need to rethink this class of fillers in terms of longevity.

Dr Timothy Flynn is a consultant dermatologist and medical director at the Cary Skin Center in Cary, North Carolina Particularly in our legal climate in the US, it can be difficult to inject silicone. It’s an off-label use. If you get complications, it could be permanent. Non FDA-approved silicone has been used for anything from deep filling to tiny acne scars.

I have seen a few patients who got treated 20 years ago and have small bumps—the silicone elicits a collagen response which keeps going, resulting in a lump. The only way to get rid of it is to cut it out.

In the States, we don’t yet have a great HA deep filler—products from the Juvederm, Esthélis and Belotero ranges do a good job. But when we want deeper filling, we’re looking for robustness and longevity so I tend to use calcium hydroxylapatite, or Radiesse, instead.

It only takes one intravascular injection or vascular occlusion to wish for HAs for all indications. When you see the blanching that occurs immediately after injection, you know exactly what could be happening. Literature reports a case of complete alar necrosis requiring reconstruction following an intravascular occlusion, so it can be very serious.

So I love the reversibility idea. We 38

always have hyaluronidase in the clinic.

When I had my first intravascular occlusion, I was glad I had hyaluronidase. It occurred while injecting Radiesse, but the patient had a large amount of HA present around the nasolabial folds so I could dissolve the extra pressure from the HA. We got return of good blood flow and typical venous stasis on the outside, but no cutaneous or mucosal necrosis.

Mr Rajiv Grover is a consultant plastic surgeon at King Edward VII Hospital and practices privately in Harley Street I don’t have much experience with silicone or permanent fillers. If I was using a permanent product in large volumes, I’d generally use fat. In terms of temporary fillers, I’m a big fan of HAs. I like the deep volume aspect.

In the lower face, HAs can be quite heavy. Some patients have very thin skin here so if you want to build up a small amount of volume, I find Sculptra very useful. Some patients are not suitable or ready for a facelift, so you can build them up using Sculptra to give them good volume.

Dr Tim Flynn There is still an opinion that HA fillers only last six to twelve months. I injected the nasolabial fold in one of my patients.

She was around 50 years old and pleased with the results.

About 18 months later, she came back with a basal cell carcinoma (BCC) above the area we injected. We used the Mohs technique to remove the BCC and found large pools of Restylane in the subdermal plane that we’d injected 18 months earlier.

So they’re evidently more durable.

These HAs can also stimulate collagen.

With repeat treatments, our patients are returning to us less often than we expect.

Dr Derek Jones One study on Restylane found that it lasted around 36 months after repeat treatment. Repeat treatment studies on Juvederm and Belotero prove a similar increased duration after repeat treatment and we often see it in our clinics.

Patients come back in for Botox and request more filler—they think that because they need one, they need the other.

Yet they often have optimal correction after a handful of HA treatments and don’t

require retreatment..

I was recently involved in a debate looking at the five year safety data on polymethylmethacrylate, under the trade name of Artefill in the US. It does not share a large percentage of the marketplace as many people are afraid of it. The five-year data is good and the long-term complications are just a fraction of 1% when used properly. It’s a good product, yet many of us are reluctant to use it because of its permanent nature.

Dr Tim Flynn First of all, we have the reversability of HA and the success of injectable crosslinked hylauronic acid. Faces change and as people gain or lose weight, or have bone resorption, you have to change your treatments with the patients as they change.

I’m a little nervous about a product that stays in there for such a long time.

Physicians may also be influenced by the early Artecoll complications— also methylmethacrylate but in a different carrier and the spheres are different shapes. I’m having great success with HA and patients are happy with results so I’m happy to stick with it.

Mr Rajiv Grover When SubQ first launched in 2003, it was designed for use with a cannula. It required a small incision which not everybody was keen to do and occasionally leaves a small scar. So there was a search for how it could be used without the small incision. So the needle became more popular.

But one of the things to avoid is the presence of blood. If you have blood in the cheek, you’re not only going to get bruising but it will lead to an inflammatory response. Avoiding this results in a more controllable, more reliable recovery.

I find using a cannula more helpful.

The pixel cannula is much finer than the original 18G cannulas marketed for SubQ. You do have to make a small hole with a green needle—have the pixel cannula in your hand so that when you take the needle out, you can put the cannula straight in.

The pixel cannula also has a little arrow on the hub, pointing to the opening.

I find this valuable because I tend to treat the cheek laterally.

I want that opening to be pointing downwards so that when I’m injecting, on withdrawal, I’m putting the product into the body of the cheek fat pad and not around the junction of the lid and cheek.

If you get product above that junction, it shows as a small bleb. body language www.bodylanguage.net

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8329 Training Ad:Layout 1 20/12/2010 10:20 Page 1 Clarityâ&#x201E;˘ Skin Advisor System 1000 is a registered trademark of BrighTex Bio-Photonics, LLC. BL Half Horiz.indd 2 BodyLan Harley HPH.indd 1

Product knowldge courses

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Business development and ongoing www.moritexcosmetics.com market support

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30/04/2008 11:55:29 13/3/08 09:32:02 Variety of flexible courses, full day, half Body Language March/April 2009

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SMARTXIDE2 DOT/RF

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SMARTXIDE DOT/RF CO2 and RF: the Perfect Synergy for Skin Rejuvenation Smartxide2 System: Unique, Versatile, Multidisciplinary DEKA Intelligent Technologies: Experts from the Start If you are a Smartxide Dot user and might be interested in a trade in for the new Smartxide2, contact DEKA at dekaexp@deka.it

MEDICINE AND AESTHETICS

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skin Barbara A Green

Powerful peptides Small, biologically active peptides can help slow facial ageing, reduce dark circles under the eyes and lighten unwanted spots, write Barbara A Green RPh, MS and Ronni Weinkauf PhD

T

he topical replacement of certain peptides could reinvigorate the natural processes involved in connective tissue renewal and cell proliferation. Although peptides have generally been considered too large for good cutaneous penetration, they can be effectively incorporated into cosmetic care products if they are small enough, stabilised and made sufficiently fat-soluble.

Fibroblast cells ensure the cohesion and good maintenance of dermal connective tissue through production of the protein and glycoprotein components of the extracellular matrix.

When incubated with human fibroblasts at concentrations of up to 5 ppm, the peptide Pal-GHK (palmitoyl-glycyl-histidyllysine; palmitoyl oligopeptide) was found to increase de novo glycosaminoglycan synthesis by 46% and collagen synthesis by up to 350%.

The dermal protective and repairing effect of this peptide was evaluated in skin biopsy samples that had undergone UVA irradiation to simulate photoageing. Following treatment with Pal-GHK at a concentration of 5 ppm, these irradiated skin samples exhibited an increase in collagen fibre density compared to pretreatment.

The effect of Pal-GHK on skin thickness (epidermis/dermis) was measured in 23 participants following daily application to their forearms. Over four weeks, the topical cream, containing PalGHK at a concentration of 4 ppm, produced a significant increase in skin thickness compared with a placebo cream (P < .05).

Another structurally related peptide, Pal-GQPR (PalmitoylGlycyl-Glutaminyl-Prolyl-Arginine; palmitoyl tetrapeptide-7), has also been shown to improve skin quality. When 17 participants applied a cream formulated with Pal-GQPR at a concentration of 15 ppm for one month, skin firmness increased by 19% and 40% in the face and neck, respectively, and skin elasticity increased by 17% and 27% in the face and neck, respectively. Examination of the skin surface in the same participants revealed enhanced smoothness, a 56% decrease in the deepest wrinkles, and a 14% overall reduction in skin roughness after application of the peptide-containing cream for just 15 days.

body language www.bodylanguage.net

Pigmented spots Oligopeptide-34 has been found to decrease melanin synthesis in skin melanocytes and reduce the transfer of pigment granules, or melanosomes, to keratinocytes. When Asian women with pigmented spots on the skin applied a preparation containing oligopeptide-34 twice daily for eight weeks, a significant lightening effect on those spots was observed using colorimetric measurement. At the end of the eight-week period, 53% of the women rated the results as “good” or “very good”, and a further 42% rated the results as “fairly good”.

Oligopeptide-34 is available as CG-TGP2 (Caregen Co. Ltd., Gyeonggi-do, Korea).

Barbara A. Green, RPh, MS, is vice-president of clinical affairs and Ronni Weinkauf, PhD, is vice-president of research and development at NeoStrata Company, Inc in Princeton, New Jersey CARAGEN CO

Synergistic effects Peptides may have even more pronounced effects on extracellular matrix reconstitution when used in combination. An in vitro study looked at the change in markers of collagen production following exposure to Pal-GHK alone, Pal-GQPR alone, or a combination of the two peptides over 72 hours. Greater increases in all of the markers tested—collagen I, fibronectin, and hyaluronic acid—were observed with the combination of peptides than would be accounted for simply by the sum of their effects.

This observation is supported by in vivo data. In a two-month clinical study, 24 female volunteers (aged 42 –67 years) applied a commercial preparation containing both Pal-GHK and PalGQPR on one side of their faces and a placebo cream containing the vehicle components only on the other side in the morning and again at night. Digital analysis of the crow’s feet region after two months found that, whereas the placebo cream had no significant effect, the peptide-containing cream produced smoother skin, a “lifted” surface, and improvement in skin tone.

Pal-GHK and Pal-GQPR are available as Matrixyl 3000 (Sederma SAS, Le Perray en Yvelines, France).

