Body Language Issue 57

may/june

57

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

LIFTING THE FACE Experts share their techniques for rejuvenating the ageing face

ď‚— Thread lifts Avoiding scarring for darker skin

ď‚— Combination therapy Fillers, toxins, PRP and lasers

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contents

body language number 57 11

7 OBSERVATIONS ANALYSES Reports and comments  Lifting the lid on aesthetic regulation In light of Sir Bruce Keogh’s report on cosmetic industry regulation, Dr Stephen Bassett surveys its key recommendations

18 Non-surgical The Lipstick Effect The trend for minimally invasive procedures is continuing its exponential rise, according to recent US statistics. Dr Timothy Flynn reviews the data and discusses how, in combination, toxins and fillers can provide an ‘injectable face-lift’

Guest Editor David Hicks 020 7514 5989 david@face-ltd.com Production Editor Helen Unsworth 020 7514 5981 helen@face-ltd.com

18

Sales Executive Monty Serutla 020 7514 5976 monty@face-ltd.com Assistant Sales Executive Simon Haroutunian 020 7514 5982 simon@face-ltd.com

Silhouette thread lift Conventional face lifts for patients with South Asian skin types can result in noticeable scarring. Dr Viraj Tambwekar discusses the silhouette thread lift alternative for facial rejuvenation

29 Non-surgical The celebrity facelift Traditional facelifts can leave patients needing substantial recovery time. Dr Aamer Khan discusses an alternative, noninvasive solution for patients in the public eye or those requiring subtle rejuvenation of the face

Publisher Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com Contributors Dr Stephen Bassett Catherine Quinn Dr Timothy Flynn Dr Viraj Tambwekar Dr Aamer Khan Mr Kambiz Golchin Dr Daniel Sister Miss Zahida Butt Dr Flor Kent Dr Raj Acquilla Dr Raj Persaud Dr Zein Obagi Dr Simon Poole Charles Southey Lorna Bowes Dr Michael Kane

23 SURGICAL

31 Aesthetic medicine

56

The Angel Lift Tailoring skin rejuvenation treatments to individual patients can improve clinical outcomes and patient satisfaction. Mr Kambiz Golchin describes the application of the Angel Lift, a therapy combining fractional CO2 laser with autologous fat grafting and concentrated platelet rich plasma

35 Injectables Combination therapy Hyaluronic acid can provide rejuvenation for age-related changes to the soft facial tissues, but not the underlying bone.

A combination approach using platelet rich plasma can target all aspects of facial ageing, writes Dr Daniel Sister

38 Conference

63 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 2013 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 6

FACE 2013 Mark June 21—23 in your diary to attend the UK’s premier facial aesthetic conference and exhibition

45 Surgery Easy on the eye While the eyes and periorbital tissues play an important part in the perception of facial beauty, they are one of the first areas to show signs of ageing. Miss Zahida Butt discusses the benefits and techniques of upper and lower lid blepharoplasty surgery

50 Aesthetics In the eye of the beholder The aesthetic industry revolves around the concept of beauty, youth and attractiveness. Dr Flor Kent explores the origins of body language www.bodylanguage.net

71

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 .

Mr Ravi Jandhyala is a member of the Royal College of Surgeons of Glasgow, and a founding member of the UKBTGA. He is also a member of the Faculty of Pharmaceutical Medicine and is an expert in the science behind botulinum toxins for aesthetics. He is the president of the United Kingdom Society for the Study of Aesthetic Medicine.

beauty, its relationship with the Golden Proportion, and how we recognise a beautiful face

53 MASTERCLASS TEAR TROUGH TECHNIQUE Treatment of tear trough and lid/cheek deformity can provide effective rejuvenation for the ageing face. But practitioners must consider anatomy and good injection technique, writes Dr Raj Acquilla

56 Psychology Body fat and beauty Dr Raj Persaud surveys the latest research into the link between body fat percentage and measuring female attractiveness

59 Skincare Appealing results Dr Zein Obagi discusses proper use of peeling agents to promote healthy skin

63 Nutrition Busting fat myths The relationship between dietary fats and a healthy lifestyle have been a constant source of misunderstanding among those seeking weight loss and better nutrition. Dr Simon Poole dispels the myths

69 Marketing Design for success The most important factor affecting website performance is design—good design makes us feel better, writes Charles Southey

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

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

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

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

Anthony Erian FRCS (Erg) FRCS (Ed) is an aesthetic plastic surgeon with more than 30 years’ experience.

He is a member of the American Academy of Aesthetic and Restorative Surgery and chairman of the European Academy of Aesthetic Surgery. Mr Erian practices in Cambridge and Harley St. Dr Stephen Bassett is medical director of the Aesthetic Training Academy and ShapeCYMRU Cosmetics. He is a Syneron luminary and member of the Merz academy, focusing on RF facial procedures. He is a barrister, fellow of the Society of Advanced Legal Studies and a legal consultant.

Elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies.

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

71 Skincare

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

Under the sun The dangers associated with under application of topical sunscreens are still misunderstood by the majority of consumers. Lorna Bowes discusses the latest US and EU regulations for sun protection products and cosmeceuticals

Dr Raj Persaud FRCPsych is a consultant psychiatrist who has worked as a consultant at the Bethlem Royal and Maudsley NHS Hospitals in London from 19942008, and as an honorary senior lecturer at the Institute of Psychiatry, University of London—the premiere research and training institutions for psychiatry in Europe.

77 Products On the market The latest products in aesthetic medicine, as reported by Helen Unsworth

78 Experience State of the art Dr Michael Kane describes his aesthetic pathway, and how his artistic background has provided a solid foundation on which to base his approach to facial ageing body language www.bodylanguage.net

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.

7

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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.

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observations

60

second brief

TOP PROCEDURES

The American Society for Aesthetic Plastic Surgery have released statistics for the top five surgical and non-surgical procedures performed in the USA throughout 2012:

Surgical 1. Breast augmentation 330,631 2. Lipoplasty 313,011 3. Abdominoplasty 156,508 4. Blepheroplasty 163,171 5. Rhinoplasty 143,801 Non-Surgical 1. Boyulinum toxin type A 3,267,913 2. Hyaluronic acid 1,423,706 3. Laser hair removal 883,893 4. Microdermabrasion 498,821 5. Chemical peels 443,834 Source: The American Society for Aesthetic Plastic Surgery

body language www.bodylanguage.net

The Keogh Review— regulations recommended Calls for cosmetic patients to receive the same regulatory protection as in medical practice Following the PIP scandal, the cosmetic industry came under scrutiny and NHS medical director Bruce Keogh launched a full-scale review into cosmetic practices.

The findings conclude that cosmetic patients should be entitled to the same ‘safety net’ of standards and redress as they would be given on the NHS. In particular, the review raised concern that patients assumed certain levels of safety and redress of cosmetic procedures, which were not in place.

The review focused on tightening regulations around dermal fillers. Keogh raised concerns with an industry he found to be filled with ‘cowboys’ and ‘untrained staff’. In light of the PIP scandal, the report highlighted the fillers industry as similarly unregulated, dubbing it ‘a disaster waiting to happen.’

Keogh’s recommendations proposed that dermal fillers should be classified under the EU Medical Devices Directive.

As part of this change, Keogh also suggested that new legislation be rapidly enacted to classify fillers as a ‘prescription only medical device’.

New regulations were also suggested around the level of staff qualifications needed to administer fillers. “I am concerned that some practitioners who are giving non-surgical treatments may not have had any appropriate training whatsoever,” says Koegh. “This leaves people exposed to unreasonable risks, and possibly permanent damage.”

Under these regulations, fillers could only be injected by qualified medical staff, or those who hold a recognised qualification in injecting. However, the report made no suggestion as to what those qualifications might be, or who would be in

charge of enforcing them.

The report was damning about the level of regulation surrounding regulations on fillers themselves. Keogh announced deep concern that those purchasing a filler treatment had no more consumer right to safety standards than those buying a ballpoint pen.

Industry insurance policies, and public understanding of cosmetic safety standards, were also brought into question.

“Research has shown that the public expect procedures that are so widely available to be safe,” reports Keogh, “whereas they are largely unregulated.”

The report suggests measures are taken from a more informed and empowered public, and calls for a clearer and more accessible right to resolution and that redress be formulated.

Part of this proposal includes the tightening up of regulations surrounding the advertising of cosmetic procedures. Keogh also advised that closer attention be paid to informing patients clearly of potential risks before they undergo treatment.

The British Association of Aesthetic Plastic Surgeons (BAAPS) has declared itself broadly in support of the issues raised in the report. President Rajiv Grover has pointed out that many BAAPS members rectify botched procedures carried out by others, which have come about through the nonregulation of the industry. The Association agrees with the need to protect the public from untrained individuals administering unregulated products.

Following the PIP scandal, it seems like the UK government will view these suggestions in a proactive manner— ministers have already pledged their support to enacting Keogh’s recommendations.

9

observations

Toxins could change emotions Paralysing facial muscles may alter long-term mood A study has found that botox could alter emotions, and could even be used to treat mood disorders. The research, led by Dr Michael Lewis of the School of Psychology, Cardiff, Wales, tracked 25 people, following injections with botox. They found that the treatment, to disrupt natural expressions, could also alter mood.

“The expressions that we make on our face affects the emotions we feel,” explains Dr Lewis. “We smile because we are happy, but smiling also makes us happy. Treatment with drugs like Botox prevents the patient from being able to make a particular expression.”

Initially, the researchers investigated the possibility of botox having a depressant action.

Facial muscles associated with smiling, are known to have a ‘feedback effect’, channelling messages back to the brain, to

maintain an uplifted mood.

If these muscles are paralysed, such as in the application of botox to certain areas of the face, this feedback doesn’t occur.

Dr Lewis’s study found higher self-reported depression in patients treated for crow’s feet (the ‘smile’ eye area) and frown lines, than frown lines alone.

Dr Lewis also suggests the findings have applications in preventing obsessive compulsive disorder. He theorises, that facial muscles associated with disgust could be paralysed, using botox. In theory, this could help alleviate the strong feelings which compel OCD sufferers to carry out obsessive behaviours.

“Those treated for frown lines with Botox are not able to frown as strongly,” he explains.

“This interrupts the feedback they would normally get from their face and they feel less sad.”

Cosmetic surgery often needed for dog bite injuries Young children can require complex treatments A report, in the March Journal of Craniofacial Surgery, published by Lippincott Williams & Wilkins, (a part of Wolters Kluwer Health), found that dog-bites are common, and frequently require complex cosmetic surgery.

The study, led by Dr. Barry L. Eppley of Indiana University Health North Hospital, Carmel, and Dr. Arno Rene Schelich of Hans Privatklinikum, Graz, Austria, reviewed evidence of dog-bite injuries ten years after the event.

They found that treatment often required secondary revision surgery, to tackle scarring, and even with several interventions, permanent scarring was 10

common. Researchers urged medics to align expectations of families of injured children, with the possible need for more than one cosmetic surgical intervention, and unavoidable scarring.

The main issue for surgeons, was the difficulty in closing wounds without risk of infection—a possibility which called for more complicated treatment than straight-forward stitching.

Researchers found that three-quarters of dog bite cases resulted in ‘scar revision’ surgery. “Even with favourable results from scar revisions, the patient and family may still regard the scars as a permanent disfigurement,” said Eppley.

training & events MAY

28 June, ZO Medical, Wigmore Medical, London W: wigmoremedical.com 10 & 11 May, PRP and Microsclerotherapy & Facial Telangiectasia training, Wigmore Medical, London 28 June, Sclerotherapy training, The Paddocks W: wigmoremedical.com Clinic, Bucks W: cosmeticcourses.co.uk 14 May, Obagi Workshop, Obagi Medical, Glasgow 29 & 30 June, Botulinum Toxin and Dermal Fillers W: obagi.uk.com in Facial Aesthetics, Innomed Training Academy, London 16 May, Chemical peels, Dr Brian Franks, Watford, W: innomedtraining.co.uk/courses.html North London W: drbrianfranks.com JULY 17–19 May, Summit in Aesthetic Medicine 2013, Dana Point, USA W: globalacademycme.com/sdef 18 & 19 May, Advanced Botulinum Toxin and Advanced Dermal Fillers, Innomed Training Academy, London W: innomedtraining.co.uk/courses.html

20–23 May, Dermaroller, Introduction to Skincare & Peels, Toxins and Dermal Fillers Courses, Wigmore Medical, London 23 & 24 May, Botulinum Toxin and Dermal Fillers Part 1, Dr Brian Franks, Watford, London W: drbrianfranks.com 29–31 May, Beauty Through Science, Stockholm, SWEDEN W: beautythroughscience.com 30 & 31 May, Dermaroller, Chemical Peel and Medical Microdermabrasion training, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 31 May, CPR & Anaphylaxis Update, Wigmore Medical, London W: wigmoremedical.com 31 May, Dermaroller training, Dr Brian Franks, Watford, North London W: drbrianfranks.com JUNE 1 & 2 June, Microsclerotherapy & Facial Telangiectasia and Refresher Toxins & Fillers training, Wigmore Medical, London W: wigmoremedical.com 6–8 June, PRP, Advanced Toxins & Dermal Fillers and Mesotherapy training, Wigmore Medical, London W: wigmoremedical.com 10–13 June, Dermaroller, Introduction to Skincare & Peels, Toxins and Dermal Fillers Courses, Wigmore Medical, London W: wigmoremedical.com

4 & 6 July, Foundation Botulinum Toxin Part I and Foundation Dermal Fillers Part I, Dr Brian Franks Training, Watford, London W: drbrianfranks.com 5 & 6 July, CPR & Anaphylaxis Update and Microsclerotherapy training, Wigmore Medical, London W: wigmoremedical.com 9 July, Sculptra training, Wigmore Medical, London W: wigmoremedical.com 9 July, ZO Medical, Wigmore Medical, Manchester W: wigmoremedical.com 12 July, ZO Medical, Wigmore Medical, London W: wigmoremedical.com 13 July, Foundation Botulinum Toxin and Dermal Filler, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 15–19 July, Medik8 Dermal Roller, Skincare & Chemical Peels, Intro to Toxins, Intro to Dermal Fillers and Refresher Toxins & Fillers training, Wigmore Medical, London W: wigmoremedical.com 26 July, Sculptra Refresher training, Wigmore Medical, London W: wigmoremedical.com 27–29 July, IMCAS Asia 2013 – International Master Course on Aging Skin Singapore City, Singapore W: imcas.com/en/asia2013/congress 31 July–4 August, American Academy of Dermatology Summer Meeting, New York, USA W: aad.org AUGUST 8 & 9 August, Foundation Botulinum Toxin Part I and Foundation Dermal Fillers Part I, Dr Brian Franks Training, Watford, London W: drbrianfranks.com

12–15 August, Medik8 Dermal Roller, Skincare 14 June, Business Development training, Wigmore & Chemical Peels, Intro to Toxins, Intro to Dermal Medical, London Fillers training, Wigmore Medical, London W: wigmoremedical.com W: wigmoremedical.com 14 June, Obagi Workshop, Obagi Medical, London W: obagi.uk.com

16 August, Business Development training, Wigmore Medical, London W: wigmoremedical.com

15 June, Foundation Botulinum Toxin and Dermal Filler, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk

17 August, Foundation Botulinum Toxin and Dermal Filler, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk

20 & 21 June, Dermaroller, Chemical Peel and Medical Microdermabrasion Training, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 21–23 June, FACE Conference, London W: faceconference.com 26–30 June, Vegas Cosmetic Surgery 2013, Las Vegas, Nevada, USA W: vegascosmeticsurgery.info/2013 27–30 June, World Congress of Cosmetic Dermatology, Athens, Greece W: wcocd2013.com

FACE Conference June 21–23, London

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

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Pliaglis Prescribing Information (UK)

Presentation: 1 gram of cream contains 70mg lidocaine & 70mg tetracaine.

Indications: For use in adults to produce local dermal anaesthesia on intact skin prior to dermatological procedures. Dosage and Administration: For procedures such as pulsed-dye laser therapy, Pliaglis should be applied at a thickness of 1mm for 30 minutes. For procedures such as laser-assisted tattoo removal, Pliaglis should be applied at a thickness of 1mm for 60 minutes. After the required time, the peel must be removed from the skin prior to the procedure. The maximum application area should not exceed 400 cm2. For facial procedures, Pliaglis should be applied by healthcare professionals only. Pliaglis should be applied with a flat surfaced tool, never with fingers. Pliaglis is for single patient use. Contraindications: Hypersensitivity to lidocaine, tetracaine, other anaesthetics of the amide or ester type, to paraaminobenzoic acid or any of the other excipients. Should not be used on mucous

membranes or on broken or irritated skin. Precautions and Warnings: Avoid contact with eyes. Treated area should not be occluded before removing Pliaglis from skin.

Should not be applied for a longer time than recommended. Local anaesthetics, including tetracaine, have been associated with methemoglobinemia. It is not recommended to use Pliaglis before injection of live vaccines as lidocaine has been shown to inhibit viral & bacterial growth. Use with caution in patients with hepatic, renal or cardiac impairment, and in patients with increased sensitivity to systemic circulatory effects of lidocaine and tetracaine. Avoid trauma to skin whilst under effects of Pliaglis. Interactions: No interaction studies have been performed. Interactions following appropriate use are unlikely as only low concentrations of lidocaine and tetracaine are found in the plasma after topical administration of recommended doses. Patients taking drugs associated with drug-induced methemoglobinemia are at greater risk for developing methemoglobinemia. Undesirable Effects: In clinical

trials, localised skin reactions at the application site were very common but were generally mild and transient in nature. Reported adverse reactions include: Very common (≥1/10): erythema, skin discolouration; Common (≥1/100 to <1/10): skin oedema; Uncommon (≥1/1,000 to <1/100): pruritus, pain of skin, pain; Rare (≥1/10,000 to <1/1,000): paresthesia, eyelid oedema, pallor, skin burning sensation, swelling face, skin exfoliation, skin irritation; Not known (cannot be estimated from available data): urticaria. Rare allergic or anaphylactoid reactions associated with lidocaine and tetracaine or other ingredients in Pliaglis can occur. Prescribers should consult the SPC in relation to other side-effects. Packaging Quantities and Cost: 15g £22.95 (NHS). MA Number: PL 10590/0059. 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: December 2012.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to Galderma (UK) Ltd Date of preparation: March 2013

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observations

Lifting the lid on aesthetic regulation In light of Sir Bruce Keogh’s long-awaited report on cosmetic industry regulation, Dr Stephen Bassett surveys its key recommendations Sir Bruce Keogh’s report, “A review of the Regulation of Cosmetic Interventions” (DOH, 2013) has been released; a long wait for a short report produced in the long shadow cast over UK cosmetic surgery by the PIP scandal.

Sometimes sensible, sometimes sensationalist, Keogh resonates with a distinct journalistic tone of moral panic: “A person having a non-surgical cosmetic intervention has no more protection and redress than someone buying a ballpoint pen or a toothbrush”. Really?

There is one big positive point. Beside a fleeting reference in Keogh’s introduction, and a column in the “Regulation at a Glance” chart, the lack of attention to botulinum toxins is an implicit recognition that their administration for the improvement of glabellar and peri-orbital rhytides by suitably qualified doctors and nurses is safe and needs minimal changes.

The non-surgical sector is 75% of the value of the whole cosmetic intervention sector, and I focus on the implications of the three headline recommendations for that non-surgical field: on its products, practitioners and its patients.

Keogh suggests some potentially tectonic changes to the landscape of aesthetic medicine.

Key recommendations: Products “Legislation should be introduced to classify fillers as a prescription-only medicine” The boldest of Keogh’s recommendations is the reclassification of dermal fillers as prescription only medicines (POMs) under the Medicines Act 1968. Keogh contends that dermal fillers are exempt from classification as medical devices under Council Directive 93/42/EEC, a view at odds with most authorities.

Dermal fillers are currently classified as class III medical devices in the EU and, therefore, the UK. They are materials for the replacement or modification of the anatomy which do not achieve their principal intended actions in or on the human body by pharmacological, immunological or metabolic means, but which may be assisted in its function by such means.

Keogh wants fillers to be medicines. The classification of medicines as codified in the Human Medicines Regulations 2012 consolidate all the existing medicines regubody language www.bodylanguage.net

lations, implementing Directive 2004/27/ EC amending directive 2001/83/EC on the Community code relating to medicinal products for human use. The main purpose of the regulations is to safeguard public health, but a competing EU objective is avoiding hindrance of development of the pharmaceutical industry or trade in medicinal products in the EU, which will be important in any inevitable challenges to changes in fillers’ licensing status.

A medicine (or correctly, a ‘medicinal substance’) has the property of exerting a pharmacological, immunological or metabolic action. Fillers would not, initially, seem to possess these properties.

Keogh wants fillers to be POMs. Prescription only status will apply where: a direct or indirect danger exists to human health from a product, even when used correctly; if used without medical supervision; if there is frequently incorrect use which could lead to direct or indirect danger to human health; if further investigation of

activity and/or side-effects is required; or if the product is normally prescribed for parenteral administration (Article 71 of Directive 2001/83/EC as amended: Human Medicine Regulations 2012 regulation 62(3)). Some of these points may apply to dermal fillers.

Keogh’s aims require no new legislation—the existing framework suffices.

