Body Language Issue 51 by Body Language Journal

may/june

The UK Journal of Medical Aesthetics and Anti-Ageing

 REdUCE fACIAL And body fAT  REJUVEnATE hAndS  REVoLUMISE ThE fACE

SP EC IA

How to

FA L PRE CE VIEW

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contents

body language number 51 16

ANALYSES Reports and comments

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

Editor David Williams 01273 622 944 david@face-ltd.com

16 DEVICES NON-SURGICAL BODY CONTOURING Today’s patient wants to avoid the downtime and potential complications associated with surgery. Non-invasive devices provide alternative solutions for body contouring procedures. Practitioners give their reports

Assistant Editor Helen Twinam 01273 622 944 helent@face-ltd.com Designer Helen Unsworth 020 7514 5981 helen@face-ltd.com

9 OBSERVATIONS

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

29 PSYCHOLOGY MIND AND MATTER Even beautiful people have to interact in an engaging manner to gain social approval, writes Dr Raj Persaud. Good behaviour clearly complements good looks

30 FACE 2012 PREVIEW

Publisher Head of Sales Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com

PLANNING AHEAD What a difference a decade makes. Now in its 10th year, FACE is the UK’s leading medical aesthetic event. Mark your calendar and we’ll see you there

Contributors Dr Rohit Kotnis Dr Urdiales Galvez Dr Diane Irvine Duncan Dr Nada Souiedan Mr Alex Karidis Mr Lucian Ion Dr Raj Persaud Eddie Hooker Dr Kate Goldie Theresa Arnold Dr John Quinn Dr Osman Bashir Dr Carl Thornfeldt Dr Sheldon Pinnell Dr Bruce Freedman Professor Giorgio de Santis Dr Derek Jones Dr Maria Angelo Khattar Dr Mark Whiteley Dr Aamer Khan Professor Marco Gasparotti

35 INSURANCE

VICARIOUS LIABILITY Have you covered all your employees with insurance in the event of negligence? You might not have if you have not thought about vicarious liability. Eddie Hooker elaborates

37 INJECTABLES HAND IN HAND Most anti-ageing treament regimes focus on facial rejuvenation but the hands should addressed at the same time. Dr Kate Goldie discusses her approach to hand rejuvenation and augmentation

39 PRODUCTS ON THE MARKET Latest arrivals that are stirring discussion in aesthetics

40 DESIGN

46 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@face-ltd.com Advertising: advertising@face-ltd.com Body Language can be ordered online at www.bodylanguage.net body language www.bodylanguage.net

HOW CLINICS PROFIT FROM GOOD DESIGN What attracts patients to your clinic—comfort and soft furnishings or clean lines and minimalism? Helen Twinam speaks to architects and clinic owners for their views on effective design

46 CLINICAL PRACTICE MICROPIGMENTATION When treatments fail to solve skin conditions, micropigmentation can restore order by altering appearance and renewing confidence in patients, writes Theresa Arnold

48 INJECTABLES FILLERS AND RADIOFREQUENCY Combination treatments are common practice, with toxins and fillers being the most prevalent. Dr John Quinn discusses both, with the addition of radio frequency 3

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 51

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.

51 PRACTICE Fiona Collins and Marie Duckett are registered nurses and members of the Royal College of Nursing forum for nurses in aesthetic medicine. Their clinic, Fiona and Marie Aesthetics Ltd, is based in Harley Street. Anthony Erian FRCS (Erg) FRCS (Ed) is an aesthetic plastic surgeon with more than 30 years’ experience. He is a member of the American Academy of Aesthetic and Restorative Surgery and chairman of the European Academy of Aesthetic Surgery. Mr Erian practices in Cambridge and Harley St. Dr Stephen Bassett is medical director of the Aesthetic Training Academy and ShapeCYMRU Cosmetics. He is a Syneron luminary and member of the Merz academy, focusing on RF facial procedures. He is a barrister, fellow of the Society of Advanced Legal Studies and a legal consultant. Elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies. She is now director of education at LCS Academy Ltd in Milton Keynes. Dr Séan Cummings MBBS T(GP), DRCOG, DFFP, MRCGP, LLM is a cosmetic doctor practising in Harley Street. Dr Cummings has more than 20 years’ experience as a practitioner and has a masters degree in medical law. Dr Cummings works as an expert witness and has sat on GP disciplinary hearings Renato Calabria MD is part of the voluntary faculty of the Department of Plastic Surgery at the University of Southern California, Los Angeles. He is a member of the American Society of Plastic Surgery, and the International Society of Plastic Surgery. Dr Calabria practises in Beverly Hills, Milan and Rome. Dr Bessam Farjo MB ChB BAO LRCP&SI practises hair restoration at his clinics in Manchester and London. Dr Farjo is a fellow International College of Surgeons, founder member British Association of Hair Restoration Surgeons and president of the International Society of Hair Restoration Surgery.

PRACTISING IN PAKISTAN Dr Osman Bashir returned to practise in his home town of Lahore after working in England and Singapore. He shares his observations on aesthetic medicine in Pakistan

53 PEER TO PEER SUN, SKIN AND FILLERS In the run up to summer, our panel covers a range of topics from antioxidants, sunscreens, vitamin D deficiency and filler techniques

59 HYPERHIDROSIS LASER SWEAT ABLATION Axillary hyperhidrosis, or excessive sweating around the armpit, is not uncommon and can cause considerable embarassment to sufferers. Dr Mark Whiteley describes a modified method of curettage and laser ablation

62 SURGERY AUTOLOGOUS FAT Treatments involving autologous fat transplantation offer a natural alternative for volumisation, filling and rejuvenation. Dr Aamer Khan reviews the evolution of the concept

63 SURGERY BUTTOCK AUGMENTATION Professor Marco Gasparotti runs through the options available for enhancing the buttocks, including lipofilling and liposuction, fillers and the thread lift

66 COMMENT CONCLUSION Letter from the Editor, cartoon

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

body language www.bodylanguage.net

Your partner in injectable facial aesthetics

According to comparative clinical study results1 in glabellar frown lines Bocouture® vs Botox®: Comparable Efficacy 1:1 Clinical Conversion Ratio

Unit doses recommended for Bocouture are not interchangeable with those for other preparations of botulinum toxin 1 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. List 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 FEB 2012. 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 yellowcard.mhra.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.

1081/BOC/FEB/2012/JH

Date of preparation March 2012

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

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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

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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

observations

Macrolane withdrawn for breast use BAAPS repeats calls for fillers to be reclassified as medicines Quick-fix, non-surgical cosmetic procedures, such as the “lunchtime boob job”, are an attractive and cost-effective alternative for surgery-shy patients who want minimal downtime. But Q-Med, manufacturer of dermal filler Macrolane, has stopped promoting its use in breast enhancement until “consensus has been reached regarding best practice in breast radiology examination following Macrolane treatment”. Macrolane comprises a stabilised hyaluronic acid injectable gel for providing temporary treatment for volume restoration, body contouring, scar reduction and to fill concavities resulting from liposuction. Apart from the breast, Macrolane has been indicated for a number of areas, including the buttocks, calves and concave deformities. As with any aesthetic treatment, adverse events can occur, in Macrolane’s case infection, lumps and encapsulation. But as Mr Christopher Inglefield wrote in our special report on implants in our last issue (“Is Macrolane a good alternative?”BL 50) his four years’ experience using the product showed it to be a satisfactory alternative to breast implants. According to Q-Med, a safety reporting system has been in place since the

product’s launch and no safety concerns have been identified. However, Macrolane has been found to interfere with breast mammograms, thereby delaying cancer diagnosis or providing an inaccurate X-ray reading. Following consultation with regulatory authorities, Q-Med has withdrawn its indication for breast enhancement until satisfactory screening procedures can be decided. The Medicines and Healthcare products Regulatory Agency has advised that women who have undergone Macrolane breast augmentation and a mammogram should contact their GP in case they need further tests. However, Q-Med has made assurances that women who have undergone breast augmentation with the filler do not need any further action other than routine follow-up consultations or as directed by their doctor. The British Association of Aesthetic Plastic Surgeons (BAAPS) welcomes the decision. The organisation cites a 2009 study published in the International Journal of Plastic, Reconstructive and Aesthetic Surgery which warns that Macrolane could interfere with breast screening and recommended that it should not be used in women with a personal or family history of cancer. BAAPS president Fazel Fa-

tah says that, while the simple treatment of breast augmentation through injection of a filler may seem appealing, such a procedure can be deemed safe only when the long-term effects on cancer screening are known. “Without good long-term studies over 5–10 years, it is wise that Macrolane has finally been withdrawn for breast use. At BAAPS, we have been calling for dermal fillers to be reclassified as medicines, which will require further studies into their efficacy and safety similar to the US Food and Drug Administration’s approval process,” Mr Fatah says.

Q-Med has conducted a 24-month study in Sweden and France to assess the effectiveness of an alternative screening method using a combination of digital mammography and ultrasonography. The company says preliminary results have shown that an “adequate examination can be performed using these techniques” and the data will be made available to the radiologist community. Q-Med has recommended women with Macrolane injections should inform their doctor before receiving a mammogram to account for it when screening.

Chin implant growth jumps in US, says ASPS Increased visual communication cited as a reason The annual tally of American Society of Plastic Surgeons (ASPS) statistics for 2011 shows that, in percentage terms, malarplasty, or chin augmentation, grew by more than breast enhancement, Botox and liposuction combined last year—up 71%, with the largest increase in patients over 40. ASPS attributes the rise to increased use of video chat technology—which leads to more visual communication and more sight of lumps and bumps. By comparison, the UK has seen a slow increase in the procedure. Other procedures that saw an increase in popularity were lip augmentation, cheek implants, laser skin resurfacing and soft tissue fillers. Among the 14 million procedures performed on American consumers, botulinum toxin type A still tops the list as the most popular, with 5.67 million injections in 2011—5% more than in 2010.

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MEDICAL AEsthEtICs:

itâ&#x20AC;&#x2122;s A Question

of QuAlity

At Allergan, we passionately believe in quality. Our 35 years of commitment to science and innovation in medical aesthetics means that practitioners and their patients can make decisions with confidence. We are launching a landmark public awareness and education campaign to help start a conversation between practitioners and patients about why quality matters. Ask your AllergAn representAtive for more informAtion.

March 2012 UK/0326/2012

35 years of quality, science and innovation

observations

Thyme will tell for herbal acne treatment Tincture seen as effective alternative Benzoyl peroxide is a common topical acne treatment that reduces bacteria and increases skin turnover. Side-effects include irritation, a burning sensation and dryness. Herbal tinctures are often used by herbalists and alternative medicine practitioners to treat acne, but little research has been carried out into their effectiveness. A study at Leeds Metropolitan University has found that thyme can be more effective in killing the skin’s bacteria than chemical-based creams. The herb, along with myrrh and marigold, was steeped in alcohol to create a tincture and extract compounds from the plant. The tincture's activity was measured and compared with the effectiveness of benzoyl peroxide against the bacteria. Senior lecturer in microbiology and genetics, Dr Margarita Gomez Escalada, says that while all preparations tested were able to kill a number of bacteria, the most effective was thyme tincture. “We now need to carry out

further tests in conditions that mimic the skin to confirm the effectiveness in practical use. If positive, it could provide a natural alternative to current treatments,” she says. l An Israeli study of 15,000 adolescents and young adults has found that patients taking acne drug isotretinoin, or Roaccutane, have a two-fold risk of developing eye problems such as pink eye and conjunctivitis. There are already known serious side-effects associated with isotretinoin, such as bone growth delay in teenagers and birth defects when taken by pregnant women. It is thought the drug may disrupt the function of the meibomian glands on the eyelids—which prevent the eye from drying—leading to inflammation. Metabolites of the drug in the tear film may also irritate the eye’s surface. Authors of the study have recommended that if isotretinoin is prescribed, physicians should offer eye lubricants to prevent drying and irritation.

Bioengineering raises hope for baldness cure Follicles show normal hair cycles in bald mice Hair follicles derived from adult stem cells have shown interaction with surrounding tissue and normal hair cycles in the skin of bald mice, in a study published in Nature Communications. The Japanese study is particularly notable because adult, rather than embryonic, stem cells were used and the bioengineered follicles were fully functional and integrated into surrounding tissue, which has not been managed before. Hair follicle germ cells were bioengineered from adult epithelial and dermal papilla cells.

When implanted into the skin of hairless mice, the follicles showed normal hair cycles and, after dead hairs fell out, new hairs took their place. The cells showed signs of piloerection, where the hair stands on end when the surrounding muscles contract, and made connections with the epidermis, arrector pili muscles and nerve fibres. The researchers say the study raises hopes for a baldness cure and represents a “significant advance towards the next generation of organ replacement regenerative therapies”.

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second brief Collateral damage

The latest UK figures show that more women may be affected by faulty implants from French manufacturer Poly Implant Prothèse (PIP) than previously thought. Andrew Lansley, the health secretary, has reiterated that all those affected will have full NHS support. “We are still working to get private clinics to live up to their responsibilities and look after their patients. Our commitment is to ensure support from the NHS for all women if needed. We will continue to press for the same standard of care or redress from private providers,” he says. We run through PIP’s vital statistics

 Poly Implant Prothèse (PIP) produced around 100,000 implants per year over 20 years  Marketing, distribution and use of PIP implants suspended in 2010  According to French authorities, use of industrialgrade silicone in PIP implants began in 2001. But after questions from Medicines and Healthcare products Regulatory Agency, it is now thought that its use started earlier  The revelation is that 7,000 more women may be affected than thought  However, 1 in 5 implants need replacing within 10 years so it is unlikely all 7000 still have PIP implants  But around 47,000 UK women may now have been given substandard implants  95% of these were provided privately for purely cosmetic reasons  5% were provided on the NHS  400,000 patients worldwide are thought to have PIP implants  While previous studies reported failure rates between 2–5%, new data shows as many as 1 in 3 PIP implants may rupture  Cancer so far found in 20 women with the implants, but there is still no proven link with the disease, according to French health authorities Source: MHRA, DoH, NHS and Journal of Plastic, Reconstructive and Aesthetic Surgery

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) €187.05 (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: January 2011.

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.

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.

The passage of time

A secret to reveal beauty

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

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: February 2012 AZZ/005/0212

an aesthetic choice

observations

training & events MAY 16th May Core of Knowledge Course, Lynton Clinic Training Centre, Cheadle, Cheshire W: lynton.co.uk 17th - 19th May 20th Annual World Congress on Anti-Aging & Regenerative Medicine, Orlando, Florida W: a4m.com 18th - 20th May Controversies, Art & Technology in Breast & Body Contouring Aesthetic Surgery, Ghent, Belgium W: coupureseminars.com

8th June Lipomodelling Surgery Course, University Hospital of North Tees, Stockton W: cytoriexchange.com 9th June Advanced Toxins & Fillers Course, Wigmore Medical, London W: wigmoremedical.com/events 9th - 11th June VII International Plastic Surgery Course, Ekaterinburg, Russia W: b-med.ru

19th May British Association of Sclerotherapists Annual Meeting, Ettington Chase, The Midlands W: bassclerotherapy.co.uk

11th June HealthXchange Obagi Training Workshop, London W: obagi.uk.com

21st May Laser/IPL Hair Removal Masterclass, Lynton Clinic Training Centre, Cheadle, Cheshire W: lynton.co.uk

13th - 15th June British Occuloplastic Surgery Society Meeting, Curve Theatre, Leicester W: bopss.org

21st - 22nd May Association of Breast Surgery Conference & AGM, Bournemouth International Centre W: associationofbreastsurgery.org.uk

15th - 17th June Facial Aesthetics Conference & Exhibition (FACE 2012), Royal College of Physicians, London W: faceconference.com

22nd May Introduction to Skincare & Chemical Peels Course, Wigmore Medical, London W: wigmoremedical.com/events

16th - 19th June 4th Eurasian International Aesthetic Surgery Course, Istanbul, Turkey E: ncerkes@hotmail.com

22nd - 23rd May SkinBrands SkinCeuticals Training Course, Ealing, London W: skinbrands.co.uk 24th - 26th May UV-Radiation Induced Disease: Roles of UVA and UVB, Stockholm, Sweden W: ki.se 25th May Dr Brian Franks Foundation Botulinum Toxin Training Course Part I, London W: drbrianfranks.com 25th- 26th May 12th Annual Congress of the European Society for Photodynamic Therapy, Tivoli Hotel & Congress Center, Copenhagen, Denmark W: euro-pdt.com 28th May Palomar UK Users Meeting with Dr Maurice Adatto, Radisson Blu Hotel, Stansted Airport W: edenaesthetics.com 28th May SkinGeeks Half Day Skin Conference, The Dorchester Hotel, London W: skingeeks.co.uk 28th May Innomed Physiology of Ageing and Regeneration Treatments Course: Day One, Central London W: innomedtraining.co.uk 30th May Tattoo Removal Masterclass, Lynton Clinic Training Centre, Cheadle, Cheshire W: lynton.co.uk JUNE 1st June ISAPS Beauty on the Lake: Advances in Facial Aesthetic Rejuvenation Course, Villa Erba Cernobbio (Como), Italy W: isapscomo2012.com 1st - 3rd June 2nd St Petersburg International Course on Aesthetic Plastic Surgery, St Petersburg, Russia E: khrustalevai@mail.ru 2nd - 3rd June Innomed Basic Botulinum Toxin & Dermal Fillers for Beginners Courses, Central London W: innomedtraining.co.uk

18th June Eden Aesthetics Epionce Training, Royal Society of Medicine, London W: edenaesthetics.com 18th June SkinGeeks Advanced Chemical Peeling, Oxford Science Park W: skingeeks.co.uk 19th June Introduction to Skincare & Chemical Peels Course, Wigmore Medical, London W: wigmoremedical.com/events 19th - 20th June SkinBrands Medik8 Training Course, Ealing, London W: skinbrands.co.uk 20th June Skin-Laser Applications Course, Lynton Clinic Training Centre, Cheadle, Cheshire W: lynton.co.uk 21st June ISAPS Symposium: Facial Rejuvenation, Palais des Congres, Paris, France W: sofcep-lecongres.info 22nd June HealthXchange Obagi Blue Peel Workshop, London W: obagi.uk.com 22nd - 23rd June Yorkshire Plastic Surgery Course, Wakefield W: myplasticsurgerycourse.org 23rd June Cosmetic Courses Foundation Botulinum Toxin & Dermal Fillers Training Course, National Training Centre, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 23rd - 24th June Dr Brian Franks Foundation Botulinum Toxin & Dermal Fillers Part I Courses, London W: drbrianfranks.com 23rd June Microsclerotherapy & Facial Telangiectasia Course, Wigmore Medical, London W: wigmoremedical.com/events 25th - 27th June Principles in Head and Neck Reconstruction Course, Paris E: patricia.mathieu@igr.fr

