Body Language Issue 49 by Body Language Journal

jan/feb

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

■ Response times of toxins ■ Re-examining body contouring ■ Combined power of antioxidants

HOW OUR MODERN DIET IS KILLING US LESSONS FOR LONG, HEALTHY LIVING FROM 60,000 YEARS AGO

Your partner in injectable facial aesthetics

Belotero® now approved by the FDA • One of only 3 HA fillers approved by the FDA currently promoted in the US • Optimal integration1 for superior evenness2 • Minimal local inflammation3 for sustained patient satisfaction4

BEL050/1111/JH

Call Merz Aesthetics Customer Services now to find out more or place your orders: Tel: +44(0) 333 200 4140 Fax: +44(0) 208 236 3526 Email: customerservices@merz.com 1 Histological examination of human skin (eyelid dermis layer). Courtesy Dr. J. Reinmüller, Wiesbaden, Germany 2 Prager W, Steinkraus V. A prospective, rater-blind, randomized comparison of the effectiveness and tolerability of Belotero Basic versus Restylane for correction of nasolabial folds. Eur J Dermatol 2010;20 (6):748-52. 3 Taufig A, et al. A new strategy to detect intradermal reactions after injection of resorbable dermal fillers. J Ästhetische Chirurgie 2009; 2: 29-36 4 Reinmüller J et al. Poster presented at the 21 World Congress of Dermatology, Buenos Aires, Argentina, Sept 30 – Oct 5, 2007. Thereafter published as a supplement to Dermatology News: Kammerer S. Dermatology News 2007; 11: 2-3.

www.belotero.uk.com Merz Pharma Uk Ltd 260 Centennial Park, Elstree Hill South Elstree, Hertfordshire, WD6 3SR Tel: +44(0) 333 200 4140

contents

body language number 49 14

PEER PRESS REVIEW Dr Rohit Kotnis surveys academic and association journals to report on advances in research

14 TOXINS

SPEED OF RESPONSE Patients’ response times to toxins were usually measured as starting one week after injection. But in practice patients have responded much more quickly, and researchers have proven that to be the case in large and smaller studies, writes Professor Andy Pickett

18 PSYCHOLOGY DEEP DOWN Practitioners try to address the cause of a problem rather than simply the effect but often fail to identify mental health issues. Dr Raj Persaud discusses new research

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

20 COVER STORY

Classiﬁed Sales Simon Haroutunian 020 7514 5982 simon@face-ltd.com

DIETARY DEVOLUTION We have progressed as a species in mental advancement, but our health could benefit from taking a number of steps backward to our origins in the African savannas. Evolutionary lifestyle anthropologist Geoff Bond looks at what we can learn from our ancestors’ way of living

Publisher Head of Sales Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com Contributors Andy Pickett Geoff Bond Dr Dai Davies Dr Rupert Gabriel Mr Ayham Al-Ayoubi Dr Bryan Mayou Mr Shailesh Vadodaria Professor Marco Gasparotti Mr Chris Inglefield Dr Chantal Sciuto Barbara Green PhD Dr Soren Denim Dr Raj Persaud Kim Pearson Dr David Eccleston Dr Haroun Gajraj Martin Murray

ANALYSES Reports and comments

12 RESEARCH

Editor David Williams 01273 622 944 david@face-ltd.com Assistant Editor Helen Twinam 01273 622 944 helent@face-ltd.com

7 OBSERVATIONS

24 FORUM COMPETENCE VS QUALIFICATIONS Should a general practitioner with a special interest in aesthetic medicine be allowed to perform complex surgical procedures like liposuction? A panel of mixed disciplines discuss the issue

28 RESEARCH OXIDATIVE STRESS Soren Demin describes the role of oxidative stress in the ageing process and methods of measurement

30 SKIN

32 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 2012 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

COMBINED POWER The skin is constantly under attack from molecules known as free radicals. Today there is a range of potent antioxidants with distinct mechanisms that can join forces in multi-component regimens to help the skin fight back, write Barbara A Green RPh MS and Ronni Weinkauf PhD

32 DEVICES ON THE RIGHT WAVELENGTH Body contouring can truly help patients achieve the figures they want, but hype and false statement are common and simply confound the patient, writes Mr Christopher Inglefield LOW LEVEL ATTACK ON FAT Dr Chantal Sciuto describes her experiences with a low level five-diode 635nm laser for body contouring

body language

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 .

number 49

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.

40 PEER TO PEER 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.

MICRONEEDLING AND LASERS Our panel discuss the benefits of microneedling for acne scarring, combination treatments, skin brightening and lasers

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

47 VEINS HOW LIPOSUCTION HAS ADVANCED VEIN TREATMENTS Advances made in one area of medicine often find application in other specialisations. Dr Haroun Gajraj writes about how he has changed his vein procedures following advances in liposuction

52 NUTRITION OPERATIVE DIETS Patients need to be especially vigilant about what they eat before and after surgery. Kim Pearson discusses how diet helps patients to heal

54 ACCOUNTANCY MAJOR CHANGES TO PENSIONS ARE ON THE HORIZON Benefits, contributions and taxation changes to pensions are in the pipeline. Martin Murray reports

58 COMMENT CONCLUSION Letter from the Editor, cartoon

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. 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.

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Your partner in injectable facial aesthetics

BOCOUTURE® vs Vistabel®: Equal Potency1 1:1 Clinical Conversion Ratio2

Unit doses recommended for BOCOUTURE are not interchangeable with those for other preparations of botulinum toxin1 1 BOCOUTURE SmPC, June 2010 2 Sattler, G. et al. Dermatol Surg 2010; 36: 2146–2154

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). 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. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. 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 Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. 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. 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. Interactions 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 observed within the first week after treatment. 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 May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. 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 JAN 2011. 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.

1070/MER/AUG/2011/JH

Date of preparation November 2011

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

C R O S S - L I N K E D H YA L U R O N I C A C I D + L I D O C A I N E

A new generation of dermal fillers Emervel® is a new scientifically-advanced range of cross-linked hyaluronic acid fillers. Formulated using Optimal Balance TechnologyTM, Emervel® delivers instant and optimal results for you and your patients. For more information visit www.emervel.co.uk

Emervel® is a medical device. Injectable solution for aesthetic use. Emervel® is a trademark owned by Galderma S.A. Emervel® CE 0459. Copyright © 2011 Galderma (UK) Ltd. EME/007/1210 Date of preparation: January 2011

observations

Timetable for EU aesthetic standard Public inquiry until 22 May to gather comments from stakeholders in member states The draft of the European Standard for Aesthetic Surgery Services (CEN TC403), which includes injectables and cosmetic lasers, has been finalised and a public inquiry on the text will be open to 22 May 2012. During this time, national members of the European Committee for Standardization (CEN) will collect comments from stakeholders. In the UK, CEN member British Standards Institute uses a website to collect comments on the document (www.bsigroup. com/en/Standards-and-Publications/Current-work/DPCs/). Comments are sent to the committee to prepare the final text of the standard. CEN expects the standard to be published by the end of 2013. CEN began work on devising a European standard last year after accepting a proposal from the Austrian Standards InstituteLansdc(ASI) to create a project committee (CEN/ TC 403) for aesthetic surgery services. EU member states differ on which professionals are allowed to perform aesthetic procedures. The draft standard refers to a practitioner as a medical doctor. Despite a BSI request to postpone the standard’s timetable, owing to the omission of registered nurses and dentists, the go-ahead was given because of CEN guidelines on time limitations. There is a committee of dentistry in CEN, and the General Dental Council and the British Dental Association will meet for discussions in January. Sally Taber, director of Independent Healthcare Advisory Services, whose members include aesthetic medicine practitioners from a range of backgrounds, said: “The lack of recognition of registered nurses is disappointing. We will urge the CEN committee to reconsider the inclusion of registered

nurses when they can show that they had undertaken training formally accredited by their national regulatory authority.” The European Laser Association has stated that lasers should be operated only by medically trained professionals. “This is of extreme concern for the UK in view of the model operated in the UK,” MS Taber said. “CO2 lasers will be referred to as ablative lasers in the standards.” Accreditation by the European Union of Medical Specialists (UEMS) is seen as critical, as it is the independent body responsible for providing training standards for surgeons across Europe. “CEN standards will include and apply to aesthetic medical doctors once training and accreditation is in place and recognised by UEMS,” according to Ms Taber.

EU: harmonising contrasting member states’ aesthetics standards

European Standards are voluntary but their impact can be significant and influence the law of member states. According to CEN, the aesthetic standard “will provide a real added-value for the aesthetic surgery market by helping consumers to make informed choices, by creating an

equal level playing field for aesthetic surgery service providers, complementing existing legislation and filling gaps where no regulation or standard exists”. CEN typically makes standards for products, but it has moved towards services, especially healthcare and social services.

Call for guidelines following bariatric procedures Survey shows nearly half support NHS funding for body contouring The British Association for Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) is calling for national guidelines to be drawn up on reconstructive body contouring surgery following bariatric weight loss procedures. With a growing obesity epidemic in the UK, the number of patients undergoing bariatric surgery is increasing rapidly. Under NICE criteria, about 1.5 million British adults are eligible for these procedures. On average, gastric band patients will lose 50-60 per cent of their excess weight and gastric bypass patients will lose 70 per cent. Many of these patients experience massive weight loss and develop medi-

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cal problems caused by excess skin. These problems can be dealt with by body contouring surgery. However, there are no guidelines on the provision for this type of surgery and NHS funding is limited. A recent survey of 1,000 GPs in November shows that 45 per cent support NHS funding for body contouring surgery. A pilot study by Mark Soldin, a BAPRAS consultant plastic surgeon at Kingston and St Georges University Teaching Hospitals, has found significant improvements in patients’ physical and emotional wellbeing once they have undergone body contouring surgery

following massive weight loss. “We know that excess skin following massive weight loss can lead to significant on-going problems including soreness, recurrent infections, functional problems, depression, difficulty with sexual function and poor body image,” says Mr Soldin. Initial findings from the study’s research shows significant physical and emotional benefits to patients, who go on to lead a far more physically active and healthy life. “With the growing incidence of bariatric surgery in the UK, it is essential that the aftercare for patients be given greater thought,” says Mr Soldin. 7

Face the future

with confidence Azzalure® is a Botulinum Toxin Type A for aesthetic use. • Fast onset of action (median time to onset 2-3 days)1 • Long duration of action (up to 5 months)1 • High level of patient satisfaction (93% after 6 months, following one treatment session)2

Azzalure® is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when the severity of these lines has an important psychological impact on the patient.

an aesthetic choice Azzalure Abbreviated Prescribing Information Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions ®

are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP) IRE 2 Vial Pack (2 x 125u) €183.78 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: September 2010. Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Galderma (UK) Ltd. References 1. Azzalure® Summary of Product Characteristics. 2. Ascher B et al. J Am Acad Dermatol 2004; 51: 223-33. Azzalure® is a registered trademark of Galderma. Date of preparation: November 2010 AZZ/543/1110

observations

training & events JANUARY 13th January Healthxchange Obagi Training Workshop, Manchester W: obagi.uk.com

25th February Cosmetic Courses Foundation Botulinum Toxin & Dermal Fillers Course, Bucks W: cosmeticcourses.co.uk

27th February Healthxchange Obagi Blue Peel Training Workshop, London 14th - 15th January European Society of Aesthet- W: obagi.uk.com ic Surgery Master Class in Breast Surgery ft. Live Surgery Workshop, Cambridge Park Hospital 28th February Interventional Cosmetics: New W: eusas.com Treatments & Management of Complications, Royal Society of Medicine, London 18th January Dental Block Training, Heather W: rsm.ac.uk Irvine Aesthetics Academy, Bradford, W. Yorks W: heatherirvineaestheticsacademy.co.uk MARCH 18th January Lynton Lasers Core of Knowledge Course, Lynton Clinic Training Centre, Cheadle, Cheshire W: lynton.co.uk

1st - 3rd March 3rd Bergamo Open Rhinoplasty Course: From Fundamentals to Finesse, Bergamo, Italy W: bergamoplast.com

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

4th - 5th March Professional Beauty 2012, ExCeL London W: professionalbeauty.co.uk

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

12th March ISAPS Symposium, Boracay Island, Philippines W: isaps.org

24th January British Association of Cosmetic Nurses Workshop on Managing Complications in Aesthetics, Ark Conference Centre, Basingstoke W: cosmeticnurses.org 24th - 26th January Wigmore Medical Introduction to Skincare & Chemical Peels, Toxins and Dermal Fillers Courses, London W: wigmoremedical.com

13th - 15th March Wigmore Medical Introduction to Skincare & Chemical Peels, Toxins and Dermal Fillers Courses, London W: wigmoremedical.com 14th - 15th March International Society of Dermatopathology 15th Joint Meeting, Westin Gaslamp Quarter, San Diego W: intsocdermpath.org

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

16th - 20th March American Academy of Dermatology 70th Annual Meeting 2012, San Diego Convention Center, San Diego W: aad.org

26th January LCS Academy Laser/IPL Core of Knowledge Course, Milton Keynes W: lcsacademy.co.uk

17th March BACD Spring Conference, Royal Society of Medicine, London W: cosmeticdoctors.co.uk

26th - 29th January International Master Course on Aging Skin (IMCAS 2012), Palais des Congres, Paris W: imcas.com

21st March Lynton Lasers Skin Laser Applications Course, Lynton Clinic Training Centre, Cheadle, Cheshire W: lynton.co.uk

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

24th March Cosmetic Courses Foundation Botulinum Toxin & Dermal Fillers Course, Bucks W: cosmeticcourses.co.uk

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

27th-28th March SkinBrands SkinCeuticals Training Course, Ealing, London W: skinbrands.co.uk

31st January - 4th February 8th World Congress of Cosmetic Dermatology of the IACD, Fiesta Americana, Hotel Grand Coral Beach, Cancun, Mexico W: wcocd2012.com FEBRUARY 8th February Mapperley Park Core of Knowledge Course, London W: mapperleypark.co.uk/training 8th February Wigmore Medical Advanced Toxins & Fillers Course, London W: wigmoremedical.com 9th - 11th February 46th Annual Baker Gordon Educational Symposium, Hyatt Regency Hotel, Coconut Grove, Florida W: bakergordonsymposium.com 17th - 19th February 3rd Mexico City Congress in Anti-Aging, Mexico W: a4m.com 18th February Innomed Chemical Peel and Medical Skincare Course, London W: innomedtraining.co.uk 20th - 23rd February LCS Academy BTEC Medical Laser/IPL Course, Milton Keynes W: lcsacademy.co.uk 22nd February Healthxchange Obagi Training Workshop, London W: obagi.uk.com

29th - 31st March 10th Anti-Aging Medicine World Congress & Medispa, Monaco W: euromedicom.com APRIL 11th - 13th April Wigmore Medical Introduction to Skincare & Chemical Peels, Toxins and Dermal Fillers Courses, London W: wigmoremedical.com 18th April Lynton Lasers Vascular and Pigment Masterclass Course, Lynton Clinic Training Centre, Cheadle, Cheshire W: lynton.co.uk 19th - 21st April COSMODERM 18th Congress of the European Society of Cosmetic and Aesthetic Dermatology, Prague, Czech Republic W: escad.org MAY 3rd - 8th May American Society for Aesthetic Plastic Surgery Annual Meeting (ASAPS) 2012, Vancouver W: surgery.org 10th - 12th May Laser Europe 2012, Cumberland Hotel, London W: lasereurope2012.co.uk

If you have an item you would like included in Training & Events, send it for consideration to editorial@bodylanguage.net

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‘Gaze training’ aids surgical trainees Study shows eye-locking promotes concentration A study by researchers at The technique, adopted by the University of Exeter has experienced surgeons, led stufound that trainee surgeons dent away from simply tracklearn technical surgical skills ing the tip of the surgical tool, more quickly when they encouraging accuracy and are taught to mimic the eye avoiding distraction from the movements of experts. The surrounding environment. findings, which have been After repeating the task, published in Surgical En- students’ eye movements were doscopy journal, could trans- found to mimic those of a surform the way surgeons are geon at work. prepared for the operating Dr Samuel Vine, of the Unitheatre. versity of Exeter, says: “These The researchers devised a individuals were also able to “gaze training programme” successfully multi-task without which taught the trainees “ex- their technical skills breaking pert visual control patterns”. down, something that we know Thirt y experienced medical surgeons students are capable were diof doing in v i d e d the operatinto three ing theatre. groups unTe a c h i n g der ta k ing eye moveone type ments rathof training. er than the One group motor skills was taught may have how to use reduced the the surgiworking cal instrumemory ments; anrequired to other was complete left to learn the task. independThis may ently; and be why they the other were able was taught to multiu s i n g Trainee surgeons learn more quickly task while the “gaze following experts’ eye movements the other training groups were technique” in which students not,” Dr Vine says. were shown a video captured The findings suggest that by an eye tracker. This showed trainees could be prepared earwhere and when the surgeon’s lier for the operating room by eyes were fixed during a simu- gaining more hands-on surgilated surgical procedure. cal experience, which may be The group undertook the welcomed following tighter task wearing an eye-tracking government budgets and new device and was encouraged to EU working time directives. use the same eye movements as The research team is now the surgeon. following up with an analysis of Students learned to “lock” the eye movements of surgeons their eyes to a critical location performing real-life operations when performing complex and is working towards develmovements using surgical in- oping a software training packstruments. age to guide trainees. 9

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observations

Blood thinner lowers clot risk after surgery Treatment duration needs more research Venous thromboembolism (VTE), or deep vein thrombosis in the legs and pulmonary embolism in the lungs, is one of the most serious potential complications for patients undergoing major cosmetic surgical procedures. Risk factors include heart or respiratory disease, predisposition to clotting, varicose veins, obesity and smoking. A combination of any for plastic surgery patients coupled with the type of surgery may predispose a patient to VTE. A US study, published in the November 2011 issue of Plastic and Reconstructive Surgery, examined whether post-operative administration of the drug enoxaparin prevents VTE in adult plastic surgery patients. A total of 3334 patients were included in the study, receiving treatment in 2009 at four sites across the US. Enoxaparin sodium is marketed by Sanofi under the trade names Lovenox in the US and Clexane in the UK. The drug is a low molecular weight heparin and anticoagulant used to prevent and treat VTE.

