Body Language UK - Issue 60

nov/dec

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

Face of the future OUR PANEL OF EXPERTS DISCUSS HOW TOXINS AND FILLERS MAY EVOLVE

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin.

Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, LambertEaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution.

4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis),vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin.

Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May

result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany.

Date of revision of text: FEB 2012. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at yellowcard.mhra.gov.uk Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456.

3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154.

4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58.

5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1127/BOC/OCT/2013/LD Date of preparation: October 2013

contents

body language number 60 14

THE PIP SCANDAL Mr Miles Berry and Mr Jan Stanek describe the scandal’s impact from a surgeon’s perspective

8 OBSERVATIONS ANALYSES Reports and comments

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

14 COVER STORY FILLERS AND TOXINS Our panel of experts discuss filler techniques and complications, as well as toxin resistance and the future of injectables

29

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

21 INJECTABLES TARGETING PTOSIS Drooping of the eyelid, or ptosis, is a side effect of botulinum toxin injections, which can be caused by poor injection technique. Dr Zahida Butt describes the side effects and contraindications using apraclonidine, or Iopidine, to treat botulinum toxin induced ptosis

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

25 DERMATOLOGY

Publisher Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com Contributors Mr Miles Berry Mr Jan Stanek Mr Rajiv Grover Dr Fredric Brandt Dr Michael Kane Dr Timothy Flynn Dr Nick Lowe Dr Zahida Butt Anna Jean Lloyd Dr Raj Persaud Adrian Furnham Dr Anne Klassen Dr Stefan Cano Dr Andrea Pusic Eva Sanchez Lorna Jackson Adam Hampson Andrew Saunders Dr Carlos A Román Richard Crawford-Small Mr Christopher Inglefield

7 SPECIAL REPORT

EARN YOUR STRIPES While stretch marks are—to some women—a badge of honour following pregnancy, many others seek ways to banish them for good. Anna Jean Lloyd reviews the available treatments and technologies

31

29 PSYCHOLOGY THE RED EFFECT Red has long been associated with romance, passion and energy. Dr Raj Persaud and Adrian Furnham investigate psychological research that suggests the colour might render young women as more sexually attractive to men

31 RESEARCH MEASURING UP Reliable, scientific measurements of patient outcomes improve patient satisfaction and education, and provide support to clinical studies and research. The international team describe the BREAST-Q, FACE-Q and BODY-Q scales

41 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

36 SURGERY COMPRESSION GARMENTS Post-operative complications can be reduced or even avoided through the use of compression garments. Eva Sanchez runs through the key features to consider when choosing garments for your patients

41 DERMATOLOGY THE LASH EFFECT Long, full eyelashes are a commonly desired element of a youthful, beautiful face. Lorna Jackson runs through the active ingredients of eyelash enhancing products, both prescription-based and cosmetic

3

body language

editorial panel

number 60

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

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

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.

4

60 47 MARKETING THE POWER OF BRANDING A strong, consistent brand is essential to separate you from your competitors and attract new customers. Adam Hampson discusses how to market your clinic’s brand on emotions and experience

49 SURGERY STEM THE TIDE Haemostasis, or the prevention of excessive blood loss, is an essential part of all surgical procedures. Andrew Saunders describes the efficacy of the QuikClot Hemostatic Dressing, which uses kaolin as its active ingredient

53 PRODUCTS ON THE MARKET The latest products in aesthetic medicine

55 NUTRITION FOOD FOR THOUGHT Dr Carlos A Román investigates the link between refined carbohydrates, diabetes and heart disease, and how they can affect the ageing process

60 TECHNOLOGY CUSTOMER RELATIONSHIP MANAGEMENT The use of technology can strengthen the relationship between the medical aesthetic practitioner and the patient. Richard Crawford-Small discusses customer relationship management systems and the role they play in bringing business practices into the 21st century

62 EXPERIENCE INNOVATE TO EDUCATE Mr Christopher Inglefield talks about how his passion for helping people and problem-solving spurred him to study medicine, and how important innovation is to those practicing aesthetic surgery body language www.bodylanguage.net

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observations

The PIP scandal: Special Report Mr Miles Berry and Mr Jan Stanek describe the scandal’s impact from a surgeon’s perspective Poly Implant Prothèse (PIP) silicone breast implants were used by Mr Stanek from January 2000. At the time, they were equal in cost to competitors and gave similarly satisfactory early results but over the following five years, a propensity for premature rupture appeared.

At the time, figures available from the Medicines and Healthcare products Regulatory Agency (MHRA) were inconclusive. However, an emergent trend and PIP’s reluctance to take concerns seriously led to complete cessation of their use in August 2005.

Two other surgeons, Lahiri and Berry, reported their concerns with case reports in the scientific literature shortly after but the devices continued to be widely used. Somewhere between 300,000–400,000 are believed to have been used worldwide since their appearance in 1999, with 40,000 of those in Britain.

After increasing industry rumours and a price that had fallen well below competitors’, the only real surprise about their withdrawal from the market in April 2010 was that so many large commercial companies were still using them at all, let alone in such large numbers.

We instigated a product recall study of 460 patients shortly after and published initial findings in 2012, in The Sunday Times and later in the Journal of Plastic, Reconstructive & Aesthetic Surgery.

We uncovered a crude rupture rate of 15.9–33.8%, but were surprised that 40% of our cohort did not respond for free evaluation, given the degree of media interest. Such a high figure for device failure was questioned by many and even the MHRA produced figures suggesting a mere 0.28% rupture rate from 2001–2009.

We also demonstrated a noticeable reduction of durability as time progressed; the mean time to rupture for the year 2000 having fallen from 10.3 years to 5.8 years by 2005.

The death of a Frenchwoman in late 2011 from lymphoma attributed to her PIP breast implants sparked a global media frenzy and facilitated a more complete follow up of our own patients. Many requested an ultrasound scan and/or implant exchange, allowing us to derive a more accurate figure for 10 year rupture prevalence of 19– 40%. Ultrasound scans were found to be accurate in over 90% of cases and, importantly, 32% of women were found to

References 1. Lahiri A, Waters R. “Locoregional silicone spread after high cohesive gel silicone implant rupture.” J Plast Reconstr Aesthet Surg 2006; 59: 885-6 2. Berry RB. “Rupture of PIP breast implants.”

J Plast Reconstr Aesthet Surg 2007; 60: 967-8 MHRA Medical Device Alert MDA/2010/025, issued 31st March 2010 3. http://www.thesundaytimes.co.uk/sto/ news/uk_news/Health/article853162.ece 4. Berry MG, Stanek JJ. “The PIP mammary prosthesis: a product recall study.”

J Plast Reconstr Aesthet Surg 2012; 65: 697-704 5. https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/216537/ dh_134043.pdf (accessed 9/10/13) body language www.bodylanguage.net

have a rupture of which they were entirely unaware.

By this time, other studies had started to filter through and our rupture rate was looking rather less outlandish. A study of 224 women implanted between 2000 and 2001 with PIP prostheses in the Netherlands showed a 33% rate of rupture using MRI scanning.

Another study, of 338 patients from Scotland showed 35.2% rupture per patient. Interestingly, they too documented decreasing device durability with time, giving credence to the belief that while the earliest implants were probably satisfactorily manufactured, quality control declined with time.

Finally, two smaller studies, of 65 and 44 patients, have showed ruptures in 27% at 7.2 years and 21.8% respectively.

The latter accorded with our own finding of a high rate of asymptomatic rupture.

Early results from PIP used in breast reconstruction following cancer extirpation have also reaffirmed the declining implant durability with time. The Institut Curie in Paris showed a less than 5% rupture pre-2008, but an increase to 23% by 2011.

The evidence, it would appear, is clear that PIP manufactured substandard implants

6. Berry MG, Stanek JJ. “PIP implant biodurability: A post-publicity update.” J Plast Reconstr Aesthet Surg 2013; 66: 1174-81 7. Maijers MC, Niessen FB. “Prevalence of rupture in Poly Implant Prothèse silicone breast implants, recalled from the European market in 2010.” Plast Reconstr Surg 2012; 129: 1372-8 8. Quaba O, Quaba A. “PIP silicone breast implants: Rupture rates based on the explantation of 676 implants in a single surgeon series.” J Plast Reconstr Aesthet Surg 2013; 66: 1182-7 9. Khan UD. “Poly Implant Prothèse (PIP) incidence of device failure and capsular contracture: a retrospective comparative analysis.”

Aesthet Plast Surg 2013; 37: 906-13 10. Chummun S, McLean NR. “Poly Implant

and placed profit well ahead of patient care. Given that the trial is in progress, yet no information about what raw materials may have been used and at what point in time, suggests a persistently maleficent intent.

What is less clear is how such a systematic and fraudulent circumvention of Europe’s highest regulatory standard for implantable devices can be prevented from happening again, particularly as PIP was uncovered only after a tip-off.

While the MHRA survived fairly trenchant criticism in Lord Howe’s report, the French Health Products Safety Agency (AFSSAPS) has undergone the ignominy of a name change, to ANSM. Additionally, despite being a signatory of the CE Marking system and directly responsible for the MHRA, the UK government has appeared positively backward in coming forward to assist patients at their time of need: a complete contradistinction to the assistance, and rumoured £40bn cost, of bailing out the banks.

Mr Miles Berry is a specialist registered plastic and aesthetic surgeon based in London. Mr Jan Stanek is a consultant cosmetic surgeon and is well known as 10 Years Younger’s resident surgeon.

Prothèse (PIP) breast implants: our experience.” Surgeon 2013; 11: 241-5 11. Reyal F, Feron J-G, Detour SL et al. “The impact of Poly Implant Prothèse fraud on breast cancer patients: a report by the Institut Curie.” Plast Reconstr Surg 2013; 131: 690-5 12. Swarts E, Kop AM, Nilasaroya A, Keogh CV, Cooper T. “Rupture of Poly Implant Prothèse silicone breast implants: an implant retrieval study.” Plast Reconstr Surg 2012; 131: 480e-9e 13. http://www.reuters.com/article/2012/02/02/us-breast-implants-mas-idUSTRE8110WY20120202 (accessed 24/1/13) 14. https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/192028/ Review_of_the_Regulation_of_Cosmetic_Interventions.pdf (accessed 9/10/13) 7

observations

training & events UK aesthetic research institute launched

Key campaign aims to address implant safety

BODY Conference, November 2nd & 3rd, London

NOVEMBER 2-3 November, BODY conference, The Royal Society of Medicine, London W: bodyconference.co.uk 6 November, Platelet Rich Plasma training, Wigmore Medical, London W: wigmoremedical.com

28 November, CPR & Anaphylaxis Update training, Wigmore Medical, London W: wigmoremedical.com 29 November, Microsclerotherapy Training The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk DECEMBER

6 November, ZO Medical (Birmingham), training, Wigmore Medical, London W: wigmoremedical.com

2&3 December, SKINSYNERGY training seminar, Aestheticare, Birmingham W: aestheticare.co.uk

6-10 November, DASIL: 2nd Annual Congress, Millennium Hilton Bangkok, Thailand W: thedasil.org/Annual_Congress.htm

4&5 December, ZO Medical and ZO Medical Intermediate training, Wigmore Medical, London W: wigmoremedical.com

7-10 November, QMP’s 9th Aesthetic Surgery Symposium, Renaissance Chicago Downtown Hotel, Chicago, USA W: qmp.com/meeting2013/aesthetic/

5-7 December, Cosmetic Surgery Forum, Aria Hotel Resort and Casino, Las Vegas, USA W: cosmeticsurgeryforum.com

8-9 November, ECAMS Congress 2013, Palau de Congressos de Catalunya, Barcelona, Spain W: ecams-conference.com 11-15 November, Medik8 Dermal Roller, Skincare & Chemical Peels, Intro to Toxins, Intro to Fillers, and Refresher Toxins & Fillers training, Wigmore Medical, London W: wigmoremedical.com 16 November, Botox & Dermal Fillers Foundation, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 16-17 November, IMCAS India, Radisson Blu Resort Goa Cavelossim, South Goa, India W: imcas.com 20&21 November, ZO Medical Introductory and Intermediate workshops, Wigmore Medical, London W: wigmoremedical.com 21&22 November, Dermaroller, Chemical Peel and Microdermabrasion, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 21-24 November, 11th Annual Meeting: International Federation for Adipose Therapeutics and Science (IFATS), New York, USA W: ifats.org 23 November, Botox & Dermal Fillers Advanced, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 24 November, Botox & Dermal Fillers Foundation, Manchester W: cosmeticcourses.co.uk 25&26 November, GloTherapeutics and Advanced GloTherapeutics training, Wigmore Medical, London W: wigmoremedical.com 25&26 November, SKINSYNERGY training seminar, Aestheticare, London W: aestheticare.co.uk

5-7 December, The Cutting Edge 2013, Waldorf Astoria Hotel, New York, USA W: nypsf.org 6 December, Platelet Rich Plasma (PRP) training, Wigmore Medical, London W: wigmoremedical.com 7 December, Microsclerotherapy training, Wigmore Medical, London W: wigmoremedical.com 9-12 December, Medik8 Dermal Roller, Skincare & Chemical Peels, Intro to Toxins and Intro to Dermal Fillers, Wigmore Medical, London W: wigmoremedical.com 12&13 December, ZO Medical introductory and intermediate training, Wigmore Medical, Dublin W: wigmoremedical.com 14 December, Botox & Dermal Fillers Foundation The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk JANUARY

The British Association of Aesthetic Plastic Surgeons (BAAPS) and the Healing Foundation have launched a joint initiative, the National Institute of Aesthetic Research (NIAR) to boost research into the efficacy and risks of cosmetic procedures.

The government-endorsed NIAR seeks to address the “data-vacuum” surrounding operations in the sector, as highlighted in Sir Bruce Keogh’s 2013 Report on the Review of Cosmetic Interventions, by introducing a programme of research and setting relevant priorities.

The Report noted: “There is insufficient research and data on the effectiveness and risks of many cosmetic procedures on which to base patient information materials.

“More research and reviews of the available evidence for both existing and emerging procedures should be encouraged,” Sir Keogh stated.

Research shows breast augmentation as one of the most popular cosmetic surgery procedures and, as a result of heightened concerns following the PIP scandal, NIAR has announced that its first priority will be to establish a Breast Implant Safety Campaign.

While the parameters of the

campaign are still to be finalised, the programme aims to improve all aspects of breast implant safety, treatment and aftercare.

Potential areas of enquiry include the analysis of existing data on breast surgery to provide best practice advice for surgeons, as well as the promotion of clinical research into the safety and efficacy of surgical techniques.

Other areas of research include the causes of capsular contracture following breast implants, and longer term scientific research into implant design and technology.

The campaign also aims to improve the comprehension of psychological factors leading women to seek breast augmentation.

As well as working with corporate partners, NIAR is raising funds by inviting breast implant manufacturers across the globe to donate the equivalent of £1 per device sold to their research programme.

The launch of NIAR was warmly welcomed by Sir Bruce Keogh, the medical director of the NHS, who states: “This joint initiative is the first recommendation of my review to be implemented and I know it will provide a major contribution to patient safety.”

15-18 January, AACS 30th Annual Scientific Meeting, Florida, USA W: cosmeticsurgery.org 20&21 January, SKINSYNERGY training seminar, Aestheticare, Manchester W: aestheticare.co.uk 23-25 January, 5th International Congress in Aesthetic Dermatology, Bangkok, Thailand W: euromedicom.com 23-25 January, ASAPS Aesthetic Symposium, Las Vegas, Nevada, USA W: surgery.org/lasvegas2014 30 January, 7th Oculoplastic Symposium, Atlanta, USA W: sesprs.org 30 January-2 February, IMCAS Paris, Le Palais des Congrès, Paris, France W: imcas.com

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

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observations

60

second brief

Male Grooming The mens grooming market has expanded in recent years, leading to more product launches being targeted at the male audience. Products such as serum and eye cream have been adopted into the male grooming routine and research by Mintel shows that products targeted to men are more likely to be dermatologically tested, ethical or environmentally friendly.

Botox proposed to tackle obesity Study on rats yields positive results With an increasing number of bariatric patients opting for gastric surgery, research has been undertaken into a less drastic option—using Botox to tackle morbid obesity. Helene Johannessen, a PhD candidate at the Norwegian University of Science and Technology, instigated the study using the injectable in rats.

The team injected the vagus nerve in the stomachs of rats with Botox, effectively paralysing the nerve. They observed that over a five-week period, the rats were eating less and had lost 20–30% of their total body weight. According to the ongoing study, it is thought that by paralysing the nerve—which controls the passing of food

from the stomach to the intestine—other stomach muscles are paralysed, thereby slowing the passage of food through the stomach.

“The idea is that if we can trick this nerve we could make people feel more easily satiated,” says Ms Johannessen. The effect may lead to treatments causing people to feel fuller for longer, and provide an alternative to risky gastric surgery.

Obesity operations are irreversable and can cause side effects such as infection, leakage, ulcers and nutritional deficiency disorders. The research team has announced that they will start human clinical trials once approval has been received from the Norwegian medical ethics authority.

Fat cells reduce scar pain and tightness, says study Therapeutic approach for scar remodelling

 Products specifically targeted at men have increased globally by 70% between 2007 and 2012  The UK male grooming market has grown by 12% over the last six years, going from £512 million in 2007 to £574 million in 2012  Products marketed to men are more likely than products for women to be dermatologically tested (21% vs 14%), ethical or environmentally friendly (11% vs 4%), and aromatherapeutic (6% vs 3%)  Up to 74% of British men are defined as keen shoppers when buying personal care products  42% of British men use facial moisturisers  In America, 37% of men use facial cleanser as part of their regular grooming routine, 22% use exfoliating scrubs, 17% anti-ageing products and 12% eye cream or gels Source: mintel.com

body language www.bodylanguage.net

Autologous fat grafting for scar remodelling has led to significant improvements from both “an aesthetic and functional point of view” according to a six-year study led

by Dr Marco Klinger from the University of Milan.