The European Court of Justice, which interprets Member States’ implementation of Community Directives, acknowledges that Member States have autonomy to classify substances as medicinal or not on an individual case-by-case basis, even though this may mean different classification of substances in different Member States (Re Eye Lotions: EC Commission v Germany, [1995] 2 CMLR 65).

There may be a considerable element of judgement in deciding a product’s medicinal status and many factors—including public perception of risks, as well as actual risks—may be taken into account (Medi13

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

cines Control Agency ex parte Pharma Nord, [1998] EWCA Civ 891) in discharging the responsibility to public health, so the current flap could have a bearing on status determination.

Regulation 165 of the Human Medicines Regulations 2012 allows the Medicines and Healthcare products Regulatory Agency (MHRA) to simply declare that a product is medicinal where there is an identifiable risk to public health and/or patient safety.

This could apply to dermal fillers, although given the compositional diversity of fillers—NASHA, L-polylactate, calcium hydroxyapatite and CMC—and the manufacturers’ claims of further molecular tweaking, this would probably need to be done on an individual basis for the nearly 200 products, potentially triggering a legislation-avoidance arms race. The MHRA could do this immediately—it has not. Is it as convinced of the risks as Keogh?

Fillers can cause serious injury including necrosis, blindness and granulomata

body language www.bodylanguage.net

Keogh implies that in reclassifying dermal fillers as POMs, this will remove them from the hands of non-medical and nonnursing practitioners. But this ignores the possibility of illegal importation of differently classified and more readily available products, as well as counterfeit products, from other EC countries (Pickett A, 2011) But most importantly, Keogh implies that the reclassification of dermal fillers as medicinal products is essential because there is no other means of reining in unqualified practitioners, as they do not fall under any regulatory regime such as those that govern doctors and nurses, the GMC and NMC: “In the case of dermal fillers, the treatments are almost entirely unregulated—anyone can perform them, anywhere and with any product—this is a crisis waiting to happen”.

Keogh, in keeping with most current discussions, does not explore an option which I believe is ripe for development— the use of existing criminal law.

All medical interventions are assaults (technically ‘batteries’), but a patient’s consent provides a defence to the practitioner.

The case of Wilson [1996] 2 Cr App R 241, where the Court of Appeal overturned Wilson’s conviction for branding his initials onto his wife’s buttocks with an iron at her request and with her consent, has been used to argue that any consent protects against criminal sanction.

Clearly, the case law on this subject is evolving, and in Konzani [2005] EWCA Crim 706, informed consent becomes important when serious harm is in play. The House of Lords case Brown [1994] 1 AC 212, clearly stated that one cannot consent to serious injury, a ruling approved at the European Convention on Human Rights (ECHR).

Fillers can clearly cause serious injury— necrosis, blindness and disfiguring granulomata. Clearly an unskilled, untrained, uninformed injector cannot be aware of these risks, let alone explain them. There is now a window of opportunity to review the application of the Offences Against the Person Act to unqualified filler administration.

Where permanent injury, such as blindness, lip necrosis or paralysis resulted, s47 OAPA ABH could result in a custodial sentence (Sentencing Guideline Committee, 2008). Imposition of this sort of justice would send a shockwave through the ranks of the unskilled and unscrupulous.

Little attention has been paid to the underused s24 Offences Against the Person Act 1861, which criminalises the unlawful and malicious administration of poison or destructive or noxious thing, with intent to

injure, aggrieve or annoy.

The Court of Appeal in Marcus [1981] 2 All ER 833, has allowed the category of “noxious thing” to be very wide and reflecting all the circumstances of the case.

In my view, fillers with their immunogenic, embolic properties could be considered noxious in untrained hands.

Ignoring a lack of knowledge of anatomy, physiology, complications and corrective measures would cross the threshold for maliciousness (Cunningham [1957] 41 Crim App 155) needed to ground this offence. The Konzani [2005] EWCA Crim 706 HIV case makes clear that it is not the penetrating act of the needle which causes serious injury, but the continuous presence of a non-inert biosubstance.

It is open to the Crown Prosecution Service to pursue unqualified injectors on the basis of public safety, especially where there is exploitation of vulnerabilities and differential knowledge of risks and hazards (CPS Code for Crown Prosecutors (2010) para 4.16 (j) and (m)). Why has this not been done—nervousness about criminalisation? In my view, this would be the most direct route by which to take regulation to the marketplace. Regulate the people, not the product.

I do not propose to tackle product liability law in the space available, but this has been insufficiently explored as a means of redress in general, and in Keogh specifically. The same can be applied to the Supply of Goods and Services Act 1982, which I presume resulted in the recently celebrated Arblaster tattoo case (“Woman’s tattoo ‘removed’ by practitioner with one hour’s training”; The Telegraph, 15th November 2012).

Local Authorities can also use enforcement powers under the Health and Safety at Work Act 1974 and Local Government (Miscellaneous Provisions) Act 1982, as amended by the Local Government Act 2003, perhaps more powerfully than Keogh suggests.

Key recommendations: Practitioners “The Health Education England’s (HEE’s) mandate should include the development of appropriate accredited qualifications for providers of non-surgical interventions and it should determine accreditation requirements for the various professional groups. This work should be completed in 2013.”

Keogh bemoans the “highly fragmented” nature of the cosmetic interventions sector. So it is surprising that his chosen vehicle for training reform is HEE—which has no mandate in the devolved administrations, and has yet to find its feet in the 15

observations

High quality care should be provided by appropriately skilled practitioners

new world of Local Education and Training Boards and clinical commissioning groups, following the demise of Deaneries under the Health and Social Care Act 2012.

Non-surgical cosmetic interventions are overwhelmingly provided by medics and nurses in private sector contexts, which is also the natural milieu of training providers. HEE could pull off such an undertaking, but as a Special Health Authority with deep NHS mind-set and methods, it’s simply colossally misaligned and unsuited to the task. Completion of a politically viable model in the remaining six months of 2013 is utterly unfeasible.

When stripped of moral panic, and in light of the evidence that almost all adverse events from toxins are transient needle effects (Flynn T, 2012), single day training for medical practitioners is wholly responsible.

The treatment of lateral epicondylitis with corticosteroid produces major ADRs in 7% of cases (Tonks JH et al, 2007), but few would suggest more than a day to be suitably accredited. Training must reflect risk.

On that note, dermal filler training needs a total rethink. The drivers of safety and quality must be insurers and defence organisations, requiring more detail, depth and demonstration of skills. Most current training is insufficiently rigorous. Here is our Achilles’ heel.

But, as Keogh acknowledges, but I 16

think underestimates, Appraisal for Revalidation—in accordance with the GMC’s Supporting Information for Appraisal and Revalidation (2012)—and its mandatory review of the whole scope of practice will for the first time require non-surgical cosmetic medical practitioners to bring evidence of peer-reviewed CPD to appraisal for ultimate endorsement by Responsible Officers who shoulder a considerable statutory burden of probity. This is a sea change which will wash away much sub-standard practice.

Groups like our industry supported Medical Aesthetic Complication Expert Group will also help in clarifying complication frequencies and mechanisms, and pathways for their management.

Key recommendations: Patients “Existing advertising recommendations and restrictions should be updated and better enforced. The use of financial inducements and time-limited deals to promote cosmetic interventions should be prohibited to avoid inappropriate influencing of vulnerable consumers. All individuals performing cosmetic procedures must possess adequate professional indemnity cover.”

It is submitted that, properly enforced, GMC and NMC codes of practice already sufficiently dictate practitioners’ duties here. Clearly, it is not an absence of regulation but enforcement which results in practitioners being allowed to fall short.

A medical practitioner and nurse ad-

ministering botulinum toxin are specifically regulated by “Good Medical Practice” (2013) and “The code: Standards of Conduct, Performance and Ethics for Nurses and Midwives” (2008) respectively, documents with quasi-legislative force, produced under the regulatory bodies’ statutory responsibilities.

For a doctor, “Good Medical Practice” requires that (s)he is competent, recognises and works within the limits of that competence, keeps up-to-date, is in compliance with relevant law and guidelines, is responsive to risks to safety and is taking steps to monitor and improve the quality of their work, which must be evidence-based and thoroughly documented.

They must provide a confidential, holistic, respectful, dignified, commercially transparent and unbiased assessment of each patient individually, during which honesty about experience and qualifications is required, and if this consultation is in response to an advertisement, the advertisement is factual and non-exploitative.

They must be responsive to complaints and be adequately indemnified.

These obligations satisfy Keogh’s “overarching objectives” of: (1) high quality care provided by appropriately skilled practitioners to (2) informed and empowered patients, who have made informed decisions based on clear, easily accessible and unbiased information as part of an expectation managing consent process (3) with appropriate indemnity arrangements in place.

The same can be said of nurses, whose Code requires them to not abuse their privileged position for their own ends, to ensure that their professional judgement is not influenced by any commercial considerations and to not use their professional status to promote causes that are not related to health.

They must cooperate with the media only when they can confidently protect the confidential information and dignity of those in their care. They must uphold the reputation of their profession at all times.

As Robert Francis concluded (“Final Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry,” 2013) to achieve a relentless focus on the patient’s interests and the obligation to keep patients safe and protected from substandard care, means that the patient must be first in everything that is done. This does not require radical reorganisation but re-emphasis of what is truly important.

Stephen Bassett is a cosmetic doctor, barrister, member of the Association of Regulatory & Disciplinary Lawyers. Tweet Stephen @stephendbassett body language www.bodylanguage.net

LOOK HOW YOU FEEL

Azzalure Abbreviated Prescribing Information (UK & IRE)

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 Date of preparation: March 2013

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). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 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: March 2013

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Galderma (UK) Ltd.

AZZ/019/0313

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non-surgical Dr Tim Flynn

The lipstick effect The trend for minimally invasive procedures is continuing its exponential rise, according to recent US statistics. Dr Timothy Flynn reviews the data and discusses how, in combination, toxins and fillers can provide an ‘injectable face-lift’

T

he American Society for Plastic and Reconstructive Surgery (ASPRS) recently released its 2012 survey data on cosmetic procedures performed in the United States. Amazingly, in a down economy, minimally invasive procedures—such as the use of fillers and neuromodulators—were up by six percent. At the same time, the society reported that surgical procedures were down by three percent. Americans are spending more on smaller procedures while holding off on larger, more expensive surgery such as a face-lift or tummy tuck.

Much of this was explained by the press as the “lipstick ef20

fect”, a term coined by consumer psychologists. It is well documented that during hard times, a woman is more likely to buy a new tube of lipstick than she is to spend money on an expensive pair of designer shoes.

Following the devastation of Hurricane Katrina, dermatologists in New Orleans reported that they were very busy with injectables, with their patients commenting that toxin treatments boosted their self esteem. Other researchers have discovered that people will spend money on beauty items which make them feel good when facing hard times, either personal or economic.

There is an emotional component to beauty purchases, subbody language www.bodylanguage.net

non-surgical Dr Tim Flynn

stantiated by data showing that during this same period of the depressed American economy, record numbers of dollars were spent on “beauty services”, such as spa treatments or hair care.

Money spent on nails during 2012 also achieved a record high.

When we are feeling a bit down and stressed, we like to do small things that feel good while we conserve our large expenditures.

When reporting on the ASPRS statistics, the press failed to recognise that using injectables in combination could produce what some have termed “the injectable face-lift.” Increased use of toxins and fillers has also been documented by the American Society of Dermatologic Surgery (ASDS), who noted that the use of neuromodulators increased by 24% and the use of injectable fillers increased by 10% by their members.

ASDS members have also noticed that the increasing use or the combination use of both fillers and neuromodulators have begun to restore the face to its youthful volume in correct proportion and return the ageing face and restore youthful beauty. body language www.bodylanguage.net

Members have noted those patients who have chosen to continue injectable treatments to a point where they have a sufficient amount of volume restoring material placed correctly, have begun to hold time at bay or even look younger. Some physicians’ marketing have used the neologism “re-flation” for this youthful restoration of volume.

Anthropology The reason why these injectable techniques are working so well can be linked back to two discoveries in two specialities—plastic surgery and anthropology. Doctors Rohrich and Pessa, while working with ageing cadavers, documented significant facial fat loss and detailed the fat compartments of the face. Using injectable dyes, they demonstrated that these fat compartments are isolated one from another and, when injected with visible dyes, they inflated and retained the dye within each individual anatomic fat pad.

21

non-surgical Dr Tim Flynn

Age-related bony changes in the skull are an additional cause of volume loss—the underlying hard structure supporting the facial fat pads and overlying skin shrinks

Advanced injectors from core aesthetic specialties, working with newer injectable agents, have understood the power that placing volume in and around the fat pads can have. The deeper injectable fillers that have been used include hyaluronic acids, calcium hydroxyapatite and poly-L-lactic acid. These agents are often used in a diluted fashion to evenly distribute these filler materials.

Each deeper filling agent has its own particular technique, with properties specific to that agent. For example, Sculptra is exclusively a deep filling agent, where the poly-L-lactic acid particles cause a tissue response over time, building up volume by stimulating the body to produce its own collagen.

Multiple treatments are to be expected, and certain patients respond better than others. More robust hyaluronic acids can often achieve correction in one or two treatment sessions, and hyaluronic acids can be used more superficially as well as deeply.

Some practitioners favour the use of a blunt cannula, while others use a sharp needle—there are advantages and disadvantages to each delivery system.

Anthropologists made another advance. Scientists working on the effect of age on the human skull documented that the skull changes predictably as we get older. They showed that there are specific structural changes that occur within the skull, which assist them in documenting the age of the deceased individual.

Radiologic techniques were used in living people to confirm these bony changes, showing that as we age, our eye sockets widen, there is dental and bone resorption, and malar collapse.

These age-related bony changes in the skull are an additional cause of volume loss—the underlying hard structure support-

By using the correct fillers deeply, areas of bone resorption can be built up 22

ing the facial fat pads and overlying skin shrinks. The eyes sink into the skull producing sags under the eyes and nasolabial folds develop. Lines around the mouth develop because of soft and hard tissue loss.

By using the correct fillers deeply, the areas of bone resorption can be “built up”, pushing the soft tissues outward and stretching the skin to correct concavities to convexities. Hyaluronic acids are used subdermally to build up areas of soft tissue loss and to correct individual wrinkles and depressions. Fine lines can now be treated with the injectable filler Belotero—a hyaluronic acid whose technology enables it to intercalate itself in and amongst collagen bundles within the dermis.

This filler can be used, diluted with lidocaine to reduce pain, with a 32 gauge needle to treat fine lines, particularly around the mouth. We love combination treatment when neuromodulators are used with fillers to stop excessive muscle movement and correct lines caused by overactive facial muscles. The combination can truly restore individuals’ appearance to that of a younger age, with beauty restored.

Americans will be seeing more “re-flation” or the “liquid face-lift” with the expected approval of Voluma from Allergan.

This hyaluronic acid should provide us an even better ability to restore volume in the ageing face. It is possible that the surgical face-lift may be put off by several years as people gently correct the slow loss of soft and hard tissues.

Whatever terms are used, it is after all not a true face-lift.

There are individuals who do need surgical procedures and these procedures are often the best money spent on their face.

However, many rhytidectomy patients will still benefit from proper volume restoration and further aesthetic treatment particularly in the central face. The complete aesthetic practitioner can also never forget the value of attention to proper skin care and the use of lasers and light-based technologies to restore agerelated colour change and dyschromia.

Dr Timothy Corcoran Flynn is a consultant dermatologist, medical director at the Cary Skin Center, USA and current president of the American Society for Dermatologic Surgery body language www.bodylanguage.net

C

onfidence is Reliable1,2 Rewarding 3 Performance 4,5 BOTOX® is licensed for the treatment of moderate to severe glabellar lines Delivers long-lasting patient satisfaction, time after time 2,3 Has been used for over 20 years in over 26 million treatment sessions worldwide6 Is the world’s first and most studied botulinum toxin*7

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

burning/stinging, oedema and/or bruising may be associated with the injection. Frequency By Indication: Defined as follows: Very Common (> 1/10); Common (>1/100 to <1/10); Uncommon (>1/1,000 to <1/100); Rare (>1/10,000 to <1/1,000); Very Rare (<1/10,000). Infections and infestations. Uncommon: Infection. Psychiatric disorders. Uncommon: Anxiety. Nervous system disorders. Common: Headache. Uncommon: Paresthesia, dizziness. Eye disorders. Common: Eyelid ptosis. Uncommon: Blepharitis, eye pain, visual disturbance. Gastrointestinal disorders.

Uncommon: Nausea, oral dryness. Skin and subcutaneous tissue disorders. Common: Erythema, Uncommon: Skin tightness, oedema (face, eyelid, periorbital), photosensitivity reaction, pruritus, dry skin. Musculoskeletal and connective tissue disorders. Common: Localised muscle weakness, Uncommon: Muscle twitching. General disorders and administration site conditions. Common: Face pain, Uncommon: Flu syndrome, asthenia, fever. Adverse reactions possibly related to spread of toxin distant from injection site have been reported very rarely (exaggerated muscle weakness, dysphagia, constipation or aspiration pneumonia which can be fatal). Rare reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Rare reports of serious and/or immediate hypersensitivity (including anaphylaxis, serum sickness, urticaria, soft tissue oedema and dyspnoea) associated with BoTox use alone or in conjunction with other agents known to cause similar reaction. Very rare reports of angle closure glaucoma following treatment for blepharospasm. New onset or recurrent seizure occurred rarely in predisposed patients, however relationship to botulinum toxin has not been established. Needle related pain and/or anxiety may result in vasovagal response.

NHS Price: 50 Units: £77.50, 100 Units: £138.20, 200 Units £276.40. Marketing Authorization Number: PL 00426/0074 Marketing Authorization Holder: Allergan Pharmaceuticals (Ireland) Ltd., Westport, Co. Mayo, Ireland. Legal Category: PoM. Date of preparation: December 2012.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

References: 1. De Almeida A et al. Dermatologic Surgery 2007;33:S37–43. 2. Carruthers A et al. J Clin Res, 2004;7:1–20. 3. Stotland MA et al. Plast Reconstr Surg, 2007;120:1386–1393.

4. Beer KR et al. J Drugs Dermatol, 2011;10(1) :39–44. 5. Lowe et al. Am Acad Dermatol, 2006;55:975-980. 6. Allergan data on file. BoTGL/001/SEP 2011 7. Allergan Data on File VIS/006/JUL2011. *Allergan botulinum toxin type A. Global figures. Launched in 1989 in the US. UK/0008/2013 Date of Preparation: January 2013

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surgical Dr Viraj Tambwekar

Silhouette thread lift Conventional face lifts carried out on patients with South Asian skin types can result in noticeable scarring. Dr Viraj Tambwekar discusses the silhouette thread lift alternative for facial rejuvenation

T

he face lift is undoubtedly the gold standard treatment for patients who want to rejuvenate their youthful looks. But plastic surgeons are still trying to develop the ideal facelift procedure—one that is less traumatic, with less downtime and longer lasting results than the average 7–10 years that the current procedure lasts.

Facelifts have evolved over time and, from being skin-only procedures, they have run the gamut of various degrees of aggressiveness. Common to all is the principle of lifting and fixating. The relative popularity of various procedures is measured by the amount of time the results last and how quickly patients can get back to their routine lifestyle.

Conventional facelifts have consistently produced good results but have had a few problems—duration of surgery, length of hospitalisation, recovery time, occasional facial nerve related problems and visible scarring, hairline deformity and ear lobule deformity.

Scarring is not really an issue for Caucasian patients. But in South Asian body language www.bodylanguage.net

patients, the scar stands out clearly as a white line in stark contrast to their darker complexion, no matter how well the surgeon hides it.

To address this concern, I first started performing thread lifts for facial rejuvenation, and realised this procedure had many other benefits, including less recovery and surgical time, minimising the complication of nerve damage and the amount of dissection.

The concept is quite simple. The technique relies on remote access when lifting the malar tissues in the temporal hairline, therefore hiding the scar. The lift is achieved from fixing and elevating the malar tissue to absorbable cones in the thread at multiple points. We have to provide firm fixation and suspension to and from a firm structure—the deep temporal fascia (DTF).

The elevation and fixation differs from the conventional technique as it is achieved as a differential lift at multiple points. This reduces the tension at each point of elevation, as opposed to the conventional open facelifts where the eleva-

tion and fixation is at a single point with considerably higher tension.

The thread lift achieves the lift much like a shish kebab and a collapsing accordion; with the thread being the metal rod of the shish kebab and the tissues differentially piling up on each other like a collapsing accordion. This prevents the thread from cutting through the elevated tissue like a wire through cheese.

The chemical composition of the cones promotes collagen formation and the building up of a strong fibrotic scar that maintains the lift after the cones have been absorbed. The technique is minimally invasive and can be performed quickly with minimal dissection thereby decreasing the operating and recovery time.

History Thread lifts were introduced in the late 1990’s by Dr Marlen Sulamanidze and have evolved through the contributions of Dr Woffles Wu, Dr Gregory Ruff and Dr Nicanor Isse. The technique began by using barbed threads without any firm 25

surgical Dr Viraj Tambwekar

While the conventional face lift produces consistent results, the silhouette thread lift avoids the scarring issues often suffered by patients of South Asian ethnicity. Above: Before, during surgery and post-procedure

fixation, to a technique that used fixation with barbed threads. In its current form, popularised by Dr Pizzamiglio and Dr Javier de Benito, the technique uses a thread with absorbable cones.