Patients on enoxaparin are around 60% less likely to develop clots

The drug is administered by subcutaneous or intravenous injection and has a long halflife compared with standard heparin. It can be administered by doctors, nurses or patients themselves to prevent or treat the development of blood clots. Eligibility requirements for the study included adult patients undergoing an operation under general anaesthesia, postoperative submission to the hospital for at least one night, and a moderate to high risk for VTE, measured using the Caprini Risk Assessment Model. The model assesses the likelihood of a patient developing clots in the deep veins of the legs or lungs following surgery. The higher the Caprini score, the more likely blood clots will develop after surgery. For the study, patients with a score of three or more received post-operative enoxaparin prophylaxis for the duration of inpatient stay. The control group received no chemoprophylaxis for 60 days following surgery. Results of the study show that post-operative enoxaparin was protective against venous thromboembolism events over 60 days following surgery in high-risk patients (Caprini >7). Patients receiving the drug immediately after treatment were around 60% less likely to develop VTE. Length of patient stay greater than four days was shown to be an independent risk factor for VTE but administration of enoxaparin helps prevent the condition. While the study followed patients for 60 days after surgery, the risk of VTE may remain elevated for up to 90 days. The authors conclude that duration of chemoprophylaxis, or drug administration, in plastic surgery patients following treatment needs more research, as optimal duration is not yet known.

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second brief

TOP 20 COUNTRIES International Society of Aesthetic Plastic Surgery (ISAPS) has published its annual study of aesthetic/ cosmetic surgery procedures. The study reveals the hierarchy of countries with the most surgical and non-surgical aesthetic procedures performed by board certiﬁed (or equivalent) plastic surgeons in 2010. l The most popular surgical procedure in the top five countries—US, Brazil, China, Japan and India—is lipoplasty, while botulinum toxin type A ranks as the most common non-surgical procedure for all five. Lipoplasty represents 23% of all surgical procedures performed. l The study includes average surgeons’ fees per surgical procedure. Facelifts proved most expensive at an average of $5526, followed by abdominoplasty, breast reduction, breast lift and breast augmentation.

1 United States

11 Germany

2 Brazil

12 Turkey

3 China

13 Spain

4 Japan

14 Russia

5 India

15 Canada

6 Mexico

16 United Kingdom

7 Italy

17 Taiwan

8 South Korea

18 Venezuela

9 France

19 Argentina

10 Columbia

20 Thailand

Source: ISAPS/www.isaps.org

peer press review

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

Same-patient prospective comparison of Botox versus Dysport for the treatment of primary axillary hyperhidrosis and review of literature. Vergilis-Kalner IJ. J Drugs Dermatol, 2011 Sep 1;10(9):1013-5.

Two non-bioequivalent toxins, Botox and Dysport, were compared for treating primary axillary hyperhidrosis to compare the injection site pain, efficacy, safety and tolerability of Botox versus Dysport using a conversion factor of 1:3, respectively. A patient with primary axillary hyperhidrosis was treated with 100 units of Botox into the right axilla and 300 units of Dysport into the left axilla. Patient was blinded as to which axilla received treatment. Pain at the injection site of these two toxins was evaluated. The patient was subsequently followed for the next 10 months to evaluate the difference in these two toxins for side effects, time to the onset of reduction of sweating and the duration of action of these two toxins. A significant difference was observed in the onset of action, with dramatic reduction in sweating after one week of injection with Botox and after two weeks of injection with Dysport. At two-weeks, a similar success in eliminating sweating was reported in both axilla. The duration of benefits differed between the two toxins, with elimination of sweating in the Dysport-treated axilla lasting six months and, in the Botoxtreated axilla, nine months. No other differences were observed between these two toxins. Both Botox and Dysport led to a similar perceived reduction of sweating in the treatment of primary axillary hyperhidrosis when a conversion factor of 1:3 12

was used. However, Botox treatment resulted in a quicker onset of action and longer duration of benefits. An interesting and useful study for practitioners to consider when choosing a product for axilla treatment and also when discussing the effects with their clients. Comparison of the spread of three botulinum toxin type A preparations. Kerscher M, Roll S, Becker A, Wigger-Alberti W. Arch Dermatol Res 2011 Oct 15.

Unwanted effects can occur when neurotoxin diffuses into untargeted muscle. The aim of this study was to investigate the spread of three approved botulinum toxin type A preparations by measuring and comparing the size of the anhidrotic halos they produced following injection of equivalent doses in an identical volume into the forehead of patients. The results showed that incobotulinumtoxinA and onabotulinumtoxinA displayed comparable spread at six weeks and over six months. However, abobotulinumtoxinA, when assuming a 1:2.5 injection volume ratio, produced a statistically significantly greater maximal area of anhidrosis within six weeks and over six months. All preparations were well tolerated. The results of this study demonstrate that incobotulinumtoxinA and onabotulinumtoxinA have comparable spread, while abobotulinumtoxinA has significantly greater spread than incobotulinumtoxinA. Lip nodules caused by hyaluronic acid filler injection: report of 3 cases. Shahrabi Farahani S, Sexton J, Stone JD, Quinn K, Woo SB. Head Neck Pathol 2011 Oct 8.

Many dermal fillers have been used for reducing facial skin lines and for lip augmentation, and hyaluronic acid (HA) is one of the most widely used agents.

Although HA is non-immunogenic, hypersensitivity and granulomatous foreign body reactions have been reported. The paper reports three female patients (average age 56 years) who presented with firm nodular lesions of the lip and a history of injection with HA. Histopathologically, all cases showed pools of amorphous hematoxyphilic material surrounded by bands of densely collagenised connective tissue with no inflammation or foreign body reaction. Histochemical stains confirmed the presence of acid mucopolysaccharides such as HA. The authors conclude HA is an inert filler that may persist at an injection site, resulting in a tumor-like nodule. This paper focuses on a well recognised side-effect of lip augmentation and highlights the need for attention to detail. Further experience with permafacial implants for lip augmentation: a review of 100 implants. Narsete T, Ersek R, Narsete MP. Aesthet Surg J 2011 Jul;31(5):488-92.

Although fillers and surgical lip lifts are effective ways of treating the perioral area, both have inherent downsides. Fillers lack permanence, and lip lifts do not address the issue of fullness. The authors present the results of a long-term follow-up study of Permafacial implants for lip augmentation. The authors’ original publication demonstrated the benefits of inserting Permafacial implants concurrent with a facelift procedure. In this long-term follow-up study, the results of the first 100 implants (50 patients) are presented; this initial group of patients was followed up for one to two years. Implant migration, lip function, implant position, sensation, and patient satisfaction are reviewed. Very few complications were reported; these included migration

with revision, along with patient-requested size adjustments or removal. No extrusions were reported. The degree of patient satisfaction with these implants was high. Although the authors initially experienced a significant migration rate, a modification in technique reduced this rate over the long term. . Clinical experience with hyaluronic acid-filler complications. Park TH, Seo SW, Kim JK, Chang CH. J Plast Reconstr Aesthet Surg 2011 Jul;64(7):892-6. Epub 2011 Feb 9.

The authors evaluated and treated 28 cases of HA-filler-related complications that were referred over five years from July 2004 to October 2009. Twenty-eight patients were included: 82.1% of the patients were female and 17.9% were male. Complications were classified as nodular masses, inflammation, tissue necrosis and dyspigmentation. Affected locations, in descending order of frequency, were the perioral area, forehead, including glabella, nose, nasolabial fold, mentum, including marionette wrinkles, cheek area and periocular wrinkles. The most disastrous complication was alar rim necrosis following injection of the nasolabial fold. The authors propose two ‘danger zones’ that are particularly vulnerable to tissue necrosis following filler injection: the glabella and nasal ala. This serves as a reminder of the potential serious complications of fillers and the need for practitioners to evaluate the risks / benefits when injecting into the area and informed consent considerations.

Reviewing PPR is Dr Rohit Kotnis (Lon), Dip SEM (ED). Rohit is an advanced tutor at Dermis Deep, Birminghamand a member of the Body Language editorial panel

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Speed of response

Patients’ response times to toxins were usually measured as starting one week after injection. But in practice patients have responded much more quickly, and researchers have proven that to be the case in large and smaller studies, writes Professor Andy Pickett

he growing use of non-surgical aesthetic procedures is phenomenal. There are no exact figures, because they are not recorded in most countries. The annual survey by the American Society of Plastic Surgeons reports 5.4 million botulinum toxin (BoNT) procedures in 2010. This is the tally for only one society’s members in one country. The figure must be at least twice this for worldwide use of BoNT alone. South America, Asia and Europe are equally important markets as the US, and BoNT for aesthetic treatments is growing, as are dermal filler sales. There is a similar growth in discerning patients. More patients want to know details of their procedures, the products and their clinicians’ experience. Although much non-surgical treatment is repeat business from satisfied customers, word14

of-mouth recommendation is important in spreading growth. This does not mean patients are less demanding. Two key questions of modern BoNT treatment foremost in patients’ and doctors’ minds are how fast will the product work and how long will the effects last? Until 2009, no one had really looked at how fast a BoNT product worked after injection. There are uncountable publications on both the aesthetic and medical uses of BoNT—even in controlled clinical trials—that have the first study time point as seven days after injection. Apparently, the assumption was that nothing would be seen before seven days. But in 2009 our knowledge changed significantly as new data appeared from the US trials of Dysport looking at what happened before seven days1. The results were remarkable. The data

clearly showed that 50% of patients were responding by 2.5 days after injection. As important, this effect was repeated for the five cycles of treatment in the study. This was the first time that such data became available. This was a large study: 1200 patients were enrolled, receiving at least one cycle of BoNT. It wasn’t until 2011 that similar data appeared for Botox 2, almost saying this important aspect of treatment had not been systematically studied for the product before. The study published was for only 45 patients, a small data-set considering Botox’s widespread use. In fact, speakers for the manufacturer were seen at international aesthetic meetings presenting pictures of their early patient records to try to persuade the audience this was old news. But this remarkable finding—against body language www.bodylanguage.net

toxins Andy Pickett

Table 1 Onset of action of the two major types of BoNT used for frontalis treatment. Summarised from reference3. Differences significant at p = 0.01 or higher. Effect onset

Rating

Median time to onset (hours)

Minimum decrease in Maximum Baseline Elevation

Dysport

Botox

20%

Full

33%

Complete

≥ 66%

120

Initial

all the old beliefs of BoNT action— served to really get people interested in finding out what was a real time for onset of action. Many clinicians reported anecdotally that many of their patients felt they were seeing (and feeling) an effect a few hours after injection. Remarkable data from Mark Nestor and Glynis Ablon, based in the US, show a head-to-head comparison of Botox and Dysport that looks at the time of action onset after injection into the frontalis3. Five injection points were used, one product on each side of the patient’s forehead, and effects measured on a four-point frontalis rating scale. For the comparison in 20 patients, 25 units of Dysport were injected (five units per injection point) and 10 units of Botox (two units per injection point). Their findings are summarised in Table 1. Overall, an initial onset for Dysport was found in 12 hours, but took 48 hours for Botox. Complete onset for Dysport occurred in 72 hours and for Botox in 120 hours, according to the rating scale. The differences were highly significant. These data showed, for the first time, a clear difference in onset of action between the two main BoNT-A products. Why would such a difference occur? After all, the active component is the

same in both products, BoNT-A neurotoxin. We do not have an answer yet from BoNT science and any potential reason would be pure speculation at this time. We already have too much speculation and myths about the BoNT products, so now is not the time to add another subject. But the difference seems real. So how about the duration of action? Are there any product differences there? Nestor and Ablon have published, simultaneously to their work on onset of action, a direct head-to-head comparison of duration of action of the two main products, using the same doses and sites of injection as before4. This is probably the same patient population but also looking at duration of action. Again their findings were clear (Table 2). The mean duration of different effects, now using two ways of measurement, were longer for Dysport in every case compared with Botox. A product difference was once more identified. Other studies, on the treatment of glabellar lines in particular, have not shown such differences in duration of action between the main products (summarised by Rzany and Nast5). The strong and short corrugator and procerus muscles treated for glabellar lines are, however, very different from the wide, flat frontalis muscle

Table 2 Duration of effect of the two major types of BoNT used for frontalis treatment. Summarised from reference4. Effect onset

Rating Minimum decrease in Maximum Baseline Elevation

Median duration of effect (days) Dysport

Botox

Partial

20%

105

Full

33%

103

Complete

≥ 66%

145

Change rated on 4-point scale Partial

≥ 1 point

160

Full

≥ 2 point

119

Complete

3 point

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studies by Nestor and Ablon in detail, so perhaps differences in responses might be expected? The studies summarised by Rzany and Nast show that both products are capable of producing continuing effects out to 120 days after injection in about 30% of patients. Other studies on Dysport have looked as far out as six months after injection and found about 10% of patients still have a good effect6. Equivalent data exist for Botox. What we can now say, with substantial supporting clinical evidence, is that BoNT products give a rapid onset of action, in some cases within half a day, and have a long duration of effect, perhaps as long as six months. There do seem to be product differences and we cannot yet explain these, but we wait now, once again, for the science to catch up with the clinical practice of using BoNT, to give us that next stage of explanation. This has been a permanent feature of BoNT use, in any indication. Clinical uses have always outpaced the science. We now hope the scientists find the key to two of the most important aspects of BoNT aesthetic use, supplying the next answers for the patients. Professor Andy Pickett is director and founder of Toxin Science Ltd. He previously worked for Ipsen Biopharm and has been in the toxin field for 23 years

References

1 Moy R, et al. “Long-term safety and efficacy of a new botulinum toxin type A in treating glabellar lines,” Arch.Facial.Plast.Surg 2009. 11(2): pp77-83. 2 Beer, K.R., et al. “Rapid Onset of Response and Patient-reported Outcomes After OnabotulinumtoxinA Treatment of Moderateto-Severe Glabellar Lines,” J Drugs Dermatol 2011. 10(1): pp39-44. 3 Nestor, MS and GR Ablon, “Comparing the Clinical Attributes of AbobotulinumtoxinA and OnabotulinumtoxinA Utilizing a Novel Contralateral Frontalis Model and the Frontalis Activity Measurement Standard,” Journal of Drugs in Dermatology: JDD, 2011. 10(10): pp1148-57. 4 Nestor, MS and GR Ablon. “Duration of Action of AbobotulinumtoxinA and OnabotulinumtoxinA: A Randomized, Doubleblind Study Using a Contralateral Frontalis Model,” The Journal of Clinical and Aesthetic Dermatology, 2011. 4(9): pp43-9. 5 Rzany, B and A Nast, “Head-to-head studies of botulinum toxin A in aesthetic medicine: Which evidence is good enough?” Journal of the American Academy of Dermatology, 2007. 56(6): pp1066-1067. 6 Ascher, B et al. “A multicenter, randomized, double-blind, placebo-controlled study of efficacy and safety of 3 doses of botulinum toxin A in the treatment of glabellar lines,” J Am Acad Dermatol, 2004. 51(2): pp223-233.