Numerous people suffer from persistent, painful scars resulting from burns, surgery or other causes, which can cause tightening of the skin and may limit motion.

Over the period of the study, published in the Journal of Craniofacial Surgery, Dr Klinger and his colleagues treated nearly 700 patients suffering from difficult-to-treat scars with fat grafts using the patient’s own tissue.

A small amount of fat was collected from the patient’s hips or abdomen and the fat cells were then re-injected un-

derneath the scarred skin in different directions, creating a “web” of support for the damaged skin.

Following treatment, patients reported increased scar elasticity and reduced pain, as well as improved motion in areas where the tightness or stiffness of scars had limited mobility.

In addition, the study noted that the treated areas regained characteristics similar to normal skin.

The team also performed objective observation and hardness assessments on a subgroup of the patients, which supported the conclusions of the study.

The benefits from the fat grafting were observable within two weeks of treatments, and continued through one year and beyond, say the authors.

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The UK’s premier medical aesthetic c o n f e r e n c e and exhibition T: 020 7514 5989 E: info@face-ltd.com W: faceconference.com Twitter: @face_ltd Facebook: facebook.com/faceltd

20 th–2 2n d J u n e 2014 QEII CONFERENCE CEN T RE, WES T MINS TER, LONDON

F

ACE is the UK’s largest scientific and business congress for practitioners of all specialities working in facial aesthetics.

Whether you work as a sole practitioner or part of a large clinic team, FACE provides the best opportunity to learn about the latest treatments, procedures and business tips—all delivered by leading experts in their respective fields.

FACE 2014 will build on its heritage as the scientific forum devoted to facial aesthetics by combining it with

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the largest dedicated medical aesthetics exhibition ever seen in the UK. Last year 150 speakers and over 1,000 delegates attended the FACE conference, which provided CPD certified learning and a unique and comprehensive set of agendas devoted to facial aesthetics.

Unparalleled choice What sets FACE apart from many other international conferences is that it provides specific agendas devoted to injectables, cosmeceuticals, equipment used in facial rejuvenation and the important

topic of marketing and business development.

This allows our delegates to only attend lectures that will benefit their professional development. For example, clinicians interested in the latest techniques of cosmetic injectables can focus on their learning requirements, whilst a clinic manager or marketeer may attend the business section and an aesthetician may want to review their understanding of the latest developments in cosmeceuticals.

Whatever your medical speciality, FACE provides learning for doctors, nurses,

surgeons, dentists, aestheticians, therapists, clinic managers and marketers working in the aesthetic industry.

New for 2014 is lectures devoted to HAIR treatments and as a huge up and coming area within facial aesthetics it is a perfect platform to identify all the different opportunities available for the treating of thinning hair, from hair implants to PRP to dermaroller treatments.

Flexible pricing FACE features a flexible pricing structure, allowing delegates to only attend the ex-

body language www.bodylanguage.net

three days of unparallelED choice including: – Over 150 international expert speakers

– Three day facial injectables agenda

– Three day business agenda

– Two day facial rejuvenation agenda

– One day thinning hair agenda

– Two day aesthetic therapists forum

hibition and workshops, book specific agendas for one or two days, or enjoy the benefits of choosing from all agendas for the most comprehensive scientific forum in the world within the dynamic facial aesthetics market.

Whether you have been in the industry since its birth or have just opened up your first clinic, FACE 2014 is the ideal conference for you to expand every aspect of your business model, no matter what size your clinic.

Summer Ball In the usual tradition of the Aesthetic Industry Summer

Ball, we will be hosting another event on the Saturday in a venue filled with all that is best with London. A perfect opportunity to enjoy a lovely summer night with your industry colleagues, this is a must-attend event that continues to be the highlight of the aesthetic industry social calendar. The venue and pricing will be announced shortly.

To register for FACE 2014, visit our website faceconference.com or call 020 7514 5989. To keep up to date with the latest news and offers, please email info@face-ltd.com to register for our newsletter

body language www.bodylanguage.net

– Skin agenda: Cosmeceuticals & diseases

– Three days of exhibitor workshops

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Fillers and toxins Mr Rajiv Grover is a consultant plastic surgeon and President of the British Association of Aesthetic Plastic Surgeons (BAAPS) Dr Fredric Brandt is a cosmetic dermatologist, innovative researcher and expert when it comes to injectables Dr Michael Kane is a consultant plastic surgeon who has taught thousands of practitioners how to inject toxins and fillers Dr Timothy Flynn is a consultant dermatologist and is recognised as an expert in skin cancer and dermatologic surgery Dr Nick Lowe is a consultant dermatologist and clinical professor of dermatology and has pioneered research with Botulinum toxins

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Our panel of experts discuss filler techniques and complications, as well as toxin resistance and the future of injectables Treating the chin Mr Rajiv Grover: Dr Brandt, you often use fillers to treat the chin and I think this is a very under-utilised area. In terms of the lower face, the chin has quite an effect on the relationship to the mouth and the neck. Can you expand on how often you tend to inject the chin and any specific techniques you use?

Dr Fredric Brandt: I think the chin is very important to treat past a certain age. Obviously if you’re 25 years old and you want your lips done you don’t need your chin done at the same time. But the chin I always say is a support structure— a foundation for your lips. I tend to use Restylane or Perlane—I use a lot and inject it sub-muscularly. I find if you inject it below the muscle, you’ll get a much smoother result and a better lifting to the area. It depends on the person’s age but I can inject one to two syringes of filler in the chin.

However it doesn’t last as long as on the cheek or certain areas because there is constant muscle movement and muscle tension in that area. Most people need a touch-up in about four or five months.

Dr Michael Kane: Some years ago I wrote a few articles about eyelid injec-

tion and tear troughs, so I probably inject more eyelids than anything else, followed by noses—many of the secondary rhinoplasty surgeons that don’t do injections send me these patients. However for people that walk through the front door and want something done, I probably inject the mandibular border, which runs into the chin from the jowl, as often as any area in the face. A patient in their early 40s gets more turnaround with jowl hiding from doing that, than anything else we do.

Mr Rajiv Grover: I think the message we’re getting is that patients come in with a particular problem but a good clinician is one that can look at their face, analyse it and tell them what they need rather than what they’re asking for. Dr Flynn, your thoughts on the chin?

Dr Timothy Flynn: I agree, it is an under-treated area but my least favourite line in the face is the marionette line. In order to treat the marionette line you have to put structure in the lower area. There can be a lot of sinking occurring there, so once we’ve treated that and lifted the marionette up—as it’s such an obvious sign of ageing—then I may augment an area in addition to the chin, just to rebody language www.bodylanguage.net

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store. We’re all doing more mid-face going down to the lower face and augmenting as we go along.

Dr Nick Lowe: Chins can be improved considerably, in some instances just by using one of the deep volume fillers—my favourite is Voluma. I’ll inject it in the sub-muscular area and I may even do it over more than one session. I bring the chin forward and it’s very useful to treat regressive chins and also helps to define the jaw line.

Don’t be afraid to bring the patient back after a month or so and do a little bit more. Another way to achieve longer lasting results if you are treating a very mobile mentalis muscle with the puckering peau d’orange appearance, choose your time to put some botulinum toxin in the central muscle to diminish puckering and movement and help the filler last longer.

Mr Rajiv Grover: That’s the message of the Carruthers paper about treating the glabellar with a combination of toxins and fillers—if you reduce the movement, the lifespan of the filler is a little longer.

The other thing that I found when treating the chin is definitely use a cannula because it is quite a vascular area.

I treated a lady with some Restylane SubQ to the chin whilst performing a facelift—at that time I was using the needle—and I got more bruising from this than from the entire face and neck lift. You can get quite dramatic bruising in some individuals so definitely use the cannula.

What are the thoughts of the panel on needle versus cannula, and do you have any preferences in particular areas?

Dr Fredric Brandt: I think it depends on the physician and what they’re more comfortable with—whatever works better for you. I happen to use cannulas for the cheek area, for filling facial compartments. I don’t use them for the temple because it’s too hard to get through that fascia for me to get to the periosteum.

I don’t use it on the chin because it’s too uncomfortable to get under the muscles for the patient so I tend to use needles.

I do agree chins bruise more, but I find it’s hard to be comfortable getting deep in the muscle without the patient feeling a lot of moving those muscles around and it is a little traumatic for them.

Mr Rajiv Grover: I do inject with local anaesthetic which I suppose defeats the point of not using a cannula because there’s a needle to put it in, but I do infiltrate with a little bit of local in the actual chin because it’s quite fibrous. I agree, it would be difficult to push through but as I anaesthetise, it’s a little easier. Michael? body language www.bodylanguage.net

Dr Michael Kane: I experimented with cannulas a couple of years ago and really gave it a go for a while but I’m mostly a needle person now, although I’ll occasionally use cannulas. The only area I would almost always use a cannula is the dorsum of the hand. You have pros and cons everywhere. I tend to put my filler superficially in the dermis and I don’t think you can do that with a cannula.

When you’re using a cannula you’re putting your filler deeper and I think you have a little less volume control. I like to use really tiny needles and shearing down the particle size, so I like the control with the needle. Since you’re deeper with cannulas, I think you need more product per gain, or something that you can see in the skin, which is a disadvantage.

Patients bruise a little less when using a cannula but I think you beat up that port hole a little bit more than you do when injecting with needles. So they each have their pros and cons.

Mr Rajiv Grover: I’m also reminded that your referral base is often people who may have had previous surgery, revision cases, eyelids, noses—they’ll be very difficult with a cannula so the needle will break through the scar tissue. That’s probably also your practice, Tim? Dr Timothy Flynn: I’m very similar to Michael. In the back of the hands, which I traditionally treat with Radiesse, I’d use a 22G, two to three inch cannula.

Cannulas are interesting because the other area where I use them is in fat transfers.

When harvesting fat I still use the 18G Coleman fat transfer cannula—I would just re-sterilise. That’s a big cannula but for those of us who have experience in liposuction it’s used in the same way.

You have to have a certain amount of controlled force as you move through the tissue and deposit. So I would say for me, I use cannulas for fat transfers and back of the hands only, otherwise needles.

Dr Nick Lowe: I use more cannulas than the others. I did a clinical audit for the Care Quality Commission on the use of fillers and, from 150 responses, 60% were injected with cannulas compared to 40% with needles. I use needles if I’m lifting and I want to put filler straight into the periosteum, on the malar eminence or onto the zygomatic arch to lift with one of the deep volume fillers.

If I want to fill, I will use one of the modern cannulas. If I want to define the lip border or inject the jawline I will use a cannula. The other thing our audit showed us is that there was a 20%—25% incidence of bruising with needles and about half that with cannulas.

Volume in the cheeks Mr Rajiv Grover: What would be the average volume you would inject into your cheek patients for example, both ideally and what you actually do in practice?

Dr Fredric Brandt: It’s so variable depending on what the patient is looking for and what the aesthetic is.

Many people are afraid to have huge cheekbones now because they see a lot of cheeks that are over-inflated, so it depends on the patient. I don’t think you need that much volume, and it depends if they’re a virgin patient. Maybe 1cc per cheek, perhaps a little bit more if you want to be dramatic.

It also depends on their age. If somebody comes in in their 40s, you just need a small amount. Somebody in their 60s or 70s is going to need four times that amount. You can use anywhere from 1cc for both cheeks to 4–5cc on both cheeks, really depending on the age and what you’re trying to accomplish.

Mr Rajiv Grover: That is very enlightening to me because I was expecting for Upper East Side New York high volumes and yet you started off with very low volumes which for us in the UK is reassuring. Michael?

Dr Michael Kane: I think it depends.

There are two patient cohorts—the person you see for the first time that wants to get maxed out and filled up and the person who comes back for maintenance.

That first time patient may get seven, eight or ten syringes over the whole face, but if they come back in four or five months they’re getting one syringe or two syringes spread over eight areas of the face. So if you were to take my last 100 charts, because it is so variable, and look for that median dose, it would probably be 0.3cc or 0.4cc per cheek—very small volumes.

Dr Timothy Flynn: I’m the opposite of Michael simply because of the patients that come to see me in my rural type university environment where I live. I would usually like to put more volume in the cheek than they’ll let me, largely due to cost and the fear of looking different. I may end up getting to where Michael is by repeat injections about every two to three months.

On initial injection I would tend to use Radiesse which I would dilute 1:1, and put about 1cc in each cheek in the deeper fat pads. Then when they come back to see me I may add an additional 2–3cc later on. It’s totally age dependent though. When a patient is young, we use a little. When a patient is 55–65, we have to do a lot more volume restoration.

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Problems with migration of product in the cheeks lessen with deeper injecting

Dr Nick Lowe: I agree with Tim here entirely. It depends on the age and the degree of volume loss. After weight loss, post pregnancy or post partum I tend to use a little bit more.

But my average would be no more than 2cc per side to start with, and most of my patients don’t want to suddenly look different. They want a gradual improvement so I’ll ask patients to come back after a month or so. If you then layer on top and re-finesse it you not only get more bang for your buck but you also get it to last a bit longer.

Mr Rajiv Grover: I find the cheeks really last a long time once you do them a few times.

Dr Timothy Flynn: What’s also interesting is that cosmetic patients will find the practitioner that suits their needs.

Somebody who’s looking for a more dramatic result may find an injector who does a higher volume and somebody who is concerned about an obvious outcome may find somebody who does just a little bit and over time, will get enough treatment to achieve good correction.

Mr Rajiv Grover: Are there any problems with migration in the cheek?

Dr Timothy Flynn: I don’t think there’s a lot of migration but I use relatively small volumes in that space so maybe I’m injecting small, discreet packets.

Dr Michael Kane: I think there’s less migration if you’re injecting deep. You get slightly more migration when you’re injecting more superficially, but if you’re injecting on the periosteum and building a tower like Gerhard Sattler described, then you’re not going to get much migration. body language www.bodylanguage.net

Resistance to toxins Mr Rajiv Grover: The biggest barrier to treatment in this country is trust, and you build trust by doing things gradually. The next area that I want to discuss is resistance to toxins. According to a feature in The Sunday Times Style Magazine there is a big problem because people develop antibodies and they become resistant.

I don’t see so much of this and one of the arguments related to whether or not the different botulinum toxins that are available now have different levels of foreign protein in addition to the botulinum. So do they have different effects on patients becoming resistant?

Dr Nick Lowe: Yes, I think I was one of the culprits quoted in that article. In fact, we were able to prove quite clearly that several patients had acquired resistance to all three Type A toxins that we have in this country. It does occur but it’s rare in my extensive experience. I’ve had five that I can say have definitely developed an acquired resistance to Type A. Mr Rajiv Grover: And you wouldn’t say that any of the Type A toxins are any different to each other?

Dr Nick Lowe: I tried all three Type A toxins in these patients and none of them responded. Is it going to be less with the ones that have less protein, like Incobotulinumtoxin known as Xeomin? I don’t know. I don’t think anybody knows because the problem is that you can get resistance in the absence of antibodies against botulinum toxin and you can get antibodies against botulinum toxin and you can still get responders. I don’t think it’s been worked out and I think it’s a different pharmacological mechanism than antibody formation.

Dr Timothy Flynn: What we can say for sure is that at cosmetic doses it’s a relatively infrequent occurrence.

Dr Nick Lowe: It is very infrequent.

Dr Timothy Flynn: Nick, were these patients complete non-responders or did you pick up on a partial response or decreased response to what they were having to the injections?

Dr Nick Lowe: They were patients who I’d been following for some time.

They were previous responders and they became total non-responders.

Dr Timothy Flynn: It is a very interesting phenomenon. Certainly this idea of resistance is more seen in therapeutic doses, so if you have cerebral palsy or any of the other neuromuscular disorders where patients are using hundreds of units, then you have problems with resistance.

Dr Michael Kane: I’ve been injecting toxins for 22 years and have probably in-

jected about 30,000 people and I’ve had two non-responders. It doesn’t matter if they’re demonstrable antibody positive or negative—we’re talking about nonresponse and we’re looking at the wrong cohorts. That is not going to come out of our world, it’s going to come out of the physical medicine world where in long term studies over 2% of people become non-responders.

The hapten effect means that a protein load can stimulate your immune system and up-regulate your cells to start making antibodies. The idea that the other toxins with more proteins are priming the pump and creating more antibodies remains to be seen and we’ll probably know within a few years. If there are matched trials in the physical medicine world with giant doses that are given much closer together, we’ll start to see something.

In response to your question, I think it’s both things. I think it’s dose and timing or interval but probably interval is more important. There are a few studies in murine rats where they’re given toxin doses, and I wrote a commentary on one.

It seems that depending how accurately you can measure for antibodies, after one dose you can measure some response. It’s just not a clinically significant response.

They don’t become non-responders. And it seemed in several studies, including this one, that this interval was more important than time.

Dr Fredric Brandt: I agree with Michael—I think it has more to do with interval than amount. The problem I face in my practice is that people come in and want touch-ups and if you don’t give it to them, they’re going to go somewhere else.

It becomes a problem. Especially in New York, I find that if patients see one muscle moving they want to come back instantly so it’s hard to keep them on a four-month schedule.

Dr Michael Kane: First of all let’s define the touch-up. If someone comes back and their DAOs are a little off and their mouth is crooked, that’s something you have to fix. The question is if they want a little more—you’re going to do it typically to keep them happy but I will read them the riot act and explain that long term, it is not a good idea as it may increase the chance of becoming resistant. If a patient returns and asks for another touch-up, I’ll give them the talk again and gradually they tend to do it less. They listen to you.

