Body Language Issue 53 by Body Language Journal

sept/oct

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

SKIN OF COLOUR Expert advice on solutions, lasers and peels

 Automated versus manual microneedling  Avoiding and managing filler complications  Expert approach to facial contouring

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a Galderma Division

Date of Preparation: February 2012 RES/004/0212(2)

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contents

body language number 53 7

DEPTH CHARGES Many technologies exist for fractional resurfacing. The principal questions are when is each useful and at what depth should the energy be placed? The clinical target dictates the answer, writes Dr Shlomit Halachmi

16 SKIN

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

Publisher Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com Contributors Dr Shlomit Halachmi Dr Zein Obagi Susan McNeece Dr Mukta Sachdev Dr Luiz S Toledo Mr Jonathan Britto Mr Henri Thuau Dr Raina Zarb Adami Professor Tony Chu Mr Baljit Dheansa Mr Rajiv Grover Mr Omar Durrani Mike Regan Mr Kambiz Golchin Dr Timothy Flynn Dr Michael Kane

ANALYSES Reports, training and events, comments

12 LASERS

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

Sales Executive Monty Serutla 020 7514 5976 monty@face-ltd.com

7 OBSERVATIONS

WITH FLYING COLOURS Treatments for skin of colour present their own set of challenges. Dr Zein Obagi discusses his method that revolves around restoration of skin health, treatment and stabilisation n STRATEGY FOR CHEMICAL PEELS You can obtain good results with chemical peels. Much depends on patient selection and your programme. Susan McNeece elaborates n PATIENT

SELECTION AND CARE Selecting patients carefully and exercising caution are key considerations in treating skin of colour, whether it is a peel or a dermaroller, counsels Dr Mukta Sachdev. Cultural differences present their own set of challenges

n APPLYING LASERS The choice of laser is paramount to achieve good results and minimise the likelihood of complications when treating skin of colour, writes Dr Mukta Sachdev

30 PRACTICE ETHNIC CONSIDERATIONS Races and cultures have long leapt nations’ borders. Multicultural societies are now the norm. As a practitioner, you need to know how to assess different racial groups. Dr Luiz S Toledo discusses his experiences

32 CONFERENCE BODY 2012 The UK’s only parallel conference dedicated to both surgical and non-surgical body aesthetic treatment

34 SURGERY

34 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

FROM ALL PERSPECTIVES Facial aesthetics often requires multiple techniques to achieve the best results. Mr Jonathan Britto sees surgery as one of the elements of overall treatment

39 MAXILLOFACIAL COMPLETING THE PICTURE Establishing facial balance demands optimising skeletal relations and contour definition as well as enhancing soft tissue support. Mr Henri Thuau elaborates

40 AESTHETICS FACIAL CONTOURING Restoration of facial contouring and enhancement are the primary goals of patients desiring to roll back the years. Dr Raina Zarb Adami discusses the anatomy of beauty, causes of ageing, and how she helps her patients look younger 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 53

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.

47 WORKSHOP 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.

FILLER COMPLICATIONS Problems arising from speedy injections, the Tyndall effect and excessive bruising are among the challenges practitioners face injecting fillers. Master injectors Dr Michael Kane and Dr Timothy Flynn offer their advice

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.

50 PRODUCTS

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.

DERMAPEN VERSUS DERMAROLLER The Dermaroller has established itself as a key tool for treating skin. Professor Tony Chu and colleagues conducted a study to see how the Dermapen compares

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. 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.

ON THE MARKET Latest arrivals stirring discussion in aesthetics

52 STUDY

56 RESEARCH PEER PRESS REVIEW David Williams surveys academic and association journals to report on advances in research

59 PEER TO PEER SAFETY STANDARDS The failure of authorities to prevent the marketing of products such as PIP implants is among the safety issues discussed by our panel and audience

61 MEDIA TRAINING READY, SET, ACTION! Practitioners are called often by the media to comment on a procedure or to discuss their technique. Mr Baljit Dheansa volunteered to be filmed consulting with a patient right up to the surgery that ultimately followed. He passes on what can be learned from his experience

62 OPTHALMOLOGY EYE MOVEMENTS Major advances in eye surgery have not only increased procedural safety but also resulted in new procedures, writes Mr Omar Durrani

66 COMMENT CONCLUSION

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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

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

GMC says doctors must not prescribe medicines remotely

Gillies’ archive of surgical records online

Clarification of longstanding issue welcomed by professional associations The General Medical Council has made it clear in new guidance (“Remote prescribing via telephone, fax, videolink or online,” 23 July) that it does not condone remote prescribing of medicines. The GMC expects doctors to comply with its standards of good practice or, without good reason, face removal from the medical register. The guidance states doctors “must undertake a physical examination of patients before prescribing non-surgical cosmetic medicinal products such as Botox, Dysport or Vistabel or other injectable cosmetic medicines” and that they must not be prescribed by telephone, fax, video-link, or online. The ruling affects doctors who have sanctioned prescriptions by way of an intermediary without assessing patients face to face as well as those intermediaries who relied on their services. It is seen as finally resolving a longstanding issue that has been exploited.

Dr Samantha Gammell , president of the British College Of Aesthetic Medicine (formerly the British Association of Cosmetic Doctors) said in a statement: “We welcome the new guidelines on remote prescribing. Per our articles of association, all BCAM members are expected to understand and have a working knowledge of the code of practice as set out by GMC and must adhere to it in daily practice.” The British Association of Cosmetic Nurses welcomed the GMC’s clarification, pointing out that nurses who have passed the nurse independent prescribing course are able to prescribe and administer botulinum toxins and other medicines within their area of competence. BACN adds: ”Non-prescribing qualified nurses working in partnership with doctors or nurse prescribers are also working within the correct legal framework when their patients are consulted by the prescribers who then delegates an order to

administer to the nurse.” Private Independent Aesthetic Practices Association chair Yvonne Senior said she hopes the guidance will prevent “exploitation of loopholes arising from claims of ambiguous interpretation of medicine standards from the medical profession”. Beauty clinic owners and those relying on external injectors have been urged by companies offering training services such as Innomed Clinic Services to check qualifications. In a press release it warns: “Clinic owners will need to reassess their practitioner qualifications and possibly look for alternative personnel.” Hamilton Fraser Cosmetic Insurance says that all malpractice insurance policies it offers are conditional on the practitioner following professional guidelines. Hamilton Fraser will indemnify the practitioner only if acting under the direction of an authorised prescribing practitioner.

Records of the pioneering plastic surugery of Dr Harold Gillies on World War One soldiers are now online at findmypast.co.uk. The release of the Gillies Archive marks the 130th birth year of the surgeon and 95th anniverary of the opening of the Queen’s Hospital in Sidkup, Kent where modern plastic surgery began. Dr Gillies is renowned for developing the first skin grafting and plastic surgery technique to treat First World War soldiers left wounded with severe facial disfigurements. Over 11,000 operations were performed from 1917–1925 which led to a knighthood in 1930.

A lieutenant admitted to the hospital with a ‘gunshot wound nose’

Revalidation raises admin and compliance issues Dr Stephen Bassett, appraiser for Welsh revalidation support unit, discusses the process Revalidation of licensed doctors will be implemented from January 2013, when the Secretary of State for Health completes the sign-off process. This will depend on his having received statements of readiness from all the interlocking organisations involved, specifically the General Medical Council, the responsible officers and the English and devolved administration revalidation support infrastructures. Most of these organisations are already reporting readiness. Such is the political pressure on the Secretary to deliver revalidation to Parliament and the public that it seems unlikely dissenting voices will be afforded much of an audience for their cautions and criticisms. A potential problem for cosmetic doctors offering general medical services who remain on a medical performers’ list in Engbody language www.bodylanguage.net

land is that it is highly likely they will need to have their main appraisal conducted by the organisation providing general practice appraisals for revalidation. In Wales this will be the case. This will apply even if that doctor spends only a little work out of hours providing general medical services. The process, termed “whole practice appraisal”, will be the final collection point of all a doctor’s medical roles, including aesthetics. Doctors will be expected to gather evidence about and from within each of their roles where the role depends on the possession of a medical license, even where membership of a performers’ list is not, per se, essential for the delivery of that role. It will not be required that all sources of essential evidence be gathered from within each role. MSF, for example, should be performed across various roles, and SEAs are also globally and generically derived, and

may not in a specific appraisal period derive information from one specific role. It is expected that, for each role, some form of organisational sign-off will be required, endorsing the doctor’s evidence from within that domain of practice. This will be easy where there is a recognised infrastructure, superstructure or hierarchy, such as working in a hospital OPD, but much harder for many other roles. This continues to be an area on which I lobby via my seat on the BMA’s general practitioners committee. It is acutely germane for cosmetic doctors, who largely work alone and outside of an organisation, appropriately enough in most cases. However, fortune favours the risk-conscious, so I would advise associating with the BACM or IDF, which are likely to be most able to deliver such organisational sign-off when the time comes. 7

observations

second brief

unFITNESS legacy UK medical officers must be hoping for a rise in physical activity and more attention to diets following Olympicsmania. An analysis of statistics collated on obesity, physical activity and diet of UK citizens show much room for improvement. The UK chief medical officers recommend that adults should achieve at least 150 minutes of moderate intensity physical activity a week. Despite widespread promotion of healthy eating—the government’s recommendations are five portions of fruit and vegetables daily—few fill their plates properly andcontinue their affair with food and drink high in salt, fat and sugar.

41% of respondents in 2010

in Britain said they made walks of 20 minutes or more at least three times a week and an additional 23% said they did so at least once or twice a week. But 20% of respondents reported that they took walks of at least 20 minutes “less than once a year or never”.

39% & 29% of men and women aged 16 and over in 2008 met the government’s recommendations for physical activity, compared with 32% and 21% respectively in 1997. This is based on respondents’ own self-reported accounts. 6% & 4% of men and women actually achieved the

government’s recommended physical activity based on the results of an accelerometer study in 2008, which monitored the respondents. Clearly a discrepancy with the above!

-0.9% & +0.4% are the amounts household purchases of fruit fell and vegetables rose by in 2010 (11.6% lower than in 2007 and 2.9% lower than in 2007). 25% & 27% of men and women consumed the recommended five or more portions of fruit and vegetables daily in 2010.

22% & +14% of men and women in 2010 were estimated to be at increased risk of health problems using both BMI and waist circumference as an assessment. 31% & 29% of boys and girls (aged 2–15) were classed as either overweight or obese.

36% & 28% of males and females (aged 21– 60) will be obese by 2015. By 2025 further extrapolations of data show an increase to 47% men and 36% women. Source: Statistics on obesity, physical activity and diet: England, 2012, The Health and Social Care Information Centre, Lifestyles Statistics 8

Patients want to see actual results in person Photos of breast reconstruction insufficient A survey by Harris Interactive has found that about 89% of American women want to see what breast reconstruction surgery results would look like before choosing to have treatment for breast cancer. But breast cancer patient organisations report most women want more than before and after photos and see actual results of breast reconstruction procedures in person, and have the opportunity to discuss them with survivors. “It is our job as doctors to fully inform our patients about breast reconstruction options,” said American Society of Plastic Surgeons president Malcolm Z Roth. “Women are telling us that they want to actually see what reconstruction results would look like beforehand, and as

their physicians we need to do everything we can to honour their request.” The survey also found: • Fewer than one-quarter (23%) of women know the wide range of breast reconstruction options available. • Only 22% of women are familiar with the quality of outcomes that can be expected. • Only 19% of women understand the timing of their treatment and the timing of their decision to undergo reconstruction greatly impacts their options and results. • Not only are some women never shown breast reconstruction surgery results, but previous research shows 7 out of 10 women diagnosed with breast cancer are never even told about their breast reconstruction options.

Mechanism discovery set to improve skin formulations Ion channel likely target of future skin enhancers A team of investigators from UC Davis and Peking University have discovered a mechanism that may explain how alpha hydroxyl acids (AHAs) work to enhance skin appearance, which may lead to better cosmetic formulations. The cellular pathway the research team studied focuses on an ion channel known as transient receptor potential vanilloid 3 (TRPV3) located in the cell membrane of keratinocytes, the predominant cell type in the outer layer of skin. The channel is known from other studies to play an important role in normal skin physiology and temperature sensitivity. In a series of experiments that involved recording electrical currents across cultured cells exposed to AHAs, the investigators developed a model

that describes how glycolic acid (the smallest and most biologically available AHA) enters into keratinocytes and generates free protons, creating acidic conditions within the cell. The low pH strongly activates the TRPV3 ion channel, opening it and allowing calcium ions to flow into the cell. Because more protons also enter through the open TRPV3 channel, the process feeds on itself. The resulting calcium ion overload in the cell leads to its death and skin exfoliation. “Our experiments are the first to show that the TRPV3 ion channel is likely to be the target of the most effective skin enhancer in the cosmetics industry,” said Jie Zheng, professor of physiology and membrane biology at UC Davis and one of the principal investigators

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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.

1086/BOC/JUN/2012/JH

Date of preparation July 2012

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

observations

training & events SEPTEMBER 15 September Cosmetic Courses Foundation Botulinum Toxin & Dermal Fillers Training Course, National Training Centre, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 15 – 16 September Cosmoderm XIX, Mumbai, India W: escad.org 15 – 16 September British College of Aesthetic Medicine Autumn Conference, The Celltic Manor Resort, Newport,Wales W: bcam.ac.uk 17 – 20 September LCS Academy BTEC Medical Laser/IPL Qualification, Milton Keynes W: lcsacademy.co.uk 17 September SkinGeeks London & Oxford Theory and Practical, London & Oxford W: skingeeks.co.uk 19 – 22 September 42nd Annual European Society for Dermatological Research Meeting, Venice, Italy W: esdr.org 26 – 28 September XVIII International Course of Plastic and Aesthetic Surgery of Clinica Planas, Barcelona, Spain W: clinicaplanas.com 27 – 30 September 21st European Academy of Dermatology and Venereology Conference, Prague, Czech Republic W: prague2012.eadv.org OCTOBER 3 October Vascular and Pigment Masterclass, Lynton Clinic Training Centre, Cheadle, Cheshire W: lynton.co.uk

24 – 25 October OBESITY 2012, Hallam Conference Centre, London W: mahealthcareevents.co.uk/cgi-bin/go.pl/ events_new.html 24 – 27 October 3rd Continental Congress Dermatology of the International Society of Dermatology & the 65th National Congress of the Dermatology Society of South Africa, Durban, South Africa W: ccd2012.co.za/ 26 – 30 October Plastic Surgery 2012, New Orleans Convention Center, New Orleans W: plasticsurgery.org 31 October – 4 November The Dasil Congress, St Julian’s, Malta W: thedasil.org NOVEMBER 3-4 November Body Conference, Royal College of Medicine, London W: bodyconference.co.uk 9-10 November 26th Congress Laser Medicine Ausitorium St. Apollonia, Firenze, Italy W: laserflorence.eu 9-11 November Ultimate Skin Health Symposium, Montage Hotel, Beverly Hills W: ultimateskinsymposium.com 10 November Foundation Botulinum Toxin & Dermal Fillers Training Course, National Training Centre, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk

4-6 October IMCAS Asia, Hong Kong W: imcas.com

16 – 18 November Beauty from the Inside Out, 9th Congress of the American Academy of Aesthetic Medicine, The Westin Colonnade Hotel, Coral Gables, Florida, USA W: aaamed.or

9/11 October Dr Carl Thornfeldt Epionce Seminar & Training, London (09/10) Manchester (11/10) W: http://edenaesthetics.com/events

17 November Introduction to Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com/events

12 – 14 October 8th European Masters in Aesthetic and Anti-Aging Medicine (EMAA), Palais des Congres, Paris W: euromedicom.com

23-24 November The International Congress in Aesthetic, Anti-Aging Medicine & Medical Spa Middle East, Habtoor Grand Beach Resort, Dubai W: euromedicom.com/icaam-2012/index.html

13 October Cosmetic Courses Foundation Botulinum Toxin & Dermal Fillers Training Course, National Training Centre, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk

23 – 24 November Investigations and interventions in dermatology, Radisson Edwardian Hotel Manchester W: bad.org.uk//site/691/default.aspx

13 October Microsclerotherapy and Facial Telangiectasia Course, Wigmore Medical, London W: wigmoremedical.com/events 13-14 October IMCAS India, Gurgaon W: imcas.com 15 October SkinGeeks Oxford Theory and Practical, Oxford W: skingeeks.co.uk 15-18 October BTEC Aesthetic Laser/IPL Qualification, the Beaufort Clinic, Milton Keynes W: lcsacademy.co.uk/calendar.html 18 –20 October Shanghai World Congress on Anti-Aging Medicine and Regenerative Biomedical Technologies, Shanghai World Expo Exhibition & Convention Center W: http://www.a4mcn.com/en/

26 Nov 2012 – 28 Nov Trichology-2012 – International Conference on Hair Transplantation & Trichology, Hilton Airport Hotel, San Antonio, USA W: omicsonline.org/trichology2012 28 November – 01 December Aesthetic surgery of the breast – 5th European symposium, Marriott Hotel, Milan W: breastsurgeryinnovations.com/wp/ 30 November – 01 December Facial Rejuvenation - Surgical & Nonsurgical Procedures Hilton Park Hotel, Munich W: congress@bb-mc.com DECEMBER 1 December Microsclerotherapy & Facial Telangiectasia, Wigmore Medical, London W: wigmoremedical.com/events 13 – 15 December International Winter Consensus Conference, (What’s new and what’s true in Dermatology) Kitzbuhel, Austria W: iwc-conference.com JANUARY 31 January – 3 February, 2013 IMCAS annual meeting, Paris W: imcas.com

Shanghai: World Congress on Anti-Aging

Letter to the editor

19 October Lips Course (Dermal Fillers Part II) Jury’s Inn, Watford W: drbrianfranks.com/course-dates.html

If you have an item you would like included in Training & Events, send it for consideration to helen@face-ltd.com

