Body Language Issue 58 by Body Language Journal

july/aug

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

 What goes into skincare products

 Mole imaging in aesthetic practice

Cellulite

CURRENT UNDERSTANDING OF THE CONDITION AND TREATMENT OPTIONS

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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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contents

body language number 58 14

ANALYSES Reports and comments

Guest Editor David Hicks 020 7514 5989 david@face-ltd.com

14 COVER STORY THE DOGMA OF CELLULITE Cellulite is one of the most common skin care concerns seen in modern day dermatology. Dr Masud Haq and Professor Syed Haq discuss the current understanding of the condition, using an evidence-based approach

Production Editor Helen Unsworth 020 7514 5981 helen@face-ltd.com Editorial Assistant Lara Arslanian 020 7514 5989 lara@face-ltd.com Sales Executive Monty Serutla 020 7514 5976 monty@face-ltd.com

 21 EXPRESS DELIVERY Mesotherapy involves the use of micro-injections to deliver vitamins directly to the skin’s mesotherm layer, activating circulation and regenerating cells. Malti O’Mahoney describes the benefits of treatment, particularly for cellulite  25 BODY CONTOURING Dr Yoram Harth discusses the latest advances in RF technology for treatment of cellulite

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

27 CONFERENCE SHAPING THE FUTURE OF AESTHETICS Book your place at the BODY Conference and Exhibition, held this year on the 2nd – 3rd November at the Royal Society of Medicine, London

Publisher Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com Contributors Dr Masud Haq Professor Syed Haq Malti O’Mahoney Dr Yoram Harth Dr Raj Persaud Esther Rantzen Anna Jean Lloyd Dr Julia Hunter David Rose David Hicks Wendy Lewis John D Warren Mr Shiva Singh Dr Anil Shrestha Dr Zein Obagi

7 OBSERVATIONS

30 PSYCHOLOGY

WAR PAINT Recessions, or tough economic climates, can subconsciously increase a woman’s desire to boost her attractiveness, or attract a mate. Dr Raj Persaud and Esther Rantzen survey the latest research into the “lipstick effect”

33 DERMATOLOGY A TOUGH ITCH TO SCRATCH Psoriasis is a chronic and prevalent disease, with limited effective treatment options. Anna Jean Lloyd takes a look at the existing landscape of therapies available and areas of promise on the horizon

36 SKINCARE

40 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 body language www.bodylanguage.net

RECIPE FOR SUCCESS Many skincare products make big promises, but we need to get past the marketing spiel to find out exactly what we’re putting on our patients’ skin. Dr Julia Hunter delves into the science behind product ingredients, particularly their role in inflammation and skin toxicity

40 FINANCE EQUIPMENT FINANCE When considering acquiring new equipment, the question of how to pay for it has to be addressed. David Rose provides an overview of the available options and considerations before making your decision

43 ANTI-AGEING DIVIDE AND CONQUER Research into the health effects of telomere shortening and cell division is still in its infancy but their role in disease and ageing 3

body language

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

number 58

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. Professor Syed Haq trained at Harvard Medical School, Massachusetts General Hospital and Tufts University, New England Medical Center. Professor Haq is Director of The London Preventative Medicine Centre, Harley Street. Syed is an honorary consultant at the Chelsea and Westminster Hospital NHS Foundation Trust. Professor Andy Pickett has worked on botulinum toxins for over 23 years. Andy has lectured around the world on the products, translating the science into practical understanding for injectors. In 2011 Andy founded Toxin Science Ltd and is head of development at Q-Med.

Fiona Collins and Marie Duckett are registered nurses and members of the Royal College of Nursing forum for nurses in aesthetic medicine. Their clinic, Fiona and Marie Aesthetics Ltd, is based in Harley Street. Anthony Erian FRCS (Erg) FRCS (Ed) is an aesthetic plastic surgeon with more than 30 years’ experience. He is a member of the American Academy of Aesthetic and Restorative Surgery and chairman of the European Academy of Aesthetic Surgery. Mr Erian practices in Cambridge and Harley St. Dr Stephen Bassett is medical director of the Aesthetic Training Academy and ShapeCYMRU Cosmetics. He is a Syneron luminary and member of the Merz academy, focusing on RF facial procedures. He is a barrister, fellow of the Society of Advanced Legal Studies and a legal consultant. Elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies. She is now director of education at LCS Academy Ltd in Milton Keynes. Dr Séan Cummings MBBS T(GP), DRCOG, DFFP, MRCGP, LLM is a cosmetic doctor practising in Harley Street. Dr Cummings has more than 20 years’ experience as a practitioner and has a masters degree in medical law. Dr Cummings works as an expert witness and has sat on GP disciplinary hearings 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. 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.

is becoming more widely understood. David Hicks describes their function and the significance of telomerase

47 MEDICAL AESTHETICS FACE OF THE FUTURE With the industry evolving year on year, Wendy Lewis runs through the top ten medical aesthetic trends of 2013, including advanced technology, fillers and social influence

50 DERMATOLOGY SKIN LESION IMAGING With high melanoma rates, the UK has a comparatively low number of consultant dermatologists and mole clinics. John D Warren discusses the integration of mole imaging within private aesthetic practices to cut unnecessary excision rates and describes the benefits of Derma Medical’s MoleMax systems

55 PRODUCTS ON THE MARKET The latest products in aesthetic medicine, as reported by Helen Unsworth

58 SURGERY FLEX YOUR MUSCLES The appearance of toned muscles, both in the legs and chest, are a common aesthetic ideal among consumers. Relatively low-risk surgical procedures such as calf and pectoral augmentation can provide natural results, writes Mr Shiva Singh

60 DENTAL HOLLYWOOD SMILE When it comes to the ageing face, one of the most effective cosmetic enhancements concerns the teeth—restoring our pearly whites to their former glory. Dr Anil Shrestha discusses the origins and benefits of the smile makeover

62 EXPERIENCE UNDER THE SKIN Dr Zein Obagi describes the origin of his approach to skin health body language www.bodylanguage.net

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observations

Sweden recommends PIP implant removal MHRA advises against the measure

A report released by the Swedish Medical Products Agency (MPA) and the National Board of Health and Welfare has stated that all breast implants manufactured in the country by Poly Implant Prothèse (PIP) should be removed as a preventive measure. More than 300,000 women across 65 countries received PIP implants, of which 4,000 reported ruptures. Implants manufactured by PIP have a poorer mechanical durability, increasing the risks of ruptures, and also contain the irritant substance octamethylcyclotetrasiloxane (D4) in higher concentrations than other silicone breast implants. The MPA implemented a ban on the use of PIP breast implants in March 2010. Clinics that have used PIP implants in the past have been recommended to inform affected patients of the risks. The recommendations from the Swedish report are based

on a “changed state of knowledge”, stating that “the examination of a number of removed PIP implants with large ruptures shows that the silicone gel within the coating has changed its character”. Despite no immediate health risks associated with PIP implants, the MPA recommends that they should be removed as a precautionary measure. Clinics should also contact women who have received PIP implants to inform them; those who choose not to have the implants removed should be made aware of the signs of a ruptured implant or inflammation. The British Association of Aesthetic Plastic Surgeons (BAAPS) has reiterated its call for similar measures to be brought into effect in the UK. BAAPS President Mr Rajiv Grover says the Association has long been warning that a safety loophole with PIP implants relates to a lack of in vivo testing, or analysis performed on im-

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plants removed from the body. “The Swedish findings, which have been undertaken in this manner, show that when inside the body the silicone alters in such a way that doesn’t ‘stick together’ as well, allowing it to disperse more easily. “It is known that there is a subgroup of PIP implants in which the concentration of an irritant compound (known as D4) is higher than in others, but there is no way of knowing which ones are affected. This is why the Swedish government has made the decision to remove all PIPs as a preventative measure,” says Mr Grover. “The combination of higher concentrations of D4 and the changes in the silicone which happen when the implant is within the body, finally explain the issues that surgeons and patients have been seeing and experiencing around the country. We urge the Government, who we know have collected in vivo specimens, to perform similar analyses—as a matter of urgency,” he says. However, the UK’s Department of Health disagrees, and recommends that implants should not be removed. “Our independent expert group— chaired by the NHS Medical Director Professor Sir Bruce Keogh—looked in detail at worldwide toxicological studies last year and found that the silicone contained in PIP breast implants does not pose a longterm risk to human health,” says the statement released by the DoH. The response states that siloxanes—silicone derivatives commonly used in consumer hair and skin products—have been investigated and that only small concentrations were found in the defective implants, posing no significant risk to health. “The UK regulator, the MHRA, keeps all evidence under review and will speak to the Swedish health au-

thorities to explore the basis for their advice,” says the DoH. Sir Keogh’s “Final Report of the Expert Group” came to the conclusion that “rigorous world-wide chemical and toxicological analyses of a wide variety of PIP implants have not shown any evidence of significant risk to human health.” As a result, “there is no reason to believe that further testing will change this conclusion, given the results of the chemical analysis and the number of batches that have now been tested world-wide, which have all reached a similar conclusion.”

Book unveils evolution of facial surgery A new book has been writen by Dr Bryan Mendelson, plastic surgeon and former president of the ISAPS, to provide insight into the evolution of facial plastic surgery and the reasons people desire to change the way they look. “In Your Face” is aimed towards the public, however the book now also forms part of the reading curriculum for trainee surgeons undertaking a cosmetic surgery degree at Anglia Ruskin University in Essex. According to Dr Mendelson, aesthetic surgery patients often “have reached a point in their lives where their appearance is holding them back in some way or affecting their ability to fully enjoy their lives.” For Dr Mendelson, surgery is a vehicle to improving self-esteem. “People don’t have surgery to look better, they have surgery to improve the way they feel about the way they look”, he explains.

observations

second brief

UNDER THE INFLUENCE In a blind online consumer survey on cosmetic dermatologic procedures, the American Society for Dermatologic Surgery (ASDS) asked more than 6,300 consumers for consumer opinion on cosmetic treatments. The survey shows that three in 10 consumers are considering cosmetic procedures, with dermatologists named as the greatest influence for their decision.

While 6.4% of those surveyed had had a cosmetic treatment, nearly 30% said they were considering a procedure. For 9/10 procedures, consumers chose dermatologists as the physician of their choice.

Growth attributed to technology and efficiency According to a US market report published by Transparency Market Research, the global skincare devices market is predicted to reach an estimated value of USD10.7 billion by 2018. The report, “Skincare Devices Market— Global Industry Analysis, Size, Share, Growth, Trends and Forecast, 2012-2018”, says the market was valued at USD 5.4 billion in 2011. The forecast annual 10.1% projected growth has been attributed to technological advancements in product design, increasing device efficiency and adoption of minimally and non-invasive procedures for enhanced patient comfort. Skincare devices included in the report are those used for lasabrasion, microdermabrasion, liposuction, LED therapy, desmotoscopes, skin rejuvenation, cellulite reduction, skin tightening, body contouring and hair removal. “Skincare devices are gaining importance not only due to their extensive use in aesthetics but also the increasing incidence of skin dis-

orders worldwide,” says Transparency Market Research. The sector’s market growth relates to a rise in global incidence of skin cancer and skin disorders such as psoriasis, dermatitis and acne, and abnormalities such as moles, warts and lesions. Demand for aesthetic procedures such as liposuction, skin rejuvenation, skin tightening, hair removal and body contouring is also expected to drive the market. LED therapy devices account for the largest share of the total skincare treatment device market, while the lasabrasion devices market is to record the highest growth during the forecast period. The increase of liposuction and hair removal procedures make these market segments highly appealing in terms of revenue, and interest in laser and light based devices for aesthetic treatments will add to annual growth. North America accounted for the largest market in 2011, while the Asia-Pacific region is expected to record the highest growth at a CAGR of more than 11%.

Conditions that consumers are most concerned about include:

Call for junk food ban in hospitals

 Excess Weight (80%)

NHS: food brands “normalise” environment

 Lines and wrinkles around the eyes (63%)

In an effort to fight rising obesity rates across the UK, the British Medical Association has been called upon to help ban unhealthy food and drink from British hospitals. The motion, proposed by cardiologist Dr Aseem Malhotra, will be put into effect if supported by health professionals. “An oversupply of nutritionally poor and energy dense foods loaded with sugar, salt and trans fats, fuelled by aggressive and irresponsible mar-

 Skin texture and/or dislocation (62%)  Sagging facial skin (61%)  Excess fat under the chin (60%)  Lines, wrinkles and/or folds in the mid-face around the cheeks and mouth (60%) Consumer satisfaction rates for cosmetic procedures were overall higher when performed by dermatologists than by other practitioners, with 92% of consumers being satisfied with the wrinkle and injectable filler treatments performed by dermatologists. Source: The American Society for Dermatologic Surgery

Skincare devices market to reach $10bn by 2018

keting by the junk food industry has even been allowed to hijack the very institutions that at are supposed to set an example and promote positive health messages; our hospitals,” says Dr Malhotra. However, NHS management has already showed resistance. Dr Johnny Marshall, GP and NHS Confederation director of policy, says: “These brands and outlets help normalisation of the hospital environment, which is important for good patient experience”.