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psychology Dr Raj Persaud

Deep down P

sychiatrist Walter Ricci has collaborated with Steven Prstojevich, Harriet Langley and Matthew Hlavacek, cosmetic, oral and maxillofacial surgeons in the USA, in producing a fascinating paper, “Psychological Risks Associated with Appearance-Altering Procedures: Issues ‘Facing’ Cosmetic Surgery”, Oral and Maxillofacial Surgery Clinics of North America, Vol 22, Iss 4, Nov 2010, pp439–444. In the article they marshal sobering evidence of why aesthetic practitioners should be more aware of the psychological dimension of their work. At one extreme, the authors point out, its well known for serious psychiatric disorders to remain hidden, but only manifest in the desire for surgical intervention. The authors point to data that up to 47.7% of those who seek cosmetic procedures meet diagnostic criteria for having some formal mental disorder. These include body dysmorphic disorder, which occurs in 5–15% of patients; narcissistic personality disorder, in 25%, and histrionic personality disorders, in 9.7%. Given the prevalence of these diagnoses, the authors contend, importance of a psychiatric evaluation of anyone at risk to these issues is apparent. Why the paper should be read widely by cosmetic and aesthetic professionals is its sensitive consideration of the more subtle end of the psychological spectrum. There is an even larger number of clients who wouldn’t tick the boxes required for a formal psychiatric diagnosis but who, nonetheless, betray a mammoth psychological dimension to their appearancealtering desires. The key concept the authors of this paper invoke, and which I believe practitioners could be more sensitive to in their handling of patients, is the tricky issue of 18

Practitioners try to address the cause of a problem rather than simply the effect but often fail to identify mental health issues. Dr Raj Persaud discusses new research

shame. The authors define shame in aesthetics as the patients’ experience of the gap between society’s standard of looks and their actual appearance. Because shame is not so easily openly expressed, it can be manifested in subtle ways, which the clinician needs to be aware of. At one end of the spectrum of shame is avoidance—this can be as extreme as not going out at all—to as understated as a tendency to cover one’s mouth when laughing. Another way shame can be subtly expressed is in relationships where patients behave as a “doormat” and so get abused but feel such low self-esteem that they feel they deserve the maltreatment or that they couldn’t survive outside the relationship. Clinicians need to be thinking about how shame of one’s looks could be manifesting itself within a relationship. Such problems could be driving someone to seek an alteration in their exterior, so this underlying psychological dimension might need addressing. Otherwise, a return to an abusive or negative relationship could easily wipe out the potential emotional gains resulting from enhanced appearance. Shame, oddly enough, can be the underlying cause of excessive displays of wealth such as driving exotic fast cars or wearing expensive jewelry. The theory is that these are attempts to compensate for, or distract from, an underlying sense of inadequacy. It’s because you are ashamed of some aspect of self that you need to compensate or distract with beauty or attention-grabbing displays elsewhere. The clinician aware of this perhaps unusual way of thinking about shame could take a peek at the car park to see what form of transport the client arrived in as part of their psychological evalua-

tion. Ricci and colleagues make the point that shame can manifest itself by a tendency to constantly criticise and attack others. The theory is that you bring others down to compensate for feeling inferior much of the time. The key message is that patients who seek cosmetic surgery don’t have to be suffering from formal psychiatric disorder to warrant some thought to a psychological approach to help them negotiate the complex issue of appearance-altering procedures. It could be that just having the procedure is sufficient, but it is possible that including a more nuanced psychological understanding of the patient’s motivation can help improve the outcome. The paper concludes that it is natural for surgeons to develop a checklist to the mental health of their prospective patients. Is the patient psychologically fit enough to handle the procedure? Should the surgeon avoid or get a psychiatric evaluation if enough boxes are ticked that warning bells are going off about the possibility there are serious mental health problems? That patients may be suffering from or wrestling with profound psychological issues such as shame but not be formally mentally ill indicates surgeons should be including a psychological dimension to their care. Surgery should be within a clear context of the true role it will play in the patient’s life. If not, it’s possible that a procedure which has worked perfectly OK in the surgeon’s eyes hasn’t really addressed the underlying issue, and therefore doesn’t produce the right outcome for the patient. Dr Raj Persaud FRCPsych is a consultant psychiatrist working in private practice at 10 Harley Street, London W1 body language www.bodylanguage.net

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cover story Geoff Bond

Dietary devolution We have progressed as a species in technical development but our health could benefit from taking a number of steps backward to our origins in the African savannas. Evolutionary lifestyle anthropologist Geoff Bond looks at what we can learn from our ancestors’ way of living

ealth and beauty are often linked. Beauty is the brain’s way of saying something is attractive, that this is probably beneficial, that this benefit is probably healthy and so probably “fit for purpose”. In one important sense, beauty is health. What is this “purpose”? It is to be fit for life in our ancestral homeland, the savannas of East Africa. This big breakthrough came from an unexpected quarter: genetics. Studies of DNA show that everyone is descended from a small group of people who lived just 60,000 years ago (some 2,000 generations) in that area. Crucially, we are still living with bodies and brains designed for that kind of life. We still have the same physiology, digestive system, biochemistry, and mentalities. The key question is: what is this savanna lifestyle that has shaped us humans? Our ancestors lived in forager bands of eight

to ten families. Each band had a territory of about 200 square miles. They camped for a while in one place and when they were done, they walked 10 to 15 miles to the next foraging area. Every day the women went off foraging, carrying children on their backs. After a few hours, the women returned carrying some 15 to 20 pounds of food. The men went off singly: trapping, scavenging or occasionally hunting. They provided about 20% of the band’s food supply almost entirely in the form of animal matter. Taken both together, people ate two to three pounds plant food per day and eight to twelve ounces of animal food. Our foraging ancestors didn’t suffer from obesity, cancer, heart disease, diabetes, osteoporosis, arthritis, and all the other diseases of civilisation. They didn’t suffer from body-image ailments such as varicose veins, acne, cellulite or crooked, cramped teeth. Despite eating more cholesterol than Westerners, their blood cholesterol levels are low; their blood pressure remained low even into old age. All these conditions—from major metabolic diseases to the smaller ailments—are due to the mismatch between the lifestyle designed for us by our evolutionary history and the way we live today. Plant food Our ancient ancestors were consuming large volumes of a particular kind of plant food rich in micronutrients and fibres: soluble, insoluble and downright inedible. It was strongly alkalising. Our bodies came to expect a high throughput of that kind of body language www.bodylanguage.net

cover story Geoff Bond

ar spikes. This is now commonplace, but the corollary is that humanity’s diet is low insulinemic, too. Today, most people are in a state of hyperinsulinemia. This is a problem because insulin is a powerful hormone, and when it dysfunctions it creates havoc: it depresses the immune system (allowing cancers to flourish), it depresses bone building, increases histamine, depresses mood, increases blood clotting and has many other adverse effects. It is one of the main reasons we have high cholesterol; it is even a factor in acne.

plant food. By micronutrients we mean not only vitamins and minerals but also “phytochemicals”—those tens of thousands of flavonoids, carotenes, terpenes and the like. Our biochemistry came to depend on them. We are not like a cat, which can manage without most phytochemicals. For us micronutrient starvation is a factor in a great many diseases. It even affects attractiveness: our brains are programmed to detect health through complexion. Attractiveness correlates with a healthy complexion which correlates with high micronutrient intake. We now know that nature designed our bodies to rely on a healthy biomass in our colons, for which a plentiful supply of fibre is vital. Without it, things go wrong—from an undermined immune system to a leaky colon to disturbed biochemistry, which is happening today. Instead of a herb garden, we are creating a toxic sewer, leading to diseases such as irritable bowel, Crohn’s, diverticulitis and cancer. Moreover, this toxic sewer is often backed up by constipation, a major factor in varicose veins. Throughout the history of mankind, humans squatted on their haunches to relieve themselves. The modern practice of sitting on a toilet seat can contribute to varicose veins. Foragers’ food was chewy. Remarkably, new research has found this is important in triggering proper growth of our jaws. Modern soft diets are one reason weak jaws and cramped teeth have become common in the past few decades. Throughout history, our diet has been low glycaemic and our bodies simply don’t know how to handle today’s high blood sugbody language www.bodylanguage.net

Origin Our diet started to go wrong when we began farming around 11,000 years ago. People began to eat grass seed—cereal grains. First, grains are starchy, and starch is just another form of sugar: a slice of toast hits the blood stream faster than a teaspoon of sugar, tipping us straight into the mischief of hyperinsulinemia. The extra sugar goes straight to fatten hips and thighs. Second, grains are poor in micronutrients. By eating grains, we are starving our body of the tens of thousands of compounds that it expects for it to work properly. Third, grains contain anti-nutrients, which our bodies do not know how to handle. Gluten is an obvious example; others are lectins, alkyl resorcinols and many more. They all conspire to subtly undermine our health. There is a tuber that Shakespeare hardly knew which has come to dominate our diets in the last 200 years. It’s the potato. Like grains, the potato is just as insulinemic, just as micronutrient poor, and it contains some nasty plant poisons—the glycoalkaloids. Then there is sugar itself. Hunter-gatherers consumed only about four pounds per head per year of sugar in the form of honey. That was everyone’s ration until just 250 years ago. With the advent of cheap sugar, its consumption has rocketed to 160 pounds per head per year in the USA—a 4,000 per cent increase. We all know that sugar is a menace: it is highly insulinemic, fattening and devoid of micronutrients. The savanna environment was not particularly low fat for us humans—some 25% of calories—but much more importantly it had a particular fatty acid profile. Two fatty acids were always there, such that our bodies came to depend on them: they are essential and without them we sicken and die. The body uses them to make powerful hormones called eicosanoids. What one fatty acid’s eicosanoids do, the other fatty acid’s eicosanoids undo. For example, one increases blood clotting, the other decreases it; one builds bones, the other dissolves them, and so on. For good health these two fatty acids—the omega-3s and omega-6s—need to be present in equal amounts. Each uses the same machinery to be metabolised. So if one is using it, the other one cannot. Under savanna life, the machinery would oscillate between the two like a see-saw. Today this is significantly unbalanced. In my lifetime omega-6 oils, typically corn oil, peanut oil, sunflower oil, safflower oil and many more, have come to dominate the diet. They are good for us but not in excess. As a result of this imbalance, we are over-producing a wide range of powerful eicosanoids (prostaglandins series II, thromboxanes, leukotrienes), which are factors in many conditions: acne, arthritis, allergies, cancer, high blood pressure and many more. Meanwhile omega-3 oils have become flavour of the month: fish oils, of course, plus omega-3 rich eggs and one or two vegetable oils, notably flax and rape seed. We need only a gramme a day. The challenge is to strip out the omega-6 oils to the point where we are also consuming only a gramme a day, because high 21

cover story Geoff Bond

absolute amounts of omega-6 blocks any amount of omega3—it breaks the see-saw. About 2,000 years ago, the herders of north-west Europe developed the odd idea of consuming the secretions from the mammary glands of their lactating animals—they drank cows’ milk! These herders, Slavs, Germans, Anglo-Saxons and Scandinavians, put the production of milk and its products onto a formal footing—they invented dairy farming as a major industry. But consuming milk is not normal human adult behaviour. Foragers were not creeping around under female antelopes suckling their teats! Indeed, dairy consumers represent only about 20% of the world’s population. The remaining 80%—Asians, Africans, Latin Americans—not only think milk consumption is grotesque but also it makes them sick. The milk of the species is for the young of the species. Even human milk isn’t right for humans after the age of about four years old. After weaning, we don’t have the digestive enzymes or the biochemistry to handle it; our bodies don’t need it any more. Think of it this way: a new-born baby is actually an unfinished fetus; milk is its finishing-food. After weaning, fetus-food consumption creates problems: obesity, cancer, heart disease, colitis, allergies and acne. Good food Think of a blank food pyramid. Down at the bottom layer, instead of all the breads, starches, pastas and breakfast cereals that the authorities want us to consume, we have low-starch, raw plant food. Following it is quite easy—one big salad every day, using all the usual ingredients we think of as salad vegetables. Next layer up we have low-starch vegetables. These are the usual vegetables with the exception of the potato. We should also go easy on sweet potato, carrots and peas. Next layer up we have low glycaemic fruits. Fruits in our ancestral homeland were much less sugary than most of the fruits we have today, and so we have to navigate that. However, most berries (strawberries, blueberries, raspberries) are low glycaemic and conforming. They are also micronutrient powerhouses. We should go easy on sugary fruits such as pineapple, mango, melons, and so on. Next layer up we have good proteins. All tree nuts are OK; all seafood is fine, particularly the oily fish; omega-3 rich eggs are fine—but the most conforming eggs come from hens that have been scratching around a farmyard. Most poultry is fine: wild game such as pheasant and grouse, also duck, goose, and turkey. Do avoid battery chickens—their fatty acid profile is terrible. Exotic meats such as venison, goat, crocodile, ostrich, and caribou are good. Most animal matter is acceptable, so long as it isn’t beef, lamb or, especially, pork. These red meats, as farmed,

One big salad a day provides the foundation of a low-starch diet 22

have high saturated fats such as palmitic acid and myristic acid. These fats were rare in our ancestral homeland and our bodies never learned to deal with them. Result: disrupted biochemistry, cardiovascular disease, cancers and more. At the peak of the pyramid we have the good fatty acid profile. Basically balance the omega see-saw and avoid palmitic and myristic acids. What about celebrations? Even foragers had times of plenty when there would be a gathering of the clans and over-indulgence. A healthy body can tolerate the occasional overindulgence, but do save it for a special occasion like a birthday or Christmas. When we think of our evolutionary history, humans spent 365 days a year naked under a tropical sun. If that was the case for millions of years, we can be sure that our bodies came to depend on it. Yet now, because of a totally misplaced fear of melanoma, Westerners are suffering from chronic sunshine deficiency. Sunshine starvation is a factor in obesity, osteoporosis, dementia, depression, MS, diabetes, and many more. It is a factor in cancer including, ironically, melanoma. A good suntan looks right, even attractive. It’s our brain detecting healthy sunshine nutrition. Just avoid burning. Our ancestral women walked three to four miles a day, carrying loads, often with a toddler on their backs. The men walked and ran sometimes eight-plus miles a day. If this was the physical activity for eons, we can be sure our bodies came to depend on it. Without it, things start to go wrong: obesity, diabetes, heart disease and many more. So our Pleistocene ancestors were physically fit. Even to our eyes today, physical fitness looks right, even beautiful. Our brains are recognising fitness for purpose. But the physical activity doesn’t have to be intense. One study finds that regular golfers on average live five years longer than non-golfers. But apart from sports and recreation, think about other changes—such as working at the computer standing up. The mismatch between our savanna-bred mentality and the way of life today triggers stresses several times a day that were designed only to be invoked a few times a year. Huge, frequent spikes in stress hormones such as norepinephrine, adrenaline and cortisol are a factor in so many diseases. In particular, cortisol lays down fat, increases appetite and sugar cravings, and depresses satiety. Adjustments It is within our power to adjust some of our life choices to be more in harmony with our ancestors’ savanna lifestyle. Small changes can be highly effective. Foragers wake up slowly with the dawn. In keeping with that pattern, we can try a sunrise simulator to wake up instead of a stressful alarm clock. We have to accept some changes might not be in tune with the times. Foragers worked for themselves; they were in control of their livelihoods. Having to hustle for a job, not being in control of your livelihood, being an employee, is unnatural and stressful. Alternatives to this economic development that engulfs most of our livelihoods are to be found now that you are aware what to look out for. For optimum health and image-appeal, we have to go back to our roots and align the way we live today with the way nature intended. No one can do it for us. We have to take control. Geoff James Bond MS, MICE, MITI, MIL, is an evolutionary lifestyle anthropologist and author of Deadly Harvest: The Intimate Relationship Between Our Health and Our Food W: geoffbond.com body language www.bodylanguage.net

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forum

Competence vs qualifications

Should a general practitioner with a special interest in aesthetic medicine be allowed to perform complex surgical procedures like liposuction? A panel of mixed disciplines discuss the issue

Mr Dai Davies consultant plastic surgeon, London We have seen a few cases in the news about patients who have died following liposuction procedures—one, in particular, was carried out by a GP. The establishment’s response was to improve the training for people undertaking cosmetic surgery procedures. An interface specialty group was set up comprising plastic surgeons, ENT surgeons, eye surgeons, oncoplastic breast surgeons and dermatologists—but not GPs. This is funded directly by the Department of Health. Participants are given three months’ training in cosmetic surgery. I am concerned for the patients. They should understand what is going to be done to them by whom. After I had finished surgery recently, a surgeon arrived to take over the theatre. It transpired that he was, in fact, a GP carrying out high definition Vaser liposuction. He hadn’t organised an anaesthetist so mine took over. He spent five hours performing this liposuction and took seven litres of fat away from the patient. In my book, this is dangerous. America has seen deaths resulting from liposuction, usually during office procedures where large volumes of fat are removed. 24

Dr Rupert Gabriel GP, WIltshire I work as a GP with a surgical interest, or GPSI. I carry out procedures such as carpal tunnel surgery, vasectomies and removal of skin cancers. There has been a frame shift out of the hospitals into appropriate general practice. But my procedures are carried out in an operating theatre with all the appropriate facilities and is appropriately staffed. I do not perform treatments under general anaesthetic or sedation. Some consultant hand surgeons accepted that GPs can perform carpal tunnel surgery; others did not. But times are changing. Techniques are more refined. Some of these treatments can be appropriately carried within a general practice setting. Over the past decade, the quality and standard of our audit figures and outcomes have even exceeded what our hospital-based colleagues can achieve. The example you mentioned is particularly extreme—seven litres of fat under anaesthetic is not what I or many of my other GP aesthetic physician colleagues do. We’re doing a very limited, safe, well-researched procedure backed up by scientific evidence with good outcomes in addition body language www.bodylanguage.net

forum

to our other non-surgical treatments. But I will refer, if necessary, to our surgical colleagues. If I see an uncomplicated carpal tunnel syndrome, I will operate. If I see an elderly patient with recurrent disease and problems, I refer to my hand surgeon. It’s a matter of degree. Mr Dai Davies Mr Al-Ayoubi, as an ENT surgeon, where does the ENT spectrum fit into this? I understand you carry out breast uplifts— this is a bit of a stray from ENT?