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‘Inadequate response’ unfair criticism I read with interest the article entitled “Classification of Dermal Fillers” (Body Language July/August 2012). Merz has more than 100 years of pharmaceutical heritage and a product portfolio that is FDA-approved. Our outlook has always been primarily that of a pharmaceutical company rather than a medical devices company, and as such we are fully supportive of high standards of patient safety in medical aesthetics. Against this backdrop the emphasis your article placed on the Austrian case series (Schuller-Petrović et al) of just four patients did not fairly represent the approach taken by Merz Aesthetics in the withdrawal of Novabel from the UK and Ireland. When Merz made the decision to remove Novabel from the market (June 2010) it did so with one primary motive—to protect patient safety. At that time our international pharmacovigilance section had received 70 adverse event case reports (from an estimated total number of 12,000 patients treated). This number included short-term transient adverse reactions such as redness, bruis-

ing, pain and swelling (common with all fillers). Included in these reports were 26 patients presenting with nodules and 10 patients with induration. There were three cases of histologically confirmed granuloma. Subsequent rigorous pharmacovigilance analysis has shown that the UK incidence of granuloma per patient treated was <0.1%. During the period Novabel was promoted, only those customers who were trained in its use (because its administration characteristics were so different) could purchase it. At the time of withdrawal, and since, Merz Aesthetics has been open and transparent with healthcare professionals and endeavoured to ensure information was widely and rapidly shared. The “inadequate response of the manufacturer” referred to in the article does not reflect the professionalism and efforts that the team at Merz Aesthetics made and continues to make regarding patient safety and customer satisfaction. Quality, ethics and excellence underpin all that we do. Stuart Rose Managing Director Merz Pharma Ltd

Lords inquiry into regenerative medicine The House of Lords Science and Technology committee is investigating whether the UK can exploit its research in regenerative medicine. The committee will investigate whether the science is being translated into practical applications, the commercial potential for regenerative medicine, whether the government is doing enough to attract in-

vestment, and what business models are most appropriate to support development? Lord Krebs, chairman of the committee, says regenerative medicine can not only aid the treatment of chronic diseases but can also drive growth in the pharmaceutical sector. “We welcome evidence from anyone with experience or knowledege of the sector.”

lasers Dr Shlomit Halachmi

Depth charges B Dr Shlomit Halachmi

roadly speaking, the changes of dermal and dermal targeting, as the epiMany technologies exist for the ageing face can be classified dermal treatment requires low power and fractional resurfacing. The as epidermal and dermal. epiderhigh density, while the dermal treatment principal questions are when requires high power and lower density. mal changes are generally those is each useful and at what of superficial texture and colour and arise This can be accomplished by two passes: from cumulative sun damage to keratinoone pass for the deeper tissue followed depth should the energy be cytes and melanocytes. Dermal changes by a second pass for the superficial treatplaced? The clinical target are manifested as lines, wrinkles, and ment. dictates the answer, writes overall loss of dermal volume and elasticOne device—CO2RE by SyneronDr Shlomit Halachmi ity due to solar elastosis and collagen loss. Candela—overcomes this by allowing When the goal is epidermal texture a combination of superficial and deep correction, generally a superficial treatchannels in a single pulse in the “fusion” ment will suffice and ablative treatments mode. The handpiece has a scanner whose are preferred. For dermal correction, software allows the user to place dense, there is a role for ablation, but heating is a low fluence foci as well as less-dense, high critical component. Therefore, to address fluence foci in each pulse. This makes for these two components, one must choose a single-pass treatment that can cover, for the depth as well as the temperature. example, 40% density at low power and At very high temperatures, near the 5% at very high power. Immediately after fusion treatment boiling point of water, there is immediate Another way to approach this is to apvaporisation of tissue. This is the basis of ablative procedures ply “sublative” energy. In this technology, RF is delivered by a and skin resurfacing. Since this is an irreversible change, new handpiece (from eMatrix or eTwo, Syneron-Candela) in such a tissue must be generated to replace the ablated tissue. geometry that there is immediate, rapid heating at the epiderAt slightly lower temperatures of 60–90deg, heating causes mis, followed by milder but broader heating in the dermis. immediate denaturation of the proteins. This induces collagen In contrast to the “V” or “U” shaped lesions of CO2 and shrinkage, perceived clinically as immediate tightening. Tem- erbium:YAG lasers, the lesions formed in sublative rejuvenation peratures above 40deg but below the temperature of denaturation are “^” shaped, with a small focus of epidermal ablation and a cause fibroblast stimulation and induce new collagen synthesis. broad base of dermal heating. This approach is useful when there Ablative treatments induce heating as well. Histological stud- is a need for mild epidermal treatment and a greater need for deries show that around the ablated tissue in a CO2 (10,600nm) mal heating. Its main benefit over laser is the lower downtime. laser treatment, there is a zone of collagen denaturation. This Some patients may have the opposite need: only dermal taris the area where the temperature was in the 60–90deg range. geting is required, and the epidermis should be spared from Outside this is another zone (which cannot be visualised by ablation or heating. For these patients, micro-needle RF is exhistology) of fibroblast stimulation where the temperature was cellent, as the energy is delivered directly into the dermis with 40–60deg. For erbium:YAG (2940nm) lasers, which have a micro-needles, with no energy deposition at the epidermis. This higher water absorption coefficient than CO2, there is generally reduces downtime and risk of hyper- or hypopigmentation. a thinner zone of heating around the ablated tissue. The first and most published of such devices is the bipolar With radio frequency (RF), the size and shape of the zones of system developed by Dr Basil Hantash, which has been acquired ablation and heating will vary with the parameters. RF has a prac- and is now marketed by Syneron-Candela as ePrime. The device tical advantage over lasers in that, due to its contact nature, the RF has a disposable tip comprising pairs of RF electrodes, pin-like devices can monitor tissue temperature during treatment and po- in appearance. When they enter the dermis, and are confirmed tentially adjust or stop the energy based on temperature changes. by feedback to be within the dermis based on electric impedWith this as background, one can approach the treatment by ance, they deliver a time-limited electric current. deciding on the depth and heating requirements. For epidermal The device allows the user to programme the exact temtreatments, the goal is to ablate, while heating may not be needed. perature to which the tissue should be raised, and the duration The ablation should be at a high density to maximise the effect of of that temperature. Histological studies show that heating is the fractional treatment. A fractional CO2 or erbium:YAG, using confined to the area between the needs, with no peripheral or low fluence and high density, or RF with high density and settings epidermal damage. that favour fast heating (for ablation) can provide this. In vivo studies also show increased collagen and elastin folFor dermal treatment, the heating component is important, lowing the treatment, and clinical studies show dermal thickboth for immediate collagen denaturation and for fibroblast ening and improvement in fine lines in difficult to treat areas, stimulation. For this, CO2 and RF are appropriate. The depth, such as the lower face. Clinical studies using the standardised of course, must be greater, and the energy higher. Fitzpatrick and Alexiades scales show over 90% improvement However, since there is a zone of heating around each ablated from baseline at three months and nearly 100% in six months, channel, to avoid overlap of the heating zones, the density of the and patient satisfaction rates of 89% and 91%. ablated channels must be reduced. Consequently, higher-powered treatments will require modification of the fractional density. Dr Shlomit Halachmi is a consultant dermatologist who practises The challenge comes in treating patients who need both epi- in the US and Israel 12

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skin Dr Zein Obagi

colours With flying

Treatments for skin of colour present their own set of challenges. Dr Zein Obagi discusses his method that revolves around restoration of skin health, treatment and stabilisation 16

riginal skin colours are the dark black, dark Asian and light white (stable colour). Any other colour (light black, light Asian, normal white and brunettes) is considered a deviation from the original. Unstable colour, with increased frebody language www.bodylanguage.net

skin Dr Zein Obagi

thin skin—complex skin. This skin colour is very unstable and can’t be considered original, and requires longer and more aggressive treatment. With all skin, we must determine its tolerance: thin skin is a subjective criterion. When a patient complains about sensitive skin, this sensitivity must be addressed first. Skin sensitivity indicates damaged or altered barrier function, which can be manifested by symptoms of irritation or inflammation to certain topical agents or other external elements (sun, cold, and heat) or internal factors (excessive sebum, skin hygiene). Every effort should be made to restore a normal barrier function using retinoic, anti-oxidants and anti-inflammatory agents in what is called “skin conditioning” for 4-6 weeks before any procedure. For the same period after procedures, these agents are used in any long-term treatment plan for all skin pigmentation disorders. The objectives of skin reconditioning include the restoration of even and proper hydration of the skin. This is important because water is the chromophore for both laser resurfacing and chemical peels, which helps ensure the evenness and response of the procedures.

quency and severity of post-inflammatory hyperpigmentation and pigmentation disorders, require more aggressive and longer treatment compared with the original colour. A group of the population that lives in geographic areas such as India, Pakistan, and Indonesia has another classification of body language www.bodylanguage.net

Re-epithelialisation After procedures, the skin has to undergo re-epithelialisation at home. Melanocytes have to be controlled, and the response and activity of the skin must be improved. Complications such as post-inflammatory hyperpigmentation (PIH), acne flare, redness and sensitivity must be prevented or reduced. Practitioners must monitor treatments and judge the results. Skin health restoration is the ideal approach for treating a wide variety of skin problems, especially in skin of colour. Healthy skin is smooth firm/tight, has an even colour, is tolerant and hydrated. Achieving this is important in making a detailed diagnosis. General skin repair can be directed to include specific agents that address the main problems— specific repair. Skin health restoration steps needed to achieve healthy skin can be expanded by adding disease-specific agents to treat the main problem while restoring skin health. For example, specific repair may include hydroquinone for hyperpigmentation, or non-hydroquinone stabilisation (Brightenex) benzoyl peroxide for acne. Certain topical agents need to be used. These comprise bleaching with hydroquinone to suppress tyrosinase (leading to suppression of melanin); blending hydroquinone and tretinoin to allow normal distribution of melanin (even tone); employing ultra violet protective agents such as sunscreen or physical blockers; and using sebum reducing agents (astringents) topically, even sometimes orally (isotretinoin). These agents are important for two reasons. First, sebum is an inflammatory agent that, when in excess, irritates skin and increases melanocyte activity. Second, sebum reduces the penetration and efficiency of hydroquinone and other topical agents. Restoring the skin’s health while treating skin pigmentation or other disorders is more effective and leads to better results than focusing on the disease alone. This is accomplished by ad17

skin Dr Zein Obagi

dressing skin at the cellular level and improves cellular functions that will assist disease-specific topical agents in treatment, leading to a better result. There have been new findings in the treatment of skin pigmentation.  Hydroquinone is effective in bleaching and blending when used for three to five months. Continued use beyond this can lead to photo sensitivity due to the reduction of skin melanin; a building of resistance in certain individuals; idiosyncratic reactions such as rebound hyperpigmentation; and ochronosis with long-term usage and inadequate sun protection.  Retinoic acid is essential in regulating and enhancing cellular functions and is a must in the treatment of many skin disorders (acne, melisma, sun damage, for example) and needs to be used aggressively (high concentration, proper amount and frequency) creating initially (redness, dryness, exfoliation) that many patients do not like. Retinoic acid can increase photosensitivity allowing rebound pigmentation problems when stopped. Fewer benefits and higher incidences of irritation can arise after five to six months of usage. Retinoic acid’s activity and benefits are minimal in low concentration with sporadic usage.  Topical steroids should not be used to treat skin pigmentation. Long-term usage (more than 10 days) can lead to skin atrophy, telangliectasia and inhibits all cellular functions and activity.  Most non-hydroquinone agents, arbutin, kujic acid and others do not work well.  Chemical peels are better for skin pigment problems than lasers. Laser heat can aggravate melasma and have higher incidence of PIH. However, peels or lasers should follow proper skin condition-

ing for six weeks and should be never the first line of treatment. Skin stabilisation is a new concept and its objective is to increase skin tolerance and resistance to all the factors that affect skin negatively (inflammation, sun, heat, injury, procedures, hormones, diseases). This can be achieved by utilising the cumulative effects of retinol (in capsulated formulation that releases the retinol intracellularly), anti-oxidants, and anti-inflammatory agents. Stabilising the epidermis is achieved by strengthening the barrier function, protecting keratinocytes, DNA, enhancing epidermal renewal (thicker epidermis) and melanocyte production of melanin (preventing pigment disorders). One product that provides skin with stabilisation and that contains all the needed topical agents is Brightenex. Skin stabilisation is the new approach for creating meaningful daily skin care that is preventative and provides maintenance after completion of treatments. Topical products can provide both skin health restoration ability and treat the abnormal pigmentation at the same time. These typically comprise retinoic acid AHAs, antioxidants and anti-inflammatory agents; or hydroquinone alone, hydroquinone + retinoic acid, or sebum- reducing agents. These should be used for three to five months. Chemical peels, specific pigment lasers and laser resurfacing can be used as indicated at the same time with topical agents. Upon completion of the treatment, stabilisation should be started as maintenance and prevention. Dr Zein Obagi is a fellow of the American Academy of Dermatology and medical director of ZO Skin Health, Inc

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 Melasma stabilisation. Facial cleansing was in the morning and evening. The sebum was controlled with topical astringent. Stabilisation was by a non-hydroquinone (retinol, anti-inflammatory, reducing melanogenesis) Brightenex with subsequent sun protection.  Dermal melanosis. S melanocyte and laser Facial cleansing was in the morning and evening. Following sebum control, hydroquinone 4% was used to control melanocytes morning and evening, and retinoic acid plus hydroquinone 4% for blending in the evening with subsequent sun protection.  PIH (chemical peel) Melanocyte control: bleaching and blending. The protocol for six months was facial cleansing in the morning and evening. Hydroquinone 4%) was applied morning and evening. Retinoic acid plus hydroquinone 4% blending in the evening with subsequent sun protection. Controlled depth peel to the papillary dermis was performed three times, two months apart.  S melanocyte. The protocol for melasma treatment was facial cleansing in the morning and evening. The sebum was controlled with topical astringent. Stabilisation was with non-hydroquinone (retinol, antiinflammatory, reducing melanogenesis) Brightenex with subsequent sun protection. Hydroquinone was not used to avoid bleaching the skin, as the patient did not want to be bleached.  Melanocyte control hydroquinone. The protocol for melasma treatment was facial cleansing in the morning and evening. Sebum control. Bleaching (hydroquinone) in the morning and evening, and blending (retinoic acid plus hydroquinone) in the evening. Bleaching of the skin is apparent— PIH from acne and dark circles. After RX completion, stabilisation started and hydroquinone was stopped.

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skin Susan McNeece

Strategy for chemical peels You can obtain good results with chemical peels. Much depends on patient selection and your programme. Susan McNeece elaborates

Perfect skin in three Fitzpatrick types IV through VI. The main concerns for treatment in types IV–VI are post-inflammatory hyperpigmentation and hypopigmentation, hypertrophic scarring and keloid formation

hemical peels are simple, affordable and effective for treating conditions in darker skin types such as dyschromias, including melasma and post-inflammatory hyperpigmentation (PIH), acne and acne scarring, textural changes and pseudofolliculitis barbae. There are important considerations to keep in mind when selecting chemical peel treatments for patients with darker skin types—especially Fitzpatrick’s skin types IV through VI. This includes patients of African, Asian, Australian, Caribbean, Hispanic, South American, Middle Eastern, Mediterranean and Eastern Indian descent. The primary concerns are post-inflammatory hyperpigmentation and hypopigmentation, as well as potential for hypertrophic scarring and keloid formation. When looking at differences in melanin in darker skin types, there is no difference in the number of melanocytes,