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observations

training & events FDA approves silicone gel implant

Long term follow up needed

IMCAS ASIA 27 – 29 July, Singapore

JULY

SEPTEMBER

18 – 20 July, 8th World Congress of Melanoma, Hamburg, Germany W: esdr.org

2 & 3 September, ZO Medical and Sculptra training, Wigmore Medical, London W: wigmoremedical.com

27 July, Introduction to Toxins training, Wigmore Medical, London W: wigmoremedical.com

3 – 4 September, Advanced Skills in Hand and Wrist Surgery 2013, The Royal College of Surgeons of England, London W: rcseng.ac.uk

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 3 August, Mesotherapy training, Wigmore Medical, London W: wigmoremedical.com 5 August, ZO Medical training, Wigmore Medical, London W: wigmoremedical.com 9 August, PRP training, Wigmore Medical, London W: wigmoremedical.com 8 & 9 August, Foundation Botulinum Toxin Part I and Foundation Dermal Fillers Part I, Dr Brian Franks Training, Watford, London W: drbrianfranks.com 15 & 16 August, Advanced Botulinum Toxin Part II and Advanced Dermal Fillers (Volumising) Part III, Dr Brian Franks Training, Watford, London W: drbrianfranks.com 16 August, Business Development training, Wigmore Medical, London W: wigmoremedical.com 17 August, Foundation Botulinum Toxin and Dermal Filler, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 22 – 25 August, 5th European Plastic Surgery Research Council, Hamburg, Germany W: epsrc.eu 23 – 25 August, Swedish Society for Aesthetic Plastic Surgery 5th Scandinavian Aesthetic Surgery, Uppsala, Sweden W: sfep2013.se 25 – 29 August, 34th Annual Conference of the International Society for Clinical Biostatistics, Munich, Germany W: iscb2013.info/welcome-to-munich.html

5 – 7 September, 8th BAPRAS Congress & IPRAS Symposium, Budva, Montenegro W: baprascongress2013.com 9 – 13 September, Medik8 Dermal Roller, Skincare & Chemical Peels, Intro to Toxins, Intro to Dermal Fillers and Refresher Toxins & Fillers, Wigmore Medical, London W: wigmoremedical.com 12 – 14 September, German Society of Plastic, Reconstructive and Aesthetic Surgeons 44th Annual Meeting of the DGPRÄC and 18th Annual Meeting of the VDÄPC, Exhibition And Congress Centre Hall, Muenster, Germany W: dgpraec-tagung.de 18 – 21 September, 5-Continent Congress, Palais des Festivals et des Congrès, Cannes, France W: 5-cc.com 20 & 21 September, Innovations in Aesthetic Breast Surgery 2013, Tulsa Surgical Arts, Tulsa, USA W: cosmeticsurgery.org 20 & 21 September, Canadian Society For Aesthetic Plastic Surgery 40th Annual Meeting, Fairmont Hotel, Vancouver, Canada W: http://csaps.ca 23 – 25 September, Oncoplastic and Reconstructive Breast Surgery 5th International Meeting, East Midlands Conference Centre, Nottingham W: orbsmeetings.com 25 – 28 September, Italian Society Of Plastic Reconstructive And Aesthetic Surgery 2013, Sheraton Nicolaus Hotel, Bari, Italy W: sicpre.it OCTOBER 2 – 5 October, World Congress of Liposuction, Millennium Broadway New York, USA W: cosmeticsurgery.org 2 – 6 October, 22nd EADV Congress, Istanbul, Turkey W: eadvistanbul2013.org

3 – 5 October, American Society for Surgery of the Hand 68th Annual Meeting 2013, Moscone West Convention Center, San Francisco, USA W: assh.org/annualmeeting/AnnualMeeting2013/ 28 – 31 August, 15th European Burns Association Pages/default.aspx Congress, Vienna, Austria 10 – 13 October, 51st Annual Meeting of the W: eba2013.org German Society for Plastic and Reconstructive 28 – 31 August, Australasian Society of Aesthetic Surgery Association 2013, Ulrania, Berlin W: dgpw-kongress2013.de Plastic Surgery Non-Surgical Symposium 2013, Hilton Sydney, Australia 10 – 18 October, Business Development, ZO W: asapsevents.org Medical, Skincare & Chemical Peels, Intro to 31 August, Microsclerotherapy training, Wigmore Toxins, Intro to Fillers and Advanced Toxins & Fillers training, Wigmore Medical, London Medical, London W: wigmoremedical.com W: wigmoremedical.com To have an item included in Training & Events, send it for consideration to helen@face-ltd.com

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After processing six years’ worth of data from 955 implant patients, the US Food and Drug Administration (FDA) has given the green light to the Mentor siliconegel filled MemoryGel breast implants. The implants have been approved for women aged 22 years or more, and for women of any age requiring breast reconstruction procedures. The investigation concluded that complication rates and outcomes were fairly similar to other approved breast implants already found on the market. According to Mentor, the teardrop shape of MemoryGel breast implants gives a “more natural shape and youthful feel” for breast augmentation and reconstruction procedures. The implants are filled with a cohesive gel that enables shape retention. Reported complications from MemoryGel breast im-

plants include capsular, asymmetry, wrinkling and implant removal. Few cases of Gel fracture were observed. Dr J Shuren, FDA director of the Center for Devices and Radiological Health, says the breast implants will require long-term monitoring. “The data we reviewed showed a reasonable assurance of safety and effectiveness. We will be looking at the results for post-approval studies that will focus on the implants’ long-term safety and effectiveness.” Post-approval studies require Mentor to keep on following the 955 study patients for a period of ten years. As part of a continued access study, five-year evaluations must also be followed on 350 women who received the MemoryGel medium height moderate profile breast implants. Data gathering on long-term local complications will be carried out on around 2,500 women receiving MemoryGel Breast Implants.

Stress resistant stem cells found in fat May provide understanding of cancer cells A new population of stressresistant human pluripotent stem cells has been discovered by scientists at the UCLA Department of Obstetrics and Gynecology. The Multi-Lineage Stress-Enduring (MuseAT) cells are easily derived from adipose tissue and are able to discern every cell type in the human body without genetic modification—providing “potentially superior cell sources for regenerative medicine”. The cells were discovered by “scientific accident”, when a piece of equipment failed to work in the lab. All stem cells suffocated in the experiment, except the Muse-AT cells. The

study’s senior author Dr Gregorio Chazenbalk found that not only are Muse-AT cells able to survive under severe stress, they may even be activated by it. An examination of genetic characteristics confirmed their specialised functions, as well as their capacity to regenerate tissue when transplanted back into the body following their “awakening”. Dr Chazenbalk believes that as well as providing a potential source of cells for regenerative medicine, Muse-AT cells may provide a better understanding of cancer cells; the only other cells known to display similar stress resistance. 11

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cover story Professor Syed Haq & Dr Masud Haq

The dogma of

cellulite Cellulite is one of the most common skin care concerns seen in modern day dermatology. Dr Masud Haq and Professor Syed Haq discuss the current understanding of the condition, using an evidence-based approach

he widely recognised presence of cellulite is represented by areas of “orange peel” or “cottage cheese” skin, most notably distributed in the lower extremities. Cellulite is regarded as a major problem affecting both genders, though it is most prevalent in postpubertal women (80-90%) and is rarely observed in men. Cellulite was first described as “a spreading gangrenous infection of the subcutaneous cellular tissue”. In fact it is the herniation of fat within fibrous connective tissue that manifests topographically as skin dimpling and nodularity. Other names which have been used as descriptive terms include gynoid lipodystrophy, liposclerosis, oedematofibrosis and dermapanniculitis. Causes The aetiology of cellulite is multifactorial. Causes include hormonal dysfunction with increased oestrogen release being central, abnormalities of oestrogen receptor function, hyperinsulinemia, altered catecholamine ratios, hyperprolactinaemia, an abnormal hypothalmao-pituitary-adrenal axis, adipose tissue hypoxia and genetic causality (especially in men as seen in the trisomy Klienfelter’s Syndrome 47XXY). Dietary practices can also have a positive and negative im-

pact. Excessive dieting can lead to stress. So even though one may be losing subcutaneous fat, an individual can actually worsen the appearance of cellulite; it’s not simply because ones herniated fat is more visible. The role of genetic polymorphisms in the pathogenesis of cellulite has been recently highlighted. Adipose tissue hypoxia, with reduced peripheral circulation or dysfunctional microvasculature, could be associated with an increased risk of cellulite. In a 2010 landmark paper by Emanuele et al., an analysis of 200 lean women compared with 200 age- and BMI-matched women showed an association with two particular types of genetic polymorphisms. The first polymorphism was observed in the angiotensinconverting enzyme exopeptidase (RAAS), which is important in the regulation of blood pressure, water reabsorption, sodium and potassium balance. The second was found in the transcription factor—hypoxia-inducible factor 1-alpha (HIF-1α). So why is this so important? A 2011 paper by Zhang et al. showed that inhibiting the HIF transcription factor can lead to increased dietary obesity. The transcription factor functions both at the level of hypothalamus and peripherally, so will affect adipocyte tissue, adipogenesis and propagation of a disease such as cellulite. body language www.bodylanguage.net

cover story Professor Syed Haq & Dr Masud Haq

However, cellulite can have a positive or negative impact. In 2002, Dr Goldman described cellulite as a normal physiologic state in post-adolescent women. When maximising subcutaneous fat retention during pregnancy for example, caloric reserve can only be achieved with sufficient levels of energy intake, thus conferring support for the unborn fetus and thermal protection. In terms of cosmetic appearance, it has a negative impact on women. Its classic distribution can be defined as the upper and lower limbs, breast, pelvic region and, most commonly, the gluteal-femoral zone and abdomen. The clinical classification and grading of cellulite was first defined by Nürnberger and Muller in 1978. The gradation ranges from zero to three and the key element to look for is the emergence of the “mattress phenomenon” upon a pinch test. This is demonstrated when dimpling of the skin is present when the patient is lying down, standing or both. In the worst case—grade three—the dimpling is always there, irrespective of the patient’s position. With grade one, cellulite only appears when carrying out a pinch test. In 2000, Rossi et al. expanded the classical criteria of cellulite grading to include the principle of gluteal contraction. Using a classification system ranging from grade 1–3, where grade three signifies the worst clinical grade and the greatest emergence of symptoms. Grade one refers to skin appearing smooth with the patient standing, with dimpling being observed on contraction of the gluteus muscles alone. Grade two to three refers to a gradual worsening, being most unsightly in grade three where body language www.bodylanguage.net

dimpling is most visible independently of contraction of the gluteus maximus. The photonumerical scale has also been used, as described by Perin et al. in 2000. This uses a compression model of the thigh, showing a visible increased gradation of cellulite. Pathogenesis As previously described, the aetio-pathogenesis of cellulite is a very complex problem. Oedema, or fluid retention, has a part to play. When we see excessive hydrophilia, with increased glycosaminoglycan deposition in the coonective tissue, this has the effect of alterating in the intercellular matrix and activating local fibroblasts. Regional activation of fibroblasts can disrupt the connective Cellulite grading (Nürnberger and Müller 1978) Grade

Definition

• Smooth surface of skin while lying down and standing • Wrinkles upon pinch test

• Smooth surface of skin while lying down and standing • Mattress-phenomenon upon pinch test

• Smooth surface of skin while lying down • Mattress-phenomenon spontaneously while standing

• Mattress-phenomenon spontaneously while standing and lying down 15

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cover story Professor Syed Haq & Dr Masud Haq

(i)

(ii)

(iii) The Rossi clinical grade for cellulite

SEVERITY A photonumerical scale for cellulite, using the compressed thigh model

Epidermis dermis

PIT VALLEY SEPTUM

RADIAL septae

Papillae adiposae

Subcutis Fat-cell chambers

Altered subcutaneous fat distribution is a hallmark feature in cellulite 2. Herniation of Hypodermis

1. Dermis 3. Superficial HD

4. Middle HD Areolar zone 5. Deep HD Lamellar Zone

Schematic representation of the hypodermis body language www.bodylanguage.net

CAMPER’S FASCIA

tissue. Micro circulatory changes, altered subcutaneous tissue and gender differences in the extracellular matrix are additional causal factors. Altered subcutaneous fat distribution is a hallmark feature of cellulite. Vertical and radial septi are normally found in the subcutis—also known as the hypodermis—and is distal to the dermis (see “Altered subcutaneous fat distribution”, upper panel). When cellulite is present, valleys or invaginations of fat create pits when there is insufficient tensile strength pulling back the fat from emerging and encroaching into the dermis (see “Altered subcutaneous fat distribution”, lower panel). This exterior dimpling results in papillae adiposae. Microvasculature changes are very important to the pathogenesis of cellulite. Blood vessel ectasia, microvaricosities and altered capillary flow have a tendency to lead to increased zonal hypoxia, which effects the underlying tissue architecture through premature cell loss in the subcutis. Cellular changes go from anisopoikilocytosis, cellular membrane rupture, apoptotic adipocytes and, ultimately, to sclerosis. A schematic diagram, defined by Mirrashed et al. in 2004, describes herniation into the dermis by adipose tissue. The superficial hypodermis, middle hypodermis (areola zone) and deep hypodermis (lamellar zone), which are separated by Camper’s fascia, show the complex nature of the subcutis architecture. Camper’s fascia is very important as the demarcation line between the areola and lamellar zones. The areolar zone of fat is very sensitive to oestrogen, while the deeper lamellar zone is more weight sensitive—when women lose fat, this area is particularly prone. Sometimes over-zealous use of phyto-oestrogens can impact on cellulite risk by directly affecting the areolar zone. This is more clearly represented in a high spatial MRI of the back of the thigh, when thinner slices of 0.5mm are taken (see “High spatial 2D MRI imaging of the hypodermis”). The scan shows that adipocytes are quite vertically positioned. Below Camper’s fascia, they appear more “columnar-like” and flatly-aligned. The vertical septi are non-angulated, which increases the risk of developing cellulite through herniation into the dermis. The number of superficial hypodermic herniations correlate with the grade of cellulite. Fibrous septi Gender differences also play a major part in whether or not one has cellulite. There are certain reasons why some women have an increased risk. When we look at the vertical septi in women, there is a greater preponderance of herniation of the adipose tissue into the corium, also known as the deep dermis. In men, however, a tangential cross-hatching of their connective tissue halts the herniation of fat. The differences in fibrous septi architecture is partly hormonal and genetic in origin. A 3D generated image of a female cellulite sufferer’s hypodermis (see “Fibrous septi 3D architecture”) shows very vertical, perpendicular fibrous septi. A woman with no cellulite has a much higher concentration of vertical septi which prevents the herniation from occurring. In men, this is even more apparent, with cross hatching and a tangential appearance of the fibrous septi. The regulation and determination of the patterning of fibrous septi suggests multiple causes including activation of retinoic acid, retinoid receptors and PPAR-gamma (the peroxisome proliferator of activated receptor). All three function as nuclear receptors. They are hormone sensitive and can be regulated by retinoic acid, or derivatives, like the 9-cis-retinoic acid or various ligands. The nuclear receptors have been shown to regulate 17

cover story Professor Syed Haq & Dr Masud Haq

lipolysis, thermogenesis, melanogenesis and fibroblast activation, as well as metallomatrix proteases—which have an integral part to play. Treatment options The treatment options for cellulite are wide ranging and vary in efficacy. Consideration of an evidence-based methodology to treat cellulite have pointed to the potential benefits of a number of topical agents. The methylxanthines—like caffeine, theophylline and aminophyllines—may provide a modest solution. These have shown positive effects, with around a 10% improvement. Certain herbal additives, such as capsaicin (a caffeine-like substance), when applied topically have also been associated with modest improvement. An average 2.8mm reduction in cellulite has been observed using topical horse chestnut and ivy when examined in prospective studies. Using topical retinoids at a dose of 0.3% (w/v), over a prolonged period of time can lead to quite significant dermal-epidermal protein production with the resultant increase in oncotic pressure causing reduced oedema. Conjugated linoleic acids also reduce invagination, increase collagen synthesis and alter adipogenesis. Linoleic acid is a regulator of PPAR-gamma and is found in a number of cellulite topical products. Alpha-hydroxy acids do not have an effect on the dermis— they effectively resurface the epidermis, so a cosmetic effect but not a structural change can be achieved. Oral derivatives of linoleic acid and dacosahexaenoic acid have been shown to stimulate PPAR-gamma. A study demonstrated that 75% of women had nearly a one inch reduction in their thigh circumference and improvement in their cellulite over 60 days when using either agent. Centalla asiatica is also a PPAR-gamma agonist and has been shown to reduce the diameter of adipose size and improve lymphatic drainage when taken orally. Finally green tea, which contains polyphenols, can result in a 4.8% reduction in body weight and waist circumference because of its action on gastric lipases and thermogenesis. It also stimulates PPAR-gamma and alpha and has been shown to have a positive impact on cellulite. Other methods that are routinely used to battle against cellulite include massage. In certain multi-platform systems, deep mechanical massage—first introduced in the 1990s with Endermologie—showed a 28.5% improvement at 12 weeks. Importantly, there were variable results observed with a single element treatment option. The mechanism of action used increased tensional force, improved collagen banding, tensile strength and promoted keratinocyte proliferation and adipocyte differentiation. This had a clear effect on the fibrous septi framework. Early studies by Dr Fink, on a fairly small population of patients, showed short term improvement using intense pulsed References 1. Nürnberger F, Müller G. “So-called cellulite: an invented disease”. J Dermatol Surg Oncol. 1978 Mar;4(3):221-9. 2. Emanuele E, Bertona M, Geroldi D. “A multilocus candidate approach identifies ACE and HIF1A as susceptibility genes for cellulite”. J Eur Acad Dermatol Venereol. 2010 Aug;24(8):930-5. 3. Rossi AB, Vergnanini AL. “Cellulite: a review”. J Eur Acad Dermatol Venereol. 2000 Jul;14(4):251-62. 4. Perin F, Perrier C, Pittet JC, Beau P,

light, with around 50% efficacy in terms of numbers of responders. Combination devices, as described by Dr Gold showed in 2006 that with a 20-minute, three weekly session of TriActive, patients saw a 23% improvement in cellulite. With VelaShape, which uses a bipolar radiofrequency and infrared system, you can see an even better improvement with some maintenance and sustained effects over a six-month period. One of the drawbacks of this particular system, however, is the ecchymosis and bruising that you can get in about a third of patients. Cynosure’s SmoothShapes is a low energy (FDA-cleared light) device that uses two wavelengths within its system. The shorter wavelength makes the adipocyte more porous. Liquefaction of fat and improved lymphatic drainage are features of the device. In a larger population study of 65 patients, patients saw an 88.9% improvement. A combinatorial approach in the treatment protocol must be the way forward in developing an effective long term therapy for cellulite, as we have to deal with many underlying issues that include altered microvascular function, transcriptional, altered lymphatic drainage and the extracellular matrix. Dr Masud Haq is a consultant endocrinologist and Professor Syed Haq is a consultant physician at the London Preventative Medicine Centre, 10 Harley street. Both physicians are on the editorial board of Body Language