6th - 8th June Rome Breast Surgery Symposium: 27th June - 1st July 3rd World Psoriasis & PsoriReconstruction & Aesthetic Excellence as the Com- atic Arthritis Conference, Stockholm, Sweden mon Challenge, Rome, Italy W: ifpaworldconference.com W: breastsurgery.it 28th - 30th June 3rd ACREP Perforator Flap 6th - 10th June 9th European Academy of Course, Amiens, France Dermatology and Venereology Spring Symposium, W: perforatorflap.eu Verona, Italy W: eadv.org 7th - 9th June Akademikliniken Beauty Through Science Meeting 2012, Stockholm, Sweden W: beautythroughscience.com

Letter to the editor

7th - 8th June Specialty Skills in Plastic Surgery, Royal College of Surgeons, London W: rcseng.ac.uk

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

body language www.bodylanguage.net

Clarification of association’s role In Dr Mark Harrison’s article “Aesthetics Takes A Beating” (Body Language, number 50), your section on the Independent Healthcare Advisory Services (IHAS) is inaccurate about IHAS. IHAS is a membership organisation and not a regulator, nor has it ever claimed to be a regulator in any form. Nowhere on its website or elsewhere does it claim to register any profession. Its website says IHAS “is a trade body for the independent healthcare sector. Impartial among its members, IHAS provides the facility for otherwise competitive members to share innovation, knowledge and expertise for the common good.” Dr Harrison is correct in saying that the regulated professions do have their own professional bodies, the British Dental Association being one of them. The professional regulators, of course, are the General Medical Council (GMC), the General Dental Council (GDC), and the Nursing and Midwifery Council (NMC). These regulators are there to ensure patient safety. By contrast, cosmetic injectables do not come within the oversight of the system regulators (eg, CQC) in any of the four countries of the UK. Where Dr Harrison refers to Treatments You Can Trust (TYCT), the Department of Health-backed register of regulated cosmetic injectable providers which is managed by the IHAS, he does not name TYCT, and does not acknowledge the fact that TYCT has a totally separate and independent website to that of the IHAS. It is on the TYCT website, www.treatmentsyoucantrust.org.uk, that the clinics, doctors, dentists and registered nurses he refers to are registered as members of the scheme. Dr Harrison’s criteria for the role of a new regulatory body are a mixture of a professional association and an insurer. The only section in the entire article with which I agree is: “Increasingly beauticians are passing themselves off as aesthetic practitioners...” Sally Taber, Director, IHAS

Technique leads to faster removal of tattoos A study published in February’s Journal of the American Academy of Dermatology reports that the “whitening” reaction seen immediately after QS laser treatment may act as a temporary block to subsequent laser passes. The authors suggest that, as this reaction resolves within 20 minutes, further passes can be applied within the same office visit, with faster end results. The R20 method is a series of passes over the tattooed area,

spaced 20 minutes apart (hence its abbreviated name), during one visit rather than one pass per session. The protocol ensures more ink is lifted from the skin and disintegrated per visit. The pilot study was performed on 18 tattoos created by professional and amateur tattooists using black, green and blue inks on the skin of Caucasian adults. One half of each tattoo was treated with a singlepass QS-alexandrite laser, and the other with four passes with the R20 method. Around 61% of the R20 method sites cleared after a single treatment, compared with none of the single-pass sites. 13

peer press review

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

Clinical relevance of botulinum toxin immunogenicity. Benecke R. BioDrugs. 2012 Apr 1;26(2).

The reported prevalence of immunoresistance varies greatly, depending on factors such as study design and treated indication. This review presents what is known about the immunogenicity of botulinum toxin and how this impacts upon patient non-response to treatment. The role of neutralising and non-neutralizing antibodies in the response to botulinum toxin is discussed, with an assessment of neutralising antibody measurement techniques. Different botulinum toxins have been developed. The new preparations of botulinum toxin aim to minimise the risk of immunoresistance in patients being treated for chronic clinical conditions. This article provides background information to explain immunoresistance. A concept that has been known about for some time with botulinum toxin and may have clinical implications. Facing depression with botulinum toxin: A randomized controlled trial. Wollmer MA et al. J Psychiatr Res 23 Feb. 2012 [Epub ahead of print].

Positive effects on mood have been observed in subjects who underwent treatment of glabellar frown lines with botulinum toxin and, in an open case series, depression remitted or improved after such treatment. Using a randomised doubleblind placebo-controlled trial design, the authors assessed botulinum toxin injection to the glabellar region as an adjunctive treatment of major depression. Thirty patients were randomly assigned to a verum 14

(onabotulinumtoxinA, n=15) or placebo (saline, n=15) group. The primary end point was change in the 17-item version of the Hamilton Depression Rating Scale six weeks after treatment compared to baseline. The verum and the placebo groups did not differ significantly in the collected baseline characteristics. Throughout the 16-week follow-up, there was a significant improvement in depressive symptoms in the verum group compared with the placebo group as measured by the Hamilton Depression Rating Scale. The effect size was even larger at the end of the study (d=1.80). Treatment-dependent clinical improvement was reflected in the Beck Depression Inventory, and in the Clinical Global Impressions Scale. This study shows that a single treatment of the glabellar region with botulinum toxin may shortly accomplish a strong and sustained alleviation of depression in patients who did not improve sufficiently on previous medication. It supports the concept that the facial musculature not only expresses but also regulates mood states. Blindness Following Cosmetic Injections of the Face. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S. Plast Reconstr Surg 2012 Apr;129(4):995-1012.

Complications following facial cosmetic injections have heightened awareness of the possibility of iatrogenic blindness. The authors conducted a systematic review of the available literature to provide the best evidence for the prevention and treatment of this serious eye injury. The authors included in the study only the cases in which blindness was a direct consequence of a cosmetic injection procedure of the face. Twentynine articles describing 32 patients were identified.

In 15 patients, blindness occurred after injections of adipose tissue; in the other 17, it followed injections of various materials, including corticosteroids, paraffin, silicone oil, bovine collagen, polymethylmethacrylate, hyaluronic acid, and calcium hydroxyapatite. Some precautions may minimise the risk of embolisation of filler into the ophthalmic artery following facial cosmetic injections. Intravascular placement of the needle or cannula should be demonstrated by aspiration before injection and should be further prevented by application of local vasoconstrictor. Needles, syringes, and cannulas of small size should be preferred to larger ones and be replaced with blunt flexible needles and microcannulas. Low-pressure injections with the release of the least amount of substance possible should be considered safer than bolus injections. The total volume of filler injected during the entire treatment session should be limited, and injections into pretraumatised tissues should be avoided. Actually, no safe, feasible, and reliable treatment exists for iatrogenic retinal embolism. Nonetheless, therapy should theoretically be directed to lowering intraocular pressure to dislodge the embolus into more peripheral vessels of the retinal circulation, increasing retinal perfusion and oxygen delivery to hypoxic tissues. A useful review article highlighting the potential dangers of filler injections and giving practical advice and guidance to minimise such significant complications. Combination of microneedling and glycolic acid peels for the treatment of acne scars in dark skin. Sharad J. J Cosmet Dermatol 2011 Dec;10(4):317-23

Acne scars can cause emotional

and psychosocial disturbance to the patient. Various modalities have been used for the treatment of acne scars, such as punch excision, subcision, peels, microdermabrasion, unfractionated and fractioned lasers. The latest in the treatment armamentarium is microneedling. Acne scars commonly coexist with postinflammatory hyperpigmentation. A combination of microneedling and glycolic acid (GA) peels was found to give excellent results in the treatment of such scars. The aim was to study the efficacy of a combination of microneedling with glycolic peel for the treatment of acne scars in pigmented skin. Thirty patients in the age group of 20â&#x20AC;&#x201C;40, with rolling scars with postinflammatory hyperpigmentation were chosen for the study. Two groups were made. The first group comprised 30 patients in whom only microneedling was performed once in six weeks for five sessions. In the second group of 30 patients, a combination of microneedling and 35% GA peels was carried out. Based on the objective scoring and its statistical analysis, there was significant improvement in superficial and moderately deep scars (grade 1â&#x20AC;&#x201C;3). There was improvement in skin texture and reduction in postacne pigmentation in the second group. Microneedling is a simple, inexpensive office procedure with no downtime. It is safe in darker skin (skin types III-IV). The combined sequential treatment with GA peel caused a significant improvement in the acne scars without increasing morbidity. Reviewing the peer press is Rohit Kotnis (Lon), Dip SEM (ED). Rohit is an advanced tutor at Dermis Deep, Birmingham and a member of the Body Language editorial panel

body language www.bodylanguage.net

THE NEXT GENERATION RADIOFREQUENCY TECHNOLOGY Unique Multi-source Phase-controlled

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devices

Non-surgical body contouring Today’s patient wants to avoid the downtime and potential complications associated with surgery. Non-invasive devices provide alternative solutions for body contouring procedures. Practitioners give their reports

Accent RF Dr Urdiales Galvez describes the combined use of selecive lipolysis ultrasound and contouring radiofrequency for body contouring, facial treatments and cellulite with the Accent platform

here are a number of minimally invasive methods for fat removal, such as lasers, light, radiofrequency (RF), ultrasound and cryolipolysis. RF uses electromagnetic radiation to create heat in the tissue through the rotational movement of water molecules, produced by electromagnetic waves. But there are two kinds of RF—monopolar and bipolar. Monopolar gets heat deep into the tissue while bipolar comprises superficial RF. The safest RF to use to treat fat is between 13– 80MHz. Papers studying the use of monopolar and bipolar RF have shown an increase in collagen type one because with this technology we produce heat-shock proteins. With the increase of temperature, RF induces transforming growth factor stimulus and production of head shock proteins, resulting in procollagen aminotherminal propeptide type one showing in urine. So with RF—at a temperature between 55°–62°—we warm up collagen. The action mechanism involves contraction of the collagen fibres, increasing and retracting the cutaneous tissue, and tightening the septum fibres. The heat generated by RF in the dermis progressively triggers an increase in new collagen, resulting in cutaneous remodelling and continuous stretching. Accent With the Accent platform from Alma Lasers, there are various handpieces using different kinds of RF for different skin problems—UniPolar, UniForm and UniFace. The UniFace features a frequency of 40.68MHz to treat fat, which is safer. The Accent machine stimulates collagenesis of the dermis and septum fibres, tightening the skin. When we’re treating cellulite, the machine stimulates blood circulation at a cutaneous level, improving skin quality, and drains the fat lymphatic excess, decreasing the orange peel effect and decreasing body mass. The mechanical effect of Accent UniForm uses massage to improve microcirculation, facilitate nterstitial fluid drainage to 16

the lymphatic system and break adherences. The cellulite classification scale ranges from 0 (smooth skin without dimples) to 4 (skin with a ‘cottage cheese’ appearance). Symptoms include a taut and weighty sensation in the affected areas and flaccidity of the skin when pinched, pressed or vigorously massaged. Areas affected are the buttocks and thigh, abdomen, back of neck and arms. We like to use ultrasound to make a diagnostic of cellulite and to see the results at the end of treatment. With edematous cellulite in the legs, we see a lot of black tissue which is full of liquid. We can make different measurements for different kinds of fat; whether the fat is fibrotic or if there is a lot of liquid inside. In fibrotic cellulite in the bottom, the fat tissue has increased thickness. Ultrasound results before and after RF treatment show that superficial adipose tissue is more compact and with adipose tissue reconstruction with fibrilar reordering—the fibrilar collagen grid of the tissue increases. Poor blood circulation in the skin can contribute to cellulite development, as the circulatory and lymphatic systems work together. Toxins and waste products aren’t removed—Accent RF with the UniForm handpiece can improve venous return and lymphatic circulation. Treatment protocol We don’t treat excessively overweight patients. They should have general good health and realistic expectations. We are very systematic in our treatment protocol. With a surgical pen, we draw 100cm² squares or rectangles, take ‘before’ photographs and document measurements of the area. We usually treat with 3–5 30-second passes of the device, maintaining a 40–43° temperature in the treated area, using zig zag movements. Temperature measurements are taken with a laser thermometer. In each pass, we alternate the direction of the zig zag, from horizontal to vertical—the head must move continually across the skin. At least eight sessions are normally required. body language www.bodylanguage.net

devices

The first pass usually treats the adipose tissue. In the second pass, we operate over the Langer tension lines and in the third pass we operate over the traction areas and mix monopolar and bipolar RF. In terms of immediate results, a variable decrease can be observed in contours in around 70% of patients—but measurements must be taken before and after treatment, as patients often cannot see changes. In the long-term, patients experience a loss of volume, improvement in orange peel appearance and tauter skin. We avoid patients with pacemakers and extensive metallic implants as well as those with collagenopathies, neuropathy and patients more than 15kg over their ideal weight. In terms of pain, this treatment is tolerable and dose-dependable. Side effects are minimal—patients can experience discreet oedema and erythema, which clears in hours. But you must be careful with tissue atrophy, which can be produced with repetitive, frequent sessions, which is why the sessions must be spaced one month or more. Ultrasound The future of body sculpting will involve using RF and ultrasound at the same time. Therapeutic ultrasound comprises focused and non-focused modailities, both involve pulsed and continuous, mechanical and thermal effects. Accent Ultra is a non-focused ultrasound for lipolysis. We can use RF to prepare the fatty cells to be destroyed with the ultrasound. As with Accent RF, there are different heads that we can use, with different wavelengths. The newest is the shear wave, or cold model, of ultrasound. This uses a transversal wave at 69kHz. For example, when you are using 70kHz, you are in the mechanical area index. This produces cavitation with no thermal effect. Sound waves that produce a mechanical effect are less aggressive. Longitudinal waves for the hot mode and transverse waves for the cold mode can be combined to obtain the best results. The longitudinal ultrasonic wave creates oscillations which occur in the direction of wave propagation. Many ultrasonic devices employ this wave, causing too much heat and cavitation injury. Cavitation is produced through high acoustic pressures and is necessary to make microbubbles and collapse fatty cells in the tissue. Cavitation must be achieved through non-thermal effect to avoid side effects. But Accent Ultra uses a transverse, or shear wave, for its mechanical effect. It doesn’t increase the temperature of the tissue and treatment involves resonant vibration power and selective adipolysis, which produce cavitation with low energy. For facial treatment, it’s important to understand the different compartments of fat in the face and how the face will age. People see thinning of the face, particularly around the temporal area and mouth, thickening of the nasolabial fold and jowl, a lack of submandibular shadow and submental laxity accumulation. Most patients come to the clinic to treat their jowls. Six years ago, the only method to treat these jowls was surgery. Now these patients can be treated with good results with these technologies.

We use Viscan to take measurements of the percentage of fat mass and the circumference of the area. We always use both hot and cold waves for the same treatment. We first do RF with UniForm followed by the Accent Ultra. The cells are affected by RF and begin apoptosis. They are therefore more sensitive to receive hot and cold ultrasound waves. Patients treated only with RF show fantastic results for orange peel skin and collagen improvement. But we don’t obtain a reduction of fat volume with just RF. It produces apoptosis, but you don’t see the big volume changes. For this, we employ ultrasound. Dr Fernando Urdiales Galvez is an aesthetic doctor and director of the Miramar Medical Institute in Spain

Accent treatments

Before and after Accent RF and Ultra Facial on a 56-year-old patient

Before and after five sessions of Accent Ultra and RF on the abdomen and on the hips

Thighs and ultrasound: before and after five sessions of Accent Ultra and RF on the abdomen and thighs

FaceTite and NeckTite The clinical results of the FaceTite/NeckTite handpieces of the BodyTite device are comparable with results of surgical procedures such as a mini-facelift, writes Dr Diane Irvine Duncan

he FaceTite applicator is a bipolar, solid probe, radiofrequency device. The silicone coated internal electrode is passed directly under the skin in the superficial hypodermal-subcutaneous fat space. The internal and the external electrodes are connected at the hand-grip. The RF energy body language www.bodylanguage.net

is emitted from the tip of the internal electrode from the small, uncoated region, behind a bullet-shaped, isolated blunt tip. The internal electrode of the NeckTite, unlike the FaceTite, is a cannula that can connect into a pump, enabling simultaneous aspiration. The RF energy from the internal electrode causes 17

devices

a coagulative necrosis of the sub-dermal fat. It coagulates blood vessels and tightens the fibrous components of the adipose layer, leading to tissue lifting and reduction of the skin surface. The RF energy is delivered directionally to the external electrode, which delivers gentle, sub-necrotic RF energy across the epidermal surface into the papillary dermis. The internal electrode moves slowly, in tandem, through the superficial sub-dermal fat. The FaceTite and NeckTite are attached directly to the BodyTite platform. The RF energy and cut-off values are set to the desired epidermal temperature. This helps prevent thermal damage. The skin surface to be treated is divided into zones. In FaceTite treatment, which is superficial, there are two clinical end points. The first pass is done with a stamping technique, in which the handpiece is held in one spot for about 1–2 seconds, depending on the fat and skin thickness, until there is an audible popping. This sound represents the RF coagulative necrosis of the adipose tissue immediately under the dermis. Once all the skin in the treatment zone has been treated, the applicator is passed slowly through the same tissue again until reaching an epidermal temperature of 38–40oC. The FaceTite applicator is then moved to the next zone until all the lax skin has been treated. Reaching these two end points is critical to achieving the desired tightening effect. Usually no suction is needed, and so the FaceTite handpiece is equipped with a solid rod and not with a cannula. However, if needed, a little suction may be done with a syringe following the procedure. The NeckTite handpiece may be used slightly deeper in the neck hypodermis, and even deeper in areas such as the arms. It has a cannula for simultaneous suction and a control to adjust depth of the treatment. The NeckTite is passed slowly through the fat layer until an epidermal temperature of 38-40oC is achieved, like the second stage of FaceTite treatment. The NeckTite handpiece may be used on small lax body areas such as the arms, inner thighs, knees and umbilical area in a similar manner. Patients with brow, cheek, lower lid and/or jaw line and neck laxity, as well as lax arms presented for treatment. Age range was 45–66 years and skin type included I–V.