Central to the success of the procedure is the Silhouette thread. It is a 3-0 polypropylene thread with seven knots approximately 8mm apart, with six cones of L-lactic acid and glycolide polymer between them. On one end of the thread is an eight inch long 18-gauge straight stainless steel needle. The apex of the cone is toward the straight needle. At the other end of the suture is swaged a 26mm half circle needle.

The “Introducer” is an instrument with a blunt trocar inside a sharp cannula. The trocar is 18-gauge stainless steel.

When the trocar is removed, the straight needle of the thread can go through the sharp cannula with ease.

A 1 x 1cm prolene mesh is supplied with the thread. It is used to as a base through and on which the threads fix the elevated malar tissue to the DTF. It also enables the surgeon to find the knots with ease in case a re-tensioning is desired.

The procedure is performed under sedation which can be oral, or IV and local anesthesia. Local anesthesia can be injected along the suture tract and the incision or at points of the trigeminal nerve and locally in the incision.

The patient is marked in an upright position. The surgeon asks the patient to sit on a stool facing a mirror and sits in 26

between the patient and the mirror on a mobile height adjustable stool so that the patient can see what the surgeon is doing and help in decision making.

The 3cm incision is marked approximately 3cm behind the temporal hairline, superiorly closer to it and inferiorly further away. The superior part of the incision is approximately 1cm inferior to the temporal crest. It is an oblique incision more or less parallel to a line that is a tangent to the superior part of the lateral orbital rim.

Next, the face is marked. Between four to six points are marked as exit points of the sutures. The first is approximately halfway down a line along the nasolabial fold, a little lateral to it—never in the trough of the fold. The second point is 1–2cm lateral to the oral commisure along the same line.

The third and fourth points are 1–2cm further lateral and inferior to this point along a line, which is parallel to the lower border of the mandible. If the patient has a large face, two more points may be added to ensure a better result. So the first two points are along the naso-labial fold and the latter two along a “jowl” line.

Straight lines are then marked over the malar and temporal area connecting the incision to the exit points. The vector of these lines is such that the lines from the first two points are directed towards the inferior part of the incision and those from the latter two are directed towards the superior part of the incision. These

lines of the lift mimic the direction of descent of the tissues.

Procedure The patient is asked to lie supine on the operating table with a 30 degree head high incline and with the head straight.

Prepping and draping is done in such a manner that the head can be turned freely from side to side during the procedure.

The scalp is incised along the marked and infiltrated line using a “trichophilic’” technique and deepened to the DTF. Dissection is carried out along this plane in a temporal direction and a small flap is raised. The prolene mesh is then fixed to the DTF in the space created with a 3-0 nylon suture.

The next step is the insertion of the Silhouette suture. To achieve this, the Introducer is inserted through the incision and directed towards the corresponding exit point along the lines marked earlier.

The plane of insertion is deep at first and as the Introducer crosses the temporal hairline, the plane is more superficial— just beneath the dermis and superficial to the superficial musculoaponeurotic system (SMAS).

The superficial insertion has to be done carefully and in the same plane. The convexity of the malar region can make this a tricky endeavour. A very superficial insertion may cause dimpling due to dermal “pick-up” and a deep insertion may not yield an adequate lift due to the natural fixity of the continued on page 26  body language www.bodylanguage.net

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surgical Dr Viraj Tambwekar

tissues in the deeper plane.

At the exit point the blunt trocar is withdrawn slightly and the skin is pierced with the sharp tip of the cannula, which is pulled out slightly. The entire cannula now rests in the facial tissues, one hollow end coming out of the incision and the other through an exit point.

The Silhouette suture is now inserted into the cannula with the straight needle—from the cranial end—and as the tip of the needle appears at the exit point the cannula is pulled out through the exit point. The needle is now grasped and pulled out through the exit point dragging the suture behind it till the first cone appears at the exit point.

The distance between the zygoma and the exit point is measured to estimate the length of cone-bearing sutures to leave within the tissue. Keeping this distance as a guide, excess suture with cones is pulled out through the exit point. Some cones are therefore sacrificed to ensure that there are no cones in the area of the zygoma and the temporal area.

It is important that the cones remain only in the tissue to be lifted. The ‘extra’ extruded cones are discarded by cutting the suture just beneath the knot of the last cone that the surgeon decides to leave within the malar area.

The cranial end of the suture, swaged to the curved needle is grasped and gentle traction is applied in the cranial direction to ascertain that there is adequate fixation

of the malar tissue in the cones. A deep bite of the DTF through the mesh is now taken with the curved needle and further traction is applied to take away any slack in the suture.

The remaining sutures are also introduced in the same manner. At this stage of the procedure we have four to six sutures inserted into the face with cones only in the malar tissue and the cranial

as a reminder to the patient that a surgical procedure has been performed.

The patient is then sent home and advised not to do anything that will cause excessive stretching and pulling of the facial tissue and not to shower with water pouring down the face with force.

Sutures in the hairline are removed on the seventh day and regular follow-up is maintained. Any asymmetry or loosening of the lift is corrected with a retensioning of the lift by dissecting the knot free and placing it further cranially with the use of a loop 3-0 nylon suture.

This procedure is quick, easy to perform, can be done as an outpatient procedure—it has minimal morbidity and recovery time. The result of such a lift is not dramatic but is subtle and the patient looks refreshed. The result lasts between three to five years and can be repeated as desired.

This procedure can be combined with volumising treatments for the face as required and using botulinum toxin to relax muscles of facial expression to give a well-rounded result.

Since the scars are completely hidden, the procedure is very well suited for patients of South Asian ethnicity. Admittedly the procedure does not last as long as an open face lift but most patients accept the trade-off very well.

The treatment can be performed as an outpatient procedure, with minimal morbidity or recovery time

References 1. Tonnard P, Verpaele A, Monstrey S. et al. “Minimal access cranial suspension lift: a modified S-lift.” Plast Reconstr Surgery 2002. 109:2074-2086 2. Sulamanidze MA, Fournier PF, Paikidze TG et al “Removal of facial soft tissue ptosis with special threads.” Dermatol Surg 2002. 28:367-471 3. Isse N. “Elevating the midface with barbed polypropylene sutures.” Aesth Surg J 2005.

25:301-303 4. Biasaccia E, Razan K, Saap L, Rogachefsky A. “A novel specialized suture and inserting

28

ends firmly embedded in the DTF. Adjacent threads are grasped and firm traction is applied on them with a series of gentle tugs resulting in a visible lifting of the tissue through which these threads run. Any dimpling is corrected by releasing the cones with gentle manipulation with the finger tips and the threads are tied to each other over the prolene mesh with a surgeons knot. This procedure is repeated with the remaining set(s) of threads.

The wound is closed in layers with absorbable 3-0 sutures and the skin is closed with nylon or staples. The thread lift is now complete on one side and can be repeated on the opposite side.

Post-procedure Steri-strips are applied on the face along the line of insertion of the threads in a slight exaggeration of the lift. This serves

device for the resuspension of ptotic facial tissues: early results.” Dermatol Surg 2009.

35:645-650 5. Isse N. “Silhouette sutures for treatment of facial aging: facial rejuvenation, remodeling and facial tissue support.” Clin Plast Surg 2008. 35:481-486 6. Gamboa GM, Vasconez LO. “Suture suspension technique for midface and neck rejuvenation.” Ann Plast Surg 2009.

62(5) 7. Paul MD. “Complications of barbed sutures.” Aesth Plast Surg 2008. 32(1): 149 8. Garvey PB, Ricciardelli EJ, Gampper T. “Outcomes in

Dr Viraj S Tambwekar is a cosmetic surgeon at the Bombay Cosmetic Clinic, Mumbai, India E: drgetafix@gmail.com

threadlift for facial rejuvenation.” Ann Plast Surg 2009.

62(5): 482-485 9. Helling ER, Okpaku A, Wang PTH, Levine RA. “Complications of facial suspension sutures.”

Aesth Surg J 2007.

10. Sulamanidze MA, Paikidze TG, Sulamanidze GM et al.

“Facial-lifting with “Aptos” threads: featherlift.” Otolaryngol Clin North America 2005.

38(5): 1109-1117 11. Wu WTL. “Barbed sutures in facial rejuvenation.” Aesth Surg J 2004 24:582 12. Sasaki GH, KomorowskaTimek ED, Bennett DC, Gabriel A. “An objective comparison of

holding, slippage, and pull-out tensions for eight suspension sutures in the malar fat pads of fresh frozen human cadavers.”

Aesth Surg J 2008. 28(4) 13. De Benito J, Pizzamiglio R, Theodorou D, Arvas L. “Facial rejuvenation and improvement of malar projection using sutures with absorbable cones: Surgical technique and case series.” Aesth Plast Surg 2010.

DOI 10.1007/s00266-0109570-2 14. Mulholland SR, Paul MD. “Lifting and wound closure with barbed sutures.” Clin Plast Surg 2011. 38 521-535 DOI:10.1016/j.cps.2011.06.002

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non-surgical Dr Aamer Khan

The celebrity facelift Traditional facelifts can leave patients needing substantial recovery time. Dr Aamer Khan discusses an alternative, non-invasive solution for patients in the public eye or those requiring subtle rejuvenation of the face

T

here are a myriad of facelift procedures available, but the majority have one common link; they require going under the knife, involving general anaesthetic and cutting of the skin, which disrupts blood vessels leading to bruising and swelling. We also have to consider the downtime involved—some cases may take up to six months while everything settles after surgery.

In the current economic climate, when many people are battling to keep hold of their jobs, this just isn’t an option. Many women—and men—may also not be ready for the commitment or cost of a surgical procedure.

Many of our clients earn their living in the public eye so, more often than not, they do not want it to be obvious that they have had a treatment. The procedures we have developed for them are not meant to give the “wow factor” which would be obvious on camera and disastrous for continuity in a soap opera.

Fortunately, there are now many techniques for facial rejuvenation that don’t involve a scalpel; a multitude of minimally invasive techniques which have enabled us to achieve the results of a full facelift without the risks, downtime or, more importantly, the scarring associated with traditional facial surgery.

Combination The celebrity facelift was developed as more than just a toxin and filler treatment but to still achieve subtle results. Hyaluronic acid filler is used for volumisation rather than as a filler in the old style. Traditional use of toxins for the forehead and periorbital area is standard and the added extras come from the use

of radiofrequency for skin tightening and platelet rich plasma (PRP) for freshening the skin. These last two procedures are difficult to scientifically quantify but make a massive difference to patient satisfaction.

Using a combination of non-surgical procedures means we don’t have to change the structure of someone’s face, which surgery can often do. We can instead address other areas of the ageing face—for instance volume, skin tone and fine lines.

These combination treatments can be performed in less than an hour and are minimally invasive, with patients only needing a day or so to recover. If Fractora is used, this can increase downtime to up to four days depending on power levels and the patient’s skin. The treatments address four features of ageing: 1. Muscular change with dynamic lines and wrinkles, and brow ptosis.

2. Loss of volume in the mid face, with malar fat pad descent.

3. Loss of elasticity of the skin, resulting in lower facial descent and jowling.

4. Skin thinning and discolouration, leading to fine lines around the eyes and dull skin appearance.

Although originally developed as a procedure for celebrities, this treatment has now become a favoured option for our regular patients for the same reasons—they would like more than a standard toxin and filler but don’t want to appear to have had a treatment.

For an overall subtle rejuvenation, Azzalure was used to soften fine lines and wrinkles in the brow and periorbital areas, forehead and neck. Teosyal was used to contour and restore volume and Fractora treatment has tightened the jowls. Lastly PRP has been used to brighten and tighten the skin. body language www.bodylanguage.net

Dr Aamer Khan is a cosmetic doctor and the clinical and managing director of the Harley Street Skin Clinic, London W: harleystreetskinclinic.com E: aamer.khan@harleystreetskinclinic.com 31

aesthetic medicine Mr Kambiz Golchin

The Angel Lift Tailoring skin rejuvenation treatments to individual patients can improve clinical outcomes and patient satisfaction. Mr Kambiz Golchin describes the application of the Angel Lift, a therapy combining fractional CO2 laser with autologous fat grafting and concentrated platelet rich plasma

T

his decade has seen an explosion in the number of non-surgical aesthetic procedures carried out in the UK and worldwide. The main driving force behind this is the ever increasing demand by patients for less invasive procedures with less down time.

However less invasive treatments have traditionally been associated with less dramatic results.

As clinicians, we have an ever expanding array of aesthetic treatments at our fingertips with exciting emergent combination therapies—both surgical and nonsurgical techniques that are expanding both patient and clinician choice. These emerging treatment modalities incorporate a wide range of autologous biotherapies and innovative technologies that provide a spectrum of treatments that can be designed to the exact requirements of the patient. This is individualised health and aesthetic choice at its elegant best.

The convergence of new biotherapies and established technologies are providing a raft of new therapies that are rapidly becoming mainstream in skin rejuvenation, tissue reconstruction and tissue regeneration. For example the application of autologous concentrated platelet rich plasma (cPRP) and autologous fat grafts (AFG) have generated a great deal of excitement amongst the clinicians. However, the key to the successful integration of these technologies is science and the clinical techniques to optimise individual patient treatment and clinical outcomes.

Components The Angel Lift is a treatment using this aesthetic ‘alchemy’ concept, combining the use of autologous biotherapies with laser technologies. The critical component of this combination of therapies is clinical technique and a good understanding of the scientific principles. There are three treatment options for the Angel Lift: 1. Angel PRP, using cPRP which can be used on its own or in conjunction with body language www.bodylanguage.net

other non-surgical aesthetic procedure such as dermal fillers.

2. Angel Lift, combining fractional laser technology and concentrated platelet rich plasma. This is ideal for patients with the need for comprehensive skin rejuvenation including wrinkles, photodamage and loss of collagen.

3. Angel Lift Plus, incorporating autologous fat grafts with Angel Lift, specifically for older patients with volume loss, poor skin elasticity and photodamaged skin.

Defining which of the treatment components—autologous fat, platelet concentration or laser resurfacing—are more effective, remains difficult to quantify.

There is good experience to date with each individual treatment but the sum of the parts has a greater impact as there is a synergistic effect. Results obtained are more than encouraging, with a natural approach to turning back the years using patients’ own stem cells and growth

factors to aid the healing process and improve results.

In determining whether or not to provide this treatment, it is important to remember that the primary indicator of ageing is the appearance of skin. A major component of aged skin is the fragmentation of the dermal collagen matrix. This results from enzymes such as metalloproteinase impairing the structural integrity of the skin. Fibroblasts that produce collagen cannot attach to fragmented collagen. This inability to attach causes loss of support and the fibroblasts collapse, producing low levels of collagen and high levels of collagen degradation enzymes.

This creates a never-ending cycle which contributes to ageing skin.

Dissecting out the constituent components of the Angel Lift concept provides the scientific and clinical rationale behind the choice of the technologies and the autologous biotherapies involved in the procedures, specifically:

Above: before and four weeks after the Angel Lift Plus procedure, combining autologous fat grafts with fractional laser technology and concentrated platelet rich plasma 33

aesthetic medicine Mr Kambiz Golchin

• Fractionated CO2 laser resurfacing • Concentrated platelet rich plasma therapy • Autologous fat grafting (AFG) The fractionated CO2 laser is the gold standard approach to resurfacing the skin. The laser is used to ablate and resurface the epidermis, with the aim of improving overall skin tone, texture and appearance whilst simultaneously stimulating collagen formation at the level of the reticular dermis.

Research Described by Marx et al., platelets contain seven fundamental groups of protein growth factors, which are released to initiate wound healing. These include: three isomers of platelet derived growth factors (PDGFαα, PDGFαβ, PDGFββ); transforming growth factor (TGFβ1 and TGFβ2); vascular endothelial growth factors (VEGF); transforming growth factors; and insulin-like growth factors (IGF).

Work by Zuk et al. in the early 2000s provided us with insights into the potential of the adipose derived adult mesenchymal stem cells (AD-MSC), the importance of the progenitor cells within the stromal vascular fraction (SVF) in conjunction with the extracellular matrix (ECM) and their overall synergistic effect on the viability of the autologous fat grafts. This opened the way to new areas of reconstructive surgery as well as clinical regenerative therapies.

The latest research suggests that the role of progenitor cells is even more im-

G

portant than previously acknowledged and that the long-term survival of AFG is directly linked to the activation and proliferation of these progenitor cells within the SVF to differentiate into the target cells for replacement.

This intricate biological ballet occurs within a “cellular microenvironment of cell-to-cell/cell to matrix, and autocrine/ paracrine signaling,” and concentrated platelet rich plasma—rich in chemokines, cytokines and growth factors—is considered to optimise the cellular microenvironment.

Autologous fat grafts are at the vanguard of these clinical applications, particularly as adipose tissue is relatively easily and safely accessible. They simultaneously provide a rich source of heterogenous stromal stem cells capable of forming a ‘bioactive scaffold’ for various non-surgical and surgical aesthetic and reconstructive procedures as well as providing a volumising and filling effect.

As our knowledge and understanding of the use of fat grafts has expanded, new techniques have emerged in the harvesting of fat, based largely upon our increased understanding of the cellular activity and homeostatic environment required for the maintenance of the integrity of the harvested fat and therefore the viability of the fat graft.

Using concentrated PRP in combination with the progenitor SVF-enriched fluid improves the viability of the fat graft and survival rates are therefore improved, as described by Gentile et al. in their study

Mr Kambiz Golchin is a consultant ENT facial plastic surgeon, who practises at the Beacon Face and Dermatology clinic in Dublin, Ireland. E: dr@bfd.ie W: beaconfaceanddermatology.ie References 1. Marx, R.E. “Platelet Rich Plasma: Evidence to support its use.” Journal of Oral Maxillofacial Surgery 2004, 62:489-496.

2. Zuk, P.,A., Zhu, M., Ashjian, P. et al.

“Human Adipose tissue is a source of multi-potent stem cells.” MolBiol Cell 2002;13(12):4279-4295.

3. Strem, B.M., Hicok, H.C., Zhu, M. “Multipotential differentiation of adipose-derived stem cells.” Keio Journal of Medicine. 2005;54(3):132-141 4. Alexander, R.W. “Use of PRP in Autologous Fat Grafting.” Springer, Berlin 2010 5. Alexander, R.W., Harrell, D.B. “Autologous fat grafting: use of closed syringe microcannula system for enhanced autologous structural grafting.” Clinical, Cosmetic and Investigational Dermatology 2013:6 91-102.

6. Gentile P, Orlandi A, Scioli MG, Di Pasquali C, Bocchini I, Curcio CB, Floris , M ,Fiaschetti V, Floris R, Cervell V. “A comparative translational study: the combined use of enhanced stromal vascular fraction and platelet-rich plasma improves fat grafting maintenance in breast reconstruction.” Stem Cells Transl Med. 2012 Apr;1(4):341-51. doi: 10.5966/ sctm.2011-0065. Epub 2012 Apr 13.

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References: 1. Raspaldo H. J Cosmetic and Laser Therapy, 2008;10:134–142. 2. Fischer TC. Poster presented at EMAA, 1–3 October 2009, Paris. 3. Allergan Data on File (DoF), 2011.

4. Allergan Data on File (DoF) Marketing overview, 2011. Instructions and directions for use of JUvéDeRm® vOLUmA® with Lidocaine are available on request. Lidocaine does not affect the intrinsic performances of JuvéDERM® vOLuMA® and its safety profile, therefore, JuvéDERM® vOLuMA® data is representative of JuvéDERM® vOLuMA® with Lidocaine3

Date of Preparation: January 2013 UK/0008/2013a

Autologous fat grafts provide a rich source of stromal stem cells as well as a volumising and filling effect

on fat grafting in breast reconstruction.

The Angel Lift procedures are scientifically-based and technique-dependent, incorporating laser technologies and autologous biotherapies into a combination treatment package designed to improve clinical outcomes and provide clinicians and patients with a range of treatment options.

10/01/2013 12:38

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injectables Dr Daniel Sister

Hyaluronic acid can provide rejuvenation for age-related changes to the soft facial tissues, but not the underlying bone.

A combination approach using platelet rich plasma can target all aspects of facial ageing, writes Dr Daniel Sister

Combination therapy

T

he ageing process causes damage to the dermis and epidermis and decreases collagen, elastin, skin, fatty layers, cell numbers and the extra cellular matrix. This, in turn, leads to changes in skin texture, firmness, radiance, volume, flexibility and the appearance of wrinkles.

But the ageing process is more than this—it is a complex interaction between a variety of facial elements, which occurs like a domino effect. It happens in the four main facial layers: skin, fat, muscles and bones.

Fat decreases with age causing a deflated effect, which leads to volume loss. The hydrating and elastic functions of the skin don’t work as efficiently. The fibroblasts producing elastin, collagen and hyaluronic acid work better when they are under a degree of stretch. When the fat depletes, this stretch is lessened and the skin—not functioning as well—sags.

The bony facial skeleton changes, mainly the facial apertures. The size of the nose and the eye sockets increase by 20% with age and the infra orbital region physically moves backwards so the holes are not only bigger, but are also pushed back.

Hyaluronic acid For some time now, aesthetic practitioners have used hyaluronic acid (HA) with good results for skin and volume enhancement.

The presence of HA in the skin declines over the years, resulting in a loss of moisture, elasticity, firmness and volume.