The two patients I had who were nonresponders were not garden variety patients. One was the wife of a plastic surgeon and so had a lot of Botox with short intervals and became a true non-respond17

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er. The other was a patient who was getting a lot of toxin from several different doctors back in the mid-90s. Back then, before they changed the batch in 1997, there was a much higher protein load in botulinum toxins and it wasn’t just accessory proteins, it was inactive neurotoxin as well. This is the real danger because it primes the immune system. Since they cleaned that up, the amount of these incidents seems to have gone down.

Dr Fredric Brandt: I find that in those patients who are not responding to Botox, I’ll switch them to Dysport or Xeomin and they do very well. You can try switching them around and in certain cases you’ll get longer duration of action.

Dr Nick Lowe: I think that’s partly true. I do the same to keep some of my patients happy. I have a group of patients that definitely have longer duration with one of the toxins compared to the other.

I think Dysport is better for crow’s feet, possibly because you’re getting more migration into the orbicularis oculi. But I think the incidence of true resistance is so rare in the dosages we are using for aesthetic use that it’s probably a rarity that’s interesting to us partial academics, but it’s not a major clinical problem.

The future of fillers Mr Rajiv Grover: What might be the future in years to come—what will be the next paradigm shift for fillers?

There’s talk that they will include skin modulators to try and stimulate, in the way that fat grafting does with stem cells, fibroblast proliferation and rejuvenate the skin as well.

Dr Fredric Brandt: I think it depends on where you’re injecting the filler.

With products to improve skin texture, you’re probably going to see fillers that are injected with a gun or very superficially into the dermis. Maybe in the future we’ll even be able to inject products that will affect bone and the deeper level, or be able to include an antimicrobial substance that will prevent formation of bacterial growth in the substance. We don’t need a filler that lasts five years in the face—I think the fillers we currently have available already last quite a long time if they’re done correctly.

Dr Michael Kane: I think two big things are going to happen. One is already here and is currently undergoing trials and one is a little further in the future. I agree that fillers last as long as they need to and I don’t need my fillers to last any longer because you can get great longevity with what we have. But patients always want that—if you were to give a 18

patient a questionnaire, that would be the number one request.

So I think what we will see is peptides being used more. We don’t have much mesotherapy going on in the States and some peptides clearly have efficacy. Some peptides are thought to have anti-natural hyaluronidase qualities, so by incorporating those peptides into hyaluronic acid, the natural enzyme is prevented from breaking it down so the filler lasts longer.

That’s one interesting thing.

The second advance involves solid state HA threads, which use regular HA cross linked with BDDE and polymerised to make it a smooth thread—it comes on a long Keith needle. It’s a different way of delivering HA that’s very volume controlled. I have patients who I treat for 45 minutes to an hour, working on those horizontal wrinkles in their forehead because they have tremendous brow ptosis and are constantly working their frontalis—you don’t want to drop them further. I can do that but it’s a pain in the neck. It’s a very unforgiving area with the light coming down, and it’s all about volume control.

If you use these threads, you can put in a perfectly dosed volume right through each of those lines. There is a study currently going on in Canada with these threads—I don’t know how soon they will come to market but while they won’t replace gels and needles, they could be a nice addition for those difficult to treat areas.

Dr Timothy Flynn: If we could get stem cells to focally improve and proliferate certain areas, such as an agent that caused fat stem cells to turn into a mature adipose site, it would be great to be able to put that into an atrophic fat pad. People are playing around with fat; you can grow bone out of fat, which is amazing. If that technology goes forward, we could control where the proliferation occurs—that would be very attractive.

The problem is we can get problems with cellular proliferations so we have to look at the long-term side effects. It’s one thing to transfer an adipose site, but it’s another to try and take something and get it to change and mature and grow. You’ve got to make sure there’s no uncontrolled growth which is a result of causing the stimulation to those cells.

Dr Nick Lowe: It’s fascinating to conceive of a hyaluronic acid injectable being an excellent vehicle for a whole variety of different active peptides and active growth factors. There are some fascinating peptides that I’ve come across in putting my skincare product hat on that are really being refined very nicely, including

Will the future of fillers see the inclusion of skin modulators to try and stimulate fibroblast proliferation and rejuvenate the skin as well?

neocollagenesis and even peptides that can regulate inflammation and pigmentation.

I’m sure there can be biologically active non-peptides that could be incorporated into a hyaluronic acid as injectables, one that could then stimulate more fibroblast activity. The problem is, as Tim has said, do you really want to stimulate too much fibroblast activity? Every time you add an additional complication and additional complexity, you add the potential for extra complications and side effects.

Complications Mr Rajiv Grover: The last topic we’re going to discuss is complications. One of the things that concerns us about injecting larger volumes into the cheek— because you’re effectively putting in an implant rather than a filler—are the inbody language www.bodylanguage.net

peer to peer

flammation or biofilm-type effects. What would be your finding of these incidents and what would you do practically to try and reduce the effects of biofilms or these types of complications?

Dr Fredric Brandt: We always say biofilms—but is it truly a biofilm or is it more of a streptococcal antigen in the product that the patients are reacting to? Is it something else that has stimulated the patient’s immune system? When somebody gets a dental abscess, you can get a nodule but is it the bacteria going into that area or is it just a heightened immune response? I think that there are certain cases where we’ve seen certain batches of material react more than the other so we don’t know if it’s a manufacturing defect.

To treat a nodule resulting from hyaluronic acid, the best thing is to dissolve body language www.bodylanguage.net

it right away with hyaluronidase. You can give the patient Biaxin, Doxycycline or Minocin but we’re not sure if it’s the antimicrobial or the anti-inflammatory effect that’s working to suppress the immune response.

We know it’s an immune response but we don’t have a lot of histological data to prove that it’s truly a biofilm. Is it just a heightened immune reaction to some of the protein that we know that these materials come from—strep antigens are not always washed out completely and there are different degrees of purification.

We need to know what we’re actually treating. However I think if you have a reaction to hyaluronic acid, just get rid of it with hyaluronidase.

I’ve seen patients where I’ve injected a syringe and 90% of the areas won’t react and one area will react on the face and it’s not related to an infection. Usually when it’s an infectious process it lights the area up. But I’ve seen cases where just one area reacts and I can’t figure it out. Was there more protein in that area, was the product not purified? It’s a gel so not everything is distributed equally through it. So in the manufacturing process, they may have more foreign body in one portion of gel than the other.

The patient had no obvious infection process. I’ve had a couple of patients that have dental abcess, their cheeks blew up and the abscess was cleared in a day. But then there are other patients who react and they have no obvious sign of infection. We didn’t do an ID work-up and we didn’t draw blood cultures but they have no dental pain, no sinus issues, no obvious other infectious signs in their body and it’s one area—not the whole face—that’s blown up. It’s one area from the same syringe. I have other colleagues and we talk about this and we can’t figure out why that happens but it does happen and I think if you use enough of any filler you’re going to see it.

Dr Michael Kane: I agree with Fred.

We don’t know what’s going on. I’m not sure if it’s a little antigen in there or if you’re really getting a biofilm. There were reports about the early batches of Restylane in the 90s where people were getting “little red bumps” or inflammatory episodes. But since they cleaned up the proteins, it has became much less common.

I’ve seen one person who called me up and said they thought they had the little red bumps. She came in and I think she had a little zit on her face which was a little inflamed, so I put her on Doxycycline because that’s what we’re supposed to do.

Now, it got better. I don’t know if that’s

because of its antimicrobial effect or the anti-inflammatory effect. However, I do think that if I had given her nothing, it would have gone away.

Dr Timothy Flynn: Do we really see this much of a problem in real practice?

How many people are really calling up our office and saying I have these terrible angry red bumps? We don’t see it really all that much. I think we need careful cleansing of the skin, using a sterile technique when you implant it and injecting small amounts in a distribution rather than one large pool. I just don’t think it’s as much of a concern as we all talk about.

It is a mystery in a sense because when it does occur, it could be injected in a variety of areas but there’s that one area which has become inflamed. What we really don’t have is people taking a little blade, nicking that and then culturing it in order to grow out a micro-organism.

Dr Fredric Brandt: I had a colleague in New York who had somebody do that—she was at university and they couldn’t grow anything. But how do you know if you’re getting enough material to culture? It’s not like you’re getting pus out that you can really culture. So I agree it’s a great idea but this was in a university setting so they had a whole department there to handle it and nothing grew.

Dr Timothy Flynn: I think that’s quite interesting because in defining an infectious process, you’d like to prove what the infectious process was caused by and we have a lot of trouble proving that.

Dr Nick Lowe: I don’t think these are infectious processes. My own suspicion is that it’s a fibrotic reaction around some fillers. I had a patient that I’m currently treating who was very negligent, or I was negligent about pushing her on a clear history about what fillers she’d had before. She only said that she’d had several Restylane and Juvéderm before but as it turned out, I injected her with a little bit of Voluma, just 0.5cc each side, and two weeks later her left cheek ballooned.

On closer questioning, she’d had Bio Alcamid ten years ago, and I am quite convinced that during the course of my injection, there was a fibrotic capsule around the Bio Alcamid—I disturbed that and it caused an intense inflammatory response. I cultured it, and while the cultures are pending, they are until now totally negative.

I’ve asked for different cultures and tried to do a biopsy, which she declined and I don’t blame her. So she’s on low dose antibiotics, she’s on hyalase and intermittent Triamcinolone injections as needed and we’re getting an improvement.

19

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injectables Dr Zahida Butt

Targeting ptosis Drooping of the eyelid, or ptosis, is a side effect of botulinum toxin injections, which can be caused by poor injection technique. Dr Zahida Butt describes the side effects and contraindications using apraclonidine, or Iopidine, to treat Botox-induced ptosis

T

he global use of botulinum toxin, or Botox, is becoming more common as an aesthetic procedure. However, one of its side effects is ptosis—the product’s effect on ocular muscles is dependent on the dosage of Botox reaching the levator palpebrae superioris muscle. The levator allows the eyelid to open properly and fully.

The incidence of ptosis after Botox injections is reported to be around 1%.

The problem can occur up to two weeks after injection, usually if the Botox is incorrectly placed or resulting from unusual anatomy. Total reversal of ptosis induced

by Botox can take up to three months to achieve.

Iopidine Isolated case reports have shown that use of Iopidine, otherwise known as Apraclonidine 0.5%–1%, three times a day can sometimes be effective. In normal clinical practice, there is no improvement in eyelid elevation when Iopidine is administered topically but in the absence of levator function, this drug may be of some use.

Iopidine is an adrenergic agonist which selectively increases eyelid elevation in the absence of levator function, indirectly combating the effects of Botox.

The Iopidine acts by selectively targeting alpha-2 adrenergic receptors on smooth muscle which results in the contraction of Müller’s muscle. This muscle joins on to the levator palpebrae superioris muscle and, on contraction, helps to elevate the eyelid by 1–3mm.

It is very important not to confuse brow ptosis, related to an excessive dose of Botox on the frontalis muscle of the forehead which causes brow droop, with true eyelid ptosis (figs 1, 2).

Iopidine is delivered as a stat dose to treat or prevent high pressure inside the eye that may occur during and after laser eye treatment. Iopidine is thought to work by acting on receptors in the walls of blood vessels in the eye. It causes the blood vessels to narrow which restricts the flow of blood through the vessels.

This decreases the production of a watery body language www.bodylanguage.net

fluid called aqueous humour that fills the back of the eye—this reduction in aqueous humour inflow into the eyeball decreases pressure within the eye.

Side effects Along with its required effects, Iopidine may cause some unwanted side effects.

Although not all of these side effects may occur, they may need medical attention if they do.

Based on 1% Iopidine delivery, hypersensitivity occurs in up to 20% of patients, including ocular discomfort, hyperaemia, pruritis, tearing, oedema of the eyelids and conjunctiva, and foreign body sensation. In a study of 40 patients, subjects received Iopidine for 90 days— allergic reactions tended to occur 30–60 days after treatment began and resolved on discontinuation of the drug. Although up to 20% of patients developed allergic symptoms, only two patients elected to discontinue therapy for this reason.

Another double-blind, placebo-controlled study, showed that 12.9% of the 84 patients treated with one to two drops of Iopidine 0.5%, three times daily, discontinued treatment because of hypersensitivity side effects.

In terms of ocular side-effects, hyperaemia and pruritis are experienced by 10–13% of patients treated with Iopidine, while 4–6% suffer from ocular discomfort and tearing. There is a 1–5% incidence of lid oedema, blurred vision, foreign body sensation, dry eye, conjunctivitis, discharge and blanching.

Rare ocular occurrences, noted in less than 1% of patients, include: lid margin crusting, conjunctival follicles, conjunctival oedema, abnormal vision, ocular pain, keratitis, blepharitis, photophobia, corneal staining, lid erythema, blepharoconjunctivitis, irritation, corneal erosion, corneal infiltrate, keratopathy, lid scales and lid retraction. Follicular conjunctivitis and hypotony have been reported rarely and mydriasis has also been seen. Many ocular side effects are transient and may not be seen until 5–7 hours after dosing.

A 66 year old man with proliferative diabetic retinopathy and increased intraocular pressure successfully underwent trabeculoplasty to lower the pressure. He received one drop of 1% Iopidine in the left eye one hour before and immediately after the procedure. At one and two hours postoperatively, the intraocular pressure in his left eye was measured at 8mm Hg and 6mm Hg respectively.

After examination, the patient was discharged. When the intraocular pressure in the left eye was measured one and four days postoperatively, results showed 10mm Hg and 28mm Hg respectively.

It was believed that the use of Iopidine almost certainly contributed to low intraocular pressure in this patient, although trabeculoplasty itself can result in an acute decrease in pressure.

Cardiovascular Some patients experience cardiovascular side effects, with less than 3% reporting arrhythmias and peripheral oedema, and 21

injectables Dr Zahida Butt

It is very important not to confuse brow ptosis ( related to excessive dose of Botox on the frontalis muscle of the forehead which causes brow droop) with true eyelid ptosis

less than 2% presenting with an irregular heartbeat.

Although long term studies have not yet been carried out, systemic side effects from Iopidine are expected to be relatively infrequent relative to Clonidine, which is used orally to reduce blood pressure, as Iopidine is far less lipophilic. The relative hydrophilia of Iopidine markedly reduces the risk of central alpha adrenergic stimulation.

In a double-blind, crossover study of 20 healthy female volunteers, the use of 0.5% Iopidine did not produce any significant changes in resting or exercise heart rate or blood pressure relative to placebo.

This study did not address chronic use of Iopidine in the elderly or in patients with glaucoma.

A single case of syncope and chest tightness has been associated with Iopidine. A 67 year old woman with a history of hypertension, diabetes and renal calculi was scheduled to undergo argon laser iridotomy. She had no known history of coronary artery disease or arrythmias.

Her regular medications included insulin, Frusemide and Metoprolol. Around 22

10 minutes after the instillation of one drop of 1% Iopidine to the right eye, to prevent elevated intraocular pressure, she complained of chest tightness—her pulse was “strong and regular”.

But within one to two minutes, her pulse was undetectable and the patient lost consciousness. She was in sinus rhythm. She was successfully resuscitated following aggressive intravenous fluid therapy. Her blood glucose was 180mg/ dl and her ECG was normal. The patient subsequently underwent successful argon laser iridotomy without the use of Iopidine.

There have been occasional reports of bradycardia, chest heaviness or burning, palpitations, reduced blood pressure and orthostatic hypotension, flushing and clammy palms when 1% Iopidine is administered once or twice daily for four weeks. One study showed blood pressure reduction averaged 6% and was not considered clinically significant although occasionally blood pressure decreased by 20%. Heart rate changes ranged from a 42% decrease to a 44% increase.

There have been rare occurrences of respiratory problems such as nasal congestion, rhinitis, dyspneoa, pharyngitis and asthma. Increased pharyngeal secretions, nasal burning or dryness and head cold sensations have also been reported following Iopidine therapy for up to four weeks.

Dry mouth has been reported in 10% of those treated with Iopidine and dysgeusia in around 3% of patients. Patients have also reported abdominal pain, diarrhoea, constipation, gastric discomfort, nausea, dyspepsia and vomiting.

Relating to the nervous system, lethargy affects up to 14% of patients who have been using Iopidine for up to four weeks.

Abnormal coordination, asthenia, dizziness, headache, insomnia, malaise, nervousness, paraesthesia and somnolence has been seen in up to 3% of patients.

Decreased libido, dream disturbances, fatigue, irritability, numbness or pain of extremities have also been noted, as has depression in less than 1% of patients.

Other side effects, such as contact dermatitis and pruritis (<3%), myalgia (0.2%) and chest pain, dry nose, facial oedema, taste perversion and parosmia (<3%) have been noted.

The respiratory, cardiovascular and nervous system side effects have been reported in patients who have used Iopidine for up to four weeks of therapy. For those receiving 1% Iopidine, more common side effects include increase in pupil size, paleness of the eye or inner lining of the

eyelid and raising of the upper eyelid.

Contraindications Iopidine should be used with caution in patients taking monoamine oxidase inhibitors, tricyclic antidepressants such as amitriptyline, and imipramine-related antidepressants such as mianserin.

A 15% discontinuation rate has been reported. Serious side effects are very rare but to avoid them, it would be prudent to take a full medical history and use with caution in severe kidney failure, depression, recent heart attack, high blood pressure, heart failure, angina or vasovagal attack.

Iopidine should not be used in patients with known hypersensitivity or allergy to any ingredient including benzalkonium chloride preservative, or in people with severe coronary insufficiency.

Iopidine may cause temporary blurred vision after being applied. If affected, it is best to advise patients not to drive or operate machinery until this has worn off.

The medication may also cause dizziness or fatigue so it is therefore best to caution patients regarding these side effects. Alcohol intake should also be limited while on this medication as the side effects can be potentiated.

The ptosis induced by Botox is selflimiting and therefore, even without treatment, the ptosis reversal would be complete in three to four months. The eyelid droop from Botox usually disappears in the vast majority of patients within the first two months so the drug can be discontinued before most side effects could occur.