For pain control, all procedures were performed under minitumescent local anaesthesia. The local anaesthetic solution was a mixture of one bottle of 1% lidocaine mixed in one litre of Ringers lactate and 2ml of epinephrine 1:1000. About 150cc of infiltrate was used for the brow, cheek, lower face and another 100cc was used for neck treatments. Prior to the tumescent anesthesia, supra-orbital, infra-orbital, zygomatico-facial, temporal and mental nerve blocks were performed with 1% lidocaine. After waiting 8–10 minutes for the vasoconstrictive epinephrine effect, the FaceTite procedure was performed. The access ports (a #11 blade, 1mm dermatologic punch, or a 22G syringe needle) were the hairline for the brow, crow’s feet for the lower lids, commissural for the nasolabial fold, the cheek-upper lipnasolabial, and marionette lines. The jaw line was treated from a sub-lobular port and neck from sub-mental and sub-lobular ports. The incisions for NeckTite may need a stitch for closure; the FaceTite incisions often are small enough to remain unstitched. Results All patients were followed up for a minimum of two months. All before and after photos were analysed. Significant tightening of the lower lid, malar pads, cheeks, nasolabial and marionette folds was observed in all patients, along with substantial skin texture improvement. Jaw line, chin enhancement and tightening were apparent in all patients. The NeckTite applied to lax arms has shown a mean surface area reduction of 33.5% and vertical shortening of 50%. Patients experienced only mild discomfort post-operatively, but oedema and swelling were present for five to seven days. There were no burns or major complications and ecchymosis was minimal. All patients were satisfied with the degree of tightening achieved and the short downtime. FaceTite may be used for neck tightening, however, when there is additional problem of excessive fat, the NeckTite that provides simultaneous liposuction may be more suitable. Dr Diane Irvine Duncan FACS is a plastic surgeon with a special interest in minimally invasive techniques

FACETITE TREATMENTS

1. Treatment of the full face before and two months after 2. Marionnette lines before and three months after treatment 3. Treatment of jaw, chin and neck before and after four months

BODYTITE TREATMENTS

4. Treatment of neck before and after two months. 5a. and 5b. Arms before and after one year 18

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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

devices

CoolSculpting

COOLSCULPTING TREATMENTS

Zeltiq’s CoolSculpting device induces apoptosis and lipolysis through tissue cooling. The benefits of non-invasive cryolipolysis are discussed by Dr Nada Souiedan

number of disciplines are looking into how to tackle the growing problem of obesity, particularly around fat cells. There are many ways to target fat, via pharmaceuticals, appetite suppressants, behavioural modification, surgical removal of fat and non-invasive procedures that kill the fat cells. We have interaction through mechanical, thermal, chemical or a combination of all, and the mode of delivery can be invasive, minimally invasive or non-invasive. Mechanical interaction, using machines, perform vigorous massage and produce shockwaves. Chemical methods use phosphatidylcholine, solvents or photodynamic therapy. Thermal treatments can be provided with lasers, RF ultrasound and cryotreatment. There are hundreds of machines on the market for tackling and killing fat cells. But how do they work? The fat can be cooked through heat using RF, ultrasound or laser but this is not selective. Patients can experience necrosis through cavitation, particularly through high intensity ultrasound, and possible fibrosis. We can chemically target adipocytes by poisoning the fat cells with mesotherapy, but some countries forbid the use of lipo-dissolve and, again, there can be necrosis and no selectivity. We can also chill the fat cell which leads to apoptosis, or natural cell death. We have no necrosis or fibrosis in the treated area and it is selective to the fat cells. The technique was discovered by Dr Dieter Manstein and Dr Rox Anderson, co-inventors of the Fraxel laser. They were inspired by case reports from popsicle panniculitis in children with fat atrophy in the cheeks, and a case of a woman with inner thigh panniculitis secondary to horseback riding in the cold. They discovered that fat cells are more susceptible to cold than skin, nerve and muscle, and that it is possible to trigger apoptosis through skin cooling. Cryolipolysis Cryolipolysis involves the non-invasive cooling of fat to induce lipolysis without damaging other tissues or structures. With precise cooling to the skin surface, we only injure fat cells, with no damage to the surrounding skin, nerves or muscles. This leads to crystallisation of the lipids within the fat cell which triggers apoptosis, followed by slow dissolution of the cell and gradual release of the lipids through the lymphatic system. Zeltiq’s CoolSculpting is the first and only non-invasive fat reduction procedure that is based on cryolipolysis. There are other machines on the market claiming to do the same thing, in less time at a reduced cost. But they don’t give the same result. Many people therefore say that cooling fat does not work—but if you are using the proper machine, under the proper conditions, then it works. This technology is based on science. The first cryolipolysis studies were carried out on pigs. An area on the pig was treated with a cooling device and 90 days later there was a 40% decrease in the fat cell layer. Immediately after treatment, nothing was seen by histology. But three to seven days later, you can see the lipolysis and inflammation around the fat cells. This effect continued up to 90 days' post-treatment. This was documented further using ultrasound—results 20

Before and two months after a single treatment to each love handle

Before and three months after one CoolSculpting treatment, showing reduction of bulge

Treated area immediately after the coolsculpting procedure, showing the “butter stick” appearance

For good patient selection, the treatment area should represent a discreet fat bulge with distinct borders

showed a >40% decrease in the thickness of the fat layer after 90 days. The cooling effect was selective because there was no change in skin colour or in the muscle. Non-invasive cryolipolysis works through controlled energy extraction from the tissue, maintained for a certain time while protecting the dermis. This causes crystallisation of the fat cells, triggering apoptotic fat cell death. These dead cells are removed by the natural biological inflammatory process, or phagocytosis. It’s important to differentiate between apoptosis and necrosis. Apoptosis is a natural biological process responsible for the death of lipocytes; it’s a programmed cell death, so there is no scar tissue formation in the body. Necrosis occurs with mechanical forms of traumatic cell death, resulting from acute cellular injury which triggers a wound healing response. We will then end up with scar tissue. Human studies were carried out showing, after seven days, misshapen cell membranes indicating the onset of apoptosis. At day 14 there is the peak of the inflammatory cell infiltrate which continues up to 90 days after the procedure. There was a 25% decrease in the fat layer over a period of four months. Most of the affected cells are removed by day 90. These fat cells and their contents are reabsorbed by the body through the body language www.bodylanguage.net

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devices

CoolSculpting applied vertically on the right and left abdomen, showing before and two months after treatment

lymphatic system and liver and there is no evidence of damage or inflammation in or around the dermis, epidermis, nerves, vessels or muscles. The process of fat cell removal is equivalent to eating a small amount of fatty food—there is no overload of lipids on the body. Clinical study A clinical study was carried out on 341 subjects treated for the love handles and back fat area. There were no reports of serious side effects. Any side effects were minor and transient, consisting of minimal bruising, minor pain, reduced sensation and temporary oedema. All side effects resolved on their own within a week. Less than 0.04% of patients complained of pain, ranging from pins and needles to a more severe sharp burning, stabbing, shooting or cramping. These complaints resolved on their own within two to three weeks. Skin changes happened in less than 0.02%. Safety features are in place to prevent this occurrence through tissue freeze. Temporary hyperpigmentation resolved completely within four months. Cryolipolysis is a low-risk, minimal downtime procedure that produces consistent fat layer reduction in properly selected

patients. Patient selection is very important. A suitable patient has a bulge with distinct borders that you can hold between your fingers. Overly thin or fat patients, those who have visceral fat or no distinct bulges are not good patients. Conditions to avoid are obvious skin laxity, firm fibrous tissue, open or infected wounds, pregnancy or lactation, known sensitivity to cold and neuropathic disorders. Localised skin cooling is contraindicated in patients with cryoglobulinemia and paroxysmal cold haemoglobinuria. Expectations You also need to set realistic expectations. I usually take 45 minutes for the consultation. Patients will always get results but they have to understand that, while this treatment is non-invasive, safe with no downtime, results take two to four months to appear. It’s a gradual improvement, so they have to be patient. The machine itself has the vacuum applicator, with a touch pad and cooling panels inside. We also use a gel pad—a nonwoven cotton sheet which protects the skin and ensures proper thermal cooling. The applicator is applied to the skin surface and energy is extracted from the fat tissue to cool the fat layer. The body’s natural inflammatory response to apoptotic fat cell death results in natural removal of cells and lipids. Once the applicator is in place, the physician is not required to be present throughout the whole procedure. The best patients are those with a persistent bulge which cannot be eradicated by exercise or diet. They don’t want to have to have surgery so this is an effective, minimally-invasive alternative. Dr Nada Soueidan is a consultant dermatologist based in Lebanon

VelaShape The VelaShape can target cellulite and offer a non-surgical body-contouring alternative for patients who don’t want surgery, writes Mr Alex Karidis

hile non-excisional lipoplasty and lipectomies are still the most effective way to achieve body reshaping, non-invasive body contouring is increasing in popularity—not everybody wants surgery. But, as with any procedure, patient selection is key. You can classify body contouring devices according to the mode of action and energy base. The basic premise of all platforms is to modify and reduce the size and number of adipocytes, resulting in a measurable reduction of fat and a circumferential reduction of the treated area. There is also strong concurrent demand for treating cellulite, with or without reshaping. Radiofrequency (RF) energy devices currently dominate the global non-invasive body contouring device market. VelaShape was the first device that was FDA cleared for both cellulite and circumference reduction. It uses four technologies: infrared light, radiofrequency, vacuum and mechanical rollers. The infrared light heats the tissue up to a depth of 3mm, RF heats the tissue from 2–20mm depth, and the vacuum and massage help optimise the RF passage through the tissues. The VelaShape Two uses 60W of RF energy, allowing for faster heating of the tissues, shorter treatment times and fewer treatment sessions. The combination of infrared, vacuum and body language www.bodylanguage.net

RF cause deep heating to the skin, fat and connective tissues. They promote an increase in collagen deposition and local cellular metabolism, which tends to reduce skin laxity and adipose cell volume. Around 90% of women have cellulite to varying

VELASHAPE

Before and after four sessions of VelaShape for circumferential reduction and cellulite 23

devices

This patient was treated with VelaShape to correct skin laxity six months after power-assisted liposuction. The photos show baseline on the left, results after one treatment, after four treatments and after six treatments

degrees. It usually appears after the initiation of menstruation and mainly appears on the hips, buttocks and legs. Subcutaneous fat lobules are separated from one another by thin strands of connective tissues called interlobular trabeculae, across the fatty layers and connect the reticular dermis to the underlying fascia. The fat cells within these chambers expand against the vertical, non-compliant and more rigid connective tissue structures, like a balloon expanding inside a plastic bag, and resulting in bulging. This leads to congestion by blood and lymph vessels being compressed, an accumulation of intracellular fluids and physiological waste. We know oestrogen stimulates lipogenesis and inhibits lipolysis, resulting in adipocyte hypertrophy in genetically predisposed individuals. This sets off a chain of events: alterations in vascular permeability, results in oedema; followed by hyperplasia of the reticular network; leading to the formation of deposits around the fat cells. You also get organisation of collagen fibres, forming micro-nodules which coalesce to form macro-nodules. Factors that induce cellulite are genetics, hormones, smoking and lack of exercise all play a role. As oestrogen is implicated, the condition is less likely in men. Degrees The first degree of cellulite is that the condition is only evident when you do a pinch test. The second degree is that you can see it simply by standing. Third degree shows raised and depressed areas, and nodules. You can also classify the condition as primary or secondary; secondary to obesity, skin flaccidity, post injection fat atrophy, or any inflammatory process. Non-excisional lipoplasty does not cure cellulite, although it can help by reducing the fat content and disrupting the fibrous bands that contribute to cellulite. However it can cause postoperative fibrosis which can disturb the micro vascular unit and exacerbate the condition. The VelaShape has two applicators. The VSmooth is 40mm x 40mm and designed for stronger dermal heating. It is mainly used for cellulite and has roller electrodes which knead out the tissue in addition to the RF. The VContour applicator is 30mm x 30mm, and is designed for small fat deposits. It can also be used for post-liposuction irregularities, where you get isolated small pockets of fat. The device’s infrared mode lights the tissue down to the deep dermis and the RF heats down to the subcutaneous tissue. You

have to achieve a certain temperature to get collagen stimulation but anything too high could cause damage with coagulation and necrosis. Hyperthermia affects metabolism—the Arrhenius equation says that the rate of metabolic reaction is an exponential function of tissue temperature. Regardless of the mechanism used to heat the tissues, you have to reach between 40°–45° and hold it there for 5–10 minutes to start the stimulatory process. You have to adhere to treatment protocols to ensure you’re directing the heat to the right place. Hyperthermia increases the diffusivity of oxygen and leads to increased metabolism. Heating increases the rate of fat metabolic reaction which accelerates lipid turnover. We then get regressive triglycerides and fatty acids outside the cell, leading to fat cell shrinkage and reduced volume. Heating also facilitates fibroblast activity, increasing derma-collagen and ground substance, as well as tightening the skin and connective tissue. Blood flow The vacuum effects of the VelaShape improve the blood supply. Around 90% of blood vessels are compressed at normal atmospheric pressure and by applying negative pressure to this, we get vessel dilatation and increased blood flow, which also contributes to increasing the substance exchange. The VelaShape’s design means tissues are heated equally, increasing the RF pathway and providing a more even transfer of energy. The device’s mechanical rollers massage and enhance the drainage of trapped, intercellular fluid to the lymphatics and stimulate fibroblast stimulation. We recommend VelaShape to patients with cellulite in our clinic. If a patient wants body contouring but declines surgery, we’ll probably offer this treatment. If the results are then not up to what they wanted, some may convert to surgery. For postliposuction contour irregularities, you tend to get a mixture of raised and depressed areas. For these, you can use the smaller VContour applicator. The VSmooth is more appropriate for multiple irregularities. You can use the VelaShape in all skin types, providing they have no medical contraindications to the infrared or RF. It’s not recommended for overweight patients, because you simply won’t get a result. Treatment protocol comprises 4–6 sessions, once a week and a monthly maintenance treatment afterwards. Mr Alex Karidis is a consultant plastic surgeon with a private practice in central London

VelaShape can treat the depressions and surface irregularities caused by liposuction. Results before and after four treatment sessions 24

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2012 Seminar

Schedule

As the exclusive distributor of

Seminar Dates

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devices

Radiofrequency-assisted liposuction While traditional liposuction is the gold standard for surgical body contouring, energy-assisted treatments provide added benefits such as skin tightening, writes Mr Lucian Ion

adiofrequency-assisted liposuction (RFAL) has primarily been introduced to fill the gaps with problems that suction-assisted liposuction (SAL) can’t address. In firmer tissue, sometimes SAL can be more difficult to use. In gynaecomastia, there is the effort to minimise scarring and therefore energy-assisted treatments can provide improvement as well as some skin tightening. RFAL focuses on selective tissue destruction and removal using electromagnetic energy. It works by liquefying the tissue. It attempts to generate skin retraction and reduce volume. We want the container to match the volume left behind. It is computer-controlled with internal and external electrodes, realtime monitoring for the surface temperature and impedance to improve safety. By heating the reticular dermis and the area just below, the device changes the characteristics of the skin. I prefer not to describe this as skin tightening or contracture because we generate a different response. The main actions are liquefaction and coagulation of the smaller blood vessels. But the long-term effect comes from the following nine months of the wound-healing sequence. In terms of infiltration, I tend to use the same parameters as for SAL, using a wet technique. I am on the cautious side with energy. But you can control the energy you provide. You set the power which will determine the energy, the temperature limit and the impedance limit. In larger volumes, never treat all layers. Under the skin’s surface and the fat shell, there has to be something soft for the skin to look normal, otherwise we will generate problems with transfer from lying down to standing. After liposuction, patients might look fine when you lie them but when they stand up, strange shapes appear in the area. Some surgeons do the extraction first with SAL and follow it up with RF heating. Consultation When I consult with these patients and decide whether to use RF versus another technique, I need to ask myself what I’m trying to achieve. I’m mainly trying to achieve skin suspension. Skin tightening is slightly overrated because the appreciation of a firm body is an amalgamation of support and elasticity of the outer layers. It is not purely related to the characteristics of the skin. But naturally, we also want to try to improve the skin. By using RF—and to some extent laser-assisted liposuction—we can improve the natural zones of adhesions, with better contact between the skin and the underlying tissues leaving sufficient elasticity that it doesn’t look bizarre. We need to remember that aggressive treatment in a young patient who will fluctuate in weight might lead to distortions because of the way the fat is limited in expanding. But one of the key points is that the treatment has to be performed without causing damage. In my practice, it has enhanced the endpoint in situations where I found SAL or power-assisted liposuction (PAL) to be limiting. All energy techniques go through the same pathway of adult wound healing. We are not generating elastic collagen production, because we hit the tissue with a different form of energy— there’s not much hope that we will create elasticity where none body language www.bodylanguage.net

was before. And we can’t thicken the dermis, such as in a patient with very thin, weakened skin. I have used the technique for most areas of the body and have also treated lipodystrophy which is a relatively difficult tissue. Maximum temperature at the start should be around 37°. It can be brought up to 42° only in select cases. If you start readily with high temperatures it will be more likely to produce damage than to help patients. Following the procedure, the amount of bruising generated—even with large-volume extractions—is quite limited. Around three months post-operatively, you can get a nice impression of tightening. I do not think this is skin tightening. I do not see the same effect with LAL, because the volumetric fibroplasias may be generated better with RF—there is more heat at the cannula tip than with the laser. HIV-related lipodystrophy is one of the most difficult areas to treat but I have found nice long-term results. With sundamaged and aged skin, you may see a pebbling effect. If you’ve done the treatment carefully, this should disappear as the wound healing progresses. But you have to be aware of the potential side effect and be able to reassure patients that it will heal if it occurs. I have used RFAL with endoscopic abdominoplasty to thin the flap. It will not create so much damage in the skin that it suffers necrosis with undermining. When harvesting for a fat transfer for the breasts, with simple SAL and fine technique you can get a nice contouring effect. In areas with moderate laxity and patients don’t want incisional techniques, it is an alternative to SAL or PAL. I have found the technique useful in difficult zones where you can see the tissue adhesion areas are the troublemakers. You want to break these and to allow the tissue to remodel around. Patients who have had previous treatments with SAL but want more sculpting can be treated with the RFAL. It can also be used for large-volume treatments. However, these are a poor indication for liposuction of any type. Liposuction won’t get them to weigh less. But if the SAL part of the treatment is correct, it can be used nicely. I have used it to help reduce the need for tightening in someone who doesn’t want periocular scars. Complications I have had three complications with RFAL concerning burns. If you want to perform RFAL, the point where it can create damage is where you advance the tip of the cannula when it’s active. I would suggest starting treatment by advancing the cannula without the foot on the pedal—just put your foot on the pedal when you withdraw. This way you never have the hot point at the very tip that can damage the tissues. You will also be able to get the tissue to loosen up, enabling back and forth movement with less risk. In terms of limitations and learning curve, safe cut-off is not a guarantee. You have to be aware and careful of what you’re doing and the operation attention is fundamental. Mr Lucian Ion is a consultant plastic surgeon who practices in Harley Street, London 27