The formation of dark circles and bags under the eyes commonly occurs as a result of erythrocyte leakage from fragile microvessels around the eye. Rupture of these erythrocytes outside of the microvessels releases hemoglobin and, subsequently, its pigmented degradation products—bilirubin/biliverdin and iron. When these products are poorly eliminated, discolouration of the surrounding skin occurs, and over time, this periorbital discoloration can become permanent.

Peptides can reduce the fragility of the skin around the eyes and strengthen the dermal matrix supporting the microvascular network. A recent study looked at the effect on periorbital discoloration of a topical preparation that included the peptides Pal-GHK and Pal-GQPR in combination with the flavenoid chrysin (which enhances elimination of the bilirubin/biliverdin pigments deposited around the eyes) and the chelating agent N-hydroxysuccinimide (which neutralises the cutaneous iron).

A group of 22 female volunteers with violet rings under their eyes applied the cream twice daily for eight weeks. Analysis of skin colour using a computerised image processing program demonstrated markedly decreased red pigmentation in 70% of participants and markedly decreased blue pigmentation in 60% of participants.

Pal-GHK and Pal-GQPR are available as Haloxyl (Sederma SAS, Le Perray en Yvelines, France).

Caregen Oligopeptide-34: Noticeable lightening of pigmented spots in an Asian woman after application of 20ppm oligopeptide-34 in a cream formulation used twice daily for eight weeks 41

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nutrition Kim Pearson

Micronutrition and immunity The best offence to bolster the immune system is a strong defence, writes Kim Pearson

l

ouis Pasteur, who revolutionised modern medicine and is best remembered for the discovery of penicillin, believed that, to prevent disease, we should focus on the human body’s defence, not the invading organism.

Almost 200 years later, society is obsessed with constantly developing medications to eradicate bacteria and viruses and formulating household cleaners that aim to “kill 99.9% of all known germs”. Is this the answer to preventing disease and infection? We are seeing more antibiotic resistant superbugs, and we still see deaths from flu and outbreaks of food poisoning.

Perhaps the answer lies in a stronger immune system, which ensures greater resistance not only to infections and colds, but also it helps to prevent auto-immune diseases and cancer; it prolongs life generally and makes us feel and look better.

Good nutrition is one of the most effective and natural ways to optimise our body’s immunity.

Between 70-80% of the entire body’s immunity lies in the gut, and so maintaining optimal beneficial gut flora ensures less likelihood of harmful bacteria adhering to the gut wall and causing infection. Many factors in modern life compromise gut immunity: poor food choices, environmental pollutants and medications including statins, antacids and antibiotics.

As well as carrying out their job of killing pathogenic bacteria, antibiotics also destroy beneficial bacteria in the gut. Repeated use of antibiotics results in a weakened immune system, creating a vicious cycle of recurrent infections, antibiotic prescriptions and an increasingly weakened immune system.

Often, people who have had courses of antibiotics suffer from digestive issues such as bloating, discomfort, inability to digest certain food effectively, constipation or diarrhoea. Following antibiotic use, it is essential to avoid compromising the immune system by replacing probiotic bacteria—strains such as the lactobacillus family should be supplemented, which can be quantified after laboratory tests.

body language www.bodylanguage.net

The micronutrient most commonly associated with immunity is Vitamin C, which is instrumental in the optimal functioning of the immune system. The ability of animals to produce T-lymphocytes has been shown to be compromised when deficient in vitamin C and their production to increase with vitamin C supplements.

A study lead by Dr David Golde at Memorial Sloan-Kettering Cancer Centre showed that exposure to high vitamin C levels (more than 20 times greater than normal) decreased replication of the AIDS virus and was generally more toxic to HIVinfected cells than to the uninfected cells.

Many nutrients act in synergy; vitamin C’s efficacy is partly dependent on the availability of vitamin E. Large doses (800–1,600ius per day) have been shown to improve immune response by increasing levels of B- and T-lymphocytes.

B vitamin deficiency has long been known to affect immunity. People suffering from B5 or B6 deficiency may suffer atrophy of the thymus gland and spleen where production of lymphocytes and macrophages begins.

Zinc is possibly the most deficient mineral in Britain. Our average intake is 9–10mg, well short of the recommended 15mg. Stress depletes zinc, as does pregnancy, lactation and other environmental factors. Zinc is needed to heal wounds and fight infection. One study reported a 221% increase in T-lymphocyte function once zinc deficiency had been corrected.

Vitamin A is fundamental in maintaining the integrity of epithelia. Vitamin A deficiency is associated with pathological alterations in ocular, respiratory, gastrointestinal and genitourinary, epithelial tissues which increases the risk of infection.

The American Society for Microbiology reviewed the effects of vitamin A on immune responses and their clinical outcomes. Among its findings it reported that vitamin A supplementation to preschool children not only decreases the risks of mortality and morbidity from some forms of diarrhoea, measles, HIV infection, and malaria, but also has the potential to im-

prove the antibody response to some vaccines, including tetanus and diphtheria toxoids and measles.

There are many other nutrients essential for the optimal functioning of our immune system. As we discover more about nutrition, the future of immunity appear to lie in understanding and implementing methods for prevention, rather than discovering cures.

Kim Pearson is a nutritionist and works in the commercial department of Ysonut. T: 07950 189281. E: k.pearson@ysonut.com

How to optimise immunity Probiotics: Natural live yogurts and other fermented food products contain probiotics, which can help strengthen gut immunity.

Vitamin A and C: Eat plenty of antioxidant rich fruit and vegetables. Five a day is a minimum recommendation.

Vitamin E: Consume vitamin E found in almonds, peanuts, sunflower seeds, avocado and canola oil.

Zinc: Present in red meats, fish, eggs. Ensure you eat organic whenever possible.

Protein. Ensure you consume optimal amounts of lean protein for your gender and size.

Fats: Limit foods high in saturated and trans fats like fatty cuts of red meat, dairy products and processed foods.

Omega-3: Increase intake of fatty acids found in canola oil, nuts, flaxseed and fish such as salmon, herring, trout, swordfish and mackerel.

Sleep: Get a minimum of eight hours of sleep a night. Sleep deprivation lowers the percentage of natural killer cells in peripheral blood.

Exercise: While moderate exercise is believed to strengthen the immune system, over exercising has the potential to suppress immune function. Aim for 30 minutes of moderate intensity exercise five times a week.

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market ON THE

The latest products in aesthetic medicine, as reported by Helen Twinam

FUllFAST

So you have to lose weight quickly—not a lot, but a few kilos because…well, because you just want to. You decide to do it naturally, but which path do you go down? Exercise? Diet? Slimming pills?

Another choice is FullFast, an appetite-control spray.

Pump three sprays under your tongue a few seconds apart five times a day before or after eating and you are on your way. FullFast is a food supplement made from plant extracts containing artichoke, centella and taraxacum to promote the drainage of body fluids, plus Guarana extract to help maintain body weight.

A clinical study has given more, ahem, weight, to claims made CellUlAZe

A 1440nm Nd:YAG side-firing laser shows early promise as an effective surgical treatment for cellulite.

Cynosure’s Cellulaze laser attacks the fat tissue in three steps. It is inserted through small incisions in the skin, placed just underneath the top layer and pointed down to melt excess fat lying beneath the epidermis, and is pointed horizontal to cut through the stiffened fibrous bands, releasing the “valleys” that cause the orange peel effect. The laser is then placed in the up position to thicken and elasticise the top layer of skin, smoothing out the surface for tight and toned skin.

One US plastic surgeon commented that a single treatment continued to improve appearance up to one year later.

A study by Barry DiBernardo MD and Gordon Sasaki MD reports a patient satisfaction rate after a one-year follow-up of 92.5%. Adverse effects were limited to mild discomfort, bruising, swelling and numbness with complete resolution for body language www.bodylanguage.net

for FullFast. In a double-blind, placebo-controlled clinical study lasting eight weeks, female volunteers followed a weight-loss programme, used three sprays of FullFast five times a day.

Around the fifth day they started to feel less hungry and experienced a significantly greater feeling of fullness than the placebo group.

I wouldn’t call this spray “great tasting” as the packaging claims, it is just very sweet and certainly doesn’t evoke a whiff of cordon bleu dining—you won’t be counting down the seconds until the next squirt.

Whether FullFast works in practice is in the knives and forks and willpower of the user. It is not a miracle cure, nor does it claim to be. You need to combine FullFast with a well-balanced low-calorie diet, a healthy lifestyle and, at the very least, a mild exercise programme.

Wigmore Medical, 23 Wigmore St, London W1U 1PL. W: fullfastonline.co.uk all patients after three months.

Another study by Bruce Katz, MD, clinical professor, Mt Sinai School of Medicine, focused on the efficacy of a bi-directional sidelight optical fibre and Cellulaze in the treatment of cellulite, as measured by 3-D surface imaging.

The results of the 15-person study were that 68% of subjects showed significant improvement in cellulite by photographic evaluation and 65% with Vectra 3D surface imaging.

Patient and physician evaluations also revealed good to excellent results in 76% and 69% of cases, respectively.

Cynosure UK 01628 522252; W: cynosureuk.com

SyNeRoN CANDelA ePRIMe

Syneron Candela’s RF (radiofrequency) system delivers the critical temperature for skin rejuvenation in a single treatment and monitors real time temperature for greater thermal management, says the m a nu f a c t u rer.