Our bodies are in a continual state of rebuilding—new skin cells, for example, replace old ones every 20–30 days. Hyaluronic acid in skin tissue is normally broken down by hyaluronidase, and the rate of degradation can be increased by excess intake of riboflavin (B-2), ultraviolet radiation exposure or viruses. Signs of natural skin ageing become apparent with wrinkles, loss of volume in the cheeks and thinning lips.

Hyaluronic acid is a polysaccharide composed of alternating molecules of N-acetyl glucosamine and D-glucuronic acid, present in almost every cell in the human body. It can be found within collagen throughout the body but 50% of hyaluronic acid is concentrated in the skin. In the extracellular matrix, body language www.bodylanguage.net

hyaluronic acid performs a range of biological functions but mainly it regulates moisture, increases fibroblast activity and stimulates collagen synthesis.

Commercial sources of hyaluronic acid may come from cockscombs, chicken cartilage or microbial fermentation. When combined with water, it swells when in gel form, causing a wrinkle smoothing effect. In some cases, hyaluronic acid used in wrinkle fillers is chemically modified—cross-linked—to make it last longer in the body, as well as lengthen its effect.

Hyaluronic acid is an abundant matrix component and is degraded into polymers of various sizes. HR Choi of Seoul National University, suggested in a study that oligosaccharides of hyaluronic acid increase the differentiation of the epidermis. In addition, increased number of p63, a putative stem cell marker of the skin, showed that oligosaccharides of HA promote the survival of basal stem cells by modulating the expression of integrin-α6 and integrin-β1. Inflammation-induced small-sized oligosaccharides could therefore have beneficial effects on epidermal regeneration.

Unfortunately, the effects are temporary, short lasting and somehow HA does not re-create what is continuously disappearing. The ageing phenomenon of the face is not limited to collagen and fibroblasts but also to bone loss on which HA does not have any effect.

The size of the eye sockets increase by 20% with age and the infra orbital region moves backwards, so the holes are also pushed back 37

injectables Dr Daniel Sister

Using platelet rich plasma in combination with hyaluronic acid, we can counteract the ageing process with less HA and provide real rejuvenation on the bone structure and type I collagen. Above and below: before and after treatment with HA and PRP

HA and PRP Platelet rich plasma (PRP) is not a volumetric filler, but biological cell therapy with a patient’s own growth factors and enriched plasma.

I use the “Dracula kit” to harvest PRP which can then be used to improve the skin’s complexion, with visible changes within three to four weeks. Facial soft tissue augmentation can be carried out without synthetic filler or animal products and the dermis and epidermis can be augmented by enhancing the growth of keratinocytes, fibroblasts and deposition of collagen.

This improves skin tone, texture and colour and stops the bone resorption.

When a patient is injected with hyaluronic acid, we do recreate volume and by creating more tension we do not achieve more hydration and have no effect on the ageing process itself.

Using PRP, we have an active therapy against the ageing process.

We can obtain better skin tone, more fibroblasts and stop bone resorption but the volumetric gain is limited.

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For the treatment, I use a two way connector to mix hyaluronic acid (24mg/ml) within the PRP, in a ratio of 1/2ml of HA for three to four of PRP. This cocktail gives the best of both worlds. Firstly I inject very deeply, in contact to the bone to stop the bone loss, then at a medium depth to initiate fibroblast action.

This protocol enables me to counteract the facial ageing process with less HA and achieve a longer lasting effect, and real rejuvenation on the bone structure and type I collagen. It is important to note that we minimise the risks of irregularities, bumps and lumps—especially infra orbital and in the jaw line.

PRP can be used on its own, either superficially (mesotherapy, dermaroller) or deeper, either mixed with HA or alone. After chemical peeling or CO2 fractional lasers, PRP can be applied and massaged through the skin to accelerate the healing process.

Dr Daniel Sister is a cosmetic surgeon who practices in both London and Paris body language www.bodylanguage.net

conference FACE 2013

21–23 June

QEII Conference Centre, London

FACE 2013 The UK’s premier facial aesthetic conference and exhibition

T

he FACE conference is the UK’s largest scientific and business congress for practitioners of all specialities, business owners, clinic managers and marketeers working in the field of facial aesthetics.

Whether you work as a sole practitioner, or part of a large clinic team, FACE provides the best opportunity to learn about the latest treatments, procedures, scientific data, practical treatment tips, and marketing and business strategies all delivered by leading experts.

FACE 2013 will build on its heritage as the premier scientific forum devoted to facial aesthetics by combining it with the largest dedicated medical aesthetics exhibition ever seen in the UK. FACE features three days of unparalleled choice including:  Over 100 national and international expert speakers  Three day facial cosmetic injectables agenda  Two day aesthetic equipment agenda  Two day aesthetic therapists forum  Three day agenda focusing on business 40

and marketing  Skin forum with one day devoted to cosmeceuticals and one day concentrating on treatment of ageing skin  Three days of exhibitor workshops  The UK’s largest aesthetic exhibition Facial injectables agenda The most comprehensive agenda devoted to facial injectables ever seen in the UK. A host of national and international lecturers, trainers and clinical triallists will provide scientific updates and practical pearls to help you maximise results and minimise problems when using cosmetic injectables for total facial contouring.

Different techniques, new treatment approaches and concepts will be explored alongside practical demonstrations.

This year will feature a two hour session exploring the evidence for platelet rich plasma “Vampire Facelift” as a treatment for facial rejuvenation. If you are passionate about cosmetic injectables, FACE is an essential date for your diary.

You won’t find a better industry focused event anywhere in the world this year.

Equipment Agenda The use of lasers, radiofrequency, ultrasound and other aesthetic equipment for facial rejuvenation has exploded over the last decade, providing new approaches to the treatment of skin lesions and skin ageing. This two day agenda explores the latest equipment, protocols and treatment approaches to a wide range of different skin problems.

Aesthetic therapists forum The last 10 years have seen the role of beauty therapists, laser technicians and other non-medically qualified practitioners working in the aesthetics market rapidly evolve.

We’re excited to announce a new two day event tailored specifically to exploring advanced treatments that are performed by practitioners with different skill sets, interests and backgrounds. As this is the first time we have run this event, we are not limiting topics covered to just facial treatments, but are also encompassing laser and IPL hair removal and non-surgical body contouring, including practibody language www.bodylanguage.net

conference FACE 2013

cal demonstration sessions. Many of the lectures are delivered by therapists who have specialist expertise and experience in their chosen field. The aim is to share knowledge and stimulate debate amongst therapists working in this exciting and rapidly developing market.

Business agenda In a broader economic environment, that will continue to be challenging for the foreseeable future, mastering the wide range of skillsets required to market and run a business profitably is essential. This three day event explores a wide range of

topics related to the day to day challenges of making decisions and creatively marketing an aesthetic business. This provides a unique opportunity for clinic managers, marketeers and aesthetic business owners to learn from respective experts in their fields, network and share ideas with peers and come away with practical solutions to maximise profitability.

SKIN forum This two day forum will focus predominantly on topical non-injectable/non-device approaches to preventing and treating signs and symptoms of ageing skin.

Cosmeceuticals are an important adjunctive approach to in-clinic treatments, both to enhance results and as a valuable, additional revenue source. A scientific approach to selecting products from the bewildering array of topical treatments available today will be explored, alongside practical tips to effectively and safely treat darker skin types.

Our new website faceconference.com provides the latest information on the complete lecture programme, speakers and registration options. You can also follow us on twitter @face_ltd email info@ face-ltd.com or call 020 7514 5989.

Friday June 21st COSMETIC INJECTABLES

COSMECEUTICALS

BUSINESS

REGISTRATION & EXHIBITION 9:25–9:30 Conference Introduction

9:25–9:30 Conference Introduction

9:25–9:30 Conference Introduction

9:30–9:50 TBA

9:30–9:50 TBA

9:30–9:50 Phone Systems—to VOIP or not to VOIP

9:50–10:10 Anatomy Review of the Upper Third of the Face Focussing on Practical Tips to Maximise Outcomes and Minimise Adverse Events, Dr Ali Pirayesh

9:50–10:10 Moisturisers—Are They Really Effective? Dr Zein Obagi

9:50–10:10 Cloud Based Computing, Charles Southey

10:10–10:30 Skin Lightening Agents for Darker Skin Types, Dr Mukta Sachdev

10:10–10:30 Customer Relationship Management Platforms, Mark Lainchbury

10:30–10:50 Antioxidants—Skin Preparation Before Fractional Treatments, Dr Ros Debenham

10:30–10:50 Using Technology for Consultations, Dr Natalie Blakeley

10:50–11:00 Q&A

10:50–11:00 Q&A

10:50–11:00 Q&A

11:30–12:20 Periorbital Rejuvenation with Cosmetic Injectables— Literature Review and Toxin Demonstration, Dr Tim Flynn

11:30–11:50 Essential Antioxidants for Optimal Skincare Today, Dr Sandeep Cliff

11:30–11:50 Live Phone Answering Services, Gilly Dickons

11:50–12:30 The Role of Cosmeceuticals in Offering an Integrated Skincare Approach Within an Aesthetic Clinic, Dr Stefanie Williams

11:50–12:10 How to Train Your Receptionist to Maximise Impact of a Client’s First Experience of Your Business, Martyn Roe

12:30–12:50 Vitamin A—Best Formulation? Dr Zein Obagi

12:10–12:30 Sales Versus Medicine—Can You do Both?

Dr Richard Brighton Knight

10:10–10:50 How I do it: Expert`s Approach on Injectables for the Upper Face, Dr Sabine Zenker

COFFEE BREAK & EXHIBITION

12:20–12:50 Rhinomodulation Using Hyaluronic Acid Fillers, Dr Raj Acquilla

12:30–12:50 Dysmorphia Needs a Poster Girl, Deborah Sandler 12:50–13:00 Q&A

12:50–13:00 Q&A

12:50 - 13:00 Q&A LUNCH & EXHIBITION

14:30–14:50 Growth Factors and Cytokines for Injectable and Topical Skin Rejuvenation: The Concept, the Evidence and the Clinical Relevance, Dr Hema Sunderam

14:30–14:50 Botanicals—The Evidence, Dr Mervyn Patterson

14:30–14:50 Pay Per Click Marketing—The True Value, Ben Wightman

14:50–15:10 PRGF Endoret—15 Years of Clinical Research Using Plasma Rich in Growth Factors, Professor Bob Khanna and Dr Xabier Abad

14:50–15:10 New Advances in Topical Skin Protection: The Role of Sunscreen, Antioxidants and DNA Repair Enzymes, Dr Joe Lewis

14:50–15:10 Search Engine Optimisation

15:10–15:30 Treatment of Dark Circles Using PRP Thrombin Gel, Dr Alain Gondinet

15:10–15:30 Breakthrough Technologies—A Novel Tyrosine Amino Acid Derivative for Topica Wrinkle Filling, Dr Beth Briden

15:10–15:30 Web Design, Charles Southey

15:30–16:15 Comparison of Different PRP Systems, Panel Discussion

15:30–15:50 Topical Growth Factors and Stem Cells—Their Role in Cosmeceuticals, Dr Ahmed Al Qatani

15:30–15:50 E-Mail Marketing

16:15–16:25 PRP + Hyaluronic Acid Injection Demonstration, Dr Daniel Sister

15:50–16:10 Compliance With the New EU Cosmetic Regulation No. 1223/2009: Ensuring Your Product is Safe, Compliant and Genuine, Cliff Betton

15:50–16:10 Google Analytics and Heat Maps, Adam Hampson

16:25–16:35 Treating Tear Troughs with PRP Demonstration, Dr Hema Sunderam 16:35–16:45 “The Angel Lift” PRP Demonstration, Mr Kambiz Golchin

16:10–16:45 Which Skincare Ingredient Gives You the Best Bang for Your Buck! Dr Joe Lewis, Dr Zein Obagi and Dr Beth Briden

16:10–16:30 Link Building, Alexander Bodikian 16:30–16:45 Q&A

16:45–17:15 Drinks and Canapés 17:15–19:00 An Evening with Dr Nick Lowe body language www.bodylanguage.net

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conference FACE 2013

Saturday June 22nd COSMETIC INJECTABLES

EQUIPMENT

SURGICAL

REGISTRATION & EXHIBITION 8:15–9:00 Open Plenary Session—Review of Bruce Keogh Cosmetic Surgery Report and CEN European Standards for Cosmetic Surgery Update, Mike Regan and Dr Andrew Vallance Owen 9:25–9:30 Chairman’s Introduction

9:25–9:30 Chairman’s Introduction

9:25–9:30 Chairman’s Introduction

9:30–10:10 Facial Contouring Workshop, TBA

9:30–9:50 Literature Update for the Use of Lasers/IPL for Vascular/ Pigmented Lesions, Professor John Harper

9:30–9:50 Stem Cells for facial Soft Tissue Augmentation—Latest Developments and Clinical Evidence, Mr Ali Ghanem

9:50–10:10 Practical Tips for Treating Common Vascular Lesions, Professor John Harper, Dr Neil Walker

9:50–10:10 Micro Fat Grafting to the Face—Artistic Concepts, Original Technique and Results, Dr Fahd Bensamid

10:10–10:30 What Treating Over 50,000 Patients Has Taught Me, Dr Brian Newman

10:10–10:25 Squeeze and Suck—A New Technique for Harvesting Fat Grafts, Mr Shailesh Vadodaria

10:30–10:50 Pain Matters: Innovations in Topical Anaesthesia to Enhance Patients Satisfaction Under Aesthetic Treatments, Dr Matteo Tretti Clementoni

10:25–10:45 Dealing with Problems and Complications of Fat Transfer, Mr Rizwan Alvi

10:50–11:00 Q&A

10:45–11:00 Q&A

10:10–11:00 What Women Want! Dr Tracey Mountford and Dr Beatriz Molina

COFFEE BREAK & EXHIBITION 11:30–12:10 Tear Trough Treatment—The Correct Approach, Mr Raman Malhotra

12:10–12:50 A 3 Dimensional Aesthetic Approach to the Ageing Process, Dr Danny Vleggaar

12:50–13:00 Q&A

11:30–11:50 Acne Scarring Treatment Using a Powered Needling Device, Dr Tony Chu

11:30–11.45 Cross Cartilaginous Approach to Rhinoplasty, Mr Rajan Uppal

11:50–12:10 Advance Acne & Scar Management Using Revolutionary Fractional Radiofrequency Microneedling, Dr Un-Cheol Yeo

11:45–12:00 Open Tip Rhinoplasty for Improving Precision of Nasal Sculpturing, Mr Shailesh Vadodaria

12:10–12:30 Fractional Ablative (RF) and Acoustic Pressure Wave Technology for Trans-Epidermal Delivery in the Treatment of Atrophic and Hypertrophic Scars, Dr Mario Trelles

12:00–12:20 The Forgotten Art of Closed Rhinoplasty, Dr Raj Kanodia

12:30–12:50 CO2 Lasers—Treatment of Really Unusual Cases, Dr Neil Walker 12:50–13:00 Q&A

12:20–12:35 Ear Surgery in Private Practice, Mr Walid Sabbagh 12:35–12:45 Correction of Prominent Ears Under Local Anaesthetic, Mr Shailesh Vadodaria 12:45–13.00 Q&A

LUNCH & EXHIBITION 14:30–14:50 Pearls of Anatomy in the Lower Face to Improve Your Injection Technique: The Magic Touch for Reducing Risk and Better Results, Mr Rajiv Grover 14:50–15:35 Peri-Oral Rejuvenation with Cosmetic Injectables— Literature Review and Lip Contouring Demonstration, Dr David Eccleston 15:35–16:00 Nasolabial and Melomental Folds—Giving Patients the Best Bang for Their Buck, Dr Tim Flynn

16:00–16:30 Considerations of Nasal Contouring with Injectables, Mr Santdeep Paun

14:30–14:50 Advanced Facial Contouring and Tightening Using Radiofrequency, Dr Raj Acquilla

14:30–14:45 One Stitch Facelift, TBA

14:50–15:10 Skin Tightening update RF, Laser and Ultrasound: Where are we? Dr Stephen Mulholland

14:45–15:00 Quill MACS Facelift—Evolution of MACS, Mr Brent Tanner

15:10–15:30 Multi-Source, Phase Controlled Radiofrequency: The Latest Clinical Developments in Fractional Skin Resurfacing and Microneedle Skin Remodeling, Dr Yoram Harth

15:00–15:15 I-Guide Necklift, Mr Taimur Shoaib

15:30–15:50 Ultrasound for Facial Rejuvenation, Mr Alex Karidis

15:50–16:10 Combination Approaches to Skin Tightening, Dr Mukta Sachdev 16:10–16:30 Q&A

15:15–15:30 Surgiwire for Nasolabial Release, Mr Adrian Richards 15:30–15:45 Facial Thread Lift in Asian Patients, Dr Viraj Tambwekar 15:45–16:00 The Volumising Facelift: Adding More Than Just Volume, Mr Rajiv Grover 16:00–16:15 Radiofrequency Assisted Facelift, Dr Stephen Mulholland 16:15–16.30 Q&A

COFFEE BREAK & EXHIBITION

17:00–17:30 TBA, Dr Fred Brandt

17:00–17:20 Practical Tips for Optimal Maintenance of Your Laser, David Base

17:00–17:15 Aesthetic Volume Balance in the Periorbital Region: To Inject or to Operate? Mr Jonathan Britto

17:20–17:40 Laser Safety—Avoiding and Dealing with Complications, Dr Sean Lanigan

17:15–17:30 Eyelid Rejuvenation Techniques, TBA

17:40–18:00 Combination of Injectables and RF Energy for Total Facial Rejuvenation, Dr Ines Verna

17:30–17:45 Extended Lower Eyelid Blepharoplasty Designed for Elegant Restoration of the Mid Face, Mr Bijan Beigi 17:45–18:00 TBA

17:30–18:15 FACE of the Future: Hot Topics Panel Discussion, Dr Michael Kane, Dr Tim Flynn, Mr Rajiv Grover, Dr Fred Brandt 18:00–18:15 Q&A

18:00–18:15 Q&A

AESTHETIC INDUSTRY SUMMER BALL

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conference FACE 2013

AESTHETICIANS

BUSINESS REGISTRATION & EXHIBITION

9:25–9:30 Chairman’s Introduction

9:25–9:30 Chairman’s Introduction

9:30–9:50 Laser/IPL - Fundamental Principles in Laser Hair Removal, Dr Elizabeth Raymond Brown

9:30–9:50 Essential Policies, Protocols and Procedures for an Aesthetic Clinic, Paul Stapleton

9:50–10:10 Laser Hair Removal: Avoiding and Managing Complications, Dr Pablo Naranjo

9:50–10:10 Consent—What is and isn’t Valid, Kate Williams

10:10–10:30 Electrolysis vs Laser for Transgender Clients, Julie Ann Hawkes

10:10–10:30 Medical Indemnity Insurance, Janine Revill

10:30–10:50 Patient Consent and Record Keeping, Sheila Godfrey

10:30–10:50 Medical Waste—Legal Requirements and Contracts, TBA

10:50–11:00 Q&A

10:50–11:00 Q&A COFFEE BREAK & EXHIBITION

11:30–11:50 Facial Peels—What Can be Used and Which Conditions Treated? Sally Durant 11:50–12:10 Hydradermabrasion—Skin Health for Life; Concept and Demonstration, Anna Silsby 12:10–12:30 LED Systems and Their Role in Aesthetic Practice, TBA

11:30–13:00 Decoding Social: Relevant Strategies and Viable Tactics for Aesthetic Clinics, Wendy Lewis

12:30–12:50 Using Ultrasound For Deep Skin Cleansing, TBA 12:50–13:00 Q&A LUNCH & EXHIBITION 14:30–14:50 Dry Needling Techniques, Dawn Forshaw

14:30–14:50 Video Marketing, Steve Handisides

14:50–15:10 Medical Tattooing, Cathy Brown

14:50–15:10 Referral Marketing, Harry Singh and Smita Mistry

15:10–15:30 Advanced Electrolysis, Elaine Stoddart

15:10–15:30 Using Psychology in Aesthetic Practice to Increase Revenue, Jason Williams

15:30–15:50 Medical Skin Needling Using Rollers, Debbie Thomas

15:30–15:50 Text Marketing, TBA

15:50–16:10 Skin Lesions—What you Shouldn’t Treat, Dr Anna Chapman

15:50–16:10 Developing a Clientele of Elegance, Richness, and Longevity, Michael Polokov

16:10–16:30 Panel Discussion

16:10–16:30 Panel Discussion

Join us for a taste of the prohibition era at the Aesthetic Industry Summer Ball. It has taken almost a century to restore flavour to the wine and class to the cocktails, so head to The Brewery to celebrate life’s pleasures of fine wine, exquisitely crafted cocktails, beautifully prepared food and impeccable sipping spirits. Those who shun the night, we tip our hat. To those who shine after dusk, we offer you a warm embrace, a roof over your head and a jar to raise to an evening to remember.