CAMPER’S FASCIA 3 mm slice

0.5 mm slice

High Spatial 2D MRI imaging of the hypodermis Female—cellulite

Female—no cellulite

Male

Fibrous septi 3D architecture, comparing female sufferer with female non-sufferer

Schnebert S, Perrier P. “Assessment of skin improvement treatment efficacy using the photograding of mechanically-accentuated macrorelief of thigh skin”. Int J Cosmet Sci. 2000 Apr;22(2):147-56. 5. Piérard GE, Nizet JL, Piérard-Franchimont C. “Cellulite: from standing fat herniation to hypodermal stretch marks”. Am J Dermatopathol. 2000 Feb;22(1):34-7. 6. Mirrashed F, Sharp JC, Krause V, Morgan J, Tomanek B. “Pilot study of dermal and subcutaneous fat structures by MRI in individuals who differ in gender, BMI, and

cellulite grading”. Skin Res Technol. 2004 Aug;10(3):161-8. 7. Zhang H, Zhang G, Gonzalez FJ, Park SM, Cai D. “Hypoxia-inducible factor directs POMC gene to mediate hypothalamic glucose sensing and energy balance regulation”. PLoS Biol. 2011 Jul;9(7):e1001112. 8. Querleux B, Cornillon C, Jolivet O, Bittoun J. “Anatomy and physiology of subcutaneous adipose tissue by in vivo magnetic resonance imaging and spectroscopy: relationships with sex and presence of cellulite”. Skin Res Technol. 2002 May;8(2):118-24.

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Azzalure® Abbreviated Prescribing Information Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP) IRE 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: January 2011.

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injectables Malti O’Mahoney

Express delivery Mesotherapy involves the use of micro-injections to deliver vitamins directly to the skin’s mesotherm layer, activating circulation and regenerating cells. Malti O’Mahoney describes the benefits of treatment, particularly for cellulite

evised by French physician Dr Michael Pistor in the 1950s, mesotherapy was originally used for treating conditions such as rheumatic diseases, sports traumas, infectious diseases, vascular diseases and for improvement of the circulation. With mesotherapy, the medicine is injected into the cellulite or fatty tissue to improve circulation of lymphatic and venous drainage by increasing metabolism of injected area. The procedure mimics the biological fat burning mechanism during weight loss. Mesotherapy has been part of mainstream medicine in France since 1987, when it was recognised by the French Académie Nationale de Médecine as a medical speciality. The first university degree course in mesotherapy was introduced in Marseille in 1989, and other universities in Paris, Bordeaux, Dijon and elsewhere followed suit. The UK saw its first university-accredited training course for registered doctors and nurses introduced at the University of Greenwich in 2008. Since its inception in France, physicians across the globe have increasingly

body language www.bodylanguage.net

begun to incorporate mesotherapy into their practice. Its popularity spread first across Europe and South America and it is now increasingly being practised in North America, Canada and Australia. It is estimated that around 18,000 physicians worldwide now practice it regularly and the number is increasing. Therapy The philosophy of mesotherapy concentrates on delivering treatment direct to the problem site, thereby increasing its effectiveness. The mesoderm is the middle of three germ layers formed in the human embryo during gastrulation. It differentiates into numerous different organs and tissues, including: cardiac, skeletal and smooth muscle, bones, cartilage, the majority of kidney tissue, red blood cells and the layer of skin beneath the epidermis comprising the dermis and subcutaneous tissue. The skin here is richly vascularised and innervated, which may account for some of the systemic effects achieved by small, local injections of medication. When delivered to the dermis, these medications can enter the blood and lymphatic circu-

latory systems whilst avoiding the main digestive system, and waste products are excreted through the kidneys as urea. Cellulite appears in the subcutaneous level of skin tissue. Fat cells are arranged in chambers surrounded by connective tissue called septae. As water is retained, fat cells held within the perimeters of this area expand and stretch the connective tissue. Eventually this connective tissue contracts and hardens (sclerosis) holding the skin at a non-flexible length, while surrounding tissue continues to expand with weight or water gain. In women, the dermis reaches its maximal thickness at 30 years of age. After that, the dermis area—which is bound together by the connective tissue—starts to get looser due to the ageing process of the collagen and elastic fibres. This allows more adipose cells to protrude into the dermis area, accentuating the sight of cellulite. In addition, an increased deposition of subcutaneous body fat may often reflect a lifestyle with less exercise and changes in dietary consumption. It is well-established that women generally have a higher percentage of body fat than men. 21

injectables Malti O’Mahoney

Cellulite is rarely seen in men—both obese and non-obese—because the epidermis, dermis and uppermost part of the subcutaneous tissue is different in males. Men have thicker epidermis and dermis tissue layers in the thighs and buttocks. More distinctively dissimilar, the first layer of fat, which is slightly thinner in men, is assembled into polygonal units, separated by criss-crossing connective tissue. These differences in subcutaneous fat cell structure in men and women occur during the third trimester of foetus development and are manifested at birth. Variations in hormones between genders largely explain this skin structure deviation. It has been shown that men who are born deficient in male hormones will often have a subcutaneous fat appearance similar to females. Mesotherapy technique As the medication reaches the target directly, thereby avoiding metabolism by the digestive system, doses can be minimal compared with those that are orally ingested. Dr Pistor summarised the three core tenets of mesotherapy as the use of the “smallest dose, infrequently, in the right place”. As well as delivering medications to precisely where they are needed, this also reduces the likelihood of side effects and allergies in patients. The procedure uses tiny hypodermic needles only 3–8mm long, so the treatment is minimally invasive—an attractive alternative to surgery and medications delivered by the standard oral and intravenous routes. In addition to the pharmacological effects of the medications, the needle punctures involved in administering mesotherapy may have a mechanical effect on the nervous system. Stimulation of the nerves in the dermis may rebound over the visceral nervous system, alleviating pain and possibly having a neuro-stimulatory effect elsewhere in the body. This perhaps accounts for some of Dr Pistor’s findings. Mesotherapy aimed at treating cellulite is comprised of ingredients designed to activate lipolysis. L-carnitine helps transport fatty acids into the mitochondria for energy production and directs them towards oxidation rather than the neoformation of triglycerides. Triac, a lipolytic derived from the transformation of the thyroid hormone in the liver, increases the cellular concentration of cyclic adenosine monophoshate (cAMP)—a second messenger synthesised from the energy molecule adenosine triphosphate (ATP) which regulates 22

The medicine is injected into the cellulite or fatty tissue to improve circulation of lymphatic and venous drainage

lipolysis. Organic silica likewise increases the cellular concentration of cAMP, as well as being an important structural component of the connective tissue. Lipolyticus (extract of artichoke) is added because it exercises some control over lipolysis and has an additional mild diuretic and detoxifying role. Mixtures are injected into the cellulite or fatty tissue to improve the circulation of lymphatic and venous drainage by increasing the metabolism of the injected area. Having performed its therapeutic task, the medicine is then broken down by enzymes in the bloodstream and transported to the kidneys to be removed as a waste product in urine. Therefore very little, if any, medicine reaches the general circulation. In any case, the level is so low that it has no effect on the rest of the body. Protocol After initial consultation and assessment, a recommendation is suggested for the set of treatments required. I recommend mesotherapy for all types of cellulite and fatty areas, including advance cases with steatomas—the lumpy, sluggish, orangepeel effect at the top of the thighs. It also treats the symptoms of cellulite such as heavy legs and thighs, saddles, love handles, upper arms, inner and outer thighs, poor circulation and toxin deposits. Once the cellulite has gone, with a

bit of patience and willpower, good diet and routine exercise, it should be possible to ensure the cellulite remains at bay. The best way to avoid cellulite is to eat a healthy diet which includes plenty of water, fresh fruit and vegetables and cutting down on wheat and dairy products. A session of mesotherapy usually takes 30–60 minutes. Mesotherapy is usually performed once or twice a week over a four to eight week period. The dosage of the individual components is based on characteristics and response of each client. When the desired effects are achieved, annual maintenance is required over the four to six weeks. Various techniques are used in the mesotherapy. Mesopuncture involves multiple punctures, all less than 2mm in depth, over a specific target area into the skin. Intradermic nappage uses multiple punctures with a 4mm depth, injecting the medication into the superficial dermis or epidermis at an angle of 30–45 degrees. Each puncture site can be 0.1 or 0.2mm, allowing the skin to absorb the medication. Intradermic papule is used in mesovaccination, with a 2mm puncture and 0.1ml of medication injected. The veno-arterial axis is used to treat cellulite triggered by circulatory problems, vasoprotective medications and vasodilators are applied at pre-determined points along the blood vessels on the large extremities, such as the veno-arterial axes on both legs. I use one simple standardised technique for all mesotherapy procedures— point-to-point. This is a deep intradermal or hypodermic injection technique, consisting of separate injections at a depth of 4–12mm, or even 15mm depending on the area and indications for the treatment. This technique is generally used in aesthetic medicine as well as in rheumatology and sports pathology. However, it is up to the individual mesotherapy practitioner to decide what technique works best for them. Mesotherapy guns can also be used, but they do not make the therapeutic act faster. The philosophy of these systems is to provide the patient with comfort and standardise the injection depth and dose. Mesotherapy is safe and effective and the body of scientific literature proving mesotherapy’s efficacy in the cosmetic arena is growing. Meanwhile its visible effects are repeatedly described by clients who have tried it as a definite reality. Malti O’Mahoney is an aesthetic nurse who specialises in mesotherapy body language www.bodylanguage.net

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equipment Dr Yoram Harth

Body contouring Dr Yoram Harth discusses the latest advances in RF technology for treatment of cellulite

ach year after adolescence, we lose 1-2% of our collagen and this, combined with ultraviolet exposure, are the primary factors influencing our skin. This loss of collagen is an issue we need to address when treating skin ageing and the development of skin laxity and cellulite. I believe that the main factor in regards to cellulite, is loosening of the collagen and of the fibrous tissue between the fat cells and in the dermis. I see this as the primary factor causing the visual bumps on the skin that characterise cellulite—all other factors I believe are secondary. Therefore for cellulite my primary treatment goal is to tighten this collagen both in the dermis and between the fat cells and there have been many treatments that have attempted to address this issue. I think many clinicians understand that lasers and light are not the solution because they are absorbed in the superficial layers of the skin—in the chromophore—so cannot penetrate to the depth required. Massage and vacuum are logical alternatives, but I would argue do not address the primary issue and the results they achieve are relatively short term. I prefer to use a treatment option that is colour independent and can penetrate into the dermis and deeper in to the subcutaneous adipose or fatty tissue.

body language www.bodylanguage.net

Dr Yoram Harth is a board certified dermatologist, and founder and medical director of EndyMed Medical Ltd, Israel

Fiona Wright

Radiofrequency Apart from ultrasound, the other main non-invasive treatment option for cellulite and other cosmetic skin conditions associated with loss of collagen and skin laxity is radio frequency. The primary radiofrequency (RF) modalities available and used are known as monopolar and bipolar RF. More recently we have seen the development of multi-source phase controlled modalities and these are becoming established in the treatment of ageing and cosmetically impaired skin. RF has a wavelength that is able to penetrate the dermis to the depth of subcutaneous tissue—a key requirement for the treatment of skin ageing, collagen loss and associated conditions such as cellulite. The target is to create a controlled heating of the dermis and targeted tissue to a level that produces heat shock proteins and a trauma that the fibroblasts—through a wound healing cascade—will use as a stimulus to create new collagen. Monopolar RF uses a small electrode on the surface of the skin and usually will have a grounding plate/pad under the body. The RF energy runs throughout the body in a relatively uncontrolled manner. Treatments can be efficacious but as the flow of energy is somewhat uncontrolled, relatively high energy levels are required to produce sufficient levels of heat in the deeper tissue for body contouring and cellulite treatment. This can lead to excessive heating particularly in the epidermis and papillary dermis and can cause pain so cooling is necessary but can be counter intuitive. Controlled heating of the papillary dermis is one of the treatment objectives, and cooling may not overcome the pain issues so sometimes secondary pain management methods such as built-in vibration or administered analgesia/anaesthesia are required. The relatively uncontrolled nature of the flow of energy can also affect the predictability of treatment outcomes. Bipolar technology uses two electrodes on the skin surface. The RF takes the shortest path between the electrodes, so when

used with electrodes on the surface of the skin it will be always be relatively superficial, limiting it’s efficacy especially where the target is the reticular dermis and subcutaneous layers. A newer generation of multi-source phase-controlled RF technology has been developed to help overcome some of the limitations and issues of monopolar and bipolar RF. I use the EndyMedPRO which employs multi-source phase-controlled RF technology, using up to six RF generators, working together at the same time, within the same device. This is the multi-source element. The second key element addresses the way the generators are arranged and controlled—the phase control mechanism. When a handpiece using six electrodes on the surface of the skin is employed, we can have three electrodes with a positive charge and three electrodes with a negative charge at the same time. This utilises the principle that the RF energy will take the shortest route between electrodes. The multiple sources of RF energy and the phase control of each of the RF generators—and the flow of this energy to and between the electrodes—means that the three flows of RF energy have to overlap and take increasingly deeper routes. This interaction forces the energy deeper into the dermis and into the subcutaneous layer. The energy and heat is focused and controlled, and the heating of the epidermis is minimised meaning no cooling of the epidermis or papillary dermis is required. The number of electrode pairs and distance between the electrodes can control the depth of penetration and different handpieces for different body areas can provide this. For example the body handpiece can achieve depths of up to 11mm, where as the iFine handpiece—with smaller and more closely arrayed electrodes for peri-orbital and peri-oral areas—achieves a penetration depth of up to 2mm. From a clinical outcomes perspective we are seeing high levels of predictability. When body tightening and contouring was assessed in 33 patients (Royo de la Torre et al, J Clinical and Aesthetic Dermatology 2011) significant circumference reduction and skin laxity improvement was achieved at the end of the treatment course. These patients were then subjected to three monthly follow-ups over a 12 month period and these outcomes were sustained to a significant level.