Syneron Candela ePrime uses a minimally invasive microneedle electrode array to deliver bipolar RF energy into the deep reticular dermis without heating the epidermis.

The controlled fractional injury creates new collagen, elastin and hya luronic acid, says the manuf a c t u r e r, and creates fractionated zones of thermal injury, re- s u l ting in “a solid foundation of new dermal volume”.

The microneedle uses a 20deg angle to deliver the energy, and the thermal profile is contained within the electrode. The treatment results in neocollagenesis and neoelastogenesis, improved skin tone and volume, and is safe for all skin types, says Syneron Candela.

The handpiece features an integrated tissue stabiliser and thermokinetic skin-cooling bar, with a singleuse treatment cartridge and five independently controlled bipolar microneedle pairs.

Syneron Candela 0845 521 0698; W: www.candelalaser.co.uk 45

products

manufacturer, and prevents UV-induced inflammation and melanin distribution.

The productâ&#x20AC;&#x2122;s key ingredients are: 4-ethoxybenzaldehyde, which suppresses the release of PGE2; niacinamide to improve barrier function and reduce sebum production; and squalene and jojoba oil to moisturise and control the release of inflammatory cytokines.

CalmPlex, which is distributed by SkinBrands, is said to even out skin tone and can prevent hyperpigmentation.

DeRMAQUeST SKINBRITe The product provides a permanent soOne of the key aims of facial rejuvenation lution to prescription treatments which is reducing pigmentation and brightening primarily address rosacea lesions, and have the complexion. little impact on the associated redness, Dermaquest Skin Therapy SkinBrite is says SkinMedica. a skin brightening product line aimed at reviving and illuminating the skin.

The range suppresses melanocyte activity and corrects pigmentation issues such as hyperpigmentation, melasma and age spots, says Dermaquest.

Active ingredients include chromabright, a stable tyrosinase inhibitor with photoprotective qualities; BV-OSC, a lipid-soluble derivative of vitamin C and matrix metalloproteinase (MMP) inhibitor that brightens the skin while stimulating collagen production; and embilica, an antioxidant that lightens pigmentation, increases hydration and reduces inflammation.

Some anti-acne products can dry out The SkinBrite range will comprise four home-care products for the eye, hand and the skin and cause irritation. Also disbody areas, as well as a cream and serum. tributed by SkinBrands is Medik8â&#x20AC;&#x2122;s latest A SkinBrite peel has been developed professional-strength treatment, which for practitioner use, containing phytic, targets acne and spot breakouts while hydrating the skin.

20% lactic, citric and mandelic acids.

Medik8 Betagel can be used on indiThe peel can suppress melanin and lighten discolouration to treat hyperpig- vidual blemishes or larger problem areas mentation, post-inflammatory hyto cleanse the skin, reduce redness and perpigmentation and melasma, says prevent further breakouts, says distributor SkinBrands.

Dermaquest.

Dermaquest 0845 246 4666; The gel contains azelaic and salicylic acids and niacinamide. Azelaic W: dermaquestinc.co.uk acid soothes irritation and reduces SKINMeDICA AND MeDIK8 inflammation. It also has similar Visible redness caused by menoproperties to hydroxy acids to repause, rosacea and cosmetic promove dead skin cells and increase cedures can be hard to cover up cell turnover. and can cause embarrassment for Salicylic acid neutralises bacthe sufferer. teria and removes dead skin.

Redness Relief CalmPlex, Niacinamide keeps the skin a skin-care product from hydrated, reduces redness and SkinMedica, helps to reduce prevents blocked pores. prostaglandin E2 (PGE2), a The area is kept hydrated contributing factor to skin and supple, says SkinBrands, redness. and reduces the discomfort By decreasing PGE2, caused by inflamed spots.

CalmPlex prevents the vaThe product can be used on sodilatory effect, the primary all skin types and underneath cause of redness in postmakeup. The manufacturer menopausal women, says the recommends the product be 46

applied onto the blemish in the morning and/or evening after cleansing. The gel can also be used on the whole face to control more severe acne.

SkinBrands 05603 141956; W: skinbrands.co.uk AQ ACTIVe SeRUM

Growth factors are natural proteins important for skin health and are involved in cell turnover, and collagen and elastin production. As the skin ages or suffers photodamage from sun exposure, it produces fewer growth factors.

Topical products containing growth factors claim regenerative benefits on ageing skin. Active serum from AQ Skin Solutions contains high concentrations of multiple growth factors and plant-based ingredients to support the repair of DNA damage, says distributor SkinGeeks.

The product contains progenitor foreskin stem cells; the richest progenitor of stem cell tissue, says the manufacturer, and the production process ensures only the most effective growth factors for regeneration are selected for dermal application.

The serum formula contains chaperone proteins to protect active ingredients and help them penetrate deeper into the skin layers, and it fights free radical damage which causes premature ageing.

AQ Active Serum provides a firmer, smoother complexion with a brighter skin tone, claims the manufacturer, and reduces fine lines, wrinkles and hyperpigmentation. Improvement is usually seen within six weeks of daily use.

SkinGeeks 01865 338046; W: skingeeks.co.uk

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research Dr Nick Lowe

practice Evidence-based

Practitioners must combine clinical expertise with independent research. Dr Nick Lowe reviews the effectiveness of current study protocols and the importance of data-based evidence

T

DR LOWE

he definition of evidence-based practice is integrating clinical expertise with the best available independent research. So you use your clinical expertise and judgement which, ideally, should be backed up with separate research investigating the problem you’re treating. Definitions of the quality of clinical trials range from Level A—the truly randomised, controlled clinical study—down to Level D, opinions without critical appraisal.

So how are outcomes measured in the aesthetic arena? The patient looks better, they look worse, or they’re a responder or a non-responder. There is a range of severity ratings and acronyms, such as FWS (facial wrinkle score). But there are better ways of measuring treatment outcome which can be coupled with clinical judgement.

I have used the Canfield Vectra system to measure volume after injection of hyaluronic acid. The resulting difference between the measured and injected amount can be attributed to oedema and swelling.

Three dimensional imaging is a valuable way of providing immediate measurement of tissue swelling, potential for persistence of augmentation and for studying. One important area we could use this technology is to measure the improvement of atrophic scars. These systems can be modified to do that.

We recently published a paper investigating sequential measurements of injections of poly-L-lactic acid into the nasolabial and medial cheek folds. We took photographs and layered pretreatment with post-treatment outcomes. We were able to measure the differences.

We found that using Sculptra in sequential sessions provides

Using 3D digital surface imaging to measure results of injectable poly-Llactic acid, before and six months after treatment 48

a steady increase in volume. Mid-face volume measurement using the Canfield Vectra system showed a steady increase.

We have a growing number of botulinum toxin choices, all of which need adequate training in their use. Data on botulinum toxin show a huge variety of suggested dose ratios. Some suggest we shouldn’t even use dose ratios, and that we should learn how to inject each individual toxin.

There is also a variability of study designs. There are differences in dilution, volume, defining efficacy and defining duration, and vague statements of preference. Some even have definitive statements of preference of one over the other, which is hardly evidence-based data. For research, we can apply objective assays to this.

We were involved in an evidence-based review of the papers that have been published. But the problem with this type of analysis is that the methodology will not be consistent throughout the papers. Meta-analysis is very valuable, but be aware that the measurement may be different.

Are pilot studies of any value, or do we need large cohort studies? One pilot study we carried out with Botox on crow’s feet turned out to be accurately predictive of a large volume study.

But we need data-based evidence.

Topical products A number of topical products exist on the market, making various claims. Some are factual, while others are less so. We investigated a peptide and marine algae-based product and saw, quite definitively, a reduction of the crow’s feet wrinkle score.

In terms of measuring skin redness, it is important to be able to track the response to pulsed lights and vascular lasers for people with erythema of the face or rosacea. The Minolta chromometer is a very valuable tool for this.

You can also use spectral photography. A pilot study investigated a group of people with red faces and graded them clinically, photographically and with a spectral photographic system.

We measured the degree of redness, treated them with a topical cream programme and then measured every month afterwards and the results were very clear.

These systems can be useful for patient education. We saw one young lady who was addicted to tanning. She had tanned several times a week for two years. We showed her a spectral photograph of her face, which managed to stop her from tanning. We then put her on a morning/evening cream programme and saw improvement in eight weeks.

There are some situations where you really have to use your eye and judgement. By combining non-surgical techniques, it is possible to get good improvements. And combining data scientifically-derived from clinical acumen measurements and assessments is the way to go in the clinic.

Dr Nick Lowe is consultant dermatologist at the Cranley Clinic for Dermatology in London. He is also clinical professor of dermatology at UCLA School of Medicine, Los Angeles body language www.bodylanguage.net

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dermatology Dr Sangeeta Punjabi

Atopic eczema

The prevalence of eczema is rising, caused by genetics and environmental factors.

Dr Sangeeta Punjabi discusses treatment and patient management

A

topic eczema is a multifactorial genetic disease— genetic inheritence of the disease links three genes together resulting in predisposition to asthma and hayfever as well as eczema (atopy). We often see instances of children with eczema whose parents have suffered from asthma or hayfever so it’s always important to ask for a history of atopic background Classically eczema—and most commonly atopic eczema—is characterised by a red, itchy rash that involves the flexures, or folds. As a hospital dermatologist, I have seen the severe end of the eczema spectrum, involving other sites such as the extensors.

While initially it favours the flexures, the condition can move to other parts of the body, including the face and hands.