P lat i n um S p on sorS :

COFFEE BREAK & EXHIBITION 17:00–17:20 The Medical Aesthetician in a Canadian MedSpa: Optimising Safety, Efficacy and Profitability, Dr Stephen Mulholland

17:00–17:20 Recruitment Strategies, TBA

17:20–17:40 Digital Skin Analysis Systems—How to Use Them to Increase Sales, Louise Taylor

17:20–17:40 Essential HR Policies, TBA

17:40–17:50 The 10 minute Core of Knowledge, Why You Need to Know More, Paul Stapleton 17:50–18:00 Advanced Online Training Programmes for Therapists, Sally Durant 18:00–18:15 Q&A

GOL D S pon sorS :

17:40–18:00 Appraisal Systems, TBA

18:00–18:15 Q&A

S ILVER S pon sor:

S ILVE R AN D SK IN S ponsor:

AESTHETIC INDUSTRY SUMMER BALL

body language www.bodylanguage.net

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conference FACE 2013

Sunday June 23rd COSMETIC INJECTABLES

EQUIPMENT

SKIN ANTI-AGEING

REGISTRATION & EXHIBITION 9:30–9:50 Biophysical Characteristics of Hyaluronic Acid and Their Relevance to a 3D Volumetric Approach, Dr Hema Sundaram

9:30–9:50 Skin Rejuvenation: To Ablate and Fractionate, is it the Best? Dr Stephen Mulholland

9:30–9:50 Treatment Approaches in Different Fitzpatrick Skintypes, Dr Tapan Patel

9:50–10:10 Botulinum Toxins—Dealing with Patient Complaints, Side Effects, and Adverse Events, Dr Christopher Rowland Payne

9:50–10:10 Fractional CO2 Laser Together with the Simultaneous Delivery of Radio Frequency, Professor Paolo Bonan

9:50–10:10 Advances in the Treatment of Ethnic Skin, Dr Mukta Sachdev

10:10–10:30 Dermal Fillers—Dealing with Patient Complaints, Side Effects and Adverse Events, Dr Daniel Cassuto

10:10–10:30 Q-Switch Technology for Non-Ablative Rejuvenation, TBA

10:10–10.30 How I Treat Ethnic Skin, Dr Zein Obagi

10:30–10:50 Hyaluronidase—The Why, When and How, Helena Collier

10:30–10:50 Dramatical Absorption of Topicals With 1927 Diode Laser, Dr Sunil Chopra

10:30–10:50 UV Light, Skin Ageing and Skin Health—Cellular and Immunological Damage and Management, Dr Marina Venturini

10:50–11:00 Q&A

10:50–11:00 Q&A

10:50–11:00 Panel Discussion and Q&A COFFEE BREAK & EXHIBITION

11:30–11:50 The Past, Present and Future of Botox, Dr Mitchell Brin

11:30–11:50 Empowering Acne Patients—Latest Clinical Results with Home use Devices, Dr David Eccleston and Dr Johanna Ward

11:30–11:50 Approaches to Peel Choice, Dr Beth Briden

11:50–12:10 The Psychology of Medical Aesthetics—Gauging Reality for Natural Outcomes, Dr Kate Goldie

11:50–12:10 Advances in Skin Regeneration Using a Unique Nitrogen Plasma Device, Dr Fabrice Rogge

11:50–12:10 TBA, Dr Julia Hunter

12:10–12:30 Intercontinental Standards of Beauty—The Beautiful Asian vs The Beautiful Caucasian Face, Dr Michael Kane

12:10–12:30 Skin Rejuvenation and Scar Repair—Skin Needling Treatments and New Electrical Medical Devices, Dr Sabine Zenker

12:10–12:30 TBA, Dr Zein Obagi

12:30–12:50 TBA

12:30–12:50 LED Systems—Their Place in a Medical Aesthetic Practice, Dr Tapan Patel

12:50–13:00 Q&A

12:50–13.00 Q&A

14:30–15:00 Bruxism—Botulinum Toxin; to Treat or Not to Treat?

Prof Bob Khanna and Dr Martin Kinsella

14:30–14:50 Transdermal Drug Delivery Devices and Their Future, Dr Mukta Sachdev

14:30–14:50 Skin and Oxidative, DNA and Glycation Damage and it’s Treatment, Dr Hema Sunderam

15:00–15:20 3D Imaging on Volumetric Changes After Treatment with Polycaprolactone, Dr Maria Angelo-Khattar

14:50–15:10 TBA

14:50–15:10 Hormone Balance for Ageing Skin, Dr Terry Loong

15:20–15:40 Focussed Cold Therapy for Wrinkle Reduction, Dr Daniel Cassuto

15:10–15:30 Ablative and Non-Ablative Comprehensive Paradigm for Facial Skin Rejuvenation, Dr Mario Trelles

15:10–15:30 Future Proof Your Skin—How Nutrition and Lifestyle Changes can Slow Down the Clock, Dr Stephanie Williams

15:40–16:00 TBA

15:30–15:50 Minimally Invasive Necklift Using Lasers, Dr Salvatore Pagano

15:30–15:50 TBX

16:00–16:20 TBA

15:50–16:10 TBA, Dr Rupert Gabriel

15:50–16:10 Choosing a Cohesive Anti-Ageing Product Range for Your Clinic, Wendy Lewis

16:20–16:30 Q&A

16:10–16:30 KineticLift—A New Approach for Non-Invasively Lifting Facial Structures, Dr Sabine Zenker

16:10–16:30 Q&A

12:30–13:00 Panel Debate and Audience Debate

LUNCH & EXHIBITION

16:30–17:00 MEETING CLOSE

EXHIBITOR WORKSHOPS Friday 21st June Keats Room 09:30–10:30 Zeltiq, CoolSculpting: A Revolutionary Approach to Non-Surgical Fat Reduction, Tracy Mountford 11:30–12:30 SkinBrands, White Balance Click: 7 routes to Skin Lightening, Elliot Isaacs 14:30–15:30 SkinBrands, Beyond Brightening, Sally Durrant 15:45–16:45 Galderma, Going Beyond Skin Hydration to Skinboosting—New Techniques and Innovations to Enhance the Patient Experience, Dr Toni Phillips Wordsworth Room 11:30–12:30 AesthetiCare, TBC 14:30–16:45 Merz Aesthetics, TBC Wesley Room 09:30–16:45 Sinclair Pharma, TBC

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Shelley Room 09:30–11:00 Invasix, Masterclass in BodyTite & Fractora with Q&A Session, Dr Stephen Mulholland 11:30–12:30 Invasix, European Launch of Inmode, Dr Stephen Mulholland 14:30–15:30 Silhouette Lift, Silhouette Soft Sutures Workshop, TBC Saturday 22nd June Caxton Lounge East 09:30–17:30 ZO Skin Health European Symposium, Learn the philosophy and methods for achieving optimum skin health, Dr Zein Obagi, Dr Raj Acquilla, Miss Jonquille Chantrey, Dr David Eccleston, Dr Rachael Eckel Keats Room 09:30–10:30 Invasix, Inmode MD—The Future of Aesthetic Treatments That Will Grow Your Clinic, TBC 11:30–12:30 Aesthetic Source, Managing Highly Potent

Cosmeceuticals and Peels, Dr Beth Briden 14:30–15:30 AQTIS Medical, Ellansé Hands—The only Dermal Filler Specifically Designed for Hand Rejuvenation, Dr Martyn King and Sharon King 15:30–16:30 BTL Aesthetics, TBC 17:00–18:00 Schuco, TBC Wordsworth Room 09:30–13:00 Merz Aesthetics, TBC 09:30–13:00 Myoscience, TBC 15:30 – 16:30 AesthetiCare, The Latest Treatments and Techniques from EndyMed 3DEEP, Mr Chris Inglefield, Dr Yoram Harth, Dr Sach Mohan, Mrs Alison Telfer Wesley Room 09:30–10:30 Healthxchange, Workshop with Global Leader in Radio Frequency Treatment, Dr Un Cheol Yeo 11:30–12:30 iConsultAesthetic, Maximising Your Consultations With iConsultAesthetic, Richard Crawford-Small & Guests

body language www.bodylanguage.net

conference FACE 2013

AESTHETICIANS

BUSINESS REGISTRATION & EXHIBITION

9:30–9:50 Demonstration of “Rejuveneyes” Fractional Radiofrequency for Skin Rejuvenation, TBA

9:30–9:50 Accounting Platforms, TBA

9:50–10:10 Treatment of Vascular and Pigmented Lesions with Laser and IPL—What Should we Treat and How? Ruth Breeden

9:50–10:10 Choosing an Accountant, TBA

10:10–10:30 TBA

10:10–10:30 Banks and Borrowing, TBA

10:30–10:50 Radiofrequency for Skin Tightening, TBA

10:30–10:50 Lease Finance, TBA

10:50–11:00 Q&A

10:50–11:00 Panel Discussion and Q&A COFFEE BREAK & EXHIBITION

11:30–12:10 Understand Your Products by Understanding Their Active Ingredients, Dr Zein Obagi

11:30–11:50 Concept Planning for Developing a Clinic, Michael Polokov 11:50–12:10 Business Planning Systems, TBA

12:10–12:30 TBA

12:10–12:30 Business Success Habits - Building a Clinic That Produces Results, Kurt Won

12:30–12:50 Narrow Your Search for Effective Topical Anti-ageing Ingredients—What Really Works? Dr Joe Lewis

12:30–12:50 Business Consultants—Why Use Them?

Richard Crawford Small

12:50–13:00 Q&A

12:50–13.00 Q&A LUNCH & EXHIBITION

14:30–14:50 Non-Surgical Body Contouring—The Market Opportunity, Vanessa Bird

14:30–14:50 Copywriting and It’s Importance, TBA

14:50–15:10 Ultrasound and Mechanical Massage, Daisy Compton

14:50–15:10 Graphic Design—Key Principles, TBA

15:10–15:30 Cryolipolysis, TBA

15:10–15:30 Tracking ROI on the Web, TBA

15:30–15:50 Low level Laser Therapy, Rita Vandaele

15:30–15:50 Radio Advertising—The Benefits, TBA

15:50–16:10 TBA

15:50–16:10 Public Relations, Tingy Simoes

16:10–16:30 Q&A

16:10–16:30 Q&A 16:30–17:00 MEETING CLOSE

14:30–15:30 Vitalmed, TBC 15:30–16:30 Solta Medical, Non-invasive Approach to Facial Lifting, Dr Radmilla Lukian Shelley Room 09:30–13:00 Syneron Candela, TBC 14:30–15:30 Lifestyle Aesthetics, Innovation For Tear Trough Rejuvenation, Dr Kieren Bong 15:30 – 16:30 Lifestyle Aesthetics, Non-Surgical Rhinoplasty, Dr A Farhan Haq Sunday 23rd June Keats Room 12:00–13:00 Elixir Aesthetics, Introduction & Demonstration of RRS—Injectable Meso & Bio Revitalisation products, including RRS Tensor Lift, Dr Phillipe Deprez and Dr Evgeniya Ranneva 14:30–16:30 Invasix, Inmode MD—The Most Comprehensive Collection Of In-Demand Aesthetic Applications, Dr Stephen Mulholland

body language www.bodylanguage.net

Wordsworth Room 12:00–13:00 AesthetiCare, TBC 14:30–16:30 Uma Jeunesse, Advanced Injection Techniques With Uma Jeunesse, Peter Sharma and Dr Antonino De Pasquale Wesley Room 09:30–13:00 Sinclair Pharma, TBC 14:30–15:30 Energist, TBC

Please visit faceconference.com for the full programme of Exhibitor Workshops and registration options. All agendas are correct at the time of printing but are subject to change prior to the event. Please check the website for up to date information.

Speakers include: Dr Danny Vleggaar, is a dermatologist practicing at the Centre Dermo-Cosmetique in Geneva, Switzerland. He has extensive experience in the use of injectable fillers and is an expert in the use of poly-L-lactic acid.

Dr Michael Kane, is a consultant plastic surgeon, with a private practice in New York, USA. He has taught thousands of physicians injection technique for toxins and fillers and is the author of The Botox Book.

Mr Rajiv Grover, is a consultant plastic surgeon and president of The British Association of Aesthetic Plastic Surgeons (BAAPS).

He has published over 60 book chapters and journal articles in the UK and USA. Professor Nick Lowe, is a consultant dermatologist and clinical professor of dermatology. He has been the principal investigator on over 200 clinical research projects in the last 25 years and has pioneered toxin research.

Dr Mario Trelles, is a consultant plastic, aesthetic and reconstructive surgeon and president of The European Society Laser Aesthetic Surgery (ESLAS), the Spanish Laser Society (SELMO) and the European Laser Association (ELA).

Dr Fredric Brandt, is a cosmetic dermatologist with practices in Coral Gables and Manhattan, USA. He is a leader in injectables and pioneer in cosmetic dermatology and as such is a sought after physician.

Dr Zein Obagi, is a consultant dermatologist and a leading authority on skin rejuvenation. He is the ZO Skin Health Inc. founder and medical director and develops new skincare treatments and protocols.

Dr Christopher RowlandPayne, is a consultant dermatologist at The London Clinic. He is currently secretary-general of the European Society for Cosmetic and Aesthetic Dermatology at Universita Roma-Marconi.

45

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surgery Miss Zahida Butt

Easy on the eye While the eyes and periorbital tissues play an important part in the perception of facial beauty, they are one of the first areas to show signs of ageing.

Miss Zahida Butt discusses the benefits and techniques of upper and lower lid blepharoplasty surgery

B

lepharoplasty has become one of the most commonly requested and performed aesthetic procedures in recent years. With a developing focus on peri-orbital and brow ageing, upper eyelid surgery has gained much interest.

Lower blepharoplasty, on the other hand, has been referred to as one of the more challenging procedures in plastic surgery.

In terms of anatomy, the upper and lower eyelids are separated into the anterior lamella with skin and muscle—orbicularis muscle in the lower eyelids, and orbicularis, levator and Muller’s muscles in the upper eyelids—and the posterior lamella, comprising the tarsus and conjunctiva. The orbital septum comprises the middle lamella and separates the orbital fat from the anterior lamella of the eyelids.

Orbital fat protrusion into the lower

body language www.bodylanguage.net

eyelid occurs secondary to weakened septae within the orbital septum. It is more apparent with age through the thinning of the tissues, more inferiorly in the area of the tear trough. By identifying the anatomical abnormalities and choosing the proper techniques, surgeons can achieve satisfactory eyelid rejuvenation, providing a natural look while preserving function and minimising complications.

Recognition of the specific features of the patient’s aesthetic concerns during pre-operative evaluation will help to focus on the patient’s understanding and expectations of realistic surgical results.

Upper eyelid surgery The upper eyelid is compounded by ageing—the brows tend to descend and progressive relaxation of the tissues occurs, leading to larger folds of the upper eyelid skin. Traditional blepharoplasty has often

involved the excision of both lax skin and muscle with excessive removal of fat.

Today, it is better to take a more conservative approach which is sufficient for most patients, with removal of lax skin but little or no removal of fat.

The evaluation of the upper eyelid must include the eyebrow. Brow ptosis should be corrected to achieve repositioning of heavy eyebrow skin, which may be compensated by frontalis action to keep the eyebrows above the orbital rim. Ageing causes the eyebrow fat to descend over the upper lid giving it a full appearance.

A common pitfall of upper eyelid blepharoplasty is the failure to correct the position of the eyebrow when planning the surgery. In many cases, much of the excessive skin present in the upper eyelid is produced by inferior displacement of the eyebrow that occurs with ageing.

These cases should be managed with 47

surgery Miss Zahida Butt

a combined upper eyelid blepharoplasty and forehead lift. One way of avoiding this mistake is to consider all the excess skin outside of the orbit caused by inferior eyebrow descent compared to the excess skin on the eyelid itself. To correct the upper eyelid skin excess with blepharoplasty alone and obtain a satisfactory result, the incision may need to be extended laterally.

By identifying the anatomical abnormalities and choosing the proper techniques, surgeons can achieve satisfactory eyelid rejuvenation. Above: Three patients before and after blepharoplasty 48

Lower eyelid surgery Lower lid blepharoplasty is the cornerstone of cosmetic rehabilitation of the lower eyelid and midface. A youthful appearance is defined by a harmonious continuum between the lower eyelid and cheek. A prominent nasojugal fold (tear trough), facial deflation and pseudoherniation of orbital fat into the lower eyelid characterise the ageing face. The perceived eyelid-cheek junction in the young is defined by the lower eyelid crease which descends with ageing.

The tear trough is an external manifestation of the orbicularis retaining ligament and its prominence is enhanced by pseudoherniation of the orbital fat and descent of the deflated midface. While the tear trough deformity may appear in youth, exacerbation is common with age and frequently generates cosmetic complaints.

Patients evaluated for lower eyelid blepharoplasty have complaints of lower eyelid â&#x20AC;&#x153;bagsâ&#x20AC;?, a tired appearance or dark circles under the eyes. The shadow within the tear trough groove is generally the basis for dark circles perceived by ageing patients. Treatment is performed to re-contour the lower eyelid, lessen the prominence of tear trough deformity and smooth and tighten the peri-ocular skin.

As we have developed a greater appreciation for the anatomic and aesthetic consequences of ageing, peri-ocular rejuvenation techniques have followed suit.

Techniques of lower eyelid blepharoplasty have evolved from simple subtractive techniques to volume enhancement through orbital fat repositioning and fat grafting.

Traditional lower lid blepharoplasty described a subtractive approach to pseudoherniation of orbital fat into the lower eyelid. Surgical techniques were directed at orbital fat sculpting in an attempt to level the pre-septal portion of the eyelid with the inferior orbital rim. The approach to subtractive lower lid blepharoplasty can be either transcutaneous or transconjunctival.

Transconjunctival lower eyelid blepharoplasty which only removes fat tends to body language www.bodylanguage.net

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surgery Miss Zahida Butt

leave the skin looking more wrinkled and redundant—this can be addressed with an ablative carbon dioxide, erbium laser or a medium depth peel. However, to improve the aesthetic benefits of subtractive lower lid blepharoplasty, more conservative techniques have been developed that involve fat preservation with fat repositioning, management of the tear trough and augmentation of the orbital rim.

Lower lid blepharoplasty with orbital fat repositioning not only provides a “filler” for the base of the tear trough groove, but also appears to elevate the eyelid-cheek junction. Fat repositioning is carried out by mobilising the medial and central fat pads of the lower lid.

A subperiosteal pocket is then created inferiorly and medially. The fat pads are repositioned into the subperiosteal pocket with internal sutures. This helps to elevate and lessen the prominence of the tear trough. Because fat repositioning decreases the pre-septal eyelid volume and vertically elevates the eyelid-cheek junction, increased anterior lamella redundancy is a common consequence causing lower eyelid excess skin and wrinkling.

Tightening of the lower eyelid may be necessary for an optimal aesthetic result, which can be addressed with either direct skin excision or skin resurfacing. Either a medium depth chemical peel, such as 30% trichloroacetic acid (TCA), or laser skin resurfacing with a CO2 or Erbium YAG laser can be effective. Lateral canthopexy is performed in all cases of significant lower eyelid laxity or in cases requiring skin excision.

The goal of the lower eyelid rejuvenation is to achieve the desired cosmetic outcome without compromising structure and function. Conservative skin removal is one of the most important steps to avoid complications in surgery—overresection is one of the most common mistakes during lower lid blepharoplasty.

After the flap is elevated and re-draped in a superior and lateral vector, the excessive skin is usually much less than predicted because of the contraction caused by scarring and healing.

Lower lid retraction most commonly occurs after scar contraction of the septum and posterior lamella to the orbital

rim. To avoid lower lid retraction, several surgeons have recommended less invasive lower lid blepharoplasty techniques. Attention must be paid to features associated with increased risk of postoperative lid retraction including, pre-operative scleral show, canthal laxity, prominent eyes and patients presenting for repeat blepharoplasty several years later. Adding canthal support to the lower lid blepharoplasty when indicated may reduce the incidence of lid retraction in high risk patients.

Lower eyelid blepharoplasty is commonly combined with eyelid blepharoplasty, brow lift, ptosis repair, mid-face lift or other facial aesthetic procedures to provide the desired surgical result.

Complications Common complaints following upper or lower eyelid blepharoplasty can include ocular irritation and blurry vision associated with ocular surface irregularities or swelling. Reverse ptosis with lower eyelid riding above the inferior corneal limbus may be initially bothersome to patients after transconjunctival approaches due to lower eyelid retractor release, but resolves within several weeks.

Lower eyelid ectropion may be seen in the early postoperative period and generally responds to temporising measures.

Ectropion may rarely require a formal repair with lateral canthoplasty or full thickness skin grafting.

Oedema, eccyhmosis and conjunctival chemosis are universal in the postoperative period. If excessive or prolonged, a short course of oral corticosteroids— 40mg prednisolone initially, tapering over three days—may be effective in shortening the time course of oedema.

The repositioned fat in lower lid blepharoplasty can become swollen and hard about two weeks after surgery where it crosses the orbital rim. This is normal and will resolve in around two weeks.

Diplopia is rare with proper surgical technique and identification of the inferior oblique muscle during dissection. Visual loss caused from orbital haematoma is also a rare complication. Appropriate surgical technique with meticulous haemostasis is necessary.

Avoidance of medications with anti-

Our goal is to achieve the desired cosmetic outcome without compromising structure or function 50

coagulant properties and appropriate control of hypertension is recommended for all patients undergoing lower eyelid blepharoplasty. Treatment of orbital haematoma causing visual loss may involve emergency orbital evacuation or lateral canthotomy with cantholysis. Infection is another rare complication following eyelid surgery. Most infections are limited and superficial, responding to topical and oral antibiotics. An infection requiring more aggressive treatment, such as hospitalisation or emergency treatment, is exceedingly rare.

If too much excess skin is inadvertently removed in either upper or lower lid blepharoplasty, the patient can have long term disabling dry-eye problems which may need a lower lid full thickness graft.