Mr Ayham Al-Ayoubi ENT and facial plastic surgeon, London Whatever our surgical or medical background, we start out doing what we were trained to do. I trained in ENT through an intensive programme at the Royal College of Surgeons of England. Halfway through this, I started to do facial plastic surgery. I have always had an interest in lasers, so from lasers for middle ear surgery and throat cancer, I moved to SmartLipo. The technology is laser lipolysis. I treated more than 500 patients in two years on the chin and small areas with good results. I moved on to larger areas, and then laser-assisted liposuction. I tighten the skin, laser the fat and suck it out. But I never went beyond two litres of fat in one session. During this period, laser technology evolved from small machines with limited energy to those that give much more energy. Radiofrequency evolved and BodyTite came on the scene and now what we are doing is proper liposuction. Who should do this procedure? An ENT surgeon who has never performed traditional liposuction after adequate training? There is no training available from a proper academic establishment. This is a very grey area. Training is the crucial point. It’s not about qualifications. The cosmetic surgery industry is evolving haphazardly. It is not structured.

Professor Marco Gasparotti consultant plastic surgeon, Italy I know general practitioners, ENT surgeons and gynaecologists—ophthalmologists are doing breast augmentation, dentists are doing rhinoplasty and facial procedures. Each of us should stick to his own profession. If the law allows surgeons to do everything except radiology and anaesthesiology, we cannot stop this. I would suggest focusing on the right teachers for cosmetic surgery training courses; otherwise, we will have confusion in the field with bad results and bad publicity. Physicians need to be well trained and the procedures carried out using good technology, an anaesthesiologist and good safety. body language www.bodylanguage.net

Mr Bryan Mayou consultant plastic surgeon, London We [consultant plastic surgeons] have had huge, lengthy training. We had exams, and accompanying senior practitioners every day taught us so much. It was a successful way of doing things. Training is much shorter now. We tend to think it will be evident to patients that trained practitioners are going to be better than those who are not. Nowadays, if you have the right website, you will get the patients, no matter what your qualifications are. Patients aren’t discriminating enough, so we still have to show that we do things better. As for GPs carrying out procedures, they must have appropriate training. They have to know the field they’re operating in. They need to have colleagues around to consult with. They need to have good anaesthetists, a proper hospital and all the accoutrements of surgery. A GP cosmetic surgeon is unlikely to have all of that. I’m sure there are extremely gifted GP surgeons who have not had any surgical training other than minimal training for that particular technique. While I’m sure they’re very good at what they do, they will be few and far between. It will be harder for them to have high standards and they’re not going to know their limits. Dr Gabriel says that he knows his limits and when to refer, but in practice many don’t. Mr Dai Davies As a GP, do you pay excess on your medical defence union? Dr Rupert Gabriel I have a separate insurance with another company. I’d like to point out that if insurers were having huge lawsuits for every procedure we did, they’d quickly increase policy costs to beyond our reach or to refuse to insure altogether. They research procedures that they cover. If you look at the way they look at the market, it shows there are a reasonable number of non-surgical operators doing procedures in a safe and reliable manner. Mr Bryan Mayou But over the years, we’ve seen disaster after disaster from the same surgeons. Somehow they’re very thick-skinned and keep going. Dr Rupert Gabriel Patient selection is critical. The patients you would select to treat, I would select to refer. In terms of results, do you look forward to seeing your reviews or do you dread them? If you look forward to your reviews because you can confidently expect good results in the vast majority, then that is a telling thing. Mr Dai Davies We’re all registered with the GMC but anyone in this country can call themselves anything they like. There is no attachment to the words “cosmetic, surgeon or plastic surgeon”. 25

forum

Mr Al-Ayoubi: “Training is the crucial point. It’s not about qualifications.”

nique—bipolar has a very high risk of secondary bleeding. Now, there are hundreds of ENT surgery consultants in the UK who carry out only bipolar tonsillectomies. They have a very low rate of secondary bleeding. Their argument is, “I am doing a good job, why should I suddenly change to laser tonsillectomy with all the problems of lasers?” Cosmetic GPs entering this field, ENT surgeons like myself, ophthalmologists and gynaecologists are not doing traditional liposuction. At my own clinic, we have three operating theatres with all the facilities for treatments from Botox injections to aesthetic plastic surgery. A plastic surgeon has done hundreds of traditional liposuction procedures. Why should he bother about sticking a laser under the skin or using a radiofrequency machine? In America, many plastic surgeons are doing laser-assisted liposuction. While they all trained as plastic surgeons, they took it one step further and embraced the technology. Mr Dai Davies What about the responsibility of the companies selling their machines through high-powered marketing?

Mr Hugh Henderson, plastic surgeon, commenting from the floor Unless plastic surgeons or the group involved in regulation are willing to forgo a significant portion of their income to get regulation, we won’t have it and the system will remain chaotic. There are too many people who see an easy way of making a quick buck. The problem is ignorance. Practitioners don’t know what they don’t know and therein lies the danger. Even after reasonable training, practitioners continue to make mistakes. They are cavalier. The best practitioners to perform an operation are those who are humble and know you can make mistakes. They are willing to discuss it beforehand and are prepared to see patients more than once. I’m a great believer in two consultations. From just one consultation, the practitioner gives the patient the impression the procedure is easy and there is not much to discuss. The patient will then go away thinking: “It must be a very simple operation or I would need to talk more about it.” There are many intrinsic dangers, not only in surgery but also in the preparation, the consultation process. This is totally unregulated. Mr Bassim Matti, plastic surgeon consultant, commenting from the floor As a doctor, you have to be ethical. If you are just doing the job for the sake of money, you will fail. If you are training and you know you won’t help the patients, you will have a problem with yourself because you have a conscience. If you don’t have a conscience, then it’s up to you and your abilities. Mr Ayham Al-Ayoubi We need to look at the wider picture. As a surgeon—with no exception in any surgical field—you go through your training and then reach a turning point. You gain experience in whatever you are doing, whether you are a gynaecologist, ENT surgeon, maxillary facial surgeon, and you adopt the necessary skills. Take, for example, a tonsillectomy. I have done thousands of traditional tonsillectomies. You then start to do bipolar, followed by laser tonsillectomy. Is one way any better than another? A huge audit was carried out through the Royal College of Surgeons of England and the British Association of Otolaryngologists, which concluded that the best and safest tonsillectomy method for our ENT patients is the classic dissection tech26

Mr Bryan Mayou We supply machines to surgeons and qualified practitioners. When we brought SmartLipo to the UK, we marketed the machine, showing that all it would do is take small areas of spot fat away that diet and exercise could not. Now, doctors are adventurous by nature and many wanted to turn themselves into plastic surgeons overnight. I can’t do anything about that, but the marketing we did for the machine was fair, honest and we, as a company, never deviated. Dr Rupert Gabriel I have run minor surgery courses for GPs at Bath University for over a decade. We go through all the techniques. We practice on models and observe technique but I say to them at the end, “This doesn’t qualify you to operate on someone. You need to do supervised cases, keep a log book and be signed off when you’re competent for each specific procedure.” Professor Marco Gasparotti In reality, patients come to me and ask, “Can I have a lunchtime liposuction?” What is a lunchtime liposuction? If you go on the internet or read magazines, lunchtime liposuction is a €1000 liposuction procedure done in the office in half an hour. This is the problem. If everybody advertised that liposuction is a lunchtime procedure at €1000 and they come to us and it’s €12,000, they will go for the former. This causes much confusion among patients and harms plastic surgery.

Mr Shailesh Vadodaria, consultant plastic surgeon, London There are four factors for anyone providing body sculpting procedures. First is to know the equipment we use, whether it is traditional suction lipolysis or a machine. Second is the aesthetic eye, beyond the science and medicine. The third is medical and body language www.bodylanguage.net

forum

surgical knowledge about performing the procedure, and last, how to identify and manage major complications such as fat embolism, intraperitoneal rupture and intrathoracic rupture. Mel Braham, chairman, Harley Medical Group, commenting from the floor In terms of people doing plastic surgery, a law was introduced in 2002 in the UK that says that unless you have been registered as a plastic surgeon, you’re not allowed to carry out cosmetic surgery. It’s obviously not being implemented. It comprises a report of the chief medical officer. It clearly states that if you performed any plastic surgery before 2002, you will be grandfathered. You have to be registered with the CQC [Care Quality Commission], maintain expertise and continue within your level of competence. It also clearly states that there are around 65 GPs who were performing cosmetic surgery before that date who will be allowed to continue. Audience comment We have liposuction as performed by plastic surgeons and liposuction as performed by Dr Gabriel. I think they’re different. Dr Jeffrey Klein, a dermatologist, popularised microcannular liposuction at a time when plastic surgeons were performing under general anaesthetic without any tumescence. He revolutionised liposuction in the United States, moving it from hospitals to an office setting. He is one of the great exponents of the type of liposuction that Dr Gabriel is doing. As far as I’m aware, there have been no deaths from small cannula liposuction performed under local anaesthetic. It’s a very safe procedure involving small amounts of fat—localised deposits which will not shift with exercise or diet.

poor patient selection leading to poor results, which are probably more relevant. Mr Taimur Shoaib, plastic surgeon, from the floor It was reported in the media recently that someone was sent to prison in the US following an office-based death after liposuction. Consensus of opinion was that lidocaine toxicity caused the death. Mr Dai Davies If there is to be any control in the industry, it’s got to be by law and the government have to take it seriously. Otherwise these instances will just increase. Mr Hugh Henderson, plastic surgeon, from the floor Until there is regulation, we won’t get anywhere. Now we also have a total deregulation of lasers which, to me, is an indication at government level that they don’t give a damn.

Mr Dai Davies A study was carried out by the American Society of Plastic Surgery about the major mortality and morbidity for liposuction. The commonest causes of death were fat embolism, intraperitoneal/intrathoracic internal injury and infection while the cannulas were being restabilised and they were not being disposed of. These occurrences were in small clinics.

Audience comment We are behind in the UK. Since June 2011 in France, it is forbidden for any doctor or surgeon to perform traditional laser lipolysis or cryolipo, or any technique that involves fracturing the fat. The media took the approach that liposuction is bad surgery, that it’s catastrophic—instead, we should do this magical daytime or lunch hour procedure. This has officially died in France and is dying in the UK. But appropriate indication and patient selection are important. We must all have an ethical approach to our patients. The government has found there is no point in regulating laser hair removal or vascular lasers. But only proper establishments are registered with the Care Quality Commission. So we’ll soon see that the traditional liposuction is coming back into favour. On the other hand, many forms of technology-assisted liposuctions are taking place. But we’re going through great upheaval with revalidation and appraisal. Structures are now in place where concerns can be brought forward. The debate should not be so much about operating outside your sphere of expertise but about being competent as a surgeon.

Audience comment We’re forgetting one very basic thing: why are the patients coming to us? They’re coming for an aesthetic result. While death is obviously the extreme, much can go wrong, including loose skin irregularity. There is often a lack of technical competence and

Mr Dai Davies It comes back to the level of expertise that you can give to your patient. I’m quite happy to say that if you are doing hundreds of Vaser liposuctions, you will be better at it than me because I don’t do any. Liposuction as performed by plastic surgeons and liposuction as performed by GPs are different

body language www.bodylanguage.net

research Dr Soren Denim

Oxidative stress

he theory of oxidative Soren Demin describes the role of oxidative Measurement stress has been around stress in the ageing process and methods of So how can we measure oxidasince the 1960s. If the tive stress? We can measure almeasurement body suffers a trauma dehyde in the breath. But this reaction, we see the cause and isn’t very reliable as many diseffect of damage, involving free radicals and antioxidants. eases affect aldehyde, not just oxidative stress. There is a BioPhoOxidative stress is cumulative. It is not reparable damage tonics machine which measures oxidative stress within the body and it ages you. Damage is caused to the DNA, shortening the and creates an easy to understand reaction. But the machine is chromosomes. Cellular damage leads to the next set of DNA expensive. when your cells replicate. In terms of visual evidence, we have I was employed by the University of Cambridge to devise a the oxidative phenomenon—if we cut an apple in half, it will go method of monitoring oxidative stress within the body over long brown. This is oxidation. periods of time. We created a device which works similarly to a diabetes monitor. Through a pinprick of blood, it provides levCauses els of reactive oxygen species. It measures superoxide dismutase Environmental factors, such as lifestyle, stress and environmen- (SOD) in plasma. Results are instant. tal conditions, cause oxidative stress, followed by accumulation If you take a blood sample and ship it to the lab, results will of lipids, damage and reactive oxygen species. Hypoxia is a large show higher peroxidase and oxidation because the plasma has contributing factor, as well as radiation, cold, trauma, surgery, been oxidating in a natural environment. Results of this device chemicals (including pollution) and biological gradients that oc- are equal to a lab machine. cur in the body. While oxidative stress fights immune reactions, We sent the device out to 2000 people across the UK in difwe need balance between the two. ferent ethnic populations and looked at lifestyle factors such as It begins with the stimulus, followed by the reactive oxida- diet. We noticed that removing something from the diet comtive species imbalance. Free radicals form the reaction to oxi- pletely is more damaging than changing the levels of intake. It dative species versus antioxidants that occur in the body. They significantly increases the number of free radicals. combat each other. Natural glutathione fights oxidative species. But when we started supplementing the diet, we saw a reducWhen the oxidative species goes up, we get prophylactic genes, tion in free radicals. We tested introducing supplements individcytokines, chemokines followed by chronic inflammation and ually and grouping them, we looked at synergies, compatibilities damage, and cellular-associated diseases. and delivery methods, and tried to optimise the best compounds These diseases can range from Alzheimer’s to diabetes, and for the body. It is important to have a good balance of micronuincludes skin ageing. trients within the body. In normal cellular responses, the cell wall or membrane is attacked by oxidative stress. When proteins are attacked, creating Outcomes oxidative stress, they are oxidised. They then become damaged We looked at genetic maps and consequent levels of oxidated and cannot do their jobs. stress and antioxidants. We saw upregulation and downregulaThere have been studies into apoptosis, or cell death. It in- tion of genes. We put 3466 genes on an oxidated stress map— volves cytokines, kinase and P66. Others include autophagy and most of those involved in creating reactive oxygen species were capsaicin inhibition, particularly with calorie restricted diets. downregulated, while most enzymes were upregulated. HowThere are a number of studies looking into senescence. It in- ever, their immunity wasn’t impaired. volves telomere shortening, which is often caused by oxidative We also carried out an animal model study involving worms. stress damage within the body. We fed them supplements versus none and measured their Many different processes result from oxidative stress. We lifespan. Those we supplemented lived longer. We reduced the have glutathione oxidative reduction, AAB and EPH reaction, levels of oxidative stress within their body by supplementing which help balance the oxidative stress within the body. We can their diet with micronutrients, making them live longer. measure some of these by electron paramagnetic resonance. In our study, we also noticed that oxidative stress rises durWe get accumulation of damage with age, which we measure ing exercise. We discovered that when you start causing muscle with oxidative lipid reactions. We see how a cell is oxidised and damage, you cause your oxidated stress levels to rise. However, the amount of oxidation that occurs. Lipid oxidisation can be these wear off over time as the body adapts to reducing the stress used to monitor the number of free radicals in the body over a levels. time period. But this is difficult with the ageing process, as we’re Once diet is improved, there is a significant reduction in free looking backwards through time. radicals. It is also important to note that micronutrients act over We can look at the effects of antioxidants and ageing. Studies a period of time. You need to keep feeding the body over a six using animal models show that if you increase the amount of month period. If you look at patients with anaemia, for example, mitochondria and knock out P66 genes, we discover the mice they should be given iron over a three or four month period. It is live longer. then possible for them to retain stores. We produce some antioxidants within the body while some we intake through our diet, such as vitamin E, vitamin C and Soren Demin is a biotechnology researcher who works at the Harley selenium. Street Skin Clinic