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but melanosomes are often larger and singly dispersed into melanocytes and keratinocytes, producing greater epidermal melanin. When it comes to PIH and even hypopigmentation, the etiology or pathogenesis has not been clearly determined, but we do know that cytokines and inflammatory mediators are involved. Hypertrophic scarring is more common than keloid formation. Again, we are not sure of the full pathogenesis, but we know there is an over production of collagen—collagen synthesis in keloids is about 20 times greater than in normal unscarred skin and three times greater than in hypertrophic scars with an elevated type I to type III ratio. The response to chemical peels will consequently vary among patients. This is why it is imperative to start with a complete assessment of a patient’s history to determine risk factors for possible complications and to develop the best overall treatment plan. Patient assessment should

consider ethnicity, age, dermatological and medical conditions, and current medications. Some topical and oral medications can increase melanin production and skin sensitivity. Understanding any history of reactions and complications from previous procedures is also crucial when it comes to potential for hypertrophic scarring or keloid formation. Patient expectations and their commitment and compliance to the treatment programme must also be assessed. Are they going to follow the instructions for the recommended home-care programme that supports their overall result? An uncooperative patient with unrealistic expectations can increase risk of post-inflammatory response. Contraindications for chemical peels include complications associated with scarring, delayed wound healing, any active viral or bacterial infections, open lesions of any sort, atopic dermatitis, isotretinoin use within the last year, and others. If a patient is prone to cold sores caused by herpes simplex virus, he or she will need to be placed on suppressive treatment to prevent an occurrence. Categories There are three categories of peels: superficial, mid-depth and deep. We should begin with a review of depth of penetration and the types of peels that fall into these categories in general, and then highlight the range of peels most widely used with darker skin types. Superficial chemical peels penetrate the stratum corneum to the papillary dermis. The peels that fall into this category are the glycolic acid peels—anywhere from 20–70% are common; salicylic acid in the 20–30% range; trichloracetic acid (TCA) from 10–30%; tretinoin at 1%; and Jessner’s solution, which is 14% each of resorcinol, lactic acid, and salicylic acid. 21

skin Susan McNeece

An illustration of the anatomy of the dermis

Medium-depth peels enter the stratum corneum and penetrate through the epidermis into the upper reticular dermis. TCA peels in the range of 35–50% fit into this category. To have more control and less potential risk caused by higher concentrations of TCA, combination peels are often utilised to gain medium depth penetration with lower concentrations of TCA at 35%. Using a glycolic or Jessner’s peel before the TCA within a single treatment increases the keratolytic effect to achieve this goal of deeper penetration. Phenol at 88% would also be considered a medium-depth peel. Deep chemical peels penetrate from the stratum corneum to the mid-reticular dermis. The most widely recognised peel in this category is the Baker-Gordon formula, which gave the phenol/croton oil combination visibility and credibility in the 1960s. There are now variations of this combination with a range of phenol from 45–80% and croton oil at 0.16–2.05%. When undergoing this treatment, patients would need strong sedation or general anaesthesia, with risk factors including possible cardiac and renal toxicity. Application of deep chemical peels is not recommended for darker skin types due to greater potential for hypopigmentation, hypertrophic scarring and keloid formation. The most common peels used in treatment of skin of colour are glycolic acid 20–70%, salicylic acid, 20–30%, Jessner’s solution and TCA 10–15%. Some practitioners will use deeper peels, but you need to exercise caution and acclimate the skin with superficial treatments first. In most cases, however, results can be achieved through use of superficial peels. Glycolic acid—an alpha-hydroxy acid—is excellent for keratolytic effects, increasing cellular turnover, stimulation of fibroblasts, and dispersing melanin. It increases dermal collagen synthesis and stimulates glycosaminoglycans, thus building volume within the skin. Salicylic acid—a betahydroxy acid—is 22

derived from willow bark, as is aspirin, so you must be cautious of salicylate sensitivities or allergies. Due to higher lipid content in darker skin types, this lipophilic peel has proven highly effective in addressing many concerns including acne and textural issues without much risk. With Jessner’s solution, considerations are the number of layers and depth. Start cautiously and use multiple layers as needed. TCA is a universal peeling agent with little risk at lower concentrations in the 10 to15% range. Pearl Grimes, MD, is one of the leading physicians specialising in peels of higher Fitzpatrick types. In one study she assessed 17 patients from Fitzpatrick IV to VI, applying 4x4cm areas on the back, and 2 x 2cm postauricular sites on which she did biopsies at 24 hours to assess the differences in depth of penetration. Peels tested were 70% glycolic, 30% salicylic, Jessner’s solution, and 25% and 30% TCA. The glycolic acid induced the most significant stratum corneum necrosis. When salicylic acid and Jessner’s were used, there was some macrophage response in the dermal layer, but mild compared with any of the other forms of acids. The 25% and 30% TCA induced the most severe damage, according to the biopsies, with deep epidermal necrosis and more dense papillary dermal reaction of macrophage activity. When looking at the level of wounding and inflammation induced by chemical peels, the importance of a comprehensive treatment plan is evident. PIH is possible with even the lowest concentrations of superficial peels. One strategy to prevent complications is to start with a milder baseline peel and build into a progression of treatments. For example, start with a glycolic acid peel at 20 to 40% and build up to 70%. Partially neutralised glycolic gel peels allow more control over wounding for a more progressive approach. From there, move into salicylic peels and start at 20% before moving to 30%. You can then move up the ladder into the lower level TCAs and Jessner’s. Topical home-care An important part of the overall treatment plan is to recommend a topical home-care programme for two to six weeks before beginning peel applications. Introduction of resurfacing agents such as glycolic acid or retinol will aid in revving up cellular turnover, acclimating skin to higher concentrations of acids and providing a baseline of potential risk—if a patient reacts to 12% glycolic or 0.5–1%

retinol solutions, the patient is clearly not ready for a 70% peel. Resurfacing the skin before a peel treatment will assist in providing deeper, more even penetration of the peel solution. That said, caution should be taken with higher risk patients by possibly suspending use of both prescription or nonprescription retinoids for up to one week before treatment. Tyrosinase inhibitors Incorporating tyrosinase inhibitors is also important in suppressing melanin leading into the treatment to help prevent PIH. Depending on the trigger for melanogenesis, there is strong potential that hyperpigmentation will continue to reoccur over time as well. This is something that will need to be managed and controlled over long-term maintenance though proper home care. Talk to your patients and manage their expectations while developing their programme. A combination of tyrosinase inhibitors such as azelaic acid, dipotassium glycyrrhizate (derived from licorice root extract), hexylresorcinol, alpha arbutin and kojic acid will address the various phases of the melanogenesis process and are safe for long-term use in rotation with or in place of hydroquinone solutions. Along with tyrosinase inhibitors, a combination therapy incorporating technologies such as glycolic acid, salicylic acid, retinol (vitamin A), vitamin C, vitamin E, peptides, growth factors, a range of antioxidants and sunscreen will provide excellent results in addressing concerns while reducing erythema and inflammation to prepare the skin preprocedure, maintain long-term results and prevent future damage. In summary, develop a full treatment strategy by obtaining a detailed history to assess the potential for risk, devising a comprehensive home-care programme, and then performing clinical treatments in progression of intensity. Susan McNeece is senior director of global education at Jan Marini Skin Research, corporate office, San Jose References S Taylor et al, Treatments for Skin Of Color, Elsevier; 2011. Grimes PE (2000), “Agents for ethnic skin peeling,” Dematol Ther 13:159-164 A Tosti et al (eds), Color Atlas of Chemical Peels (2nd ed). Heidelberg, Germany: Springer; 2012.

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skin Dr Mukta Sachdev

Patient selection and care Selecting patients carefully and exercising caution are key considerations in treating skin of colour, whether it is a peel or a dermaroller, counsels Dr Mukta Sachdev. Cultural differences present their own set of challenges

n India, we deal with all shades of skin. The classifications of skin colour are not adequate; Fitzpatrick really doesn’t work for skin of colour any more. The alternatives are Taylor, Roberts and Obagi. The old thought was that, by 2050, half of the US population would be skin of colour, including the Afro-Americans, the Asians, the Pacific Islanders, and therefore it was increasingly important to recognise clinical and cultural differences in skin of colour. The National Geographic concluded in its Population 7 Billion series on the human race that a 28-year-old male Han Chinese man is the most typical person on the planet, of which there are 900 million. Within the next 20 years the most typical person will reside in India. By 2030, demographic shifts point to the most common face on the planet being 24

Indian. All skin clinicians need to understand how to treat pigmented skin. If you’re doing procedures, focus on skincare. In skin of colour, it’s the basis of anti-ageing—don’t be trigger happy. What should you look for? Skin-of-colour patients age slower: less visible crow’s feet, but more pigmentation and scarring. What’s the same? Most people don’t believe they need sunscreens; all look for a quick fix across the board—so colour is no bar here. With coloured skin you get bruising which will last from seven to 10 days; counsel your patients.When injecting fillers, sometimes the blanching erythema is difficult to visualise—you need to anticipate complications, because you may not see them until it’s too late. Avoid multiple puncture sites because you can get postinflammatory hyperpigmentation at each site of the injection.

We have been using an injector devices for around three years—these enable fewer painful injections and cause less bruising, but are expensive. We’re now using the fillers with local anaesthetic: they’re more comfortable, easy to inject but they give more bruising in coloured patients. As for Botox, a complication can be puncture-mark pigmentation; we have had patients pigment at each injection site and that takes six weeks to fade. You can do chemical peels on skin of colour: we use everything from gel peels to combination peels. Avoid the deeper peels—you will almost certainly risk post-inflammatory hyperpigmentation. Learn to pick the subtle signs of the end points. Feathering is a definite issue in skin of colour. Prepare your patients: it’s mandatory and definitely will minimise your PIH problems. In darker skin, it can be hard to see an body language www.bodylanguage.net

skin Dr Mukta Sachdev

end point, but superficial peels can give good results. Your biggest complication is hyperpigmentation, even with standard protocols. Today everybodyâ&#x20AC;&#x2122;s more aggressive, the doctors are more aggressive, the products are more aggressive, and company information and experience may not be applicable across all skin types, so I urge you to be conservative. Persistent erythema can arise from a basic 35% glycolic acid peel as can persistent hypo-pigmentation due to medium depth peeling with TCA. This is not to say that we donâ&#x20AC;&#x2122;t have successful results. You have to be cautious. In different cultures there are home remedies you need to be aware of. One patient with polycystic ovary syndrome used a home remedy of garlic juice. We treated her with a topical anti-biotic steroid combination. Another patient with body language www.bodylanguage.net

acne had applied lemon and turmeric on the mark to fade it. So make sure you take a history. Another cultural example of skin of colour problems arises from things like jewellery, flowers, henna, bangles. Kumkum is a sign of marriage and you get stick on ones containing adhesive. There is an increasing incidence of irritant contact dermatitis, and you can get depigmentation both in men and women. This is a real concern, because vitiligo or white patches are a real social stigma. Irritant contact dermatitis arises from temporary henna tattoos. The permanent tattoos, of course, cause complications. There is a festival in India called Holi where bright coloured powder is used, but you can have some serious irritant contact dermatitis. Mercury is in the powders and it can create skin problems. Saris look beautiful, but one patient

presented with a skin patch of post-inflammatory hyperpigmentation because, as Saris donâ&#x20AC;&#x2122;t have pockets, she used to put her purse inside and nickel coins increased pigmentation. Sindoor powder, which women put Chemical peels have been tried for treating post-inflammatory hyperpigmentation in skin of colour from lichen planus

skin Dr Mukta Sachdev

on their forehead when married, contains lead oxide, so again we’re having irritant contact dermatitis. We have also seen post-inflammatory depigmentation due to that. Tamarind is now the new kid on the block for lightening—there is much interest in the cosmeceutical. There is an obsession with fair skin, so lightening creams are rampant. The gold standard is, of course, hydroquinone but you need to do localised controlled treatment. It is important to be aware of the newer procedures and the older traditions, which seem to be making a comeback. Skin of colour in India and worldwide is a complex integration of factors—melanin is just one of the considerations. Whatever colour of skin you’re dealing with in cosmetic dermatology, choose your patient and your treatment carefully.

Post-inflammatory hyperpigmentation seen in skin of colour post-dermaroller

The appearance of a patient’s skin before and after a chemical peel

Applying lasers The choice of laser is paramount to achieve good results and minimise the likelihood of complications when treating skin of colour, writes Dr Mukta Sachdev

here is a dangerous flaw in the perception that lasers can remove everything, from hair to tattoos to birth marks and moles, without the potential to cause harm. There is a regulatory angle that has allowed the availability of cheaper non-standardised technologies and devices and, therefore, we are having more complications. If it is an unregulated burst of energy that you cannot predict, you will have a problem. Among the lasers I use is an ablative carbon dioxide, 1060nm, one of our oldest lasers, and many practitioners resurface with this laser. The precise control of the CO2 and the Erbium YAG lasers over the extent of tissue vaporisation minimises thermal damage to the skin, thereby reducing the risk of scarring while maximising the therapeutic efficacy. This is what you will see with any ablative technology, but this is applicable only for Caucasian skin. In darker skins, if you resurface with an ablative CO2, I guarantee you will have PIH. I have been using the Erbium YAG laser for around three years, which is definitely safer for darker skin. But counsel the patients, as they are going to have seven to 10 days’ downtime. It is important to choose the correct machine. 26

One machine is unlikely to work for everything and everyone. If you don’t have the right laser, don’t treat the condition. Refer your patient to someone who has. I can show you complications of the wrong laser being used and they are drastic. Pigmented lesions can be classified according to the location of the pigment deposit—they can be in the epidermis, dermis or both. Non-pigment selective machines such as carbon dioxide and ablative erbium may remove superficial pigmented lesions. If you know your settings, you know your fluences, you can control your energies, you can get some good results. What are the pigment-specific lasers you can use? Not all pigmented lesions respond to lasers. The principle of selective photo-thermalysis is the fundamental principle in low-risk treatment. Your chroma four is melanin. There is a broad absorption spectrum, and your selective range for melanin lies between 630 and 1100nm, which is wide. You need good skin penetration and a preferential absorption by the melanin to avoid pigmentation. Your thermal relaxation time (TRT) should be 25–1000ns, your pulse duration should be 40 –750ns, and you should

be able to induce selective melanosome destruction. These are wide ranges to work with, so what machine are you going to choose? The shorter wavelength—anything less than 600—damages pigmented cells with low energy fluences. The longer wavelengths—more than 600—penetrate deeper into the skin, but you need more energy to induce melanosome destruction. Shorter wavelengths are selected to treat the superficial lesions such as freckles and lentigines. The longer wavelengths are chosen to treat pigmented lesions in the dermis. Pigment-selective lasers can be a Qswitched Ruby or a Q-switched Alexandrite. When we go deep or when we get any erythema, a patient may get a PIH. Or you may induce ulceration, blistering, burns, and then you are dealing with PIH. We tell the patients four to six sessions. In India patients will are happy to proceed slowly with their treatments. Before laser work, a facial skin biopsy is paramount to diagnosis before treatment. A patient with hyperpigmentation may look like he has melasma, but a biopsy might reveal he has Hori’s nevus. This presents as bilateral facial blue-grey macules, seen in continued on page 29  body language www.bodylanguage.net

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MEDICAL AEsthEtICs:

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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.

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35 years of quality, science and innovation

skin Dr Mukta Sachdev

Q-Switch laser, post-first session after treating freckles and lentigines. Mild erythema seen post-treatment

0.8% of the Asian population. This skin condition is common in Asians and Orientals and typically is misdiagnosed. The pigmentation is acquired, does not involve the mucosa, unlike Nevus of Ota, melasma and Hori’s nevus can present concurrently. The choice of laser is a Q-switched Nd:YAG. Don’t skirt away from doing a facial skin biopsy because, clinically, the condition looks like melasma or Nevus of Ota. You could be dealing with something else that will respond better to a specific technology. So you’re using the Q-switch, you take off the glasses—because they are orange you can’t really see much—and the skin looks normal. Three minutes later and suddenly erythema develops. Be cautious with your settings and go slow. Don’t do multiple passes because you can induce pigmentation. A patient presented with Becker’s melanosis. A practitioner had used an ablative erbium for a test patch and she developed this. Does Q-switched Nd:YAG work on Becker’s? There is little evidence; the treatment is extremely limited and one needs to be cautious. Lasers and light therapies should be considered as third line treatments in severe refractory melasma patients who have not responded to topical preparations or chemical peels and who are willing to accept the risks of these procedures. This is the worldwide consensus of experts. Skin of colour is prone to post-procedural dispigmentation and this needs to be a critical consideration in patient evaluation and selection for laser as an option in melasma. So what’s the bottom line? Laser is not a choice for melasma. For superficial pigmented lesions such as freckles and lentigines, one to three treatment sessions should be sufficient; the deeper pigmented lesion often require seven to ten treatment sessions. Becker’s has a high risk of recurrence. Combination with ablative may have a lower risk of recurrence. Test spots should always be done. body language www.bodylanguage.net

For acne scars, my choice is a fractional erbium, I’ve had one for more than three years, but I’ve also had post-inflammatory hyperpigmentation. It is unpredictable, so you need to be careful with your fluences. Fractional CO2 I find high risk and it’s not something I use regularly. For skin rejuvenation, everybody is talking about non-ablative. There’s a high demand, it’s non-invasive, minimal downtime. Are they harmless because they’re non-invasive? Don’t think that just because they’re non-ablative they’re not capable of doing harm. Hair removal For hair removal I use three technologies: long pulse, Nd:YAG and diode. You can get good results with the hair removal. It is advisable not to strictly follow the company guidelines, as they can be too aggressive for darker skins. Start at lower energies; always use cooling. My preference is contact inbuilt cooling. When you’re doing hair removal laser work on Asian women, you may need to do a hormonal profile for undiagnosed and incorrectly managed polycystic ovarian syndrome. We have the same lasers all over the world; the key is your setting. Immediately post-laser you can get erythema. You can get a little folliculitis, but this will settle. Hyperpigmentation is commonly seen in patients who do tweezing, waxing, threading and all the other hair removal methods. We’ve found that you can reduce the post-inflammatory hyperpigmentation (PIH). As laser treatments are performed, pigmentation is reduced because threading and waxing are needed less and trauma to the skin is reduced. I’ll give you a tip here, blistering and burns are not the endpoint of hair removal laser in darker skin. I have patients saying “but the doctor said it was okay”; it is not “okay” if you get a blister—this is not a desired endpoint. Don’t over-treat, take a thorough patient consent and minimise your risks by appropriate and conservative parameters. We are working with several laser companies to rework their parameters for skin of colour. If you do get hyperpigmentation, the standard protocol is hydroquinone, and it usually responds in six to eight weeks. Your procedure mostly needs to be under topical anaesthesia. Redness, mild swelling can occur. If there’s any burning, use ice, use pain killers. We generally prescribe topical anti-biotics, emollients and, obviously, everybody gets sun protection.