Post-operative care No dressings are used but iced compresses to the eyelid during the first three days are advocated, as they can reduce oedema and ecchymosis. It is advisable to provide ophthalmic lubrication to the cornea and conjunctival sac until the orbicularis muscle tone has returned and the risk of lagophthalmos (inability to close eyelids) during sleep has disappeared.

Artificial tears can be used three or four times a day and ointment preparations can be used at night. Antibiotics are not necessary but are widely used. Sutures are removed on the fifth post-operative day for upper lids and tenth post-operative day for lower lids.

This technique of fat repositioning lower eyelid blepharoplasty is technically straightforward, and effectively deals with fat pseudoherniation in the lower eyelid and increased prominence of the tear trough in facial ageing. This approach to lower eyelid blepharoplasty provides a safe and effective surgical technique to resolve ageing concerns in the lower eyelid and integrates nicely with other techniques of midface rehabilitation.

The complications that can occur after blepharoplasty range from a subtle change in eye shape to frank ectropion with corneal ulceration. Primary blepharoplasty goals should be aimed at preventing these complications. Conservative skin and fat resection, careful preoperative assessment and canthal support when indicated can avoid most of these complications.

Miss Zahida Butt is an NHS consultant ophthalmic and oculoplastic surgeon based at the Queen Elizabeth Hospital, King’s Lynn. She is also founder of The Cosmetic Clinic, King’s Lynn body language www.bodylanguage.net

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aesthetics Dr Flor Kent

In the eye of the beholder The aesthetic industry revolves around the concept of beauty, youth and attractiveness.

Dr Flor Kent explores the origins of beauty, its relationship with the Golden Proportion, and how we recognise a beautiful face

T

hroughout history there has been an enduring quest to understand and define the concept of beauty.

As Aristotle noted: “Beauty is a greater recommendation than any letter of introduction”. Some dictionaries define it as “a combination of qualities that give pleasure to the senses”.

Anthropologists and other researchers have studied beauty from many angles, and have disparately described it as everything from a ‘social necessity’ to a ‘gift from God’. Most agree that it is a requirement for sexual selection, leading to improved opportunity for reproduction.

When Darwin travelled on the Beagle in the 19th Century, he found a universal “passion for ornament”, often involving sacrifice and suffering that was “wonderfully great”. People scarred, painted, pierced, padded, stiffened, plucked and buffed their bodies in the name of beauty.

Today’s voluntary procedures, involving tearing or burning skin, suctioning fat and implanting foreign materials, show that these values have not changed.

Beauty and the brain But does beauty reside in the object or in the perceiving subject? In other words, is it about the beauty conditions in the object or how it makes us feel? In a study aiming to locate “beauty” in the brain, ten subjects were shown several paintings and were asked to rate them as beautiful, neutral or ugly. The same subjects viewed the paintings again while being scanned with an MRI machine. Researchers found there were precise areas in the visual cortex of the brain that were activated with each feature. (Kawabata H & Zeki S, 2004) There are two schools of thought that try to explain when this sensitivity to beauty is acquired. One says that beauty is not instinctively recognisable and that we must be trained from childhood to discriminate it (Lakoff R & Scherr R, Face Value). Another says that we are actually born with preferences, or beauty receptors, and that even a baby knows beauty when he sees it.

An interesting study used 100 slides 52

with people’s faces of all races and ages.

They were shown first to adults to rate for attractiveness and then presented to 3–6 month old babies. The babies stared significantly longer at the faces found attractive by the adults, indicating that babies have beauty detectors and that human faces may share universal features of beauty (Langlois J et al., 1991).

Historically an enduring belief persisted—that physical beauty reflected spiritual beauty and that ugliness was a sign of the bad, the mad or the dangerous. Since early Greek times, whatever was beautiful was considered good. For ancient Egyptians Nefertiti (the “Perfect One”) immortalised beauty due to her ideal and harmonious facial proportions and symmetry. Throughout the Renaissance there was a pursuit for the classical idea of Greek beauty, which involved an orthognathic profile with a long straight nose and pronounced cupid’s bow. The Venus de Milo is a famous example.

Later, the old masters pursued this ideal of beauty and aimed to create an idealised beauty—a beauty higher than nature. Perhaps this continues today, with sectors of the population pursuing bigger lips, bigger breasts, bigger cheeks and chins or bigger and whiter teeth.

line is to the greater segment, so is the greater to the lesser.”

A

C

B

In the diagram, C divides the line segment AB according to the Golden Ratio.

The ratio AC to CB is equal to the ratio AB to AC. The ratio AC to CB equals 1.618—an irrational number. Many mathematicians worked on calculations until Fibonacci (1220 BC) came to a sequence. By dividing each number in this sequence, you arrive at 1:1.618. The ratio of each number in the sequence divided by the one before it: 1/1 = 1, 2/1 = 2, 3/2 = 1.5, 5/3 = 1.666, 8/5 = 1.6, 13/8 = 1.625, 21/13 = 1.61538, 34/21 = 1.61905, 55/34 = 1.61764, 89/55 = 1.61861 Phi Φ = 1.61861 Everything in the universe is based on the Phi proportion—1:1.618. This golden proportion is found in both natural and man made objects, and has been used by architects and artists to produce objects of great beauty. Leonardo da Vinci’s “Vitruvian Man” shows the ideal proportion of humans fitted into geometrical shapes.

The same idea of using proportions was applied to facial features. There is a strong belief that beautiful faces—regardless of race, age, sex and other variables—conform to this divine proportion.

The Golden Proportion To better understand the concept of beauty, we have to first understand proportion and symmetry. Pythagoras (6 BC) postulated that beauty could be explained through mathematical laws and laws of proportion—part of the mathematical order of the universe. He used the term ‘cosmos’ to describe beauty; the origin of the word ‘cosmetic’.

Euclid of Alexandria (300 BC) defines a proportion derived from a division of a line into what he calls its extreme and mean Stephen Marquardt’s mask overlay determines whether a face falls ratio. “As the whole into the ideal proportion, as in Marilyn Monroe’s example above body language www.bodylanguage.net

aesthetics Dr Flor Kent

Nefertiti immortalised beauty due to her harmonious facial proportions and symmetry

The way facial features, and the width and length of the face, relate to each other is the key to beauty.

Stephen Marquardt, a maxillofacial surgeon from California, created a mask overlay to determine whether a face falls into the ideal proportion. It is widely used by surgeons today and interestingly fits the image of Nefertiti 3,200 years before its creation.

But attempts to correlate ideal facial proportions with the Golden Proportion don’t always work. The proportions thought to have been used by Da Vinci in the Mona Lisa rendered a face that only a few would consider beautiful. Additionally, faces of professional models don’t always match its dimensions.

A study looking at aesthetic improvement of patients undergoing orthognathic surgery (Baker BW & Woods MG, 2001) found that, while most subjects were considered to have aesthetic improvement after treatment, the proportions were equally likely to move away from, or towards, the Golden Proportion Furthermore, researchers at the University of California and University of Toronto found that beautiful faces actually have average proportions. Women considered classically beautiful, including Jessica Alba and Shania Twain, have facial proportions close to the average of any female profile (Pallett P M, Link S & Lee K, 2010). Several studies also support the idea that average faces are actually more beautiful, because they indicate genetic diversity. A simple example is where two facial images are morphed into a third, with the end product often being considered more attractive.

One study used photographs of up to 32 students and morphed them to an “average” of attractiveness. Averaged faces were rated significantly higher than indibody language www.bodylanguage.net

vidual faces. A face closer to the population ‘average’ is fundamental to attractiveness. It was found that the more faces used in this final image, the more attractive it was rated by people. The study concluded that a facial configuration that is close to the population average is fundamental to attractiveness. (Langlois J & Roggman L, 1997) But not everybody agrees that average or ideal proportions indicate beauty.

Some researchers claim that striking features can carry more weight than a perfectly proportioned face.

A 2002 study showed that individual faces were preferred to the composites.

When computers were used to exaggerate some of the features—perhaps making the eyes bigger—these shape differences were preferred, even though they moved away from the average (Perrett D, 2002).

Research by Dr Alfred Linney at the Maxillofacial Unit at University College Hospital, London, found precise measurements of top models’ faces showed their features to be as varied as the rest of the population. Perfect faces can also be considered a little bland and lacking in character—Audrey Hepburn, regarded as an extraordinarily beautiful woman, was technically imperfect. She had a far from perfect nose with high nostrils, thick eyebrows and an unusually small chin.

Neoteny An attractive face is considered the most valued aspect of human beauty—a beautiful face over a beautiful body. The facial aspects which indicate beauty in order of importance are: symmetry, a flawless skin, flowing healthy hair, high cheekbones, large eyes, small narrow nose, full lips, thin eyelids, long eyelashes, dark eyebrows and large, aligned white teeth.

Many of these fall into the features of a child, which brings us to the concept of neoteny or a “baby face”.

Some theories suggest that we are attracted to facial features that represent high levels of male or female hormones— an association with fertility. Female models have features that give a younger appearance. They are perceived as ultrafeminine, a sign of high hormone levels.

The ‘sex bomb’ phenomenon has exaggerated fertility signals and the potential to provoke higher levels of arousal in males.

Anthropologist Doug Jones and his team examined the facial proportions of female models and found that they corresponded to 6.5–7.5 year old girls. Most species are biologically programmed to fall in love with babies. Kate Moss is a case in point—her facial features and

proportions are similar to a toddler, while other aspects of her appearance show maturity, such as the lips of an oestrogenladen woman.

Every epoch has a preferred a sign of facial maturity. Today’s love affair with cheekbones stems from Hollywood films and their signature chiaroscuro lighting techniques on actresses such as Greta Garbo or Marlene Dietrich. Dietrich actually had her top molars removed, to accentuate the curved shadows produced under strong direct light.

Ageing However, we cannot refer to beauty without mentioning its nemesis; ageing. Ageing is considered the erosion of beauty.

Bone changes, which happen earlier in women (between young and middle-age) than men, include orbit loss—becoming wider and longer with sinking of the eyeballs into the sockets.

The reduction in the angles of the brow affects the soft tissue and contributes to the formation of frown lines, crow’s feet and droopy eyelids. The frontal bone loses convexity, the bones of the middle face shrink, the nasal space widens, the maxilla flattens and the zygoma looses volume and projection.

Changes in the lower face include a decrease in height and length of the mandible and lateral narrowing. As the jaw gives support to the lower face, this translates into a loss of chin projection, sagging skin, double chin and ageing of the neck.

Soft tissue changes include fat loss and fat redistribution. Female lips, having reached their fullest volume at 14 years old, start losing volume and eventually collapse. Only the constant input of oestrogen slows the deflation process.

The female lips are oestrogen-dependent which explains why, unlike men, women tend to get ‘smokers’ lines and are in need of lip enhancements to maintain a youthful look. Skin becomes thinner, dull and loses elasticity.

Guidelines used by clinicians today are based on those initially described in art. Qualifying beauty is fraught with controversy and there is no consensus of opinion. Accepted notions of what constitutes facial beauty seem to be multifactorial and ever-changing, and will require more evidence to substantiate its true significance in the clinical assessment of facial aesthetics.

Dr Flor Kent is a dental surgeon, specialist in prosthodontics and sculptor with permanent works of art in cities including London, Vienna and Prague.

53

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masterclass Dr Raj Acquilla

Treatment of tear trough and lid/cheek deformity can provide effective rejuvenation for the ageing face. But practitioners must consider anatomy and good injection technique, writes Dr Raj Acquilla

Tear trough T

technique

he tear trough is essentially a valley between two hills.

The hill above the tear trough is the infraorbital fat pad and the hill below is the malar fat pad.

The tear trough itself is demarcated by the tethering of the orbicularis retaining ligament, which is a fascial condensation of the orbicularis oculi muscle. The true anatomical tear trough is the medial aspect of this lid/cheek junction from the medial canthus to its intersection with the zygomatic retaining ligament which gives rise to the malar groove.

Many factors can influence the appearance of the tear trough and are often associated with peri-orbital ageing. Dermal atrophy and transparency of the skin revealing the underlying vasculature and musculature can be improved by collagen induction therapy—for example, topical retinoids, radiofrequency (RF), micro needling, resurfacing and delicate precise injection of hyaluronic acid (HA).

Peri-orbital hyperpigmentation can be subject to hereditary influence and can be effectively treated with topical retinoids, hydroquinone and melanogenesis ladder inhibitors.

Fat displacement often dictates the depth of the tear trough due to anterior herniation of the infra-orbital fat compartment body language www.bodylanguage.net

into the lower lid—causing the eye bag—while the malar fat compartment undergoes atrophy and slides infero-laterally. The combined effect of these changes makes the tear trough appear deeper.

Orbital remodelling occurs through age-related bony resorbtion, which changes the orbit from a spherical socket to a more rhomboidal structure with flattening of the orbital floor. This loss of the anterior orbital lip allows the infraorbital fat pad to herniate forwards into the lower lid, creating a bulge or bag.

Classification Mild—this often presents in young patients with textural change in the tear trough, with little or no volume deficit. It can be treated with a low viscosity, low molecular weight (LMW) HA filler via a 32–33G needle as fine micro threads in the deep dermis.

The skin can be as thin as 0.6mm in this area, so depth control and minimal product use is essential in optimising the result. The objective is to restore youthful strength and integrity in the lower eyelid and anterior lamella and is ideal for peri-orbital beautification of young patients.

55

masterclass Dr Raj Acquilla

1

2

3

4

Tear trough deformity, which can be associated with different stages of ageing, can be classified as mild (1), moderate (2) or severe (3, 4)

Moderate—this is usually associated with the onset of midfacial ageing and early migration of the infra-orbital and malar fat compartments.

Medium depth tear trough may be addressed by malar volumetry and direct injection into the tear trough using a light HA filler via a 30G needle or micro-cannula deep to the orbicularis oculi in small micro droplets or linear threads.

Care must be taken to under-correct this area to avoid hydrophilic rebound swelling. Correcting to 70% of the desired outcome is usually sufficient to produce good results.

Severe—this is typically associated with significant volume shift, giving the appearance of eye bags with a deep tear trough extending through the lid/cheek junction, through to the malar groove.

Optimal correction may be achieved by correction of the malar deficit in preference to the tear trough using a deep supraperiosteal technique with a medium viscosity LMW HA filler

via a needle or cannula. The rationale for this approach is to shorten the lid/cheek junction by vertical elevation and support of the malar fat compartment.

Complex cases may benefit from a “sandwich technique” from malar to tear trough in both the deep retro-orbicularis and intradermal tissue planes.

Anatomy It is vital to understand where the following structures lie in order to identify the areas to inject and in particular those to avoid.

Fat compartments—See image below. The infraorbital fat pad (1) is separated from the malar fat pad (2, 4) by the orbicularis retaining ligament which demarcates the lid/cheek junction.

The zygomatic retaining ligament divides the medial one third and the lateral two thirds of the malar fat pad, which is commonly referred to as the malar groove.

Correcting the area of greatest volume loss will give the best results, which usually corresponds to the triangular depression at the superior aspect of the malar groove.

Orbicularis oculi—understanding how the orbicularis oculi presents is important in understanding the dynamic element of the infra-orbital area. Like a dartboard, the bulls-eye over the eyelids is the pretarsal component.

Peripheral to that is a preseptal component, which condenses to the orbital septum. We also have the junction between the preseptal and the orbital component of orbicularis oculi.

This fibro-muscular union is typically where we find the tear trough and the fascial condensation of the orbicularis retaining ligament, which attaches the skin to the infra-orbital rim.

Peri-orbital blood supply—there are many vascular considerations in this region, but generally if treating the correct area there are few significant vascular structures in our path.

The main consideration would be the angular artery, which is the superior termination of the facial artery before it enters the orbit just above the medial canthus and is known to have a variable anastamosis with the ophthalmic artery.

Infraorbital vessels are also relevant and should be avoided.

The tear trough is usually superior to the infraorbital foramen and lateral to the angular artery so staying in a safe plane will reduce vascular injury significantly. Technique is, of course, critical to good results and risk management. I would advocate tiny quantities of HA with slow and consistent movement of the needle, minimising the chance of vessel embolisation.

The literature would indicate that larger volume depot techniques have been associated with vascular compromise in the past.

The lacrimal gland is not really relevant to the tear trough as it’s in the upper outer quadrant of the orbit. However, the lacrimal sac and its duct are significant because of their proximity to the tear trough adjacent to the medial canthus.

The vertical canaliculus runs within the medial 2–5mm of the tear trough and is particularly sensitive to pressure changes

It is vital to understand the anatomical structures to identify the areas to inject and to avoid. Fat compartments (L) and orbicularis oculi (R)

56

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masterclass Dr Raj Acquilla

2–4 weeks through hydrophilic swelling and possibly collagen induction.

Point 4: Lateral orbito-malar junction—treat this area in the same manner as Point 3 but work from the lateral canthus, directing the needle medially and inject on the periosteum, as the supportive soft tissue here is fairly shallow.

Again, aspirate on deep injection to avoid injecting into a superior branch of the transverse facial artery.

The lacrimal sac and its duct are close to the tear trough and adjacent to the medial canthus, requiring careful injection technique

and occlusion. If compromised then tear incontinence could occur, resulting in the need for surgical canalisation. I would therefore recommend sparing at least 5mm from the medial canthus when injecting the tear trough.

Technical strategy The rationale for the four-point injection strategy is to inject the fewest points with the smallest amount of product to create the highest impact whilst minimising risk. Employing methodology in your approach allows for consistent and reproducible results, which can be adapted for different case types.

The sequence of injections can also improve adjacent areas.

For example, as can be seen in “Four point injection strategy”, Point 1 corrects Point 2, improving Point 3, which can help Point 4. Overall correction from inferior to superior and deep to superficial tends to work best in this area.

Point 1: Malar groove—this usually corresponds to the area of greatest volume deficit and therefore corrective need. Volumetry of the malar fat compartment is also known to shorten the lid/cheek deformity and reduce the need for direct injection into the tear trough.

Product selection and delivery should be based on the indication but generally a soft and harmonious material with good lifting capacity and integration is ideal.

Injection of the needle into the fat pad or onto the periosteum is fine, although microcannulae may be preferable where the zygomatic retaining ligament is tethered and needs to be subcised and blunt dissected to create a more uniform tissue plane.

Point 2: Orbito-malar (lid/cheek) junction—the technique outlined at Point 1 can be continued with feathering of material at the lid/cheek junction to avoid the appearance of a festoon or malar mound.

Point 3: Anatomical tear trough—as described above, use a low viscosity LMW HA filler via a fine gauge needle or cannula deep to the orbicularis oculi in tiny micro-depots or microstreams to achieve approximately 70% of the desired correction.

The remaining 20–30% should take place over the following Four point injection strategy

Risks and complications Redness and swelling cannot be avoided, and the bruising rate in this area tends to be around 40%, compared with <10% in the mid and lower face.

Prolonged periorbital oedema tends to appear in patients who are a minority group, and present with heavy bags in the morning when they wake up which improve through the day.

These patients already have a degree of lymphatic drainage compromise, and by putting pressure into the tear trough and further occluding draining, there will be more issues. Always be aware of this and take a good history before you treat.

Rebound hydrophilic overcorrection refers to the nature of the product and also the volume and depth of injection. There can be a surge of moisture into the HA material anywhere up to two weeks post-procedure, which can produce overcorrection.

To avoid this, aim to under correct to the order of around 70% of total.

You must also consider the Tyndall effect—a blue/silver discolouration—which can be product related but also volume related. If you inject large pools of product, as opposed to putting in thin streams or small droplets, there will be more issues because of the change in wavelength of light as it penetrates into the product.

Lumps and nodules are reported more often when injecting over the top of orbicularis oculi, particularly when not using a light HA product and in larger amounts. The muscle fibres may trap the HA particles and cause aggregation when injected at this level.

Lacrimal incontinence will occur when pressure is applied to the vertical canaliculus and obstruct normal tear drainage so always spare a 5mm margin from the medial canthus where possible.

There is an argument that we should be aspirating for every injection to avoid vessel embolisation. The theory behind this is that a small amount of HA—a fragment—could pass through the artery and end up into one of the terminal branches, which in this case would be the ophthalmic and central retinal artery.

This should be discussed with patients, to ensure fully informed consent. But the risks are very low with good, safe injecting technique and using the right products. In the literature to date, only 32 cases of visual acuity compromise have occurred from injecting HA into the per-orbital region and most of these have been from supra-orbital approaches.

Treatment of the tear trough and lid/cheek deformity is a popular and useful technique to offer patients. But we must proceed with due care and attention and try, where possible, to improve the area but influencing the area through indirect approaches such as malar volumetry to manage risks appropriately.

By using the right product and procedure, we can achieve some quite exceptional results which may last for 2–3 years in some cases.

Dr Raj Acquilla MBChB MRCGP MBCAM is a cosmetic dermatology expert with 10 years’ experience in the field.

W: rajacquilla.com; the-masterclass.co.uk. E: rajacquilla@me.com

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psychology Dr Raj Persaud

Body fat and beauty Dr Raj Persaud surveys the latest research into the link between body fat percentage and measuring female attractiveness

T

here are various ways scientists try to measure how attractive a body is. Science relies on precise measurement so various numbers have been devised to capture what a body looks like.

Perhaps the most famous number is body mass index (BMI) which is calculated by working out your weight in kilograms and then dividing this number by your height in metres squared.