Before and after a course of six body contouring treatments with the EndyMedPRO 25

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

conference BODY 2013

Shaping the future of aesthetics

Book your place at the BODY Conference and Exhibition, held this year on the 2nd – 3rd November at the Royal Society of Medicine, London

s the sister conference to FACE—the UK’s largest scientific conference on facial aesthetics—BODY follows the same format, providing the highest quality national and international speakers in their respective fields of scientific interest, to update your clinical knowledge and explore new market opportunities in the dynamic body aesthetics industry. BODY, now in its 5th year, is the largest UK congress devoted to the non-surbody language www.bodylanguage.net

gical and surgical body aesthetics sector of the cosmetic market. It is a must attend event for practitioners and clinics operating in, or wishing to enter this exciting market segment. BODY provides a broad cosmetic agenda across two days, bringing practitioners working in the non-surgical and surgical body aesthetics industry together at one meeting. This provides a unique opportunity for debate and learning more about the specifics of the different segments that make up the market place.

Non-surgical agenda The last 10 years has seen unprecedented growth in non-surgical facial aesthetics, but also increasing competition as barriers to entry are generally low. Many of the UK’s leading clinics are capitalising on increased consumer demand for body aesthetic treatments and are expanding their treatment menu as more effective and less invasive options for fat reduction, cellulite treatment and décolletage and hand rejuvenation continue to evolve. Over the coming years, many medi27

conference BODY 2013

SPEAKERS INCLUDE: Mr Andrew Batchelor, Consultant Plastic Surgeon, UK Mr Batchelor qualified in medicine at St Mary’s, winning the Cheadle Medal and trained in plastic surgery in Slough, Nottingham and Glasgow. Mr Batchelor was appointed Consultant Plastic Surgeon to Leeds & York. He resigned in 2003 and continued in independent practice. He examined for the specialist fellowship 1986-2003. Andy is a member of BAPRAS.

Dr Sandeep Cliff, Consultant Dermatologist, UK Dr Sandeep Cliff graduated in 1991 and pursued dermatology specialist training in London including a Mohs/dermatology surgical fellowship in Europe. Dr Cliff has private practices in London and Surrey and heads up skin clinics as dermatologist lead in the NHS. His clinical interest is in the use of combination procedures and cosmeceutical skincare.

Mr Haroun Gajraj, Consultant Vascular Surgeon, UK Mr Gajraj has been treating people with vein disorders for over 25 years. He was trained in London at St Thomas’s and St George’s Hospitals and was Consultant Vascular Surgeon in the NHS for nearly 15 years. He has established private vein clinics in the Southwest and treats varicose veins and thread veins by sclerotherapy, endo-venous laser and RF ablation.

Professor Marco Gasparotti, Consultant Plastic Surgeon, Italy Professor Gasparotti is a world famous plastic surgeon who pioneered the concept of superficial liposculpture. It led to the publication of the ‘bible’ in this discipline, “Superfical Liposculpture”, in 1992 and he became the first person to receive the American Academy of Cosmetic Surgery’s “Excellence in CosmeticSurgery” Award consecutively in 2001 and 2002.

Professor Luiz Toledo, Consultant Plastic Surgeon, Dubai Prof. Luiz Toledo is known and respected as an innovator in the surgical techniques of facial rejuvenation and body contouring. As a sought after lecturer, Prof. Toledo demonstrates his techniques for recontouring the face and body, with the removal and replacement of localised fat. He has written and edited several books has published more than 60 scientific papers.

Mr Shailesh Vadodaria, Consultant Plastic Surgeon, UK Mr Vadodaria is at the forefront of body contouring and liposuction procedures in the UK. He was the first surgeon to use radio frequency sssisted liposuction in the UK and is a national trainer on both RFAL and laser lipolysis. He has innovated new instruments, simulators and plastic surgical techniques which are published in peer reviewed journals.

cal practitioners focusing predominantly on facial injectable treatments, will need to incorporate other services into their business in order to maintain growth. Although non-surgical body contouring options are experiencing rapid growth, mainstream markets such as laser hair removal, treatment of leg thread veins and varicose veins, blemishes—including skin tags moles and warts—and unwanted tattoos are also attractive market options as newer technologies improve outcomes and the potential to generate a predictable revenue stream. BODY will explore the latest technologies and business models for the treatment of unwanted hair, fat, cellulite and stretch marks, alongside new and emerging concepts for the management of hyperhidrosis, leg veins and tattoo removal. Surgical agenda The surgical agenda will explore the latest techniques related to body contouring procedures such as breast augmentation, breast reduction and liposuction, with an international panel of experts in their fields. Following on from last year’s problems related to PIP implants, a special session devoted to best practice to avoid complaints and deal with litigation will also feature including exploring MDU/MPS medical indemnity insurance cover versus commercial organisations. Exhibition and workshops Specialist suppliers in the body aesthetics market will be exhibiting and providing additional learning opportunities related to specific device and business models for different market segments, providing additional choice and value for delegates visiting this year’s event. BODY 2013 will allow delegates to learn how to capitalise on the rapid growth and refinement of surgical and non-surgical body aesthetic technologies With so many different devices and surgical and non-surgical treatment approaches now available to the market, it can be a time consuming process to evaluate all of the opportunities available. BODY gives you access to some of the world’s leading experts alongside a range of companies offering devices and treatment options for body aesthetics. In addition, you will be able to network with practitioners from all over the UK who operate different business models in the medical aesthetic market. For further information and enquiries about BODY Conference and Exhibition, or to register your place at this years event, please visit bodyconference.co.uk, call 020 7514 5989 or email us at info@face-ltd.com body language www.bodylanguage.net

psychology Dr Raj Persaud and Esther Rantzen

War paint Recessions, or tough economic climates, can subconsciously increase a woman’s desire to boost her attractiveness, or attract a mate. Dr Raj Persaud and Esther Rantzen survey the latest research into the “lipstick effect”

ales figures from one of the world’s largest cosmetics companies—L’Oreal—revealed that during 2008, a year when the rest of the economy suffered record declines in sales, the company experienced sales growth of 5.3%. But why? A series of psychology experiments have confirmed for the first time that while tougher economic times decrease desire for most items, they also reliably increase women’s yearning for products that boost their attractiveness. Psychologists contend that this “lipstick effect” operates largely below conscious awareness of both men and women, and therefore requires precise experiments to reveal it. The 2012 study, entitled “Boosting Beauty in an Economic Decline: Mating, Spending, and the Lipstick Effect” is the first experimental demonstration of this psychological phenomenon, with psychologists confirming that it is driven by the female desire to attract mates “with resources”. The authors of the study—Sarah Hill, Christopher Rodeheffer et al.—argue that over evolutionary history, our human ancestors regularly went through cycles of abundance and famine. This has genetically shaped us towards prioritising the seeking of mates when times get tough; passing on our genes becomes a greater priority in harsher environments. Wars, for example, are known for moments of the most intense romance. According to evolutionary theory, female reproductive success through history rests on their ability to secure a partner able to invest resources in themselves and their offspring. An economic recession may signal that financially stable men are becoming scarcer, so women should compete more ferociously for richer men during financially tougher times. The study examined monthly fluctuations in US unemployment over the last 20 years and found that when unemployment increased, people allocated smaller portions of their monthly spending budgets on electronics or leisure and hobby products. Yet relative spending on personal care or cosmetics products went up.

Gender differences But was this men or women who were buying cosmetics or personal care products? In another part of the study, published in the Journal of Personality and Social Psychology, men who read a news article about a recent economic recession developed less desire to purchase consumer products. When women read the same magazine article on a recession—in comparison with reading an article on modern architecture—unlike men, their desire to purchase products that could enhance appearance, including lipstick, increased. In another part of the series of experiments, undergraduate unmarried women were prompted to reflect about economic recessions by viewing a slideshow entitled, “The New Economics of the 21st Century: A Harsh and Unpredictable World.” This portrayed the current state of the US economy—including unemployment lines, home foreclosure signs and empty office buildings. In the comparison condition of the experiment, participants viewed a slideshow titled, “Making the Grade: No Longer a Walk in the Park.” This slideshow represented students working to meet stringent academic requirements imposed by college administrators. As predicted, the recession slideshow led more women to report that they wanted members of the opposite sex to perceive them as pretty, that they thought it was important to look good, and that they cared more about how attractive they looked. So economic recession reminders cause women to become more concerned with looking physically attractive to men. Women viewing the economic recession slides also placed more emphasis on a potential relationship partner’s access to financial resources. But does this “lipstick effect” reflect women in a recession being drawn to cheap pleasures—such as lipstick—rather than expensive indulgences? If women believe that an expensive luxury product will make them more desirable to men, recessions should still increase women’s desire for that product, according to evolutionary theory. To this end, the psychologists reminded women about the body language www.bodylanguage.net

psychology Dr Raj Persaud and Esther Rantzen

recession and measured their interest in purchasing luxury “attractiveness enhancement” products, such as designer jeans, and two classes of inexpensive control products: low-cost indulgences that don’t enhance attractiveness, such as coffee; and discount brand versions of the attractiveness-enhancement products such as supermarket-branded jeans. The findings of the experiment showed that the lipstick effect involves seeking products that are more effective at enhancing attractiveness—even if such products cost more. Another theory is the lipstick effect simply reflects greater financial desperation in a recession. Because resources—historically at least—tend to be controlled by men, the psychologists conducting these experiments reasoned that economic recessions should prompt women to attract wealthy mates specifically as a means to financial support. The authors found from their experiments that the lipstick effect is not driven specifically by impoverished women lacking access to resources of their own. The concept applied powerfully to all women, no matter what their own financial predicament was. In other words, women who were better off were still vulnerable to the lipstick effect. This might suggest this extraordinary effect operates below conscious awareness, and is genetically hard-wired into brains because of evolutionary history. Goal immediacy This fits with the theory that evolution has wired into our genes and brains the reflexive tendency to prioritise mating during tougher times, as there may not be much time left to procreate. Greater “goal immediacy” of mating, combined with diminished access to high-quality or richer mates, prompts much fiercer mate attraction efforts in women during recessionary times. The psychologists speculated that if economic recessions increase the premium women place on a man’s access to resources, men may become more competitive to garner these resources. For instance, a harsh economic climate might lead better off men—particularly those seeking romantic partners—to flaunt body language www.bodylanguage.net

their wealth more conspicuously to attract mates. Another possibility is that recessionary conditions may cause men who are unable to maintain steady employment to be more likely to resort to lying, cheating or stealing as a means of resource acquisition. The authors also speculate that recessions could raise women’s willingness to take attractiveness-enhancement risks, such as extreme dieting, tanning or cosmetic surgery. It might even promote greater hostility towards other women. This research suggests some unexpected consequences of recessions on women. Recessions may have a negative impact on a woman’s health and the quality and durability of her female friendships. It can be argued that women cheer themselves up during tough times by “pampering” with a treat—one of the cheapest ways remains buying lipstick. Applying it and smiling at the mirror sends women away into a harsher world with a spring in their step. So the lipstick effect could be no more than just women’s natural instinct to counteract the depressing effect of the recession. But even if it’s not about women needing to find a rich man during tougher times—given the pressure on the household purse, when families struggle to cope with necessary spending on food and rent—many women may conceal the fact that they are also buying products as frivolous as cosmetics; hiding the truth even from themselves. Although the lipstick effect theoretically relates to all cosmetics, or anything that enhances female attractiveness, lipstick itself might be particularly primal—unique in its ability to immediately and dramatically transform appearance. The study’s authors quote a specific example of a 34-year old unmarried teacher. Despite increasing bills and economic recession, Melissa McQueeney adamantly refuses to stop buying lipstick. As she defiantly strides to the cash register with a new lip gloss, she is quoted as declaring, “I didn’t even try it on. I’m just splurging.” Dr Raj Persaud is a consultant psychiatrist in private practice at 10 Harley Street and in Surrey. Esther Rantzen is a journalist and television presenter. 31

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dermatology Anna Jean Lloyd

A tough itch to scratch Psoriasis is a chronic and prevalent disease, with limited effective treatment options. Anna Jean Lloyd takes a look at the existing landscape of therapies available and areas of promise on the horizon

soriasis affects around 125 million individuals or 2-3% of the population in Western countries. Though it varies in severity and characteristics, psoriasis is popularly recognised as one of the most frustrating skin conditions to have and to treat. As a chronic, prevalent and currently unmet need in dermatology, however, psoriasis is also of great interest to drug developers and skin care manufacturers who see in it an untapped potential. But does the recent boom in development offer new hope, or just an increasingly confused market? Psoriasis is an inflammatory skin condition characterised by skin cells that replicate eight times faster than the 30 day cycle typical of healthy skin. Plaque psoriasis—the most common variant of the disease—presents as red, itchy patches covered in silvery scales of varying thickness. These patches commonly occur symmetrically on the knees, elbows, lower part of back, scalp or nails. Other forms of the disease may include pustules or red, drop-like lesions. The severity of psoriasis is generally assessed on how much of a person’s body is affected (BSA). Mild, or “limited” psoriasis involves less than 2% of the body’s surface area; moderate between 2% and 10%; and severe over 10%. It is a disease with a strong psychosocial component, so quality of life factors are also accounted for when, for instance, hands, nails or the groin are affected. While the visual appearance of psoriasis is often the most immediate concern to the patient, associated itch, disease progression and treatment side effects body language www.bodylanguage.net

can have significant impact on a patient’s lifestyle and, consequently, perceptions of severity. Treatment There is no cure for psoriasis. Rather, treatments are geared towards containing disease symptoms, prolonging periods of down time and proactively treating the early signs of a flare-up. According to the University of Toronto’s Dr Gary Sibbald, available topical options are messy and adherence is inconsistent. Steroids are a common but imperfect front-line therapy for psoriasis. In addition to affecting skin quality in the long term, Dr Sibbald describes their longevity as limited: “We know topical steroids peak in efficacy at about two weeks, so patients are often transitioned to steroidsparing therapies such as Vitamin A or Vitamin D derivatives.” Phototherapy, involving one to three weekly sessions of short wave UVB, is another widely recommended, though often inconvenient, treatment for mild to moderate disease. Systemic drugs, including an increasing number of biologics, are popularly prescribed for moderate to severe psoriasis. Used in conjunction and as monotherapies, popular systemic options include methotrexate, adalimumab, etanercept and ustekinumab. The duration of prescribed systemics range from a few months to over a year, depending on the patient’s response, the practitioner’s preference and the sensitivity of both to associated risks. Though rare, long term use of systemic drugs have been linked to serious side effects includ-