body language www.bodylanguage.net

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power

The skin is constantly under attack from molecules known as free radicals. Potent antioxidants with distinct mechanisms can join forces in multi-component regimens to help the skin fight back, write Barbara A Green RPh MS and Ronni Weinkauf Ph

ree-radical formation occurs continuously in cells as lar and widely available, they are not especially potent scavengers a result of normal essential metabolic processes and of free radicals. The ability of a compound to quench peroxyl exposure to external sources, such as ultraviolet (UV) free radicals can be reliably measured using hydrogen atom radiation, environmental pollutants and industrial transfer (HAT) assays, such as the oxygen radical absorbance chemicals. These free radicals are unstable and highly capacity (ORAC) assay. reactive molecules that attack other molecules in an attempt to Grape seeds are rich in polyphenolic components that have achieve stability. a variety of beneficial properties, including free-radical scavengCell membranes, DNA, and RNA are all highly susceptible ing and inhibition of lipid peroxidation and elastase. Using the to such attack. Free radicals have been implicated in several dis- ORAC assay, a chardonnay grape seed extract with anti-ageing, eases, and cell damage by free radicals is believed to be a leading skin firming, and astringent properties was found 85% more efcause of the dermatologic changes associated with ageing. fective than vitamin E in scavenging free radicals and 36% more Antioxidants prevent, slow, or halt the oxidation of com- effective than vitamin C. pounds at any stage, and the benefits of antioxidants in diet Besides its popularity as an ornamental plant, the lilac has are widely known. Topical application of antioxidants has been been known throughout history for its medicinal properties. shown to be beneficial in protecting the skin from damage Leaves and fruit from lilac plants have long been used to control caused by free radicals, and antioxidants are included in some sunscreens to neutralise the generation of UV-induced free radicals. There is a growing body of clinical data to support the role of antioxidants in anti-ageing therapy. There are many naturally occurring mechanisms for protection against oxidative damage. These include quenching of singlet oxygen, superoxide anion, peroxynitrite, hydroxyl, and peroxyl free radicals; protection of DNA; chelation of metals; reduction of UV-induced peroxide and nitric oxide formation and lipid peroxidation; and reduction of elastin breakdown. The most well-known free radical scavengers are vitamins C and E, and these agents are commonly used in topical skin care products. Pure vitamin C, however, is highly unstableâ&#x20AC;&#x201D;it is sensitive to oxidation and gives finished formulas a yellowish tint. Tetrahexyldecyl ascorbate is a stable, oil-soluble form of vitamin C. When applied topically, tetrahexyldecyl ascorbate exhibits excellent penetration in keratinocytes, and dose-dependent protection from UV-induced damage has been observed in human fibroblasts treated with tetrahexyldecyl ascorbate. Naturally occurring mechanisms for protection against oxidative damage Although vitamins C and E are popu30

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skin Barbara A Green

Metal chelation and gene inhibition Metals such as iron appear to contribute to skin photodamage through participation in oxygen free-radical production. Initial work in animal models found that topical application of an iron-chelating (or trapping) agent can protect the skin from photodamage. Besides inhibiting lipid peroxidation, maltobionic acid traps oxidation-promoting metals, making it a valuable component of antiWeek 0 Week 16 ageing therapy. The polyhydroxy acid, gluconolacWeek 0 Week 8 tone, is also a metal chelating agent, but it has an additional characteristic that is beneficial in anti-ageing therapy. Chronic photoageing results in solar elastosis—the substantial accumulation of elastotic material in the upper and middle dermis. It has been demonstrated that UV radiation can activate the human elastin promoter gene, which facilitates enhanced elastin biosynthesis and contributes to the clinical and morphologic changes seen in ageing skin. Free-radical species appear to mediate this process. In a transgenic photoageing model, free-radical generation reNoticeable improvement in facial photodamage following daily application of a high-potency, multi-mechanism skin care regimen containing antioxidants. Farris PK, Brouda I, Edison BL, sulted in a greater than six-fold increase in Weinkauf RL, Green BA. “A new high-potency, multi-mechanism skincare regimen for photo- elastin promoter gene activity. damaged skin: results from a vehicle-controlled clinical trial,” Poster PO312, 20th Congress of the Gluconolactone inhibits elastin proEuropean Academy of Dermatology and Venereology, 20–24 October 2011, Lisbon moter gene activity via an antioxidant fever, disease, and skin disorders. These benefits may be related, effect. In an in vitro study, a 7.5% gluconolactone preparation in part, to the plant’s ability to protect against free radicals. A inhibited the UV-induced increase in elastin promoter gene aclilac cell culture extract containing verbascoside—a potent tivity in fibroblasts by 50% (P<.001). quencher of several free radical species—has been found to be The effects of a high-potency, multi-mechanism skin care highly effective in humans as a cell protectant, with potential regimen containing antioxidant ingredients on photodamaged for topical skin care applications, including anti-ageing therapy. skin were presented at the 20th Congress of the European AcadGreen tea extract has become popular as an additive to skin emy of Dermatology and Venereology in October in Lisbon. care products. The beneficial effects of green tea extract derive The regimen was evaluated in a double-blind, vehicle-controlled predominantly from its polyphenol component, epigallocate- clinical trial involving 69 women aged 45–65 years with mildchin-3-gallate (EGCG), which has been found to have antioxi- to-moderate facial photodamage (4–7 on a 0–9 grading scale dant, immunomodulatory, photoprotective, antiangiogenic, and for fine lines and coarse wrinkles in the eye area, and mottled anti-inflammatory properties. Several studies have shown that pigmentation on the face). purified EGCG can act as an antioxidant by trapping peroxyl The group of women who applied the multi-mechanism regiradicals and inhibiting lipid peroxidation. men daily began to show improvement in ageing parameters Exposing the skin to UV radiation induces infiltration into as early as week two compared with women using the vehicle the dermal tissue by leukocytes (macrophages and neutrophils); alone. By week 12, women using the multi-mechanism regimen once activated, neutrophils accumulate in tissues and release showed significant improvement (P<.05) in all ageing paramtoxic oxygen metabolites. Along with trapping peroxyl radicals eters assessed. and inhibiting lipid peroxidation, a high-purity EGCG preparaSkin ageing is a multifaceted biological process that cannot tion, applied topically before UV exposure, has been shown to be fully addressed by any single skin care ingredient. New highreduce leukocyte infiltration into the skin and protect against potency skin care regimens, combining multiple mechanisms UV-induced tissue damage. Several studies have found that both that have been proven to be beneficial, deliver advanced comgreen and black tea—and EGCG, in particular—help protect prehensive anti-ageing benefits to skin through the synergistic DNA from damage caused by UV exposure. effects of the individual components. Maltobionic acid has been shown to prevent peroxidation of Today, given the diverse range of antioxidant mechanisms lipids and, as a result, it is believed to prevent damage to cell that can help protect against the effects of ageing on the skin, membranes and mitochondria in dermal tissue. Malondialde- application of an appropriate complex of ingredients that offer hyde is an oxidative degradation end product produced by UV- distinct antioxidant mechanisms should be a central component induced lipid peroxidation. of skin care. In a study presented at the American Academy of Dermatology’s 2010 summer academy meeting, maltobionic acid was Barbara A Green, RPh, MS, is vice president of clinical affairs and shown to reduce the production of malondialdehyde in skin cells Ronni Weinkauf PhD is vice president of R&D at NeoStrata Comthat have been exposed to UV radiation. pany, Inc in Princeton, New Jersey body language www.bodylanguage.net

devices

On the right wavelength Body contouring can truly help patients achieve the figures they want, but hype and false statement are common and simply confound the patient, writes Mr Christopher Inglefield

osmetic surgery procedures have continued to increase, but nowhere as near as much as the non-surgical variety. According to one source, these have multiplied by nearly 800 per cent since 1997. Clearly, patients want non-invasive procedures, and non-invasive liposuction is attractive to patients because they do not want the risks, scars and general complications of surgery. It doesn’t matter whether I say I am the best liposuction surgeon in the world. Most patients don’t want me to stick cannulas into them. Why don’t they want surgery? Because everything they consider that’s invasive involves an anaesthetic, has risk, creates scars, causes down-time, and there’s the stigma of surgery. What patients want from us is a treat32

ment that’s safe, effective, comfortable, doesn’t induce suffering, doesn’t require numerous repeat visits, and has virtually no down-time—because we’re all living in a busy world. They can’t afford three to six weeks of downtime, and they want long-lasting treatments with few maintenance procedures. Terminology A problem patients have is confusing terminology, particularly non-invasive liposuction and non-invasive fat reduction. Do a search on the web for non-invasive liposuction and both terms feature interchangeably. The following is quoted from a popular website. “Vaser liposuction, the latest fat removal technology, is a minimally invasive procedure under local anaesthetic.

It is less invasive than traditional liposuction. There is no hospital stay. Vaser lipo is a walk-in walkout procedure with minimal downtime. You will be able to leave our clinic straightaway after your vaser liposuction procedure.” But this and other so-called “noninvasive” liposuction is still surgery. It might be minimally invasive, but it is surgery and we need to be very clear about that. We have injections, lipotherapy, laser, lipolaser, lipolights, radio frequency— there is much confusion. There is much collective deception for marketing purposes that does the industry no good. If we want to be treated with respect and with high esteem within the medical profession, not just the cosmetic industry, we need to raise our game. body language www.bodylanguage.net

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Key technologies Water-assisted, ultrasound-assisted, laserassisted and radio-assisted frequency liposuction are key technologies that use different energy sources. The Body Jet is using pulsed water; Vaser is using sound for cavitation, Smart Lipo is using laser

light for a thermal result, and radio frequency (RF) is devised for a thermal result. Selectivity is important because it impacts on possible side-effects. RF has been called “very selective”, but yet patients present with paraesthesia in the treated area for three weeks. If it is highly selective, why is paraesthesia caused? With Body Jet and RF you have the advantage that the fat removal is done in a synchronous manner, whereas with Vaser and Smart Lipo you have to do the treatment and then suck the fat out. The fiction is that surgery is about invasion or it involves pain, that there is always bruising, that it requires a hospital stay and that there is always a recovery. There is nothing marketed as noninvasive that you can say is truly not invasive. Pain should be minimal for 99% of the patient procedures that we do. It should be well controlled, but we should not be talking about something that is better because it causes no pain. There should be minimal bruising for all our patients because we should be good at performing the procedures and we should not be getting much bruising. About 99% of the procedures I do now are day cases. When I started in plastic surgery, patients in the NHS for abdominoplasty were in bed for five days. They were ill for five days occupying a hospital bed. I haven’t had an abdominoplasty patient stay overnight in hospital for the last seven years. These patients just do not stay in a hospital. Patients having a procedure lasting longer than four hours must stay in hospital overnight.

All of these procedures have a recovery period from weeks to months. They are not “a lunch hour procedure” after which patients can go back to work and be fine. Most of the body contouring procedures have recovery periods. Patients expect the highest standard of care from us. The techniques we incorporate must meet those standards. As practitioners we must ensure that when patients ask us to use a Body Jet system that it can do what we want to get the results. Minimally invasive devices must demonstrate the same safety and efficacy as surgery. Beyond that, they have to achieve much more than non-invasive procedures, because if you have a truly non-invasive procedure that really has no down-time, then your minimally invasive procedure must be pushing the boundaries to be better than that, not worse. You have a duty of care to stick to the facts and not deceive your patients into saying we offer the latest non-invasive techniques when what you are doing is an updated version of liposuction. Avoid the fiction please; it does not do us any good. As effective as some of these non-invasive techniques can be, the most successful form of body sculpting is carried out five times a week for a mere 30 minutes and it is a unique combination of therapy. We like this idea of combining therapies. It is exercise and a healthy diet. Mr. Christopher Inglefield BSc, MBBS, FRCS (Plast) is a plastic surgeon who practises at London Bridge Plastic Surgery & Aesthetic Clinic, 54 Wimpole Street, London W1. W: lbps.co.uk

Ultrashape How effective is variable depth focus ultrasound for body reshaping? Mr Christopher Inglefield reports

on-focused ultrasound produces a result by thermally increasing the temperature in the tissue. Focused ultrasound can produce an injury to the cells or to a target tissue without any temperature increase. This is not to be confused with thermal imaging. It is a sound—a pressure effect. Fat cells can withstand compression because they have evolved to do just that. What they cannot stand is a sudden release of that pressure, and when they rapidly expand it fractures the cell membrane. This is how cavitation works—a completely mechanical effect with absolutely no thermal body language www.bodylanguage.net

injury. UltraShape has a focused pressure. The new UltraShape device has a variable depth focus so that you have a larger area of pressure induction. So there’s no fibrosis because it’s cavitation. It does allow multiple treatments at early time intervals. If you perform a treatment and you have a recovery time, you cannot retreat that area until it has recovered. If it takes three months to recover, you cannot retreat that patient within three months. UltraShape is selective, permanently destroys fat cells, and is clinically proven. No other non-invasive technology has 33

DR WENDY TINK

MR CHRISTOPHER INGLEFIELD

devices

A reduction of 5cm in the abdomen with no weight change after three treatments. The after photo was taken four weeks later

DR ARIE BENCHETRIT

DR MORENO-MORAGA

Before and after three treatments of the lower abdomen concluded in a 6.5cm reduction and a patient who was delighted with the results

A reduction of 4.7cm on the upper abdomen and 5.4cm on the lower abdomen four weeks after three treatments. Weight changed by –2.2kg

as much peer-reviewed data as this UltraShape device. It is undergoing FDA approval, is in use in over 50 countries, and more than 250,000 treatments have been done worldwide. The safety profile is unbeatable—there have been no serious adverse events with this device. The protocol is typically three treatments because most patients treat their love handles, their abdomen and take off 6–8cm of fat. There is no anaesthetic

A reduction of 5cm in the lateral thighs after use of the Ultrashape. Altogether, three treatments were performed

required, nothing topical and no downtime. It’s a comfortable treatment. There’s no pain associated with this treatment. Patients will feel a vibration sense, but it’s not painful. There’s a reduction in localised fat within two weeks. I’ve used it on the abdomen, flanks, thighs, I’ve used it on the arms, I’ve used it on the male chest, I’ve used it on inner thighs, I’ve used it on the knees, I’ve used it on the legs, because it’s

so adaptable. UltraShape is a computercontrolled system that helps to ensure the target area is adequately treated uniformly. You don’t get lumps and bumps, which are the downsides of any kind of liposuction-type technique. The Ultrashape has an RF device that integrates with the unit to help, in pre- and post-treatment, to improve the outcomes by enhancing the skin tightening effect.