In terms of BMI, a healthy weight range is supposed to be between 20-25—but supermodels and other groups of highly attractive women have been found to score 19.

It’s therefore useful to have a numerical target such as this one to aim for when trying to get fitter. It’s much more precise than simply intuitively deciding what should be your BMI from how tight your clothes are or whether you are feeling bloated or not.

But new research has established there is another number that is much more powerful in predicting how physically attractive you will be rated, compared with BMI. This new number is referred to percentage body fat.

Body fat percentage Mark Faries and John Bartholomew, researchers at Stephen F. Austin State University, Texas and the University of Texas, Austin have for the first time scientifically addressed the question of the link between body fat percentage and attractiveness.

In their study entitled “The role of body fat in female attractiveness” (Evolution and Human Behavior, 2012), Faries and Bartholomew point out that there are various pointers to the key role that body fat percentage plays in our appreciation of beauty.

They emphasise the prevalence of cosmetic surgery and liposuction to remove excess fat and cite a 2010 report from the American Society of Plastic Surgeons, detailing that liposuction was a top five cosmetic procedure in all age categories, including 13–19 years.

Body fat, the authors of this new research argue, produces a great level of disgust. For example 46% of survey respondents report that they would be willing to give up one year of their life rather than to be obese, while 15% were willing to give up 10 years or more of their life.

Those considered to be normal weight or underweight reported even greater willingness to give up years of their life, with up to 22% willing to lose a limb rather than be obese.

These researchers found a body fat percentage of 15-20% was found the most attractive, though it was women who tended to prefer female body images linked with lower body fat percentages.

The most significant finding was that body fat percentage turned out to be more important in predicting what men and women found attractive in a female body than BMI. This sug58

Research has shown that percentage body fat is more powerful in predicting how physically attractive you are.

gests that if looks are important to you, you may want to focus on body fat percentage.

Scales are available at drug stores or chemists that automatically calculate BMI and percentage body fat, just by standing on them. Body fat percentage is calculated by passing a small electric current through your body—fat impedes electricity in different amounts to the way water and bone and other minerals impede it. Having such specific numbers to aim for is motivationally helpful compared to more vague targets of just aiming to look good.

Dr Raj Persaud is a consultant psychiatrist in private practice at 10 Harley Street and in Surrey. body language www.bodylanguage.net

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Appealing results Dr Zein Obagi discusses proper use of peeling agents to promote healthy skin

P

eels are still one of the most effective ways to treat signs of ageing, discolouration and UV damage. The intensity of the peel directly relates to the improvement the patient will see and the downtime and irritation they will feel post-peel. Depending on the patient’s time demands, you can also recommend at-home peels for a slower, yet cumulative effect.

Peels can be used to correct and reduce conditions of weakened skin such as damaged skin surface, pigmentation, uneven texture, lines and wrinkles. Not only will peels reverse these conditions, they will increase the overall health of the skin.

Traditional chemical peels offer no stimulation. To make a difference, peels must go deep. They work best for skin tightening, while laser rejuvenation including Fraxel is superior for improving skin texture such as wrinkles and scars. Peels also better reach and reverse deep pigmentation issues.

It has been said that scar prevention and seamless wound healing is the holy grail of medical aesthetics, and proper skin conditioning during the perioperative period can stave off scarring. This includes applying retinoic acid for 20 days after suture removal.

It is essential to develop a strategy that prevents keloid and hypertrophic scars from forming in the first place. This requires a strong offense. Use of topical agents and exfoliation, steroid injections before surgery, and treatment with the flashlamp pulsed dye (FLPD) laser can prevent early fibrosis.

These clear steps provide any doctor who works with the skin with the tools and straightforward algorithms to identify and treat existing skin issues and maintain the improvement of patients’ skin over time.

The ZO Medical Controlled Depth Peel can treat a variety of skin conditions

ZO Medical Controlled Depth Peel My new ZO Medical Controlled Depth Peel utilises trichloracetic acid (TCA) at a 30% concentration buffered to 20% or 26% to treat a variety of skin conditions including acne, wrin-

kles, fine lines, pigmentation disorders like melasma and sun damage.

When TCA is applied to the skin, it causes surface skin cells to dehydrate—and then peel off—over a period of four to 10 days. When the surface skin peels away, it exposes a new layer of undamaged skin, which has a smoother texture, improved firm-

Before and two weeks after the ZO 3 Step Peel

Before and four weeks after the ZO Controlled Depth Peel

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61

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help strengthen the skin to improve barrier function.

My new ZO Medical 3-Step Stimulation Peel works to improve the health of facial skin through exfoliation, cellular stimulation and a calming post-treatment cream—with little to no downtime. This is a highly effective treatment for many of the signs of skin ageing, including melasma, photo damage, fine lines, uneven texture, large pores, dullness, and acne.

ZO Medical 3-Step Stimulation Peel works to improve the health of facial skin through exfoliation, cellular stimulation and a calming posttreatment cream

ness and a more even skin tone and radiance.

After redness and peeling have subsided, the patient will see a dramatic improvement in: skin firmness, brown spots, age spots and uneven skin pigmentation; the appearance of melasma; improved texture of leathery, sun damaged skin; a reduction of acne conditions and post-inflammatory hyperpigmentation; and a reduction in fine lines and wrinkles.

The ZO Medical Controlled Depth Peel can be customised so that the absorption and penetration rate are varied and controlled. Depending upon the amount of TCA used, the peel can penetrate just the epidermis, or deeper into the dermis for a mild, moderate, or aggressive peel.

To mix the peel, you add 30% TCA (not included in the kit) to the ZO Controlled Depth Peel Base, which is pH balanced.

Enriched with skin lipid supplements, skin redness modulators, and antioxidants, the base minimises skin redness, replenishes skin barrier function, and minimises newly exposed skin cells from post-peel damaging oxidative stress. The peel has a blue tint to it, and is applied in layers, depending upon the desired intensity. The peel does not have to be neutralised after application.

Immediately afterwards, the cleanser is applied to lift any residue left on the skin following application of the base. This foaming cleanser contains a beta-hydroxy acid exfoliant that provides secondary removal of any remaining dead surface skin cells. In addition, vitamin B3-niacinamide penetrates the upper layers of skin to help aid the skin’s natural cellular renewal processes that accelerate creation of new skin cells and help maintain healthy skin for your patients.

For best results, pre-conditioning the skin prior to the application of the peel will improve skin health as well as accelerate post-peel healing. It is important not to peel skin that has not been prepared properly. If the skin is sensitive or dehydrated, it is not ready to be peeled.

I recommend having the patient use ZO Basic Skin Conditioning System for three to four weeks before having the ZO Medical Controlled Depth Peel. The skin must be ready to tolerate the peel safely. Using retinol or retinoids consistently will 62

Three steps The first step is the peel itself, which is formulated to remove the outermost layer of skin. Composed of salicylic acid (17%), trichloracetic acid (10%) and lactic acid (5%), it also contains saponins to minimise inflammation and glycerin for hydration.

Step two is application of the Stimulating 6% Retinol Creme.

Applied after the peel solution, the cream works to stimulate cellular function at a deep skin level. The results include collagen enhancement as well as firming and wrinkle reduction.

Step three refers to the application of the Calming Crème-Post Procedure Skin Relief. This cream works to minimise inflammation and irritation that may result from the first two steps, as well as restore the moisture balance of the skin. The patient can take the cream home to apply twice daily following the treatment to speed the healing process.

Post treatment peeling is mild in many cases, as most of the dead cells are removed by the twice daily washing following the peel. There is minimal or no downtime with this peel, and the patient’s skin will look healthier rapidly. The 3-Step Stimulation Peel is suitable for any skin type or colour, and I recommend preconditioning the skin with a retinol regime.

My new philosophy promotes epidermal stabilisation to increase skin tolerance and natural resistance to ultraviolet light, and to suppress inflammation plus physical blockers and externally applied natural melanin. Physical blockers offer short-term protection, and the melanin protects skin for six to eight hours.

Melanin has staying power because it does not get sweated, washed, or rubbed off like sunscreens and blockers. My ZO Skin Health Oclipse Sunscreen + Primer SPF30 was developed with two different physical sunscreens plus melanin to address optimum UV protection.

Dr Zein Obagi, is a consultant dermatologist and ZO Skin Health Inc. founder

ZO SKIN HEALTH SYMPOSIUM This June London will be host for the first ZO Skin Health European Symposium. Using the world renowned FACE Conference and Exhibition as the setting, we hope that you are all able to enjoy learning the philosophy and the methods of achieving optimum Skin Health.

With a focus on the art and science of skin treatments and rejuvenation, the symposium will cover the science of how to restore skin health, cellular activity and function, and how to improve the skin’s ability to tolerate any procedure.

This is a unique forum for industry leaders to introduce their latest research, breakthroughs and advances in the science of skin care and health.

Please join Dr Zein Obagi and our esteemed faculty for this exclusive and informative symposium taking place at the heart of the aesthetic industry in the UK. To book your place, call 020 7514 5989 or go to the FACE conference website faceconference.com and register for the Saturday Exhibition and Workshop Pass.

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Sun protection Offer your patients innovative sun care from La Roche-Posay’s Anthelios range

F

or over 30 years La Roche-Posay has developed unique expertise in sun protection and established its pioneering Anthelios range as the “go-to” sun protection range for sensitive and sun intolerant skin.

Recommended by dermatologists worldwide, Anthelios XL offers ultra-high UVA-UVB sun protection and proven dermatological tolerance to help protect against damage caused by UV rays.

La Roche-Posay was the first laboratory to introduce Mexoryl SX in 1993, Mexoryl XL in 1998 and most recently Mexoplex into its sun care range.

Mexoplex offers ultra high UVA-UVB protection, as well as excellent photostability, with a reduced content of chemical filters while ensuring optimal tolerance for sensitive and sun intolerant skin.

Mexoplex helps to boost sun protection due to a unique synergy of sun filters: • The combination of Tinosorb S and Mexoryl SX gives twice as much UVA and UVB protection as Tinosorb S alone.

• The unique synergy of the Mexoplex system means that Anthelios achieves this ultra-high protection with 15% less chemical filters.

Clinical studies Anthelios is backed by 19 in vivo clinical studies carried out on sun sensitive skin, provoked by UVA in particular. These 19 clinical studies led by globally renowned dermatology experts have appeared in reference dermatological reviews.

Superior tolerance for sensitive skin The La Roche-Posay Anthelios sun protection range offers clinically proven effectiveness and tolerance to help to protect against the damage caused by UV rays. The range adheres to a strict formulation charter and is non-comedogenic, non-perfumed, has no parabens, is water resistant and is tested on sensitive skin.

In addition to providing ultra-high UVA-UVB protection, the La RochePosay scientists also focus their efforts on developing the most innovative and sensorial textures possible which are tailored to individual skin types, ideal for daily use. Their objective is always the same— improving compliance, an issue close to 64

dermatologists’ hearts and key to effective protection. La Roche-Posay does not believe that there should be a need to compromise when it comes to sun protection.

Its mission is simple—efficacy, tolerance and wearability.

Product range Anthelios XL Melt-in Cream SPF50+ is specifically developed for normal to dry skin types. It melts into the skin without leaving white marks and is water resistant. It is available on prescription in the UK for skin conditions and adverse effects caused by UV rays. It is also available in a tinted version.

Anthelios XL Fluid Extreme SPF50+ provides ultra high UVA-UVB protection in a light, fluid texture, specifically designed for normal to combination skin types. Its ultra-light fluid texture instantly soaks into the skin leaving no oily or sticky sensation. Fluid Extreme spreads easily on the skin leaving no white marks or shiny effect and is also available in a tinted version.

New for 2013, La Roche-Posay has introduced Anthelios XL Dry Touch GelCream which is inspired by the “toque seco” (dry touch) innovation characteristic of Brazilian sun care products—on application this gel-cream is instantly absorbed, leaving an ultra-dry finish. This unexpected sensation is ideal for combination and oily skin and also for skin which is prone to sweating and shine.

To achieve its dry touch effect, the formula features a sugar-derived polymer for an invisible finish and a blend of antishine powders for an ultra-dry finish: • Perlite to provide a blotting effect.

• Silica to neutralise sebum.

• Corn starch for a soft feel.

• Zinc gluconate—a reference anti-sebum active ingredient in dermatology.

In blind tests under real-life conditions* 94% of users found it easy to apply and distribute over skin, 90% said their skin was not shiny, post-application and 88% were impressed with the no white streaks formulation.

La Roche-Posay will be exhibiting at FACE 2013 from the 21st–23rd June in London on stand 60. For more information on the Anthelios range, contact La Roche-Posay W: laroche-posay.co.uk * Satisfaction test on 93 women aged 20 to 50, blind use of Dry touch Gel-Cream SPF 50+ over one to two weeks in areas with intensely sunny climate, percentages agreeing.

Mole and Sun Advice Roadshow La Roche-Posay are proud sponsors of the 2013 Mole & Sun Advice Roadshow organised

by UK skin cancer experts the British Association of Dermatologists.

The roadshow aims to encourage people to pay more attention to their skin and learn what warning signs to look out for, and how best to protect their skin in the sun.

Thousands of members of the public will be provided with free mole and sun care advice from expert dermatologists and nurses, and complimentary sunscreen, in a bid to make people aware of skin cancer risks and how to enjoy the sun safely.

Visit besunaware.com to discover more about the 2013 British Association of Dermatologists Mole & Sun Advice Roadshow sponsored by La Roche-Posay.

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nutrition Dr Simon Poole

Busting fat myths

The relationship between dietary fats and a healthy lifestyle have been a constant source of misunderstanding among those seeking weight loss and better nutrition. Dr Simon Poole dispels the myths

F

at has had a bad press over the years. Perhaps this is not surprising given its high calorific value in comparison with proteins and carbohydrates. The word is also used pejoratively to describe the end result of the complex series of metabolic processes which dictate our body weight, appearance and which itself ultimately contributes to our state of health.

The adipose tissue responsible for obesity is comprised mainly of lipids that we create and accumulate. However, the dietary factors which determine the extent of these stores is dependent on more than simply the quantity of fat and number of calories we consume. It is a much more subtle story.

We are now able to describe different classes and subclasses of fatty acids which have very different effects on health and body shape. This has led to a more sophisticated understanding of the advice we need to give to clients and patients. In recent years, there have been significant misunderstandings of the relationship between dietary fats and health, resulting in counterintuitive outcomes such as the promotion of relatively high saturated fat diets for weight loss and the “fortification” of spreads with polyunsaturated fats which have been purported to possess cholesterol lowering effects. body language www.bodylanguage.net

It is incontrovertible that fats are an important source of energy and are essential for some physiological processes and the bioavailability of fat-soluble vitamins. But it is also important that health professionals are able to share the most recent advances in our understanding so people can make choices which will most benefit their health.

Dietary fats and weight It is a measure of how deeply embedded the “low fat, high carbohydrate” mantra of the last few decades has become, that we see so many nutritionists still advocating this kind of diet for weight loss. This is despite compelling evidence that a moderately high monounsaturated fat “Mediterranean” diet with low glycaemic index carbohydrates is more likely to be associated with long term optimum weight maintenance as well as better blood lipid profiles. Several studies have confirmed these observations, most recently the long term follow up DIRECT study which demonstrated the benefits over six years (Fig 1).

Saturated fats are described as fatty acids which have no double bonds between the carbon atoms, and are therefore “saturated” with maximum hydrogen molecules. Since the 1950s, an association has been noted between high intake of saturated fats 65

nutrition Dr Simon Poole

recognised that saturated fats might have a harmful effect on blood lipid and cholesterol levels and it was observed by Ancel Keys and others that the high unsaturated fat in the Mediterranean Diet conferred widespread benefits. There followed a concerted effort in the West to replace dietary saturated with unsaturated fats.

Since seed oils were easily produced in Northern Europe and the USA, and contained omega-6 polyunsaturates (linoleic acid – LA), the population was encouraged to use sunflower oil, and margarine manufacturers promoted their “high in polyunsaturates” convenience fats to replace butter.

While there had been early evidence to suggest that polyunsaturated fats (PUFAs) had a beneficial effect on blood cholesterol levels, it was misunderstood that our natural diet relies on an approximate 1:1 balance between omega 6 polyunsaturates (LA) and the essential omega–3 polyunsaturates (alpha linoleic acid or ALA) and its derivatives.

These omega-3 polyunsaturated fats are derived from oily fish, nuts and plant sources and have well documented positive effects including a decreased risk of cardiac arrhythmias. But such advantages are rapidly diminished in an environment high with an excess of omega-6 fats.

As our ratio of omega-6 to omega-3 polyunsaturates reached a staggering 20:1, the benefits of polyunsaturates have been clearly and significantly undermined by our reliance on seed oils and compounded by Governments and the food industry propagating flawed nutritional advice. Even more recently, Ramsden et al have questioned the very assumptions that replacing saturated fats with polyunsaturates might result in better outcomes.

and cardiovascular disease, reflected in advice which suggests limiting intake from the World Health Organisation, Governments, Charities and other agencies including the European Health Safety Authority.

Transfats, manufactured by hydrogenation, have been used by the food industry to lengthen product shelf-life and to add texture. Banned in some European countries, these fats have recently been estimated to result in 11,000 heart attacks and 7,000 avoidable deaths in the UK every year, with 5g (a mere 2% of daily energy intake) associated with a 23% increase in ischaemic heart disease as reported by Coombs in “Transfats – chasing a global ban”.

Monounsaturated fats Landmark studies in the last few decades have described dietary patterns associated with reduced risks of cardiovascular disease, cancers and even arthritis and dementia.

While this is not solely dependent on the fat profile of such lifestyles, the increased intake of monounsaturated fats (MUFAs)—in association with low saturates—and a balance of omega-3 and omega-6 polyunsaturated fats play a pivotal role in the prevention of disease.

The traditional Mediterranean Diet has an abundance of monounsaturates, especially with olive oil as the main source of fat. Other fatty fruits such as avocados, nuts, some meats and wheats can also provide sources of MUFAs. Not only has olive oil been shown to increase satiety and therefore reduce the risk of obesity, but monounsaturated fats in general are more subject to oxidation in the body and are thus far less obesogenic when compared with saturated fats, which are much more readily converted for storage in adipose tissue.

Not all calories are as equal in the context of weight gain and obesity.

MUFAs, which include oleic acid, have positive effects on blood lipids and cholesterol, and the micronutrients such as the accompanying polyphenol antioxidants in olive oil, for example, have other significant advantageous effects.

Polyunsaturated fats We now are more aware that a low fat diet is not to be recommended. Although this pattern of eating may reduce harmful saturated fats, it does not confer a sustained reduction in weight and may discourage eating foods with unsaturated fats which we now recognise can confer substantial health benefits.

However, we are again presented with another lesson which has clearly led to poor nutritional advice in recent years. It was

The evolving science of fats As we gain increasing knowledge of the important role of fat in our diet, and perhaps as we learn to reappraise some of the false assumptions of recent years, there are further fascinating developments which should have an impact on optimum dietary advice.

There is evidence, for example, to suggest that our methods of agriculture have consequences in relation to dietary fat. With

Avocados can also be a source of monounsaturated fats which play a part in prevention of disease

66

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EARLY BIRD REGISTRATION: UNTIL 30.06.2013

Topics

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Special Sessions

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USA Israel Belgium Switzerland Germany Hong Kong USA

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• Rejuvenation: Fractional Vs. Non-fractional

• Fact Or Fiction?

• Cosmeceuticals

• Awards And Plenary: Whats On The Horizon?

• Analyzing Beauty: The Face

• International Peeling Society

• The Role Of Sun

• International Society Of Augmentation And Wrinkle Treatment

• Chemical Peels 2013 • Psychology In The Aesthetic Practice • Toxins And Fillers: History, Development And Differences

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nutrition Dr Simon Poole

Cooking with extra virgin olive oil is safe and fat soluble vitamins such as vitamin E, and antioxidants transfer into oils whilst cooking and may make the absorption of these important nutrients more complete

detailed scrutiny, even within classes of fats, there are points of difference which have significant physiological consequences.

The fat profile of meat is dependent on how it is reared. It has been observed that meat from animals which roam and graze freely may be significantly different in its fat profile, containing more MUFAs and a better ratio of PUFAs when compared with the less healthy grain-fed caged animal husbandry so commonly seen in intensive farming methods.

Similarly, a detailed study of the saturated fat profile of cheese from goats and ewes demonstrated a greater quantity of less harmful medium-chain saturated fatty acids in comparison with the long chain saturated fatty acids in harder cheeses from cows.

Even the saturated fat profile of, for example, dark chocolate is worth a closer look, with a high proportion of the fats being modified by our bodies and converted into MUFAs. Fats are used widely as a vehicle to cook with, and there has been much debate in recent years about the “smoking point” of various oils—the temperature at which it breaks down to potentially harmful glycerol and free fatty acids. Some oil producers cite this as evidence to use oils which appear to be able to withstand higher temperatures. While it is important to encourage cooking at temperatures below 200C for reasons other than

References 1. N Engl J Med 2012; 367:1373-1374 October 4, 2012 2. Joint WHO/FAO Expert Consultation (2003). “Diet, Nutrition and the Prevention of Chronic Diseases (WHO technical report series 916).” World Health Organization. pp.81–94.

3. “Frequently Asked Questions about Fats” American Heart Association.

4. “Scientific Opinion on Dietary Reference Values for fats, including saturated fatty acids, polyunsaturated fatty acids, monounsaturated fatty acids, trans fatty acids, and cholesterol”. European Food Safety

68

Authority, May 2012.