ing organ-specific toxicity. One systemic drug, Efalizuma, was voluntarily pulled from the market in 2009 following four reported cases of a fatal brain infection. When biologics first hit the market, they brought promise of better results, fewer side effects and longer periods of down time. Made from living cells, biologics address psoriasis by targeting specific parts of the immune system rather than the system in its entirety. Although biologics have benefited many patients from a quality of life perspective, they have not provided a silver bullet. As Dr Sibbald asserts, “biologics can be quite expensive and are limited by a window of effectiveness after which the psoriasis eventually comes back and requires a higher dose to control.” Success rates Despite the number of available options, success rates with front-line therapies and systemic drugs are underwhelming. A review of results in a real world, clinical practices revealed that only 24–48% of patients undergoing phototherapy or systemic drugs could be graded as clear or almost clear by a physician. The review also showed that, while commonly prescribed biologics outperformed traditional drugs like methotrexate, the differences between them are relative and have little clinical significance. The lack of therapies with staying power is especially problematic, given the unpredictability of psoriasis. The sporadic nature of the disease adds insult to injury for its sufferers. While triggers do exist—stress, allergies, infection, pregnancy and even excessive alcohol—the sponta33

dermatology Anna Jean Lloyd

neity of symptoms can wreak havoc on a patient’s normal life, affecting everything from social and sexual health to their ability to join health clubs. It is in this context of messy, shortterm therapies, expensive biologics and poor patient adherence that the psoriasis market continues to want for an affordable, consistent and cosmetically-acceptable therapy. New solutions to this need are being advanced from many angles. In terms of the demand for more efficacious treatment options, Dr Sibbald suggests that meaningful improvement might come from a therapy—biologic or otherwise— that offers an absolute benefit of 20% or more over what is currently available. Apremilast (Celgene) is an experimental drug vying to meet this threshold. Having shown good safety results in a Phase 3 trial, stakeholders are hopeful that the drug will be a blockbuster. Preliminary tests for efficacy are, however, modest, approximating PASI (Psoriasis Area Severity Index) reductions comparable to Enbrel (Amgen) and inferior to Stelara (Johnson & Johnson) and AbbVie’s Humira. Biosimilars From an affordability perspective, biosimilars are endeavouring to put the benefits of biologics within the reach of a greater number of psoriasis sufferers. Highly alike to already approved biologic drugs, biosimilars promise more affordable alternatives to patients who might struggle to pay for therapy in the long term. Whereas generic versions of typical, chemical drugs can follow quickly on the heels of a predecessors’ term of exclusivity, the approval pathways for biosimilars are not as clear. Because biosimilars are not exact copies of biologics, physicians and regulatory entities are wary of their efficacy and potential side effects, making it uncertain when they will be widely available. Compared to new drugs, novel OTC

Psoriasis is an inflammatory skin condition characterised by skin cells that replicate eight times faster than the 30 day cycle typical of healthy skin

solutions for psoriasis face relatively few barriers to market entry. Indeed, emollients such as urea and glaxal based creams are frequently recommended during periods of disease remission in order to maintain optimal levels of skin hydration and minimise initial symptoms of a flare. Despite the fact that 75-85% of psoriasis patients are deemed “mild” there are few OTC products that specifically address their needs beyond moisturization. Of those that do exist, most contain ingredients such as coal tar, a highly irritating and potentially carcinogenic compound, or salicylic acid, which provides basic keratolytic activity. One new ingredient, MAx75 (BASIS Medical Technologies), intends to fill this vacuum in the over-the-counter market. Derived from the Mahonia Aquifolium plant, MAx75 has been standardised to

References 1 “Worldwide market for Dermatological Drugs.” Kalorama Information, 2010 2 Mrowietz U, Kragballe K, Reich K, Spuls P. “Definition of treatment goals for moderate to severe psoriasis: a European consensus.” Arch Dermatol Res. 2011 Jan;303(1) 3 Gelfand J M, Wan J, Callis Duffin K. “Comparative Effectiveness of Commonly Used Systemic Treatments or Phototherapy for Moderate to Severe Plaque Psoriasis in the Clinical Practice Setting” Arch Dermatol. 2012 April; 148(4): 487–494.

provide 75 times the concentration of beneficial alkaloids available in the plant’s native state. A patented, more efficacious active, MAx75 can be used in the long term and without the risk of irritancy. Studies show that MAx75 is as effective as mid-potency steroids and Calcipotriene in the improvement of psoriasis and atopic dermatitis. Novel products notwithstanding, experts argue that new treatment goals for psoriasis are key to improved outcomes and quality of life. A 2010 initiative by a group of European dermatologists sought to delineate success and failure in psoriasis treatment. The group stated: “patients are frequently left on treatments for too long even though they may be ineffective,” and stressed that a lack of general consensus has resulted in the under-treatment and under-service of psoriasis patients. The resulting consensus defined successful treatment at 16 weeks as a reduction in PASI of 75% or more, and failure as 50% or less, with some input for quality of life factors. Patients who had success in this “induction period” were recommended to continue on their treatment while those who failed modified their regimen. The implementation of these standards will be the subject of review in a subsequent programme. Be it more efficacious drugs, better products for daily use or standardised treatment goals, developments in psoriasis are expected to drive growth in the market to above $3.1 billion by 2014. With the bulk of research focused on biologics, this category of drugs is estimated to dominate future markets. Physicians and patients hold out hope not just for one blockbuster drug, however, but a spectrum of therapies that will meet the diverse needs and preferences characteristic of the disease. Anna Jean Lloyd is Principal at Artindale Strategic Marketing & Communications and holds the position of EVP for BASIS Medical Technologies, both based in Toronto, Canada. E: aj@artindale.com

4 Geschek P. “Is Celgene’s Apremilast A Potential Blockbuster or Not?”, SeekingAlpha. Retrieved May 13, 2013, from http://seekingalpha.com 5 National Psoriasis Foundation: Cure-E-News, March 2013. 6 Studies on file BASIS Medical Technologies 7 Mrowietz U, Kragballe K, Reich K, Spuls P. “Definition of treatment goals for moderate to severe psoriasis: a European consensus.” Arch Dermatol Res. 2011 Jan;303(1) 8 “Worldwide market for Dermatological Drugs,” Kalorama Information 2010.

body language www.bodylanguage.net

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skincare Dr Julia Hunter

Recipe for success Many skincare products make big promises, but we need to get past the marketing spiel to find out exactly what we’re putting on our patients’ skin. Dr Julia Hunter delves into the science behind product ingredients, particularly their role in inflammation and skin toxicity

hen it comes to skincare, it’s all about the ingredients. Patients want products with ideally organic and certainly healthy ingredients and an overall lack of toxicity, as well as good penetration into the skin and provide best visible results. Before training as a dermatologist, I started my career as an anaesthetist, working with some of the most prominent plastic surgeons in the US. As I watched patients being operated on, I realised that we needed to do something more substantial about their rosacea, acne, brown spots, enlarged pores and hyperpigmentation. Following this fantastic surgery, their skin still 36

looked terrible. We should be trying to cure people rather than just treating their symptoms in perpetuity—we have to address the “why”. So I focused on the number one goal in medicine: to use the best tool for the job but do it in a non-toxic, non-inflammatory way, and to do no harm. Some of the older peeling agents have issues with toxicity so, fortunately, we have some alternatives available in today’s industry. Science vs marketing As medical practitioners, we’re looking for accurate science behind these products. We have to negotiate marketing which can body language www.bodylanguage.net

skincare Dr Julia Hunter

sometimes have less objective facts and skewed viewpoints. We have to get beyond this and find out why we should use one product versus another. What is the best tool for the job, and which is physiologically correct for the skin? Ingredients are an essential part of that. Inflammation is the cause of all disease in ageing. So with every treatment we want to provide, we want it to be non-inflammatory. One of the biggest problems we have in today’s world is toxicity. Studies have shown that foetuses are perfused with toxins. Breast milk is perfused with toxins. So we don’t want to introduce any therapies that increase inflammation, disease or the toxic load that the body has to handle. There are a number of additives and chemicals added to these products which result in inflammation, thinning the skin and ageing it. Youthful skin is volumized skin. But is inflammation the cause or the effect? It’s generally the cause; the effect results in biological processes that occur, enhancing internal inflammation. The skin is a window to what’s going on inside the body, so many skin conditions are a result of internal inflammatory processes—we don’t want to do anything that enhances those. Acne is an inflammatory condition. Rosacea is an inflammatory condition—we’ve been treating rosacea with all sorts of medications over the years but we’ve never been successful. However, if body language www.bodylanguage.net

you treat the internal inflammation, the rosacea will decrease, whether or not you put the right ingredients on the surface of the skin. Melasma and hyperpigmentation involve internal inflammation. The sun causes inflammation. Even hair loss has been shown to be caused by a variety of internal inflammation conditions. Anti-inflammatory research is vital because we have to address inflammation in order to minimise disease and slow down the ticking of the biological clock. Inflammation decreases the collagen content in the skin thickness, therefore decreasing the skin’s immunity and increasing the risk of cutaneous infections and carcinogenic potential. Harmful ingredients In choosing a therapy for a specific skin problem, we have to consider ingredients. There are a number of ingredients to avoid which enhance inflammation and disrupt hormones. Triethanolamine and parabens are hormone disrupters. Sodium lauryl sulphate and propylene glycol enhance inflammation and increase carcinogenic potential. These are all included in products because they’re cheap—they’re not necessary if you use the right ingredients. Acrylates need to be avoided, while triclosans are a form of pesticide. Thiazolidinones, ammonias and 37

skincare Dr Julia Hunter

sodium bisulfite increase allergic potential. We’re seeing patients are increasingly allergic to a variety of things, in particular the salicylates. So is there anything wrong with the products we’re using? I always want to make sure I’m optimising results for patients. I consider glycolic to be a very strong irritant and, most importantly, there is no receptor for it in the skin. It has to be neutralised because when it goes into the skin, it has nowhere to go; it doesn’t have a receptor to meet. I choose not to use glycolic acid because I think it has a greater downside than an upside. Glycolic acid activates the free radical cascade and dissolves the protective barrier. It’s also known to be corrosive and metabolises TO oxalic acid which is toxic and increases kidney stone formation. You have to be very careful using it on people who have any compromised kidney function. The vast majority of glycolic acid is now synthetic, so you have to be careful because this is made from formaldehyde, not from grapes and fruits. Hydroquinone is banned in the EU but is still available in the US. But the product is a phenol in its chemical structure, and is known to cleave DNA and RNA. Its metabolites are known

to be nephrotoxic and liver toxic. They are also known to be a carcinogen and increase sun and pigment risk —we don’t want to use anything on our skin that increases our UV exposure. Again, there is no receptor in the body for hydroquinone. Trichloroacetic acid (TCA) is unstable and very difficult to control; it dissolves the skin. It doesn’t cause building and thickening, instead it thins the skin. TCA coagulates, is corrosive, has pigment issues and increases UV exposure. Bearing in mind that youthful skin is volumised skin, we don’t want to do anything that thins the skin in perpetuity because this defeats our purpose. Salicylic acid is incredibly drying and, in my practice, patients simply won’t tolerate it. I’m increasingly seeing a huge amount of allergies to salicylic acid. Absorption also causes metabolic acidosis, which translates to increased inflammation. Alternatives We want ingredients that work at least as well, if not better, and we want to avoid inflammation as much as possible. We want to build and volumise, to enhance the skin components, enhance collagen production and increase depth of penetration. All products should be synergistic with technology, which enables us to penetrate down into the deep dermis. There are alternatives to the glycolics, TCAs, Jessners and phenols that work just as well and are non-toxic. L-mandelic acid comes from bitter almonds and is a non-toxic alpha hydroxy acid (AHA). It’s stronger than glycolic acid and is anti-microbial and anti-pigment—it has shown to have a 50% reduction in studies with a low dose L-mandelic. It also provides collagen and skin component stimulation and is an anti-inflammatory, providing increased volumisation and penetration. The ingredient can also be used on skin of any colour. Lactic acid is a non-toxic AHA. It hydrates, exfoliates and is non-inflammatory. It enhances ceramide production and stimulates collagen and skin components, resulting in volumisation. L-Malic acid is produced by the body in the Krebs cycle. It also comes from apples, is a non-toxic AHA and an anti-inflammatory. It facilitates the penetration of other ingredients and is a strong exfoliator. Chirally correct We need to use physiologically correct peels because they’re non-toxic and are equally, if not more, restorative in anti-ageing. Chirally correct ingredients that are put on the skin mimic natural ingredients, allowing us to put them on skin of any colour. Chirally correct means chemically correct. It means the body has a receptor for the specific ingredient that you’re putting on the skin. Drugs that have been taken off the market in recent years have harmed people. One example is the synthetic oestrogens that came from horse urine, which were chemically chirally incorrect. They may not have had a receptor that the body could join with that ingredient—when the body has a receptor, it essentially switches on a good and not a bad chemical function. Many of the synthetic products, such as the synthetic oestrogens, have a receptor but they are bound incorrectly to the receptor. They therefore turn on a bad chemical reaction that the body can’t stop. Chirally correct ingredients optimise your therapy.