Patients with Botox-related ptosis can be successfully treated with 0.5%–1% Iopidine. The resultant significant decrease in the amount of ptosis can help patients cope better with the disabling side effect of this cosmetic treatment.

Miss Zahida Butt is an NHS consultant ophthalmic and oculoplastic surgeon based at the Queen Elizabeth Hospital, King’s Lynn. She is also founder of The Cosmetic Clinic, King’s Lynn References 1. Malhotra PS, Danahey DG and Hilger P. “Botox injections to improve facial aesthetics.” 2010 http//emedicine Medscape.com article 2. Schenfield N. “The use of Apraclonidine eyedrops to treat ptosis after the administration of Botulinum toxin to the upper face.” Dermatology Online Journal.

2005 Volume 1, Issue 1 (1) 9. body language www.bodylanguage.net

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dermatology Anna Jean Lloyd

Earn your stripes While stretch marks are—to some women—a badge of honour following pregnancy, many others seek ways to banish them for good. Anna Jean Lloyd reviews the available treatments and technologies

I

n the realm of skin concerns, stretch marks (stria distensae) are among the most prevalent and, maddeningly, elusive to treat. Often associated with emotions of distress, these red, white and purple scars bear a significance for many that is more than cosmetic. The result is a market place saturated with products claiming to remedy the appearance of stretch marks—and an increasingly confused consumer.

Characterised as atrophic linear scars, stretch marks are essentially micro-tears in the dermis, brought on by periods of skin strain, hormonal surges, systemic drug use—or a combination of all. Both women and men are susceptible to stretch marks and those with a personal or family history may be especially at risk.

Pregnancy and adolescence Stretch marks are most popularly associated with pregnancy.

Research by the American Pregnancy Association indicates that approximately 90% of new mothers report stretch marks of varying degrees. However, while some women accept their new skin as a mark of motherhood, the vast majority (89%) buy topical products in an effort to prevent them—an average of two products throughout the term of their pregnancy and spending around $85 in the same period of time.

The same research, in fact, shows that another 69% of new mums will seek therapy post-partum, including a segment of women who describe feelings of “desperation and helplessness” associated with their stretch marks.

These findings were reiterated by a recent study published in The Daily Mail in which 1,736 new mothers were surveyed on the topic of stretch marks. Nearly all of the study participants reported stretch marks due to their pregnancies, with 78% reporting marks on their abdomen and 50% across their breasts, hips and thighs.

Among the respondents, 11% reported being “covered in” stretch marks and one third stated that they were “so embarrassed” by their stretch marks that they did not want partner to see them naked.

While hormonal fluctuations, weight gain and skin stretching contribute to some of the most severe stretch marks being in pregnant women, mothers are not alone in being affected. As much as 70% of adolescent females report stretch marks resulting from puberty or weight gain and an unnumbered cohort of post-pubescent boys are also affected by the same.

In fact, feedback from the retail level indicates that the adolescent market—perhaps ultra-motivated by typical teen selfconsciousness—is the major driver in over the counter purchases for stretch mark products.

Of course, no matter who the bearer, not all stretch marks are created equal.

Broadly speaking, stretch marks can be classified in three ways: stria gravidum, stretch marks as a result of pregnancy; stria rubra, fresh, red scarring; and stria alba, mature, white stretch marks. Although popularly lumped together, these classificabody language www.bodylanguage.net

Mature stretch marks on female abdomen/hips

tions represent important physical differences relating to the nature of the scar and the way in which it should be addressed.

Treatment options Despite their multitude, the array of over the counter products for stretch marks varies little in the way in which they address the problem. A ubiquitous offering on pharmacy shelves is cocoa butter. Used by grandmothers around the globe, cocoa butter’s properties have long been touted for the prevention of stretch marks.

However, while cocoa butter-based products provide hydrating properties that may minimise the risk of developing the problem, a 2009 study showed no significant advantage in using a cocoa butter cream versus a placebo in the prevention of stretch marks from pregnancy.

Nonetheless, sales of these products—such as Palmer’s Cocoa Butter—are growing in some markets and are driven, in part, by women opting for natural actives over efficacy during their pregnancies.

Reaching near cult status in the stretch mark sphere is Bio Oil. It contains a blend of ingredients including Vitamin A and E, lavender, chamomile and other botanical oils—the South African brand has come to dominate the product category in 17 25

dermatology Anna Jean Lloyd

Source: Mohamed L et al, 2009

Different topical products and their speculated modalities of action Product

Indication

Suggested mode of action

Tretinoin

Therapeutic

Exact mechanism unclear, but recent studies suggest fibroblastic stimulation

bined with home care for optimal results.

Prevention The literature as a whole does Trofolastin Therapeutic Active ingredient (centella asiatica) stimulates fibroblasts not indicate that any one apand inhibits glucocorticoids proach to stretch marks is eiVerum Preventive Active ingredient hyaluronic acid is speculated to increase ther more consistent or signifitensile resistance to mechanical forces cantly advantageous than any Alphastria Preventive Hyaluronic acid, the main ingredient, acts by increasing other. What it does show, howvolume to oppose mecanical atrophy ever, is the advantage of a proactive, preventative approach.

Massage with oils Preventive Dual action of massage and hydrant action of oils Prevention can take the Therapeutic Glycolic acid is reported to stimulate collagen production Glycolic acid and form of prophylaxis—whether by fibroblasts and to increase their proliferation in vivo trichloroacetic acid in the form of massage oils, and in vitro peels cocoa butter or silicone gel use during pregnancy or a period international markets, including the UK, Canada and Australia. of growth. The benefits of massage and hydration in preventing Though the manufacturer does not provide any peer review stretch marks are generally accepted. evidence to support the product’s comparative advantage, many Lifestyle choices may also reduce the likelihood or severity of of its ingredients are accepted as having moisturising properties stretch marks. Avoiding periods of excessive weight gain unrewhich—combined with daily massage—may reduce the chance lated to pregnancy is crucial. Steroid use similarly predisposes an of stretch marks. individual to stretch marks and, while there is not a lot of data Following Bio Oil’s lead, a suite of products based on plant to support the effects of diet and exercise on the development derivatives including onion extract (Mederma), Lupin Seed Ex- of stretch marks, healthy choices in both contribute to a stable tract (Cussons) and sweet almond oil (Weleda) are being mar- weight and healthy, more resilient skin. keted as over the counter stretch mark remedies, largely on the The plethora of treatment options aside, the physiology of basis of their moisturising abilities. stretch marks remains poorly understood and treatment outRounding out mass-market options is a category of higher- comes vary widely. Unswayed by the lack of a silver bullet, wompriced products for stretch marks, led by StriVectinSD. Known en and men affected by stretch marks continue to test the claims for its anti-ageing claims, StriVectinSD generated interest in the of manufacturers and skin care professionals in their remedy. stretch mark category on the basis of its proprietary NIA-114 An understanding of the available options and which are appeptide and “collagen boosting” properties. StrivectinSD com- propriate to the type of stretch mark present can increase the mands a following of loyal users but, with a list of ingredients as likelihood of satisfactory results for the patient. long as your arm, it might not be a pregnant woman’s first choice for prevention.

Anna Jean Lloyd is principal at Artindale Strategic Marketing & As both demand and OTC product selection for stretch mark Communications, a medical and consumer health consultancy in treatments grow, so too does interest in professionally-adminis- Toronto, Ontario. tered treatments. Laser therapy, including pulsed dye and fractional modalities, are among the conventional options offered References by clinicians for the revision of stretch marks and stria rubra in 1. http://americanpregnancy.org/weekbyweek/week13.htm particular.

2. BioOil Stretch Mark Survey, June 2011American Pregnancy AsTargeting the dilated blood vessels that mark the early stage sociation www.thinkbaby.co.uk Survey of New Moms) of stretch mark formation, McDaniel et al specified an optimal 3. http://www.dailymail.co.uk/news/article-2366377/Half-mothtreatment fluence using a pulsed dye of 3 J/cm2 using a 10-mm ers-refuse-wear-bikini-stretch-marks.html spot size. Though treatment is suggested to increase the col4. http://stretchmarkguide.org lagen content of the extra-cellular matrix, it is also noted that 5. Buchanan K, Fletcher HM, Reid M. “Prevention of striae PDL—and many light/laser options—may not be appropriate gravidarum with cocoa butter cream.” Int J Gynecol Obstet 108 for Fitzpatrick skin types IV and higher.

(2010) 65–68 Another study tackled stria alba, or mature stretch marks, 6. http://www.bio-oil.com/en/product/accolades and demonstrated 60%–70% amelioration in the hypopigmen7. McDaniel DH, Ash K, Zukowoski M. “Treatment of stretch tation using a 308nm excimer laser. A total of nine treatments marks with the 585 nm flashlamp pumped pulsed dye laser.” was typically needed with the excimer and maintenance theraDermatol Surg 1996;22:332–7. pies were required every 1–4 months to sustain results.

8. Alexiades-Armenakas MR, Bernstein LJ, Friedman PM, GeroneWhile laser and microdermabrasion regimens may be beyond mus RG. “The Safety and Efficacy of the 308-nm Excimer Laser a patient’s pocket book or effort threshold, topical prescription for Pigment Correction of Hypopigmented Scars and Striae Alba.” treatments like tretinoin may offer a more affordable, conveni(Reprinted) Arch Dermatol Vol 140, Aug 2004 ent option for physicians. Although not recommended for use 9. Rangel O, Arias L, Garcia E, et al. “Topical tretinoin 0.1% for during pregnancy, studies have shown between 8–20% impregnancy-related abdominal striae: an open-label, multicenter, provement in active stria rubra and a variable effect on mature, prospective study.” Adv Ther 2001;18: 181–6. whitish lesions, or stria alba.

10. Elsaie ML, Baumann LS, Elsaaiee LT. “Striae Distensae (Stretch Chemical peel regimens including trichloroacetic acid and Marks) and Different Modalities of Therapy: An Update” Am Soc glycolic acid have, anecdotally, yielded some results in the imDerm Surg 2009 provement of the appearance of stretch marks and may be com26

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psychology Dr Raj Persaud & Adrian Furnham

The red effect Red has long been associated with romance, passion and energy. Dr Raj Persaud and Adrian Furnham investigate psychological research that suggests the colour might render young women as more sexually attractive to men

A

rchaeological records from Africa reveal that women extensively used red ochre and other red pigments for cosmetic purposes and as a symbol of their fertility. The latest research into the colour red, published in the Journal of Experimental Social Psychology, focuses on the link between red and sexuality The study was conducted at the Technische Universität Dortmund and the Bergische Universität Wuppertal, Germany and was partly inspired by previous research which found that when a woman wore a red T-shirt, men chose to sit closer to her than a woman wearing blue.

Attraction The study, entitled “Romantic red revisited: Red enhances men’s attraction to young, but not menopausal women” contends that red is rated as a very positive colour, because it is associated with love, passion, and warmth.

The authors chose to investigate the reaction of men to younger and older women, documenting two key theories as to why men appear more attracted to women if they wear red. The first is that there is a cultural connection between red with romance. There is also an association with sex; in many societies, red signals sexual availability in “redlight” districts.

The second theory is that men are attracted to women wearing red because of our biology. In some female primates, increased sex hormone levels just prior to ovulation leads to increased blood flow to the periphery of the body, causing the skin at the genitals and face to become redder. Male primates appear to

become sexually attracted to these outer markers that female ovulation is occurring and therefore, should mating occur, would have a better chance of passing on their genes to future generations.

Psychologists also argue that a woman’s face, neck, and upper chest redden during the blush of flirtation and the flush of sexual arousal. Previous psychological research has found that when nearing ovulation during their monthly cycle, women subconsciously wear more revealing clothing, so their slightly redder skin will be more apparent to men.

The German study has found men were more attracted to a young woman in front of a red background than to the same ‘target’ in front of a white background. The experiment was repeated with an older-looking woman— however, the background colour had no significant effect on the sexual attractiveness of an older woman. While red had an impact on the sexual attractiveness of the younger woman, the older woman was

body language www.bodylanguage.net

not perceived as more sexually attractive against the red background.

Therefore, these findings cannot be explained by simple perceptual mechanisms whereby red is just found to be a more attractive or pleasant colour—following this reasoning, the older woman should also be perceived as more sexually attractive against the red background.

It could be that red is seen as a clue to a woman’s ovulation status. As the older woman was probably nearing menopause, the colour red was no longer a valid cue to fertility.

Global red effect The study authors believe the “red effect” seems to be automatic and probably below awareness. If a man finds himself more sexually attracted to a woman wearing red, he won’t be consciously aware that his desire is being stimulated because of the colour.

Psychologists Andrew Elliot, Jessica Tracy, Adam Pazda and Alec Beall conducted a similar experiment which

concluded that the red effect appears almost universal across the globe. The same study method was used, but instead of studying European men and women, the authors examined the impact of red on an isolated small-scale society in Burkina Faso, Africa.

The remote place was chosen because the men would be unlikely to be influenced by Western cultural assumptions about the symbolic erotic power of red. Any impact of red on male sexual attraction might then be more likely down to biological theories.

The results of the study, entitled, “Red enhances women’s attractiveness to men: First evidence suggesting universality”, indicated that the red effect on attraction is present in Burkina. The authors argue these findings represent the first evidence suggesting that red may be a “universal language of love”.

Red not only enhanced Burkinabé mens’ attraction to a target woman, but the red effect was specific to romantic attraction. No differences emerged in mens’ ratings of the woman’s general likeability, suggesting that the red effect is about sexual desire.

However, the German experiment showed that older men with an average age of 54 rated the older woman as more sexually attractive than the group of younger men, who had an average age of 24.

The younger woman was not considered as more attractive by the older men.

So everyone’s got a chance.

As in all advertising, just know who your target audience is.

Dr Raj Persaud is a consultant psychiatrist in private practice at 10 Harley Street and in Surrey.

29

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research

Measuring up Reliable, scientific measurements of patient outcomes improve patient satisfaction and education, and provide support to clinical studies and research. The international team describe the BREAST-Q, FACE-Q and BODY-Q scales

I

n the cosmetic surgery industry, new techniques and technology are rapidly evolving. At the same time, patients are becoming savvy consumers who want valid and reliable information about treatment outcomes. People specifically want to know what other patients have experienced to be able to make informed choices about treatments and healthcare providers, as well as avoid disastrous outcomes.

To fully capture the patient perspective, clinically meaningful and scientifically sound patient-reported outcome measures (PROMs) are needed. PROMs measure concepts—such as symptoms, satisfaction and health-related quality of life—by asking the patient directly, without interpretation by a clinician or anyone else. Such measures are increasingly being be used to support patient advocacy, cost-effectiveness analysis, patient education and local, national and international research efforts.

Furthermore, when incorporated into routine clinical practice, patients are given the opportunity to report their concerns directly to their healthcare provider who can use patients’ results in real-time clinical decision-making to improve patient satisfaction and health-related quality of life.

Over the last ten years, our team has worked to develop a set of PROMs to measure the outcomes that matter to cosmetic and plastic surgery patients using state-of-the-art methods to maximise both the clinical meaning and the scientific quality of the tools produced. Importantly, patients have been involved in all stages of the development process, as are experts whose input is crucial in the design of the content of each PROM and its subsequent evaluation. Our goal has been to ensure that the PROMs we develop are valid and reliable, not only for use in health services research but also for use in clinical care with individual patients.

body language www.bodylanguage.net

Our PROMs measure concepts such as appearance, body image, psychosocial wellbeing and satisfaction with care, and provide meaningful, precise and reliable feedback on important patient-centred outcomes. All PROMs are developed with strict adherence to international guidelines, such as the Medical Outcomes Trust and the US Food and Drug Administration (FDA), for instrument development.

We started the development of each PROM with a series of in-depth qualitative interviews with cosmetic and plastic surgery patients—155 patient interviews in total—and used the data to develop a set of scales composed of items that are really a set of statements that patients said to us in their interviews. Our scales measure things that patients care about, in their own words.

The end result is the development of three comprehensive PROMS called the BREAST-Q, FACE-Q and BODY-Q. Each of these plastic surgery-specific tools is composed of multiple scales that may be used to evaluate key aspect of outcome for plastic surgery patients. Importantly, the scales are designed to function independently and therefore only those scales that are most relevant to the research objectives and appropriate for the target patient population need be selected and administered.

This structure facilitates comprehensive, yet pragmatic, assessment of outcomes that matter to patients with minimal respondent burden and high response rates. All scales are scored on a 0-100 continuum, with higher scores meaning higher satisfaction or better quality of life.

BREAST-Q The BREAST-Q, which was made available in 2008, is our most established PROM and is designed for pre- and post-operative patients. The scales can be used to evaluate patient expectations 31

research

(preoperative), satisfaction with care, satisfaction with breasts and health-related quality of life. The BREAST-Q has been translated into over 12 languages and is in widespread use in international clinical trials and quality improvement programmes.

In the UK, the BREAST-Q was used by the NHS as the main outcome measure in a national mastectomy and breast reconstruction audit involving over 8,000 women who were followed up at three and 18 months. The BREAST-Q has separate modules for patients undergoing breast augmentation, mastopexy/reduction, breast conserving therapy (lumpectomy and/ or radiation therapy), mastectomy and breast reconstruction.

FACE-Q The FACE-Q can be used to measure outcomes in any type of facial cosmetic surgery, minimally invasive cosmetic procedure or facial injectable. Treatments include: cosmetic facial surgery, such as facelift, rhinoplasty or eyelid surgery; facial injectables, such as Botox, lip and line fillers; and dermatologic procedures like laser resurfacing and chemical peels.

To measure appearance, a large number of scales have been developed that cover all parts of the face, as well as scales that

measure the signs and appearance of ageing. Scales also measure health-related quality of life, adverse effects and satisfaction with care. FACE-Q scales are being used in international clinical trials and have been translated into French, German and Italian.