I use a Woods lamp as an important diagnostic tool. Reducing the pigmentation with topicals or normal pulse lasers may allow for a deeper penetration of a pigment laser. Remember to take before and after clinical photographs. Patients will come back saying I’m not any better almost always. The reduction in pigment is slow, so you need to document every visit. What we are investigating now is the radio frequency pixel and pushing in a cosmeceutical to try to get deeper into the dermis for efficacy. I’m cautious because we’ve already see some PIH. We have had some promising results. The risk of PIH can be reduced with proper patient selection, an appropriate laser or light device, and good peri-operative skin care. Dr Mukta Sachdev is professor and head of the department of dermatology in Manipal Hospital in Bangalore, India. She runs a private clinic and has been is cosmetic dermatological practice since 1995

Laser hair removal. Operators must exercise caution with laser settings to prevent post-inflammatory hyperpigmentation

Practice Dr Luiz S Toledo

Ethnic considerations Races and cultures have long leapt nations’ borders. Multicultural societies are now the norm. As a practitioner, you need to know how to assess different racial groups. Dr Luiz S Toledo discusses his experiences

Cultural influences on aesthetics vary among countries. Bollywood films influence n a multi-culCompletely appearance in India tural city such distant from these as Dubai, divermodern influencsity and ethnices, there is a tribe ity are intrinsic to in the centre of identity. As more Saudi Arabia that people of different believes the ideal nationalities are shape for a womseeking aesthetic an’s nose should plastic surgery, be like the beak of doctors are making a falcon. Patients new efforts to prehave brought into serve ethnic identimy office a cardty while enhancing board mould to beauty. show the exact proAesthetic surfile they wanted— gery has historivery similar to the cally been tailored profile of the bird, to Caucasian faces, a national symand so today’s surbol in many Arab geons have a twocountries. We plaspronged challenge. First, they must define beautiful features for tic surgeons know that to create a nasal hump is not easy and it ethnic groups such as Arabs, Asians and Africans. Second, they might need some bone grafting, with bone removed from the need to determine how to modify standard operations to achieve iliac crest. The extent we should comply with these requests is a these goals. question many of us will have to ponder and decide. Physicians generally need to be more sensitive to the aesthetic In India it is Bollywood films that dictate the fashionable concerns of their patients and exercise greater skill in treating body and face. Six-pack abs and bleached skin are becoming darker skin, which is more prone to scarring and pigment chang- popular. es than white skin. For years, surgeons did the same operations Should practitioners succumb and submit their patients to for all groups, but this doesn’t work because racial anatomical something that will change their faces and bodies forever bestructures are not the same, and healing is different. If a surgeon cause of the latest movie or TV show? The answer is obviously uses western textbook measurements to guide his scalpel, the no. However, patients’ wishes should be considered during the result can be poor, as such books usually specify dimensions for consultation, and a degree of compromise may be achieved, so European faces. long as it does not cause a permanent and irreversible defect. We Apart from different body frames and proportions, we have have to consider that the same impulse that brings a patient this to consider all the influences that dictate the beauty standards year looking for a certain type of look, may bring her next year in certain areas of the world. The Arab countries, for example, looking for something different. are heavily influenced by the images of soap opera stars and pop In the UK I have seen a wide mixture of ethnic groups, and singers generated by Lebanese or Egyptian television channels. although the differences might not be as obvious as in the MidRhinoplasties are Arab women’s most popular surgery; for dle East, we should be aware of them and study them properly Asians, the creation of a crease in the eyelid to give the eye a before we face them in a consultation. Whichever country you more open look is desirable; for African women, breast reduction practise in, you must set aside time to interview prospective pais in demand. Experts ascribe the growing interest in aesthetic tients to match them to the appropriate procedure and check surgery among ethnic groups to a newfound prosperity. that they are ready to proceed for the right reasons. It is crucial that practitioners are aware of the ideals of beauty in ethnic groups. There is a certain pattern for small turned-up Luiz Toledo is a plastic surgeon based in Dubai and spent many noses, high cheekbones and big lips, which are desirable to Mid- years practising in Brazil. T: 971 50 702 2780; E: ToledoDubai@ dle Eastern women. gmail.com; W: luiztoledo.com 30

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conference BODY 2012

BODY 2012

3–4 November, Royal Society of Medicine, London

The UK’s only parallel conference dedicated to both surgical and non-surgical body aesthetic treatment

ODY 2012 is the sister conference to FACE—the UK’s largest scientific facial aesthetics conference. It follows the same format in aiming to provide the highest quality national and international speakers in their respective fields of scientific interest. The objective is to update practitioners’ clinical knowledge and explore new market opportunities in body aesthetics. Many practitioners attend events focused around their individual speciality and do not often meet others with different training and backgrounds working in the UK aesthetic industry. BODY provides a broad cosmetic agenda that brings all practitioners and clinic owners together at one meeting to create an excellent opportunity for debate and to learn more about the specifics of the many market segments that make up the aesthetic marketplace of the body. BODY 2012 is the largest UK congress devoted to the non-surgical and surgical body aesthetics sector and is a must-attend 32

event for practitioners and clinics operating in or wishing to enter this exciting market. Choice and value The BODY conference offers choice and value for delegates with the inclusion of separate parallel agendas providing dedicated scientific content for plastic surgeons, cosmetic surgeons, cosmetic doctors, dermatologists, nurses, clinic owners, laser therapists and other aesthetic practitioners. This allows you a greater choice of specific topics that interest you. Two-day surgical conference The programme is designed to provide you with interactive open discussion amongst the experts and will cover the latest topics related to breast implants, managing PIP patients, traditional versus other methods of liposuction, buttock augmentation, abdominoplasty and reconstructive procedures following massive weight loss. The confirmed speaker faculty to date includes: Marco Gasparot-

ti from Italy, Luiz Toledo from Dubai, Dennis Hurwitz from the USA, Alfredo Hoyos from Colombia, Amin Kalaaji from Norway, Barry Jones, Fazal Fatah, Lucian Ion, Shiva Singh, Shailesh Vadodaria and CC Kat from the UK. Two-day non-surgical conference Saturday 3 November is dedicated to exploring the wide variety of effective non-surgical treatment solutions for fat reduction and cellulite in this popular and rapidly expanding market segment. We shall also explore the potentially lucrative market for the effective treatment of stretch marks comparing evidence for different scientific concepts for this challenging, but common cosmetic indication. Sunday will cover a wide range of other topics including tattoo removal, incorporating bio-identical hormone treatments into an aesthetic practice, 3D imaging systems and hand, knee and décolletage rejuvenation. body language www.bodylanguage.net

conference BODY 2012

SPEAKERS INCLUDE: Professor Marco Gasparotti

Consultant plastic surgeon, Italy. Professor Gasparotti is becoming a regular speaker at Body. He is known as pioneering superficial liposculpture. His publication, Superfical Liposculpture in 1992, became a reference book for many practitioners. He became the first person to receive the American Academy of Cosmetic Surgery’s “Excellence in Cosmetic Surgery” award in consecutive years in 2001 and 2002.

Dr Alfredo Hoyos

Consultant plastic surgeon, Colombia. Dr Hoyos is the inventor of high definition liposculpture (HDL), dynamic definition lipoplasty (4D), and other advanced techniques in body contouring. In combination with cutting-edge technology such as Vaser, he designed the Vaser high definition lipoplasty (VHD) procedure. Dr Hoyos and his associates have performed more than 1500 VHD procedures.

Professor Syed Haq

Consultant physician and founder of The London Preventative Medicine Centre. Prof Haq is the clinical and scientific director of Daval International Ltd., a biopharmaceutical company developing a platform for the treatment of autoimmune, neurodegenerative and inflammatory conditions. He has been co-chairman of the Anti-ageing Conference London (2008-11), and a speaker at numerous international conferences.

To follow updates you can look for the hashtag #BODY2012 on Twitter Laser hair removal and skin treatment symposium For those businesses specialising in laser and IPL treatments, or for clinics and practitioners wishing to explore this popular and profitable market segment. Another symposium is on Sunday 4 November. The morning will explore laser training, treating dark skins and dealing with resistant hair-removal cases alongside discussions in detail of the differences between five leading laser hair removal systems. The afternoon will review laser skin rejuvenation of the décolletage, leg vein treatments and onychomycosis, one of the newest laser indications. Other features  Condensed Laser Core of Knowledge workshop run by Mapperley Park Training  Separate in-depth Laser Hair Removal workshop on dealing with problems run by Syneron Candela body language www.bodylanguage.net

 Wide range of separate exhibitor workshops  Dedicated BODY aesthetics exhibition featuring a range of leading suppliers AND “An Evening With” Dr Alfredo Hoyos: Plastic Surgeon from Colombia who is an ardent painter, sculptor and inventor with 10 patents to his name and who has pioneered work in plastic surgery, in particular the art of body sculpting. With a list of patients who include famous actors, models, celebrities, top athletes and even royalty, he enjoys travelling the world to lecture and share his unique techniques. Don’t miss out on BODY 2012, a conference dedicated to the latest scientific information, alongside clinical and practical tips revealed by experts specialising in body aesthetics. For more detailed speaker and agenda information and to register for the BODY conference online, please visit www.bodyconference.co.uk. Or to register by telephone, call 020 7514 5989.

Miss Chien Kat

Consultant plastic and reconstructive surgeon, UK. CC Kat was appointed at the University Hospital of Birmingham in 2000. In 2010, she set up her own clinic, CC Kat Aesthetics, where she now works full time, providing surgical and non-surgical procedures. A founding member of the Nagor West Midlands Aesthetic Fellowship, CC Kat takes an active role in training the next generation of aesthetic surgeons.

Mr Lucion Ion

Consultant plastic surgeon, UK. Mr Ion is involved in research projects evaluating the role of 3-D photography for assessment and planning of facial surgery including rhinoplasty, implant surgery and rejuvenation, and planning for breast reshaping and liposuction. He has been featured in television documentaries on aesthetic surgery on Discovery Health and Channel 5.

Mr Shailesh Vadodaria

Consultant plastic surgeon, UK. Mr Vadodaria is at the forefront of body contouring and liposuction. He was the first surgeon to use radiofrequency-assisted liposuction in the UK and is a national trainer on both RFAL and laser lipolysis. Mr Vadodaria has presented more than 50 papers in the national and international plastic surgical congresses. He has innovated instruments, simulators and plastic surgical techniques.

surgery Jonathan Britto

From all Facial aesthetics often requires multiple techniques to achieve the best results. Mr Jonathan Britto sees surgery as one of the elements of overall treatment

ur patients want facial aesthetic change. They want to look younger, and often specifically they want to regain or refresh an aspect of their appearance. There are, of course, other groups as well—those who want to look different, to relieve themselves of an unloved feature (such a skin lesion or a nasal asymmetry), or the toughest group, those want to “feel better”. We can’t save a marriage or a career with anything that we do, but we can make a loss or bereavement a little easier to cope with, and managing the expectations of our patients is key. In my practice, what most people seek is a comprehensive, harmonious, result that doesn’t make them look as if they’ve been “done”. It is perhaps reasonable to think that a good procedure is “invisible”—the outcome should be “how healthy do you look” and not: “Wow! Who did your facelift?” We now have many tools: these may be predominantly vectoral, such as brow lifts and neck lifts; others that are predominantly volumetric, such as for the mid-face; and techniques for skeletal structure and integrity, for skin quality, hydration of the skin, resurfacing techniques and so on. If I look at my practice, it splits into three “aesthetic ages”. British people of a certain age will be familiar with Club 18-30, because it picks up on a group of people: young adults, with disposable income, generally fairly hedonistic and narcissistic, who want a good time. These are our youngest patients, and generally their

aim is not rejuvenation, but to change an unloved feature. The next group, in their mid-30s to late 40s, comprises those with increasing responsibilities, families, career pressures, and so on. They want to maintain their appearance quickly, efficiently, and with minimum downtime. This is the group that the cosmeceutical firms target, offering high-reward, low-demand treatments. The 50+ age group has more disposable income and time, and are able to devote those resources into regaining or refreshing what they have had before. I have a cadre of patients up into their 70s who want facelifts and breast reductions to improve their quality of life, and so we find the parameters are shifting. Here we find a radical change, because, of course, those groups are now overlapping significantly, and this is most evident in the media. We have Helen Mirren looking fantastic in a two-piece in her sixties; we have Jane Fonda looking gracefully at 70 as if she’s in her fifties; and rather more disgracefully, Tom Jones and Grace Jones looking fabulous at the Queen’s jubilee! At 54, Michelle Pfeiffer looks 10 years younger. We can see skeletal and soft tissue volume changes, but she still looks amazing. This is the expectation that our patients now have of us. Thus our assessment skills have to change, and if you’re a surgeon, the surgical platform upon which we work has to change, together with our management of patient expectation. As aesthetic plastic surgeons, we learn also from our reconstructive surgery

results. In the best reconstructive surgery, each cosmetic unit of the face runs smoothly into the next: the brow and upper lid; the shape of the eye; the position of the lateral canthus; the commissure; and the volume of the lower lid, matched to the cheek; all show a smooth, balanced flow. Before reconstruction, however, appearance can be distressing because it is unbalanced, and lacks proportion. Appearance is not necessarily about symmetry. In my craniofacial reconstructive practice, I may split the face into thirds, and subdivide that further, but in our aesthetic practice we’re after flow, balance, and harmony, and making each unit in the face flow cosmetically into the next. Applying those principles to the periorbital region, I look at the brow and I think, what is the prominence of the brow? Is there a positive vector? How deep is the upper eyelid sulcus? Are there folds in the upper eyelid skin? What’s the quality of the skin? What’s the tilt of the canthal axis? Is it positive, negative, neutral? Crucially, what is this distance between the lateral canthus and the lateral brow— important because that aesthetic unit should form four harmonious curves: eyebrow, skeletal margin, supratarsal crease and ciliary margin. If the beautician sets the lateral eyebrow point too high this can be very difficult to correct. In the lateral canthus, we’re looking for crow’s feet, but more importantly, we need to know that patient’s personal history. Who is their medical aesthetician? What’s their relationship with that person? Do they have regular therapy with body language www.bodylanguage.net

surgery Jonathan Britto

toxins? How long do they last? Are they well-managed? In the mid-face, I want to investigate volume balance: the lower lid, tear trough, and mid-face itself. Is there an undulating “ski-slope” or is there a smooth curve? If this Ogee curve is balanced from lower lid to lip, is there an injectable history? Is there a high molecular weight hyaluronic acid in there? In the brow, balance is relatively straightforward. We all know about the “tug of war” of frontalis versus the brow depressors, and we all know that we can reset that tug of war with toxins, and this is predominantly vectoral and not really volumetric. The role of brow lifting has declined, an observation based on my practice as well as international data from the professional associations. Nonetheless, some patients desire more specialist composite effects in the brow and upper lid together, and browlifting has a place. One of my female patients, for example, had a positive vector in the lateral skeletal brow. An upper lid blepharoplasty would have been unfavourable aesthetically because this would have caused a sunken upper eyelid and made that prominence more obvious. From the craniofacial perspective we can reduce that prominence. At risk is the eyebrow position which might float the brow up. How that anatomy works is key in managing these patients. The objective is to achieve harmony between the brow line, the skeletal margin, the supratarsal crease and the eyelash margin to provide a basis of proportion upon which toxins and other injectables can act. Toxins, however, can change the way we assess our patients. Toxin therapy can deal with crow’s feet beautifully, but administered incorrectly may slightly weaken the lateral part of the orbicularis and drop the eyelid. As the remaining orbicularis fibres are working so hard you may see malposition in the lower lid. What surgical solutions can do is give symmetry and balance to the aesthetic units. It is difficult to reconstitute a hyper-elevated lateral brow, for instance, and the beautician must resist the tempation to hyperelevate the hairline of the lateral brow. Surgery doesn’t have to be big to be valuable. An upper eyelid blepharoplasty can give the whole face a rejuvenation. Toxins will maintain many a patient’s brow position and there’s no need for a brow lift. One young male patient had a glabody language www.bodylanguage.net

Necklifts are predominantly vectoral. The transverse skin crease elevates, the neck is narrower and given a triangular definition

The combination of volumetric blepharoplasty and mid-facelift harmonises the fat pads of the eyelid and cheek. Preoperative volume loss in the lid, and volume droop in the cheek are transformed to volume harmony across the two aesthetic sub-units

This patient has many aesthetic challenges to the midface. Preoperatively, there is xanthelasma (fatty deposits in the eyelids), volume loss in the lids, lid laxity, midface volume ptosis and volume imbalance between eyelid and cheek. A combination of surgical principles restores volume balance, tightens the eyelid, and removes the xanthelasma for a youthful lid cheek balance

surgery Jonathan Britto

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 Assessment of the forehead, brow, eyelids and cheek is a stepwise 1-4 manner, taking in prominence of the forehead and cheek and soft tissue volume balance  The eyelid and midface fat pads in volume disharmony! Surgical transblepharoplasty midface lift resets midface harmony, which can be maintained with injectables

bellar volume loss created by a raphe between the frontalis and procerus muscles. Previous toxin therapy had made that worse, creating muscle imbalance, and hyaluronic acid had been static in an otherwise mobile field. The solution was 20 minutes of surgery just below the eyebrow, and the muscle distributed back into the gap, allowing for a normal mobile glabella with regular volume distribution across it and a small scar. The toxins and the injectables can now provide the benefit they should. The mid-face is “tiger country” for everyone. Typically, patients may present with volume imbalance between the eyelids and upper or lower cheek. A useful recent publication has shown that, if you superimpose women’s faces in their 70s onto their own daughters in their 40s, the dominant feature of mid-facial ageing is clearly volume loss. We all have our favourite tools to address this. A good outcome in my estimation is a smooth line of curve between the lower eyelid and the oral commissure. This all derives from volume balance and the underlying fat pad anatomy. In the mid-face you’ve got three fat pads: a subcutaneous fat pad under the skin—the malar fat; deep to that, under the orbicularis muscle, there’s the submuscular layer of fat—the suborbicularis oculi fat (Soof); and above that and behind it and the orbital septum, is a retroseptal fat pad. Harmonisation of all those fat pads leads to really powerful aesthetic change. 36

More difficult to treat is excessive volume in the eyelid, with volume loss in the tear trough and mid-face ptosis. The key to managing this is re-approximation of that volume change. You might put a volumiser into the tear trough and into the malar crescent in the form of a filler which gives symptomatic relief, but this doesn’t address the cause of the problem. An alternative for surgeons is autologous fat transfer. Injection of fat or filler at high pressure runs the risk of driving an embolus through the external arterial system into the internal system, with the potential risk of stroke and blindness. Knowledge of which planes in the lower lid and cheek are relatively avascular is, of course, a prerequisite. The optimum solution in my book is to balance the three fat pads. Elevation of the malar fat pad, and retroseptal fat pad surgery harmonises the fat pads and restores aesthetic balance. If necessary, Soof surgery will add to the volume balance, and this can then be maintained by injectables as required. Not all young patients either need a facial scar or will accept it. We can lift the mid-face through the lower eyelid to lift the Soof and give volume balance, and this is a good platform for injectable maintenance. I do use injectables around the orbit, and the safest place is just deep to the orbicularis muscle, into the gutter created between the levator labii superioris muscles and the orbicularis. The anatomy of

the area is not as complex as it sounds, and is important to safe results. Where there are weak lower eyelids, they likely to fall away from the globe: any force that creates inflammation in that lid is going to create a lower lid malposition. In these cases, as part of a surgical solution, we can tighten the lids and restore eyelid support. I have used the same principles to remove difficult lower eyelid xanthalasma: create a wound, support the lower lid with the Soof, support it again with orbicularis muscle, and balance the volume in the lid in the mid-face. It can yield good aesthetic results, which can be a platform for subsequent injectable therapy if necessary. The peri-oral and lip area is often the best place for HAs. Where there is scarring, however, injectables may end up distant from where they are placed. Thus, surgery in a scarred upper lip tubercle may be better than HAs, where in the unscarred lip, HAs are more rewarding. A multi-disciplinary approach starts with resetting the soft tissue balance of the face, and indeed the underlying skeleton, if necessary. We maintain this balance with injectables and surface treatments. The traditional role of facial aesthetic surgery has changed: we must now see the surgical role as part of an overall treatment plan, which may incorporate the surgical and the non-surgical at different times in different patients for a truly bespoke experience. Mr Jonathan A Britto is a consultant plastic and cranofacial surgeon at Great Ormond Street Hospital for Children and University College Hospital, London

Volume loss in the glabellar region from a frontalis muscle raphe. Local anaesthesia outpatient surgical release from a scar below the right eyebrow allows reapproximation of the muscles body language www.bodylanguage.net

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adequacy of training and qualification in the cosmetic sector following the PIP scandal. Chaotic deregulation also coincides with the rise of the cheap Chinese laser; it’s never been easier to set up as a laser practitioner – unfortunately, anyone can have a go for around £1000. A BTEC award expresses professionalism. It sets you apart from the unskilled as one of the few Healthcare or Beauty Professionals to formalise their expertise through Qualification. Most laser and ILS training is through distributor’s instruction, often to a very high standard. Qualification is different, measuring knowledge and understanding and at Mapperley Park, through small-group, round-the-laser workshops. This is a degree-level qualification, independent of any particular laser or light interest, run by Jo Martin and Paul Stapleton. Jo has run the Clinic – and a daily clinic list - since setting it up in 1993. We have delivered more than 200,000 treatments in 20 years of

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We have London and Nottingham venues but the advantage is on our home ground, where we have £1million of equipment already emplaced across 6 treatment rooms and a minor ops facility. The London premium covers the extra cost of delivery away from home.