EndyMed Pro Multisource radio frequency has proven to be a useful technology for skin treatments, says Mr Christopher Inglefield

became involved with skin tightening when non-invasive alternatives to facelifting escalated. Many patients had sagging skin from ageing but didn’t want surgery. CO2 lasers could produce great results but at the cost of extensive down-time. Radio frequency (RF) is one solution. This is an electromagnetic radiation that uses the energy from that wavelength to impact on the target. Certain body tissues have a higher resistance to the transmission of this energy wave; therefore, the higher the resistance, the more heat build-up occurs. The tissues that allow rapid transition 34

of this wave form will increase little in temperature. It’s not a difficult concept. During any procedure we have the RF energy flowing through the skin and then being held up like a traffic jam in certain areas. The collagen fibres, fortunately, transmit RF very slowly, causing a build-up of energy and, therefore, heat generation. This has an immediate impact on the collagen, producing tightening, but also activating within the tissue a wound healing response, because of the heat generation, Whatever your medical background, you’ve seen from wound healing the immediate collagen contraction, the inflambody language www.bodylanguage.net

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e m b r a c e

l i f e

I VIDER MD

devices

J ROYO DE LA TORRE

Before and six months after a course of six body contouring treatments

I VIDER MD

Before and after a course of six body contouring treatments

FIONA WRIGHT MD

Before and eight months after a course of six body contouring sessions

Facial tightening before and after a course of six treatments

matory response occurring within the first three days, tissue proliferation, and maturation and remodelling of the collagen. The two types of RF used frequently are monopolar and bipolar technologies; they work well but they do have limitations. This led to the development of multisource phase control RF. By using three

pairs of electrodes and six RF generators, heat within the target tissue can be more selectively deposited, which is in the dermal collagen. This also enables us get into some deeper, subdermal collagen septae. One advantage is that you have a controlled, focused and uniform heat deposition, which gives good clinical results. It is a clinically proven “hypodermal coagulation simulation”, which provides good volumetric heating. It is far superior to standard bipolar RF. The heat build-up is selectively within the collagen fibres because that is where the resistance is rather than in the fat. We see because of the stimulation of collagen there is an increase in collagen density, there is collagen remodelling, so you get a much more youthful or new collagen build-up within a treated area. A paper in 2011 (“A novel method for real-time skin impedance measurement during radiofrequency skin tightening treatments,” Yoram Harth, MD and Daniel Lischinsky, BSc. Journal of Cosmetic Dermatology, 2011, 10:24-29) observed 30 patients with facial wrinkles receiving three treatments. The patients improved progressively after each treatment. At three months 86.7% had good results or better (decrease of two or more grades in Fitzpatrick’s wrinkle scale). The increase is logical owing to an activation of the healing response and the build-up of collagen resulting in a gradual improvement. Circumference structure and cellulite improvement show some relative contraindications and it is important to understand what these are. But the abso-

lute contraindications are patients with immunosuppressive disease, who are on immunosuppressive medication or have immune system compromise, any implantable pacemakers or defibrillators, any known history of heart irregularity or arrhythmias. You need to be careful. Most patients will see a visible lift. When we first started this procedure we would always treat one side of the patient’s face and then get the patient to look in the mirror to see the difference. Many are not seeking a dramatic change, they just want improvement in skin laxity. The protocol that is used is a course of six treatments. Four treatments are carried out on a weekly interval; the second two treatments are carried out two to three weeks apart. We advise patients that it will be three months before they see the maximum effect as they get this collagen building up. In just over a year we have treated more than 200 patients, mostly face, neck, décolletage, as well as arms, abdomen, inner thighs, knees. It is quite versatile, it’s very easy to use, and patients like it. Patients, having finished their course of six treatments, come back and ask: “When can I book more treatments?” They are keen to maintain the treatments to continue improving their skin. The EndyMed Pro is a new multisource phase controlled RF device with a high degree of control. It has focused and uniform deep heating, multiple indications, is not limited to any particular body area, gives good patient comfort and safety with no down-time, no pain and the results are certainly predictable.

Zerona Dr Chantal Sciuto describes her experiences with a low level five-diode 635nm laser for body contouring

harmacodynamics involves the effects of drugs on a cell, which can be analogous, endogenous or exogenous and have a response after binding a specific cell. Zerona, a low level laser manufactured by Erchonia, works in the same way for body contouring. Band resistors stimulate the pathways to suppress cellulose pathology. This laser targets photoreceptors to stimulate these path-

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ways and pathological function. While drugs can metabolise and alter cells to interact with other targets, Zerona’s mechanism of action has no comparable adverse events. Zerona is a low level laser made of five 635nm laser diodes. Zerona emits nearly 45 billion photons per second, of which around 27 billion reach the subdermal tissue.

The adipocytes are responsible for the storage of lipids and their diameter can expand by more than 20 times for greater storage. Zerona has been shown to target the photoreceptor cytochrome c oxidase, a terminal enzyme positioned within the 37

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no loss of skin tone. The fatty debris enters the interstitial space, regulated by the lymphatic system. These hypertrophic adipocytes are linked to an elevation in serum low density lipoprotein and triglyceride. Reduced adipocyte cell volume restores a lean state modulating serum chemistry. In one placebo-controlled, randomised, double-blind study at four centres, 67 participants were treated every other day with the Zerona laser for two weeks, totalling six treatments. Each treatment comprised 20 minutes at the front and another 20 minutes on the back. Evaluation was baseline in the first week, the second week and a follow-up after two weeks. Compared with baseline the study endpoint levels revealed a significant decrease of -12.32 points (p<0.01). Participants demonstrated a statistically significant mean reduction in low-density lipoprotein levels of 12.05 points, a 13% reduction at study endpoint (p<0.005). HDL levels exhibited an average reduction of -0.895 points (p>0.05)—almost stationary. Following the modified Zerona procedure coupled with diet recommendations, patients revealed an overall reduction of -6.6 inches across the waist alone as well as all other categories. A 7.5cm reduction in two weeks was determined meaningful by FDA clinicians. At our clinic, we treated 48 patients; 36 women and 12 men aged 28–57. We focused treatment on the adipocytes and localised area. When treating patients with lasers, we never treat anyone who is pregnant, breast feeding, has a pacemaker or a BMI over 30. I don’t treat fickle patients, such

as those who want to see a result on the same day. Before treatment, I take photographs of the front, back, both sides and the circumference measurements, depending on the area to treat. Men and women require different areas of treatment. I was particularly interested in the triceps and treated two patients with this machine with good results. The protocol is 20 minutes on the front and 20 minutes on the back. Over the last two months, for some patients I have used an intensive protocol of every day except Sundays—ten treatments over two weeks. It is important to give patients information about daily dietary supplements, topical therapy and physical activity. After treatment, we carried out a follow-up 15 or 30 days after the last treatment. We took photos and circumference measurements. Following treatment, the clinical study showed a reduction of 103–91 in the LDL level. According to FDA guidelines, a change from start to end during a clinical study is considered relevant if it is 15% or more. There was a reduction in HDL cholesterol. Visual results also showed a reduction in cellulite retention and improvement in tone. This laser involves minimal pain, invasion or inflammation. It involves no surgery or skin damage, no recovery time and no significant side effects have been reported. Dr Chantal Sciuto is a clinical professor in aesthetic medicine at the International School of Aesthetic Medicine, Fatebenefratelli Hospital, Rome. She also runs her own aesthetic medicine and dermatology clinic

The total loss in average for the patients was 9.1cm in the wiast, hips, and thighs. FDA clinicians described a 7.5cm reduction in two weeks as meaningful. Zerona was FDA-cleared in 2010 for the reduction of subcutaneous fat mass of the waist, hips, and thighs as determined via circumferential reduction

cell mitochondria. Stimulation of this receptor induces a transient rise in adenosine triphosphate along with reactive oxygen species (ROS). An increase in ROS can induce lipid peroxidation, a process in which ROS reacts with cholesterol molecules found throughout the outer cell membrane. This process induces no apoptosis. There are no dead adipocytes—the cell remains viable after evacuation of the lipid contents. It is a fast process—the adipocyte collapses within 18 minutes. The adipocyte membrane deteriorates, liberating the lipid contents. As the cell remains viable, there is no apoptosis but the cells can still act on proteins. There is therefore 38

Fat cells: Zerona was cleared in 2010 as a Class IIIB device by the FDA for reducing subcuutaneous fat of the waist, hip and thighs

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Wigmore Medical 020 7514 5104 invasix@wigmoremedical.com

peer to peer

Dr David Eccleston is a general practitioner and clinical director of MediZen Clinic, specialising in lasers and injectables

Dr Stephen Mulholland is a consultant plastic and reconstructive surgeon and owner of SpaMedica Infinite Vitality Clinics in Canada

Dr Moshe Lapidoth is consultant dermatologist. He is also head of the laser unit and senior physician in the Department of Dermatology, Rabin Medical Center in Israel

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

Microneedling and lasers Our panel discuss the benefits of microneedling for acne scarring, combination treatments, skin brightening and lasers Q Do you have to prepare the skin before microneedling to get optimised results? Can you perform it in a single session? Dr Robin Stones: It depends on what you’re doing. You don’t have to prep the skin, but you want your clients to be on a good skincare regime. My patients use a lot of tretinoin. Some of my colleagues are actually rolling tretinoin into the skin, but I think this could cause a significant inflammatory reaction. You can combine microneedling with other treatments. But I wouldn’t provide it at the same time as Botox, for example—you need to stretch the skin and apply manual pressure. Obviously, you need to clean and disinfect the skin before a treatment.

Q Do you prescribe antibiotics or antivirals? Dr Robin Stones: No, you don’t need to. One exception, perhaps, would be a patient with recurrent herpes simplex in an area that you’re going to roll. Otherwise, no. I have never seen a single infection after this treatment. Q It can be difficult to get good bleeding with patients with severe acne scarring. How do you deal with this? Dr Robin Stones: I use the Genuine Dermaroller for this. It has two widths. The MS4 is a narrow, half-width device which enables the practitioner to angle it and roll into the side walls. This can be helpful in depressed fibrotic scarring. I don’t expect a deep icepick scar to disappear with micro medical needling. I will treat that in a different way, such as punch excision or subcision. But it’s not difficult to get bleeding with extensive acne scarring, providing you stretch the skin properly and roll it in that way. If you try to roll slack skin, you won’t reach your end point as quickly as you could. 40

Dermarollers can be used for all skin types. The 1.5mm roller is good for facial work. For thicker skin, such as the very thick dermis on the back, the 1.5mm won’t make much impact. You need to choose the needle length according to the thickness of skin or thickness of scarring.

Q What are the long-term results of microneedling, particularly on scarring? Do you do long-term follow ups on patients? Dr Robin Stones: Yes, I’ve been performing these treatments for a few years and I do follow them up. I find patients do get long-term benefits, particularly with acne scarring, which is my favourite application for microneedling. I don’t yet know the long-term benefits for keloid and hypertrophic scarring. But in the other types of scarring, once the skin is remodelled, it is a long-term result. Q Microneedling

seems to be quite a painful procedure, how do you deal with this issue? Also, I believe that fractional lasers have a role in the treatment of acne scars, mainly because of the coagulation and creation of new collagen afterwards. I don’t think you can get the same amount of neocollagenesis by the microneedle, what are your thoughts? Dr Robin Stones: Firstly, the treatment is very well-tolerated. While it looks brutal, nobody has ever not been able to tolerate treatment and it’s not painful afterwards. I just use topical anaesthetic and treatment is very quick. Secondly, I agree. I use lasers as well as microneedling. But this treatment is particularly helpful if cost, lifestyle factors and recovery time are important. We see a huge variation here. body language www.bodylanguage.net

peer to peer

Many of the clients I see are not prepared to have five days’ of down time and and do not want to pay a lot of money for treatment. For those clients, microneedling ideal. If these factors were different, you would achieve more with the fractional C02 laser. I have performed a comparison between microneedling and a fractional ablative Erbium laser. I can get as good a result with this as the Erbium but not as good as a CO2 laser.

Q I think it’s a bit counterintuitive to use this technique in hypertrophic scars. How exactly does this treatment work? Dr Robin Stones: It strongly upregulates the TGFβ 3, rather than TGFβ 1 and TGFβ 2. Prolonged upregulation of these allows remodelling with normal collagen formation. This comes from dermal and epidermal damage. It may be that signalling for keloid scars comes from the epidermis. But quite a few burn scars Patients can get long-term benefits from microneedling, particularly with have been treated acne scarring by this kind of device and it doesn’t seem to exacerbatie the problem. But I wouldn’t treat an active keloid scar.

Q What

do you use as a dressing? Dr Robin Stones: Following the procedure, you can apply an antioxidant anti-inf lammatory cream. We advise patients not to touch or wash their face until the following morning. They can then revert to their normal skincare regime because the tiny microinjuries have sealed off by then.

Q Dr

Lapidoth, how long do the effects of your depigmenting technique last? Dr Moshe Lapidoth: It is a reversible process. As long as you are applying the cream, it will be effective. Patients have to use the cream permanently—if they stop using it, the pigmentation will come back. It is not a single-use treatment. We presented at the American Society of Lasers and Medicine Surgery a combination of fractional laser, fractional ALS with a bleaching agent. This combination seems to work nicely. When you re-create micro-pores, hydroquinone can penetrate much deeper. Penetration is increased by 50–60 times, compared with just topical hydroquinone. Eventually, you don’t need the pores. The pores created by a laser are being blocked after six to eight hours by blood clots and debris. But you are causing a significant dermal/epidermal barrier disruption which will improve the penetration of any

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topical product for 3–4 weeks after treatment. Resistant cases of melasma show particularly good results.

Q I do medico-legal and medical negligence work and see the far end of the spectrum for laser problem cases, particularly with depilation in Asian girls. They can have unusual patterns because of the way the laser is applied, like cat stripes. Using your technique, does it differentially depigment the hyperpigmented areas and leave the non-pigmented areas untouched? Dr Moshe Lapidoth: For some reason, the treatment works extraordinarily well on post-inflammatory hyperpigmentation. One case involved a woman who had laser treatment for diffused solar lentigines on her upper arms and on her face. Although she had skin type III, she developed post-inflammatory hyperpigmentation and was quite upset with us. We treated her with hydroquinone which, for some reason, didn’t work very well. And when we shifted to the green perioxidase cream, it worked in days. This is a permanent response—in post-inf lammatory hyperpigmentation, you don’t have the creation of new pigmentation after the event. We also have several cases with lasers and IPL treatment, post-hair removal, and it seems to work nicely. It depends on the severity. The less severe the case, the better it will work, but we can see some good improvement.

Q There tends to be a number of patients who show little or no response to radiofrequency (RF) treatment. How do you manage patients who, perhaps, have had a fairly expensive treatment option, come back and show very little or no response? Dr Stephen Mulholland: The question, really, is management of patient expectations with or without RF, because it happens in any sort of situation. So my experience would be Thermage, monopolar, bipolar IR combos, tripolar and octopolar. Expectation management is critical, but I try to always bundle a series of treatments where there is always an upside for the patient. They don’t always achieve their endpoint. You can’t always predict the outcome. The older patient with photodamage may not have success with transepidermal techniques. In my practice, if patients buy a five pack and are unhappy, we will give 41

peer to peer

'One unhappy patient will tell 20 people, while a happy patient will tell 2.8 people. We want to try to recapture those unhappy patients'

them some complimentary treatments. It can sell up to the next stage of invasiveness, such as a subdermal or ablative treatment. They will get a better result and some monetary value against it. Generally, this will recapture most unhappy patients. One unhappy patient will tell 20 people. One happy patient tells 2.8 people. We want to try to recover those people. Dr David Eccleston: The most important thing is that we need to under-promise and over-deliver. We’re so used to treating with toxins and fillers and getting a rapid response. When you get good at a technique, you know that 95% of your patients will be happy. With an RF device, there are so many variables. It’s not only technique dependent, but different tissues respond in different ways. You can’t predict the healing process when you don’t know how well the patient’s going to be following the post-operative advice. So under-promise, over-deliver and you will have much happier patients. Now that we have such a big toolbox, bundling is the way forward. If you can provide what the guy down the road doesn’t provide, then they’re not going to go elsewhere unless they’re very unhappy.

Q Why do you think there is such a low uptake of radiofrequency into clinical practices in the UK? Dr Stephen Mulholland: The bipolar elos world was purely nonablative with multiple treatments. Every physician should consider some form of ablative fractional device in their clinic. If you are performing Botox and filler injections, ablative fractional lasers are synergistic with your fillers and your toxin. They need to go together. There is also still a role for non-ablative RFs, the transepidermals. But if you’re not offering some type of selective fractional ablative or interdermal or subdermal approaches, your patients will go elsewhere. They are not difficult to learn. If you can inject fillers into a patient’s face, you can do these treatments and these techniques. Dr David Eccleston: The initial problems we had with Thermage 42

were not a good start. Thermage has since picked itself up and developed new techniques, delivering more predictable results. But some of the other devices were very technique dependent. In good hands, you could get fabulous results, but many relied on the ouch factor. Practitioners would keep going until the patient said, “ouch” and then treatment would stop. That’s not particularly well controlled. With the fractional CO2 laser, you set the parameters according to skin type and the nature of the problem. You know roughly what the result will be. When you’re relying on an individual’s pain tolerance, you hit issues. If you’re treating a man, you will be able to put half as much energy in as a woman. If the woman is being treated at a certain time of the month, she may be more sensitive to pain. There are so many variables which can affect the eventual outcome of treatment. So the honeymoon period was rocky. But now, we have some serious evidence-backed devices that are showing some serious results.