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psychology Dr Raj Persaud

Mind and matter Even beautiful people have to interact in an engaging manner to gain social approval, writes Dr Raj Persaud. Good behaviour clearly complements good looks

t is easy to be lured into thinking that you just have to look good and the world falls into your lap. Aesthetic practitioners need to help clients to be realistic about the impact on their lives of any improvement in appearance. This seems a strange statement made alongside many of the previous articles in this series. I have highlighted empirical evidence that physically attractive people earn more and enjoy other social benefits. An emerging trend in the social psychological literature on attractiveness is “interaction effects”. This means that the impact of being good-looking is mediated by other social strategies. It's not just having a pretty face that matters, it's what you do with it. Aesthetic enhancement, therefore, is only part of the story if clients are going to benefit most from any physical changes. Professionals need to explain this somewhat delicate point. A paper by Michelle Quist and Benedict Jones, the School of Psychology, University of Aberdeen, and the School of Natural Sciences, University of Stirling (“Integrating social knowledge and physical cues when judging the attractiveness of potential mates,” Journal of Experimental Social Psychology), finds that women report a significantly greater attraction to masculine men with a reputation for being faithful compared with those known for infidelity. Men who flirted with other women, for example, while on a date with a subject in the experiment, rated worse in attractiveness, even if they were supposed to be physically more appealing. It wasn't just how they looked that mattered, but how they behaved. This is an intriguing finding, not least because the darker motivations for physical enhancement include more dominance or power in social life. People may want to abuse or exploit enhanced desirability achieved by physical improvement. It might be useful to get a sense of where a client is on this spectrum during the initial psychological assessment. The authors of the paper point to fMRI ex-

body language www.bodylanguage.net

Men who flirted rated less attractive

periments that suggest we find it more rewarding to view physically attractive faces when they appear to demonstrate positive social interest in us by, say, making eye contact or smiling. In other words, it's not enough to be just good-looking—you've got to look good and show an interest in the viewer, as opposed to being standoffish. Similarly, the authors draw attention to other research where participants report stronger attraction to physically attractive faces when they are smiling at them rather than showing an averted gaze or a more negative expression. These enhanced preferences seem to be for the physically attractive who appear willing to reciprocate investment of social effort. It is positively mentally healthy that we are not just drawn to a pretty face, we are also drawn to those in whom our social investment is likely to be reciprocated. A pretty face may be thought about subconsciously as a potential receiver of our effort and we are unlikely to want to waste our investment on receivers who are not going to benefit us with a return on our investment. Judgements of this nature involve social skills that are difficult to learn formally and are probably acquired through the school of hard knocks. Michelle Quist's study formalises a well-known observation: women can be positively put-off by a good-looking man because they reason he is highly likely to

be unfaithful. This demonstrates that we don't just make judgements about how good-looking someone is, we also assess behaviour. Being good-looking can be a twoedged sword. You may get discounted as a potential mate by those looking to make a “serious investment” in the market for partners because, while there will be shortterm rewards, there may be no long-term high interest. Again, this is fine if those seeking physical enhancements are aware that, while this may aid a short-term mating strategy, it may not fare as well for attracting partners for the longer term. The study demonstrates that perhaps women in particular are involved in juggling various trade-offs when appraising a future mate—sure, being good-looking is a plus, but there is also a trade-off. The notion that it's not just how you look, but the over-all impression you create through your behaviour, may not register with those overly obsessed with appearance. These people may be guided by media imagery and not realise that in real-life encounters, which ordinary social life consists of, behaviour has a massive interaction effect with how you look to produce your overall desirability quotient as translated into actual responses to you. The danger for professional aestheticians is that if they just stick to physical appearance changes, without entering a conversation with the client about what is the actual social goal, they will end up producing a disappointed and angry recipient of a physical change. In another behavioral context the same alteration to appearance could have delivered precisely the social goal being sought. The client needs to understand they just can't lie back and think of England after any cosmetic procedure, they need to harness the increased confidence that should arise and change their behaviour. It is the combination of both transformations that will deliver what they desire. Raj Persaud is a consultant psychiatrist in private practice at 10 Harley St, London W1 29

FACE 2012 preview

Planning ahead What a difference a decade makes. Now in its 10th year, FACE is the UK’s leading medical aesthetic event. Mark your calendar and we’ll see you there

nniversaries are special because they are markers of achievement. In 10 years FACE has evolved from a friendly get-together of practitioners sharing their experiences of a new, exciting specialisation to a meticulously planned conference that has mirrored the growth of aesthetic medicine. This year’s FACE conference at the Royal College of Physicians will offer even more value for delegates over the three days of 15–17 June. Two clinical agendas will run in parallel. A nonsurgical agenda explores the latest techniques, trials and safety data of injectable cosmetic treatments backed up with live workshops, and it investigates the latest data on fractional and nonfractional devices for facial rejuvenation and skin tightening. A surgical day probes into modern cosmetic surgery procedures for facial rejuvenation. Sessions will shed light on common skin diseases and the unique problems of treating skin of colour, complemented by a dedicated half-day workshop featuring Dr Zein Obagi. FACE 2012 will see the launch of HAIR, which will examine non-surgical and surgical options, including hair transplants.

Hair transplant surgeon Dr Bessam Farjo will conduct a halfday hair-loss workshop. A separate two-day agenda devoted to marketing and business aspects of running and promoting a successful aesthetic service will be chaired by Wendy Lewis, who has more than 15 years' experience in the US cosmetic market sector. Sessions will feature business and marketing experts. FACE’s popular “Evening With” sessions, where you get to hear from fellow practitioners about what has made them so successful, this year features Dr Zein Obagi. Not one to mince his words, Dr Obagi shares his views, discusses his own career and provides insights into running a successful private cosmetic clinic and multi-million pound skincare line. Many other fascinating lectures and a wide range of exhibitor workshops are lined up, not to mention the trade exhibits, the gala evening and refreshment and sustenance, including that much talked-about cheese board. For more information please visit www.faceconference.com and click on the conference button to view detailed agendas for each lecture theatre. These will be updated weekly before the event to keep you abreast of developments.

AMONG THE SCHEDULED PRESENTERS AT FACE…

Dr Zein Obagi

Professor Arie Orenstein

Leading skincare expert Dr Obagi brought to market the original Obagi Nu-Derm system and later ZO Skin Health. Dr Obagi is a pioneer of aesthetic dermatology.

Arie Orenstein, Professor of Plastic Surgery in Israel, is the director of the Sheba Medical Center Department of Plastic and Reconstructive Surgery and Burns.

Mr Rajiv Grover

DR MICHAEL KANE

Mr Grover is the president-elect of BAAPS and runs a private practice. Rajiv has a particular interest in the interaction of art and surgical aesthetics.

Dr Kane is a board-certified plastic surgeon with a private aesthetic plastic surgery practice in New York. He has taught thousands of physicians how to inject Botox and Restylane.

Dr Nick Lowe

DR SAM RIZK

Dr Lowe, a consultant dermatologist, has published more than 450 clinical and research articles. He has studied the effects of toxins, filler, lasers and skin-care products.

Dr Rizk is a double board-certified facial plastic surgeon specialising in face lifts, neck lifts, blepharoplasty, brow lifts and rhinoplasty. Dr Rizk has lectured extensively at conferences.

Dr Timothy Flynn

MR ADRIAN RICHARDS

Dr Flynn is a consultant dermatologist and an expert in dermatologic surgery. Dr Flynn is a well-established speaker on aesthetics and is a perennial favourite at FACE.

Mr Richards has been a consultant plastic surgeon for 10 years and has written more than 30 papers and a best-selling plastic surgery textbook.

Dr Shlomit Halachmi

DR BESSAM FARJO

Dr Halachmi is a member of numerous associations, including the American Academy of Dermatology and European Academy of Dermatology and Venereology.

After general surgery training, Dr Farjo trained in hair restoration surgery in Canada and co-founded the Farjo Medical Centre in Manchester and London.

Dr Diane Duncan

SCOTT MCCLELLAN

Dr Duncan, an American consultant plastic surgeon, describes her main area of interest as non-excisional correction of deformities within the adipose layer.

Mr McClellan is a consultant in aesthetic dermatology who regularly attends and presents at international conferences and workshops.

Dr Sabine Zenker

DR MARGE UIBU

Dr Sabine Zenker, founder and owner of the Dermatology Surgery Clinic in Munich, practises medical and surgical dermatology and is active in cosmetic dermatology.

Dr Uibu, a consultant in dermatology and allergology, is the founder and chief physician of Ihoakatemia, an aesthetic clinic in Helsinki.

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FACE 2012 preview

MAIN LECTURE PROGRAMME FRIDAY JUNE 15th

SATURDAY JUNE 16TH

SUNDAY JUNE 17th

8:30 | 9:25

REGISTRATION & EXHIBITION

8:30 | 9:20

REGISTRATION & EXHIBITION

08:30 | 09:25

REGISTRATION & EXHIBITION

09:25 | 09:30

Conference Introduction David Hicks

09:20 | 09:25

Chairmans Introduction

09:25 | 09:45

Moving Against the Myths New Directions for Botulinum Toxin in 2012 Andy Pickett

09:30 | 09:50

Notions of Beauty and Youth in Science, Arts and Culture Dr Flor Kent

09:25 | 09:55

New European “Aesthetics Standard”: Status Update Mike Regan

09:45 | 10:10

Avoiding and Managing Complications Associated with Botulinum Toxins Dr Timothy Flynn

09:50 | 10:10

Fractional Radiofrequency Microneedling in Combined Aesthetic Treatments Dr Marge Uibu

09:55 | 10:05

PIP Scandal - What Lessons for Facial Aesthetics? Mr Rajiv Grover

10:10 | 10:30

Non-Ablative Fractional Lasers Dr Stephen Murdoch

10:05 | 10:15

Dermal Filler Regulation - a US Perspective Dr Timothy Flynn

10:30 | 10:50

Local use of ReCell Spray-On Skin Benefits to Fractional CO2 Laser Treatment of Facial Wrinkles and Acne Scars in the Face Dr Klauss Hoffmann

10:15 | 10:25

Dermal Filler Regulation - A European Perspective Mr Kambiz Golchin

10:50 | 11:00

Q&A

10:25 | 11:00

Roundtable Debate on The Practical Approaches to Raising Standards in Dermal Filler Treatments

11:00 | 11:30

10:10 | 11:00

Botulinum Toxin Demonstration Dr Timothy Flynn | Dr Michael Kane

COFFEE BREAK & EXHIBITION

11:30 | 11:50

Novel Multi-Source Phase Controlled Radio Frequency for Skin Tightening and Fractional Resurfacing: The Need, the Science and the Clinical Evidence Dr Yoram Harth

11:30 | 11:50

Advanced Laser Treatment of Resistant Vascular Lesions and Malformations Dr Shlomit Halachmi

11:30 | 11:50

Avoiding and Managing Complications Associated with Dermal Fillers Dr Michael Kane, Dr Timothy Flynn

11:50 | 12:10

Radiofrequency 2nd Generation Technology for Skin Tightening Dr Tracy Mountford

11:50 | 12:10

Combining Fractional Lasers for the Treatment of Pigmentation Dr Yannis Alexandrides

11:50 | 12:10

ArqueDerma, Artistic Restoration Lift: A Novel and Highly Effective Approach in Administering Dermal Fillers Leslie Fletcher

12:10 | 12:30

The Outcomes of Delivery of Focusing Different Fractional Energies at Different Depths in the Skin Dr Shlomit Halachmi

12:10 | 12:30

International Standards of Beauty Creating the Right Jawline for the Right Patient Dr Michael Kane

12:30 | 12:50

Tear Trough - A Global Approach Dr Raj Acquilla

12:50 | 13:00

Q&A

14:30 | 14:50

To be announced

14:50 | 15:30

Creating the Perfect Lips

12:10 | 12:50

An Expert Approach to Facial Contouring Dr Raina Zarb Adami

12:30 | 12:50

Fractional Lasers for Eye Rejuvenation Dr Patrick Treacy

12:50 | 13:00

Q&A

12:50 | 13:00

Q&A

14:30 | 14:50

Overview and Role of Focused Ultrasound Therapy in a Surgical Practice Mr Alex Karidis

14:30 | 14:55

Botulinum Toxins - 20 Years Personal Use and Study Dr Nick Lowe

14:50 | 15:10

How to Mould Soft Tissue and Restore Not Only a Youthful Shape but Correct Flabbiness and “Granny Skin” Dr Diane Duncan

14:55 | 15:15

Superficial Mechanical Abrasion - Why it’s Still Important in a Medical Aesthetic Clinic Dr Stefanie Williams

15:10 | 15:30

Laser 360IQ the Innovative Approach to Skin Rejuvenation & Anti Ageing Professor Arie Orenstein

15:15 | 15:35

State of the Art Vision Correction Mr Omar Durrani

15:30 | 15:50

Non-Invasive Submental Fat Reduction

15:35 | 15:55

Aesthetic Synergy: Multi-Plane Rejuvenation With Lasers/Light, Fillers & Toxins Dr Hema Sundaram

15:30 | 15:50

The Role of Mannitol in HA Dermal Fillers Dr Ingrid Arion

15:50 | 16:10

Facial Skin Ageing: A New Treatment Option Through Mechano-Stimulation Dr Ferial Fanian

15:55 | 16:15

Anatomy of the Cheek and Lid Cheek Junction: How to Treat the Midface Safely Mr Rajiv Grover

15:50 | 16:00

Q&A

16:10 | 16:30

Advanced Needlework Elaine Stoddart

16:00 | 16:20 16:15 | 16:30

Q&A

PRP: Important Facts for Dermal Regeneration and Dermal Filling Dr Sabine Zenker

16:20 | 16:40

Mesotherapy Explained Dr Fernando Bouffard

16:30 | 17:00

COFFEE BREAK & EXHIBITION

16:40 | 17:00

CLOSE OF FACE 2012

17:00 | 17:20

The Practical Utilisation of MN Needles for Facial Rejuvenation with Dermal Fillers Dr Bernard Hertzog

17:20 | 17:50

Facial Volumising with the Pix’L Microcannula Dr Tina Alexander

17:50 | 18:05

FACE of the Industry: The Future of Cosmetic Injectables

18:05 | 18:15

Q&A

19:30 | 02:00

AESTHETIC INDUSTRY SUMMER BALL

13:00 | 14:30

LUNCH & EXHIBITION

16:30 | 16:45

Q&A

16:45 | 19:00

EXHIBITION, DRINKS & CANAPES FOLLOWED BY AN EVENING WITH DR ZEIN OBAGI

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Please note that this agenda is preliminary and speakers and lectures may change before the event

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

15th – 17th June 2012

THE UK’S PREMIER MEDICAL AESTHETIC CONFERENCE AND EXHIBITION

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.

Celebrating 10 Years of FACE

Opportunities to learn new and advanced techniques from leading practitioners in this limited space full day training course. 2012 Will mark the start of on going training courses through the weekend which will also offer hands on trainign for all participating delegates.

FACE Conference has provided over 2500 delegates from around the world the chance to see some of the most enterprising speakers, treatments and topics in Aesthetic Medicine. 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 heldby some of the worlds best practitoners and pioneers in facial aeshtetics.

EXHIBITION

Wendy Lewis, Beauty Consultant

ADVANCED TRAINING

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. FACE of the Clinic will be spread over 2 days in 2012 in order to cover all aspects of Business Managment and Maintenance.

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. FACE is proud to confirm that Dr Zein Obaji will be entertaining all delegates at An Evening With in 2012.

WWW.FACECONFERENCE.COM

0207 514 5989

“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.”

INFO@FACE-LTD.COM

The

AESTHETIC INDUSTRY 2012

Summer Ball

HENRY STUART

Saturday June 16th

Madame Tussauds, London

London will be even more special this June. Join FACE on the eve of the Summer Olympics to celebrate in style at our 10th anniversary. You can expect doubles all round at Madame Tussaud’s on Saturday 16th June at the Aesthetic Industry’s 2012 Summer Ball. Join us and your favourite stars. Raise your glass, let your hair down and enjoy a dance or two.

Sponsored By:

To book your place at the Aesthetic event of the year, call 020 7514 5989 or email info@face-ltd.com for more information

SKIN

Skin is the most visible organ affected by ageing and a variety of common skin diseases such as acne and rosacea. This year, in conjunction with the usual wide range of lectures devoted to treating ageing skin, we also have sessions related to treating common skin diseases and dealing with the unique problems associated with treating skin of colour.

HAIR

With recent widely publicised hair transplant, the market for treatments that increase the thickness and density of hair is more buoyant than ever. For the first time at FACE, we are devoting a session to examining different non-surgical and surgical options for the treatment of alopecia and exploring the business opportunity in this market segment.

SURGICAL FOCUS

Although the largest sector of the facial rejuvenation market is now dominated by nonsurgical procedures, it is vital that we understand when to refer to a Surgeon in order to achieve the more dramatic results that patients sometimes need. Our new Surgical session will explore the boundaries between non-surgical and surgical treatments alongside the latest techniques that are being employed in the Facial Cosmetic Surgery market.

ANTIOXIDANTS – THE DEBATE

A comparison of studies is the ideal way for a practitioner to decide on what product to use, and with skincare sales at an all time high, what better than a debate on the different antioxidants available.

GOLD SPONSOR

SILVER SPONSOR

FACE LTD

SKIN SPONSORS

Discover The Light

s i lv e r sponsor

cosmetic news xpo 2012 E

29th - 30th april 2012 | business design centre, islington, london w w w. c o s m e t i c n e w s u k . c o m

t h e u k ’ s o n ly free of charge aesthetics exhibition

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cosmetic news xpo 2012

Advanced Skin Lightening

29th - 30th april 2012 | business design centre, islington, london w w w. c o s m e t i c n e w s u k . c o m

t h e u k ’ s o n ly free of charge aesthetics exhibition

Fast, Safe and Gentle Skin Appearance Improvement Syneron’s elure product line is an Advanced Skin Lightening Technology, based on the proprietary enzyme Melanozyme™ - our patented version of the naturally occurring enzyme lignin peroxidase. elure is the ﬁrst clinically demonstrated skin lightening product to temporarily reduce the appearance of melanin in the skin to reveal a visibly more radiant and more even skin tone. The elure™ Promise o 5NIQUE SCIENTIüC DISCOVERY o 0ROVEN FASTER SAFER MORE VISIBLE RESULTS o 2EVOLUTIONARY PATENTED FORMULA o -ELANOZYME p A SAFE NATURALLY OCCURRING ENZYME o (YDROQUINONE FREE DERMATOLOGIST TESTED CLINICALLY PROVEN o (EALTHIER BRIGHTER YOUNGER LOOKING SKIN

Before China Clinical Trial

After (Day 28)

Before

After (Day 28) Courtesy: Tess Mauricio, M.D.