5. Barton P, Andronis L, Briggs A, McPherson K, Capewell S. “Effectiveness and costeffectiveness of cardiovascular disease prevention in whole populations: modelling study.”

BMJ 2011;343:d4044.

6. Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. “Trans fatty acids and cardiovascular disease.” N Engl J Med 2006;354:1601-13.

7. “Transfats – chasing a global ban.” BMJ 2011;343:d5567 8. Simopoulos. “The importance of the ratio of omega-6/ omega-3 essential fatty acids.”

National Institutes of Health.

smoke points—such as the preservation of beneficial micronutrients in foods—the antioxidant quality of the oil should also be noted, since antioxidants protect oils from such break down.

We can be reassured that the evidence of cooking with, for example, extra virgin olive oil is safe and it is also known that fat soluble vitamins (such as vitamin E) and antioxidants transfer into oils whilst cooking and may make the absorption of these important nutrients more complete.

The typical western diet, high in saturated fat rich dairy products, fatty animal meats and processed foods with an overreliance on seed oils and poor animal husbandry, is providing a pattern of eating which is likely to increase the risk of early morbidity and obesity.

When advising patients or clients to improve their diet, it is important for us to stress the benefits of an eating pattern rich in monounsaturated fats such as extra virgin olive oil and containing a healthy quantity of omega-3 polyunsaturated fats in the form of fish, nuts or other plant sources. We should be reassuring them that such a diet, in the context of a healthy lifestyle, is entirely consistent with optimum nutrition and the most likely means to achieve and maintain target weight.

Dr Simon Poole is a GP, author and authority on the Mediterranean diet

9. Ramsden, C; Zamora, D; Leelarthaepin, B; MajchrzakHong, S; Faurot, K; Suchindran, C; Ringel, A; Davis, J et al.

(February 2013). “Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis”. BMJ Group. doi:10.1136/bmj.e8707.

10. Sofi F, Cesari F, Abbate R, Gensini GF, Casini A (2008).”Adherence to Mediterranean diet and health status: meta-analysis”. BMJ (Clinical research ed.) 337 (sep11 2): a1344.doi:10.1136/bmj.a1344

11. P. Schieberle, V. Somoza, M. Rubach, L. Scholl, M. Balzer.

“Identifying substances that regulate satiety in oils and fats and improving low-fat foodstuffs by adding lipid compounds with a high satiety effect; Key findings of the DFG/ AiF cluster project “Perception of fat content and regulating satiety: an approach to developing low-fat foodstuffs”, 2009-2012 12. “Consumption of fried foods and risk of coronary heart disease: Spanish cohort of the European Prospective Investigation into Cancer and Nutrition study” BMJ 2012;344:e363

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G

ood design is known to have lasting positive effects on humans and website design is no exception. We expend much time and energy on marketing to get people to our website but often forget to recognise that a website’s design will directly affect its performance. If your website is poorly designed, users could click off as fast as they have clicked on. It is essential to have both a functional and attractive website. Remember, it is a direct reflection of your business.

A beautifully designed website is one that not only adheres to design principles but, more importantly, gets a message across and creates a lasting emotional impact on the person looking at it. A website should be both aesthetically striking and easy to use. If you can do all this you will greatly increase the performance of your website and, crucially, your business.

User experience If the person visiting your website can’t find what they are looking for or aren’t enjoying their visit, it’s too easy for them to quickly browse to another website. Internet users are, by nature, flighty and happy to look at other options without a second thought.

Gather your thoughts on what your website needs to do, how you want it to look, and in what way you want it to represent your business. It’s also useful to gain some market research. Most people are happy to offer an opinion that may provide you with key considerations which will make your updated or new website a resounding success.

Having a clear idea of what you want will make the task of building or updating your website much easier than if you simply have a vague notion of what you require.

When you have a firm idea in your mind, take it to an expert. In the website design world, you really do get what you pay for. You’ve probably seen the do-ityourself website packages advertised on television— while these are a good option for personal blogs or hobbyist websites, I’m not in favour of them for professional and business purposes. Would you feel

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safe living in a house in which you drew up the plans? Or would you prefer to live in a house designed by an architect?

It’s more important than ever to justify investments, both big and small. An investment in your website should pay for itself within a few months and, when executed properly, a website will probably be the best investment you’ll ever make as a business and you will reap the rewards of a job well done.

It can be tempting to opt for a cheap option but you simply won’t get the quality or the results from a DIY website that you would from working with a professional digital agency. You must keep in mind that the quality of your website is a direct reflection of your business.

The perfect partner Choose a website design agency that focuses on understanding your goals and puts a strategy together to help you achieve them. It also helps to find a company with experience working in your sector. Find out which team members will

be working on your project and see if you like them—you’re going to have to speak to them regularly for the next few weeks!

With a well thought out brief and tangible goals, a good agency will work with you to produce something truly fantastic that won’t cost a fortune.

A good website is a massive asset to a business. Intuitive, simple and elegant, it will not only represent you and your business positively but will undoubtedly increase sales and revenue.

Charles Southey is Operations Director at Digital Results, a digital agency that specialises in designing and developing highly effective websites and internet marketing campaigns for medical, healthcare and dental companies. As well as working with Wigmore Medical to produce their website, he has had great successes working on behalf of several organisations, in particular with FMC where he launched and continues to orchestrate the UK’s leading dental news website, Dentistry.co.uk. Follow Charles on Twitter - @csouthey 71

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skincare Lorna Bowes

Under the sun The dangers associated with under application of topical sunscreens are still misunderstood by the majority of sun-seeking consumers. Lorna Bowes discusses the latest US and EU regulations concerning sun protection products and cosmeceuticals

M

ost consumers are familiar with the acronym SPF—Sun Protection Factor—but what is frequently misunderstood is the scope of an SPF and the possibilities that cosmeceutical ingredients offer. They can help prevent dermal penetration of damaging ultraviolet light, as well as support the epidermis and dermis to withstand and avoid the changes associated with photoaging and photosensitivity.

From a dermatological point of view, the primary aim of SPF application is to limit exposure to ultra violet (UV) damage— the primary cause of skin cancer. UV is known to cause 90% of non-melanoma skin cancer and 67% of melanomas. However, over many years in aesthetic practice, I believe that patient motivation for application of topical products containing SPF can be divided equally between the desire for an even long lasting tan, body language www.bodylanguage.net

and the hope that applying SPF on a daily basis will reduce or prevent the ageing effects of sun exposure.

For many patients, the application of a topical to reduce the incidence of skin cancer is still too remote an idea for compliance. Understanding individual patient motivation may affect the level of success we achieve with patients when recommending that they apply appropriate and sufficient sun protection.

Chemical and physical SPF can be divided in to two main categories—chemical sunscreens and physical sunscreens. The main mode of action of physical sunscreens, such as titanium dioxide, is to scatter and block sunlight from penetrating the epidermis. Formulating cosmetically elegant sun protection with physical sunscreens has long been a challenge to manufacturers. Although the days of 73

skincare Lorna Bowes

the cricketer with the white striped nose are long gone, it is still complex to formulate a cream with no trace of white or blue sheen.

Chemical sunscreens simply absorb UV radiation, which then needs to be dissipated. This can cause creation of reactive oxygen species, and often leads to sensitivities. Chemical sunscreens are themselves damaged by exposure to UV, and as a result reapplication is necessary at frequent intervals—many sun protection products will be formulated with a wide selection of chemical sunscreens alongside physical sunscreen.

It is well documented that application of sun protection is frequently insufficient, with various studies underlying the chronic under-application of protection. One study showed that 98% of 352 family groups applied their sun protection once at the beach and therefore were not applying the sun protection as per the instructions for use which stated application 30 minutes before sun exposure.

A further study that looked at total application dosages showed that a dose of 30ml would be required for coverage at the standard recommended dose of 2mg/cm2 of skin.

This would represent less than seven doses in a 200ml bottle.

Facial powders require 1.2g for coverage to match recommended levels of the SPF stated on the manufacturers label; normal application of cosmetically appealing makeup coverage is less than 0.085g.

competent authority.

Many sun protection products—as with the vast majority of cosmeceutical ranges— are available both in the EU and the United States; indeed many top brands are manufactured in the US. Therefore FDA rules also affect the products available to us in UK and European aesthetic practice.

Since December 2012, new US regulations have been in place with regards to sun protection and sunscreen products. These rules apply to all products that state SPF or sun protection regardless of whether they are firstly sun protection products or cosmetics with the additional benefit of sun protection.

As a result of changes both in the US and Europe, there will hopefully be more information available to the general public regarding the scope of SPF. Very few people understand that an SPF only protects against UVB, so the new broad spectrum categorisation that requires a minimum of one third of the SPF rating to be UVA, the balance being UVB protection, should highlight this to the consumer.

Under EU regulation, SPF6 or below cannot be marketed as a sun protection product.

In the FDA ruling, only broad spectrum—UVA and UVB—sunscreens with an SPF value of 15 or higher can claim to reduce the risk of skin cancer and early skin ageing and then only if used as directApplication of sun protection is frequently ed with other sun protection insufficient with studies documenting measures. Non-broad specchronic under-application trum sunscreens and broad spectrum sunscreens with an Regulations SPF value between 2–14 can only claim to help prevent sunburn.

In the European Union, cosmeceuticals—including those claimThe claims “waterproof”, “sweatproof” or “sunblock” are ing sun protection benefits—fall under the regulations relating now no longer accepted by the FDA. Manufacturers cannot to cosmetics and new regulations that come in to force this year. claim to provide sun protection for more than two hours without The EU Cosmetics Directive 76/768/EEC is being replaced by reapplication or to provide instant protection immediately after Cosmetic Products Regulation 1223/2009, with the aim of har- application without submitting data to support these claims and monising and simplifying the cosmetics regulations across the obtaining FDA approval.

EU member states.

Water resistance claims must make clear whether the sunA major change introduced by the Regulation (EC) No. screen remains effective for 40 or 80 minutes while swimming 1223/2009 is with regard to cosmetovigilance, with the obliga- or sweating, based on standard testing—there is no longer cattion for brands and their distributors to notify Serious Unde- egory. Sunscreens that are not water resistant must include insirable Effects occurring in Europe to the corresponding local structions for consumers that it is necessary to use a water resist-

74

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skincare Lorna Bowes

It is important to protect the skin against UV, with protective clothing or a topical sun protectant

ant sunscreen if swimming or sweating.

Application of sunscreen can be subdivided in to two different scenarios—every day sun protection for exposed areas such as face, neck, forearms and lower limbs, and holiday sun protection for full body exposure. In both cases, however, application of the SPF whether as a lotion, cream, spray, gel, oil or powder is rarely in sufficient quantity to achieve the recommended level of protection, and rarely repeated adequately throughout the time of exposure.

There is a further conundrum to bear in mind when considering advice on sun protection. Sun is recognised as the best source of vitamin D and there is some evidence that vitamin D protects against cancers such as lung and prostate cancer. A glass of milk will provide 100IU of vitamin D whereas 20 minutes of unprotected full body sun exposure can provide 10,000IU. The conundrum is complicated by conflicting study results with regard to vitamin D and skin cancer protection. One large study of 374 control and melanoma patients showed no relationship between vitamin D consumption and melanoma risk. Another study suggests that sunscreen protection does not reduce vitamin D absorption. In contrast there are compelling studies showing reduced vitamin D levels associated with sunscreen application.

Ultraviolet protection There is a significant growth in the availability of clothing containing ultraviolet protection factor (UPF), including hats. Apparel manufacturers have voluntarily adopted this system which was developed in Australia in the mid 1990s. The tests have been developed worldwide, and vary from area to area with America referring to both the American Association of Textile Chemists and Colorists (AATCC) Test Method 183 and the American Society for Testing and Materials (ASTM) D 6544. A UPF labeling guide (ASTM D 6603) has also been adopted.

The European Committee for Standardization (CEN) has also created standards—a working group, CEN/TC 248 WG14 “UV protective clothing”, was set up with the mission to produce standards on the UV-protective properties of textile materials. The first part of the standard (EN 13758-1) dealt with all details of test methods—such as spectrophotometric meas76

urements for textile materials. The second part (EN 13758-2) covered classification and marking of apparel textiles.

UV-protective clothes claiming compliance with this standard must fulfill all stringent instructions of testing, classification and marking, including a UV protection factor (UPF) larger than 40 (UPF 40+), average UVA transmission lower than 5%, and design requirements as specified. Compliant garments are marked EN 13758-2 and state a UPF of 40+.

With all of this in mind, in a clinical setting it is relevant to counsel patients to wear a sun protection product during daylight hours, ensuring adequate application both in terms of volume and frequency, and to wear protective clothing. We also need to explain the need for cosmeceutical ingredients to protect and repair the dermis and epidermis as a result not only of the UV that will still affect the skin despite all the above measures and to manage and repair the existing photodamage.

Lorna Bowes is an aesthetic nurse with special interest in dermatology References 1. Hiom S. “Public awareness regarding UV risks and vitamin D – The challenges for UK skin cancer campaigns.” Progress in Biophysics and Molecular Biology, 2006, 92, 161-166.

2. Robinson JK, Rademaker AW. “Sun protection by families at the beach.” Arch Pediatr Adolesc Med. 1998:152:466.

3. Bauman L, Avashia N, Castanedo-Tardan MP. Cosmetic Dermatology; 29:245-255 4. Wienstock MA, Stampfer MJ et al. “Case controlled study of melanoma and dietary vitamin D: implication for advocacy of sun protection and sunscreen use.” J Invest Dermatol 1992;98:809 5. Marks R, Foley PA et al. “The effects of regular sunscreen use on vitamin D levels in an Australian population. Results of a randomised controlled trial.” Arch Dermatol 1995:131;415 6. Matsuoka LY, Wortsman J et al. “Chronic sunscreen use decreases circulating concentrations of 25-hydroxyvitamin D. A preliminary study.” Arch Dermatol 1988; 124:1802 7. Gambichler T, Laperre J, Hoffmann K. “The European standard for sun-protective clothing: EN 13758.” J Eur Acad Dermatol Venereol. 2006 Feb;20(2):125-30.

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

MULTIVITAMIN POWER SERUM

Dermalogica have launched MultiVitamin Power Serum containing hydroxypinacolone retinoate (HPR) to intercept signs of ageing including photodamage.

HPR does not require metabolic conversion and therefore does not trigger redness and irritation. The product also contains vitamins A, C, E and F to help reduce hyperpigmentation and smooth the surface of the skin and is fortified with palmitoyl hexapeptide-14 to aid collagen biosynthesis.

MultiVitamin Power Serum has been created as the daytime counterpart of Dermalogica’s Overnight Serum.

Dermalogica T: 01372 363600; W: dermalogica.com

 The ENERPEELS are chemical peels which focus on achieving activity within the skin rather than on the skins surface. They treat problems such as rosacea, thread veins and pigmentation.

ENERPEEL T: 08702 922014 ; W: skinmed.co.uk

ILIPO

i-Lipo is a multi platform body contouring system which uses visible red and infra red laser to biostimulate metabolic pathways resulting in the release of fatty acids and glycerol thus shrinking fat cells, say manufacturer Chromogenex. iLipo can be used to treat cellulite, stretch marks as well as providing circumferential reduction. i-Lipo can also measure body fat instantly and provides detailed analysis.

Chromogenex T: 01554 755444; W: chromogenex.com

 Iovera is a toxin free dynamic wrinkle treatment which uses Focused Cold Therapy.

It works by using the body’s natural response to cold to temporarily relax facial muscles that cause wrinkles. myoscience T: 02380 676733; W: iovera.com

PLIAGLIS

Pliaglis is a new self-occluding, nondrip topical anaesthetic cream from Galderma. It promises easy application and removal for convenience and enhanced patient experience.

Pliaglis contains a combination of 7% lidocaine and 7% tetracaine giving improved comfort to patients during dermatological procedues, along with long duration pain relief with a mean duration of anaesthesia of 9.4 hours.

Galderma T: 01923 208950; W: galderma.com

SILKANN

Sterimedix are introducing the Silkann range of aesthetic cannulas, designed for use injecting dermal fillers. These cannulas incorporate safety features alongside ease of use and are manufactured in the UK. Sterimedix Silkann cannulas come packed with a pre-hole needle in a larger size to facilitate smooth cannula insertion. Sizes range from 18g to 30g with varying lengths.

Sterimedix T: 01527 501480; W: silkann.com

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 Needlesafe has been developed to address the safe disposal of medical sharps. It has been designed to safely destroy hypodermic needles and in coming years will be developed to cover the full range of medical sharps.

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 Tropocells Platelet Rich Plasma has just been launched

by Medira Ltd. It is a clinically proven PRP system that will replace My Cells PRP in the UK. Tropocells uses a standard centrifuge and is FDA cleared and CE certified.

Medira Ltd T: 0800 2922014; W: medira.co.uk 79

experience Dr Michael Kane

State of the art Dr Michael Kane describes his aesthetic pathway, and how his artistic background has provided a solid foundation on which to base his approach to facial ageing

M

y obsession with beauty apparently began at a young age.

My mother tells me that when I was a toddler, I started tearing pictures out of magazines. Never pictures of cars or trucks or guns—this was the sixties—but only of beautiful women. Doris Day was my early favourite and her image was used to calm me down when in the throes of a “terrible twos” tantrum.

The story goes that I favoured Doris for some time—until I saw my first image of Audrey Hepburn and that was it for poor Doris. At least I had an excellent archetype of female beauty.

My next brush with art came as a fourth grader, during a city-wide art contest for each grade. Using coloured gels, glue and a marker, we were to design and submit a stained glass window. I liked the different colours I could make by overlapping the gels and started to free-form arrange them on my paper. My teacher told me not to overlap them because no one would be able to tell what I was making—I hated being told what to do.

Once my abstract colour collage was in place, I started to draw the wouldbe mortar between the glass bricks. My teacher told us to make sure we carefully outlined each of our colour transparencies so that the judges would be able to tell what we had made.

Since this was impossible due to my overlapping gels, I drew shapes I thought complemented but which did not mim-

80

ic my gels, to the consternation of my teacher. The other children made religious symbols and bridges; iconic things.

I made something beautiful.

Having won, my prize was a number of free Saturday morning art lessons at a school forty minutes away with the other grade winners. For our first lesson, we were given a handful of sharp gouges, linoleum tiles, ink and paper. I carved a few different leaf patterns—some positive and some negative—and printed them out with varying quantities of ink in decidedly irregular patterns. This began my obsession with negative space. I was a fan of Japanese artists Utagawa Hiroshige and Katsushika Hokusai before ever hearing their names or seeing their work.

Later, I was performing an upper and lower blepharoplasty with an excellent surgeon during my residency. He cut out the loose hanging skin, trimmed the hypertrophic muscle, cut out some fat and put it all back together with exquisite care. Her wrinkles and bulges were gone.

But looking at it from a negative space perspective, I thought she looked awful.

She looked older and quite unhealthy. She needed the hollows around her eyes filled and we had just done exactly the opposite.

When I became a plastic surgeon and started out on my own, I was still in my twenties which was unusual for that time—I had graduated from College in one year. I also looked a lot younger than I was so I figured it would be a tough start in practice. So I decided to do what I really wanted to do; go to film school.

At New York University, I was able to take most of my classes at night—except for lighting and cinematography, for obvious reasons. These also turned out to be my favourite classes, which spoon fed me the art of cinema, my least favourite.

I already had my own ideas about that. I suppose I wanted to be Stanley Kubrick.

If you wanted to light your leading lady of any age outdoors, you needed a reflector below her chin just out of the frame. Indoors, you needed a soft light from all angles. This allowed you to shoot her without those hollows showing up. We were working solely with young actresses trying to get their Screen Actors Guild cards. I always thought how difficult it would be to light an older actress

or, even worse, one who had her skin pulled and hollows worsened by an expert plastic surgeon.

Eight short years later and I was finished with film school. Next up for me was graphic and digital design at Parsons.

My favourite classes were package design, with no relevance to facial beauty, and sculpting. My sculpting teacher had a profound effect on my career. He knew more about facial ageing than any panel of plastic surgery experts at any meeting—or at least any panel that does not include Joel Pessa or Val Lambros.

When we wanted to age a bust, we would remove volume from around the eyes, mid, and upper face and add volume to the jawline and neck. This is exactly the opposite of current aesthetics teaching. Most podium experts will tell you to add toxin to the upper face (further atrophying it) and add volume to the lower face (adding to its descent).

For years, I had been performing a fat sparing lower blepharoplasty after seeing a Sam Hamra presentation, placing small amounts of fat in the lower lid. But for the past fourteen years, I have been adding, not subtracting, volume to the upper and lower lids, to the brows, to the temples, to the forehead and to the midface.

I try to make my patients more beautiful, not necessarily more smooth.

I still cannot stand being told what to do. I have never had a boss since my stints as a cook during medical school. I have never wanted an academic appointment because of this.

I have a secret goal of writing the most books, chapters and papers without an academic appointment anywhere. I have a feeling the artists I look up to now also have a low opinion of being ordered about. My current heroes are Nauman, Harvey, Bogosian and Sherman. Not a traditional painter or sculptor among them. But they all look at the world a little differently than everyone else does and that’s something I try to do every day.

Dr Michael Kane is a consultant plastic surgeon with a private practice limited to aesthetic plastic surgery in New York body language www.bodylanguage.net

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