These one-day events are spent primarily in Jo’s company but may also involve other industry experts. Topics currently include, Tattoo, depilation, vascular, ablative/non-ablative.

Watch the diary or give Latoyah a call to discuss your needs

Call 0115 969 0111 or Email: training@mapperleypark.co.uk mapperleypark.co.uk/training Mapperley Park Clinic is registered and therefore licenced by the Care Quality Commission to provide a range of medical services as Provider ID; 0000026452.

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maxillofacial Mr Henri Thuau

Completing the picture Establishing facial balance demands optimising skeletal relations and contour definition as well as enhancing soft tissue support. Mr Henri Thuau elaborates

hen it comes to the osteocartilagenous facial foundations, we can speak of the inner face. Under the surface, an intricate combination of bone, cartilage and teeth that supports the overlying soft tissues define the contour, shape and projection of the facial features. This explains facial depressions, asymmetries or excessive projections. Some patients will, therefore, benefit from procedures involving mainly the underlying bone, cartilage or both; others will require only soft tissue interventions, from fillers or aesthetic surgery. One can modify the underlying facial bone structures by moving or reshaping them. Close collaboration between the facial aesthetic specialist team is mandatory to achieve the best surgical outcome. The soft tissue procedures achieve or combine reduction, augmentation or resuspension. As we know, more than one modality is usually required. Multi-disciplinarity and sharing knowledge is the key to success: specialists nowadays work together for the benefit of their patients, rather than intervene in isolation. Over the past 10 years, new surgical techniques have appeared. Morphing modalities in imaging programs have allowed a remarkably accurate 3D assessment of the face, the underlying soft and hard tissues (bone). Cone beam CT low-radiation scanning provides a fantastic mapping of the skeletal structures, facilitating understanding of where the problem is and what needs to be done. Simulations are becoming more reliable and enable a clearer visualisation of body language www.bodylanguage.net

the planned procedure. They are also useful for discussions with patients. Facial capture permits the analysis of the face from any possible angle. Every face is asymmetric. Itâ&#x20AC;&#x2122;s the harmonious relation between different asymmetries that generate beauty. We have to ensure our intervention will not enhance a neighbouring asymmetry that was looking beautiful before, but after we have intervened it has become noticeable in a negative way. We should not forget that the skeletal foundations together with the soft tissues of the face evolve with age. Individuals may present with different qualities of soft tissues, muscular activities and tonus between each side of the face. Others may have significant facial bone of jaw deformities that compromise their appearance. The visualisation, planning and simulation will determine the choice of procedure involving soft or hard tissues. Facial balance The surgical aims are to establish facial balance, to optimise skeletal relations and contour definition, and to enhance soft tissue support. Sometimes this can be achieved by repositioning or recontouring (facial implants) of the facial/jaw bones or by combining with soft tissue procedures. The face is like a geographical map, with convexities and concavities, which all are in close relation. If you address one, you need to make sure you do not undo the beautiful perspective of the other. The assessment of the quality and projection of the skeletal structures is crucial. We must consider the quality of the soft tissues and particularly the muscular

tonus, because a difference in tonus may mimic a skeletal deformity. Sometimes both skeletal and soft tissue asymmetries co-exist, and the different options (movement of jaws, chin operation, facial implants, facial recontouring) need to be carefully considered. The choice will obviously depend on the patientâ&#x20AC;&#x2122;s wishes, but also other critical parameters such as age, medical condition and compliance of the patient will need to be taken into account. The ultimate objective is to try to re-establish a harmony between the different thirds of the face and give a youthful appearance. The pioneer of the aesthetic genioplasty was Professor Hugo Obwegeser in 1957. He described double jaw surgery to re-establish facial aesthetics and function, which has become the gold standard. How do you choose between a genioplasty or a chin enhancement? The genioplasty is more versatile, as it allows changes to the labiomental height and the labiomental fold. An implant is more appropriate if the aim is to enhance and widen the chin prominence. A genioplasty may be associated with fillers to optimise the overall appearance of the chin. Facial features can be significantly improved by many modalities: skeletal movements or re-contouring, soft tissue interventions, and often a combination of both. Multi-disciplinarity and close collaboration between specialists are important to offer patients the best care. Mr Henri Thuau is a consultant maxillofacial surgeon at the Chelsea Westminster Hospital 39

aesthetics Dr Raina Zarb Adami

Facial

contouring Restoration of facial contouring and enhancement are the primary goals of patients desiring to roll back the years. Dr Raina Zarb Adami discusses the anatomy of beauty, causes of ageing, and how she helps her patients look younger

s_bukley / Shutterstock.com

Featureflash / Shutterstock.com

Nature has demonstrated beauty in the golden ratio of 1:1.618. For example, the width of the base of the nose to the width of the mouth, the width of the face to the length of the face, and the thickness of the upper lip to the thickness of the lower lip. In the ideal face, these all follow this ratio, and this is seen even in the length of the bones of the hand. The ratio of the length of the distal phalanx to the middle phalanx follows phi, and so on up to the metacarpals. We see it in seashells and in many other things in nature, and in architecture. An American surgeon, Marquardt, put these lines into a facial mask. The classical beauties of today and in days gone by all fit this mask. The lines of the face are also notable. Our eyes fall naturally onto smooth lines, and so a smooth jaw line is considered more attractive than one made irregular by the presence of jowls. If you look at a patient’s profile, a straight line between the glabella, the subnasale, and

Certain imperfections add to the allure of stars, such as Cindy Crawford’s mole. Angelina Jolie has a beautiful Ogee curve and rather full lips. George Clooney’s prominent jaw is considered classically handsome for men

Featureflash / Shutterstock.com

hen discussing facial contouring, revolumisation immediately springs to mind or, “liquid facelift” is often mentioned. I find this term a little restrictive because, while youth is a significant player in appearance and beauty, many other contributors exist. Symmetry is commonly recognised as one. When the left side of the face mirrors the right, this tends to be perceived as more beautiful. We find this in most classical beauties. However, we know that many people who are considered beautiful are not symmetrical at all. Proportion has been defined in many ways. We have heard about the face being divided into vertical fifths, where one-fifth is ideally the width of an eye, and in the ideal face, these are all equal. Horizontal lines divide the ideal face is divided into equal thirds. These thirds lie between the hairline and the glabella, the glabella and the subnasale, and the subnasale and the menton.

body language www.bodylanguage.net

aesthetics Dr Raina Zarb Adami



The descent of the malar fat pad is a gradual process that results in the formation of naso-labial folds, which leads to down-turning corners of the mouth and the formation of marionette lines and eventually jowls After marking the orbital rim, the next structure to consider is the infraorbital nerve. Identify it and mark it. You don’t want to prang that nerve or inject product next to, or worse still, into it, because it will cause the patient a sharp pain that might persist Blood supply to the face



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body language www.bodylanguage.net

the menton is considered attractive as well. Of course, the texture and condition of the skin are important, too. Most of these factors apply to men and women and women alike, but some key properties differ, especially in youth. In a man, it is considered more acceptable to look older. The “silver fox” is still considered attractive. In a woman, large eyes, high cheekbones with a corresponding narrow jaw with a curvaceous sigmoid Ogee curve, a smooth jawline, and a baby face are considered contributors to beauty. In women, there is some beauty to be found in certain imperfections, such as Cindy Crawford’s mole. That was her major selling point. Fuller lips come across to people as being a warmer person, therefore more approachable and, in turn, more attractive. Angelina Jolie has a beautiful Ogee curve and rather full lips. What she has, which is not considered feminine, but nobody would say she’s unattractive, is her prominent jawline. Marilyn Monroe, as well, has a rather long face with a beauty spot, and Kate Moss has the typical baby face. She has a high forehead with large eyes, prominent cheekbones and thick lips. Narrower facial shape Men, on the other hand, tend to have a narrower facial shape with fuller and more symmetrical lips, the upper half of the face being broader in relation to the lower, with higher cheekbones and a prominent lower jaw. A prominent chin in a man is considered more masculine, and a full head of hair, if a man has a full head of hair, is considered to be more attractive. This is, of course, completely subjective. There are no rights or wrongs, but for us, as the medical practitioners, we have a few rules to go by to help a guide a patient to achieve an improvement in facial appearance. Some of the men considered attractive include George Clooney, who claims he has not had any interventions. We know he does have a few wrinkles, and there was speculation he might play Simon Cowell in a film. Apparently Simon Cowell said: “If he’s going to play me, he needs loads of Botox.” When we speak to and see people, we rarely just see them front on; we have to appreciate them from the oblique and lateral view. The oblique view is often the most important and is the biggest giveaway of a person’s age. This is because of the curve formed by the zygomatic prominence. The Ogee curve is the curve seen on an oblique photo formed by the lateral margin of the superior orbital rim, the eye socket, the malar prominence, and the rest of the cheek. The curvier this is, the more attractive this is considered. The inferior part of the curve tends to be more of a straight line. As we grow older, this curve tends to flatten. What detracts from beauty, or why do we become less attractive as we grow older? Major components are muscular hyperactivity and volume loss. Up to the age of 25, our dermis has produced all the hyaluronic acid, collagen, and elastin it will ever produce. After that, we are just drawing from a bank. As we grow older, the dermis thins out and facial volume diminishes. We also use our elevator and the depressor muscles 41

aesthetics Dr Raina Zarb Adami

more—dynamic lines morph into static rhytids. One of the biggest telling factors is the malar fat pad. When we were medical students, we never gave much importance to this adipose tissue. As the years take their toll and we study the science of aesthetics, we find that it is the root of most of our patients’ grief. The malar fat pad has two components: a superficial and a deep component. The deep component is fixed and doesn’t migrate with age. However, the superficial component descends with age. As the malar fat pad descends, the naso-jugal fold (commonly known as the tear trough) makes it debut. This leads to the formation of naso-labial folds taking with them the oral commissures, thus leading to down-turning corners of the mouth. In younger people, oral commissures curve upwards slightly, slowly descending with time. This leads to the formation of shadows called the marionette lines, and eventually jowls. This is, of course, a gradual process, but it is all related to the descent of the malar fat pad. This process can be accelerated by smoking and by sudden weight loss. Very often we see skeletonisation in people who have lost weight suddenly due to diet, exercise or both. Often, the bodies of runners and people who have dieted look brilliant, but their face gives their age away because they have a sudden, gaunt appearance. This is the same with people taking anti-retroviral medication. This is the reason cheek fillers became so popular, when people on these medications were stigmatised because they were losing this fat due to lipodystrophy. Suddenly, they could be identified as HIV-positive patients. When it comes to marking the cheeks for rejuvenation or augmentation, we must remember the appearance of a cheek depends on many things—not just the malar fat pad. There is the underlying bony structure, the parotid gland, the musculature, especially the muscle mass of the masseter, and the overlying skin. However, there is little we can do to many of these anatomical components, but we can restore

volume, or introduce it where it is needed to augment appearance, such as those with relatively narrow faces, perhaps due to elongation of the maxilla. It is imperative to warn patients of the possibility of bruising. We avoid bruising the patient by keeping in mind the patient’s anatomy. The most important structures to consider are the facial artery, which is the fourth branch of the external carotid artery coming up superficially and anterior to the masseter. This artery takes a tortuous path, so it’s not always easy to predict its exact location. In rather thin patients, the pulsation is palpable. It takes a path towards the angle of the mouth, giving off the inferior labial and superior labial arteries, coursing up towards the corner of the nose, and ending up as the angular artery next to the medial canthus of the eye. The veins follow a more direct course and are more lateral. Inadvertent intra-arterial injection may result in embolism and block off the end artery, causing necrosis to the structures supplied by that artery. Aspiration before injection is wise. There are various ways to mark the patient. I tend to start with the inferior orbital rim, as a superior margin. Injecting above it, is likely to cause a Tyndall effect and give the patient prominent bulges under the eyes. After marking the orbital rim, the next structure to consider is the infraorbital nerve. In many people, you can just palpate along the inferior orbital rim and feel the notch. In patients where you can’t feel that, just tap along and ask them when an altered sensation is felt. It usually resembles a tingling sensation radiating to the upper molars. Identify it and mark it. You don’t want to prang that nerve or inject product next to, or worse still, into it, because it will cause the patient a sharp pain that might persist. Hinderer’s line is a line drawn from the lateral canthus to the oral commissure. We aim to avoid injecting medial to that line. The next line you draw is Frankfort’s horizontal line, a horizontal line from the superior aspect of the tra- continued on page 44 

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

DR RAINA ZARB ADAMI

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 and  A patient lost much weight and looked gaunt. I injected 2mm of Juvéderm Voluma on both sides of the cheeks and a little Juvéderm 4 into the nasolabial folds and added some toxin  and  One patient had sworn against surgery and said she wanted only subtle results. I used Voluma in the cheeks and jowl area and Juvéderm 4 in the nasolabial folds  and  I injected this patient with Juvéderm Voluma with lidocaine into the malar area and just underneath. I used a bolus technique onto the cheekbone with a little fanning underneath. All she needed was 1mm on each side

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aesthetics Dr Raina Zarb Adami

gus of the ear going through the inferior orbital rim. Generally, in most people, it ends up just above the nasal ala. We don’t want to inject above this line because, when a patient opens her eyes, she wants to see what’s in front of her. She doesn’t want to see cheeks. Case studies Typical patients I have treated (page 42) include Amanda, a 43-year-old mother of four, who I injected with Juvéderm Voluma with lidocaine into the malar area and just underneath. I used a bolus technique onto the cheekbone with a little fanning underneath. She was not too far gone, and all she needed was 1mm on each side, which has caused a big improvement in the nasojugal area, nasolabial folds and in the marionette lines. A hint of a jowl remained, but I didn’t think she needed any further intervention. Another patient, Mark, turned 50 recently, and decided to lose much weight. He did so successfully, but at the expense of looking rather gaunt. He told me that people were asking him whether he was ill instead of telling him he looked fabulous and healthy, because he had the body he always wanted. I injected Mark with 2mm on both sides of the cheeks with Juvéderm Voluma, but I put a little Juvéderm 4 into the nasolabial folds and some toxin as well. I first treated the cheek volume and then observed the rest of the face. When treating the cheek area, which is often the cause of problems further down

We don’t want to inject above Frankfort’s horizontal line because, when a patient opens her eyes, she wants to see what is in front of her the face, you often see an improvement in the lower face. If needs be, I add other products afterwards. I’ve always found that, when I’m treating the face with dermal fillers, I start from the top and tackle the problem first. Another patient, Sarah, was an ideal candidate for a surgical facelift and not so much for nonsurgical intervention, but she has sworn against surgery. However, if there is more than an inch to grab between your thumb and index finger in the jowl area, you cannot perform miracles with dermal fillers alone, and it’s very important that patients do understand this. Nevertheless, she was pleased with her treatment. She said she wanted only subtle results, and she got more than that, but she was pleased. I used Voluma in the cheeks and jowl area and Juvéderm 4 in the nasolabial folds. Dr Raina Zarb Adami is a cosmetic doctor and the medical director of Aesthetic Virtue, with clinics in Harley Street, Knightsbridge and Malta. She is also the director of the Academy of Aesthetic Excellence, which provides courses in aesthetic medicine for medical professionals

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body language www.bodylanguage.net

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Unit 54-55, Shrivenham Hundred Park, Majors Road, Shrivenham, Wiltshire, England. SN6 8TY T: 0845 0701782 E: info@lifestyleaesthetics.com Web: www.lifestyleaesthetics.com

advertorial SkinCeuticals

Professional peels for individual skincare SkinCeuticals, pioneers in cosmeceutical skin-care, offers advanced, professional skin-care in a portfolio of products formulated to prevent damage from aggressors and free radicals, to protect the skin from UV and to help correct existing signs of ageing

kinCeuticals’ retail skin-care products are widely available in professional sizes, allowing integration into numerous clinical procedures for enhanced results. These are accompanied by professional chemical peels that vary in strength and acidity, enabling clinics to offer a customised solution for their patients. The SM Gel Peel, 20% salicylic and 10% mandelic acid, can revitalise sensitive skin types and help to improve the overall appearance of imperfection-prone skin. A great companion for other skincare treatments, such as microdermabrasion or IPL, this peel can be used successfully with little downtime and patients can expect to see visibly enhanced radiance in their overall skin after a series of four to six treatments. The new peels to be added to the SkinCeuticals peel range are the Micropeel 20 and 30, a 20% and 30% glycolic peel offering launching this autumn. Designed to address the visible signs of photoageing, the Micropeel 20 and 30 have little downtime for the patient and can be used as a customisable treatment to: • Help improve the visible appearance of epidermal lines • Even the appearance of epidermal pigmentation • Refine and reduce the appearance of pore size • Make skin appear smoother and feel softer • Brighten dull-looking skin