It is important to optimise results for patients and avoid srtong irritants

Dr Julia Hunter is a dermatologist and founder of Wholistic Dermatology, Skin Fitness Plus, Beverly Hills, CA, USA. T: 310-2478744; E: info@juliathuntermd.com body language www.bodylanguage.net

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finance David Rose

Equipment finance When considering acquiring new equipment, the question of how to pay for it has to be addressed. David Rose provides an overview of the available options and considerations before making your decision

ssentially there are three options when considering equipment purchase: cash resources or savings; bank funding; and a finance provider or leasing company. Cash resources or savings are an option if you have unlimited amounts, but you will be using your cash resources to invest in an asset that will reduce in value over time. You may also compromise the system that you want to acquire by being limited to the amount of a capital you have at your disposal. Your cash resources may also have to cover other aspects of your business where alternative funding is not available, such as staffing costs, marketing or day to day revenue expenditure. Your business could also be affected by variables like the weather, holidays or cancelled appointments, when income will be hit but costs remain the same, so a buffer would be prudent. In terms of bank funding, the bank will be an important partner for facilities such as day-to-day current account, overdraft facilities and bank loans may also be involved in funding your premises. If using the bank for equipment finance, consideration should be given as to whether it will compromise the amount of additional flexible funding available if you need to increase an overdraft or short term loan facility. Itâ&#x20AC;&#x2122;s also worth considering whether bank funding for equipment finance is on an unsecured basis or a fixed rate, and the set up and admin costs that will be incurred. If you were to use a finance provider, or leasing company, a leasing option provides you with a fixed, unsecured monthly payment plan based on the full cost of the equipment of your choice. It would mean you can preserve your cash resourc40

es and bank funding lines. The length of plan will normally be between two and five yearsâ&#x20AC;&#x201D;the decision is governed by the useful life of the equipment and what best suits your budget. Payment plans There are two different plans available; a lease plan or a purchase plan. A lease plan is a rental agreement that allows you to have use of the asset without having the risks associated with ownership. The leasing company pays for the asset at the outset and retains title of the equipment. The lessee, or user, has the option of extending the lease into a secondary period for a nominal annual cost or can return the equipment to the lessor, the leasing company, if the equipment has become obsolete and new equipment is being acquired. Rentals are calculated on the equipment costs and VAT is added to each rental rather than being payable in a lump

sum at the outset, which affords an additional cash flow benefit. Lease rental interest is 100% allowable against your pre-tax profits and the asset will also appear on your balance sheet. A purchase plan is a straightforward repayment contract where the lessee eventually owns the asset at the end of the agreement. As with the lease plan, the total value of the asset, including VAT, can be financed and a fixed rate is used for the duration of the contract. The lessee can claim capital allowances on the asset and the interest element of repayments is allowable against taxable profits. At the end of the primary term, ownership transfers to the lessee for a nominal purchase option fee. It is common for both plans to have similar monthly repayment, so the choice is often down to how your accountant would like to maximise the tax advantages. All plans have the same features, including being offered on an unsecured basis, normally no deposits, fixed repayments and funding for the total cost of the equipment including delivery and installation costs. You also only start paying the first rental once the equipment is up and running. In terms of equipment maintenance, you will be responsible for the ongoing maintenance arrangements with the supplier. However, all warranties that are included with the system are automatically transferred to you. The insurance of the equipment must also be added to your policy. David Rose is a sales manager at Siemens Financial Services, which provides finance solutions to the medical and healthcare industry, E: david.rose@siemens.com body language www.bodylanguage.net

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anti-ageing David Hicks

Divide and conquer Research into the health effects of telomere shortening and cell division is still in its infancy but their role in disease and ageing is becoming more widely understood. David Hicks describes their function and the significance of telomerase

nside the centre or nucleus of human cells, our genes are located on twisted, double stranded molecules of DNA— these are our chromosomes. Protecting the ends of these chromosomes are stretches of DNA called telomeres, whose function is to protect our generic data and make it possible for our cells to divide. These telomeres also hold clues to ageing and the occurrence of cancer. A popular analogy of telomeres is that they are like the plastic tips of shoelaces; they prevent the chromosome ends ‘fraying’ and sticking to each other. This would result in the scrambling of an organism’s genetic information which could potentially lead to diseases such as cancer, or even death. As a cell divides, the telomeres grow shorter. When they become too short, the cell can no longer replicate and becomes inactive—‘senescent’—or dies. This process is linked with cancer, ageing and an increased risk of death. The structure of a telomere is the same as the rest of a chromosome and its genes. Telomeres are sequences of a chemical code and, like other DNA, consist of four nucleic acid bases: G for guanine; A for adenine; T for thymine; and C for cytosine. Telomeres are made of multiple sequences of TTAGGG on one strand of DNA and AATCCC on the other strand. One section of a telomere is a ‘repeat’ consisting of six base

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pairs. In human blood, the length of telomeres is around 8,000 base pairs at birth, dropping to 3,000 base pairs with ageing. The length can be as low as 1,500 in the elderly. To put this into context, an entire chromosome has around 150 million base pairs. Every time a cell divides, there is a loss of around 30 to 200 base pairs from each end of that cell’s telomeres. The telomeres’ division limit is usually around 50–70 times—they continue getting shorter until the cells become senescent, die or sustain genetic damage. Cells in the areas such as the heart muscle do not continually divide so there is no telomere shortening. Division Without telomeres, the main part of the chromosomes containing genes essential to life would shorten on each cell division. This division is required to enable renewal of skin, blood, bones and other cells when required. Telomeres allow this division without the loss of genes. If the ends of the chromosome weren’t protected by the telomeres, fusion could occur leading to degradation of the cell’s genetic blueprint making the cell malfunction, become cancerous or die. Broken DNA is dangerous; a cell has the ability to understand this and repair chromosome damage. Without tel43

anti-ageing David Hicks

Telomeres and cancer As a cell becomes cancerous, it divides more often and its telomeres become very short—if they become too short, the cell could die. It can counteract this fate by becoming a cancer cell and activating telomerase, preventing further shortening of the telomeres. Studies have found shortened telomeres in many cancers including pancreatic, bone, prostate, bladder, lung , kidney, head and neck. It is possible that measuring telomeres may help in the detection of cancers. Theoretically blocking telomerase production in cancer cells could cause the cancer cells to age and die. Laboratory researchers have been able to block telomerase activity in human breast and prostate cancer cells, causing the tumour cells to die. But there would be a risk of impaired fertility, wound healing and a lack of telomerase would affect the production of blood cells and immune system cells. Telomeres would appear to have a significant influence in ageing. US geneticist Dr Richard Cawthon and a team at the University of Utah found shorter telomeres were associated with shorter lives. In study subjects aged over 60, those with shorter telomeres were three times as likely to die from heart disease and eight times as likely to die from an infectious disease. While telomere shortening has been linked to ageing, it has

not been established whether they are just a sign of ageing or a contributory factor. If telomerase makes cancer cells immortal, could it prevent normal cells from ageing? Is it possible to extend the lifespan of healthy cells by increasing the telomere length using telomerase? Would this increase cancer risk? Research is, so far, inconclusive but scientists have been able to use telomerase to keep human cells dividing far past their normal limits and the cells have not become cancerous. Theoretically it would be possible to mass produce human cells for transportation, insulin-producing cells to treat diabetes, muscle cells for muscular dystrophy, cartilage cells and skin cells for burn patients. Longevity Dr Cawthon’s study also indicated that when subjects were divided into two groups based on telomere length, the half with longer telomeres lived up to five years longer than those with short telomeres. This suggests that lives could theoretically be extended in those with short telomeres. If this were possible, Dr Cawthon estimates life could be lengthened by between 10–30 years. Recent research suggests that telomeres can lengthen as well as shorten over time. In particular, activities such as exercise, a healthy diet and reducing psychological stress may influence how quickly our telomeres shorten or lengthen. A study in 2004 by Dr Elizabeth Blackburn and Dr Elissa Eppel showed a link between psychological stress and telomere length. Dr Eli Puteman found that when highly stressed individuals exercised consistently, there was no shortening of telomeres. It would appear that engaging in physical activity helps protect us from stress. One of the major causes of ageing is oxidative stress which damages DNA, proteins and lipids due to oxidants, which are highly reactive substances containing oxygen. These are produced naturally when we breathe but also result from inflammation, infection as well as cigarettes and alcohol. Another factor in ageing is ‘glycation’, caused when glucose sugar from our food binds to our DNA proteins and lipids, leaving them ineffective in their roles. This problem increases with age, causing the malfunction of body tissues. Studies in laboratory animals indicate that calorie restriction can increase longevity. The research into telomeres and the effect that telomerase is still in early stages, but is advancing rapidly. The knowledge to date does, however, offer great potential for understanding and possibly controlling diseases associated with old age. David Hicks is a pharmacist and chairman of FACE Ltd. T: 020 7514 5989; E: david@face-ltd.com

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omeres, the ends of the chromosomes would appear to be broken DNA—the cell would then try to repair something that was not broken. The cell would stop dividing and would eventually die. So why do telomeres shorten on each cell division? Before cell division, the chromosomes in it are duplicated so that each of the two new cells contain identical genetic materials. The two strands on the chromosome have to unwind and then separate. An enzyme (DMA polymerase) proceeds to make the two new strands of DNA to replicate each of the unwound strands. It does this using short pieces of RNA. When each matching strand is completed, it is slightly shorter than the original because of room needed at the end by this short piece of RNA. One analogy is someone painting himself into the corner of a room who cannot quite finish the job! To counteract this telomere shortening, the body uses the enzyme telomerase, which adds bases to the ends of telomeres. In young cells, telomerase prevents them wearing down excessively. However, as cells repeatedly divide, there is not always sufficient telomerase so the telomeres shorten and the cells age. Telomerase does remain active in both sperm and eggs which are passed from one generation to the next. If these reproductive cells did not have telomerase to maintain the length of their telomeres, any organism with such cells would become extinct.

10/01/2013 12:38

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medical aesthetics Wendy Lewis

FACE of the future With the industry evolving year on year, Wendy Lewis runs through the top ten medical aesthetic trends of 2013, including advanced technology, fillers and social influence

osmetic surgery has gone from a relatively taboo subject to something that people are more open to talking about. While celebrities have helped popularise anti-ageing procedures, the uptick in those having liposuction and breast augmentation, as well as neurotoxins, fillers and skin rejuvenation lasers, is well documented. Branded procedures There is much global emphasis is on less invasive, quick fix style treatments, as well as branded procedures marketed directly to consumers, such as the Quick Lift or Vampire Facelift. Some of the technologies appealing to todayâ&#x20AC;&#x2122;s aesthetic consumers include Ultherapy deep ultrasound system for skin tightening, Coolsculpting cryotherapy device for tummy and waistline whittling, sublative rejuvenation with eMatrix, which uses fractionated bi-polar radiofrequency for acne scars and brown spots, and Cellulaze for cellulite reduction. Stem cells and PRP Stem cell technologies that aim to benefi-

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cially alter the state of organs and tissues to target disorders, disabilities and/or diseases have captured widespread attention. Aesthetic doctors are using autologous fat grafting in record numbers. The theory is that fat contains the largest reservoir of adult stem cells and growth factors. Although autologous fat transfer is not new, the procedure is enjoying a global rebirth as the now ubiquitous stem cell facelift, as well as for breast enhancement and reconstruction. Platelet rich plasma, or PRP, has taken centre stage as both an adjunct to other facial rejuvenation techniques such as fat grafting, and a stand-alone therapy for treating ageing skin and acne scarring. Technological advances Consumers are choosing more hightech or equipment-based solutions as an alternative to more expensive cosmetic surgery. Microdermabrasion, dermal infusion, microcurrents, ultrasound, radiofrequency, cold laser, LED, IPL and other energy-based therapies have become a mainstay in clinics and medispas. Microneedling and skin rollers have become widely accepted across Europe and, more

recently, the US, with pens, handheld instruments that enhance transdermal delivery of peeling agents or hyaluronic acid, and other variations. Home care Combination therapies with products for home use being used in tandem with professional treatments are flourishing. At-home devices that firm and tone, fight acne, remove hair, grow hair, diminish lines and wrinkles, and brighten teeth are becoming increasingly popular as consumers look to take control of their beauty procedures. Home-care devices continue to show strong growth and increased consumer acceptance fueled by convenience, greater ease of use, portability, advanced efficacy and affordability. Anti-ageing topicals As consumer demand to manage their ageing from the comfort of their homes grows, so does the sophistication of cosmetic products. Skin volumisersâ&#x20AC;&#x201D;collagen-building skincare treatments that promise to reduce the look of deep lines and fine wrinklesâ&#x20AC;&#x201D;are more prevalent than ever. 47

medical aesthetics Wendy Lewis

contouring, perioral restoration and pan facial rejuvenation. The bread and butter procedures of clinical practice, however, remain treating the nasolabial folds, nasomental folds, and lip enhancement.

One trend we are seeing is for novel techniques for injecting facial injectables

US dermatologist Dr Beth Briden says anti-ageing cosmeceuticals are introduced to the market daily, claiming to reduce lines and wrinkles but few, if any, have valid scientific clinical studies to substantiate their claims. However, plant stem cells in topical skincare are revolutionising the cosmetics industry. They help to protect and repair ageing skin cells and to replace damaged cells with healthy new ones. All plants contain stem cells that are located at their apical and root meristem. Meristems are composed of stem cells capable of generating an entire organism. Plant stem cells are found in the areas of plants where growth takes place. Plant stem cell extracts from edelweiss, Swiss apples, Alpine roses, and grapes have been shown to have an age-reversing effect on skin. By combining plant-derived stem cells with other ingredients, such as peptides and enzymes, it may be possible to rejuvenate skin cell DNA, which is the holy grail of anti-ageing cosmeceuticals. Filler boom Another trend is the variety of novel techniques for injecting facial injectables, including soft needles and cannula delivery. Consultant dermatologist Professor Nicholas Lowe says there is a proliferation of dermal fillers in the European market. “We have too many dermal fillers in Europe. However there are some that will be soon be available in the USA that I have found to be safe and valuable for my patients. For example, Voluma, which is a deep volume filler used for lifting as well as filling the face,” he says. Advanced techniques becoming popular include hand rejuvenation, tear trough and periorbital injections, nasal 48

Regulatory hurdles “The UK medical beauty industry has grown faster than the regulations for procedures and policies in the UK market,” says consultant dermatologist Dr Penelope Tympanidis, while Dr Lowe says both UK and US dermatology specialists and consultants share a goal of reducing untrained, inappropriately qualified injectors. “This is an uphill task and it remains to be seen if recent recommendations in the UK are implemented. This is a matter of great importance for the safety of patients,” he says. In light of the PIP crisis, there is a renewed initiative in the EU and the UK on clinical data and standards that we hope will not be short lived. Peel revolution New approaches to chemical peeling, including combining peels with other cosmetic procedures for more effective results, are a popular focus among dermatologists. Dr Briden says: “Chemical peeling remains one of the most popular and effective non-invasive anti-ageing treatments available. Of all the peeling agents available, glycolic acid remains one of the most effective and versatile agents. Glycolic acid peels are non-toxic, natural, organic acids which can be used on all skin types for addressing many different skin problems.” According to Beverly Hills dermatologist Dr Zein Obagi: “Traditional chemical peels offer no stimulation. To make a difference, peels must go deep. They work best for skin tightening, while laser rejuvenation including fractionated platforms are better for improving skin texture such as wrinkles and scars. Peels can also better reach and reverse deep pigmentation issues.” Dr Tympanidis stresses the importance of education for practitioners, particularly the science of peeling and the fact that “peeling is the core of skincare and anti-ageing.” Skin of colour Uneven pigmentation remains a major concern for all skin tones. “There is an emphasis on providing a well rounded approach in diverse skin types,” says Dr Mukta Sachdev, a dermatologist from India. “There is an increasing interest in how to handle skin of colour condi-

tions and complications across the board, which confirms that globalisation and mixed racial ethnicities are becoming more common in clinical practice. There is a new focus on the extended synergy between skin care and newer technologies, which is definitely the future of aesthetic dermatology and surgery.” Skin brightening and lightening formulations continue to show growth, and new hydroquninone-free products continue to be introduced to address pigmentary disorders. Dr Obagi says: “Treatment of pigmentation disorders such as melasma, PIH, freckles and lentigo as well as congenital skin disorders such as dermal melanosis and nevus of ota vary based on the exact nature and cause of the disorder. “For example, topical agents that regulate sebum, hydroquinone and nonhydroquinone bleaching and blending treatments and certain lasers can help reverse certain pigmentation disorders. UV protection remains an important part of this treatment regimen as well,” he says. Social influence Another trend is an emphasis on the challenges of running a successful clinic—including management, staffing, training, marketing, dispensing, PR and patient satisfaction. Reputation management and generating positive reviews have become critical factors for success. A strong online presence is important and the influence of social media channels on the aesthetic industry at large cannot be overlooked. Consumers are primarily getting their information online, and they have all the power. Social platforms have made it easier for consumers to connect with each other and engage with clinics. The business landscape has been transformed by the digital age, and clinics must change with the times or be left behind. Emerging channels such as Pinterest and Instagram, along with Facebook, Twitter and blogs offer new ways to reach prospective customers. Relevant and original content, mobile platforms, eye catching images and videos are now vital components of a marketing programme. Technology may keep changing, but people don’t. The basic principles of marketing and storytelling will always apply even though the methodology may continue to shift. Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, author of 11 books, and founder/ Editor in Chief of beautyinthebag.com; E: wl@wlbeauty.com body language www.bodylanguage.net