Q Which types of lasers would you recommend? Dr Stephen Mulholland: It’s more an approach to what kind of patient you’re treating. If you’re doing fillers and toxins in women between 35–55 years, RF or laser fractional ablation is important. If you wanted to move into tightening, you can learn the hypodermal infiltration technique with a little infiltrator and a 25 or 22 spinal. It depends where your practice is, what kind of patients you have and whether or not you are comfortable with full face and neck hypodermal infiltration. Q Why not keep it simple by not spending a huge amount on lasers and just providing microneedling treatment? Dr Stephen Mulholland: While microneedling has an important role, deeper dermatological issues require the application of energy. Does mechanical epidermal dermis disruption work? It does. It has limits, but it’s an affordable way to get a decent result in some patients. But you won’t be able to get all the results in all the patients. body language www.bodylanguage.net

products

market ON THE

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

ELURE ADVANCED SKIN LIGHTENING

Hydroquinone has long been classed as the gold standard in skin lightening, but patients can suffer from side effects. The Elure Advanced Skin Lightening product line from Syneron Candela is an enzymatic skin lightening treatment that doesn’t use hydroquinone. Instead, the range utilises melanozyme, a natural bio-active substance. Melanozyme’s active ingredient is lignin peroxidase, an enzyme derived from a tree fungus—the enzyme breaks down lignin in decaying trees, causing decolourisation. According to Syneron Candela, the molecular structure of lignin is similar to melanin and research shows that lignin peroxidase has the potential to TITEFX

Electroporation, or the increase in electrical permability of the cell membrane, can destroy large fat cells. Invasix, manufacturers of the BodyTite skin tightening RFAL device, has introduced a handpiece for body shaping and contouring. The TiteFX is designed to operate on the Invasix platform and combines radiofrequency with high voltage pulses for non-invasive RF lipolysis. The device uses electroporation high voltage pulses to destroy adipocytes permanently and reduce fat cells. Radiofrequency heats the skin for tightening and body shaping, and vacuum massage applies pressure to the area allowing for maximum depth of treatment, says Invasix. The handpiece provides skin temperature measurements and a cut-off to regulate temperature and ensure patient comfort, says the manufacturer. TiteFX can be combined with other modalities through the Invasix platform body language www.bodylanguage.net

ARTISS

break down or depolymerise melanin. Melanozyme disintegrates melanin in the skin to diminish dark coloured pigment. The Elure range does not contain hydroquinone and. Other skin lightening products inhibit melanin formation, but Elure targets existing melanin resulting in a faster lightening effect, says Syneron Candela. In studies, 91% of patients graded their satisfaction between good to excellent after eight days using Elure, and 9% as fair. At the end of the study, 93% graded their satisfaction between good to excellent, and 7% as fair. Syneron Candela 0845 5210698; W: syneron.com and is an alternative or adjunct to liposuction procedures. Wigmore Medical 020 7491 0150; W: wigmoremedical.com

Staples or sutures during surgery can leave a dead space under tissue flaps or skin grafts, potentially leading to post-operative fluid accumulation such as haematoma or seroma. Artiss is a premixed, slow-setting fibrin sealant for sealing and adhering subcutaneous tissues in plastic, reconstructive and burn surgery. The sealant can improve haemostatis on subcutaneous tissue surfaces, says manufacturer Baxter International. Artiss is made from two components of human plasma— sealer protein and thrombin, which, when combined, mimic the final stage of the blood coagulation cascade. Artiss is sprayed onto the wound, after which surgeons have 60 seconds to position the tissue to ensure a tight seal and adherence to the subcutaneous tissue. The manufacturer claims that clinical studies show Artiss to be well tolerated and generates similar outcomes to using staples to attach skin grafts in burn patients. Studies also show reduced incidence of haematoma and seroma on Artiss-treated sites on day one, says Baxter. Plastic surgeon professor Paul McArthur says: “Eliminating the need to remove staples means that patients, particularly young children, will not undergo what is a painful procedure or require an additional anaesthetic. If Artiss proves effective for other plastic and reconstructive surgery procedures, early drain removal or drain-free surgery could mean patients going home sooner.” Baxter Healthcare 01635 206103; W: baxter.com 43

products

RETINOL PLUS MD

All-trans retinol is a popular addition to topical anti-ageing products—it is converted into retinoic acid when applied to the skin to help target fine lines and wrinkles. Retinol Plus MD, part of Jan Marini’s Age Intervention skincare line, combines stabilised alltrans-retinol with peptides, antioxidants, hydrators and skin smoothing agents that maximise product efficacy while eliminating acclimation concerns, says distributor JMS Europe. The product contains 1% all-trans-retinol, palmitoyl oligopeptide and palmitoyl tetrapeptide-7, green tea extract, chrysin, bisabolol, hyaluronic acid and shea butter. Retinol Plus MD can be used as an accelerator for the Age Intervention skincare management system to maximise improvement in texture, discolouration, fine lines and wrinkles. According to the distributor, the combination of retinol, peptides and antioxidants work together to “improve overall skin health, boost collagen and elastin and rejuvenate and rebuild the skin, reduce sensitivity and inflammation and protect the skin from environmental damage.” The product can be used on all skin types. JMSR Europe Ltd E: info@jmsreurope.com; W: janmarini.co.uk

quences found in the body’s defence and repair system, says SkinBrands. Meadowfoam seed oil is an emollient triglyceride composed of 98% long chain fatty acids and antioxidant tocopherols, which forms a moisture barrier to help prevent moisture loss. Sodium hyaluronate is a humectant that helps maintain hydration balance, while resveratrol and licorice root help to reduce pigmentation, says the distributor. In a clinical study of 30 patients, 70% had visible improvement in stretch marks after two weeks, and more than 90% saw overall improvement after 12 weeks’ continued use, says SkinBrands. SkinBrands 05603 141956; W: skinbrands.co.uk POLLOGEN

Fractional RF skin resurfacing can provide effective treatment for acne scars and pigmentation. Pollogen’s 10 x 10 disposable TriFractional tip has been launched for use with its TriFractional applicator, which provides fractional RF skin resurfacing. The applicator is provided with 7 x 7 tips for deep penetration to the mid-dermis layer. The new 10 x 10 tip reaches the APOTHEDERM STRETCH MARK CREAM upper dermis layer and has a denser surPeptides can provide anti-ageing and re- face coverage and requires slightly more parative effects in skin-care products, such downtime than the smaller tip, says Polas building collagen and helping logen. Both tips can be combined barrier function. Apothederm for optimal treatment, says the Stretch Mark Cream helps to manufacturer. reinforce the skin’s support TriFractional energy crestructures and repair existates micro-wounds which ing stretch marks, says distrigger the body’s natural tributor SkinBrands. healing response mechanism Its formulation contains and inducing neocollagennatural emollients—she1a esis, says the manufacturer. butter, cocoa butter, olive oil The technology can be and meadowfoam seed oil— used for wrinkle and pigas well as heptapeptide-7, mentation reduction and resveratrol, licorice extract, scar reduction—particularly amino acids and sodium acne scars and skin tightenhyaluronate. The cream can ing. The TriFracreduce the appearance of red tional applicaand silver stretch marks and tor received improve skin’s texture, says CE mark the distributor. Heptapepapproval in Septide-7 contains seven amino tember 2011 and is a module of acids commonly found in the Pollogen’s Maximus platform, skin, modelled on natural sewhich comprises TriLipo RF,

TriLipo Dynamic Muscle Activation and TriFractional. Practitioners can use the platform to treat all four layers of tissue, says Pollogen—the epidermis, dermis, muscles and fat. Pollogen W: pollogen.com TISSUGLU

A surgical adhesive has been developed for large flap surgical procedures such as abdominoplasty to help reduce fluid accumulation and facilitate natural healing, says manufacturer Cohera Medical. The product, TissuGlu, may reduce the need for surgical drains and result in a more comfortable recovery. TissuGlu is a low molecular weight, hyper-branched prepolymer that cures in the presence of moisture. On application, the ends of the molecules adhere to tissue surfaces. Water reacts with the ends of unbounded molecules, binding them and forming large polymeric chains. This allows the adhesive to remain soft and flexible while maintaining the tissue bond, says Cohera. As the tissues heal, hydrolysis degrades the adhesive into absorbable subcomponents. TissuGlu is indicated for adhering tissue layers where subcutaneous dead space exists between the tissue planes. The material forms a bond between the layers and has five times the holding strength of fibrin-based sealants, says the manufacturer. The product is resorbable, biocompatible for internal use and uses no human or animal-based ingredients. The TissuGlu applicator features a multi-tip pivoting head for rapid application of meas-

ured adhesive droplets. It features a built-in spacer guide to apply an evenly-spaced grid of adhesive to the tissue bed. Cohera Medical +31 (0) 800 100 4017; W: coheramedical.com body language www.bodylanguage.net

R OYA L CO L L E G E O F PHYSICIANS LONDON

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. ADVANCED TRAINING Opportunities to learn new and advanced techniques from leading practitioners in this limited space full day training course. EXHIBITION A concurrent exhibition and exhibitor workshops help you keep up to date with leading-edge products with over 50 of the industry’s key manufacturers and distributors. 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. AN EVENING WITH... 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 agendas on each day FACE 2012 will undoubtedly be the biggest FACE conference yet.

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 David Goldberg, Clinical Dermatologist “One of the most dynamic and exciting cosmetic meetings I have ever lectured at.” Dr Tess Mauricio, Clinical Dermatologist “Face has been wonderful, able to bring together world leaders in aesthetics. Definitely the conference to go to.” Dr Aamer Khan, Cosmetic Doctor “FACE is the pinnacle of our industry, educates and brings people together.”

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veins Dr Haroun Gajraj

How liposuction has advanced vein treatments Advances made in one area of medicine often find application in other specialisations. Dr Haroun Gajraj writes about how he has changed his vein procedures following advances in liposuction

body language www.bodylanguage.net

cence” and “tumesce” are derived from the Latin tumere (v) meaning “to swell”; the adjectives reflect the swelling that occurs with the infiltration of large volumes of local anaesthetic fluid. The addition of adrenaline causes the blood vessels to constrict so that the action of the anaesthetic is prolonged (lasting 10 hours or more) and there is no bleeding during the operative procedures. In vein treatments, TLA causes the veins

to collapse and they are easier to remove. As with liposuction, TLA has revolutionised vein treatments from a brutal surgical operation, into a precise, gentle procedure performed in a few hours without the need for a hospital. Local anaesthetic I first used TLA in my vein practice in 2002. As a vascular surgeon, I was used to performing vein procedures in a hospital HAROUN GAJRAJ

t first, you might think that liposuction has little to do with varicose vein treatment and removal. In fact, the modern era of vein treatments was made possible by Dr Jeffery Klein, a Californian dermatologist. In 1997, he invented a new local anaesthetic technique for liposuction, tumescent local anaesthetic (TLA). In a matter of just a few years, TLA changed a dangerous, brutal operation performed under general anaesthetic with big cannulas into a gentle, precise outpatient procedure performed under local anaesthetic. Dr Klein introduced microcannulas so that the excess fat could be removed through tiny punctures only a few millimetres in size. In 1995, the first reports of vein removal with TLA were published in the medical literature. Again, dermatologists were at the forefront of this development. But the powerful advantages of TLA were soon recognised by vein specialists worldwide, and now modern phlebologists can treat all vein problems under local anaesthetic as a walk in, walk out procedure in a clinic rather than in a hospital and without general anaesthesia. So what is TLA? Dr Klein invented the use of large volumes of dilute local anaesthetic to which adrenaline has been added. The words “tumescent”, “tumes-

Patient before and after vein removal under TLA: the phlebectomy sites are not visible 47

veins Dr Haroun Gajraj

Instruments for vein removal Under TLA. From top to bottom: phlebectomy hook, clamp x 2, 1mm dermal punch

Dermal punch in use to excise 1mm disc of skin

HAROUN GAJRAJ

The resulting 1mm (diameter) circular skin defect

Vein extracted with vein hook 48

operating theatre under general anaesthetic, so TLA took getting used to. However, within a few months, the advantages were clear. In the last eight years, I have performed a vein treatment under general anaesthetic only once and this was for a lad of 18 years old, who was too nervous for TLA. I am amazed that most vascular surgeons in the UK still treat people with varicose veins under a general anaesthetic. There are many advantages of TLA for varicose vein removal and here are a few: • faster recovery • safer • less bruising • more precise technique • fewer complications • no need for hospital • less risk of infection • highly cost effective, and • applicable to people with medical conditions that preclude general anaesthesia. So why don’t all vein specialists use TLA? With an impressive list of advantages, you would think that all vein treatments would be performed under local. Well, there are some disadvantages and they all relate to the surgeon. First, patience and extra time are needed for the local anaesthetic to take effect. Second, the patient is awake and the surgeon may need to talk to him or her. Third, not all surgeons have the right temperament for TLA. Fourth, a gentle technique is needed. Fifth, a nervous patient will need reassurance and kindness. General anaesthetics for vein procedures are really for the benefit of the surgeon, not for the benefit of the patient. My technique Klein recommends TLA solutions of different formulations for different parts of the body. My TLA solution is one litre of normal saline (0.9% sodium chloride) to which 1mg of adrenaline, 10 mEq of sodium bicarbonate and 1g of lidocaine have been added. This formulation works well for removal of leg veins. The concentration of lidocaine provides excellent analgesia, the adrenaline provides vasoconstriction and bloodless vein extraction and the bicarbonate neutralises the slightly acidic pH and so minimises the stinging and discomfort when the local anaesthetic solution is infiltrated. Originally, I made a small linear incision for phlebectomy with a scalpel blade, but since 2008, I now use a 1mm circular dermal punch to introduce the phlebectomy instrument, and once the resulting skin defect has healed it is virtually invisible.

Skin is elastic, so the circular defect easily stretches when removing large veins. Once the vein has been extracted, the defect returns to 1mm in size. Previously, my experience has been that linear incisions tend to tear and enlarge when large veins are extracted and the resulting scar can be unsightly. The dermal punch is well known to dermatologists for performing small skin biopsies for histological examination and Klein recommends dermal punches to enable the introduction of microcannulas for liposuction. Using TLA, only a few instruments are needed for vein extraction and the technique is simple. In my practice, the cosmetic results of vein extraction using TLA and a dermal punch are excellent. Nowadays, many patients wish to avoid admission to hospital and general anaesthesia and use the internet to find specialists who provide vein treatments under TLA. Patient choice is the driver and I see this trend increasing. It is likely that most vein treatments will performed under TLA within the next two to five years and vascular surgeons will need to embrace this change. Advances in liposuction and vein surgery have resulted from a cross-fertilisation of ideas from different specialties, namely dermatology and vascular surgery. Sometimes it is difficult to predict where the next “big idea” might come from, which is why I enjoy reading Body Language and attending conferences that expose me to a variety of specialists outside my own field. Dr Haroun Gajraj is director of the VeinCare Centre W: theveincarecentre.co.uk References

Klein JA. “Tumescent technique for liposuction surgery,” Am J Cosmetic Surg 1987; 4: 263-7 2. Klein JA. “Tumescent technique for regional anesthesia permits lidocaine doses of 35mg/kg for liposuction,” Dermatol Surg Oncol 1990; 16:248-63 3. Klein JA. “Tumescent technique chronicles. Local anesthesia, liposuction and beyond,” Dermatol Surg 1995; 21:449-57 4. Klein JA. “Tumescent technique for local anesthesia,” Dermatology 1996; 164:51 5. Cohn MS, Seiger E, Goldman S. “Ambulatory Phlebectomy using the tumescent technique for local anesthesia,” Dermatol Surg 1995; 21: 315-18 6. Janne d’Othee B, Faintuch S, Schirmang T, Lang EV. “Endovenous laser ablation of the saphenous veins: bilateral versus unilateral single-session procedures,” J Vasc Interv Radiol 2008; 19: 211-5 7. Klein JA. “Tumescent technique,” Mosby 2000 187-195 8. Gajraj H. “Phlebectomy without surgical scars: a new technique,” Phlebology 2011; 26:257 Abstract 17

body language www.bodylanguage.net

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Continued professional growth and ongoing education is key to the development of any specialty, especially in one so dynamic and ever changing as aesthetic medicine. That is why the Cosmetic News Expo Conference has been designed to not only help you to expand your business but also to develop your skills to keep you one step ahead of the competition – whether you are an experienced practitioner of just starting out. Running alongside the Cosmetic News Expo at the Business Design Centre Islington on April 29-30 2012, the Cosmetic News Conference offers aesthetic professionals the chance to gain CPD accredited education at the same time as networking and exchanging information with their peers. Since its launch in 2010, the Cosmetic News Expo has become one of the ‘must-visit’ events in the aesthetics calendar, bringing together more aesthetic practitioners, manufacturers and suppliers under one roof than any other meeting. The conference programme will see the very best uk and international speakers, discussing the latest topics and demonstrating the most up-to-date techniques in aesthetics.

kEY TOPICS fOr 2012 INCludE: • TrEaTING MENOPauSal ClIENTS • adVaNCEd laSEr WOrkSHOP • bEGINNErS laSEr WOrkSHOP • ClINICal PHOTOGraPHY WOrkSHOP • INJECTION TECHNIQuES • TrEaTING blaCk aNd aSIaN SkIN • TrEaTING MalE ClIENTS • POST-PrEGNaNCY TrEaTMENTS • adVaNCEd INJECTOrS MaSTErClaSS • bEGINNErS INJECTOrS MaSTErClaSS ks

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due to demand there will be a small charge for the 2012 conference. Advance bookings will be charged at £45 per day or £80 for both days. On the day bookings will be charged at £75 per day/£150 for both days. A complimentary lunch and VIP ticket to the Cosmetic News Expo after party at the Pitcher and Piano will also be included.