NOW Available in the UK! www.elureskin.com, info@elureskin.com, elureuk@syneron.com, Tel: 0845 521 0698 © 2011. All rights reserved. Syneron, the Syneron Logo, Melanozyme and elure are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. PB70931EN th TH now - learn Jan NOWavailable AVAILABLEinINthe THEuk UK - LEARNmore MOREatATSmart SMARTideaS IDEAS718 FEB2012 2012 VISIT WWW.SMARTSEMINAR.CO.UK FORfor MORE INFORMATION viSit www.smartseminar.co.uk more information

e m b r a c e

l i f e

insurance Eddie Hooker

VICARIOUS LIABILITY Have you covered all your employees with insurance in the event of negligence? You might not have if you have not thought about vicarious liability. Eddie Hooker elaborates

any cosmetic practitioners will usually take out insurance or indemnity cover to protect their own practice, but sometimes fail to consider the consequences of not having the appropriate insurance cover for the work of all the staff in their employment such as nurses, clinical technicians or beauticians. Whether they are employed, self-employed or freelance, it is advisable that you protect yourself against the consequences of them acting negligently. Depending on your circumstances, it may be necessary for you to contemplate cover for vicarious liability, which is when someone—other than the person who was actually negligent—may be

under contract law. As such, most employers require insurance cover to avoid such liability. An employer will avoid liability only if it can be shown that an employee acted in a way unconnected with his or her employment. Such as if the employee physically harms someone then the employee would be wholly responsible for their actions unless they were told to do it by the employer or it was part of their job. Whether cosmetic practitioners will be indemnified or offered assistance with any vicarious liability related issues by their appropriate medical defence organisation (MDO) is unclear and you will need to discuss your own individual circumstances with your indemnity pro-

A self-employed worker may be considered an employee of a practice if the majority of their income is derived from working in that practice. Temprorary staff and agency workers may also be considered employees held responsible for the negligent actions of another person. The most noteworthy vicarious liability relationship is between the employer and employee, because one party has control over the other party. In English Law, an employer is absolutely responsible for all acts and omissions of its employees, occurring during the course of their employment, which cause injury or hurt, including damage to property, to another. Although a patient can sue a negligent employee, it is rare. Usually the employer is sued. In the event of such a claim, the patient is fully entitled in law to sue the company for compensation, not only under the law governing negligence but also body language www.bodylanguage.net

vider. It is doubtful that indemnity cover held in an individual’s name would automatically be extended to protect a legal entity such as a limited company. In terms of commercial indemnity providers, such as my own organisation, vicarious liability is automatically provided under the malpractice section of the policy subject to a) the name of policy is stated as the company name and b) the member of staff undertaking the treatments being named on the policy. To remain covered by an employer's vicarious liability clause, an employee must work only within their area of assessed competence and within the responsibilities of their role and job description.

Vicarious liability throws up the question as to who is considered an employee. Many people think that a worker is considered an employee only if they are included in the practice’s PAYE scheme, and that contracting self-employed or freelance workers clears them of any responsibility of their actions. A self-employed worker may be considered an employee of a practice if the majority of their income is derived from working in that practice. Temporary staff and agency workers may also be considered employees. It is therefore advisable that these types of workers continue to be included within a practice insurance policy. You should ensure that they carry their own medical malpractice insurance for the treatments they undertake, and check this regularly, as in the event of a claim the insurance company may wish to bring the worker into any action. If you wish to ensure that you take no responsibility for the actions of a selfemployed worker, you will need to clearly promote the independence of that worker from your practice. This will include statements on consent forms and other promotional material within the practice that the worker is operating under his or her own direction and is not connected to your practice, and payments by the patient for the treatment should be made directly to the self-employed worker. Even then, there is no fail-safe “get out of jail free” solution. If the patient perceives that the worker is connected to your business, the chances are that you will hold some responsibility for their actions. My suggestion is to seek independent legal advice from an employment specialist. Eddie Hooker is chief executive officer of Hamilton Fraser Cosmetic Insurance 35

Experience the difference Your skill â&#x20AC;&#x201C; Artisteâ&#x20AC;&#x2122;s technology. The perfect partnership delivering a new level of performance.1,2

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www.experienceartiste.com help@nordsonmicromedics.com Micromedics, Inc.: 00 1 651 452 1977 European Distributor: +44 (0) 1582 691905 References: 1. Micromedics Inc. Clinical study data on fi le 2. Micromedics Inc. Survey results on fi le

MICROMEDICS

injectables Dr Kate Goldie

Hand in hand Most anti-ageing treament regimes focus on facial rejuvenation but the hands should addressed at the same time. Dr Kate Goldie discusses her approach to hand rejuvenation and augmentation

e’re now performing aesthetic facial rejuvena- will solve the problem. In terms of injectable treatments, we have tion procedures with outstanding results so the poly-L-lactic acid, hyaluronic acid (HA), fat grafting and calcium mismatch between a treated face and untreated hydroxylapatite, or Radiesse. A light HA, such as Belotero Bahands has become much more obvious. sic, can be used in small injections in a mesotherapy fashion. But Every day, our hands are exposed to many negative environ- Radiesse has a number of properties that makes it better for hand mental factors—including the sun, trauma and chemicals—and rejuvenation than HAs. It is more viscous, elastic and opaque. so they age quickly. But as with the face, hands also suffer from So you need to assess what treatment the patient needs. If fat loss, bone loss, muscle loss and skin laxity. So we should take you see a young patient with great skin but no fat in her hands, the same systematic approach to hand augmentation as we do to she will just need volumisation. But if someone has volume loss face augmentation. as well as crepey, thin, dehydrated skin then you can volumise So who needs treatment? Patients with age-related volume the hand with Radiesse and add a thin layer of HA in the dermis loss and environmental ageing and younger, thin women with for hydration. bony hands that look older than their face. Some may not need Volume loss appears between the metacarpals. The area is facial rejuvenation but are aware that their hands look older than bound between the metacarpal joint and where the carpals are their face as they do not have the subcutaneous fat cover. articulating with the metacarpals of the wrist. So the area rests Another group of patients are those who, through exercise, between the second to the fifth metacarpal. have built up their We also need muscles to such an to take into acextent that they count the properneed extra venous ties of the product. support—their veins Radiesse has 30% have become much microspheres in the more prominent. gel, so you have to Plastic surmassage to get it in geon Dr Robert the right place. You Baines, performed want to get the sura questionnaire to face as flat and even find out what it is as you can. You also about hands that need to advise your makes them old. patients not to masRespondents said sage the hands across older hands have the knuckles or up wrinkles, prominent against your wrists veins and joints, thin after treatment— skin, poor skin qualyou want your cority and dyschromia. rection to stay where Interestingly, the Before and after injections of Radiesse into the hands for volumisation. Hyaluronic acid can be you’ve put it. questionnaire also added in the dermis afterwards for hydration There are two showed that hands layers of fascia on the are a more reliable indicator of age than hands. The most statisti- hand—a superficial layer of dorsal fascia and a deep one. Undercally significant indicator of age proved to be vein prominence. neath the superficial fascia are the superficial veins and nerves that So that’s something we need to focus on when augmenting the run on the dorsum of the hand. You inject the Radiesse on top of hand. The Merz hand-grading scales feature photographs grad- the superficial fascia. To get to that plane, just pull the skin up in ing different soft tissue deficits. So, for example, you can show the hand—where you see it tenting up is where you need to inject. the scale to your patient and tell them, “You’re a three at the mo- Augmentation will last at least a year, sometimes longer. ment because you have severe fat loss, visible tendons and a few To hydrate afterwards with an HA, like Belotero, injection brown spots. But, by the end of treatment, we’re going to get you is totally superficial and not subcutaneous. Just inject into the to a one.” Patients like numbers and being graded in that way. dermis to improve skin texture. But we’re also diagnosing the hand in the same way as we should diagnose a face. We need to look at skin quality: is there Dr Kate Goldie is founder of Medics Direct (Europe) Ltd, a medical loss of elasticity? Is the skin baggy? Do the pinch test; does it snap cosmetic training company. She is also clinical director and founder back quickly? This is important to determine which treatment of Advanced Rejuvenation Clinic in Glasgow

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products

market On the

Latest arrivals stirring discussion in aesthetics Lidocaine added to Voluma

Allergan has launched Juvéderm Voluma with Lidocaine to increase patient comfort during the injection. The injectable is available in a 2x1ml syringe package or a 1x2ml syringe. Dr Raina Zarb Adami, medical director of the Academy of Aesthetic Excellence, a provider of training courses, says: “This may make the treatment more appealing to those who have previously been nervous about trying facial injectable treatments. I look forward to including it in my portfolio of dermal fillers.” l Allergan commissioned a survey to determine European consumers’ understanding of the causes of facial ageing. It identified considerable misunderstandings about what changes can lead to an ageing appearance. Only 40% of women identified volume loss as a contributor to ageing looks, and only 5% of responders identified that a main cause of volume loss was the reduction of fat beneath the skin. Allergan, W: juvedermultra.co.uk

Firm, supple, smooth approach to anti-ageing A face and body skin-care line billed as “the next generation in anti-ageing and cellulite reduction” has been launched by LPG Endermologie. Soins Techniques LPG is a group of home-care products that include an “Essential Day and Night” range with three results-driven face creams and a “Specialised” range of three targeted products. The products target the three main effects of ageing: sagging, hollowing and thickening, with active ingredients that stimulate natural cellular activity of antiageing functions. LPG, W: lpgendermologie.co.uk

Aesthetic nutrition protocols devised Ysonut Laboratories is launching its aesthetic nutrition protocols in the UK. The protocols enhance the effects of treatments provided by medical aesthetic practitioners, the company claims. The micronutrition supplement has protocols to tackle cellulite; for use before and after cosmetic surgery and injectable procedures to reduce bruising and swelling and increase healing; and to increase the efficacy of clinic-based treatments by balancing hormones and correcting nutrient deficiencies responsible for promoting acne. Ysonut, W: ysonut.com; T: 08008 400 890.

InnoSearch range finds a new UK home The complete InnoSearch range, including Inno-Roller, Inno-Derma, Inno-Peel, InnoTDS and Inno-Caps will supersede the Dermaceutic range at Medical Aesthetic Group. Inno-Roller is a line of solutions for use with a dermaroller for transdermal delivery and stimulation of cell renewal, and Inno-Derma targets basic daily skin and body care. Summing up the other products, Inno-Peel is a line of professional peeling products; Inno-TDS is a trans-dermal release mesotherapy system that includes weight, cellulite, hair loss and anti-ageing solutions; and Inno-Caps is a range of nutricosmetic products. Innosearch formulates and manufactures all its products in Barcelona. Medical Aesthetic Group, W: magroup.co.uk; T: 02380 676733.

Lumenis Ltd has introduced SCAAR FX (Synergistic Coagulation and Ablation body language www.bodylanguage.net

for Advanced Resurfacing), an UltraPulse mode that treats surgical and acne scars, commonly characterised as conspicuous, complex and deep skin lesions up to 4mm deep. Cynosure has demonstrated favourable results for its picosecond Alexandrite laser technology, designed for multiple applications, including tattoo removal and pigmented lesions. A study of 22 subjects with multicoloured tattoos were treated with Cynosure's picosecond laser platform over two weeks with more than 80% tattoo

clearance. On average, 94% clearance was achieved for blue and green ink. ARTISTE injection system ranked favourably among clinical injectors, says Micromedics, which markets the automated injector. A three-centre, 52-subject study in the US found it led to better results, easier treatment, fewer injections and more consistency. One centre reported a reduction of filler compared with manual injection. Reduced thumb fatigue and greater control over the syringe were cited as advantages compared with manual techniques.

Brushstrokes

Erchonia Europe,  the provider of low level laser technology for medical applications, has been renamed Primcogent Solutions and has exclusive North American and western European distribution rights to the Zerona non-invasive body contouring laser.

DR RAJ ACQUILLA

design

How clinics profit from good design What attracts patients to your clinic—comfort and soft furnishings or clean lines and minimalism? Helen Twinam speaks to architects and clinic owners for their views on effective design

hether it is a doctor’s surgery, dental clinic, hospital or cosmetic clinic for a voluntary procedure, most people become nervous walking into a medical building. The prospect of an invasive or painful treatment can cause anxiety and often reduce even the most confident of patients to a bag of nerves. A relaxing and calming atmosphere is a vital ingredient of a good patient experience, and good design plays a large role in achieving that. A 2011 report by the British Medical Association stated that healthcare building design should extend

beyond functional efficiency, marketing and cost and “promote wellness by creating physical surroundings that are psychologically supportive”. A medical environment can employ “wellness design”, a concept concerned with the healing and overall well being of patients through design of space and environment. Those involved in the design and construction of a new clinic—architects, interior designers, project managers—tend to employ the principles of evidencebased design (EBD), which uses credible research to assist the design process. Elements involved are observational research

(patient interaction); quantitative data (reviewing existing literature); and primary data from site visits. Medical Architecture (MAAP), a global healthcare planning and architecture firm, specialises in designing environments for healthcare and applies EBD within the design process. The company’s clients range from state-supported health systems, such as the NHS, to smaller commissions with private clinics. Founding director Christopher Shaw says the design process for a medical environment should take into account the same concerns as any workplace. “The space and rooms for medical treatment body language www.bodylanguage.net

design

Opulence, comfort and privacy were Dr Raj Acquilla’s principal considerations for the design of his clinic in Cheshire

colour through the day’s cycle. MAAP uses natural materials that are familiar and communicate positive values. “We try to use wood that is warm to touch and stone or brick that ages and takes on a patina where possible,” Christopher says.

should be designed with exactly the same concern for ergonomics and human comfort that you would adopt in any workplace, public amenity or residential environment. There is little difference. Design must respond to the human condition, and this means there may be features that provide reassurance and support for anxious and ill people,” he says. In an industry that is constantly evolving—with new technology surfacing every year—changes must be reflected in architecture and design to enable future growth. “Innovation is generally evolutionary, but there have been a number of major shifts in recent years. There is recognition that the environment should support a broader well being of patients, staff and visitors and that design has a role body language www.bodylanguage.net

in supporting healthier lifestyles. “The design of a medical environment is governed by a range of demands. Florence Nightingale’s requirement that ‘the building should do no harm’ is still a valid starting point. Organisation, movement, sufficient space, managed airflow and selection of surface materials all help in reducing acquired infection, slips and harm,” Christopher says. Surfaces, materials, colour and lighting affect patient satisfaction. “Comfort, recognition and good communication are important. We use interior designers and artists to work closely within the design team. The use of colour and lighting can be managed to change the mood. We have used stained glass to modify daylight and LEDs to change lighting condition and

Aesthetic aims Dr Stefanie Williams, a dermatologist and medical director of European Dermatology London, based at the Chelsea Bridge clinic, says her approach was to keep the space “clean and clinical”, emulating continental clinic architecture. “I have strong opinions about what I like and what I don’t like. The clinic is mostly white with straight lines, non-ornamental shapes and furniture. I specifically avoided carpets, curtains and any ‘fluffy’ feel, and kept the clinic design sharp and—to some extent—minimalistic. “There is a difference between clinic designs in the UK and the continent, where I grew up and trained. If you look around in Harley Street, for example, you will find lots of clinics with carpets, curtains and many soft furnishings, which to me looks a bit unhygienic and old-fashioned. I wanted to avoid this ‘granny’s front room’ look and keep things simple, clean and clinical, like most clinics in Germany are,” says Dr Williams. A clinical, minimal approach to design undoubtedly promotes hygiene and cleanliness, an essential factor in a clinic providing medical procedures. Dentistturned-architect Dr Richard Mitzman agrees: “It is top priority. Design out clutter, otherwise it all has to be cleaned—the less you have, the less there is to clean.” Most of Dr Mitzman’s architectural successes have involved dental practices, opthalmic and plastic surgery clinics; his alternative career path has enabled him to lend a surgical eye to his designs. “You only have one life. I had achieved a lot in dentistry and wanted to try sculpture. After several years I commenced a part-time degree course in architecture, thinking this would push my sculpture in a spatial direction. Nine years later I had gained the degree, diploma and professional exams and was an architect!” Apart from a clean and simple design, Dr Mitzman promotes his twin-surgery principle in dental clinics. “Twin chairs are central to my philosophy. I install twin surgeries in all my practices and it always works.” A second dentist’s chair enables the first surgery to be cleaned while the other is in use, saving around five minutes per patient. 41

onfidence is Reliable1,2 Rewarding3 Performance4,5 BOTOX® is licensed for the treatment of moderate to severe glabellar lines Delivers long-lasting patient satisfaction, time after time2,3 Has been used for over 20 years in over 26 million treatment sessions worldwide6 Is the world’s first and most studied botulinum toxin*7

BOTOX® (botulinum toxin type A) Abbreviated Prescribing Information Presentation: Botulinum toxin type A (from clostridium botulinum), 50 or 100 or 200 Allergan Units/vial. Indications: Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar lines), in adults <65 years, when the severity of these lines has an important psychological impact for the patient. Dosage and Administration: See Summary of Product Characteristics for full information. Do not inject into blood vessels. Doses of botulinum toxin are not interchangeable between products. Not recommended for patients <18 or >65 years. Use for one patient treatment only during a single session. Reconstitute vial with 1.25ml of 0.9% preservative free sodium chloride for injection (4U/0.1ml). The recommended injection volume per muscle site is 0.1ml (4U). Five injection sites: 2 in each corrugator muscle and 1 in the procerus muscle: total dose 20U. Contraindications: Known hypersensitivity to any constituent. Infection at proposed injection site(s). Warnings/Precautions: Relevant anatomy and changes due to prior surgical procedures must be understood prior to administration. Do not exceed recommended dosages and frequency of administration. Adrenaline and other anti-anaphylactic measures should be available. Reports of side effects related to spread of toxin distant from injection site, sometimes resulting in death. Therapeutic doses may cause exaggerated muscle weakness. Caution in patients with underlying neurological disorder and history of dysphagia and aspiration. Patients should seek medical help if swallowing, speech or respiratory disorders arise. Clinical fluctuations may occur during repeated use. Too frequent or excessive dosing can lead to antibody formation and treatment resistance. The previously sedentary patient should resume activities gradually. Caution in the presence of inflammation at injection site(s) or when excessive weakness/ atrophy is present in target muscle. Caution when used for treatment of patients with peripheral motor neuropathic disease. Use with extreme caution and close supervision in patients with defective neuromuscular transmission (myasthenia gravis, Eaton Lambert Syndrome). Contains human serum albumin. Procedure related injury could occur. Interactions No interaction studies have been performed. No interactions of clinical significance have been reported. Theoretically, the effect may be potentiated by aminoglycoside antibiotics or other drugs that interfere with neuromuscular transmission. Effects of administering different botulinum toxin stereotypes simultaneously, or within several months of each other, is unknown and may cause exacerbation of excessive neuromuscular weakness. Pregnancy: BOTOX® should not be used during preganancy unless clearly necessary. Lactation: use during lactation cannot be recommended. Adverse Effects: See Summary of Product Characteristics for full information on side effects. Based on controlled clinical trial data, the proportion of patients that would be expected to experience an adverse reaction after treatment is 23.5% (placebo: 19.2%). In general, reactions occur within the first few days following injection and are transient. Pain/burning/stinging, oedema and/or bruising may be associated with the

injection. Frequency By Indication: Defined as follows: Very Common (> 1/10); Common (>1/100 to <1/10); Uncommon (>1/1,000 to <1/100); Rare (>1/10,000 to <1/1,000); Very Rare (<1/10,000). Infections and infestations. Uncommon: Infection. Psychiatric disorders. Uncommon: Anxiety. Nervous system disorders. Common: Headache. Uncommon: Paresthesia, dizziness. Eye disorders. Common: Eyelid ptosis. Uncommon: Blepharitis, eye pain, visual disturbance. Gastrointestinal disorders. Uncommon: Nausea, oral dryness. Skin and subcutaneous tissue disorders. Common: Erythema, Uncommon: Skin tightness, oedema (face, eyelid, periorbital), photosensitivity reaction, pruritus, dry skin. Musculoskeletal and connective tissue disorders. Common: Localised muscle weakness, Uncommon: Muscle twitching. General disorders and administration site conditions. Common: Face pain, Uncommon: Flu syndrome, asthenia, fever. The following other adverse events have been reported since the drug has been marketed: dysarthria; abdominal pain; vision blurred; pyrexia; focal facial paralysis; hypoaesthesia; malaise; myalgia; pruritus; hyperhidrosis; diarrhoea; anorexia; hypoacusis; tinnitus; radiculopathy; syncope; myasthenia gravis; erythema multiforme; dermatitis psoriasiform; vomiting and brachial plexopathy; rash; psoriasiform eruption; anaphylactic reaction (angiodema, bronchospasm); alopecia and madarosis. Adverse reactions possibly related to spread of toxin distant from injection site have been reported very rarely (exaggerated muscle weakness, dysphagia, or aspiration pneumonia which can be fatal). NHS Price: 50 Units: £77.50, 100 Units: £138.20, 200 Units £276.40. Marketing Authorization Number: PL 00426/0074 Marketing Authorization Holder: Allergan Pharmaceuticals (Ireland) Ltd., Westport, Co. Mayo, Ireland. Legal Category: POM. Date of preparation: November 2011.