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dermatology John D Warren

Skin lesion imaging With high melanoma rates, the UK has a comparatively low number of consultant dermatologists and mole clinics. John D Warren discusses the integration of mole imaging within private aesthetic practices to cut unnecessary excision rates and describes the benefits of Derma Medical’s MoleMax systems

here is a great need for mole clinics and associated imaging equipment in Europe, particularly for the early detection of melanoma. Australia and New Zealand have the highest melanoma rates in the world, followed by North America. Northern Europe is next on the list, with the UK and Ireland being in the top seven European countries for melanoma rates. In terms of UK melanoma occurrence among males versus females, the rate per 1000 in males is far greater than that in females. But women between the ages of 20–60 have a greater rate of melanoma rate than their male counterparts. This may be related to interest in exposing the skin to ultra-violet rays in that age range. In the UK, we have only around 500 consultant dermatologists. So the availability of skin lesion detection and monitoring systems is low. The standard, and easiest, procedure has been to excise the lesion. According to a 2008 study published in the Medical Journal of Australia, around 55% of lesions excised are, in fact, non-malignant. So to quickly get rid of these, excision is possibly the first recourse. The benefits, then, of equipment that can monitor and compare moles throughout their existence are that they would reduce the number of excisions. This is something that, in the UK, we haven’t carried through to any great extent. NHS clinics Associated with the finance of excision, the cost in the UK of assessing a mole, excising it and carrying out the compulsory

analysis, is approximately £500 per excision. We, as aesthetic doctors, carry out 300,000 excisions per year. If 45–55 excisions are unnecessary and monitoring systems are available, the cost of equipment could be recouped quickly if there were a monitoring protocol in place. First we need to consider how clinics could be set up with the NHS. The problem with setting up mole clinics is availability and location within hospitals or clinics. Where will you place the equipment? This has traditionally been fairly large and not necessarily very portable. However, the volumes of people that can be assessed and monitored over a period of time number several hundred thousand. In setting up these clinics, there should also be local awareness and marketing of the service. Along with the low number of consultant dermatologists and an increased number of people that wish to have lesions looked at, it would then be necessary to have a greater number of skintrained nurses to allow them to do rather more than simply looking at skin and skin lesions. The use of a skin-trained nursing team to triage clients and obtain images is something else that the NHS would have to consider. The actual cost involved in these three things is, in fact, enormous and mitigates against setting up of a service altogether. The consultant assessment of images and decision-making regarding excision should be done by the consultant, under triage guidance from a nursing team. With modern technology, these high quality images can be assessed on all sides whether an excision should take place, but this process takes time and money to set up. body language www.bodylanguage.net

dermatology John D Warren

The NHS has not been able to fully contemplate an expansion of these services due to the extra expense and pressure on physical space. Therefore private practice and private services need to be considered for the assessment of moles. Private services Private clinics could absorb the service on behalf of the trust, at a cost per patient. There are several private practices whose consultants have been working in the NHS, and have set up their own private practices for cosmetic work, taking on the service of mole assessment on behalf of the trust at a cost per patient. Private hospitals could also expand their services to better utilise the facilities that they already have. Private aesthetic practice also capitalises on an increased concern by individuals on skin issues. We know, for example that the media—particularly in the early summer—highlight the concern people have about skin, skin cancer and mole problems. As far as a private practice is concerned, bringing in people to have skin analysis or to have a mole examination would also increase footfall through the practice for greater awareness of other clinic activities. Skin examinations require repeat visits on an annual basis and if the patient has a suspect lesion, they would need a monitoring service every three months until the lesion is identified and, perhaps, an excision decided upon. A skin-trained nurse is required to reduce the consultant’s work, acting as the triage agent for putting together patients he/ she feels ought to be seen. Initial assessment of images can also be carried out by the nurse. The service then needs to be advertised—people need to know that the service is available. By regularly carrying out advertisements, practices can grow considerably in a short space of time. Extra services are used by patients who come to have their moles looked at and it raises awareness within the community of the availability of a variety of different cosmetic services. In terms of viability, facility and equipment considerations obviously need to be taken into account. But there is increasing awareness of UV-related skin problems and as people are now taking a greater amount of holidays throughout the year, it’s not a ‘one season’ issue. Lesion imaging Lesion imaging systems such as the MoleMax—developed by Derma Medical in Austria—use epiluminescent microscopy. This is a digital service which enables dermatologists to look at the skin surface and provide a wide angle or a micro view. A wide-angle camera lens view enables large areas of the body, or indeed, the whole body to be viewed and recorded, and the lesions pinpointed. Using the micro view, close up cameras can get 20, 40, 60, or 100 times magnification. The MoleMax systems also use polarised light, which is very useful because it enables the light to penetrate slightly under the surface of the skin. A lesion can then be viewed, not just from the surface, but slightly underneath— some idea of the lesion’s depth can then be determined. The MoleMax HD is a photographic suite which involves a computer system and two high definition screens. An upper screen focuses on the individual mole being examined and a lower screen represents the history of that particular patient and details of the mole images that were taken previously to compare. The camera has a zoom feature and the front lenses can be changed for higher magnification. There is a small screen on the back of the HD camera for ease of mole location. Another videodermoscopy system, the MoleMax I has both micro and macro body language www.bodylanguage.net

Body mapping is important for patients with large numbers of moles. Body mapping software can pinpoint moles (documented by green rings) and pinpoint their location

For body mapping, the MoleMax has an inbuilt lighting system to ensure even lighting for comparison at future visits

Existing moles can be pictured, analysed and compared side by side after a time interval 51

dermatology John D Warren

The specialist is guided through ABCD decisions (or 7 point rule systems) to provide a histogram of likely risk, also using a traffic light guide

camera modes, and all functions can be controlled through the camera itself. However, these imaging systems are fairly static devices— they can be moved from room to room, but not easily transferred by vehicle to different sites. In terms of portability, the DermDoc is a small, handheld device that works through a laptop. It uses the same camera as the MoleMax I, and this system can be linked to a desktop HD screen to give better imaging quality, if required. Software The same software is used with all systems and, with the DermDoc, can be set up at different locations. Once the image has been taken, it can be compared with other mole images in the database that are known to have been active. There is also software available for body-mapping, which is important for patients with large numbers of moles. Body-mapping software can pinpoint mole locations and show where new ones have appeared. In terms of accuracy, these are around 90–95% accurate so a great deal of care has to be used with this kind of software. One of the problems with software trying to track moles is even lighting. It’s important that the physical distance from the patient is determined. There are a variety of positions where the central stand (see “Inbuilt lighting”) can be moved, such as the upper shoulders, middle of the back, posterior, upper leg, lower leg, ankles and bottom of the feet. There are also individual lighting elements to guarantee that if a stand is set up at a specific distance from the background, the lighting will be the same if the patient is returning within two or three months, or after one or two years.

ing aggressive or not. The mole scoring uses a traffic light system, with red, yellow and green. The positioning within that, based on the decisions made by the consultants, give an idea of the percentage chances of that lesion being a melanoma or some other kind of skin cancer. When each of the pictures are taken on successive times, trending graphs can show physical evidence of the justification for the mole removal. The PhotoMAX EOS system, also from Derma Medical, uses a Canon EOS camera—the standard lens provides wide angle body shots, while a special close up lens provides 30x lesion image magnification. This particular lens system also has inbuilt lighting inside it with a rechargeable battery. The DermaFoto is a 12 megapixel, HD image capture system in a smartphone-sized device. This uses polarised light and has the availability of seeing below the skin surface. The device also has the Woods Lamp feature, fluorescing to indicate fungal or bacterial infections. The system can also transfer images via WiFi to a computer, enabling visual examination on a large screen. While this has less ability than larger systems for detailed work, it is portable and cost-effective for the recording and analysis of moles and analysis of moles. John D Warren is a product specialist in the fields of dermoscopy, aesthetics and dermatology The PhotoMAX EOS system uses a Canon EOS camera—a special close up lens provides 30x lesion image magnification with internal lighting.

Mole monitoring Images are taken of the existing mole, and then analysed and compared side by side after a time interval. You can then see if there has been any growth or changes that have taken place within the mole. Some imaging systems use automatic mole scoring devices, which automatically tell you the degree of danger. Others are manual, and require the consultant to make the determination. MoleMax systems have the standard ABCD or seven point rule systems, which require a decision at each stage—alternatives are given and decisions are made by the consultant so that the end results show a proportion of chances of that particular mole be52

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products

market On the

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

NEOSTRATA Active Line Lift The new NeoStrata Skin Active Line Lift is now available in the UK, and this two step topical line treatment is the latest addition in the range of Neostrata Skin Active products. Neostrata claim the product lifts deep lines and wrinkles at four weeks as Skin Active Line Lift contains high strength of Aminofil—a tyrosine amino acid derivative (N-acetyl tyrosinamide). Skin Active Line Lift is said to improve the appearance of deep expression lines in both men and women with photodamage and can be used as a stand-alone treatment. The product is also a topical adjunct to cosmetic procedures such a neurotoxins, peels, microdermabrasion and light based treatments. It is suitable for patients who have filler resistant lines or needle phobia as well as those who are not ready for cosmetic treatments to tackle early signs of photodamage. Applied twice daily, the treatment can also target deep expression lines. Skin Acitve Line Lift contains NeoCitriate and NeoGlucosamine which work together synergistically to help build glycosaminoglycans including hyaluronic acid and collagen. NeoStrata say this provides volume in the deep skin matrix and visibly lifts lines that can’t be addressed by an anti-ageing topical skincare regimen alone. The Skin Active Line Lift duo is a two step treatment, be applied morning and night. The first step consists of a roller-ball applying Aminofil to targeted expression lines and wrinkles, followed by gentle massaging into the skin. The second step involves application of a light cream to seal in the Aminofil. Aesthetic Source, T: 01234 313130; W: aestheticsource.com

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Mycrolator skin prep

Developed by Black et Blanc, medical device experts for both the pharmaceutical industry and the beauty sector, Mycrolator skin prep reduces the appearance of lines, wrinkles, scars and blemishes, aiming to leave both men and women with a flawless facial skin. The medically certified device contains precision-engineered tiny metal micro-projections that are to gently be dabbed onto the skin. This lightly disrupts the uppermost layer of the skin containing dead cells, leading to the creation of micro-pockets. The reaction increases the skin’s surface area, into which the filtered oils are able to absorb and form micro-reservoirs allowing the oils to be gradually absorbed into the skin for a long duration say Black et Blanc. Black et Blanc, T: 0203 1371 650; W: alexsilver.co.uk

Grahame Gardner

Grahame Gardner is now a fundraising partner with Ovarian Cancer Action, supporting the charity by first, offering customers the chance to have their logo branded on any tunic from the Vitality range by making a £1 donation and second, by donating £2 to the charity for each branded tunic sold. Ovarian Cancer Action is the UK’s leading ovarian cancer charity. Based at Imperial College London, the charity focuses mainly on improving the prognosis of all women diagnosed with ovarian cancer through specific scientific research. James Greenlees, Managing Director at Grahame Gardner comments on the new relationship: “Ovarian cancer has the potential to devastate the lives of women and their families. Here in the UK a woman dies every two hours from ovarian cancer and we were keen to do something that would help address this and aid greater understanding of the disease.” Ovarian Cancer Action W: ovarian.org.uk Graham Gardner T: 0116 255 6326; W: grahamgardner.co.uk

products

brushstrokes Toleriane Ultra

La Roche-Posay has launched a new skincare product, developed specifically for ultra-sensitive and intolerant skin. It is the company’s first skincare product containing neurosensine and Toleriane Ultra is the only skincare product to be awarded the ‘Allergy UK Seal of Approval’. Toleriane Ultra contains no paraben, perfume, alcohol, colorants and lanolin. The product uses La Roche-Posay thermal spring water, a powerful antioxidant, rich in selenium, clinically proven to be soothing and anti-irritating, coupled with shea butter and glycerine that restores comfort to the skin. Observations over a period of three weeks have been made on women aged 25 to 50 with intolerant, reactive or allergic skin. 99% of users reported it was suitable for intolerant and allergic skin, 99% described a pleasant texture and 94% evaluated the formula as ‘non-sticky’. La Roche Posay T: 0800 055 6822; W: laroche-posay.co.uk;

 LipoCryo is a new technology developed by Clinipro to offer localised fat reduction. LipoCryo say this treatment is pain free, quick and is an effective way to reduce fat. Fat cells are eliminated by a process combining the application of vacuum and cooling. Through the vacuum, the fat tissue is isolated to avoid damage in the surrounding tissues, and the application of cold causes the elimination of fat cells. Afterwards, the adipocytes are removed by the body’s own metabolism. LipoCryo, T: +34 935 903 108l; W: lypocryo.com

Ultradent Opalescence

Gemstar

Gemstar has launched its latest hot towel dispenser which comes in a compact size with a built in UV sterilisation system, producing hot towels in seconds. The new device allows patients to freshen up and remove any excess material around the face and these hot towels can be used as alternatives to dampered tissues or wet wipes. No plumbing or specialist installation is required and as the towels are disposable there are no additional laundry costs. The added feature of a built in UV sterilisation system complements the safe and hygienic environment of any practice. Gemstar T: 01787 464058; W: gemstaruk.com

Optident have re-launched their Ultradent Opalescence tooth whitening gels, and to meet the demand for an at-home, ready to use whitening product, Ultradent have introduced Tres White. This product has all the properties of Opalescence and does not require the use of a custom-made application tray. Tres White is supplied as a 6% hydrogen peroxide gel and comes in a ready to wear tray. When removed, the product leaves an inner tray in situ, which ought to be left in place for an hour each day. Noticeable results can be seen in five to ten days. This method of teeth whitening is also useful for patients who have had previous whitening treatments and want a top up. Two gel flavours are available—regular and mint. Optident Ltd, T: 01943605050; W: optident.co.uk

 Lipotripsy is a new clinically proven radical wave treatment that offers cellulite and inch loss results in just four weeks, with the first results seen after just two weeks. Available in some of the UK’s leading aesthetic, Lipotripsy is delivered by a therapist through a small hand piece, passing over the skin and reaching the fat cells in the dermis. Lipotripsy T: 0120 2761198; W: lipotripsy.com

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s new procedures, products and services are launched and patients’ demands intensify, your own knowledge needs to keep up with change. Whether you wish to know about the efficacy and contraindications of a new filler or borrow tips from a master injector of toxins, you can rely on Body Language to keep you informed and up to date. Body Language is a bi-monthly journal aimed at all medical practitioners in medical aesthetics and anti-ageing. It is full of practical information written by leading specialists with the intention of helping you in your pursuit of best practice. Assisting professionals in medical aesthetics, Body Language has taken stock of developments and investigates the methods of experienced practitioners around the world, commissioning experts to pass on their knowledge in our editorial pages. Our editorial provides you with professional accountancy and legal advice that alone can save you thousands of pounds. You can also help yourself to continuing professional development (CPD) points. You can determine how many within the CPD scale that our articles are worth to you and self-certify your training. As a subscriber, you can access back issues of Body Language. You will be emailed your own code to enable you to read articles online. That in itself is a big time-saver. Rather than have to track down a misplaced issue from six, nine or 14 months ago to reread an article, you can refer to it online in seconds. Body Language continues to be at the forefront of publications in the medical aesthetics sector. Its leading position owes much to it being a practical journal that puts theory into practice and assists you to do your job as best as you can. You cannot afford to be without Body Language.