The final peel offered by SkinCeuticals is the Pigment Balancing Peel, designed to help correct the appearance of hyperpigmentation. Combining brightening agents with a 40% glycolic peeling solution, this medical-only peeling procedure significantly improves photodamaged, mottled-looking skin. It is ideal for patients who have had regular topical treatments and have previously undergone starter chemical peels and are ready for the next level of treatment. Integrated skin-care As with all SkinCeuticals professional peels, there is a strong link to home-care recommendations before and after treatment. Cients should be recommended one of SkinCeuticals’ potent antioxidants and the hydrating and exfoliating serum, Retexturing Activator, to ensure the skin is healthy and in optimum condition for the procedure. SkinCeuticals Epidermal Repair is ideal post-procedure to keep the skin soothed and nourished, while its extensive range of efficacious corrective products work to support and maintain the effects of the treatment. A clinical study* shows that, by incorporating products into the treatment and recommending a targeted at-home regimen before and after the procedure, the client receives a completely integrated skin-care system, which often provides optimal end results. SkinCeuticals Pigment Regulator, a product designed to address the appear-

Why offer SkinCeuticals peels?  High degree of efficacy and instant results  Industry-leading peel expertise—over 10 years’ experience  Tested and safe technologies  Strong link to home-care  Customised application minimises waste and cost  Little to no flaking  Ease of application

ance of hyperpigmentation, contains some of the same brightening and peeling agents used within the Pigment Balancing Peel, providing an ideal at-home maintenance regimen following a series of treatments. For more information on the advanced professional skin-care offered by SkinCeuticals and the range of professional chemical peels, call SkinCeuticals on 05603 141 956. *A clinical study evaluating a series of Pigment Balancing Peel treatments with SkinCeuticals’ home-care products, including Pigment Regulator, was conducted to determine the effects. Twenty-five subjects received a series of six in-office Pigment Balancing Peel treatments in conjunction with home-care products (Pigment Regulator, Epidermal Repair, Ultra Facial UV Defense SPF 50). An evaluation followed based on blinded expert rating, clinical evaluation and a subject questionnaire. The study reports a 38% reduction of hyperpigmentation spots in 60 days and a 67% reduction after 84 days. (Draelos ZD. “Skin lightening challenges,” GCI Magazine 2009; February, pp 1-6.)

body language www.bodylanguage.net

workshop Dr Timothy Flynn and Dr Michael Kane

Michael Kane

Timothy Flynn

Filler complications Problems arising from speedy injections, the Tyndall effect and excessive bruising are among the challenges practitioners face injecting fillers. Master injectors Dr Michael Kane and Dr Timothy Flynn offer their advice

Michael Kane: When you are injecting fillers, slow down. Nearly all filler complications come from squirting too much too quickly in one spot. Sometimes I use small needles for minimal pressure on the outflow, and my needle is always moving. I do not inject a filler with my needle stationary. In the one-in-a million chance that I’ve cannulated a little arteriole, I’m out of there in a fraction of a second. We have to be careful saying that cannulas are safer: there’s no science to back that up. They are a little faster, maybe a little lumpier, but certainly you have less control squirting in in a large clump with a cannula than you do with dribbling filler out of the end of a 32-gauge needle. Cannula injection is deeper so that tends to hide some of the lumpiness or irregularities, but when people talk about decreased risk of a vessel puncture and blindness, this can be refuted. A well-known case in New York involved someone who had fat injections with a blunt cannula in their nasolabial folds and became blind in one eye. One study looked at different rates of injection, and the people who injected slower had a much lower rate of adverse events as rated by patients in their diaries. Tim Flynn: Bruising from injectables is common. In one 32-year-old patient I treated, I injected 1.6cc, two syringes of Juvederm Ultra into the premalar fat pads. One week later, she had a horrible bruising under each eye. In a study by Brandt on the lower face using biphasic HA (Restylane/Perlane), it was found that most patients had at least one injection site reaction, and the bruising was the most common. We ask our patients whether they are on any blood thinners and to stop them if they can. Some say they can’t tolerate a bruise, and we have to tell them that we can’t guarantee they won’t bruise, but we can try to minimise it. The oral intake of medicines and supplements contribute, so body language www.bodylanguage.net

we ask whether they are on elective aspirin, Plavix, Aggrenox, Indomethacin, or nutritional supplements such as ginkgo biloba, fish oil, or other nutritionals—all these can contribute to increased bleeding. We give patients a long list of substances and ask if they can stop taking them. Garlic supplements increase bleeding time; they inhibit platelets and they lead to a fibrinolytic effect. The garlic’s presence causes the clot to be dissolved a little bit faster. It has been reported to increase post-operative bleeding. Vitamin E has no effect on normal platelets, but on abnormal platelets, such as those in people who have diabetes or are on dialysis, it causes reduced platelet aggregation. Ginkgo biloba is one of the top-selling herbs in the US. It is used largely for treating depression, and is supposed to improve cognitive function in dementia, and it inhibits platelet activity. You can reduce bruising with dietary supplements such as arnica. Multiple studies have shown it doesn’t reduce bruising much, but two small blinded studies suggested it may decrease mechanical bruising. There are other natural substances that you can use to reduce bleeding such as bromelain if arnica or vitamin K doesn’t work. To return to the patient with the bruising under the eyes one week after injection, she said she had a headache before and took some aspirin. This was the cause, and so we asked her to stop taking it, and now she’s a regular patient and does fine without such extreme bruising. Michael Kane: Lumps arise from squirting too much too quickly in one spot. Luckily, most of the HAs and the calcium fillers are fairly compliant—you can get away with little lumps and rub them out easily. When I do eyelids, I often do many superficial, fine injections into the dermis, a technique that is not so forgiving. When you get a little lump in the superficial dermis, it is a harder thing 47

workshop Dr Timothy Flynn and Dr Michael Kane

to rub out. You can make it better, but often you can’t make it go away. The biggest thing for me is volume and placement control. Again, I inject really slowly. When I do a set of lower lids, or what people commonly call tear troughs, it takes me about 45 minutes. When I do a set of lips, I can’t—once I get started with the needle—finish in less than 20 minutes. It takes me about 22–25 minutes. It’s painstakingly boring to watch: it’s the very slow threading of the needle over and over, but I avoid complications. A complication I’m asked about most commonly, because I inject eyelids a lot, is the Tyndall effect. I rarely get this type of complication and almost only get a Tyndall effect when I’m doing deep injections. The Tyndall effect is due to light coming through the surface of the skin that refracts it like in a prism. It bounces around in an optical cavity and scatters where it comes out. It looks a little blue-grey because of its the frequency, and it depends on the size and depth of the optical cavity, the colour temperature of the light coming through the skin, and the skin’s complexion. When I tell other practitioners that I inject superficially, I have heard them say that I would get a Tyndall effect because I couldn’t put clear filler into an optical cavity so close to the skin. But I’m not creating a large optical cavity. When I have lower lids that I want to put much volume into, I break up the areas that I inject. You can put a sheet right above the muscle, you can put a sheet right under the orbicularis, and you can put a little lake right on top of the bone. I maximise the volume that I squirt into the eyelid, yet I don’t have one big optical chamber; I have smaller ones, which makes it much less likely to get a Tyndall effect. Lately, in selected high-risk patients, I have been mixing some Radiesse with the HA to make it a little milky white so that the opacity doesn’t create an optical chamber. I can’t squeeze that through a 32-gauge needle, so I use a 31. Tim Flynn: Intradermal injections are a slow process. To do them well they take a long time, and you really can’t hurry them or you will get irregularities. Hyaluronidase is a great product—every practitioner should have it in case of a vascular occlusion. You can use it for Tyndall effect. Say you’ve injected lips and you get a case where, the next day, the patient calls back and says their lip is enormous and asks you to do something. You can bring them back, test their arm to ensure they don’t have an allergic reaction to the hyaluronidase, and then melt the hyaluronic acid away. Some of these patients really want a tiny lump to go away, they don’t want all that other HA that you put in to vanish. But we use hyaluronidase to increase the diffusion of injectable anaesthesia, so you have to tell them that everything will be taken away, and that you can then go back and replace what is needed. Michael Kane: The dosage depends on whether you’re using a compounded hyaluronidase, vitrase or ovine hyaluronidase, and on the tissue. I probably get two or three bad tear troughs referred to me a month, and to eliminate the HA across a lower lid takes me about 40 or 50 units. But the hyaluronidases are different, so you cannot suggest dosages with any certainty. The worst thing that can go wrong with tear troughs is blindness. A colleague calls this the most under reported complication in what we do. Most cases of blindness are from the particulates: collagen, Triamcinolone injections—not so much the HAs. One paper in the German literature discussed an instant pain in one eye during an HA injection. They then did a fundoscopy, 48

When you inject fillers, slow down. Problems can arise from injecting too much too quickly

and took a photograph of a little plug in the artery. The patient ended up with no visual acuity deficit, so it looked like they got an embolisation with HA but it didn’t stay. Tim Flynn: Shortly there will be a recombinant product on the market that is identical to human hyaluronidase. In the preliminary studies, there were no allergies. body language www.bodylanguage.net

advertorial Fullfast

Expanding line pulls its weight Two appetite control products and a metabolic booster are proving popular point of sale items for complementing body contouring and fat-reduction treatments

atients often ask for advice about diets to enhance or maintain treatments. This is an opportunity for clinics to add value to their service and distinguish themselves. An optimal diet is essential to gain the best results from any treatment aimed at body contouring or reducing body fat. Offering patients advice on diet and lifestyle will not only optimise their results but also add value to their overall experience of visiting your clinic. Patients are often interested to learn about products for promoting weight loss. There are a huge variety of “diet pills” on the market—most are likely to have little impact on the reduction of body fat. But one natural aid consistently shown in research to have a positive effect on weight loss is tryptophan, a natural amino acid. Tryptophan is the precursor to the neurotransmitter serotonin and evidence suggests that brain serotonin is an important regulator of appetite, macronutrient preference and mood. Plasma tryptophan concentrations are reportedly low in overweight to obese subjects and remain low after dieting, typically decreasing while subjects are on a diet. It has been hypothesised that

this is one reason for a high relapse rate after diet-related weight loss. Tryphophan is present in many protein foods; however, therapeutic effects cannot be obtained from food alone, as amino acids use competitive modes of transport to cross the blood-brain barrier. Optimal levels of tryptophan promote not only serotonin synthesis but can also increase plasma levels of leptin, the hormone synthesised from fat that inhibits feelings of hunger in the hypothalamus. Fullfast can assist with reducing body fat mass. The product is an appetite control spray, based on a synergistic combination of natural ingredients, including tryptophan in the form of 5hydroxytryptophan. Fullfast has been proven to achieve results. In a twomonth randomised, placebocontrolled trial of 27 patients, statistically significant differences between the treatment groups were found for the mean change in BMI, skinfold thicknesses (biceps, triceps, suprailiac, subscapular) and hip circumference. In all cases, a significant change from baseline was present in the treated but not in the placebo group. The treated subjects also showed significant

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improvement in depression and binge-eating assessments. Wigmore is now launching two more Fullfast products: an appetite control chewing gum and a metabolic booster. The Fullfast chewing gum is gaining much interest owing to its method of delivery: instead of relying on the user to remember to use the spray five times a day, it simply requires the subject to chew the mintflavoured gum containing the Fullfast formula. Metabolico complements the Fullfast appetite control formula with its synergistic combination of bioactive food ingredients, including epigallocatechin gallate (an extract from green tea), capsaicins (compounds found in chilli peppers), piperine (from black pepper) and L-carnitine (an amino acid). Each compound has been independently researched and shown effective in reducing body fat mass. But it is the therapeutic combination of ingredients in Metabolico that is so effective. An eight-week trial comprising 86 overweight subjects assessed the efficacy on metabolic changes produced by the combination of bioactive food ingredients in Metabolico versus a placebo as part of a therapeutic lifestyle-change diet. As well as showing a positive

impact on body fat loss, consumption of the dietary supplement was associated with a significantly greater decrease in insulin resistance, a condition strongly associated with obesity, which can eventually lead to type two diabetes. There were also significant improvements in in LDL-cholesterol levels and the leptin/ adiponectin ratio—hormones that control glucose regulation and fatty acid breakdown. Obesity is a proinflammatory disease and the supplement demonstrated significant antiinflammatory effects. Aesthetics clinics have reported Fullfast has been a successful brand to stock simply because customers have had good results. When patients use it and Metabolico alongside their clinical treatment for body contouring and undertake the appropriate dietary changes, results of the treatment can be greater than when clients undertake the treatment alone. As a point of sale product, Fullfast is a simple concept for all clinic staff to understand and promote. It is stocked by quality independent retailers and is considered a popular, top-selling product. For more information visit www.fullfastonline.co.uk 49

products

market On the

blemish + AGE DEFENSE

Latest arrivals stirring discussion in aesthetics UNDER THE MICROSCOPE SLENDERTONE FACE

My first experiences with Slendertone were when I worked out in a gym and applied it afterwards to tighten my abdomen. The thought of electrical pulses finessing my body by causing muscles to contract and expand while I did nothing had a strong appeal, particularly after hours of uncomfortably active exercise. Like the Slendertone machines of yesteryear, the Face comprises pads—in this case on each side of a headset—that you position on muscles, which transmit an electrical charge from a control unit. The user attaches a pair of moist gel pads to each side of the headset to provide good contact. The Face package comes with 12 pairs. When the set is not in use, to keep the pads moist you simply press on the transparent covers that you peeled off. The core of Face, available in male and female models, is a lightweight headset and control box it plugs into. After charging the control unit for three hours in the mains, you attach the headset and are ready to go. You simply position the headset around the back of your neck so that the pads make contact with your cheeks. The pads transmit pulses that target nerves controlling muscles affecting the zygomatic, buccal and mandibular branches. The goal is to exercise the facial muscles to reduce the natural sagging skin of the ageing process. The unit has three programmes: lift, radiance and massage. You can increase or decrease the intensity from 0–99 by using + and – symbols. Positioning the headset and choosing a comfortable pulse are what takes a little time. I had to move the headset as the pulses made my eyes twitch, and I had to reduce the intensity of the pulse until I became used to the tingling sensation. The lift program lasts 20 minutes, although you can pause it at any time. The manufacturer recommends five 20-minute sessions per week for three months, after which, according to data from an independent clinical trial cited by Slendertone, 94% of users reported their face felt firmer, 90% reported an improvement in facial tone and muscle plumpness increased by 18.6%. Slendertone says that Face complements botulinum toxin “as the muscles not treated by it will be exercised”. It also says “Face will counteract any atrophy of the muscles” resulting from repeated toxin use. All it advises for use with fillers is to wait at least 24 hours after injection. I felt like I had a facial workout when I used Face, but I can’t say conclusively that it works. In its favour, Face does come from a stable of tried and tested machines that have built a reputation over the years. I shall continue to use Face to see how I get on. T: 0845 070 7777; W: slendertone.com/en-uk/

Brushstrokes

ADVANCED NUTRITION PROGRAMME, produced by iiaa, now includes Skin Vit A (left) to provide a daily dose of oral vitamin A. The iiaa says topical applications of nutrients are hard to absorb and to increase vitamins by taking a food supplement orally to enable the body to process them directly. 50

LASER PHYSICS has launched Neoheal, a hydrogel laser treatment pad. Neoheal can be used in a wide range of dermatological and aesthetic procedures, with all 4001100nm laser systems, and for cooling and soothing after dermabrasion and peeling operations. Neoheal is a sterile treatment pad that provides; gentle cooling of the skin.

One year after its release and the SkinCeuticals Blemish + Age Defense is proving to be an effective and popular formulation in tackling signs of ageing. The serum was tested alongside prescription drugs BenzaClin for treating acne and with Tretinoin for improvements in skin tone, blotchiness, roughness, dullness, fine lines, clogged pores and total lesions. In the BenzaClin comparison, 28 men and women aged 18–40 with mild to moderate acne, fine lines and wrinkes were studied. In the Tretinoin comparison, 30 men and woman aged 35+ with moderate signs of ageing and acne were studied. Trials were undertaken at a single centre using a split-face double-blind methodology for eight weeks. The studies report little difference between Blemish + Age Defense, BenzaClin and Tretinoin for treating acne. Blemish performed “statistically better” than Tretinoin for skin tone, blotchiness and total lesions. T: 05603 141956; W: skinceuticals.co.uk

LUMINA R system Launched by Lynton is a skin rejuvenation laser, Lumina R System, that utilises multiple technologies including fractional 2940 Erbium:YAG laser for treating acne, pigmentation, vascular lesions, acne scarring, surgical scarring, wrinkles, stretch marks, sun damage and congestion. Add-ons enable laser hair removal and tattoo removal. Dr Philip Hampton, Newcastle Hospitals NHS Foundation Trust, says: “The Lumina is delivering excellent results for our rosacea patients with widespread facial telangiectasia.” T: 01477 536 977; W: lynton.co.uk

VELD’S, based in Paris, says it has developed a fragrance with Robertet that contains ingredients which release ß-endorphins in the skin, transmitting a message of pleasure to the brain that reduces the need to over eat. According to unsubstantiated data, 75% of women aged 18–70 felt the perfume limited the need to snack.