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026. References: 1. De Almeida A et al. Dermatologic Surgery 2007;33:S37–43. 2. Carruthers A et al. J Clin Res, 2004;7:1–20. 3. Stotland MA et al. Plast Reconstr Surg, 2007;120:1386–1393. 4. Beer KR et al. J Drugs Dermatol, 2011;10(1) :39–44. 5. Lowe et al. Am Acad Dermatol, 2006;55:975-980. 6. Allergan data on file. BOTGL/001/SEP 2011 7. Allergan Data on File VIS/006/JUL2011. *Allergan botulinum toxin type A. Global figures. Launched in 1989 in the US. UK/1010/2011 Date of Preparation November 2011

RICHARD MITZMAN

design

Maple Orthodontics in Slough, designed by Dr Richard Mitzman, features glass and clean lines, reflecting the architect’s ‘clutter-free’ philosophy

To ensure productivity and hygiene, a medical workspace must be well organised, separated and zoned. In fact, MAAP director Christopher Shaw says the organisation of space is as important as the functional space itself. “Clear zoning and separation of activities enables patients, staff and visitors to interact effectively. The logistical systems that support holding and flows of supplies and clinical waste need to be unobtrusive but work well,” says Christopher. “Rooms need to provide ergonomic support for complex medical activities supported by staff and equipment. They often need to be able to cater for multiple functions and be adaptable for future activities,” he says. Breaking up the vast expanse of white

in the European Dermatology clinic are Skin Art Inner Portraits—bespoke, colourful artworks derived from microscopic images of the skin. “These images are like a refreshing splash of colour in the white rooms and the natural focus of attention,” says Dr Williams. As well as boosting revenue, eyecatching artwork provides a distraction for patients in the waiting room. Much research has been carried out on the positive effects of visual art on patients. A 2003 study by Professor Roger Ulrich and Laura Gilpin found that nature art, or representations of nature, promote health restoration, particularly if the images include calm or slowly-moving water, verdant foliage, flowers, Savannahlike properties or unthreatening wildlife. An earlier 1984 study by Ulrich showed that postoperative gall-bladder surgery in patients whose rooms had views of a park had better outcomes than those with views of a brick wall. Clinics must also focus on providing a calming, relaxing space. “In our waiting area, which is very open, with lots of space and a view onto Chelsea Bridge and the river, we provide coffee and tea for our patients,” says Dr Williams. “I would love to extend this to an outside space in which patients could sit, relax and enjoy their coffee—but of course we would need better weather.” While a clinical design and environment promotes cleanliness and state-ofthe-art features, some patients simply prefer a home-from-home—comfortable,

cosy surroundings in which they can relax. Cheshire-based Dr Raj Acquilla says his design focuses on comfort, furnishings and privacy. He practises from two Cheshire-based clinics; the state-of-theart Gatehouse clinic in Whitegate and Cheshire Cosmetic clinic at Kingsmead Medical Centre, both of which feature contrasting designs. “One is luxurious, discreet and opulent for the more discerning patient while the other is larger, more clinical and functional. They differ in their location and client base, which is an important factor when deciding how to pitch the design of a clinic,” Dr Acquilla says. Alongside his architect, Dr Acquilla designed the interior of his clinic himself. He aimed to create a “sense of space, luxury, privacy and tranquility”, using contrasting materials such as silk, soft textiles, crystal, mirrored glass, marble and quartz to give a feel of natural harmony. His patients have responded positively. “They feel relaxed, comfortable, cared for and pampered. My clinic offers a unique alternative to a high street option. Access is via a private gated entrance with secluded parking, then the grounds and clinic are exclusively at the disposal of the individual or group. “We allow only one party at a time, giving a real sense of privacy, time and space—ideal for those discerning clients who are looking for a discreet and luxurious bespoke experience. While your clinic must convey an air of safety, compliance and quality, this is ultimately an

2012 MEDICAL ARCHITECTURE

Surfaces, materials, colour and lighting affect patient satisfaction—use of colour and lighting can be managed to change the mood, as with MAAP’S design of mental health facility Rosewood Park

body language www.bodylanguage.net

DR STEFANIE WILLIAMS

design

Dr Stefanie Williams’ clinic emulates a continental ‘hygienic’ approach to design, featuring straight lines, minimalistic decoration and no ‘fluffiness’

aesthetic space and thoughtful and sympathetic design will encourage a positive feeling among the patients and enhance their experience,” says Dr Acquilla. The privacy element of aesthetic clinic design is often appreciated by patients, particularly if they have a public profile. Dr Raj Kanodia is a California-based plastic surgeon, with a clinic located in the heart of Beverly Hills—home to the rich and famous. His plastic surgery centre was built in 1993 and promotes a “clean surgery” environment, with two operating rooms and two minor procedure suites. During the design process, confidentiality for celebrity clients dictated the need for a separate entrance and exit to the main clinic and private suites are designated to each patient, “giving a sense of privacy and tranquility to their overall experience.” But while a well-designed clinic has a great effect on patients, it also creates a happy group of employees. “My team love spending time in the clinic as a space they can enjoy as well as the patients,” says Dr Acquilla. Christopher Shaw concurs. “Staff are crucial to good patient care. Clients comment on the role of good design in

recruiting and retaining the best staff.” A 2004 study, carried out by the Commission for Architecture and the Built Environment (CABE) looked at the role of hospital design in recruiting and retaining NHS nurses. Focus groups highlighted concerns that would improve employee satisfaction, such as lighting, relaxation and “civic value”—how the design engages with the local community. The study found that 84% of directors of nursing have experienced some degree of difficulty with recruiting nursing staff, with 78% of directors saying hospital design impacts on recruitment. Nurses said visiting a poorly designed workplace may dissuade them from working there. One nurse extolled the benefits of natural light when they are working. Others highlighted the need for sufficient staff facilities, particularly relaxing staff rest areas and attractive outside spaces. “It would show that they care about us by having a place where we can relax.” Whichever way you look at it, design has a profound effect on staff, customers, well being and, of course, the bottom line. Helen Twinam is the assistant editor of Body Language

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clinical practice Theresa Arnold

Micropigmentation When treatments fail to solve skin conditions, micropigmentation can restore order by altering appearance and renewing confidence in patients, writes Theresa Arnold

qualified with a medical degree in Sydney, Australia and at first followed the traditional route of residency with a view to becoming a general physician. After several rotations, I realised that I was most interested in aesthetic medicine and particularly in the treatment pigmentation disorders. I observed that many such conditions had tremendously debilitating sociological and psychological effects on those suffering from them, but that treatments generally available were not always effective or appropriate. I have always believed that a patient’s state of mind can have a huge impact. In working with patients, especially those following cancer surgery, helping to make them feel better aesthetically has a huge positive impact on their overall feeling of health and well being. I subsequently moved to the US, where I continued further education in pain management and was given the opportunity to further develop techniques of medical micropigmentation while working with some of the US’s leading dermatologists and surgeons, including those in the department of dermatological surgery at Stanford University. For many patients, micropigmentation is their last hope and this always represents a great challenge. Typically, I receive a referral from a dermatologist or plastic surgeon who may well have initially attempted laser or topical treatments. Owing to a variety of factors often outside the practitioner’s control, these may not have had the desired impact or success. The most difficult cases are often those where laser therapy has already been attempted but has proved ineffective or left the patient’s skin with unsightly scars and hyper or hypopigmenting. This hyperpigmenting, especially in dark-skinned patients, can appear far worse than their original condition.

One patient, Pooja S, first presented having already had several laser treatments with an experienced dermatologist for the vitiligo on her hands (see photos). This had caused her great distress, impacting both her career and social life to such an extent that she rarely left the house following her last unsuccessful treatment. After an initial consultation and test patch were performed to test her suitability for micropigmentation, six custom medical grade pigments were blended to match her natural skin tone and inserted using needles in gauges ranging from 26 to 33. Affected areas with little or no subcutaneous fat are more difficult to treat and can be more painful for the patient. Hands and feet are the most difficult areas to treat and are subjected to a great deal of wear and tear, take longer to heal, and will require more follow-up treatments to maintain the desired colour than other areas of the body. Another patient, Erica P, had suffered with a vascular nevus birthmark from birth that covered a large part of her right cheek, ear and eye (see photos). It had been stable for many years and had been similarly resistant to the Q-switched laser. She would spend several hours a day applying make-up in an attempt to mask the stain, but found this would rub off on clothes, especially when she began to sweat. My treatment was performed over five sessions, each lasting approximately 90 minutes (30 minutes numbing). The size of the birthmark required the procedure to be broken into two sections, lower and upper face, with small circular areas of 2–3 inches being treated at a time. The treatments were scheduled six weeks apart. Despite advances in treating pigmented nevi, post-inflammatory hyperpigmentation, hypopigmentation, vitligo

Vitiligo before treatment, after the third session and six weeks after the fourth treatment body language www.bodylanguage.net

clinical practice Theresa Arnold

Spectrocolorimeter A spectrocolorimeter, a small hand-held optical device that takes a reading from a colour sample and converts the given colour into a numerical value within the visible light range, can assist in matching and may be utilised to help predict the appearance of injected skin. A variety of instruments are used for dye placement. In most instances, needles are used. Not all patients are suitable for micropigmentation, and typically those presenting with psoriasis or who have active rashes or skin condition such as acne are not suitable candidates. As procedures require patients to remain relatively still throughout, children under the age of five are not suitable candidates. It is often impossible to predict which patients will respond most favourably to the treatments. As such, following an initial consultation, a small test patch generally no larger than 3mm in diameter can be performed. After 10–14 days, if the patch has responded well, micropigmentation can begin with sessions lasting from 30–60 minutes, depending on the size and complexity of areas requiring treatment. Pigments are inserted directly into the subcutaneous tissue. Dye injected shallower than the epidermal basal layer disappears over several weeks and will not provide a lasting result owing to the regular regeneration of the epidermal stem cells. The pigments are inserted into the skin in a circular pattern around the afbody language www.bodylanguage.net

fected area, in a similar manner in which tattoo inks are manipulated when creating tattoo designs. This is why this procedure is often called “medical tattooing”. But pigments used medically must be metabolically inert, and are different from any kind of tattooing ink. These pigments are immune to the biological changes in the skin, or changes induced by external factors, ensuring that the original shades of the pigment are retained. Standard tattoo inks must not be used, because they have a high rate of oxidation, migration and are known to change colour in the skin. In some instances they cause severe allergic reaction and granulomas. An after-care package is given to the patient that includes antibotic gel, vitimans A and D ointment as well sunblock. Procedures are scheduled 4–6 weeks apart. The expertise of the practitioner is critical to the end result and patient satisfaction. The immediate results of this approach and its non-invasive nature have made it a preferred option for many patients. The procedure does not require surgical sedation or hospitalisation.

THERESA ARNOLD

and striae, such abnormalities can resist treatment. Micropigmentation can be the solution—not curing the condition, of course, but providing a good cosmetic result that helps rebuild patients’ confidence. A typical procedure begins with numbing the patient with a topical anaesthetic such as BLT (20% benzocaine, 6% lidocaine, and 4% tetracaine), which is applied 10–30 minutes before the commencement of a procedure to minimise patient discomfort. In some patients an injection of lidocaine may be needed. Pigment dye is then selected from a range of flesh tone medical pigments and mixed to match the patient’s natural skin colour surrounding the affected area. Predicting the colour outcome is dependent on the experience of the practitioner.

Wide variety The procedure may be used to treat a wide spectrum of pigmentation conditions and diseases of cosmetic importance. Micropigmentation is being used for various medical indications such as moderate to severe striae; post-surgery scars including burn scars, Mohs surgery scars, facelift scars and abdominoplasty scars; birthmarks including congenital pigmented nevi and port wine stains; vitiligo; and nipple-areola reconstruction. Micropigmentation vitiligo treatment is recommended only when the vitiligo is stable and has been resistant to other therapies. People with a medical history of skin problems such as active acne or psoriasis are not satisfactory candidates for micropigmentation. The procedure is relatively easy, provides permanent camouflage, and is generally devoid of any significant adverse effects. But infections can be transmitted from one patient to another if the universal precautions for sterilisation of instruments used for micropigmentation are not adhered to. Theresa Arnold MBBS founded DermInk in 2005.

Before treatment, during the procedure with small circular areas of 2–3 inches being treated at a time, and six weeks post-fourth treatment 47

injectables Dr John Quinn

Fillers and radio frequency Combination treatments are common practice, with toxins and fillers being the most prevalent. Dr John Quinn discusses both, with the addition of radio frequency

DR JOHN QUINN

n the last few years we have become aware of the importance of volume loss as a central cause of facial ageing. The concept of a pyramid of youth is well recognised. In youth, the base of this pyramid is in the mid-face and the apex points downwards. The cheek is full and the jaw well-defined. As we age, the orientation of this pyramid reverses. Several distinct fat pads in the mid-face tend to deplete in a specific sequence. With time, the base of the pyramid sits, as jowls, on the lower border of the face. The gold standard treatment for significant jowls is a surgical lower facelift. But many patients do not want surgery. They look to non-surgical practitioners for ways to delay or avoid this. Facial revolumisation replaces what is lost during ageing in the mid-face, the temples and along the jaw line. Hyaluronic acid (HA) has been around since the 1990s, Restylane being the original gold standard. It is a naturally occurring polysaccharide, found within the skin. It is thus well tolerated. HA is extremely hydrophilic, with one gram of the substance capable of binding up to three litres of water. Unless it

 48

is cross-linked in some form, it does not have much longevity on injection. Many HA fillers are available. Dermal fillers are currently classed as medical devices rather than prescription medications. While HA dermal fillers are well tolerated, their use as volumising agents has been somewhat limited by longevity issues in the past. Lift capacity is of great importance when choosing a revolumising agent. It is self-evident that, for revolumising, we require a product with high lift capacity. This capacity is a function of two properties, namely the elastic modulus and the cohesivity of the filler. The elastic modulus is also known as the gel hardness or G' (G prime). The higher the G', the more palpable the filler in the skin generally. Cohesivity describes how well a product retains its shape once injected. G' is primarily influenced by the degree of cross-linking, HA concentration and gel sizing. The amount of uncross-linked HA has a secondary role. Cohesivity, however, is affected primarily by the amount of uncross-linked HA. This acts as a lubricant. It is only influenced secondarily by the degree of cross-linking.

The Juvederm Ultra range relies on high cohesivity, which compensates for lower gel hardness to provide lift capacity. Certainly in my experience it is less palpable in the skin than some other HA fillers. Juvederm Voluma is high in both G' and cohesivity. It achieves this by using low molecular weight HA chains, which are tightly cross-linked. This explains its high lift capacity and its longevity. The product has been available in the UK since 2009 and has been well studied. Herve Raspaldo in France carried out a retrospective study of 102 patients treated in the mid-face region. Improvements were assessed by both the investigator, using the global aesthetic improvement scale (GAIS) and by the patient. Using the GAIS at one month and at 6–18 months revealed that most patients were very much or much improved; 98% at one month and 81% at the 6–18-month assessments; 98% of patients would recommend the treatment to their friends. Judging the lift capacity of Sculptra and Radiesse is not straightforward. Recent studies published looking at the G’ of Radiesse are somewhat confusing, since the revolumising capacity of the product is not entirely due to direct ef-

 body language www.bodylanguage.net

injectables Dr John Quinn

fect. Similarly, Sculptra does not directly fill, rather it stimulates collagenesis. My issue with this is reproducibility. Fat has a G’ and a low lift capacity. I find that, increasingly, I combine treatments in my practice. There are several factors behind this. Certain treatment modalities make sense in certain areas. We know that botulinum toxins are first line in the treatment of glabellar frown lines. Dermal fillers are first line in treating marionette folds. However, sometimes a combination of both works better. The second factor is patient demand. Increasingly, patients wishing to avoid surgery present for facial rejuvenation. They request surgical quality results with no downtime. Consumers Modern patients are also consumers. With internet knowledge, my patients specifically request new treatment modalities. It is the role of a good cosmetic doctor to know what works and what doesn't. My advice is not to jump on the bandwagon of every new treatment that comes along. Having said that, cosmetic medicine is a wonderful, growing speciality. We should offer combination treatments simply because effective combinations are available. There is no excuse for over treating with toxin or fillers or both and not looking at other modalities. Radio frequency skin tightening uses electrical energy to generate heat in the dermis through resistance. The technology is frequently divided into monopolar or bipolar modalities. In monopolar machines, the handpiece contains one electrode only. An earth pad is thus required to be placed somewhere else on the body, usually the back.

 body language www.bodylanguage.net

Bipolar machines contain both electrodes within the handpiece. They both aim for the same effect, to partially disrupt the collagen fibril structure. This damage stimulates repair which leads to new collagen production. There are numerous machines on the market. To my knowledge, no head-tohead studies have been performed. Newer machines involving needle penetration of the skin are certainly more aggressive and may even prove more efficacious. Monopolar device I chose the Ellman Pelleve for my practice (available from Sigmacon UK). This monopolar device has two main advantages. First, it gives an immediate effect which patients appreciate. Second, it doesn't hurt. It really suits needle-phobic patients and patients who object to neurotoxins and fillers. White paper studies have found it to be efficacious. I have been using the machine since July last year and I find that it fits nicely into my portfolio of treatments. It is best used within a combination treatment plan. My preference is to perform two Pelleve treatments to the lower face, separated by about a month. Midway between the two treatments I add mid-face volume using generally 2ml of Juvederm Voluma. I finish by using Botox to lift the brows. I call the process the “Q Lift”. Regular audit of our results is an integral part of our continuing professional development as healthcare professionals. It allows us to compare our work to that our peers and to identify areas for improvement. We undertook an audit of the 50 patients who we had seen for facial revolu-

misation, Pelleve or a combination. The audit consisted of a chart review and an anonymous online survey using the online resource surveymonkey.com. We had a total of 38 responses. Of these, 34 were female (89.5%) and four were male (10.5%). This reflects our practice population quite accurately. The bulk of respondents were older than 46 (n 29, 76.3%). Almost 90% (n 34) of patients had been seen for facial revolumisation. Over 40% (n 16) had been seen for Pelleve. It was possible for patients to have had one or other or both. Patients rated satisfaction high in all treated groups. Of the 24 who answered to being treated with revolumisation only, 22 were very satisfied and two were satisfied. Nine patients had Pelleve only, with seven being very satisfied, one satisfied and one somewhat satisfied. No patients responded to say that they were not satisfied. My particular interest was in the responses of those who had a combination of revolumisation and Pelleve. Of the 17 patients who had combination treatment, more that 70% (n 13) were very satisfied, with the remaining (n 4) being satisfied. Thirteen of 16 patients who answered the question said the combination was superior to either modality alone. Both procedures were well tolerated with the vast majority finding them easily tolerable or not painful. All 32 patients who answered the question said they would have Juvederm Voluma again. My patients are satisfied with both Juvederm Voluma and Pelleve, which work well in combination and are well tolerated. Dr John Quinn (BACD) has worked as a GP in the NHS since 2004 and has been in practice in aesthetic medicine since 2005

1) 1ml of Voluma was injected into each malar fat pad using a 22g Softfill cannula. The after-photo was taken right after treatment. 2) 2ml of Voluma was injected into each malar fat pad using a 22g Softfill cannula. The after photo is two weeks later. 3) Skin laxity on the neck was partly related to previous surgery. Shown are before and after the first Pelleve treatment. The after photo was taken immediately following treatment 49

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strict parameters established by the Duke research. With Phloretin CF Gel, new state of the art technology allows the actives to be suspended in an acidic gel matrix to penetrate skin down to the target site, just as the Vitamin C serums traditionally do. The light, gel fresh gel texture ensures the actives are released in a more controlled manner and are slowly driven down to the target site with maximum penetration. Used in the morning, Phloretin CF Gel helps prevent free radical damage and leaves skin looking more even, reducing the appearance of wrinkles and fine lines while leaving skin feeling firmer, looking more radiant and with a brighter complexion. It is suitable for oily, normal and problematic skin. The gel provides slower delivery, making it ideal for sensitive skin types, men who find a serum irritating post-shaving as well as those clients who prefer a gel texture.