The prevalence of eczema has been rising and while genetics has a major role to play, environmental factors are also to blame.

Essentially, the barrier function of the skin is defective. In childhood, the face takes preponderance, which changes to flexural eczema as we move into adulthood. Around 10% of atopic sufferers can continue to have facial and hand eczema.

Appearance We use and abuse our hands and faces, and the face comes into contact with many products—the facial skin is also more sensitive in transferring allergens from other parts of the body.

When you view the skin biopsy under a microscope, the top layer of skin comprises a basket weave pattern of flat cells known

50

as the corneocytes, (stratum corneum). This is the dead skin cell layer, which provides an epidermal barrier to loss of water from the skin.

Each individual cell is filled with water, and each cell is analogous to a brick in a wall. The gluey substance between the cells is made up of the three main lipids that comprise the human stratum corneum—free fatty acids, cholesterol and ceramides, the proportion of which varies in different parts of the skin.

Certain areas may have a high ceramide content compared with cholesterol and fatty acids. But essentially, this is what a healthy skin barrier is made up of.

In eczema skin, there is a deficiency of these lipids, causing transepidermal water loss, a major mechanism of loss of barrier function in the skin. Individual corneocytes shrink, crack and allow enemies like allergens and infections to penetrate the skin.

We always ask for a family history—if there is a long-standing history of eczema, I will always ask if patients had any eczema in childhood; if they suffer from asthma or hayfever; and if any of their immediate family are sufferers. This gives a clue whether there is an atopic tendency, or atopic diathesis, in the family.

Eczema is multifactorial. If, for instance, somebody with a genetic predisposition to eczema starts working as a hairdresser, they will be exposing themselves to irritants and allergens.

We often come across people who will come up in a rash if they apply any cream to their skin. But are they sensitive, is it contact dermatitis or is it an irritant? Just one consultation may body language www.bodylanguage.net

dermatology Dr Sangeeta Punjabi

not be enough to elicit all the information you need. Repeat open applications tests with products show whether they are allergic to products or have sensitive skin.

When considering treatment, you need to address all aspects of the disease—dryness, inflammation and infection. Treating these will address the key component of eczema, which is itching.

Topical steroids are inherently very dry in nature so it is important to moisturise the skin beforehand. There is up to five times better fold penetration of steroid cream after moisturisation. Studies have shown that there is a reduction in the amount of steroid needed if the skin is adequately moisturised, particularly using emollient bath oils.

Most eczema patients have been long time sufferers. They have used moisturisers in the past and it hasn’t taken the redness or itching away, so they don’t understand the rationale of being advised to use a moisturising cream. But the key message to pass on to them is that it is the first vital step in the level of eczema treatment—a background treatment in order to treat the condition.

Many patients, once they feel that their eczema has improved, will go back to perfumed bubble baths and shower gels. Patients must understand that eczema has an increased tendency to barrier dysfunction so they must continue to use their prescribed products. While emollients replace the lipid glue, we still need to tackle the inflammation. But this treatment will work better on a background which has been corrected, rather than one which is dry and irritated.

Triggers Soaps and detergents strip the skin of oil and have to be avoided.

We see a large number of patients who blame foods for their eczema but we have to make it clear that there is no direct link in adults of food sensitivity in eczema. Genuine food allergies do exist but are rare.

If you do test for allergies and have a slight positivity for apples or wheat, and they stop consuming these foods, their eczema still exists. If their condition is caused by genetics, it will not go away by blaming a food.

Dryness is a component of impaired barrier function. We get dry skin as we get older—legs of elderly patients have a lot of dryness so general moisture therapy is advised. But as well as atopic eczema, dryness is a key component in psoriasis, ichthyosis and other dermatitis.

The term moisturisers and emollients are often used anonymously. While both essentially do the same job, moisturisers often contain humectants which can hydrate the stratum corneum. Some emollients need to be washed off so patients need to read the instructions carefully.

Most of our dermatological products are emollient bath oils and emollients to apply on the skin, which can be left on after they have finished their shower or bath. These provide an oily film to replace the natural lipid loss.

Which emollient should you suggest? The key components body language www.bodylanguage.net

of lipids are fatty acids, cholesterol and ceramide. So a moisturiser that is pleasant to use, non-perfumed, with components addressing naturally-existing elements, such as ceramides, would be ideal. Patient must like using the product so they may have to go through trial and error before they select the right moisturiser to suit their skin. As practitioners, we have to guide them.

We also need to consider the amount of moisturiser to use. If your patient has eczema or dermatitis, it is probably not enough to just use moisturiser once a day as those with normal skin would.

This is a key component of our consultation. Patients often fail to understand the importance of moisturiser. They say, “Betnovate cream works for me—can I have some more or something stronger because my eczema has flared up?” We ask what they are using to wash with or bathe in, and they say generic, perfumed products. So while they have been using strong steroid creams, they are not addressing the dryness.

Without that, the steroid cream cannot perform long term.

The GP refers to us, and we re-establish the regime of dryness, inflammation and infection control. While we don’t have a cure for eczema, the same person with a renewed prescription is much better controlled.

It’s the patient’s choice about which emollient they would prefer but you have to guide them. Explain which products are non-greasy—sometimes I give patients two emollients, one less greasy for daytime and a greasier emollient for night. Absorption is better, hydration is longer lasting and patient satisfaction is higher.

Dr Sangeeta Punjabi is associate specialist and locum consultant in dermatology, Hammersmith and Charing Cross Hospitals

There is up to five times better fold penetration of steroid cream after moisturisation

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peer to peer

Dr Aamer Khan is a cosmetic physician and clinical and managing director of the Harley Street Skin Clinic

Dr Danné Montague King is a US-based biochemist specialising in skincare. He is also the creator of the Remove, Rebuild, Protect and Maintain skincare system

Dr Derek Jones is a consultant dermatologist and founder of the Skin Care and Laser Physicians of Beverly Hills

Dr Michael Kane is a consultant plastic surgeon with a private practice in New York, USA

Dr Michael Godin is a consultant facial plastic and reconstructive surgeon based in Virginia, USA

Dr Harryono Judodihardjo is a consultant cosmetic dermatologist, and owner and medical director of the Cellite Clinic in Cardiff

Under the skin

Dr Jean-Luc H Vigneron is a dermatologist based in France. He practises from his clinic, Villabianca Dermatologie in Saint Paul de Vence, Nice

In this issue, our panel of experts discuss dermatological issues and skin treatments, as well as the best hyaluronic acid techniques for facial rejuvenation Q Can

your treatments be provided and prescribed solely as a home care programme?

Dr Danne Montague King: Many people around the world would love the possibility of a home treatment programme.

It’s true that home prescriptives can help a great deal if someone lives in a place where they can’t get to a clinic. But the treatment process will take a long time.

The products are merely tools and the professional approach is always the best.

Q Rosacea

is often termed “acne rosacea”, but they are two different diseases?

Dr Jean-Luc H Vigneron: Yes. Real acne is centred by the sebaceous gland while rosacea isn’t. This is important. In England, it is called acne rosacea. Americans and the French call it rosacea. But rosacea is not acne.

Rosacea concerns inflammation of the skin, not the sebaceous gland. But we treat the two diseases with almost the same medicine. Not for topical treatment, but for general systemic treatment. But it is a different disease.

Dr Aamer Khan: Acne is such a common condition that it’s no longer just a dermatological issue. In the UK, our dermatology services aren’t geared up for treating

body language www.bodylanguage.net

acne. We don’t have enough dermatologists, so the condition is coming more into the field of cosmetic dermatology and cosmetic skin specialists and we get a lot of referrals.

We approach it as an inflammatory condition. If acne came and went without inflammation or scarring, it wouldn’t be a problem. The attitude of “you’ll grow out of it,” doesn’t help. They may grow out of it but it would leave them with devastating scars, which has a huge impact on self esteem and confidence. We’re seeing more instances, and this is the arena where it’s going to be treated.

you can get an alkaline burn. There is a lot of exfoliation but it’s not like a sheeting effect. Desquamation is more like a very quick softening, which only takes around four minutes.

We’ve treated some patients over the years with up to 15–20 minutes, but that’s pushing the envelope. If you see erythema, that’s no big deal but if there is blanching, you stop treatment.

The PH has to be restored immediately afterwards, otherwise they could have an alkaline burn. The treatment is quite effective for scar removal but it’s just a tool—it’s not a treatment on its own.

Q What

Q Can

is the difference between treating the skin with an alkaline treatment, as opposed to acid peels?

Dr Danne Montague King: You have to think not in terms of the individual modality but of the pH of the skin. As we know, alpha hydroxy acids are hygroscopic. They work by pulling moisture up into the dead corneum which swell up, overfill, burst and detach from the skin.

Phenols work differently, by hardening the cells severely until they break away.

In some cases, we may want to go up to pH12 which immediately desquamates everything, including impacted hair follicles. But it must be controlled, because

the treatment be used on all types of skin?

Dr Danne Montague King: Yes, apart from Indian skin. Certain Indian skins can be very delicate, and you can cause hyperpigmentation. But it’s very effective on all other skin types.

Q How important is the combination approach to skin treatments?

Dr Aamer Khan: Companies providing us with antibiotics now appreciate that we also need an anti-inflammatory effect.

We’re getting lower dose sustained release at a level where we’re getting anti-inflammatory effect without the antibacterial or 53

peer to peer

Inject fillers superficially to avoid bruising in the periocular area

photosensitising effects. There isn’t any single treatment that’s going to control any skin condition. So as long as we have this multi-factorial approach, we can start gauging results and putting case studies together and sharing information.