L’OREAL is launching an active ingredient in September that awakens dormant hair and enhances hair density. The product will be called Neogenic, which relates to the phase when hair moves from dormant to active. The development arises from the company’s patented molecule stemoxydine, which is seen to increase capilliary density.

body language www.bodylanguage.net

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TRAINING

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Courses in Central London Intro to Skincare – 19th September, 16th October, 14th November Intro to Toxins – 20th September, 17th October, 15th November Intro to Fillers – 21st September, 18th October, 16th November Intermediate Toxins & Fillers – 5th September, 7th November Advanced Toxins & Fillers – 6th September Microsclerotherapy – 13th October, 20th October, 3rd November Sculptra – 8th October* Medik8 Dermal Roller – 26th September, 19th October, 10th December CPR & Anaphylaxis – 7th September, 5th October, 2nd November Blunt Cannula (Magic Needle) – Please contact Clive Shotton - 07814 687206 glōMinerals – 17th September, 22nd October glōTherapeutics – 18th September, 6th November Courses in Newcastle Advanced Toxins & Filler - 16th September Intermediate Toxins & Fillers - 18th November There will be NO course price increases from 2011. All courses carry CPD points. * indicates the first day of a two-day course. The scond day is 6 weeks after the first.

Wigmore Medical Training, 21 Wigmore Street, London, W1U 1PJ training@wigmoremedical.com, www.wigmoremedical.com Twitter: @wigmoretraining

Sculptra

Dermal Roller

study Professor Tony Chu

Dermapen Dermaroller versus

The Dermaroller has established itself as a key tool for treating skin. Professor Tony Chu and colleagues conducted a study to see how the Dermapen compares

ur study aimed to compare the safety and efficacy of the Dermaroller, which is the standard treatment, to the Dermapen for treating atrophic acne scarring. I have used the same technique in treating other forms of scars, which seems good for thickened burn scars and for lines and wrinkles. The questions we wanted to answer were how well are they tolerated, is one better than the other, how easy are they to use, how long is the downtime and how

effective are they in improving scarring, using both subjective and objective measures. Much of the study was conducted by colleagues under my supervision. A typical Dermaroller gives brilliant results in treating scars, and the beauty of it is that you can use it on any skin type. So I can use it on a type 1 skin, after which the patient looks sunburned, but the downtime is only four days. I have used it on type 3, type 5 and type 6 skin and there was no pigmentatary change at all. You can use it to treat atrophic acne

scars in all ethnic groups. With a typical Dermaroller, stainless steel acupuncture needles, 0.25mm gauge, I always used a 1.5mm length of needle. Now you can buy Dermarollers from 0.5mm, which is really the cosmetic form that you can use at home, right the way through to 2.5mm, which I think is too deep. The Dermapen is based on an electric pen. At the top you have a tip that is exchangeable. It takes seconds just to click a sterile tip in and the tip has 11 stain-

follow-up questions Q: How often do you use the Dermaroller and Dermapen? The skin becomes rather recalcitrant to further stimulation for about six weeks, so I will not do another Dermaroller or a Dermapen before then. You are stimulating collagen type three production by the fibroblasts, and they get almost over stimulated if you do this more than every six weeks. With many of my patients, I’ll say we’ll do it every three months. If you want to go beyond that I always make them have a six month break because the collagen production continues for at least six months.

scars, a few box scars (remember the TCA cross that you can do at the same time, which helps to fill up those little pits), and there’s nothing on the upper lip, nothing on the nose, I will often go for the Dermaroller, mainly because it’s something I’ve been using for the last five years. For someone with more extensive scarring—young ladies often present with much scarring of the upper lip, the lower lip, even the nose—I’ll choose the Dermapen. For lines and wrinkles, where I want to get around the eyes and perhaps even do the eyelids, I’ll always use the Dermapen.

Q: What is the risk of contamination? With the Dermapen there is no risk. Even after a big session where you’ve had a lot of bleeding, there’s only ever blood contamination of the tip of the needle. The needle unit is quite long with a long stem, and there’s absolutely no risk from the actual handle itself. We will swab it with a bit of alcohol just in case, but there’s no blood contamination there.

Q: How many needles do you use in a Dermapen session? I’m a complete miser. I use one needle for the whole lot. The needles are incredibly sharp, they don’t go blunt and there’s no problem.

Q: Why do you still use the Dermaroller? If I have someone who has scars predominantly on the cheeks, rolling

Q: Do you microneedle platelet rich plasma (PRP) into scars with Dermaroller? I’ve looked at this carefully because many colleagues particularly in South East Asia are doing this. If you can purify your platelets, and inject them into the skin under the scars, you’ll enhance the effects. Systems that enable you to separate the platelets sterilely are

body language www.bodylanguage.net

study Professor Tony Chu

less steel acupuncture needles on it and they shoot out. You can vary the length of the needle from 0.5–2.5mm, even while you’re doing a procedure. If I want to do an eyelid, I’ll go to 0.5mm; if I’ve got a slightly deeper scar, I can go to 2mm or 2.5mm. Normally I’d stick at 1.5mm. You can vary the speed from one, which is 25 shoots per second, so that’ll be 250 holes per second, up to seven, which will get you about 1,000 holes per second. My usual protocol for a patient with a little scarring is to start with EMLA cream, leave it on for an hour under polythene occlusion. We use ordinary cling film with little holes cut out for the eyes and the mouth, and patients tolerate it well. With the Dermaroller, you roll four times in three different directions: horizontally, vertically and diagonally. You need to apply enough pressure to get pinpoint bleeding, and you do get bleeding. If you haven’t got bleeding, you’re not going to have achieved anything. I’m absolutely astonished that people will buy these things on the internet and try to do it at home. There’s absolutely no way you can. I’ve had young men who have screamed through the entire procedure; I’ve had young women who have said it tickles—so there is much varia-

tion. Although there’s been a massive proliferation of the use of the Dermaroller, from the feedback I get from patients who come to see me, it’s often not done correctly, and that’s why the results aren’t as good as they should be. With the Dermapen, you do exactly the same: you anaesthetise the patient, you wipe the EMLA cream off, you sterilise with alcohol, and with the Dermapen, you do need a little lubrication, otherwise the needle can stick, and so I use Fillast serum. You then do a circular motion first and then horizontal and then vertical straight lines. It takes almost the same time as a normal Dermaroller and most patients find it much more comfortable. Our study was a randomised control trial. Patients had all had at least one Dermaroller, session, so they knew what to expect. 60 patients were recruited. The treatment was used as normal, EMLA Cream first, normal Dermaroller with 1.5 mm needles or Fillast serum with the Dermapen. Thirty of the patient group A had a Dermaroller and 30 had a Dermapen. At day 0, patients were recruited, randomised and a scar was identified to examine. This was a nice rolling scar that was marked with a pen and then photographed. The scar was then scanned with the Visioscan. This is an ultraviolet scan-

incredibly expensive. There’s an Italian system comprising tubes that you put blood into and spin round, take the interface off and put an activator in, and it’s very much cheaper. So I tend to use that where I’ve got deeper scars, but it is fiddly and time-consuming. When you have rolling scars that almost burrow into the skin, putting in PRP does help. One patient had a dreadful scar here that he had revised three times in America, and it kept on breaking down, but with PRP subcision and Dermapen we got him looking acceptable, and he was quite happy with that. I know dermatologists who have applied PRP to the skin and then Dermaroller or Dermapen on top, and that’s a valid way of doing it. You will get penetration. But for a deep scar, I prefer to inject. I use a diabetic syringe with a fixed needle. I inject and then Dermaroller or Dermapen on top. Q: Why do you think Dermapen gives better results? When you use a conventional Dermaroller, you’re producing about 250 holes per square millimetre. With the Dermapen you’re producing 1000 holes per second. You’re looking at a phenomenal number of holes and each will cause the damage that stimulates the fibroblasts to produce more collagen. Logically, you’re going to have better results.

ning machine that measures the depth and volume of scars. After treatment, patients filled in a questionnaire about pain and the three dermatologist practitioners were asked whether it was easier to use, very much easier, easier, the same, more difficult or much more difficult. At visit two the patients were questioned about downtime. Almost all my patients treated with Dermaroller have a downtime of four days, after which they will be back to work and look completely normal. We wanted to know whether the downtime could be less with the Dermapen. We also used the Visioscan software to measure the volume and calculated the percentage reduction. At day 84, patient and operator repeated the questionnaire and the Visioscan was repeated. Of the 60 patients, 48 completed visits one and two, 20 in group A and 28 in group B. We lost eight patients to follow up, and they were mainly in group A; four patients had not completed their final visit by the time the results were collated, so we didn’t include their results. The Dermaroller was performed in the normal way, rolling four times, horizontally, diagonally and vertically. The Dermapen, once again, circular motion horizontally then vertically at speed

and up to 100% trichloracetic acid, you administer it just to the base of the scar using a sharpened orange stick and as soon as you get frosting, you wash it off. This causes localised damage and a local proliferation of collagen. A real box scar, will do that and eventually flatten. It’s the only thing that really works well with proper box scars. The Dermapen and Dermaroller will improve them, but unless you use the TCA cross as well, you’ll never get a perfect result. Q: How does the Dermapen work on stretch marks? If you’ve got a stretch mark that has depth, it’s fantastic. You’re not only going to induce new collagen, but of course the reason that you’ve got a stretch mark is that there’s no elastic fibres there and the Dermaroller or Dermapen will induce new elastic fibres, so you get the elasticity back. But it doesn’t necessarily improve the colour. I had a Middle Eastern woman who had some bad stretch marks. I got them flat, but she still wasn’t happy because they looked silvery and she could still see them, and there was nothing we could do about that. I’ve had Caucasian women with bad stretch marks on the stomach, and after three or four Dermaroller sessions you could hardly see them.

Q: How do you do the TCA cross technique with the Dermaroller? The TCA cross technique was developed by a Korean dermatologist several years ago. It’s not widely used, but you essentially use 40%

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study Professor Tony Chu

seven, producing 1000 holes per second. Blood was wiped away with sterile gauze, skin washed with normal sterile saline and cold packs were applied for five minutes, which is my standard practice. With the Dermapen you can get wherever you want to: under the eyes, because the tip is quite small, right up to the nose, which you can treat easily, and the upper lip. I’ve always had trouble treating the upper lip with the Dermaroller, even thinner varieties. With the Dermapen you can easily treat the upper lip right up to the vermilion border. Again, some bleeding is evident, which is what you’d expect. It takes about three minutes to do the entire side of the face. With dark skin you often don’t get the intense erythema that you do with the Dermaroller. With the Dermapen you can sometimes get a little petechial haemorrhage over the bony prominences and that perhaps extends the downtime a little, but in general we found downtime was less. Most people after Dermapen treatment said they were back to normal in two or three days, and we had one patient who said he hardly noticed anything and was fine the next day. From a discomfort point of view, everybody said the Dermapen was much less painful. Most men made little noise and tolerated it well.

In group B, which is the Dermapen, 18 of 28 felt it was very much less painful; 10 found it less painful; none found it as painful as the Dermaroller. Remember, all of these patients have had a least one Dermaroller before. Patients’ verdict Patients were pleased with the results from their Dermaroller treatments. You can’t look at a patient and say, you’ll need one, two, three or four, sessions and you’ll be wonderful. It depends on the patient’s expectation. But the improvements can be dramatic, and once again, the beauty of this technique is you can change people’s lives, you can give them back their confidence and it does do a lot for them. Patients’ perceptions were that the Dermapen was more successful than the Dermaroller, and once again, they’d all had a Dermaroller before. The operators’ assessment on improvement paralleled that. We felt the patients had improved, and we had photographs to try to judge that, too. Looking at the volume assessed with the Visioscan, the Dermaroller was calculated to give about a 30% improvement in the depth of the scar. Improvements with the Dermapen were more like 50%. I have been a great fan of the Dermaroller. I still use it, patients come to see me, we discuss the different treatments and

some will have Dermapen, some will have Dermaroller, and the Dermaroller works extremely well. But the conclusions of this study are that the Dermapen does have significant advantages over the Dermaroller. It’s easier to use, you have your stem, you have the sterile needles that literally just look like ordinary needles that you click in, it takes only seconds to put them in, you can change the speed and also the depth of the needle, and it’s much easier to use in those areas you want to really get to. So with the older woman with the furrows around the lips where you really want to get to the upper lip, it’s fantastic. People who have scars on the nose are difficult to treat with the Dermaroller, but the Dermapen allows you to do it very easily. The Dermapen is less painful and better tolerated by patients. They’ll still find it painful if they have never had a Dermaroller. They’ll still say “ouch”, but if they’ve had a Dermaroller, they will know it’s much less painful with less downtime. I find it more effective in improving atrophic acne scarring. I will still use the Dermaroller, but the Dermapen has rather taken over in my clinic. Professor Tony Chu is professor of dermatologic oncology at the University of Buckingham and consultant dermatologist at Imperial Health Care Trust, Hammersmith Hospital and Ealing District Hospital

CONDITIONS TREATED BY DERMAPEN

Before and after five fortnightly acne scarring treatments

Stretch marks: 2–3 sessions recommended every 4–8 weeks

Lines: about three sessions recommended once every 6–8 weeks

Facial scarring: recommended four times once every 6–8 weeks

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Wigmore Medical 020 7514 5104 invasix@wigmoremedical.com

peer press review

Peer press review David Williams surveys academic and association journals to report on advances in research A Novel Foil Flip-Over System as the Final Layer in Wound Closure: Excellent Cosmetic Results and Patient Comfort Iatrogenic Retinal Artery Occlusion Caused by Cosmetic Facial Filler Injections Park SW, Woo SJ, Park KH, Huh JW, Jung C, Kwon OK Am J Ophthalmol. 2012 Jul 24 [Epub ahead of print].

The clinical manifestations and visual prognosis of retinal artery occlusion from cosmetic facial filler injections were studied in 12 consecutive patients with retinal artery occlusion caused by facial filler injections. Seven patients had ophthalmic, two had central retinal, and and three had branch retinal artery occlusions. Injected materials were autologous fat (seven cases), hyaluronic acid (four), and collagen (one). Injection sites were the glabellar (seven cases), nasolabial fold (four cases), or both (one case). Autologous fat was associated with the worst final best-corrected visual acuity. All patients with ophthalmic artery occlusion had ocular pain and no improvement in best-corrected visual acuity. Optical coherence tomography revealed thinner and lessvascular choroids in eyes with ophthalmic artery occlusion. Concomitant brain infarction developed in two cases each of central retinal artery occlusion and ophthalmic artery occlusion. Phthisis developed in one ophthalmic artery occlusion. Filler injections into the glabellar or nasolabial fold can cause retinal artery occlusion. Iatrogenic ophthalmic artery occlusion is associated with painful blindness, a thin choroid, brain infarction, and poor visual outcomes, particularly when autologous fat is used. Ophthalmic examination and systematic brain MRI should be performed in patients with ocular pain after such injections. 56

Deerenberg EB, Goyen HJ, Kaufmann R, Jeekel J, Munte K. Dermatol Surg 2012 Jul 23. doi: 10.1111/j.1524-4725.2012.02525.x. [Epub ahead of print]

Wound closure after excision is commonly done with sutures or staples. A sutureless foil flipover system for excision of small skin lesion was evaluated for wound healing, patient comfort, and cosmetic results. Ninety-six patients with 103 lesions who presented to the department of dermatology of Erasmus University medical center in Rotterdam over 18 months were studied. Three independent physicians scored photographs of the scars. Evaluation tools used were comfort and body image questionnaires and visual analogue scales. The surgeon scored wound healing as excellent or good in 96%; no wound infections occurred; 92% of patients scored removal of the system as comfortable. The median patient grade of scar after one month was eight out of 10 points. Sutureless foil flip-over is seen as promising, with excellent patient comfort and good to excellent cosmetic results. Soft Versus Hard Implants in Dorsal Nasal Augmentation: A Comparative Clinical Study El-Shazly M, El-Shafiey H. Aesthetic Plast Surg 2012 Jul 26 [Epub ahead of print]

In this study, 21 women and seven men with a mean age of 23.5 years underwent augmentation rhinoplasty between December 2007 and July 2011. Conchal and septal cartilage grafts and Medpor were categorised as hard implants and applied for 15 patients. Soft implants, inserted in 13 patients, included diced auricular carti-

lage wrapped in Surgicel sheets, dermofat blocks, and rolls of Prolene mesh. Patient satisfaction was assessed by simple postoperative questionnaires. In the soft implant group it was 100%; the overall satisfaction rate was 82.2%. Unsatisfactory results and complications were recorded in the hard implant group: dissatisfaction was 33.3%, contributing to a general dissatisfaction rate of 17.8% in the whole series. The authors conclude by recommending soft implants for both aesthetic and reconstructive surgeries because of their better ability to achieve a dorsum with a smoother contour and pad. They say soft implants have fewer complications, higher satisfaction rates and can be applied for most indications using both closed and open methods.

excluded and 40 patients, 20 in each group, were evaluated. The median follow-up for both groups was 3.5 years. The aesthetic outcome was evaluated by a panel of experts and lay people, and by the patients. Quality of life was evaluated with a validated questionnaire. Of the patients in the onestage group, 70% had revision surgery, mostly because of upper pole fullness and poor ptosis. These findings agreed with the data from the two-dimensional scanning and from the expert panel and the patients’ subjective judgment. Quality of life was similar in the two groups. The permanent expander method failed significantly as a one-stage procedure. The crescent two-stage method gave the most acceptable results both objectively and subjectively.

A Prospective Randomized Study Comparing Two Different Expander Approaches in Implant-Based Breast Reconstruction: One Stage versus Two Stages

Medical students hierarchy of values and sense of responsibility

Eriksen C, Lindgren EN, Frisell J, Stark B. Plast Reconstr Surg 2012 Aug;130(2):254e-64e.

Ethical skills and personal values contribute to making students competent and humane physicians. However, there is not much research done on medical students’ personal values and sense of responsibility. This study examined personal values and sense of responsibility between medical students and their peers. The students were tested using Scheler’s Value Scale and Responsibility Scale. Medical students scored higher than students in other faculties in responsibility and in values of hedonism and truth; they scored lower in values of religion and secularism. They did not differ from the control group in values of vitality, aesthetics, morals, physical fitness and strength and stamina.