En rE k EnTow N OW W W.CO E WS u k.CO coCO n fN e rf e cN e CTEi cTkI C eT aT aT w wWw.co s mSeM T iEcTnI C eN ws u k.co m M

nutrition Kim Pearson

Operative diets Patients need to be especially vigilant about what they eat before and after surgery. Kim Pearson discusses how diet helps patients to heal

urgery places numerous stresses on the body. Good nutrition is essential for expediting wound healing, reducing risk of infection and scarring, and optimising desired results. In aesthetic medicine, surgery is usually elective, allowing preparation time. Unless your patients eat a consistently exceptional diet, they are unlikely to meet the recommended daily intake for macronutrients, vitamins, and minerals. Increased demand for nutrients during and post-surgery requires optimal nutrition through diet and supplementation. Preparation for surgery should start at least one month before the procedure. Protein deficiency impairs wound healing, as protein is needed for fibroblast proliferation, new blood vessel formation and collagen production. Apart from wound healing, proteins are essential to the function of the immune system and the central nervous system. Women should aim for 1.2g protein per kg (ideal) body weight per day and men should aim for 1.5g protein per kg (ideal) body weight per day as a minimum. The best sources are lean organic meats, wild fish, eggs and vegetable sources such as nuts, seeds, soya products and quinoa. The stress of surgery increases freeradicals that can damage tissue and slow down healing. Antioxidants such as vitamin C, vitamin, A, selenium, CoQ10 and manganese provide protection against free-radical damage. Fruit and vegetables are rich sources of antioxidants, and patients should consume a minimum of five a day of organic fruit and vegetables. It is also worth supplementing a quality antioxidant complex. Foods high in refined sug52

ar or with a high glycaemic index such as carbohydrates can suppress immune function and promote inflammation and should be avoided. One week before surgery: certain foods can interfere with anaesthesia, bleeding time, immune function and healing time. • Omega 3s can increase bleeding time. Patients should either decrease intake of oily fish high or balance it with lean red meat, which has arachidonic acid and counteracts blood thinning. • Vitamins E, C, K, B, fish oils and all herbal supplements should all be stopped one week pre-surgery (includ-

ing the multivitamin). • Green tea, cayenne, ginkgo, garlic, ginger, flaxseed, tomatoes, potatoes, and eggplant may affect anaesthesia or bleeding time. • Neurotoxins such as alcohol, caffeine, aspartame and MSG should be avoided. • Aspirin and all other nonsteroidal anti-inflammatory drugs that thin the blood should not be taken. Post-operative: The goal of optimal postsurgery nutrition is to promote quick healing, lessen the likelihood of infection (through a well-supported immune system) and reduce pain, inflammation and swelling. Scientific studies have estab-

lished that requirements for certain nutrients can increase by up to five times during the healing phase after surgery. Lack of nutritional support during this crucial period can adversely affect recovery from cosmetic surgery. Pre-operative supplement regimens may be resumed, while sugar, caffeine, and alcohol should continue to be avoided. To improve recovery, foods eaten 72 hours post-op should be bland, soft and easy to digest, as digestion is compromised during periods of stress. Soups and smoothies containing protein are ideal. For the first week after surgery the one week pre-surgery protocol should be followed. Foods high in monounsaturated fats can be added to diets, such as extra-virgin olive oil, avocado, tart/ sour cherries and blueberries, which have a profound anti –inflammatory effect. Foods that increase inflammation, including saturated and transfats and refined sugars should be avoided. Supplements such as arnica, glutamine and probiotics can be continued. Consumption of vitamin E, vitamin C, vitamin K, B vitamins, fish oils, and a multivitamin can resume three days post-op. The post-op protocol should be followed until the patient has fully recovered from the operation. These recommendations will assist in achieving optimal results from surgery by promoting healing of surgical wounds, supporting the immune system to prevent infection and reducing inflammation and scarring. Kim Pearson is a nutritionist and works in the commercial department of Ysonut. T: 07950 189281 body language www.bodylanguage.net

nutrition Kim Pearson

Key nutrients Nutrient

Benefits

Recommended Daily Dosage

Direction for Use

High Highstrength strengthmulti-vitamin multi-vitaminand mineral and mineral

Guarantees micronutrient levels needs to prepare the body for post-surgery tissue repair

As directed by the manufacturer

Take with breakfast preand post- operatively Stop one week pre-surgery

BBcomplex complexvitamins vitamins

Work in synergy to aid wound healing. Required for collagen linkage, protein synthesis, DNA synthesis and ensures a healthy immune system

Thiamine (B1) 50mg, riboflavin (B2) 50mg, niacin (B3) 50gm, pantothenic acid (B5) 50gm, vitamin B6 50mg, folic acid 400mcg, biotin 200mcg, vitamin B12 50mg

Take with breakfast pre and post operatively Stop one week pre-surgery

Vitamin VitaminCC

Increasing collagen and elastin synthesis, essential for proper healing of incisions and surgical scars. Improves blood vessel dilation, which increases blood flow and nutrients to damaged tissues for wound healing. Enhances white blood cell and neutrophil function of the immune system, helping to prevent infection

1000mg

Take with breakfast pre and post operatively Stop one week pre-surgery

Zinc Zinc

Essential for normal nucleic acid metabolism, DNA synthesis, protein synthesis, synthesis of structural proteins such as collagen, the function of several hundred enzymes, normal insulin-like growth factor (IGF-1) production

20mg

Choose a multivitamin that includes zinc

Copper Copper

Essential cofactor for the enzyme lysyl oxidase, which plays a role in the cross-linking (and strengthening) of connective tissue

75mcg

Choose a multivitamin that includes copper

Glutamine Glutamine

Increased tissue concentrations of this amino acid during the pre-operative period will reduce healing time and aid in surgery recovery

Take with breakfast preand post- operatively

Probiotics Probiotics

Antibiotics given for surgery kill bad bacteria and prevent and/or treat infections but can also wipe out the good gut bacteria. Probiotics ensure that good bacteria inhabit the gut and prevent possible digestive side effects (nausea, gas, bloating, constipation) and associated immunosuppression

Four billion live probiotic cultures: lactobacillus acidophilus and bifidobacteriumbifidum strains

Take with breakfast preand post-operatively

Arnica Arnica

This well-known anti-inflammatory herb acts by dilating capillaries, facilitating blood flow to the injured tissue to reduce swelling and pain

Take 5 30C pellets three times daily

Start three days before surgery Continue for one week post-surgery

Bromelain Bromelain

An enzyme shown to have significant anti-inflammatory and analgesic properties. Used before and following a surgical procedure, it can help to reduce healing time, swelling and bruising

Take 200-400 mg tablets on an empty stomach two to three times daily

Take pre-and post-operatively. As bromelain is a powerful anticoagulant, it should not be taken with blood-thinners such as aspirin Stop one week pre-surgery

body language www.bodylanguage.net

accountancy Martin Murray

Major changes to pensions are on the horizon Benefits, contributions and taxation changes to pensions are in the pipeline. Martin Murray reports

ost cosmetic practitioners are, or have been, members of the NHS pension scheme. Many of you will have received the NHS pensions options choice in which you could decide to remain within the 1995 scheme or transfer to the new 2008 scheme. For many doctors who had started with the NHS after leaving university without any major breaks, the choice was relatively straightforward and depended on whether you wanted to work to 60 or 65. For others, particularly nurse practitioners, choosing between the two was more difficult. In addition, there is a consultation document that deals with increasing contributions to fund the scheme. The results of this and the wider public sector review will not be known for some time. The big changes in taxation in the current year and with effect from April 2012 are changes in what is known as the annual allowance and lifetime allowance. These changes will affect those with high or previously high earnings within the NHS. These changes were brought about to generate an additional £3.5bn–£5bn. It is anticipated that the impact on any cosmetic nurse practitioner will be minimal. However, for certain cosmetic doctors, professional advice is needed. The annual allowance for the current year dropped to £50,000 from the previous £255,000. This figure relates to what tax relief can be obtained on pension contributions. For private pensions, any contribution reduces it on a £1 for £1 basis. For cosmetic doctors employed within the NHS and general medical practitioners, it is based on the deemed increase in benefits from the beginning of the tax year to the end. Most cosmetic doctors should not exceed the limit. Those likely to exceed it will be any cosmetic doctor who pays large amounts into a private scheme and, or, receives a large pay rise, say, by a merit award in the current year. For general medical practitioners, a large rise in their share of practice profits, such as moving up to parity with other 54

partners, may trigger an infringement. The biggest change that takes effect from 6 April 2012 is the reduction in what is known as the lifetime allowance from its present £1.8m to £1.5m. There have been many articles and publications relating to this change and methods of protecting oneself from any future impact. Unfortunately, some have been misleading and also wrong. At the end of November 2011, the Revenue published further clarification of what are very complex rules. For a cosmetic doctor to exceed the reduced lifetime allowance of £1.5m, he or she requires an annual pension from the NHS of £65,217 with a lump sum of £195,652 before what is known as commutation is factored in. Commutation is the process whereby a person retiring from the NHS can elect to take a reduced annual pension for an additional lump sum. Each £1 of annual pension commuted generates an additional £12 of a lump sum benefit. During the current year, commutation can be used to reduce the notional value of the NHS pension for comparison with the lifetime allowance and for some doctors avoid a tax recovery charge. This loophole will not be available from 6 April 2012. For example, a cosmetic doctor with an NHS pension anticipated to be £75,000 would have a capital value of the NHS pension equate to £1,725,000. Of this pension, £75,000 will be paid annually and £225,000 as a lump sum before commutation is decided on. This exceeds the lifetime allowance of £1.5m by £225,000, which will be subject to an additional tax charge. This is either 55% of the value of the lump sum threshold exceeded or 25% divided by a factor of 20 to be deducted each year from the annual pension of the amount by which the lifetime allowance has been exceeded. In this example, the 55% will not apply since the lump sum threshold of £1.5m equates to £375,000, so the 25% charge is applied. Based on £225,000, the person retiring will have a tax charge

of £56,250 divided by 20 so that his or her pension each year will be reduced by £2,812.50. In respect of an annual pension of £75,000, this is not as great a hit as many commentators erroneously said, giving the impression 55% tax is payable immediately on the excess. In this example, the person retiring through commutation could increase their lump sum, not suffer a 55% tax charge and incur only the 25% divided by 20, which has less of an impact. Private pension schemes to be taken as a lump sum should be discussed with your financial adviser, in light of what is available from the NHS and to remain below the threshold of when the 55% is applied. There are forms of protection from the changes. Some may have what is known as enhanced or primary protection, which are historical and rare! Thankfully, the government will honour these in respect of the new rules. There is a new form available which needs to be applied for before 5 April 2012. This is known as “fixed protection”. Unfortunately, it is neiither as good nor as flexible as that of its historical predecessors. For all but the few, this means that you have to cease contributing to the NHS pension scheme to stand a chance of qualifying. If you pay into any private scheme after 6 April 2012 you will not be eligible unless it was part of a life insurance policy. For those who may be affected and can take advantages of protection, advice needs to be sought from your financial adviser. For those who are basically too young to defer membership of the NHS pension scheme, here’s hoping to the limit being uplifted. If it is not, try not to exceed the lump sum thresholds, incurring a 55% tax on the excess. Martin Murray is a partner at Sandison Easson & Co, a specialist medical chartered accountancy firm with offices in London and Cheshire, T: 01625 527 351; 0207 307 8759; E: info@sandisoneasson.co.uk; W: sandisoneasson.co.uk body language www.bodylanguage.net

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comment David Williams

Conclusion BY DAVID WILLIAMS

Agreement of a standard

tandards serve society on many levels. Early examples include our 365-day calendar, which the Egyptians developed based on the rising of Sirius every 365 days. This was important as it coincided with the annual inundation of the Nile, which enriched the soil and was the foundation for crops. Another example is King Henry I of England standardising measurement by devising the ell, the equivalent to the length of his arm. In 2013, or thereabouts, aesthetic medicine will have its own EU standard—the European Standard for Aesthetic Surgery Services, distinguished by the seemingly innocuous, eminently forgettable CEN TC403. Nevertheless, in a couple of years this designation will probably stick in practitioners’ memories like used chewing gum to a pavement. Up to 22 May, CEN (European Committee for Standardisation) will collect comments from associations and aesthetic medicine practitioners for helping to devise a common standard. Already, some noses in the UK have collectively been put out of joint because their skills have have not been recognised in the preliminary consultations as pertinent to aesthetic medicine. Dentists and registered nurses were looked over; although, the former are likely to have input through dental committees, and the latter, to some extent, through aesthetic associations. The associations are all trying to be heard, because the standard’s final wording will very much depend on their influence. This is a loud clamour, as the UK has a fair number of associations whose members practise aesthetic medicine. Add each member state’s associations and the total climbs steeply. How the wording is determined will be influenced by the practice of aesthetic medicine in each state, and this does vary. In France, for example, prospective patients must wait a minimum of 15 days after consultation before any cosmetic 58

procedure—be it an injectable or surgery. And if patients desire a toxin treatment, their choice will be restricted because it is considered a drug best administered by five medical specialities—dermatology, plastic surgery, opthamology, neurology and ENT. In the UK, such restrictions would suit the British Association of Aesthetic Plastic Surgeons (BAAPS), which censures most other practitioners as predictably as a forecast for a tepid, cloudy summer. In September 2010, BAAPS called for the government-sponsored quality assurance mark to be put on hold pending guidance from CEN and its UK affiliate, the BSI. Nigel Mercer, BAAPS president in 2010, said: “Clinics already have to register with the Care Quality Commission because it is the law and it is the job of this agency to regulate the facilities where these treatments are performed. IHAS [Independent Healthcare Advisory Services] has no teeth to stop poor practice. It seems to be sold to the profession on the basis of marketing rather than patient safety.” BAAPS has high hopes for the CEN standard, citing its emphasis on patient

safety rather than marketing. It will have “teeth”, it opines, because it cannot be ignored by national governments. Predictably, CEN, rather self-servingly, sees the standard as providing real added value for aesthetic surgery by “helping consumers to make informed choices by creating a level playing field for aesthetic surgery providers, complementing existing legislation and filling gaps where no regulation or standard exists”. The reality is that European standards are voluntary. Nevertheless, their impact can be significant and influence the law of member states. Ultimately, patient safety is of the utmost importance. By working collectively the aesthetic sector can reduce risk, improve products and services, and finetune technique for the benefit of patients across the EU. To progress, posturing, petty squabbling, self-interests and egos need to be checked in at reception. Such self-effacement will help the development of aesthetic medicine. This will be for the good of all concerned. I hope it is not asking for too much.

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