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surgery Mr Shiva Singh

Flex your muscles The appearance of toned muscles, both in the legs and chest, are a common aesthetic ideal among consumers. Relatively low-risk surgical procedures such as calf and pectoral augmentation can provide natural results, writes Mr Shiva Singh

s media and fashion have driven public taste, wellshaped legs and subtly defined muscles have become standards objects of desire. Reconstructive surgery can either provide contouring to enhance definition, or add an implantation to increase volume. Patients—both men and women—seeking shapely legs or defined pectoral muscles generally require an improvement in volume, contour and symmetry. Body builders often request treatment to improve muscle appearance. Others require therapeutic treatment, for abnormalities resulting from talipes equinovarus (club foot) surgery during childhood or post-polio, when the muscles often haven’t developed.

Calf augmentation The surface anatomy of the calf runs in the following order: the semitendinosus, the semimembranosus and the gracilis muscle; the biceps; the popliteal fossa; and the medial and lateral heads of the gastrocnemius. There are two basic types of calf implants available. The first has an asymmetrical base, where the top is wider than the bottom. These implants are usually favoured by men and intended for a more athletic look. They are available in volumes between 33cc–140cc. There are also symmetrical base implants, which are more popular among women. These are wider in the middle, tapering at the top and bottom. The size range is similar to the asymmetrical base implant sizes. Calf implant surgery is safe and has a high rate of patient satisfaction. However, there is an associated risk of a 10–11% rate of revision surgery. Patient selection is therefore crucial, and they need to have realistic expectations. This procedure can also be combined with liposuction to reduce volume in certain areas, or fat transfer can provide volume if needed. There are cases of complications. I have seen one patient who had a minor infection which was immediately treated with antibiotics. Another patient had implant malposition which required revisions. However, there were no seromas. Pectoral implants As we become more body conscious, there is much more demand for aesthetic procedures like pectoral implants. Patients suffering from Poland syndrome, characterised by the underdevelopment of one side of the chest muscle, can require implants to enhance the defective side of their chest. I have also seen patients who had post-traumatic deformity, who requested pectoral augmentation. They had ruptured their pectoralis major and clavicular head—conditions which were followed by atrophy. Silicone implants are available in volumes between 180cc– 230cc. Projection is estimated between 2.2–2.6cm and implants can also be customised. 58

The surgical procedure is performed under general anaesthetic. I go through the posterior border of the pectoralis major muscle, in the anterior axillary line. I have been able to do it through the axilla with one or two patients. Under direct vision, the pectoralis major muscle is lifted up, because it is a free border. I insert an illuminated retractor to observe and use diathermy with extension for separating the muscle. As opposed to breast implants, where the pectoralis muscle is lowered, the full width of the pectoralis major is lifted on to the lower pole. This is because the male chest has a very short area at the inframammary fold. It is generally a bloodless procedure— but if bleeding occurs, it has to be stopped immediately. Common complications generally involve the creation of hematomas—I have had two patients who required hematoma evacuation. No seroma or infections have been observed but malposition has been present in four patients who needed a change of size and position. In such cases, expectations have to be qualified at the pre-operative consultation. Mr Shiva Singh is an aesthetic surgeon, based in London, UK

Before and after silicone implants for pectoral augmentation

Before and one week after 120cc symmetrical base implants body language www.bodylanguage.net

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dental Dr Anil Shrestha

Hollywood smile When it comes to the ageing face, one of the most effective cosmetic enhancements concerns the teeth—restoring our pearly whites to their former glory. Dr Anil Shrestha discusses the origins and benefits of the smile makeover

he term ‘smile makeover’ is wellunderstood by most lay patients. It represents an attempt to improve the aesthetics, symmetry and harmony of a patient’s smile and to rejuvenate degenerated and worn teeth. In the early 1930s, the first recording of smile makeover treatment was documented by Dr Charles Pincus. A famous Hollywood dentist, Dr Pincus made acrylic veneers that were temporarily cemented onto famous actors’ teeth to improve the appearance of their smile. These were not bonded like modern materials and were non-functional—purely for aesthetic enhancement. Clearly, the improvement in appearance was highly prized and became the progenitor for the term ‘Hollywood smile’. A recent survey by the American Academy of Cosmetic Dentistry showed that 92% of US respondents considered an attractive smile to be an important

social asset and one that could enhance career success. Anatomy The teeth are an integral and central part of the maxillo-facial scaffold, upon which the soft tissues of the face effectively hang. The loss of teeth and the dento-alveolar complex often leads to loss of soft tissue support, with signs of premature ageing and wrinkling. A good dental surgeon can restore soft tissue support and reduce or even obviate the need for the use of facial fillers in the perioral area. For example, eversion of the lips and elimination of naso-labial folds and circumoral creasing following tooth extraction can be restored with the restoration of the dentition and alveolar bone that supports the hard tissues. In dentistry, the relationship between mathematics, symmetry and proportion could arguably be easier to discern

in the hard tissues of the teeth compared to other aspects of the body such as the nose, face or breasts. It is important for all healthcare practitioners practising cosmetic procedures to give consideration to the dentition and treat their patients holistically to produce the best overall appearance. Contemporary dental materials and advances in techniques have come a long way to produce exceptional and predictable functional improvements in appearance. As well as the use of porcelain laminate veneers, new bonding techniques and all-ceramic restorations, multi-disciplinary approaches including a combination of orthodontics (movement of teeth), orthognathic surgery (manipulation of bones in the orofacial complex), and all aspects of dental implant surgery serve to produce the optimal aesthetic outcome in a smile makeover. It is said that there is an art to smile de-

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dental Dr Anil Shrestha

sign, reflecting the subjective perception of beauty based on mathematical models of symmetry and proportion established by the ancient Greeks. The challenge for the cosmetic dentist is to combine these elements to give both an improvement in aesthetics and predictable functionality. They must understand what is regarded as the ideal shape of a tooth and how it functions. The tooth must be placed in an optimum position to harmonise with adjacent teeth, the gingival architecture, the lips and circumoral tissues and—equally importantly—the overall face. Smile design The assessment of smile design can be methodically analysed by looking at several key components: the central incisor dimensions; the central incisor mid-line; golden proportions; axial inclinations; the arch form; incisal embrasures and contacts; gingival architecture; and the buccal corridor. The maxillary central incisors (upper two front teeth) dominate the smile. They ideally exhibit a width-to-lengthratio of 75-80% and this ideal proportion enhances a youthful appearance. Wear of the incisal edges with age can change this proportion, producing the appearance of shorter and flatter teeth and closing face height. The central incisor mid-line should coincide with the mid-line of the face and a line drawn perpendicular to the interpupilary line. Oblique lines create asymmetry and significantly detract from a pleasing appearance. The “Golden Proportions” rule in dentistry is a progressive tooth-to-tooth relationship that is used as a guide only. It can help determine the dominance of each tooth as it relates to its neighbour and the effect on the overall smile. This is only a two-dimensional perspective as viewed from the front, therefore has obvious limitations.

But deviations from the proportion reflect disharmony and disrupt the subjective flow of the smile. Axial inclinations of teeth relate to the orientation and therefore directly to a Golden Proportion. Again, this is a reflection of symmetry as perceived through all angles on assessment. The ideal arch form of a tooth should follow a symmetrical ovoid when viewed from an occlusal perspective. Development of teeth in a symmetrical U-shaped arch creates expansion of the buccal corridor, which is needed to increase the physical size of a person’s smile, allowing the teeth to be displayed in their proper shape to their fullest extent. The incisal and cuspal embrasures reflect the tooth-to-tooth relationships that are important to create a smooth transition from one tooth to another. It gives a young and vibrant appearance, whereas lack of incisal embrasures indicates wear and ageing. The relationship of the gingival tissues to the teeth and lips should be pleasing and symmetrical. This is known as the gingival architecture and effectively frames the teeth within the soft circumoral tissues. Repositioning and enhancement of these tissues is a sub-specialty of dentistry called perioplastic surgery. The use of crowns, veneers and changing the shape of the teeth are linked to the gingival architecture in terms of the emergence profile from the gum tissues. A good cosmetic dentist will ensure that the gingival architecture is accounted for with the final porcelain restorations. The buccal corridor is the space between the facial surface of the posterior teeth and the inner aspect of the lips at the commissures. The most attractive, broad smiles have very small buccal corridors, producing a full appearance of the smile. This can be achieved by the use of porcelain veneers, but more predictably in the long term through orthodontic therapy.

Anterior teeth Most patients express concern about the anterior teeth when seeking cosmetic treatments. Apart from the correct alignment of the teeth, concerns regarding the appearance of the teeth relate primarily to the effects of ageing. Aesthetic manifestations of anterior tooth ageing fall into three basic categories: wear and the effects of erosion, attrition, abrasion and abfraction (a unique type of biological flexure of the teeth in function causing characteristic V-shaped defects at the gum line); size and position of teeth in relation to each other and to surrounding tissues; and colour of the teeth. Other age-related factors include histological transformation, chemical transformation, metamorphosis of supporting bone and surrounding soft tissue structures of the face, and changes in muscle tension. Several aspects of the appearance are important but youthful smiles generally reveal 75–100% of the maxillary teeth below the inter commissure line. As the amount of reveal dips below 40 and approaches or becomes zero, the face becomes markedly aged. The restoration of appropriate tooth length and proportion can give a more youthful appearance when performed as part of a carefully thought-out treatment plan, critically taking account of their involvement in the overall occlusal scheme. Darker teeth are also generally associated with older age. Bleaching can have dramatic youth-enhancing effects on select patients with otherwise healthy teeth. Dr Anil Shrestha is a registered specialist in prosthodontics who trained at the Eastman Dental Institute in London. He has his own private specialist referral practice at Lister House in Wimpole Street and is clinical director of Smiles Dental.

Before and after improvement in the aesthetics, symmetry and harmony of the smile, as well as rejuvenation of degenerated and worn teeth body language www.bodylanguage.net

experience Dr Zein Obagi

Under the skin Dr Zein Obagi describes the origin of his approach to skin health

y career i n d e rmatology began almost 50 years ago in my home country of Syria. My 16-year-old sister was walking in the house when my mother tripped and accidentally spilled boiling water on her back. She had to be rushed to the hospital and ended up with secondand third-degree burns. I saw the frustration on the faces of the doctors who were treating her because they couldn’t do much, except to control the infection. As a result, my sister’s back was scarred and severely disfigured. I felt very badly for her—this was the first time I thought about becoming a doctor. As a young man, I noticed skin problems among my family and friends yet I didn’t even know the field of dermatology existed. My grandfather had basal cell carcinoma and lost half of his nose. I was a boxer and noticed many of my friends had acne scars—the treatments administered were not successful, so I became determined to become a doctor and vowed to treat skin problems. During my medical education, I rotated through many departments but was unsure of the path to take. One professor who I respected suggested I pursue pathology. The science was fascinating to me, but I soon had had my fill of microscopes and wanted to interact with people. So I applied for an OB/GYN residency in Detroit, but kept my pathology knowledge up-to-date by visiting the lab. One night, while reviewing slides, one in particular caught my attention. It was marked as a melanoma from a 23-yearold patient who was scheduled for surgery the next day to dissect the lymph nodes in her neck. I looked at the slide and knew immediately that this was not a melanoma. It looked like one, but was actually a Spitz tumour. I called the surgeon to tell him that the diagnosis was incorrect. Unfortunately the information was not well received, especially by the chairs of the OB/GYN and pathology depart62

ments. However, they sent the slide to the Naval Medical Center in Bethesda, Maryland for evaluation. The Navy’s report confirmed my diagnosis; the tumor was not a malignant melanoma. The department chairs absolved my action seeing as I had saved the patient’s life. At this point, I was still living in Detroit with my wife—I was not a big fan of the snow and realised OB/GYN was not my true calling. One day, I was sitting in the resident’s room and a Marine came in and asked for Dr Obagi. To my surprise, it was the father of the 23-year old melanoma patient. He came to personally thank me for saving his daughter’s life. After hearing my story, he suggested I join the US Navy. I did and became the private physician for a General based in Hawaii. My wife was happy to leave the cold winters of Detroit for the palm trees and white beaches of paradise. This was a real turning point in my career. Part of my job was to rotate among the hospitals in Hawaii, including the Tripler Army Medical Center in Honolulu. The dermatology department was filled with Marines suffering from severe scars, sun damage and tropical skin infections. This experience encouraged me to explore becoming a dermatologist, but competition in the US Navy was extremely high. There were only 12 dermatology positions and over 200 applicants wanting to fill them. Due to my extensive pathology training, experience in the Navy and favourable recommendations from my superiors, I was selected as one of the 12 doctors to be trained in dermatology. A Harvard medical school graduate with an eidetic memory was my toughest competition in the dermatology department. But

when we started treating patients, I learned that being a good dermatologist is less about perfect recall than about successfully treating a patient with outstanding results. After being honourably discharged from the Navy, I purchased a dermatology clinic in San Diego, California in 1981, where I practiced general dermatology. Dermatology was solely devoted to the treatment of skin diseases and other conditions that result in unhealthy skin. Cosmetic dermatology did not even exist at the time, but I was determined to change that. I have never accepted conventional thinking, so started to approach skin from a different perspective. I established the concept of creating healthy skin where there is no disease present—a notion that was unheard of at the time. Textbooks were solely focused on skin diseases and there was simply no explanation of what defined healthy skin. I began studying and analysing all skin tones and types; from light to dark, thick and thin, oily and dry, and even sensitive. I created a new standard of analysis through histology and pathology that defined the wide variety of skin types in humans. My research evolved to include more studies on what should be used and the optimal treatments needed to achieve the best results for various skin types. The culmination of my career lies in my comprehensive skin health philosophy. I have been fortunate to fulfill my vision of establishing the benchmarks for healthy skin, and develop the tools and protocols to achieve it. I can now turn to my physician partners and skincare colleagues to incorporate these protocols into clinical practice for their patients. Dr Zein Obagi is a dermatologist in Beverly Hills, California and is medical director of ZO Skin Health. body language www.bodylanguage.net

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