The serum-in-a-gel technology behind Phloretin CF Gel is found within SkinCeuticals new AOX+ Eye Gel, a triple antioxidant treatment formulated for the eye area. A unique preventative product is required for the delicate eye area, where the skin is 10 times thinner than the skin on the face. The formulation is enriched with targeted ingredients, ruscus aculeatus and caffeine to address specific eye concerns, puffiness and dark circles, while providing optimum protection from free radical damage. The latest research from SkinCeuticals will be presented at the FACE conference on Sunday 17th June at 16.10pm. We urge you to attend to further understand the SkinCeuticals brand and to hear about the latest ground-breaking research. For further information on SkinCeuticals, call 020 8762 4987.

Breakthrough SkinCeuticals has rejuvenated the topical antioxidant market with its new Phloretin CF Gel antioxidant. Formulated with an optimal concentration of 2% phloretin, 10% L-ascorbic acid and 0.5% ferulic acid, the serum protects skin from the range of skin damage known to be the result of daily environmental aggressors. Typically an aqueous solution was not formulated at a low enough pH to meet the body language www.bodylanguage.net

clinical Dr Osman Bahir

Practising in Pakistan Dr Osman Bashir returned to practise in his home town of Lahore after working in England and Singapore. He shares his observations on aesthetic medicine in Pakistan

ifestyle differences in southern Asian countries are very different, due to the religious and social norms in this part of the world. The sun is totally avoided, and both sexes are keen on skin lightening skin products. Women of all ages have usually tried over-the-counter products to lighten the skin before seeing a doctor. Local markets that sell clothes and bangles for women sell dangerous mixtures of skin-whitening creams that contain prescription steroids. I have seen many a facial skin devoid of colour, with severe acne and telangiectasia due to the skin thinning and atrophy from long-term application of these mixtures. Brides are preferred “fair and glowing”, so beauty parlours have “bridal whitening packages” that apply hydrogen peroxide-based products over the body. Even male salons have whitening facials! In India, movie superstar Shahrukh Khan (Hollywood equivalent of Tom Cruise) endorses skin whitening products for men. Sunscreen is seldom applied, and there is a casual approach towards it. Typically, patients say they don’t use it because they do not spend much time in the sun. In Pakistan, prescription-based hydroquinione and steroid creams can be bought from the pharmacy without prescription. Being fairer is viewed as superior, and many say this skin whitening “complex” can be traced to Britain’s occupation. Food habits in southern Asian are generally better than the West. Processed foods, tinned foods and fast foods are generally eaten on weekends by the younger population. A diet rich in antioxidants such as turmeric, legumes and vegetables is consumed, and fresh fruits of the season are present in almost every home. Home-cooked food is regarded as best, and there are many poems about food made by the hands of a mother. I have seen food colouring, additives and artificial flavouring prevalent in the daily diet in the West and I believe this is a cause of skin problems such as acne vulgaris and allergies. In the Islamic parts of southern Asia, alcohol is forbidden, and cigarette smoking is shunned by the elderly population. But it is prevalent among the young, although much less than in the West. Practising muslims perform wudhu, cleansing the face, behind the ears, hands to the elbows and feet, five times a day for prayers. During prayers the forehead touches the ground as many as 40 times a day. Possibly this helps to increase blood circulation. I have noticed clearer, healthier and radiant skin among those leading a clean lifestyle, praying, avoiding alcohol and cigarettes, and late nights. The skin cleansing, prayer poses, sun avoidance and sleeping at proper times does have its benefits in anti-ageing. Darker skin types possess an increased epidermal melanin providing a natural SPF body language www.bodylanguage.net

but are prone to post-inflammatory hyperpigmentation. Visits to dermatologists and plastic surgeons for ageing skin, exhibiting jowls and sagging, is much later as compared with the West. Patients desiring a facelift or necklift are usually older than 60. Patients usually complain of dyspigmentation owing to melasma, for which skin peels and tretinoin/hydroquinonebased creams work well. I have seen many a skin exhibiting hyperpigmentation and hypopigmentation from fractionated and laser-based technologies on southern Asian skin types. Laser hair removal is one of the most requested procedures, as southern Asian women are generally hairier than Western counterparts. Commonly, women in southern Asian apply hot oil and massage their scalp regularly, a practice mothers include in their daughters’ beauty regime from childhood. The oils are from almonds, coconut or are herbal mixtures. I have seen much stronger and thicker hair, with fewer cases of damaged hair and hair-fall that can arise from chemicals in Western hair care products. Men, however, exhibit similar balding patterns, which are of course genetic but sometimes stress-related. Hair transplants are probably the cheapest in the world in Pakistan, and I have seen a doctor offering a mega-transplant for a few hundred pounds! Many politicians and movie actors have had hair transplants and medical tourism offers packages for men to fly in, have a transplant and sight-seeing tour before heading home. Non-surgical treatments are popular among the wealthier population and media personalities, with toxins and fillers more acceptable than surgery. Body contouring is popular, with tummy-tucks and liposuction favoured by women who have completed their family. Breast augmentation is much less popular than in the West. Breast cancer deaths are among the highest in the world, accounting for 40,000 deaths per year in Pakistan. Lack of education among the poorer population and environmental causes may be contributing factors. Rhinoplasty is requested by those desiring a more Western nose, one that is slimmer and smaller. Southern Asian skin of the nose is more sebaceous and thicker, but there is variation in South Asian noses. People in the more northern countries, such as Afghanistan, North West Pakistan and Northern India, have larger and thinner noses, which can be traced back to the armies of Alexander the Great. Southern areas of South Asia have a darker skinned population, and their noses are similar to African American noses. Dr Osman Bashir MBBS, MRCSEd, PGDipaesthetic surgery (QMUL), is a board certified American Academy of Aesthetic Medicine aesthetic surgeon in private practice in Lahore, Pakistan 51

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Dr Carl Thornfeldt is a dermatologist and founder of Episciences Inc, which manufactures global skincare line Epionce

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

Dr Sheldon Pinnell is a dermatological scientist and chief medical consultant for SkinCeuticals

Dr Bruce Freedman is a consultant plastic surgeon based in the USA. He is also medical director of Plastic Surgery Associates of Northern Virginia

Professor Giorgio de Santis is a professor of plastic and reconstructive surgery in Italy

Sun, skin and fillers In the run up to summer, our panel covers a range of topics from antioxidants, sunscreens, vitamin D deficiency and filler techniques Q Could you put any figures on the risk of melanocyte cytotoxicity with hydroquinone? Dr Carl Thornfeldt: When you look at the in vitro data, there was a reasonable amount of variation which I was surprised about. Studies range from pretty low rates, in the neighbourhood of 50%60%. But there was one case that had almost 100% incidence of toxicity at the doses they were using. This latter toxicity was at a higher dose. When you looked at doses that people could theoretically get in, they were in the 70-80% range for toxicity. That's why many worldwide regulatory agencies, especially in Europe, have taken hydroquinone off the market. Q What alternative ingredients to hydroquinone do you use in your treatment for pigmentation? Do you use retinol? Dr Carl Thornfeldt: No retinol. No vitamin C. No vitamin A. No traditional lightening agents, many of which weren’t potent enough to work in these formulations. We screened about 130 ingredients and found that many of them weren’t strong enough. Our complex contains 15 herbs and two different algae.

Q When you’re treating melasma, are you getting good results as opposed to hyperpigmentation which could be superficial in a lot of photodamaged patients? Dr Carl Thornfeldt: As you know, there is dermal melasma as well as the more body language www.bodylanguage.net

superficial melasma. The superficial melasma has very good results and the dermal melasma takes longer. With postinflammatory hyperpigmentation, many of those will resolve but it will take 8–12 months. So it will take longer to treat these patients, particularly those who have had previous destructive treatments, such as intense pulsed light since PIH is frequently induced by these treatments

Q Do you advocate that being used as a topical one-size-fits-all standalone treatment? What about antioxidants? Dr Carl Thornfeldt: Generally, yes, since the cutaneous pathology of most types of hyperpigmentation are similar with increased melanin, although it may have abberant distribution. Lentigos also have also have increased melanocytes making therapy more difficult. Dermal melasma and PIH have also have melanin in dermis so will also take 2–3 times longer to clear but it may never completely clear. Many of the herbs have high concentrations of a variety of antioxidants and anti-inflammatories. Herbal products have many active ingredients that are already stable so this allowed us to make very sophisticated formulations that we knew were going to be stable. The extracts we used were highly extracted so they were up to six to eight active ingredients within them. So they have very good activity. We didn’t include green tea because it wasn’t potent enough, and the same with grapeseed extract. We found that a number of the other botanicals that we

could deliver at high enough concentrations into the skin without irritation were significantly more potent in depigmenting activity than traditional agents. When you’re using herbal products, you have to go through a 10-step product development cycle to make sure the product is stable and consistently effective. We carried out double-blind prospective controlled clinical trial against a prescription market leader after having done safety studies—which are not required in the cosmetic arena. As a clinician, I feel morally and ethically that I need to have products I know are safe and effective to prescribe my patients.

Q Is

there any contraindication for using the vitamin C phloretin with vitamin A creams? Do they work synergistically? Dr Sheldon Pinnell: There is no contraindication. Vitamin A preparations are ordinarily used at night and we recommend using the antioxidant preparations in the morning. So that works out quite well.

Q Sun protection is a big issue in the media. Patients understandably have a lot of questions concerning efficacy of sunscreens and what they do or don’t do. How should we counsel patients in terms of sunscreen and topical antioxidant use? Dr Sheldon Pinnell: My own preference is to use antioxidants on a daily basis. If you protect the skin from further damage then it has the chance to repair itself. Topical antioxidants are not particularly 53

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Q There are some sunscreens out there that contain antioxidants. What are your thoughts on that combination? Dr Sheldon Pinnell: I don’t have any problem with a combination product, as long as it works. There are lots of antioxidant products out there but they use ingredients I don’t know how to get into skin— some are incredibly good antioxidants, so the comparisons you usually see are, “My antioxidants are better than yours.” But their clinical trials have nothing to do with getting the product through the stratum corneum; if it doesn’t get through, it’s dead in the water. Dr Carl Thornfeldt: I’d like to second Dr Pinnell on that. When we screened our botanicals, many of which were reported to be lighteners and depigmenters, we could not get high enough concentrations of many botanicals to have any impact at all in the melanocytes. The doses required that could impact the melanocytes produced such high rates of irritation. So the formulation chem-

istry with natural products is extremely important. Unless the product has gone through rigorous blinded placebo or prescription controlled clinical trials, I would label the natural claims as voodoo science. Companies wanting you to sell their product have to prove it works and is safe. A review was carried out by Dr Pinnell in 2006, that discusses the difficulty with delivery of these types of agents. You’re being asked to sell a lot of products with many different ingredients. Patients are expecting you to tell them what’s safe and effective for them. In one screen we did of six vitamin C products, only one had measurable benefit against UVB-induced erythema, the specific reaction that we were looking for in human skin.

Q In

the US, the FDA has come forward to regulate sunscreens. Do you think this might happen in the supplement world? Dr Carl Thornfeldt: I think there is a chance that it will, as well as some cosmeceutical regulation. I was glad to see the FDA come out with a final ruling, particularly because a lot of research has shown that the critical aspect for the development of skin cancer is sunburn cell damage and a variety of other signals that we look at. The correlation of just protecting against erythema was not enough. Destruction occurs in the skin at sub-erythema doses and there are a lot of different effects that can occur in affected cells. But the FDA is somewhat bound by budgetary issues and has not been as aggressive in the supplement arena as I think they should be. I would like to see more regulation because of incredible claims made without credible clinical proof. One of our early products we’d taken through phase two clinical trials and were preparing for phase three. When the FDA

changed the topical rules in 2000, they told us that because the product contained more than 10% natural products, they were no longer going to regulate that.

Q What do think about the fact that the pendulum has shifted so much that we are getting patients with vitamin D deficiencies because we are protecting ourselves from sun damage? Dr Sheldon Pinnell: I think the solution to the problem is potentially simple—dietary supplementation of vitamin D. Even though it doesn’t take a lot of exposure to make the daily amount of vitamin D that you need on exposed skin, we’ve got people so protected, even in places where they don’t get exposure, that it’s possible that we are creating a vitamin D deficient population. In America, about one third of people get blood studies that are vitamin D deficient so how do you decide what the minimal daily requirement is in those circumstances. But even with dietary vitamin D supplements, people still aren’t drinking or consuming dairy products or there’s something wrong with the test that we’re doing or our understanding of it. I think it’s a serious problem that we shouldn’t ignore just because the dermatology associations say that it’s not important. Q I’ve

started taking blood samples of every patient I see, which include vitamin D studies. Around 90% have showed low levels. Even my staff, including me, showed to be deficient so we all had vitamin D shots. Dr Carl Thornfeldt: With some aspects of the vitamin D issue, the jury is still out. The FDA recently changed the vitamin D RDA only up to 600IU. This was shocking to those of us involved with traditional medicine who see a lot of those patients with a cancer history. My patient population involves a huge

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good, compared with sunscreens, at protecting against sunburn. But we’re not really talking about oxygen radical protection when we speak about sunburn—it’s more of an inflammatory response. Most of the oxidative stress and ultraviolet light comes from UVA light, which is obviously important to protect against. So it’s a bit radical at this point but my own feeling is that sunscreens are good for protecting yourself against excessive sun exposure. I always come back to the point that I’m a guy, and guys don’t use sunscreens because we’re not used to having things on our face. But certainly, you can use antioxidants which you don’t feel at all. We’re talking about half the population, and if we can get them to use antioxidants to protect themselves, that would be a big advantage.

12/01/2012 17:03

body language www.bodylanguage.net

Wigmore Medical 020 7514 5104 invasix@wigmoremedical.com

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amount of skin cancer and inflammatory diseases like psoriasis and dermatitis, so I’ve been measuring vitamin D levels for a while. I’ve also been seeing very high rates of vitamin D deficiency. I think there is definitely a correlation with systemic cancer as well. The problem is that the FDA, looking at this whole body of evidence, was not willing to change the RDA more than 200IU, from 400–600IU. A number of studies are saying that 2000IU should be recommended. I advise my patients as I would myself or my family—I would take the 2000IU just to be sure. When I was training, we did studies and could bring the vitamin D level up to that 400IU with a noon-time application of sunshine 20 minutes each day to the head, neck and dorsum of the hands. There is a proven correlation with vitamin D deficiency and systemic cancer. Dr Sheldon Pinnell: In addition, I’m not aware that antioxidants would interfere in any way with vitamin D synthesis. That’s perhaps another reason to choose antioxidants over sunscreens.

Q It’s no good treating a patient who is then going to wreck their skin by sun or smoking. No one treatment is a panacea, there has to be a degree of compliance and there has to be a commitment from the patient. What are your thoughts? Dr Bruce Freedman: With these treatments, which have little or no recovery time needed, it’s easy to take the time to educate them about skincare and skin health while they are in the office. There was a time—at least in the States—where patients would come in for a quick fix and they wanted us to transform them dramatically, quickly with no input. It’s like they leave their face on our shelf and then pick it up later. But I think they now realise they have to be as active a participant in their own care as possible. This isn’t rocket science—at least, with non-surgical treatments—and the process is easier for patients to understand, especially when products like antioxidants are everywhere. They embrace that idea.

Q In

the States, neither Aquamid or Bio-Alcamid have been FDA approved. Around a decade ago, an unlicensed practitioner in Tijuana, Mexico advertised polyacrylamide for treating lipoatrophy or HIV patients. A few years later, we saw cases with late appearing abscesses. It’s made me very wary of hydrogel polymers. What is your experience with polyacrylamide

While patients are being advised to slather on sunscreen, many are suffering from vitamin D deficiency as a result—oral supplements may be one solution

and the differences between Bio-Alcamid and Aquamid? Professor Giorgio De Santis: If there is a field in which you can consider the use of permanent filler, it’s the field of HIV patients. In our clinic, we treat around 40 patients per week with Aquamid. After analysing the cost benefits, technique and safety, we tried to choose something that would last at least a few years. I think the injection technique is always important. Our method uses a small amount of Aquamid—1CC each sitting, every 15– 30 days, while the report of Bio-Alcamid used large volumes in the face in one go. In terms of the vascularisation of the surrounding tissues, the technique is important. We inject Aquamid very slowly, in small volumes, many times.

Q Are you using the linear retrograde threading or bolus technique? Professor Giorgio De Santis: We use the retrograde technique with Aquamid. We have fewer instances of infection with Aquamid than are reported with Bio-Alcamid because the volumes used are smaller. A while ago there was a polyacrylamide from Russia which had questions over its sterilisation. This was used in large volumes to correct any type of depression and there was a high number of infections. But now, with our understanding of technique and sterilisation, in this category of patients it is a good product to use.