The scales are designed for pre- and post-treatment administration so that data can be collected to evaluate the effectiveness of surgical and nonsurgical treatments.

BODY-Q The BODY-Q is designed for use with bariatric or body contouring surgery patients. The BODY-Q scales are fully developed and now being field-tested in Canada and the USA. They can be used to evaluate outcomes for patients undergoing bariatric, or weight-loss, surgery. The scales can also be used to measure outcomes for massive weight loss patients who undergo body contouring procedures such as abdominoplasty or arm lifts and for patients who undergo cosmetic body contouring such as liposuction.

To measure appearance, there is a range of scales that measure satisfaction with the appearance of different parts of the body, as well as scales to measure body image, quality of life and

BREAST-Q

FACE-Q

BODY-Q

Satisfaction with Appearance

Breasts; Nipples; Abdomen; Back

Face; Skin; Lines (e.g., Crowâ&#x20AC;&#x2122;s Feet, Marionette lines); Forehead and eyebrows; Eyes; Eyelashes; Cheekbones; Cheeks; Ears; Nose; Nasolabial folds; Lips; Chin; Lower face and jawline; Area under chin; Neck

Body; Abdomen; Arms; Back; Buttocks; Inner thighs; Hips and outer thighs; Skin; Scars

Quality of Life and Adverse Effects

Psychosocial wellbeing; Sexual wellbeing; Physical wellbeing chest and upper body; Physical wellbeing abdomen and trunk; Physical wellbeing back

Psychological distress; Psychological well-being; Social well-being; Aging appraisal; Recovery early life impact; Recovery early symptoms; Skin; Forehead, scalp and eyebrows; Eyes; Nose; Lower face and neck; Lips; Ears

Sexual wellbeing; Body image; Psychological wellbeing; Social wellbeing; Physical function; Physical symptoms

Expectations

Support from medical staff; Pain; Recovery; Coping; Breast appearance and outcome; Psychosocial wellbeing; Sexual wellbeing

Change in appearance and quality of life

Change in appearance and quality of life

Process of Care

Outcome; Doctor; Information; Medical team; Office staff

Outcome; Decision; Doctor; Information; Office staff; Office appearance

Outcome; Decision; Doctor; Information; Medical team; Office staff

32

body language www.bodylanguage.net

research

satisfaction with care.

In the UK, the recent review of the regulation of cosmetic interventions report by NHS medical director Sir Bruce Keogh identified a lack of evidence supporting the efficacy of common cosmetic procedures. Keogh called for the establishment of an aesthetic research institute to provide the necessary scientific evidence and best practice for aesthetic treatments.

With funding from the Healing Foundation and in conjunction with the British Association of Aesthetic Plastic Surgeons, the National Institute for Aesthetic Research was launched in References 1. Klassen AF, Cano SJ et al.

“Measuring outcomes that matter to facelift patients: development and validation of FACE-Q appearance appraisal scales and adverse effects checklist.” Plast Reconstr Surg.

2. Panchapakesan V, Klassen AF, Cano SJ, Scott AM, Pusic AL. “Development and psychometric evaluation of the aging appearance appraisal scale: a new PRO instrument for facial aesthetics patients.” Aesthetic Surg. In press.

3. Pusic A, Klassen AF, Scott AM, Cano SJ. “Development and psychometric evaluation of the FACE-Q Satisfaction with Appearance Scale: A new PRO instrument for facial aesthetics patients.” Clin Plast Surg. 2013; 40:249-60.

4. Wildgoose P, Scott A et al.

“Psychological screening measures for cosmetic plastic surgery patients: a systematice review.” Aesthet Surg J. 2013 Jan 1;33(1):152-9 5. Cano SJ, Klassen AF, Scott AM, Cordeiro PG, Pusic AL. “The BREAST Q: Further validation in independent clinical samples.” Plast Reconstr Surg

2012 Sept; 129:293-302.

6. Pusic AL, Klassen AF, Snell L, Cano SJ, McCarthy C, Scott A, Cemal Y, Cordeiro PG. “Measuring and managing patient expectations for breast reconstruction: Impact on quality of life and patient satisfaction.” Expert Rev Pharmacoecon Outcome Res 2012 Apr; 12:149-58.

7. Klassen AF, Cano S, Scott A et al. “Satisfaction and Quality of Life Issues in Body Contouring Surgery Patients: A qualitative study.” Obes Surg 2012 Oct; 22(10):1527-34.

8. Reavey PL, Klassen AF, Cano S, McCarthy C, Rubin JP, Shermak M, Pusic AL. “Measuring Quality-of-Life and Patient Satisfaction after Body Contouring: A systematic review of patientreported outcome measures.”

Aesthet Surg J 2011 Sept; 31:807-13.

9. Pusic A, Lemaine V, Klassen AF, Scott AM, Wedderburn W, Cano SJ. “Patient-reported outcome measures in plastic surgery: use and interpretation for evidence-based practice.”

Plast Reconstr Surg 2011 Mar; 127:1361-7.

10. McCarthy CM, Klassen AF,

September 2013. As the cosmetics industry continues to expand, it is vital that research is conducted to measure outcomes that matter to patients.

Our team’s PROMs were developed to reflect patients concerns and provide a set of tools that can now be used to gather data to understand the impact that cosmetic interventions have on patients in a holistic manner.

Dr Anne Klassen E: aklass@mcmaster.ca; Dr Stefan Cano E: stefanjcano@gmail.com; Dr Andrea Pusic E: pusica@mskcc.org Cano SJ, Scott A, Vanlaeken N, Lennox PA, Alderman AK, Mehrara BJ, Disa JJ, Cordeiro PG, Pusic AL. “Patient satisfaction with postmastectomy breast reconstruction: a comparison of saline and silicone implants.”

Cancer 2010; 116:5584-91.

Epub 2010 Nov 8.

11. Cano S, Klassen A, Scott A, Thoma A, Feeny D, Pusic A. “Health outcomes and economic measurement in breast cancer surgery: challenges and opportunities.” Expert Rev Pharmacoecon Outcomes Res. 2010; 10:583-594.

12. Klassen AF, Cano S, Pusic A. “Satisfaction and quality of life in women who undergo breast surgery: a qualitative study.”

In press. BMC Women’s Health 2009; 1:9:11.

13. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. “Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q.” Plast Reconstr Surg 2009; 124:345-53.

14. Pusic AL, Reavey PL, Klassen AF, Scott A, McCarthy C, Cano S. “Measuring patient outcomes in breast augmentation: Introducing the BREAST-Q:

Augmentation Module.” Clin Plast Surg 2009; 36:23-32.

15. Kosowski TR, McCarthy C, Reavey PL, Scott AM, Wilkins EG, Cano SJ, Klassen AF, Carr N, Cordeiro PG, Pusic AL. “A systematic review of patient reported outcome measures after facial cosmetic surgery and/or non-surgical facial rejuvenation.” Plast Reconstr Surg 2009; 123:1819-27.

16. Pusic AL, McCarthy C, Cano SJ, Klassen AF, Kerrigan CL. “Clinical Research in Breast Surgery: Reduction and postmastectomy Reconstruction.”

Clin Plast Surg 2008; 35:215226.

17. Klassen AF, Cano SF, Scott A, Snell L, Pusic AL. “Measuring patient-reported outcomes in facial aesthetic patients: development of the Face-Q.” Facial Plast Surg 2010: 26:3039. Epub 2010 Jul 27.

18. Pusic A, Chen CM, Cano S, Klassen A, McCarthy C, Collins D, Cordeiro P. “Measuring quality of life in cosmetic and reconstructive breast surgery: A systematic review of patient-reported outcome instruments.”

Plast Reconstr Surg 2007; 120:823-37.

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Tzikas T. A 52 month Summary of Results Using Calcium Hydroxylapatite for Facial Soft Tissue Augmentation.

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surgery Eva Sanchez

Compression garments Post-operative complications can be reduced or even avoided through the use of compression garments. Eva Sanchez runs through the key features to consider when choosing garments for your patients

F

or many hospitals and private clinics, it has become standard practice to provide cosmetic surgery patients with appropriate compression garments immediately following their procedure. These specially-designed bras, girdles, vests and binders provide compression and support throughout the recovery period. For many plastic surgeons they are considered an essential part of post-surgery care.

However, there appears to be no real consensus among cosmetic surgery professionals on the use of compression wear.

This is hardly surprising, since despite the plethora of information available through the publications and websites of manufacturers and suppliers, clinical research into the use of compression garments after aesthetic surgery procedures is somewhat limited.

Compression therapy is nothing new.

It has long been considered the most effective treatment for lymphoedema and venous ulcers, and as a means of reducing swelling and oedema resulting from injuries such as sprains. Over 2,400 years ago, Hippocrates himself recommended the use of a double compress to treat varicose veins and ulcers of the leg.

While the principle of modern compression therapy is very similar to this ancient practice, the method for applying it has evolved. Since modern liposuction techniques were first initiated by Arpad and Giorgio Fischer in the mid-1970â&#x20AC;&#x2122;s, and further developed by Yves-GĂŠrard Illouz and Pierre Fournier, compression therapy has become an integral aspect of post-liposuction care.

However, the therapeutic benefits of external pressure on affected areas following surgery are not restricted to liposuctionâ&#x20AC;&#x201D;they are applicable to a range of procedures. Specialised area-specific gar36

Girdles are commonly used for multiple surgical procedures

ments have been developed for breast surgery, abdominoplasty, brachioplasty, face lifts and gynaecomastia surgery in men.

Purpose From the perspective of plastic surgeons, the main purpose of wearing compression garments is to alleviate the more common post-operative complications resulting

from trauma to subcutaneous layers of the skin, particularly bruising and oedema.

The external pressure provided by an appropriately-fitted garment mitigates bruising by restricting bleeding from capillaries and promotes the drainage of tissue fluids from the affected area by elevating the interstitial hydrostatic pressure in the deeper layers of the skin. Compresbody language www.bodylanguage.net

surgery Eva Sanchez

sion garments are also thought to control the occurrence of haematomas and seromas after surgery, and promote patient recovery from these complications.

There is also evidence to suggest that post-operative compression therapy can reduce the incidence of hypertrophic or keloid scar formation, particularly when applied in conjunction with silicone gel.

Although there is medical research demonstrating the efficacy of this method of treatment, the mechanism is not yet fully understood.

In terms of the overall aesthetic results achieved with cosmetic surgery, there is fairly widespread agreement amongst surgeons that compression garments provide some benefits. It is thought that they promote and guide the natural retraction of the skin and formation of fibrous connective tissue, while reducing the risk of unwelcome fibroses, folds and creases.

Since cosmetic surgery patients are ultimately concerned with their eventual appearance after their procedure, these potential advantages are likely to be of particular interest to them. However, it is essential that prospective patients discuss the likely results with their surgeon before a procedure to ensure that they have realistic expectations of both the surgery and the healing process.

One aspect of compression garments that patients typically report is that it helps to relieve post-operative pain, particularly in the initial stages of recovery.

This effect seems to be related to the immobilisation and support of the skin and underlying tissues, as patients often notice an increased level of discomfort after removing their garment for bathing.

The pain management function of compression garments may improve patient compliance with this form of treatment. This means they can benefit from the other practical benefits of compression garment wear, such as their role as a physical barrier to wound site infection and as a means of holding absorbent pads in place.

While compression garments offer a variety of potential benefits for recovery, it is crucial that patients follow the the advice of their surgeon to maximise the advantages. To some extent, compression therapy can be tailored to the individual; specifically the type of garment worn, area of coverage, strength of compression and period of wear.

Surgeons differ in their opinions regarding the most effective application of garments and recommendations to patients vary depending on the procedure undertaken, expected rate of recovbody language www.bodylanguage.net

ery and any anticipated complications.

However, despite variability in prescribed regimes—ranging from as little as two weeks to as long as three months—it is generally accepted that the initial two to three weeks post-surgery are the most significant.

Key features The features many surgeons look for in a compression garment are coverage, firm compression, convenience, comfort and durability. Adapting the coverage of a garment to suit the patient and the procedure they have undertaken should be relatively easy to accomplish.

There is a wide range of specialised garments available, with the option of providing general cover over the whole section of the body, or targeting the cover to a specific area only—for example, a body suit versus an abdominal binder.

In terms of compression, it is generally agreed that the pressure should be comfortably firm without being too constrictive. To be effective, a garment needs to provide sufficient compression to mitigate bruising and oedema. However, it is important that it does not over-compress the tissues, as this can have the counterproductive effect of restricting the flow of lymph and potentially result in oedema in surrounding areas.

It is also advantageous if the pressure over the affected area is evenly distributed, which is more likely with four-waystretch fabrics, which stretch and compress lengthwise and crosswise.

Convenience is also important. It is important that theatre staff can dress the patient with the garment and, subsequently, that the patient can dress themselves without placing undue strain on the skin. This is made easier with frontmounted fastenings and hook-and-eye closures, which have the added benefit of being adjustable to account for fluctuations in size from swelling and contraction.

Since it is usually recommended that compression garments are worn continuously and only removed for bathing or changing, they will also ideally have an open crotch design to allow patients to use the toilet with ease.

Considering the demanding regime expected of patients with post-surgery compression, comfort should be prioritised when selecting suitable garments.

If a patient is comfortable when wearing their garment, it increases the likelihood that they will comply with the treatment, potentially mitigating complications.

Patient comfort tends to be influenced

by a number of different factors, not least their subjective tolerance of wearing tight garments for long periods of time after painful surgery. Nevertheless, we have come a long way since the elastic wraps, or “French tape”, of the late 70’s and early 80’s. Modern garments can be very comfortable, with many patients even opting to wear them beyond their recovery phase.

Patients tend to appreciate the softness of their garment and its elasticity. Ideally a compression garment will feel smooth against the skin, with no irritation and will move and flex with the body with normal activity, preventing undue friction or creasing that can result in uneven pressure and localised soreness. A wellfitted compression garment should feel like a “second skin”.

Durability of compression wear is an essential feature, as it will be worn continuously by patients while they go about

Binders are a good example of targeted compression wear

37

surgery Eva Sanchez

Features to Look For

Features to Avoid

Medical-grade compression garments

Non-specialised compression wear

Firm and consistent compression

Ineffectual or excessive compression

Soft, breathable, ‘four-way-stretch’ fabrics

Abrasive fabrics that irritate sensitive skin

Durable construction for continuous wear

Potential allergens such as latex

Flat seams and wide shoulder straps

Metal stays that can cause irritation

Front or side-mounted fastenings

Rear fastenings that are hard to reach

Adjustable fastenings to account for swelling

Unprotected fastenings that could snag skin

Good, comfortable fit (‘second skin’)

Folds in the garment when worn

Reasonable freedom of movement

Poor flexibility and friction during movement

their daily activities for a number of weeks, or potentially months. To ensure that they continue to deliver firm and consistent external pressure, compression garments need to retain their elasticity and structural integrity throughout long periods of wear and numerous wash cycles.

Some medical-grade garment manufacturers conduct regular quality control testing on their fabrics to ensure that they retain their strength and elasticity after being stretched and washed repeatedly, which helps to maintain the effectiveness of the products.

Garment specifications Considering these key features, it is not as simple as it might initially seem to choose an appropriate compression garment for patient recovery. Choosing garments for each patient is often a duty performed by clinic staff on behalf of the surgeon.

However, in some instances, the patients themselves purchase them directly from suppliers, often with some degree of guidance. Considering the wide range of manufacturers and garments aimed at a variety of surgical procedures, the choice can be bewildering. In particular, it is not always clear to patients what the differences are between medical-grade garments and conventional sports or slimming compression wear.

Specialised post-surgery garments differ from sports compression in a number of ways. Most notably, they should provide stronger and more durable compression because of the properties of the fabrics used and the specialised construction of the garments. Post-operative garments are designed to be worn continuously for as long as two to three months. Sports compression wear simply isn’t designed for such intensive use and could lose integrity if used for post-surgical recovery.

The fabrics used in medical-grade garments should offer a good balance of elas38

ticity, usually provided by elastane—such as LYCRA—and tensile strength and durability, usually provided by polyamide, or nylon. Fabric composition varies between manufacturers and garment types, and tends to range between 10% and 55% elastane. The yarns, and the way in which they are woven, also varies from fabric to fabric and can alter the degree of stretch, compression and other key properties.

Fine yarns, such as nylon microfibre, can provide additional softness against the skin. In addition to the nature of the fabric, the construction of medical-grade garments is also an important differentiation. They should be manufactured in a way that minimises irritation against the skin and especially against surgical wounds. Therefore, garments should have flat seams, and bras and girdles should have wide shoulder straps and no metal stays. They should also be completely free of any potential allergens such as latex.

Sizing There is a lot to consider when choosing compression wear for each patient, but it doesn’t end at the selection of a suitable garment. The fit of a garment to the patient is a critical detail which can have significant effects on the outcome of the post-operative recovery and on patient comfort and support.

A poorly-fitting compression garment that is too loose, too tight or that has an uneven distribution of pressure can result in unnecessary discomfort and could have a negative impact on the overall outcome of the procedure. Therefore, it is an essential aspect of surgery preparations to ensure that the patient is correctly measured for their garment using the manufacturer’s sizing system.

For patients with atypical body shapes and sizes, such as very tall individuals or those with a large bust for their size, it is more effective to wear two separate garments of different sizes than to cover

the affected areas with one ill-fitting garment or to order custom-made garments.

Patients typically wear their garments constantly, so it is usually advisable for them to have at least two to allow them to change regularly to maintain personal hygiene, particularly if there is drainage from surgical wounds.

For many patients it is possible to switch to less intensive, “second-stage” garments, around two to three weeks after surgery. These differ from “first-stage” compression garments in that they are usually pull-on, without any fastenings, and tend to be more discreet under clothing. This makes them more comfortable for patients to wear continuously and, in some cases, second-stage garments are worn for longer than is strictly required for recovery, simply because patients appreciate the additional support they provide.