Implant-based reconstruction is performed in the majority of women offered primary reconstruction for breast cancer. Two different expander implants were compared prospectively. The primary endpoint was the number of operations needed in each group to obtain patient satisfaction. Secondary endpoints were evaluation of breast volume and shape and aspects of quality of life. Seventy consecutive breast cancer patients were randomised to either a one-stage reconstruction with a round permanent expander implant (Becker 25; n=35) or a twostage reconstruction with a crescent-shaped expander (LV 133; n=35), later replaced by a form-stable anatomical implant. Thirty patients had to be

Pawelczyk A, Pawelczyk T, RabeJablonska J. Teach Learn Med. 2012 Jul;24(3):211-4.

Reviewing the peer press is Body Language editor David Williams

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Opportunities to learn new and advanced techniques from leading practitioners in this limited space, full day training course. Advanced training will include injectables, lasers and skincare taking place through out the weekend.

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NEW LOCATION FOR FACE 2013 FACE Conference has provided over 3000 delegates the chance to see some of the most enterprising speakers, treatments and topics in aesthetic medicine. In 2012 FACE celebrated 10 years and has eveloved with the very industry it serves. FACE 2013 will be moving to the QEII in Westminster, London to help accommodate the growing lecture programmes. With over 70 exhibitors and 100 hours of lectures by the worlds best practitoners and pioneers in facial aesthetics, FACE 2013 promises to be larger than ever. “The FACE Conference is without doubt the premier facial aesthetic meeting in the UK. The unique contribution from all subspecialties makes FACE the best way to keep up to date.” RAJIV

GROVER, CONSULTANT PLASTIC SURGEON

“One of the best, most enjoyable, informative aesthetic meetings in the world.” DR TIMOTHY FLYNN, COSMETIC DOCTOR “The FACE Conference brings together National and International leaders within the cosmetic and aesthetic industry and year-on-year represents the ultimate forum for practitioners who wish to expand their knowledge base and practical skills.”

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peer to peer

Dr Timothy Flynn is a board-certified dermatologist who practises at the Cary Skin Center in North Carolina

Mr Rajiv Grover is president elect of the British Association of Aesthetic Plastic Surgeons and and runs a private practice in Harley Street

Mike Regan is a certificated laser protection adviser and a director of Bioptica Laser Aesthetics Ltd

Mr Kambiz Golchin is a consultant ENT and facial plastic surgeon

Safety standards The failure of authorities to prevent the marketing of products such as PIP implants is among the safety issues discussed by our panel and audience Q What can be done to improve patient safety and raise standards so that we don’t have a repeat of the PIP implant scandal? Dr Timothy Flynn: We really do want the best products for our patients, and we all want to improve patient safety. Many of us in the US have wanted a central repository for injectable complications. In the US a complication is reported back to the company only if a doctor chooses to do so. The company investigates the report, and the FDA reviews these reports. If a world-wide reporting body had existed, something like Bio-Alcamid may have been picked up for complications earlier. Mr Rajiv Grover: The only way to get regulation of a product and its complications is to have a compulsory system. If there is a voluntary system, for example, if there is a a drug reaction in this country we have to fill in a yellow card. Probably not all of us have filled in every yellow card we needed to. As for something like fillers, the body required to regulate them would need to be large, and who would fund it? That’s the problem; it always comes down to money. If we trust our own conscience, just because something has come out that is new, would you want it injected in your face? Probably not. So why use it? Mike Regan: There is a distinction between product standards and service standards. There are problems associated body language www.bodylanguage.net

with the notified bodies in terms of the product accreditation and CE marking in Europe. As for services standardisation, and in particular the prEN 16372 “Aesthetic surgery services” draft standard, this is a recent and ongoing development. It’s much less developed than product certification. But even with these fairly mature product certification processes, we have of course recently seen some horrendous problems in the aesthetic products sector. Sally Taber (from the audience): If we tightened up in all areas, the notified body, the competent authority and the supply box stating that dermal fillers should be going only to appropriately trained doctors, dentists, registered nurses and pharmacists then we could prevent beauty therapists from obtaining them. There is also the issue of insurance. One insurer will insure beauty therapists; another insurer is insuring podiatrists. I was at a meeting where European countries called us a disgrace for allowing beauty therapists to undertake an agenda when they are not appropriately trained. I informed our minister of public health and she issued a statement to stop beauty therapists being involved in the cosmetic injectable agenda. Has it made any difference to them? No, it hasn’t, because we all work in isolated associations. If we all pulled together in this country, I really think we could cut out bad practice

and take this agenda forward as has been done in the States. Kambiz Golchin: The quickest way of bringing in more standards for dermal fillering and injectables is to regulate the insurers. If you can regulate them, the bar is higher to obtain insurance to practise. This will cut out many dodgy practitioners. If we could influence our insurers, we would see results much more quickly.

Q In Australia, if a clinical nurse purchases botulinum toxin or fillers, she faces immediate deregulation. What is the situation in the UK? Kambiz Golchin: Most nurse practitioners are working under the umbrella of a physician. Having said that, nurse prescribers can prescribe and purchase toxins. From the audience: In the UK, nurses may take a qualification to become independent prescribers, and then they can prescribe to their patients and purchase the product on behalf of their patient. So I would disagree that the majority of nurses work under supervision of a doctor, that’s not necessarily the case. Omar Durrani (from the audience): I’m an ocular plastic surgeon. I just wanted to highlight a point that there are now about 15 reported cases of blindness from fillers. It’s not just the quality of the product, this has to be looked at from a technique point of view. This is getting worse, and we are seeing more problems. 59

WIGMORE

TRAINING

peer to peer

Advanced Training Tim Flynn: Certainly another aspect is is because the public are yet to wake up to tremely well about what can go wrong, technique and patient management. If the reality about who is performing these but not a good way of changing what is you get a complication, do you know procedures and what they are injecting. going wrong. If we report a filler is not how to respond? Can you recognise it? Four or five years from now the public working terribly well to the manufacturer, Can you treat it? This takes experience will questions and vote with their it is going to keep that to itself and view it Skincare & ask theseMicro Photodynamic CPR & Sculptra and education. feet. If Sclerotherapy we all put ourselvesTherapy in a position as an isolated case. Is somebodyDermal likely to Chemical Anaphylaxis Roller Hazel Innes (from the audience): I am Peels a where we are well trained—from whatever talk to a colleague and say, I injected and qualified nurse, but I also went to uni- background—they will choose us. this is what happened? It doesn’t matter versity for four years to study podiatry. This is not a case of what we want, it’s how well qualified I am. Sometimes— So I find it amazing that I’m beingCourses com- in Central a case of who the public will choose to be thankfully, not often—I am at a loss to London to Skincare – 13th March;people 13th & who April, put 22ndthemselves May, 19th June understand why that swelling happened pared with someone who can do a Intro beauty treated. Those to Toxins – 14th March; 11ththey April, are 23rdwell-trained— May, 20th June course. I have a local anaesthesia Intro certififorward to show with that product. Intro to Fillers – 15th March; 12th April, 24th May, 21st June cate, I studied biology, and indeed Advanced we did Toxins whether it’s through the nurse prescribers’ Rajiv Grover: There were lots of pieces & Fillers – 28th March training with the medical students Microsclerotherapy for the course –or10th whatever—they inJune the press about the PIP implants, and & 24th March; 14thwill April; be 12thbusy May; 23rd April*; 8th June*; 7th August*; October* first two years of my qualification.Sculptra There – 3rd and have a good practice.8thThose who they said things about their CE approvMedik8 Roller 12th March; 10th April; 21st May; 16th & 18th June that none of the surgeons using are different podiatry standards and may-Dermal don’t will– eventually be weeded out. al and CPR & Anaphylaxis – 30th March; 17th April; 31st May; 22nd June be that’s where the problem is with your Tim Flynn: We have to be honest here them were using something they knew Photodynamic Therapy – 8th March; 5th April; 11th May information. and say we really all do learn from one was bad. But the cost difference was glōMinerals - 19th March; 25th June glōTherapeutics – 20thI March; 28th Maya number of injecKambiz Golchin: You’re obviously well another. have learned well publicised. PIP implants were about qualified. The average podiatrist is not a tion techniques from excellent injectors £50 each, whereas normal implants are Courses in Newcastle nurse, and we have to make a distinction from all disciplines. This is how an intel- £200–£300 each. Intro to Toxins & Fillers – 18th March who can actually do these injections. lectual body knowledge is &developed, IntroJust to Skincare – 21st April;ofAdvanced Toxins Fillers – 20th May A patient said to me: “Dr Grover, these because you can hold a syringe in your isn’t it? It wasn’t just one physicist who de- implants were regulated, but if I went to There will be NO course price increases from 2011. All courses carry CPD points. * indicates day of a two-day course. The bomb; scond day isit6 was weeks multiple after the first. hand doesn’t give you the qualifications orthe first veloped the atomic buy a Burberry handbag and somebody the right. Some practitioners need to look people pooling their ideas, sharing their sold me something that was quarter of Wigmore Medical Training Wigmore London, W1Uwould 1PJ I think it was at their conscience. Should a dietician be  thoughts, conducting studies,21 and doing Street, the normal price,  020 7514 5979  020 7495 3768  training@wigmoremedical.com  www.wigmoremedical.com doing dermal fillers? The answer is no. research. The body of knowledge grows, dodgy?” If the public think that, we Rajiv Grover: People from various back- and we grow together. should have a sense of what is normal and grounds are doing these things, and that From the audience: We are talking ex- what is right as well.

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media training Mr Baljit Dheansa

Ready, set, action! Practitioners are called often by the media to comment on a procedure or to discuss their technique. Mr Baljit Dheansa volunteered to be filmed consulting with a patient right up to the surgery that ultimately followed. He passes on what can be learned from his experience

recently appeared on Channel 4’s Embarrassing Bodies when I was involved in the treatment of a patient who required an abdominoplasty and a mons reduction following pregnancyinduced changes. It was an incredibly interesting process and one that I enjoyed. Overall, I felt that the patient was treated very well and was given the appropriate support and dignity while ensuring the episode was informative for viewers. I became involved because the McIndoe Surgical Centre, where I practice, has had previous patients involved in the series. I was asked to take part because I have a particular interest in abdominoplasty, and the specific brief for this patient was a tummy tuck and a reduction to the pubis area. This had become enlarged following pregnancy. Additionally, the caesarean scar had tightened over time and contributed to the problem. The whole process was quite an eye-opener because of the attention to detail and the logistics involved. The patient had to receive appropriate and timely care but at the same time filming had to take place in an environment no different from that experienced by any other patient. This meant that all the patient-care happened in consulting rooms at the McIndoe Surgical Centre along with the surgery. This meant I didn’t get to meet Dr Pixie, Dr Christian or their colleagues, but on the positive side I didn’t have to travel. The hospital PR team advised me to act as naturally as possible and follow the lead of the production team. The only stipulation from the crew was to ensure the moment we accepted the patient for surgery was captured on film and not revealed during our private consultation. The consultation process was not as straightforward as it normally is, because we had to film the consultation from several different angles. Often we had to repeat parts of the consultation so that it could be filmed from another perspective. It can be hard to remain natural and spontaneous when you have done something for the third or fourth time. It is also difficult to make sure you are focusing on the patient as much as possible body language www.bodylanguage.net

when you have a camera right next to you. However, I had had a brief conversation with the patient beforehand. We agreed that if comprehension became difficult, we would stop and go over certain points without the cameras. The filming made me focus on ensuring that I spoke clearly and with straightforward language that could be understood by a wider audience. It made me think about particular messages I wanted to put across. This is particularly important, as often you are filmed for a long time but only a short amount of filming will be eventually put on the screen. In such a situation, if a surgeon wants to get a particular point across, it is important that he covers this at several points throughout the consultation and uses short sentences that can be easily edited to allow them to be screened. At the end of the whole process, I felt that the patient had received good care, had been supported by both myself and the television company and was able to contribute to the further education of the audience. I learned that you have to focus on the patient and avoid looking or thinking about the cameras that are in the consulting room and in the theatres. I also learned that you need to set aside quite a long period for filming and not to expect much screen time. This show reaches a large number of people and, therefore, is one of the best ways to educate the public. Overall, it was a very positive experience and I would be happy to do it again. I would recommend it to other surgeons, so long as they know to take time, focus on the patient and be clear in what they are trying to achieve. After the show aired many people came forward through the programme’s website to say that they too had the same problem and asked for advice. We were also contacted here at the hospital by several others, one of whom came for a consultation. Baljit Dheansa is a consultant plastic surgeon 61

ophthalmology Mr Omar Durrani

Eye movements Major advances in eye surgery have not only increased procedural safety but also resulted in new procedures, writes Mr Omar Durrani

asers have driven improvements in ophthalmic care. The latest development is the Femto-second laser, whose key property is the duration of pulse applied to tissue. It delivers a huge amount of energy in a tiny area in an extremely tiny fraction of time. This creates a focused area of plasma followed by a shockwave and gas bubble formation. This process cleaves tissue, breaking it down without generating heat or steam and can be used to make precise cuts in tissue. Cataract surgery on the NHS broadly is its safest major operation, with a success rate of about 99%, but if you compare it with Lasik surgery, there’s still some room for improvement, and that is why Femto-Phako surgery is the treatment for the future. It is two technologies that have come together: the Femto laser technology, which was developed for laser refractive surgery, and a high-resolution imaging system devised for the retina. These were combined to provide high resolution images of the cornea, the lens and the different structures within the eye. You can now remove cataracts up to about grade four or five with the FemtoPhako. With the Femto-Phako, a surgeon can perform some of the key steps of cataract surgery much more precisely, including the capsulotomy, the fragmentation of the nucleus and the incisions. The capsulotomy is a key step in cata62

ract surgery. In this step a round opening is made in the outer covering or the capsule of the lens. The capsule is about 20 microns thick, and the laser can make a perfect circular cut within that. This is important because intraocular lenses are heading towards multi-focals, and these lenses need to be perfectly centred for good vision. These premium lenses allow the eye to focus for distance, intermediate vision and do away with the need for glasses. Fragmentation—where you break up the cataract—is much quicker, safer and more efficient, as you use less energy. Currently, this step is performed by inserting an ultrasonic cannula into the eye. Once the nucleus is broken down, it is aspirated from the eye and you can put in whichever lens you want. It could be a single vision or multifocal or accommodating lens, which enables distant or near objects to be seen clearly. Corneal incisions can be made much more precisely using a laser rather than doing them by hand. The Femto-Phako laser does have a future. When Phako emulsification, the current cataract technique, came out about 15 years ago, within two or three years, all hospitals were doing it. A Femto-Phako machine currently costs £500,000. A London clinic is doing Femto-Phako cataract surgery for a premium of £1000 per eye on top of the normal fee.

In 5–10 years, everyone will convert. There’s a big marketing push towards the blade-free Lasik, where the eye is not touched by a keratome. Why do people have refractive surgery? If they are longsighted or short-sighted, eyes don’t focus the light as clearly as they should. Short sight focuses in the middle; long sight, towards the back. By lifting a thin flap of corneal tissue and applying a laser to the deeper surface, you change the shape of the cornea so that the focus of the light is correct and glasses are not necessary. The evidence says you can control the flap dimensions better with the Femto than a Moria keratome, but like for like there’s absolutely no difference in recovery and visual outcome. Companies that sell this are pushing this as a safer outcome and a quicker recovery, because they charge up to £500 per eye more. The biggest growing market is clear lens extraction, arising from the baby boom generation having to wear glasses. This market comprises people who will need to wear glasses for the first time in their 50s. The condition arises with age. When the eye is at rest, it focuses at infinity. As an object comes towards you, the ciliary muscle contracts, the lens becomes thicker, and the eye focuses on it. With age, we lose this ability to focus on things that are close to us, which is why glasses become necessary. body language www.bodylanguage.net

ophthalmology Mr Omar Durrani

The procedure involves removing the eye’s natural lens and replacing it with an artificial lens (lens implant), whose power is calculated to eliminate the prescription in glasses or contact lenses, hence resulting in improved vision. The natural lens inside the eye sits inside a lens capsule, like a bag. When it is removed, the capsule is left intact. The new artificial lens is placed back into the capsule in the exact position as the natural lens was located before it was removed. You never get a cataract because the lens has been taken out, and you have perfect vision for distance, near and intermediate and apparently few complications. Distant, near and intermediate vision are achieved with multifocal or accommodative lenses, costing £600–£2000 each. Accommodating lenses slightly shift their position inside the eye to change focus from distance to near. Multifocal lenses are simpler in design: they have different zones within the lens for focusing on multiple areas. As about half the light is used to focus for distance, a quarter for intermediate and a quarter for near, contrast sensitivity is reduced, and there is some blur. The new lenses are much better and the technology is evolving. If someone were to ask me when to have this, I would say perhaps in five years. Eye colour change A new technology is being developed that shines a laser onto the iris and can change eye colour from brown to blue. Stroma Medical, the company set up to commercialise the process, hopes to market the device worldwide in around three years. The laser works by damaging and bleaching the pigment cells in the iris. An unspecified number of 20 seconds cycles are required to cause the change in eye colour. The body’s immune system recognises the damage to the pigment cells and special house-keeping cells called macrophages are sent in to clear the damage. This results in the permanent removal of the pigment cells on the surface of the iris. This is exactly the same mechanism used by the body to clear damage from inflammation or infection in the eye. There is great concern about the safety of this procedure and because of this the FDA has refused permission to conduct human trials in the US. The procedure is undergoing un-regulated human trials in Mexico.

Developments in opthalmology

 The Victus platform is the first femtosecond laser capable of supporting cataract and corneal procedures on a single platform. It received 510(k) clearance from the FDA in August and CE mark approval in November 2011. It has been used for more than 2000 cataract or refractive procedures  The Synchrony accommodative dual optic features a plus-powered anterior lens and a minus-powered posterior lens joined by a spring system. When the two lenses are close together, the eye is set for distance. When the ciliary body contracts, reducing capsular bag and zonular tension, the front lens moves forward, changing the eye’s focus to intermediate or near vision  A US company is researching a device that turns brown eyes blue. Concerns have been expressed about the safety of the procedure, and the FDA has refused permission to conduct trials on patients in the US

Mr Omar Durrani is a consultant ophthalmic plastic and reconstructive surgeon at the Birmingham & Midland Eye Centre body language www.bodylanguage.net

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