Q In

our Los Angeles practice, we carry out microdermabrasion on quite a number of patients. How can we add antioxidants to the treatment? Dr Bruce Freedman: As one of our controls, we started out in the proof of concept idea, and having patients manually apply the serum to their skin on a daily

basis for the duration of the study, around six weeks. We’d then measure the antioxidant levels. Looking at normal versus dermabrated skin, we found that in the nondermabrated skin—just application of the antioxidant serum—we were unable to demonstrate an increased level of antioxidants. Clearly, the dermabrated skin is more permeable and that’s what we want to work with.

Q My patients are happy with the results of hyaluronic acids but there are still concerns regarding longevity and cost over time. In light of the fact the facial anatomy does change, why not put a base down of permanent filler, like polymethyl-methacrylate—for example, one syringe in the deep nasolabial fold—that will always stay there, but not enough that it could cause problems with time-related changes to the face. Then continuously put a layer of HA over the top? Dr Derek Jones: That would probably be a good way to go. There is certainly a market for Artefill, or PMMA, and some patients like the idea of a permanent filler because they don’t have to keep coming back. I don’t use the product because I’m a fairly conservative physician and don’t like to take excess risk. I do think many of those with deeper nasolabial folds may be candidates for a filler like Artefill, especially some of these male folds which are very deep and just don’t respond well to anything, including calcium hydroxylapatite. But for routine cosmetic use, I don’t think I’d use it, particularly in the lips or tear troughs. But laying HA over the top would be perfectly reasonable. I lay HAs over the top of Radiesse and silicone and have seen no problems with that technique. body language www.bodylanguage.net

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hyperhidrosis Dr Mark Whiteley

Axillary hyperhidrosis, or excessive sweating around the armpit, is not uncommon and can cause considerable embarassment to sufferers. Dr Mark Whiteley describes a modified method of curettage and laser ablation

Laser sweat ablation W e mainly provide laser sweat ablation for patients with axillary hyperhidrosis but we’re also seeing more cases of bromhidrosis. The most important consequences of axillary hyperhidrosis are social embarrassment, difficulties at work and regular clothing changes. It affects around 1.5% of the population— general hyperhidrosis is thought to affect 3% of the population and axillary accounts for half that amount. Patient perception, temperature, air saturation, activity and hydration all factor in axillary hyperhidrosis.

Ablation The technique started with subdermal laser ablation. In 1999, a report in Japan described using a carbon dioxide laser underneath the skin to target the eccrine glands. But while they reported good results, they stopped doing it. Dr Guillermo Blugerman then carried out a lot of research in Buenos Aires doing subdermal curettage as well as using an Nd:YAG laser. In April 2008, the technique was brought to Croatia—we completed our first case in 2009 with average results, so we have done a huge amount of work to modify the procedure. The principles are simple. We call the technique laser sweat ablation but it’s important to understand the procedure— body language www.bodylanguage.net

some practitioners are offering the treatment, but all they are doing is putting a laser in under local anaesthetic, wiggling it about and pulling it out. Or, worse still, inserting a liposuction catheter and actually removing fat. The anatomy is simple—the epidermis, dermis and subcutaneous fat dermal layer. The eccrine glands, particuarly the large hypotrophic ones, sit low in the dermis and is the target area. First, you make a blunt dissection. While in the original subdermal laser ablation, Blugerman classically fries the area first, I don’t see the point of frying something with a laser then removing it—you spend a lot of laser energy on something that you’re going to remove. So we’ve changed the technique around and curette it first, to remove as many of the larger sweat glands as we can. After that, we will use the laser to ablate what’s left. Once we have this area of coagulation, we basically have a full thickness skin graft that we’re putting on to the fat and hoping it’s going to take. We perform the Minor’s iodine test, which uses starch and alcoholic iodine to find out the area of sweating. Through studies, we’ve shown that if there is an isolated area with one area of hyperhidrosis, the patient will get good results. Those with scattered hyperhidrosis and no focal area of hyperhydrotic

glands do not get good results. So this precursor test is very important. We also do a volumetric analysis to measure how much sweat there is. It is a simple cotton wool ball test measured down to 0.02g over one hour. Once you’ve worked the tumescence in, you just lift the skin up, followed by a blunt dissection. Many plastic surgeons who do this technique leave small tunnels with blood flow afterwards so the skin still gets a blood supply. But we’ve shown this is associated with poor results. We now don’t leave any tunnels at all and clear the whole area. You then use a suction grater to remove it. It is difficult to see how deep we’re going and we’re still working on ways to measure how much we’re removing. We use the Fotona XP2, 10W and quasi continuous wave at 40Hz. We then do ablation of the deep dermis and angle the endpiece into the skin. When we started using the Blugerman technique, we saw coagulation all the way up to the epidermis and, not surprisingly, we saw some skin breakdown. By using certain techniques in studies, we now just get coagulation of the deep dermis and complete sparing of the upper dermis and epidermis. So ideally you want to kill the deep dermis but not the superficial dermis to 59

hyperhidrosis Dr Mark Whiteley

target as many of these glands as possible. So we’ve changed wound placement and reduced laser power, Some practitioners who have used the technique have been reusing fibres, which get cloudy—it’s very important that you know exactly how much energy is going through. We’ve tried different catheters and used skin cooling on the outside so that as we’re heating from the inside, we’re cooling the epidermis. We’ve altered the pattern of how we treat it. The treatment started out just firing large amounts of laser but that really doesn’t work; you have to be very regimented in how you do the procedure. For post-operative anaesthesia, we use Chirocaine which gives patients around eight hours’ comfort. By the time it’s wearing off, they no longer have acute pain. We’ve treated 84 patients for hyperhidrosis. Only 49 have returned for follow-up—many patients fly in to have this done because they’ve seen it on the internet and are just not interested in coming back for follow-up for research. Subjectively, two were very unhappy with treatment and wouldn’t return. Those patients experienced skin breakdown in the early days of the technique but even those showed reduced sweating. Of those who have returned, five have received further treatment for missed patches. That’s why you need the iodine test beforehand and why you have to be very rigid with the technique inside. Two patients felt they were sweating more after treatment, although when we tested them, they weren’t. One of these was a teacher and whenever she went into a certain class, she started sweating—it was because in that class there was a very difficult child who she dreaded teaching.

One of the difficulties is trying to work out what is hyperhidrosis and what is the secondary overlay of the perception of hyperhidrosis. At the moment, there is no medical way of testing that. Of the 49 follow-ups, 42 are very happy with their sweat reduction. Results We saw skin breakdowns early in the technique but now we see incredibly few because of the way we’ve changed the procedure. We also changed the incision sites to be less noticeable—one of my patients pointed out that they were visible if they were wearing an evening dress. As long as you have a 90° crossover, that’s all you need to ensure you’re getting enough coverage. Immediately afterwards, the area looks awful but after six weeks, it’s hard to see there is a problem. By three months, it’s really difficult to see anything has happened there at all. Patients can experience hair loss, especially if they have darker hair. If they have darker skin, you have to warn them that there may be some hypopigmentation with an Nd:YAG. Good results show minor healing scars and no sign of any sweat. When they return for testing, they can show a volumetric analysis of 80-85% reduction. Of course, there are failures but even these show a 40% reduction. During the procedure, you can miss ectopic sweat glands. Be careful treating bodybuilders. Research presented in Denmark showed that 14% of men who go to the gym and have good bodies are using steroids. They are thereby shrivelling their testicles, undergoing a menopause and sweating profusely. Only 1% ever tell anyone they’ve

used steroids. So you would be treating generalised hyperhidrosis, not a regional one and would therefore get bad results; they will never be happy. While this procedure is effective for bromhidrosis, I don’t particularly like treating it because that’s not what I set out to do. There is no objective sniff test to tell whether someone is better, it is all down to perception. But I do treat it because there is no other treatment for these sufferers—so far, when my patients have graded themselves afterwards, they have judged a 50–100% improvement. Endoscopy Once we’ve done the blunt dissection, you can use an endoscope to look inside. When you look at the dermis, you can see what appear to be dermal pegs or hypertrophic sweat glands from the inside. Using the endoscope, you can see down into the axilla. When you grate these lumps away, you traumatise the hypertrophic sweat glands. The only obvious effects we can see through endoscopy inside are from the suction curettage, not the laser ablation, because we make a morphological change. When we point the laser up inside and ablate, we see very little difference afterwards. If anything, it’s slightly smoother, but there are no visible effects from the laser. If there is a use for the endoscope, it would be to make sure you haven’t missed any lumps. But taking into account the cost it adds to the procedure, I’m not sure if it’s worthwhile. Mr Mark Whiteley is a consultant vascular surgeon and founder of the Whiteley Clinic in Guildford and London

Laser sweat ablation procedure

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1: Before treatment, perform an iodine test. 2,3: Work in the tumescence, lift up the skin and perform a blunt dissection. 4: Suction curettage with removal of tissue with a suction ‘grater’. 5: Perform a laser ablation of the deep dermis to target the sweat glands. 6,7,8,9: Results after, showing minimal cosmetic scarring and clear iodine test

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Autologous fat Treatments involving autologous fat transplantation offer a natural alternative for volumisation, filling and rejuvenation. Dr Aamer Khan reviews the evolution of the concept

edical cellular treatments have been around since ancient times. The first recorded cosmetic surgery procedures and those involving tissue transfer occurred around 800BC in India. Sushruta, known as the father of surgery, recorded findings in 600BC in Sanskrit. Egyptians and Romans became rather au fait with the body and repairing tissues. For religious reasons, the Romans would not desecrate the human body. During war, injuries to their heads and faces were repaired using tissue grafts. Tissues would be taken from other parts of the body and placed in the area needed for cosmetic improvement—this was more to do with religion than surgery and medicine. German surgeon Gustav Neuber published the first report on fat autografting in humans in 1893. He was experimental and doubtless received criticism from his peer group. But he made observations about the size of the tissue graft being important to its survival—the smaller the pieces, the surer the success. Innovation The modern history of autologous grafting started with lipectomy; taking pieces of shaped fat and transferring them to another part of the body. In 1974, Fischer and Fischer introduced liposuction using a mechanical machine, allowing liposuction aspirate to be produced after tumescing the area. This opened the door to the modern era of autografting. Dr Briscoe described autograft autologous fat transplantation in 1982; the first recorded documentation using lipoaspiration fat. Lipoinjection—using a syringe rather than placing fat in the area—was first described in 1987. The American Society of Plastic Reconstructive Surgeons convened an ad hoc committee on new procedures and produced a report, the conclusion of which stated that autologous fat injections had a historical and scientific basis. Fat injection has achieved variable, but predictable, results. 62

The variability lies in technique and harvesting of fat. But there is a great deal of controversy surrounding fat grafting to the breasts. Some believe fat transfer to the breast can inhibit early detection of breast carcinoma and is hazardous to public health. But radiographers state that the calcification from fat necrosis is easily differentiated from carcinoma-specific changes seen on mammography. In 2007, Dr Sydney Coleman produced a paper revisiting the safety and efficacy of fat grafting. The study concluded that it was a safe alternative to breast augmentation and reconstruction. But it’s not just used for breasts—we see great results for facial and hand rejuvenation too. Lipostructure Dr Coleman called his technique lipostructure—restructuring tissues using fat micrografting. In the early days, we had problems with fat survival and he addressed this issue to a degree. Figures tend to vary from study to study. Traditional fat grafting using liposuction showed survival rates between 20-50%, meaning most of the fat would go. This is down to the grafting process. Large graft sizes relate to poor graft success. Papers have looked at the relationship between graft size and its success. During normal lipoaspiration, we’re getting fat collections around 1.7mm on average. While size matters in this case, preoperative preparation also affects the outcome. The patient should be prepped properly and advised not to take anti-inflammatories or steroids beforehand. These interfere with the grafting process and blood vessel formation and they increase bleeding. Preselection of patients and ensuring they are healthy makes a big difference. Aspiration techniques have been investigated. The presence of large amounts of oil when we aspirate indicates apoptosis and tissue damage. The pressure used to aspirate the fat—whether manual or powered—affects the ability to get viable collections body language www.bodylanguage.net

surgery Professor Marco Gasparotti

of cells of a certain size. Injection technique is also important. Depending on the pressure applied on the syringe, fat cells may be destroyed during the procedure. As studies showed that fat wasn’t taking, people were overfilling the areas, increasing pressure on the graft and inhibiting the grafting process. The time between harvest and injec-

tion also affects its survival. If the fat is stored for more than 24 hours, we see a degradation in the tissue quality. In my experience, we should try to harvest and inject in the same procedure. During breast procedures, the fat injection is not into the breast tissue itself. It is retromammary along the muscle line to give a lift behind the breast tissue and subcutaneous to give the overall outer shape. We’re getting great results volumising face and skin quality also improves. It’s down to how we inject—the microdroplet, multi-layer technique. But we also have to make sure we look after the fat and not destroy it. Washing the fat washes away much of the basic architecture required for vascular setup. It’s all about the fight between vascularisation and degradation. The sooner the graft vascularises, the quicker it sets in and the longer the results will last. In terms of aftercare, some put supportive garments on the grafted area but I find this is too much pressure which will cause a reduction in the uptake. We’re getting much better results in our clinic with less compression. We need to focus on advancing technology for stem cells and regenerative cells. If we can improve the vascularisation of the graft into the area, we will get better results and more longevity. Dr Aamer Khan is a cosmetic physician and general practitioner. He is also clinical and managing director of the Harley Street Skin Clinic, London

Buttock augmentation Professor Marco Gasparotti runs through the options available for enhancing the buttocks, including lipofilling and liposuction, fillers and the thread lift

ll patients who come to me for buttock augmentation want round and high cheeks. Lipofilling, or removal of fat from one area and using it to augment another, can be a great method for this. We see long lasting, good results with no complications. I’ve seen no more than a couple of cases of infection and a few asymmetries in 9000 procedures. Results last even after eight or nine years and patients get nice projections. So we see stable results. While Dr Sydney Coleman introduced centrifuging the fat and injecting and fitting cannulas, we no longer use the abdomen as a source of fat because it doesn’t take. We started using the Holloman technique, using a thin cannula to remove a small amount of fat. We then centrifuged and cleaned the fat, and re-injected in the buttock with a thin needle. But this procedure took time. We found a cheaper, faster and more simple procedure of removing fat from the lateral femora, injecting with a 60cc syringe and using the piston of a 20cc syringe as a lock. We can inject 8000cc body language www.bodylanguage.net

of fat this way with no problems. But fat injection must be harmonious and in the subcutaneous plane, above and in the muscle. We can also inject in the hips—everywhere we need to have a nice round shape. So the goals of using liposuction and lipofilling are to address concavity, convexity and provide a long lasting and nicely shaped result. We are mostly lifting the area upward with vertical tunnels. Never do horizontal tunnels or you will end up with waves. We also collect most of the fat removed from liposuction for future use by the patient. If we take young fat from a young lady, after five or ten years she may want those powerful stem cells reinjected. So we freeze them through a Belgian company and can use it after a few months for cheek, chin or breast rejuvenation, or in the future as a source of stem cells for neoangiogenesis and revitalisation of the chest and face. For patients who want filling in the buttocks but no liposuction, we can use Macrolane. While I’ve been using the filler for many years, I have had filler migration, perhaps because I injected into the

muscle. I had to incise the resulting bulge and remove it. So I only use it for selective cases, particularly those seeking a simple, non-invasive solution to light asymmetry. But it works very well for this indication and it’s very well tolerated. It’s also useful when you have a patient who has already had liposuction and has little fat for good buttock enhancement. If you’re afraid of lumps or contractions from a filler, you can give the patient a thread lift. You undermine the area and make a round suture—an elastic thread that enters right on the periosteum or the sacrum—and it redistributes the fat previously undermined around the bulge. Results last over a year and the procedure can be re-done. You can get very nice projections. I use it when a patient has a sagging gluteus with little fat to inject. I can combine the liposuction and a thread lift. It also helps to fix the redistribution of the skin upwards. The patient then wears an elastic garment—the LipoShape—for a month. Professor Marco Gasparotti is a consultant plastic surgeon based in Italy 63

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comment David Williams

Conclusion BY DAVID WILLIAMS

Design for success G

ood design is, of course, not simply about appearance but also about function. Design dictates performance. Computers can run only so fast, cars have top speeds, planes can fly only so high… everything is enabled and constrained by its design. Such constraints can be deliberate. The computer keyboard of QWERTY is a design inherited from the typewriter, which was intended to slow down typists so that the keys did not collide when moving from rest to the platen and back. The design has somehow stuck. Usually, if there is a need to exceed the performance capabilities of the existing design, a redesign follows. All businesses have an inherent design, just like their products, services, applications and departments. Good design fosters collaboration, communicates strategy, sets expectations, improves the efficiency of a team, and inspires and motivates. Medicine is no different, but you would not think that by entering NHS hospitals, where aesthetics makes way for cheap functionality. In fact, the driving force of private medicine aesthetics in buildings, fixtures and fittings is geared at distinguishing itself from institutional design. Private patients want to feel nurtured, comfortable, relaxed, confident. They don’t want to be told by a dispassionate receptionist to take a seat and wait their turn, and then anxiously watch the clock tick only to be met by a GP who is always mindful of the time with an eye frequently roving to his watch. Clinical staff benefit from aesthetics, too. An attractive clinic is a nicer place to work, engendering a feel-good factor that increases productivity. The relationship between design and quality is intertwined for the Japanese, who believe that, to have a quality product or service, it needs to be created in a way that satisfies two concepts: atarimae hinshitsu, roughly, “taken-for-granted quality,” and miryokuteki hinshitsu, “enchanting quality”. The first concerns itself with function; the second, aesthetics. 66

An example of atarimae quality is the function of a simple mobile phone, chiefly, to make phone calls. Ease of use contributes to this quality. Miryokuteki hinshitsu is the phone’s colour, texture, appearance, and materials, which comprise an integral part of the quality and add value to the product. These design considerations can also affect ease of use, so we can see the symbiotic relationship between both concepts. What constitutes “good” design, varies, of course, and again this will be dictated by how it connects with function. The primary function of medical products is that they work exceedingly well, because they affect quality of life and sometimes life itself. You do not see much cost-cutting and a half-measured method in medical design, as there is an intensity of purpose that runs much deeper than the stylistic considerations of a new Nokia, Blackberry or iPhone. While clinical design does not have such high stakes as life and death, it can contribute to the failure of a business. Assuming you were going to create a clinic, how would you design it? Would you sim-

ply come up with a rough design and employ an architect, builders and tradesmen to carry out your wishes? Good clinical design needs to match the right business model and service in creating a pleasant experience for patients and staff. Your own experiences will help you devise your blueprint and this will be formed or supplemented by listening to your patients, asking questions, and openness to new ideas. You can consult the experts by reading up on design. As you would expect there are contrasting views, right from the starting point of what design is or what are its effects. My own favourite quotes start with data scientist and artist Edward Tufte, who said: “Good design is a lot like clear thinking made visual.” Brenda Laurel, who specialises in human-computer interaction, said: “A design isn’t finished until somebody is using it.” The graphic artist Frank Chimero said: “People ignore design that ignores people.” However you define and apply it, good clinical design may not in itself lead to queues of patients, but it can be pivotal to your success.

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