Selecting the right post-surgery garment can be more of a challenge than one might expect but, with due care and consideration, the eventual choice has the potential for promoting a smooth and complication-free recovery for each patient.

For this reason, it is prudent to begin preparing for post-surgery recovery, including choosing suitable compression garments, in tandem with planning for the procedure itself. The extra effort involved is likely to yield rewards in the form of improved patient comfort and well-being and even the overall outcome of the surgery.

Eva Sanchez is the founder and managing director of Recova Post-Surgery, which is based in London W: recovapostsurgery.com

References 1. Partsch H, Flour M, Smith PC, International Compression Club. “Indications for Compression Therapy in Venous and Lymphatic Disease Consensus Based on Experimental Data and Scientific Evidence. Under the Auspices of the IUP.” Int Angiol 2008 Jun; 27(3): 193-219.

2. Warren AG, Brorson H, Borud LJ, Slavin SA. “Lymphedema: A Comprehensive Review”. Ann Plast Surg 2007; 59: 464-472.

3. Brorson H, Ohlin K, Olsson G, Svensson B, Svensson H. “Controlled Compression and Liposuction Treatment for Lower Extremity Lymphedema”.

Lymphology. 2008; 41: 52-63.

4. Royle J, Somjen GM. “Varicose Veins: Hippocrates to Jerry Moore”. ANZ J Surg 2007; 77: 1120-1127.

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dermatology Lorna Jackson

The lash effect Long, full eyelashes are a commonly desired element of a youthful, beautiful face. Lorna Jackson runs through the active ingredients of eyelash enhancing products, both prescription-based and cosmetic

T

he appearance of long, thick eyelashes which can be fluttered flirtatiously at the opposite sex has always been a key element when looking at ideals of beauty.

From babies to animals and even cartoon characters, the appearance of full lashes is an attractive feature.

People, especially women, have been dyeing, colouring, adorning and elongating lashes for thousands of years. Kohl first became popular with the Egyptians in around 4000BC, followed by Cleopatra and her famously depicted eye make-up in 6930 BC, all the way through to the invention of mascara in 1840 by Eugene Rimmel.

The first modern day mascara, made from mixing coal dust and petroleum jelly, appeared in 1913 from American chemist T L Williams who called his product Maybelline—a combination of his sister Mabel’s name and Vaseline. This was swiftly followed by the invention of false lashes made from human hair in 1916, eye lash curlers in the 1920s, waterproof mascaras in the 1930s and the current day mascara applicator wands and tubes in the 1950s. The concept of making eyelashes a prominent part of the face is by no means a new fashion.

Around half of all cosmetic sales are for mascara products, with over 60% of women worldwide being regular wearers.

Research by Mintel in February 2012 even showed that 33% of 9–17 year olds wear mascara on a daily basis. According to Medical Insights, global sales of physician-dispensed eyelash products reached $164.1 million in 2012. Growth in the sector is projected at 10.2% per year until 2017.

Eyelash growth Like other hair on our bodies, eyelashes have a similar growth cycle (anagen, catagen and telogen) and vary in thickness, proliferation and strength. However, what separates eyelashes from hairs on the scalp, for example, are unique properties of their body language www.bodylanguage.net

growth cycle: a relatively long telogen phase and a short anagen phase, a slow rate of growth and a lack of influence by androgens. It is thought that these characteristics may allow for specially formulated products to make specific interventions, enhancing lash properties.

Some people may be predisposed to thin, fine, short or sparse lashes, while others have lost the lash fullness. Eyelash loss or damage can be caused by age or illness and associated medical treatments, such as alopecia or cancer treatment drugs. Other environmental factors include the over-use of eye make-up or removal products, false lashes, curling devices and UV exposure, which can make lashes brittle. The medical term for inadequate or too few lashes is hypotrichosis.

On the upper eyelids, we have around 100–150 lashes, arranged in two or three rows of follicles. The lower eyelashes are fewer in number, by about half. Their main function is to protect the eye from debris and trigger the blinking reflex.

The lifecycle of an eyelash can range from five to 11 months, with the anagen phase lasting one to two months and the telogen phase four to nine months. The differing lengths of the anagen phase amongst different individuals have an effect on the final hair length. Therefore, a product harnessing the ability to extend the anagen phase would be useful for enhancing lashes.

Key ingredients Eyelash enhancing products fall into two main categories— prescription-only medicines and non-prescriptive, cosmetic formulations, which account for the majority. Licensing, safety and efficacy evidence requirements differ depending on the categorisation of the products. In the US, much legal wrangling has occurred over the composition of many products and their marketing or legal claims.

There are two main types of ingredients currently used in 41

dermatology Lorna Jackson

Eyelash enhancing brands and products currently available in the UK marketplace Ageless Lashes uses a blend of peptides and Follicusan, an ingredient used in shampoos to treat alopecia.

Hydrolysed soy protein acts to repair damaged hair and various botanicals provide nutrients for the hair bulb.

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amalian LASHES uses a patent pending prostaglandin derivative which is encapsulated in a polysaccharide (HA) complex that acts as a carrier to direct the ingredient into the hair follicles in a slow release mechanism.

Marini Lash Eyelash Conditioner contains a proprietary peptide blend and is non-prostaglandin based.

Its key ingredient is myristoyl pentapeptide-17, although this is combined with myristoyl tetrapeptide-12.

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dermagenica.co.uk

RevitaLash Advanced Eyelash Conditioner contains a prostaglandin analogue, peptides and botanicals—its key ingredients are dechloro dihydroxy difluoro ethylcloprostenolamide, biotinyl tripeptide-1 and octapeptide-2.

Zoria Boost Lash Intensifying Serum uses a patented polypeptide which includes myristoyl pentapeptide-17 and cocoyl-oligopeptide-1. The product also includes camellia sinensis, soy amino acid and magnesium ascorbyl phosphate

42

obagi.uk.com

PRIORI MD Clinical Lash & Brow Enhancer is the only prostaglandinfree lash enhancer that utilises three potent lipopeptides—myristoyl pentapeptide-17, myristoyl hexapeptide-16 and myristoyl octapeptide-1.

Renokin Lash Lash contains patented biomimetic peptides of Caregen (Decapeptide-18 (CG-WINT), Oligopeptide-54 (CG-Nokkin), Decapeptide-10 (CG-Keramin2) and Oligopeptide-42 (CG-Fibramin).

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MD Lash Factor Eyelash Conditioner uses a cytokine complex, including milk protein and also thiotaine (ergothioneine), a mushroom-derived peptide and antioxidant, panthenol (provitamin B5) and biotin (vitamin H).

OBAGI ELASTILash Eyelash Solution is a non-prescription product aimed at achieving the appearance of thicker, fuller lashes. The key ingredient is myristoyl pentapeptide-17 and the product should be applied once daily.

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eyelash enhancing products; prostaglandin analogues—commonly prescriptive drugs—and peptides.

The key to all eyelash enhancing products is how high up the ingredient list the active ingredient is. The further down the list, the lower the concentration which will likely have a bearing on the speed of effect and consequent results. This will affect patient satisfaction and perceived value for money if they don’t see results as quickly as they expect.

Product marketing is tricky—claiming that the product can “grow” lashes is avoided, as this implies a medical outcome rather than a cosmetic one. Instead, popular terms include claims of ‘conditioning’, ‘fuller-looking’ and ‘thicker appearance’. Some US manufacturers include a disclaimer indicating that their products are cosmetics by stating the product “is not intended to stop, prevent, cure, relieve, reverse or reduce eyelash or eyebrow loss or to promote the growth of eyelashes or eyebrows.”

Prostaglandin analogues Almost twenty years ago, ophthalmologists noticed that some prostaglandin (PGF)-based drugs prescribed to treat patients with glaucoma or ocular hypertension were causing the side effect of increased eyelash growth, or hypertrichosis.

Various prostaglandin analogues, available to eye specialists, are now documented as causing varying degrees of hypertrichosis in glaucoma patients. They also cause less desirable side effects including increased pigmentation in the surrounding skin of the eye and in the iris.

In 2007, Allergan embarked on clinical trials using their 0.03% bimatoprost prostaglandin analogue, Lumigan—the ethylamide derivative of 17-phenyl-trinor PGF2alpha—for cosmetic use as an eyelash enhancer, with plans to initially launch it under the name Lumilash. The following year, the product (rebranded as Latisse) was approved by the FDA as a prescriptiononly product to “increase the length, thickness and darkness of eyelashes in people with hypotrichosis of the eyelashes”.

Bimatoprost activates prostamide alpha F2 receptors found in the hair follicle to stimulate its growth rate. It is a lipid compound derived from fatty acids which is designed to bind to prostaglandin receptors which are present in the hair, particularly in the dermal papilla and outer root sheath. Although the precise mechanism of action is unknown, prostaglandin receptors are thought to be involved in the development and regrowth of the hair follicle by increasing the percent of hairs in, and the duration of, the anagen phase. The company claims results are visible after eight weeks, with full results at 16 weeks. However, lashes will eventually return to normal through a hair growth cycle if the product is discontinued.

However, there is a lengthy list of potential side effects from bimatoprost use for cosmetic eyelash growth including: burning sensation (eyelid), erythema periorbital, eye swelling, eyelid irritation, eyelid oedema, eyelids pruritus, iris hyperpigmentation, lacrimation increase, madarosis and trichorrhexis (temporary eyelash loss and temporary eyelash breakage, respectively), periorbital and lid changes associated with a deepening of the eyelid sulcus, rash (including macular, erythematous, and pruritic limited to the eyelids and periorbital region), periorbital skin discolouration and blurred vision.

Latisse is a single use product with disposable applicators required to deliver the solution—one per eye, per application.

While this is not required with many cosmetic products available on the market, Allergan argue that the sterile, dose-specific brushes ensure accurate application by the patient, thereby avoiding potential side effects such as increased brown pigmentation to the pupil. body language www.bodylanguage.net

Award winning, evidence based comprehensive, professional antiaging skincare Tel: 0207 491 015 0 order s@wi gmoremedic al.com w w w.wi gmoremedic al.com

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Distributed in the UK by Aesthetic Source, also available through leading pharmacies

dermatology Lorna Jackson

Several companies have created controversial products based on prostaglandin analogues at various concentrations as nonprescription cosmetics, leading to legal action, withdrawals and reformulations. While products can legally contain prostaglandin analogues, the issue between ‘medical’ and ‘cosmetic’ comes down to the concentration used. Cosmetic products use very low concentrations—the active prostaglandin analogue is often at the end of the ingredient list by percentage, so in some cases peptides are included to boost the effect.

To avoid being classed as a medicine which requires a licence, the manufacturer needs to be careful about the physiological or anatomical changes that the product can have on the body, such as hair growth or pigmentary changes. This all makes the regulation of eyelash enhancers, just like cosmecuticals and other contentious products like dermarollers, a controversial arena.

Peptides When using a prostaglandin analogue as a base for a cosmetic lash enhancer, many manufacturers have investigated the use of peptides as an alternative, to improve lashes. Some have incorporated widely-used and ready-formulated peptides, along with added botanicals and moisturisers, while others have created proprietary and patented formulations of their own.

The use of peptides has led to increased marketing efforts pointing out that products are non-prescriptive and prostaglandin-free, and are therefore side effect free. One of the commonly used peptides is myristoyl pentapeptide-17. Both this peptide and myristoyl pentapeptide-16 were developed by Symrise who create active ingredients for the cosmetic industry. Their clinical trials have shown a 25% increase in lash length when the peptide is used in eyelash serums.

It is believed that the peptides encourage eyelash growth by stimulating the keratin genes in the body, which are responsible for growing the lashes. The peptide is also commonly found in fingernail strengthening products.

The market for eyelash enhancing products is fast becoming inundated. All products promise essentially the same thing and are not always able to adequately prove efficacy through hard clinical data. Comparative trials and studies are conspicuous by their absence.

A number of brands have reformulated over the years, many resulting from legal issues, leaving consumers wondering which formulation is better and making brand loyalty an issue for some. Without peer reviewed data and comparison studies, it is impossible to take on board more than this anecdotal evidence when deciding which camp to choose.

Choosing a product therefore requires research, considering

the compounds used, their concentration and history in hair enhancement science. Costs to the practitioner and clients also need to be taken into account. A high price tag is not proof of efficacy, so it’s key to compare and contrast the active ingredients and available data to ensure you make the right choice for you and your patients.

It’s worth noting that all products state that discontinuation of use will result in the eyelashes returning to their original state during one cycle of the hair growth. Once the desired results are achieved, users will need to spend money on ongoing maintenance top-ups using the products at least twice a week—therefore ensuring repeat purchase!

Most evidence and drive within the eyelash enhancement market lies in the prostaglandin analogues. However, ongoing research shows that other options may be open to exploration.

A paper published this year showed a comparison between four prostaglandin analogues of rabbit eyelashes, concluding: “Only bimatoprost is approved for growing eyelashes, and our research shows that tafluprost could be further explored by the cosmetic and pharmaceutical industry.

Additional research using travoprost and latanoprost as agents for eyelash growth should be performed in the future using prolonged treatment periods to determinate whether or not these prostaglandin analogues induce eyelash growth, and investigate other possible side effects.”

Despite comprehensive data to back up the science, safety and efficacy, the simple act of requiring a prescription will mean that many of the cosmetic products will still maintain good market share due to their greater availability and reduced cost to the consumer.

However, many medical aesthetic clinics will no doubt be keen to offer premium products not accessible in beauty salons and on the Internet.

Lorna Jackson is the editor of The Consulting Room, the UK’s largest aesthetic information website. W: consultingroom.com; Twitter: @Consulting_Room References 1. http://www.fda.gov/safety/medwatch/safetyinformation/ ucm275785.htm 2. http://www.examiner.com/article/the-best-eyelash-growthserums-that-really-make-skimpy-lashes-fuller-and-longer 3. http://www.goodguide.com/ingredients/377055-myristoylpentapeptide-17 4. http://www.ncbi.nlm.nih.gov/pubmed/23981234

Practitioners & their patients feel the difference...

“The favourable safety profile has lead to high patient satisfaction and subsequent recommendations from one patient to another, increasing our practice1” n

®

1.

Kuhne, U et al. Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients.

J Drugs Dermatol. 2012 Sep; 11(9):1032-5

2.

Data on File: BEL-DOF2_001 Belotero Juvederm Study MRZ 90028_4007

BEL065/0813/LD Date of Preparation: August 2013

44

Not palpable2

No Tyndall Effect1 ®

Comfortable on injection2 ®

Tel: +44(0) 333 200 4140 Fax: +44(0) 208 236 3526 Email: customerservices@merz.com

®

body language www.bodylanguage.net

S

D N A E IB 5% CR 1 SB VE SU A

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Introducing Introducing ePlus! ePlus!

Science. Results. Trust.

Science. Results. Trust.

Finally, a multi-application system for professionals!

Finally, a multi-application system for professionals!

Defined by Physicians, Designed by the Market Leader.

Defined by Physicians, Designed by the Market Leader.

• elōs™ technology - a combination of optical energy • elōs™ technology - a combination of optical energy with bi-polar radio frequency - for safe and effective with bi-polaron radio frequency treatments all skin types - for safe and effective on with all skin • treatments Upgradeable, 10 types different applicators •• Upgradeable, 10 different applicators Intuitive user with interface with easy to use guided • Intuitive interface with easy to use guided treatmentuser modes modes • treatment Motif Mode™ for fast, effective and “pain free” hair • Motif Mode™ for fast, effective and “pain free” hair removal and skin treatments andfractionated skin treatments • removal Sublative™ bi-polar radio frequency

• Sublative™ fractionated bi-polar radio epidermal frequency for increased collagen with minimal for increased collagen with minimal epidermal disruption disruption • triniti™ - a total skin rejuvenation protocol in the • triniti™ - a total skin rejuvenation protocol in the same visit same visit

TM TM

www.syneron-candela.co.uk | info@syneron-candela.co.uk | Tel 0845 521 0698

* This ad is not intended for use in the U.S. market. ©2012. All rights reserved. Syneron, the Syneron logo, triniti, Motif, ePlus, Sublime, Sublative and elōs are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. elōs (electro-optical synergy) is a proprietary technology of Syneron Medical. PB77501EN * This ad is not intended for use in the U.S. market. ©2012. All rights reserved. Syneron, the Syneron logo, triniti, Motif, ePlus, Sublime, Sublative and elōs are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. elōs (electro-optical synergy) is a proprietary technology of Syneron Medical. PB77501EN

marketing Adam Hampson

The power of branding A strong, consistent brand is essential to separate you from your competitors and attract new customers. Adam Hampson discusses how to market your clinic’s brand on emotions and experience

I

f someone asked you to define your brand, could you? When was the last time you identified your brand values or pinpointed what differentiates you from competitors? When you think of your brand, do you automatically think of your logo?

According to BusinessDictionary. com, “Branding aims to establish a significant and differentiated presence in the market that attracts and retains loyal customers”. In other words, it’s not just a logo. Without the right guidance, many practices and clinics spend far too much time and money on the details of their logo without fully recognising that a logo is simply one element of a brand that helps customers find them and identify them from others. Even the greatest logos are unlikely to create brand loyalty and repeat business, unless they reflect the wider brand experience.

The most successful businesses are those that recognise that their true brand values lie in the emotions and experience behind their products and services. How you make your customers feel is central to your brand and this lies in your responses, service, pricing, aftercare and quality.

Patient brand journey When working with a practice to build their brand, the first thing we do at H&P is to help our clients map out the linear process a new potential patient goes through to become an actual patient, and then a repeat patient. This is what we call the brand journey, which can be broken down into various touch points.

A patient’s brand journey is likely to begin with a visit to your website, or a telephone or email enquiry, to find out about treatments and their associated costs. Visits to the practice might include an initial consultation, treatment and aftercare appointments.