Dr Danne Montague King: Education must be made more available to the paramedical and non-medical people. They’re starving for more education and many of the larger companies don’t pay attention to that. They just provide product knowledge classes and say, “that’s it, go out and work with the doctors”. They can’t—they have no diagnostic or prognostic skills.

They need education.

Dr Harryono Judodihardjo: The main reason why there are so many treatments available is because we don’t have enough knowledge. If we know the exact cause, in the future we can just have one particular treatment. If you have diabetes, they give you insulin and that’s it. It’s the only treatment, there’s no second choice.

Q What

are the components of the spot peel you use?

Dr Jean-Luc H Vigneron: It contains retinol and 15% Idebenone, a derivative of co-enzyme Q10, which is 100 times more potent than vitamin E as an antioxidant.

It also contains emblica, which is a very strong antioxidant, and mandelic acid.

The spot peel is a single peel in-clinic and then a one-month treatment at home.

The patient applies a cream containing the same ingredients as the spot peel but in a lower dosage. It’s a minimum one month protocol to treat it long term.

Dr Aamer Khan: Whenever we do an acid treatment, we prepare the skin to get a more predictable outcome. Treating a pa54

tient straight off with the stronger glycolic acids can lead to problems, because the skin can react in an unpredictable way.

Q Dr Vigneron, why do you only use the 1mm medical roller, and not the 1.5mm? Is there a difference in results?

Dr Jean-Luc H Vigneron: The 1.5mm is very painful for the patient. I only use it if the scar is very fibrotic. If there is no deep fibrosis, the 1mm will be enough. If you do use the 1.5mm, you can provide Xylocaine, a local anaesthetic, beforehand.

Topical cream is enough for the 1mm roller.

Q How

do you deal with hyperpigmentation or inflammatory reactions in Asian skins?

Dr Danne Montague King: In my own experience, enzymatic treatments don’t cause a problem. It is the use of acids or alkalines on certain types of Asian skin.

Classically, Asian skin is very successful, but we have to be careful with a particular type of Indian patients.

Melanin is created by tyrosinase and tyrosene. If you put something between them, they can’t produce melanin—these are inhibitors, which I’ve been using for 40 years. Most of the redundant browning effect in skin pigmentation is caught up in the upper epithelium, which is easily removed using various methods. But the key is to stop melanin at the site of production while removing the pigmentation, so the skin goes back to its normal tone.

Melanin comes from the golgi apparatus in the skin cell. It transfers up to the epidermis through many mechanisms, all of which are defence mechanisms. The

skin is trying to protect itself. But through over-stimulation, particularly as a person gets older, it becomes spotty rather than uniform. So with Asian skin, we need to tread carefully and stop melanogenesis at its production site with inhibitors while removing any excess that’s caught up in the cuticle.

Dr Aamer Khan: Whenever we do any exfoliating skin treatments and turning the skin over, we’re removing the skin’s natural protection against UV light. It’s so important to include sun protection with any treatments that we do for the skin. Not just laser and light treatments, but exfoliation treatments. We must have sun protection or we’ll run into problems with over-production of melanin in darker skins and UV damage.

Dr Jean-Luc H Vigneron: I don’t find it difficult to treat pigmentation by the sun. But treating post-inflammatory hyperpigmentation or melasma requires removal of the pigmentation and a longlasting effect on the melanocytes. This is difficult because a melanocyte has the best memory. You may have a good result for six months, but after six months it returns.

In my clinic, spot peels followed by a home care treatment is effective. Treatment for melasma lasts more than a year.

In France, we refer to it as pigmentation disease. People have a tendency for pigmentation over a number of years so they require long term treatment. But you have to find a balance with good activity of melanisation—not too much, and not too little. You have to be in touch with your patient every six weeks to monitor the results. It can be difficult.

Dr Harryono Judodihardjo: If I have a patient with post-inflammatory hyperpigmentation, the most important thing is to let the skin calm down because the skin is still very angry. Just start off with sunscreen and something to calm down the skin. If after 3–6 months it’s still persistent, you can think about treating with enzyme inhibitors such as hydroquinone.

Dr Aamer Khan: I find that if we use hydroquinone after inflammation, because the skin is angry it can actually worsen the state. It can stimulate rather than suppress so you get a paradoxical effect.

Dr Danne Montague King: We have other treatments that act like hydroquinone.

Some are controversial, even though they are botanical—some regulatory boards say, “wait, we don’t know what this is.”

It’s difficult, because they really do work and, unlike hydroquinone, there are no contraindications.

Dr Aamer Khan: One of the problems is body language www.bodylanguage.net

peer to peer

that it’s been used in Asia for a long time for total body treatment. We use it in a controlled way. Most of our medicines are originally derived from botanicals. But while they are botanicals, it doesn’t necessarily mean they’re not toxic. They can be. More work needs to be done looking at safety in all topical applications.

QI

have found that the appearance of HA in the tear trough area changes depending on the patient’s water content and degrades over time, as the chain links are getting shorter and the molecular weight is reducing. What is your experience with the duration and longevity of HA in the periocular area?

Dr Michael Kane: Injecting superficially is a high risk, high reward technique— HA in the lower lids changes during the day. The area looks different from when patients wake up to when they go to bed at night. But this is why I prefer to use a more superficial technique with less volume. If I have injected a large amount of material, I will see more of a change.

Q I tend to inject superficially in the infraorbital area. But I find that I cannot avoid bruising in that area—patients almost always bruise. Are there any other techniques you can suggest to help us avoid bruising?

Dr Michael Kane: If you’re injecting superficially and getting bruising, you’re too deep—you’re not injecting superficially enough. Almost the only time I get a bruise is when I’m injecting through the orbicularis muscle. If you’re not injecting that far down, it’s unusual to get a bruise.

When the compounding pharmacy mixes up the products, they can put some

phenylephrine in which causes a little blanching. When I tried this, I didn’t notice an appreciable change in the amount of bruising. You shouldn’t be getting bruising if you’re superficial. I don’t think the resulting vessel constriction does enough to prevent bruising.

Q When I’m performing a periocular injection, I always mention the potential risk of blindness on the consent form. The patient always comes back with: “That sounds serious. How often does it occur?” I don’t have an answer for them other than, “It’s very rare, but it’s serious and you should know about it.” How you deal with the issue when you’re discussing it with the patient?

Dr Michael Kane: I don’t think there are any confirmed cases of blindness after HA injection around the orbit. One German article on periorbital injection had one patient with eye pain following injection. The patient had a fundoscopy which showed a small plug of what appeared to be HA in an artery in the retina but it passed and there was no change in visual acuity.

Many cases of collagen, triamcinolone and fat injections have caused blindness but not HA. Millions of patients have been injected without one case of blindness that I am aware of.

Q What is your approach to the periocular area?

Dr Michael Godin: I have a more standard approach, right on the bone. I want to feel the needle on the bone, keeping under the muscle to avoid swelling and bleeding. I feel my way along the bone with a 30G 1” needle, injecting in a retrograde fashion slowly and using the thinnest HA I can find along the rim.

You see the area fill immediately. It is a nice effect and lasts a long time—about twice as long in that area than in other areas in the face.

Dr Derek Jones: I used to use the same technique; a 30G 1” needle, dropping down and along the periosteum and doing a linear retrograde technique. But now I use a 32G half inch needle, injecting small threading injections in the suborbicularis oculi plane above the trough.

I tend to get a more controlled injection and better correction with that.

Q How When treating Asian skin, we need to stop melanogenesis at its production site with inhibitors while removing excess that is caught up in the cuticle body language www.bodylanguage.net

many points along the rim would you inject?

Dr Derek Jones: Around four or five points, injecting 0.05ccs. Some people prefer Restylane there, as it’s a more particulate product which lays down better.

But I use Juvéderm and results are good.

Q Do you find it necessary to massage the area after deep injections?

Dr Derek Jones: I always massage. Hyaluronic acids are very hydrophilic polymers. When you inject them into tissue, they will absorb water, especially in a thin-skinned area like the lower eyelid.

So you must not treat to optimal correction. You have to take the swelling into account.

This is probably one of the main reasons we see poor results—we’re filling up to optimal correction and send them away. But they start absorbing water and come back a week later with sausages underneath the eyes, so we have to remove the HA.

Q When you mix adrenaline and lidocaine in the syringe, how do you maintain sterility as well as getting an even distribution of product in the syringe?

Dr Derek Jones: You use a sterile technique adding 10% volume. With a 1cc syringe, you take 0.1cc of 2% Lidocaine, with or without epinephrine. I prefer epinephrine because it creates a vasoconstriction and prevents purpura. Using a female-to-female adapter, you make sure there is no air in the column and perform at least ten full revolutions back and forth. It mixes nicely as long as you follow the sterile technique.

I am not aware of any infections associated with this type of mixing. There is controversy as to whether or not the epinephrine does anything beneficial. But if there is anything I can do to prevent bruising, I will do it. I think the epinephrine helps.

Dr Michael Kane: I agree. In the future, I think most people will gravitate towards a mid-level injection in the lower lid. It’s not as high risk as the superficial injection and it gives you a better result than the deep injection under the muscle.

Q In

the tear trough, the traditional approach is to inject deep and then laterally, followed by going superficially as you inject medially. Is there any problem with that? Do you inject laterally?

Dr Derek Jones: I inject deep the whole way along the periosteum. However, many people are treating tear troughs when there is more deficit in the mid-face.

It is imperative that you correct the midface deficit before you go up into the tear trough; otherwise, you will be over-corrected in some places and under-corrected in others.

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t h g i l e h Follow t As well as being an effective skin cancer treatment, photodynamic therapy can be a useful addition to your armamentarium for conditions such as acne and rosacea. Dr Aamer Khan describes the procedure and aftercare

P

hotodynamic therapy (PDT) can been used, with or without Metvix cream, as part of a combined treatment for acne, rosacea and inflammation—particularly in superficial layers with porphyrin collection.

PDT has been around a long time. It was initially described in Germany in 1904, where research was carried out on phototherapy and photosensitising. The modern era of PDT started in the early 1970s in Canada. The process involves an interaction between the porphyrins, between oxygen within the cells and light.

We first perform a Visia skin analysis. If they have a number of porphyrins, they will respond well to PDT and treatment can be combined with peels. We exfoliate the skin first for better light penetration and put them under the PDT. It is a ten minute treatment without the need for Metvix if the porphyrins are photosensitive. Inflammation is settled more quickly when we use this.

They would normally have three sessions about a week apart.

Patients would come in and have a glycolic peel followed by PDT. Blue light also works well, and is possibly a better treatment in combination with peels.

We photosensitise the area of a lesion and then expose it to light with PDT. It’s a non-thermal treatment, but when you pretreat and photosensitise, the cellular damage and destruction causes pain. It’s a sharp, pinprick of pain and can be compared to the pain of CO2 resurfacing. But the pain only lasts for a short time and topical cooling helps. We put swabs with saline on an ice pack and apply over the area to cool it down. Patients receive the total dosage within that treatment program—a ten minute exposure can be done over 12 minutes with short gaps when we cool the skin down.

We traditionally prepare the area with a photosensitiser for three hours. I have extended that up to six hours, which gets more of a reaction and more exfoliation.

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Metvix is classified as an antineoplastic agent and has indication for PDT use. While the applications are different, PDT research is also being carried out on pancreatic, bowel, lung and vascular tumours—PDT may well be the future in targeted tumour killing therapies. It kills cancer cells while leaving normal cells alone which is very important.

When you’re targeting a lesion, Metvix is absorbed specifically into the cancer cells. Damaged cells have an increased uptake of amino acid, so absorption does not just take place across the cell membrane but through specific channels into the cells.

Amino acid uptake channels are very active in damaged cells, particularly in tumour cells. Normal cells have a lower requirement for uptake of amino acid so there is less of a target.

When we add light, we get selective tumour necrosis. Tumours can’t repair themselves whereas normal cells, even if they do take on a degree of Metvix, will be able to. Reactive oxygen species cause localised damage to organelles within the cells, particularly the mitochondria, and the cells then die. Some will rupture resulting in apoptosis and others will die over a period of time. As cells die, they produce chemicals which will induce cellular regeneration. These regenerative changes within the skin also result in a cosmetic response.

When you use Metvix with blue light, you get a more intense reaction. It penetrates down to the dermal epidermal junction resulting in regeneration, so it’s a nice wavelength to use for acne.

But the shorter wavelengths release energy in a shorter space so you can get more blistering.

One of the most important aspects is homogenous light distribution, which we can get with the LED ActiLight. The dosage is preset so we’re limited—doctors often want to experiment with higher powers so this can be a good thing. The ActiLight can cover large areas and do repeated treatments. But this does have associated costs, such as having patients sit in a room for three body language www.bodylanguage.net

dermatology Dr Aamer Khan

hours. We use this for actinic cheilitis on the scalp and full facial treatment for acne. We also use it for basal cell carcinoma (BCC).

Patients undergoing hair transplants can get a scalp reaction—if they pre-treat with PDT, they tend not to get the reaction and healing is better.

A lower dose is being delivered over a longer period of time so while the total dosage is the same, there is less pain. It can treat up to 24mm size lesion. It is difficult to apply to certain areas but devices are now being manufactured which can fold over the nose.

Cosmetically, they’re great for solitary lesions, chest rejuvenation and the hands.

Procedure Metvix is applied to the area and covered with a Tegaderm dressing, without the pad so the light can penetrate through. The device is applied, switched on and the patient can leave—they don’t need to see you again until the review. It’s a small, lightweight device which can be covered over, so they can go back to work.

It won’t switch on for three hours and it has indicators. If it’s not working, the red light will come on and the patient will have to come back for reapplication and retreatment.

So for small areas, particularly on extremities, people can go back to work. It would be useful to have a device that will go around corners—if I treat one side of the face, then the other side, the middle tends to get a higher dose.

We pretreated one patient on half of her face—she didn’t stay in the clinic and went out for a coffee. When she came back, she was beetroot red on one side. She had already had the treatment with solar exposure, or ultraviolet light, which can be harmful. I prefer to do the treatment with the infrared spectrum.

We get specific uptake and porphyrin production within the lesions, but the uptake is more peripherally in cells where we can’t see the lesion. When I’m treating a BCC, I will spread it around the area. There may be pre-cancerous cells or microscopic tumours that we can’t see. It is generally advised to spread one centimetre outside the lesion but I like to go a little bit more than that.

Current licenses are for non-keratotic, non-pigmented lesions on the face, such as tinea keratosis. It usually comprises one treatment cycle for superficial or nodular BCC. For nodular BCC, there are varying results but the best are achieved if we de-bulk the tumour before we apply. Two treatment cycles are necessary.

For many patients with carcinoma, we need to know which lesions to treat and when to appropriately refer on. Safe treatment within cosmetic dermatology is very important.

The patient’s journey starts with patient consent and documentation. The patient needs to know what to expect. We take them through the consenting procedure and they should have aftercare instructions discussed at that time. We wouldn’t perform treatment on the first consultation—they have to go away with the information, think about it and research further.

We need to document the area to be treated, and have good, reproducible photography. You, as a physician, may see an improvement because you don’t see them often but people check their skin every day. If we’re using this as a cosmetic treatment, the results may initially be subtle and progressively get better over time so we have to document what we’re doing.

We also have to keep careful notes because while we’re using it off-licence for cosmetic treatment, it is still prescription medication. People can react to it. We have to ask the right questions.

In terms of contraindications, for any patient who is photosensitive, we have to think about porphyria. Anybody who has had photosensitising reactions in the past need to be checked for porphyria. We de-bulk the lesion with a curette or a simple scalpel blade. If we’re performing a cosmetic treatment, I would just use body language www.bodylanguage.net

the scalpel blade to exfoliate the dead skin. They can also have a glycolic or enzymatic peel beforehand for good exfoliation.

For tumour lesions, Metvix is applied around one millimetre thick. For cosmetic purposes, you can have a thinner spread but leave it on for longer.

Keeping records is so important when treating cancerous or pre-cancerous lesions. Occlusion is important for better penetration but for larger areas for cosmetic purposes, I tend not to occlude. The nice thing about the smaller lesions is that you can apply the disposable device, the patient leaves and the device does the work for you.

Half a tube of Metvix would be enough for a full face treatment. Spread it thinly and leave it on for between three and six hours. Pain management is important with lots of damaged cells.

The level of discomfort is quite high when we’re treating active acne.

We’re not just treating the porphyrins within the colonies of P. Acnes bacteria, we’re also targeting damaged cells. The T cells which cause the inflammation seem to have a higher uptake of porphyrins, so there is a higher level of discomfort. You can’t switch the light on and leave the patient. It’s a cold light treatment with a fan there but you have to be present and talk to the patient throughout the treatment.

Aftercare We have to manage erythema, swelling, crusting and oozing.

Some type one and two skins get blistering—they seem to be more reactive to any treatment. Patients need sun protection and patience. They won’t see a result immediately. Some of my patients have had flaking for up to a month. Ultimate results are seen around three months down the road.

Safety issues are very important. Treatment involves a very bright light. While it’s not a laser, and won’t cause blindness, wear protective glasses because it will affect colour vision and you will go colour blind for a while if you’re not wearing them.

We’re doing case studies, looking at how long the treatment is lasting in the cosmetic arena. I have used the treatment in particularly difficult acne cases, where we’ve been unable to control it any other way. The only other alternative would have been prescribing Roaccutane, which has risks associated with its use.

We’ve been striving to control acne without resorting to Roaccutane and have found the treatment with Metvix and PDT effective.

Dr Aamer Khan is a cosmetic physician and clinical and managing director of the Harley Street Skin Clinic Patients undergoing hair transplants can get a scalp reaction. If they pre-treat with PDT, they tend not to get the reaction and healing is better

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medical

TRAINING

WIGMORE

New Training Course: Photodynamic Therapy (PDT) We are excited to announce a new course title that will have its initial airing on the 25th of August at Wigmore Medical’s training facility in Central London. After months of cooperation between Galderma, Ambicare Health and Wigmore Medical, this half-day course tackles a subject that is close to a lot people’s hearts Galderma’s Aktilite 128 Ambicare Health’s Ambulight

Photodynamic Therapy is a modern, highly effective treatment for certain types of precancerous lesions as well as non-melanoma skin cancers (NMSCs). Although they are known medically as actinic keratoses, basal cell carcinomas and Bowen’s disease, doctors may refer to them as AKs and BCCs, or simply ‘lesions’.