By plotting and understanding all the possible touch points of the brand journey, this ensures that you don’t miss an opportunity to think about what you really need to say, show or demonstrate to not only maximise your conversion rate but also your customers’ satisfaction.

How easy to do you make it to buy from you? Do you address your customers’ pain points or their aspirations? What body language www.bodylanguage.net

do you do to make a potential customer feel valued as an individual? Do you keep in touch with your clients after they’ve parted with their money for a procedure?

If you create a better experience for your customers, they will come back and tell their friends about it, bringing with them more business and greater profits.

Be authentic and consistent Consistency is essential to building a successful brand. Potential customers may find you via your website, direct marketing or one of the various social media platforms. They may also hear about you through word of mouth recommendations. Ideally, however this first contact with your practice occurs, every customer should come away with the same perception and experience of your brand.

To achieve this, your brand needs a distinctive and authentic tone of voice. It should look and feel the same way whether your customers are reading your brochure or browsing your website. The strongest brands are recognisable at a glance.

Membership schemes, thank you cards, appointment reminders, aftercare and payment plans are also brand touch points that should reflect the ethos and values of your business. Let your existing customers know that they matter. Feeling noticed and valued is an emotional response to which we can all relate.

Taken in isolation, the visual representations of your brand have little tangible value. No matter how attractive or compelling your logo or letterhead is, neither is likely to be allocated a monetary worth in an independent audit of your business.

However, your brand as a whole has monetary value, bringing extra worth to your practice beyond your physical assets.

By creating customer loyalty through your brand, you can demonstrate a following of repeat customers who are prepared to pay a premium to buy from you.

Make your brand aspirational Ultimately, when you build your brand on emotions and experience, you can tap into some of our core human desires. Peo-

Consistency is an essential part of building a successful brand Make a promise to your customers through your brand and stick to that promise. If you’re unsure what that brand promise should be, why not ask your existing customers what matters to them? Find out what it is about your practice that they value; ask them how they feel, what you do well or even what you could do better. By understanding your strengths, and building on areas that need improvement, it is easier to be authentic and deliver on your brand promise.

Repeat customers cost less Numerous business studies have shown that bringing back existing customers costs much less than attracting new ones.

By building a brand around emotions and experience, and being consistent at every touch point, you can nurture a strong sense of brand loyalty that will keep customers coming back to your practice.

ple aspire to a better life, to being healthier, more attractive, wealthier, better educated, desirable, or to be cared for and connected with others. What we buy and who we buy from reflects how we want the world to see us. It also communicates our desire for a better life.

The most successful brands are aspirational. They promise something more, appealing to our emotions and our deepest desires. Ask yourself what you can do to be more consistent. How can you make things easier for your patients? How can you demonstrate the benefits of your products and services?

Stop thinking of your brand as a logo and start seeing it as an experience.

To discuss your branding, contact medical aesthetics design and marketing specialists, H&P design. T: 01159 140 640 W: handpdesign.co.uk 47

Introducing Introducing ePlus! ePlus!

Science. Results. Trust.

Science. Results. Trust.

Finally, a multi-application system for professionals!

Finally, a multi-application system for professionals!

Defined by Physicians, Designed by the Market Leader.

Defined by Physicians, Designed by the Market Leader.

• elōs™ technology - a combination of optical energy • elōs™ technology - a combination of optical energy with bi-polar radio frequency - for safe and effective with bi-polaron radio frequency treatments all skin types - for safe and effective on with all skin • treatments Upgradeable, 10 types different applicators •• Upgradeable, 10 different applicators Intuitive user with interface with easy to use guided • Intuitive interface with easy to use guided treatmentuser modes modes • treatment Motif Mode™ for fast, effective and “pain free” hair • Motif Mode™ for fast, effective and “pain free” hair removal and skin treatments andfractionated skin treatments • removal Sublative™ bi-polar radio frequency

• Sublative™ fractionated bi-polar radio epidermal frequency for increased collagen with minimal for increased collagen with minimal epidermal disruption • disruption triniti™ - a total skin rejuvenation protocol in the • triniti™ - a total skin rejuvenation protocol in the same visit same visit

TM TM

www.syneron-candela.co.uk | info@syneron-candela.co.uk | Tel 0845 521 0698

* This ad is not intended for use in the U.S. market. ©2012. All rights reserved. Syneron, the Syneron logo, triniti, Motif, ePlus, Sublime, Sublative and elōs are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. elōs (electro-optical synergy) is a proprietary technology of Syneron Medical. PB77501EN * This ad is not intended for use in the U.S. market. ©2012. All rights reserved. Syneron, the Syneron logo, triniti, Motif, ePlus, Sublime, Sublative and elōs are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. elōs (electro-optical synergy) is a proprietary technology of Syneron Medical. PB77501EN

surgery Andrew Saunders

Stem the tide Haemostasis, or the prevention of excessive blood loss, is an essential part of all surgical procedures.

Andrew Saunders describes the efficacy of the QuikClot Hemostatic Dressing, which uses kaolin as its active ingredient

H

aemostatic dressings can effectively stem potentially fatal haemmorhage following trauma or surgical procedures, controlling bleeding and avoiding unnecessary tissue destruction. There are a number of ways to achieve haemostasis, including chemical agents, electrocoagulation or sutures and sponges.

The QuikClot Hemostatic Dressing (QHD) consists of a non-woven rayon and polyester gauze pad impregnated with kaolin, an inert mineral that does not contain animal or human proteins. Kaolin is a strong contact pathway activator agent initiating rapid clot formation in a wound.

Kaolin improves clotting time around seven-fold in vitro and has been tested extensively in stringent models of lethal vascular injury in vivo. Following independent, pre-clinical testing at both the US Army’s Institute for Surgical Research and the Naval Medical Research Center, QuikClot Combat Gauze, a derivative of QHD, was selected as the haemostatic agent of choice by the US Department of Defense. Current TCCC guidelines also recommend its use in helping adherence to bleeding tissues as well as promoting haemostasis. Previously tested products such as HemCon, QuikClot and WoundStat are no longer being recommended.

conjunction with five minutes of manual compression, the survival rate of the swine was 100% in the transaction model and 88% in the puncture model. When filled with blood, QHD achieved exceptional contact with the surface of the wound, exerting a consistent wound compression which prevented further blood flow. It was observed and dually noted that the fabric used in QHD ensured good initial contact and absorption, which is crucial in initial haemostasis.

Mechanism of action Kaolin is a natural occurring mineral known to foster platelet adhesion and accelerate clotting at the wound site. Kaolin, a substance known as an “activating surface,” promotes the activation of Hageman factor (factor XII) indirectly by altering its structure so that it is more prone to proteolytic activation by other plasma or cellular proteases.

Kaolin particles have a high surface negative charge (anionic) so that the binding of protein molecules, such as factor XII, can occur through simple, nonspecific electrostatic interactions. On exposure to human plasma, kaolin causes an electrostatic re-arrangement of factor XII in space, making it more susceptible to becoming activated. This is the process defined as “contact activation”. Kaolin therefore promotes clotting via a direct interaction with factor XII, the first protein of the intrinsic pathway of the coagulation cascade. This reaction leads to the transformation of factor XII, factor XI and prekallikrein to their activated forms.

Haemostasis following percutaneous arterial procedures is the final and most critical stage of a complicated procedure.

QuikClot Interventional Hemostatic Bandage (QCI), packaged with a 3M Tegaderm adhesive bandage, is indicated for use to control surface bleeding from vascular access sites, percutaneous catheters, or tubes using introducer sheaths of sizes up to 12 French. It is effective in stopping arterial and venous bleeding in conjunction with manual compression, within five minutes of application following vascular access in both experimental animal models and for routine clinical use.

The QuikClot Hemostatic Dressing was evaluated in two vascular injury models in swine. When QHD was applied in

Trials In a study testing the efficacy and acute safety of four haemostatic dressings (HemCon, Celox-D, TraumaStat and QHD) in a standard arterial hemorrhage model in swine, QHD yielded the highest survival rates and lowest blood loss in the swine models.

“The flexibility of CG, which is not changed by kaolin coating, and its large size are additional advantages that allow packing any type of wounds with his material and covering the entire damaged tissues. The ease of application and familiarity with gauze material make this dressing a superior product to use in the field for self-application or buddy aid,” say the study authors.

When the efficacy of 10 different haemostatic agents was tested in controlling bleeding in a groin transaction model in swine, QHD exhibited a greater survival rate than others tested.

QHD showed superior bleeding arrest by maintaining a low incidence of re-bleeding and low volume blood loss. Only QHD and WS demonstrated haemostatic properties that promoted blood clotting, which consequentially reduced post-treatment blood loss and increased the rate of survival.

A safety study investigated the potential thrombolic risk of using smectite granules, or Woundstat, when compared with kaolin-impregnated gauze, QHD, or regular gauze, Kerlix in treating an external wound with vascular injuries in a pig model.

Post-treatment blood loss was less and the total compression time to achieve haemostasis was shorter in animals treated with QHD and WS than in controls using Kerlix.

The histologic changes of WS-treated vessels exhibited injury and damage while QHD- and Kerlix-treated vessels were equivalent in almost every way—with the exception being a high incidence of microthrombi in the lung and brain of pigs from the

body language www.bodylanguage.net

49

surgery Andrew Saunders

KX group. The study authors note: “The lack of toxicity of kaolin in QHD, as noted in this study, may be attributed to the fact that only a small amount of kaolin powder is incorporated into each roll of QHD and that perhaps most of the mineral remains in the gauze when it is applied to the wound (indirect exposure).

“Besides the haemostatic properties, this product offers all the advantages of a regular surgical sponge: it is easy to use without requiring complicated training; it is pliable and can be introduced in deep cavities even through small orifices, easily reaching distant bleeding points”. they say.

Human clinical experience The kaolin-based gauze is currently being used in hospitals across the US and Europe. It also has been tested in several clinical trials.

In 2007, the gauze was used in 130 paediatric ENT operations—mainly tonsillectomy and adenoidectomy—in Mexico and compared retrospectively to standard surgical haemostasis.

Children treated with QHD showed significantly shorter surgery time and decreased intra-operative blood loss. Also, they required significantly less pain medications because of decreased oedema and inflammation of the pharynx.

In 2009, the QHD was also tested in a clinical trial in interventional cardiology in Italy. Patients undergoing either diagnostic or interventional procedures were randomised versus standard treatment. Results showed that in 100 patients, despite the use of multi-drug anti-coagulation, QHD controlled bleeding at the puncture site significantly faster than controls and patients were able to ambulate at four hours—controls required 12 hours of bed rest.

The same product was also tested in a 120 patient prospective randomised trial in interventional cardiology at the level of the radial artery. Results showed that QHD can control bleeding at the arterial puncture site and patients also experience a significantly reduced rate of radial artery obstruction than controls.

A clinical trial has been recently completed in paediatric patients undergoing spine surgery. Results are currently being analysed for publication. Preliminary findings show that QHD allows significantly less blood loss during the procedure.

These human data are corroborated by a post-market surveillance test performed on over 400 patients in the US where health care professionals were asked to fill out a questionnaire References 1. Kheirabadi BS, Mace JE, Terrazas IB, Fedyk CG, Estep JS, Dubick MA, Blackbourne LH. “Safety Evaluation of New Hemostatic Agents, Smectite Granules, and Kaolin-Coated Gauze in a Vascular Injury Wound Model in Swine.” J Trauma 2010;68(2):269-78.

2. Pahari M, Moliver R, Lo D, Pinkerton D, Basadonna G. “QuikClot® Interventional™ Hemostatic Bandage (QCI): A Novel Hemostatic Agent for Vascular Access.” Cath Lab Digest 2010;18(1):28-30.

3. Basadonna G. “From the Mountainous Battlefields of Afghanistan…to the Cath Lab.”

50

Cath Lab Digest 2009;17(9):74.

4. Ling GSF, Rhee P, Ecklund JM. “Surgical Innovations Arising from the Iraq and Afghanistan Wars.” Annu Rev Med 2010;61:457-68.

5. Griffin JH. “Role of surface in surface-dependent activation of Hageman factor (blood coagulation factor XII)”; Proceedings of the National Academy of Sciences of the United States of America 1978; 75:1998-2002.

6. Kirby EP, McDevitt PJ. “The binding of bovine factor XII to kaolin.” J Blood 1983; 61: 652-9.

7. Griffin JH, Cochrane CG. “Mechanisms for the involvement of high molecular weight kininogen in surface-dependent

following the use of QHD. These uses spanned across most healthcare areas including trauma, surgery, emergency care and obstetrics and gynaecology. Results show that QHC was successful in controlling bleeding and reaching complete haemostasis in 98.2% of cases.

In 2005 a European consensus conference defined the four most important qualities that an ideal haemostatic agent should have: safety, efficacy, simplicity of use and cost effectiveness. We believe QHC is safe since it based on kaolin as its main active ingredient. Kaolin is an inert mineral with no direct biological activity of its own and has no protein of either animal or human origin, so cannot elicit an allergic reaction or be a vehicle for viral or bacterial infections. A large number of safety tests were conducted internally and by outside researchers and the conclusions are that QHC is as safe as standard surgical gauze.

QHC is effective in controlling severe bleeding and promotes quick haemostasis even in the presence of anti-coagulation.

These findings are corroborated by in vitro and in vivo studies both in animals and in humans. Currently, this product is the first choice for products carried by all branches of the US Military to control severe bleeding on the battlefield. QHC can stop effectively the most severe bleeding within minutes when applied in combination with manual compression.

For further information regarding QuikClot contact Andrew Saunders of Fenton Pharmaceuticals Ltd. E: andrew@fent-pharm.co.uk; T: 0207 433 8595

reactions of Hageman factor.”

Proceedings of the National Academy of Sciences of the United States of America 1976;73(8):2554-8.

8. Arnaud F, Teranishi K, Okada T, Parreño-Sacdalan D, Hupalo D, McNamee G, Carr W, Burris D, McCarron R. “Comparison of Combat Gauze and TraumaStat in Two Severe Groin Injury Models.” J Surg Res 2010:1-7.

9. Kheirabadi BS, Scherer MR, Estep JS, Dubick MA, Holcomb JB. “Determination of Efficacy of New Hemostatic Dressings in a Model of Extermity Arterial Hemorrhage in Swine.” J Trauma 2009;67(3):450-60.

10. Arnaud F, Parreño-Sacdalan

D, Tomori T, Delima MG, Teranishi K, Carr W, McNamee G, McKeague A, Govindaraj K, Beadling C, Lutz C, Sharp T, Mog S, Burris D, McCarron R. “Comparison of 10 Hemostatic Dressings in a Groin Transection Model in Swine.” J Trauma 2009;67(4):848-55.

11. Arnaud F, Teranishi K, Tomori T, Carr W, McCarron R. “Comparison of 10 hemostatic dressing in a groin puncture model in swine.” J Vasc Surg 2009;50(3):632-9.e1.

12. Basadonna G, Lo D, Pahari M. “A Novel Kaolin coated Surgical Gauze Improves Hemostasis Both in Vito and in Vivo.” J Surg Res 2008;144(2):440.

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market On the

brushstrokes

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

MACOM MEDICAL

A seamless surgical bra with adjustable frontal closure, adjustable straps and fully expandable cups has been launced by Macom Medical. The only measurement required is the back size due to the expandable cups and the bra moulds to the new cup size, say Macom. It is designed to be used after breast augmentation, breast reduction, breast lift, support and for daily use.

The deep back also makes it ideal for use as a sports bra post surgery.

Macom T: 020 7351 0488; W: macom-medical.com

 Beautylab have launched the Black Diamond Range of skincare products containing black diamond particles. Beautylab say that when delivered to the skin the diamond particles settle in wrinkles and illuminate a blue glow to decrease the appearance of wrinkles. The range which comprises an Energizing Serum and a Moisture Complex, also contains anti-ageing peptides.

Beautylab T: +44 0 844 247 1240; W: www.beautylab.co.uk

TEOSYAL KISS

Teoxane Laboratories have launched Teosyal Kiss New Formulation, a hyaluronic acid-based product specifically adapted to the mobility of the lips which offers a long-lasting efficacy thanks to its high cohesivity. The smooth gel is very supple and easy to inject, allowing optimal control of the injection for the practitioner, say Teoxane and can be used to contour lips, enhance lips texture and plump the lips. It is also available with lidocaine.

Teoxane T: +44 (0) 845 0701782 W: lifestyleaesthetics.com

Dermastir Bio-Cellular Mask

Alta Care Laboratoires have launched the Dermastir Post-op Bio-cellular mask range, made from the fermentation of microorganisms. Biotechnological techniques have been used to manufacture the skin tissue-like material and masks can be used postoperatively to inhibit enzymes that break down hyaluronic, collagen and elastin in the skin, say Alta Care.

Alta Care Laboratories T: 0039 (0)6 69380852; W: altacare.com

SAPPHIRE

The Sapphire is an IPL system designed and produced in the UK specifically for use in salons. The Sapphire incorporates multivariable-pulse-technology (MVPT) for hair removal and allows the machine to operate at higher fluence without causing thermal damage to the skin, say distributor Laser SOS. Laser SOS T: +44 1480 460990; W: lasersos.com

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 Tebiskin EGF (epidermal growth factor) has been launched to counteract skin hypertrophy following various surgical or medical procedures using EGF—a synthetic age-prevention ingredient that supports cell renewal and wound repair.

Skinmed T: 08701 909 369; W: skinmed.co.uk  Hyalual Daily DeLux spray contains hyaluronic acid and succinate in spray formulation for easy application to the skin surface. A thin HA membrane covers the face which increases stratum corneum hydration thus opening it for bio‐active cream substances.