PDT is a very different way to treat these lesions compared to conventional approaches e.g. cryotherapy chemotherapy, radiotherapy or surgery. It takes advantage of the chemical interaction between light and a light-activated substance, leading to a series of chemical reactions resulting in damage and death of tumour cells.

The treatment consists of applying a cream to the skin lesion and 3 hours later, shining a pure red light on it. The light and cream targets the lesion cells only leaving the healthy skin unharmed. Only where the two are combined will they treat the abnormal area of your skin.

The course is available only to doctors, dentists and nurses. The fee is £500 (inclusive of VAT) and a maximum of six people will be trained per session.”

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accountancy

Structural integrity With the onset of the 50% tax rate and potential loss of personal allowances, Martin Murray outlines the pros and cons of financial structures available to cosmetic practitioners

M

ost cosmetic doctors practice in a relatively simple manner compared to other businesses. They rent consulting rooms from private hospitals or clinics and use the equipment available to them in those institutions. Some own their own clinic and equipment but complex cases are referred to larger hospitals with the necessary back up resources.

Many practitioners are still actively engaged within the NHS so little time is available to plan the structure of their practice in terms of accounting and tax.

Reliance is placed on accountants, solicitors and financial advisors.

A number of arrangements can instead be undertaken by busy cosmetic doctors, some of which have stimulated discussion with the onset of the 50% tax rate and the loss of personal allowances.

Structures The traditional model of a cosmetic doctor is that of a sole practitioner, which benefits from simplicity—whatever is left in the bank is yours to keep, after taking into account who you owe money to. But profits are taxed at marginal rates. So if you have NHS-employed income, your profits are added to this to determine the rate of tax payable.

If combined earnings are over £112,500, you may lose your personal allowances. If over £150,000, earnings over that figure are taxed at 50%. The easiest and most cost effective way of reducing your tax is to employ your spouse or partner. Amounts can be substantial, running into tens of thousands, providing this can be justified to the Revenue. This uses lower rates of tax to reduce the tax burden on the family as a whole. National Insurance also needs to be taken into account to determine the overall saving.

The second model to consider is that of a partnership between the cosmetic doctor and his/her spouse or partner. The

body language www.bodylanguage.net

split is usually 60:40 or 70:30, in favour of the cosmetic doctor. A portion of the profits is shifted to the spouse, using up their lower rates of tax and providing a saving to the family unit. This portion also suffers less National Insurance compared with the salary route.

However, indemnity insurance can be increased by a few hundred pounds and there is a risk of matrimonial dispute. The latter is less of an issue as the partner will have a significant entitlement to matrimonial assets even if there was no partnership arrangement. In terms of the sole practitioner route, each partner is taxed at their marginal rates of tax. However, this will be lower overall for the family unit.

The Limited Liability Partnership is not considered here as most partners opt for the simple partnership model.

Limited company The last structure to consider is that of a limited company. Since the onset of the 50% rate of tax, this structure has received much interest. The most significant benefit is the lower rate of tax and the possibility of selling your sole practice to the company, generating ‘goodwill’. A spouse or partner who pays tax at a lower rate can also be a shareholder, just like the partnership route.

However, this only works in the long term if monies can be left in the company.

It is, in essence, a deferral vehicle as most individuals need everything they earn.

Unlike the partnership route, a matrimonial dispute with a spouse or partner as a shareholder may be more difficult to

resolve—the company is a separate legal entity in which they have an investment and the arrangement may not be easily dissolved.

Some accountants sell the idea of a 20% corporation rate of tax payable by the company, but fail to tell you that income tax may be payable on dividends and salary taken from the company. The combined amount of corporation tax and income tax is greater in some cases than if you remained as sole practitioner.

They may also tell you that school fees can be paid by the company. While this can be true, the Revenue will tax you on this amount as a ‘benefit in kind’. So the benefit of paying through the company is cancelled and may be more than if you paid it personally!

The upside of ‘goodwill’ is that it can provide a one off saving of tax. But once this has been extinguished, if all income needs to be extracted it may have been more beneficial to have remained as a sole practitioner or form a partnership.

In the eyes of the Revenue, ‘goodwill’ is not just an arithmetical multiple of your practice income. They will look to see what has been transferred and will not accept ‘personal goodwill’ as being sellable to the company. This has an impact on the value of the practice.

Martin Murray is a partner at Sandison Easson & Co, a specialist medical chartered accountancy firm with offices in London and Cheshire. Tel: 01625 527 351; 0207 307 8759; E: info@sandisoneasson.co.uk; W: sandisoneasson.co.uk

The most cost effective way of reducing your tax is to employ your spouse or partner. Amounts can be substantial, running into tens of thousands, providing this can be justified to the Revenue. This uses lower rates of tax to reduce the tax burden on the family as a whole 59

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antioxidants Dr Sheldon Pinnell

Under the sun The sun may have set on the British summer but our skin is still under attack. Dr Sheldon Pinnell explains why topical antioxidants may provide skin protection that is not possible with sunscreens

O

xidative stress causes havoc in the skin and these reactions can modify nucleic acids, proteins and lipids. These changes can also lead to photoageing and skin cancer.

The body naturally deals with this problem using low molecular weight antioxidants—so if we can apply these topically to the skin, it may add to the body’s reservoir of antioxidants and provide additional protection.

We have found that the only two antioxidants that can be absorbed into the skin are L-ascorbic acid, or vitamin C, and alpha-tocopherol, or vitamin E. To get Vitamin C into skin, we have to take the charge off the molecule. Charged molecules can’t penetrate skin, so we have to remove the charge using a proteinate and formulate it at a low pH. Most skin care products are formulated at a high pH, but no Vitamin C can absorb into the skin. If you get below its pK of 3.2, large amounts of Vitamin C can get into skin.

In terms of concentration, you get maximum amounts of Vitamin C with levels of 20% ascorbic acid. If you use 15% Vitamin C formulated at a low pH, the skin can be saturated in three days. If the Vitamin C is stopped, it gets stabilised inside the skin and remains with a half-life of around four days. This is very different to a sunscreen, which needs to be re-applied. Once Vitamin C is in the skin, it can’t be removed.

Vitamin E is a very important antioxidant, particularly in the body language www.bodylanguage.net

lipid phase of the body. It protects cell membranes—when a free radical hits a cell membrane, vitamin E stops the chain reaction.

We have one vitamin E molecule for every cell in our body. They become lodged in the membrane and when they stop the chain reaction, they are oxidised and become a free radical themselves.

Vitamin E molecules work together with vitamin C, which regenerates the vitamin E so that it can work again. Antioxidants work better together than alone.

Stability All antioxidants are unstable compounds, so vitamin C has had to be stabilised. It has been stabilised for use in vitamin pills and works extremely well. Most vitamin C topical preparations contain analogues of the antioxidant. If it goes through the stomach in pill form, vitamin C works.

But the skin can’t make the necessary conversion in an effective way. L-ascorbic acid is able to deliver large amounts of vitamin C into the skin. Likewise, vitamin E is an unstable molecule and ester derivatives enable delivery of the antioxidant to the skin.

Vitamin C was first marketed in the US around 15 years ago.

Five years later, the combination of vitamin C and vitamin E was introduced—this doubles the photoprotection from vitamin C alone, which we can’t do with either ingredient, even in huge amounts.

The third generation used a compound called ferulic acid, 61

antioxidants Dr Sheldon Pinnell

ine dimer DNA mutation, which is the signature footprint for sun-damaged DNA and is involved in skin cancer formation.

Unprotected skin develops a number of thymine dimers, while antioxidant-protected skin makes very few.

Information about sunlight protection has always focused on the ultraviolet spectrum. But we have found that lots of free radicals are generated by visible and infrared light, and are not protected by any sunscreen. Recent studies have shown that visible light and infrared radiation induce oxidative stress in skin.

We would expect antioxidants to be effective against these oxidative products.

If it goes through the stomach in pill form, vitamin C works. But the skin can’t make the necessary conversion in an effective way

which doubles the photoprotection when combined with vitamin C and E. The fourth generation product uses another antioxidant called phloretin.

Ferulic acid is an antioxidant made by all plants, which have to be protected from the sun. They can’t move away from the sun so they make very good antioxidants. Ferulic acid concentrates on the periphery of the plant’s leaves—the first place to be hit by the sun.

It stabilises the vitamin C and E formulation well. Ferulic acid can also be absorbed by the skin. Phloretin is an antioxidant derived from apples and, like ferulic acid, can be delivered into the skin in large amounts.

To test the antioxidants on unprotected skin, we use a UV light source that mimics the UV output of the sun to put a minimally observable sunburn spot on the skin. We then increase the amount of energy that we use to 2–5 times that amount.

We measure photoprotection using a sunburn cell. After 24 hours, we can see the cells as eosinophilic blobs under a microscope. You can see many sunburn cells that have been destroyed by the UV light in unprotected skin. But if you protect skin with phloretin, there are virtually none.

These antioxidants are very good at protecting against thym-

Protection Skin is designed to protect the body from the outside. We have discovered four antioxidants that can penetrate the skin—vitamin C, vitamin E, ferulic acid and phloretin. Virtually no other antioxidant tested absorbs into skin, which is necessary to neutralise oxygen radicals and provide protection.

Sunscreens protect the skin by absorbing UV wavelengths of 290–380nm. Few work well above 380nm. They are designed to work on the outside of the skin, have to be applied evenly, can be removed by washing and rubbing and have to be reapplied.