Continued use can help skins hydration and protection Rederm T: 0844 69 32326; W: rederm. co.uk

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nutrition Dr Carlos A Román

Food for thought Dr Carlos A Román investigates the link between refined carbohydrates, diabetes and heart disease, and how they can affect the ageing process

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umans are generally unable to handle a lot of refined carbohydrates. When we eat large amounts of dessert, bread, pasta, rice and other highly processed starches and sugar, our ability to utilise insulin becomes impaired—we become insulin resistant and glucose intolerant.

We put out excessive amounts of insulin which, in turn, creates diabetes, hypertension and atherosclerosis; the garden variety form of heart disease.

In the early 20th century, Thomas L Cleave carried out research that found a link with diabetes and heart disease to the consumption of refined carbohydrates in a typical Westernised diet. His work found that anyone who is genetically prone to diabetes and coronary heart disease and who also eats a high carbohydrate diet, is almost certain to make that genetic tendency manifest.

In the year 1900—a time before heart disease had become a leading cause of death—Americans consumed more carbohydrates than today, but only a relatively small percentage of them could be classified as refined. At that time, grains were not milled to such an extent that they lost their nutrition.

While people did eat a lot of sugar, it was often in the form of unrefined molasses; a rich source of iron and B vitamins. More importantly, the fats they ate were chiefly butter and lard—trans fats hadn’t yet been invented.

Heart disease and diabetes are inextricably linked with a diet high in carbohydrates. Refining of carbohydrates is, in reality, the greatest unacknowledged cause of death in world history.

body language www.bodylanguage.net

Diabetes Type II diabetes, also known as adult onset or noninsulin diabetes, affects 95% of the 16 million diabetics in America. An additional 60 million Americans who are very likely pre-diabetic are afflicted, whether they know it or not, with some form of insulin disorder. These disorders progress in stages from insulin resistance to a diagnosis of full-blown diabetes.

Each stage has its own findings and, even though new symptoms may not be noticeable, each opens a door to a range of degenerative diseases we associate with ageing. It is worth knowing the stages of this disease to help understand the connections between carbohydrates, disease and ageing.

In stage one, insulin—a hormone made in the pancreas— can no longer perform its major roles in the body to their full extent. This situation is referred to as insulin resistance.

Insulin’s major role is to convert excess sugar, or glucose, into a storage form of energy—glycogen. Glycogen is used as a fuel for periods between meals, but excess glycogen can be converted into stored fat, or triglyceride.

Insulin resistance is hard to diagnose in normal medical practice because it involves the simultaneous measurement of glucose from an artery and a vein in the same leg. Instead, we diagnose the condition by inference—weight gain or the finding of the second stage of diabetes.

The major breakthrough in understanding diabetes was the introduction of technology to measure serum insulin levels.

Much to everyone’s surprise, it was quickly discovered that type 55

nutrition Dr Carlos A Román

II diabetics were the polar opposite of type I insulin-dependent diabetics. Type II sufferers create too much insulin—they have hyperinsulinism. As type I diabetics have a damaged pancreas, they don’t create any insulin.

The scientific community clearly demonstrated the difference between the two illnesses—type I coming from lack of insulin and type II deriving from insulin resistance. However, the American Diabetes Association erroneously insists that they are variants of the same disease and usually treats type II patients with insulin or insulin-releasing drugs.

Shortly after the discovery that insulin levels could be measured, it was established that excessive insulin could itself lead to heart disease and other illnesses. Dr Gerald Reaven of Stanford University summarised the impact of hyperinsulinism, to which he gave the name “Syndrome X”. The five major features of Syndrome X include abdominal obesity, hypertension, a variety of blood sugar abnormalities, and two heart risk factors; high triglycerides and low HDL cholesterol.

Therefore the link between diabetes and heart disease begins with the second stage of pre-diabetes—the condition can cause heart disease before it is even recognised as diabetes.

Blood sugar abnormalities Diagnosing the common stage three requires a glucose tolerance test (GTT). It is such an important test that I have ordered more than 1000 at my own complementary medicine clinic. The GTT shows when the insulin disorder is starting to affect the blood sugar’s response to oral intake of glucose.

The abnormality sometimes appears at the beginning of the test, when the blood glucose rises to a point higher than that of a normal person’s, which is generally considered to be 160mg/dl.

More often, however, it appears on the downward slope. Affected by the increased quantity or effectiveness of the insulin hyperactivity, the glucose level drops at a rate exceeding 50 points in a single hour, or 100 points in total.

Interpreting the GTT is occasionally quite subjective, but it’s often obvious when the criteria of abnormality are exceeded in a major way. I always administer the GTT in conjunction with a symptom questionnaire—the symptoms of blood sugar instability, as noticed by the patient, are every bit as important in establishing a diagnosis as the GTT. The major symptoms resulting from unstable blood sugar response are hourly changes in energy level, mood and brain function, and irritability brought on by hunger which is relieved by food or caffeine. Carbohydrate cravings, prominent hunger and excessive tiredness are also commonly noted.

If a patient’s dietary habits include large amounts of refined carbohydrates, fruit juice, caffeine, sweets or alcohol, the suspicion that they may be in the third, and last, pre-diabetic stage may serve them just as well as the certainty that they are.

Stage three is quite common. I see bona fide abnormalities in GTT in patients four times more often than I see diabetes, suggesting there are four times more pre-diabetics than diabetics. Around 8–9% of the adult American population is thought to have diabetes, meaning one third of Americans has one of the stages of pre-diabetes. Once the third stage has been recognised, it is possible to avoid progressing to stage four by making necessary dietary changes and taking appropriate vitanutrients.

Diabetes stage four There is little difference between the typical form of type II diabetes and stage three pre-diabetes. No new symptoms develop, there is rarely a change in the obesity problem that plagues more than 80% of sufferers and there is rarely a worsening of heart 56

symptoms. The insulin resistance and hyperinsulinism that define stages 1–3 are still there. The key symptom is that the blood sugars are generally elevated throughout the day.

Type II diabetes responds to the same low-carbohydrate diet and vitanutrients that bring the pre-diabetic stages under control. However, many diabetologists recommend continuance of high-carbohydrate food consumption and prescribe drugs, which can include those which increase the insulin levels and therefore the likelihood of a fatal heart attack.

Not all stage four type II diabetics continue to create excessive insulin throughout their illness. They do, however, continue to have blood sugar elevations for the reason common to all five stages of type II; they are insulin resistant. It is not until this late stage of diabetes that insulin output reduces and insulin failure leads to stage five.

Diabetologists who confuse type I with type II diabetes are justified in their error only when stage five is reached. By this point, in a type II diabetic’s life, their insulin output has finally become subnormal.

It is best to test type II diabetics by drawing insulin levels before and after a high-carbohydrate test meal. If there is any elevation of insulin after breakfast, it can come only from a functioning pancreas. In our diabetic patients, only 10% produce insulin levels that are inadequate to be managed without an insulin supplement.

Around 44% of type II diabetics who consult diabetes specialists are prescribed insulin, the majority of which are unnecessary. If excessive insulin is harmful to an early-stage diabetic, it has been demonstrated to be equally harmful to a late-stage one.

It is important to have an understanding of the technical aspects of diabetes—both to recognise the condition in practice and understand its connection with ageing. The avoidance of diabetes-related illness is a key factor to consider in the treatment of ageing. By restricting carbohydrates, my heart patients almost always report improvement in symptoms and are able to reduce or stop medications for heart disease, high blood pressure, and/or diabetes.

Dr Carlos A Román is a specialist in complementary medicine who has focused his practice on nutritional medicine and metabolic lesions. E: carlosroman9@yahoo.com; T: San Jose (506)2257-2493

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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.

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technology Richard Crawford-Small

Customer Relationship Management The use of technology can strengthen the relationship between the medical aesthetic practitioner and the patient. Richard Crawford-Small discusses customer relationship management systems and the role they play in bringing business practices into the 21st century

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ccording to Wikipedia, the origin of salesmanship can be found in the English definition of “Hawkers & Peddlers”, first noted in 1225AD. Those early traveling salesmen, peddling their wares door to door, undoubtedly relied on memory. Then one innovative hawker—let’s call him Steve, from Dunstable— decided to jot down the names of his best customers so he could remember to send a card on their birthday and, lo and behold, customer relationship management (CRM) was born.

In this clearly untrue story, the key thing to note is that “Steve” has done two things; jotted down the name, and decided to send a card. The jotting creates a database, while his intention to build a relationship with his customer is CRM. These are two related but very different actions.

The Gartner definition of CRM is “a model for managing a company’s interactions with current and future customers. It

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involves using technology to organize, automate, and synchronize sales, marketing, customer service, and technical support”.

The perfect system Over the last few years, we have seen such a considerable increase in the number of database-driven systems available to aesthetic practitioners that I am amazed there are still paperbased practices.

There is no one perfect CRM system or database, as none will satisfy 100% of your requirements. In my career I have used ACT!, Siebel, Salesforce, Oasis and Scout to name a few. But they all have one thing in common—I did not relish using them.

It’s not their fault; they are just products of their time.

If asked, many would say their CRM system is too complicated. Why would a company like Oracle or SAP create 1,000 individual systems when one large one will do? Many CRM systems have become too feature-rich, containing thousands of body language www.bodylanguage.net

technology Richard Crawford-Small

functions of which you may only use 10%. This results in an uncomfortable “sinking feeling”, slow user adoption and, ultimately, the system’s failure to integrate.

However, these systems have huge capabilities. They are powerful and can collect large amounts of data and interrogate that data to provide complex reports. Large organisations have sales operations departments, with the sole role of digesting and interpreting that data to provide an output that can be understood and acted upon.

At the other end of the spectrum we have paper files, which are very easy to use but have no capability. You can’t interrogate that data or use it to inform your business decisions.

However, the knight in shining armour has arrived from Apple—the iPad. Products When used well, CRM systems can transform your business and provide rich data to plan your marketing campaigns or track enquiries from initial contact through to that contact becoming a patient. This is brilliant, but reports need to be easy to get.

The first challenge is the design. With Microsoft Outlook and Siebel, the data is laid out in a linear fashion—a design language typical of the the mid 90‘s Windows platform. In order to reduce training and improve acceptance, systems were deliberately designed to function as an extension of Windows.

The arrival of iOS in 2007 changed the landscape of computing forever. The future is mobile- and cloud-based, and the race is on to develop the next generation of CRM systems. The design and visual language of Oracle, SAP and Microsoft will change to reflect the post-PC era we live in. In some cases, it has already changed with the emergence of mobile patient management systems for the aesthetics sector such as iConsult (iConsult Software Ltd), Consentz (Light Touch Clinics) and eClinic One (edataware).

The emergence of iOS-based design has succeeded where all else has failed—it has led to the simplification of software user interfaces and a change towards design-led, rather than featureled systems. This can only be a good thing, as the main complaint against CRM systems in the past has been that they are feature-heavy and over complicated.

Simplified design The simplification of design is a wonderful advance that will make software developers stop and think more about user interaction instead of the latest “must have” feature. The simpler these systems are to use, the more practitioners will adopt them—the more they are adopted, the more data will be available.

Imagine if the PIP fiasco had taken place in the data-rich near future. As there is an iPad in the theatre, all implants are scanned, logged at the point of implantion and that infomation is made available to the patient. There are no more information requests, lost consent forms, or waiting 40 days and not knowing what they have been given.

Patient level access to information will be as commonplace as signing consent on a tablet, which was once thought of as illegal.

It’s not—it’s pretty much de rigueur these days.

Widespread adoption of mobile CRM would have a huge impact on safety— the patient, as well as the practitioner, would have full knowledge of the products being used. This may seem uncomfortable to some, as the risk of a patient taking your intellectual property to another provider would exist. However, the Information Commissioner’s Office assures that this is the future trend and it won’t be long before patients are demanding body language www.bodylanguage.net

transparency themselves.

The Keogh Report called for high quality care, safe products and an informed public. The technology exists for this to be monitored and enforced, and this will become a future use of CRM in the aesthetics marketplace.

Future trends The technological literacy of an individual can be categorised as being technofused, technoliterate or technophobic.

The technofused are easy to spot. They’re generally under 35 and looking at a smartphone, on average, 150 times a day. They are active on Twitter, Facebook, Instagram and Google+. They know that the reason their BMW works is because of an engine and JAVA, but they are useless in a powercut.

The technoliterate are mainly 40+ and are very familiar with technology. However, they might not hyperventilate if they are without broadband. The technoliterate are users of social media and, in the event of a powercut, would look for a candle using the iPad screen as a torch.

The technophobic are afraid of not “getting” technology, but are experts at surviving powercuts. Given the simplification of software through tablet computing, they could be given little encouragement to become technoliterate. They may have to, as the pace increases and more of their daily life will be dominated by technology. Skype GP appointments for 90 year olds? Don’t discount it.

So, the future trend is the emergence of CRM 2.0. The convergence of mobile and social media is likely to accelerate as the technological capabilities and awareness of social media continues to extend into the older demographic. However, this will pose some significant challenges around patient records and whether or not it is appropriate for a patient to post their before and after pictures on social media sites. Technically, it’s your copyright, but it’s their image.

Benefits Patients do care, as they put their iPad away to fill out your paper medical history. Your risk of falling foul of the Data Protection Act will greatly reduce if you digitise your records and using a CRM adds another level of security should your iPad get stolen.

You can get fined £500,000 for severe breaches of the Data Protection Act and, with the amount of patient records I see lying around in clinics I visit, it’s only a matter of time before a high profile patient’s treatment record ends up on Facebook.

Modern CRM servers incredibly secure, so it’s a safer way of doing business.

Another benefit is that your process will improve, giving you more time to treat or not to treat. But make sure you adopt a CRM system which you feel comfortable with, whether it’s cloud-based, tablet, papyrus or excel—you can always change later.

After 20 years of development, system design will continue to evolve at an ever-increasing rate and mobile technologies are set to dominate the space in the coming years. The evolution of CRM, and the technologies that support it, is only one part of the picture. Going back to Steve from Dunstable, these tools support the intent to add value to the customer journey.

Regardless of what route you decide, congratulations—caring for your business and your patients enough to use a CRM system is something that will never go out of fashion.

Richard Crawford Small is the director of iConsult Software and the creator of iConsult 61

experience Mr Christopher Inglefield

Innovate to educate Mr Christopher Inglefield talks about how his passion for helping people and problem-solving spurred him to study medicine, and how important innovation is to those practicing aesthetic surgery

F

rom a very young age, I was interested in biology and how living things work. I was also passionate about helping people and medicine seemed to be the conduit through which I could fulfil this passion.

So. following my degree in Canada, I decided to go and study medicine in Jamaica. It was a tumultuous time, as Jamaica was experiencing escalating troubles at the time. I relocated to the UK and from my early days as a “young” doctor, I enjoyed surgery for its dynamic and challenging scenarios and got great satisfaction from fixing problems.

It was during my surgery rotation in Aberdeen that I got my first exposure to plastic surgery. I was fortunate to work

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with some very good plastic surgeons who inspired me to develop my skills.

Plastic surgery provided me with all the elements I needed to fulfil my passions for helping people and solving challenging problems, with great satisfaction in doing so.

Plastic surgery evolved out of the need to treat the horrendous injuries sustained during the first and second world wars.

Innovation was necessary because no techniques were able to deal with these injuries. I am therefore always looking out for innovative ideas or techniques which will improve the quality of life of my patients!

I introduced botulinum toxin for sweating and was told that it would never work—it’s now a well-known technique for controlling hyperhidrosis.

With my colleague Alex Karidis, we brought the first MicroAire power assisted liposuction device into the UK, which has become the main device for assisted liposuction worldwide.

In 2005, I introduced UltraShape to the UK at the start of the revolution in non-invasive body shaping—I recognised the potential of the technology before it was fully developed and it is now the most important device in this sector.

During the latter years of my training in plastic surgery, I was instrumental in making immediate nipple reconstruction the gold standard for women having breast reconstruction for cancer.

I was lucky enough to hear James Dalrymple speak at the Royal Society of Medicine about his work with gender reassignment surgery (GRS) and was impressed by his humility and caring approach to this challenging area.

I began assisting him with GRS patients and developed my skills before he retired. My expertise allows me to help transgender patients live a normal and fulfilling life.

For me, the trust my patients place in me is a huge responsibility. Facial feminisation surgery has developed over the years as more of our patients request facial surgery and again, I am able to use my expertise and experience to provide them

with optimal results.

There have been so many amazing points throughout my career that it’s hard to single out one or two. One of my patients, a 16 year old girl with a sarcoma in her thigh, had been given just six months to live when I first met her. I was involved in her surgery which proved successful— the wonderful feeling of seeing her with her mother three years later, alive, happy and healthy at school is something I will never forget.

I also remember meeting a female paraplegic patient who was told nothing could be done for a fistula from her bladder into her vagina, which she had to have daily visits from the district nurse to clean. I was able to use my skill and experience in reconstructive surgery to eradicate the infection in her pubic bone, close the fistula and repair her vagina—her quality of life was dramatically improved.

I saw another patient for botulinum toxin and filler treament and noticed a suspicious mole on her neck which I advised her to have removed. The mole was an early melanoma and she was extremely grateful that I saw it.

I was also very proud to have been able to save the lives of twin two year old boys who had been seriously injured in a car accident. If my wife and I had not been at the scene, they would have died by the side of the road. I received a call one year later from their father, thanking us for saving his sons’ lives.

My overall experience has taught me about being a good doctor first, while developing the skills and the experience needed to be a good plastic surgeon. I believe in research, acquisition of knowledge and innovation to be able to provide patients with better outcomes, with lower risks and improved quality of life. It’s something that my team and I work for every day.

Mr Christopher Inglefield is a plastic and reconstructive surgeon at London Bridge Plastic Surgery and Aestetic Clinic body language www.bodylanguage.net

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Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin.

Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, LambertEaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution.

4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis),vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin.

Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May

result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany.

Date of revision of text: FEB 2012. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at yellowcard.mhra.gov.uk Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456.

3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154.

4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58.

5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1127/BOC/OCT/2013/LD Date of preparation: October 2013