A UK study, using the best broad spectrum sunscreens available, found that application of 2mg/cm² only blocked 55% of the oxidative reactions.

Antioxidants protect the skin by neutralising oxidative reactions caused not only by sunlight, but pollution; particularly smoking, which generates lots of free radicals.

They are designed to work on the inside of the skin. Once inside, they are stabilised, cannot be removed by washing or rubbing and remain for several days after application.

For ultimate skin protection, I would suggest daily use of antioxidants. Daily protection allows the skin to repair itself without dealing with additional damage.

People using antioxidants like that it evens their complexion—this takes a long period of time but if you avoid further damage, the skin can repair the skin very well.

We all know that sunscreens are good for protecting against sunburn. But antioxidants and sunscreens work using different mechanisms. The use of both is supplemental.

Dr Sheldon Pinnell is a consultant dermatologist and chief emeritus of dermatology at Duke University Medical Center, North Carolina

While effective, sunscreens are designed to work on the outside of the skin, have to be applied evenly, can be removed by washing and rubbing and have to be reapplied.

62

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65

comment David Williams

Conclusion

BY DAVID WILLIAMS

Tax and cosmetic surgery

A

s Mark Twain said: “The only two certainties in life are death and taxes.” What is open to interpretation is the extent of taxation and how it is applied.

If you live in the UK, the extent is far-reaching. It applies to most consumer purchases, our inheritance, and soon possibly—no doubt inevitably—to cosmetic surgery procedures. In one fell swoop 20% may be added to the price of a liposuction, breast implant, facelift and other operations not performed for “therapeutic purposes”.

The reality is, of course, price-cutting and marketing schemes will be devised to absorb part of the hike to make a clinic’s services more competitive, but the overall effect would bite into the pockets of both practitioner and patient.

The reason for considering adding VAT to cosmetic surgery in the near future arises from the government’s need to raise more revenue. Like much of its citizens, the UK is struggling to pay its bills. Whitehall has calculated that the burden could be eased by the additional £500 million collected annually from taxing surgery consumed for purely aesthetic reasons.

The distinction between what is purely aesthetic and what isn’t can, as we know, be blurred. As one surgeon put it, many cosmetic procedures inhabit a grey area between what is aesthetically desirable and what is purely functional. “Should children having their teeth straightened pay VAT? There is no functional element in straightening teeth; it's essentially to give them a nice smile,” he says.

Perhaps rubbing their hands in anticipation are the lawyers, who always thrive in grey areas fertile for argument.

As one tax barrister said: “This could raise all sorts of practical and ethical problems if HMRC claim the VAT status, and hence cost, of a medical procedure had to be decided by whether it thought the procedure a luxury while another con-

66

sidered it vital.”

Some commentators have been quick to point out that President Obama’s socalled “Bo-tax” had to be repealed following loud objections from lobby groups.

But they failed to mention that individual states have applied their own tax independent of Washington. New Jersey imposed a 6% tax on cosmetic surgery procedures in 2004.

Critics of the tax could have bolstered their argument with the state’s decision to phase the tax out in July 2013 in three phases. No doubt the New Jersey aesthetic medicine lobbyists raised the point that the tax made them less competitive than neighbouring states. A higher tax is yet another reason for prospective UK consumers to shop abroad for surgical procedures.

While professionals understandably protect their own interests, the layperson appears not to be too bothered by the prospect of VAT-able breast implant procedures. Readers of that most reasoned of national newspapers, the Daily Mail,

thought cosmetic procedures attracted VAT already.

On the paper’s website, one reader said he was “shocked” that non-therapeutic boob jobs were not subject to VAT. “The VAT take from Katie Price alone might have saved several libraries.”

Kate from Manchester was less vindictive, providing a more reasoned answer.

“As long as plastic surgery is free on the NHS for the people whose needs are urgent and necessary following accident, burns, mastectomy or to correct a physical abnormality from birth, I really don't see any problem in adding VAT to those who elect to have cosmetic surgery just for reasons of vanity. As such procedures are cosmetic, then they should be subject to the same taxing as all non-essential luxuries. If the government can tax petrol, adult clothing…”

Ultimately, the issues of what is taxable, why, and by how much are among more far-reaching questions answered by the society we live in and by whom we choose as our leaders.

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Vistabel® is licensed for the treatment of moderate to severe glabellar lines Delivers lasting patient satisfaction, time after time1,2 Trusted with over 1 million cosmetic procedures across Europe3* The world’s first and most studied botulinum toxin4†

Satisfaction that shows

Vistabel® (botulinum toxin type A) Abbreviated Prescribing Information Presentation: Botulinum toxin type A (from clostridium botulinum), 50 Allergan Units/vial.

Indications: Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown, in adults <65 years, when the severity of these lines has an important psychological impact for the patient.

Dosage and Administration: See Summary of Product Characteristics for full information.

Do not inject into blood vessels. Doses of botulinum toxin are not interchangeable between products. Not recommended for patients <18 or >65 years. Use for one patient treatment only during a single session. Reconstitute vial with 1.25ml of 0.9% preservative free sodium chloride for injection (4U/0.1ml). The recommended injection volume per muscle site is 0.1ml (4U). Five injection sites: 2 in each corrugator muscle and 1 in the procerus muscle: total dose 20U. Contra-indications: Known hypersensitivity to any constituent. Myasthenia gravis, Eaton Lambert syndrome. Infection at proposed injection sites. Pregnancy or lactation.

Warnings/Precautions: Use for one patient treatment only during a single session.

Relevant anatomy and changes due to prior surgical procedures must be understood prior to administration. Product contains less than 1mmol sodium (23mg) per dose. Do not exceed recommended dosages and frequency of administration. Epinephrine (adrenaline) or any other anti-anaphylactic measures should be available. Very rare reports of adverse reactions possibly related to spread of toxin distant from site of injection. Therapeutic doses may cause exaggerated muscle weakness. Caution in patients with history of dysphagia and aspiration. Patients or caregivers should seek immediate medical care if swallowing, speech or respiratory disorders arise. Too frequent or excessive dosing can result in risk of antibody formation, which may lead to treatment failure. Caution in the presence of inflammation at the proposed injection site(s) or when excessive muscle weakness or atrophy is present. Caution when used in patients with amyotrophic lateral sclerosis or with peripheral neuromuscular disorders. Effects of administering different botulinum toxin stereotypes simultaneously, or within several months of each other, is unknown and may cause exacerbation of excessive neuromuscular weakness.

Interactions: Theoretically, effect may be potentiated by aminoglycoside antibiotics or other drugs that interfere with neuromuscular transmission.

Adverse Effects: See Summary of Product Characteristics for full information on side effects. Based on controlled clinical trial data, the proportion of patients that would be expected to experience an adverse reaction after treatment is 23.5% (placebo: 19.2%).

These adverse reactions may be related to treatment, injection technique or both. In general, reactions occur within the first few days following injection and are transient and of mild to moderate severity. Pain/burning/stinging, oedema and/or bruising may be associated with the injection. Frequency By Indication: Defined as follows: Very Common (≥1/10), Common (≥1/100, <1/10), Uncommon (≥1/1,000, <1/100), Rare (≥1/10,000, <1/1,000), Very Rare (<1/10,000). Infections and infestations. Uncommon: Infection.

Psychiatric disorders. Uncommon: Anxiety. Nervous system disorders. Common: Headache. Uncommon: Paresthesia, dizziness. Eye disorders. Common: Eyelid ptosis.

Uncommon: Blepharitis, eye pain, visual disturbance. Gastrointestinal disorders.

Uncommon: Nausea, oral dryness. Skin and subcutaneous tissue disorders. Common: Erythema, Uncommon: Skin tightness, oedema (face, eyelid, periorbital), photosensitivity reaction, pruritus, dry skin. Musculoskeletal and connective tissue disorders. Common: Localised muscle weakness, Uncommon: Muscle twitching. General disorders and administration site conditions. Common: Face pain, Uncommon: Flu syndrome, asthenia, fever. The following have been reported rarely for glabellar lines and other indications: rash, urticaria, pruritus, erythema multiforme, psoriasiform eruption, anaphylactic reaction (angiodema, bronchospasm), alopecia, madarosis, tinnitus and hypoacousia. Adverse reactions possibly related to spread of toxin distant from injection site have been reported very rarely (muscle weakness, dysphagia, or aspiration pneumonia which can be fatal).

Price: £85.00 per vial.

Marketing Authorization Number: PL 05179/0010 Marketing Authorization Holder: Allergan Pharmaceuticals (Ireland) Ltd., Westport, Co. Mayo, Ireland.

Legal Category: POM. Date of preparation: December 2008.

Adverse events should be reported.

Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026 References: 1. Stotland MA et al. Plast Reconstr Surg, 2007;120:1386-1393.

2. Carruthers A et al. Journal of Clinical Research, 2004;7:1-20. 3. Allergan Data on File (DoF) VIS/003/DEC 2010. 4. Allergan Data on File (DoF) VIS/005/MAR 2011. *Given in 5 key EU countries since VISTABEL® launch. Data taken from UK, France, Spain, Italy and Germany.

Global figures. Launched in 1989 in the U.S. Search strategy conducted using; Medline, Embase, Embal, Biosis, SciSearc, Pascal, HCAPlus, IPA. Search applied to Allergan, Ipsen & Merz botulinum toxin type A presentations (cosmetic indication).

†

Date of search: February 2011.

UK/0101/2011 Date of Preparation: March 2011